Is there any effect of pneumoperitoneum pressure on coagulation and fibrinolysis during laparoscopic cholecystectomy?

Effects of surgical trauma and intraoperative blood loss on tumour progression

Surgery is the primary treatment of choice for tumours, and improves prognosis, prolongs survival and is potentially curative. Previous studies have described the effects of anaesthesia and changes in the neuroendocrine, circulatory and sympathetic nervous systems on postoperative cancer progression. There is growing evidence that intraoperative blood loss is an independent prognostic factor for tumour recurrence, postoperative inflammation is a predictor of cancer prognosis, and immunosuppressive status correlates with the degree of surgical damage. This paper outlines the potential mechanisms by which blood loss, surgical trauma and postoperative immunosuppressive status contribute to tumour growth and recurrence by reducing intraoperative haemorrhage and perioperative immunotherapy, thereby reducing tumour growth and recurrence, and improving long-term prognosis.

Novel risk prediction models for deep vein thrombosis after thoracotomy and thoracoscopic lung cancer resections, involving coagulation and immune function

The main focus of this study was to compare the predictive value of coagulation, fibrinolysis, thromboelastography, stress response, and immune function in predicting the incidence of deep venous thrombosis (DVT) in lung cancer (LC) patients undergoing thoracoscopic LC resection vs thoracotomy LC resection. To do that, a prospective, single-center, case-control study involving 460 LC patients was conducted. The risk indicators affecting patients with DVT after LC resection in the testing cohort were determined using logistic regression and receiver operator characteristic (ROC) analyses. One validation cohort was used to assess the risk prediction models. DVT incidence was higher in the thoracoscopic group (18.7%) than in the thoracotomy group (11.2%) in the testing cohort (χ ² = 4.116, P = 0.042). The final model to predict the incidence of DVT after thoracoscopic LC excision (1 day after surgery) was as follows: Logit(P) = 9.378 - 0.061(R-value) - 0.109(K value) + 0.374(α angle) + 0.403(MA) + 0.298(FIB) + 0.406(D-D) + 0.190(MDA) - 0.097(CD4⁺/CD8⁺). For thoracotomy LC resection, the final model (3 days after operation) was: Logit(P) = -2.463 - 0.026(R-value) - 0.143(K value) + 0.402(α angle) + 0.198(D-D) + 0.237(MDA) + 0.409(SOD). In the validation cohort, this risk prediction model continued to demonstrate good predictive performance. As a result, the predictive accuracy of postoperative DVT in patients who underwent thoracoscopic LC resection and thoracotomy LC resection was improved by risk prediction models.

Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis

BACKGROUND

Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group.

MATERIALS AND METHODS

We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay.

RESULTS

Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73).

CONCLUSIONS

Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.

Effect of obesity on venous hemodynamics of the lower limbs during laparoscopic cholecystectomy

OBJECTIVE

The present study aims to compare the changes of venous flow parameters of the lower limbs under the assessment based on the duplex ultrasound scanning in obese and non-obese individuals by complying with body mass index during laparoscopic cholecystectomy.

METHODS

A prospective cohort study was conducted in non-obese (body mass index <25 kg/m²) and obese individuals (body mass index >30 kg/m²) during laparoscopic cholecystectomy to analyze venous hemodynamics of the lower limbs. The assessment was conducted on Femoral vein diameter, Femoral vein cross-sectional area, Femoral vein peak velocity, and Femoral vein volume flow. The change values (%) of venous flow parameters of the lower limbs were calculated as a percentage by: (intra-operative parameter-pre-operative parameter)/ pre-operative parametersX100%.

RESULTS

45 right lower limbs were examined in 45 non-obese individuals and 33 right lower limbs in 33 obese individuals during laparoscopic cholecystectomy. The statistically significant difference was identified in the pre-operative and intra-operative values of Femoral vein diameter, Femoral vein cross-sectional area, Femoral vein peak velocity, as well as Femoral vein volume flow in both groups when these were analyzed independently (p = .00). When the change values of venous flow parameters of the lower limbs of the two groups were compared, more changes were identified significantly in the obese group, Femoral vein diameter (p = .042), Femoral vein cross-sectional area (p = .013), Femoral vein peak velocity (p = .002), and Femoral vein volume flow (p = .032).

CONCLUSION

The changes of lower limb venous flow parameters showed more significant difference in obese than in non-obese individuals during laparoscopic cholecystectomy. The mentioned findings may in part explain why obese patients undergoing laparoscopic cholecystectomy have a higher rate of post op deep venous thrombosis.

Low-pressure versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials

Introduction

It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor.

Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy.

Materials and methods

This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions.

Results

This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome).

Conclusions

This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09201-1.

Caprini score and surgical times linked to the risk for venous thromboembolism after robotic-assisted radical prostatectomy

OBJECTIVE

To evaluate the Caprini score as an independent predictor of venous thromboembolism (VTE) in patients undergoing robotic-assisted radical prostatectomy (RARP) and to identify appropriate cut-points for clinical use.

MATERIAL AND METHODS

We performed a retrospective review of patients who underwent RARP for prostate cancer between December 2003 and February 2016. VTE cases developed the condition within 90 days of discharge. The control group was comprised of patients whose RARP most closely preceded and followed each VTE case in time and who were matched on lymph node dissection and surgeon. The Caprini score was calculated for each patient, and the groups were compared on a number of clinical variables. Multiple logistic regression was used to evaluate whether the Caprini score was an independent predictor of VTE. Receiver operating characteristics (ROC) curves were used to establish appropriate clinical cutpoints.

RESULTS

A total of 3719 patients underwent RARP during the study period. A total of 52 (1.4%) of patients met the criteria for cases. Data were available for 97 patients who met the criteria for controls. Multiple logistic regression indicated that the Caprini score and operative time were independently both significant predictors of VTE (p=0.005 and p=0.044, respectively). ROC indicated that the Caprini score showed a significant but moderate relationship to VTE (area under curve [AOC]=0.64; p=0.004). A Caprini score >6 was the best arithmetic balance for sensitivity (61.5; 95% confidence interval [CI]: 47.0-74.7) and specificity (59.8; 95% CI: 49.3-69.6).

CONCLUSION

The Caprini score predicts postoperative VTE in patients undergoing RARP.

Comparison of the effects of spinal epidural and general anesthesia on coagulation and fibrinolysis in laparoscopic cholecystectomy: a randomized controlled trial: VSJ Competition, 2nd place

Introduction

Laparoscopic cholecystectomy (LC) is usually performed under general anesthesia. Recently, laparoscopic cholecystectomy under regional anesthesia has become popular, but this creates a serious risk of thromboembolism because of pneumoperitoneum, anesthesia technique, operative positioning, and patient-specific risk factors.

Aim

This randomized controlled trial compares the effects of two different anesthesia techniques in laparoscopic cholecystectomy on coagulation and fibrinolysis.

Material and methods

This randomized prospective study included 60 low-risk patients with deep vein thrombosis (DVT) who underwent elective LC without thrombo-emboli prophylaxis. The patients were randomly divided into two groups according to the anesthesia technique: the general anesthesia (group 1, n = 30) and spinal epidural anesthesia (group 2, n = 30) groups. Measurement of the prothrombin time (PT), thrombin time (TT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), and blood levels of D-dimer (DD) and fibrinogen (F) were recorded preoperatively (pre), at the first hour (post 1) and 24 h (post 24) after the surgery. These results were compared both between and within the groups.

Results

The mean age was 51.5 ±16.7 years (range: 19–79 years). Pneumoperitoneum time was similar between group 1 (33.8 ±7.8) and group 2 (34.8 ±10.4). The TT levels significantly declined postoperatively in both groups. The levels of PT, aPTT, INR, D-dimer and fibrinogen dramatically increased postoperatively in both groups.

Conclusions

While there was not any DVT, there was a significant decline in TT. There was a dramatic rise in the PT, INR, D-dimer, fibrin degradation products (FDP), and fibrinogen following LC. This may be attributed to the effects of pneumoperitoneum and anesthesia techniques on portal vein flow.