RESPIRATORY PHYSIOLOGY IN UPPER ABDOMINAL SURGERY

Short- and Long-Term Outcomes in Elderly Patients Following Hand-Assisted Laparoscopic Surgery for Colorectal Liver Metastasis

(1) Background: Hand-assisted laparoscopic surgery (HALS) has engendered growing attention as a safe procedure for the resection of metastatic liver disease. However, there is little data available regarding the outcomes of HALS for colorectal liver metastasis (CRLM) in patients over the age of 75. (2) Methods: We compare the short- and long-term outcomes of patients >75-years-old (defined in our study as "elderly patients" and referred to as group 1, G1), with patients <75-years-old (defined in our study as "younger patients" and referred to as group 2, G2). (3) Results: Of 145 patients, 28 were in G1 and 117 were in G2. The most common site of the primary tumor was the right colon in G1, and the left colon in G2 (p = 0.05). More patients in G1 underwent laparoscopic anterior segment resection compared with G2 (43% vs. 39% respectively) (p = 0.003). 53% of patients in G1 and 74% of patients in G2 completed neoadjuvant therapy (p = 0.04). The median size of the largest metastasis was 32 (IQR 19-52) mm in G1 and 20 (IQR 13-35) mm in G2 (p = 0.001). The rate of complications (Dindo-Clavien grade ≥ III) was slightly higher in G1 (p = 0.06). The overall 5-year survival was 30% in G1 and 52% in G2 (p = 0.12). (4) Conclusions: Hand-assisted laparoscopic surgery for colorectal liver metastasis is safe and effective in an elderly patient population.

Current Status and Trends of Minimally Invasive Gastrectomy in Korea

Since its introduction in the early 1990s, laparoscopic gastrectomy has been widely accepted for the treatment of gastric cancer worldwide. In the last decade, the Korean Laparoendoscopic Gastrointestinal Surgery Study group performed important clinical trials and exerted various efforts to enhance the quality of scientific knowledge and surgical techniques in the field of gastric cancer surgery. Laparoscopic gastrectomy has shifted to a new era in Korea due to recent advances and innovations in technology. Here, we discuss the recent updates of laparoscopic gastrectomy—namely, reduced-port, single-incision, robotic, image-guided, and oncometabolic surgery.

Postoperative morbidity and quality of life between totally laparoscopic total gastrectomy and laparoscopy-assisted total gastrectomy: a propensity-score matched analysis

BACKGROUND

This study aimed to evaluate the surgical outcome and quality of life (QoL) of totally laparoscopic total gastrectomy (TLTG) compared with laparoscopy-assisted total gastrectomy (LATG) in patients with clinical stage I gastric cancer.

METHODS

From 2012 to 2018, EGC patients who underwent TLTG (n = 223), including the first case with intracorporeal hemi-double stapling, were matched to those who underwent LATG (n = 114) with extracorporeal circular stapling, using 2:1 propensity score matching (PSM). Prospectively collected morbidity was compared between the TLTG and LATG groups in conjunction with the learning curve. The European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30, STO22, and OG25 were prospectively surveyed during postoperative 1 year for patient subgroups.

RESULTS

After PSM, grade I pulmonary complication rate was lower in the TLTG group (n = 213) than in the LATG group (n = 111) (0.5% vs. 5.4%, P = 0.007). Other complications were not different between the groups. The learning curve of TLTG was overcome at the 26th case in terms of the comprehensive complication index. The TLTG group after learning curve showed lower grade I pulmonary complication rate than the matched LATG group (0.5% vs. 4.7%, P = 0.024). Regarding postoperative QoL, the TLTG group (n = 63) revealed less dysphagia (P = 0.028), pain (P = 0.028), eating restriction (P = 0.006), eating (P = 0.004), odynophagia (P = 0.023) than the LATG group (n = 21). Multivariate analyses for each QoL item demonstrated that TLTG was the only common independent factor for better QoL.

CONCLUSIONS

TLTG reduced grade I pulmonary complications and provided better QoL in dysphagia, pain, eating, odynophagia than LATG for patients with clinical stage I gastric cancer.

Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis

BACKGROUND

Pancreatic cancer is a disease of the elderly. Surgical resection is usually offered to patients in early stage disease; however, pancreatic resection in the elderly is controversial.

METHODS

MEDLINE, EMBASE and Cochrane Library, were searched for studies comparing short- and long-term outcomes of elderly (above the age of 70) with non-elderly patients (below the age of 70) following pancreatic resection for pancreatic adenocarcinoma over the period from the inception of electronic database to 2017. Twelve articles documenting 4860 patients were included. A meta-analysis of data on patient characteristics, operative techniques, and perioperative outcomes were analysed. Our primary endpoint was postoperative mortality, defined as 30-day mortality or in-hospitalisation mortality.

RESULTS

There were 919 patients in the elderly group and 3941 patients in the non-elderly group. Elderly patients had worse ASA scores (p < 0.001) and more cardiovascular comorbidities (p = 0.002). Tumour size, T-stage, N-stage and tumour grade were similar between the elderly and non-elderly group (p > 0.05). Fewer elderly patients received a concomitant venous resection with their pancreatectomy (RR0.80, p = 0.003, I2 = 0%), achieved a negative margin status (RR0.76, p = 0.02, I2 = 28%) and underwent adjuvant chemotherapy treatment (RR0.69, p < 0.001, I2 = 42%). Overall complication (RR1.15, p < 0.001, I2 = 47%), in particular, respiratory complications (RR2.33, p = 0.004, I2 = 39%), was higher in the elderly group. There was no difference in postoperative pancreatic fistula formation, postoperative haemorrhage, intraabdominal abscess and length of hospital stay between both groups (p > 0.05). Postoperative mortality was similar between both groups (p = 0.17). Subgroup analysis according to the time of enrolment (<2000, ≥2000) showed a significant subgroup effect (Chi2 = 3.44, p = 0.06, I2 = 70.9%) and revealed that postoperative mortality in the elderly group improved over time (Before 2000: n = 1654, subtotal RR2.27, p = 0.02, I2 = 0%; From 2000 onwards: n = 3206, subtotal RR1.00, p = 0.99, I2 = 0%).

CONCLUSION

Fewer elderly patients received chemotherapy and portal vein resection to achieve a clear margin. Pancreatic resection of pancreatic adenocarcinoma can be performed safely on elderly patients with acceptable risks in experienced centres by specialist hepatobiliary surgeons. Age alone should not be the only determinant for the selection of patients for surgical treatment of pancreatic adenocarcinoma.

Effect of Thoracic Epidural Anesthesia in a Rat Model of Phrenic Motor Inhibition after Upper Abdominal Surgery

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: One important example of impaired motor function after surgery is diaphragmatic dysfunction after upper abdominal surgery. In this study, the authors directly recorded efferent phrenic nerve activity and determined the effect of the upper abdominal incision. The authors hypothesized that phrenic motor output would be decreased after the upper abdominal incision; it was also hypothesized that blocking sensory input from the incision using thoracic epidural anesthesia would diminish this incision-induced change in phrenic motor activity.

METHODS

Efferent phrenic activity was recorded 1 h to 10 days after upper abdominal incision in urethane-anesthetized rats. Ventilatory parameters were measured in unanesthetized rats using whole-body plethysmography at multiple time points after incision. The authors then determined the effect of thoracic epidural anesthesia on phrenic nerve activity and ventilatory parameters after incision.

RESULTS

Phrenic motor output remained reduced by approximately 40% 1 h and 1 day after incision, but was not different from the sham group by postoperative day 10. One day after incision (n = 9), compared to sham-operated animals (n = 7), there was a significant decrease in spike frequency area-under-the-curve (median [interquartile range]: 54.0 [48.7 to 84.4] vs. 97.8 [88.7 to 130.3]; P = 0.0184), central respiratory rate (0.71 [0.63 to 0.79] vs. 0.86 [0.82 to 0.93]/s; P = 0.0460), and inspiratory-to-expiratory duration ratio (0.46 [0.44 to 0.55] vs. 0.78 [0.72 to 0.93]; P = 0.0023). Unlike humans, a decrease, not an increase, in breathing frequency has been observed after the abdominal incision in whole-body plethysmography. Thoracic epidural anesthesia attenuated the incision-induced changes in phrenic motor output and ventilatory parameters.

CONCLUSIONS

Upper abdominal incision decreased phrenic motor output and ventilatory parameters, and this incision-induced impairment was attenuated by thoracic epidural anesthesia. The authors' results provide direct evidence that afferent inputs from the upper abdominal incision induce reflex inhibition of phrenic motor activity.

Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis

BACKGROUND

The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching.

METHODS

The study included 630 patients (age, ≥ 75 years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80 years).

RESULTS

Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively).

CONCLUSION

LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75 years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.

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.

Comparative study of respiratory muscle strength in women undergoing conventional and single-port laparoscopic cholecystectomy

PURPOSE

To evaluate respiratory muscle strength (PImax and PEmax) before and 24 and 48 h after conventional and single-port laparoscopic cholecystectomy.

METHODS

Forty women with symptomatic cholelithiasis (18 to 70 years) participated in the study. The patients were divided into two groups: 21 patients undergoing conventional laparoscopic cholecystectomy and 19 patients undergoing single-port laparoscopic cholecystectomy. Differences were considered to be significant when p<0.05.

RESULTS

The results showed a greater decline in PImax after 24 h in the group submitted to conventional laparoscopic cholecystectomy, with a significant difference between groups (p=0.0308).

CONCLUSION

Recovery of the parameters studied was more satisfactory and respiratory muscle strength was less compromised in the group submitted to single-port laparoscopic cholecystectomy.

Minimally invasive liver resection for primary and metastatic liver tumors: influence of age on perioperative complications and mortality

BACKGROUND

As minimally invasive technique becomes more popular, an increasing number of elderly patients were considered for minimally invasive liver resection (MILR). Limited physiologic reserve remains a major concern, which frequently leads surgeons to recommend nonresectional alternatives. We sought to evaluate complications and outcomes of elderly patients undergoing MILR.

METHODS

Eight hundred and thirty-one patients who underwent MILR were classified into groups A, B, and C based on age [(< 70, n = 629), (70-79, n = 148), (≥ 80, n = 54) years old, respectively].

RESULTS

Gender distribution, BMI, and cirrhotic status were comparable among all groups. Groups B and C had higher MELD (p = 0.047) and ASA (p = 0.001) scores. Operative time (170, 157, 152 min; p = 0.64) and estimated blood loss (145, 130, 145 ml; p = 0.95) were statistically equal. Overall postoperative complications were greater in groups B and C (12.9 and 9.3 vs. 6.5%, respectively). Complications in group C were all minor. Clavien-Dindo grade III-IV complications were higher in group B when compared to group A (6.8 vs. 2.7%, p = 0.43). There was no significant difference in cardiopulmonary complications, thromboembolic events, ICU admissions, and transfusion rates seen in groups B and C when compared to group A. Duration of hospital stay was statistically longer in groups B and C (3.6, 3.5 vs. 2.5 days, p = 0.0012). 30- and 90-day mortality rates were comparable among the groups, irrespective of age.

CONCLUSIONS

In spite of greater preoperative comorbidities and ASA score, there was no significant increase in postoperative morbidity after minimally invasive liver resection in patients ≥ 70 years of age.

Laparoscopic Versus Open Liver Resection for Colorectal Metastases in Elderly and Octogenarian Patients: A Multicenter Propensity Score Based Analysis of Short- and Long-term Outcomes

OBJECTIVE

This study aims to compare the perioperative and oncological outcomes of laparoscopic and open liver resection for colorectal liver metastases in the elderly.

BACKGROUND

Laparoscopic liver resection has been associated with less morbidity and similar oncological outcomes to open liver resection for colorectal liver metastases (CRLMs). It has been reported that these benefits continue to be observed in elderly patients. However, in previous studies, patients over 70 or 75 years were considered as a single, homogenous population raising questions regarding the true impact of the laparoscopic approach on this diverse group of elderly patients.

METHOD

Prospectively maintained databases of all patients undergoing liver resection for CRLM in 5 tertiary liver centers were included. Those over 70-years old were selected for this study. The cohort was divided in 3 subgroups based on age. A comparative analysis was performed after the implementation of propensity score matching on the 2 main cohorts (laparoscopic and open groups) and also on the study subgroups.

RESULTS

A total of 775 patients were included in the study. After propensity score matching 225 patients were comparable in each of the main groups. Lower blood loss (250 vs 400 mL, P = 0.001), less overall morbidity (22% vs 39%, P = 0.001), shorter High Dependency Unit (2 vs. 6 days, P = 0.001), and total hospital stay (5 vs. 8 days, P = 0.001) were observed after laparoscopic liver resection. Comparable rates of R0 resection (88% vs 88%, P = 0.999), median recurrence-free survival (33 vs 27 months, P = 0.502), and overall survival (51 vs 45 months, P = 0.671) were observed. The advantages seen with the laparoscopic approach were reproduced in the 70 to 74-year old subgroup; however there was a gradual loss of these advantages with increasing age.

CONCLUSIONS

In patients over 70 years of age laparoscopic liver resection, for colorectal liver metastases, offers significant lower morbidity, and a shorter hospital stay with comparable oncological outcomes when compared with open liver resection. However, the benefits of the laparoscopic approach appear to fade with increasing age, with no statistically significant benefits in octogenarians except for a lower High Dependency Unit stay.

Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications

INTRODUCTION

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.

METHODS

Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.

RESULTS

Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).

CONCLUSION

Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A3 online Instructions to Authors. www.springer.com/00266 .

Pulmonary Complications After Open Abdominal Aortic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

Postoperative pulmonary complications (PPC) are among the most common complications after noncardiac surgery. Men, smokers, and elderly patients with chronic obstructive pulmonary disease or heart failure are more likely to experience PPC. The majority of patients undergoing vascular surgery belong in these categories and are at higher risk of developing PPC. Moreover, the surgical site is one of the most important risk factors associated with PPC, and aortic surgery carries the highest risk. The aim of this systematic review was to obtain an additional understanding of the real incidence of PPC after open abdominal aortic surgery and the impact of PPC on survival.

DESIGN

Systematic review and meta-analysis.

SETTING

Hospitals PARTICIPANTS: Patients who underwent open abdominal aortic surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A literature search was performed on BioMedCentral, PubMed, Embase, and the Cochrane Register of clinical trials. All prospective or retrospective studies reporting data on PPC after open abdominal aortic surgery were included. Co-primary endpoints were the PPC rate and the correlation between PPC and perioperative mortality. The secondary endpoint was the difference in the PPC rate and mortality between elective and urgent surgery. Data on 269,637 patients from 213 studies were analyzed. The overall median incidence of PPC was 10.3% (interquartile range 5.55%-19.1%). Pneumonia, respiratory insufficiency, prolonged mechanical ventilation, need for unplanned mechanical ventilation, atelectasis, acute respiratory distress syndrome, pulmonary edema, and pleural effusions were the most common PPC reported in the literature. Occurrence of PPC was associated with postoperative mortality (r = 0.65, p<0.01) and was significantly higher in urgent procedures (p<0.001).

CONCLUSIONS

Incidence of PPC after open abdominal aortic surgery is high and is associated with increased postoperative morbidity and mortality.

Laparoscopy Decreases Pulmonary Complications in Patients Undergoing Major Liver Resection: A Propensity Score Analysis

OBJECTIVE

To compare both incidence and types of postoperative pulmonary complications (PPCs) between laparoscopic major hepatectomy (LMH) and open major hepatectomy (OMH).

BACKGROUND

LMHs are increasingly performed. Yet, the benefits of laparoscopy over laparotomy regarding PPCs remain unknown.

METHODS

In this multi-institutional study, all patients undergoing OMH or LMH between 1998 and 2013 were retrospectively reviewed. Risk factors for PPCs were analyzed on multivariate analysis. Comparison of both overall rate and types of PPCs between OMH and LMH patients was performed after propensity score adjustment on factors influencing the choice of the approach.

RESULTS

LMH was performed in 226 (18.6%) of the 1214 included patients. PPCs occurred in 480 (39.5%) patients including symptomatic pleural effusion in 366 (30.1%) patients, respiratory insufficiency in 141 (11.6%), acute respiratory distress syndrome in 84 (6.9%), pulmonary infection in 80 (6.5%), and pulmonary embolism in 47 (3.8%) patients. On multivariate analysis, preoperative hypoprotidemia [hazard ratio (HR): 1.341, 95% confidence interval (CI): 1.001-1.795; P = 0.049], open approach (HR: 2.481, 95% CI: 1.141-6.024; P = 0.024), right-sided hepatectomy (HR: 2.143, 95% CI: 1.544-2.975; P < 0.001), concomitant extrahepatic procedures (HR: 1.742, 95% CI: 1.103-2.750; P = 0.017), transfusion (HR: 2.851, 95% CI: 2.067-3.935; P < 0.001), and operative time more than 6 hours (HR: 1.510, 95% CI: 1.127-2.022; P = 0.006) were independently associated with PPCs. After propensity score matching, the overall incidence of PPCs (13.2% vs 40.5%, P < 0.001), symptomatic pleural effusion (11.6% vs 26.4%, P = 0.003), pleural effusion requiring drainage (1.7% vs 9.9%, P = 0.006), and acute respiratory distress syndrome (1.7% vs 9.9%, P = 0.006) were significantly lower in the laparoscopy group than in the open group.

CONCLUSIONS

Pure laparoscopy allows reducing PPCs in patients requiring major liver resection.

Does the Difference of Invasiveness between Totally Laparoscopic Distal Gastrectomy and Laparoscopy-Assisted Distal Gastrectomy Lead to a Difference in Early Surgical Outcomes? A Prospective Randomized Trial

BACKGROUND

Resection and anastomosis in laparoscopic distal gastrectomy can be performed extracorporeally or intracorporeally. Most surgeons have performed laparoscopy-assisted distal gastrectomy (LADG) because of technical difficulties of intracorporeal anastomosis. However, totally laparoscopic distal gastrectomy (TLDG) has recently been attempted and is expected to be feasible and less invasive compared with LADG. In this study, we tried to evaluate the clinical effect of the difference of invasiveness between TLDG and LADG, by way of a randomized prospective trial.

METHODS

From February 2011 to September 2013, a total of 110 patients with primary gastric cancer were randomly assigned to either TLDG or LADG. Clinicopathologic features, operative details, postoperative course, and quality of life (QoL) were compared between the two groups. QoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 and gastric module STO22 at 2 weeks and 3 months after surgery.

RESULTS

The two groups were comparable in clinical and pathological characteristics. The proximal resection margin was significantly longer and the length of wound was shorter in the TLDG group. We could not find any significant difference in postoperative inflammatory parameters, postoperative pulmonary function, postoperative recovery, and QoL scores at 2 weeks and 3 months after surgery. There were no significant differences in complication rates.

CONCLUSIONS

This study suggests that TLDG is as safe and feasible as LADG in gastric cancer. The parameters used routinely in the clinical field to evaluate early surgical outcomes could not reflect the delicate difference in surgical invasiveness between TLDG and LADG.

Laparoscopic major hepatectomy for colorectal liver metastases in elderly patients: a single-center, case-matched study

BACKGROUND

The incidence of colorectal cancer liver metastases (CRLM) among elderly patients has increased; therefore, older patients are increasingly being considered for hepatic resection. However, data regarding the outcome of laparoscopic major hepatectomy (LMH) in elderly patients are limited. The aim of this study was to evaluate the safety and feasibility of LMH in elderly patients with CRLM.

METHODS

From January 1998 to September 2013, a total of 31 patients aged ≥ 70 years (elderly group) were matched with 62 patients < 70 years (young group) by demographics, tumor characteristics, and details of surgical procedures.

RESULTS

The elderly group was characterized by a higher incidence of hypertension (41.9 vs. 17.7 %, P = 0.022), ≥ 2 comorbidities (32.3 vs. 11.3 %, P = 0.021), and lower prevalence of metastatic rectal cancer (12.9 vs. 38.7 %, P = 0.015). Intraoperative variables, such as surgical duration (300 vs. 240 min, P = 0.920), blood loss (400 vs. 300 mL, P = 0.361), and transfusion rate (9.7 vs. 12.9 %, P = 0.726), were not notably different between the groups. Postoperative mortality (0 vs. 0 %), complications (54.8 vs. 41.9 %, P = 0.276), and major complications (27.4 vs. 16.1 %, P = 0.303, respectively) were comparable between the groups. The 3-year overall survival rates were 61.7 % in the young group (median 40 months) and 57.9 % in the elderly group (median 39 months), respectively (P = 0.842).

CONCLUSIONS

Our results clearly demonstrated that LMH for CRLM could be safely performed in elderly patients; thus, advanced age itself should not be regarded as a contraindication for LMH.

Pulmonary Function After Pedicled Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction

Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, have been shown to increase intra-abdominal pressure, thereby decreasing thoracopulmonary compliance and increasing the workload of breathing. The purpose of this article was to quantitate pulmonary function in patients who underwent pedicled TRAM flap breast reconstruction.A prospective clinical trial was conducted involving 22 women undergoing unilateral or bilateral pedicled TRAM flap breast reconstruction. Pulmonary function testing was conducted 1 week before the operation, 24 hours postoperatively, and 2 months postoperatively. The patients were stratified by age (<50 years vs ≥50 years), type of TRAM flap (unilateral vs bilateral), tobacco use (smoker vs nonsmoker), and body mass index. Changes were analyzed using 1-way repeated-measures analysis of variance and paired t tests. All comparisons used a 2-tailed test at the 0.05 level of significance.Other than residual volume, the 24-hour postoperative values were significantly lower than the preoperative values. The smokers had less change in functional residual capacity, total lung capacity, and forced vital capacity values than the nonsmokers at 24 hours postoperatively; however, they were noted to have decreased pulmonary function at baseline. The patients 50 years or older had significantly greater decline in functional residual capacity and residual volume compared with the younger cohort. No significant difference in pulmonary function testing values existed between those undergoing bilateral versus unilateral pedicled TRAM flap reconstruction. Pulmonary function tests returned to baseline at 2-month follow-up.Pulmonary function test values were significantly decreased at 24 hours after pedicled TRAM flap breast reconstruction.

Intensive pulmonary care after liver surgery: a retrospective survey from a single center

BACKGROUND

Prevention from postoperative pulmonary complications (PPCs) has been an important topic. The aims of this study were to determine the risk factors for PPC after liver surgery and to analyze the efficacy of postoperative pulmonary care on PPC prevention.

MATERIALS AND METHODS

We retrospectively analyzed variables of 81 patients who underwent hepatectomy and 4 transplantations between January 2007 and March 2012.

RESULTS

Nineteen patients suffered PPCs (22.4%). Bivariate analysis identified four risk factors: preoperative anemia (odds ratio [OR] = 5.69), the American Society of Anesthesiologists (ASA) score of 3 or 4 (OR = 5.36), blood transfusion (OR = 2.81), and prolonged operative time (OR = 1.01). Upon multivariate analysis, only prolonged operative time was an independent risk factor for PPC (OR = 1.01). Pulmonary function test (PFT) was performed for 22 of 41 patients with an ASA score ≥ 2 (53.7%); there was no significant relationship between abnormal PFTs (n = 13) and the development of PPCs (P = .12).

CONCLUSIONS

The elimination of risk factors may reduce the incidence of PPCs. Postoperative intensive pulmonary care should be given to all patients after liver surgery but particularly to patients with high ASA scores and those with abnormal PFTs irrespective of age.

Laparoscopy-assisted gastrectomy versus open gastrectomy for resectable gastric cancer: an update meta-analysis based on randomized controlled trials

BACKGROUND

We carry out a meta-analysis to evaluate the effectiveness and safety of laparoscopy-assisted gastrectomy (LAG) versus open gastrectomy for resectable gastric cancer.

METHODS

We searched EMBASE, the Cochrane Library, PubMed, Science Citation Index (SCI), Chinese biomedicine literature database to identify randomized controlled trials (RCTs) from their inception to April 2012. Meta-analyses were performed using RevMan 5.0 software. It was in line with the preferred reporting items for systematic reviews and meta-analyses statement. The quality of evidence was assessed by GRADEpro 3.6.

RESULTS

Eight RCTs totaling 784 patients were analyzed. Compared with open gastrectomy group, no significant differences were found in postoperative mortality (OR = 1.49; 95 % CI 0.29-7.79), anastomotic leakage (OR = 1.02; 95 % CI 0.24-4.27) , overall mean number of harvested lymph nodes [weighed mean difference (MD) = -3.17; 95 % CI -6.39 to 0.05]; the overall postoperative complication morbidity (OR = 0.54; 95 % CI 0.36-0.82), estimated blood loss (MD = -107.23; 95 % CI -148.56 to -65.89,) frequency of analgesic administration (MD = -1.69; 95 % CI -2.18 to -1.21, P < 0.00001), incidence of pulmonary complications (OR = 0.43, 95 % CI 0.20-0.93, P = 0.03) were significantly less in LAG group; LAG had shorter time to start first flatus (MD = -0.23; 95 % CI -0.41 to -0.05) and decreased hospital stay (MD = -1.72; 95 % CI -3.40 to 0.04), but, LAG still had longer operation time (MD = 76.70; 95 % CI 51.54-101.87).

CONCLUSIONS

On the basis of this meta-analysis we conclude that although LAG was still a time-consuming and technically dependent procedure, it has the advantage of better short-term outcome. Long term survival data from other studies are urgently needed to estimate the survival benefit of this technique.

Respiratory pressures and expiratory peak flow rate of patients undergoing coronary artery bypass graft surgery

Background

To evaluate clinical and laboratorial parameters that predict decreased respiratory function in patients subjected to coronary artery bypass graft surgery (CABG).

Material/Methods

This was a prospective study evaluating 61 patients subjected to CABG with cardiopulmonary bypass, median sternotomy, and under mechanical ventilation for up to 24 h. One day before surgery, clinical information was recorded. Maximal inspiratory (MIP) and expiratory (MEP) pressures, and expiratory peak flow rate (EPFR) values were assessed 1 day before surgery and on the fifth postoperative day. Student’s t test, 2-way ANOVA, Pearson’s linear correlation, and logistic regression were used for statistical analysis.

Results

Patients were 63±10 years old, 67% males. Arterial hypertension was found in 75.4% of the patients, diabetes in 31.2%, dyslipidemia in 63.9%, tabagism in 25%, and chronic obstructive pulmonary disease (COPD) in 16.4%. Previous myocardial infarction was found in 67%. Preoperative hemoglobin levels were 12.8±1.71 g/dL. Older individuals had lower preoperative MEP and EPFR values. Preoperatively, positive association was found between hemoglobin levels and maximal respiratory pressures and EPFR values. Patients with both class III angina and COPD presented higher reductions in pulmonary pressures between the preoperative period and the 5^th postoperative day.

Conclusions

Older age and low hemoglobin levels are associated with preoperative low maximal respiratory pressures and EPFR. The combination of severe angina and COPD results in higher postoperative reduction of maximal respiratory pressures for patients who underwent CABG.

Prevention of postoperative pulmonary complications through intensive preoperative respiratory rehabilitation in patients with esophageal cancer

Postoperative pulmonary complications (PPCs) after esophagectomy have been reported to occur in 15.9-30% of patients and lead to increased postoperative morbidity and mortality, prolonged duration of hospital stay, and additional medical costs. The purpose of this retrospective cohort study was to investigate the possible prevention of PPCs by intensive preoperative respiratory rehabilitation in esophageal cancer patients who underwent esophagectomy. The subjects included 100 patients (87 males and 13 females with mean age 66.5 ± 8.6 years) who underwent esophagectomy. They were divided into two groups: 63 patients (53 males and 10 females with mean age 67.4 ± 9.0 years) in the preoperative rehabilitation (PR) group and 37 patients (34 males and 3 females with mean age 65.0 ± 7.8 years) in the non-PR (NPR) group. The PR group received sufficient preoperative respiratory rehabilitation for >7 days, and the NPR group insufficiently received preoperative respiratory rehabilitation or none at all. The results of the logistic regression analysis and multivariate analysis to correct for all considerable confounding factors revealed the rates of PPCs of 6.4% and 24.3% in the PR group and NPR group, respectively. The PR group demonstrated a significantly less incidence rate of PPCs than the NPR group (odds ratio: 0.14, 95% confidential interval: 0.02~0.64). [Correction added after online publication 25 June 2012: confidence interval has been changed from -1.86~ -0.22] This study showed that the intensive preoperative respiratory rehabilitation reduced PPCs in esophageal cancer patients who underwent esophagectomy.

Multivariate analysis of risk factors for pulmonary complications after hepatic resection

OBJECTIVE

To generate the first evaluation of risk factors for postoperative pulmonary complications (PPCs) after hepatectomy.

BACKGROUND

Postoperative pulmonary complications (PPCs) after surgery are associated with significant morbidity and have been shown to increase the length of hospital stays. Several studies have been conducted to identify the risk factors for PPCs after abdominal surgery.

METHODS

Between January 2006 and December 2009, 555 patients underwent elective hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PPCs, pleural effusion, pneumonia, and pulmonary embolism.

RESULTS

Multivariate analysis identified 5 independent risk factors for global PPCs: prolonged surgery [odds ratio (OR) = 1], presence of a nasogastric tube (OR = 1.6), intraoperative blood transfusion (OR = 1.7), diabetes mellitus (OR = 2.7), and a transverse subcostal bilateral muscle cutting incision (OR = 3.4). There were 4 independent risk factors for pleural effusion: prolonged surgery (OR = 1), surgery on the right lobe of the liver (OR = 1.6), neoadjuvant chemotherapy (OR = 2), and a transverse subcostal bilateral muscle cutting incision (OR = 2.5). There were 3 independent risk factors for pneumonia: intraoperative blood transfusion (OR = 1.9), diabetes mellitus (OR = 2.2), and atrial fibrillation (OR = 3). For pulmonary embolism, history of previous thromboembolic events was identified as the only risk factor (OR = 8.8).

CONCLUSIONS

The correction of modifiable risk factors among the identified factors could reduce the incidence of PPCs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery

OBJECTIVE

To determine the impact of smoking on the rate of pulmonary and upper respiratory complications following laparoscopic gynecologic surgery.

METHODS

We retrospectively identified all patients who underwent laparoscopic gynecologic surgery at one institution between January 2000 and January 2009. Pulmonary and upper respiratory complications were defined as atelectasis, pneumonia, upper respiratory infection, acute respiratory failure, hypoxemia, pneumothorax, or pneumomediastinum occurring within 30 days after surgery

RESULTS

Nine hundred three patients underwent attempt at laparoscopic surgery. Fifty-four were excluded because of conversion to laparotomy and 31 because of insufficient data. Of the 818 patients included, 356 (43%) had cancer. A total of 576 (70%) patients were never smokers, 156 (19%) were past smokers, and 86 (10%) were current smokers (smoked within 6 weeks before surgery). These three groups were similar with regard to median body mass index, operative time, and length of hospital stay. Compared to never and past smokers, current smokers were more likely to undergo high-complexity laparoscopic procedures (10.4%, 15.4%, and 19.8%, respectively; p=0.015) and had younger median age 49 years, 51 years, and 46 years, respectively; p=0.035. Nineteen (2.3%) patients experienced pulmonary complications - symptomatic atelectasis (n=9), pneumonia (n=5), acute respiratory failure (n=2), hypoxemia (n=1), pneumomediastinum (n=1), and pneumothorax (n=2). The rate of pulmonary complications was 2.1% (12 of 564 patients) in never smokers, 4.5% (7 of 156 patients) in past smokers, and zero in current smokers.

CONCLUSION

In this cohort, smoking history did not appear to impact postoperative pulmonary and upper respiratory complications. In smokers scheduled for operative procedures, laparoscopy should be considered when feasible.

A meta-analysis of prospective randomized trials comparing minimally invasive and open distal gastrectomy for cancer

Current literature suggests that minimally invasive distal gastrectomy (MIDG) may enhance post-operative recovery and decrease morbidity compared to open surgery (ODG) in patients with gastric cancer. A meta-analysis of six Prospective Randomized Trials comparing MIDG (343 patients) and ODG (323 patients) for gastric cancer was conducted. MIDG was associated with increased operative time, reduced blood loss and overall morbidity. There was not sufficient data to draw solid conclusions about the oncologic quality of MIDG.

The effect of abdominal support on functional outcomes in patients following major abdominal surgery: a randomized controlled trial

PURPOSE

Immobility and pain are modifiable risk factors for development of venous thromboembolism and pulmonary morbidity after major abdominal surgery (MAS). The purpose of this study was to investigate the effect of abdominal incision support with an elasticized abdominal binder on postoperative walk performance (mobility), perceived distress, pain, and pulmonary function in patients following MAS.

METHODS

Seventy-five patients scheduled to undergo MAS via laparotomy were randomized to experimental (binder) or control (no binder) groups. Sixty (33 male, 27 female; mean age 58±14.9 years) completed the study. Preoperative measurements of 6-minute walk test (6MWT) distance, perceived distress, pain, and pulmonary function were repeated 1, 3, and 5 days after surgery.

RESULTS

Surgery was associated with marked postoperative reductions (p<0.001) in walk distance (∼75-78%, day 3) and forced vital capacity (35%, all days) for both groups. Improved 6MWT distance by day 5 was greater (p<0.05) for patients wearing a binder (80%) than for the control group (48%). Pain and symptom-associated distress remained unchanged following surgery with binder usage, increasing significantly (p<0.05) only in the no binder group.

CONCLUSION

Elasticized abdominal binders provide a non-invasive intervention for enhancing recovery of walk performance, controlling pain and distress, and improving patients' experience following MAS.

Comparison of respiratory function recovery in the early phase after laparoscopy-assisted gastrectomy and open gastrectomy

BACKGROUND

Laparoscopic gastrectomy (LAG) is recognized as a less invasive surgery, but no advantage in terms of respiratory function recovery has been demonstrated. We investigated respiratory function recovery in the early period after LAG compared with open gastrectomy (OG) for measuring the recovery of oxygen saturation level (SaO(2)).

METHODS

The study population comprised 454 patients who underwent distal gastrectomy or total gastrectomy for preoperatively diagnosed T1N0 gastric cancer: 192 underwent laparoscopy-assisted distal gastrectomy (LADG), 190 underwent open distal gastrectomy (ODG), 42 underwent laparoscopy-assisted total gastrectomy (LATG), and 30 underwent open total gastrectomy (OTG).

RESULTS

The number of days until SaO(2) reached 95% or higher in room air was significantly smaller in the LADG group (1.54 days) than in the ODG group (1.81 days; p = 0.010) and also significantly smaller in the LATG group (1.48 days) than in the OTG group (2.03 days; p = 0.043).

CONCLUSIONS

LAG patients recovered their oxygenation earlier than OG patients. The laparoscopic procedure might confer a respiratory benefit for gastrectomy patients.

The effects of different abdominal pressures on pulmonary function test results in laparoscopic cholecystectomy

This study aimed to examine the effects of differing intra-abdominal pressures on pulmonary function test results in laparoscopic cholecystectomy. Forty-five patients were operated on under 3 different intra-abdominal pressures: group A (8 mm Hg), group B (12 mm Hg), and group C (15 mm Hg). On the first day before and after the operation, forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC rate, peak expiratory flow speed (PEF), and maximal middle expiration speed (FEF25-75) values were measured using Vmax 229 spirometry. No significant differences were observed among the 3 groups regarding preoperative and postoperative FVC, FEV1, FEV1/FVC, PEF, and FEF25-75 values (P=0.96, P=0.73, P=0.48, P=0.34, and P=0.33, respectively). When the groups' preoperative and postoperative values were compared, FVC, FEV1, and PEF values significantly decreased in each group. The FEF25-75 values statistically significantly decreased in groups B and C when compared with their preoperative values; however, the decrease in group A was not significant. In conclusion, different intra-abdominal pressures during laparoscopic cholecystectomy had similar effects on pulmonary function test results. However, lower intra-abdominal pressures were associated with slightly more negative effects on FEF25-75 values.

Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: a randomized controlled pilot study

Objective: To investigate the feasibility and effects of preoperative inspiratory muscle training on the incidence of atelectasis in patients at high risk of postoperative pulmonary complications scheduled for elective abdominal aortic aneurysm surgery.

Design: Single-blind randomized controlled pilot study.

Setting: Gelderse Vallei Hospital Ede, the Netherlands.

Subjects: Twenty high-risk patients undergoing elective abdominal aortic aneurysm surgery were randomly assigned to receive preoperative inspiratory muscle training or usual care.

Main measures: Effectiveness outcome variables were atelectasis, inspiratory muscle strength and vital capacity, and feasibility outcome variables were adverse effects and patient satisfaction with inspiratory muscle training.

Results: Despite randomization, patients in the intervention group were significantly older than the patients in the control group (70 ± 6 years versus 59 ± 6 years, respectively; P = 0.001). Eight patients in the control group and three in the intervention group developed atelectasis (P = 0.07). The median duration of atelectasis was 0 days in the intervention group and 1.5 days in the control group (P = 0.07). No adverse effects of preoperative inspiratory muscle training were observed and patients considered that inspiratory muscle training was a good preparation for surgery. Mean postoperative inspiratory pressure was 10% higher in the intervention group.

Conclusion: Preoperative inspiratory muscle training is well tolerated and appreciated and seems to reduce the incidence of atelectasis in patients scheduled for elective abdominal aortic aneurysm surgery.

Morbidity after breast cancer treatment and physiotherapeutic performance

Breast cancer (BC) accounts for >30% of all new cancer patients among women but with increased early detection rates and improved adjuvant therapy, the 5-year survival rate presently reaches >85%. As the number of BC survivors increases, research into the sequelae of the cancer and its treatment on quality of life is a priority. Understanding the potential complications of treatment and developing effective rehabilitation techniques can reduce the impact of such effects on activities of daily life. The aim of this review is to discuss the major sequelae of treatment for BC, and the physiotherapist's role in the prevention and treatment of such complications. Breast cancer treatment can result in pulmonary and upper extremity morbidities that may manifest either early or late. Prevention and treatment of lymphoedema, scar adherence and pulmonary complications can be achieved. Additionally pain reduction and maintenance of range of movement, muscle strength and adequate posture are parts of physiotherapy, which is an important component in the rehabilitation of women with BC.

Risk factors for postoperative pulmonary complications in upper abdominal surgery

BACKGROUND

Pulmonary complications are the most frequent cause of postoperative morbidity and mortality in upper abdominal surgery (UAS). We aimed to examine the influence of possible preoperative, operative and postoperative risk factors on the development of early postoperative pulmonary complications (POPC) after UAS.

METHODS

A prospective study of 60 consecutive patients was conducted who underwent elective UAS in general surgical unit. Each patient's preoperative respiratory status was assessed by an experienced chest physician using clinical examination, chest radiographs, spirometry and blood gas analysis . Anaesthetical risks, surgical indications, operation time, incision type, duration of nasogastric catheter and mobilization time were noted. Forty-eight hours after the operation, pulmonary examinations of the patients were repeated.

RESULTS

Postoperative pulmonary complications were observed in 35 patients (58.3%). The most common complication was pneumonia, followed by pneumonitis, atelectasis, bronchitis, pulmonary emboli and acute respiratory failure. The presence of preoperative respiratory symptoms and the spirometric parameter of forced expiratory volume in 1 s/forced vital capacity were the most valuable risk factors for early prediction of POPC. The sensitivity, specificity and diagnostic efficiency of the presence of preoperative respiratory symptoms in the POPC prediction were 70, 61 and 66%, respectively.

CONCLUSION

We recommend a detailed pulmonary examination and spirometry in patients who will undergo UAS by chest physicians to identify the patients at high risk for POPC, to manage respiratory problems of the patients before surgery and also to help surgeons to take early measures in such patients before a most likely POPC occurrence. Improvement of lung function in those patients at risk for POPC before operation may decrease morbidity in surgical patients.

Noninvasive positive pressure ventilation prevents postoperative pulmonary complications in chronic ventilators users

OBJECTIVE

To evaluate the postoperative pulmonary complications and the long-term impact on pulmonary function of different surgical procedures with general anaesthesia in chronic respiratory failure (CRF) patients who were using noninvasive positive pressure ventilation (NPPV).

DESIGN

We retrospectively studied 20 stable patients on NPPV for CRF secondary to: kyphoscoliosis (eight), morbid obesity (six), thoracoplasty (four), neuromuscular diseases (two), who underwent surgical procedures with general anaesthesia, between January 1998 and December 2003.

MATERIAL AND METHODS

The variables studied were: type of surgery, hours of orotracheal intubation, hours of stay in the postsurgical reanimation unit (PRU), postoperative pulmonary complications and days of hospital stay. These results were compared with those obtained in patients without respiratory pathology and who were submitted to the same type of surgical interventions during the study period. All patients were tested for: arterial blood gases, forced vital capacity (FVC) and forced expiratory volume in 1s (FVE1). These tests were carried out both prior to surgical intervention and 12 months after this intervention, and the use of medical assistance resources the year prior to and the year after the surgical intervention were also analysed.

RESULTS

Sixteen patients were using NPPV at home at the time of the intervention and four patients were adapted to NPPV before surgery. The surgical procedures were: gastroplasty: six; mastectomy: five; septoplasty: three; hip prosthesis: two; cholecystectomy: one; Gasserian ganglion thermocoagulation: one; hysterectomy: one; and endoscopic retrograde cholangiopancreatography (ERCP): one. The mean postoperative intubation time was 3.8+/-3.2h, and only one patient remained intubated for more than 12h. The mean stay in the PRU was 19+/-9h (vs 19+/-6h in the general population, p>0.05). The days of hospital stay for the different pathologies were in the majority of cases greater than in the general population. We did not find significant differences on comparing the arterial blood gases, in pulmonary function or in use of assistance resources between the year previous to and the year following the surgical intervention.

CONCLUSIONS

In high-risk patients with chronic respiratory failure as a consequence of a restrictive lung pathology, NPPV can play an important role to confront surgical procedure with general anaesthesia with greater security. To obtain these results, it was fundamental to coordinate between the Pulmonary Services and the Anaesthesia Services as well as to follow up jointly in the PRU.

Changes in Lung Function and Respiratory Muscle Strength after Sternotomy vs. Laparotomy in Patients without Ventilatory Limitation

A relevant ventilatory defect occurs after sternotomy, a very common thoracic surgical opening. The mechanism of the ventilatory impairment is unclear. Moreover, until now, the effect of sternotomy on pulmonary gas exchange has scarcely been investigated. We evaluated the time-course up to recovery and changes in spirometry, maximum static inspiratory (PI(max)) and expiratory (PE(max)) mouth pressures and pulmonary gas exchange in 6 patients after sternotomy and in 8 patients after laparotomy. All patients were free of cardiopulmonary diseases and had normal preoperative lung function. Sternotomy and laparotomy decreased forced vital capacity (FVC) by 67 and 49%, respectively. Moreover, the percent decreases in PI(max), PE(max) and PaO(2) after sternotomy vs. laparotomy were respectively 54 vs. 57%, 54 vs. 60%, and 22.6 vs. 7.5% (p < 0.05). Following sternotomy, the percent decreases in FVC correlated with the percent decreases in PI(max) (p < 0.05) and PE(max) (p < 0.01). The return to baseline values occurred after approximately 2 weeks. The present study shows that sternotomy can induce greater respiratory effects than laparotomy and suggests a relevant involvement of respiratory muscle weakness after surgical opening of the thorax. The study also supports the view that the evaluation of patient's lung function before sternotomy can be clinically relevant.

Risk factors for pulmonary complications after emergency abdominal surgery

OBJECTIVE

Pulmonary complications are common after abdominal surgery. Although a variety of risk factors have been described for these complications, studies so far have focused on elective interventions. The aim of this study was to determine the incidence and predictors of pulmonary complications following emergency abdominal surgery.

METHODS

This was a prospective cohort study. Pre and intra-operative data were collected through interview and chart review and their association with the occurrence of postoperative pulmonary complications (PPC) were analyzed.

RESULTS

Two hundred and sixty-six consecutive adult patients were included and seventy-five (28.2%) developed PPC. Age >50 years (adjusted OR=3.86; P<0.001), body mass index (BMI) <21 kg/m(2) or 30 kg/m(2) (adjusted OR=2.43; P=0.007) and upper or upper/lower abdominal incision (adjusted OR=2.57; P=0.027) were independently associated with PPC. Patients submitted to multiple procedures tended to be at a higher risk for PPC (adjusted OR=1.73; P=0.079). The development of PPC was associated with prolonged hospital stay (P<0.001) and increased death rate (P<0.001).

CONCLUSIONS

Pulmonary complications are frequent among patients undergoing abdominal emergency surgery and lead to increased length of hospital stay and death rate. Older age, abnormal BMI, upper or upper/lower abdominal incision and multiple procedures are predictors of PPC in this setting.

Left hemidiaphragmatic mobility: assessment with ultrasonographic measurement of the craniocaudal displacement of the splenic hilum and the inferior pole of the spleen

OBJECTIVE

The purpose of this study was to evaluate the correlation between the radiographic and ultrasonographic measurements of craniocaudal displacement of the left hemidiaphragm.

METHODS

Forty-nine patients with clinical indications for interventional procedures prospectively underwent radiographic evaluation of left hemidiaphragmatic mobility and B-mode ultrasonographic measurement of craniocaudal displacement of the hilum and the inferior pole of the spleen. Ultrasonography was performed with a 3.5-MHz convex transducer in a left intercostal position under a longitudinal orientation. Statistical analyses were performed with linear regression, a paired Student t test, and Bland-Altman analyses.

RESULTS

The correlation between the craniocaudal splenic hilum displacement and radiographic measurements was found to be linear: hemidiaphragmatic mobility = 17.795 + 0.429 x splenic hilum displacement (SE for the regression coefficient = 0 .12; P = .0012), although the values obtained with both methods were statistically different (P < .05). The same results could be observed with the use of the inferior pole of the spleen: hemidiaphragmatic mobility = 9.5596 + 0.5455 x inferior polo displacement (SE for the regression coefficient = 0 .11; P < .0001). The mean difference between the values obtained by ultrasonography and by radiography was statistically significant (16.7 +/- 16.1 mm; P < .05 [hilum]; 18.9 +/- 14.2 mm; P < .05 [inferior pole]).

CONCLUSIONS

These results allow us to conclude that ultrasonography can be used as an alternative method for left hemidiaphragm mobility evaluation compared with radiography.

Assessment of pulmonary function in patients before and after laparoscopic and open esophagogastric surgery

BACKGROUND

Laparoscopy is a technique used in various surgical procedures. Few studies in the literature compare stress between laparoscopic and open surgery used for esophagogastric surgical procedures. Pulmonary function is known to be significantly affected in open surgeries, increasing postoperative morbidity and mortality. The current study aimed to assess pulmonary function in patients before and after open and laparoscopic esophagogastric surgery.

METHODS

For this study, 75 patients were divided into two groups: 50 patients undergoing laparoscopy and 25 patients undergoing open surgery. The following parameters were determined by spirometry before and after surgery: forced expiratory volume in the first second (FEV(1)), forced vital capacity (FVC), and forced expiratory flow in the midexpiratory phase (FEF(25-75%)).

RESULTS

A decrease in FEV(1,) FVC, and FEF((25-75%)) was observed in the two groups on postoperative days 2, 3, and 4, as compared with the preoperative period. Likewise, FEV(1) and FVC showed a significant reduction on postoperative days 2, 3, and 4 in the patients who underwent to open surgery, but only on the day 2 in those who underwent to laparoscopic surgery. A significant decrease in FEF((25-75%)) was observed only on postoperative day 2 in the group that underwent open surgery. Significant differences in FEV(1) between the groups were observed on postoperative days 2, 3, and 4. No significant difference in FVC was noted between the groups, and a difference in FEF((25-75%)) was observed only on postoperative day 4.

CONCLUSIONS

Postoperative pulmonary dysfunction was more important for the patients undergoing open surgery than for those undergoing laparoscopic surgery.

Physiological responses to the early mobilisation of the intubated, ventilated abdominal surgery patient

The aim of this study was to investigate the effects of mobilisation on respiratory and haemodynamic variables in the intubated, ventilated abdominal surgical patient. Mobilisation was defined as the progression of activity from supine, to sitting over the edge of the bed, standing, walking on the spot for one minute, sitting out of bed initially, and sitting out of bed for 20 minutes. Seventeen patients with age (mean +/- SD) 71.4 +/- 7.1 years satisfied inclusion criteria. Respiratory and haemodynamic parameters were measured in each of the above positions and compared with supine. In the 15 subjects who completed the protocol, standing resulted in significant increases in minute ventilation (VE) from 15.1 +/- 3.1 l/min in supine to 21.3 +/- 3.6 l/min in standing (p < 0.001). The increase in VE in standing was achieved by significant increases in tidal volume (VT) from 712.7 +/- 172.8 ml to 883.4 +/- 196.3 ml (p = 0.008) and in respiratory rate (fR) from 21.4 +/- 5.0 breaths/min to 24.9 +/- 4.5 breaths/min (p = 0.03). No further increases were observed in these parameters beyond standing when activity was progressed to walking on the spot for one minute. When supine values were compared with walking on the spot for one minute, inspiratory flow rates (VT/TI) increased significantly from 683 +/- 131.8 ml/sec to 985.1 +/- 162.3 ml/sec (p = 0.001) with significant increases in rib cage displacement (p = 0.001) and no significant increase in abdominal displacement (p = 0.23). Arterial blood gases displayed no improvements following mobilisation. Changes in VT, fR, and VE were largely due to positional changes when moving from supine to standing.

Clinical variables of preoperative risk in thoracic surgery

CONTEXT

Pulmonary complications are the most common forms of postoperative morbidity in thoracic surgery, especially atelectasis and pneumonia. The first step in avoiding these complications during the postoperative period is to detect the patients that may develop them.

OBJECTIVE

To identify risk variables leading to early postoperative pulmonary complications in thoracic surgery.

DESIGN

Prospective study.

SETTING

Hospital das Clínicas, Faculdade de Ciências Médicas, Universidade Estadual de Campinas.

PATIENTS

145 patients submitted to elective surgery were classified as low, moderate and high risk for postoperative pulmonary complications using a risk assessment scale.

PROCEDURES

The patients were followed up for 72 hours after the operation. Postoperative pulmonary complications were defined as atelectasis, pneumonia, tracheobronchitis, wheezing, prolonged intubation and/or prolonged mechanical ventilation.

MAIN MEASUREMENTS

Univariate analysis was applied in order to study these independent variables: age, nutritional status, body mass index, respiratory disease, smoking habit, spirometry and surgery duration. Multivariate logistic regression analysis was performed in order to evaluate the relationship between independent and dependent variables.

RESULTS

The incidence of postoperative complications was 18.6%. Multivariate logistic regression analysis showed that the variables increasing the chances of postoperative pulmonary complications were wheezing (odds ratio, OR = 6.2), body mass index (OR = 1.15), smoking (OR = 1.04) and surgery duration (OR = 1.007).

CONCLUSION

Wheezing, body mass index, smoking and surgery duration increase the chances of postoperative pulmonary complications in thoracic surgery

Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery

OBJECTIVE

To investigate associations between preoperative variables and postoperative pulmonary complications (PPC) in elective upper abdominal surgery.

DESIGN

Prospective clinical trial.

SETTING

A tertiary university hospital.

PATIENTS

408 patients were prospectively analyzed during the preoperative period and followed up postoperatively for pulmonary complications.

MEASUREMENTS

Patient characteristics, with clinical and physical evaluation, related diseases, smoking habits, and duration of surgery. Preoperative pulmonary function tests (PFT) were performed on 247 patients.

RESULTS

The postoperative pulmonary complication rate was 14 percent. The significant predictors in univariate analyses of postoperative pulmonary complications were: age >50, smoking habits, presence of chronic pulmonary disease or respiratory symptoms at the time of evaluation, duration of surgery >210 minutes and comorbidity (p <0.04). In a logistic regression analysis, the statistically significant predictors were: presence of chronic pulmonary disease, surgery lasting >210 and comorbidity (p <0.009).

CONCLUSIONS

There were three major clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, comorbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (p <0.001). PFT is indicated when there are uncertainties regarding the patient's pulmonary status.

Preoperative smoking habits and postoperative pulmonary complications

OBJECTIVE

To examine the effect of preoperative smoking behavior on postoperative pulmonary complications.

DESIGN

Prospective cohort study.

SETTING

The Veterans Administration Medical Center, Syracuse, NY.

PARTICIPANTS

Patients scheduled for noncardiac elective surgery (n=410).

MEASUREMENTS AND RESULTS

Smoking status was determined by self-report. Postoperative pulmonary complications were determined by systematic extraction of medical record data. Postoperative pulmonary complications occurred in 31 of 141 (22.0%) current smokers, 24 of 187 (12.8%) past smokers, and 4 of 82 (4.9%) never smokers. The odds ratio (OR) for developing a postoperative pulmonary complication for current smokers vs never smokers was 5.5 (95% confidence interval [CI], 1.9 to 16.2) and 4.2 (95% CI, 1.2 to 14.8) after adjustment for type of surgery, type of anesthesia, abnormal chest radiograph, chronic cough, history of pulmonary disease, history of cardiac disease, history of COPD, education level, pulmonary function, body mass index, and age. Current smokers who reported reducing cigarette consumption prior to surgery were more likely to develop a complication compared with those who did not (adjusted OR=6.7, 95% CI, 2.6 to 17.1).

CONCLUSIONS

Current smoking was associated with a nearly sixfold increase in risk for a postoperative pulmonary complication. Reduction in smoking within 1 month of surgery was not associated with a decreased risk of postoperative pulmonary complications.

Diaphragm function during sighs in awake dogs after laparotomy

Pulmonary complications after upper abdominal surgery are usually ascribed to temporary postoperative impairment of diaphragm function, which may not originate from intrinsic, structural injury but from reflex inhibition of diaphragm contractility. Spontaneous breathing is interrupted periodically by sighs, even after upper abdominal surgery. If postoperative dysfunction of the diaphragm arises from a reflexic inhibition, then the sigh should temporarily override the inhibition and restore normal diaphragm function. We implanted sonomicrometer and electromyogram transducers chronically in six dogs by laparotomy, then directly measured length, shortening, and electromyogram activity of costal and crural diaphragm segments, parasternal intercostal, and transversus abdominis muscles an average of 8.7 (range, 1-16) d later during resting tidal breathing and sighs. In each animal we analyzed a sequence of breaths, including a sigh, when costal or crural diaphragm contractility was abnormal. With each sigh, the shape and amplitude of costal and crural diaphragm segmental shortening improved abruptly, from 0.9 and 1.4% of baseline length (% LBL) during resting breathing to 12.1 and 11.1% LBL, respectively, during sighs. The sighs were compared to CO2-stimulated breaths of equivalent tidal volume, which did not show either pattern or amplitude of shortening equivalent to sighs. We conclude that diaphragm dysfunction after laparotomy arises from a reflex inhibition, which is overridden abruptly to return diaphragm function briefly to normal during each spontaneous sigh.

Effect of bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty

STUDY OBJECTIVE

Upper abdominal surgery results in a postoperative restrictive pulmonary syndrome. Bi-level positive airway pressure (BiPAP System; Respironics Inc; Murrysville, Pa), which combines pressure support ventilation and positive end-expiratory pressure via a nasal mask, could allow alveolar recruitment during inspiration and prevent expiratory alveolar collapse, and therefore limit the postoperative pulmonary restrictive syndrome. This study investigated the effect of BiPAP on postoperative pulmonary function in obese patients after gastroplasty.

DESIGN

Prospective controlled randomized study.

SETTING

GI surgical ward in a university hospital.

PATIENTS

Thirty-three morbidly obese patients scheduled for gastroplasty were studied.

INTERVENTION

The patients were assigned to one of three techniques of ventilatory support during the first 24 h postoperatively: O2 via a face mask, BiPAP System 8/4, with inspiratory and expiratory positive airway pressure set at 8 and 4 cm H2O, respectively, or BiPAP System 12/4 set at 12 and 4 cm H2O. Pulmonary function (FVC, FEV1, and peak expiratory flow rate [PEFR]) were measured the day before surgery, 24 h after surgery, and on days 2 and 3. Oxygen saturation by pulse oximeter (SpO2) was also recorded during room air breathing.

RESULTS

Three patients were excluded. After surgery, FVC, FEV1, PEFR, and SpO2 significantly decreased in the three groups. On day 1, FVC and FEV1 were significantly improved in the group BiPAP System 12/4, as compared with no BiPAP; SpO2 was also significantly improved. After removal of BiPAP System 12/4, these benefits were maintained, allowing faster recovery of pulmonary function. No significant effects were observed on PEFR. BiPAP System 8/4 had no significant effect on the postoperative pulmonary restrictive syndrome.

CONCLUSION

Prophylactic use of BiPAP System 12/4 during the first 24 h postoperatively significantly reduces pulmonary dysfunction after gastroplasty in obese patients and accelerates reestablishment of preoperative pulmonary function.