Tolerance of the Liver to Intermittent Pringle Maneuver in Hepatectomy for Liver Tumors

Man, Kwan; Fan, Sheung‐Tat; Ng, Irene Oi–Lin; Lo, Chung‐Mau; Liu, Chi-Leung; Yu, Wenli; Wong, John

doi:10.1001/archsurg.134.5.533

Cited by 108 publications

(80 citation statements)

References 17 publications

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“…It is very effective at reducing bleeding, but also causes both hepatic ischaemia and significant reperfusion injury when carried out continuously for prolonged periods of time (a maximum of 60-120 min is most frequently cited [18,19]). An intermittent Pringle's manoeuvre involves periods of total inflow occlusion (15-20 min) followed by a short period (5 min) of reperfusion with or without prior ischaemic pre-conditioning.…”

Section: Discussionmentioning

confidence: 99%

Methods of Haemostasis During Liver Resection - A UK National Survey

et al. 2013

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Background: Although haemorrhage is a major cause of morbidity and mortality in liver surgery, there is very little available guidance on its management. Methods: The aim of this study was to identify current practice in the UK in this regard. An online survey was created and hepatobiliary (HPB) specialists who were members of a specialist society and others who were known practitioners were invited by e-mail to complete the survey anonymously. Results: Fifty-one percent responded (n = 36/70), and most of these respondents worked at large HPB centres (>100 liver resections/year; n = 24, 66%). Not all questionnaires were fully completed by the individual surgeons. Thirty-eight percent of the surgeons routinely used Pringle's manoeuvre. Most surgeons used ligation of the inflow vessels (n = 16, 44%) and stapled the outflow vessels (n = 15, 42%). The Cavitron ultrasonic surgical aspirator (CUSA; 54%, 13/24) was preferred for parenchymal transection. The majority routinely used haemostatic adjuncts (n = 22, 62%), whilst 33% (n = 12) used them occasionally. Twenty-three (64%) felt manufactured haemostatic adjuncts played a major role in maintaining haemostasis and 19 preferred fibrin-based products. Conclusion: The Pringle manoeuvre is a popular technique amongst specialist UK liver surgeons and the CUSA is used by nearly half of the surgeons. Despite the absence of definitive evidence for their benefit, manufactured haemostatic adjuncts are still widely used, especially the fibrin-based adjuncts.

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Section: Discussionmentioning

confidence: 99%

Methods of Haemostasis During Liver Resection - A UK National Survey

et al. 2013

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“…The attention in recent years for ischaemia/reperfusion injury resulting from prolonged continuous clamping has clearly led to a distinct preference for techniques that protect the liver from ischaemic damage, such as intermittent clamping or ischaemic preconditioning [18, 20, 35]. Overall, ischaemia times are usually within 30 min, nonetheless, we calculated that 1 out of 10 patients are routinely clamped for longer than half an hour.…”

Section: Discussionmentioning

confidence: 99%

European Survey on the Application of Vascular Clamping in Liver Surgery

et al. 2007

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Background: This study evaluated the frequency, the indications and techniques of vascular clamping during liver resection and during thermal destruction therapies, as currently used by hepatic surgeons throughout Europe. Methods: A web-based questionnaire was distributed among 621 physicians, including all members of the European Hepato-Pancreato-Biliary Association and the European Surgical Association. Results: The overall response rate was 50%. During liver resection, vascular clamping is never applied by 10%, on indication by 71%, and routinely by 19%. Routine clamping is particularly performed by high-volume and senior surgeons and appears to be associated with longer ischaemia times. Intermittent inflow occlusion is the clamping method of choice for more than 65% of surgeons and total ischaemia times are usually limited to 15–30 min. During thermal ablation, vascular clamping is never used by 57%, on indication by 37%, and routinely by 7%; it is particularly applied for large tumours and for tumours close to large vessels, and ischaemia times are shorter. Conclusions: Vascular clamping during liver resection is frequently used; during thermal ablation it is preserved for larger tumours or tumours in the vicinity of large vessels. Complete inflow occlusion is the most frequently used technique, with a distinct preference for intermittent clamping.

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“…Thus, the liver seems to tolerate a period of (normothermic) ischemia of up to 90 min. Nevertheless, the liver can tolerate IPM if the duration of accumulated ischemic times is shorter than 120 min (PM for 20 min and a 5-min clamp-free interval) [11] . Patients with an ischemic time of more than 120 min showed less blood loss from the transection area (14 vs. 22 ml/cm 2 , p !…”

Section: How Much Ischemia Can the Liver Tolerate?mentioning

confidence: 99%

Vascular Occlusion or Not during Liver Resection: The Continuing Story

et al. 2012

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Background: Vascular occlusion can be applied during liver resection to reduce blood loss. Herein, we provide an update of the current evidence concerning vascular occlusion. Methods: A systematic literature search was conducted to review the effects of liver in- and outflow occlusion techniques during liver resection, focusing on blood loss and hepatic ischemia-reperfusion injury. Results: The Pringle maneuver (PM) is effective in controlling blood loss; however, there is no indication for routine vascular clamping during hepatic resection in uncomplicated patients. During complex resections and in patients with abnormal liver parenchyma, the intermittent PM is preferred over continuous clamping. Total hepatic vascular exclusion (THVE) is indicated only in resection of tumors involving the inferior caval vein or the caval hepatic junction. THVE can be applied with the preservation of caval vein flow. This mode of selective hepatic vascular exclusion results in less blood loss in combination with the PM. Conclusion: If clamping is necessary during complex resections or in abnormal liver parenchyma, intermittent PM is advised. THVE or selective hepatic vascular exclusion may be considered in tumors involving the inferior caval vein or the caval hepatic junction. There is no evidence supporting the use of ischemic preconditioning, maintenance of a low central venous pressure or of pharmacological interventions during liver resection.

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Tolerance of the Liver to Intermittent Pringle Maneuver in Hepatectomy for Liver Tumors

Cited by 108 publications

References 17 publications

Methods of Haemostasis During Liver Resection - A UK National Survey

Methods of Haemostasis During Liver Resection - A UK National Survey

European Survey on the Application of Vascular Clamping in Liver Surgery

Vascular Occlusion or Not during Liver Resection: The Continuing Story

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