Prospective study of the safety and efficacy of intermittent inflow occlusion (Pringle maneuver) in living donor left hepatectomy

The Effect of Pringle Maneuver Applied during Living Donor Hepatectomy on the Ischemia-Reperfusion Injury Observed in the Donors and Recipients

Background and Objectives: The aim of this study is to evaluate the clinical and laboratory changes of ischemia and reperfusion injury in the remnant livers of donors with and without Pringle maneuver. Furthermore, we evaluated the recipients who have been transplanted with liver grafts from these donors. Methods and Materials: A total of 108 patients (54 living liver donors and 54 liver recipients) who underwent donor hepatectomy and recipients who living donor liver transplantation, were included in this randomized double-blind study between February 2021 and June 2021. The donors were divided into two groups: Pringle maneuver applied (n = 27) and Pringle maneuver not applied (n = 27). Similarly, recipients with implanted liver obtained from these donors were divided into two groups as the Pringle maneuver was performed (n = 27) and not performed (n = 27). Blood samples from donors and recipients were obtained on pre-operative, post-operative 0 h day (day of surgery), post-operative 1st day, post-operative 2nd day, post-operative 3rd day, post-operative 4th day, post-operative 5th day, and liver tissue was taken from the graft during the back table procedures. Liver function tests and complete blood count, coagulation tests, IL-1, IL-2, IL-6, TNF-α, and β-galactosidase measurements, and histopathological findings were examined. Results: There was no statistically significant difference in the parameters of biochemical analyses for ischemia-reperfusion injury at all periods in the donors with and without the Pringle maneuver. Similarly, there was no statistically significant difference between in the recipients in who received liver grafts harvested with and without the Pringle maneuver. There was no statistically significant difference between the two recipient groups in terms of perioperative bleeding and early bile duct complications (p = 0.685). In the histopathological examinations, hepatocyte damage was significantly higher in the Pringle maneuver group (p = 0.001). Conclusions: Although the histological scoring of hepatocyte damage was found to be higher in the Pringle maneuver group, the Pringle maneuver did not augment ischemia-reperfusion injury in donors and recipients that was evaluated by clinical and laboratory analyses.

Short-Term and Long-Term Effects of Ischemic Conditioning on Liver Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Although liver transplantation (LT) is one of the definitive treatments for patients with end-stage liver failure, it inevitably results in ischemic reperfusion injury. It is known that prognosis is improved when temporary ischemic conditioning (IC) is applied to patients with ischemic reperfusion injury. The objective of this meta-analysis was to determine the short-term and long-term effects of IC on the clinical outcomes of LT recipients.

METHODS

Randomized controlled studies on IC in patients with LTs were included. Patients were compared between an IC group and a sham group. Studies were retrieved from PubMed, Embase, and Cochrane Library. The risk of bias was evaluated using RoB 2.0. Mortality, graft function, and major complications were synthesized using RevMan 5.4.1.

RESULTS

Among 316 papers, 17 articles (1196 patients) were included. There was an insignificant increase in short-term mortality (risk ratio [RR]: 3.00, 95% CI: 0.32-28.14, P = .34). However, long-term mortality was lower in the IC group than in the sham group, but not significantly (RR: 0.75; 95% CI: 0.47-1.20, P = .23). Short-term graft function (acute graft rejection and primary graft non-function) was not improved by IC. One-year graft loss tended to show better results in the IC group (RR: 0.53, 95% CI: 0.26-1.07, P = .08).

CONCLUSION

Ischemic conditioning did not have a beneficial effect on LT. Although long-term outcomes appear to be better in the IC group than in the sham group, further randomized controlled trials are needed.

Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA)

OBJECTIVE

The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority.

BACKGROUND

Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines.

METHODS

A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience.

RESULTS

Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee.

CONCLUSIONS

The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Effects of remote ischemic preconditioning on liver injury following hepatectomy: a systematic review and meta-analysis of randomized control trials

The protective effect of remote ischemic preconditioning (RIPC) against liver ischemia-reperfusion injury caused by hepatectomy remains controversial. We conducted this meta-analysis to evaluate the effectiveness and safety of RIPC strategies. PubMed, SinoMed, Embase, Cochrane Library, Medline, and Web of Science databases were searched for randomized controlled trials (RCT) that assessed the effectiveness and safety of RIPC strategies. The primary outcomes were operation time, index of liver function on postoperative day (POD) 1, postoperative complications, and postoperative hospital stay. The pooled odds ratios and weighted mean differences at 95% confidence interval (95% CI) were estimated using a fixed-effects or random-effects model. A total of 459 patients were included in seven RCTs. The alanine aminotransferase (ALT) and alanine aminotransferase (AST) values on POD1 were significantly different between the RIPC group and the N-RIPC group (P = 0.009 and P = 0.02, respectively). However, the heterogeneity was significant (I² = 84% and I² = 86%), and the results of a sensitivity analysis were unstable. There was no significant difference in the total bilirubin levels (P = 0.25) between the two groups on POD1. Subgroup analysis revealed no significant difference in the AST and ALT levels on POD1 between the RIIPC group and the N-RIPC group, regardless of whether the vascular control technique was used (all P > 0.05). Based on current evidence, RIPC does not alleviate liver injury caused by IRI after hepatectomy.

Effect of the intermittent Pringle maneuver on liver damage after hepatectomy: a retrospective cohort study

Background

The Pringle maneuver (PM) interrupts the blood flow through the hepatic artery and portal vein to help control bleeding. This study analyzes the effects of the intermittent Pringle maneuver (IPM) on the surgical process and postoperative liver injury.

Methods

This study retrospectively evaluated 182 hepatocellular carcinoma patients who underwent hepatectomy. In the IPM group, hepatic blood flow was intermittently interrupted via clamping, with cycles of 10 minutes of inflow occlusion followed by 5 minutes of reperfusion that were repeated until the end of the surgery. In the non-IPM group, liver resection was performed without hepatic vascular blockage.

Results

For postoperative complications, the incidence rates of ascites and pleural effusion in the IPM group were significantly lower than those in the non-IPM group. The postoperative hospitalization time in the IPM group was significantly lower than that in the non-IPM group (p=0.0008). On the first day after the operation, the platelet count was significantly lower (p=0.0381) but the prothrombin time (PT) (p=0.0195) and activated partial thromboplastin time (APTT) (p=0.0071) were significantly higher in the non-IPM group than those in the IPM group. At discharge, only albumin was significantly higher in the non-IPM group than that in the IPM group (p=0.0303). Regression analysis showed that a prolonged interruption time was related to increased ALT and AST levels on the first day after surgery, but not on the seventh day or at discharge.

Conclusion

The IPM does not cause additional liver damage during hepatectomy, and use of the IPM results in shorter hospital stays compared to surgery without using the IPM. The results of this study require further confirmation because of the retrospective design.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1680-y) contains supplementary material, which is available to authorized users.

Methods to decrease blood loss during liver resection: a network meta-analysis

BACKGROUND

Liver resection is a major surgery with significant mortality and morbidity. Specialists have tested various methods in attempts to limit blood loss, transfusion requirements, and morbidity during elective liver resection. These methods include different approaches (anterior versus conventional approach), use of autologous blood donation, cardiopulmonary interventions such as hypoventilation, low central venous pressure, different methods of parenchymal transection, different methods of management of the raw surface of the liver, different methods of vascular occlusion, and different pharmacological interventions. A surgeon typically uses only one of the methods from each of these seven categories. The optimal method to decrease blood loss and transfusion requirements in people undergoing liver resection is unknown.

OBJECTIVES

To assess the effects of different interventions for decreasing blood loss and blood transfusion requirements during elective liver resection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Science Citation Index Expanded to September 2015 to identify randomised clinical trials. We also searched trial registers and handsearched the references lists of identified trials.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) comparing different methods of decreasing blood loss and blood transfusion requirements in people undergoing liver resection.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and collected data. We assessed the risk of bias using Cochrane domains. We conducted a Bayesian network meta-analysis using the Markov chain Monte Carlo method in WinBUGS 1.4, following the guidelines of the National Institute for Health and Care Excellence Decision Support Unit guidance documents. We calculated the odds ratios (OR) with 95% credible intervals (CrI) for the binary outcomes, mean differences (MD) with 95% CrI for continuous outcomes, and rate ratios with 95% CrI for count outcomes, using a fixed-effect model or random-effects model according to model-fit. We assessed the evidence with GRADE.

MAIN RESULTS

We identified 67 randomised clinical trials involving a total of 6197 participants. All the trials were at high risk of bias. A total of 5771 participants from 64 trials provided data for one or more outcomes included in this review. There was no evidence of differences in most of the comparisons, and where there was, these differences were in single trials, mostly of small sample size. We summarise only the evidence that was available in more than one trial below. Of the primary outcomes, the only one with evidence of a difference from more than one trial under the pair-wise comparison was in the number of adverse events (complications), which was higher with radiofrequency dissecting sealer than with the clamp-crush method (rate ratio 1.85, 95% CrI 1.07 to 3.26; 250 participants; 3 studies; very low-quality evidence). Among the secondary outcomes, the only differences we found from more than one trial under the pair-wise comparison were the following: blood transfusion (proportion) was higher in the low central venous pressure group than in the acute normovolemic haemodilution plus low central venous pressure group (OR 3.19, 95% CrI 1.56 to 6.95; 208 participants; 2 studies; low-quality evidence); blood transfusion quantity (red blood cells) was lower in the fibrin sealant group than in the control (MD -0.53 units, 95% CrI -1.00 to -0.07; 122 participants; 2; very low-quality evidence); blood transfusion quantity (fresh frozen plasma) was higher in the oxidised cellulose group than in the fibrin sealant group (MD 0.53 units, 95% CrI 0.36 to 0.71; 80 participants; 2 studies; very low-quality evidence); blood loss (MD -0.34 L, 95% CrI -0.46 to -0.22; 237 participants; 4 studies; very low-quality evidence), total hospital stay (MD -2.42 days, 95% CrI -3.91 to -0.94; 197 participants; 3 studies; very low-quality evidence), and operating time (MD -15.32 minutes, 95% CrI -29.03 to -1.69; 192 participants; 4 studies; very low-quality evidence) were lower with low central venous pressure than with control. For the other comparisons, the evidence for difference was either based on single small trials or there was no evidence of differences. None of the trials reported health-related quality of life or time needed to return to work.

AUTHORS' CONCLUSIONS

Paucity of data meant that we could not assess transitivity assumptions and inconsistency for most analyses. When direct and indirect comparisons were available, network meta-analysis provided additional effect estimates for comparisons where there were no direct comparisons. However, the paucity of data decreases the confidence in the results of the network meta-analysis. Low-quality evidence suggests that liver resection using a radiofrequency dissecting sealer may be associated with more adverse events than with the clamp-crush method. Low-quality evidence also suggests that the proportion of people requiring a blood transfusion is higher with low central venous pressure than with acute normovolemic haemodilution plus low central venous pressure; very low-quality evidence suggests that blood transfusion quantity (red blood cells) was lower with fibrin sealant than control; blood transfusion quantity (fresh frozen plasma) was higher with oxidised cellulose than with fibrin sealant; and blood loss, total hospital stay, and operating time were lower with low central venous pressure than with control. There is no evidence to suggest that using special equipment for liver resection is of any benefit in decreasing the mortality, morbidity, or blood transfusion requirements (very low-quality evidence). Radiofrequency dissecting sealer should not be used outside the clinical trial setting since there is low-quality evidence for increased harm without any evidence of benefits. In addition, it should be noted that the sample size was small and the credible intervals were wide, and we cannot rule out considerable benefit or harm with a specific method of liver resection.

The impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels: A systematic review and meta-analysis

BACKGROUND AND AIMS

Intraoperative vascular occlusion techniques during liver surgeries have been performed and refined for decades. However, the impact of these techniques on postoperative peak ALT levels remains uncertain. Thus, we performed a literature review and meta-analysis to determine the impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels.

METHODS

A systematic literature search of the PubMed database was conducted to discover relevant controlled clinical trials. Studies that reported postoperative peak ALT values for both an observation group and a control group were included. The Q statistic and the I(2) index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test and Orwin's fail-safe N test.

RESULTS

Of the 281 retrieved articles, 10 articles fulfilled the inclusion criteria. These 10 articles involved 12 randomized controlled trials with a total of 1443 records. The pooled estimation results indicated that intraoperative vascular occlusion significantly elevated postoperative peak ALT levels (test for SMD: Z = 4.09, P < 0.001; 95% CI: 0.59-1.68), with high heterogeneity (I(2) = 93.8%). Subgroup analysis revealed that intermittent inflow occlusion and Pringle's maneuver vascular occlusions may be the potential crucial factors. No obvious publication bias was detected by Egger's test (P = 0.541) or Orwin's fail-safe N test (Nfs0.05 = 2059.19).

CONCLUSIONS

Intraoperative vascular occlusion, especially intermittent inflow occlusion and Pringle's maneuver vascular occlusions, may be a potential risk factor that could lead higher postoperative peak ALT values than non-occlusion procedures for liver surgeries.