Use Of Pringle Maneuver Research Articles

Association Between Preoperative Angioembolization and Bleeding Complications in Patients With Benign Liver Tumors: Analysis of a National Database

The role of angioembolization (AE) in patients with benign liver diseases is an area of active research. This study aims to assess any difference in liver resection outcomes in patients with benign tumors dependent on utilization of preoperative AE. A retrospective cohort study of patients undergoing elective liver resections for benign liver tumors was performed using the National Surgical Quality Improvement Program database (2014-2019). Only tumors of 5cm in size or more were included in the analysis. We categorized the patients based on preoperative AE (AE+versus AE -). The primary outcome measured included bleeding complications within 72h. The secondary outcomes were to determine predictors of bleeding. After propensity score matching, there were 103 patients in both groups. There was no difference in intraoperative or postoperative blood transfusions within 72h of surgery (14.6% versus 12.6%; P=0.68), reoperation (1.9% versus 1.9%; P = 1), or mortality (1.0% versus 0.0%; P=1) between the two groups. Multivariate regression analysis revealed an open surgical approach (odds ratio [OR]: 4.59 confidence interval [CI]: 2.94-7.16), use of Pringle maneuver (OR: 1.7, CI: 1.26-2.310), preoperative anemia (OR: 2.79, CI: 2.05-3.80), and preoperative hypoalbuminemia (OR: 1.53 [1.14-2.05]) were associated with the need for intraoperative or postoperative blood transfusions within 72h of surgery. Preoperative AE was not associated with reducing intraoperative or postoperative bleeding complications or blood transfusions within 72h after surgery.

Minimally invasive vs. open approach to the simultaneous treatment of colorectal tumors with synchronous liver metastasis: a single center, propensity-score matched analysis from Mayo clinic

Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections. 384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed. MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality. Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority.

Fluorescence-Guided Robotic Segment 8 Superior Liver Resection. Technical Approach to Sectoral Inflow Occlusion.

In the past decade, precision hepatectomy which requires the understanding of segmental and subsegmental liver anatomy has gained popularity due to its parenchymal-sparing benefits. The importance of this concept has led liver surgeons to a consensus conference and its guideline in regards to precision anatomy in minimally invasive liver resection, held in Tokyo in 2020. A precise control of the sectoral hepatic artery and portal vein allows for a bloodless liver resection, without the use of Pringle maneuver. In the literature, technical description of the right anterior portal pedicle dissection during minimally invasive robotic liver surgery is limited. In this study, we therefore demonstrate such a technique using fluorescence guidance during robotic segment 8 superior liver resection.

Operative and long-term oncologic outcomes of laparoscopic versus open major liver resection in high body mass index patients: A propensity score matching analysis

Laparoscopic liver resection (LLR) in high body mass index (BMI) patients has been reported to be particularly challenging owing to technical difficulties and various comorbidities. We reviewed medical records of patients in high BMI (≥ 25.0 kg/m2) with various liver disease who underwent major liver resection between January 2009 and November 2018 at our center. In total, 521 patients were included in this study and divided into LLR (n = 140) and OLR (n = 381) groups. For group comparisons, 1:1 PSM was used with covariates of baseline characteristics, including tumor characteristics and surgical liver resection procedures. After PSM, there were 120 patients in each groups. LLR group had significantly lower blood loss and shorter postoperative hospital stay (p < 0.001, respectively). Otherwise, the operation time of LLR were significantly longer than that of OLR in obese patients (p < 0.001). Age ≥ 70 years, ≥ 30 BMI, malignancy disease, and use of pringle maneuver were independent predictors for postoperative complication in multivariate analysis. In subgroup analysis with HCC patients, there was no significant difference between the two groups in overall survival hazard ratio (HR), 0.225; 95% confidence interval (CI), 0.049-1.047; p = 0.057) or recurrence-free survival rates (HR. LLR for various liver disease in obese patients results in shorter postoperative hospital stays and lower blood loss compared with OLR. In addition, morbidity and long-term oncological outcomes were comparable between LLR and OLR for obese patient with HCC. Our experience suggests that obesity should not be seen as a contraindication for LLR, which is a safe and feasible option for obese patients.

State of the art in robotic liver surgery: a meta-analysis.

Although the number of robotic hepatectomy (RH) performed is increasing, few studies have reported its efficacy in comparison with the conventional surgical modalities. The aim of this meta-analysis was to evaluate the perioperative results of RH vs. open hepatectomy (OH) and RH vs. laparoscopic hepatectomy (LH). We systematically searched for English papers published in PubMed (Medline), Embase, and Cochrane library before March 1, 2020. A total of 39 papers and 2999 patients were eventually included. Among the included patients, 1249, 1010, and 740 underwent RH, LH, and OH, respectively. Compared with OH, the operation time was significantly increased but the intraoperative blood loss, blood transfusion rate, incidence of severe complications, and length of postoperative hospitalization were significantly reduced in patients with RH. However, there was no significant difference in the use of Pringle maneuver and overall incidence of complications. Compared with LH, the operation time was significantly increased, and the intraoperative blood loss was also more in RH. However, there were no differences in blood transfusion rate, use of Pringle maneuver, incidence of complications, incidence of severe complications, and length of postoperative hospitalization between the two groups. A longer operation time remains the main shortcoming of RH. However, based on the perioperative clinical efficacy, we conclude that RH is comparable to LH but is better than OH for selected patients.

Pringle maneuver and risk of colonic leakage in combined colorectal and hepatic resections: myth or reality?

Background: The aim of the present study was to compare the outcome of combined colorectal and hepatic resections with and without pringle maneuver and to analyse the possible effect of liver-related factors on colonic anastomosis leakage. Methods: 250 Combined colorectal and hepatic resections performed in two european referral centers were stratified according to intraoperative use of Pringle maneuver. 71 procedures with Pringle (Pringle group) were matched with 71 procedures without pringle (NoPringle group) using propensity scores in a 1:1 ratio. Results: The two groups resulted similar in terms of preoperative characteristics (distibution of rectal tumors and neoadjuvant treatments). Intraoperative blood loss was reduced in the Pringle Group (150 ±100 mL) compared with the noPringle group(250 ± 200 mL, p=0.05), while postoperative morbidity (29.5% and 32.4% respectively) and incidence (9.9% in both groups) and severity of colonic fistula. At uni- and multivariate analysis for liver-related factors potentially affecting risk of colonic fistula, a preoperative albumin level < 3.5 g/dL resulted associated with leakage. Extension of liver resection, Pringle maneuver and length of Pringle maneuver did not show a significant correlation with anastomotic leakage. Conclusion: The use of Pringle maneuver in the setting of combined hepatic and colorectal resections allows to maintain a potential advantage in terms of reduction of intraoperative bleeding, without negatively affecting the risk of anastomotic leakage. On the contrary, an impaired synthesis of protein (resulting in a low preoperative level of albumin) seems to affect the risk of leakage, as a result of an ineffective wounds healing.

Quantintative risk assessment for post-hepatectomy liver failure: analysis of the 2015 ACS-NSQIP procedure-targeted hepatectomy database

Background: Post-hepatectomy liver failure (PHLF) is a feared complication following liver resection and a major cause of significant perioperative morbidity and mortality. The aim of this study was to analyze the quantitative risk association of perioperative factors with PHLF. Methods: Analysis of patients in the 2015 ACS NSQIP Procedure-Targeted Hepatectomy Database, who underwent hepatectomy, was done. In this database, PHLF is graded according to the International Study Group of Liver Surgery (ISGLS). Multiple regression model was performed to assess the association of perioperative factors with PHLF. Results: A total of 3,854 patients who underwent hepatectomy were analyzed. PHLF occurred in 218 patients (5.7%). Of these, 106 (48.6%) had ISGLS grade A PHLF, 64 (29.4%) grade B, and 48 (22%) grade C. Open hepatectomy was associated with 13-fold risk of PHLF compared to minimally invasive hepatectomy (p = 0.018), postoperative bile leak with a 5-fold risk of PHLF (p < 0.0001) and liver cirrhosis and parenchymal congestion with 2-fold risk of PHLF (p = 0.004 and 0.02). Increased INR and bilirubin on or after postoperative day 5 were associated with slightly increased risk of PHLF (p < 0.0001 and p < 0.001). Preoperative stenting, hepatitis B/C status, intraoperative ablation, major versus minor hepatectomy, duration of drain, and drain bilirubin level had no association with PHLF. Pringle maneuver use and hepatobiliary reconstruction were protective against PHLF. Conclusion: PHLF occurs in 5.7% of hepatectomies. The risk of developing PHLF is 13-fold after open hepatectomy compared to minimally invasive hepatectomy, 5-fold in patients with post- hepatectomy bile leak, and 2-fold in patients with liver parenchymal congestion and cirrhosis. Use of Pringle maneuver and hepatobiliary reconstruction are protective against PHLF.

Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases.

Most studies analyzing the learning experience of laparoscopic liver resection (LLR) focused on the experience of one or two expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of LLR based on the contemporary collective experiences of multiple surgeons at single institution. Retrospective review of 324 consecutive LLR from 2006 to 2016. The cases were performed by 10 surgeons over various time periods. Four surgeons had individual experience with <20 cases, four surgeons with 20-30 cases, and two surgeons with >90 cases. The cohort was divided into two groups: comparing a surgeon's experience between the first 20, 30, 40, and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions, and major hepatectomies. As individual surgeons gained increasing experience, this was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver resections, increased major resections, and increased resections of tumors located at the posterosuperior segments. This resulted in significantly longer operation time and increased use of Pringle maneuver but no difference in other outcomes. Analysis of LLR for tumors in the posterosuperior segments demonstrated that there was a significant decrease in conversion rates after a surgeon had experience with 20 LLR. For major hepatectomies, there was a significant decrease in morbidity, mortality, and length of stay after acquiring experience with 20 LLR. LLR can be safely adopted today especially for lesions in the anterolateral segments. LLR for lesions in the difficult posterosuperior segments and major hepatectomies especially in cirrhosis should only be attempted by surgeons who have acquired a minimum experience with 20 LLR.

A 15-year experience of two hundred and twenty five consecutive right hepatectomies

In case of liver tumor, surgical resection is the therapeutic gold standard to increase patient survival. Among liver resections, right hepatectomy (RH) is defined as a major hepatectomy. The first aim of this study was to analyze the overall morbidity and mortality of patients undergoing RH, the second aim was to assess changes in both patients characteristic and surgical parameters and mortality rates in a single center institution. From 2001 to December 2015, 225 RH were performed in our center. We analyzed two time period: 2001-2007 and 2008-2015. Ninety days post operative mortality was observed in 9 cases (4%) for the overall cohort. We observed a difference between the two groups in the use of Pringle Maneuver (p<0,001). This result is consistent in each major surgical indication: HCC (p=0,001), CLM (p=0,015) and BT (p=0,015). The estimated blood losses improved (p=0,028), particularly for the HCC cases (p=0,024). No difference was observed in terms of number of transfusions received between the two groups. Reduced length of stay was observed in the second group (p<0,001), more markedly for CLM cases (p=0,001). To further improve the outcomes of RH, it is important to performed this major hepatectomy in hepatobiliary centers with an overall liver resection experience of at least few hundred cases.

Early survival and safety of ALPPS: first report of the International ALPPS Registry.

To assess safety and outcomes of the novel 2-stage hepatectomy, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), using an international registry. ALPPS induces accelerated growth of small future liver remnants (FLR) to allow curative resection of liver tumors. There is concern about safety based on reports of higher morbidity and mortality. A Web-based data entry system was created with password access and data pseudoencryption (NCT01924741). All patients with complete 90-day data were included. Multivariate logistic regression analysis was performed to identify independent risk factors for severe complications and mortality and volume growth of the FLR. Complete data were available for 202 patients. A total of 141 (70%) patients had colorectal liver metastases (CRLM). Median starting standardized future liver remnants of 21% increased by 80% within a median of 7 days. Ninety-day mortality was 19/202 (9%). Severe complications including mortalities (Clavien-Dindo≥IIIb) occurred in 27% of patients. Independent factors for severe complications were red blood cell transfusion [odds ratio (OR), 5.2), ALPPS stage I operating time greater than 300 minutes (OR, 4.4), age more than 60 years (OR, 3.8), and non-CRLM (OR, 2.7). Age, use of Pringle maneuver, and histologic changes led to less volume growth. In patients younger than 60 years with CRLM, 90-day mortality was similar to conventional 2-stage hepatectomies for CRLM. This is the first analysis of the ALPPS registry showing that ALPPS has increased perioperative morbidity and mortality in older patients but better outcomes in patients with CRLM.

The incidence and risk factors of gastrointestinal complications after hepatectomy: a retrospective observational study of 1329 consecutive patients in a single center

Despite of the importance of gastrointestinal (GI) complications in morbidity and mortality after major and moderate surgeries, it is not yet specifically studied in patients undergoing hepatectomy. This study was aimed to investigate the in-hospital incidence and potential risk factors of GI complications after open hepatectomy in our hospital. Prospectively recorded perioperative data from 1329 patients undergoing elective hepatectomy were retrospectively reviewed. The in-hospital incidence of GI complications was investigated, and independent risk factors were analyzed by multiple logistic regression. GI complications occurrence was 46.4%. Univariate analysis showed that preoperative Child-Pugh score, total bilirubin, aspartate transaminase, anesthesia duration, operation duration, intraoperative blood loss, crystalloid and colloid infusion, blood transfusion, urine output, use of Pringle maneuver were statistically different between patients with and without GI complications (P<0.05). Moreover, patients with GI complications had a more prolonged postoperative parenteral nutrient supporting time, hospital stay and ICU stay, and higher incidence of other complications than those without GI complications (P<0.05). Multivariate regression indicated that long duration of anesthesia (odds ratio 2.51, P<0.001) and use of Pringle maneuver (odds ratio 1.37, P=0.007) were independent risk factors of GI complications after hepatectomy. The incidence of GI complications after hepatectomy is high, which is related to an increase of other complications and a prolonged hospital stay. Avoidance of routinely use of Pringle maneuver and shortening the duration of anesthesia are important measures to reduce the postoperative GI complications.

Factors affecting acid base status during hepatectomy in cirrhotic patients

ObjectiveTo study acid base changes during hepatectomy in cirrhotic patients and their relations to intraoperative variables and different preoperative scoring systems used to asses hepatic patients.MethodsAfter obtaining approval of the Ethics and Research Committee of the National Liver Institute – Menoufia University and written informed patient consent, 80 patients scheduled for hepatectomy for hepatocellular carcinoma were included in the study. Anesthesia was induced with propofol, fentanyl, and rocuronium then maintained with desflurane and 50% O2 in air. Samples for arterial blood gases and serum lactate were withdrawn from a left radial artery catheter just before the start of resection of liver parenchyma and immediately after its completion. Intraoperative events were recorded including use of Pringle maneuver and fluids and blood products infusions.ResultsNo differences were found in study parameters between Child class A and B patients except for the preresection lactate (p = 0.02). Patients with MELD score <11 had higher preresection HCO3 (p = 0.004), higher BE (p = 0.002), and lower lactate (p = 0.001) than patients with MELD score ⩾11. These findings were true also for patients with MELD-Na score <11 as they had higher preresection HCO3 (p = 0.001), higher BE (p = 0.001), and lower lactate (p < 0.001) than patients with MELD-Na score ⩾11. All patients had significant decrease in pH (p < 0.001), HCO3 (p < 0.001), and BE (p < 0.001) and significant increase in lactate (p < 0.001). These changes were augmented by intraoperative RBCs and FFP transfusion, using Pringle maneuver, but type of hepatectomy had significant effect only on HCO3 and BE. Again these changes in pH, HCO3, BE, and lactate were more obvious in patients with preoperative MELD score ⩾11, and this was also true in patients with preoperative MELD-Na score ⩾11 only with HCO3, BE, and lactate, but not with pH.ConclusionChanges occurred in acid base status during hepatectomy in cirrhotic patients are affected by the preoperative condition of the patient (MELD and MELD-Na scores) as well as by intraoperative transfusion of blood products, use of Pringle maneuver and to a lesser extent by major versus minor hepatectomy.

Living Donor Hepatectomies with Procedures to Prevent Biliary Complications

Biliary complications in donor hepatectomies are still common, and occur in approximately 5% of the procedures. To evaluate the usefulness of the management and surgical procedures to prevent the biliary complications in donor hepatectomies, a total of 343 donors were retrospectively studied. The clinical and surgical parameters of the donors and the postoperative biliary complications were evaluated. Fourteen donors had biliary complication (BC) during the follow-up period (4.1%). Donors were divided into 2 groups; donors without BC (non-BC group; n = 329) and donors with BC (BC group; n = 14). Mean peak level of total bilirubin, mean duration of hospital stay after surgery, and medical cost in the BC group were significantly higher than in the non-BC group (p < 0.01). As improved procedures to prevent the BC were established at 2005, including the use of a real-time cholangiography by the C-arm, a minimized dissection of the hepatic vessels, the meticulous closure of the bile duct, and/or the use of Pringle maneuver during the parenchymal transection, the donors were divided into 2 groups before and after these establishments (the early period, n = 173; the later period, n = 170). Refinements in the management and surgical procedures reduced the occurrence of biliary complications from 6.4% during the early period to 1.8% during the later period (p < 0.01), and no biliary complications in the last 69 consecutive donors were observed. Technical refinements described in this study might be useful to prevent the occurrence of biliary complications in a donor hepatectomy. It is particularly important to preserve the blood supply for the biliary tract of both the graft and the remnant liver.

Neutrophil phenotype and function in partial hepatectomy in man

Hepatic resections are still associated with considerable morbidity mainly because of postoperative infection. Adequate function of neutrophils is a crucial element in host defense. The aim of the study was to characterize neutrophils during partial hepatectomy. Fourteen patients undergoing partial liver resection were enrolled. Twenty-four hours pre-, intra- (after induction of anesthesia, after preparation of the liver, and 15 min after release of the Pringle maneuver), as well as postoperatively (3 h after Pringle; 24, 48, and 120 h after surgery), blood samples were obtained. In addition, healthy volunteers (n = 5) were investigated. Adhesion molecules (CD 62, CD 18), Fcy receptors (CD 16, CD 32), and phagocytosis by neutrophils were characterized by fluorescence-activated cell sorter analysis. Spontaneous and stimulated (formyl-methionyl-leucyl-phenylalanine) oxygen radical generation was measured by lucigenin-enhanced chemiluminescence. Numeric upregulation of CD 62 and CD 18 on neutrophils was seen before the use of Pringle maneuver and persisted thereafter (p < 0.05). Spontaneous numeric expression of Fcy receptors (CD16 and CD 32) was unchanged during liver dissection but downregulated after Pringle maneuver was opened (p < 0.05). Although numeric Fcy receptors were downregulated, phagocytosis of heterologous opsonized Escherichia coli bacteria by neutrophils was unaffected. Spontaneous oxygen radical production peaked sharply 15 min after release of the Pringle maneuver (p < 0.05), contrary to stimulated oxygen radical production, which was depressed 3 h after the release of the Pringle maneuver (ns). Uneventful partial hepatectomy in man resulted already in a significant change in the phenotype but in less significant changes in the functions of neutrophils.