Hemihepatic Vascular Inflow Occlusion Research Articles

Regional Ischemic Preconditioning Has Clinical Value in Cirrhotic HCC Through MAPK Pathways

BackgroundThis study assessed the clinical value of regional ischemic preconditioning (RIP) and the role of the mitogen-activated protein kinase (MAPK) pathways in the protective mechanism of RIP in cirrhotic hepatocellular carcinoma (HCC) patients undergoing hepatectomy. MethodsLiver resection was performed with hemi-hepatic vascular inflow occlusion (HHV) under RIP (RIP group) or with HHV alone (HHV group). Clinical data, surgical outcomes, and the levels of phosphorylated MAPKs before occlusion and 30 min after reperfusion were estimated. ResultsHHV under RIP was associated with less intraoperative blood loss (300 vs. 400 ml; P = 0.042), postoperative plasma transfused (400 vs. 800 ml; P = 0.019), and a higher level of prothrombin activity at postoperative days 3, 5, and 7 compared to HHV alone. The level of phosphorylated ERK protein was significantly increased and the levels of phosphorylated p38 and JNK proteins were significantly decreased 30 min after reperfusion compared to HHV group in the RIP group. ConclusionsHHV under RIP may have clinical value in cirrhotic HCC patients requiring resection and the protective mechanism of RIP may be associated with changes in the protein phosphorylation level of MAPK pathways.

Does liver cirrhosis have an impact on the results of different hepatic inflow occlusion methods in laparoscopic liver resection? a propensity score analysis

BackgroundFew studies have analyzed the impact of liver cirrhosis on different hepatic inflow occlusion methods in laparoscopic liver resection (LLR). Intermittent Pringle (IP) was compared to continuous hemihepatic vascular inflow occlusion (CHVIO) in LLR in patients with or without cirrhosis. MethodsPatients who underwent LLR at the West China Hospital of Sichuan University form January 2015 to October 2017 were grouped according to occlusion methods and severity of cirrhosis. A matched propensity score analysis was performed. ResultsAmong patients without cirrhosis, there were no significant differences in blood loss (238 ± 30 ml VS 265 ± 46 ml, P = 0.653), operative time (228 ± 9 min VS 265 ± 20 min, P = 0.437) or other postoperative results between the IP and CHVIO groups after propensity score matching. Among patients with cirrhosis, blood loss (279 ± 24 ml VS 396 ± 35 ml, P = 0.012) and operative time (237 ± 11 min VS 285 ± 24 min, P = 0.041) were significantly lower in the IP group, while postoperative liver function did not significantly differ between the two groups after propensity score matching. ConclusionsIn patients without cirrhosis, IP is as efficient and as safe as CHVIO in cirrhotic patients. IP offers the advantages of shorter operative time and less blood loss and does not result in worse postoperative liver function.

Extra-glissonian Approach for Total Laparoscopic Left Hepatectomy: A Prospective Cohort Study.

Laparoscopic liver resection under hemihepatic vascular inflow control has advantages over Pringle's maneuver, especially in patients with cirrhosis. From January 2016 to August 2016, 7 patients who underwent total laparoscopic left hepatectomy under hemihepatic vascular inflow occlusion using the extra-glissonian approach were included in this study. All were hepatitis B carriers and 4 had cirrhosis. The mean operation time was 247 minutes. The mean transection time was 110 minutes. No patient needed additional Pringle's maneuver. The mean intraoperative blood loss was 74 ml and no patient required blood transfusion. No open conversion happened. Postoperatively, no patient developed complications and there was no perioperative mortality. The mean resection margin was 2 cm. The mean hospital stay was 6 days. Upon a mean follow-up of 9 months, no patient developed tumor recurrence. The technique of total laparoscopic left hepatectomy using extra-glissonian approach was safe and feasible. The early surgical outcomes were good.

Pure laparoscopic right hemihepatectomy via anterior approach

In open hepatectomy ear, right hemihepatectomy via anterior approach has been accepted as one of the standard methods in some specialized centers. However, pure laparoscopic right hemihepatectomy by anterior approach is technically demanding [1-5]. Here, we described the technique of pure laparoscopic right hemihepatectomy via anterior approach. We performed three pure laparoscopic right hemihepatectomies via anterior approach between 2013 and 2014. This video illustrated this procedure steps in a 32years old male with hepatocellular carcinoma. Right hemihepatectomy was performed after hemihepatic vascular inflow occlusion using the lowering of the hilar plate approach [6]. The hepatic parenchyma transection via anterior approach was performed with Ligasure, ultrasound scalpel and bipolar electrocoagulation. The right hepatic vein was divided with an endoscopic vascular stapler. Thereafter, mobilization of the right liver was performed. The operation time was 240min, and the blood loss was 150ml. The recovery was uneventful and the patient discharged on postoperative day 8. The pathology was hepatocellular carcinoma with vascular invasion and also satellites foci adjacent to the main tumor. The resection margin was negative. Pure laparoscopic right hemihepatectomy via anterior approach was safe and feasible.

Clinical efficacy of laparoscopic left hemihepatectomy for the treatment of intrahepatic bile duct stones

Objective To explore the clinical efficacy of laparoscopic left hemihepatectomy for the treatment of intrahepatic bile duct stones. Methods The clinical data of 30 patients with left intrahepatic bile duct stones who were admitted to the Second Affiliated Hospital of Nanchang University from June 2013 to June 2014 were retrospectively analyzed. All the patients underwent laparoscopic left hemihepatectomy by the Glisson intra- and extrapedicles vascular inflow occlusion techniques together with the removal of choledocholithiasis and right bile duct stones, and T tube placement or laparoscopic primary suture of common bile duct were selected according to the condition of bile duct. All the 30 patients were readmitted to hospital and detected by color Doppler ultrasound (CDUS) , computed tomography (CT) and T tube cholangiography at postoperative month 1, and then received CDUS reexamination every 3 months. CT and MRI reexaminations were applied to patients with complication of residual stones if necessary. All the patients were followed up till July 2014. Results All the 30 patients were treated by laparoscopic hepatectomy with left hemihepatic vascular inflow occlusion, including 5 with conversion to open surgery and 25 with successful operation. The Glisson extra- and intra-pedicel vascular inflow occlusion techniques were used in 11 and 14 patients, respectively. The operation time and volume of blood loss were (158 ±85) minutes and (405 ±215) mL. Two patients received intraoperative blood transfusion. There were no residual stones in the 8 patients with choledocholithiasis by intraoperative choledochoscope, and primary suture of bile duct and T tube placement were done in 5 and 3 patients, respectively. No patients died. After operation, there were 2 patients with bile leakage and 1 with pleural effusion, and they were cured though drainage. One patient with subphrenic effusion was cured by B ultrasound-guided puncture and drainage. One patient had bleeding with the volume of blood loss of 500 mL, and was cured by conservative treatment. The duration of hospital stay in all the patients was (8. 5 ±2. 3) days. No bile leakage and abdomen infection were detected by outpatient examination. The time of follow-up was 1-12 months, without recurrence of stones. Conclusion Laparoscopic left hemihepatectomy for the treatment of left intrahepatic bile duct stones is safe and feasible with satisfactory outcome. Key words: Cholelithiasis; Laparoscopy; Hepatectomy

Laparoscopic right hemihepatic vascular inflow occlusion by lowering of the hilar plate.

Laparoscopic liver resection under hemihepatic vascular inflow occlusion has advantages over the conventional Pringle's maneuver, especially in patients with cirrhosis. However, laparoscopic hemihepatic vascular inflow occlusion is technically challenging. From March 2013 to August 2013, 8 consecutive patients who underwent laparoscopic liver resection under right hemivascular inflow occlusion using the lowering of the hilar plate approach. There were 3 women and 5 men, with a mean age of 52.6 years (range, 44-73 years). The pathologies were hepatocellular carcinoma (n=3), sarcomatoid liver carcinoma (n=1), hepatic vascular epithelial tumor (n=1), hemangioma (n=2), and colorectal liver metastases (n=1). The types of resection included right hepatectomy (n=3), right anterior sectionectomy (n=1), segments 5 and 6 resection (n=1), and segment 6 resection (n=2). All patients underwent right hemivascular inflow occlusion. The mean operation time was 186.2 minutes (range, 100-280 minutes). The mean time taken to prepare for hemivascular inflow occlusion was 17.8 minutes (range, 15-20 minutes). The mean intraoperative blood loss was 218.8 mL (range, 100-300 mL). The mean duration of vascular control was 25.6 minutes (range, 15-40 minutes). No patients developed postoperative liver failure. There was no postoperative morbidity or mortality. The mean hospital stay was 6 days (range, 5-7 days). Hemihepatic vascular inflow occlusion using the lowering of the hilar plate approach was safe and feasible. It facilitated laparoscopic liver resection by minimizing blood loss during liver parenchymal transection.

Laparoscopic liver resection under hemihepatic vascular inflow occlusion using the lowering of hilar plate approach

With advances in technology, laparoscopic liver resection is widely accepted. Laparoscopic liver resection under hemihepatic vascular inflow occlusion has advantages over the conventional total hepatic inflow occlusion using the Pringle's maneuver, especially in patients with cirrhosis. From November 2011 to August 2012, eight consecutive patients underwent laparoscopic liver resection under hemihepatic vascular inflow occlusion using the lowering of hilar plate approach with biliary bougie assistance. The types of liver resection included right hepatectomy (n=1), right posterior sectionectomy (n=1), left hepatectomy and common bile duct exploration (n=1), segment 4b resection (n=1), left lateral sectionectomy (n=2), and wedge resection (n=2). Four patients underwent right and 4 left hemihepatic vascular inflow occlusion. Four patients had cirrhosis. The mean operation time was 176.3 minutes. The mean time taken to achieve hemihepatic vascular inflow occlusion was 24.3 minutes. The mean duration of vascular inflow occlusion was 54.5 minutes. The mean intraoperative blood loss was 361 mL. No patient required blood transfusion. Postoperatively, one patient developed bile leak which healed with conservative treatment. No postoperative liver failure and mortality occurred. The mean hospital stay of the patients was 7 days. Our technique of hemihepatic vascular inflow vascular occlusion using the lowering of hilar plate approach was safe, and it improved laparoscopic liver resection by minimizing blood loss during liver parenchymal transection.

A Prospective Randomized Controlled Trial to Compare Pringle Manoeuvre with Hemi-hepatic Vascular Inflow Occlusion in Liver Resection for Hepatocellular Carcinoma with Cirrhosis

BackgroundThe duration of hepatic vascular inflow occlusion and the amount of intraoperative blood loss have significant negative impacts on postoperative morbidity, mortality and long-term survival outcomes of patients who receive partial hepatectomy for hepatocellular carcinoma (HCC) with cirrhosis. AimThis study aimed to compare the perioperative outcomes of partial hepatectomy for HCC superimposed on hepatitis B-related cirrhosis using two different occlusion techniques. MethodsA randomized controlled trial was carried out to evaluate the impact of two different vascular inflow occlusion techniques. The postoperative short-term results were compared. ResultsDuring the study period, 252 patients received partial hepatectomy for HCC with cirrhosis. Of these patients, 120 were randomized equally into two groups: the Pringle manoeuvre group (n = 60) and the hemi-hepatic vascular inflow occlusion group (n = 60). The number of patients who had poor liver function on postoperative day 5 with ISLGS grade B or worse was 24 and 13, respectively (P = 0.030). The postoperative complication rate was significantly higher in the Pringle manoeuvre group (40 versus 22 %, P = 0.030). However, the Pringle manoeuvre group had significantly shorter operating time (116 versus 136 min, P = 0.012) although there was no significant difference in intraoperative blood loss between the two groups [200 ml (range 10–5,000 ml) versus 300 ml (range 100–1,000 ml); P = 0.511]. There was no perioperative mortality. ConclusionsThe results indicated that for patients with HCC with cirrhosis, hemi-hepatic vascular inflow occlusion was a better inflow occlusion method than Pringle manoeuvre.

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy

Background Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes. Methods A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality. Results A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay. Conclusions All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.

Continuous normothermic hemihepatic vascular inflow occlusion over 60 min for hepatectomy in patients with cirrhosis caused by hepatitis B virus

To evaluate the safety of remnant liver in cirrhotic patients who had undergone irregular hepatectomy with continuous normothermic hemihepatic vascular inflow occlusion for over 60 min. A group of 133 cirrhotic patients who had hepatitis B virus accompanied by hepatocellular carcinoma and had undergone irregular hepatectomy by hemihepatic vascular inflow occlusion was studied. According to the time of hemihepatic vascular inflow occlusion, patients were assigned either to the control group, treatment(60) group, or treatment(90) group. The quantity of blood loss and blood transfusion, routine liver biochemistry and postoperative complications were retrospectively analyzed. The data showed that there were no significant differences in postoperative complications between the three groups. Compared to the preoperative day, the levels of aspartate transaminase (AST), alanine transaminase (ALT), prothrombin time (PT) and serum bilirubin on postoperative days 1 and 3 were significantly increased in all three groups and the levels of albumin and platelet were significantly decreased on postoperative day 1. Duration of hospital stay and the levels of ALT and AST on postoperative days 1, 3 and 7 were higher in the treatment(90) group than in the control group and treatment(60) group (P < 0.05). However, no significant differences were displayed in the length of hospital stay and the levels of AST, ALT, PT, albumin, platelet count and serum bilirubin on postoperative days 1, 3 and 7 between the control group and the treatment(60) group (P > 0.05). Hemihepatic vascular inflow occlusion over 60 min is a possible method for irregular hepatectomy in patients with cirrhosis caused by the hepatitis B virus. However, caution must be exercised in utilizing this method where the time of vascular occlusion is over 90 min.