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Erschienen in: Annals of Surgical Oncology 13/2023

01.08.2023 | Thoracic Oncology

Quantitative Evaluation of Periodontitis for Predicting the Occurrence of Postoperative Pneumonia After Oncologic Esophagectomy

verfasst von: Yasukazu Kanie, MD, Akihiko Okamura, MD, Ken Tomizuka, DDS, Takao Uchiyama, DDS, Jun Kanamori, MD, Yu Imamura, MD, Tomoki Ebata, MD, Masayuki Watanabe, MD

Erschienen in: Annals of Surgical Oncology | Ausgabe 13/2023

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Abstract

Background

Periodontitis is a biofilm-associated inflammatory periodontal disease associated with postoperative complications after esophagectomy. However, few studies have evaluated the inflammatory burden posed by periodontitis quantitively for patients undergoing oncologic esophagectomy. This study aimed to clarify the relationship between periodontitis and postoperative pneumonia using periodontal inflammatory surface area (PISA).

Methods

The study analyzed 251 patients who underwent esophagectomy for esophageal cancer. The patients were classified into low-PISA and high-PISA groups according to preoperative PISA, and the relationship between the occurrence and severity of postoperative pneumonia was investigated.

Results

The high-PISA group (n = 69) included more males (P < 0.001) and patients with poor performance status (P < 0.024). Postoperative pneumonia occurred more frequently in the high-PISA group than in the low-PISA group (31.9 % vs. 15.9 %; P = 0.008), whereas the incidences of other complications did not differ significantly. In addition, the incidence of severe pneumonia was significantly higher in the high-PISA group (7.2 % vs. 1.6 %; P = 0.038). In the multivariable analysis for adjustment of preoperative confounders, age older than 70 years (odds ratio [OR], 2.62; P = 0.006), high PISA (OR, 2.45; P = 0.012), and smoking history (OR, 2.78; P = 0.006) were the independent variables predicting postoperative pneumonia.

Conclusion

Preoperative higher PISA was significantly associated with the occurrence of overall and severe postoperative pneumonia. The quantitative evaluation of periodontitis using PISA is a useful measure for predicting postoperative pneumonia, and intensive periodontal intervention may contribute to decreasing postoperative pneumonia.
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Literatur
1.
Zurück zum Zitat Takeuchi H, Miyata H, Gotoh M, et al. A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web-based database. Ann Surg. 2014;260:259–66.CrossRefPubMed Takeuchi H, Miyata H, Gotoh M, et al. A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web-based database. Ann Surg. 2014;260:259–66.CrossRefPubMed
2.
Zurück zum Zitat Okamura A, Yamamoto H, Watanabe M, et al. Association between preoperative HbA1c levels and complications after esophagectomy: analysis of 15 801 esophagectomies from the National Clinical Database in Japan. Ann Surg. 2022;276:393–9.CrossRef Okamura A, Yamamoto H, Watanabe M, et al. Association between preoperative HbA1c levels and complications after esophagectomy: analysis of 15 801 esophagectomies from the National Clinical Database in Japan. Ann Surg. 2022;276:393–9.CrossRef
3.
Zurück zum Zitat Kitagawa Y, Matsuda S. Prevention of postoperative pulmonary complication is desired to reduce mortality and improve long-term survival after esophagectomy for esophageal cancer. Ann Gastroenterol Surg. 2020;4:478–9.CrossRefPubMedPubMedCentral Kitagawa Y, Matsuda S. Prevention of postoperative pulmonary complication is desired to reduce mortality and improve long-term survival after esophagectomy for esophageal cancer. Ann Gastroenterol Surg. 2020;4:478–9.CrossRefPubMedPubMedCentral
4.
Zurück zum Zitat Yoshida N, Harada K, Iwatsuki M, Baba Y, Baba H. Precautions for avoiding pulmonary morbidity after esophagectomy. Ann Gastroenterol Surg. 2020;4:480–4.CrossRefPubMedPubMedCentral Yoshida N, Harada K, Iwatsuki M, Baba Y, Baba H. Precautions for avoiding pulmonary morbidity after esophagectomy. Ann Gastroenterol Surg. 2020;4:480–4.CrossRefPubMedPubMedCentral
5.
Zurück zum Zitat Shinozaki H, Matsuoka T, Ozawa S. Pharmacological treatment to reduce pulmonary morbidity after esophagectomy. Ann Gastroenterol Surg. 2021;5:614–22.CrossRefPubMedPubMedCentral Shinozaki H, Matsuoka T, Ozawa S. Pharmacological treatment to reduce pulmonary morbidity after esophagectomy. Ann Gastroenterol Surg. 2021;5:614–22.CrossRefPubMedPubMedCentral
6.
Zurück zum Zitat Kikuchi H, Endo H, Yamamoto H, et al. Impact of reconstruction route on postoperative morbidity after esophagectomy: analysis of esophagectomies in the Japanese National Clinical Database. Ann Gastroenterol Surg. 2022;6:46–53.CrossRefPubMed Kikuchi H, Endo H, Yamamoto H, et al. Impact of reconstruction route on postoperative morbidity after esophagectomy: analysis of esophagectomies in the Japanese National Clinical Database. Ann Gastroenterol Surg. 2022;6:46–53.CrossRefPubMed
7.
Zurück zum Zitat Baba Y, Yoshida N, Shigaki H, et al. Prognostic impact of postoperative complications in 502 patients with surgically resected esophageal squamous cell carcinoma: a retrospective single-institution study. Ann Surg. 2016;264:305–11.CrossRefPubMed Baba Y, Yoshida N, Shigaki H, et al. Prognostic impact of postoperative complications in 502 patients with surgically resected esophageal squamous cell carcinoma: a retrospective single-institution study. Ann Surg. 2016;264:305–11.CrossRefPubMed
8.
Zurück zum Zitat Saeki H, Tsutsumi S, Tajiri H, et al. Prognostic significance of postoperative complications after curative resection for patients with esophageal squamous cell carcinoma. Ann Surg. 2017;265:527–33.CrossRefPubMed Saeki H, Tsutsumi S, Tajiri H, et al. Prognostic significance of postoperative complications after curative resection for patients with esophageal squamous cell carcinoma. Ann Surg. 2017;265:527–33.CrossRefPubMed
9.
Zurück zum Zitat Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. Lancet. 2013;381:400–12.CrossRefPubMed Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. Lancet. 2013;381:400–12.CrossRefPubMed
10.
Zurück zum Zitat Soutome S, Yanamoto S, Funahara M, et al. Effect of perioperative oral care on prevention of postoperative pneumonia associated with esophageal cancer surgery: a multicenter case-control study with propensity score matching analysis. Medicine Baltimore. 2017;96:e7436.CrossRefPubMedPubMedCentral Soutome S, Yanamoto S, Funahara M, et al. Effect of perioperative oral care on prevention of postoperative pneumonia associated with esophageal cancer surgery: a multicenter case-control study with propensity score matching analysis. Medicine Baltimore. 2017;96:e7436.CrossRefPubMedPubMedCentral
11.
Zurück zum Zitat Kuriyama K, Sohda M, Watanabe T, et al. Resistance to preoperative oral care is associated with postoperative pneumonia after oesophageal cancer surgery. Anticancer Res. 2021;41:1507–14.CrossRefPubMed Kuriyama K, Sohda M, Watanabe T, et al. Resistance to preoperative oral care is associated with postoperative pneumonia after oesophageal cancer surgery. Anticancer Res. 2021;41:1507–14.CrossRefPubMed
12.
Zurück zum Zitat Palmer LB, Albulak K, Fields S, Filkin AM, Simon S, Smaldone GC. Oral clearance and pathogenic oropharyngeal colonization in the elderly. Am J Respir Crit Care Med. 2001;164:464–8.CrossRefPubMed Palmer LB, Albulak K, Fields S, Filkin AM, Simon S, Smaldone GC. Oral clearance and pathogenic oropharyngeal colonization in the elderly. Am J Respir Crit Care Med. 2001;164:464–8.CrossRefPubMed
13.
Zurück zum Zitat Akutsu Y, Matsubara H, Shuto K, et al. Preoperative dental brushing can reduce the risk of postoperative pneumonia in esophageal cancer patients. Surgery. 2010;147:497–502.CrossRefPubMed Akutsu Y, Matsubara H, Shuto K, et al. Preoperative dental brushing can reduce the risk of postoperative pneumonia in esophageal cancer patients. Surgery. 2010;147:497–502.CrossRefPubMed
14.
Zurück zum Zitat Yuda M, Yamashita K, Okamura A, et al. Influence of preoperative oropharyngeal microflora on the occurrence of postoperative pneumonia and survival in patients undergoing esophagectomy for esophageal cancer. Ann Surg. 2020;272:1035–43.CrossRefPubMed Yuda M, Yamashita K, Okamura A, et al. Influence of preoperative oropharyngeal microflora on the occurrence of postoperative pneumonia and survival in patients undergoing esophagectomy for esophageal cancer. Ann Surg. 2020;272:1035–43.CrossRefPubMed
15.
Zurück zum Zitat Sato Y, Motoyama S, Takano H, et al. Esophageal cancer patients have a high incidence of severe periodontitis and preoperative dental care reduces the likelihood of severe pneumonia after esophagectomy. Dig Surg. 2016;33:495–502.CrossRefPubMed Sato Y, Motoyama S, Takano H, et al. Esophageal cancer patients have a high incidence of severe periodontitis and preoperative dental care reduces the likelihood of severe pneumonia after esophagectomy. Dig Surg. 2016;33:495–502.CrossRefPubMed
16.
Zurück zum Zitat Nesse W, Abbas F, van der Ploeg I, Spijkervet FK, Dijkstra PU, Vissink A. Periodontal inflamed surface area: quantifying inflammatory burden. J Clin Periodontol. 2008;35:668–73.CrossRefPubMed Nesse W, Abbas F, van der Ploeg I, Spijkervet FK, Dijkstra PU, Vissink A. Periodontal inflamed surface area: quantifying inflammatory burden. J Clin Periodontol. 2008;35:668–73.CrossRefPubMed
17.
Zurück zum Zitat Pietropaoli D, Del Pinto R, Ferri C, et al. Association between periodontal inflammation and hypertension using periodontal inflamed surface area and bleeding on probing. J Clin Periodontol. 2020;47:160–72.CrossRefPubMed Pietropaoli D, Del Pinto R, Ferri C, et al. Association between periodontal inflammation and hypertension using periodontal inflamed surface area and bleeding on probing. J Clin Periodontol. 2020;47:160–72.CrossRefPubMed
18.
Zurück zum Zitat Yoshihara A, Iwasaki M, Miyazaki H, Nakamura K. Bidirectional relationship between renal function and periodontal disease in older Japanese women. J Clin Periodontol. 2016;43:720–6.CrossRefPubMed Yoshihara A, Iwasaki M, Miyazaki H, Nakamura K. Bidirectional relationship between renal function and periodontal disease in older Japanese women. J Clin Periodontol. 2016;43:720–6.CrossRefPubMed
19.
Zurück zum Zitat Boyapati R, Vudathaneni V, Nadella SB, Ramachandran R, Dhulipalla R, Adurty C. Mapping the link between cardiac biomarkers and chronic periodontitis: a clinico-biochemical study. J Indian Soc Periodontol. 2020;24:309–15.CrossRefPubMedPubMedCentral Boyapati R, Vudathaneni V, Nadella SB, Ramachandran R, Dhulipalla R, Adurty C. Mapping the link between cardiac biomarkers and chronic periodontitis: a clinico-biochemical study. J Indian Soc Periodontol. 2020;24:309–15.CrossRefPubMedPubMedCentral
20.
Zurück zum Zitat Takeda K, Mizutani K, Minami I, et al. Association of periodontal pocket area with type 2 diabetes and obesity: a cross-sectional study. BMJ Open Diabetes Res Care. 2021;9:e002139.CrossRefPubMedPubMedCentral Takeda K, Mizutani K, Minami I, et al. Association of periodontal pocket area with type 2 diabetes and obesity: a cross-sectional study. BMJ Open Diabetes Res Care. 2021;9:e002139.CrossRefPubMedPubMedCentral
21.
Zurück zum Zitat Edahiro A, Okamura T, Motohashi Y, et al. Severity of dementia is associated with increased periodontal inflamed surface area: home visit survey of people with cognitive decline living in the community. Int J Environ Res Public Health. 2021;18:11961.CrossRefPubMedPubMedCentral Edahiro A, Okamura T, Motohashi Y, et al. Severity of dementia is associated with increased periodontal inflamed surface area: home visit survey of people with cognitive decline living in the community. Int J Environ Res Public Health. 2021;18:11961.CrossRefPubMedPubMedCentral
22.
Zurück zum Zitat Watanabe M, Mine S, Nishida K, et al. Improvement in short-term outcomes after esophagectomy with a multidisciplinary perioperative care team. Esophagus. 2016;13:337–42.CrossRef Watanabe M, Mine S, Nishida K, et al. Improvement in short-term outcomes after esophagectomy with a multidisciplinary perioperative care team. Esophagus. 2016;13:337–42.CrossRef
23.
Zurück zum Zitat Brierley JDGM, Wittekind C, editors. TNM Classification of Malignant Tumors. 8th edn. Oxford: International Union Against Cancer; 2017. Brierley JDGM, Wittekind C, editors. TNM Classification of Malignant Tumors. 8th edn. Oxford: International Union Against Cancer; 2017.
24.
Zurück zum Zitat Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–55.CrossRefPubMed Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–55.CrossRefPubMed
25.
Zurück zum Zitat Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96.CrossRefPubMed Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187–96.CrossRefPubMed
26.
Zurück zum Zitat Kitagawa Y, Uno T, Oyama T, et al. Esophageal cancer practice guidelines 2017 edited by the Japan Esophageal Society: part 1. Esophagus. 2019;16:1–24.CrossRefPubMed Kitagawa Y, Uno T, Oyama T, et al. Esophageal cancer practice guidelines 2017 edited by the Japan Esophageal Society: part 1. Esophagus. 2019;16:1–24.CrossRefPubMed
27.
Zurück zum Zitat Kitagawa Y, Uno T, Oyama T, et al. Esophageal cancer practice guidelines 2017 edited by the Japan esophageal society: part 2. Esophagus. 2019;16:25–43.CrossRefPubMed Kitagawa Y, Uno T, Oyama T, et al. Esophageal cancer practice guidelines 2017 edited by the Japan esophageal society: part 2. Esophagus. 2019;16:25–43.CrossRefPubMed
29.
Zurück zum Zitat Kanda Y. Investigation of the freely available easy-to-use software “EZR” for medical statistics. Bone Marrow Transplant. 2013;48:452–8.CrossRefPubMed Kanda Y. Investigation of the freely available easy-to-use software “EZR” for medical statistics. Bone Marrow Transplant. 2013;48:452–8.CrossRefPubMed
30.
Zurück zum Zitat Akutsu Y, Matsubara H, Okazumi S, et al. Impact of preoperative dental plaque culture for predicting postoperative pneumonia in esophageal cancer patients. Dig Surg. 2008;25:93–7.CrossRefPubMed Akutsu Y, Matsubara H, Okazumi S, et al. Impact of preoperative dental plaque culture for predicting postoperative pneumonia in esophageal cancer patients. Dig Surg. 2008;25:93–7.CrossRefPubMed
32.
Zurück zum Zitat Park SY, Ahn S, Lee JT, et al. Periodontal inflamed surface area as a novel numerical variable describing periodontal conditions. J Periodontal Implant Sci. 2017;47:328–38.CrossRefPubMedPubMedCentral Park SY, Ahn S, Lee JT, et al. Periodontal inflamed surface area as a novel numerical variable describing periodontal conditions. J Periodontal Implant Sci. 2017;47:328–38.CrossRefPubMedPubMedCentral
33.
Zurück zum Zitat Nishi H, Ohta K, Kuramoto Y, et al. Periodontal inflamed surface area in oral cavity associated with febrile neutropenia in patients with hematologic malignancy undergoing chemotherapy. Sci Rep. 2022;12:2483.CrossRefPubMedPubMedCentral Nishi H, Ohta K, Kuramoto Y, et al. Periodontal inflamed surface area in oral cavity associated with febrile neutropenia in patients with hematologic malignancy undergoing chemotherapy. Sci Rep. 2022;12:2483.CrossRefPubMedPubMedCentral
34.
Zurück zum Zitat Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL. Evidence for cigarette smoking as a major risk factor for periodontitis. J Periodontol. 1993;64:16–23.CrossRefPubMed Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL. Evidence for cigarette smoking as a major risk factor for periodontitis. J Periodontol. 1993;64:16–23.CrossRefPubMed
35.
Zurück zum Zitat Alexandridi F, Tsantila S, Pepelassi E. Smoking cessation and response to periodontal treatment. Aust Dent J. 2018;63:140–9.CrossRefPubMed Alexandridi F, Tsantila S, Pepelassi E. Smoking cessation and response to periodontal treatment. Aust Dent J. 2018;63:140–9.CrossRefPubMed
36.
Zurück zum Zitat Keestra JA, Grosjean I, Coucke W, Quirynen M, Teughels W. Non-surgical periodontal therapy with systemic antibiotics in patients with untreated aggressive periodontitis: a systematic review and meta-analysis. J Periodontal Res. 2015;50:689–706.CrossRefPubMed Keestra JA, Grosjean I, Coucke W, Quirynen M, Teughels W. Non-surgical periodontal therapy with systemic antibiotics in patients with untreated aggressive periodontitis: a systematic review and meta-analysis. J Periodontal Res. 2015;50:689–706.CrossRefPubMed
37.
Zurück zum Zitat Khattri S, Kumbargere Nagraj S, Arora A, et al. Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis. Cochrane Database Syst Rev. 2020;11:cd012568.PubMed Khattri S, Kumbargere Nagraj S, Arora A, et al. Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis. Cochrane Database Syst Rev. 2020;11:cd012568.PubMed
38.
Zurück zum Zitat Watanabe T, Sohda M, Kim M, et al. Preoperative evaluation of oral hygiene may predict the overall survival of patients with esophageal cancer. Esophagus. 2023;20:99–108.CrossRefPubMed Watanabe T, Sohda M, Kim M, et al. Preoperative evaluation of oral hygiene may predict the overall survival of patients with esophageal cancer. Esophagus. 2023;20:99–108.CrossRefPubMed
39.
Zurück zum Zitat Hayashi C, Gudino CV, Gibson FC III, Genco CA. Review: pathogen-induced inflammation at sites distant from oral infection: bacterial persistence and induction of cell-specific innate immune inflammatory pathways. Mol Oral Microbiol. 2010;25:305–16.CrossRefPubMedPubMedCentral Hayashi C, Gudino CV, Gibson FC III, Genco CA. Review: pathogen-induced inflammation at sites distant from oral infection: bacterial persistence and induction of cell-specific innate immune inflammatory pathways. Mol Oral Microbiol. 2010;25:305–16.CrossRefPubMedPubMedCentral
Metadaten
Titel
Quantitative Evaluation of Periodontitis for Predicting the Occurrence of Postoperative Pneumonia After Oncologic Esophagectomy
verfasst von
Yasukazu Kanie, MD
Akihiko Okamura, MD
Ken Tomizuka, DDS
Takao Uchiyama, DDS
Jun Kanamori, MD
Yu Imamura, MD
Tomoki Ebata, MD
Masayuki Watanabe, MD
Publikationsdatum
01.08.2023
Verlag
Springer International Publishing
Erschienen in
Annals of Surgical Oncology / Ausgabe 13/2023
Print ISSN: 1068-9265
Elektronische ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-023-14030-0

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