Perioperative management of hepatic resection

Colorectal cancer (CRC) represents the third most common malignancy in the United States, and almost half the affected patients will develop hepatic metastases during the course of their disease (1-3). Resection of CRC liver metastases remains the best option for potential cure for selected patients (4,5); however, hepatic resection is not without its inherent risks to the patient. Intraoperatively patients may be subjected to major hemorrhage and hypotension, while postoperatively, issues may include ongoing hemorrhage, coagulopathy, renal failure, cardiac, and pulmonary disturbances in addition to the inherent complications of hepatic resection such a biliary fistula and liver failure. After the initial steps of proper patient selection, management decisions made in the perioperative setting can have lasting implications for surgical recovery and patient survival. Many of the maneuvers aimed at preparing the patient with colorectal cancer liver metastases for the operating room are geared towards reducing blood loss during surgery, as acute blood loss anemia requiring blood product transfusion remains a challenge in liver surgery (6,7). Transfusion may be associated with poor surgical outcomes, early cancer recurrence, and reduced survival for this subset of patients (8-18). Prior reports have examined the role of transfusion for cancer patients in the perioperative period, and while the precise mechanism is unclear, the generalized immune dysregulation from transfusion has shown to potentially enhance tumor growth, hasten recurrence, and decrease cancer-specific survival (19,20). In the colorectal cancer patient with liver metastasis undergoing hepatectomy, the risk of blood transfusion has been found to be particularly concerning (8,21). Improvements in surgical technology and technique and perioperative management have resulted in marked reductions in mortality and morbidity over time (6,22). Despite this progress, considerable room remains for further improvement. This chapter will review established and innovative measures to manage CRC liver metastases patients in the perioperative setting. Attention will be given to anesthesia and analgesia, blood conservation and transfusion. Particular attention will be paid to perioperative strategies designed to decrease the need for blood transfusion.