Predictive Effects of Lung function test on Postoperative Pneumonia in Squamous Esophageal Cancer

Concomitant preoperative airflow obstruction confers worse prognosis after trans-thoracic surgery for esophageal cancer

Background

Airflow obstruction is a critical element of chronic airway diseases. This study aimed to evaluate the impact of preoperative airflow obstruction on the prognosis of patients following surgery for esophageal carcinoma.

Methods

A total of 821 esophageal cancer patients were included and classified into two groups based on whether or not they had preoperative airflow obstruction. Airflow obstruction was defined as a forced expiration volume in the first second (FEV₁)/forced vital capacity (FVC) ratio below the lower limit of normal (LLN). A retrospective analysis of the impact of airflow obstruction on the survival of patients with esophageal carcinoma undergoing esophagectomy was performed.

Results

Patients with airflow obstruction (102/821, 12.4%) had lower three-year overall (42/102, 58.8%) and progression-free survival rate (47/102, 53.9%) than those without airflow obstruction (P < 0.001). Multivariate analyses showed that airflow obstruction was an independent risk factor for overall survival (Hazard Ratio = 1.66; 95% CI: 1.17-2.35, P = 0.004) and disease progression (Hazard Ratio = 1.51; 95% CI: 1.1-2.08; P = 0.01). A subgroup analysis revealed that the above results were more significant in male patients, BMI < 23 kg/m² patients or late-stage cancer (stage III-IVA) (P = 0.001) patients and those undergoing open esophagectomy (P < 0.001).

Conclusion

Preoperative airflow obstruction defined by FEV₁/FVC ratio below LLN was an independent risk factor for mortality in esophageal cancer patients after trans-thoracic esophagectomy. Comprehensive management of airflow obstruction and more personalized surgical decision-making are necessary to improve survival outcomes in esophageal cancer patients.

Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer

Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I-III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV_1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56-67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47-17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48-15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.

Risk factors and therapeutic measures for postoperative complications associated with esophagectomy

Esophageal cancer is one of the most common cancers associated with the high mortality rate. Timely diagnosis and treatment are important to manage the disease and prevent comorbidities. Surgical resection of the tumor and lymph nodes is usually practiced either with or without chemo or chemoradiotherapy. Despite advancements in surgical methods and skills, complex nature of the esophagus and invasiveness of the surgery can lead to serious complications in these patients. In order to predict postoperative outcomes, preoperative examination of the patients, in addition to risk factors, should be conducted. Conclusion: Lastly, early detection of adverse postoperative events may help faster recovery, reduce hospital stay and prevent other morbidities.

Determination of the optimal surgical procedure by identifying risk factors for pneumonia after transthoracic esophagectomy

BACKGROUND

Esophagectomy is associated with a high risk of postoperative complications, and the respiratory complications are the most common. Therefore, stratification of patients based on preoperative risk factors is essential. This study aimed to identify the risk of postoperative pneumonia (POP) based on the preoperative factors and determine the optimal perioperative surgical management strategy.

METHODS

This retrospective study involved 207 patients who underwent esophagectomy. The patients were divided into two groups, namely, with POP and without POP. To identify the risk factors for POP, the pre- and perioperative characteristics were analyzed. A receiver operating characteristics curve was used to determine a cutoff value of 2.40 L for the forced expiratory volume in 1 s (FEV1.0) and the cohort was divided into a high- and low-FEV1.0 group. A second analysis was then performed to determine the optimal surgical management for patients at a high risk for POP.

RESULTS

POP occurred in 45 (21.7%) patients. A multiple logistic regression analysis showed that FEV1.0 was significantly lower in the POP (+) group (P = 0.020); thus, a low FEV1.0 was found to be a risk factor for POP. Multiple logistic regression analysis showed that open thoracotomy was a significant risk factor for POP in low FEV1.0 patients (P = 0.013).

CONCLUSIONS

A low FEV1.0 and an open thoracotomy are risk factors for POP. Therefore, patients with low FEV1.0 should be managed carefully and video-assisted thoracic surgery should be considered.

Preoperative Serum Albumin Level As A Predictor Of Postoperative Pneumonia After Femoral Neck Fracture Surgery In A Geriatric Population

Purpose

Femoral neck fracture usually occurs in the geriatric population. Postoperative pneumonia (POP) is known to be devastated, and it is the most frequent complication among patients receiving surgical treatment for femoral neck fractures. However, whether patients who have hypoalbuminaemia are susceptible to the development of POP is a serious concern, although it has not been investigated. We attempted to investigate the association between newly developed POP and hypoalbuminaemia and to identify whether hypoalbuminaemia is an independent risk factor for POP after femoral neck fracture in geriatric population.

Patients and methods

We retrospectively reviewed the records from the first 30 days after surgery of patients who were ≥65 years of age and who had a femoral neck fracture treated with surgery between January 2018 and December 2018 at the Honghui Hospital, Xi’an Jiaotong University. Patients were divided into two groups based on whether they did or did not experience POP, and their clinical characteristics were compared. Binomial logistic regression was used to identify potential risk factors of POP by analysing demographic factors, preoperative comorbidities, laboratory results, and surgical factors.

Results

A total of 720 patients were included in the analysis, and 54 patients experienced POP. The incidence of POP after surgical treatment for a femoral neck fracture in this geriatric population was 7.5%. In addition, patients with POP had significantly longer hospital stays than patients without POP. The binary logistic regression analysis revealed that preoperative hypoalbuminaemia [odds ratio =5.187, 95% confidence interval (CI): 2.561–10.506, P<0.0001], COPD (OR =3.819, 95% CI: 1.247–11.701, P=0.019), prior stroke (OR =3.107, 95% CI: 1.470–6.568, P=0.003) and the time from injury to surgery (OR =1.076, 95% CI: 1.034–1.119, P<0.0001) were predominant and independent risk factors associated with POP after femoral neck fracture in this geriatric population.

Conclusion

The current study revealed that among a geriatric population admitted for femoral neck fracture surgery, preoperative hypoalbuminaemia was a predictor of POP, followed by COPD, prior stroke and the time from injury to surgery. Thus, patients who undergo femoral neck fracture surgery and have preoperative hypoalbuminaemia should receive additional monitoring and perioperative care.

Risk Prediction of Postoperative Pneumonia After Subtotal Esophagectomy Based on Preoperative Serum Cholinesterase Concentrations

BACKGROUND

Patients undergoing subtotal esophagectomy for esophageal cancer frequently experience postoperative pneumonia. Development of preoperatively determined predictors for postoperative pneumonia will facilitate identifying high-risk patients and will assist with informing patients about their risk of postoperative pneumonia, enabling physicians to estimate with greater accuracy, will result in tailoring perioperative management.

METHODS

Postoperative pneumonia was defined according to the revised Uniform Pneumonia Score. We analyzed the data for 355 patients to compare 32 potential predictive variables associated with postoperative pneumonia after subtotal esophagectomy.

RESULTS

Forty-one patients (11.5%) had postoperative pneumonia. Preoperative cholinesterase (ChE) concentrations demonstrated the greatest area under the curve value (0.662) to predict postoperative pneumonia (optimal cutoff value = 217 IU/l). Univariate analysis identified a continuous value of preoperative ChE concentration as a significant risk factor for postoperative pneumonia (P = 0.0014). Multivariable analysis using factors potentially relevant to pneumonia revealed that preoperative ChE concentration was one of independent risk factors for pneumonia after esophagectomy (P = 0.008). Patients with low ChE concentrations were at increased risk of postoperative pneumonia in most patient subgroups. Moreover, the odds ratios of low ChE concentrations were highest in patients undergoing neoadjuvant treatment. A combination of preoperative serum ChE concentrations and Brinkman index stratified patients into low, intermediate, and high risk of postoperative pneumonia.

CONCLUSIONS

Our findings indicate that preoperative ChE concentrations, particularly in combination with Brinkman index, may serve simply as a determined predictor of pneumonia after subtotal esophagectomy and may facilitate physicians' efforts to reduce the incidence of postoperative pneumonia.

The Epidemiology and Risk Factors for Postoperative Pneumonia

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