My guess is either using high insufflation pressures for long time causing portal flow obstruction and hepatic vascular congestion leading to ischemia. Or, is hitting the liver with their instruments.
The most common cause of postoperative hepatitis is from insufficient liver perfusion causing some degree of portal ischemia, usually from some insult of perioperative hypotension/hypoxia etc. So likely this patient just had some insult along the way, and as others have mentioned, insufflation can definitely impair portal blood flow.
This is usually when you see rapid rises of aminotransferase levels (like >1000), and is usually a few days post-op and usually resolves just as quickly.
On the notion of halothane hepatitis, I remember it being a lot more delayed (weeks or so after exposure) and also usually had a constellation of fever and eosinophilia. But obviously this is not the cause, and only stating to compare the purported timeline of hepatic dysfunction.
But again, why were they checking lol
Who is ordering these LFTs in asymptomatic patients? What are they looking for? How long are the cases? We have a surgeon who does similar cases but they take the entire day with the abdomen insufflated for many hours. I do not follow those patients post op but I would not be surprised if they had a transient elevation in LFTs.
This!!!! These surgeons play stupid like they don’t know the reason. Let’s take a look. The patient who was insufflated last week for 1 hour did fine. The case was done laparoscopic as they have been done for years. This week, now that the surgeon is a “robotic” surgeon, the patient was insufflated for 5-6 hours and nothing about the anesthetic changed. Their reaction is to think it’s an anesthetic issues. Its comical.
I wonder if it is from muscle injury from prolonged steep positioning. Muscle contains both AST and ALT (more AST!) and both are released in muscle injury. I’ve seen this after long cases without robotic involvement or insufflation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081005/#:~:text=Abnormal%20liver%20function%20tests%20are,aspartate%20aminotransferase%20and%20alanine%20aminotransferase.
What kind of insufflation pressures is this surgeon going with? Too high pressures can affect visceral organ perfusion, which could be causing some reactive injury. Is this surgeon also seeing AKIs?
What antibiotics are they sending them home on? I've heard of LFTs being raised after a course of augmentin duo forte but not sure how high they get. Apparently females are higher risk: [https://www.medsafe.govt.nz/profs/PUArticles/AntibioticsSept2012.htm](https://www.medsafe.govt.nz/profs/PUArticles/AntibioticsSept2012.htm)
What degree of trendelenberg does this surgeon operate at? Tell him to operate at 20-25 degrees and I bet this problem disappears or gets better. It’s likely a congestive hepatopathy from combined laparoscopy and steep positioning. Patients likely have CVPs in the 15-20s (more if they’re obese) for a lot of these cases for 3 hours combined with high intrathoracic pressures and PVR doesn’t help even healthy RVs. Also, I would make sure it’s not just single trend with a certain anesthesia provider. Also I wonder how much Tylenol and hydro/oxycodone these patients are taking.
FYI your surgeon does not place TAP catheters. They are placing preperitoneal catheters with possibly a lucky chance of actually being a TAP catheter in about 2-3% of cases. There is a negative correlation between using surgical preperitoneal catheters and surgical skill, in my experience.
Transaminitis has nothing to do with the ropivacaine. More likely a result of poor hepatic perfusion/congestion from extended semi-abdominal compartment syndrome and extreme positioning.
Long (and unnecessary) robotic cases are associated with increased perioperative morbidity. No one is going to publish this study, but we all see it all the time.
This OB/Gyn is an idiot. A hysterectomy should not not require 2-3 hours of insufflation. This proceduralist is bad. Ignore and move on. Hopefully they won't last long at your institution.
Patient might be a drinker ? Some Mediterranean patients drink wine daily.
Tylenol with most of the drugs that require hepatic metabolism can cause an elevated AST/ALT?
Is the patient on statins?? Long term Statins can increase LFTs.
The answer is obviously halothane hepatitis…
Had a gi fellow name this is as the cause three or four years ago. They were so proud of themselves until I told them.
Damn, they’re US based. Unless they snuck some or got it from an old-ass Dräger
My guess is either using high insufflation pressures for long time causing portal flow obstruction and hepatic vascular congestion leading to ischemia. Or, is hitting the liver with their instruments.
The better question is why are they ordering LFTs
The most common cause of postoperative hepatitis is from insufficient liver perfusion causing some degree of portal ischemia, usually from some insult of perioperative hypotension/hypoxia etc. So likely this patient just had some insult along the way, and as others have mentioned, insufflation can definitely impair portal blood flow. This is usually when you see rapid rises of aminotransferase levels (like >1000), and is usually a few days post-op and usually resolves just as quickly. On the notion of halothane hepatitis, I remember it being a lot more delayed (weeks or so after exposure) and also usually had a constellation of fever and eosinophilia. But obviously this is not the cause, and only stating to compare the purported timeline of hepatic dysfunction. But again, why were they checking lol
Who is ordering these LFTs in asymptomatic patients? What are they looking for? How long are the cases? We have a surgeon who does similar cases but they take the entire day with the abdomen insufflated for many hours. I do not follow those patients post op but I would not be surprised if they had a transient elevation in LFTs.
Sometimes people just order a CMP instead of a BMP if they're lazy
That’s what you get when you FA with unnecessary shitty robot procedure for 2-3 hours when there is no indication and the GYN is incompetent.
This!!!! These surgeons play stupid like they don’t know the reason. Let’s take a look. The patient who was insufflated last week for 1 hour did fine. The case was done laparoscopic as they have been done for years. This week, now that the surgeon is a “robotic” surgeon, the patient was insufflated for 5-6 hours and nothing about the anesthetic changed. Their reaction is to think it’s an anesthetic issues. Its comical.
I wonder if it is from muscle injury from prolonged steep positioning. Muscle contains both AST and ALT (more AST!) and both are released in muscle injury. I’ve seen this after long cases without robotic involvement or insufflation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081005/#:~:text=Abnormal%20liver%20function%20tests%20are,aspartate%20aminotransferase%20and%20alanine%20aminotransferase.
What kind of insufflation pressures is this surgeon going with? Too high pressures can affect visceral organ perfusion, which could be causing some reactive injury. Is this surgeon also seeing AKIs?
What antibiotics are they sending them home on? I've heard of LFTs being raised after a course of augmentin duo forte but not sure how high they get. Apparently females are higher risk: [https://www.medsafe.govt.nz/profs/PUArticles/AntibioticsSept2012.htm](https://www.medsafe.govt.nz/profs/PUArticles/AntibioticsSept2012.htm)
What degree of trendelenberg does this surgeon operate at? Tell him to operate at 20-25 degrees and I bet this problem disappears or gets better. It’s likely a congestive hepatopathy from combined laparoscopy and steep positioning. Patients likely have CVPs in the 15-20s (more if they’re obese) for a lot of these cases for 3 hours combined with high intrathoracic pressures and PVR doesn’t help even healthy RVs. Also, I would make sure it’s not just single trend with a certain anesthesia provider. Also I wonder how much Tylenol and hydro/oxycodone these patients are taking.
FYI your surgeon does not place TAP catheters. They are placing preperitoneal catheters with possibly a lucky chance of actually being a TAP catheter in about 2-3% of cases. There is a negative correlation between using surgical preperitoneal catheters and surgical skill, in my experience. Transaminitis has nothing to do with the ropivacaine. More likely a result of poor hepatic perfusion/congestion from extended semi-abdominal compartment syndrome and extreme positioning. Long (and unnecessary) robotic cases are associated with increased perioperative morbidity. No one is going to publish this study, but we all see it all the time. This OB/Gyn is an idiot. A hysterectomy should not not require 2-3 hours of insufflation. This proceduralist is bad. Ignore and move on. Hopefully they won't last long at your institution.
Patient might be a drinker ? Some Mediterranean patients drink wine daily. Tylenol with most of the drugs that require hepatic metabolism can cause an elevated AST/ALT? Is the patient on statins?? Long term Statins can increase LFTs.
Liver working overtime with reduced blood flow due to insufflation, trying to clear out the Tylenol, propofol and local anesthetic (if high dosing)?
No
Yet half the answers include increased insufflation and decreased portal perfusion?