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The Association of Preoperative Malnutrition with Delayed Wound Healing and Related Postoperative Complications: A Systematic Review Pretika Prameswari; Raka Jati Prasetya; Mutia Juliana
The Indonesian Journal of General Medicine Vol. 19 No. 2 (2025): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/jpfdb756

Introduction: Preoperative malnutrition is a prevalent and modifiable risk factor in surgical patients, yet its full impact on postoperative recovery remains a critical area of clinical investigation. The objective of this systematic review is to comprehensively synthesize the existing evidence linking preoperative malnutrition to delayed wound healing and a broad spectrum of other adverse postoperative outcomes. Methods: A systematic search of the PubMed, EMBASE, and Cochrane Library databases was conducted to identify relevant observational studies and meta-analyses. Studies were selected if they investigated the association between a defined measure of preoperative malnutrition and postoperative outcomes in adult surgical patients. The methodological quality and risk of bias of included studies were rigorously assessed using the Cochrane "Risk Of Bias In Non-randomized Studies - of Interventions" (ROBINS-I) tool. Data were extracted for a minimum of 15 distinct outcomes, with a primary focus on wound healing complications. Results: Twenty-five studies, encompassing a wide range of surgical specialties and patient populations, met the inclusion criteria. The analysis revealed a consistent and statistically significant association between various markers of malnutrition—including hypoalbuminemia, low Prognostic Nutritional Index (PNI), and high Nutritional Risk Screening 2002 (NRS-2002) scores—and adverse postoperative events. Malnourished patients demonstrated significantly increased rates of surgical site infections (Odds Ratio range: 1.97 to 4.12), wound dehiscence (OR up to 3.24), and anastomotic leakage. Furthermore, malnutrition was strongly correlated with prolonged length of hospital stay (mean difference up to 5.58 days), increased 30-day mortality (OR up to 3.61), higher readmission rates, and a greater incidence of systemic complications such as pulmonary, cardiac, and renal events. Discussion: The synthesized evidence underscores the systemic impact of malnutrition on the physiological response to surgical stress and subsequent recovery. The findings suggest that nutritional deficiencies impair fundamental biological processes, including immune function and tissue synthesis, which are critical for uncomplicated wound healing. The clinical implications are significant, highlighting the necessity of integrating nutritional screening into routine preoperative assessment to identify at-risk patients who may benefit from targeted nutritional optimization. Conclusion: Preoperative malnutrition is a robust and independent predictor of delayed wound healing and a wide array of associated postoperative complications. The integration of routine nutritional assessment and appropriate intervention into standard preoperative care pathways is strongly recommended to improve surgical outcomes, reduce healthcare utilization, and enhance patient safety.

The Association Between Early Menarche and Increased Risk of Cervical Cancer: A Systematic Review Bangar Parlinggoman Tua; Yahya Nurlianto; Mutia Juliana; Lina Haryani; Nanik Cahyati
The Indonesian Journal of General Medicine Vol. 19 No. 2 (2025): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/gpe4zr59

Introduction: Cervical cancer (CC) remains a significant global health burden, primarily driven by persistent high-risk human papillomavirus (HPV) infection. While HPV is the necessary cause, the role of host reproductive cofactors, such as early menarche, in promoting carcinogenesis remains controversial. This systematic review synthesizes the epidemiological evidence on the association between early menarcheal age and the risk of cervical cancer and its precursors. Methods: This review was conducted adhering to the PRISMA 2020 guidelines. A systematic search of PubMed, EMBASE, and Web of Science was performed to identify observational (cohort and case-control) studies published to date. Studies assessing the risk of invasive cervical cancer (ICC), cervical intraepithelial neoplasia (CIN/HSIL), or high-risk HPV (HR-HPV) infection in relation to menarcheal age were included. The methodological quality and risk of bias for included non-randomized studies were rigorously assessed using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool. Results: Seventeen studies met the inclusion criteria. A subset of case-control and cross-sectional studies reported a statistically significant positive association between early menarche and cervical disease. Notably, one meta-analysis of Chinese studies reported a pooled Odds Ratio (OR) of 3.242 for ICC. Another study found a strong association between early menarche (<13 years) and HPV 16/18 infection (OR = 6.2). A 2023 study also identified early menarche as a significant risk factor for high-grade squamous intraepithelial lesions (HSIL). However, these findings are contradicted by larger, more methodologically robust prospective cohort and pooled case-control analyses. These high-quality studies, which included comprehensive adjustment for key confounders, found no significant independent association between menarcheal age and risk of ICC. The evidence demonstrates that the observed association is strongly mediated by age at first sexual intercourse (AFSI), which is significantly predicted by early menarche (e.g., OR = 6.4). Discussion: The data highlights a critical epidemiological challenge in distinguishing between behavioral mediation and biological causation. The findings are evaluated through two primary pathways: 1) The behavioral-mediation pathway, where early menarche serves as a robust proxy for early AFSI and subsequent HPV exposure; and 2) The biological-plausibility pathway, which posits that early endogenous estrogen exposure creates a "window of vulnerability" in the cervical transformation zone, increasing susceptibility to HPV. The robust null findings in studies that control for AFSI, alongside recent data distinguishing risk for uterine (significant) versus cervical (null) cancer, strongly support the behavioral-mediation pathway. Conclusion: While several studies report a significant positive association, the weight of the highest-quality epidemiological evidence suggests that early menarche is not a direct, independent causal factor for cervical cancer. Instead, it functions as a significant indirect risk marker. The association is robustly and almost entirely mediated by the strong correlation between early menarche and early sexual debut. Public health interventions should therefore focus on this behavioral link, targeting education and HPV vaccination to adolescents, particularly those undergoing early pubertal maturation.

The Relationship Between Nutritional Status and Chemotherapy Toxicity in Patients with Cervical Cancer: A Systematic Review Bangar Parlinggoman Tua; Yahya Nurlianto; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 2 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/tcw7d817

Introduction: Cervical cancer imposes a significant global health burden, disproportionately affecting low- and middle-income countries where malnutrition is also endemic. Antineoplastic therapy, particularly concurrent chemoradiotherapy (CCRT) with platinum-based agents, is the standard of care but is associated with severe toxicities. This systematic review investigates the central hypothesis that poor nutritional status—defined by a range of anthropometric, serological, and body composition metrics—is an independent and significant predictor of increased chemotherapy-related toxicity in cervical cancer patients. Methods: This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A systematic search of PubMed, Scopus, and the Cochrane Library was performed to identify studies evaluating the relationship between nutritional status and chemotherapy toxicity in cervical cancer patients. Eligibility criteria were based on the Population (cervical cancer patients), Exposure (malnutrition), Comparison (well-nourished), and Outcome (toxicity) framework. Methodological quality was appraised using the Cochrane Risk-of-Bias 2 (RoB 2) tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for observational studies. Results: A total of 16 studies (2 RCTs and 14 observational cohorts) met the inclusion criteria. The results demonstrate a consistent and statistically significant association between malnutrition and increased treatment toxicity. Specifically, poor nutritional status assessed by the Patient-Generated Subjective Global Assessment (PG-SGA) was an independent predictor of both Grade 3+ toxicity and Toxicity-Induced Modification of Treatment (TIMT). Sarcopenia (low Skeletal Muscle Index, SMI) was significantly associated with higher rates of treatment interruption due to toxicity (p=0.024) and was a determining factor for Grade 3+ adverse events. Low Body Mass Index (BMI < 18.5 kg/m²) was linked to severe Grade 3/4 gastrointestinal complications, including bowel obstruction (p<0.001). A low Prognostic Nutritional Index (PNI) correlated with increased severity of fatigue, nausea, and diarrhea (p<0.05). Nutritional interventions, such as omega-3 supplementation, were shown in an RCT to significantly reduce the incidence of chemotherapy toxicity. Discussion: The evidence converges to confirm that malnutrition is a critical determinant of chemotherapy tolerance. The mechanisms are multifactorial. Pharmacokinetic alterations, such as hypoalbuminemia, increase the free, active fraction of protein-bound drugs, leading to toxicity. Pharmacodynamic failures, particularly in sarcopenic patients, result in a relative overdose from standard Body Surface Area (BSA)-based dosing due to a smaller volume of distribution. Malnutrition also impairs the host's ability to repair healthy tissue (e.g., gut mucosa, bone marrow) damaged by chemotherapy. Conclusion: Nutritional status is a powerful, modifiable predictor of severe chemotherapy-related toxicity in cervical cancer patients. These findings mandate the integration of nutritional screening (e.g., PG-SGA) and objective assessment (e.g., CT-based SMI) into routine oncological practice. Such screening can risk-stratify patients and trigger pre-emptive nutritional interventions to improve treatment tolerance, reduce toxicity-related interruptions, and optimize clinical outcomes

The Association Between Parity and Cervical Cancer Risk: A Systematic Review Bangar Parlinggoman Tua; Yahya Nurlianto; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 2 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/s0harx65

Introduction: Cervical cancer remains the fourth most common cancer in women globally (Sung et al., 2021; World Health Organization, 2024). While persistent infection with high-risk human papillomavirus (HPV) is established as the necessary cause, it is insufficient for carcinogenesis (Walboomers et al., 1999). Parity (the number of live births) has long been suspected as a critical cofactor, but evidence has been inconsistent (Tekalegn et al., 2022). This review synthesizes the epidemiological evidence on this association. Methods: This systematic review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines (Page et al., 2021). A systematic search of MEDLINE/PubMed, Scopus, HINARI, Google Scholar, and Science Direct was performed (Tekalegn et al., 2022). Inclusion criteria were case-control or cohort studies quantifying the association between parity and cervical cancer risk. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale (NOS) (Wells et al., 2000). Results: A total of 18 observational studies, comprising 17 case-control studies and one prospective cohort study, were included in the final synthesis. A recent, high-quality meta-analysis incorporating many of these studies (Tekalegn et al., 2022) reported a significant pooled odds ratio (OR) from 6,685 participants. The analysis showed that women with high parity had 2.65 times higher odds of developing cervical cancer compared to their low-parity counterparts (OR = 2.65, 95% CI: 2.08–3.38). This review confirms this finding and further highlights a significant dose-response relationship, with risk increasing progressively with each additional birth (Muñoz et al., 2002; Sharma and Pattanshetty, 2018). Discussion: The evidence confirms that high parity is a major, independent cofactor that promotes carcinogenesis, particularly in HPV-positive women (Muñoz et al., 2002). This association is not an artifact of confounding by sexual behavior. Proposed biological mechanisms include: (1) supraphysiological hormonal changes during pregnancy promoting HPV oncogene expression; (2) persistent eversion (ectropion) of the cervical transformation zone, increasing epithelial vulnerability (Jensen et al., 2013); (3) cervical trauma during childbirth facilitating viral persistence; and (4) localized, pregnancy-related immunomodulation that impairs viral clearance. Conclusion: High parity is a robust and significant risk factor for cervical cancer. This finding has direct implications for public health, identifying women with high parity as a high-risk group that should be prioritized for cervical screening and HPV vaccination programs, especially in resource-limited settings where both high parity and cervical cancer incidence are prevalent.

The Impact of Prophylactic HPV Vaccination on the Incidence of High-Grade Cervical Intraepithelial Neoplasia (CIN2/CIN3): A Systematic Review Bangar Parlinggoman Tua; Yahya Nurlianto; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 2 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/kjmnzx32

Introduction: Cervical cancer is the fourth most common cancer in women globally, etiologically linked to persistent high-risk human papillomavirus (HPV) infection (World Health Organization, 2024a; World Health Organization, 2024b). High-grade cervical intraepithelial neoplasia (CIN), specifically CIN2 and CIN3, are the direct, histologically confirmed precursor lesions (Cleveland Clinic, 2023). This systematic review synthesizes the evidence from randomized controlled trials (RCTs) and real-world observational studies on the effectiveness of prophylactic HPV vaccination in reducing the incidence of CIN2 and CIN3 (CIN2+). Methods: Following PRISMA guidelines, a systematic search of PubMed, Embase, and the Cochrane Library was conducted (Ghebrekidan et al., 2024; Khalil et al., 2023). Studies were included if they were RCTs or observational (cohort, case-control) studies assessing the efficacy or effectiveness of prophylactic HPV vaccination (bivalent, quadrivalent, or nonavalent) on histologically confirmed CIN2+ outcomes in females. Methodological quality was appraised using the Cochrane Risk of Bias 2 (RoB 2) tool for RCTs (Sterne et al., 2019; Cochrane, 2024) and the Newcastle-Ottawa Scale (NOS) for observational studies (Wells et al., 2024; Ohri, 2024). Results: This synthesis includes 17 high-quality studies. Foundational RCTs (e.g., FUTURE, PATRICIA) demonstrated near-perfect efficacy (98-100%) against vaccine-type HPV 16/18-related CIN2+ in per-protocol (HPV-naïve) populations (FUTURE II Study Group, 2007; Paavonen et al., 2009; Kjaer et al., 2018). A high-certainty Cochrane review confirmed a 63% reduction in any CIN2+ (irrespective of HPV type) in hrHPV-negative young women (Risk Ratio 0.37, 95% CI 0.25-0.55) (Arbyn et al., 2018). Recent, large-scale real-world effectiveness (RWE) studies from national registries report profound, significant reductions in high-grade lesions. In England, cohorts vaccinated at age 12-13 showed an 87% reduction in invasive cervical cancer and a 97% reduction in CIN3 (Falcaro et al., 2021). In Sweden, vaccination before age 17 was associated with an 88% reduction in invasive cervical cancer (Lei et al., 2020), and in Scotland, an 86% reduction in CIN3+ was observed in the 12-13 age cohort (Palmer et al., 2019). Effectiveness is strongly dependent on vaccination age (Hariri et al., 2023; Herweijer et al., 2016). Furthermore, significant evidence demonstrates high effectiveness (74-87% reduction) in preventing the recurrence of high-grade lesions when used as an adjuvant to surgical conization (Dvořák et al., 2024; Ghelardi et al., 2021). Discussion: The evidence is overwhelming and consistent. The near-100% efficacy observed in controlled trial settings has translated directly into profound population-level effectiveness in countries with high, sustained vaccine uptake (Ghebrekidan et al., 2024; Drolet et al., 2019). The dependency of effectiveness on age confirms the vaccine's prophylactic mechanism, underscoring the criticality of pre-adolescent vaccination. Conclusion: Prophylactic HPV vaccination provides a significant, robust, and long-lasting reduction in the incidence of high-grade cervical precancer (CIN2/3). High-coverage national programs are demonstrating the potential to "almost eliminate" (Falcaro et al., 2021) cervical cancer in vaccinated generations, representing a major public health triumph.

The Relationship Between Pap Smear Screening Adherence and Cervical Cancer Mortality: A Systematic Review Bangar Parlinggoman Tua; Yahya Nurlianto; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 3 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/xnj3se72

INTRODUCTION: Cervical cancer remains a leading cause of cancer-related mortality for women globally, with a disproportionate burden concentrated in low- and middle-income countries (LMICs) (World Health Organization, 2024). This significant disparity is largely attributable to inadequate implementation of, and adherence to, preventive screening programs (Bray et al., 2024). This systematic review synthetically evaluates the quantitative association between adherence to Papanicolaou (Pap) smear screening and cervical cancer mortality. METHODS: A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). Major electronic databases (including PubMed, MEDLINE, Embase, and Web of Science) were searched for observational studies (cohort and case-control) that assessed cervical cancer mortality or the incidence of invasive cervical cancer as an outcome of cytology screening history (Peirson et al., 2013). Study quality and risk of bias were assessed using the Newcastle-Ottawa Scale (NOS), the standard, validated tool for non-randomized studies (Wells et al., 2000). RESULTS: A total of 16 high-impact observational studies met the inclusion criteria. The findings are overwhelmingly consistent and statistically significant in demonstrating a profound protective effect. Large-scale cohort studies demonstrate that women adhering to screening have a substantially lower risk of mortality; one major study found a 70% reduction in cervical cancer mortality (Hazard Ratio: 0.30; 95% Confidence Interval [CI]: 0.12–0.74) (Makino et al., 2006). Case-control studies report exceptionally strong protective effects, with odds ratios (OR) for mortality as low as 0.08 (95% CI: 0.07–0.09) (Landy et al., 2016) and 0.34 (95% CI: 0.14–0.49) (Lönnberg et al., 2013). Furthermore, a meta-analysis of case-control studies on invasive cancer (the precursor to mortality) found a pooled protective effect (OR: 0.35; 95% CI: 0.30–0.41), signifying an approximate 65% reduction in risk (Peirson et al., 2013). DISCUSSION: The evidence irrefutably confirms a significant inverse relationship between screening adherence and mortality. The epidemiological findings demonstrate that the public health failure is not one of diagnostic efficacy but of implementation. This discussion synthesizes the quantitative efficacy of screening with the major documented barriers—economic, psychosocial, cultural, and provider-level—that suppress adherence rates and perpetuate this preventable mortality (Akin-Odanye et al., 2024). CONCLUSION: Adherence to Pap smear screening is a critical, primary determinant in the prevention of cervical cancer mortality. Public health strategies must shift from proving efficacy to aggressively dismantling the known structural and psychosocial barriers to adherence to achieve global elimination targets.

A Systematic Review of the Association of Preoperative Optimization of Diabetic Patients with Perioperative Glycemic Control and Postoperative Outcomes Pretika Prameswari; Raka Jati Prasetya; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 3 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/ptswat97

Introduction: The prevalence of diabetes mellitus (DM) in surgical populations is substantial and represents a significant independent risk factor for postoperative complications. Preoperative optimization of glycemic control has emerged as a key strategy to mitigate these risks by improving patients' physiological resilience to surgical stress. This review systematically evaluates the association between preoperative glycemic status and postoperative outcomes. Methods: A systematic search of PubMed and the Cochrane Library was conducted for studies published through 2024. Inclusion criteria specified randomized controlled trials and observational studies evaluating preoperative glycemic markers (e.g., glycated hemoglobin ( HbA1c ), blood glucose) or structured optimization interventions in adult diabetic patients undergoing surgery. Primary outcomes included surgical site infection (SSI), 30-day mortality, and major adverse cardiovascular events (MACE). Secondary outcomes included length of stay (LOS), acute kidney injury (AKI), and other morbidities. Study quality was appraised using the Cochrane Risk of Bias 2 and ROBINS-I tools. Results: Seventeen studies, encompassing randomized trials and large cohort analyses, met the inclusion criteria. The evidence consistently links poor preoperative glycemic control, indicated by elevated HbA1c or acute hyperglycemia, with a significantly increased risk of postoperative complications. Specifically, high HbA1c levels were strongly associated with higher rates of SSI (Odds Ratio ranging from 2.13 to 3.0) and prolonged hospital LOS. Acute perioperative hyperglycemia was a more direct predictor of MACE and mortality (Hazard Ratio 1.26 for adverse cardiac events). Structured interventions, such as multidisciplinary preoperative clinics, demonstrated efficacy in reducing preoperative HbA1c levels, particularly in patients with the poorest baseline control. Discussion: The synthesized evidence highlights a critical debate regarding the predictive primacy of chronic ( HbA1c ) versus acute (perioperative blood glucose) hyperglycemia. While acute hyperglycemia appears to be the more proximate driver for immediate adverse events like myocardial injury, HbA1c serves as an essential tool for risk stratification, identifying patients who will benefit most from intensive perioperative management. The heterogeneity of the existing literature, particularly the scarcity of high-quality randomized trials, underscores the complexity of this issue. Conclusion: Poor preoperative glycemic control is unequivocally associated with adverse postoperative outcomes in diabetic patients. While the optimal strategy for preoperative optimization remains to be defined by high-quality evidence, current data support a shift from using HbA1c as a rigid surgical gatekeeper to a trigger for activating comprehensive, multidisciplinary perioperative management pathways.

Association of Deep versus Moderate Neuromuscular Blockade with Surgical Conditions and Postoperative Pulmonary Complications: A Systematic Review of Randomized Controlled Trials Pretika Prameswari; Raka Jati Prasetya; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 3 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/b7aatk91

Introduction: The optimal depth of intraoperative neuromuscular blockade (NMB) remains a subject of clinical debate. Deep NMB is hypothesized to improve surgical conditions, particularly in minimally invasive surgery, but has historically been associated with an increased risk of postoperative pulmonary complications (PPCs) due to residual neuromuscular blockade (rNMB). This systematic review evaluates the evidence from randomized controlled trials (RCTs) to compare the effects of deep versus moderate NMB on surgical conditions and the incidence of PPCs. Methods: A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify RCTs comparing deep NMB (defined as a post-tetanic count of 1-2) with moderate NMB (defined as a train-of-four count of 1-2) in adult surgical patients. Primary outcomes were measures of surgical conditions (e.g., surgical rating scales, intraoperative patient movement) and the incidence of a composite of PPCs (e.g., pneumonia, atelectasis, respiratory failure). Secondary outcomes included postoperative pain, opioid consumption, recovery times, and other adverse events. Methodological quality was assessed using the Cochrane Risk of Bias 2 tool. Results: Seventeen RCTs met the inclusion criteria. The evidence consistently demonstrated that deep NMB was significantly associated with improved surgical conditions, including higher surgeon-rated scores, a significantly lower incidence of intraoperative patient movement, and the facilitation of lower intra-abdominal pressures during laparoscopy. Regarding safety, when deep NMB was managed with quantitative neuromuscular monitoring and reversed with appropriate agents, particularly sugammadex, there was no statistically significant increase in the incidence of composite PPCs, pneumonia, or atelectasis compared to moderate NMB. Furthermore, deep NMB was significantly associated with beneficial secondary outcomes, including reduced postoperative pain scores, lower opioid consumption, and a decreased incidence of postoperative nausea and vomiting. Discussion: The findings suggest a clear dissociation between the intraoperative depth of NMB and postoperative pulmonary risk. The primary driver of PPCs is postoperative rNMB, a risk that can be effectively mitigated with precise neuromuscular monitoring and the use of reversal agents capable of reliably antagonizing deep block. The benefits of deep NMB on surgical quality are substantial and are complemented by improvements in postoperative pain and recovery metrics. Conclusion: Deep NMB provides significant intraoperative advantages over moderate NMB, enhancing surgical conditions and safety. When implemented as part of a comprehensive strategy that includes quantitative monitoring and effective pharmacological reversal to prevent residual paralysis, it is not associated with an increased risk of postoperative pulmonary complications and may improve aspects of postoperative recovery.

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