Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data.

Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.

The Role of Cardiopulmonary Exercise Testing as a Risk Assessment Tool in Patients Undergoing Oesophagectomy: A Systematic Review and Meta-analysis.

INTRODUCTION: Cardiopulmonary exercise testing (CPET) is an objective method of assessing functional capacity to meet the metabolic demands of surgery and has been adopted as a preoperative risk-stratification tool for patients undergoing major procedures. The two main measures are the peak rate of oxygen uptake during exercise ([Formula: see text]O2peak) and anaerobic threshold (AT), the point at which anaerobic metabolism exceeds aerobic metabolism during exercise. This systematic review and meta-analysis evaluates the predictive value of CPET for patients undergoing oesophagectomy. METHODS: A systematic literature search was conducted in databases of CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, and Scopus to identify studies that examined associations between preoperative CPET variables and postoperative outcomes following oesophagectomy. Results were presented as standardised mean difference (SMD) with 95% confidence interval. RESULTS: Seven studies were included in this review. Preoperative [Formula: see text]O2peak moderately correlated with cardiopulmonary complications [SMD = - 0.43; 95% confidence interval (CI) - 0.77 to - 0.09; p = 0.013; I2 = 80.4%], unplanned ICU admissions (SMD = - 0.34; 95% CI - 0.60 to - 0.08; p = 0.011; I2 = 0.0%), and 1-year survival (SMD = 0.31; 95% CI 0.02-0.61; p = 0.045; I2 = 0.0%). Preoperative AT values moderately correlated with unplanned ICU admissions (SMD = - 0.34; 95% CI - 0.61 to - 0.07; p = 0.014; I2 = 0.0%), and 1-year survival (SMD = 0.34; 95% CI 0.00-0.68; p = 0.049; I2 = 7.4%). Neither [Formula: see text]O2peak nor AT demonstrated prognostic value for noncardiopulmonary complications. CONCLUSIONS: [Formula: see text]O2peak and AT, where measured by preoperative CPET testing, are inversely associated with postoperative cardiopulmonary complications, unplanned ICU admissions, and 1-year survival following oesophagectomy. This meta-analysis was not able to identify an absolute cutoff value for CPET variables to discriminate between patients of varying levels of operative risk.

Postoperative epidural analgesia and outcomes following pediatric bilateral lung and heart-lung transplantation: a retrospective observational study.

BACKGROUND: The value of epidural analgesia in pediatric patients having heart and lung transplant surgery is unknown. We aimed to characterize various quality outcomes in patients who did and did not have epidural analgesia. METHODS: Data were collected retrospectively for 62 patients from 2006 to 2023 at a tertiary care transplant center. Patients were evaluated by epidural status. The primary outcome was a hospital stay in days. Other measures of morbidity and mortality were measured as secondary endpoints. RESULTS: The mean age was 12.7 (3) years; 54 (87%) received bilateral lung transplantation, and 8 (13%) received en bloc heart-lung transplantation. 41 (66%) were female. Epidural utilization rate was 74 %, n=45. On univariate analysis, epidural analgesia compared with no epidural was associated with a reduction in the median length of hospital stay from 26.5 to 20 days (p=0.02). After adjustment for age, sex and type of operation, there was no significant difference in LOS. Other findings following univariate analysis included reduced time of postoperative ventilation with a median reduction of 7-2 days (p=0.019), and a reduced 5-day postoperative opioid requirement; median of 2.94-1.21 mg/kg/24 hours (p=0.004) with epidural analgesia. Epidural analgesia was not associated with a change in overall survival (p=0.49). CONCLUSION: Despite a likely improvement in analgesia, we could not demonstrate a definitive impact of epidural analgesia on outcomes in this small cohort of patients. Larger datasets through registries and institutional collaboration will be needed to increase sample size to identify effect sizes and adjust for confounders.