Heating of carbon dioxide during insufflation alters the peritoneal fibrinolytic response to laparoscopic surgery: A clinical trial

Advancement of Biomaterial-Based Postoperative Adhesion Barriers

Postoperative peritoneal adhesion (PPA) is a prevalent incidence that generally happens during the healing process of traumatized tissues. It causes multiple severe complications such as intestinal obstruction, chronic abdominal pain, and female infertility. To prevent PPA, several antiadhesion materials and drug delivery systems composed of biomaterials are used clinically, and clinical antiadhesive is one of the important applications nowadays. In addition to several commercially available materials, like film, spray, injectable hydrogel, powder, or solution type have been energetically studied based on natural and synthetic biomaterials such as alginate, hyaluronan, cellulose, starch, chondroitin sulfate, polyethylene glycol, polylactic acid, etc. Moreover, many kinds of animal adhesion models, such as cecum abrasion models and unitary horn models, are developed to evaluate new materials' efficacy. A new animal adhesion model based on hepatectomy and conventional animal adhesion models is recently developed and a new adhesion barrier by this new model is also developed. In summary, many kinds of materials and animal models are studied; thus, it is quite important to overview this field's current progress. Here, PPA is reviewed in terms of the species of biomaterials and animal models and several problems to be solved to develop better antiadhesion materials in the future are discussed.

Aspect of laparoscopic treatment of patients with adhesive small bowel obstruction (review of literature)

Nowadays, adhesive small bowel obstruction (ASBO) is a disease characterized by the stable increase in the number of patients, a significant level of postoperative complications, and a high risk of disability and death. The objective of the article was the research and analysis of relevant data of video laparoscopic treatment of patients with ASBO and possible postoperative complications. A small percentage of complications in clinical centers with a large flow of patients of this profile and rapid postoperative recovery of patients promote the active introduction of laparoscopic adhesiolysis in practical medicine. The analysis of foreign and domestic literature showed that the faithful adherence of indications for application of the technique for resolving intestinal obstruction and restoring passage through the gastrointestinal tract allows to achieve better results and avoid iatrogenic and infectious complications. Thus, laparoscopic treatment can and should be the operation of choice only in a carefully selected group of patients (the first manifestation of ASBO, the absence of pronounced ischemic changes in the intestinal wall and (or) the predicted presence of a small number of peritoneal adhesions), in all other cases, the use of laparotomy is indicated. Currently, there is a clear trend towards an increasing recognition and use of laparoscopy in surgical practice. It is becoming the preferred choice in clinical centers with extensive experience in the treatment of patients with ASBO due to an insignificant percentage of complications and a rapid postoperative recovery.

Randomized clinical trial of the effect of intraoperative humidified carbon dioxide insufflation in open laparotomy for colorectal resection

Background

Animal studies have shown that peritoneal injury can be minimized by insufflating the abdominal cavity with warm humidified carbon dioxide gas.

Methods

A single‐blind RCT was performed at a tertiary colorectal unit. Inclusion criteria were patient aged 18 years and over undergoing open elective surgery. The intervention group received warmed (37°C), humidified (98 per cent relative humidity) carbon dioxide (WHCO₂ group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3‐chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T₀) and end (T_end) of the operation. Postoperative clinical outcomes were compared between the groups.

Results

Of 40 patients enrolled, 20 in the WHCO₂ group and 19 in the control group were available for analysis. A significant log(T_end/T₀) difference between control and WHCO₂ groups was documented for interleukin (IL) 2 (5·3 versus 2·8 respectively; P = 0·028) and IL‐4 (3·5 versus 2·0; P = 0·041), whereas apoptosis assays documented no significant change in caspase activity, and similar apoptosis rates were documented along the peritoneal edge in both groups. The 3‐chlorotyrosine/tyrosine ratio had increased at T_end by 1·1‐fold in the WHCO₂ group and by 3·1‐fold in the control group. Under light microscopy, peritoneum was visible in 11 of 19 samples from the control group and in 19 of 20 samples from the WHCO₂ group (P = 0·006). The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2·5 versus 5·0 days respectively; P = 0·008).

Conclusion

The use of warmed, humidified carbon dioxide appears to reduce some markers related to peritoneal oxidative damage during laparotomy. No difference was observed in clinical outcomes, but the study was underpowered for analysis of surgical results. Registration number: NCT02975947 ( http://www.clinicaltrials.gov/).

Effects of Intraoperative Insufflation With Warmed, Humidified CO2 during Abdominal Surgery: A Review

PURPOSE

During a laparotomy, the peritoneum is exposed to the cold, dry ambient air of the operating room (20°C, 0%-5% relative humidity). The aim of this review is to determine whether the use of humidified and/or warmed CO2 in the intraperitoneal environment during open or laparoscopic operations influences postoperative outcomes.

METHODS

A review was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, OVID MEDLINE, Cochrane Central Register of Controlled Trials and Embase databases were searched for articles published between 1980 and 2016 (October). Comparative studies on humans or nonhuman animals that involved randomized controlled trials (RCTs) or prospective cohort studies were included. Both laparotomy and laparoscopic studies were included. The primary outcomes identified were peritoneal inflammation, core body temperature, and postoperative pain.

RESULTS

The literature search identified 37 articles for analysis, including 30 RCTs, 7 prospective cohort studies, 23 human studies, and 14 animal studies. Four studies found that compared with warmed/humidified CO2, cold, dry CO2 resulted in significant peritoneal injury, with greater lymphocytic infiltration, higher proinflammatory cytokine levels and peritoneal adhesion formation. Seven of 15 human RCTs reported a significantly higher core body temperature in the warmed, humidified CO2 group than in the cold, dry CO2 group. Seven human RCTs found lower postoperative pain with the use of humidified, warmed CO2.

CONCLUSION

While evidence supporting the benefits of using humidified and warmed CO2 can be found in the literature, a large human RCT is required to validate these findings.

Peritoneal changes due to laparoscopic surgery

Background

Laparoscopic surgery has been incorporated into common surgical practice. The peritoneum is an organ with various biologic functions that may be affected in different ways by laparoscopic and open techniques. Clinically, these alterations may be important in issues such as peritoneal metastasis and adhesion formation.

Methods

A literature search using the Pubmed and Cochrane databases identified articles focusing on the key issues of laparoscopy, peritoneum, inflammation, morphology, immunology, and fibrinolysis.

Results

Laparoscopic surgery induces alterations in the peritoneal integrity and causes local acidosis, probably due to peritoneal hypoxia. The local immune system and inflammation are modulated by a pneumoperitoneum. Additionally, the peritoneal plasmin system is inhibited, leading to peritoneal hypofibrinolysis.

Conclusion

Similar to open surgery, laparoscopic surgery affects both the integrity and biology of the peritoneum. These observations may have implications for various clinical conditions.