Post-Operative Pulmonary Function : A Comparison between Upper Abdominal Open Cholecystectomy and Laparoscopic Cholecystectomy

Postoperative Pulmonary Changes after Laparoscopic Cholecystectomy

Upper abdominal surgery is associated with characteristic changes in pulmonary function which increase the risk of lower lobe atelectasis. Sixteen patients undergoing open cholecystectomy and 20 patients undergoing laparoscopic cholecystectomy were prospectively evaluated by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume [FEV-1], and forced expiratory flow [FEF] 25% to 75%) before operation and on the morning after surgery to determine if the laparoscopic technique lessens the pulmonary risk. Fraction of the baseline pulmonary function was calculated by dividing the postoperative pulmonary function by the preoperative pulmonary function and multiplying by 100%. Postoperative FVC measured 52% of preoperative function for open cholecystectomy and 73% for laparoscopic cholecystectomy (p = 0.002). Postoperative FEV-1 measured 53% of baseline function for open cholecystectomy and 72% for laparoscopic cholecystectomy (p = 0.006). Postoperative FEF 25% to 75% measured 53% for open cholecystectomy and 81% for laparoscopic cholecystectomy (p = 0.07). It is concluded that laparoscopic cholecystectomy offers improved pulmonary function compared to the open technique.

Background: Specific surgical procedures, such as upper abdominal and thoracic surgery, are connected to an increased predisposition of postoperative pulmonary complications (PPCs). The incidence of PPCs could vary approximately between 20-90% with upper abdominal surgery, which can be minimized by using treatment procedures that increase lung capacity and encourage inspiration. This review aims to examine the effectiveness of already existing evidence-based interventions that promote lung expansion, thereby preventing PPCs. Method: We mainly focused on the existing evidence of preoperative education on the incentive spirometer, early mobilization, directed coughing, deep breathing exercises, chest physiotherapy, and inspiratory muscle training (IMT) to prevent PPCs. The literature search was limited to experimental, observational studies, systemic reviews, and articles published in the last 15 years, January 2007- Dec. 2022, in PubMed and Google Scholar. Result: This initial search yielded a total of 5301 articles. All articles with titles not related to the topic were eliminated. 1050 records were screened, and the final review was conducted with 22 articles, including 13 randomized controlled trials (RCTs), four systemic reviews, one retrospective review, three observational studies, and one non-experimental study. Our review reveals mixed evidence for individual interventions, including but not limited to incentive spirometry, inspiratory muscle training, early mobilization, cough, deep breathing, etc. Some studies maintain that intervention is effective; others imply there is no substantial difference in the choice of intervention. Conclusion: The literature review concluded that patients who received multiple interventions showed significant improvement in pulmonary function postoperatively. However, definitive studies need to be conducted to solidify this conclusion.

Background: Early mobilization is believed to improve pulmonary function and prevent postoperative pulmonary complications (PPCs) but adherence is low. The value of allocating resources (e.g. staff time) to increase early mobilization is unknown. This study aimed to estimate the extent to which staff-directed facilitation of early mobilization impact on recovery of pulmonary function after colorectal surgery. We also explored the association of the intervention with 30-day PPCs. Methods: Pre-planned analysis of secondary outcomes of a randomized controlled trial (Fiore Jr et al. Ann Surg 2016 [ahead of print]). Patients undergoing colorectal surgery were randomized 1:1 to usual care (preoperative education) or facilitated mobilization (staff dedicated to assist transfers and walking during hospital stay). Forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and peak cough flow (PCF) were measured preoperatively and at 1, 2, 3 days and 4 weeks after surgery. PPCs were defined according to the European Perioperative Clinical Outcome Taskforce. Results: 99 patients were randomized (57% male, 80% laparoscopic, median age 63 and predicted FEV1 97%). There was no between-group difference in recovery of FVC [adjusted difference in slopes 0.002 L/day (95% CI -0.01 to 0.01)], FEV1 [-0.002 L/s/day (-0.01 to 0.06)] or PCF [-0.003 L/s/day (-0.02 to 0.02)]. 30-day PPCs were also not different between groups [adjusted odd ratio 0.56 (0.18 to 1.71)]. Conclusion: This study does not support the need to allocate resources for enhancing early mobilization to improve pulmonary outcomes after colorectal surgery.

A best evidence topic in perioperative care was written according to a structured protocol. The question addressed was 'Does ambroxol confer a protective effect on the lung in patients undergoing cardiac surgery or having lung resection?' A total of 247 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Several studies indicate that for patients with chronic obstructive pulmonary disease (COPD) who undergo cardiac surgery or upper abdominal surgery, perioperative ambroxol administration is associated with improved pulmonary function and reduced postoperative pulmonary complications (PPCs). In patients with pulmonary lobectomy, large-dose ambroxol treatment (1000 mg/day for 3 days) is correlated with reduced PPCs (6 vs 19%, P = 0.02), decreased postoperative hospital stay (5.6 vs 8.1 days, P = 0.02) and lower postoperative cost (2499 vs 5254 €, P = 0.04) compared with low-dose ambroxol treatment. Ambroxol also has a protective effect on the lungs during extracorporeal bypass, ameliorating inflammatory reaction and oxygen stress and preserving pulmonary surfactant. However, there is no evidence for any advantage of reducing PPCs after extracorporeal circulation. We conclude that perioperative application of ambroxol, a versatile mucoactive drug, particularly in high doses, is associated with lower PPCs, especially in high-risk patients with fundamental lung disease such as COPD. Large doses of ambroxol are correlated with even lower PPCs after lung resection. We recommend that routine intravenous ambroxol should be used in large doses in high-risk patients in the perioperative period to reduce the risk of PPCs.

Background: Postoperative pulmonary complications (PPCs) following upper abdominal surgery are common, and are associated with prolonged hospital stay even for cardiopulmonary healthy patients. The development of atelectasis and the unequal distribution of perfusion-ventilation during anesthesia and surgery, and perhaps the reappearance of these disturbances after surgery, are the main hypotheses used to explain postoperative hypoxemia and pulmonary complications. Atelectasis may be increased by using a Kent retractor, which retracts the abdominal wall and compresses the lung. This study evaluated the effect of preventive intraoperative positive end-expiratory pressure (PEEP) on perioperative oxygenation and complications in patients who receive gastrectomy with a Kent retractor. Methods: Thirty eight cardiopulmonary healthy patients were randomly allocated to receive 0 (control), 5 or 10 cmHO of PEEP during surgery. Arterial blood was obtained to evaluate arterial oxygenation and the unequal distribution of perfusion-ventilation by analyzing arterial oxygen tension and alveolar-arterial oxygen tension differences ((A-a)Do) during the perioperative period. Pulmonary function and complications were also evaluated. Results: Intraoperative arterial oxygenation improved for all patients receiving 5 or 10 cm HO PEEP. In the control group, there was statistically significant decrease in PaO and increase in (A-a)Do after Kent retractor was applied, but the others did not show this effect (P

Background:Lung expansion therapy (LET) is often ordered after surgery to improve alveolar ventilation and reduce risks of postoperative pulmonary complications (PPC). The impact of LET at altering distribution of ventilation in non-intubated patients has not been described. The primary purpose of this study is to determine if there is a difference in dorsal redistribution of ventilation and incidences of PPCs when comparing Incentive Spirometry (IS) to EzPAP LET after upper abdominal surgery. Our a priori null hypothesis is that there are no differences. Methods:This IRB approved prospective randomized controlled trial enrolled adult human subjects who underwent upper abdominal surgery from January 2017 to April 2018. Subjects were allocated to receive LET with IS targeting predicted inspiratory capacity or EzPAP targeting 15 cm H2O TID on postoperative days (POD) 1-5. An electrical impedance tomography (EIT) device (Pulmovista 500; Draeger) was connected to subjects for a single LET session on POD 1, 3, and 5 to measure baseline changes in post-LET dorsal end-expiratory lung impedance (ΔEELI %). LET sessions with EIT included 2-min normal breathing, 3 breath cycles x 10 breaths, and 2-min normal breathing after breath cycle 3. The EIT device was removed after POD monitoring sessions but LET continued as scheduled. PPCs were screened until hospital discharge. Mann-Whitney U, x2, and Fisher's exact tests were applied as appropriate. Data are reported as count (n), percent, and median [IQR]. Alpha (2-tail) is < .05. Results:81 subjects were enrolled to receive IS (n=41) or EzPAP (n=40) LET. Groups were equal for descriptive characteristics such as age (62 [52-71] y), sex (57% female), BMI (28. 1 [24. 7-33.6]), ARISCAT PPC risk index (Score=41; intermediate risk) and comorbidities (P > .05). Whipple (38%) and hepatic resection (30%) accounted for the majority of surgical procedures. Protocol adherence (93% vs 89%, P = .39) and study dropout (4% vs 1%, P= .37) was similar between groups. Post-LET dorsal ΔEELI % increased for both groups, but median dorsal ΔEELI % for IS and EzPAP on POD 1 (16% vs 13%, P= .42), POD 3 (5% vs 6%, P= .42), and POD 5 (12% vs 9%, P= .95) was not significantly different. Hospital length of stay (4 d, P= .79) and incidence of PPCs (1% vs 4%, P= .19) was also similar. Conclusions:There is no difference in post-LET dorsal redistribution of ventilation or incidence of PPCs among adults who receive IS or EzPAP TID after upper abdominal surgery.

Postoperative pulmonary complications are most often seen after upper abdominal and thoracic surgery. Mild signs of retained secretions and pulmonary infection may be present in 50%–80% of these patients, but even without clinical signs a pronounced arterial hypoxaemia is usually seen in the postoperative period. PaO2 returns to preoperative levels 7–10 days after upper abdominal surgery; after thoracic surgery this may take up to 14 days.

There is body of evidence regarding the efficacy of Pulmonary Rehabilitation (PR) in the comprehensive management of patients with respiratory disease, and PR programs are practiced worldwide. Positive results in terms of improvement in dyspnoea, exercise capacity and Quality of Life (QoL) are recognized in Chronic Obstructive Pulmonary Disease (COPD). However PR is beneficial in other forms of chronic respiratory diseases, like asthma, cystic fibrosis, restrictive thoracic disease etc. Moreover, PR is becoming a crucial component of the overall treating strategy in high risk surgical patients (i.e. lung volume reduction surgery [LVRS] and lung transplantation), and in the preand post-operative period of patients who are candidates or have undergone lung resection (LR) for Non-Small Cell Lung Cancer (NSCLC). Pulmonary function is commonly altered after surgery, particularly in patients with COPD, current o ex smokers, who have had chest or upper abdominal surgery. The physiological changes observed are directly related to anesthesia (general or regional) and to the type of incision and surgical technique employed, and are reflected by decreases in total pulmonary capacity and pulmonary volumes and by a parallel reduction of Pa02. These functional alterations are in turn implicated in the development of postoperative pulmonary complications (PPC), which are the main causes of morbidity and mortality among surgical patients. Therefore, the recovery of a good physical and respiratory function, the improvement of dyspnoea and quality of life are an important outcome in the postoperative management of these patients. Breathing exercises have commonly been used to increase pulmonary volumes and improve gas exchange and ventilation distribution. Diaphragmatic, segmental, and costal respiratory exercises, as well as sustained maximal inspiration, may alleviate surgically induced alterations such as

To identify risk variables leading to early postoperative pulmonary complication (POPC) in thoracic and upper abdominal surgery. 297 patients submitted to elective surgery were classified as low, moderate and high risk for POPC using PORT scale, following Torrington & Henderson (1988). The patients were followed up for 72 hours postoperative. POPC were defined as atelectasis, pneumonia, tracheobronchitis, wheezing, prolonged intubation and/or prolonged mechanical ventilation. Univariate analysis was applied to study these independent variables: type of surgery, age, nutritional status (BMI), respiratory disease, smoking habit, spirometry and surgical time. Multivariate logistic regression analysis were performed in order to evaluate the relationship between independent and dependent (POPC) variables. POPC incidence was 12.1%. By multivariate logistic regression analysis the variables increasing chance to POPC was cough with yellow mucus (OR= 3.8), thoracic surgery (OR=2.9) compared to abdominal surgery, BMI (OR=1.13), duration of smoking (OR=1.03) and prolonged duration of surgery (OR=1.007). In the thoracic surgery group, multivariate logistic regression analysis showed: wheezing (OR=6.2), BMI (OR=1.15), long time smoking (OR= 1.04) and prolonged duration of surgery (OR= 1.007) related to POPC. The variables occurrence that increased chance to POPC in thoracic and upper abdominal surgery were: cough with yellow mucus, thoracic surgery, BMI, duration of smoking and duration of surgery. Regarding the thoracic surgery group the significance variables were wheezing, BMI, duration of smoking and duration of surgery.

Field exercise tests have been increasingly used for pulmonary risk assessment. The 6-min walking distance (6MWD) is a field test commonly employed in clinical practice; however, there is limited evidence supporting its use as a risk assessment method in abdominal surgery. The aim was to assess if the 6MWD can predict the development of post-operative pulmonary complications (PPCs) in patients having upper abdominal surgery (UAS). This prospective cohort study included 137 consecutive subjects undergoing elective UAS. Subjects performed the 6MWD on the day prior to surgery, and their performance were compared with predicted values of 6MWD (p6MWD) using a previously validated formula. PPCs (including pneumonia, tracheobronchitis, atelectasis with clinical repercussions, bronchospasm and acute respiratory failure) were assessed daily by a pulmonologist blinded to the 6MWD results. 6MWD and p6MWD were compared between subjects who developed PPC (PPC group) and those who did not (no PPC group) using Student's t-test. Ten subjects experienced PPC (7.2%) and no significant difference was observed between the 6MWD obtained in the PPC group and no PPC group (466.0 ± 97.0 m vs. 485.3 ± 107.1 m; P = 0.57, respectively). There was also no significant difference observed between groups for the p6MWD (100.7 ± 29.1% vs. 90.6 ± 20.9%; P > 0.05). The results of the present study suggest that the 6-min walking test is not a useful tool to identify subjects with increased risk of developing PPC following UAS.

Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry (IS) compared to no therapy, or physiotherapy including coughing and deep breathing, on all-cause postoperative pulmonary complications and mortality in adult patients admitted for upper abdominal surgery. To assess the effects of incentive spirometry compared to no such therapy (or other therapy) on all-cause postoperative pulmonary complications (atelectasis, acute respiratory inadequacy) and mortality in adult patients admitted for upper abdominal surgery. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE, EMBASE, and LILACS (from inception to July 2006). There were no language restrictions. We included randomized controlled trials of incentive spirometry in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures. Two authors independently assessed trial quality and extracted data. We included 11 studies with a total of 1754 participants. Many trials were of only moderate methodological quality and did not report on compliance with the prescribed therapy. Data from only 1160 patients could be included in the meta-analysis. Three trials (120 patients) compared the effects of incentive spirometry with no respiratory treatment. Two trials (194 patients) compared incentive spirometry with deep breathing exercises. Two trials (946 patients) compared incentive spirometry with other chest physiotherapy. All showed no evidence of a statistically significant effect of incentive spirometry. There was no evidence that incentive spirometry is effective in the prevention of pulmonary complications. We found no evidence regarding the effectiveness of the use of incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large randomized trials of high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.

The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study

BackgroundLung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). Preliminary evidence suggests that ERAS processes can reduce overall incidence of PPCs as short- and long-term recovery improved by supporting units to adopt evidence-based care. However, the evidence is inconclusive due to insufficient high-level studies in this research field. No well-designed, adequately powered, randomized controlled trials (RCTs) have investigated the effects of pulmonary rehabilitation based ERAS program (PREP) on post-operative pulmonary complications, pulmonary function, and health related quality of life following lung cancer surgery.MethodsThe PREP trial is a pragmatic, investigator-initiated, multi-center, randomized controlled, parallel group, clinical trial. Five hundred patients scheduled for minimally invasive pulmonary resection at six hospitals in China will be randomized with concealed allocation to receive either i) a pre-operative assessment and an information booklet or ii) a pre-operative assessment, an information booklet, plus an additional education, a 30-min pulmonary rehabilitation training session and the post-operative pulmonary rehabilitation program. The primary outcome is incidence of PPCs defined with the Melbourne Group Scale diagnostic scoring tool. Secondary outcomes include incidence of cardiopulmonary and other complications, pulmonary function, cardiopulmonary endurance, muscle strength, activity level, health-related quality of life (HRQoL), pre- and post-operative hospital length of stay (LOS), and total hospital LOS.DiscussionThe PREP trial is designed to verify the hypothesis that pulmonary rehabilitation based ERAS program reduces incidence of PPCs and improves pulmonary function and HRQoL in patients following lung cancer surgery. This trial will furthermore contribute significantly to the limited knowledge about the pulmonary rehabilitation based ERAS program following lung cancer surgery, and may thereby form the basis of future recommendations in the surgical community.Trial registrationChinese Clinical Trial Registry: ChiCTR1900024646, 21 July 2019.

Repercussions of preterm birth on symptoms of asthma, allergic diseases and pulmonary function, 6–14 years later