Abstract
Objective
To compare the clinical outcome of patients undergoing liver resection under portal triad clamping (PTC) versus hepatic vascular exclusion (HVE).
Methods
A systematic literature search was performed following the guidelines of the Cochrane collaboration. Randomized controlled trials (RCT) comparing PTC to any technique of HVE were eligible for inclusion. Two authors independently assessed methodological quality of included trials and extracted data on overall morbidity, mortality, cardiopulmonary and hepatic morbidity, intraoperative blood loss, transfusion rates, postoperative transaminase and bilirubin levels, prothrombin time, and hospital stay. Meta-analyses were performed using a random-effects model.
Results
Of the 1,383 identified references, four RCTs were finally included. These trials compared PTC to selective hepatic vascular exclusion (SHVE), total hepatic vascular exclusion (THVE), and a modified technique of HVE (MTHVE), respectively. Meta-analyses revealed no significant difference in morbidity and mortality between PTC and techniques of HVE. Further analyses showed significantly reduced overall morbidity for the PTC compared to the THVE group. There was a significantly lower transfusion rate for HVE compared to PTC.
Conclusion
Hepatic vascular exclusion does not offer any benefit regarding outcome of patients undergoing hepatic resection compared to PTC alone. Further, well-designed RCTs evaluating adequate vascular control in major hepatectomy and in patients with underlying liver disease appear justified.
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Abbreviations
- PTC:
-
portal triad clamping
- HVE:
-
hepatic vascular exclusion
- RCT:
-
randomized controlled trial
- SHVE:
-
selective hepatic vascular exclusion
- THVE:
-
total hepatic vascular exclusion
- MHVE:
-
modified technique of hepatic vascular exclusion
- RR:
-
relative risk
- WMD:
-
weighted mean difference
- CI:
-
confidence intervals
References
Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 2002;236:397–406. doi:10.1097/00000658-200210000-00001.
Wei AC, Tung-Ping PR, Fan ST, Wong J. Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma. Br J Surg 2003;90:33–41. doi:10.1002/bjs.4018.
Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, et al. Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Ann Surg 2004;240:698–708. doi:10.1097/01.sla.0000143808.63039.51.
Virani S, Michaelson JS, Hutter MM, Lancaster RT, Warshaw AL, Henderson WG, et al. Morbidity and mortality after liver resection: results of the patient safety in surgery study. J Am Coll Surg 2007;204:1284–1292. doi:10.1016/j.jamcollsurg.2007.02.067.
Belghiti J, Hiramatsu K, Benoist S, Massault P, Sauvanet A, Farges O. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection. J Am Coll Surg 2000;191:38–46. doi:10.1016/S1072-7515(00)00261-1.
Laurent C, Sa CA, Couderc P, Rullier E, Saric J. Influence of postoperative morbidity on long-term survival following liver resection for colorectal metastases. Br J Surg 2003;90:1131–1136. doi:10.1002/bjs.4202.
Rahbari NN, Wente MN, Schemmer P, Diener MK, Hoffman K, Motschall E, Schmidt J, Weitz J, Buchler MW. A systematic review and meta-analysis of the impact of portal triad clamping on outcome after hepatic resection. Br J Surg 2008;95:424–432.
Heaney JP, Stanton WK, Halbert DS, Seidel J, Vice T. An improved technic for vascular isolation of the liver: experimental study and case reports. Ann Surg 1966;163:237–241. doi:10.1097/00000658-196602000-00012.
Emre S, Schwartz ME, Katz E, Miller CM. Liver resection under total vascular isolation. Variations on a theme. Ann Surg 1993;217:15–19. doi:10.1097/00000658-199301000-00004.
Cherqui D, Malassagne B, Colau PI, Brunetti F, Rotman N, Fagniez PL. Hepatic vascular exclusion with preservation of the caval flow for liver resections. Ann Surg 1999;230:24–30. doi:10.1097/00000658-199907000-00004.
Gurusamy KS, Kumar Y, Sharma D, Davidson BR. Methods of vascular occlusion for elective liver resections. Cochrane Database Syst Rev. 2007;CD006409.
Cochrane Handbook of Systematic Reviews of Interventions 4.2.6 [updated September 2006]. In: Chichester, UK: John Wiley & Sons; 2006.
Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408–412. doi:10.1001/jama.273.5.408.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1–12. doi:10.1016/0197-2456(95)00134-4.
Boutron I, Moher D, Tugwell P, Giraudeau B, Poiraudeau S, Nizard R, et al. A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus. J Clin Epidemiol 2005;58:1233–1240. doi:10.1016/j.jclinepi.2005.05.004.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7:177–188. doi:10.1016/0197-2456(86)90046-2.
Demets DL. Methods for combining randomized clinical trials: strengths and limitations. Stat Med 1987;6:341–350. doi:10.1002/sim.4780060325.
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557–560. doi:10.1136/bmj.327.7414.557.
Cohen J. Weighted kappa. Psychol Bull 1968;70:213–220. doi:10.1037/h0026256.
Egger M, Davey SG, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629–634.
Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 1999;354:1896–1900. doi:10.1016/S0140-6736(99)04149-5.
Clavien PA, Camargo CA Jr, Gorczynski R, Washington MK, Levy GA, Langer B, et al. Acute reactant cytokines and neutrophil adhesion after warm ischemia in cirrhotic and noncirrhotic human livers. Hepatology 1996;23:1456–1463. doi:10.1002/hep.510230623.
Smyrniotis VE, Kostopanagiotou GG, Gamaletsos EL, Vassiliou JG, Voros DC, Fotopoulos AC, et al. Total versus selective hepatic vascular exclusion in major liver resections. Am J Surg 2002;183:173–178. doi:10.1016/S0002-9610(01)00864-9.
Ji XQ, Li CL, Yang JC, Liu XG, Wang ML, Liu ZQ, Lin JH. [Application of ischemic preconditioning before hepatic vascular exclusion for resection of hepatocellular carcinoma]. Di Yi Jun Yi Da Xue Xue Bao 2004;24:66–68, 71.
Smyrniotis V, Theodoraki K, Arkadopoulos N, Fragulidis G, Condi-Pafiti A, Plemenou-Fragou M, et al. Ischemic preconditioning versus intermittent vascular occlusion in liver resections performed under selective vascular exclusion: a prospective randomized study. Am J Surg 2006;192:669–674. doi:10.1016/j.amjsurg.2006.02.019.
Kostopanagiotou G, Pandazi AK, Andreadou I, Markantonis SL, Niokou D, Teloudis A, et al. Effects of mannitol in the prevention of lipid peroxidation during liver resection with hepatic vascular exclusion. J Clin Anesth 2006;18:570–574. doi:10.1016/j.jclinane.2006.03.014.
Benoist S, Salabert AS, Penna C, Karoui M, Julie C, Rougier P, et al. Portal triad clamping (TC) or hepatic vascular exclusion (VE) for major liver resection after prolonged neoadjuvant chemotherapy? A case-matched study in 60 patients. Surgery 2006;140:396–403. doi:10.1016/j.surg.2006.03.023.
Zhou W, Li A, Pan Z, Fu S, Yang Y, Tang L, et al. Selective hepatic vascular exclusion and Pringle maneuver: a comparative study in liver resection. Eur J Surg Oncol 2008;34:49–54. doi:10.1016/j.ejso.2007.07.001.
Belghiti J, Noun R, Zante E, Ballet T, Sauvanet A. Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg 1996;224:155–161. doi:10.1097/00000658-199608000-00007.
Smyrniotis V, Kostopanagiotou G, Lolis E, Theodoraki K, Farantos C, Andreadou I, et al. Effects of hepatovenous back flow on ischemic-reperfusion injuries in liver resections with the pringle maneuver. J Am Coll Surg 2003a;197:949–954. doi:10.1016/j.jamcollsurg.2003.07.009.
Smyrniotis VE, Kostopanagiotou GG, Contis JC, Farantos CI, Voros DC, Kannas DC, et al. Selective hepatic vascular exclusion versus Pringle maneuver in major liver resections: prospective study. World J Surg 2003b;27:765–769. doi:10.1007/s00268-003-6978-8.
Chen XP, Zhang ZW, Zhang BX, Chen YF, Huang ZY, Zhang WG, et al. Modified technique of hepatic vascular exclusion: effect on blood loss during complex mesohepatectomy in hepatocellular carcinoma patients with cirrhosis. Langenbecks Arch Surg 2006;391:209–215. doi:10.1007/s00423-006-0043-7.
Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001;357:1191–1194. doi:10.1016/S0140-6736(00)04337-3.
Delva E, Camus Y, Nordlinger B, Hannoun L, Parc R, Deriaz H, et al. Vascular occlusions for liver resections. Operative management and tolerance to hepatic ischemia: 142 cases. Ann Surg 1989;209:211–218. doi:10.1097/00000658-198902000-00012.
Elias D, Desruennes E, Lasser P. Prolonged intermittent clamping of the portal triad during hepatectomy. Br J Surg 1991;78:42–44. doi:10.1002/bjs.1800780115.
Man K, Fan ST, Ng IO, Lo CM, Liu CL, Yu WC, et al. Tolerance of the liver to intermittent pringle maneuver in hepatectomy for liver tumors. Arch Surg 1999;134:533–539. doi:10.1001/archsurg.134.5.533.
Kooby DA, Fong Y, Suriawinata A, Gonen M, Allen PJ, Klimstra DS, et al. Impact of steatosis on perioperative outcome following hepatic resection. J Gastrointest Surg 2003;7:1034–1044. doi:10.1016/j.gassur.2003.09.012.
Behrns KE, Tsiotos GG, DeSouza NF, Krishna MK, Ludwig J, Nagorney DM. Hepatic steatosis as a potential risk factor for major hepatic resection. J Gastrointest Surg 1998;2:292–298. doi:10.1016/S1091-255X(98)80025-5.
McCormack L, Petrowsky H, Jochum W, Furrer K, Clavien PA. Hepatic steatosis is a risk factor for postoperative complications after major hepatectomy: a matched case-control study. Ann Surg 2007;245:923–930. doi:10.1097/01.sla.0000251747.80025.b7.
Hasegawa T, Ito Y, Wijeweera J, Liu J, Malle E, Farhood A, et al. Reduced inflammatory response and increased microcirculatory disturbances during hepatic ischemia-reperfusion injury in steatotic livers of ob/ob mice. Am J Physiol Gastrointest Liver Physiol 2007;292:G1385–1395. doi:10.1152/ajpgi.00246.2006.
Vetelainen R, van Vliet AK, van Gulik TM. Severe steatosis increases hepatocellular injury and impairs liver regeneration in a rat model of partial hepatectomy. Ann Surg 2007;245:44–50. doi:10.1097/01.sla.0000225253.84501.0e.
Sun CK, Zhang XY, Zimmermann A, Davis G, Wheatley AM. Effect of ischemia-reperfusion injury on the microcirculation of the steatotic liver of the Zucker rat. Transplantation 2001;72:1625–1631. doi:10.1097/00007890-200111270-00008.
Hilden M, Christoffersen P, Juhl E, Dalgaard JB. Liver histology in a ‘normal’ population-examinations of 503 consecutive fatal traffic casualties. Scand J Gastroenterol 1977;12:593–597.
Belghiti J, Noun R, Malafosse R, Jagot P, Sauvanet A, Pierangeli F, et al. Continuous versus intermittent portal triad clamping for liver resection: a controlled study. Ann Surg 1999;229:369–375. doi:10.1097/00000658-199903000-00010.
Clavien PA, Selzner M, Rudiger HA, Graf R, Kadry Z, Rousson V, et al. A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg 2003;238:843–850. doi:10.1097/01.sla.0000098620.27623.7d.
Azoulay D, Lucidi V, Andreani P, Maggi U, Sebagh M, Ichai P, et al. Ischemic preconditioning for major liver resection under vascular exclusion of the liver preserving the caval flow: a randomized prospective study. J Am Coll Surg 2006;202:203–211. doi:10.1016/j.jamcollsurg.2005.10.021.
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Nuh N. Rahbari and Moritz Koch contributed equally to this work
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Rahbari, N.N., Koch, M., Mehrabi, A. et al. Portal Triad Clamping Versus Vascular Exclusion for Vascular Control During Hepatic Resection: A Systematic Review and Meta-analysis. J Gastrointest Surg 13, 558–568 (2009). https://doi.org/10.1007/s11605-008-0588-6
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DOI: https://doi.org/10.1007/s11605-008-0588-6