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Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery

A Report From the International Registries

Dickson, Edward A., B.M.B.S., M.R.C.S.1; Penna, Marta, M.B.B.S., M.R.C.S.1,2; Cunningham, Chris, M.D., F.R.C.S.1; Ratcliffe, Fiona M., F.R.C.A.3; Chantler, Jonathan, F.R.C.A.3; Crabtree, Nicholas A., F.R.C.A.3; Tuynman, Jurriaan B., M.D., Ph.D.4; Albert, Matthew R., M.D.5; Monson, John R.T., M.D.5; Hompes, Roel, M.D.6 on behalf of the International TaTME Registry Collaborative

Diseases of the Colon & Rectum: July 2019 - Volume 62 - Issue 7 - p 794–801
doi: 10.1097/DCR.0000000000001410
Original Contribution: Colorectal Cancer
Denotes Associated Video Abstract
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BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision.

OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique.

DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event.

SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries.

MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured.

RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12–20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths.

LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists.

CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at

1 Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, United Kingdom

2 Department of Academic Surgery, St. Mary’s Hospital, London, United Kingdom

3 Department of Anesthesia, Oxford University Hospitals, Oxford, United Kingdom

4 Department of Surgery, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands

5 Center for Colon and Rectal Surgery, Florida Hospital, Orlando, Florida

6 Department of Surgery, Oncologic and Lower GI Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands

Funding/Support: None reported.

Financial Disclosure: M.R.A. has received consulting, teaching, and speaking fees for Conmed Ltd, Applied Medical, and Stryker.

Correspondence: Roel Hompes, M.D., Department of Surgery, Oncologic and Lower GI Surgery, Amsterdam UMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands. E-mail:

© 2019 The American Society of Colon and Rectal Surgeons