Anna-Maria Koivusalo

SPLANCHNIC AND RENAL DETERIORATION DURING AND AFTER LAPAROSCOPIC CHOLECYSTECTOMY: A COMPARISON OF THE CARBON DIOXIDE PNEUMOPERITONEUM AND THE ABDOMINAL WALL LIFT METHOD

Carbon dioxide (CO2) pneumoperitoneum together with an increased intraabdominal pressure (IAP) induces a hemodynamic stress response, diminishes urine output, and may compromise splanchnic perfusion.A new retractor method may be less traumatic. Accordingly, 30 ASA physical status I or II patients undergoing laparoscopic cholecystectomy were randomly allocated to a CO2 pneumoperitoneum (IAP 12-13 mm Hg) (control) or to a gasless abdominal wall lift method (retractor) group. Anesthesia and intravascular fluids were standardized. Direct mean arterial pressure (MAP), urine output, urine-N-acetyl-beta-D-glucosaminidase (U-NAG), arterial blood gases, gastric mucosal PCO2, and intramucosal pH (pHi) were measured. Normoventilation was instituted in all patients. MAP increased (P < 0.001) only with CO2 pneumoperitoneum. Minute volume of ventilation had to be increased by 35% with CO2 insufflation. PaCO2 was significantly higher (P < 0.05) for 3 h postoperatively in the control group. Diuresis was less (P < 0.01) and U-NAG levels (P < 0.01) higher in the control group. The pHi decreased after induction of pneumoperitoneum up to three hours postoperatively and remained intact in the retractor group. We conclude that the retractor method for laparoscopic cholecystectomy ensures stable hemodynamics, prevents respiratory acidosis, and provides protection against biochemical effects, which reveal the renal and splanchic ischemia caused by CO2 insufflation. Implications: A mechanical retractor method (gasless) was compared with conventional CO2 pneumoperitoneum for laparoscopic cholestectomy. The gasless method ensured stable hemodynamics, prevented respiratory acidosis, and provided protection against the renal and splanchnic ischemia seen with CO2 pneumoperitoneum. (Anesth Analg 1997;85:886-91)

A comparison of gasless mechanical and conventional carbon dioxide pneumoperitoneum methods for laparoscopic cholecystectomy

Carbon dioxide (CO2) insufflation with increased intraabdominal pressure (IAP) has adverse hemodynamic, pulmonary, and renal effects.To avoid these problems, an abdominal wall lift method with a retractor was used to provide the surgical view without CO2 insufflation. Twenty-six patients undergoing elective laparoscopic cholecystectomy were randomly allocated to either the gasless, retractor group, or conventional CO2 pneumoperitoneum group (CPP). Hemodynamic data, ventilatory variables, urine output, urine oxygen tension, and blood samples for determining stress hormones were collected throughout the perioperative period. Patients in the retractor group had lower mean arterial pressure, heart rate, and central venous pressure (P < 0.001). They also had higher pulmonary dynamic compliance and needed a lower minute volume of ventilation to achieve normocarbia (P < 0.001). Urine output and oxygen tension in urine were higher (P < 0.05) with the retractor method than with CPP. Increase in plasma renin activity (P < 0.05) and decrease in core temperature (P < 0.001) were smaller with the gasless method than with CPP. The gasless method for laparoscopic cholecystectomy might be beneficial, especially in patients with compromised cardiorespiratory or renal function. Implications: Totally gasless laparoscopic cholecystectomy was compared with conventional pressure pneumoperitoneum with CO (2) insufflation. The gasless method resulted in more stable hemodynamics and pulmonary function, as well as higher urine, output than conventional pressure pneumoperitoneum. No changes in renal oxygenation was seen with the gasless method, compared with conventional pressure pneumoperitoneum.

Surgical stress index as a measure of nociception/antinociception balance during general anesthesia

Background: No validated monitoring method is available for evaluating the nociception/antinociception balance. We assessed the surgical stress index (SSI), computed from finger photoplethysmographic waveform amplitudes and pulse‐to‐pulse intervals, in patients undergoing shoulder surgery under general anesthesia (GA) and interscalene plexus block and in patients with GA only.

The effect of molecular adsorbent recirculating system treatment on survival, native liver recovery, and need for liver transplantation in acute liver failure patients*

Acute liver failure (ALF) is a medical emergency. Molecular adsorbent recirculating system (MARS), an artificial liver support system, can partly compensate for the detoxifying function of the liver by removing toxins from blood. To analyze the efficacy of MARS treatment, the outcomes of 113 ALF patients, treated with MARS between 2001 and 2007, were compared with a historical control group of 46 ALF patients treated without MARS between 1995 and 2001. Overall survival of transplanted patients was 94% in the MARS group and 77% in the control group (P = 0.06). Without transplantation, survival was 66% and 40% (P = 0.03), respectively. However, the etiological distribution of ALF differed significantly between the groups. In ALF patients with unknown etiology, groups were comparable at baseline; 91% and 69% of transplanted patients survived the MARS and control groups and the native liver recovered in 20% and 8% of the patients, respectively. Of the originally nonencephalopathic patients of unknown etiology, 36% underwent liver transplantation in the MARS group compared to 100% in the control group. Interpretation of the results was difficult in toxic etiology patients on account of differing baseline statuses. MARS treatment might partly explain the trend toward increased survival of ALF patients with unknown etiology.

Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score.

Cost issues in liver transplantation (LT) have received increasing attention, but the cost‐utility is rarely calculated. We compared costs per quality‐adjusted life year (QALY) from the time of placement on the LT waiting list to 1 year after transplantation for 252 LT patients and to 5 years after transplantation for 81 patients. We performed separate calculations for chronic liver disease (CLD), acute liver failure (ALF), and different Model for End‐Stage Liver Disease (MELD) scores. For the estimation of QALYs, the health‐related quality of life was measured with the 15D instrument. The median costs and QALYs after LT were €141,768 and 0.895 for 1 year and €177,618 and 3.960 for 5 years, respectively. The costs of the first year were 80% of the 5‐year costs. The main cost during years 2 to 5 was immunosuppression drugs (59% of the annual costs). The cost/QALY ratio improved from €158,400/QALY at 1 year to €44,854/QALY at 5 years, and the ratio was more beneficial for CLD patients (€42,500/QALY) versus ALF patients (€63,957/QALY) and for patients with low MELD scores versus patients with high MELD scores. Although patients with CLD and MELD scores > 25 demonstrated markedly higher 5‐year costs (€228,434) than patients with MELD scores < 15 (€169,541), the cost/QALY difference was less pronounced (€59,894/QALY and €41,769/QALY, respectively). The cost/QALY ratio for LT appears favorable, but it is dependent on the assessed time period and the severity of the liver disease. Liver Transpl 17:1333–1343, 2011.

Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum is safe even for high-risk patients.

BackgroundBecause of absorbed carbon dioxide (CO2) and elevated intraabdominal pressure (IAP), CO2 pneumoperitoneum (CO2PP) has potentially harmful intraoperative circulatory and ventilatory effects. Although not clinically significant for healthy patients, these effects are assumed to be deleterious for patients with a high risk for anesthesia (American Society of Anesthesiology [ASA] 3 and 4) and significant cardiopulmonary, renal, or hepatic diseases. The authors assessed CO2PP-related adverse effects by comparing ASA 3 and 4 patients who underwent laparoscopic cholecystectomy (LC) with or without CO2PP.MethodsA total of 20 successive ASA 3 and 4 patients who underwent LC were randomized into CO2PP (n = 10) and abdominal wall elevator (Laparolift) (n = 10) groups. The parameters for perioperative hemodynamics, ventilation, perfusion of intraabdominal organs, and blood chemistry were recorded periodically from before the induction of the anesthesia until postoperative day 2 and compared between the groups.ResultsMean age, height, weight, the proportional number of ASA 3 vs ASA 4 patients, the volume of perioperative fluid loading, and the dose of analgesics did not differ significantly between the groups. The length of the operation was 49.9 ± 10.6 min for the CO2PP group and 50.6 ± 17.2 min for Laparolift group (nonsignificant difference). The mean central venous pressure (CVP) 30 min after insufflation was higher (12.3 ± 4.8 vs 7.9 ± 3.7 mmHg) and the (Gastric Mucosal pH) pHi at the end of the operation was lower (7.29 ± 0.07 vs 7.35 ± 0.04) in the CO2PP group than in the Laparolift group (p < 0.05). Later, CVP and pHi did not differ significantly. Other parameters of hemodynamics including oxygenation, perfusion, and blood chemistry did not differ significantly.ConclusionsFor LC for patients with an ASA 3 and 4 risk for anesthesia, no significant adverse effects could be attributed to CO2 pneumoperitoneum. For high-risk patients, preoperative preparation and active perioperative monitoring are essential for safe anesthesia for LC with or without CO2PP.

Postoperative drowsiness and emetic sequelae correlate to total amount of carbon dioxide used during laparoscopic cholecystectomy

AbstractBackground: After laparoscopy with carbon dioxide (CO2) insufflation early postoperative recovery is often complicated with drowsiness and postoperative nausea and vomiting (PONV). Methods: 25 ASA I − II patients undergoing elective laparoscopic cholecystectomy under standardized anaesthesia were studied in a randomized, prospective study. The conventional CO2 pneumoperitoneum was compared with the mechanical abdominal wall lift (AWL) method with minimal CO2 insufflation with special reference to postoperative recovery. Results: Postoperative drowsiness was of a significantly longer duration with the conventional method (p < 0.001) compared with the AWL technique. There was a positive correlation with the total amount of CO2 used and the duration of drowsiness (r = 0.75, p < 0.01). PONV was seen significantly more often in patients with CO2 insufflation of more than 121 (p < 0.05). Conclusions: Avoiding excessive CO2 is beneficial for smoother and more uneventful recovery after laparoscopic cholecystectomy.

Albumin dialysis has a favorable effect on amino acid profile in hepatic encephalopathy

According to one popular theory, hepatic encephalopathy (HE) is partly caused by an imbalance in plasma amino acid levels. The Fischer’s ratio between branched chain amino acids (BCAAs) and aromatic amino acids (AAAs) correlates with the degree of HE; the lower Fischer’s ratio, the higher the grade of HE. Extra-corporeal liver support systems, like MARS®-albumin dialysis (Molecular Adsorbents Recirculating System), can improve HE. The MARS® system uses a hyperosmolar albumin circuit to remove both water-soluble and albumin-bound substances. Plasma levels of neuroactive amino acids were analyzed in 82 consecutive patients with life-threatening liver failure admitted to our ICU. All patients fulfilled our indications for MARS treatment and most also fulfilled the criteria for liver transplantation (LTx). In patients with acute liver failure (ALF), as compared to those with acute decompensation of chronic liver failure (AcOChr), levels of leucine and isoleucine were significantly higher before MARS® treatment. In all patients, before MARS® treatment the higher the grade of HE grade the lower was the Fischer’s ratio and higher were the levels of inhibitory neuroactive amino acids. During MARS® treatments the Fischer’s ratio increased, and the grade of HE decreased. The increase in Fischer’s ratio was mainly due to the decrease in AAAs. The plasma levels of neuroactive amino acids, methionine, glutamine, glutamate, histidine and taurine decreased during MARS®-treatment. In this study MARS®-albumin dialysis had a favorable effect on the plasma amino acid profile of patients with HE.

Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children: a preliminary report.

BackgroundThe repair of choice for persistent rectal prolapse (PRP) in children is disputed. Laparoscopic suture rectopexy (LSRP) is effective in adults, but its usefulness in pediatric PRP is unknown. We compared LSRP with posterosagittal rectopexy (PSRP).MethodsSixteen children, with a median age of 6.5 years (range, 0.8–16.8) and duration of symptoms of 2.8 years (range, 0.5–10.2), underwent surgery for PRP. Eight (1991–2000) had PSRP, and eight (2002–2005) had LSRP. Three patients with LSRP were healthy; the others had mental retardation and epilepsy (n = 1), cerebral palsy (n = 1), Aspeger’s syndrome (n = 1), meningomyelocele (n = 1), and bladder extrophy (n = 1). Preoperative cologram (n = 6), sigmoideoscopy (n = 3), and anorectal manometry (n = 2) were normal in patients with LSRP. In LSRP, the rectum was mobilized and sutured to the sacral periosteum.ResultsMedian operation time for LSRP was 80 min (range, 62–90) and for PSRP 40 min (range, 25–70) (p < 0.05); median hospital time was 6 days (range, 3–8) for LSRP and 6 days (range, 3–9) for PSRP (not significant). Six patients with LSRP had a median follow-up of 13 months (range, 4–24). None have had recurrences, and two patients (33%) require laxatives. Of the patients with PSRP, two (25%) had recurrence and underwent abdominal rectopexy with sigmoid resection.ConclusionMedium-term results indicate that LSPR is effective in pediatric PRP. Constipation is the only postoperative problem in a significant proportion of patients.

Experience with albumin dialysis in five patients with severe overdoses of paracetamol

Five patients in whom the serum paracetamol levels or the amount of ingested paracetamol was high enough to cause severe liver injury were treated with N‐acetyl‐cysteine (NAC) and a molecular absorbant recirculating system (MARS). MARS treatment was started as early as possible in order to prevent or retard the development of hepatocyte necrosis. Four of our five patients survived without liver transplantation, and one died due to brain oedema. The early commencement with NAC and MARS treatments in paracetamol intoxication might give enough time for the liver to regenerate and thus avoid liver transplantation.