Postoperative Pneumonia Research Articles

Validation of Artificial Intelligence-Based POTTER Calculator in Emergency General Surgery Patients Undergoing Laparotomy: Prospective, Bi-Institutional Study.

The POTTER calculator, a widely used interpretable artificial intelligence (AI) risk calculator, has been validated in population-based studies and shown to predict outcomes in emergency general surgery (EGS) patients better than surgeons. We sought to prospectively validate POTTER. Patients undergoing an emergency exploratory laparotomy for non-trauma indications at two Academic Medical Centers between June 2020 and March 2022 were included. POTTER preoperative risk calculations and postoperative outcomes were systematically recorded. POTTER's performance in predicting 30-day postoperative mortality, septic shock, respiratory failure, bleeding, and pneumonia was assessed using the c-statistic methodology. A total of 361 patients were included. The median age was 63 years (IQR: 51-72), 45.4% were females, and the overall mortality and morbidity were 24.1% and 51.4%, respectively. POTTER predicted mortality accurately with a c-statistic of 0.90. POTTER also accurately predicted the occurrence of individual postoperative complications, with c-statistics ranging between 0.80 and 0.89. This is the first prospective validation of the AI-enabled POTTER calculator. The superior accuracy, user-friendliness, and interpretability of POTTER make it a useful bedside tool for preoperative patient and family counseling.

Perioperative intervention of dysphagia rehabilitation team is effective in older adults with gastric cancer: An inverse probability weighting analysis

IntroductionThis study aimed to evaluate the efficacy of perioperative dysphagia rehabilitation in older adult patients diagnosed with gastric cancer who underwent gastrectomy. Materials and methodsThis retrospective study included 149 patients over 80 years who underwent gastrectomies between January 2000 and December 2020. The patients were divided into two groups based on the intervention of the dysphagia rehabilitation team (DRT group: n = 101) and the non-intervention control group (C group: n = 48). Inverse probability weighting (IPW) analysis was used to reduce bias caused by potential confounding. ResultsThe incidence of overall complications was significantly lower in the DRT group (odds ratio [OR]; 0.27[0.08–0.93]), among which the incidence of postoperative pneumonia (OR; 0.07[0.01–0.43]) and aspiration pneumonia (OR; 0.05[0.01–0.44] was significantly reduced. Ten patients developed postoperative pneumonia; seven were in the C group, and three were in DRT group. Sixty percent of these patients had preoperative comorbidities related to the respiratory system. Regarding the time of onset of aspiration pneumonia, two patterns were observed: onset within a short period after surgery and onset after the start of eating. In contrast, five patients underwent preoperative dysphagia rehabilitation in the DRT group. Among them, postoperative aspiration pneumonia was prevented in four patients, and the others were prevented from severe pneumonitis by the intervention of the dysphagia rehabilitation team. DiscussionPerioperative intervention in dysphagia rehabilitation is not only associated with reduced postoperative pneumonia but also creates awareness in the medical staff and promotes careful observation of swallowing in patients, thereby controlling the incidence of postoperative pneumonia. The perioperative intervention of the dysphagia rehabilitation team is useful for older adult patients with gastric cancer.

Early injection laryngoplasty for acute unilateral vocal fold paralysis after thoracic aortic surgery

ObjectiveUnilateral vocal fold paralysis (UVFP) following open thoracic aortic surgery increases pulmonary complications and hospital stays. An intervention protocol with early injection laryngoplasty (IL) and swallowing maneuvers was developed for acute UVFP following thoracic aortic surgery. This study aimed to compare the incidence of complications and length of medical care between the non-VFP and the IL-UVFP group managed under this protocol. MethodsPatients who underwent open thoracic aortic surgery from March 2020 to February 2023 were included, excluding those with preoperative VFP or postoperative bilateral VFP. Under the protocol, patients with UVFP and incomplete glottic closure received IL and swallowing maneuvers within one week after diagnosis, while those without a glottic gap started a soft diet along with swallowing maneuvers. Postoperative complications, including reintubation, ICU re-transfer, pneumonia, stroke, delirium, wound infection, and bleeding, as well as hospital and ICU stay, were assessed. ResultsOf the 355 patients included in the study, 51 (14.4%) developed postoperative UVFP, while 304 (85.6%) had normal VF function. In the UVFP group, 42 patients underwent IL, while 9 patients without a glottic gap did not undergo IL. The incidence of complications and length of medical care were analyzed in the non-VFP and the IL-UVFP groups. The IL-UVFP group had a longer median hospital stay compared to the non-VFP group (20.5 vs. 16.0 days), though this difference was not statistically significant (P = .0681). ICU stay (P = .5396) and ICU re-transfer rates (P = 1.00) were also comparable between the groups. There was no significant difference in the incidence of pneumonia between the IL-UVFP group (4.8%) and the non-VFP group (9.5%) (P = .4003). Additionally, no significant differences were observed in the incidence of stroke, delirium, wound infection, or bleeding between the groups. No IL-related complications were reported. ConclusionsThe protocol with early IL appears to help reduce complication rates in acute UVFP patients following thoracic aortic surgery to levels comparable to those in patients without VFP. This protocol could serve as a guideline for otolaryngologists in managing UVFP patients. Level of evidence2b/Individual cohort study.

Peak expiratory flow predicts the occurrence of postoperative pneumonia after esophagectomy for esophageal cancer.

Expiratory flow is an important factor in the achievement of airway clearance that is required to prevent postoperative pneumonia (POP). Although peak expiratory flow (PEF) has been shown to predict the occurrence of POP in lung cancer patients after lobectomy, its predictive power in relation to esophagectomy for esophageal cancer remains unknown. This study assesses PEF as a predictor of POP in patients with esophageal cancer undergoing radical esophagectomy. We conducted a single-center, retrospective cohort study of patients who underwent radical esophagectomy with gastric tube reconstruction at our institution between January 2007 and December 2022. Preoperative pulmonary functions, including PEF, were assessed before surgery. Additionally, POP was diagnosed as a Clavien-Dindo classification of Grade II or higher. Survival and pneumonia incidence were compared using the Kaplan-Meier method. Logistic regression analysis was used to examine the relationship between these variables and POP. The study included 513 patients, of which 441 were men. POP occurred in 86 patients (16.7%). When all patients were stratified by %PEF into two groups, the group with %PEF lower that 80% had significantly poorer prognosis and higher incidence of pneumonia. Multivariable logistic regression analysis indicated that %PEF (OR: 0.986, 95%CI: 0.974-0.999, P = 0.030), along with age, BMI, preoperative treatment, and recurrent laryngeal nerve palsy were independent protective factors against POP. These results reveal that %PEF predicts the development of POP following esophagectomy for esophageal cancer.

Optimal surgical timing for lung cancer following SARS-CoV-2 infection: a prospective multicenter cohort study

BackgroundWith the ongoing prevalence of the emerging variant and global vaccination efforts, the optimal surgical timing for patients with resectable lung cancer in the Omicron-dominant period requires further investigation.MethodsThis prospective multicenter study involved patients who underwent radical surgery for lung cancer between January 29, 2023 and March 31, 2023. Patients were categorized into four groups based on the interval between SARS-CoV-2 infection and surgery. The main outcomes evaluated were 30-day mortality and 30-day morbidity.ResultsA total of 2081 patients were enrolled in the study, of which 1837 patients (88.3%) had a confirmed SARS-CoV-2 diagnosis before surgery. Notably, no instances of 30-day mortality were observed in any patient. Patients without prior infection had a 30-day morbidity rate of 15.2%, with postoperative pneumonia occurring in 7.0% of cases. In contrast, patients diagnosed with SARS-CoV-2 before surgery had significantly higher rates of 30-day morbidity and postoperative pneumonia when surgery was performed within 4–5 weeks (adjusted odds ratio (aOR) (95% CI):2.18 (1.29–3.71) and 2.39 (1.21–4.79), respectively) or within 6–7 weeks (aOR (95% CI):2.07 (1.36–3.20) and 2.10 (1.20–3.85), respectively). Conversely, surgeries performed ≥ 8 weeks after SARS-CoV-2 diagnosis exhibited similar risks of 30-day morbidity and pneumonia compared to those in the no prior infection group (aOR (95% CI):1.13 (0.77–1.70) and 1.12 (0.67–1.99), respectively).ConclusionsThoracic surgery for lung cancer conducted 4–7 weeks after SARS-CoV-2 infection is still associated with an increased risk of 30-day morbidity in the Omicron-dominant period. Therefore, surgeons should carefully assess the individual risks and benefits to formulate an optimal surgical strategy for patients with lung cancer with a history of SARS-CoV-2 infection.

Robot-assisted minimally invasive esophagectomy for esophageal cancer in the left lateral decubitus position.

The use of robot-assisted minimally invasive esophagectomy (RAMIE) in the prone position for esophageal cancer has been currently increasing worldwide. In future, as surgical-assisted robots become more widespread, it is estimated that only two methods of transthoracic approach will remain: RAMIE and open thoracotomy for thoracic esophageal cancer. RAMIE in the left lateral decubitus position (RAMIE-LLDP) has the same field of view as open thoracotomy, is safe in emergency situations, and provides education on open thoracotomy. Between September 2020 and April 2024, RAMIE-LLDP was performed in 64 consecutive patients with esophageal cancer. RAMIE-LLDP was performed with the operating table rotated and tilted 45° to the ventral side under artificial pneumothorax. The hand-control setting of the surgical-assist robot system was reversed left to right when the Patient Cart was rolled from the same direction as the RAMIE in the prone position. The mean total surgery and console times during the thoracic procedure were 254-min overall and 225min in the last 24 cases and 195-min overall and 178-min in the last 24 cases, respectively. The mean amount of blood loss was 203.4g overall and 28.3g in the last 24 cases. Postoperative recurrent laryngeal nerve palsy with Clavien-Dindo classification (CD) was ≥ 2 in six patients (9.4%). Postoperative pneumonia with CD ≥ 2 was observed in 11 patients (17.2%). Conversion to open thoracotomy was observed in three patients (4.7%). In all three patients, an immediate conversion to thoracotomy without patients' position change was actually possible and no serious complications were noted. No mortality occurred within 30days postoperatively. RAMIE-LLDP which facilitates emergency thoracotomy has perioperative results comparable to those of conventional thoracoscopic esophagectomy and is educational for open surgery. RAMIE-LLDP is the safest and most optimal surgery for esophageal cancer.

Risk Factors for Postoperative Pneumonia in Esophageal Cancer Patients

Purpose Patients undergoing surgery for esophageal cancer (EC) frequently experience postoperative pneumonia (POP). POP promotes poor prognosis as well as increased medical costs and longer hospital stays. Therefore, it is desirable to prevent and strictly control high-risk cases to reduce the incidence of pneumonia. The present study aimed to determine the risk factors for POP in EC. Patients and Methods The subjects of this retrospective study were 151 patients with EC who underwent subtotal esophagectomy in our department between January 2012 and December 2021. Univariate and multivariate logistic regression analyses were used to evaluate the association between the incidence of POP and clinical factors. Results Among 151 patients, 33 cases (21.8%) developed POP. Multivariate analysis identified preoperative C-reactive protein-to-albumin ratio (CAR) ≥0.03 [odds ratio (OR), 2.69; P = 0.0352], chronic obstructive lung disease (COPD) (OR, 7.32; P = 0.0001), and diabetes mellitus (DM) (OR, 3.35; P = 0.0252) as independent risk factors for POP. In accordance with the number of risk factors, the incidence rate of POP drastically increased, and its rate in patients with 3 risk factors was 80%. Conclusion High CAR, COPD, and DM are independent risk factors for the development of POP in patients undergoing subtotal esophagectomy for EC. Clinicians should be aware of the risk factors for POP and consider more intensive preventive measures and postoperative management in patients with EC.

The role of prehabilitation in reducing the incidence of postoperative pulmonary complications in patients undergoing elective cardiac surgery: Results from the Pre Surgery Check Team study.

Despite its importance, prehabilitation, has only been implemented in very few cardiac surgery centers. The Pre Surgery Check Team study was designed to evaluate the impact of comprehensive interdisciplinary assessment and implementation of the prehabilitation program on the incidence of postoperative pulmonary complications after elective cardiac surgery. 725 adult patients (338 in the study group, 387 in the control group) were included in this single-center, prospective, observational study. Multimodal prehabilitation consisted of four elements: interdisciplinary medical assessment by cardiologist, anesthesiologist and cardiac surgeon, pulmonary assessment for patients at high risk of postoperative pulmonary complications, psychological assessment, and physiotherapeutic assessment and training. The primary endpoint was the occurrence of the postoperative pulmonary complications, and the secondary outcomes were: surgical site infection, rethoracotomy, ICU length of stay and hospital length of stay. Prehabilitation reduced the number of postoperative complications by 23%. Postoperative pneumonia was almost 3 times less common (5.33% vs 14.21%), and the surgical site infection - 1.4 times less common in the PreScheck group (8.28 vs 11.37%). In the logistic regression model, prehabilitation reduced the odds of postoperative pneumonia (by 0.346) and the odds of respiratory failure (by 0.479). Prehabilitation had no direct effect on ICU length of stay. Prehabilitation according to the Pre Surgery Check Team standard reduces the incidence of postoperative pulmonary complications and the total number of postoperative complications in patients undergoing elective cardiac surgery. The main benefit of attending the PreScheck Team visit is the opportunity to perform supportive preoperative interventions.

Breathing exercises for patients with early-stage lung cancer: a meta-analysis

BackgroundPostoperative pneumonia is a common but serious complication in patients with lung cancer. This meta-analysis aims to evaluate the effect of respiratory exercise on reducing postoperative pneumonia in patients with lung cancer and to provide a reliable basis for clinical treatment and nursing of patients with lung cancer.MethodsTwo reviewers searched PubMed, Embase, Web of Science, Cochrane Library, China Knowledge Network, Wanfang, and Weipu databases. We searched for the randomized controlled trials (RCTs) published in Chinese or English on the breathing exercises in patients with lung cancer up to January 30, 2024. The quality of the literature was evaluated with the Cochrane Risk of Bias Tool 2 (ROB 2). RevMan 5.3 software was used for meta-analysis.ResultsEleven RCTs with 1429 patients with lung cancer were included, and 710 patients received breathing exercises. The meta-analysis results showed that breathing exercises could significantly reduce the incidence of postoperative pneumonia [RR = 0.35, 95%CI (0.25, 0.51)], improve the FEV1 [MD = − 0.49, 95%CI (− 0.73, − 0.24)], FVC [MD = − 0.59, 95%CI (− 0.83, − 0.35)] in patients with lung cancer (all P < 0.05). There were significant differences in the incidence of pneumonia for patients undergoing breathing exercises with single exercise time ≥ 15 min (RR = 0.37, 95%CI 0.24 ~ 0.62), breathing exercises for 1 week (RR = 0.29, 95%CI 0.16 ~ 0.55) or for 2 weeks (RR = 0.48, 95%CI 0.28 ~ 0.85) and breathing exercises > 4 times (RR = 0.36, 95%CI 0.23 ~ 0.57) per day (all P < 0.05).ConclusionBreathing exercises have shown the capacity to augment pulmonary function in patients with lung cancer, concurrently mitigating the risk of postoperative pneumonia.

Development and validation of a machine-learning model for predicting postoperative pneumonia in aneurysmal subarachnoid hemorrhage.

Pneumonia is a common postoperative complication in patients with aneurysmal subarachnoid hemorrhage (aSAH), which is associated with poor prognosis and increased mortality. The aim of this study was to develop a predictive model for postoperative pneumonia (POP) in patients with aSAH. A retrospective analysis was conducted on 308 patients with aSAH who underwent surgery at the Neurosurgery Department of the First Affiliated Hospital of Soochow University. Univariate and multivariate logistic regression and lasso regression analysis were used to analyze the risk factors for POP. Receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the constructed model. Finally, the effectiveness of modeling these six variables in different machine learning methods was investigated. In our patient cohort, 23.4% (n = 72/308) of patients experienced POP. Univariate, multivariate logistic regression analysis and lasso regression analysis revealed age, Hunt-Hess grade, mechanical ventilation, leukocyte count, lymphocyte count, and platelet count as independent risk factors for POP. Subsequently, these six factors were used to build the final model. We found that age, Hunt-Hess grade, mechanical ventilation, leukocyte count, lymphocyte count, and platelet count were independent risk factors for POP in patients with aSAH. Through validation and comparison with other studies and machine learning models, our novel predictive model has demonstrated high efficacy in effectively predicting the likelihood of pneumonia during the hospitalization of aSAH patients.

Predictive values of serum amyloid A, toll-like receptor 4, and sTREM-1 for ventilator-associated pneumonia in elderly patients undergoing abdominal surgery with tracheal intubation and general anesthesia.

This study aimed to conduct a retrospective study to identify inflammatory biomarkers for predicting ventilator-associated pneumonia in elderly patients. Our retrospective study included 265 elderly patients (age ≥60years) undergoing abdominal surgery with tracheal intubation and general anesthesia, with 93 experiencing varying degrees of ventilator-associated pneumonia during hospitalization, and 172 without. Serum concentrations of serum amyloid A (SAA), toll-like receptor 4 (TLR4), and soluble myeloid triggering receptor 1 (sTREM-1) were measured at 24h post-operation using enzyme-linked immunosorbent assay. Comparisons of SAA, TLR4, and sTREM-1 and other risk factors at 24h post-operation between elderly patients with and without ventilator-associated pneumonia were performed. The study revealed a 35.1% incidence of postoperative ventilator-associated pneumonia among elderly patients. Upregulations of SAA, TLR4, and sTREM-1 were observed in patients with ventilator-associated pneumonia. Chronic obstructive pulmonary disease, smoking, and tracheal intubation were identified as independent risk factors. The joint prediction model was demonstrated with superior predictive accuracy (area under the curve=0.89) compared to individual biomarkers. Correlations with procalcitonin further supported the predictive potential of SAA, TLR4, and sTREM-1 in an inflammatory response. SAA, TLR4, and sTREM-1, particularly when combined, serve as valuable prognostic indicators for postoperative ventilator-associated pneumonia in elderly patients undergoing abdominal surgery with tracheal intubation and general anesthesia. The joint prediction model offered a promising tool for early risk assessment.

Strategy of Severe Pneumonia and Management of Related Complications After Autogenous Cartilage Microtia Reconstruction.

Since the pioneering use of autologous costal cartilage for microtia reconstruction, significant progress has been made in treating microtia, effectively improving patients' quality of life and reducing their psychological burden. Cartilage auricle reconstruction is the primary treatment, but many postoperative complications can occur. Common postoperative complications include infection and hematoma at the recipient site, pleural tears at the donor site, and thoracic scoliosis. Among these, severe postoperative pneumonia is a rare but potentially fatal complication. This study presents a case of severe pneumonia after auricular reconstruction with autologous cartilage. It details the complications associated with autologous cartilage microtia reconstruction, especially pulmonary complications, and suggests a possible relationship between pulmonary complications and auricular reconstruction using cartilage.

Risk of postoperative pneumonia after extubation with the positive pressure versus normal pressure technique: a single-center retrospective observational study.

A normal pressure extubation technique (no lung inflation before extubation), proposed by the Japanese Society of Anesthesiologists to prevent droplet infection during the coronavirus disease 2019 (COVID-19) pandemic, could theoretically increase postoperative pneumonia incidence compared with a positive pressure extubation technique (lung inflation before extubation). However, the normal pressure extubation technique has not been adequately evaluated. This study compared postoperative pneumonia incidence between positive and normal pressure extubation techniques using a dataset from the University of Tsukuba Hospital. In our hospital, the extubation methods changed from positive to normal pressure extubation techniques on March 3, 2020 due to the COVID-19 pandemic. Thus, we compared the risk of postoperative pneumonia between the positive (April 1, 2017 to December 31, 2019) and normal pressure extubation techniques (March 3, 2020 to March 31, 2022) using propensity score analyses. Postoperative pneumonia was defined using the International Classification of Diseases, 10th Edition (ICD-10) codes (J13-J18), and we reviewed the medical records of patients flagged with these ICD-10 codes (preoperative pneumonia and ICD-10 codes for prophylactic antibiotic prescriptions for pneumonia). We identified 20,011 surgeries, including 11,920 in the positive pressure extubation group (mean age 48.2years, standard deviation [SD] 25.2years) and 8,091 in the normal pressure extubation group (mean age 47.8years, SD 25.8years). The postoperative pneumonia incidences were 0.19% (23/11,920) and 0.17% (14/8,091) in the positive and normal pressure extubation groups, respectively. The propensity score analysis using inverse probability weighting revealed no significant difference in postoperative pneumonia incidence between the two groups (adjusted odds ratio 0.98, 95% confidence interval 0.50 to 1.91, P = 0.94). These results indicated no increased risk of postoperative pneumonia associated with the normal pressure extubation technique compared with the positive pressure extubation technique. Clinical trial number: UMIN000048589 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000055364.

Comparison of targeted next-generation sequencing and metagenomic next-generation sequencing in the identification of pathogens in pneumonia after congenital heart surgery: a comparative diagnostic accuracy study

BackgroundThis study aimed to compare targeted next-generation sequencing (tNGS) with metagenomic next-generation sequencing (mNGS) for pathogen detection in infants with severe postoperative pneumonia after congenital heart surgery.MethodsWe conducted a retrospective observational study using data from the electronic medical record system of infants who developed severe pneumonia after surgery for congenital heart disease from August 2021 to August 2022. Infants were divided into tNGS and mNGS groups based on the pathogen detection methods. The primary outcome was the efficiency of pathogen detection, and the secondary outcomes were the timeliness and cost of each method.ResultsIn the study, 91 infants were included, with tNGS detecting pathogens in 84.6% (77/91) and mNGS in 81.3% (74/91) of cases (P = 0.55). No significant differences were found in sensitivity, specificity, PPA, and NPA between the two methods (P > 0.05). tNGS identified five strains with resistance genes, while mNGS detected one strain. Furthermore, tNGS had a faster detection time (12 vs. 24 h) and lower cost ($150 vs. $500) compared to mNGS.ConclusiontNGS offers similar sensitivity to mNGS but with greater efficiency and cost-effectiveness, making it a promising approach for respiratory pathogen detection.

Efficacy and safety of step-by-step Baduanjin exercise based on doctor-nurse-patient integration mode for pulmonary rehabilitation in patients after lobectomy due to pulmonary tuberculosis: a randomized controlled clinical trial

BackgroundSome pulmonary tuberculosis patients may require lung resection surgery. Postoperative pulmonary rehabilitation is essential to restore the lung function and maintain quality of life. We aimed to study the pulmonary rehabilitation outcomes and complications of step-by-step Baduanjin exercise under a doctor-nurse-patient integration mode in patients after lobectomy due to pulmonary tuberculosis.MethodsWe performed a randomized controlled clinical trial in patients undergoing lobectomy due to pulmonary tuberculosis between September 2017 and August 2021. Eligible patients were randomly assigned into the control group or interventional group. The control group received routine postoperative care. The interventional group received step-by-step Baduanjin exercise based on the doctor-nurse-patient integration mode in addition to the routine care. The primary outcomes were the pulmonary functions, including forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC. The secondary outcomes were the maximum walking distance in a 6-min walk test and postoperative pulmonary complications, including atelectasis, pneumonia, and respiratory failure.ResultsA total of 100 patients were enrolled into the study, with 50 patients in the control and interventional groups. There were 60 female patients (60%). The mean patient age was 37.9 (± 2.8) years old. At the one- and two-month postoperative follow-ups, pulmonary function tests showed statistically significantly better performances in FEV1/prediction, FVC/prediction, and FEV1/FVC in the interventional group than the control group. The 6-min walk test also revealed longer walking distances in the interventional group than the control group. There were no statistically significant differences in postoperative complications between the two groups.ConclusionsA step-by-step Baduanjin exercise regimen under the doctor-nurse-patient integration mode could safely improve pulmonary rehabilitation in patients after lobectomy due to pulmonary tuberculosis.

Perioperative Outcomes of Total Hip Arthroplasty in Trisomy 21 Patients in Comparison With a Control Population: Analysis From a Large National Sample of 367,894 Patients.

Literature on the outcomes of total hip arthroplasty (THA) has established the procedure as a gold standard for hip arthritis. However, postoperative outcomes after THA in specific conditions such as Down's syndrome (DS) have been sparsely described. This large database analysis of over 367,000 patients was aimed at evaluating the immediate postoperative results including morbidity and mortality rates after THA among DS patients and comparing these with a control population. Data from the National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project (HCUP) was reviewed retrospectively from 2016 to 2019 on THAs. Among 367,894 patients, 129 were identified with a diagnosis of DS. Complex primaries and revisions were excluded. Demographics, admission details, and perioperative variables including morbidity and mortality rates were compared between DS patients and controls. Patients with DS were younger than the control population (43.3 versus 65.9 years, p=0.002), had a greater preponderance of men, had a lower incidence of smoking and diabetes, and had a relatively higher incidence of non-elective THA. The former also had a longer mean length of stay (LoS) and higher mean costs to healthcare. Two patients with DS died after a THA, making the mortality rate 17-fold higher in DS patients. Higher rates of postoperative anemia (31.8% versus 19.6%, p<0.001), pneumonia (2.3% versus 0.3%), and pulmonary embolism (p=0.0.12) were seen in the DS group. Also seen in the DS group were higher risks of periprosthetic fractures (p=0.020) and periprosthetic joint infections (PJIs) (p=0.047). Results from a total hip arthroplasty continue to positively transform the lives of patients with end-stage hip arthritis from varying etiologies. In the special cohort of Down's syndrome, a thorough discussion is essential with reference to the relatively higher morbidity and mortality in this group of patients. Documented conversations between patients and their families and healthcare providers should consist of detailed deliberations on the pros and cons of surgery and its potential impacts.

Risk-scoring system predicting need for hospital-specific interventional care after peroral endoscopic myotomy.

Early identification of patients needing hospital-specific interventional care (HIC) following endoscopic treatment is valuable for optimizing postoperative hospital stays. We aimed to develop and validate a risk-scoring system for predicting HIC in patients who underwent peroral endoscopic myotomy (POEM). This study included patients with esophageal motility disorders who underwent POEM at our hospital between April 2015 and March 2023. HIC was defined as any of the following situations: fasting for gastrointestinal rest to manage adverse events (AEs); intravenous administration of medications such as antibiotics and blood transfusion; endoscopic, radiologic, and surgical interventions; intensive care unit management; or other life-threatening events. A risk-scoring system for predicting HIC after postoperative day (POD) 1 was developed using multivariable logistic regression and was internally validated using bootstrapping and decision curve analysis. Of the 589 patients, 50 (8.5%) experienced HIC after POD1. Risk scores were assigned for four factors as follows: age (0 points for <70 years, 1 point for 70-79 years, 2 points for ≥80 years), preoperative prognostic nutritional index (0 points for >45, 1 point for 40-45, 4 points for <40), postoperative surgical site AEs on second-look endoscopy (7 points), and postoperative pneumonia on chest radiography (6 points). The discriminative ability (concordance statistics, 0.85; 95% confidence interval, 0.78-0.91) and calibration (slope 1.00; 0.74-1.28) were satisfactory. The decision curve analysis demonstrated its clinical usefulness. This risk-scoring system can predict the HIC after POD1 and provide useful information for determining discharge.

335. IMPACT OF POSTOPERATIVE COMPLICATIONS ON LONG-TERM OUTCOMES AFTER ESOPHAGECTOMY

Abstract Background Recently, it has been reported that postoperative complications after esophagectomy not only prolong hospital stay and reduce quality of life, but also have impact on the long-term outcomes. However, this still remains controversial. Here, we aimed to evaluate the prognostic impact of postoperative complications after esophagectomy, focusing on the type and severity of complications. In addition, we examined the impact of postoperative pneumonia on long-term prognosis stratified by the presence of COPD. Methods In total, 254 consecutive patients who underwent esophagectomy for esophageal cancer between 2009 and 2021 were eligible. We examined the association between postoperative complications and long-term outcomes. Severe postoperative complications can be defined as C-D III-V in this study. Results Postoperative complications occurred in 150 out of 254 cases (59.1%). Patients with postoperative pneumonia and anastomotic leakage had significantly lower OS, CSS and RFS rates compared to those without, whereas other complications were not associated with long-term outcomes. Regarding severity, non-severe complications did not affect long-term prognosis, whereas patients with severe complications significantly lower OS, CSS, and RFS rates (P &amp;lt; 0.01). In addition, patients without COPD who developed postoperative pneumonia had significantly lower long-term outcomes (P &amp;lt; 0.01). However, in patients with COPD, no survival difference between patients with and without postoperative pneumonia was observed. Conclusion Severe postoperative pneumonia and anastomotic leakage were found to strongly influence the long-term outcomes. Meanwhile, postoperative pneumonia may have a minimal impact on long-term outcomes in COPD patients.

Factors associated with and outcomes of respiratory adverse events following thoracic endovascular aortic repair

ObjectiveRespiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized owing to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR. MethodsWe identified patients in the Vascular Quality Initiative undergoing TEVAR isolated to zones 0 to 5 from 2010 to 2023 for nontraumatic pathologies. After determining the incidence of postoperative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined preoperative and intraoperative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression models were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other nonrespiratory postoperative complications in a separate model. ResultsOf 10,708 patients, 8.3% had any RAE (pneumonia only, 2.1%; reintubation only, 4.8%; both, 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication, 46% vs no respiratory complication, 35%; P < .001), and be symptomatic (58% vs 48%; P < .001). Developing RAEs after TEVAR was associated with male sex (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], 1.01-1.41; P = .037), obesity (aRR, 1.31; 95% CI, 1.07-1.61; P = .009), morbid obesity (aRR, 1.68; 95% CI, 1.20-2.32; P = .002), renal dysfunction (aRR, estimated glomerular filtration rate 30-45, 1.45; 95% CI, 1.15-1.82; P = .002; estimated glomerular filtration rate <30/hemodialysis, 1.7; 95% CI, 1.37-2.11; P < .001), anemia (aRR, 1.31; 95% CI, 1.09-1.58; P = .003), aortic diameter >65 mm (aRR, 1.54; 95% CI, 1.25-1.89; P < .001), proximal disease in the aortic arch (aRR, 1.23; 95% CI, 1.03-1.48; P = .025) or ascending aorta (aRR, 1.61; 95% CI, 1.19-2.14; P = .002), acute aortic dissection (aRR, 2.13; 95% CI, 1.72-2.63; P < .001), ruptured presentation (aRR, 3.07; 95% CI, 2.43-3.87; P < .001), same-day surgical thoracic branch treatment (aRR, 1.51; 95% CI, 1.25-1.82; P < .001), chronic obstructive pulmonary disease on home oxygen (aRR, 1.58; 95% CI, 1.08-2.25; P = .014), limited self-care or bed-bound status (aRR, 2.12; 95% CI, 1.45-3.03; P < .001), and intraoperative transfusion (aRR, 1.88; 95% CI, 1.47-2.40; P < .001). Patients who developed postoperative RAEs had higher 30-day mortality (27% vs 4%; P < .001) and 5-year mortality than patients without respiratory complications (46% vs 20%; P < .001). After adjusting for preoperative and postoperative variables, the 5-year mortality was higher in patients who developed any postoperative RAE (adjusted hazard ratio [aHR], 1.8; 95% CI, 1.6, 2.1; P < .001), postoperative pneumonia only (aHR, 1.4; 95% CI, 1.0, 1.8; P = .046), reintubation only (aHR, 2.2; 95% CI, 1.8, 2.6; P < .001) or both (aHR, 1.5; 95% CI, 1.1, 2.0; P = .008). ConclusionsRAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, chronic obstructive pulmonary disease on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intraoperative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other postoperative complications. Considering these factors in assessing the risks and benefits of TEVAR procedures, along with implementing customized postoperative care, can potentially improve clinical outcomes.

453. ROBOT ESOPHAGECTOMY WITH EXTENDED MEDIASTINAL LYMPH NODE DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background Radical surgical resection may play role in prognosis improvement of the esophageal squamous cell carcinoma (ESCC) patients. Because esophagectomy with radical lymphadenectomy is highly invasive, we introduced thoracoscopic esophagectomy in 1999, and have performed over 600 cases. In 2009, we developed a hybrid of the prone and left lateral decubitus positions for thoracoscopic esophagectomy with extended LN dissection and reported good long-term outcomes especially in cT1bN0M0 ESCC patients. We reported 3y and 5y RFS was 96% and 96%, and 3y and 5y OS was 94% and 92% in those patients. We introduced robot-assisted esophagectomy (RMIE) using daVinci Xi system in June 2018 and have performed for 80 cases. We perform RMIE with the prone position instead of the hybrid position with same concept of thoracoscopic esophagectomy with extended LN dissection. Thanks to a three-dimensional magnified view, fully wristed dexterity and tremor filtration of da Vinci Xi system, the robotic system facilitates precise dissection especial for upper mediastinal lymph node dissection. We show safety introduction and technical pitfalls of robot-assisted esophagectomy with extended LN dissection. Methods: The patient is fixed on prone position. We use Monopolar curved scissors for superficial layer, bipolar cut for dissection with maryland bipolar forceps for deeper layer around Aorta and trachea, and Sharp dissection with Potts scissors around recurrent laryngeal nerves. After esophageal mobilization and mediastinal lymphadenectomy were completed, bilateral recurrent laryngeal nerve, bilateral subclavian artery, trachea, bilateral bronchus, aorta, left pulmonary artery and vein, left pleura, pericardium and hiatus are all skeletonized. Results: We could standardize surgical procedure in first 20 cases. Average operation time in the thoracic procedure is 234.4min and 190.2min in last 30 cases. Median blood loss is 0ml. Postoperative pneumonia and vocal cord palsy were occurred only 6 case in 80 cases. Conclusion: Robot assisted esophagectomy with extended LN dissection was safely introduced in our facility and it is feasible and beneficial for the lymph node dissection especially for lymph node dissection around the recurrent laryngeal nerve. https://www.dropbox.com/scl/fi/w8na39w6bo9ivwwz7x2rh/Hirofumi-Kawakubo-ISDE-2024.mp4?rlkey=p9mvt7dotyeaj6xfwvud8vcmr&amp;dl=0