Continuous Assessment of Intrahepatic Metabolism by Microdialysis
During and After Portal Triad Clamping
1
Bengt Isaksson, M.D., Ph.D.,
*
,2
Melroy A. D’souza, M.S., D.N.B., M.R.C.S.Ed.,
*
Ulf Jersenius, M.D., Ph.D.,
*
Johan Ungerstedt, M.D., Ph.D.,
*
Lars Lundell, M.D., Ph.D.,
*
Johan Permert, M.D., Ph.D.,
*
Mikael Bjo
¨
rnstedt, M.D., Ph.D.,‡ and Greg Nowak, M.D., Ph.D.
*
,
†
*Department of Surgery; †Department of Transplantation Surgery, and Department of Clinical Science, Intervention, and Technology;
and ‡Division of Pathology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
Submitted for publication August 16, 2009
Background. Ischemia-reperfusion injury is a major
concern with portal triad clamping (PTC) in liver sur-
gery. Microdialysis allows continuous intraoperative
monitoring of tissue metabolism in the liver. Our aim
was to evaluate the feasibility of microdialysis as
a tool to assess the intrahepatic metabolic effects of
PTC in patients undergoing liver resection.
Methods. Eleven patients who underwent liver re-
section were subjected to intrahepatic microdialysis.
Dialysis fluid samples were collected before, during,
and after a 20-min period of PTC. Glucose, lactate,
pyruvate (markers of ischemia), and glycerol (marker
of cell membrane damage) were analyzed and the lac-
tate/pyruvate ratio was calculated.
Results. During PTC, intrahepatic glucose, lactate,
and glycerol increased from 9.1 ± 2.2 to 14.5 ± 2.4mM,
from 2.2 ± 0.3 to 5.8 ± 0.5mM, and from 63 ± 14 to
142 ± 28 mM, respectively. Pyruvate was unchanged, re-
sulting in an increased lactate/pyruvate ratio (from
39 ± 10 to 104 ± 32). During initial reperfusion, glucose
further increased to 16.4 ± 2.9mM. Pyruvate increased
after reperfusion (from 93 ± 18 to 138 ± 23 mM), while
lactate was stable, resulting in a normalized lactate/
pyruvate ratio. Glycerol continued to increase during
initial reperfusion.
Conclusions. PTC was associated with considerable
intrahepatic metabolic alterations with anaerobic
metabolism, increased glycogenolysis, and cellular
membrane damage resulting in increased levels of
glucose, lactate, glycerol, and lactate/pyruvate ratio.
Microdialysis is easy to use and allows continuous
monitoring of intrahepatic metabolism during liver
surgery.
Ó 2011 Elsevier Inc. All rights reserved.
Key Words: warm liver ischemia; ischemia-reperfu-
sion injury; reperfusion; microdialysis; portal triad
clamping; Pringle maneuver; metabolic changes.
INTRODUCTION
Improved understanding of liver anatomy, advances
in perioperative care, and better surgical techniques
have resulted in a remarkable increase in the number
and complexity of liver resections being performed
worldwide [1, 2]. Furthermore, modern oncologic treat-
ment strategies for patients with malignant liver
tumors have improved short-and long-term outcomes
after partial hepatectomies [3], leading to increasing
numbers of patients undergoing complex and extended
resections on livers exposed to chemotherapy. While
mortality has decreased considerably, morbidity post-
liver surgery remains a significant concern, especially
in patients with underlying liver disease like cirrhosis,
steatosis, and in livers exposed to chemotherapy. While
remnant liver volume after resection is an obvious pre-
dictor of outcome, major operative blood loss and trans-
fusion requirements have been related to increased
morbidity and tumor recurrence after hepatectomy
[4–6]. A number of techniques have been used to reduce
intraoperative blood loss during hepatectomy, of which
clamping of the hepatic pedicle by the Pringle maneu-
ver or portal triad clamping (PTC) is probably the
1
Presented as an abstract at the IHPBA Congress, Mumbai,
India, 2008.
2
To whom correspondence and reprint requests should be
addressed at Division of Surgery, CLINTEC, Karolinska University
Hospital, Huddinge, SE-141 86 Stockholm, Sweden. E-mail: bengt.
isaksson@karolinska.se.
0022-4804/$36.00
Ó 2011 Elsevier Inc. All rights reserved.
214
Journal of Surgical Research 169, 214–219 (2011)
doi:10.1016/j.jss.2009.11.720