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Liver Resection Without Pedicle Clamping: Feasibility and Need for “Salvage Clamping”. Looking for the Right Clamping Policy. Analysis of 512 Consecutive Resections

  • Original Article
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Journal of Gastrointestinal Surgery

Abstract

Background

Pedicle clamping during liver resection (LR) is debated. The purpose of this study is to validate non-clamping policy across a large series of LR and to evaluate the need for salvage clamping (SC) and its outcomes.

Methods

Five hundred twelve consecutive LR without initial pedicle clamping performed between 2004 and 2009 were analyzed.

Results

Among 512 LR (171 major hepatectomies), 90.2% were completed without clampage. Fifty (9.8%) required SC. Blood loss were higher in SC group (555 vs. 175 mL, p < 0.0001), while transfusion rate was not. No differences were observed in terms of mortality (0%/1.3%), morbidity (38%/38.3%), liver dysfunction (4%/3.7%), and renal dysfunction (0%/1.3%). Bile leak rate was increased in the SC group (20%/10.2%, p = 0.036). At multivariate analysis, three predictive factors of SC were identified: arterial hypertension (p = 0.007, SC rate = 13%), cirrhosis (p = 0.003, SC rate = 26%), and LR conducted along the right portal scissure (p = 0.010, SC rate = 32%). One protective factor was identified: LR confined to antero-lateral segments (Sg2–6, p = 0.001, SC rate = 2%). Extension of LR had no impact on need for SC.

Conclusions

The majority of LR can be safely performed without clamping with excellent outcomes. SC is a safe procedure and does not worsen postoperative outcomes, except for bile leak rate. Clamping policy should be tailored to the type of LR and presence of cirrhosis.

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References

  1. Pringle JH. Notes on the arrest of hepatic haemorrhage due to trauma. Ann Surg 1909;48:541–549.

    Article  Google Scholar 

  2. Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, Wong J. 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(4):698–708.

    PubMed  Google Scholar 

  3. Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, Corvera C, Weber S, Blumgart LH. Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade. Ann Surg 2002;236: 397–406.

    Article  PubMed  Google Scholar 

  4. Imamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano K, Takayama T, Makuuchi M. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 2003;138(11):1198–1206.

    Article  PubMed  Google Scholar 

  5. Ercolani G, Ravaioli M, Grazi GL, Cescon M, Del Gaudio M, Vetrone G, Zanello M, Pinna AD. Use of vascular clamping in hepatic surgery: lessons learned from 1260 liver resections. Arch Surg 2008;143(4):380–387.

    Article  PubMed  Google Scholar 

  6. Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, Wong J. Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths. Ann Surg 1999;229:322–330.

    Article  PubMed  CAS  Google Scholar 

  7. Capussotti L, Muratore A, Ferrero A, Massucco P, Ribero D, Polastri R. Randomized clinical trial of liver resection with and without hepatic pedicle clamping. Br J Surg 2006;93:685–689.

    Article  PubMed  CAS  Google Scholar 

  8. Belghiti J, Noun R, Malafosse R, Jagot P, Sauvanet A, Pierangeli F, Marty J, Farges O. Continuous versus intermittent portal triad clamping for liver resection: a control study. Ann Surg 1999;229:369–375.

    Article  PubMed  CAS  Google Scholar 

  9. Torzilli G, Procopio F, Botea F, Marconi M, Del Fabbro D, Donadon M, Palmisano A, Spinelli A, Montorsi M. One-stage ultrasonographically guided hepatectomy for multiple bilobar colorectal metastases: a feasible and effective alternative to the 2-stage approach. Surgery 2009;146(1):60–71.

    Article  PubMed  Google Scholar 

  10. van der Bilt JD, Livestro DP, Borren A, van Hillegersberg R, Borel Rinkes IH. European Survey on the Application of Vascular Clamping in Liver Surgery. Dig Surg 2007; 24:423–435.

    Article  PubMed  Google Scholar 

  11. Rahbari NN, Wente MN, Schemmer P, Diener MK, Hoffmann K, Motschall E, Schmidt J, Weitz J, Büchler MW. Systematic review and meta-analysis of the effect of portal triad clamping on outcome after hepatic resection. Br J Surg 2008;95(4):424–432.

    Article  PubMed  CAS  Google Scholar 

  12. Scatton O, Massault PP, Dousset B, Houssin D, Bernard D, Terris B, Soubrane O. Major liver resection without clamping: a prospective reappraisal in the era of modern surgical tools. J Am Coll Surg 2004;199(5):702–708.

    Article  PubMed  Google Scholar 

  13. Descottes B, Lachachi F, Durand-Fontanier S, Geballa R, Atmani A, Maisonnette F, Sodji M, Valleix D. Right hepatectomies without vascular clamping: report of 87 cases. J Hepatobiliary Pancreat Surg 2003;10(1):90–94.

    PubMed  CAS  Google Scholar 

  14. Nuzzo G, Giuliante F, Giovannini I, Vellone M, De Cosmo G, Capelli G. Liver resections with or without pedicle clamping. Am J Surg 2001;181(3):238–246.

    Article  PubMed  CAS  Google Scholar 

  15. Capussotti L, Ferrero A, Viganò L, Sgotto E, Muratore A, Polastri R. Bile leakage and liver resection: Where is the risk? Arch Surg 2006;141(7):690–694.

    Article  PubMed  Google Scholar 

  16. Ferrero A, Russolillo N, Viganò L, Sgotto E, Lo Tesoriere R, Amisano M, Capussotti L. Safety of conservative management of bile leakage after hepatectomy with biliary reconstruction. J Gastrointest Surg 2008;12(12):2204–2211.

    Article  PubMed  Google Scholar 

  17. Fong Y, Brennan MF, Brown K, Heffernana N, Blumgart LH. Drainage is unnecessary after elective liver resection. Am J Surg 1996;171(1):158–162.

    Article  PubMed  CAS  Google Scholar 

  18. Sun HC, Qin LX, Lu L, Wang L, Ye QH, Ren N, Fan J, Tang ZY. Randomized clinical trial of the effects of abdominal drainage after elective hepatectomy using the crushing clamp method. Br J Surg 2006;93(4):422–426.

    Article  PubMed  Google Scholar 

  19. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42(6):1206–52.

    Article  PubMed  CAS  Google Scholar 

  20. Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet 1997;349(9055):825–832.

    Article  PubMed  CAS  Google Scholar 

  21. Strasberg SM, Belghiti J, Clavien PA, Gadzijev E, Garden JO, Lau WY, Makuuchi M, Strong RW. Terminology Committee of the IHPBA (authors). The Brisbane 2000 Terminology of Liver Anatomy and Resection. HPB 2000;2:333–339.

    Google Scholar 

  22. Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, Durand F. The “50–50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 2005;242(6):824–828.

    Article  PubMed  Google Scholar 

  23. Man K, Fan ST, Ng IO, Lo CM, Liu CL, Wong J. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study. Ann Surg 1997;226:704–711.

    Article  PubMed  CAS  Google Scholar 

  24. Rees M, Plant G, Wells J, Bygrave S. One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery. Br J Surg 1996;183:1526–1529.

    Article  Google Scholar 

  25. Franco D. Liver surgery has become simpler. Eur J Anaesthesiol 2002;19(11):777–779.

    PubMed  Google Scholar 

  26. Yamashita Y, Hamatsu T, Rikimaru T, Tanaka S, Shirabe K, Shimada M, Sugimachi K. Bile leakage after hepatic resection. Ann Surg 2001;233(1):45–50.

    Article  PubMed  CAS  Google Scholar 

  27. Nagano Y, Togo S, Tanaka K, Masui H, Endo I, Sekido H, Nagahori K, Shimada H. Risk factors and management of bile leakage after hepatic resection. World J Surg 2003;27(6):695–698.

    Article  PubMed  Google Scholar 

  28. Hayashi M, Hirokawa F, Miyamoto Y, Asakuma M, Shimizu T, Komeda K, Inoue Y, Arisaka Y, Masuda D, Tanigawa N. Clinical risk factors for postoperative bile leakage after liver resection. Int Surg 2010;95(3):232–238.

    PubMed  Google Scholar 

  29. Okano T, Ohwada S, Nakasone Y, Sato Y, Ogawa T, Tago K, Morishita Y. Blood transfusion causes deterioration in liver regeneration after partial hepatectomy in rats. J Surg Res 2001;101:157–165.

    Article  PubMed  CAS  Google Scholar 

  30. Kooby DA, Stockman J, Ben-Porat L, Gonen M, Jarnagin WR, Dematteo RP, Tuorto S, Wuest D, Blumgart LH, Fong Y. Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 2003;237:860–870.

    PubMed  Google Scholar 

  31. Wang CC, Iyer SG, Low JK, Lin CY, Wang SH, Lu SN, Chen CL. Perioperative factors affecting long-term outcomes of 473 consecutive patients undergoing hepatectomy for hepatocellular carcinoma. Ann Surg Oncol 2009;16(7):1832–1842.

    Article  PubMed  Google Scholar 

  32. Poon RT, Fan ST, Lo CM, Ng IO, Liu CL, Lam CM, Wong J. Improving survival results after resection of hepatocellular carcinoma: a prospective study of 377 patients over 10 years. Ann Surg 2001;234(1):63–70.

    Article  PubMed  CAS  Google Scholar 

  33. Giuliante F, Ardito F, Pulitanò C, Vellone M, Giovannini I, Aldrighetti L, Ferla G, Nuzzo G. Does hepatic pedicle clamping affect disease-free survival following liver resection for colorectal metastases? Ann Surg 2010;252(6):1020–1026.

    Article  PubMed  Google Scholar 

  34. Ferrero A, Russolillo N, Viganò L, Lo Tesoriere R, Muratore A, Capussotti L. Does Pringle maneuver affect survival in patients with colorectal liver metastases? World J Surg 2010;34(10):2418–2425.

    Article  PubMed  Google Scholar 

  35. van der Bilt JD, Kranenburg O, Borren A, van Hillegersberg R, Borel Rinkes IH. Ageing and hepatic steatosis exacerbate ischemia/reperfusion-accelerated outgrowth of colorectal micrometastases. Ann Surg Oncol 2008;15(5):1392–1398.

    Article  PubMed  Google Scholar 

  36. van der Bilt JD, Kranenburg O, Nijkamp MW, Smakman N, Veenendaal LM, Te Velde EA, Voest EE, van Diest PJ, Borel Rinkes IH. Ischemia/reperfusion accelerates the outgrowth of hepatic micrometastases in a highly standardized murine model. Hepatology 2005;42(1):165–175.

    Article  PubMed  Google Scholar 

  37. 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.

    Article  PubMed  CAS  Google Scholar 

  38. Yin XY, Lai PBS, Lee JFY, Lau WY. Effects of hepatic blood inflow occlusion on liver regeneration following partial hepatectomy in an experimental model of cirrhosis. Br J Surg 2000;87: 1510–1515.

    Article  PubMed  CAS  Google Scholar 

  39. Clavien PA, Selzner M, Rüdiger HA, Graf R, Kadry Z, Rousson V, Jochum W. A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg 2003;238:843–852.

    Article  PubMed  Google Scholar 

  40. Melendez JA, Arslan V, Fischer ME, Wuest D, Jarnagin WR, Fong Y, Blumgart LH. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 1998;187:620–625.

    Article  PubMed  CAS  Google Scholar 

  41. Vigano’ L, Laurent A, Tayar C, Tomatis M, Ponti A, Cherqui D. The learning curve in laparoscopic liver resection. Improved feasibility and reproducibility. Ann Surg 2009;250(5):772–782.

    Article  Google Scholar 

  42. Viganò L, Tayar C, Laurent A, Cherqui D. Laparoscopic liver resection: a systematic review. J Hepatobiliary Pancreat Surg 2009;16(4):410–421.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Largo Turati 62, 10128, Turin, Italy

    Luca Viganò, Syed A. A. Jaffary, Alessandro Ferrero, Nadia Russolillo, Serena Langella & Lorenzo Capussotti

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  1. Luca Viganò
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  2. Syed A. A. Jaffary
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  3. Alessandro Ferrero
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  4. Nadia Russolillo
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  6. Lorenzo Capussotti
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Correspondence to Luca Viganò.

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Viganò, L., Jaffary, S.A.A., Ferrero, A. et al. Liver Resection Without Pedicle Clamping: Feasibility and Need for “Salvage Clamping”. Looking for the Right Clamping Policy. Analysis of 512 Consecutive Resections. J Gastrointest Surg 15, 1820–1828 (2011). https://doi.org/10.1007/s11605-011-1625-4

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  • DOI: https://doi.org/10.1007/s11605-011-1625-4

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