A case of carbon dioxide embolism during the transperineal approach in total pelvic exenteration for advanced anorectal cancer

Abstract

The transanal and transperineal endoscopic approaches are useful advanced surgical options for removing rectal and anorectal cancers. Intraoperative carbon dioxide (CO 2) embolisms, however, have been increasingly reported as potentially fatal complications associated with surgery employing these approaches. We report our experience with a CO 2 embolism that was detected because of a sudden drop in end-tidal CO 2 with decreasing saturation of percutaneous arterial oxygen during total pelvic exenteration using the transperineal endoscopic approach under pneumopelvis/pneumoperitoneum. Transesophageal echocardiography confirmed that it was a CO 2 embolus. We reversed the pneumopelvis and pneumoperitoneum, which alleviated the cardiopulmonary problems, and the surgery then proceeded to achieve R0 resection. The patient was discharged without severe complications other than the CO 2 embolism.

Carbon dioxide embolism during transanal total mesorectal excision: A hint of prevention from a case report

“…Echocardiography is essential for diagnosing CO 2 embolism. Transesophageal echocardiography is especially useful for finding air bubbles in the right atrium and ventricle 10 . If CO 2 embolism occurs and cardiopulmonary collapse is not severe, we can wait until the vital signs are stabilized with CO 2 absorption.…”

“…Transesophageal echocardiography is especially useful for finding air bubbles in the right atrium and ventricle. 10 If CO 2 embolism occurs and cardiopulmonary collapse is not severe, we can wait until the vital signs are stabilized with CO 2 absorption. Approximately 85% of the cases could resume the procedure with or without delay.…”

Detection of carbon dioxide embolism by transesophageal echocardiography during transanal/perineal endoscopic surgery: a pilot study

“…We have previously had a case of CDE during tp-TPE in which the patient's condition worsened due to delayed diagnosis of CDE and conversion to laparotomy was required 21 . Early detection and management of CDE is important to prevent a deteriorating situation.…”

Carbon Dioxide Embolism During Transanal Total Mesorectal Excision: Case Report and Literature Review

“…(d) A decrease in pneumopelvic pressure (10-12 mmHg) reduces the pressure gradient between the pneumopelvis and the colorectal venous plexus (5). Notably, the patient should not be placed in the Trendelenburg position for a sustained period; pressure gradient caused by the surgical site being above the level of the heart tends to increase the risk of CO 2 embolism (7). If the patient does not have myocardial compromise, crystalloids must be administered preoperatively to increase the central venous pressure (26).…”

“…The anesthesiologist should set the threshold for P ET CO 2 within a narrow range, and the possibility of CO 2 embolism should always be considered when biphasic evolution of P ET CO 2 is noticed and a sudden deterioration in hemodynamics occurs. For high-risk patients, TEE or PCD are necessary monitoring methods (7).…”