Pringle Maneuver in Extended Liver Resection: A propensity score analysis

Abstract

Despite the ongoing decades-long controversy, pringle maneuver (pM) is still frequently used by hepatobiliary surgeons during hepatectomy. The aim of this study was to investigate the effect of PM on intraoperative blood loss, morbidity, and posthepatectomy hemorrhage (PHH). A series of 209 consecutive patients underwent extended hepatectomy (eH) (≥5 segment resection). The association of pM with perioperative outcomes was evaluated using multivariate analysis with a propensity score method to control for confounding. Fifty patients underwent PM with a median duration of 19 minutes. Multivariate analysis revealed that risk of excessive intraoperative bleeding (≥1500 ml; odds ratio [OR] 0.27, 95%-confidence interval [CI] 0.10-0.70, p = 0.007), major morbidity (OR 0.41, 95%-CI 0.18-0.97, p = 0.041), and PHH (OR 0.22, 95%-CI 0.06-0.79, p = 0.021) were significantly lower in PM group after EH. Furthermore, there was no significant difference in 3-year recurrence-free-survival between groups. pM is associated with lower intraoperative bleeding, pHH, and major morbidity risk after eH. Performing PM does not increase posthepatectomy liver failure and does not affect recurrence rate. Therefore, PM seems to be justified in EH. Extended hepatectomy (EH) is the only curative treatment option for patients with large primary or bilobar metastatic liver malignancies 1. Better patient selection and developments in surgical techniques and instruments have increased the number and safety of EH 2,3. However, the risk of complications such as intraoperative bleeding, especially in patients with large tumors or tumors near to major vessels, is still high. These factors are associated with poorer postoperative outcomes 4,5. Patients with massive intraoperative blood loss have a higher rate of posthepatectomy morbidity and mortality 2 and lower recurrence-free survival due to blood transfusion 6. Therefore, reducing intraoperative bleeding during EH and reducing the amount of blood products transfused are important points in liver surgery. Despite the ongoing controversy regarding the advantages and disadvantages of hepatic inflow control during hepatectomy, the Pringle maneuver (PM) remains the most commonly used and evidence-based method of hepatic inflow control 7. The PM significantly decreases intraoperative blood loss, the amount of blood products transfused, and operation time, especially when performed in combination with low central venous pressure 8-10. Nevertheless, there is no evidence that the PM can reduce posthepatectomy morbidity and mortality 11,12 ; in fact, the PM may result in ischemia-reperfusion injury of the liver, which negatively affects hepatocyte metabolism, thereby increasing the rate of posthepatectomy liver failure (PHLF) 13,14. Despite several studies investigating the role of the PM in liver resection, the effects of the PM on intra-and postoperative outcomes have not been investigated exclusively in EH, which has a higher risk of intraoperative bleeding than minor hepatectomies 15. In addition, applica...

Meta-analysis of the effect of the pringle maneuver on long-term oncological outcomes following liver resection

“…This finding is in similar line with our previously published report. Our results showed that PM is useful in patients who underwent extended liver resection, but this surgical maneuver may not be beneficial in minor hepatectomies 9 . It can be derived that PM is associated with encouraging early perioperative outcomes without worsening the long-term survival among well-selected patients.…”

“… Author (year) Country Study type Age Sample size Type of hepatectomy Duration of Pringle (min) Type of Pringle Diagnosis PM NPM PM NPM PM NPM Al-Saeedi (2020) 9 Germany Retrospective cohort 58.4 60.5 50 159 All patients underwent extended hepatectomy 19 Intermittent HCC and CRLM Lee (2019) 10 China Retrospective cohort 58 60.5 88 88 Minor: 51 (58.0%) Major: 37 (42.0%) Minor: 54 (61.4%) Major: 34 (38.6%) Mean (range) 45 (15–87) Intermittent HCC Famularo (2018) 4 Italy Retrospective cohort 65.1 67.6 176 265 Minor: 153 (87.4%) Major: 22 (12.6%) Minor: 228 (86.4%) Major: 36 (13.6%) Mean (range) 23 (14–30) Intermittent HCC Jiang (2017) 11 China Retrospective cohort NA NA ...…”

“…Although some studies have suggested that prolonged PM increases recurrence 1 , 20 , others have demonstrated no effect 15 , 19 , 34 . For instance, Al-Saeedi et al revealed that a PM of less than 20 min did not increase the recurrence rate after 3 years 9 . Recent studies showed that the PM has no significant positive impacts on clinical outcomes after minor liver surgeries 13 , 32 .…”

Recent trends in postoperative mortality after liver resection- A systemic review and metanalysis of studies published in last 5 years and metaregression of various factors affecting 90 days mortality

“…Total 29931 patients’ data who underwent liver resections for various etiologies were pooled from 41 studied included. [13-52]. 1257 patients died within 90 days post operatively.…”

Hemorheological and Microcirculatory Factors in Liver Ischemia-Reperfusion Injury—An Update on Pathophysiology, Molecular Mechanisms and Protective Strategies

“…Despite of the availability of modern devices controlling bleeding of parenchymal organs, temporarily clamping the hepatoduodenal ligament (Baron or Pringle maneuver) is still widely used in liver surgery for hepatic blood inflow control during major resections (open and laparoscopic/robotic surgery) to reduce bleeding and the need for perioperative blood transfusion [ 88 , 89 , 90 , 91 , 92 ]. Despite its obvious technical benefits during surgery, its use remains controversial due to potential negative effects on the clinical outcomes.…”