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Abstract
The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.
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Affiliation(s)
- Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7AS, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
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Effects of Heated Pneumoperitoneum on Inflammation, Oxidative Stress, and Peritoneal Histology in Female Dogs That Underwent Video-Assisted Ovariohysterectomy. Vet Med Int 2021; 2021:5515559. [PMID: 34721833 PMCID: PMC8556121 DOI: 10.1155/2021/5515559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/05/2021] [Indexed: 12/08/2022] Open
Abstract
Laparoscopic procedures require the creation of pneumoperitoneum. CO2, which must be cold and dry, is the standard gas used in such surgeries. The type of gas used, its temperature, and moisture may change the peritoneal surface and cause systemic and local oxidative stress. Our objective is to evaluate the influence of pneumoperitoneum heating on the occurrence of histological lesions in the peritoneum, inflammation, plasma oxidative stress, and on the mesothelial surface in patients undergoing video-assisted ovariohysterectomy. Twenty canine females were included and distributed evenly into two groups: heated CO2 (HG) and unheated CO2 (UHG). The biomarkers of inflammation and oxidative stress were evaluated before insufflation (T0), at 30 min (T1), and at 60 min (T2) of exposure to CO2. Biopsies of the peritoneal tissue for histological evaluation were performed at T0 and T2. Regarding plasma parameters, acetylcholinesterase (AChE) showed a greater activity in the HG at T1 (p=0.0268) and T2 (p=0.0423); in turn, butyrylcholinesterase (BChE) showed a greater activity at T2 in the HG (p=0.0175) compared with T0. Catalase activity (CAT) was different between HG times; it was higher at T1 (p=0.0253). There was a decrease in the levels of substances reactive to thiobarbituric acid (TBARS) (p=0.0117) and in glutathione (GSH) (p=0.0114) between T0 and T2 in the UHG. Regarding tissue oxidative stress, the CAT in the HG showed a greater activity at T2 than T1 (p=0.0150). By comparing the groups at each time, there was a difference only at T2 (p=0.0288), being greater in the HG. Regarding the activity of superoxide dismutase (SOD) in the HG, there was a difference between T2 in relation to T0 and T1 (p=0.0181); finally, there was an increase only at T1 (p=0.0287) in the UHG when comparing groups at the same time. There were no differences in the histological parameters evaluated. Our study demonstrates that the heating of CO2 generates a greater inflammatory response and forms reactive oxygen species (ROS) at the plasma and peritoneal levels.
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Bickel A, Khatib S, Kakiashvilli E, Palzur E. Reappraisal of ischemia-reperfusion injury in a short duration laparoscopic surgery, a pilot study. BMC Surg 2021; 21:346. [PMID: 34544418 PMCID: PMC8451121 DOI: 10.1186/s12893-021-01339-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background Serum biochemical changes during laparoscopic surgery and positive pressure pneumoperitoneum (PP) may reflect mild oxidative stress due to the ischemia-reperfusion (I/R) mechanism. However, there is still a controversy regarding the exact mechanism of PP in creating oxidative stress and whether the induction of PP causes I/R effects at all. To elucidate this debated issue, we studied, for the first time, the changes of I/R parameters in the serum, in a pilot study, during laparoscopic cholecystectomy using a reliable, independent exogenous oxidative biomarker, together with common intrinsic biomarkers of oxidative stress. Patients and methods Our study included 20 patients scheduled for elective laparoscopic cholecystectomy. We evaluated the levels of the extrinsic and endogenous markers for oxidative stress during awareness, under anesthesia, the end of surgery (abdominal CO2 evacuation), and 2 h afterward. Results After an initial increase in oxidative stress following anesthesia, we did not notice any further significant rise in the levels of the synthetic exogenous and the endogenous biomarkers at the end of the surgery and 2 h later on. However, a positive correlation was noted between the levels of both the intrinsic and extrinsic markers. Conclusions In our study, the capability of the extrinsic biomarker to detect mild oxidative stress was not validated. Our study stresses the heterogeneous nature of the oxidative reactions and the diversity of the endogenous and exogenous biomarkers while detecting various biochemical patterns under mild oxidative stress, during the short period of laparoscopic surgery.
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Affiliation(s)
- Amitai Bickel
- Department of Surgery A, Galilee Medical Center, P.O.Box 21, 22100, Nahariya, Israel. .,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.
| | - Soliman Khatib
- Department of Biochemistry, MIGAL Galilee Research Institute, Kiryat Shmona, Israel
| | - Eli Kakiashvilli
- Department of Surgery A, Galilee Medical Center, P.O.Box 21, 22100, Nahariya, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Eilam Palzur
- Eliachar Research Laboratories, Galilee Medical Center, Nahariya, Israel
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A comparison of the oxidative stress response in single-incision laparoscopic versus multi-trocar laparoscopic totally extraperitoneal inguinal hernia repair. Wideochir Inne Tech Maloinwazyjne 2020; 15:567-573. [PMID: 33294071 PMCID: PMC7687664 DOI: 10.5114/wiitm.2020.93202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/13/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction Surgical treatment is always associated with tissue damage and the subsequent development of oxidative stress. Aim To compare the oxidative stress response in patients treated operatively for inguinal hernia with multi-trocar laparoscopic totally extraperitoneal technique (TEP) or single-incision laparoscopic totally extraperitoneal technique (TEP-SI). Material and methods A randomized group of 34 patients with one-sided inguinal hernia was enrolled in the study. Seventeen patients were treated with a standard TEP method (group 1) and the other 17 patients were treated with the TEP-SI technique (group 2). Thiobarbituric acid reactive substances (TBARS) and total antioxidant status (TAS) as the oxidative stress markers were measured before surgery (0), 1 day (1) and 4 days (2) after surgery. Results A decrease in TAS on the first day after surgery was observed in both groups. Sustained reduction on the fourth day after surgery was observed in group 1, whereas in group 2 an increase followed. A statistically significant difference was observed in TAS (2 : 0) ratio with a meaningful decrease in group 1. TBARS concentration was elevated 1 day after surgery in both groups. It remained at an elevated level on the fourth day after surgery in group 1, while it decreased in group 2. The duration of surgery was higher in group 2 (mean: 57.5 min) than in group 1 (mean: 50.0 min) (p = 0.0286). Conclusions Oxidative stress levels are lower in patients treated operatively by TEP-SI technique than by TEP. TEP-SI may be considered as a less invasive technique associated with less tissue injury.
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de Freitas Junior S, Bustorff-Silva JM, Ramos CD, Brunetto SQ, da Costa APM, Antunes AG, Biavatti BBV, Franchi Junior GC, Moreira MM, Felix PCG, Miranda ML. Scintigraphic Evaluation of the Impact of Pneumoperitoneum on Renal Blood Flow: A Rabbit Model. J Laparoendosc Adv Surg Tech A 2019; 29:1271-1275. [PMID: 31483185 DOI: 10.1089/lap.2019.0194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Increased intra-abdominal pressure resulting from pneumoperitoneum can cause renal physiological changes, such as oliguria and anuria, in mammals. Although videolaparoscopic operations are common, the occurrence of renal lesions due to these procedures has not been precisely documented in the literature. The aim of this study was to evaluate the impact of pneumoperitoneum on renal blood flow using renal scintigraphy in a rabbit model. Methods: Six New Zealand male rabbits weighing 3 kg, previously anesthetized, were mechanically ventilated and underwent pneumoperitoneum. Each animal served as its own control and was analyzed in two different moments: [99mTc] diethylenetriaminepentaacetic acid (DTPA) renal blood flow evaluation in baseline conditions (T0) and 30 minutes after installation of 15 mmHg-pneumoperitoneum (T1). The animals were monitored throughout the study by capnography, oximetry, and arterial pressure median, and were euthanized at the end of the experiment. Results: The quantitative analysis of the scintigraphic images of renal uptake of the radiopharmaceutical evidence reduced renal arterial blood flow during pneumoperitoneum. Compared with baseline conditions, all animals presented a reduction of renal blood flow varying from 16% to 82%, with mean [±standard deviation] of 53% [±24%]. Conclusions: Pneumoperitoneum induces a significant reduction of the renal blood flow, as determined in this experimental method in rabbits and dynamic renal scintigraphy with [99mTc] DTPA is an adequate method to investigate this event in the experimental setting.
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Affiliation(s)
| | | | - Celso Dario Ramos
- Department of Radiology, State University of Campinas, Campinas, Brazil
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Effects of propofol on the inflammatory response during robot-assisted laparoscopic radical prostatectomy: a prospective randomized controlled study. Sci Rep 2019; 9:5242. [PMID: 30918320 PMCID: PMC6437140 DOI: 10.1038/s41598-019-41708-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/21/2019] [Indexed: 12/20/2022] Open
Abstract
Robot-assisted laparoscopic radical prostatectomy (RALRP) is a minimally invasive procedure; however, some amount of surgical trauma that can trigger systemic inflammation remains. Moreover, pneumoperitoneum during RALRP induces ischemia–reperfusion injury (IRI). Propofol, an anesthetic, is known to have anti-inflammatory and antioxidant properties. In the present study, we compared the effects of propofol with those of desflurane on inflammation and IRI during RALRP via measurements of different biomarkers and evaluation of perioperative renal function. Fifty patients were randomized to receive either desflurane (n = 25) or propofol (n = 25) with remifentanil during RALRP. Serum levels of interleukin (IL)-6 (IL-6), tumor necrosis factor alpha, C-reactive protein, and nitric oxide were measured 10 min after anesthesia induction (T1), 100 min after carbon dioxide (CO2) insufflation (T2), and 10 min after CO2 deflation (T3). Perioperative urine outputs and the serum creatinine level at 24 h after surgery were also recorded. We found that IL-6 levels at T2 and T3 were higher than those at T1 in both groups, although the increases were significant attenuated only in the propofol group. The other parameters showed no differences among the three time points in both groups. The intraoperative urine output was significantly higher in the propofol group than in the desflurane group, while the creatinine level showed no significant changes in either group. Our findings suggest that propofol can not only attenuate the inflammatory response during and after pneumoperitoneum in patients undergoing RALRP but also prevent oliguria during pneumoperitoneum.
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Comparison of the impact of prolonged low-pressure and standard-pressure pneumoperitoneum on myocardial injury after robot-assisted surgery in the Trendelenburg position: study protocol for a randomized controlled trial. Trials 2016; 17:488. [PMID: 27724965 PMCID: PMC5057242 DOI: 10.1186/s13063-016-1609-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 09/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background Robot-assisted laparoscopic radical prostatectomy and robot-assisted radical cystectomy have gradually become the preferred choices for urologists as they allow surgeons to perform complex procedures more precisely and effectively. The pneumoperitoneum, which is normally applied in these surgeries to provide visual clarity and space to perform the procedure, may cause hemodynamic disturbance, potentially myocardial injury. Thus surgeons have recently considered opting for the low-pressure pneumoperitoneum to lower this negative impact. Herein we describe a protocol for a clinical trial to compare the impact of prolonged low-pressure and standard-pressure pneumoperitoneum on myocardial injury after robot-assisted surgery. Methods/design This study is designed to be a bicenter clinical trial. In total 280 patients scheduled to undergo robot-assisted laparoscopic radical prostatectomy or robot-assisted radical cystectomy will be enrolled and randomized into two groups, with standard- (12–16 mmHg) and low-pressure (7–10 mmHg) pneumoperitoneum, respectively. Troponin T will be measured as the primary endpoint to assess the extent of myocardial injury. Nt-proBNP and hemodynamic indexes will also be recorded for further analysis. Discussion The significance of this study is emphasized by the fact that there are few studies that have focused on the impact of prolonged pneumoperitoneum on myocardial injury, which is relevant to postoperative mortality. We hope that the conclusions drawn from this study could provide reference and basis to the future of the pneumoperitoneum in clinical practice. Trial registration Registered at https://www.clinicaltrials.gov with the Identifier NCT02600481 on November 5, 2015 Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1609-5) contains supplementary material, which is available to authorized users.
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Koninckx PR, Gomel V, Ussia A, Adamyan L. Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue. Fertil Steril 2016; 106:998-1010. [PMID: 27523299 DOI: 10.1016/j.fertnstert.2016.08.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 02/08/2023]
Abstract
A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO2 pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N2O to the CO2 pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.
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Affiliation(s)
- Philippe R Koninckx
- Department of Obstetrics and Gynecology, Catholic University Leuven, University Hospital, Gasthuisberg, Leuven, Belgium; Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy.
| | - Victor Gomel
- Department of Obstetrics and Gynecology, University of British Columbia, Women's Hospital, Vancouver, British Columbia, Canada
| | - Anastasia Ussia
- Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Center for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia, Russian Federation
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A prospective double-blinded randomized controlled trial comparing systemic stress response in Laparoascopic cholecystectomy between low-pressure and standard-pressure pneumoperitoneum. Int J Surg 2016; 28:28-33. [PMID: 26892713 DOI: 10.1016/j.ijsu.2016.02.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 01/31/2016] [Accepted: 02/11/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) has become the gold-standard treatment for gallstone diseases. However, despite huge reduction in operative injury, systemic stress response remains high. This randomized controlled trial (RCT) aimed to compare systemic stress response between 2 different techniques of CO2 pneumoperitoneum. METHODS Trough a prospective, double-blinded RCT, serum levels of cortisol, adrenaline, glucose, and C-reactive protein (CRP) were compared between the two groups consisted of 50 patients undergoing LC under low-pressure and standard-pressure CO2 pneimoperitoneum. RESULTS A total of fifty patients undergoing LC were equally assigned to 2 groups of twenty five patients. Average age was 48 ± 13.8 years (range, 19-74 years). Operative time was similar between standard-pressure group (47.8 ± 16.8 min) and low-pressure group (53.6 ± 25.1). Moreover, intra-operative IV volume administration and urine output did not differ significantly between the 2 groups (p > 0.05). Although the average heart rate and mean arterial pressure were slightly higher in a standard-pressure group compared with a low-pressure group, serial measurements of these parameters were statistically similar between the 2 groups. Serial changes of serum levels of cortisol, glucose, adrenaline, and CRP were compared between surgery day, postoperative 6-h and 1st postoperative day, which did not differ significantly between the standard-pressure and the low-pressure groups (p > 0.05). CONCLUSION Our study did not reveal any alteration in systemic stress response with reduction in intra-abdominal pressure of pneumoperitoneum in LC. RCT REGISTRATION: irct.ir ID: IRCT201110072982N5.
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