Quality of Recovery and Innate Immune Homeostasis in Patients Undergoing Low-pressure Versus Standard-pressure Pneumoperitoneum During Laparoscopic Colorectal Surgery (RECOVER)

Abstract

Objective: To study the effects of intra-abdominal pressure on the quality of recovery and innate cytokine production capacity after laparoscopic colorectal surgery within the enhanced recovery after surgery program. Background: There is increasing evidence for the safety and advantages of low-pressure pneumoperitoneum facilitated by deep neuromuscular blockade (NMB). Nonetheless, there is a weak understanding of the relationship between clinical outcomes, surgical injury, postoperative immune dysfunction, and infectious complications. Methods: Randomized controlled trial of 178 patients treated at standard-pressure pneumoperitoneum (12 mm Hg) with moderate NMB (train-of-four 1-2) or low pressure (8 mm Hg) facilitated by deep NMB (posttetanic count 1-2). The primary outcome was the quality of recovery (Quality of Recovery 40 questionnaire) on a postoperative day 1 (POD1). The primary outcome of the immune substudy (n = 100) was ex vivo tumor necrosis factor α production capacity upon endotoxin stimulation on POD1.Results: Quality of Recovery 40 score on POD1 was significantly higher at 167 versus 159 [mean difference (MD): 8.3 points; 95% confidence interval (CI): 2.5, 14.1; P = 0.005] and the decline in cytokine production capacity was significantly less for tumor necrosis factor α and interleukin-6 (MD: −172 pg/mL; 95% CI: −316, −27; P = 0.021 and MD: −1282 pg/ mL; 95% CI: −2505, −59; P = 0.040, respectively) for patients operated at low pressure. Low pressure was associated with reduced surgical site hypoxia and inflammation markers and circulating damage-associated molecular patterns, with a less impaired early postoperative ex vivo cytokine production capacity. At low pressure, patients reported lower acute pain scores and developed significantly less 30-day infectious complications. Conclusions: Low intra-abdominal pressure during laparoscopic colorectal surgery is safe, improves the postoperative quality of recovery and preserves innate immune homeostasis, and forms a valuable addition to future enhanced recovery after surgery programs.

The role of surgical tissue injury and intraoperative sympathetic activation in postoperative immunosuppression after breast-conserving surgery versus mastectomy: a prospective observational study

“…For both groups, HMGB1 and HSP70 were not significantly increased one hour and 3 days after surgery compared to before surgery. This was an unexpected finding, as several previous studies report an increase in these DAMPs after different types of surgery [ 21 , 42 – 44 ]. Either the expression of these DAMPs is simply not increased after breast cancer surgery, or possibly the window of increase was outside the measured timepoints.…”

“…It is well recognized that the early postoperative immune response is predominantly immunosuppressive [ 49 ]. Leijte et al [ 21 ] and Albers et al [ 44 ] have previously described the association between DAMPs and ex vivo cytokine production capacity. Nonetheless, the fact that the ex vivo cytokine production capacity (regarded as the capacity to elicit an inflammatory response when encountering a pathogen [ 50 ]) is nearly absent one hour after surgery has not been described before.…”

Laparoscopic-Assisted Colorectal Resection Can Reduce the Inhibition of Immune Function Compared with Conventional Open Surgery: A Retrospective Clinical Study

“…The application of pneumoperitoneum requires the introduction of large amounts of CO 2 gas into the abdominal cavity, and studies have shown that CO 2 pneumoperitoneum may produce hypercapnia and have immunological effects on the body [ 24 ]. Kim I. and his colleague reported that low intra-abdominal pressure during laparoscopic colorectal surgery, which means less CO 2 , preserved innated immune homeostasis and formed a valuable addition to future enhanced recovery [ 25 ]. This issue has been controversial; however, from the present study, even though pneumoperitoneum affects the immune function of the organism, its effect is less compared to an open abdominal injury.…”

Low Pneumoperitoneum Pressure Reduces Gas Embolism During Laparoscopic Liver Resection

“…To date, few studies have assessed the effects of PP levels on the quality of recovery. A laparoscopic colorectal surgery 48 and a laparoscopic nephrectomy surgery 49 study reported the quality of recovery using the QoR-40 questionnaire and found no difference between the low and standard PP strategies. Similarly, we found no significant difference in recovery quality using the PostopQRS between the low and standard PP groups in the post-anesthesia care unit, on POD1 and POD3.…”