Ajay P Belgaumkar1, Kirstin A Carswell2, Robin D Hughes3, Alberto Quaglia3, Anil Dhawan3, Ragai R Mitry3, Ameet G Patel2. 1. Department of Minimally Invasive, Bariatric and Laparoscopic HPB Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. ajay.belgaumkar@kcl.ac.uk. 2. Department of Minimally Invasive, Bariatric and Laparoscopic HPB Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. 3. Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK.
Abstract
BACKGROUND: The combination of pneumoperitoneum and intraoperative retraction of the left lobe of the liver leads to hepatocellular injury during laparoscopic gastric surgery. Fatty livers are more susceptible to ischaemic insults. This trial investigated whether the antioxidant N-acetylcysteine (NAC) reduced liver injury during laparoscopic sleeve gastrectomy (LSG). METHODS:Patients undergoing LSG were randomised (single blinded) to receive intraoperative NAC infusion or standard anaesthetic treatment. Blood samples were taken before and after surgery (days 0 to 4). Primary endpoints included serum aminotransferases. Secondary measures were C-reactive protein, weight cell count (WCC), cytokines (interleukin 6 and 10) and cytokeratin-18 as markers of apoptosis. Intraoperative liver biopsy samples were assessed using a locally developed injury score. RESULTS:Twenty patients (14 females, mean age 44.5 (SEM ± 2.9) years, mean BMI 60.8 (SEM ± 2.4) kg/m(2)) were recruited (NAC n = 10, control n = 10). The trial was stopped early after a planned interim analysis. Baseline liver function was similar. The peak rise in liver enzymes was on day 1, but levels were not significantly different between the groups. Rates of complications and length of stay were not significantly different. Secondary outcome measures, including white cell count (WCC), cytokines and cytokeratin (CK)-18 fragments, were not different between groups. Liver injury scores did not differ significantly. CONCLUSIONS:NAC did not reduce intraoperative liver injury in this small number of patients. The heterogenous nature of the study population, with differences in co-morbidities, body mass index and intraabdominal anatomy, leads to a varied post-operative inflammatory response. Significant hepatocyte injury occurs through both necrosis and apoptosis.
RCT Entities:
BACKGROUND: The combination of pneumoperitoneum and intraoperative retraction of the left lobe of the liver leads to hepatocellular injury during laparoscopic gastric surgery. Fatty livers are more susceptible to ischaemic insults. This trial investigated whether the antioxidant N-acetylcysteine (NAC) reduced liver injury during laparoscopic sleeve gastrectomy (LSG). METHODS:Patients undergoing LSG were randomised (single blinded) to receive intraoperative NAC infusion or standard anaesthetic treatment. Blood samples were taken before and after surgery (days 0 to 4). Primary endpoints included serum aminotransferases. Secondary measures were C-reactive protein, weight cell count (WCC), cytokines (interleukin 6 and 10) and cytokeratin-18 as markers of apoptosis. Intraoperative liver biopsy samples were assessed using a locally developed injury score. RESULTS: Twenty patients (14 females, mean age 44.5 (SEM ± 2.9) years, mean BMI 60.8 (SEM ± 2.4) kg/m(2)) were recruited (NAC n = 10, control n = 10). The trial was stopped early after a planned interim analysis. Baseline liver function was similar. The peak rise in liver enzymes was on day 1, but levels were not significantly different between the groups. Rates of complications and length of stay were not significantly different. Secondary outcome measures, including white cell count (WCC), cytokines and cytokeratin (CK)-18 fragments, were not different between groups. Liver injury scores did not differ significantly. CONCLUSIONS:NAC did not reduce intraoperative liver injury in this small number of patients. The heterogenous nature of the study population, with differences in co-morbidities, body mass index and intraabdominal anatomy, leads to a varied post-operative inflammatory response. Significant hepatocyte injury occurs through both necrosis and apoptosis.
Authors: Stuart M Robinson; Rehan Saif; Gourab Sen; Jeremy J French; Bryon C Jaques; Richard M Charnley; Derek M Manas; Steven A White Journal: HPB (Oxford) Date: 2013-01-07 Impact factor: 3.647
Authors: Ninh T Nguyen; Scott Braley; Neal W Fleming; Lindsey Lambourne; Ryan Rivers; Bruce M Wolfe Journal: Am J Surg Date: 2003-07 Impact factor: 2.565