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Giakoustidis A, Papakonstantinou M, Gkoutzios C, Chatzikomnitsa P, Gkaitatzi AD, Myriskou A, Bangeas P, Loufopoulos PD, Papadopoulos VN, Giakoustidis D. Transient Elevation of Liver Function Tests and Bilirubin Levels After Laparoscopic Cholecystectomy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1885. [PMID: 39597070 PMCID: PMC11596356 DOI: 10.3390/medicina60111885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Revised: 11/08/2024] [Accepted: 11/13/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: Laparoscopic cholecystectomy constitutes the current "gold standard" treatment of symptomatic gallstone disease. In order to avoid intraoperative vasculobiliary injuries, it is mandatory to establish the "critical view of safety". In cases of poor identification of the cystic duct and artery leading to a missed intraoperative injury, patients present with elevated liver function tests (LFTs) or increased bilirubin postoperatively. The aim of this study is to present a series of patients of our institute with elevated liver enzymes and bilirubin after laparoscopic cholecystectomy in the absence of intraoperative injury or any other obvious etiology and to provide a possible explanation of this finding. Materials and Methods: From 2019 to 2023, 200 patients underwent elective laparoscopic cholecystectomy at the Papageorgiou General Hospital and at the European Interbalkan Medical Center of Thessaloniki utilizing the "critical view of safety" method. We retrospectively collected the intraoperative reports, and the pre- and postoperative imaging and laboratory studies of the patients included in this series. Postoperative LFTs and bilirubin levels were extracted and the reason for their transient elevation was examined. Results: From 200 cases of laparoscopic cholecystectomy, elevated LFTs and bilirubin were found in six patients on the first postoperative day, which is suggestive of a missed intraoperative injury. All patients were asymptomatic. During the investigatory workup, a triple-phase CT of the liver and/or an MRCP were ordered, but no pathological findings, such as biliary injury, hepatic artery injury or choledocholithiasis, were found. On postoperative day 3, LFTs and bilirubin levels decreased or normalized without any intervention. No postoperative complications were reported. Conclusions: In select cases, a transient increase in LFTs and/or bilirubin may be observed in the early postoperative period after elective laparoscopic cholecystectomy in the absence of an obvious etiology. A possible interpretation of these findings could involve the pneumoperitoneum or the anesthesia regimens used intra- or perioperatively. The specific cause, however, remains undetermined and yet to be examined by future studies.
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Affiliation(s)
- Alexandros Giakoustidis
- A’ Department of Surgery, General Hospital Papageorgiou, 56429 Thessaloniki, Greece; (M.P.); (C.G.); (P.C.); (A.D.G.); (A.M.); (P.B.); (P.D.L.); (V.N.P.); (D.G.)
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Cornely OA, Cisneros JM, Torre-Cisneros J, Rodríguez-Hernández MJ, Tallón-Aguilar L, Calbo E, Horcajada JP, Queckenberg C, Zettelmeyer U, Arenz D, Rosso-Fernández CM, Jiménez-Jorge S, Turner G, Raber S, O'Brien S, Luckey A. Pharmacokinetics and safety of aztreonam/avibactam for the treatment of complicated intra-abdominal infections in hospitalized adults: results from the REJUVENATE study. J Antimicrob Chemother 2021; 75:618-627. [PMID: 31828337 PMCID: PMC7021089 DOI: 10.1093/jac/dkz497] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/21/2019] [Accepted: 11/03/2019] [Indexed: 12/29/2022] Open
Abstract
Objectives To investigate pharmacokinetics (PK) and safety (primary objectives) and efficacy (secondary objective) of the investigational monobactam/β-lactamase inhibitor combination aztreonam/avibactam in patients with complicated intra-abdominal infection (cIAI). Methods This Phase 2a open-label, multicentre study (NCT02655419; EudraCT 2015-002726-39) enrolled adults with cIAI into sequential cohorts for 5–14 days treatment. Cohort 1 patients received an aztreonam/avibactam loading dose of 500/137 mg (30 min infusion), followed by maintenance doses of 1500/410 mg (3 h infusions) q6h; Cohort 2 received 500/167 mg (30 min infusion), followed by 1500/500 mg (3 h infusions) q6h. Cohort 3 was an extension of exposure at the higher dose regimen. Doses were adjusted for creatinine clearance of 31–50 mL/min (Cohorts 2 + 3). All patients received IV metronidazole 500 mg q8h. PK, safety and efficacy were assessed. Results Thirty-four patients (Cohort 1, n = 16; Cohorts 2 + 3, n = 18) comprised the modified ITT (MITT) population. Mean exposures of aztreonam and avibactam in Cohorts 2 + 3 were consistent with those predicted to achieve joint PK/pharmacodynamic target attainment in >90% patients. Adverse events (AEs) were similar between cohorts. The most common AEs were hepatic enzyme increases [n = 9 (26.5%)] and diarrhoea [n = 5 (14.7%)]. Clinical cure rates at the test-of-cure visit overall were 20/34 (58.8%) (MITT) and 14/23 (60.9%) (microbiological-MITT population). Conclusions Observed AEs were consistent with the known safety profile of aztreonam monotherapy, with no new safety concerns identified. These data support selection of the aztreonam/avibactam 500/167 mg (30 min infusion) loading dose and 1500/500 mg (3 h infusions) maintenance dose q6h regimen, in patients with creatinine clearance >50 mL/min, for the Phase 3 development programme.
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Affiliation(s)
- Oliver A Cornely
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
| | | | | | | | | | - Esther Calbo
- Hospital Universitario Mútua de Tarrasa and Universitat Internacional de Catalunya, Barcelona, Spain
| | | | - Christian Queckenberg
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
| | - Ulrike Zettelmeyer
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
| | - Dorothee Arenz
- University of Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Clinical Trials Centre Cologne (CTC Cologne), Faculty of Medicine, University Hospital Cologne, Department I of Internal Medicine, German Centre for Infection Research (DZIF) partner site Cologne, Cologne, Germany
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Yildirim MB, Ozkan MB, Topçu R. The Effect of L-Hook Dissection and Scissors Dissection on Liver Injury in Laparoscopic Cholecystectomies. Cureus 2021; 13:e15245. [PMID: 34178550 PMCID: PMC8226039 DOI: 10.7759/cureus.15245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose: Laparoscopic cholecystectomy is generally performed with the help of monopolar cautery. We aimed to reveal the effect of monopolar cautery use on liver damage in this study. Method: Data of patients who underwent elective cholecystectomy between January 2016 and April 2020 were collected retrospectively. The patients were divided into two groups according to the surgical technique as hook dissection (HD) and scissor dissection (SD). The amount of increase in the preoperative and postoperative alanine aminotransferase (ALT) and aspartate aminotransferase (AST) values of the patients was compared between the two groups. Findings: Over 970 patients were included in the study. The changes in pre-post ALT and AST values were statistically significantly different between the HD (n=469) and SD (n=501) groups (p<0.001; p0.001). ALT (26 (−25, 338)) and AST (27 (−23, 444)) changes in the HD method were statistically significantly higher than ALT (11 (−16, 371)) and AST (10.8 (−37, 617)) changes in the SD method. Results: ALT and AST values increase after all laparoscopic cholecystectomies. Although the increase in ALT and AST in the HD patients is statistically significant when compared to the SD group, both methods of laparoscopic cholecystectomy can be safely performed because they do not cause permanent liver injury.
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Affiliation(s)
| | - Murat B Ozkan
- General Surgery, Hitit University, Faculty of Medicine, Corum, TUR
| | - Ramazan Topçu
- General Surgery, Hitit University, Faculty of Medicine, Corum, TUR
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Comparison of Short-Term Outcomes Between Hand-assisted Laparoscopic Distal Gastrectomy and Laparoscopy-assisted Distal Gastrectomy in Gastric Cancer. Surg Laparosc Endosc Percutan Tech 2021; 30:249-256. [PMID: 32049871 DOI: 10.1097/sle.0000000000000768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hand-assisted laparoscopic surgery is considered to provide the benefits of laparoscopic surgery in various diseases. However, limited information is available regarding the feasibility of hand-assisted laparoscopic distal gastrectomy (HALDG)-a subset of hand-assisted laparoscopic surgery-as a gastric cancer treatment. This study aimed to evaluate the usefulness of HALDG compared with laparoscopy-assisted distal gastrectomy (LADG). Consecutive patients who underwent HALDG (n=58) or LADG (n=90) for stage I gastric cancer between 2005 and 2016 were eligible. Operative time was significantly shorter and blood loss was significantly higher in HALDG than in LADG (P<0.001, both). Postoperative aminotransferase levels were significantly lower in HALDG than in LADG (P<0.001). There was no significant difference in perioperative complications, a number of analgesics, postoperative C-reactive protein levels, and 3-year relapse-free and overall survival rates between the groups. This study suggests that HALDG is a safe and feasible approach and could become an effective option for stage I gastric cancer treatment.
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Mazahreh TS, Aleshawi AJ, Al-Zoubi NA, Altabari M, Aljarrah Q. Comparison of postoperative liver function between different dissection techniques during laparoscopic cholecystectomy. Future Sci OA 2020; 6:FSO462. [PMID: 32257375 PMCID: PMC7117547 DOI: 10.2144/fsoa-2019-0160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim: In this study, we investigated and compared the effect of different types of dissector (Maryland vs Hook) on changes in liver function tests (LFTs) after laparoscopic cholecystectomy. Patients & methods: The enrolled patients were divided into two groups. Group A patients underwent dissection by Maryland dissecting forceps, group B by Hook dissecting instrument. LFTs were measured preoperatively and at 1 day and 1 week, postoperatively. Results: For both Maryland and Hook dissection, the 1-day postoperative values for total bilirubin, alanine aminotransferase and aspartate aminotransferase were significantly higher than the preoperative values. Also, there were no statistical differences between Hook and Maryland. Conclusion: The elevation of LFTs seems to be attributed to other factors. Laparoscopic cholecystectomy (LC) is an alternative to laparotomy and has become the standard treatment of benign gallbladder diseases. However, it has been noted that (following LC) the serum level of certain liver function tests (LFT) raises markedly in patients who had preoperatively normal LFT. Pneumoperitoneum is the main contributing factor. This is the first study to evaluate the effect of different dissectors on alteration of LFTs after LC. As there were no statistical differences in the variation of LFTs between the Maryland and Hook, it seems that the dissector type has no effect on the alteration of LFTs.
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Affiliation(s)
- Tagleb S Mazahreh
- Department of General Surgery & Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Abdelwahab J Aleshawi
- King Abdullah University Hospital, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Nabil A Al-Zoubi
- Department of General Surgery & Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Mohammad Altabari
- Department of General Surgery & Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Qusai Aljarrah
- Department of General Surgery & Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
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Rose JB, Hawkins WG. Diagnosis and management of biliary injuries. Curr Probl Surg 2017; 54:406-435. [DOI: 10.1067/j.cpsurg.2017.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/20/2017] [Indexed: 12/11/2022]
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Liu Y, Cao W, Liu Y, Wang Y, Lang R, Yue Y, Wu AS. Changes in duration of action of rocuronium following decrease in hepatic blood flow during pneumoperitoneum for laparoscopic gynaecological surgery. BMC Anesthesiol 2017; 17:45. [PMID: 28320323 PMCID: PMC5359965 DOI: 10.1186/s12871-017-0335-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 03/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A moderate insufflation pressure and deep neuromuscular blockade (NMB) have been recommended in laparoscopic surgery in consideration of the possible reduction in splanchnic perfusion due to the CO2-pneumoperitoneum. Since the liver is the major organ for rocuronium metabolism, the question of whether NMB of rocuronium would change with the variation of liver perfusion during pneumoperitoneum during laparoscopic surgery merits investigation. METHODS In this prospective study, a total of sixty female patients scheduled for either selective laparoscopic gynaecological surgery (group laparoscopy) or laparotomy for gynaecological surgery (group control) were analyzed. Rocuronium was administered with closed-loop feedback infusion system, which was also applied to monitor NMB complied with good clinical research practice (GCRP). The onset time, clinical duration, and recovery index were measured. Hepatic blood flow was assessed by laparoscopic intraoperative ultrasonography before insufflation/after entering the abdominal cavity (T1), 5 min after insufflation in the Trendelenburg position/5 min after skin incision (T2), 15 min after insufflation in the Trendelenburg position/15 min after skin incision (T3), 30 min after insufflation in the Trendelenburg position/30 min after skin incision (T4), and 5 min after deflation/before closing the abdomen (T5) in group laparoscopy/group control respectively. The relationship between the clinical duration of rocuronium and portal venous blood flow was analyzed using linear or quadratic regression. RESULT The clinical duration and RI of rocuronium were both prolonged significantly in group laparoscopy (36.8 ± 8.3 min; 12.8 ± 5.5 min) compared to group control (29.0 ± 5.8 min; 9.8 ± 4.0 min) (P < 0.0001; P = 0.018). A significant decrease was found in portal venous blood flow during the entire pneumoperitoneum period in group laparoscopy compared with group control (P < 0.0001). There was a significant correlation between the clinical duration of rocuronium and portal venous blood flow (Y = 51.800-0.043X + (1.86E-005) X 2; r2 = 0.491; P < 0.0001). CONCLUSION Rocuronium-induced NMB during laparoscopic gynaecological surgery might be prolonged due to the decrease in portal venous blood flow induced by CO2-pneumoperitoneum. Less rocuronium could be required to achieve a desirable NMB in laparoscopic gynaecological surgery. TRIAL REGISTRATION ChiCTR. Registry number: ChiCTR-OPN-15007524 . Date of registration: December 4, 2015.
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Affiliation(s)
- Yang Liu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
| | - Wen Cao
- Department of Ultrasonography, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
| | - Yu Liu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
| | - Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
| | - Ren Lang
- Department of Liver and Gallbladder, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
| | - Yun Yue
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District 100020 Beijing, China
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Redkin AV, Vdovin VV, Vakhtel VM, Lukyanovich PA, Malkina NA. Reduce Adverse Effects of Laparoscopic Cholecystectomy with Pulse Width Modulated LED Light (625 nm, 76 Hz, 23% Duty Cycle). Photomed Laser Surg 2017; 35:293-299. [PMID: 28301292 DOI: 10.1089/pho.2016.4211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Reducing adverse effects in laparoscopic cholecystectomy (LCE) is important to avoid complications. After removal, the porta hepatis and gallbladder bed of liver were treated with pulse width modulated (PWM) red LED light with parameters λ = 625 ± 5 nm, full width at half maximum 17 nm, 76 Hz, duty cycle 23%, 15-30 mW/cm2, and 0.9-1.8 J/cm2. The changes of eight blood parameters were studied: red blood cell, hemoglobin, white blood cell, erythrocyte sedimentation rate (ESR), bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and amylase. BACKGROUND DATA Other current methods of reducing undesirable effects of LCE significantly affect surgery and are not commonly used in practice. MATERIALS AND METHODS Before LCE, 263 patients were randomized into the control and test groups. Patients in the test group were treated with light radiated for 2 min during the surgery on the bed of the removed gallbladder and porta hepatis. Blood samples were taken before surgery and on the third day after surgery, studied, and compared by nonparametric statistical methods. RESULTS The test group revealed significant reduction in postsurgery gain of levels of ALT, AST, and ESR compared with the control group. CONCLUSIONS Treatment of the removed gallbladder bed and porta hepatis by red LED PWM radiation during LCE significantly reduces the adverse effects of surgery while increasing its time insignificantly and does not affect the surgical best practices deployed.
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Affiliation(s)
- Alexander V Redkin
- 1 Department of Oncology, Radiotherapy and Imaging Diagnosis, Voronezh State Medical University , Voronezh, Russia
| | - Victor V Vdovin
- 2 Department of Surgery, Voronezh Railways Clinical Hospital , Voronezh, Russia
| | - Victor M Vakhtel
- 3 Department of Nuclear Physics, Voronezh State University , Voronezh, Russia
| | - Pavel A Lukyanovich
- 4 Department of Mathematical Physics, Voronezh State University , Voronezh, Russia
| | - Natalia A Malkina
- 5 Department of General Surgery, Voronezh State Medical University , Voronezh, Russia
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Özdemir-van Brunschot DMD, van Laarhoven KCJHM, Scheffer GJ, Pouwels S, Wever KE, Warlé MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc 2015; 30:2049-65. [PMID: 26275545 PMCID: PMC4848341 DOI: 10.1007/s00464-015-4454-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/16/2015] [Indexed: 12/20/2022]
Abstract
Background Laparoscopic surgery has several advantages when compared to open surgery, including faster postoperative recovery and lower pain scores. However, for laparoscopy, a pneumoperitoneum is required to create workspace between the abdominal wall and intraabdominal organs. Increased intraabdominal pressure may also have negative implications on cardiovascular, pulmonary, and intraabdominal organ functionings. To overcome these negative consequences, several trials have been performed comparing low- versus standard-pressure pneumoperitoneum. Methods A systematic review of all randomized controlled clinical trials and observational studies comparing low- versus standard-pressure pneumoperitoneum. Results and conclusions Quality assessment showed that the overall quality of evidence was moderate to low. Postoperative pain scores were reduced by the use of low-pressure pneumoperitoneum. With appropriate perioperative measures, the use of low-pressure pneumoperitoneum does not seem to have clinical advantages as compared to standard pressure on cardiac and pulmonary function. Although there are indications that low-pressure pneumoperitoneum is associated with less liver and kidney injury when compared to standard-pressure pneumoperitoneum, this does not seem to have clinical implications for healthy individuals. The influence of low-pressure pneumoperitoneum on adhesion formation, anastomosis healing, tumor metastasis, intraocular and intracerebral pressure, and thromboembolic complications remains uncertain, as no human clinical trials have been performed. The influence of pressure on surgical conditions and safety has not been established to date. In conclusion, the most important benefit of low-pressure pneumoperitoneum is lower postoperative pain scores, supported by a moderate quality of evidence. However, the quality of surgical conditions and safety of the use of low-pressure pneumoperitoneum need to be established, as are the values and preferences of physicians and patients regarding the potential benefits and risks. Therefore, the recommendation to use low-pressure pneumoperitoneum during laparoscopy is weak, and more studies are required.
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Affiliation(s)
- Denise M D Özdemir-van Brunschot
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Kees C J H M van Laarhoven
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sjaak Pouwels
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Kim E Wever
- Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Hasukić Š. Low-pressure and gasless laparascopy in abdominal surgery. SCRIPTA MEDICA 2015. [DOI: 10.5937/scrimed1501066h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Lai H, Mo X, Yang Y, Xiao J, He K, Chen J, Lin Y. Association between duration of carbon dioxide pneumoperitoneum during laparoscopic abdominal surgery and hepatic injury: a meta-analysis. PLoS One 2014; 9:e104067. [PMID: 25110982 PMCID: PMC4128655 DOI: 10.1371/journal.pone.0104067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/06/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The aim of this study is to accurately assess whether the duration of intraoperative carbon dioxide pneumoperitoneum (CDP) is associated with the induction of hepatic injury. METHODS We conducted a systematic review of PubMed, Embase, and Cochrane Library databases (through February 2014) to identify case-match studies that compared high-pressure CDP with low-pressure CDP or varied the duration of CDP in patients who underwent abdominal surgery. The outcome of interest was postoperative liver function (ALT, AST, TB). RESULTS Eleven comparative studies involving 2,235 participants were included. Overall, levels of ALT, AST, and TB (on postoperative days 1, 3, and 7) were significantly elevated in the study groups. However, the results of the subanalyses of those who underwent laparoscopic colorectal cancer resection (LCR) versus open colorectal cancer resection (OCR) and those who underwent laparoscopic gastric bypass (LGBP) versus open gastric bypass (OGBP) were inconsistent. CONCLUSIONS The current evidence suggests that the duration of CDP during laparoscopic abdominal surgery may be associated with hepatic injury. Additional large-scale, randomized, controlled trials are urgently needed to further confirm this.
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Affiliation(s)
- Hao Lai
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
| | - Xianwei Mo
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
| | - Yang Yang
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
| | - Jun Xiao
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
| | - Ke He
- Department of Neck and Head Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
| | - Jiansi Chen
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
| | - Yuan Lin
- Department of Gastrointestinal Surgery, Affiliated Cancer Hospital of Guangxi Medical University, Nanning, Guangxi Autonomous Region, China
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Wang MJ, Li JL, Zhou J, Wu Z, Peng B. Consecutive laparoscopic gallbladder and spleen resections in cirrhotic patients. World J Gastroenterol 2014; 20:546-554. [PMID: 24574724 PMCID: PMC3923030 DOI: 10.3748/wjg.v20.i2.546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/08/2013] [Accepted: 11/30/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the feasibility, safety, and effectiveness of consecutive laparoscopic cholecystectomy (LC) plus splenectomy (LS) in liver cirrhosis patients.
METHODS: From 2003 to 2013, 17 (group 1) patients with liver cirrhosis complicated by hypersplenism and symptomatic gallstones were treated with combined LC and LS, while 58 (group 2) patients with liver cirrhosis and hypersplenism received LS alone. An additional 14 (group 3) patients who received traditional open procedures during the same period were included as controls. Data were retrospectively collected and reviewed in regard to demographic characteristics and preoperative, intraoperative and postoperative features. Differences between the three groups were assessed by statistical analysis.
RESULTS: The three groups showed no significant differences in the demographic characteristics or preoperative status. However, the patients treated with LC and LS required significantly longer operative time, shorter postoperative stay as well as shorter time of return to the first oral intake, and suffered less intraoperative blood loss as well as fewer postoperative surgical infections than the patients treated with traditional open procedures (group 1 vs group 3, P < 0.05 for all). The patients treated with LC and LS showed no significant differences in the intraoperative and postoperative variables from those treated with LS alone (group 1 vs group 2). All patients showed significant improvements in the haematological responses (preoperative period vs postoperative period, P < 0.05 for all). None of the patients treated with LC and LS presented with any gallstone-associated symptoms following discharge, while the patients treated with the traditional open procedures expressed complaints of discomfort related to their surgical incisions.
CONCLUSION: Consecutive LC and LS is an appropriate treatment option for liver cirrhosis patients with gallstones and hypersplenism, especially for those with Child-Pugh A and B.
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Ahmad NZ. Routine testing of liver function before and after elective laparoscopic cholecystectomy: is it necessary? JSLS 2011; 15:65-9. [PMID: 21902946 PMCID: PMC3134700 DOI: 10.4293/108680811x13022985131291] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study suggests that mild to moderate elevation in preoperative liver function tests may not be associated with deleterious effects, and in the absence of clinical indications, routine preoperative or postoperative liver function testing may not be necessary. Background and Objectives: Liver function tests (LFTs) include alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), and bilirubin. The role of routine testing before and after laparoscopic cholecystectomy was evaluated in this study. Patients and Methods: A total of 355 patients were retrospectively analyzed by examining the LFTs the day before, the day after, and 3 weeks after the surgery. The Wilcoxon signed-rank test and Student t test were performed to determine statistical significance. Results: Alterations in the serum AST, ALT, and GGT were seen on the first postoperative day. Minor changes were seen in bilirubin and ALP. An overall disturbance in the LFTs was seen in more than two-thirds of the cases. Repeat LFTs performed after 3 weeks on follow-up were found to be within normal limits. Conclusion: Mild-to-moderate elevation in preoperative LFTs may not be associated with any deleterious effect, and, in the absence of clinical indications, routine preoperative or postoperative liver function testing is unnecessary.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Mid Western Regional Hospital, Ennis, County Clare, Republic of Ireland.
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Shinohara T, Kanaya S, Yoshimura F, Hiramatsu Y, Haruta S, Kawamura Y, Giacopuzzi S, Fujita T, Uyama I. A protective technique for retraction of the liver during laparoscopic gastrectomy for gastric adenocarcinoma: using a Penrose drain. J Gastrointest Surg 2011; 15:1043-8. [PMID: 20824387 DOI: 10.1007/s11605-010-1301-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 08/05/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Retraction of the liver is necessary to ensure an adequate working space in laparoscopic surgery, but the retraction force applied may cause transient liver dysfunction. We have introduced the technique using a Penrose drain to suspend the liver with the performance of laparoscopic gastrectomy for gastric adenocarcinoma. METHODS 111 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy using either a Penrose drain (n = 47) or a Nathanson's retractor (n = 64) for displacement of the liver. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, alkaline phosphatase (ALP) and albumin were compared among the groups at baseline, immediately after operation, and on postoperative days (POD) 1, 2, 3, 5, and 7. RESULTS The levels of ALT on POD 2, 3, and 5 were significant higher in the Nathanson's retractor group than in the Penrose drain group. Levels of AST on POD 2 and 3 were also higher in the Nathanson's retractor group than in the Penrose drain group. There was no significant difference in total bilirubin, ALP, and serum albumin levels between groups. CONCLUSIONS The use of the Penrose drain for retraction of the liver appears to attenuate postoperative liver dysfunction during laparoscopic gastrectomy for gastric adenocarcinoma.
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Affiliation(s)
- Toshihiko Shinohara
- Department of Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, 470-1192, Aichi, Japan.
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15
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Jeong GA, Cho GS, Shin EJ, Lee MS, Kim HC, Song OP. Liver function alterations after laparoscopy-assisted gastrectomy for gastric cancer and its clinical significance. World J Gastroenterol 2011; 17:372-8. [PMID: 21253398 PMCID: PMC3022299 DOI: 10.3748/wjg.v17.i3.372] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Revised: 09/07/2010] [Accepted: 09/14/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the factors associated with liver function alterations after laparoscopy-assisted gastrectomy (LAG) for gastric cancer.
METHODS: We collected the data of gastrectomy patients with gastric cancer and divided them into 2 groups: open gastrectomy (OG) and LAG. We also collected the data of patients with colon cancer to evaluate the effect of liver manipulations during surgery on liver function alterations. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and alkaline phosphatase were measured on the preoperative day and postoperative day 1 (POD1), POD3, POD5, and POD7.
RESULTS: No changes in liver function were observed after the operation in patients with colon cancer (n = 121). However, in gastric cancer patients (n = 215), AST and ALT levels increased until POD5 compared to those in colon cancer patients and these findings were observed both in the LAG and OG without a significant difference except at POD1. The mean hepatic enzyme levels at POD1 in the LAG group were significantly higher than those in the OG group (P = 0.047 for AST and P = 0.039 for ALT). The factors associated with elevated ALT on POD1 in patients with gastric cancer were body mass index (P < 0.001), operation time (P < 0.001), intraoperative hepatic injury (P = 0.048), and ligation of an aberrant left hepatic artery (P = 0.052) but not type of operation (OG vs LAG, P = 0.094).
CONCLUSION: We conclude that the liver function alteration after LAG may have been caused by direct liver manipulation or aberrant hepatic artery ligation rather than the CO2 pneumoperitoneum.
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Ruiz Gómez F, Ramia Ángel JM, García-Parreño Jofré J, Figueras J. Lesiones iatrogénicas de la vía biliar. Cir Esp 2010; 88:211-21. [DOI: 10.1016/j.ciresp.2010.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 02/21/2010] [Accepted: 03/12/2010] [Indexed: 12/20/2022]
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Abstract
Bile duct injuries incurred during laparoscopic cholecystectomies remain a major complication in an otherwise safe surgery. These injuries are potentially avoidable with proper techniques and correct interpretation of the anatomy. The scope of the injury can range from a simple cystic duct leak to the injury of the left and right hepatic duct confluence. The key to successful outcomes from these injuries is to know when a referral to a specialized tertiary center is necessary. Evaluation and treatment of bile duct injuries is complex and often requires the expertise of an advanced endoscopist, interventional radiologist, and hepatobiliary surgeons. Before any planned intervention or operative repair, detailed evaluation of the biliary system and its associated vasculature is required. Better outcomes are achieved when patients are referred to centers specialized in biliary injury evaluation, treatment, and performing pretreatment planning early.
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Affiliation(s)
- Yuhsin V Wu
- Division of General Surgery, Department of Surgery, Washington University School of Medicine, Surgery House Staff Office, 1701 West Building, Campus Box 8109, 660 South Euclid Avenue, St Louis, MO 63110, USA
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18
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Bostanci EB, Yol S, Teke Z, Kayaalp C, Sakaogullari Z, Ozel Turkcu U, Bilgihan A, Akoglu M. Effects of carbon dioxide pneumoperitoneum on hepatic function in obstructive jaundice: an experimental study in a rat model. Langenbecks Arch Surg 2009; 395:667-76. [PMID: 20012315 DOI: 10.1007/s00423-009-0577-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2009] [Accepted: 11/15/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS The physiology of the patient during laparoscopy differs from that of open surgery. Both pneumoperitoneum and obstructive jaundice impair the hepatic function, but the combined insult has not been previously examined. In this study, we aimed to investigate the effects of carbon dioxide (CO(2)) pneumoperitoneum on hepatic function in a rat model of obstructive jaundice. METHODS Forty-four male Sprague-Dawley rats were divided into four groups: group 1 (n = 10), sham-operated group; group 2 (n = 12), obstructive jaundice group; group 3 (n = 10), CO(2) pneumoperitoneum group; and group 4 (n = 12), obstructive jaundice and CO(2) pneumoperitoneum group. Common bile duct was ligated and divided in the obstructive jaundice groups. After 6 days, a 12-mmHg pneumoperitoneum was induced, maintained for 60 min, and released for 120 min. Blood samples were drawn for the measurement of white blood cell and platelet counts, serum liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], total bilirubin). Tissue samples were obtained for analyses of malondialdehyde (MDA), glutathione (GSH), and superoxide dismutase (SOD) levels. We evaluated the degree of liver injury on a grading scale from 0 to 4, histopathologically. RESULTS Pneumoperitoneum after biliary obstruction resulted in an increase in AST and ALT levels and a decrease in white blood cell and platelet counts. However, changes in liver tissue MDA, GSH, and SOD levels did not correlate with the changes in AST and ALT levels and white blood cell and platelet counts. After sham operation with pneumoperitoneum, the GSH levels in liver homogenate were significantly decreased in the group 3 when compared to the group 2. On the other hand, obstructive jaundice itself caused significant reduction in the SOD activity of liver homogenate in comparison to the group 3. Histopathologically, sinusoidal congestion and vacuolization were more severe in the group 3. CONCLUSIONS Alterations in hepatic function occur in pneumoperitoneum applied jaundiced subjects. However, there were no statistically significant differences between the groups 2 and 4 with regard to white blood cell and platelet counts, serum liver enzymes including AST, ALT, and total bilirubin values, MDA and GSH levels and SOD activity of liver homogenate, and histologic damage. These results indicate that there is no additional risk on liver function associated with pneumoperitoneum performed in obstructive jaundice.
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Affiliation(s)
- Erdal Birol Bostanci
- Department of Gastroenterological Surgery, Turkey Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey.
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19
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The impact of carbon dioxide pneumoperitoneum on liver regeneration after liver resection in a rat model. Surg Endosc 2009; 24:1-8. [PMID: 19533243 DOI: 10.1007/s00464-009-0536-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 04/03/2009] [Accepted: 05/01/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND In recent years, laparoscopic hepatic resection is performed by an increasing number of surgeons. Despite many advantages of the laparoscopic procedure, it is unclear whether the pneumoperitoneum affects the postoperative liver regeneration after liver resection. The current study aimed to investigate the influence of a carbon dioxide (CO(2)) pneumoperitoneum on liver regeneration in a rat model. METHODS In this study, 60 male Wistar rats were subjected to 70% partial hepatic resection. Of these 60 animals, 30 underwent preoperative pneumoperitoneum at 9 mmHg for 60 min. After hepatic resection, the rats were killed at 12, 24, and 48 h, and on days 4 and 7. The outcome parameters were hepatocellular injury (plasma aminotransferases), oxidative stress (plasma malondialdehyde), interleukin-6 (IL-6), and liver regeneration (mitotic index, KI-67; regenerating liver mass). RESULTS The mitotic index was significantly lower in the pneumoperitoneum group than in the group without pneumoperitoneum at all time points (p < 0.05). In the pneumoperitoneum group, KI-67 was significantly lower on day 4 (p < 0.05). The liver regeneration rate was significantly lower for the animals with pneumoperitoneum on days 2 and 4 (p < 0.05). The postoperative hepatocellular injury was significantly greater after pneumoperitoneum at 12, 24, and 48 h (p < 0.05). Plasma malondialdehyde and IL-6 were significantly higher in the pneumoperitoneum group at 24 h and on day 4 (p < 0.05). CONCLUSION This study showed that pneumoperitoneum before extended liver resection impaired postoperative liver regeneration. Oxidative stress reaction and hepatocellular damage was markedly higher after pneumoperitoneum. Further investigations, especially with patients that have impaired liver function, are necessary for clinical consequences to be drawn from these results.
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20
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Morris-Stiff G, Jones R, Mitchell S, Barton K, Hassn A. Retraction transaminitis: an inevitable but benign complication of laparoscopic fundoplication. World J Surg 2009; 32:2650-4. [PMID: 18825455 DOI: 10.1007/s00268-008-9744-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transient transaminitis has been identified following laparoscopic abdominal surgery. However, the importance of posture, duration of surgery, and mechanical retraction in its etiology remain unclear. METHODS Liver function was assessed preoperatively then at 8, 24, 48 and 72 h following laparoscopic surgery including the following procedures: Nissen fundoplication (LN: n = 10); cholecystectomy (LC: n = 10); inguinal herniorrhaphy (LH: n = 10); and gastrectomy (LG: n = 5). RESULTS Aspartate aminotransferase (AST) levels in LN patients exhibited a rapid rise within 8 h, peaking at 48 h before returning toward baseline. In the LN group, AST levels were significantly higher at 8 h and 24 hours compared to all other groups and compared to LG at 48 h and 72 h. At 6-week follow-up all AST levels were normal. No significant differences were seen in other hepatic parameters, and no correlation between AST and duration of operation, gender, or age was identified. CONCLUSIONS Antireflux surgery is associated with transaminitis related to hepatic retraction, which is independent of patient posture or duration of observation, and it resolves spontaneously with no clinical consequences.
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Affiliation(s)
- Gareth Morris-Stiff
- Department of Surgery, Princess of Wales Hospital, Coity Road, Bridgend, CF31 1RQ, Wales, UK.
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Atila K, Terzi C, Ozkardesler S, Unek T, Guler S, Ergor G, Bora S, Gulay H. What is the role of the abdominal perfusion pressure for subclinical hepatic dysfunction in laparoscopic cholecystectomy? J Laparoendosc Adv Surg Tech A 2009; 19:39-44. [PMID: 19196087 DOI: 10.1089/lap.2008.0085] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Subclinical hepatic dysfunction after laparoscopic cholecystectomy (LC) has been described in the literature. However, this alteration is not encountered in all patients. In order to address this situation, a prospective study was conducted to investigate the effect of abdominal perfusion pressure (APP) on liver function tests after LC performed under constant intra-abdominal pressure (IAP). PATIENTS AND METHODS Of 78 patients who underwent LC between May 2007 and October 2007, 40 patients were eligible for the study. In all the patients, six parameters of liver function (aspartate aminotransferase, alanine aminotransferase, direct bilirubin, indirect bilirubin, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients who showed more than a 100% increase in at least one parameter (group 1) were compared to those who did not (group 2) regarding age, sex, body weight, body height, operation time, pneumoperitoneum time, IAP, preoperative, and intraoperative APP. RESULTS Of the patients, 37.5% showed more than a 100% increase in at least one parameter of liver function. No significant difference was found between the two groups with regard to age, sex, body weight, body height, operation time, pneumoperitoneum time, and IAP. There were significant increase in AST and ALT at 24 hours postoperatively in group 1, as compared with group 2 (P = 0.000, P = 0.001). In comparison of preoperative APP with intraoperative APP values, group 1 showed a statistically significant decrease (P = 0.000), while no difference was found in group 2. CONCLUSION Subclinical hepatic dysfunction after LC could mostly be attributed to the negative effects of the pneumoperitoneum on hepatic blood flow. For the evaluation of hepatic hypoperfusion, APP may be a new criterion as a determinant of interaction with mean arterial pressure (MAP) and IAP.
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Affiliation(s)
- Koray Atila
- Department of Surgery, Dokuz Eylul University, School of Medicine, Izmir, Turkey.
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22
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Bickel A, Weiar A, Eitan A. Evaluation of liver enzymes following elective laparoscopic cholecystectomy: are they really elevated? J Gastrointest Surg 2008; 12:1418-21. [PMID: 18516716 DOI: 10.1007/s11605-008-0557-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2008] [Accepted: 05/02/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Studies made on a small number of patients have demonstrated significant modifications in liver function tests (LFT) following laparoscopic cholecystectomy. AIM To assess retrospectively, post-operative LFT in a large group of patients undergoing elective uneventful laparoscopic cholecystectomy. METHODS Between 1999 and 2007, 1,997 patients were scheduled for laparoscopic cholecystectomy. In 1,034 patients (the study group), the surgery was elective and normal LFT were measured a day prior to surgery. Exclusion criteria included acute cholecystitis, acute pancreatitis, pre-operative endoscopic retrograde cholangio-pancreatography, medication that may affect liver metabolism, and intra-operative complications. Liver function tests were evaluated pre-operatively and 20-24 h post-operatively. RESULTS The mean post-operative value of liver function tests and amylase were well within normal limits, although mild increase was inspected in part of it. We observed post-operative mild hepatic enzyme increase only in 41 patients (3.9%), in nine of these, choledocholithiasis was found. CONCLUSIONS In contrary to previously published data, we have validated, in light of our broad sampling, that the induction of CO(2) pneumoperitoneum does not cause deranged liver function tests.
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Affiliation(s)
- Amitai Bickel
- Department of Surgery, Western Galilee Hospital, P.O. Box 21, Nahariya, 22100, Israel.
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Baltayian S. A brief review: anesthesia for robotic prostatectomy. J Robot Surg 2008; 2:59. [PMID: 27637501 DOI: 10.1007/s11701-008-0088-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 05/12/2008] [Indexed: 10/22/2022]
Abstract
A brief review of the anesthesia for robotic prostatectomies, with a description of the procedure, the physiological principles involved, anesthetic management, problems, and possible complications.
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Affiliation(s)
- Sarkis Baltayian
- Division of Anesthesiology, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
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Bivalacqua TJ, Schaeffer EM, Alphs H, Mettee L, Wagner AA, Su LM, Pavlovich CP. Intraperitoneal effects of extraperitoneal laparoscopic radical prostatectomy. Urology 2008; 72:273-7. [PMID: 18355906 DOI: 10.1016/j.urology.2007.12.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 11/24/2007] [Accepted: 12/05/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To compare routine radiologic and laboratory findings after extraperitoneal and transperitoneal laparoscopic radical prostatectomy (eLRP, tLRP) and assess relevant clinical correlations. METHODS Fifty consecutive eLRP and tLRP (laparoscopic and robot-assisted) were evaluated. Preoperative complete metabolic panel and complete blood count were determined, and these serum tests and amylase and lipase level measurements were repeated postoperatively. Ten consecutive eLRP and tLRP patients also underwent flat and upright abdominal x-rays. Operative time, perioperative complications, length of hospital stay, and amount of narcotic used were measured for each group. RESULTS On postoperative day 1, all eLRP patients evaluated (100%) had radiographic free air in the abdomen, as did 80% of the tLRP patients. Only 1 of 50 patients (2%) had elevated aspartate aminotransferase (eLRP), 2 of 50 (4%) had elevated alanine aminotransferase (both eLRP), and 4 of 50 (8%) had elevated amylase (3 eLRP, 1 tLRP). Postoperative narcotic usage (eLRP 25 +/- 3 mg versus tLRP 23 +/- 5 mg morphine equivalents) and operative times (eLRP 3.6 +/- 0.1 hours versus tLRP 3.8 +/- 0.1 hours) were similar between the groups. Length of hospital stay was lower in the eLRP compared with the tLRP group (1.9 +/- 0.1 days versus 2.2 +/- 0.1 days, P <0.05). Perioperative complications did not differ significantly between groups. CONCLUSIONS Extraperitoneal LRP and tLRP patients had comparable perioperative outcomes, and few had abnormal serum metabolic laboratory values postoperatively. Unexpectedly, abdominal free air was found in all eLRP patients evaluated radiographically on postoperative day 1, a finding that should be interpreted as normal and not specific for bowel injury in this context.
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Affiliation(s)
- Trinity J Bivalacqua
- The Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland 21224, USA
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Alexakis N, Gakiopoulou H, Dimitriou C, Albanopoulos K, Fingerhut A, Skalistira M, Patsouris E, Bramis J, Leandros E. Liver histology alterations during carbon dioxide pneumoperitoneum in a porcine model. Surg Endosc 2008; 22:415-20. [PMID: 17593439 DOI: 10.1007/s00464-007-9440-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study aimed to investigate the time course changes in liver histology during carbon dioxide (CO(2)) pneumoperitoneum in a large animal model. METHODS For this study, 14 white pigs were anesthetized. Liver biopsies performed 0, 1, and 2 h after establishment of CO(2) pneumoperitoneum (at 12 mmHg) and after peritoneal desufflation were sent for histologic examination. Heart rate, mean blood pressure, hepatic artery flow, portal vein flow, and aortic flow were recorded in 10-min increments. Three animals served as control subjects. RESULTS A statistically significant time course increase was observed in portal inflammation, intralobular inflammation, edema, sinusoidal dilation, sinusoidal hyperemia, centrilobular dilation, centrilobular hyperemia, pericentrilobular ischemia, and focal lytic necrosis scores. There were no significant changes in the control group. This eliminated an effect of anesthesia only. The portal vein flow increased as much as 21%, and the hepatic artery flow decreased as much as 31% of baseline, but these differences did not attain statistical significance. Aortic flow remained relatively stable. CONCLUSION Histomorphologic changes occurred, indicating liver tissue injury during CO(2) pneumoperitoneum at an intraabdominal pressure of 12 mmHg in the porcine model. Portal vein flow increased, and hepatic artery flow decreased, whereas aortic flow remained relatively unaffected in this experiment.
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Affiliation(s)
- N Alexakis
- Department of Surgery, Medical School, University of Athens, Hippocration Hospital, V Sofias 114, Athens, 11527, Greece.
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Nickkholgh A, Barro-Bejarano M, Liang R, Zorn M, Mehrabi A, Gebhard MM, Büchler MW, Gutt CN, Schemmer P. Signs of reperfusion injury following CO2 pneumoperitoneum: an in vivo microscopy study. Surg Endosc 2008; 22:122-128. [PMID: 17483991 DOI: 10.1007/s00464-007-9386-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 01/30/2007] [Accepted: 02/24/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND During laparoscopic surgery, pneumoperitoneum is generally established by means of carbon dioxide (CO(2)) insufflation which may disturb hepatic microperfusion. It has been suggested that the desufflation at the end of the procedure creates a model of reperfusion in a previously ischemic liver, thus predisposing it to reperfusion injury. METHODS To study the effects of pneumoperitoneum on hepatic microcirculation, Sprague-Dawley rats underwent pneumoperitoneum with an intraabdominal pressure of 8 or 12 mmHg for 90 min. Subsequently, in vivo microscopy was performed to assess intrahepatic microcirculation and transaminases were measured to index liver injury. RESULTS A CO(2) pneumoperitoneum of 8 mmHg did not change serum transaminases; however, further increase of intraperitoneal pressure to 12 mmHg significantly increased AST, ALT, and LDH measured after desufflation to almost 1.5 times as much as control values of 49 +/- 5 U/L, 31 +/- 3 U/L, and 114 +/- 12 U/L. In parallel, in all subacinar zones the permanent adherence of both leukocytes and platelets to the endothelium increased by about sixfold and threefold, respectively. Furthermore, Kupffer cells labeled with latex beads as an index for their activation were significantly increased compared to controls. CONCLUSION This in vivo observation demonstrated traces of reperfusion injury in liver induced by the insufflation and desufflation of CO(2 )pneumoperitoneum. The clinical relevance of this finding and the issue of using hepatoprotective substances to prevent this injury should be further investigated.
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Affiliation(s)
- Arash Nickkholgh
- Department of General Surgery, Ruprecht-Karls-University, Heidelberg, Germany
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27
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Open Abdomen. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ure BM, Suempelmann R, Metzelder MM, Kuebler J. Physiological responses to endoscopic surgery in children. Semin Pediatr Surg 2007; 16:217-23. [PMID: 17933662 DOI: 10.1053/j.sempedsurg.2007.06.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The knowledge on the physiological impact of endoscopic surgery in infants and children is limited. Cardiovascular effects of pneumoperitoneum are mainly the result of an increase in intraabdominal pressure, absorption of carbon dioxide, and a stimulation of the neurohumoral vasoactive system. In infants, pneumoperitoneum alters the heart rate, mean arterial pressure, left ventricular endsystolic and end-diastolic volume, and meridional wall stress. Urine production is significantly reduced, and cerebral oxygenation and blood flow are altered. However, postoperative immune function is preserved or restored faster, and specific physiological responses to endoscopic surgery are well tolerated by otherwise healthy infants and children. The effects in children with specific conditions, such as sepsis, cancer, or organ dysfunction, remain to be investigated.
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Affiliation(s)
- Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.
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Omari A, Bani-Hani KE. Effect of carbon dioxide pneumoperitoneum on liver function following laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2007; 17:419-24. [PMID: 17705719 DOI: 10.1089/lap.2006.0160] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND It has been noted that following a laparoscopic cholecystectomy (LC), liver function parameters were disturbed. The causes of this disturbance are still controversial. PATIENTS AND METHODS The serum levels of eight parameters of liver function were measured both before and 24 hours after surgery in 142 consecutive patients who underwent LC, 23 patients who underwent open cholecystectomy (OC), and in 25 patients who underwent a conventional hernial repair. The same anesthetic protocol was applied to all patients in the various groups and in the case of LC; the intra-abdominal pressure was maintained at 12 mmHg of CO2. RESULTS Twenty-four (24) hours after surgery, there was a statistically significant change of all the eight parameters studied, except alkaline phosphatase in patients who underwent LC, whereas there were only 3 patients from the OC group who had changes of alanine aminotransferase and aspartite aminotransferase and 2 patients who had raised levels of direct bilirubin, and no changes were observed among those who had conventional hernial repair. We found that 83% of the patients showed more than a 100% increase in at least one parameter, 43% showed an increase in two or more parameters, and 23% showed an increase in three or more parameters. We also observed a significant drop of total proteins and albumin levels in all patients who had LC. CONCLUSIONS It appears that the pneumoperitoneum plays a major role in these changes. Although these changes of liver function were of no clinical relevance in healthy patients, the safety of the procedure must nonetheless be assessed in those with underlying liver diseases.
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Affiliation(s)
- Abdulkarim Omari
- Department of Surgery, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Szold A, Weinbroum AA. Carbon dioxide pneumoperitoneum-related liver injury is pressure dependent: A study in an isolated-perfused organ model. Surg Endosc 2007; 22:365-71. [PMID: 17661139 DOI: 10.1007/s00464-007-9411-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 03/13/2007] [Accepted: 03/24/2007] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disturbed liver function tests are associated with the pneumoperitoneum applied for biliary and non-biliary laparoscopic surgical procedures. The extent, duration and reversibility of such an injury are unknown. An isolated organ model was used to assess reversibility of liver injury in a CO(2)-pneumoperitoneum-like environment. METHODS Rat livers (n = 63) were isolated and perfused within a chamber pressurized at 0, 3, 5, 8, 12, 15 or 18 mmHg for 60 minutes. Pressure was annulled during the ensuing 61-90 minutes in one-half of the groups and markers of liver function were measured and recorded. RESULTS Inflow pressure level, flow rate, effluent partial O(2) and CO(2) pressures, O(2) extraction rate, lactate dehydrogenase level, lactic to pyruvic acid ratio, and total xanthine oxidase and dehydrogenase levels became abnormal, starting at 15 minutes after a pressure >5 mmHg was applied in the chamber. Signs of injury slowly reversed towards baseline values in all groups except for the 15 mmHg and 18 mmHg-pressurized ones, even after pressure had been annulled for 30 minutes. CONCLUSIONS CO(2)-pneumoperitoneum-like conditions directly injured rat liver tissue to a degree which correlated with the amount of applied pressure. Damage caused by pressure >or=15 mmHg was no longer reversible if it had been applied over a 60-minute period.
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Affiliation(s)
- Amir Szold
- Endoscopic Surgery Service, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Etoh T, Shiraishi N, Tajima M, Shiromizu A, Yasuda K, Inomata M, Kitano S. Transient Liver Dysfunction after Laparoscopic Gastrectomy for Gastric Cancer Patients. World J Surg 2007; 31:1115-20. [PMID: 17426897 DOI: 10.1007/s00268-007-0237-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The effect of laparoscopic surgery under CO2 pneumoperitoneum on liver function is not clear. The aim of this study was to clarify whether laparoscopy-assisted distal gastrectomy (LADG) is associated with changes in liver function compared with open distal gastrectomy (ODG). METHODS A total of 205 patients who underwent LADG (n = 147) or ODG (n = 58) between January 1994 and April 2004 were included in this study. Liver function tests-aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, total bilirubin-were examined before surgery and at 1, 3, and 7 days after surgery. The postoperative clinical course was compared between the two groups. RESULTS AST levels on day 1 and ALT levels on days 1 and 3 were significantly higher in the LADG group. Albumin levels showed a marked decrease after operation in both groups, but the level recovered more rapidly in the LADG group than in the ODG group, showing significant differences on days 3 and 7. The total bilirubin levels remained unchanged from baseline. The postoperative complication rate was similar in the two groups, although 3 LADG patients among the 27 patients with liver disease suffered severe enteritis. CONCLUSIONS Transient liver dysfunction was documented in patients after laparoscopic gastrectomy under CO2 pneumoperitoneum.
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Affiliation(s)
- Tsuyoshi Etoh
- Department of Surgery I, Oita University Faculty of Medicine, 1-1 Hasama-machi, Oita, 879-5593, Japan.
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Abstract
BACKGROUND Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury than the open approach. METHODS A review was performed of the English language literature on the management of bile duct injury listed on Medline databases. RESULTS AND CONCLUSION There is consensus that careful dissection and correct interpretation of the anatomy avoids the complication of bile duct injury during cholecystectomy. Routine intraoperative cholangiography is associated with a lower incidence and early recognition of bile duct injury. Early detection and repair is associated with an improved outcome, and the minimum standard of care after the recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. Surgery provides the mainstay of treatment, with proximal hepaticojejunostomy Roux en Y being the operation of choice; a selective role for endoscopic or radiological treatment exists. The outcome after bile duct injury remains poor, especially in relation to the initial expectation of the cholecystectomy. Patients are often committed to a decade of follow-up.
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Affiliation(s)
- S Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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Serum Laboratory Values Following Uncomplicated Laparoscopic Urological Surgery. J Urol 2006. [DOI: 10.1097/00005392-200601000-00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Anderson JK, Matsumoto ED, Abdel-Aziz K, Svatek R, Cadeddu JA. Serum Laboratory Values Following Uncomplicated Laparoscopic Urological Surgery. J Urol 2006; 175:167-9. [PMID: 16406899 DOI: 10.1016/s0022-5347(05)00045-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Revised: 07/08/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Presentation of complications following laparoscopic surgery can be different from corresponding open surgical complications. While leukopenia has been identified as a common finding in patients with unrecognized bowel injury following laparoscopy, to our knowledge no study has determined if leukopenia or other serum abnormalities are unique to patients with laparoscopic complications. We present an analysis of postoperative laboratory values from patients after uncomplicated urological laparoscopic surgery. MATERIALS AND METHODS A retrospective review of 50 adult patients who had previously undergone uncomplicated laparoscopic urological procedures was performed. Exclusion criteria were preexisting hematological, immune, liver or pancreatic disorders. Common serum laboratory values were measured on postoperative day 1. RESULTS All values for bilirubin were within normal limits. Of patients undergoing a right side renal procedure, 10 of 16 (63%) had a postoperative increase in liver function tests. Amylase or lipase was increased in a total of 12 (24%) patients. Patients undergoing laparoscopic prostatectomy accounted for the majority of this group with 9 of 21 (43%) patients having increased amylase or lipase. Finally, there were no patients with immediate postoperative leukopenia. CONCLUSIONS Following uncomplicated laparoscopic procedures, bilirubin levels are rarely affected, amylase and lipase may be acutely increased following laparoscopic prostatectomy, and white blood count is commonly increased. While 16 (36%) patients had postoperative leukocytosis, leukopenia was not detected after uncomplicated laparoscopic urological surgery and should alert the surgeon to the possibility of an undiagnosed complication.
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Affiliation(s)
- J Kyle Anderson
- Clinical Center for Minimally Invasive Urologic Cancer Treatment, Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Hasukić S. Postoperative changes in liver function tests: randomized comparison of low- and high-pressure laparoscopic cholecystectomy. Surg Endosc 2005; 19:1451-5. [PMID: 16206003 DOI: 10.1007/s00464-005-0061-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2005] [Accepted: 05/30/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pneumporeitoneum at 14 mmHg causes dangerous hemodynamic disturbances in some patients, leading to splanchnic ischemia. Laparoscopic cholecystectomy (LC) using low-pressure pneumoperitoneum (7 mmHg) minimizes adverse hemodynamic effects on hepatic portal blood flow and hepatic function. This study evaluated the changes in liver function tests after high-pressure LC (HPLC; 14 mmHg) and low-pressure LC (LPLC; 7 mmHg). METHODS For this study, 50 patients were randomly assigned to undergo either HPLC (n = 25) or LPLC (n = 25) Liver function tests including total bilirubin, gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were obtained preoperatively, then 24 and 48 h postoperatively. All patients had normal values on the preoperative liver function tests. The anesthesiologic protocol was uniform. RESULTS The findings showed that ALT after 24 h (LPLC: 1473.72 +/- 654.85; HPLC: 2233.74 +/- 1247.33; p = 0.0096) and 48 h (LPLC: 1322.99 +/- 601.51; HPLC 2007.80 +/- 747.55; p = 0.0008) and AST after 24 h (LPLC: 1189.96 +/- 404.79 i.j.; HPLC: 1679.40 +/- 766.13; p = 0.0069) were increased in the patients who underwent HPLC. The AST levels after 48 h were statistically unchanged from baseline in both groups. Total bilirubin, ALP, and GGT levels remained unchanged from baseline in both groups, without a significant difference between the two groups. CONCLUSIONS Because LPLC minimizes adverse hemodynamic effects on hepatic function, a low-pressure pneumoperitoneum should be considered for patients with compromised liver function, particularly those undergoing prolonged laparoscopic surgery.
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Affiliation(s)
- S Hasukić
- Department of Surgery, University Clinical Center Tuzla, Faculty of Medicine, University of Tuzla, Trnovac b.b, 75,000, Tuzla, Bosnia-Herzegovina
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Gómez Quiles L, Pérez Ruiz L, Ros López S, Mías Carballal C. [Liver enzymes levels after laparoscopic cholecystectomy]. Med Clin (Barc) 2005; 125:356. [PMID: 16185638 DOI: 10.1157/13078779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Hasukic S, Kosuta D, Muminhodzic K. Comparison of postoperative hepatic function between laparoscopic and open cholecystectomy. Med Princ Pract 2005; 14:147-50. [PMID: 15863986 DOI: 10.1159/000084630] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Accepted: 07/28/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE In this prospective study, we evaluated the effects of pneumoperitoneum on hepatic function during laparoscopic (LC) and open cholecystectomy (OC). SUBJECTS AND METHODS One hundred patients who underwent LC (n = 50) or OC (n = 50) were included in the study. The groups were similar in age, sex, weight and height. Following liver function tests (total bilirubin; gamma-glutamyltransferase, GGT; alkaline phosphatase, ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) were obtained preoperatively and at 24 and 48 h postoperatively. Similar anesthesiologic protocol was used for both LC and OC. During LC, the intra-abdominal pressure was maintained within the conventional range of 12-14 mm Hg. RESULTS Total bilirubin, ALP, GGT and LDH levels remained unchanged from baseline in both groups without significant difference between them. A higher number of patients had increased values of ALT (26/50 vs. 5/50) and AST (23/50 vs. 6/50) in LC compared to OC group. Although the difference was statistically significant (p < 0.000 for ALT and p = 0.0004 for AST) the increased level decreased at 48 compared to 24 h. CONCLUSION The results indicate that LC is associated with transient elevation of ALT and AST. The disturbances in the function of the liver after LC are self-limited and not associated with any morbidity in patients with a normal liver function.
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Affiliation(s)
- Sefik Hasukic
- Department of Surgery, University Clinical Center, Faculty of Medicine, University of Tuzla, Tuzla, Bosnia-Herzegovina.
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Meierhenrich R, Gauss A, Vandenesch P, Georgieff M, Poch B, Schütz W. The Effects of Intraabdominally Insufflated Carbon Dioxide on Hepatic Blood Flow During Laparoscopic Surgery Assessed by Transesophageal Echocardiography. Anesth Analg 2005; 100:340-347. [PMID: 15673853 DOI: 10.1213/01.ane.0000143566.60213.0a] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Conflicting results have been published about the effects of carbon dioxide (CO(2)) pneumoperitoneum on splanchnic and liver perfusion. Several experimental studies described a pressure-related reduction in hepatic blood flow, whereas other investigators reported an increase as long as the intraabdominal pressure (IAP) remained less than 16 mm Hg. Our goal in the present study was to investigate the effects of insufflated CO(2) on hepatic blood flow during laparoscopic surgery in healthy adults. Blood flow in the right and middle hepatic veins was assessed in 24 patients undergoing laparoscopic surgery by use of transesophageal Doppler echocardiography. Hepatic venous blood flow was recorded before and after 5, 10, 20, 30, and 40 min of pneumoperitoneum, as well as 1 and 5 min after deflation. Twelve patients undergoing conventional hernia repair served as the control group. The induction of pneumoperitoneum produced a significant increase in blood flow of the right and middle hepatic veins. Five minutes after insufflation of CO(2) the median right hepatic blood flow index increased from 196 mL/min/m(2) (95% confidence interval (CI), 140-261 mL/min/m(2)) to 392 mL/min/m(2) (CI, 263-551 mL/min/m(2)) (P < 0.05) and persisted during maintenance of pneumoperitoneum. In the middle hepatic vein the blood flow index increased from 105 mL/min/m(2) (CI, 71-136 mL/min/m(2)) to 159 mL/min/m(2) (CI, 103-236 mL/min/m(2)) 20 min after insufflation of CO(2). After deflation blood flow returned to baseline values in both hepatic veins. Conversely, in the control group hepatic blood flow remained unchanged over the entire study period. We conclude that induction of CO(2) pneumoperitoneum with an IAP of 12 mm Hg is associated with an increase in hepatic perfusion in healthy adults.
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Affiliation(s)
- Rainer Meierhenrich
- Departments of Anesthesiology and *General Surgery, University of Ulm, Germany
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Ali NA, Eubanks WS, Stamler JS, Gow AJ, Lagoo-Deenadayalan SA, Villegas L, El-Moalem HE, Reynolds JD. A method to attenuate pneumoperitoneum-induced reductions in splanchnic blood flow. Ann Surg 2005; 241:256-61. [PMID: 15650635 PMCID: PMC1356910 DOI: 10.1097/01.sla.0000153034.54128.5e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if increasing nitric oxide bioactivity by inclusion of ethyl nitrite (ENO) in the insufflation admixture would attenuate pneumoperitoneum-induced decreases in splanchnic perfusion. SUMMARY BACKGROUND DATA Organ blood flow is reduced during pneumoperitoneum and can contribute to laparoscopy-associated morbidity and mortality. Previous attempts to control such decreases in flow have been ineffective. METHODS Laser-Doppler flow probes were placed on the liver and right kidney of anesthetized pigs. After a baseline recording period, animals were insufflated to a final intraperitoneal pressure of 15 mm Hg. Group one received CO2 (standard practice), whereas group 2 received CO2 plus 100 ppm ENO. Insufflation was maintained for 60 minutes and then the abdomen was manually deflated; monitoring was continued for another 60 minutes. RESULTS CO2 insufflation (n = 5) cut liver blood flow in half; liver flow remained at this level throughout the postinsufflation period. Inclusion of 100 ppm ENO (n = 6) attenuated both the acute and prolonged blood flow decreases. Statistical modeling of the data showed that, on average, liver blood flow was 14.3 U/min higher in the ENO pigs compared with the CO2 group (P = 0.0454). In contrast, neither treatment significantly altered kidney blood flow (P = 0.6215). CONCLUSION The data indicate that ENO can effectively attenuate pneumoperitoneum-induced blood flow decreases within the peritoneal cavity. The result suggests a novel therapeutic method of regulating hemodynamic changes during laparoscopic procedures.
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Affiliation(s)
- Nishath Athar Ali
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Gutt CN, Oniu T, Mehrabi A, Schemmer P, Kashfi A, Kraus T, Büchler MW. Circulatory and respiratory complications of carbon dioxide insufflation. Dig Surg 2004; 21:95-105. [PMID: 15010588 DOI: 10.1159/000077038] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although providing excellent outcome results, laparoscopy also induces particular pathophysiological changes in response to pneumoperitoneum. Knowledge of the pathophysiology of a CO(2) pneumoperitoneum can help minimize complications while profiting from the benefits of laparoscopic surgery without concerns about its safety. METHODS A review of articles on the pathophysiological changes and complications of carbon dioxide pneumoperitoneum as well as prevention and treatment of these complications was performed using the Medline database. RESULTS The main pathophysiological changes during CO(2) pneumoperitoneum refer to the cardiovascular system and are mainly correlated with the amount of intra-abdominal pressure in combination with the patient's position on the operating table. These changes are well tolerated even in older and more debilitated patients, and except for a slight increase in the incidence of cardiac arrhythmias, no other significant cardiovascular complications occur. Although there are important pulmonary pathophysiological changes, hypercarbia, hypoxemia and barotraumas, they would develop rarely since effective ventilation monitoring and techniques are applied. The alteration in splanchnic perfusion is proportional with the increase in intra-abdominal pressure and duration of pneumoperitoneum. CONCLUSION A moderate-to-low intra-abdominal pressure (<12 mm Hg) can help limit the extent of the pathophysiological changes since consecutive organ dysfunctions are minimal, transient and do not influence the outcome.
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Affiliation(s)
- C N Gutt
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany.
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Tan M, Xu FF, Peng JS, Li DM, Chen LH, Lv BJ, Zhao ZX, Huang C, Zheng CX. Changes in the level of serum liver enzymes after laparoscopic surgery. World J Gastroenterol 2003; 9:364-7. [PMID: 12532468 PMCID: PMC4611348 DOI: 10.3748/wjg.v9.i2.364] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: The purpose of this study was to investigate the effect of laparoscopic surgery on liver function in humans and the possible mechanisms behind such effect.
METHODS: Blood samples from 286 patients who underwent laparoscopic cholecystectomy (LC) and 40 patients who underwent open cholecystectomy (OC) were tested for liver function by measuring the level of serum alanine aminotrasferase (ALT) and aspartate aminotrasferase (AST) before and after the operations. The same tests were also applied to 18 laparoscopic colorectal cancer resection (LCR) patients and 23 open colorectal cancer resection (OCR) patients to determine whether CO2 pneumoperitoneum could alter the serum liver enzymes.
RESULTS: The level of serum ALT and AST increased significantly during the first 48 h post operations in both LC and LCR patients. However, no significant change of the serum liver enzymes was detected in both OC and OCR patients. As a result, there was statistically significant difference in change of both ALT and AST levels between LC and OC patients and LCR and OCR patients, respectively. By the 7th day post operation, the level of both enzymes returned to normal values in LC, OC and OCR patients except LCR patients whose enzymes remained at a higher level.
CONCLUSION: Transient elevation of hepatic transaminases occurred after laparoscopic surgery. The major causative factor seemed to be the CO2 pneumoperitoneum. In most of the laparoscopic surgery patients, the transient elevation of serum liver enzymes showed no apparent clinical implications. However, if preoperative liver function was very poor, laparoscopic surgery may not be the best choice for the treatment of patients with certain abdominal diseases.
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Affiliation(s)
- Min Tan
- Department of General Surgery, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2 Road, Guangzhou 510080, Guangdong Province China.
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Al-Jaberi TM, Tolba MF, Dwaba M, Hafiz M. Liver function disturbances following laparoscopic cholecystectomy: incidence and significance. J Laparoendosc Adv Surg Tech A 2002; 12:407-10. [PMID: 12590720 DOI: 10.1089/109264202762252668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Unexplained disturbances of liver function parameters after laparoscopic cholecystectomy have been reported in a few previous studies. We aimed to assess the incidence of these disturbances, and their relation to age, sex, duration of surgery, and type of gallbladder inflammation, as well as their clinical significance. PATIENTS AND METHODS All patients undergoing laparoscopic cholecystectomy at Dallah Hospital, Riyadh, Saudi Arabia, during the year 2001 were prospectively evaluated. In all the patients, six parameters of liver function (direct bilirubin, indirect bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients with suspected chronic liver disease or common bile duct pathology were excluded. Patients who showed more than a 100% increase in at least one parameter (group I) were compared with those who did not (group II) regarding age, sex, duration of surgery, and type of gallbladder inflammation. RESULTS Of the patients, 67.1% showed more than a 100% increase in at least one parameter of liver function. No significant difference was noticed between the two groups regarding age, duration of surgery, or type of gallbladder inflammation. Female patients, however, showed a significantly higher incidence of liver function changes (P = .011). No clinical adverse reactions were reported in those who showed liver function changes. CONCLUSION Changes in liver function parameters after laparoscopic cholecystectomy are common, carrying no clinical sequalae. They are more common in female patients and are not related to age, duration of surgery, or the acuteness of gallbladder inflammation. Assessment of direct bilirubin and alkaline phosphatase is sufficient for the routine evaluation of these patients postoperatively.
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Affiliation(s)
- Tareq M Al-Jaberi
- Department of General Surgery, Dallah Hospital, Riyadh, Kingdom of Saudi Arabia.
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Richter S, Olinger A, Hildebrandt U, Menger MD, Vollmar B. Loss of physiologic hepatic blood flow control ("hepatic arterial buffer response") during CO2-pneumoperitoneum in the rat. Anesth Analg 2001; 93:872-7. [PMID: 11574348 DOI: 10.1097/00000539-200110000-00014] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
UNLABELLED We analyzed whether a compensatory increase of hepatic arterial (HA) flow, known as the "hepatic arterial buffer response" (HABR), may serve for maintenance of liver blood supply during laparoscopy-associated portal venous (PV) flow reduction. We assessed HA and PV flow, as well as hepatic tissue oxygenation (PO2) during CO2-pneumoperitoneum in anesthetized and mechanically ventilated Sprague-Dawley rats (n = 7). Control animals (n = 7) without pneumoperitoneum, but tourniquet-induced PV flow reduction served to demonstrate physiologic HABR. Although stepwise tourniquet-induced reduction of PV flow to 20% of baseline values led to a significant (P < 0.05) increase of HA flow from 4.3 +/- 0.7 mL/min to 9.9 +/- 1.7 mL/min, stepwise intraabdominal pressure-induced decrease of PV flow was paralleled by a linear reduction of HA flow from 2.4 +/- 0.3 mL/min to 1.2 +/- 0.5 mL/min at 18 mm Hg intraabdominal pressure. This loss of HABR was sustained during a subsequent 2 h-period of CO2-pneumoperitoneum contrasting the 2 h of maintenance of HABR in controls. Hepatic tissue PO2 decreased during the 2 h-period of pressure- and tourniquet-induced PV flow reduction by 35% to 51%, respectively. On tourniquet release, all variables regained baseline values, whereas evacuation of the pneumoperitoneum allowed all variables except hepatic PO2 to return to baseline, indicating prolonged tissue hypoxia despite restored total liver blood flow in the Laparoscopic group. Concomitantly, increased liver enzyme activities reflected moderate tissue damage after 2 h of pneumoperitoneum. In conclusion, intraabdominal CO2-insufflation-induced hemodynamic alterations may impair tissue oxygenation and enzyme release, indicating the potential risk for hepatic tissue damage after prolonged periods of laparoscopic interventions. IMPLICATIONS We investigated the effect of CO2-pneumoperitoneum on liver blood flow, hepatic tissue oxygenation (PO2) and liver enzyme release. CO2-insufflation reduces portal venous flow without a compensatory increase of hepatic arterial flow ("hepatic arterial buffer response"), resulting in reduced hepatic PO2 and increased ratios of serum alanine aminotransferase to serum aspartate aminotransferase.
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Affiliation(s)
- S Richter
- Institute for Clinical & Experimental Surgery, University of Saarland, D-66421 Homburg/Saar, Germany
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