Postoperative Respiratory Morbidity Research Articles

Association of preoperative COVID-19 and postoperative respiratory morbidity during the Omicron epidemic wave: the DROMIS-22 multicentre prospective observational cohort study

Preoperative COVID-19 has been associated with excess postoperative morbi-mortality. Consequently, guidelines were developed that recommended the postponement of surgery for at least 7 weeks after the infection. We hypothesised that vaccination against the SARS-CoV-2 and the large predominance of the Omicron variant attenuated the effect of a preoperative COVID-19 on the occurrence of postoperative respiratory morbidity. We conducted a prospective cohort study in 41 French centres between 15 March and 30 May 2022 (ClinicalTrials NCT05336110), aimed at comparing the postoperative respiratory morbidity between patients with and without preoperative COVID-19 within 8 weeks prior to surgery. The primary outcome was a composite outcome combining the occurrence of pneumonia, acute respiratory failure, unexpected mechanical ventilation, and pulmonary embolism within the first 30 postoperative days. Secondary outcomes were 30-day mortality, hospital length-of-stay, readmissions, and non-respiratory infections. The sample size was determined to have 90% power to identify a doubling of the primary outcome rate. Adjusted analyses were performed using propensity score modelling and inverse probability weighting. Of the 4928 patients assessed for the primary outcome, of whom 92.4% were vaccinated against the SARS-CoV-2, 705 had preoperative COVID-19. The primary outcome was reported in 140 (2.8%) patients. An 8-week preoperative COVID-19 was not associated with increased postoperative respiratory morbidity (odds ratio 1.08 [95% CI 0.48-2.13]; p=0.83). None of the secondary outcomes differed between the two groups. Sensitivity analyses concerning the timing between COVID-19 and surgery, and the clinical presentations of preoperative COVID-19 did not show any association with the primary outcome, except for COVID-19 patients with ongoing symptoms the day of surgery (OR 4.29 [1.02-15.8]; p=0.04). In our Omicron-predominant, highly immunised population undergoing general surgery, a preoperative COVID-19 was not associated with increased postoperative respiratory morbidity. The study was fully funded by the French Society of Anaesthesiology and Intensive Care Medicine (SFAR).

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Postoperative respiratory morbidity can adversely affect prognosis in thoracoscopic esophagectomy for esophageal cancer: a retrospective study.

Esophagectomy for esophageal cancer is associated with frequent respiratory morbidities, which may deteriorate postoperative survival outcomes. Thoracoscopic esophagectomy (TE) is less invasive and is associated with fewer respiratory morbidities than open esophagectomy. However, the relationship between post-TE respiratory morbidity and prognosis has not been well established. This study included 378 patients who underwent TE for esophageal cancer between May 2011 and November 2020. Patients were divided into two groups based on the presence of respiratory morbidity. Short-term and long-term outcomes of the groups were retrospectively compared. Respiratory morbidity was significantly associated with heavy past smoking habits (Brinkman index, p = 0.0039), short duration of smoking cessation (p = 0.0012), worse American Society of Anesthesiologists physical status (p = 0.016), frequent cardiovascular comorbidities (p = 0.0085), and long hospital stay (p < 0.001). Respiratory morbidity significantly deteriorated overall survival (OS) (p = 0.011) and relapse-free survival (p = 0.062) and could be an independent prognostic factor for OS (hazard ratio = 1.90, 95% confidence interval = 1.093-3.311, p = 0.023) along with clinical stage. Respiratory morbidity can adversely affect prognosis after TE. Various prophylaxes for respiratory morbidity are required to improve the short-term and long-term outcomes of TE for esophageal cancer.

Effect of dosimetric parameters on postoperative respiratory morbidity in locally advanced esophageal cancer treated with preoperative chemoradiotherapy (CRT).

e16075 Background: Postoperative pulmonary complications are common after neoadjuvant CRT of locally advanced esophageal cancers. Using data from the French multicenter randomized phase II PROTECT trial (NCT02359968), we aimed to evaluate the dosimetric parameters which could be associated with the occurrence of postoperative respiratory morbidities in patients (pts) who underwent preoperative CRT. Methods: Key eligibility criteria for the PROTECT trial were stage II or III resectable adenocarcinoma or squamous cell carcinoma of the esophagus located below the carina. Pts received FOLFOX or Carboplatin-Paclitaxel, combined with radiotherapy (RT): total dose of 41.4 Gy, 5 fractions of 1.8 Gy per week, starting at day 1 of chemotherapy. The patient's position and definition of the target volumes and organs at risk were the same as in the CROSS trial (van Hagen, 2012). Pts were treated using 3D conformal RT or IMRT. Surgery occurred 4 to 8 weeks after completion of CRT through a transthoracic or mini-invasive approach with a two field extended lymphadenectomy. Pts recruited in the PROTECT trial up to Sept. 2019 who underwent surgery after CRT were eligible for this ancillary study. The primary endpoint of our translational study was the occurrence of postoperative respiratory morbidity, of any grade (Clavien-Dindo classification for early morbidity &lt; 31 days; NCI-CTCAE v4 for later events), up to 1 year following surgery, considering disease progression or death as competing events. Cause-specific Cox models were used to model the risk of respiratory morbidity, considering the following factors: performance status, BMI, smoking, histological subtype, tumor site, FEV1, RT technique, time interval between CRT and surgery, and dosimetric parameters derived from the Dose-Volume Histogram analysis (mean lung dose, V10Gy, V20Gy and V30Gy, as other parameters strongly correlated to these 4 ones). Results: Among the 98 pts recruited in the PROTECT trial from Feb. 2015 to Sept. 2019, 78 underwent surgery after CRT and were included in our translational study. Median age was 63.5 years (range 33 to 79). Tumor was located at the middle or lower third of the esophagus for 67% of pts. Mean lung dose was 10.2 Gy (sd = 3.2). Mean PTV volume was 566 cc (sd = 272). A total of 33 pts experienced at least one respiratory morbidity (16 pneumonia, 7 pleural effusion, 4 ARDS, 21 miscellaneous events). The cumulative incidence of respiratory morbidity was 42% one month after surgery (95% CI, 32-54), 44% at 3 months (32-54), and 46% at 6 months (35-57). None of the dosimetric parameters and other studied factors appeared associated with postoperative respiratory morbidity. Conclusions: We did not identify dosimetric factors that could predict the risk of postoperative respiratory morbidity after treatment with preoperative CRT with FOLFOX or Carboplatin-Paclitaxel. Clinical trial information: NCT02359968.

High Pretreatment Mean Corpuscular Volume Can Predict Worse Prognosis in Patients With Esophageal Squamous Cell Carcinoma who Have Undergone Curative Esophagectomy: A Retrospective Multicenter Cohort Study.

To establish the prognostic value of mean corpuscular volume (MCV) in patients with esophageal squamous cell carcinoma (ESCC) who have undergone esophagectomy. The MCV increases in patients with high alcohol and tobacco consumption. Such a lifestyle can be a risk factor for malnutrition, comorbidities related to those habits, and multiple primary malignancies, which may be associated with frequent postoperative morbidity and poor prognosis. This study included 1673 patients with ESCC who underwent curative esophagectomy at eight institutes between April 2005 and November 2020. Patients were divided into normal and high MCV groups according to the standard value of their pretreatment MCV. Clinical background, short-term outcomes, and prognosis were retrospectively compared between the groups. Overall, 26.9% of patients had a high MCV, which was significantly associated with male sex, habitual smoking and drinking, multiple primary malignancies, and malnutrition, as estimated by the body mass index, hemoglobin and serum albumin values, and the Geriatric Nutritional Risk Index. Postoperative respiratory morbidity (P = 0.0075) frequently occurred in the high MCV group. A high MCV was an independent prognostic factor for worse overall survival (hazard ratio, 1.27; 95% confidence interval, 1.049-1.533; P = 0.014) and relapse-free survival (hazard ratio, 1.23; 95% confidence interval, 1.047-1.455; P = 0.012). A high MCV correlates with habitual drinking and smoking, malnutrition, and multiple primary malignancies and could be a surrogate marker of worse short-term and long-term outcomes in patients with ESCC who undergo esophagectomy.

The Short-term in-hospital Pulmonary Rehabilitation versus perioperative Short-term in-hospital Chest Therapy before lung cancer resection: a randomized controlled trial

Objective: The aim of this study is to evaluate the effect of pulmonary resection and perioperative Short-term in-hospital Pulmonary Rehabilitation (SPR) versus perioperative Short-term in-hospital Chest Therapy (SCT) on the functional capacity and postoperative morbidity of patients with poor lung function. Design: Single-blind randomized control trial. Setting: Thoracic surgery department at “Santo Spirito” Civil Hospital – Pescara (Italy) Participants: Patients undergoing elective lung cancer resection (N=30). Interventions: Patients were randomly assigned to receive daily SPR (pulmonary rehabilitation, self-management and endurance training) versus daily SCT (breathing exercises). Both groups received early postoperative rehabilitation. Outcome Measures: Pulmonary functional parameters assessed at baseline and prior to surgery (phase 1), hospital length of stay and pulmonary complications assessed after lung cancer resection (phase 2). Results: Thirty patients were randomly assigned to the SPR arm (15) and SCT arm (15). During phase 1 evaluation: Forced Vital Capacity (FVC) (p 0,0001); percentage of predicted FVC (p 0,0002); Forced Expiratory Volume in the first second (FEV1) (p 0,0001); percentage of predicted FEV1 (p 0,0001). Percentage of change from baseline to prior to surgery in two groups SPR: FVC (18%); percentage of predicted FVC (20%); FEV1 (29%); percentage of predicted FEV1 (25%). SCT: FVC (10%); percentage of predicted FVC (11%); FEV1 (9%); percentage of predicted FEV1 (9%). Phase 2: the SPR group SPR group was in a favorable clinical condition compared with the SCT arm and the SPR group had a shorter length of postoperative stay (15 ± 5 vs 17 ±5, respectively). Conclusions: Despite poor lung function, these findings suggest that a feasible perioperative SPR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity.

Clinical Importance of Sputum in the Respiratory Tract as a Predictive Marker of Postoperative Morbidity After Esophagectomy for Esophageal Cancer.

Respiratory morbidity is common after esophagectomy and can be a major cause of surgery-related mortality. Thus, it is important to identify novel predictors that can preoperatively estimate the incidence of postoperative respiratory morbidity. Asymptomatic sputum in the respiratory tract is sometimes observed on preoperative computed tomography (CT). This study aimed to determine the clinical importance of sputum in the respiratory tract as a predictor of postoperative morbidity after esophagectomy for esophageal cancer. The study included 609 consecutive patients who underwent three-incisional esophagectomy for esophageal cancer between April 2005 and November 2018. Among the patients, 76 (12.5%) had sputum in the respiratory tract on preoperative CT. This finding was significantly associated with older age, more extreme smoking habit, worse performance status, lower forced expiratory volume 1%, and more frequent pulmonary comorbidities. Additionally, the incidence of postoperative pneumonia was higher in these patients than in those without sputum (16 vs 8%, p = 0.028). Sputum in the main bronchus was associated with higher frequencies of morbidity of Clavien-Dindo classification (CDc) ≥ II (p = 0.019), severe morbidity of CDc ≥ IIIb (p = 0.058), pneumonia (p = 0.10), and pulmonary morbidity (p = 0.19) compared with the finding of sputum in the trachea alone. On multivariate analysis, sputum in the respiratory tract was an independent risk factor (hazard ratio, 2.07; 95% confidence interval, 1.019-4.207; p = 0.044) for postoperative pneumonia. Sputum in the respiratory tract is a novel predictor of postesophagectomy pneumonia. Patients with sputum in the more distal respiratory tract might have high risk of postoperative morbidities.

Efficacy of melatonin on sleep quality after laparoscopic cholecystectomy.

CONTEXT:Postoperative sleep and circadian rhythm disturbances were associated with prolonged postoperative convalescence, respiratory, and cardiovascular morbidity. Sleep disturbances have been shown to be due to decreased levels of circulating melatonin after surgery. If this sleep pattern and circadian rhythm are recycled, outcome after surgery could be improved.AIMS:The aim of this study was to observe the effect of melatonin on the quality of sleep in patients undergoing laparoscopic cholecystectomy (LC).SUBJECTS AND METHODS:Hundred patients of LC participated in this randomized, placebo-controlled, double-blind, clinical trial. Patients were randomized equally into Group A who received 6 mg melatonin tablets 45 min before sleep for 3 days after surgery and Group B who received placebo.RESULTS:Melatonin usage results in decrease in sleep latency (SL) as compared to placebo (13.6 ± 14.95 vs. 20.10 ± 16.18 min, P = 0.04). There was also increased total sleep duration (TSD) on postoperative day (POD) 1 (P = 0.004) and POD 2 (P = 0.001) in Group A. There was a decrease in daytime naps and night awakenings after surgery in Group A though it was not significant statistically. Subjective assessment of sleep on visual analog scale showed reduced sleep scores (P = 0.001 on POD 1 and 2) and decreased pain (P = 0.02 on POD 1) in Group A. Statistically significant difference was not observed in fatigue or general well-being among groups.CONCLUSIONS:Results in this study could demonstrate that melatonin as a single agent could improve the quality of sleep after LC by decreasing SL and increasing TSD.

Management of Congenital Heart Disease Associated with Ellis-van Creveld Short-rib Thoracic Dysplasia

To evaluate clinical outcome of patients with Ellis-van Creveld syndrome (EVC) in whom congenital heart disease (CHD) repair was delayed intentionally to reduce the risk of postoperative respiratory morbidity and mortality. This retrospective review of 51 EVC c.1886+5G>T homozygotes born between 2005 and 2014 focused on 18 subjects who underwent surgery for CHD, subdivided into early (mean, 1.3 months) vs delayed (mean, 50.1 months) repair. Growth trajectories differed between control subjects and patients with EVC, and CHD was associated with slower weight gain. Relative to controls, infants with EVC had a 40%-75% higher respiratory rates (independent of CHD) accompanied by signs of compensated respiratory acidosis. Blood gases and respiratory rates approached normal values by age 4 years. Hemodynamically significant CHD was present in 23 children, 18 (78%) of whom underwent surgical repair. Surgery was performed at 1.3 ± 1.3 months for children born between 2005 and 2009 (n = 9) and 50.1 ± 40.2 months (P = .009) for children born between 2010 and 2014 (n = 9). The latter had shorter postoperative mechanical ventilation (1.1 ± 2.4 days vs 49.6 ± 57.1 days; P = .075), shorter intensive care duration of stay (16 ± 24 days vs 48.6 ± 44.2 days; P = .155), and no postoperative tracheostomies (vs 60%; P = .028) or deaths (vs 44%; P = .082). Among children with EVC and possibly other short-rib thoracic dysplasias, delayed surgical repair of CHD reduces postoperative morbidity and improves survival. Respiratory rate serves as a simple indicator for optimal timing of surgical repair.

Airway ciliary dysfunction: Association with adverse postoperative outcomes in nonheterotaxy congenital heart disease patients

ObjectiveHeterotaxy (HTX) congenital heart disease (CHD) patients with ciliary dysfunction (CD) have been shown to have increased postoperative respiratory morbidity. We hypothesized that non-HTX CHD infants with CD also will have increased postoperative morbidity, particularly respiratory complications. MethodsSixty-three infants with non-HTX CHD undergoing cardiac surgery were enrolled. Tests commonly used to assess for CD, nasal nitric oxide (nNO) measurements and nasal epithelial ciliary motion (CM) assessment, were obtained. Baseline characteristics and postoperative outcomes were collected and analyzed. ResultsNon-HTX CHD infants exhibited a high prevalence of abnormal CM (32%) and low nNO (39%). This finding was not correlated with demographics or surgical complexity. Infants with abnormal CM had increased odds of requiring noninvasive positive pressure ventilation (odds ratio [OR], 6.5; 95% confidence interval [CI], 1.5-29.4; P = .016) and respiratory medication use (OR, 4.4; 95% CI, 1.5-13.3; P = .01). In contrast, infants with low nNO showed evidence of abnormal pre- and postoperative systolic function (40% vs 4%; P = .004, and 34% vs 13%; P = .056, respectively) and had greater odds of acquiring infections (OR, 4.9; 95% CI, 1.4-17; P = .014). ConclusionsNon-HTX CHD infants with abnormal CM showed increased postoperative morbidity associated with poor respiratory outcomes. In contrast, low nNO correlated with reduced hemodynamic function. These findings suggest screening for abnormal CM may allow perioperative interventions to reduce pulmonary morbidities. Whether low nNO may prognosticate poor hemodynamic function warrants further investigation.

Impact of Presurgical Mild Acute Respiratory Distress Syndrome on Surgical Mortality After Surgical Repair of Acute Type A Aortic Dissection.

To evaluate the impact of presurgical mild acute respiratory distress syndrome (ARDS) on surgical mortality in patients undergoing surgical repair of acute type A aortic dissection by means of deep hypothermic circulatory arrest (DHCA) in a single-center, retrospective study.From January 2011 to December 2015, 333 eligible patients were divided into either a mild-ARDS group (n = 136) or a no-ARDS group (n = 197). The definition of mild ARDS referred to the recent revision of ARDS definition (Berlin criteria). The surgical mortality and major postoperative morbidity were investigated and analyzed.A total of 136 patients developed presurgical mild ARDS, with an incidence of 40.8%. No significant difference emerged between the 2 groups in major postoperative morbidity except for pulmonary complications. Multivariate logistic regression displayed that the risk of postoperative pulmonary complications in patients with presurgical mild ARDS was 4.25 times that in patients without presurgical ARDS (OR = 4.25, 95% CI 2.05-7.72). Twenty-four patients died after surgery, with significantly higher surgical mortality in the mild-ARDS group compared with the no-ARDS group (12.5% versus 3.6%, P = 0.002). Kaplan-Meier curves showed a poor surgical survival in the mild-ARDS group (χ2=12.958, Log-Rank P < 0.001). And Cox regression revealed the hazard ratio for surgical mortality in the mild-ARDS group compared with the no-ARDS group was 2.52 (95%CI 1.41-5.32, P = 0.016).Presurgical mild ARDS increased postoperative respiratory morbidity, and then increased surgical mortality after surgical repair of acute type A aortic dissection by means of DHCA.

Electromyographic activity of the diaphragm during neostigmine or sugammadex-enhanced recovery after neuromuscular blockade with rocuronium: a randomised controlled study in healthy volunteers.

The use of neuromuscular blocking agents has been associated with severe postoperative respiratory morbidity. Complications can be attributed to inadequate reversal, and reversal agents may themselves have adverse effects. To compare the electromyographic activity of the diaphragm (EMGdi) during recovery from neuromuscular blockade using neostigmine and sugammadex. The hypothesis was that there would be better neuromuscular coupling of the diaphragm when sugammadex was used. A randomised, controlled, parallel-group, single-centre, double-blinded study. District general hospital in Belgium. Twelve healthy male volunteers. Individuals were anaesthetised with propofol and remifentanil. After rocuronium 0.6 mg kg, a transoesophageal electromyography (EMG) recorder was inserted. For reversal of neuromuscular blockade, volunteers received sugammadex 2 mg kg (n = 6) or neostigmine 70 μg kg (n = 6). EMGdi, airway pressure and flow were continuously measured during weaning from the ventilator until tracheal extubation. Arterial blood gas samples were obtained for PaO2 and PaCO2 analysis at the first spontaneous breathing attempt and after tracheal extubation. During weaning, 560 breaths were retained for analysis. The median (95% CI) peak EMGdi was 1.1 (0.9 to 1.5) μV in the neostigmine group and 1.6 (1.3 to 1.9) μV in the sugammadex group (P < 0.001). Individuals in the neostigmine group had 125 of 228 (55%) breaths with associated EMGdi at least 1 μV vs. 220 of 332 (66%) breaths in the sugammadex group (P = 0.008). The median (95% CI) tidal volume was 287 (256 to 335) ml after neostigmine and 359 (313 to 398) ml after sugammadex (P = 0.013). The median (95% CI) PaO2 immediately after extubation was 30.5 (22.8 to 37.1) kPa after sugammadex vs. 20.7 (12.9 to 27.5) kPa after neostigmine (P = 0.03). EMGdi, tidal volume and PaO2 following tracheal extubation were increased after sugammadex compared with neostigmine, reflecting diaphragm-driven inspiration after sugammadex administration. Sugammadex may free more diaphragmatic acetylcholine receptors than neostigmine, which has an indirect effect. EudraCT ref: 2013-002078-30.

Effects of neostigmine reversal of nondepolarizing neuromuscular blocking agents on postoperative respiratory outcomes: a prospective study.

We tested the hypothesis that neostigmine reversal of neuromuscular blockade reduced the incidence of signs and symptoms of postoperative respiratory failure. We enrolled 3,000 patients in this prospective, observer-blinded, observational study. We documented the intraoperative use of neuromuscular blocking agents and neostigmine. At postanesthesia care unit admission, we measured train-of-four ratio and documented the ratio of peripheral oxygen saturation to fraction of inspired oxygen (S/F). The primary outcome was oxygenation at postanesthesia care unit admission (S/F). Secondary outcomes included the incidence of postoperative atelectasis and postoperative hospital length of stay. Post hoc, we defined high-dose neostigmine as more than 60 μg/kg and unwarranted use of neostigmine as neostigmine administration in the absence of appropriate neuromuscular transmission monitoring. Neostigmine reversal did not improve S/F at postanesthesia care unit admission (164 [95% CI, 162 to 164] vs. 164 [161 to 164]) and was associated with an increased incidence of atelectasis (8.8% vs. 4.5%; odds ratio, 1.67 [1.07 to 2.59]). High-dose neostigmine was associated with longer time to postanesthesia care unit discharge readiness (176 min [165 to 188] vs. 157 min [153 to 160]) and longer postoperative hospital length of stay (2.9 days [2.7 to 3.2] vs. 2.8 days [2.8 to 2.9]). Unwarranted use of neostigmine (n = 492) was an independent predictor of pulmonary edema (odds ratio, 1.91 [1.21 to 3.00]) and reintubation (odds ratio, 3.68 [1.10 to 12.4]). Neostigmine reversal did not affect oxygenation but was associated with increased atelectasis. High-dose neostigmine or unwarranted use of neostigmine may translate to increased postoperative respiratory morbidity.

Pure oxygen ventilation during general anaesthesia does not result in increased postoperative respiratory morbidity but decreases surgical site infection. An observational clinical study.

Background. Pure oxygen ventilation during anaesthesia is debatable, as it may lead to development of atelectasis. Rationale of the study was to demonstrate the harmlessness of ventilation with pure oxygen.Methods. This is a single-centre, one-department observational trial. Prospectively collected routine-data of 76,784 patients undergoing general, gynaecological, orthopaedic, and vascular surgery during 1995–2009 were retrospectively analysed. Postoperative hypoxia, unplanned ICU-admission, surgical site infection (SSI), postoperative nausea and vomiting (PONV), and hospital mortality were continuously recorded. During 1996 the anaesthetic ventilation for all patients was changed from 30% oxygen plus 70% nitrous oxide to 100% oxygen in low-flow mode. Therefore, in order to minimize the potential of confounding due to a variety of treatments being used, we directly compared years 1995 (30% oxygen) and 1997 (100%), whereas the period 1998 to 2009 is simply described.Results. Comparing 1995 to 1997 pure oxygen ventilation led to a decreased incidence of postoperative hypoxic events (4.3 to 3.0%; p < 0.0001) and hospital mortality (2.1 to 1.6%; p = 0.088) as well as SSI (8.0 to 5.0%; p < 0.0001) and PONV (21.6 to 17.5%; p < 0.0001). There was no effect on unplanned ICU-admission (1.1 to 0.9; p = 0.18).Conclusions. The observed effects may be partly due to pure oxygen ventilation, abandonment of nitrous oxide, and application of low-flow anesthesia. Pure oxygen ventilation during general anaesthesia is harmless, as long as certain standards are adhered to. It makes anaesthesia simpler and safer and may reduce clinical morbidity, such as postoperative hypoxia and surgical site infection.

Pulmonary rehabilitation during induction chemoradiotherapy for lung cancer improves pulmonary function

Chemoradiotherapy for non-small cell lung cancer can impair pulmonary function, particularly when it is followed by surgery. This study aimed to document the changes in respiratory function as a result of a perioperative intensive pulmonary rehabilitation program in patients with non-small cell lung cancer who underwent induction chemoradiotherapy. A total of 82 consecutive patients underwent pulmonary resection after undergoing induction chemoradiotherapy. A pulmonary rehabilitation program was started at the same time as the induction chemoradiotherapy. Standard respiratory function tests were performed before and after induction chemoradiotherapy. Treatment-related mortality and the incidence of postoperative respiratory complications were investigated. The Wilcoxon signed-rank test was used to analyze the differences in spirometric changes. All patients underwent a pulmonary rehabilitation program for an average of 10 weeks. Significant increases were observed in forced vital capacity (+6.4%, P = .0096) and forced expiratory volume in 1 second (+10.4%, P < .0001). Diffusing capacity of the lung for carbon monoxide decreased (-14.0%, P < .0001). Patients with respiratory impairment (forced vital capacity <80% predicted or forced expiratory volume in 1 second/forced vital capacity <70%) showed significant improvements in forced vital capacity (+13.9%, P = .0025) and forced expiratory volume in 1 second (+22.5%, P < .0001). Significant increases were observed in forced vital capacity (+7.0%, P = .0042) and forced expiratory volume in 1 second (+10.8%, P = .0001) in patients with a smoking history. There was no mortality, and postoperative respiratory morbidity was 6.1%. A pulmonary rehabilitation program for patients with non-small cell lung cancer undergoing induction chemoradiotherapy seems to improve respiratory function. It is particularly recommended for smokers and patients with respiratory impairment.

Analysis of Risk Factors, Morbidity, and Cost Associated with Respiratory Complications following Abdominal Wall Reconstruction

Ventral hernia remains a continued and expensive problem for general and reconstructive surgeons, alike. The aim of this study was to assess perioperative factors and cost associated with postoperative respiratory morbidity in abdominal wall reconstruction. A retrospective review of abdominal wall reconstruction patients operated on between 2007 and 2012 was performed. Analysis of perioperative factors associated with postoperative respiratory morbidity was performed using hospital-defined International Classification of Diseases, Ninth Revision codes. Bivariate and multivariate logistic regression analyses were used to assess independent predictors of postoperative respiratory morbidity, and linear regression was used to determine the financial impact. One hundred thirty-four consecutive abdominal wall reconstructions performed by a single surgeon over a 5-year period were included. Respiratory complications occurred in 15.7 percent of patients (n = 21); 5.2 percent required reintubation (n = 7) and 5.2 percent failed to wean from ventilatory support postoperatively (n = 7). Patients experiencing respiratory morbidity stayed on average 16.2 days longer (p < 0.0001) and represented the only three patients in the study experiencing mortality (p = 0.003). Regression analysis demonstrated that intraoperative blood transfusions (p = 0.008), highest peak intraoperative airway pressure (p = 0.017), fascial closure (p = 0.013), and American Society of Anesthesiologists physical status (p = 0.019) were all associated with postoperative respiratory morbidity. Linear regression analysis demonstrated that respiratory complications added a cost of $60,933 per patient (p < 0.001). Postoperative respiratory morbidity following abdominal wall reconstruction is a common occurrence linked to identifiable perioperative risk factors and associated with significant mortality and a tremendous cost burden. These findings underscore the importance of preoperative risk stratification and patient selection to optimize outcome and contain cost.

Risk Factors for Postoperative Respiratory Mortality and Morbidity in Patients Undergoing Coronary Artery Bypass Grafting

Nowadays, coronary artery bypass grafting (CABG) is considered to be one of the most common surgical procedures. This procedure has been the main topic in many clinical research studies, which have assessed the effect of the procedure on patients outcomes. Like other surgical procedures, this procedure is also accompanied by a number of unwanted complications, including those of the respiratory system. Since the respiratory system plays an integral role in defining the clinical outcome of patients, improvements in studies that can assess and predict clinical outcomes of the respiratory system, assume greater importance. There are a number of predictive models which can assess patients in the preoperative period and introduce a number of risk factors, which could be considered as prognostic factors for patients undergoing CABG. The respiratory system is among the clinical systems that are assessed in many prediction scoring systems. This review assesses the main studies which have evaluated the possible risk factors for postoperative respiratory mortality and morbidity, in patients undergoing CABG.

Preoperative Pulmonary Rehabilitation Versus Chest Physical Therapy in Patients Undergoing Lung Cancer Resection: A Pilot Randomized Controlled Trial

ObjectiveTo evaluate the effect of 4 weeks of pulmonary rehabilitation (PR) versus chest physical therapy (CPT) on the preoperative functional capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection. DesignRandomized single-blinded study. SettingA teaching hospital. ParticipantsPatients undergoing lung cancer resection (N=24). InterventionsPatients were randomly assigned to receive PR (strength and endurance training) versus CPT (breathing exercises for lung expansion). Both groups received educational classes. Main Outcome MeasuresFunctional parameters assessed before and after 4 weeks of PR or CPT (phase 1), and pulmonary complications assessed after lung cancer resection (phase 2). ResultsTwelve patients were randomly assigned to the PR arm and 12 to the CPT arm. Three patients in the CPT arm were not submitted to lung resection because of inoperable cancer. During phase 1 evaluation, most functional parameters in the PR group improved from baseline to 1 month: forced vital capacity (FVC) (1.47L [1.27–2.33L] vs 1.71L [1.65–2.80L], respectively; P=.02); percentage of predicted FVC (FVC%; 62.5% [49%–71%] vs 76% [65%–79.7%], respectively; P<.05); 6-minute walk test (425.5±85.3m vs 475±86.5m, respectively; P<.05); maximal inspiratory pressure (90±45.9cmH2O vs 117.5±36.5cmH2O, respectively; P<.05); and maximal expiratory pressure (79.7±17.1cmH2O vs 92.9±21.4cmH2O, respectively; P<.05). During phase 2 evaluation, the PR group had a lower incidence of postoperative respiratory morbidity (P=.01), a shorter length of postoperative stay (12.2±3.6d vs 7.8±4.8d, respectively; P=.04), and required a chest tube for fewer days (7.4±2.6d vs 4.5±2.9d, respectively; P=.03) compared with the CPT arm. ConclusionsThese findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity.

Ellis-van Creveld Syndrome and Congenital Heart Defects: Presentation of an Additional 32 Cases

We read with interest the recent article in Pediatric Cardiology by Hills et al. [1]: Ellis-van Creveld Syndrome and Congenital Heart Defects: Presentation of an Additional 32 Cases. The authors are to be commended for their work, which sheds further light on the breadth and complexity of congenital heart disease (CHD) seen in patients with Ellis-van Creveld syndrome (EvC). We agree with the authors that the diagnostic precision afforded by the Pediatric Cardiac Care Consortium (PCCC) database is of great value in its application to EvC because such anatomic detail has not been provided in prior clinical reports. For a syndrome with a 60–70% incidence of CHD, the detailed focus on CHD in this paper is of value to pediatric cardiologists, cardiovascular surgeons, and other providers involved in the care of children with EvC. With respect to outcomes after CHD surgery for patients with EvC, however, some of the results described by Hills et al. [1] were unclear to us. We recently reported outcomes of CHD surgery for children with EvC during the recent era in a smaller, mostly Amish, population [2]. Similar to the findings by Hills et al. [1], we noted a relatively high incidence of systemic venous abnormalities (33%) in our study. However, and in seeming contrast to the data reported by Hills et al. [1], we found that CHD surgery for patients with EvC was associated with a postoperative mortality rate of 44%, with the deaths occurring at a median of 102 days (range, 25–149 days) postoperatively. This incidence is substantially higher than that reported in the study by Hills et al. [1], in which no postoperative deaths were reported. In our study, the majority of deaths were related to respiratory complications, presumably on account of the thoracic dystrophy that is a hallmark of EvC. It is unclear to us how Hills et al. [1] evaluated followup and postoperative mortality in their series of patients. A major limitation of the PCCC database is incomplete or missing follow-up data [3]. In the study by Hills et al. [1], therefore, what was the duration of the follow-up period? A shorter follow-up period (i.e., 30 days), used frequently to determine postoperative mortality, may not be sufficient to capture the true effect of CHD surgery on the respiratory system in EvC. Although we certainly support the concept of repair or palliation of CHD in patients with EvC, we stress that surgery for CHD in patients with EvC is a highrisk undertaking. In our study, substantial mortality was not the only notable finding. In addition, all those surviving surgery experienced postoperative respiratory morbidity (prolonged need for supplemental oxygen, prolonged mechanical ventilation, and tracheostomy). Those involved in the care of children with EvC must consider such data when making treatment decisions and counseling families.

Angiotensin Converting Enzyme Inhibitors Are Not Associated with Respiratory Complications or Mortality After Noncardiac Surgery

General use of angiotensin-converting enzyme inhibitors (ACEIs) is associated with upper-airway complications such as cough, angioedema, and bronchospasm; furthermore, preoperative use is associated with increased morbidity or mortality. Our primary goal in this study was thus to evaluate the association of ACEI therapy with perioperative respiratory morbidity in adult noncardiac surgical patients. Our secondary goals were to evaluate the association between preoperative use of ACEI and 30-day mortality, as well as to a composite outcome of in-hospital morbidity and mortality in adult noncardiac surgical patients having general anesthesia. We evaluated 79,228 patients (9905 ACEI users [13] and 66,620 [87%] non-ACEI users) who had noncardiac surgery at the Cleveland Clinic between 2005 and 2009. Propensity matching successfully paired 9028 ACEI users (91% of 9905 patients) with 9028 controls. Matched intraoperative ACEI users and non-ACEI users were compared on intraoperative and postoperative respiratory morbidity composites as well as individual complications, 30-day mortality, and a composite of in-hospital morbidity and mortality. The association between ACEI use and respiratory morbidity composites was not statistically significant intraoperatively (OR: 1.09 [97.5% CI: 0.91, 1.31], ACEI versus non-ACEI; P = 0.28) or postoperatively (OR: 0.97 [97.5% CI: 0.81, 1.16], ACEI versus non-ACEI; P = 0.69). Within the propensity-matched subset, ACEI usage was not associated with either 30-day mortality (OR: 0.93 [95% CI: 0.73, 1.19], ACEI versus non-ACEI; P = 0.56) or the composite of in-hospital morbidity and mortality (OR: 1.06 [95% CI: 0.97, 1.15], ACEI versus non-ACEI; P = 0.22). We also observed that the ACEI and the non-ACEI groups were descriptively similar (standardized differences <0.03) on multiple time periods of intraoperative hemodynamic characteristics, vasopressor use, and colloid and crystalloid infusions. We did not find any association between use of ACEIs and intraoperative or postoperative upper-airway complications. Furthermore, ACEI use was not associated with in-hospital complications or increased 30-day mortality.