Risk factors for pulmonary complications after emergency abdominal surgery

The Role of Bronchoscopy and Chest Physiotherapy in Postoperative Patients With Acute Lung Atelectasis Due to Airway Mucus Plugging: A Case Series and Review of Entity

Mechanical ventilation and endotracheal intubation can cause airway damage and inflammation resulting in excessive mucus secretions, thereby increasing the risk of respiratory failure post extubation. An abundance of secretions may result in bronchial obstruction and lung collapse distant from the site of obstruction. If lung collapse is diagnosed, extra support, including oxygen and, rarely, reintubation, can be necessary. The combination of chest wall percussion and vibrations, patient positioning to facilitate mucus drainage, coughing, and breathing exercises was the chest physiotherapy method employed for airway clearance in this study. Since the late 20th century, pulmonary rehabilitation strategies have been a standard aspect of care to prevent lung collapse in postoperative cases. Bronchoscopic aspiration and lavage are the common techniques used to remove retained secretions or mucus plugs. Large-volume saline instillation in aliquots and repeated suctioning are required during the procedure. Thus, the current case series emphasizes the role of bronchoscopy and pulmonary rehabilitation in the management of acute lung atelectasis during the postoperative period.

Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial

Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.

Comparison of 6-min walk test distance vs. estimated maximum oxygen consumption for predicting postoperative pulmonary complications in patients undergoing upper abdominal surgery: a prospective cohort study

OBJECTIVE

The present study aims to evaluate the predictive ability of estimated maximum oxygen consumption (e[Formula: see text]O_2max) and 6-min walk distance (6MWD) for postoperative pulmonary complications (PPCs) in adult surgical patients undergoing major upper abdominal surgery.

METHOD

This study was conducted by collecting data prospectively from a single center. The two predictive variables in the study were defined as 6MWD and e[Formula: see text]O_2max. Patients scheduled for elective major upper abdominal surgery from March 2019 to May 2021 were included. The 6MWD was measured for all patients before surgery. e[Formula: see text]O_2max was calculated using the regression model of Burr, which uses 6MWD, age, gender, weight, and resting heart rate (HR) to predict aerobic fitness. The patients were categorized into PPC and non-PPC group. The sensitivity, specificity, and optimum cutoff values for 6MWD and e[Formula: see text]O_2max were calculated to predict PPCs. The area under the receiver operating characteristic curve (AUC) of 6MWD or e[Formula: see text]O_2max was constructed and compared using the Z test. The primary outcome measure was the AUC of 6MWD and e[Formula: see text]O_2max in predicting PPCs. In addition, the net reclassification index (NRI) was calculated to assess ability of e[Formula: see text]O_2max compared with 6MWT in predicting PPCs.

RESULTS

A total of 308 patients were included 71/308 developed PPCs. Patients unable to complete the 6-min walk test (6MWT) due to contraindications or restrictions, or those taking beta-blockers, were excluded. The optimum cutoff point for 6MWD in predicting PPCs was 372.5 m with a sensitivity of 63.4% and specificity of 79.3%. The optimum cutoff point for e[Formula: see text]O_2max was 30.8 ml/kg/min with a sensitivity of 91.6% and specificity of 79.3%. The AUC for 6MWD in predicting PPCs was 0.758 (95% confidence interval (CI): 0.694-0.822), and the AUC for e[Formula: see text]O_2max was 0.912 (95%CI: 0.875-0.949). A significantly increased AUC was observed in e[Formula: see text]O_2max compared to 6MWD in predicting PPCs (P < 0.001, Z = 4.713). And compared with 6MWT, the NRI of e[Formula: see text]O_2max was 0.272 (95%CI: 0.130, 0.406).

CONCLUSION

The results suggested that e[Formula: see text]O_2max calculated from the 6MWT is a better predictor of PPCs than 6MWD in patients undergoing upper abdominal surgery and can be used as a tool to screen patients at risk of PPCs.

Three Weeks of Pulmonary Rehabilitation Do Not Influence Oscillometry Parameters in Postoperative Lung Cancer Patients

Background: Thoracic surgery is a recommended treatment option for non-small cell lung cancer patients. An important part of a patient’s therapy, which helps to prevent postoperative complications and improve quality of life, is pulmonary rehabilitation (PR). The aim of this study was to assess whether the implementation of physical activity has an influence on forced oscillation technique (FOT) values in patients after thoracic surgery due to lung cancer. Methods: In this observational study, we enrolled 54 patients after thoracic surgery due to lung cancer, 49 patients with idiopathic interstitial fibrosis (IPF), and 54 patients with chronic obstructive pulmonary disease/asthma−COPD overlap (COPD/ACO). All patients were subjected to three weeks of in-hospital PR and assessed at the baseline as well as after completing PR by FOT, spirometry, grip strength measurement, and the 6-min walk test (6MWT). Results: We observed differences between FOT values under the influence of physical activity in studied groups, mostly between patients after thoracic surgery and COPD/ACO patients; however, no significant improvement after completing PR among FOT parameters was noticed in any group of patients. Improvements in the 6MWT distance, left hand strength, and right hand strength after PR were noticed (p < 0.001, 0.002, and 0.012, respectively). Conclusions: Three weeks of pulmonary rehabilitation had no impact on FOT values in patients after thoracic surgery due to lung cancer. Instead, we observed improvements in the 6MWT distance and the strength of both hands. Similarly, no FOT changes were observed in IPF and COPD/ACO patients after completing PR.

Identification of risk factors for postoperative pulmonary complications in general surgery patients in a low-middle income country

BACKGROUND

Postoperative pulmonary complications (PPCs) are an important cause of perioperative morbidity and mortality. Although risk factors for PPCs have been identified in high-income countries, less is known about PPCs and their risk factors in low- and middle-income countries, such as South Africa. This study examined the incidence of PPCs and their associated risk factors among general surgery patients in a public hospital in the province of KwaZulu-Natal, South Africa to inform future quality improvement initiatives to decrease PPCs in this clinical population.

METHODS

A retrospective secondary analysis of adult patients with general surgery admissions from January 1, 2013 to December 31, 2017 was conducted using data from the health system's Hybrid Electronic Medical Registry. The sample was comprised of 5352 general surgery hospitalizations. PPCs included pneumonia, atelectasis, acute respiratory distress syndrome, pulmonary edema, pulmonary embolism, prolonged ventilation, hemothorax, pneumothorax, and other respiratory morbidity which encompassed empyema, aspiration, pleural effusion, bronchopleural fistula, and lower respiratory tract infection. Risk factors examined were age, tobacco use, number and type of pre-existing comorbidities, emergency surgery, and number and type of surgeries. Bivariate and multivariable logistic regression models were conducted to identify risk factors for developing a PPC.

RESULTS

The PPC rate was 7.8%. Of the 418 hospitalizations in which a patient developed a PPC, the most common type of PPC was pneumonia (52.4%) and the mortality rate related to the PPC was 11.7%. Significant risk factors for a PPC were increasing age, greater number of comorbidities, emergency surgery, greater number of general surgeries, and abdominal surgery.

CONCLUSIONS

PPCs are common in general surgery patients in low- and middle-income countries, with similar rates observed in high-income countries. These complications worsen patient outcomes and increase mortality. Quality improvement initiatives that employ resource-conscious methods are needed to reduce PPCs in low- and middle-income countries.

Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial

BACKGROUND

Postoperative pneumonia and delayed physical recovery are significant problems after emergency laparotomy. No randomized controlled trial has assessed the feasibility, safety, or effectiveness of intensive postoperative physical therapy in this high-risk acute population.

METHODS

The internal pilot phase of the Incidence of Complications after Emergency Abdominal Surgery: Get Exercising (ICEAGE) trial was a prospective, randomized controlled trial that evaluated the feasibility, safety, and clinical trial processes of providing intensive physical therapy immediately following emergency laparotomy. Fifty consecutive patients were recruited at the principal participating hospital and randomly assigned to standard-care or intensive physical therapy of twice daily coached breathing exercises for 2 days and 30 minutes of daily supervised rehabilitation over the first 5 postoperative days.

RESULTS

Interventions were provided exactly as per protocol in 35% (78 of 221 patients) of planned treatment sessions. Main barriers to protocol delivery were physical therapist unavailability on weekends (59 of 221 patients [27%]), awaiting patient consent (18 of 99 patients [18%]), and patient fatigue (26 of 221 patients [12%]). Despite inhibitors to treatment delivery, the intervention group still received twice as many breathing exercise sessions and four times the amount of physical therapy over the first 5 postoperative days (23 minutes [interquartile range, 12-29 minutes] vs. 86 minutes [interquartile range, 53-121 minutes]; p < 0.001). One adverse event was reported from 78 rehabilitation sessions (1.3%), which resolved fully on cessation of activity without escalation of medical care.

CONCLUSION

Intensive postoperative physical therapy can be delivered safely and successfully to patients in the first week after emergency laparotomy. The ICEAGE trial protocol resulted in intervention group participants receiving more coached breathing exercises and spending significantly more time physically active over the first 5 days after surgery compared with standard care. It was therefore recommended to progress into the multicenter phase of ICEAGE to definitively test the effect of intensive physical therapy to prevent pneumonia and improve physical recovery after emergency laparotomy.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level II.

Root causes and outcomes of postoperative pulmonary complications after abdominal surgery: a retrospective observational cohort study

Background

Postoperative pulmonary complications (PPCs) contribute significantly to overall postoperative morbidity and mortality. In abdominal surgery, PPCs remain frequent. The study aimed to analyze the profile and outcomes of PPCs in patients submitted to abdominal surgery and admitted in a Portuguese polyvalent intensive care unit.

Methods

From January to December 2017 in the polyvalent intensive care unit of Hospital Garcia de Orta, Almada, Portugal, we conducted a retrospective, observational study of inpatients submitted to urgent or elective abdominal surgery who had severe PPCs. We evaluated the perioperative risk factors and associated mortality. Logistic regression was performed to find which perioperative risk factors were most important in the occurrence of PPCs.

Results

Sixty patients (75% male) with a median age of 64.5 [47-81] years who were submitted to urgent or elective abdominal surgery were included in the analysis. Thirty-six patients (60%) developed PPCs within 48 h and twenty-four developed PPCs after 48 h. Pneumonia was the most frequent PPC in this sample. In this cohort, 48 patients developed acute respiratory failure and needed mechanical ventilation. In the emergency setting, peritonitis had the highest rate of PPCs. Electively operated patients who developed PPCs were mostly carriers of digestive malignancies. Thirty-day mortality was 21.7%. The risk of PPCs development in the first 48 h was related to the need for neuromuscular blocking drugs several times during surgery and preoperative abnormal arterial blood gases. Median abdominal surgical incision, long surgery duration, and high body mass index were associated with PPCs that occurred more than 48 h after surgery. The American Society of Anesthesiologists physical status score 4 and COPD/Asthma determined less mechanical ventilation needs since they were preoperatively optimized. Malnutrition (low albumin) before surgery was associated with 30-day mortality.

Conclusion

PPCs after abdominal surgery are still a major problem since they have profound effects on outcomes. Our results suggest that programs before surgery, involve preoperative lifestyle changes, such as nutritional supplementation, exercise, stress reduction, and smoking cessation, were an effective strategy in mitigating postoperative complications by decreasing mortality.

Incidence and risk factors of pulmonary atelectasis in mechanically ventilated trauma patients in ICU: a prospective study

AIM

The aim of the study was to obtain information about the incidence and risk factors for pulmonary atelectasis in mechanically ventilated patients in the trauma ICU (TMICU). Pulmonary atelectasis is a common complication leading to serious lung dysfunction in patients in the TMICU and early identification of patients at risk is important for their effective management.

METHODS

All trauma patients admitted to the TMICU with mechanical ventilation for more than 1 day were included in a prospective 12-month study. Pulmonary atelectasis was diagnosed from chest radiographs by a critical care doctor and radiologist.

RESULTS

A total of 405 trauma patients were identified and data from 338 patients analyzed showing the incidence of pulmonary atelectasis to be 14%. Multivariate analysis revealed significant risk factors to be chest injury with an adjusted odds ratio (AOR) of 102.8, abdominal injury (AOR: 4.6), surgical intervention (AOR: 8.4), comorbidity (AOR: 13.7), Acute Physiology and Chronic Health Evaluation II score (APACHE II) of at least 15 (AOR: 4.8), sedation of at least 7 days (AOR: 7.5) and mechanical ventilation of at least 9 days (AOR: 3.43). Patients with chronic pulmonary disease tended to have higher risk for pulmonary atelectasis (AOR: 8.8). Patients with pulmonary atelectasis had longer stays in TMICU (P < 0.001) and higher mortality (P = 0.013).

CONCLUSION

The incidence of pulmonary atelectasis in TMICU in Thailand is comparable with that of the developed world. Pulmonary atelectasis is particularly associated with chest trauma, whereas abdominal injury, APACHE II of at least 15, surgery, comorbidity and prolonged mechanical ventilation are also significant risk factors. Early interventions to prevent or treat pulmonary atelectasis in these patients may improve outcome and shorten their stay in the TMICU and hospital.

Development and validation of a nomogram predicting postoperative pneumonia after major abdominal surgery

PURPOSE

Postoperative pneumonia (POP) is a common complication that can adversely affect the outcomes after surgery. This study aimed to devise and validate a model for stratifying the probability of POP in patients undergoing abdominal surgery.

METHODS

We included 1050 patients who underwent major abdominal surgery between 2012 and 2013. A nomogram was devised by evaluating the predictive factors for POP.

RESULTS

Of the 1050 patients, 56 (5.3%) developed POP. Multivariable logistic regression analysis revealed that the independent predictive factors for POP were age, male sex, history of cerebrovascular disease, Brinkman Index (BI) ≥ 900, and upper midline incision. A nomogram was devised by employing these five significant predictive factors. The prediction model showed a relatively good discrimination performance, with a concordance index of 0.77.

CONCLUSIONS

A nomogram based on age, male sex, history of cerebrovascular disease, BI ≥ 900, and upper midline incision may be useful for identifying patients with a high probability of developing POP after major abdominal surgery.

Early physical therapy intervention in gynaecological surgery: "Case series"

PURPOSE

To implement a physical therapy intervention protocol targeting patients admitted for gynaecological surgery to the gynaecological ward of XXXX Hospital.

METHOD

A prospective, cross-sectional and observational study was conducted with women admitted to the gynaecology ward, from June 2014 through June 2015. The study was divided into three phases with data on admissions to the gynaecology ward. A total of 565 women were included, corresponding to phases I (197), II (178) and III (190). The physical therapy staff implemented an early ambulation protocol as well as a mobility assessment.

RESULTS

The physical therapy protocol was implemented, and the rate of adherence was 100%. All participants received preoperative instruction on the importance of early mobilisation. On postoperative day 1, the participants in phase I walked a mean of 77.4 m. Following implementation of the physical therapy protocol, the walked distance increased to 292.6 m in phase II, followed by a slight decrease to a mean of 233 m in phase III.

CONCLUSIONS

The physical therapy protocol could be implemented, and the patients' adherence was satisfactory. Early ambulation can be optimised, and the participants began ambulation starting at 13 h after surgery.

ICEAGE (Incidence of Complications following Emergency Abdominal surgery: Get Exercising): study protocol of a pragmatic, multicentre, randomised controlled trial testing physiotherapy for the prevention of complications and improved physical recovery after emergency abdominal surgery

Background

Postoperative complications and delayed physical recovery are significant problems following emergency abdominal surgery. Physiotherapy aims to aid recovery and prevent complications in the acute phase after surgery and is commonplace in most first-world hospitals. Despite ubiquitous service provision, no well-designed, adequately powered, parallel-group, randomised controlled trial has investigated the effect of physiotherapy on the incidence of respiratory complications, paralytic ileus, rate of physical recovery, ongoing need for formal sub-acute rehabilitation, hospital length of stay, health-related quality of life, and mortality following emergency abdominal surgery. We hypothesise that an enhanced physiotherapy care package of additional education, breathing exercises, and early rehabilitation prevents postoperative complications and improves physical recovery following emergency abdominal surgery compared to standard care alone.

Methods

The Incidence of Complications following Emergency Abdominal surgery: Get Exercising (ICEAGE) trial is a pragmatic, investigator-initiated, multicentre, patient- and assessor-blinded, parallel-group, active-placebo controlled randomised trial, powered for superiority. ICEAGE will compare standard care physiotherapy to an enhanced physiotherapy care package in 288 participants admitted for emergency abdominal surgery at three Australian hospitals. Participants will be randomised using concealed allocation to receive either standard care physiotherapy (education, single session of coached breathing exercises, and daily early ambulation for 15 min) or an enhanced physiotherapy care package (education, twice daily coached breathing exercises for a minimum 2 days, and 30 min of daily supervised early rehabilitation for minimum five postoperative days). The primary outcome is a respiratory complication within the first 14 postoperative hospital days assessed daily with standardised diagnostic criteria. Secondary outcomes include referral for sub-acute rehabilitation services, discharge destination, paralytic ileus, hospital length of stay and costs, intensive care unit utilisation, 90-day patient-reported complications and health-related quality of life and physical capacity, and mortality at 30 days and at 1 year following surgery.

Discussion

The morbidity, mortality, and fiscal burdens following emergency abdominal surgery are some of the worst within surgery. Physiotherapy may be an effective, low-cost, minimal harm intervention to improve outcomes and reduce hospital utilisation following this surgery type. ICEAGE will test the benefits of this commonly provided intervention within a methodologically robust, multicentre, double-blinded, active-placebo controlled randomised trial.

Trial registration

ACTRN 12615000318583. Registered 8 April 2015

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0189-y) contains supplementary material, which is available to authorized users.

FUNCTIONALITY OF UPPER GASTROINTESTINAL CANCER PATIENTS WHICH HAVE UNDERTAKEN SURGERY IN HOSPITAL PHASE

Background:

Cancer patients present various physiological, metabolic, social and emotional changes as a consequence of the disease’s own catabolism, and may be potentiated in the gastrointestinal tract cancer by their interference with food intake, digestion and absorption.

Aim: T

o evaluate the functionality of upper gastrointestinal cancer patients which have undertaken surgery and analyze the factors associated with changes in strength and functionality during hospitalization time.

Methods:

Prospective analytical study in patients with cancer of the upper gastrointestinal tract which have undertaken surgery. Was evaluated the handgrip strength using a hand dynamometer and functionality through the functional independence measure and Functional Status Scale for Intensive Care Unit in the preoperative period, 2^nd and 7^th postoperative day.

Results:

Were included 12 patients, 75% men, and mean age was 58.17 years old. The most prevalent tumor site was stomach (66.7%). There was a progressive reduction from the pre-operative palmar grip strength to the 2^nd and 7^th postoperative day, respectively. There was a decrease in functional performance from the preoperative period to the 2^nd and a gain from the 2^nd to the 7^th postoperative day (p<0.001).

Conclusion:

An important reduction in the handgrip strength and functionality was evidenced during the postoperative period in relation to the basal value in the pre-operative period.

Comparison of breathing patterns, pressure, volume, and flow characteristics of three breathing techniques to encourage lung inflation in healthy older people

Background: It is important to encourage lung inflation to prevent postsurgical pulmonary complications and we compared three breathing techniques that place different emphasis on inspiratory flow and breath-holding. Methods: Fourteen healthy older people (69 ± 3.6 yrs) used diaphragmatic breathing (DB), Triflo II (TF), and a water pressure threshold device (BreatheMAX; BM) in a randomized and balanced crossover design. Outcome measures were inspiratory flow and pressure, inspiratory time (Ti), tidal volume (Vt), and breathing frequency. Results: Inspiratory flow with TF was significantly faster than DB and BM (p < 0.001: 0.96 ± 0.1; 0.43 ± 0.20 and 0.28 ± 0.1 L.s^-1, respectively) and pressures greater (p < 0.001: -1.3 ± 0.6, -5.5 ± 1.2 and -2.8 ± 3.6 cm H₂O). However, Ti was shorter (TF, 1.16 ± 0.21s; DB, 3.31 ± 0.97 s, p < 0.001; BM, 5.53 ± 1.92 s, p < 0.001), resulting in smaller Vt (TF, 1.12 ± 0.29 L; DB, 1.28 ± 0.29L, p = 0.003; BM, 1.37 ± 0.43L, p = 0.016). Breathing frequency was faster with TF compared to DB and BM (p < 0.001). Conclusions: Substantial lung inflation could be achieved with any of the above-mentioned methods, although Vt was smaller with TF and the high inspiratory flow with this method may not inflate the lower lung. The high pressures and rapid breathing with TF could increase the sense of effort. Trials are needed to determine the clinical value of the different breathing exercises.

Thoracic Empyema as Rare Complication of an Appendicular Mass: A Case Study and Review of the Literature

Introduction

Thoracic empyema is an infrequent complication of appendicitis that has rarely been reported in the literature.

Case Presentation and Review of the Literature

The case of a 11-year-old boy who was admitted for medical management of an appendicular mass is presented. His clinical course was complicated by the development of an appendicular abscess and an extensive right-sided empyema. A comprehensive review of the literature was conducted including the most representative cases. The data were collected and analyzed by two independent investigators. Ten cases were found. Most patients were young individuals (mean age: 25.1 years; male : female ratio: 0.5). Risk factors for thoracic empyema included pregnancy (10%) and age (60%). The most frequent organisms isolated were Escherichia coli, Bacteroides spp., and Klebsiella spp. The survival rate was 100%.

Conclusion

Thoracic empyema should be considered a potential cause of respiratory distress in patients with appendicitis. Furthermore, the abdomen should be carefully evaluated as a source of infection in patients with thoracic empyema without an underlying lung disease.

Utilization pattern and survival outcomes of adjuvant therapies in high-grade nonretroperitoneal abdominal soft tissue sarcoma: A population-based study

BACKGROUND

Nonretroperitoneal abdominal soft tissue sarcoma (NRA-STS) is a rare disease with limited data supporting its management. Our study aimed to reveal the utilization patterns of adjuvant therapy and its potential survival benefits using the National Cancer Data Base.

MATERIALS

The analysis included patients with resected high-grade NRA-STS. Chi-square analysis was used to evaluate distribution of patient and tumor-related factors within treatment groups. The Kaplan-Meier and Cox proportional hazards model were utilized to evaluate overall survival according to treatment approach. Multivariate analysis was used to determine the impact of these factors on patients' outcome. Matched propensity score analysis was implemented to control for imbalance of confounding variables.

RESULTS

At median follow-up of 49 months, 5-year overall survival improved from 46% without adjuvant radiation therapy to 52% (P = 0.009) with radiotherapy delivery with a 30% reduction in hazard of death (95% confidence interval = 0.58-0.84). On multivariate analysis, age <50, tumor <8 cm, negative margins and radiotherapy delivery were significant predictors of improved survival. Chemotherapy was not associated with significant survival improvement (Hazard Ratios [HR]: 0.89, P = 0.28).

CONCLUSION

Adjuvant radiotherapy was associated with improved survival in high-grade NRA-STS. Chemotherapy was not associated with a survival improvement; however, further studies are needed to refine treatment strategies.

Predictors and Outcomes of Postoperative Pulmonary Complications following Abdominal Surgery in a South Indian Population

Background

Postoperative pulmonary complications (PPC) following abdominal surgery are associated with increased morbidity and poorer outcomes. We prospectively examined risk factors associated with the development of PPC in patients undergoing abdominal surgery.

Aims

The primary outcome was to determine the association of predefined risk factors in the prediction of PPC after abdominal surgery. Secondary outcomes were evaluation of outcomes of PPC.

Setting and Design

This was a prospective study conducted in the gastrosurgical and urological units of a tertiary care referral hospital in patients undergoing abdominal surgery over a period of 6 months (November 2015-April 2016).

Materials and Methods

Relevant preoperative and intraoperative variables were recorded by the anesthesiologist in a pro forma provided. Postoperatively, data from the Intensive Care Unit (ICU) were collected from data sheets. PPC were defined according to preset criteria and outcomes of the patients including ICU stay, hospital stay, and mortality were noted.

Statistical Analysis

Chi-square test was used to find the association of risk factors of PPC. Mann-Whitney test was used for continuous variables and McNemar's test for postoperative respiratory variables. A final regression analysis was performed with factors with significant association (P < 0.1).

Results

One hundred and fifty patients were included, and 24 patients (16%) developed PPC as defined by our criteria. Emergency surgery (44.4% of PPC) and cardiac comorbidity (23.9% of PPC) were significant associations for pulmonary complications. The length of ICU and hospital stay (LOICU, LOHS) and mortality were higher in the group with pulmonary complications (P < 0.001).

Conclusions

Emergent surgery and cardiac comorbidities were independent predictors for the development of PPC. PPC are associated with increased LOHS, LOICU stay, and mortality.

Is preoperative spirometry a predictive marker for postoperative complications after colorectal cancer surgery?

Background

Spirometry is a basic test that provides much information about pulmonary function; it is performed preoperatively in almost all patients undergoing colorectal cancer (CRC) surgery in our hospital. However, the value of spirometry as a preoperative test for CRC surgery remains unknown. The aim of this study was to determine whether spirometry is useful to predict postoperative complications (PCs) after CRC surgery.

Methods

The medical records of 1236 patients who had preoperative spirometry tests and underwent CRC surgery between 2005 and 2014 were reviewed. Preoperative spirometry results, such as forced vital capacity (FVC), one-second forced expiratory volume (FEV1), %VC (FVC/predicted VC) and FEV1/FVC (%FEV1), were analyzed with regard to PCs, including pneumonia.

Results

PCs were found in 383 (30.9%) patients, including 218 (56%) with surgical site infections, 67 (17%) with bowel obstruction, 62 (16%) with leakage and 20 (5.2%) with pneumonia. Of the spirometry results, %VC was correlated with PC according to logistic regression analysis (odds ratio, OR = 0.99, 95% confidence interval, CI = 0.98-0.99; P = 0.034). Multivariate analysis after adjusting for male sex, age, laparoscopic surgery, tumor location, operation time and blood loss showed that a lower %VC tends to be a risk factor for PC (OR = 0.99, 95% CI = 0.98-1.002; P = 0.159) and %VC was an independent risk factor for postoperative pneumonia in PCs (OR = 0.97, 95% CI = 0.94-0.99; P = 0.049).

Conclusions

In CRC surgery, %VC may be a predictor of postoperative complications, especially pneumonia.

Pulmonary Complications after Surgery for Rectal Cancer in Elderly Patients: Evaluation of Laparoscopic versus Open Approach from a Multicenter Study on 477 Consecutive Cases

Aim

To evaluate the impact of open or laparoscopic rectal surgery on pulmonary complications in elderly (>75 years old) patients.

Methods

Data from consecutive patients who underwent elective laparoscopic or open rectal surgery for cancer were collected prospectively from 3 institutions. Pulmonary complications were defined according to the ACS/NSQUIP definition.

Results

A total of 477 patients (laparoscopic group: 242, open group: 235) were included in the analysis. Postoperative pulmonary complications were significantly more common after open surgery (8 out of 242 patients (3.3%) versus 23 out of 235 patients (9.8%); p = 0.005). In addition, PPC occurrence was associated with the increasing of postoperative pain (5.04 ± 1.62 versus 5.03 ± 1.58; p = 0.001) and the increasing of operative time (270.06 ± 51.49 versus 237.37 ± 65.97; p = 0.001).

Conclusion

Our results are encouraging to consider laparoscopic surgery a safety and effective way to treat rectal cancer in elderly patients, highlighting that laparoscopic surgery reduces the occurrence of postoperative pulmonary complications.

Value of procalcitonin as a biomarker for postoperative hospital-acquired pneumonia after abdominal surgery

Background

Hospital-acquired pneumonia (HAP) is a common complication after abdominal surgery. The aim of this study was to evaluate the role of procalcitonin (PCT) and C-reactive protein (CRP) as early biomarkers for the diagnosis of postoperative HAP after abdominal surgery.

Methods

This study was conducted on 100 patients undergoing abdominal surgery. White blood cell counts, highest body temperature, and serum levels of CRP and PCT were recorded preoperatively and daily postoperatively until postoperative day (POD) 5. Chest radiography was performed preoperatively and daily postoperatively until POD 5.

Results

HAP was diagnosed in 14% of patients. Regarding the biomarkers studied after POD 1, CRP and PCT were significantly higher in patients with HAP than in those without HAP (P < 0.05). On POD 2, PCT had higher sensitivity and specificity (84% and 72%, respectively) than those for CPR (70% and 60%, respectively). The cut-off value of PCT on POD 2 was 1.4 ng/ml. On POD 3, 4, and 5, the sensitivity and specificity of PCT and CRP were not significantly different.

Conclusions

PCT and CRP are accurate biomarkers for early prediction of postoperative HAP after abdominal surgery. The diagnostic ability of PCT was significantly better than that of CRP on POD 2. After POD 2, the diagnostic ability was not significantly different between the biomarkers.

Risk Factors for Postoperative Pulmonary Complications after Abdominal Surgery

BACKGROUND

Incidence of postoperative pulmonary complications (PPC) in patients undergoing non-cardiothoracic surgery remains high and the occurrence of these complications has enormous implications for the patient and the health care system.

AIM

The aim of the study was to identify risk factors for PPC in patients undergoing abdominal surgical procedures.

MATERIALS AND METHODS

A prospective cohort study in abdominal surgical patients, admitted to the emergency and surgical ward of the UHC of Tirana, Albania, was conducted during the period: March 2014-March 2015. We collected data on the occurrence of a symptomatic and clinically significant PPC using clinical, laboratory, and radiology data. We evaluated the relations between PPCs and various pre-operative or intra-operative factors to identify risk factors.

RESULTS

A total of 450 postoperative patients admitted to the surgical emergency and surgical ward were studied. The mean age were 59.85 ±13.64 years with 59.3% being male. Incidence of PPC was 27.3% (123 patients) and hospital length of stay was 4.93 ± 4.65 days. Length of stay was substantially prolonged for those patients who developed PPC (7.48 ± 2.89 days versus 3.97± 4.83 days, p < 0.0001. PPC were identified as risk factors for mortality, OR: 21.84; 95% CI: 11.66-40.89; P < 0.0001. The multivariate regression analysis identified as being independently associated with an increased risk of PPC: age ≥ 65 years (OR 11.41; 95% CI: 4.84-26.91, p < 0.0001), duration of operation ≥ 2.5 hours (OR 8.38; 95% CI: 1.52-46.03, p = 0.01, history of previous pulmonary diseases (OR 11.12; 95% CI: 3.28-37.65, P = 0.0001) and ASA > 2 (OR 6.37; 95% CI: 1.54-26.36, P = 0.01).

CONCLUSION

We must do some efforts in reducing postoperative pulmonary complications, firstly to identify which patients are at increased risk, and then following more closely high-risk patients because those patients are most likely to benefit.

Intra-operative adherence to lung-protective ventilation: a prospective observational study

BACKGROUND

Lung-protective ventilation in patients with acute respiratory distress syndrome improves mortality. Adopting this strategy in the perioperative period has been shown to reduce lung inflammation and postoperative pulmonary and non-pulmonary sepsis complications in patients undergoing major abdominal surgery. We conducted a prospective observational study into the intra-operative ventilation practice across the West Midlands to assess the use of lung-protective ventilation.

METHODS

Data was collected from all adult ventilated patients undergoing surgery across 14 hospital trusts in the West Midlands over a 2-day period in November 2013. Data collected included surgical specialty, patient's biometric data, duration of procedure, grade of anesthetist, and ventilatory parameters. Lung-protective ventilation was defined as the delivery of a tidal volume between 6 and 8 ml/kg/predicted body weight, a peak pressure of less than 30 cmH2O, and the use of positive end expiratory pressure of 6-8 cmH2O. Categorical data are presented descriptively, while non-parametric data are displayed as medians with statistical tests from Mann-Whitney U tests or Kruskal-Wallis tests for independent samples while paired samples are represented by Wilcoxon signed rank tests.

RESULTS

Four hundred six patients with a median age of 56 years (16-91) were included. The majority of operations (78 %) were elective procedures with the principal anesthetist being a consultant. The commonest surgical specialties were general (29 %), trauma and orthopedic (19 %), and ENT (17 %). Volume-controlled ventilation was the preferred ventilation strategy in 70 % of cases. No patients were ventilated using lung-protective ventilation. Overall peak airway pressure (pPeak) was low (median 20 cmH2O (inter-quartile range [IQR] 10-43 cmH2O)) with median delivered tidal volumes of 8.4 ml/kg/predicted body weight (PBW) (IQR 3.5-14.5 ml/kg/PBW). The median positive end expiratory pressure (PEEP) was only 4 cmH2O (0-5 cmH2O) with PEEP not used in 152 cases.

CONCLUSIONS

Perioperative lung protection ventilation can improve patient outcomes from major surgery. This large prospective study demonstrates that within the West Midlands lung-protective ventilation during the perioperative period is uncommon, especially in relation to the use of PEEP, and that perhaps further trials are required to promote wider adoption of practice.

Leukopenia is associated with worse but not prohibitive outcomes following emergent abdominal surgery

BACKGROUND

There are little data currently available to guide surgical decision making regarding emergent surgical interventions in leukopenic patients. The purpose of this study was to investigate the impact of leukopenia among patients undergoing emergency abdominal operations to better guide preoperative decision making.

METHODS

The 2005 to 2012 American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify patients who underwent emergent laparotomy. Patients were stratified by preoperative white blood cell (WBC) count (<4.0 × 10(9)/L vs. 4.0-12.0 × 10(9)/L). Baseline demographics, comorbidities, and outcomes were compared. Multivariable logistic regression was performed to estimate the adjusted association between leukopenia and mortality, taking into account the robust array of patient-related factors.

RESULTS

Of the 20,443 patients who met study criteria, 2,057 (8.2%) were leukopenic (WBC < 4.0) before surgery. Unadjusted comparison demonstrated significantly increased major morbidity (45.4% vs. 26.9%, p < 0.001) as well as mortality (24.4% vs. 10.8%, p < 0.001) for patients with leukopenia compared with patients with a normal preoperative WBC count. Only 46.0% (n = 947) of patients with leukopenia before surgery were able to avoid major morbidity or mortality compared with 69.4% (n = 15,974) of patients with a normal preoperative WBC count (p < 0.001). After multivariable adjustment for patient-related factors, leukopenia was maintained as a significant predictor of mortality.

CONCLUSION

Although leukopenia remains associated with mortality in patients undergoing emergent laparotomy despite adjustment for other patient-related factors, it is not necessarily prohibitive. Understanding the risk of complications and mortality associated with these procedures is pertinent for preoperative clinical decision making.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Predictive Factors of Ventilator Dependency after Colon and Rectal Surgery

There is limited data analyzing ventilator dependency by operative diagnoses and types of the procedures performed in colorectal surgery. We sought to identify predictive factors of ventilator dependency in colorectal surgery and investigate complication rates across various colorectal procedures. The National Surgical Quality Improvement Program database was used to examine the clinical data of patients with ventilator dependency for more than 48 hours after colorectal resection during 2005–2013. Multivariate regression analysis was performed to identify predictors of ventilator dependency. A total of 219,716 patients who underwent colorectal resection were identified. The rate of ventilator dependency was 3.9 per cent. The rate varied significantly based on patient diagnosis; with the highest rate seen in patients with acute mesenteric ischemia (25.9%). The highest risk of ventilator dependency according to the patients indication of surgery, type of the procedure, and preoperative factors exist in lower gastrointestinal bleeding [adjusted odds ratio (AOR): 77.44, P < 0.01], total colectomy (AOR: 1.58, P = 0.04), and American Society of Anesthesiologists classification of three or greater (AOR: 2.52, P < 0.01). Also, serum albumin level (AOR: 0.67, P < 0.01) seems to be associated with ventilator dependency. The overall rate of ventilator dependency is 3.9 per cent in colorectal surgery. However, depending on the indication for surgery, rates can be as high as 25.9 per cent. American Society of Anesthesiologist score can predict the risk of postoperative ventilator dependency in patients undergoing colorectal surgery. Serum albumin level is reversely associated with postoperative ventilator dependency.

[Risk factors for nosocomial pneumonia in patients with abdominal surgery]

BACKGROUND

The risk of post-operative pneumonia is a latent complication. A study was conducted to determine its risk factors in abdominal surgery.

MATERIAL AND METHODS

A cross-sectional study was performed that included analysing the variables of age and gender, chronic obstructive pulmonary disease and smoking, serum albumin, type of surgery and anaesthesia, emergency or elective surgery, incision site, duration of surgery, length of hospital stay, length of stay in the intensive care unit, and time on mechanical ventilation. The adjusted odds ratio for risk factors was obtained using multivariate logistic regression.

RESULTS

The study included 91 (9.6%) patients with pneumonia and 851 (90.4%) without pneumonia. Age 60 years or over (OR=2.34), smoking (OR=9.48), chronic obstructive pulmonary disease (OR=3.52), emergency surgery (OR=2.48), general anaesthesia (OR=3.18), surgical time 120 minutes or over (OR=5.79), time in intensive care unit 7 days or over (OR=1.23), time on mechanical ventilation greater than or equal to 4 days (OR=5.93) and length of post-operative hospital stay of 15 days or over (OR=1.20), were observed as independent predictors for the development of postoperative pneumonia.

CONCLUSIONS

Identifying risk factors for post-operative pneumonia may prevent their occurrence. The length in the intensive care unit of greater than or equal to 7 days (OR=1.23; 95% CI 1.07 - 1.42) and a length postoperative hospital stay of 15 days or more (OR=1.20; 95% CI 1.07 - 1.34) were the predictive factors most strongly associated with lung infection in this study.

Incidence and risk factors of postoperative pulmonary complications in noncardiac Chinese patients: a multicenter observational study in university hospitals

Purpose. To assess the incidence of postoperative pulmonary complications (PPCs) in Chinese inpatients, and to develop a brief predictive risk index. Methods. Between August 6, 2012, and August 12, 2012, patients undergoing noncardiac operations in four university hospitals were enrolled. The cohort was divided into two subsamples, cohort 1 to develop a predictive risk index of PPCs and cohort 2 to validate it. Results. 1673 patients were enrolled. PPCs were recorded for 163 patients (9.7%), of whom the hospital length of stay (LOS) was longer (P < 0.001). The mortality was 1.84% in patients with PPCs and 0.07% in those without. Logistic Regression modeling in cohort 1 identified nine independent risk factors, including smoking, respiratory infection in the last month, preoperative antibiotic use, preoperative saturation of peripheral oxygen, surgery site, blood lost, postoperative blood glucose, albumin, and ventilation. The model was validated within cohort 2 with an area under the receiver operating characteristic curve of 0.90 (95% CI 0.86 to 0.94). Conclusions. PPCs are common in noncardiac surgical patients and are associated with prolonged LOS in China. The current study developed a risk index, which can be used to assess individual risk of PPCs and guide individualized perioperative respiratory care.

Correlation between intra-abdominal pressure and pulmonary volumes after superior and inferior abdominal surgery

OBJECTIVE

Patients undergoing abdominal surgery are at risk for pulmonary complications. The principal cause of postoperative pulmonary complications is a significant reduction in pulmonary volumes (FEV1 and FVC) to approximately 65-70% of the predicted value. Another frequent occurrence after abdominal surgery is increased intra-abdominal pressure. The aim of this study was to correlate changes in pulmonary volumes with the values of intra-abdominal pressure after abdominal surgery, according to the surgical incision in the abdomen (superior or inferior).

METHODS

We prospectively evaluated 60 patients who underwent elective open abdominal surgery with a surgical time greater than 240 minutes. Patients were evaluated before surgery and on the 3rd postoperative day. Spirometry was assessed by maximal respiratory maneuvers and flow-volume curves. Intra-abdominal pressure was measured in the postoperative period using the bladder technique.

RESULTS

The mean age of the patients was 56 ± 13 years, and 41.6% 25 were female; 50 patients (83.3%) had malignant disease. The patients were divided into two groups according to the surgical incision (superior or inferior). The lung volumes in the preoperative period showed no abnormalities. After surgery, there was a significant reduction in both FEV1 (1.6 ± 0.6 L) and FVC (2.0 ± 0.7 L) with maintenance of FEV1/FVC of 0.8 ± 0.2 in both groups. The maximum intra-abdominal pressure values were similar (p=0.59) for the two groups. There was no association between pulmonary volumes and intra-abdominal pressure measured in any of the groups analyzed.

CONCLUSIONS

Our results show that superior and inferior abdominal surgery determines hypoventilation, unrelated to increased intra-abdominal pressure. Patients at high risk of pulmonary complications should receive respiratory care even if undergoing inferior abdominal surgery.

Risk factors and bacterial spectrum for pneumonia after abdominal surgery in elderly Chinese patients

Postoperative pneumonia is a common complication of abdominal surgery in the elderly. The aim of this study was to determine risk factors and bacterial spectrum for pneumonia after abdominal surgery in elderly Chinese patients. We performed a case-control study in a total of 5431 patients aged 65 years and over who had undergone abdominal surgery at the 2nd affiliated hospital of Kunming medical college between June 2003 and June 2011. Postoperative pneumonia developed in 86 patients (1.58%). Gram-negative bacilli were the principal microorganisms (82.86%) isolated from patients. The most common organisms isolated were Klebsiella spp. (28.57%), Acinetobacter spp. (17.14%) and Pseudomonas aeruginosa (17.14%). Multivariate analysis confirmed the following to be independent risk factors for postoperative pneumonia in the elderly after abdominal surgery: age ≥70 (OR 1.93, 95% CI 1.16-3.22, p=0.01), upper abdominal surgery (OR 2.07, 95% CI 1.18-3.64, p=0.01) and duration of operation >3 h (OR 2.48, 95% CI 1.49-4.15, p=0.00). Identifying these risk factors may help achieve better prevention and treatment for postoperative pneumonia in elderly patients after abdominal surgery.

Predicting postoperative pulmonary complications in the general population

PURPOSE OF REVIEW

Postoperative pulmonary complications (PPCs) are common and lead to longer hospital stays and higher mortality. A wide range of patient, anaesthetic and surgical factors have been associated with risk for PPCs. This review discusses our present understanding of PPC risk factors that can be used to plan preoperative risk reduction strategies. The methodological and statistical basis for building risk scores is also described.

RECENT FINDINGS

Studies in specific surgical populations or large patient samples have identified a range of predictors of PPC risk. Factors such as age, types of comorbidity and surgical characteristics have been found to be relevant in most of these studies. Recently, researchers have begun to develop risk scoring systems for a PPC composite outcome or for specific PPCs, especially pneumonia and respiratory failure. Preoperative arterial oxyhaemoglobin saturation is an objective measure that is easy to record and discriminates level of risk for impaired cardiorespiratory function. Preoperative anaemia and recent respiratory infection are factors that have lately been found to confer risk for PPCs.

SUMMARY

PPC risk prediction scales based on large population studies are being developed. New studies to confirm the validity of these scales in different geographic areas will be needed before we can be sure of their generalizability.

Preoperative 6-min walking distance does not predict pulmonary complications in upper abdominal surgery

BACKGROUND AND OBJECTIVE

Field exercise tests have been increasingly used for pulmonary risk assessment. The 6-min walking distance (6MWD) is a field test commonly employed in clinical practice; however, there is limited evidence supporting its use as a risk assessment method in abdominal surgery. The aim was to assess if the 6MWD can predict the development of post-operative pulmonary complications (PPCs) in patients having upper abdominal surgery (UAS).

METHODS

This prospective cohort study included 137 consecutive subjects undergoing elective UAS. Subjects performed the 6MWD on the day prior to surgery, and their performance were compared with predicted values of 6MWD (p6MWD) using a previously validated formula. PPCs (including pneumonia, tracheobronchitis, atelectasis with clinical repercussions, bronchospasm and acute respiratory failure) were assessed daily by a pulmonologist blinded to the 6MWD results. 6MWD and p6MWD were compared between subjects who developed PPC (PPC group) and those who did not (no PPC group) using Student's t-test.

RESULTS

Ten subjects experienced PPC (7.2%) and no significant difference was observed between the 6MWD obtained in the PPC group and no PPC group (466.0 ± 97.0 m vs. 485.3 ± 107.1 m; P = 0.57, respectively). There was also no significant difference observed between groups for the p6MWD (100.7 ± 29.1% vs. 90.6 ± 20.9%; P > 0.05).

CONCLUSIONS

The results of the present study suggest that the 6-min walking test is not a useful tool to identify subjects with increased risk of developing PPC following UAS.

Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery service in the United Kingdom

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a potentially complicated surgery with significant hospitalisation, especially during the learning curve. There are inadequate data on fast-track LRYGB in relation to learning curve. This study highlights the outcomes of a fast-track LRYGB service.

METHODS

This observational study examined the perioperative outcome data of 406 consecutive LRYGB patients over a 4-year period. Perioperative outcome data were analysed and compared between severe obesity, morbid obesity and super obesity groups.

RESULTS

Mean BMI was 48.6 ± 8.3, mean age was 42 years and male to female ratio was 1:4. About 4% of patients had concurrent ventral hernia repair. Median duration of combined LRYGB and ventral hernia repair was 115 min, compared to 95 min for LRYGB alone (p = 0.09). Intraoperative complication rate was 0.5%. Postoperative complications occurred in 3.4% of patients with 60% within 24 h. The complication rate per obesity group was <7% and similar between groups (p = 0.4). There was no perioperative mortality. More super obese patients received postoperative intensive care compared to others (p = 0.001). Mean length of hospital stay was similar between obesity groups and decreased from 2 to 1 day over 2 years. There was a learning curve of 109 cases over 2 years.

CONCLUSION

LRYGB is a safe technique of bariatric surgery with low risk of perioperative complications. Establishing a fast-track LRYGB service requires a learning curve of 100 cases, and a good indicator is length of hospital stay, which decreases as the service matures. Most LRYGB patients can be safely discharged by 24 h.

Risk of adverse events after coronary artery bypass graft and subsequent noncardiac surgery

Aims: Coronary artery bypass grafts (CABGs) are increasingly performed in elderly patients. Risk factors and outcomes are poorly described for those undergoing noncardiac surgery within 1 year after CABG. Our objectives were to assess the risk and predictors of major adverse events associated with noncardiac surgery within 1 year after CABG. Methods: In a retrospective review of medical records at Mayo Clinic (Rochester, MN, USA), over a period of 5 years, we identified patients who underwent noncardiac procedures within 1 year post-CABG. All events that occurred within 30 days after noncardiac surgery and deaths within 1 year after noncardiac surgery were considered to be related to CABG. Results: We identified 211 patients; of these, 21 patients had 24 adverse events. Within 1 year, 11 died, and within the first 30 days, three myocardial infarctions, six acute congestive heart failure episodes, three cerebrovascular accidents and one deep vein thrombosis episode had occurred. Predictors of an adverse event included emergency operation (odds ratio: 6.8), ejection fraction less than 45% (p < 0.001) and elevated right ventricular systolic pressure by 40 mmHg or more (p = 0.03). After the noncardiac procedure, patients requiring dialysis (p = 0.02), ventilatory support (p = 0.03) and longer hospital stay (p = 0.03) had greater rates of adverse outcomes. Conclusion: Post-CABG, preoperative ejection fraction less than 45%, right ventricular systolic pressure of 40 mmHg or more, as well as emergent noncardiac surgery, were predictors of adverse outcomes after the noncardiac procedure. Longer postoperative hospital stay, dialysis, as well as ventilatory support, were predictors of adverse outcomes after CABG.

Chest physiotherapy with positive expiratory pressure breathing after abdominal and thoracic surgery: a systematic review

A variety of chest physiotherapy techniques are used following abdominal and thoracic surgery to prevent or reduce post-operative complications. Breathing techniques with a positive expiratory pressure (PEP) are used to increase airway pressure and improve pulmonary function. No systematic review of the effects of PEP in surgery patients has been performed previously. The purpose of this systematic review was to determine the effect of PEP breathing after an open upper abdominal or thoracic surgery. A literature search of randomised-controlled trials (RCT) was performed in five databases. The trials included were systematically reviewed by two independent observers and critically assessed for methodological quality. We selected six RCT evaluating the PEP technique performed with a mechanical device in spontaneously breathing adult patients after abdominal or thoracic surgery via thoracotomy. The methodological quality score varied between 4 and 6 on the Physiotherapy Evidence Database score. The studies were published between 1979 and 1993. Only one of the included trials showed any positive effects of PEP compared to other breathing techniques. Today, there is scarce scientific evidence that PEP treatment is better than other physiotherapy breathing techniques in patients undergoing abdominal or thoracic surgery. There is a lack of studies investigating the effect of PEP over placebo or no physiotherapy treatment.

Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality

BACKGROUND

The purposes of this study were to determine clinical presentations and surgical outcomes of perforated peptic ulcer (PPU), and to evaluate the accuracy of the Boey scoring system in predicting mortality and morbidity.

METHODS

We carried out a retrospective study of patients undergoing emergency surgery for PPU between 2001 and 2006 in a university hospital. Clinical presentations and surgical outcomes were analyzed. Adjusted odds ratio (OR) of each Boey score on morbidity and mortality rate was compared with zero risk score. Receiver-operating characteristic curve analysis was used to compare the predictive ability between Boey score, American Society of Anesthesiologists (ASA) classification, and Mannheim Peritonitis Index (MPI).

RESULTS

The study included 152 patients with average age of 52 years (range: 15-88 years), and 78% were male. The most common site of PPU was the prepyloric region (74%). Primary closure and omental graft was the most common procedure performed. Overall mortality rate was 9% and the complication rate was 30%. The mortality rate increased progressively with increasing numbers of the Boey score: 1%, 8% (OR=2.4), 33% (OR=3.5), and 38% (OR=7.7) for 0, 1, 2, and 3 scores, respectively (p<0.001). The morbidity rates for 0, 1, 2, and 3 Boey scores were 11%, 47% (OR=2.9), 75% (OR=4.3), and 77% (OR=4.9), respectively (p<0.001). Boey score and ASA classification appeared to be better than MPI for predicting the poor surgical outcomes.

CONCLUSIONS

Perforated peptic ulcer is associated with high rates of mortality and morbidity. The Boey risk score serves as a simple and precise predictor for postoperative mortality and morbidity.

Role of pathogenic oral flora in postoperative pneumonia following brain surgery

BACKGROUND

Post-operative pulmonary infection often appears to result from aspiration of pathogens colonizing the oral cavity. It was hypothesized that impaired periodontal status and pathogenic oral bacteria significantly contribute to development of aspiration pneumonia following neurosurgical operations. Further, the prophylactic effects of a single dose preoperative cefazolin on the oral bacteria were investigated.

METHODS

A matched cohort of 18 patients without postoperative lung complications was compared to 5 patients who developed pneumonia within 48 hours after brain surgery. Patients waiting for elective operation of a single brain tumor underwent dental examination and saliva collection before surgery. Bacteria from saliva cultures were isolated and periodontal disease was scored according to type and severity. Patients received 15 mg/kg cefazolin intravenously at the beginning of surgery. Serum, saliva and bronchial secretion were collected promptly after the operation. The minimal inhibitory concentrations of cefazolin regarding the isolated bacteria were determined. The actual antibiotic concentrations in serum, saliva and bronchial secretion were measured by capillary electrophoresis upon completion of surgery. Bacteria were isolated again from the sputum of postoperative pneumonia patients.

RESULTS

The number and severity of coexisting periodontal diseases were significantly greater in patients with postoperative pneumonia in comparison to the control group (p = 0.031 and p = 0.002, respectively). The relative risk of developing postoperative pneumonia in high periodontal score patients was 3.5 greater than in patients who had low periodontal score (p < 0.0001). Cefazolin concentration in saliva and bronchial secretion remained below detectable levels in every patient.

CONCLUSION

Presence of multiple periodontal diseases and pathogenic bacteria in the saliva are important predisposing factors of postoperative aspiration pneumonia in patients after brain surgery. The low penetration rate of cefazolin into the saliva indicates that its prophylactic administration may not be sufficient to prevent postoperative aspiration pneumonia. Our study suggests that dental examination may be warranted in order to identify patients at high risk of developing postoperative respiratory infections.

Colonoscopic perforation: A report from World Gastroenterology Organization endoscopy training center in Thailand

AIM: To determine the incidence of colonoscopic perforation (CP), and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.

METHODS: All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients’ characteristics, endoscopic information, intra-operative findings, management and outcomes were analyzed.

RESULTS: A total of 17 357 endoscopic procedures of the colon (13 699 colonoscopies and 3658 flexible sigmoidoscopies) were performed in Siriraj hospital over a 9-year period. Fifteen patients (0.09%) had CP: 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon (80%), followed by the transverse colon (13%). Perforations were caused by direct trauma from either the shaft or the tip of the endoscope (n = 12, 80%) and endoscopic polypectomy (n = 3, 20%). All patients with CP underwent surgical management: primary repair (27%) and bowel resection (73%). The mortality rate was 13% and postoperative complication rate was 53%.

CONCLUSION: CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.