[Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: a prospective study]

Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures

Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.

Effects of Pneumoperitoneum on Splanchnic Oxygenation during Abdominal Laparoscopic Surgery in Paediatric Patients: A prospective, Observational Study

Objective

Pneumoperitoneum can cause disruption in splanchnic perfusion. This study aims to investigate effects of pneumoperitoneum on splanchnic oxygenation during abdominal laparoscopic surgery in paediatric patients with NIRS (Near-Infrared Spectroscopy).

Material and methods

A total of 45 patients between 1 and 4 years of age with ASA physical status I–II and scheduled to undergo abdominal laparoscopic surgery under general anaesthesia were enrolled in this prospective, observational surgery. No premedication was used. Standard monitoring and regional splanchnic saturation (rSPcO₂), regional cerebral oxygen saturation (rScO₂) with NIRS were established before anaesthesia. Anaesthesia was induced with an inhalational agent and maintained with an oxygen/air mixture and sevoflurane. Peripheral oxygen saturation (SPO₂), rSPcO₂, rScO₂, heart rate (HR), mean arterial pressure (MAP), end tidal CO₂ (Et-CO₂), and insufflation pressure (IP) were continuously monitored during administration of anaesthesia and recorded. After intubation (baseline T0); before CO₂ insufflation induced pneumoperitoneum (PP) (T1); CO₂ PP insufflation (T2); 5 minutes after PP insufflation (T3); 10 minutes after PP insufflation (T4); 15 minutes after PP insufflation (T5); 20 minutes after PP insufflation (T6); 30 minutes after PP insufflation (T7), 60 minutes after PP insufflation (T8), and after desufflation (T9). Bradycardia and hypotension were recorded. Paracetamol IV 10 mg kg⁻¹ was applied for post-operative analgesia. p<0.05 wasconsidered significant.

Results

HR, rScO₂, and rSPcO₂ decreased at all measured time intervals when compared to T0 (p<0.01) MAP decreased at T1 compared to T0 (p<0.001). Et-CO₂ increased at T3-T4-T5-T6 compared to T0 (p<0.001).

Conclusion

We found that pneumoperitoneum reduced splanchnic oxygenation during laparoscopic abdominal surgery in paediatric patients, which was measured using NIRS.

Cerebral and Renal Oxygenation in Infants Undergoing Laparoscopic Gastrostomy Tube Placement

AIM

The aim of this study was to evaluate the effects of a carbon dioxide pneumoperitoneum on cerebral and renal oxygenation and oxygen extraction, in a cohort of infants from the neonatal intensive care unit, undergoing laparoscopic gastrostomy.

METHODS

After institutional review board approval, between February 2018 and June 2019, infants 0-3 mo corrected age, undergoing laparoscopic gastrostomy tube placement, were included. Strict exclusion criteria created a homogeneous cohort. Cerebral and renal tissue oxygen saturation (rSO₂) by near-infrared spectroscopy, skin surface oxygen saturation (SpO₂), by pulse oximetry, and amplitude-integrated electroencephalography were measured. Monitoring was divided into preoperative, intraoperative and postoperative time periods. Cerebral and renal fractional tissue oxygen extraction was calculated using arterial (SpO₂) and tissue oxygen saturation (rSO₂): (SpO₂-rSO₂SpO₂)X100. Data were averaged into one-minute epochs and significant changes from baseline during the intraoperative and postoperative periods were detected using one-way analysis of variance with repeated measures.

RESULTS

This pilot study examined sixteen infants, born at a median gestational age of 34.2 wk (range: 23.0-40.6) with a median corrected age of 42.9 wk (range: 40.0-46.3) at operation. None had seizure activity or altered sleep-wake cycles. No statistically significant variations in cerebral and renal tissue oxygenation and extraction were observed. Pulse oximetry did demonstrate significant variation from baseline on analysis of variance, but post hoc analysis did not identify any one specific time point at which this difference was significant.

CONCLUSIONS

During a short infant laparoscopic procedure, no significant alteration in cerebral or renal oxygenation or oxygen extraction was observed. No seizure activity or changes in infant sleep-wake cycles occurred.

Changes in cerebral and renal oxygenation during laparoscopic pyloromyotomy

Although a laparoscopic approach may be preferred over open procedures for abdominal surgery, there are limited data on the effect of laparoscopic procedures on cerebral and renal oxygenation in neonates and young infants. Here, we evaluated the effect in neonates and infants. In this two-center prospective observational study, we evaluated changes in cerebral and renal regional oxygen saturation (rSO₂) in infants during laparoscopic pyloromyotomy. Intraoperative hemodynamic and respiratory parameters and rSO₂ were recorded. For the primary outcome, these parameters were compared at incision and at the end of pneumoperitoneum. The study cohort included 25 infants with a mean age of 40 ± 10 days and weight of 4.0 ± 0.6 kg. IAP at the beginning of laparoscopy was 10 ± 2 mmHg (range 7-15 mmHg). Although both cerebral and renal rSO₂ decreased from incision compared to the end of laparoscopy, the decrease reached statistical significance only for cerebral rSO₂ (81 ± 12 to 76 ± 16, p = 0.033). Similarly, the increase in fractional tissue oxygen extraction (FTOE) was only statistically significant for cerebral FTOE (0.18 ± 0.12 to 0.23 ± 0.16, p = 0.037). No change in hemodynamic or respiratory parameters was found. Although there was a decrease in cerebral rSO₂ and increase in cerebral FTOE during pneumoperitoneum, the values did not decrease below those noted before anesthetic induction.

Influence of intra-abdominal pressure on the amplitude of fluctuations of cerebral hemoglobin concentration in the respiratory band

An intra-abdominal pressure (IAP) is correlated with cerebral perfusion, in a mechanism of reducing venous outflow. The elevated intra-abdominal pressure leads to an increase in the intracranial pressure and a decrease in the cerebral perfusion pressure. We studied the relationship between the IAP and the cerebral oxygenation with the use of the near infrared spectroscopy technique during a gynecological surgery. The changes in hemoglobin concentrations were analyzed in the time-frequency domain in the frequency band related to respiration. The measurements were carried out in 15 subjects who underwent laparoscopic surgery. During the laparoscopy, the intra-abdominal cavity was insufflated with CO₂, which caused a controlled increase in the IAP. It was observed that the amplitudes of respiration-related waves present in hemoglobin concentration signals show an increase of 1.5 to 8.5 times during elevation of the IAP by 15 mmHg.

Cerebral Oxygen Saturation and Negative Postoperative Behavioral Changes in Pediatric Surgery: A Prospective Observational Study

OBJECTIVE

To evaluate if an intraoperative cerebral regional oxygen saturation (crSO₂) decrease, less pronounced than 20% below baseline (the current threshold believed to be associated with cognitive dysfunction in adults), is associated with negative postoperative behavioral changes (NPOBC) in the pediatric population after noncardiac surgeries.

STUDY DESIGN

A prospective observational study was conducted with 198 children aged 2-12 years old scheduled for noncardiac procedures under general anesthesia. Intraoperatively, crSO₂ was monitored with a cerebral oximeter. On postoperative day 7, the Post-Hospital Behavior Questionnaire was used to diagnose NPOBC.

RESULTS

The incidence of NPOBC was 38.8%. Logistic regression analysis revealed that with every 1% reduction of crSO₂ from the baseline value, the odds of developing NPOBC were 1.199 higher. Likewise, preoperative anxiety (OR 2.832, P = .006), duration of surgery (OR 1.026, P < .0001), and being between the ages of 2 and 3 years (OR 2.604, P = .048) were associated with NPOBC incidence. The multivariable logistic regression model receiver operating characteristic curve showed an area under the curve (95% CI) = 0.820 (0.759-0.881).

CONCLUSIONS

During noncardiac surgeries in the pediatric population, an intraoperative decrease in crSO₂ less pronounced than 20% from the baseline value is associated with negative postoperative behavior changes on postoperative day 7. The long-term implications remain to be determined, but this supports attention to crSO₂ during noncardiac surgeries.

Effects of Carbon Dioxide Insufflation and Trendelenburg Position on Brain Oxygenation During Laparoscopy in Children

PURPOSE

Laparoscopic appendectomy has become more popular compared with the open appendectomy in children, but there are limited data on the effects of pneumoperitoneum and Trendelenburg position on cerebral oxygenation. This study was designed to evaluate the changes in cerebral saturation using near-infrared spectroscope during laparoscopic surgery in children.

METHODS

The children underwent laparoscopic (LAP Group, n=22) or open appendectomy (OPEN Group, n=22). Right and left cerebral oxygenation (RScO2-LScO2), heart rate (HR), mean arterial pressure (MAP), end-tidal CO2pressure (PETCO2), and peripheral oxygen saturations (SpO2) were recorded between anesthesia induction (T0, baseline), after induction (T1), after intubation (T2), 5 minutes after intubation (T3), 5 minutes after pneumoperitoneum-15th minute at OPEN (T4), 5 minutes after Trendelenburg-20th minute at OPEN (T5), 30 minutes after pneumoperitoneum-45th minute at OPEN (T6), 5 minutes after supine position-skin suturing at OPEN (T7), 5 minutes postextubation (T8).

RESULTS

Groups were similar with respect to their demographic data. In LAP group, a significant increase in HR was recorded at T5. No significant difference was observed in the MAP, PETCO2, SpO2, RScO2, and LScO2 values between the groups. There was a significant increase in the perioperative T1 to T8 values compared with the T0 values in LScO2 of the LAP group.

CONCLUSIONS

Our results suggest that pneumoperitoneum and Trendelenburg position does not alter the hemodynamic values and can be safely performed in children without altering regional brain oxygenation levels.

Neurodevelopment impact of CO2-pneumoperitoneum in neonates: experimental study in a rat model

BACKGROUND

Laparoscopy is becoming more common in neonates. However, concerns remain about the impact of the carbon-dioxide (CO₂)-insufflation over the neonatal brain. We aim to evaluate the peripheral (serum) and central (cerebrospinal fluid [CSF]) cytokine response after neonatal CO₂-pneumoperitoneum and its impact over neurodevelopmental milestones acquisition and long-term behavioral outcomes.

MATERIALS AND METHODS

Rats were subjected to a systematic assessment of neurodevelopmental milestones between postnatal day 1 (PND 1) and PND 21. At PND 10, neonatal rats were anesthetized, mechanically ventilated, and exposed to different pressures and times of abdominal CO₂-insufflation. Immediately after pneumoperitoneum, corticosterone was analyzed in serum. Twenty-four hours after intervention, serum and CSF were collected to assess inflammatory response (interleukin [IL]-10, IL-1β, tumor necrosis factor [TNF]-α, and interferon [IFN]-γ). In adulthood, animals from each group were submitted to several tests to assess different behavioral domains (locomotion, anxiety, mood, and cognition).

RESULTS

The antiinflammatory cytokine IL-10 was significantly increased in CSF in CO₂-insufflated groups, with no other significant changes in the other biomarkers. Acquisition of neurodevelopmental milestones was maintained in all studied groups. No significant differences were observed in adult behavior in the different CO₂-insufflation conditions.

CONCLUSIONS

Neonatal CO₂-pneumoperitoneum does not seem to have any negative impact on neurodevelopment or induce behavioral alterations in adulthood. Minimally invasive surgery results in a central antiinflammatory profile, and further studies on the functional consequences of these phenomena are needed.

Pediatric Laparoscopy and Adaptive Oxygenation and Hemodynamic Changes

Adaptive changes in oxygenation and hemodynamics are evaluated during pediatric laparoscopy. The children underwent laparoscopy (LAP Group, n=20) or open surgery (Open Group, n=10). Regional cerebral (rScO₂) and peripheral oxygen saturation (SpO₂), heart rate (HR), diastolic (DP) and systolic pressure (SP) were monitored at different intervals: basal (T0); anesthesia induction (T1); CO₂PP insufflation (T2); surgery (T3); CO₂PP cessation (T4); before extubation (T5). At T1, in both the LAP and Open groups significant changes in rScO₂, DP and SP were recorded compared with T0; a decrease in SatO₂ was also observed at T5. In the LAP group, at T2, changes in HR related to CO₂PP pressure and in DP and SP related to IAP were noted; at T4, a SP change associated with CO₂PP desufflation was recorded. Open group, at T3 and T5 showed lower rScO₂ values compared with T1. Pneuperitoneum and anesthesia are influent to induce hemodynamics changes during laparoscopy.

Laparoscopy in children and its impact on brain oxygenation during routine inguinal hernia repair

BACKGROUND

The systemic impact of intra-abdominal pressure (IAP) and/or changes in carbon dioxide (CO2) during laparoscopy are not yet well defined. Changes in brain oxygenation have been reported as a possible cause of cerebral hypotension and perfusion. The side effects of anaesthesia could also be involved in these changes, especially in children. To date, no data have been reported on brain oxygenation during routine laparoscopy in paediatric patients.

PATIENTS AND METHODS

Brain and peripheral oxygenation were investigated in 10 children (8 male, 2 female) who underwent elective minimally invasive surgery for inguinal hernia repair. Intraoperative transcranial near-infrared spectroscopy to assess regional cerebral oxygen saturation (rScO2), peripheral oxygen saturation using pulse oximetry and heart rate (HR) were monitored at five surgical intervals: Induction of anaesthesia (baseline T1); before CO2insufflation induced pneumoperitoneum (PP) (T2); CO2PP insufflation (T3); cessation of CO2PP (T4); before extubation (T5).

RESULTS

rScO2decreases were recorded immediately after T1 and became significant after insufflation (P = 0.006; rScO2decreased 3.6 ± 0.38%); restoration of rScO2was achieved after PP cessation (P = 0.007). The changes in rScO2were primarily due to IAP increases (P = 0.06). The HR changes were correlated to PP pressure (P < 0.001) and CO2flow rate (P = 0.001). No significant peripheral effects were noted.

CONCLUSIONS

The increase in IAP is a critical determinant in cerebral oxygenation stability during laparoscopic procedures. However, the impact of anaesthesia on adaptive changes should not be underestimated. Close monitoring and close collaboration between the members of the multidisciplinary paediatric team are essential to guarantee the patient's safety during minimally invasive surgical procedures.

Effect of general anesthesia on serum β-amyloid protein and regional cerebral oxygen saturation of elderly patients after subtotal gastrectomy

The aim of the present study was to investigate the influence of general anesthesia on serum β-amyloid protein (Aβ) and regional cerebral oxygen saturation (rSO₂) of elderly patients after subtotal gastrectomy. From June, 2014 to December, 2015, among 168 patients undergoing subtotal gastrectomy, the Mini-Mental State Examination and Montreal Cognitive Assessment was administered the day prior to surgery and the second and ninth days after the operation. In addition, we administered the tests to 168 healthy adult volunteers (healthy controls) who were treated in our hospital medical center in the same period. Near-infrared spectroscopy technology was used for continuous monitoring of the intraoperative rSO₂, and the mean of intraoperative rSO₂ was then calculated. Of the 168 patients, 28 developed postoperative cognitive dysfunction (POCD) and the remaining 140 patients were normal (control). The ELISA method was used to test the expression levels of serum Aβ in the three groups and statistical analyses were conducted. Serum Aβ level in the POCD group was significantly higher than that in the control and healthy control groups, and the difference was statistically significant (P<0.05). The rSO₂ level in the patients with POCD was significantly lower than the control group (P<0.05). The correlation analysis with Aβ as an independent variable and other factors as dependent variables revealed that the serum Aβ level negatively correlated with rSO₂ (r=-1.6749, P<0.05). The combined Aβ and rSO₂ may be useful for the diagnosis and prevention of POCD after subtotal gastrectomy under general anesthesia.