Yu Tianwu, Cheng Yao, Wang Xiaomei, Tu Bing, Cheng Nansheng, Gong Jianping, Bai Lian
Department of Hepatobiliary Surgery, Yongchuan Hospital, Chongqing Medical University, No. 439, Quxuanhua Road, Chongqing, China, 402160.
Cochrane Database Syst Rev. 2017 Jun 21;6(6):CD009569. doi: 10.1002/14651858.CD009569.pub3.
This is an update of the review published in 2013.Laparoscopic surgery is now widely performed to treat various abdominal diseases. Currently, carbon dioxide is the most frequently used gas for insufflation of the abdominal cavity (pneumoperitoneum). Although carbon dioxide meets most of the requirements for pneumoperitoneum, the absorption of carbon dioxide may be associated with adverse events. People with high anaesthetic risk are more likely to experience cardiopulmonary complications and adverse events, for example hypercapnia and acidosis, which has to be avoided by hyperventilation. Therefore, other gases have been introduced as alternatives to carbon dioxide for establishing pneumoperitoneum.
To assess the safety, benefits, and harms of different gases (i.e. carbon dioxide, helium, argon, nitrogen, nitrous oxide, and room air) used for establishing pneumoperitoneum in participants undergoing laparoscopic general abdominal or gynaecological pelvic surgery.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 9), Ovid MEDLINE (1950 to September 2016), Ovid Embase (1974 to September 2016), Science Citation Index Expanded (1970 to September 2016), Chinese Biomedical Literature Database (CBM) (1978 to September 2016), ClinicalTrials.gov (September 2016), and World Health Organization International Clinical Trials Registry Platform (September 2016).
We included randomised controlled trials (RCTs) comparing different gases for establishing pneumoperitoneum in participants (irrespective of age, sex, or race) undergoing laparoscopic abdominal or gynaecological pelvic surgery under general anaesthesia.
Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated risk ratio (RR) for dichotomous outcomes (or Peto odds ratio for very rare outcomes), and mean difference (MD) or standardised mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI). We used GRADE to rate the quality of evidence, MAIN RESULTS: We included nine RCTs, randomising 519 participants, comparing different gases for establishing pneumoperitoneum: nitrous oxide (three trials), helium (five trials), or room air (one trial) was compared to carbon dioxide. Three trials randomised participants to nitrous oxide pneumoperitoneum (100 participants) or carbon dioxide pneumoperitoneum (96 participants). None of the trials was at low risk of bias. There was insufficient evidence to determine the effects of nitrous oxide and carbon dioxide on cardiopulmonary complications (RR 2.00, 95% CI 0.38 to 10.43; two studies; 140 participants; very low quality of evidence), or surgical morbidity (RR 1.01, 95% CI 0.18 to 5.71; two studies; 143 participants; very low quality of evidence). There were no serious adverse events related to either nitrous oxide or carbon dioxide pneumoperitoneum (three studies; 196 participants; very low quality of evidence). We could not combine data from two trials (140 participants) which individually showed lower pain scores (a difference of about one visual analogue score on a scale of 1 to 10 with lower numbers indicating less pain) with nitrous oxide pneumoperitoneum at various time points on the first postoperative day, and this was rated asvery low quality .Four trials randomised participants to helium pneumoperitoneum (69 participants) or carbon dioxide pneumoperitoneum (75 participants) and one trial involving 33 participants did not state the number of participants in each group. None of the trials was at low risk of bias. There was insufficient evidence to determine the effects of helium or carbon dioxide on cardiopulmonary complications (RR 1.46, 95% CI 0.35 to 6.12; three studies; 128 participants; very low quality of evidence) or pain scores (visual analogue score on a scale of 1 to 10 with lower numbers indicating less pain; MD 0.49 cm, 95% CI -0.28 to 1.26; two studies; 108 participants; very low quality of evidence). There were three serious adverse events (subcutaneous emphysema) related to helium pneumoperitoneum (three studies; 128 participants; very low quality of evidence).One trial randomised participants to room air pneumoperitoneum (70 participants) or carbon dioxide pneumoperitoneum (76 participants). The trial was at unclear risk of bias. There were no cardiopulmonary complications or serious adverse events observed related to either room air or carbon dioxide pneumoperitoneum (both outcomes very low quality of evidence). The evidence of lower hospital costs and reduced pain during the first postoperative day with room air pneumoperitoneum compared with carbon dioxide pneumoperitoneum (a difference of about one visual analogue score on a scale of 1 to 10 with lower numbers indicating less pain, was rated as very low quality of evidence.
AUTHORS' CONCLUSIONS: The quality of the current evidence is very low. The effects of nitrous oxide and helium pneumoperitoneum compared with carbon dioxide pneumoperitoneum are uncertain. Evidence from one trial of small sample size suggests that room air pneumoperitoneum may decrease hospital costs in people undergoing laparoscopic abdominal surgery. The safety of nitrous oxide, helium, and room air pneumoperitoneum has yet to be established.Further trials on this topic are needed, and should compare various gases (i.e. nitrous oxide, helium, argon, nitrogen, and room air) with carbon dioxide under standard pressure pneumoperitoneum with cold gas insufflation for people with high anaesthetic risk. Future trials should include outcomes such as complications, serious adverse events, quality of life, and pain.
这是对2013年发表的综述的更新。腹腔镜手术目前广泛用于治疗各种腹部疾病。目前，二氧化碳是腹腔充气（气腹）最常用的气体。虽然二氧化碳满足气腹的大多数要求，但二氧化碳的吸收可能与不良事件相关。麻醉风险高的人更有可能发生心肺并发症和不良事件，例如高碳酸血症和酸中毒，这必须通过过度通气来避免。因此，已引入其他气体作为二氧化碳建立气腹的替代物。
评估在接受腹腔镜普通腹部或妇科盆腔手术的参与者中，用于建立气腹的不同气体（即二氧化碳、氦气、氩气、氮气、氧化亚氮和室内空气）的安全性、益处和危害。
我们检索了Cochrane对照试验中心注册库（CENTRAL）（Cochrane图书馆，2016年第9期）、Ovid MEDLINE（1950年至2016年9月）、Ovid Embase（1974年至2016年9月）、科学引文索引扩展版（1970年至2016年9月）、中国生物医学文献数据库（CBM）（1978年至2016年9月）、ClinicalTrials.gov（2016年9月）和世界卫生组织国际临床试验注册平台（2016年9月）。
我们纳入了比较在全身麻醉下接受腹腔镜腹部或妇科盆腔手术的参与者（无论年龄、性别或种族）中用于建立气腹的不同气体的随机对照试验（RCT）。
两位综述作者确定纳入试验、收集数据并独立评估偏倚风险。我们使用Review Manager 5进行荟萃分析。我们计算二分法结局的风险比（RR）（或极罕见结局的Peto比值比），以及连续结局的均值差（MD）或标准化均值差（SMD），并给出95%置信区间（CI）。我们使用GRADE对证据质量进行评级。
我们纳入了9项RCT，随机分配519名参与者，比较用于建立气腹的不同气体：将氧化亚氮（3项试验）、氦气（5项试验）或室内空气（1项试验）与二氧化碳进行比较。3项试验将参与者随机分为氧化亚氮气腹组（100名参与者）或二氧化碳气腹组（96名参与者）。没有一项试验的偏倚风险较低。没有足够的证据确定氧化亚氮和二氧化碳对心肺并发症的影响（RR 2.00，95%CI 0.38至10.43；两项研究；140名参与者；证据质量极低），或对手术发病率的影响（RR 1.01，95%CI 0.18至5.71；两项研究；143名参与者；证据质量极低）。没有与氧化亚氮或二氧化碳气腹相关的严重不良事件（三项研究；196名参与者；证据质量极低）。我们无法合并两项试验（140名参与者）的数据，这两项试验分别显示在术后第一天的不同时间点，氧化亚氮气腹的疼痛评分较低（在1至10分的视觉模拟评分量表上相差约1分，分数越低疼痛越轻），这被评为极低质量。四项试验将参与者随机分为氦气腹组（69名参与者）或二氧化碳气腹组（75名参与者），一项涉及33名参与者的试验未说明每组的参与者数量。没有一项试验的偏倚风险较低。没有足够的证据确定氦气或二氧化碳对心肺并发症的影响（RR 1.46，95%CI 0.35至6.12；三项研究；128名参与者；证据质量极低）或疼痛评分（1至10分的视觉模拟评分量表，分数越低疼痛越轻；MD 0.49 cm，95%CI -0.28至1.26；两项研究；108名参与者；证据质量极低）。有三项与氦气腹相关的严重不良事件（皮下气肿）（三项研究；128名参与者；证据质量极低）。一项试验将参与者随机分为室内空气气腹组（70名参与者）或二氧化碳气腹组（76名参与者）。该试验的偏倚风险不明确。未观察到与室内空气或二氧化碳气腹相关的心肺并发症或严重不良事件（两项结局的证据质量均极低）。与二氧化碳气腹相比，室内空气气腹在术后第一天的住院费用更低且疼痛减轻的证据（在1至10分的视觉模拟评分量表上相差约1分，分数越低疼痛越轻）被评为极低质量的证据。
当前证据的质量非常低。与二氧化碳气腹相比，氧化亚氮和氦气腹气腹的影响尚不确定。一项小样本试验的证据表明，室内空气气腹可能会降低接受腹腔镜腹部手术患者的住院费用。氧化亚氮、氦气和室内空气气腹的安全性尚未确立。需要对此主题进行进一步试验，应在标准压力气腹和冷气体充气条件下，比较各种气体（即氧化亚氮、氦气、氩气、氮气和室内空气）与二氧化碳对麻醉风险高的患者的影响。未来的试验应包括并发症、严重不良事件、生活质量和疼痛等结局。
