The effect of intraabsominal pressure on the thiole-disulfide balance in patients operated with laparoscopic cholecystectomy under general anesthesia

Classical open cholecystectomy had been the traditional technique in surgical management of cholelithiasis. Recently laparoscopic cholecystectomy has taken over and is now considered the gold standard in the management of gall bladder diseases due to lower complication rate. Anesthetic considerations for laparoscopic cholecystectomy are similar to those for other laparoscopic procedures and result from the creation of a pneumoperitoneum by insufflation of carbon dioxide (CO2) into the abdominal cavity. The resultant problems in CO2 insufflation such as decreased functional residual capacity, increased airway pressure, hypercarbia, and circulatory impairment are well known. All open surgeries increase the oxidative stress level, but the oxidative stress is less in laparoscopic methods. However, the effect of CO2 pneumoperitoneum on oxidative stress is not known exactly.The aim of this study is to evaluate oxidative stress level via thiol disulfide balance, in patients who underwent laparoscopic cholecystectomy performed at different abdominal pressures. Material and methods A total of 98 patients (ASA I–II) receiving laparoscopic for symptomatic uncomplicated cholecystolithiasis were enrolled in this prospective controlled study. Venous blood samples were collected, and levels of ischemia modified albumin (IMA) IMA levels were analyzed, native thiols, total thiols, and disulfides were determined with a novel automated assay. Blood samples were collected preoperatively (5 min. before the operation) 30 min after insufflation, 30 min after deflation, and 24 hours postoperatively for measurement of the serum levels of ischemia modified albumin (IMA) and an analysis of thiol-disulfide levels. The patients were divided into two groups, 49 patients in each. Group A included patients VI who underwent laparoscopic cholecystectomy at a CO2 pneumoperitoneum pressure of 11 mmHg, Group B patients who underwent laparoscopic cholecystectomy at a CO2 pneumoperitoneum pressure of 13 mmHg. Comparisons between and within groups were made.Preoperative-postoperative differences of thiol-disulfide and IMA levels (ΔNative thiol, ΔTotal thiolΔdisulfide, ΔIMA) were calculated in all time points. Results The median age of the patients was 48.2. Groups A and B were similar in age (median 50 vs 45 years, p=0.105) and gender (53% female vs 48% female, p=0.686). In comparison within groups, native thiol (p<0.001), total thiol (p<0,001) and disulfide (p=0.001) levels decreased up to 30 min after insufflation and increased regularly thereafter in both groups. However, IMA levels increased up to 30 min after insufflation and decreased up to 30 min after deflation, and increased to postoperative 24 hours (p<0.001). In comparison between groups, in group B, ΔNative thiol (p=0.021) and ΔTotal thiol levels (p=0.005) are higher than group A (in preoperative-after insufflation). Similarly, in deflation-insufflation period, ΔNative thiol (p=0.005) and ΔTotal thiol levels (p=0.002) are higher in group B than group A. However, the disulfide level did not differ significantly between the groups in all time points. ΔIMA levels between insufflation and deflation, are higher in group B than group A (p=0.009). Conclusion The different level of intra-abdominal pressures in laparoscopic cholecystectomy is associated with oxidative stress and ischemia. Complications related to pneumoperitoneum can be reduced by preferring low pressure pneumoperitoneum in laparoscopic surgeries. Key words: Laparoscopic cholecystectomy, Pneumoperitoneum, CO2 insufflation, Oxidative stress, Thiol-disulfide balance