# Impacts of pringle maneuver on hepatectomies: analysis of survival and clinical effects

## TL;DR

This study shows that the intermittent Pringle maneuver during liver surgery reduces mortality risk despite longer operation times, and early signs of liver dysfunction strongly predict poor outcomes.

## Contribution

The study provides evidence that the intermittent Pringle maneuver reduces mortality risk by 46% in hepatectomy patients when applied with standardized protocols.

## Key findings

- The Pringle maneuver reduced mortality risk by 46% despite longer surgical times and ICU stays.
- Early liver dysfunction markers like elevated bilirubin and low prothrombin activity strongly predicted poor outcomes.
- A Pringle duration of 16–30 minutes was associated with better survival and shorter operative times.

## Abstract

The Pringle maneuver remains a widely used technique in hepatic surgery with varying opinions on its effects on postoperative outcomes and survival, requiring evidence-based evaluation of its impact on liver function and long-term results.

The aim of this study was to evaluate the impact of the intermittent Pringle maneuver on postoperative liver function and survival in hepatectomy patients, focusing on early dysfunction markers as prognostic factors.

In this retrospective cohort of 198 patients (106 women and 92 men; mean age, 59 years), the Pringle group showed longer surgical times (226.87±82.18 vs. 184.00±80.90 min, p<0.001) and extended intensive care unit stays (4.02±2.1 vs 3.11±1.9 days, p=0.026), but lower bilirubin levels (2.18±0.33 vs. 3.13±0.39 mg/dL, p=0.049). Multivariate analysis revealed that the Pringle maneuver reduced mortality risk (hazard ratio [HR]=0.540, 95% confidence interval [95%CI]: 0.333–0.876, p=0.013). Early liver dysfunction markers strongly predicted worse outcomes: elevated bilirubin nearly doubled mortality risk (HR 1.975, 95%CI 1.100–3.545, p=0.023), and decreased prothrombin activity tripled it (HR 3.055, 95%CI 1.839–5.075, p<0.001).

While the Pringle maneuver extends operative time and intensive care unit stay, it demonstrates a protective effect on survival. Early postoperative liver dysfunction strongly predicts poor outcomes, emphasizing the importance of careful postoperative monitoring regardless of vascular control strategy. These findings suggest that a controlled intermittent Pringle maneuver offers survival benefits when properly timed.

The intermittent Pringle maneuver reduced mortality risk by 46% in hepatectomy patients, despite longer operative times.

Early postoperative liver dysfunction markers (bilirubin >2 mg/dL or prothrombin activity <50%) strongly predicted poor outcomes and increased mortality risk up to threefold.

Optimal Pringle duration of 16–30 min was associated with favorable survival outcomes and shortest operative times.

Careful postoperative monitoring of liver function remains essential regardless of the vascular control strategy used.

Hepatic ischemia-reperfusion resulting from the Pringle maneuver can induce cellular and tissue damage, potentially leading to postoperative hepatic dysfunction. Moreover, portal congestion caused by the maneuver may lead to bacterial translocation and endotoxemia, potentially contributing to systemic complications. The duration and type of clamping (continuous or intermittent) are critical factors influencing the impact of the Pringle maneuver on postoperative outcomes. However, when properly timed with standardized protocols, the intermittent Pringle maneuver may offer protective effects on long-term survival.

In this retrospective cohort of 198 hepatectomies, intermittent Pringle maneuver using standardized 15-min ischemia/5-min reperfusion cycles reduced mortality risk by 46% (hazard ratio=0.540, p=0.013), despite longer operative times and increased intensive care unit stays. Early postoperative liver dysfunction emerged as a powerful predictor of poor outcomes, with elevated bilirubin nearly doubling mortality risk and decreased prothrombin activity tripling it. These findings underscore the importance of meticulous postoperative monitoring of hepatic function markers to identify high-risk patients who may require intensified interventions. Future prospective multi-institutional trials should validate optimal Pringle protocols tailored to specific pathologies and patient profiles.