Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : PC14 - PC17 Full Version

Alterations in Liver Enzymes in the Postoperative Period Following Laparoscopic and Open Cholecystectomy: A Prospective Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59653.18084
Upasana Choudhury, Partha Sarathi Dutta

1. Senior Resident, Department of General Surgery, Bankura Sammilani Medical College, Bankura, West Bengal, India. 2. Associate Professor, Department of General Surgery, Bankura Sammilani Medical College, Bankura, West Bengal, India.

Correspondence Address :
Upasana Choudhury,
BID Villa, Opposite Durga Mandir, Throght The Lane Beside Cure Hospital, Lokpur, Bankura-722102, West Bengal, India.
E-mail: upasanachoudhury743@gmail.com

Abstract

Introduction: Laparoscopic Cholecystectomy (LC) is one of the most common procedures that is being performed by a general surgeon, and is the treatment of choice for symptomatic gallstone disease. Any abnormalities in the postoperative period because of the procedure is a thing of concern for the operating surgeon.

Aim: To compare the changes in the levels of liver enzymes in the immediate and delayed postoperative period following LC and following Open Cholecystectomy (OC) with respect to the preoperative values.

Materials and Methods: This was prospective interventional study carried out in the General Surgery wards of Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India, from February 2020 to August 2021. A total of 43 patients who underwent LC and 43 patients who underwent OC were randomly selected from the surgical wards. Their levels of Alkaline Phosphatase (ALP), Aspartate Transaminase (AST), Alanine Transaminase (ALT) and total bilirubin were noted in the preoperative period, 24 hours after the surgery and seven days after the surgery. The changes in the levels of the above-mentioned parameters were analysed using paired t-test via International Business Machines Statistical Package for the Social Sciences II (IBM SPSS II) software version 25.0.

Results: The mean age of the study participants who underwent OC was 40.98±12.46 years while the mean age for those who underwent LC was 36.42±10.53 years. There was a significant increase in the levels of AST (27.02±7.272 IU/L to 53.70±19.902 IU/L), ALT (26.21±7.399 IU/L to 50.21±14.410 IU/L) and total bilirubin (0.601±0.173 mg/dL to 0.782±0.261 mg/dL) in the immediate postoperative period (24 hours after surgery) p-value <0.01 among the patients who underwent LC but returned to its baseline preoperative value within seven days of the surgery. No such significant change was noted in the levels of the liver enzymes (AST: 30.93±8.160 IU/L to 32.14±16.988 IU/L, ALT: 31.51±10.762 IU/L to 31.14±10.921 IU/L) among patients undergoing OC.

Conclusion: The transient increase in the liver enzymes (AST, ALT and total bilirubin) 24 hours after LC maybe related to the increased intra-abdominal pressure due to CO2 pneumoperitoneum which decreases the venous return and thereby cardiac output, thus leading to tissue ischaemia. Absence of this effect leads to no significant change in the liver enzymes in the postoperative period following OC.

Keywords

Aspartate, Bilirubin, Pneumoperitoneum, Transaminases

The LC is one of the most common procedures which is being performed by all general surgeons on a daily basis for gallstone disease. The worldwide prevalence of the gallstone disease varies widely, ranging from 5% in China, 10-22% in India to 9-21% among Europeans to as high as 64-73% among American Indians (based on ultrasonographic survey among females) (1). The liver enzymes namely ALP, ALT, and AST and total bilirubin levels should theoretically remain unchanged in the postoperative following cholecystectomy. A rise in the above mentioned parameters following cholecystectomy is usually suggestive of injury to the biliary tree (1).

Despite being the gold standard procedure, laparoscopic surgery comes with its own set of complications pertaining to pneumoperitoneum. Pneumoperitoneum has been seen to cause air embolism, hypercarbia with acidosis, ventricular arrhythmia and a significant change in liver enzymes (2). A significant change in the liver enzymes namely AST and ALT after LC without any bile duct injury in the intraoperative period may thus raise concern among the surgeons as well as the patients.

Similar study have been attempted in the past comparing the liver function parameters in the preoperative and postoperative period after laparoscopic surgery (3). While, this study not only makes the similar comparison but also compares it with the alterations of the same parameters after open surgery. The aim of this study was to compare the changes in levels of ALP, AST, ALT and total bilirubin levels in the postoperative period after LC and after OC.

Material and Methods

This prospective interventional study was conducted in the surgical wards of Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India, between February 2020 and August 2021. All patients admitted in the General Surgery wards who were taken up for elective cholecystectomy. After getting approval from the Institutional Ethics Committee, data was collected using a predesigned questionnaire which included interview, clinical examination and laboratory investigation after obtaining appropriate consent from the patient.

Inclusion criteria: All patients in the age group of 18-60 years who were admitted for cholecystectomy were included in the study.

Exclusion criteria: Patients having deranged liver function tests since the preoperative period, cholelithiasis along with choledocholithiasis, stage I carcinoma of gallbladder and patients for whom laparoscopic technique was converted to open due to some unavoidable reason are excluded from the study.

Study Procedure

Simple randomisation technique has been used for selection of the sample. At the beginning of every week (Sunday), a day was randomly selected (by the roll of a dice and the corresponding day of the week was chosen according to the result), and on that day, the first patient who met all the above selection criteria, who underwent LC, and the first patient who underwent OC were included in the groups LC and OC, respectively. A total of 86 patients were selected and divided equally into two groups of 43; namely OC (those who underwent OC) and LC (those who underwent LC).

Measurement of the liver function test parameters in the preoperative period (24 hours before the surgery) and in the postoperative period, on day 1 (24 hours after the surgery) and on day 7. These parameters included serum ALP, AST, ALT, and serum total bilirubin levels.

The normal values for the above-mentioned parameters were taken as follows (2):

• ALP: 40-129 IU/L
• AST (SGOT): 8-48 IU/L
• ALT (SGPT): 7-55 IU/L
• Total bilirubin: 0.1-1.2 mg/dL

All laboratory investigations were done from the biochemistry laboratory of the institution.

Operative standardisations: All the OC procedures were performed in supine position, while all the LC procedures were carried out in reverse Trendelenburg’s position. All patients irrespective of the type of surgery received same preanaesthetic medications. All surgeries were done under general anaesthesia using propofol as the induction agent, and scoline for intubation. Sevoflurane and atracurium were used for the maintenance of the anaesthesia, and neostigmine was used during reversal. The average duration for OC (from skin incision to closure of the wound) was two hours, while that for LC (from insertion of trocar through the umbilical port to removal of gallbladder via the umbilical port) was 1.5 hours. The intra-abdominal pressure following pneumoperitoneum in LC was maintained at 12-15 mm of Hg.

Statistical Analysis

Analysis of the collected data was done using IBM SPSS-II software version 25.0. The means of the preoperative values of the different parameters of the liver function test were compared with the means of the postoperative (after 24 hours and after seven days) values of the same parameters. The means were compared using paired t-test. The p-value less than 0.05 were considered statistically significant.

Results

The mean age of the patients who underwent OC was 40.98±12.46 years while the mean age was 36.42±10.53 years for those who underwent LC. The age and gender distribution of the two groups have been demonstrated in (Table/Fig 1).

There was no mortality or morbidity. In (Table/Fig 2), among the patients who underwent OC, the ALP shows a significant decrease 24 hours after the surgery and remains so after seven days of the surgery while ALT, AST and total bilirubin, there was no significant change in the values of these parameters in the immediate as well as delayed postoperative period compared to the preoperative values.

In (Table/Fig 3), among the patients who underwent LC, ALP value did not show any significant change in the postoperative period, compared to its preoperative value while AST, ALT and total bilirubin shows a rising trend 24 hours after the surgery only to decline seven days after the surgery.

Discussion

The mean values of AST and ALT of the present study are similar to studies conducted by Tan M et al., in 2001-2002 among 286 patient who had underwent LC, and that of Ibrahim AM et al., who had conducted the study among 60 patients who had underwent various laparoscopic procedures both of these studies compared the means of AST and ALT levels in the preoperative period with those on the postoperative days 1 and 7 (Table/Fig 4) (4),(5).

The significant change in AST, ALT and total bilirubin levels following LC is transient. Not noticing such a change among the patients who underwent OC, the first factor to be considered is CO2 pneumoperitoneum. Halevy A et al., in 1994 were the first, who studied 67 patients who had underwent LC, to demonstrate the significant increase in AST and ALT after the surgery, and had postulated certain explanations for the same, the first one being increased intra-abdominal pressure following pneumoperitoneum (6). In the year 2002, Nguyen NT et al., found that there was an increase in the level of transaminases, no change in the levels of Gamma-glutamyl Transferase (GGT) and decrease in the levels of ALP in the postoperative period after 24 hours among a group of 18 patients who underwent laparoscopic gastric bypass surgery compared to another group of 18 patients who underwent open gastric bypass (7). The rise in the levels of transaminases was two to three-fold compared to their preoperative levels. And this change was attributed to the increased intra-abdominal pressure due to pneumoperitoneum. The increased intra-abdominal pressure created by the insufflation of CO2 may have an ischaemic effect on the liver. This ischaemia of the liver tissue is caused by the reduction in the stroke volume. In 1999, Dexter SP et al., studied the hemodynamic changes in the body during LC with high pressure versus low pressure CO2 pneumoperitoneum among 20 patients (8). According to the study, the net venous outflow is a result of two opposing pressures- the mean systemic pressure which empties the veins, thereby increasing the venecaval outflow to the heart resulting in increase in the stroke volume as well as the cardiac output, and venous resistance which decreases the outflow of the veins. It has been seen that the dominant pressure at an intra-abdominal pressure of 15 mm of Hg is the venous resistance, thereby resulting in the decrease in the cardiac output (even below the pre-insufflation baseline). Thus, blood supply to liver is also compromised leading to tissue ischaemia and rise in blood levels of AST and ALT. At low pressure (7 mm of Hg) CO2 pneumoperitoneum, the dominant pressure is the mean systemic pressure thereby an increase in the cardiac output is noted. In our study, we have created pneumoperitoneum with an intra-abdominal pressure of 12-15 mm of Hg, thereby making it one of the possible reasons for the rise of liver enzymes. In 2005, Hasuki S et al., in 2014, Singal R et al., also noted these changes in liver enzymes in their studies (9),(10). They further noted that an intra-abdominal pressure of 12-14 mm of Hg of CO2 caused more increase in the levels of serum transaminases than a pressure of 7-8 mm of Hg of CO2, the latter being almost equal to portal venous pressure. Also, damage to the liver by the free radicals generated at the end of a laparoscopic procedure, as a result of ischaemia-reperfusion phenomenon was a possible factor for this change.

Another mechanism as suggested by Halevy A et al., in their study in 1994 is the “squeeze” effect on the liver which causes it to release the enzymes, as stated by other similar studies due to the prolonged traction of the gallbladder (6). The prolonged traction of the gallbladder towards cephalad direction, causes the gallbladder to impinge on the liver bed and also indirectly putting pressure on the inferior vena cava, thereby decreasing the preload and hence the cardiac output. However, this traction is also applied in the OC where, along with the traction to the gall bladder, the edge of the liver is also elevated and retracted to expose the gallbladder fossa. This manoeuvre, to some extent relieves the pressure from the inferior vena cava thereby not decreasing the cardiac output. This may explain the absence of rise in the liver enzymes following OC.

The third mechanism which may cause injury to the liver as mentioned by Halevy A et al., is the prolonged use of diathermy, which generates heat that may damage the liver tissue (6). The diathermy is used to dissect the gallbladder out from the liver bed. However, diathermy is used in open as well as in LC, hence, cannot explain the rise in liver enzymes exclusively in the postoperative period of LC.

Tan M et al., (2001-2002) in their study, pointed out the role of general anaesthesia in causing transient liver dysfunction (4). However, both the groups LC and OC had been anaesthetised using the same drugs. Scapa E et al., (1998) explored the effect of general anaesthesia on the hepatic sinusoidal cells, 24 hours after the surgery in 20 patients after orthopaedic surgery, only to find a mild decrease in albumin level as the significant change (11). Guven HE and Oral S (2003-2005) conducted a study among 267 patients who underwent LC and 54 patients who underwent OC, comparing the levels of ALP, AST, ALT, Lactate Dehydrogenase (LDH) and GGT levels in the postoperative period (after 24 hours) with their preoperative levels in both the groups (12). They observed that there was significant rise in the levels of the AST, ALT, LDH and GGT 24 hours after the surgery among the patients who underwent LC, but no such elevation was noted among those who underwent OC. They ruled out the role of anaesthetic agents in contribution to the alteration in the hepatic enzymes as same drugs were used in both the group of patients.

Aberrant anatomy of the duct, cystic artery and right hepatic artery is not uncommon (13),(14). Inadvertent clipping of the right hepatic artery while clipping the cystic duct or cystic artery, will lead to increase in the liver enzymes in the postoperative period. But this rise in the ALT and AST shall be massive and it will continue to increase over time. The rise in the enzymes in this study was transient. So, as serious as a complication of clipping right hepatic artery may not be a suitable mechanism to explain this rise.

Limitation(s)

The limitation of the present study was limited sample size only among patients of the surgical ward of one hospital. It fails to explore whether the rise in the liver enzymes following LC is an exclusive feature for cholecystectomy or whether such changes are noted in other laparoscopic procedures.

Conclusion

Thus, there was a significant but transient rise in the levels of ALT, AST and total bilirubin levels while the levels of ALP did not show a significant change in the first 24 hours following LC, which was not seen in the case of OC. The most likely mechanism which brings about this change is raised intra-abdominal pressure due to CO2 pneumoperitoneum which leads to decreased blood supply to the liver, thereby causing ischaemic damage to the tissues, resulting in the liberation of the liver enzymes into the blood. If the liver function test was normal in the preoperative period, the operating laparoscopic surgeon need not worry.

Acknowledgement

Authors were grateful to Dr. Soumik Ghosh for the technical help that he has provided for this research. Also, this research would have been incomplete without the inputs from my friend, Pritwish Mitra.

References

1.
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DOI and Others

DOI: 10.7860/JCDR/2023/59653.18084

Date of Submission: Aug 14, 2022
Date of Peer Review: Nov 11, 2022
Date of Acceptance: Feb 01, 2023
Date of Publishing: Jun 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 23, 2022
• Manual Googling: Dec 21, 2022
• iThenticate Software: Jan 31, 2023 (3%)

ETYMOLOGY: Author Origin

EMENDATIONS: 7

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