Mesenteric Traction Research Articles

Clinical evidence on visceral pain. Systematic review

ABSTRACT BACKGROUND AND OBJECTIVES: Visceral pain is induced by abnormalities of organs such as stomach, kidneys, bladder, gallbladder, intestines and others and includes distension, ischemia, inflammation and mesenteric traction. It is responsible for physical and psychic incapacity, absenteeism and poor quality of life. This study aimed at discussing major aspects of pain with regard to prevalence, etiology and diagnosis. CONTENTS: According to Evidence-Based Medicine concepts, pain etiology, diagnosis and prognosis were reviewed in LILACS, EMBASE and Pubmed databases. Therapeutic studies were not selected. The following terms were used as search strategy: (visceral pain[MeSH Terms] OR (visceral[All Fields] AND Fields]) OR visceral pain[All Fields]). Only studies published in Portuguese, English or Spanish were included. Narrative reviews with opinionated content and specific therapeutic procedures of medical specialties were excluded. Studies on pain related to heart, cancer and musculoskeletal diseases and pregnancy were also excluded. CONCLUSION: Visceral pain is a heterogeneous condition where most frequent presentation is abdominal pain in the course of irritable bowel syndrome. Other diseases induce pain and adequate diagnosis is critical for effective treatment.

Intracorporeal versus extracorporeal anastomosis in right hemicolectomy: a systematic review and meta-analysis

BackgroundLaparoscopic right hemicolectomy for colon cancer is associated with substantial morbidity despite the introduction of enhanced recovery protocols and laparoscopic surgery. Laparoscopic right hemicolectomy with an intracorporeal anastomosis (IA) is less invasive than laparoscopic assisted hemicolectomy, possibly leading to further decrease in post-operative morbidity and faster recovery. The current standard technique includes an extracorporeal anastomosis with mobilization of the colon, mesenteric traction and a extraction wound located in the mid/upper abdomen with relative more post-operative morbidity compared to extraction wounds located in the lower abdomen.MethodsA systematic review of PubMed and Embase databases was performed on studies comparing the intracorporeal versus the extracorporeal performed anastomosis in laparoscopic right hemicolectomy. Primary outcomes were mortality, short-term morbidity and length of stay. For quality assessment, the MINORS checklist was used. Meta-analysis was performed using a random-effects model, and a subgroup analysis was performed for data regarding short-term morbidity and length of stay in studies published in 2012≥.ResultsA total of 2692 papers were identified, 12 non-randomized comparative studies were included in the analysis with a total number of 1492 patients. No significant change in mortality was found (OR 0.36, 95 % CI 0.09–1.46; I2 = 0 %). Short-term morbidity decreased significantly in favour of IA (OR 0.68, 95 % CI 0.49–0.93; I2 = 20 %). Length of stay was decreased, but with serious risk of heterogeneity (MD −0.77 days, 95 % CI −1.46 to −0.07; I2 = 81 %). Subgroup analysis for papers published in 2012≥ resulted in an even larger decrease in short-term morbidity (OR 0.65, 95 % CI 0.50–0.85; I2 = 0 %) and a significant decrease in length of stay with low risk of heterogeneity (MD −0.77 days, 95 % CI −1.17 to −0.37; I2 = 4 %).ConclusionIntracorporeal anastomosis in laparoscopic right hemicolectomy is associated with reduced short-term morbidity and decreased length of hospital stay suggesting faster recovery as shown in this meta-analysis.

Hemodynamics of mesenteric traction syndrome measured by FloTrac sensor

BackgroundMesenteric traction syndrome (MTS) develops in the early phase of laparotomy, which is triggered by pulling of the mesentery. We attempted to analyze the circulatory dynamics of MTS by using the FloTrac sensor. MethodsProspective randomized control study, the MTS trial, was conducted with or without prophylactic administration of flurbiprofen axetil in order to control MTS development in 57 elective open colorectal surgeries. None of the Flurbipurofen group patients (n = 23) develop MTS and were allocated to the non-MTS group. Among the non-flurbiprofen group, 28 patients (82%) developed MTS and were categorized into the MTS group. For these patients, in addition to blood pressure, stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured by FloTrac sensor. ResultsThe lowest blood pressure was noted within 30 minutes from the beginning of the intra-abdominal examination; in the non-MTS group, the mean blood pressure decreased by 16.7%, and in the MTS group, it decreased by 34.2% (P < .01). SVV of the 28 MTS patients was as follows: <9% in 10 patients (35.7%), >9% and <13% in 8 patients (28.6%), and >13% in 10 patients (35.7%). SVRI rose in the non-MTS group by 5.1%, whereas it fell in the MTS group by 15.1% (P < .01), indicating the close relationship between MTS and SVRI. ConclusionsThe SVV results indicate that fluid loading is not that optimal treatment against hypotension of MTS and that it is also important to consider the use of a vasoconstrictor. FloTrac is therefore useful for making an appropriate decision on the treatment strategy for MTS.

Intravenous Flurbiprofen Axetil Can Stabilize the Hemodynamic Instability Due to Mesenteric Traction Syndrome—Evaluation With Continuous Measurement of the Systemic Vascular Resistance Index Using a FloTrac® Sensor

Evaluation of the stabilizing effect of intravenous flurbiprofen axetil against hemodynamic instability due to mesenteric traction syndrome (MTS) by continuous measurement of systemic vascular resistance index (SVRI) using a FloTrac(®) sensor was evaluated. Prospective randomized trial. A single-center study performed in an educational hospital. Two prospective studies were carried out, each with 40 patients scheduled for elective open abdominal surgery. Twenty patients received 50 mg of flurbiprofen axetil after the recognition of MTS by the anesthesiologist (group FT). The remaining patients served as controls (groups CP and CT). SVRI data was collected every 20 seconds for 1 hour after starting the laparotomy. The average SVRI prior to skin incision was taken as the baseline. Following 3 values were devised to evaluate MTS: the S-value (sum total of changes in SVRI from baseline), the T-value (period during which SVRI remained 20% or more below baseline), and the M-value (maximum change in SVRI from baseline). In group FP, decrease in SVRI was smaller than in group CP, and statistical differences in the 3 values were found. In group FT, SVRI recovered earlier than in group CT, and statistical differences were found in S-value and T-value. However, the M-value had no statistical differences. Intravenous flurbiprofen axetil can stabilize the hemodynamic instability due to MTS.

Flurbiprofen axetil provides a prophylactic benefit against mesenteric traction syndrome associated with remifentanil infusion during laparotomy

Mesenteric traction syndrome (MTS) is caused by PGI(2) release during abdominal procedures and is often observed during abdominal surgery. We have demonstrated that MTS occurs more frequently in cases using remifentanil than in those that are not. The aim of this study was to assess the prophylactic benefit of flurbiprofen axetil on MTS in patients undergoing abdominal surgery using remifentanil. Thirty ASA physical status I and II patients were enrolled. They were scheduled to undergo abdominal surgery under general anesthesia with remifentanil and were randomly assigned to receive flurbiprofen axetil (group F) or saline (group C) preoperatively (n=15 each). MTS was defined according to our simplified diagnostic criteria. Arterial blood pressure and heart rate were recorded, and the plasma 6-keto-PGF(1α) (a stable metabolite of PGI(2)) concentration was measured just before skin incision and at 20 and 60min after skin incision (T(0), T(20), T(60)) to confirm the diagnosis of MTS. Twelve of 15 (80%) patients developed MTS in group C, whereas only 1 of 15 (6.7%) patients in group F developed MTS. At T(20), the group C patients showed significantly lower arterial blood pressure (P<0.05) and a faster heart rate (P<0.01) than those in group F. The mean plasma 6-keto-PGF(1α) concentration was significantly elevated in group C at T(20) (P<0.01), whereas the plasma 6-keto-PGF(1α) level remained low throughout the observation period in group F. We found that preoperative administration of flurbiprofen axetil reduced the incidence of MTS during abdominal surgery with remifentanil analgesia.

Interleukin-6 production is reduced by the extraperitoneal approach in elective abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) repair through a transperitoneal approach induces a systemic interleukin-6 (IL-6) response which may be related to manipulation of the bowel and mesenteric traction. This study investigates the effect of avoiding intestinal manipulation on IL-6 production by comparing the use of extraperitoneal and transperitoneal approaches in elective infrarenal AAA repair. Patients undergoing elective AAA repair were randomized into either transperitoneal (n=10) or extraperitoneal (n=8) groups. Samples of systemic and portal blood were collected intraoperatively before, during and after aortic cross clamping. In addition, systemic blood samples were obtained pre-induction, post-induction, and 6, 12, 24, and 48 hours after abdominal incision. Plasma IL-6 concentration was measured using a bioassay based on the proliferation of IL-6 dependent B9 Hybridoma cells (sensitivity of assay is 30–40 pg/ml). In the extraperitoneal group, IL-6 was not detected in either the portal or systemic circulations intraoperatively. With the transperitoneal group, IL-6 was detected in 15 of 40 (38%) portal, and 8 of 40 (20%) systemic intraoperative samples (p<0.001,x2 test). Postoperatively, IL-6 was detected in only 14 of 32 (44%) samples taken during the 48 hours after extraperitoneal repair but in 35 of 40 (88%) samples after transperitoneal repair (p<0.001,x2 test). At 6 hours, the systemic IL-6 concentration was significantly higher in the transperitoneal group (p<0.01, Mann-WhitneyU test). No correlation was seen between the plasma IL-6 concentration and aortic clamp time, duration of operation, or amount of blood lost or transfused. These results supports the suggestion that intestinal manipulation plays an important role in driving the systemic inflammatory response that may be seen after transperitoneal AAA repair.

Remifentanil increases the incidence of mesenteric traction syndrome: preliminary randomized controlled trial

The use of remifentanil is often associated with the observation of mesenteric traction syndrome (MTS) soon after manipulation of the intestine during abdominal surgery. MTS symptoms include facial flushing, hypotension, and tachycardia. In the study reported here, we prospectively investigated the effects of remifentanil on the incidence of MTS in abdominal surgery. One hundred patients scheduled for abdominal surgery were randomly assigned to two groups. In one group (n = 50), fentanyl alone was used as intravenous analgesic (control, group C); in the second group (n = 50), both fentanyl and remifentanil were used (remifentanil group, group R). In all patients, anesthesia was induced with propofol and rocuronium and then maintained with sevoflurane inhalation. Remifentanil was continuously infused for patients in group R as an analgesic. Plasma concentration of 6-keto-PGF(1α) was measured before surgery and 20min after the skin incision was made in six patients of group R and seven patients of group C. MTS occurred in 20 cases in group R (40.0%), but in only five cases in group C (10.0%). In both groups, the incidence of MTS was higher in laparotomy than in laparoscopic surgery. The plasma concentration of 6-keto-PGF(1α) was low in both groups before surgery and was elevated 20min after skin incision in both groups in patients in whom MTS appeared. The results of this study suggest that the use of remifentanil in laparotomy facilitates MTS.

Retroperitoneal Approach to Abdominal Aortic Aneurysm Repair Preserves Splanchnic Perfusion as Measured by Gastric Tonometry

We investigated if minimizing bowel manipulation and mesenteric traction using the retroperitoneal approach in open abdominal aortic aneurysm (AAA) repair preserves splanchnic perfusion, as measured by gastric tonometry, and reduces the systemic inflammatory response and dysfunction of the various organs. Patients undergoing elective AAA repair were randomized into three groups. Group I had repair via the retroperitoneal approach, while groups II and III were repaired via the transperitoneal approach with the bowel packed within the peritoneal cavity or exteriorized in a bowel bag, respectively. A tonometer was used to measure gastric intramucosal pH (pHi), as an indicator of splanchnic perfusion, just prior to aortic clamping, during clamping, and at 0.5, 1, 2, 4, 6, and 12 hr after clamp release. Multiorgan dysfunction syndrome (MODS) and systemic inflammatory response syndrome (SIRS) scores were calculated and systemic interleukins (IL-6 and IL-10) measured at predetermined intervals. Thirty-four patients were successfully randomized. The gastric pHi was significantly lower in group II (n=12) and group III (n=11) compared to group I (n=11) during aortic clamping and immediately after clamp release (p<0.05). The aortic clamp time, blood loss, MODS and SIRS scores, and systemic cytokine response were similar in all three groups. When the three groups were combined, there were significant positive correlations between the operation time, aortic clamp time, and amount of blood lost and transfused with plasma IL-6 levels and MODS score on the first postoperative day. The retroperitoneal approach for open AAA repair is associated with gastric tonometric evidence of better splanchnic perfusion compared to the transperitoneal approach.

Response Time of Different Methods of Cardiac Output Monitoring During Cardiopulmonary Resuscitation and Recovery

partial pressure (PETCO2) and mixed venous hemoglobin oxygen saturation (SvO2) also were continuously monitored and recorded. During the laparotomy, hypotension and tachycardia were noted and were accompanied by facial flushing. This was diagnosed as mesenteric traction syndrome and was treated with fluid administration and intermittent intravenous ephedrine. During this period, high cardiac output was recorded with all devices. The maximal values recorded were 6.9 L/min, 9.2 L/min, 17.4 L/min, and 17.9 L/min via the EDM, NICO, STAT CCO, and trend CCO monitors, respectively. At this point, the SvO2 was 89% and VCO2 was 137 mL/min. These symptoms eventually disappeared, and the patient’s CO subsequently stabilized (measured as 5.5 L/min, 5.1 L/min, 10.1 L/min, and 11.3 L/min via the EDM, NICO, STAT CCO, and CCO monitors, respectively; SvO2 85%, VCO2 126 mL/min. The CO at this point as measured with a bolus thermodilution was 7.0 L/min. During surgical exposure of the aortic aneurysm, a sudden onset of ventricular premature contraction was followed by sustained ventricular tachycardia (VT). Because initial DC cardioversion failed to stop the VT, phenylephrine, lidocaine, nitroglycerin, and epinephrine were administered while closed-chest compression was provided. During CPR, the patient was manually ventilated to ensure adequate ventilation. The minute volume provided during CPR was between 11 L/min and 12 L/min. The third DC cardioversion finally restored the patient to sinus rhythm. The duration of VT was 9 minutes, and chest compression provided a systolic pressure of more than 60 mmHg and diastolic pressure of more than 20 mmHg during CPR. The trend for the EDM, NICO, STAT CCO, and trend CCO monitors are summarized in Figure 1, along with PETCO2 and SvO2 during the CPR period. The CO measured with EDM varied from 0 to 2.5 L/min, and the signal of descending aortic blood flow caused by chest compression was clearly visible during this event using EDM. Three rebreathing cycles were used with a NICO monitor during CPR. The first rebreathing cycles were applied at 2 minutes after the onset of VT and the CO and VCO2 were reported as 2.9 L/min and 104 mL/min, respectively. The second cycle was applied 5 minutes after the onset of VT and failed to estimate the CO. The third rebreathing cycle was applied at 8 minutes after the onset of VT, and the CO and VCO2 were

Retroperitoneal Repair of Abdominal Aortic Aneurysm Reduces Bowel Dysfunction

To assess the effect of intestinal manipulation and mesenteric traction on gastro-intestinal function and postoperative recovery in patients undergoing abdominal aortic aneurysm (AAA) repair. Thirty-five patients undergoing AAA repair were randomised into 3 groups. Group I (n = 11) had repair via retroperitoneal approach while Group II (n = 12) and Group III (n = 12) were repaired via transperitoneal approach with bowel packed within the peritoneal cavity or exteriorised in a bowel bag respectively. Gastric emptying was measured pre-operatively (day 0), day 1 and day 3 using paracetamol absorption test (PAT) and area under curve (P(AUC)) was calculated. Intestinal permeability was measured using the Lactulose-Mannitol test. Aneurysm size, operation time and PAT (on day 0 and day 3) were similar in the three groups. On day 1, the P(AUC) was significantly higher in Group I, when compared with Group II and Group III (P = .02). Resumption of diet was also significantly earlier in Group I as compared to Group II and Group III. The intestinal permeability was significantly increased in Group II and Group III at day 1 when compared with day 0, with no significant increase in Group I. Retroperitoneal repair was also associated with significantly shorter intensive care unit (P = .04) and hospital stay (P = .047), when compared with the combined transperitoneal repair group (Group II and III). Retroperitoneal AAA repair minimises intestinal dysfunction and may lead to quicker patient recovery when compared to transperitoneal repair.

Prostaglandin I2 release following mesenteric traction during abdominal surgery is not COX-2 dependent

Prostaglandin I2 release following mesenteric traction during abdominal surgery is not COX-2 dependent

Prostaglandin I 2 release following mesenteric traction during abdominal surgery is mediated by cyclooxygenase-1

Our study aimed to determine the role of cyclooxygenase-2 in the release of prostaglandin-(PG)-I 2 following mesenteric traction during abdominal surgery. In a prospective double-blind, randomized, placebo-controlled study, 40 patients electively scheduled for non-laparoscopic abdominal surgery, were pretreated with the cyclooxygenase-2 inhibitor parecoxib ( n = 20) or placebo ( n = 20). Heart rate, arterial blood pressure, oxygenation ratio and plasma concentrations of the stable PGI 2-metabolite 6-keto-PGF 1α were compared between groups before injection of parecoxib (− 40 min), immediately before mesenteric traction (0 min), and 5, 10, and 30 min thereafter. In addition, plasma concentrations of valdecoxib, the active metabolite of the prodrug parecoxib, were determined. Plasma concentrations of 6-keto-PGF 1α and heart rate increased in both groups after mesenteric traction. There were no significant differences between groups at individual times in heart rate, arterial blood pressure and plasma concentrations of 6-keto-PGF 1α. Oxygenation ratio decreased after 10 and 30 min following mesenteric traction in the parecoxib group with a significant difference between treatment groups at 10 and 30 min. Plasma concentrations of valdecoxib revealed therapeutic values. Our data indicate that PGI 2 release following mesenteric traction is mediated by cyclooxygenase-1.

Central neuraxial blockade increased the severity of hypotension due to mesenteric traction during major abdominal surgery

Central neuraxial blockade increased the severity of hypotension due to mesenteric traction during major abdominal surgery

Mesenteric Traction Syndrome or Gut in Distress

The mesenteric traction syndrome (MTS) remains, seventeen years after its first designation as a distinct pathologic entity, an aspect of surgical practice that has received limited attention. Apart from its symptomatology, there is mostly speculation about its exact causes and pathophysiologic mechanisms. Even though full-blown MTS is rather rare, the advent of laparoscopic surgery has indicated that there are different stages of stress associated with open abdominal surgery. Some evidence points to the involvement of mast cell derived vasoactive mediators and suggests possible pharmacologic management.

Treatment of refractory mesenteric traction syndrome without cyclooxygenase inhibitors

Mesenteric traction may be necessary for surgical exposure during colonic or aortic surgery. Traction on the mesentery releases prostacyclin, producing variable degrees of hypotension. Numerous cases of severe, life-threatening hypotension have been reported. The published literature suggests that treatment of severe hypotension from mesenteric traction with routine doses of vasoconstrictors may be ineffective, but inhibition of prostacyclin synthesis with cyclooxygenase inhibitors can successfully treat or prevent hypotension. This rationale, while highly beneficial, would place patients with allergies to cyclooxygenase inhibitors at a severe disadvantage, and would also leave no therapeutic options if intravenous cyclooxygenase inhibitors were not immediately available. We report the successful use of high-dose phenylephrine in the treatment of mesenteric traction syndrome.

Interleukin-6 production is reduced by the extraperitoneal approach in elective abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) repair through a transperitoneal approach induces a systemic interleukin-6 (IL-6) response which may be related to manipulation of the bowel and mesenteric traction. This study investigates the effect of avoiding intestinal manipulation on IL-6 production by comparing the use of extraperitoneal and transperitoneal approaches in elective infrarenal AAA repair. Patients undergoing elective AAA repair were randomized into either transperitoneal (n=10) or extraperitoneal (n=8) groups. Samples of systemic and portal blood were collected intraoperatively before, during and after aortic cross clamping. In addition, systemic blood samples were obtained pre-induction, post-induction, and 6, 12, 24, and 48 hours after abdominal incision. Plasma IL-6 concentration was measured using a bioassay based on the proliferation of IL-6 dependent B9 Hybridoma cells (sensitivity of assay is 30–40 pg/ml). In the extraperitoneal group, IL-6 was not detected in either the portal or systemic circulations intraoperatively. With the transperitoneal group, IL-6 was detected in 15 of 40 (38%) portal, and 8 of 40 (20%) systemic intraoperative samples (p<0.001,x 2 test). Postoperatively, IL-6 was detected in only 14 of 32 (44%) samples taken during the 48 hours after extraperitoneal repair but in 35 of 40 (88%) samples after transperitoneal repair (p<0.001,x 2 test). At 6 hours, the systemic IL-6 concentration was significantly higher in the transperitoneal group (p<0.01, Mann-Whitney U test). No correlation was seen between the plasma IL-6 concentration and aortic clamp time, duration of operation, or amount of blood lost or transfused. These results supports the suggestion that intestinal manipulation plays an important role in driving the systemic inflammatory response that may be seen after transperitoneal AAA repair.

Decrease in urine output during mesenteric traction syndrome is an early predictor of multiorgan dysfunction

Decrease in urine output during mesenteric traction syndrome is an early predictor of multiorgan dysfunction

Changes in Gastric Intramucosal pH following Mesenteric Traction in Patients Undergoing Pancreas Surgery

Background/Aim: During major abdominal surgery, mesenteric traction (MT) may result in hemodynamic instability mainly due to endogenous prostacyclin release. Gastric intramucosal pH (pHi) and PiCO₂ are indicators of splanchnic tissue perfusion with a predictive value for the postoperative outcome. We investigated the influence of MT on gastric pHi and on postoperative outcome in patients undergoing pancreas surgery. Methods: Forty-six consecutive patients scheduled for pancreas surgery were investigated. We registered hemodynamics and pHi by gastric tonometry and documented postoperative outcome (complications, hospital stay). Baseline data (T0) were recorded after skin incision. Further assessments followed 30, 60 and 120 min after intentional MT (T1–3) and at the end of surgery (T4). Results: Thirty-three patients demonstrated a decrease in mean arterial pressure (MAP) following MT, whereas 13 patients showed entirely stable hemodynamics. The significant reduction in MAP in patients with an MT response was not associated with changes in pHi as compared to patients with no response (stable MAP) (T0 7.34 ± 0.08 vs. 7.35 ± 0.06; T1 7.34 ± 0.05 vs. 7.32 ± 0.07; T2 7.32 ± 0.05 vs. 7.31 ± 0.08; T3 7.32 ± 0.05 vs. 7.32 ± 0.07; T4 7.26 ± 0.1 vs. 7.27 ± 0.08; mean ± SD, MT response vs. no response). Neither MT response nor gastric intramucosal acidosis as evidenced by a pHi <7.32 at the end of surgery predicted postoperative complications or longer hospital stay. Conclusion: No deterioration of gastric pHi was found, which could reflect acceptable splanchnic perfusion and oxygenation despite systemic blood pressure reactions in patients experiencing an MT response.

The Impact of Prostanoids on Pulmonary Gas Exchange During Abdominal Surgery with Mesenteric Traction

We investigated the effect of intravenous (iv) ibuprofen on prostanoid release and on pulmonary gas exchange after abdominal mesenteric traction (MT) during either abdominal aortic surgery or pancreas resection.In a prospective, randomized, double-blind study, 400 mg ibuprofen (pancreas n = 13, aorta n = 13) or a placebo (pancreas n = 13, aorta n = 13) was administered iv before skin incision. MT was applied uniformly. The prostanoid plasma concentrations, venous admixture (Qva/Qt), and PaO (2/FIO)2 ratio were determined at baseline (before MT) and 5, 15, 45, and 90 min after MT. Patients who underwent aortic surgery were older and exhibited a lower preoperative PaO2 than those who underwent pancreas resection. Placebo-treated patients revealed a 30-fold peak increase in 6-keto-prostaglandin F1 alpha (stable metabolite of prostacyclin) levels after intentional MT during aortic as well as pancreatic operations. This response was accompanied by an increase in Qva/Q (t) (ibuprofen: pancreas 7% +/- 1%, aorta 14% +/- 2%; placebo: pancreas 16% +/- 3%, aorta 26% +/- 3%/15 min after MT [mean +/- SEM, p < 0.05, placebo vs ibuprofen]), which resulted in decreased PaO2/FIO2 ratio only in the aortic surgery patients (ibuprofen: 310 +/- 19; placebo: 237 +/- 24 15 min after MT, [mean +/- SEM, P < 0.05]). The authors conclude that ibuprofenpretreated patients demonstrated almost constant prostanoid levels without changes in pulmonary gas exchange after MT. (Anesth Analg 1997;85:274-80)

Perioperative endotoxemia and bacterial translocation during major abdominal surgery

To investigate the potential role of endogenous prostacyclin (PGI2) released after mesenteric traction during major abdominal surgery on perioperative endotoxemia and bacterial translocation. Prospective, randomized, double-blind clinical study. Operating room and surgical intensive care unit in a university hospital. Fifty consecutive patients scheduled for major abdominal surgery (pancreas resection, abdominal aortic surgery). Fifteen minutes before skin incision, either 400 mg of ibuprofen or a placebo equivalent were administered intravenously. Immediately after peritoneal incision, eventration and action of the small bowel was intentionally performed in a uniform fashion. Baseline values were obtained before induction of anesthesia. Additional measurements, along with assessments of hemodynamics and gas exchange, were performed before incision of the peritoneum and at 5, 30, and 45 mins and 3, 6, and 24 hrs after mesenteric traction. Arterial plasma concentrations of 6-keto-prostaglandin F1 alpha and thromboxane B2 (stable metabolites of PGI2 and thromboxane A2) were determined by radioimmunoassay. Endotoxin was measured by limulus amebocyte lysate test. Mesenteric lymph nodes were sampled in 31 patients (ibuprofen n = 14, placebo n = 17) and sent for culture under sterile conditions. Transient hypotension and a marked increase of plasma 6-keto-prostaglandin F1 alpha concentrations occurred up to 6 hrs after mesenteric traction in untreated patients with median peak concentrations (2243 vs. 72 ng/L [p < .0001, placebo vs. ibuprofen], observed 5 mins after mesenteric traction). Endotoxemia occurred in both study groups. However, after mesenteric traction, plasma endotoxin concentrations were significantly higher in the ibuprofen group. Median peak concentrations (0.12 vs. 0.27 EU/mL [p < .001, placebo vs. ibuprofen]) were observed 3 hrs after mesenteric traction. Gram-negative bacteria in mesenteric lymph nodes were detected exclusively in the ibuprofen group (n = 5, p < .01). In ibuprofen-pretreated patients, significantly higher endotoxin concentrations as well as bacterial translocation to mesenteric lymph nodes occurred, despite the absence of a transient decrease in mean arterial pressure that had been associated with PGI2 release. Therefore, we hypothesized that during major abdominal surgery, endogenous PGI2 released in response to mesenteric traction may play a crucial role in maintaining splanchnic microcirculation and thus preserving gut mucosal barrier function.