Abstract
Background/Aim: Laparoscopic surgery with pneumoperitoneum is not usually recommended for patients with heart failure due to the potential risks associated with cardiopulmonary stress. Few studies, however, have directly examined whether a laparoscopic approach can be used safely in patients with severe chronic heart failure. Patients and Methods: We retrospectively evaluated the safety and feasibility of laparoscopic colorectal cancer surgery in 13 patients with severe chronic heart failure, defined as left ventricular ejection fraction <40% and/or brain natriuretic peptide >100 pg/ml (NT-proBNP >400 pg/ml). Intraoperative hemodynamics, including systolic blood pressure, diastolic blood pressure, mean blood pressure, and heart rate, were carefully monitored. Results: The median left ventricular ejection fraction value was 35% (18-62%), and the median brain natriuretic peptide value was 171.7 pg/ml (109.5-961.4 pg/ml). The time-series mean ratio of the patients’ blood pressure and heart rate during surgery indicated that soon after the induction of general anesthesia, mean blood pressure was significantly decreased (p<0.05) from baseline. In all 13 cases, laparoscopic surgery was performed successfully, with no significant complications. Conclusion: The present study showed that laparoscopic surgery for colorectal cancer can be performed safely in patients with severe chronic heart failure.
Laparoscopic surgery has been established as a safe technique for a series of general surgical procedures, superior to the conventional surgical approach (1, 2). Laparoscopic colorectal cancer surgery is a preferred alternative to open surgery because it provides more rapid recovery with comparable long-term results (3-6).
However, the pneumoperitoneum that is necessary for securing the field of view in laparoscopic surgery is known to affect respiratory and cardiocirculatory dynamics (7, 8). Joris et al. showed that there is a decrease in cardiac index (CI) during pneumoperitoneum (8). In addition to the positive intra-abdominal pressure that is caused by pneumoperitoneum, changes in patient position during surgery also affect the hemodynamics (8, 9). Due to these factors, careful consideration should be given to the suitability of laparoscopic surgery for a patient with severe chronic heart failure (CHF) (10). To date, there are no clear criteria established for the indication of laparoscopic surgery under these circumstances.
Several studies have previously demonstrated the safety of laparoscopic cholecystectomy in patients with cardiovascular disease (11-13). However, to date there are no reports regarding laparoscopic surgery in patients with colorectal cancer (CRC), which is a much lengthier and invasive procedure compared to cholecystectomy.
In our hospital, we successfully performed laparoscopic surgery on patients with severe heart failure. The aim of the present study was to evaluate the safety of laparoscopic colorectal surgery for CRC in patients with severe CHF.
Patients and Methods
Patients. From January 2013 to November 2021, 13 patients with severe CHF underwent laparoscopic surgery for CRC at the Osaka University Hospital, with intensive monitoring by an anesthetist. Severe CHF was defined as a left ventricular ejection fraction (LVEF) <40%, as assessed by transthoracic echocardiography, and/or preoperative plasma brain natriuretic peptide (BNP) value >100 pg/ml or NT-proBNP >400 pg/ml.
Of 13 patients, 10 exhibited low LVEF and 3 exhibited high BNP (2 patients had both low LVEF and high BNP). During surgery, we monitored the patient’s hemodynamics using continuous arterial pressure wave measurements and prepared for quick switch to laparotomy, if necessary.
For this study, medical records of 13 patients who underwent surgery for colorectal cancer were reviewed retrospectively, and clinical data were collected, including patient demographics (age and sex), medical history, preoperative evaluation [blood tests, chest X-ray, transthoracic echocardiography, and American Society of Anesthesiology (ASA) physical status using the ASA Physical Status Classification System], as well as intra- and post-operative data, including any complications.
In each case, we explained the risks of laparoscopic surgery and the possibility of conversion to laparotomy to the patients and their families, and obtained written informed consent prior to surgery. This study was approved by the ethics committee of Osaka University School of Medicine. Written consent was obtained from all patients and interested parties for this paper. This study was conducted in accordance with the Declaration of Helsinki.
Variables. Blood pressure and time points. Intraoperative changes in hemodynamics were measured, including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and heart rate (HR). Blood pressure data were collected before the induction of anesthesia (T1), 15 min after the induction of anesthesia (T2), immediately after the beginning of pneumoperitoneum and r tilting the position to head-down (T3), and 15 min after the beginning of pneumoperitoneum and repositioning (T4).
Results
Baseline patient characteristics. The background and clinical parameters of the 13 patients are shown in Table I. Nine of the 13 patients were male. The median age was 77 years old (65-88 years). Four patients had underlying dilated cardiomyopathy, two had first-degree atrioventricular block one had cardiac sarcoidosis, one had a history of aortic valvuloplasty, mitral valvuloplasty, and maze surgery for atrial fibrillation, one had atrial fibrillation, one had low output syndrome, one had a history of coronary artery bypass grafting surgery, one had a history of myocardial infarction, and one had coronary arteriosclerosis. The patients’ median LVEF value was 35 % (18-62%), the median plasma BNP value was 171.7 pg/ml (109.5-961.4 pg/ml), and the median cardiothoracic ratio measured by chest X-ray was 63 % (40-82%). All 13 patients were considered to have an ASA physical status of 3.
Background and clinical parameters of the 13 surgical candidates with severe CHF.
Surgical procedures. The preoperative diagnoses, surgical procedures, and intraoperative courses of patients are shown in Table II. Twelve patients underwent laparoscopic surgery, with the following operative methods: laparoscopic right colectomy (single-port surgery), 2 cases; laparoscopic right colectomy (multi-port surgery), 3 cases; laparoscopic sigmoidectomy (single-port surgery), 1 case; laparoscopic sigmoidectomy (multi-port surgery), 2 case; laparoscopic abdominoperineal resection and lateral and inguinal lymph node dissection on both sides (multi-port surgery), 1 case; laparoscopic examination and colostomy (single-port surgery), 1 case; laparoscopic left colectomy, 1 case; and laparoscopic subtotal colectomy, 1 case. One patient had robotic low anterior resection. The median operative time was 208 min (84-792 min), the median total pneumoperitoneum time was 173 min (15-610 min), and the median intraoperative blood loss volume was 50 ml (0-370 ml).
Preoperative diagnosis, operative method, and intraoperative course of the 13 patients.
Circulatory dynamics during surgery. Among the 13 cases, none required conversion to laparotomy. Seven patients required administration of catecholamine to maintain hemodynamics. Changes in intraoperative hemodynamics (SBP, DBP, MBP, and HR) were measured, and ratios were calculated between the value at each timepoint and that at T1. The mean ratios calculated for the 13 patients are shown in Table III. Figure 1 shows the time-series of the mean ratio of MBP, and HR for the 13 patients.
Time series of hemodynamic measurements. Mean ratios for the 13 patients calculated at each timepoint compared to the value at T1 are shown.
Time-series of mean ratio of MBP and HR, comparing values for the 13 patients at each timepoint to T1. After the induction of anesthesia (T2), there is a significant (p<0.05) decrease in MBP compared with baseline (T1). T1: Timepoint before the induction of anesthesia. T2: Timepoint 15 min after the induction of anesthesia. T3: Timepoint immediately after the beginning of pneumoperitoneum and repositioning. T4: Timepoint 15 min after the beginning of pneumoperitoneum and repositioning. MBP: Mean blood pressure; HR: heart rate.
In all 13 cases, laparoscopic surgery was performed successfully, without intraoperative complications such as hemodynamic failure. After the surgeries, 6 of the 13 patients stayed overnight in the intensive care unit, as planned, and the postoperative courses of all of the patients were uneventful.
Discussion
Laparoscopic surgery in patients with CHF has generally been regarded as a risky procedure, due to concerns about adverse effects of the dynamic change in the patient position and the pneumoperitoneum, that could lead to decreased cardiac index (CI) and stroke work index, as well as increased systemic and pulmonary vascular resistance (7, 14).
Safran et al. reported that pneumoperitoneum affects hemodynamics due to elevated intra-abdominal pressure, rather than increased pCO2 concentration (10). Thus, CHF has been considered to be an absolute or relative contraindication for laparoscopy (10).
Recent reports indicate that laparoscopic cholecystectomy can be performed safely in patients with CHF (11, 12). However, laparoscopic colorectal surgery for CRC takes much longer than cholecystectomy and requires a more dynamic change in the patients’ position during the procedure, so the risks of this surgery must be carefully considered.
In the present study, our data showed that the hemodynamics were transiently adversely affected by the induction of anesthesia, but not by the pneumoperitoneum or the change in position. Our experience indicates that laparoscopic colorectal surgery for CRC can be performed safely, even in patients with severe CHF. Two crucial aspects to consider during the procedure are minimizing changes in position, and keeping the intra-abdominal pressure as low as possible. Our data indicated that the induction of general anesthesia itself affected the hemodynamics most significantly, and that any adverse effects caused by pneumoperitoneum and position changes could be controlled adequately by strict intraoperative management.
Although this study was small, involving only 13 patients, it demonstrates that laparoscopic surgery can be performed with efficacy and safety for CRC patients with severe CHF.
However, this study did not examine the surgeon’s proficiency or postoperative complications. It has been suggested that proficiency in intracorporeal anastomosis may contribute to a lower incidence of organ and intraluminal surgical site infection and postoperative hospitalization (15). A significantly higher incidence of SSI and umbilical incisional hernia in laparoscopic colorectal resection has been reported (15). Therefore, prevention of postoperative complications should be considered in the future.
Further studies are needed to develop clear criteria for the indication of laparoscopic surgery in patients with severe CHF, including a larger number of patients and a review of postoperative complications.
Footnotes
Authors’ Contributions
Shoichiro NaKajo and Mamoru Uemura substantially contributed to the study conceptualization. Shoichiro NaKajo significantly contributed to data analysis and interpretation. Shoichiro NaKajo substantially contributed to the manuscript drafting. Shoichiro NaKajo, Mamoru Uemura, Yuki Sekido, Tsuyoshi Hata, Atsushi Hamabe, Takayuki Ogino, Norikatsu Miyoshi, Hirofumi Yamamoto, Yuichiro Doki, and Hidetoshi Eguchi critically reviewed and revised the manuscript draft and approved the final version for submission.
Conflicts of Interest
Shoichiro NaKajo, Mamoru Uemura, Yuki Sekido, Tsuyoshi Hata, Atsushi Hamabe, Takayuki Ogino, Norikatsu Miyoshi, Hirofumi Yamamoto, Yuichiro Doki, and Hidetoshi Eguchi have no conflicts of interest to declare and received no financial support for this study.
- Received September 28, 2023.
- Revision received November 10, 2023.
- Accepted November 15, 2023.
- Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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