Gas embolism under standard versus low pneumoperitoneum pressure during laparoscopic liver resection (GASES): study protocol for a randomized controlled trial

Abstract

Background Gas embolism induced by CO2 pneumoperitoneum is commonly identified as a risk factor for morbidity, especially cardiopulmonary morbidity, after laparoscopic liver resection (LLR) in adults. Increasing pneumoperitoneum pressure (PP) contributes to gas accumulation following laparoscopy. However, few studies have examined the effects of PP in the context of LLR. In LLR, the PP-central venous pressure (CVP) gradient is increased due to hepatic vein rupture, hepatic sinusoid exposure, and low CVP management, which together increase the risk of CO2 embolization. The aim of this study is to primarily determine the role of low PP (10 mmHg) on the incidence of severe gas embolism. Methods Adult participants (n = 140) undergoing elective LLR will be allocated to either a standard (15 mmHg) or low (10 mmHg) PP group. Anesthesia management, postoperative care, and other processes will be performed similarly in both groups. The occurrence of severe gas embolism, which is defined as gas embolism ≥ grade 3 according to the Schmandra microbubble method, will be detected by transesophageal echocardiography (TEE) and recorded as the primary outcome. The subjects will be followed up until discharge and followed up by telephone 1 and 3 months after surgery. Postoperative outcomes, such as the Post-Operative Quality of Recovery Scale, pain severity, and adverse events, will be assessed. Serum cardiac markers and inflammatory factors will also be assessed during the study period. The correlation between intraoperative inferior vena cava-collapsibility index (IVC-CI) under TEE and central venous pressure (CVP) will also be explored. Discussion This study is the first prospective randomized clinical trial to determine the effect of low versus standard PP on gas embolism using TEE during elective LLR. These findings will provide scientific and clinical evidence of the role of PP. Trial status Protocol version: version 1 of 21-08-2020 Trial registration ChiCTR2000036396 (http://www.chictr.org.cn). Registered on 22 August 2020.

Minimally invasive mesohepatectomy for centrally located liver lesions—a case series

“…Therefore, many hepatobiliary surgeons use intra-abdominal pressure rates of 10–14 mmHg to control back bleedings from hepatic veins during parenchymal transection, whereas other hepatobiliary surgeons reported pressure rates of 16–20 mmHg without safety issues [ 30 , 40 , 41 ]. However, a definitive consensus on which pressure to be used is not available due to the lack of prospective clinical trials [ 30 , 42 ]. In our study, none of the patients had gas embolism using a pneumoperitoneum rate up to 18 mmHg.…”

Acute respiratory distress syndrome secondary to carbon dioxide gas embolism after single-port robotic-assisted perineal radical prostatectomy: a case report

“…According to the reported literature, the incidence of severe CO 2 embolism was less than 1%, but the mortality rate could reach 28% ( 7 ). However, it has also been shown that the overall incidence of intraoperative venous gas embolization was 38% and 69% in laparoscopic radical prostatectomy and cholecystectomy, respectively ( 8 ). One obvious mechanism of gas entering the vascular system is the open connection of the vein to the environment when the venous pressure is lower than the ambient pressure.…”

Comparing the efficacy and safety of three surgical approaches for total hysterectomy (TSATH): protocol for a multicentre, single-blind, parallel-group, randomised controlled trial

“…This protocol will follow the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) reporting guidelines, which are reported in the SPIRIT checklist. 17 …”