Background: Hepatectomy can be performed with a low mortality rate, but mas
sive hemorrhage during the operation remains a potentially lethal problem.
The Pringle maneuver is traditionally used during hepatectomy to reduce blo
od loss, but the effect on the metabolic function of hepatocytes is potenti
ally harmful. Although our randomized study showed that an intermittent Pri
ngle maneuver is safe and effective during hepatectomy, the upper limit of
the duration of the Pringle maneuver is not known.
Hypothesis: The liver can tolerate intermittent Pringle maneuver if the dur
ation is not excessive.
Design: From July 20, 1995, to November 25, 1997, 112 patients undewent hep
atectomy for liver tumors. The data of 50 patients who had hepatectomy with
out the Pringle maneuver were compared with those of 62 patients who had a
liver transection using a Pringle maneuver for 20 minutes and a S-minute cl
amp-free interval. The data were collected prospectively.
Main Outcome Measures: The surface area of liver transection was measured,
and blood loss during liver transection per centimeter square of transectio
n area was calculated. Routine liver biochemical tests, arterial ketone bod
y ratio (AKBR), and plasma cytokine-interleukin (IL) 1 alpha, 1 beta, 2, an
d 6, and tumor necrosis factor alpha-levels were measured before and after
the operation. The morbidity and hospital, mortality rates were also compar
ed among the patients with different ischemic durations and those without a
n intermittent Pringle maneuver.
Setting: Tertiary referral center.
Results: The cutoff point of accumulated ischemic time that induced substan
tial liver damage, as shown by the postoperative recovery rate of the AKBR,
was found to be 120 minutes. Compared with the control group, the patients
whose accumulated ischemic time was shorter than 120 minutes had less bloo
d loss related to transection area (10 mL/cm(2) vs 22 mL/cm(2); P<.001),les
s blood transfused (0 L vs 0.6 L; P=.004), a shorter transection time relat
ed to transection area (2.0 min/cm(2) vs 2.8 min/cm(2); P=.002), a signific
antly higher AKBR in the first 2 hours after liver transection, an equal re
covery rate of the AKBR, and a comparable increase of the plasma level of I
L-6 postoperatively. For the patients whose accumulated ischemic time was l
onger than 120 minutes, blood loss from the transection area was less than
for the control group (14 mL/cm(2) vs 22 mL/cm(2); P<.05); but the transect
ion time related to the transection area and the blood transfusion volume d
id not differ from those of the control group. Furthermore, they had a sign
ificantly lower recovery rate of the AKBR and higher plasma levels of IL-6
postoperatively than the control group.
Conclusion: The upper limit of tolerance of the liver to intermittent Pring
le maneuver is 120 minutes.