Survival Impact of Intraoperative CO2 Dysregulation in patients undergoing Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

Authors

Ashley Wetzel, Thomas Jefferson UniversityFollow
Andrea Feci, Thomas Jefferson UniversityFollow
Joseph Gorman, Thomas Jefferson UniversityFollow
Isabel Lavine, Thomas Jefferson UniversityFollow
Edoardo Manca, Thomas Jefferson UniversityFollow
Richard Zheng, MD, Thomas Jefferson UniversityFollow
Nader Hanna, MD, Thomas Jefferson UniversityFollow
Harish Lavu, MD, Thomas Jefferson UniversityFollow
Charles J. Yeo, MD, Thomas Jefferson UniversityFollow
Avinoam Nevler, MD, Thomas Jefferson UniversityFollow

Files

Description

Purpose: Pancreatic ductal adenocarcinomas (PDAC) are aggressive malignancies with poor prognoses. Emerging evidence suggests tissue hypercapnia (elevated CO₂) promotes aggressive, treatment resistant tumor biology. End-tidal CO₂ (ETCO₂) offers a composite measure of ventilation, systemic perfusion, and tissue CO₂ production. During curative-intent pancreaticoduodenectomy, we hypothesized that intraoperative ETCO₂ could serve as a marker of tissue CO₂ dyscapnia; both low levels indicating decreased circulatory reserves and high levels indicating tissue hypercapnia may result in worse outcomes.

Methods: We conducted a retrospective review (2017-2023) of 343 patients undergoing pancreaticoduodenectomy for PDAC. Intraoperative ETCO₂ data were obtained from anesthesia records, excluding the first and last 45 minutes of surgery. Patients with overall or disease-free survival (OS & DFS) under 90 days or intraoperative metastasis discovery were excluded. Mean ETCO₂ was calculated per patient. ETCO₂ groups were stratified by quartiles: low (Q1), normal (Q2-3), and high (Q4). Primary endpoints were DFS and OS.

Results: 243 total patients (49% male, average age: 68.5 (61.3–74.9 years)) were analyzed. Normocapnic patients had significantly better OS and DFS compared with both low and high ETCO₂ groups (P< 0.05, each, Figure 1A). Hypocapnia had poorer DFS than normocapnia (12.9 vs. 22.4 months, P=0.03, Figure 1B). Cox regression showed both hypocapnia and hypercapnia independently predicted recurrence (HR=1.58 and 1.50; P=0.02 and 0.05, respectively) and mortality (HR=1.65 and 1.66; P=0.03 and 0.04, respectively).

Conclusions: Mean intraoperative ETCO₂ is strongly associated with oncologic outcomes post- pancreaticoduodenectomy for PDAC. Both low and high ETCO₂ were linked to worse survival, indicating ETCO₂’s potential as a clinically relevant prognostic marker.

Publication Date

2-2-2026

Keywords

end-tidal CO2, hypercapnia, pancreatic ductal adenocarcinoma, pancreaticoduodenectomy

Disciplines

Medicine and Health Sciences | Surgery

Comments

Presented at the 2026 AOA Research Symposium.

Recommended Citation

Wetzel, Ashley; Feci, Andrea; Gorman, Joseph; Lavine, Isabel; Manca, Edoardo; Zheng, MD, Richard; Hanna, MD, Nader; Lavu, MD, Harish; Yeo, MD, Charles J.; and Nevler, MD, Avinoam, "Survival Impact of Intraoperative CO2 Dysregulation in patients undergoing Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma" (2026). Alpha Omega Alpha Research Symposium Posters. 30.
https://jdc.jefferson.edu/aoa_research_symposium_posters/30