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Postoperative pulmonary complications after gynecologic surgery
International Journal of Gynecology and Obstetrics (2006) 93, 74 — 76
www.elsevier.com/locate/ijgo
SPECIAL ARTICLE
Postoperative pulmonary complications after gynecologic surgery S. Pappachen, P.R. Smith *, S. Shah, V. Brito, F. Bader, B. Khoury The Department of Obstetrics and Gynecology, and the Division of Pulmonary Medicine, Long Island College Hospital, Brooklyn, New York, USA Received 16 October 2005; received in revised form 12 January 2006; accepted 17 January 2006
KEYWORDS Postoperative pulmonary complications; Gynecologic surgery; Abdominal surgery; Smoking; Length of stay
Abstract Objective: Investigate the frequency of, and risks for postoperative pulmonary complications after surgery for non-malignant gynecologic disorders. Method: A retrospective component included medical record data for one year. A prospective component enrolled 300 patients consecutively who were scheduled for gynecologic surgeries. Result: Postoperative pulmonary complications occurred in 1.22% of 328 open abdominal procedures in the retrospective study, and 2.16% of 232 in the prospective study. Pooling the data yielded a frequency estimate of 1.61%. Mean hospital length of stay (pooled data) increased 1.75 days in those with postoperative pulmonary complications. Smoking was the only significant risk factor (relative risk = 3.9 using pooled data). Conclusion: Postoperative pulmonary complications after surgery for non-malignant gynecologic disorders are infrequent but increase hospital length of stay. Smokers are at increased risk. D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Postoperative pulmonary complications (PPCs) are the most frequent cause of postoperative morbid-
* Corresponding author. Division of Pulmonary Medicine, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201, USA. Tel.: +1 718 780 2905; fax: +1 718 780 1256. E-mail address: [email protected] (P.R. Smith).
ity and mortality [1]. The risk is highest after thoracic and abdominal surgeries and is 1.5 times greater for upper abdominal compared to lower abdominal procedures [2]. Operations for nonmalignant gynecologic disorders are predominantly lower abdominal procedures and are the most frequently performed gynecologic surgeries, but PPCs have not been thoroughly studied in these patients. The present study assessed the frequency of, and the risk factors for PPCs in women
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.01.014
Postoperative pulmonary complications
75
Table 1 Open abdominal surgeries for non-malignant gynecologic disorders Hysterectomy Myomectomy Other Total
Retrospective
Prospective
Pooled
160 118 50 328
113 70 49 232
273 188 99 560
distribution) after testing for heterogeneity using chi-square. Computations were done using SPSS 13.0, and StatXact. P-values less than 0.05 were considered significant. The study was approved by the hospital’s Institutional Review Board. Women in the prospective study gave informed consent.
3. Results undergoing elective surgery for non-malignant gynecologic disorders.
2. Materials and methods The study was conducted in 2 parts at a 450 bed community hospital. A retrospective analysis included all cases performed between November 1, 2001 and October 31, 2002. A prospective study entered 300 patients consecutively beginning November 1, 2002. The frequency of PPCs was assessed in each arm of the study and demographic and clinical data were recorded which included variables previously identified as risk factors for PPCs in the literature. PPCs were defined as 2 or more of the following for 2 or more consecutive days within the first postoperative week: (1) new cough/sputum, (2) physical examination findings consistent with atelectasis or pneumonia, (3) temperature z 38 8C, (4) radiographic evidence of atelectasis or new infiltrate. In addition, PPCs included exacerbation of pre-existing pulmonary disorders, and the development of respiratory failure. This definition is similar to that used by Brooks-Brunn in a study of PPCs after hysterectomy [3]. Retrospective cases were identified from the database of the hospital’s Department of Medical Records. In the prospective group, women were enrolled preoperatively. and evaluated daily during the first postoperative week. In both arms of the study, differences in continuous variables were tested using the Student’s t-test. Categorical variables were tested using Fisher’s Exact test. Data from the 2 arms of the study were also pooled (assuming a Poisson
In the retrospective study 328 open abdominal surgeries were performed (Table 1). Four patients (1.22%) developed PPCs. The severity was mild (pneumonia in 1, atelectasis and pneumonia in 1, bronchitis with fever in 2). Risk factors for PPCs, and hospital lengths of stay (LOS) are compared in patients with and without PPCs in Table 2. The frequency of the various risk factors was not different in the 2 groups. Mean LOS (excluding 16 patients with non-pulmonary complications) was greater in the 4 patients with PPCs (4.25 days) compared to the 308 patients without PPCs (1.92 days). In the prospective study, 68 of 300 patients enrolled were excluded because of a final diagnosis of malignancy, laparoscopic or vaginal procedures only, or refusal to continue in the study. The procedures performed in the remaining 232 patients who underwent open abdominal procedures are shown in Table 1. In this cohort, PPCs occurred in 5 patients (2.16%). The severity of the complications was mild (pneumonia in 2, and bronchitis with fever in 3). Risk factors for PPCs and LOS are compared in those with and without PPCs in Table 3. Smoking within 12 months of surgery was the only significant risk factor for PPCs. In patients with PPCs (excluding those who also had non-pulmonary complications), mean LOS was greater than in those without PPCs (4.6 versus 2.94 days). When the retrospective and prospective data were pooled, the PPC frequency was 1.61% (95% confidence interval 0.7—3.1%). Using pooled data, smoking at the time of surgery was the only significant risk factor for PPCs (relative risk = 3.9, 95% confidence interval 1.98—7.83, p = 0.01). Mean
Table 2 Retrospective study—risk factors for PPCs and lengths of stay after open abdominal surgery for nonmalignant gynecologic disorders in patients with PPCs versus those without PPCs c
PPCs No PPCs P value a b c
Age (mean)
Smokera
ASA (mean)
Lung disease
Anesth. time (mean)
LOSb
43.8 42.8 0.81
2/4 (50%) 51/324 (15.7%) 0.12
1.8 1.89 0.45
0 33/324 (10.2%) 0.68
203 min 178 min 0.45
4.25 days 2.33 days 0.001
Smoker at the time of surgery. Length of stay (excludes patients with non-pulmonary complications). Postoperative pulmonary complications.
76
S. Pappachen et al.
Table 3 Prospective study—risk factors for PPCs and lengths of stay after open abdominal surgery for nonmalignant gynecologic disorders in patients with PPCs versus those without PPCs
PPCsd No PPCs P value a b c d
Age (mean)
Smokersa
Smokersb
BMI (mean)
ASA (mean)
Lung disease
Anesth. time (mean)
LOS (mean)c
44.6 43.2 0.73
3/5 (60%) 29/204 (14.2%) 0.03
2/5 (40%) 24/203 (11.8%) 0.13
34.8 29.6 0.12
2 1.9 0.59
1/5 (20%) 39/222 (17.5%) 0.87
208 min 166 min 0.12
4.6 days 2.94 days 0.001
Smoker within 12 months before surgery. Smoker at the time of surgery. Length of stay (excludes patients with non-pulmonary complications). Postoperative pulmonary complications.
LOS was 1.75 days longer (95% confidence interval 1.18—2.32, P = 0.001) in women with PPCs compared to those without these complications.
4. Discussion The frequency of PPCs reported in the literature varies widely even for similar types of surgical procedures and similar anatomic regions. Overall, the rate of PPCs has ranged from 5% to 80% [4]. Possible reasons for this variability include differences in the populations studied, improvements in surgical and anesthetic techniques over time, and variation in the definition of PPCs in different studies. There are relatively few studies on PPCs after gynecologic surgery. The CREST study [5] (1982) reported postoperative pneumonia in 0.4% of 1851 woman after hysterectomy for benign disease. Harris [6] reported similar findings in a Medline search from 1982 to 1995. More recently, BrooksBrunn in a prospective study [3] identified PPCs in 11% of 120 women undergoing abdominal hysterectomy for either benign or malignant disease. Findings in the present study are more consistent with the 2 earlier reports [5,6]. The definition of PPCs in the current study was similar to that of Brooks-Brunn [3] but the frequency of PPCs was only about 15% of that seen in her study. Possible explanations for this difference include the larger number of patients in the current study and exclusion of malignancies. In Brooks-Brunn’s report, 8 of 13 patients with PPCs had a history of malignancy. Hysterectomy for malignant disease has a greater risk of postoperative complications overall [6] suggesting that PPCs are also more likely. Additionally, 15 of the 120 patients (12.5%) studied by Brooks-Brunn had upper abdominal or combined upper/lower abdominal incisions, and 5 of these 15 developed PPCs. In the prospective arm of the current study, only 6% of the incisions
extended to or above the umbilicus, and none of these patients developed PPCs. The modest rate of PPCs in the present study made identification of risk factors difficult. Only a history of smoking was statistically significant. A recent prospective study of non-thoracic surgeries, [7] identified PPCs in 28 of 1055 patients (2.7%). Independent risk factors for PPCs in multivariate analysis were age, positive cough test (recurrent coughing after deep inspiration and initial cough), perioperative nasogastric tube, and anesthesia duration. In the present study, nasogastric tubes were rarely used, cough tests were not performed, and neither age nor anesthesia duration were significantly associated with PPCs. Despite the low frequency of PPCs in this study, their impact on LOS was impressive. LOS was significantly greater in the retrospective, prospective, and pooled data sets in those with PPCs. In the pooled data, mean LOS was 1.75 days (68%) longer in patients who developed PPCs.
References [1] Doyle RL. Assessing and modifying the risk of postoperative pulmonary complications. Chest 1999;115S:77 – 81. [2] Mitchell C, Garrahy P, Peake P. Postoperative respiratory morbidity: identification and risk factors. Aust N Z J Surg 1982;52:203 – 9. [3] Brooks-Brunn JA. Risk factors associated with postoperative pulmonary complications following total abdominal hysterectomy. Clin Nurs Res 2000;9:27 – 46. [4] Lubin m, Walker K, Smith R, editors. Medical management of the surgical patient. 3rd ed. Philadelphia7 Lippincott; 1995. [5] Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, Peterson HB, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982;144:841 – 8. [6] Harris WJ. Early complications of abdominal and vaginal hysterectomy. Obstet Gynecol Surv 1995;50:795 – 805. [7] McAlister FA, Bertsch K, Man J, Bradley J, Jacka M. Incidence and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med 2005; 171:514 – 7.
www.elsevier.com/locate/ijgo
SPECIAL ARTICLE
Postoperative pulmonary complications after gynecologic surgery S. Pappachen, P.R. Smith *, S. Shah, V. Brito, F. Bader, B. Khoury The Department of Obstetrics and Gynecology, and the Division of Pulmonary Medicine, Long Island College Hospital, Brooklyn, New York, USA Received 16 October 2005; received in revised form 12 January 2006; accepted 17 January 2006
KEYWORDS Postoperative pulmonary complications; Gynecologic surgery; Abdominal surgery; Smoking; Length of stay
Abstract Objective: Investigate the frequency of, and risks for postoperative pulmonary complications after surgery for non-malignant gynecologic disorders. Method: A retrospective component included medical record data for one year. A prospective component enrolled 300 patients consecutively who were scheduled for gynecologic surgeries. Result: Postoperative pulmonary complications occurred in 1.22% of 328 open abdominal procedures in the retrospective study, and 2.16% of 232 in the prospective study. Pooling the data yielded a frequency estimate of 1.61%. Mean hospital length of stay (pooled data) increased 1.75 days in those with postoperative pulmonary complications. Smoking was the only significant risk factor (relative risk = 3.9 using pooled data). Conclusion: Postoperative pulmonary complications after surgery for non-malignant gynecologic disorders are infrequent but increase hospital length of stay. Smokers are at increased risk. D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Postoperative pulmonary complications (PPCs) are the most frequent cause of postoperative morbid-
* Corresponding author. Division of Pulmonary Medicine, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201, USA. Tel.: +1 718 780 2905; fax: +1 718 780 1256. E-mail address: [email protected] (P.R. Smith).
ity and mortality [1]. The risk is highest after thoracic and abdominal surgeries and is 1.5 times greater for upper abdominal compared to lower abdominal procedures [2]. Operations for nonmalignant gynecologic disorders are predominantly lower abdominal procedures and are the most frequently performed gynecologic surgeries, but PPCs have not been thoroughly studied in these patients. The present study assessed the frequency of, and the risk factors for PPCs in women
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.01.014
Postoperative pulmonary complications
75
Table 1 Open abdominal surgeries for non-malignant gynecologic disorders Hysterectomy Myomectomy Other Total
Retrospective
Prospective
Pooled
160 118 50 328
113 70 49 232
273 188 99 560
distribution) after testing for heterogeneity using chi-square. Computations were done using SPSS 13.0, and StatXact. P-values less than 0.05 were considered significant. The study was approved by the hospital’s Institutional Review Board. Women in the prospective study gave informed consent.
3. Results undergoing elective surgery for non-malignant gynecologic disorders.
2. Materials and methods The study was conducted in 2 parts at a 450 bed community hospital. A retrospective analysis included all cases performed between November 1, 2001 and October 31, 2002. A prospective study entered 300 patients consecutively beginning November 1, 2002. The frequency of PPCs was assessed in each arm of the study and demographic and clinical data were recorded which included variables previously identified as risk factors for PPCs in the literature. PPCs were defined as 2 or more of the following for 2 or more consecutive days within the first postoperative week: (1) new cough/sputum, (2) physical examination findings consistent with atelectasis or pneumonia, (3) temperature z 38 8C, (4) radiographic evidence of atelectasis or new infiltrate. In addition, PPCs included exacerbation of pre-existing pulmonary disorders, and the development of respiratory failure. This definition is similar to that used by Brooks-Brunn in a study of PPCs after hysterectomy [3]. Retrospective cases were identified from the database of the hospital’s Department of Medical Records. In the prospective group, women were enrolled preoperatively. and evaluated daily during the first postoperative week. In both arms of the study, differences in continuous variables were tested using the Student’s t-test. Categorical variables were tested using Fisher’s Exact test. Data from the 2 arms of the study were also pooled (assuming a Poisson
In the retrospective study 328 open abdominal surgeries were performed (Table 1). Four patients (1.22%) developed PPCs. The severity was mild (pneumonia in 1, atelectasis and pneumonia in 1, bronchitis with fever in 2). Risk factors for PPCs, and hospital lengths of stay (LOS) are compared in patients with and without PPCs in Table 2. The frequency of the various risk factors was not different in the 2 groups. Mean LOS (excluding 16 patients with non-pulmonary complications) was greater in the 4 patients with PPCs (4.25 days) compared to the 308 patients without PPCs (1.92 days). In the prospective study, 68 of 300 patients enrolled were excluded because of a final diagnosis of malignancy, laparoscopic or vaginal procedures only, or refusal to continue in the study. The procedures performed in the remaining 232 patients who underwent open abdominal procedures are shown in Table 1. In this cohort, PPCs occurred in 5 patients (2.16%). The severity of the complications was mild (pneumonia in 2, and bronchitis with fever in 3). Risk factors for PPCs and LOS are compared in those with and without PPCs in Table 3. Smoking within 12 months of surgery was the only significant risk factor for PPCs. In patients with PPCs (excluding those who also had non-pulmonary complications), mean LOS was greater than in those without PPCs (4.6 versus 2.94 days). When the retrospective and prospective data were pooled, the PPC frequency was 1.61% (95% confidence interval 0.7—3.1%). Using pooled data, smoking at the time of surgery was the only significant risk factor for PPCs (relative risk = 3.9, 95% confidence interval 1.98—7.83, p = 0.01). Mean
Table 2 Retrospective study—risk factors for PPCs and lengths of stay after open abdominal surgery for nonmalignant gynecologic disorders in patients with PPCs versus those without PPCs c
PPCs No PPCs P value a b c
Age (mean)
Smokera
ASA (mean)
Lung disease
Anesth. time (mean)
LOSb
43.8 42.8 0.81
2/4 (50%) 51/324 (15.7%) 0.12
1.8 1.89 0.45
0 33/324 (10.2%) 0.68
203 min 178 min 0.45
4.25 days 2.33 days 0.001
Smoker at the time of surgery. Length of stay (excludes patients with non-pulmonary complications). Postoperative pulmonary complications.
76
S. Pappachen et al.
Table 3 Prospective study—risk factors for PPCs and lengths of stay after open abdominal surgery for nonmalignant gynecologic disorders in patients with PPCs versus those without PPCs
PPCsd No PPCs P value a b c d
Age (mean)
Smokersa
Smokersb
BMI (mean)
ASA (mean)
Lung disease
Anesth. time (mean)
LOS (mean)c
44.6 43.2 0.73
3/5 (60%) 29/204 (14.2%) 0.03
2/5 (40%) 24/203 (11.8%) 0.13
34.8 29.6 0.12
2 1.9 0.59
1/5 (20%) 39/222 (17.5%) 0.87
208 min 166 min 0.12
4.6 days 2.94 days 0.001
Smoker within 12 months before surgery. Smoker at the time of surgery. Length of stay (excludes patients with non-pulmonary complications). Postoperative pulmonary complications.
LOS was 1.75 days longer (95% confidence interval 1.18—2.32, P = 0.001) in women with PPCs compared to those without these complications.
4. Discussion The frequency of PPCs reported in the literature varies widely even for similar types of surgical procedures and similar anatomic regions. Overall, the rate of PPCs has ranged from 5% to 80% [4]. Possible reasons for this variability include differences in the populations studied, improvements in surgical and anesthetic techniques over time, and variation in the definition of PPCs in different studies. There are relatively few studies on PPCs after gynecologic surgery. The CREST study [5] (1982) reported postoperative pneumonia in 0.4% of 1851 woman after hysterectomy for benign disease. Harris [6] reported similar findings in a Medline search from 1982 to 1995. More recently, BrooksBrunn in a prospective study [3] identified PPCs in 11% of 120 women undergoing abdominal hysterectomy for either benign or malignant disease. Findings in the present study are more consistent with the 2 earlier reports [5,6]. The definition of PPCs in the current study was similar to that of Brooks-Brunn [3] but the frequency of PPCs was only about 15% of that seen in her study. Possible explanations for this difference include the larger number of patients in the current study and exclusion of malignancies. In Brooks-Brunn’s report, 8 of 13 patients with PPCs had a history of malignancy. Hysterectomy for malignant disease has a greater risk of postoperative complications overall [6] suggesting that PPCs are also more likely. Additionally, 15 of the 120 patients (12.5%) studied by Brooks-Brunn had upper abdominal or combined upper/lower abdominal incisions, and 5 of these 15 developed PPCs. In the prospective arm of the current study, only 6% of the incisions
extended to or above the umbilicus, and none of these patients developed PPCs. The modest rate of PPCs in the present study made identification of risk factors difficult. Only a history of smoking was statistically significant. A recent prospective study of non-thoracic surgeries, [7] identified PPCs in 28 of 1055 patients (2.7%). Independent risk factors for PPCs in multivariate analysis were age, positive cough test (recurrent coughing after deep inspiration and initial cough), perioperative nasogastric tube, and anesthesia duration. In the present study, nasogastric tubes were rarely used, cough tests were not performed, and neither age nor anesthesia duration were significantly associated with PPCs. Despite the low frequency of PPCs in this study, their impact on LOS was impressive. LOS was significantly greater in the retrospective, prospective, and pooled data sets in those with PPCs. In the pooled data, mean LOS was 1.75 days (68%) longer in patients who developed PPCs.
References [1] Doyle RL. Assessing and modifying the risk of postoperative pulmonary complications. Chest 1999;115S:77 – 81. [2] Mitchell C, Garrahy P, Peake P. Postoperative respiratory morbidity: identification and risk factors. Aust N Z J Surg 1982;52:203 – 9. [3] Brooks-Brunn JA. Risk factors associated with postoperative pulmonary complications following total abdominal hysterectomy. Clin Nurs Res 2000;9:27 – 46. [4] Lubin m, Walker K, Smith R, editors. Medical management of the surgical patient. 3rd ed. Philadelphia7 Lippincott; 1995. [5] Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, Peterson HB, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982;144:841 – 8. [6] Harris WJ. Early complications of abdominal and vaginal hysterectomy. Obstet Gynecol Surv 1995;50:795 – 805. [7] McAlister FA, Bertsch K, Man J, Bradley J, Jacka M. Incidence and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med 2005; 171:514 – 7.