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Correspondence |
Seoul, Korea
To the Editor:
We evaluated the clinical impact of CO2 pneumoperitoneum vs abdominal lift for laparoscopic procedures with respect to the splanchnic circulation, surgical stress, and the magnitude of the immune response.
Thirty-two patients were randomly divided into pneumoperitoneum (P) or wall lift (W) groups. Gastric intramucosal PCO2 (PrCO2), CO2 gap (PrCO2 - PaCO2), intramucosal Ph (pHi), and plasma concentration of epinephrine and norepinephrine were measured: 1) after induction of anesthesia; 2) during operation; 3) at the end of operation; and 4) at two hours after operation. The serum concentrations of TNF- and IL-6 were measured at 24 hr before operation, 24 hr and 72 hr after operation. The TNF- and IL-6 level of peritoneal macrophage were measured.
The PrCO2 and CO2 gap increased significantly during and after operation in P and after operation in W. The pHi decreased significantly during and after operation in P and after operation in W. These variables were significantly different between the groups during operation. Urine output was significantly higher in W (112.9 ± 50.2 mL) than in P (37.1 ± 17.0 mL). The results suggest that CO2 pneumoperitoneum induces acidosis of the intestinal mucosal and also possibly impedes splanchnic circulation.1,2 Further studies are needed to confirm the effect of insufflated CO2 on intramucosal PCO2.
Epinephrine and norepinephrine increased significantly in both groups but epinephrine was higher in W at the end of operation. Surgical manipulation may mask the difference of stress response between the two methods until the end of operation. The results suggest that the hormonal stress response induced by wall lift is more important than with CO2 pneumoperitoneum.3
TNF- and IL-6 increased markedly 24 hr postoperatively and recovered at 72 hr in both groups, without significant differences between groups. This suggests that the magnitude of surgical injury and immune response are similar with both methods.4
The levels of TNF- and IL-6 of peritoneal macrophage were similar in both groups. CO2 has been known to induce an impaired production of cytokines in peritoneal macrophages.5 We suggest that peritoneal irritation by the elevator may have some influence on the activity of peritoneal macrophages, similar to insufflation with CO2.
We conclude that CO2 pneumoperitoneum induces gastrointestinal mucosal acidosis and decreases urine output during laparoscopic cholecystectomy. The wall lift method induces more significant stress response. However, the magnitude of the immune response is similar with both methods.
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1 Koivusalo A, Kellokumpu I, Ristkari S, Lindgren L. Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: a comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method. Anesth Analg 1997; 85: 886–91.[Abstract]
2 Bongard F, Pianim N, Dubecz S, Klein SL. Adverse consequences of increased intra-abdominal pressure on bowel tissue oxygen. J Trauma 1995; 39: 519–24.[Medline]
3 Ishizuka B, Kuribayashi Y, Kobayashi Y, et al. Stress responses during laparoscopy with CO2 insufflation and with mechanical elevation of the abdominal wall. J Am Assoc Gynecol Laparosc 2000; 7: 363–71.[Medline]
4 Gupta A, Watson DI. Effect of laparoscopy on immune function. Br J Surg 2001; 88: 1296–306.[Medline]
5 West MA, Baker J, Bellingham J. Kinetics of decreased LPS-stimulated cytokine release by macrophages exposed to CO2. J Surg Res 1996; 63: 269–74.[Medline]
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