Clamp-crush technique seems to be the method of choice in liver parenchymal transection

Liver resection (removal of a part of the liver) is performed mainly for cancerous and non-cancerous tumours in the liver. About 1000 liver resections are performed each year in the United Kingdom. Blood loss during liver resection is one of the main factors affecting the development of surgical complications. Different parenchymal transection techniques (techniques used to divide the liver) have been suggested to decrease blood loss. In this systematic review of seven randomised clinical trials including 556 patients, various methods of parenchymal transection techniques were compared. The infective complications and transection blood loss were greater in the radio frequency dissecting sealer (RFDS ) than clamp-crush technique. There were no significant differences in the mortality or in the morbidity between the other techniques of parenchymal transection. There was also no difference in the markers of liver parenchymal injury or liver dysfunction between the different methods used. Intensive therapy unit stay and hospital stay were similar. The blood transfusion requirements were lower in the clamp-crush technique than CUSA (cavitron ultrasonic surgical aspirator) and hydrojet. There was no difference in the transfusion requirements of clamp-crush technique and sharp dissection. Clamp-crush technique is quicker than CUSA, hydrojet, and RFDS. The transection speed of sharp dissection and clamp-crush technique was not compared. There was no clinically or statistically significant difference in the operating time between sharp dissection and clamp-crush techniques. Clamp-crush technique is two to six times cheaper than the other methods depending upon the number of surgeries performed each year. Clamp-crush technique is advocated as the method of choice in liver parenchymal transection because it avoids the need for special equipment and the newer methods do not seem to offer any benefit in decreasing the morbidity or transfusion requirement.

Authors' conclusions: 

Clamp-crush technique is advocated as the method of choice in liver parenchymal transection because it avoids special equipment, whereas the newer methods do not seem to offer any benefit in decreasing the morbidity or transfusion requirement.

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Background: 

Blood loss during elective liver resection is one of the main factors affecting the surgical outcome. Different parenchymal transection techniques have been suggested to decrease blood loss.

Objectives: 

To assess the benefits and risks of the different techniques of parenchymal transection during liver resections.

Search strategy: 

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (March 2008).

Selection criteria: 

We considered for inclusion all randomised clinical trials comparing different methods of parenchymal dissection irrespective of the method of vascular occlusion or any other measures used for lowering blood loss.

Data collection and analysis: 

Two authors identified the trials and extracted the data on the population characteristics, bias risk, mortality, morbidity, blood loss, transection speed, and hospital stay independently of each other. We calculated the odds ratio (OR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals based on 'interntion-to-treat analysis' or 'available case analysis' using RevMan 5.

Main results: 

We included seven trials randomising 556 patients. The comparisons include CUSA (cavitron ultrasound surgical aspirator) versus clamp-crush (two trials); radiofrequency dissecting sealer (RFDS) versus clamp-crush (two trials); sharp dissection versus clamp-crush technique (one trial); and hydrojet versus CUSA (one trial). One trial compared CUSA, RFDS, hydrojet, and clamp-crush technique. The infective complications and transection blood loss were greater in the RFDS than clamp-crush. There was no difference in the blood transfusion requirements, intensive therapy unit (ITU) stay, or hospital stay in this comparison. There was no significant differences in the mortality, morbidity, markers of liver parenchymal injury or liver dysfunction, ITU, or hospital stay in the other comparisons. The blood transfusion requirements were lower in the clamp-crush technique than CUSA and hydrojet. There was no difference in the transfusion requirements of clamp-crush technique and sharp dissection. Clamp-crush technique is quicker than CUSA, hydrojet, and RFDS. The transection speed of sharp dissection and clamp-crush technique was not compared. There was no clinically or statistically significant difference in the operating time between sharp dissection and clamp-crush techniques. Clamp-crush technique is two to six times cheaper than the other methods depending upon the number of surgeries performed each year.

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