A prospective randomized controlled trial: Comparison of two different methods of hepatectomy

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Abstract

Background

Hemorrhage and liver failure are the two major complications in partial hepatectomy. The finger fracture or clamp crushing technique has been a standard technique used for transection of liver parenchyma. Hepatic vascular Inflow occlusion (Pringle maneuver, PM) is often used to minimize blood loss, but hepatic ischemia-reperfusion may result with an increased risk of post-operative liver failure. The Harmonic scalpel (HS) has been shown to be effective in reducing blood loss during liver parenchymal transection without any hepatic vascular inflow occlusion.

Methods

A randomized controlled trial was carried out to evaluate the impact of the two different hepatic transection techniques. The post-operative short-term results were compared.

Results

During the study period, 160 of 212 patients who received partial hepatectomy in our hospital were randomized into 2 groups: the PM group (n = 80) and the HS group (n = 80). The numbers of patient who had a poor liver function on post-operative day 5 (ISLGS Grade B) were 30, and 18, respectively (p < 0.05). The post-operative complication rate was significantly higher in the PM group (41.3% versus 22.5%, p < 0.05). The HS group had significantly less blood loss and blood transfusion requirements than the PM group (p < 0.05).

Conclusions

In conclusion, liver resection carried out using HS without hepatic vascular occlusion was better than using finger fracture or clamp crushing technique with Pringle maneuver. The use of HS allowed liver resection to be safely performed, with earlier recovery of liver function, and less surgical complication.

Introduction

Partial hepatectomy remains the most commonly used curative treatment for malignant liver tumor. The finger fracture or clamp crushing technique has been a standard technique used in transection of liver parenchyma.1 Hepatic vascular inflow occlusion in the form of Pringle maneuver is commonly used in partial hepatectomy to reduce intraoperative blood loss during parenchymal transection.2 The major concern in the use of hepatic vascular inflow occlusion is ischemia-reperfusion injury.

Harmonic scalpel (HS) allows sealing of small vessels during transection of liver parenchyma with resultant reduced blood loss and transection time.3, 4, 5 The ultrasonically activated shears seal small vessels between the vibrating blades. The coagulation effect is caused by protein denaturation, which occurs as a result of destruction of hydrogen bonds in proteins and generation of heat in vibrating tissue.6 Blood vessels up to 3–4 mm in diameter are coagulated.7, 8 The tissue-cutting effect derives from a saw mechanism in the direction of the vibrating blades. The benefit of Harmonic scalpel without hepatic vascular inflow occlusion in open liver resection remains uncertain, and there is no randomized trial in the medical literature.

This randomized controlled study was carried out to compare the perioperative outcomes of partial hepatectomy using either finger fracture or clamp crushing technique with PM or HS without hepatic vascular inflow occlusion.

Section snippets

Trial design

From January 2012 to September 2012, 160 patients who underwent partial hepatectomy for liver tumors at the Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital were considered to be included into the study. The inclusion criteria were: (1) elective liver resection; (2) inflow occlusion was needed if the finger fracture and clamp crushing technique was used for transection of liver parenchyma; (3) inflow occlusion was not needed if the Harmonic Scalpel was used for

Results

During the study period, 212 patients received partial liver resection in our hospital. 52 patients were excluded from this study because:- tumors were combined with tumor thrombosis of portal vein branch or bile duct (n = 21), metastatic tumors were resected together with colorectal primary (n = 3), tumors had invaded the hepatic vessel or were located at special sites such as the caudate lobe that required total hepatic vascular occlusion or hepatic vein occlusion (n = 28). No patients

Discussion

Intraoperative factors that affect patients' outcome, including bleeding, bile leakage, abdominal collection, and infections, are often related to the surgeon's techniques.17, 18, 19, 20, 21 Control of bleeding is crucial in good liver surgery as blood loss is an independent factor which increases post-operative morbidity and mortality.22, 23, 24 There are different vascular occlusion techniques which can be used to reduce blood loss during liver parenchymal transection,25 such as total hepatic

References (31)

  • G. Nuzzo et al.

    Liver resections with or without pedicle clamping

    Am J Surg

    (2001)
  • O. Scatton et al.

    Major liver resection without clamping: a prospective reappraisal in the era of modern surgical tools

    J Am Coll Surg

    (2004)
  • Y. Sugiyama et al.

    Effects of intermittent Pringle's manoeuvre on cirrhotic compared with normal liver

    Br J Surg

    (2010)
  • F. Vyhnánek et al.

    Liver transection with the harmonic scalpel in elective liver surgery

    Rozhl Chir

    (2002)
  • W.R. Wrightson et al.

    The role of the ultrasonically activated shears and vascular cutting stapler in hepatic resection

    Am Surg

    (2000)
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