Two clinically relevant pressures of carbon dioxide pneumoperitoneum cause hepatic injury in a rabbit model

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

PURPOSE

The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed.

METHODS

Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal.

RESULTS

Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique.

CONCLUSIONS

LC can be performed using different techniques, although the use of EBVS is highly recommended.

Transperitoneal versus extraperitoneal robot-assisted laparoscopic radical prostatectomy on postoperative hepatic and renal function

Background

In this retrospective study, we evaluated the effect of two approaches of robotic-assisted laparoscopic radical prostatectomy (RALP). The first approach was pneumoperitoneum via transperitoneal (TP-RALP), and the second approach was extraperitoneal (EP-RALP) on visceral function. We aimed to provide clinical evidence for the perioperative safety with RALP and to help the surgical team choose an appropriate approach for those with hepatic or renal insufficiency.

Methods

One hundred and fifty-seven eligible prostate cancer patients from 2015 to 2019 were included in this study. The postoperative related laboratory tests were compared between transperitoneal and extraperitoneal. The primary endpoint was hepatic and renal function. We also evaluate the intraoperative amount of bleeding, the length of postoperative hospital stays, the occurrence of postoperative complications (lymphatic leakage, bleeding, and infection), and the prostate-specific antigen (PSA).

Results

Postoperative total bilirubin and bound bilirubin in both groups were significantly increased, while total protein, albumin, globulin, urea, and uric acid were significantly decreased (P<0.05). The total protein, albumin, and globulin are significantly higher in the EP-RALP group than in the TP-RALP group (P<0.05) postoperatively. There are no statistical differences in estimated glomerular filtration rate (eGFR) and creatinine clearance (CCR) between these two groups, postoperatively.

Conclusions

RALP had a significant effect on hepatic function after both TP-RALP and EP-RALP approaches, while the latter showed a lesser extent. Our results suggested that pneumoperitoneal pathways have significant effects on protein consumption. Thus, we should require a more cautious choice of surgical approaches when it comes to patients with impaired hepatic function or under risk of hepatic malfunction.

Cardiovascular and respiratory effects of carbon dioxide pneumoperitoneum in the domestic rabbit (Oryctolagus cuniculus)

The objective of this study was to evaluate the effect of intra-abdominal pressure (IAP) on cardiorespiratory parameters during pneumoperitoneum with carbon dioxide in domestic rabbits. Six juvenile female New Zealand white rabbits were assigned to randomized sequences of IAP (0, 4, 8 mmHg) in a crossover study. The following parameters were measured at each IAP: direct arterial blood pressure (ABP); cardiac output, (CO), cardiac index, and stroke volume index (CI, SVI); heart rate; end-tidal carbon dioxide (ETCO₂); arterial blood gases (PaCO₂, PaO₂); peak inspiratory pressure (PIP); and peripheral oxygen saturation (SpO₂). Between IAPs, the abdomen was desufflated for a 5-minute washout period. Mixed linear regression models were used for statistical analysis. Heart rate, SpO₂, and ABP were not significantly affected by IAP, although there was a positive increase in ABP with IAP. Partial pressure of carbon dioxide (PaCO₂) was increased at an IAP of 8 mmHg and ETCO₂ and PIP were greater with each IAP applied. Cardiac output and CI were significantly decreased with IAP and, although SVI showed the same trend, it was not statistically significant. In conclusion, pneumoperitoneum with carbon dioxide causes an increase in ETCO₂, PaCO₂, and PIP, whereas cardiac output and CI decrease. These cardiorespiratory changes should be considered when determining the optimal IAP for laparoscopic procedures in rabbits.

What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review

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.

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.

Effects of neurolytic celiac plexus block on liver regeneration in rats with partial hepatectomy

Liver regeneration is the basic physiological process after partial hepatectomy (PH), and is important for the functional rehabilitation of the liver after acute hepatic injury. This study was designed to explore the effects of neurolytic celiac plexus block (NCPB) on liver regeneration after PH. We established a model of PH in rats, assessing hepatic blood flow, liver function, and serum CRP, TNF-α, IL-1β and IL-6 concentrations of the residuary liver after PH. Additionally, histopathological studies, immunohistochemistry, and western blotting were also performed. Our results indicated that NCPB treatment after PH improved liver regeneration and survival rates, increased hepatic blood flow, reduced hepatocyte damage, decreased the secretion and release of inflammatory cytokines, increased the expression of B cell lymphoma/leukemia-2 (Bcl-2), and decreased the expression of Bcl-2 associated X protein (Bax). Additionally, Western blotting revealed that the expression of NF-κB p65 and c-Jun were decreased in liver after NCPB. In conclusion, the results of our present study indicate that NCPB treatment has a favorable effect on liver regeneration after PH. We suggest that NCPB can be utilized as an effective therapeutic method to help the functional rehabilitation of the liver after acute hepatic injury or liver cancer surgery.