Risk Of Postoperative Respiratory Complications Research Articles

Preoperative GLP-1 Receptor Agonist Use and Risk of Postoperative Respiratory Complications

This cohort study evaluates the risk of postoperative respiratory complications among patients with diabetes undergoing surgery who had vs those who had not a prescription fill for glucagon-like peptide 1 receptor agonists.

Sublobar resection or lobectomy and postoperative respiratory complications in emphysematous lungs.

Pulmonary resection in patients with severe emphysema may impact postoperative respiratory complications. Low-attenuation areas evaluated using three-dimensional computed tomography to assess emphysematous changes are strongly associated with postoperative respiratory complications. Herein, we investigated the relationship between low-attenuation area, the surgical procedure and resected lung volume, which has not been explored in previous studies. We retrospectively evaluated patients with primary or metastatic lung cancer who underwent surgical resection. The low-attenuation area percentage (low-attenuation area/total lung area × 100) and resected lung volume were calculated using three-dimensional computed tomography software, and the relationship with postoperative respiratory complications was analysed. Postoperative respiratory complications occurred in 66 patients (17%) in the total cohort (n = 383). We set the median value of 1.1% as the cut-off value for low-attenuation area percentage to predict postoperative respiratory complications, which occurred in 24% and 10% of patients with low-attenuation area >1.1% and <1.1%, respectively (P < 0.001). Postoperative respiratory complications occurred in approximately one-third of the patients with low-attenuation area >1.1%, whose resected lung volume was ≥15.8% or ≥5 resected subsegments. Multivariable analysis revealed that sublobar resection was associated with a significantly lower risk of postoperative respiratory complications in patients with low-attenuation area >1.1% (odds ratio 0.4, 95% confidence interval 0.183-0.875). Emphysema is a risk factor for postoperative respiratory complications, and lobectomy is an independent predictive risk factor. Preserving more lung parenchyma may yield better short-term prognoses in patients with emphysematous lungs.

Personalized Noninvasive Respiratory Support in the Perioperative Setting: State of the Art and Future Perspectives.

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives: This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results: During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions: There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience.

Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. A total of twentytwo patients (68% male, median age 70years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

Analgesic efficacy of systemic lidocaine using lean body mass based dosing regime versus placebo in bariatric surgery: a prospective, randomised, double-blind, placebo-controlled, single-centre study

BackgroundIntravenous lidocaine is used as an adjuvant analgesic agent in perioperative settings. It has been investigated in various patient populations and surgical interventions, but there are limited data on its efficacy, particularly for patients undergoing bariatric surgery. Obese patients are at high risk of postoperative respiratory complications and can be expected to benefit from anaesthetic techniques that minimise opioid administration. MethodsWe studied administration of lidocaine hydrochloride 1% i.v. to general anaesthesia at a dose of 1.5 mg kg−1 (lean body mass×1.28) or placebo in patients undergoing bariatric surgery. Subjects randomly assigned to each group were surveyed for 48 h after surgery for experienced pain (primary outcome), and administered opioids, postoperative nausea and vomiting (PONV), resumption of bowel function, and length of hospital stay (secondary outcomes). ResultsWe recruited and randomised 140 subjects to either the lidocaine or placebo group; 137 completed the study. Subjects with pain numeric rating scale (NRS) >3 within the first 4 h postoperatively were similar in both groups (proportion of any NRS >3 within first 4 h lidocaine group: 47/68 (69%) vs placebo group: 44/69 (63%), P=0.507; within first h P=0.177, within second h P=0.513, within third h P=0.145, within fourth h P=0.510). There was no difference in maximal pain score, opioid consumption, recovery of bowel function, incidence of PONV, or length of hospital stay. ConclusionsLidocaine does not improve postoperative pain scores, analgesia, or any secondary outcomes in patients undergoing bariatric surgery. Clinical trial registrationNCT03667001.

ROCURONIUM BROMIDE – ESMERON

&lt;div&gt;&lt;p&gt;Repeated neuromuscular-blocking agent administration lengthens the duration of action, and intraoperative use of high doses of neuromuscular-blocking agent may compromise respiratory security. We tested the main hypothesis that intermediate-acting neuromuscular-blocking agents are dose dependently associated with the risk of postoperative respiratory complications in a hospital-based registry study that took place between January 2022 and June 2022 on 70 patients that we worked with who received these medications. Additionally, we looked at the relationship between respiratory problems and the dose of neostigmine used to reverse neuromuscular blockers. We assessed the impact of proper neostigmine reversal on respiratory complications post hoc. Compared to low doses, high doses of neuromuscular-blocking drugs were linked to a higher risk of postoperative respiratory complications. A dose-dependent increase in the risk of postoperative respiratory complications was linked to neostigmine. According to post hoc analysis, the dose-dependent relationship between neuromuscular-blocking drugs and respiratory complications was eliminated by the proper neostigmine reversal. The risk of postoperative respiratory complications was dose-dependently correlated with the use of neuromuscular-blocking drugs. The risk of respiratory complications increased dose-dependently after neostigmine reversal. The exploratory data analysis, however, indicates that the proper use of neostigmine, guided by the results of the monitoring of neuromuscular transmission, can help eliminate the postoperative respiratory complications brought on by the use of neuromuscular-blocking drugs. For newborns and small infants, rocuronium should be administered in lower doses.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;span&gt;Keywords: &lt;/span&gt;&lt;/strong&gt;&lt;span&gt;respiratory complications, Esmeron, neostigmine, surgery, anesthetic, intubation, etc.&lt;/span&gt;&lt;/p&gt;&lt;/div&gt;

Analysis of Postoperative Complications of Minimally Invasive Surgery for Carcinoma of Oesophagus: A Single Centre Retrospective Cohort Study

Introduction: Traditional transthoracic oesophagectomy is associated with high perioperative morbidity. Minimally Invasive Oesophagectomy (MIE) techniques have been shown to have a decreased incidence of respiratory complications and an improvement in perioperative outcomes, such as length of hospital stay and wound infection rates. Aim: To evaluate the incidence of postoperative respiratory complications, 30-day mortality, and length of hospital stay among patients with carcinoma of the oesophagus undergoing, VideoAssisted Thoracoscopic Surgery (VATS) oesophagectomy. Materials and Methods: A cross-sectional study was conducted in the Department of Anaesthesiology in a new thoracic oncology unit at a Tertiary Cancer care centre, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India. A total of 67 patients with resectable oesophageal cancer who underwent VATS oesophagectomy from September 2019 to December 2021 were included. Patients who had surgery by open thoracotomy and inoperable cases were excluded. The patients’ clinicodemographic profile, intraand postoperative variables, and complications were studied. Descriptive statistics were used for analysis. A p-value ≤0.05 was considered statistically significant at a 5% level of significance. Results: Out of 67 patients, 45 (67.2%) were male, and 22 (32.8%) were female. The age ranged from 33 to 78 years with a median age of 55 years (IQR 47-61). The median body weight was 45 kg (IQR 42-53). Nineteen (28.4%) patients developed postoperative complications, including respiratory distress in 7 (10.4%) and anastomotic leakage in 5 (7.5%) patients. Other complications included symptomatic Coronavirus Disease 2019 (COVID-19) infection, pneumonia, mediastinitis, Multiorgan Dysfunction Syndrome (MODS) with sepsis, seizure and cardiac arrest, and surgical re-exploration. The 30-day mortality was 2.98%. The median length of hospital stay was 19 days (Interquantile Range (IQR) 16-22), which was higher in those with complications (p&lt;0.001). One-lung ventilation was associated with a higher risk of postoperative respiratory complications (p=0.077). Conclusion: VATS oesophagectomy, even in a new thoracic oncology unit, was associated with lower perioperative complications, a shorter hospital length of stay, and decreased mortality compared to historical controls.

Difficult intubation and postoperative aspiration pneumonia associated with Moebius syndrome: a case report

BackgroundMoebius syndrome is a rare congenital disorder characterized by non-progressive palsy of the abducens (VI) and facial (VII) cranial nerves. Its common features include dysfunctions associated with other cranial nerves, orofacial abnormalities, skeletal muscle hypotonia, and other systemic disorders of differing severities. There are several concerns in the perioperative management of patients with Moebius syndrome.Case presentationWe present a report on the management of general anesthesia of a 14-year-old male patient with Moebius syndrome who was scheduled for mandibular cystectomy. The patient was diagnosed with Moebius syndrome at the age of 7 years based on his clinical manifestations of nerve palsy since birth and cranial nerve palsy of the trigeminal (V), facial (VII), glossopharyngeal (IX), vagus (X), and sublingual nerves (XII). The patient’s oral morphological abnormalities made intubation difficult. He also experienced dysphagia and aspiration pneumonia on a daily basis. Oral secretions were frequently suctioned postoperatively. However, after discharge, the patient developed aspiration pneumonia and was readmitted to the hospital.ConclusionsThe main problem arising when administering general anesthesia to patients with this syndrome is difficult airway management. The oral abnormalities in these patients, such as small jaw and extreme dental stenosis, make mask ventilation and intubation difficult. Furthermore, this syndrome often involves respiratory impairment and dysphagia due to cerebral nerve palsy, so there is a high risk of postoperative respiratory complications. Since multiple organs are affected in patients with Moebius syndrome, appropriate perioperative management strategies must be prepared for these patients.

The risk of postoperative respiratory complications following adenotonsillar surgery in children with or without obstructive sleep apnea: A systematic review and meta-analysis.

Obstructive sleep apnea (OSA) appears in 2%-5% of children, with first-line treatment being adenotonsillar (AT) surgery. Our aim was to examine the risk of postoperative respiratory complications (PoRCs) in non-OSA and the different OSA severity (mild, moderate, severe) groups. We conducted a systematic review and meta-analysis of studies comparing PoRCs following AT surgery in children with and without OSA. Nineteen observational studies were identified with the same search key used in MEDLINE, Embase, and CENTRAL. The connection between PoRCs, the presence and severity of OSA, and additional comorbidities were examined. Odds ratios (OR) were calculated with 95% confidence intervals (CI). We found that PoRCs appeared more frequently in moderate (p = 0.048, OR: 1.79, CI[1.004, 3.194]) and severe OSA (p = 0.002, OR: 4.06, CI[1.68, 9.81]) compared to non-OSA patients. No significant difference was detected in the appearance of major complications (p = 0.200, OR: 2.14, CI[0.67, 6.86]) comparing OSA and non-OSA populations. No significant difference was observed in comorbidities (p = 0.669, OR: 1.29, CI[0.40, 4.14]) or in the distribution of PoRCs (p = 0.904, OR: 0.94, CI[0.36, 2.45]) between the two groups. Uniform guidelines and a revision of postoperative monitoring are called for aschildren with moderate and severe OSA are more likely to develop PoRCs following AT surgery based on our results, but no significant difference was found in mild OSA. Furthermore, the presence of OSA alone is not associated with an increased risk of developing major complications.

Reliability of dynamic perfusion digital radiography as an alternative to pulmonary perfusion scintigraphy in predicting postoperative lung function and complications.

BackgroundAccurate perioperative risk assessment can enhance the perioperative management of patients undergoing radical surgery for lung cancer. In this study, we compared the accuracy of predicting perioperative complications by lung function values, estimated by blood flow ratios (BFRs), to determine whether dynamic perfusion digital radiography (DPDR) could substitute for pulmonary perfusion scintigraphy (PPS).MethodsPatients scheduled for radical surgery for lung cancer who underwent simultaneous dynamic chest radiography (DCR) and lung perfusion scintigraphy were assessed. We confirmed the agreement between two methods in the assessment of the BFR and its predicted postoperative (ppo) value. Besides, the best spirometry thresholds for the risk of perioperative respiratory or cardiovascular complications were calculated from a receiver operating characteristic (ROC) analysis. The imaging methods were compared for sensitivity and specificity.ResultsAmong the 44 cases enrolled, DPDR and PPS showed high correlations in BFR (r=0.868, P<0.01) and its postoperative value (r=0.975, P<0.01) and between the predicted and measured spirometry values. In both imaging modalities, the estimated postoperative diffusing capacity test for carbon monoxide (DLco) had the best prediction [area under the curve (AUC) >0.7] for respiratory complications within 1 month (with different cut-offs for same target cases). For predicting, respiratory complications within 1–3 months after surgery, these values were similar between two modalities. Furthermore, the ppoDLco values from both imaging methods were excellent indicators of the induction of postoperative long term oxygen therapy, with the AUC greater than 0.8.ConclusionsThis study showed that simple and less invasive DPDR can be a good alternative to PPS for predicting postoperative pulmonary function values and the risk of postoperative respiratory complications. This new imaging modality will offer new insights and possible functional analyses of pulmonary circulation.

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis

ObjectivesTo evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery. MethodsMedline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4). ResultsOut of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I2 = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I2 = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I2 = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I2 = 0%, p = 0.94) between early and delayed groups. ConclusionWhile early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances. Level of evidenceTreatment study, level 3.

Association between intraoperative tidal volume and postoperative respiratory complications is dependent on respiratory elastance: a retrospective, multicentre cohort study

BackgroundThe impact of high vs low intraoperative tidal volumes on postoperative respiratory complications remains unclear. We hypothesised that the effect of intraoperative tidal volume on postoperative respiratory complications is dependent on respiratory system elastance. MethodsWe retrospectively recorded tidal volume (Vt; ml kg−1 ideal body weight [IBW]) in patients undergoing elective, non-cardiothoracic surgery from hospital registry data. The primary outcome was respiratory failure (requiring reintubation within 7 days of surgery, desaturation after extubation, or both). The primary exposure was defined as the interaction between Vt and standardised respiratory system elastance (driving pressure divided by Vt; cm H2O/[ml kg−1]). Multivariable logistic regression models, with and without interaction terms (which categorised Vt as low [Vt ≤8 ml kg−1] or high [Vt >8 ml kg−1]), were adjusted for potential confounders. Additional analyses included path mediation analysis and fractional polynomial modelling. ResultsOverall, 10 821/197 474 (5.5%) patients sustained postoperative respiratory complications. Higher Vt was associated with greater risk of postoperative respiratory complications (adjusted odds ratio=1.42 per ml kg−1; 95% confidence interval [CI], 1.35–1.50]; P<0.001). This association was modified by respiratory system elastance (P<0.001); in patients with low compliance (<42.4 ml cm H2O−1), higher Vt was associated with greater risk of postoperative respiratory complications (adjusted risk difference=0.3% [95% CI, 0.0–0.5] at 41.2 ml cm H2O−1 compliance, compared with 5.8% [95% CI, 3.8–7.8] at 14 ml cm H2O−1 compliance). This association was absent when compliance exceeded 41.2 ml cm H2O−1. Adverse effects associated with high Vt were entirely mediated by driving pressures (P<0.001). ConclusionsThe association of harm with higher tidal volumes during intraoperative mechanical ventilation is modified by respiratory system elastance. These data suggest that respiratory elastance should inform the design of perioperative trials testing intraoperative ventilatory strategies.

Meta-analysis of the association between obstructive sleep apnea and postoperative complications

ObjectiveTo clarify the association between obstructive sleep apnea (OSA) and postoperative outcomes, investigate whether preoperative diagnosis and continuous positive airway pressure (CPAP) therapy reduce the risks and examine the impact of OSA severity on postoperative outcomes. MethodsThe PubMed, Cochrane Library and Embase databases were searched from inception until April 2021 for studies evaluating the association between OSA and postoperative adverse events. A random effects model was used to calculate the pooled outcome. Sensitivity analysis and publication bias were conducted to verify the robustness and reliability of the results. ResultsIn total, 46 studies were eligible for further analysis. OSA was significantly associated with higher risks of postoperative respiratory complications (OR = 1.91; 95% CI = 1.54 to 2.36) and cardiac complications (OR = 1.74; 95% CI = 1.25 to 2.42), and the risks increased with OSA severity. OSA also increased the risk of intensive care unit (ICU) transfer (OR = 1.92; 95% CI = 1.32 to 2.80), increased the risk of postoperative delirium (OR = 1.83; 95% CI = 1.26 to 2.66) and prolonged the length of hospital stay (WMD = 0.48; 95% CI = 0.15 to 0.82). Subgroup analysis indicated that preoperative diagnosis and use of CPAP decrease the risk of postoperative respiratory complications (OR = 1.87; 95% CI = 1.43 to 2.43) and cardiac complications (OR = 1.17; 95% CI = 0.91 to 1.51). ConclusionsPatients with OSA have a higher risk of postoperative cardiopulmonary complications, ICU transfer, delirium, pneumonia, bleeding and prolonged length of hospital stay. OSA severity is an important risk modifier for postoperative complications, preoperative diagnosis and CPAP therapy may attenuate the occurrence of postoperative complications. The conclusions need to be interpreted with caution due to the limitations in the data, despite this, the results indicate and inform the need for further and larger trials. ProsperoCRD42021254374.

Respiratory prehabilitation in pediatric anesthesia in children with muscular and neurologic disease.

Children with neuromuscular, chronic neurologic, and chest wall diseases are at increased risk of postoperative respiratory complications including atelectasis, pneumonia, and respiratory failure with the possible need for reintubation or even tracheostomy. These complications negatively impact patient outcomes, including increased healthcare resource utilization and increased surgical mortality. In these children, the existing respiratory reserve is often inadequate to withstand the stresses brought on during anesthesia and surgery. A thorough clinical assessment and objective evaluation of pulmonary function and gas exchange can help identify which children are at particular risk for poor postoperative outcomes and thus merit preoperative interventions. These may include initiation and optimization of non-invasive ventilation and mechanical insufflation-exsufflation. Furthermore, such an evaluation will help identify children who may require a postoperative extubation plan tailored to neuromuscular diseases. Such strategies may include avoidance of pre-extubation lung decruitment by precluding continuous positive airway pressure trials, aggressively weaning to room air and directly extubating to non-invasive ventilation with a high inspiratory to expiratory pressure differential of at least 10cm H20. Children with cerebral palsy and other neurodegenerative or neurodevelopmental disorders are a more heterogeneous group of children who may share some operative risk factors with children with neuromuscular disease; they may also be at risk of sleep-disordered breathing, may also require non-invasive ventilation or mechanical insufflation-exsufflation, and may have associated chronic lung disease from aspirations that may require perioperative treatment.

Retrospective Analysis of Patients Who Underwent Larynx Biopsy: Three-year Results In The Post-Anesthesia Care Unit

Objective:Direct laryngoscopy is a procedure which is used for both making a diagnosis and taking a biopsy specimen, in patients with larynx pathology. All patients who have undergone airway examination and surgery are at risk for postoperative respiratory complications and require close follow up. For this reason, in our center, such patients are followed-up in Post Anesthesia Care Unit (PACU) post-operatively for close follow-up and treatment. Methods:The data of 406 patients who have undergone direct laryngoscopy and suspension biopsy procedures and followed-up in PACU, were examined retrospectively. The time until extubation, total time spent in the PACU, analgesic, sedative and any additional medication requirements were recorded. Patients were observed for complications. Descriptive statistics, Student T-test and Friedman Test were applied. Results:The records of 406 patients who have undergone direct laryngoscopy and suspension biopsy procedures and admitted to PACU post-operatively in a 3 year time period were reviewed. Of all the patients, 333 were male and 73 were female. We found that time until extubation was 91 ± 45 minutes and total time spent in PACU was 186 ± 77 minutes. There was no statistically significant difference in the systolic, diastolic, and mean arterial pressure, oxygen saturation, and heart rates of patients during the PACU follow-up (p:0.12, p:0.27, p:0.17, p:0,41, p:0,07; respectively). During the PACU follow-up 7 patients have experienced complications and 8 patients had a prolonged PACU stay because of airway edema [total 15 patient (3, 69 % Conclusion:We think that admittance and follow up in the PACU, in the early post-operative period for patients who undergone upper airway surgery is useful.

Sternal lifting increases the operating space in esophagectomy via mediastinoscopy: a prospective cohort study.

BackgroundEsophagectomy with combined single-port inflatable mediastinoscopy and laparoscopy reduces the risk of postoperative respiratory complications as it obviates the need to pass through the pleural space. However, it has strict indications owing to the narrow space for operation. Therefore, we adopted a sternal lifting method using a retractor that enables the expansion of the operating space, a technique which has not been previously reported. We describe our experience and report the results of an evaluation of this new approach.MethodsThirty-nine patients with esophageal squamous cell carcinomas underwent esophagectomy using combined single-port inflatable mediastinoscopy and laparoscopy from March 2019 to August 2021. Among them, 20 cases received sternal suspension [sternal suspension group (SS group)], and 19 cases did not receive sternal suspension [non-sternal suspension group (NSS group)]. The short-term efficacy of the two groups was observed.ResultsPatients in the SS group had a shorter intramediastinal operation time (82.50 vs. 110.00 minutes; P<0.001), more dissected chest lymph nodes (14 vs. 12; P=0.036), and a lower incidence of postoperative hoarseness (2 vs. 6; P=0.235) than did those in the NSS group. There were no significant differences between the SS group and NSS group in terms of intraoperative blood loss, postoperative hospital stay, post-surgical pathologic TNM classification (pTNM), post-surgical pathologic tumor classification (pT), post-surgical pathologic extent of lymph node involvement (pN), and total number of dissected lymph nodes. There were no statistical differences in the incidence of anastomotic fistula, respiratory complications, arrhythmia, or chylothorax between the two groups. There was no mortality during hospitalization in the two groups.ConclusionsSternal lifting increases the working space in esophagectomy via mediastinoscopy. It can make video-assisted radical esophagectomy by a transmediastinal approach with total pneumomediastinum assistance (VARETT) easier to perform, and sternal suspension in VARETT is safe and effective.

Postoperative respiratory complications after adenotonsillectomy in children with obstructive sleep apnea

ObjectiveChildren with obstructive sleep apnea are considered high risk for postoperative respiratory complications, but opinions differ regarding the polysomnography (PSG) criteria that suggest the need for postoperative admission. Our objective was to determine if otherwise healthy children age ≥3 years with an apnea-hypopnea index (AHI) < 24 on overnight PSG can be safely discharged on the same day of surgery. MethodsCase series with chart review of children age <18 years with positive PSG (AHI > 2) who underwent adenotonsillectomy (T&A) between January 2013 and August 2019. Data collected included patient demographics, medical history, comorbidities, PSG results, operative details, length of stay, intraoperative and postoperative respiratory complications and management. Potential predictors of respiratory complications were evaluated using chi-square/Fisher's exact test and 2-tailed unpaired t tests with the Bonferroni adjustment for multiple comparison artifact. The percentages of healthy children age ≥3 years who were discharged on the day of surgery at various PSG cutoffs were calculated. ResultsOf the 560 children, mean (SD) age was 6.4 (3.7) years, 318 (56.8%) were male, 438 (78.2%) were African American, 243 (43.4%) were obese, 16 (2.9%) had Down Syndrome and 12 (2.1%) had sickle cell disease. Median (range) AHI was 12.3 (2–145). Fifteen children (2.7% [95% CI 1.3, 4.0]) had an intraoperative or postoperative respiratory complication. Minor complications including mild desaturation, stridor, croupy cough, and laryngospasm occurred in 9 patients and did not prolong the planned ambulatory or hospital stay. Of the 6 children with more severe complications including prolonged desaturation, tachypnea, atelectasis, intercostal retraction and obstructive apnea requiring continuous positive airway pressure, all were planned admissions based on age, severe sleep study indices (AHI ≥ 24 or oxygen saturation nadir < 80%) or underlying medical condition. Of the 165 children age ≥3 without medical comorbidities known to be predictive of postoperative complications with an AHI ≥10 but <24, 113 (68.5%) were discharged home on the same day of surgery without additional respiratory sequelae. ConclusionsThis study demonstrates a low risk of respiratory complications after T&A. Otherwise healthy children age ≥3 years with AHI <24 may be considered for ambulatory discharge.

Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study.

Study objectiveTo evaluate the effectiveness of preoperative gabapentinoid administration. DesignRetrospective hospital registry study. SettingTertiary referral center (Boston, MA). Patients111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018. InterventionsPreoperative administration of gabapentinoids (gabapentin or pregabalin). MeasurementsWe tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications. Main resultsGabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [ORadj] 0.80 [95% CI, 0.75–0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4–11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (ORadj 0.74 [0.60–0.90]; p = 0.003), neuro-psychiatric complications (ORadj 0.66 [0.49–0.87]; p = 0.004), non-surgical site infections (ORadj 0.68 [0.52–0.88; p = 0.004) and trauma or poisoning (ORadj 0.25 [0.16–0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (ORadj 0.77 [0.70–0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (ORadj 0.61 [0.50–0.75]; p < 0.001 and ORadj 0.70 [0.53–0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (ORadj 0.74 [0.65–0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery. ConclusionsThe preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.

Robotic Intraoperative Tracheobronchial Repair during Minimally Invasive 3-Stage Esophagectomy

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

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

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