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Meta-Analysis
. 2016 Oct 19;10(10):CD007821.
doi: 10.1002/14651858.CD007821.pub3.

Heated insufflation with or without humidification for laparoscopic abdominal surgery

Daniel W Birch  1 , Jerry T Dang, Noah J Switzer, Namdar Manouchehri, Xinzhe Shi, Ghassan Hadi, Shahzeer Karmali
Affiliations
Meta-Analysis

Heated insufflation with or without humidification for laparoscopic abdominal surgery

Daniel W Birch et al. Cochrane Database Syst Rev. .

Abstract

Background: Intraoperative hypothermia during both open and laparoscopic abdominal surgery may be associated with adverse events. For laparoscopic abdominal surgery, the use of heated insufflation systems for establishing pneumoperitoneum has been described to prevent hypothermia. Humidification of the insufflated gas is also possible. Past studies on heated insufflation have shown inconclusive results with regards to maintenance of core temperature and reduction of postoperative pain and recovery times.

Objectives: To determine the effect of heated gas insufflation compared to cold gas insufflation on maintaining intraoperative normothermia as well as patient outcomes following laparoscopic abdominal surgery.

Search methods: We searched Cochrane Colorectal Cancer Specialised Register (September 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, Issue 8), Ovid MEDLINE (1950 to September 2016), Ovid Embase (1974 to September 2016), International Pharmaceutical Abstracts (IPA) (September 2016), Web of Science (1985 to September 2016), Scopus, www.clinicaltrials.gov and the National Research Register (1956 to September 2016). We also searched grey literature and cross references. Searches were limited to human studies without language restriction.

Selection criteria: Only randomised controlled trials comparing heated (with or without humidification) with cold gas insufflation in adult and paediatric populations undergoing laparoscopic abdominal procedures were included. We assessed study quality in regards to relevance, design, sequence generation, allocation concealment, blinding, possibility of incomplete data and selective reporting. Two review authors independently selected studies for the review, with any disagreement resolved in consensus with a third co-author.

Data collection and analysis: Two review authors independently performed screening of eligible studies, data extraction and methodological quality assessment of the trials. We classified a study as low-risk of bias if all of the first six main criteria indicated in the 'Risk of Bias Assessment' table were assessed as low risk. We used data sheets to collect data from eligible studies. We presented results using mean differences for continuous outcomes and relative risks for dichotomous outcomes, with 95% confidence intervals. We used Review Manager (RevMan) 5.3 software to calculate the estimated effects. We took publication bias into consideration and compiled funnel plots.

Main results: We included 22 studies in this updated analysis, including six new trials with 584 additional participants, resulting in a total of 1428 participants. The risk of bias was low in 11 studies, high in one study and unclear in the remaining studies, due primarily to failure to report methodology for randomisation, and allocation concealment or blinding, or both. Fourteen studies examined intraoperative core temperatures among heated and humidified insufflation cohorts and core temperatures were higher compared to cold gas insufflation (MD 0.31 °C, 95% CI, 0.09 to 0.53, I2 = 88%, P = 0.005) (low-quality evidence). If the analysis was limited to the eight studies at low risk of bias, this result became non-significant but remained heterogeneous (MD 0.18 °C, 95% CI, -0.04 to 0.39, I2= 81%, P = 0.10) (moderate-quality evidence).In comparison to the cold CO2 group, the meta-analysis of the heated, non-humidified group also showed no statistically significant difference between groups. Core temperature was statistically, significantly higher in the heated, humidified CO2 with external warming groups (MD 0.29 °C, 95% CI, 0.05 to 0.52, I2 = 84%, P = 0.02) (moderate-quality evidence). Despite the small difference in temperature of 0.31 °C with heated CO2, this is unlikely to be of clinical significance.For postoperative pain scores, there were no statistically significant differences between heated and cold CO2, either overall, or for any of the subgroups assessed. Interestingly, morphine-equivalent use was homogeneous and higher in heated, non-humidified insufflation compared to cold insufflation for postoperative day one (MD 11.93 mg, 95% CI 0.92 to 22.94, I2 = 0%, P = 0.03) (low-quality evidence) and day two (MD 9.79 mg, 95% CI 1.58 to 18.00, I2 = 0%, P = 0.02) (low-quality evidence). However, morphine use was not significantly different six hours postoperatively or in any humidified insufflation groups.There was no apparent effect on length of hospitalisation, lens fogging or length of operation with heated compared to cold gas insufflation, with or without humidification. Recovery room time was shorter in the heated cohort (MD -26.79 minutes, 95% CI -51.34 to -2.25, I2 = 95%, P = 0.03) (low-quality evidence). When the one and only unclear-risk study was removed from the analysis, the difference in recovery-room time became non-significant and the studies were statistically homogeneous (MD -1.22 minutes, 95% CI, -6.62 to 4.17, I2 = 12%, P = 0.66) (moderate-quality evidence).There were also no differences in the frequency of major adverse events that occurred in the cold or heated cohorts.These results should be interpreted with caution due to some limitations. Heterogeneity of core temperature remained significant despite subgroup analysis, likely due to variations in the study design of the individual trials, as the trials had variations in insufflation gas temperatures (35 ºC to 37 ºC), humidity ranges (88% to 100%), gas volumes and location of the temperature probes. Additionally, some of the trials lacked specific study design information making evaluation difficult.

Authors' conclusions: While heated, humidified gas leads to mildly smaller decreases in core body temperatures, clinically this does not account for improved patient outcomes, therefore, there is no clear evidence for the use of heated gas insufflation, with or without humidification, compared to cold gas insufflation in laparoscopic abdominal surgery.

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Conflict of interest statement

  1. DWB: no conflict of interest

  2. JD: no conflict of interest

  3. NS: no conflict of interest

  4. NM: no conflict of interest

  5. XS: no conflict of interest

  6. GH: no conflict of interest

  7. SK: no conflict of interest

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
4
4
Forest plot of comparison: 2 Core temperature, outcome: 2.1 Change in core temperature
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5
Forest plot of comparison: 2 Core temperature, outcome: 2.2 Change in core temperature for low risk of bias studies
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Forest plot of comparison: 1 Core temperature, outcome: 1.5 Change in core temperature in heated, humidified vs cold groups with OR > 120 Minutes
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7
Forest plot of comparison: 2 Core temperature, outcome: 2.3 Change in core temperature in heated, humidified vs cold groups with external warming
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8
Forest plot of comparison: 1 Core temperature, outcome: 1.4 Change in temperature in heated, humidified vs cold groups without external warming
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Forest plot of comparison: 1 Pain score, outcome: 1.1 Day 1 pain score
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Forest plot of comparison: 1 Pain score, outcome: 1.3 Day 1 pain score for low risk of bias study
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Forest plot of comparison: 1 Pain score, outcome: 1.2 Day 2 pain score
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Forest plot of comparison: 1 Pain score, outcome: 1.4 Day 2 pain score of low risk of bias studies
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Forest plot of comparison: 3 Morphine consumption, outcome: 3.1 Up to 6 hours
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Forest plot of comparison: 3 Morphine consumption, outcome: 3.2 Day 1 morphine
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Forest plot of comparison: 3 Morphine consumption, outcome: 3.3 Day 2 morphine
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Forest plot of comparison: 4 Hospital stay, outcome: 4.1 Hospital stay
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Forest plot of comparison: 7 Recovery room stay, outcome: 7.1 Recovery time
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Forest plot of comparison: 7 Recovery room stay, outcome: 7.2 Recovery time for low risk of bias studies
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Forest plot of comparison: 5 Lens fogging, outcome: 5.1 Lens fogging
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Forest plot of comparison: 6 Operative time, outcome: 6.1 Operative time
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Funnel plot of comparison: 2 Core temperature, outcome: 2.1 Change in core temperature
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Funnel plot of comparison: 1 Pain Score, outcome: 1.1 Day 1 pain score
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Funnel plot of comparison: 3 Morphine consumption, outcome: 3.2 Day 1 morphine
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Funnel plot of comparison: 4 Hospital stay, outcome: 4.1 Hospital stay
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Funnel plot of comparison: 6 Operative time, outcome: 6.1 Operative time
1.1
1.1. Analysis
Comparison 1 Core temperature (ºC), Outcome 1 Change in core temperature.
1.2
1.2. Analysis
Comparison 1 Core temperature (ºC), Outcome 2 Change in core temperature for low risk of bias studies.
1.3
1.3. Analysis
Comparison 1 Core temperature (ºC), Outcome 3 Change in core temperature for operations > 120 Minutes.
1.4
1.4. Analysis
Comparison 1 Core temperature (ºC), Outcome 4 Change in core temperature with external warming.
1.5
1.5. Analysis
Comparison 1 Core temperature (ºC), Outcome 5 Change in temperature without external warming.
2.1
2.1. Analysis
Comparison 2 Pain score (0 to 10‐point VAS scale), Outcome 1 Day 1 pain score.
2.2
2.2. Analysis
Comparison 2 Pain score (0 to 10‐point VAS scale), Outcome 2 Day 1 pain score for low risk of bias studies.
2.3
2.3. Analysis
Comparison 2 Pain score (0 to 10‐point VAS scale), Outcome 3 Day 2 pain score.
2.4
2.4. Analysis
Comparison 2 Pain score (0 to 10‐point VAS scale), Outcome 4 Day 2 pain score of low risk of bias studies.
3.1
3.1. Analysis
Comparison 3 Morphine consumption (morphine equivalent daily doses), Outcome 1 Up to 6 hours.
3.2
3.2. Analysis
Comparison 3 Morphine consumption (morphine equivalent daily doses), Outcome 2 Day 1 morphine.
3.3
3.3. Analysis
Comparison 3 Morphine consumption (morphine equivalent daily doses), Outcome 3 Day 2 morphine.
4.1
4.1. Analysis
Comparison 4 Hospital stay (days), Outcome 1 Hospital stay.
5.1
5.1. Analysis
Comparison 5 Recovery room stay (minutes), Outcome 1 Recovery time.
5.2
5.2. Analysis
Comparison 5 Recovery room stay (minutes), Outcome 2 Recovery time for low risk of bias studies.
6.1
6.1. Analysis
Comparison 6 Lens fogging, Outcome 1 Times cleaned.
7.1
7.1. Analysis
Comparison 7 Operative time (minutes), Outcome 1 Operative time.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Barragan 2005 {published data only}
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Birch 2011
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Publication types