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

Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Bunkyo-ku, Tokyo 113-8421, Japan.
British Journal of Surgery (Impact Factor: 5.21). 07/2010; 97(7):1062-9. DOI: 10.1002/bjs.7039
Source: PubMed

ABSTRACT Although patients with liver cirrhosis are supposed to tolerate ischaemia-reperfusion poorly, the exact impact of intermittent inflow clamping during hepatic resection of cirrhotic compared with normal liver remains unclear.
Intermittent Pringle's manoeuvre was applied during minor hepatectomy in 172 patients with a normal liver, 59 with chronic hepatitis and 97 with liver cirrhosis. To assess hepatic injury, delta (D)-aspartate aminotransferase (AST) and D-alanine aminotransferase (ALT) (maximum level minus preoperative level) were calculated. To evaluate postoperative liver function, postoperative levels of total bilirubin, albumin and cholinesterase (ChE), and prothrombin time were measured.
Significant correlations between D-AST or D-ALT and clamping time were found in each group. The regression coefficients of the regression lines for D-AST and D-ALT in patients with normal liver were significantly higher than those in patients with cirrhotic liver. Irrespective of whether clamping time was 45 min or less, or at least 60 min, D-AST and D-ALT were significantly lower in patients with cirrhosis than in those with a normal liver. Parameters of hepatic functional reserve, such as total bilirubin, prothrombin time, albumin and ChE, were impaired significantly after surgery in patients with a cirrhotic liver.
Patients with liver cirrhosis had a smaller increase in aminotransferase levels following portal triad clamping than those with a normal liver. However, hepatic functional reserve in those with a cirrhotic liver seemed to be affected more after intermittent inflow occlusion.

  • [Show abstract] [Hide abstract]
    ABSTRACT: This study aimed to examine the hepatocyte apoptosis in a hepatic blood inflow occlusion rat model without hemi-hepatic arterial control and its association with the expressions of the apoptosis-regulating genes bcl-2 and bax. Wistar rats were equally and randomly assigned to undergo sham operation (control group, n = 8), Pringle's maneuver (group PR, n = 32), hemi-hepatic occlusion (group HH, n = 32), or hemi-hepatic artery-preserved portal occlusion (group HP, n = 32). The hepatic blood inflow was interrupted for 30 min using a microvascular clip in the three experimental groups. The clips were removed to achieve hepatic reperfusion for up to 24 h. Blood samples and liver specimens were collected following reperfusion to perform pathologic examination, serum transferase assay, apoptosis analysis, and determination of bcl-2 and bax mRNA and protein expressions. The reperfusion-related hepatocytic injuries were more severe in the PR group than in the HH and HP groups, both pathologically and biochemically. More reperfused hepatocytes became apoptotic in the PR group than in the HH and HP groups. However, the values of the HH and HP groups were comparable in cellularity, levels of serum transferases, and apoptosis rate following reperfusion. The ratios of bcl-2/bax were reversed, which was more evident in the HH and HP groups than in the PR group. Hemi-hepatic artery-preserved portal occlusion had little effect on hepatocyte apoptosis compared with Pringle's maneuver and caused minor ischemia-reperfusion injury as shown by the reversed bcl-2/bax ratio.
    Journal of Surgical Research 01/2011; 174(2):298-304. DOI:10.1016/j.jss.2010.12.030 · 2.12 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This paper reviews and interprets a method for determining the nutritional value of D-amino acids, D-peptides, and amino acid derivatives using a growth assay in mice fed a synthetic all-amino acid diet. A large number of experiments were carried out in which a molar equivalent of the test compound replaced a nutritionally essential amino acid such as L-lysine (L-Lys), L-methionine (L-Met), L-phenylalanine (L-Phe), and L-tryptophan (L-Trp) as well as the semi-essential amino acids L-cysteine (L-Cys) and L-tyrosine (L-Tyr). The results show wide-ranging variations in the biological utilization of test substances. The method is generally applicable to the determination of the biological utilization and safety of any amino acid derivative as a potential nutritional source of the corresponding L-amino acid. Because the organism is forced to use the D-amino acid or amino acid derivative as the sole source of the essential or semi-essential amino acid being replaced, and because a free amino acid diet allows better control of composition, the use of all-amino-acid diets for such determinations may be preferable to protein-based diets. Also covered are brief summaries of the widely scattered literature on dietary and pharmacological aspects of 27 individual D-amino acids, D-peptides, and isomeric amino acid derivatives and suggested research needs in each of these areas. The described results provide a valuable record and resource for further progress on the multifaceted aspects of D-amino acids in food and biological samples.
    Amino Acids 04/2011; 42(5):1553-82. DOI:10.1007/s00726-011-0915-1 · 3.65 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Studies that compare laparoscopic to open liver resection for hepatocellular carcinoma (HCC) in cirrhotic patients are rare and may have suffered from low patient numbers. This work was designed to determine the impact of laparoscopic resection on postoperative and long-term outcomes in a large series of cirrhotic patients with hepatocellular carcinoma (HCC) compared with open resection. From 2002 to 2009, 36 patients with chronic liver disease with complicating HCC were selected for laparoscopic resection (laparoscopic group, LG). The outcomes were compared with those of 53 patients who underwent open hepatectomy (open group, OG) during the same period in a matched-pair analysis. The two groups were similar in terms of tumor number and size and number of resected segments. Morbidity and mortality rates were similar in the two groups (respectively 25 and 0% in LG vs. 35.8 and 7.5% in OG; p = 0.3). Severe complications were more frequent in OG (13.2%) than in LG (2.8%; p = 0.09). Despite similar portal hypertension levels, complications related to ascites (namely evisceration or variceal bleeding) were fatal in 4 of 12 affected patients in OG but 0 of 5 cases in LG (p = 0.2). The mean hospitalization durations were 6.5 ± 2.7 days and 9.5 ± 4.8 days in LG and OG, respectively (p = 0.003). The surgical margins were similar in the two groups. Although there was a trend toward better 5-year overall survival in LG (70 vs. 46% in OG; p = 0.073), 5-year disease-free survival was similar (35.5 vs. 33.6%). Laparoscopic resection of HCC in patients with chronic liver disease has similar results to open resection in terms of postoperative outcomes, surgical margins, and long-term survival.
    Surgical Endoscopy 06/2011; 25(11):3668-77. DOI:10.1007/s00464-011-1775-1 · 3.31 Impact Factor