Randomized clinical trial of the effect of intraoperative humidified carbon dioxide insufflation in open laparotomy for colorectal resection

Abstract

Background: Animal studies have shown that peritoneal injury can be minimized by insufflating the abdominal cavity with warm humidified carbon dioxide gas.

Methods: A single-blind RCT was performed at a tertiary colorectal unit. Inclusion criteria were patient aged 18 years and over undergoing open elective surgery. The intervention group received warmed (37°C), humidified (98 per cent relative humidity) carbon dioxide (WHCO2 group). Multiple markers of peritoneal inflammation and oxidative damage were used to compare groups, including cytokines and chemokines, apoptosis, the 3-chlorotyrosine/native tyrosine ratio, and light microscopy on peritoneal biopsies at the start (T0 ) and end (Tend ) of the operation. Postoperative clinical outcomes were compared between the groups.

Results: Of 40 patients enrolled, 20 in the WHCO2 group and 19 in the control group were available for analysis. A significant log(Tend /T0 ) difference between control and WHCO2 groups was documented for interleukin (IL) 2 (5·3 versus 2·8 respectively; P = 0·028) and IL-4 (3·5 versus 2·0; P = 0·041), whereas apoptosis assays documented no significant change in caspase activity, and similar apoptosis rates were documented along the peritoneal edge in both groups. The 3-chlorotyrosine/tyrosine ratio had increased at Tend by 1·1-fold in the WHCO2 group and by 3·1-fold in the control group. Under light microscopy, peritoneum was visible in 11 of 19 samples from the control group and in 19 of 20 samples from the WHCO2 group (P = 0·006). The only difference in clinical outcomes between intervention and control groups was the number of days to passage of flatus (2·5 versus 5·0 days respectively; P = 0·008).

Conclusion: The use of warmed, humidified carbon dioxide appears to reduce some markers related to peritoneal oxidative damage during laparotomy. No difference was observed in clinical outcomes, but the study was underpowered for analysis of surgical results. Registration number: NCT02975947 ( www.ClinicalTrials.gov/).

© 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.

Figures

Figure 1

CONSORT diagram for the trial WHCO2, warmed, humidified carbon dioxide.

Figure 2

Change in levels of cytokines/chemokines in carbon dioxide and control groups Fold change in inflammatory cytokines and chemokines at the start (T0) and end (Tend) of the operation in control and warmed, humidified carbon dioxide (WHCO2) groups: a interleukin (IL) 1α; b IL‐1β; c IL‐2; d IL‐4; e IL‐6; f IL‐8; g IL‐10; h IL‐12; i IL‐17; j IL‐13; k tumour necrosis factor (TNF) α; l monocyte chemotactic protein (MCP) 1; m RANTES (regulated on activation, normal T‐cell expressed and secreted); n growth‐regulated oncogene (GRO) α; o inducible protein (IP) 10. Values are mean(s.e.m.). *P < 0·050, †P < 0·010, ‡P < 0·001 (ANOVA using Tukey's multiple comparison test).

Figure 3

Change in degree of apoptosis in isolated peritoneal tissue Fold change in caspase‐3/7 activity in control and warmed, humidified carbon dioxide (WHCO2) groups at the start (T0) and end (Tend) of the operation. Values are mean(s.e.m.). *P ≤ 0·050 (ANOVA using Tukey's multiple comparison test).

Figure 4

TUNEL assay of peritoneal edges Red arrows indicate areas of fluorescence green (apoptosis/necrosis) along the peritoneal edge. TUNEL, terminal deoxynucleotidyl transferase‐mediated dUTP nick‐end labelling.

Figure 5

Change in level of oxidative damage in control and carbon dioxide groups Fold change in 3‐chlorotyrosine/tyrosine ratio (Cl‐Tyr/Tyr) from the start (T0) to the end (Tend) of the operation in warmed, humidified carbon dioxide (WHCO2) and control groups. Values are mean(s.e.m.). *P < 0·050 (Mann–Whitney U test).

Figure 6

Visible peritoneum Haematoxylin and eosin‐stained section showing visible peritoneal edge (blue arrows).

Figure 7

Peritoneal damage Haematoxylin and eosin‐stained sections showing denudation of the peritoneum (blue arrows). The last three images also show white cell infiltration of the peritoneum (green arrows).