title: Liver resection without pedicle clamping: feasibility and need for "salvage clamping". Looking for the right clamping policy. Analysis of 512 consecutive resections.
abstract: BACKGROUND
  Pedicle clamping during liver resection (LR) is debated. The purpose of this study is to validate non-clamping policy across a large series of LR and to evaluate the need for salvage clamping (SC) and its outcomes.
  
  
  METHODS
  Five hundred twelve consecutive LR without initial pedicle clamping performed between 2004 and 2009 were analyzed.
  
  
  RESULTS
  Among 512 LR (171 major hepatectomies), 90.2% were completed without clampage. Fifty (9.8%) required SC. Blood loss were higher in SC group (555 vs. 175 mL, p < 0.0001), while transfusion rate was not. No differences were observed in terms of mortality (0%/1.3%), morbidity (38%/38.3%), liver dysfunction (4%/3.7%), and renal dysfunction (0%/1.3%). Bile leak rate was increased in the SC group (20%/10.2%, p = 0.036). At multivariate analysis, three predictive factors of SC were identified: arterial hypertension (p = 0.007, SC rate = 13%), cirrhosis (p = 0.003, SC rate = 26%), and LR conducted along the right portal scissure (p = 0.010, SC rate = 32%). One protective factor was identified: LR confined to antero-lateral segments (Sg2-6, p = 0.001, SC rate  = 2%). Extension of LR had no impact on need for SC.
  
  
  CONCLUSIONS
  The majority of LR can be safely performed without clamping with excellent outcomes. SC is a safe procedure and does not worsen postoperative outcomes, except for bile leak rate. Clamping policy should be tailored to the type of LR and presence of cirrhosis.
authors.affiliation: Department HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy. lvigano@ymail.com
authors.forename: Luca
authors.initials: L
authors.lastname: Viganò
authors.forename: Syed A A
authors.initials: SA
authors.lastname: Jaffary
authors.forename: Alessandro
authors.initials: A
authors.lastname: Ferrero
authors.forename: Nadia
authors.initials: N
authors.lastname: Russolillo
authors.forename: Serena
authors.initials: S
authors.lastname: Langella
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Capussotti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D002985:Clinical Protocols; D003250:Constriction; D005240:Feasibility Studies; D005260:Female; D006488:Hemostasis, Surgical; D006498:Hepatectomy; D006801:Humans; D008107:Liver Diseases / Q000150:complications / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult