Effects Of Peritoneal Or Retroperitoneal Laparoscopic Surgery On Gastro-esophageal Reflux, Respiratory And Circulatory Function

Objective To compare the effects of patient’s position on gastro-esophageal reflux(GER) and respiratory, circulatory function in peritoneal or retroperitoneal laparoscopic surgery under general anesthesia with endotracheal intubation.Method Ninety patients undergoing selective peritoneal or retroperitoneal laparoscopic surgery, 18~64yrs, ASA I/II,,BMI 18~30 kg/m2, with 47 males and 43 females. Exclusion criterion includ history or symptoms suggesting a diagnosis of GER and use of ulser medication or medications that could affect intestinal transit. Patients with cardiovascular or respiratory system disease also excluded. According to different typies of surgeries under general anesthesia, patients were divided into three groups( n=30):Trendelenburg position group( group T), reverse Trendelenburg position group( group Tre) or lateral jack-knife position group( group L). Opened upper limb venous pathway after patients arrived the operating room, and then connected multifunctional monitor.Induction of anesthesia with midazolam, sufentanil, propofol and cisatracurium, and maintained with propofol and remifentanyl. Before intravenous injection, dose must be calculate in strict accordance with weight(kg). When muscles relaxed, inserted the endotracheal tube with video laryngoscope. Listened to the lung respiratory sound with use of stethoscope to make sure that the endotracheal tube in the appropriate position. Made use of target controlled infusion of propofol and remifantanyl with the plasma concentration of 2 ~ 3 μg/ml and 3 ~ 5 ng/ml respectively during anesthesia maintenance. When finished intubation, patients were placed in lateral jack-knife position, and then surgery began and CO2 was infused to retroperitoneal space in group L. In group T and Tre, surgeries began first after intubation, and then infused CO2 to peritoneal cavity. At last, patients were placed to Trendelenburg position or reverse Trendelenburg position according to different surgeries. Vasoactive drugs was used intraoperative to maintain stable hemodynamic parameters and ranged of no more than 20% basis. Administration ondansetron 4 mg as prevention of postoperative nausea and vomiting half hour before the end of surgery. When operation finished, patients regained consciousness, while spontaneousbreathing recoveried, cough and swallowing reflex recoveried, we extubated the endotracheal tube. Listened to the lung respiratory sound again and patients was taken to PACU.a) Comparison of gastro-esophageal refluxDigitrapper MKⅢ p H value recorder was connected to the conducting wire, which has a p H-sensitive probe and a reference electrode. It was calibrated with standard solution in p H 7.01 and 1.07 before use. After reference electrode coated with glue, electrode was fixed in the upper chest. Before anesthesia induction, p H probe was inserted through nose into lower esophagus and p H was continuously recorded. GER was defined as p H≤4 for longer than 1 min in lower esophagus during surgery. Stopped recording 1 min after extubation and then the p H electrode was also pulled up.Recording indicator including duration of anesthesia, duration of pneumoperitoneum,duration of operation, duration of GER, total p H monitoring time and pneumoperitoneum pressure. Made record of p H in gastric and the basis p H value of the lower esophagus as basic values. Recorded cases of patient with GER, total episodes of GER, the lowest p H during GER and other adverse effect.b) Comparison of respiratory and circulatory functionIn group T and Tre, made record of MAP, HR, PPEAK, PETCO2 and Sp O2 in 7 time points as follows, 5 min after intubation( basic value in T0), post-pneumoperitoneum 10 min in supine, 5min, 15 min, 30 min after changing position( Trendelenburg position in group T or reverse Trendelenburg position in group Tre), 10 minutes after pneumoperitoneum stopped and 5min after recovering supine.While in group L, recoding MAP, HR, PPEAK, PETCO2 and Sp O2 in 7 time points as follows, 5 min after intubation(supine 1), 5 min after changing positon( lateral 1), 5 min( P5), 15 min( P15), 30 min( P30) after pneumoperitoneum, 10 min after pneumoperitoneum stopped( lateral 2) and 5 min after recovering supine( supine 2).Results There’s no significant difference among three groups in age, gender composition, ASA scale and BMI(P>0.05).a). Comparison of gastro-esophageal refluxDuration of anesthesia, duration of pneumoperitoneum, duration of operation, total p H monitoring time and pneumoperitoneum pressure have no statistical difference among three groups(P>0.05). Value of p H in gastric juice and lower esophagus before anesthesia has no difference among groups(P>0.05).The incidence of GER between groups L, T and Tre is 27%(8 in 30), 13%(4 in 30) and 3%(1 in 30), respectively. Episodes of GER in groups L, T and Tre is 10 in 8 cases, 5 in 4 cases and 1 in 1case. Compared with group Tre, the incidence and episodes GER occurred were significantly increased in Group L(P<0.05). But there’s no difference in the incidence or episodes of GER between group T and L(P>0.05).8 cases of GER in group L occurred in patients with duration of GER followed by 70 min, 60 min, 40 min, 15 min, 7 min, 5 min, 2 min, 1 min. 4 cases of GER in group T occurred in patients with duration of GER followed by 10 min, 7 min, 3 min, 1min, while there’s only 1 patient occurred in group Tre with duration of GER of 2 min. When GER developed, the lowest p H value in the lower esophagus was 2.1±1.3、2.6±1.2 and 3.5 in L, T and Tre groups, respectively.Incidence of GER in different directions of lateral jack-knife position has no statistical difference, with the same incidence of 13%( P>0.05).b) Comparison of resperitory and circulatory functioni. Comparison between group T and TreCompared with T0, MAP, HR, PPEAK, PETCO2 in patients has no difference in T1, T2, T3 and in T4 in group T and Tre( P<0.05).Compared with group Tre, group T has a higer Ppeak and PETCO2 at time point T2, T3 and T4( P<0.05). Compared with group Tre, patients has a higer MAP and HR in group T at time point T4(P<0.05).There’s no difference between groups in Sp O2( P>0.05).ii. Resperitory and circulatory function in group LHR and MAP in patients increased after retroperitoneum began, but there’s no difference( P>0.05). PPEAK and PETCO2 elevated significantly after retroperetoneumbegan( P < 0.05). All monitoring indices decreased when 10 min after pneumoperitoneum stopped compared with retroperetoneum began(P<0.05). after recovering supine, all monitoring indices returned to basic level. Changes of Sp O2 has no statistical difference(P>0.05).Conclusion 1) In patients undergoing laparoscopic surgery under general anesthesia with intubation, incidence of GER is 13% and 3%with Trendelenburg position or reverse Trendelenburg position, respectively. Compared with Trendelenburg and reverse Trendelenburg position, patients in laparoscopic surgery with lateral jack-knife position have a higher risk of GER with the incidence of 27%.2)When GER occurred in patients under laparoscopic surgery with lateral jack-knife position, stomach contents of reflux has a low p H and duration of reflux lasted for a long time. It indicates that patients have a high risk of GER with lateral jack-knife position.3) Different directions of lateral jack-knife position has no different effect on the incidence of GER, with the same incidence of 13%.4) Laparoscopic surgery patients with pneumoperitoneum in peritoneal cavity have a large effect on hemodynamics and characterized by a significant rise in HR and MAP. Compared with reverse Trendelenburg position, Trendelenburg position has a more significant change on circulatory function. For the influence on respiratory function, in the process of peritoneal cavity pneumoperitoneum, although PPEAK and PETCO2 both significantly increased, PPEAK is higher in Trendelenburg position, and absorbed of more CO2 during pneumoperitoneum so that PETCO2 is much higher.5)Compared with laparoscopic surgery, retroperitoneal laparoscopic surgery has little influence on hemodynamics, but has great effect on the respiratory function. When peritoneal cavity pneumoperitoneum founded, PPEAK and PETCO2 were significantly increased.In conclusion, compared with laparotomy surgery, laparoscopic surgery andretroperitoneal laparoscopic surgery for patients exert a great effect on GER and respiratory,circulatory function. And they can cause intraoperative physiological dysfunction easily. Retroperitoneal laparoscopic surgery has more significant influence on gastroesophageal reflux, and has a much higher risk for GER. But it has less impact on the respiratory function significantly than laparoscopic surgery. Compared with reverse Trendelenburg position, patients under laparoscopic surgery with Trendelenburg position have a higher risk to gastro-esophageal reflux. Both pneumoperitoneum and position have significant effects on respiratory function.For anesthesia management, endotracheal tube with a higher leakproofness can be choosed as airway management tool and appropriate anesthesia depth and muscle relaxant should be maintained. When patient’s position changed, medical staff should be coorperate with each other, and keep neck and body vertical axis in a straight line with act slowly and gentlely.Under the premise of meet the requirements of operation, we should change patients position in a smaller degree and using lower pneumoperitoneum pressure. After CO2 infused, we use low volume ventilation strategy, that is, increasing breathing rate to maintain PETCO2 at appropriate levels and avoiding hypercapnia and respiratory acidosis. After pneumoperitoneum, excessive ventilation continued to maintain a certain time, so as to eliminate excess CO2 in the body. We should strengthen perioperative monitoring, pay close attention to respiratory and circulatory parameters and control it in time.Alert and prevent the happening of the gastroesophageal reflux and aspiration to ensure the safety in perioperative patients.