Direct Peritoneal Resuscitation Improves Obesity-Induced Hepatic Dysfunction after Trauma - 28/03/12

Doi : 10.1016/j.jamcollsurg.2011.12.016

Paul J. Matheson, PhD ^b, Glen A. Franklin, MD, FACS ^a,^b,^⁎ , Ryan T. Hurt, MD, PhD ^c, Cynthia D. Downard, MD, FACS ^a, Jason W. Smith, MD, FACS ^a, Richard N. Garrison, MD, FACS ^a,^b
^a Department of Surgery, University of Louisville, Louisville, KY
^b Robley Rex Veteran's Affairs Medical Center, Louisville, KY
^c Department of Internal Medicine, Mayo Clinic, Rochester, MN

Correspondence address: Glen A Franklin, MD, FACS, Department of Surgery, 2^nd Floor ACB, University of Louisville, Louisville, KY 40202

Résumé

Background

The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outcomes in trauma patients. Experimentally, obesity compromises liver blood flow. We sought to correlate the effect of obesity, injury severity, and liver dysfunction with trauma outcomes. We hypothesized that obesity-related liver dysfunction could be mitigated with the novel technique of adjunctive direct peritoneal resuscitation (DPR).

Study Design

This study has clinical and experimental arms. The clinical study was a case-controlled retrospective analysis of ICU trauma patients (n = 72 obese, n = 187 nonobese). The experimental study was a hemorrhagic shock model in obese rats to assess the effect of DPR on liver blood flow, liver function, and inflammatory mediators.

Results

In trauma patients, univariate and multivariate analyses demonstrated increasing mortality (p < 0.05), septic complications (p < 0.05), liver dysfunction (p < 0.001), and renal impairment (p < 0.05) with increasing body mass index and injury severity score. Obesity in rats impairs liver blood flow, liver function, renal function, and inflammation (interleukin [IL]-1β, IL-6, high mobility group protein B1[HMGB-1]). The addition of DPR to shock resuscitation restores liver blood flow, improves organ function, and reverses the systemic proinflammatory response.

Conclusions

Our clinical review substantiates that obesity worsens trauma outcomes regardless of injury severity. Obesity-related liver and renal dysfunction is aggravated by injury severity. In an obese rat model of resuscitated hemorrhagic shock, the addition of DPR abrogates trauma-induced liver, renal, and inflammatory responses. We conclude that the addition of DPR to the clinical resuscitation regimen will benefit the obese trauma patient.

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Abbreviations and Acronyms : ALT, BMI, DPR, EHBF, HEM, IL, ISS, MAP, NAFLD, NASH, RES