PROSPECTIVE EVALUATION OF PRINGLE MANEUVER IN HEPATECTOMY FOR LIVER-TUMORS BY A RANDOMIZED STUDY

Objective To evaluate whether vascular inflow occlusion by the Pringle maneuver during hepatectomy can be safe and effective in reducing blo od loss. Summary Background Data Hepatectomy can be performed with a l ow mortality rate, but massive hemorrhage during surgery remains a pot entially lethal problem. The Pringle maneuver is traditionally used du ring hepatectomy to reduce blood loss, but there is a potential harmfu l effect on the metabolic function of hepatocytes. There has been no p rospective randomized study to determine whether the Pringle maneuver can decrease blood loss during hepatectomy, improve outcome, or affect the metabolism of hepatocytes. Methods From July 1995 to February 199 7, we studied 100 consecutive patients who underwent hepatectomy for l iver tumors. The patients were randomly assigned to liver transection under intermittent Pringle maneuver of 20 minutes and a 5-minute clamp -free interval (n = 50), or liver transection without the Pringle mane uver (n = 50). The surface area of liver transection was measured and blood loss during transection per square centimeter of transection are a was calculated. Routine liver biochemistry, arterial ketone body rat io (AKBR), and the indocyanine green (ICG) clearance test were done. R esults The two groups were comparable in terms of preoperative liver f unction and in the proportion of patients having major hepatectomy. Th e Pringle maneuver resulted in less blood loss per square centimeter o f transection area (12 mL/cm(2) vs. 22 mL/cm(2), p = 0.0001), a shorte r transection time per square centimeter of transection area (2 min/cm (2) vs. 2.8 min/cm(2), p = 0.016), a significantly higher AKBR in the first 2 hours after hepatectomy, lower serum bilirubin levels in the e arly postoperative period, and, in cirrhotic patients, higher serum tr ansferrin levels on postoperative days 1 and 8. The complication rate, the hospital mortality rate, and the ICG retention at 15 minutes on p ostoperative day 8 were equal for the two groups. Conclusion Performin g the Pringle maneuver during liver transection resulted in less blood loss and better preservation of liver function in the early postopera tive period. This is probably because there was less hemodynamic distu rbance induced by the bleeding.