J Gastrointest Surg (2014) 18:2149–2154 DOI 10.1007/s11605-014-2681-3
ORIGINAL ARTICLE
A Prospective Clinical Study Evaluating the Development of Bowel Wall Edema During Laparoscopic and Open Visceral Surgery Goran Marjanovic & Jasmina Kuvendziska & Philipp Anton Holzner & Torben Glatz & Olivia Sick & Gabriel Seifert & Birte Kulemann & Simon Küsters & Jodok Fink & Sylvia Timme & Ulrich Theodor Hopt & Ulrich Wellner & Tobias Keck & Wojciech Konrad Karcz
Received: 25 June 2014 / Accepted: 10 October 2014 / Published online: 18 October 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background To examine bowel wall edema development in laparoscopic and open major visceral surgery. Methods In a prospective study, 47 consecutively operated patients with gastric and pancreatic resections were included. Twenty-seven patients were operated in a conventional open procedure (open group) and 20 in a laparoscopic fashion (lap group). In all procedures, a small jejunal segment was resected during standard preparation, of which we measured the dry-wet ratio. Furthermore, HE staining was performed for measuring of bowel wall thickness and edema assessment. Results Mean value (±std) of dry-wet ratio was significantly lower in the open than in the lap group (0.169±0.017 versus 0.179± 0.015; p=0.03) with the same amount of fluid administration in both groups and a longer infusion interval during laparoscopic surgery. Subgroup analyses (only pancreatic resections) still showed similar results. Histologic examination depicted a significantly larger bowel wall thickness in the open group. Conclusions Laparoscopic surgery does not seem to lead to the bowel wall edema observed to occur in open surgery regardless of the degree of intravenous fluid administration, thus supporting its use even in major visceral surgery. Keywords Bowel wall edema . Laparoscopic surgery . Visceral surgery
Part of the following work was presented at the German Visceral Medicine Association Meeting (Viszeralmedizin 2013) in September 2013 in Nuernberg as a 5-minute oral presentation. G. Marjanovic (*) : J. Kuvendziska : P. A. Holzner : T. Glatz : O. Sick : G. Seifert : B. Kulemann : S. Küsters : J. Fink : U. T. Hopt Department of General and Digestive Surgery, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany e-mail:
[email protected] S. Timme Institute of Pathology, Freiburg, Germany U. Wellner : T. Keck : W. K. Karcz Surgical Department, University of Lübeck, Lübeck, Germany
Introduction When Semm introduced minimal invasive surgery for abdominal procedures in the 1980s, it was first designated a treatment option for small uncomplicated operations like cholecystectomy or appendectomy.1 The development of these techniques to highly-standardized techniques was significantly accelerated by the technical innovation of laparoscopic equipment. In the last two decades, more and more complex gastrointestinal procedures have been performed in minimal invasive fashion such as major hepatic resections, gastrectomy, esophageal resections, and pancreatic head resections. This development was mainly driven by the known advantages of minimal invasive surgery, including shorter and better recovery, faster bowel movement and generally reduced overall complication rates compared to conventional open techniques. The reduced perioperative morbidity is considered to be the result of the main differences of the laparoscopic approach as less trauma, less blood loss, and altered intraoperative
2150
J Gastrointest Surg (2014) 18:2149–2154
conditions.2–7 Especially the closed environment during laparoscopy with an intraabdominal pressure of approximately 12 mmHg is assumed to be a major reason for less general third space fluid loss which in consequence may lead to a reduction of intravenous perioperative fluid resuscitation.8, 9 Our current prospective clinical study aims to answer the question if laparoscopic techniques are able to reduce bowel wall edema during large gastrointestinal procedures compared to conventional open surgery.
Table 1 Distribution and total number (n) of operations performed in the two groups
Patients and Methods
reconstruction was done through a small epigastric midline incision.
Operation type
Open group (n)
Lap group (n)
Pancreatic head resection Pancreatectomy Total gastrectomy Multivisceral resection
15 2 6 1
12 3 5 0
Biliodigestive anastomosis Total number
3 27
0 20
Patient Collective The local Ethics Committee of the University of Freiburg approved this prospective study (application number 495/11) which was registered at DRKS as a clinical trial (DRKS00005414). All patients gave full informed consent for material and data acquisition and for all following experiments. From January 2012 until July 2013, forty-seven patients consecutively underwent major gastrointestinal procedures at our Department of Digestive Surgery and were included in the study. Twenty-seven patients were operated in a conventional open fashion (open group), 20 were operated laparoscopically (lap group). Patients were assigned for laparoscopic surgery if the tumor was rather localized without infiltration of adjacent organs or large vessels, otherwise open technique was chosen. Mean age was 64 years (±13) in the open and 62 years (±17) in the lap group. Following leading diagnoses were found in the open group: pancreatic head cancer (n=9), periampullary cancer (n=2), intraductal papillary mucinous neoplasia (n=2), gastric cancer (n=6), chronic pancreatitis (n=3), and other tumors (n=5). In the lap group, the leading diagnoses were as follows: pancreatic head cancer (n=2), periampullary cancer (n=2), intraductal papillary mucinous neoplasia (n=5), gastric cancer (n=5), chronic pancreatitis (n=1), and other tumors (n=5). Operative Procedures The procedures performed were pancreatic head resections (either Whipple or mostly pylorus-preserving pancreatic head resections=PPPD), total pancreatectomies, total gastrectomies with Roux-en-Y esophagojejunostomy, palliative biliodigestive anastomoses, and multivisceral resections. Pancreatic and gastric resections predominated in both groups (Table 1). Patients in the lap group were technically operated as laparoscopic-assisted resections. Both in pancreatic or gastric resections, the preparative phase, including complete resection of the organ, were performed laparoscopically while
Time to Bowel Segment Resection and Intraoperative Parameters A proximal jejunal segment (approximately 5 cm) was resected during the standard course of operation in all operative procedures. In patients of the lap group, resection of the small jejunal segment was performed directly after conversion to the open reconstructive part of the procedure. The time from skin incision to resection of this segment was documented as well as the amount and sort (balanced crystalloids (Ionosteril ®), colloids (Volulyte®), blood transfusion) of intravenous fluid replacement. Dry-Wet Ratio and Histologic Analyses of Edema Formation Directly after resection, the wet weight of the resected segment was measured and then the segment was dried in an oven (Heraeus electronic UT5042EK, Hanau, Germany) to constant weight (24h; 100°C), which is defined as dry weight. Calculations were made to express the dry-wet ratio as a measure of small bowel wall water content. One part of each sample was formalin-fixed and paraffin-embedded. The slides were then scanned into Panoramic Viewer (3DHISTECH Ltd.) for further analyses. Three slides of each sample were analyzed in a blinded fashion related to whole bowel wall thickness (distance from serosal side to the apex of the villus in between two plicae circulares). Mean value of respectively three slides was assumed to be the bowel wall thickness of corresponding samples. Furthermore, the presence of edema (pale band in the submucosal layer) was descriptively assessed by one blinded pathologist. Statistical Analysis Statistical analysis was performed with GraphPad Prism 5.0. All data are expressed as mean ± standard deviation. Comparisons between the groups were made by t test for independent groups when normally distributed. Mann-
J Gastrointest Surg (2014) 18:2149–2154
Whitney U test was used for non-normally distributed data. Significance was assumed for p
