BACKGROUND:Healthcare-associated intra-abdominal infections (HC-IAIs) after abdominal surgery are a major cause of sepsis in intensive care units. While predictors of mortality are well established, the determinants of septic shock remain insufficiently defined. METHODS:This retrospective multicenter study included all adult patients who developed HC-IAI after initial abdominal surgery between 2009 and 2021 in three French intensive care units. Clinical, microbiological, and management data were collected. Independent predictors of septic shock and 90-day mortality were identified using multivariate logistic regression. RESULTS:Among 271 patients [median age 65 (55-74) years, 75.6% with cancer], septic shock occurred in 154 (57%) and 90-day mortality was 14.4%. Independent predictors of septic shock were American Society of Anesthesiologists physical status classification >II [odds ratio (OR): 2.48 (1.42-4.40)], absence of cancer [OR: 2.03 (1.03-4.12)], antibiotic exposure within 48 hours [OR: 1.85 (1.03-3.38)], fungal colonization [OR: 4.37 (1.23-20.94)], and Escherichia coli bacteremia [OR: 3.25 (1.15-10.78)]. Female sex was protective [OR: 0.57 (0.33-0.99)]. The 90-day mortality was independently associated with American Society of Anesthesiologists physical status classification >II [OR: 2.83 (1.08-7.97)], age [OR: 1.10 (1.05-1.16)], Sequential Organ Failure Assessment at reoperation [OR: 1.20 (1.05-1.38)], fungal colonization [OR: 14.36 (2.50-89.21)], and treatment failure [OR: 12.15 (2.09-81.90)], whereas effective source control was protective [OR: 0.22 (0.04-0.84)]. CONCLUSIONS:Determinants of septic shock and 90-day mortality partly overlap but differ in therapeutic implications. Fungal colonization and patient frailty emerged as shared risk factors, while mortality was influenced by age, organ failure, and inadequate source control. Early identification of high-risk profiles and timely, targeted interventions may improve outcomes in postoperative HC-IAI.

Resection of the celiac artery (CA) during surgery for locally advanced pancreatic cancer (LAPC) carries a significant risk of hepatic and gastric ischemia.1,2 In addition, in the current context, where patients undergo intensive chemotherapy before surgery, a new complication has emerged: post-pancreatectomy liver injury (PPLI).3 A 59-year-old patient with biopsy-confirmed locally advanced pancreatic cancer arising from the pancreatic body (Video and Fig. 1) underwent extended neoadjuvant FOLFIRINOX (folinic acid [leucovorin], fluorouracil, irinotecan, and oxaliplatin). The patient was restaged using the A-B-C criteria,4 adding the target approach for anatomical feasibility,5 metabolic imaging, and survival prediction.6 The patient underwent extended pancreatosplenectomy, including resection of the left adrenal gland and the CA (Mayo Clinic class Ia), divestment of the superior mesenteric artery, and portal-superior mesenteric vein reconstruction using a left renal vein graft interposition. Arterial reconstruction was initially deemed unnecessary, as proper hepatic artery flow was maintained—albeit dampened—via the gastroduodenal artery, confirmed by visual inspection and Doppler ultrasound. Postoperatively, the course was notable for a rapid rise in alanine aminotransferase levels without overt clinical or radiological deterioration (Fig. 2). Emergency re-exploration was undertaken with the objective of hepatic arterial revascularization (Fig. 3). We hypothesized that, in the setting of underlying metabolic dysfunction–associated steatotic liver disease, arterial inflow was insufficient to meet the demands of an already vulnerable parenchyma, with increased intrahepatic resistance further compounding ischemic liver injury consistent with clinically relevant (CR)-PPLI. Liver biopsy confirmed acute steatohepatitis and extensive ischemic necrosis. Early postoperative recognition and grading of CR-PPLI is critical to prevent liver failure, as static imaging may fail to reflect dynamic hepatic perfusion. A disproportionate rise in alanine aminotransferase within 48 h is a key warning sign. Prospective multicenter studies are needed to better define the incidence, risk factors, and optimal management of CR-PPLI.

Background: Splenectomy remains necessary in selected oncologic and hematologic indications but is associated with significant postoperative morbidity and mortality. The data on outcomes in this high-risk population remain limited, particularly in mixed cohorts. Methods: We conducted a retrospective cohort study including all patients undergoing splenectomy for oncologic or hematologic causes between 2009 and 2022 at a cancer referral center. The primary outcomes were the occurrence of major complications at day 90 and the 1-year all-cause mortality. Multivariate logistic regression was used to identify independent predictors. Results: Among the 8503 ICU admissions from surgical wards, 204 splenectomies were performed; 179 patients were analyzed. The median age was 64 years, and 100 patients (55.9%) were female. Splenectomy was performed for hematologic malignancies in 76 cases (42.5%) and for oncologic causes in 103 cases (57.5%). Laparotomy was used in 154 cases (86.0%), and metastasectomy was performed in 54 patients (30.2%). At day 90, 86 patients (48.0%) developed a major complication: 12 deaths (6.7%), 44 surgical complications (24.6%), and 71 episodes of sepsis (39.7%). In a multivariate analysis, weight loss (OR 3.39, 95% CI [1.32-8.70], p = 0.011), laparotomy (OR 4.38 [1.09-17.60], p = 0.038), and a higher SAPS II score (OR 1.08 per point [1.03-1.13], p = 0.003) were associated with complications, while metastasectomy was protective (OR 0.23 [0.08-0.67], p = 0.007). At one year, the mortality reached 22.4%. Independent predictors of death were sepsis at one year (OR 5.04, 95% CI [1.30-25.96], p = 0.029), the Charlson Comorbidity Index (OR 1.30 per point, 95% CI [1.04-1.68], p = 0.030), invasive mechanical ventilation (OR 14.94, 95% CI [2.83-118.93], p = 0.003), and a performance status >1 (OR 7.84, 95% CI [2.38-27.75], p < 0.001). Encapsulated bacteria were not isolated; sepsis was mainly due to Gram-negative and enterococcal organisms. Conclusions: Splenectomy in onco-hematologic patients is associated with high rates of sepsis and mortality. In addition to surgical factors, frailty, immune status, and infection independently contribute to the patients' outcomes. These results support risk-adapted perioperative strategies and long-term infectious surveillance in immunocompromised patients.

Introduction: Transhiatal esophagectomy (THE) is used for specific gastroesophageal junction adenocarcinomas. THE is a high-risk surgical procedure. We aimed to assess the impact of postoperative sepsis (sepsis or septic shock) on the 1-year mortality after THE and to determine the risk factors associated with these outcomes. Secondly, we aimed to assess the impact of postoperative sepsis and other risk factors on 1-year cancer recurrence. Method: A retrospective, observational study was undertaken at the Paoli-Calmettes Institute, Marseille, from January 2012 to March 2022. Results: Of 118 patients, 24.6% (n = 29) presented with postoperative sepsis. Their 1-year mortality was 11% (n = 13), and their 1-year cancer recurrence was 23.7% (n = 28). In the multivariate analysis, independent factors for 1-year mortality were the following: postoperative sepsis (OR: 7.22 (1.11–47); p = 0.038), number of lymph nodes removed (OR: 0. 78 (0.64–0.95); p = 0.011), recurrence at one year (OR: 9.22 (1.66–51.1); p = 0.011), mediastinitis (OR: 17.7 (1.43–220); p = 0.025) and intraoperative driving pressure (OR: 1.77 (1.17–2.68); p = 0.015). For postoperative sepsis, independent factors were low-dose vasopressors (OR: 0.26; 95% CI: 0.07–0.95; p = 0.049), a cervical abscess (OR: 5.33; 95% CI: 1.5–18.9; p = 0.01), bacterial pneumonia (OR: 11.1; 95% CI: 2.99–41.0; p < 0.001) and a high SOFA score on day 1 (OR: 2.65; 95% CI: 1.36–5.19; p = 0.04). For 1-year cancer recurrence, independent factors were the number of lymph nodes removed (sHR: 0.87; 95% CI: 0.79–0.96; p = 0.005), pTNM stages of III or IV (sHR: 8.29; 95% CI: 2.71–25.32; p < 0.001) and postoperative sepsis (sHR: 6.54; 95% CI: 1.70–25.13; p = 0.005). Conclusions: Our study indicates that after THE, postoperative sepsis influences survival and cancer recurrence. We identified the associated risk factors, suggesting an early diagnosis might decrease mortality and recurrence.

Introduction Surgical site infections (SSIs) are the second leading cause of healthcare-associated infections in Europe with the highest rates being reported in colorectal surgery (ranging from 9% to 30%). Surgical antibiotic prophylaxis (SAP) is one of the most efficient measures for SSI prevention and should be started before surgical incision. Cefoxitin is an antibiotic widely used as SAP for colorectal surgery, but its continuous administration is currently the subject of debate due to its potential pharmacokinetic advantages. Therefore, the aim of the PROPHYLOXITIN study is to demonstrate that a loading dose followed by continuous infusion of cefoxitin during colorectal surgery (intervention group) decreases the rate of SSI compared to an intermittent bolus administration (control group).Methods and analysis The PROPHYLOXITIN study is a superiority, prospective, double-blind, randomised and multicentre study of 2000 patients undergoing colorectal surgery. The primary objective is to demonstrate the superiority of a loading dose of cefoxitin followed by continuous infusion over intermittent bolus administration in reducing the proportion of SSIs within 30 days after colorectal surgery. Subjects will be randomised 1:1 using a secure web-based random-number generator to one of two study groups. Randomised allocation of treatment will be done by minimisation and stratified according to the centre, the localisation of surgery (colon or rectum) and the type of surgical procedure (laparoscopy or laparotomy).Ethics and dissemination This research has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.Trial registration number EudraCT 2022-003262-20 and Clinical trial NCT05755789.

Background: Acute kidney injury (AKI) frequently occurs following major liver resection, adversely affecting both short- and long-term outcomes. This study aimed to determine the incidence of AKI post-hepatectomy and identify relevant pre- and intraoperative risk factors. Our secondary objectives were to develop a predictive score for postoperative AKI and assess the associations between AKI, chronic kidney disease (CKD), and 1-year mortality. Methods: This was a retrospective study in a cancer referral center in Marseille, France, from 2018 to 2022. Results: Among 169 patients, 55 (32.5%) experienced AKI. Multivariate analysis revealed several independent risk factors for postoperative AKI, including age, body mass index, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, time to liver resection, intraoperative shock, and bile duct reconstruction. Neoadjuvant chemotherapy was protective. The AKIMEBO score was developed, with a threshold of ≥15.6, demonstrating a sensitivity of 89.5%, specificity of 76.4%, positive predictive value of 61.8%, and negative predictive value of 94.4%. AKI was associated with increased postoperative morbidity and one-year mortality following major hepatectomy. Conclusion: AKI is a common complication post-hepatectomy. Factors such as time to liver resection and intraoperative shock management present potential clinical intervention points. The AKIMEBO score can provide a valuable tool for postoperative risk stratification.

BACKGROUND:The optimal method to prevent treatment failure after tracheal extubation in postoperative critically ill patients with obesity and morbid obesity remains unknown. METHODS:We conducted a secondary analysis of the EXTUBOBESE multicentre RCT comparing prophylactic noninvasive ventilation (NIV) and oxygen therapy (high-flow nasal oxygen [HFNO] and standard oxygen) in 585 postoperative critically ill patients with obesity (BMI ≥30 kg m-2) and morbid obesity (BMI ≥40 kg m-2). The primary outcome was treatment failure within 3 days after extubation, a composite of reintubation within 3 days (also analysed separately as secondary outcome), switch to the other study treatment, or premature study treatment discontinuation. The primary outcome analysis used a χ2 test. A Cox model was used for time without reintubation. RESULTS:Treatment failure occurred in 39/292 patients (13.4%) in the NIV group and in 70/293 patients (23.9%) in the oxygen therapy group (absolute risk difference: -10.5; 95% confidence interval: -16.8 to -4.3). Similar results were found when analysing separately HFNO from standard oxygen in the oxygen therapy group. Reintubation rate was 8.6% (25 patients) in the NIV group and 9.9% (29 patients) in the oxygen therapy group (P=0.58). Interaction test was significant for level of obesity (P=0.045). Time without reintubation according to level of obesity significantly differed between NIV group and oxygen therapy group (P=0.02) in patients with BMI ≥40 kg m-2, but not in patients with 30≤BMI<40 kg m-2 (P=0.70). CONCLUSIONS:Among postoperative critically ill adults with obesity undergoing tracheal extubation, our results suggest that use of noninvasive ventilation is effective to reduce treatment failure in comparison with oxygen therapy alone. These effects were more pronounced in patients with morbid obesity. CLINICAL TRIAL REGISTRATION:NCT04014920.

PURPOSE:Prophylactic platelet transfusions (PT) aim to reduce bleeding. We assessed whether restrictive PT compared to prophylactic strategy could apply in ICU. MATERIAL AND METHODS:We conducted a retrospective monocentric study including patients >18 yo with haematological malignancy admitted to the ICU with thrombocytopenia <20 G/L between 2018 and 2021. Patients were classified in 2 groups according transfusion strategy applied during the first 3 days: prophylactic or restrictive transfusion. RESULTS:180 patients were included, 87 and 93 in the restrictive and prophylactic groups respectively. After propensity-score analysis, 2 groups of 54 matched patients were analyzed. Restrictive strategy led to a significant reduction in PT with incidence rate for 100-ICU-patients-days of 34.9 and 49.9, incidence rate ratio = 0.699 [0.5-0.9], p = 0.006, representing a 31% decrease. Decreased PT persisted until day 28 with platelet concentrates transfusions-free days at day 28 of 21 [13-25] and 16.5 [10.2-21] in the 2 groups (p = 0.04). Restrictive strategy did not result in higher grade ≥ 2 bleeding. Transfusion efficiency was low with similar number of days with platelet <10 or < 20 G/L regardless of strategy. Platelet transfusion strategy was not associated with 28-day mortality. Platelet nadir <5G/L was associated with day-28 mortality with HR = 1.882 [1.011-3.055], p = 0.046. CONCLUSION:A restrictive PT strategy appears feasible in the ICU.

BACKGROUND:Biliary sepsis is common in patients with digestive cancer. Recommendations call for antibiotic de-escalation (ADE) as a strategy for antibiotic treatment of sepsis or septic shock. The aim of this study was to identify factors influencing 90-day mortality and to evaluate the impact of ADE. METHODS:This retrospective study was conducted between November 2008 and December 2019 in a referral cancer center. Adults with biliary sepsis or septic shock admitted to the ICU were included. Variables associated with 90-day mortality were identified using univariate and multivariate Cox proportional hazards models. RESULTS:122 patients were included. The 90-day mortality was 30.3% (n = 37). After multivariate analysis, the factors independently associated 90-day mortality were metastatic stage (p = 0.004), biliary tract tumour compression (p = 0.001), multi drug resistant (MDR) bacteria carriage on intensive care unit (ICU)admission (p = 0.048), serum lactate on ICU admission (p < 0.001), the use of extra-renal replacement (p = 0.008), factor V < 50% (p = 0.009) and performance status (ECOG-PS) > 2 (p < 0.001). ADE of the pivotal antibiotic (p = 0.041) and recent cancer surgery (p < 0.001) appeared to be associated with survival. CONCLUSION:The 90-day mortality of biliary sepsis seems to be favourable. The 90-day mortality is associated with organ dysfunctions, but also with ECOG-PS, cancer stage, MDR bacteria colonisation. ADE seems to be safe.

BACKGROUND:Acute pulmonary embolism (PE) is a life-threatening situation in cancer patients. In this situation, anticoagulant therapy is complex to administer due to the risk of bleeding. Only few studies have been conducted when these patients are admitted to the intensive care unit (ICU). The aim of this study was to assess the association between anticoagulation strategies as well as other factors with 90-day mortality in patients with cancer and PE admitted to ICU. Major bleeding was also evaluated according to the type of anticoagulation. METHODS:Retrospective study carried out in 4 ICUs in France over a 12-year period (2009-2021). All patients with cancer and PE were included. An overlap propensity score weighting analysis was performed in the subgroup of patients treated with either unfractionated heparins (UFH) alone or low-molecular-weight heparins (LMWH) alone on 90-day mortality and major bleeding. RESULTS:A total of 218 consecutive cancer patients admitted to ICU and presenting PE were included. The 90-day mortality rate was 42 % for the global cohort. After propensity score analysis in the subgroup of patients treated with either "UFH alone" (n = 80) or "LMWH alone" (n = 71), the 90-day mortality was similar in patients treated with UFH alone (42.6 %) vs LMWH alone (39.9 %): OR = 1.124, CI 95 % [0.571-2.214], p = 0.750. There was a significant increased toward major bleeding rates in the "UFH alone" group (25.5 %) as compared to "LMWH alone" group (11.5 %), p = 0.04. CONCLUSION:In 218 patients admitted to ICU and presenting PE, the 90-day mortality rate was 42 %. Treatment with UFH alone was associated with a mortality comparable to treatment with LMWH alone but it appeared to be more prone to major bleeding.

BackgroundCurrent guidelines recommend using antifungals for selected patients with health care-associated intra-abdominal infection (HC-IAI), but this recommendation is based on a weak evidence. This study aimed to assess the association between early empirical use of antifungals and outcomes in intensive care unit (ICU) adult patients requiring re-intervention after abdominal surgery.MethodsA retrospective, multicentre cohort study with overlap propensity score weighting was conducted in three ICUs located in three medical institutions in France. Patients treated with early empirical antifungals for HC-IAI after abdominal surgery were compared with controls who did not receive such antifungals. The primary endpoint was the death rate at 90 days, and the secondary endpoints were the death rate at 1 year and composite criteria evaluated at 30 days following the HC-IAI diagnosis, including the need for re-intervention, inappropriate antimicrobial therapy and death, whichever occurred first.ResultsAt 90 days, the death rate was significantly decreased in the patients treated with empirical antifungals compared with the control group (11.4% and 20.7%, respectively, p = 0.02). No differences were reported for the secondary outcomes.ConclusionThe use of early empirical antifungal therapy was associated with a decreased death rate at 90 days, with no effect on the death rate at 1 year, the death rate at 30 days, the rate of re-intervention, the need for drainage, and empirical antibiotic and antifungal therapy failure at 30 days.

BACKGROUND:Radical cystectomy (RC) is a major surgery associated with a high morbidity rate. Perioperative fluid management according to enhanced recovery after surgery (ERAS) protocols aims to maintain patients in an optimal euvolemic state while exposing them to acute kidney injury (AKI) in the event of hypovolemia. Postoperative AKI is associated with severe morbidity and mortality. Our main objective was to determine the association between perioperative variables, including some component of ERAS protocols, and occurrence of postoperative AKI within the first 30 days following RC in patients presenting bladder cancer. Our secondary objective was to evaluate the association between a postoperative AKI and the occurrence or worsening of a chronic kidney disease (CKD) within the 2 years following RC. METHODS:We conducted a retrospective observational study in a referral cancer center in France on 122 patients who underwent an elective RC for bladder cancer from 01/02/2015 to 30/09/2019. The primary endpoint was occurrence of AKI between surgery and day 30. The secondary endpoint was survival without occurrence or worsening of a postoperative CKD. AKI and CKD were defined by KDIGO (Kidney Disease: Improving Global Outcomes) classification. Logistic regression analyse was used to determine independent factors associated with postoperative AKI. Fine and Gray model was used to determine independent factors associated with postoperative CKD. RESULTS:The incidence of postoperative AKI was 58,2% (n = 71). Multivariate analysis showed 5 factors independently associated with postoperative AKI: intraoperative restrictive vascular filling < 5ml/kg/h (OR = 4.39, 95%CI (1.05-18.39), p = 0.043), postoperative sepsis (OR = 4.61, 95%CI (1.05-20.28), p = 0.043), female sex (OR = 0.11, 95%CI (0.02-0.73), p = 0.022), score SOFA (Sequential Organ Failure Assessment) at day 1 (OR = 2.19, 95%CI (1.15-4.19), p = 0.018) and delta serum creatinine D1 (OR = 1.06, 95%CI (1.02-1.11), p = 0.006). During the entire follow-up, occurrence or worsening of CKD was diagnosed in 36 (29.5%). A postoperative, AKI was strongly associated with occurrence or worsening of a CKD within the 2 years following RC even after adjustment for confounding factors (sHR = 2.247, 95%CI [1.051-4.806, p = 0.037]). CONCLUSION:A restrictive intraoperative vascular filling < 5ml/kg/h was strongly and independently associated with the occurrence of postoperative AKI after RC in cancer bladder patients. In this context, postoperative AKI was strongly associated with the occurrence or worsening of CKD within the 2 years following RC. A personalized perioperative fluid management strategy needs to be evaluated in these high-risk patients.

The effect of neutropenia and the use of granulocyte colony-stimulating factor (G-CSF) in critically ill patients with cancer are controversial, notably in those with lung injury. Neutropenia recovery can be associated with an acute respiratory failure (ARF) requiring intensive care unit (ICU) admission, especially when G-CSF is administered. In a single-center retrospective study, we evaluated (1) the effect of neutropenia recovery on the 90-day mortality and (2) the impact of G-CSF use on the outcome of patients with cancer and neutropenia with ARF admitted to the ICU. Among 1098 screened patients, 152 were neutropenic at ICU admission. The 90-day mortality was 44.7

Background Data about critically ill metastatic cancer patients functional outcome after unplanned admission to the ICU are scarce. The aim of this study was to assess factors associated with 90-day return home and 1-year survival in this population. Study design and methods A multicenter retrospective study included all consecutive metastatic cancer patients admitted to the ICU for unplanned reason between 2017 and 2020. Results Among 253 included metastatic cancer patients, mainly with lung cancer, 94 patients (37.2%) could return home on day 90. One-year survival rate was 28.5%. Performance status 0 or 1 (OR, 2.18; 95% CI 1.21–3.93; P = 0.010), no malnutrition (OR, 2.90; 95% CI 1.61–5.24; P < 0.001), female gender (OR, 2.39; 95% CI 1.33–4.29; P = 0.004), recent chemotherapy (OR, 2.62; 95% CI 1.40–4.90; P = 0.003), SOFA score ≤ 5 on admission (OR, 2.62; 95% CI 1.41–4.90; P = 0.002) were significantly predictive for 90-day return home. Malnutrition (HR, 1.66; 95% CI 1.18–2.22; P = 0.003), acute respiratory failure (ARF) as reason for admission (HR, 1.40; 95% CI 1.10–1.95; P = 0.043), SAPS II on admission (HR, 1.03; 95% CI 1.02–1.05; P < 0.001) and decisions to forgo life-sustaining therapies (DFLST) (HR, 2.80; 95% CI 2.04–3.84; P < 0.001) were independently associated with 1-year mortality. Conclusions More than one out of three metastatic cancer patients could return home within 3 months after an unplanned admission to the ICU. Previous performance and nutritional status, ongoing specific treatment and low severity of the acute illness were found to be predictive for return home. Such encouraging findings should help change the dismal perception of critically ill metastatic cancer patients.

BACKGROUND:Non-invasive ventilation (NIV) and oxygen therapy (high-flow nasal oxygen [HFNO] or standard oxygen) following extubation have never been compared in critically ill patients with obesity. We aimed to compare NIV (alternating with HFNO or standard oxygen) and oxygen therapy (HFNO or standard oxygen) following extubation of critically ill patients with obesity. METHODS:In this multicentre, parallel group, pragmatic randomised controlled trial, conducted in 39 intensive care units in France, critically ill patients with obesity undergoing extubation were randomly assigned (1:1) to either the NIV group or the oxygen therapy group. Two randomisations were performed: first, randomisation to either NIV or oxygen therapy, and second, randomisation to either HFNO or standard oxygen (also 1:1), which was nested within the first randomisation. Blinding of the randomisation was not possible, but the statistician was masked to group assignment. The primary outcome was treatment failure within 3 days after extubation, a composite of reintubation for mechanical ventilation, switch to the other study treatment, or premature discontinuation of study treatment. The primary outcome was analysed by intention to treat. Effect of medical and surgical status was assessed. The reintubation within 3 days was analysed by intention to treat and after a post-hoc crossover analysis. This study is registered with ClinicalTrials.gov, number NCT04014920. FINDINGS:From Oct 2, 2019, to July 17, 2021, of the 1650 screened patients, 981 were enrolled. Treatment failure occurred in 66 (13·5%) of 490 patients in the NIV group and in 130 (26·5%) of 491 patients in the oxygen-therapy group (relative risk 0·43; 95% CI 0·31-0·60, p<0·0001). Medical or surgical status did not modify the effect of NIV group on the treatment-failure rate. Reintubation within 3 days after extubation was similar in the non-invasive ventilation group and in the oxygen therapy group in the intention-to-treat analysis (48 (10%) of 490 patients and 59 (12%) of 491 patients, p=0·26) and lower in the NIV group than in the oxygen-therapy group in the post-hoc cross-over (51 (9%) of 560 patients and 56 (13%) of 421 patients, p=0·037) analysis. No severe adverse events were reported. INTERPRETATION:Among critically ill adults with obesity undergoing extubation, the use of NIV was effective to reduce treatment-failure within 3 days. Our results are relevant to clinical practice, supporting the use of NIV after extubation of critically ill patients with obesity. However, most of the difference in the primary outcome was due to patients in the oxygen therapy group switching to NIV, and more evidence is needed to conclude that an NIV strategy leads to improved patient-centred outcomes. FUNDING:French Ministry of Health.

Background: Laparoscopic technique and the enhanced recovery after surgery (ERAS) protocol have become the standard of care in patients undergoing right colon cancer surgery, reducing hospital stay and postoperative morbidity. However, the optimal anastomosis technique [intracorporeal anastomosis (ICA) or extracorporeal anastomosis (ECA)] remains debated. This study aimed to determine the optimal perioperative approach (ICA vs. ECA combined with the ERAS program vs. standard care) for patients undergoing laparoscopic right colectomy for cancer.Materials and Methods: This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic right hemicolectomy for cancer between January 2012 and June 2021. Patient data were analyzed in 4 treatment groups according to the type of anastomosis and the care protocol. The primary endpoint was total postoperative hospital stay (THS). The secondary endpoints were recovery time and overall morbidity rate.Results: The baseline characteristics of the 373 included patients were comparable between the 4 groups. THS was significantly shorter in the ICA/ERAS group than in the ECA/standard and ICA/standard groups (P<0.01), but there was no significant difference between the ICA/ERAS and ECA/ERAS groups (5.7 vs. 6.4 d; P=0.17). Recovery time was significantly shorter in the ICA/ERAS group (P<0.01). The overall morbidity rate, including anastomotic morbidity, was comparable among the 4 groups. Regression analysis showed that ICA and the ERAS program were both predictive factors to reduce the THS and recovery time.Conclusions: ICA combined with the ERAS program achieves the best outcomes and thus seems to be the optimal approach for the management of patients undergoing laparoscopic right colectomy for cancer.