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

A silicone disc for liver retraction in laparoscopic gastrectomy reduces the postoperative increase in the liver enzyme level

PURPOSE

To compare changes in liver enzyme levels on postoperative day 1 between patients with and without silicone disc (SD) use during liver retraction in laparoscopic gastrectomy for gastric cancer and laparoscopic gastric mobilization for esophageal cancer.

METHODS

This prospective randomized controlled phase II trial was conducted between June 30, 2020, and November 30, 2022, to investigate the benefits of using an SD with a Nathanson liver retractor (NLR) compared with those using an NLR in laparoscopic gastrectomy and gastric mobilization. The primary endpoint was the change in transaminase level on postoperative day 1.

RESULTS

A total of 86 patients received randomized assignments and were included in the analysis, with 44 assigned to the SD (-) group and 42 to the SD (+) group. On postoperative day 1, the SD (+) group showed a significantly lower increase in the aspartate aminotransferase levels than the SD (-) group (SD [+], 94.4% vs. SD [-], 179.8%; p = 0.012). Similarly, the SD (+) group showed a significantly lower increase in alanine aminotransferase levels than the SD (-) group (SD [+], 71.6% vs. SD [-], 201.5%; p = 0.014).

CONCLUSION

In laparoscopic gastrectomy, the use of an SD combined with an NLR appears to mitigate postoperative liver dysfunction.

CT characterization of retractor related liver injuries after pancreaticoduodenectomy: Retrospective analysis of a single institution experience

PURPOSE

Retractor related liver injuries (RRLI) are reported after upper gastrointestinal tract surgeries; most commonly laparoscopic cholecystectomy and gastric surgeries. The aim of this study was to characterize the incidence, identification, type, severity, clinical features and risk factors for RRLI after open and robotic pancreaticoduodenectomy.

METHODS

A 6-year retrospective study of 230 patients was performed. Clinical data was extracted from the electronic medical record. Post-operative imaging was reviewed and graded using the American Association for the Surgery of Trauma (AAST) liver injury scale.

RESULTS

109 patients met eligibility criteria. RRLI occurred in 23/109 (21.1%), with a higher incidence in the robotic/combinedapproach (4/9) compared with open (19/100). Most common injury was an intraparenchymal hematoma (56.5%), grade II (78.3%), located in segments II/III (77%). 39.1% of injuries were not reported on the CT interpretation. There was a statistically significant elevation of postoperative AST/ALT in the RRLI group [median AST 219.5 vs. 72.0 (p < 0.001), ALT 203.0 vs. 69.0 (p < 0.001)]. Trends toward lower preoperative platelet counts and longer operations were observed in the RRLI group. No significant difference in hospital length of stay or post-operative pain scores were noted.

CONCLUSION

RRLI occurred frequently after pancreaticoduodenectomy, however most injuries were low grade and the only clinical significance was a transient increase in transaminases. A trend toward higher injury rates was observed in robotic cases. In this population, RRLI was often unrecognized on postoperative imaging.

Liver Dysfunction After Use of Nathanson Retractor During Laparoscopic Gastrectomy for Gastric Cancer

Background: Cardiopulmonary complications and liver dysfunction are also specific complications and problems associated with laparoscopic surgery. The main causes of postoperative liver dysfunction, which may often occur after laparoscopic surgery, include carbon dioxide pneumoperitoneum and ligation of the aberrant left hepatic artery. Hepatic steatosis may develop as a natural consequence of neoadjuvant therapy, although rarely, owing to chemotherapy. Nathanson retractor may cause a prolonged elevation in liver enzymes of these patients compared with those who do not receive neoadjuvant therapy. Materials and Methods: The data of 151 patients who underwent laparoscopic radical gastrectomy between January 2017 and January 2022 for histologically proven primary gastric cancer in our clinic were retrospectively reviewed. Results: The mean length of hospital stay was 6.21 days. The mean time normalization of the aspartate aminotransferase (AST) value was 2.45 ± 1.83 (range, 0-12) days postoperatively. The analysis of the correlation between the preoperative and postoperative 1-day values of alanine aminotransferase (ALT) and AST revealed a significant difference between the preoperative and postoperative 1-day median values of both parameters (P < .001). Each one unit increase in ALT led to an increase of 0.338 days in the length of intensive care stay and an increase of 0.345 days in the overall length of hospital stay. As the time to normalization of the AST value increased, the length of both intensive care stay and hospital stay increased. Each one unit increase in AST resulted in an increase of 0.316 days in the length of intensive care stay and an increase of 0.376 days in the overall length of hospital stay. Conclusion: Alternative retraction methods can be used safely in laparoscopic surgery for gastric cancer patients receiving neoadjuvant therapy. We are of the opinion that the Nathanson retractor should be used only during dissection of the relevant regions to shorten the intraoperative intermittent release or the time of use.

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

Comparison of the Pretzelflex Retractor and Nathanson Retractor in Laparoscopic Sleeve Gastrectomy Surgery

PURPOSE

Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. The left lobe of the liver may be enlarged, and laceration, hematoma, or necrosis may develop in the liver due to retraction. In this study, the results of use of the Nathanson retractor (NR) and PretzelFlex retractor (PFR) in the patients undergoing laparoscopic sleeve gastrectomy (LSG) were compared.

MATERIALS AND METHODS

The patients who underwent LSG were divided into three groups based on the type of liver retraction device used. Group 1: NR was used fixed during the operation; Group 2: PF retractor was used; Group 3: NR were used only for fundus dissection and when necessary. All groups were evaluated in terms of demographic characteristics, liver function tests, and developing complications.

RESULTS

The study was conducted with a total of 120 consecutive patients. Operation time in the second group was found to be significantly lower than the other two groups (p = 0.009; p = 0.001; p < 0.01). The duration of retractor use in the first group was significantly higher than the other two groups (p = 0.001; p = 0.001; p < 0.01). While aspartate aminotransferase (AST) values were found to be high in Group 1, alanine aminotransferase (ALT) values were found to be high in Groups 1 and 3.

CONCLUSION

PFR has shorter operating and retraction times. It causes less measurable liver damage. Although the NR will be used, intermittent use causes less damage to the liver as in PFR.

Risk Factors for Postoperative Liver Enzyme Elevation After Laparoscopic Gastrectomy for Gastric Cancer

BACKGROUND/AIM

Laparoscopic gastrectomy (LG) is more frequently associated with postoperative liver enzyme elevation (PLEE) than open gastrectomy in phase III clinical trials for Japanese gastric cancer patients. The aim of this study was to determine the risk factors for PLEE after LG for gastric cancer.

PATIENTS AND METHODS

This study enrolled 153 consecutive patients with gastric cancer who underwent LG. The patient characteristics, the liver retraction method [silicone disc (SD) or Nathanson liver retractor (NLR)], and perioperative outcomes were compared between patients with and without PLEE.

RESULTS

PLEE was observed in 26 patients (17%). The patients with PLEE exhibited longer operative times (p=0.005) and more frequent use of the NLR for liver retraction (p=0.022). In the multivariate analysis, liver retraction using the NLR (p=0.003) and aberrant left hepatic artery (ALHA) ligation (p=0.042) were independent risk factors of PLEE.

CONCLUSION

Liver retraction with the SD during LG was shown to be the safer method that is less likely to cause postoperative liver dysfunction. ALHA preservation may contribute to avoiding postoperative liver dysfunction.

Iatrogenic hepatic granuloma (suspected liver metastatic lesion on imaging) caused by liver retraction during laparoscopic gastrectomy: A case report

There are no previous reports of hepatic granuloma secondary to intraoperative liver retraction. Using softer hepatic retraction instruments and keeping hepatic retraction time to a minimum are vital in preventing postoperative liver damage.

K-Wire Retractor, a Trocar-Free Liver Retraction Technique in Bariatric Surgery

BACKGROUND

Liver retractor helps in the provision of an adequate operative field in bariatric surgery. Though several retractors have been introduced, an optimal retraction method is yet to be desired. We have developed a K-wire retractor, a simple trocar-free liver retractor used in our bariatric surgery. The efficacy and safety of the K-wire retractor were examined.

METHODS

A retrospective review was performed on patients undergoing laparoscopic bariatric surgery from January 2016 to April 2019. Based on the application of liver retractors during surgery, patients were divided into the K-wire retractor group and the suture-based retractor group for comparative analyses. Patients with severe liver injury or missing data, or treated with other types of retractors were excluded.

RESULTS

A total of 317 patients were included in our study and there was no conversion to open surgery. There were no significant differences in patient demographics (age, gender, BMI) and types of bariatric surgery between the two groups. The time taken for placement of retractor was significantly shorter in the K-wire retractor group, in addition to higher operative view score and lesser ALT/AST elevation compared with the suture-based retractor group. Although the K-wire retractor group was less inclined to require additional retraction techniques, patients with BMI ≥ 50 Kg/m² were associated with higher risk (OR:3.8; 95% CI: 1.2, 12.8) of requiring additional retractors. There were no severe K-wire retractor-related complications observed.

CONCLUSION

The trocar-free K-wire liver retractor is safe, simple, and effective as a standard liver retraction method in bariatric surgery.

Novel use of the Nathanson liver retractor to prevent postoperative transient liver dysfunction during laparoscopic gastrectomy

INTRODUCTION

The Nathanson liver retractor (N) has been known to cause postoperative transient liver dysfunction (POTLD) in laparoscopic gastrectomy (LG). To reduce the incidence of POTLD, specifically we added to the retractor the use of a disk (N + D) to reduce the localized pressure, and furthermore repositioned the retractor every 30 minutes (N + D TM) to reduce the liver retraction time. Before and after introducing this retractor, we assessed four consecutive retraction procedures. These included the following disk suspension methods (D), N, N + D, and N + D TM.

METHODS

We retrospectively enrolled 85 patients who underwent an LG. In the D, N, N + D, and N + D TM groups, we evaluated the postoperative serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values.

RESULTS

For the D and N groups, the AST value significantly increased from the immediate post-operation time point (IPOT) to the third postoperative day (POD3). Additionally, the ALT value increased from IPOT to POD7. In the N + D group, the only decrease was in the ALT value at IPOT compared to the N group. The N + D TM group decreased in both the AST value from IPOT to POD3 and in the ALT value from IPOT to POD7, compared to the N group.

CONCLUSIONS

Our findings demonstrate the importance of reducing both the localized pressure and liver retraction time when using the Nathanson retractor to prevent POTLD during an LG. To make this possible, we successfully introduced the use of both a disk and the repositioning of the retractor at 30 minute intervals.

A Novel Technique to Predict Liver Damage After Laparoscopic Gastrectomy From the Stomach Volume Overlapping the Liver by Preoperative Computed Tomography

BACKGROUND

During laparoscopic gastrectomy (LG), it is necessary to manipulate the lateral segment of the liver to secure the surgical field. Liver retraction during surgery often causes liver dysfunction after LG. However, no previous studies have used preoperative image evaluations to predict postoperative liver damage associated with surgical retraction. We aimed to predict postoperative liver damage after LG.

METHODS

In all, 117 consecutive patients with gastric cancer who underwent LG were included in this study. Using preoperative computed tomography (CT), the volume of the stomach overlapping the liver was integrated and calculated as the liver projecting stomach volume (LPSV). The liver projection ratio (LPR) was calculated by dividing the LPSV by the volume of the whole stomach. The relationships among liver damage, the LPSV and LPR were evaluated.

RESULTS

A total of 112 patients were divided into two groups as follows: 33 patients in the liver dysfunction group (D group) and 79 patients in the non-dysfunction group (N group). The LPSV was significantly larger in the D group than in the N group (median 77.1 vs 50.1 cm³; p = 0.0061). Similarly, LPR values in the D group were significantly higher than those in the N group (median 33.6 vs 26.2%; p = 0.003). Receiver operating characteristic curve analysis indicated a statistically significant ability of the LPSV and LPR to predict postoperative liver damage (area under the curve; 0.705 and 0.735, respectively). Furthermore, multivariate logistic regression analysis revealed that the increase in the LPR was an independent predictor of postoperative liver damage (odds ratio: 1.042; 95% confidence interval: 1.009-1.078; p = 0.019).

CONCLUSIONS

We have developed a novel technique for predicting postoperative liver damage associated with surgical liver retraction following LG. This method confirms the degree of the LPSV and LPR of the stomach via preoperative CT.

Differential advantage of liver retraction methods in laparoscopic fundoplication for neurologically impaired patients: a comparison of three kinds of procedures

AIM OF THE STUDY

Liver retraction during laparoscopic fundoplication is important for obtaining an optimal space. Several methods have been developed, but the risks and benefits are unclear. We compared three different approaches and evaluated their safety and utility.

METHODS

Forty-three neurologically impaired patients who underwent laparoscopic fundoplication between 2005 and 2018 were classified into three groups: A, snake retractor method, n = 18; B, crural suture method, n = 13; C, needle grasper method, n = 12. Patients' characteristics and outcomes were reviewed.

MAIN RESULTS

The liver retraction time was significantly shorter in group C than in A or B (p < 0.05). The operative times were shorter in groups B and C than in A. There were no significant differences in the liver enzyme levels. The liver enzyme levels increased temporarily but improved within a week. The C-reactive protein levels were significantly lower in group B than in A or C (p < 0.05).

CONCLUSIONS

The most convenient method was the needle grasper method, as the other two approaches create conflict with the operator's forceps. The crural suture method damages the liver less, but requires higher surgical skill levels. It is important to select the appropriate method according to the operator's skill and the patient's size and deformity.

Short-term and Long-term Outcomes Following Laparoscopic Gastrectomy for Advanced Gastric Cancer Compared With Open Gastrectomy

INTRODUCTION

To investigate the oncological feasibility and technical safety of laparoscopic gastrectomy with D2 lymphadenectomy for advanced gastric cancer.

METHODS

A total of 186 advanced gastric cancer patients treated by gastrectomy with D2 lymphadenectomy were eligible for inclusion including those with invasion into the muscularis propria, subserosa, and serosa without involvement of other organs, and stages N0-2 and M0. We retrospectively compared the short-term and long-term outcomes between laparoscopic gastrectomy and open gastrectomy.

RESULTS

We analyzed short-term outcomes by comparing distal with total gastrectomy results. We found no significant difference for distal gastrectomy for postoperative morbidity [laparoscopic vs. open: n=4 (4.6%) vs. n=1 (3.6%); P=1.00]. We also found no significant difference in postoperative morbidity for total gastrectomy [laparoscopic vs. open: n=2 (4.0%) vs. n=1 (4.0%); P=1.00]. No deaths occurred in any group.The entire cohort analysis revealed no statistically significant differences in overall-free or recurrence-free survival between the laparoscopic and open groups. For overall survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.29 and 0.27, respectively), and for pathologic stage II or III (P=0.88 and 0.86, respectively). For recurrence-free survival, there were no significant differences between open and laparoscopic groups for clinical stage II or III (P=0.63 and 0.60, respectively), and for pathologic stage II or III (P=0.98 and 0.72, respectively).

CONCLUSION

Laparscopic gastrectomy for advanced gastric cancer compared favorably with open gastrectomy regarding short-term and long-term outcomes.

Intractable hyperkalemia caused by hepatic infarction developed during laparoscopic gastrectomy in a patient with end-stage renal failure: a case report

Background

Patients with renal failure are susceptible to electrolyte disturbances including life-threatening hyperkalemia, and intraoperative hepatic damage exacerbates it. We report a case on hemodialysis who developed intraoperative remarkable hyperkalemia caused by hepatic damage during laparoscopic gastrectomy.

Case presentation

A 48-year-old man underwent laparoscopic gastrectomy for gastric cancer. He had been on hemodialysis for chronic renal failure. Serum K⁺ continued to increase to a maximum level of 7.4 mEq/L, despite the infusion of glucose with insulin during surgery. Postoperative computed tomography revealed hepatic infarction. Combined with increased hepatic enzymes, hepatic infarction caused by intraoperative mechanical traction would have exacerbated hyperkalemia.

Conclusions

We report a case on hemodialysis who developed intraoperative hyperkalemia due to hepatic damage. Our case highlights hepatic damage during laparoscopic gastrectomy as a potential cause of hyperkalemia.

Comparison of Two Types of Liver Retractors in Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

BACKGROUND

Retraction of the left lobe of the liver is an important step in most bariatric surgical procedures. Bariatric patients may have enlarged, fatty livers and retraction can be complicated with injuries, haematoma, or necrosis. The aim of this study was to compare the effects of two standard liver retractors, Nathanson and PretzelFlex on patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

All consecutive patients undergoing LRYGB in our center from April 2017 to January 2019 were analysed. The type of retractor used was dependent on the surgeon's preference and the availability of instruments. Patients were divided into two groups, based on the type of liver retraction device used. Each group was assessed and compared for postoperative pain score, presence of nausea or vomiting, blood test results (liver function tests and C-reactive protein), and length of hospital stay.

RESULTS

LRYGB was performed on 167 patients in which Nathanson was used in 93 patients and PretzelFlex in 74 patients. The duration of surgery was similar in both groups. Alanine transaminase (ALT) levels and C-reactive protein (CRP) were significantly higher in the group where Nathanson's retractor was used. The postoperative pain score and length of stay were also higher when Nathanson's retractor was used but it did not reach statistical significance.

CONCLUSION

The PretzelFlex liver retractor causes significantly less measurable liver damage and is associated with less postoperative pain and nausea when compared with Nathanson's retractor.

A novel liver retraction method in laparoscopic gastrectomy for gastric cancer

BACKGROUND

Retracting the lateral liver segment during laparoscopic distal gastrectomy is important for achieving an optimal surgical field. However, excessive force may injure the liver, causing temporary abnormalities of liver function tests after laparoscopic surgery. We developed a new liver retraction method and assessed its safety and utility.

PATIENTS AND METHODS

We retrospectively analyzed records in our surgical database of consecutive surgical patients who underwent laparoscopic distal gastrectomy for early gastric cancer. We divided the 229 patients into two groups based on the liver retraction method used, either flexible liver retraction with clipping and suturing (FLICS) or the Nathanson retractor (NR). One-to-one propensity score matching was performed to match patients, resulting in the records of 53 pairs of cases extracted from the database. Operative and postoperative outcomes were assessed, including following the values of serum liver enzymes, total bilirubin, and C-reactive protein until postoperative day 30.

RESULTS

There were no significant differences in patient characteristics or preoperative data in the two groups. The retraction method was not changed intraoperatively for any patients. The operative time was significantly shorter in the FLICS group, but the amount of bleeding did not differ. Liver injury was not observed as a result of liver retraction during surgery. In both groups, serum liver enzymes temporarily increased after surgery but improved rapidly thereafter. The postoperative increases in aspartate transaminase, alanine transaminase, and C-reactive protein levels were significantly lower in the FLICS than in the NR group. No serious complications associated with liver retraction were observed in either group.

CONCLUSIONS

Our new liver retraction technique provided an optimal surgical field without inducing liver dysfunction. It is a simple, safe, and effective liver retraction technique.

Short-term surgical outcomes from a phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer: Japan Clinical Oncology Group Study JCOG0912

BACKGROUNDS

No confirmatory randomized controlled trials (RCTs) have evaluated the efficacy of laparoscopy-assisted distal gastrectomy (LADG) compared with open distal gastrectomy (ODG). We performed an RCT to confirm that LADG is not inferior to ODG in efficacy.

METHODS

We conducted a multi-institutional RCT. Eligibility criteria included histologically proven gastric adenocarcinoma in the middle or lower third of the stomach, clinical stage I tumor. Patients were preoperatively randomized to ODG or LADG. This study is now in the follow-up stage. The primary endpoint is relapse-free survival (RFS) and the primary analysis is planned in 2018. Here, we compared the surgical outcomes of the two groups. This trial was registered at the UMIN Clinical Trials Registry as UMIN000003319.

RESULTS

Between March 2010 and November 2013, 921 patients (LADG 462, ODG 459) were enrolled from 33 institutions. Operative time was longer in LADG than in ODG (median 278 vs. 194 min, p < 0.001), while blood loss was smaller (median 38 vs. 115 ml, p < 0.001). There was no difference in the overall proportion with in-hospital grade 3-4 surgical complications (3.3 %: LADG, 3.7 %: ODG). The proportion of patients with elevated serum AST/ALT was higher in LADG than in ODG (16.4 vs. 5.3 %, p < 0.001). There was no operation-related death in either arm.

CONCLUSIONS

This trial confirmed that LADG was as safe as ODG in terms of adverse events and short-term clinical outcomes. LADG may be an alternative procedure in clinical IA/IB gastric cancer if the noninferiority of LADG in terms of RFS is confirmed.