The pringle maneuver for Budd-Chiari syndrome-related orthotopic liver transplantation: an experience from a large referral center.

Background: Orthotopic liver transplantation (OLT) in Budd-Chiari Syndrome (BCS)-related liver cirrhosis is quite technically challenging due to the difficult handling of an enlarged and congested liver along with the risk of massive intraoperative bleeding. Therefore, we aimed to evaluate the efficacy of occluding the hepatic blood inflow tract by the Pringle maneuver (PM) at the beginning of the hepatectomy phase of BCS-related OLT procedure.

Methods: The current retrospective study of prospectively collected data was conducted between 2010 and 2022 in our referral center for OLT. Patients were divided into PM (after 2018) and non-PM (NPM, before 2018) groups. Intraoperative blood loss, packed red blood cell (PC) transfusion, operation time, 30-day mortality, and liver and renal function indexes were collected retrospectively.

Results: From a total of 3539 records, a total of 55 patients included in this study; the PM and NPM groups consisted of 17 and 38 patients, respectively. The mean intraoperative blood loss (1418 ± 621 vs. 2240 ± 1591 ml, p = 0.04) and amount of PC transfusion (418 ± 423 vs. 1263 ± 1557 ml, p = 0.03) were significantly lower in the PM group. In the NPM group, duration of operation (282 ± 52 vs. 257 ± 32 min) and 30-day mortality rate (16% vs. 0%) were higher, which are statistically nonsignificant but clinically noteworthy.

Conclusion: Using the PM can be an effective approach to reducing intraoperative bleeding, PC transfusion, and the length of surgery during OLT for BCS. It decreases the incoming blood to the congested liver, helps porta hepatis collaterals to shrink, and eases the division of hepatic ligaments and diaphragmatic attachments during the hepatectomy phase. These factors potentially facilitate the procedure for surgeons.