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The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: a systematic review and meta-analysis

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Abstract

Purpose

Up to 30% of patients undergoing abdominal surgery suffer from postoperative pulmonary complications. The purpose of this systematic review and meta-analyses was to investigate whether postoperative respiratory interventions and mobilization interventions compared with usual care can prevent postoperative complications following abdominal surgery.

Methods

The review was conducted in line with PRISMA and GRADE guidelines. MEDLINE, Embase, and PEDRO were searched for randomized controlled trials and observational studies comparing postoperative respiratory interventions and mobilization interventions with usual care in patients undergoing abdominal surgery. Meta-analyses with trial sequential analysis on the outcome pulmonary complications were performed. Review registration: PROSPERO (identifier: CRD42019133629)

Results

Pulmonary complications were addressed in 25 studies containing 2068 patients. Twenty-three studies were included in the meta-analyses. Patients predominantly underwent open elective upper abdominal surgery. Postoperative respiratory interventions consisted of expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV), assisted inspiratory flow modalities (IPPB, IPAP), patient-operated ventilation modalities (spirometry, PEP), and structured breathing exercises. Meta-analyses found that ventilation with high expiratory resistance (CPAP, EPAP, BiPAP, NIV) reduced the risk of pulmonary complications with OR 0.42 (95% CI 0.18–0.97, p = 0.04, I2 = 0%) compared with usual care, however, the trial sequential analysis revealed that the required information size was not met. Neither postoperative assisted inspiratory flow therapy, patient-operated ventilation modalities, nor breathing exercises reduced the risk of pulmonary complications.

Conclusion

The use of postoperative expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV) after abdominal surgery might prevent pulmonary complications and it seems the preventive abilities were largely driven by postoperative treatment with CPAP.

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Data availability

Data already available as this is a systematic review and meta-analyses.

Code availability

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References

  1. Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. 1995;10:671–8. https://doi.org/10.1007/bf02602761.

    Article  CAS  PubMed  Google Scholar 

  2. Schwieger I, Gamulin Z, Forster A, Meyer P, Gemperle M, Suter PM. Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy. A controlled randomized study. Chest. 1986;89:652–6.

    Article  CAS  PubMed  Google Scholar 

  3. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531–7. https://doi.org/10.1016/j.jamcollsurg.2004.05.276.

    Article  PubMed  Google Scholar 

  4. Kazaure HS, Roman SA, Sosa JA. Association of postdischarge complications with reoperation and mortality in general surgery. Arch Surg. 2012;147:1000–7. https://doi.org/10.1001/2013.jamasurg.114.

    Article  PubMed  Google Scholar 

  5. Brooks-Brunn JA. Postoperative atelectasis and pneumonia. Heart Lung. 1995;24(2):94–115.

    Article  CAS  PubMed  Google Scholar 

  6. LAS Vegas investigators. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS—an observational study in 29 countries. Eur J Anaesthesiol. 2017;34:492–507. https://doi.org/10.1097/eja.0000000000000646.

    Article  Google Scholar 

  7. Warner DO. Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology. 2000;92:1467–72.

    Article  CAS  PubMed  Google Scholar 

  8. Denehy L, Carroll S, Ntoumenopoulos G, Jenkins S. A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery. Physiother Res Int. 2001;6:236–50.

    Article  CAS  PubMed  Google Scholar 

  9. Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br J Surg. 1997;84:1535–8.

    Article  CAS  PubMed  Google Scholar 

  10. Jung R, Wight J, Nusser R, Rosoff L. Comparison of three methods of respiratory care following upper abdominal surgery. Chest. 1980;78:31–5.

    Article  CAS  PubMed  Google Scholar 

  11. Mackay MR, Ellis E, Johnston C. Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Aust J Physiother. 2005;51:151–9.

    Article  PubMed  Google Scholar 

  12. Sanal Bas S, Kultufan TS. Comparison of effect of noninvasive pressure techniques on postoperative pulmonary functions in patients undergoing major abdominal surgery. J Crit Intensive Care. 2017;8:71–6.

    Google Scholar 

  13. Thomas JA, McIntosh JM. Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Phys Ther. 1994;74:3–10. https://doi.org/10.1093/ptj/74.1.3.

    Article  CAS  PubMed  Google Scholar 

  14. Hall JC, Tarala R, Harris J, Tapper J, Christiansen K. Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery. Lancet. 1991;337:953–6. https://doi.org/10.1016/0140-6736(91)91580-n.

    Article  CAS  PubMed  Google Scholar 

  15. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis. 1984;130:12–5. https://doi.org/10.1164/arrd.1984.130.1.12.

    Article  CAS  PubMed  Google Scholar 

  16. Chumillas S, Ponce JL, Delgado F, Viciano V, Mateu M. Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study. Arch Phys Med Rehabil. 1998;79:5–9.

    Article  CAS  PubMed  Google Scholar 

  17. Vester-Andersen M, Lundstrom LH, Møller MH, Waldau T, Rosenberg J, Møller AM. Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. Br J Anaesth. 2014;112:860–70. https://doi.org/10.1093/bja/aet487.

    Article  CAS  PubMed  Google Scholar 

  18. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535. https://doi.org/10.1136/bmj.b2535.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1. https://doi.org/10.1186/2046-4053-4-1.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Greenhalgh T, Peacock R. Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. BMJ. 2005;331:1064–5. https://doi.org/10.1136/bmj.38636.593461.68.

    Article  PubMed  PubMed Central  Google Scholar 

  21. https://www.covidence.org. Accessed 14 Mar 2017.

  22. Higgins JPT. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. London: The Cochrane Collaboration; 2011.

    Google Scholar 

  23. Sterne JAC, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016. https://doi.org/10.1136/bmj.i4919.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Fernandez-Bustamante A, Frendl G, Sprung J, Kor DJ, Subramaniam B, Ruiz RM, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152:157–66. https://doi.org/10.1001/jamasurg.2016.4065.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Tusman G, Bohm SH, Warner DO, Sprung J. Atelectasis and perioperative pulmonary complications in high-risk patients. Curr Opin Anaesthesiol. 2012;25:1–10. https://doi.org/10.1097/ACO.0b013e32834dd1eb.

    Article  CAS  PubMed  Google Scholar 

  26. Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011;343:d4002. https://doi.org/10.1136/bmj.d4002.

    Article  PubMed  Google Scholar 

  27. Schünemann H BJ, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. guidelinedevelopmentorg/handbook. 2013

  28. Tyson AF, Kendig CE, Mabedi C, Cairns BA, Charles AG. The effect of incentive spirometry on postoperative pulmonary function following laparotomy a randomized clinical trial. JAMA Surg. 2015;150:229–36.

    Article  PubMed  Google Scholar 

  29. Ali J, Serrette C, Wood LD, Anthonisen NR. Effect of postoperative intermittent positive pressure breathing on lung function. Chest. 1984;85:192–6.

    Article  CAS  PubMed  Google Scholar 

  30. Arvidsson L, Hallbook T, Lindblad B, Lindroth B, Wolff T. Is the physiotherapeutic respirator care as postoperative prevention valuable? Lakartidningen. 1982;79:1480–1.

    CAS  PubMed  Google Scholar 

  31. Baxter WD, Levine RS. An evaluation of intermittent positive pressure breathing in the prevention of postoperative pulmonary complications. Arch Surg. 1969;98(6):795–8.

    Article  CAS  PubMed  Google Scholar 

  32. Carlsson C, Sonden B, Thylen U. Can postoperative continuous positive airway pressure (CPAP) prevent pulmonary complications after abdominal surgery? Intensive Care Med. 1981;7:225–9.

    Article  CAS  PubMed  Google Scholar 

  33. Chuter TA, Weissman C, Mathews DM, Starker PM. Diaphragmatic breathing maneuvers and movement of the diaphragm after cholecystectomy. Chest. 1990;97:1110–4.

    Article  CAS  PubMed  Google Scholar 

  34. Dohi S, Gold MI. Comparison of two methods of postoperative respiratory care. Chest. 1978;73:592–5.

    Article  CAS  PubMed  Google Scholar 

  35. Hallbook T, Lindblad B, Lindroth B, Wolff T. Prophylaxis against pulmonary complications in patients undergoing gall-bladder surgery. A comparison between early mobilization, physiotherapy with and without bronchodilatation. Ann Chir Gynaecol. 1984;73:55–8.

    CAS  PubMed  Google Scholar 

  36. Heisterberg L, Johansen TS, Larsen HW, Holm M, Andersen B. Postoperative pulmonary complications in upper abdominal surgery. A randomized clinical comparison between physiotherapy and blow-bottles. Acta Chir Scand. 1979;145:505–7.

    CAS  PubMed  Google Scholar 

  37. Lederer DH, Van de Water JM, Indech RB. Which deep breathing device should the postoperative patient use? Chest. 1980;77:610–3.

    Article  CAS  PubMed  Google Scholar 

  38. Lunardi AC, Paisani DM, Silva C, Cano DP, Tanaka C, Carvalho CRF. Comparison of lung expansion techniques on thoracoabdominal mechanics and incidence of pulmonary complications after upper abdominal surgery: a randomized and controlled trial. Chest. 2015;148:1003–100. https://doi.org/10.1378/chest.14-2696.

    Article  PubMed  Google Scholar 

  39. Lyager S, Wernberg M, Rajani N, Boggild-Madsen B, Nielsen L, Nielsen HC, et al. Can postoperative pulmonary conditions be improved by treatment with the Bartlett-Edwards incentive spirometer after upper abdominal surgery? Acta Anaesthesiol Scand. 1979;23:312–9.

    Article  CAS  PubMed  Google Scholar 

  40. Morran CG, Finlay IG, Mathieson M, McKay AJ, Wilson N, McArdle CS. Randomized controlled trial of physiotherapy for postoperative pulmonary complications. Br J Anaesth. 1983;55:1113–7.

    Article  CAS  PubMed  Google Scholar 

  41. O'Connor M, Tattersall MP, Carter JA. An evaluation of the incentive spirometer to improve lung function after cholecystectomy. Anaesthesia. 1988;43:785–7.

    Article  CAS  PubMed  Google Scholar 

  42. Pantel H, Hwang J, Brams D, Schnelldorfer T, Nepomnayshy D. Effect of incentive spirometry on postoperative hypoxemia and pulmonary complications after bariatric surgery: a randomized clinical trial. JAMA Surg. 2017;152:422–8. https://doi.org/10.1001/jamasurg.2016.4981.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Possa SS, Amador CB, Costa AM, Sakamoto ET, Kondo CS, Vasconcellos ALM, et al. Implementation of a guideline for physical therapy in the postoperative period of upper abdominal surgery reduces the incidence of atelectasis and length of hospital stay. Rev Port Pneumol. 2014;20:69–77.

    Article  Google Scholar 

  44. Ricksten SE, Bengtsson A, Soderberg C, Thorden M, Kvist H. Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Chest. 1986;89:774–81.

    Article  CAS  PubMed  Google Scholar 

  45. Rocha M, Souza S, Costa CMD, Merino DFB, Montebelo MIL, Rasera-Junior I, et al. Airway positive pressure vs exercises with inspiratory loading focused on pulmonary and respiratory muscular functions in the postoperative period of bariatric surgery. Arq Bras Cir Dig. 2018;31(2):e1363. https://doi.org/10.1590/0102-672020180001e1363.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Schuppisser JP, Brandli O, Meili U. Postoperative intermittent positive pressure breathing versus physiotherapy. Am J Surg. 1980;140:682–6.

    Article  CAS  PubMed  Google Scholar 

  47. Silva YR, Li SK, Rickard M. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Physiotherapy. 2013;99:187–93.

    Article  CAS  PubMed  Google Scholar 

  48. Sleszynski SL, Kelso AF. Comparison of thoracic manipulation with incentive spirometry in preventing postoperative atelectasis. J Am Osteopat Assoc. 1993;93:834–46.

    CAS  Google Scholar 

  49. Ahn KY, Hur H, Kim DH, Min J, Jeong DH, Chu SH, et al. The effects of inpatient exercise therapy on the length of hospital stay in stages I–III colon cancer patients: randomized controlled trial. Int J Colorectal Dis. 2013;28:643–51. https://doi.org/10.1007/s00384-013-1665-1.

    Article  PubMed  Google Scholar 

  50. Le H, Khankhanian P, Joshi N, Maa J, Crevensten H. Patients recovering from abdominal surgery who walked with volunteers had improved postoperative recovery profiles during their hospitalization. World J Surg. 2014;38:1961–5. https://doi.org/10.1007/s00268-014-2491-5.

    Article  PubMed  Google Scholar 

  51. Ferreyra GP, Baussano I, Squadrone V, Richiardi L, Marchiaro G, Del Sorbo L, et al. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg. 2008;247:617–26. https://doi.org/10.1097/SLA.0b013e3181675829.

    Article  PubMed  Google Scholar 

  52. Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009;374:250–9. https://doi.org/10.1016/s0140-6736(09)60496-7.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Pelosi P, Jaber S. Noninvasive respiratory support in the perioperative period. Curr Opin Anaesthesiol. 2010;23:233–8. https://doi.org/10.1097/ACO.0b013e328335daec.

    Article  PubMed  Google Scholar 

  54. Sibbald WJ. Myocardial function in the critically ill: factors influencing left and right ventricular performance in patients with sepsis and trauma. Surg Clin N Am. 1985;65:867–93.

    Article  CAS  PubMed  Google Scholar 

  55. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI, Timmermans C. The effect of incentive spirometry on postoperative pulmonary complications: a systematic review. Chest. 2001;120:971–8. https://doi.org/10.1378/chest.120.3.971.

    Article  CAS  PubMed  Google Scholar 

  56. Guimaraes MM, El Dib R, Smith AF, Matos D. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev. 2009. https://doi.org/10.1002/14651858.CD006058.pub2.

    Article  PubMed  Google Scholar 

  57. Liu VX, Rosas E, Hwang J, Cain E, Foss-Durant A, Clopp M, et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg. 2017;152:e171032. https://doi.org/10.1001/jamasurg.2017.1032.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011. https://doi.org/10.1002/14651858.CD007635.pub2.

    Article  PubMed  Google Scholar 

  59. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014;38:1531–41. https://doi.org/10.1007/s00268-013-2416-8.

    Article  PubMed  Google Scholar 

  60. Pöpping DM, Elia N, Marret E, Remy C, Tramèr MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg. 2008;143:990–9. https://doi.org/10.1001/archsurg.143.10.990.

    Article  PubMed  Google Scholar 

  61. Canet J, Gallart L, Gomar C, Paluzie G, Valles J, Castillo J, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113:1338–500. https://doi.org/10.1097/ALN.0b013e3181fc6e0a.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Center for Surgical Science, Department of Surgery, Zealand University Hospital and Copenhagen University, Lykkebækvej 1, 4600, Køge, Denmark

    Dunja Kokotovic, Adam Berkfors, Ismail Gögenur, Sarah Ekeloef & Jakob Burcharth

  2. Platanvej 5, 1810, Frederiksberg C, Denmark

    Dunja Kokotovic

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  1. Dunja Kokotovic
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  2. Adam Berkfors
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Correspondence to Dunja Kokotovic.

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Electronic supplementary material

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Supplementary file1 TSA analysis of required information size for CPAP (TIFF 26330 kb)

68_2020_1522_MOESM2_ESM.tiff

Supplementary file2 TSA analysis of required information size for assisted inspiratory flow only (IPPB, IPAP) (TIFF 26330 kb)

68_2020_1522_MOESM3_ESM.tiff

Supplementary file3 TSA analysis of required information size for patient operated ventilation devices (spirometry, PEP) (TIFF 26330 kb)

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Supplementary file4 Meta-analysis of patient operated ventilation devices (spirometry, PEP) vs usual care on pulmonary complications in patients undergoing upper GI surgery with a) Forest Plot and b) Funnel Plot (TIFF 26330 kb)

68_2020_1522_MOESM5_ESM.tiff

Supplementary file5 Meta-analysis of patient operated ventilation devices (spirometry, PEP) vs usual care on pulmonary complications in patients undergoing open surgery with a) Forest Plot and b) Funnel Plot (TIFF 26330 kb)

68_2020_1522_MOESM6_ESM.tiff

Supplementary file6 TSA analysis of required information size for respiratory interventions with breathing exercises (TIFF 26330 kb)

68_2020_1522_MOESM7_ESM.tiff

Supplementary file7 Meta-analysis of breathing exercises vs usual care on pulmonary complications in patients undergoing upper GI surgery with a) Forest Plot and b) Funnel Plot (TIFF 26330 kb)

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Kokotovic, D., Berkfors, A., Gögenur, I. et al. The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 47, 975–990 (2021). https://doi.org/10.1007/s00068-020-01522-x

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