Modifications of Renal Blood Flow and Serum Interleukin Levels Induced by Laparoscopic and Open Living Donor Nephrectomies For Kidney Transplant: An Experimental Study in Pigs

Noosa, 2 years later… a critical analysis of recent literature

INTRODUCTION

Since the second World Congress on the Abdominal Compartment Syndrome (WCACS) in Noosa 2 years ago, interest and publications on intra-abdominal hypertension (IAH) and ACS have increased exponentially. This paper aimed to critically review recent publications and put this new data into the context of already acquired knowledge concerning IAH/ACS.

METHODS

A Medline and PubMed search was performed from January 2005 up to now using "intra-abdominal pressure (IAP)", "intra-abdominal hypertension (IAH)", "abdominal compartment syndrome (ACS)" and "decompressive laparotomy" as search items.

RESULTS

Although consensus definitions of IAH/ACS have been formulated recently, data on awareness are still disconcerting. Several groups refined current IAP measurement techniques and tested new direct IAP measurement devices for use in selected subpopulations. A series of recent publications identified specific patient subpopulations in IAH/ACS, like patients with burns or severe acute pancreatitis, with their specific pathophysiology and therapy. Although many studies already assessed the effect of elevated IAP on regional and micro-circulatory organ perfusion, a number of new publications attempted to unravel the link between elevated IAP and more "downstream" organ function or histology. Finally, therapy for IAH/ACS still reveals more questions than it answers. Global resuscitation does not necessarily equate with organ resuscitation. In fact, fluid-resuscitation may even induce IAH/ACS.

CONCLUSIONS

After publication of consensus guidelines on IAH/ACS, there is an urgent need for human intervention studies and, in parallel, clinically relevant animal models. Given moderately low incidence of ACS and the complex and interrelated pathologies of the critically ill patient with IAH/ACS, large animal models of pathology-induced IAH/ACS might create the opportunity to gain clinically relevant knowledge on the treatment of IAH/ACS.

Laparoscopic donor nephrectomy: an increasingly common cause for testicular pain and swelling

INTRODUCTION

Laparoscopic donor nephrectomy (LDN) is now a well established method for kidney procurement from living donors. In our centre, LDN is currently offered only to donors suitable for a left nephrectomy. The aim of this study was to investigate the incidence of testicular pain and swelling following LDN.

METHODS

A total of 25 left-sided LDN male patients were assessed in a prospective structured interview together with a control cohort of 25 male patients who had undergone left-sided open donor nephrectomy (ODN).

RESULTS

Data were collected on testicular pain, swelling, numbness, urinary symptoms and sexual dysfunction from all 50 patients (100% response rate). Of the 25 LDN patients, 11 (44%) experienced ipsilateral testicular pain and/or swelling. In most instances, pain was of immediate onset, mild to moderate in severity, lasted for a few days to several weeks and was associated with testicular swelling (10 of 11 cases). However, testicular pain and/or swelling were not apparent in ODN patients, with only 2 of 25 (8%) experiencing mild testicular pain, 1 of whom also had swelling.

CONCLUSIONS

Testicular pain and swelling following LDN is a common problem. It is underreported in the literature and should be included in the differential diagnoses of testicular pain and swelling. Further investigation is required to confirm our findings.

Systemic immunologic and inflammatory response after laparoscopic versus open nephrectomy: a prospective cohort trial

PURPOSE

To compare the dynamics of systemic inflammatory indices during laparoscopic nephrectomy (LN) and standard open donor nephrectomy.

PATIENTS AND METHODS

Participants in this cohort study were 54 adults without a history of renal surgery and no evidence of urinary tract infection who underwent transperitoneal LN (n=29) and open donor nephrectomy (n=25, control group). We recorded demographic characteristics, intraoperative parameters, and changes 24 hours postoperatively in systemic inflammatory and immunologic values (body temperature, concentrations of white blood cell count [WBC], C-reactive protein [CRP], interleukin [IL]-6, and tumor necrosis factor [TNF]-α), and compared the mean changes between groups.

RESULTS

Mean age was older in the LN group (45.6 vs 30.9 years; P<0.0001), and mean operative time was significantly shorter (83.1 min vs 101.6 min; P=0.004). Mean postoperative increase in IL-6 and body temperature in LN was significantly less than in control: For IL-6, 15.87 vs 29.09 pg/mL, P=0.03; for body temperature, +0.22°C vs +0.71°C, P=0.001). Mean postoperative increases in levels of other inflammatory markers (CRP, TNF-α, WBC) did not differ significantly. No statistical correlation was found between operative time and changes in IL-6, CRP, TNF-α, WBC, or body temperature.

CONCLUSION

Based on the smaller increase in serum IL-6 as the most important indicator of surgical stress, the surgical trauma-induced immune dysfunction may be less intense after LN than open surgery. This may explain the smooth convalescence after LN.

Transgastric endoscopic pneumoperitoneum versus laparoscopy: effects on host systemic and peritoneal inflammatory responses in a porcine model

BACKGROUND

The host systemic and peritoneal immune responses during natural orifice transluminal endoscopic surgery (NOTES) continues to be delineated. The immune response to laparoscopy (LAP) has been favorably depicted. However, the immunologic effects of NOTES are yet to be determined, and the introduction of contaminants via the host orificium may have deleterious effects. The purpose of this study was to characterize the effect that NOTES would have on porcine systemic and peritoneal immune function.

METHODS

Twenty-four pigs were divided into three groups: ENDO (upper-endoscopy control), NOTES, and LAP. All animals had blood and peritoneal lavage samples collected for cytokine analysis pre- and postoperatively. Interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor α (TNFα), and interferon γ (IFNγ) levels were quantified using enzyme-linked immunosorbent assay (ELISA). Peritoneal lavage samples were cultured and identified by group and time of collection for microbiological analysis.

RESULTS

TNFα was found in detectable levels in serum samples of all three groups. For the NOTES group, there was a significant increase in TNFα at t = 1 h (P < 0.01), which dropped significantly at t = 48 h (P < 0.01). IL-1β was present as an early response in NOTES lavage samples (t = 0 and t = 1 h). Both LAP and NOTES had similar elevation of IL-1β in the final lavage samples at t = 48 h. The other cytokines were not consistently found above detectable levels in any group. Similar microbiological contaminants were found in the ENDO and LAP groups. In the NOTES group, no significant growth was observed from cultures at 48 h.

CONCLUSIONS

For measurable cytokines, the NOTES inflammatory response was not significantly different from that of the LAP group. NOTES did not carry a significantly increased amount of microbiological contamination at 48 h compared to LAP. These data suggest that the host immune response to NOTES does not significantly differ from that to LAP in a porcine model.

Changes in visceral flow induced by laparoscopic and open living-donor nephrectomy: experimental model

Increased intra-abdominal pressure during laparoscopy changes visceral flow. The objective of the present study was to analyze the changes in peripheral and intra-abdominal flow induced by laparoscopic living-donor nephrectomy in an experimental model. Twenty pigs underwent left-sided nephrectomy, 10 at laparoscopy and 10 in an open approach. Renal blood flow (RBF), hepatic arterial flow (HAF), portal flow (PF), and carotid flow (CF) were measured using an electromagnetic probe placed around these vessels. Comparative analysis between the groups demonstrated increased CF (mean [SD], 125.73 [41.69] vs 291.70 [51.52] mL/min; P < .001) and decreased PF (973.67 [131.70] vs 546.83 [217.53] mL/min; P = .001) and HAF (278.00 [94.71] vs 133.33 [112.32] mL/min; P = .03) in pigs that underwent laparoscopy compared with those who underwent open surgery; no significant differences were observed in RBF. In conclusion, laparoscopic nephrectomy induces increased CF and decreased total hepatic flow, at the expense of PF and HAF. With adequate intravascular volume expansion, no differences were observed in RBF between the laparoscopic and open approaches.

[Ischemia-reperfusion syndrome and role of preservation graft technique after laparoscopic versus open nephrectomy in a experimental model of living donor kidney transplant]

INTRODUCTION

Delayed graft function alter living donor transplantation is a subject of debate. Delayed graft function can be partially explained by renal ischemia-reperfusion injury, when severe is associated with decreased graft survival. In this experimental living donor model study, we analyze the hemodynamic, histological and biochemical effects of laparoscopic nephrectomy. We also, analyze the effect of a pulsatile machine perfusion for kidney preservation during cold ischemia time.

MATERIAL AND METHODS

Twenty large-white pigs (average weight 40-45 kgrs) were divided in 4 experimental groups: Group A: Laparoscopic nephrectomy+ immediate graft perfusion in pulsatile vacuum pump+autotransplant Group B: Laparoscopic nephrectomy+ immediate graft perfusion by gravity+autotransplant Group C: Open nephrectomy+immediate graft perfusion in pulsatile vacuum pump+autotransplant Group D: Open nephrectomy+ immediate graft perfusion by gravity+autotransplant Both laparoscopic and open nephrectomy were completed transperitoneally according to standardized technique. Hypothermic perfusion was done in a system designed in our lab.

RESULTS

We observed a decreased renal artery flow in kidneys procured laparoscopically compared to open nephrectomy. We found an artery flow recovery during the first 60 minutes after revascularization. Renal machine perfusion during cold ischemia time seems to have no beneficial effect, but shows a deleterious effect on hemodynamic event for renal transplantation. Lower plasma nitric oxide level is observed in kidneys obtained by laparoscopy compared with open surgical technique. And finally, we also found higher histological damage in proximal tubular and endothelial cell, in kidneys obtained by laparoscopy compared with open surgery.

CONCLUSIONS

In our experience: Laparoscopic nephrectomy versus open nephrectomy produces, in a model of living donor transplant, a lower value or renal blood flow and a higher value of renal vascular resistanse. These hemodynamic findings tend to normalize by 60 min after the reperfusion. A lower blood concentration of nitric oxide after the transplant was detected in laparoscopic group Vs open surgery group.

[Comparative analysis of renal graft function after open vs. laparoscopic nephrectomy: experimental model]

INTRODUCTION

Living donor renal transplant reports a higher patient and graft survival in comparison to cadaver donor and represents a good alternative facing the current lack of organs for transplant.

GOALS

To analyze comparatively in an experimental model (pig) the influence of ischemia-reperfusion and functional outcome of renal graft retrieved by open Vs laparoscopic nephrectomy.

MATERIAL AND METHODS

30 lab pigs were nephrectomized (left kidney): 15 by laparoscopy and 15 by open surgery, as living donors, in a model of renal autotransplant. Renal blood flow (RBF) was measured by means of an electromagnetic probe and creatinine levels during the first week after the implant.

RESULTS

Comparative analysis of RBF during the immediate 60 min after unclamping showed a significant reduction of average RBF in laparoscopic group in comparison to open group (p < 0.001), with a more evident reduction of RBF in the laparoscopic group during the 5-min period after unclamping (p < 0.001) and a progressive recuperation of RBF during the 1st hour, slowest in laparoscopic group. Creatinine levels in the first week after the transplant decreased progressively from 1.3 to 0.8 mgrs/dl in the open group and from 2 to 1.1 mg/dl in laparoscopic group (p < 0.001).

CONCLUSIONS

Renal grafts retrieved by laparoscopy presents a more evident ischemia-reperfusion syndrome shown by a lower average RBF after unclamping and a significant deterioration of renal function during the first week after transplant.

Late phase TNF-alpha depression in natural orifice translumenal endoscopic surgery (NOTES) peritoneoscopy

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) allows access to the peritoneal cavity without skin incisions. Contamination of the peritoneal cavity by enteric contents may render NOTES more physiologically and immunologically invasive than previously thought. Measurement of interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) is a validated method to quantify surgical stress. The physiologic and immunologic impact of NOTES is unknown.

METHODS

A total of 37 swine underwent abdominal exploration via transgastric NOTES peritoneoscopy, laparoscopy (LX), laparotomy (OPEN), or sham surgery (CONTROL) and were allowed to survive. TNF-alpha, IL-1beta, and IL-6 plasma levels were determined at the start and completion of surgery, and at 1 hour, 2 days, and 14 days postoperatively.

RESULTS

At surgical completion, OPEN animals demonstrated higher TNF-alpha levels than all groups. TNF-alpha levels were similar for all groups at 1 hour and 2 days. NOTES animals had significantly reduced plasma levels of TNF-alpha than all other groups on postoperative days 7 and 14. Controlling for baseline cytokine variability, analysis was repeated using normalized data, which confirmed significantly reduced TNF-alpha levels for NOTES compared with all groups at 14 days. Subset analysis excluding LX and OPEN complications revealed lower NOTES TNF-alpha levels at 7 and 14 days compared with all groups. IL-1beta and IL-6 levels were undetectable in 66.8% and 70.5% of samples, respectively, without significant trends.

CONCLUSIONS

Diagnostic NOTES peritoneoscopy demonstrated similar levels of systemic proinflammatory cytokine TNF-alpha compared with diagnostic laparoscopy and exploratory laparotomy in the immediate postoperative period despite gross intraperitoneal contamination. None of the surgical groups, however, produced a measurable, consistent trend in IL-1beta or IL-6. Consistently reduced levels of TNF-alpha in NOTES animals in the late postoperative period indicates an immunomodulatory effect of the NOTES surgical technique not present in laparoscopy or laparotomy.

Living donor of the kidney—open—video

BACKGROUND AND AIMS

Living donor nephrectomy (LDN) has evolved a variety of different surgical techniques. Minimal invasive strategies were introduced to benefit the healthy donors. This paper attempts to identify the best possible practise in live kidney donation with special respect to donor safety.

MATERIALS AND METHODS

We present a single-centre experience of 173 live kidney donations and describe the surgical technique of open retroperitoneal donation in detail and by video sequences. Additionally, the evidence for donor safety (mortality and morbidity) and the integrity of the graft function are reviewed, comparing different surgical techniques for LDN.

RESULTS

Focussing on maximal donor safety, a retroperitoneal access seems mandatory. Very detailed informed consent, including the offer for different retrieval techniques, has led to a total of 163 open and 10 hand-assisted retroperitoneal live kidney donations at our institution. Published and own data reveal longer operating and warm ischaemic times for minimal invasive kidney removal when compared with open technique. Adequate perioperative analgesia (peridural catheter) provides comparable patient comfort, duration of hospital stay, complications and graft function although there are some procedure-associated risks for minimal invasive techniques.

CONCLUSION

The special ethical situation of live donation necessitates maximal donor safety. Although open antero-lateral incision and retroperitoneal access does provide some inconveniences for the surgeon, we are convinced that this and the hand-assisted retroperitoneal approach are the only two options for LDN.