Total Hepatic Inflow Occlusion Research Articles

Comparison of the benefits and risks of hemihepatic inflow occlusion: a systematic review and meta-analysis.

Application of hemihepatic inflow occlusion (HIO) and total hepatic inflow occlusion (TIO) are two common approaches for hepatectomy. However, their efficacy and safety remain controversial. Randomized control trials (RCTs) published before 15t January 2023 were included by a systematic literature search, which compared the clinical outcomes between HIO and TIO. The primary outcome was the estimated blood loss (EBL). Three independent authors screened and extracted the data and resolved disagreements by consensus. The ROB2.0 tool was used for evaluating the risk of bias. A total of 1026 patients (511 TIO and 515 HIO) from 9 studies were analyzed in the meta-analyses. The EBL between TIO and HIO group was similar, while HIO was associated with a lower proportion of patients required transfusion (P=0.002), less units of blood transferred (P<0.001) and a lower overall complication rate (P=0.008). There were no significant differences between TIO and HIO in mortality (P=0.37), length of stay (P=0.97), bile leak rate (P=0.58), liver failure rate (P=0.96), reoperation rate (P=0.48), postoperative haemorrhage rate (P=0.93) and incidence of postoperative ascites (P=0.96). The operative time of HIO was usually no more than 15 min longer than that of TIO (P<0.001). Comparing with the TIO, HIO increased the operative time and failed to further reduce the EBL in patients with liver surgery. However, despite the complexity of the operation, HIO was recommended due to the similar effect on the consumption of blood products and the postoperative complications.

A commentary on "Hemihepatic versus total hepatic inflow occlusion for laparoscopic hepatectomy: A randomized controlled trial." (Int J Surg. 2022;107:106961.).

aHepatological Surgery Department, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China bHepatopancreatobiliary Surgery Clinic, Kunming Medical University Second Hospital, Kunming, Yunnan Province, China Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Published online ■ ■ *Corresponding author. Address: Kunming Medical University Second Hospital, Kunming, China China. . E-mail address: [email protected] (J. Huang). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Hemihepatic versus total hepatic inflow occlusion for laparoscopic hepatectomy: A randomized controlled trial

BackgroundAn appropriate bleeding control technique for laparoscopic liver resection (LLR) is needed to decrease intraoperative blood loss and avoid large hemorrhages. To date, hemihepatic inflow occlusion (HIO) versus total hepatic inflow occlusion (TIO) for LLR is still controversial. Thus, we performed this randomized controlled trial (ChiCTR-IOR-17013866) to compare the perioperative outcomes between HIO and TIO for LLR. MethodsFrom December 2017 to August 2019, patients met the criteria via surgical exploration in the operation room and were randomly assigned to both groups. Perioperative data between both groups were recorded and compared, and subgroup analysis was further performed. Results258 patients were allocated to the TIO (n = 129) and HIO (n = 129) groups, respectively. There was no significant difference between the two groups in terms of intraoperative blood loss, operative time, postoperative complications, changes in postoperative liver function or early mortality. However, for patients whose transection plane was located on the liver Cantlie's plane, subgroup analysis results indicated that TIO had a shorter operative time (median, 220 vs. 240 min, P = 0.030) and occlusion time (median, 45 vs. 60 min, P = 0.011) and less intraoperative blood loss (median, 200 vs. 300 ml, P = 0.002) than HIO, whereas the morbidity and mortality of the two groups were comparable. ConclusionBoth the TIO and HIO approaches could be safely performed for LLR in selected patients when performed by experienced surgeons. The TIO technique for LLR had the advantage of being easier to master than the HIO approach. Additionally, when the transection plane was located on the liver Cantlie's plane, TIO seems to have some superior perioperative outcomes.

Impact of hepatic blood inflow occlusion without hemihepatic artery control on tumor suppression and liver function in rat liver cancer model

Objective To study the effect of hepatic blood inflow occlusion without hemihepatic artery control on tumor suppression and liver function in rat liver cancer model. Methods Thirty SD rats were randomly divided into total hepatic inflow occlusion control group, hepatic vascular occlusion group, and hepatic blood inflow occlusion without hemihepatic artery control group. Three days after liver cancer moldel was established, the blood flow reperfusion was performed on the livers after 60 min of hepatic vascular occlusion. Five days after reperfusion, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and albumin (ALB), and superoxide dismutase (SOD) and malondialdehyde (MDA) in liver tissues were determined. Liver cell apoptosis rate and tumor suppression rate were calculated. Results In hepatic vascular occlusion group and hepatic blood inflow occlusion without hemihepatic artery control group, serum ALT and AST levels were significantly lower, and ALB levels were significantly higher than in control group [(70.97±8.62) vs. (72.04±8.54) vs. (268.26±46.39) IU/L, (386.86±50.28) vs. (392.53±22.47) vs. (1 109.24±279.35) IU/L, (29.54±2.16) vs. (28.63±2.27) vs. (25.29±2.13) g/L, t=13.222, 8.048, 4.430, 13.151, 8.087 and 3.393, P=0.001, 0.008, 0.018, 0.000, 0.008, 0.024]. In hepatic vascular occlusion group and hepatic blood inflow occlusion without hemihepatic artery control group, liver tissue SOD levels were significantly higher, and MDA and liver cell apoptosis rate were significantly lower than in control group [(152.32±16.21) vs. (148.47±15.24) vs. (89.12±9.45) U/mgprot, (18.36±3.14) vs. (19.32±2.95) vs. (48.36±5.23) nmol/mg, (14.35±1.45)% vs. (15.12±1.54)% vs. (25.14±2.14)%, t=10.651, 15.552, 13.200, 10.466, 15.294 and 12.018, P=0.001, 0.001, 0.001, 0.001, 0.001, 0.001]. In hepatic vascular occlusion group and hepatic blood inflow occlusion without hemihepatic artery control group, tumor weight was significantly reduced as compared with control group [(1.83±0.32) vs. (1.90±0.35) vs. (2.62±0.41) g, t=4.803, and 4.224, P=0.008, 0.018]. There were no statistically significant differences in ALT, AST, SOD, MDA, liver cell apoptosis rate, tumor weight, and tumor suppression rate between hepatic vascular occlusion group and hepatic blood inflow occlusion without hemihepatic artery control group. Conclusion Hepatic blood inflow occlusion without hemihepatic artery control can reduce liver ishemia-reperfusion injury in rat liver cnacer model, promote tumor suppression effect, and the operation security is higher than hepatic vascular occlusion. Key words: Carcinoma, hepatocellular; Ischemia-reperfusion; Hepatic blood inflow occlusion without hemihepatic artery control; Liver function

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.

Minimizing blood loss during hepatectomy: A literature review

There are numerous techniques surgeons employ to reduce blood loss during partial hepatectomy. In this literature review, prospective studies from the last 20 years are examined to determine the techniques that are best supported by the literature. Some of the techniques include vascular control, multiple parenchymal transection techniques, various hemostatic agents, low central venous pressure, and hemodilution. The strategies supported most convincingly by the literature include low CVP and total hepatic inflow occlusion.

Hemihepatic versus total hepatic inflow occlusion during hepatectomy: a systematic review and meta-analysis.

To evaluate the clinical outcomes of patients undergoing hepatectomy with hemihepatic vascular occlusion (HHO) compared with total hepatic inflow occlusion (THO). Randomized controlled trials (RCTs) comparing hemihepatic vascular occlusion and total hepatic inflow occlusion were included by a systematic literature search. Two authors independently assessed the trials for inclusion and extracted the data. A meta-analysis was conducted to estimate blood loss, transfusion requirement, and liver injury based on the levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Either the fixed effects model or random effects model was used. Four RCTs including 338 patients met the predefined inclusion criteria. A total of 167 patients were treated with THO and 171 with HHO. Meta-analysis of AST levels on postoperative day 1 indicated higher levels in the THO group with weighted mean difference (WMD) 342.27; 95% confidence intervals (CI) 217.28-467.26; P = 0.00 001; I(2) = 16%. Meta-analysis showed no significant difference between THO group and HHO group on blood loss, transfusion requirement, mortality, morbidity, operating time, ischemic duration, hospital stay, ALT levels on postoperative day 1, 3 and 7 and AST levels on postoperative day 3 and 7. Hemihepatic vascular occlusion does not offer satisfying benefit to the patients undergoing hepatic resection. However, they have less liver injury after liver resections.

Clinical study of the method of hepatic vascular occlusion during resection of liver carcinoma

To evaluate the optimal method for hepatic vascular occlusion during resection of liver carcinoma. One hundred and twenty-four patients with liver carcinoma were divided into four groups of hepatectomy with total hepatic inflow occlusion (group A, 51 cases), selective hepatic inflow occlusion (group B, 38 cases), selective exclusion of hepatic inflow and outflow (group C, 24 cases) and total hemi-hepatic vascular exclusion (group D, 11 cases). The time of operation and hepatic vascular occlusion, intraoperative blood loss and transfusion, postoperative liver function, complications and mortality were compared among the four groups. There were no significant difference among the four groups statistically in preoperative basic states (P > 0.05). The duration of operation was prolonged significantly in group C and D than that of group A, but intra-operative blood loss and transfusion requirements were decreased significantly in group C and D versus group A and B (P < 0.05). There was no significant difference among the four groups regarding ischemia time, postoperative complications and mortality (P > 0.05). The level of postoperative alanine aminotransferase was higher in group A than other three groups (P < 0.05). The postoperative total bilirubin increased significantly in group A contrast to group B (P < 0.05). Each hepatic vascular occlusion technique has its place in liver resection. The size and location of tumor, preoperative liver function, underlying liver disease, cardiovascular and cerebral vessels status, and most important the experience and capability to weigh the merits and demerits of the surgeon should be taken into account to select the most appropriate occlusion method.

Hypertonic saline dextran alleviates hepatic injury in hypovolemic rats undergoing porta hepatis occlusion.

To monitor the ischemic and/or reperfusion injury after porta hepatis occlusion (Pringle maneuver) in livers subjected to hypotension, serum alanine amino transferase (ALT), liver malondialdehyde (MDA), and liver glutathione (GSH) levels were measured. MDA is a by-product of oxidant-induced lipid peroxidation, and GSH is an endogenous antioxidant. The effects of lactated Ringer's (LR) and hypertonic saline (7.5%)/Dextran (6%; HSD) resuscitation on liver injury, if any, was investigated. Rats in sham (S, n = 8) and five other groups (n = 8) underwent femoral artery and vein catheterization and laparotomy. The hemorrhage and ischemia (HI) group was bled 30% of their blood volume and had their porta hepatis occluded for 30 min. The HI, LR, and HSD groups underwent both hemorrhage and occlusion. Thirty minutes after hemorrhage, the LR and HSD groups received either LR (equivalent to three times the shed blood) or HSD (10 mL/kg) resuscitation over 30 min. Both LR and HSD resuscitation lowered the increased ALT and liver tissue MDA seen in the HI group. ALT was decreased from 348 +/- 93 IU/L in the HI group to 200 +/- 98 IU/L in the LR and 139 +/- 74 IU/L in the HSD groups. Liver tissue MDA was 353 +/- 22 nmol/g/tissue in the HI group and LR decreased it to 261 +/- 17 nmol/g/tissue, whereas HSD decreased it to 273 +/- 20 nmol/g/tissue. The decrease in ALT and the increase in liver GSH were more pronounced with HSD resuscitation (P < 0.05). HSD seems to be more effective than LR in decreasing the liver tissue damage produced by total hepatic inflow occlusion under hypovolemic conditions.

Heat shock protein 72 production in liver tissue after experimental total hepatic inflow occlusion

The pathogenesis of hepatic ischaemia-reperfusion injury is incompletely understood. This study examined the effects of reperfusion with congested portal blood on ischaemia-reperfusion injury of the liver following Pringle's manoeuvre, as monitored by heat shock protein (HSP) 72 production in rat liver tissue. Rats were randomized to three groups. In group 1 hepatic ischaemia with portal congestion was induced by Pringle's manoeuvre for 15 min; in group 2 Pringle's manoeuvre was applied for 15 min with an extracorporeal portasystemic shunt; and in group 3 the superior mesenteric vein was occluded for 15 min. The production of HSP72 in liver tissue was measured by Western blotting at 48 h after each intervention. Conventional parameters for hepatic function were examined at 1, 3 and 48 h after reperfusion. There was marked HSP72 expression in group 1, but not in group 2 or 3, showing that a combination of liver ischaemia and reperfusion of congested portal blood is required to induce strong expression of HSP72 in the tissue. On the other hand, biochemical parameters were raised equally in both groups 1 and 2, reflecting a similar degree of ischaemic hepatocyte injury. The additional stress impact of temporary portal occlusion upon ischaemia-reperfusion injury of the liver was clearly detected by in situ hepatic HSP72 production in this study.

Reduction of hepatic ischemia/reperfusion injury by a soluble P-selectin glycoprotein ligand-1.

The authors' goal was to determine the effects of specific binding and blockade of P- and E-selectins by a soluble P-selectin glycoprotein ligand-1 (PSGL-1) in rat models of hepatic in vivo warm ischemia and ex vivo cold ischemia. The authors also sought to determine the effect of selectin blockade on isograft survival in a syngeneic rat orthotopic liver transplant model. Ischemia/reperfusion (I/R) injury is a major factor in poor graft function after liver transplantation, which may profoundly influence early graft function and late changes. It is hypothesized that I/R injury leads to the upregulation of P-selectin, which is then rapidly translocated to endothelial cell surfaces within 5 minutes of reperfusion of the liver, initiating steps leading to tethering of polymorphonuclear neutrophil leukocytes to the vascular intima. Local production by leukocytes of interleukin-1, tumor necrosis factor-alpha, or both induces P-selectin expression on the endothelium and continues the cascade of events, which increases cell adherence and infiltration of the organ. To examine directly the effects of selectins in a warm hepatic I/R injury model, 100 microg of PSGL-1 or saline was given through the portal vein at the time of total hepatic inflow occlusion. The effects of PSGL-1 in cold ischemia were assessed using an isolated perfused rat liver after 6 hours of 4 degrees C storage in University of Wisconsin (UW) solution, with or without the instillation of PSGL-1 before the storage. To evaluate the effect of selectin blockade on liver transplant survival, syngeneic orthotopic liver transplants were performed between inbred male Sprague-Dawley rats after 24 hours of cold ischemic storage in UW solution. A separate group of animals received two doses of 100 microg of PSGL-1 through the portal vein before storage and before reperfusion of the transplanted liver. Recipient survival was assessed at 7 days, and the Kaplan-Meier product limit estimate method was used for univariate calculations of time-dependent recipient survival events. In an in vivo warm rat liver ischemia model, perfusion with PSGL-1 afforded considerable protection from I/R injury, as demonstrated by decreased transaminase release, reduced histologic hepatocyte damage, and suppressed neutrophil infiltration, versus controls (p < 0.05). When cold stored livers were reperfused, PSGL-1 reduced the degree of hepatocyte transaminase release, reduced neutrophil infiltration, and decreased histologic hepatocyte damage (p < 0.05 vs. UW-only controls). On reperfusion, livers treated with PSGL-1 demonstrated increased portal vein blood flow and bile production (p < 0.05 vs. UW-only controls). In addition, 90% of the rats receiving liver isografts stored in UW solution supplemented with PSGL-1 survived 7 days versus 50% of those whose transplanted syngeneic livers had been stored in UW alone (p < 0.05). Selectins play an important role in I/R injury of the liver. Early modulation of the interaction between P-selectin and its ligand decreases hepatocyte injury, neutrophil adhesion, and subsequent migration in both warm and cold rat liver ischemia models. In addition, the use of PSGL-1 before ischemic storage and before transplantation prevents hepatic injury, as documented by a significant increase in liver isograft survival. These findings have important clinical ramifications: early inhibition of alloantigen-independent mechanisms during the I/R damage may influence both short- and long-term survival of liver allografts.

肝切除時における反復全肝流入血遮断の肝に及ぼす影響

肝切離時の出血制御のために用いているPringle法による反復全肝流入血遮断が, 肝にどの程度の障害を与えているかを検討するため, 16例の肝切除例において, 術中, 非切除側の肝静脈血を採血し, 血液ガス分析, ケトン体比 (HVKBR), 過酸化脂質および動脈血ケトン体比 (AKBR) を測定し解析した. 非腫瘍部肝実質に慢性肝障害像を認める障害肝群と, それを認めない正常肝群の2群に分けて比較検討を行った. 酸素飽和度, 過酸化脂質, HVKBR, AKBRは, いずれの群においても前値と最終値との間に有意な変動を認めなかったのに対し, 障害肝群においては, PvCO2の有意な上昇とpH, HCO3-の有意な低下を認めた. 反復全肝流入血遮断の肝におよぼす虚血障害は, 非常に軽度でかつ速やかに回復しうる程度のものであるが, 慢性障害肝においては, 代謝性アシドーシスの進行に注意する必要があることが明らかになった.