Discussion
liver tumors, liver ischemia, liver lesions, primary malignancy, blood loss, liver damage, liver injury, liver tumor, organ damage
LIVER TUMORS, PRINGLE, DETACHMENT, LIVER ISCHEMIA, BLOOD LOSS, MINOR, LIVER DAMAGE, LIVER TUMOR
In this randomized control trial, we noted significantly lower postoperative peak transaminase levels in patients anesthetized by propofol than in those given sevoflurane after metastatic liver tumor resection with the Pringle maneuver.Several studies have explored the protective effect of propofol against organ damage, including liver injury, in experimental models [A series of studies by Beck-Schimner and colleagues showed the beneficial effect of sevoflurane against liver damage after liver resection using the Pringle maneuver [Other studies by Song and Slankamenac showed no difference between sevoflurane and propofol [This study set careful selection criteria for its participants to avoid potential biases. As the size of the resected liver may affect postoperative transaminase levels, we only selected patients with a set number of metastatic liver tumors and liver lesions involving less than five Couinaud segments. Consequently, no significant difference in the size of the resected liver (assessed by resected liver weight) was noted in this study.Second, TIT may also affect postoperative transaminase levels. Since we determined that the resected liver size was similar among the study participants, we speculated that the TIT during metastatic liver tumor resection would be similar. Further, the results revealed that the TIT was similar between the two groups.Third, baseline liver function can also affect postoperative transaminase levels [Overall, we think the homogenization of baseline characteristics that could affect the primary outcome was achieved. Thus, the comparison between the protective effect of anesthetic agents against liver damage could be elucidated.This study has several limitations which should be considered when interpreting its results. First, as we usually use end-tidal sevoflurane concentration monitoring during sevoflurane anesthesia, BIS was not used for titration in the sevoflurane group. Nevertheless, end-tidal anesthetic concentration monitoring is as reliable as BIS; hence, the depth of anesthesia was compatible between groups [Third, in the sevoflurane group, anesthesia and operation times were long. The difference between the former and the latter was similar;and operation time was more influential in the difference noted. As the TIT, representing the duration of liver resection, was similar between the groups, the duration of liver resection and the influence of liver ischemia might similar. These times might concern with Adhesive detachment for previous surgeries including resection of the primary malignancy. Hence, the difference in these periods might not largely affect our results.Fourth, we did not perform protocolized intraoperative management, such as maintaining a low central venous pressure. Such practices may affect intraoperative fluid volume and blood loss. However, the intraoperative fluid balance and blood loss differed between the two groups. Thus, this matter might not be significantly influential. Fifth, there was a deviation from the study protocol in three patients due to clinically justifiable causes. Nonetheless, as the predefined per-protocol analysis showed similar results, its effect was considered minimal.Lastly, SAE incidence, the most critical measure for patients, was similar between groups in this study. Although this study aimed to assess anesthetic agents’ effects on liver damage during liver resection with the Pringle maneuver, we included only minor hepatectomies to maintain baseline characteristics’ homogenization. Therefore, the incidence of SAE in the patients included in this study was essentially low. Thus, the statistical power for evaluating the influence on SAE is very weak. Further research is needed to assess whether propofol-based anesthesia lowers the incidence of SAE compared with sevoflurane-based anesthesia after major liver resection with the Pringle maneuver.In conclusion, our randomized controlled study indicates that propofol may have a more substantial protective effect during liver resection with the Pringle maneuver in a clinical setting.