Impact of the Intermittent Pringle Maneuver for Predicting Post-hepatectomy Liver Failure: A Cohort Study of 597 Consecutive Patients

Background Intermittent Pringle maneuver (PM) is widely performed to reduce blood loss during hepatectomy; however, its impact on clinically relevant post-hepatectomy liver failure (PHLF) remains controversial. This study aimed to assess the impact of PM on PHLF and explore whether PM provides additional value for predicting PHLF. Methods Consecutive patients, who underwent hepatectomy without biliary and/or vascular reconstruction between 2011 and 2018 in a single institution, were retrospectively analyzed. The main outcome was PHLF grades B/C as defined by the International Study Group of Liver Surgery. A multivariable logistic regression model of variables significantly associated with PHLF was established. The model’s predictive ability was assessed by the area under the receiver operating characteristic curve (AUROC). Results Among 597 patients, PHLF occurred in 42 (7.0%). PM was applied in 421 patients (70.5%) and was associated with the development of PHLF (PM vs. no-PM: 9.7 vs. 0.6%, P < 0.001). After the propensity score matching, patients with PM experienced significantly increased rates of PHLF ( P = 0.010). Rem-ALPlat index (including future liver remnant, preoperative albumin level, and platelet count; P < 0.001), the number of PMs ( P = 0.032), and blood loss ( P = 0.007) were identified as significant predictors of PHLF. The model’s AUROC combined with the intraoperative variables was higher than that of the preoperative model alone (0.877 vs. 0.789, P = 0.004). Conclusions PM was involved in the occurrence of clinically relevant PHLF. Further, intraoperative factors including PM may provide additional value to predict PHLF and may facilitate early post-hepatectomy intervention.