| Objective:On the basis of clinical and animal experiments,to investigate the impact of Pringle ’ s maneuver to liver and pancreas,and to explore the mechanism of these injuries.Methods:First of all,Clinical data of patients who underwent hepatectomy using the Pringle’s maneuver from January 2103 to June 2015 were analysed retrospectively.According to the selection criteria:(1)The Child-Pugh classification of liver function was grade A or B grade after shortterm treatment improved to the A level;(2)Preoperative serum amylase was normal(0~220U/L),no medical history of pancreatitis and cholelithiasis;(3)The method for blocking hepatic blood flow was Pringle’s maneuver and longest time for each block is 20 min,separated by 5 minutes reperfusion periods;(4)All the patients had good conditions;(5)No treatment was given after surgery;(6)All patients had complete preoperative and postoperative data.There were 87 patients who met the inclusion criteria and we analysis the effects of Pringle ’ s maneuver to postoperative amylase and liver function.Animal experiment was designed to validate the clinical data.70 male SD rats(Guang Xi Medical Universityproviding)in a SPF grade were randomly divided into 3 groups:Control group group(A)has 10 rats-without processing;continuous clamping group has 30rats-continuous hepatic pedicle clamping lasting 45 minutes;intermittent group has 30 rats intermittent.Blood samples were taken on the 1,2,3 postoperative day from 10 rats respectively of the B and C group per each group(subgroups B1,B2,B3,and C1,C2,C3,each consisting of 10 animals)by a puncture portal vein,and serum activities of ALT,AST and amylase were measured.On the same occasion,liver and pancreas tissue samples were also taken,fixed with 10%formal-dehyde,stained using hematoxylin and eosine(HE)and analyzed with light microscopy.The pancreas were also fixed with glutar-aldehyde and analyzed with electron microscope.Results:According to the clinical data analysis,we found that the relationship of postoperative hyperamylasemia with the Pringle’s maneuver was statistically significant(P<0.05).A statistically significant serum amylase was detected in B and C subgroup compared to A on the first day after operation.(B:2437.6±589.3 U/Lvs 909±221.9 U/L,P < 0.05,C:1858.5±579.7 U/Lvs909±221.9 U/L,P < 0.05),and B was higher than A(2437.6±589.3U/Lvs1858.5±579.7 U/L,P < 0.05).A statistically significant ALT was also detected in B and C subgroup compared to A on the first day after operation(B:453.2±163.9 U/L vs65.4±13.1 U/L,P < 0.05;C:199.4±80.5 U/L vs65.4±13.1 U/L,P < 0.05),and B was also higer than A(453.2±163.9 U/L vs199.4±80.5 U/L,P<0.05).A statistically significant AST was also detected between the B and C group compared to A on the first day after operation(B:628.4±69.2 U/Lvs118.8±15.9 U/L,P<0.05;C:430.2 ±133.0 U/Lvs118.8±15.9U/L,P<0.05),and B was also higer than A(628.4±69.2 U/Lvs430.2 ±133.0U/L,P<0.05).A statistically significant MDA in liver tissue was also detected inB and C subgroup compared to A on the first day after operation(B:3.63±1.89nmol/mgprotvs0.98±0.25nmol/mgprot,P < 0.05;C1.87±0.46 nmol/mgprot vs0.98±0.25 nmol/mgprot,P<0.05),and B was also higer than A(3.63±1.89 nmol/mgprotvs1.87±0.46 nmol/mgprot,P < 0.05);in the second day after operation,there were also statistically significant between B and C group(2.71±0.81nmol/mgprotvs1.49±0.61nmol/ mgprot,P<0.05).A statistically significant MDA in pancreatic tissue was also detected in B subgroup compared to A after operation(1.23±0.75 mgprotvs0.58±0.31 mgprot,P<0.05),and B was also higer than A(1.23±0.75 mgprotvs0.51±0.28 mgprot,P<0.05),in the second day after operation,there were also statistically significant between B and C group(0.99±0.31 mgprotvs 0.71±0.26 mgprot,P<0.05).A statistically significa nt SOD in liver tissue was also detected in B and C subgroup compared to A after operation(B:93.58±15.95 U/Lvs190.1±15.8 U/L,P < 0.05;C:111.57±14.11 U/L vs190.1±15.8 U/L,P < 0.05),and B was lower than A(93.58±15.95 U/Lvs111.57±14.11 U/L,P<0.05);in the second and third day after operation,there were also statistically significant between B and C group(second day :102.7±22.89 U/Lvs147.67 ±20.91 U/L,P < 0.05;third day:116.7±32.4 U/Lvs146.77±27.4 U/L,P<0.05).A statistically significa nt SOD in pancreatic tissue was also detected in B and C subgroup compared to A after operation(B:85.4±38.1 U/Lvs 257.51±43.1 U/L,P < 0.05;C:145.5 ±75.1 U/Lvs 257.51±43.1 U/L,P<0.05),and B was lower than A(85.4±38.1 U/Lvs145.5 ±75.1 U/L,P<0.05);in the second and third day after operation,group B was also lower than group C(118.13±44.01 U/Lvs 176.54±36.84 U/L,P<0.05)The control group cell of endocrine portion and exocrine portion had no histopathological examination.The examination of the pancreatic tissue of hepatectomy animals revealed the presence of pancreatitis at both time points.Pancreatitis was moresevere after 24 h of reperfusion.There was increased necrosis,edema,vacuolar degeneration,whereas no differences were seen in inflammatory infiltration and hemorrhagic and more severe ischemic injury after using the continuous Pringle’s maneuver compared to the intermittent one.In the liver tissue samples of B1 numerous hepatocyte adaptation mechanisms(including cellular atrophy,hyperplasia and condensation),different types of degeneration,necrosis and Inflammatory cell infiltration were observed,and more severe injury after 24 h of reperfusion.The pathological changes of C1 were lighter.The regenerated hepatocytes and fibrosis were seen on the third day after operation.Obvious swelling was observed in the dictyosome and mitochondria in the B1 analyzed withelectron microscope,in the pancreatic tissue samples of C1 had no histopathological changes.Conclusion:(1)The Pringle’s maneuver can carry a potential risk of serum amylase and ALT/AST elevation,and may be related to the damage of hepatic ischemia reperfusion injury and congestion of pancreas.(2)The research results obviously proved a bad tolerance of continuous Pringle maneuver compared to the intermittent one in hepatectomy. |
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