Safety of intermittent Pringle maneuver during minimally invasive liver resection in patients with hepatocellular carcinoma with and without cirrhosis

Abstract

Purpose The aim of this study was to analyze the impact of minimally invasive intermittent Pringle maneuver (IPM) on postoperative outcomes in patients with hepatocellular carcinoma (HCC) and liver cirrhosis. Methods In this retrospective cohort study, we evaluated the safety of IPM in patients with HCC who underwent minimally invasive liver resection during five years at our center. Factors influencing the use of IPM were examined in univariate and multivariate regression analysis. Cases with use of IPM (IPM) and those without use of IPM (no IPM) were then compared regarding intraoperative and postoperative outcomes after propensity score matching (PSM) for surgical difficulty. Results One hundred fifty-one patients underwent liver resection for HCC at our center and met inclusion criteria. Of these, 73 patients (48%) received IPM with a median duration of 18 min (5–78). One hundred patients (66%) had confirmed liver cirrhosis. In multivariate analysis, patients with large tumors (≥ 3 cm) and difficult tumor locations (segments VII or VIII) were more likely to undergo IPM (OR 1.176, p = 0.043, and OR 3.243, p = 0.001, respectively). After PSM, there were no differences in intraoperative blood transfusion or postoperative complication rates between the IPM and no IPM groups. Neither did we observe any differences in the subgroup analysis for cirrhotic patients. Postoperative serum liver function tests were not affected by the use of IPM. Conclusions Based on our findings, we conclude that the use of IPM in minimally invasive liver resection is safe and feasible for patients with HCC, including those with compensated liver cirrhosis.

Evaluation of liver resection using cavitron ultrasonic surgical aspirator (CUSA) combined with harmonic scalpel

“…Intermittent occlusion, hemihepatic vascular occlusion, and ischemic preconditioning of the liver have been used to minimize liver damage while simultaneously reducing intraoperative bleeding. [14] This study demonstrates that parenchymal transection using CUSA and harmonic scalpel is a standardized procedure causing minimal blood loss thus decreasing morbidity and mortality and minimizing the dangers of hepatic inflow occlusion incurred with alternative techniques such as the Pringle maneuver. [15,16] CUSA selectively destroys and aspirates parenchyma leaving vessels and biliary ducts almost intact with larger vessels and large intrahepatic bile ducts to be ligated or clipped.…”

Protective benefit of minimally invasive liver surgery for hepatocellular carcinoma prior to transplant

“…While the benefits of LLR in Child-Turcotte-Pugh (CTP) cirrhotic patients for HCC have been well known, it still remains unclear for Child-Pugh B cirrhosis, the superior benefits of MILS over laparotomy HCC resection were recently demonstrated for patients without preoperative portal hypertension and score of CTP B7 cirrhosis [18] . By using the IWATE classification, the complexity and extent of LR are determined [19,20] . Long-term survival is most impacted by patient comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery with > 2 comorbidities, older age, grade 3-4 disease, regional lymph node metastasis (N1), and hepatectomy with microscopic exposure of tumor margins (R1) as predictors of worse overall survival [21][22][23][24][25][26][27] .…”

Current Trends in Surgical Management of Hepatocellular Carcinoma

“…Recent studies have focused on testing the feasibility and safety of blood loss control surgical techniques that may already be well-established in open surgery in the setting of minimally invasive resection. For example, IPM was recently demonstrated to be a safe technique in minimally invasive hepatic resection for patients with HCC, including those with compensated cirrhosis, showing no differences in postoperative complications or liver function tests [105]. During IPM, the surgeon clamps vascular inflow at the hilum, resulting in total hepatic inflow occlusion (TIO).…”