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A. Bessodes - L. Chiche
The
n e w e ng l a n d j o u r na l
of
m e dic i n e
review article
medical progress
1545
n e w e ng l a n d j o u r na l
The
Normal anatomy
of
m e dic i n e
VIII
II
IV
Hypertrophy
VIII
III
II
IV
III
VII
VII
VI
V
Right portal
vein
VI
Portal vein
D
Multiple liver tumors
Tumor
Right hemihepatectomy
Figure 1. Normal Liver Anatomy and the Principle of Portal-Vein Occlusion with and without Concomitant Chemotherapy.
COLOR FIGURE
Panel A shows normal liver anatomy, with segments II through VIII shown. Segment I, which lies posteriorly, next
to the vena cava, is not shown. The portal vein is shown, with the right portal vein, the Rev7
left portal vein, and03/22/07
the left
medial branch to segment IV. Panel B shows occlusion of the right portal vein, which
results inDr.
ipsilateral
atrophy
of
Author
Clavien
the right hemiliver (segments V through VIII) and contralateral compensatory hypertrophy
of the
Fig #
1 left hemiliver segments I through IV. Panel C shows metastases throughout the liver. Panels D, E, and
TitleF show a two-stage procedure.
In the first stage, small tumorectomies in the potential left remnant hemiliver and occlusion of the right portal vein
ME
by means of portal-vein embolization or ligation are performed (Panel D) with concomitant local intraarterial or sysIngelfinger hyperDE with compensatory
temic chemotherapy, resulting in the shrinkage of residual tumors and the right hemiliver,
Daniel
Muller
Artist
trophy of the contralateral hemiliver (Panel E). In the second stage, a curative liver resection (right
hemihepatectomy,
AUTHOR PLEASE
segments V through VIII, or extended right hemihepatectomy, including segment IV) is performed
(Panel NOTE:
F).
Issue date
1546
04/12/2007
Medical Progress
L i v er R egener at ion
response to major tissue loss
Liver regeneration has been studied in rodent models, an approach that permits the determination
of cellular events and the analysis of the molecular triggers governing regeneration.1-3 Briefly, the
l i v er volume
Minimal volume for the Surgically Created
Liver Remnant or Allograft
Below a certain threshold volume, a liver remnant cannot sustain metabolic, synthetic, and
1547
The
Vascular endothelial
growth factor
n e w e ng l a n d j o u r na l
of
m e dic i n e
Stellate cell
Hepatocyte
Platelets
Inactive hepatocyte
growth factor
S phase
Extracellular
proteases
Lipopolysaccharides
Serotonin
Kupffer cell
Transforming
growth factor
Inhibition
Hepatocyte
growth factor
Tumor
necrosis
factor
Farnesoid X
receptor
G1 phase
Leukocyte
Interleukin-6
Nucleus
Sinusoidal
endothelial cell
Bile acids
Release
G0 or G1
phase
Epidermal
growth factor
Matrix
metalloproteases
Transforming
growth factor
The best-studiedIssue
underlying
liver disease in
date
04/12/2007
persons undergoing resection is cirrhosis, which
is associated with the development of hepatocellular carcinoma. The cirrhotic liver tolerates acute
tissue loss poorly, given its impaired function and
decreased ability to regenerate.26 In addition, portal hypertension, if present, is associated with a
poor outcome because of compromised portal
flow and the risk of postoperative upper gastrointestinal bleeding.27 These features are critical in
selecting patients with cirrhosis for surgery.27 For
example, a right hemihepatectomy is associated
with a low risk of liver failure or death in patients
with cirrhosis who have normal serum bilirubin
levels and prothrombin times and do not have
Medical Progress
fatty liver
Hepatitis
Intraoperative blood loss
Ischemia
Obstructive cholestasis
Preoperative chemotherapy
Steatosis
such patients.33 In addition, severe hepatic sinusoidal obstruction, occasionally associated with
nodular regenerative hyperplasia, has been ascribed
to oxaliplatin-based chemotherapy.35-37 These
vascular obstructions result in a bluish appearance
of the liver, known as the blue liver syndrome.36
Patients with this histologic feature are at higher
risk for intraoperative blood loss and postoperative complications than are patients without this
feature. Bevacizumab (Avastin, HoffmannLa
Roche), a monoclonal antibody targeting vascular
endothelial growth factor (VEGF) in combination
with cytotoxic chemotherapy, appears to improve
survival in patients with metastatic colorectal cancer.38 Because VEGF influences liver regeneration
through its regulation of angiogenesis and the
release of growth factors, and because bevacizu
mab therapy impairs wound healing,39 the effect
of bevacizumab may be deleterious.40 However,
when there is a window of 6 to 8 weeks between
the administration of bevacizumab and the surgery, the risk of perioperative complications after
liver resection may not be increased.41 Although
most experienced clinicians favor wedge, rather
than major, resection in patients exposed to extensive chemotherapy, there is currently no consensus for managing the care of such patients,
liver after chemotherapy
and the optimal window between the completion
An increasing number of patients with tumors of chemotherapy and surgery remains uncertain.
undergo extensive chemotherapy with multiple
drugs before surgery. Drugs such as irinotecan remnant donor liver and partial graft
(Campto, Pfizer) and, to a lesser degree, oxaliplatin Particular caution is indicated when subjecting
(Eloxatin, Sanofi Aventis) have been associated healthy living donors to the major liver surgery
with the development of steatohepatitis,33,34 and that donation necessitates. Zero mortality and
among patients receiving these drugs, the rates low morbidity are the goals, and surgery should
of complications and death after major liver resec- not be considered if the liver remnant of a potention are likely to be increased, as compared with tial donor would be below 35% of its initial volthe rates among patients not receiving these ume.11,42 Furthermore, although potential donors
drugs.33,34 We and others avoid major resection in with up to 15% steatosis are generally accepted
n engl j med 356;15 www.nejm.org april 12, 2007
1549
The
n e w e ng l a n d j o u r na l
of
m e dic i n e
ferase, and alkaline phosphatase levels), a coagulation profile, and a platelet count, combined with
the proper assessment of the predicted volume of
the liver remnant on CT or magnetic resonance
imaging (MRI), generally suffice for an assessment of a candidate with normal liver parenchyma for major liver surgery. The situation is more
complicated in a candidate with preexisting liver
dysfunction. In a patient with cirrhosis, the evaluation most often used relies on the ChildTurcotte
Pugh classification, which is based on a score
that includes bilirubin and albumin levels, prothrombin time, and the presence or absence of
ascites and encephalopathy (Table 2).46,47 Many
clinicians add upper gastrointestinal endoscopy to
rule out esophagogastric varices, a sign of portal
hypertension. A low platelet count (<100,000 per
cubic millimeter) or the presence of large varices
on preoperative imaging (CT or MRI) rules out
patients with cirrhosis as candidates for major
liver resection.48 Other practitioners recommend
direct measurement of the actual hepatic venous
pr eoper at i v e e va luat ion
pressure gradient in order to select patients with
clinical and biochemical tests
cirrhosis who might be candidates for liver resecAssessment of the volume of the potential liver tion.27
remnant or allograft as well as measurement of
preoperative liver function are essential. Routine dynamic liver tests
liver biochemical measurements (i.e., bilirubin, Other quantitative liver-function tests are most
aspartate aminotransferase, alanine aminotrans- often used in Asia, where the majority of patients
Table 2. ChildTurcottePugh Classification.*
Biochemical and Clinical Criteria
Points
1
Albumin (g/dl)
>3.5
2.83.5
<2.8
Bilirubin (mg/dl)
>2.0
2.03.0
<3.0
46
>6.0
1.72.3
>2.3
Prothrombin time
Seconds
<4
<1.7
Ascites
None
Encephalopathy
None
* Most authors divide the cumulative score of the ChildTurcottePugh classification into grade A (56 points, indicating
well-compensated disease), grade B (79 points, significant functional compromise), and grade C (1015 points, decompensated disease). Encephalopathy is graded according to the West Haven criteria of altered mental state in hepatic
encephalopathy,45 as follows: grade I, lack of awareness, shortened attention, euphoria, or anxiety; grade II, lethargy or
apathy and minimal disorientation; grade III, somnolence to semistupor with gross disorientation; grade IV, coma with
unresponsiveness to verbal or noxious stimuli. Asterixis (flapping tremor) is often observed in patients with grade I
altered mental state and is always present in patients with grades II and III. To convert values for bilirubin to micromoles per liter, multiply by 17.1.
1550
Medical Progress
undergoing liver surgery have hepatocellular carcinoma related to hepatitis B or C cirrhosis. Metabolic tests (Table 3) target different aspects of
hepatic physiology.49-51 The most commonly used
test is intravenous injection of indocyanine green
(0.5 mg per kilogram), a dark bluish-green tricarbo
cyanine dye that rapidly binds to plasma -lipoprotein and is completely and exclusively removed
by hepatocytes. Indocyanine green is excreted into
bile in unmodified form and does not enter the
enterohepatic recirculation.52 The rate of retention
of indocyanine green determined at 15 minutes
after injection must be interpreted in the context
of other factors.50,52 For example, patients with
a favorable ChildTurcottePugh score of A (Table 2) and a retention rate of indocyanine green
at 15 minutes of less than 14% generally tolerate
major hepatectomy well, whereas those with a
retention rate greater than 20% should be excluded from major liver resection. Patients with
retention rates between 14 and 20% should undergo surgery only after an assessment of liver
volume with possible preoperative portal-vein
embolization (Fig. 3A).48,53
Test
Principle of Test
Microsomal hepatic
function
Breath tests are used to probe hepatic microsomal P450 enzyme activity and
investigate hepatocellular function by assessing liver oxidation. The exhaled
labeled CO2 is measured.
Clearance tests probe the hepatic microsomal P450 enzyme activity and
measure either the metabolic elimination of the test compound or the
appearance of metabolites in the blood that are primarily dependent on
the hepatic metabolic capacity.
Cytosolic hepatic
function
Indocyanine green is distributed in the serum, removed by the liver, and excret
ed unchanged into bile without entering the enterohepatic circulation.
Liver perfusion
The high rate of hepatic extraction of low-dose galactose and sorbitol by the
sinusoidal membrane of hepatocytes implies a hepatic plasma flow
dependent mechanism.
Hepatocyte mass
1551
The
n e w e ng l a n d j o u r na l
New strategies have focused on combining selective portal-vein obstruction with the concomitant
administration of systemic59,64,69,70 or selective
intraarterial hepatic65 chemotherapy before liver
resection, with the aim of achieving both a reduction in the tumor size and a change in liver volume (Fig. 1 and Fig. 4). These strategies have been
applied mainly in patients with a nonresectable,
advanced tumor load and a liver remnant that
was predicted to be too small for resection. The
regimen and the timing of systemic chemotherapy and portal-vein embolization have been variable, but fluorouracil-based chemotherapy with or
without oxaliplatin, irinotecan, or bevacizumab is
the regimen most often used.59,64,70 In a pilot
study, continuous delivery of selective intraarterial chemotherapy with floxuridine (FUDR, HoffmannLa Roche) and right portal-vein ligation in
11 patients with multiple nonresectable metastases of colorectal origin were associated with a
1552
of
m e dic i n e
significant decrease in tumor volume and a significant increase in the volume of the contralateral left hemiliver (Fig. 4).65 About one third of the
patients receiving this treatment underwent curative liver resection 3 months after the start of
treatment. Impairment of the hypertrophy induced
by portal-vein obstruction that results from concomitant continuous chemotherapy, although a
concern, has not been observed to date.71 When
liver resection is not performed after portal-vein
embolization or ligation, the use of further systemic or regional chemotherapy remains possible. The main complication of selective hepatic
delivery of floxuridine appears to be the development of intrahepatic and extrahepatic biliary strictures.72,73
portal-vein embolization
with chemoembolization
Patients with hilar cholangiocarcinomas often require complex liver resection. Since segment I is
also removed during such resection because of a
high incidence of recurrence at this location, the
Medical Progress
Yes
No
Portal-vein embolization
Resection
Yes
No resection
No
ChildTurcottePugh
score of A
ChildTurcottePugh
score of B or C
Portal hypertension
No
Yes
No
Yes
<14%
1420%
>20%
Portal-vein embolization
Resection
Yes
ICM
REG F
No resection
No
AUTHOR: Clavien
RETAKE
FIGURE: 3 of 3
CASE
1st
2nd
3rd
Revised
Line
4-C april 12,SIZE
n EMail
engl j med 356;15 www.nejm.org
2007
ARTIST: ts
H/T
H/T
33p9
Enon
Combo
1553
The
n e w e ng l a n d j o u r na l
m e dic i n e
of the planned resection has been reported to reverse cholestasis and increase the size of the potential liver remnant before surgery.77-79 Although
the optimal timing of these interventions has not
been determined, we, and others,80 now perform
portal-vein embolization within 1 to 3 weeks
after biliary drainage and consider surgery after
the cholestasis resolves (usually when the bilirubin level is less than 50 mol per liter [2.9 mg
per deciliter]) and there is an adequate regenerative response (Fig. 3). With the use of this strategy, several studies of extensive liver resections for
hilar cholangiocarcinomas without perioperative
deaths have been reported.61,77,78
of
Medical Progress
risk for complications after partial liver transplantation.42 Such patients should be considered
candidates only for the transplantation of a whole
cadaveric organ.
Injury to small grafts is associated with portal
hyperperfusion, caused by the combination of a
low liver volume and preexisting portal hypertension.25 Although enhanced liver regeneration
might have been anticipated on the basis of increased portal flow, portal hyperperfusion is
currently seen by many as the cause of failure in
small grafts. One explanation is that changes in
portal flow induce reciprocal effects on hepatic
arterial flow, implying that post-transplantation
portal hyperperfusion results in a compensatory
decrease in arterial flow.88 A reduction in the por
tal venous flow by means of portal banding,
splenic-artery ligation, or a hemiportocaval shunt
may prevent postoperative liver failure, resulting
in improved survival of the graft and the patient
after transplantation of a partial liver graft.25,89
For split-liver transplantation of a cadaveric graft,
only optimal grafts are used, and grafts from
older donors (>50 years of age), steatotic organs,
and organs with a low ratio of the graft weight
to the total body weight of the recipient should
be avoided.90,91
Efforts to develop pharmacologic means of protecting the liver from damage during regeneration
have identified a few molecular targets. Our group
has recently shown that pentoxifylline (Trental,
HoechstRoussel), an inhibitor of TNF- synthesis in Kupffer cells that has other properties
such as vasodilatation and induction of the interleukin-6 pathway, reduces the likelihood of inadequate liver function in the liver remnant in a
murine model of partial liver transplantation.20
Pretreatment of a small graft (30% of the total
liver volume) and of the recipient with pentoxifylline prevents lethal outcomes and fully restores
regeneration.16
Acetylcysteine, a precursor of glutathione, has
been widely studied as a protective molecule. Clini
cal trials of its use in the perioperative treatment
of patients undergoing liver transplantation showed
reduced levels of circulating selectins92 and a
reduction in the severity of rejection in pediatric
patients undergoing liver transplantation,93 but
Occlusion of the portal triad (the Pringle maneuver) and total vascular exclusion (concomitant
clamping of the infrahepatic and suprahepatic
vena cava and the portal triad) are techniques
used to minimize blood loss and the need for
blood transfusions during liver surgery.8,99 Both
techniques, however, cause inevitable ischemic
injury that may impair liver regeneration after
major hepatectomy.100 Intermittent clamping of
the portal triad and ischemic preconditioning
(a brief period of ischemia followed by a short
interval of reperfusion) are established nonpharmacologic strategies to protect the liver from prolonged ischemic injury.101-103 The underlying protective principle of ischemic preconditioning is
that cells are exposed to a limited stress that triggers natural defense mechanisms against subsequent ischemic injury.104-106 Intermittent clamping and ischemic preconditioning are highly and
equally effective in minimizing postoperative
injury to the liver, but intermittent clamping appears to be superior for long periods of ischemia
(75 minutes).103,107,108 (For detailed insights into
hepatoprotective strategies, see Selzner et al.109)
1555
The
n e w e ng l a n d j o u r na l
C onclusions
There has been substantial progress in both liver
surgery and liver transplantation owing to improved preoperative diagnosis and intraoperative
and postoperative care. Factors that limit the
achievement of curative tumor resection are the
high morbidity and mortality rates associated
with insufficient volume of the liver remnant.
Many tumors that were previously considered to
be unresectable are now amenable to complete resection through innovative strategies that make
manipulation of the liver volume possible. Portalvein embolization or ligation causes atrophy of
the ipsilateral hemiliver and hypertrophy of the
contralateral side. Portal-vein embolization appears to be particularly valuable in patients who
have underlying liver disease. The concomitant
administration of chemotherapy may further decrease both the tumor load and postoperative recurrences.
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Amann-Vesti B, Graf R, Clavien PA. Mouse
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Medical Progress
106. Peralta C, Prats N, Xaus C, Gelpi E,
1559
www.elsevier.com/locate/emcar
MOTS CLS
Hpatectomie ;
Anesthsie ;
Cirrhose ;
Clampage vasculaire ;
Transfusion ;
Embolie gazeuse ;
Transplantation
hpatique
KEYWORDS
Hepatectomy;
Anaesthesia;
Cirrhosis;
Vascular clamping;
Transfusion;
Gas embolism;
Liver transplantation
Rsum La chirurgie hpatique est une chirurgie majeure dont les indications sont
principalement carcinologiques. Cest une chirurgie qui expose un risque dhmorragie
et dembolies gazeuses peropratoires, et a une morbidit postopratoire importante.
Lamlioration des techniques chirurgicales, mais aussi des avances importantes dans la
comprhension de la physiopathologie du cirrhotique, a permis de rduire le risque de ces
interventions et de proposer cette chirurgie aux patients cirrhotiques (notamment aprs
une hpatite C), qui dveloppent des carcinomes hpatocellulaires. La transplantation
hpatique est une des greffes dorgane les plus frquemment ralises en France et reste
une intervention haut risque qui pose de nombreux problmes per- et postopratoires.
Le manque de greffons hpatiques et la mortalit leve des patients inscrits sur les listes
dattente conduisent proposer de nouvelles techniques de prlvement sur donneur en
tat de mort encphalique (partition hpatique ou split) et des prlvements sur donneur
vivant.
2004 Publi par Elsevier SAS.
Abstract Liver surgery is a major surgical procedure, mainly indicated for cancer resection. Intraoperative risk includes hemorrhage and air embolism, and severe postoperative
complications are frequent. Improvement in surgical technique and recent advance in the
understanding of cirrhosis-related alteration in cardiovascular, pulmonary and renal
function have permitted to perform hepatic surgery in cirrhotic patients, especially when
cirrhosis is secondary to hepatitis C. Orthotopic liver transplantation is one of the most
frequently performed transplantation in France, and it remains a high risk surgery. The
inadequate supply of donor livers has lead to development of new surgical technique,
including liver splitting of cadaveric graft and living related donors.
2004 Publi par Elsevier SAS.
Introduction
De nombreuses avances techniques chirurgicales,
danesthsie et de ranimation et une meilleure
* Auteur correspondant.
Adresse e-mail : e1samain@chu-besancon.fr (E. Samain).
2004 Publi par Elsevier SAS.
doi: 10.1016/j.emcar.2004.02.002
Figure 2 Clampages vasculaires au cours de la chirurgie hpatique. a : clampage pdiculaire ; b : exclusion vasculaire du foie,
associant un clampage pdiculaire et le clampage sus- et soushpatique de la veine cave infrieure (VCI) ; AH : artre hpatique ; TP : tronc porte.
Comparaison des effets secondaires des deux principales techniques de clampage vasculaire au cours de lhpatec-
Inconvnients
Moins efficace pour le contrle des embolies gazeuses
Absence de gain en termes de cytolyse postopratoire
ou de syndrome de reperfusion
Retentissement hmodynamique systmique moins Pas de contrle du saignement sus-hpatique
marqu
Exclusion vasculaire Seule technique possible pour les tumeurs adhren- Dcompensation dune insuffisance coronarienne ou
du foie
tes la VCI ou aux veines sus-hpatiques
cardiaque
Meilleur contrle dun saignement sur plaie de la VCI Mauvaise tolrance en cas dhypovolmie
Tolrance imprvisible chez 20 % des sujets sains
Meilleur contrle des embolies gazeuses
Altration des fonctions rnale, respiratoire
Hospitalisation prolonge
Monitorage lourd ncessaire (Swan-Ganz ou ETO)
Clampage pdiculaire intermittent
Avantages
Meilleure tolrance
Rduction des complications postopratoires
Tableau 2 Variations hmodynamiques rapportes dans la littrature, au cours des manuvres de clampage pdiculaire ou
dexclusion vasculaire du foie.
Clampage pdiculaire
Delva40 (n = 48)
FC
PAM
DC
PAPO
IRVS
IRVP
3%#
21 % #
17 % &
10 % &
48 % #
15 % #
Belghiti15 (n = 20)
12 % #
10 % &
7%&
42 % #
Belghiti15 (n = 24)
Stable
38 % &
25 % &
86 % ##
Delva39
(n = 25)
15 % #
Stable
52 % &
74 % &
135 % ##
PAP 24 % &
FC : frquence cardiaque ; PAM : pression artrielle moyenne ; DC : dbit cardiaque ; PAPO : pression artrielle pulmonaire
docclusion ; IRVS : index de rsistances vasculaires systmiques ; IRVP : index de rsistances vasculaires pulmonaires.
Mauvaise tolrance
PAM < PAMprXc x 0,6
et DC < DCprXc x 0,5
Tolrance correcte
PAM > PAMprXc x 0,6
et DC > DCprXc x 0,5
Poursuivre chirurgie
Dclampage possible
(test de tolrance)
Dclampage impossible
(hmorragie, embolie)
Test de remplissage
(collode 500 ml)
Expansion volmique
(collode 500 ml)
Phnylprine 250 g IVD
Adrnaline 0,1-0,2 mg IVD
puis relais IV continue
Tolrance correcte
PAM > PAMprXc x 0,6
et DC > DCprXc x 0,5
Poursuivre chirurgie
Mauvaise tolrance
PAM < PAMprXc x 0,6
et DC < DCprXc x 0,5
Adrnaline IV
CEC
Contre-indication clampage
Figure 3 Prise en charge hmodynamique de lexclusion vasculaire du foie mal tolre. PAM : pression artrielle moyenne ; PAMprXc :
PAM avant clampage de la veine cave infrieure ; DC : dbit cardiaque ; DCprXc : DC avant clampage ; CEC : circulation extracorporelle ; I.V. (D) : intraveineuse (directe).
RVS
2 000
1614
p = 0,04
1368
1225
1 500
827
1 000
500
0
Tmoin
Child A
PA
Child C
p = 0,002
p = 0,025
200
150
Child B
147 5
146 9
132 5
103 3
100
73 3
67 1
66 3
PAD
PAS
54 2
50
0
Tmoin
Child A
Child C
Child B
DC
7,57
6,97
5, 4
5,89
4
2
0
Tmoin
Child A
Child B
Child C
Anomalies hmodynamiques
La cirrhose entrane une vasodilatation artriolaire, responsable dune baisse importante des RVS
et une augmentation du DC. La baisse des RVS est
directement lie la gravit de la cirrhose (Fig. 4A,
B, C). La PAM est normale ou modrment abaisse,
mais on observe une inversion du rythme circadien
normal, avec une PAM plus basse le jour que la
nuit.66 Ces anomalies vasculaires sont lies une
altration des systmes de rgulation, notamment
Alvole
Capillaire
Figure 5 Mcanismes de lhypoxmie chez le cirrhotique. La contribution de chacun de ces mcanismes varie dun patient lautre.
1. Sujet normal ; 2. anomalie du rapport ventilation-perfusion (ascite, bronchopathie, altration de la vasoconstriction hypoxique) ;
3. trouble de la diffusion (alvolite lymphocytaire, fibrose) ; 4. hypoventilation ; 5. shunt anatomique ; 6. zone mal ventile,
perfuse.
Anomalies de lhmostase
Laltration de lhmostase chez le cirrhotique est
un facteur de gravit de la maladie, (la baisse du
taux de prothrombine [TP] tant un des paramtres
du score de Child et Pugh) (Tableau 4) et favorise le
saignement. La baisse des facteurs de coagulation
ne rsume pas les anomalies de lhmostase, et
certains troubles de mcanismes complexes en partie lis la dysfonction endothliale sont gnrateurs de phnomnes thromboemboliques.50,77 De
faon schmatique, on peut distinguer :
la baisse de la synthse hpatique des facteurs
II, V, VII (baisse prcoce dans lvolution de la
maladie) et X, responsable dun allongement
des tests de coagulation globaux (TP et international normalized ratio [INR] notamment) ;
les anomalies de lhmostase primaire, frquentes et secondaires la thrombopnie de
Tableau 4
Ascite
Albuminmie (g/l)
Encphalopathie
Bilirubinmie (lmol/l)
Temps de Quick (%)
Points
Absente
> 35
Absente
< 34
> 56
1
Modre
30-35
Modre
34-51
45-56
2
Importante
< 30
Svre
> 51
< 45
3
Le score total (5-15) des cinq critres est class en trois grades. A : 5-6 points ; B : 7-9 points ; C : 10-15 points. On parle en
classification de Child-Pugh, afin de prciser la gravit de linsuffisance hpatique, en associant la cotation chiffre et la
classification (exemple : C11 ou B 8 ...).
9
4%
2%
1%
8%
10-19
27 %
5,6 %
13 %
26 %
20-29
76 %
50 %
0%
56 %
30-39
83 %
_
_
66 %
40
100%
_
_
100%
Transplantation hpatique
Technique chirurgicale
La TH comporte trois phases :
hpatectomie ;
anhpatie pendant laquelle le transplant est
mis en place ;
revascularisation du greffon (veine porte et
artre hpatique) puis anastomoses biliaires.
La technique classique consiste enlever le foie
natif avec le segment de veine cave qui lui est
attenant et impose un clampage cave sus- et soushpatique et une double anastomose cave
(Fig. 6).111
La technique avec prservation de veine cave
(piggy-back des Anglo-Saxons), plus rcente, laisse
en place la veine cave du receveur et ne ncessite
quun clampage cave latral et une anastomose
cavocave entre la partie antrieure de la veine
cave du receveur et une palette de veine cave
prserve sur le greffon (Fig. 7).16,20
Phase dhpatectomie
Aprs incision cutane, gnralement bi-souscostale, les diffrents lments du pdicule hpatique du foie natif sont isols et contrls et le foie
frquemment associe, et lvaluation propratoire doit prciser les diffrents points dvelopps
plus haut. Dautre part, lextension des indications
Tableau 7 Bilan complmentaire effectuer lors de la
consultation prtransplantation.
Radiographie de thorax de face et de profil (atlectasies,
panchement pleural notamment)
chographie cardiaque
-valuation de la fonction ventriculaire gauche
-valuation indirecte de la PAPs par la quantification de
la fuite tricuspide
Cathtrisme cardiaque droit avec mesure de la POD, PAPO
et du calcul du Qc, en cas danomalie chocardiographique
Gaz du sang debout/couch
-hypoxmie de repos
-baisse de PaO2 > 10 %, en faveur dun syndrome
hpatopulmonaire
Hmostase complte
-temps de Quick, temps de cphaline active
-facteurs I, II, V, VII+X
-D-dimres, produits de dgradation de la fibrine
-temps de lyse des euglobulines
-temps de saignement
NFS, plaquettes
Ionogrammes sanguin et urinaire, clairance de la cratinine
(mesure ou calcule)
Calcmie, phosphormie
Groupe ABO-Rhsus, recherche dagglutinines irrgulires
PAPs : pression artrielle pulmonaire systolique ; POD :
pression dans loreillette droite ; PAPO : pression artrielle
pulmonaire docclusion ; Qc : dbit cardiaque ; PaO2 : pression partielle en oxygne dans le sang artriel ; NFS :
numration-formule sanguine.
Relatives
Cardiopathie svre
HTAP svre, fixe
Insuffisance respiratoire chronique
Insuffisance rnale chronique
Affection neurologique majeure
Absolues
Affection maligne dissmine
Infection hpatobiliaire non contrle
Sida
Incapacit suivre un traitement immunosuppresseur
thylisme chronique ou toxicomanie
HTAP : hypertension artrielle pulmonaire.
Figure 8 Circulation extracorporelle partielle pour hpatectomie avec exclusion vasculaire du foie mal tolre ou transplantation hpatique avec clampage cave total. 1. Veine porte ; 2.
veine cave infrieure ; 3. veine saphne ; 4. veine sous-clavire ;
5. pompe centrifuge.
les critres dextubation en postopratoire immdiat ne sont pas diffrents de ceux dune chirurgie
lourde, et lon extubera les patients normothermes
et stables sur le plan hmodynamique, en labsence
de syndrome de reperfusion majeur et danomalie
de lhmatose.
Autres techniques
Split in situ
Cette technique consiste utiliser le foie dun
donneur afin de le sparer et de raliser deux TH.
Le foie gauche est le plus souvent utilis pour un
enfant, le foie droit pour un adulte.
Foie auxiliaire
La technique du foie auxiliaire est le plus souvent
utilise dans les hpatites fulminantes ou dans les
insuffisances hpatiques aigus lorsque lon pense
quune rgnration est possible au dcours de la
phase aigu. Un hmifoie est transplant en position htrotopique et assure une supplance
jusqu la reprise fonctionnelle attendue du foie
natif.
Technique du domino
Il sagit dune technique encore peu pratique, en
cours dexprimentation, destine rentabiliser
les greffons : un greffon provenant dun donneur en
tat de mort encphalique est transplant un
patient prsentant une maladie mtabolique dorigine hpatique comme lamylose, occasionnant une
surcharge tissulaire responsable de troubles neurologiques et de la conduction cardiaque. La TH permet dinterrompre lvolution de la maladie chez
ce receveur. Le foie de ce patient, bien que responsable de cette anomalie mtabolique, ne prsente
pas danomalie fonctionnelle. Il peut donc tre
greff un autre patient prsentant une maladie
hpatique terminale, la rpercussion de la maladie
amylode ntant pas symptomatique avant plusieurs dcennies. Une information objective de ce
receveur sur la qualit du greffon est bien entendu
indispensable.
Conclusion
Les progrs raliss dans la prise en charge priopratoire multidisciplinaire de la chirurgie hpatique ont permis dtendre les indications des rsections hpatiques, particulirement en chirurgie
carcinologique. Dautre part, la meilleure comprhension du retentissement de la cirrhose sur les
fonctions cardiovasculaires et respiratoires fait que
cette chirurgie peut tre propose dans des centres
spcialiss chez les patients ayant une cirrhose de
gravit moyenne. La TH a vu se dvelopper de
nouvelles techniques, parmi lesquelles la TH avec
donneur vivant qui connat une expansion considrable ces dernires annes.
Points essentiels
Les principales rsections hpatiques sont (par ordre dimportance dcroissante), la lobectomie
droite, lhpatectomie droite, lhpatectomie gauche et la lobectomie gauche.
Lexistence dune cirrhose hpatique doit tre recherche, et ses consquences sur la coagulation,
le systme nerveux autonome, la fonction rnale (syndrome hpatornal), la circulation pulmonaire
(hypertension portopulmonaire ou syndrome hpatopulmonaire) doivent tre values.
Au terme de cette valuation, le risque de la chirurgie peut tre estim, notamment grce
lutilisation de scores de risque chez le cirrhotique.
La rduction du risque hmorragique et dembolie gazeuse pendant la section hpatique fait appel
au clampage du pdicule hpatique, ou plus rarement lEVF. Ces manuvres ont un retentissement
hmodynamique propre et exposent aux consquences hpatique et gnrale de la reperfusion
hpatique.
Le saignement peut galement tre rduit dans certaines circonstances par des moyens pharmacologiques, notamment laprotinine. Cependant, une transfusion de concentrs rythrocytaires ou de
facteurs de coagulation ou de plaquettes est frquemment ncessaire et doit tre anticipe.
Les indications de la TH sont les pathologies hpatiques en phase terminale (cirrhose le plus
souvent), les hpatites fulminantes ou les carcinomes hpatocellulaires.
Elle comporte une phase dhpatectomie, une phase danhpatie pendant laquelle le transplant est
mis en place puis une phase de revascularisation du greffon et danastomoses biliaires.
La technique classique impose un clampage cave sus- et sous-hpatique qui impose le plus souvent
une assistance circulatoire veinoveineuse. La technique avec prservation de veine cave (piggy-back),
ne ncessite quun clampage cave latral de la veine cave infrieure.
Le saignement et les troubles de lhmostase (prexistants ou secondaires la chirurgie) sont les
principaux problmes des deux premires phases. Le retentissement hmodynamique de la phase de
reperfusion du greffon est parfois trs important et prolong dans le temps.
Le manque de greffon de donneur en tat de mort encphalique conduit au dveloppement de
nouvelles techniques telles que le prlvement sur donneur vivant, la division du greffon ou le domino.
Ces techniques posent des problmes spcifiques actuellement en cours dvaluation.
Autovaluation
Questions
I
A - Selon la classification de Couinaud, le lobe droit du foie est form des segments I III
B - Lartre hpatique assure 70 % du dbit sanguin hpatique
C - Selon la nomenclature internationale, on dfinit comme hpatectomie majeure toute rsection
dau moins trois segments hpatiques
D - La lobectomie droite associe une hpatectomie droite la rsection du segment IV
E - En termes de quantit de parenchyme hpatique rsqu, la lobectomie gauche est plus
importante que la lobectomie droite
II
A - Le temps cumul dischmie tolrable pour un foie sain lors de la manuvre de Pringle est de
lordre de 45 minutes
B - Lorsquune EVF est prvue, il est habituel de raliser une preuve de clampage avant le dbut
de la dissection hpatique
C - On dfinit le syndrome de reperfusion par une chute de la PAM de plus de 30 % de sa valeur avant
clampage et persistant plus de 1 minute
D - On peut rsquer jusqu 75 % dun foie sain sans induire dinsuffisance hpatique aigu
E - Chez un cirrhotique mme svre, une embolisation de la rgion rsquer par radiologie
interventionnelle entrane en 1 mois une hypertrophie ractionnelle suffisante pour pratiquer
la rsection hpatique dans de bonnes conditions
P. Dilly et al.
III
A - Une induction anesthsique squence rapide est recommande pour les patients prsentant une
ascite
B - Aprs rsection hpatique tendue, le pic de cytolyse postopratoire est observ j7
C - La prsence dun foramen ovale permable expose au passage systmique dun embole gazeux lors
dune plaie de la veine cave
D - La dcouverte dun dficit neurologique aprs embolie gazeuse, mme plusieurs heures aprs
lintervention, doit faire poser lindication dune oxygnothrapie hyperbare
E - Lembolie gazeuse est le risque principal de la chirurgie hpatique
IV
A - Au cours des rsections hpatiques, le temps le plus hmorragique est la dissection de la tranche
hpatique
B - La rcupration peropratoire du sang en chirurgie carcinologique hpatique est classiquement
contre-indique
C - Lutilisation daprotinine doit tre systmatique lors des hpatectomies
D - La morphine est contre-indique aprs hpatectomie en raison dun coefficient dextraction
hpatique lev
E - Lemploi du paractamol est contre-indiqu chez le cirrhotique, mme doses rduites, car il peut
entraner des pousses dinsuffisance hpatique aigu
V
A - La cirrhose est frquemment associe une diminution du dbit cardiaque
B - La baisse des RVS est directement lie la gravit de la cirrhose
C - La prvalence de la neuropathie dysautonomique est de 10 % chez le cirrhotique
D - La frquence dun SHR est de 20 % chez le cirrhotique ascitique
E - La survenue dun SHR de type II est un facteur de mauvais pronostic
VI
A - Dans le SHP, il existe une hypoxmie de repos
B - Le SHP est prsent chez 50 % des cirrhotiques graves
C - Le traitement par btabloquant, propos dans lHTP, peut amliorer le SHP
D - Le SHP est rattach un trouble du mtabolisme du NO
E - Un SHP doit tre recherch systmatiquement chez tout cirrhotique grave par la mesure des gaz du
sang, en position couche et debout
VII
A - LHPP est le plus souvent asymptomatique
B - Lapparition dune insuffisance cardiaque droite au cours dune HPP est trs pjorative
C - La survenue de syncopes est vocatrice dune forme grave dHPP
D - Le traitement de lHPP repose sur ladministration continue de vasoconstricteurs
E - La transplantation hpatique permet de traiter dfinitivement lHPP svre
VIII
A - Chez le cirrhotique il existe une baisse de la synthse hpatique des facteurs II, III, V, IX
B - La surexpression du facteur von Willebrand est frquente chez le cirrhotique
C - Les principales indications du TIPSS sont les hmorragies digestives par rupture de VO, lascite
rfractaire, le SHR et le syndrome de Budd-Chiari
D - La mise en place dun TIPSS entrane une augmentation du retour veineux et expose un risque
ddme pulmonaire
E - La valve de Leveen consiste en une drivation pritonoportale
IX Au cours de la TH
A - Les troubles mtaboliques (acidose, hyperkalimie) doivent tre corrigs avant la reperfusion du
greffon
B - La dure dischmie du greffon est corrle limportance des manifestations hmodynamiques
lors de la reperfusion
C - Dans les premires heures qui suivent la reperfusion du greffon, il faut imprativement normaliser
la glycmie par un apport dinsuline adapt
D - La correction propratoire des troubles de lhmostase a fait la preuve de son efficacit en
termes de rduction du saignement peropratoire
E - Lalbumine a montr sa supriorit par rapport aux macromolcules comme produit de remplissage
Rponses
I
A - Faux : le lobe droit est form des segments IV VIII
B - Faux : lartre hpatique nassure que 30 % du dbit sanguin hpatique, le reste provenant de
la veine porte
C - Vrai
D - Vrai
E - Faux
II
A - Faux : le temps cumul acceptable est de lordre de 120 minutes (huit pisodes de clampage de
15 minutes chacun)
B - Vrai : si aprs 3 5 minutes, la baisse de la PAM ou du DC est suprieure 50 %, lEVF est
interrompue et une optimisation hmodynamique simpose (en premier lieu, la recherche
dune hypovolmie)
C - Vrai
D - Vrai
E Faux
III
A - Vrai
B - Faux : le pic survient la 48e heure
C - Vrai
D - Vrai
E - Faux : le risque principal est lhmorragie
IV
A - Vrai
B - Vrai
C - Faux
D - Faux
E - Vrai
V
A - Faux : cest linverse
B - Vrai
C - Faux : sa prvalence est de 70 % chez le cirrhotique, ce qui justifie sa recherche
systmatique en propratoire
D - Vrai
E - Vrai : la survie des patients prsentant un SHR de type II est infrieure, classe de Child
gale, celle des cirrhotiques sans atteinte rnale
VI
A - Vrai : le SHP associe une hpatopathie avec hypertension portale, une hypoxmie de repos
avec orthodoxie et une vasodilatation intrapulmonaire
B - Faux : il nest prsent que chez 10 15 % des cirrhotiques graves
C - Faux : cest linverse, il laggrave
D - Vrai
E - Vrai
VII
A - Vrai
B - Vrai
C - Vrai
D - Faux : il repose au contraire sur ladministration de vasodilatateurs
E - Faux
VIII
A - Faux : il sagit des facteurs II, V, VII et X
B - Vrai
C - Vrai
D - Vrai
E - Faux
IX Au cours de la TH
A - Vrai
B - Faux : en revanche, il existe une corrlation entre la tolrance hmodynamique lors du clampage
et la frquence du syndrome de reperfusion
C - Faux
D - Faux
E - Faux
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