Risk Of Pulmonary Complications Research Articles

Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study)

BackgroundPregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period.MethodsWe conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome.ResultsTwenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs.ConclusionThis study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.

Managing the Risk of Lung Toxicity with Trastuzumab Deruxtecan (T-DXd): A Canadian Perspective.

Ongoing advances in precision cancer therapy have increased the number of molecularly targeted and immuno-oncology agents for a variety of cancers, many of which have been associated with a risk of pulmonary complications, among the most concerning being drug-induced interstitial lung disease/pneumonitis (DI-ILD). As the number of patients undergoing treatment with novel anticancer agents continues to grow, DI-ILD is expected to become an increasingly significant clinical challenge. Trastuzumab deruxtecan (T-DXd) is an antibody-drug conjugate targeting human epidermal growth factor receptor 2 that is gaining widespread use in the metastatic breast cancer setting and is undergoing exploration for other oncologic indications. ILD/pneumonitis is an adverse event of special interest associated with T-DXd, which has potentially fatal consequences if left untreated and allowed to progress. When identified in the asymptomatic stage (grade 1), T-DXd-related ILD can be monitored and treated effectively with the possibility of treatment continuation. Delayed diagnosis and/or treatment, however, results in progression to grade 2 or higher toxicity and necessitates immediate and permanent discontinuation of this active agent. Strategies are, therefore, needed to optimize careful monitoring during treatment to ensure patient safety and optimize outcomes. Several guidance documents have been developed regarding strategies for the early identification and management of T-DXd-related ILD, although none have been within the context of the Canadian health care environment. A Canadian multidisciplinary steering committee was, therefore, convened to evaluate existing recommendations and adapt them for application in Canada. A multidisciplinary approach involving collaboration among medical oncologists, radiologists, respirologists, and allied health care professionals is needed to ensure the proactive identification and management of T-DXd-related ILD and DI-ILD associated with other agents with a similar toxicity profile.

Regional Anesthesia for Lobectomy and Risk of Pulmonary Complications: A National Safety Quality Improvement Program Propensity-Matching Analysis

To determine whether general anesthesia (GA) in conjunction with regional anesthetic (RA) techniques are associated with favorable pulmonary outcomes versus GA alone among patients undergoing lobectomy by either video-assisted thoracoscopic surgery (VATS) or open thoracotomy. A retrospective cohort (2014-2017). The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing lobectomy by either VATS or open thoracotomy. Two groups of patients were identified based on the use of GA alone or GA in conjunction with RA (RA+GA) techniques (either neuraxial or peripheral nerve blocks). Both groups were propensity-matched based on pulmonary risk factors. The authors' primary outcome was composite postoperative pulmonary complication (PPC), including pneumonia, reintubation, and failure to wean from the ventilator. A total of 4,134 VATS (2,067 in GA and 2,067 in RA+GA) and 3,112 thoracotomies (1,556 in GA and 1,556 in RA+GA) were included in the final analysis. Regional anesthetic, as an adjuvant to GA, did not affect the incidence of PPC among patients undergoing lobectomy by VATS (odds ratio [OR] 1.07, 95% CI 0.81-1.43, p=0.622), as well as in those undergoing lobectomy via thoracotomy (OR 1.19, 95% CI 0.93-1.51, p=0.174). There was no statistically significant difference between groups in terms of readmission rates, length of stay, and mortality at 30 days. The RA techniques were not associated with a lower incidence of pulmonary complications in lobectomy surgery.

Effect of positioning and expiratory rib-cage compression on atelectasis in a patient who required prolonged mechanical ventilation: a case report

BackgroundPulmonary complications can be caused by intraoperative mechanical ventilation. In particular, prolonged mechanical ventilation is associated with a high mortality rate, a risk of pulmonary complications, prolonged hospitalization, and an unfavorable discharge destination. Pre- and postoperative rehabilitation are important for the resolution of pulmonary complications in acute cases. However, there has been a lack of studies on interventions for pulmonary rehabilitation of patients with chronic pulmonary complications caused by prolonged mechanical ventilation. Accordingly, we describe the effect of pulmonary rehabilitation in such a patient.Case presentationWe examined a 63-year-old Japanese woman with hypoxic–ischemic encephalopathy after subarachnoid hemorrhage who required prolonged mechanical ventilation. Radiographic and computed tomographic images revealed atelectasis of the right upper lobe. In addition, this atelectasis reduced the tidal volume, minute volume, and oxygen saturation and caused an absence of breath sounds in the right upper lobe during auscultation. We aimed to ameliorate the patient’s atelectasis and improve her ventilation parameters by using positioning and expiratory rib-cage compression after endotracheal suctioning. Specifically, the patient was seated in Fowler’s position, and mild pressure was applied to the upper thorax during expiration, improving her inspiratory volume. Immediately, breath sounds were audible in the right upper lobe. Furthermore, resolution of the patient’s atelectasis was confirmed with chest radiography performed on the same day. In addition, her ventilation parameters (tidal volume, minute volume, and oxygen saturation) improved.ConclusionsOur results indicate that physical therapists should consider application of specific positioning and expiratory rib-cage compression in patients who exhibit atelectasis because of prolonged mechanical ventilation.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. British Journal of Surgery Society.

Postoperative pulmonary complications with adjuvant regional anesthesia versus general anesthesia alone: a sub-analysis of the Perioperative Research Network study

BackgroundAdjuvant regional anesthesia is often selected for patients or procedures with high risk of pulmonary complications after general anesthesia. The benefit of adjuvant regional anesthesia to reduce postoperative pulmonary complications remains uncertain. In a prospective observational multicenter study, patients scheduled for non-cardiothoracic surgery with at least one postoperative pulmonary complication surprisingly received adjuvant regional anesthesia more frequently than those with no complications. We hypothesized that, after adjusting for surgical and patient complexity variables, the incidence of postoperative pulmonary complications would not be associated with adjuvant regional anesthesia.MethodsWe performed a secondary analysis of a prospective observational multicenter study including 1202 American Society of Anesthesiologists physical status 3 patients undergoing non-cardiothoracic surgery. Patients were classified as receiving either adjuvant regional anesthesia or general anesthesia alone. Predefined pulmonary complications within the first seven postoperative days were prospectively identified. Groups were compared using bivariable and multivariable hierarchical logistic regression analyses for the outcome of at least one postoperative pulmonary complication.ResultsAdjuvant regional anesthesia was performed in 266 (22.1%) patients and not performed in 936 (77.9%). The incidence of postoperative pulmonary complications was greater in patients receiving adjuvant regional anesthesia (42.1%) than in patients without it (30.9%) (site adjusted p = 0.007), but this association was not confirmed after adjusting for covariates (adjusted OR 1.37; 95% CI, 0.83–2.25; p = 0.165).ConclusionAfter adjusting for surgical and patient complexity, adjuvant regional anesthesia versus general anesthesia alone was not associated with a greater incidence of postoperative pulmonary complications in this multicenter cohort of non-cardiothoracic surgery patients.

The efficacy of pulmonary rehabilitation exercise training on complications and mortality after lung cancer resection: a systematic review and meta-analysis.

BackgroundThe efficacy of pulmonary rehabilitation exercise training for patients after lung cancer resection has been controversial. We sought to evaluate the efficacy of pulmonary rehabilitation on the incidence of complications and mortality in patients after lung cancer resection.MethodsSearch English databases PubMed, EMBASE, Medline to obtain literature. The literature compared the effect of pulmonary rehabilitation exercise training intervention or not on the efficacy of patients after lung cancer resection, and the outcomes included postoperative complications and mortality. The quality of the included literature was assessed according to the Cochrane risk of bias assessment work. The chi-square test was used to test for heterogeneity. When there is heterogeneity, a random effect model is used; when there is no heterogeneity, a fixed effect model is used.ResultsA total of 9 prospective clinical studies (comprising 1,338 patients) were included in this meta-analysis. Among the patients, there were 571 cases in the rehabilitation group and 767 cases in the control group. The incidence of postoperative complications in the rehabilitation group was lower than that in the control group. The odds ratio (OR) value was 0.66 and 95% confidence interval (CI) was 0.47–0.94 (P=0.02). There was no heterogeneity among studies and no publication bias. The incidence of postoperative pulmonary complications in the rehabilitation group was lower than that in the control group, OR =0.33 (95% CI: 0.22–0.50) (P<0.00001). There was no heterogeneity among studies and no publication bias. There was no significant difference in postoperative mortality between the 2 groups (OR =0.77; 95% CI: 0.26–2.30; P=0.65). There was no heterogeneity among studies and no publication bias.DiscussionImplementing pulmonary rehabilitation significantly reduced postoperative complications and the risk of pulmonary complications in lung cancer patients, but had no significant effect on mortality. Pulmonary rehabilitation exercise training is recommended for patients undergoing lung cancer resection.

Morphometric indicators for selection of dual endobronchial tube in thoracic anesthesiology

For the purpose of single-lung ventilation, various methods of lung isolation are used in the world, which is a prerequisite for many thoracic, cardiac and esophageal surgeries. Numerous studies have reported various methods for determining the optimal suitability between the diameter of the tube and the diameter of the left main bronchus for adequate ventilation and gas exchange during operations on the thoracic cavity. However, there is no consensus among anesthesiologists on the choice of tube size for effective lung ventilation and isolation. We have developed a new mathematical formula for determining the appropriate size of the left bilateral luminal endobronchial tube (LDT). The aim of the study was to determine the effectiveness of the developed standardized mathematical formula for determining the appropriate size of LDT for use in thoracic anesthesiology. The study was performed on 192 patients with diseases of the thoracic cavity (esophagus, lungs, mediastinum), operated on in the thoracoabdominal department of the Shalimov National Institute of Surgery and Tranplantology. A retrospective comparison group – 96 patients after thoracic surgery, which used the choice of LDT size according to the well-known Slinger method “according to the patient’s height”. The study group consisted of 96 patients after thoracic surgery, in which the choice of the size of the bifurcated endobronchial tube was used according to the developed method (according to the formula that evaluates morphometric indicators of height, sex and diameter of the left main bronchus). The application of the proposed method reduces (p = 0.001) the risk of pulmonary complications, HR = 0.39 (95 % CI 0.22-0.70) compared to traditional methods. The risk decreased 2.5 times.

Multiple Machine Learning Approaches Based on Postoperative Prediction of Pulmonary Complications in Patients With Emergency Cerebral Hemorrhage Surgery.

ObjectiveThis study aimed to create a prediction model of postoperative pulmonary complications for the patients with emergency cerebral hemorrhage surgery.MethodsPatients with hemorrhage surgery who underwent cerebral hemorrhage surgery were included and divided into two groups: patients with or without pulmonary complications. Patient characteristics, previous history, laboratory tests, and interventions were collected. Univariate and multivariate logistic regressions were used to predict postoperative pulmonary infection. Multiple machine learning approaches have been used to compare their importance in predicting factors, namely K-nearest neighbor (KNN), stochastic gradient descent (SGD), support vector classification (SVC), random forest (RF), and logistics regression (LR), as they are the most successful and widely used models for clinical data.ResultsThree hundred and fifty four patients with emergency cerebral hemorrhage surgery between January 1, 2017 and December 31, 2020 were included in the study. 53.7% (190/354) of the patients developed postoperative pulmonary complications (PPC). Stepwise logistic regression analysis revealed four independent predictive factors associated with pulmonary complications, including current smoker, lymphocyte count, clotting time, and ASA score. In addition, the RF model had an ideal predictive performance.ConclusionsAccording to our result, current smoker, lymphocyte count, clotting time, and ASA score were independent risks of pulmonary complications. Machine learning approaches can also provide more evidence in the prediction of pulmonary complications.

Spirometric lung age for predicting the risk of pulmonary complications after thoracic surgeries

Annotation. Surgical interventions for diseases of the thoracic cavity are one of the most invasive surgical procedures, which are often accompanied by postoperative complications, which increase mortality, prolong hospital stays, require additional costs and correlate with poor long-term survival. However, respiratory complications remain the most common of non-surgical complications and their frequency varies from 13 to 38%. So far, several studies have shown that respiratory dysfunction is an independent risk factor for postoperative pneumonia. The aim – investigate whether it is possible to use spirometric lung age to predict the occurrence of postoperative pneumonia after thoracic surgeries. The study was performed on 192 patients with diseases of the thoracic cavity (esophagus, lungs, mediastinum), underwent surgery in the thoracoabdominal department of the Shalimov’s National Institute of Surgery and Transplantation. Statistical software EZR v.1.54 was used for statistical calculations (graphical user interface for statistical software R version 4.0.3, R Foundation for Statistical Computing, Vienna, Austria). We found a very strong association between the risk of developing pulmonary complications and the age of the lungs, AUC=0.97 (95% confidence interval from 0.94 to 0.99). When choosing the optimal point for predicting the risk of pulmonary complications obtained: Lung age critical = 99.6 years. Thus, at Lung age &gt;99.6 years, the development of postoperative pulmonary complications is predicted. At Lung age &lt;99.6 years, the absence of postoperative pulmonary complications is predicted. When choosing this decision point, the sensitivity is 93.5% (82.1-98.6%), specificity – 95.9% (91.3-98.5%). Therefore, spirometric age of the lungs was associated with the incidence of postoperative pulmonary complications in patients undergoing surgery for thoracic disease. This parameter deserves attention as a predictor of the probability of developing postoperative pneumonia after thoracic surgeries and can help in assessing the state of respiratory function of patients.

Perioperative Outcomes After Combined Esophagectomy and Lung Resection

The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality. Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression. Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P=0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P=0.04) and sepsis (11.5% versus 7.1%, P=0.03), however major complication rates overall were similar (40.8% versus 35.3%, P=0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]). Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.

Development and validation of a nomogram to predict postoperative pulmonary complications following thoracoscopic surgery.

BackgroundPostoperative pulmonary complications (PPCs) after thoracoscopic surgery are common. This retrospective study aimed to develop a nomogram to predict PPCs in thoracoscopic surgery.MethodsA total of 905 patients who underwent thoracoscopy were randomly enrolled and divided into a training cohort and a validation cohort at 80%:20%. The training cohort was used to develop a nomogram model, and the validation cohort was used to validate the model. Univariate and multivariable logistic regression were applied to screen risk factors for PPCs, and the nomogram was incorporated in the training cohort. The discriminative ability and calibration of the nomogram for predicting PPCs were assessed using C-indices and calibration plots.ResultsAmong the patients, 207 (22.87%) presented PPCs, including 166 cases in the training cohort and 41 cases in the validation cohort. Using backward stepwise selection of clinically important variables with the Akaike information criterion (AIC) in the training cohort, the following seven variables were incorporated for predicting PPCs: American Society of Anesthesiologists (ASA) grade III/IV, operation time longer than 180 min, one-lung ventilation time longer than 60 min, and history of stroke, heart disease, chronic obstructive pulmonary disease (COPD) and smoking. With incorporation of these factors, the nomogram achieved good C-indices of 0.894 (95% confidence interval (CI) [0.866–0.921]) and 0.868 (95% CI [0.811–0.925]) in the training and validation cohorts, respectively, with well-fitted calibration curves.ConclusionThe nomogram offers good predictive performance for PPCs after thoracoscopic surgery. This model may help distinguish the risk of PPCs and make reasonable treatment choices.

EP.WE.429Surgery during the COVID-19 pandemic: Are we obtaining informed consent?

BackgroundIt was estimated that 1 in 4 inpatients with COVID-19 acquired the virus whilst admitted in December 2020. Surgical patients that contract COVID-19 have poor outcomes, with mortality rates as high as 24% and risk of pulmonary complications as high as 50%. The Royal College of Surgeons of England published COVID-19 consenting guidelines in June 2020.AimsTo identify the proportion of surgical patients who were informed of the risk of acquiring COVID-19 during the consenting process at two District General Hospitals.MethodsThe consent forms of 220 surgical patients who had either elective or emergency surgery during the second COVID-19 lockdown were reviewed retrospectively (1/11/2020-20/11/2020). This included General Surgery, Trauma and Orthopaedics and Urology. Patients with incomplete notes or who lacked capacity were excluded.ResultsIn total, 193 patients were included. We found that 41.5% of patients were consented for the risk of acquiring COVID-19 peri-operatively. This did not vary significantly between elective and non-elective patients.ConclusionsOur study shows that current practice does not meet national recommendations. In order to provide informed consent, surgeons must engage in emerging research regarding the local prevalence of COVID-19 and the implications of infection during the peri-operative period. Only with this knowledge, will surgeons be able to balance the risks and benefits on a case by case basis, to provide the patient with necessary information for consent. We recommend that trusts adopt a COVID-19 consenting policy, as part of the pre-operative assessment.

Incidence of postoperative pulmonary complications in patients undergoing minimally invasive versus median sternotomy valve surgery: propensity score matching

ObjectivePostoperative pulmonary complications (PPCs) are common incidents associated with an increased hospital stay, readmissions into the intensive care unit (ICU), increased costs, and mortality after cardiac surgery. Our study aims to analyze whether minimally invasive valve surgery (MIVS) can reduce the incidence of postoperative pulmonary complications compared to the full median sternotomy (FS) approach.MethodsWe reviewed the records of 1076 patients who underwent isolated mitral or aortic valve surgery (80 MIVS and 996 FS) in our institution between January 2015 and December 2019. Propensity score-matching analysis was used to compare outcomes between the groups and to reduce selection bias.ResultsPropensity score matching revealed no significant difference in hospital mortality between the groups. The incidence of PPCs was significantly less in the MIVS group than in the FS group (19% vs. 69%, respectively; P < 0.0001). The most common PPCs were atelectasis (P = 0.034), pleural effusions (P = 0.042), and pulmonary infection (P = 0.001). Prolonged mechanical ventilation time (> 24 h) (P = 0.016), blood transfusion amount (P = 0.006), length of hospital stay (P < 0.0001), and ICU stay (P < 0.0001) were significantly less in the MIVS group. Cardiopulmonary bypass (CBP), aortic cross-clamping, and operative time intervals were significantly longer in the MIVS group than in the matched FS group (P < 0.001). A multivariable analysis revealed a decreased risk of PPCs in patients undergoing MIVS (odds ratio, 0.25; 95% confidence interval, 0.006–0.180; P < 0.0001).ConclusionMIVS for isolated valve surgery reduces the risk of PPCs compared with the FS approach.

723 TWO- VS. THREE-FIELD LYMPHADENECTOMY FOR ESOPHAGEAL CANCER. A SYSTEMATIC REVIEW AND META-ANALYSIS OF SHORT- AND LONG-TERM OUTCOMES.

Abstract Nowadays, there is still no consensus about the benefits of adding neck lymphadenectomy to the traditional two-fields esophagectomy. An extended lymphadenectomy could potentially increase operation time and the risks for postoperative complications. However, extended lymphadenectomy allows resection of cervical nodes at risk for metastases, potentially increasing long-term survival rates. This study aims to estimate whether cervical prophylactic lymphadenectomy for esophageal cancer influences short- and long-term outcomes through a systematic review of literature and meta-analysis. Methods A systematic review was conducted in PubMed, Embase, Cochrane Library Central, and Lilacs (BVS). The inclusion criteria were: (1) studies that compare two-field vs. three-field esophagectomy; (2) adults (&amp;gt;18 years); (3) articles that analyze short- or long-term outcomes; and (4) clinical trials or cohort studies. The results were summarized by forest plots, with effect size (ES) or risk difference (RD) and 95% CI. Results Twenty-five articles were selected, comprising 8,954 patients. Three-field lymphadenectomy was associated to higher operation time (ES: -1.51; 95%CI -1.84, −1.18) and higher blood loss (ES: -0.24; 95%CI: −0.37, −0.11). Also, neck lymphadenectomy inputs additional risk for pulmonary complications (RD: 0.03; 95%CI: 0.01, 0.05). No difference was noted for morbidity (RD: 0.01; 95%CI: −0.01, 0.03); leak (−0.02; 95%CI: −0.07, 0.03); postoperative mortality (RD: 0.00; 95%CI: −0.00, 0.01), and hospital stay (ES: -0.05; 95%CI -0.20, 0.10). Three-field lymphadenectomy allowed higher number of retrieved lymph nodes (MD: -1.51; 95%CI -1.84, −1.18), but did not increase the overall survival (HR: 1.11; 95%CI: 0.96, 1.26). Conclusion Prophylactic neck lymphadenectomy for esophageal cancer should be performed with caution once it is associated with poorer short-term outcomes compared to traditional two-field lymphadenectomy and does not improve long-term survival. Future esophageal cancer studies should determine the subgroup of patients who could benefit from prophylactic neck lymphadenectomy in long-term outcomes.

O42 Evaluation of risk prediction models for postoperative pulmonary complications in adults undergoing major abdominal surgery: a systematic review and external validation study in the respiratory complications after abdominal surgery (RECON) cohort

Abstract Introduction Postoperative pulmonary complications (PPCs) following major abdominal surgery result in substantial morbidity and mortality, yet stratifying patients for risk-modifying interventions remains challenging. This study aimed to systematically review and externally validate existing PPC risk prediction models in an international, prospective cohort. Method A systematic search of the MEDLINE and EMBASE databases according to PRISMA guidelines was performed to identify original risk prediction models for PPC following abdominal surgery. Subsequent external validation was performed based on a prospective dataset (REspiratory COmplications after abdomiNal surgery) which encompassed adult patients undergoing major abdominal surgery from January to April 2019 across the UK, Ireland and Australia. The primary outcome was 30-day PPC (StEP-COMPAC criteria definition), and multivariable logistic regression model discrimination were compared (with an area under the curve (AUC) ≥0.7 considered “good”). Result Thirty original risk prediction models were identified from 2819 records, with notable heterogeneity in risk factors considered. Within the validation dataset, the 30-day PPC rate was 7.8% (n = 903/11591), and 6 scores had all variables represented to enable external validation. No score demonstrated statistically significant “good” discrimination for identifying pulmonary complications, with no significant differences between scores. However, the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score achieved the highest discrimination (AUC = 0.709, 95% CI = 0.692–0.727). Conclusion The risk of PPC for patients following major abdominal surgery in the pre-covid era is not well described by existing prediction tools. New prediction tools are required to account for additional variation introduced for patients affected by SARS-CoV-2 infection. Take-home Message The risk of PPC for patients following major abdominal surgery in the pre-covid era is not well described by existing prediction tools. New prediction tools are required to account for additional variation introduced for patients affected by SARS-CoV-2 infection.

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

BackgroundPost-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low Vt, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery.MethodsThis single-centre, pilot randomized clinical trial was conducted at the University Hospital “Maggiore della Carità” (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6–8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO2. Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality.ResultsA total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups.ConclusionsLPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements.Trial registrationregistered on the Australian New Zealand Clinical Trial Registry (www.anzctr.org.au), registration number ACTRN12615000707561.

Functional avoidance-based intensity modulated proton therapy with 4DCT derived ventilation imaging for lung cancer.

The primary objective is to evaluate the potential dosimetric gains of performing functional avoidance‐based proton treatment planning using 4DCT derived ventilation imaging. 4DCT data of 31 patients from a prospective functional avoidance clinical trial were evaluated with intensity modulated proton therapy (IMPT) plans and compared with clinical volumetric modulated arc therapy (VMAT) plans. Dosimetric parameters were compared between standard and functional plans with IMPT and VMAT with one‐way analysis of variance and post hoc paired student t‐test. Normal Tissue Complication Probability (NTCP) models were employed to estimate the risk of two toxicity endpoints for healthy lung tissues. Dose degradation due to proton motion interplay effect was evaluated. Functional IMPT plans led to significant dose reduction to functional lung structures when compared with functional VMAT without significant dose increase to Organ at Risk (OAR) structures. When interplay effect is considered, no significant dose degradation was observed for the OARs or the clinical target volume (CTV) volumes for functional IMPT. Using fV20 as the dose metric and Grade 2+ pneumonitis as toxicity endpoint, there is a mean 5.7% reduction in Grade 2+ RP with the functional IMPT and as high as 26% in reduction for individual patient when compared to the standard IMPT planning. Functional IMPT was able to spare healthy lung tissue to avoid excess dose to normal structures while maintaining satisfying target coverage. NTCP calculation also shows that the risk of pulmonary complications can be further reduced with functional based IMPT.

702 Evaluation of Risk Prediction Models for Postoperative Pulmonary Complications in Adults Undergoing Major Abdominal Surgery: A Systematic Review and External Validation Study in The Respiratory Complications After Abdominal Surgery (RECON) Cohort

IntroductionPostoperative pulmonary complications (PPCs) following major abdominal surgery result in substantial morbidity and mortality, yet stratifying patients for risk-modifying interventions remains challenging. This study aimed to identify and externally validate PPC risk prediction models in an international, prospective cohort.MethodA systematic review was conducted to identify risk prediction models for PPC following abdominal surgery. External validation was performed using data from a prospective dataset of adult patients undergoing major abdominal surgery from January to April 2019 in the UK, Ireland, and Australia. The primary outcome was identification of PPC within 30-days (StEP-COMPAC criteria definition). Model discrimination and diagnostic accuracy were compared.ResultsSix unique risk prediction models were eligible from 2819 records (112 full texts). These were validated across 11,591 patients, with an overall PPC rate of 7.8% (n = 903). The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score provided the best discrimination (AUROC: 0.709 (95% CI: 0.692-0.727), yet no risk prediction model demonstrated good discrimination (AUROC >0.7).ConclusionsThe risk of PPC for patients following major abdominal surgery in the pre-covid era is not well described by existing prediction tools. New prediction tools are required to account for additional variation introduced for patients affected by SARS-CoV-2 infection.

V2 Evaluation of risk prediction models for postoperative pulmonary complications in adults undergoing major abdominal surgery: A systematic review and external validation study of the REspiratory COmplications after abdomiNal surgery (RECON) cohort

BackgroundPostoperative pulmonary complications (PPCs) following major abdominal surgery result in substantial morbidity and mortality, yet stratifying patients for risk-modifying interventions remains challenging. This study aimed to identify and externally validate PPC risk prediction models in an international, prospective cohort.MethodsA systematic review was conducted to identify risk prediction models for PPC following abdominal surgery. External validation was performed using data from a prospective dataset of adult patients undergoing major abdominal surgery from January to April 2019 in the UK, Ireland and Australia. The primary outcome was identification of PPC within 30-days (StEP-COMPAC criteria definition). Model discrimination and diagnostic accuracy were compared.ResultsSix unique risk prediction models were eligible from 2819 records. These were validated across 11,591 patients, with an overall PPC rate of 7.8% (n = 903). The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score provided the best discrimination (AUC: 0.709 (95% CI: 0.692-0.727), yet no risk prediction model demonstrated good discrimination (AUC >0.7).ConclusionThe risk of PPC for patients following major abdominal surgery in the pre-covid era is not well described by existing prediction tools. New prediction tools are required to account for additional variation introduced for patients affected by SARS-CoV-2 infection.