title: Biomolecular inflammatory response to surgical energy usage in laparoscopic surgery: results of a randomized study.
abstract: Use of surgical energy is integral to laparoscopic surgery (LS). Energized dissection (ED) has a potential to impact the biomolecular expression of inflammation due to ED-induced collateral inflammation. We did this triple-blind randomized controlled (RCT) study to assess this biomolecular footprint in an index LS, i.e., laparoscopic cholecystectomy (LC).
  
  
  
  This RCT was conducted in collaboration with tertiary-level institutions, from January 2014 to December 2014 with institutional review board clearance. Consecutive, unselected, consenting candidates for LC were randomized (after anesthesia induction) into group I (ED) and group II (non-ED). They were managed with compliance to universal protocols for ethics, informed consent, anesthesia, drug usage and clinical pathway with blinded observers. Biomolecular inflammatory markers, i.e., interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α) and highly sensitive CRP (HS-CRP), were measured with blood drawn juxta-preoperatively (H0), at 4 h (H4) and at 24 h (H24). The quantitative changes induced by ED on IL-6, TNF-α and HS-CRP at H0, H4 and H24 with their kinetic behavior were the study endpoint. Prospective data were analyzed statistically with a p value of <0.05 being significant.
  
  
  
  Two cases from the ED group had biliary injury and hence were withdrawn from analysis. The ED (n = 49) and non-ED (n = 51) groups had similar demographic, clinical and H0 biomolecular variables. There was a significant increase in IL-6, TNF-α and HS-CRP from H0 to H4 in both the groups (p values <0.001). From H4 to H24, all three cytokines showed significant increase in ED group (p < 0.05), whereas in the non-ED group, IL-6 showed significant fall (p = 0.004) and TNF-α showed no significant change (p = 0.063). Both the groups showed H4-H24 elevation of HS-CRP (p = 0.000).
  
  
  
  Energized dissection adds to the cytokine-mediated postoperative inflammation. The additional ED-induced inflammation can be measured objectively by IL-6 and TNF-α levels.
  
  
  
  Clinical Trials Registry, India (REF/2014/06/007153).
authors.affiliation: Department of General and Laparoscopic Surgery, Ganga Ram Institute of Post Graduate Medical Education and Research (GRIPMER), New Delhi, India. endosurgeon@gmail.com.
authors.forename: Brij B
authors.initials: BB
authors.lastname: Agarwal
authors.affiliation: Department of General and Laparoscopic Surgery, Ganga Ram Institute of Post Graduate Medical Education and Research (GRIPMER), New Delhi, India.
authors.forename: Juhil D
authors.initials: JD
authors.lastname: Nanavati
authors.affiliation: University College of Medical Sciences, New Delhi, India.
authors.forename: Nayan
authors.initials: N
authors.lastname: Agarwal
authors.affiliation: University College of Medical Sciences, New Delhi, India.
authors.forename: Naveen
authors.initials: N
authors.lastname: Sharma
authors.affiliation: Safdarjang Hospital, New Delhi, India.
authors.forename: Krishna A
authors.initials: KA
authors.lastname: Agarwal
authors.affiliation: Department of General and Laparoscopic Surgery, Ganga Ram Institute of Post Graduate Medical Education and Research (GRIPMER), New Delhi, India.
authors.forename: Kumar
authors.initials: K
authors.lastname: Manish
authors.affiliation: Department of Academics, Ganga Ram Institute of Post Graduate Medical Education and Research (GRIPMER), New Delhi, India.
authors.forename: Satish
authors.initials: S
authors.lastname: Saluja
authors.affiliation: Department of Anatomy, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Sneh
authors.initials: S
authors.lastname: Agarwal
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects* / Q000379:methods; D004210:Dissection / Q000009:adverse effects* / Q000379:methods; D004311:Double-Blind Method; D004598:Electrosurgery / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D007249:Inflammation / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D015850:Interleukin-6 / Q000097:blood; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000097:blood / Q000175:diagnosis / Q000209:etiology*; D011184:Postoperative Period; D011446:Prospective Studies; D014409:Tumor Necrosis Factor-alpha / Q000097:blood
chemical_list: D015415:Biomarkers; C508600:IL6 protein, human; D015850:Interleukin-6; D014409:Tumor Necrosis Factor-alpha; D002097:C-Reactive Protein
keywords: CBD injury; Complications of laparoscopic cholecystectomy; Cytokines; Laparoscopic surgery; Patient safety; Surgical energy