Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries

Edward A. Dickson, Marta Penna, Chris Cunningham, Fiona M. Ratcliffe, Jonathan Chantler, Nicholas A. Crabtree, Jurriaan B. Tuynman, Matthew R. Albert, John R. T. Monson, Roel Hompes, International TaTME Registry Collaborative

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.
Original languageEnglish
Pages (from-to)794-801
JournalDiseases of the Colon and Rectum
Volume62
Issue number7
DOIs
Publication statusPublished - 1 Jan 2019

Cite this

Dickson, E. A., Penna, M., Cunningham, C., Ratcliffe, F. M., Chantler, J., Crabtree, N. A., ... International TaTME Registry Collaborative (2019). Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries. Diseases of the Colon and Rectum, 62(7), 794-801. https://doi.org/10.1097/DCR.0000000000001410
Dickson, Edward A. ; Penna, Marta ; Cunningham, Chris ; Ratcliffe, Fiona M. ; Chantler, Jonathan ; Crabtree, Nicholas A. ; Tuynman, Jurriaan B. ; Albert, Matthew R. ; Monson, John R. T. ; Hompes, Roel ; International TaTME Registry Collaborative. / Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries. In: Diseases of the Colon and Rectum. 2019 ; Vol. 62, No. 7. pp. 794-801.
@article{81c67c90140040dc8f9a9effff375252,
title = "Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries",
abstract = "BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4{\%} (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52{\%}) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68{\%}) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40{\%}). After carbon dioxide embolus, 84{\%} of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.",
author = "Dickson, {Edward A.} and Marta Penna and Chris Cunningham and Ratcliffe, {Fiona M.} and Jonathan Chantler and Crabtree, {Nicholas A.} and Tuynman, {Jurriaan B.} and Albert, {Matthew R.} and Monson, {John R. T.} and Roel Hompes and {International TaTME Registry Collaborative} and Walaa Abdelmoaty and Michel Adamina and Felix Aigner and Karim Alavi and Benjamin Albers and Matthew Albert and {Al Furajii}, Hazar and Andrew Allison and {Alonso Araujo}, {Sergio Eduardo} and Apostolides, {George Y.} and Alberto Arezzo and Arnold, {Steven J.} and Kamal Aryal and Shady Ashamalla and Shazad Ashraf and Vikram Attaluri and Ralph Austin and Giuliano Barugola and Andrew Beggs and Belgers, {H. J.} and Stephen Bell and Willem Bemelman and Stefano Berti and Matthias Biebl and Joris Blondeel and Balazs Binky and Ioannis Baloyiannis and Dibyendu Bandyopadhyay and Luigi Boni and Liliana Bordeianou and Benjamin Box and Stephen Boyce and Walter Brokelman and Brown, {Carl J.} and Lukas Bruegger and Christian Buchli and Buchs, {Nicolas Christian} and Joep Knol and Miranda Kusters and Colin Sietses",
year = "2019",
month = "1",
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}

Dickson, EA, Penna, M, Cunningham, C, Ratcliffe, FM, Chantler, J, Crabtree, NA, Tuynman, JB, Albert, MR, Monson, JRT, Hompes, R & International TaTME Registry Collaborative 2019, 'Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries' Diseases of the Colon and Rectum, vol. 62, no. 7, pp. 794-801. https://doi.org/10.1097/DCR.0000000000001410

Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries. / Dickson, Edward A.; Penna, Marta; Cunningham, Chris; Ratcliffe, Fiona M.; Chantler, Jonathan; Crabtree, Nicholas A.; Tuynman, Jurriaan B.; Albert, Matthew R.; Monson, John R. T.; Hompes, Roel; International TaTME Registry Collaborative.

In: Diseases of the Colon and Rectum, Vol. 62, No. 7, 01.01.2019, p. 794-801.

Research output: Contribution to journalArticleAcademicpeer-review

TY - JOUR

T1 - Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries

AU - Dickson, Edward A.

AU - Penna, Marta

AU - Cunningham, Chris

AU - Ratcliffe, Fiona M.

AU - Chantler, Jonathan

AU - Crabtree, Nicholas A.

AU - Tuynman, Jurriaan B.

AU - Albert, Matthew R.

AU - Monson, John R. T.

AU - Hompes, Roel

AU - International TaTME Registry Collaborative

AU - Abdelmoaty, Walaa

AU - Adamina, Michel

AU - Aigner, Felix

AU - Alavi, Karim

AU - Albers, Benjamin

AU - Albert, Matthew

AU - Al Furajii, Hazar

AU - Allison, Andrew

AU - Alonso Araujo, Sergio Eduardo

AU - Apostolides, George Y.

AU - Arezzo, Alberto

AU - Arnold, Steven J.

AU - Aryal, Kamal

AU - Ashamalla, Shady

AU - Ashraf, Shazad

AU - Attaluri, Vikram

AU - Austin, Ralph

AU - Barugola, Giuliano

AU - Beggs, Andrew

AU - Belgers, H. J.

AU - Bell, Stephen

AU - Bemelman, Willem

AU - Berti, Stefano

AU - Biebl, Matthias

AU - Blondeel, Joris

AU - Binky, Balazs

AU - Baloyiannis, Ioannis

AU - Bandyopadhyay, Dibyendu

AU - Boni, Luigi

AU - Bordeianou, Liliana

AU - Box, Benjamin

AU - Boyce, Stephen

AU - Brokelman, Walter

AU - Brown, Carl J.

AU - Bruegger, Lukas

AU - Buchli, Christian

AU - Buchs, Nicolas Christian

AU - Knol, Joep

AU - Kusters, Miranda

AU - Sietses, Colin

PY - 2019/1/1

Y1 - 2019/1/1

N2 - BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.

AB - BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.

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UR - https://www.ncbi.nlm.nih.gov/pubmed/31188179

U2 - 10.1097/DCR.0000000000001410

DO - 10.1097/DCR.0000000000001410

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VL - 62

SP - 794

EP - 801

JO - Diseases of the Colon and Rectum

JF - Diseases of the Colon and Rectum

SN - 0012-3706

IS - 7

ER -