Postoperative Aspiration Pneumonia Research Articles

Whipple's pancreaticoduodenectomy for cancer of the head of the pancreas in a patient with amyotrophic lateral sclerosis: perioperative challenges.

The association of amyotrophic lateral sclerosis and pancreatic cancer is rare. Amyotrophic lateral sclerosis is a neurodegenerative disease characterised by pure motor symptoms in the form of progressive muscle weakness and wasting, and can involve the bulbar and respiratory muscles, leading to significant morbidity. Successful surgery for patients with amyotrophic lateral sclerosis for pancreatic cancer has rarely been reported. Surgery in such patients is a dual-edged sword and is decided based on risk-benefit ratio. Patients are at high risk for general anaesthesia because of muscular weakness, increased sensitivity to muscle relaxants and certain anaesthetic drugs. There is a high chance of prolonged postoperative ventilatory support, aspiration pneumonia and pulmonary complications. We report a patient with cancer of the head of the pancreas who underwent successful elective pancreaticoduodenectomy.

Effects of preoperative oral management by dentists on postoperative outcomes following esophagectomy: Multilevel propensity score matching and weighting analyses using the Japanese inpatient database.

The purpose of this study was to investigate the effects of preoperative oral management (POM) by dentists on the incidence of postoperative pulmonary complications (PPCs), length of hospital stay, medical costs, and days of antibiotics administration following both open and thoracoscopic esophagectomy.Dental plaque is an established risk factor for postoperative pneumonia, which could be reduced by POM. However, few clinical guidelines for cancer treatment, including those for esophageal cancer, recommend POM as routine perioperative care.We extracted data of esophagectomy cases from the Japanese Diagnosis Procedure Combination database. We subsequently conducted propensity score (PS) analyses for multilevel data, including matching, inverse probability of treatment weighting (IPTW), and standardized mortality ratio weighting (SMRW), to estimate the effect of POM by dentists on the outcomes of esophagectomy.We analyzed 3412 esophagectomy cases of which 812 were open, and 2600 were thoracoscopic surgery. In IPTW analysis to estimate the average treatment effect, the risk difference of postoperative aspiration pneumonia ranged from -2.49% to -2.02% between the POM and control groups of both open and thoracoscopic esophagectomy cases. IPTW analyses indicated that the total medical costs of thoracoscopic esophagectomy were reduced by 221,200 to 253,100 Japanese Yen (equivalent to about $2000-$2200). In PS matching and SMRW analyses to estimate average treatment effect on treated, there was no difference in outcomes between the POM and control groups.Our results suggested that in patients undergoing open or thoracoscopic esophagectomy, POM by dentists prevented the occurrence of postoperative aspiration pneumonia. It could also reduce the total medical costs of thoracoscopic esophagectomy. Thus, POM by dentists can be considered as a routine perioperative care for all patients undergoing esophagectomy, regardless of the expected risk for PPC.

A Double-Blind Randomized Controlled Trial to Determine the Preventive Effect of Hangekobokuto on Aspiration Pneumonia in Patients Undergoing Cardiovascular Surgery.

Purpose: This study aimed to assess whether hangekobokuto (HKT) can prevent aspiration pneumonia in patients undergoing cardiovascular surgery.Methods: We performed a single-center, double-blinded, randomized, placebo-controlled study of HKT in patients undergoing cardiovascular surgery. JPS HKT extract granule (JPS-16) was used as HKT. The primary endpoint was defined as the prevention of postoperative aspiration pneumonia. The secondary endpoints included complete recovery from swallowing and coughing disorders.Results: Between August 2014 and August 2015, a total of 34 patients were registered in this study. The rate of subjects with postoperative aspiration pneumonia was significantly lower in the HKT group than in the placebo group (p = 0.017). In high-risk patients for aspiration pneumonia, the rate was significantly lower in the HKT group than in the placebo group (p = 0.015). The rate of subjects with swallowing disorders tended to be lower in the HKT group than in the placebo group (p = 0.091), and in high-risk patients, the rate was significantly lower in the HKT group than in the placebo group (p = 0.038).Conclusions: HKT can prevent aspiration pneumonia in patients undergoing cardiovascular surgery. In high-risk patients for aspiration pneumonia, HKT can prevent aspiration pneumonia and improve swallowing disorders.

Effects of preoperative cisapride on postoperative aspiration pneumonia in dogs with laryngeal paralysis.

Retrospective evaluation of a preoperative prokinetic protocol using a constant-rate infusion of a serotonin 5-HT4 receptor agonist, cisapride, and its association with frequency of postoperative aspiration pneumonia in dogs undergoing unilateral arytenoid lateralisation as compared to a historical population at the same institution. Medical records of dogs undergoing unilateral arytenoid lateralisation for laryngeal paralysis were reviewed for historical findings, imaging findings, anaesthesia and surgery durations, perioperative medications and if surgery was performed as an emergency. Aspiration pneumonia events in the first 72 hours after surgery were recorded. The study group received a preoperative cisapride constant-rate infusion; historical 'controls' did not receive the cisapride protocol. One of 50 dogs in the cisapride group and six of 52 dogs in the historical group developed aspiration pneumonia within the immediate postoperative period. The cisapride protocol was largely well tolerated. A markedly lower rate of aspiration pneumonia in patients administered butorphanol with acepromazine preoperatively and buprenorphine postoperatively was noted, but the overall low frequency of aspiration pneumonia and variation in case management protocols precluded definitive conclusions with respect to optimal perioperative drug choices. Laryngeal paralysis is commonly treated by unilateral arytenoid lateralisation, and aspiration pneumonia is one of the most serious potential complications of this procedure. This study suggests that further investigation of a cisapride constant-rate infusion to prevent this complication is warranted.

Endoscopic laryngo-pharyngeal surgery for elderly patients

ObjectiveDue to the rising number of elderly patients and advances in endoscopic devices, early laryngeal and pharyngeal cancers are increasingly found in elderly patients. In these cases, minimally invasive endoscopic larygo-pharyngeal surgery (ELPS) may be indicated. However, the safety and efficacy of ELPS in elderly populations has not been established. The purpose of this study was to investigate the safety, outcomes and feasibility of ELPS in very elderly patients. MethodsBetween February 2010 and April 2016, 29 pharyngeal cancerous or pre-cancerous lesions in 19 patients aged 75 years or older were treated with ELPS. Twenty-six resections were performed in total, and the patients’ clinical courses were reviewed. ResultsSixteen patients had multiple comorbidities and moderate to severe comorbidities were observed in 17 patients. The average surgical time and hospitalization period was 54.3min and 18.8 days, respectively. On average, oral intake began 4.4days after the procedure, and all patients eventually received nourishment by mouth; no percutaneous endoscopic gastrostomy dependency was observed. Complications included post-operative bleeding and aspiration pneumonia in two cases each, and all complications were safely managed. The 3-year overall survival rate was 90.2% and the 3-year disease-specific survival rate was 100%. ConclusionELPS was safely performed in elderly patients, suggesting that it is a feasible treatment option for pharyngeal lesions in very elderly patients.

PS01.189: A STUDY ON THE UTILITY OF INTRAOPERATIVE NEUROSTIMULATION MONITORING SYSTEM FOR RECURRENT LARYNGEAL NERVE IN ESOPHAGECTOMY

Abstract Background Recurrent laryngeal nerve paralysis in esophagectomy is one of the most concerned complications. In recent years, intraoperative neurostimulation monitoring system (IONM) in thyroid surgery have been widespread for identification of recurrent laryngeal nerve and assessment of soundness. Therefore, IONM is often used during esophagectomy in Japan. In this study, we examined the efficacy of IONM in the patients undergoing esophagectomy. Methods Of 66 patients underwent esophagectomy since April 2015 until December 2017, IONM used in 27 patients in the surgery for the examination of recurrent nerve paralysis. We retrospectively reviewed these cases for intraoperative findings, neurostimulation monitoring findings and their outcomes. Results Of 27 patients, 25 were male and two were female, and the median age at operation was 66 years old. Although IONM was used in cervical lymph node dissection, there were no vocal cord responses in 5 patients (left side in 4 and right side in 1) with stimulation of the vagus nerve. Because all patients had no vocal cord paralysis due to stimulation of the cervical recurrent laryngeal nerve, it was diagnosed that there was the recurrent laryngeal nerve injury due to thoracic para recurrent nerve lymph node dissection. IONM was able to facilitate the identification and preservation of cervical recurrent nerve in all patients. Three out of 5 patients with no vocal cord response by IONM were confirmed recurrent laryngeal nerve paralysis in postoperative endoscope. In patients with vocal cord paralysis by IONM, it was possible to carefully performed postoperative management. On the other hand, in patients without paralysis, extubation on the operation day seemed possible without the concern for aspiration. Conclusion By using IONM in esophagectomy, we were able to evaluate the damage of the recurrent laryngeal nerve in real-time. Confirming the intraoperative recurrent nerve injuries is important for postoperative management or prediction of postoperative aspiration pneumonia. IONM in esophagectomy was useful not only in terms of surgical procedures but also in the evaluation of postoperative management. Disclosure All authors have declared no conflicts of interest.

Application value of tubular gastric interposition for esophageal reconstruction in esophageal and gastric carcinoma

Objective To investigate the application value of tubular gastric interposition for esophageal reconstruction in esophageal and gastric cancer. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 6 patients with esophageal and gastric cancer who were admitted to the General Hospital of Jinan Military Area of PLA between January 2013 and December 2016 were collected. Among 6 patients, 2 and 4 were respectively confirmed as mid-thoracic and low esophageal cancers; tumors of 4 and 3 patients were respectively located in the gastric antrum and gastric body at lesser curvature side, including 1 with tumor in the gastric antrum and body. Esophageal cancer and gastric tumor were simultaneous resected, and proximal stomach replaced esophagus resected, with a blood-supply through right gastroepiploic vessels. There was an anastomosis between proximal tubular stomach and esoghagus. According to resection extent of resection extent, distal anastomosis included: (1) tubular stomach-duodenum BillrothⅠ anastomosis in case 1; (2) tubular stomach-jejunum Billroth Ⅱ anastomosis in case 2, 3 and 4; (3) tubular stomach-jejunum Billroth Ⅱ anastomosis + jejunum-jejunum side-to-side anastomosis in case 5 and 6. Observation indicators: (1) intra- and post-operative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and quality of life up to May 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Intra- and post-operative recovery situations: 6 patients underwent successful operation. The operation time, volume of intraoperative blood loss, gastrointestinal function recovery time, drainage-tube removal time and duration of hospital stay were respectively (206±50)minutes, (106±24)mL, (3.8±2.1)days, (6.8±5.0)days and (12.5±4.2)days. Of 6 patients, 1 with postoperative aspiration pneumonia and 1 with incomplete intestinal obstruction were cured by medical treatment. There was no anastomotic complication. (2) Postoperative pathological examination: number of lymph node dissectted of 6 patients was 13±3. Case 2 had intra-abdominal lymph node metastasis. Pathological type: esophageal cancers were comfirmed as squamous cell carcinomas, gastric tumor were comfirmed as adenocarcinomas in 5 patients and stromal tumor were in 1 patient. (3) Follow-up and survival situations: 6 patients were followed up for 5-28 months, with a median time of 14 months. During the follow-up, case 1 had severe symptom of reflux, and other 5 patients didn′t have symptoms of reflux. Case 2 died of abdominal metastasis at 11 months postoperatively, and other 5 patients had survival. Conclusion Tubular gastric interposition replacing esophagus resected is safe and feasible in esophageal and gastric cancer, easy to operate and consistent with the physiological characteristics, meanwhile, it will provide opportunities and options of radical resection. Key words: Esophageal neoplasms; Gastric neoplasms; Radical resection; Tubular stomach; Interposition; Digestive tract reconstruction

Complications After Endoscopic Laryngopharyngeal Surgery.

Endoscopic laryngopharyngeal surgery (ELPS), a hybrid of head and neck surgery and gastrointestinal endoscopic treatment, has been attracting attention as a new therapeutic modality for superficial laryngopharyngeal cancers. Although this technique is less invasive than traditional open procedures, some complications including postoperative bleeding, subcutaneous emphysema, or aspiration pneumonia can occur after treatment. The purpose of this study was to investigate the complications associated with ELPS to better understand the indications for this procedure. Retrospective medical chart review. One hundred five patients with 159 laryngeal or pharyngeal lesions were treated with ELPS between August 2009 and September 2015 at Kyoto University Hospital. In total, 147 resections were performed, and complications after the resections were reviewed. Of the 147 resections, postoperative bleeding, subcutaneous emphysema, and aspiration pneumonia were observed in 10, 17, and 10 cases, respectively. All cases with postoperative bleeding and aspiration pneumonia occurred in patients over 65 years of age. A history of taking anticoagulation/platelet medications, and macroscopic 0-IIa lesions were shown to correlate with postoperative bleeding after ELPS. Resection of lesions in the pyriform sinus was found to be associated with subcutaneous emphysema. All complications after ELPS were safely managed. A history of taking anticoagulation/platelet medications and macroscopic 0-IIa lesions were identified as risk factors for postoperative bleeding, whereas resection of pyriform sinus lesions was found to be a risk factor for subcutaneous emphysema. These risk factors should be carefully considered when treating pharyngeal and laryngeal lesions by ELPS. 4. Laryngoscope, 128:1546-1550, 2018.

Impact of routine recurrent laryngeal nerve monitoring in prone esophagectomy with mediastinal lymph node dissection.

The problem of recurrent laryngeal nerve (RLN) paralysis (RLNP) after radical esophagectomy remains unresolved. Several studies have confirmed that intraoperative nerve monitoring (IONM) of the RLN during thyroid surgery substantially decreases the incidence of RLN damage. This study tried to determine the feasibility and effectiveness of IONM of the RLN during thoracoscopic esophagectomy in the prone position for esophageal cancer. All 108 patients who underwent prone esophagectomy at Tohoku University Hospital between July 2012 and March 2015 were included in this study. We divided patients into two groups: a control group (No-Monitoring group, surgery without IONM; n=54) and a study group (Monitoring group, surgery with IONM; n=54). In Monitoring group, neural stimulation was performed for both RLNs before and after dissection in the thoracic procedure, then for RLNs and vagus nerves (VNs) in the cervical procedure. The feasibility of IONM in Monitoring group and early surgical outcomes were retrospectively compared with those in No-Monitoring group. IONM could be performed for 47 cases (87.0%) in Monitoring group. Reasons for discontinuation were use of muscle relaxants (3 patients), change in thoracotomy procedure (2 patients), past rib bone fracture (1 patient), and allergic shock by transfusion (1 patient). Right RLNPs were identified postoperatively in 4 patients, and left RLNPs in 23 patients. IONM sensitivities were 92.7 and 88.0% for the right and left VNs, respectively. Incidences of postoperative RLNP, aspiration, and primary pneumonia did not differ significantly between groups. This study confirmed the feasibility and safety of IONM of the RLN for thoracoscopic esophagectomy in the prone position. No significant differences in postoperative outcomes were seen between esophagectomy with and without IONM.

Incidence and risk factors for aspiration pneumonia after cardiovascular surgery in elderly patients.

Pneumonia after cardiovascular surgery is the leading cause of mortality. Postoperative aspiration pneumonia becomes a critical issue in the management of cardiovascular surgery in the aging society. The aim of this study was to investigate the incidence and risk factors of aspiration pneumonia after cardiovascular surgery for elderly patients. This study consisted of 123 elderly patients (>65years old) who survived their final extubation following cardiovascular surgery at Kinan Hospital. Patients were divided into aspiration pneumonia and no pneumonia groups. Postoperative aspiration pneumonia was diagnosed by two independent physicians according to the nursing- and healthcare-associated pneumonia guidelines by the Japanese Respiratory Society. Among the patients, 12 (9.8%) had aspiration pneumonia. There were no differences in patients' characteristics between the groups except for a history of cerebral vascular disorder (aspiration pneumonia 42% vs no pneumonia 15%, p=0.04) and ejection fraction (EF) (aspiration pneumonia 56±21% vs no pneumonia 66±13%, p=0.02). Only six (5%) patients needed more than 12h intubation. There was no difference in the operative factors between the groups. Neurological deficit was more frequently observed in the aspiration pneumonia group (33 vs 5%, p=0.005). Multivariable logistic regression analysis showed that the history of cerebral vascular disorder and neurological deficit after surgery was independent risk factors for aspiration pneumonia after cardiovascular surgery. Our results could assist in screening elderly patients who should be more carefully evaluated before oral nutrition to minimize morbidity and mortality after cardiovascular surgery.

Postoperative Respiratory Function and Survival After Pneumonectomy in Dogs and Cats.

To describe indications for, and outcomes after, pneumonectomy in dogs and cats, including assessment of immediate postoperative respiratory function in comparison to dogs undergoing single lung lobectomy. Retrospective case series. Dogs (n=16) and cats (n=7) with naturally occurring pulmonary disease. Medical records (1990-2014) of dogs and cats undergoing right or left pneumonectomy were reviewed. Data retrieved included signalment, history, preoperative diagnostics, operative descriptions, postoperative data including respiratory function, and postdischarge outcomes. For respiratory function comparisons, medical records of dogs having undergone a single lung lobectomy via median sternotomy (n=15) or intercostal thoracotomy (n=15) were reviewed. Twenty-three cases (16 dogs, 7 cats) were included. Pneumonectomy was performed for congenital (1 dog, 1 cat), neoplastic (8 dogs, 1 cat), and infectious (7 dogs, 5 cats) disease. Postoperative aspiration pneumonia occurred in 2 dogs; 15 of 16 dogs (94%) and 6/7 cats (86%) survived to hospital discharge. After pneumonectomy, dogs had a significantly higher postoperative PaO2 on 21% oxygen (P=.033) and lower postoperative A-a gradient (P=.004) compared to dogs undergoing single lung lobectomy. Survival times (right-censored at last follow-up) for dogs ranged from 2 days to 7 years (estimated median=1,868 days) and for cats from 1-585 days. Dogs and cats have acceptable respiratory function immediately postoperatively and most have protracted long-term survival after pneumonectomy for a variety of pulmonary diseases.

Effect of Metoclopramide on the Incidence of Early Postoperative Aspiration Pneumonia in Dogs with Acquired Idiopathic Laryngeal Paralysis.

Evaluate the effect of a perioperative intravenous continuous rate infusion (CRI) of metoclopramide on the incidence of aspiration pneumonia in the short term postoperative period in dogs undergoing unilateral arytenoid lateralization. Prospective, randomized, multi-center clinical trial. 61 client-owned dogs with idiopathic laryngeal paralysis and normal preoperative thoracic radiographs. All dogs underwent unilateral arytenoid lateralization with a uniform anesthetic, analgesic, and management protocol. Dogs in the treatment group received an intravenous CRI of metoclopramide for 24 hours perioperative. All dogs were assessed for clinical signs of aspiration pneumonia based on the results of physical examination and owner interview up to the point of suture removal (10-14 days postoperative). Any dog with suspected aspiration pneumonia had thoracic radiographs performed. Six dogs developed aspiration pneumonia in the short term postoperative period (2/28 control dogs and 4/33 treated dogs), accounting for an overall frequency of 10% with no significant difference between control and treated dogs. No variables measured in the study were significantly different between control and treated dogs. Perioperative metoclopramide, at the doses used in this study, did not affect the incidence of aspiration pneumonia in the short term postoperative period in dogs with idiopathic laryngeal paralysis undergoing unilateral arytenoid lateralization.

Risk factors for fatal outcome in surgical patients with postoperative aspiration pneumonia

IntroductionAspiration pneumonia in hospitalized surgical patients has been associated with a mortality of approximately 30%. The aim of this study was to assess pre-, intra- and postoperative risk factors for mortality in patients suffering aspiration pneumonia after abdominal surgery. MethodsRetrospective study from 01/2006–12/2012 of patients with clinically and radiologically confirmed aspiration pneumonia after abdominal surgery. ResultsA total of 70 patients undergoing abdominal surgery and postoperative aspiration pneumonia were identified. There were 53 (76%) male patients, the mean age was 71 ± 12 years and the mean ASA score was 3 ± 1. The surgical procedures included 32 colorectal or small bowel resections, 10 partial liver resections, 9 gastric surgeries, 8 esophageal resections, 5 pancreatic surgeries, and 6 hernia repairs. Aspiration pneumonia occurred at mean postoperative day 7 ± 10. Overall, 53% (n = 37) of patients required re-intubation, with 4 ± 5 days of additional mechanical ventilation. Mean hospital and ICU length of stay was 32 ± 25 days and 6 ± 9 days, respectively. Overall mortality was 27% (n = 19). Forward logistic regression revealed older age [OR 7.41 (95% CI: 1.29–42.62)], bilateral aspiration pneumonia [OR 7.39 (95% CI: 1.86–29.29)] and intraoperative requirement of blood component transfusion [OR 5.09 (95% CI: 1.34–19.38)] as independent risk factors for mortality (overall R2 = 0.336). ConclusionPostoperative aspiration pneumonia remains a severe complication with significant mortality. Increasing age, the need for intraoperative blood component transfusion and bilateral pulmonary infiltrates are independent risk factors for fatal outcome after aspiration pneumonia. Therefore, these patients suffering aspiration pneumonia require special attention and increased monitoring.

Risk factors for the development of aspiration pneumonia after unilateral arytenoid lateralization in dogs with laryngeal paralysis: 232 cases (1987-2012).

To identify risk factors for the development of aspiration pneumonia after unilateral arytenoid lateralization in dogs with laryngeal paralysis. Retrospective case series. 232 client-owned dogs with a diagnosis of laryngeal paralysis treated with left-sided unilateral arytenoid lateralization. Medical records were reviewed. Signalment, medical history, surgical complications, and outcome data were collected. Follow-up was performed via review of medical records and by telephone interview with the owner, referring veterinarian, or both. At the 1-, 3-, and 4-year follow-up periods, aspiration pneumonia occurred in 18.6%, 31.8%, and 31.8% of dogs, respectively. The 1-, 3-, and 4-year survival rates for dogs with postoperative aspiration pneumonia were 83.1%, 51.5%, and 25.8%, respectively. None of the dogs with aspiration pneumonia before surgery developed clinical signs of aspiration pneumonia after surgery. Postoperative megaesophagus (hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.56 to 3.93) and postoperative administration of opioid analgesics prior to discharge (HR, 1.69; 95% CI, 1.12 to 2.80) were significant risk factors for the long-term development of aspiration pneumonia in this study. Perioperative metoclopramide administration did not significantly decrease the risk for development of aspiration pneumonia (HR, 0.94; 95% CI, 0.67 to 1.37). In the present study, aspiration pneumonia was the most commonly reported postoperative complication of unilateral lateralization in dogs treated for laryngeal paralysis; however, preexisting aspiration pneumonia was not associated with an increased risk for development of aspiration pneumonia after surgery. Megaesophagus was identified as an important risk factor for eventual development of aspiration pneumonia. Administration of an opioid analgesic may increase the risk of aspiration pneumonia in dogs treated surgically for laryngeal paralysis.

Outcome of Tracheostomy Closure in Oral Cancer Surgery Patients

Objective: We investigated the outcome of tracheal fistula in patients with oral cancer who underwent tracheostomy at the time of initial surgery. Study Design: retrospective study Methods: We retrospectively investigated the outcome of tracheal fistula in 57 patients with oral cancer who underwent tracheostomy. The patients were classified into three groups, which were patients in whom the tracheal fistula closed spontaneously (Group A), patients in whom closure of the tracheal fistula did not occur spontaneously and surgical closure was required (Group B), and patients in whom closure of the tracheostomy could not be achieved (Group C). The following factors were examined for associations with failure of spontaneous closure: patient demographics, primary tumor site, T classification, N classification, stage classification, presence or absence of neck dissection, presence or absence of reconstructive surgery, presence or absence of postoperative (chemo)radiotherapy, presence or absence of postoperative aspiration pneumonia, and duration of tracheal cannula placement. Results: Among the 57 subjects, Group A were 27 (47.4%), Group B were 23 (40.4%), and Group C were 7 (12.3%). In Group B, surgical closure with a hinge flap was performed in all 23 patients. We found that neck dissection and postoperative (chemo) radiotherapy were both factors that had an independent influence on whether closure of the tracheostomy could be achieved. Conclusion: Although early removal of the tracheal cannula is advantageous for improving the QOL of the patient, long-term cannulation does not interfere with spontaneous closure. Accordingly, it is necessary to carefully consider the timing of decannulation.

Functional outcome assessment of swallowing (FOAMS) scoring and videofluoroscopic evaluation of perioperative swallowing rehabilitation in radical esophagectomy.

Oropharyngeal swallowing dysfunction following esophagectomy has been associated with the surgical disruption of muscle strength and flexibility of the oropharyngeal structures. We assessed the value of perioperative swallowing rehabilitation (SR) in patients who underwent radical esophagectomy. We instituted routine perioperative SR for patients with esophageal cancer and retrospectively compared postoperative swallowing function between the patients who received (n=12) vs. those who did not receive (n=14) SR. The average duration of pre- and postoperative SR was 23.0 and 26.0days, respectively. Preoperatively, the functional outcome assessment of the swallowing (FOAMS) score was 7 (full marks) in all 26 patients, whereas the average score at hospital discharge was 6.3 vs. 5.5 in the patients who received vs. those who did not receive SR, respectively (p=0.049). Videofluoroscopic examination (n=12) demonstrated that the maximum superior excursion of hyoid bone increased significantly with preoperative SR (p=0.030), as well as postoperative SR (p=0.046). However, perioperative SR did not reduce the incidence of postoperative aspiration pneumonia or the duration of hospital stay. Swallowing function after radical esophagectomy was improved by perioperative SR; however, further investigations are needed to assess the clinical significance of SR in reducing surgical complications.

Predicting Mortality in Octogenarians and Nonagenarians following Cervical Spinal Surgery

Introduction Cervical spine surgery in the octogenarian and nonagenarian populations is challenging. In both the UK and the US, the population demographics have shifted, with a consistent rise in the population over the age of 80 years. Therefore, a methodology for selecting surgical candidates in this elderly age group is required to reduce postoperative mortality and obtain the best outcome. Our study looks at whether a well-established scoring system used in medical patients, the Charlson comorbidity index, can be directly applied to octogenarians and nonagenarians undergoing cervical spine surgery to predict perioperative mortality. In our study, social drift was evaluated to better understand the social and financial implications imposed by cervical spine surgery in this elderly age group. Materials and Methods A retrospective analysis was performed in patients in the age group of 80 to 100 years who underwent cervical spine surgery for degenerative disease (usually myelopathy), spinal tumors, or trauma between 2006 and 2013 at our institution. The analysis specifically looked at patient comorbidities scored using the Charlson comorbidity index and the relationship to the perioperative and 6-month mortality, length of stay, approach (anterior, posterior, and combined), and instrumentation which was collated from patient records. We looked at social drift in this elderly cohort of patients after cervical spine surgery by evaluating residential status before and after surgery, that is, home, residential home, or nursing home. Results In our study, there were 74 patients (62 octogenarians and 12 nonagenarians) who underwent cervical spine surgery with an average age of 85.1 ± 3.7 years. There were 28 male and 46 female patients. The average length of stay was 22 ± 30.5 days with a large variability (maximum 191 days). There were 45 patients with myelopathy, 1 patient with radiculopathy, 3 patients with spinal tumors, and 25 patients with cervical spine fractures. An anterior approach was used in 15 cases, a posterior approach in 42 cases, and a combined approach in 2 cases. There were 7 perioperative deaths and a total of 17 deaths at 6 months. No correlation was found between Charlson comorbidity index and perioperative or 6-month mortality. Social drift was statistically significant in our study ( p = 0.007, Fisher exact test). Interestingly, a statistically significant relationship was found with the postoperative complications aspiration pneumonia (relative risk 7.34, 95% CI: 2.40–7.84) and hospital-acquired pneumonia (HAP) (relative risk 4.25, 95% CI: 2.20–8.19), and 6-month mortality. Conclusion With the aging population, cervical spinal surgery in this age group is becoming more prevalent. Our study has shown that predicting mortality following cervical spine surgery in this elderly age group is difficult. A larger patient cohort is required to determine if the Charlson comorbidity index can predict postoperative mortality. Postoperatively, a significant number of our patients required discharge to a facility with an increased level of care. This may be attributable to the neurological status postoperatively, but the confounding factor of unmet preoperative social care exists. Postoperative complications of aspiration pneumonia and HAP carry a significant 6-month mortality; therefore, careful attention to feeding and chest physiotherapy is important.

Outcome of 45 dogs with laryngeal paralysis treated by unilateral arytenoid lateralization or bilateral ventriculocordectomy.

The purpose of this retrospective study was to assess risk factors and complications affecting postoperative outcome of dogs with laryngeal paralysis treated by either unilateral arytenoid lateralization (UAL) or bilateral ventriculocordectomy (VCC). Medical records of all dogs having either UAL or VCC between 2000 and 2011 were analyzed. Twenty-five dogs had VCC and 20 dogs had UAL. The overall postoperative complications rates for VCC and UAL were similar (52% and 60%, respectively; P = .0887). Dogs that had UAL were more likely to have acute postoperative respiratory distress and aspiration pneumonia (P = .0526). Dogs with VCC were more likely to have chronic postoperative respiratory distress and aspiration pneumonia (P = .0079). Revision surgery was required in 6 dogs (24%) following VCC and 2 dogs (10%) following UAL. Sex, breed, presenting complaint, type of service provided, and concurrent diseases were not significantly associated with higher risk of either death or decreased survival time postoperatively with either procedure. Overall postoperative complication rates, required revision surgeries, and episodes of aspiration pneumonia were similar in dogs undergoing UAL and VCC surgeries. Dogs that had VCC appeared to have an increased risk of lifelong complications postoperatively compared with UAL; therefore, VCC may not be the optimal choice for treatment of laryngeal paralysis.

Incidence, Outcomes, and Mortality of Reintubation After Anterior Cervical Fusion

Retrospective database analysis. To compare perioperative patient characteristics, hospital resource utilization, and early postoperative outcomes in patients requiring reintubation after anterior cervical fusion (ACF). Airway compromise is a potential complication after anterior cervical surgery. Postsurgical soft-tissue edema or hematoma formation may be so severe that an unplanned reintubation may be required. The rate of reintubation after ACF and the effect on hospital outcomes remains unknown. The Nationwide Inpatient Sample database was queried from 2002-2011. Patients undergoing elective ACF procedures for degenerative diagnoses were selected. Those who required an unplanned reintubation after ACF were identified. Patient demographics, comorbidities, length of stay, costs, number of levels fused, and mortality were analyzed. SPSS version 20 was used for statistical analysis and a P < 0.001 denoted statistical significance. A total of 262,425 patients underwent an elective ACF between 2002 and 2011 of which 1464 patients (5.6 per 1000 cases) required reintubation during their admission. The rate of reintubation was statistically greater for 3+-level fusions than the 1- to 2-level fusion cases. On average, patients requiring reintubation were older and had a greater number of comorbidities. These patients also incurred a significantly greater hospital stay and total hospital costs than unaffected patients. In addition, significant predictors for reintubation included 3+-level fusions, congestive heart failure, anemia, postoperative aspiration pneumonia, hematoma, thromboembolic events, and dysphagia. The reintubation rate after an elective ACF is 0.5%, and it increases to 1.6% after 3+-level fusions. Older patients with greater comorbidities are at an increased risk for reintubation. Given the greater LOS, costs and mortality associated with reintubation, it is imperative to identify patients at increased risk to help improve patient outcomes and decrease hospital resource utilization. 4.

A safe anastomotic technique of using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction after laparoscopy-assisted total gastrectomy for proximal malignant tumors of the stomach

BackgroundTo explore the safety and feasibility of the transorally inserted anvil (OrVil™) in laparoscopy-assisted total gastrectomy for gastric cancer.MethodsFrom December 2010 to June 2011, a total of 28 patients underwent laparoscopy-assisted total gastrectomy with a Roux-en-Y-esophagojejunostomy anastomosis with OrVil™. Perioperative treatments, intraoperative data, postoperative complications and hospital length of stay were evaluated.ResultsThere were no conversions to the open gastrectomy. The mean operation time was 143 minutes and the mean blood loss was 70 ml. Patients resumed an oral liquid diet on postoperative days 4 to 5. Two patients (7%) who suffered postoperative aspiration pneumonia were cured by conservative treatment. The median hospital length of stay was 9.6 days (8 to 11 days), with no inhospital mortalities. The median follow-up time was 14.8 months (12 to 18 months), and postoperative endoscopic examination revealed no anastomosis stenosis in patients who had dysphagia.ConclusionThe use of the OrVil™ is technically feasible and relatively safe for Roux-en-Y reconstruction after laparoscopy-assisted total gastrectomy.