title: The Effect of Intraoperative N-Acetylcysteine on Hepatocellular Injury During Laparoscopic Bariatric Surgery. A Randomised Controlled Trial.
abstract: The combination of pneumoperitoneum and intraoperative retraction of the left lobe of the liver leads to hepatocellular injury during laparoscopic gastric surgery. Fatty livers are more susceptible to ischaemic insults. This trial investigated whether the antioxidant N-acetylcysteine (NAC) reduced liver injury during laparoscopic sleeve gastrectomy (LSG).
  
  
  
  Patients undergoing LSG were randomised (single blinded) to receive intraoperative NAC infusion or standard anaesthetic treatment. Blood samples were taken before and after surgery (days 0 to 4). Primary endpoints included serum aminotransferases. Secondary measures were C-reactive protein, weight cell count (WCC), cytokines (interleukin 6 and 10) and cytokeratin-18 as markers of apoptosis. Intraoperative liver biopsy samples were assessed using a locally developed injury score.
  
  
  
  Twenty patients (14 females, mean age 44.5 (SEM ± 2.9) years, mean BMI 60.8 (SEM ± 2.4) kg/m(2)) were recruited (NAC n = 10, control n = 10). The trial was stopped early after a planned interim analysis. Baseline liver function was similar. The peak rise in liver enzymes was on day 1, but levels were not significantly different between the groups. Rates of complications and length of stay were not significantly different. Secondary outcome measures, including white cell count (WCC), cytokines and cytokeratin (CK)-18 fragments, were not different between groups. Liver injury scores did not differ significantly.
  
  
  
  NAC did not reduce intraoperative liver injury in this small number of patients. The heterogenous nature of the study population, with differences in co-morbidities, body mass index and intraabdominal anatomy, leads to a varied post-operative inflammatory response. Significant hepatocyte injury occurs through both necrosis and apoptosis.
authors.affiliation: Department of Minimally Invasive, Bariatric and Laparoscopic HPB Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. ajay.belgaumkar@kcl.ac.uk.
authors.forename: Ajay P
authors.initials: AP
authors.lastname: Belgaumkar
authors.affiliation: Department of Minimally Invasive, Bariatric and Laparoscopic HPB Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
authors.forename: Kirstin A
authors.initials: KA
authors.lastname: Carswell
authors.affiliation: Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK.
authors.forename: Robin D
authors.initials: RD
authors.lastname: Hughes
authors.affiliation: Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK.
authors.forename: Alberto
authors.initials: A
authors.lastname: Quaglia
authors.affiliation: Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK.
authors.forename: Anil
authors.initials: A
authors.lastname: Dhawan
authors.affiliation: Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK.
authors.forename: Ragai R
authors.initials: RR
authors.lastname: Mitry
authors.affiliation: Department of Minimally Invasive, Bariatric and Laparoscopic HPB Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
authors.forename: Ameet G
authors.initials: AG
authors.lastname: Patel
mesh_terms: D000111:Acetylcysteine / Q000627:therapeutic use*; D000293:Adolescent; D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000009:adverse effects* / Q000379:methods; D015992:Body Mass Index; D015897:Comorbidity; D016207:Cytokines / Q000097:blood; D005260:Female; D016166:Free Radical Scavengers / Q000627:therapeutic use; D005743:Gastrectomy; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007431:Intraoperative Complications / Q000097:blood / Q000517:prevention & control; D053538:Keratin-18 / Q000097:blood; D010535:Laparoscopy / Q000009:adverse effects; D008099:Liver / Q000293:injuries* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000503:physiopathology / Q000601:surgery*; D011184:Postoperative Period; D016037:Single-Blind Method; D016896:Treatment Outcome; D015431:Weight Loss; D055815:Young Adult
chemical_list: D016207:Cytokines; D016166:Free Radical Scavengers; D053538:Keratin-18; D000111:Acetylcysteine
keywords: Bariatric surgery; N-acetylcysteine; Sleeve gastrectomy