Intervention Review

Ischaemic pre-conditioning for elective liver resections performed under vascular occlusion

  1. Kurinchi Selvan Gurusamy1,*,
  2. Yogesh Kumar2,
  3. Viniyendra Pamecha1,
  4. Dinesh Sharma1,
  5. Brian R Davidson1

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 21 JAN 2009

Assessed as up-to-date: 22 AUG 2008

DOI: 10.1002/14651858.CD007629


How to Cite

Gurusamy KS, Kumar Y, Pamecha V, Sharma D, Davidson BR. Ischaemic pre-conditioning for elective liver resections performed under vascular occlusion. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD007629. DOI: 10.1002/14651858.CD007629.

Author Information

  1. 1

    Royal Free Hospital and University College School of Medicine, University Department of Surgery, London, UK

  2. 2

    Leeds Teaching hospital, General Surgery, Leeds, UK

*Kurinchi Selvan Gurusamy, University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, NW3 2QG, UK. kurinchi2k@hotmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 21 JAN 2009

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Vascular occlusion is used to reduce blood loss during liver resection surgery. The enzyme markers of liver injury are elevated if vascular occlusion is employed during liver resection. It is not clear whether ischaemic preconditioning prior to vascular occlusion has a protective effect during elective liver resections.

Objectives

To assess the advantages (decreased ischaemia-reperfusion injury) and any potential disadvantages of ischaemic preconditioning prior to vascular occlusion during liver resections.

Search methods

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2008.

Selection criteria

We included randomised clinical trials comparing ischaemic preconditioning versus no ischaemic preconditioning prior to vascular occlusion (irrespective of the method of vascular occlusion) during elective liver resections (irrespective of language or publication status).

Data collection and analysis

Two authors independently assessed trials for inclusion and independently extracted the data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. We calculated the risk ratio, mean difference, or standardised mean difference with 95% confidence intervals based on intention-to-treat or available data analysis.

Main results

We included four trials with 271 patients undergoing open liver resections. The patients were randomised to ischaemic preconditioning (n = 135) and no ischaemic preconditioning (n = 136) prior to continuous vascular occlusion (portal triad clamping in three trials and hepatic vascular exclusion in one trial). All the trials excluded cirrhotic patients. We assessed all the four trials as having high risk of bias. There was no difference in mortality, liver failure, other peri-operative morbidity, hospital stay, intensive therapy unit stay, and operating time between the two groups. The proportion of patients requiring blood transfusion was lower in the ischaemic preconditioning group. There was also a trend towards a lower amount of red cell transfusion favouring ischaemic preconditioning group. There was no difference in the haemodynamic changes, blood loss, bilirubin, or prothrombin activity between the two groups. The enzyme markers of liver injury were lower in the ischaemic preconditioning group on the first post-operative day.

Authors' conclusions

Currently, there is no evidence to suggest a protective effect of ischaemic preconditioning in non-cirrhotic patients undergoing liver resection under continuous vascular occlusion. Ischaemic preconditioning reduces the blood transfusion requirements in patients undergoing liver resection.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

No evidence that ischaemic preconditioning has a protective role in liver resections performed utilising vascular occlusion.

More than 1000 elective liver resections (planned operation) are performed annually in the United Kingdom alone. When liver resection is performed, the inflow of blood to the liver can be blocked (vascular occlusion), thereby reducing the blood loss. There are concerns about liver damage when the blood supply is blocked. Ischaemic preconditioning involves ischaemia (blocking the blood supply) and reperfusion (unblocking the blood supply) for a short period of time before exposure to prolonged vascular occlusion. The aim of this review was to assess the role of ischaemic preconditioning in liver resections performed utilising vascular occlusion. Four randomised clinical trials including 271 patients undergoing open liver resections fulfilled the inclusion criteria of this review. The patients were randomised to ischaemic preconditioning (n = 135) and no ischaemic preconditioning (n = 136) prior to continuous vascular occlusion. All the trials excluded cirrhotic patients. We assessed all the four trials as having high risk of bias (high risk of systematic error). There was no difference in mortality, liver failure, post-operative complications, hospital stay, intensive therapy unit stay, and operating time between the two groups. The proportion of patients requiring blood transfusion was lower in the ischaemic preconditioning group. The reasons for this are not clear. There was no difference in blood loss or enzyme markers of liver function between the two groups. The enzyme markers of liver injury were lower in the ischaemic preconditioning group on the first post-operative day. Currently, there is no evidence to suggest a protective effect of ischaemic preconditioning in non-cirrhotic patients undergoing liver resection under continuous vascular occlusion. Ischaemic preconditioning reduces the blood transfusion requirements in patients undergoing liver resection. Further high quality randomised clinical trials are necessary to assess the role of ischaemic preconditioning. Further studies are necessary to understand the mechanism of ischaemic preconditioning.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

缺血前置處理用於採用血流阻斷術之選擇性肝臟切除術

血流阻斷術用於降低肝切除手術過程中的血液損失。如果肝臟切除過程中使用血流阻斷術,肝臟受損的?標記物會增加。但尚不清楚是否在血流阻斷術前實施缺血前置處理對選擇性肝臟切除的過程具有保護作用。

目標

評估在肝臟切除過程中血流阻斷術前實施缺血前置處理的好處 (減少缺血再灌注引起的損害) 和潛在壞處

搜尋策略

我們搜尋截至2008年8月的The Cochrane HepatoBiliary Group Controlled Trials Register, Cochrane Library的Cochrane Central Register of Controlled Trials (CENTRAL)、 MEDLINE、EMBASE和Science Citation Index Expanded。

選擇標準

我們收納在選擇性肝臟切除過程中血流阻斷術前(不受血流阻斷術方法的限制)實施缺血前置處理對照無缺血前置處理的隨機臨床試驗 (不受語言,發表狀態的限制) 。

資料收集與分析

2位作者獨立評估收錄的試驗,獨立摘錄數據。我們使用RevMan 以固定效果模式和隨機效果模式分析資料。根據治療意向或已獲取的資料分析,我們計算風險比率(risk ratio),平均差(mean difference),標準平均差(tandardised mean difference)及其95% 信賴區間。

主要結論

我們收納了4個試驗,其中有271位病人接受開腹肝切除手術。 隨機把病人分配至在持續性血流阻斷術(3個試驗實施肝門阻斷,一個試驗執行肝血流阻斷術)之前實施缺血前置處理 (n = 135)和無缺血前置處理 (n = 136)。 所有試驗排除肝硬化的病人。 我們評估所有4個試驗具有較高的偏誤風險。2組在死亡率、肝臟衰竭、其他手術期間發病率, 住院日、加護病房停留時間和手術時間方面沒有差異。在缺血前置處理組,需要輸血的病人比例較低。 同樣,在缺血前置處理組,出現了紅血球輸血減少的趨勢。 兩組在血液動力變化、失血、膽紅素或凝血素活性方面沒有差異。手術後第一天,缺血前置處理組的肝臟損害?標記物較低。

作者結論

目前沒有證據建議選擇性肝臟切除術在持續性血流阻斷術的情況下使用缺血前置處理會對非肝硬化病人達到保護作用。 缺血前置處理降低肝臟切除後的病人的輸血要求。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有證據指出缺血前置處理對肝臟切除手術在血流阻斷術的狀態下起到保護作用:每年單單是英國就會實施1000例以上的選擇性肝臟切除手術(計畫內手術)。實施肝切除後,應停止肝臟內的血液流動(血流阻斷),這樣才能潛在降低血液的損失。人們關心供血停止時對肝臟產生的損害。缺血前置處理包括持續較短時間的缺血(停止供血)和再灌注(不中斷供血),然後才能採取延長血流阻斷術的方法。 本次文獻回顧的目的在於評估缺血前置處理對肝臟切除手術在血流阻斷術的狀態下的作用。 共有4個試驗,其中有271位病人接受開腹肝切除手術,符合本次文獻回顧的納入標準。隨機把病人分配至在持續性血流阻斷術之前實施缺血前置處理 (n = 135)和無缺血前置處理 (n = 136)。所有試驗排除肝硬化的病人。我們評估所有4個試驗具有較高的偏誤風險(系統誤差風險高)。兩組在死亡率、肝臟衰竭、術後併發症、住院日、 重症監護室停留時間和手術時間方面沒有差異。在缺血前置處理組,需要輸血的病人比例較低。 原因不明。 兩組在也血液損失或肝臟功能?標記物方面沒有差異。 手術後第一天,缺血前置處理組的肝臟損害?標記物較低。 目前沒有證據建議肝臟切除術在持續性血流阻斷術的情況下使用缺血前置處理會對非肝硬化病人起到保護作用。缺血前置處理降低了肝臟切除中對病人的輸血要求。 需要更多品質較高的隨機臨床試驗來評估缺血前置處理的作用。 需要進一步研究瞭解缺血前置處理的機制。