Non-thoracic Surgery Research Articles

Comparative Rates of Stroke and Rehospitalization of Atrial Fibrillation in Patients with Perioperative Atrial Fibrillation Following Major Emergency Abdominal Surgery and Patients with Non-perioperative Atrial Fibrillation.

Major emergency abdominal surgery is associated with postoperative complications and high mortality. Long-term outcomes in patients with perioperative atrial fibrillation (POAF) have recently received increased attention, especially POAF in non-thoracic surgery. This study aimed to compare long-term AF related hospitalization and stroke in patients with POAF in relation to major emergency abdominal surgery and in patients with non-perioperative AF. We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with POAF, and patients who developed AF in a non-perioperative setting. Patients with POAF were matched in a 1:5 ratio on age, sex, year of AF diagnosis and oral anticoagulation (OAC) status at the beginning of follow-up with patients with non-perioperative AF. From discharge, we examined adjusted hazard ratios (HR) of stroke using multivariable Cox regression analysis. The study population comprised 1,041 (out of 42,021 who underwent major emergency abdominal surgery) patients with POAF and 5,205 patients with non-perioperative AF. The median age was 78 years [interquartile range: 71-84] for those initiated on OAC therapy and 78 years [interquartile range: 71-85] for those not initiated on OAC therapy. During the first year of follow up, POAF was associated with similar rates of stroke as non-perioperative AF (patients initiated on OAC: HR 0.96 (95% confidence interval (CI) 0.52-1.77) and patients not initiated on OAC: HR 0.69 (95% CI 0.41-1.15). POAF in relation to major emergency abdominal surgery was associated with similar rates of stroke as non-perioperative AF. These results suggest that POAF not only carry an acute burden but also a long-term burden in patients undergoing major emergency abdominal surgery.

Disparities in Access to Thoracic Surgeons among Patients Receiving Lung Lobectomy in the United States

Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.

Spontaneous hyperinflation of a giant bulla of the non-ventilated lung during laparoscopic cholecystectomy under one-lung ventilation: a case report

BackgroundAnesthetic management of non-thoracic surgery in patients with giant bullae is challenging. We present a case of laparoscopic cholecystectomy in a patient with a giant bulla managed with one-lung ventilation (OLV).Case presentationA 75-year-old man with a giant bulla occupying the lower half of the right hemithorax underwent laparoscopic cholecystectomy. We managed anesthesia with OLV to avoid positive pressure ventilation of the giant bulla. Surgery was completed uneventfully; however, postoperative chest radiography indicated a large lucency occupying the entire right hemithorax. Although we suspected a pneumothorax due to a ruptured bulla, chest computed tomography (CT) led to a diagnosis of giant bulla hyperinflation. The giant bulla deflated gradually to its preoperative size within three postoperative days.ConclusionsManaging laparoscopic cholecystectomy in a patient with a giant bulla with OLV resulted in spontaneous hyperinflation of the giant bulla. Chest CT ruled out a pneumothorax.

The effectiveness of ARISCAT Risk Index, other scoring systems, and parameters in predicting pulmonary complications after thoracic surgery.

The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk index, which is frequently used in nonthoracic surgery, may not be sufficient to predict postoperative pulmonary complications (PPCs). We aimed to evaluate the effectiveness of the ARISCAT risk index, ASA, preoperative albumin level, neutrophil/lymphocyte ratio (NLR), and other parameters in predicting PPCs after thoracic surgery.Patients undergoing elective thoracic surgery with 1-lung ventilation (OLV) were prospectively analyzed. Demographic data, ARISCAT score, ASA, Nutritional Risk Score-2002, NLR, white blood cell counts, albumin, hemoglobin levels, intraoperative complications, postoperative average visual analogue scale (VAS) score for pain at the 24th-hour, the length of stay in the postoperative intensive care unit, chest tube removal time, postoperative complications, and discharge time were recorded. Patients were assessed for morbidity and mortality on the 90th-day.120 patients’ data were analyzed. PPCs developed in 26 patients. The development of PPCs was statistically significant in patients with high ARISCAT scores (P = .002), high ARISCAT grades (P = .009), and ASA III (P = .002). The albumin level was statistically significantly lower in patients who had mortality within 3 months (P = .007). When scoring systems and laboratory parameters were evaluated together, patients with high ARISCAT grade, Albumin < 35g/L, and ASA III had significantly higher development of PPCs (P = .004).ARISCAT risk index and ASA were found to be significant in predicting PPCs after thoracic surgery. They were also valuable when evaluated in combination with preoperative albumin levels. Additionally; age, male gender, duration of surgery, and duration of OLV were also found to be associated with PPCs.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications.

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in non-thoracic surgery. We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy). 46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry). As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before non-thoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.

Determinants of postoperative atrial fibrillation: A retrospective evaluation of postoperative atrial fibrillation in cardiac surgery

Introduction: Atrial fibrillation is the most common postoperative arrhythmia and is associated with increased length of stay, cost, morbidity and mortality. The incidence of postoperative atrial fibrillation for noncardiac, nonthoracic surgeries ranges from 0.4% to 26%. The incidence increases to 20%–50% in cardiac surgery, occurring in approximately 30% of isolated coronary artery bypass grafting (CABG), approximately 40% of isolated valve surgeries and up to 50% of CABG plus valve surgeries. Our aim was to identify risk factors that may predispose patients to postoperative atrial fibrillation and compare the efficacy of previously developed prediction tools to a new bedside prediction tool. We sought to develop a bedside screening tool using 4 easily identifiable variables: body mass index, age, congestive heart failure and hypertension (BACH). We predicted that our model would compare similarly to previously developed and validated prediction models but would be easier to use.&#x0D; Methods: We retrospectively identified 672 patients without a history of atrial fibrillation who had undergone cardiac surgery from July 2011 to December 2018. The risk factors for atrial fibrillation were evaluated alongside previously developed prediction tools. Using logistic regression, t tests and receiver operator characteristic (ROC) analysis, we compared previously used risk stratification scores of CHA2DS2-VASc, CHARGE-AF and age. We also compared our proposed BACH risk prediction tool to our population and compared it against CHA2DS2-VASc, CHARGE-AF and age. In a subpopulation analysis of 259 people, we evaluated if left atrial size was an independent risk factor for the development of postoperative atrial fibrillation.&#x0D; Results: A total of 131 patients—approximately 20%—developed postoperative atrial fibrillation. CHA2DS2-VASc had the lowest area under the curve (AUC) and did not perform as well at classifying patients with postoperative atrial fibrillation as the other 3 predictors. CHARGE-AF, age by itself and age per 5 years performed relatively similarly to one another. ROC was greatest for age alone (ROC area .634, 95% CI: .581–.688), followed by CHARGE-AF (ROC area .631, 95% CI: .577–.684), and finally CHA2DS2-VASc (ROC area .564, 95% CI: .509–.619). A logistic model was fit for the BACH variables (continuous versions of body mass index, age, congestive heart failure and hypertension). The model achieved good fit, χ2(671, N=672)=633.029, P=.816, Nagelkerke R2=.070. However, only the predictors of age and prior heart failure were found to be significant. For BACH, the C-statistic (and AUC) for the model was .645 (95% CI: .601, .707), which was marginally better than age alone. All the models that were fit using ROC analyses were not statistically different from one another in terms of performance. No statistical significance was found between the 2 groups for preoperative left atrial size.&#x0D; Conclusion: These findings suggest that age may be the highest risk factor for postoperative atrial fibrillation. The bedside prediction tool BACH compared slightly better than age alone but was not statistically different from the other prediction tools’ performance. The BACH prediction tool is easy to use, includes only 4 factors that are readily available at the bedside and improves prediction over age alone.

The Effect of the Preoperative Fasting Regimen on the Incidence of Gastro-Oesophageal Reflux in 90 Dogs

Simple SummaryGastro-oesophageal reflux (GOR), a potential risk during anaesthesia, happens when the stomach contents move up into the oesophagus. The refluxed contents can damage the lining of the oesophagus or the respiratory tract. For many years it was believed that an increase in the stomach contents’ volume increases the risk of GOR. However, more recent studies have demonstrated this to be incorrect. The objective of this study was to compare the effects of three different pre-anaesthetic fasting regimens on the frequency of GOR in dogs under anaesthesia. Ninety dogs undergoing non-abdominal and non-thoracic elective surgery were included in the study and equally allocated to three groups. The results of this study suggest that the administration of a meal 3 h before anaesthesia does not have any beneficial effect in the reduction of GOR incidence in dogs compared to the administration of a meal 12 h before anaesthesia.This study aimed to investigate the effect of three different preoperative fasting regimens on the incidence of gastro-oesophageal reflux (GOR) in dogs under general anaesthesia. Ninety dogs undergoing non-abdominal and non-thoracic elective surgery were included in the study and equally allocated to three groups. Dogs received canned food providing half the daily resting energy requirements (RER) 3 h prior to premedication (group 3H), a quarter of the daily RER 3 h before premedication (group 3Q), and half the daily RER 12 h before premedication (group 12H). The animals were premedicated with acepromazine and pethidine, anaesthesia was induced with propofol and maintained with isoflurane vaporised in oxygen. Oesophageal pH was monitored throughout anaesthesia. Demographic and surgery-related parameters were not different among groups. The incidence of GOR was 11/30 in group 3H (36.7%), 9/30 in group 3Q (30.0%) and 5/30 in group 12H (16.7%), which was not statistically different (p = 0.262). Reduction of the amount of the preoperative meal from half to a quarter of the daily RER did not reduce the incidence of GOR but resulted in a lower oesophageal pH (p = 0.003). The results of this study suggest that the administration of a meal 3 h before anaesthesia does not have any beneficial effect in the reduction of GOR incidence in dogs compared to the administration of a meal 12 h before anaesthesia.

Peri-operative diaphragm ultrasound as a new method of recognizing post-operative residual curarization

BackgroundThis study sought to evaluate the diagnostic accuracy of peri-operative diaphragm ultrasound in assessing post-operative residual curarization (PORC).MethodsPatients undergoing non-thoracic and non-abdominal surgery under general anaesthesia were enrolled from July 2019 to October 2019 at Peking Union Medical College Hospital. A train-of-four ratio (TOFr) lower than 0.9 was considered as the gold standard for PORC. Diaphragm ultrasound parameters included diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) during quiet breathing (QB) and deep breathing (DB). The diaphragm excursion fraction (DEF) was calculated as the DE-QB divided by the DE-DB. The diaphragm excursion difference (DED) was defined as DE-DB minus DE-QB. Receiver operating characteristic curve analysis was used to determine the cut-off values of ultrasound parameters for the prediction of PORC.ResultsIn total, 75 patients were included, with a PORC incidence of 54.6%. The DE-DB and DED were positively correlated with the TOFr, while the DEF was negatively correlated with the TOFr. The DE-DB cut-off value for predicting PORC was 3.88 cm, with a sensitivity of 85.4% (95% confidence interval [CI]: 70.1–93.9%), specificity of 64.7% (95% CI: 46.4–79.7%), positive likelihood ratio of 2.42 (95% CI 1.5–3.9), and negative likelihood ratio of 0.23 (95% CI: 0.1–0.5). The DED cut-off value was 1.5 cm, with a specificity of 94.2% (95% CI: 80.3–99.3%), sensitivity of 63.4% (95% CI: 46.9–77.9%), positive likelihood ratio of 10.78 (95% CI: 2.8–42.2), and negative likelihood ratio of 0.39 (95% CI: 0.3–0.6).ConclusionsPeri-operative diaphragm ultrasound may be an additional method aiding the recognition of PORC, with DED having high specificity.

Importance of Pre Operative Pulmonary Function Test to Predict Risk of Pulmonary Complications after Abdominal Surgery- An Evidence Based Study

Background: Spirometry is a universal, simple, and non-invasive pulmonary function test. Spirometry, along with calculation of the forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), is helpful for diagnosing obstructive or restrictive lung disease. Postoperative Pulmonary Complications are defined as unintended pulmonary abnormalities that occur as a result of surgery which cause identifiable dysfunction. Purpose: To find the evidence showing the importance of pre-operative PFT to predict risk of pulmonary complications after abdominal surgery Methodology: The study was conducted according to Preferred Reporting Items for systematic reviews and meta-analysis guidelines. Evidences selected since year 2002- 2020 from PubMed, Google Scholar, Physiotherapy Evidence Database (PEDro), ResearchGate and ScienceDirect. Key words used were: Pulmonary Function Tests, Post-Operative Pulmonary Complications, and Abdominal Surgery. Analysis was done using 2 scales: Centre for Evidence-Based Medicine Levels of Evidence Scale. Total 12 articles were found. Among them 10 were selected. Results: 5 articles showed that preoperative PFT is important in prediction of PPCs while the other half concluded that routine preoperative spirometry is not necessary before non-thoracic surgeries. Conclusion: Based on evidences, in the nutshell it is reviewed that there is controversy regarding the value of preoperative pulmonary functions test in non-thoracic surgeries. Keywords: Pulmonary Function Tests, Post-Operative Pulmonary Complications, and Abdominal Surgery

Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial

ObjectiveTo assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery.DesignPhase III, randomised, double blind, placebo controlled trial.Setting34 centres in France, December 2017 to March...

Expression of serous fibroblast growth factor 7 and related inflammatory factors in patients with acute exacerbation of chronic obstructive pulmonary disease

To investigate the expression of fibroblast growth factor 7 (FGF7) and related inflammatory factors in the serum of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). A case control study was conducted. The patients with AECOPD admitted to the First Affiliated Hospital of Xinjiang Medical University from November 2016 to January 2020 were enrolled. The patients were divided into mild group [forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio (FEV1/FVC) < 0.70, FEV1 percentage in predicted value (FEV1%) ≥ 80%], moderate group (FEV1/FVC < 0.70, 50% ≤ FEV1% < 80%), and severe group (FEV1/FVC < 0.70, 30% ≤ FEV1% < 50%) based on their lung function test results, with 20 patients in each group, and 20 patients with normal pulmonary function who underwent elective non-thoracic surgery such as gastrointestinal surgery and orthopedics surgery in the same period were selected as controls. The demographic data, FEV1/FVC, FEV1%, FVC, maximum mid-expiratory flow percentage in predicted value (MMEF%), 6-minute walking test (6MWT), and St George Respiratory Questionnaire (SGRQ) score were recorded respectively. Serum levels of FGF7, interleukins (IL-6, IL-1β) and tumor necrosis factor-α (TNF-α) were determined by enzyme linked immunosorbent assay (ELISA). Pearson correlation was used to analyze the correlation between TNF-α and lung function. Compared with the normal pulmonary function group, the levels of FEV1/FVC, FEV1%, MMEF% and 6MWT in the mild, moderate and severe groups were significantly decreased, and the SGRQ scores were increased, the indicators continued to deteriorate with the aggravation of the disease, the statistical differences were found between severe group and normal pulmonary function group [FEV1/FVC: 0.39±0.09 vs. 0.81±0.04, FEV1%: (38.80±6.28)% vs. (109.58±13.80)%, MMEF%: (0.34±0.14)% vs. (2.69±0.99)%, 6MWT (m): 279.00±41.61 vs. 402.85±53.97, SGRQ scores: 34.95±6.71 vs. 2.60±2.06, all P < 0.05]. Compared with the normal pulmonary function group, the levels of FGF7 in the mild, moderate and severe groups were significantly lowered (ng/L: 6.31±2.65, 6.10±1.39, 6.64±1.77 vs. 8.29±3.51, all P < 0.05), but no significant difference was found among the mild, moderate and severe groups (all P > 0.05). Compared with the normal pulmonary function group, IL-6 and TNF-α levels were significantly increased in the mild, moderate and severe groups, and TNF-α increased with the aggravation of the disease, the statistical difference was found between severe group and normal pulmonary function group (ng/L: 7.42±2.28 vs. 3.83±0.92, P < 0.05). There was no significant difference in IL-1β level between the normal pulmonary function group and the mild, moderate, severe groups. Correlation analysis showed that TNF-α was negatively correlated with FEV1/FVC and FEV1% (r values were -0.350 and -0.527, respectively, both P < 0.01). In AECOPD patients, serum FGF7 was decreased, while IL-6 and TNF-α were increased; however, with the aggravation of the disease, there was no significant change in the level of FGF7 in the peripheral blood, but the TNF-α level might be increased, accompanied by severe damage of small airway function.

Preoperative levels of natriuretic peptides and the incidence of postoperative atrial fibrillation after noncardiac surgery: a prospective cohort study

Postoperative atrial fibrillation (POAF) is associated with clinically significant short- and long-term complications after noncardiac surgery. Our aim was to describe the incidence of clinically important POAF after noncardiac surgery and establish the prognostic value of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) in this context. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study was a prospective cohort study involving patients aged 45 years and older who had inpatient noncardiac surgery that was performed between August 2007 and November 2013. We determined 30-day incidence of clinically important POAF (i.e., resulting in angina, congestive heart failure, symptomatic hypotension or requiring treatment) using logistic regression models to analyze the association between preoperative NT-proBNP and POAF. In 37 664 patients with no history of atrial fibrillation, we found that the incidence of POAF was 1.0% (95% confidence interval [CI] 0.9%-1.1%; 369 events); 3.2% (95% CI 2.3%-4.4%) in patients undergoing major thoracic surgery, 1.3% (95% CI 1.2%-1.5%) in patients undergoing major nonthoracic surgery and 0.2% (95% CI 0.1%-0.3%) in patients undergoing low-risk surgery. In a subgroup of 9789 patients with preoperative NT-proBNP measurements, the biomarker improved the prediction of POAF risk over conventional prognostic factors (likelihood ratio test p < 0.001; fraction of new information from NT-proBNP was 16%). Compared with a reference NT-proBNP measurement set at 100 ng/L, adjusted odds ratios for the occurrence of POAF were 1.31 (95% CI 1.15-1.49) at 200 ng/L, 2.07 (95% CI 1.27-3.36) at 1500 ng/L and 2.39 (95% CI 1.26-4.51) at 3000 ng/L. We determined that the incidence of clinically important POAF after noncardiac surgery was 1.0%. We also found that preoperative NT-proBNP levels were associated with POAF independent of established prognostic factors. Trial registration: ClinicalTrials.gov, no. NCT00512109.

Dexamethasone for Patients Undergoing Major Noncardiac Surgery: A Multicenter, Double-Blind, Controlled Randomized Trial

Background: Surgery initiates inflammation which contributes to postoperative morbidity and mortality. We aim ed to assess the effects of dexamethasone on postoperative complications in patients undergoing major surgery. Methods: In a multicenter, randomized, double-blind trial, patients over 50 years of age undergoing non-cardiac surgery with expected duration of more than 90 minutes were recruited from 34 centers. We randomly assigned patients to dexamethasone (0·2 mg.kg-1 after the procedure, and on day+1) or to placebo. Randomization was stratified on two criteria: cancer and thoracic procedure. The primary outcome was a composite of major complications and all-cause mortality assessed: i) in the intention-to-treat population (ITT) with multiple imputation methods for missing data and adjusted on stratification factors and center as random effect and ii) in the modified intention to treat population. Findings: Of the 1,222 patients enrolled from the 13th of December 2017 through the 19th of February 2019, 613 patients were randomized to dexamethasone, and 609 to placebo in ITT. 104 patients (17.1%) in the dexamethasone group and 123 patients (20 · 4%) in the placebo group had major complications or died within 14 days after surgery (adjusted odds ratio, 0 · 78; 95% confidence interval [CI], 0 · 59-1 · 04; P=0 · 09, crude odds ratio 0 · 79; 95%CI, 0 · 60-1 · 07, P=0 · 13). In the stratum of patients having non-thoracic surgery (n=1061 patients), the adjusted odd ratio of primary outcome with dexamethasone was 0 · 71 (95%CI 0 · 53-0 · 96). The adjusted hazard ratio with dexamethasone for mechanical ventilation was 0 · 68 (95%CI 0 · 53-0 · 88, P=0 · 003). Adverse events were reported in 47% and 48 · 6% of patients who received dexamethasone or placebo (odd ratio: 0 · 92; 95%CI 0 · 74-1 · 15, P=0 · 46). Interpretation: After major non-cardiac surgery, dexamethasone did not result in significantly less mortality or fewer major complications 14 days after surgery. Trial Registration: The trial was registered with clinicaltrial.gov NCT03218553. Funding Statement: Funded by French Ministry of Health, PHRCN 2016, RC16_0442. Declaration of Interests: Dr Asehnoune reports receiving lecture fees from Baxter, Fisher & Paykel, LFB and consulting fees from Edward Lifesciences, LFB. Dr. Boisson reports receiving consulting fees from BD. Dr. Jaber reports receiving personal fees from Drager, Medtronic, Baxter, Medtronic and Fisher & Paykel, Fresenius-Xenios. Dr Leone reports receiving consulting fees from Aspen, Orion, MSD, Pfizer, 3M, Octapharma and Edward. Dr Futier reports receiving consulting fees from Drager Medical, GE Healthcare, Edwards Lifesciences, and Orion Pharma and lectures fees from Fresenius Kabi, Baxter and Fisher & Paykel. Dr. Roquilly reports receiving consulting fees from Merck and bioMerieux. Other authors declare that they have no conflicts of interest involving the work under consideration for publication. No compensation was received for this study. Ethics Approval Statement: The PACMAN trial was approved in June 2017 by an institutional review board (Sud Mediterranee V) and was conducted in accordance with the Declaration of Helsinki. Patients provided written informed consent before participation.

A nationwide survey of intraoperative management for one-lung ventilation in Taiwan: time to accountable for diversity in protective lung ventilation

BackgroundThere is a major paradigm shift for intraoperative mechanical ventilator support by the introduction of lung protective ventilation strategies to reduce postoperative pulmonary complications and improve overall clinical outcomes in non-thoracic surgeries. However, there is currently a lack of standardized practice guideline for lung protection during thoracic surgeries that require one-lung ventilation (OLV). This study aimed to collect the expert opinions of the thoracic anesthesiologists in perioperative care for OLV surgery in Taiwan.MethodsThis prospective cross-sectional study was undertaken in 16 tertiary hospitals in Taiwan from January to February 2019. A structured survey form was distributed across the participating hospitals and the thoracic anesthesiologists were invited to complete the form voluntarily. The survey form consisted of three parts, including the basic information of the institutional anesthesia care standards, ventilatory settings for a proposed patient receiving OLV surgery and expert opinions on OLV.ResultsA total of 71 thoracic anesthesiologists responded to the survey. Double-lumen tubes are the most commonly used (93.8%) airway devices for OLV. The most commonly recommended ventilator setting during OLV is a tidal volume of 6–7 ml/kg PBW (67.6%) and a PEEP level of 4–6 cmH2O (73.5%). Dual controlled ventilator modes are used by 44.1% of the anesthesiologists. During OLV, high oxygen fraction (FiO2 > 0.8) is more commonly supplemented to achieve an oxygen saturation higher than 94%. The consensus of anesthesiologists on the indices for lung protection in thoracic surgery is considerably low. Large majority of the anesthesiologists (91.5%) highly recommend that an international clinical practice guideline on the protective lung ventilation strategy for thoracic anesthesia should be established.ConclusionsThis study found that the thoracic anesthesiologists in Taiwan share certain common practices in ventilator support during OLV. However, they are concerned about the lack of fundamental clinical evidences to support the beneficial outcomes of the current lung protective strategies applicable to OLV. Large-scale trials are needed to form an evidence-based clinical practice guideline for thoracic anesthesia.

Financial impact of adapting robotics to a thoracic practice in an academic institution.

In the current healthcare environment there is increasing pressure to deliver high quality care to more people at less cost. Robotic assisted thoracic surgical procedures (RATS) have been shown by some to be more expensive than conventional endoscopic or open surgery. We initiated this study to assess the financial impact of RATS compared to robotic non-thoracic surgery in an academic institution. A retrospective study was performed for all patients who underwent any robotically assisted surgical procedure at Temple University Hospital (TUH) in fiscal year 2015. Surgical volume, operative time, length of stay (LOS), case mix index (CMI), direct and indirect costs, hospital charges, surgical charges, contribution margin (CM) and net margin (NM) were collected for the thoracic surgery service in addition to other services which performed more than 20 robotic cases a year. We analyzed the data according to the following strategy: (I) financial performance for both inpatient and outpatient robotic procedures for the entire hospital; (II) compared financial data for robotic and non-robotic surgeries in the thoracic surgery division; (III) compared thoracic surgery data with the STS database for the same time period in order to calculate any potential cost saving (PCS). In FY15, a total of 696 robotic procedures were performed by the various services at TUH with a mean of 58 cases each month. Although CM was highest for cardiovascular surgery, the highest NM was by thoracic surgery. Despite having the highest volume and a positive CM, the mostly outpatient urology service showed a negative NM in FY15. A CMI-adjusted comparison on 208 of the 589 robotic procedures where there was a comparable group of inpatients who had open procedures, the mean direct cost for non-robotic procedures was $6,239, 9% less than for robotic procedures. The mean total cost for non-robotic procedures was only 3.64% ($435) less than that for robotic procedures ($11,502 vs. $11,937). When compared with the UHC expected LOS, the robotic group had a lower LOS while the non-robotic group had a higher LOS. The mean total direct costs were $3,510 less for the robotic procedures ($16,502 vs. $20,012). When compared to similar cases reported to the STS in FY 2015, the length of stay, conversion rate, transfusion rate, post-operative complications and OR time compared favorably. Using calculations based on published data, the potential cost savings are in the 1 to 2 million dollar range compared to traditional endoscopic or open procedures reported to the STS. High acuity services such as Thoracic Surgery drive higher CM per case as long as variable costs especially LOS are kept low. Procedures with lower CMI may not provide a high enough CM to offset the fixed and variable costs. Robotic surgical cases performed in the outpatient setting may incur significant losses as the reimbursement does not cover the direct costs. Hospitals should preferentially allocate robotic resources to inpatient procedures with higher CMI and work to decrease overall LOS.

Preoperative Evaluation of Patients With Interstitial Lung Disease

Preoperative Evaluation of Patients With Interstitial Lung Disease

A prospective randomized comparison of airway seal using the novel vision-guided insertion of LMA-Supreme® and LMA-Protector®.

The laryngeal mask airways supreme (LMA-Supreme™) and protector (LMA-Protector™) are generally placed blindly, often resulting in a less than optimal position and vision-guided placement has been recommended. This prospective, randomized controlled study compared the efficacy of airway seal by measuring the oropharyngeal leak pressure in 100 surgical patients who underwent a variety of non-thoracic surgery under general anaesthesia, suitable with a supraglottic airway device. Patients were allocated to either the LMA-Supreme (n = 50) or LMA-Protector (n = 50) group. All insertions were performed under vision of a videolaryngoscope using an 'insert-detect-correct-as-you-go' technique with standardized corrective measures. Our primary endpoint, mean oropharyngeal leak pressure, was significantly higher in the LMA-Protector (31.7 ± 2.9cm H2O) compared to the LMA-Supreme (27.7 ± 3.5 cm H2O) group (mean difference 4.0 cm H2O, 95% confidence interval (CI) 2.7-5.3 cm H2O, p < 0.001) after achieving a near-optimal fibreoptic position in the LMA-Protector (94%) and LMA-Supreme (96%) groups. No statistically significant differences were shown for secondary outcomes of alignment, number of insertion attempts and malpositions, and final anatomical position as scored by fibreoptic evaluation. Corrective manoeuvres were required in virtually all patients to obtain a correct anatomically positioned LMA. Position outcomes of the two devices were similar except for the proportion of procedures with folds in the proximal cuff (90% LMA-Supreme vs. 2% LMA-Protector, p < 0.001), the need for intracuff pressure adjustments (80% LMA-Supreme vs. 48% LMA-Protector, p = 0.001) and size correction (18% LMA-Supreme vs. 4% LMA-Protector, p = 0.025). In conclusion, a higher oropharyngeal leak pressure can be achieved with LMA-Protector compared to LMA-Supreme with optimal anatomical position when insertion is vision-guided.

Evaluation of risk factors for postoperative pulmonary complications after elective open upper abdominal surgery in chronic obstructive pulmonary diseases patients

Background: Postoperative pulmonary complications (PPCs) range from 9% to 40% in various nonthoracic surgeries. Various risk factors are attributed for these complications. The aim of this study was to determine the risk factors for PPC in chronic obstructive pulmonary disease (COPD) patients submitted to elective open upper abdominal surgery. Materials and Methods: This was a prospective cohort study conducted in a tertiary care center after obtaining ethical committee clearance. Two hundred and twenty-nine of 427 patients planned for elective abdominal surgeries were labeled as COPD based on spirometry test. PPC and various factors affecting it were analyzed. Pre- and intra-operative data were collected and their association with the occurrence of PPC was analyzed. Relationship between PPC and other variables was tested by linear and logistic regression. Multivariate logistic regression was performed using a backward stepwise approach and accepting statistical significance at P Results: Of 229 COPD patients, 34 (14.84%) suffered PPC. The mean age was 55.76 ± 8.40 years with 78.6% being male. Patients having age >50 years and the American society of anesthesiologists IV status were more prone to developing PPC. The multivariate analysis revealed body mass index (BMI) >30 kg/m2, duration of surgery >150 min, and pCO2>45 mmHg in arterial blood gas as independent predictors of PPC. Conclusions: The present study concluded that increased pCO2, BMI, and longer duration of surgery increase PPC in COPD patients. Hence, preoperative optimization of pCO2, BMI, and a proper plan to shorten the duration surgery may reduce PPC in COPD patients undergoing open upper abdominal surgeries.

Value of preoperative spirometry test in predicting postoperative pulmonary complications in high-risk patients after laparoscopic abdominal surgery.

Whether preoperative spirometry in non-thoracic surgery can predict postoperative pulmonary complications (PPCs) is controversial. We investigated whether preoperative spirometry results can predict the occurrence of PPCs in patients who had undergone laparoscopic abdominal surgery. This retrospective observational study analyzed the records of patients who underwent inpatient laparoscopic gastric or colorectal cancer surgery at Seoul National University Bundang Hospital between January 2010 and June 2017. Preoperative spirometry was performed for patients at a high risk of PPCs, such as elderly patients (age >60 years), patients aged <60 years with chronic pulmonary disease, and current smokers. The main outcome was the association between the results of spirometry tests performed within 1 month prior to surgery and the occurrence of PPCs, as determined by multivariable logistic regression analysis. Of the 898 included patients who underwent laparoscopic gastric (372 patients) or colorectal cancer surgery (526 patients), PPC occurred in 117 patients (gastric cancer: 74, colorectal cancer: 43). A 1% greater preoperative forced vital capacity (FVC) was associated with a 2% lower incidence of PPCs after laparoscopic gastric or colorectal cancer surgery (odds ratio: 0.98, 95% confidence interval: 0.97–0.99, P = 0.018). However, the preoperative forced expiratory volume in 1 second (FEV1) (%) and FEV1/FVC (%) were not significantly associated with PPCs (P = 0.059 and P = 0.147, respectively). In conclusion, lower preoperative spirometry FVC, but not FEV1 or FEV1/FVC, may predict PPCs in high-risk patients undergoing laparoscopic abdominal surgery.

Defining risk of general surgery in patients with chronic obstructive pulmonary diseases.

The relationship between chronic obstructive pulmonary disease (COPD) and perioperative outcomes remains incompletely understood. Our purpose is to evaluate the features of postoperative adverse outcomes for geriatric surgical patients with COPD receiving non-thoracic surgeries. To evaluate the potential impact of COPD history on the outcome after general surgery. A retrospective cohort study with matching procedure by propensity score. We conducted a nationwide study of 15 359 COPD patients aged 65 years and older who received major non-thoracic surgeries in 2008-2013 from the Taiwan National Health Insurance Research Database. Comprehensive matching procedure with propensity score were used to select 15 359 surgical patients without COPD for comparison. Major postoperative complications and 30-day in-hospital mortality were evaluated among patients with and without COPD by calculating adjusted odds ratios (ORs) and 95% CIs. Patients with COPD had significantly increased risk for postoperative complications, including pneumonia (OR = 90.3; 95% CI: 60.3-135), septicemia (OR = 3.11; 95% CI: 2.82-3.43), acute renal failure (OR = 2.53; 95% CI: 2.11-3.02), pulmonary embolism (OR = 2.74; 95% CI: 1.52-4.96), and 30-day postoperative mortality (adjusted OR = 2.09; 95% CI: 1.76-2.50), compared with surgical patients without COPD. Longer length of hospital stay and higher medical expenditures were also noted in COPD patients than those without COPD. Geriatric patients with COPD showed significantly higher postoperative adverse outcome rates with risk of 30-day mortality nearly twofold when compared with patients without COPD. Our findings remind surgical care team pay more attention to this specific population.