Pre/Post Surgery

Written By Elizabeth Gaffney

Hyperbaric Oxygen Therapy Pre and Post-Surgery

Introduction

Hyperbaric Oxygen Therapy (HBOT) consists of breathing oxygen at a pressure higher than local atmospheric pressure for multiple sessions for the treatment or prevention of specific diseases. As per the European Code of Good Practice (Kot et al.), there is a general consensus that the term HBOT can only be applied when the partial pressure of oxygen in breathing mixture exceeds 1.5 absolute atmosphere (ATA) for a minimum period of 60 minutes (excluding compression and decompression).

HBOT is a valuable adjunctive perioperative treatment in surgical settings. HBOT can be used both preoperatively and postoperatively to enhance oxygen delivery to tissues and may promote angiogenesis, reduce inflammation and support tissue repair, thereby improving surgical outcomes, particularly in high-risk patients and complex surgical scenarios.

Mechanisms of Action of HBOT

HBOT may benefit patients undergoing surgery through several mechanisms, primarily by enhancing oxygen delivery to tissues to relieve chronic hypoxia. Hyperbaric Oxygenation, which may be before and/or after surgery, is a form of therapy directed to significantly increase the partial pressure of oxygen in the blood and in the tissues of the patients to the levels significantly exceeding those achieved in normobaric conditions.

1. Enhanced oxygenation: Prior to surgery, especially in patients with compromised vascular systems, HBOT increases the oxygen in blood and tissues, ensuring that poorly perfused areas receive adequate oxygenation (Cannellotto et al., 2024).

2. Reduction of inflammation: The immune response in wounds is modulated by HBOT (Capó et al., 2023), which could potentially mitigate the inflammatory response triggered by surgical trauma.

3. Angiogenesis: Wound healing is promoted by HBOT via increased angiogenesis and oxygen availability (Cannellotto et al., 2024), which are vital for collagen synthesis, fibroblast function, and tissue repair.

4. Reduction of oedema: HBOT causes vasoconstriction without compromising oxygen delivery, reducing oedema and swelling (Nylander et al., 1985).

5. Antimicrobial effects: Leukocyte function is enhanced by HBOT (Memar et al., 2019), which may reduce surgical site infections.

6. Bone growth: HBOT accelerates osteoblast differentiation and promotes bone formation (Al Hadi et al., 2015).

Benefits of Perioperative HBOT

HBOT is generally well tolerated and serious side effects are rare (Camporesi, 2014). Patients undergoing surgery may experience a range of benefits from adjunctive HBOT that can significantly improve their quality of life and prognosis.

1. Improved surgical outcomes: By optimising tissue oxygenation and reducing inflammation, HBOT can improve surgical outcomes. Patients receiving HBOT may experience fewer complications such as infections or poor wound healing, thereby reducing hospital stays and lowering healthcare costs.

2. Enhanced recovery: HBOT can accelerate the recovery process by promoting wound healing and bone integration, which is particularly significant for patients with comorbidities that impair healing.

3. Reduced infection rates: HBOT can enhance immune function, and its antimicrobial effects reduce the risk of postoperative infections, leading to better recovery outcomes.

4. Pain reduction: By reducing inflammation and oedema, HBOT can contribute to pain relief, thus enhancing patient comfort and enabling better participation in rehabilitation activities.

Clinical Evidence Supporting Perioperative HBOT

Clinically, HBOT may be used to enhance wound healing and manage complications and perioperative HBOT is particularly useful for patients with conditions that may impair healing or increase surgical risk, such as patients with diabetes.

1. Postoperative complications: A retrospective cohort study showed that preoperative HBOT (100% O2, 2 ATA, 90 mins, 1–3 daily sessions) can reduce postoperative complications in abdominoplasty patients (Friedman et al., 2019).

2. Diabetic foot ulcers: In patients with diabetic foot ulcers requiring surgical intervention, preoperative HBOT (100% O2, 2.5 ATA, 60 mins, 30 sessions) in addition to standard care accelerated healing and improved outcomes (Munjewar et al., 2016).

3. Skin grafts and flaps: In tissue compromised by irradiation or decreased perfusion, HBOT (100% O2, 2–3 ATA, 90–120 mins, 10–20 perioperative sessions) increases the viability of compromised tissue and reduces the need for regrafting or repeat flap procedures (Francis & Baynosa, 2017; Kleban & Baynosa, 2020).

4. Orthopaedic surgery: In orthopaedic surgery, particularly in procedures involving bone grafts or implants, HBOT (typically 100% O2, 2–3 ATA, 90 mins, 25–40 postoperative sessions) may enhance bone healing and reduce infection rates (Jeyaraman et al., 2023). Adjunct perioperative HBOT (100% O2, 2.4 ATA, 120 mins, 30 sessions) may improve surgical outcomes for osteonecrosis of the femoral head (Bozkurt et al., 2022; Jeyaraman et al., 2023).

5. Dental surgery: HBOT may be beneficial for osteonecrosis of the jaw, periodontal disease and dental implants, and may promote bone regeneration and osseointegration (Re et al., 2019; Meligy et al., 2018). For example, Sharma (2003) treated patients with HBOT (100% O2, 2.5 ATA, 90 mins, 12–40 sessions pre- and post-surgery) for osteonecrosis of the jaw with favourable results. A systematic review and meta-analysis concluded that HBOT may be effective for implant treatment in irradiated maxillofacial patients (Shah et al., 2017).

6. Cardiovascular surgeries: The benefits of HBOT have also been investigated in the context of cardiovascular surgeries. Yogaratnam et al. (2010) found that two 30-minute HBOT sessions at 2.4 ATA prior to surgery reduced vascular ischaemic events, improved healing and reduced the incidence of wound infections in patients undergoing coronary artery bypass grafting.

7. Surgical site infections: HBOT (typically 1.4–3 ATA, 90 mins, 20–40 sessions) may result in rapid healing and epithelialisation of surgical wounds and is potentially beneficial in the treatment of surgical site infections following cardiac, neuromuscular scoliosis, coronary artery bypass and urogenital surgeries (Zhou et al., 2023).

8. Knee surgery: HBOT (typically 100% O2, 2–3 ATA, 90 mins, 25–40 postoperative sessions) can be used as an adjuvant treatment to prevent complications and chronic disorders that commonly follow knee surgery (Leite et al., 2023).

9. Reconstruction surgery following breast cancer: HBOT (typically 100% O2, 4–3 ATA, 90 mins, 20–40 sessions) may mitigate complications following nipple-sparing mastectomy (NSM), including infections, re-operation, flap loss, seroma and haematoma (Idris et al., 2024) and may be beneficial in standard post-surgical care protocols for patients undergoing NSM or other types of reconstruction surgery (Rajpal., et al 2019).

Conclusion

HBOT may be an effective adjunctive treatment before and/or after surgery. By enhancing oxygen delivery, promoting angiogenesis, reducing inflammation and improving immune function, HBOT may be beneficial for patients undergoing surgery, including improved outcomes, accelerated recovery and reduced infection rates.

References

  • Al Hadi, H., Smerdon, G. R., & Fox, S. W. (2015). Hyperbaric oxygen therapy accelerates osteoblast differentiation and promotes bone formation. Journal of Dentistry, 43(3), 382-388.

  • Bozkurt, I., Yalcin, N., Uluyardimci, E., & Akgul, E. A. (2022). Combination of hyperbaric oxygen and core decompression therapies improve outcomes in the treatment of hip osteonecrosis. Hip International, 32(6), 759-765.

  • Camporesi, E. M. (2014). Side effects of hyperbaric oxygen therapy. Undersea & Hyperbaric Medicine, 41(3), 253-257.

  • Cannellotto, M., Yasells García, A., & Landa, M. S. (2024). Hyperoxia: Effective mechanism of hyperbaric treatment at mild-pressure. International Journal of Molecular Sciences, 25(2), 777.

  • Capó, X., Monserrat-Mesquida, M., Quetglas-Llabrés, M., Batle, J. M., Tur, J. A., Pons, A., … & Tejada, S. (2023). Hyperbaric oxygen therapy reduces oxidative stress and inflammation, and increases growth factors favouring the healing process of diabetic wounds. International Journal of Molecular Sciences, 24(8), 7040.

  • Francis, A., & Baynosa, R. C. (2017). Hyperbaric oxygen therapy for the compromised graft or flap. Advances in Wound Care, 6(1), 23-32.

  • Friedman, T., Menashe, S., Landau, G., Sherf, M., Wiser, I., Seligman, Y., Friedman, M., Hadanny, A., Efrati, S., & Heller, L. (2019). Hyperbaric oxygen preconditioning can reduce postabdominoplasty complications: A retrospective cohort study. Plastic & Reconstructive Surgery, 7(10), e2417.

  • Idris, O. A., Ahmedfiqi, Y. O., Shebrain, A., Al-Assil, T., Pacione, S. C., Haj, D., … & Steeg, K. V. (2024). Hyperbaric Oxygen Therapy for Complications in Nipple-Sparing Mastectomy with Breast Reconstruction: A Systematic Review. Journal of Clinical Medicine, 13(12), 3535.

  • Jeyaraman, M., Sami, A., Nallakumarasamy, A., Jeyaraman, N., & Jain, V. K. (2023). Hyperbaric oxygen therapy in orthopaedics: An adjunct therapy with an emerging role. Indian Journal of Orthopaedics, 57(5), 748-761.

  • Kleban, S., & Baynosa, R. C. (2020). The effect of hyperbaric oxygen on compromised grafts and flaps. Undersea & Hyperbaric Medicine, 47(4).

  • Kot J, Desola J, Lind F, Mueller P, Jansen E, Burman F, Working Group WG. A European code of good practice for hyperbaric oxygen therapy – Review 2022. Diving Hyperb Med. 2023 Dec 20;53(4)(Suppl) :1-17.

  • Leite, C. B., Tavares, L. P., Leite, M. S., & Demange, M. K. (2023). Revisiting the role of hyperbaric oxygen therapy in knee injuries: Potential benefits and mechanisms. Journal of Cellular Physiology, 238(3), 498-512.

  • Meligy, S. S., Shehadat, S. A. A. I., & Samsudin, A. R. (2018). Hyperbaric oxygen therapy: A review of possible new era in dentistry. Journal of Dental Health, Oral Disorders & Therapy, 9, 174-179.

  • Memar, M. Y., Yekani, M., Alizadeh, N., & Baghi, H. B. (2019). Hyperbaric oxygen therapy: Antimicrobial mechanisms and clinical application for infections. Biomedicine & Pharmacotherapy, 109, 440-447.

  • Munjewar, C., Nabi, I., Gautam, S., Ahirwar, N., Chaudhary, P., Kumar, R., … & Ramteke, V. K. (2016). Evaluation of the role of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers: a prospective comparative study. Hellenic Journal of Surgery, 88, 219-224.

  • Nylander, G., Lewis, D., Nordström, H., & Larsson, J. (1985). Reduction of postischemic edema with hyperbaric oxygen. Plastic & Reconstructive Surgery, 76(4), 596-601.

  • Rajpal, N., Walters, E. T., Elmarsafi, T., Pittman, T. A., & Johnson-Arbor, K. K. (2019). Use of hyperbaric oxygen therapy for tissue ischemia after breast reconstruction. Undersea & Hyperbaric Medicine, 46(4).

  • Re, K., Patel, S., Gandhi, J., Suh, Y., Reid, I., Joshi, G., … & Khan, S. A. (2019). Clinical utility of hyperbaric oxygen therapy in dentistry. Medical Gas Research, 9(2), 93-100.

  • Shah, D. N., Chauhan, C. J., & Solanki, J. S. (2017). Effectiveness of hyperbaric oxygen therapy in irradiated maxillofacial dental implant patients: a systematic review with meta-analysis. Journal of Indian Prosthodontic Society, 17(2), 109-119.

  • Sharma, A. (2003). Role of hyperbaric oxygen therapy in dental surgery. Indian Journal of Aerospace Medicine, 47(1), 23-29.

  • Yogaratnam, J. Z., Laden, G., Guvendik, L., Cowen, M., Cale, A., & Griffin, S. (2010). Hyperbaric oxygen preconditioning improves myocardial function, reduces length of intensive care stay, and limits complications post coronary artery bypass graft surgery. Cardiovascular Revascularization Medicine, 11(1), 8-19.

  • Zhou, D., Fu, D., Yan, L., & Xie, L. (2023). The role of hyperbaric oxygen therapy in the treatment of Surgical Site Infections: a narrative review. Medicina, 59(4), 762.

Elizabeth Gaffney https://www.sourceprojects.co
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