Abstract
BackgroundAnimal studies have shown that peritoneal injury can be minimized by insufflating the abdominal cavity with warm humidified carbon dioxide gas.MethodsA single‐blind RCT was performed at a tertiary colorectal unit. Inclusion criteria were patient aged 18 years and over undergoing open elective surgery. The intervention group received warmed (37°C), humidified (98 per cent relative humidity) carbon dioxide (WHCO2 group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3‐chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T0) and end (Tend) of the operation. Postoperative clinical outcomes were compared between the groups.ResultsOf 40 patients enrolled, 20 in the WHCO2 group and 19 in the control group were available for analysis. A significant log(Tend/T0) difference between control and WHCO2 groups was documented for interleukin (IL) 2 (5·3 versus 2·8 respectively; P = 0·028) and IL‐4 (3·5 versus 2·0; P = 0·041), whereas apoptosis assays documented no significant change in caspase activity, and similar apoptosis rates were documented along the peritoneal edge in both groups. The 3‐chlorotyrosine/tyrosine ratio had increased at Tend by 1·1‐fold in the WHCO2 group and by 3·1‐fold in the control group. Under light microscopy, peritoneum was visible in 11 of 19 samples from the control group and in 19 of 20 samples from the WHCO2 group (P = 0·006). The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2·5 versus 5·0 days respectively; P = 0·008).ConclusionThe use of warmed, humidified carbon dioxide appears to reduce some markers related to peritoneal oxidative damage during laparotomy. No difference was observed in clinical outcomes, but the study was underpowered for analysis of surgical results. Registration number: NCT02975947 ( http://www.clinicaltrials.gov/).
Highlights
Open abdominal surgery is performed routinely for a number of diseases; it can be complicated by postoperative ileus, infection, anastomotic leak and, in the long term, bowel obstruction
Patients were excluded if they had emergency surgery, laparoscopic surgery and/or presented with chronic obstructive pulmonary disease (COPD) requiring home oxygen, were carbon dioxide retainers, or if it was determined that their forced expiratory volume in 1 s (FEV1) was less than 1 litre, or predicted FEV1/forced vital capacity ratio was below 50 per cent
Between February 2013 and December 2016, 40 patients were recruited for the trial and randomly allocated into two groups, each of 20 subjects
Summary
Open abdominal surgery is performed routinely for a number of diseases; it can be complicated by postoperative ileus, infection, anastomotic leak and, in the long term, bowel obstruction. Open surgery exposes the intestine to ambient air (20∘C, 0–5 per cent relative humidity), which, combined with operating theatre negative air ventilation, has the potential to cause serosal/peritoneal desiccation[1]. The intervention group received warmed (37∘C), humidified (98 per cent relative humidity) carbon dioxide (WHCO2 group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3-chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T0) and end (Tend) of the operation. The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2⋅5 versus 5⋅0 days respectively; P = 0⋅008).
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