The review, led by Thomas F. O’Shea and colleagues at the University of Colorado Anschutz Medical Center, systematically assembled the published experience with ECMO-assisted adult non-cardiac surgery across airway, trauma, burn, vascular, and obstetric care. The authors searched PubMed/MEDLINE, PubMed Central, and Google Scholar from database inception through July 14, 2026, and drew on case reports, case series, retrospective cohorts, database analyses, and prior reviews. Crucially, they distinguished between two clinically different scenarios: planned or enabling ECMO, initiated specifically to permit an operation that would otherwise be technically or physiologically prohibitive, and ECMO-supported surgery, in which a necessary non-cardiac operation is performed while a patient is already on ECMO for respiratory or circulatory failure.

The most mature application, by far, is airway and tracheobronchial surgery. Here, ECMO is often deployed electively, before the first incision, because the operation itself would make conventional ventilation impossible. When surgeons resect the trachea or carina, the very structure that carries air to the lungs, there is no safe way to ventilate the patient through the surgical field. ECMO solves this by taking over gas exchange entirely, allowing the surgical team to work in an unobstructed field without an endotracheal tube crossing the lesion or the anastomosis. One narrative review cited in the paper summarized 168 published cases of extracorporeal life support during airway surgery, and institutional series have reported safe completion of tracheal resections with VV-ECMO support lasting as little as 10 to 31 minutes, with no in-hospital deaths in one series of seven oncologic tracheal operations.

The choice between the two main ECMO configurations follows a simple physiological logic. Venovenous ECMO, or VV-ECMO, drains deoxygenated blood from a vein, passes it through an external membrane oxygenator, and returns it to the venous system, providing gas exchange only. It is the preferred mode when the lungs, but not the heart, are the problem. Venoarterial ECMO, or VA-ECMO, returns oxygenated blood to the arterial system, providing both circulatory and respiratory support, and is chosen when hemodynamic compromise, anticipated major bleeding, or the demands of the procedure require more complete cardiopulmonary support. In the airway literature, VV-ECMO was commonly sufficient; in vascular and trauma settings, VA-ECMO predominates.

Trauma represents a different paradigm. Rather than enabling planned operations, ECMO in trauma patients is principally a stabilizing bridge that buys time for time-sensitive surgical injuries to be addressed. The review highlights striking examples: a multicenter analysis of the Trauma Registry-DGU found that 1.1 percent of patients with neurologic trauma received ECMO, with 61.8 percent surviving to discharge, challenging the historical view that brain injury is a contraindication to the therapy. One reported patient with severe respiratory distress syndrome, a large intracerebral hematoma, and multiple injuries after a fall underwent craniotomy while on VV-ECMO and was later discharged with full neurologic recovery. Small series describe femoral fracture fixation, pelvic ring fixation, and even posterior spinal fixation performed during ECMO support, with all reported femoral fixation patients surviving to discharge.

Abdominal trauma adds another layer of complexity. Damage-control laparotomy, the rapid staged approach to hemorrhage and bowel ischemia, has traditionally been viewed with suspicion in anticoagulated patients. Yet a single-center retrospective study of 52 patients supported with VV-ECMO before or after damage-control laparotomy reported an overall survival rate of 58 percent, and after adjustment for confounders, patients who could tolerate anticoagulation had improved survival. The authors concluded that damage-control laparotomy should not be considered a contraindication to VV-ECMO, or vice versa, a finding that could reshape how trauma teams think about the interplay of bleeding risk and extracorporeal support.

In burn care, the review found that ECMO has been used to support excision, debridement, and wound coverage in patients with severe inhalation injury or burn-associated respiratory distress syndrome. One burn center proposed a standardized perioperative protocol centered on multidisciplinary planning, individualized anticoagulation, and point-of-care viscoelastic coagulation monitoring, targeting a low-dose heparin regimen with an activated partial thromboplastin time of approximately 40 seconds during surgery. The dominant challenges are surgical blood loss, hypothermia, infection, and the resource intensity of repeated wound care, all compounded by the need to keep the ECMO circuit free of clots while the patient bleeds.

Vascular surgery illustrates both the promise and the risks of the technology. VA-ECMO has been used as planned support for high-risk thoracoabdominal aortic aneurysm repair and as a bridge during emergent pulmonary embolectomy, and some teams propose advantages over conventional cardiopulmonary bypass, including lower anticoagulation targets, reduced blood-air interface, and avoidance of systemic cooling. But peripheral cannulation carries its own vascular toll: a systematic review of 47 studies involving 6,583 patients reported an overall pooled vascular complication rate of 29.5 percent, with limb ischemia in 12.6 percent and significant bleeding in 15.4 percent. Preventive strategies include ultrasound-guided access, the smallest adequate arterial cannula, prophylactic distal perfusion cannulation, and serial perfusion checks by examination, Doppler, and near-infrared spectroscopy.

Obstetric applications are among the most dramatic. The literature consists primarily of cesarean delivery performed during ongoing ECMO support for severe maternal cardiopulmonary failure, with early reports dating back more than a decade and the COVID-19 pandemic expanding the experience considerably. A ten-year case series of 54 pregnant and postpartum patients requiring ECMO identified acute respiratory distress syndrome as the most common indication, and a systematic review and meta-analysis identified 1,460 reported cases of pregnant patients receiving VA- or VV-ECMO, with survival rates of 62.8 percent for VA-ECMO and 83.6 percent for VV-ECMO. These figures, however, come from heterogeneous cohorts not restricted to surgical patients and cannot be read as estimates of the effect of ECMO-facilitated delivery itself.

The review’s most important message may be its caution. The evidence base is dominated by single-patient case reports and small observational series from experienced centers, with substantial publication and selection bias: successful, unusual operations are far more likely to be reported than unsuccessful attempts or patients who were considered but not selected. No randomized studies define thresholds for ECMO use, optimal cannulation strategy, or standardized anticoagulation targets in this setting, and comparator populations are generally absent. The authors are explicit that the current literature should not be interpreted as establishing a survival or treatment-effectiveness benefit. What the review does establish is a practical framework: multidisciplinary planning, individualized cannulation and anticoagulation, hemorrhage preparedness, careful anesthetic and ventilatory management, and coordinated postoperative critical care are the recurring pillars of every successful reported case. Until robust multicenter and comparative data arrive, ECMO-assisted non-cardiac surgery remains a selective strategy for experienced teams, deployed when the patient’s physiology, the operative requirement, and the likelihood of a meaningful surgical objective all align.

Subject of Research: Use of extracorporeal membrane oxygenation to facilitate adult non-cardiac surgery

Article Title: ECMO-facilitated adult non-cardiac surgery: a structured narrative review

Article References: O’Shea, T. F., Bashian, E. J., Park, S. Y., Carpenter, R., Hoffman, J. R. H., Cain, M. T., Kowalsky, M., Abrams, B., Clendenen, N., Teman, N. R., & Wilkey, B. (2026). ECMO-facilitated adult non-cardiac surgery: a structured narrative review. Frontiers in Anesthesiology, 5, Article 1944652. https://doi.org/10.3389/fanes.2026.1944652

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1944652

Keywords: ECMO, non-cardiac surgery, airway surgery, trauma surgery, burn surgery, vascular surgery, obstetrics, anticoagulation, VV-ECMO, VA-ECMO, perioperative care, critical care

The study, published in the Archives of Dermatological Research, enrolled 140 patients with clean, granulating wounds who were candidates for split-thickness skin grafting between July 2024 and November 2025. Participants were divided into two groups of 70 according to the harvesting technique used by the operating surgeon. Group A underwent the tumescent technique, in which a super-wet infiltration of dilute anesthetic solution was injected into the donor site before the dermatome was run. Group B underwent the traditional non-tumescent technique, in which the graft is harvested without prior infiltration. Grafts were taken at a standardized thickness in both arms, and the researchers tracked three primary endpoints: the percentage of graft acceptance at day 5, day 10 and week 3; donor-site healing at day 10 and week 3; and postoperative pain measured with the Visual Analogue Scale.

The results favored the tumescent approach at every measured time point. Graft acceptance in the tumescent group reached 97.5 percent at day 5 compared with 94.0 percent in the non-tumescent group, 94.9 percent versus 88.9 percent at day 10, and 88.0 percent versus 83.1 percent at week 3, with all differences statistically significant at p less than 0.001. In practical terms, that gap means fewer patients returning to the operating room for revision grafting, fewer days of open wound care and a shorter, less costly hospital course. Graft take — the process by which a transplanted sheet of skin reattaches to its new bed through revascularization — is notoriously sensitive to conditions at the recipient site, and any intervention that nudges acceptance upward by several percentage points is clinically meaningful.

Even more striking were the differences at the donor site itself. By day 10, 87.1 percent of tumescent patients had achieved complete healing of the harvest wound, compared with 70.0 percent of those in the conventional group, a difference the authors report as significant at p equal to 0.013. The divergence widened further: the entire tumescent arm achieved complete donor-site healing within one to two weeks, whereas only 31.4 percent of the non-tumescent arm had done so by the same interval, a difference with a p value below 0.001. Epithelialization — the migration of new skin cells across the raw surface left by the dermatome — is the rate-limiting step in donor-site recovery, and accelerating it by even a few days can translate into less dressing changes, less nursing time and a faster return to normal activity.

Pain, the symptom patients most dread after graft harvesting, also fell decisively in the tumescent group. Postoperative analgesia requirements were significantly reduced compared with the conventional arm, with a p value below 0.001 on the Visual Analogue Scale comparisons. The mechanism is straightforward pharmacology: the tumescent solution contains a local anesthetic, typically lidocaine in dilute concentration, which bathes the nerve endings in the dermis and subcutaneous tissue and blocks pain signaling at the source. Because the solution is injected in large volume under low pressure — the super-wet approach — it also physically distends the tissue, firming the donor surface so the dermatome can cut a smoother, more uniform graft with less mechanical trauma.

Adrenaline, the second key ingredient in the infiltrate, does the hemostatic work. By constricting the small dermal vessels that bleed freely when the skin is shaved, it dries the donor field, reduces intraoperative blood loss and may improve the visibility and precision of the harvest. The concept is not new: the tumescent technique was originally described in 1987 for liposuction surgery, where large volumes of dilute anesthetic and adrenaline are infiltrated into subcutaneous fat, and it has since been adapted for a range of dermatosurgical procedures. Burn surgeons in particular have reported that tumescent infiltration significantly reduces blood loss during excision of burn wounds, and several smaller comparative studies have suggested benefits for skin graft harvesting specifically.

What sets the new study apart is its prospective design and its size relative to much of the earlier literature. Previous comparisons of tumescent and non-tumescent graft harvesting have often been retrospective, single-arm or small cross-sectional analyses. By enrolling 140 patients consecutively at a single tertiary care facility, standardizing graft thickness across both groups and pre-specifying objective endpoints at fixed time points, the Indian team produced one of the more rigorous datasets on the question to date. Complications told a consistent story: overall complications occurred in 7.1 percent of the tumescent group versus 20.0 percent of the non-tumescent group, a difference the authors report as statistically significant at p equal to 0.048. The reduction was driven primarily by graft loss, which fell from 10.0 percent in the conventional arm to 1.4 percent in the tumescent arm, significant at p equal to 0.011.

The biological logic behind these numbers is plausible on several fronts. A drier, better-hemostased donor bed may allow the harvested graft to be handled and applied with less contamination by blood, which can lift the graft off the recipient bed and prevent the capillary ingrowth required for take. The vasoconstriction induced by adrenaline may also create a transient ischemic stimulus at the donor site that some investigators believe accelerates re-epithelialization, although the precise mechanism remains debated. There is even laboratory evidence that tumescent infiltration fluid has antibacterial properties, which could reduce low-grade infection at both the donor and recipient sites. And because the anesthetic effect persists into the immediate postoperative period, patients start their recovery with better-controlled pain, which itself supports mobilization, sleep and wound perfusion.

The authors are careful about the limits of their evidence. As a prospective observational study rather than a randomized controlled trial, allocation to the two techniques followed the practice of the operating surgeon rather than a random process, leaving open the possibility of selection bias — for example, if surgeons preferentially used tumescence in patients they judged better candidates. The analysis relied on Student’s t-test and the chi-square test with a significance threshold of p less than 0.05, and while the differences in graft take and donor healing were large and consistent, observational designs cannot fully exclude confounding by surgeon skill, wound characteristics or adjunctive care. The authors themselves conclude that these encouraging findings warrant broader evaluation in prospective randomized controlled trials before the tumescent technique is definitively integrated into standard clinical practice.

Still, the direction of the evidence is hard to ignore. A technique that costs little more than a syringe, a dilute anesthetic solution and a few minutes of infiltration time delivered measurable gains in graft survival, donor-site healing speed, pain control and complication rates across 140 patients. For burn units, wound centers and plastic surgery services in resource-constrained settings — where revision surgery and prolonged dressing care carry the heaviest costs — a low-tech intervention with this effect profile could change routine practice. If randomized trials confirm what this observational study suggests, the humble act of inflating the donor site with fluid before cutting may become as standard a step in skin grafting as the dermatome itself.

Subject of Research: Comparison of tumescent and non-tumescent techniques for split-thickness skin graft harvesting and donor-site outcomes

Article Title: Tumescent vs. non-tumescent techniques for split-thickness skin grafting: a prospective observational study

Article References: Kambaiahgari, M. M. R., Sivamurugan, A., Pravin Dhas, A., Debarath Das, D., & Raman, L. (2026). Tumescent vs. non-tumescent techniques for split-thickness skin grafting: a prospective observational study. Archives of Dermatological Research, 318(1), Article 482. https://doi.org/10.1007/s00403-026-04878-z

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04878-z

Keywords: split-thickness skin graft, tumescent technique, donor site healing, graft take, postoperative pain, adrenaline infiltration, local anesthesia, epithelialization, burn surgery, reconstructive surgery, dermatological research, surgical outcomes