Risk Of Postoperative Pulmonary Complications Research Articles

Predictive factors of pathological complete response after induction (ypT0N0M0) in non-small cell lung cancer and short-term outcomes: Results of the Spanish Group of Video-assisted Thoracic Surgery (GE-VATS)

IntroductionTo analyze the predictors of pCR in NSCLC patients who underwent anatomical lung resection after induction therapy and to evaluate the postoperative results of these patients. MethodsAll patients prospectively registered in the database of the GE-VATS working group undergone anatomic lung resection by NSCLC after induction treatment and recruited between 12/20/2016 and 3/20/2018 were included in the study. The population was divided into two groups: patients who obtained a complete pathological response after induction (pCR) and patients who did not obtain a complete pathological response after induction (non-pCR). A multivariate analysis was performed using a binary logistic regression to determine the predictors of pCR and the postoperative results of patients were analyzed. ResultsOf the 241 patients analyzed, 36 patients (14.9%) achieved pCR. Predictive factors for pCR are male sex (OR: 2.814, 95% CI: 1.015−7.806), histology of squamous carcinoma (OR: 3.065, 95% CI: 1.233−7.619) or other than adenocarcinoma (OR: 5.788, 95% CI: 1.878−17.733) and induction therapy that includes radiation therapy (OR: 4.096, 95% CI: 1.785−9.401) and targeted therapies (OR: 7.625, 95% CI: 2.147−27.077). Prevalence of postoperative pulmonary complications was higher in patients treated with neoadjuvant chemo-radiotherapy (p = 0.032). ConclusionsMale sex, histology of squamous carcinoma or other than ADC, and induction therapy that includes radiotherapy or targeted therapy are positive predictors for obtaining pCR. Induction chemo-radiotherapy is associated with a higher risk of postoperative pulmonary complications.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation-Implications for Physiotherapists.

ObjectivesTo investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI).MethodsA total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op.ResultsThe mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as “high risk” prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ.ConclusionThis is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Associations of dynamic driving pressure and mechanical power with postoperative pulmonary complications–posthoc analysis of two randomised clinical trials in open abdominal surgery

SummaryBackgroundWhile an association of the intraoperative driving pressure with postoperative pulmonary complications has been described before, it is uncertain whether the intraoperative mechanical power is associated with postoperative pulmonary complications.MethodsPosthoc analysis of two international, multicentre randomised clinical trials (ISRCTN70332574 and NCT02148692) conducted between 2011–2013 and 2014–2018, in patients undergoing open abdominal surgery comparing the effect of two different positive end–expiratory pressure (PEEP) levels on postoperative pulmonary complications. Time–weighted average dynamic driving pressure and mechanical power were calculated for individual patients. A multivariable logistic regression model adjusted for confounders was used to assess the independent associations of driving pressure and mechanical power with the occurrence of a composite of postoperative pulmonary complications, the primary endpoint of this posthoc analysis.FindingsIn 1191 patients included, postoperative pulmonary complications occurrence was 35.9%. Median time–weighted average driving pressure and mechanical power were 14·0 [11·0–17·0] cmH2O, and 7·6 [5·1–10·0] J/min, respectively. While driving pressure was not independently associated with postoperative pulmonary complications (odds ratio, 1·06 [95% CI 0·88–1·28]; p=0.534), the mechanical power had an independent association with the occurrence of postoperative pulmonary complications (odds ratio, 1·28 [95% CI 1·05–1·57]; p=0.016). These findings were independent of body mass index or the level of PEEP used, i.e., independent of the randomisation arm.InterpretationIn this merged cohort of surgery patients, higher intraoperative mechanical power was independently associated with postoperative pulmonary complications. Mechanical power could serve as a summary ventilatory biomarker for the risk for postoperative pulmonary complications in these patients, but our findings need confirmation in other, preferably prospective studies.FundingThe two original studies were supported by unrestricted grants from the European Society of Anaesthesiology and the Amsterdam University Medical Centers, Location AMC. For this current analysis, no additional funding was requested. The funding sources had neither a role in the design, collection of data, statistical analysis, interpretation of data, writing of the report, nor in the decision to submit the paper for publication.

Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: a patient-level meta-analysis of three randomised clinical trials

BackgroundHigh intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. MethodsThe three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. ResultsComplete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75–1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26–0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60–2.17). ConclusionsHigh PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. Clinical trial registrationNCT03937375 (Clinicaltrials.gov).

Lung-Protective Effects of Lidocaine Infusion on Patients with Intermediate/ High Risk of Postoperative Pulmonary Complications: A Double-Blind Randomized Controlled Trial.

PurposeThe non-local anesthetic effects of lidocaine have been widely reported, but there are still few studies on lung protection. We aimed to test the hypothesis that intravenous infusion of lidocaine exerts lung-protective effects in patients at intermediate/high risk of postoperative pulmonary complications (PPCs) on major abdominal surgery.Patients and MethodsPatients ≥18 years, ASA II or III, with intermediate/high risk for PPCs, were included. Patients were randomly assigned into group lidocaine (received a bolus of lidocaine 1.5 mg kg−1 before the induction of anesthesia, then followed by a continuous infusion of 2.0 mg kg−1 h−1 intraoperatively until the end of surgery) or group control (received 0.9% saline in place of lidocaine at the same time points). The incidence of PPCs within 7 postoperative days was measured, defined as a collapsed composite outcome of atelectasis, respiratory infection, pleural effusion, pneumonia, respiratory failure or acute respiratory distress syndrome (ARDS) developed within 7 postoperative days, or hospital discharge, whichever came sooner.ResultsOf 200 subjects screened, 195 patients were finally analyzed. Overall, 35.9% (70/195) patients sustained PPCs, which occurred fewer in group lidocaine 25.8% (25/97), compared with group control 45.9% (45/98) (relative risk: 0.56, 95% CI: 0.38 to 0.84; absolute risk reduction: −20.1%; P = 0.003). Considering single PPCs episode, the most common PPC in both groups was atelectasis. The atelectasis incidence was 11.3% (11/97) in group lidocaine, much lower than that in group control 29.6% (29/98) (relative risk: 0.38, 95% CI: 0.20 to 0.72; absolute risk reduction: −18.3%, P = 0.002). However, the incidences of any other PPCs episodes were similar between the two groups.ConclusionIntraoperative intravenous infusion lidocaine could decrease the incidence of PPCs in patients at intermediate/high risk of postoperative pulmonary complications undergoing major abdominal surgery.

Impact of smoking status and chronic obstructive pulmonary disease on pulmonary complications post lung cancer surgery.

IntroductionSmoking and chronic obstructive pulmonary disease (COPD) are associated with an increased risk of post-operative pulmonary complications (PPCs) following lung cancer resection. It remains unclear whether smoking cessation reduces this risk.MethodsRetrospective review of a large, prospectively collected database of over 1000 consecutive resections for lung cancer in a quaternary lung cancer centre over a 23-year period.ResultsOne thousand and thirteen patients underwent curative-intent lobectomy or pneumonectomy between 1995 and 2018. Three hundred and sixty-two patients (36%) were ex-smokers, 314 (31%) were current smokers and 111 (11%) were never smokers. A pre-operative diagnosis of COPD was present in 57% of current smokers, 57% of ex-smokers and 20% of never smokers. Just over 25% of patients experienced a PPC. PPCs were more frequent in current smokers compared to never smokers (27% vs 17%, p = 0.036), however, no difference was seen between current and ex-smokers (p = 0.412) or between never and ex-smokers (p = 0.113). Those with a diagnosis of COPD, independent of smoking status, had a higher frequency of both PPCs (65% vs 35%, p<0.01) and overall complications (60% vs 40%, p<0.01) as well as a longer length of hospital stay (10 vs 9 days, p<0.01).ConclusionSmoking and COPD are both associated with a higher rate of PPCs post lung cancer resection. COPD, independent of smoking status, is also associated with an increased overall post-operative complication rate and length of hospital stay. An emphasis on COPD treatment optimisation, rather than smoking cessation in isolation, may help improve post-operative outcomes.

Effect of high-flow nasal therapy on patient-centred outcomes in patients at high risk of postoperative pulmonary complications after cardiac surgery: a study protocol for a multicentre adaptive randomised controlled trial

BackgroundHigh-flow nasal therapy is a non-invasive form of respiratory support that delivers low-level, flow dependent positive airway pressure. The device can be better tolerated by patients than alternatives such as continuous positive airway pressure. The primary objective is to determine if prophylactic high-flow nasal therapy after tracheal extubation can result in an increase in the number of days alive and at home within the first 90 days after surgery, when compared with standard oxygen therapy. The co-primary objective is to estimate the incremental cost-effectiveness and cost-utility of high-flow nasal therapy vs standard oxygen therapy at 90 days, from the view-point of the public sector, the health service and patients.MethodsThis is an adaptive, multicentre, international parallel-group, randomised controlled trial with embedded cost-effectiveness analysis comparing the use of high-flow nasal therapy with control in patients at high risk of respiratory complications following cardiac surgery. Participants will be randomised before tracheal extubation and allocated either high-flow nasal therapy or standard oxygen therapy for a minimum of 16 h immediately post extubation. Participants will be followed up until 90 days after surgery. The total sample size needed to detect a 2-day increase in DAH90 with 90% power with an intention to treat analysis is 850 patients. The adaptive design includes an interim sample size re-estimation which will provide protection against deviations from the original sample size assumptions made from the single-centre pilot study and will allow for a maximum sample size increase to 1152 patients.DiscussionEvidence to support routine use of high-flow nasal therapy will inform the development of effective enhanced recovery care bundles. Reducing complications should reduce length of stay and re-admission to hospital and provide an important focus for cost reduction. However; high-quality studies evaluating the clinical and cost effectiveness of high-flow nasal therapy after cardiothoracic surgery are lacking.Trial registrationThe study has been registered with ISRCTN (ISRCTN14092678, 13/05/2020)Clinicaltrials.gov Registration Pending

Nocebo Effects of Clinical Communication and Placebo Effects of Positive Suggestions on Respiratory Muscle Strength.

Introduction:The effects of specific suggestions are usually studied by measuring parameters that are directly addressed by these suggestions. We recently proposed the use of a uniform, unrelated, and objective measure like maximal muscle strength that allows comparison of suggestions to avoid nocebo effects and thus to improve communication. Since reduced breathing strength might impair respiration and increase the risk of post-operative pulmonary complications, the aim of the present study was to evaluate the effects of the suggestions on respiratory muscle power. Both the identification and neutralization of negative suggestions in the clinical context and stimulating suggestions could improve breathing force, a predictor of physical fitness and convalescence.MethodsIn 50 healthy, adult volunteers, respiratory muscle strength was measured by maximal inspiratory and expiratory pressures, as well as by maximal inspiratory and expiratory flows. Baseline was compared to values after application of eleven suggestions, five out of clinical context, including memory of negative or positive past, risk information for informed consent, and a non-verbal suggestion. Six stimulating suggestions included self-affirmation, empowering words, a heroic mirror image, and an imagination.ResultsAll suggestions showed an impact on respiratory muscle strength, indicating placebo and nocebo effects. No single parameter could represent the breathing force in its complexity, however, trends and different specific aspects of it were measured. The strongest reaction was observed with the recall of a previous negative situation resulting in a reduction in expiratory flow to 96.1% of baseline (p = 0.041). After risk information, a decrease was observed in three of the parameters, with the highest extend in expiratory pressure by 4.4%. This nocebo effect was neutralized by adding positive aspects to the risk information. Every intended strengthening suggestion resulted in statistically significant increases of at least one parameter, with changes of up to 10% (e.g., MEP 110.3%, p = 0.001), indicating placebo effects. Here, expiration was more affected than inspiration. Sex was the only influencing factor reaching statistical significance, with stronger reactions in women.ConclusionRespiratory muscle strength proved to be sensitive to suggestions with clinical context, as well as suggestions intended for stimulation. With this objective measurement, evaluation, and comparison of different suggestions is possible to help avoid nocebo effects. The demonstrated effect of supporting suggestions can be followed up and used in clinical practice.

The impact of ultrasound-guided recruitment maneuvers on the risk of postoperative pulmonary complications in patients undergoing general anesthesia.

IntroductionPostoperative pulmonary complications are among the most frequent problems in perioperative care. The risk of their development depends not only on the parameters associated with the patient’s initial clinical condition, but also on the employed anesthesia technique, the method of mechanical ventilation, and the type and technique of the surgical procedure. Atelectasis is the most common complication, affecting nearly 90% of the patients undergoing general anesthesia.AimThe aim of this study was to determine whether it was possible to positively impact the postoperative period and reduce the frequency of postoperative pulmonary complications via patient-based intraoperative ultrasound-guided recruitment maneuvers.MethodologyThe course of the postoperative period was analyzed in two groups of patients. One of them comprised 100 patients in whom no recruitment maneuvers were performed during general anesthesia. The other group (100 patients) consisted of patients in whom patient-based ultrasound-guided pulmonary recruitment maneuvers were performed.ResultsIn the recruitment group, the postoperative hospitalization was statistically significantly shorter (p = 0.003) and the risk of intensive care treatment significantly lower. Additionally, the need for prolonged postoperative mechanical ventilation was reduced, as was the risk of respiratory tract infections.ConclusionsIntraoperative ultrasound-guided recruitment maneuvers reduce the frequency of postoperative pulmonary complications.

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.

The Strategy to Use Sugammadex to Reduce Postoperative Pulmonary Complications after da Vinci Surgery: A Retrospective Study.

In 2000, the da Vinci Surgery System was approved by the United States Food and Drug Administration for general laparoscopic surgery and it became the first commercially available robotic surgery system. The aim of this study was to identify the incidence of postoperative pulmonary complications (PPCs) in patients undergoing da Vinci surgery and to observe whether the incidence of PPCs was affected by the usage of Sugammadex. Sugammadex is a gamma-cyclodextrin that encapsulates and subsequently inactivates steroidal neuromuscular blocking agents. A retrospective study was conducted on patients who had undergone da Vinci surgery in a single medical center in southern Taiwan during the period from January 2018 to December 2018. We extracted data on patient characteristics, usage of Sugammadex and PPCs for analysis. Three hundred and thirty-three patients were enrolled in the final analysis. While the overall incidence of PPCs was 30.3% (101/333 patients), the incidence of PCC in patients who received Sugammadex (24.2%) was significantly lower than those without (37.3%) (p = 0.001). Risk factors that appeared to be closely associated with PCC included age, malignancy, hypertension, chronic kidney disease, blood loss amount and anemia. The use of Sugammadex decreased the risk of PPC. In order to enhance early recovery after da Vinci surgery, the use of Sugammadex to rapidly reverse muscle relaxants may be an appropriate choice.

Acute lung injury after pulmonary resection surgery for lung cancer and anesthetic management

Although the outcome of patients undergoing pulmonary resection surgeries for lung cancer has improved, postoperative acute lung injury (ALI) remains the leading cause of death. High oxygen concentration, high peak airway pressure, and hyper-perfusion due to hypoxic pulmonary vasoconstriction play a major role in the development of ALI in the ventilated dependent lung during one-lung ventilation. In the collapsed non-dependent lung, mechanical stress induced by re-expansion, ischemia-reperfusion injury, and direct surgical manipulation are associated with the onset of ALI. These contributing factors to ALI elicit local inflammatory responses, resulting in pulmonary edema that resembles acute respiratory distress syndrome histologically. Some preventive strategies to reduce ALI are recommended during mechanical ventilation, OLV support in particular. A lung protective strategy, including sufficient positive end-expiratory pressure, low tidal volume, and lower inspiratory oxygen concentration, should be adopted to attenuate lung damage. The application of continuous positive airway pressure to the collapsed non-dependent lung has been shown to reduce inflammatory cytokines. Given that excessive fluid administration is associated with the risk of postoperative pulmonary complications, a fluid restrictive strategy should be considered to prevent ALI. Anesthetic management may affect the onset of postoperative ALI. Compared to propofol anesthesia, volatile anesthetics have been shown to attenuate local inflammatory responses in both lungs during thoracic surgeries. Thoracic epidural analgesia may attenuate a local inflammatory response in the lung through the blockade of sympathetic nerve stimulation. Thus, more effective strategies to prevent ALI should be investigated to improve the prognosis of patients undergoing thoracic surgeries.

En Bloc Diaphragmatic Resection for Hepatocellular Carcinoma with Diaphragmatic Invasion, a Propensity Score Matched Analysis

Aim: This study aimed to evaluate the impact of en bloc diaphragmatic resection (DR) in patients with hepatocellular carcinoma(HCC). Method: Patients who received DR at the time of hepatectomy for HCC between 1997 to 2017 were retrospectively identified on a prospectively maintained database. Outcomes were compared to HCC patients without DR using propensity score matching(PSM) of 1:4 by controlling for alpha-fetoprotein levels and UICC staging. Results: During study period, 1744 patients received hepatectomy for HCC. Amongst them, 122 had en bloc DR, with 38 showing diaphragmatic invasion on histopathology. The diaphragm was repaired either primarily(n=112) or by mesh repair(n=10). Patients who required DR were more symptomatic on presentation, with higher AFP levels, larger tumour size, and more advanced UICC staging(P<0.001). After PSM, 122 patients with DR were matched to 488 patients without DR. Patients in the DR group were more likely to require major hepatectomy(87.7% vs. 73.6%, P=0.001), with higher risk of developing pulmonary complications(27.1% vs. 19.1%, P=0.007) and severe complication(27% vs. 14.1%, P=0.001). There was no difference in pathological UICC staging, but patients with DR were more likely to develop extrahepatic metastasis(21.3% vs. 12.7%, P=0.102). 5-year OS were 28.1% and 39.2%(P=0.009), while 5-year DFS were 17.9% and 23.4%(P=0.251) for the DR and non-DR groups respectively. Preoperative albumin, AFP, UICC stage, involved resection margin and the need for ICU support were associated with poor DFS but DR was not prognostic. Conclusion: HCC with diaphragmatic invasion was associated with poor tumor pathology and higher risk of postoperative pulmonary complications.

Regional Anesthesia for Abdominal Surgery in a Patient with Severe Chronic Respiratory Failure: A Case Report

General anesthesia is associated with a risk for postoperative pulmonary complications. The risk is even higher in patients with chronic respiratory failure, and postoperative mortality rates are high. Proper perioperative anesthetic management is important in such patients. Therefore, it is essential to optimize the patient’s physical status before anesthesia and to determine the optimal anesthesia technique based on the pre-anesthesia evaluation of the patient’s pulmonary function. We successfully performed abdominal surgery under spinal anesthesia in a patient with severe chronic respiratory failure.

Severe pulmonary complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are common and contribute to decreased overall survival.

Extensive abdominal surgery is associated with the risk of postoperative pulmonary complications. This study aims to explore the incidence and risk factors for developing postoperative pulmonary complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and to analyze how these complications affect overall survival. Data were collected on 417 patients undergoing surgery between 2007 and2017 at Uppsala University Hospital, Sweden. Postoperative pulmonary complications were graded according to the Clavien-Dindo classification system where Grade ≥ 3 was considered a severe complication. A logistic regression analysis was used to analyze risk factors for postoperative pulmonary complications and a Cox proportional hazards model to assess impact on survival. Seventy-two patients (17%) developed severe postoperative pulmonary complications. Risk factors were full thickness diaphragmatic injury and/or diaphragmatic resection [OR 5.393, 95% CI 2.924-9.948, p = < 0.001]. Severe postoperative pulmonary complications, in combination with non-pulmonary complications, contributed to decreased overall survival [HR 2.285, 95% CI 1.232-4.241, p = 0.009]. Severe postoperative pulmonary complications were common and contributed to decreased overall survival. Full thickness diaphragmatic injury and/or diaphragmatic resection were the main risk factors. This finding emphasizes the need for further research on the mechanisms behind pulmonary complications and their association with mortality.

Risk factors for pulmonary complications after neoadjuvant chemoradiotherapy followed by surgery for non-small cell lung cancer.

BackgroundWe aimed to investigate the characteristics and pretreatment risk factors for postoperative pulmonary complications (PPCs) after neoadjuvant concurrent chemoradiotherapy (CRTx) in patients with non‐small cell lung cancer (NSCLC).MethodsWe retrospectively reviewed data of 122 patients who underwent curative resection after neoadjuvant CRTx for NSCLC between 2007 and December 2019. Clinical data, including pulmonary function and body mass index (BMI) at the time of concurrent CRTx initiation, were analyzed. We performed logistic regression analyses to identify the risk factors for PPCs and built a nomogram with significant factors.ResultsOf the 122 patients included (mean age, 60.1 ± 9.7 years; 69.7% male), 27 experienced PPCs (severity grade ≥ 2). The most common PPCs were pneumonia (n = 17). Patients with PPCs had a significantly longer hospital stay (median 6.0 vs. 17 days, p < 0.001) and a higher in‐hospital mortality rate (1.1% vs. 29.6%, p < 0.001). In multivariable analysis, lower BMI (odds ratio [OR] 0.796, 95% confidence interval [CI] 0.628–0.987, p = 0.038), no comorbidity (OR 0.220, 95% CI: 0.059–0.819, p = 0.048), smoking history (OR 4.362, 95% CI: 1.210–15.720, p = 0.024), and %predicted DLCO <60% (OR 3.727, 95% CI: 1.319–10.530, p = 0.013) were independent risk factors for PPCs. The predictive accuracy of the nomogram built with factors was excellent (concordance index: 0.756).ConclusionsThe nomogram constructed with factors identified in multivariable analysis could serve as a reliable tool for evaluating the risk of PPCs in the patients who underwent neoadjuvant CRTx for NSCLC.

Asymptomatic Patients with Airflow Limitation are at Higher Risk of Postoperative Pulmonary Complications After Lung Surgeries: An Ambispective Cohort Study.

PurposeWith the use of pulmonary function tests (PFTs) as a preoperative examination, it is not rare to screen out airflow limitation (AFL) in asymptomatic patients undergoing lung surgeries. This study aims to elucidate whether there is a difference in the prevalence and prognosis of postoperative pulmonary complications (PPCs) between asymptomatic patients with newly diagnosed AFL and the normal population undergoing lung surgeries.Patients and MethodsThe medical records of asymptomatic patients undergoing lung surgeries who were spirometrically diagnosed with AFL between January and October 2017 were collected in Qilu hospital. These patients were subsequently followed up until February 2021. The diagnosis of PPCs was based on a recommended consensus definition. The incidence of PPCs between the newly diagnosed AFL group and the normal group was compared and a propensity score-matched analysis (PSM) was performed. The survival analysis was performed to investigate the long-term prognosis of the two groups.ResultsOverall, 535 asymptomatic subjects were recruited and 126 subjects (11.4%) were spirometrically diagnosed as AFL. The incidence of PPCs was significantly higher in the newly diagnosed AFL group than in the normal population (28.6%VS 14.4%, P < 0.001), especially in the FEV1/FVC≤65% group (P < 0.001), which were all confirmed by PSM analysis. Furthermore, these patients were at a higher risk of ICU admissions (P < 0.001) and 90-day hospital readmissions secondary to PPCs (P < 0.001). No significant differences were found in the overall, in-hospital and 90-day mortality between the AFL group and the normal group (P values >0.05).ConclusionAsymptomatic patients with AFL are at higher risk of PPCs than the general population after lung surgeries, along with an increase in ICU admissions and 90-day hospital readmissions secondary to PPCs. Although these patients tended to report worse current conditions, they were similar in the in-hospital, 90-day and overall mortality during the follow-up.

Do ARISCAT scores help to predict the incidence of postoperative pulmonary complications in elderly patients after upper abdominal surgery? An observational study at a single university hospital

BackgroundThe incidence of postoperative pulmonary complications (PPCs) is increasing in line with the rise in the number of surgical procedures performed on geriatric patients. In this study, we determined the incidence and risk factors of PPCs in elderly Thai patients who underwent upper abdominal procedures, and we investigated whether the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score helps to predict PPCs in Thais.MethodsA retrospective study was conducted on upper abdominal surgical patients aged over 65 years who had been admitted to the surgical ward of Siriraj Hospital, Mahidol University, Thailand, between January 2016 and December 2019. Data were collected on significant PPCs using the European Perioperative Clinical Outcome definitions. To identify risk factors, evaluations were made of the relationships between the PPCs and various preoperative, intraoperative, and postoperative factors, including ARISCAT scores.ResultsIn all, 1100 elderly postoperative patients were analyzed. Their mean age was 73.6 years, and 48.5% were male. Nearly half of their operations were laparoscopic cholecystectomies. The incidence of PPCs was 7.7%, with the most common being pleural effusion, atelectasis, and pneumonia. The factors associated with PPCs were preoperative oxygen saturation less than 96% (OR = 2.6, 1.2–5.5), albumin level below 3.5 g/dL (OR = 1.7, 1.0–2.8), duration of surgery exceeding 3 h (OR = 2.0, 1.0–4.2), and emergency surgery (OR = 2.8, 1.4–5.8). There was a relationship between ARISCAT score and PPC incidence, with a correlation coefficient of 0.226 (P < 0.001). The area under the curve was 0.72 (95% CI, 0.665–0.774; P < 0.001).ConclusionsPPCs are common in elderly patients. They are associated with increased levels of postoperative morbidities and extended ICU and hospital stays. Using the ARISCAT score as an assessment tool facilitates the classification of Thai patients into PPC risk groups. The ARISCAT scoring system might be able to be similarly applied in other Southeast Asian countries.

Prognostic Value of Preoperative Peak Expiratory Flow to Predict Postoperative Pulmonary Complications in Surgical Lung Cancer Patients.

ObjectivesCough impairment may lead to excessive accumulation of pulmonary secretions and increase the risk of postoperative pulmonary complications (PPCs). Peak expiratory flow (PEF) is a sensitive indicator of cough ability. We aimed to investigate the correlation between PEF and PPCs for lung cancer patients undergoing lobectomy or segmental resection for improved risk assessment.MethodsThis retrospective study assessed 560 patients with non-small cell lung cancer admitted for surgery between January 2014 to June 2016. The measurements of PEF were performed before surgery and the clinical outcomes were recorded, including PPCs, postoperative hospital stay, hospitalization costs, and other variables.ResultsPreoperative PEF was significantly lower in PPCs group compared to non-PPCs group (294.2 ± 95.7 vs. 363.0 ± 105.6 L/min, P < 0.001). Multivariable regression analysis showed that high PEF (OR=0.991, 95%CI: 0.988-0.993, P < 0.001) was an independent protective factor for PPCs. According to the receiver operating characteristic (ROC) curve, a PEF value of 250 L/min was selected as the optimal cutoff value in female patients, and 320 L/min in male patients. Patients with PEF under cutoff value of either sex had higher PPCs rate and unfavorable clinical outcomes.ConclusionsPreoperative PEF was found to be a significant predictor of PPCs for surgical lung cancer patients. It may be beneficial to consider the cutoff value of PEF in perioperative risk assessment.

Development and validation of a novel nomogram for postoperative pulmonary complications following minimally invasive esophageal cancer surgery.

Postoperative pulmonary complications (PPCs) are the most common complications following minimally invasive esophagectomy (MIE) and can be associated with adverse outcomes. This study aims to construct a nomogram based on clinical factors to predict PPCs and investigate related early outcomes. Clinical data of 969 consecutive patients receiving MIE were retrospectively collected. Univariate and multivariate analysis were performed to select independent predictors. Using independent predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal verification. Early outcomes of PPCs were analyzed. The incidence of PPCs following MIE was 39.6% (384 out of 969). In multivariate analysis, older age (Odds ratio (OR) 1.034, P < 0.001), higher body mass index (OR 0.993, P = 0.003), heavy smoking (OR 1.396, P = 0.027), FEV1/FVC < 105% (OR 1.958, P < 0.001), chemoradiotherapy (OR 0.653, P = 0.039), estimated blood loss ≥ 400mL (OR 2.582, P = 0.018), general anesthesia (vs Combined thoracic paravertebral blockade, OR 1.578, P = 0.014), operative time ≥ 240min (OR 1.388, P = 0.027), squamous cell carcinoma (OR 2.099, P = 0.036) and conversion to thoracotomy (OR 2.820, P = 0.026) were independent predictors for PPCs. These ten independent predictors were used to develop a nomogram, with concordance index (C index) value of 0.662 and good calibration. After internal validation, similarly good calibration and discrimination (C index, 0.654; 95% CI 0.614-0.690) were observed. Patients developing PPCs had higher rates of anastomotic leakage, reoperation, ICU and 30-day readmissions, and prolonged ICU and hospital stays (P < 0.05). Our study identified ten predictors for PPCs, which were associated with poor early outcomes. The proposed nomogram can be a useful tool to identify patients at high risk of PPCs after MIE.