Total Intermittent Pringle Maneuver during Liver Resection Can Induce Intestinal Epithelial Cell Damage and Endotoxemia

Simon A W G Dello,Steven W M Olde Damink,Maartje A J Van Den Broek,Ronald M Van Dam,Toin H Van Kuppevelt,Wim A Buurman,Kostan W Reisinger,Martijn Poeze,Marc H A Bemelmans,Cornelis H C Dejong

doi:10.1371/journal.pone.0030539

Abstract

ObjectivesThe intermittent Pringle maneuver (IPM) is frequently applied to minimize blood loss during liver transection. Clamping the hepatoduodenal ligament blocks the hepatic inflow, which leads to a non circulating (hepato)splanchnic outflow. Also, IPM blocks the mesenteric venous drainage (as well as the splenic drainage) with raising pressure in the microvascular network of the intestinal structures. It is unknown whether the IPM is harmful to the gut. The aim was to investigate intestinal epithelial cell damage reflected by circulating intestinal fatty acid binding protein levels (I-FABP) in patients undergoing liver resection with IPM.MethodsPatients who underwent liver surgery received total IPM (total-IPM) or selective IPM (sel-IPM). A selective IPM was performed by selectively clamping the right portal pedicle. Patients without IPM served as controls (no-IPM). Arterial blood samples were taken immediately after incision, ischemia and reperfusion of the liver, transection, 8 hours after start of surgery and on the first post-operative day.Results24 patients (13 males) were included. 7 patients received cycles of 15 minutes and 5 patients received cycles of 30 minutes of hepatic inflow occlusion. 6 patients received cycles of 15 minutes selective hepatic occlusion and 6 patients underwent surgery without inflow occlusion. Application of total-IPM resulted in a significant increase in I-FABP 8 hours after start of surgery compared to baseline (p<0.005). In the no-IPM group and sel-IPM group no significant increase in I-FABP at any time point compared to baseline was observed.ConclusionTotal-IPM in patients undergoing liver resection is associated with a substantial increase in arterial I-FABP, pointing to intestinal epithelial injury during liver surgery.Trial RegistrationClinicalTrials.gov NCT01099475

Highlights

Intra-operative blood loss and red blood cell transfusions are associated with short- and long-term complications in liver surgery, such as operative mortality or major complications that require post-operative radiologic or surgical intervention [1,2]
Application of total-intermittent Pringle maneuver (IPM) resulted in a significant increase in intestinal fatty acid binding protein levels (I-FABP) 8 hours after start of surgery compared to baseline (p,0.005)
In the not require IPM served as controls (no-IPM) group and selective IPM (sel-IPM) group no significant increase in IFABP at any time point compared to baseline was observed

Summary

Introduction

Intra-operative blood loss and red blood cell transfusions are associated with short- and long-term complications in liver surgery, such as operative mortality or major complications that require post-operative radiologic or surgical intervention [1,2]. In an attempt to avoid blood loss, the intermittent Pringle maneuver (IPM) is frequently applied in patients undergoing liver surgery This implies intermittent clamping of the hepatoduodenal ligament, thereby occluding hepatic inflow [3]. Loss of intestinal epithelial integrity is clinically important, as it is associated with the development of sepsis and multiple organ failure (MOF) following major surgery, trauma and shock [13,14]. This might be especially important in patients with small for size liver remnant volume and/or parenchymal dysfunction due to neo-adjuvant chemotherapy, cholestasis and/or cirrhosis [15,16,17]

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