A randomized controlled trial of effect of 15- or 25-minute intermittent Pringle maneuver on hepatectomy for hepatocellular carcinoma

Impact of the Prolonged Intermittent Pringle Maneuver on Post-Hepatectomy Liver Failure: Comparison of Open and Laparoscopic Approaches

BACKGROUND

The influence of prolonged intermittent Pringle maneuver (IPM) on post-hepatectomy liver failure (PHLF) remains unclear. We evaluated the impact of the prolonged IPM on PHLF in patients undergoing open and laparoscopic hepatectomy.

METHODS

We retrospectively included 546 patients who underwent hepatectomy using IPM. The patients were divided into open (n = 294) and laparoscopic (n = 252) groups. Odds ratios for PHLF occurrence were estimated in each group according to cumulative Pringle time (CPT). The cut-off value was set at CPT of 120 min. Risk factors for PHLF were evaluated in the open and laparoscopic groups. Additionally, we analyzed the post-operative outcomes in the open and laparoscopic groups with CPT ≥ 120 min and performed propensity score matching analysis based on PFLF-associated factors.

RESULTS

In the open group, the risk of PHLF increased as CPT increased, particularly after 120 min. However, in the laparoscopic group, PHLF did not occur at less than 60 min, and the risk of PHLF was not significantly different at more than 60 min. Multivariate analysis identified CPT ≥ 120 min as an independent risk factor for PHLF in the open group (p < 0.001), but not in the laparoscopic group. Propensity score matching analysis showed that the PHLF rate was significantly lower in the laparoscopic group with CPT ≥ 120 min (p = 0.027). The post-operative transaminase levels were significantly lower in the laparoscopic group with CPT ≥ 120 min.

CONCLUSIONS

Laparoscopic hepatectomy may cause less PHLF with prolonged IPM compared with open hepatectomy.

Laparoscopic anatomical left hemihepatectomy guided by middle hepatic vein in the treatment of left hepatolithiasis with a history of upper abdominal surgery

BACKGROUND

This study aimed to investigate the safety and efficacy of laparoscopic anatomical left hemihepatectomy guided by the middle hepatic vein (MHV) for the treatment of patients with hepatolithiasis who had a history of upper abdominal surgery.

METHODS

Retrospective data analysis was performed on patients who underwent laparoscopic left hepatectomy for hepatolithiasis and with previous upper abdominal surgery at the Second Affiliated Hospital of Nanchang University from January 2018 to April 2022. According to the different surgical approaches, patients were divided into laparoscopic anatomical left hepatectomy guided by the MHV group (MHV-AH group) and laparoscopic traditional anatomical left hepatectomy not guided by the MHV group (non-MHV-AH group).

RESULTS

This study included 81 patients, with 37 and 44 patients in the MHV-AH and non-MHV-AH groups, respectively. There was no significant difference in the basic information between the two groups. Five cases were converted to laparotomy, and the remaining were successfully completed under laparoscopy. Compared to the non-MHV-AH group, the MHV-AH group had a slightly longer operation time (319.30 min vs 273.93 min, P = 0.032), lower bile leakage rate (5.4% vs 20.5%, P = 0.047), stone residual rate (2.7% vs 20.5%, P = 0.015), stone recurrence rate (5.4% vs 22.7%, P = 0.028), and cholangitis recurrence rate (2.7% vs 22.7%, P = 0.008).There were no significant differences in the results of other observation indices between the groups.

CONCLUSIONS

Laparoscopic anatomical left hepatectomy guided by the MHV is safe and effective in the treatment of left hepatolithiasis with a history of upper abdominal surgery. It does not increase intraoperative bleeding and reduces the risk of postoperative bile leakage, residual stones, stone recurrence, and cholangitis recurrence.

Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: protocol for a randomized controlled trial

BACKGROUND

Our previous randomized controlled trial (RCT) have demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval can be applied safely and efficiently in open or laparoscopic hepatectomy in patients with hepatocellular carcinoma (HCC) patients. But prolonging the hepatic inflow blocking time will inevitably aggravate the ischemia-reperfusion injury (IRI) caused by systemic response. This RCT aims to evaluate the effect of administration of dexamethasone versus placebo before clamping the hilar pedicle on postoperative liver function, inflammatory response, and perioperative outcomes among HCC patients undergoing liver resection with 25-min hepatic inflow occlusion.

METHODS AND ANALYSIS

This will be a randomized, dual-arm, parallel-group, double-blinded trial. All eligible and consecutive patients are coming from a regional medical center who are diagnosed with HCC and underwent radical R0/R1 resection. All participates are randomly allocated in dexamethasone group or placebo group. All surgeons, anesthesiologists, and outcome assessors will be blinded to allocation status. Primary endpoints are transaminase-based postoperative hepatic injury on seven consecutive days after surgery and assessed by their peak values as well as area under the curve (AUC) of the postoperative course of aminotransferases. Secondary endpoints are postoperative total bilirubin (TBil), coagulation function, inflammatory cytokines and their respective peaks, intraoperative blood loss, postoperative hospital stay, morbidity, and mortality. The above parameters will be compared using the corresponding statistical approach. Subgroup analysis will be performed according to the liver cirrhosis and major hepatectomy.

DISCUSSION

Based on our previous study, we will explore further the effect of glucocorticoid administration on attenuating the surgical stress response in order to follow securely 25-min hepatic inflow occlusion. Therefore, the trial protocol is reasonable and the results of the trial may be clinically significant.

TRIAL REGISTRATION

This trial was registered on 3 December 2022, in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), ChiCTR2200066381. The protocol version is V1.0 (20221104).

A safe and simple exposure and Pringle maneuver in laparoscopic anatomical liver resection of segment 7

BACKGROUND

Laparoscopic access to liver segment 7 (S7) is difficult for deep surgical situations and bleeding control. Herein, our proposed laparoscopic technique for S7 lesions using a self-designed tube method is introduced.

METHODS

Clinical data of patients who underwent laparoscopic anatomical liver resection of S7 (LALR-S7) with the help of our self-designed tube to improve the exposure of S7 and bleeding control in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from April 2019 to December 2021 were retrospectively analyzed to evaluate feasibility and safety.

RESULTS

Nineteen patients were retrospectively reviewed. The mean age was 51.3 ± 10.3 years; mean operation time, 194.5 ± 22.7 min; median blood loss, 160.0 ml (150.0-205.0 ml); and median length of hospital stay, 8.0 days (7.0-9.0 days). There was no case conversion to open surgery. Postoperative pathology revealed all cases of hepatocellular carcinoma (HCC). Free surgical margins were achieved in all patients. No major postoperative complications were observed. Patients with postoperative complications recovered after conservative treatment. During outpatient follow-up examination, no other abnormality was presented. All patients survived without tumor recurrence.

CONCLUSIONS

The preliminary clinical effect of our method was safe, reproducible and effective for LALR-S7. Further research is needed due to some limitations of this study.

Risk factors of major bleeding detected by machine learning method in patients undergoing liver resection with controlled low central venous pressure technique

BACKGROUND

Controlled low central venous pressure (CLCVP) technique has been extensively validated in clinical practices to decrease intraoperative bleeding during liver resection process; however, no studies to date have attempted to propose a scoring method to better understand what risk factors might still be responsible for bleeding when CLCVP technique was implemented.

METHODS

We aimed to use machine learning to develop a model for detecting the risk factors of major bleeding in patients who underwent liver resection using CLCVP technique. We reviewed the medical records of 1077 patients who underwent liver surgery between January 2017 and June 2020. We evaluated the XGBoost model and logistic regression model using stratified K-fold cross-validation (K = 5), and the area under the receiver operating characteristic curve, the recall rate, precision rate, and accuracy score were calculated and compared. The SHapley Additive exPlanations was employed to identify the most influencing factors and their contribution to the prediction.

RESULTS

The XGBoost classifier with an accuracy of 0.80 and precision of 0.89 outperformed the logistic regression model with an accuracy of 0.76 and precision of 0.79. According to the SHapley Additive exPlanations summary plot, the top six variables ranked from most to least important included intraoperative hematocrit, surgery duration, intraoperative lactate, preoperative hemoglobin, preoperative aspartate transaminase, and Pringle maneuver duration.

CONCLUSIONS

Anesthesiologists should be aware of the potential impact of increased Pringle maneuver duration and lactate levels on intraoperative major bleeding in patients undergoing liver resection with CLCVP technique.   What is already known on this topic-Low central venous pressure technique has already been extensively validated in clinical practices, with no prediction model for major bleeding. What this study adds-The XGBoost classifier outperformed logistic regression model for the prediction of major bleeding during liver resection with low central venous pressure technique. How this study might affect research, practice, or policy-anesthesiologists should be aware of the potential impact of increased PM duration and lactate levels on intraoperative major bleeding in patients undergoing liver resection with CLCVP technique.

"Hooking method" for hepatic inflow control: a new approach for laparoscopic Pringle maneuver

BACKGROUND

The laparoscopic Pringle maneuver is crucial for controlling bleeding during laparoscopic hepatectomy. In this study, we introduce a new laparoscopic Pringle maneuver and preliminarily investigate its application in laparoscopic hepatectomy.

METHODS

We collected and analyzed the clinical data of 17 consecutive patients who underwent laparoscopic hepatectomy at the Department of Hepatic Surgery, the First Affiliated Hospital of the University of Science and Technology of China, from January 2022 to January 2023. All patients underwent the hooking method for intermittent occlusion of hepatic inflow. Intraoperative and postoperative clinical indices were observed and recorded.

RESULTS

All 17 patients underwent laparoscopic hepatectomy with hepatic inflow control using the hooking method. Four patients with adhesions under the hepatoduodenal ligament successfully had occlusion loops placed using the hooking method combined with Zhang's modified method during surgery. The median occlusion time for the 17 patients was 34 (12-60) min, and the mean operation time was 210 ± 70 min. The mean intraoperative blood loss was 145 ± 86 ml, and no patients required intraoperative blood transfusion. The patients' postoperative peak AST was 336 ± 183 U/L, and the postoperative peak ALT was 289 ± 159 U/L. Postoperative complications occurred in 2 patients (11.8%), including 1 Clavien-Dindo grade I and 1 Clavien-Dindo grade II complication. No Clavien-Dindo grade IIIa or higher complications or deaths occurred in any patient. None of the patients developed portal vein thrombosis or hepatic artery aneurysm formation. The median postoperative hospital stay was 6 (4-14) days.

CONCLUSION

The hooking method combines the advantages of both intracorporeal Pringle maneuver and extracorporeal Pringle maneuver. It is a simple, safe, and effective method for controlling hepatic inflow and represents a promising approach for performing totally intracorporeal laparoscopic Pringle maneuver.

Laparoscopic Hepatectomy for Giant Hepatic Hemangioma Using the Involved Intrahepatic Anatomic Markers Approach

BACKGROUND

Hepatic hemangioma has been one of the absolute indications of laparoscopic hepatectomy (LH).¹ However, the risk of catastrophic intraoperative bleeding and the difficulty to control it make the laparoscopic treatment of giant hepatic hemangioma (GHH) a technical challenge for hepatobiliary surgeons.² Herein, we presented a video of LH for GHH using the involved intrahepatic anatomic markers approach.

METHODS

A 22-year-old female was referred for treatment of an intractable GHH (18 cm), which involved the left hepatic pedicle, left hepatic vein (LHV), and middle hepatic vein (MHV), resulting in the invisibility of the above intrahepatic anatomic markers on CT. The procedure was performed according to the following steps: (1) dissecting and ligating the left hepatic artery (LHA) and left portal vein (LPV) via intrafascial approach, respectively; (2) cutting the accessory LHA; (3) transecting parenchymal along the demarcation line in a caudal-to-cranial direction and exposing the involved caudal middle hepatic vein (MHV); (4) isolating and transecting the involved left hepatic duct; (5) preserving the integrity of involved MHV; (6) isolating and transecting the left hepatic vein (LHV) and splenic vein (SV); (7) mincing and extracting the specimen. This study was approved by the West China Hospital Ethics Committee and was conducted in accordance with the ethical guidelines of the Declaration of Helsinki. All treatments were performed after obtaining written informed consent from the patients.

RESULTS

The operative time was 286 min, and blood loss during operation was 160 ml. This procedure ensured the integrity of MHV and maximized the residual functional hepatic volume. The histopathologic examination confirmed the hepatic cavernous hemangioma. The patient had an uneventful postoperative recovery and was discharged on the fifth day after operation.

CONCLUSION

LH using the involved intrahepatic anatomic markers approach is feasible and effective for intractable GHH. Its advantages lie in decreasing the risk of disastrous hemorrhage or open conversion rate while maximizing the postoperative functional hepatic reserve.³.

Current evidence on posthepatectomy liver failure: comprehensive review

INTRODUCTION

Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF.

METHODS

A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022.

RESULTS

Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited.

DISCUSSION

Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.

Hemihepatic versus total hepatic inflow occlusion for laparoscopic hepatectomy: A randomized controlled trial

BACKGROUND

An appropriate bleeding control technique for laparoscopic liver resection (LLR) is needed to decrease intraoperative blood loss and avoid large hemorrhages. To date, hemihepatic inflow occlusion (HIO) versus total hepatic inflow occlusion (TIO) for LLR is still controversial. Thus, we performed this randomized controlled trial (ChiCTR-IOR-17013866) to compare the perioperative outcomes between HIO and TIO for LLR.

METHODS

From December 2017 to August 2019, patients met the criteria via surgical exploration in the operation room and were randomly assigned to both groups. Perioperative data between both groups were recorded and compared, and subgroup analysis was further performed.

RESULTS

258 patients were allocated to the TIO (n = 129) and HIO (n = 129) groups, respectively. There was no significant difference between the two groups in terms of intraoperative blood loss, operative time, postoperative complications, changes in postoperative liver function or early mortality. However, for patients whose transection plane was located on the liver Cantlie's plane, subgroup analysis results indicated that TIO had a shorter operative time (median, 220 vs. 240 min, P = 0.030) and occlusion time (median, 45 vs. 60 min, P = 0.011) and less intraoperative blood loss (median, 200 vs. 300 ml, P = 0.002) than HIO, whereas the morbidity and mortality of the two groups were comparable.

CONCLUSION

Both the TIO and HIO approaches could be safely performed for LLR in selected patients when performed by experienced surgeons. The TIO technique for LLR had the advantage of being easier to master than the HIO approach. Additionally, when the transection plane was located on the liver Cantlie's plane, TIO seems to have some superior perioperative outcomes.