Pedicle clamping with ischemic preconditioning in liver resection

Abstract

Hepatic pedicle clamping (HPC) is widely used to control intraoperative bleeding during hepatectomy; intermittent HPC is better tolerated but is associated with blood loss during each period of reperfusion. Recently, it has been shown that ischemic preconditioning (IP) reduces the ischemia-reperfusion damage for up to 30 minutes of continuous clamping in healthy liver. We evaluated the safety of IP for more prolonged periods of continuous clamping in 42 consecutive patients with healthy liver submitted to hepatectomy. IP was used in 21 patients (group A); mean +/- SD of liver ischemia was 54 +/- 19 minutes (range, 27-110; in 7 cases >60 minutes). In the other 21 patients, continuous clamping alone was used (Group B); liver ischemia lasted 36 +/- 14 minutes (range, 13-70; in 2 cases >60 minutes). Two patients in Group A (9.5%) and 3 in Group B (14.2%) received blood transfusions. In spite of the longer duration of ischemia (P=.001), patients with IP had lower aspartate aminotransferase (AST; P=.03) and alanine aminotransferase (ALT; P=not significant) at postoperative day 1, with a similar trend at postoperative day 3. This was reconfirmed by multiple regression analysis, which showed that although postoperative transaminases increased with increasing duration of ischemia and of the operation in both groups, the increases were significantly smaller (P<.001) with the use of preconditioning. In conclusion, the present study confirms that IP is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping.

Ischemic preconditioning of the liver: A few perspectives from the bench to bedside translation

“…Therefore, the majority of subjects enrolled in the clinical trials of IPC in LR (Table 3) mirror the nonlethal models of warm ischemia in the laboratory. 20,21,23 Hence, it is not surprising that although IPC decreases RP injury in patients undergoing LR, it does not improve clinical outcomes. Conceptually, although the improvement of even mild to moderate RP injury is likely to translate into improved clinical outcomes, such a small incremental benefit of IPC is hard to demonstrate unless a very large numbers of patients (probably several hundreds) are enrolled.…”

Role of ischaemic preconditioning in liver regeneration following major liver resection and transplantation

“…However, cur rent research has demonstrated that the beneficial effects of IPC on liver regeneration is mediated by up regulating growth- Clavien et al [204] ( 2003) 100 (50) Nuzzo et al [209] ( 2004) 42 ( Chouker et al [206] ( 2004) 68 ( Chouker et al [207] Protective against IRI by attenuating neutrophil activation and IL-8 release…”

“…Further human liver resection studies have shown that IPC reduces post-operative serum aminotransferase levels in both steatotic [204] and cirrhotic [205] livers and improves postreperfusion haemodynamic stability [206] (Table 1). Although IPC is protective against IRI [207,208] , it did not influence the morbidity and mortality rates in human studies [204,209,210] . In the transplant setting, Jassem et al [211] reported lower serum aminotransferase levels and shorter intensive care stay in IPC-treated cadaveric donor allografts.…”

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.…”