Risk factors for postoperative pneumonia in elderly patients with colorectal cancer: a sub-analysis of a large, multicenter, case-control study in Japan

Impact of Enhanced in-Hospital Infection Prevention During the COVID-19 Pandemic on Postoperative Pneumonia in Older Surgical Patients

Purpose

We aimed to investigate the impact of enhanced in-hospital infection prevention during the coronavirus disease 2019 (COVID-19) pandemic on postoperative pneumonia in older surgical patients.

Patients and Methods

We retrospectively reviewed the electronic medical records of consecutive patients ≥70 years who underwent elective surgery between 2017 and 2021 at our institution. All perioperative variables were retrieved from the electronic medical records. The primary outcome was new-onset postoperative pneumonia during the hospitalization period. Since February 2020, our institution implemented a series of policies to enhance infection prevention, hence patients were divided into groups according to whether they underwent surgery before or during the COVID-19 pandemic. An interrupted time series analysis was performed to evaluate the difference between pre- and post-intervention slopes of the primary outcome.

Results

Among the 29,387 patients included in the study, 10,547 patients underwent surgery during the COVID-19 pandemic. Although there was a decreasing trend of the monthly incidence rate of postoperative pneumonia compared to before the COVID-19 pandemic, there was no statistical significance in the trend (slope before COVID-19 period: β-coefficient, -0.007; 95% CI, -0.022 to 0.007).

Conclusion

Our study revealed that enhanced in-hospital infection prevention implemented to manage the COVID-19 pandemic did not significantly affect the decreasing trend of postoperative pneumonia at our institution.

The Prevalence of Back Pain in Patients Operated on Due to Colorectal Cancer Depending on the Type of Surgical Procedure Performed

PURPOSE

Low back pain presents a serious challenge for numerous medical specialties. The purpose of this study was to assess disability due to low back pain in patients operated on due to colorectal cancer depending on the type of surgery performed.

METHODS

This prospective observational study was carried out in the period of July 2019 through March 2020. Included in the study were patients with colorectal cancer for scheduled surgeries including anterior resection of rectum (AR), laparoscopic anterior resection of rectum (LAR), Hartmann's procedure (HART), or abdominoperineal resection of rectum (APR). The Oswestry Low Back Pain Disability Questionnaire was used as the research tool. The study patients were surveyed at three time points: before surgery, six months after surgery, and one year after surgery.

RESULTS

The analysis of study results revealed that an increase in the degree of disability and functioning impairment occurred in all groups between time points I and II, with the differences being statistically significant (p < 0.05). The inter-group comparative analysis of the total Oswestry questionnaire scores revealed statistically significant differences, with the impairment of function being most severe within the APR group and least severe within the LAR group.

CONCLUSION

The study results showed that low back pain contributes to impaired functioning of patients operated on due to colorectal cancer regardless of the type of procedure performed. A reduction in the degree of disability due to low back pain was observed one year after the procedure in patients having undergone LAR.

An assessment of burden of hospital-acquired pneumonia among abdominal surgical patients in tertiary university hospital in Serbia: A matched nested case-control study

Background

In the population of abdominal surgical patients hospital-acquired pneumonia (HAP) significantly increases morbidity and mortality.

Patients and methods

Through regular hospital surveillance of patients who received abdominal operations, we identified postoperative HAP from 2007 to 2019. In an initial nested case-control study, every surgical patient with HAP was compared with three control patients without HAP. Control patients were matched to the cases by age, gender, the American Society of Anesthesiologists score, and type of surgical operation. Also, the patients with HAP, who died were compared with those who survived.

Results

Multivariate logistic regression analysis (MLRA) revealed that other postoperative infections, length of intensive care unit stay, use of H2RA, use of PPI/ H2RA, multiple transfusion, and use of vancomycin in surgical prophylaxis were independent RFs for occurrence of HAP. Also, MLRA identified that age, lenght of hospital stay, use of mechanical ventilation and ceftriaxone in HAP therapy were indepedenttly associated with poor outcome of HAP. All Acinetobacter baumannii isolates were resistant to aminoglycoside antimicrobial agents and showed carbapenem resistance. The most frequently used antibiotics in patients with HAP and without HAP were vancomycin and metronidazole, respectively.

Conclusion

Our study provided an insight into the burden of HAP in abdominal surgical patients, and highlighted several priority areas and targets for quality improvement.

Effects of Perioperative Oral Management in Patients with Cancer

Perioperative oral management (POM) is used to prevent pneumonia in patients with cancer. However, the factors that expose hospitalized patients to increased risk of developing pneumonia remain unclear. For example, no study to date has compared the incidence of pneumonia in hospitalized patients by cancer primary lesion, or POM implementation, or not. We determined which patients were most likely to benefit from POM and examined the effects of POM on pneumonia prevention and mortality. In a total of 9441 patients with cancer who underwent surgery during hospitalization, there were 8208 patients in the No POM group, and 1233 in the POM group. We examined between-group differences in the incidence of pneumonia and associated outcomes during hospitalization. There was no significant between-group difference in the incidence of pneumonitis, however, patients with lung, or head and neck cancers, demonstrated a lower incidence of postoperative pneumonia. Among patients with lung and pancreatic cancers, mortality was significantly lower in the POM group. POM appears effective at reducing the risk of postoperative pneumonia in patients with certain cancers. Further, mortality was significantly lower in patients with lung and pancreatic cancers who received POM; hence, POM may be an effective adjuvant therapy for patients with cancer.

Perioperative Pulmonary Support of the Elderly

Purpose of Review

With the projected increase in the geriatric patient population, it is of the utmost importance to understand and optimize conditions in the perioperative period to ensure the best surgical outcome. Age-associated changes in respiratory physiology affect the surgical management of geriatric patients. This review focuses on perioperative pulmonary management of elderly individuals.

Recent Findings

The physiological changes associated with aging include both physical and biochemical alterations that are detrimental to pulmonary function. There is an increased prevalence of chronic lung disease such as COPD and interstitial lung disease which can predispose patients to postoperative pulmonary complications. Additionally, elderly patients, especially those with chronic lung disease, are at risk for frailty. Screening tools have been developed to evaluate risk and aid in the judicious selection of patients for surgical procedures. The concept of “prehabilitation” has been developed to best prepare patients for surgery and may be more influential in the reduction of postoperative pulmonary complications than postoperative rehabilitation. Understanding the age-associated changes in metabolism of drugs has led to dose adjustments in the intraoperative and postoperative periods, reducing respiratory depression and lung protective ventilation and minimally invasive procedures have yielded reductions in postoperative pulmonary complications.

Summary

The perioperative management of the geriatric population can be divided into three key areas: preoperative risk mitigation, intraoperative considerations, and postoperative management. Preoperative considerations include patient selection and thorough history and physical, along with smoking cessation and prehabilitation in a subset of patients. Operative aspects include careful selection of anesthetic agents, lung protective ventilation, and choice of surgical procedure. Postoperative management should focus on selective use of agents that may contribute to respiratory depression and encouragement of rehabilitation.

Surgical Outcomes of Colorectal Cancer Surgery for ≥ 85-year-old Patients in Our Hospital: Retrospective Comparison of Short- and Long-term Outcomes with Younger Patients

OBJECTIVES

To evaluate future problems in colorectal cancer surgery for elderly patients.

METHODS

We conducted a retrospective review of patients receiving colorectal cancer surgery in our hospital from January 2010 to December 2018. Patients were divided into the ≥ 85-year-old patient group and the younger patient group. We compared patient backgrounds, surgical outcomes (surgical procedure, reduction of lymph node dissection range, operative duration, and blood loss), postoperative short-term outcomes (mortality, morbidity, and postoperative length of stay) and prognosis.

RESULTS

We performed colorectal cancer surgery on 1,240 patients during the study period. Of them, 109 (8.7%) were ≥ 85 years old, and 1,131 (91.2%) were < 85 years old. The American Society of Anesthesiologists physical status (ASA-PS) was significantly poorer in the elderly group than in the younger group and patients with a history of cardiac disease and anticoagulant use were significantly more in the elderly group. The rate of reduction of lymph node dissection range was significantly higher in the elderly group (16.8% vs. 3.8%, p < 0.05). Overall morbidity was significantly higher in the elderly group (42.2% vs. 21.9%, p < 0.05), as were the respective frequencies of pneumonia and thromboembolism (8.2% vs. 0.7%, p < 0.05 and 3.6% vs. 0.8%, p < 0.05, respectively). Postoperative hospital stay was significantly longer in the elderly group (17 vs. 12 days, p < 0.05). Overall survival was significantly lower in the elderly group (p < 0.05), but relapse-free survival and colorectal cancer-specific survival were not statistically different between the groups (p = 0.05 and p = 0.15, respectively).

CONCLUSIONS

Prevention of postoperative pneumonia and thromboembolism remains a problem. After proper assessment and careful management of peri-operative surgical risks, surgery can be indicated in elderly patients.

Association of Respiratory Tract Infection after Gastroenterological Surgery with Postoperative Duration of Hospitalization and Medical Expenses: Subanalysis of Data from a Multicenter Study

BACKGROUND

Postoperative infections can be classified as surgical site infections and remote infections. Postoperative respiratory tract infections (PRTI) are a type of remote infection and may be associated with prolonged hospitalization and increased medical expenses. This study compared postoperative duration of hospitalization and medical expenses between patients with and without PRTI after gastrointestinal surgery.

METHODS

We retrospectively analyzed data from a multicenter study of centers affiliated with the Japan Society for Surgical Infection and used 1-to-1 matching analysis to evaluate 86 patients who underwent gastrointestinal surgery during the period from March 1, 2014 through February 29, 2016.

RESULTS

Duration of postoperative hospitalization was significantly longer for patients with PRTI (38.6 days) than for those without PRTI (16.1 days), and postoperative medical expenses were significantly higher for patients with PRTI (1388.2 USD) than for those without PRTI (629.4 USD).

CONCLUSIONS

Duration of hospitalization is longer and medical expenses are higher for patients that develop surgical site infections. This study found that this was also the case for patients with PRTI after gastrointestinal surgery. However, further studies are needed in order to confirm these results.

Analyzing non-cancer causes of death of colorectal carcinoma patients in the US population for the years 2000-2016

Background

Colorectal cancer (CRC) treatment and patient survival improved greatly. Consequently an increased incidence of non‐cancer‐related deaths is observed. This study analyzed the causes of non‐cancer death for people suffering from CRC based on the year of diagnosis, follow‐up time, and patient's age.

Methods

The data from patients diagnosed with CRC in the years 2000–2016 were taken from the Surveillance, Epidemiology, and End Results 18 database. Patients were categorized according to: death from CRC, non‐CRC cancer, and non‐cancer. Constituent ratios and standardized mortality ratios (SMRs) were calculated to describe the death causes distribution and relative death risks.

Results

Between 2000 and 2016, a stable and rapid drop for the original diagnosis as death cause for CRC patients was observed (70.19% to 49.35%). This was coupled to an increase in non‐cancer‐associated death reasons (23.38% to 40.00%). The most common non‐cancer death cause was heart disease, especially for elderly patients. However, deaths from accidents and adverse effects were frequent in younger CRC patients. Patients died from septicemia more often within the first follow‐up year; however, a 6‐fold increase in death from Alzheimer's disease was found for after at least 180 months follow‐up time.

The SMRs of all 25 non‐cancer death causes initially decreased in all CRC subgroups, followed by an increase with follow‐up times. Gradually decreasing SMR values were observed with increasing age of CRC patients.

Conclusions

These findings could help modify and sharpen preventive measures and clinical management and raise physician's awareness to potential non‐CRC death risk factors for CRC patients.

Multidisciplinary treatment for colorectal liver metastases in elderly patients

BACKGROUND

Limited data describe the therapeutic practice and outcomes of colorectal liver metastases (CRLMs) in elderly patients. We aimed to evaluate the impact of age on multidisciplinary treatment for CRLMs.

METHODS

We reviewed treatment and outcomes for patients in different age groups who underwent initial hepatectomy for CRLMs from 2004 through 2012.

RESULTS

We studied 462 patients who were divided into three groups by age: ≤ 64 years (n = 265), 65-74 years (n = 151), and ≥ 75 years (n = 46). The rate of major hepatectomy and incidence of postoperative complications did not differ between groups. Adjuvant chemotherapy was used less in the ≥ 75-year group (19.6%) than that in the ≤ 64 (54.3%) or 65-74 age group (43.5%). Repeat hepatectomy for liver recurrence was performed less in the ≥ 75-year group (35%) than in the ≤ 64 (57%) or 65-74 (66%) age group. The 5-year disease-specific survival (DSS) rate of 44.2% in the ≥ 75-year group was lower than in the ≤ 64 (59.0%) or 65-74 (64.7%) age group. Multivariate analysis revealed age ≥ 75 years was an independent predictor of poor DSS.

CONCLUSIONS

Liver resection for CRLMs can be performed safely in elderly patients. However, repeat resection for recurrence are performed less frequently in the elderly, which may lead to the poorer disease-specific prognosis.

Predictors of early postoperative pneumonia after oncologic surgery with the patients receiving professional oral health care: A prospective, multicentre, cohort study

This study was a prospective, multicentre, cohort study on 685 patients who had undergone oncologic surgery. The patients were divided into two groups according to the presence or absence of postoperative pneumonia. The two groups were compared with respect to their background, index operation, food eaten, oral condition, contents of oral care and dental treatment, laboratory data, and bacterial flora. All postoperative pneumonias occurred in six cases within four days postoperatively. The multivariable logistic regression analysis showed that preoperative serum C-reactive protein was the strongest predictor of postoperative pneumonia. In addition, decreased postoperative Candida albicans colonies was an effective predictor of postoperative pneumonia. For patients with predictors of postoperative pneumonia, perioperative strategies for its prevention should be considered in addition to professional oral health care. This study was approved by the National Hospital Organization's Central Ethics Review Board and was also approved by the directors of the participating institutions.

The influence of pulmonary comorbidities on treatment choice and short-term surgical outcomes among elderly patients with colorectal cancer

PURPOSE

Most elderly patients with colorectal cancer have comorbidities and reduced functional reserve, which may increase their risks of postoperative morbidity and mortality, and subsequently influence the treatment choice. Therefore, this study aimed to investigate the treatment choice and compare laparoscopic and open surgery in this setting.

METHODS

This retrospective study evaluated 118 patients with colorectal cancer (≥ 85 years old between January 2007 and February 2018) to determine the influence of comorbidities on treatment choice, as well as the safety and feasibility of laparoscopic surgery for these patients.

RESULTS

The patients included 42 men (35.6%) and 106 patients (89.8%) with comorbidities. The treatments were curative resection for 90 patients and palliative surgery for 16 patients, including 5 cases of colostomy/ileostomy because of the difficulty of primary cancer resection, pneumonia, or pulmonary hypertension. Twelve patients received non-surgical treatment, including 7 patients with decreased respiratory function because of chronic obstructive pulmonary disease or pneumonia. Forty-three patients underwent open curative resection and 47 patients underwent laparoscopic curative resection, which was associated with a significantly shorter hospital stay (14 days vs. 19days, P < 0.01), a lower morbidity rate (17.0% vs. 37.2%, P = 0.035), and less blood loss (10 mL vs. 140 mL, P < 0.01). One patient in each group died during the postoperative period because of worsened pre-existing pneumonia.

CONCLUSION

Laparoscopic surgery was safer and less invasive than open surgery for colorectal cancer among ≥ 85-year-old patients. Pulmonary comorbidities affected the choice of non-curative surgery and may be related to the risk of postoperative mortality.

Restrictive Ventilatory Patterns in Residents of Continuing Care Retirement Communities

Restrictive ventilatory patterns (RVPs) in older adults may contribute to morbidity and decreased quality of life. The purpose of this study was to begin to understand (a) the number of older adults residing in Continuing Care Retirement Communities with RVPs, (b) factors associated with RVP, and (c) whether RVP is associated with ambulation level. This descriptive study was conducted at three sites. RVP was evident in 34 of the 65 participants (52%), and 33 (97%) of these were either moderate or severely restricted. Dementia, dyspnea, kyphosis, and lower muscle strength were significant predictors of RVP. Eighty percent of the nonambulatory participants had RVP and 38% of the ambulatory participants had RVP. Designing interventions to address modifiable factors associated with RVP may prevent respiratory infections, help people to achieve better lung health, and increase physical activity tolerance.