Physiologic effects of pneumoperitoneum in adults with sickle cell disease undergoing laparoscopic cholecystectomy

ABSTRACT

Chronic hemolysis predisposes adults with sickle cell disease [SCD] to the formation of bilirubinate cholelithiasis. Cholecystectomy is the most frequent surgical procedure performed in SCD patients. Many studies have demonstrated the adverse consequences of pneumoperitoneum; however, few studies have examined the physiologic effects of pneumoperitoneum in adults with SCD during laparoscopic cholecystectomy [LC]. 40 ASA I-II patients, with cholelithiasis, scheduled for elective LC were randomly allocated into one of two equal groups Group [1] normal patients without SCD [control group] and group [2] patients with SCD. In group [2] eleven patients [55%] were managed with a preoperative transfusion regimen to achieve a hemoglobin value of >/= 10g/dl, independent of hemoglobin S percentage. Study parameters [in the two groups] included heart rate/min, mean blood pressure [mmHg], PETCO[2], and Spo[2] at the following intervals Before induction of anesthesia in the supine position [all except PETCO[2]], after anesthesia and before CO[2] insufflation in the supine position, 15, 30, 45, 60min after CO[2] insufflation in the anti-Trendelenburg position, at the end of CO[2] exsufflation in the supine position and 5min after the end of CO[2] exsufflation in the supine position. Arterial blood gases, to measure pH, PaCO[2] and PaO[2], were determined after induction of anesthesia and before CO[2] insufflation in the supine position, then 30min after CO[2] insufflation in the anti-Trendelenburg position, and 5min after the end of CO[2] exsufflation in the supine position. Statistical significance was established at p<0.05. Induction of anesthesia produced significant increase in HR in both groups. CO[2] insufflation led to additional increase in HR and persisted till abdominal deflation. As regards MAP, induction of anesthesia produced significant decrease in MAP in the two study groups. After CO[2] insufflation, MAP significantly increased from the baseline at 15, 30, 45, 60min and just before deflation in the anti-Trendelenburg position. CO[2] insufflation led to significant increase in ETCO[2] in the study groups to reach the maximum level just before abdominal deflation in the anti-Trendelenburg position. Five min later after deflation in the supine position, ETCO[2] decreased significantly. pH decreased significantly 30min after CO[2] insufflation in the anti-Trendelenburg position in both groups while PaCO[2] increased significantly 30min after CO[2] insufflation. Regarding SpO[2] and PaO[2], there were insignificant changes in the two study groups all over the time of the procedure. In group [2], none of the patients experienced vaso-occlusive crises or other SCD-related complications. There were no common bile duct injuries or deaths in the two study groups. The mean hospital stay in group [1], was 1.9 days [range, 1-3]. In group [2], nine patients [45%] were discharged on the 2[nd] postoperative day. The mean hospital stay, in this group, was 2.6 days [range, 2-4]. This study proved, beyond doubt, the safety of LC in patients with SCD and cholelithiasis. LC allows faster and safer postoperative recovery. A successful outcome can only be achieved by close consultation and mutual cooperation among surgeon, anesthesiologist, and hematologist