Mchoney, M; (2006) The metabolic and inflammatory response to laparoscopic surgery in infants and children. Doctoral thesis , UCL (University College London).

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Abstract

The metabolic response to laparoscopy in children is not well established. The work done in this thesis investigates some of the metabolic responses and their relationship to the inflammatory responses in children. The aim was to compare the responses between open and laparoscopic surgery. The hypothesis was that laparoscopic surgery is associated with a blunting of the metabolic response to surgery compared to open surgery. Firstly the intraoperative response to pneumoperitoneum and CO2 absorption was investigated in children undergoing laparoscopy compared to open surgery. There was a continuous increase in CO2 elimination throughout the period of pneumoperitoneum. CO2 absorption was greater in smaller and younger patients. There was intraoperative hyperthermia associated with increased oxygen consumption in children undergoing laparoscopy, which was also more marked in smaller and younger children. The effects on postoperative metabolism were explored in a randomised controlled trial comparing open and laparoscopic surgery. Whole body energy metabolism (indirect calorimetry) and protein metabolism (stable isotope infusion) was measured in the preoperative and early postoperative period. There was a significant decrease in resting energy expenditure after 24 hours in children undergoing open surgery but no significant change in the laparoscopic group. Concomitantly, there was a decrease in whole body protein catabolism 4 hours postoperatively in the open group, which was blunted by laparoscopy. Laparoscopy also dissociated the influence of insulin on protein metabolism and the hormonal control of energy metabolism. Laparoscopy therefore altered postoperative energy and protein metabolism by altering intraoperative thermoregulation. The altered metabolic response may be responsible for some of the differences in the postoperative immune response, as protein catabolism may be an important source of glutamine for cells of the immune system. Monocyte class II MHC surface expression decreased in both groups, but tended to be better preserved by laparoscopy. This may have important implication for the risk of postoperative infections. These studies demonstrated that laparoscopy alters intraoperative thermoregulation in children. This altered intraoperative thermoregulation translates into a preservation of early postoperative energy and protein metabolism compared to open surgery.

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