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Peer-reviewedCC BY 4.0Journal of Clinical Medicine

Routine Pringle Maneuver During Recipient Hepatectomy Is Associated with Improved Perioperative and Early Graft Outcomes After Adult Liver Transplantation

  • Ashraf Imam1
  • Ahmad Salhab1
  • Suha Shabaneh1
  • Michael Rivin1
  • Alaa Altiti1
  • Mohammad Emar1
  • Natalia Kuzmina2
  • Penina Yehudit Dienstag2
  • Rifaat Safadi3
  • Abed Khalaileh1
  1. 1Transplantation Unit, Department of Surgery, Hadassah Medical Organization, Hadassah-Hebrew University, Jerusalem 9112001, Israel
  2. 2Department of Anesthesiology, Hadassah Medical Organization, Hadassah-Hebrew University, Jerusalem 9112001, Israel
  3. 3Liver Institute, Hadassah Medical Organization, Hadassah-Hebrew University, Jerusalem 9112001, Israel
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Abstract

Background: Recipient hepatectomy during orthotopic liver transplantation (OLT) is frequently complicated by severe bleeding due to portal hypertension and collateral circulation. The Pringle maneuver’s benefit in this setting remains uncertain. Methods: We retrospectively analyzed data from 141 adults who underwent primary deceased-donor OLT at a single center between January 2020 and June 2026. A routine intermittent Pringle maneuver was introduced in 2023; 79 subsequent recipients comprised the Pringle group, while 62 earlier recipients served as historical controls. Multivariable regression and inverse probability of treatment weighting (IPTW) were used to address confounding, and temporal trends within each period were examined. Results: Indication for transplantation, markers of hepatic decompensation, and extended-criteria donor status did not differ between groups. Compared with controls, the Pringle group required fewer packed red blood cell units (median 2 {IQR 0–4} vs. 3 {1–5}; p = 0.046), fresh frozen plasma units (4 {0–6} vs. 4 {3–8}; mean 4.1 vs. 6.9; no plasma transfused in 30.8% vs. 13.6%; p = 0.005), and total blood products (5 {0–9} vs. 8 {4–14}; p = 0.009). Recipient hepatectomy was shorter (129 {105–165} vs. 177 {146–208} minutes; p < 0.001), and postoperative bleeding (2.5% vs. 22.6%; p < 0.001), biliary leak (2.5% vs. 11.3%; p = 0.043), and early allograft dysfunction (EAD; 6.3% vs. 29.0%; p < 0.001) were less frequent. After adjustment, the Pringle maneuver remained associated with shorter hepatectomy (time ratio 0.76; 95% CI 0.67–0.87), reduced fresh frozen plasma (IRR 0.60; 0.40–0.91) and total blood product use (IRR 0.61; 0.40–0.92), and lower odds of postoperative bleeding (OR 0.04; 0.01–0.25), biliary leak (OR 0.13; 0.02–0.63), and EAD (OR 0.14; 0.04–0.58). Packed red blood cell transfusion was nonsignificant after adjustment (IRR 0.70; 0.43–1.12). IPTW yielded consistent findings. Overall survival did not differ (p = 0.885). Conclusions: In this historical-control study, routine intermittent Pringle maneuver was associated with improved operative efficiency, lower transfusion requirements, and fewer early complications without affecting survival; given the retrospective design and the modest absolute differences in transfusion, these findings require prospective confirmation.

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Cite

BibTeXRIS
BibTeX
@article{imam2026routine,
  title = {{Routine Pringle Maneuver During Recipient Hepatectomy Is Associated with Improved Perioperative and Early Graft Outcomes After Adult Liver Transplantation}},
  author = {Ashraf Imam and Ahmad Salhab and Suha Shabaneh and Michael Rivin and Alaa Altiti and Mohammad Emar and Natalia Kuzmina and Penina Yehudit Dienstag and Rifaat Safadi and Abed Khalaileh},
  journal = {Journal of Clinical Medicine},
  year = {2026},
  month = oct,
  doi = {10.3390/jcm15207939},
  url = {https://www.mdpi.com/2077-0383/15/20/7939},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Routine Pringle Maneuver During Recipient Hepatectomy Is Associated with Improved Perioperative and Early Graft Outcomes After Adult Liver Transplantation
AU  - Ashraf Imam
AU  - Ahmad Salhab
AU  - Suha Shabaneh
AU  - Michael Rivin
AU  - Alaa Altiti
AU  - Mohammad Emar
AU  - Natalia Kuzmina
AU  - Penina Yehudit Dienstag
AU  - Rifaat Safadi
AU  - Abed Khalaileh
PY  - 2026
DA  - 2026/10/01
JO  - Journal of Clinical Medicine
DO  - 10.3390/jcm15207939
UR  - https://www.mdpi.com/2077-0383/15/20/7939
AB  - Background: Recipient hepatectomy during orthotopic liver transplantation (OLT) is frequently complicated by severe bleeding due to portal hypertension and collateral circulation. The Pringle maneuver’s benefit in this setting remains uncertain. Methods: We retrospectively analyzed data from 141 adults who underwent primary deceased-donor OLT at a single center between January 2020 and June 2026. A routine intermittent Pringle maneuver was introduced in 2023; 79 subsequent recipients comprised the Pringle group, while 62 earlier recipients served as historical controls. Multivariable regression and inverse probability of treatment weighting (IPTW) were used to address confounding, and temporal trends within each period were examined. Results: Indication for transplantation, markers of hepatic decompensation, and extended-criteria donor status did not differ between groups. Compared with controls, the Pringle group required fewer packed red blood cell units (median 2 {IQR 0–4} vs. 3 {1–5}; p = 0.046), fresh frozen plasma units (4 {0–6} vs. 4 {3–8}; mean 4.1 vs. 6.9; no plasma transfused in 30.8% vs. 13.6%; p = 0.005), and total blood products (5 {0–9} vs. 8 {4–14}; p = 0.009). Recipient hepatectomy was shorter (129 {105–165} vs. 177 {146–208} minutes; p < 0.001), and postoperative bleeding (2.5% vs. 22.6%; p < 0.001), biliary leak (2.5% vs. 11.3%; p = 0.043), and early allograft dysfunction (EAD; 6.3% vs. 29.0%; p < 0.001) were less frequent. After adjustment, the Pringle maneuver remained associated with shorter hepatectomy (time ratio 0.76; 95% CI 0.67–0.87), reduced fresh frozen plasma (IRR 0.60; 0.40–0.91) and total blood product use (IRR 0.61; 0.40–0.92), and lower odds of postoperative bleeding (OR 0.04; 0.01–0.25), biliary leak (OR 0.13; 0.02–0.63), and EAD (OR 0.14; 0.04–0.58). Packed red blood cell transfusion was nonsignificant after adjustment (IRR 0.70; 0.43–1.12). IPTW yielded consistent findings. Overall survival did not differ (p = 0.885). Conclusions: In this historical-control study, routine intermittent Pringle maneuver was associated with improved operative efficiency, lower transfusion requirements, and fewer early complications without affecting survival; given the retrospective design and the modest absolute differences in transfusion, these findings require prospective confirmation.
SN  - 2077-0383
ER  -