Intestinal permeability and systemic endotoxemia after laparotomic or laparoscopic cholecystectomy

Abstract

Objective: Because laparoscopic cholecystectomy (LC) is widely recognized as a "mild" or "mini-invasive" kind of surgery, in this prospective nonrandomized study, we investigated the effect of intestinal manipulation on intestinal permeability and endotoxemia, in patients undergoing elective cholecystectomy by comparing the laparoscopic with the laparotomic approach.

Summary background data: The intestine is susceptible to operations at remote locations, and the barrier function is altered during intestinal manipulation, leading to bacterial or endotoxin translocation into the systemic circulation.

Methods: Forty-three patients undergoing elective cholecystectomy were divided into either the laparotomic (n = 22) or laparoscopic (n = 21) approach. Intestinal permeability was measured preoperatively and at day 1 and day 3 after surgery using the lactulose/mannitol absorption test. Serial venous blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, and 48 hours after surgery, for endotoxin measurement using the chromogenic limulus amoebocyte lysate assay.

Results: Intestinal permeability was significantly increased at day 1 [0.106 +/- 0.005 (mean +/- SEM)] in the laparotomic group compared with the preoperative level (0.019 +/- 0.005, P < 0.05) and to the laparoscopic group at day 1 (0.019 +/- 0.005, P < 0.05), which showed no change in comparison with the preoperative level. A significantly higher concentration of systemic endotoxin was detected intraoperatively in the laparotomic group of patients in comparison to the laparoscopic group (P < 0.05). There was a significant positive correlation between systemic endotoxemia and intestinal permeability (r(s) = 0.958; P = 0.001).

Conclusions: An increase in intestinal permeability and a greater degree of systemic endotoxemia are observed during laparotomic cholecystectomy. This suggests that intestinal manipulation may impair gut mucosal barrier function and contribute to the systemic inflammatory response see in open cholecystectomy.

Figures

FIGURE 1. Intestinal permeability measured by lactulose/mannitol excretion ratio (L/M ratio). *P < 0.05 versus Preop. †P < 0.05 versus laparoscopy day 1. (▪), laparotomy group; (), laparoscopy group.

FIGURE 2. Systemic endotoxin concentration (mean ± SEM) *P < 0.05 versus 60, 90, and 120 minutes. (▪), laparotomy group; (), laparoscopy group.

FIGURE 3. Correlation between systemic endotoxin concentration and intestinal permeability measured as lactulose/mannitol excretion ratio (L/M ratio) in the laparotomy group (rs = 0.958; P = 0.001).