To describe the timing and type of the first targeted breathing exercises after abdominal and cardiothoracic surgery, and to identify factors associated with early initiation (Commencement within three hours after arriival to a postoperative ward).

Multicentre observational study.

In 18 hospitals in Sweden, the start time and type of targeted breathing exercises were recorded in consecutive series of patients who underwent abdominal or cardiothoracic surgery. Demographic data were retrieved from hospital records. Patients were divided into seven groups based on the category of surgery.

In total, 1492 patients were included in this study; of these, 1128 (76%) performed some form of targeted breathing exercise after surgery. Targeted breathing exercises commenced a median of 3.63 hours (interquartile range 1.58 to 11.75 hours) after arrival on a postoperative ward, with earlier commencement after minor abdominal surgery and later commencement after major abdominal surgery (P < 0.001). Most patients who performed targeted breathing exercises used positive expiratory pressure (n = 968/1492, 65%) or deep breathing without any devices (n = 207/1492, 14%). The odds of initiating breathing exercises within the first 3 hours after arrival on a postoperative ward were higher if a patient underwent pulmonary or abdominal surgery [odds ratio (OR) > 2.04; P < 0.001], or had intravenous analgesia (OR 1.50, 95% CI 1.05 to 2.14; P = 0.026). The odds were lower (OR 0.43, 95% CI 0.21 to 0.88; P = 0.021) for patients who arrived on the postoperative ward in the evening/night or for patients who had undergone laparoscopic surgery (OR 0.63, 0.43-0.92, p=0.018).

The majority (76%) of patients undergoing abdominal or cardiothoracic surgery performed some form of targeted breathing exercise, starting a median of 3.63 hours after arrival on a postoperative ward.

"FoU in Sweden" (Research and Development in Sweden) ID: 275357 and Clinical Trials NCT04729634. CONTRIBUTION OF THE PAPER.

While smoking has been consistently identified as a significant contributor to postoperative complications, the existing literature on its association with postoperative pulmonary complications remains conflicting.

We examined the association of preoperative smoking with the occurrence of postoperative pulmonary complications (PPCs).

Post hoc analysis of an observational study in 146 hospitals across 29 countries. We included patients at increased risk of PPCs, according to the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score (≥ 26 points). The primary endpoint was the occurrence of one or more predefined PPCs in the first five postoperative days, including unplanned postoperative need for supplementary oxygen, respiratory failure, unplanned need for invasive ventilation, ARDS, pneumonia and pneumothorax. Secondary endpoints included length of hospital stay and in-hospital mortality. We performed propensity score matching to correct for factors with a known association with postoperative outcomes.

Out of 2632 patients, 531 (20.2 %) patients were smokers and 2102 (79.8 %) non-smokers. At five days after surgery, 101 (19.0 %) smokers versus 404 (19.2) non-smokers had developed one or more PPCs (P = 0.95). Respiratory failure was more common in smokers (5.1 %) than non-smokers (3.0 %) (P = 0.02), while rates of other PPCs like need for supplementary oxygen, invasive ventilation, ARDS, pneumonia, or pneumothorax did not differ between the groups. Length of hospital stay and mortality was not different between groups. Propensity score matching did not change the findings.

The occurrence of PPCs in smokers is not different from non-smokers.

This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anaesthesiology through their Clinical Trial Network and the Amsterdam University Medical Centers, Amsterdam, The Netherlands.

LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223).

Preliminary study results have been presented at the Euroanaesthesia 2024 International Congress, in Munich, Germany.

Elderly patients are known to be vulnerable to postoperative pulmonary complications (PPCs), especially pneumonia. Apart from elder age, preoperative pulmonary diseases, anaemia, malnutrition, dysphagia and frailty may all be contributing factors to PPCs. Poor oral hygiene is a risk factor for PPC as well, as oropharyngeal microflora might be introduced to the lower respiratory tract following endotracheal intubation for general anaesthesia during surgery. Immune regulation, nutrition supplementation and improvement of oropharyngeal microflora might regulate immune and stress response and can be beneficial to elderly patients exposed to surgical stress. In this study, we will explore the effects of perioperative oral decontamination and immunonutrition supplementation on the incidence of postoperative pneumonia in high-risk elderly surgical patients.

This study is a multicentre, two-by-two factorial randomised controlled trial evaluating the efficacy of immunonutrition supplementation and oral chlorhexidine decontamination. A total of 592 patients aged 65 years and older who are scheduled for elective non-cardiac surgeries in seven tertiary hospitals in China will be recruited. Patients will be excluded if they have contraindications to the intervention. Patients will be randomised into four groups in a 1:1:1:1 ratio (oral decontamination vs routine oral care, immunonutrition supplementation vs routine nutrition advice). The primary outcome is the incidence of PPCs within 7 days after surgery. The secondary outcomes are the incidence of postoperative pneumonia, infectious complications, Comprehensive Complication Index, postoperative functional recovery, length of hospital stay and hospital expenses. Intention to treat principles will be applied to all outcomes. Descriptive analysis will be used to compare patients' baseline characteristics. Logistic regression will be used to compare the incidence of PPCs within 7 days after surgery between different groups.

The study protocol has been approved by the Research Ethics Committee of Peking Union Medical College Hospital (I-23PJ953). All participants will provide written informed consent. Study results will be published in peer-reviewed journals and presented at academic conferences.

NCT05971810.

A recent retrospective study examined a composite of postoperative pulmonary complications after neostigmine or sugammadex for reversal of neuromuscular block in patients undergoing interventional pulmonology and bronchoscopic procedures. This study reviewed the electronic medical records of 8557 patients across hospitals within a single health system, finding an increased risk of a composite of postoperative pulmonary complications in those receiving sugammadex (odds ratio 1.44; 95% confidence interval: 1.02-2.05). We discuss the challenge of interpreting conflicting findings in the contemporary perioperative literature arising from heterogeneous definitions of postoperative pulmonary complications.

The objective is to systematically gather relevant research to determine and quantify the risk factors and pooled prevalence for pneumonia after a radical gastrectomy for gastric cancer.

The reporting procedures of this meta-analysis conformed to the PRISMA 2020. Chinese Wan Fang data, Chinese National Knowledge Infrastructure (CNKI), Chinese Periodical Full-text Database (VIP), Embase, Scopus, CINAHL, Ovid MEDLINE, PubMed, Web of Science, and Cochrane Library from inception to January 20, 2024, were systematically searched for cohort or case-control studies that reported particular risk factors for pneumonia after radical gastrectomy for gastric cancer. The pooled prevalence of pneumonia was estimated alongside risk factor analysis. The quality was assessed using the Newcastle-Ottawa Scale after the chosen studies had been screened and the data retrieved. RevMan 5.4 and R 4.4.2 were the program used to perform the meta-analysis.

Our study included data from 20,840 individuals across 27 trials. The pooled prevalence of postoperative pneumonia was 11.0% (95% CI = 8.0% ~ 15.0%). Fifteen risk factors were statistically significant, according to pooled analyses. Several factors were identified to be strong risk factors, including smoking history (OR 2.71, 95% CI = 2.09 ~ 3.50, I2 = 26%), prolonged postoperative nasogastric tube retention (OR 2.25, 95% CI = 1.36-3.72, I2 = 63%), intraoperative bleeding ≥ 200 ml (OR 2.21, 95% CI = 1.15-4.24, I2 = 79%), diabetes mellitus (OR 4.58, 95% CI = 1.84-11.38, I2 = 96%), male gender (OR 3.56, 95% CI = 1.50-8.42, I2 = 0%), total gastrectomy (OR 2.59, 95% CI = 1.83-3.66, I2 = 0%), COPD (OR 4.72, 95% CI = 3.80-5.86, I2 = 0%), impaired respiratory function (OR 2.72, 95% CI = 1.58-4.69, I2 = 92%), D2 lymphadenectomy (OR 4.14, 95% CI = 2.29-7.49, I2 = 0%), perioperative blood transfusion (OR 4.21, 95% CI = 2.51-7.06, I2 = 90%), and hypertension (OR 2.21, 95% CI = 1.29-3.79, I2 = 0%). Moderate risk factors included excessive surgery duration (OR 1.51, 95% CI = 1.25-1.83, I2 = 90%), advanced age (OR 1.91, 95% CI = 1.42-2.58, I2 = 94%), nutritional status (OR 2.62, 95% CI = 1.55-4.44, I2 = 71%), and history of pulmonary disease (OR 1.61, 95% CI = 1.17-2.21, I2 = 79%).

This study identified 15 independent risk factors significantly associated with pneumonia after radical gastrectomy for gastric cancer, with a pooled prevalence of 11.0%. These findings emphasize the importance of targeted preventive strategies, including preoperative smoking cessation, nutritional interventions, blood glucose and blood pressure control, perioperative respiratory training, minimizing nasogastric tube retention time, and optimizing perioperative blood transfusion strategies. For high-risk patients, such as the elderly, those undergoing prolonged surgeries, experiencing excessive intraoperative blood loss, undergoing total gastrectomy, or receiving open surgery, close postoperative monitoring is essential. Early recognition of pneumonia signs and timely intervention can improve patient outcomes and reduce complications.

Postoperative pulmonary complications (PPCs) are a leading cause of morbidity, death, and increased use of health-care resources. We aimed to determine whether a perioperative lung expansion bundle including individualised intraoperative management reduces PPC severity in patients undergoing major open abdominal surgery compared with usual care.

In this multicentre, randomised controlled phase 3 trial (PRIME-AIR), we enrolled adult patients (age ≥18 years) scheduled for an elective open abdominal surgery that would last at least 2 h, who were at intermediate or high risk for PPCs on the basis of their Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score (a score of ≥26), and who had a BMI below 35 kg/m2 at 17 academic hospitals across ten states in the USA. Participants were randomly assigned (1:1), using permuted block randomisation (a mixture of blocks sizes of 2 and 4; in a 1:2 ratio), stratified by centre, to either usual care or a lung expansion bundle. The bundle comprised preoperative education on PPCs, intraoperative protective ventilation with individualised positive end-expiratory pressure (PEEP) to maximise respiratory system compliance, intraoperative neuromuscular blockade administration and reversal based on patient's weight and neuromuscular transmission monitoring, and postoperative supervised incentive spirometry and mobilisation encouragement. Anaesthesiologists at each site were also randomly assigned to either the intervention bundle group or usual care group, and at each site, at least one unmasked and one masked investigator was designated for each participant. Assessors were masked to treatment assignment. The primary outcome was the highest severity (grade 0-4) of a composite of PPCs by postoperative day 7, including hypoxaemia, respiratory symptoms, atelectasis, bronchospasm, respiratory infection, hypercapnia, pneumonia, pleural effusion, pneumothorax, and ventilatory dependence. The primary endpoint and safety were assessed in the modified intention-to-treat (mITT) population (ie, all participants randomly assigned to treatment who received surgery, and did not withdraw consent or verbal agreement, and excluded those found to be ineligible after randomisation, or for whom consent was not obtained for other reasons). This study is registered with ClinicalTrials.gov, NCT04108130, and is now complete.

Between Jan 24, 2020, and April 5, 2023, we screened 1462 patients, of whom 794 were enrolled and randomly assigned to treatment. The mITT population included 751 participants, of whom 379 (50%) were in the intervention bundle group and 372 (50%) were in the usual care group. Mean age was 61·8 years (SD 12·8); 360 (48%) of 751 patients were female and 391 (52%) were male; 572 (76%) were White, 44 (6%) were Black, 35 (5%) were Asian, and ten (1%) were other races or more than one race. Adherence to bundle components was high (72-98%). Patients in the intervention bundle group received higher mean PEEP (7·5 cmH2O [SD 2·5] vs 5·6 cmH2O [1·4]) and more frequent per-protocol dosing of neuromuscular blockade (334 [88%] of 379 vs 214 [58%] of 372) and reversal (322 [86%] of 375 who received reversal medication vs 250 [70%] of 358) than did those in the usual care group. By postoperative day 7, the most common PPC severity was grade 2 (211 [56%] of 379 in intervention bundle group vs 225 [60%] of 372 in the usual care group). Mean PPC severity was similar in both groups (1·60 [SD 0·94] vs 1·53 [0·93]; mean difference 0·07 [95% CI -0·03 to 0·18]; p=0·19). Occurrence of serious adverse events was similar in both groups. At 7 days postoperatively, one (<1%) patient in the intervention bundle group and two (1%) in the usual care group had died; at 30 days, cumulatively, one (<1%) patient and four (1%) patients had died; and at 90 days, cumulatively, six (2%) patients and five (1%) patients had died, respectively. Adverse events occurred in 71 (19%) of 379 patients in the intervention bundle group and 54 (14%) of 372 in the usual care group, and 35 (9%) patients in each group had serious adverse events.

In patients with a BMI of less than 35 kg/m2 who are at moderate-to-high risk of PPCs and undergoing prolonged major open abdominal surgery, a perioperative lung expansion bundle did not reduce PPC severity compared with usual care provided at US academic hospitals.

US National Institutes for Health National Heart, Lung, and Blood Institute.

Background: Upper abdominal surgeries exceeding two hours and operated in a lateral decubitus position present an "intermediate" risk for pulmonary complications. The objectives of this study were to observe the sonographic and clinical changes during and after surgeries with one recruitment maneuver (RM) performed intraoperatively before extubation. Methods: Laparoscopic nephrectomy patients were randomized into pre-extubation single RM (Group RM) and control (Group NoRM) groups. The LUS (Lung Ultrasound Score) was evaluated after intubation (T1), at the end of surgery before the RM (T2), after the RM but before extubation (T3), and 30 min after arrival to the Post-Anesthesia Care Unit (T4) in Group RM; in Group NoRM, it was evaluated at the T1, T2, and T4 time points. The primary outcome was the effect on the pre-extubation LUS (T2 in Group NoRM versus T3 in Group RM). The secondary outcomes included the effects on the T4 LUS, PPC occurrence, and PaO2/FiO2 ratios, and the sensitivity and specificity of the LUS in predicting PPCs. Results: The data of 54 patients were analyzed. The pre-extubation LUS was significantly lower in Group RM (16 (12.5, 17) vs. 18 (17, 20), p < 0.001). The T4 LUS was only different in the upper zones in the dependent lung (2 (1, 3.5) in Group RM vs. 4 (3, 4.5) in Group NoRM, p = 0.01). The perioperative PaO2/FiO2 ratios were similar (p > 0.05). The pre-extubation LUS exhibited 91% sensitivity (p = 0.04), whereas the T4 LUS sensitivity was 82% (p = 0.01). The PPC risk was 10-fold higher in patients with a pre-extubation LUS exceeding 19. Conclusions: A pre-extubation single RM instantly increases the LUS. However, this does not persist postoperatively or diminish respiratory complications. More importantly, the LUS was found to be a sensitive tool for predicting PPCs when performed just before extubation.

Major emergency abdominal surgery is associated with high morbidity and mortality. Understanding trends in outcomes over time can reveal critical practice-changing improvements, identify gaps in postoperative care, and establish a large-scale benchmark for future research.

To investigate trends in morbidity and mortality after major emergency abdominal surgery in Denmark.

This was a nationwide, population-based cohort study. Analyses were performed based on data from Danish nationwide administrative registries. Within the public health care system in Denmark, all adult patients undergoing major emergency abdominal surgery from 2002 to 2022 were included. Major emergency abdominal surgeries included laparotomy or laparoscopy due to intra-abdominal pathologies, including intestinal perforation, ischemia, bowel obstruction, abscess, or bleeding.

Major emergency abdominal surgery.

The primary outcome was the trend in 30- and 90-day mortality after major emergency abdominal surgery over time.

A total of 61 476 patients (mean [SD] age, 66.2 [16.3] years; 34 827 female [56.7%]) were included. The annual number of surgeries remained constant, with a mean (SD) of 3044 (165) surgeries per year. The 30- and 90-day mortality was reduced from 25% and 33%, respectively, to 13% and 18%, respectively (P < .001). Median (IQR) hospital length of stay was decreased from 10 (5-17) days to 6 (4-13) days (P < .001). The rate of 30-day postoperative complications (classified Clavien-Dindo ≥3a) was reduced from 49% to 44% (P <.001) and the 90-day rate was reduced from 53% to 48% (P <.001), however, with a tendency toward more patients undergoing earlier intervention. The 30- and 90-day readmission rate increased drastically from 9% and 13%, respectively, to 25% and 33%, respectively (P < .001).

Results of this cohort study suggest notable reductions in mortality and hospital length of stay after major emergency abdominal surgery. A marked increased readmission rate and a persistently high rate of postoperative complications were found. These shifts underscore the need for enhanced postoperative monitoring and postdischarge follow-up.

The COVID-19 pandemic introduced challenges including delaying elective surgery. For cancer patients, reducing delays is preferred to prevent unfavorable outcomes. there is a lack of consensus regarding the optimal timing of elective surgery following a SARS-CoV-2. This study aimed to find the optimal time to elective surgery to minimize 30-day postoperative morbidity and mortality.

This is a retrospective chart review of all adult patients who underwent elective surgery with a confirmed preoperative COVID-19 diagnosis between September 2020 and April 2023. Patients' elective surgeries delays were examined to determine the optimal time to surgery in terms of postoperative complications. Analysis was controlled for age, ASA score, comorbidities, and smoking status.

358 records examined, 94.7% had delayed surgery and 5.3% had cancelled surgery. The optimal time to surgery was ≥ 17 days to minimize postoperative pulmonary complications [OR: 0.299, p = 0.048], other postoperative complications [OR: 0.459, p = 0.01], and a decrease in length of hospital stay. In multivariate analysis, the only significant predictors for postoperative complications were time to surgery; surgery ≥ 17 days after diagnosis had better postoperative outcomes [p < 0.001], and COVID-19 symptoms status [p = 0.019].

The best time to surgery in this cohort is at least 17 days (or a range of 2-3 weeks) for optimal results. Further research is needed to investigate the effect of such delays on oncological outcomes in this cohort.

Comparison of flow-controlled ventilation (FCV) to standard of pressure-controlled ventilation (PCV) in thoracic surgery procedures requiring one-lung ventilation.

Prospective, non-blinded, randomized, controlled trial.

Operating theater at a university hospital, Austria.

Patients scheduled for elective, thoracic surgery.

Participants received ventilation randomly either with FCV or PCV per-protocol for the duration of anesthesia.

The primary endpoint was oxygenation assessed by paO2 / FiO2 ratio 30 min after the start of OLV. Secondary endpoints included the required minute volume for CO2 removal, applied mechanical power and incidence of postoperative pulmonary complications.

A total of 46 patients were enrolled and 43 included in the primary analysis. The primary endpoint paO2 / FiO2 ratio was significantly higher in the FCV group (n = 21) compared to the control group (PCV n = 22) (187 vs 136 mmHg, MD 39 (95 % CI 1 to 75); p = 0.047). The required respiratory minute volume to obtain comparable mild hypercapnia during OLV was significantly lower in FCV (3.0 vs 4.5 l/min, MD -1.3 (95 % CI -1.9 to -0.8); p < 0.001). The applied mechanical power was also significantly lower (3.5 versus 7.6 J/min, MD -3.8 (95 % CI -5.3 to -2.7); p < 0.001).

In this single-center randomized controlled trial, flow-controlled ventilation improved gas exchange parameters in terms of oxygenation and carbon dioxide removal during one-lung ventilation in patients undergoing thoracic surgery and reduced the mechanical impact of artificial ventilation.

 Pulmonary complications are among the main causes of increased mortality, and morbidity, as well as prolonged intensive care unit (ICU) and hospital stay after cardiac surgery. Recently, a sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced. A higher risk of pulmonary injury could be anticipated due to the thoracic incision and the longer duration of surgery. Pulmonary complications in TCRAT were compared to standard coronary artery bypass grafting (CABG) via full median sternotomy (FS).

 Records of 151 consecutive TCRAT (from September 2021 to November 2022) and 229 consecutive FS patients (from January 2017 to December 2018) patients, who underwent elective or urgent CABG, were analyzed. Preoperative baseline characteristics (age, sex, body mass index, diabetes, hypertension, chronic obstructive pulmonary disease, smoking status, left ventricular ejection fraction, pulmonary hypertonus, and EuroScore II) were comparable between groups.

 Differences between examined groups examined were found for the pulmonary parameters: Horowitz index 6 hours after operation (TCRAT 270 ± 72 vs. FS 293 ± 73, p < 0.05), pneumothorax (TCRAT 0% vs. FS 2.6%, p < 0.05), bronchoscopies (TCRAT 5.9% vs. FS 1.7%, p < 0.05), and pleural effusion (TCRAT 8.6% vs. FS 3.5%, p < 0.05). Moreover, there were differences between groups with regard to mean ICU stay (TCRAT 2.4 ± 3.0 days vs. FS 1.8 ± 1.8 days, p < 0.05), stroke (TCRAT 0% vs. FS 1.3%, p < 0.05), and hospital stay (TCRAT 10.9 ± 8.5 days vs. FS 13.2 ± 9.3 days, p < 0.05). There were no differences regarding atelectasis, reintubations, tracheostomies, ventilation time, and mortality.

 Pulmonary complications in terms of pleural effusions were more common with TCRAT, however, without substantial impact on clinical outcome.

Introduction With the global trend of aging populations, the number of nonagenarians diagnosed with malignancies, including lung cancer, is increasing. Despite advancements in minimally invasive surgical techniques, lung resection for nonagenarians remains rare due to concerns regarding comorbidities and surgical risks. This study evaluates the surgical outcomes of lung resection in nonagenarians and introduces a holistic assessment approach to optimize patient care. Methods A retrospective review of surgical records from January 2011 to December 2022 identified seven nonagenarians who underwent lung resection under 3-port video-assisted thoracoscopic surgery (VATS). Patient characteristics, surgical details, and postoperative outcomes were analyzed. To holistically evaluate each patient, multifaceted surgical tolerance and prognostic factors were summarized and visualized in a radar plot. Results The study cohort consisted of four males and three females aged 90 to 96 years. Wedge resection was performed in six patients, and one patient underwent lobectomy. Mediastinal lymph node dissection was not performed. The median duration of chest tube insertion was two days, and 86% of patients were discharged within one week. Postoperative complications were minimal, with one case of delirium and no occurrences of pneumonia. All patients were discharged in stable condition without deterioration of their activities of daily living. The median overall survival was 4.1 years. One patient succumbed to lung cancer progression, while the remaining patients exhibited favorable long-term survival without recurrence, including one patient whose lung tumor was a metastasis from colorectal cancer. As depicted in the radar plots, all patients had at least one risk factor other than their age. Conclusion Lung resection under a minimally invasive approach is feasible for carefully selected nonagenarians, yielding favorable short- and long-term outcomes. Because super-elderlies likely harbor multiple comorbidities, a holistic assessment of each patient is important for personalized patient care.

The integration of enhanced recovery after surgery (ERAS) protocols into the peri-operative management of video-assisted thoracic surgery (VATS) has facilitated rapid patient recovery, enabling discharge within 48 h. However, postoperative pulmonary complications (PPCs) postdischarge pose significant concerns for patient welfare. Despite the established utility of lung ultrasound (LUS) in diagnosing the causes of dyspnoea, the effectiveness of quantitative LUS in predicting PPCs after VATS remains uncertain.

To determine whether quantitative LUS performed 24 h after surgery can identify patients with a higher risk of developing PPCs within 30 days after discharge from hospital.

Single-centre prospective cohort study.

Academic tertiary care medical centre.

Adults scheduled for elective VATS under general anaesthesia from November 2022 to January 2023.

This primary aim was to verify the association between lung ultrasound score (LUSS) on postoperative day 1 (POD1) and PPCs. The secondary aim was to identify other relevant peri-operative factors closely related to PPCs and establish a model capable of predicting the risk of PPCs in patients undergoing fast-track VATS.

Of the 200 recruited patients, 182 completed the LUS examination and 30-day follow-up. Of these, 66 (36.2%) developed various types of PPCs. These patients had a higher LUSS on POD 1 ( P  < 0.001), and more subpleural consolidation areas compared to those without PPCs ( P  < 0.001). Receiver-operating characteristics (ROC) analysis identified the optimal LUSS cut-off value at 6 points for predicting the occurrence of PPCs, with an area under the curve (AUC) of 0.838 (95% CI, 0.768 to 0.909). Patients with PPCs had higher rates of immune system diseases and ARISCAT score, longer hospital stay and procalcitonin levels, increased frequency of lobar resection, longer durations of surgical and mechanical ventilation, and greater incidence of unplanned hospital readmissions within 30 days postdischarge, compared with those without PPCs (all P  < 0.001). Multivariable logistic regression analysis indicated that the comorbidity of immune system disease, along with postoperative 24 h LUSS, were independent risk factor for PPCs within 30 days after VATS.

LUSS on POD 1 emerged as an independent risk factor for PPCs in fast-track VATS patients and reliably predicted the occurrence of PPCs within 30 days of hospital discharge.

ClinicalTrials. gov No. ChiCTR2200065865.

Placing patients in the steep Trendelenburg position with a pressurised pneumoperitoneum during laparoscopic colorectal surgery increases pulmonary airway pressure, increasing the risks of lung injury and postoperative pulmonary complications, even in patients with healthy lungs.

The aim was to determine whether an integrated anaesthesia protocol was superior to traditional protective ventilation in terms of preventing pulmonary complications.

This study used a randomised, controlled, parallel-group design.

This single-centre trial was conducted at the National Cancer Centre/Cancer Hospital of the Chinese Academy of Medical Sciences from January to May 2023.

A total of 120 patients who underwent laparoscopic surgery for colorectal cancer with intermediate to high risk of pulmonary complications, as determined by the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score.

Participants were randomly assigned to either lung protective ventilation with a tidal volume of 6 ml kg-1 of predicted body weight + deep neuromuscular block (a train-of-four count of 0 and post tetanic of 1 to 2) + low peritoneal pressure (10 mmHg) or conventional pulmonary ventilation with a tidal volume of 8 ml kg-1 of predicted body weight + moderate neuromuscular block (a train-of-four count of 1 to 2) + standard peritoneal pressure (15 mmHg).

The primary outcome was the incidence of pulmonary complications within 30 postoperative days. The secondary outcomes included serological biomarkers of lung injury.

The lung protective group had a significantly lower incidence of pulmonary complications (15.0%) than the conventional group (38.3%; hazard ratio, 0.332; 95% CI, 0.153 to 0.718; P = 0.003). There were no significant differences in the plasma biomarker levels of soluble receptor for advanced glycation end products and angiopoietin-2 for lung injury between the groups. The treatment-by-covariate interactive analysis revealed that the lung-protective strategy conferred considerable benefits for males and individuals aged 60 years or above. A nomogram that predicted pulmonary complications incorporating four variables exhibited a strong discriminative performance, and the results of the decision curve analysis revealed the potential clinical value of this nomogram.

Compared with traditional strategies, the integrated lung-protective approach may mitigate pulmonary complications without causing lung injury in intermediate to high-respiratory-risk patients undergoing laparoscopic colorectal surgery.

Chinese Clinical Trial Register Identifier: ChiCTR2100054215.

Tumour-induced osteomalacia is a metabolic disorder that causes hypophosphataemia, resulting in bone mineralisation defects. If not treated definitively with tumour resection, this produces life-threatening anatomical changes. The anaesthetic management is tailored to address tumour location, perioperative positioning, as well as airway and pulmonary concerns.We report the anaesthesia delivery for the surgical excision of a tibial mass in a man in his late 30s with oncogenic osteomalacia. He had cervical spine deformity, pectus carinatum, severe kyphosis, lower limb atrophy with flexion contractures, severe restrictive lung disease and an inability to tolerate both lateral and sitting positions. Orthopaedic surgery was successfully done under peripheral nerve blockade and mild sedation, avoiding airway manipulation and the detrimental pulmonary effects of general anaesthesia.The physiological, anatomical and psychiatric issues governed the anaesthetic plan for the patient. While there are no established protocols for these cases, the basic goals of restfulness, analgesia, immobility and respiratory stability were achieved.

Postoperative patients constitute majority of critically ill patients, although factors predicting extubation failure in this group of patients remain unidentified. Aiming to propose clinical predictors of reintubation in postoperative patients, we conducted a post-hoc analysis of a multicenter prospective observational study.

This study included postoperative critically ill patients who underwent mechanical ventilation for > 24 h and were extubated after a successful 30-min spontaneous breathing trial. The primary outcome was reintubation within 48 h after extubation, and clinical predictors for reintubation were investigated using logistic regression analyses.

Among the 355 included patients, 10.7% required reintubation. Multivariable logistic regression identified that the number of endotracheal suctioning episodes during the 24 h before extubation and underlying respiratory disease or pneumonia occurrence were significantly associated with reintubation (adjusted odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.18, p < 0.001; adjusted OR 2.58, 95%CI 1.30-5.13, p = 0.007). The probability of reintubation was increased significantly with the higher frequency of endotracheal suctioning, as indicated by restricted cubic splines. Subgroup analysis showed that these predictors were consistently associated with reintubation regardless of the use of noninvasive respiratory support after extubation.

Endotracheal suctioning frequency and respiratory complications were identified as independent predictors of reintubation. These readily obtainable predictors may aid in decision-making regarding the extubation of postoperative patients.

The ARISCAT score, a prospectively developed generic classification for postoperative pulmonary complications (PPCs), has shown excellent predictive performance in general surgery. However, there is no reliable classification instrument for PPCs prediciton in thoracic surgery.

This study aimed to develop and validate a novel nomogram for estimating the risk of pulmonary complications in older patients (≥ 65 years) within 30 days after NCTS.

A nomogram was developed using predefined candidate predictors of 30-day PPCs. It was fitted with least absolute shrinkage and selection operator and logistic regression methods. Internal validation was performed using a bootstrap-resampling approach, while external validation used an independent, temporally separated cohort. The model's performance was assessed based on its discriminative potential (area under the receiver operating characteristic curve [AUC]), predictive ability (calibration plots), and clinical utility (net benefit).

In the development (n = 1449) and validation (n = 449) cohorts, 34.9% and 31.4% of patients, respectively, developed pulmonary complications 30 days post-surgery. The final nomogram incorporated eight predictors (age, surgical approach, desaturation of < 92% for more than 2 min, duration of surgery, smoking status, FEV1/FVC%, respiratory infection in the last 30 days, and neoadjuvant chemotherapy). The nomogram showed excellent discrimination (AUC = 0.866, 95% confidence interval [CI], 0.846-0.885), calibration (Hosmer- Lemeshow test, P = 0.97) and overall performance (Brier score = 0.014) in the development cohort. Similar results were observed in the external validation cohort (AUC = 0.825, 95% CI, 0.786-0.864). A decision curve analysis indicated that the nomogram offers a positive net benefit compared with the ARISCAT and LAS VEGAS scores.

This novel nomogram can reliably identify older patients with a high risk for pulmonary complications within 30 days after NCTS.

ChiCTR2100051170.

Postoperative pulmonary complications (PPCs) are frequent after abdominal surgery and significantly affect postoperative outcomes. Intraoperative protective ventilation (IPV) has been demonstrated to mitigate PPCs. However, the comparative effectiveness of two common IPV regimens-IPV with or without periodic lung recruitment manoeuvres (PLRM)-in preventing PPCs is unclear. This study aims to compare the effects of these two IPV regimens on PPCs.

This study is a prospective, double-blinded, randomised controlled trial. A total of 1060 patients at intermediate or high risk for PPCs, scheduled to undergo major abdominal surgery, will be enrolled and randomly assigned to receive either an IPV with PLRM (intensive IPV group) or an IPV without PLRM (moderate IPV group). Patients assigned to the intensive IPV group will receive positive end-expiratory pressure (PEEP) of 6-10 cm H2O with lung recruitment manoeuvres performed every 30 min. Patients in the moderate IPV group will receive the same level of PEEP without lung recruitment manoeuvres. Both groups will receive a tidal volume of 7 mL/kg predicted body weight and an inspired oxygen fraction of 0.3-0.4. The primary outcome is respiratory failure within the first 7 postoperative days. Secondary outcomes include other PPCs, extrapulmonary complications, unplanned admissions to the intensive care unit, length of postoperative hospital stay and mortality from any cause.

This protocol has been approved by the Ethics Committee of the Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. The first participant was recruited on 9 October 2022, with an estimated completion date of 30 May 2025. The results of this trial are expected to be published in peer-reviewed journals.

NCT05556174.

Upon the induction of general anesthesia, a predictable sequence of physiological changes occurs within the respiratory and neuromuscular systems. The sequelae of these changes include an assortment of postoperative pulmonary complications (PPCs), including postoperative respiratory depression (PORD), that are observed during the immediate postoperative period and in the post-anesthesia care unit (PACU). These adverse events are anticipated, because several of the drugs that are used during surgery (e.g., opioids, which are traditionally used to manage pain during and after surgery), albeit therapeutically beneficial, have these adverse effects as part of their pharmacology. Nevertheless, the effects are traditionally considered transitory. However, several studies provide evidence suggesting that PPC-related morbidity and mortality extend 30, 60, and even 90 days after discharge from the hospital. These studies are summarized and assessed in this narrative review. Although exact estimates vary depending on the definitions used, the type of surgery, patient population, and risk factors (such as age), it is clear that PORD and other PPCs can be severe postoperative complications with significant associated mortality risks that extend weeks to months after discharge from the hospital.

ObjectiveThe purpose of this study was to investigate the risk factors associated with postoperative pulmonary complications(PPCs) in critically ill patients transferred to intensive care unit(ICU) after abdominal surgery and develop a predictive model for this disease.MethodsData for 3716 patients who were admitted to ICU after abdominal surgery in Peking University People's Hospital between January 2015 and December 2020 were retrospectively collected and analyzed to identify the risk factors and develop a nomogram prediction model. Data for patients admitted to ICU following abdominal surgery at Peking University People's Hospital from March 2021 to December 2022 were prospectively collected as a validation set to validate and assess the model.Results10 independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model was constructed for PPCs in this group patients, the area under ROC curve was 0.771[95%CI: 0.756,0.786] and 0.759[95%CI: 0.726,0.792] in the training set and validation set, respectively.ConclusionsIn this study, independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model for PPCs in critically ill surgical population was constructed using these factors, demonstrating a good predictive value.

Patients with severe comorbidities and refractory lower leg and foot infections face high risks from prolonged anaesthesia and complex soft tissue reconstruction. Our institution collaborates with anaesthetists to perform limb salvage using free flaps, primarily under combined spinal-epidural anaesthesia (CSE) without general anaesthesia (GA). This study aimed to evaluate the treatment outcomes of our limb salvage algorithm in high-risk patients.

Between January 2020 and December 2023, we included patients with ASA class III or higher undergoing limb salvage for chronic osteomyelitis or diabetic gangrene, who desired limb preservation, had palpable main arteries and no urgent cardiovascular conditions. We investigated 12 patients with 13 limbs and 14 free flaps who underwent infection control and free flap reconstruction under CSE without GA.

Among the 14 free flaps, 9 were ASA class III and 5 were class IV. The median anaesthesia time was 562 min and median surgical time was 479 min. All flap surgeries, except for one, required no vasopressor usage to control intraoperative hypotension. Partial necrosis occurred in 2 flaps, but all flaps survived. One limb with recurrent osteomyelitis required a vascularised fibula graft. No severe systemic complications were observed, and all limbs were preserved with weight-bearing function in 11 of 13 limbs (85%).

Our treatment algorithm using CSE without GA for severe lower limb infections demonstrates that limb salvage can be safely achieved by preventing flap necrosis and systemic complications.

Postoperative pulmonary complications (PPCs), such as pneumonia, atelectasis, and respiratory failure, pose a significant challenge, particularly in patients with compromised respiratory function. Regional anesthesia is well-known for its numerous advantages, including its effectiveness in mitigating PPCs by circumventing the need for general anesthesia and intubation. A 79-year-old man with no significant medical history other than chronic obstructive pulmonary disease presented with left lower limb swelling, gait disturbance, and cold sensation. Computed tomography revealed a 5 cm left popliteal artery aneurysm, which was diagnosed as the cause of the patient's symptoms. He underwent popliteal artery aneurysm repair using peripheral nerve blocks (PNBs) and sedation. Sciatic, femoral, and obturator nerve blocks with 0.25% levobupivacaine provided effective analgesia. Despite intraoperative challenges, such as elevated partial pressure of carbon dioxide (PaCO2) and prolonged operative time due to vascular reconstruction revisions, the patient remained hemodynamically stable throughout the procedure, and PNBs allowed the preservation of spontaneous respiration. The patient was discharged on postoperative day 15 without pneumonia or respiratory failure. This case underscores the utility of PNBs and sedation in mitigating PPCs like pneumonia.

Postoperative Pulmonary Complications (PPC) are a significant source of increased morbidity and mortality after surgical procedures. Measures to enhance 30-day PPC risk stratification are an area of significant clinical interest, and integrating common preoperative investigations, such as echocardiography, may enhance quantitative risk prediction when combined with clinical score-based systems, particularly for high-risk populations. The authors hypothesized that Right Ventricular Systolic Pressure (RVSP) would significantly enhance the predictive capabilities of the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score in the prediction of 30-day PPC in a Pulmonary Hypertension (PH) study cohort.

277 patients with the diagnosis of PH, ARISCAT score, and echocardiography-derived RVSP within 12-months of surgical procedure were analyzed. The primary endpoint was the 59-variable 30-day Agency for Healthcare Research and Quality PPC composite. Secondary endpoints included sub composites of Pneumonia (PNA), Respiratory Failure (RF), Pulmonary Aspiration (ASP) and thromboembolic Phenomenon (PE). Adjusted multivariable logistic regression models followed by Receiver Operating Characteristic Curves (ROC) and Area Under the Curve (AUC) analysis were employed to assess the prediction of 30-day PPC.

Mean RVSP was 52.1 mmHg (±17.4). Overall PPC incidence was 29.9%, with RF (19.5%), PNA (12.3%), ASP (5.4%), and PE (3.6%) composites. Logistic regression showed no significant association between RVSP and PPC (Odds Ratio [OR = 1.01], p = 0.307). The ARISCAT score was associated with 30-day PPC risk (OR = 1.02, p = 0.037). Receiver Operating Characteristic (ROC) curve analysis revealed an Area Under the Curve (AUC) of 0.555 for RVSP alone, 0.575 for the ARISCAT score, and 0.591 for the combination of RVSP+ARISCAT for the primary endpoint.

RVSP demonstrated limited efficacy as a standalone predictor of 30-day PPC in patients with PH. Although integrating RVSP with ARISCAT scoring yielded marginal improvements in predictive accuracy, neither metric, independently or in combination, achieved adequate clinical significance for reliable risk stratification. These findings highlight a critical gap in the current preoperative risk assessment for PH-specific predictive tools. Future research should focus on alternative measures that better capture vulnerability to the hemodynamic complexities underscoring PPC in this high-risk population.

Prior research on postoperative pneumonia (POP) risk models focused on preoperative factors but overlooked intraoperative variables vital for precision. These models also neglected the higher-risk elderly population. This study seeks to develop and evaluate preoperative and combined models to predict POP risk in elderly patients undergoing non-cardiothoracic surgery.

A retrospective cohort of 444 patients who underwent non-cardiothoracic surgery at Nanjing First Hospital from March 2021 to April 2022 was included. Univariate analysis and Least Absolute Shrinkage and Selection Operator (LASSO) regression were employed to develop preoperative and combined logistic regression models.

The area under the receiver operating characteristic curve for both models exceeded 0.80, indicating excellent discriminatory ability. Furthermore, the combined model demonstrated superior predictive accuracy compared to the preoperative model.

This study developed preoperative and combined nomograms that offer practical and innovative tools for clinicians to predict POP risk and improve patient care.

Postoperative complications after major surgery, especially in vascular procedures, are associated with a significant increase in costs and mortality. Postoperative pulmonary complications (PPCs) have a notable impact on morbidity and mortality. The primary aim of this present study was to evaluate the effects of spinal anesthesia compared with general anesthesia on the incidence of PPCs in patients undergoing lower extremity bypass surgery.

This study was designed as a prospective, randomized controlled clinical trial with 2 parallel arms.

Two tertiary teaching hospitals.

We enrolled 128 adult patients with American Society of Anesthesiologists status II to IV who were scheduled to undergo elective lower extremity arterial bypass surgery.

Patients were assigned randomly to receive either general anesthesia or spinal anesthesia.

The primary outcome was the incidence of PPCs and secondary end points included hemodynamic and blood gas analysis perioperatively. A total of 128 patients were included in the study, with 123 patients completing the study protocol. Approximately 26.7% of patients who received general anesthesia experienced PPC, compared with 12.7% of those who received spinal anesthesia (p = 0.051). Patients who underwent spinal anesthesia had a lower incidence of hypotension and required fewer intraoperative vasoactive drugs (p < 0.001).

In this study, spinal anesthesia did not significantly reduce the incidence of PPCs in patients undergoing peripheral vascular surgery compared with general anesthesia. Neuraxial anesthesia may reduce the incidence of hypotension and the need for hemodynamic pharmacological support in patients undergoing peripheral arterial surgery, although further dedicated studies are required to validate these findings.

Enhanced respiratory muscle management is imperative in cardiac surgery patients due to their universal risk of decreased perioperative respiratory muscle strength.

Most existing articles primarily examine respiratory muscle exercise during either the preoperative, postoperative, or at-home phases. Consequently, there is a crucial need to consolidate the evidence for respiratory muscle exercise throughout the perioperative period of cardiac surgery.

A literature search was performed, encompassing guideline networks and databases up until July 2023. The literature was classified into seven thematic categories: preoperative assessment, patient education, trainers, training plans, quality control, safety monitoring, and outcome assessment. The quality of the included literature was assessed using the GRAGE evidence grading system to ascertain the level of recommendation associated with each piece of evidence.

Nineteen papers were reviewed, encompassing 24 suggestions. These consisted of two suggestions on preoperative assessment, four on patient education, two on trainers, six on training programs, seven on quality control, two on safety monitoring, and one on outcome assessment. All 24 suggestions were categorized as strong recommendations, with 14 classified as high-quality evidence and ten as moderate-quality evidence.

Our study presents a succinct synthesis of the most robust evidence available on perioperative respiratory muscle exercise in cardiac surgery patients. We identified ten high-quality suggestions while an additional 14 moderate-quality suggestions. In the context of perioperative exercise, we recommend that moderate-intensity inspiratory muscle exercises be provided during the preoperative and postoperative phases upon transfer to the ward. We advocate for the implementation of low-intensity inspiratory muscle exercises during the postoperative phase while patients are in the intensive care unit.

Elderly adults with hip fractures are particularly vulnerable to perioperative pulmonary complications (POPCs) throughout the surgical process. While most studies have focused on predicting postoperative pulmonary complications (PPCs), there has been a lack of focus on preoperative and intraoperative phases. To address this gap, this bidirectional cohort study aims to develop and validate a predictive model for POPCs across all surgical stages in elderly patients with hip fracture. This study will involve 3481 patients, with 1914 in the retrospective dataset and 1567 in the prospective dataset, and will analyse 44 perioperative risk factors. LASSO and multiple logistic regression will be used to identify key predictors, and nomogram prediction models will be constructed via the RMS packages. The accuracy and variability of the model will be assessed using receiver operating characteristic (ROC) curve analysis and calibration plots. The primary outcome measure is the incidence of pulmonary complications from hospital admission to 30 days post-surgery, and the secondary outcomes include complications such as heart failure, myocardial infarction, renal failure, deep venous thrombosis, stroke, and death within 30 days post-surgery. This study aims to construct a comprehensive model for predicting POPCs in this patient population and verify its accuracy and ability to differentiate POPCs using both internal and external data.

Klebsiella pneumoniae is a Gram-negative bacterium and the third most commonly isolated microorganism in blood cultures from septic patients. Despite extensive research, the mechanisms underlying K. pneumoniae-induced sepsis and its pathogenesis remain unclear. Acute respiratory failure is a leading cause of mortality in systemic K. pneumoniae infections, highlighting the need to better understand the host immune response and bacterial clearance mechanisms.

To investigate the impact of K. pneumoniae infection on organ function and immune response, we utilized a systemic infection model through intraperitoneal injection in mice. Bacterial loads in key organs were quantified, and lung injury was assessed. Survival analysis was performed in wild-type (WT) and gene deficient mice. Mitochondrial damage and reactive oxygen species (ROS) production, as well as cytokine levels were measured in macrophages isolated from these mice to evaluate their contribution to bacterial clearance capacity.

Our findings demonstrate that K. pneumoniae systemic infection results in severe lung injury and significant bacterial accumulation in multiple organs, with the highest burden in the lungs. Deficiency of caspase-11 or NLRP3 led to prolonged survival, a reduction in pulmonary bacterial load, increased blood oxygen levels, and decreased IL-6 levels in the lungs compared to WT controls. Furthermore, caspase-11- and NLRP3-deficient macrophages exhibited elevated mitochondrial ROS production in response to K. pneumoniae, which correlated with more effective bacterial clearance.

These results suggest that caspase-11 and NLRP3 contribute to K. pneumoniae-induced sepsis by impairing mitochondrial function and reducing ROS production in macrophages, thereby compromising bacterial clearance. The observed reduction in lung injury and increased survival in caspase-11- and NLRP3-deficient mice indicate that targeting these pathways may offer potential therapeutic strategies to improve host defense against systemic K. pneumoniae infection.

Iron deficiency anemia in the perioperative setting is treated predominantly with intravenous iron formulation, of which ferric carboxymaltose may induce hypophosphatemia by modulating fibroblast growth factor 23.

In this single-center, prospective, randomized, double-blind trial, we consented 92 adult patients scheduled for elective major abdominal or thoracic surgery. These patients either had isolated iron deficiency (plasma ferritin <100 ng/mL or transferrin saturation < 20 %) or iron deficiency anemia (hemoglobin (Hb) 100-130 g/L with plasma ferritin <100 ng/mL or transferrin saturation < 20 %). Preoperatively, participants received a single preoperative intravenous dose of ferric carboxymaltose and were then randomly assigned to receive either phosphate or placebo, administered orally three times a day for 30 days corresponding to an 18 mmol dose of daily phosphate supplementation in the intervention group. The primary endpoint was the minimum serum phosphate concentration during follow-up visits. The key secondary efficacy endpoint was mean perioperative hemoglobin concentration of postoperative days 0, 2 and 4, assessing the non-inferiority of additional phosphate supplementation.

We randomly consented 46 patients in each group (mean ± SD age 56 ± 17 years, 57 % female). Minimal phosphate concentration was 0.49 ± 0.21 mmol/L in the treatment group and 0.42 ± 0.17 mmol/L in the placebo group (p = 0.12, two-sided p-value). Average mean hemoglobin was 110 ± 16 g/L in the treatment and 113 ± 13 g/L in the placebo group (p = 0.023, one-sided p-value for non-inferiority). Hypophosphatemia occurred in 32 patients (70 %) of the treatment group and in 39 patients (85 %) of the placebo group (odds ratio 0.15, 95 % CI from 0.02 to 0.77, p = 0.014). Secondary outcomes, such as rescue medication use, core muscle strength and MOCA test scores, did not differ between groups.

Co-administration of oral phosphate supplementation to ferric carboxymaltose cannot prevent hypophosphatemia. However, hypophosphatemia occurs in fewer patients. Phosphate co-administration did not impede the treatment of iron deficiency anemia with ferric carboxymaltose.

Although baby boomer generation accounts for a little more than 15% of the US population, the cohort represents a disproportionate percentage of patients undergoing surgery. As this group continues to age, a multitude of challenges have arisen in health care regarding the safest and most effective means of providing anesthesia services to these patients. Many older adults patients may be exquisitely sensitive to the effects of anesthesia and surgery and may experience cognitive and physical decline before, during, or after hospital admission. In this review article, the authors briefly examine the physiologic processes underlying aging and explore steps necessary to deliver safe, empathetic care.

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

Despite the maturity and sophistication of anaesthesia workstations, improvements in our understanding of intraoperative mechanical ventilation, and use of less invasive surgical techniques, postoperative pulmonary complications (PPCs) are still a common problem in surgical patients of all ages. PPCs are associated with a higher incidence of perioperative morbidity and mortality, longer hospital stays, and higher healthcare costs. PPCs are strongly associated with anaesthesia-induced atelectasis, which predisposes to lung damage when partially collapsed lungs are subjected to mechanical ventilation. Lung protective ventilation is thus a modifiable factor that can positively impact the incidence of PPCs after surgery. Intraoperative protective ventilation strategies have been based on two main but intrinsically different hypotheses: one based on sole reduction of tidal volume and pressures, using minimal positive end-expiratory pressure (PEEP), tolerating the presence of lung collapse, and the other also limiting tidal volume and pressures after actively resolving atelectasis by lung recruitment and PEEP individualisation, the individualised open-lung approach. We review the concepts of the individualised open-lung approach, its potential benefits, and outstanding questions. We conclude with a proposal for personalised lung protective ventilation.

The impact of distinct primary colorectal cancer (CRC) sites on lung injury and complications remains largely unexplored, despite the palpable differences in surgical positions, procedures, and the resulting mechanically induced respiratory pressures at each site.

This study employed a forwards-looking approach utilising the propensity score matching (PSM) method; 300 patients with pathological CRC after laparoscopic surgery from April 2019 to May 2023 were enrolled. Two categories were bifurcated based on their surgical locations: the rectosigmoid colon (RSC) group and the descending/ascending colon (DAC) group, with a 2:1 ratio. The occurrence of postoperative pulmonary complications (PPCs) within a 30-day postoperative period was meticulously evaluated. Additionally, assessments have been performed for plasma biomarkers of immune response dynamics and lung injury (plasma soluble advanced glycation end-product receptor [sRAGE], angiopoietin-2 [ANG-2], interleukin-1β/6 [IL-1β/IL-6]) and other parameters.

Although the increase in postoperative lung epithelial damage, as indicated by the plasma sRAGE levels, was significant in the RSC group (DAC vs. RSC; 1029.6 [576.8-1365.2] vs. 1271.6 [896.3-1587.6]; odds ratio=0.999; 95% CI: 0.998 to 1.000; P=0.007), a significantly increased percentage of PPCs was observed in the DAC group (DAC vs. RSC; hazard ratio=1.669; 95% CI, 1.141 to 2.439; P=0.008). A univariate Cox proportional hazards model revealed that sRAGE, ANG-2, IL-1β, and IL-6 levels were not correlated with the incidence of time-to-PPCs across the two cohorts (P>0.05). Propensity score-weighted Cox regression and causal mediation analysis further demonstrated that the DAC site directly affected the incidence of PPCs, regardless of the other baseline confounders and clinical covariates related to the tumour site and PPCs.

The primary site of CRC is an independent predictor of the development of PPCs. Despite the steep Trendelenburg position of the RSC group inciting more pulmonary stress, inflammation and lung epithelial injury, as indicated by higher sRAGE, it demonstrated a lower PPCs occurrence relative to its DAC counterpart, with a slightly inclined or reversed Trendelenburg position. None of the plasma biomarkers of inflammation or lung injury indicated sufficient prognostic value for PPCs.

To investigate the incidence rate, risk factors, and clinical implications of postoperative pulmonary complications (PPCs) in patients undergoing colorectal cancer surgery (CRC). The study extracted data from the National Inpatient Sample (NIS) between 2010 and 2019. Patients' data were analyzed to identify predictors of PPCs, and the association between possible factors and PPCs were also assessed. A total of 169,067 CRC surgery patients were included and 15,494 (9.16%) were diagnosed with PPCs in the study. Our study found that age, gender, number of comorbidities, type and location of hospital, and certain preoperative comorbidities, such as fluid and electrolyte disorders (odd ratio [OR] 2.53), coagulopathy (OR 2.16), congestive heart failure (OR 1.91), and chronic pulmonary disease (OR 1.57) were the risk factors of PPCs. In addition, postoperative complications, such as continuous mechanical ventilation (OR 8.18), sepsis (OR 4.46), deep vein thrombosis (OR 4.17) and shock (OR 4.07) were the most important risk factors of PPCs. PPCs prolonged the length of hospital stay (14 days vs. 6 days) and led to a higher mortality rate (13.04% vs. 1.20%). Optimizing perioperative care practices are essential steps to reduce the incidence rate of PPCs in CRC patients.

Laparoscopic-assisted single-port mediastinoscopic esophagectomy is a safe and effective emerging minimally invasive esophagectomy, but little has been reported about the learning curve for this technology. The goal of the study was to determine the number of procedures to achieve different levels of proficiency on the learning curve.

This study retrospectively analyzed data from consecutive surgeries performed by the same surgeon at the same center from 2016 to 2021. Learning curves were quantitatively assessed by unadjusted cumulative sums, different segments were derived using jointpoint linear regression analysis, and variables were compared between subgroups using trend analysis.

The learning curve could be divided into 3 different proficiency stages: the 1st-91st, 91st-125th, and 125th-182nd procedures comprised the preliminary, transition, and proficient stages, respectively. Compared with the preliminary stage, the procedure time [275 (250-300) vs 178.5 (161.5-205.0) min, P < .001], bleeding volume [100 (100-200) vs 50 (50-80) mL, P < .001], postoperative hospital stays [15 (13-31) vs 13 (11-17) d, P = .006], and the incidence of anastomotic fistula(20.9% vs 5.2%, P = .017) were significantly lower in the proficiency stage, whereas the number of harvested total lymph nodes [17 (12-23) vs 22 (16-29), P = .002], total mediastinal lymph nodes [7 (5-11) vs 13 (9-18), P < .001] and the rate of recurrent laryngeal nerve lymph node harvest (71.4% vs 96.6%, P < .001) was significantly higher.

There may be 3 stages of varying proficiency in the learning curve of laparoscopic-assisted single-port mediastinoscopic esophagectomy. Approximately 91 consecutive procedures were required to overcome the preliminary stage, whereas proficiency in this technique required approximately 125 consecutive procedures.

Postoperative pulmonary complications (PPCs) significantly impact surgical outcomes, and Controlling Nutritional Status (CONUT) score, a simple and easily available nutritional score, has been demonstrated to be significantly associated with postoperative patient outcomes and complications, including PPCs. However, there are few studies that specifically focus on patients undergoing radical surgery for colorectal cancer (CRC).

We retrospectively analyzed the clinical data of 2,553 patients who underwent radical surgery for CRC at the Sixth Affiliated Hospital of Sun Yat-sen University. Patients were divided into three groups: normal nutrition group (CONUT≤1), mild malnutrition group (2 ≤ CONUT≤4), and moderate-to-severe malnutrition group (CONUT≥5). Risk factors for PPCs and all-cause mortality were evaluated by multivariate regression. In addition, we assessed surgical outcomes including ICU admission, hospital stay, 1-year mortality and tumor-related mortality.

The incidence of PPCs was 9.0% (n = 230). Multiple regression showed that the higher the CONUT score, the higher the risk of PPCs (mild malnutrition group vs. normal nutrition group, OR: 1.61, 95% CI: 1.18-2.20, p = 0.003; moderate-to-severe malnutrition group vs. normal nutrition group, OR: 2.41, 95% CI: 1.51-3.84, p < 0.001). All-cause mortality was significantly higher in moderate-to-severe malnutrition group than that in normal nutrition group, HR: 1.88, (95% CI: 1.34-2.62, p < 0.001). Older age, male sex, chronic heart disease, open surgery, blood transfusion during surgery, distant metastasis of tumor and colon tumor were all risk factors for PPCs. Furthermore, the malnutrition groups had poor surgical outcomes including postoperative pneumonia (mild vs. normal nutrition, OR: 1.64, 95% CI: 1.07-2.52, p = 0.024; moderate-to-severe vs. normal nutrition, OR: 2.51, 95% CI: 1.36-4.62, p = 0.00), ICU admission (mild vs. normal nutrition, OR: 2.16, 95% CI: 1.31-3.56, p = 0.002; moderate-to-severe vs. normal nutrition, OR: 3.86, 95% CI: 2.07-7.20, p < 0.001), hospital stay ≥14 days (mild vs. normal nutrition, OR: 1.30, 95% CI: 1.08-1.56, p = 0.006) and 1-year mortality (mild vs. normal nutrition, HR: 1.65, 95% CI: 1.11-2.46, p = 0.014; moderate-to-severe vs. normal nutrition, HR: 2.27, 95% CI: 1.28-4.02, p = 0.005).

The preoperative CONUT score is a potential indicator for predicting PPCs and surgical outcomes in CRC patients.

Lung ultrasound-guided alveolar recruitment manoeuvres (RMs) may reduce the lung ultrasound score. However, whether the use of this strategy can reduce the incidence of postoperative pulmonary complications (PPCs) in the adult obese population has not yet been tested.

This is a single-centre, two-arm, prospective, randomised controlled trial. A total number of 476 obese patients scheduled for bariatric surgeries will be enrolled. They will be randomly assigned to receive either lung ultrasound-guided RMs (intervention group) or conventional RMs (control group) intraoperatively. The occurrence of PPCs will be recorded as the primary outcome.

To the best of our knowledge, this is the first trial to test the effect of lung ultrasound-guided RMs on PPCs. The results of this trial will support the anaesthesiologists in choosing a potentially more efficient method to perform RMs for bariatric surgery patients.

www.chictr.org.cn ChiCTR2400080203. Registered on 23 January 2024.

This study aimed to investigate whether driving pressure-guided ventilation can reduce postoperative pulmonary complications in patients who have undergone heart transplantation. Patients who underwent orthotopic heart transplantation were divided into two groups according to the perioperative ventilation strategy: (1) conventional lung-protective ventilation (group C) and (2) driving pressure-guided ventilation (group D). The primary outcome was the occurrence of postoperative pulmonary complications within 30 days of surgery. Univariate and multivariate logistic regression analyses were performed to evaluate the independent risk factors associated with postoperative pulmonary complications (PPCs). Compared with group C, patients in group D exhibited lower driving pressure. Oxygenation improved significantly in the early period after surgery in patients in group D. Group C exhibited a higher number of patients with postoperative pulmonary complications, especially respiratory infections and atelectasis. Patients in group D experienced a shorter duration of postoperative mechanical ventilation and a shorter stay in the intensive care unit. The conventional ventilation strategy, the high driving pressure level and the low PaO2 value at the end of the surgery were the independent risk factors for PPCs in heart transplantation. Compared with conventional lung-protective ventilation, driving pressure-guided ventilation was associated with improved pulmonary oxygenation and lower incidences of pulmonary complications among patients after heart transplantation.