Pringle Maneuver in Extended Liver Resection: Is it Justified?

Abstract

Background: The rates of intraoperative bleeding and postoperative complications are considerable in extended hepatectomy (EH). Despite the ongoing decades-long controversy regarding the advantages and disadvantages of hepatic inflow occlusion during hepatectomy, the Pringle maneuver (PM) is still frequently used by hepatobiliary surgeons. The aim of this study was to evaluate the effect of PM on the outcome in patients underwent EH. Methods: A series of 209 consecutive patients underwent EH (resection of ≥five liver segments) between 2001 and 2017. The association of PM with intraoperative bleeding, posthepatectomy haemorrhage (PHH), and major morbidity was evaluated using multivariate regression analysis. The recurrence rate was compared using Kaplan-Meier survival curves. Results: Fifty of patients (23.9%) underwent PM with a mean duration of 9.4 ± 4.0 minutes. There were no significantly differences regarding preoperative and intraoperative data such as demographic data, transection technique, and site of resection between PM and no-PM groups. Multivariate analysis revealed that risk of excessive intraoperative bleeding ≥ 1500 ml (odds ratio [OR] 3.7, 95% confidence interval [CI] 1.5–8.9, p=0.003), PHH (OR 4.3, 95% CI 1.3–15.1, p=0.021), and major morbidity (OR 2.4, 95% CI 1.0–5.6, p=0.040) were significantly lower in patients underwent PM after EH. There was no significant difference in mortality and 3-year recurrence rate between the two groups. Conclusions: PM seems to be justified in EH. It is associated with lower intraoperative bleeding (≥ 1500 ml), PHH, and major morbidity risk and does not affect the recurrence rate after EH. This association was independent of other related parameters.