Risk factors for postoperative pneumonia after gastrectomy for gastric cancer

Incidence of postoperative pneumonia in various surgical subspecialties: a retrospective study

Postoperative pneumonia (POP) can be defined as either hospital-acquired pneumonia (HAP, pneumonia developing 48-72 h after admission) or ventilator-associated pneumonia (VAP, pneumonia developing 48-72 h after endotracheal intubation)' or within 30 days in postoperative patients. POP accounts for 2.7-3.4% of postoperative complications. Few studies have evaluated the incidence and the risk factors of POP. This study aimed to estimate the incidence of POP and identify the predictive factors of POP in King Abdul-Aziz University Hospital (KAUH), Jeddah, Saudi Arabia. This retrospective record review included all patients diagnosed with POP at KAUH between 2011 and 2021. Patients younger than 18 years of age and those diagnosed with congenital heart or lung disease were excluded from the study. Data were analyzed using the SPSS program version 26. Of the 2350 patients, 236 met the inclusion criteria. The mean age of patients was 58.12± 17.66 years; 82.6% had comorbidities. ENT (6.4%) and cardiothoracic surgeries associated with POP were the most common surgeries (4.2%). Comorbidities were found as an independent predictor of pneumonia among the studied patients (P = 0.024). The incidence of developing POP was (19.9%). Therefore, Physicians should be aware of POP. Especially when treating patients with comorbidities and patients on corticosteroids.

Prognostic impact of pulmonary dysfunction in older gastric cancer patients

The influence of pulmonary dysfunction on postoperative outcomes in older patients with gastric cancer was assessed. In this retrospective study, 352 older patients (age ≥ 75 years) with gastric cancer who underwent preoperative spirometry and curative gastrectomy were enrolled. Of these patients, 200 underwent laparoscopic gastrectomy. Restrictive and obstructive pulmonary dysfunction were defined as percentage of vital capacity (%VC) < 80% and percent of forced expiratory volume in one second (FEV1.0%) < 70%, respectively. Twenty-six (7.3%) and 123 (34.9%) exhibited restrictive and obstructive pulmonary dysfunction, respectively. The low-%VC group showed a higher incidence of postoperative pneumonia (p = 0.018) while the low-FEV1.0% group did not (p = 0.677). Multivariate analysis identified a decreased %VC as a significant risk factor for postoperative pneumonia. However, this association was not observed in patients who underwent laparoscopic gastrectomy. Concerning the long-term outcomes, restrictive dysfunction was a significant prognostic factor in older patients with gastric cancer who underwent either laparotomy or laparoscopy, whereas obstructive dysfunction did not. Restrictive pulmonary dysfunction increased the risk of postoperative pneumonia and had a negative prognostic effect in older patients with gastric cancer, whereas obstructive pulmonary dysfunction did not.

The development of a risk assessment tool for patients with postoperative pneumonia after gastrectomy for gastric cancer

BACKGROUND

Although frail patients are known to experience increased postoperative complications, this is unclear for postoperative pneumonia (POP). We investigated associations between frailty and POP in patients with gastric cancer (GC) undergoing gastrectomy.

METHODS

In this prospective study conducted between August 2016 and December 2022, we preoperatively assessed frailty in 341 patients with GC undergoing gastrectomy using a frailty index (FI). Patients were divided into high FI vs low FI groups to examine frailty and pneumonia rates after gastrectomy for GC.

RESULTS

Of 327 patients, 18 (5.5%) experienced POP after gastrectomy. Multivariate analyses showed that a high FI and total or proximal gastrectomy (TG/PG) were independent risk factors for POP (high FI: odds ratio [OR], 5.00; 95% CI, 1.77-15.54; TG/PG: OR, 3.07; 95% CI, 1.09-8.78). The proportion of patients with POP was 2.4% in those with nonhigh FI and non-TG/PG, 5.3% in those with nonhigh FI and TG/PG, 7.1% in those with high FI and non-TG/PG, and 28.0% in those with high FI and TG/PG (P < .001). The area under the receiver operating characteristic curve for this risk assessment for predicting POP was 0.740.

CONCLUSION

In patients with GC undergoing gastrectomy, POP was independently associated with preoperatively high FI and TG/PG. Our simple POP risk assessment method, which combines these factors, may effectively predict and prepare patients for POP.

Association of Cholinesterase With Postoperative Pneumonia After Gastrectomy for Gastric Cancer

INTRODUCTION

Cholinesterase is a classical marker that reflects nutritional and inflammatory status. The aim of the present study was to evaluate the association between serum cholinesterase levels and postoperative infectious complications in patients undergoing gastrectomy for gastric cancer.

MATERIALS AND METHODS

This retrospective study comprised 108 patients who underwent gastrectomy for gastric cancer. We comprehensively investigated the association between clinicopathological variables and postoperative infectious complications after gastrectomy. Then patients were divided into the cholinesterase-high and -low groups to analyze their clinicopathological variables. Finally, we analyzed the types of infectious complications that were most associated with preoperative serum cholinesterase levels.

RESULTS

Twenty-six patients (24%) developed postoperative infectious complications. Multivariate analysis revealed that serum cholinesterase levels (P = 0.026) and N stage (P = 0.009) were independent risk factors for postoperative infectious complications. In particular, the incidence of pneumonia (P = 0.001) was significantly higher in the cholinesterase-low group. Age (P = 0.023), cerebrovascular comorbidities (P = 0.006), serum cholinesterase levels (P = 0.013), and total gastrectomy (P = 0.017) were identified as independent risk factors for postoperative pneumonia.

CONCLUSIONS

Preoperative serum cholinesterase levels were associated with postoperative pneumonia after gastrectomy for gastric cancer, suggesting the importance of preoperative nutritional assessment in gastric cancer surgery.

Impact of the perioperative assessment of deglutition on postoperative respiratory complications in elderly patients undergoing gastrectomy for gastric cancer

PURPOSE

To investigate the association between perioperative deglutition screening and postoperative respiratory complications (PRCs) in elderly patients undergoing gastrectomy for gastric cancer.

METHODS

We analyzed data from 86 patients with gastric cancer (aged ≥ 70 years) who underwent gastrectomy between October, 2016 and November, 2018. Videofluoroscopic swallowing examinations (VFSEs) were performed before and after surgery. We examined the association of these results with postoperative respiratory complications, as well as the relationships between demographic, operative, and swallowing function assessment data.

RESULTS

PRCs were identified in 16 patients. The results of pre- and postoperative VFSE showed abnormalities in 28 and 32 patients, respectively. Multivariate analysis revealed that abnormalities in the postoperative VFSEs were strongly associated with the development of PRCs (P = 0.002). The findings of this analysis suggests that ventilatory impairment, a Charlson comorbidity index score ≥ 3, and an open surgical approach are independent risk factors for PRCs.

CONCLUSION

This is the first study to demonstrate the efficacy of perioperative assessment of swallowing function using VFSE for predicting PRCs in elderly patients undergoing gastrectomy for gastric cancer.

Association between admission hyperglycemia and postoperative pneumonia in geriatric patients with hip fractures

BACKGROUND

Admission hyperglycemia is a common phenomenon in the early stages of injury. This study aimed to determine the relationship between admission hyperglycemia and postoperative pneumonia in geriatric patients with hip fractures.

METHODS

A total of 600 geriatric patients admitted to Dandong Central Hospital with hip fractures were included. Patients were divided into four groups based on quartiles of admission blood glucose levels: Q1- Q4. Multivariable logistic regression and propensity score-matched analyses were conducted to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for postoperative pneumonia. Receiver operating characteristic (ROC) curves were used to determine the cut-off value of admission hyperglycemia for predicting postoperative pneumonia.

RESULTS

The incidence of postoperative pneumonia was significantly higher among hyperglycemic patients than those with normal glucose levels (OR = 2.090, 95% CI: 1.135-3.846, p = 0.016). Admission hyperglycemia showed moderate predictive power, with an area under the ROC curve of 0.803. Furthermore, propensity score-matched analyses demonstrated that patients in the Q3 (OR = 4.250, 95% CI: 1.361-13.272, p = 0.013) and Q4 (OR = 4.667, 95% CI: 1.251-17.405, p = 0.022) quartiles had a significantly higher risk of postoperative pneumonia compared to patients in the Q1 quartile.

CONCLUSIONS

Admission hyperglycemia in elderly hip fracture patients increases the risk of postoperative pneumonia. This biomarker can aid clinical assessment and perioperative management.

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

Background

Identifying preoperative risk factors for complications following total shoulder arthroplasty (TSA) has both clinical and financial implications. The purpose of this study was to determine the influence of different degrees of preoperative INR elevation on complications following TSA.

Methods

Patients undergoing primary TSA from 2007 to 2018 were identified in a national database. Patients were stratified into 4 cohorts: INR of <1.0, INR of >1.0 to 1.25, INR of >1.25 to 1.5, and INR of >1.5. Postoperative complications were assessed. Multivariate logistic regressions were performed to adjust for differences in demographics and comorbidities among the INR groups.

Results

Following adjustment and relative to patients with an INR of <1.0, those with INR of >1.0-1.25, >1.25-1.5, and >1.5 had 1.6-times, 2.4-times, and 2.8-times higher odds of having postoperative bleeding requiring transfusion, respectively (p < 0.05 for all). Relative to patients with INR <1.0, those with INR of > 1.25-1.5 and INR of >1.5 had 7.8-times and 7.0-times higher odds of having pulmonary complications, respectively (p < 0.05 for both).

Discussion

With increasing INR levels, there is an independent and step-wise increase in odd ratios for postoperative complications. Current guidelines for preoperative INR thresholds may need to be adjusted for more predictive risk-stratification for TSA.

Level of Evidence

III.

Risk score for predicting death from other causes after curative gastrectomy for gastric cancer

BACKGROUND

The number of patients who die from causes other than gastric cancer after R0 resection is increasing in Japan, due in part to the aging population. However, few studies have comprehensively investigated the clinicopathological risks associated with deaths from other causes after gastrectomy. This study aimed to build a risk score for predicting such deaths.

METHODS

We retrospectively reviewed clinical data for 3575 patients who underwent gastrectomy for gastric cancer at nine institutions in Japan between January 2010 and December 2014.

RESULTS

The final study population of 1758 patients were assigned to Group A (n = 187): patients who died from other causes within 5 years of surgery, and Group B (n = 1571): patients who survived ≥ 5 years after surgery. Multivariate analysis identified nine characteristics as risk factors for poor survival: age ≥ 75 years, male sex, body mass index < 22 kg/m², Eastern Cooperative Oncology Group Performance Status (≥ 1), diabetes mellitus, cardiovascular/cerebrovascular disease, other malignant diseases, preoperative albumin level < 3.5 g/dL, and total gastrectomy. Patients with risk scores of 0-2, 3-4, or 5-9 (based on 1 point per characteristics) were classified into Low-risk, Intermediate-risk, and High-risk groups, respectively. The 5-year survival rates were 96.5%, 85.3%, and 56.5%, for the Low-, Intermediate-, and High-risk groups, respectively, and the hazard ratio (95% confidence intervals) was 16.33 (10.85-24.58, p < 0.001) for the High-risk group.

CONCLUSIONS

The risk score defined here may be useful for predicting deaths from other causes after curative gastrectomy.

Significance of Preoperative Pulmonary Function on Short- and Long-Term Outcomes Following Gastrectomy for Gastric Cancer

BACKGROUND

Preoperative pulmonary function assessment is useful for selecting surgical candidates and operative methods and assessing the risk of postoperative pulmonary complications. However, few studies have investigated the relationship between preoperative pulmonary function and short- and long-term outcomes in patients who underwent gastrectomy for gastric cancer.

METHODS

Of the 1040 patients with gastric cancer (stages I-III) who had undergone R0 gastrectomy between 2009 and 2020, 750 who underwent preoperative spirometry were included. Restrictive ventilatory impairment was defined as a vital capacity of the predicted value (%VC) < 80%, while obstructive ventilatory impairment was defined as forced expiratory volume in one second (FEV1%) < 70%. Postoperative complications were assessed using the Clavien-Dindo (CD) classification. The relationship between clinical factors, including %VC, FEV1%, severe postoperative complications (CD ≥ 3b), overall survival (OS), and relapse-free survival, were assessed.

RESULTS

The mean age of the 750 patients was 68 ± 10.5 years. Severe postoperative complications were observed in 25 (3.3%) patients and were significantly associated with FEV1% < 70% in the univariate analysis. The 5-year OS was 72.5%. Multivariate analysis showed that the cancer stage, age > 75 years, preoperative comorbidities, %VC < 80%, total gastrectomy, severe postoperative complications, and postoperative adjuvant chemotherapy were the significant independent factors affecting OS. Pneumonia was significantly associated with %VC < 80%.

CONCLUSIONS

FEV1% < 70%was associated with the development of severe postoperative complications, while %VC < 80% was associated with poor OS independent of the cancer stage because of death from pneumonia. Spirometry helps surgeons and patients discuss the risks and benefits of surgery.

Impact of Preoperative Handgrip Strength on Postoperative Outcome after Radical Gastrectomy for Gastric Cancer Patients

In this study, we investigated whether preoperative low-handgrip strength (HGS) defined by the Asian working group for sarcopenia could be a predictor of postoperative outcomes in patients with gastric cancer. A total of 327 patients who underwent radical gastrectomy for c-stage I-III primary gastric cancer with pre-operative HGS records were included. The cut-off values of HGS were defined as 28 kg for males and 18 kg for females, with values below and above the cut-off defined as low-HGS and high-HGS, respectively. The primary outcome was infectious complications. We compared the postoperative outcomes of the groups after adjusting for the background using propensity score matching. Of the 327 patients, 246 (75.2%) and 81 (24.8%) were in the high and low-HGS groups, respectively. After adjusting for background, there were 57 patients in both groups. After matching, the low-HGS group had significantly more infectious complications (17.5% vs. 1.8%, p = 0.008). Multivariate analysis of infectious complications in the low-HGS group demonstrated chronic kidney disease and diabetes as independent risk factors (odds ratio 4.390, 95% confidence interval 1.120-17.20, p = 0.034). Preoperative low-HGS according to the Asian criteria was associated with infectious complications after gastrectomy. Chronic kidney disease and diabetes were independent risk factors for infectious complications among patients with low-HGS.

The comparison of prognoses between total and distal gastrectomy for gastric cancer in elderly patients ≥ 80 years old

PURPOSE

In Japan, the number of distal gastrectomy for patients ≥ 80 years old is increasing, whereas that of total gastrectomy is decreasing. Surgeons seem to avoid total gastrectomy for elderly patients. Total gastrectomy is reported to have a poorer prognosis than distal gastrectomy, and postoperative pneumonia may be involved in the cause.

METHODS

The medical records of 39 and 108 patients ≥ 80 years old who underwent total and distal gastrectomy, respectively, at 2 affiliated institutions between 2010 and 2019 were retrospectively reviewed. Prognoses were compared between the two groups, focusing on death from pneumonia.

RESULTS

The median overall survival time after total and distal gastrectomy was 21.3 and 74.1 months, respectively, with a significantly poorer prognosis after total gastrectomy than after distal gastrectomy (p < 0.01, hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.37-3.53). The gastric cancer-specific survival time was significantly worse after total gastrectomy than after distal gastrectomy (p < 0.01, HR 2.73, 95% CI 1.29-5.79). The pneumonia-specific survival time was also significantly worse after total gastrectomy than after distal gastrectomy (p = 0.01, HR 3.44, 95% CI 1.25-9.48).

CONCLUSIONS

Patients who underwent total gastrectomy had a poorer prognosis than those who underwent distal gastrectomy, because many patients died of pneumonia early after total gastrectomy.

Effects of Perioperative Oral Management in Patients with Cancer

Perioperative oral management (POM) is used to prevent pneumonia in patients with cancer. However, the factors that expose hospitalized patients to increased risk of developing pneumonia remain unclear. For example, no study to date has compared the incidence of pneumonia in hospitalized patients by cancer primary lesion, or POM implementation, or not. We determined which patients were most likely to benefit from POM and examined the effects of POM on pneumonia prevention and mortality. In a total of 9441 patients with cancer who underwent surgery during hospitalization, there were 8208 patients in the No POM group, and 1233 in the POM group. We examined between-group differences in the incidence of pneumonia and associated outcomes during hospitalization. There was no significant between-group difference in the incidence of pneumonitis, however, patients with lung, or head and neck cancers, demonstrated a lower incidence of postoperative pneumonia. Among patients with lung and pancreatic cancers, mortality was significantly lower in the POM group. POM appears effective at reducing the risk of postoperative pneumonia in patients with certain cancers. Further, mortality was significantly lower in patients with lung and pancreatic cancers who received POM; hence, POM may be an effective adjuvant therapy for patients with cancer.

Ferret acute lung injury model induced by repeated nebulized lipopolysaccharide administration

Inflammatory lung diseases affect millions of people worldwide. These diseases are caused by a number of factors such as pneumonia, sepsis, trauma, and inhalation of toxins. Pulmonary function testing (PFT) is a valuable functional methodology for better understanding mechanisms of lung disease, measuring disease progression, clinical diagnosis, and evaluating therapeutic interventions. Animal models of inflammatory lung diseases are needed that accurately recapitulate disease manifestations observed in human patients and provide an accurate prediction of clinical outcomes using clinically relevant pulmonary disease parameters. In this study, we evaluated a ferret lung inflammation model that closely represents multiple clinical manifestations of acute lung inflammation and injury observed in human patients. Lipopolysaccharide (LPS) from Pseudomonas aeruginosa was nebulized into ferrets for 7 repeated daily doses. Repeated exposure to nebulized LPS resulted in a restrictive pulmonary injury characterized using Buxco forced maneuver PFT system custom developed for ferrets. This is the first study to report repeated forced maneuver PFT in ferrets, establishing lung function measurements pre- and post-injury in live animals. Bronchoalveolar lavage and histological analysis confirmed that LPS exposure elicited pulmonary neutrophilic inflammation and structural damage to the alveoli. We believe this ferret model of lung inflammation, with clinically relevant disease manifestations and parameters for functional evaluation, is a useful pre-clinical model for understanding human inflammatory lung disease and for the evaluation of potential therapies.

Risk Factors for Postoperative Pneumonia: A Case-Control Study

Background

Postoperative pneumonia is a preventable complication associated with adverse outcomes, that greatly aggravates the medical expenses of patients. The goal of our study is to identify risk factors and outcomes of postoperative pneumonia.

Methods

A matched 1:1 case-control study, including adult patients who underwent surgery between January 2020 and June 2020, was conducted in the Second Affiliated Hospital of Kunming Medical University in China. Cases included all patients developing postoperative pneumonia within 30 days after surgery, defined using consensus criteria. Controls were selected randomly from the matched eligible population.

Results

Out of 17,190 surgical patients, 264 (1.54%) experienced postoperative pneumonia. Increased age, chronic obstructive pulmonary disease, emergency surgery, postoperative reduced albumin, prolonged ventilation, and longer duration of bed rest were identified as significant risk factors independently associated with postoperative pneumonia. Regarding prognostic implications, postoperative pneumonia was associated with longer length of hospital stay, higher ICU occupancy rate, higher unplanned re-operation rate, and higher in-hospital mortality rate. Postoperative pneumonia was most commonly caused by Gram-negative pathogens, and multidrug resistant bacteria accounted for approximately 16.99% of cases.

Conclusions

Postoperative pneumonia is associated with severe clinical outcomes. We identified six independent risk factors that can aid in risk stratification and management of patients at risk of postoperative pneumonia, and the distribution of causative pathogens can also help in the implementation of effective interventions.

Clinical Trial Registration

www.chictr.org.cn, identifier: chiCTR2100045986.

Long-term postoperative pneumonia in elderly patients with early gastric cancer

Background

Pneumonia is a major cause of death in the elderly population. Considering body weight loss, muscle loss, and reflux after gastrectomy, elderly patients are considered to be at very high risk for pneumonia, which could decrease overall survival because early gastric cancer is mostly curable only by surgery. We aimed to clarify the incidence of pneumonia in the long-term period after gastrectomy in elderly patients who were diagnosed with early gastric cancer and its risk factors.

Methods

We retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and who were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. Long-term postoperative pneumonia was diagnosed by chest computed tomography every year until 2 years after surgery. The presence of preoperative sarcopenia was assessed using preoperative L3 skeletal muscle index.

Results

167 patients were included in this study. Long-term postoperative pneumonia was observed in 44 (26%) patients. Of the 44 people diagnosed with long-term postoperative pneumonia, 33 were diagnosed in the 1st year and 11 in the 2nd year. 117 patients (70%) were diagnosed with sarcopenia which was significantly frequently found in the patients who developed long-term postoperative pneumonia (91%) than those without (63%). Preoperative sarcopenia was the only independent risk factor in multivariate analysis. Type of gastrectomy was not a significant risk factor.

Conclusions

Long-term postoperative pneumonia was frequently observed in the elderly patients. Preoperative sarcopenia was associated with long-term postoperative pneumonia in elderly patients who underwent curative surgery for gastric cancer. After gastrectomy, long-term special care would be required for elderly patients, especially with sarcopenia.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in non-thoracic surgery.

METHODS

We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy).

RESULTS

46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry).

CONCLUSION

As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before non-thoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.

Prognosis after curative resection for stage IA gastric cancer in elderly patients: endoscopic submucosal dissection versus surgery

PURPOSE

To establish whether gastrectomy for early gastric cancer (EGC) in elderly patients is related to poor survival.

METHODS

The subjects of this retrospective study were patients aged ≥ 75 years with primary stage IA EGC, who underwent curative resection with endoscopic submucosal dissection (ESD) or surgery.

RESULTS

We analyzed data on 365 patients who underwent ESD and 170 patients who underwent surgery. Overall survival (OS) was not significantly different for the ESD group vs. the surgery group (5-year cumulative rates, 81.5% vs. 79.7%; log-rank test, P = 0.506). Multivariate analysis revealed that treatments; namely, ESD or surgery, were not associated with OS (hazard ratio 1.09, 95% confidence interval 0.77-1.51). Similar results were observed even in the subgroups with worse conditions, such as age > 80 years, Eastern Cooperative Oncology Group performance status 2-3, Charlson comorbidity index ≥ 2, and prognostic nutritional index ≤ 46.7. Using propensity score matching, we selected 88 pairs of patients who underwent ESD or surgery with baseline characteristics matched and found that OS was not different between the two groups (log-rank test, P = 0.829).

CONCLUSION

OS was comparable for elderly patients who underwent ESD and those who underwent surgery for EGC. Surgical invasiveness did not worsen the prognosis, even for elderly patients.

Is surgery the best treatment for elderly gastric cancer patients?

As the elderly population increases, the number of patients with gastric cancer has also been increasing. Elderly people have various preoperative problems such as malnutrition, high frequency of comorbidities, decreased performance status, and dementia. Furthermore, when surgery is performed, high postoperative complication rates and death from other diseases are also concerns. The goal of surgery in the elderly is that short-term outcomes are comparable to those in nonelderly, and long-term outcomes reach life expectancy. Perioperative problems in the elderly include: (1) Poor perioperative nutritional status; (2) Postoperative pneumonia; and (3) Psychological problems (dementia and postoperative delirium). Malnutrition in the elderly has been reported to be associated with increased postoperative complications and dementia, pointing out the importance of nutritional management. In addition, multidisciplinary team efforts, including perioperative respiratory rehabilitation, preoperative oral care, and early postoperative mobilization programs, are effective in preventing postoperative pneumonia. Furthermore, there are many reports on the usefulness of laparoscopic surgery for the elderly, and we considered that minimally invasive surgery would be the optimal treatment after assessing preoperative risk.

E-PASS scoring system serves as a predictor of short- and long-term outcomes in gastric cancer surgery

PURPOSES

This study aimed to evaluate the estimation of the physiological ability and surgical stress (E-PASS) scoring system for predicting the short- and long-term outcomes in gastric cancer (GC) surgery.

METHODS

We analyzed a multi-institutional dataset to study patients who underwent gastrectomy with a curative intent between 2010 and 2014. This study evaluated the associations between the optimal E-PASS score cutoff value and the following outcomes: (1) the incidence of postoperative complications in stage I-III GC patients and (2) the prognosis in stage II-III GC patients.

RESULTS

A total of 2495 GC patients were included. A cutoff value of 0.419 was determined using the ROC curve analysis. Postoperative complications were observed more frequently in the E-PASS-high group than that in the E-PASS-low group (30% vs. 17%, p < 0.0001). Among pStage II-III GC patients (n = 1009), the overall survival time of the E-PASS-high group was significantly shorter than that of the E-PASS-low group (hazard ratio 2.08; 95% confidence interval 1.64-2.65; p < 0.0001). A forest plot revealed that E-PASS-high was associated with a greater prognostic factor for overall survival in most subgroups.

CONCLUSIONS

The E-PASS scoring system may therefore be a useful predictor of the short- and long-term outcomes in patients with GC who have undergone radical gastrectomy.

A nomogram for predicting postoperative pulmonary infection in esophageal cancer patients

Background

Although postoperative pulmonary infection (POI) commonly occurs in patients with esophageal cancer after curative surgery, a patient-specific predictive model is still lacking. The main aim of this study is to construct and validate a nomogram for estimating the risk of POI by investigating how perioperative features contribute to POI.

Methods

This cohort study enrolled 637 patients with esophageal cancer. Perioperative information on participants was collected to develop and validate a nomogram for predicting postoperative pulmonary infection in esophageal cancer. Predictive accuracy, discriminatory capability, and clinical usefulness were evaluated by calibration curves, concordance index (C-index), and decision curve analysis (DCA).

Results

Multivariable logistic regression analysis indicated that length of stay, albumin, intraoperative bleeding, and perioperative blood transfusion were independent predictors of POI. The nomogram for assessing individual risk of POI indicated good predictive accuracy in the primary cohort (C-index, 0.802) and validation cohort (C-index, 0.763). Good consistency between predicted risk and observed actual risk was presented as the calibration curve. The nomogram for estimating POI of esophageal cancer had superior net benefit with a wide range of threshold probabilities (4–81%).

Conclusions

The present study provided a nomogram developed with perioperative features to assess the individual probability of infection may conducive to strengthen awareness of infection control and provide appropriate resources to manage patients at high risk following esophagectomy.

Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA.

METHODS

Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA.

RESULTS

Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA.

CONCLUSION

This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

The Relationship between Diabetes Mellitus and Gastric Cancer and the Potential Benefits of Metformin: An Extensive Review of the Literature

The objective of this review is to summarize the findings of published research that investigated the relationship between diabetes mellitus and gastric cancer (GCa) and the potential benefits of metformin on GCa. Related literature has been extensively reviewed, and findings from studies investigating the relationship between diabetes mellitus and GCa suggest that hyperglycemia, hyperinsulinemia and insulin resistance are closely related to the development of GCa. Although not supported by all, most observational studies suggest an increased risk of GCa in patients with type 2 diabetes mellitus, especially in women and in Asian populations. Incidence of second primary malignancy diagnosed after GCa is significantly higher in diabetes patients. Diabetes patients with GCa may have more complications after gastrectomy or chemotherapy and they may have a poorer prognosis than patients with GCa but without diabetes mellitus. However, glycemic control may improve in the diabetes patients with GCa after receiving gastrectomy, especially after procedures that bypass the duodenum and proximal jejunum, such as Roux-en-Y gastric bypass or Billroth II reconstruction. The potential links between diabetes mellitus and GCa may involve the interactions with shared risk factors (e.g., obesity, hyperglycemia, hyperinsulinemia, insulin resistance, high salt intake, smoking, etc.), Helicobacter pylori (HP) infection, medications (e.g., insulin, metformin, statins, aspirin, proton pump inhibitors, antibiotics, etc.) and comorbidities (e.g., hypertension, dyslipidemia, vascular complications, heart failure, renal failure, etc.). With regards to the potential benefits of metformin on GCa, results of most observational studies suggest a reduced risk of GCa associated with metformin use in patients with T2DM, which can be supported by evidence derived from many in vitro and animal studies. Metformin use may also reduce the risk of HP infection, an important risk factor of GCa. In patients with GCa, metformin users may have improved survival and reduced recurrence. More studies are required to clarify the pathological subtypes/anatomical sites of GCa associated with type 2 diabetes mellitus or prevented by metformin, to confirm whether GCa risk can also be increased in patients with type 1 diabetes mellitus and to explore the possible role of gastric microbiota in the development of GCa.

Risk factors of post-operative pneumonia in elderly patients with gastric cancer: a retrospective cohort study

BACKGROUND

Post-operative pneumonia is a major complication after general elective surgery in elderly patients and is often caused by aspiration associated with oesophageal reflux. The aim of this study was to identify the risk factors of post-operative pneumonia after gastrectomy in elderly patients with gastric cancer with two potential risk factors of ageing and oesophageal reflux.

METHODS

We retrospectively examined the data of 251 patients ≥75 years old who underwent gastrectomy between January 2014 and December 2018 in our institution. The reconstruction methods were Billroth-I or Roux-Y after distal gastrectomy, jejunal interposition or double tract after proximal gastrectomy and Roux-Y after total gastrectomy. The severity of pneumonia was evaluated by the Clavien-Dindo classification.

RESULTS

Post-operative pneumonia was identified in 15 patients (5.9%) and was significantly associated with an age ≥80 years old, poor performance status, history of smoking and cardia-non-preserving gastrectomy (total gastrectomy and proximal gastrectomy) in univariate analyses. Multivariate analyses showed that a poor performance status and cardia-non-preserving gastrectomy were independent risk factors for post-operative pneumonia. The patients who suffered post-operative pneumonia required a longer hospital stay than those without post-operative pneumonia (P = 0.002).

CONCLUSION

We identified a poor performance status and cardia-non-preserving gastrectomy, which are likely to lead to oesophageal reflux, as risk factors for post-operative pneumonia in elderly patients with gastric cancer. These results warrant further prospective studies to evaluate their utility for reducing the rate of post-operative pneumonia in elderly patients through cardia-preserving gastrectomy or anti-reflux reconstruction.

Risk factors for postoperative pneumonia after laparoscopic gastrectomy in patients aged 75 years and over with gastric cancer

INTRODUCTION

The proportion of patients aged 75 years and over who undergo minimally invasive surgery for gastric cancer is increasing. However, the safety and feasibility of laparoscopic gastrectomy (LG) in this age group is controversial. This study aimed to evaluate whether LG is safe and effective in patients aged 75 years and over.

METHODS

The study included 728 patients with early and advanced gastric cancer who underwent curative LG between 2009 and 2017; 166 of these patients (22.8%) were aged 75 or over. All surgeries were performed laparoscopically. Selected clinical factors were compared between the 166 patients aged 75 years and over and the 562 patients aged under 75 years.

RESULTS

There were significant differences in presence of comorbidity, respiratory function and American Society of Anesthesiologists physical status scores between the older and younger groups. The older patients more frequently developed complications than the younger ones, particularly postoperative pneumonia. According to multivariate analyses of all participants, age, chronic obstructive pulmonary disease (COPD), and D2 lymphadenectomy were independent risk factors for postoperative pneumonia. Advanced stage and D2 lymphadenectomy were independent risk factors in the older group, whereas only COPD was an independent risk factor in the younger group.

CONCLUSIONS

LG for gastric cancer can be safely performed in patients aged over 75 years with an acceptable complication rate. However, the present data suggest that care should be taken in selecting LG with D2 lymphadenectomy to treat advanced cancer in these patients because the risk of postoperative complications, especially postoperative pneumonia, increases.

Incidence, Patient-Related Risk Factors, and Outcomes of Postoperative Pneumonia after Cholecystectomy: A Population-Based Cohort Study

Background

Cholecystectomy is one of the most common surgical procedures performed worldwide. The objective of this large, population-based cohort study is to explore the risk factors of pneumonia after cholecystectomy in Taiwan.

Methods

From the Taiwanese National Health Insurance Research Database, we selected all patients who underwent cholecystectomy by using ICD-9-codes, from January 1, 1998, to December 31, 2016. The patients were separated into two groups based on the presence or absence of postoperative pneumonia. Basic information, comorbidities, and postoperative complications were evaluated using a t-test or chi-square test. There were 6056 patients in the pneumonia group and 24224 patients in the control group. These two groups were shown in a ratio of 1 : 4 and were matched by age and sex. The log-rank test was used to examine differences in postoperative mortality between patients with and without pneumonia. Preoperative risk factors were analyzed using logistic regression analysis, after adjusting for age and sex.

Results

The final dataset included 282184 cholecystectomy patients. Of these patients, 6056 (2.15%) had postoperative new-onset pneumonia. The patient-related risk factors for pneumonia after cholecystectomy in the order of relevance were chronic obstructive pulmonary disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, surgical type, hemodialysis, coronary artery disease, and liver cirrhosis. Compared to patients without postcholecystectomy pneumonia, those with postcholecystectomy pneumonia had higher rates of mortality (within first month, 1.72% vs. 2.28%, P < 0.005) and admission to intensive care unit (15.02% vs. 41.80%, P < 0.0001) and longer hospital stays (10.71 vs. 18.55 days, P < 0.0001).

Conclusion

Our results show that postcholecystectomy associated with pneumonia had higher rates of morbidity and mortality in this clinical population. Early identification and possible management of risk factors for pneumonia could improve outcomes of cholecystectomy and lower the risk for patient comorbidities after surgery.

Factors Affecting the Length of Hospital Days After Laparoscopic Gastrectomy for Elderly Patients with Gastric Cancer

PURPOSE

To clarify the factors affecting the length of hospitalization after laparoscopic gastrectomy based on the physical function, body composition, and postoperative course of the patients.

METHODS

Of the patients with gastric cancer who underwent laparoscopic resection at the Ageo Central General Hospital, Japan, during 2018-2019, 51 underwent physical therapy. Data regarding the objective variables, such as length of postoperative hospital stay, and baseline attributes, such as age, body weight, body mass index (BMI), and corrected limb muscle mass, postoperative course (operation time, the estimated blood loss, the day before walking independently), preoperative physical function (grip strength, 6-min walking distance), and preoperative respiratory function (vital capacity [VC]%, one-second rate) were collected retrospectively from the medical records and analyzed using multiple regression plots.

RESULTS

The most suitable hospital day model after surgery is one that incorporates the total postoperative course, respiratory function, physical function (R² = 0.45, p < 0001), and operation time (β = 0.12, p < 0.06). The information of the day before independent walking (β = 0.68, p < 0.001) and % VC (β = -0.19, p < 0.04) was extracted as factors.

CONCLUSION

We concluded that the operation time, walking independence days, and % VC influence the postoperative length of hospital days.

Development and validation of a nomogram to predict intraoperative blood transfusion for gastric cancer surgery

OBJECTIVE

To construct and validate a nomogram composed of preoperative variables to predict intraoperative blood transfusion for gastric cancer surgery.

BACKGROUND

Intraoperative transfusion for gastric cancer surgery is a common medical procedure that is associated with increased postoperative complications.

METHODS

A total of 999 patients who underwent gastrectomy between January 2010 and June 2019 were randomly allocated into the primary and validation cohorts in a 2:1 ratio. In the primary cohort, logistic analyses were performed to identify independent predictors for transfusion. Using the Akaike information criterion, selected variables were incorporated to construct a nomogram. Validations of the nomogram were performed in the primary and validation cohorts. The discrimination ability of the nomogram was assessed by the concordance index (C-index), and calibration was assessed by calibration curves and the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

The following risk factors for transfusion were identified and used to construct the nomogram: ASA status (III-IV vs I-II: odds ratio [OR] 1.74), comorbidities (yes vs no: OR 1.57), tumour location (diffuse vs lower: OR 4.05), cTNM stage (III vs I: OR 1.95), and a preoperative haemoglobin level less than 80 g/L (vs over 120 g/L: OR 35.30). The C-index was 0.859 and 0.850 in the primary and validation cohorts, respectively, which both indicated good discrimination of the nomogram. Additionally, both calibration curves and Hosmer-Lemeshow tests (p-value 0.184 and 0.887, respectively) demonstrated high agreement between the predictions and actual outcomes.

CONCLUSION

A nomogram composed of preoperative variables to predict blood transfusion for gastric cancer surgery was effectively developed and validated. This nomogram could be used to improve the utilisation of red blood cells for gastrectomy.

Association between low preoperative skeletal muscle quality and infectious complications following gastrectomy for gastric cancer

PURPOSE

It is known that sarcopenia affects the overall short- and long-term outcomes of patients with gastric cancer (GC); however, the effect of muscle quality on infectious complications after gastrectomy for GC remains unclear. We investigated the associations between the preoperative quantity and quality of skeletal muscle on infectious complications following gastrectomy for GC.

METHODS

The subjects of this retrospective study were 353 GC patients who underwent radical gastrectomy between 2009 and 2018. We examined the relationships between their clinical factors, including skeletal muscle mass index and intramuscular adipose tissue content (IMAC), and infectious complications after gastrectomy.

RESULTS

Infectious complications developed in 59 patients (16.7%). The independent risk factors for infectious complications identified by multivariate analysis were male gender (P < 0.001), prognostic nutritional index below 45 (P = 0.006), and high IMAC (P = 0.011). Patients with a high IMAC were older and had a higher body mass index, as well as a greater age-adjusted Charlson comorbidity index, than those with low or normal IMAC.

CONCLUSIONS

Low skeletal muscle quality defined by a high IMAC is a risk factor for infectious complications following gastrectomy. When feasible, preoperative nutritional intervention and rehabilitation aiming to improve muscle quality could reduce infectious complications after gastrectomy for GC.

Postoperative Long-Term Outcomes in Elderly Patients with Gastric Cancer and Risk Factors for Death from Other Diseases

BACKGROUND

Elderly patients with gastric cancer are frequently treated surgically in current clinical practice. Although several studies have investigated short-term outcomes after gastrectomy in elderly patients, most did not evaluate long-term outcomes.

METHODS

We analyzed 1154 consecutive patients who underwent curative gastrectomy for gastric cancer between 2001 and 2013. We classified them into two groups: the elderly group (n = 241), consisting of patients aged ≥75 years, and the non-elderly group (n = 913), consisting of patients aged <75 years, and compared the short- and long-term outcomes between the two groups. The risk factors for death from other diseases in elderly patients were also examined.

RESULTS

Although the incidence of postoperative pneumonia was significantly higher in the elderly group (P < 0.001), the proportion of overall postoperative complications did not differ significantly between the two groups (P = 0.097). The disease-specific survival was similar between the two groups (P = 0.743), whereas the overall survival in the elderly group was significantly shorter than that in the non-elderly group (P < 0.001) because of a higher incidence of death from other diseases throughout all gastric cancer stages. Multivariate analysis revealed that a low preoperative prognostic nutrition index (PNI) and multiple comorbidities were significant risk factors for death from other diseases within 5 years in the elderly group.

CONCLUSIONS

Despite acceptable short-term outcomes, long-term outcomes in elderly patients with gastric cancer were poor due to the high incidence of death from other diseases. Indications for surgery in elderly patients with a low PNI or multiple comorbidities should be considered carefully.

Risk Factors for Postoperative Infectious Complications in Elderly Patients with Gastric Cancer

Background

Elderly patients with gastric cancer (GC) are at increased risk of infectious complications following gastrectomy. A limited set of risk factors has been identified to predict complications in these patients. To improve the safety of gastrectomy in this population, we investigated the incidence of infectious complications and associated clinicopathologic, nutritional and surgical risk factors in a cohort of elderly patients with GC.

Methods

Elderly GC patients (≥70 years) who underwent gastrectomy between January 2013 and December 2017 in Peking Union Medical College Hospital were included in the study. Clinicopathologic data were collected retrospectively. Severity of complications was classified using the Clavien–Dindo system. Infectious complications were assessed based on clinical diagnosis of health care-associated infection as defined by the US Centers for Disease Control and Prevention. Multivariate logistic regression analyses were performed to determine the risk factors for infectious complications.

Results

Three hundred thirty-one consecutive patients were included, with a median age of 74 years (range 70–88). The rate of surgical morbidity was 37.5% and the mortality rate was 1.2%. The incidence of infectious complications was 19.6%, with the most common infectious complication being pulmonary infection (11.5%). Preoperative weight loss ≥5% (odds ratio [OR] = 2.21; 95% CI, 1.15–4.28; p = 0.018), Charlson comorbidity index score ≥3 (OR = 2.83; 95% CI, 1.30–6.16; p = 0.009) and preoperative hsCRP level ≥10 mg/L (OR = 2.48; 95% CI, 1.14–5.38; p = 0.022) were independently associated with infectious complications.

Conclusion

Preoperative weight loss, elevated hsCRP level and comorbidity burden can be used to predict postoperative infectious complications in elderly GC patients. It is recommended to pay more attention to the treatment of elderly GC patients with these risk factors.

Risk factors for postoperative pneumonia after general and digestive surgery: a retrospective single-center study

PURPOSE

Pneumonia is the second-most common complication in postoperative patients and is associated with significant morbidity and high costs of care. We aimed to determine the risk factors for pneumonia after general and digestive surgery.

METHODS

The medical records of 1,016 patients who underwent general and digestive surgery between January 2016 and March 2019 in our hospital were reviewed.

RESULTS

Of the 1,016 patients, 67 (6.6%) developed postoperative pneumonia. The multivariate analysis showed that significant predictors of postoperative pneumonia were a poor Eastern Cooperative Oncology Group performance status (ECOG-PS), low forced vital capacity and low forced expiratory volume in one second in the spirometry test, malnutrition (low serum albumin levels and low controlling nutritional status scores and prognostic nutritional index [PNI] values), esophagectomy, upper gastrointestinal surgery, and nonlaparoscopic surgery. Of these factors, the combination of PNI and ECOG-PS clearly stratified patients into low-, intermediate-, and high-risk groups with respect to developing postoperative pneumonia (area under the curve: 0.709).

CONCLUSIONS

Although postoperative pneumonia is associated with many clinical variables, active medical intervention for the prevention of pneumonia in patients with multiple risk factors can improve the postoperative course. In particular, perioperative nutritional care may prevent postoperative pneumonia in patients with malnutrition and a poor PS.

Systemic Inflammation Score as a Predictor of Pneumonia after Radical Resection of Gastric Cancer: Analysis of a Multi-Institutional Dataset

BACKGROUND

Curative treatment for gastric cancer (GC) comprising gastrectomy with systematic lymph node dissection can result in postoperative complications. Postoperative pneumonia is sometimes fatal, like surgery-related complications such as anastomotic leakage. In this retrospective study, we analyzed a multi-institutional collaborative dataset with the aim of identifying predictors of postgastrectomy pneumonia.

METHODS

From a retrospective database of 3,484 patients who had undergone gastrectomy for GC at nine Japanese institutions between 2010 and 2014, 1,415 patients who met all eligibility criteria were identified as eligible for analysis. Predictive values of 31 candidate variables for postoperative pneumonia were assessed.

RESULTS

Forty-two patients (3.0%) had grade II or higher postoperative pneumonia. Preoperative systemic inflammation score (SIS) had the greatest area under the curve (0.655) for predicting postoperative pneumonia (optimal cutoff value = 2). The odds ratio (OR) of high SISs associated with postoperative pneumonia was 3.10 (95% confidence interval [CI], 1.54-6.07; p < 0.001). Multivariate binomial logistic analysis identified high SIS as an independent risk factor for postoperative pneumonia (OR, 2.31; 95% CI, 1.19-4.48; p = 0.013). A forest plot revealed that ORs of high SISs were highest in female patients.

CONCLUSIONS

Our findings indicate that the preoperative SIS may serve as a simple predictor of postgastrectomy pneumonia, assisting physicians' efforts to take preventive measures against this complication.

Development and validation of a prognostic nomogram for predicting post-operative pulmonary infection in gastric cancer patients following radical gastrectomy

The aim of this retrospective study was to develop and validate a nomogram for predicting the risk of post-operative pulmonary infection (POI) in gastric cancer (GC) patients following radical gastrectomy. 2469 GC patients who underwent radical gastrectomy were enrolled, and randomly divided into the development and validation groups. The nomogram was constructed based on prognostic factors using logistic regression analysis, and was internally and crossly validated by bootstrap resampling and the validation dataset, respectively. Concordance index (C-index) value and calibration curve were used for estimating the predictive accuracy and discriminatory capability. Sixty-five (2.63%) patients developed POI within 30 days following surgery, with higher rates of requiring intensive care and longer post-operative hospital stays. The nomogram showed that open operation, chronic obstructive pulmonary disease (COPD), intra-operative blood transfusion, tumor located at upper and/or middle third and longer operation time (≥4 h) in a descending order were significant contributors to POI risk. The C-index value for the model was 0.756 (95% CI: 0.675−0.837), and calibration curves showed good agreement between nomogram predictions and actual observations. In conclusion, a nomogram based on these factors could accurately and simply provide a picture tool to predict the incidence of POI in GC patients undergoing radical gastrectomy.

Influence of age on postoperative complications especially pneumonia after gastrectomy for gastric cancer

Background

The aim of this study was to investigate the influence of patients’ age on postoperative morbidities including pneumonia.

Methods

We reviewed the clinical records of 211 patients with stages I – III gastric cancer undergoing curative distal gastrectomy (DG) or total gastrectomy (TG). Patients were classified into an elderly (≧80 y.o.) or a control (< 80 y.o.) group. We compared patient characteristics (sex ratio, disease stage, degree of lymph node dissection, number of retrieved lymph nodes, and type of reconstruction) and early postoperative outcomes (operation time, intra-operative blood loss, and postoperative morbidity including pneumonia, and mortality) between the two groups separately in DG and TG.

Results

There were 134 and 77 patients who underwent DG and TG, respectively. The numbers of patients in the elderly and control groups were 25 and 109 in DG and 12 and 65 in TG. The percentage of female patients in the elderly group was greater than that in the control group in both DG and TG. The extent of lymph node dissection did not differ between two groups in TG; in contrast in DG, the rate of a D1 dissection was greater in the elderly group than in the control group. There were no differences between the two groups in distribution of disease stage, number of retrieved lymph nodes, operation time, and blood loss in DG and in TG. Overall postoperative morbidity did not differ between two groups after DG and after TG. The rate of infectious complications in the elderly group was not different from that in the control group after DG and after TG. The incidence of pneumonia was more frequent in the elderly group compared to the control group after DG (8% vs. 1%, P < 0.05) but not after TG (17% vs. 5%). When patients were compared between the elderly and the control groups regardless of type of gastrectomy, the incidence of pneumonia in the elderly group (4/37 (11%)) was greater than that in the control group (4/174 (2%), P < 0.05).

Conclusions

These results suggest that pneumonia is increased in patients older than 80 years after DG.

Risk calculator for predicting postoperative pneumonia after gastroenterological surgery based on a national Japanese database

BACKGROUND

The aim of the present study was to develop a risk calculator predictive of postoperative pneumonia in patients undergoing gastroenterological surgery.

METHODS

We analyzed data from 382 124 patients undergoing eight main gastroenterological surgeries between 2011 and 2013 using the National Clinical Database in Japan. A risk model was developed using multivariate logistic regression analysis with patient data from 2011 to 2012 (n = 247 604) and validated using data from 2013 (n = 134 520).

RESULTS

Pneumonia was observed in 11 105 patients (2.9%). After the input of significant primary disease and surgical procedures, 18 patient characteristics including gender, chronic obstructive pulmonary disease, sepsis, and need for any assistance in the activities of daily living, six laboratory parameters, and two intraoperative factors were used for risk calculation. Area under the receiver-operating characteristic curve was 0.822 (95% confidence interval, 0.817-0.826) in the derivation group and 0.826 (0.819-0.832) in the validation group.

CONCLUSION

The risk calculator accurately predicted the occurrence of pneumonia following gastroenterological surgery.

Type 2 diabetes and postoperative pneumonia: An observational, population-based study using the Spanish Hospital Discharge Database, 2001-2015

Purpose

We analyzed temporal trends, demographic and clinical characteristics and hospital mortality rates of postoperative pneumonia among type 2 diabetes mellitus (T2DM) patients in Spain from 2001 to 2015. We also compared the incidence, comorbidities and mortality between patients with and without T2DM suffering from postoperative pneumonia. Finally, we analyzed the factors involved in the prediction of in-hospital mortality among patients suffering postoperative pneumonia.

Methods

We used the Spanish National Hospital Discharge Database for the period 2001–2015. We analyzed patients aged 40 years or over who had been hospitalized for a surgical procedure and suffered pneumonia or ventilator-associated pneumonia during their hospital admission. We compared patients with and without T2DM. The main outcome measures were the type of surgical procedure, the presence of a comorbidity, the type of isolated pathogens, admission to the emergency room (ER) and in-hospital mortality (IHM).

Results

We selected 117,665 hospitalized patients who suffered postoperative pneumonia (16.9% with T2DM). After multivariable adjustment, T2DM patients had a 21% higher incidence of postoperative pneumonia than nondiabetic patients (IRR 1.21, 95% CI 1.03–1.42). The IHM was approximately 31% in both groups. Predictors of IHM included age, the presence of comorbidities, treatment with a pleural drainage tube, dialysis, blood transfusion, mechanical ventilation and admission to the ER. From 2001 to 2015, the IHM decreased significantly in both populations. Suffering from T2DM was not a predictor of IHM (OR 0.99, 95% CI 0.96–1.03) in our investigation.

Conclusions

T2DM patients have a higher incidence of postoperative pneumonia than those without this disease. The IHM decreased from 2001 to 2015, regardless of T2DM status. T2DM did not predict a higher IHM after suffering from postoperative pneumonia.

Feasibility of Laparoscopic Distal Gastrectomy for Stage I Gastric Cancer in Patients Outside of Clinical Trials

BACKGROUND

Randomized controlled trials, including the Japan Clinical Oncology Group (JCOG) 0912 trial, have shown the safety of laparoscopy-assisted distal gastrectomy (LADG) for select healthy patients. It is unclear whether LADG is feasible in patients who do not meet trial eligibility criteria.

METHODS

The present study retrospectively reviewed 547 patients with clinical stage I gastric cancer who underwent distal or pylorus-preserving gastrectomy. Of these, 185 were identified as not fulfilling the eligibility criteria of JCOG 0912; the short-term surgical outcomes between LADG and open distal gastrectomy (ODG) were compared in this group before and after propensity score matching.

RESULTS

Patients who were not eligible for inclusion in the trial comprised 33.8% of the total. After matching, there were 59 patients each in the LADG and ODG groups, with an improved balance of confounding factors between the two groups. LADG was associated with significantly longer operation time, less blood loss, and shorter postoperative hospital stay than ODG. The rate of overall postoperative complications of Clavien-Dindo Grade II or higher did not differ significantly between the LADG and ODG groups (23.7 vs. 18.6%, respectively; p = 0.653). The incidence of pneumonia (6.8 vs. 5.1%), intra-abdominal infectious complications (5.1 vs. 3.4%), and stasis syndrome (5.1 vs. 3.4%) was also comparable between the two groups.

CONCLUSION

LADG was as safe as ODG in patients who did not meet the eligibility criteria of JCOG 0912. LADG could be a standard treatment option for patients with stage I gastric cancer, regardless of their general condition.

Colon Interposition for Esophageal Reconstruction in Cancer Patients

Objective:

The aim of this study was to report our experience with colon interposition (COI) and to compare the results with an extensive review of the COI literature.

Summary of Background Data:

The stomach is the first choice as an esophageal substitute following esophagectomy in cancer patients, while COI is reserved for patients where the stomach is not available or must be included in the resection due to cancer.

Methods:

We retrospectively reviewed the records of cancer patients undergoing colon interposition from 2006 to 2017. Outcomes were compared with an extensive review of the literature published between 2000 and 2017.

Results:

A total of 13 patients underwent planned COI. Mortality was zero and overall morbidity was 53%; 4 patients suffered from leakage and 2 patients from strictures. None of the patients suffered from necrosis of the interponat and there was no need for subsequent redundancy operations.

The extensive review identified 23 publications. Overall study grading was low (grade C). Only 3 studies were prospective, no randomized studies were found, and many outcomes were poorly defined. The rates for 30-day and in-hospital mortality were 1% and 2%, respectively. Overall morbidity was 43%. The reported number of leakages, strictures, necrosis of the interponat, and redundancy operations varied between 0% and 50%, 0% and 21%, 0% and 9%, and 0% and 2%, respectively.

Conclusions:

COI is a complex technique that is necessary in a relatively small group of selected patients after esophagectomy for cancer. Prospective and comparative studies with strict outcome definitions, long-term follow up, and patient reported outcome measures are lacking.

Impact of peri-operative blood transfusion on post-operative infections after radical gastrectomy for gastric cancer: a propensity score matching analysis focusing on the timing, amount of transfusion and role of leukocyte depletion

Purpose

Allogeneic blood transfusions (BTF) are sometimes inevitable during radical gastrectomy with lymphadenectomy for advanced gastric cancer. The aim of this retrospective study was to investigate the association between BTF and post-operative infections, focusing on the impact of timing, amount of transfusion and the role of leukocyte depletion.

Methods

The study cohort was 2064 patients who underwent gastrectomy for gastric cancer from November 2010 to August 2017. The association between BTF and post-operative infections was estimated by univariate and multivariate analyses after propensity score matching. Subgroup analysis was performed according to the timing and amount of transfusion, and leukocyte depletion or not.

Results

Out of a total 2064 patients, 426 (20.6%) received peri-operative BTF. After one-to-one matching, 361 pairs of patients were included for further analysis, of who 68 (9.4%) developed infections. Multivariate analysis identified that an operation time ≥ 240 min, combined multi-organ resection, BTF and BMI ≥ 25 kg/m² were independent risk factors for post-operative infection. Patients given a high-volume (> 7.5 U), intra-operatively of leukocyte-non-depleted BTF had the highest risk of developing infections clarified by subgroup analysis.

Conclusion

Infection was the most common complication following gastrectomy for gastric cancer and BTF was identified as an independent risk factor by propensity score matching and multivariate analyses. The timing, amount of transfusion and leukocyte depletion had an impact on the incidence of infection. To decrease infection, BTF should be avoided where possible, particularly during operation, with a large amount and leukocyte-not-depleted blood.

Surgical outcomes after gastrectomy in very elderly patients with gastric cancer

PURPOSE

Whether or not gastrectomy is feasible for very elderly gastric cancer patients is unclear. This study aimed to clarify the feasibility and safety of surgical treatment for patients in this age group.

METHOD

The study included 55 very elderly patients with resectable gastric cancer who underwent gastrectomy (≥ 85 years of age; very-E group). The surgical outcomes were compared with those of 611 elderly patients (75-84 years old; E group).

RESULTS

Female sex, a poor physical and performance status, and a low serum albumin level patients were more frequent in the very-E group than in the E group. Lymphadenectomy was less aggressive in the very-E group than in the E group (P < 0.001). The overall postoperative complication rate was not significantly different between the groups (46 vs 33%; P = 0.073). A multivariate analysis to predict the overall survival identified male sex (hazard ratio 1.75, 95% confidence interval 1.30-2.36), low body mass index (2.19, 1.52-3.16), poor performance status (2.14, 1.60-2.86), low serum albumin level (1.84, 1.37-2.48), and advanced tumor stage (1.71, 1.29-2.27) but not age (1.31, 0.84-2.03) as independent prognostic factors.

CONCLUSION

Chronological age alone is not a contraindicative factor for gastrectomy in very elderly patients.

Prospective phase II study evaluating the efficacy of swallow ability screening tests and pneumonia prevention using a team approach for elderly patients with gastric cancer

BACKGROUND

Aging partly impairs swallowing function, which is considered a risk factor for postoperative pneumonia (PP). We evaluated the efficacy of a new team-based strategy to reduce the incidence of PP in elderly patients with gastric cancer.

METHODS

This single-center, prospective phase II study included elderly patients (≥75 years old) with gastric cancer undergoing gastric surgery. The primary endpoint was the incidence of Clavien-Dindo grade II or higher PP. Patients were initially screened using three swallowing function screening tests: a symptom questionnaire, the modified water swallow test (MSWT), and the repetitive saliva swallowing test (RSST). All patients were provided standard preoperative oral checks and care and simple neck muscle training. For patients who screened positive, a videofluorographic swallowing study was performed; if an abnormality was found, the patient was given intensive swallowing rehabilitation both pre- and postoperatively.

RESULTS

Of 86 eligible patients enrolled, PP developed in 3 (3.5%). The 60% confidence interval of 1.8-6.3% had an upper limit below the prespecified threshold of 7.8%. Positive screening results were found for 19 patients (22.1%) on the symptom questionnaire, 3 (3.5%) on the MSWT, and 1 (1.2%) on the RSST. PP was not observed in any patients who screened positive.

CONCLUSION

In conclusion, although the screening tests we adopted here were not sufficient to identify patients at high risk of aspiration pneumonia, perioperative interventions using a team approach might be effective in reducing the incidence of PP in elderly patients with gastric cancer.

Incidence and risk factors of postoperative pneumonia following cancer surgery in adult patients with selected solid cancer: results of "Cancer POP" study

The aim of this study was to investigate the incidence and risk factors of postoperative pneumonia (POP) within 1 year after cancer surgery in patients with the five most common cancers (gastric, colorectal, lung, breast cancer, and hepatocellular carcinoma [HCC]) in South Korea. This was a multicenter and retrospective cohort study performed at five nationwide cancer centers. The number of cancer patients in each center was allocated by the proportion of cancer surgery. Adult patients were randomly selected according to the allocated number, among those who underwent cancer surgery from January to December 2014 within 6 months after diagnosis of cancer. One‐year cumulative incidence of POP was estimated using Kaplan–Meier analysis. An univariable Cox's proportional hazard regression analysis was performed to identify risk factors for POP development. As a multivariable analysis, confounders were adjusted using multiple Cox's PH regression model. Among the total 2000 patients, the numbers of patients with gastric cancer, colorectal cancer, lung cancer, breast cancer, and HCC were 497 (25%), 525 (26%), 277 (14%), 552 (28%), and 149 (7%), respectively. Overall, the 1‐year cumulative incidence of POP was 2.0% (95% CI, 1.4–2.6). The 1‐year cumulative incidences in each cancer were as follows: lung 8.0%, gastric 1.8%, colorectal 1.0%, HCC 0.7%, and breast 0.4%. In multivariable analysis, older age, higher Charlson comorbidity index (CCI) score, ulcer disease, history of pneumonia, and smoking were related with POP development. In conclusions, the 1‐year cumulative incidence of POP in the five most common cancers was 2%. Older age, higher CCI scores, smoker, ulcer disease, and previous pneumonia history increased the risk of POP development in cancer patients.

Prognostic significance of postoperative pneumonia after curative resection for patients with gastric cancer

Few studies have been designed to investigate the incidence of postoperative pneumonia after radical gastrectomy and its effect on prognosis of these patients. Incidences of postoperative pneumonia after radical gastrectomy in our department between January 1996 and December 2014 were summarized. Their effects on prognosis were retrospectively analyzed using survival curves and Cox regression. A total of 5237 patients were included in this study, 767 (14.4%) of them had complications, including 383 cases of postoperative pneumonia (7.2%). The 5‐year overall and disease‐specific survival of patients with postoperative pneumonia were both lower than those without this complication (P < 0.001). Stratified analysis demonstrated that this difference existed in all Stage I, II, and III patients (log‐rank, P < 0.05). Multivariate analysis revealed that age, neoadjuvant chemotherapy, tumor size, tumor stage, and postoperative pneumonia were independent risk factors for disease‐specific survival. Postoperative pneumonia after radical gastrectomy is an independent risk factor for prognosis of gastric cancer patients, especially in stage III.

The Effect of Neoadjuvant Chemoradiation on Anastomotic Leak and Additional 30-Day Morbidity and Mortality in Patients Undergoing Total Gastrectomy for Gastric Cancer

INTRODUCTION

In addition to increased perioperative morbidity, anastomotic leak following gastric resection for gastric cancer can have detrimental effects on overall and disease-free survival. The risk of anastomotic leak following neoadjuvant therapy remains unknown. The purpose of this study is to investigate the association of preoperative chemotherapy and radiation therapy with postoperative anastomotic leak and additional 30-day morbidity and mortality outcomes following total gastrectomy with reconstruction for gastric cancer using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent total gastrectomy with reconstruction for gastric cancer from 2005 to 2012 were identified. Within the NSQIP database, anastomotic leak is captured as an organ space infection. The association of preoperative chemotherapy and radiation therapy with anastomotic leak and additional 30-day morbidity and mortality outcomes was investigated using chi-squared analysis, Fisher's exact test, and Student's t test.

RESULTS

A total of 1135 patients met inclusion criteria; 121 (10.7%) patients underwent preoperative chemotherapy within 30 days of surgery, and 53 (4.7%) patients underwent preoperative radiation therapy within 90 days of surgery. Neither preoperative chemotherapy nor radiation therapy was associated with an increased risk of anastomotic leak (p = 0.12 and p = 0.58, respectively). When compared to patients who did not undergo neoadjuvant therapy, patients who underwent either preoperative chemotherapy or radiation therapy did not experience a higher frequency of 30-day mortality (p = 0.41), cardiac (p = 0.49), wound (p = 0.76), renal (p = 0.13), septic (p = 0.55), or venous thromboembolism (p = 0.19) events and were significantly less likely to experience a pulmonary event (p = 0.02).

CONCLUSION

Neoadjuvant therapy prior to gastric resection for gastric cancer is not associated with an increased risk of anastomotic leak or other additional short-term morbidity or mortality.

Long-term impact of postoperative pneumonia after curative gastrectomy for elderly gastric cancer patients

With the extension of life expectancy, cancer has been increasing in elderly populations. Postoperative pneumonia can negatively influence immediate mortality following gastrectomy for elderly patients, but its impact on long‐term survival remains unclear. We retrospectively reviewed the cases of patients aged ≥75 years who underwent curative gastrectomy for gastric cancer from 2000 to 2014 to determine the long‐term effects of postoperative pneumonia and to identify independent risk factors along with physical status and surgical procedure. Of 250 patients, 32 (12.8%) developed postoperative pneumonia. Patients with postoperative pneumonia had significantly worse overall survival (OS) than those without postoperative pneumonia (P<.001). A multivariate analysis identified postoperative pneumonia as a prognostic factor for OS (hazard ratio, 2.06; 95% CI, 1.05‐3.75; P=.036). Significant risk factors for the development of postoperative pneumonia were male gender (P=.026) and D2 lymphadenectomy (P<.001). D2 lymphadenectomy was associated with poorer OS than D1 or D1+lymphadenectomy in patients with an American Society of Anesthesiologists (ASA) score 3 (P=.026), but did not influence OS negatively in patients with an ASA score ≤2. Limited lymphadenectomy did not affect the cancer‐specific survival of elderly patients with ASA score 3. Postoperative pneumonia following gastrectomy has an adverse impact on the long‐term survival of elderly gastric cancer patients. A limited lymphadenectomy during curative resection should be considered to prevent postoperative pneumonia in frail elderly patients with ASA score 3. Postoperative pneumonia following gastrectomy has an adverse impact on the long‐term survival of elderly gastric cancer patients. Extent of lymph node dissection during curative resection should be limited to prevent postoperative pneumonia, based on the patient's frailty.

The Epidemiology and Risk Factors for Postoperative Pneumonia

Postoperative pneumonia is a common complication of surgery, and is associated with marked morbidity and mortality. Despite advances in surgical and anesthetic technique, it persists as a frequent postoperative complication. Many studies have aimed to assess its burden, as well as associated risk factors. However, this complication varies among the different surgical specialties, and there is a paucity of reports that comprehensively evaluate this complication. Therefore, the purpose of this study was to review the epidemiology and risk factors of postoperative pneumonia in the setting of: 1) general surgery; 2) cardiothoracic surgery; 3) orthopedic and spine surgery; and 4) head and neck surgery.

Randomized clinical trial of 24 versus 72 h antimicrobial prophylaxis in patients undergoing open total gastrectomy for gastric cancer

BACKGROUND

Open total gastrectomy carries a high risk of surgical-site infection (SSI). This study evaluated the non-inferiority of antimicrobial prophylaxis for 24 compared with 72 h after open total gastrectomy.

METHODS

An open-label, randomized, non-inferiority study was conducted at 57 institutions in Japan. Eligible patients were those who underwent open total gastrectomy for gastric cancer. Patients were assigned randomly to continued use of β-lactamase inhibitor for either 24 or 72 h after surgery. The primary endpoint was the incidence of SSI, with non-inferiority based on a margin of 9 percentage points and a 90 per cent c.i. The secondary endpoint was the incidence of remote infection.

RESULTS

A total of 464 patients (24 h prophylaxis, 228; 72 h prophylaxis, 236) were analysed. SSI occurred in 20 patients (8·8 per cent) in the 24-h prophylaxis group and 26 (11·0 per cent) in the 72-h group (absolute difference -2·2 (90 per cent c.i. -6·8 to 2·4) per cent; P < 0·001 for non-inferiority). However, the incidence of remote infection was significantly higher in the 24-h prophylaxis group.

CONCLUSION

Antimicrobial prophylaxis for 24 h after total gastrectomy is not inferior to 72 h prophylaxis for prevention of SSI. Shortened antimicrobial prophylaxis might increase the incidence of remote infection. Registration number: UMIN000001062 ( http://www.umin.ac.jp).

Clinicopathologic Characteristics of Elderly with Gastric Cancer, and the Risk Factors of Postoperative Complications

PURPOSE

In China, gastric cancer (GC), which is one of the most common malignant tumors, has an increasing incidence in elderly population due to aging process. Since a considerable number of elderly patients with GC accepting surgical treatments developed postoperative complications, it is necessary to evaluate risk factors for postoperative complications.

MATERIALS AND METHODS

In the present study, the clinicopathologic characteristics of 3,024 elderly patients (aged ≥65 years) with GC, who underwent surgery between 1996 and 2006, were examined and contributing factors for postoperative complications were analyzed. A total of 2,915 non-elderly patients (aged <65 years) with GC during the same period were enrolled as a control group. Clinicopathologic characteristics of non-elderly patients were investigated and compared with elderly group.

RESULTS

As to clinicopathologic characteristics, significant differences were detected in terms of location of primary lesions between elderly patients and non-elderly patients (p <.05), whereas no statistical difference was observed in other characteristics between two groups (p >.05). Surgical property and method in elderly patients were similar to that in non-elderly patients (p >.05). Regression analysis showed that diabetes, chronic pulmonary disease, preoperative anemia, preoperative hypoalbuminemia, combined organ excision, and blood transfusion were independent factors for complications in elderly patients (p <.05), with some differences from non-elderly group.

CONCLUSIONS

Elderly group with GC had distinctive clinicopathologic characteristics. Surgery remains principal treatment for elderly, and proper preoperative measures are required to decrease postoperative complications.