Examination of Pathological and Biochemical Findings of the Damage Caused by Liver Retraction During Abdominal Surgeries Using an Experimental Model

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Materials and Methods: Thirty Sprague-Dawley rats were allocated to the following four groups: (1) Control group (2): Retraction group: Pressure was applied to the liver with Farabeuf’s retractor (3): Crush group: The liver was crushed with a bulldog clamp, and (4): Deviation group: The liver was deviated cranially as creating angling to vascular structures. A liver tissue sample was taken for pathological and biochemical examination. Blood samples were collected for ALT, AST and LDH measurements. Results: The crush group showed a significant elevation of serum ALT, AST and LDH levels, decreased tissue GSH levels, increased MDA levels, severe sinusoidal dilatation/congestion, and necroinflammatory focus in the postoperative histopathological findings. The deviation group showed elevation in serum ALT levels, sinusoidal dilatation/congestion and necroinflammatory focus postoperatively. According to the histopathological findings, although balloon cell degeneration, sinusoidal dilatation/ congestion and necroinflammatory focus were still seen on the 28 th day in the retraction, crush and deviation groups, the difference did not show statistical significance with the control group. Conclusions We found that the crush mechanism was more harmful to the liver tissue than the angling of vascular structures. We recommend keeping the hepatic retractions at minimum tension during the surgical procedures to protect the liver tissue, especially in patients with limited liver function such as cirrhotic cases and newborns with biliary atresia. hepatic damage retraction abdominal surgery Figures Figure 1 Figure 2 Figure 3 Background During operations such as those involving the hepatobiliary system, stomach and gastroesophageal junction, hepatic retraction is needed to visualize the operation field. Especially during operations performed in infants with biliary atresia, hepatic tissue resources are critically important. We observed that patients' serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) levels increased after these operations. It is known that ALT, AST and LDH blood levels increase in humans in hepatic injury [ 1 , 2 ]. Thus, ALT, AST and LDH values are good indicators for hepatic injury and have been used to evaluate hepatic injury in previous studies [ 3 – 14 ]. It has been shown that for open surgery, ALT, AST and LDH blood levels increased during gastric and biliary system operations more than other operations [ 3 – 6 ]. Retraction or local trauma is thought to be the cause. Clinical studies also investigate the mechanism of hepatic enzyme increase after laparoscopic cholecystectomy. In these studies, hepatic enzyme levels of patients undergoing different operations were compared [ 7 – 14 ]. The results were conflicting: some authors mentioned that the increases in hepatic enzyme levels were due to increased intra-abdominal carbon dioxide pressure leading to decreased splanchnic blood flow [ 7 – 10 ], while others stated that the increase in hepatic enzyme levels might be secondary to hepatic retraction [ 3 , 5 , 6 , 11 , 12 ], and some stated that the increase in hepatic enzymes could be multifactorial including both the increase in intraabdominal pressure and the squeeze pressure effect of the traction [ 15 ]. These data raise the question about the presence of hepatic tissue injury and its contemporary damage to the liver during hepatic retraction. The mechanism of hepatic retraction can be divided into “crush” due to pressure applied to liver tissue or “deviation” due to cranial deviation of the liver, causing angling in the vascular system. If there is damage to hepatic tissue, which of these mechanisms should be cited as the cause? To resolve this question, we separately simulated hepatic retraction, crush and deviation in rats. A few studies investigating whether or not hepatic retraction is harmful to the hepatic tissue were found in the available literature [ 5 , 16 ]. Our aim in this study is to answer whether hepatic retraction during upper abdominal surgery has long-time damage to the hepatic tissue. If damage is present, we also aimed the find answers to which mechanism is responsible. If we could understand the mechanism of damage, we could think about ways of decreasing the damage to the liver, especially in already damaged liver tissue, such as in biliary atresia and cirrhosis cases. Methods This study was approved by … Ethical Committee for Experimental Research on Animals (Project no: DA 10/13) and supported by … University Research Fund. Animals: Thirty Sprague-Dawley rats weighing 200–250 g were included in the study. The number of rats required to be in the groups was calculated by a biostatistician while preparing the experimental project. The Experimental Research Center of the Medical Faculty of … University provided rats. The rats were housed in a windowless animal quarter in which temperature (22°C ± 2°C) and illumination (light on at 7:00 AM and off at 9:00 PM, 14-hour light, 10-hour dark cycle) were controlled automatically. Humidity ranged from 50–55%. Rats were fed with standard rat chow and tap water ad libitum . The lost or severely ill rats were excluded from the study. Thirty animals were allocated to the following four groups: (1) Control group (n = 6): No interventions were done; (2): Retraction group (n = 8): Retraction was applied to the liver with Farabeuf’s retractor for 30 minutes (min) (a wet sponge was placed between the retractor and liver), and a weight of 100 g was suspended on to the retractor (Fig. 1 ); (3): Crush group (n = 8): The liver was crushed with a bulldog clamp for 30 min without angling the vascular structures (a wet sponge was placed between the clamp and liver) (Fig. 2 ); and (4): Deviation group (n = 8): The liver was deviated cranially as creating angling to vascular structures and sutured to the diaphragm for 30 min (Fig. 3 ) (after 30 min, the sutures were removed and the sutured liver tissue was discarded from the obtained sample tissue) Experimental Protocols: The rats were anesthetized with ketamine HCl (60 mg/kg) and xylazine HCl (7 mg/kg) intraperitoneally, and their liver was exposed through a midline abdominal incision in control, crush and deviation groups and through a subcostal incision in retraction group. The liver was traumatized by Farabeuf’s retractor in the retraction group (Fig. 1 ), by bulldog clamp in the crush group (one clamp to one lobe; a total of two clamps to two lobes) (Fig. 2 ) and by cranial deviation in the deviation group (two lobes of the liver) (Fig. 3 ). After 30 min, the traumatizing devices were removed, and a liver tissue sample was taken from one of the traumatized liver lobes in retraction, crush and deviation groups and from a healthy lobe in the control group. The tissue sample was divided into two parts: one for pathological examination and one for tissue biochemical examination. The part taken for histological evaluation was placed in 10% neutral buffered formalin solution, and the part taken for tissue biochemical examination was rinsed with isotonic solution, dried and stored at -80°C. Blood samples of 0.75 cc were collected from the tail vein in all rats at the following time points: before opening the abdominal cavity (preoperative), 30 min after the operation (postoperative), and on the first day (24 hours), second day (48 hours) and third day (72 hours) after the operation for ALT, AST), and LDH measurements. After the preoperative blood sample was collected, before laparotomy, 5 cc isotonic saline was given subcutaneously for fluid resuscitation. Twenty-eight days later, the animals were sacrificed by ketamine HCl (150 mg/kg) intravenously, and liver lobes (normal lobe in the control group and the ones previously traumatized in retraction, crush and deviation groups) were removed and divided into two parts for histological and biochemical examinations. Tissue Biochemical Measurements: Malondialdehyde (MDA) is a toxic end product of the disintegration of non-enzymatic oxidative lipid peroxidation products. The level of MDA increases in the presence of oxygen radicals, causing cell injury. In many studies, MDA has been used as a parameter to determine tissue injury [ 17 , 18 ]. Glutathione (GSH) is a tripeptide consisting of glutamic acid, cysteine and glycine and is more concentrated in the intracellular fluid. It is important as a reducing agent and an antioxidant, protecting cells from the harmful effects of endogenous and exogenous oxidants by maintaining cellular oxidation-reduction balance [ 19 ]. GSH facilitates the chemical clearance of these radicals by reacting with oxygen radicals, so GSH decreases when oxygen radicals increase. As a result, GSH has been used in many studies as a parameter to determine injury caused by oxygen radicals [ 17 , 18 ]. Hydroxyproline (Hyp) is an important intermediate product in collagen metabolism. The Hyp level determines the severity of cirrhosis and hepatic fibrosis [ 20 , 21 ]. Tissue MDA and Hyp levels increase, and GSH levels decrease when tissue injury is present. MDA and GSH levels in the liver tissue were measured to demonstrate tissue injury, and hydroxyproline levels in the liver tissue were measured to demonstrate fibrosis. Determination of tissue MDA and GSH concentrations: Liver homogenates were prepared in ice-cold 0.15 M KCl (10%, w/v) using an all-glass homogenizer MDA, as a marker of lipid peroxidation, was determined according to the thiobarbituric acid reaction described by Buege and Aust [ 22 ]. One sample volume was combined with two reagent volumes containing 15% trichloroacetic acid, 0.375% thiobarbituric acid and 0.25 M HCl. The mixture was kept in a boiling water bath for 15 minutes and centrifuged at 1000 x g for 10 minutes after cooling. The absorbance was measured at 535 nm against a reagent blank. Quantitations were obtained using the molar extinction coefficient of 1.56 x 10 5 M − 1 cm − 1 , and the results were expressed as nmol MDA/g tissue. GSH levels were assayed in tissue homogenates according to the method of Ellman [ 23 ]. After deproteinization of the samples, the Ellman color reagent was added to the supernatant, and the absorbance of the generated color complex was detected immediately at 412 nm against a reagent blank. Concentrations were calculated by using the GSH calibration curve, and the results were expressed as nmol GSH/g tissue. Determination of tissue hydroxyproline (Hyp) concentrations: Liver homogenates were prepared in ice-cold saline (2g/5 ml, w/v) using an all-glass homogenizer. Hyp levels were assayed in tissue homogenates according to the method of Reddy and Enwemeka [ 24 ]. Homogenates and Hyp standards were hydrolyzed in an alkaline medium (2N NaOH). After neutralization, samples were oxidized with chloramine–T, and the absorbance of the generated color complex with the Ehrlich reagent was detected immediately at 563 nm against a reagent blank. Concentrations were calculated using the Hyp calibration curve, and results were expressed as gHyp/g tissue. Histopathological Examination: Tissue samples taken were fixed in 10% formalin, embedded in paraffin and stained by hematoxylin and eosin. All biopsies were investigated by the same pathologist (NH), who was blinded for the groups. All specimens were examined and graded according to balloon cell degeneration, steatosis, single cell necrosis, centrilobular necrosis, necroinflammatory focus, widespread necrosis, sinusoidal dilatation/congestion, atrophy of hepatocytes, and cholestasis. Statistical Analysis: Definitive values were expressed as median (minimum–maximum). For comparing independent groups, the Kruskal-Wallis test was used. When a difference was found, the multiple comparison test of Conover was used to define the group causing the difference. For categorical variables, chi-square was used. For repeated measures, ANOVA for repeated measures and the Bonferroni test were used to compare repeated measures over time. We performed the Mann-Whitney U test for non-parametric and Student’s t-test for parametric continuous variables. The Statistical Package for the Social Sciences (SPSS) program for Windows (version 21.0; IBM Corp., NY, USA) was used for all statistical analyses. A p-value of less than 0.05 was considered statistically significant. Results One of the rats from the crush group was lost during the operation, and one each from the retraction and deviation groups was lost during the follow-up. When serum biochemical investigations were evaluated, in all groups, AST and ALT increased at the 30th minute and 24th hour (For AST p = 0.05, p < 0.01, respectively and for ALT p = 0.02, p < 0.01, respectively) and decreased at the 48th hour and 72nd hour significantly (For AST p = 0.05, p = 0.02, respectively and for ALT p = 0.02, p < 0.01, respectively). In all groups, AST and ALT values at the 72nd hour were in between the values at the 30th minute and the values at the 24th -hour values (For AST p = 0.231, p = 1.000, respectively and ALT p = 0.418, p = 0.432, respectively). In all groups, LDH first increased at the 30th minute and decreased afterward. However, the increase at the 30th minute and decrease at the 24th hour was not significant (p = 1.00, p = 0.252, respectively), but the decrease at the 48th hours and 72nd hours was significant (p < 0.01, p < 0.01, respectively) compared to the first measurement. The results are given in Table 1 . At postoperative 30th min, ALT and AST levels were higher in the crush group (p = 0.004, p = 0.005, respectively), and ALT level was higher in the deviation group (p = 0.030) compared to the control group. LDH levels at the 48th hour was significantly higher in the crush group compared to other groups (p = 0.020) (Table 1 ). Table 1 Serum and tissue biochemical results according to groups (Important ratios with statistical significance are shown in bold). Group 1 Group 2 P value (Group 1 vs 2) Group 3 P value (Group 1 vs 3) Group 4 P value (Group 1 vs 4) ALT (U/L) (Mean ±) Preoperative 39.8 ± 12.7 90.2 ± 60.4 0.218 46.7 ± 11.9 0.457 75.2 ± 74.8 0.704 Postoperative 30 min 44.7 ± 15.1 136.2 ± 152.4 0.105 301.7 ± 180.9 0.004 123.4 ± 78.1 0.030 After 24 hours 575.2 ± 261.6 703.2 ± 264.9 0.500 1173.9 ± 786.2 0.801 923.5 ± 538.1 0.900 After 48 hours 632.3 ± 500.0 194.6 ± 65.9 0.093 508.3 ± 268.4 0.886 200.0 ± 50.6 0.121 After 72 hours 85.8 ± 18.2 83.8 ± 23.0 0.858 93.6 ± 45.8 0.712 101.5 ± 46.0 0.449 AST (U/L) (Mean ±) Preoperative 86.5 ± 32.0 160.4 ± 94.2 0.688 115.3 ± 36.7 0.416 138.1 ± 112.2 0.982 Postoperative 30 min 129.8 ± 59.0 228.0 ± 267.6 0.502 358.1 ± 140.4 0.005 149.4 ± 79.9 0.745 After 24 hours 777.2 ± 291.1 892.9 ± 438.4 0.622 1374.0 ± 1004.1 0.617 1260.5 ± 489.5 0.548 After 48 hours 805.2 ± 598.7 302.8 ± 136.9 0.093 797.4 ± 498.7 0.775 344.0 ± 125.1 0.245 After 72 hours 173.5 ± 101.6 173.1 ± 57.3 0.993 182.0 ± 82.2 0.821 218.1 ± 105.0 0.441 LDH (U/L) (Mean ±) Preoperative 1415.8 ± 1296.4 1601.6 ± 1076.2 0.105 2251.9 ± 1439.1 0.343 1653.0 ± 843.9 0.095 Postoperative 30 min 2789.8 ± 3046.6 1297.8 ± 1408.5 0.181 3901.3 ± 2022.3 0.433 1150.7 ± 826.6 0.102 After 24 hours 1458.8 ± 730.1 765.9 ± 383.1 0.028 2159.0 ± 2218.5 0.696 1105.4 ± 457.5 0.175 After 48 hours 567.8 ± 196.8 402.0 ± 144.6 0.093 1292.4 ± 610.9 0.020 536.7 ± 382.6 0.723 After 72 hours 711.5 ± 312.8 634.2 ± 347.0 0.675 438.4 ± 434.1 0.240 285.9 ± 11.3 0.018 MDA (nmol MDA/g) (Mean ±) Postoperative 30 min 28.7 ± 8.6 29.5 ± 8.5 0.888 49.2 ± 26.8 0.052 32.8 ± 8.5 0.287 On 28th day 21.6 ± 6.6 20.1 ± 4.8 0.628 19.8 ± 2.7 0.410 19.7 ± 2.7 0.516 GSH (nmol GSH/g) (Mean ±) Postoperative 30 min 3.6 ± 1.6 3.9 ± 1.6 0.366 1.6 ± 1.1 0.064 2.4 ± 0.4 0.293 On 28th day 5.0 ± 1.2 5.6 ± 0.8 0.324 4.8 ± 1.0 0.691 5.2 ± 0.9 0.685 Hyp (gHyp/g) (Mean ±) Postoperative 30 min 65.8 ± 43.7 67.9 ± 26.1 0.805 51.4 ± 9.7 0.213 69.3 ± 10.4 0.696 On 28th day 91.4 ± 21.1 68.6 ± 18.3 0.051 75.1 ± 10.7 0.117 84.5 ± 15.4 0.505 Important ratios with statistical significance are shown in bold. When tissue biochemical investigations were considered, MDA and Hyp did not differ significantly between groups at postoperative 30 min (p = 0.200, p = 0.054) or on the 28th day (p = 0.999, p = 0.152). In the crush group at postoperative 30 min MDA was high (p = 0.052), and GSH was low (p = 0.064) than the control group, whereas the difference had disappeared on the 28th day (p = 0.410, p = 0.691, respectively) (Table 1 ). When the histopathological examination was considered, no steatosis, atrophy of hepatocytes or cholestasis was observed in any of the groups at any time. The findings of the histopathological examination were given in Table 2 (Table 2 ). Table 2 Histopathological examination of liver tissue samples taken at postoperative 30 min and on the 28th day (Important ratios with statistical significance are shown in bold). Postoperative 28th day Group 1 (n = 6) Group 2 (n = 7) Group 3 (n = 7) Group 4 (n = 7) P value Group 1 (n = 6) Group 2 (n = 7) Group 3 (n = 7) Group 4 (n = 7) P value Balloon cell degeneration Absent 83% 62% 100% 75% 0.274 83% 14% 14% 14% 0.092 Mild 17% 38% 0 25% 17% 57% 57% 43% Medium 0 0 0 0 0 14% 29% 14% Severe 0 0 0 0 0 14% 0 29% Single cell necrosis Absent 100% 100% 100% 88% 0.572 100% 100% 100% 100% Present 0 0 0 12% 0 0 0 0 Centrilobular necrosis Absent 100% 100% 100% 75% 0.105 100% 100% 100% 86% 0.375 Present 0 0 0 25% 0 0 0 14% Necroinflam-matory focus Absent 100% 62% 43% 38% 0.048 50% 71% 14% 43% 0.141 Present 0 38% 57% 62% 50% 29% 86% 57% Necrosis Absent 100% 75% 100% 75% 0.230 83% 71% 100% 86% 0.470 Focal 0 25% 0 25% 17% 29% 0 14% Sinusoidal dilatation/ congestion Absent 50% 0 0 0 0.000 83% 29% 43% 14% 0.207 Focal 33% 38% 0 0 17% 57% 29% 43% Mild 0 12% 0 25% 0 14% 14% 43% Medium 17% 50% 14% 63% 0 0 14% 0 Severe 0 0 86% 12% 0 0 0 0 When the histopathological examination was compared statistically between groups, only postoperative necroinflammatory focus and sinusoidal dilatation/congestion showed significant differences (p = 0.048 and p < 0.001, respectively) (Table 2 ). All three experimental groups (retraction, crush and deviation) showed prominent balloon cell degeneration on the 28th day, although the difference was not significant (p = 0.092). Concerning necroinflammatory focus, the retraction, crush and deviation groups differed when compared to the control group (p < 0.001) but did not differ amongst themselves. Concerning sinusoidal dilatation/congestion, there were differences between all groups; however, there was no difference on the 28th -day examinations (p = 0.207) (Table 2 ). Discussion Trauma to the liver after hepatic retractor usage during the resection of gastric malignancy was detected in Yassa and Peters’ study, which investigated preoperative and postoperative computerized tomography of 250 patients. They determined lesions which have the same findings as those after blunt abdominal trauma, in the left lobe of the liver in 10 patients and increased liver enzymes. The authors concluded that hepatic retraction during gastric resection led to hepatic trauma in these patients [ 16 ]. Similarly, Kinjo et al. reported that one of their patients had hepatic infarction after laparoscopic gastrectomy in which a Nathanson liver retractor had been used [ 5 ]. We also observed an increase in the liver enzyme (AST, ALT) in our patients operated on for gastric or biliary system operations. In our study, serum biochemical analysis showed that serum ALT levels in the crush and deviation groups significantly increased after the operation compared to the control group, indicating hepatic injury. The serum AST levels had also increased in the crush group. Similar to other studies, the difference within groups disappeared at 72 hours when all the levels decreased to near-normal levels [ 12 , 14 , 15 ]. Some clinical studies have shown that liver enzymes (AST, ALT) increased after upper abdominal surgeries (gastrectomy, cholecystectomy, antireflux surgery, obesity surgery, etc.), both laparoscopic and open, while did not change after lower abdominal surgeries (inguinal hernia repair, etc.) [ 5 , 12 , 14 , 25 ] or after other surgeries out of the abdominal region (head and neck, breast, thorax, testis, etc. operations) [ 3 , 4 ]. Most of these studies concluded that liver retraction is the cause of the increase in liver enzymes [ 3 – 5 , 12 , 14 ], and some authors added the effects of anesthetic drugs [ 12 ]. However, some authors concentrated on the effects of position (head up position during laparoscopy) and pneumoperitoneum [ 25 ]. Saranita et al. showed that their patient with an open Roux-en-Y gastric bypass had increased liver enzymes after the hepatic retractor was placed [ 26 ]. Also some studies were conducted to define which type of liver retraction was less harmful to the liver tissue [ 6 ]. When tissue biochemical analyzes are examined, the only significant difference seen as MDA increased and GSH decreased in the crush group, indicating mild oxidative injury, although the differences were not statistically significant. The MDA increase and GSH depletion in the crush group showed recovery on the 28th day. The crush group also showed a significant increase in serum ALT and AST levels postoperatively and serum LDH levels on the second day, indicating that the crush group caused hepatic injury more prominently. The postoperative presence of necroinflammatory focus showed statistical significance in the retraction, crush and deviation groups compared to the control group. Necroinflammatory focus is a tissue injury finding, though non-specific. Postoperative presence of sinusoidal dilatation/congestion showed statistical significance within groups. Interestingly, postoperatively, the most severe sinusoidal dilatation/ congestion was observed in the crush group. This could be due to the compression of venules by the applied pressure, impairing venous return and causing congestion. Furthermore, the deviation group showed mostly medium congestion postoperatively, which was thought to be due to the angulation of veins, causing venous stasis. Congestion in the retraction group was not as severe as in the crush group and significantly more than in the control group. As congestion was significant, and cholestasis was not seen, we can say that the bile ductile is more resistant to compression and pressure trauma than hepatic venules. For all groups, although the necroinflammatory focus and sinusoidal dilatation/congestion had not recovered on the 28th day, the severity decreased, and the difference within the groups disappeared. However, balloon cell degeneration, a finding of hepatocyte death and apoptosis, became more evident on the 28th day. This shows that all three mechanisms may cause hepatocyte apoptosis in the long term. Necrosis was the most important finding for tissue injury. Although it was only seen in the retraction and deviation groups at postoperative 30 min, statistical analysis showed no significant difference within the four groups. Interestingly, necrosis was not seen in the crush group either at postoperative 30 min or on the 28th day, although a significant increase in serum ALT, AST and LDH levels, an increase in tissue MDA levels and a decrease in tissue GSH levels were observed, indicating tissue injury. These findings can also enlighten the pathology of blunt hepatic trauma as a similar mechanism with crush injury seems to happen at blunt trauma hepatic injury. This study has some limitations. The sample size was small. As no previous study was designed for this topic, we did not have data to calculate the sample size of groups during the planning stage of the study. However, the results could be more precise if the sample size was bigger. Secondly, we could not find a way to equalize retraction pressure and crush pressure applied by bulldog clamps. Crush pressure may be more than retraction pressure in this study. Thirdly, the hepatic enzymes increased in all groups, including the control group, which may be due to anesthetic drugs, making comparisons more difficult. Last, as we could not find any study discussing hepatic damage or histopathological changes due to retraction, the discussion and comparison of our results with the literature were limited. Conclusions While the crush group showed significant injury, with an elevation of serum ALT, AST and LDH levels, an increase in tissue MDA levels, a decrease in tissue GSH levels, severe sinusoidal dilatation/congestion, and the presence of a necroinflammatory focus in the postoperative histopathological findings, the retraction and deviation groups showed signs of hepatic injury only by the postoperative presence of sinusoidal dilatation/congestion and necroinflammatory focus. According to the histopathological findings, although balloon cell degeneration, sinusoidal dilatation/ congestion and necroinflammatory focus were still seen on the 28th day in the retraction, crush and deviation groups, statistical analysis did not reach the level of significance. These findings show that the crush mechanism was more harmful to the liver tissue than the angling of vascular structures for a short time. So, we recommend keeping the hepatic retractions at minimum tension during the surgical procedures to protect the liver tissue, especially in biliary atresia surgeries and in cirrhotic cases. Mild damage occurs to liver tissue immediately after the operation due to liver retraction, and the effects of the damage were evident in the long term. Abbreviations ALT serum alanine aminotransferase AST aspartate aminotransferase LDH lactate dehydrogenase MDA Malondialdehyde GSH Glutathione Hyp Hydroxyproline Declarations Ethics approval and Consent to Participate: This study was approved by Başkent University Ethical Committee for Experimental Research on Animals (Ethics approval number: DA 10/13) Consent for Publication: Not applicable. Availability of Data and Material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This study was supported by the Başkent University Research Fund. Apart from this, no funds, grants, or other support was received. Authors’ contribution: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed TAD, NH and DAA. The first draft of the manuscript was written by TAD and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Oldham KT, Guice KS, Kaufman RA, Martin LW, Noseworthy J (1984) Blunt hepatic injury and elevated hepatic enzymes: a clinical correlation in children. J Pediatr Surg 19:457–461. https://doi.org/10.1016/s0022-3468(84)80275-4 Hennes HM, Smith DS, Schneider K, Hegenbarth MA, Duma MA, Jona JZ (1990) Elevated liver transaminase levels in children with blunt abdominal trauma: a predictor of liver injury. Pediatrics 86:87–90. 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Peng Z, Fernandez P, Wilder T, Yee H, Chiriboga L, Chan ESL, et al (2008) Ecto-5'-nucleotidase (CD73)-mediated extracellular adenosine production plays a critical role in hepatic fibrosis. FASEB J 22(7):2263–2272. https://doi.org/10.1080/15257770802146403 . Buege JA, Aust AD (1978) Microsomal lipid peroxidation. Methods Enzymol 52:302–310. https://doi.org/10.1016/s0076-6879(78)52032-6 . Ellman GL (1959) Tissue sulfhydryl groups. Arch Biochem Biophys 82:70–77. https://doi.org/10.1016/0003-9861(59)90090-6 . Reddy GK, Enwemeka CS (1996) A simplified method for the analysis of hydroxyproline in biological tissues. Clin. Biochem 29(3):225–229. https://doi.org/10.1016/0009-9120(96)00003-6 . Glantzounis GK, Tsimaris I, Tselepis AD, Thomas C, Galaris DA, Tsimoyiannis EC (2005) Alterations in plasma oxidative stress markers after laparoscopic operations of the upper and lower abdomen. Angiology 56(4):459–465. https://doi.org/10.1177/000331970505600414 . Saranita J, Soto RG, Paoli D (2003) Elevated liver enzymes as an operative complication of gastric bypass surgery. Obes Surg 13(2):314–316. https://doi.org/10.1381/096089203764467289 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6517992","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448114624,"identity":"ac0a562e-7db5-4829-b11c-89016c03cb7c","order_by":0,"name":"Tuğba ACER-DEMİR","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYHACNijNfICBsYEI9TwILWwJJGvhMSBOi71E+rUHPxjs5Pmlz3yT+LnDRo6B/fDRDXhtkcgpN+xhSDac2Ze7TbL3TJoxA09a2g0CWtIkeBiYEwzO8G6T4G07nNggwWNGUIvkH4b6BPszPM8k/xKnJf2YNA/D4QQDHh42aeJsOfOG3ViG4bjhjDNsxtaybWnGbIT8wt6e/uzhG4Zqef4e5oc337bZyPGzHz6GVwskOv6BWSwSIJINr2qIPQ9gLOYPhFWPglEwCkbBSAQAHEFB+80en+sAAAAASUVORK5CYII=","orcid":"","institution":"Başkent University","correspondingAuthor":true,"prefix":"","firstName":"Tuğba","middleName":"","lastName":"ACER-DEMİR","suffix":""},{"id":448114625,"identity":"f750eea6-7272-4882-9d94-fa653a75400e","order_by":1,"name":"Nihan HABERAL","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Nihan","middleName":"","lastName":"HABERAL","suffix":""},{"id":448114626,"identity":"3bd4e36e-1754-40f7-ac63-2333cb1c403d","order_by":2,"name":"Derya AKAYDIN-ALDEMİR","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Derya","middleName":"","lastName":"AKAYDIN-ALDEMİR","suffix":""}],"badges":[],"createdAt":"2025-04-24 07:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6517992/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6517992/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82277309,"identity":"91282567-8502-45d9-a434-0b69dd110425","added_by":"auto","created_at":"2025-05-08 14:50:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4263992,"visible":true,"origin":"","legend":"\u003cp\u003eRetraction group: Pressure was applied to the liver with Farabeuf’s retractor for 30 min (a wet sponge was placed between the retractor and liver), and a weight of 100 g was suspended on to the retractor\u003c/p\u003e","description":"","filename":"Figure114.png","url":"https://assets-eu.researchsquare.com/files/rs-6517992/v1/8e7b3c0df3f209ccbda3cdc4.png"},{"id":82275790,"identity":"5c752b40-f31c-49fe-8473-05b83ebe319e","added_by":"auto","created_at":"2025-05-08 14:42:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4334775,"visible":true,"origin":"","legend":"\u003cp\u003eCrush group: The liver is crushed with a bulldog clamp for 30 min (a wet sponge is placed between the clamp and liver)\u003c/p\u003e","description":"","filename":"Figure215.png","url":"https://assets-eu.researchsquare.com/files/rs-6517992/v1/248fe5dac4717d60a45aadd0.png"},{"id":82275792,"identity":"e8769cc6-444c-42e4-aa92-6045b4cbe6b5","added_by":"auto","created_at":"2025-05-08 14:42:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4666067,"visible":true,"origin":"","legend":"\u003cp\u003eDeviation group: The liver was deviated cranially and sutured to the diaphragm for 30 min.\u003c/p\u003e","description":"","filename":"Figure310.png","url":"https://assets-eu.researchsquare.com/files/rs-6517992/v1/82f847fef6555832009213ba.png"},{"id":89174176,"identity":"123d9b3d-0ce2-4bb3-9a90-842bc14057b2","added_by":"auto","created_at":"2025-08-15 21:16:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":13496394,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6517992/v1/513ef908-c51a-4bbd-9389-c5bee74938e7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Examination of Pathological and Biochemical Findings of the Damage Caused by Liver Retraction During Abdominal Surgeries Using an Experimental Model","fulltext":[{"header":"Background","content":"\u003cp\u003eDuring operations such as those involving the hepatobiliary system, stomach and gastroesophageal junction, hepatic retraction is needed to visualize the operation field. Especially during operations performed in infants with biliary atresia, hepatic tissue resources are critically important. We observed that patients' serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) levels increased after these operations.\u003c/p\u003e \u003cp\u003eIt is known that ALT, AST and LDH blood levels increase in humans in hepatic injury [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Thus, ALT, AST and LDH values are good indicators for hepatic injury and have been used to evaluate hepatic injury in previous studies [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It has been shown that for open surgery, ALT, AST and LDH blood levels increased during gastric and biliary system operations more than other operations [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Retraction or local trauma is thought to be the cause. Clinical studies also investigate the mechanism of hepatic enzyme increase after laparoscopic cholecystectomy. In these studies, hepatic enzyme levels of patients undergoing different operations were compared [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The results were conflicting: some authors mentioned that the increases in hepatic enzyme levels were due to increased intra-abdominal carbon dioxide pressure leading to decreased splanchnic blood flow [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], while others stated that the increase in hepatic enzyme levels might be secondary to hepatic retraction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and some stated that the increase in hepatic enzymes could be multifactorial including both the increase in intraabdominal pressure and the squeeze pressure effect of the traction [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These data raise the question about the presence of hepatic tissue injury and its contemporary damage to the liver during hepatic retraction.\u003c/p\u003e \u003cp\u003eThe mechanism of hepatic retraction can be divided into \u0026ldquo;crush\u0026rdquo; due to pressure applied to liver tissue or \u0026ldquo;deviation\u0026rdquo; due to cranial deviation of the liver, causing angling in the vascular system. If there is damage to hepatic tissue, which of these mechanisms should be cited as the cause? To resolve this question, we separately simulated hepatic retraction, crush and deviation in rats.\u003c/p\u003e \u003cp\u003eA few studies investigating whether or not hepatic retraction is harmful to the hepatic tissue were found in the available literature [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our aim in this study is to answer whether hepatic retraction during upper abdominal surgery has long-time damage to the hepatic tissue. If damage is present, we also aimed the find answers to which mechanism is responsible. If we could understand the mechanism of damage, we could think about ways of decreasing the damage to the liver, especially in already damaged liver tissue, such as in biliary atresia and cirrhosis cases.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was approved by \u0026hellip; Ethical Committee for Experimental Research on Animals (Project no: DA 10/13) and supported by \u0026hellip; University Research Fund.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAnimals:\u003c/h2\u003e \u003cp\u003eThirty Sprague-Dawley rats weighing 200\u0026ndash;250 g were included in the study. The number of rats required to be in the groups was calculated by a biostatistician while preparing the experimental project. The Experimental Research Center of the Medical Faculty of \u0026hellip; University provided rats. The rats were housed in a windowless animal quarter in which temperature (22\u0026deg;C\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u0026deg;C) and illumination (light on at 7:00 AM and off at 9:00 PM, 14-hour light, 10-hour dark cycle) were controlled automatically. Humidity ranged from 50\u0026ndash;55%. Rats were fed with standard rat chow and tap water \u003cem\u003ead libitum\u003c/em\u003e. The lost or severely ill rats were excluded from the study.\u003c/p\u003e \u003cp\u003eThirty animals were allocated to the following four groups: (1) Control group (n\u0026thinsp;=\u0026thinsp;6): No interventions were done; (2): Retraction group (n\u0026thinsp;=\u0026thinsp;8): Retraction was applied to the liver with Farabeuf\u0026rsquo;s retractor for 30 minutes (min) (a wet sponge was placed between the retractor and liver), and a weight of 100 g was suspended on to the retractor (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e); (3): Crush group (n\u0026thinsp;=\u0026thinsp;8): The liver was crushed with a bulldog clamp for 30 min without angling the vascular structures (a wet sponge was placed between the clamp and liver) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); and (4): Deviation group (n\u0026thinsp;=\u0026thinsp;8): The liver was deviated cranially as creating angling to vascular structures and sutured to the diaphragm for 30 min (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (after 30 min, the sutures were removed and the sutured liver tissue was discarded from the obtained sample tissue)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExperimental Protocols:\u003c/h3\u003e\n\u003cp\u003eThe rats were anesthetized with ketamine HCl (60 mg/kg) and xylazine HCl (7 mg/kg) intraperitoneally, and their liver was exposed through a midline abdominal incision in control, crush and deviation groups and through a subcostal incision in retraction group. The liver was traumatized by Farabeuf\u0026rsquo;s retractor in the retraction group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), by bulldog clamp in the crush group (one clamp to one lobe; a total of two clamps to two lobes) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) and by cranial deviation in the deviation group (two lobes of the liver) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After 30 min, the traumatizing devices were removed, and a liver tissue sample was taken from one of the traumatized liver lobes in retraction, crush and deviation groups and from a healthy lobe in the control group. The tissue sample was divided into two parts: one for pathological examination and one for tissue biochemical examination. The part taken for histological evaluation was placed in 10% neutral buffered formalin solution, and the part taken for tissue biochemical examination was rinsed with isotonic solution, dried and stored at -80\u0026deg;C. Blood samples of 0.75 cc were collected from the tail vein in all rats at the following time points: before opening the abdominal cavity (preoperative), 30 min after the operation (postoperative), and on the first day (24 hours), second day (48 hours) and third day (72 hours) after the operation for ALT, AST), and LDH measurements. After the preoperative blood sample was collected, before laparotomy, 5 cc isotonic saline was given subcutaneously for fluid resuscitation. Twenty-eight days later, the animals were sacrificed by ketamine HCl (150 mg/kg) intravenously, and liver lobes (normal lobe in the control group and the ones previously traumatized in retraction, crush and deviation groups) were removed and divided into two parts for histological and biochemical examinations.\u003c/p\u003e\n\u003ch3\u003eTissue Biochemical Measurements:\u003c/h3\u003e\n\u003cp\u003eMalondialdehyde (MDA) is a toxic end product of the disintegration of non-enzymatic oxidative lipid peroxidation products. The level of MDA increases in the presence of oxygen radicals, causing cell injury. In many studies, MDA has been used as a parameter to determine tissue injury [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlutathione (GSH) is a tripeptide consisting of glutamic acid, cysteine and glycine and is more concentrated in the intracellular fluid. It is important as a reducing agent and an antioxidant, protecting cells from the harmful effects of endogenous and exogenous oxidants by maintaining cellular oxidation-reduction balance [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. GSH facilitates the chemical clearance of these radicals by reacting with oxygen radicals, so GSH decreases when oxygen radicals increase. As a result, GSH has been used in many studies as a parameter to determine injury caused by oxygen radicals [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHydroxyproline (Hyp) is an important intermediate product in collagen metabolism. The Hyp level determines the severity of cirrhosis and hepatic fibrosis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTissue MDA and Hyp levels increase, and GSH levels decrease when tissue injury is present. MDA and GSH levels in the liver tissue were measured to demonstrate tissue injury, and hydroxyproline levels in the liver tissue were measured to demonstrate fibrosis.\u003c/p\u003e\n\u003ch3\u003eDetermination of tissue MDA and GSH concentrations:\u003c/h3\u003e\n\u003cp\u003eLiver homogenates were prepared in ice-cold 0.15 M KCl (10%, w/v) using an all-glass homogenizer\u003c/p\u003e \u003cp\u003eMDA, as a marker of lipid peroxidation, was determined according to the thiobarbituric acid reaction described by Buege and Aust [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. One sample volume was combined with two reagent volumes containing 15% trichloroacetic acid, 0.375% thiobarbituric acid and 0.25 M HCl. The mixture was kept in a boiling water bath for 15 minutes and centrifuged at 1000 x g for 10 minutes after cooling. The absorbance was measured at 535 nm against a reagent blank. Quantitations were obtained using the molar extinction coefficient of 1.56 x 10\u003csup\u003e5\u003c/sup\u003e M\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003ecm\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, and the results were expressed as nmol MDA/g tissue.\u003c/p\u003e \u003cp\u003eGSH levels were assayed in tissue homogenates according to the method of Ellman [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. After deproteinization of the samples, the Ellman color reagent was added to the supernatant, and the absorbance of the generated color complex was detected immediately at 412 nm against a reagent blank. Concentrations were calculated by using the GSH calibration curve, and the results were expressed as nmol GSH/g tissue.\u003c/p\u003e\n\u003ch3\u003eDetermination of tissue hydroxyproline (Hyp) concentrations:\u003c/h3\u003e\n\u003cp\u003eLiver homogenates were prepared in ice-cold saline (2g/5 ml, w/v) using an all-glass homogenizer.\u003c/p\u003e \u003cp\u003eHyp levels were assayed in tissue homogenates according to the method of Reddy and Enwemeka [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Homogenates and Hyp standards were hydrolyzed in an alkaline medium (2N NaOH). After neutralization, samples were oxidized with chloramine\u0026ndash;T, and the absorbance of the generated color complex with the Ehrlich reagent was detected immediately at 563 nm against a reagent blank. Concentrations were calculated using the Hyp calibration curve, and results were expressed as gHyp/g tissue.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHistopathological Examination:\u003c/h2\u003e \u003cp\u003eTissue samples taken were fixed in 10% formalin, embedded in paraffin and stained by hematoxylin and eosin. All biopsies were investigated by the same pathologist (NH), who was blinded for the groups. All specimens were examined and graded according to balloon cell degeneration, steatosis, single cell necrosis, centrilobular necrosis, necroinflammatory focus, widespread necrosis, sinusoidal dilatation/congestion, atrophy of hepatocytes, and cholestasis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eDefinitive values were expressed as median (minimum\u0026ndash;maximum). For comparing independent groups, the Kruskal-Wallis test was used. When a difference was found, the multiple comparison test of Conover was used to define the group causing the difference. For categorical variables, chi-square was used. For repeated measures, ANOVA for repeated measures and the Bonferroni test were used to compare repeated measures over time. We performed the Mann-Whitney U test for non-parametric and Student\u0026rsquo;s t-test for parametric continuous variables. The Statistical Package for the Social Sciences (SPSS) program for Windows (version 21.0; IBM Corp., NY, USA) was used for all statistical analyses. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOne of the rats from the crush group was lost during the operation, and one each from the retraction and deviation groups was lost during the follow-up.\u003c/p\u003e \u003cp\u003eWhen serum biochemical investigations were evaluated, in all groups, AST and ALT increased at the 30th minute and 24th hour (For AST p\u0026thinsp;=\u0026thinsp;0.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, respectively and for ALT p\u0026thinsp;=\u0026thinsp;0.02, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, respectively) and decreased at the 48th hour and 72nd hour significantly (For AST p\u0026thinsp;=\u0026thinsp;0.05, p\u0026thinsp;=\u0026thinsp;0.02, respectively and for ALT p\u0026thinsp;=\u0026thinsp;0.02, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, respectively). In all groups, AST and ALT values at the 72nd hour were in between the values at the 30th minute and the values at the 24th -hour values (For AST p\u0026thinsp;=\u0026thinsp;0.231, p\u0026thinsp;=\u0026thinsp;1.000, respectively and ALT p\u0026thinsp;=\u0026thinsp;0.418, p\u0026thinsp;=\u0026thinsp;0.432, respectively). In all groups, LDH first increased at the 30th minute and decreased afterward. However, the increase at the 30th minute and decrease at the 24th hour was not significant (p\u0026thinsp;=\u0026thinsp;1.00, p\u0026thinsp;=\u0026thinsp;0.252, respectively), but the decrease at the 48th hours and 72nd hours was significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, respectively) compared to the first measurement. The results are given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. At postoperative 30th min, ALT and AST levels were higher in the crush group (p\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;=\u0026thinsp;0.005, respectively), and ALT level was higher in the deviation group (p\u0026thinsp;=\u0026thinsp;0.030) compared to the control group. LDH levels at the 48th hour was significantly higher in the crush group compared to other groups (p\u0026thinsp;=\u0026thinsp;0.020) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSerum and tissue biochemical results according to groups (Important ratios with statistical significance are shown in bold).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003cp\u003e(Group 1 vs 2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGroup 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value (Group 1 vs 3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGroup 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP value (Group 1 vs 4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eALT (U/L) (Mean \u0026plusmn;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e39.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e90.2\u0026thinsp;\u0026plusmn;\u0026thinsp;60.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e46.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e75.2\u0026thinsp;\u0026plusmn;\u0026thinsp;74.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e136.2\u0026thinsp;\u0026plusmn;\u0026thinsp;152.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e301.7\u0026thinsp;\u0026plusmn;\u0026thinsp;180.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e123.4\u0026thinsp;\u0026plusmn;\u0026thinsp;78.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 24 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e575.2\u0026thinsp;\u0026plusmn;\u0026thinsp;261.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e703.2\u0026thinsp;\u0026plusmn;\u0026thinsp;264.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e1173.9\u0026thinsp;\u0026plusmn;\u0026thinsp;786.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e923.5\u0026thinsp;\u0026plusmn;\u0026thinsp;538.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 48 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e632.3\u0026thinsp;\u0026plusmn;\u0026thinsp;500.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e194.6\u0026thinsp;\u0026plusmn;\u0026thinsp;65.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e508.3\u0026thinsp;\u0026plusmn;\u0026thinsp;268.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e200.0\u0026thinsp;\u0026plusmn;\u0026thinsp;50.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e85.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e83.8\u0026thinsp;\u0026plusmn;\u0026thinsp;23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.858\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e93.6\u0026thinsp;\u0026plusmn;\u0026thinsp;45.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.712\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e101.5\u0026thinsp;\u0026plusmn;\u0026thinsp;46.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.449\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAST (U/L) (Mean \u0026plusmn;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e86.5\u0026thinsp;\u0026plusmn;\u0026thinsp;32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e160.4\u0026thinsp;\u0026plusmn;\u0026thinsp;94.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e115.3\u0026thinsp;\u0026plusmn;\u0026thinsp;36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e138.1\u0026thinsp;\u0026plusmn;\u0026thinsp;112.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e129.8\u0026thinsp;\u0026plusmn;\u0026thinsp;59.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e228.0\u0026thinsp;\u0026plusmn;\u0026thinsp;267.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e358.1\u0026thinsp;\u0026plusmn;\u0026thinsp;140.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e149.4\u0026thinsp;\u0026plusmn;\u0026thinsp;79.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 24 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e777.2\u0026thinsp;\u0026plusmn;\u0026thinsp;291.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e892.9\u0026thinsp;\u0026plusmn;\u0026thinsp;438.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e1374.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1004.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e1260.5\u0026thinsp;\u0026plusmn;\u0026thinsp;489.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.548\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 48 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e805.2\u0026thinsp;\u0026plusmn;\u0026thinsp;598.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e302.8\u0026thinsp;\u0026plusmn;\u0026thinsp;136.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e797.4\u0026thinsp;\u0026plusmn;\u0026thinsp;498.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e344.0\u0026thinsp;\u0026plusmn;\u0026thinsp;125.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.245\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e173.5\u0026thinsp;\u0026plusmn;\u0026thinsp;101.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e173.1\u0026thinsp;\u0026plusmn;\u0026thinsp;57.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e182.0\u0026thinsp;\u0026plusmn;\u0026thinsp;82.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e218.1\u0026thinsp;\u0026plusmn;\u0026thinsp;105.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eLDH (U/L) (Mean \u0026plusmn;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1415.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1296.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1601.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1076.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e2251.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1439.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e1653.0\u0026thinsp;\u0026plusmn;\u0026thinsp;843.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2789.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3046.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1297.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1408.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e3901.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2022.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e1150.7\u0026thinsp;\u0026plusmn;\u0026thinsp;826.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 24 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1458.8\u0026thinsp;\u0026plusmn;\u0026thinsp;730.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e765.9\u0026thinsp;\u0026plusmn;\u0026thinsp;383.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e2159.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2218.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e1105.4\u0026thinsp;\u0026plusmn;\u0026thinsp;457.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 48 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e567.8\u0026thinsp;\u0026plusmn;\u0026thinsp;196.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e402.0\u0026thinsp;\u0026plusmn;\u0026thinsp;144.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e1292.4\u0026thinsp;\u0026plusmn;\u0026thinsp;610.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e536.7\u0026thinsp;\u0026plusmn;\u0026thinsp;382.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.723\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter 72 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e711.5\u0026thinsp;\u0026plusmn;\u0026thinsp;312.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e634.2\u0026thinsp;\u0026plusmn;\u0026thinsp;347.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e438.4\u0026thinsp;\u0026plusmn;\u0026thinsp;434.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e285.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMDA (nmol MDA/g) (Mean \u0026plusmn;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.888\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;26.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e32.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOn 28th day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e19.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGSH (nmol GSH/g) (Mean \u0026plusmn;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOn 28th day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHyp (gHyp/g) (Mean \u0026plusmn;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative 30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e65.8\u0026thinsp;\u0026plusmn;\u0026thinsp;43.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e67.9\u0026thinsp;\u0026plusmn;\u0026thinsp;26.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e51.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e69.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.696\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOn 28th day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e91.4\u0026thinsp;\u0026plusmn;\u0026thinsp;21.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e68.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e75.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c8\"\u003e \u003cp\u003e84.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.505\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eImportant ratios with statistical significance are shown in bold.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen tissue biochemical investigations were considered, MDA and Hyp did not differ significantly between groups at postoperative 30 min (p\u0026thinsp;=\u0026thinsp;0.200, p\u0026thinsp;=\u0026thinsp;0.054) or on the 28th day (p\u0026thinsp;=\u0026thinsp;0.999, p\u0026thinsp;=\u0026thinsp;0.152). In the crush group at postoperative 30 min MDA was high (p\u0026thinsp;=\u0026thinsp;0.052), and GSH was low (p\u0026thinsp;=\u0026thinsp;0.064) than the control group, whereas the difference had disappeared on the 28th day (p\u0026thinsp;=\u0026thinsp;0.410, p\u0026thinsp;=\u0026thinsp;0.691, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen the histopathological examination was considered, no steatosis, atrophy of hepatocytes or cholestasis was observed in any of the groups at any time. The findings of the histopathological examination were given in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHistopathological examination of liver tissue samples taken at postoperative 30 min and on the 28th day (Important ratios with statistical significance are shown in bold).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003e28th day\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 1 (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup 2 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup 3 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGroup 4 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGroup 1 (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGroup 2 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGroup 3 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eGroup 4 (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBalloon cell degeneration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSingle cell necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCentrilobular necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNecroinflam-matory focus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e62%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e43%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e38%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e71%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e38%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e57%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e62%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNecrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e71%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.470\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eSinusoidal dilatation/ congestion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e50%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.207\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e33%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e38%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e12%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e25%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e17%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e50%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e14%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e63%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e86%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e12%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen the histopathological examination was compared statistically between groups, only postoperative necroinflammatory focus and sinusoidal dilatation/congestion showed significant differences (p\u0026thinsp;=\u0026thinsp;0.048 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All three experimental groups (retraction, crush and deviation) showed prominent balloon cell degeneration on the 28th day, although the difference was not significant (p\u0026thinsp;=\u0026thinsp;0.092).\u003c/p\u003e \u003cp\u003eConcerning necroinflammatory focus, the retraction, crush and deviation groups differed when compared to the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) but did not differ amongst themselves. Concerning sinusoidal dilatation/congestion, there were differences between all groups; however, there was no difference on the 28th -day examinations (p\u0026thinsp;=\u0026thinsp;0.207) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTrauma to the liver after hepatic retractor usage during the resection of gastric malignancy was detected in Yassa and Peters\u0026rsquo; study, which investigated preoperative and postoperative computerized tomography of 250 patients. They determined lesions which have the same findings as those after blunt abdominal trauma, in the left lobe of the liver in 10 patients and increased liver enzymes. The authors concluded that hepatic retraction during gastric resection led to hepatic trauma in these patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, Kinjo et al. reported that one of their patients had hepatic infarction after laparoscopic gastrectomy in which a Nathanson liver retractor had been used [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. We also observed an increase in the liver enzyme (AST, ALT) in our patients operated on for gastric or biliary system operations.\u003c/p\u003e \u003cp\u003eIn our study, serum biochemical analysis showed that serum ALT levels in the crush and deviation groups significantly increased after the operation compared to the control group, indicating hepatic injury. The serum AST levels had also increased in the crush group. Similar to other studies, the difference within groups disappeared at 72 hours when all the levels decreased to near-normal levels [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome clinical studies have shown that liver enzymes (AST, ALT) increased after upper abdominal surgeries (gastrectomy, cholecystectomy, antireflux surgery, obesity surgery, etc.), both laparoscopic and open, while did not change after lower abdominal surgeries (inguinal hernia repair, etc.) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] or after other surgeries out of the abdominal region (head and neck, breast, thorax, testis, etc. operations) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most of these studies concluded that liver retraction is the cause of the increase in liver enzymes [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and some authors added the effects of anesthetic drugs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, some authors concentrated on the effects of position (head up position during laparoscopy) and pneumoperitoneum [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSaranita et al. showed that their patient with an open Roux-en-Y gastric bypass had increased liver enzymes after the hepatic retractor was placed [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Also some studies were conducted to define which type of liver retraction was less harmful to the liver tissue [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen tissue biochemical analyzes are examined, the only significant difference seen as MDA increased and GSH decreased in the crush group, indicating mild oxidative injury, although the differences were not statistically significant. The MDA increase and GSH depletion in the crush group showed recovery on the 28th day. The crush group also showed a significant increase in serum ALT and AST levels postoperatively and serum LDH levels on the second day, indicating that the crush group caused hepatic injury more prominently.\u003c/p\u003e \u003cp\u003eThe postoperative presence of necroinflammatory focus showed statistical significance in the retraction, crush and deviation groups compared to the control group. Necroinflammatory focus is a tissue injury finding, though non-specific.\u003c/p\u003e \u003cp\u003ePostoperative presence of sinusoidal dilatation/congestion showed statistical significance within groups. Interestingly, postoperatively, the most severe sinusoidal dilatation/ congestion was observed in the crush group. This could be due to the compression of venules by the applied pressure, impairing venous return and causing congestion. Furthermore, the deviation group showed mostly medium congestion postoperatively, which was thought to be due to the angulation of veins, causing venous stasis. Congestion in the retraction group was not as severe as in the crush group and significantly more than in the control group. As congestion was significant, and cholestasis was not seen, we can say that the bile ductile is more resistant to compression and pressure trauma than hepatic venules.\u003c/p\u003e \u003cp\u003eFor all groups, although the necroinflammatory focus and sinusoidal dilatation/congestion had not recovered on the 28th day, the severity decreased, and the difference within the groups disappeared. However, balloon cell degeneration, a finding of hepatocyte death and apoptosis, became more evident on the 28th day. This shows that all three mechanisms may cause hepatocyte apoptosis in the long term.\u003c/p\u003e \u003cp\u003eNecrosis was the most important finding for tissue injury. Although it was only seen in the retraction and deviation groups at postoperative 30 min, statistical analysis showed no significant difference within the four groups. Interestingly, necrosis was not seen in the crush group either at postoperative 30 min or on the 28th day, although a significant increase in serum ALT, AST and LDH levels, an increase in tissue MDA levels and a decrease in tissue GSH levels were observed, indicating tissue injury.\u003c/p\u003e \u003cp\u003eThese findings can also enlighten the pathology of blunt hepatic trauma as a similar mechanism with crush injury seems to happen at blunt trauma hepatic injury.\u003c/p\u003e \u003cp\u003eThis study has some limitations. The sample size was small. As no previous study was designed for this topic, we did not have data to calculate the sample size of groups during the planning stage of the study. However, the results could be more precise if the sample size was bigger. Secondly, we could not find a way to equalize retraction pressure and crush pressure applied by bulldog clamps. Crush pressure may be more than retraction pressure in this study. Thirdly, the hepatic enzymes increased in all groups, including the control group, which may be due to anesthetic drugs, making comparisons more difficult. Last, as we could not find any study discussing hepatic damage or histopathological changes due to retraction, the discussion and comparison of our results with the literature were limited.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWhile the crush group showed significant injury, with an elevation of serum ALT, AST and LDH levels, an increase in tissue MDA levels, a decrease in tissue GSH levels, severe sinusoidal dilatation/congestion, and the presence of a necroinflammatory focus in the postoperative histopathological findings, the retraction and deviation groups showed signs of hepatic injury only by the postoperative presence of sinusoidal dilatation/congestion and necroinflammatory focus. According to the histopathological findings, although balloon cell degeneration, sinusoidal dilatation/ congestion and necroinflammatory focus were still seen on the 28th day in the retraction, crush and deviation groups, statistical analysis did not reach the level of significance. These findings show that the crush mechanism was more harmful to the liver tissue than the angling of vascular structures for a short time. So, we recommend keeping the hepatic retractions at minimum tension during the surgical procedures to protect the liver tissue, especially in biliary atresia surgeries and in cirrhotic cases. Mild damage occurs to liver tissue immediately after the operation due to liver retraction, and the effects of the damage were evident in the long term.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eserum alanine aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003easpartate aminotransferase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elactate dehydrogenase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMalondialdehyde\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGSH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGlutathione\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHyp\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHydroxyproline\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to Participate:\u003c/strong\u003e This study was approved by Başkent University Ethical Committee for Experimental Research on Animals (Ethics approval number: DA 10/13)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u003c/strong\u003e The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was supported by the Başkent University Research Fund. Apart from this,\u0026nbsp;no funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution:\u003c/strong\u003e All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed TAD, NH and DAA. The first draft of the manuscript was written by TAD and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOldham KT, Guice KS, Kaufman RA, Martin LW, Noseworthy J (1984) Blunt hepatic injury and elevated hepatic enzymes: a clinical correlation in children. 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Obes Surg 13(2):314\u0026ndash;316. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1381/096089203764467289\u003c/span\u003e\u003cspan address=\"10.1381/096089203764467289\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hepatic, damage, retraction, abdominal, surgery","lastPublishedDoi":"10.21203/rs.3.rs-6517992/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6517992/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Our aim in this study is to answer whether hepatic retraction during abdominal surgery causes damage to the hepatic tissue.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e Thirty Sprague-Dawley rats were allocated to the following four groups: (1) Control group (2): Retraction group: Pressure was applied to the liver with Farabeuf’s retractor (3): Crush group: The liver was crushed with a bulldog clamp, and (4): Deviation group: The liver was deviated cranially as creating angling to vascular structures. A liver tissue sample was taken for pathological and biochemical examination. Blood samples were collected for ALT, AST and LDH measurements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u0026nbsp; The crush group showed a significant elevation of serum ALT, AST and LDH levels, decreased tissue GSH levels, increased MDA levels, severe sinusoidal dilatation/congestion, and necroinflammatory focus in the postoperative histopathological findings. The deviation group showed elevation in serum ALT levels, sinusoidal dilatation/congestion and necroinflammatory focus postoperatively. According to the histopathological findings, although balloon cell degeneration, sinusoidal dilatation/ congestion and necroinflammatory focus were still seen on the 28\u003csup\u003eth\u003c/sup\u003e day in the retraction, crush and deviation groups, the difference did not show statistical significance with the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e We found that the crush mechanism was more harmful to the liver tissue than the angling of vascular structures. We recommend keeping the hepatic retractions at minimum tension during the surgical procedures to protect the liver tissue, especially in patients with limited liver function such as cirrhotic cases and newborns with biliary atresia.\u003c/p\u003e","manuscriptTitle":"Examination of Pathological and Biochemical Findings of the Damage Caused by Liver Retraction During Abdominal Surgeries Using an Experimental Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 14:34:42","doi":"10.21203/rs.3.rs-6517992/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b1ea856-2915-49f9-a6b7-221c3548dac1","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-15T21:08:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 14:34:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6517992","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6517992","identity":"rs-6517992","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}