Inflammatory response in open and laparoscopic cholecystectomy

The modifications of IL-6. CRP, ceruloplasmin, alpha 1 antitrypsin, fibrinogen, transferrin, albumin and leukocytes counts have been evaluated after traditional open cholecystectomy (OC) or laparoscopic cholecystectomy (LC). Forty-two patients were included in this study, 20 underwent to OC and 22 underwent to LC. Serum samples were performed before surgery and at distance of 6, 24, 48 and 168 hours. The results show a more significant increase in acute phase inflammatory response after OC compared with LC as attested by highest values of leukocytosis, IL-6, CRP, fibrinogen and alpha 1 antitrypsin and lower levels of albumin. In conclusion, after LC, the phase acute response is attenuate and it can explain the reduced period of convalescence of patients treated with LC.

Th1-like and Th2-like cytokines in patients undergoing open versus laparascopic cholecystectomy

The advantages of laparoscopic (LC versus, open cholecystectomy (OC) seems to be related to minimal invasive procedure and to the moderate inflammatory response. The aim of this study is to define the involvement of Th1 (IFN-gamma) and Th2 (IL-4, IL-6, IL-10, IL-13) cytokines production in vivo and in vitro in patients undergoing OC or LC. In 42 patients undergoing LC (n = 22) and OC (n = 20) Th1-like and Th2-like was evaluated before operation and at 6, 24 and 48 hours after operation for white blood cell counting and cytokines (IL-4, IL-6, IL-10, IL-13, IFN-gamma, TNF-alpha) in the sera and in the supernatants from circulating mononuclear cells stimulated with phytohemagglutinin or lipopolysaccharide. The acute phase response cytokine, IL-6, appeared significantly increased following OC than after LC. All other cytokines did not very significantly. In vitro data shows a reduction of IFN-gamma and increase in Th2-like cytokines in OC patients compared with the basal value. In LC subjects we observed an high production of IFN-gamma associated to an increase of Th2-like cytokines, like IL-10 and IL-13, even though IL-4 and IL-6 were unmodified. In contrast to OC, LC did not significantly affect immunocompetence, maintaining a moderate inflammatory response and an adequate balance between Th1 and Th2 cytokine. Furthermore, the strong activation of cells producing Th1-like cytokines in LC patients following mitogen activation indicated a consistent anti-microbial activity, that was not detectable in OC patients, that showed after activation only a Th2 response.

[Fibrinolytic system after laparoscopic cholecystectomy]

BACKGROUND

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are the most important causes of morbility and mortality in patients submitted to surgical intervention: some peculiar factors of laparoscopic surgery can modify their risk. The aim of this study is to evaluate possible variations of the fibrinolytic system after cholecystectomy.

METHODS

Eighteen patients affected by symptomatic and non-complicated gallstones have been included in this study. They were divided into two groups of nine patients each: the first group was submitted to laparoscopic cholecystectomy (LC) and the second to open cholecystectomy (OC). Antitrombin III (ATIII), fibrinogen degradation products (FDP), tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI) have been evaluated preoperatively and 6, 12, 24 and 48 hours after the operation.

RESULTS

The levels of ATIII did not present significantly variations. The FDP in both groups were significantly increased 48 hours after open cholecystectomy. Levels of PAI instead were increased in comparison to the basal values at 6, 12, 24, 48 hours with p < 0.05; p < 0.01 and p < 0.05 respectively in patients submitted to OC, in the LC group no variations were observed; a comparison between the groups showed a significant modification (p < 0.05) only at the 12th hour.

CONCLUSIONS

The early mobilization of patients in the postoperative course and the lower invasion of LC can oppose the prothrombotic effect in the lower limbs.

[Cell-mediated immunity after laparoscopic cholecystectomy]

Cell-mediated immunity (CMI) is temporarily decreased after major surgical procedures in relation to type of anaesthesia, length and severity of an intervention. In this study it has been evaluated CMI response in vivo, after laparoscopic (LC) and open cholecystectomy (OC). 5 healthy persons and 16 patients with symptomatic and uncomplicated gallstones were studied. They were subdivided in two groups: 8 were treated by OC, 8 by LC. A skin test system (Multitest, IMC-Institute Merieux, Lyon, France) consisting of a plastic disposable multiple-puncture device capable of simultaneous application of seven delayed-type hypersensitivity antigens and a glycerin and saline diluent (negative control) was used. The test was performed 48 hours before and 24 hours after the surgical procedure. A diameter of 2 mm or more of the induration was considered as a positive response. A score expressed, as the sum in millimeters of all the mean diameters (DM) of positive reactions and as numbers of antigens (NA) positive was calculated. Statistics was assessed by Student's t test for comparison of averages. There was no difference of age, sex, anesthesiologic risk, length of the operation between the two groups. We observed a significative reduction of DM (P < 0.05) and of NA (P < 0.05) in patients in which OC was performed while there were no significant in the group treated by LC. Results show a significant suppression of the CMI after OC, no particular changes after LC according to other studies in vitro.

[Changes in the hemostatic system after laparoscopic cholecystectomy]

A 30 degrees reverse Trendelenburg position and the pneumoperitoneum performed in patients undergoing at Laparoscopic Cholecystectomy (LC) cause haemodynamic modifications in inferior cava vein and in femoral veins producing a venous stasis in lower limbs. So that activation of coagulation with hypercoagulability occurs. The aim of this study is to value the modification of the haemocoagulative and fibrinolytic factors during LC and OC. 18 patients with symptomatic and non complicated lithiasis were examined. They were divided in two groups, nine patients for each group. LC was performed in first group and OC in the other group. Prothrombin time (PT), plasma-activated partial thromboplastin time (PTT), Antithrombin III (AT III) fibrinogen degradation products (FDP) were valued before and at 6, 12, 24, 48 hours after operation. For the statistical analysis Student "t" for average comparison was used. There were no relevant alterations of PT, PTT and ATIII after operation in the two groups. FP was increased after surgery, especially at 24th-48th hours in the group in which OC (p < 0.05) was performed. FDP were increased in both groups but only at 24 and 48 hour after OC (p < 0.05) the result was significant. Earlier mobilization and reduced invasivity of laparoscopy could contrast thrombotic effects of the blood stasis in the lower limbs when 30 degrees-45 degrees reverse Trendelenburg and pneumoperitoneum are performed.

[Agenesis of the gallbladder]

The authors report a case of agenesis of gallbladder associated with lithiasis of common bile duct. A review of the literature confirms the rarity of this congenital malformation. In 40-60% of cases it is associated with other gastrointestinal, skeletal, cardiovascular and genitourinary malformations. In 20-50% of cases it can be associated with common bile duct stones. Patients are asymptomatic in the majority of cases. A preoperative diagnosis is difficult despite of high accuracy of the modern diagnostic imaging techniques.