Routine Pringle Maneuver During Recipient Hepatectomy Is Associated with Improved Perioperative and Early Graft Outcomes After Adult Liver Transplantation

Background: Recipient hepatectomy during orthotopic liver transplantation (OLT) is frequently complicated by severe bleeding due to portal hypertension and collateral circulation. The Pringle maneuver’s benefit in this setting remains uncertain. Methods: We retrospectively analyzed data from 141 adults who underwent primary deceased-donor OLT at a single center between January 2020 and June 2026. A routine intermittent Pringle maneuver was introduced in 2023; 79 subsequent recipients comprised the Pringle group, while 62 earlier recipients served as historical controls. Multivariable regression and inverse probability of treatment weighting (IPTW) were used to address confounding, and temporal trends within each period were examined. Results: Indication for transplantation, markers of hepatic decompensation, and extended-criteria donor status did not differ between groups. Compared with controls, the Pringle group required fewer packed red blood cell units (median 2 {IQR 0–4} vs. 3 {1–5}; p = 0.046), fresh frozen plasma units (4 {0–6} vs. 4 {3–8}; mean 4.1 vs. 6.9; no plasma transfused in 30.8% vs. 13.6%; p = 0.005), and total blood products (5 {0–9} vs. 8 {4–14}; p = 0.009). Recipient hepatectomy was shorter (129 {105–165} vs. 177 {146–208} minutes; p < 0.001), and postoperative bleeding (2.5% vs. 22.6%; p < 0.001), biliary leak (2.5% vs. 11.3%; p = 0.043), and early allograft dysfunction (EAD; 6.3% vs. 29.0%; p < 0.001) were less frequent. After adjustment, the Pringle maneuver remained associated with shorter hepatectomy (time ratio 0.76; 95% CI 0.67–0.87), reduced fresh frozen plasma (IRR 0.60; 0.40–0.91) and total blood product use (IRR 0.61; 0.40–0.92), and lower odds of postoperative bleeding (OR 0.04; 0.01–0.25), biliary leak (OR 0.13; 0.02–0.63), and EAD (OR 0.14; 0.04–0.58). Packed red blood cell transfusion was nonsignificant after adjustment (IRR 0.70; 0.43–1.12). IPTW yielded consistent findings. Overall survival did not differ (p = 0.885). Conclusions: In this historical-control study, routine intermittent Pringle maneuver was associated with improved operative efficiency, lower transfusion requirements, and fewer early complications without affecting survival; given the retrospective design and the modest absolute differences in transfusion, these findings require prospective confirmation.