title: Meta-analysis of the clamp-crushing technique for transection of the parenchyma in elective hepatic resection: back to where we started?
abstract: BACKGROUND
  After introduction of the clamp-crushing technique in the 1970s, various devices have been developed for transection of the liver with the aim of further reducing blood loss and improving the outcome of patients who undergo hepatic resection. We performed a meta-analysis to quantitatively compare the clamp-crushing technique to any subsequently introduced transection technique with respect to patients' perioperative outcome.
  
  
  METHODS
  A systematic literature search was conducted to identify randomized controlled trials comparing the clamp-crushing technique to any alternative method of hepatic transection. Relative risks (RR) were calculated for each outcome and reported along with their 95% confidence intervals (95% CI). Meta-analyses were stratified for the various types of transection techniques compared with the clamp-crushing technique and were carried out by a random effects model.
  
  
  RESULTS
  Seven randomized controlled trials with a total of 554 patients were included in final analyses. Analyses of overall morbidity (RR .89; 95% CI, .63-1.25), biliary leakage (RR 1.03; 95% CI, .50-2.13), transfusion rates (RR .69; 95% CI, .31-1.51), and mortality RR (.20; 95% CI, .02-1.65) revealed no difference between the clamp-crushing and alternative transection techniques. None of the identified studies demonstrated a clinically important benefit of an alternative transection method in terms of blood loss, parenchymal injury, transection time, and hospital stay.
  
  
  CONCLUSIONS
  This meta-analysis does not indicate a benefit of any alternative transection technique on patients' perioperative outcome compared with the clamp-crushing technique. The clamp-crushing technique remains the reference technique for transection of the parenchyma in elective hepatic resection.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg 69120, Germany. nuh.rahbari@med.uni-heidelberg.de
authors.forename: Nuh N
authors.initials: NN
authors.lastname: Rahbari
authors.forename: Moritz
authors.initials: M
authors.lastname: Koch
authors.forename: Thomas
authors.initials: T
authors.lastname: Schmidt
authors.forename: Edith
authors.initials: E
authors.lastname: Motschall
authors.forename: Thomas
authors.initials: T
authors.lastname: Bruckner
authors.forename: Kathrin
authors.initials: K
authors.lastname: Weidmann
authors.forename: Arianeb
authors.initials: A
authors.lastname: Mehrabi
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
authors.forename: Jürgen
authors.initials: J
authors.lastname: Weitz
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008107:Liver Diseases / Q000601:surgery*; D011183:Postoperative Complications / Q000601:surgery; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D016896:Treatment Outcome