Continuous versus intermittent portal triad clamping for liver resection: a controlled study

OBJECTIVE: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.     

Prolonged intermittent clamping of the portal triad during hepatectomy

From 112 consecutive hepatectomies for malignant tumours performed with intermittent portal triad clamping, we have retrospectively selected the 20 cases in which clamping exceeded 90 min. Intermittent portal clamping of prolonged duration was used because of abnormal liver texture in 13 cases (mainly patients who had received intra-arterial chemotherapy) and/or because of technically difficult hepatectomy. The mean(s.d.) duration of intermittent portal clamping was 109(18) min and in two cases it exceeded 140 min (148 and 150 min). There was no postoperative mortality and the rate of postoperative morbidity was 35 per cent. Postoperative changes in biochemical liver tests were not major and transient hepatic failure occurred in only one patient following subtotal resection of the liver. We conclude that intermittent portal clamping is a useful manoeuvre in partial hepatectomy when resection is difficult or prolonged, or when the liver parenchyma is abnormal. Such clamping may be used for longer than 120 min without major complications.     

大肝癌手术切除术中不同肝血流阻断方法的临床研究

目的：比较大肝癌手术切除术中3种不同的入肝血流阻断法的临床效果。
　　方法：回顾性分析2011年1月—2013年3月期间218例大肝癌（>5cm）手术患者的临床资料,术中88例采用Pringle法间断阻断全肝血流（肝门阻断组）,51例行选择性的半肝血流阻断（半肝阻断组）,79例行肝下下腔静脉阻断联合Pringle法阻断入肝血流（联合阻断组）。比较3组患者的术中与术后的相关指标。
　　结果：3组患者的术前情况、手术时间、入肝血流阻断时间及肝切除量的差异均无统计学意义（均P>0.05）;半肝阻断组与联合阻断组的术中出血量、输血量、输血率均明显低于肝门阻断组,且联合阻断组的输血量、输血率明显低于半肝阻断组（均P<0.05）;3组患者术后第1天肝功能指标差异无统计学意义（均P>0.05）,但半肝阻断组与联合阻断组第3、7天的转氨酶和总胆红素水平均明显低于肝门阻断组（均P<0.05）;3组术后并发症的发生率差异无统计学意义（P>0.05）。
　　结论：大肝癌切除术术中采用肝下下腔静脉阻断联合Pringle法阻断入肝血流不仅能够有效减少术中失血量,而且有利于术后肝功能的恢复。     

Tolerance of the liver to intermittent pringle maneuver in hepatectomy for liver tumors.

BACKGROUND: Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during the operation remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but the effect on the metabolic function of hepatocytes is potentially harmful. Although our randomized study showed that an intermittent Pringle maneuver is safe and effective during hepatectomy, the upper limit of the duration of the Pringle maneuver is not known. HYPOTHESIS: The liver can tolerate intermittent Pringle maneuver if the duration is not excessive. DESIGN: From July 20, 1995, to November 25, 1997, 112 patients underwent hepatectomy for liver tumors. The data of 50 patients who had hepatectomy without the Pringle maneuver were compared with those of 62 patients who had a liver transection using a Pringle maneuver for 20 minutes and a 5-minute clamp-free interval. The data were collected prospectively. MAIN OUTCOME MEASURES: The surface area of liver transection was measured, and blood loss during liver transection per centimeter square of transection area was calculated. Routine liver biochemical tests, arterial ketone body ratio (AKBR), and plasma cytokine-interleukin (IL) 1alpha, 1beta, 2, and 6, and tumor necrosis factor alpha--levels were measured before and after the operation. The morbidity and hospital mortality rates were also compared among the patients with different ischemic durations and those without an intermittent Pringle maneuver. SETTING: Tertiary referral center. RESULTS: The cutoff point of accumulated ischemic time that induced substantial liver damage, as shown by the postoperative recovery rate of the AKBR, was found to be 120 minutes. Compared with the control group, the patients whose accumulated ischemic time was shorter than 120 minutes had less blood loss related to transection area (10 mL/cm2 vs 22 mL/cm2; P<.001), less blood transfused (0 L vs 0.6 L; P = .004), a shorter transection time related to transection area (2.0 min/cm2 vs 2.8 min/ cm2; P = .002), a significantly higher AKBR in the first 2 hours after liver transection, an equal recovery rate of the AKBR, and a comparable increase of the plasma level of IL-6 postoperatively. For the patients whose accumulated ischemic time was longer than 120 minutes, blood loss from the transection area was less than for the control group (14 mL/cm2 vs 22 mL/cm2; P<.05), but the transection time related to the transection area and the blood transfusion volume did not differ from those of the control group. Furthermore, they had a significantly lower recovery rate of the AKBR and higher plasma levels of IL-6 postoperatively than the control group.     

持续肝动脉阻断预防破裂性肝癌肝切除术中大出血

目的 探讨应用持续肝动脉阻断技术对预防破裂性肝癌肝切除术中大出血的价值.方法 回顾性分析2006年5月至2010年4月第三军医大学西南医院收治的36例应用Pringle法+持续肝动脉阻断技术对破裂性肝癌患者(研究组)行肝切除术的临床资料.在肝癌数据库中配对选取同期36例采用纱布压迫止血的肝癌破裂出血手术患者(对照组).对两组患者术中和术后的相关指标采用方差分析、x2检验、Fisher确切概率法进行对比分析.结果 研究组患者动脉持续阻断中位时间为58 min(36～98 min);术中中位出血量为400ml,明显少于对照组的750ml(F=16.47,P＜0.05);研究组78%(28/36)的患者未进行输血治疗,明显优于对照组的53%(19/36),两组比较,差异有统计学意义(x2=6.01,P＜0.05).两组患者围手术期AST、TBil均在术后第2天达到最高值,然后逐渐下降,1周左右降至正常范围.两组患者的术后并发症发生率和并发症分级比较,差异无统计学意义(x2=1.83,0.89,P＞0.05).结论 应用持续肝动脉阻断技术可明显减少破裂性肝癌肝切除术的术中出血量,且不会对肝功能产生明显的不良影响.     

肝切除术式合理决策要点

切除病变肝组织是肝胆疾病有效的治疗手段，合理肝切除方案需要在彻底切除病灶、确保手术安全和病人最优预后等关键性治疗目标间取得平衡。肝胆恶性肿瘤肝切除术的决策要点在于合理的肝切除范围、肿瘤切缘以及对肝脏储备功能的准确评估。研究结果表明，肿瘤生物学异质性、肝段间血管交通支或流域重合的存在、肿瘤微环境新生血管等多个因素的影响可能会弱化肝细胞癌实施解剖性肝切除的治疗效应，而手术宽切缘是肝细胞癌预后获益的独立显著性因素；淋巴结转移是肿块型肝内胆管癌决策合理切缘的重要考量因素；除肿瘤累及右肝门者，扩大肝切除范围对pT2期及以上的胆囊癌并无生存优势；R1-vas切缘对肝细胞癌和结直肠癌肝转移以及肝门部胆管癌侵及肝动脉的治疗价值，值得更多探索性研究。基于保留更多功能性肝实质的理念，联合肝静脉主干切除的限制性肝切除对生长于第二肝门、肝静脉主干受侵的肝细胞癌，以及围肝门切除对于Bismuth-Corlette Ⅲ~Ⅳ型肝门部胆管癌，具有临床价值。     

Randomized clinical trial of liver resection with and without hepatic pedicle clamping

BACKGROUND: The purpose of this study was to compare the perioperative outcome of liver resection with and without intermittent hepatic pedicle clamping. METHODS: Between June 2002 and June 2004, 126 consecutive patients with resectable liver tumours were randomized to undergo resection with (63 patients) or without (63 patients) intermittent hepatic pedicle clamping. RESULTS: The transection time was significantly higher in the group without hepatic pedicle clamping. The blood loss per cm(2) was similar in the two groups: 2.7 ml/cm(2) in the group with versus 3.2 ml/cm(2) in group without hepatic pedicle clamping (P = 0.425). In the subset of patients with an abnormal liver, there were no differences in blood loss per transection surface: 3.1 ml/cm(2) in the group with versus 2.9 ml/cm(2) in the group without clamping (P = 0.829). The rate of blood transfusions was not higher in the non-clamping group. No differences were observed in the postoperative liver enzyme serum levels, the in-hospital mortality (one patient in each group) or the number of complications. CONCLUSION: This study showed clearly that liver resection without hepatic pedicle clamping is safe, even in patients with a diseased liver.     

Extraparenchymal control of hepatic veins during mesohepatectomy

BACKGROUND: Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding. STUDY DESIGN: We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver. RESULTS: Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins). CONCLUSIONS: Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.     

Outcome using hemihepatic vascular occlusion versus the pringle maneuver in resections limited to one hepatic section or less

Consensus is lacking concerning how to manage afferent vessels during hepatectomy, particularly as to the Pringle maneuver vs. selective hemihepatic clamping. Data for 81 hepatocellular carcinoma patients with chronic hepatitis or liver cirrhosis whose liver resection was limited to one section or less, including intraoperative data and postoperative liver function data, were analyzed retrospectively to compare two strategies. No significant differences of intraoperative data or postoperative clinical course were seen between the two groups, even in patients with chronic hepatitis or liver cirrhosis whose postoperative deterioration of liver function could be expected to be more than patients with a normal liver. The difference was evident only in serum alanine aminotransferase level on postoperative day 10 (mean ± SEM, 64.5±5.1 IU in the Pringle group vs. 51.6±4.4 IU in the selective clamping group; P<0.05). During liver resection limited to one section or less, even with underlying chronic hepatitis or cirrhosis, intermittent use of the Pringle maneuver preserved liver function to the same extent as selective clamping.     

机器人肝切除术：附17例报告

目的：总结机器人手术系统在肝脏切除术应用中的临床经验。方法：对于2009年1月至2010年7月实施的17例机器人外科手术系统所行肝切除术的资料进行回顾性分析。结果：17例机器人肝脏手术病人中男∶女=8：9,平均年龄（55±16）（27～85）岁。包括原发性肝细胞癌3例;胆管细胞癌3例（BismuthⅢb型肝门部胆管癌1例,肝内胆管囊腺癌2例）;转移性肝癌3例;良性肝脏肿瘤4例（肝血管瘤3例,胆管囊腺瘤1例）;左肝内胆管结石4例。手术方式：规则性左半肝切除术2例,左肝外叶切除术5例,肝局部或楔形切除7例,亚肝段（s5a）切除术1例,联合其他机器人术式12例。机器人肝切除的平均手术时间为280 min,术中出血量为150 mL。术中发生大出血3例,其中2例（11.8%）为巨大肝血管瘤中转开腹切除。采用Pringle法肝切除4例,采用肝实质缝扎和超声刀离断肝实质交替法实施左肝外叶切除4例。机器人肝切除病例的平均住院时间为7（5～16）d。术后发生严重并发症2例（11.8%）：腹腔内出血1例,肺部感染1例,经保守治疗治愈,无胆漏等严重并发症和围手术期死亡。结论：机器人肝切除术安全、可行,疗效确切。探索适合机器人手术系统优势的肝切除止血方法等创新性技术将是今后机器人肝切除的重点之一。     

Treatment of centrally located hepatocellular carcinoma with central hepatectomy

BACKGROUND: For treatment of centrally located hepatocellular carcinoma (HCC), central hepatectomy (including central trisegmentectomy [Couinaud's segments 4, 5, and 8] and anterior segmentectomy [Couinaud's segments 5 and 8]) may have an important advantage (ie, preservation of nontumorous parenchyma) over conventional lobectomy or extended lobectomy. For determination of the efficacy of this technique, we compared the outcomes of patients with HCC who underwent treatment with the central and conventional methods. PATIENTS AND METHODS: In our institute, 52 patients with HCC underwent treatment with central hepatectomy (group 1) and 63 patients with comparable tumor size underwent treatment with conventional major hepatectomy (group 2) from November 1993 to April 1999. Overall patient survival and disease-free survival rates were calculated and analyzed. The possible prognostic risk factors for patient and disease-free survival in group 1 were analyzed. RESULTS: Group 1 had comparable overall patient and disease-free survival rates with those of group 2. Vascular invasion, higher pathology grading, and resection margin less than 1 cm appeared to be the prognostic factors for overall patient survival, and vascular invasion was the only risk factor for disease-free survival. CONCLUSION: Central hepatectomy is a safe and effective operative procedure for the treatment of centrally located HCC. The patient and disease-free survival rates were the same as those of conventional major hepatectomy. Although it is technically more demanding, central hepatectomy preserves more nontumor liver parenchyma, which is important for the survival of those patients with liver cirrhosis.     

肝下下腔静脉阻断与控制性低中心静脉压在复杂肝切除术中应用的比较

目的:比较肝下下腔静脉(IIVC)阻断与控制性低中心静脉压(CLCVP)技术在复杂肝切除术中应用的安全性及有效性。方法:回顾性分析2016年3月—2017年12月行复杂肝切除术的103例原发性肝癌患者临床资料,术中所有患者均采用Pringle法控制入肝血流,其中56例行IIVC阻断(IIVC阻断组),47例行CLCVP技术(CLCVP组)降低中心静脉压(CVP)。比较两组切肝过程中CVP的变化、切肝过程出血量、手术总出血量、术中尿量、输血率、术后并发症发生率、术后肝功能与肾功能变化。结果:两组患者一般资料差异无统计学意义(均P0.05)。与切肝前对比,两组患者在切肝过程中CVP均明显下降,但IIVC阻断组CVP较CLCVP降低更明显,且IIVC阻断组切肝过程中出血量、手术总出血量、术后第3天ALT和术后第3、7天TBIL均明显低于CLCVP组(均P0.05)。两组患者术中尿量、输血率及术后并发症发生率、肾功能情况差异无统计学意义(均P0.05)。结论:IIVC阻断联合Pringle法操作简单方便,相对于CLCVP技术,其对全身血流动力学影响较小,肝功能恢复更快,且更容易降低CVP,减少术中肝脏断面出血,有利于提高复杂肝切除术的安全性。     

Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease

HYPOTHESIS: Laparoscopic liver resection for subcapsular hepatocellular carcinoma in patients with chronic liver disease is associated with lower morbidity than open resections. DESIGN: A case-comparison study. SETTING: A tertiary referral center. PATIENTS AND INTERVENTION: From December 1, 1998, to November 30, 2000, 13 patients with chronic liver disease who underwent laparoscopic resection of hepatocellular carcinoma formed the laparoscopic group (LG). Tumors were 5 cm or smaller, subcapsular, and located in anterolateral segments (segments II-VI). A control group was created by matching each laparoscopic case with patients identical for liver disease, tumor size, and location and type of hepatectomy who underwent open liver resection. Fourteen patients fulfilled the criteria and formed the open group (OG). MAIN OUTCOME MEASURES: Postoperative mortality and morbidity. RESULTS: One segment or less was resected in 21 patients and 2 in 6 patients. Operative duration and cumulative portal triad clamping times were longer in the LG (267 +/- 79 minutes vs 182 +/- 57 minutes, P =.006; 68 +/- 24 minutes vs 25 +/- 19 minutes, P =.006, respectively). Mortality rates were 0% in the LG and 14% (2/14) in the OG (P =.2). Postoperative liver failure and ascites occurred in 8% (1/13) in the LG and 36% (5/14) in the OG (P =.15). Surgical margin was not different in the 2 groups. Three-year survival was significantly higher in the LG (89% vs 55%; P =.04), but 3-year recurrence rates were similar (46% vs 44%). CONCLUSION: Our study suggests that, despite longer operative and clamping times without clinical consequences, the rate of decompensation of liver disease could be lower after laparoscopy.     

Hepatectomy using an ultrasonically activated scalpel for hepatocellular carcinoma

BACKGROUND: The first retrospective studies were performed to compare the efficacy of the ultrasonic cavitational aspirator (aspirator group) and the ultrasonically activated scalpel (scalpel group) for hepatic resection in patients with hepatocellular carcinoma. PATIENTS AND METHODS: The aspirator group consisted of 8 patients (6 with liver cirrhosis and 2 with chronic hepatitis in the nontumorous liver), and the scalpel group of 7 patients (6 with liver cirrhosis and 1 with chronic hepatitis). All patients underwent limited hepatic resection, and the intermittent Pringle maneuver was applied during hepatic transection. RESULTS: There were no significant differences in preoperative hepatic function, type of hepatectomy, tumor size and maximum cross-sectional area of the resected specimen between the 2 groups. The amount of intraoperative blood loss was significantly less in the scalpel group than in the aspirator group (684 versus 1,859 ml, p < 0.05). The operation time was significanly shorter in the scalpel group than in the aspirator group (176 versus 262 min, p < 0.05). There were no significant differences in postoperative liver function and morbidity between the 2 groups. CONCLUSIONS: The ultrasonically activated scalpel is effective in reducing blood loss and in shortening the time of operation, and can be employed during limited resection of the liver with cirrhosis or chronic hepatitis.     

Localized hepatic ischemia after liver resection: a prospective evaluation

OBJECTIVE: To prospectively assess the frequency, severity, and extension of localized ischemia in the remaining liver parenchyma after hepatectomy. BACKGROUND: Major blood loss and postoperative ischemia of the remnant liver are known factors contributing to morbidity after liver surgery. The segmental anatomy of the liver and the techniques of selective hilar or suprahilar clamping of the Glissonian sheaths permit identification of ischemia on the surface of the corresponding segments for precise section of the parenchyma. Incomplete resection of a segment, or compromised blood supply to the remaining liver, may result in ischemia of various extension and severity. METHODS: Patients undergoing hepatectomy received enhanced computerized tomodensitometry with study of the arterial and venous phases within 48 hours after resection. We defined hepatic ischemia as reduced or absent contrast enhancement during the venous phase. We classified the severity of ischemia as hypoperfusion, nonperfusion, or necrosis. The extension of ischemia was identified as marginal, partial, or segmental. Factors that may influence postoperative ischemia were analyzed by univariate and multivariate analyses. RESULTS: One hundred fifty consecutive patients (70 F, 80 M, mean age 62 +/- 12 years) underwent 64 major and 81 minor hepatectomies and 5 wedge resections. We observed radiologic signs of ischemia in 38 patients (25.3%): 33 hypoperfusions (17 marginal, 12 partial, and 4 segmental), 3 nonperfusions (1 marginal, 1 partial, and 1 segmental), and 2 necroses (1 partial, 1 segmental). One patient with a segmental necrosis underwent an early reoperation. In all other cases, the evolution was spontaneously favorable. Postoperative peak levels of serum aspartate aminotransferase and alanine aminotransferase were significantly higher in patients with ischemia. Patients with ischemia had a significantly higher risk of developing a biliary leak (18.4% vs. 2.6%, P < 0.001). There was no correlation between liver ischemia and mortality (2%). None of the following factors were associated with ischemia after univariate and multivariate analysis: age, preoperative bilirubin level, liver fibrosis, malignant tumor, type of hepatectomy, surface of transection, weight of resected liver, Pringle maneuver, blood loss, and number of transfusions. CONCLUSIONS: Some form of localized ischemia after hepatectomy was detected in 1 of 4 of our patients. Its clinical expression was discreet in the large majority of cases, even if it might have been one of the underlying causes of postoperative biliary fistulas. Clinical observation is sufficient to detect the rare patient with suspected postoperative liver ischemia that will require active treatment.     

Evaluation of a protease inhibitor in the prevention of ischemia and reperfusion injury in hepatectomy under intermittent Pringle maneuver

BACKGROUND: The severity of ischemia and reperfusion (I/R) injury is an important determinant of patient outcome in hepatic surgery. The aim of this study was to investigate the efficacy of a protease inhibitor in alleviating I/R injury to human liver in the setting of hepatectomy under intermittent Pringle maneuver. METHODS: Sixty patients who underwent liver resection under conditions of intermittent inflow occlusion were randomly assigned to 2 groups (n = 30 each) according to the use of a synthetic protease inhibitor (gabexate mesilate or GM). GM was administered intravenously at a dosage of 2.0 mg/kg/h starting 12 hours before surgery until postoperative day 2. Preoperative and intraoperative clinical variables and postoperative outcomes were evaluated. The plasma levels of a cytokine, interleukin (IL)-6, as well as laboratory biochemical liver function parameters were analyzed to evaluate hepatic I/R injury. RESULTS: The 2 groups of patients were comparable with regard to hepatic inflow occlusion time, extent of liver resection, and background liver histology. The preoperative administration of GM (GM group) substantially alleviated hepatic I/R injury compared with the untreated control group; postoperative serum transaminase levels were significantly decreased in association with marked suppression of IL-6 levels in blood circulation during surgery. This was accompanied by a lower incidence of postoperative complications. The patients without postoperative complications had significantly lower activities of plasma IL-6 at 24 hours after surgery. CONCLUSIONS: This prospective randomized study demonstrated the hepatoprotective effect of a synthetic protease inhibitor in the setting of hepatectomy under the intermittent Pringle maneuver.     

手助腹腔镜左肝大肝癌切除22例

目的探讨手助腹腔镜左肝大肝癌切除的可行性和安全性。方法对病变位于左肝的22例大肝癌病人,肝细胞癌19例,肝内胆管细胞癌2例,肝转移性鳞癌1例。采用手助腹腔镜行规则性左半肝或肝左外叶切除术。结果22例手助腹腔镜肝切除均获得成功,肝左外叶切除18例,左半肝切除4例,术中13例行肝门阻断,平均阻断时间15.5 min,平均手术时间为103.2 min,平均出血量106 ml,瘤体大小平均7.8 cm,切除的肝组织最长径平均10.2 cm,术后无严重并发症发生,术后平均进食时间为2.5 d,术后平均住院日为8 d。结论只要病例选择得当,手助腹腔镜左肝大肝癌切除是安全可行的。     

Ischemic preconditioning for major liver resection under vascular exclusion of the liver preserving the caval flow: a randomized prospective study

BACKGROUND: Two randomized prospective studies suggested that ischemic preconditioning (IP) protects the human liver against ischemia-reperfusion injury after hepatectomy performed under continuous clamping of the portal triad. The primary goal of this study was to determine whether IP protects the human liver against ischemia-reperfusion injury after hepatectomy under continuous vascular exclusion with preservation of the caval flow. STUDY DESIGN: Sixty patients were randomly divided into two groups: with (n=30; preconditioning group) and without (n=30; control group) IP (10 minutes of portal triad clamping and 10 minutes of reperfusion) before major hepatectomy under vascular exclusion of the liver preserving the caval flow. Serum concentrations of aspartate transferase, alanine transferase, glutathione-S-transferase, and bilirubin and prothrombin time were regularly determined until discharge and at 1 month. Morbidity and mortality were determined in both groups. RESULTS: Peak postoperative concentrations of aspartate transferase were similar in the groups with and without IP (851 +/- 1,733 IU/L and 427 +/- 166 IU/L respectively, p=0.2). A similar trend toward a higher peak concentration of alanine transferase and glutathione-S-transferase was indeed observed in the preconditioning group compared with the control group. Morbidity and mortality rates and lengths of ICU and hospitalization stays were similar in both groups. CONCLUSIONS: IP does not improve liver tolerance to ischemia-reperfusion after hepatectomy under vascular exclusion of the liver with preservation of the caval flow. This maneuver does not improve postoperative liver function and does not affect morbidity or mortality rates. The clinical use of IP through 10 minutes of warm ischemia in this technique of hepatectomy is not currently recommended.     

Extracorporeal Pringle maneuver in robot-assisted liver surgery

Hemorrhage is a major complication in laparoscopic liver surgery and inflow occlusion methods are difficult to be reproduced in this setting. This study investigated 10 consecutive patients who underwent robot-assisted liver resection. An extracorporeal Pringle maneuver was carried out encircling the hepato-duodenal ligament using an endowristed robotic arm and exteriorizing the tourniquet at the epigastrium allowing the on-table surgeon to independently control intermittent clamping. The extracorporeal Pringle maneuver was effective and without complications for all patients. The assistant was able to apply consecutive clampings whereas the console surgeon proceeded in parenchyma transection. Robot-assisted liver surgery can be made safer by the use of the extracorporeal Pringle maneuver.     

Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study.

OBJECTIVE: To evaluate whether vascular inflow occlusion by the Pringle maneuver during hepatectomy can be safe and effective in reducing blood loss. SUMMARY BACKGROUND DATA: Hepatectomy can be performed with a low mortality rate, but massive hemorrhage during surgery remains a potentially lethal problem. The Pringle maneuver is traditionally used during hepatectomy to reduce blood loss, but there is a potential harmful effect on the metabolic function of hepatocytes. There has been no prospective randomized study to determine whether the Pringle maneuver can decrease blood loss during hepatectomy, improve outcome, or affect the metabolism of hepatocytes. METHODS: From July 1995 to February 1997, we studied 100 consecutive patients who underwent hepatectomy for liver tumors. The patients were randomly assigned to liver transection under intermittent Pringle maneuver of 20 minutes and a 5-minute clamp-free interval (n = 50), or liver transection without the Pringle maneuver (n = 50). The surface area of liver transection was measured and blood loss during transection per square centimeter of transection area was calculated. Routine liver biochemistry, arterial ketone body ratio (AKBR), and the indocyanine green (ICG) clearance test were done. RESULTS: The two groups were comparable in terms of preoperative liver function and in the proportion of patients having major hepatectomy. The Pringle maneuver resulted in less blood loss per square centimeter of transection area (12 mL/cm2 vs. 22 mL/cm2, p = 0.0001), a shorter transection time per square centimeter of transection area (2 min/cm2 vs. 2.8 min/cm2, p = 0.016), a significantly higher AKBR in the first 2 hours after hepatectomy, lower serum bilirubin levels in the early postoperative period, and, in cirrhotic patients, higher serum transferrin levels on postoperative days 1 and 8. The complication rate, the hospital mortality rate, and the ICG retention at 15 minutes on postoperative day 8 were equal for the two groups.CONCLUSION: Performing the Pringle maneuver during liver transection resulted in less blood loss and better preservation of liver function in the early postoperative period. This is probably because there was less hemodynamic disturbance induced by the bleeding.