Can Prevention of Mesothelial Damage during Endoscopic Surgery Decrease Adhesion Formation and Tumor Implantation ?
Kan Preventie van Mesotheelschade tijdens Endoscopische Chirurgie Adhesievorming en Tumorimplantatie Verminderen ?
Verguts, Jasper; S0069333
Laparoscopic surgery advanced over the last years as it holds the promise of reduced invasiveness and thus of reduced adhesion formation. Results on reduced adhesion formation were however not as good as expected and new approaches to prevent the deleterious complications such as bowel obstruction, infertility and chronic pelvic pain were investigated.Over the last years we developed a laparoscopic mouse model on which preventive measurements concerning gas (temperature, humidification, oxygen) and other means (i.e. dexamethasone, barriers) were tested and the most promising were selected. These favorable actions needed to be brought into clinical practice to reduce adhesion formation and to bring laparoscopic surgery to a new standard.Tumor implantation reduced with the addition of 3% of oxygen to the CO2 pneumoperitoneum in our laparoscopic mouse model. There was however no clinical correlation with reduced port site metastases by adding 4% of oxygen to the CO2 pneumoperitoneum in women undergoing laparoscopy for ovarian malignancies.Intraperitoneal injection of cultured mesothelial cells did decrease adhesion formation in a dose-response dependable way. To bring this approach to clinical practice will need the development of other means to safely remove, culture and inject mesothelial cells in humans in the peri-operative phase.The direct beneficial effect on the peritoneum of the addition of oxygen to the CO2 pneumoperitoneum was demonstrated in mice with scanning electron microscopy, but these experiments were not reproducible in humans. Indirect ways to measure the influence of the addition of oxygen to the CO2 pneumoperitoneum were investigated.Absorption of CO2 was investigated by the study of end tidal CO2 (ET CO2) where we noticed a significant decrease when 4% oxygen was added to the CO2 pneumoperitoneum. Perhaps related to this, was the significant decrease in post-operative pain and inflammation in women who received the oxygenated gas.From ongoing mice experiments we learned that full conditioning of the peritoneal cavity with humidification of the gas at 32°C and with addition 4% of oxygen and 10% of nitrous oxide further reduced adhesion formation.Clinical experiments with full conditioning of the peritoneal cavity studying ET CO2, pain, inflammation and fluid resorption as we carried out with the addition of 4% of oxygen all showed a beneficial effect, with even some more pronounced results on pain and inflammation.To preserve the integrity of the mesothelial layer, injection of cultured mesothelial cells or altering the insufflation gas did provide evidence, but also extensive lavage of the peritoneal cavity did improve inflammatory parameters, suggesting a depletion of inflammatory cells able to degrade the surgical lesion.The peritoneum is a delicate organ which is influenced by its environment in a direct way. Homeostasis of the environment is essential to decrease adhesion formation, post-operative pain and to minimize anesthesiologic problems.Preserving is better than restoring and with this new way of looking at, and entering the peritoneal cavity, laparoscopic surgery may step into a new era.