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Lekamalage BBW, Seidelin J, Arachchi A. Is there a role for warm humidified carbon dioxide insufflation in open abdominal surgery? ANZ J Surg 2024; 94:508-509. [PMID: 37984535 DOI: 10.1111/ans.18774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023]
Affiliation(s)
| | | | - Asiri Arachchi
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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Sharma S, McKechnie T, Khamar J, Wu K, Hong D, Eskicioglu C. The role of warmed-humidified carbon dioxide insufflation in colorectal surgery: A systematic review and meta-analysis. Colorectal Dis 2024; 26:7-21. [PMID: 37985859 DOI: 10.1111/codi.16798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/30/2023] [Accepted: 09/10/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Maintenance of normothermia is a crucial part of enhanced recovery after colorectal surgery. Dry-cold carbon dioxide (CO2 ) traditionally used for insufflation in laparoscopic surgery and negative pressure operating theatres has been associated with intraoperative hypothermia. Studies suggest that use of warmed-humidified CO2 may promote normothermia. However, due to a scarcity of high-quality studies demonstrating a proven benefit on intraoperative core body temperature, its use in colorectal surgery remains limited. Therefore, the aim of this review was to evaluate the effects of warmed-humidified CO2 compared to traditional dry-cold CO2 , or ambient air in operating theatres, during colorectal surgery. METHODS A search of Medline, EMBASE, and CENTRAL was performed. Randomised controlled trials (RCTs) that compared patients receiving warmed-humidified CO2 with either dry-cold CO2 insufflation in laparoscopic procedures or no insufflation during open surgery were included. The primary outcome was change in intraoperative core body temperature. Secondary outcomes included length of stay, operating time, return of gastrointestinal function, wound infection, and postoperative pain. A pairwise meta-analysis was performed using inverse variance random effects. RESULTS Among the six RCTs included, 208 patients received warmed-humidified CO2 (42.3% female, mean age: 65.8 years) and 210 patients received either dry-cold CO2 in laparoscopic procedures or no gas insufflation during open procedures (46.2% female, mean age: 66.1 years). No significant difference was found for change in intraoperative core body temperature (MD = 0.01, 95% CI: -0.1, 0.11, p = 0.90, very low certainty). Patients in the warmed-humidified CO2 group had significantly higher pain scores on postoperative day 1 (MD = 1.61, 95% CI: 0.91, 2.31, p < 0.05, very low certainty). No significant differences were found in any of the other secondary outcomes studied. CONCLUSION Patients undergoing colorectal surgery receiving warmed-humidified CO2 do not experience any clinically meaningful difference in core body temperature change compared to their counterparts receiving dry-cold CO2 insufflation or no insufflation. However, patients may report greater pain scores on postoperative day 1 with warmed-humidified CO2 . There is likely no clinically important difference between warmed-humidified CO2 and dry-cold CO2 for patients undergoing colorectal surgery. Patient, clinician, and institution factors should be considered when deciding between these two insufflation modalities.
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Affiliation(s)
- Sahil Sharma
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kathy Wu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Chien AL, Doppalapudi SK, Pfail JL, Lee G, Mikhail M, Ahuja B, Tito ET, Shah U, Barone J, Ahmed H, Elsamra S. Comparison of a Valveless Trocar System and Conventional Insufflation in Pediatric Urologic Surgery. J Endourol 2024; 38:47-52. [PMID: 37819689 DOI: 10.1089/end.2023.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
Abstract
Background: Conventional operative insufflation uses a one-way trocar to handle instruments while maintaining pneumoperitoneum. In 2007, the AirSeal® valveless trocar insufflation system was introduced, which maintains stable pneumoperitoneum while continuously evacuating smoke. Although this device has been validated in adult patients, it has not been extensively validated in the pediatric population. Materials and Methods: A retrospective cohort study of pediatric urology patients aged 0 to 21 who underwent laparoscopic pyeloplasty between March 2016 and October 2021 was performed. Intraoperative physiologic parameters, procedure characteristics, postoperative outcomes, and demographics of each patient in whom either AirSeal insufflation system (AIS) or conventional insufflation system (CIS) was utilized were obtained from hospital records. Data were compared across the AIS and CIS cohorts. The primary outcomes were intraoperative anesthetic and physiologic parameters, including end tidal carbon dioxide, oxygen saturation, body temperature, positive inspiratory pressure, systolic blood pressure, and heart rate. Results: There were no significant differences in the anesthetic and physiologic parameters in the AIS and CIS groups. In addition, no differences in demographics, procedural characteristics, or complication rates were found between the cohorts. Conclusion: The AirSeal valveless trocar insufflation system demonstrates comparable intraoperative anesthetic and physiologic outcomes compared to conventional one-way valve insufflation in pediatric laparoscopic pyeloplasty. Certain surgeon-related qualitative metrics are underappreciated in this study, however, including improved visualization with vigorous suctioning and pressure maintenance with frequent instrument exchanges. Surgeon experience may mask the benefits of these characteristics as it pertains to quantitative surgical outcomes such as estimated blood loss, operative time, and perioperative complications.
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Affiliation(s)
- Austin L Chien
- Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Sai Krishnaraya Doppalapudi
- Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - John L Pfail
- Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Grace Lee
- Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mark Mikhail
- Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Brittany Ahuja
- Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Emmanuel Tadjou Tito
- Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Usman Shah
- Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Joseph Barone
- Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Haris Ahmed
- Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Sammy Elsamra
- Division of Urology, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Garoufalia Z, Gefen R, Emile SH, Zhou P, Silva-Alvarenga E, Wexner SD. Financial and Inpatient Burden of Adhesion-Related Small Bowel Obstruction: A Systematic Review of the Literature. Am Surg 2023; 89:2693-2700. [PMID: 36113044 DOI: 10.1177/00031348221126952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Postoperative adhesions may occur after >90% of laparotomies and is the most common cause of small bowel obstruction (SBO). Despite the high incidence, there is a lack of data related to financial implications of adhesion-related SBO (ASBO). This systematic literature review of in-hospital costs for treatment of ASBO searched PubMed, Scopus and Google Scholar databases according to PRISMA guidelines. Exclusion criteria were reviews, editorials, clinical vignettes, studies of patients <18 years of age, studies with no English full text and studies assessing adhesiolysis for causes other than SBO or that used extrapolations with economic models. Main outcome measures were financial costs per patient and national costs. RESULTS Seven studies, published between 1999 and 2016, incorporating a total of 39 573 patients, were identified. Four were undertaken in European countries, one in the USA, 1 in New Zealand and 1 in Nigeria. Overall national costs regarding treatment of patients with ASBO ranged between $3.468 million and $1.77 billion. Median overall cost in the medical management group was $2371.5 ($1814-$2568) vs $12370 ($4914-$25321) in the surgical group. Median length of stay was 4 (3-7) days for patients conservatively treated and 11.5 (8-16.3) days for patients who underwent surgery. Median length of stay of operated patients on was almost triple that of patients conservatively managed. CONCLUSIONS Given the major financial implications of ASBO, further initiatives are needed to avoid operations for SBO when clinically appropriate and minimize delays taking patients with high suspicion of complete SBO to the operating room.
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Affiliation(s)
- Zoe Garoufalia
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Rachel Gefen
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Sameh Hany Emile
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Peige Zhou
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Arachchi A, Lee A, Metlapalli M, Antoniou E, Rajan R, Narasimhan V, Rajagopalan A, Key S, Teoh WMK, Nguyen TC, Lim JTH, Chouhan H, Waxman BP, Smith JA. Does intra-operative humidification with warmed CO 2 reduce surgical site infection in open colorectal surgery? A randomized control trial. ANZ J Surg 2022; 93:970-979. [PMID: 36259219 DOI: 10.1111/ans.18116] [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: 07/16/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUNDS Surgical site infections (SSI) are a significant cause of postoperative morbidity and mortality, contributing to a considerable financial burden on the healthcare system. Insufflation of the open surgical wound with warm, humidified carbon dioxide (CO2 ) is a novel measure aimed to reduce SSI. The local atmosphere of warm, humidified CO2 within the open surgical wound is proposed to decrease airborne contamination, bacterial growth, desiccation, and heat loss while improving tissue oxygenation and perfusion. This randomized controlled trial evaluates the impact of the HumiGard™ surgical humidification system on the incidence of SSI in patients undergoing open colorectal surgery. METHODS We conducted a multi-site single-blinded randomized control trial on patients undergoing elective or emergency laparotomy at a single tertiary Colorectal Surgery service. The primary outcome measure was the incidence of SSI, with secondary outcomes including ICU length of stay (LOS), total LOS and mean core temperature. RESULTS Patients who received HumiGard™ had a lower incidence of SSI, although this did not reach statistical significance (4.5% for treatment group versus 13.0% for control group; P = 0.092). There was no significant difference in ICU LOS or total LOS between cohorts. The HumiGard™ group had a higher mean core temperature than the control at the end of surgery (P < 0.001). CONCLUSION The present study could not confirm that utilization of warm, humidified CO2 with HumiGard™ reduces SSI in open colorectal surgery. Further research is indicated to validate and extend these findings.
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Affiliation(s)
- Asiri Arachchi
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Alice Lee
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Manisha Metlapalli
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ellathios Antoniou
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Ruben Rajan
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Vignesh Narasimhan
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ashray Rajagopalan
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Seraphina Key
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - William M K Teoh
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Thang Chien Nguyen
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - James Tow-Hing Lim
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Hanumant Chouhan
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Bruce P Waxman
- Department of Colorectal Surgery, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
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Garrett C, Steffens D, Ansari N, Koh C. A phase I, nonrandomized controlled trial demonstrating the novel technique of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy utilizing warm humidified carbon dioxide insufflation. Colorectal Dis 2021; 23:1573-1578. [PMID: 33599086 DOI: 10.1111/codi.15588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/25/2021] [Accepted: 02/11/2021] [Indexed: 12/12/2022]
Abstract
AIM The aim of this work was to report on the safety and feasibility of warm humidified CO2 (WHCO2 ) insufflation during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHOD Ten consecutive patients with histologically confirmed peritoneal cancer were enrolled in this phase I pilot nonrandomized controlled trial. They were alternately assigned to CRS and HIPEC with WHCO2 versus standard procedure. WHCO2 was delivered at 10 L/min, a pressure of 4.5 bar, 37ºC and 98% relative humidity during CRS using the HumiGardTM system. HIPEC was performed with an open abdomen using the Coliseum technique at 42ºC for 60 min. All patients were admitted to the intensive care unit and commenced on total parenteral nutrition postoperatively. Surface and core temperatures were measured every 30 min using an infrared camera and nasopharyngeal probe, respectively. Clinicopathological, intra- and postoperative details were collated between groups, and median surface and core temperatures were statistically compared. RESULTS Surface and core temperatures were generally higher in the WHCO2 group. Core temperature at 120 and 180 min was significantly higher in the WHCO2 versus the non-WHCO2 group (p = 0.028 and 0.008, respectively). There was a significant linear relationship between core and surface temperature at 30, 60, 90, 120, 150 and 180 min (p = 0.033, 0.004, 0.007, 0.021, 0.009 and 0.006, respectively). The peritoneal cancer index was lower but the estimated blood loss was higher in the non-WHCO2 than the WHCO2 group. CONCLUSION WHCO2 in CRS and HIPEC appears to be safe and feasible. An appropriately powered phase II trial will be required to determine if WHCO2 is associated with improved intra- and postoperative outcomes.
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Affiliation(s)
- Celine Garrett
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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