Intra-operative open-lung ventilatory strategy reduces postoperative complications after laparoscopic colorectal cancer resection: A randomised controlled trial

Abstract

BACKGROUNDThe role of the positive end-expiratory pressure (PEEP) and lung recruitment manoeuvre (LRM) combination (termed open-lung strategy, OLS) during intra-operative mechanical ventilation is not clear.OBJECTIVETo determine whether an open-lung strategy constituting medium PEEP (6-8cmH2O) and repeated LRMs protects against postoperative complications in at-risk patients undergoing laparoscopic colorectal cancer resection under low-Tidal-volume ventilation.DESIGNA prospective, assessor-blinded, randomised controlled trial.SETTINGSingle university-Affiliated hospital, conducted from January 2017 to October 2018.PATIENTSA total of 280 patients at risk of pulmonary complications, scheduled for laparoscopic colorectal cancer resection under general anaesthesia and low-Tidal-volume (6-8mlkg-1predicted body weight) ventilation.INTERVENTIONThe patients were randomly assigned (1:1) to a PEEP of 6-8cmH2O with LRMs repeated every 30min (OLS group) or a zero PEEP without LRMs (non-OLS group).MAIN OUTCOME MEASURESThe primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within 7days after surgery. The secondary outcomes included intra-operative potentially harmful hypotension and the need for vasopressors.RESULTSA total of 130 patients from each group were included in the primary outcome analysis. Primary outcome events occurred in 24 patients (18.5%) in the OLS group and 43 patients (33.1%) in the non-OLS group [relative risk, 0.46; 95% confidence interval (CI), 0.26 to 0.82; P=0.009). More patients in the OLS group developed potentially harmful hypotension (OLS vs. non-OLS, 15% vs. 4.3%; P=0.004) and needed vasopressors (25% vs. 8.6%; P<0.001).CONCLUSIONAmong at-risk patients undergoing laparoscopic colorectal cancer resection under low-Tidal-volume ventilation, an open-lung strategy with a PEEP of 6-8cmH2O and repeated LRMs reduced postoperative complications compared with a strategy using zero PEEP without LRMs. Of note, LRMs should be used with caution in patients with haemodynamic instability.TRIAL REGISTRATIONClinicaltrials.gov identifier: NCT03160144.