Quality of Recovery and Innate Immune Homeostasis in Patients Undergoing Low-pressure Versus Standard-pressure Pneumoperitoneum During Laparoscopic Colorectal Surgery (RECOVER): A Randomized Controlled Trial. Issue 6 (13th December 2022)

• Record Type: Journal Article
• Authors: Albers, Kim I.; Polat, Fatih; Helder, Leonie; Panhuizen, Ivo F.; Snoeck, Marc M.J.; Polle, S. (Bas) W.; de Vries, Hilbert; Dias, Esther M.; Slooter, Gerrit D.; de Boer, Hans D.; Diaz-Cambronero, Oscar; Mazzinari, Guido; Scheffer, Gert-Jan; Keijzer, Christiaan; Warlé, Michiel C.
• Other Names: Bindels Manon author non-byline.; Bökkerink Guus M.J. author non-byline.; Graat Leon J. author non-byline.; Groh Laszlo A. author non-byline.; van Helden Esmee author non-byline.; Leclercq Wouter K.G. author non-byline.; Marques Mari Ana I. author non-byline.; Meijer Patrick author non-byline.; Reijnders Gabby author non-byline.; de Zeeuw Sharonne author non-byline.
• Is Part Of: Annals of surgery. Volume 276:Issue 6(2022)
• Page Start: e664
• Page End: e673
• Publication Date: 2022-12-13
• Subjects: laparoscopy -- laparoscopic surgery -- low pressure pneumoperitoneum -- intra-abdominal pressure -- deep neuromuscular blockade -- QoR-40 -- DAMPs -- innate immunity -- postoperative infections; Surgery -- Periodicals; 617.005
• DOI: 10.1097/SLA.0000000000005491
• Languages: English
• ISSNs: 0003-4932

Abstract

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.