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Intraperitoneal microdialysis: technique and results
Örebro University, Department of Clinical Medicine.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Microdialysis has recently developed from a laboratory research method of animals to a useful clinical tool to evaluate parameters suggesting tissue ischemia. It is now used in neurosurgery, plastic surgery and liver transplantation.

Shock and multiple organ failure after surgery are rare but serious complications with a high mortality rate and splanchnic ischemia is an early and important step in this development. Splanchnic ischemia is leading to increased permeability of the intestinal mucosa and to activation of macrophages. Subsequent release of inflammatory mediators like cytokines initiates shock, which may result in multiple organ failure and death. The importance of splanchnic hypoxia/ischemia is investigated in these five studies in relation to activation of cytokines (intraperitoneal and systemic) during a normal recovery and in case of surgical complications after major gastrointestinal surgery.

Postoperatively the metabolic substances, glucose, pyruvate, lactate and glycerol were analysed and the LP ratio was calculated using microdialysis intraperitoneally and subcutaneously. Two studies are focused on the activation of the immunologic system by measurement of the cytokines TNF-, IL-6 and IL-10 and the relationship between LP ratio and the cytokines. Three studies are describing the performance of intraperitoneal microdialysis, different responses depending on the site of measurement, the difference between intraperitoneal and subcutaneous measurements and normal values in postoperative gastrointestinal surgery. Patients with clinical complications are described separately.

No adverse effects of the intraperitoneal measurement technique were seen. An increase of the intraperitoneal LP ratio and decrease of glucose were in several cases preceding clinical complications. Intraperitoneal LP ratio, glucose and cytokines were higher in the abdominal cavity compared to subcutaneous and systemic measurements in a normal postoperative recovery. An intraperitoneal correlation between TNF-a and the LP ratio was found. Intraperitoneal concentrations of the cytokines and the LP ratio were decreasing in parallel during a normal postoperative recovery.

The intraperitoneal inflammatory response is higher, during a normal postoperative recovery as well as in patients suffering from complications, compared to systemic findings, emphazising the importance of the gastrointestinal tract as the source of early immunological reactions postoperatively. IPM enables safe and sensitive analysis of glucose, pyruvate, lactate and glycerol from the intraperitoneal organs measured in the intraperitoneal fluid.

Measurement of the LP ratio with microdialysis seems to detect early splanchnic hypoxia/ischemia that correlates to the intraperitoneal inflammation. IPM may have a future as an important clinical tool for monitoring patients at risk of developing postoperative surgical complications.

Place, publisher, year, edition, pages
Örebro: Örebro universitetsbibliotek , 2004. , p. 61
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 2
Keyword [en]
kirurgi
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-73ISBN: 91-7668-395-8 (print)OAI: oai:DiVA.org:oru-73DiVA, id: diva2:137181
Public defence
2004-06-11, B-husets aula, Universitetssjukhuset, Södra Grev Rosengatan, Örebro, 10:00
Opponent
Supervisors
Available from: 2004-06-08 Created: 2004-06-08 Last updated: 2017-10-18Bibliographically approved
List of papers
1. Human intraperitoneal microdialysis: increased lactate/pyruvate ratio suggests early visceral ischaemia
Open this publication in new window or tab >>Human intraperitoneal microdialysis: increased lactate/pyruvate ratio suggests early visceral ischaemia
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2003 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 38, no 9, p. 1007-1011Article in journal (Refereed) Published
Abstract [en]

Background: Previous studies suggest that visceral ischaemia precedes shock and multiple organ failure, though methods for studying humans are lacking. We aimed to evaluate intraperitoneal microdialysis, a new technique for detecting splanchnic ischaemia in clinical practice. Methods: Right-sided hemicolectomy was performed in eight patients who were studied by microdialysis postoperatively for glucose, lactate, pyruvate and glycerol levels. Results: Six of the eight patients showed a normal postoperative course and had lactate/pyruvate ratios between 7.1 and 21.7, glucose between 4.5 and 14.3 &#114 mmol/L and glycerol between 10.4 and 296 &#114 &#55 mol/L. In one patient, intraperitoneal lactate/pyruvate ratio and glycerol increased and glucose decreased 5 &#114 h before low oxygenation appeared. Another patient exhibited a period of increased lactate/pyruvate ratio before a period of atrial fibrillation. Conclusion: Intraperitoneal microdialysis was performed safely. Two out of the eight patients exhibited changes of metabolic markers followed by clinical symptoms that were probably related to transient visceral ischaemia. Our findings suggest that intraperitoneal microdialysis may become a useful tool for monitoring splanchnic ischaemia in clinical practice.

National Category
Medical and Health Sciences Surgery
Research subject
Medicine; Surgery
Identifiers
urn:nbn:se:oru:diva-3152 (URN)10.1080/00365520310004065 (DOI)
Available from: 2004-06-08 Created: 2004-06-08 Last updated: 2017-12-14Bibliographically approved
2. Intraperitoneal cytokine response after major surgery: higher postoperative intraperitoneal versus systemic cytokine levels suggest the gastrointestinal tract as the major source of the postoperative inflammatory reaction
Open this publication in new window or tab >>Intraperitoneal cytokine response after major surgery: higher postoperative intraperitoneal versus systemic cytokine levels suggest the gastrointestinal tract as the major source of the postoperative inflammatory reaction
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2004 (English)In: American Journal of Surgery, ISSN 0002-9610, E-ISSN 1879-1883, Vol. 187, no 3, p. 372-377Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Cytokine response is an important factor in the development of shock and organ failure. The aim of this study was to investigate intraperitoneal (peritoneal) and venous (systemic) postoperative cytokine release after major surgery.

METHODS: Major abdominal surgery was performed in 19 patients. Preoperative systemic measurements and postoperative systemic and peritoneal measurements of C-reactive protein (CRP) and the cytokines tumor necrosis factor-alpha (TNF-alpha), interleukin (IL-6), and IL-10 were performed.

RESULTS: Significantly higher TNF-alpha, IL-6, and IL-10 peritoneal values were recorded compared with systemic values, whereas peritoneal CRP was significantly decreased. CRP increased significantly over time, whereas postoperative values of IL-6, IL-10, and peritoneal TNF-alpha decreased. Systemic TNF-alpha was constant over time, but values after emergent abdominal surgery showed a more extensive response. An additional effect of surgery and emergent abdominal disease was seen in increased TNF-alpha and IL-10 levels.

CONCLUSIONS: Compared with systemic cytokines, peritoneal cytokines respond extensively after major surgery, indicating that measurement of peritoneal cytokines is a more sensible method to determine postoperative inflammatory reaction. A normal postoperative course is characterized by decreasing levels of peritoneal cytokines.

National Category
Medical and Health Sciences Surgery
Research subject
Medicine; Surgery
Identifiers
urn:nbn:se:oru:diva-3153 (URN)10.1016/j.amjsurg.2003.12.019 (DOI)15006565 (PubMedID)
Available from: 2004-06-08 Created: 2004-06-08 Last updated: 2017-12-14Bibliographically approved
3. Postoperative on line monitoring with intraperitoneal microdialysis is a sensitive clinical method for measuring increased anaerobic metabolism that correlates to the cytokine response
Open this publication in new window or tab >>Postoperative on line monitoring with intraperitoneal microdialysis is a sensitive clinical method for measuring increased anaerobic metabolism that correlates to the cytokine response
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2004 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 39, no 5, p. 434-439Article in journal (Refereed) Published
Abstract [en]

Background: Visceral ischaemia and cytokine release are early stages in the development of shock and multiorgan failure. Because of lack of methods to measure anaerobic metabolism or visceral hypoxia in the early phase, diagnosis is not usually established until shock and organ failure are evident. Methods: Nineteen patients were studied postoperatively after major abdominal gastrointestinal surgery. A microdialysis catheter was placed intraperitoneally before closure of the abdomen. Analysis of glucose, pyruvate and lactate was performed every second hour and the ratio between lactate and pyruvate was calculated. Peritoneal fluid was collected from a peritoneal drainage for analysis of tumour necrosis factor alpha (TNF‐α) and interleukin 10 (IL‐10). Results: Sixteen of the patients had a normal postoperative course; the lactate/pyruvate ratio started at the level of 20 immediately postoperatively and decreased significantly during the first 45 postoperative hours (P = 0.007). A similar pattern was recorded for peritoneal TNF‐α, which decreased correspondingly (P = 0.003). A correlation coefficient of 0.303 (P < 0.001) between lactate/pyruvate ratio and TNF‐α was found. After an initial short increase, IL‐10 decreased over time (P < 0.001). Three of the patients had abnormalities in the microdialysis results, cytokines and clinical outcome. These patients are presented separately. Conclusions: A normal postoperative course results in a decrease in the intraperitoneal lactate/pyruvate ratio, TNF‐α and IL‐10. A correlation between the intraperitoneal lactate/pyruvate ratio and TNF‐α was found which suggests that intraperitoneal microdialysis is a sensitive, indirect method in analysing the postoperative intraperitoneal inflammatory response. A complicated postoperative course was preceded by increase of the peritoneal lactate/pyruvate ratio interpreted as splanchnic hypoxia and also an increased TNF‐α level.

National Category
Medical and Health Sciences Surgery
Research subject
Medicine; Surgery
Identifiers
urn:nbn:se:oru:diva-3154 (URN)10.1080/00365520310008548 (DOI)
Available from: 2004-06-08 Created: 2004-06-08 Last updated: 2017-12-14Bibliographically approved
4. Results of intraperitoneal microdialysis depend on the location of the catheter
Open this publication in new window or tab >>Results of intraperitoneal microdialysis depend on the location of the catheter
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2004 (English)In: Scandinavian Journal of Clinical and Laboratory Investigation, ISSN 0036-5513, E-ISSN 1502-7686, Vol. 64, no 1, p. 63-70Article in journal (Refereed) Published
Abstract [en]

Background and Objective: Intraperitoneal microdialysis was recently described as a method for early detection of visceral ischemia. The method seems safe and accurate. The intra-abdominal catheter used may imply variations in results depending on the location of the catheter. The aim of the study was to investigate possible differences in metabolic parameters obtained depending on various locations of the intra-abdominal catheter, compared with using the subcutaneous reference catheter. Method: After right-sided hemicolectomy in 12 patients, three catheters were placed and fixed intraperitoneally: one at the anastomosis, one in the omentum and one embedded between the small intestinal loops. A subcutaneous catheter placed in the pectoral region was used as reference. Analyses of lactate/pyruvate ratio and glucose and glycerol levels were done during a period of 45 hours postoperatively. Results: Lactate/pyruvate ratio decreased numerically at all three intraperitoneal locations during the study while the subcutaneous lactate/pyruvate ratio increased slightly. Significant differences between intraperitoneal and subcutaneous locations were found as well as differences between the three intraperitoneal locations. Highest values of the lactate/pyruvate ratio were found at the anastomosis, while the widest range was found at the small intestine. Subcutaneous glucose levels were lower while glycerol levels were higher compared with intraperitoneal values. Conclusions: In evaluating postoperative metabolism, intraperitoneal microdialysis is influenced by the location of the microdialysis catheter. The same pattern is, however, recorded over time. The juxta-anastomotic region and the small intestinal loop area seem to be the most reasonable locations for measurements.

National Category
Medical and Health Sciences Surgery
Research subject
Medicine; Surgery
Identifiers
urn:nbn:se:oru:diva-3155 (URN)10.1080/00365510410004100 (DOI)
Available from: 2004-06-08 Created: 2004-06-08 Last updated: 2017-12-14Bibliographically approved
5. Normal values and differences between intraperitoneal and subcutaneous microdialysis in patients after non‐complicated gastrointestinal surgery
Open this publication in new window or tab >>Normal values and differences between intraperitoneal and subcutaneous microdialysis in patients after non‐complicated gastrointestinal surgery
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2005 (English)In: Scandinavian Journal of Clinical and Laboratory Investigation, ISSN 0036-5513, E-ISSN 1502-7686, Vol. 65, no 4, p. 273-282Article in journal (Refereed) Published
Abstract [en]

Objective. Visceral ischemia is an early event in the development of shock and organ failure. Microdialysis has been presented as a promising method for detection of visceral hypoxia and ischemia. The aim of this study was to investigate differences in the metabolic response measured by microdialysis between intraperitoneal and subcutaneous locations and to estimate normal values of lactate/pyruvate ratio, glucose and glycerol. Material and methods. Intraperitoneal and subcutaneous metabolic responses were compared regarding lacate/pyruvate ratio, glucose and glycerol, during 45 postoperative hours in 33 patients undergoing various non‐complicated elective major gastrointestinal surgery. Results. Intraperitoneal lactate/pyruvate ratio started around 15 and decreased over time, while subcutaneous levels were stable around 9. Glucose levels were higher intraperitoneally and increased rapidly during the first 9 h to 8.6 mM, while the subcutaneous levels increased during 21 h to 7.5 mM. Intraperitoneal glycerol levels were stable around 100 µM, while subcutaneous values started around 230 µM and then increased. Conclusions. In a non‐complicated postoperative course the lactate/pyruvate ratio and glucose levels are higher intraperitoneally, suggesting a higher postoperative intraperitoneal metabolism. Glycerol levels are higher and increase subcutaneously, suggesting increased postoperative energy demand, particularly in the visceral organs, as being responsible for the lipolysis seen in the subcutaneous tissue.

National Category
Medical and Health Sciences Surgery
Research subject
Medicine; Surgery
Identifiers
urn:nbn:se:oru:diva-3156 (URN)10.1080/00365510510013802 (DOI)
Available from: 2004-06-08 Created: 2004-06-08 Last updated: 2017-12-14Bibliographically approved

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