Liver Resection Without Pedicle Clamping: Feasibility and Need for "Salvage Clamping". Looking for the Right Clamping Policy. Analysis of 512 Consecutive Resections

Background: Pedicle clamping during liver resection (LR) is debated. The purpose of this study is to validate non-clamping policy across a large series of LR and to evaluate the need for salvage clamping (SC) and its outcomes. Methods: Five hundred twelve consecutive LR without initial pedicle clamping performed between 2004 and 2009 were analyzed. Results: Among 512 LR (171 major hepatectomies), 90. 2% were completed without clampage. Fifty (9. 8%) required SC. Blood loss were higher in SC group (555 vs. 175 mL, p <0. 0001), while transfusion rate was not. No differences were observed in terms of mortality (0%/1. 3%), morbidity (38%/38. 3%), liver dysfunction (4%/3. 7%), and renal dysfunction (0%/1. 3%). Bile leak rate was increased in the SC group (20%/10. 2%, p = 0. 036). At multivariate analysis, three predictive factors of SC were identified: arterial hypertension (p = 0. 007, SC rate = 13%), cirrhosis (p = 0. 003, SC rate = 26%), and LR conducted along the right portal scissure (p = 0. 010, SC rate = 32%). One protective factor was identified: LR confined to antero-lateral segments (Sg2-6, p = 0. 001, SC rate = 2%). Extension of LR had no impact on need for SC. Conclusions: The majority of LR can be safely performed without clamping with excellent outcomes. SC is a safe procedure and does not worsen postoperative outcomes, except for bile leak rate. Clamping policy should be tailored to the type of LR and presence of cirrhosis.