Postoperative Pneumonia Research Articles

Pulse pressure variation guided goal-direct fluid therapy decreases postoperative complications in elderly patients undergoing laparoscopic radical resection of colorectal cancer: a randomized controlled trial

ObjectiveThe use of goal-directed fluid therapy (GDFT) has been shown to reduce complications and improve prognosis in high-risk abdominal surgery patients. However, the utilization of pulse pressure variation (PPV) guided GDFT in laparoscopic surgery remains a subject of debate. We hypothesized that utilizing PPV guidance for GDFT would optimize short-term prognosis in elderly patients undergoing laparoscopic radical resection for colorectal cancer compared to conventional fluid therapy.MethodsElderly patients undergoing laparoscopic radical resection of colorectal cancer were randomized to receive either PPV guided GDFT or conventional fluid therapy and explore whether PPV guided GDFT can optimize the short-term prognosis of elderly patients undergoing laparoscopic radical resection of colorectal cancer compared with conventional fluid therapy.ResultsThe incidence of complications was significantly lower in the PPV group compared to the control group (32.8% vs. 57.1%, P = .009). Additionally, the PPV group had a lower occurrence of gastrointestinal dysfunction (19.0% vs. 39.3%, P = .017) and postoperative pneumonia (8.6% vs. 23.2%, P = .033) than the control group.ConclusionUtilizing PPV as a monitoring index for GDFT can improve short-term prognosis in elderly patients undergoing laparoscopic radical resection of colorectal cancer.Registration numberChiCTR2300067361; date of registration: January 5, 2023.

Application of machine learning algorithms to predict 30-day hospital readmission following cement augmentation for osteoporotic vertebral compression fractures

ObjectiveOsteoporosis is a common skeletal disease that greatly increases the risk of pathologic fractures and accounts for approximately 700,000 vertebral compression fractures (VCFs) annually in the United States. Cement augmentation procedures such as balloon kyphoplasty (KP) and percutaneous vertebroplasty (VP) have demonstrated efficacy in the treatment of VCFs, however, some studies report rates of readmission as high as 10.8% following such procedures. The purpose of this study was to employ Machine Learning (ML) algorithms to predict 30-day hospital readmission following cement augmentation procedures for the treatment of VCFs using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. MethodsACS-NSQIP was queried to identify patients undergoing either KP or VP from 2011 to 2014. Three ML algorithms were constructed and tasked with predicting post-operative readmissions within this cohort of patients. Results: Postoperative pneumonia, ASA Class 2 designation, age, partially-dependent functional status, and a history of smoking were independently identified as highly predictive of readmission by all ML algorithms. Among these variables postoperative pneumonia (p < 0.01), ASA Class 2 designation (p < 0.01), age (p = 0.002), and partially-dependent functional status (p < 0.01) were found to be statistically significant. Predictions were generated with an average AUC value of 0.757 and an average accuracy of 80.5%. ConclusionsPostoperative pneumonia, ASA Class 2 designation, partially-dependent functional status, and age are perioperative variables associated with 30-day readmission following cement augmentation procedures. The use of ML allows for quantification of the relative contributions of these variables toward producing readmission.

Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis.

Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes. The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling. Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001). Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.

Risk Factors for 30-Days Mortality After Proximal Femoral Fracture Surgery, a Cohort Study.

The primary objective of this study was to identify new risk factors and to confirm previously reported risk factors associated with 30-day mortality after hip fracture surgery. A prospective hip fracture database was used to obtain data. In total, 3523 patients who underwent hip fracture surgery between 2011 and 2021 were included. Univariable and multivariable logistic regression was used to screen and identify candidate risk factors. Twenty-seven baseline factors and 16 peri-operative factors were included in the univariable analysis and 28 of those factors were included in multivariable analysis. 8.6% of the patients who underwent hip fracture surgery died within 30 days after surgery. Prognostic factors associated with 30-day mortality after hip fracture surgery were as follows: age 90-100 years (OR = 4.7, 95% CI: 1.07-19.98, p = 0.041) and above 100 years (OR = 11.3, 95% CI: 1.28-100.26, p = 0.029), male gender (OR = 2.6, 95% CI: 1.97-3.33, p < 0.001), American Society of Anesthesiologists (ASA) 3 and ASA 4 (OR = 2.1, 95% CI: 1.44-3.14, p < 0.001), medical history of dementia (OR = 1.7, 95% CI: 1.25-2.36, p = 0.001), decreased albumin level (OR = 0.94, 95% CI: 0.92-0.97, p < 0.001), decreased glomerular filtration rate (GFR) (OR = 0.98, 95% CI: 0.98-0.99, p < 0.001), residential status of nursing home (OR = 2.1, 95% CI: 1.44-2.87, p < 0.001), higher Katz Index of Independence in Activities of Daily Living (KATZ-ADL) score (OR = 1.1, 95% CI: 1.01-1.16, p=0.018) and postoperative pneumonia (OR = 2.4, 95% CI: 1.72-3.38, p < 0.001). A high mortality rate in patients after acute hip fracture surgery is known. Factors that are associated with an increased mortality are age above 90 years, male gender, ASA 3 and ASA 4, medical history of dementia, decreased albumin, decreased GFR, residential status of nursing home, higher KATZ-ADL score and postoperative pneumonia.

Early predictors of bacterial pneumonia infection in children with congenital heart disease after cardiopulmonary bypass: a single-centre retrospective study

ObjectivesThe objective of this study was to evaluate the early predictors of bacterial pneumonia infection in children with congenital heart disease (CHD) after cardiopulmonary bypass (CPB).DesignRetrospective study.SettingA freestanding tertiary paediatric...

Cardiac interventions on total knee arthroplasty: a national inpatient sample-based analysis.

Comorbid cardiovascular diseases have been associated with poor outcomes in total knee arthroplasty (TKA); however, our understanding of TKA with prior cardiac treatment procedures has largely been undocumented. In this study, we examined TKA patients who had undergone different cardiac interventions that addressed their condition. The purpose was to characterize and compare outcomes for a growing patient population not yet analyzed. The 2016-2019 Nationwide Inpatient Sample database was queried for 558,256 patients who had TKA (ICD-10CM). Backgrounds significant for pacemaker [PM] (n = 8025), coronary artery bypass [CABG] (n = 12,683), heart valve surgery [HV] (n = 4125), or coronary stent [CS] (n = 19,483) were compared against those without, across demographics, admission information, and various complications. Cardiac interventions were associated with increased age, male gender, length of stay, and cost of care. CABG, and Stent groups had more diabetics, but HV had significantly fewer (p = 0.008). PM and HV had significantly less tobacco use and, in addition to CABG, less obesity. Postoperatively, mortality was elevated in the PM [Odds ratio (OR) 2.89, p = 0.008], CABG (OR 2.53, p = 0.006) and CS group (OR 1.94, p = 0.018), but not HV. Myocardial infarctions were elevated in the CABG (OR 3.874) and CS group (OR 5.11) (p < 0.001). PM, HV, and CS had increased odds of periprosthetic fracture by 2.15-fold (p < 0.001), 2.09-fold (p < 0.001), 1.29-fold (p = 0.011) respectively. HV saw increased periprosthetic mechanical complications (OR 1.48, p = 0.006). CABG increased the odds of deep surgical site infection 14.23-fold and CS 9.22-fold (p < 0.001). Postoperative pneumonia was increased in PM, CABG, and CS groups (OR 2.15,), (OR 2.21,), (OR 1.64,) (p < 0.001). Patients who have undergone cardiac intervention are generally at risk for adverse stays. Furthermore, risk factors and complications vary between the groups. Our analysis emphasizes the importance of individualized medical care and as a basis for electing and informing patients for TKA.

A retrospective observational cohort study on the postoperative respiratory complications and their risk factors in brachycephalic dogs undergoing BOAS surgery: 199 cases (2019-2021).

To observe the occurrence of postanaesthetic respiratory complications and to determine their prevalence and risk factors in dogs undergoing brachycephalic obstructive airway syndrome surgery. Data from 199 clinical records were retrospectively analysed. Univariable logistic regression followed by multivariable logistic regression was used to identify associations between the dependent variables (set as the postoperative respiratory complications observed in the study dogs) and various independent covariates. The quality of model-fit was assessed using the likelihood ratio test. P≤0.05 was considered statistically significant. Four postoperative respiratory complications were observed: hypoxaemia (n=10/199; 5%), dyspnoea requiring tracheal re-intubation (n=13/199, 7%), dyspnoea requiring tracheostomy (n=10/199, 5%) and aspiration pneumonia (n=12/199, 6%). Univariable logistic regression showed an association between postoperative aspiration pneumonia and increasing body condition score and American Society of Anaesthesiology classification; however, when these covariates were evaluated in the multivariable model significance was not maintained. Risk factors for tracheostomy were preoperative and postoperative aspiration pneumonia (odds ratio: 9.52, 95% confidence interval: 1.56 to 57.93) and increasing brachycephalic obstructive airway syndrome grade (odds ratio: 4.65, 95% confidence interval: 0.79 to 27.50). High brachycephalic obstructive airway syndrome grade and aspiration pneumonia, either developing peri-operatively or as pre-existing condition, may represent risk factors for postoperative tracheostomy. Preoperative diagnosis of aspiration pneumonia may further increase the risk of postoperative complications.

A case of Legionella pneumonia after robot‐assisted radical prostatectomy

IntroductionPostoperative Legionella pneumonia is very rare.Case presentationA 71‐year‐old male patient with prostate cancer (cT2bN0M0) underwent a robotic‐assisted radical prostatectomy. On the 5th postoperative day, the patient developed chills and a fever of 39.2°C. Chest radiography revealed decreased permeability in the right middle lung field, leading to the diagnosis of postoperative pneumonia. Antimicrobial therapy was initiated immediately. Blood tests on postoperative day 10 revealed mild liver function abnormalities, electrolyte abnormalities, and a markedly elevated inflammatory response. Legionella pneumonia was suspected based on blood sample results and systemic symptoms, such as diarrhea and nausea. Furthermore, Legionella antigens were detected in the patient's urine, prompting further administration of levofloxacin. The patient's subsequent clinical course was favorable.ConclusionWhen bacterial pneumonia fails to respond to antimicrobial therapy and systemic symptoms develop, atypical pneumonia, caused by pathogens such as Legionella pneumophila, should be considered even in cases of postoperative pneumonia.

The effects of gastrojejunostomy tube placement on pulmonary and gastrointestinal complications following spinal fusion for neuromuscular scoliosis.

To evaluate whether preoperative conversion from a gastrostomy tube (G-tube) to a gastrojejunostomy tube (GJ-tube) decreases short-term postoperative aspiration pneumonia and gastrointestinal complications in children with neuromuscular scoliosis. We conducted a retrospective chart review from January 2006 to October 2021 of pediatric patients who had neuromuscular scoliosis and were fed with a G-tube before spinal fusion. Eligible patients were divided into two groups based on whether they were converted to a GJ-tube preoperatively. Preoperative characteristics and 30-day postoperative outcomes were compared between groups using Chi-square tests. Of 261 eligible patients, 205 were converted to a GJ-tube, while 56 underwent spinal fusion with a G-tube. Common complications following G-tube to GJ-tube conversion were feeding intolerance (25.2%), GJ-tube malfunction (17.7%), and at least one episode of vomiting (17.4%). Within 30 days of discharge, 12.5% of GJ-tube patients and 11.5% of G-tube patients experienced aspiration pneumonia (P = 0.85). The GJ-tube group received postoperative tube feeds 7 hours earlier than the G-tube group on average (51.6 h vs. 44.5 h, P = 0.02). Within 30 days of discharge, one (0.5%) patient from the GJ-tube group died of gastrointestinal complications unrelated to conversion and two (3.6%) patients in the G-tube group died from aspiration pneumonia (P = 0.12). Results suggest that there were no appreciable differences in outcomes between patients converted to a GJ-tube preoperatively compared to those who continued to use a G-tube. However, preoperative characteristics indicate that a higher number of complex patients were converted to a GJ-tube, indicating potential selection bias in this retrospective sample. Level of evidence: Level III.

Preservation of the pulmonary branches of the vagus nerve during three-dimensional thoracoscopic radical resection of lung cancer: a retrospective study

BackgroundIn this study, we investigated the effect of preservation of the pulmonary branches of the vagus nerve during systematic dissection of mediastinal lymph nodes, when performing radical resection of lung cancer, on the postoperative complication rate.MethodsThe clinical data for 80 patients who underwent three-dimensional thoracoscopic radical resection of lung cancer in the Department of Thoracic Surgery at Huizhou Municipal Central Hospital between 2020 and 2022 were analyzed. The patients were divided into two groups according to whether the pulmonary branches of the vagus nerve were retained during intraoperative carinal lymph node dissection. The operation time, time until first postoperative defecation, duration for which a chest tube was needed, total chest drainage volume, average pain intensity during the first 5 postoperative days, incidence of postoperative pneumonia, and postoperative length of stay were compared between the two groups.ResultsThere was no statistically significant difference in histological staging or in time until first postoperative defecation between the two groups (p > 0.05). However, there were significant differences in operation time, the duration for which a chest tube was needed, total chest drainage volume, average pain intensity during the first 5 postoperative days, white blood cell count and procalcitonin level on postoperative days 1 and 5, and postoperative length of stay between the two groups (p < 0.05).ConclusionPreserving the pulmonary branches of the vagus nerve during carinal lymph node dissection when performing three-dimensional thoracoscopic radical resection of lung cancer can reduce the risk of postoperative complications.

Robot-assisted transcervical esophagectomy with a bilateral cervical approach for thoracic esophagectomy.

Thoracic esophageal cancer resection through the neck approach has recently been reported as mediastinoscopic surgery. We present the first report of a new minimally invasive technique for thoracic esophageal cancer: robot-assisted transcervical esophagectomy with a bilateral cervical approach. Ten cases of robot-assisted bilateral transcervical esophagectomy performed at the National Cancer Center Hospital East, Japan, from February 2023 to August 2023 were reviewed. The short-term surgical outcomes were presented, and the feasibility and efficacy of this procedure were discussed. The mean operation time for the cervical procedure was 184.2 ± 23.6min. The total time for the whole procedure was 472.7 ± 28.4min, and total intraoperative blood loss was 162.2 ± 40.0ml. Among the 10 cases, one patient developed recurrent nerve paralysis, one patient developed pulmonary complications, and no patients developed postoperative pneumonia. The median postoperative hospital stay was 22 (range: 12-43) days. No patients developed severe postoperative surgical complications, which were graded as Clavien-Dindo ≥ III. The total number of surgically harvested mediastinal lymph nodes was 37.2 ± 11.2. Robot-assisted bilateral transcervical esophagectomy, a novel procedure for thoracic esophageal cancer, was safe and feasible. Using this procedure, the incidence of recurrent nerve palsy, which is a problem with transcervical esophagectomy and mediastinoscopic esophagectomy, is expected to decrease.

Diagnostic value of systematic bronchial aspirate on postoperative pneumonia after pulmonary resection surgery for lung cancer: a monocentre retrospective study.

Intraoperative bacterial airway colonization seems to be associated with an increased risk of postoperative pneumonia (POP). It can be easily assessed by performing a bronchial aspirate (BA). The objective of this study is to assess the diagnostic performance of the BA to predict POP. We conducted a single-centre retrospective observational study over a period of 10 years, from 1 January 2011 to 30 December 2020. The population study included patients admitted for a scheduled pulmonary resection surgery for lung cancer. Patients were classified into 2 populations depending on whether or not they developed a POP. Uni- and multivariable analyses were performed to identify risk factors for developing POP. The diagnostic performance of BA was represented by its sensitivity, specificity and positive and negative predictive values. A total of 1006 patients were included in the study. Uni- and multivariable analyses found that a positive BA was independently associated with a greater risk of developing POP with an odds ratio of 6.57 [4.165-10.865]; P < 0.001. Its specificity was 95%, sensitivity was 31%, positive predictive value was 66% and negative predictive value was 81%. A positive intraoperative BA is an independent risk factor for POP after lung cancer surgery. Further trials are required to validate the systematic implementation of BA as an early diagnostic tool for POP.

Clinical characteristics and anaesthetic management of severe scoliosis patients with spinal muscular atrophy: case series

Introduction and importance: There is no expert consensus or guidance on perioperative anaesthesia management for spinal surgery of spinal muscular atrophy (SMA) patients with severe scoliosis (Cobb≧90°). We provide a comprehensive summary of the perioperative characteristics observed in patients with SMA and propose an optimized perioperative management strategy for anaesthesia. Methods: This study is a retrospective single-centre research. Twenty-six SMA patients with severe scoliosis underwent posterior spinal fusion surgery from September 2019 to September 2022 were enroled. The main outcomes were to show the patients’ characteristics in anaesthesia, intra- and post-operative periods. Outcomes: Nineteen patients underwent awake transnasal/transairway intubation. The median anaesthesia time of 25 patients treated under total intravenous anaesthesia was 425 min. After operation, the Cobb angle and correction rate in the coronal plane were median 54.0° and 54.4%. The length of mechanical ventilation with endotracheal intubation in ICU was median 17.5 h in 8 patients. The ICU length of stay of postoperative hospital was median 19 days. Postoperative pneumonia developed in nine patients, atelectasis in two patients, and pleural effusion in six patients. All patients did not need special oxygen therapy after discharge. Conclusion: Multidisciplinary consultation, lung-protective ventilation strategy, appropriate anaesthetic drugs and reasonable blood transfusion scheme and postoperative monitoring were important in anaesthesia, intraoperative and postoperative periods in the patients of severe scoliosis with spinal muscular atrophy.

High flow nasal oxygen vs. conventional oxygen therapy over respiratory oxygenation index after esophagectomy: an observational study.

Postoperative pulmonary complications after esophagectomy still represent a matter of concern. High flow nasal cannula (HFNC) early after major abdominal and thoracic surgery has demonstrated some advantages over conventional oxygen therapy. Data about respiratory effect of HFNC after esophagectomy is scarce. The primary aim of this study is to investigate if the early use of HFNC after esophagectomy could enhance patients' postoperative respiratory oxygenation (ROX) index and, ultimately, reduce postoperative pneumonia. In this single center retrospective study all patients undergoing to esophagectomy for cancer from May 2020 to November 2022 were evaluated. Historical cohort (HC) received postoperative oxygen supplementation with Venturi mask or nasal goggles, and a cohort was put under HFNC (HFNC cohort). ROX index, blood gas analysis, radiological atelectasis score (RAS), post-operative complications' data and information on hospital stay have been collected and analyzed. Seventy-one patients were included for the final statistical analysis, 31 in the HFNC and 40 in the HC cohort. Mean age was 64±10 years and body mass index (BMI) was 26 [24-29] kg/m2. ROX index was higher in the HFNC patients than in the HC, 20.8 [16.7-25.9] vs. 14.9 [10.8-18.2] (P<0.0001). In the HFNC cohort patients, pH was higher, 7.42 [7.40-7.44] vs. 7.39 [7.37-7.43] than HC, while PaCO2 was lower in HFNC cohort compared with HC, 39 [36-41] vs. 42 [39-45] mmHg, respectively (P=0.01). RAS was similar between the two cohorts of patients, 1.5±0.98 vs. 1.4±1.04 in the HFNC and the HC cohort, respectively (P=0.611). Lower acute respiratory failure (ARF) rate was recorded among HFNC than HC cohort, 0% vs. 13% respectively, P=0.06. No difference in pneumonia frequency between two cohorts was shown. HFNC improved the ROX index after esophagectomy through significant respiratory rate reduction. This tool should be considered for early respiratory support after extubation in this category of patients, not only as a rescue therapy for ARF, but also to optimize early postoperative respiratory function. Whether this will improve patients' outcomes requires further large randomized controlled trials.

A European multicenter outcome study on the different perioperative airway management policies following midface surgery in syndromic craniosynostosis: a proposal for a Standard Operating Procedure.

Perioperative airway management following midface advancements in children with Apert and Crouzon/Pfeiffer syndrome can be challenging, and protocols often differ. This study examined airway management following midface advancements and postoperative respiratory complications. A multicenter, retrospective cohort study was performed to obtain information about the timing of extubation, perioperative airway management, and respiratory complications after monobloc / le Fort III procedures. Ultimately, 275 patients (129 monobloc and 146 Le Fort III) were included; 62 received immediate extubation and 162 delayed extubation; 42 had long-term tracheostomies and nine perioperative short-term tracheostomies. Short-term tracheostomies were in most centers reserved for selected cases. Patients with delayed extubation remained intubated for three days (IQR 2 - 5). The rate of no or only oxygen support after extubation was comparable between patients with immediate and delayed extubation, 58/62 (94%) and 137/162 (85%) patients, respectively. However, patients with immediate extubation developed less postoperative pneumonia than those with delayed, 0/62 (0%) versus 24/161 (15%) (P = 0.001), respectively. Immediate extubation also appeared safe in moderate/severe OSA since 19/20 (95%) required either no or only oxygen support after extubation. The odds of developing intubation-related complications increased by 21% with every extra day of intubation. Immediate extubation following midface advancements was found to be a safe option, as it was not associated with respiratory insufficiency but did lead to fewer complications. Immediate extubation should be considered routine management in patients with no/mild OSA and should be the aim in moderate/severe OSA after careful assessment.

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

PurposeAcute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery.MethodsWe conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) < 60 ml/min/1.73 m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72 h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD.ResultsWe studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7 days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7 days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P < 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P < 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21–3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%.ConclusionOne in ten major surgery patients developed AKD beyond 7 days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors.

Neutrophil-lymphocyte ratio on first and third postoperative days: associated with severe pneumonia in aneurysmal subarachnoid hemorrhage patients undergoing surgeries.

Severe postoperative pneumonia can increase the risk of poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to explore the associations of preoperative or postoperative inflammatory markers calculated from blood cell counts with severe pneumonia. This retrospective study was conducted at the First Affiliated Hospital of Yangtze University from January 2019 to June 2023. The associations of neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), and systemic inflammation response index (SIRI) with severe pneumonia were analyzed. There were 159 patients with pneumonia and 21 patients without pneumonia. There were 41 patients with severe pneumonia and 118 patients with non-severe pneumonia. The multivariate logistic regression analysis showed that NLR on the first postoperative (OR = 2.574, 95%CI: 1.035-6.403, p = 0.042) and third postoperative days (OR = 4.296, 95%CI: 1.699-10.860, p = 0.002) were associated with severe pneumonia in aSAH patients. Among patients ≥ 60years, SIRI on the preoperative day (OR = 7.430, 95%CI: 1.443-38.251, p = 0.016) and NLR on the third postoperative day (OR = 4.748, 95%CI: 1.286-17.801, p = 0.020) were associated with severe pneumonia. Among patients < 60years, NLR on the first postoperative day (OR = 24.149, 95%CI: 3.476-167.747, p = 0.001) was associated with severe pneumonia. The NLR on the first and third postoperative days were possibly associated with severe pneumonia in aneurysmal subarachnoid hemorrhage patients undergoing clipping or embolization surgeries. Dynamic detection of NLR during early perioperative period may help clinicians to predict the development of severe pneumonia.

Intrahepatic Glisson Intrathecal Dissection via a Hepatic Parenchymal Transection-First Approach for Laparoscopic Anatomical Hemihepatectomy in Patients with Left/Right Glisson Pedicle Involvement.

Background: Because of lack of an appropriate surgical approach, laparoscopic surgery in patients with left/right Glisson pedicle involvement is still rarely conducted. This study aimed to discusses the methods of intrahepatic Glisson intrathecal dissection via a hepatic parenchymal transection-first approach for laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement. Materials and Methods: We retrospectively analyzed the clinical data of 21 patients who underwent laparoscopic hepatectomy in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from March 2021 to May 2022. Results: The mean age of the patients was 53.1 ± 11.6 years; mean operation time, 191.9 ± 22.3 minutes; median intraoperative blood loss, 205 mL (160-300 mL); and median length of hospital stay, 8 days (7-9 days). None of the patients underwent conversion to open procedure. Thirteen patients had pathologically confirmed hepatocellular carcinoma (HCC) with portal tumor thrombi (PVTT), and 8 was confirmed hepatolithiasis. Intraoperative frozen pathology and final pathology showed tumor free surgical margins in HCC with PVTT patients. After conservative treatment, all the complications such as postoperative liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding, and bile leak were cured. During outpatient follow-up examination, no other abnormality was detected. All HCC with PVTT patients were treated with a tyrosine kinase inhibitor after the operation and survived tumor-free. Conclusions: Proposed here is a more safe and feasible method of laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement, but many problems still needs further exploration.

Clinical characteristics of elderly hip fracture patients with chronic cerebrovascular disease and construction of a clinical predictive model for perioperative pneumonia

IntroductionThe recovery of cerebrovascular disease (CVD) will increase the incidence of perioperative pneumonia (POP). However, there is limited research on POP in elderly patients with hip fractures complicated by CVD. Therefore, our research focuses on the following two issues: (1) What are the clinical features of elderly patients with hip fractures combined with CVD? (2) What are the predictive factors for the occurrence of POP in such patients? HypothesisMale, femoral neck fracture and hypoalbuminemia can be predictive factors for the development of POP after hip fracture in CVD patients. Material and methodsThis is a nested case-control study that included patients aged 65 to 105 years with CVD who had a hip fracture between January 2021 and January 2023. According to the occurrence of POP, they were divided into case group and control group. Collecting data includes demographic information, clinical data, and surgical information. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to select variables. The constructed predictive model was transformed into a nomogram. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). ResultsWe ultimately included 714 patients, 69.3% female, with a median age of 80 years. Asymptomatic cerebral infarction (ACI) is the most common CVD (55.7%). More patients developed intertrochanteric fractures than femoral neck fractures (57.1 vs. 42.9%). In total, 606 patients (84.9%) underwent surgery. The most common perioperative complications were anemia (76.9%) and hypoalbuminemia (71.8%). POP (20.0%) was more common preoperatively (89.5%). Factors such as fracture type, surgical wait time, implant used for surgery, and anesthesia type did not differ between the presence or absence of postoperative pneumonia. 143 patients with POP served as the case group. Five hundred and seventy one patients did not develop POP and served as the control group. The predictors of POP were male (OR 1.699,95%CI 1.150–2.511, p<0.05), femoral neck fracture (OR 2.182,95%CI 1.491–3.192, p<0.05), and hypoalbuminemia (OR 3.062, 95%CI 1.833–5.116, p<0.05). This model has good discrimination, calibration, and clinical practicality. DiscussionIn this study, we constructed a clinical prediction model for the occurrence of POP in CVD combined with hip fracture in the elderly, with risk factors including gender, fracture type and perioperative hypoproteinemia. Therefore, we can take effective preventive measures against the occurrence of POP in patients with these factors in our clinical work. Level of proofIV; nested case-control study.

Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study

BackgroundEsophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear.MethodsAfter the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications.ResultsAmong 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545–682] minutes; total intraoperative infusion volume was 3,747 [3,038–4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42–6.73] mL/kg/h; and fluid balance was + 2,648 [2,015–3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels.ConclusionsAmong patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.