Impact of the Pringle manoeuvre on the mitochondrial redox state of hepatocytes in colorectal cancer patients with liver metastases.

INTRODUCTION: Novel surgical strategies for metastatic colorectal cancer (CRC) treatment offer survival benefits even in the case of multiple bilobar liver injury. However, an inability to overcome the biological consequences of an ischaemia-reperfusion phenomenon among cancer patients remains an oncological issue throughout the last 3 decades. The aim of this study was to assess the values of molecular markers of the mitochondrial redox state of hepatocytes in CRC patients during liver surgery and Pringle manoeuvre (PM) application. MATERIAL AND METHODS: We conducted a prospective study of 114 CRC patients who underwent liver resection for CRC metastases between March 2017 and December 2020. RESULTS: PM application was associated with higher superoxide radicals (SR) level generation compared to liver surgery without blood inflow control - 0.32 ± 0.12 and 0.42 ± 0.21 nmol/gm raw tissue × min, respectively. Levels of NO-Fe-S cluster protein complexes in liver stump parenchyma in the end of transection with and without PM was 0.35 ± 0.09 RU and 0.16 ± 0.04 RU, respectively. The most significant impact of long-term ischaemia was found to be the rate of SR generation in liver stump: 152.4 ± 24.4 (95% CI: 104.1-200.7), R2 = 0.46, p = 0.001. CONCLUSIONS: PM exacerbates the disruption of the mitochondrial respiratory chain and potentiates SR generation. The redox status molecular markers of the hepatocytes in CRC patients with liver metastases can be used to assess the functional status of organ and tissues and improve the existing surgical strategies.

The application of pringle manoeuvre, type three liver mobilisation, full thickness diaphragmatic resection with primary closure technique and peritonectomy in the management of advanced ovarian malignancy.

OBJECTIVE: We present an educational technique for the safe completion of complete cytoreduction of diaphragmatic disease for the management of advanced ovarian malignancy. METHODS: We demonstrated these steps with attention to anatomical landmarks and surgical approaches, considering intraoperative and postoperative morbidity and mortality. RESULTS: We present the case of a 49-year-old female patient diagnosed with suspected stage 3C ovarian malignancy following diagnostic laparoscopy. We demonstrate the surgical application of the Pringle manoeuvre, type 3 liver mobilisation, and full-thickness diaphragmatic resection. This was completed with a primary closure technique, with integrity ensured through the performance of an air test and Valsalva manoeuvre. Final histology confirmed a serous borderline tumour with invasive implants within a port site nodule (stage 4A). CONCLUSION: This technique affirms the essential skills in gynaecological oncology training and details a challenging case requiring advanced surgical skills and knowledge, with specific consideration for intraoperative multidisciplinary decision-making.

Does repeat laparoscopic hepatectomy without extracorporeal Pringle manoeuvre worsen treatment outcomes?

Introduction: The Pringle manoeuvre is used in most hospitals to counteract intraoperative haemorrhage in laparoscopic hepatectomy by occluding the flow of blood to the liver. However, in laparoscopic repeat hepatectomy (LRH), outcomes of previous surgery and the influence of other factors frequently make it difficult to occlude the inflow of blood. Aim: To discuss the value of inflow occlusion during LRH and provide tips for its performance. Material and methods: Sixty-three patients who underwent LRH with or without the Pringle manoeuvre were analysed retrospectively. We investigated the efficacy and safety of the Pringle manoeuvre in LRH. Student's t and χ2 tests, Mann-Whitney's U test, Wilcoxon's signed-rank test, and Fisher's exact test were used in the statistical analysis. Results: Nineteen patients underwent LRH with the Pringle manoeuvre, and 44 patients underwent LHR without the Pringle manoeuvre. After propensity score matching, there were no significant differences in terms of operative time, estimated blood loss, and postoperative complication rate (p = 0.973, 0.120, and not applicable, respectively). However, the rate of conversion to open repeat hepatectomy (ORH) was significantly lower in the Pringle manoeuvre group (p = 0.034). In many cases, the cause of conversion to ORH was the non-use of inflow occlusion and the resulting inability to control intraoperative haemorrhage. Laboratory data collected after surgery showed no significant difference between the 2 groups regardless of whether blood flow was occluded or not. Conclusions: LRH with the Pringle manoeuvre can be performed safely using various surgical devices. However, it is often challenging to perform the Pringle manoeuvre in patients with a history of cholecystectomy or segment 5 resection of the liver, and caution is required.

Perioperative and oncological outcomes of renal cell carcinoma with venous tumour thrombus.

AIM: The aim of the present study is to report the perioperative and long-term surgical outcomes of renal cell carcinoma (RCC) with venous tumour thrombus (VTT). MATERIALS AND METHODS: Data of 34 patients (males = 23, females = 11) from 2009 to 2020 who underwent radical nephrectomy with thrombectomy for RCC and VTT was retrospectively analysed. The parameters recorded include tumour laterality, size, level of thrombus, surgical approach, blood loss, transfusion rates, operative time, hospital stay, Clavien complications, tumour histology, follow-up duration, local recurrence, distant metastasis, overall and cancer-specific survival rates. RESULTS: The extent of thrombus was level I in thirteen, level II in twelve, level III (a-1, b-2, c-1, d-2) in six and level IV in three patients respectively. Mean operative time was 320 (±145) min, mean blood loss was 1371.15 (±1020.8) ml and mean hospital stay was 9.6 (±7.4) days. Mean transfusion rate was 6.4 (±3.2) units. Three patients died within the first 30 days of surgery. Cardiopulmonary bypass (CPB) was utilized in three patients. Median follow-up period was 58 (Range: 4-101) months. A statistically significant correlation was found between operative time (p = 0.014) and median survival (p = 0.003) respectively and tumour thrombosis level. Nine patients died due to metastasis, and ten due to unrelated causes. The estimated actuarial survival rates at a median of 58 months were 35.3%. CONCLUSION: An accurate preoperative assessment of the thrombus extent with the involvement of a multidisciplinary team approach is crucial in achieving optimal surgical outcomes in patients of RCC with VTT, particularly with level III and IV thrombus.

The effect of immunonutrition on bacterial translocation after Pringle maneuverer in rats.

INTRODUCTION: Temporary clamping of the hepatoduodenal ligament (the Pringle manoeuvre) is the most commonly used method to prevent intraoperative blood loss in liver surgery. Some side effects of the Pringle manoeuvre (PM) can occur. AIM: To investigate the effectiveness of preoperative immunonutritional support to prevent bacterial translocation (BT) in rats due to PM. MATERIAL AND METHODS: Forty Wistar albino rats were randomly divided into four groups. Groups 1 and 2 were fed with normal rat diet and water, and groups 3 and 4 were fed with enteral immunonutrition (Impact Glutamine) containing 1 g/kg/day amino acid in the preoperative period. Group 1 (n = 10) and 4 (n = 10) rats were treated only with laparotomy; group 2 (n = 10) and 3 (n = 10) rats were treated with PM for 30 min with laparotomy. After 30 min, relaparotomy was applied to all groups and portal blood, mesentery, spleen samples were taken for culture purposes. RESULTS: Proliferation in portal blood cultures was significantly higher in the samples from the normally fed group (group 2) in whom PM was applied, compared to the other groups (p < 0.001). No proliferation was observed in the PM-treated group (group 3), who also received preoperative immunonutritional support. CONCLUSIONS: Preoperative immunonutritional support is effective in the prevention of BT due to PM in rats.

Pringle manoeuvre versus selective hepatic vascular exclusion in partial hepatectomy for tumours adjacent to the hepatocaval junction: a randomized comparative study.

OBJECTIVE: To compare the efficacy of selective hepatic vascular exclusion versus Pringle manoeuvre in partial hepatectomy for tumours adjacent to the hepatocaval junction. METHODS: A randomized comparative trial was carried out. The primary endpoint was intraoperative blood loss. The secondary endpoints were operation time, blood transfusion, postoperative liver function recovery, procedure-related morbidity and in-hospital mortality. RESULTS: 160 patients were randomized into 2 groups: the Pringle manoeuvre group (n = 80) and the selective hepatic vascular exclusion (SHVE) group (n = 80). Intraoperative blood loss and transfusion requirements were significantly less in the SHVE group. In the SHVE group, laceration of hepatic veins happened in 18 patients. Profuse intraoperative blood loss of over 2 L happened in 2 patients but no patient suffered from air embolism because the hepatic veins were controlled. In the Pringle group, the hepatic veins were lacerated in 20 patients, with profuse blood loss of over 2 L in 7 patients and air embolism in 3 patients. The rates of postoperative bleeding, reoperation, liver failure and mortality were significantly higher and the ICU stay and hospital stay were significantly longer in the Pringle group. CONCLUSIONS: SHVE was more efficacious than Pringle manoeuvre for partial hepatectomy in patients with tumours adjacent to the hepatocaval junction.

Meta-analysis of intermittent Pringle manoeuvre versus no Pringle manoeuvre in elective liver surgery.

BACKGROUND AND OBJECTIVES: Intermittent Pringle manoeuvre (IPM) is frequently used during liver surgery. This meta-analysis aimed to review the impact on blood loss, operating time and morbidity and mortality with and without use of IPM. METHODS: An electronic search was performed of the MEDLINE, EMBASE, PubMed databases using both subject headings (MeSH) and truncated word searches to identify all articles published that related to this topic. Pooled risk ratios were calculated for categorical outcomes, and mean differences (MDs) for secondary continuous outcomes, using the fixed-effects and random-effects models for meta-analysis. RESULTS: Four randomized controlled trials encompassing 392 patients were analysed to achieve a summated outcome. Pooled data analysis showed the use of IPM resulted in reduced transection time/cm(2) (MD -0.53 (-0.88, -0.18) min/cm(2) (P = 0.003)) but with comparable blood loss (mL/cm(2)) (MD -1.67 (-4.41, 1.08) mL/cm(2), P = 0.23), overall blood loss (MD -20.42 (-89.42, 48.58) mL), blood transfusion requirements (risk ratio 0.78 (0.40, 1.52, P = 0.47)) and morbidity and mortality compared to no Pringle manoeuvre. In addition, there was no significant difference in the post-operative hospital stay (MD 0.37 (-0.60, 1.34) days). CONCLUSIONS: There is no evidence that the routine use of IPM improves perioperative and post-operative outcomes compared to no Pringle manoeuvre and its routine may not be recommended.