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

Comparative Study of Levels of Serum Bilirubin, Serum Transaminase, Serum Alkaline Phosphatase, and Prothrombin Time After Laparoscopic Cholecystectomy and Open Cholecystectomy

Laparoscopic cholecystectomy (LC) is universally accepted as the gold standard treatment for symptomatic gallstones. However, it has some drawbacks. Some of the major drawbacks of LC include increased bile duct injuries and longer operation time. Furthermore, it may cause changes in the body systems, such as alterations in acid-base, pulmonary status, cardiovascular system, and liver function. Thus far, no causes for these changes have been identified. This study aimed to evaluate the effect of laparoscopic and open cholecystectomy on liver enzymes, prothrombin time (PT), and serum bilirubin. In the current study, we found significant increases in aspartate transferase (AST), alanine transaminase (ALT), and total bilirubin, on day 1 and day 3 after LC but no significant change in alkaline phosphatase (ALKP) and PT. It is important for surgeons to know about these transient changes in the immediate postoperative period to avoid misdiagnosis and adopt proper treatment and management.

Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration.

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.

Patienten* nach unauffälliger elektiver laparoskopischer Cholezystektomie können ohne Laborwertkontrollen entlassen werden – Ergebnisse einer prospektiven Studie

Hintergrund

Die Bedeutung postoperativer Laborkontrollen nach elektiver laparoskopischer Cholezystektomie (lap. CHE) ist umstritten. Das Ziel dieser prospektiven Studie war es, herauszufinden, ob Patienten* bei unauffälligem perioperativem Verlauf nach lap. CHE ohne Laborwertkontrollen sicher entlassen werden können.

Methodik

Vom 09/20 bis 03/22 wurden alle Patienten* mit einer lap. CHE gescreent und nach Erhalt des Einverständnisses in die Studie eingeschlossen. Der Verlauf wurde mit einem Scoring- (Punktewert 3–15 Punkte) und Befragungsbogen strukturiert verfolgt. Ein Scoringwert von ≤ 9 Punkten beschrieb einen unauffälligen perioperativen Verlauf. Die Ethikkommission Heidelberg hat dieser Studie zugestimmt (S-026/2020).

Ergebnisse

Es wurden 275 Patienten* mit Gallenblasenoperation erfasst. Davon unterzogen sich 80 % einer elektiven lap. CHE. 56 Patienten* (25 %) wurden in die Studie eingeschlossen, 51 Patienten* wurden bei einem Scoringwert ≤ 9 Punkten ohne Blutentnahme entlassen. Das Durchschnittsalter der 51 Patienten* war 50,8 Jahre, der durchschnittliche Krankenhausaufenthalt betrug 2,6 Tage. 40 von 51 Patienten* (78,4 %) konnten postoperativ befragt werden. Bei keinem der Patienten* kam es nach Entlassung zu relevanten Komplikationen. 27 der 40 Patienten* (67,5 %) sind postoperativ noch einmal zum Hausarzt gegangen. Aufgrund anderer Operationen und einer endoskopischen Intervention sind 4 Patienten* erneut stationär behandelt worden. Alle Patienten* waren mit dem chirurgischen Verlauf zufrieden.

Diskussion

Patienten* mit unauffälligem perioperativem Verlauf nach elektiver lap. CHE (Scoringwert ≤ 9 Punkten) können ohne postoperative Laborwertkontrolle entlassen werden.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

[Which patient needs controls of laboratory values after elective laparoscopic cholecystectomy?-Can a score help?]

BACKGROUND

Laparoscopic cholecystectomy is nearly exclusively carried out as an inpatient operation in Germany. The aim of the study was to evaluate for which patients postoperative laboratory control values are necessary.

METHODS

This retrospective analysis included 100 patients who underwent elective laparoscopic cholecystectomy. A scoring and data collection sheet was developed, which enables a risk stratification. Using the scoring system patients can achieve between 3 and 15 points.

RESULTS

In total 100 patients were included in the study. Of the patients 64 (group 1) had between 3 and 8 points, 29 patients (group 2) between 9 and 11 points and 7 patients (group 3) between 12 and 15 points. In comparison to group 1 the C‑reactive protein values as well as the duration of hospital stay were significantly increased in group 2 and group 3 (p > 0.05). In group1 a total of 60 patients (93.7%) were discharged regularly on postoperative days 1-3. In group 2 there were 17 patients (58.6%) who could be discharged with unremarkable blood values and in group 3 there were 3 patients (42.8%). In the total collective hospital discharge without a laboratory control of blood values would have been justified in 80% of the patients.

CONCLUSION

A postoperative control of laboratory blood values is not routinely necessary for patients after elective laparoscopic cholecystectomy with a score <9 points.

Comparison of postoperative liver function between different dissection techniques during laparoscopic cholecystectomy

Aim:

In this study, we investigated and compared the effect of different types of dissector (Maryland vs Hook) on changes in liver function tests (LFTs) after laparoscopic cholecystectomy.

Patients & methods:

The enrolled patients were divided into two groups. Group A patients underwent dissection by Maryland dissecting forceps, group B by Hook dissecting instrument. LFTs were measured preoperatively and at 1 day and 1 week, postoperatively.

Results:

For both Maryland and Hook dissection, the 1-day postoperative values for total bilirubin, alanine aminotransferase and aspartate aminotransferase were significantly higher than the preoperative values. Also, there were no statistical differences between Hook and Maryland.

Conclusion:

The elevation of LFTs seems to be attributed to other factors.

Laparoscopic cholecystectomy (LC) is an alternative to laparotomy and has become the standard treatment of benign gallbladder diseases. However, it has been noted that (following LC) the serum level of certain liver function tests (LFT) raises markedly in patients who had preoperatively normal LFT. Pneumoperitoneum is the main contributing factor. This is the first study to evaluate the effect of different dissectors on alteration of LFTs after LC. As there were no statistical differences in the variation of LFTs between the Maryland and Hook, it seems that the dissector type has no effect on the alteration of LFTs.

Evaluation and comparison of postoperative levels of serum bilirubin, serum transaminases and alkaline phosphatase in laparoscopic cholecystectomy versus open cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) requires the creation of a pneumoperitoneum via insufflations of carbon dioxide; resulting in increased partial pressure of carbon dioxide (CO2) and intraperitoneal pressure which leads to the changes in pulmonary function and hemodynamic measurements. Hypercarbia leads to visceral organ ischemia including liver and venous stasis/thromboembolism or both due to impaired flow. The present study has been undertaken to see the changes in liver function tests (LFTs) after laparoscopic/open cholecystectomy (OC), the incidences of such change, their relation to age, sex, duration of surgery and to know the clinical significances of such disturbances.

AIMS AND OBJECTIVES

To compare and correlate the serum level of bilirubin, alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP) in patients who underwent LC to those who underwent OC.

MATERIALS AND METHODS

The present study was conducted in the Department of Surgery at MMIMSR, MM University, Mullana, Ambala. A total number of 200 patients diagnosed as cholelithiasis were included in the study from May 2012 to May 2014. These cases were randomly divided into two groups (A and B) consisting of 100 cases each. LC was performed in group A patients and OC was done in group B patients. Three blood samples were taken: (I) pre-operatively; (II) after 24 hours of surgery; and (III) after 72 hours of surgery for comparison of the enzyme level alterations.

RESULTS

In LC patients, there were rise in the levels of serum bilirubin, AST and ALT after 24 hrs of surgery from the preoperative value and then again fall was noted (near to normal value) after 72 hrs of surgery except in that of ALP. ALP levels showed slight fall after 24 hrs of surgery and then slight rise after 72 hrs which was within the normal limit. Whereas in OC patients, there were slight variations in the liver enzymes (which were within the normal range).

CONCLUSIONS

Transient elevation of serum bilirubin, AST and ALT occurs after LC or after OC. The alteration in the liver enzymes can be attributed to CO2 pneumoperitoneum, surgical manipulations, diathermy, patient position, and arterial injury may also other factors. These changes return to normal in 3-4 days after procedure and they have no clinical consequences in patients with normal hepatic function but they may still cause worry to the surgeon regarding the integrity of biliary tree.

Cardiac and Liver Marker Alterations After Laparoscopic Gynaecologic Operations

OBJECTIVE

In our study, we aimed to investigate the effect of laparoscopic procedures in which the abdominal cavity at a Trendelenburg position of 15 degrees was insufflated with CO2 on cardiac and liver markers.

METHODS

Forty patients scheduled for laparoscopic gynaecological surgery were included in the study. Venous blood samples were taken the day before operation and 6 hours after surgery, and later, lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase-MB (CK-MB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), myoglobin (MY) and d-dimer (d-D) were measured.

RESULTS

There was no statistically significant difference in the values of preoperative and postoperative ALT (16.8±9.4 and 17.8±9.3; p=0.579), AST (19.4±7 and 20.9±7.6; p=0.361) and ALP (65.2±16.2 and 63.3±16.9; p=0.609), but LDH (385.1±117.3 and 460.6±156.3; p=0.003), CK (113.8±138.5 and 247.9±283.5; p=0.0001), CK-MB (22.8±13.3 and 28.7±16; p=0.011), MY (28.1±12.9 and 138.8±129; p=0.0001) and d-D (509.5±815: 1026±1054; p=0.0001) increased significantly.

CONCLUSION

After laparoscopic operations in the Trendelenburg position, postoperative serum ALT, AST and ALP levels, remained unchanged, when compared to preoperative values, but LDH, CK, CK-MB, myoglobin and d-dimer values increased significantly.

Assessment of gallstone predictor: comparative analysis of ultrasonographic and biochemical parameters

Background

Gallstones represent a significant burden for health care systems worldwide and are one of the most common disorders presenting to emergency room. Ultrasonography, complete blood picture test and liver function tests are procedures of choice in suspected gallstones or biliary diseases. They are the most sensitive, specific, non-invasive and inexpensive tests for the detection of gallstones. Our main objective was to evaluate the relationship of ultrasonographic findings, hemolytic indices and liver function tests with gallstones.

Methodology

It was a prospective study carried out in Civil Hospital Karachi (DUHS) and Liaquat National Hospital, two largest tertiary care hospitals of Karachi, Pakistan. Duration of the study was from July 2011 to October 2012. The study was carried out on diagnosed, pre-operative and symptomatic patients of cholelithiases. Exclusion criteria were patients of gallbladder and pancreatic carcinoma, emergency operations, patients having age <12 years and non-cooperative patients, who refused to give written consent for participation in the study. Total two tests were performed on each patient after diagnosis by ultrasonography. These were complete blood count and liver function tests. All the demographic data, laboratory findings and ultrasonographic features were noted in a pre-structured Performa. Sample size was calculated by using open-epidemiological sample size calculator prevalence (p) = 35%, d = 5%, and confidence interval (CI) 95% = 350. All the data was entered and analyzed through SPSS 19.

Result

There were 454 diagnosed and pre-operative cases of gallstones present in the study. There were 120(26.4%) males and 334(73.6%) females, with a mean age of 42.80 ± 12.26 years. Most of the suspects had multiple stones 384 (84.5%) while few had single stones 70(15.4%). Fatty liver was found to be present in 144(31.7%) patients and 92(20.2%) had hepatomegaly. Splenomegaly was present in 16(3.5%) patients. Alkaline phosphatase was elevated in 186(41.0%) patients while SGPT was found to be raised in 160(35.2%). Blood urea nitrogen was found to be elevated in 186(41%) patients and serum creatinine was elevated in 46(10.1%) patients.

Conclusion

In the light of findings it is recommend that all patients should go through the process of ultrasonography and all the biochemical parameters should be analyzed before surgery.