Intermittent inflow occlusion in living liver donors: Impact on safety and remnant function

Abstract

Clamping of the portal triad accomplishes complete inflow occlusion. This maneuver is commonly used during liver surgery to minimize blood loss but is not widely used in living donors undergoing resection for liver transplantation. We compared outcomes in living donors who underwent resection with and without inflow occlusion. We reviewed data on 2 nonsimultaneous living liver donor cohorts. The first 20 donors (group 1) underwent resection without inflow occlusion. In the next 15 donors (group 2), inflow occlusion was used during parenchymal transection, using cycles of 10 -15 minutes occlusion and 6 minutes reperfusion. In donors, we recorded type of resection; ischemia times; blood loss; transfusions; peak ALT, AST, bilirubin, and INR in the first 5 days; hospital length of stay (LOS), and major complications. In recipients, we recorded peak ALT. In group 1, 19 of 20 donors underwent right hepatectomy. In group 2, 8 donors underwent right hepatectomy, and 7 donors had left lobectomies. Total ischemic time ranged from 16 -49 minutes (mean, 31 ؎ 9 minutes). In group 1, two donors received a total of 5 U of allogeneic blood. In group 2, no donor required transfusion. Mean peak ALT was significantly higher in group 1 (521 ؎ 336 U/L) than group 2 (322 ؎ 162 U/L; P ‫؍‬ 0.03). Mean INR was significantly higher in group 1 (1.8 ؎ 0.2) vs. group 2 (1.5 ؎ 0.2; P ‫؍‬ 0.001). There were 4 major complications in group 1 (incisional hernia, transient liver failure, biliary stricture, and biliary leak) and no major intraoperative or postoperative complications in group 2. Mean LOS was significantly longer in group 1 (7.9 ؎ 2.9 days) than group 2 (6.2 ؎ 1.1 days; P ‫؍‬ 0.04). Mean peak ALT in recipients trended lower in group 2. In conclusion, inflow occlusion was associated with reduced blood loss and less ischemic injury to hepatic remnants in the donors and the grafts in the recipients. These benefits were associated with a diminished incidence of major complications and shorter LOS. Inflow occlusion should be an essential part of living donor hepatectomy. (Liver Transpl 2004;10:244 -247.)

Live donor liver transplantation

“…Although the need for cholecystectomy seems intuitive for surgeons, it is not so for donors, who are often quite startled to learn of it if they were not prepared in advance. The use of intermittent inflow occlusion (i.e., Pringle maneuver) has been demonstrated to be beneficial 63. Donors rarely require banked blood transfusions 21, 64.…”

Intermittent Pringle Maneuver and Hepatic Function: Perioperative Monitoring by Noninvasive ICG‐Clearance

“…In contrast, there are no differences between the three groups for Hb, platelet count, creatinine, PT, Alb, total protein, AST, T Bil, and LDH. Many studies have used aminotransferase levels to assess the severity of hepatic injury resulting from ischemia [30][31][32]. Although serum AST and ALT levels are currently considered by many clinicians as most sensitive markers reflecting liver ischemic damage they also are influenced by the injury caused by liver transection resulting in much higher levels.…”

Liver Transplantation

“…Intraoperative cholangiography by using a radio-opaque marker tagging method and direct bile duct probing through the cystic duct was routinely used to identify an adequate location for bile duct division, minimizing the number of graft duct openings obtained from various donor bile duct anatomies 95. For the parenchymal transection, ultrasound or water-jet dissector are generally used in combination with electrocautery under without hilar occlusion or using only intermittent clamping 96. Graft retrieval is performed without portal cannulation in donor's abdominal cavity.…”