Complete versus selective portal triad clamping for minor liver resections: a prospective randomized trial

Abstract

Objective: To evaluate the feasibility, safety, efficacy, amount of hemorrhage, postoperative complications, and ischemic injury of selective clamping in patients undergoing minor liver resections.

Summary background data: Inflow occlusion can reduce blood loss during hepatectomy. However, Pringle maneuver produces ischemic injury to the remaining liver. Selective hemihepatic vascular occlusion technique can reduce the severity of visceral congestion and total liver ischemia.

Patients and methods: Eighty patients undergoing minor hepatic resection were randomly assigned to complete clamping (CC) or selective clamping (SC). Hemodynamic parameters, including portal pressure and the hepatic venous pressure gradient (HVPG), were evaluated. The amount of blood loss, measurements of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and postoperative evolution were also recorded.

Results: No differences were observed in the amount of hemorrhage (671 +/- 533 mL versus 735 +/- 397 mL; P = 0.54) or the patients that required transfusion (10% versus 15%; P = 0.55). There were no differences on postoperative morbidity between groups (38% versus 29%; P = 0.38). Cirrhotic patients with CC had significantly higher ALT (7.7 +/- 4.6 versus 4.5 +/- 2.7 mukat/L, P = 0.01) and AST (10.2 +/- 8.7 versus 4.9 +/- 2.1 mukat/L; P = 0.03) values on the first postoperative day than SC. The multivariate analysis demonstrated that high central venous pressure, HVPG >10 mm Hg, and intraoperative blood loss were independent factors related to morbidity.

Conclusions: Both techniques of clamping are equally effective and feasible for patients with normal liver and undergoing minor hepatectomies. However, in cirrhotic patients selective clamping induces less ischemic injury and should be recommended. Finally, even for minor hepatic resections, central venous pressure, HVPG, and intraoperative blood loss are factors related to morbidity and should be considered.

Figures

FIGURE 1. The entire hilar pedicle is encircled with a rubber tape to perform a Pringle maneuver with a tourniquet.

FIGURE 2. Either the “en bloc” right or left portal pedicle is isolated and encircled with a rubber tape.

FIGURE 3. Intraoperative evolution of hepatic venous pressure gradient. T1: basal; T2: clamping; T3: 10 minutes after unclamping. * P < 005; comparison between groups. ▪, CC group; •, SC group.

FIGURE 4. Evolution of ischemic injury parameters. A, Postoperative evolution of ALT. (μKat/L). POD, postoperative day.* The levels on postoperative day 1 were significantly higher in the CC group (P = 0.01). ALT normal value <0.9 μkat/L. B, Postoperative evolution of AST (μkat/L). POD, postoperative day.* The levels on postoperative day 1 were significantly higher in the CC group (P = 0.03); normal value <0.6 μkat/L. C, Evolution of lactate levels (mmol/L). T1: basal; T3: 10 minutes after unclamping. MaxPO, maximum value on postoperative period. Normal value <2 mmol/L. ▪, CC group; •, SC group.