title: Total intermittent Pringle maneuver during liver resection can induce intestinal epithelial cell damage and endotoxemia.
abstract: OBJECTIVE
  The intermittent Pringle maneuver (IPM) is frequently applied to minimize blood loss during liver transection. Clamping the hepatoduodenal ligament blocks the hepatic inflow, which leads to a non circulating (hepato)splanchnic outflow. Also, IPM blocks the mesenteric venous drainage (as well as the splenic drainage) with raising pressure in the microvascular network of the intestinal structures. It is unknown whether the IPM is harmful to the gut. The aim was to investigate intestinal epithelial cell damage reflected by circulating intestinal fatty acid binding protein levels (I-FABP) in patients undergoing liver resection with IPM.
  
  
  METHODS
  Patients who underwent liver surgery received total IPM (total-IPM) or selective IPM (sel-IPM). A selective IPM was performed by selectively clamping the right portal pedicle. Patients without IPM served as controls (no-IPM). Arterial blood samples were taken immediately after incision, ischemia and reperfusion of the liver, transection, 8 hours after start of surgery and on the first post-operative day.
  
  
  RESULTS
  24 patients (13 males) were included. 7 patients received cycles of 15 minutes and 5 patients received cycles of 30 minutes of hepatic inflow occlusion. 6 patients received cycles of 15 minutes selective hepatic occlusion and 6 patients underwent surgery without inflow occlusion. Application of total-IPM resulted in a significant increase in I-FABP 8 hours after start of surgery compared to baseline (p<0.005). In the no-IPM group and sel-IPM group no significant increase in I-FABP at any time point compared to baseline was observed.
  
  
  CONCLUSIONS
  Total-IPM in patients undergoing liver resection is associated with a substantial increase in arterial I-FABP, pointing to intestinal epithelial injury during liver surgery.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01099475.
authors.affiliation: Department of Surgery, Maastricht University Medical Center & Nutrim School for Nutrition, Toxicology and Metabolism, Maastricht University, Maastricht, The Netherlands. S.dello@maastrichtuniversity.nl
authors.forename: Simon A W G
authors.initials: SA
authors.lastname: Dello
authors.forename: Kostan W
authors.initials: KW
authors.lastname: Reisinger
authors.forename: Ronald M
authors.initials: RM
authors.lastname: van Dam
authors.forename: Marc H A
authors.initials: MH
authors.lastname: Bemelmans
authors.forename: Toin H
authors.initials: TH
authors.lastname: van Kuppevelt
authors.forename: Maartje A J
authors.initials: MA
authors.lastname: van den Broek
authors.forename: Steven W M
authors.initials: SW
authors.lastname: Olde Damink
authors.forename: Martijn
authors.initials: M
authors.lastname: Poeze
authors.forename: Wim A
authors.initials: WA
authors.lastname: Buurman
authors.forename: Cornelis H C
authors.initials: CH
authors.lastname: Dejong
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000032:analysis / Q000097:blood; D016063:Blood Loss, Surgical / Q000517:prevention & control; D016923:Cell Death; D003250:Constriction; D019446:Endotoxemia / Q000097:blood / Q000453:epidemiology / Q000209:etiology* / Q000473:pathology; D004847:Epithelial Cells / Q000473:pathology; D050556:Fatty Acid-Binding Proteins / Q000032:analysis / Q000097:blood; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects* / Q000379:methods*; D006801:Humans; D007410:Intestinal Diseases / Q000097:blood / Q000453:epidemiology / Q000209:etiology / Q000473:pathology; D007413:Intestinal Mucosa / Q000293:injuries* / Q000473:pathology; D008099:Liver / Q000098:blood supply / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000097:blood / Q000453:epidemiology / Q000209:etiology*; D013997:Time Factors
chemical_list: D015415:Biomarkers; C493404:FABP2 protein, human; D050556:Fatty Acid-Binding Proteins