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Tang SC, Diao YK, Lin KY, Li C, Xu X, Liang L, Kong J, Chen QJ, Wang XM, Liu FB, Gu WM, Zhou YH, Liang YJ, Liu HZ, Wang MD, Yao LQ, Pawlik TM, Shen F, Lau WY, Yang T, Zeng YY. Association of Pringle maneuver with postoperative recurrence and survival following hepatectomy for hepatocellular carcinoma: a multicenter propensity score and competing-risks regression analysis. Hepatobiliary Surg Nutr 2024; 13:412-424. [PMID: 38911192 PMCID: PMC11190521 DOI: 10.21037/hbsn-23-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/27/2023] [Indexed: 06/25/2024]
Abstract
Background The application of Pringle maneuver (PM) during hepatectomy reduces intraoperative blood loss and the need for perioperative transfusion, but its effect on long-term recurrence and survival for patients with hepatocellular carcinoma (HCC) remains controversial. We sought to determine the association between the application of PM and post-hepatectomy oncologic outcomes for patients with HCC. Methods Patients who underwent curative hepatectomy for HCC at 9 Chinese hospitals from January 2010 to December 2018 were identified. Using two propensity score methods [propensity score matching (PSM) and inverse probability of treatment weight (IPTW)], cumulative recurrence rate and cancer-specific mortality (CSM) were compared between the patients in the PM and non-PM groups. Multivariate competing-risks regression models were performed to adjust for the effect of non-cancer-specific mortality and other prognostic risk factors. Results Of the 2,798 included patients, 2,404 and 394 did and did not adopt PM (the PM and non-PM groups), respectively. The rates of intraoperative blood transfusion, postoperative 30-day mortality and morbidity were comparable between the two groups (all P>0.05). In the PSM cohort by the 1:3 ratio, compared to 382 patients in the non-PM group, 1,146 patients in the PM group also had the higher cumulative 5-year recurrence rate and CSM (63.9% and 39.1% vs. 55.3% and 31.6%, both P<0.05). Similar results were also yielded in the entire cohort and the IPTW cohort. Multivariate competing-risks regression analyses demonstrated that no application of the PM was independently associated with lower recurrence rate and CSM based on various analytical cohorts [hazard ratio (HR), 0.82 and 0.77 in the adjusted entire cohort, HR 0.80 and 0.73 in the PSM cohort, and HR 0.80 and 0.76 in the IPTW cohort, respectively]. Conclusions The findings suggested that no application of PM during hepatectomy for patients with HCC reduced the risk of postoperative recurrence and cancer-specific death by approximately 20-25%.
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Affiliation(s)
- Shi-Chuan Tang
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Yong-Kang Diao
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Kong-Ying Lin
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Chao Li
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiao Xu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Nantong University, Nantong, China
| | - Lei Liang
- Department of Hepatobiliary Surgery, People’s Hospital of Zhejiang Provincial, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Jie Kong
- Department of Hepatobiliary, Heze Municiple Hospital, Heze, China
| | - Qing-Jing Chen
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Xian-Ming Wang
- Department of General Surgery, First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Fu-Bao Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei-Min Gu
- The First Department of General Surgery, Fourth Hospital of Harbin, Harbin, China
| | - Ya-Hao Zhou
- Department of Hepatobiliary Surgery, Pu’er People’s Hospital, Pu’er, China
| | - Ying-Jian Liang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong-Zhi Liu
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
| | - Ming-Da Wang
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Lan-Qing Yao
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Timothy M. Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Feng Shen
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Wan Yee Lau
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Tian Yang
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
- Department of Hepatobiliary Surgery, People’s Hospital of Zhejiang Provincial, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yong-Yi Zeng
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, China
- Department of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- The Liver Disease Research Center of Fujian Province, Fuzhou, China
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Tang SC, Xu JH, Yang YF, Shi JN, Lin KY, Kong J, Wang XM, Fan ZQ, Gu WM, Zhou YH, Liu HZ, Liang YJ, Shen F, Lau WY, Zeng YY, Yang T. Impact of Hepatic Pedicle Clamping on Long-Term Survival Following Hepatectomy for Hepatocellular Carcinoma: Stratified Analysis Based on Intraoperative Blood Transfusion Status. Ann Surg Oncol 2024; 31:1812-1822. [PMID: 38038790 DOI: 10.1245/s10434-023-14642-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Hepatic pedicle clamping (HPC) is frequently utilized during hepatectomy to reduce intraoperative bleeding and diminish the need for intraoperative blood transfusion (IBT). The long-term prognostic implications of HPC following hepatectomy for hepatocellular carcinoma (HCC) remain under debate. This study aims to elucidate the association between HPC and oncologic outcomes after HCC resection, stratified by whether IBT was administered. PATIENTS AND METHODS Prospectively collected data on patients with HCC who underwent curative resection from a multicenter database was studied. Patients were stratified into two cohorts on the basis of whether IBT was administered. The impact of HPC on long-term overall survival (OS) and recurrence-free survival (RFS) between the two cohorts was assessed by univariable and multivariable Cox regression analyses. RESULTS Of 3362 patients, 535 received IBT. In the IBT cohort, using or not using HPC showed no significant difference in OS and RFS outcomes (5-year OS and RFS rates 27.9% vs. 24.6% and 13.8% vs. 12.0%, P = 0.810 and 0.530). However, in the non-IBT cohort of 2827 patients, the HPC subgroup demonstrated significantly decreased OS (5-year 45.9% vs. 56.5%, P < 0.001) and RFS (5-year 24.7% vs. 33.3%, P < 0.001) when compared with the subgroup without HPC. Multivariable Cox regression analysis identified HPC as an independent risk factor of OS and RFS [hazard ratios (HR) 1.16 and 1.12, P = 0.024 and 0.044, respectively] among patients who did not receive IBT. CONCLUSIONS The impact of HPC on the oncological outcomes following hepatectomy for patients with HCC differed significantly whether IBT was administered, and HPC adversely impacted on long-term survival for patients without receiving IBT during hepatectomy.
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Affiliation(s)
- Shi-Chuan Tang
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
- Department of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jia-Hao Xu
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Yi-Fan Yang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Jia-Ning Shi
- Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Kong-Ying Lin
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
- Department of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jie Kong
- Department of Hepatobiliary, Heze Municiple Hospital, Shandong, China
| | - Xian-Ming Wang
- Department of General Surgery, First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong, China
| | - Zhong-Qi Fan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Wei-Min Gu
- The First Department of General Surgery, Fourth Hospital of Harbin, Heilongjiang, China
| | - Ya-Hao Zhou
- Department of Hepatobiliary Surgery, Pu'er People's Hospital, Pu'er, China
| | - Hong-Zhi Liu
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Ying-Jian Liang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Harbin Medical University, Heilongjiang, China
| | - Feng Shen
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Wan Yee Lau
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Yong-Yi Zeng
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian Province, China.
- Department of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
- The Liver Disease Research Center of Fujian Province, Fuzhou, China.
| | - Tian Yang
- Department of Hepatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian Province, China.
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University (Second Military Medical University), Shanghai, China.
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China.
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Hu L, Wang A, Qiao Y, Huang X. Effect of intermittent Pringle maneuver on perioperative outcomes and long-term survival following liver resection in patients with hepatocellular carcinoma: a meta-analysis and systemic review. World J Surg Oncol 2023; 21:359. [PMID: 37986187 PMCID: PMC10662549 DOI: 10.1186/s12957-023-03244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Intermittent Pringle maneuver (IPM) is commonly used to control bleeding during liver resection. IPM can cause ischemia-reperfusion injury, which may affect the prognosis of patients with hepatocellular carcinoma (HCC). The present meta-analysis was conducted to evaluate the effect of IPM use on perioperative outcomes and long-term survival in patients with HCC. METHODS A systemic literature search was performed in the PubMed, Embase, Web of Science, and Cochrane Library databases to identify randomized controlled trials and retrospective studies that compared the effect of IPM with no Pringle maneuver during liver resection in patients with HCC. Hazard ratio (HR), risk ratio, standardized mean difference, and their 95% confidence interval (CI) values were calculated based on the type of variables. RESULTS This meta-analysis included nine studies comprising one RCT and eight retrospective studies and involved a total of 3268 patients. Perioperative outcomes, including operation time, complications, and length of hospital stay, except for blood loss, were comparable between the two groups. After removing the studies that led to heterogeneity, the results showed that IPM was effective in reducing blood loss. Five studies reported overall survival (OS) and disease-free survival (DFS) data and eight studies reported perioperative outcomes. No significant difference in OS and DFS was observed between the two groups (OS: HR, 1.01; 95% CI, 0.85-1.20; p = 0.95; DFS: HR, 1.01; 95% CI, 0.88-1.17; p = 0.86). CONCLUSION IPM is a useful technique to control blood loss during liver resection and does not affect the long-term survival of patients with HCC.
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Affiliation(s)
- Lingbo Hu
- Department of Hepatopancreatobiliary Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang, China
- Department of Hepatopancreatobiliary Surgery, Taizhou Enze Medical Center (Group), Enze Hospital, Zhejiang, China
| | - Aidong Wang
- Department of Hepatopancreatobiliary Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang, China
| | - Yingli Qiao
- Department of Hepatopancreatobiliary Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang, China
- Department of Hepatopancreatobiliary Surgery, Taizhou Enze Medical Center (Group), Enze Hospital, Zhejiang, China
| | - Xiandan Huang
- Department of Hepatopancreatobiliary Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang, China.
- Department of Hepatopancreatobiliary Surgery, Taizhou Enze Medical Center (Group), Enze Hospital, Zhejiang, China.
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Hayashi H, Shimizu A, Kubota K, Notake T, Masuo H, Yoshizawa T, Hosoda K, Sakai H, Yasukawa K, Soejima Y. Impact of sarcopenic obesity on post-hepatectomy bile leakage for hepatocellular carcinoma. PLoS One 2023; 18:e0286353. [PMID: 37796798 PMCID: PMC10553327 DOI: 10.1371/journal.pone.0286353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/15/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Post-hepatectomy bile leakage (PHBL) is a potentially fatal complication that can arise after hepatectomy. Previous studies have identified obesity as a risk factor for PHBL. In this study, we investigated the impact of sarcopenic obesity on PHBL in hepatocellular carcinoma (HCC) patients. METHODS In total, we enrolled 409 patients who underwent hepatectomy without bilioenteric anastomosis for HCC between January 2010 and August 2021. Patients were grouped according to the presence or absence of PHBL. Patient characteristics, including body mass index and sarcopenic obesity, were then analyzed for predictive factors for PHBL. RESULTS Among the 409 HCC patients included in the study, 39 developed PHBL. Male sex, hypertension, cardiac disease, white blood cell counts, the psoas muscle area, and visceral fat area, and intraoperative blood loss were significantly increased in the PHBL (+) group compared with the PHBL (-) group. Multivariate analysis showed that the independent risk factors for the occurrence of PHBL were intraoperative blood loss ≥370 mL and sarcopenic obesity. CONCLUSIONS Our results show that it is important to understand whether a patient is at high risk for PHBL prior to surgery and to focus on reducing intraoperative blood loss during surgery for patients with risk factors for PHBL.
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Affiliation(s)
- Hikaru Hayashi
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Akira Shimizu
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Koji Kubota
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Tsuyoshi Notake
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hitoshi Masuo
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Takahiro Yoshizawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Kiyotaka Hosoda
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Hiroki Sakai
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Koya Yasukawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
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Khajeh E, Shafiei S, Al-Saegh SAH, Ramouz A, Hammad A, Ghamarnejad O, Al-Saeedi M, Rahbari N, Reissfelder C, Mehrabi A, Probst P, Oweira H. Meta-analysis of the effect of the pringle maneuver on long-term oncological outcomes following liver resection. Sci Rep 2021; 11:3279. [PMID: 33558606 PMCID: PMC7870962 DOI: 10.1038/s41598-021-82291-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
Hepatic pedicle clamping reduces intraoperative blood loss and the need for transfusion, but its long-term effect on survival and recurrence remains controversial. The aim of this meta-analysis was to evaluate the effect of the Pringle maneuver (PM) on long-term oncological outcomes in patients with primary or metastatic liver malignancies who underwent liver resection. Literature was searched in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (via PubMed), and Web of Science databases. Survival was measured as the survival rate or as a continuous endpoint. Pooled estimates were represented as odds ratios (ORs) using the Mantel–Haenszel test with a random-effects model. The literature search retrieved 435 studies. One RCT and 18 NRS, including 7480 patients who underwent liver resection with the PM (4309 cases) or without the PM (3171 cases) were included. The PM did not decrease the 1-year overall survival rate (OR 0.86; 95% CI 0.67–1.09; P = 0.22) or the 3- and 5-year overall survival rates. The PM did not decrease the 1-year recurrence-free survival rate (OR 1.06; 95% CI 0.75–1.50; P = 0.75) or the 3- and 5-year recurrence-free survival rates. There is no evidence that the Pringle maneuver has a negative effect on recurrence-free or overall survival rates.
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Affiliation(s)
- Elias Khajeh
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Saeed Shafiei
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Sadeq Ali-Hasan Al-Saegh
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ali Ramouz
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ahmed Hammad
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Omid Ghamarnejad
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Nuh Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Arianeb Mehrabi
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany. .,Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany.
| | - Pascal Probst
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Hani Oweira
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Wassmer CH, Moeckli B, Berney T, Toso C, Orci LA. Shorter Survival after Liver Pedicle Clamping in Patients Undergoing Liver Resection for Hepatocellular Carcinoma Revealed by a Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13040637. [PMID: 33562666 PMCID: PMC7916026 DOI: 10.3390/cancers13040637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Hepatocellular carcinoma (HCC) is the most prevalent tumor of the liver and represents the second most common cause of oncological-related deaths worldwide. Despite all progress made in the field, surgical resection or liver transplantation are, at the moment, the only curative therapies available. Liver resection, especially for large, central tumors, are at risk of important bleeding. Significative hemorrhage during HCC resections have been linked to an increased rate of post-operative complications and tumor recurrence. Therefore, hepatic pedicle clamping during surgery has been used in order to reduce the bleeding risks. However, this method induces ischemia/reperfusion injuries, which has also been associated with tumor recurrence. For this reason, we aimed to evaluate if pedicle clamping is indeed associated with tumor recurrence and shorter survival, by performing a systematic review of the literature and meta-analysis. Abstract Liver pedicle clamping minimizes surgical bleeding during hepatectomy. However, by inducing ischemia-reperfusion injury to the remnant liver, pedicle clamping may be associated with tumor recurrence in the regenerating liver. Hepatocellular carcinoma (HCC) having a high rate of recurrence, evidences demonstrating an eventual association with pedicle clamping is strongly needed. We did a systematic review of the literature until April 2020, looking at studies reporting the impact of liver pedicle clamping on long-term outcomes in patients undergoing liver resection for HCC. Primary and secondary outcomes were overall survival (OS) and disease-free survival, respectively. Results were obtained by random-effect meta-analysis and expressed as standardized mean difference (SMD). Eleven studies were included, accounting for 8087 patients. Results of seven studies were pooled in a meta-analysis. Findings indicated that, as compared to control patients who did not receive liver pedicle clamping, those who did had a significantly shorter OS (SMD = −0.172, 95%CI: −0.298 to −0.047, p = 0.007, I2 = 76.8%) and higher tumor recurrence rates (odds ratio 1.36 1.01 to 1.83. p = 0.044, I2 = 50.7%). This meta-analysis suggests that liver pedicle clamping may have a deleterious impact on long-term outcomes. An individual patient-data meta-analysis of randomized trials evaluating liver pedicle clamping is urgently needed.
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Affiliation(s)
| | - Beat Moeckli
- Correspondence: (C.-H.W.); (B.M.); Tel.: +41-7866-82206 (C.-H.W.)
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Lee KF, Chong CCN, Cheung SYS, Wong J, Fung AKY, Lok HT, Lai PBS. Impact of Intermittent Pringle Maneuver on Long-Term Survival After Hepatectomy for Hepatocellular Carcinoma: Result from Two Combined Randomized Controlled Trials. World J Surg 2020; 43:3101-3109. [PMID: 31420724 DOI: 10.1007/s00268-019-05130-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes. METHODS Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated. RESULTS There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16-30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival. CONCLUSION IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16-30 min. TRIAL REGISTRATION NCT00730743 and NCT01759901 ( http://www.clinicaltrials.gov ).
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Affiliation(s)
- Kit Fai Lee
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Sunny Y S Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Hon Ting Lok
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32, Ngan Shing Street, Shatin, N.T., Hong Kong SAR, China.
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8
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Lin N, Li J, Ke Q, Xin F, Zeng Y, Wang L, Liu J. Does the intermittent Pringle maneuver affect the recurrence following surgical resection for hepatocellular carcinoma? A systematic review. PLoS One 2020; 15:e0229870. [PMID: 32160231 PMCID: PMC7065790 DOI: 10.1371/journal.pone.0229870] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 02/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIM To evaluate the effect of intermittent pringle maneuver (IPM) on the long-term prognosis and recurrence of hepatocellular carcinoma (HCC). METHODS Eligible studies were identified by PubMed and other databases from Jan 1st 1990 to Mar 31st 2019. Hazard ratios (HR) with 95% confidence interval (CI) were calculated to evaluate the effects of IPM on the long-term prognosis and recurrence of patients with HCC. RESULTS Six studies were enrolled in this meta-analysis. Results showed that there were no differences between IPM group and non-IPM group in the pooled HRs for the overall survival (OS) and disease-free survival (DFS) (HR 1.04, 95%CI 0.84~1.28, P = 0.74; HR 0.93, 95%CI 0.81~1.07, P = 0.29; respectively). However, subgroup analysis showed that the pooled Odd ratios (OR) for the 1-year OS and DFS rates of the IPM group when compared with the non-IPM group were 0.65 (95% CI 0.45~0.94, P = 0.02), 0.38 (95% CI 0.20~0.72, P = 0.003), respectively. In addition, there were no significant differences in the proportions of liver cirrhosis, HBsAg (+), Child-Pugh A class, multiple tumor, vascular invasion, and major hepatectomy between groups of IPM and non-IPM. CONCLUSION Since IPM would increase the risk of early-recurrence, it should be used cautiously in the procedure of hepatectomy for resectable HCC. However, the current conclusion needs further validation. TRIAL REGISTRY NUMBER CRD 42019124923.
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Affiliation(s)
- Nanping Lin
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jingrong Li
- Department of Laboratory, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qiao Ke
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Fuli Xin
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yongyi Zeng
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Lei Wang
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
- Department of Radiation Oncology, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jingfeng Liu
- Department of Hepatopancreatobiliary Surgery, Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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Garnier J, Faucher M, Marchese U, Meillat H, Mokart D, Ewald J, Delpero JR, Turrini O. Severe acute kidney injury following major liver resection without portal clamping: incidence, risk factors, and impact on short-term outcomes. HPB (Oxford) 2018; 20:865-871. [PMID: 29691124 DOI: 10.1016/j.hpb.2018.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/20/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following major hepatectomy (MH) remains inadequately investigated. This retrospective study aimed to assess the risk factors and prognostic value of AKI on short-term outcomes following MH without portal pedicle clamping. METHODS From January 2014 through June 2017, 111 consecutive patients underwent MH without portal pedicle clamping, but with intraoperative low-crystalloid infusion. Kidney Disease Improving Global Outcomes stages II and III were classified as severe AKI. RESULTS A total of 102 patients did not develop AKI or only AKI stage I (92%, control group), whereas 9 patients developed severe AKI (8%, severe AKI group). Hepatectomy (P = 0.002) and surgery (P = 0.011) durations were longer in the severe AKI group. Clavien-Dindo grades 3 to 5 morbidity (55% versus 9%, P = 0.001), liver failure (P = 0.017), and 90-day mortality (33% versus 2%, P = 0.003) were significantly higher in the severe AKI group. After a multivariate analysis, the duration of hepatectomy (cut-off: 250 min; P = 0.029) and urea serum levels on postoperative day 3 (P = 0.006) were identified as independent predictors of severe AKI. DISCUSSION Severe AKI, is common with increased duration of hepatectomy, was associated with poor short-term outcomes, and can be predicted by operative duration greater than 250 minutes.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France.
| | - Marion Faucher
- Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
| | - Hélène Meillat
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Djamel Mokart
- Department of Anesthesiology and Critical Care, Institut Paoli Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France; AixMarseille University, Marseille, France
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