Long-term postoperative pneumonia in elderly patients with early gastric cancer

Risk factors for pneumonia after radical gastrectomy for gastric cancer: a systematic review and meta-analysis

OBJECTIVE

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

A nomogram to predict pulmonary complications after gastrointestinal surgery: a retrospective study

OBJECTIVE

We aimed at developing a nomogram able to predict postoperative pulmonary complications (PPC) after gastrointestinal surgery.

METHODS

We retrospectively analyzed the clinical data of patients who underwent gastrointestinal surgery at Jiangnan University Affiliated Hospital from December 2017 to May 2022. Patients were randomly divided into training cohort and validation cohort at a 7:3 ratio. The training cohort is divided into PPC group and Non-PPC group. The Least Absolute Shrinkage and Selection Operator (LASSO) method and logistic regression were used to determine the independent risk factors. The identified risk factors were used to construct a nomogram model for predicting the risk of PPC after gastrointestinal surgery. The nomogram model was validated by the area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA).

RESULTS

A total of 563 patients were admitted. The incidence of PPC was 17.6% (99/563). In the training cohort, multiple logistic regression showed that age, hypertension, history of respiratory diseases, preoperative albumin, intraoperative blood loss, postoperative intensive care unit (ICU) time, postoperative arterial oxygen partial pressure (PaO2), and postoperative tracheal intubation time were identified as the influencing factors of PPC (P < 0.05). We constructed a nomogram model for predicting the PPC of the training cohort, with a C-index of 0.857 (95%CI 0.812-0.902). In the validation cohort, the C-index of the model is 0.936 (95%CI 0.890-0.982). The ROC curve of the training cohort is 0.875 (95%CI 0.832-0.918), similar with validation cohort 0.929 (0.876-0.982). The calibration curve indicates that the predicted results are correlated with the observed results.

CONCLUSIONS

The constructed nomogram model has certain predictive value, and can provide a scientific reference for predicting the occurrence of PPC after gastrointestinal surgery.

Sarcopenia and risk of postoperative pneumonia: a systematic review and meta-analysis

BACKGROUND

Identifying patients at risk for postoperative pneumonia and preventing it in advance is crucial for improving the prognoses of patients undergoing surgery. This review aimed to interpret the predictive value of sarcopenia on postoperative pneumonia.

METHODS

Science Citation Index Expanded (SCIE), Embase, Medline, and Cochrane Central Register of Controlled Trials were searched from inception to August 2nd, 2023 to retrieve eligible studies. The risk of bias was assessed by the Newcastle-Ottawa Scale (NOS). For each study, we computed the odds ratio (OR) and 95% confidence interval (CI) for postoperative pneumonia in patients with and without preoperative sarcopenia, and the I-squared (I2) test was employed to estimate heterogeneity.

RESULTS

The search identified 6530 studies, and 32 studies including 114,532 participants were analyzed in this review. In most of the studies included, the risk of bias was moderate. The most reported surgical site was the chest and abdomen, followed by the abdomen, chest, limbs and spine, and head and neck. Overall, patients with preoperative sarcopenia have a 2.62-fold increased risk of developing postoperative pneumonia compared to non-sarcopenic patients [OR 2.62 (I2 = 67.5%, 95%CI 2.04-3.37). Subgroup analysis focusing on different surgical sites revealed that sarcopenia has the strongest predictive effect on postoperative pneumonia following abdominal surgery (OR 4.69, I2 = 0, 95% CI 3.06-7.19). Subgroup analyses targeting different types of research revealed that sarcopenia has a stronger predictive effect on postoperative pneumonia in prospective studies (OR 5.84 vs. 2.22).

CONCLUSIONS

Our research findings indicate that preoperative sarcopenia significantly increases the risk of postoperative pneumonia. Future high-quality prospective studies and intervention studies are needed to validate the relationship between sarcopenia and postoperative pneumonia and improve patient outcomes.

Risk factors for postoperative pneumonia in older adults aged ≥ 80 years with gastric cancer

BACKGROUND

In Japan, the proportion of elderly gastric cancer patients is increasing. Although surgery in patients aged ≥ 80 years is relatively safe, postoperative pneumonia often occurs, reducing quality of life and being fatal. We retrospectively investigated the risk factors for pneumonia after gastrectomy in elderly patients at our hospital.

METHODS

Between 2010 and 2019, 113 patients aged ≥ 80 years underwent gastrectomy for gastric cancer at our hospital. Of these, 88 patients were retrospectively investigated, excluding 25 patients who did not receive sufficient postoperative follow-up. The diagnosis of pneumonia was based on chest CT findings. Univariate and multivariate analyzes for risk factors of pneumonia were performed using the Cox proportional hazards model.

RESULTS

The patients were aged 80-93 years (median 83 years) and consisted of 63 males and 25 females. The surgical procedures included distal gastrectomy in 54, total gastrectomy in 25, proximal gastrectomy in two, and local resection in seven. Postoperative pneumonia was observed in 38 patients. Seventeen of them died from pneumonia. The time to onset of pneumonia was 0.2-144.6 months (median 12.0 months), and the median observation period for patients without pneumonia was 38.8 months. Multivariate analysis revealed that age, Geriatric Nutritional Risk Index, respiratory history, and extent of gastrectomy (total vs. distal: hazard ratio 3.91, 95% confidence interval 1.69-9.02) were independent pneumonia factors.

CONCLUSIONS

In patients aged ≥ 80 years, age, low nutritional status, respiratory history, and total gastrectomy were risk factors for postoperative pneumonia.

Geriatric prognostic scoring system predicts survival after hepatectomy for elderly patients with liver cancer

Aim

The number of elderly patients with liver cancer is increasing with the aging society. The Geriatric Prognostic Scoring System is useful in predicting the postoperative prognosis for elderly patients with gastrointestinal cancer. The aim of the present study was to assess the predictive ability of the geriatric prognostic scoring system for postoperative survival in elderly patients with liver cancer.

Methods

Eighty-eight patients aged ≥75 years who were treated for primary liver cancer and metastatic liver tumor were retrospectively analyzed. The Geriatric Prognostic Score (GPS) was created by several clinical parameters such as age, sex, type of cancer, stage, performance status, body mass index, and comprehensive geriatric assessment. Each patient was divided into two groups of high-risk to low-risk according to their GPS: ≧30 high-risk group and <30 low-risk. The predictive ability of geriatric prognostic scoring system for postoperative survival was assessed in univariate and multivariate analyses.

Results

Of the 88 patients, 75 were diagnosed as hepatocellular carcinoma and 13 as colorectal liver metastasis. After geriatric prognostic scoring system assessments, 26 patients were diagnosed as high-risk and the remaining 62 as low-risk. The 3-year overall survival rates were 78.5% in the low-risk group and 35.1% in the high-risk group (p < 0.001). The univariate and multivariate analyses of overall survival identified high GPS as an independent significant factor (p < 0.001).

Conclusions

We could conclude that the geriatric prognostic scoring system is useful in predicting patients' prognosis after hepatectomy and it can provide helpful information to surgeons for determining treatment strategies for elderly patients with liver cancer.

The emerging role of medical foods and therapeutic potential of medical food-derived exosomes

Medical food is consumed for the purpose of improving specific nutritional requirements or disease conditions, such as inflammation, diabetes, and cancer. It involves partial or exclusive feeding for fulfilling unique nutritional requirements of patients and is different from medicine, consisting of basic nutrients, such as polyphenols, vitamins, sugars, proteins, lipids, and other functional ingredients to nourish the patients. Recently, studies on extracellular vesicles (exosomes) with therapeutic and drug carrier potential have been actively conducted. In addition, there have been attempts to utilize exosomes as medical food components. Consequently, the application of exosomes is expanding in different fields with increasing research being conducted on their stability and safety. Herein, we introduced the current trends of medical food and the potential utilization of exosomes in them. Moreover, we proposed Medi-Exo, a exosome-based medical food. Furthermore, we comprehensively elucidate various disease aspects between medical food-derived exosomes (Medi-Exo) and therapeutic natural bionanocomposites. This review highlights the therapeutic challenges regarding Medi-Exo and its potential health benefits.

Pneumonia Risk Increased by Dementia-Related Daily Living Difficulties: Poor Oral Hygiene and Dysphagia as Contributing Factors

OBJECTIVE

Although pneumonia is the leading cause of death among patients with dementia, the specific underlying causes remain unclear. In particular, the potential connection between pneumonia risk and dementia-related daily living difficulties, such as oral hygiene practice and mobility impairment, and the use of physical restraint as a management practice, has not been extensively studied.

METHODS

In our retrospective study, we included 454 admissions corresponding to 336 individual patients with dementia who were admitted to a neuropsychiatric unit due to behavioral and psychological symptoms. The admissions were divided into two groups: those who developed pneumonia while hospitalized (n=62) and those who did not (n=392). We investigated differences between the two groups in terms of dementia etiology, dementia severity, physical conditions, medical complications, medication, dementia-related difficulties in daily living, and physical restraint. To control potential confounding variables, we used mixed effects logistic regression analysis to identify risk factors for pneumonia in this cohort.

RESULTS

Our study found that the development of pneumonia in patients with dementia was associated with poor oral hygiene, dysphagia, and loss of consciousness. Physical restraint and mobility impairment showed a weaker, nonsignificant association with the development of pneumonia.

CONCLUSIONS

Our findings suggest that pneumonia in this population may be caused by two primary factors: increased pathogenic microorganisms in the oral cavity due to poor hygiene, and an inability to clear aspirated contents due to dysphagia and loss of consciousness. Further investigation is needed to clarify the relationship between physical restraint, mobility impairment, and pneumonia in this population.

Acceleration of sarcopenia in elderly patients who develop asymptomatic pneumonia shadow within one year after surgery for early gastric cancer

BACKGROUND

Although early gastric cancer is curable with local treatment, the overall survival in elderly patients did not reach 80% at five years after surgery. The major cause of death in elderly patients with early gastric cancer is not cancer itself but is related to postoperative sarcopenia. Elderly patients frequently develop postoperative asymptomatic pneumonia shadow, which is associated with a poor prognosis. However, why asymptomatic pneumonia shadow worsens the prognosis remains unclear. We investigated whether sarcopenia is accelerated in patients who developed asymptomatic pneumonia shadow.

METHODS

We retrospectively examined patients of > 75 years of age who underwent R0 gastrectomy for gastric cancer and were diagnosed with T1 disease at National Cancer Center Hospital between 2005 and 2012. The diagnosis of asymptomatic pneumonia shadow was defined by diagnostic findings of pneumonia (consolidation type, reticular type, and nodular type) which were newly observed on chest computed tomography performed one year after surgery in comparison to preoperative computed tomography. Postoperative muscle loss was assessed by a computed tomography-based analysis using the L3 skeletal muscle index before and two years after surgery and the rate of decrease was calculated. Patients were classified into two groups according to the rate of decrease (cut-off value: 10%).

RESULTS

Of the 3412 patients who underwent gastrectomy in our hospital during the study period, 142 were included in this study. Asymptomatic pneumonia shadow was found in 26 patients (18%). Patients who developed asymptomatic pneumonia shadow showed a significantly greater loss of muscle volume in comparison to patients who did not develop asymptomatic pneumonia shadow. In the multivariate analysis, total gastrectomy and asymptomatic pneumonia shadow were the independent risk factors for severe muscle loss. However, there was no significant difference in prognosis between the two groups.

CONCLUSIONS

Sarcopenia was accelerated in elderly patients who developed asymptomatic pneumonia shadow after surgery for early gastric cancer. However, the poor prognosis in these patients may not be related to accelerated sarcopenia.

Causes of Death Following Gastric Cancer Diagnosis: A Population-Based Analysis

BACKGROUND Causes of death (CODs) in patients with gastric cancer (GC) need to be studied. We examined the cancer-specific and non-cancer deaths among patients diagnosed with GC from 1975 to 2019. MATERIAL AND METHODS We obtained medical records from the Surveillance, Epidemiology, and End Results (SEER) database. We used SEER*Stat software to calculate standardized mortality ratios (SMRs) for specific CODs and performed a competing risk analysis to evaluate the cumulative mortality of specific CODs. RESULTS The final study cohort included 42 813 patients with GC, with a mean age at diagnosis of 67.7 years. As the end of 2021, a total of 36 924 (86.2%) patients died. Of these deaths, 24 625 (66.7%) were from GC, 6513 (17.6%) were from other types of cancers, and 5786 (15.7%) were from non-cancer causes. The most prevalent non-cancer CODs were heart diseases (2104; 5.7%), cerebrovascular diseases (501; 1.4%), and pneumonia/influenza (335; 0.9%). Among patients who survived over 5 years, non-cancer causes surpassed GC as the main CODs. Patients with GC had a higher risk of dying from many non-cancer causes than expected in the general population, particularly from suicide (SMR, 3.03; 95% CI, 2.35-3.85) and septicemia (SMR, 2.93; 95% CI, 2.51-3.4). The competing risk analysis showed that the cumulative mortality of GC gradually declined with a more recent diagnosis. CONCLUSIONS Although GC was the leading COD among patients with GC, non-cancer CODs accounted for a substantial number of deaths. These findings provide useful guidance on potential death risks among patients with GC.

Comparison of medical resource consumption between oral cavity squamous cell carcinoma with and without sarcopenia: A nationwide population-based cohort study

PURPOSE

No study has compared long-term medical resource consumption between patients with oral cavity squamous cell carcinoma (OCSCC) with and without sarcopenia receiving curative surgery.

PATIENTS AND METHODS

Generalized linear mixed and logistic regression models were employed to evaluate the number of postoperative visits and medical reimbursement for head and neck cancer or complications and the number of hospitalizations for treatment-related complications over 5 years after curative surgery, respectively.

RESULTS

The mean difference (95% CI) in total medical claims amounts between the nonsarcopenia and sarcopenia groups were new Taiwan dollars (NTD) 47 820 (35 864-59 776, p < 0.0001), 11 902 (4897-18 908, p = 0.0009), 17 282 (10 666-23 898, p < 0.0001), 17 364 (9644-25 084, p < 0.0001), and 8236 (111-16 362, p = 0.0470) for the first, second, third, fourth, and fifth years, respectively.

CONCLUSION

The long-term medical resource consumption was higher in the sarcopenia group than in the nonsarcopenia group.

The comparison of prognoses between total and distal gastrectomy for gastric cancer in elderly patients ≥ 80 years old

PURPOSE

In Japan, the number of distal gastrectomy for patients ≥ 80 years old is increasing, whereas that of total gastrectomy is decreasing. Surgeons seem to avoid total gastrectomy for elderly patients. Total gastrectomy is reported to have a poorer prognosis than distal gastrectomy, and postoperative pneumonia may be involved in the cause.

METHODS

The medical records of 39 and 108 patients ≥ 80 years old who underwent total and distal gastrectomy, respectively, at 2 affiliated institutions between 2010 and 2019 were retrospectively reviewed. Prognoses were compared between the two groups, focusing on death from pneumonia.

RESULTS

The median overall survival time after total and distal gastrectomy was 21.3 and 74.1 months, respectively, with a significantly poorer prognosis after total gastrectomy than after distal gastrectomy (p < 0.01, hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.37-3.53). The gastric cancer-specific survival time was significantly worse after total gastrectomy than after distal gastrectomy (p < 0.01, HR 2.73, 95% CI 1.29-5.79). The pneumonia-specific survival time was also significantly worse after total gastrectomy than after distal gastrectomy (p = 0.01, HR 3.44, 95% CI 1.25-9.48).

CONCLUSIONS

Patients who underwent total gastrectomy had a poorer prognosis than those who underwent distal gastrectomy, because many patients died of pneumonia early after total gastrectomy.