Prognostic impact of pulmonary dysfunction in older gastric cancer patients

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

Preoperative forced expiratory volume in one second and postoperative respiratory outcomes in nonpulmonary and noncardiac surgery: a retrospective cohort study

BACKGROUND

Although the usefulness of pulmonary function tests has been established for lung resection and coronary artery bypass surgeries, the association between preoperative pulmonary function test and postoperative respiratory complications in nonpulmonary and noncardiac surgery is inconclusive. The purpose of this study was to determine the association between preoperative forced expiratory volume in one second (FEV1) on pulmonary function test and the development of postoperative respiratory failure and/or death in patients undergoing major nonpulmonary and noncardiac surgery.

METHODS

Adult patients aged ≥ 18 years and who underwent nonpulmonary and noncardiac surgery with expected moderate to high risk of perioperative complications from June 2012 to March 2019 were included. The primary exposure was preoperative FEV1 measured by pulmonary function test within six months before surgery. The primary outcome was respiratory failure (i.e., invasive positive pressure ventilation for at least 24 h after surgery or reintubation) and/or death within 30 days after surgery. A logistic regression model was used to adjust for the respiratory failure risk index, which is a scoring system that predicts the probability of postoperative respiratory failure based on patient and surgical factors, and to examine the association between preoperative FEV1 and the development of postoperative respiratory failure and/or death.

RESULTS

Respiratory failure and/or death occurred within 30 days after surgery in 52 (0.9%) of 5562 participants. The incidence of respiratory failure and/or death in patients with FEV1 ≥ 80%, 70%- < 80%, 60%- < 70%, and < 60% was 0.9%, 0.6%, 1.7%, and 1.2%, respectively. Multivariable logistic regression analysis showed no significant association between preoperative FEV1 and postoperative respiratory failure and/or death (adjusted odds ratio per 10% decrease in FEV1: 1.01, 95% confidence interval: 0.88-1.17, P = 0.838). Addition of FEV1 information to the respiratory failure risk index did not improve the prediction of respiratory failure and/or death [area under the receiver operating characteristics curve: 0.78 (95% confidence interval: 0.72-0.84) and 0.78 (95% confidence interval: 0.72-0.84), respectively; P = 0.84].

CONCLUSION

We found no association between preoperative FEV1 and postoperative respiratory failure and/or death in patients undergoing major nonpulmonary and noncardiac surgery.

Pulmonary function testing in preoperative high-risk patients

BACKGROUND

Postoperative respiratory failure is the most frequent complication in postsurgical patients. The purpose of this study is to assess whether pulmonary function testing in high-risk patients during preoperative assessment detects previously unknown respiratory impairments which may influence patient outcomes.

METHODS

A targeted patient screening by spirometry and the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) was implemented in the anesthesia department of a tertiary university hospital. Patients of all surgical disciplines who were at least 75 years old or exhibited reduced exercise tolerance with the metabolic equivalent of task less than four (MET < 4) were examined. Clinical characteristics, history of lung diseases, and smoking status were also recorded. The statistical analysis entailed t-tests, one-way ANOVA, and multiple linear regression with backward elimination for group comparisons.

RESULTS

Among 256 included patients, 230 fulfilled the test quality criteria. Eighty-one (35.2%) patients presented obstructive ventilatory disorders, out of which 65 were previously unknown. 38 of the newly diagnosed obstructive disorders were mild, 18 moderate, and 9 severe. One hundred forty-five DLCO measurements revealed 40 (27.6%) previously unknown gas exchange impairments; 21 were mild, 17 moderate, and 2 severe. The pulmonary function parameters of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and DLCO were significantly lower than the international reference values of a healthy population. Patients with a lower ASA class and no history of smoking exhibited higher FVC, FEV1, and DLCO values. Reduced exercise tolerance with MET < 4 was strongly associated with lower spirometry values.

CONCLUSIONS

Our screening program detected a relevant number of patients with previously unknown obstructive ventilatory disorders and impaired pulmonary gas exchange. This newly discovered sickness is associated with low metabolic equivalents and may influence perioperative outcomes. Whether optimized management of patients with previously unknown impaired lung function leads to a better outcome should be evaluated in multicenter studies.

TRIAL REGISTRATION

German Registry of Clinical Studies (DRKS00029337), registered on: June 22nd, 2022.

Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial

Background

Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively.

Methods/design

In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I–III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively.

Discussion

Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting.

Trial registration

ClinicalTrials.gov NCT05040490. Registered on 3 September 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06328-3.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The value of preoperative spirometry testing for predicting postoperative risk in upper abdominal and thoracic surgery assessed using big-data analysis

Background

Spirometry is used to evaluate postoperative outcomes in thoracic surgery. However, the clinical utility of spirometry for predicting postoperative complications has not been determined. We used big-data analysis to examine the relationship between pulmonary function tests and postoperative complications.

Methods

We retrospectively analysed clinical data from 31,827 patients who underwent spirometry within the 3 months prior to their surgery between January 2000 and December 2014 at a single tertiary referral hospital. The data were extracted in de-identified form via the automated clinical research information system. Surgical procedures included thoracic and upper abdominal surgery.

Results

Multivariable logistic regression analysis showed that type of surgery, older age (>65 years), low albumin and smoking were associated with postoperative infections [95% confidence interval (CI) of the odds ratio (OR) 1.27–1.60 (>65 years); 1.52–1.96 (low albumin); 1.40–1.98 (current smoker)]. Notably, lower forced vital capacity (FVC) was an independent risk factor for postoperative infection, prolonged intensive care unit stay, and in-hospital death, regardless of airflow limitation [OR 95% CI: 1.31–1.69 (FVC 50–80%); 2.02–4.24 (FVC <50%)]. Lower forced expiratory volume in 1 sec (FEV₁) was also an independent risk factor for postoperative infection [OR 95% CI: 1.61–2.26 (FEV₁ 50–80%); 2.27–4.21 (FEV₁ <50%)]. Airflow limitation assessed by FEV₁ was negatively correlated with postoperative infection in multivariable analysis (OR 95% CI: 0.51–0.88).

Conclusions

Lower preoperative FVC could be used to predict postoperative infection and complications in thoracic and upper abdominal surgery regardless of airflow limitation.

Preoperative cardiac and respiratory investigations do not predict cardio-respiratory complications after pancreatectomy

BACKGROUND

The process of undergoing a pancreatic resection places a patient under notable physiologic strain throughout the perioperative journey, with well recognized risks of postoperative cardiopulmonary complications. Preoperative preparations and screening often incorporate a barrage of testing, including electrocardiograms, transthoracic echocardiography, chest X-rays and spirometric evaluations. However, the current literature does not demonstrate whether these common tests provide any predictive correlation with postoperative cardiopulmonary complications. This retrospective study is structured to identify complications in post-pancreatic resection patients and assess for a predictive correlation with preoperative test results.

METHODS

A retrospective analysis of all patients having undergone a pancreatic resection at a single tertiary centre, between 2014 and 2016. The inpatient medical records were reviewed for 30-day postoperative complications, including acute myocardial infarction, cardiac dysrhythmia, pulmonary embolism, pneumonia or pleural effusions. The results of routine preoperative diagnostic tests and complication rates were analysed.

RESULTS

A total of 244 patients, median age of 66 years (range 18-88 years) were included in the study. Of these, 11 patients experienced a cardiac complication and 16 patients experienced a respiratory complication. Among those who experienced cardiac events, only two patients had abnormalities in their preoperative electrocardiograms. Patients who sustained a cardiac or respiratory event did not have any evidence of abnormality in their preoperative transthoracic echocardiography or respiratory investigations, respectively.

CONCLUSION

Despite the recommendation that high-risk procedures such as pancreatic resections warrant thorough, routine, preoperative cardiac and respiratory investigation, a more functional preoperative assessment should be considered to stratify and predict postoperative outcomes.

Prediction of early postoperative desaturation in extreme older patients after spinal anesthesia for femur fracture surgery: a retrospective analysis

Background

Postoperative desaturation in older individuals is rarely addressed in the literature. The objective of this retrospective study was to investigate whether a preoperative spirometric test and arterial blood gas analysis (ABGA) might predict postoperative desaturation after spinal anesthesia in extreme older patients.

Methods

The medical records of 399 patients (age ≥ 80 yrs) who were administered spinal anesthesia for a femur neck fracture surgery were retrospectively reviewed. Early postoperative desaturation was defined as a reduction of oxygen saturation (SpO₂) below 90% within 3 days of surgery, despite O₂ supply via a nasal prong. Binary logistic regression analysis was used to identify predictors of early postoperative desaturation.

Results

The incidence of postoperative desaturation was 12.5%. Major morbidity rate was significantly higher in the desaturation group (n = 50) than that in the non-desaturation group (n = 349) (14% vs. 3.2%, P = 0.001) with more frequent postoperative stays in the intensive care unit (22% vs. 12%, P = 0.004). In a binary logistic regression analysis, preoperative ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂ ratio) (OR, 0.972; 95% CI 0.952–0.993; P = 0.010) and history of cardiovascular disease (OR, 2.127; 95% CI 1.004–4.507; P = 0.049) predicted postoperative desaturation.

Conclusions

Preoperative PaO₂/FiO₂ ratio, but not preoperative spirometry, was predictive of the postoperative desaturation in older patients after being administered spinal anesthesia for femur fracture surgery. Based on our results, preoperative ABGA may be helpful in predicting early postoperative desaturation in these patients.

Value of preoperative spirometry test in predicting postoperative pulmonary complications in high-risk patients after laparoscopic abdominal surgery

Whether preoperative spirometry in non-thoracic surgery can predict postoperative pulmonary complications (PPCs) is controversial. We investigated whether preoperative spirometry results can predict the occurrence of PPCs in patients who had undergone laparoscopic abdominal surgery. This retrospective observational study analyzed the records of patients who underwent inpatient laparoscopic gastric or colorectal cancer surgery at Seoul National University Bundang Hospital between January 2010 and June 2017. Preoperative spirometry was performed for patients at a high risk of PPCs, such as elderly patients (age >60 years), patients aged <60 years with chronic pulmonary disease, and current smokers. The main outcome was the association between the results of spirometry tests performed within 1 month prior to surgery and the occurrence of PPCs, as determined by multivariable logistic regression analysis. Of the 898 included patients who underwent laparoscopic gastric (372 patients) or colorectal cancer surgery (526 patients), PPC occurred in 117 patients (gastric cancer: 74, colorectal cancer: 43). A 1% greater preoperative forced vital capacity (FVC) was associated with a 2% lower incidence of PPCs after laparoscopic gastric or colorectal cancer surgery (odds ratio: 0.98, 95% confidence interval: 0.97–0.99, P = 0.018). However, the preoperative forced expiratory volume in 1 second (FEV1) (%) and FEV1/FVC (%) were not significantly associated with PPCs (P = 0.059 and P = 0.147, respectively). In conclusion, lower preoperative spirometry FVC, but not FEV1 or FEV1/FVC, may predict PPCs in high-risk patients undergoing laparoscopic abdominal surgery.