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Shin Y, Kim YJ, Jin J, Lee SB, Kim HS, Kim YG. Machine learning model for predicting immediate postoperative desaturation using spirometry signal data. Sci Rep 2023; 13:21881. [PMID: 38072984 PMCID: PMC10711018 DOI: 10.1038/s41598-023-49062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
Postoperative desaturation is a common post-surgery pulmonary complication. The real-time prediction of postoperative desaturation can become a preventive measure, and real-time changes in spirometry data can provide valuable information on respiratory mechanics. However, there is a lack of related research, specifically on using spirometry signals as inputs to machine learning (ML) models. We developed an ML model and postoperative desaturation prediction index (DPI) by analyzing intraoperative spirometry signals in patients undergoing laparoscopic surgery. We analyzed spirometry data from patients who underwent laparoscopic, robot-assisted gynecologic, or urologic surgery, identifying postoperative desaturation as a peripheral arterial oxygen saturation level below 95%, despite facial oxygen mask usage. We fitted the ML model on two separate datasets collected during different periods. (Datasets A and B). Dataset A (Normal 133, Desaturation 74) was used for the entire experimental process, including ML model fitting, statistical analysis, and DPI determination. Dataset B (Normal 20, Desaturation 4) was only used for verify the ML model and DPI. Four feature categories-signal property, inter-/intra-position correlation, peak value/interval variability, and demographics-were incorporated into the ML models via filter and wrapper feature selection methods. In experiments, the ML model achieved an adequate predictive capacity for postoperative desaturation, and the performance of the DPI was unbiased.
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Affiliation(s)
- Youmin Shin
- Department of Transdisciplinary Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
- Interdisciplinary Program in Bio-engineering, Seoul National University, Seoul, Republic of Korea
| | - Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Juseong Jin
- Interdisciplinary Program in Bio-engineering, Seoul National University, Seoul, Republic of Korea
- Integrated Major in Innovative Medical Science, Seoul National University, Seoul, Republic of Korea
| | - Seung-Bo Lee
- Department of Medical Informatics, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
| | - Young-Gon Kim
- Department of Transdisciplinary Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Kim YJ, Kim BR, Kim HW, Jung JY, Cho HY, Seo JH, Kim WH, Kim HS, Hwangbo S, Yoon HK. Effect of driving pressure-guided positive end-expiratory pressure on postoperative pulmonary complications in patients undergoing laparoscopic or robotic surgery: a randomised controlled trial. Br J Anaesth 2023; 131:955-965. [PMID: 37679285 DOI: 10.1016/j.bja.2023.08.007] [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: 02/01/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Individualised positive end-expiratory pressure (PEEP) improves respiratory mechanics. However, whether PEEP reduces postoperative pulmonary complications (PPCs) remains unclear. We investigated whether driving pressure-guided PEEP reduces PPCs after laparoscopic/robotic abdominal surgery. METHODS This single-centre, randomised controlled trial enrolled patients at risk for PPCs undergoing laparoscopic or robotic lower abdominal surgery. The individualised group received driving pressure-guided PEEP, whereas the comparator group received 5 cm H2O fixed PEEP during surgery. Both groups received a tidal volume of 8 ml kg-1 ideal body weight. The primary outcome analysed per protocol was a composite of pulmonary complications (defined by pre-specified clinical and radiological criteria) within 7 postoperative days after surgery. RESULTS Some 384 patients (median age: 67 yr [inter-quartile range: 61-73]; 66 [18%] female) were randomised. Mean (standard deviation) PEEP in patients randomised to individualised PEEP (n=178) was 13.6 cm H2O (2.1). Individualised PEEP resulted in lower mean driving pressures (14.7 cm H2O [2.6]), compared with 185 patients randomised to standard PEEP (18.4 cm H2O [3.2]; mean difference: -3.7 cm H2O [95% confidence interval (CI): -4.3 to -3.1 cm H2O]; P<0.001). There was no difference in the incidence of pulmonary complications between individualised (25/178 [14.0%]) vs standard PEEP (36/185 [19.5%]; risk ratio [95% CI], 0.72 [0.45-1.15]; P=0.215). Pulmonary complications as a result of desaturation were less frequent in patients randomised to individualised PEEP (8/178 [4.5%], compared with standard PEEP (30/185 [16.2%], risk ratio [95% CI], 0.28 [0.13-0.59]; P=0.001). CONCLUSIONS Driving pressure-guided PEEP did not decrease the incidence of pulmonary complications within 7 days of laparoscopic or robotic lower abdominal surgery, although uncertainty remains given the lower than anticipated event rate for the primary outcome. CLINICAL TRIAL REGISTRATION KCT0004888 (http://cris.nih.go.kr, registration date: April 6, 2020).
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Affiliation(s)
- Yoon Jung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bo Rim Kim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Hee Won Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Yoon Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeoung-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Suhyun Hwangbo
- Department of Genomic Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Gao D, Sun L, Wang N, Shi Y, Song J, Liu X, Yang Q, Su Z. Impact of 30° Reserve Trendelenburg Position on Lung Function in Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy. Front Surg 2022; 9:792697. [PMID: 35284476 PMCID: PMC8907616 DOI: 10.3389/fsurg.2022.792697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to evaluate the impact of patients' positioning before and after intubation with mechanical ventilation, and after extubation on the lung function and blood oxygenation of patients with morbid obesity, who had a laparoscopic sleeve gastrectomy. Methods Patients with morbid obesity (BMI ≥ 30 kg/m2, ASA I – II grade) who underwent laparoscopic sleeve gastrectomy at our hospital from June 2018 to January 2019 were enrolled in this prospective study. Before intubation, after intubation with mechanical ventilation, and after extubation, arterial blood was collected for blood oxygenation and gas analysis after posturing the patients at supine position or 30° reverse Trendelenburg position (30°-RTP). Results A total of 15 patients with morbid obesity were enrolled in this self-compared study. Pulmonary shunt (Qs/Qt) after extubation was significantly lower at 30°-RTP (18.82 ± 3.60%) compared to that at supine position (17.13 ± 3.10%, p < 0.01). Patients' static lung compliance (Cstat), during mechanical ventilation, was significantly improved at 30°-RTP (36.8 ± 6.7) compared to that of those in a supine position (33.8 ± 7.3, p < 0.05). The PaO2 and oxygen index (OI) before and after intubation with mechanical ventilation were significantly higher at 30°-RTP compared to that at supine position, and in contrast, the PA−aO2 before and after intubation with mechanical ventilation was significantly reduced at 30°-RTP compared to that at supine position. Conclusion During and after laparoscopic sleeve gastrectomy, patients with morbid obesity had improved lung function, reduced pulmonary shunt, reduced PA−aO2 difference, and increased PaO2 and oxygen index at 30°-RTP compared to that supine position.
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Affiliation(s)
- Dengyu Gao
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Lu Sun
- Department of Anesthesiology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Ning Wang
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yubo Shi
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jianli Song
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Xiaoying Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Qiyao Yang
- Education Centre, China Medical Tribun, Beijing, China
| | - Zhenbo Su
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, China
- *Correspondence: Zhenbo Su
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AY N, ŞAHİN AS, SARGIN A, SALİHOĞLU Z, DERBENT A. Jinekolojik laparoskopi uygulanan hastaların serebral oksijenasyon takiplerinin retrospektif olarak incelenmesi. EGE TIP DERGISI 2019. [DOI: 10.19161/etd.470623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Wang Y, Wang H, Wang H, Zhao X, Li S, Chen L. Exploring the intraoperative lung protective ventilation of different positive end-expiratory pressure levels during abdominal laparoscopic surgery with Trendelenburg position. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:171. [PMID: 31168452 DOI: 10.21037/atm.2019.03.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The intraoperative lung protective effect of mechanical ventilation of different positive end-expiratory pressure (PEEP) levels on patients undergoing abdominal laparoscopic surgery with the steep Trendelenburg position remains undefined. The purpose of the study was to explore the optimal PEEP. Methods Sixty patients scheduled for abdominal laparoscopic surgery were randomized to four groups including: PEEP 0, 4, 8 and 12 cmH2O. The pulmonary dynamic compliance (Cdyn), dead space to tidal volume ratio (VD/VT), and intrapulmonary shunt ratio (QS/QT) were measured after anesthesia induction (T0), 5 min after pneumoperitoneum (PNP) with position change (T1), 30 (T2) and 60 min (T3) after PEEP, and end of surgery (T4). Results Cdyn increased when different levels of PEEP (including the 4, 8, and 12 cmH2O) were used vs. no PEEP (P<0.05). The VD/VT in PEEP 8 and 12 cmH2O were significantly improved than no PEEP (P<0.05). Meanwhile, the QS/QT in PEEP 12 cmH2O was higher than others during the procedures. Conclusions A moderate PEEP level (8 cmH2O) with low tidal volume was sufficient to improve Cdyn and to decrease VD/VT without increasing QS/QT, which was suggested to be a good choice of intraoperative lung protective ventilation during abdominal laparoscopic surgery with Trendelenburg position.
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Affiliation(s)
- Yun Wang
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai 201620, China
| | - Hong Wang
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai 201620, China
| | - Huijuan Wang
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai 201620, China
| | - Xiao Zhao
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai 201620, China
| | - Shitong Li
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai 201620, China
| | - Lianhua Chen
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, Shanghai 201620, China
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Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection. Int J Colorectal Dis 2017; 32:1237-1242. [PMID: 28667498 DOI: 10.1007/s00384-017-2848-y] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an increasing number of operations are being performed on more elderly patients with the trend set to continue. Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease. The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer. METHODS A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included. The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival. RESULTS The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (p = 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet. CONCLUSION Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.
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Shimomura A, Obi Y, Fazl Alizadeh R, Li S, Nguyen NT, Stamos MJ, Kalantar-Zadeh K, Ichii H. Association of pre-operative estimated GFR on post-operative pulmonary complications in laparoscopic surgeries. Sci Rep 2017; 7:6504. [PMID: 28747700 PMCID: PMC5529443 DOI: 10.1038/s41598-017-06842-4] [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] [Received: 02/23/2017] [Accepted: 06/19/2017] [Indexed: 12/22/2022] Open
Abstract
Despite a large body of evidence showing the pandemic of chronic kidney disease, the impact of pre-operative kidney function on the risk of post-operative pulmonary complications (PPCs) is not well known. We used multivariable logistic regression analyses with 3-level hierarchical adjustments to identify the association of pre-operative estimated glomerular filtration rate (eGFR) with PPCs in laparoscopic surgeries. Among 452,213 patients between 2005 and 2013 in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database, a total of 3,727 patients (0.9%) experienced PPCs. We found a gradient association between lower eGFR and higher likelihood of PPCs in the unadjusted model. In the case-mix adjusted model, a reverse-J-shaped association was observed; a small albeit significant association with the highest eGFR category emerged. Further adjustment slightly attenuated these associations, but the PPCs risk in the eGFR groups of <30, 30-60, and ≥120 mL/min/1.73 m2 remained significant: odds ratios (95% confidence intervals) of 1.82 (1.54-2.16), 1.38 (1.24-1.54), and 1.28 (1.07-1.53), respectively (reference: 90-120 mL/min/1.73 m2). Our findings propose a need for careful pre-operative evaluation of cardiovascular and pulmonary functions and post-operative fluid management among patients with not only lower but also very high eGFR.
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Affiliation(s)
- Akihiro Shimomura
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California, Irvine, Orange, California, USA.
| | - Reza Fazl Alizadeh
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Shiri Li
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Ninh T Nguyen
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, Orange, California, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology & Hypertension, University of California, Irvine, Orange, California, USA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
- Los Angeles Biomedical Research Institute, Harbor-University of California, Los Angeles, Torrance, California, USA
| | - Hirohito Ichii
- Department of Surgery, University of California, Irvine, Orange, California, USA.
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Lian M, Zhao X, Wang H, Chen L, Li S. Respiratory dynamics and dead space to tidal volume ratio of volume-controlled versus pressure-controlled ventilation during prolonged gynecological laparoscopic surgery. Surg Endosc 2016; 31:3605-3613. [PMID: 28039643 DOI: 10.1007/s00464-016-5392-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscopic operations have become longer and more complex and applied to a broader patient population in the last decades. Prolonged gynecological laparoscopic surgeries require prolonged pneumoperitoneum and Trendelenburg position, which can influence respiratory dynamics and other measurements of pulmonary function. We investigated the differences between volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) and tried to determine the more efficient ventilation mode during prolonged pneumoperitoneum in gynecological laparoscopy. METHODS Twenty-six patients scheduled for laparoscopic radical hysterectomy combined with or without laparoscopic pelvic lymphadenectomy were randomly allocated to be ventilated by either VCV or PCV. Standard anesthesic management and laparoscopic procedures were performed. Measurements of respiratory and hemodynamic dynamics were obtained after induction of anesthesia, at 10, 30, 60, and 120 min after establishing pneumoperitoneum, and at 10 min after return to supine lithotomy position and removal of carbon dioxide. The logistic regression model was applied to predict the corresponding critical value of duration of pneumoperitoneum when the Ppeak was higher than 40 cmH2O. RESULTS Prolonged pneumoperitoneum and Trendelenburg position produced significant and clinically relevant changes in dynamic compliance and respiratory mechanics in anesthetized patients under PCV and VCV ventilation. Patients under PCV ventilation had a similar increase of dead space/tidal volume ratio, but had a lower Ppeak increase compared with those under VCV ventilation. The critical value of duration of pneumoperitoneum was predicted to be 355 min under VCV ventilation, corresponding to the risk of Ppeak higher than 40 cmH2O. CONCLUSIONS Both VCV and PCV can be safely applied to prolonged gynecological laparoscopic surgery. However, PCV may become the better choice of ventilation after ruling out of other reasons for Ppeak increasing.
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Affiliation(s)
- Ming Lian
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, No. 650, New Songjiang Road, Shanghai, 201620, China
| | - Xiao Zhao
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, No. 650, New Songjiang Road, Shanghai, 201620, China
| | - Hong Wang
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, No. 650, New Songjiang Road, Shanghai, 201620, China
| | - Lianhua Chen
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, No. 650, New Songjiang Road, Shanghai, 201620, China.
| | - Shitong Li
- Department of Anesthesiology, Shanghai General Hospital of Nanjing Medical University, No. 650, New Songjiang Road, Shanghai, 201620, China
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Park SJ, Kim BG, Oh AH, Han SH, Han HS, Ryu JH. Effects of intraoperative protective lung ventilation on postoperative pulmonary complications in patients with laparoscopic surgery: prospective, randomized and controlled trial. Surg Endosc 2016; 30:4598-606. [PMID: 26895920 DOI: 10.1007/s00464-016-4797-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/03/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Respiratory functions are usually impaired during pneumoperitoneum for laparoscopic surgery. This randomized, controlled and single-blinded study was performed to evaluate whether intraoperative protective lung ventilation influences postoperative pulmonary complications after laparoscopic hepatobiliary surgery. METHODS Sixty-two patients were randomized to receive either conventional ventilation with alveolar recruitment maneuver (tidal volume of 10 ml/kg with inspiratory pressure of 40 cmH2O for 30 s after the end of pneumoperitoneum, group R), or protective lung ventilation (low tidal volume of 6 ml/kg with positive end-expiratory pressure [PEEP] of 5 cmH2O, group P). Induction and maintenance of anesthesia were done with balanced anesthesia. Respiratory complications such as atelectasis, pneumonia or desaturation were observed postoperatively. The length of hospital stay, arterial blood gas analysis, peak inspiratory pressure and hemodynamic variables were also recorded. Results are presented as mean ± SD or number of patients (%). RESULTS Postoperative pulmonary complications (P = 0.023) and desaturation below 90 % (P = 0.016) occurred less frequently in group P than in group R. Eight patients of group R and 3 patients of group P showed atelectasis. Pneumonia was diagnosed in 1 patient of group R. No differences were observed in the length of hospital stay, arterial blood gas analysis (pH, PaO2, PaCO2 and PAO2) and hemodynamic variables except PAO2, AaDO2 and peak inspiratory pressure between the two groups. CONCLUSION Protective lung ventilation (low tidal volume with PEEP) during pneumoperitoneum was associated with less incidences of pulmonary complications than conventional ventilation with alveolar recruitment maneuver after laparoscopic hepatobiliary surgery.
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Affiliation(s)
- S J Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Gumiro-Gil 173, Bundang-gu, Seong-Nam Si, Seoul, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-do, South Korea
| | - B G Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Gumiro-Gil 173, Bundang-gu, Seong-Nam Si, Seoul, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-do, South Korea
| | - A H Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Gumiro-Gil 173, Bundang-gu, Seong-Nam Si, Seoul, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-do, South Korea
| | - S H Han
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Gumiro-Gil 173, Bundang-gu, Seong-Nam Si, Seoul, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-do, South Korea
| | - H S Han
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-do, South Korea
| | - J H Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Gumiro-Gil 173, Bundang-gu, Seong-Nam Si, Seoul, 13620, South Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Gyeonggi-do, South Korea.
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Obesity is associated with decreased lung compliance and hypercapnia during robotic assisted surgery. J Clin Monit Comput 2016; 31:85-92. [PMID: 26823286 PMCID: PMC5253149 DOI: 10.1007/s10877-016-9831-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 01/19/2016] [Indexed: 12/03/2022]
Abstract
Robotic assisted surgery (RAS) represents a great challenge for anesthesiology due to the increased intraabdomial pressures required for surgical optimal approach. The changes in lung physiology are difficult to predict and require fast decision making in order to prevent altered gas exchange. The aim of this study was to document the combined effect of patient physical status, medical history and intraoperative position during RAS on lung physiology and to determine perioperative risk factors for hypercapnia. We prospectively analyzed 62 patients who underwent elective RAS. Age, co-morbidities and body mass index (BMI) were recorded before surgery. Ventilatory parameters and arterial blood gas analysis were determined before induction of anesthesia, after tracheal intubation and on an hourly basis until the end of surgery. In RAS, the induction of pneumoperitoneum was associated with a significant decrease in lung compliance from a mean of 42.5–26.7 ml cm H2O−1 (p = 0.001) and an increase in plateau pressure from a mean of 16.1 mmHg to a mean of 23.6 mmHg (p = 0.001). Obesity, demonstrated by a BMI over 30, significantly correlates with a decrease in lung compliance after induction of anesthesia (p = 0.001). A significant higher increase in arterial CO2 tension was registered in patients undergoing RAS in steep Trendelenburg position (p = 0.05), but no significant changes in end-tidal CO2 were recorded. A higher arterial to end-tidal CO2 tension gradient was observed in patients with a BMI > 30 (p < 0.001). In conclusion, patients’ physical status, especially obesity, represents the main risk factor for decreased lung compliance during RAS and patient positioning in either Trendelenburg or steep Trendelenburg during surgery has limited effects on respiratory physiology.
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Kumagai K, Hiki N, Nunobe S, Jiang X, Kubota T, Aikou S, Tanimura S, Sano T, Yamaguchi T. Potentially fatal complications for elderly patients after laparoscopy-assisted distal gastrectomy. Gastric Cancer 2015; 17:548-55. [PMID: 23996129 DOI: 10.1007/s10120-013-0292-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/04/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The safety of surgery for gastric cancer in the elderly has been shown previously. However, potentially fatal complications based on an established severity grading system were not well described, and associated risk factors have not been assessed. The present study sought to examine severity-dependent postoperative complications after laparoscopy-assisted distal gastrectomy (LADG) in elderly patients and risk factors of potentially fatal postoperative complications. METHODS The study included 189 patients aged 70 years or older and who underwent LADG for early gastric cancer. Patient characteristics, perioperative outcomes, postoperative complications including severity assessment using the Clavien-Dindo classification, and risk factors related to postoperative complications were analyzed. RESULTS The overall complication rate was 24.9 % (47/189). The most frequent complication was abdominal fluid collection (9 cases, 4.8 %). Severe complications classified as grade III or above in the Clavien-Dindo grading system were found in 20 (10.6 %) patients. Multivariate analysis identified preoperative serum albumin concentration (odds ratio, 5.200; 95 % CI, 1.706-15.850), Roux-en-Y reconstruction (odds ratio, 3.611; 95 % CI, 1.103-11.817), and simultaneous cholecystectomy (odds ratio, 5.008; 95 % CI, 1.378-18.201) as independent predictors of a higher rate of severe postoperative complications after LADG in elderly patients. CONCLUSION The incidence of severe complications after LADG in the elderly was quite acceptable considering the risks associated with radical surgery with extensive lymphadenectomy. Preoperative serum concentrations of albumin (<4.0 g/dl), Roux-en-Y reconstruction, and simultaneous cholecystectomy are independent risk factors for severe postoperative complications in these patients.
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Affiliation(s)
- Koshi Kumagai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Özdemir M, Yanlı PY, Tomruk ŞG, Bakan N. Anaesthesia Management of a Patient with Incidentally Diagnosed Diaphragmatic Hernia During Laparoscopic Surgery. Turk J Anaesthesiol Reanim 2015; 43:50-4. [PMID: 27366465 DOI: 10.5152/tjar.2014.82787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 04/01/2014] [Indexed: 11/22/2022] Open
Abstract
Diaphragmatic hernia is usually congenital. However, it is rarely traumatic and can stay asymptomatic. In this report, we aimed to present the anaesthetic management of a patient with diaphragmatic hernia due to previous trauma (14 years ago), which was diagnosed incidentally during surgery for rectal cancer. The patient (53 years, 56 kg, 165 cm, American Society of Anaesthesiologist (ASA) II), to whom laparoscopic surgery was planned because of rectal cancer, had a history of falling from a height 14 years ago. Preoperatively, the patient did not have any sign except small right diaphragmatic elevation on the chest x-ray. After induction, maintenance of anaesthesia was continued with sevoflurane and O2/N2O. The patient was given a 30° Trendelenburg position. When the trochars were inserted by the surgeon, the diaphragmatic hernia was seen on the right part of the diaphragm, which was hidden by the liver. The surgery was continued laparoscopically but with low pressure (12 mmHg), because the patient did not have any haemodynamic and respiratory instability. The patient, who had stable haemodynamic parameters and no respiratory complications during the operation, was transferred to the ward for monitorised care. Traumatic diaphragmatic hernias can be detected incidentally after a long period of acute event. In our case, it was diagnosed during laparoscopic surgery. The surgery was completed with appropriate and careful haemodynamic monitoring and low intra-abdominal pressure under inhalational anaesthesia without any impairment in the patient's haemodynamic and respiratory parameters.
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Affiliation(s)
- Mehtap Özdemir
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Pınar Yonca Yanlı
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Şenay Göksu Tomruk
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Nurten Bakan
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
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Park JS, Ahn EJ, Ko DD, Kang H, Shin HY, Baek CH, Jung YH, Woo YC, Kim JY, Koo GH. Effects of pneumoperitoneal pressure and position changes on respiratory mechanics during laparoscopic colectomy. Korean J Anesthesiol 2012. [PMID: 23198035 PMCID: PMC3506851 DOI: 10.4097/kjae.2012.63.5.419] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background This study was designed to assess the effects of pneumoperitoneal pressure (PP) and positional changes on the respiratory mechanics during laparoscopy assisted colectomy. Methods Peak inspiratory pressure, plateau pressure, lung compliance, and airway resistance were recorded in PP of 10 mmHg and 15 mmHg, with the position change in 5 steps: head-down at 20°, head-down at 10°, neutral position, head-up at 10° and head-up at 20°. Results When the patient was placed head-down, the position change accentuated the effects of pneumoperitoneum on respiratory mechanics. However, when the patient was placed in a head-up position during pneumoperitoneum the results showed no pattern. In the 20° head-up position with the PP being 10 mmHg, the compliance increased from 30.6 to 32.6 ml/cmH2O compared with neutral position (P = 0.002). However with the PP being 15 mmHg, the compliance had not changed compared with neutral position (P = 0.989). In 20° head-down position with the PP of 10 mmHg, the compliance was measured as 24.2 ml/cmH2O. This was higher than that for patients in the 10° head-down position with a PP of 15 mmHg, which was recorded as 21.2 ml/cmH2O. Also in the airway resistance, the patient in the 20° head-down position with the PP of 10 mmHg showed 15.8 cmH2O/L/sec, while the patient in the 10° head-down position with the PP of 15 mmHg showed 16.2 cmH2O/L/sec of airway resistance. These results were not statistically significant but still suggested that the head-down position accentuated the effects of pneumoperitoneum on respiratory mechanics. Conclusions Our results suggest that respiratory mechanics are affected by the patient position and the level of PP - the latter having greater effect.
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Affiliation(s)
- Jin Suk Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
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Choi DK, Lee IG, Hwang JH. Arterial to end-tidal carbon dioxide pressure gradient increases with age in the steep Trendelenburg position with pneumoperitoneum. Korean J Anesthesiol 2012; 63:209-15. [PMID: 23060976 PMCID: PMC3460148 DOI: 10.4097/kjae.2012.63.3.209] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/26/2012] [Accepted: 04/12/2012] [Indexed: 11/10/2022] Open
Abstract
Background Several factors affect the end-tidal carbon dioxide pressure (PETCO2) and increase the arterial to end-tidal carbon dioxide pressure gradient (Pa-ETCO2) during general anesthesia. We evaluated the relationship between age and Pa-ETCO2 during pneumoperitoneum in the steep Trendelenburg position in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). Methods Ninety-two consecutive patients undergoing RALP were divided by age into a middle-aged (45-65 years) and an elderly (> 65 years) group. Anesthesia was standardized. Heart rate, mean arterial pressure, peak inspiratory pressure, lung compliance, minute ventilation, PaO2, PETCO2, PaCO2, and Pa-ETCO2 were measured 10 min after intubation in the supine position without pneumoperitoneum (T0); and 10 (T1), 60 (T2), and 120 (T3) min after pneumoperitoneum in the Trendelenburg position. Results Although PETCO2 did not change significantly during surgery, PaCO2 and Pa-ETCO2 increased gradually with time during pneumoperitoneum in the Trendelenburg position, and both parameters showed greater increases in the elderly than in the middle-aged group. Simple linear regression analyses revealed significant correlations between age and Pa-ETCO2 at T0 (P = 0.018), T1 (P = 0.006), T2 (P < 0.001), and T3 (P = 0.001). Linear mixed model analysis showed that Pa-ETCO2 was associated statistically significantly with age and duration of pneumoperitoneum in the Trendelenburg position, but age and duration of pneumoperitoneum in the Trendelenburg position were not associated (P = 0.090). Conclusions The magnitude of Pa-ETCO2 during pneumoperitoneum in the steep Trendelenburg position increased with age, which could be attributed to age-related respiratory physiological changes.
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Affiliation(s)
- Dae-Kee Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
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Gupta K, Mehta Y, Jolly AS, Khanna S. Anaesthesia for Robotic Gynaecological Surgery. Anaesth Intensive Care 2012; 40:614-21. [DOI: 10.1177/0310057x1204000406] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Robotic surgery is gaining widespread popularity due to advantages such as reduced blood loss, reduced postoperative pain, shorter hospital stay and better visualisation of fine structures. Robots are being used in urological, cardiac, thoracic, orthopaedic, gynaecological and general surgery. Robotic surgery received US Food and Drug Administration approval for use in gynaecological surgery in 2005. The various gynaecological robotic operations being performed are myomectomy, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, tubal reanastomosis, lymph node dissection, surgery of retroperitoneal ectopic pregnancy, Moskowitz procedure and endometriosis surgery. The anaesthetic considerations include difficult access to the patient intraoperatively, steep Trendelenburg position, long surgical duration and the impact of pneumoperitoneum. We highlight the complications encountered in these surgeries and methods to prevent these complications. Robotic gynaecological surgery can be safely performed after considering the physiological effects of the steep Trendelenburg position and of pneumoperitoneum. The benefits of the surgical procedure should be weighed against the risks in patients with underlying cardiorespiratory problems.
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Affiliation(s)
- K. Gupta
- Department of Anaesthesia, Medanta Medicity Hospital, Gurgaon, Delhi, India
- Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
| | - Y. Mehta
- Department of Anaesthesia, Medanta Medicity Hospital, Gurgaon, Delhi, India
| | - A. Sarin Jolly
- Department of Anaesthesia, Medanta Medicity Hospital, Gurgaon, Delhi, India
| | - S. Khanna
- Department of Anaesthesia, Medanta Medicity Hospital, Gurgaon, Delhi, India
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Does hypocapnia before and during carbon dioxide insufflation attenuate the hemodynamic changes during laparoscopic cholecystectomy? Surg Endosc 2011; 26:391-7. [DOI: 10.1007/s00464-011-1884-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 08/04/2011] [Indexed: 10/17/2022]
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Vecchio R, Gelardi V, Persi A, Intagliata E. Laparoscopic surgery in the elderly: personal experience in 141 cases. J Laparoendosc Adv Surg Tech A 2010; 20:527-31. [PMID: 20578921 DOI: 10.1089/lap.2010.0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION As life expectancy increases, the number of elderly patients presenting with surgically correctable diseases will rise as well. For advantages, which are well recognized in young patients, laparoscopic surgery has been proposed also for older patients. Because of underlying chronic diseases, however, elderly patients have been considered at high risk for the laparoscopic approach. Several studies have pointed out the risks related to cardiac, respiratory, or general comorbidities when elderly patients are proposed for laparoscopic treatment of their surgical disease. PATIENTS AND METHODS In this study, we reported our experience in 141 patients older than 65 years who were submitted to laparoscopic procedures for several indications. According to American Society of Anesthesiologists (ASA) score, patients were classified as ASA I in 70.9% of cases, ASA II in 27.6%, and ASA III in 1%. RESULTS No mortality has been reported. Conversion rate was 5.3% for bleeding in 4 cases or intraoperative hypotension in 2 cases. Mean hospital stay was 5 days. Postoperative complication was reported in 1 case and consisted of a hearth attack. CONCLUSIONS Laparoscopic surgery in the elderly is a safe procedure, if preoperative selection of the patients is accomplished. An experienced surgical team and multidisciplinary approach are mandatory.
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Affiliation(s)
- Rosario Vecchio
- Department of General Surgery, University of Catania, Catania, Italy.
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20
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Le cloisonnement vaginal : indications, technique et résultats. Prog Urol 2009; 19:1031-6. [DOI: 10.1016/j.purol.2009.09.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 09/21/2009] [Indexed: 11/18/2022]
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Awad H, Santilli S, Ohr M, Roth A, Yan W, Fernandez S, Roth S, Patel V. The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy. Anesth Analg 2009; 109:473-8. [PMID: 19608821 DOI: 10.1213/ane.0b013e3181a9098f] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraocular pressure (IOP) increases in steep Trendelenburg positioning, but the magnitude of the increase has not been quantified. In addition, the factors contributing to this increase have not been studied in robot-assisted prostatectomy cases. In this study, we sought to quantify the changes in IOP and examine perioperative factors responsible for these changes while patients are in the steep Trendelenburg position during robotic prostatectomy. METHODS In this prospective study, we measured IOP using a Tono-pen XL in 33 patients undergoing robot-assisted prostatectomy. The IOP was measured before anesthesia while supine and awake (baseline T1), anesthetized and supine (T2), anesthetized after insufflation of the abdomen with carbon dioxide (CO(2)) (T3), anesthetized in steep Trendelenburg (T4), anesthetized in steep Trendelenburg at the end of the procedure (T5), anesthetized supine before awakening (T6), and 1 hr after awakening in the supine position (T7). RESULTS On average, IOP was 13.3 +/- 0.58 (mean +/- SE) mm Hg higher at the end of the period of steep Trendelenburg position (T5) compared with supine position T1 (P < 0.0001). The least square estimates for each time point in mm Hg were as follows: T1 = 15.7, T2 = 10.7, T3 = 14.6, T4 = 25.2, T5 = 29.0, T6 = 22.2, T7 = 17.0. Using univariate mixed effects models for the T1-T5 time periods, peak airway pressure, mean arterial blood pressure, ETco(2), and time were significant predictors of the IOP increase, whereas age, body mass index, blood loss, volume of IV fluid administered, mean airway pressure, and desflurane concentration were not predictive. In T4-T5, which involved no significant positional or perioperative interventions, we performed a multivariate analysis to evaluate predictors of IOP increases. Surgical duration (in minutes) and ETco(2) were the only significant variables predicting changes in IOP during stable and prolonged Trendelenburg positioning. On average, IOP increased 0.21 mm Hg per mm Hg increase in ETco(2) after adjusting for time. An increase of 0.05 mm Hg in IOP per minute of surgery on average was observed during this period in the Trendelenburg position after adjusting for ETco(2). CONCLUSIONS IOP reached peak levels at the end of steep Trendelenburg position (T5), on average 13 mm Hg higher than the preanesthesia induction (T1) value. Surgical duration and ETco(2) were the only significant predictors of IOP increase in the Trendelenburg position (T4-T5).
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Affiliation(s)
- Hamdy Awad
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio 43210, USA.
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Park HP, Hwang JW, Kim YB, Jeon YT, Park SH, Yun MJ, Do SH. Effect of Pre-emptive Alveolar Recruitment Strategy before Pneumoperitoneum on Arterial Oxygenation during Laparoscopic Hysterectomy. Anaesth Intensive Care 2009; 37:593-7. [DOI: 10.1177/0310057x0903700419] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In a randomised, controlled, single-blind trial, we examined the effect of a pre-emptive alveolar recruitment strategy on arterial oxygenation during subsequent pneumoperitoneum. After intubation, 50 patients were randomly allocated to receive either tidal volume 10 ml/kg with no positive end-expiratory pressure (group C) or alveolar recruitment strategy of 10 manual breaths with peak inspiratory pressure of 40 cmH2O plus positive end-expiratory pressure of 15 cmH2O before gas insufflation (group P). During pneumoperitoneum, group P was ventilated with the same setting as group C (FiO2=0.35, tidal volume 10 ml/kg). PaO2 measured during peumoperitoneum was higher in group P than in group C (166∓32 mmHg vs 145∓34 mmHg at 15 minutes, P=0.028, 155∓30 mmHg vs 136∓32 mmHg at 30 minutes, P=0.035). Alveolar-arterial oxygen gradient in group P increased less after gas insufflation (13∓9 to 60∓34 mmHg vs 10∓9 to 37∓31 mmHg, P=0.013). We conclude that the alveolar recruitment strategy we applied before insufflation of the peritoneal cavity may improve oxygenation during laparoscopic hysterectomy.
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Affiliation(s)
- H.-P. Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Assistant Professor, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - J.-W. Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Y. B. Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Assistant Professor, Department of Obstetrics and Gynecology. Seoul National University Bundang Hospital
| | - Y.-T. Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - S.-H. Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - M. J. Yun
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - S. H. Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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Maracajá-Neto LF, Verçosa N, Roncally AC, Giannella A, Bozza FA, Lessa MA. Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery. Acta Anaesthesiol Scand 2009; 53:210-7. [PMID: 19175578 DOI: 10.1111/j.1399-6576.2008.01826.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The effect of neuromuscular blockade (NMB) and positive end-expiratory pressure (PEEP) on the elastic properties of the respiratory system during pneumoperitoneum (PnP) remains a controversial subject. The main objective of the present study was to evaluate the effects of NMB and PEEP on respiratory mechanics. METHODS We performed a dynamic analysis of respiratory mechanics in patients subjected to PnP. Twenty-one patients underwent cholecystectomy videolaparoscopy and total intravenous anesthesia. The respiratory system resistance (R(RS)), pulmonary elastance (E(P)), chest wall elastance (E(CW)), and respiratory system elastance (E(RS)) were computed via the least squares fit technique using an equation describing the motion of the respiratory system, which uses primary signs such as airway pressure, tidal volume, air flow, and esophageal pressures. Measurements were taken after tracheal intubation, PnP, NMB, establishment of PEEP (10 cmH2O), and PEEP withdrawal [zero end-expiratory pressure (ZEEP)]. RESULTS PnP significantly increased E(RS) by 27%; both E(P) and E(CW) increased 21.3 and 64.1%, respectively (P < 0.001). NMB did not alter the respiratory mechanic properties. Setting PEEP reduced E(RS) by 8.6% (P < 0.05), with a reduction of 10.9% in E(P) (P < 0.01) and a significant decline of 15.7% in R(RS) (P < 0.05). These transitory changes in elastance disappeared after ZEEP. CONCLUSIONS We concluded that the 10 cmH2O of PEEP attenuates the effects of PnP in respiratory mechanics, lowering R(RS), E(P), and E(RS). These effects may be useful in the ventilatory approach for patients experiencing a non-physiological increase in IAP owing to PnP in laparoscopic procedures.
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Affiliation(s)
- L F Maracajá-Neto
- Service of Anesthesiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Klopfenstein CE, Schiffer E, Pastor CM, Beaussier M, Francis K, Soravia C, Herrmann FR. Laparoscopic colon surgery: unreliability of end-tidal CO2 monitoring. Acta Anaesthesiol Scand 2008; 52:700-7. [PMID: 18419725 DOI: 10.1111/j.1399-6576.2007.01568.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The relatively good haemodynamic and respiratory tolerance to abdominal CO(2) insufflation has mostly been observed in healthy patients during short-lasting laparoscopic procedures. End-tidal CO(2) pressure (PetCO(2)) has been shown to be a reliable method to assess arterial CO(2) (PaCO(2)) in the absence of cardio-respiratory disease in this setting. However, no study has investigated whether PetCO(2) is accurately related to PaCO(2) during laparoscopic colon surgery. Indeed, these procedures last longer, prolonging the pneumoperitoneum and requiring a Trendelenburg position. The aim of the present study was to measure the PaCO(2)-PetCO(2) difference over time in patients undergoing laparoscopic colon surgery and to determine whether PaCO(2) is reliably assessed by PetCO(2). METHODS Forty consecutive patients (ASA I and II) scheduled for laparoscopic colon surgery were anaesthetized and ventilated to obtain a PetCO(2) between 4.0 and 5.5 kPa. After initiation of CO(2) insufflation, PaCO(2) and PetCO(2) were recorded every 30 min during surgery. RESULTS No complication was observed during anaesthesia. The mean arterial pressure increased significantly after CO(2) insufflation and remained steady up to the end of pneumoperitoneum. The heart rate remained stable over time. The relation between PaCO(2) and PetCO(2) was not constant among patients and increased over time within the same patients. The R(2) values fluctuated and did not show a constant correlation between PaCO(2) and PetCO(2). CONCLUSION The correlation between PaCO(2) and PetCO(2) during laparoscopic colon surgery is inconsistent mainly due to inter- and intra-individual variability.
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Affiliation(s)
- C E Klopfenstein
- Service of Anaesthesiology, University Hospitals, Geneva, Switzerland.
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Lee SW, Kim MW. Acute pulmonary edema progressing from unilateral to bilateral after brief laparoscopic surgery under lateral position in elderly patient - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.5.644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sung Won Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Dongguk University, Gyeongju, Korea
| | - Mi-Woon Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Dongguk University, Gyeongju, Korea
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