Does intermittent pringle maneuver loss its clinical value in reducing bleeding during hepatectomy? A systematic review and meta-analysis.

Abstract

The intermittent Pringle's maneuver (IPM) is conducted mainly during the procedure of hepatectomy to control intraoperative blood loss (IBL), but it has been questioned since improvement of surgical technology and intraoperative management. Hence, we conducted a systematic review and meta-analysis to validate the clinical value of IPM. Eligible studies that were designed to evaluate the IPM in the procedure of hepatectomy were searched for on PubMed, Medline, and other databases from establishment of the database to October 2019. The primary endpoints were IBL and intraoperative blood transfusion (IBT). The risk ratio (RR) with 95% confidence interval (CI) was used to determine the effect size. A total of 16 studies with six randomized controlled trials (RCTs) were enrolled in this meta-analysis, including 1,770 cases in the IPM group and 1,611 cases in the non-IPM group. Overall, there were no significant differences between the IPM and non-IPM groups in the amount of IBL and the incidence of IBT (RR=0.96, 95% CI 0.67-1.37, P=0.82), which was also confirmed in the subgroups of RCTs (P>0.05). However, subgroup analyses showed that for patients with colorectal liver metastasis (CRLM), the amount of IBL was generally higher in the IPM group than in the non-IPM group, and the incidence of IBT was significantly higher in the IPM group (RR=7.17, 95% CI 1.91-26.94, P=0.004). In addition, no significant differences were observed in terms of postoperative complications between the two groups (all P>0.05). With the current data, we concluded that IPM had lost its value in patients with CRLM, although it remained controversial in patients with hepatocellular carcinoma.