title: Ischemic preconditioning prior to intermittent Pringle maneuver in liver resections.
abstract: OBJECTIVE
  Continuous inflow vascular occlusion during liver resections causes less severe ischemia and reperfusion injury (IRI) if it is preceded by ischemic preconditioning (IP) or if intermittent inflow occlusion is used during the resection. No previous clinical trial has studied the effects of adding IP to intermittent inflow occlusion.
  
  
  METHODS
  Consecutive patients (n = 32) with suspicion of malignant liver disease had liver resections (minimum 2 segments) performed with inflow occlusion (intermittent clamping in a manner of 15 min of ischemia and 5 min of reperfusion repetitively; 15/5). Half of the patients were randomized to receive IP (10 min of ischemia and 10 min of reperfusion before parenchymal transection; 10/10). The patients were stratified according to volume of resection and none had chronic liver disease. The patients were followed for 5 days with microdialysis (μD).
  
  
  RESULTS
  All patients completed the study and there were no deaths. No differences were seen between the groups regarding demographics or perioperative parameters (bleeding, duration of ischemia, resection volume, complications, and serum laboratory tests). There were no differences in alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, or prothrombin time (PT)-INR levels, but μD revealed lower levels of lactate, pyruvate, and glucose in the IP group having major liver resections (analysis of variance; ANOVA). Nitrite and nitrate levels in μD decreased postoperatively, but no differences were seen between the groups. In one patient an elevated μD-glycerol curve was seen before the diagnosis of a stroke was made.
  
  
  CONCLUSIONS
  IP before intermittent vascular occlusion does not reduce the serum parameters used to assess IRI. IP seems to improve aerobic glucose metabolism, as the levels of glucose, pyruvate, and lactate locally in the liver were reduced, compared to controls, in patients having >3 segments resected. μD may be used to monitor metabolism locally.
authors.affiliation: Division of Surgery, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden. anders.winbladh@lio.se
authors.forename: Anders
authors.initials: A
authors.lastname: Winbladh
authors.forename: Bergthor
authors.initials: B
authors.lastname: Björnsson
authors.forename: Lena
authors.initials: L
authors.lastname: Trulsson
authors.forename: Karsten
authors.initials: K
authors.lastname: Offenbartl
authors.forename: Per
authors.initials: P
authors.lastname: Gullstrand
authors.forename: Per
authors.initials: P
authors.lastname: Sandström
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D019194:Ischemic Preconditioning / Q000379:methods*; D008099:Liver / Q000098:blood supply*; D008113:Liver Neoplasms / Q000628:therapy*; D008297:Male; D017551:Microdialysis / Q000379:methods*; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D016037:Single-Blind Method; D016896:Treatment Outcome