Systematic review of randomized controlled trials of pharmacological interventions to reduce ischaemia-reperfusion injury in elective liver resection with vascular occlusion

Abu‐Amara, Mahmoud; Gurusamy, Kurinchi Selvan; Hori, Satoshi; Glantzounis, George; Fuller, Barry; Davidson, Brian R

doi:10.1111/j.1477-2574.2009.00120.x

Cited by 32 publications

(32 citation statements)

References 59 publications

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“…Improved liver function markers and/or reduced liver injury markers indicated that methylprednisolone, trimetazidine, dextrose and ulinastatin could have possible protective effects against IRI in vascular controlled liver resections [4] . However, literature shows no significant differences in mortality, liver failure or peri-or postoperative mortality for any pharmacological intervention [4,65] . Hence, based on current evidence, it cannot be advised to administer medication with the purpose of limiting IRI in vascular controlled liver resection [65] .…”

Section: Pharmacological Interventionsmentioning

confidence: 99%

“…However, literature shows no significant differences in mortality, liver failure or peri-or postoperative mortality for any pharmacological intervention [4,65] . Hence, based on current evidence, it cannot be advised to administer medication with the purpose of limiting IRI in vascular controlled liver resection [65] . The use of these drugs should only be used in well-designed clinical trials before clinical implementation [4,62,63] .…”

Section: Pharmacological Interventionsmentioning

confidence: 99%

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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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Section: Pharmacological Interventionsmentioning

confidence: 99%

Section: Pharmacological Interventionsmentioning

confidence: 99%

Vascular Occlusion or Not during Liver Resection: The Continuing Story

et al. 2012

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“…Furthermore, the liver function of the experimental group was significantly better than that of the control group the first and fifth day after the operation. As far as ulinastatin is concerned, although it lowered the transaminase and bilirubin levels, it did not affect the rates of liver decompensation, perioperative morbidity or length of hospital stay (57,61). Based on these results, it seems that ulinastatin may offer a protective role in elective liver resections under vascular occlusion.…”

Section: Other Promising Pharmacological Interventionsmentioning

confidence: 99%

Hepatic Ischemia and Reperfusion Injury and Trauma: Current Concepts

Papadopoulos¹,

Siempis²,

Theodorakou³

et al. 2013

Arch Trauma Res

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Context: Ischemia-reperfusion injury is a fascinating topic which has drawn a lot of interest in the last several years. Hepatic ischemia reperfusion injury may occur in a variety of clinical situations. These include transplantation, liver resection, trauma, and vascular surgery. Evidence Acquisition: The purpose of this review was to outline the molecular mechanisms underlying hepatic I/R injury and present the latest approaches, both surgical and pharmacological, regarding the prevention of it. A comprehensive electronic literature search in MEDLINE/PubMed was performed to identify relative articles published within the last 2 years. Results: The basic mechanism of hepatic ischemia -reperfusion injury is one of blood deprivation during ischemia, followed by the return of flow during reperfusion. It involves a complex series of events, such as mitochondrial deenergization, adenosine-5'-triphosphate depletion, alterations of electrolyte homeostasis, as well as Kupffer cell activation, oxidative stress changes and upregulation of proinflammatory cytokine signaling. The great number of variable pathways, with several mediators interacting with each other, leads to a high number of candidates for potential therapeutic intervention. As far as surgical approaches are concerned, the modification of existing clamping techniques and the ischemic preconditioning are the most promising techniques till recently. In the search for novel techniques of protecting against hepatic ischemia reperfusion injury, many different strategies have been used in experimental models. The biggest part of this research lies around antioxidant therapy, but other potential solutions have been explored as well. Conclusions:The management of hepatic trauma, in spite of the fact that it has become increasingly nonoperative, there still remains the possibility of hepatic resection in the hepatic trauma setting, especially in severe injuries. Hence, clinicians should be familiar with the concept of hepatic ischemia-reperfusion injury and respond appropriately and timely.Keywords: Reperfusion Injury; Ischemia; Pathophysiology; Prevention Implication for health policy/practice/research/medical education: Hepatic ischemia and reperfusion injury is a complex phenomenon which is commonplace in clinical practice such as the operative management of hepatic trauma, liver transplantation and liver resection. Hence, surgeons should be familiar with it and apply the necessary methods to prevent it.

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“…Aufgrund fehlender valider Daten kann aber bisher keine pharmakologische Strategie für die Routinetherapie empfohlen werden [43,45]. [46,47].…”

Section: Disclosure Statementunclassified

Leberresektionen – was ist perioperativ zu beachten?

Kaffarnik¹,

Lock²,

Seehofer³

et al. 2011

Viszeralmedizin

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Leberresektionen sind heute Standardoperationen bei malignen und benignen Tumoren. Mit der Entwicklung neuer Resektionstechniken und Anästhesieverfahren konnte die Komplikationsrate gesenkt werden. Es gibt aber weiterhin spezifische Komplikationen, auf die im perioperativen Management besonders geachtet werden muss. Dazu zählen die Beeinträchtigung der Gerinnung, Galleleckagen, der Ischämie-/Reperfusionsschaden und das Leberversagen. Präoperative Verfahren zur Einschätzung der Leberfunktion, wie z.B. der LiMAx-Test (Maximal Liver Function Capacity), und des sich daraus ergebenden möglichen Resektionsausmaßes gehören heute zur Routinediagnostik. Sie werden auch postoperativ zum Monitoring der Restleberfunktion eingesetzt. Mit diesen Verfahren können Hochrisikopatienten bereits im Vorfeld erkannt und mögliche Komplikationen durch eine Risikostratifizierung minimiert werden. Die postoperative Therapie ist ein weiterer wichtiger Baustein der Leberchirurgie. Ein differenziertes perioperatives Volumen-, Schmerz- und Antikoagulationsmanagement ist mitentscheidend für das therapeutische Ergebnis. Hinzu kommt ein früher enteraler Kostaufbau unter Berücksichtigung etablierter Standards der perioperativen Ernährung. Damit kann das Auftreten pulmonaler und infektiologischer Komplikationen bis hin zur Sepsis vermindert werden.

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Systematic review of randomized controlled trials of pharmacological interventions to reduce ischaemia-reperfusion injury in elective liver resection with vascular occlusion

Abstract: Methylprednisolone, trimetazidine, dextrose and ulinastatin may have protective roles against IR injury in liver resection. However, based on the current evidence, they cannot be recommended for routine use and their application should be restricted to RCTs.

Cited by 32 publications

References 59 publications

Vascular Occlusion or Not during Liver Resection: The Continuing Story

Vascular Occlusion or Not during Liver Resection: The Continuing Story

Hepatic Ischemia and Reperfusion Injury and Trauma: Current Concepts

Leberresektionen – was ist perioperativ zu beachten?

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