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The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials.

ABSTRACT: BACKGROUND:Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. METHODS:An electronic database search was performed to identify randomized controlled trials (RCTs) that compared outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. A Bayesian network meta-analysis (NMA) was used to conduct pairwise meta-analyses and indirect treatment comparisons of the levels of IAP assessed across trials. RESULTS:The SLR and NMA included 22 studies. Compared with standard IAP, on a scale of 0 (no pain at all) to 10 (worst imaginable pain), low IAP was associated with significantly lower overall pain scores at 24 h (mean difference [MD]:?-?0.70; 95% credible interval [CrI]:?-?1.26,?-?0.13) and reduced risk of shoulder pain 24 h (odds ratio [OR] 0.24; 95% CrI 0.12, 0.48) and 72 h post-surgery (OR 0.22; 95% CrI 0.07, 0.65). Hospital stay was shorter with low IAP (MD:?-?0.14 days; 95% CrI?-?0.30,?-?0.01). High IAP was not associated with a significant difference for these outcomes when compared with standard or low IAP. No significant differences were found between the IAP levels regarding need for conversion to open surgery; post-operative acute bleeding, pain at 72 h, nausea, and vomiting; and duration of surgery. CONCLUSIONS:Our study of published trials indicates that using low, as opposed to standard, IAP during laparoscopic cholecystectomy may reduce patients' post-operative pain, including shoulder pain, and length of hospital stay. Heterogeneity in the pooled estimates and high risk of bias of the included trials suggest the need for high-quality, adequately powered RCTs to confirm these findings.

SUBMITTER: Raval AD

PROVIDER: S-EPMC7270984 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials.

Raval Amit D AD Deshpande Sohan S Koufopoulou Maria M Rabar Silvia S Neupane Binod B Iheanacho Ike I Bash Lori D LD Horrow Jay J Fuchs-Buder Thomas T

Surgical endoscopy 20200406 7

<h4>Background</h4>Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy.<h4>Methods</h4>An electronic database search was performed to identify randomized controlled trials (RCTs) that c ...[more]

PMID: 32253560

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Project description:Biliary diseases known since ages constitute major portion of digestive tract disorders world over. Among these cholelithiasis being the fore runner causing general ill health, thereby requiring surgical intervention for total cure. The study was undertaken in an attempt to compare the hemodynamic changes in patient undergoing laparoscopic cholecystectomy using different intra-abdominal pressures created due to carbon dioxide insufflation. The patients were randomly allocated to one of the three groups in which different levels of intra-abdominal pressures (8-10 mmHg,11-13 mmHg and 14 mmHg and above) were maintained. The base line parameters monitored were heart rate, non invasive blood pressur(systolic and mean)and end tidal carbon dioxide. All the parameters were monitored at various intervals i.e. Immediately during insufflation, 5 min, 10 min, 20 min, 30 min after CO2 insufflation and after every 10 min if surgery exceeds 30 min, at exsufflation,10 min after CO2 exsufflation. Patients were ventilated with Pedius Drager Ventilator keeping tidal volume 8-10 ml/kg and respiratory rate 12-14 breaths/min. During surgery patients were placed in reverse Trendlenburg position (head up) at 15 °. The results obtained were evaluated statistically and analyzed. Baseline characteristics were found to be comparable. Hemodynamic variables were reported as mean and standard deviation. Statistical significance among groups was evaluated using Analysis of Variance and unpaired student t test (two tailed). Inter-group comparisons were made using Bonferroni test. A p-value of <0.05 was considered as statistically significant. In all the three groups the mean heart rate (baseline 84.08?±?12.50, 87.96?±?15.73 and 86.92?±?17.00 respectively) increased during CO2 insufflation and the rise in heart rate continued till exsufflation after which it decreased and at 10 min after exsufflation the heart rates were comparable with the baseline. The inter-group comparison of mean heart rate between I & III was statistically significant at 10, 20, 30 min after CO2 insufflation which continued at exsufflation and 10 min after CO2 exsufflation [p?<?0.05]. The inter-group comparison between I & III showed statistically significant difference in systolic blood pressure at 10, 20, 30 min after CO2 insufflation, at exsufflation and 10 min after exsufflation [p?=?0.0001] and mean arterial pressure at 5, 10, 20, 30 min after CO2 insufflation, at exsufflation and 10 min after exsufflation [p?=?0.0001]. Comparison between Group I and Group III & between Group II and Group III showed highly significant statistical difference in EtCO2 immediately after insufflation and the same trend was seen till the completion of surgery and even 10 min after exsufflation [p?=?0.001]. The conclusion drawn from the study was that laparoscopic cholecystectomy induces significant hemodynamic changes intraoperatively, the majority of pathophysiological changes are related to cardiovascular system and are caused by CO2 insufflation .A high intra-abdominal pressure due to CO2 insufflation is associated with more fluctuations in hemodynamic parameters and increased peritoneal absorption of CO2 as compared to low intraabdominal pressure so low pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse hemodynamic effects of CO2 insufflation.

Project description:BackgroundThe intra-abdominal pressure (IAP) is an important clinical parameter that can significantly change during respiration. Currently, IAP is recorded at end-expiration (IAPee), while continuous IAP changes during respiration (?IAP) are ignored. Herein, a novel concept of considering continuous IAP changes during respiration is presented.MethodsBased on the geometric mean of the IAP waveform (MIAP), a mathematical model was developed for calculating respiratory-integrated MIAP (i.e. MIAPri=IAPee+i??IAP), where 'i' is the decimal fraction of the inspiratory time, and where ?IAP can be calculated as the difference between the IAP at end-inspiration (IAPei) minus IAPee. The effect of various parameters on IAPee and MIAPri was evaluated with a mathematical model and validated afterwards in six mechanically ventilated patients. The MIAP of the patients was also calculated using a CiMON monitor (Pulsion Medical Systems, Munich, Germany). Several other parameters were recorded and used for comparison.ResultsThe human study confirmed the mathematical modelling, showing that MIAPri correlates well with MIAP (R2 = 0.99); MIAPri was significantly higher than IAPee under all conditions that were used to examine the effects of changes in IAPee, the inspiratory/expiratory (I:E) ratio, and ?IAP (P <0.001). Univariate Pearson regression analysis showed significant correlations between MIAPri and IAPei (R = 0.99), IAPee (R = 0.99), and ?IAP (R = 0.78) (P <0.001); multivariate regression analysis confirmed that IAPee (mainly affected by the level of positive end-expiratory pressure, PEEP), ?IAP, and the I:E ratio are independent variables (P <0.001) determining MIAP. According to the results of a regression analysis, MIAP can also be calculated asMIAP=-0.3+IAPee+0.4??IAP+0.5?IE.ConclusionsWe believe that the novel concept of MIAP is a better representation of IAP (especially in mechanically ventilated patients) because MIAP takes into account the IAP changes during respiration. The MIAP can be estimated by the MIAPri equation. Since MIAPri is almost always greater than the classic IAP, this may have implications on end-organ function during intra-abdominal hypertension. Further clinical studies are necessary to evaluate the physiological effects of MIAP.

Project description:Concomitant procedures during endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm are performed to facilitate endograft delivery, to simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aimed to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR.We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014 and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes.The study included 4033 patients, with 1168 (29.0%) patients undergoing one or more additional procedures. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.1-11.2) and renal angioplasty or stenting (OR, 3.1; 95% CI, 1.2-8.3). Postoperative bowel ischemia was associated with hypogastric embolization (OR, 3.8; 95% CI, 1.1-13.4) and iliac angioplasty or stenting (OR, 3.5; 95% CI, 1.3-9.6). Leg ischemia was associated with unplanned graft extension (OR, 2.3; 95% CI, 1.02-5.0), other artery reconstruction (OR, 5.2; 95% CI, 1.8-15.1), thromboembolectomy (OR, 5.2; 95% CI, 1.3-20.8), and repair of arterial injury (OR, 4.6; 95% CI, 1.2-18.3). Risk factors for deterioration of renal function were iliofemoral bypass (OR, 3.9; 95% CI, 1.3-12.2), other artery reconstruction (OR, 2.7; 95% CI, 1.3-5.8), renal angioplasty or stenting (OR, 2.5; 95% CI, 1.3-4.6), and repair of arterial injury (OR, 4.5; 95% CI, 1.6-12.2). Myocardial infarction was associated with femorofemoral bypass (OR, 3.9; 95% CI, 1.7-8.7), other artery reconstruction (OR, 3.9; 95% CI, 1.6-9.2), and repair of arterial injury (OR, 6.1; 95% CI, 1.8-21.0). Wound complications were predicted by femorofemoral bypass (OR, 13.4; 95% CI, 5.8-31.1).Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thromboembolic events where possible.

Project description:IntroductionIntra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs.MethodsNine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting.ResultsAt baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance.ConclusionsIn a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.

Dataset Information

The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials.

Publications

The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials.

Similar Datasets

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