Carbon Dioxide Embolism Associated With Total Mesorectal Excision Surgery: A Report From the International Registries

Abstract

BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12–20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.

Evolution of transanal total mesorectal excision according to the IDEAL framework

“…The first combined paper from the International TaTME Registry and US TaTME registry, currently in press, reports on an incidence of 25/6375 (0.4%). They recommend awareness among surgeons and anesthetists, as early recognition and management can limit the clinical impact of such a complication 35…”

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“…Early postoperative outcomes are encouraging, showing no significant difference in 30-day postoperative complications (55) and oncologic outcomes which are equivalent (56) or even improved compared to laparoscopy (57). As with any innovation, there have been some hurdles with this approach, such as the troubling frequency of carbon dioxide embolus (58) and urethral injury (59,60). Long-term results are not yet available, but they are being systematically gathered thanks to several international registries and ongoing trials, such as the COLOR III trial currently enrolling patients to assess laparoscopic TME compared to transanal TME.…”

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“…The reported incidence varies widely, and probably depends on the type of procedure and the method used to detect embolization. When surgeons are retrospectively asked to recall clinically significant GE during transanal total mesorectal excision (TaTME), incidence is 0.45% [1]. On the other hand, transesophageal echocardiography detects gas bubbles in up to 100% of laparoscopic hysterectomies [2].…”