Does intermittent pringle maneuver loss its clinical value in reducing bleeding during hepatectomy? A systematic review and meta-analysis.

BACKGROUND: The intermittent Pringle's maneuver (IPM) is conducted mainly during the procedure of hepatectomy to control intraoperative blood loss (IBL), but it has been questioned since improvement of surgical technology and intraoperative management. Hence, we conducted a systematic review and meta-analysis to validate the clinical value of IPM. MATERIALS AND METHODS: Eligible studies that were designed to evaluate the IPM in the procedure of hepatectomy were searched for on PubMed, Medline, and other databases from establishment of the database to October 2019. The primary endpoints were IBL and intraoperative blood transfusion (IBT). The risk ratio (RR) with 95% confidence interval (CI) was used to determine the effect size. RESULTS: A total of 16 studies with six randomized controlled trials (RCTs) were enrolled in this meta-analysis, including 1,770 cases in the IPM group and 1,611 cases in the non-IPM group. Overall, there were no significant differences between the IPM and non-IPM groups in the amount of IBL and the incidence of IBT (RR = 0.96, 95% CI 0.67-1.37, P = 0.82), which was also confirmed in the subgroups of RCTs (P > 0.05). However, subgroup analyses showed that for patients with colorectal liver metastasis (CRLM), the amount of IBL was generally higher in the IPM group than in the non-IPM group, and the incidence of IBT was significantly higher in the IPM group (RR = 7.17, 95% CI 1.91-26.94, P = 0.004). In addition, no significant differences were observed in terms of postoperative complications between the two groups (all P > 0.05). CONCLUSION: With the current data, we concluded that IPM had lost its value in patients with CRLM, although it remained controversial in patients with hepatocellular carcinoma.

Comparison of long-term efficacy between endoscopic and percutaneous biliary drainage for resectable extrahepatic cholangiocarcinoma with biliary obstruction: A systematic review and meta-analysis.

BACKGROUND/AIM: For resectable extrahepatic cholangiocarcinoma with biliary obstruction, it remains a controversy whether to choose percutaneous transhepatic biliary drainage (PTBD) or endoscopic biliary drainage (EBD). A systematic review was conducted to compare the long-term efficacy between the two techniques. MATERIALS AND METHODS: Eligible studies were searched from January 1990 to May 2018, comparing the long-term efficacy between EBD and PTBD for extrahepatic cholangiocarcinoma. Primary end point was overall survival (OS) rate, and secondary end points included postoperative severe complications and seeding metastasis. Effect size on outcomes was calculated using a fixed- or random-effect model, accompanied with hazard ratio (HR) and 95% confidence interval (CI). RESULT: Six studies were included in this meta-analysis. Meta-analysis showed that EBD was superior to PTBD in OS (HR = 0.70, 95% CI 0.59-0.84,P= 0.0002). But subgroup results showed that the superiority disappeared in distal cholangiocarcinoma (HR = 0.76, 95% CI 0.56-1.01,P= 0.06). Other prognostic factors such as intraoperative blood transfusion, lymphatic metastasis and seeding metastasis, were inconsistent between groups. In addition, regional disparity was obviously apparent between Japanese and non-Japanese studies. CONCLUSION: The conclusion that EBD was superior to PTBD in OS for resectable extrahepatic cholangiocarcinoma with biliary obstruction is less convincing, and more trials need to be conducted in future.