Intra-operative open-lung ventilatory strategy reduces postoperative complications after laparoscopic colorectal cancer resection

Abstract

BACKGROUND The role of the positive end-expiratory pressure (PEEP) and lung recruitment manoeuvre (LRM) combination (termed open-lung strategy, OLS) during intra-operative mechanical ventilation is not clear. OBJECTIVE To determine whether an open-lung strategy constituting medium PEEP (6–8 cmH 2 O) and repeated LRMs protects against postoperative complications in at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation. DESIGN A prospective, assessor-blinded, randomised controlled trial. SETTING Single university-affiliated hospital, conducted from January 2017 to October 2018. PATIENTS A total of 280 patients at risk of pulmonary complications, scheduled for laparoscopic colorectal cancer resection under general anaesthesia and low-tidal-volume (6–8 ml kg −1 predicted body weight) ventilation. INTERVENTION The patients were randomly assigned (1 : 1) to a PEEP of 6–8 cmH 2 O with LRMs repeated every 30 min (OLS group) or a zero PEEP without LRMs (non-OLS group). MAIN OUTCOME MEASURES The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within 7 days after surgery. The secondary outcomes included intra-operative potentially harmful hypotension and the need for vasopressors. RESULTS A total of 130 patients from each group were included in the primary outcome analysis. Primary outcome events occurred in 24 patients (18.5%) in the OLS group and 43 patients (33.1%) in the non-OLS group [relative risk, 0.46; 95% confidence interval (CI), 0.26 to 0.82; P = 0.009). More patients in the OLS group developed potentially harmful hypotension (OLS vs. non-OLS, 15% vs. 4.3%; P = 0.004) and needed vasopressors (25% vs. 8.6%; P < 0.001). CONCLUSION Among at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation, an open-lung strategy with a PEEP of 6–8 cmH 2 O and repeated LRMs reduced postoperative complications compared with a strategy using zero PEEP without LRMs. Of note, LRMs should be used with caution in patients with haemodynamic instability. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03160144.

Factors associated with prolonged postoperative length of hospital stay after laparoscopic colorectal cancer resection: a secondary analysis of a randomized controlled trial

“…In the original study, PLOS was a secondary outcome, with no signi cant difference in the per-protocol population between the two groups [12]. In the present study, we reanalyzed the PLOS in all enrolled patients.…”

“…The main results of this trial have been previously published [12]. As a secondary outcome of the trial, the median PLOS did not differ between the two groups [12]. In this secondary analysis of the PROVOLON trial ndings, we aimed to investigate the in uencing factors (especially modi able factors) for PPLOS after laparoscopic colorectal cancer resection.…”

“…All experiments were performed in accordance with relevant guidelines and regulations. The trial included 280 patients, and the main results have been published [12].…”

“…The PROtective Ventilation using Open Lung approach Or Not (PROVOLON) trial was a prospective, randomized controlled trial that investigated a lung-protective ventilation strategy on postoperative complications after laparoscopic colorectal cancer resection [12]. The main results of this trial have been previously published [12]. As a secondary outcome of the trial, the median PLOS did not differ between the two groups [12].…”

The effect of ultrasound-guided lung recruitment maneuvers on atelectasis in lung-healthy patients undergoing laparoscopic gynecologic surgery: a randomized controlled trial

“…The use of protective intraoperative mechanical ventilation has been associated with a lower incidence of atelectasis and PPC. Although positive end-expiratory pressure (PEEP) alone can improve intraoperative oxygenation [7], studies have shown that the combination of recruitment maneuvers (RM) and PEEP can improve oxygenation and reduce the incidence of PPCs in patients better than either alone [8][9][10][11][12]. However, when low tidal volumes were used in various ventilator strategies, increasing PEEP with alveolar recruitment maneuvers did not reduce the incidence of postoperative pulmonary complications, as observed in some large studies with large sample sizes [13][14][15].…”