Postoperative Respiratory Failure Research Articles

Safety and learning curve of Da Vinci robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of obesity patients

Objective: To investigate the safety and learning curve of Da Vinci robotic single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in the treatment of obesity patients. Methods: A descriptive case series study was performed. Clinical data of obesity patients who were treated with Da Vinci robotic SADI-S in China-Japan Union Hospital of Jilin University from March 2020 to May 2021 were analyzed retrospectively. Case inclusion criteria: (1) uncomplicated obese patients with body mass index (BMI)≥37.5 kg/m(2); (2) patients with BMI of 28 to <37.5 kg/m(2) complicated with type 2 diabetes or two metabolic syndrome components, or obesity comorbidities; (3) patients undergoing SADI-S by Da Vinci robotic surgery system. Those who received other bariatric procedures other than SADI-S or underwent Da Vince robotic SADI-S as revisional operation were excluded. A total of 77 patients were enrolled in the study, including 31 males and 46 females, with median age of 33 (18-59) years, preoperative body weight of (123.0±26.2) kg, BMI of (42.2±7.1) kg/m(2) and waistline of (127.6±16.3) cm. According to the order of operation date, the patients were numbered as 1-77. The textbook outcome (TO) and Clavien-Dindo grading standard were used to analyze the clinical outcome of each patient and to classify surgical complications, respectively. The standard of textbook outcome was as follows: the operative time less than or equal to the 75th percentile of the patient's operation time (210 min); the postoperative hospital stay less than or equal to the 75th percentile of the patient's postoperative hospital stay (7 d); complication grade lower than Clavien grade II; no readmission; no conversion to laparotomy or death. The patient undergoing robotic SADI-S was considered to meet the TO standard when meeting the above 5 criteria. The TO rate was calculated by cumulative sum analysis (CUSUM) method. The curve was drawn by case number as X-axis and CUSUM (TO rate) as Y-axis so as to understand the learning curve of robotic SADI-S. Results: The operative time of 77 robotic SADI-S was (182.9±37.5) minutes, and the length of postoperative hospital stay was 6 (4-55) days. There was no conversion to laparotomy or death. Seven patients suffered from complications (7/77, 9.1%). Four patients had grade II complications (5.2%), including one with duodeno-ileal anastomotic leakage, one with abdominal bleeding, one with peritoneal effusion and one with delayed gastric emptying; two patients were grade IIIb complications (2.6%) and both of them were diagnosed with gastric leakage; one patient was grade IV complication diagnosed with postoperative respiratory failure (1.3%), and all of them were cured successfully. A total of 51 patients met the textbook outcome standard, and the TO rate was positive and was steadily increasing after the number of surgical cases accumulated to the 46th case. Taking the 46th case as the boundary, all the patients were divided into learning stage group (n=46) and mastery stage group (n=31). There were no significant differences between the two groups in terms of gender, age, weight, body mass index, waist circumference, ASA classification, standard liver volume, operative time and morbidity of postoperative complication (all P>0.05). The percent of abdominal drainage tube in learning stage group was higher than that in mastery stage group (54.3% versus 16.1%, P<0.05). The length of postoperative hospital stay in learning stage group was longer than that in mastery stage group [6 (4-22) d versus 6 (5-55) d, P<0.05)]. Conclusion: The Da Vinci robotic SADI-S is safe and feasible with a learning curve of 46 cases.

Perioperative Management of Patients With Myasthenia Gravis Undergoing Robotic-Assisted Thymectomy—A Retrospective Analysis and Clinical Evaluation

Postoperative myasthenic crisis with respiratory failure is a potentially lethal complication, warranting careful perioperative planning and extended postoperative surveillance of patients. Data on the incidence of postoperative respiratory failure and optimal management of patients after robotic-assisted thymectomy are limited. The objective of this study was to evaluate the incidence of respiratory complications and the need for intensive care unit (ICU) capacities after robotic-assisted thymectomy in patients with myasthenia gravis. Retrospective cohort study. Single University hospital in Vienna, Austria, from January 2014 to December 2019. The authors included adult patients who underwent robotic-assisted thymectomy due to myasthenia gravis. Of 72 patients, 4 patients (5.6%) developed postoperative respiratory failure, needing noninvasive ventilation/intubation. Respiratory failure occurred within the first hours after extubation when patients still were under surveillance in the recovery room or in the ICU. One patient (1.4%) suffered from worsened myasthenic symptoms several days after surgery, and was treated with plasmapheresis. Sixty-five patients (90.3%) were extubated in the operating room, 35 of these (48.6%) were transferred to the ICU, and 30 patients (41.7%) primarily were transferred to the recovery room. Fourteen patients (19.4%) were transferred to the surgical ward after extended observation in the recovery room. Furthermore, after implementation of a standardized perioperative algorithm in 2020, a reduction of ICU admissions was achieved. After careful patient selection, planning, and postoperative patient evaluation, robotic-assisted thymectomy can be performed safely without postoperative surveillance in an ICU.

Management of Complications Associated With Gorham-Stout Disease: Case Report and Review of the Literature

This case report describes the course of a patient diagnosed with Gorham-Stout Disease and reviews known complications and treatment options for this rare condition. An emphasis is placed on potential multi-systemic complications that may occur including surgical complications, obstructive sleep apnea, post-operative airway obstruction, respiratory failure and cardiac arrest.

Systemic Heparin Administration Versus No Heparin in Open Ruptured Abdominal Aortic Aneurysm Repair: A Propensity Score-matched Analysis

The role of systemic heparin administration at the time of open ruptured abdominal aortic aneurysm repair remains unknown. Our objectives were to compare postoperative outcomes in patients receiving nonfractionated heparin versus no heparin at the time of open ruptured abdominal aortic aneurysm (rAAA) repair in the Vascular Quality Initiative database. All patients who underwent open repair of rAAA between 2003 and 2020 in the Vascular Quality Initiative database were identified. 1:1 propensity score (PS) matching on 25 clinically relevant covariates was performed to match patients who received heparin to those who did not receive heparin. The primary outcome was all-cause mortality. The secondary outcomes were safety end points and included postoperative mortality, blood loss volume, number of packed red blood cell (pRBC) transfused, and complications (cardiac, renal, and respiratory). Survival was examined using Kaplan-Meier curves and compared using a Cox-proportional hazard model. Of 2410 patients that underwent open rAAA between 2003-2020, 1853 received heparin and 557 did not receive heparin. Before PS matching, patients that received heparin were younger (71.4 years vs 73.1 years), and less likely to present a American Society of Anesthesiologists class V at the time surgery (37.5% vs 48.7%). After PS matching, 519 pairs of patients had similar baseline characteristics and presentation (Table). Postoperative mortality was lower in the heparin group (37.6% vs 55.3%; P < .001). Estimated blood loss was 850 mL (95% confidence interval [CI], –350 to –1375 mL) lower in the heparin group and the median number of pRBC transfused was 2 units lower in the heparin group (interquartile range, –1 to –2.5; P < .001). There were no differences in postoperative renal dysfunction, respiratory failure, or congestive heart failure between the two groups. Overall, long-term survival was higher for patients who received heparin (hazard ratio, 0.62; 95% confidence interval, 0.53-0.72; P < .0001) at 10 years (Figure). Patients who received systemic heparin administration at the time of open rAAA repair showed significant survival benefit within 30 days and at 10 years. Heparin administration may have afforded a mortality benefit or been a surrogate for healthier and less moribund patient at the time of the procedure. Importantly, the administration of heparin did not result in increased bleeding or postoperative complications in this high-risk cohort.TableBaseline characteristics of patients before and after propensity score (PS) matchingAll patientsPS-matched patientsNo heparin (n = 557)Heparin (n = 1853)SMDNo heparin (n = 519)Heparin (n = 519)SMDDemographics Age, years, mean (SD)73.13 (8.73)71.47 (9.55)0.1872.99 (8.82)72.98 (9.10)<0.001 Female139 (25.0)421 (22.7)0.052131 (25.2)125 (24.1)0.027 Race0.0480.055Non-Whitea26 (7)103 (5.6)24 (4.6)19 (3.7)White509 (91.4)1668 (90.0)473 (91.1)475 (91.5)Unknown22 (3.9)82 (4.4)22 (4.2)25 (4.8) BMI, kg/m2, mean (SD)28.19 (5.80)28.14 (6.16)0.00928.22 (5.88)28.35 (6.30)0.021Comorbidities Hypertension421 (75.6)1426 (77.0)0.032391 (75.3)392 (75.5)0.004 Congestive heart failure44 (7.9)161 (8.7)0.02943 (8.3)41 (7.9)0.014 Chronic obstructive pulmonary disease162 (29.1)599 (32.3)0.07158 (30.4)156 (30.1)0.008 Preoperative creatinine, mg/dL, mean (SD)1.44 (0.83)1.38 (0.75)0.0691.44 (0.86)1.44 (0.74)0.01 Dialysis5 (0.9)12 (0.6)0.0295 (1.0)7 (1.3)0.036 Preoperative smoking status0.2690.055Never110 (19.7)297 (16.0)101 (19.5)105 (20.2)Prior175 (31.4)604 (32.6)166 (32.0)176 (33.9)Current238 (42.7)922 (49.8)228 (43.9)216 (41.6)Missing34 (6.1)30 (1.6)24 (4.6)22 (4.2) Prior coronary revascularization0.4410.088None283 (50.8)1207 (65.1)274 (52.8)265 (51.1)PCI or CABG81 (14.5)351 (18.9)79 (15.2)96 (18.5)Missing193 (34.6)295 (15.9)166 (32.0)158 (30.4) Prior aortic surgery40 (7.2)220 (11.9)0.1640 (7.7)39 (7.5)0.007Clinical presentation Hemoglobin, mg/dL, mean (SD)11.11 (2.29)11.68 (2.37)0.24511.15 (2.30)11.15 (2.28)0.004 Maximum AAA diameter, mm, mean (SD)79.82 (18.96)78.01 (31.77)0.06979.83 (19.12)81.55 (48.98)0.046 Concomitant iliac aneurysm115 (20.6)405 (21.9)0.03110 (21.2)121 (23.3)0.051 Mental status at presentation0.5240.032Normal298 (53.5)1425 (76.9)291 (56.1)292 (56.3)Disoriented108 (19.4)229 (12.4)102 (19.7)107 (20.6)Unconscious151 (27.1)199 (10.7)126 (24.3)120 (23.1) Systolic blood pressure <70 mm Hg278 (49.9)1361 (73.4)0.499274 (52.8)275 (53.0)0.004 Cardiac arrest150 (26.9)161 (8.7)0.491118 (22.7)110 (21.2)0.037 ASA class0.490.03811 (0.2)4 (0.2)1 (0.2)1 (0.2)22 (0.4)12 (0.6)2 (0.4)3 (0.6)320 (3.6)123 (6.6)19 (3.7)21 (4.0)4164 (29.4)886 (47.8)161 (31.0)159 (30.6)5271 (48.7)695 (37.5)251 (48.4)253 (48.7)Missing99 (17.8)133 (7.2)85 (16.4)82 (15.8) Time from symptom onset to incision, hours, mean (SD)16.65 (55.41)22.01 (47.19)0.10417.16 (57.28)16.45 (28.89)0.016Preoperative medications Aspirin203 (36.4)758 (40.9)0.092190 (36.6)199 (38.3)0.036 P2Y12 antagonist30 (5.4)176 (9.5)0.15730 (5.8)29 (5.6)0.008 Statin220 (39.5)780 (42.1)0.053205 (39.5)215 (41.4)0.039 Beta blocker229 (41.1)810 (43.7)0.053217 (41.8)212 (40.8)0.02 Anticoagulant or ACE-I/ARB0.480.03No216 (38.8)963 (52.0)211 (40.7)217 (41.8)Yes130 (23.3)574 (31.0)127 (24.5)128 (24.7)Missing211 (37.9)316 (17.1)181 (34.9)174 (33.5)Values are reported as number (%) unless otherwise indicated.AAA, Abdominal aortic aneurysm; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; ASA, American Society of Anesthesiologists; BMI, body mass index; CABG, coronary artery bypass graft; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; P2Y12, purinergic receptor; SD, standard deviation; SMD, standardized mean difference.aNon-White race includes Asian, Black, American Indian, Alaskan Native, Native Hawaiian, or other Pacific Islander. 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Outcomes and risk factors for delayed-onset postoperative respiratory failure: a multi-center case-control study by the University of California Critical Care Research Collaborative (UC3RC)

BackgroundFew interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF.MethodsThis was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF.ResultsAmong 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81–10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04–1.44), and maximum intraoperative peak inspiratory pressure per cm H20 (OR 1.14, 95% CI 1.06–1.22).ConclusionsWe identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation.

Incidence, Outcomes, and Risk Factors for Preincision Cardiac Arrest in Cardiac Surgery Patients.

We examined the incidence, postoperative outcomes, and patient-related factors associated with preincision cardiac arrest in patients undergoing cardiac surgery. We retrospectively examined adult patients undergoing elective or urgent cardiac surgery at the Cleveland Clinic between 2008 and 2019. The incidence of preincision cardiac arrest, defined as arrest between induction of general anesthesia and surgical incision, was reported. In a secondary analysis, we assessed the association between preincision cardiac arrest and major postoperative outcomes. In a tertiary analysis, we used adjusted linear regression models to explore the association between preincision cardiac arrest and prespecified patient risk factors, including severe left main coronary artery stenosis, left ventricular ejection fraction, moderate/severe right ventricular dysfunction, low-flow low-gradient aortic stenosis, and moderate/severe pulmonary hypertension. Preincision cardiac arrests occurred in 75 of 41,238 (incidence of 0.18%; 95% CI, 0.17-0.26) patients who had elective or urgent cardiac surgery. Successful cardiopulmonary resuscitation with return of spontaneous circulation or bridge to cardiopulmonary bypass occurred in 74 of 75 (98.6%) patients. Patients who experienced preincision cardiac arrest had significantly higher in-hospital mortality than those who did not (11% vs 2%; odds ratio [OR] (95% CI), 4.14 (1.94-8.84); P < .001). They were also more likely to suffer postoperative respiratory failure (46% vs 13%; OR [95% CI], 3.94 [2.40-6.47]; P < .001), requirement for renal replacement therapy (11% vs 2%; OR [95% CI], 3.90 [1.82-8.35]; P < .001), neurologic deficit (7% vs 2%; OR [95% CI], 2.49 (1.00-6.21); P = .05), and longer median hospital stay (15 vs 8 days; hazard ratio (HR) [95% CI], 0.68 [0.55-0.85]; P < .001). Reduced left ventricular ejection fraction (per 5% decrease) (OR [95% CI], 1.13 [1.03-1.22]; P = .006) and moderate/severe pulmonary hypertension (OR [95% CI], 3.40 [1.95-5.90]; P < .001) were identified as independent risk factors for cardiac arrest. Cardiac arrest after anesthetic induction is rare in cardiac surgical patients in our investigation. Though most patients are rescued, morbidity and mortality remain higher. Reduced left ventricular ejection fraction and moderate/severe pulmonary hypertension are associated with greater risk for preincision cardiac arrest.

Successful management of a mediastinum abscess with sternum destruction caused by MSSA bloodstream infection

BackgroundMultiple deep organ abscesses associated with Staphylococcus aureus bloodstream infection (SAB) have a high mortality rate, requiring rapid removal or drainage of infective foci with long-term appropriate antimicrobial therapy. Cases in which infective foci cannot be completely removed are challenging for their management.Case presentationA 77-year-old man developed multiple deep organ abscesses associated with SAB. The left anterior chest subcutaneous abscess continued into the right anterior mediastinum and had extensively destroyed the sternum. Necrotizing fasciitis was observed in the bilateral feet. The anterior mediastinum abscess was drained percutaneously, and the chest wall abscess was incised cautiously without causing an external pneumothorax. On the next day, right-sided pyothorax had developed, requiring pleural drainage. On the third day, debridement of anterior chest wall abscess followed by concurrent thoracoscopic pleural curettage and debridement of bilateral feet were performed. Thorough sternal debridement was not performed, considering the risk of respiratory failure due to the sternal defects. On the 24th day, sternum debridement and incisional drainage of sciatic rectus fossa abscess, which had been present since the time of admission, were performed to control persistent infection. The caudal half of the sternal body was resected, leaving the costal cartilage attachments. The general condition further improved without postoperative respiratory failure after the second surgery, leading to a transfer to the general ward on the 43rd day.ConclusionsWe successfully treated the severe multiple deep organ abscesses, including a mediastinum abscess with sternum destruction, by repeated removal of the infective foci while avoiding respiratory failure due to excessive debridement of the anterior chest wall, including the sternum.

Intraoperative protective mechanical ventilation in patients requiring emergency abdominal surgery: the multicentre prospective randomised IMPROVE-2 study protocol

IntroductionEmergency abdominal surgery is associated with a high risk of postoperative complications. One of the most serious is postoperative respiratory failure (PRF), with reported rates up to 20%–30% and attributable...

Machine learning-based modeling of acute respiratory failure following emergency general surgery operations.

BackgroundEmergency general surgery (EGS) operations are associated with substantial risk of morbidity including postoperative respiratory failure (PRF). While existing risk models are not widely utilized and rely on traditional statistical methods, application of machine learning (ML) in prediction of PRF following EGS remains unexplored.ObjectiveThe present study aimed to develop ML-based prediction models for respiratory failure following EGS and compare their performance to traditional regression models using a nationally-representative cohort.MethodsNon-elective hospitalizations for EGS (appendectomy, cholecystectomy, repair of perforated ulcer, large or small bowel resection, lysis of adhesions) were identified in the 2016–18 Nationwide Readmissions Database. Factors associated with PRF were identified using ML techniques and logistic regression. The performance of XGBoost and logistic regression was evaluated using the receiver operating characteristic curve and coefficient of determination (R2). The impact of PRF on mortality, length of stay (LOS) and hospitalization costs was secondarily assessed using generalized linear models.ResultsOf 1,003,703 hospitalizations, 8.8% developed PRF. The XGBoost model exhibited slightly superior discrimination compared to logistic regression (0.900, 95% CI 0.899–0.901 vs 0.894, 95% CI 0.862–0.896). Compared to logistic regression, XGBoost demonstrated excellent calibration across all risk levels (R2: 0.998 vs 0.962). Congestive heart failure, neurologic disorders, and coagulopathy were significantly associated with increased risk of PRF. After risk-adjustment, PRF was associated with 10-fold greater odds (95% confidence interval (CI) 9.8–11.1) of mortality and incremental increases in LOS by 3.1 days (95% CI 3.0–3.2) and $11,900 (95% CI 11,600–12,300) in costs.ConclusionsLogistic regression and XGBoost perform similarly in overall classification of PRF risk. However, due to superior calibration at extremes of risk, ML-based models may prove more useful in the clinical setting, where probabilities rather than classifications are desired.

Mechanical Power during General Anesthesia and Postoperative Respiratory Failure: A Multicenter Retrospective Cohort Study.

Mechanical power during ventilation estimates the energy delivered to the respiratory system through integrating inspiratory pressures, tidal volume, and respiratory rate into a single value. It has been linked to lung injury and mortality in the acute respiratory distress syndrome, but little evidence exists regarding whether the concept relates to lung injury in patients with healthy lungs. This study hypothesized that higher mechanical power is associated with greater postoperative respiratory failure requiring reintubation in patients undergoing general anesthesia. In this multicenter, retrospective study, 230,767 elective, noncardiac adult surgical out- and inpatients undergoing general anesthesia between 2008 and 2018 at two academic hospital networks in Boston, Massachusetts, were included. The risk-adjusted association between the median intraoperative mechanical power, calculated from median values of tidal volume (Vt), respiratory rate (RR), positive end-expiratory pressure (PEEP), plateau pressure (Pplat), and peak inspiratory pressure (Ppeak), using the following formula: mechanical power (J/min) = 0.098 × RR × Vt × (PEEP + ½[Pplat - PEEP] + [Ppeak - Pplat]), and postoperative respiratory failure requiring reintubation within 7 days, was assessed. The median intraoperative mechanical power was 6.63 (interquartile range, 4.62 to 9.11) J/min. Postoperative respiratory failure occurred in 2,024 (0.9%) patients. The median (interquartile range) intraoperative mechanical power was higher in patients with postoperative respiratory failure than in patients without (7.67 [5.64 to 10.11] vs. 6.62 [4.62 to 9.10] J/min; P < 0.001). In adjusted analyses, a higher mechanical power was associated with greater odds of postoperative respiratory failure (adjusted odds ratio, 1.31 per 5 J/min increase; 95% CI, 1.21 to 1.42; P < 0.001). The association between mechanical power and postoperative respiratory failure was robust to additional adjustment for known drivers of ventilator-induced lung injury, including tidal volume, driving pressure, and respiratory rate, and driven by the dynamic elastic component (adjusted odds ratio, 1.35 per 5 J/min; 95% CI, 1.05 to 1.73; P = 0.02). Higher mechanical power during ventilation is statistically associated with a greater risk of postoperative respiratory failure requiring reintubation.

Incidence and Risk Factors of Mortality in Nonagenarians and Centenarians After Intertrochanteric Fracture: 2-Year Follow-Up.

PurposeThe purpose of this study was to explore risk factors for mortality after intertrochanteric fracture (IF) surgery in nonagenarians and centenarians based on subgroups of follow-up time.Patients and MethodsA total of 144 nonagenarians and centenarians who underwent IF surgery between Jan. 2014 and Dec. 2018 were included. Data were compared between the mortality and the survival groups based on the subgroups of follow-up time in univariate, logistic regression, and Cox regression analyses.ResultsIn our study, the rates of mortality were 7.6%, 13.9%, and 28.5% at 6-month, 1-year, and 2-year follow-up, respectively. Univariate analysis showed that prolonged time from injury to surgery, more transfusion volume, lower hemoglobin (minimum), and complications (respiratory failure and anemia) were associated with mortality at 6-month follow-up. However, three factors were found to be related to mortality at 1-year and 2-year follow-up, respectively. Our results showed that postoperative respiratory failure and anemia were independent risk factors for mortality after IF surgery at 6-month in logistic regression analysis. However, postoperative respiratory failure was found as an independent risk factor for mortality at 1-year and 2-year follow-up. Moreover, Cox regression analysis showed that postoperative respiratory failure was an independent risk factor for mortality after IF surgery, which was consistent with results in logistic regression analysis.ConclusionPostoperative respiratory failure was an independent risk factor for mortality in nonagenarians and centenarians at any follow-up. Additionally, postoperative anemia was closely related to mortality. Preoperative measures should be taken to lower mortality.

Is D2 Lymphadenectomy Necessary in Elderly Gastric Cancer Patients? A Retrospective Study

Objective We retrospectively analyzed the validity of limited lymphadenectomy (D1 and D1+) in elderly gastric cancer patients. Summary of background data According to the aging trend in Japan, patients with gastric cancer are continuing to age. The extent of lymphadenectomy preferable for older patients is unclear. Methods The data of 35 and 52 patients ≥80 years old with cT2− or N(+) gastric cancer who underwent gastrectomy with D2 lymphadenectomy and limited lymphadenectomy, respectively, at 2 institutions between 2010 and 2019 were retrospectively reviewed. Results The patients who underwent limited lymphadenectomy were older and their Onodera prognostic nutritional indexes were poorer than those who underwent D2 lymphadenectomy, although the differences were not significant. After propensity score matching, 28 patients in each group were analyzed. No significant differences in postoperative complications, initial recurrence sites, or causes of death were observed between the 2 groups except for postoperative respiratory failure, which was more frequent after D2 lymphadenectomy. The median overall survival time after D2 and limited lymphadenectomy was 73.9 and 70.9 months, respectively, with a hazard ratio of 1.32 (P = 0.53). Conclusions D1+ or even D1 lymphadenectomy may be acceptable for patients ≥80 years old with advanced gastric cancer.

Treatment of acute respiratory failure: noninvasive mechanical ventilation

Background: Noninvasive ventilation (NIV) has been an important strategy to support patients with respiratory failure, while preventing complications assorted with invasive mechanical ventilation. Physicians need to be aware of the various roles of NIV and the challenges encountered in clinical practice.Current Concepts: Traditionally, the application of NIV has been well-known to be associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD) or acute pulmonary edema and those suffering from acute respiratory failure. However, despite some positive results of NIV treatment in patients with de novo hypoxemic respiratory failure such as acute pneumonia or acute respiratory distress syndrome, NIV failure (or delayed intubation) can have deleterious effects on patients outcomes. Besides, the aggravation of lung injury should also be taken into consideration when applied to patients exhibiting high respiratory drive. Nonetheless, NIV has potential for wide applications in various clinical situations such as facilitation of ventilator weaning, post-operative respiratory failure, or palliative treatment.Discussion and Conclusion: In addition to the strong evidence in patients with acute respiratory failure due to COPD or acute pulmonary edema, the NIV treatment can be potentially used for various clinical conditions. However, compared to European countries, the prevalence of NIV use continues to remain lower in South Korea. Nevertheless, when applied in appropriately selected patients in a timely manner, NIV treatment can be associated with improved patient outcomes.

Risks of postoperative respiratory failure in elderly patients after hip surgery: a retrospective study

BackgroundThe purpose of this retrospective study was to investigate the determinants of postoperative respiratory failure in elderly patients with hip fracture.MethodsThe subjects of this study were 663 elderly patients who had hip fracture and had been treated with hip surgery at our hospital from January 2014 to May 2020. According to the occurrence of postoperative respiratory failure, 626 patients with no respiratory failure were retrospectively included in the control group, and 37 cases combined with respiratory failure were enrolled in the PRF group. The clinical and surgical data of the two groups were collected and analyzed to evaluate the determinants of respiratory failure by logistic regression analysis.ResultsThere were no significant differences in the demographics and baseline variables including age, gender, fracture type and location between the groups (P > 0.05). All patients received hip surgery including total hip arthroplasty (THA), hemiarthroplasty (HA) and internal fixation with PFNA (proximal femoral nail anti-rotation). There were no significant differences in operative time and intraoperative blood loss between the groups (P > 0.05). However, close associations were found between pulmonary hypertension (univariate analysis: OR = 3.792, 95% CI = 1.421–10.203; multivariate analysis: OR = 1.132, 95% CI = 1.003–1.251), obstructive pulmonary disease (OR = 1.119, 95% CI = 1.009–1.238; multivariate analysis: OR = 13.298, 95% CI = 4.021–43.298), bronchiectasis and emphysema (OR = 4.949, 95% CI = 1.919–9.873; multivariate analysis: OR = 11.231, 95% CI = 187.87), and history of respiratory failure (OR = 6.098, 95% CI = 2.012–12.198; multivariate analysis: OR = 8.389, 95% CI = 2.391–21.982) with postoperative respiratory failure (P < 0.05).ConclusionPulmonary hypertension, obstructive pulmonary disease, bronchiectasis, emphysema, history of respiratory failure, and hypoproteinemia may be risk factors for postoperative respiratory failure in elderly patients with hip fracture.

Risk factors and outcomes of fatal respiratory events after esophageal cancer surgery from 2011 through 2018: a nationwide cohort study in South Korea.

Pulmonary complications are common after esophageal cancer surgery, but information regarding fatal respiratory events, such as postoperative acute respiratory distress syndrome (ARDS) and respiratory failure, is lacking. We aimed to investigate the prevalence, risk factors, and outcomes of fatal respiratory events after esophageal cancer surgery. We performed a retrospective population-based cohort study based on data from the National Health Insurance Service database in South Korea. All adult patients diagnosed with esophageal cancer who underwent esophageal surgery between January 2011 and December 2018 were included. A total of 7039 patients were included in the final analysis. Among them, 100 patients (1.4%) experienced fatal respiratory adverse events (ARDS, 55 patients [0.8%]; respiratory failure, 45 patients [0.6%]). On multivariable logistic regression, residence in rural areas (vs. urban areas) at the time of surgery, open thoracotomy (vs. video-assisted thoracoscopic surgery), and lower annual case volume were associated with a higher prevalence of fatal respiratory adverse events. Moreover, postoperative fatal respiratory adverse events were related to increased in-hospital mortality, 1year mortality, prolonged hospitalization, and increased total hospitalization costs. In South Korea, 1.4% of patients experienced fatal respiratory events (ARDS or respiratory failure) after esophageal cancer surgery. Some factors were revealed as risk factors for fatal respiratory events, and fatal respiratory events worsened clinical outcomes after esophageal cancer surgery.

Incorporating harms into the weighting of the revised Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator 90).

To reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome-related health states. National administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals. We estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator-eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the "average treatment effect in the treated" for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms. We estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012-2013 Centers for Medicare & Medicaid Services Medicare Fee-for-Service data. Including harms in the weighting scheme changed individual component weights from the original frequency-based weighting. In the reweighted composite, PSIs 11 ("Postoperative Respiratory Failure"), 13 ("Postoperative Sepsis"), and 12 ("Perioperative Pulmonary Embolism or Deep Vein Thrombosis") contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal-to-noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles). Reformulation of PSI 90 with harm-based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

Using Process Flow Disruption Analysis to Guide Quality Improvement.

Process flow describes the efficiency and consistency with which a process functions. Disruptions in surgical flow have been shown to be associated with an increase in error. Despite this, little experience exists in using surgical flow analysis to guide quality improvement (QI). In a 900-bed teaching hospital with an annual surgical volume of 24,000 cases, a 4-month observational study of process flow was done by experts in complex system evaluation. Identified flow disruptions were used to guide QI. Statistical analysis included descriptive and bivariate techniques. More than 200 unique process data points were evaluated. There was a high degree of variability in completion of 79 individual intraoperative data elements. Lack of completion of all elements of the time out was associated with number of times the operating room door opened during case (19, 11-27; p = 0.01). Flow disruptions were used to direct surgical QI. One example was a disruption affecting the use of Sugammadex. Resolving this flow disruption resulted in a 59% reduction in the incidence of postoperative respiratory failure (p < 0.01) and a direct and variable cost savings of $447,200 and $313,160, respectively, in the first 12 months. The use of process flow analysis to direct surgical quality initiatives is a novel approach that emphasizes system-level strategy. Resolving flow disruptions can lead to effective QI that embraces reliability by focusing attention on common processes rather than adverse events that may be unique and therefore difficult to apply broadly.

Postoperative prophylactic intermittent noninvasive ventilation versus usual postoperative care for patients at high risk of pulmonary complications: a multicentre randomised trial

BackgroundPulmonary complications are an important cause of morbidity and mortality after surgery. We evaluated the clinical effectiveness of noninvasive ventilation (NIV) in preventing postoperative acute respiratory failure. MethodsThis is an open, multicentre randomised trial that included patients at high risk of postoperative pulmonary complications after elective or semi-urgent surgery with an Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score ≥45. Patients were randomly assigned to intermittent prophylactic face-mask NIV for 6–8 h day−1 or usual postoperative care. The primary outcome was in-hospital acute respiratory failure within 7 days after surgery. Patients who underwent surgery and postoperative extubation were included in the modified intended-to-treat analysis. Results are presented as n (%) and odds ratios (ORs) with 95% confidence intervals. ResultsBetween November 2017 and October 2019, 266 patients were randomised and 253 included in the main analysis. Of these, 203 (80.2%) were male with a mean age of 68 (11) yr and an ARISCAT score of 53 (6); 237 subjects (93.7%) underwent cardiac or thoracic surgery. There were 125 patients allocated to prophylactic NIV and 128 to usual care. Unplanned treatment termination occurred in 58 subjects in the NIV group, which was linked to NIV discomfort for 36 subjects. There was no difference in the incidence of the primary outcome of postoperative acute respiratory failure between treatment groups (NIV: 30 of 125 subjects [24.0%] vs usual care: 35 of 128 subjects [27.3%]; OR 0.97 [0.90–1.04]; P=0.54). ConclusionsProphylactic NIV was difficult to implement after high-risk surgery because of low patient compliance. Prophylactic NIV did not prevent acute respiratory failure. Clinical trial registrationNCT 03629431 and EudraCT 2017-001011-36.

Liver Transplantation in Children and Impact of Intraoperative Goal Directed Therapies on Postoperative Outcome

Background: Liver transplantation is a hemorrhagic surgery with high postoperative complication rates in terms of organ dysfunction and infections. We conducted a retrospective observational monocentric study that had the objectives of determining predictors of postoperative outcome in children. In the initial cohort, 19 children underwent liver transplantation. A description of the postoperative outcomes of these patients was undertaken. Objective: To describe intraoperative and postoperative outcomes in children undergoing liver transplantation and to propose intraoperative management implementation measures for postoperative outcome improvement. Methods: Secondary analysis of liver transplanted patients included in the initial study. Results: There were 19 patients who underwent liver transplantation with a median age of 31[2-154] months. Five patients had re-operations (26.3%). Fourteen (73.7%) had intraoperative and/or postoperative complications. Five (26.3%) had intraoperative hemorrhagic shock. One (5.3%) had postoperative respiratory failure, one (5.3%) had postoperative multiple organ failure, two (10.5%) had postoperative neurologic failure and five (26.3%) had cardio-circulatory failure. One (5.3%) had postoperative pulmonary sepsis, five (26.3%) had postoperative abdominal sepsis, and six (31.6%) had postoperative septicemia. Intra-operative transfusion rate was 100%. In-hospital mortality rate was 10.5% (two patients). Conclusion: There were multiple postoperative adverse outcome predictors. Optimal intraoperative patient management with transfusion guided by point-of-care viscoelastic devices and goal-directed fluid and hemodynamic therapy with validated parameters and tools in children is a possible pathway to upgrade postoperative evolution in pediatric liver transplantation.

Reproducibility of Hospital Rankings Based on Centers for Medicare & Medicaid Services Hospital Compare Measures as a Function of Measure Reliability

Unreliable performance measures can mask poor-quality care and distort financial incentives in value-based purchasing. To examine the association between test-retest reliability and the reproducibility of hospital rankings. In a cross-sectional design, Centers for Medicare & Medicaid Services Hospital Compare data were analyzed for the 2017 (based on 2014-2017 data) and 2018 (based on 2015-2018 data) reporting periods. The study was conducted from December 13, 2020, to September 30, 2021. This analysis was based on 28 measures, including mortality (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), readmissions (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), and surgical complications (postoperative acute kidney failure, postoperative respiratory failure, postoperative sepsis, and failure to rescue). Measure reliability based on test-retest reliability testing. The reproducibility of hospital rankings was quantified by calculating the reclassification rate across the 2017 and 2018 reporting periods after categorizing the hospitals into terciles, quartiles, deciles, and statistical outliers. Linear regression analysis was used to examine the association between the reclassification rate and the intraclass correlation coefficient for each of the classification systems. The analytic cohort consisted of 28 measures from 4452 hospitals with a median of 2927 (IQR, 2378-3160) hospitals contributing data for each measure. The hospitals participating in the Inpatient Prospective Payment System (n = 3195) had a median bed size of 141 (IQR, 69-261), average daily census of 70 (IQR, 24-155) patients, and a median disproportionate share hospital percentage of 38.2% (IQR, 18.7%-36.6%). The median intraclass correlation coefficient was 0.78 (IQR, 0.72-0.81), ranging between 0.50 and 0.85. The median reclassification rate was 70% (IQR, 62%-71%) when hospitals were ranked by deciles, 43% (IQR, 39%-45%) when ranked by quartiles, 34% (IQR, 31%-36%) when ranked by terciles, and 3.8% (IQR, 2.0%-6.2%) when ranked by outlier status. Increases in measure reliability were not associated with decreases in the reclassification rate. Each 0.1-point increase in the intraclass correlation coefficient was associated with a 6.80 (95% CI, 2.28-11.30; P = .005) percentage-point increase in the reclassification rate when hospitals were ranked into performance deciles, 4.15 (95% CI, 1.16-7.14; P = .008) when ranked into performance quartiles, 1.47 (95% CI, 1.84, 4.77; P = .37) when ranked into performance terciles, and 3.70 (95% CI, 1.30-6.09; P = .004) when ranked by outlier status. In this study, more reliable measures were not associated with lower rates of reclassifying hospitals using test-retest reliability testing. These findings suggest that measure reliability should not be assessed with test-retest reliability testing.