| ObjectivesPrimary live cancer (PLC) is one of the most frequent neoplasms worldwide.Hepatocellular carcinoma (HCC) is the most common type and accounts for approximately85%of PLC. In most cases, HCC is associated with chronic hepatic fibrosis or cirrhosis.Liver resection is considered as the most potentially curative therapy for PLC patients. Theprime concern in hepatectomy is to minimize intraoperative bleeding and avoid transfusion,which constitute a substantial predictor on both short-and long-term outcome.Hepatic blood inflow occlusion (Pringle maneuver) has been proven safe and effectivein controlling massive haemorrhage during liver resection. Pringle Maneuver can beaccomplished by clamping the portal triad continuously or intermittently.Ischemic-reperfusion (IR) injury of the remnant liver parenchyma is the commondrawback of these vascular clamping methods, especially in patients with chronic liverdisease. Compared to continuous Pringle maneuver (CPM), intermittent Pringle maneuver(IPM) followed by shorts periods of reperfusion is consider with less IR injury and iscurrently widely adopted by surgeons. However, IPM may cause additional bleedingduring the period of reperfusion. More and more studies indicate that liver has a bettertolerance to prolonged warm ischemia than bleeding. There is controversy about thebenefits of IPM over CPM in patients in terms of controlling massive haemorrhage andreducing hepatocellular injury in liver resection.When the clamping time exceeds a certain threshold, the warm ischemia and reperfusionare more likely to cause an irreversible injury to the remnant liver. The current viewpoint isthat liver can tolerate30minutes normothermic ischemia induced by clamping even inpatients with cirrhosis. When the anticipated clamping times are exceed30minutes, mostsurgeons will perform the clamping procedure intermittently. Nevertheless, withimprovements in surgical techniques and advances in perioperative care, liver can welltolerate the extended warm ischemia time and can’t have serious liver damage. The abilityof liver tolerates the warm ischemia may greater than what we think. The safety duration of clamping for one time is still indeterminate. For most of liver resections, they can beaccomplished within30minutes of cumulative clamping time, and the clamping time isalso hard to estimate, so it is difficult to find out the suitable crowd and allocate themrandomly. Therefore, we design a prospective cohort study to confirm that if the liver cansafely tolerate at least30minutes of continuous inflow occlusion in patients withwell-compensated chronic liver disease. Further study is conducted to compare theoutcome of CPM and IPM in terms of controlling massive haemorrhage, recovering ofpostoperative liver function and occurring of postoperative complications.Materials and MethodsDuring the period of June2011and June2013, a total of142primary liver cancerpatients with chronic liver disease was fulfilled in the inclusion and exclusion criteria andthen enrolled in our study. The patients was divided into CPM group (n=69) and IPMgroup (n=73) by the intraoperative clamping strategy. The perioperative situation,postoperative results of liver function and complications were analyzed, we compared theintraoperative blood loss, duration of hepatic vascular inflow clamping, the operation time,the results of liver function on postoperative days1,3and6, postoperative complications,perioperative blood transfusion, and postoperative hospital stay between the two groups, tofind if there is any difference between the CPM group and IPM group.ResultsThe two groups of patients were similar in terms of age, sex, preoperative liverfunction tests, type of hepatectomy, cumulative clamping time and incidence of underlyingcirrhosis. The IPM group was associated with more volume of intraoperative blood loss(P<0.001), higher proportion of perioperative blood transfusion (P=0.002), moretransfusion requirements of packed red blood cells (P=0.001), longer operation time(P=0.029). The levels of serum total bilirubin (TBIL) and aspartate aminotransferase (AST)on postoperative days1,3and6were significantly higher in the IPM groups (P<0.05), theserum albumin (ALB) level in the IPM group was significantly lower on postoperativedays1,3and6(P<0.05). The increased level of AST on postoperative day1wassignificantly higher in the IPM group (P <0.006), and the AST level of the two groups wasreturned to baseline on postoperative day6. There was no statistically significantdifference in ALT level on the1stpostoperative day between the two groups (P=0.250).The IPM group was suffered a significantly higher proportion of postoperative bloodtransfusion (P=0.011), which was classified as Grade II complication. No statistically significant difference were observed in any other grades of complications between theCPM group and IPM group. There was no perioperative death in both of the two groups.Conclusions1. The liver can safely tolerate at least30minutes of continuous inflow occlusion inpatients with well-compensated chronic liver disease, and it doesn’t increase thepostoperative morbidity and mortality.2. Compared to the intermittent Pringle maneuver, the continuous Pringle maneuversignificantly decreases the amounts of intraoperative bleeding and reduces therequirements of blood transfusion, meanwhile it does not increase the injury to the remnantliver parenchyma. |
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