A network meta-analysis comparing perioperative outcomes of interventions aiming to decrease ischemia reperfusion injury during elective liver resection

Abstract

Network meta-analysis articleThe paper is not based on a previous communication to a society or meeting. Conflicts of Interest and Source of Funding:No conflicts of interest. No external funding.Keywords: ischemia-reperfusion injury, hepatectomy, systematic review, ischemic preconditioning, morbidity, blood loss. Excellence Decision Support Unit. Odds ratios for binary outcomes and mean differences for continuous outcomes were calculated using fixed-effect model or random-effects model according to model-fit.Results: Forty four trials with 2457 patients undergone liver resection were included, and were divided into eight classes of interventions aimed at decreasing IR injury and a control group which was surgery alone. There was no significant difference between the different interventions in mortality, quantity of blood transfusion, and Intensive Therapy Unit stay between any pairwise comparison. Patients treated with ischemic preconditioning, cardiovascular modulators, and miscellaneous interventions had significantly fewer serious adverse events compared to patients receiving surgery alone. Ischemic preconditioning patients had significantly fewer transfusion proportions and shorter operative time than patients treated with steroids. Ischemic preconditioning had significantly lower operative blood loss compared to all other interventions, and shorter length of hospital stay than surgery alone. Sensitivity analysis showed that the drugs sevoflurane (a volatile anesthetic), verapamil (a calcium channel blocker), and gabexate mesilate (a thrombin inhibitor) produced fewer serious adverse events compared to surgery alone. Conclusion:Ischemic preconditioning resulted in multiple beneficial clinical end points and further RCTs are needed to confirm its clinical benefits.

Liver resection for cancer: New developments in prediction, prevention and management of postresectional liver failure

“…A recent meta-analysis confirmed that hepatic preconditioning (i.e. intermittent vascular inflow occlusion) results in less intraoperative blood loss and a shorter operating time in comparison to hepatectomy alone, but without improved postoperative outcome [140]. Prolonged clamping should nonetheless be avoided since ischemia-reperfusion injury has been shown to induce severe hepatic damage [141].…”

Effect of Remote Ischaemic Preconditioning on Liver Injury in Patients Undergoing Major Hepatectomy for Colorectal Liver Metastasis: A Pilot Randomised Controlled Feasibility Trial

“…Ischaemic preconditioning reduces the adverse effects of IRI through previous exposure to a brief period(s) of vascular occlusion. Direct IPC has been shown to reduce IRI in experimental models of warm hepatic IRI [9] and in patients undergoing major liver resections [10, 11]. However, experimental studies have shown that direct IPC through clamping of the portal inflow vessels may impair liver regeneration [12, 13] and in a multivariate analysis of patients undergoing liver resection, this was found to be an independent predictor for increased post-operative morbidity [14].…”

Ischemic Conditioning as a Hemostatic Intervention in Surgery and Cardiac Procedures: A Systematic Review

“…10,31 In fact, local ischemic preconditioning before liver resection significantly reduced intraoperative bleeding in one RCT 35 and one meta-analysis. 91 However, a previous meta-analysis showed no effect of local ischemic preconditioning on bleeding in liver resection. 92 Hence, there is no evidence of reduced thromboembolic risk after local ischemic conditioning in patients undergoing surgery or cardiac procedures.…”