Are elevated liver enzymes and bilirubin levels significant after laparoscopic cholecystectomy in the absence of bile duct injury?

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.

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.

The Effect of L-Hook Dissection and Scissors Dissection on Liver Injury in Laparoscopic Cholecystectomies

Purpose: Laparoscopic cholecystectomy is generally performed with the help of monopolar cautery. We aimed to reveal the effect of monopolar cautery use on liver damage in this study.

Method: Data of patients who underwent elective cholecystectomy between January 2016 and April 2020 were collected retrospectively. The patients were divided into two groups according to the surgical technique as hook dissection (HD) and scissor dissection (SD). The amount of increase in the preoperative and postoperative alanine aminotransferase (ALT) and aspartate aminotransferase (AST) values of the patients was compared between the two groups.

Findings: Over 970 patients were included in the study. The changes in pre-post ALT and AST values were statistically significantly different between the HD (n=469) and SD (n=501) groups (p<0.001; p0.001). ALT (26 (−25, 338)) and AST (27 (−23, 444)) changes in the HD method were statistically significantly higher than ALT (11 (−16, 371)) and AST (10.8 (−37, 617)) changes in the SD method.

Results: ALT and AST values increase after all laparoscopic cholecystectomies. Although the increase in ALT and AST in the HD patients is statistically significant when compared to the SD group, both methods of laparoscopic cholecystectomy can be safely performed because they do not cause permanent liver injury.

Evaluation of Liver Function Tests and Serum Bilirubin Levels After Laparoscopic Cholecystectomy

Introduction

Laparoscopic cholecystectomy has been known as one of the most important prevalent and minimally invasive surgeries in medicine.

Aim

The aim here was to investigate the changes in liver enzymes and bilirubin levels after laparoscopic cholecystectomy in patients diagnosed with chronic cholecystitis.

Methods

This cross-sectional study was conducted at Poursina Hospital (Rasht, Iran) and 128 patients who met both inclusion and exclusion criteria were enrolled for further investigations. After collecting the patients' bio-demographic information, levels of serum alkaline phosphatase, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and bilirubin were checked before laparoscopic cholecystectomy and 24 (post-op 1) and 48 (post-op 2) h after laparoscopic cholecystectomy.

Results

No significant difference was found in the serum levels of ALP in post-op 1 and 2 compared both to each other and to the baseline (P>0.05). Regarding AST and ALT, there was a significant increase in post-op 1 and 2 compared to their baseline values (P<0.05). However, the difference between post-op 1 and post-op 2 was not significant for these outcomes. Compared to baseline levels, LDH had a significant increase after post-op 2 (P=0.001); but not after post-op 1 (P >0.05). Moreover, total bilirubin levels showed significant increases at post-op 1 and post-op 2 from the baseline and also in comparison with each other (P < 0.05).

Conclusion

Our results demonstrated a transient increase in liver function tests and bilirubin after laparoscopic cholecystectomy.

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.

Toxic effects of subacute inhalation exposure to trichloroethylene on serum lipid profile, glucose and biochemical parameters in Sprague-Dawley rats

The current study evaluated the inhalation toxicity of trichloroethylene (TCE) at 0, 10, 100, 250 and 400 ppm in Sprague-Dawley rats for 10 day period, because the subacute inhalation toxicity of TCE on serum lipid profile, glucose and some biochemical parameters has not been previously reported. TCE vapors were generated using the dynamic generation system based on evaporation method in the exposure chamber. On the basis of the results, mean serum low-density lipoprotein (LDL) and albumin (ALB) decreased significantly in all the groups exposed to TCE compared with the control group (p < .005), but there was a significant increase for parameters: fasting blood glucose (FBG) and alkaline phosphatase (ALP) (p < .005). Rats exposed to 400 ppm TCE showed a significant decrease in serum cholesterol (CHOL) and protein (Pr) compared with the control group (p < .005). A negative relationship was found between triglycerides (TG), very low density lipoprotein (VLDL), CHOL, LDL, Pr, ALB and urea levels and the subacute exposure to concentrations of TCE (R² = -0.26, p < .05), but there was a direct correlation for parameters FBG, ALP and alanine aminotransferase (ALT) (R² = 0.42, p < .05). In conclusion, studies with Sprague-Dawley rats demonstrated that subacute inhalation exposure to TCE (≥ 100 PPM) is associated with biochemical and lipotoxicity in the form of decreased serum ALB and LDL and raised ALP and glucose levels. The present study also provides additional evidence relating to decreased serum CHOL and Pr after subacute inhalation exposure to 400 ppm TCE.

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.

Reduce Adverse Effects of Laparoscopic Cholecystectomy with Pulse Width Modulated LED Light (625 nm, 76 Hz, 23% Duty Cycle)

OBJECTIVE

Reducing adverse effects in laparoscopic cholecystectomy (LCE) is important to avoid complications. After removal, the porta hepatis and gallbladder bed of liver were treated with pulse width modulated (PWM) red LED light with parameters λ = 625 ± 5 nm, full width at half maximum 17 nm, 76 Hz, duty cycle 23%, 15-30 mW/cm², and 0.9-1.8 J/cm². The changes of eight blood parameters were studied: red blood cell, hemoglobin, white blood cell, erythrocyte sedimentation rate (ESR), bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and amylase.

BACKGROUND DATA

Other current methods of reducing undesirable effects of LCE significantly affect surgery and are not commonly used in practice.

MATERIALS AND METHODS

Before LCE, 263 patients were randomized into the control and test groups. Patients in the test group were treated with light radiated for 2 min during the surgery on the bed of the removed gallbladder and porta hepatis. Blood samples were taken before surgery and on the third day after surgery, studied, and compared by nonparametric statistical methods.

RESULTS

The test group revealed significant reduction in postsurgery gain of levels of ALT, AST, and ESR compared with the control group.

CONCLUSIONS

Treatment of the removed gallbladder bed and porta hepatis by red LED PWM radiation during LCE significantly reduces the adverse effects of surgery while increasing its time insignificantly and does not affect the surgical best practices deployed.

Alterations in Plasma Oxidative Stress Markers After Laparoscopic Operations of the Upper and Lower Abdomen

The patient’s position during laparoscopic surgery can have a clinically relevant effect on lower limb and splanchnic circulation; this factor has not yet been investigated with respect to oxidative stress markers. In order to assess this effect, a prospective clinical trial was designed wherein 2 groups of patients were studied. In group A, 15 patients underwent upper abdominal nonhepatobiliary operations (13 modified Nissen fundoplications and 2 Taylor vagotomies) in the head-up position. In group B, 15 patients underwent lower abdominal operations (10 laparoscopic colectomies and 5 inguinal hernia repairs) in the head-down position. The pneumoperitoneum was maintained at 14 mm Hg in all cases. Plasma concentrations of thiobarbituric-acid reactive substances (TBARS), a marker of lipid peroxidation, plasma total antioxidant status (TAS), and serum uric acid concentrations were measured preoperatively, 5 minutes after deflation of the pneumoperitoneum, and 24 hours postoperatively. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) serum activities were measured preoperatively and 24 hours postoperatively. In group A, there was a significant increase in TBARS levels (p<0.005) immediately after deflation of the pneumoperitoneum and a significant decrease in TAS and uric acid levels (p<0.005) in the first postoperative day. There was also a significant postoperative elevation in both ALT and AST activities (p<0.001). In group B, no significant increase was found in postoperative TBARS or transaminase levels. TAS and uric acid levels decreased significantly in the first postoperative day (p<0.05) and (p<0.005, respectively). In conclusion, these results show that a combination of pneumoperitoneum and the head-up position causes significant increase in lipid peroxidation, decrease in plasma TAS, and increase in transaminases. The mechanism responsible for these events could be the low-flow ischemia-reperfusion syndrome induced by the pneumoperitoneum and aggravated by the head-up position.

Role of nitric oxide in kidney and liver (as distance organ) function in bilateral renal ischemia-reperfusion: Effect of L-Arginine and NG-nitro-L-Arginine methyl ester

Background:

Renal ischemia-reperfusion (RIR) is a major cause of renal dysfunction that acts through different mechanisms. We investigated the role of L-Arginine as an endogenous nitric oxide (NO) precursor and NG-nitro-L-Arginine methyl ester (L-NAME) as an NO inhibitor on kidney and liver function in RIR model.

Materials and Methods:

Fifty-eight Wistar rats were randomly assigned to four groups. Groups 1 (sham-operated, n = 13) received a single dose of saline (4 ml/kg, i.p.) and 2 (Ischemia [Isch], n = 14) received a single dose of saline (4 ml/kg, i.p.). Groups 3 (Isch + L-NAME, n = 15) received a single dose of L-NAME (20 mg/kg, i.p.) and 4 (Isch + L-Arginine n = 16) received a single dose of L-Arginine (300 mg/kg, i.p.), After 2 h, renal failure was induced by clamping both renal pedicles for 45 min, followed by 24-h reperfusion in Groups 2–4. Finally, blood samples were obtained, and kidney tissue samples were subjected for pathology investigations.

Results:

The body weight decreased, and the serum levels of blood urea nitrogen (BUN) and creatinine (Cr), and kidney tissue damage score (KTDS) increased significantly in the Isch and Isch + L-NAME groups compared with the sham group while L-Arginine improved weight reduction (P < 0.05), and it reduced the serum levels of BUN and Cr, and KTDS when compared with the Isch and Isch + L-NAME groups. Kidney weight increased significantly in all groups compared with the sham group. L-Arginine reduced the liver tissue level of malondialdehyde and increased alkaline phosphatase.

Conclusion:

L-Arginine as an NO precursor can improve kidney function against RIR. It also improves oxidative stress in liver tissue.

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.

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.

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.

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.

A protective technique for retraction of the liver during laparoscopic gastrectomy for gastric adenocarcinoma: using a Penrose drain

BACKGROUND

Retraction of the liver is necessary to ensure an adequate working space in laparoscopic surgery, but the retraction force applied may cause transient liver dysfunction. We have introduced the technique using a Penrose drain to suspend the liver with the performance of laparoscopic gastrectomy for gastric adenocarcinoma.

METHODS

111 patients with gastric adenocarcinoma underwent laparoscopic gastrectomy using either a Penrose drain (n = 47) or a Nathanson's retractor (n = 64) for displacement of the liver. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, alkaline phosphatase (ALP) and albumin were compared among the groups at baseline, immediately after operation, and on postoperative days (POD) 1, 2, 3, 5, and 7.

RESULTS

The levels of ALT on POD 2, 3, and 5 were significant higher in the Nathanson's retractor group than in the Penrose drain group. Levels of AST on POD 2 and 3 were also higher in the Nathanson's retractor group than in the Penrose drain group. There was no significant difference in total bilirubin, ALP, and serum albumin levels between groups.

CONCLUSIONS

The use of the Penrose drain for retraction of the liver appears to attenuate postoperative liver dysfunction during laparoscopic gastrectomy for gastric adenocarcinoma.

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.

Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks

BACKGROUND

Jackson Pratt (JP) drain fluid bilirubin levels may be assayed in the evaluation of possible bile leaks. Although fluid color and bilirubin level may prompt additional evaluation, there are no reference data available.

OBJECTIVE

To assess the JP drain fluid-to-serum bilirubin ratio in patients with documented bile leaks.

DESIGN

Prospective case series.

SETTING

Tertiary referral center.

METHODS

Patients referred for ERCP for the management of documented bile leaks with a JP drain in place were included. Demographic data, bile leak etiology, and serum bilirubin levels were recorded. JP drain fluid was sent for color evaluation and bilirubin concentration. Control subjects included both patients after nonbiliary surgery with a JP drain in place and medical patients with ascites undergoing paracentesis.

RESULTS

JP drain fluid-to-serum bilirubin concentration and fluid color evaluation was performed on 23 patients with documented bile leaks by ERCP and compared with 26 controls (16 surgical and 10 medical). The JP drain fluid/ascites-to-serum bilirubin ratio was significantly higher in those with bile leaks (mean ratio 45.6) compared with combined controls (mean ratio 0.9). Use of a cutoff JP drain fluid-to-serum bilirubin ratio of 5 would be 100% sensitive and specific for the prediction of a bile leak in the selected control group. There was overlap in fluid color evaluation between the groups.

LIMITATIONS

Controls did not include those with suspected bile leaks and negative technetium 99m-HIDA scintigraphy or ERCP findings.

CONCLUSIONS

JP drain fluid-to-serum bilirubin concentration ratio greater than 5 seems to be highly sensitive and specific for the detection of a bile leak. Used along with clinical criteria, this ratio could be used to select patients to proceed directly to ERCP.

Retraction transaminitis: an inevitable but benign complication of laparoscopic fundoplication

BACKGROUND

Transient transaminitis has been identified following laparoscopic abdominal surgery. However, the importance of posture, duration of surgery, and mechanical retraction in its etiology remain unclear.

METHODS

Liver function was assessed preoperatively then at 8, 24, 48 and 72 h following laparoscopic surgery including the following procedures: Nissen fundoplication (LN: n = 10); cholecystectomy (LC: n = 10); inguinal herniorrhaphy (LH: n = 10); and gastrectomy (LG: n = 5).

RESULTS

Aspartate aminotransferase (AST) levels in LN patients exhibited a rapid rise within 8 h, peaking at 48 h before returning toward baseline. In the LN group, AST levels were significantly higher at 8 h and 24 hours compared to all other groups and compared to LG at 48 h and 72 h. At 6-week follow-up all AST levels were normal. No significant differences were seen in other hepatic parameters, and no correlation between AST and duration of operation, gender, or age was identified.

CONCLUSIONS

Antireflux surgery is associated with transaminitis related to hepatic retraction, which is independent of patient posture or duration of observation, and it resolves spontaneously with no clinical consequences.

What is the role of the abdominal perfusion pressure for subclinical hepatic dysfunction in laparoscopic cholecystectomy?

BACKGROUND

Subclinical hepatic dysfunction after laparoscopic cholecystectomy (LC) has been described in the literature. However, this alteration is not encountered in all patients. In order to address this situation, a prospective study was conducted to investigate the effect of abdominal perfusion pressure (APP) on liver function tests after LC performed under constant intra-abdominal pressure (IAP).

PATIENTS AND METHODS

Of 78 patients who underwent LC between May 2007 and October 2007, 40 patients were eligible for the study. In all the patients, six parameters of liver function (aspartate aminotransferase, alanine aminotransferase, direct bilirubin, indirect bilirubin, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients who showed more than a 100% increase in at least one parameter (group 1) were compared to those who did not (group 2) regarding age, sex, body weight, body height, operation time, pneumoperitoneum time, IAP, preoperative, and intraoperative APP.

RESULTS

Of the patients, 37.5% showed more than a 100% increase in at least one parameter of liver function. No significant difference was found between the two groups with regard to age, sex, body weight, body height, operation time, pneumoperitoneum time, and IAP. There were significant increase in AST and ALT at 24 hours postoperatively in group 1, as compared with group 2 (P = 0.000, P = 0.001). In comparison of preoperative APP with intraoperative APP values, group 1 showed a statistically significant decrease (P = 0.000), while no difference was found in group 2.

CONCLUSION

Subclinical hepatic dysfunction after LC could mostly be attributed to the negative effects of the pneumoperitoneum on hepatic blood flow. For the evaluation of hepatic hypoperfusion, APP may be a new criterion as a determinant of interaction with mean arterial pressure (MAP) and IAP.

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

BACKGROUND

Studies made on a small number of patients have demonstrated significant modifications in liver function tests (LFT) following laparoscopic cholecystectomy.

AIM

To assess retrospectively, post-operative LFT in a large group of patients undergoing elective uneventful laparoscopic cholecystectomy.

METHODS

Between 1999 and 2007, 1,997 patients were scheduled for laparoscopic cholecystectomy. In 1,034 patients (the study group), the surgery was elective and normal LFT were measured a day prior to surgery. Exclusion criteria included acute cholecystitis, acute pancreatitis, pre-operative endoscopic retrograde cholangio-pancreatography, medication that may affect liver metabolism, and intra-operative complications. Liver function tests were evaluated pre-operatively and 20-24 h post-operatively.

RESULTS

The mean post-operative value of liver function tests and amylase were well within normal limits, although mild increase was inspected in part of it. We observed post-operative mild hepatic enzyme increase only in 41 patients (3.9%), in nine of these, choledocholithiasis was found.

CONCLUSIONS

In contrary to previously published data, we have validated, in light of our broad sampling, that the induction of CO(2) pneumoperitoneum does not cause deranged liver function tests.

Effect of carbon dioxide pneumoperitoneum on liver function following laparoscopic cholecystectomy

BACKGROUND

It has been noted that following a laparoscopic cholecystectomy (LC), liver function parameters were disturbed. The causes of this disturbance are still controversial.

PATIENTS AND METHODS

The serum levels of eight parameters of liver function were measured both before and 24 hours after surgery in 142 consecutive patients who underwent LC, 23 patients who underwent open cholecystectomy (OC), and in 25 patients who underwent a conventional hernial repair. The same anesthetic protocol was applied to all patients in the various groups and in the case of LC; the intra-abdominal pressure was maintained at 12 mmHg of CO2.

RESULTS

Twenty-four (24) hours after surgery, there was a statistically significant change of all the eight parameters studied, except alkaline phosphatase in patients who underwent LC, whereas there were only 3 patients from the OC group who had changes of alanine aminotransferase and aspartite aminotransferase and 2 patients who had raised levels of direct bilirubin, and no changes were observed among those who had conventional hernial repair. We found that 83% of the patients showed more than a 100% increase in at least one parameter, 43% showed an increase in two or more parameters, and 23% showed an increase in three or more parameters. We also observed a significant drop of total proteins and albumin levels in all patients who had LC.

CONCLUSIONS

It appears that the pneumoperitoneum plays a major role in these changes. Although these changes of liver function were of no clinical relevance in healthy patients, the safety of the procedure must nonetheless be assessed in those with underlying liver diseases.

Carbon dioxide pneumoperitoneum-related liver injury is pressure dependent: A study in an isolated-perfused organ model

BACKGROUND

Disturbed liver function tests are associated with the pneumoperitoneum applied for biliary and non-biliary laparoscopic surgical procedures. The extent, duration and reversibility of such an injury are unknown. An isolated organ model was used to assess reversibility of liver injury in a CO(2)-pneumoperitoneum-like environment.

METHODS

Rat livers (n = 63) were isolated and perfused within a chamber pressurized at 0, 3, 5, 8, 12, 15 or 18 mmHg for 60 minutes. Pressure was annulled during the ensuing 61-90 minutes in one-half of the groups and markers of liver function were measured and recorded.

RESULTS

Inflow pressure level, flow rate, effluent partial O(2) and CO(2) pressures, O(2) extraction rate, lactate dehydrogenase level, lactic to pyruvic acid ratio, and total xanthine oxidase and dehydrogenase levels became abnormal, starting at 15 minutes after a pressure >5 mmHg was applied in the chamber. Signs of injury slowly reversed towards baseline values in all groups except for the 15 mmHg and 18 mmHg-pressurized ones, even after pressure had been annulled for 30 minutes.

CONCLUSIONS

CO(2)-pneumoperitoneum-like conditions directly injured rat liver tissue to a degree which correlated with the amount of applied pressure. Damage caused by pressure >or=15 mmHg was no longer reversible if it had been applied over a 60-minute period.

Signs of reperfusion injury following CO2 pneumoperitoneum: an in vivo microscopy study

BACKGROUND

During laparoscopic surgery, pneumoperitoneum is generally established by means of carbon dioxide (CO(2)) insufflation which may disturb hepatic microperfusion. It has been suggested that the desufflation at the end of the procedure creates a model of reperfusion in a previously ischemic liver, thus predisposing it to reperfusion injury.

METHODS

To study the effects of pneumoperitoneum on hepatic microcirculation, Sprague-Dawley rats underwent pneumoperitoneum with an intraabdominal pressure of 8 or 12 mmHg for 90 min. Subsequently, in vivo microscopy was performed to assess intrahepatic microcirculation and transaminases were measured to index liver injury.

RESULTS

A CO(2) pneumoperitoneum of 8 mmHg did not change serum transaminases; however, further increase of intraperitoneal pressure to 12 mmHg significantly increased AST, ALT, and LDH measured after desufflation to almost 1.5 times as much as control values of 49 +/- 5 U/L, 31 +/- 3 U/L, and 114 +/- 12 U/L. In parallel, in all subacinar zones the permanent adherence of both leukocytes and platelets to the endothelium increased by about sixfold and threefold, respectively. Furthermore, Kupffer cells labeled with latex beads as an index for their activation were significantly increased compared to controls.

CONCLUSION

This in vivo observation demonstrated traces of reperfusion injury in liver induced by the insufflation and desufflation of CO(2 )pneumoperitoneum. The clinical relevance of this finding and the issue of using hepatoprotective substances to prevent this injury should be further investigated.

Utility of Liver Function Tests after Laparoscopic Cholecystectomy

Many surgeons routinely obtain liver function tests (LFTs) after all laparoscopic cholecystectomies. Others argue that LFTs provide no useful information and add time and expense to the patient's hospitalization. This purpose of this study was to determine if routine postoperative LFTs predict complications. One hundred ninety-nine consecutive patients undergoing laparoscopic cholecystectomy were included in the analysis. Nine (4.5%) patients had postoperative complications: eight with retained common bile duct stones and one with a cystic duct stump leak. All were diagnosed with postoperative endoscopic retrograde cholangiopancreatography. Only four of the nine patients had hyperbilirubinemia. Overall, 39 patients had postcholecystectomy hyperbilirubinemia, with four (10%) patients having complications (three retained stones and one had a bile leak). For the entire study population, there was no difference between pre- and postoperative total bilirubin and aspartate aminotransferase levels (0.6 vs 0.6 mg/dL; P = 0.623 and 25 vs 41 U/L; P = 0.111, respectively). There was a statistically significant difference in pre- and postoperative alanine aminotransferase and alkaline phosphatase (31 vs 50 U/L; P = 0.003 and 95 vs 90 U/L; P = 0.001, respectively). Postoperative elevations in liver function tests are frequently seen after laparoscopic cholecystectomy. These elevations do not predict postoperative complications. LFTs should be obtained only when clinically indicated.

Hepatic carbohydrate metabolism in rats after laparotomy and laparoscopy

BACKGROUND

Portal venous and mesenteric blood flow are reduced by 40-60% in humans and animals during laparoscopic surgery compared to laparotomy. Little is known about whether these intraabdominal micro- and macrocirculatory changes are associated with alterations in the hepatic energy metabolism.

METHODS

We operated on male Sprague-Dawley rats, performing either laparoscopy (CO2, 6 mmHg; n = 27) or laparotomy (n = 28), and compared the results with two control groups: intraperitoneal (i.p.) endotoxin administration (n = 28, positive control) and anesthesia only (n = 28, negative control). We investigated the impact of the two different surgical techniques on daily food intake, body weight gain, glycogen content in the liver, levels of blood glucose, and liver function tests (LFTs) on postoperative days 1, 2, 4, and 8. Local (hepatic) and systemic inflammatory responses (interleukin-6 and tumor necrosis factor-alpha) during the postoperative time course were also determined. Data were analyzed using the Kruskal-Wallis test or univariate analysis of variance.

RESULTS

Body weight gain, food intake, liver and spleen weights, as well as LFTs [except aspartate aminotransferase (AST)] did not differ among the four groups. The significant increase in the AST level following laparoscopy compared to the anesthesia-only group was found on postoperative days 1 and 2; however, a similar difference was not detected after laparotomy or i.p. endotoxin injection. Laparoscopy showed no alterations in the hepatic glycogen stores compared to anesthesia only, whereas laparotomy and endotoxinemia significantly reduced the hepatic glycogen stores on postoperative days 2 and 4. The systemic postoperative inflammatory response did not differ between laparotomy and laparoscopy, but it was higher in both groups than in anesthesia only. In rats treated with endotoxin, the systemic inflammatory response was even higher than in the two surgical groups. The hepatic inflammatory response did not differ between the four groups.

CONCLUSION

This study shows a significant postoperative decrease in the hepatic glycogen content after laparotomy and i.p. endotoxin injection but not after laparoscopy. Food intake and inflammatory response cannot explain this difference between the two surgical groups, which suggests that alterations in the postsurgical hormonal stress response are the most likely explanation for these findings.

Postoperative changes in liver function tests: randomized comparison of low- and high-pressure laparoscopic cholecystectomy

BACKGROUND

Pneumporeitoneum at 14 mmHg causes dangerous hemodynamic disturbances in some patients, leading to splanchnic ischemia. Laparoscopic cholecystectomy (LC) using low-pressure pneumoperitoneum (7 mmHg) minimizes adverse hemodynamic effects on hepatic portal blood flow and hepatic function. This study evaluated the changes in liver function tests after high-pressure LC (HPLC; 14 mmHg) and low-pressure LC (LPLC; 7 mmHg).

METHODS

For this study, 50 patients were randomly assigned to undergo either HPLC (n = 25) or LPLC (n = 25) Liver function tests including total bilirubin, gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were obtained preoperatively, then 24 and 48 h postoperatively. All patients had normal values on the preoperative liver function tests. The anesthesiologic protocol was uniform.

RESULTS

The findings showed that ALT after 24 h (LPLC: 1473.72 +/- 654.85; HPLC: 2233.74 +/- 1247.33; p = 0.0096) and 48 h (LPLC: 1322.99 +/- 601.51; HPLC 2007.80 +/- 747.55; p = 0.0008) and AST after 24 h (LPLC: 1189.96 +/- 404.79 i.j.; HPLC: 1679.40 +/- 766.13; p = 0.0069) were increased in the patients who underwent HPLC. The AST levels after 48 h were statistically unchanged from baseline in both groups. Total bilirubin, ALP, and GGT levels remained unchanged from baseline in both groups, without a significant difference between the two groups.

CONCLUSIONS

Because LPLC minimizes adverse hemodynamic effects on hepatic function, a low-pressure pneumoperitoneum should be considered for patients with compromised liver function, particularly those undergoing prolonged laparoscopic surgery.

Comparison of postoperative hepatic function between laparoscopic and open cholecystectomy

OBJECTIVE

In this prospective study, we evaluated the effects of pneumoperitoneum on hepatic function during laparoscopic (LC) and open cholecystectomy (OC).

SUBJECTS AND METHODS

One hundred patients who underwent LC (n = 50) or OC (n = 50) were included in the study. The groups were similar in age, sex, weight and height. Following liver function tests (total bilirubin; gamma-glutamyltransferase, GGT; alkaline phosphatase, ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) were obtained preoperatively and at 24 and 48 h postoperatively. Similar anesthesiologic protocol was used for both LC and OC. During LC, the intra-abdominal pressure was maintained within the conventional range of 12-14 mm Hg.

RESULTS

Total bilirubin, ALP, GGT and LDH levels remained unchanged from baseline in both groups without significant difference between them. A higher number of patients had increased values of ALT (26/50 vs. 5/50) and AST (23/50 vs. 6/50) in LC compared to OC group. Although the difference was statistically significant (p < 0.000 for ALT and p = 0.0004 for AST) the increased level decreased at 48 compared to 24 h.

CONCLUSION

The results indicate that LC is associated with transient elevation of ALT and AST. The disturbances in the function of the liver after LC are self-limited and not associated with any morbidity in patients with a normal liver function.

The physiologic effects of pneumoperitoneum in the morbidly obese

OBJECTIVE

To review the physiologic effects of carbon dioxide (CO2) pneumoperitoneum in the morbidly obese.

SUMMARY BACKGROUND DATA

The number of laparoscopic bariatric operations performed in the United States has increased dramatically over the past several years. Laparoscopic bariatric surgery requires abdominal insufflation with CO2 and an increase in the intraabdominal pressure up to 15 mm Hg. Many studies have demonstrated the adverse consequences of pneumoperitoneum; however, few studies have examined the physiologic effects of pneumoperitoneum in the morbidly obese.

METHODS

A MEDLINE search from 1994 to 2003 was performed using the key words morbid obesity, laparoscopy, bariatric surgery, pneumoperitoneum, and gastric bypass. The authors reviewed papers evaluating the physiologic effects of pneumoperitoneum in morbidly obese subjects undergoing laparoscopy. The topics examined included alteration in acid-base balance, hemodynamics, femoral venous flow, and hepatic, renal, and cardiorespiratory function.

RESULTS

Physiologically, morbidly obese patients have a higher intraabdominal pressure at 2 to 3 times that of nonobese patients. The adverse consequences of pneumoperitoneum in morbidly obese patients are similar to those observed in nonobese patients. Laparoscopy in the obese can lead to systemic absorption of CO2 and increased requirements for CO2 elimination. The increased intraabdominal pressure enhances venous stasis, reduces intraoperative portal venous blood flow, decreases intraoperative urinary output, lowers respiratory compliance, increases airway pressure, and impairs cardiac function. Intraoperative management to minimize the adverse changes include appropriate ventilatory adjustments to avoid hypercapnia and acidosis, the use of sequential compression devices to minimizes venous stasis, and optimize intravascular volume to minimize the effects of increased intraabdominal pressure on renal and cardiac function.

CONCLUSIONS

Morbidly obese patients undergoing laparoscopic bariatric surgery are at risk for intraoperative complications relating to the use of CO2 pneumoperitoneum. Surgeons performing laparoscopic bariatric surgery should understand the physiologic effects of CO2 pneumoperitoneum in the morbidly obese and make appropriate intraoperative adjustments to minimize the adverse changes.

The effects of etomidate, thiopental, and propofol in induction on hypoperfusion-reperfusion phenomenon during laparoscopic cholecystectomy

BACKGROUND

A hypoperfusion-reperfusion human model is observed during and soon after laparoscopic surgery. The aim of the study was to research the preventive effects of etomidate, thiopental, and propofol in induction on hypoperfusion- reperfusion phenomenon during laparoscopic cholecystectomy.

METHODS

Thirty-six consecutive ASA I-II patients were randomized into three groups of 12 patients each. Anaesthesia was induced with etomidate in group 1, thiopental in group 2, and propofol in group 3. Venous blood samples were obtained at different time points for measurement of plasma malondialdehyde (MDA) levels. Arterial blood and gastric juice samples were obtained for the calculation of gastric intramucosal pH (pHi). Also changes in aminotransferases, alkaline phosphatase and total bilirubin levels were assessed.

RESULTS

There was a significant decrease in pHi at 1 min before desufflation (BD) and 20 min after desufflation (AD) compared with before insufflation (BI) in all groups. Plasma level of MDA was significantly increased in group 1 at 1 min BD and 20 min AD compared with before induction of anaesthesia (baseline). Malondialdehyde levels were decreased significantly in group 3 and increased non-significantly in group 2 at the same time points. Also AST and ALT levels were significantly increased in both groups 1 and 2 at 24 h postoperatively.

CONCLUSION

Propofol with antioxidant activity may offer many advantages by scavenging reactive oxygen species and their metabolites in case of anticipated hypoperfusion-reperfusion phenomenon, such as would occur in laparoscopic surgery.

Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass

BACKGROUND

Pneumoperitoneum has been shown to reduce hepatic portal blood flow and alter postoperative hepatic transaminases. This study evaluated the changes in hepatic function after laparoscopic and open gastric bypass (GBP).

METHODS

Thirty-six morbidly obese patients were randomly assigned to undergo either laparoscopic (n = 18) or open (n = 18) GBP. Liver function tests--total bilirubin (T Bil), gamma GT (GGT), albumin, alkaline phosphatase (ALP), aspartate transferase (AST), alanine transferase (ALT)--and creatine kinase levels were obtained preoperatively and at 1, 24, 48, and 72 hours postoperatively.

RESULTS

The two groups were similar in age, sex, and body mass index. Albumin and ALP levels decreased while T Bil and GGT levels remained unchanged from baseline in both groups without significant difference between the two groups. After laparoscopic GBP, ALT and AST transiently increased by sixfold and returned to near baseline levels at 72 hours. After open GBP, ALT and AST transiently increased by fivefold to eightfold and returned to near baseline levels by 72 hours. Creatine kinase level was significantly lower after laparoscopic GBP than after open GBP at 48 and 72 hours postoperatively. There was no postoperative liver failure or mortality in either group.

CONCLUSIONS

Laparoscopic GBP resulted in transient postoperative elevation of hepatic transaminase (ALT, AST) but did not adversely alter hepatic function to any greater extent than open GBP. Creatine kinase levels were lower after laparoscopic GBP reflecting its lesser degree of abdominal wall trauma.

Estudo da função hepática de ratos espontaneamente hipertensos submetidos a diferentes pressões de pneumoperitônio com CO2

OBJETIVOS: Avaliar a função hepática de ratos hipertensos submetidos a baixa ou alta pressão de pneumoperitônio. MÉTODOS: Foram utilizados 60 ratos, distribuídos em dois grupos (n= 30), de acordo com a pressão de pneumoperitônio de 4 e 10mmHg, sendo 15 animais da linhagem EPM-1 Wistar e 15 animais da linhagem SHR. Logo após a pesagem, os animais foram submetidos à anestesia com cetamina e xilazina intramuscular e, em seguida, submetidos a pneumoperitônio, durante 1 hora e desinsuflação por mais 1 hora. Foram coletadas amostras sangüíneas logo após a realização do cateterismo da artéria femoral esquerda, após uma hora de insuflação, assim como, depois de uma hora de desinsuflação. Estas amostras foram encaminhadas para a avaliação das enzimas hepáticas (AST, ALT, DHL) e bilirrubinas (total, direta e indireta). O nível de significância estatístico foi estabelecido em 5%. RESULTADOS: Com pneumoperitônio de 4mmHg a AST e ALT apresentaram níveis iniciais menores do que após insuflação e desinsuflação enquanto a DHL, a BT e a BD não se alteraram; em ambas as linhagens. Na pressão de 10mmHg a AST e a DHL não se alteraram nos ratos normotensos e aumentaram nos hipertensos, a BD não se alterou, a ALT e a BT aumentaram para ambas as linhagens. CONCLUSÃO: A função hepática mostrou-se alterada e a medida do tempo após a desinsuflação foi curta para evidenciar uma eventual reversão dessas alterações, tanto nos animais hipertensos, como em animais hígidos.

Liver function disturbances following laparoscopic cholecystectomy: incidence and significance

BACKGROUND

Unexplained disturbances of liver function parameters after laparoscopic cholecystectomy have been reported in a few previous studies. We aimed to assess the incidence of these disturbances, and their relation to age, sex, duration of surgery, and type of gallbladder inflammation, as well as their clinical significance.

PATIENTS AND METHODS

All patients undergoing laparoscopic cholecystectomy at Dallah Hospital, Riyadh, Saudi Arabia, during the year 2001 were prospectively evaluated. In all the patients, six parameters of liver function (direct bilirubin, indirect bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients with suspected chronic liver disease or common bile duct pathology were excluded. Patients who showed more than a 100% increase in at least one parameter (group I) were compared with those who did not (group II) regarding age, sex, duration of surgery, and type of gallbladder inflammation.

RESULTS

Of the patients, 67.1% showed more than a 100% increase in at least one parameter of liver function. No significant difference was noticed between the two groups regarding age, duration of surgery, or type of gallbladder inflammation. Female patients, however, showed a significantly higher incidence of liver function changes (P = .011). No clinical adverse reactions were reported in those who showed liver function changes.

CONCLUSION

Changes in liver function parameters after laparoscopic cholecystectomy are common, carrying no clinical sequalae. They are more common in female patients and are not related to age, duration of surgery, or the acuteness of gallbladder inflammation. Assessment of direct bilirubin and alkaline phosphatase is sufficient for the routine evaluation of these patients postoperatively.

The effects of vasoactive drugs on hepatic blood flow changes induced by CO2 laparoscopy: an animal study

Laparoscopic surgery is associated with systemic and splanchnic hemodynamic alterations. Recent data suggest that small-dose dobutamine may attenuate the reduction in splanchnic blood flow associated with increments in intraabdominal pressure. We conducted this study to analyze the effects of dopamine and dobutamine on the hepatic circulation in this setting. Twenty-one pigs were anesthetized and mechanically ventilated. A flow-directed pulmonary artery and carotid artery catheters were inserted. Perivascular flow probes were placed around the main hepatic artery and the portal vein. CO2 was insufflated into the peritoneal cavity to reach an intraabdominal pressure of 15 mm Hg. After 60 min, animals received dopamine (5 microg x kg(-1) x min(-1); n = 8), dobutamine (5 microg x kg(-1) x min(-1); n = 8), or saline (n = 5) for 30 min. Pneumoperitoneum induced significant increases in heart rate, mean arterial pressure, and systemic vascular resistance, with decreases in cardiac output and hepatic artery and portal vein blood flows. Dobutamine infusion, in contrast to dopamine, corrected, at least in part, cardiac output, systemic vascular resistance, and hepatic artery blood flow alterations, but neither drug restored total hepatic blood flow.

IMPLICATIONS

Hepatic blood flow decreases during laparoscopic surgery. A small-dose infusion of neither dobutamine nor dopamine corrects the total hepatic blood flow impairment, but the former is able to restore the hepatic arterial blood supply in an animal model mimicking this condition.

Suspected biliary complications after laparoscopic and open cholecystectomy leading to endoscopic cholangiography: a retrospective comparison

To study how suspected postoperative biliary complications are influenced by surgical technique, we compared clinical profiles of 63 patients referred for ERCP after open (OC) and laparoscopic cholecystectomy (LC) over a four-year period. ERCP was not performed for postoperative pain alone and only six (9.5%) studies were normal. Referrals after LC were younger (mean 39.1 vs 53.6 years, P < 0.001) and ERCP was requested earlier (mean 71.6 vs 2360 days, P < 0.001) in the postoperative course. Choledocholithiasis (CDL) alone, the most common finding, was successfully managed with a single ERCP in 97.2% of cases. CDL after LC occurred in younger patients (35.5 vs 58.9 years, P < 0.01) who presented earlier (mean 98.6 days vs 5.1 years, P < 0.01), without biliary ductal dilatation (P < 0.01). Although CDL after LC was associated with higher ALT and bilirubin levels than after OC, the difference was not statistically significant. Cystic duct leaks (LC: six patients, OC: four patients) were typically associated with CDL after OC and 90% resolved with endoscopic therapy. Biliary ligation (four cases) was managed successfully with choledochojejunostomy. We conclude that findings at ERCP for suspected biliary obstruction or injury after OC or LC are similar and usually can be endoscopically managed. After LC, referrals currently are younger, present much earlier, and retained stones are less likely to be associated with ductal dilatation than after OC.

Morbidity and mortality of laparoscopic cholecystectomy in an institutional setup

Laparoscopic cholecystectomy (LC) though a very safe operative procedure does have its own morbidity and mortality. The present study was undertaken to analyze the morbidity and mortality of this procedure in an institutional setting. Between October 1992 and October 1995 a total of 433 patients received LC. Conversion to open cholecystectomy was required in 62 patients (14.3%). The decision to convert was made because the surgeon was forced to convert (3.7%) or the conversion was the operator's choice (10.6%). There was no difference in the conversion rate of consultants versus residents (14.4% vs. 14.2%). Major intraoperative and postoperative morbidity was encountered in 8.3% of patients. One patient required reexploration. The incidence of common bile duct (CBD) injury was 2.5%. There was no operative or 30 days mortality. However, two patients died in the follow-up period due to procedure-related complications. Low threshold for conversion, early recognition of morbidity, and prompt and judicious management of such complications under guided supervision is necessary in order to avoid major postoperative problems. The experience in a teaching hospital training program is different from that of an individual surgical setup.