Postoperative Respiratory Complications Research Articles

287 COVID-19 and Surgical Specialties – Lessons Learnt: A Rural DGH Perspective

IntroductionThe COVID-19 pandemic has seen the restructuring of surgical services worldwide. We aimed to evaluate pre-operative planning and post-operative outcomes in expedited colorectal surgery (ECRS), emergency general surgery (EGS), and emergency orthopaedic surgery (EOS) during the COVID-19 era at our rural hospital.MethodThis was a prospective observational cohort study. Electronic hospital systems identified adult patients who underwent ECRS, major EGS or EOS at our site, from the start of the UK lockdown.ResultsFollowing exclusion criteria, 98 patients were included in data analysis. Post-operative respiratory complications were seen in 27.8% of ECRS patients, 13.3% of EGS patients and 4% of EOS patients. 2 patients were diagnosed with COVID-19, with 1 COVID-19 associated mortality. Length of hospital stay was reduced for EOS in the COVID-19 setting and this was found to be statistically significant (p value <0.001).ConclusionsWhen compared to the literature, COVID-19 related complications in surgical patients were found to be lower at our rural hospital. This could be due to regional variation in the prevalence of COVID-19. If there were to be a second surge, we suggest NHS Trusts should be given the autonomy to make local decisions on modifying their elective caseload, rather than following a national ‘one-size-fits-all’ guideline.

Anesthetic Complications Associated With Severe Acute Respiratory Syndrome Coronavirus 2 in Pediatric Patients.

Coronavirus disease 2019 (COVID-19) is associated with high perioperative morbidity and mortality among adults. The incidence and severity of anesthetic complications in children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unknown. We hypothesized that there would be an increased incidence of intra- and postoperative complications in children with SARS-CoV-2 infection as compared to those with negative testing. We conducted a retrospective cohort study analyzing complications for children <18 years of age who underwent anesthesia between April 28 and September 30, 2020 at a large, academic pediatric hospital. Each child with a positive SARS-CoV-2 test within the prior 10 days was matched to a patient with a negative SARS-CoV-2 test based on American Society of Anesthesiologists (ASA) physical status, age, gender, and procedure. Children who were intubated before the procedure, underwent organ transplant surgery, or had severe COVID-19 were excluded. The primary outcome was the risk difference of a composite of intra- or postoperative respiratory complications in children positive for SARS-CoV-2 compared to those with negative testing. Secondarily, we used logistic regression to determine the odds ratio for respiratory complications before and after adjustment using propensity scores weighting to adjust for possible confounders. Other secondary outcomes included neurologic, cardiovascular, hematologic, and renal complications, unanticipated postoperative admission to the intensive care unit, length of hospital stay, and mortality. During the study period, 9812 general anesthetics that had a preoperative SARS-CoV-2 test were identified. Sixty encounters occurred in patients who had positive SARS-CoV-2 testing preoperatively and 51 were included for analysis. The matched controls cohort included 99 encounters. A positive SARS-CoV-2 test was associated with a higher incidence of respiratory complications (11.8% vs 1.0%; risk difference 10.8%, 95% confidence interval [CI], 1.6-19.8; P = .003). After adjustment, the odds ratio for respiratory complications was 14.37 (95% CI, 1.59-130.39; P = .02) for SARS-CoV-2-positive children as compared to controls. There was no occurrence of acute respiratory distress syndrome, postoperative pneumonia, or perioperative mortality in either group. Pediatric patients with nonsevere SARS-CoV-2 infection had higher rates of perianesthetic respiratory complications than matched controls with negative testing. However, severe morbidity was rare and there were no mortalities. The incidence of complications was similar to previously published rates of perianesthetic complications in the setting of an upper respiratory tract infection. This risk persisted after adjustment for preoperative upper respiratory symptoms, suggesting an increased risk in symptomatic or asymptomatic SARS-CoV-2 infection.

Preoperative use of pirfenidone and reduced risk of postoperative severe respiratory complications in patients with idiopathic pulmonary fibrosis: Propensity score-matched analysis using a nationwide database in Japan.

Patients with idiopathic pulmonary fibrosis (IPF) often develop postoperative severe respiratory complications such as acute exacerbation. Pirfenidone, an oral anti-fibrotic drug, may reduce the incidence of such complications. However, the preventive effect of pirfenidone on postoperative severe respiratory complications remains unclear. We identified patients with IPF who underwent surgery with general anaesthesia from July 2010 to March 2018 using the Diagnosis Procedure Combination database. We compared the occurrence of postoperative severe respiratory complications (receiving mechanical ventilation under endotracheal intubation and/or intravenous infusion of a high-dose corticosteroid and in-hospital death within 30 days after surgery) between patients who did and did not receive preoperative treatment with pirfenidone. Pearson's chi-square test and logistic regression analysis fitted with a generalized estimating equation were conducted in 1:4 propensity score-matched patients. Among 631 patients identified, 19% were treated with pirfenidone before surgery. The 30-day mortality rate was 3.1% and 1.7% in the control patients (n= 510) and pirfenidone-treated patients (n= 121), respectively. In the propensity score-matched population, preoperative treatment with pirfenidone was significantly associated with a lower proportion of postoperative severe respiratory complications (OR: 0.24; 95% CI: 0.07-0.76; p= 0.015). In this Japanese nationwide cohort, preoperative treatment with pirfenidone was significantly associated with a lower risk of postoperative severe respiratory complications in patients with IPF. Preoperative pirfenidone may thus be useful in preventing postoperative severe respiratory complications in patients with IPF who are planning to undergo surgery with general anaesthesia.

Urgent need to take action on reducing postoperative respiratory complications

Post-surgical complications are common in general surgery patients and contribute to increases in mortality, length of stay, and need for an increased level of care at discharge [1,2]. Postoperative respiratory complications (PRCs), the second most common serious morbidity after cardiovascular events [3], are broadly defined as conditions affecting the respiratory tract that can adversely influence clinical course of the patient after surgery. PRCs occur commonly with incidence estimates of 3 -7.9% in general surgery, have major adverse effects on patients, and are difficult to predict.

Robotic Intraoperative Tracheobronchial Repair during Minimally Invasive 3-Stage Esophagectomy

Tracheobronchial injury (TBI) is an uncommon but potentially fatal event. Iatrogenic lesions during bronchoscopy, endotracheal intubation, or thoracic surgery are considered the most common causes of TBI. When TBI is detected during surgery, concomitant surgical treatment is recommended. Herein we present a case of successful robotic primary repair of iatrogenic tracheal and left bronchial branch tears during a robot-assisted hybrid 3-stage esophagectomy after neoadjuvant chemoradiotherapy. A robotic approach can facilitate the repair of this injury while reducing both the potential risk of conversion to open surgery and the associated increased risk of postoperative respiratory complications.

Respiratory complications after surgery in Vietnam: National estimates of the economic burden

BackgroundEstimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking. MethodsWe used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits. FindingsPostoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications. InterpretationThe economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients. FundingThe authors did not receive any funds for conducting this study

Non-Invasive Respiratory Support for Management of the Perioperative Patient: A Narrative Review.

Non-invasive respiratory support including high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) is routinely used in the perioperative period. The aim of this narrative review was to discuss some of the existing literature on perioperative non-invasive respiratory support outlining its potential roles in each of the three perioperative periods (pre-, intra- and postoperatively) and to propose the way forward. During induction of anesthesia, non-invasive ventilation (NIV) was associated with improved ventilatory variables and reduced risk of postoperative respiratory complications. HFNO did not seem to confer an advantage in terms of peri-intubation hypoxemia. Intraoperative data on NIV are scarce. Upper airway obstruction and worsening hypoventilation are two risks associated with its use. Compared with conventional oxygenation, HFNO is associated with a reduced risk of hypoxemia. Postoperative NIV has been associated with improved arterial blood gases and a reduced reintubation rate, but no difference was reported for mortality, hospital length of stay, rate of anastomotic leakage, pneumonia-related complications and sepsis or infections. Head-to-head comparison of HFNO versus BiPAP showed no advantage to either mode of support. In the preoperative setting, NIV seems to be associated with improved clinical outcomes in specific patient subgroups (obesity, pregnancy). In the postoperative setting, both NIV and HFNO were associated with lower reintubation rates. The literature has provided little evidence regarding the use of non-invasive ventilatory support in other patient subgroups or intraoperatively. There is also little literature regarding the appropriateness of combining different modes of support. In the next years, the combination of several modes of respiratory support should be assessed in targeted populations.

The problem of postoperative respiratory depression.

Postsurgical recovery is influenced by multiple pre-, intra- and perioperative pharmacotherapeutic interventions, including the administration of medications that can induce respiratory depression postoperatively. We present a succinct overview of the topic, including the nature and magnitude of the problem, contributing factors, current limited options, and potential novel therapeutic approach. Pre-, intra- and perioperative medications are commonly administered for anxiety, anaesthesia, muscle relaxation and pain relief among other reasons. Several of the medications alone or in joint-action can be additive or synergistic producing respiratory depression. Given the large number of surgical procedures that are performed each year, even a small percentage of postoperative respiratory complications translates into a large number of affected patients. Due to the large number of surgeries performed each year, and the variety of medications used before, during, and after surgery, the occurrence of postoperative respiratory depression is surprisingly common. It is a significant medical problem and burden on hospital resources. There is a need for new strategies to prevent and treat the acute and collateral problems associated with postoperative respiratory depression.

Race and major pulmonary complications following inpatient pediatric otolaryngology surgery.

Compared to their white peers, black children are more likely to experience serious respiratory complications in the perioperative period. Whether a racial difference exists in the occurrence of late postoperative respiratory complications is largely unknown. Here, we evaluated a multi-institutional cohort of children who underwent various elective otolaryngology procedures to examine the racial differences in major postoperative pulmonary complications. We performed a retrospective analysis of elective inpatient otolaryngology cases from the National Surgical Quality Improvement Program (2012-2018). We used propensity score matching of black to white patients to compare the risk of postoperative pulmonary complications, defined as the occurrence of either pneumonia, unplanned reintubation, or prolonged postoperative mechanical ventilation. The matched cohort was comprised of 4786 black and white patients (2393 of each race). Black children were more likely to develop postoperative pulmonary complications compared to white peers (29.3% vs. 24.2%; odds ratio: 1.38; 95% confidence interval: 1.20, 1.59; P-value<.001). Furthermore, black children were almost two times more likely to require unplanned postoperative reintubation, relative to their white peers (2.6% vs. 1.3%; odds ratio: 2.07; 95% confidence interval: 1.33, 3.22; P-value<.001). Similarly, black children were estimated to have 37% relative greater odds of requiring prolonged mechanical ventilation (28.6% vs. 23.7%; 95% confidence interval: 1.19, 1.58; P-value<.001). Finally, being of black race conferred greater odds of requiring prolonged hospital length of stay, relative to being of white race (38.6% vs. 34.5%; odds ratio:1.24; 95% confidence interval: 1.09, 1.42; P-value=.004). Black children undergoing elective otolaryngological surgery are more likely to develop major postoperative pulmonary complications.

Comparative Study between Laparoscopic and Open Cholecystectomy: Complications and Management

Introduction: Laparoscopic cholecystectomy (LC) is currently the most widely used surgical procedure for the treatment of gallstones. The aim of the study was to analyze and compare the postoperative results of patients undergoing laparoscopic cholecystectomy or open cholecystectomy (OC) with regard to complications, recovery time and hospital stays.&#x0D; Materials and Methods: This is a retrospective study which was conducted at the General Hospital Khulna and some of the private Hospital in Khulna City from January 2015 to December 2019. This study which analyzed among 950 patients, 20-65 years old, diagnosed with gallstones undergoing LC or OC. We evaluated postoperative respiratory complications, surgical site infection, deep vein thrombosis, time to oral feeding and ambulation, use of antibiotics and duration of the postoperative period.&#x0D; Results: We analyzed 570(60%) patients undergoing LC and 380 (40%) OC. Most patients were female (55%). Patients' comorbidities were hypertension (12.8%), diabetes mellitus (4.5%) and asthma (1.00%). LC resulted in lower prevalence of postoperative complications (2.8%) than OC (3.4%). Postoperative hospitalization for 2-3 days was found in LC patients and 5-7 days in OC.&#x0D; Conclusion: Laparoscopic cholecystectomy showed higher benefits for patients with lower prevalence of postoperative complications, feeding earlier and shorter mean hospital stay compared with open cholecystectomy.&#x0D; Medicine Today 2021 Vol.33(1): 19-21

The Effect of Ventilation with Individualized Positive End-Expiratory Pressure on Postoperative Atelectasis in Patients Undergoing Robot-Assisted Radical Prostatectomy: A Randomized Controlled Trial.

For patients undergoing robot-assisted radical prostatectomy, the pneumoperitoneum with a steep Trendelenburg position could worsen intraoperative respiratory mechanics and result in postoperative atelectasis. We investigated the effects of individualized positive end-expiratory pressure (PEEP) on postoperative atelectasis, evaluated using lung ultrasonography. Sixty patients undergoing robot-assisted radical prostatectomy were randomly allocated into two groups. Individualized groups (n = 30) received individualized PEEP determined by a decremental PEEP trial using 20 to 7 cm H2O, aiming at maximizing respiratory compliance, whereas standardized groups (n = 30) received a standardized PEEP of 7 cm H2O during the pneumoperitoneum. Ultrasound examination was performed on 12 sections of thorax, and the lung ultrasound score was measured as 0–3 by considering the number of B lines and the degree of subpleural consolidation. The primary outcome was the difference between the lung ultrasound scores measured before anesthesia induction and just after extubation in the operating room. An increase in the difference means the development of atelectasis. The optimal PEEP in the individualized group was determined as the median (interquartile range) 14 (12–18) cm H2O. Compared with the standardized group, the difference in the lung ultrasound scores was significantly smaller in the individualized group (−0.5 ± 2.7 vs. 6.0 ± 2.9, mean difference −6.53, 95% confidence interval (−8.00 to −5.07), p < 0.001), which means that individualized PEEP was effective to reduce atelectasis. The lung ultrasound score measured after surgery was significantly lower in the individualized group than the standardized group (8.1 ± 5.7 vs. 12.2 ± 4.2, mean difference −4.13, 95% confidence interval (−6.74 to −1.53), p = 0.002). However, the arterial partial pressure of the oxygen/fraction of inspired oxygen levels during the surgery showed no significant time-group interaction between the two groups in repeated-measures analysis of variance (p = 0.145). The incidence of a composite of postoperative respiratory complications was comparable between the two groups. Individualized PEEP determined by maximal respiratory compliance during the pneumoperitoneum and steep Trendelenburg position significantly reduced postoperative atelectasis, as evaluated using lung ultrasonography. However, the clinical significance of this finding should be evaluated by a larger clinical trial.

Uniportal versus three-port video-assisted thoracoscopic surgery for non-small cell lung cancer: A retrospective study.

BackgroundTo investigate the uniportal video‐assisted thoracoscopic surgery (VATS) technique and safety of non‐small cell lung cancer (NSCLC) patients treated with uniportal and three‐port VATS.MethodsWe retrospectively evaluated 146 consecutive patients with NSCLC who underwent VATS lobectomy between January 2018 and May 2018. The general clinical date, perioperative data and life quality were individually compared and analyzed between the two groups.ResultsIntraoperative blood loss was significantly lower in the uniportal than in the three‐port group (p = 0.035), and significantly shorter chest tube drainage and postoperative hospital stay durations were found in the uniportal than in the three‐port group (p = 0.022 and p = 0.008). The postoperative 24 and 72 h numerical rating scale (NRS) scores were significantly lower in the uniportal group than in the three‐port group (p < 0.001 and p < 0.001). There were no significant differences between the two groups in the number or stations of total lymph node dissected (p = 0.222 and p = 0.159). There were no significant differences between the two groups in the postoperative total or respiratory complications (p = 0.917 and p = 0.930).ConclusionsUniportal VATS is a safe and effective alternative for patients with NSCLC. It is a preferable option for appropriate cases as it is conducive to patients’ postoperative recovery and quality of life.

Post-operative follow-up of 150 patients with sentinel lymph node biopsy under tumescence local anesthesia.

Sentinel lymph node biopsy (SLNB) is useful for staging of patients with melanoma. Although SLNB is mostly performed under general anesthesia (GA), tumescence local anesthesia (TLA) can also be used. However, less data are available regarding feasibility of SLNB under TLA. Here we present a post-operative follow-up of 150 patients. We prospectively analyzed data from 150 patients with primary cutaneous malignant melanoma. We assessed pain, post-operative complications and patients' satisfaction after SLNB under TLA. 32% of the patients reported post-operative pain within the first 48h after SLNB. Seroma was the most frequent complication, as 29 seromas after SLNB were observed. Wound infection was observed in 3.3% of the patients. 98.7% of the patients were satisfied with SLNB under TLA. SLNB under TLA is a safe and feasible option and should be considered for patients with melanoma. Especially with multimorbid or elderly patients, the risks of GA can be avoided.

Dynamic perfusion digital radiography for predicting pulmonary function after lung cancer resection

BackgroundAccurate prediction of postoperative pulmonary function is important for ensuring the safety of patients undergoing radical resection for lung cancer. Dynamic perfusion digital radiography is an excellent and easy imaging method for detecting blood flow in the lung compared with the less-convenient conventional lung perfusion scintigraphy. As such, the present study aimed to confirm whether dynamic perfusion digital radiography can be evaluated in comparison with pulmonary perfusion scintigraphy in predicting early postoperative pulmonary function and complications.MethodsDynamic perfusion digital radiography and spirometry were performed before and 1 and 3 months after radical resection for lung cancer. Correlation coefficients between blood flow ratios calculated using dynamic perfusion digital radiography and pulmonary perfusion scintigraphy were then confirmed in the same cases. In all patients who underwent dynamic perfusion digital radiography, the correlation predicted values calculated from the blood flow ratio, and measured values were examined. Furthermore, ppo%FEV1 or ppo%DLco values, which indicated the risk for perioperative complications, were examined.ResultsA total of 52 participants who satisfied the inclusion criteria were analyzed. Blood flow ratios measured using pulmonary perfusion scintigraphy and dynamic perfusion digital radiography showed excellent correlation and acceptable predictive accuracy. Correlation coefficients between predicted FEV1 values obtained from dynamic perfusion digital radiography or pulmonary perfusion scintigraphy and actual measured values were similar. All patients who underwent dynamic perfusion digital radiography showed excellent correlation between predicted values and those measured using spirometry. A significant difference in ppo%DLco was observed for respiratory complications but not cardiovascular complications.ConclusionsOur study demonstrated that dynamic perfusion digital radiography can be a suitable alternative to pulmonary perfusion scintigraphy given its ability for predicting postoperative values and the risk for postoperative respiratory complications. Furthermore, it seemed to be an excellent modality because of its advantages, such as simplicity, low cost, and ease in obtaining in-depth respiratory functional information.Trial registrationRegistered at UMIN on October 25, 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_his_list.cgi?recptno=R000033957Registration number: UMIN000029716

REsidual Neuromuscular Block Prediction Score Versus Train-of-Four Ratio and Respiratory Outcomes: A Retrospective Cohort Study.

Residual neuromuscular blockade is associated with an increased incidence of postoperative respiratory complications. The REsidual neuromuscular block Prediction Score (REPS) identifies patients at high risk for residual neuromuscular blockade after surgery. A total of 101,510 adults undergoing noncardiac surgery under general anesthesia from October 2005 to December 2018 at a tertiary care center in Massachusetts were analyzed for the primary outcome of postoperative respiratory complications (invasive mechanical ventilation requirement within 7 postoperative days or immediate postextubation desaturation [oxygen saturation {Spo2} <90%] within 10 minutes). The primary objective was to assess the association between the REPS and respiratory complications. The secondary objective was to compare REPS and train-of-four (TOF) ratio <0.90 on the strength of their association with respiratory complications. A high REPS (≥4) was associated with an increase in odds of respiratory complications (adjusted odds ratio [OR], 1.13 [95% confidence interval {CI}, 1.06-1.21]; P < .001). In 6224 cases with available TOF ratio measurements, a low TOF ratio (<0.9) was associated with respiratory complications (adjusted OR, 1.43 [95% CI, 1.11-1.85]; P = .006), whereas a high REPS was not (adjusted OR, 0.96 [95% CI, 0.74-1.23]; P = .73) (P = .018 for comparison between ORs). The REPS may be implemented as a screening tool to encourage clinicians to use quantitative neuromuscular monitoring in patients at risk of residual neuromuscular blockade. A positive REPS should be followed by a quantitative assessment of the TOF ratio.

Identifying high dose neostigmine as arisk factor for post-operative respiratory complications: acase-control study.

Neostigmine, an acetylcholinesterase inhibitor, is used to reverse the effects of non-depolarizing neuromuscular blocking agents. Inappropriate dosing of neostigmine can lead to post-operative respiratory complications. Post-operative respiratory complications are associated with major morbidity and mortality. The purpose of this case-control study was to determine neuromuscular blockade-related risk factors associated with post-operative respiratory complications (specifically, reintubation, respiratory insufficiency, hypoxia, and/or aspiration). We performed an Institutional Review Board-approved case-control study of all patients who underwent ageneral anesthetic requiring neuromuscular blockade at Tufts Medical Center between March 22, 2013 and June 1, 2019. Cases were patients who experienced post-operative complications. We identified 58 controls and 116 cases from adatabase of 130,178 patients during the 74-month study period. After adjusting for covariates, the administration of high dose neostigmine (> 60 mg per kg ideal body weight) was associated with increased odds of post-operative respiratory complications (odds ratio = 8.2; 95% CI: 2.5-26.6, P < 0.001). Rocuronium dose and the use of train-of-four peripheral nerve stimulator were not associated with post-operative respiratory complications. High dose neostigmine was identified as an independent risk factor for post-operative respiratory complications. Our study suggests that inappropriate dosing of neostigmine continues to be aproblem despite growing evidence of an association with respiratory complications.

Effectiveness and safety evaluation of a cough stimulation device in early postoperative respiratory rehabilitation in cardiac surgery patients

To evaluate the effectiveness and safety of cough stimulation using the mechanical in- and exsufflator in the early postoperative period in cardiac surgery patients. The study included 37 patients; mean age was 57±12.3 years. Inclusion criteria: age over 18 years; post-extubation spontaneous breathing; fully conscious and cooperative; adequate gas exchange with oxygen therapy; adequate pain control (2 points or less on 10-point visual analogue scale). Exclusion criteria: need for re-intubation and mechanical ventilation; noninvasive mask ventilation; high-flow oxygen therapy; acute cerebrovascular event; uncontrolled bleeding; heart failure (inotropic score over 10); shock; need of extracorporeal blood purification; neuromuscular disease; pneumothorax, hydro- or hemothorax. Cough stimulation was performed using the mechanical in- and exsufflator Comfort Cough Plus («Seoil Pacific Corporation», Republic of Korea). The device provides cough stimulation after high-frequency vibrations transmitted through a special vest and lung tissue recruiting by changing the airways pressure of the gas mixture, delivered through the anesthesia face mask. Cough stimulation device use was associated with an increase in the cough effectiveness; the number of patients with productive cough increased 8-fold, from 4 (10.8%) to 32 (86.4%), p=0.0000. The increase of blood oxygen saturation (SpO2) on room air from 92% to 96% (p=0.000001) and inspiratory capacity (IC) from 750 mL to 1200 mL (p=0.000002) was observed. The number of patients with IC of 1200-1500 mL increased 3-fold, and those with an IC over 1500 mL increased 2.6-fold. The proportion of patients with low oxygenation (SpO2 less than 92%) decreased 5-fold after the procedure (p=0.0011). Good tolerability and no side effects of the procedure were noted in all patients. Impaired sputum expectoration early after cardiac surgery is observed in most patients and may cause low oxygenation. The main effects of the cough stimulation device were improvement of sputum expectoration and an increase in oxygenation. An increase in blood oxygen saturation and inspiratory capacity after a single procedure with this device was demonstrated. It resulted in a significantly decreased proportion of patients with respiratory insufficiency. No adverse effects of the procedure were observed.

Perioperative Predictive Markers for Recurrence of Esophageal Cancer after Esophagectomy

Introduction: We studied whether perioperative nutritional, immunological factors or postoperative inflammatory responses predicted esophageal cancer (EC) progression and prognosis in patients who received esophagectomies. Methods: We evaluated preoperative prognostic nutritional index (PNI), BMI, neutrophil-to-lymphocyte ratio (NLR), intraoperative blood loss, postoperative C-reactive protein (CRP) max, recurrence-free survival (RFS), and overall survival (OS) in 111 patients with pStage I–IV squamous cell EC who received esophagectomies. Optimal cutoff values for each continuous parameter were determined by receiver operating characteristic curves and Youden indices. Univariate and multivariate Cox analyses were used to derive independent prognostic factors. Propensity score matching using inverse probability of treatment weighting was used in groups divided by Youden indices, as appropriate. Results: Cutoff values of continuous variables were NLR: 2.27, PNI: 44.2, blood loss: 159 mL, and CRPmax: 21.7 mg/dL. In multivariate analyses, PNI, CRPmax, and intraoperative blood loss were independent prognostic factors for OS and RFS. Among patients with stage II–IV disease, low PNI was associated with shorter RFS. Postoperative respiratory complications were associated with both higher CRP and shorter RFS. Discussion/Conclusions: Low preoperative PNI and high postoperative inflammatory response were associated with postoperative EC progression after esophagectomy. Preoperative nutritional interventions or suppression of postoperative inflammatory response, including respiratory complications, may improve patient prognosis.

Video-Assisted Thoracic Surgery for Residual Aneurysm after Total Arch Replacement

Background: Residual aneurysms after graft replacement are rare, but they can be detrimental if they are saccular and large. The etiology of residual aneurysms remains unknown, and their management is controversial. One treatment option is late open surgical conversion; however, postoperative respiratory complications resulting from the dissection of pleural adhesions, which is frequently necessary with this approach, are often unavoidable. Case presentation: Herein, we report a case of open surgical repair of a residual distal aortic arch aneurysm that occurred after total arch replacement and thoracic endovascular aortic repair. Contrast-enhanced magnetic resonance imaging was not possible in this case due to the patient’s severe renal dysfunction; however, contrast-enhanced computed tomography using minimal contrast did not detect remarkable leakage through the graft or stent graft into the aneurysm. Late open surgical conversion using video-assisted thoracic surgery was performed by thoracic surgeons, and the adhesion between the aortic wall and the lung was safely and effectively dissected. Because there was no significant pulsation or evidence of feeding arteries in the aortic wall, the aortic wall was opened carefully. No bleeding or backflow from any branch arteries into the aneurysm was noted, so the aortic wall was ligated with continuous sutures. The patient recovered without experiencing any major complications. Conclusions: This case report demonstrates that video-assisted thoracic surgery is safe and effective for late open conversion in cases of residual aneurysm; furthermore, this case suggests that video-assisted thoracic surgery may be particularly beneficial for the dissection of adhesions between the aortic wall and lung in these cases.

Transcatheter Aortic Valve Replacement vs Surgical Replacement in Patients With Pure Aortic Insufficiency

ObjectiveTo compare the outcomes of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients with pure aortic insufficiency (PAI). BackgroundThe treatment of choice for patients with severe symptomatic PAI is SAVR. However, not all patients are candidates for surgery because of comorbidities or are deemed high risk for surgery. As a result, TAVR is being used as an off-label procedure in some patients with PAI. Patients and MethodsWe analyzed the National Inpatient Sample database from January 1, 2016, to December 31, 2017, using the International Classification of Diseases, 10th Revision. Inclusion criteria were patients with aortic valve insufficiency undergoing either TAVR or SAVR. Patients with concomitant aortic stenosis, or history of infective endocarditis, and those below the age of 18 years were excluded. ResultsA total of 14,720 patients with PAI underwent valve replacement. Of those, 6.2% underwent TAVR. The TAVR group was significantly older (median age 78 years vs 64 years; P <.001). There was no evidence of a difference in in-hospital mortality between the 2 groups. However, after adjustment, patients in the TAVR group were associated with favorable outcomes in terms of acute kidney injury, cardiogenic shock, postoperative respiratory complications, and length of stay. On the other hand, those in the SAVR group were less likely to need permanent pacemakers. ConclusionThere was no evidence of a significant statistical difference in in-hospital mortality between patients with PAI treated by either SAVR or TAVR, both in unmatched and propensity-matched cohorts. TAVR could be considered for patients with PAI who are not candidates for surgery.