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Correspondence

Postoperative Pneumonia After Major Pulmonary Resections: The Importance of Gastrointestinal Tract Management

Thoracic Surgery Unit, Azienda Ospedaliera S Croce e Carle, Via Coppino 26, Cuneo 12100, Italy

(Email: alterzi{at}libero.it).

To the Editor:

We read with interest the paper by Radu and colleagues [1] about postoperative pneumonia after major pulmonary resections, and congratulate the authors. They report a 24.4% incidence of postresection pulmonary infections and 26.3% mortality among patients with postoperative pneumonia. In their series almost 50% of incidences of postoperative pneumonia occurred within the first 2 postoperative days, which suggests procedure-related onset. Their paper focuses on antibiotic prophylaxis but does not take into consideration the effect on pneumonia of gastroesophageal reflux and aspiration, either intraoperatively or during the postoperative period.

Because we believe this is an important issue, it would be interesting to know whether the authors use preemptive gastrointestinal tract management (intraoperative placement of a nasogastric tube that is removed after surgery in the recovery room; and nothing by mouth on the day of the operation, liquids on the first postoperative day, and regular diet thereafter) as reported by Roberts and colleagues [2] and Roberts [3] in an effort to reduce episodes of aspiration. Moreover, they should take into account the fasting period before surgery, which may increase residual gastric volume, increasing the risk of aspiration [4]. In our experience, with this type of gastrointestinal tract management and the same antibiotic prophylaxis used by Radu and colleagues [1], the incidence of postoperative pneumonia is far lower.

Agnew and associates [5] demonstrated that in patients at low-risk, gastrointestinal reflux is more frequent than expected with the patient in a lateral position, with an incidence of 28%, and recently Keeling and colleagues [6] showed that aspiration after thoracotomy for pulmonary resection may affect nearly 20% of patients. Thus careful management of the gastrointestinal tract, even using H2 antagonists or proton pump inhibitors, seems of paramount importance.

Although statistical significance was not reached, the use of a nasogastric tube has been shown to increase respiratory infections after lung surgery only if left in place longer than 1 day postoperatively [7].

	References

Top References

 

1. Radu DM, Jauréguy F, Seguin A, et al. Postresection pneumonia after major pulmonary resections: an unsolved problem in thoracic surgery Ann Thorac Surg 2007;84:1669-1674.[Abstract/Free Full Text]
2. Roberts JR, Shyr Y, Christian KR, Drinkwater D, Merrill W. Preemptive gastrointestinal tract management reduces aspiration and respiratory failure after thoracic operations J Thorac Cardiovasc Surg 2000;119:449-452.[Abstract/Free Full Text]
3. Roberts JR. Postoperative respiratory failure Thorac Surg Clin 2006;16:235-241.[Medline]
4. Warner MA, Caplan RA, Epstein BS, et al. Practice guidelines on preoperative fasting and the use of pharmacological agents to reduce the risk of pulmonary apiration: application to healthy patients undergoing elective procedure. Report by the American Society of Anesthesiologists Task Frce on Properative Fasting Anesthesiology 1999;90:896-905.[Medline]
5. Agnew NM, Kendall JB, Akrofi M, et al. Gastroesophageal reflux and tracheal aspiration in the thoracotomy position: should ranitidine premedication be routine? Anesth Analg 2002;95:1645-1649.[Abstract/Free Full Text]
6. Keeling WB, Lewis V, Blazick E, Maxey T, Garrett JR, Sommers E. Routine evaluation for aspiration after thoracotomy for pulmonary resection Ann Thorac Surg 2007;83:193-196.[Abstract/Free Full Text]
7. Nan DN, Fernandez-Ayala M, Farinas-Alvarez C, et al. Nosocomial infection after lung surgery Chest 2005;128:2647-2652.[Medline]

This article has been cited by other articles:

				D. M. Radu, F. Jaureguy, and E. Martinod Reply. Ann. Thorac. Surg., September 1, 2008; 86(3): 1060 - 1060. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alberto Terzi Luca Luzzi Andrea Campione Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Terzi, A. Articles by Gorla, A. Search for Related Content PubMed PubMed Citation Articles by Terzi, A. Articles by Gorla, A. Related Collections Lung - other