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Hamid M, Mostafa OES, Mohamedahmed AYY, Zaman S, Kumar P, Waterland P, Akingboye A. Comparison of low versus high (standard) intraabdominal pressure during laparoscopic colorectal surgery: systematic review and meta-analysis. Int J Colorectal Dis 2024; 39:104. [PMID: 38985344 PMCID: PMC11236862 DOI: 10.1007/s00384-024-04679-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND To evaluate outcomes of low with high intraabdominal pressure during laparoscopic colorectal resection surgery. METHODS A systematic search of multiple electronic data sources was conducted, and all studies comparing low with high (standard) intraabdominal pressures were included. Our primary outcomes were post-operative ileus occurrence and return of bowel movement/flatus. The evaluated secondary outcomes included: total operative time, post-operative haemorrhage, anastomotic leak, pneumonia, surgical site infection, overall post-operative complications (categorised by Clavien-Dindo grading), and length of hospital stay. Revman 5.4 was used for data analysis. RESULTS Six randomised controlled trials (RCTs) and one observational study with a total of 771 patients (370 surgery at low intraabdominal pressure and 401 at high pressures) were included. There was no statistically significant difference in all the measured outcomes; post-operative ileus [OR 0.80; CI (0.42, 1.52), P = 0.50], time-to-pass flatus [OR -4.31; CI (-12.12, 3.50), P = 0.28], total operative time [OR 0.40; CI (-10.19, 11.00), P = 0.94], post-operative haemorrhage [OR 1.51; CI (0.41, 5.58, P = 0.53], anastomotic leak [OR 1.14; CI (0.26, 4.91), P = 0.86], pneumonia [OR 1.15; CI (0.22, 6.09), P = 0.87], SSI [OR 0.69; CI (0.19, 2.47), P = 0.57], overall post-operative complications [OR 0.82; CI (0.52, 1.30), P = 0.40], Clavien-Dindo grade ≥ 3 [OR 1.27; CI (0.59, 2.77), P = 0.54], and length of hospital stay [OR -0.68; CI (-1.61, 0.24), P = 0.15]. CONCLUSION Low intraabdominal pressure is safe and feasible approach to laparoscopic colorectal resection surgery with non-inferior outcomes to standard or high pressures. More robust and well-powered RCTs are needed to consolidate the potential benefits of low over high pressure intra-abdominal surgery.
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Affiliation(s)
- Mohammed Hamid
- Department of General Surgery, Wye Valley NHS Trust, Hereford County Hospital, Hereford, Herefordshire, UK
| | - Omar E S Mostafa
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Queen's Hospital Burton, Burton on Trent, Staffordshire, UK
| | - Shafquat Zaman
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK.
- College of Medical and Dental Sciences, School of Medicine, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Prajeesh Kumar
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Peter Waterland
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Akinfemi Akingboye
- Department of General and Colorectal Surgery, Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, UK
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Serrano AB, Díaz-Cambronero Ó, Montiel M, Molina J, Núñez M, Mendía E, Mané MN, Lisa E, Martínez-Botas J, Gómez-Coronado D, Gaetano A, Casarejos MJ, Gómez A, Sanjuanbenito A. Impact of Standard Versus Low Pneumoperitoneum Pressure on Peritoneal Environment in Laparoscopic Cholecystectomy. Randomized Clinical Trial. Surg Laparosc Endosc Percutan Tech 2024; 34:1-8. [PMID: 37963307 DOI: 10.1097/sle.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND High CO 2 pneumoperitoneum pressure during laparoscopy adversely affects the peritoneal environment. This study hypothesized that low pneumoperitoneum pressure may be linked to less peritoneal damage and possibly to better clinical outcomes. MATERIALS AND METHODS One hundred patients undergoing scheduled laparoscopic cholecystectomy were randomized 1:1 to low or to standard pneumoperitoneum pressure. Peritoneal biopsies were performed at baseline time and 1 hour after peritoneum insufflation in all patients. The primary outcome was peritoneal remodeling biomarkers and apoptotic index. Secondary outcomes included biomarker differences at the studied times and some clinical variables such as length of hospital stay, and quality and safety issues related to the procedure. RESULTS Peritoneal IL6 after 1 hour of surgery was significantly higher in the standard than in the low-pressure group (4.26±1.34 vs. 3.24±1.21; P =0.001). On the contrary, levels of connective tissue growth factor and plasminogen activator inhibitor-I were higher in the low-pressure group (0.89±0.61 vs. 0.61±0.84; P =0.025, and 0.74±0.89 vs. 0.24±1.15; P =0.028, respectively). Regarding apoptotic index, similar levels were found in both groups and were 44.0±10.9 and 42.5±17.8 in low and standard pressure groups, respectively. None of the secondary outcomes showed differences between the 2 groups. CONCLUSIONS Peritoneal inflammation after laparoscopic cholecystectomy is higher when surgery is performed under standard pressure. Adhesion formation seems to be less in this group. The majority of patients undergoing surgery under low pressure were operated under optimal workspace conditions, regardless of the surgeon's expertise.
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Affiliation(s)
| | - Óscar Díaz-Cambronero
- Department of Anesthesiology, Perioperative Medicine Research Group, Hospital Universitari i Politécnic La Fe, Valencia, Spain
- EuroPeriscope: The ESA-IC Onco-Anaesthesiology Research Group
| | | | | | | | | | | | | | | | | | - Andrea Gaetano
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid
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Bijkerk V, Jacobs LM, Albers KI, Gurusamy KS, van Laarhoven CJ, Keijzer C, Warlé MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Cochrane Database Syst Rev 2024; 1:CD013197. [PMID: 38288876 PMCID: PMC10825891 DOI: 10.1002/14651858.cd013197.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes. OBJECTIVES To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group. AUTHORS' CONCLUSIONS There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kim I Albers
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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Arumugaswamy PR, Chumber S, Rathore YS, Maitra S, Bhattacharjee HK, Bansal VK, Aggarwal S, Dhar A, Asuri K, Kataria K, Ranjan P. Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial. Surg Endosc 2024; 38:449-459. [PMID: 38012441 DOI: 10.1007/s00464-023-10558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
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Affiliation(s)
- Prasanna Ramana Arumugaswamy
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Yashwant Singh Rathore
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Souvik Maitra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Hemanga Kumar Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Anita Dhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Krishna Asuri
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Esa U, Zaini RHM, Mazlan MZ, Omar AA, Omar SC, Rosedi A. Evaluation of surgical condition during laparoscopic gynaecological surgery in patients with moderate vs. deep neuromuscular block in low-pressure pneumoperitoneum. Anaesthesiol Intensive Ther 2024; 56:121-128. [PMID: 39166503 PMCID: PMC11284580 DOI: 10.5114/ait.2024.141209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 01/09/2024] [Indexed: 08/23/2024] Open
Abstract
INTRODUCTION The significant effect of deep neuromuscular block (NMB) in laparoscopic surgery is still controversial, especially in lower-pressure pneumoperitoneum. This study investigates the effect of deep neuromuscular block on intraabdominal pressure (IAP), surgical space quality, post-operative abdominal pain, and shoulder tip pain in laparoscopic gynaecological surgery. MATERIAL AND METHODS This is a randomised, double-blinded control trial which randomised samples to moderate NMB (train-of-four count [TOF] of 1 or 2) or deep NMB (post-tetanic count [PTC] of 1 or 2). Surgery began with IAP 8 mmHg but was allowed to increase the pressure if the surgical condition was unfavourable. The surgical condition was rated on a 4-point scale. Post-operative abdominal pain and shoulder tip pain was assessed using a numerical rating scale for pain, with 0 defined as no pain and 10 severe pain at recovery area (time 0), 30 minutes, and 24 hours post-operation. RESULTS Seventy patients completed the study. The rate of increasing IAP between the 2 groups ( P = 0.172) is not significant, but deep NMB requires less pressure - mean highest IAP of 10.31 (± 1.39) mmHg, moderate NMB 11.54 (± 1.69) mmHg. The mean surgical space condition score was significantly better in the deep NMB group at 2.4 (± 0.7) compared to moderate NMB at 3.2 (± 0.66), P < 0.005. There was a significantly lower post-operative abdominal pain score in deep NMB but no significant difference in shoulder tip pain score between the 2 groups. CONCLUSIONS Deep NMB enables the usage of lower IAP in laparoscopic surgery without interfering with surgical space condition, and it reduces the post-operative abdominal pain score in 24 hours compared to moderate NMB.
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Affiliation(s)
- Umairah Esa
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Rhendra Hardy Mohamad Zaini
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Mohd Zulfakar Mazlan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Ahmad Akram Omar
- Department of Obstetrics and Gynaecology, School of Medical Sciences, Health Campus, University of Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Sanihah Che Omar
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Anas Rosedi
- Department of Community Medicine, School of Medical Sciences, Health Campus, University of Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Robertson D, van Duijn M, Arezzo A, Mintz Y, Horeman-Franse T. The influence of prolonged instrument manipulation on gas leakage through trocars. Surg Endosc 2023; 37:7325-7335. [PMID: 37442835 PMCID: PMC10462547 DOI: 10.1007/s00464-023-10240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND During laparoscopic surgery, CO2 insufflation gas could leak from the intra-abdominal cavity into the operating theater. Medical staff could therefore be exposed to hazardous substances present in leaked gas. Although previous studies have shown that leakage through trocars is a contributing factor, trocar performance over longer periods remains unclear. This study investigates the influence of prolonged instrument manipulation on gas leakage through trocars. METHODS Twenty-five trocars with diameters ranging from 10 to 15 mm were included in the study. An experimental model was developed to facilitate instrument manipulation in a trocar under loading. The trocar was mounted to a custom airtight container insufflated with CO2 to a pressure of 15 mmHg, similar to clinical practice. A linear stage was used for prolonged instrument manipulation. At the same time, a fixed load was applied radially to the trocar cannula to mimic the reaction force of the abdominal wall. Gas leakage was measured before, after, and during instrument manipulation. RESULTS After instrument manipulation, leakage rates per trocar varied between 0.0 and 5.58 L/min. No large differences were found between leakage rates before and after prolonged manipulation in static and dynamic measurements. However, the prolonged instrument manipulation did cause visible damage to two trocars and revealed unintended leakage pathways in others that can be related to production flaws. CONCLUSION Prolonged instrument manipulation did not increase gas leakage rates through trocars, despite damage to some individual trocars. Nevertheless, gas leakage through trocars occurs and is caused by different trocar-specific mechanisms and design issues.
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Affiliation(s)
- Daniel Robertson
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
| | - Matthijs van Duijn
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tim Horeman-Franse
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
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Zhang YW, Li Y, Huang WB, Wang J, Qian XE, Yang Y, Huang CS. Utilization of deep neuromuscular blockade combined with reduced abdominal pressure in laparoscopic radical gastrectomy for gastric cancer: An academic perspective. World J Gastrointest Surg 2023; 15:1405-1415. [PMID: 37555115 PMCID: PMC10405126 DOI: 10.4240/wjgs.v15.i7.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/20/2023] [Accepted: 06/02/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Few studies have examined the specific efficacy of deep neuromuscular blockade (NMB) combined with pneumoperitoneal pressure reduction in laparoscopic radical gastrectomy (LRG) in the elderly. AIM To investigate the application effect of deep neuromuscular blockade (NMB) combined with reduced pneumoperitoneum pressure in LRG for gastric cancer (GC) in elderly patients and its influence on inflammation. METHODS Totally 103 elderly patients with GC treated in our hospital between January 2020 and January 2022 were retrospectively analyzed. Among them, 45 patients treated with surgery based on deep NMB and conventional pneumoperitoneum pressure were assigned to the control group, while the rest of the 58 patients who underwent surgery based on deep NMB and reduced pneumoperitoneum pressure were assigned to the observation group. The two groups were compared in the changes of the Leiden-surgical rating scale score, serum tumor necrosis fact-α (TNF-α) and interleukin 6 (IL-6) before and after therapy. The visual analogue scale (VAS) was adopted for evaluating the shoulder pain of patients at 8 h, 24 h and 48 h after the operation. The driving pressure of the two groups at different time points was also compared. Additionally, the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room, TOF% = 90% time and post-anesthetic recovery room (PACU) stay time were all recorded, and adverse PACU-associated respiratory events were also recorded. The postoperative hospitalization time and postoperative expenses of the two groups were counted and compared. RESULTS No significant difference was found between the two groups at the time of skin incision, 60 minutes since the operation and abdominal closure after surgery (P > 0.05). The observation group exhibited significantly lower VAS scores than the control group at 24 and 48h after surgery (P < 0.05). Additionally, the observation group had significantly lower driving pressure than the control group at 5 min and 60 min after the establishment of pneumoperitoneum (P < 0.05). Additionally, the two groups were similar in terms of the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room and TOF% = 90% time (P > 0.05), and the observation group showed significantly lower TNF-α and IL-6 Levels than the control group at 24 h after therapy (P < 0.05). Moreover, the incidence of adverse events was not significantly different between the two groups (P > 0.05), and the observation group experienced significantly less hospitalization time and postoperative expenses than the control group (P < 0.05). CONCLUSION Deep NMB combined with reduced pneumoperitoneum pressure can decrease the VAS score of shoulder pain and inflammatory reaction, without hindering the surgical vision and increasing adverse PACU-associated respiratory events, and can thus shorten the hospitalization time and treatment cost for patient.
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Affiliation(s)
- Yi-Wei Zhang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Yong Li
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Wan-Bo Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Jue Wang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Xing-Er Qian
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Yu Yang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Chang-Shun Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
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Relationship between ANI and qNOX and between MAC and qCON during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants: a prospective observational preliminary study. J Clin Monit Comput 2023; 37:83-91. [PMID: 35445895 DOI: 10.1007/s10877-022-00861-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 03/31/2022] [Indexed: 01/24/2023]
Abstract
This study was designed to investigate qCON and qNOX variations during outpatient laparoscopic cholecystectomy using remifentanil and desflurane without muscle relaxants and compare these indices with ANI and MAC. Adult patients undergoing outpatient laparoscopic cholecystectomy were included in this prospective observational study. Maintenance of anesthesia was performed using remifentanil targeted to ANI 50-80 and desflurane targeted to MAC 0.8-1.2 without muscle relaxants. The ANI, qCON and qNOX and desflurane MAC values were collected at different time-points and analyzed using repeated measures ANOVA. The relationship between ANI and qNOX and between qCON and MAC were analyzed by linear regression. The ANI was comprised between 50 and 80 during maintenance of anesthesia. Higher values of qNOX and qCON were observed at induction and extubation than during all other time-points where they were comprised between 40 and 60. A poor but significant negative linear relationship (r2 = 0.07, p < 0.001) was observed between ANI and qNOX. There also was a negative linear relationship between qCON and MAC (r2 = 0.48, p < 0.001) and between qNOX and remifentanil infusion rate (r2 = 0.13, p < 0.001). The linear mixed-effect regression correlation (r2) was 0.65 for ANI-qNOX and 0.96 for qCON-MAC. The qCON and qNOX monitoring seems informative during general anesthesia using desflurane and remifentanil without muscle relaxants in patients undergoing ambulatory laparoscopic cholecystectomy. While qCON correlated with MAC, the correlation of overall qCON and ANI was poor but significant. Additionally, the qNOX weakly correlated with the remifentanil infusion rate. This observational study suggests that the proposed ranges of 40-60 for both indexes may correspond to adequate levels of hypnosis and analgesia during general anesthesia, although this should be confirmed by further research.
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Muacevic A, Adler JR, Preethi A. Comparison of Different Carbon Dioxide Insufflation Rates on Hemodynamic Changes in Laparoscopic Surgeries: A Randomized Controlled Trial. Cureus 2023; 15:e34071. [PMID: 36843757 PMCID: PMC9944635 DOI: 10.7759/cureus.34071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction The injury and detrimental effects of carbon dioxide (CO2) insufflation during laparoscopic surgeries may be due to the higher flow rates used during insufflation. The aim of our study was to study the effects of different CO2 insufflation flow rates on hemodynamic parameters in laparoscopic surgeries. The secondary objectives were to compare the patient and surgeon satisfaction scores, postoperative shoulder scores, and surgical site pain scores. Methods This prospective, randomized, double-blinded trial was commenced after institutional ethical committee approval and The Clinical Trials Registry- India (CTRI) registration (CTRI 2021/10/037595). Ninety patients scheduled for laparoscopic cholecystectomy were randomly divided into three groups based on CO2 insufflation flow rate by computer-generated random numbers and the sealed envelope method: Group-A: 5 L/min; Group-B: 10 L/min; and Group-C: 15 L/min. General anesthesia was standardized in all three groups. Mean arterial pressure (MAP) and heart rate were recorded at different timelines, which included the arrival in the operating room (T0), just before the induction of anesthesia (T1), at the beginning of pneumoperitoneum (T2), 10 minutes (T3), 20 minutes (T4), 30 minutes (T5), and 60 minutes (T6) after the pneumoperitoneum, at the end of the operation (T7), five minutes (T8), and 15 minutes (T9) after arriving at the recovery room. The patient and surgeon satisfaction scores were assessed on a 5-point Likert scale. The visual analog score (VAS) was used to assess the surgical site pain and shoulder pain every four hours for 24 hours. The continuous data were assessed by one-way analysis of variance (ANOVA), and the categorical data were assessed by the Chi-square test. The sample size was estimated based on a pilot study and using the G Power 3.1.9.2 Program (Universitat Kiel, Germany) calculator. Results There was an increase in the mean arterial pressure (MAP) between the groups 60 min after pneumoperitoneum creation with higher flow rates. The baseline MAP was 85.76± 10.11 in group A, 86.03± 9.79 in group B, and 88.13± 8.46 in group C. At 60 min from the creation of the pneumoperitoneum, the MAP increased significantly from 99.17 ± 9.35 in group A, 102.43 ± 8.24 in group B, to 106.83 ± 8.31 in group C. This was statistically significant with a p-value of 0.004. There was a statistically significant difference in heart rate between the groups 10 minutes after pneumoperitoneum creation. No complications were reported in any of the groups. The postoperative shoulder pain was more severe when higher flows were used at 20 and 24 hours. The surgical site pain was also significantly more for up to 12 hours following surgery with higher flows. Conclusion We conclude that low-flow CO2 insufflation during laparoscopic surgeries is associated with fewer hemodynamic changes, better patient satisfaction scores, and lower postoperative pain scores.
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The impact of low-pressure pneumoperitoneum on robotic-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion: a case-control study. World J Urol 2022; 40:2467-2472. [PMID: 36065029 PMCID: PMC9512870 DOI: 10.1007/s00345-022-04117-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD). Methods A retrospective case–control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system. Results Demographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar. Conclusion With limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum.
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Ortenzi M, Montori G, Sartori A, Balla A, Botteri E, Piatto G, Gallo G, Vigna S, Guerrieri M, Williams S, Podda M, Agresta F. Low-pressure versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2022; 36:7092-7113. [PMID: 35437642 PMCID: PMC9485078 DOI: 10.1007/s00464-022-09201-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/17/2022] [Indexed: 11/30/2022]
Abstract
Introduction It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor. Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy. Materials and methods This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions. Results This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome). Conclusions This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09201-1.
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Affiliation(s)
- Monica Ortenzi
- Clinica di Chirurgia Generale e d'Urgenza, Università Politecnica delle Marche, Ancona, Italy.
| | - Giulia Montori
- Emergency Department, Leopoldo Mandic Hospital, Merate, LC, Italy
| | - Alberto Sartori
- U. O. Chirurgia Generale e d'urgenza, Ospedale San Valentino - Montebelluna, Montebelluna, Treviso, Italy
| | - Andrea Balla
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, 00053, Civitavecchia, Rome, Italy
| | | | - Giacomo Piatto
- U. O. Chirurgia Generale e d'urgenza, Ospedale San Valentino - Montebelluna, Montebelluna, Treviso, Italy
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Silvia Vigna
- U. O. Chirurgia Generale Ospedale Civile, Cittadella, Padua, Italy
| | - Mario Guerrieri
- Clinica di Chirurgia Generale e d'Urgenza, Università Politecnica delle Marche, Ancona, Italy
| | - Sophie Williams
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Ferdinando Agresta
- Department of General Surgery, AULSS2 del Veneto, Vittorio Veneto, TV, Italy
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Yang X, Cheng Y, Cheng N, Gong J, Bai L, Zhao L, Deng Y. Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery. Cochrane Database Syst Rev 2022; 3:CD009569. [PMID: 35288930 PMCID: PMC8921952 DOI: 10.1002/14651858.cd009569.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This is the second update of a Cochrane Review first published in 2013 and last updated in 2017. Laparoscopic surgery is now widely performed to treat various abdominal diseases. Currently, carbon dioxide is the most frequently used gas for insufflation of the abdominal cavity (pneumoperitoneum). Although carbon dioxide meets most of the requirements for pneumoperitoneum, the absorption of carbon dioxide may be associated with adverse events. Therefore, other gases have been introduced as alternatives to carbon dioxide for establishing pneumoperitoneum. OBJECTIVES To assess the safety, benefits, and harms of different gases (e.g. carbon dioxide, helium, argon, nitrogen, nitrous oxide, and room air) used for establishing pneumoperitoneum in participants undergoing laparoscopic abdominal or gynaecological pelvic surgery. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE, Ovid Embase, four other databases, and three trials registers on 15 October 2021 together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different gases for establishing pneumoperitoneum in participants (irrespective of age, sex, or race) undergoing laparoscopic abdominal or gynaecological pelvic surgery under general anaesthesia. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 10 RCTs, randomising 583 participants, comparing different gases for establishing pneumoperitoneum: nitrous oxide (four trials), helium (five trials), or room air (one trial) was compared to carbon dioxide. All the RCTs were single-centre studies. Four RCTs were conducted in the USA; two in Australia; one in China; one in Finland; one in Iran; and one in the Netherlands. The mean age of the participants ranged from 27.6 years to 49.0 years. Four trials randomised participants to nitrous oxide pneumoperitoneum (132 participants) or carbon dioxide pneumoperitoneum (128 participants). None of the trials was at low risk of bias. The evidence is very uncertain about the effects of nitrous oxide pneumoperitoneum compared to carbon dioxide pneumoperitoneum on cardiopulmonary complications (Peto odds ratio (OR) 2.62, 95% CI 0.78 to 8.85; 3 studies, 204 participants; very low-certainty evidence), or surgical morbidity (Peto OR 1.01, 95% CI 0.14 to 7.31; 3 studies, 207 participants; very low-certainty evidence). There were no serious adverse events related to either nitrous oxide or carbon dioxide pneumoperitoneum (4 studies, 260 participants; very low-certainty evidence). Four trials randomised participants to helium pneumoperitoneum (69 participants) or carbon dioxide pneumoperitoneum (75 participants) and one trial involving 33 participants did not state the number of participants in each group. None of the trials was at low risk of bias. The evidence is very uncertain about the effects of helium pneumoperitoneum compared to carbon dioxide pneumoperitoneum on cardiopulmonary complications (Peto OR 1.66, 95% CI 0.28 to 9.72; 3 studies, 128 participants; very low-certainty evidence), or surgical morbidity (5 studies, 177 participants; very low-certainty evidence). There were three serious adverse events (subcutaneous emphysema) related to helium pneumoperitoneum (3 studies, 128 participants; very low-certainty evidence). One trial randomised participants to room air pneumoperitoneum (70 participants) or carbon dioxide pneumoperitoneum (76 participants). The trial was at high risk of bias. There were no cardiopulmonary complications, serious adverse events, or deaths observed related to either room air or carbon dioxide pneumoperitoneum. AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effects of nitrous oxide, helium, and room air pneumoperitoneum compared to carbon dioxide pneumoperitoneum on any of the primary outcomes, including cardiopulmonary complications, surgical morbidity, and serious adverse events. The safety of nitrous oxide, helium, and room air pneumoperitoneum has yet to be established, especially in people with high anaesthetic risk.
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Affiliation(s)
- Xudong Yang
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Lian Bai
- Department of Gastrointestinal Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Longshuan Zhao
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Panin SI, Nechaj TV, Sazhin AV, Puzikova AV, Linchenko DV, Chechin ER. [Evidence-based medicine of gallstone disease regarding development of national clinical guidelines]. Khirurgiia (Mosk) 2022:85-93. [PMID: 35775849 DOI: 10.17116/hirurgia202207185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To study the Cochrane evidence base of systematic reviews and meta-analyses regarding development of national guidelines for surgical treatment of gallstone disease and its complications. MATERIAL AND METHODS We analyzed the original database involving 35 systematic reviews and meta-analyses of Cochrane Library devoted to gallstone disease and its complications. Methodology of electronic and manual searching of trials was used for identification and screening of information for the period until October 2021. RESULTS There were 430 randomized controlled trials from different countries estimated in 35 systematic reviews of Cochrane Library. At the same time, Russian-language researches are not included in the world's evidence database of biliary tract surgery. Expert groups couldn't perform meta-analysis and limited to systematic-review in 6 (17%) publications because of insufficient statistical power or primary researches. Need for further research of this issue was determined after assessment of 26 (74%) meta-analyses. CONCLUSION We have to convey foreign experience as subbase of national clinical guidelines taking into account deficiency of scientific trials with high level of evidence in our country. Need for further evidence trials, considering the peculiarities of surgical care in the Russian Federation, is determined by unsolved issues of treatment of gallstone disease and its complications.
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Affiliation(s)
- S I Panin
- Volgograd State Medical University, Volgograd, Russia
| | - T V Nechaj
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Puzikova
- Volgograd State Medical University, Volgograd, Russia
| | - D V Linchenko
- Volgograd State Medical University, Volgograd, Russia
| | - E R Chechin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Gin E, Lowen D, Tacey M, Hodgson R. Reduced Laparoscopic Intra-abdominal Pressure During Laparoscopic Cholecystectomy and Its Effect on Post-operative Pain: a Double-Blinded Randomised Control Trial. J Gastrointest Surg 2021; 25:2806-2813. [PMID: 33565010 DOI: 10.1007/s11605-021-04919-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/12/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic surgery is regarded as the gold standard for the surgical management of cholelithiasis. To improve post-operative pain, low-pressure laparoscopic cholecystectomies (LPLC) have been trialed. A recent systematic review found that LPLC reduced pain; however, many of the randomised control trials were at a high risk of bias and the overall quality of evidence was low. METHODS One hundred patients undergoing elective laparoscopic cholecystectomy were randomised to a LPLC (8 mmHg) or a standard pressure laparoscopic cholecystectomy (12 mmHg) (SPLC) with surgeons and anaesthetists blinded to the pressure. Pressures were increased if vision was compromised. Primary outcomes were post-operative pain and analgesia requirements at 4-6 h and 24 h. RESULTS Intra-operative visibility was significantly reduced in LPLC (p<0.01) resulting in a higher number of operations requiring the pressure to be increased (29% vs 8%, p=0.010); however, there were no differences in length of operation or post-operative outcomes. Pain scores were comparable at all time points across all pressures; however, recovery room fentanyl requirement was more than four times higher when comparing 8 to 12 mmHg (12.5mcg vs 60mcg, p=0.047). Nausea and vomiting was also higher when comparing these pressures (0/36 vs 7/60, p=0.033). Interestingly, when surgeons estimated the operating pressure, they were correct in only 69% of cases. CONCLUSION Although pain scores were similar, there was a significant reduction in fentanyl requirement and nausea/vomiting in LPLC. Although LPLC compromised intra-operative visibility requiring increased pressure in some cases, there was no difference in complications, suggesting LPLC is safe and beneficial to attempt in all patients. TRIAL REGISTRATION Registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12619000205134).
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Affiliation(s)
- Elliot Gin
- Department of Surgery, Northern Health, 185 Cooper St, Epping, VIC, Australia
| | - Darren Lowen
- Department of Anaesthetics, Northern Health, Epping, Australia
| | - Mark Tacey
- Department of Research, Northern Health, Epping, Australia.,Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Russell Hodgson
- Department of Surgery, Northern Health, 185 Cooper St, Epping, VIC, Australia. .,Department of Surgery, University of Melbourne, Epping, Australia.
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15
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Saini V, Samra T, Sethi S, Naik BN. Comparative evaluation of optic nerve sheath diameter in patients undergoing laparoscopic cholecystectomy using low and standard pressures of gas insufflations. J Anaesthesiol Clin Pharmacol 2021; 37:616-621. [PMID: 35340969 PMCID: PMC8944363 DOI: 10.4103/joacp.joacp_370_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/07/2019] [Accepted: 02/24/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Intra-abdominal insufflation of CO2 is associated with an increase of intracranial pressure (ICP). We conducted this randomized control trial to compare the impact of low vs standard pressure pneumoperitoneum on ICP through the ultrasonographic estimation of the optic nerve sheath diameter (ONSD). Material and Methods Patients of age group 18-80 years planned for laparoscopic cholecystectomy were randomly allocated into two groups; group S (standard pressure of 12-16 mmHg) and group L (low pressure of 8-10 mmHg) on the basis of intra-abdominal pressures used for the surgery. All were administered general anesthesia and end-tidal carbon dioxide (ETCO2) was maintained between 35 and 40 mmHg and peak airway pressures less than 35 cmH2O. ONSD was measured in either eye at a point 3 mm posterior to the globe at following time intervals; baseline, 5 min after induction, 10 min after insufflation, 10 min after reverse Trendelenburg, intraoperatively during surgery and after exsufflation in the supine position. Results The demographic profile and operative times were comparable. ONSD was measured in 100 patients in each group for both the eyes and no patient had values above the cutoff value of 5.0 mm. No significant difference in the ONSD was observed at the above mentioned time intervals between the groups. There was a statistically significant lower value of the heart rate and mean arterial pressure in the low-pressure group. Conclusion Intra-abdominal insufflation of CO2 at standard and low pressures does not increase ICP in short duration surgeries and thus both the pressures can be safely used in adult patients operated in reverse Trendelenburg position. Advantages of low pressure were limited to better hemodynamic control.
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Affiliation(s)
- Vikas Saini
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Tanvir Samra
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Sameer Sethi
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - B Naveen Naik
- Department of Anesthesia, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
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SELSI Consensus Statement for Safe Cholecystectomy — Prevention and Management of Bile Duct Injury — Part A. Indian J Surg 2021. [DOI: 10.1007/s12262-019-01993-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Chang W, Yoo T, Cho WT, Cho G. Comparing postoperative pain in various pressure pneumoperitoneum of laparoscopic cholecystectomy: a double-blind randomized controlled study. Ann Surg Treat Res 2021; 100:276-281. [PMID: 34012945 PMCID: PMC8103153 DOI: 10.4174/astr.2021.100.5.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/03/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose This study aims to evaluate the effect of different pneumoperitoneum pressures on postoperative pain, especially by subcategorizing the pressures into 3 groups during laparoscopic cholecystectomy (LC). Methods We conducted a prospective randomized, double-blinded study of 150 patients with benign and uncomplicated gallbladder disease. They were categorized into 3 groups. Each group (50 patients) underwent LC with different pneumoperitoneum methods: group VLP, very-low pressure (6–8 mmHg); group LP, low pressure (9–11 mmHg); and group SP, standard pressure (12–14 mmHg). The 3 groups were compared for pain intensity, duration, analgesic requirement, and complications. Results The characteristics of the patients were similar among all groups. Postoperative pain scores at each time point (1, 2, 4, 6, 12, 24, and 48 hours) were not significantly different among the 3 groups. Further, operation time, hospital stay, the number of analgesic consumption doses, and postoperative complications were not significantly different among the 3 groups. Conclusion This study demonstrates no difference in postoperative pain among various pneumoperitoneum pressures during LC. Therefore, routine use of lower-pressure pneumoperitoneum is not recommended unless in selected patients who require low-pressure pneumoperitoneum surgery.
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Affiliation(s)
- Wonbin Chang
- Department of Surgery, Hallym University College of Medicine, Hwaseong, Korea
| | - Tae Yoo
- Department of Surgery, Hallym University College of Medicine, Hwaseong, Korea
| | - Won Tae Cho
- Department of Surgery, Hallym University College of Medicine, Hwaseong, Korea
| | - Giyuon Cho
- Department of Surgery, Hallym University College of Medicine, Hwaseong, Korea
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Modified enhanced recovery after surgery protocol in patients with acute cholecystitis: efficacy, safety and feasibility. Multicenter randomized control study. Updates Surg 2021; 73:1407-1417. [PMID: 33751409 DOI: 10.1007/s13304-021-01031-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
Laparoscopic cholecystectomy (LC) is a common surgical procedure in acute cholecystitis (AC). Patients often suffer from considerable postoperative pain and indigestion, which prolongs in-hospital stay. The enhanced recovery after surgery (ERAS) program has proven its efficacy in elective surgery and could hypothetically improve outcomes of emergency LC. Currently, there is no ERAS program for LC in patients with AC. A modified ERAS (mERAS) protocol was studied in a prospective, randomized non-blinded clinical trial (NCT03754751). The mERAS group consisted of 88 patients the control group of 101 patients. The modified protocol included a patient information brochure; minimizing drain use; local anesthesia; low-pressure pneumoperitoneum; PONV prophylaxis, early mobilization and oral diet. The primary outcome was postoperative length of stay (pLOS). The postoperative length of stay in the mERAS group was shorter (24 (21-45.5) h) than in the control (45 (41-68) h) (p < 0.0001). One re-admission in the mERAS group was reported (p = 0.466). There difference in complications was insignificant (mERAS 6.8% vs 5% p = 0.757). Post-operative pain intensity was significantly lower in the mERAS group immediately after awaking (3.7 ± 1.8 vs 5.4 ± 1.3 p < 0.0001), 2 h (3.3 ± 1.7 vs 4.9 ± 1.6 p = 0.0006), 6 h (2.9 ± 1.5 vs 4.2 ± 1.2 p < 0.0001), 12 h (2.7 ± 0.9 vs 4.1 ± 1.2 p = 0.0001) and 24 h after surgery (2.1 ± 1.2 vs 3 ± 1.2 p < 0.0001). The incidence of shoulder and neck pain was lower in mERAS group (13.6% vs 34.7% p = 0.0009). Peristalsis recovery was similar in both groups. The proposed protocol improved postoperative recovery and reduced hospital stay in patients with AC without increasing the rate of complications or re-admissions.
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Marton Filho MA, Alves RL, do Nascimento P, Tarquinio GDS, Mega PF, Pinheiro Módolo NS. Effects of pneumoperitoneum on kidney injury biomarkers: A randomized clinical trial. PLoS One 2021; 16:e0247088. [PMID: 33606739 PMCID: PMC7895340 DOI: 10.1371/journal.pone.0247088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/29/2021] [Indexed: 01/22/2023] Open
Abstract
Background Increased intra-abdominal pressure causes hemodynamic changes that may affect renal biomarkers. Methods This randomized, single-blind, single-center clinical trial recruited patients undergoing laparoscopic cholecystectomy at a tertiary care center in Brazil. They were randomly allocated to a standard intra-abdominal pressure group (P10-12, 10–12 mm Hg) and a low intra-abdominal pressure group (P6-8, 6–8 mm Hg). The primary outcome was the change in neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C levels measured at the beginning of the procedure (T0), at the end of the procedure (T1), and 24 hours after the procedure (T2). P-values < 0.05 were considered statistically significant. Results In total, 64 patients completed the study—33 were given standard pressure and 31 were given low pressure. There was no significant difference in the biomarker between the groups (P = 0.580), but there was a significant difference between the time points with elevation at T1 (P < 0.001). Similar to NGAL, cystatin C had an elevation at T1 in both groups (P = 0.021), but no difference was found when comparing the groups. Conclusions In laparoscopic cholecystectomy, pneumoperitoneum increases NGAL and cystatin C levels intraoperatively, and the use of low-pressure pneumoperitoneum does not change the course of these biomarkers.
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Affiliation(s)
- Marcos Antonio Marton Filho
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
- Centro Universitário Estácio de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
- * E-mail:
| | - Rodrigo Leal Alves
- Department of Anesthesiology, São Rafael Hospital and Federal University of Bahia, Salvador, Brazil
| | - Paulo do Nascimento
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | | | - Paulo Ferreira Mega
- School of Medicine, Pontifícia Universidade Católica de Campinas (PUC-CAMPINAS), Campinas, São Paulo, Brazil
| | - Norma Sueli Pinheiro Módolo
- Department of Surgical Specialties and Anesthesiology, Botucatu School of Medicine, Universidade Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
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Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial. Surg Laparosc Endosc Percutan Tech 2020; 30:30-34. [PMID: 31425453 DOI: 10.1097/sle.0000000000000719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND/PURPOSE To compare the changes in hepatic enzymes and comfort level of the surgeon in low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPPLC, 7 mm Hg) with that of normal pressure pneumoperitoneum laparoscopic cholecystectomy (NPPLC, 14 mm Hg). METHODS Eighty-two patients were randomly divided into 2 groups (LPPLC and NPPLC). Serum levels of bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and lactate dehydrogenase were measured before the operation, at the time of reversal from anesthesia, 24 hours after the operation, and on day 7. Serious adverse events, intra-operative complications, surgeon's comfort level of dissection, operative time, conversion rates to an open procedure, or normal pressure pneumoperitoneum were recorded. RESULTS Of the 41 patients randomized for LPPLC, 8 patients were converted to NPPLC due to difficulty in dissection and 1 converted to open in each group. There was statistically significant fall in mean serum bilirubin level in both the groups in the immediate postoperative period (P<0.05). Statistically significant increase in its level was observed after 24 hours in the NPPLC group only (P<0.05). Levels of mean serum serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and lactate dehydrogenase increased significantly (P<0.05) in immediate postoperative period and a further increase was observed after 24 hours (P<0.05) in the NPPLC group only. The comfort level of surgeon was found to be significantly better in the NPPLC group. CONCLUSIONS LPPLC is a safe procedure, especially in the hands of an experienced surgeon with clinically insignificant systemic effects. But the comfort level of surgeon is better in normal pressure when compared with low pressure. In patients with deranged hepatic functions undergoing advanced laparoscopic procedures, it is advisable to start the surgery with low-pressure pneumoperitoneum. Pressure may be escalated further as per the surgeon's comfort.
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Balayssac D, Selvy M, Martelin A, Giroudon C, Cabelguenne D, Armoiry X. Clinical and Organizational Impact of the AIRSEAL ® Insufflation System During Laparoscopic Surgery: A Systematic Review. World J Surg 2020; 45:705-718. [PMID: 33258023 DOI: 10.1007/s00268-020-05869-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2020] [Indexed: 01/01/2023]
Abstract
Several low-impact laparoscopic strategies have been developed to improve the safety of pneumoperitoneum. We conducted a systematic review to establish the current evidence base for the use of the AIRSEAL® insufflation device for low-pressure pneumoperitoneum in laparoscopic surgery. We searched the literature using several electronic databases, for studies with comparative design published in the English language from January 2010 to April 2020. The population of interest included patients with any type of health condition who underwent laparoscopic surgery using the AIRSEAL® insufflation system or a standard CO2 insufflator. Ten studies (four randomized clinical trials/six non-randomized clinical trials), that enrolled 1394 participants in total who underwent urology, gynaecology or abdominal surgeries, were included. Total complication rates were similar between groups. Only three studies evaluated the impact of the insufflation system on post-operative pain, and showed inconsistent benefit of AIRSEAL® (significant decrease in pain in two studies, no difference in one). The same was observed in the two sole studies in which pain killers consumption was measured (significant decrease in morphine consumption 24 h after surgery in one study, no difference in the other). Operative duration was significantly shorter with AIRSEAL® in three studies. For both post-operative room and total length of stay, there was no difference between groups. No studies reported economic outcomes. Current literature supports the feasibility of the AIRSEAL® system during laparoscopic surgery but more studies are required to establish the added clinical benefit and to explore the preferences of physicians and patients.
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Affiliation(s)
- David Balayssac
- INSERM, U1107, NEURO-DOL, Université Clermont Auvergne, 63000, Clermont-Ferrand, France. .,Délégation à la Recheche Clinique et à l'Innovation, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France.
| | - Marie Selvy
- INSERM, U1107, NEURO-DOL, Université Clermont Auvergne, 63000, Clermont-Ferrand, France.,Service de Chirurgie Digestive, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Anthony Martelin
- Service Pharmacie, Unité des dispositifs médicaux, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69000, Lyon, France
| | - Caroline Giroudon
- Service de Documentation Centrale, Hospices Civils de Lyon, 69000, Lyon, France
| | - Delphine Cabelguenne
- Service Pharmacie, Unité des dispositifs médicaux, Hospices Civils de Lyon, Hôpital Lyon Sud, 69000, Lyon, France
| | - Xavier Armoiry
- Délégation à la Recheche Clinique et à l'Innovation, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France.,Faculté de Pharmacie (ISPB), UMR CNRS 5510 MATEIS, Université de Lyon, 69000, Lyon, France.,Division of Health Sciences, University of Warwick, Coventry, UK
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22
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Rohloff M, Peifer G, Shakuri-Rad J, Maatman TJ. The impact of low pressure pneumoperitoneum in robotic assisted radical prostatectomy: a prospective, randomized, double blinded trial. World J Urol 2020; 39:2469-2474. [PMID: 33057936 DOI: 10.1007/s00345-020-03486-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP). OBJECTIVE The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP. DESIGN, SETTING AND PARTCIPANTS Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status. RESULTS AND LIMITATIONS A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status. CONCLUSIONS Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and the experienced surgeon may safely perform this operation at 8 mmHg to take advantage of the proposed benefits.
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Affiliation(s)
- Matthew Rohloff
- Department of Urological Surgery, Metro Health: University of Michigan Health, 5900 Byron Center Ave., Wyoming, MI, 49519, USA.
| | - Greggory Peifer
- Department of Urological Surgery, Metro Health: University of Michigan Health, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Jaschar Shakuri-Rad
- Department of Urological Surgery, Metro Health: University of Michigan Health, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
| | - Thomas J Maatman
- Department of Urological Surgery, Metro Health: University of Michigan Health, 5900 Byron Center Ave., Wyoming, MI, 49519, USA
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23
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Luketina R, Luketina TLH, Antoniou SA, Köhler G, Könneker S, Manzenreiter L, Wundsam H, Koch OO, Knauer M, Emmanuel K. Prospective randomized controlled trial on comparison of standard CO 2 pressure pneumoperitoneum insufflator versus AirSeal®. Surg Endosc 2020; 35:3670-3678. [PMID: 32767145 PMCID: PMC7412773 DOI: 10.1007/s00464-020-07846-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022]
Abstract
Background AirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO2 insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO2 insufflators in patients undergoing the most frequently performed laparoscopic procedures. Methods One hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO2 insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien–Dindo grade complications, surgical side effect and length of hospital stay. Results Patients were randomized to either group A (n = 101) or group S (n = 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56–94] in group A vs. 69 min [52–93] in group S; p = 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0–3] in group S vs. 2 [0–4] in group A; p = 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay. Conclusion This randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO2 insufflator for short elective surgeries. ClinicalTrials.gov (NCT01740011).
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Affiliation(s)
- Rosalia Luketina
- Department Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany.
| | - Theodore L H Luketina
- Department of Anaesthesia & Intensive Care Medicine, Cantonal Hospital of Muensterlingen, Muensterlingen, Switzerland
| | - Stavros A Antoniou
- Department of Surgery, School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Gernot Köhler
- Department of General and Visceral Surgery, Congregation Hospital (Sisters of Charity), Ordensklinikum Linz, Austria
| | - Sören Könneker
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hanover, Germany
| | - Lisa Manzenreiter
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Helwig Wundsam
- Department of General and Visceral Surgery, Congregation Hospital (Sisters of Charity), Ordensklinikum Linz, Austria
| | - Oliver Owen Koch
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Michael Knauer
- Breast Center Ostschweiz, Schuppistrasse 10, 9016, St. Gallen, Switzerland
| | - Klaus Emmanuel
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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24
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Xu X, Gong Y, Zhang Y, Lang J, Huang Y. Effect of pneumoperitoneum pressure and the depth of neuromuscular block on renal function in patients with diabetes undergoing laparoscopic pelvic surgery: study protocol for a double-blinded 2 × 2 factorial randomized controlled trial. Trials 2020; 21:585. [PMID: 32600358 PMCID: PMC7322917 DOI: 10.1186/s13063-020-04477-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/31/2020] [Indexed: 01/06/2023] Open
Abstract
Background Patients with diabetes mellitus are at a high risk of developing postoperative acute kidney injury. For patients receiving laparoscopic surgery, standard-pressure pneumoperitoneum (SPP) currently applied in clinical practice also undermines renal perfusion. Several studies have shown that low-pressure pneumoperitoneum (LPP) might reduce pressure-related ischemic renal injury. However, LPP may compromise the view of the surgical field. Previous studies have indicated that deep neuromuscular blockade (NMB) can ameliorate this issue. However, the conclusion is still uncertain. The hypothesis of this study is that the joint use of LPP and deep NMB can reduce perioperative renal injury in diabetic patients undergoing laparoscopic pelvic surgery without impeding the view of the surgical field. Methods This is a double-blinded, randomized controlled trial using a 2 × 2 factorial trial design. A total of 648 diabetes patients scheduled for major laparoscopic pelvic surgeries at Peking Union Medical College Hospital will be randomized into the following four groups: SPP (12–15 mmHg) + deep-NMB (post-tetanic count of 1–2) group, LPP (7–10 mmHg) + deep-NMB group, SPP + moderate-NMB (train-of-four of 1–2) group, and LPP + moderate-NMB group. The primary outcome is serum cystatin C level measured before insufflation, after deflation, 24 h postoperatively, and 72 h postoperatively. The secondary outcomes are serum creatinine level, intraoperative urine output, erythrocytes in urinary sediment, renal tissue oxygen saturation, Leiden’s surgical condition rating scale, surgery duration, and occurrence of bucking or body movement. Discussion This study will provide evidence for the effect of LPP on renal function protection in patients with diabetes undergoing laparoscopic pelvic surgery. The trial can also help us to understand whether deep NMB can improve surgical conditions. Trial registration ClinicalTrials.gov: NCT04259112. Prospectively registered on 5 February 2020.
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Affiliation(s)
- Xiaohan Xu
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yahong Gong
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Yuelun Zhang
- Department of Medical Research Center, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, 100730, China
| | - Jiaxin Lang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yuguang Huang
- Department of Anesthesiology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, 100730, China
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25
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Foley CE, Ryan E, Huang JQ. Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery. J Robot Surg 2020; 15:299-307. [PMID: 32572753 DOI: 10.1007/s11701-020-01104-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023]
Abstract
The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ2 test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317 min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10 mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.
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Affiliation(s)
- Christine E Foley
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA. .,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Magee-Womens Hospital, 300 Halket Street, Suite 2300, Pittsburgh, PA, 15213, USA.
| | - Erika Ryan
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - Jian Qun Huang
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
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26
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Turhanoğlu S, Tunç M, Okşar M, Temiz M. Perioperative Effects of Induction with High-dose Rocuronium during Laparoscopic Cholecystectomy. Turk J Anaesthesiol Reanim 2020; 48:188-195. [PMID: 32551445 PMCID: PMC7279866 DOI: 10.5152/tjar.2019.31855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/20/2019] [Indexed: 12/02/2022] Open
Abstract
Objective We aimed to investigate the effects of high-dose rocuronium administration on intra-abdominal pressure (IAP) and surgical conditions during anaesthesia induction and laparoscopic cholecystectomy anaesthesia induction, respectively. Further, we aimed to determine postoperative nausea and vomiting (PONV) and pain scores following the laparoscopic cholecystectomy. Methods Patients with American Society of Anesthesiologists (ASA) score of I–III, aged 18 to 75 years and who were scheduled for surgery under general anaesthesia were included in the study. Patients were randomised and a high-dose of 1.2 mg kg−1 rocuronium was given to Group A and 0.6 mg kg−1 rocuronium to Group B. The intraoperative train of four (TOF) ratio and post-tetanic count (PTC) were measured. Surgery was initiated with a low IAP of 7 mmHg. The surgeon evaluated surgical conditions with a 4-step surgical field scale and increased the IAP when necessary. PONV at 4, 12 and 24 hours and postoperative pain at 2 and 24 hours and 3 days were evaluated. Results There were no significant differences in the demographic and haemodynamic parameters between the groups. In high-dose rocuronium Group A, IAP values were significantly lower in the first 20 minutes compared to Group B. The duration of operations was significantly shorter in Group A (29.00±7.39 minute vs. 34.63±12.00 minute, p=0.044). PONV in the first 12 hours was significantly lower in Group A (p<0.05). Conclusion High-dose rocuronium-induced deep neuromuscular block helped perform laparoscopic cholecystectomy operations with lower values of IAP compared to a normal dose rocuronium. It also shortened duration of operation and reduced PONV and pain.
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Affiliation(s)
- Selim Turhanoğlu
- Department of Anaesthesiology and Intensive Care, Hatay Mustafa Kemal University School of Medicine, Hatay, Turkey
| | - Mehmet Tunç
- Department of Anaesthesiology and Intensive Care, Hatay Mustafa Kemal University School of Medicine, Hatay, Turkey
| | - Menekşe Okşar
- Department of Anaesthesiology and Intensive Care, Hatay Mustafa Kemal University School of Medicine, Hatay, Turkey
| | - Muhyittin Temiz
- Department of General Surgery, Hatay Mustafa Kemal University School of Medicine, Hatay, Turkey
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Raval AD, Deshpande S, Koufopoulou M, Rabar S, Neupane B, Iheanacho I, Bash LD, Horrow J, Fuchs-Buder T. The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials. Surg Endosc 2020; 34:2878-2890. [PMID: 32253560 PMCID: PMC7270984 DOI: 10.1007/s00464-020-07527-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
Background Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. Methods An electronic database search was performed to identify randomized controlled trials (RCTs) that compared outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. A Bayesian network meta-analysis (NMA) was used to conduct pairwise meta-analyses and indirect treatment comparisons of the levels of IAP assessed across trials. Results The SLR and NMA included 22 studies. Compared with standard IAP, on a scale of 0 (no pain at all) to 10 (worst imaginable pain), low IAP was associated with significantly lower overall pain scores at 24 h (mean difference [MD]: − 0.70; 95% credible interval [CrI]: − 1.26, − 0.13) and reduced risk of shoulder pain 24 h (odds ratio [OR] 0.24; 95% CrI 0.12, 0.48) and 72 h post-surgery (OR 0.22; 95% CrI 0.07, 0.65). Hospital stay was shorter with low IAP (MD: − 0.14 days; 95% CrI − 0.30, − 0.01). High IAP was not associated with a significant difference for these outcomes when compared with standard or low IAP. No significant differences were found between the IAP levels regarding need for conversion to open surgery; post-operative acute bleeding, pain at 72 h, nausea, and vomiting; and duration of surgery. Conclusions Our study of published trials indicates that using low, as opposed to standard, IAP during laparoscopic cholecystectomy may reduce patients’ post-operative pain, including shoulder pain, and length of hospital stay. Heterogeneity in the pooled estimates and high risk of bias of the included trials suggest the need for high-quality, adequately powered RCTs to confirm these findings. Electronic supplementary material The online version of this article (10.1007/s00464-020-07527-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amit D Raval
- Center for Observational and Real-World Evidence, Merck & Co., Inc, Kenilworth, NJ, USA
| | - Sohan Deshpande
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Maria Koufopoulou
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Silvia Rabar
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Binod Neupane
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, Montreal, Canada
| | - Ike Iheanacho
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Lori D Bash
- Center for Observational and Real-World Evidence, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | - Thomas Fuchs-Buder
- Department of Anesthesiology & Critical Care, Brabois University Hospital, University de Lorraine, CHRU Nancy, 7 allée du Morvan, 54511, Vandoeuvre-les-Nancy, France.
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28
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Abstract
Neuromuscular blockade (TOF count = 0) can improve tracheal intubation and microlaryngeal surgery. It is also frequently used in many surgical fields including both nonlaparoscopic and laparoscopic surgery to improve surgical conditions and to prevent sudden muscle contractions. Currently there is a controversy regarding the need and the clinical benefits of deep neuromuscular blockade for different surgical procedures. Deep neuromuscular relaxation improves laparoscopic surgical space conditions only marginally when using low intra-abdominal pressure. There is no outcome-relevant advantage of low compared to higher intra-abdominal pressures, but worsen the surgical conditions. Postoperative, residual curarisation can be avoided by algorithm-based pharmacological reversing and quantitative neuromuscular monitoring.
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Affiliation(s)
- C Unterbuchner
- Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Universität Regensburg, Franz-Josef-Strauß-Allee 11, 93051, Regensburg, Deutschland.
| | - M Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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Optimising Surgical Technique in Laparoscopic Cholecystectomy: a Review of Intraoperative Interventions. J Gastrointest Surg 2019; 23:1925-1932. [PMID: 31240555 DOI: 10.1007/s11605-019-04296-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is one of the most commonly performed procedures worldwide but there is considerable variance amongst surgeons regarding intraoperative technique. This review aims to provide a comprehensive summary, with evidence-based recommendations, of intraoperative interventions in LC. METHODS A literature search was performed using PubMed, EMBASE, Google Scholar and Cochrane Review databases. Articles were screened for eligibility with inclusion criteria based on study design, surgical approach, surgical timing, pathology and intervention type. The most contemporary, comprehensive or relevant articles were used as the primary evidence for the final analysis and discussion. RESULTS A total of 25 systematic reviews and/or meta-analyses and 19 individual trials were identified from the literature and grouped into ten clinical intervention topics. Three intraoperative interventions offer clinical benefit and are recommended: wound/intraperitoneal local anaesthetic, low-pressure pneumoperitoneum and manoeuvres to reduce residual pneumoperitoneum. No benefit was demonstrated for routine subhepatic drain placement and gallbladder aspiration. Techniques which appear to demonstrate improvements but do not translate into clinical efficacy are the use of warmed/humidified carbon dioxide, installation of intraperitoneal saline and the use of advanced imaging techniques. Techniques demonstrating equipoise, and for which no recommendations can be made, are type of energy source and cystic duct occlusion methods. DISCUSSION This review highlights and suggests specific intraoperative techniques during uncomplicated LC that should be employed, avoided or considered by the individual surgeon. Optimising surgical technique in this way can lead to improved patient outcomes.
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Sazhin AV, Nechay TV, Titkova SM, Tyagunov AE, Anurov MV, Melnikov-Makarchuk KY, Tyagunov AA, Ermakov IV, Glagolev NS, Kurashinova LS, Ivanova EA, Nechay VS, Karpov AV, Mirzoyan AT, Ivakhov GB, Balakirev YS. [Comparison of standard and fast track rehabilitation in patients with acute appendicitis. Intermediate results of multicenter prospective randomized trial]. Khirurgiia (Mosk) 2019:15-23. [PMID: 30307416 DOI: 10.17116/hirurgia2018090115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To analyze outcomes of fast track rehabilitation in patients with acute appendicitis. MATERIAL AND METHODS Prospective, randomized multi-center trial including 86 patients was conducted. There were 38 patients in the main group and 48 in the control group. All patients underwent laparoscopic appendectomy under endotracheal anesthesia. Protocol included informing, no premedication, glucose infusion prior to surgery, antibiotics administration, mesoappendix excision, limited deployment of drainage tubes, intraabdominal prolonged anesthesia, minimal pneumoperitoneum, limited irrigation, minimum power monopolar electrocautery, antiemetics, early activation and eating (2 and 6 hours after surgery). Pain was evaluated by visual-analogue scale. Auscultative peristalsis was considered every 2 hours after surgery. Cortisol level was assessed preoperatively, in 6 and 12-24 hours after surgery in 11 (29%) and 15 (31%) patients of the main and control groups respectively. Discharge criteria: no leukocytosis, fever and pain syndrome requiring anesthesia, no signs of complications and patient's consent. RESULTS Terms of disease, gender, age and comorbidities were similar in all patients. Duration of surgery under minimal pneumoperitoneum and standard pressure was also similar: 69.2±3.98 and 70.9±3.89 min (p=0.762). Pain syndrome grade and need for analgesics were significantly lower in the main group within entire follow-up. Pain syndrome was absent at the 1st postoperative day in 16 (42%) and 2 (4.1%) patients of both groups, respectively (score 0-1). Phrenic nerve syndrome was observed in 36.8% of the main group and 60.4% of the control group (p=0.05). Incidence of dyspepsia and terms of peristalsis onset were similar. Length of hospital-stay was 1.45 days in the main group and 3.15 days in the control group (p=0.002). In the main group 18 (47%) patients were discharged on the first day after surgery. There were only 4 (8.3%) patients with similar hospital-stay in the control group (p<0.001). There were no repeated hospitalizations. Postoperative cortisol concentration was similar in both groups as well as in complicated and uneventful postoperative period. In the main group postoperative intestinal paresis (Clavien-Dindo grade 2) occurred in 1 patient. In the control group 7 patients had postoperative infiltrate and 1 patient - intestinal paresis (Clavien-Dindo grade 2). Postoperative drainage tube was deployed in 3 out of 7 patients with postoperative infiltrates and 6 of them received antibiotic therapy. Medication was successfully applied in all patients with complications. CONCLUSION There are some advantages of FTR for AA including reduced pain syndrome, morbidity and less length of hospital-stay. Issue of cortisol concentration requires further trials.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - M V Anurov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K Yu Melnikov-Makarchuk
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - A A Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - N S Glagolev
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - L S Kurashinova
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - E A Ivanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V S Nechay
- Medical Institute of Tula State University
| | - A V Karpov
- Moscow Clinical Hospital #4, Moscow, Russia
| | - A T Mirzoyan
- City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - G B Ivakhov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - Yu S Balakirev
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
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Sazhin AV, Nechay TV, Titkova SM, Anurov MV, Tyagunov AE, Balakirev YS, Ermakov IV, Tyagunov AA, Melnikov-Makarchuk KY, Glagolev NS, Mirzoyan AT, Kurashinova LS, Kolygin AV, Nechay VS, Ivanova EA, Ivakhov GB, Mosin SV. [Fast-track rehabilitation for acute cholecystitis: intermediate outcomes of prospective randomized trial]. Khirurgiia (Mosk) 2019:13-20. [PMID: 30560840 DOI: 10.17116/hirurgia201812113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze an efficacy of FT-protocol in patients with acute cholecystitis. MATERIAL AND METHODS Prospective randomized study included 102 patients (45 of main group (FT) and 57 of control groups). Patients did not differ by TG13 severity index. The protocol included information, antibiotic prophylaxis, restriction of drainage, intraperitoneal anesthesia with long-term anesthetics, low pressure pneumoperitoneum, antiemetics in the presence of risk factors, early activation and feeding of the patient. Pain was assessed by VAS immediately after surgery, and 2, 6 and 12-24 hours postoperatively. RESULTS Surgery time was similar in both groups. Need for anesthesia and pain severity were significantly lower in the FT group. A total absence of pain (VAS 0-1) on the 1st postoperative day was noted in 8 (17.7%) of the FT group and 2 (3.5%) patients of the control group (p=0.038). Shoulder pain developed in 4 (8.9%) cases of the main and 22 (38.6%) cases of the control group (p=0.001). Postoperative nausea developed in 13% of the FT group vs 40.5% in the control group (p=0.05). Hospital-stay was 1.29±0.7 days and 2.7±1.6 (p<0.0001), respectively. The time of the first stool was similar. Twenty-four (53.5%) patients of the FT group and 8,9% of the control group were discharged on 1st postoperative day. There were 2 (IIIA) complications in the main group and 3 - in the control group (IIIA, IIIB and IV). There were no mortality and readmissions. CONCLUSION FT protocol in AC reduce postoperative pain, dyspepsia, shoulder pain and in-hospital stay with equal number of postoperative complications.
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Affiliation(s)
- A V Sazhin
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Pirogov City Clinical Hospital #1, Moscow, Russia
| | - T V Nechay
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Pirogov City Clinical Hospital #1, Moscow, Russia
| | - S M Titkova
- Depatment of experimental surgery research institute of translational medicine Pirogov Russian National Research Medical University, Moscow, Russia
| | - M V Anurov
- Depatment of experimental surgery research institute of translational medicine Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Tyagunov
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia
| | - Yu S Balakirev
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Pirogov City Clinical Hospital #1, Moscow, Russia
| | - I V Ermakov
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Bauman City Clinical Hospital #29, Moscow, Russia
| | - A A Tyagunov
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Pirogov City Clinical Hospital #1, Moscow, Russia
| | - K Yu Melnikov-Makarchuk
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Bauman City Clinical Hospital #29, Moscow, Russia
| | - N S Glagolev
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Bauman City Clinical Hospital #29, Moscow, Russia
| | - A T Mirzoyan
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Bauman City Clinical Hospital #29, Moscow, Russia
| | - L S Kurashinova
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Bauman City Clinical Hospital #29, Moscow, Russia
| | - A V Kolygin
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Bauman City Clinical Hospital #29, Moscow, Russia
| | - V S Nechay
- Tul'skaya Region Clinical Hospital, Tula, Russia
| | - E A Ivanova
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia
| | - G B Ivakhov
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia; Pirogov City Clinical Hospital #1, Moscow, Russia
| | - S V Mosin
- Chair of Faculty-Based Surgery #1 of the Faculty of Medicine Pirogov Russian National Research Medical University, Moscow, Russia
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Mulier JP, Dillemans B. Anaesthetic Factors Affecting Outcome After Bariatric Surgery, a Retrospective Levelled Regression Analysis. Obes Surg 2019; 29:1841-1850. [DOI: 10.1007/s11695-019-03763-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Reduction in postoperative ileus rates utilizing lower pressure pneumoperitoneum in robotic-assisted radical prostatectomy. J Robot Surg 2019; 13:671-674. [PMID: 30604275 DOI: 10.1007/s11701-018-00915-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/13/2018] [Indexed: 12/12/2022]
Abstract
Robotic-assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer. This is a study comparing differences in postoperative outcomes between pneumoperitoneum pressures of 15 mmHg and 12 mmHg. Retrospective chart review was performed on 400 patients undergoing RARP over a 5 year period. A combination of Fisher's exact test and ANOVA were utilized for statistical analysis. Age, BMI, Gleason score, positive margin rate, complication rates, blood loss, and operative times were similar in both groups. Length of stay and postoperative ileus rates were significantly less in the 12 mmHg group (p < 0.05). RARP can be safely performed utilizing a lower pressure pneumoperitoneum. Decreasing insufflation pressures from 15 to 12 mmHg can further lead to decreased rates of postoperative ileus.
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Laučytė-Cibulskienė A, Miglinas M, Želvys A, Čekauskas A. Successful laparoscopic living donor nephrectomy: first experience in Lithuania. Acta Med Litu 2019; 26:140-146. [PMID: 31632189 PMCID: PMC6779470 DOI: 10.6001/actamedica.v26i2.4035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/14/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The aim of this paper is to share the initial results of LLDN in high-volume university centre that is performing laparoscopic nephrectomies for other indications. MATERIALS AND METHODS During 2017, four LLDNs were performed. The transperitoneal approach was used in all cases and the kidney was removed using a suprapubic incision. All donors and recipients were prospectively analysed within six-month follow-up. The patients' clinical, laboratory, and operation-related data were collected from direct interviews with them and from medical records. All patients signed written informed consent. RESULTS One male and three females donated their left kidneys by using the LLDN technique. The mean age was 58 ± 9 years; two of them with a history of previous cholecystectomy. All donated kidneys had a single renal artery and renal vein. Pre-operative average eGFR was 94.2 ± 7.1 ml/min/1.73 m2, immediately after LLDN 57.5 ± 10.3 ml/min/1.73 m2, after one month 56.0 ± 9.1 ml/min/1.73 m2. There were no intraoperative complications; surgery duration was 223.75 ± 21.74 min, the cold ischemia time was 77.5 ± 28.77 min, and the warm ischemia time 6.37 ± 3.14 min. There was one postoperative donor complication, one case of acute kidney injury, and one case of prolonged postoperative abdominal pain. The only recipient complication was one case of acute kidney rejection; there were no cases of delayed graft function. CONCLUSIONS Our initial experience confirms that LLDN is an approach that is easy to learn, especially in a high-volume university hospital with expertise in performing laparoscopic nephrectomies for other indications.
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Affiliation(s)
- Agnė Laučytė-Cibulskienė
- Clinic of Gastronenterology, Nephrourology, and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Bruintjes MH, Albers KI, Gurusamy KS, Rovers MM, van Laarhoven CJHM, Warle MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Hippokratia 2018. [DOI: 10.1002/14651858.cd013197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Moira H Bruintjes
- Radboud University Nijmegen Medical Center; Department of Surgery; Geert Grooteplein Zuid 10 Nijmegen Netherlands 6525 GA
| | - Kim I Albers
- Radboud University Nijmegen Medical Centre; Department of Anesthesiology; Nijmegen Netherlands
| | - Kurinchi Selvan Gurusamy
- University College London; Division of Surgery and Interventional Science; 9th Floor, Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Maroeska M Rovers
- Radboud University Nijmegen Medical Centre; Department of Operating Rooms; Hp 630, route 631 PO Box 9101 Nijmegen Netherlands 6500 HB
| | - Cornelis JHM van Laarhoven
- Radboud University Nijmegen Medical Centre; Department of Surgery; PO Box 9101 internal code 618 Nijmegen Netherlands 6500 HB
| | - Michiel C Warle
- Radboud University Nijmegen Medical Center; Department of Surgery; Geert Grooteplein Zuid 10 Nijmegen Netherlands 6525 GA
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Zhang J, Wang Y, Xu H, Yang J. Influence of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2018; 97:e12747. [PMID: 30407279 PMCID: PMC6250549 DOI: 10.1097/md.0000000000012747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/16/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The impact of magnesium sulfate on hemodynamic responses during laparoscopic cholecystectomy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of magnesium sulfate on hemodynamic responses for laparoscopic cholecystectomy. METHODS We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2018 for randomized controlled trials (RCTs) assessing the effect of magnesium sulfate on hemodynamic responses for laparoscopic cholecystectomy. Meta-analysis is performed using the random-effect model. RESULTS Four RCTs involving 208 patients are included in the meta-analysis. Overall, compared with control group in laparoscopic cholecystectomy, intravenous magnesium sulfate is associated with systolic blood pressure at 30 minutes [Std. MD = -1.34; 95% confidence interval (95% CI) = -1.86 to -0.82; P < .00001], diastolic blood pressure at 30 minutes (Std. MD = -1.40; 95% CI = -1.86 to -0.94; P < .00001), mean arterial pressure at 30 minutes (Std. MD = -1.19; 95% CI = -1.91 to -0.46; P = .001), systolic blood pressure at 10 minutes (Std. MD = -1.61; 95% CI = -2.08 to -1.13; P < .00001), diastolic blood pressure at 10 minutes (Std. MD = -1.54; 95% CI = -2.68 to -0.40; P = .008), heart rate at 30 minutes (Std. MD = -2.09; 95% CI = -2.87 to -1.32; P < .00001), but results in prolonged extubation time (Std. MD = 0.96; 95% CI = 0.18-1.74; P = .02). CONCLUSION Magnesium sulfate can reduce blood pressure, but with the increase in extubation time for laparoscopic cholecystectomy.
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De Robertis E, Caprino Miceli A, Colombo GL, Corcione A, Leykin Y, Scudeller L, Vizza E, Scollo P. Effects of Deep Versus Moderate Neuromuscular Blockade in Laparoscopic Gynecologic Surgery on Postoperative Pain and Surgical Conditions: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e131. [PMID: 29986847 PMCID: PMC6056743 DOI: 10.2196/resprot.9277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/28/2018] [Accepted: 02/28/2018] [Indexed: 11/24/2022] Open
Abstract
Background Postoperative pain, especially shoulder pain, is commonly reported after laparoscopic gynecologic procedures. Some studies suggest that a lower insufflation pressure may reduce the risk of postoperative pain; however, there is no agreement on the optimal pneumoperitoneum pressure during gynecologic laparoscopic surgery or whether lower pressure would lead to clinically significant improvements without increasing operative complications. Questions remain regarding the clinical significance of improvements, safety, and cost-effectiveness of deep neuromuscular blockade with low-pressure pneumoperitoneum. Objective The primary objective of this study was to assess the superiority of anesthesia with deep neuromuscular blockade with pneumoperitoneum 8 mm Hg over moderate blockade with pneumoperitoneum 12 mm Hg in terms of overall pain 24 hours after surgery in adult women undergoing pelvic surgery for hysterectomy or benign adnexal diseases. Effects on the intensity and timing of postoperative pain in specific locations, surgeon satisfaction, respiratory and hemodynamic stability, operating times, and direct and indirect costs will be assessed. Methods In this multicenter, randomized controlled trial with a superiority design, 300 patients will be randomly allocated in the ratio 1:1 to moderate neuromuscular blockade with a target insufflation pressure of 12 mm Hg or deep neuromuscular blockade with a target insufflation pressure of 8 mm Hg, with stratification by type of surgery and clinical center. The patient, the statistician, and the nurse who will assess the primary endpoint will be blinded to the allocation. Results Recruitment to this trial is expected to open in June 2018 and is expected to close in June 2019. Conclusions This study is designed to confirm the reported benefits of postoperative pain and provide additional data needed to address questions regarding the effects of this intervention on operating theater management and direct and indirect costs. Strengths of this protocol include the large sample size distributed among diverse institutions across the Italian territory and the collection and analysis of data on numerous secondary objectives. Limitations include the possible introduction of bias because the surgeon and anesthesiologist are not blinded to the intervention. Registered Report Identifier RR1-10.2196/9277
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Affiliation(s)
- Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Section of Anaesthesia and Intensive Care Medicine, University Federico II, Naples, Italy
| | | | - Giorgio L Colombo
- Department of Drug Sciences, School of Pharmacy, University of Pavia, Italy, Milan, Italy.,Studi Analisi Valutazioni Economiche, Milan, Italy
| | - Antonio Corcione
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Napoli, Italy
| | - Yigal Leykin
- Anesthesia and Intensive Care, Azienda per l'Assistenza Sanitaria n. 5 - Friuli Occidentale, Pordenone, Italy
| | - Luigia Scudeller
- Scientific Direction, Clinical Epidemiology Unit, IRCCS San Matteo Foundation, Pavia, Italy
| | - Enrico Vizza
- Gynecologic Oncology, Regina Elena Hospital, Rome, Italy
| | - Paolo Scollo
- Maternity and Early Childhood Department, Gynecology and Obstetrics, Cannizzaro Hospital, Catania, Italy
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Cho YJ, Paik H, Jeong SY, Park JW, Jo WY, Jeon Y, Lee KH, Seo JH. Lower intra-abdominal pressure has no cardiopulmonary benefits during laparoscopic colorectal surgery: a double-blind, randomized controlled trial. Surg Endosc 2018; 32:4533-4542. [DOI: 10.1007/s00464-018-6204-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 05/09/2018] [Indexed: 12/19/2022]
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Fülesdi B, Asztalos L, Tassonyi E. Deep Neuromuscular Block Facilitates Laparoscopic Surgery- or Probably Does Not? Turk J Anaesthesiol Reanim 2018; 46:73-74. [PMID: 29744238 DOI: 10.5152/tjar.2018.220318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - László Asztalos
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Edömér Tassonyi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
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Unterbuchner C. Is Deep Neuromuscular Relaxation Beneficial in Laparoscopic, Abdominal Surgery? Turk J Anaesthesiol Reanim 2018; 46:81-85. [PMID: 29744240 PMCID: PMC5937468 DOI: 10.5152/tjar.2018.090418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Christoph Unterbuchner
- Department of Anesthesiology, University Medical Centre Regensburg Franz-Josef-Strauss-Allee 11 93053 Regensburg, Germany
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Fülesdi B, Asztalos L, Tassonyi E. Does Deep Neuromuscular Block Facilitate Laparoscopic Surgery? The Picture is Not Clear. Turk J Anaesthesiol Reanim 2018; 46:86-87. [PMID: 29744241 DOI: 10.5152/tjar.2018.060418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - László Asztalos
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Edömér Tassonyi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
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Erector Spinae Plane Block for Elective Laparoscopic Cholecystectomy in the Ambulatory Surgical Setting. Case Rep Anesthesiol 2018; 2018:5492527. [PMID: 29805812 PMCID: PMC5899876 DOI: 10.1155/2018/5492527] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/22/2018] [Accepted: 02/28/2018] [Indexed: 12/23/2022] Open
Abstract
Postoperative pain after laparoscopic cholecystectomy can be severe. Despite multimodal analgesia regimes, administration of high doses of opioids is often necessary. This can further lead to several adverse effects such as drowsiness and respiratory impairment as well as postoperative nausea and vomiting. This will hinder early mobilization and discharge of the patient from the day surgery setting and is suboptimal in an Early Recovery after Surgery setting. The ultrasound-guided Erector Spinae Plane (ESP) block is a novel truncal interfascial block technique providing analgesia of the thoracic or abdominal segmental innervation depending on the level of administration. Local anesthetic penetrates anteriorly presumably through the costotransverse foramina to the paravertebral space. We demonstrate the analgesic efficacy of the ESP block in a case series of three patients scheduled for ambulatory laparoscopic cholecystectomy.
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Schietroma M, Colozzi S, Pessia B, Carlei F, Di Furia M, Amicucci G. Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial. J Minim Access Surg 2018; 14:221-229. [PMID: 29582795 PMCID: PMC6001299 DOI: 10.4103/jmas.jmas_120_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF). Materials and Methods Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated. Results A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO2group patients in comparison with the 80% FiO2group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2group; no changes were noted in 80% FiO2group (P < 0.05). Conclusions This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.
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Affiliation(s)
| | - Sara Colozzi
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | - Beatrice Pessia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
| | | | - Marino Di Furia
- Department of Surgery, University of L'Aquila, L'Aquila, Italy
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de’Angelis N, Abdalla S, Carra MC, Lizzi V, Martínez-Pérez A, Habibi A, Bartolucci P, Galactéros F, Laurent A, Brunetti F. Low-impact laparoscopic cholecystectomy is associated with decreased postoperative morbidity in patients with sickle cell disease. Surg Endosc 2017; 32:2300-2311. [PMID: 29098436 DOI: 10.1007/s00464-017-5925-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 10/08/2017] [Indexed: 01/05/2023]
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Effects of low intraperitoneal pressure and a warmed, humidified carbon dioxide gas in laparoscopic surgery: a randomized clinical trial. Sci Rep 2017; 7:11287. [PMID: 28900123 PMCID: PMC5595842 DOI: 10.1038/s41598-017-10769-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/14/2017] [Indexed: 12/29/2022] Open
Abstract
Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2 × 2 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8 mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12 mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CD gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12 hours and 0.06 (95% CI: 0.01, 0.26) at 24 hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0 hours and 0.29 (95% CI: 0.10, 0.79) at 12 hours in the WH gas group versus the CD gas group.
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Comment on Rosenberg J, et al.: "Deep Neuromuscular Blockade Improves Laparoscopic Surgical Conditions: A Randomized, Controlled Study". Adv Ther 2017. [PMID: 28631215 PMCID: PMC5504217 DOI: 10.1007/s12325-017-0574-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yu T, Cheng Y, Wang X, Tu B, Cheng N, Gong J, Bai L. Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery. Cochrane Database Syst Rev 2017; 6:CD009569. [PMID: 28635028 PMCID: PMC6481852 DOI: 10.1002/14651858.cd009569.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This is an update of the review published in 2013.Laparoscopic surgery is now widely performed to treat various abdominal diseases. Currently, carbon dioxide is the most frequently used gas for insufflation of the abdominal cavity (pneumoperitoneum). Although carbon dioxide meets most of the requirements for pneumoperitoneum, the absorption of carbon dioxide may be associated with adverse events. People with high anaesthetic risk are more likely to experience cardiopulmonary complications and adverse events, for example hypercapnia and acidosis, which has to be avoided by hyperventilation. Therefore, other gases have been introduced as alternatives to carbon dioxide for establishing pneumoperitoneum. OBJECTIVES To assess the safety, benefits, and harms of different gases (i.e. carbon dioxide, helium, argon, nitrogen, nitrous oxide, and room air) used for establishing pneumoperitoneum in participants undergoing laparoscopic general abdominal or gynaecological pelvic surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 9), Ovid MEDLINE (1950 to September 2016), Ovid Embase (1974 to September 2016), Science Citation Index Expanded (1970 to September 2016), Chinese Biomedical Literature Database (CBM) (1978 to September 2016), ClinicalTrials.gov (September 2016), and World Health Organization International Clinical Trials Registry Platform (September 2016). SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different gases for establishing pneumoperitoneum in participants (irrespective of age, sex, or race) undergoing laparoscopic abdominal or gynaecological pelvic surgery under general anaesthesia. DATA COLLECTION AND ANALYSIS Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated risk ratio (RR) for dichotomous outcomes (or Peto odds ratio for very rare outcomes), and mean difference (MD) or standardised mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI). We used GRADE to rate the quality of evidence, MAIN RESULTS: We included nine RCTs, randomising 519 participants, comparing different gases for establishing pneumoperitoneum: nitrous oxide (three trials), helium (five trials), or room air (one trial) was compared to carbon dioxide. Three trials randomised participants to nitrous oxide pneumoperitoneum (100 participants) or carbon dioxide pneumoperitoneum (96 participants). None of the trials was at low risk of bias. There was insufficient evidence to determine the effects of nitrous oxide and carbon dioxide on cardiopulmonary complications (RR 2.00, 95% CI 0.38 to 10.43; two studies; 140 participants; very low quality of evidence), or surgical morbidity (RR 1.01, 95% CI 0.18 to 5.71; two studies; 143 participants; very low quality of evidence). There were no serious adverse events related to either nitrous oxide or carbon dioxide pneumoperitoneum (three studies; 196 participants; very low quality of evidence). We could not combine data from two trials (140 participants) which individually showed lower pain scores (a difference of about one visual analogue score on a scale of 1 to 10 with lower numbers indicating less pain) with nitrous oxide pneumoperitoneum at various time points on the first postoperative day, and this was rated asvery low quality .Four trials randomised participants to helium pneumoperitoneum (69 participants) or carbon dioxide pneumoperitoneum (75 participants) and one trial involving 33 participants did not state the number of participants in each group. None of the trials was at low risk of bias. There was insufficient evidence to determine the effects of helium or carbon dioxide on cardiopulmonary complications (RR 1.46, 95% CI 0.35 to 6.12; three studies; 128 participants; very low quality of evidence) or pain scores (visual analogue score on a scale of 1 to 10 with lower numbers indicating less pain; MD 0.49 cm, 95% CI -0.28 to 1.26; two studies; 108 participants; very low quality of evidence). There were three serious adverse events (subcutaneous emphysema) related to helium pneumoperitoneum (three studies; 128 participants; very low quality of evidence).One trial randomised participants to room air pneumoperitoneum (70 participants) or carbon dioxide pneumoperitoneum (76 participants). The trial was at unclear risk of bias. There were no cardiopulmonary complications or serious adverse events observed related to either room air or carbon dioxide pneumoperitoneum (both outcomes very low quality of evidence). The evidence of lower hospital costs and reduced pain during the first postoperative day with room air pneumoperitoneum compared with carbon dioxide pneumoperitoneum (a difference of about one visual analogue score on a scale of 1 to 10 with lower numbers indicating less pain, was rated as very low quality of evidence. AUTHORS' CONCLUSIONS The quality of the current evidence is very low. The effects of nitrous oxide and helium pneumoperitoneum compared with carbon dioxide pneumoperitoneum are uncertain. Evidence from one trial of small sample size suggests that room air pneumoperitoneum may decrease hospital costs in people undergoing laparoscopic abdominal surgery. The safety of nitrous oxide, helium, and room air pneumoperitoneum has yet to be established.Further trials on this topic are needed, and should compare various gases (i.e. nitrous oxide, helium, argon, nitrogen, and room air) with carbon dioxide under standard pressure pneumoperitoneum with cold gas insufflation for people with high anaesthetic risk. Future trials should include outcomes such as complications, serious adverse events, quality of life, and pain.
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Affiliation(s)
- Tianwu Yu
- Yongchuan Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 439, Quxuanhua RoadChongqingChina402160
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Xiaomei Wang
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Bing Tu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Lian Bai
- Yongchuan Hospital, Chongqing Medical UniversityDepartment of Gastrointestinal SurgeryNo. 439, Quxuanhua RoadChongqingChina402160
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Parkin E, Stott M, Brockbank J, Galloway S, Welch I, Macdonald A. Patient-Reported Outcomes for Acute Gallstone Pathology. World J Surg 2017; 41:1234-1238. [PMID: 28074277 PMCID: PMC5394152 DOI: 10.1007/s00268-016-3854-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background A number of prominent surgical trials and clinical guidelines regard length of hospital stay and rates of daycase surgery as being of upmost importance following cholecystectomy.
However, it is unclear whether these outcomes also matter to patients. This study aimed to identify the factors patients regard as most important when admitted with acute gallstone pathology. Methods A 41-item survey was produced by combining outcomes assessed in recent clinical trials with results from a preliminary patient questionnaire. This was then given out prospectively to patients presenting with acute gallstone pathology, prior to their cholecystectomy. Patients were asked to read an information sheet about laparoscopic cholecystectomy and then complete the survey, scoring each item out of 100 in terms of importance to them. Results Fifty-six patients completed the survey (43 females; median age 51 years). Diagnoses were: cholecystitis (28 patients), biliary colic (13), pancreatitis (10), common bile duct stones (3) and cholangitis (2). The top-scoring survey item was “long-term quality of life after surgery”, with a median value of 97 out of 100. Other high-scoring items included “cleanliness of the ward environment” and “pain control after surgery” (both 96). The lowest-scoring item was “being treated as a daycase” (54). Conclusion Patients with acute gallstone pathology view long-term quality of life after surgery as the most important factor and daycase surgery as the least important. These results should be considered when planning future surgical trials and clinical guidelines. Electronic supplementary material The online version of this article (doi:10.1007/s00268-016-3854-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ed Parkin
- Department of Upper Gastrointestinal Surgery, University Hospital of South Manchester, Manchester, UK.
- Obesity and Cancer Research Group, Institute of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK.
| | - Martyn Stott
- Department of Upper Gastrointestinal Surgery, University Hospital of South Manchester, Manchester, UK
| | - Joy Brockbank
- Department of Upper Gastrointestinal Surgery, University Hospital of South Manchester, Manchester, UK
| | - Simon Galloway
- Department of Upper Gastrointestinal Surgery, University Hospital of South Manchester, Manchester, UK
| | - Ian Welch
- Department of Upper Gastrointestinal Surgery, University Hospital of South Manchester, Manchester, UK
| | - Andrew Macdonald
- Department of Upper Gastrointestinal Surgery, University Hospital of South Manchester, Manchester, UK
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Deep Neuromuscular Blockade Improves Laparoscopic Surgical Conditions: A Randomized, Controlled Study. Adv Ther 2017; 34:925-936. [PMID: 28251555 DOI: 10.1007/s12325-017-0495-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Sustained deep neuromuscular blockade (NMB) during laparoscopic surgery may facilitate optimal surgical conditions. This exploratory study assessed whether deep NMB improves surgical conditions and, in doing so, allows use of lower insufflation pressures during laparoscopic cholecystectomy. We further assessed whether use of low insufflation pressure improves patient pain scores after surgery. METHODS This randomized, controlled, blinded study (NCT01728584) compared use of deep (1-2 post-tetanic-counts) or moderate (train-of-four ratio 10%) NMB, and lower (8 mmHg) or higher (12 mmHg; 'standard') insufflation pressure in a 2 × 2 factorial design. Primary endpoint was surgeon's overall satisfaction with surgical conditions, rated at end of surgery using an 11-point numerical scale. Post-operative pain scores were also evaluated. Data were analyzed using analysis of covariance. RESULTS Of 127 randomized patients, 120 had evaluable data for the primary endpoint. Surgeon's score of overall satisfaction with surgical conditions was significantly higher with deep versus moderate NMB indicated by a least-square mean difference of 1.1 points (95% confidence interval 0.1-2.0; P = 0.026). Furthermore, strong evidence of an effect was observed for standard versus low pressure: least-square mean difference of 3.0 points (95% confidence interval 2.1-4.0; P < 0.001). No significant difference was observed in average pain scores within 24 h post-surgery for low versus standard pressure [0.17 (95% confidence interval -0.67 to +0.33); P = 0.494]. CONCLUSIONS Although associated with significantly improved surgical conditions, deep NMB alone was insufficient to promote use of low insufflation pressure during laparoscopic cholecystectomy. Furthermore, low insufflation pressure did not result in reduced pain, compared with standard pressure. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01728584. FUNDING Merck Sharp and Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.
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Niu X, Song X, Su A, Zhao S, Li Q. Low-pressure capnoperitoneum reduces stress responses during pediatric laparoscopic high ligation of indirect inguinal hernia sac: A randomized controlled study. Medicine (Baltimore) 2017; 96:e6563. [PMID: 28383434 PMCID: PMC5411218 DOI: 10.1097/md.0000000000006563] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND We aimed to evaluate the effect of different capnoperitoneum pressures on stress responses in pediatric laparoscopic inguinal hernia repair. METHODS In this prospective randomized controlled study, 68 children with indirect inguinal hernia who underwent high ligation of hernia sac were randomly divided into 3 groups: high-pressure group (12 mm Hg, HP group, n = 26); low-pressure group (8 mm Hg, LP group, n = 20); open operation group (OP group, n = 22). Heart rate (HR), blood pressure, and end-tidal CO2 (PetCO2) were recorded, as well as the levels of adrenocorticotropic hormone (ACTH) and cortisol (COR) were measured by ELISAs before operation, during operation, and after operation, respectively. RESULTS After establishing capnoperitoneum, HR, blood pressure, and PetCO2 were significantly increased in the HP group compared with the OP and LP groups (P < 0.05). Comparing the intraoperatively measured ACTH and COR concentrations of the HP group to the LP group, we noted higher values in the first (P < 0.05). There was no significant difference in the postoperative concentrations of ACTH and COR among the HP, LP, and OP groups. CONCLUSIONS Laparoscopic surgery under LP capnoperitoneum or open operation may reduce stress responses and are superior to HP capnoperitoneum.
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Affiliation(s)
| | - Xubin Song
- Department of Pharmacy, Taian City Central Hospital,
| | - Aiping Su
- Department of Surgery, Taishan Hospital of Shandong Province,
| | - Shanshan Zhao
- Department of Reproductive Genetics Center, Taian City Central Hospital, Taian, China
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