The Effect of Pringle Maneuver Applied during Living Donor Hepatectomy on the Ischemia-Reperfusion Injury Observed in the Donors and Recipients

Abstract

Background and Objectives: The aim of this study is to evaluate the clinical and laboratory changes of ischemia and reperfusion injury in the remnant livers of donors with and without Pringle maneuver. Furthermore, we evaluated the recipients who have been transplanted with liver grafts from these donors. Methods and Materials: A total of 108 patients (54 living liver donors and 54 liver recipients) who underwent donor hepatectomy and recipients who living donor liver transplantation, were included in this randomized double-blind study between February 2021 and June 2021. The donors were divided into two groups: Pringle maneuver applied (n = 27) and Pringle maneuver not applied (n = 27). Similarly, recipients with implanted liver obtained from these donors were divided into two groups as the Pringle maneuver was performed (n = 27) and not performed (n = 27). Blood samples from donors and recipients were obtained on pre-operative, post-operative 0 h day (day of surgery), post-operative 1st day, post-operative 2nd day, post-operative 3rd day, post-operative 4th day, post-operative 5th day, and liver tissue was taken from the graft during the back table procedures. Liver function tests and complete blood count, coagulation tests, IL-1, IL-2, IL-6, TNF-α, and β-galactosidase measurements, and histopathological findings were examined. Results: There was no statistically significant difference in the parameters of biochemical analyses for ischemia-reperfusion injury at all periods in the donors with and without the Pringle maneuver. Similarly, there was no statistically significant difference between in the recipients in who received liver grafts harvested with and without the Pringle maneuver. There was no statistically significant difference between the two recipient groups in terms of perioperative bleeding and early bile duct complications (p = 0.685). In the histopathological examinations, hepatocyte damage was significantly higher in the Pringle maneuver group (p = 0.001). Conclusions: Although the histological scoring of hepatocyte damage was found to be higher in the Pringle maneuver group, the Pringle maneuver did not augment ischemia-reperfusion injury in donors and recipients that was evaluated by clinical and laboratory analyses.

Keywords: Pringle maneuver; immune response; inflammatory response; ischemia–reperfusion injury; liver transplantation; living liver donors; recipients.

Figure 1

Pringle maneuver not applied group. (a) Central venule (Cv), inflammatory cell infiltration in the subcapsular area (star), Glisson’s capsule (arrowhead). H-E, ×10 (b). Portal area (arrows), hydropic damage and degeneration of hepatocytes (black star), hepatocytes with heterochromatic-pycnotic nuclei (white star). H-E, ×10 (c). Portal area (arrows), hydropic damage, and degeneration of hepatocytes (star). H-E, ×10 (d). Dense inflammatory cell infiltration in portal areas (arrows), hepatocytes with heterochromatic-pycnotic nuclei (black star), hepatocyte degeneration (white star). H-E, ×10 (e). Chromatolysis (arrow) in hepatocyte nuclei. H-E, ×40. (f). Inflammatory cell infiltration in the portal area (arrows), hepatocytes with eosinophilic cytoplasm, heterochromatic-pycnotic nuclei (star). H-E, ×10.

Figure 2

Pringle maneuver applied group. (a) Portal area (arrows), hepatocytes with heterochromatic-pycnotic nuclei (black star), hepatocyte degeneration (white star). H-E, ×10 (b). Inflammatory cell infiltration in the portal area (arrows), intracytoplasmic vacuolization in hepatocytes (star). H-E, ×10 (c). Inflammatory cell infiltration in the portal area (black arrows), intracytoplasmic bile pigmentation in hepatocytes (white arrows), hepatocytes with heterochromatic-pycnotic nuclei (black star), intracytoplasmic vacuolization in hepatocytes (white star). H-E, ×20 (d). Inflammatory cell infiltration in the portal area (black arrows), inflammatory cell infiltration in focal areas in the liver parenchyma (white arrows). H-E, ×10 (e). Granulomatous hepatocyte degeneration (star). H-E, ×20 (f). Inflammatory cell infiltration in the portal area (arrows), hydropic changes in hepatocytes (star). H-E, ×40.