Warm and Humidified vs. Cold and Dry Co2 Pneumoperitoneum in Minimally Invasive Colon Resection: A Randomized Controlled Trial

Elie Sutton, MD1, Geoffrey Bellini, MD2, Hmc Shantha Kumara, PhD2, Xiaohong Yan, PhD2, Linda Njoh2, Vesna Cekic, RN2, Richard L Whelan, MD2. 1Mount Sinai Roosevelt Hospital, Department of Surgery, New York, NY, USA; Maimonides Medical Center Department of Surgery, Brooklyn, NY, USA, 2Mount Sinai Roosevelt Hospital, Department of Surgery, New York, NY USA

Introduction: Peritoneal insufflation with warm humidified (WH) CO2 gas has been purported to be a beneficial alternative to standard cold and dry (CD) CO2 gas for laparoscopic surgery.  There is limited data regarding the use of WH CO2 for minimally invasive colorectal resection (MICR).  This randomized study was undertaken to determine the impact of WH vs CD CO2 on operative and short term clinical results.

Methods and Procedures: Demographic, operative, and short term clinical data was collected on MICR patients randomized to receive either WH (body temperature) or CD (room temperature) CO2 during surgery. Outcomes tracked included postoperative (postop) pain levels (visual analog scale) on POD 1-7, and analgesia requirements on POD 1 and 2. All narcotic totals were converted to morphine equivalents for analysis. Ketorolac and acetaminophen requirements were also assessed. In addition, the following variables were tracked: intraoperative core temperatures, length of stay as well as time to 1st flatus, BM, and tolerance of solids.

Results:  A total of 101 patients were randomized to WH CO2 (50) or CD CO2 (51).  With regards to co-morbidities and BMI, the 2 groups were similar except that there were more diabetics in the WH group (p=0.0267). There were no differences in the indications for surgery or MIS methods used. Of note, the mean CO2 volume used during MICR was 25.6% less for the WH vs the CD CO2 group (p=0.0435).  Postop, the visual analog pain scores were similar between groups, however, on POD 1 and 2, WH patients required less narcotics (p=0.0010 and p=0.0319 respectively) and ketorolac (p=0.0163 and p=0.0153 respectively) than the CD CO2 group.  No difference in acetaminophen use was noted; also, no differences in complication rates, ileus resolution time, and time to regular diet were noted.

Conclusion: This randomized study suggests that the analgesia requirement, a surrogate measure of pain, was significantly less in the WH group on POD 1 and 2 despite the fact that the visual analog scale scores were similar.  Perhaps the WH gas decreases the desiccation and loss of parietal peritoneal cells that has been shown to occur after laparoscopy done with CD gas.  It is unclear why less CO2 was required in the WH group; the clinical importance of this finding, if any, is also unclear.  Further study regarding WH CO2 is warranted in light of the pain medication differences.

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