The Effects Of Different Liver Resection Methods Different Nesthesia And Analgesia Methods On Postoperative Metabolism And Immune Function

Part1The effect of laparoscopic vs open liver resection on metabolism and immune functionObjective To assess the safety and benefits of laparoscopic liver resection by comparing the intra-and post-operative clinical issues, postoperative liver function, glucose metabolism, immune function with open procedure prospectively.Methods From August2007to Novernmber2008, a total of52liver resection cases (include left hepatectomy and left lateral sectionectomy) were enrolled in our study. Twenty six cases each were in the group of either laparoscopic procedure or open procedure. All the operations were done by the same group. All the patients received general anesthesia and endotracheal intubation. Intraoperative clinical issues including operation time, hepatectomy time, vascular occulusion ratio, blood loss volume, fluid administration volume, blood transfusion volume, urine output were recorded; postoperative issues including endotracheal tube extubation time, post anesthesia care unit (PACU) stay time, time of passage of the gas, fluid diet-intaken time, out-of-bed time, hospital stay time, postoperative complications and pathological results, the postoperative pain score in the first3days were also evaluated. Postoperative liver function was also recorded in the first5days after operation. Glucose metabolism including blood glucose level, blood insulin level and insulin resistance index were recorded in the first3days. Pro-inflammatory factors IL-1β,IFN-y and anti-inflammatory factors IL-4, IL-10and TGF-β indicating regulatory T cell function were measured. The ratio of IFN-y/IL-4(Thl/Th2) were also calculated.Results All the operations were successfully proceeded. There were14cases of left hepatectomy (53.85%) and12cases of left lateral sectionectomy (46.15%) in laparoscopic group. And12cases of left hepatectomy (46.15%) and14cases of left lateral sectionectomy (53.85%) were in open group. No statistical difference was found between two groups in the operation time and fluid administration volume. Liver resection time was significantly longer in laparoscopic group (p<0.05). The estimated blood loss and urine volume were significantly less in the laparoscopic group (P<0.01). No difference was found in the hospital stay time and postoperative complications incidence. Pain evaluated by VAS in laparoscopic group was significantly lower (P<0.01) at24hr after operation compared with open group, yet no difference was found in the dosage of pethidine.The total protein and albumin level were significantly lower after operation (P<0.01), and maintained low level to postop D5. While compared with open group, both the total protein and albumin level were significantly higher (P<0.05).The blood glucose was significantly higher after operation (P<0.01), the peak time was12hr after operation, no statistical difference between two groups. Insulin and insulin resistance index reached peak level at12hr after operation, which was significantly higher than pre-op level (P<0.01). Both of them in laparoscopic group were significantly lower than in open group at24hr (P<0.05) and72hr (P<0.01) after operation.Pro-inflammatory factor IFN-y was significantly higher than pre-op level (P<0.01) since12hr after operation in both group, and maintained high level to post-op D5, the peak level was at post-op D3. Though IFN-y level in laparoscopic group was lower than in open group, no statistical difference was found.Anti-inflammatory factors IL-4and IL-10reached lowest level just after operation. In laparoscopic group, IL-4returned to pre-op level at12hr after operation, then remain increasing and higher than pre-op level at post-op D3(P<0.01). In open group, IL-4returned to pre-op level at3hr after operation and maintained this level afterwards. IL-4level in laparoscopic group was significantly higher than in open group (P<0.05) at post-op D3and D5. Since12hr after operation, IL-10level in both group was significantly higher than pre-op level (P<0.01), and maintained this level afterwards. No statistical difference was found between two groups. The value of TGF-β which indicating secreting function of regulatory T cells in two groups was similar in both groups and no difference was found between two groups.The value of IFN-y/IL-4(Thl/Th2) in laparoscopic group elevated since12hr after operation and significantly higher than pre-op value (P<0.01). It reached peak value at24hr after operation, and maintained high level afterwards. In open group, the value elevated since3hr after operation (P<0.05), reach peak value at post-op D3. Compared with open group, the value of IFN-y/IL-4in laparoscopic group elevated later, waned earlier, and the range of elevating was smaller, significantly lower at post-op D3and D5(P<0.05).Conslusions (1) It is safe and feasible to proceed laparoscopic left hepatectomy and left lateral sectionectomy in our center. Estimated blood loss was reduced significantly and postoperative complications were similar as in open group;(2) The patients recovered more quickly, endure less pain, acquire earlier movement, earlier oral in-take and faster convalescence of gastro-intestinal function in laparoscopic group;(3) Though blood glucose was similar in two groups, insulin resistance index was lower in laparoscopic group and immune function recovered faster than in open procedure. Part2The effect of different anesthesia and analgesia methods in open liver resection on metabolism and immune functionObjective To assess the effects of different anesthesia and analgesia methods on clinical outcome, metabolism and immune function in the patients after open liver resection prospectively.Methods From August2007to Novernmber2008, a total of26liver resection cases (include left hepatectomy and left lateral sectionectomy) were enrolled in our study. Thirteen cases each were in the group of either general anesthesia followed by intravenous analgesia procedure (group G) or general combined with epidural anesthesia followed by epidural analgesia procedure (group E). All the operations and anesthesia were done by the same group. All the patients received general anesthesia and endotracheal intubation. In group G, sufentanil1μg/ml, with5ml/hr infusion rate was performed as postoperative analgesia. In group E, an epidural catheter was placed at T8-10interspaces with lidocaine tested followed by general anesthesia. Postoperative pain control was managed with thoracic epidural analgesia (0.12%ropivacaine plus0.2μg/ml sufentanil with5ml/hr infusion rate). Intraoperative clinical issues including operation time, hepatectomy time, vascular occulusion ratio, blood loss volume, fluid administration volume, blood transfusion volume, urine output were recorded; postoperative issues including endotracheal tube extubation time, post anesthesia care unit (PACU) stay time, time of passage of the gas, fluid diet-intaken time, out-of-bed time, hospital stay time, postoperative complications and pathological results, the postoperative pain score in the first3days were also evaluated. Postoperative liver function was also recorded in the first5days after operation. Glucose metabolism including blood glucose level, blood insulin level and insulin resistance index were recorded in the first3days. Pro-inflammatory factors IL-1β, IFN-γand anti-inflammatory factors IL-4, IL-10and TGF-β indicating regulatory T cell function were measured. The ratio of IFN-γ/IL-4(Thl/Th2) were also calculated. Results All the operations were successfully proceeded. There were7cases of left hepatectomy (53.85%) and6cases of left lateral sectionectomy (46.15%) in group G. And5cases of left hepatectomy (38.46%) and8cases of left lateral sectionectomy (61.54%) were in open group. No statistical difference was found between two groups in the operation time, liver resection time, fluid administration volume, estimated blood loss and urine volume. Postoperative endotracheal tube extubation time after operation and post anesthesia care unit (PACU) stay time was significantly shorter in group E (P<0.01). Pethidine dose usage in the first24hrs in group E was significantly less than in group G (P<0.05), yet no difference was found in the pain evaluation by VAS.The total protein and albumin level were significantly lower after operation (P<0.01), and maintained low level to post-op D5. While compared with group G, both the total protein and albumin level were significantly higher (P<0.05) at post-op D1, total protein level was significantly higher (P<0.05) at post-op D3, albumin level was significantly higher (P<0.05) at post-op D5.The blood glucose was significantly higher after operation (P<0.01), the peak time was3hr after operation in group G and12hr after operation in group E. It was significantly lower in group E at3hr after operation (P<0.05). Insulin and insulin resistance index reached peak level at12hr after operation, which was significantly higher than pre-op level (P<0.01). Insulin and insulin resistance index returned to pre-op level at72hr after operation in group G. While in group E, they were still significantly higher than pre-op level at72hr after operation (P<0.01). In group E, insulin level was significantly higher at24hr after operation than in group G (P<0.05), insulin resistance index was significantly lower at3hr after operation than in group G (P<0.05).Pro-inflammatory factor IL-1β was significantly lower in group E than in group G at12hr after operation (P<0.05). IFN-y was significantly higher than pre-op level since12hr after operation in both group (P<0.01in group G, P<0.05in group E), and maintained high level to post-op D5, the peak level was at24hr after operation. Though IFN-γ level in group E was lower than in group G, no statistical difference was found. Anti-inflammatory factors IL-4and IL-10reached lowest level just after operation. In group G, no statistical difference was found between post-op and pre-op level. In group E,'IL-4level was significantly lower than pre-op just after operation (P<0.05). No difference was found between two groups. IL-10level in group G was significantly higher than pre-op at post-op24hr and D3(P<0.05). While in group E, it was significantly lower than pre-op just after operation (P<0.05), returned to pre-op level at3hr after operation and elevated afterwards, significantly higher than pre-op level at12hr after operation (P<0.01), returned to pre-op level again in post-op D5. No statistical difference was found between two groups. There was no statistical difference either between pre-op and post-op value or between group G and group E as referring to the value of TGF-β which indicating secreting function of regulatory T cells.The value of IFN-γ/IL-4(Thl/Th2) in group G elevated since12hr after operation and significantly higher than pre-op value (P<0.01). It reached peak value in post-op D3, and maintained high level afterwards. In group E, the trend was similar as that in group G, though the range of increasing was lower, but still significantly higher than pre-op level (P<0.05).Conslusions (1) In open liver resection procedure, epidural anesthesia and analgesia can help early extubation of endotracheal tube, shorter PACU stay time, which can be helpful to perform fast track operation;(2) The effect of pain control was better in epidural analgesia group during first24hrs after operation;(3) In the early stage after operation, epidural anesthesia and analgesia can help to reduce insulin resistance level, reduce blood glucose and protein catabolism, help to early convalescence after open liver resection;(4) Epidural anesthesia and analgesia seems has no influence on immune alteration in patients after left liver resection. Part3Effect of selective inflow occlusion on hemodynamic conditions during laparoscopic left hemihepatectomyBackground Selective inflow occlusion instead of portal triad clamping was used during laparoscopic left hemihepatectomy in our institution. Aim of this study was to observe its hemodynamic effects during operation by Swan-Ganz catheter.Methods Eighteen consecutive patients were studied. Hemodynamic parameters including heart rate(HR), mean arterial pressure(MAP), central venous pressure(CVP), mean pulmonary artery pressure(PAP), pulmonary capillary wedge pressure(PCWP), cardiac index(CI), systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) were collected at6time points:after induction, after insufflation with CO2, after patient in reverse Trendelenburg position, after left branch of hepatic artery was occluded, after left branch of portal vein was occluded and after desufflation with patient supine.Results No severe perioperative cardiopulmonary complications were observed in all patients. Occulusion of left branch of hepatic artery brought no significant hemodynamic change. Occlusion of left branch of portal vein induced CVP and CI increased significantly (P<0.05), SVR decreased significantly (P<0.05). Carbon dioxide inflation caused HR, MAP (P<0.05) and SVR (P<0.01) increased significantly. While changed to reverse-Trendelenburg position, CVP and PAP decreased significantly (P<0.01). When operation finished and patient was set to supine with deflation, MAP, CVP, PAP, PCWP and CI were all returned to even higher than base level (P<0.01). HR and SVR returned to base level.Conclusions Using selective inflow occlusion in laparoscopic left hemihepatectomy cause only a little hemodynamic change before and after occlusion in patients without cardiopulmonary diseases. However, the change of position and whether inflation or deflation caused significant change which can be well tolerated by patients with normal cardiopulmonary function.