Yamaguchi Naoya, Yokoyama Yukihiro, Ebata Tomoki, Igami Tsuyoshi, Sugawara Gen, Asahara Takashi, Nomoto Koji, Nagino Masato
Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
Yakult Central Institute for Microbiological Research, Tokyo, Japan.
J Hepatobiliary Pancreat Sci. 2015 Jun;22(6):491-7. doi: 10.1002/jhbp.239. Epub 2015 Mar 17.
The occurrence of bacterial translocation (BT) to the mesenteric lymph nodes following the Pringle maneuver is well established; however, the incidence of BT to the portal circulation remains unclear.
Portal blood of patients with suspected hilar malignancy who underwent major hepatobiliary resection with cholangiojejunostomy was sampled three times during surgery: immediately after laparotomy (PV-1); before liver transection and after skeletonization of the hepatoduodenal ligament (PV-2); and after completion of the liver transection (PV-3). The samples were analyzed for microbes with a bacterium-specific ribosomal RNA-targeted reverse transcription-polymerase chain reaction method.
Fifty patients were enrolled in the study, with a mean total Pringle time of 86 min. Microbes in the portal blood were detected in 11 (22%) of the 50 patients. The occurrence of microbes was not different among the PV-1 samples (8% = 4/50), PV-2 samples (14% = 7/50), and PV-3 samples (14% = 7/50) (P = 0.567). Obligate anaerobes were predominantly detected. The positivity of the PV-3 samples showed no correlation with the total Pringle time or with the occurrence of postoperative infectious complications. The total Pringle time did not affect the surgical outcomes, including infectious complications, liver failure, or mortality. The concentrations of aspartate aminotransferase and alanine aminotransferase on postoperative day 1 significantly correlated with the total Pringle time.
The intermittent Pringle maneuver is unlikely to induce BT to the portal circulation and is safe, even in difficult, complicated hepatobiliary resections requiring long clamping times.
Pringle手法后细菌易位至肠系膜淋巴结的现象已得到充分证实；然而，细菌易位至门静脉循环的发生率仍不清楚。
对接受肝门部恶性肿瘤根治性肝切除并胆管空肠吻合术的疑似患者，在手术期间采集门静脉血3次：剖腹术后即刻（PV-1）；肝实质离断前及肝十二指肠韧带骨骼化后（PV-2）；肝实质离断完成后（PV-3）。采用针对细菌特异性核糖体RNA的逆转录聚合酶链反应方法对样本进行微生物分析。
50例患者纳入本研究，Pringle手法平均总时长为86分钟。50例患者中有11例（22%）门静脉血中检测到微生物。PV-1样本（8% = 4/50）、PV-2样本（14% = 7/50）和PV-3样本（14% = 7/50）中微生物的出现情况无差异（P = 0.567）。主要检测到专性厌氧菌。PV-3样本的阳性结果与Pringle手法总时长或术后感染性并发症的发生无关。Pringle手法总时长不影响手术结局，包括感染性并发症、肝衰竭或死亡率。术后第1天的天冬氨酸转氨酶和丙氨酸转氨酶浓度与Pringle手法总时长显著相关。
即使在需要长时间阻断的困难、复杂肝切除术中，间歇性Pringle手法也不太可能导致细菌易位至门静脉循环，且是安全的。
