Effects of carbon dioxide pneumoperitoneum on hepatic function in obstructive jaundice: an experimental study in a rat model

Evaluation of Liver Function Tests and Serum Bilirubin Levels After Laparoscopic Cholecystectomy

Introduction

Laparoscopic cholecystectomy has been known as one of the most important prevalent and minimally invasive surgeries in medicine.

Aim

The aim here was to investigate the changes in liver enzymes and bilirubin levels after laparoscopic cholecystectomy in patients diagnosed with chronic cholecystitis.

Methods

This cross-sectional study was conducted at Poursina Hospital (Rasht, Iran) and 128 patients who met both inclusion and exclusion criteria were enrolled for further investigations. After collecting the patients' bio-demographic information, levels of serum alkaline phosphatase, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and bilirubin were checked before laparoscopic cholecystectomy and 24 (post-op 1) and 48 (post-op 2) h after laparoscopic cholecystectomy.

Results

No significant difference was found in the serum levels of ALP in post-op 1 and 2 compared both to each other and to the baseline (P>0.05). Regarding AST and ALT, there was a significant increase in post-op 1 and 2 compared to their baseline values (P<0.05). However, the difference between post-op 1 and post-op 2 was not significant for these outcomes. Compared to baseline levels, LDH had a significant increase after post-op 2 (P=0.001); but not after post-op 1 (P >0.05). Moreover, total bilirubin levels showed significant increases at post-op 1 and post-op 2 from the baseline and also in comparison with each other (P < 0.05).

Conclusion

Our results demonstrated a transient increase in liver function tests and bilirubin after laparoscopic cholecystectomy.

Impact of Pneumoperitoneum on the Development of Acute Kidney Injury: Comparison Between Normal and Diabetic Rats

BACKGROUND

Minimally invasive surgery is considered the gold-standard approach for many surgical procedures. However, it requires CO2 insufflation and elevated intra-abdominal pressure (IAP), which may result in adverse pulmonary, cardiovascular, gastrointestinal, and renal changes. The kidneys are highly sensitive to pressure changes, where risk factors such as severe infection, dehydration, older age, and chronic kidney disease may aggravate the likelihood for the development of acute kidney injury (AKI). Unfortunately, the impact of diabetes mellitus on the deleterious effects of elevated IAP-induced AKI was not fully studied so far. The present study was designed to examine the effect of pneumoperitoneum on renal function and the development of AKI in diabetic rats.

MATERIALS AND METHODS

Sprague Dawley rats were divided into 2 groups: control (nondiabetic) rats (n=7) and diabetic rats (n=10). A Veress needle was introduced through the supravesical incision where inflating CO2 allowing the IAP to be increased to the desired pressures 7, 10, and 14 mm Hg for 45 minutes each and at the end of the experiment, the pressure was deflated to zero. During each pressure point, hemodynamic parameters were recorded and urine and blood samples were collected for analysis.

RESULTS

The baseline values of renal hemodynamic were significantly lower in diabetic rats. There were no major statistically significant changes from baseline in urinary flow, urinary sodium excretion (UNaV), glomerular filtration rate, and renal plasma flow during 7 mm Hg pressure in both groups. When the IAP was further elevated, a significant deterioration of these parameters was recorded. This trend was more pronounced among diabetic rats. When examining urinary neutrophil gelatinase-associated lipocalin, a linear correlation was observed between the IAP and the biomarker level. This correlation was more significant in the diabetic group.

CONCLUSION

The present study demonstrated a direct correlation between IAP elevation and the development of AKI. Diabetic rats were more sensitive to the deleterious effect of pneumoperitoneum, where urinary neutrophil gelatinase-associated lipocalin levels may be used as a future biomarker to predict postoperative AKI, especially in patients with diabetes.

Deleterious Effects of Increased Intra-Abdominal Pressure on Kidney Function

Elevated intra-abdominal pressure (IAP) occurs in many clinical settings, including sepsis, severe acute pancreatitis, acute decompensated heart failure, hepatorenal syndrome, resuscitation with large volume, mechanical ventilation with high intrathoracic pressure, major burns, and acidosis. Although increased IAP affects several vital organs, the kidney is very susceptible to the adverse effects of elevated IAP. Kidney dysfunction is among the earliest physiological consequences of increased IAP. In the last two decades, laparoscopic surgery is rapidly replacing the open approach in many areas of surgery. Although it is superior at many aspects, laparoscopic surgery involves elevation of IAP, due to abdominal insufflation with carbonic dioxide (pneumoperitoneum). The latter has been shown to cause several deleterious effects where the most recognized one is impairment of kidney function as expressed by oliguria and reduced glomerular filtration rate (GFR) and renal blood flow (RBF). Despite much research in this field, the systemic physiologic consequences of elevated IAP of various etiologies and the mechanisms underlying its adverse effects on kidney excretory function and renal hemodynamics are not fully understood. The current review summarizes the reported adverse renal effects of increased IAP in edematous clinical settings and during laparoscopic surgery. In addition, it provides new insights into potential mechanisms underlying this phenomenon and therapeutic approaches to encounter renal complications of elevated IAP.

Acute obstructive jaundice and chronic cirrhosis protect against the adverse renal effects of pneumoperitoneum: role of nitric oxide

BACKGROUND

Obstructive jaundice and cirrhosis are associated with impaired renal function. Previously we demonstrated that increased intra-abdominal pressure (IAP, pneumoperitoneum) in normal rats induced renal dysfunction. This study investigated the renal effects of pneumoperitoneum in rats with acute jaundice and cirrhotic rats.

METHODS

Following a baseline period, rats with obstructive jaundice or cirrhosis induced by acute or chronic bile duct ligation (BDL), respectively, and their sham-controls were subjected to consecutive IAPs of 10 and 14 mmHg for 45 min each. Urine flow (V), Na(+) excretion (UNaV), glomerular filtration rate (GFR), renal plasma flow (RPF), and urinary NO metabolites ([Formula: see text]) and cGMP (UcGMP) were determined.

RESULTS

Elevating IAP from 0 to 10 and 14 mmHg in normal rats caused IAP-dependent reductions in V, UNaV, GFR, RPF, [Formula: see text] and UcGMP. Basal renal function and hemodynamics were lower in rats with obstructive jaundice. In contrast to normal rats, application of elevated IAP of 10 and 14 mmHg significantly improved V, UNaV, GFR, RPF, and MAP along with increased [Formula: see text] and preserved UcGMP. Similarly, when identical IAP conditions were applied to cirrhotic rats, no deleterious changes in V, UNaV, GFR or RPF were observed.

CONCLUSIONS

Application of pneumoperitoneum to rats with acute BDL improves kidney function and renal hemodynamics. Likewise, increased IAP does not exert adverse renal effects in cirrhotic rats. These effects are distinct from the deleterious renal consequences of increased IAP in normal rats. Perturbations in the generation of NO/cGMP during IAP in normal rats but not in rats with BDL or cirrhosis may contribute to these differences.

Evaluation of rat models of acute and chronic obstructive jaundice

AIM: To develop rat models of acute and chronic obstructive jaundice and to evaluate the extent to which they mimic features of clinical diseases.

METHODS: Ninety Sprague-Dawley rats were randomly and equally divided into three groups: acute obstructive jaundice group, chronic obstructive jaundice group, and control group. Each group was further divided into five subgroups for testing at different time points. Liver function was determined and the diameter of the common bile duct was measured under a microscope at weeks 1, 2, 3, 4, and 5 after model induction. Pathological changes in liver tissue were also observed by microscope. Choledochoduodenostomy was performed at week 4.

RESULTS: Jaundice progressively worsened in rats with acute obstructive jaundice, and TBIL increased from 84.86 μmol/L ± 49.09 μmol/L at week 1 to 749.38 μmol/L ± 38.99 μmol/L at week 4. Meanwhile, the diameter of the common bile duct diameter increased from 0.35 cm ± 0.15 cm to 1.50 cm ± 0.30 cm, and obvious degeneration, necrosis and hyperplasia of liver cells were observed. Jaundice was obviously improved after choledochoduodenostomy (TBIL: 153.93 μmol/L ± 57.36 μmol/L; diameter of the common bile duct: 0.40 cm ± 0.20 cm). Jaundice was mild in rats with chronic obstructive jaundice, and TBIL decreased from 42.43 μmol/L ± 23.56 μmol/L at week 1 to 36.52 μmol/L ± 16.28 μmol/L at week 4. Meanwhile, the diameter of the common bile duct increased from 0.20 cm ± 0.15 cm to 0.30 cm ± 0.10 cm, and obvious degeneration and hyperplasia of liver cells were noted. Jaundice slowly subsided after choledochoduodenostomy (TBIL: 32.15 μmol/L ± 13.20 μmol/L; diameter of the common bile duct: 0.15 cm ± 0.10 cm). Total bilirubin and the diameter of the common bile duct differed significantly at different time points between rats with acute and chronic obstructive jaundice (both P < 0.05).

CONCLUSION: Rat models of acute and chronic obstructive jaundice have been successfully established. There were significantly different manifestations between rats with chronic and acute obstructive jaundice.