Renal injury after open versus laparoscopic non-cardiac surgery: a retrospective cohort analysis

Abstract

Background: Laparoscopic surgical approaches enhance recovery, reduce postoperative pain, and shorten hospital length-of-stay. Nevertheless, increased intra-abdominal pressure is associated with decreased renal blood flow, renal hypoxia and acute kidney injury. When combined with Trendelenburg positioning, renal function may further deteriorate. We tested the primary hypothesis that the combination of laparoscopic surgical approach and Trendelenburg position is associated with larger reductions in estimated Glomerular Filtration Rate (eGFR) within the initial 48 postoperative hours compared to open surgery without Trendelenburg positioning. Secondarily, we tested, if laparoscopic procedures are associated with greater incidence of postoperative acute kidney injury.

Methods: Adults who had laparoscopic colorectal surgery in Trendelenburg position at the Cleveland Clinic Main Campus from 2009 to 2016 were propensity-matched to patients who had comparable open procedures. Patients with pre-existing renal impairment were excluded.

Results: Among 7,357 eligible patients, 1,846 laparoscopic cases with Trendelenburg were matched to 1,846 open cases. No association was found between laparoscopic approach and postoperative eGFR. A significant protective effect of the laparoscopic procedure on the odds of having AKI was found. Patients who had laparoscopic surgeries were an estimated 0.70 (95% CI 0.55, 0.90, p_Holm-adj = 0.006) times as likely to have AKI as open surgical patients.

Conclusion: Despite compelling potential mechanisms, laparoscopic approach with Trendelenburg position in adult colorectal surgeries did not worsen postoperative eGFR, and actually reduced postoperative acute kidney injury. Given the other advantages of laparoscopic surgery, the approach should not be avoided for concerns about renal injury.

Keywords: Acute kidney injury; Anesthesia; Laparoscopy.

Figure 1

Types and numbers of exclusions of the available colorectal surgical cases (January 2009 – June 2016) at Cleveland Clinic Foundation Main Campus.

Figure 2

Absolute standardized difference plot showing balance between laparoscopic and open before (red) and after (blue) matching. The vertical line at absolute standardized difference = 0.1 is the pre-specified cutoff indicating balanced (left) and imbalanced (right) variables.