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

Inflow control can be safely used in laparoscopic subsegmentectomy of the liver: a single-center 10-year experience

BACKGROUND

Several techniques have been developed to reduce blood loss in liver resection. The half-Pringle and Pringle maneuvers are commonly used for inflow control. This study compared the outcomes of different inflow control techniques in laparoscopic subsegmentectomy.

METHODS

From October 2010 to December 2020, a total of 362 laparoscopic liver resections were performed by a single surgeon (C.C. Yong) in our institute. We retrospectively enrolled 133 patients who underwent laparoscopic subsegmentectomy during the same period. Perioperative and long-term outcomes were analyzed.

RESULTS

The 133 patients were divided into 3 groups: no inflow control (n = 49), half-Pringle maneuver (n = 46), and Pringle maneuver (n = 38). A lower proportion of patients with cirrhosis were included in the half-Pringle maneuver group (P = .02). Fewer patients in the half-Pringle maneuver group had undergone previous abdominal (P = .01) or liver (P = .02) surgery. The no inflow control group had more patients with tumors located in the anterolateral segments (P = .001). The no inflow control group had a shorter operation time (P < .001) and less blood loss (P = .03). The need for blood transfusion, morbidity, and hospital days did not differ among the 3 groups. The overall survival did not significantly differ among the 3 groups (P = .89).

CONCLUSIONS

The half-Pringle and Pringle maneuvers did not affect perioperative or long-term outcomes during laparoscopic subsegmentectomy. The inflow control maneuvers could be safely performed in laparoscopic subsegmentectomy.

The Application of Selective Hepatic Inflow Vascular Occlusion with Anterior Approach in Liver Resection: Effectiveness in Managing Major Complications and Long-Term Survival

BACKGROUND

Hepatectomy is always a challenge to surgeons and requires an appropriate approach for specific tumors to achieve effective complication management. Selective hepatic pedicle clamping is more considerable strategy when comparing with total hepatic pedicle clamping in the balance between reducing blood loss and transfusion with causing the hepatic parenchyma damages (two main complications affecting liver resection result).

OBJECTIVES

In this study, we aim to describe the application of selective hepatic inflow vascular occlusion (SHIVO) and anatomical anterior approach in liver resection and evaluate the results, focusing on intraoperative and postoperative complications.

METHODS

We enrolled 72 patients who underwent liver resection with SHIVO at Viet Duc University Hospital in 4-year period (2011-2014) and then followed up all of them until June 2020 (in 52.6 ± 33 months; range, 2-105 months) or up to the time of death. All the patients were diagnosed with primary or secondary liver cancer, and their future remnant liver volume measured on 64-slice CT scan (dm3) to body weight (kg) > 0.8% (for right hepatectomy). Perioperative parameters were collected and analyzed.

RESULTS

The average operation time was 196.2 ± 62.2 minutes, and blood loss was 261.4 ± 202.9 ml; total blood transfusion proportion during and after surgery was 16.7%. Complications accounted for 44.5% of patients in which pleural effusion was the most common one (41.7%). There were no liver failure and biliary fistula after surgery. No deaths were recorded during 30 days postoperatively. Average hospital stay was 11.4 ± 3.7 days. Blood transfusions during the operation and major liver resection were the factors significantly affecting the percentage of complications after liver surgery in our study. In the last follow-up evaluation, 44 patients were dead and 28 patients were alive, in which 7 with recurrence and 21 without recurrence. The overall survival rate was 38.9%.

CONCLUSION

SHIVO in anatomical liver resection is a safe and feasible approach to help resect precisely targeted tumors and manage several complications in liver resection.

Selective Hemihepatic Vascular Occlusion Versus Pringle Maneuver in Hepatectomy for Primary Liver Cancer

Background

This study was conducted to compare the clinical effects of two techniques used for inflow occlusion during hepatectomy (selective hemihepatic vascular occlusion vs. Pringle maneuver) for the treatment of primary liver cancer.

Material/Methods

A total of 63 patients with primary hepatocellular carcinoma who underwent hepatectomy during June 2006 and June 2011 were included in this retrospective study. A total of 26 patients in group A accepted selective hemihepatic vascular occlusion, and 37 patients in group B underwent the Pringle maneuver during hepatectomy. The intraoperative conditions, postoperative liver function recovery, and complication rates were compared between these two groups.

Results

There were no significant differences in intraoperative blood loss, blood transfusion, occlusion time, and postoperative complication rates between group A and group B (P>0.05). However, postoperative serum levels of alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin (TBIL), and albumin (ALB) in group A were significantly lower than those in group B (P<0.05). Moreover, there were noteworthy differences in peripheral artery pressure and sphygmus (P<0.05).

Conclusions

During hepatectomy, selective hemihepatic vascular occlusion benefits the patients with primary hepatocellular carcinoma by reducing the hepatic damage and improving postoperative hepatic function recovery, compared with the Pringle maneuver.

A New Chemical Compound, NecroX-7, Acts as a Necrosis Modulator by Inhibiting High-Mobility Group Box 1 Protein Release During Massive Ischemia-Reperfusion Injury

BACKGROUND

Necrotic cell death is common in a wide variety of pathologic conditions, including ischemia-reperfusion (IR) injury. The aim of this study was to develop an IR injury-induced hepatic necrosis model in dogs by means of selective left hepatic inflow occlusion and to test the efficacy of a new chemical compound, NecroX-7, against the IR injury-induced hepatic damage.

METHODS

A group of male Beagle dogs received intravenous infusions of either vehicle or different doses of NecroX-7 (1.5, 4.5, or 13 mg/kg) for a 20-minute period before a 90-minute left hepatic inflow occlusion followed by reperfusion.

RESULTS

The gross morphology in the NecroX-7-treated groups after occlusion appeared to be less congested and less swollen than that in vehicle-treated control group. Circulating alanine transaminase and aspartate transaminase levels in the control group were elevated during the course of IR, and were effectively blocked in the 4.5 and 13 mg/kg NecroX-7-treated groups. The serum levels of high-mobility group box 1 protein showed a peak at 8 hours after occlusion in control group, and this elevation was significantly blunted by 4.5 mg/kg NecroX-7 treatment. Histologic analysis showed a marked ischemia or IR injury-induced hepatocytic degenerations, sinusoidal and portal vein congestions, and inflammatory cell infiltrations in the control group, whereas the treatment groups showed significantly diminished histopathology in a dose-dependent manner.

CONCLUSIONS

These results demonstrated that NecroX-7 attenuated the hepatocyte lethality caused by hepatic IR injury in a large animal setting. We conclude that NecroX-7 may provide a wide variety of therapeutic options for IR injury in human patients.

Continuous Pringle maneuver does not affect outcomes of patients with hepatocellular carcinoma after curative resection

AIM

To investigate whether the use of continuous Pringle maneuver (PM) adversely impacts the outcome of patients with hepatocellular carcinoma (HCC).

METHODS

From January 1989 to January 2011, 586 HCC patients who underwent curative resection in Peking Union Medical College Hospital were identified from the database. Continuous PM was performed in 290 patients (PM group), including 163 patients with a hepatic inflow occlusion time of <15 min (PM-1 group) and 127 with 15-30 min (PM-2 group). An additional 296 patients underwent partial hepatectomy without inflow occlusion (occlusion-free, OF group).

RESULTS

The PM group showed less estimated blood loss during hepatectomy than the OF group (P = 0.005) and the two groups experienced similar incidence of perioperative complications. There were no significant differences in either overall survival or disease-free survival (DFS) between the PM and OF groups (P = 0.117 and 0.291, respectively), and between the PM-1 and PM-2 groups (P = 0.344 and 0.103, respectively). Hepatic inflow occlusion and occlusion time were not independent risk factors for OS or DFS.

CONCLUSIONS

Continuous PM effectively reduces intraoperative bleeding and does not adversely impact the outcomes of HCC patients. It remains a valuable tool in hepatic resection, even difficult, complicated resections requiring prolonged clamping times.

Hepatic ischemia reperfusion injury: A systematic review of literature and the role of current drugs and biomarkers

Hepatic ischemia reperfusion injury (IRI) is not only a pathophysiological process involving the liver, but also a complex systemic process affecting multiple tissues and organs. Hepatic IRI can seriously impair liver function, even producing irreversible damage, which causes a cascade of multiple organ dysfunction. Many factors, including anaerobic metabolism, mitochondrial damage, oxidative stress and secretion of ROS, intracellular Ca(2+) overload, cytokines and chemokines produced by KCs and neutrophils, and NO, are involved in the regulation of hepatic IRI processes. Matrix Metalloproteinases (MMPs) can be an important mediator of early leukocyte recruitment and target in acute and chronic liver injury associated to ischemia. MMPs and neutrophil gelatinase-associated lipocalin (NGAL) could be used as markers of I-R injury severity stages. This review explores the relationship between factors and inflammatory pathways that characterize hepatic IRI, MMPs and current pharmacological approaches to this disease.

Functional hepatocellular regeneration in elderly patients undergoing hepatectomy

BACKGROUND & AIMS

More than 50% of liver tumours occur in patients aged 65 years or more. Assessment of functional liver regeneration capacity is crucial to minimize postoperative liver failure. We aimed to study functional hepatocellular regeneration, through scintigraphic quantification of Mebrofenin hepatic extraction fraction (HEF), after partial hepatectomy, comparing elderly patients with younger ones.

METHODS

One hundred and two patients undergoing partial hepatectomy for primary or secondary hepatic lesions were prospectively included and divided in two groups: Group A - 58 patients aged <65 years (33 men, 53.9 ± 8.7 years), Group B - 44 patients aged ≥65 years (32 men, 71 ± 5 years). Groups were comparable in several aspects except for the presence of cirrhosis (more common in Group B, all patients Child-Pugh score A) and the initial diagnosis (Group B - primary lesions, Group A - metastases). The scintigraphic evaluation of Mebrofenin-HEF was performed before surgery, on the 5th and 30th day post-hepatectomy.

RESULTS

Mortality and morbidity were 3.4 and 12.1%, respectively, in Group A and 2.3 and 11.4% in Group B (n.s.). HEF values (%), T1/2 (min) and Tmax (min) showed no significant differences between the two groups: Group A (preoperative: HEF = 99.2 ± 1.5%, T1/2 = 36.7 ± 21.3, Tmax = 15 ± 6. Day 5: HEF = 96.3 ± 10.8%, T1/2 = 76.4 ± 75.9; Tmax = 13.3 ± 4.9. Day 30: HEF = 98.4 ± 5.5%, T1/2 = 38.6 ± 7.7, Tmax = 12.8 ± 3.6) and Group B (preoperative: HEF = 95.3 ± 13%, T1/2 = 38.1 ± 24.1; Tmax = 15.9 ± 9.4. Day 5: HEF = 98.4 ± 2.6%, T1/2 = 106.6 ± 131.7; Tmax = 15.1 ± 6.2. Day 30: HEF = 99 ± 2.1%, T1/2 = 40.5 ± 27; Tmax = 15.5 ± 6.7).

CONCLUSION

Our results suggest that functional hepatocellular regeneration is early, fast and similar between elderly and younger patients. Thus, age alone, does not appear to represent an absolute contraindication to hepatectomy.

Comparing outcomes of two vascular inflow occlusion techniques and treatment without vascular occlusion during major hepatectomy in patients with Hepatitis B-related hepatocellular carcinoma

Background

Significant hemorrhage together with blood transfusion has negative impact on postoperative morbidity, mortality, and long-term survival of liver resection. Various techniques of vascular occlusion have been developed to reduce intraoperative blood loss. The objective of this study was to compare the outcomes of Pringle maneuver, hemi-hepatic vascular occlusion, and treatment without vascular occlusion used during liver resection.

Method

Data of 574 patients with Hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC), who underwent major hepatectomy between January 2009 to March 2013 by Pringle maneuver (N = 158), hemi-hepatic vascular inflow occlusion (N = 216), or without any vascular occlusion (N = 200), were included in this retrospective study. Perioperative blood transfusion, intraoperative blood loss, and postoperative liver function, and surgical complications were analyzed and compared between the three groups.

Result

There were no significant difference observed in postoperative bilirubin, liver enzyme, and albumin levels between three groups (P>0.05). 5 patients (2.5%) in no occlusion group, 2 (1.3%) in Pringle group, and 8 (3.7%) in hemi-hepatic group had liver failure; but, there were no differences (P>0.05). The overall postoperative complications rate between three groups did not reach significant differences (33.5% vs 34.2% vs 42.6%, respectively; P>0.05). However, significant differences in intraoperative blood loss between no occlusion group (638.2±426.8 ml) and Pringle group (518.0±451.0 ml) or hemi-hepatic group (513.0±366.7 ml) (P<0.01).

Conclusion

Although there were no differences found between three groups regarding postoperative complications rate, no vascular occlusion group had more blood loss than the other two groups during liver resection.

A prospective randomized controlled trial to compare pringle manoeuvre with hemi-hepatic vascular inflow occlusion in liver resection for hepatocellular carcinoma with cirrhosis

BACKGROUND

The duration of hepatic vascular inflow occlusion and the amount of intraoperative blood loss have significant negative impacts on postoperative morbidity, mortality and long-term survival outcomes of patients who receive partial hepatectomy for hepatocellular carcinoma (HCC) with cirrhosis.

AIM

This study aimed to compare the perioperative outcomes of partial hepatectomy for HCC superimposed on hepatitis B-related cirrhosis using two different occlusion techniques.

METHODS

A randomized controlled trial was carried out to evaluate the impact of two different vascular inflow occlusion techniques. The postoperative short-term results were compared.

RESULTS

During the study period, 252 patients received partial hepatectomy for HCC with cirrhosis. Of these patients, 120 were randomized equally into two groups: the Pringle manoeuvre group (n = 60) and the hemi-hepatic vascular inflow occlusion group (n = 60). The number of patients who had poor liver function on postoperative day 5 with ISLGS grade B or worse was 24 and 13, respectively (P = 0.030). The postoperative complication rate was significantly higher in the Pringle manoeuvre group (40 versus 22 %, P = 0.030). However, the Pringle manoeuvre group had significantly shorter operating time (116 versus 136 min, P = 0.012) although there was no significant difference in intraoperative blood loss between the two groups [200 ml (range 10-5,000 ml) versus 300 ml (range 100-1,000 ml); P = 0.511]. There was no perioperative mortality.

CONCLUSIONS

The results indicated that for patients with HCC with cirrhosis, hemi-hepatic vascular inflow occlusion was a better inflow occlusion method than Pringle manoeuvre.

Hemihepatic versus total hepatic inflow occlusion during hepatectomy: A systematic review and meta-analysis

AIM: To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion (HHO) compared with total hepatic inflow occlusion (THO).

METHODS: Randomized controlled trials (RCTs) comparing hemihepatic vascular occlusion and total hepatic inflow occlusion were included by a systematic literature search. Two authors independently assessed the trials for inclusion and extracted the data. A meta-analysis was conducted to estimate blood loss, transfusion requirement, and liver injury based on the levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Either the fixed effects model or random effects model was used.

RESULTS: Four RCTs including 338 patients met the predefined inclusion criteria. A total of 167 patients were treated with THO and 171 with HHO. Meta-analysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean difference (WMD) 342.27; 95% confidence intervals (CI) 217.28-467.26; P = 0.00 001; I² = 16%. Meta-analysis showed no significant difference between THO group and HHO group on blood loss, transfusion requirement, mortality, morbidity, operating time, ischemic duration, hospital stay, ALT levels on postoperative day 1, 3 and 7 and AST levels on postoperative day 3 and 7.

CONCLUSION: Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection. However, they have less liver injury after liver resections.

Alternative management of anatomical right hemihepatectomy using ligation of inflow and outflow vessels without hilus dissection

BACKGROUND AND AIM

The conventional method of anatomical right hemihepatectomy (ARHH) requires hilus dissection. We report a method without hilus dissection to minimize intraoperative bleeding.

METHODS

We retrospectively evaluated data of 107 patients who received ARHH involving ligation of corresponding inflow and outflow vessels (LCIOV) without hilus dissection between January 2000 and October 2008. Results were compared to those of patients who underwent non-anatomical right hemihepatectomies (NARHH).

RESULTS

The two groups had similar gender and age (both, P>0.05). The LCIOV group had a higher percentage of patients without intrahepatic metastases (94.6% vs 80.3%, P=0.003). Hepatocellular carcinoma (HCC) lesion size (9.3 vs 10.2, P=0.023), durations of inferior vena cava occlusion (4 vs 4.7, P<0.001) and portal triad occlusion (7 vs 11, P<0.001), blood loss (430 vs 580 mL, P=0.001), transfusion volume (300 vs 520 mL, P<0.001), and measures of postoperative liver function (e.g. maximum aspartate aminotransferase [AST]) of the LCIOV group were also significantly less than the NARHH group. Larger hepatic cavernous hemangiomas (HCH) lesion size (16.2 vs 13.0, P<0.001), longer operative time (168 vs 154 min, P=0.017), and a lower percentage of patients with inferior vena cava occlusion (17.8% vs 35.2%, P=0.001), pleural effusions (19.3% vs 30.9%, P=0.042), and blood transfusions (10.3% vs 75.0%, P<0.001) were found in the LCIOV group.

CONCLUSION

The reported method is a safe and bloodless technique for right hemihepatectomy in select patients.

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy

BACKGROUND

blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes.

METHODS

a randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality.

RESULTS

a total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay.

CONCLUSIONS

all 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.