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PEDICLE CLAMPING WITH ISCHEMIC PRECONDITIONING IN LIVER RESECTION

Hepatic pedicle clamping is widely used to control intraoperative bleeding during hepatectomy; intermittent hepatic pedicle clamping is better tolerated then continous and it is used in cirrothic patient and also during livin donor related transplantation. The limit of intermittent clamping is possible blood loss during each period of reperfusion. Recently a new method of occlusion of inflow to the liver has been proposed by Clavien et al., based on a short period of ischemia of the liver (preconditioning) (10 minutes), followed by a short period of reperfusion (10 minutes) and subsequent prolonged continuous clamping. It has been  shown that ischemic preconditioning in  noncirrhotic liver, for up  to 54 minutes of continuous clamping, increased tolerance to ischemia-reperfusion when compared to continuous clamping alone; the serum levels of transaminases at postoperative day 1 were reduced more then 2-fold in patients in whom preconditioning was used, compared to patients in whom continuous clamping alone was used; a similar trend was observed at p.o. day 3. This positive effects of preconditioning seem to be based on a significant reduction of cellular ischiemic damage (expressed as a reduced number of apoptotic sinusoidal lining cells) and on the relased of substances such as adenosine and nitric oxide by the ischemic tissue after the period of preconditioning with significantly protect the liver against the subsequent prolonged ischemia.

Surgical Technique

Clamping of the hepatic pedicle is performed with a vascular tourniquet or vascular clamp, which is also used to clamp the accessory left artery when present, when this technique is used, resection of the liver is started immediately after initial clamping and interrupted after the first 10 minutes of preconditioning: a period of reperfusion of 10 minutes is then allowed, during which the parenchymal resection is interrupted. Continuous clamping is subsequently carried out and prolonged until the resection is completed.

Conclusion

Ischemic preconditioning is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping.

Bibliography

1. Clavien PA, Selzner M, Rudiger HA, Graf R, Kadry Z, Rousson V, Jochum W. A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg. 2003 Dec;238(6):843-50
2. Nuzzo G, Giuliante F, Vellone M, De Cosmo G, Ardito F, Murazio M, D'Acapito F, Giovannini I. Pedicle clamping with ischemic preconditioning in liver resection. Liver Transpl. 2004 Feb; 0(2 Suppl 1):S53-7.
3. Clavien PA, Yadav S, Sindram D, Bentley RC. Protective effects of ischemic preconditioning for liver resection performed under inflow occlusion in humans. Ann Surg. 2000 Aug;232(2):155-62.