When does a pringle maneuver cause harm?

Abstract

Presenter: Alexander Fagenson MD | Lewis Katz School of Medicine at Temple University Hospital Background: The Pringle Maneuver (PM) is considered to be safe and effective despite limited level one data to support its use. In addition, current evidence is mixed regarding postoperative outcomes. However, the PM has not been analyzed when stratified by extent of hepatectomy and pathology. Therefore, the aim of this analysis is to compare the outcomes of subsets of patients who have and have not undergone a PM in North America. Methods: Patients undergoing major hepatectomy (≥ 3 segments) or partial hepatectomy (≤ 2 segments) were identified in the 2014-17 ACS-NSQIP procedure-targeted database. Patients undergoing concomitant colon or another major resection were excluded. Subset analyses were performed based on hepatectomy extent and pathology type (metastatic disease and primary hepatobiliary malignancies). Outcomes of patients having a PM were compared to those with no PM after propensity score matching. Statistical analyses were performed by chi-square and Mann-Whitney U tests. Results: Prior to matching, 3,706 (24%) of 15,748 hepatectomies underwent a PM. PM was utilized in 1,445 (37%) of major hepatectomies and 2,261 (28%) of partial hepatectomies. PM was associated with worse outcomes (p < 0.05); however, these patients were significantly different at baseline. After matching, patients undergoing a PM during a partial hepatectomy had significantly increased rates of post-hepatectomy liver failure (PHLF), reintubation and septic shock (p < 0.05), but these differences were not observed in major hepatectomy patients (Table). In addition, patients with metastatic disease undergoing a PM had significantly increased rates of PHLF, septic shock and acute renal failure (p < 0.05) while these adverse outcomes did not develop in patients with primary hepatobiliary malignancies (Table). In each subset of patients operative time was significantly longer (p<0.05) when a PM was performed. Conclusion: The majority of hepatectomies are being performed without a Pringle Maneuver. The use of a Pringle Maneuver increases operative time and is associated with postoperative liver failure and septic shock. Patients undergoing a partial hepatectomy and those with metastatic disease have worse outcomes when a Pringle Maneuver is performed. The Pringle Maneuver is more likely to cause harm in patients undergoing smaller resections and in those with a more normal underlying liver.