eISSN: 1897-4309
ISSN: 1428-2526
Contemporary Oncology/Współczesna Onkologia
Current issue Archive Manuscripts accepted About the journal Supplements Addendum Special Issues Editorial board Reviewers Abstracting and indexing Subscription Contact Instructions for authors Publication charge Ethical standards and procedures
Editorial System
Submit your Manuscript
SCImago Journal & Country Rank
1/2019
vol. 23
 
Share:
Share:
Original paper

Laparoscopic liver resection for patients with cardiac disease

Yoshihiro Inoue
1
,
Syuji Kagota
1
,
Yusuke Tsuchimoto
2
,
Takeshi Ogura
2
,
Akira Asai
2
,
Shinya Fukunishi
2
,
Kazuhide Higuchi
2
,
Kazuhisa Uchiyama
1

  1. Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Takatsuki, Osaka, Japan
  2. Second Department of Internal Medicine, Osaka Medical College Hospital, Takatsuki, Osaka, Japan
Contemp Oncol (Pozn) 2019; 23 (1): 37-42
Online publish date: 2019/04/05
Article file
- Laparoscopic.pdf  [0.12 MB]
Get citation
 
PlumX metrics:
 

Introduction

Current treatments for metastatic liver cancer, hepatocellular carcinoma, and other liver tumors include liver resection, chemotherapy, radiofrequency ablation and other local ablative therapies, transarterial chemoembolization, and liver transplantation [14]. Among these, liver resection is currently recommended as the most reliable therapy.

Over the past 20 years, the noninvasive nature of laparoscopic surgery as an alternative to conventional open procedures in gastrointestinal and many other surgical fields has led to dramatic developments. Now, partial hepatectomy and a variety of other liver resections can be performed laparoscopically [35]. Many studies have shown that, as an initial surgery for liver tumors, laparoscopic partial liver resection is associated with better short-term outcomes than open partial liver resection, in that it has less intraoperative bleeding, lower rates of surgical site infection, and shorter postoperative hospital stays. It is also preferred owing to its low degree of invasiveness and for aesthetic reasons. This is the result of advances in the instruments used in laparoscopic surgery and improvements in laparoscopic liver resection technique.

Meanwhile, as the geriatric proportion of the population increases, so do conditions requiring operation on elderly patients [6]. A grave problem facing the medical world is responding to the aging of society. As many elderly patients have various comorbidities in circulatory, respiratory, renal, and other important organs and systems [7], less invasive therapies are often selected. While laparoscopic surgery is a less invasive therapy, accurate assessment of surgical risk for patients with comorbid conditions and appropriate perioperative management are extremely important for preventing fatal complications, extended postoperative hospital stays, and increased medical costs. Addressing comorbidities is a particularly urgent priority in the field of gastrointestinal surgery, which includes surgery for diseases of the liver, biliary tract, and pancreas.

With the number of patients with comorbidities, especially cardiac disease, increasing every year, the objective of the present study was to examine the preoperative statuses, perioperative outcomes, and postoperative courses of such patients undergoing laparoscopic liver resection (LLR). We also discuss the problems involved and review the relevant literature.

Material and methods

Patient population and selection

LLR was introduced in our hospital in 1998. Since then, we have gradually standardized the surgical procedure. By 2010, the procedure of LLR was well established due to the cumulative degree of experience acquired over time. Therefore, the subjects of this study were patients who underwent this standardized procedure from 2010 onward.

Between February 17, 2010, and June 13, 2018, we conducted LLR for liver tumors on 339 consecutive patients at Osaka Medical College Hospital in Takatsuki City, Japan. Liver resection was performed whenever a liver tumor could be curatively resected. A tumor size less than 10 cm was the main criterion for LLR. There was no limitation on the number or size of liver tumors with regard to hepatic functional reserve after resection. Patients with portal or hepatic venous involvement and/or metastasis to adjacent organs were not considered candidates for LLR. We evaluated hepatic function using the Child-Pugh classification [8] of liver dysfunction. Patients with complicated cirrhosis (Child-Pugh class C), in whom liver resection would not be appropriate, were excluded from the study. All patients were fully informed of the study design and provided their written, informed consent to participate. This study was approved by the Ethics Committee on Clinical Investigation of Osaka Medical College Hospital (No. 1828 and 1997).

Criteria to convert laparoscopic to open liver resection were as follows: 1) liver stumps of preserved and resected sides that could not both be expanded adequately; 2) uncontrollable intraoperative bleeding; 3) blood loss exceeding 500 ml; 4) total time of Pringle maneuver (hepatic blood flow occlusion) exceeding 120 minutes; 5) uncontrollable intraoperative bile leakage.

Surgical procedure

In this series, all patients received potentially curative liver resection with the complete removal of gross tumor with negative macroscopic margins. All procedures were performed by three experienced hepatobiliary surgeons (YI, FH, KU) during the study period.

All procedures were performed under general anesthesia. The detailed laparoscopic surgical technique routinely used in our department has been described in previous reports [3, 4, 9, 10]. Briefly, patients with tumors involving the right hepatic lobe were placed in a left lateral recumbent position. Patients with tumors involving the left hepatic lobe were positioned supine.

After the introduction of a 12-mm umbilical or other port using an open technique, continuous carbon dioxide (CO2) pneumoperitoneum was induced at a pressure limit of 12 mm Hg at a flow rate of 6 l/min to decrease the risk of gas embolism. Four 5- to 12-mm trocars and a 30-degree laparoscope (1588 AIM; Stryker Japan K.K., Tokyo, Japan) were fixed. For patients with cephalad tumors involving the right hepatic lobe (segment VII and VIII), an intercostal port was inserted (two ports for segment VII; one port for segment VIII).

The mobilization of the liver was then initiated. The lateral hepatic attachment and the triangular ligament were divided using a surgical tissue-management system (Thunderbeat, Olympus Inc., Tokyo, Japan) after the round and falciform ligaments were dissected. This dissection was typically carried up to the diaphragm, allowing more effective mobilization of the liver.

Then, the liver was evaluated in all cases using intraoperative laparoscopic ultrasonography (Prosound α7, Hitachi Aloka Medical Ltd., Tokyo, Japan). In addition to intraoperative ultrasonography, laparoscopic indocyanine green (ICG)-fluorescence imaging was also used to facilitate tumor identification. In ICG-fluorescence imaging, tumors on the liver surface in particular appear fluorescent green, and thus the tumor sites are easily identified.

Next, to perform an extracorporeal Pringle maneuver, blood flow was occluded by clamping a vascular occlusion tube (Vessel-Clude, Argon Medical Devices Inc., USA) from outside the body after adhesion of the hepatic hilar region was confirmed. Intermittent clamping was applied, with 15-minute clamping and 5-minute release periods.

By changing the port of insertion for the laparoscope, the operator formed a triangle with the laparoscope in the center, placing the operator, target area, and the laparoscopic monitor in a straight line, maintaining the co-axial position. Central venous pressure (CVP) was maintained at 0–3 mm Hg during parenchymal transection. Parenchymal transection was achieved using the Cavitron Ultrasonic Surgical Aspirator (Integra CUSA Excel Plus, Integra Neurosciences Ltd, Andover, UK) and Thunderbeat under an extracorporeal Pringle maneuver (Fig. 1A). Small vessels were ligated or coagulated using a soft-coagulation system. Intraparenchymal control of the major vessels was achieved with clips, whereas vascular and biliary radical occlusion were achieved using either clips or staples. Then, the laparoscopic Pringle maneuver was performed. The resected specimen was placed undivided in a plastic retrieval bag and removed through the slightly enlarged periumbilical incision.

Fig. 1

The cut surface of the liver during hepatic parenchymal resection: A) without severe cardiac disease, B) with severe cardiac disease. In patients without severe cardiac disease, intraoperative blood loss can be decreased, surgery can be performed safely, and the isolated side of the liver can be kept dry. In patients with severe cardiac disease, CVP values may increase, as in this case with free bleeding from the incised side of the liver

/f/fulltexts/WO/36233/WO-23-84109-g001_min.jpg

Data examined included preoperative factors, surgical factors, and pathological factors.

Preoperative factors

Preoperative factors investigated were age, sex, body mass index (BMI), viral hepatitis infection status, left ventricular ejection fraction, pathology, total bilirubin, albumin, prothrombin time (PT), platelet count, and Child-Pugh classification.

Surgical and pathological factors

Surgical factors included open conversion rate, CVP, surgical duration, intraoperative blood loss, and blood transfusion requirements. Pathological factors evaluated included the size of the largest tumor, number of tumors, and surgical margin status. “R” classification denoted the absence or presence of residual tumor after surgery [11]. R0 resection refers to excision of the tumor in one piece without violating the tumor plane or achieving negative margins after sequential re-excision of the involved margins. R1 resection involves a microscopically positive margin anywhere, and R2 resection involves (a) macroscopically positive margin(s) with visible tumor.

Postoperative evaluation

The following parameters were evaluated: transfusion rate, pathological margins, postoperative complications, 30-day mortality, and hospital stay. Morbidity was graded according to Clavien’s classification [12, 13]. Surgical site infections (SSIs) were defined according to the CDC’s National Nosocomial Infection Surveillance (NNIS) system [14].

Statistical analysis

Continuous variables were expressed as median ±standard deviation. Univariate analysis results were compared using Student’s t test, χ2 test, Mann-Whitney U test, Wilcoxon signed-rank test, or Fisher’s exact test, as appropriate. Values of p < 0.05 were considered statistically significant. All statistical analyses were performed using JMP version 12 (SAS Institute, Inc., Cary, NC, USA).

Results

Patient demographics

LLR was performed on 339 patients, one of whom had pre-existing severe valvular disease before therapy. In this case, CVP rose to 10 mm Hg, and multiple eruptions of venous blood from the transected liver surface were observed during parenchymal transection, despite performing total hepatic blood flow occlusion (Fig. 1B). Moreover, blood pressure decreased, and we converted to open liver resection for hemodynamic instability. Therefore, this case was excluded from this study. In all other patients, LLR was performed after cardiac functions were stabilized.

Of the remaining 338 patients who had undergone LLR, 16 had concomitant cardiac disease, and 322 patients were without concomitant cardiac disease. The group with coexisting cardiac disease included 13 patients being treated with medication for unstable angina, two patients with valvular disease, and two patients with cardiomyopathy. While the group without cardiac disease did not undergo echocardiography or any other preoperative examinations, their left ventricular ejection fraction was better than the mean of 66% (22–74%) observed among patients with cardiac disease (Table 1). There were no significant differences in demographic (except for age) or operative characteristics between the groups. Surgical outcomes are reported in Table 2.

Table 1

Preoperative clinical and laboratory patient data

ParameterCardiac diseaseNo cardiac diseasep-value
Number, n16322
Age, years77 (62–84)69 (13–93)0.008*
Sex (M/F)13/3194/1280.092
Body mass index, kg/m222.7 (17.8–34.5)22.8 (15.4–35.3)0.668
HCC/CCC vs. others11/5 151/1710.088
Hepatitis viral infection, n (%)6 (37.5)148 (46)0.507
Serum albumin, g/dl4.0 (3.1–4.7)4.0 (2.6–5.2)0.824
Serum total bilirubin, mg/dl0.4 (0.3–1.0)0.6 (0.2–2.1)0.088
Prothrombin time, n (%)97 (64–117)101 (43–150)0.247
Platelet count, ×104/μl17.0 (9.3–26.2)17.7 (2.6–45.5)0.507
ICGR-15, n (%)9.6 (3.8–49.3)13.2 (0.4–72.2)0.852
Child-Pugh classification, A, n (%)16 (100)312 (96.9)0.474
PNI45.4 (38.1–51.2)47.7 (32.3–64.3)0.051
EF, n (%)66 (22–74)
Number of lesions1 (1–4)1 (1–12)0.592
Size of largest tumors, cm2.6 (1.5–4.8)2.4 (0.6–7.5)0.704
Total liver volume, cm31045 (782–1594)1125 (689–2675)0.140

Data presented as median (range)

* p < 0.05, HCC/CCC – hepatocellular carcinoma/cholangiocellular carcinoma, PNI – prognostic nutritional index, ICGR-15 – indocyanine green retention rate at 15 min, EF – ejection fraction

Table 2

Outcomes of hepatic resection surgery

ParameterWith cardiac diseaseWithout cardiac diseasep-value
Number, n16322
Hepatic resection, n (%)0.059
 Parenchymal-sparing10 (62.5)273 (84.8)
 Sectionectomy 5 (31.3)39 (12.1)
 Lobectomy 1 (6.3)10 (3.1)
Convert to open surgery, n (%)3 (18.8)25 (7.8)0.120
CVP, mm Hg 4 (3–4)3 (0–5)0.521
Pringle maneuver, n (%)11 (68.8)170 (53.5)0.231
Operative time, min217 (78–497)188 (30–860)0.214
Blood loss, ml100 (0–1930)50 (0–2250)0.076
Blood transfusion, n (%)2 (12.5)35 (10.9)0.839
Surgical margin, mm5 (0–60)5 (0–37)0.051
Curative resection, R0 (%)15 (93.8)290 (90.1)0.649
Complication, n (%)
 Superficial incisional SSI0 (0)5 (1.6)0.614
 Deep incisional SSI0 (0)3 (0.9)0.698
Organ/Space SSI0 (0)19 (5.9)0.315
 Bile leakage1 (6.3)6 (1.9)0.229
 PHLF0 (0)3 (0.9)0.698
 Ascites0 (0)12 (3.7)0.432
Clavien-Dindo classification > IIIa, n (%)1 (6.3)28 (8.7)0.733
Mortality, n (%)0 (0)3 (0.9)0.698
Postoperative hospital stay, days14 (7–24)10 (2–124)0.713

[i] Data are presented as median (range), CVP – central venous pressure, SSI – surgical site infection, PHLF – post‑hepatectomy liver failure

The Pringle maneuver was performed in 11 of the 16 patients (68.8%) in the cardiac group and in 170 of the 322 patients (53.5%) in the non-cardiac group (p = 0.231). LLR was performed after cardiac functions were controlled in all 16 patients with cardiac disease, and there were no instances of increased CVP or destabilized vital signs during surgery. Intraoperative CVP did not differ between the groups (p = 0.521).

No significant differences were observed in surgical time, amounts of bleeding, intraoperative transfusion volume, or other outcomes. Furthermore, no differences in the rate of Clavien 3A or higher complications, postoperative bile leakage, post-hepatectomy liver failure incidence, or postoperative hospital stay were observed (p = 0.733, 0.229, 0.698 and 0.713, respectively).

Discussion

We have previously reported on the low invasiveness of laparoscopic liver resection compared to open liver resection, primarily with regards to reduced intraoperative bleeding [5, 14]. There have been many similar reports in recent years, and while surgical instrumentation and techniques have improved, intraoperative bleeding still requires the most attention in laparoscopic liver resection. This is because intraoperative bleeding greatly affects surgical outcomes, primarily conversion to open surgery and the incidence of postoperative complications.

During laparoscopic liver resection, the greatest increase in intraoperative bleeding is during parenchymal transection. Bleeding during parenchymal transection can occur from hepatic arteries, hepatic veins, or portal veins. Limited forceps movement and difficulty developing a field of view during laparoscopic liver resection can make it difficult to address these kinds of bleeding. As we have reported previously, at our institution the first choice for addressing intraoperative hepatic arterial and portal vein bleeding during laparoscopic liver resection is occluding blood flow to the liver using the Pringle maneuver [15]. The Pringle maneuver was first reported in 1908 by Pringle et al. as a method of occluding blood flow to the liver during open surgery [16] and is now used throughout the world. Randomized controlled trials (RCTs) have shown that it can reduce bleeding during liver transection without impacting liver functions [17]. Options for addressing venous bleeding during laparoscopic liver resection include increasing pneumoperitoneal pressure, reducing CVP, reducing the ventilatory volume, and reducing positive end expiratory pressure (PEEP) [1820]. If possible, CVP is lowered to 0–3 mm Hg, ventilatory volume to 6.5–7 ml/kg, and PEEP to 0 mm Hg.

However, as the cases examined in the present study indicate, these countermeasures may be insufficient to address intraoperative bleeding in certain environments, such as in patients who present with severe cardiac comorbidities before therapy. In the presence of cardiac comorbidities, increasing pneumoperitoneal pressure or decreasing cardiac output can raise CVP, which can increase venous bleeding on the liver parenchymal transection surface [21]. Furthermore, while laparoscopic liver resection may be a less invasive procedure involving less postoperative pain, intestinal paresis, and tissue disturbance, the increase in pneumoperitoneal pressure and decrease in venous return can reduce cardiac output and raise peripheral vascular resistance, which may actually increase the risk of acute complications [22].

Occasions for operating on patients with some type of cardiac disease are increasing, particularly in developing countries facing unprecedented aging of their societies. In patients with latent or well-defined cardiac disease, the invasiveness of liver resection carries a risk of causing fatal cardiac complications. This must be addressed during laparoscopic liver resection.

The objective of preoperative cardiovascular assessments is not only to obtain information needed to execute the surgery safely, but also to establish a comprehensive treatment plan for patients with coexisting cardiovascular diseases [2325]. In addition to the severity of the cardiac disease, factors such as the patient’s age, the invasiveness of the planned surgery, survival prognosis, quality of life, and the presence or absence of other severe complications should be given comprehensive consideration.

Based on the ACC/AHA and other guidelines [24, 25], if the cardiac complications are not severe and a low-risk procedure is planned, a more extensive cardiovascular assessment is not considered necessary. However, in the presence of risk factors such as severe cardiac disease – which may include unstable angina, recent acute myocardial infarction, acute heart failure, high-grade atrioventricular block, uncontrolled ventricular tachycardia and other forms of severe arrhythmia, or severe valvular disease – a detailed assessment of the cardiovascular system should be performed preoperatively and the surgery should be performed only after the condition has been treated and stabilized [26]. Basically, a cardiovascular specialist should be consulted to perform a detailed examination, and a change in treatment method should also be considered. While performing a planned liver resection is extremely important, in some patients treating cardiovascular diseases should be prioritized. Simply changing the order of treatments may help ensure a good long-term prognosis. Even if these precautions do not have an impact on the surgery itself, they may be helpful in general postoperative management.

Conclusions

Currently, the procedures used in LLR can be modified in several ways to ensure the operation is carried out safely, leading to less invasiveness and better outcomes than open liver resection. However, as society ages there will be more patients with coexisting cardiac disease who require full preoperative assessments. Patients with non-severe or controlled severe cardiac disease did not exhibit different postoperative courses compared to the patients without coexisting cardiac disease. The presence of severe cardiac disease before LLR can lead to unstable vital signs during surgery, such as increased CVP. In such cases, treating the cardiac disease should be prioritized, and ideally it should be controlled before proceeding with LLR. Limitations of this study include the small number of subjects and a variety of possible biases, such as those related to the types of cardiac disease, variations in treatment of pre-existing cardiac disease, or the types and quality of the liver resections. In future, larger sample sizes and further study through RCTs or meta-analyses are needed.

Acknowledgments

This work was supported by the Mitsui Life Social Welfare Foundation.

Notes

[4] Conflicts of interest The authors declare no conflict of interest.

References

1 

Pawlik TM, Schlick RD, Choti MA , authors. Expanding criteria for resectability of colorectal liver metastases. Oncologist. 2008. 13:p. 51–64

2 

Hosokawa I, Allard MA, Mirza DF, et al. , authors. Outcomes of parenchyma-preserving hepatectomy and right hepatectomy for solitary small colorectal liver metastasis: A LiverMetSurvey study. Surgery. 2017. 162:p. 223–232

3 

Inoue Y, Suzuki Y, Fujii K, et al. , authors. Laparoscopic Liver Resection Using the Lateral Approach from Intercostal Ports in Segments VI, VII, and VIII. J Gastrointest Surg. 2017. 21:p. 2135–2143

4 

Inoue Y, Suzuki Y, Ota M, Fujii K, Kawaguchi N, Hirokawa F, Hayashi M, Uchiyama K , authors. Short- and Long-Term Results of Laparoscopic Parenchyma-Sparing Hepatectomy for Small-Sized Hepatocellular Carcinoma: A Comparative Study Using Propensity Score Matching Analysis. Am Surg. 2018. 84:p. 230–237

5 

Inoue Y, Hayashi M, Tanaka R, Komeda K, Hirokawa F, Uchiyama K , authors. Short-term results of laparoscopic versus open liver resection for liver metastasis from colorectal cancer: a comparative study. Am Surg. 2013. 79:p. 495–501

6 

Yancik R , author. Population aging and cancer: a cross-national concern. Cancer J. 2005. 11:p. 437–441

7 

Epstein M , author. Effects of aging on the kidney. Fed Proc. 1979. 38:p. 168–171

8 

Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R , authors. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973. 60:p. 646–649

9 

Inoue Y, Ishii M, Tsuchimoto Y, et al. , authors. Comparison of resection site of standardized laparoscopic hepatic tumor resection. Wideochir Inne Tech Maloinwazyjne. 2018. 13:p. 333–341

10 

Inoue Y, Suzuki Y, Fujii K, et al. , authors. Laparoscopic Hepatic Resection Using Extracorporeal Pringle Maneuver. J Laparoendosc Adv Surg Tech A. 2018. 28:p. 452–458

11 

Sobin LH, Gospodarowicz MK, Wittekind C , editors. International Union against Cancer. TNM classification of malignant tumours. 2009. 7. New York: Wiley-Blackwell;

12 

Dindo D, Demartines N, Clavien PA , authors. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004. 240:p. 205–213

13 

Clavien PA, Barkun J, de Oliveira ML, et al. , authors. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009. 250:p. 187–196

14 

Inoue Y, Suzuki Y, Ota M, Fujii K, Kawaguchi N, Hirokawa F, Hayashi M, Uchiyama K , authors. Short- and long-term results of laparoscopic parenchyma-sparing hepatectomy for small-sized hepatocellular carcinoma: a comparative study using propensity score matching analysis. Am Surg. 2018. 84:p. 230–237

15 

Inoue Y, Suzuki Y, Fujii K, et al. , authors. Laparoscopic Hepatic Resection Using Extracorporeal Pringle Maneuver. J Laparoendosc Adv Surg Tech A. 2018. 28:p. 452–458

16 

Pringle JH , author. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg. 1908. 48:p. 541–549

17 

Li Z, Sun YM, Wu FX, Yang LQ, Lu ZJ, Yu WF , authors. Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy. World J Gastroenterol. 2014. 20:p. 303–309

18 

Uchiyama K, Ueno M, Ozawa S, et al. , authors. Half clamping of the infrahepatic inferior vena cava reduces bleeding during a hepatectomy by decreasing the central venous pressure. Langenbecks Arch Surg. 2009. 394:p. 243–247

19 

Bernard D, Brandely A, Scatton O, Schoeffler P, Futier E, Lescot T, Beaussier M , authors. Positive end-expiratory pressure does not decrease cardiac output during laparoscopic liver surgery. A prospective observational evaluation. HPB (Oxford). 2017. 19:p. 36–41

20 

Jayaraman S, Khakhar A, Yang H, Bainbridge D, Quan D , authors. The association between central venous pressure pneumoperitoneum, and venous carbon dioxide embolism in laparoscopic hepatectomy. Surg Endosc. 2009. 23:p. 2369–2373

21 

Tran TB, Worhunsky DJ, Spain DA, Dua MM, Visser BC, Norton JA, Poultsides GA , authors. The significance of underlying cardiac comorbidity on major adverse cardiac events after major liver resection. HPB (Oxford). 2016. 18:p. 742–747

22 

Nguyen NT, Wolfe BM , authors. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005. 241:p. 219–226

23 

Fleischmann KE, Beckman JA, Buller CE, et al. , authors. 2009 ACCF/AHA focused update on perioperative beta blockade. J Am Coll Cardiol. 2009. 54:p. 2102–2128

24 

Fleisher LA, Fleischmann KE, Auerbach AD, et al. , authors. ACC/AHA Guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014. 130:p. e278–e333

25 

Kristensen SD, Knuuti J, Saraste A, et al. , authors. Authors/TaskForce Members. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014. 35:p. 2383–2431

26 

Fleisher LA, Beckman JA, Brown KA, et al. , authors. Authors/TaskForce Members. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007. 116:p. e418–e499

Copyright: © 2019 Termedia Sp. z o. o. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
 
Quick links
© 2024 Termedia Sp. z o.o.
Developed by Bentus.