Background: Massive bleeding during hepatectomy is a risk for mortality and morbidity. We examined the risk factors for massive bleeding and their correlations with outcomes. Methods: The study was a retrospective case series. Among 353 consecutively hepatectomized patients, the mean estimated blood loss (EBL) was 825 ml. Ten patients (2.8%) experienced EBL of between 3000 and 5000 ml. Five patients (1.4%) experienced massive EBL defined as more than 5000 ml, and all five patients had undergone right major hepatectomy (RMH) for primary liver cancer (PLC). All the patients with PLC who underwent RMH were divided into two groups: group I with EBL ≤ 5000 ml (n = 19) and group II with EBL > 5000 ml (n = 5). Perioperative factors regarding massive bleeding and operative mortality and morbidity were compared between the two groups. Results: Among the ten patients who experienced EBL of between 3000 and 5000 ml, three had partial hepatectomy of no more than subsegmentectomy of the paracaval portion of the caudate lobe and three had central bisegmentectomy. The mean tumor size was 7.9 ± 4.7 cm in group I and 15.1 ± 2.2 cm in group II (P = 0 .0034). Tumor compression of the inferior vena cava (IVC) on CT scans was observed in all patients in group II, but in no patients in group I (P < 0.0001). Four of five patients in group II received surgery through an anterior approach. The liver-hanging maneuver (LHM) was applied in 14 of 19 patients (74%) in group I but could not be applied in group II (P = 0.0059). No postoperative and in-hospital mortalities occurred in group II and there were no significant differences in the incidence of mortality and morbidity between the groups. Conclusions: RMH for large PLCs, tumor compression of the IVC, and an anterior approach without the LHM are risks for massive bleeding during hepatectomy. Preparation of rapid infusion devices in these cases is necessary to avoid prolonged hypotension.
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