Intermittent Pringle Maneuver Research Articles

ICG-Enhanced Compression Anatomical Segment 7 Segmentectomy in Laparoscopic and Robotic Approach.

Minimally invasive anatomical resection (AR) for posterosuperior lesions is technically challenging.1,2 The Glissonean approach or puncture technique is generally selected.3,4 The tumor-feeding portal pedicle compression AR (C-AR) is an established procedure in open surgery.5 This technique has benefited from the association with indocyanine green (ICG) fluorescence, used to enhance the anatomical area to be resected.6 Recently, C-AR via the minimal access approach has been reported.7 Herein, we report the first cases of laparoscopic and robotic segment 7 (S7) segmentectomy using the ICG-enhanced compression technique. Two cases of CHILD-class A hepatocellular carcinoma (HCC) in segment 7 with a liver stiffness less than 7 kPa treated by laparoscopic and robotic anatomical S7 segmentectomies were reported. Using the intraoperative ultrasound (IOUS), the tumor-bearing portal pedicle and the level targeted for compression were identified. The right hemiliver was adequately mobilized to allow handling of the organ during dissection. Using the grasper and the probe itself, the S7 Glissonean pedicle was transparenchymally compressed under real-time IOUS control. To further enhance the visibility of the discolored S7, ICG was administered intravenously, obtaining the compressed area to be resected as a non-stained one. Dissection was performed under intermittent Pringle maneuver up to exposing the right hepatic vein, dividing the Glissonean pedicle to segment 7 and then completing the resection. Pathologic findings demonstrated a 4.9 cm and 7.3 cm HCC with a R0-resection margin (> 1 cm in both). Postoperative complications were nil. The patients were discharged 6 days after surgery. This preliminary experience shows that the C-AR is a feasible and reliable technique in laparoscopic and robotic approach for posterosuperior lesions. Further studies are needed to investigate its applicability and standardization.

Impact of prolonged liver ischemia during intermittent Pringle maneuver on postoperative outcome following liver resection

BackgroundThe aim of this study was to compare postoperative outcomes following liver resection between patients with prolonged cumulative ischemia time (CIT) which exceeded 60 min and patients with CIT less than 60 min. MethodsBetween March 2020 and October 2022, 164 consecutive patients underwent liver resection at the Unit for hepato-bilio-pancreatic surgery, University Clinic for Digestive Surgery in Belgrade, Serbia. Intermittent Pringle maneuver was routinely applied. Depending on CIT during transection, patients were divided into two groups: group 1 (CIT <60 min) included 101 patients, and group 2 (CIT ≥60 min) included 63 patients. ResultsMedian operative time (210 vs. 400 min) and CIT (30 vs. 76 min) were longer in the Group 2 (p < 0.001). Intraoperative blood loss was higher in the Group 2 (150 vs 500 ml), p < 0.001. The perioperative transfusion rate was similar between the groups (p = 0.107). There was no difference in postoperative overall morbidity (50.5% vs. 58.7%, p = 0.337) and major morbidity (18.8 vs. 19%, p = 0.401). In-hospital mortality, 30-day mortality, and 90-day mortality were similar between the groups (p = 0.408; p = 0.408; p = 0.252, respectively). Non-anatomical liver resection was the only predictive factor of 90-day mortality identified by multivariate analysis (p = 0.047; Relative Risk = 0.179; 95% Confidence Interval 0.033–0.981). ConclusionIntermittent Pringle maneuver with CIT exceeding 60 min is a safe method for bleeding control during liver resection with no impact on postoperative morbidity and mortality. Keywords: intermittent Pringle maneuver, liver ischemia, liver resection.

Effect of intermittent Pringle maneuver on perioperative outcomes and long-term survival following liver resection in patients with hepatocellular carcinoma: a meta-analysis and systemic review

BackgroundIntermittent Pringle maneuver (IPM) is commonly used to control bleeding during liver resection. IPM can cause ischemia–reperfusion injury, which may affect the prognosis of patients with hepatocellular carcinoma (HCC). The present meta-analysis was conducted to evaluate the effect of IPM use on perioperative outcomes and long-term survival in patients with HCC.MethodsA systemic literature search was performed in the PubMed, Embase, Web of Science, and Cochrane Library databases to identify randomized controlled trials and retrospective studies that compared the effect of IPM with no Pringle maneuver during liver resection in patients with HCC. Hazard ratio (HR), risk ratio, standardized mean difference, and their 95% confidence interval (CI) values were calculated based on the type of variables.ResultsThis meta-analysis included nine studies comprising one RCT and eight retrospective studies and involved a total of 3268 patients. Perioperative outcomes, including operation time, complications, and length of hospital stay, except for blood loss, were comparable between the two groups. After removing the studies that led to heterogeneity, the results showed that IPM was effective in reducing blood loss. Five studies reported overall survival (OS) and disease-free survival (DFS) data and eight studies reported perioperative outcomes. No significant difference in OS and DFS was observed between the two groups (OS: HR, 1.01; 95% CI, 0.85–1.20; p = 0.95; DFS: HR, 1.01; 95% CI, 0.88–1.17; p = 0.86).ConclusionIPM is a useful technique to control blood loss during liver resection and does not affect the long-term survival of patients with HCC.

PREVENTION OF PATHOLOGICAL EFFECT OF ISCHEMIA-REPERFUSION IN LIVER RESECTION BY SEVOFLURANE PRECONDITIONING.

The intermittent Pringle maneuver remains the major technique for controlling hemorrhage during liver surgery. Nevertheless, this procedure involves a risk of triggering a cascade of pathological changes resulting in the ischemia-reperfusion injury (I/R) effect. The pharmacological prevention of this I/R injury represents a promising approach. The aim of the study was to compare the effects of pharmacological preconditioning with sevoflurane and propofol-based intravenous anesthesia on the postoperative function of the liver as the primary end-point. A prospective cohort study includes the analysis of the data of 73 patients who underwent liver surgery. In the study group (n = 41), preconditioning with sevoflurane inhalation was provided 30 minutes prior to liver resection. In the control group (n = 32), sevoflurane preconditioning was not provided. The primary endpoints were blood lactate concentration shortly after the surgery and one day later; alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities on postoperative Days 1, 3, and 5 as markers of hepatocyte damage. On postoperative Day 1, in patients of the study group, lactate decreased to preoperative levels, while in the control group, lactate content increased as compared to both preoperative levels and the levels immediately after liver resection. A significant difference in AST activity levels between the groups was registered on Day 5, although this difference was not clinically relevant. The decrease in the prothrombin index in the study group on Day 3 was superior to that in the control group. The multiple regression analysis demonstrated a moderate positive association between the number of resected liver segments and the markers of the functional state of the liver in the study group while in the control group, such association was not significant. The protective effect of sevoflurane on the postoperative function of the liver is manifested by the lower level of blood lactate and the stable level of transaminase activity.

Impact of the Prolonged Intermittent Pringle Maneuver on Post-Hepatectomy Liver Failure: Comparison of Open and Laparoscopic Approaches.

The influence of prolonged intermittent Pringle maneuver (IPM) on post-hepatectomy liver failure (PHLF) remains unclear. We evaluated the impact of the prolonged IPM on PHLF in patients undergoing open and laparoscopic hepatectomy. We retrospectively included 546 patients who underwent hepatectomy using IPM. The patients were divided into open (n = 294) and laparoscopic (n = 252) groups. Odds ratios for PHLF occurrence were estimated in each group according to cumulative Pringle time (CPT). The cut-off value was set at CPT of 120min. Risk factors for PHLF were evaluated in the open and laparoscopic groups. Additionally, we analyzed the post-operative outcomes in the open and laparoscopic groups with CPT ≥ 120min and performed propensity score matching analysis based on PFLF-associated factors. In the open group, the risk of PHLF increased as CPT increased, particularly after 120min. However, in the laparoscopic group, PHLF did not occur at less than 60min, and the risk of PHLF was not significantly different at more than 60min. Multivariate analysis identified CPT ≥ 120min as an independent risk factor for PHLF in the open group (p < 0.001), but not in the laparoscopic group. Propensity score matching analysis showed that the PHLF rate was significantly lower in the laparoscopic group with CPT ≥ 120min (p = 0.027). The post-operative transaminase levels were significantly lower in the laparoscopic group with CPT ≥ 120min. Laparoscopic hepatectomy may cause less PHLF with prolonged IPM compared with open hepatectomy.

Impact of the Intermittent Pringle Maneuver for Predicting Post-hepatectomy Liver Failure: A Cohort Study of 597 Consecutive Patients.

Intermittent Pringle maneuver (PM) is widely performed to reduce blood loss during hepatectomy; however, its impact on clinically relevant post-hepatectomy liver failure (PHLF) remains controversial. This study aimed to assess the impact of PM on PHLF and explore whether PM provides additional value for predicting PHLF. Consecutive patients, who underwent hepatectomy without biliary and/or vascular reconstruction between 2011 and 2018 in a single institution, were retrospectively analyzed. The main outcome was PHLF grades B/C as defined by the International Study Group of Liver Surgery. A multivariable logistic regression model of variables significantly associated with PHLF was established. The model's predictive ability was assessed by the area under the receiver operating characteristic curve (AUROC). Among 597 patients, PHLF occurred in 42 (7.0%). PM was applied in 421 patients (70.5%) and was associated with the development of PHLF (PM vs. no-PM: 9.7 vs. 0.6%, P < 0.001). After the propensity score matching, patients with PM experienced significantly increased rates of PHLF (P = 0.010). Rem-ALPlat index (including future liver remnant, preoperative albumin level, and platelet count; P < 0.001), the number of PMs (P = 0.032), and blood loss (P = 0.007) were identified as significant predictors of PHLF. The model's AUROC combined with the intraoperative variables was higher than that of the preoperative model alone (0.877 vs. 0.789, P = 0.004). PM was involved in the occurrence of clinically relevant PHLF. Further, intraoperative factors including PM may provide additional value to predict PHLF and may facilitate early post-hepatectomy intervention.

Impact of Prolonged Liver Ischemia during Intermittent Pringle Maneuver on Postoperative Outcome Following Liver Resection

Impact of Prolonged Liver Ischemia during Intermittent Pringle Maneuver on Postoperative Outcome Following Liver Resection

Intermittent Pringle maneuver combined with controlled low Central venous pressure prolongs hepatic hilum occlusion time in patients with hepatocellular carcinoma complicated by post hepatitis B cirrhosis: a randomized controlled trial

Background: The optimal occlusion and reperfusion time to balance blood loss and ischemia–reperfusion injury to the remnant liver remains unclear. The aim was to explore the clinical impact of prolonging the hepatic hilum occlusion time from 15 to 20 min using the intermittent Pringle maneuver (IPM) combined with controlled low central venous pressure (CLCVP). Methods: A total of 151 patients were included and divided into an experimental group (Group 20,75 cases) and a control group (Group 15,76 cases). In both groups, the hepatic hilum was blocked by the IPM combined with CLCVP to control intraoperative hepatic cross-sectional bleeding. The preoperative, intraoperative and postoperative parameters and safety were compared between the two groups. Results: There were no significant differences between the two groups in the postoperative aminotransferase serum levels (p > 0.05). However, the operation time in Group 20 was significantly lower than that in Group 15 (222.4 ± 87.8 vs. 250.7 ± 94.5 min, p < 0.05). The procalcitonin at 1 day after operation in Group 20 was lower than that at 1 day after operation in Group 15 (0.78 ± 0.66 vs. 1.45 ± 1.33 ng/mL, p < 0.05). There was no significant difference in the incidence of postoperative bleeding, postoperative bile leakage and postoperative infection between the two groups (p > 0.05). Conclusions: For patients with hepatocellular carcinoma after hepatitis B cirrhosis, it is feasible and safe to prolong the hepatic hilum occlusion time from 15 to 20 min using the IPM combined with CLCVP.

Laparoscopic Left Hemihepatectomy for Intrahepatic Cholangiocellular Carcinoma: An Adequate Lymphadenectomy is Also Possible in Artery Variation

BackgroundLaparoscopic liver resection (LLR) is becoming essential in the treatment of malignant liver tumors but only a few reports exist about LLR for intrahepatic cholangiocarcinoma (IHCC).MethodsWe present a video of a laparoscopic left hemihepatectomy with lymphadenectomy for IHCC.Case presentationA 67-year-old asymptomatic male underwent a routine abdominal ultrasound, revealing a 15 × 9 mm solid nodular iso-hyperechoic lesion, located in SIII, with SII/III biliary duct dilation. Magnetic resonance imaging confirmed a 32 × 22 mm lesion in SII/III, with mild hyper-intensity on T2-weighted images and strong hypo-intensity on T1-weighted images. After administration of contrast medium, the lesion showed light peripheral enhancement on the portal and delayed phases, and hypo-intensity on the hepatospecific phase. No relevant comorbidities were reported (KPS 100). Laboratory tests showed normal liver function and normal CA19-9 levels. A laparoscopic left hemihepatectomy was indicated.ResultsOperative time was 330 min. Four intermittent Pringle maneuver cycles were applied and no blood transfusions were administered. Intraoperative ultrasound confirmed preoperative findings and additionally highlighted involvement of the SIV duct. A full replacing right hepatic artery arising from the superior mesenteric artery was identified and was preserved during hilar dissection. Postoperative course was uneventful and the patient was discharged on postoperative day 3. The pathology report indicated cholangiocellular carcinoma pT1bN0. Twelve lymph nodes were retrieved.ConclusionsAccording to recent literature reports and our experience, laparoscopic surgery for intrahepatic cholangiocellular carcinoma should be considered feasible and safe in selected patients. Hepatic artery variations allow for adequate lymphadenectomy. Oncological long-term results require multicenter randomized studies in order to be validated.

Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy

Jehovah’s Witness patients presenting for liver surgery pose challenges to the anesthetists as well as the surgeons, due to their abstinence from receiving blood products. Despite this, surgery is the only curative option for operable colorectal liver metastases (CRLM). We report a case of a Jehovah’s Witness with multiple comorbidities who had a parenchyma sparing hepatectomy (PSH) complicated by intraoperative bleeding. A 52-year-old ASA II patient with hypertension, diabetes and ischemic heart disease on dual antiplatelet therapy was scheduled for open PSH for multiple bilobar CRLMs. He was prehabilitated with an emphasis on enhancing erythropoiesis and improving his functional capacity. PSH was done using a Cavitron ultrasonic surgical aspirator (CUSA) with intermittent Pringle maneuver, a low central venous pressure and restricted intravenous fluids. His postoperative recovery was complicated by a minor upper gastrointestinal bleed that was managed conservatively.&#x0D; The authors certify that informed written consent has been obtained from patient for publication.&#x0D; Keywords: Jehovah’s Witness; Liver surgery; Anesthesia; Hepatectomy&#x0D; Citation: Dassanayake V, Sivaganesh S, Subasinghe D, Pitigala P. Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy. Anaesth. pain intensive care 2021;26(1):119–122 ;&#x0D; DOI: 10.35975/apic.v26i1.1787&#x0D; Received: October 16, 2021, Reviewed: October 28, 2021, Accepted: November 07, 2021

A randomized controlled trial of effect of 15- or 25-minute intermittent Pringle maneuver on hepatectomy for hepatocellular carcinoma

BackgroundThe feasibility and safety of using longer ischemic interval during intermittent Pringle maneuver for hepatectomy in patients with hepatocellular carcinoma are still unclear. The aim of this study was to compare the short-term outcomes of hepatectomy using intermittent Pringle maneuver with an ischemic interval of 25 minutes versus 15 minutes in hepatocellular carcinoma patients. MethodsA total of 344 patients with hepatocellular carcinoma undergoing hepatectomy were randomized to receive the intermittent Pringle maneuver with a 15-minute (n = 172) or 25-minute (n = 172) ischemic interval. Primary endpoint was transaminase-based postoperative hepatic injury, assessed by their peak values as well as area under the curve of the postoperative course of aminotransferases. Secondary endpoints included the intraoperative blood loss, transection speed, morbidity, mortality, and postoperative inflammatory reaction. ResultsThere were no significant differences between the 2 groups in the postoperative aminotransferase serum levels or their area under the curve values, but the 25-minute intermittent Pringle maneuver group was associated with significantly higher speed for liver transection (1.38 vs 1.23 cm2/min, P = .002) and a lower blood loss during transection (109 vs 166 mL, P < .001) than the 15-minute intermittent Pringle maneuver group. Postoperative complications, inflammatory cytokines serum levels, and 90-day mortality were comparable. Stratification analysis showed that the 25-minute intermittent Pringle maneuver did not aggravate the hepatic injury but resulted in a lower blood loss during transection and higher transection speed in hepatocellular carcinoma patient undergoing laparoscopic or open hepatectomy. ConclusionIntermittent Pringle maneuver with a 25-minute ischemic interval can be applied safely and efficiently in open or laparoscopic hepatectomy in patients with hepatocellular carcinoma patients.

Safety of intermittent Pringle maneuver during minimally invasive liver resection in patients with hepatocellular carcinoma with and without cirrhosis

PurposeThe aim of this study was to analyze the impact of minimally invasive intermittent Pringle maneuver (IPM) on postoperative outcomes in patients with hepatocellular carcinoma (HCC) and liver cirrhosis.MethodsIn this retrospective cohort study, we evaluated the safety of IPM in patients with HCC who underwent minimally invasive liver resection during five years at our center. Factors influencing the use of IPM were examined in univariate and multivariate regression analysis. Cases with use of IPM (IPM) and those without use of IPM (no IPM) were then compared regarding intraoperative and postoperative outcomes after propensity score matching (PSM) for surgical difficulty.ResultsOne hundred fifty-one patients underwent liver resection for HCC at our center and met inclusion criteria. Of these, 73 patients (48%) received IPM with a median duration of 18 min (5–78). One hundred patients (66%) had confirmed liver cirrhosis. In multivariate analysis, patients with large tumors (≥ 3 cm) and difficult tumor locations (segments VII or VIII) were more likely to undergo IPM (OR 1.176, p = 0.043, and OR 3.243, p = 0.001, respectively). After PSM, there were no differences in intraoperative blood transfusion or postoperative complication rates between the IPM and no IPM groups. Neither did we observe any differences in the subgroup analysis for cirrhotic patients. Postoperative serum liver function tests were not affected by the use of IPM.ConclusionsBased on our findings, we conclude that the use of IPM in minimally invasive liver resection is safe and feasible for patients with HCC, including those with compensated liver cirrhosis.

The difference in prolonged continuous and intermittent Pringle maneuver during complex hepatectomy for hepatocellular carcinoma patients with chronic liver disease: A retrospective cohort study.

PurposeTo explore the differences between prolonged continuous Pringle maneuver (CPM) and prolonged intermittent Pringle maneuver (IPM) in patients with hepatocellular carcinoma (HCC), who underwent complex hepatectomy.MethodsThis retrospective cohort study performed between June 2014 and May 2016 included 142 patients who underwent complex hepatectomy for HCC and concomitant chronic liver disease but with good liver function. Patients were categorized into CPM (n = 69) and IPM groups (n = 73). The differences in these aspects were compared between the two groups which include operation time, intraoperative bleeding, perioperative transfusion, postoperative complications, liver function injury, postoperative overall survival (OS), and tumor recurrence.ResultsThe cumulative clamping time, operation time, intraoperative bleeding, and perioperative transfusion rates were 38.0, 132 min, 300 ml, and 17.4% in CPM and 40.0, 145 min, 400 ml, and 32.9% in IPM, respectively. There were significant intergroup differences in operation time (p = 0.018), intraoperative bleeding (p < 0.001), and perioperative transfusion rates (p = 0.034). Besides, the postoperative complications and postoperative liver function injury of the CPM group were better than those of IPM. There was no significant intergroup difference in OS (p = 0.908) and tumor recurrence (p = 0.671) between two groups.ConclusionCompared with IPM, CPM with a cumulative clamping time between 30 and 50 min can shorten operation time, reduce intraoperative bleeding and perioperative transfusion, and reduce postoperative complications and postoperative liver function injury in patients who underwent complex hepatectomy for HCC and concomitant liver disease but with good liver function. There was no significant difference in OS and tumor recurrence between two groups.

Impact of pringle maneuver on the early recurrence of colorectal cancer liver metastasis after liver resection: a systematic review and meta-analysis

Purpose: Pringle maneuver (PM) includes continuous PM, intermittent PM (IPM), prolonged PM and other different types of blocking blood flow. The impact of PM on tumor recurrence of hepatectomy in patients with colorectal cancer liver metastases (CRLM) remains controversial. The present study aimed to assess whether different types of PM have an adverse effect on the recurrence of CRLM. Methods: PubMed, Embase, Web of Science, and the Cochrane Library databases were searched. We registered the protocol at the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42020179534). The IPM is defined as the portal triad clamping for several min, followed by several min of reperfusion, repeated as needed. Prolonged PM was defined as ≥20 min continuous or ≥3 cycles for maximally 15-min intermittent ischemia. Results: Nine studies encompassing 3562 patients were included in this meta-analysis. The pooled HR did not show any significant difference between IPM and non-IPM groups for disease-free survival (DFS) (HR = 0.91, 95% CI 0.80–1.04, P = 0.18). The results showed significant differences between prolonged PM and non-PM groups for DFS (HR = 1.75, 95% CI 1.28–2.40, P = 0.0005) and 1-year DFS rate (odds ratio = 2.77, 95% CI 1.15–6.72, P = 0.02). Conclusion: These findings suggested that IPM has no effect on DFS, but prolonged PM has an adverse impact on the early recurrence of patients with CRLM; however, further prospective and multicenter studies are needed.

Laparoscopic segment 8 liver resection

Presenter: Chaya Shwaartz MD | University Health Network, Toronto General Hospital Background: Laparoscopic resection of segment 8 liver lesions is technically challenging due to the anatomical complexity of the liver as well as the location of segment 8 in the dome of the liver1. In fact, segment 8 resections are considered to be one of the most challenging laparoscopic liver resections2–4. Additionally, expertise in laparoscopic surgery is needed to safely expose and dissect the hepatic veins. We present a case of a laparoscopic segment 8 resection with transthoracic trocar use. Methods: Case presentation: This is a video presentation of a 66 year-old male with a history of locally advanced rectal adenocarcinoma for which he underwent neoadjuvant chemoradiation followed by a pelvic exenteration. He was then diagnosed with a single colorectal liver metastasis in segment 8 and was started on chemotherapy with a good response. Subsequently, the patient was taken to the operating room for a laparoscopic segment 8 liver resection preserving the right and middle hepatic veins. We used intraoperative ultrasound for accurate anatomical evaluation. For the parenchymal transection, a cavitron ultrasonic surgical aspirator (CUSA) was used as well as an energy device under intermittent pringle maneuver. A trans-thoracic trocar was also introduced for better exposure and to approach the most superior aspect of the lesion. Estimated blood loss was 200 cc. Results: Final pathology showed 3.2 cm adenocarcinoma with negative resection margins. The patient had an uneventful post-operative recovery with no evidence of recurrence. Conclusion: Conclusion: Laparoscopic segment 8 liver resection is feasible and safe when performed in tertiary liver surgery centers. Trans-thoracic approach allows access to the most posterior and superior segments of the liver.

Indocyanine green fluorescence guided laparoscopic hepatectomy of segment VI for metachronous colorectal liver metastases in a severely obese patient

Purpose: Liver resections in severely obese patients (BMI > 35) are related with increased post-operative morbidity. The use of the laparoscopic approach is associated with fewer complications vs open approach. Indocyanine green (ICG) fluorescence has been recently used for tumour identification in laparoscopic liver resections. We describe a total laparoscopic hepatectomy of segment VI using ICG fluorescence guided technique in a severely obese patient. Method: 68 years old male patient was referred to our unit for management of metachronous liver metastases of segment VI. He had undergone open sigmoidectomy three years ago for a pT4aN2a sigmoid adenocarcinoma. Upon diagnosing metachronous metastatic liver disease, five cycles of preoperative chemotherapy were administered with a good response, as reflected by Carcinoembryonic antigen values and radiological assessment (PET-CT and CT abdo). The patient was severely obese (BMI:37) with a post-operative midline hernia. A laparoscopic approach was decided. Material: ICG (2,5 mg) was administered intravenously 24 hrs prior to surgery. In theatre, the patient was placed in a left lateral decubitus position. Initially, an intraoperative U/S was performed. Total laparoscopic resection of segment VI was performed. Liver transection was performed using laparoscopic Cusa, harmonic scalpel, and intermittent Pringle manoeuvre application. Liver resection with clear macroscopically margins was facilitated significantly by ICG fluorescence image-guided for tumour identification. The specimen was removed through the previous midline incision, and the incisional hernia was corrected. The post-operative course was uneventful, and the patient was discharged on the 4th post-operative day. Histopathology confirmed the presence of metastatic colon adenocarcinoma with clear resection margins (R0 resection). Conclusion: The use of image-guided techniques, for intra-operative tumour identification, facilitates the safe performance of laparoscopic liver resections in severely obese patients with good post-operative outcome.

Simultaneous Sigmoid Colectomy, Bilobar Liver Resection and Lung Metastasectomy via a Transdiaphragmatic Approach for Stage IV Colonic Adenocarcinoma

Current evidence supports the curative resection of colorectal cancer and synchronous liver and lung metastases in selected patients.1,2 This video shows simultaneous left colectomy, bilobar liver resection, and lung metastasectomy via a transdiaphragmatic approach for stage IV colorectal cancer.3 PATIENT: A 57-year-old man with a stage IV colonic adenocarcinoma was considered for simultaneous resection of primary, liver, and lung metastases without thoracic incision. The tumor mutational status was KRAS, NRAS, and BRAF wild-type, and the patient underwent preoperative chemotherapy. After performing a midline laparotomy, atypical liver resection of segments 8/4a was performed under the guidance of intraoperative ultrasonography and intermittent Pringle maneuver using the two-surgeon's technique. A small capsular lesion in segment 3 also was intraoperatively detected and resected. Lung metastasectomy of the right lower lobe was performed via a transdiaphragmatic approach using an endoscopic stapler. Sigmoid colectomy with transanal circular-stapled anastomosis was performed. Duration of surgery and blood loss were 358min and 400ml, respectively. Histopathological examination showed metastatic colonic adenocarcinoma with negative surgical margins and final stage was T3N2aM1b. The patient was discharged on postoperative day 6without complication. He was alive and free of disease at 90-day follow-up. Simultaneous colon, liver, and lung resection via a transdiaphragmatic approach is a feasible and safe surgical strategy in selected patients with peripheral lung metastases and favorable tumor biology.4 This surgical strategy avoids thoracic incision, multiple operations, and may reduce the healthcare costs and the recovery time to early implement postoperative therapy.

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

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.

Comparison of Early Clinical Outcomes between Intermittent Vascular Inflow Occlusion versus Intermittent Selective Hepatic Vascular Exclusion in Hepatic Resections for Cholangiocarcinoma Patients: A Prospective Randomized Controlled Trial Study

Background: There were reported benefits of selective hepatic vascular exclusion (SHVE) in reducing intraoperative blood loss (IBL), intraoperative packed red cell (PRC) transfusion, and perioperative complications over intermittent Pringle maneuver (IPM) in hepatectomies. However, there was lack of data regarding the use of SHVE in comparison with IPM in hepatectomies for cholangiocarcinoma (CCA) patients. Objective: To compare IBL, intraoperative PRC transfusion, total operative time (TOT), and perioperative complications between SHVE and IPM. Materials and Methods: Between October 2018 and September 2019, forty eligible CCA patients participated in the study. They were randomly allocated to the SHVE group (n=20) or the IPM group (n=20). Data regarding patient demographics, tumor characteristics, and the objectives of the study were gathered and analyzed with intention-to-treat principle. Results: The median IBL (range) 923.5 (101 to 4,979) versus 1,109 (413 to 5,305) ml; p=0.2, median intraoperative PRC transfusion (range) 112.5 (0 to 1,745) versus 296 (0 to 1,500) ml; p=0.22, and median TOT (range) 390 minute (220 to 915) versus 320 (240 to 930) minutes; p=0.55 between SHVE and IPM were not significantly different. There was no statistical difference in perioperative complications between SHVE and IPM. Conclusion: Routine use of SHVE during hepatectomies in CCA patients showed no significant difference in outcomes regarding the objectives of the study. Keywords: Selective hepatic vascular exclusion (SHVE), Hepatic vascular exclusion with preservation of caval flow (HVEPV), Hepatic resection, Cholangiocarcinoma, Intraoperative blood loss, Perioperative complications

Does the intermittent Pringle maneuver affect the recurrence following surgical resection for hepatocellular carcinoma? A systematic review.

Background and aimTo evaluate the effect of intermittent pringle maneuver (IPM) on the long-term prognosis and recurrence of hepatocellular carcinoma (HCC).MethodsEligible studies were identified by PubMed and other databases from Jan 1st 1990 to Mar 31st 2019. Hazard ratios (HR) with 95% confidence interval (CI) were calculated to evaluate the effects of IPM on the long-term prognosis and recurrence of patients with HCC.ResultsSix studies were enrolled in this meta-analysis. Results showed that there were no differences between IPM group and non-IPM group in the pooled HRs for the overall survival (OS) and disease-free survival (DFS) (HR 1.04, 95%CI 0.84~1.28, P = 0.74; HR 0.93, 95%CI 0.81~1.07, P = 0.29; respectively). However, subgroup analysis showed that the pooled Odd ratios (OR) for the 1-year OS and DFS rates of the IPM group when compared with the non-IPM group were 0.65 (95% CI 0.45~0.94, P = 0.02), 0.38 (95% CI 0.20~0.72, P = 0.003), respectively. In addition, there were no significant differences in the proportions of liver cirrhosis, HBsAg (+), Child-Pugh A class, multiple tumor, vascular invasion, and major hepatectomy between groups of IPM and non-IPM.ConclusionSince IPM would increase the risk of early-recurrence, it should be used cautiously in the procedure of hepatectomy for resectable HCC. However, the current conclusion needs further validation.Trial registry numberCRD 42019124923