Low intraoperative end-tidal carbon dioxide levels are associated with improved recurrence-free survival after elective colorectal cancer surgery

Abstract

Study objective: Higher levels of carbon dioxide (CO₂) increase the invasive abilities of colon cancer cells in vitro. Studies assessing target values for end-tidal CO₂ concentrations (EtCO₂) to improve surgical outcome after colorectal cancer surgery are lacking. Therefore, we evaluated whether intraoperative EtCO₂ was associated with differences in recurrence-free survival after elective colorectal cancer (CRC) surgery.

Design: Single center, retrospective analysis.

Setting: Anesthesia records, surgical databases and hospital information system of a tertiary university hospital.

Patients: We analyzed 528 patients undergoing elective resection of colorectal cancer at Heidelberg University Hospital between 2009 and 2018.

Interventions: None.

Measurements: Intraoperative mean EtCO₂ values were calculated. The study cohort was equally stratified into low-and high-EtCO₂ groups. The primary endpoint measure was recurrence-free survival until last known follow-up. Groups were compared using Kaplan-Meier analysis. Cox-regression analysis was used to control for covariates. Sepsis, reoperations, surgical site infections and cardiovascular events during hospital stay, and overall survival were secondary outcomes.

Main results: Mean EtCO₂ was 33.8 mmHg ±1.2 in the low- EtCO₂ group vs. 37.3 mmHg ±1.6 in the high-EtCO₂ group. Median follow-up was 3.8 (Q1-Q3, 2.5-5.1) years. Recurrence-free survival was higher in the low-EtCO₂ group (log-rank-test: p = .024). After correction for confounding factors, lower EtCO₂ was associated with increased recurrence-free survival (HR = 1.138, 95%-CI:1.015-1.276, p = .027); the hazard for the primary outcome decreased by 12.1% per 1 mmHg decrease in mean EtCO₂. 1-year and 5-year survival was also higher in the low-EtCO₂ group. We did not find differences in the other secondary endpoints.

Conclusions: Lower intraoperative EtCO₂ target values in CRC surgery might benefit oncological outcome and should be evaluated in confirmative studies.

Keywords: Carbon dioxide; Colorectal cancer surgery; Intraoperative ventilation; Postoperative complications; Recurrence-free survival.