Safety of Single Continuous Pringle Maneuver During HHA Enucleation: A Retrospective Cohort Study

Safety of Single Continuous Pringle Maneuver During HHA Enucleation: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety of Single Continuous Pringle Maneuver During HHA Enucleation: A Retrospective Cohort Study Yingjixing Luo, Yue Qiu, Ruili Wei, Ruiyi Liu, Jia Huang, Li Xu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8750472/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Objective: To evaluate the impact of different Pringle maneuver techniques (continuous vs. intermittent) and occlusion durations on postoperative liver function and surgical outcomes after hepatic hemangioma(HHA) enucleation. Methods: A total of 268 consecutive patients who underwent laparoscopic or robot-assisted HHA enucleation between January 1, 2011, and November 1, 2024, were retrospectively reviewed; 129 of them met the inclusion criteria and constituted the final study cohort.They were divided into four groups according to the Pringle maneuver and its duration. Group A, B, C had continuous Pringle maneuvers for <20 min, 20 - 40 min, 40 - 70 min respectively, and Group D had intermittent multiple Pringle maneuvers with 40 - 70 min cumulative occlusion. Post - operative complications, liver function changes, and hospital stay were compared. Results: There were no significant differences in age, gender, most parameters among groups (P > 0.05), except larger hemangioma diameter in Group C (P < 0.05). Group D had longer operation time and more blood loss (P < 0.05). Blood transfusion volume had no significant difference. Only Group C had elevated GGT on postoperative Day 3 (P < 0.05). Conclusion: For normal liver function patients having HHA enucleation, continuous Pringle maneuver up to 60 min is safe, simplifies the procedure, reduces blood loss and operation time, with comparable postoperative recovery to intermittent occlusions. Pringle maneuver hepatic inflow occlusion hepatectomy liver function hepatic hemangioma Figures Figure 1 Figure 2 Background The evolution of contemporary medical technologies has greatly enhanced the safety and effectiveness of hepatectomy [ 1 – 3 ]. Given the liver's distinctive dual blood supply, which includes contributions from the portal vein and hepatic artery, managing hemorrhage during surgery is crucial [ 4 ]. Significant intraoperative bleeding can adversely impact recovery after surgery and, in severe instances, may result in perioperative death [ 5 ]. To mitigate bleeding during procedures, the technique of hepatic inflow occlusion is frequently employed, thereby improving surgical safety. This method was first proposed by Pringle in 1908 [ 6 ] and has now become the standard approach for controlling bleeding during liver resection [ 7 – 9 ]. Regarding the Intermittent Pringle Maneuver (IPM), it is generally recommended that each occlusion period should not exceed 15–20 minutes. For patients with liver cirrhosis, the occlusion time per session should be limited to less than 10 minutes. If further occlusion is required, a 5 - minute break should be taken after each occlusion [ 10 – 11 ]. However, intermittent occlusion may lead to an extended surgical duration, potentially increase the amount of bleeding at the liver resection site, and trigger hepatic ischemia - reperfusion injury [ 12 – 13 ]. To investigate the impact of the duration of hepatic blood flow occlusion on liver function, we selected patients who underwent hepatic hemangioma resection in our hospital for this study. The inclusion criteria are as follows: First, all participants had normal liver function before surgery and did not have liver diseases such as liver cirrhosis that could potentially affect the postoperative recovery of liver function. Second, during the surgery, only the hemangioma and a small portion of the liver tissue affected by it were removed, thus ensuring the integrity of the healthy liver tissue. This approach minimized the influence of the amount of resected liver tissue on the recovery process. This study provided a relatively uniform and standardized group of research subjects to evaluate the effects of different occlusion techniques and their durations on the postoperative recovery of liver function, offering a clearer reference for clinical applications Methods Employing a retrospective cohort study design, we collected clinical data from 268 patients who underwent laparoscopic or robot - assisted HHA enucleation at our institution between January 1, 2011, and November 1, 2024. After the application of pre - specified inclusion and exclusion criteria (Fig. 1 ), 129 patients were selected for statistical analysis. These patients were classified into four groups based on the Pringle maneuver and its duration. Specifically, Group A, B, and C underwent continuous Pringle maneuvers lasting less than 20 minutes, 20–40 minutes, and 40–70 minutes, respectively. Group D, on the other hand, received intermittent multiple Pringle maneuvers with a cumulative occlusion time of 40–70 minutes. We analyzed the characteristics of four patient groups, encompassing age, gender, preoperative liver function (e.g., alanine aminotransferase [ALT], aspartate aminotransferase [AST], Gamma-Glutamyl Transferase [GGT], total bilirubin [TBIL], Direct bilirubin [DBIL]), coagulation parameters (prothrombin time [PT], fibrinogen [Fib]), and Complete Blood Count (CBC) (white blood cell count [WBC], hemoglobin [Hb], platelet count [PLT]). A comparative analysis was carried out on the operation duration, intraoperative blood loss, and allogeneic blood transfusion volume among the four patient groups. Moreover, we compared the liver function, coagulation parameters, and CBC on the 3rd and 5th days post - surgery, along with the postoperative hospital stay. Postoperative complications were assessed using the Clavien-Dindo classification system, including major complications such as hemorrhage, bile leakage, pleural effusion, surgical site infection, and 30-day mortality. Statistical analysis was performed with R software (version 4.3.0). Normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data are presented as mean ± standard deviation (SD) and were compared using one-way analysis of variance (ANOVA), with post-hoc pairwise comparisons performed by Tukey's test when indicated. Non-normally distributed data are expressed as median (interquartile range) and analyzed using the Kruskal-Wallis test, followed by Dunn's test for post-hoc comparisons. A two-sided P value < 0.05 was considered statistically significant. Results According to the inclusion and exclusion criteria, 129 out of 268 patients were enrolled (Fig. 1 ) and classified into four groups: Group A (n = 36, 27.91%), Group B (n = 35, 27.13%), Group C (n = 10, 7.75%), and Group D (n = 48, 37.21%). No significant differences were observed among the groups in terms of age, gender, preoperative liver function (Child–Pugh classification), or hemangioma location (all P > 0.05), with the exception of a larger hemangioma diameter in Group C (P < 0.05). Detailed data are presented in Table 1 . Table 1 Baseline Information and Preoperative Statistics of Liver Function、CBC、Coagulation Indicators Variables Total (n = 129) GROUP A (n = 36) GROUP B (n = 35) GROUP C (n = 10) GROUP D (n = 48) P value Age, Mean ± SD 44.45 ± 10.15 45.86 ± 9.73 46.29 ± 11.95 44.10 ± 10.10 42.12 ± 8.79 0.225 Gender, n(%) 0.782 Male 32 (24.81) 7 (19.44) 10 (28.57) 2 (20.00) 13 (27.08) Female 97 (75.19) 29 (80.56) 25 (71.43) 8 (80.00) 35 (72.92) Size, Mean ± SD 9.54 ± 2.14 8.57 ± 1.73 9.06 ± 2.21 12.00 ± 1.89 10.11 ± 1.88 < .001 Location, n(%) Left lobe Right lobe 61 (47.29) 68 (52.71) 15 (41.67) 21 (58.33) 12 (34.29) 23 (65.71) 5 (50.00) 5 (50.00) 29 (60.42) 19 (39.58) 0.103 Child-Pugh,n(%) A 129(100) 36(100) 35(100) 10(100) 48(100) 1.000 ALT, Mean ± SD 19.85 ± 10.11 18.00 ± 5.01 17.5 ± 12.12 27.33 ± 23.29 20.00 ± 7.96 0.858 AST, Mean ± SD 21.10 ± 10.13 21.83 ± 11.63 21.49 ± 11.74 19.4 ± 4.79 20.25 ± 7.17 0.872 TBIL, Mean ± SD 14.71 ± 5.97 15.97 ± 4.94 13.64 ± 7.84 13.40 ± 13.80 14.9 ± 6.18 0.531 DBIL, Mean ± SD 2.41 ± 1.20 2.07 ± 0.59 2.43 ± 1.50 2.33 ± 0.71 2.83 ± 1.38 0.091 GGT, Mean ± SD 27.16 ± 14.53 24.22 ± 9.01 25.23 ± 18.14 32.8 ± 13.80 31.32 ± 14.68 0.565 PT, Mean ± SD 13.04 ± 0.81 13.01 ± 0.67 12.97 ± 0.86 13.21 ± 0.37 13.09 ± 0.94 0.823 Fib, Mean ± SD 2.96 ± 0.70 2.88 ± 0.54 3.20 ± 0.88 2.66 ± 0.29 2.92 ± 0.69 0.098 Wbc, Mean ± SD 5.20 ± 1.55 5.26 ± 0.94 5.56 ± 2.30 4.95 ± 1.21 4.97 ± 1.30 0.387 Hb, Mean ± SD 132.17 ± 17.96 130.94 ± 14.87 135.88 ± 15.04 127.90 ± 14.04 131.38 ± 22.11 0.532 PLT, Mean ± SD 226.48 ± 54.11 225.06 ± 46.93 228.88 ± 55.68 225.80 ± 59.69 225.98 ± 58.14 0.993 F: ANOVA, SD: standard deviation; The analysis of the intraoperative data revealed that, among the four groups, Group D exhibited a significantly longer operation time and greater blood loss (P < 0.05). However, there was no statistically significant difference in the volume of allogeneic blood transfusion (Table 2 ). Table 2 Intraoperative Indicator Statistics Variables Total (n = 129) GROUP A (n = 36) GROUP B (n = 35) GROUP C (n = 10) GROUP D (n = 48) P value Time, Mean ± SD 3.42 ± 1.01 3.14 ± 0.97 2.92 ± 0.93 3.69 ± 1.26 3.95 ± 0.79 < .001 Blood loss, Mean ± SD 350.00± 244.95 366.67 ± 144.34 471.43 ± 207.88 580.00 ± 444.22 768.75 ± 233.75 < .001 Allogeneic Blood Transfusion, n(%) No 121 (93.80) 35 (97.22) 33 (94.29) 9 (90.00) 44 (91.67) 0.600 Yes 8 (6.20) 1 (2.78) 2 (5.71) 1 (10.00) 4 (8.33) F: ANOVA, SD: standard deviation; During the analysis of postoperative data, notable disparities in gamma - glutamyl transferase (GGT) levels were observed on the third postoperative day (POD 3) (P < 0.05), despite all the measured values falling within the normal range. Furthermore, significant differences in aspartate aminotransferase (AST) levels were identified on the POD 5 (P = 0.033). However, no significant differences were detected in the remaining postoperative liver function indicators, such as ALT AST, TBIL, DBIL, GGT, on either POD 3 or POD 5. Additionally, no significant differences were noted in coagulation function parameters, including prothrombin time (PT) and fibrinogen (Fib), as well as blood routine parameters, such as white blood cell count (WBC), hemoglobin (Hb), and platelet count (Plt), on POD 3 and POD 5. Moreover, there were no significant differences in the duration of postoperative hospital stays among the four groups. The detailed results are presented in Table 3 . Table 3 Postoperative-Related Indicator Statistics Variables Total (n = 129) GROUP A (n = 36) GROUP B (n = 35) GROUP C (n = 10) GROUP D (n = 48) P value POD 3 liverfunction ALT, Mean ± SD 247.34 ± 266.32 216.64 ± 177.25 205.54 ± 204.75 349.30 ± 264.13 281.00 ± 350.63 0.318 AST, Mean ± SD 146.64 ± 170.31 170.03 ± 146.87 133.80 ± 162.98 144.40 ± 141.39 132.93 ± 217.95 0.793 TBIL, Mean ± SD 17.65 ± 8.18 18.62 ± 8.01 17.03 ± 9.35 18.94 ± 5.74 17.10 ± 7.94 0.771 DBIL, Mean ± SD 4.01 ± 2.26 3.50 ± 1.18 4.23 ± 3.23 3.82 ± 1.78 4.53 ± 1.88 0.314 GGT, Mean ± SD 31.32 ± 29.02 22.92 ± 12.85 24.57 ± 18.52 47.60 ± 48.59 45.77 ± 39.18 0.002 POD 5 liverfunction ALT, Mean ± SD 128.76 ± 99.26 130.28 ± 106.45 114.80 ± 83.66 145.30 ± 53.34 136.91 ± 117.44 0.758 AST, Mean ± SD 57.75 ± 60.94 79.75 ± 85.58 51.54 ± 42.04 30.90 ± 10.54 38.62 ± 21.94 0.033 TBIL, Mean ± SD 13.58 ± 5.70 13.75 ± 5.97 11.73 ± 4.08 15.31 ± 6.32 14.89 ± 6.39 0.095 DBIL, Mean ± SD 2.52 ± 1.29 2.39 ± 0.94 2.14 ± 1.29 3.14 ± 2.51 3.08 ± 0.82 0.433 GGT ,Mean ± SD 61.19 ± 57.64 33.00 ± 7.13 64.75 ± 49.68 86.75 ± 102.84 56.64 ± 33.21 0.386 POD 3 coagulationfunction PT, Mean ± SD 14.91 ± 1.31 14.99 ± 1.36 14.52 ± 1.33 15.02 ± 1.03 15.19 ± 1.28 0.182 Fib, Mean ± SD 3.88 ± 1.58 3.64 ± 1.54 4.09 ± 1.52 4.23 ± 1.72 3.83 ± 1.66 0.578 POD 5 coagulationfunction PT, Mean ± SD 14.41 ± 1.18 14.20 ± 1.09 14.57 ± 1.18 14.16 ± 0.70 14.61 ± 1.43 0.757 Fib, Mean ± SD 5.37 ± 1.55 5.50 ± 1.43 5.02 ± 1.81 5.97 ± 0.83 5.14 ± 1.79 0.636 POD 3 CBC WBC, Mean ± SD 10.66 ± 3.18 11.12 ± 2.84 10.87 ± 3.39 10.03 ± 3.02 10.26 ± 3.33 0.568 Hb, Mean ± SD 112.50 ± 16.30 112.69 ± 11.67 116.94 ± 16.35 109.50 ± 17.21 109.63 ± 18.74 0.225 PLT, Mean ± SD 167.38 ± 49.78 170.86 ± 47.87 181.91 ± 56.88 160.10 ± 45.03 155.17 ± 44.37 0.104 POD 5 CBC WBC, Mean ± SD 8.25 ± 2.88 9.02 ± 3.33 8.22 ± 3.00 7.11 ± 1.65 7.93 ± 2.57 0.300 Hb, Mean ± SD 108.08 ± 16.09 108.12 ± 13.88 111.14 ± 14.82 109.88 ± 16.45 105.86 ± 18.31 0.679 PLT, Mean ± SD 191.52 ± 61.42 183.68 ± 60.05 202.71 ± 74.57 205.88 ± 59.94 187.25 ± 55.12 0.640 Clavien-Dino III- IV, n(%) 5 (3.8) 2 (5.5) 1 (2.9) 0 (0) 2 (4.2) 0.829 Bile Leak (3) intra-abdominal fluid collection (1) Intra-abdominal Infection (1) Bile Leak (1) Intra-abdominal Infection (1) Bile Leak (1) Bile Leak (1) intra-abdominal fluid collection (1) PHS, Mean ± SD 7.03 ± 2.08 7.28 ± 2.12 6.49 ± 2.19 7.60 ± 2.07 7.12 ± 1.95 0.291 F: ANOVA, χ²: Chi-square test;SD: standard deviation༛POD: postoperative day༛PHS: postoperative hospital stay Discussion The advancement of liver surgery has constantly been confronted with the challenge of handling intraoperative hemorrhage. Blood loss during liver resection exerts a significant influence on the recovery process [ 14 ]. Hepatic inflow occlusion, notably the Pringle maneuver, emerges as a highly effective approach for controlling bleeding during surgical operations [ 15 ]. This technique involves encircling the hepatoduodenal ligament with an occlusion band to compress both the portal vein and the hepatic artery. By obstructing the vascular inflow, it can effectively stop the bleeding [ 16 ]. The simplicity and high - efficiency of the Pringle maneuver make it an essential component in liver resection surgeries. With the growing popularity of laparoscopic procedures, its application has expanded, particularly in the field of minimally invasive surgical techniques [ 17 ]. This method of vascular control can be applied either continuously or intermittently, which may lead to warm ischemia and hypoxia in the liver when blood flow is completely blocked. Such conditions can cause ischemic injury to healthy liver tissue and subsequent reperfusion damage when blood flow is restored, posing a risk of liver failure and death, especially in cirrhotic patients [ 18 ]. It is generally advised that occlusion times should not exceed 15–20 minutes for patients without cirrhosis and 10 minutes for those with cirrhosis, with a 5-minute pause before any further occlusion is considered [ 19 – 20 ]. Although the maximum duration for total intermittent occlusion remains undetermined, research indicates that the intermittent Pringle maneuver can be safely performed for up to 120 minutes [ 21 – 22 ]. This technique is extensively utilized in a variety of liver resection procedures. Despite its widespread application, the limitations of the intermittent Pringle maneuver are quite evident. This technique requires the temporary interruption of the Pringle maneuver, which can intermittently disrupt the surgical process. Studies have shown a significant increase in bleeding at the liver transection site during the occlusion periods. The optimal duration for the single Pringle maneuver (IPM) remains a subject of ongoing debate in hepatic surgery. Early studies from the 1990s [ 23 ] demonstrated that hepatic inflow occlusion for 10–20 minutes under normothermic conditions is generally well-tolerated, while prolonged occlusion may induce hepatocellular ischemic injury. Contemporary research [ 24 ] has revealed that in patients with hepatocellular carcinoma (HCC), extending IPM duration to 25 minutes demonstrates comparable outcomes to 15-minute occlusion in terms of post-ischemic reperfusion injury, while offering additional benefits including reduced intraoperative blood loss and accelerated parenchymal transection rates. However, it should be noted that current clinical evidence predominantly derives from studies involving cirrhotic or tumor-bearing livers, leaving the optimal IPM duration for non-cirrhotic, healthy hepatic parenchyma poorly defined. This knowledge gap highlights the need for further investigation into ischemia-reperfusion tolerance in normal liver tissue. In this cohort of 129 patients, preoperative analysis identified statistically significant intergroup differences (P < 0.05) in maximum hemangioma diameter. Specifically, patients in Groups C and D presented with significantly larger hemangiomas (Fig. 2 A). No significant differences were detected among groups with respect to liver function, coagulation profiles, or hematological parameters. Analysis of intraoperative parameters revealed statistically significant differences in operative time among the groups. Specifically, both Group C and Group D exhibited significantly longer operative durations compared to Groups A and B, while no significant difference was observed between Groups C and D. Notably, although Group C presented with larger tumor diameters and correspondingly higher surgical complexity, the application of continuous portal vein clamping appeared to facilitate maintenance of surgical continuity, thereby partially mitigating the prolongation of operative time (Fig. 2 B). Further evaluation of intraoperative blood loss demonstrated that Group D had significantly higher hemorrhage volume compared to the other three groups (Fig. 2 C). This phenomenon may be associated with reperfusion-related bleeding from the transection surface following the release of intermittent portal vein clamping. In summary, our findings indicate that the adoption of continuous portal vein clamping during hepatectomy helps maintain surgical continuity, significantly reduces operative time, and effectively minimizes intraoperative blood loss. To evaluate the impact of single continuous versus multiple intermittent hepatic inflow occlusion on postoperative liver function, serum levels of alanine aminotransferase (ALT, Fig. 2 D), aspartate aminotransferase (AST, Fig. 2 E), total bilirubin (TBIL, Fig. 2 F), and direct bilirubin (DBIL, Fig. 2 G) were measured before surgery and on postoperative days 3 and 5. No statistically significant differences were observed in the dynamic changes of these biochemical parameters between the four groups, indicating that single continuous inflow occlusion—even when applied for 40 to 70 minutes—does not impair postoperative liver function recovery A one-way ANOVA of laboratory parameters at different postoperative time points revealed statistically significant differences in gamma-glutamyl transferase (GGT) levels on postoperative day 3 among the four groups (P = 0.002). The mean GGT values were 22.92 U/L in Group A and 24.57 U/L in Group B, whereas Groups C and D demonstrated markedly elevated levels of 47.60 U/L and 45.77 U/L, respectively. No significant difference was observed between Groups C and D. These findings suggest that prolonged vascular occlusion may induce intraoperative biliary mucosal injury, and that repeated brief occlusions do not appear to attenuate such damage. Additionally, a statistically significant difference in aspartate aminotransferase (AST) levels was observed among the groups on postoperative day 5 (P = 0.033). Group A (single hepatic vascular occlusion duration ≤ 20 minutes) exhibited the highest mean AST level (79.75 U/L), whereas Groups B, C, and D demonstrated lower values (51.54 U/L, 30.90 U/L, and 38.62 U/L, respectively). ALT and AST are key enzymes in the assessment of hepatic injury: ALT is predominantly localized in the hepatocyte cytoplasm, while AST is present in mitochondria and the cytoplasm of multiple tissues, including the liver, heart, skeletal muscle, and kidneys. Elevated AST may reflect mitochondrial damage within hepatocytes, whereas increased ALT is more specifically associated with hepatocellular injury. Thus, the intergroup differences in AST levels on day 5 may not be clinically meaningful. No significant differences were detected in other postoperative parameters—including ALT, TBIL, DBIL, coagulation profiles (prothrombin time [PT], fibrinogen [Fib]), and CBC (white blood cells [WBC], hemoglobin [Hb], platelets [Plt])—on days 3 or 5. Moreover, the postoperative length of hospital stay did not differ significantly across the four groups In summary, the findings demonstrate that a single prolonged Pringle maneuver did not result in statistically significant alterations in postoperative liver function, coagulation parameters, complete blood count indices, or length of hospitalization. Among non-cirrhotic patients undergoing HHA resection, continuous inflow occlusion lasting 40 to 70 minutes was not associated with adverse effects on postoperative hepatic recovery relative to intermittent clamping. A continuous operative strategy not only promotes procedural efficiency but also minimizes transection surface hemorrhage attributable to repeated cycles of occlusion and reperfusion. This study has several limitations. The relatively small cohort size, especially the limited number of cases in which hepatic inflow occlusion was maintained for ≥ 40 minutes, may have constrained the statistical power of the analyses. Future studies with larger sample sizes are warranted to corroborate the present findings. Furthermore, the interplay among the extent of hepatic resection, the technique of inflow occlusion, and the duration of ischemia in determining postoperative liver function after partial hepatectomy in non-cirrhotic livers represents a complex and multifactorial relationship that merits further systematic investigation. Abbreviations ALT Alanine aminotransferase AST Aspartate aminotransferase GGT Gamma-glutamyl transferase TBIL Total bilirubin DBIL Direct bilirubin PT Prothrombin time Fib Fibrinogen WBC White blood cell count Hb Hemoglobin PLT Platelet count POD Postoperative day HHA Hepatic hemangioma IPM Intermittent Pringle maneuver CBC Complete blood count. Declarations Ethics approval and consent to participate This study was approved by the Medical Ethics Committee of China-Japan Friendship Hospital (Approval No. 2024-KY-385). As a retrospective cohort study that involved no patient intervention and used fully anonymized data, the requirement for informed consent was waived by the Ethics Committee. All procedures performed in this study were in accordance with the ethical standards of the Declaration of Helsinki. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including images, videos, or clinical details) that would compromise anonymity. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the China-Japan Friendship Hospital High-Level Hospital Clinical Expenses Special Clinical Research Project (No. 2025-NHLHCRF-JBGS-A-WZ-07) and the National High-Level Hospital Clinical Research Funding & Elite Medical Professionals Project of China-Japan Friendship Hospital (No. ZRJY2023-GG04). Authors' contributions Yingjixing Luo: Conceptualization, Data curation, Formal analysis, Writing – original draft. Yue Qiu: Data curation, Investigation, Writing – review & editing. Ruili Wei: Data curation, Methodology, Validation. Ruiyi Liu: Formal analysis, Software, Visualization. Jia Huang: Investigation, Resources. Li Xu: Project administration, Supervision. Yongliang Sun: Validation, Visualization. Zhiying Yang: Conceptualization, Funding acquisition, Supervision, Writing – review & editing. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al.Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. (2002) 236(4):397–406. doi: 10.1097/00000658-200210000-00001 . Imamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano K, et al. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg. (2003) 138(11):1198–206. doi: 10.1001/archsurg.138.11.1198 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8750472","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":602398889,"identity":"566b770a-e923-4622-98a3-9bb0accb7c64","order_by":0,"name":"Yingjixing Luo","email":"","orcid":"","institution":"Beijing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yingjixing","middleName":"","lastName":"Luo","suffix":""},{"id":602398890,"identity":"ccac2d59-1bcf-4b5b-a69b-f39eadf95c44","order_by":1,"name":"Yue Qiu","email":"","orcid":"","institution":"Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yue","middleName":"","lastName":"Qiu","suffix":""},{"id":602398891,"identity":"ed5654cd-bf26-45a1-82b6-c2a48334f0f5","order_by":2,"name":"Ruili Wei","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruili","middleName":"","lastName":"Wei","suffix":""},{"id":602398892,"identity":"3a75eebf-65db-47a5-8483-55d24001e656","order_by":3,"name":"Ruiyi Liu","email":"","orcid":"","institution":"Peking University Health Science Center China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruiyi","middleName":"","lastName":"Liu","suffix":""},{"id":602398893,"identity":"4e27aa7a-c2ff-42a0-b22f-66a9309ea779","order_by":4,"name":"Jia Huang","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Huang","suffix":""},{"id":602398894,"identity":"ebe1fed7-e6b2-4a59-b926-a89234727c1a","order_by":5,"name":"Li Xu","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Xu","suffix":""},{"id":602398895,"identity":"b59896b9-6aab-4a69-b9a1-deabc37991ab","order_by":6,"name":"Yongliang Sun","email":"","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yongliang","middleName":"","lastName":"Sun","suffix":""},{"id":602398896,"identity":"e39123ca-1a71-4f8f-842f-d1899f355913","order_by":7,"name":"Zhiying Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYLACxgYGOQZ2IEmSFmMGZlK1JDYwE6va4PjZwy9/7jic3t/M3CbNu4NBnl/sAAEtZ/LSLCTPHM6dcZgRqOUMg+HM2QkEtBzIMTMwbDuc2wDW0saQYHCbkJbzb8wMEtsOp8sTr+VGjvGDg22HEwyI1iJ5440ZY2NbuuHGw4zNlnPbJAj7he98jvHHn23W8nLH2x/eeNtmI88vTUCLwgEGNgkGhmYQmwXIkMCvHATkGxiYPzAw1IHYIMYoGAWjYBSMAkwAAP2ERrp2HXp8AAAAAElFTkSuQmCC","orcid":"","institution":"China-Japan Friendship Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zhiying","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-01-31 14:08:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8750472/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8750472/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104337931,"identity":"7e6897ee-76ac-46d6-ba97-ff0eec21003a","added_by":"auto","created_at":"2026-03-10 16:17:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150541,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of Study Participants Inclusion Process.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8750472/v1/bd0e661dc95e49e5052f10a3.png"},{"id":104808400,"identity":"35db7b1d-8242-4543-9757-8b7a43094b52","added_by":"auto","created_at":"2026-03-17 12:37:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":422710,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Baseline Tumor Size, Intraoperative Outcomes, and Postoperative Liver Function Among Groups. \u003c/strong\u003e(A) Tumor size; (B) Operation time; (C) Intraoperative blood loss; (D) Dynamic changes in ALT levels at pre-operation, postoperative day (POD) 3, and POD 5; (E) Dynamic changes in AST levels at corresponding time points. The data are presented as line and bar charts, indicating that single continuous occlusion preserves surgical efficiency even with larger tumors, without significantly impacting the recovery of postoperative liver function.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8750472/v1/8af9e594b93186e9208e6c51.png"},{"id":104835526,"identity":"7e413742-7527-47ff-846d-b45ef6f0fd39","added_by":"auto","created_at":"2026-03-17 17:45:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1444509,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8750472/v1/e2e4437f-c932-4050-b9f1-b46352538ac8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety of Single Continuous Pringle Maneuver During HHA Enucleation: A Retrospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe evolution of contemporary medical technologies has greatly enhanced the safety and effectiveness of hepatectomy [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Given the liver's distinctive dual blood supply, which includes contributions from the portal vein and hepatic artery, managing hemorrhage during surgery is crucial [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Significant intraoperative bleeding can adversely impact recovery after surgery and, in severe instances, may result in perioperative death [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. To mitigate bleeding during procedures, the technique of hepatic inflow occlusion is frequently employed, thereby improving surgical safety. This method was first proposed by Pringle in 1908 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and has now become the standard approach for controlling bleeding during liver resection [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Regarding the Intermittent Pringle Maneuver (IPM), it is generally recommended that each occlusion period should not exceed 15\u0026ndash;20 minutes. For patients with liver cirrhosis, the occlusion time per session should be limited to less than 10 minutes. If further occlusion is required, a 5 - minute break should be taken after each occlusion [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, intermittent occlusion may lead to an extended surgical duration, potentially increase the amount of bleeding at the liver resection site, and trigger hepatic ischemia - reperfusion injury [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo investigate the impact of the duration of hepatic blood flow occlusion on liver function, we selected patients who underwent hepatic hemangioma resection in our hospital for this study. The inclusion criteria are as follows: First, all participants had normal liver function before surgery and did not have liver diseases such as liver cirrhosis that could potentially affect the postoperative recovery of liver function. Second, during the surgery, only the hemangioma and a small portion of the liver tissue affected by it were removed, thus ensuring the integrity of the healthy liver tissue. This approach minimized the influence of the amount of resected liver tissue on the recovery process. This study provided a relatively uniform and standardized group of research subjects to evaluate the effects of different occlusion techniques and their durations on the postoperative recovery of liver function, offering a clearer reference for clinical applications\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eEmploying a retrospective cohort study design, we collected clinical data from 268 patients who underwent laparoscopic or robot - assisted HHA enucleation at our institution between January 1, 2011, and November 1, 2024. After the application of pre - specified inclusion and exclusion criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 129 patients were selected for statistical analysis. These patients were classified into four groups based on the Pringle maneuver and its duration. Specifically, Group A, B, and C underwent continuous Pringle maneuvers lasting less than 20 minutes, 20\u0026ndash;40 minutes, and 40\u0026ndash;70 minutes, respectively. Group D, on the other hand, received intermittent multiple Pringle maneuvers with a cumulative occlusion time of 40\u0026ndash;70 minutes.\u003c/p\u003e \u003cp\u003eWe analyzed the characteristics of four patient groups, encompassing age, gender, preoperative liver function (e.g., alanine aminotransferase [ALT], aspartate aminotransferase [AST], Gamma-Glutamyl Transferase [GGT], total bilirubin [TBIL], Direct bilirubin [DBIL]), coagulation parameters (prothrombin time [PT], fibrinogen [Fib]), and Complete Blood Count (CBC) (white blood cell count [WBC], hemoglobin [Hb], platelet count [PLT]). A comparative analysis was carried out on the operation duration, intraoperative blood loss, and allogeneic blood transfusion volume among the four patient groups. Moreover, we compared the liver function, coagulation parameters, and CBC on the 3rd and 5th days post - surgery, along with the postoperative hospital stay. Postoperative complications were assessed using the Clavien-Dindo classification system, including major complications such as hemorrhage, bile leakage, pleural effusion, surgical site infection, and 30-day mortality.\u003c/p\u003e \u003cp\u003eStatistical analysis was performed with R software (version 4.3.0). Normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and were compared using one-way analysis of variance (ANOVA), with post-hoc pairwise comparisons performed by Tukey's test when indicated. Non-normally distributed data are expressed as median (interquartile range) and analyzed using the Kruskal-Wallis test, followed by Dunn's test for post-hoc comparisons. A two-sided P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAccording to the inclusion and exclusion criteria, 129 out of 268 patients were enrolled (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and classified into four groups: Group A (n\u0026thinsp;=\u0026thinsp;36, 27.91%), Group B (n\u0026thinsp;=\u0026thinsp;35, 27.13%), Group C (n\u0026thinsp;=\u0026thinsp;10, 7.75%), and Group D (n\u0026thinsp;=\u0026thinsp;48, 37.21%). No significant differences were observed among the groups in terms of age, gender, preoperative liver function (Child\u0026ndash;Pugh classification), or hemangioma location (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), with the exception of a larger hemangioma diameter in Group C (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Detailed data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Information and Preoperative Statistics of Liver Function、CBC、Coagulation Indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;129)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGROUP A\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGROUP B\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGROUP C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGROUP D\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.45\u0026thinsp;\u0026plusmn;\u0026thinsp;10.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.86\u0026thinsp;\u0026plusmn;\u0026thinsp;9.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.29\u0026thinsp;\u0026plusmn;\u0026thinsp;11.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.10\u0026thinsp;\u0026plusmn;\u0026thinsp;10.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.12\u0026thinsp;\u0026plusmn;\u0026thinsp;8.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.782\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (24.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (19.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (28.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (27.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (75.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (80.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (71.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (80.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35 (72.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation, n(%)\u003c/p\u003e \u003cp\u003eLeft lobe\u003c/p\u003e \u003cp\u003eRight lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (47.29)\u003c/p\u003e \u003cp\u003e68 (52.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (41.67)\u003c/p\u003e \u003cp\u003e21 (58.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (34.29)\u003c/p\u003e \u003cp\u003e23 (65.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (50.00)\u003c/p\u003e \u003cp\u003e5 (50.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29 (60.42)\u003c/p\u003e \u003cp\u003e19 (39.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild-Pugh,n(%)\u003c/p\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.85\u0026thinsp;\u0026plusmn;\u0026thinsp;10.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.33\u0026thinsp;\u0026plusmn;\u0026thinsp;23.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.858\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.10\u0026thinsp;\u0026plusmn;\u0026thinsp;10.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.83\u0026thinsp;\u0026plusmn;\u0026thinsp;11.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.49\u0026thinsp;\u0026plusmn;\u0026thinsp;11.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.25\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.872\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBIL, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.71\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.97\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.64\u0026thinsp;\u0026plusmn;\u0026thinsp;7.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.40\u0026thinsp;\u0026plusmn;\u0026thinsp;13.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBIL, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGGT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.16\u0026thinsp;\u0026plusmn;\u0026thinsp;14.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.22\u0026thinsp;\u0026plusmn;\u0026thinsp;9.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.23\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.32\u0026thinsp;\u0026plusmn;\u0026thinsp;14.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.823\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFib, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWbc, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132.17\u0026thinsp;\u0026plusmn;\u0026thinsp;17.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130.94\u0026thinsp;\u0026plusmn;\u0026thinsp;14.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e135.88\u0026thinsp;\u0026plusmn;\u0026thinsp;15.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e127.90\u0026thinsp;\u0026plusmn;\u0026thinsp;14.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e131.38\u0026thinsp;\u0026plusmn;\u0026thinsp;22.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226.48\u0026thinsp;\u0026plusmn;\u0026thinsp;54.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e225.06\u0026thinsp;\u0026plusmn;\u0026thinsp;46.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e228.88\u0026thinsp;\u0026plusmn;\u0026thinsp;55.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e225.80\u0026thinsp;\u0026plusmn;\u0026thinsp;59.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e225.98\u0026thinsp;\u0026plusmn;\u0026thinsp;58.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.993\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eF: ANOVA, SD: standard deviation;\u003c/p\u003e \u003cp\u003eThe analysis of the intraoperative data revealed that, among the four groups, Group D exhibited a significantly longer operation time and greater blood loss (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there was no statistically significant difference in the volume of allogeneic blood transfusion (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative Indicator Statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;129)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGROUP A\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGROUP B\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGROUP C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGROUP D\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e350.00\u0026plusmn;\u003c/p\u003e \u003cp\u003e244.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e366.67\u0026thinsp;\u0026plusmn;\u0026thinsp;144.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e471.43\u0026thinsp;\u0026plusmn;\u0026thinsp;207.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e580.00\u0026thinsp;\u0026plusmn;\u0026thinsp;444.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e768.75\u0026thinsp;\u0026plusmn;\u0026thinsp;233.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllogeneic Blood Transfusion, n(%)\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (93.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (97.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (94.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (90.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44 (91.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (5.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (8.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eF: ANOVA, SD: standard deviation;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the analysis of postoperative data, notable disparities in gamma - glutamyl transferase (GGT) levels were observed on the third postoperative day (POD 3) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), despite all the measured values falling within the normal range. Furthermore, significant differences in aspartate aminotransferase (AST) levels were identified on the POD 5 (P\u0026thinsp;=\u0026thinsp;0.033).\u003c/p\u003e \u003cp\u003eHowever, no significant differences were detected in the remaining postoperative liver function indicators, such as ALT AST, TBIL, DBIL, GGT, on either POD 3 or POD 5. Additionally, no significant differences were noted in coagulation function parameters, including prothrombin time (PT) and fibrinogen (Fib), as well as blood routine parameters, such as white blood cell count (WBC), hemoglobin (Hb), and platelet count (Plt), on POD 3 and POD 5. Moreover, there were no significant differences in the duration of postoperative hospital stays among the four groups. The detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative-Related Indicator Statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;129)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGROUP A\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGROUP B\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGROUP C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGROUP D\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOD 3 liverfunction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e247.34\u0026thinsp;\u0026plusmn;\u0026thinsp;266.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e216.64\u0026thinsp;\u0026plusmn;\u0026thinsp;177.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e205.54\u0026thinsp;\u0026plusmn;\u0026thinsp;204.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e349.30\u0026thinsp;\u0026plusmn;\u0026thinsp;264.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e281.00\u0026thinsp;\u0026plusmn;\u0026thinsp;350.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146.64\u0026thinsp;\u0026plusmn;\u0026thinsp;170.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170.03\u0026thinsp;\u0026plusmn;\u0026thinsp;146.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133.80\u0026thinsp;\u0026plusmn;\u0026thinsp;162.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e144.40\u0026thinsp;\u0026plusmn;\u0026thinsp;141.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e132.93\u0026thinsp;\u0026plusmn;\u0026thinsp;217.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.793\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBIL, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.65\u0026thinsp;\u0026plusmn;\u0026thinsp;8.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.62\u0026thinsp;\u0026plusmn;\u0026thinsp;8.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.03\u0026thinsp;\u0026plusmn;\u0026thinsp;9.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.94\u0026thinsp;\u0026plusmn;\u0026thinsp;5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17.10\u0026thinsp;\u0026plusmn;\u0026thinsp;7.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.771\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBIL, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGGT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.32\u0026thinsp;\u0026plusmn;\u0026thinsp;29.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.92\u0026thinsp;\u0026plusmn;\u0026thinsp;12.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.57\u0026thinsp;\u0026plusmn;\u0026thinsp;18.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.60\u0026thinsp;\u0026plusmn;\u0026thinsp;48.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.77\u0026thinsp;\u0026plusmn;\u0026thinsp;39.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOD 5 liverfunction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128.76\u0026thinsp;\u0026plusmn;\u0026thinsp;99.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130.28\u0026thinsp;\u0026plusmn;\u0026thinsp;106.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114.80\u0026thinsp;\u0026plusmn;\u0026thinsp;83.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e145.30\u0026thinsp;\u0026plusmn;\u0026thinsp;53.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e136.91\u0026thinsp;\u0026plusmn;\u0026thinsp;117.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.758\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.75\u0026thinsp;\u0026plusmn;\u0026thinsp;60.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.75\u0026thinsp;\u0026plusmn;\u0026thinsp;85.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.54\u0026thinsp;\u0026plusmn;\u0026thinsp;42.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.90\u0026thinsp;\u0026plusmn;\u0026thinsp;10.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.62\u0026thinsp;\u0026plusmn;\u0026thinsp;21.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTBIL, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.58\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.31\u0026thinsp;\u0026plusmn;\u0026thinsp;6.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.89\u0026thinsp;\u0026plusmn;\u0026thinsp;6.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBIL, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.433\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGGT ,Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.19\u0026thinsp;\u0026plusmn;\u0026thinsp;57.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.75\u0026thinsp;\u0026plusmn;\u0026thinsp;49.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e86.75\u0026thinsp;\u0026plusmn;\u0026thinsp;102.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56.64\u0026thinsp;\u0026plusmn;\u0026thinsp;33.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOD 3 coagulationfunction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFib, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOD 5 coagulationfunction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFib, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOD 3 CBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.66\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112.50\u0026thinsp;\u0026plusmn;\u0026thinsp;16.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112.69\u0026thinsp;\u0026plusmn;\u0026thinsp;11.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116.94\u0026thinsp;\u0026plusmn;\u0026thinsp;16.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e109.50\u0026thinsp;\u0026plusmn;\u0026thinsp;17.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e109.63\u0026thinsp;\u0026plusmn;\u0026thinsp;18.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167.38\u0026thinsp;\u0026plusmn;\u0026thinsp;49.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e170.86\u0026thinsp;\u0026plusmn;\u0026thinsp;47.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e181.91\u0026thinsp;\u0026plusmn;\u0026thinsp;56.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e160.10\u0026thinsp;\u0026plusmn;\u0026thinsp;45.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e155.17\u0026thinsp;\u0026plusmn;\u0026thinsp;44.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOD 5 CBC\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWBC, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108.08\u0026thinsp;\u0026plusmn;\u0026thinsp;16.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108.12\u0026thinsp;\u0026plusmn;\u0026thinsp;13.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111.14\u0026thinsp;\u0026plusmn;\u0026thinsp;14.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e109.88\u0026thinsp;\u0026plusmn;\u0026thinsp;16.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e105.86\u0026thinsp;\u0026plusmn;\u0026thinsp;18.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191.52\u0026thinsp;\u0026plusmn;\u0026thinsp;61.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e183.68\u0026thinsp;\u0026plusmn;\u0026thinsp;60.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e202.71\u0026thinsp;\u0026plusmn;\u0026thinsp;74.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e205.88\u0026thinsp;\u0026plusmn;\u0026thinsp;59.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e187.25\u0026thinsp;\u0026plusmn;\u0026thinsp;55.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.640\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClavien-Dino\u003c/p\u003e \u003cp\u003eIII- IV, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBile Leak (3)\u003c/p\u003e \u003cp\u003eintra-abdominal fluid collection (1)\u003c/p\u003e \u003cp\u003eIntra-abdominal Infection\u0026nbsp;(1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBile Leak (1)\u003c/p\u003e \u003cp\u003eIntra-abdominal Infection\u0026nbsp;(1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBile Leak (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBile Leak (1)\u003c/p\u003e \u003cp\u003eintra-abdominal fluid collection (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHS, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.03\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.28\u0026thinsp;\u0026plusmn;\u0026thinsp;2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eF: ANOVA, χ\u0026sup2;: Chi-square test;SD: standard deviation༛POD: postoperative day༛PHS: postoperative hospital stay\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe advancement of liver surgery has constantly been confronted with the challenge of handling intraoperative hemorrhage. Blood loss during liver resection exerts a significant influence on the recovery process [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Hepatic inflow occlusion, notably the Pringle maneuver, emerges as a highly effective approach for controlling bleeding during surgical operations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This technique involves encircling the hepatoduodenal ligament with an occlusion band to compress both the portal vein and the hepatic artery. By obstructing the vascular inflow, it can effectively stop the bleeding [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The simplicity and high - efficiency of the Pringle maneuver make it an essential component in liver resection surgeries. With the growing popularity of laparoscopic procedures, its application has expanded, particularly in the field of minimally invasive surgical techniques [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This method of vascular control can be applied either continuously or intermittently, which may lead to warm ischemia and hypoxia in the liver when blood flow is completely blocked. Such conditions can cause ischemic injury to healthy liver tissue and subsequent reperfusion damage when blood flow is restored, posing a risk of liver failure and death, especially in cirrhotic patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It is generally advised that occlusion times should not exceed 15\u0026ndash;20 minutes for patients without cirrhosis and 10 minutes for those with cirrhosis, with a 5-minute pause before any further occlusion is considered [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the maximum duration for total intermittent occlusion remains undetermined, research indicates that the intermittent Pringle maneuver can be safely performed for up to 120 minutes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This technique is extensively utilized in a variety of liver resection procedures. Despite its widespread application, the limitations of the intermittent Pringle maneuver are quite evident. This technique requires the temporary interruption of the Pringle maneuver, which can intermittently disrupt the surgical process. Studies have shown a significant increase in bleeding at the liver transection site during the occlusion periods.\u003c/p\u003e \u003cp\u003eThe optimal duration for the single Pringle maneuver (IPM) remains a subject of ongoing debate in hepatic surgery. Early studies from the 1990s [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] demonstrated that hepatic inflow occlusion for 10\u0026ndash;20 minutes under normothermic conditions is generally well-tolerated, while prolonged occlusion may induce hepatocellular ischemic injury. Contemporary research [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] has revealed that in patients with hepatocellular carcinoma (HCC), extending IPM duration to 25 minutes demonstrates comparable outcomes to 15-minute occlusion in terms of post-ischemic reperfusion injury, while offering additional benefits including reduced intraoperative blood loss and accelerated parenchymal transection rates.\u003c/p\u003e \u003cp\u003eHowever, it should be noted that current clinical evidence predominantly derives from studies involving cirrhotic or tumor-bearing livers, leaving the optimal IPM duration for non-cirrhotic, healthy hepatic parenchyma poorly defined. This knowledge gap highlights the need for further investigation into ischemia-reperfusion tolerance in normal liver tissue.\u003c/p\u003e \u003cp\u003eIn this cohort of 129 patients, preoperative analysis identified statistically significant intergroup differences (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in maximum hemangioma diameter. Specifically, patients in Groups C and D presented with significantly larger hemangiomas (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). No significant differences were detected among groups with respect to liver function, coagulation profiles, or hematological parameters.\u003c/p\u003e \u003cp\u003eAnalysis of intraoperative parameters revealed statistically significant differences in operative time among the groups. Specifically, both Group C and Group D exhibited significantly longer operative durations compared to Groups A and B, while no significant difference was observed between Groups C and D. Notably, although Group C presented with larger tumor diameters and correspondingly higher surgical complexity, the application of continuous portal vein clamping appeared to facilitate maintenance of surgical continuity, thereby partially mitigating the prolongation of operative time (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Further evaluation of intraoperative blood loss demonstrated that Group D had significantly higher hemorrhage volume compared to the other three groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). This phenomenon may be associated with reperfusion-related bleeding from the transection surface following the release of intermittent portal vein clamping.\u003c/p\u003e \u003cp\u003eIn summary, our findings indicate that the adoption of continuous portal vein clamping during hepatectomy helps maintain surgical continuity, significantly reduces operative time, and effectively minimizes intraoperative blood loss.\u003c/p\u003e \u003cp\u003eTo evaluate the impact of single continuous versus multiple intermittent hepatic inflow occlusion on postoperative liver function, serum levels of alanine aminotransferase (ALT, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD), aspartate aminotransferase (AST, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE), total bilirubin (TBIL, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eF), and direct bilirubin (DBIL, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eG) were measured before surgery and on postoperative days 3 and 5. No statistically significant differences were observed in the dynamic changes of these biochemical parameters between the four groups, indicating that single continuous inflow occlusion\u0026mdash;even when applied for 40 to 70 minutes\u0026mdash;does not impair postoperative liver function recovery\u003c/p\u003e \u003cp\u003eA one-way ANOVA of laboratory parameters at different postoperative time points revealed statistically significant differences in gamma-glutamyl transferase (GGT) levels on postoperative day 3 among the four groups (P\u0026thinsp;=\u0026thinsp;0.002). The mean GGT values were 22.92 U/L in Group A and 24.57 U/L in Group B, whereas Groups C and D demonstrated markedly elevated levels of 47.60 U/L and 45.77 U/L, respectively. No significant difference was observed between Groups C and D. These findings suggest that prolonged vascular occlusion may induce intraoperative biliary mucosal injury, and that repeated brief occlusions do not appear to attenuate such damage.\u003c/p\u003e \u003cp\u003eAdditionally, a statistically significant difference in aspartate aminotransferase (AST) levels was observed among the groups on postoperative day 5 (P\u0026thinsp;=\u0026thinsp;0.033). Group A (single hepatic vascular occlusion duration\u0026thinsp;\u0026le;\u0026thinsp;20 minutes) exhibited the highest mean AST level (79.75 U/L), whereas Groups B, C, and D demonstrated lower values (51.54 U/L, 30.90 U/L, and 38.62 U/L, respectively). ALT and AST are key enzymes in the assessment of hepatic injury: ALT is predominantly localized in the hepatocyte cytoplasm, while AST is present in mitochondria and the cytoplasm of multiple tissues, including the liver, heart, skeletal muscle, and kidneys. Elevated AST may reflect mitochondrial damage within hepatocytes, whereas increased ALT is more specifically associated with hepatocellular injury. Thus, the intergroup differences in AST levels on day 5 may not be clinically meaningful. No significant differences were detected in other postoperative parameters\u0026mdash;including ALT, TBIL, DBIL, coagulation profiles (prothrombin time [PT], fibrinogen [Fib]), and CBC (white blood cells [WBC], hemoglobin [Hb], platelets [Plt])\u0026mdash;on days 3 or 5. Moreover, the postoperative length of hospital stay did not differ significantly across the four groups\u003c/p\u003e \u003cp\u003eIn summary, the findings demonstrate that a single prolonged Pringle maneuver did not result in statistically significant alterations in postoperative liver function, coagulation parameters, complete blood count indices, or length of hospitalization. Among non-cirrhotic patients undergoing HHA resection, continuous inflow occlusion lasting 40 to 70 minutes was not associated with adverse effects on postoperative hepatic recovery relative to intermittent clamping. A continuous operative strategy not only promotes procedural efficiency but also minimizes transection surface hemorrhage attributable to repeated cycles of occlusion and reperfusion.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The relatively small cohort size, especially the limited number of cases in which hepatic inflow occlusion was maintained for \u0026ge;\u0026thinsp;40 minutes, may have constrained the statistical power of the analyses. Future studies with larger sample sizes are warranted to corroborate the present findings. Furthermore, the interplay among the extent of hepatic resection, the technique of inflow occlusion, and the duration of ischemia in determining postoperative liver function after partial hepatectomy in non-cirrhotic livers represents a complex and multifactorial relationship that merits further systematic investigation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAlanine aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAspartate aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGGT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGamma-glutamyl transferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTBIL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal bilirubin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDBIL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirect bilirubin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProthrombin time\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFib\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFibrinogen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWhite blood cell count\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHb\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlatelet count\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePostoperative day\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHepatic hemangioma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntermittent Pringle maneuver\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComplete blood count.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e This study was approved by the Medical Ethics Committee of China-Japan Friendship Hospital (Approval No. 2024-KY-385). As a retrospective cohort study that involved no patient intervention and used fully anonymized data, the requirement for informed consent was waived by the Ethics Committee. All procedures performed in this study were in accordance with the ethical standards of the Declaration of Helsinki.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e Not applicable. This manuscript does not contain any individual person\u0026apos;s data in any form (including images, videos, or clinical details) that would compromise anonymity.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e This study was funded by the China-Japan Friendship Hospital High-Level Hospital Clinical Expenses Special Clinical Research Project (No. 2025-NHLHCRF-JBGS-A-WZ-07) and the National High-Level Hospital Clinical Research Funding \u0026amp; Elite Medical Professionals Project of China-Japan Friendship Hospital (No. ZRJY2023-GG04).\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cbr\u003e Yingjixing Luo: Conceptualization, Data curation, Formal analysis, Writing \u0026ndash; original draft. Yue Qiu: Data curation, Investigation, Writing \u0026ndash; review \u0026amp; editing. Ruili Wei: Data curation, Methodology, Validation. Ruiyi Liu: Formal analysis, Software, Visualization. Jia Huang: Investigation, Resources. Li Xu: Project administration, Supervision. Yongliang Sun: Validation, Visualization. Zhiying Yang: Conceptualization, Funding acquisition, Supervision, Writing \u0026ndash; review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e Not applicable.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, et al.Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. (2002) 236(4):397\u0026ndash;406. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00000658-200210000-00001\u003c/span\u003e\u003cspan address=\"10.1097/00000658-200210000-00001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano K, et al. One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg. 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PMID: 37526089; PMCID: PMC10651268.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pringle maneuver, hepatic inflow occlusion, hepatectomy, liver function, hepatic hemangioma","lastPublishedDoi":"10.21203/rs.3.rs-8750472/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8750472/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate the impact of different Pringle maneuver techniques (continuous vs. intermittent) and occlusion durations on postoperative liver function and surgical outcomes after hepatic hemangioma(HHA) enucleation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A total of 268 consecutive patients who underwent laparoscopic or robot-assisted HHA enucleation between January 1, 2011, and November 1, 2024, were retrospectively reviewed; 129 of them met the inclusion criteria and constituted the final study cohort.They were divided into four groups according to the Pringle maneuver and its duration. Group A, B, C had continuous Pringle maneuvers for \u0026lt;20 min, 20 - 40 min, 40 - 70 min respectively, and Group D had intermittent multiple Pringle maneuvers with 40 - 70 min cumulative occlusion. Post - operative complications, liver function changes, and hospital stay were compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThere were no significant differences in age, gender, most parameters among groups (P \u0026gt; 0.05), except larger hemangioma diameter in Group C (P \u0026lt; 0.05). Group D had longer operation time and more blood loss (P \u0026lt; 0.05). Blood transfusion volume had no significant difference. Only Group C had elevated GGT on postoperative Day 3 (P \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e For normal liver function patients having HHA enucleation, continuous Pringle maneuver up to 60 min is safe, simplifies the procedure, reduces blood loss and operation time, with comparable postoperative recovery to intermittent occlusions.\u003c/p\u003e","manuscriptTitle":"Safety of Single Continuous Pringle Maneuver During HHA Enucleation: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 16:17:00","doi":"10.21203/rs.3.rs-8750472/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-15T05:30:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T14:56:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42693936293283462202479346153482881590","date":"2026-03-11T09:03:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T21:00:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242476252476172821899589983304338928314","date":"2026-03-09T19:35:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106307333064240090753411699956649960682","date":"2026-03-09T16:36:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T06:51:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T00:14:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251786789267578196090024463535735766550","date":"2026-03-07T00:04:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182967575436970290924922445932119850874","date":"2026-03-06T19:12:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T15:39:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86948715020910793407101553945322718111","date":"2026-03-04T20:16:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T18:23:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274554951687235349930877315910475177268","date":"2026-03-04T18:16:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-04T16:24:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T06:31:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-14T09:54:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2026-02-13T12:42:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f673b324-03b9-41cf-a13c-9d920982a432","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T01:39:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 16:17:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8750472","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8750472","identity":"rs-8750472","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}