Selective or total inflow occlusion? You be the judge

This is my latest highlight from the journal HPB

The best way to control bleeding during the parenchymal transection phase of liver resection remains controversial. Using a selective approach to vascular inflow occlusion has the benefit of avoiding ischemia to the future liver remnant but does not stop cross circulation from the vascularized to the non-vascularized liver. Using total inflow occlusion or Pringle manouevre may control cross circulation but renders the future liver remnant temporarily ischemic.

In this issue of HPB, Boleslawski and colleagues from Lille in France, present data from 181 patients undergoing right hepatectomy without portal triad clamping. Their technique combines selective right inflow occlusion and division of the right hepatic vein prior to parenchymal transection. Their results showed that the technique is possible in the majority of patients but, interestingly, a quarter of patients still required total inflow occlusion.

While these data show promise for the technique, the strength of evidence is limited by the design of the study and it would have been better if patients had been randomly allocated to selective or total vascular occlusion. Without such quality of evidence, I suspect that individual surgeons will continue to follow their own preference. Single centres often struggle to answer such questions regarding surgical technique because of the disparity between their case volume and the sample size required to achieve adequate statistical power and avoid type 2 error. Perhaps the time has come for national or international collaborative research projects to address these important questions in HPB surgery?

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