Evaluation of liver enzymes following elective laparoscopic cholecystectomy: are they really elevated?

The effect and clinical significance of using nathanson liver retractor on liver function tests in laparoscopic gastric cancer surgery

ABSTRACT Aim: There are very few studies in the literature investigating the changes caused by the Nathanson retractors in liver function tests (LFT) after LG and its clinical significance. The present study investigated the changes made by the Nathanson retractor used during LG on LFT and its clinical significance. Material and Method: The data of 236 patients, who underwent radical gastrectomy for primary gastric cancer at Surgical Oncology Unit in the period between January 2015 and January 2020 were retrospective studied. The patients were divided into two groups: laparoscopic gastrectomy (LG; 136 cases) and open gastrectomy (OG; 106 cases). Patients who have undergone cholecystectomy, with primary or secondary liver tumors, with chronic hepatic disease, who have preoperative high ALT, AST and bilirubin values were excluded from the study. LFT were measured preoperatively and postoperative day 1 (LFT1), LFT3, LFT5 and LFT7. LFT: ALT, AST and Total bilirubin (BIL). Results: ALT1, ALT3, ALT5, ALT7 ALT values and AST1, AST3, AST5 AST values of the patients in the LG group were found to be significantly higher (P <0.001). Mean total bilirubin values of the groups were similar (P >0.05). In order to evaluate how the increase in LFT due to the use of the Nathanson retractors reflected on the patients' clinic, we divided the patients who underwent LG into two groups based on ALT increase in ALT1: Normal and Elevated. The in-hospital mortality rates (P = 0.080) and oral nutrition time (P = 0.913) of the groups were similar. No liver infarction developed in any of the groups. The duration of stay in the ICU was significantly longer in individuals with elevated LFT (P = 0.019). Conclusion: Although the use of the Nathanson retractor during LG causes an increase in liver function tests, this does not cause major clinical problems in patients. Key Words: Gastrectomy; gastric cancer; laparoscopy; liver enzymes; liver dysfunciton

Utility of routine blood tests after elective laparoscopic cholecystectomy for symptomatic gallstones

AIM

To evaluate the value of blood testing after elective laparoscopic cholecystectomy and its association with procedure related complications.

METHODS

Charts of all patients undergoing elective laparoscopic cholecystectomy from January 2013 through December 2014 were reviewed retrospectively for demographics, indication for surgery, operative course and outcome. In our institution the decision to perform postoperative blood analysis is left for the discretion of the surgeon, therefore we had the possibility to compare the results of those who had blood analyses results to those who did not. Analysis was performed to identify variables associated with the decision to perform postoperative blood tests. Subsequently a univariate and multivariate analyses was performed comparing the two cohorts. Secondary subgroup analysis was performed to identify factors associated with procedure related complications.

RESULTS

Five hundred and thirty-two elective laparoscopic cholecystectomies for symptomatic gallstones were performed during the study period. Sixty-four percent of the patients (n = 340) had blood tests taken post operatively. Patients that had laboratory tests taken were older (P = 0.006, OR = 1.01), had longer surgery (P < 0.001, OR = 3.22) had more drains placed (P < 0.001, OR = 3.2) and stayed longer in the hospital (P < 0.001, OR = 1.2). A subgroup analysis of the patients who experienced complications revealed longer stay in the hospital (P < 0.001), higher body mass index (BMI) (P = 0.04, OR = 1.08), increased rates of drain placement (P = 0.006, OR = 3.1) and higher conversion rates (P = 0.01, OR = 14.6). Postoperative blood tests withdrawals were not associated with complications (P = 0.44). On Multivariate analysis BMI and drain placement were independently associated with complications.

CONCLUSION

The current study indicate that routine postoperative blood tests after elective laparoscopic cholecystectomy for symptomatic gallstones does not predict complications and may have an added benefit in diagnosis and management of cases were the surgeon encountered true technical difficulty during surgery.

Laparoscopic Splenectomy for the Elderly Liver Cirrhotic Patients With Hypersplenism: A Retrospective Comparable Study

A growing body of evidence has supported the benefits of laparoscopic splenectomy (LS) for hypersplenism due to liver cirrhosis. With the increased proportion of elderly persons worldwide, it is necessary to investigate the risks and benefits of LS in elderly liver cirrhotic patients.From September 2003 to March 2012, LS and open splenectomy (OS) were performed for 21 (Group 1) and 19 (Group 3) patients, respectively, all of whom were 65 years of age and older; in addition, 39 patients who were <65 years old were treated with LS and referred to as Group 2. Data (i.e., demographic characteristics and preoperative, intraoperative, and postoperative information) were retrospectively collected. Between-group comparisons were performed for the above-mentioned data.Compared with the patients in Group 3, the patients in Group 1 required longer operative times, fewer transfusions, less intensive care, a shorter postoperative course, and a shorter time to the first oral intake, and they had less blood loss and fewer postoperative short-term complications. During the follow-up period, compared with the preoperative status, significant changes in hemoglobin, leukocyte, platelet, and albumin levels were observed in all groups, whereas changes in the total BILirubin (BIL), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels were inconspicuous.Patients >65 years of age with hypersplenism caused by liver cirrhosis can safely undergo LS.

Prevention of transient liver damage after laparoscopic gastrectomy via modification of the liver retraction technique using the Nathanson liver retractor

INTRODUCTION

Although laparoscopic radical gastrectomy has several advantages over conventional surgery, postoperative liver dysfunction is an unwanted complication. The major cause is considered to be use of mechanical liver retraction. To prevent liver damage after laparoscopic gastrectomy, we modified the liver retraction method: the retractor was used only after lymph node dissection along the greater curvature had been completed, and it was released before reconstruction and intermittent repositioning to avoid discoloration of the liver parenchyma. This study sought to determine whether postoperative liver dysfunction could be prevented by making these simple modifications.

METHODS

In this retrospective study involving 114 laparoscopic gastrectomy patients, postoperative serum aspartate aminotransferase, alanine aminotransferase (ALT), and total bilirubin levels were compared between laparoscopic gastrectomy patients who had undergone the modified procedure and those who had not. Discoloration of the liver was classified into three groups just before the retractor was released at the end of surgery.

RESULTS

Aspartate aminotransferase and ALT levels on postoperative days 1 and 2 and the proportion of patients with elevated aspartate aminotransferase or ALT levels on postoperative day 1 were significantly lower after the modifications. ALT level on postoperative day 1 was significantly higher in the subgroup with broad liver discoloration.

CONCLUSIONS

Reducing the duration of liver retraction and moving the position of the retractor or releasing it intermittently before discoloration of the liver parenchyma may be effective for preventing postoperative liver damage.

Effect of contrast injection into the biliary tract during intraoperative cholangiogram on postoperative liver function tests

INTRODUCTION

Postoperative abnormal liver function tests (LFT) following laparoscopic cholecystectomy (LC) could present a substantial clinical dilemma due to suspicion of missed choledocholithiasis or more serious complications such as bile duct injury. We noted that LFT were more likely to be abnormal when an intraoperative cholangiogram (IOC) had been performed. This study aims to examine if contrast injection into the biliary tract during IOC is associated with deranged LFT.

METHODS

Data on all LC performed in a tertiary referral hospital network over a period of 30 months were collected retrospectively, and two groups were identified depending on successful performance of an IOC. Identical inclusion and exclusion criteria were applied to both groups to identify eligible patients. Alkaline phosphatase, gamma-glutamyl transferase (GGT), alanine transaminase (ALT), and bilirubin levels were recorded, and the mean difference between preoperative and postoperative values was analyzed.

RESULTS

There were 177 eligible patients: 147 patients in the LC with IOC test group (IOC group) and 30 patients in the LC without IOC control group (NO IOC group). Demographics and preoperative mean LFT were not significantly different between groups. In the IOC group, the mean ALT difference (43 ± 57, P =< 0.001) and GGT difference (34 ± 66, P =< 0.001) were significantly higher than in the NO IOC group (ALT [19 ± 25], GGT [7 ± 20]). The mean alkaline phosphatase difference (IOC [9 ± 47], NO IOC [-2 ± 14], P = 0.214) and mean bilirubin difference (IOC [-2 ± 9], NO IOC [-1 ± 8], P = 0.911) were not significantly different.

CONCLUSION

The performance of an IOC is associated with elevated GGT and ALT but does not affect alkaline phosphatase and bilirubin concentrations.

Association between duration of carbon dioxide pneumoperitoneum during laparoscopic abdominal surgery and hepatic injury: a meta-analysis

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.

Consecutive laparoscopic gallbladder and spleen resections in cirrhotic patients

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.

Long-term postoperative outcomes of hypersplenism: laparoscopic versus open splenectomy secondary to liver cirrhosis

BACKGROUND

Hypersplenism is a common clinical manifestation in patients with liver cirrhosis. For treatment, surgeons can choose between two options: open splenectomy (OS) or laparoscopic splenectomy (LS). Although splenectomy has wide exposure and acceptance as a remedy for the patients with hypersplenism secondary to liver cirrhosis, the data are sparse with regard to its long-term outcomes, including hematologic response and liver function after the surgery. This study aimed to determine the long-term effect of OS versus LS for cirrhotic patients with hypersplenism.

METHODS

Between September 2003 and June 2011, the study enrolled 63 consecutive patients with hypersplenism secondary to liver cirrhosis who were treated with LS (n = 34) or OS (n = 29). The hematologic parameters and liver function in both groups were evaluated before and after splenectomy, and a comparative study of the long-term follow-up period was conducted.

RESULTS

Postoperatively, 100% of the patients in both groups had a complete response in terms of platelet and leukocyte counts. No changes in liver function were noted. The LS group benefited from less intraoperative blood loss and a shorter postoperative hospital stay than the OS group experienced. The mean follow-up period was 25 months. To date, no death has been reported in either group. All the patients showed complete or partial hematologic response to splenectomy and exhibited improvement in liver function. None of the parameters differed significantly between the two groups. Portal or splenic vein thromboses were detected in three patients (2 in OS and 1 in LS), whereas esophageal variceal bleeding occurred for one patient in the LS group and one patient in the OS group.

CONCLUSION

This study investigated patients with hypersplenism secondary to liver cirrhosis. The findings showed that LS can be considered a well-disposed surgical procedure with good surgical outcomes compared with OS.

Routine testing of liver function before and after elective laparoscopic cholecystectomy: is it necessary?

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.

Comparison of liver function after laparoscopically assisted and open distal gastrectomies for patients with liver disease

Background

Several studies have suggested that carbon dioxide (CO₂) pneumoperitoneum may have an effect on liver function. This study aimed to compare liver function after laparoscopically assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) for patients with liver disease.

Methods

Between January 2006 and December 2007, the study enrolled 50 patients with EGC and liver disease including 18 liver cirrhosis patients, 3 fatty liver patients (n = 3), and 29 healthy hepatitis B or C virus carriers. Albumin, total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase levels as well as the volume of drainage in the LADG (n = 18) and ODG (n = 32) groups were determined to assess liver function.

Results

The albumin level on postoperative day 7 was significantly higher in the LADG group (3.5 mg/dl) than in the ODG group (3.1 mg/dl; p = 0.042), and the volume of drainage on postoperative day 2 was significantly lower in the LADG group (154.3 ml) than in the ODG group (403.1 ml; p = 0.013). Diuretics were needed by three patients (16.7%) in the LADG group and six patients (18.7%) in the ODG group for control of ascites (p = 0.587). For the patients with liver cirrhosis, none of the parameters between the two groups were significantly different.

Conclusion

For gastric cancer patients with chronic liver disease, LADG can be considered a safe surgical procedure showing surgical outcomes comparable with those for ODG.

Liver function alterations after laparoscopy-assisted gastrectomy for gastric cancer and its clinical significance

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.