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Gielen AHC, Schoenmakers M, Breukink SO, Winkens B, van der Horst J, Wevers KP, Melenhorst J. The value of C-reactive protein, leucocytes and vital signs in detecting major complications after oncological colorectal surgery. Langenbecks Arch Surg 2024; 409:76. [PMID: 38409295 PMCID: PMC10896856 DOI: 10.1007/s00423-024-03266-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE To assess the association of postoperative C-reactive protein (CRP), leucocytes and vital signs in the first three postoperative days (PODs) with major complications after oncological colorectal resections in a tertiary referral centre for colorectal cancer in The Netherlands. METHODS A retrospective cohort study, including 594 consecutive patients who underwent an oncological colorectal resection at Maastricht University Medical Centre between January 2016 and December 2020. Descriptive analyses of patient characteristics were performed. Logistic regression models were used to assess associations of leucocytes, CRP and Modified Early Warning Score (MEWS) at PODs 1-3 with major complications. Receiver operating characteristic curve analyses were used to establish cut-off values for CRP. RESULTS A total of 364 (61.3%) patients have recovered without any postoperative complications, 134 (22.6%) patients have encountered minor complications and 96 (16.2%) developed major complications. CRP levels reached their peak on POD 2, with a mean value of 155 mg/L. This peak was significantly higher in patients with more advanced stages of disease and patients undergoing open procedures, regardless of complications. A cut-off value of 170 mg/L was established for CRP on POD 2 and 152 mg/L on POD 3. Leucocytes and MEWS also demonstrated a peak on POD 2 for patients with major complications. CONCLUSIONS Statistically significant associations were found for CRP, Δ CRP, Δ leucocytes and MEWS with major complications on POD 2. Patients with CRP levels ≥ 170 mg/L on POD 2 should be carefully evaluated, as this may indicate an increased risk of developing major complications.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
| | - Maud Schoenmakers
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Stephanie O Breukink
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jischmaël van der Horst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Kevin P Wevers
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
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2
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Talboom K, van Helsdingen CPM, Abdelrahman S, Derikx JPM, Tanis PJ, Hompes R. Usefulness of CT scan as part of an institutional protocol for proactive leakage management after low anterior resection for rectal cancer. Langenbecks Arch Surg 2022; 407:3567-3575. [PMID: 36002771 DOI: 10.1007/s00423-022-02652-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Highly selective fecal diversion after low anterior resection (LAR) for rectal cancer requires a strict postoperative protocol for early detection of anastomotic leakage (AL). The purpose of this study was to evaluate C-reactive protein (CRP)-based CT imaging in diagnosis and subsequent management of AL. METHODS All patients that underwent a CT scan for suspicion of AL after transanal total mesorectal excision for rectal cancer in a university center (2015-2020) were included. Outcome parameters were diagnostic yield of CT and timing of CT and subsequent intervention. RESULTS Forty-four out of 125 patients underwent CT (35%) with an overall median interval of 5 h (IQR 3-6) from CRP measurement. The anastomosis was diverted in 7/44 (16%). CT was conclusive or highly suspicious for AL in 23, with confirmed AL in all those patients (yield 52%), and was false-negative in one patient (sensitivity 96%). CT initiated subsequent intervention after median 6 h (IQR 3-25). There was no or minor suspicion of AL on imaging in all 20 patients without definitive diagnosis of AL. After CT imaging on day 2, AL was confirmed in 0/1, and these proportions were 6/6 for day 3, 7/10 for day 4, 2/4 for day 5, and 9/23 beyond day 5. CONCLUSION In the setting of an institutional policy of highly selective fecal diversion and pro-active leakage management, the yield of selective CT imaging using predefined CRP cut-off values was 52% with a sensitivity of 96%, enabling timely and tailored intervention after a median of 6 h from imaging.
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Affiliation(s)
- K Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C P M van Helsdingen
- Department of Paediatric Surgery, Emma Childrens Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - S Abdelrahman
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J P M Derikx
- Department of Paediatric Surgery, Emma Childrens Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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3
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Moita LF, Sweeney TE, Póvoa P. A new possibility: gene-expression-based diagnostics for presymptomatic diagnosis of hospital-acquired infections. Intensive Care Med 2022; 48:1206-1207. [PMID: 35916912 DOI: 10.1007/s00134-022-06823-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Luís F Moita
- Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | | | - Pedro Póvoa
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal. .,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark. .,Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Estrada Do Forte Do Alto Do Duque, 1449-005, Lisbon, Portugal.
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4
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Trends in the national early warning score are associated with subsequent mortality – A prospective three-centre observational study with 11,331 general ward patients. Resusc Plus 2022; 10:100251. [PMID: 35620180 PMCID: PMC9127395 DOI: 10.1016/j.resplu.2022.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 10/25/2022] Open
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5
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The science of anastomotic healing. SEMINARS IN COLON AND RECTAL SURGERY 2022; 33. [DOI: 10.1016/j.scrs.2022.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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6
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Clark DA, Steffens D, Solomon M. An umbrella systematic review of drain fluid analysis in colorectal surgery for the detection of anastomotic leak: Not yet ready to translate research studies into clinical practice. Colorectal Dis 2021; 23:2795-2805. [PMID: 34314559 DOI: 10.1111/codi.15844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/13/2021] [Accepted: 06/28/2021] [Indexed: 02/08/2023]
Abstract
AIM Anastomotic leak (AL) is the most important complication of intestinal surgery with an anastomosis. Whilst a number of studies have defined risk factors for AL, frustratingly, low-risk patients still develop AL. Studies have looked at drain fluid analysis for detection of AL, but these findings have failed to translate into routine clinical practice. This umbrella systematic review aims to provide an overview of the promising candidate biomarkers (BMs) that show potential to translate into clinical practice. METHODS A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane, KSR Evidence and the Epistemonikos databases on the 14 April 2021. Only systematic reviews of cohort or controlled studies measuring drain fluid biomarkers in humans were included. The methodological quality of the reviews was assessed using the AMSTAR 2 instrument. Clinical trial registries were searched for trials actively investigating drain fluid BMs. Candidate BMs were classified, and threshold values investigated. RESULTS Nine systematic reviews, published between 2007 and 2020, met the inclusion criteria, and contained a total of 36 cohort studies. A total of 38 different BMs were studied. The most promising category of drain fluid BM was the extravasated intra-luminal substances (EILS) and five registered trials of these BMs were found. Two of nine reviews were of moderate quality. CONCLUSIONS The majority of BMs show inconsistent threshold values and are in the experimental stage. A number are not readily available for adoption into routine clinical practice. Most do not state a cut-off value to be considered as diagnostic.
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Affiliation(s)
- David A Clark
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,University of Qld, St Lucia, Qld, Australia.,St Vincent's Private Hospital Northside, Brisbane, Qld, Australia
| | - Daniel Steffens
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael Solomon
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Shi J, Wu Z, Wu X, Shan F, Zhang Y, Ying X, Li Z, Ji J. Early Diagnosis of Anastomotic Leakage After Gastric Cancer Surgery Via Analysis of Inflammatory Factors in Abdominal Drainage. Ann Surg Oncol 2021; 29:1230-1241. [PMID: 34550478 DOI: 10.1245/s10434-021-10763-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is the most serious postoperative complication for patients with gastric cancer. We aim to develop clinically tools to detect AL in the early phase by analysis of the inflammatory factors (IFs) in abdominal drainage. METHODS We prospectively included 326 patients to establish two independent cohorts, and the concentration of IFs within abdominal drainage was detected. In the primary cohort, an IF-based AL prediction model was constructed using the least absolute shrinkage and selection operator (LASSO) regression. The predictive value of the model was later validated via the validation cohort. RESULTS Analyzing the IFs with LASSO regression, we developed an Anastomotic Score system on postoperative Day 3 (AScore-POD3), which yielded high diagnostic efficacy in the primary cohort (the area under the curve (AUC) = 0.87). The predictive value of AScore-POD3 was validated in the validation cohort, and its AUC was 0.83. We further built an AScore-POD3 based nomogram by combining the AScore-POD3 system with other clinical risk factors of AL. The C-index of the nomogram was 0.93 in the primary cohort and 0.82 in the validation cohort. CONCLUSIONS Our study suggests that AL can be early diagnosed after gastric cancer surgery by measuring drainage IFs.
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Affiliation(s)
- Jinyao Shi
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China
| | - Zhouqiao Wu
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China
| | - Xiaolong Wu
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China
| | - Fei Shan
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China
| | - Yan Zhang
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China
| | - Xiangji Ying
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China
| | - Ziyu Li
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China.
| | - Jiafu Ji
- Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Hai-Dian District, Beijing, People's Republic of China.
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8
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The Role of Heart Rate, Body Temperature, and Respiratory Rate in Predicting Anastomotic Leakage following Surgery for Rectal Cancer. Mediators Inflamm 2021; 2021:8698923. [PMID: 34456630 PMCID: PMC8390156 DOI: 10.1155/2021/8698923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To explore the value of the heart rate, body temperature, and respiratory rate in the early prediction of anastomotic leakage after rectal cancer surgery. Methods Clinical data from patients with rectal cancer who underwent anterior rectal resection in the Department of Gastroenterology, Renmin Hospital of Wuhan University, from January 2017 to December 2019 were collected and analyzed retrospectively. Based on the occurrence of anastomotic leakage after surgery, the patients were divided into two groups: those with and without anastomotic leakage. The quantitative values of the heart rate, body temperature, and respiration rate at day 7 postsurgery were compared between the two groups. The ROC curve was used to analyze their role in the early prediction of anastomotic leakage. Results Among 441 patients with rectal cancer, 30 (6.81%) had clinical anastomotic leakage and were diagnosed at 7 ± 3 days postsurgery. Within 7 days postsurgery, the heart rate, body temperature, and respiratory rate in the anastomotic leakage group were higher than those in the nonanastomotic leakage group. The differences in heart rate (1-5 d), body temperature (2-7 d), and respiratory rate (1-7 d) were statistically significant (P < 0.05). The three ROC curves were drawn, respectively. The predictive value of the heart rate is greatest at days 2-3 postsurgery. The predictive value of the body temperature is greatest at days 4-6 postsurgery. The predictive value of the respiratory rate is best at days 1-4 postsurgery. Conclusion The changes of vital signs (heart rate, body temperature, and respiratory rate) have a certain value in the early prediction of anastomotic leakage after rectal cancer surgery. Observation of postoperative vital signs at 7 days postsurgery is helpful for the early diagnosis of anastomotic leakage.
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9
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García-Del-Valle S, Arnal-Velasco D, Molina-Mendoza R, Gómez-Arnau JI. Update on early warning scores. Best Pract Res Clin Anaesthesiol 2021; 35:105-113. [PMID: 33742570 DOI: 10.1016/j.bpa.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 12/23/2022]
Abstract
Early warning scores (EWS) have the objective to provide a preventive approach for detecting those patients in general wards at risk of deterioration before it begins. Well implemented and combined with a tiered response, the EWS expect to be a relevant tool for patient safety. Most of the evidence for their use has been published for the general EWS. Their strengths, such as objectivity and systematic response, health provider training, universal applicability and automatization potential need to be highlighted to counterbalance the weakness and limitations that have also been described. The near future will probably increase availability of EWS, reliability and predictive value through the spread and acceptability of continuous monitoring in general ward, its integration in decision support algorithms with automatic alerts and the elaboration of temporal vital signs patterns that will finally allow to perform a personal modelling depending on individual patient characteristics.
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10
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Twohig K, Ajith A, Mayampurath A, Hyman N, Shogan BD. Abnormal vital signs after laparoscopic colorectal surgery: More common than you think. Am J Surg 2020; 221:654-658. [PMID: 32847687 DOI: 10.1016/j.amjsurg.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anastomotic leak is a feared complication. The presence of abnormal vital signs is often cited as an important overlooked predictive clue in retrospective settings once the diagnosis of leak has already been established. We aimed to determine the prevalence of abnormal vital signs following colorectal resection and assess its predictive value. METHODS We retrospectively studied patients undergoing colorectal resection. The performance of vital signs in predicting anastomotic leak was assessed using discrete-time survival analysis and receiver operator characteristic curve. RESULTS 1662 patients (841 laparoscopic, 821 open) were included. Clinical anastomotic leak was diagnosed in 50 patients (3.1%). 96.8% of patients of the entire cohort had at least one abnormal vital sign during their postoperative course. No individual vital sign was a strong predictor of anastomotic leak in either laparoscopic or open cohorts. CONCLUSION Vital sign abnormalities are extremely common following open and laparoscopic colorectal surgery and alone are poor predictors of anastomotic leak.
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Affiliation(s)
- Kelly Twohig
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Aswathy Ajith
- Center for Research Informatics, University of Chicago, Chicago, IL, USA
| | | | - Neil Hyman
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, IL, USA
| | - Benjamin D Shogan
- Division of Colon and Rectal Surgery, University of Chicago, Chicago, IL, USA.
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11
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Tsai YY, Chen WTL. Management of anastomotic leakage after rectal surgery: a review article. J Gastrointest Oncol 2019; 10:1229-1237. [PMID: 31949944 DOI: 10.21037/jgo.2019.07.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leaks (ALs) are associated with increased perioperative morbidity and mortality, prolonged length of stay, higher readmission rates, the potential need for further operative interventions, and unintended permanent stomas; resulting in increased hospital costs and resource use, and decreased quality of life. This review article is to present definition, diagnosis and management strategies for AL after rectal surgery.
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Affiliation(s)
- Yuan-Yao Tsai
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
| | - William Tzu-Liang Chen
- Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taichung
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12
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Abstract
Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.
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13
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Santos DRD, Calvo FC, Feijó DH, Araújo NPD, Teixeira RKC, Yasojima EY. New training model using chickens intestine for pediatric intestinal anastomosis. Acta Cir Bras 2019; 34:e201900709. [PMID: 31531529 PMCID: PMC6756215 DOI: 10.1590/s0102-865020190070000009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/20/2019] [Indexed: 12/02/2022] Open
Abstract
Purpose: To develop a new low-cost, easy-to-make and available training model using chickens’ intestine for infant intestinal anastomosis. Methods: Segments of chicken intestine were used to create an intestinal anastomosis simulator. We tried to perform an end-to-end, end-to-side and side-to-side anastomosis. Handsewn sutured anastomosis were performed in single layered with interrupted prolene 5-0 suture. The parameters analyzed were cost, intestine's diameter and length, anastomosis patency and flow-through and leakage amount. Results: In all cases it was possible to make the anastomosis in double layered without difficulties, different from the usual ones. There was a positive patency at all anastomoses after the end of the procedure, with no need for reinterventions. Conclusion: The new training model using chickens’ intestine for infant intestinal anastomosis is low-cost, easy-to-make and easy available.
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Affiliation(s)
- Deivid Ramos Dos Santos
- Fellow Master degree, Postgraduate Program in Surgery and Experimental Research, Universidade do Estado do Pará (UEPA), Belem-PA, Brazil. Acquisition and interpretation of data; conception, design, intellectual and scientific content of the study; interpretation of data; manuscript writing
| | - Faustino Chaves Calvo
- Graduate student, School of Medicine, UEPA, Belem-PA, Brazil. Acquisition and interpretation of data, manuscript writing
| | - Daniel Haber Feijó
- Fellow Master degree, Postgraduate Program in Surgery and Experimental Research, UEPA, Belem-PA, Brazil. Acquisition and interpretation of data
| | - Nayara Pontes de Araújo
- Graduate student, School of Medicine, UEPA, Belem-PA, Brazil. Acquisition and interpretation of data, manuscript writing
| | - Renan Kleber Costa Teixeira
- MS, Department of Experimental Surgery, School of Medicine, UEPA, Belem-PA, Brazil. Interpretation of data, statistics analysis, critical revision
| | - Edson Yuzur Yasojima
- PhD, Associate Professor, Department of Experimental Surgery, School of Medicine, UEPA, Belem-PA, Brazil. Conception, design, intellectual and scientific content of the study, final revision
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14
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Li YD, He KX, Zhu WF. Correlation between invasive microbiota in margin-surrounding mucosa and anastomotic healing in patients with colorectal cancer. World J Gastrointest Oncol 2019; 11:717-728. [PMID: 31558976 PMCID: PMC6755102 DOI: 10.4251/wjgo.v11.i9.717] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Impaired anastomotic healing is one of the major complications resulting from radical resection in colorectal cancer (CRC). Accumulating evidence suggests that intestinal microbiota is correlated with anastomotic healing.
AIM To explore the microbiota structural shift in margin-surrounding mucosa and evaluate the predictive ability of selected bacterial taxa for impaired anastomotic healing.
METHODS Margin-surrounding mucosa samples derived from 37 patients were collected to characterize the microbial community structure by 16s rRNA gene sequencing. The patients were divided into two groups according to the healing status of anastomoses: well-healing group (n = 30) and impaired-healing group (n = 7). Statistic differences in bacteria taxa were compared by Wilcoxon test and chi-squared test. The predictive ability of the selected bacterial taxa for the healing status of anastomoses was evaluated by the area under the receiver operator characteristic curve.
RESULTS Community structure shifts were observed in the impaired-healing group and well-healing group. Six bacterial species were found to be significantly correlated with anastomotic healing, and among these species, Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis were considered as the predictive factors. Taking the known risk factor age into consideration, Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis improved predictive ability for the healing status of anastomoses.
CONCLUSION These data show that Alistipes shahii, Dialister pneumosintes, and Corynebacterium suicordis could be considered as supplementary factors in the prediction of anastomosis healing status in patients after CRC radical resection.
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Affiliation(s)
- Yan-Dong Li
- Division of Colon and Rectal Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Kang-Xin He
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Wei-Fang Zhu
- Division of Dermatology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Sweeney TE, Liesenfeld O, May L. Diagnosis of bacterial sepsis: why are tests for bacteremia not sufficient? Expert Rev Mol Diagn 2019; 19:959-962. [PMID: 31446810 DOI: 10.1080/14737159.2019.1660644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Larissa May
- Department of Emergency Medicine, Davis School of Medicine, University of California Davis Health , Sacramento , CA , USA
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16
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Lee JA, Chico TJA, Renshaw SA. The triune of intestinal microbiome, genetics and inflammatory status and its impact on the healing of lower gastrointestinal anastomoses. FEBS J 2018; 285:1212-1225. [PMID: 29193751 PMCID: PMC5947287 DOI: 10.1111/febs.14346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/07/2017] [Accepted: 11/24/2017] [Indexed: 12/11/2022]
Abstract
Gastrointestinal resections are a common operation and most involve an anastomosis to rejoin the ends of the remaining bowel to restore gastrointestinal (GIT) continuity. While most joins heal uneventfully, in up to 26% of patients healing fails and an anastomotic leak (AL) develops. Despite advances in surgical technology and techniques, the rate of anastomotic leaks has not decreased over the last few decades raising the possibility that perhaps we do not yet fully understand the phenomenon of AL and are thus ill-equipped to prevent it. As in all complex conditions, it is necessary to isolate each different aspect of disease for interrogation of its specific role, but, as we hope to demonstrate in this article, it is a dangerous oversimplification to consider any single aspect as the full answer to the problem. Instead, consideration of important individual observations in parallel could illuminate the way forward towards a possibly simple solution amidst the complexity. This article details three aspects that we believe intertwine, and therefore should be considered together in wound healing within the GIT during postsurgical recovery: the microbiome, the host genetic make-up and their relationship to the perioperative inflammatory status. Each of these, alone or in combination, has been linked with various states of health and disease, and in combining these three aspects in the case of postoperative recovery from bowel resection, we may be nearer an answer to preventing anastomotic leaks than might have been thought just a few years ago.
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Affiliation(s)
- Jou A. Lee
- Department of Infection Immunity and Cardiovascular DiseaseThe Bateson CentreUniversity of SheffieldUK
| | - Timothy J. A. Chico
- Department of Infection Immunity and Cardiovascular DiseaseThe Bateson CentreUniversity of SheffieldUK
| | - Stephen A. Renshaw
- Department of Infection Immunity and Cardiovascular DiseaseThe Bateson CentreUniversity of SheffieldUK
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17
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van Rooijen SJ, Jongen ACHM, Wu ZQ, Ji JF, Slooter GD, Roumen RMH, Bouvy ND. Definition of colorectal anastomotic leakage: A consensus survey among Dutch and Chinese colorectal surgeons. World J Gastroenterol 2017; 23:6172-6180. [PMID: 28970733 PMCID: PMC5597509 DOI: 10.3748/wjg.v23.i33.6172] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/28/2017] [Accepted: 07/24/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the level of consensus on the definition of colorectal anastomotic leakage (CAL) among Dutch and Chinese colorectal surgeons.
METHODS Dutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus in the online questionnaire was defined as > 80% agreement between respondents on various statements regarding a general definition of CAL, and regarding clinical and radiological diagnosis of the complication.
RESULTS Fifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the proposed elements of a general definition of CAL in both countries: ‘extravasation of contrast medium after rectal enema on a CT scan’. Another two were found relevant according to Dutch surgeons: ‘necrosis of the anastomosis found during reoperation’, and ‘a radiological collection treated with percutaneous drainage’. No consensus was found for all other proposed elements that may be included in a general definition.
CONCLUSION There is no universally accepted definition of CAL in the Netherlands and China. Diagnosis of CAL based on clinical manifestations remains a point of discussion in both countries. Dutch surgeons are more likely to report ‘subclinical’ leaks as CAL, which partly explains the higher reported Dutch CAL rates.
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Affiliation(s)
- Stefanus J van Rooijen
- Department of Surgery, Máxima Medical Center, 5500 MB Veldhoven, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Audrey CHM Jongen
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Zhou-Qiao Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Ward I of Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Jia-Fu Ji
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Ward I of Gastrointestinal Cancer Center, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, 5500 MB Veldhoven, The Netherlands
| | - Rudi MH Roumen
- Department of Surgery, Máxima Medical Center, 5500 MB Veldhoven, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
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18
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Petit C, Bezemer R, Atallah L. A review of recent advances in data analytics for post-operative patient deterioration detection. J Clin Monit Comput 2017; 32:391-402. [PMID: 28828569 DOI: 10.1007/s10877-017-0054-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/14/2017] [Indexed: 12/20/2022]
Abstract
Most deaths occurring due to a surgical intervention happen postoperatively rather than during surgery. The current standard of care in many hospitals cannot fully cope with detecting and addressing post-surgical deterioration in time. For millions of patients, this deterioration is left unnoticed, leading to increased mortality and morbidity. Postoperative deterioration detection currently relies on general scores that are not fully able to cater for the complex post-operative physiology of surgical patients. In the last decade however, advanced risk and warning scoring techniques have started to show encouraging results in terms of using the large amount of data available peri-operatively to improve postoperative deterioration detection. Relevant literature has been carefully surveyed to provide a summary of the most promising approaches as well as how they have been deployed in the perioperative domain. This work also aims to highlight the opportunities that lie in personalizing the models developed for patient deterioration for these particular post-surgical patients and make the output more actionable. The integration of pre- and intra-operative data, e.g. comorbidities, vitals, lab data, and information about the procedure performed, in post-operative early warning algorithms would lead to more contextualized, personalized, and adaptive patient modelling. This, combined with careful integration in the clinical workflow, would result in improved clinical decision support and better post-surgical care outcomes.
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Affiliation(s)
- Clemence Petit
- Department of Electrical Engineering, Technical University of Eindhoven, P.O. Box 513, 5600 MB, Eindhoven, The Netherlands
- Patient Care and Measurements Department, Philips Research Eindhoven, High Tech Campus 34, 5656 AE, Eindhoven, The Netherlands
| | - Rick Bezemer
- Patient Care and Measurements Department, Philips Research Eindhoven, High Tech Campus 34, 5656 AE, Eindhoven, The Netherlands
| | - Louis Atallah
- Acute Care Solutions Department, Philips Research North America, 2 Canal Park, Cambridge, MA, 02141, USA.
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19
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Gabayan GZ, Gould MK, Weiss RE, Derose SF, Chiu VY, Sarkisian CA. Emergency Department Vital Signs and Outcomes After Discharge. Acad Emerg Med 2017; 24:846-854. [PMID: 28375565 DOI: 10.1111/acem.13194] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 03/16/2017] [Accepted: 03/23/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Vital signs are critical markers of illness severity in the emergency department (ED). Providers need to understand the abnormal vital signs in older adults that are problematic. We hypothesized that in patients age > 65 years discharged from the ED, there are abnormal vital signs that are associated with an admission to an inpatient bed within 7 days of discharge. METHODS We conducted a retrospective cohort study using data from a regional integrated health system of members age > 65 years during the years 2009 to 2010. We used univariate contingency tables to assess the relationship between hospital admission within 7 days of discharge and vital sign (including systolic blood pressure [sBP], heart rate [HR], body temperature, and pulse oximetry [SpO2 ] values measured closest to discharge) using standard thresholds for abnormal and thresholds derived from the study data. RESULTS Of 104,025 ED discharges, 4,638 (4.5%) were followed by inpatient admission within 7 days. Vital signs had a greater odds of admission beyond a single cutoff. The vital signs with at least twice the odds of admission were sBP < 97 mm Hg (odds ratio [OR] = 2.02, 95% CI = 1.57-2.60), HR > 101 beats/min (OR = 2.00 95% CI = 1.75-2.29), body temperature > 37.3°C (OR = 2.14, 95% CI = 1.90-2.41), and pulse oximetry < 92 SpO2 (OR = 2.04, 95% CI = 1.55-2.68). Patients with two vital sign abnormalities per the analysis had the highest odds of admission. A majority of patients discharged with abnormal vital signs per the analysis were not admitted within 7 days of ED discharge. CONCLUSION While we found a majority of patients discharged with abnormal vital signs as defined by the analysis, not to be admitted after discharge, we identified vital signs associated with at least twice the odds of admission.
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Affiliation(s)
- Gelareh Z. Gabayan
- Department of Medicine; University of California; Los Angeles CA
- Department of Medicine; Greater Los Angeles Veterans Affairs Healthcare System; Los Angeles CA
| | - Michael K. Gould
- Department of Research and Evaluation; Kaiser Permanente Southern California; Pasadena CA
| | - Robert E. Weiss
- Department of Biostatistics; UCLA Fielding School of Public Health; Los Angeles CA
| | - Stephen F. Derose
- Department of Research and Evaluation; Kaiser Permanente Southern California; Pasadena CA
| | - Vicki Y. Chiu
- Department of Research and Evaluation; Kaiser Permanente Southern California; Pasadena CA
| | - Catherine A. Sarkisian
- Department of Medicine; University of California; Los Angeles CA
- Department of Medicine; Greater Los Angeles Veterans Affairs Healthcare System; Los Angeles CA
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20
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Wright EC, Connolly P, Vella M, Moug S. Peritoneal fluid biomarkers in the detection of colorectal anastomotic leaks: a systematic review. Int J Colorectal Dis 2017; 32:935-945. [PMID: 28401350 DOI: 10.1007/s00384-017-2799-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak (AL) in colorectal surgery leads to significant morbidity, mortality and poorer oncological outcomes. Diagnosis of AL is frequently delayed as current methods of detection are not 100% sensitive or specific. 'Biomarkers', such as cytokines and markers of ischaemia, from the milieu of the anastomosis may aid early detection. This paper aims to review the evidence for their role in AL detection, allowing identification of targets for future research. METHODS A systematic review was performed using PubMed, MEDLINE and Cochrane Library databases. Papers concerning detection or prediction of AL with biomarkers were identified. References within the papers were used to identify further relevant articles. RESULTS Research has taken place in small cohorts with varying definitions of AL. Lactate has consistently been shown to be elevated in patients with intra-abdominal complications and ALs. pH on post-operative day 3 showed excellent specificity. Despite mixed results, a meta-analysis found that the cytokines tumour necrosis factor-α and interleukin-6 were elevated early in AL. Detection of bacteria in drain fluid by RT-PCR has good specificity but a high rate of false positives. CONCLUSIONS Peritoneal cytokines, lactate and pH have the potential to identify AL early. The consistency of the results for lactate and pH, alongside the fact that they are easy, quick and inexpensive to test, makes them the most attractive targets. Studies in larger cohorts with standardized definitions of AL are required to clarify their usefulness. Emerging biosensor technology may facilitate the development of small, low-cost and degradable intra-abdominal devices to measure peritoneal fluid biomarkers.
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Affiliation(s)
- Emma C Wright
- Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK.
| | - Patricia Connolly
- Department of Biomedical Engineering, Wolfson Centre, University of Strathclyde, Glasgow, G4 0NW, UK
| | - Mark Vella
- Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK
| | - Susan Moug
- Department of General Surgery, Royal Alexandra Hospital, Ward 26 Day Room, Corsebar Road, Paisley, PA2 9PN, UK
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21
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van Rooijen SJ, Engelen MA, Scheede-Bergdahl C, Carli F, Roumen RMH, Slooter GD, Schep G. Systematic review of exercise training in colorectal cancer patients during treatment. Scand J Med Sci Sports 2017; 28:360-370. [PMID: 28488799 DOI: 10.1111/sms.12907] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2017] [Indexed: 12/11/2022]
Abstract
Colorectal cancer surgery results in considerable postoperative morbidity, mortality and reduced quality of life. As many patients will undergo additional (neo)adjuvant therapy, it is imperative that each individual optimize their physical function. To elucidate the potential of exercise in patient optimization, we investigated the evidence for an exercise program before and after surgical treatment in colorectal cancer patients. A systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions, the guidelines of the Physical Therapy Journal and the PRISMA guidelines. No literature pertaining to exercise training during preoperative neoadjuvant treatment was found. Seven studies, investigating the effects of regular exercise during adjuvant chemotherapy for patients with colorectal cancer or a mixed population, were identified. A small effect (effect size (ES) 0.4) of endurance/interval training and strength training (ES 0.4) was found in two studies conducted in patients with colorectal and gastrointestinal cancer. In five studies that included a mixed population of cancer patients, interval training resulted in a large improvement (ES 1.5; P≤.05). Endurance training alone was found to increase both lower extremity strength and endurance capacity. The effects of strength training in the lower extremity are moderate, whereas, in the upper extremity, the increase is small. There is limited evidence available on exercise training during treatment in colorectal cancer patients. One study concluded exercise therapy may be beneficial for colorectal cancer patients during adjuvant treatment. The possible advantages of training during neoadjuvant treatment may be explored by prehabilitation trials.
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Affiliation(s)
- S J van Rooijen
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, The Netherlands
| | - M A Engelen
- Department of Physiotherapy, Máxima Medical Center, Veldhoven, The Netherlands
| | - C Scheede-Bergdahl
- Department of Kinesiology and Physical Education, McGill University, Montréal, QC, Canada.,Department of Anesthesiology, The Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - F Carli
- Department of Anesthesiology, The Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - R M H Roumen
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, The Netherlands
| | - G D Slooter
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, The Netherlands
| | - G Schep
- Department of Sports Medicine, Máxima Medical Center, Veldhoven, The Netherlands
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22
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Tabatabaie O, Maleki S, Talebpour M. Leukocytosis and neutrophilia after laparoscopic gastric plication. Acta Chir Belg 2017; 117:99-103. [PMID: 27876451 DOI: 10.1080/00015458.2016.1258826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Laparoscopic gastric plication (LGP) is a relatively novel bariatric surgery technique. We have encountered a noticeable proportion of our LGP patients with findings such as leukocytosis and neutrophilia and hypothesized that they are part of normal body response to the operation. OBJECTIVE To evaluate the prevalence and clinical importance of leukocytosis, neutrophilia and abnormal vital signs in patients undergoing LGP during postoperative period. METHODS Forty-four consecutive LGP patients were prospectively followed for 3 months. Records of 44 laparoscopic cholecystectomy patients were also reviewed for comparison. Preoperative and postoperative laboratory test were performed. Minor and major complications were recorded during the study period. RESULTS Mean body mass index (BMI) and age were 37and 42.5, respectively. Mean hospital stay was 3.6 days (range: 3-8 days). Leukocytosis and neutrophilia were detected in 63% and 72% of the LGP patients, respectively, 48 h after the procedure. Whereas, after cholecystectomy only 38.5% and 18% of patients had leukocytosis and neutrophilia, respectively. 25% of the patients suffered from at least one minor complication after LGP. There was no mortality. CONCLUSIONS Leukocytosis and neutrophilia are very common after LGP in both the complicated and uncomplicated cases, and may be a part of normal response to surgery.
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Affiliation(s)
- Omidreza Tabatabaie
- Laparoscopic Surgery Ward, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Siamak Maleki
- Laparoscopic Surgery Ward, Sina Hospital Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Talebpour
- Head, Laparoscopic Surgery Ward, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Postoperative peritonitis is still a life-threatening complication after abdominal surgery and approximately 10,000 patients annually develop postoperative peritonitis in Germany. Early recognition and diagnosis before the onset of sepsis has remained a clinical challenge as no single specific screening test is available. The aim of therapy is a rapid and effective control of the source of infection and antimicrobial therapy. After diagnosis of diffuse postoperative peritonitis surgical revision is usually inevitable after intestinal interventions. Peritonitis after liver, biliary or pancreatic surgery is managed as a rule by means of differentiated therapy approaches depending on the severity.
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Affiliation(s)
- J F Lock
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - C Eckmann
- Klinik für Allgemein-, Viszeral-,Thorax- und Minimal-Invasive Chirurgie, Klinikum Peine, Peine, Deutschland
| | - C-T Germer
- Klinik & Poliklinik für Allgemein- und Viszeralchirurgie, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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24
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Sammour T, Lewis M, Thomas ML, Lawrence MJ, Hunter A, Moore JW. A simple web-based risk calculator (www.anastomoticleak.com) is superior to the surgeon’s estimate of anastomotic leak after colon cancer resection. Tech Coloproctol 2016; 21:35-41. [DOI: 10.1007/s10151-016-1567-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
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25
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Mizrahi I, Eltawil R, Haim N, Chadi SA, Shen B, Erim T, DaSilva G, Wexner SD. The Clinical Utility of Over-the-Scope Clip for the Treatment of Gastrointestinal Defects. J Gastrointest Surg 2016; 20:1942-1949. [PMID: 27688214 DOI: 10.1007/s11605-016-3282-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/17/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The over-the-scope clip (OTSC) is a novel endoscopic tool that enables non-surgical management of gastrointestinal (GI) defects. The aim of this study was to report our experience with OTSC for patients with GI defects. METHODS A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC from 2012 to 2015. Primary outcome was the clinical success of the OTSC for the individual indication. Secondary outcome was the number of additional procedures needed following OTSC. RESULTS Fifty-one patients were treated with OTSC: upper GI (UGI) 30 and lower GI (LGI) 21. GI leak (n = 24; UGI = 12, LGI = 12) and fistulae (n = 17; UGI = 8, LGI = 9) were the most common indications. Overall success rate for the treatment of leaks was 59 % [UGI 66 % vs. LGI 33 % (p = 0.1)]. A lower success rate (35 %) was noted for fistulae [UGI 62 % vs. LGI 0 % (p = 0.001)]. Success rates for UGI perforation, bleeding, and stent anchoring indications were 75, 75, and 50 %, respectively. Additional endoscopic or surgical interventions following OTSC were indicated in 68.6 % of the patients. CONCLUSIONS OTSC appears to have additional value in treating UGI defects. However, lower success rates for LGI defects were noted, specifically for fistulae. Most patients require an additional endoscopic or surgical procedure after one OTSC application.
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Affiliation(s)
- Ido Mizrahi
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Rana Eltawil
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Nadav Haim
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Sami A Chadi
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Bo Shen
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tolga Erim
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
| | - Giovanna DaSilva
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Steven D Wexner
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
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26
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Postpercutaneous Nephrolithotomy Systemic Inflammatory Response Syndrome Is Not Associated With Unplanned Readmission. Urology 2016; 100:33-37. [PMID: 27641935 DOI: 10.1016/j.urology.2016.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/07/2016] [Accepted: 09/03/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the incidence of systemic inflammatory response syndrome (SIRS) following percutaneous nephrolithotomy (PCNL) and evaluate any association with unplanned 90-day readmission. METHODS We retrospectively reviewed consecutive patients undergoing PCNL in 2 dedicated endourologic practices between 2009 and 2013. We collected patient demographics, perioperative culture data, and operative characteristics. SIRS was defined as having 2 or more of the following: maximum white blood cell count >12,000 or <4000, temperature >38 or <34°C, heart rate >90, and respiratory rate >20 within the first 24 hours following PCNL. Proportions between groups were compared to identify significant associations. RESULTS We identified 389 patients undergoing PCNL and 43% (167 of 389) met SIRS criteria, more commonly in patients with multiple PCNL accesses (OR 2.3; CI: 1.1-4.8, P = .025). Readmission was required in 8% (31 of 389), most commonly for infection (n = 21). Although possession of a struvite stone was associated with unplanned readmission (16% vs 4%, P < .01), SIRS in the absence of fever within 48 hours postoperative was not associated with readmission (29.4% vs 25.8%, P = .837). CONCLUSION Nearly half of the patients undergoing PCNL met the criteria for SIRS within the first postoperative day. There was no association between SIRS and unplanned readmission in the postoperative PCNL patient. Despite discharge during the first postoperative day, patients with SIRS (without fever or struvite stones) had no increased risk for unplanned return. Our findings suggest that the development of SIRS immediately following PCNL does not preclude safe discharge on the first postoperative day.
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27
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Oliveira MAP, Pereira TRD, Gilbert A, Tulandi T, de Oliveira HC, De Wilde RL. Bowel complications in endometriosis surgery. Best Pract Res Clin Obstet Gynaecol 2016; 35:51-62. [DOI: 10.1016/j.bpobgyn.2015.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/05/2015] [Indexed: 12/17/2022]
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28
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Sammour T, Hayes IP, Jones IT, Steel MC, Faragher I, Gibbs P. Impact of anastomotic leak on recurrence and survival after colorectal cancer surgery: a BioGrid Australia analysis. ANZ J Surg 2016; 88:E6-E10. [PMID: 27255690 DOI: 10.1111/ans.13648] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/03/2016] [Accepted: 05/08/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is conflicting evidence regarding the oncological impact of anastomotic leak following colorectal cancer surgery. This study aims to test the hypothesis that anastomotic leak is independently associated with local recurrence and overall and cancer-specific survival. METHODS Analysis of prospectively collected data from multiple centres in Victoria between 1988 and 2015 including all patients who underwent colon or rectal resection for cancer with anastomosis was presented. Overall and cancer-specific survival rates and rates of local recurrence were compared using Cox regression analysis. RESULTS A total of 4892 patients were included, of which 2856 had completed 5-year follow-up. The overall anastomotic leak rate was 4.0%. Cox regression analysis accounting for differences in age, sex, body mass index, American Society of Anesthesiologists score and tumour stage demonstrated that anastomotic leak was associated with significantly worse 5-year overall survival (χ 2 = 6.459, P = 0.011) for colon cancer, but only if early deaths were included. There was no difference in 5-year colon cancer-specific survival (χ 2 = 0.582, P = 0.446) or local recurrence (χ 2 = 0.735, P = 0.391). For rectal cancer, there was no difference in 5-year overall survival (χ 2 = 0.266, P = 0.606), cancer-specific survival (χ 2 = 0.008, P = 0.928) or local recurrence (χ 2 = 2.192, P = 0.139). CONCLUSION Anastomotic leak may reduce 5-year overall survival in colon cancer patients but does not appear to influence the 5-year overall survival in rectal cancer patients. There was no effect on local recurrence or cancer-specific survival.
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Affiliation(s)
- Tarik Sammour
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ian P Hayes
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Colorectal Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian T Jones
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Colorectal Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Malcolm C Steel
- Colorectal Unit, Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Ian Faragher
- Colorectal Unit, Department of Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Peter Gibbs
- Department of Medical Oncology, Walter + Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
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29
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Leaks, Pearls, and Pitfalls in Diagnostic Testing. Dis Colon Rectum 2016; 59:477-8. [PMID: 27145303 DOI: 10.1097/dcr.0000000000000597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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30
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Abstract
BACKGROUND Accumulating evidence suggests that peritoneal cytokine concentrations may predict anastomotic leak after colorectal surgery, but previous studies have been underpowered. OBJECTIVE We aimed to test this hypothesis by using a larger prospectively collected data set. DESIGN This study is an analysis of prospectively collected data. SETTINGS This study was conducted at 3 public hospitals in Auckland, New Zealand. PATIENTS Patients undergoing colorectal surgery recruited as part of 3 previous randomized controlled trials were included. MAIN OUTCOME MEASURES Data on peritoneal and plasma levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α on day 1 after colorectal surgery were reanalyzed to evaluate their predictive value for clinically important anastomotic leak. Area under receiver operating characteristic curve analysis was performed. RESULTS A total of 206 patients with complete cytokine data were included. The overall anastomotic leak rate was 8.3%. Concentration levels of peritoneal interleukin-6 and interleukin-10 on day 1 after colorectal surgery were predictive of anastomotic leak (area under receiver operating characteristic curve, 0.72 and 0.74; p = 0.006 and 0.004). Plasma cytokine levels of interleukin-6 were higher on day 1 after colorectal surgery in patients who had an anastomotic leak, but this was a poor predictor of anastomotic leak. Levels of other peritoneal and plasma cytokines were not predictive. LIMITATIONS The study was not powered a priori for anastomotic leak prediction. Although the current data do suggest that peritoneal levels of interleukin-6 and interleukin-10 are predictive of leak, the discriminative value in clinical practice remains unclear. CONCLUSIONS Peritoneal levels of interleukin-6 and interleukin-10 on day 1 after colorectal surgery can predict clinically important anastomotic leak.
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31
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Haskins IN, Krpata DM, O'Rourke CP, Rosenblatt S, Rosen MJ. The clinical significance of postoperative tachycardia following ventral hernia repair. Surgery 2016; 160:418-25. [PMID: 27083481 DOI: 10.1016/j.surg.2016.02.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/12/2016] [Accepted: 02/24/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Early identification of serious adverse events following ventral hernia repair (VHR) could result in improved patient outcomes. Establishment of clinical markers that correlate with serious adverse events following VHR would help facilitate a more timely diagnosis of such events. We investigated the clinical utility of postoperative tachycardia to predict serious adverse events in patients undergoing VHR. METHODS Consecutive patients undergoing VHR at the Cleveland Clinic Comprehensive Hernia Center from September 2013 through June 2015 were identified within the Americas Hernia Society Quality Collaborative database. Tachycardia was classified according to frequency and duration. Sustained tachycardia was defined as >8 consecutive hours of tachycardia on any postoperative day. Serious adverse events were defined as cardiac events, venous thromboembolism, infection, bleeding, and anastomotic leak or missed enterotomy. Association between tachycardia class and serious adverse events was investigated using the Pearson χ(2) test. RESULTS A total of 377 patients underwent VHR during the study period. A total of 119 (31.6%) patients experienced at least 1 episode of tachycardia. There were 26 (6.9%) patients with a serious adverse event. Tachycardia was present in 21 (80.7%) of these patients. Sustained tachycardia had a significant association with serious adverse events (P = .007). The presence of postoperative tachycardia was associated with the occurrence of a serious adverse event, having a positive likelihood ratio of 2.9 (95% confidence interval 2.2-3.7). CONCLUSION Postoperative tachycardia is common following VHR. Nevertheless, sustained tachycardia is associated with a significant risk for serious postoperative adverse events and mandates further investigation.
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Affiliation(s)
- Ivy N Haskins
- Cleveland Clinic Comprehensive Hernia Center, Department of General Surgery, The Cleveland Clinic, Cleveland, OH.
| | - David M Krpata
- Cleveland Clinic Comprehensive Hernia Center, Department of General Surgery, The Cleveland Clinic, Cleveland, OH
| | - Colin P O'Rourke
- Cleveland Clinic Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, OH
| | - Steven Rosenblatt
- Cleveland Clinic Comprehensive Hernia Center, Department of General Surgery, The Cleveland Clinic, Cleveland, OH
| | - Michael J Rosen
- Cleveland Clinic Comprehensive Hernia Center, Department of General Surgery, The Cleveland Clinic, Cleveland, OH
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Soguero-Ruiz C, Hindberg K, Mora-Jiménez I, Rojo-Álvarez JL, Skrøvseth SO, Godtliebsen F, Mortensen K, Revhaug A, Lindsetmo RO, Augestad KM, Jenssen R. Predicting colorectal surgical complications using heterogeneous clinical data and kernel methods. J Biomed Inform 2016; 61:87-96. [PMID: 26980235 DOI: 10.1016/j.jbi.2016.03.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/27/2016] [Accepted: 03/06/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In this work, we have developed a learning system capable of exploiting information conveyed by longitudinal Electronic Health Records (EHRs) for the prediction of a common postoperative complication, Anastomosis Leakage (AL), in a data-driven way and by fusing temporal population data from different and heterogeneous sources in the EHRs. MATERIAL AND METHODS We used linear and non-linear kernel methods individually for each data source, and leveraging the powerful multiple kernels for their effective combination. To validate the system, we used data from the EHR of the gastrointestinal department at a university hospital. RESULTS We first investigated the early prediction performance from each data source separately, by computing Area Under the Curve values for processed free text (0.83), blood tests (0.74), and vital signs (0.65), respectively. When exploiting the heterogeneous data sources combined using the composite kernel framework, the prediction capabilities increased considerably (0.92). Finally, posterior probabilities were evaluated for risk assessment of patients as an aid for clinicians to raise alertness at an early stage, in order to act promptly for avoiding AL complications. DISCUSSION Machine-learning statistical model from EHR data can be useful to predict surgical complications. The combination of EHR extracted free text, blood samples values, and patient vital signs, improves the model performance. These results can be used as a framework for preoperative clinical decision support.
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Affiliation(s)
- Cristina Soguero-Ruiz
- Dept. of Signal Theory and Communications, Telematics and Computing, Universidad Rey Juan Carlos, Fuenlabrada, Spain.
| | - Kristian Hindberg
- Dept. Mathematics and Statistics, University of Tromsø (UiT), Tromsø, Norway
| | - Inmaculada Mora-Jiménez
- Dept. of Signal Theory and Communications, Telematics and Computing, Universidad Rey Juan Carlos, Fuenlabrada, Spain
| | - José Luis Rojo-Álvarez
- Dept. of Signal Theory and Communications, Telematics and Computing, Universidad Rey Juan Carlos, Fuenlabrada, Spain
| | - Stein Olav Skrøvseth
- Norwegian Centre for Integrated Care and Telemedicine, Norway; University Hospital of North Norway (UNN), Norway; IBM T.J. Watson Research Center, Yorktown Heights, NY, USA
| | - Fred Godtliebsen
- Dept. Mathematics and Statistics, University of Tromsø (UiT), Tromsø, Norway
| | - Kim Mortensen
- Dept. of Gastrointestinal Surgery, UNN, Tromsø, Norway; Institute of Clinical Medicine, UiT, Tromsø, Norway
| | - Arthur Revhaug
- Dept. of Gastrointestinal Surgery, UNN, Tromsø, Norway; Clinic for Surgery, Cancer and Women's Health, UNN, Tromsø, Norway
| | - Rolv-Ole Lindsetmo
- Dept. of Gastrointestinal Surgery, UNN, Tromsø, Norway; Institute of Clinical Medicine, UiT, Tromsø, Norway
| | - Knut Magne Augestad
- Norwegian Centre for Integrated Care and Telemedicine, Norway; Dept. of Surgery, Hammerfest Hospital, Norway; Dept. of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, USA; Institute of Clinical Medicine, UiT, Tromsø, Norway
| | - Robert Jenssen
- Norwegian Centre for Integrated Care and Telemedicine, Norway; Dept. of Physics and Technology, UiT, Tromsø, Norway
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Ortega-Deballon P. [How can we decrease mortality due to anastomotic fistula in colorectal surgery?]. Cir Esp 2016; 94:250-1. [PMID: 26874399 DOI: 10.1016/j.ciresp.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/06/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Pablo Ortega-Deballon
- Service de Chirurgie Digestive Cancérologique, CHU Bocage Central Unité de Recherche INSERM 866 «Thérapie locorrégionale en chirurgie», Dijon, Francia.
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Krezalek MA, Umanskiy K, Hyman NH. Reoperative surgery following colorectal anastomotic leaks. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2015.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Wu Z, Boersema GSA, Taha D, Fine I, Menon A, Kleinrensink GJ, Jeekel J, Lange JF. Postoperative Hemodynamic Index Measurement With Miniaturized Dynamic Light Scattering Predicts Colorectal Anastomotic Healing. Surg Innov 2015; 23:115-23. [PMID: 26603692 DOI: 10.1177/1553350615618286] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Perioperative bowel perfusion (local hemodynamic index [LHI]) was measured with a miniaturized dynamic light scattering (mDLS) device, aiming to determine whether anastomotic perfusion correlates with the anastomotic healing process and whether LHI measurement assists in the detection of anastomotic leakage (AL) in colorectal surgery. METHODS A partial colectomy was performed in 21 male Wistar rats. Colonic and anastomotic LHIs were recorded during operation. On postoperative day (POD) 3, the rats were examined for AL manifestations. Anastomotic LHI was recorded before determining the anastomotic bursting pressure (ABP). The postoperative LHI measurements were repeated in 15 other rats with experimental colitis. Clinical manifestations and anastomotic LHI were also determined on POD3. Diagnostic value of LHI measurement was analyzed with the combined data from both experiments. RESULTS Intraoperative LHI measurement showed no correlation with the ABP on POD3. Postoperative anastomotic LHI on POD3 was significantly correlated with ABP in the normal rats (R(2) = 0.52; P < .001) and in the rats with colitis (R(2) = 0.63; P = .0012). Anastomotic LHI on POD3 had high accuracy for identifying ABP <50 mm Hg (Area under the curve = 0.86; standard error = 0.065; P < .001). A cutoff point of 1236 yielded a sensitivity of 100% and a specificity of 65%. On POD3, rats with LHIs <1236 had significantly higher dehiscence rates (40% vs 0%), more weight loss, higher abscess severity, and lower ABPs (P < .05); worse anastomotic inflammation and collagen deposition were also found in the histological examination. CONCLUSION Our data suggest that postoperative evaluation of anastomotic microcirculation with the mDLS device assists in the detection of AL in colorectal surgery.
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Affiliation(s)
- Zhouqiao Wu
- Erasmus University Medical Center, Rotterdam, Netherlands Peking University Cancer Hospital and Institute, Beijing, China
| | | | - Diman Taha
- Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Anand Menon
- Academic Colorectal Center, Havenziekenhuis, Rotterdam, Netherlands
| | | | | | - Johan F Lange
- Erasmus University Medical Center, Rotterdam, Netherlands
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Bozkurt IH, Aydogdu O, Yonguc T, Koras O, Sen V, Yarimoglu S, Degirmenci T. Predictive Value of Leukocytosis for Infectious Complications After Percutaneous Nephrolithotomy. Urology 2015; 86:25-9. [PMID: 26142577 DOI: 10.1016/j.urology.2015.04.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 03/19/2015] [Accepted: 04/23/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the natural history of white blood cell (WBC) values and incidence of leukocytosis after percutaneous nephrolithotomy (PCNL), factors associated with development of postoperative leukocytosis, and predictive value of WBC count for infection. METHODS A total of 303 patients who underwent PCNL for renal stones were included in the recent study. Electronic medical records of the patients were reviewed retrospectively to collect daily serum leukocyte counts and perioperative cultures. WBC count was followed daily for patients with positive urine culture and/or postoperative fever until leukocyte levels turned to normal limits. RESULTS Leukocytosis was detected in 133 of the 303 patients (43.9%). The mean preoperative and postoperative WBC counts were 7.73 ± 2.01 × 10(6) cells/μL and 11.9 ± 3.31 × 10(6) cells/μL, respectively. The average postoperative WBC count increased by 4.2 ± 2.99 × 10(6) cells/μL over the first 2 postoperative days. Receiver operating characteristic curve analysis resulted in an area under the curve of 0.87 and 0.80 for postoperative WBC count and absolute WBC count difference, respectively. The thresholds provided by the analysis were 14.05 × 10(6) cells/μL and an increase greater than 5.25 × 10(6) cells/μL, respectively. CONCLUSION Our data show postoperative leukocytosis is common after PCNL and represents a normal physiologic response to surgery. Our study demonstrated that 14.05 × 10(3) × 10(6) cells/μL WBC count and absolute difference in WBC count from baseline of 5.25 × 10(3) × 10(6) cells/μL were significantly associated with post-PCNL sepsis development. Further studies are needed to determine the significance of leukocytosis for infectious complications after PCNL.
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Affiliation(s)
| | - Ozgu Aydogdu
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Tarik Yonguc
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Omer Koras
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Volkan Sen
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Serkan Yarimoglu
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Tansu Degirmenci
- Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
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Wu Z, Freek D, Lange J. Do normal clinical signs and laboratory tests exclude anastomotic leakage? J Am Coll Surg 2014; 219:164. [PMID: 24952453 DOI: 10.1016/j.jamcollsurg.2014.03.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 03/31/2014] [Indexed: 11/19/2022]
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