Postoperative Pneumonia After Major Pulmonary Resections: The Importance of Gastrointestinal Tract Management

Abstract

We read with interest the paper by Radu and colleagues [1Radu D.M. Jauréguy F. Seguin A. et al.Postresection pneumonia after major pulmonary resections: an unsolved problem in thoracic surgery.Ann Thorac Surg. 2007; 84: 1669-1674Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar] about postoperative pneumonia after major pulmonary resections, and congratulate the authors. They report a 24.4% incidence of postresection pulmonary infections and 26.3% mortality among patients with postoperative pneumonia. In their series almost 50% of incidences of postoperative pneumonia occurred within the first 2 postoperative days, which suggests procedure-related onset. Their paper focuses on antibiotic prophylaxis but does not take into consideration the effect on pneumonia of gastroesophageal reflux and aspiration, either intraoperatively or during the postoperative period. Because we believe this is an important issue, it would be interesting to know whether the authors use preemptive gastrointestinal tract management (intraoperative placement of a nasogastric tube that is removed after surgery in the recovery room; and nothing by mouth on the day of the operation, liquids on the first postoperative day, and regular diet thereafter) as reported by Roberts and colleagues [2Roberts J.R. Shyr Y. Christian K.R. Drinkwater D. Merrill W. Preemptive gastrointestinal tract management reduces aspiration and respiratory failure after thoracic operations.J Thorac Cardiovasc Surg. 2000; 119: 449-452Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] and Roberts [3Roberts J.R. Postoperative respiratory failure.Thorac Surg Clin. 2006; 16: 235-241Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] in an effort to reduce episodes of aspiration. Moreover, they should take into account the fasting period before surgery, which may increase residual gastric volume, increasing the risk of aspiration [4Warner M.A. Caplan R.A. Epstein B.S. et al.Practice guidelines on preoperative fasting and the use of pharmacological agents to reduce the risk of pulmonary apiration: application to healthy patients undergoing elective procedure. Report by the American Society of Anesthesiologists Task Frce on Properative Fasting.Anesthesiology. 1999; 90: 896-905Crossref PubMed Scopus (577) Google Scholar]. In our experience, with this type of gastrointestinal tract management and the same antibiotic prophylaxis used by Radu and colleagues [1Radu D.M. Jauréguy F. Seguin A. et al.Postresection pneumonia after major pulmonary resections: an unsolved problem in thoracic surgery.Ann Thorac Surg. 2007; 84: 1669-1674Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar], the incidence of postoperative pneumonia is far lower. Agnew and associates [5Agnew N.M. Kendall J.B. Akrofi M. et al.Gastroesophageal reflux and tracheal aspiration in the thoracotomy position: should ranitidine premedication be routine?.Anesth Analg. 2002; 95: 1645-1649Crossref PubMed Scopus (27) Google Scholar] demonstrated that in patients at low-risk, gastrointestinal reflux is more frequent than expected with the patient in a lateral position, with an incidence of 28%, and recently Keeling and colleagues [6Keeling W.B. Lewis V. Blazick E. Maxey T. Garrett J.R. Sommers E. Routine evaluation for aspiration after thoracotomy for pulmonary resection.Ann Thorac Surg. 2007; 83: 193-196Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar] showed that aspiration after thoracotomy for pulmonary resection may affect nearly 20% of patients. Thus careful management of the gastrointestinal tract, even using H2 antagonists or proton pump inhibitors, seems of paramount importance. Although statistical significance was not reached, the use of a nasogastric tube has been shown to increase respiratory infections after lung surgery only if left in place longer than 1 day postoperatively [7Nan D.N. Fernandez-Ayala M. Farinas-Alvarez C. et al.Nosocomial infection after lung surgery.Chest. 2005; 128: 2647-2652Crossref PubMed Scopus (47) Google Scholar]. ReplyThe Annals of Thoracic SurgeryVol. 86Issue 3PreviewWe would like to thank Dr Terzi and coworkers [1] for their valuable comments, which bring into discussion the role of tracheobronchial aspiration of gastric content in the development of postoperative pulmonary injury. Full-Text PDF