1
|
Chinda D, Shimoyama T, Fujiwara S, Kaizuka M, Yasuda K, Akitaya K, Arai T, Sawada Y, Hayamizu S, Tatsuta T, Kikuchi H, Yanagimachi M, Mikami T, Sakuraba H, Fukuda S. Assessment of the Physical Invasiveness of Peroral Endoscopic Myotomy during the Perioperative Period Based on Changes in Energy Metabolism. Metabolites 2023; 13:969. [PMID: 37755250 PMCID: PMC10536107 DOI: 10.3390/metabo13090969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/12/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
A novel treatment method for achalasia of the esophagus and related disorders is known as peroral endoscopic myotomy (POEM). This study aimed to calculate the resting energy expenditure (REE) and evaluated the degree of physical invasiveness based on metabolic changes during the perioperative period of POEM. Fifty-eight patients who underwent POEM were prospectively enrolled; REE, body weight (BW), and basal energy expenditure were measured on the day of POEM, postoperative day 1 (POD 1), and three days after POEM (POD 3). The median REE/BW increased from 19.6 kcal/kg on the day of POEM to 24.5 kcal/kg on POD 1. On POD 3, it remained elevated at 20.9 kcal/kg. The stress factor on POD 1 was 1.20. Among the factors, including the Eckardt score, operation time, and the length of myotomy, the length of myotomy was associated with changes in REE/BW. During the perioperative period of POEM, the level of variation in energy expenditure was lower than that of esophageal cancer surgeries performed under general anesthesia. However, because the length of myotomy is a factor affecting changes in energy expenditure, careful perioperative management is desirable for patients with longer myotomy lengths.
Collapse
Affiliation(s)
- Daisuke Chinda
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki 036-8563, Japan
| | | | - Sae Fujiwara
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Masatoshi Kaizuka
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Kohei Yasuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Kazuki Akitaya
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Tetsu Arai
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Yohei Sawada
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Shiro Hayamizu
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Hidezumi Kikuchi
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Miyuki Yanagimachi
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan;
| | - Tatsuya Mikami
- Center of Healthy Aging Innovation, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan;
| | - Hirotake Sakuraba
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| |
Collapse
|
2
|
Howell TC, Lumpkin S, Chaumont N. Predicting Colorectal Surgery Readmission Risk: a Surgery-Specific Predictive Model. IISE TRANSACTIONS ON HEALTHCARE SYSTEMS ENGINEERING 2023; 13:175-181. [PMID: 37588752 PMCID: PMC10426736 DOI: 10.1080/24725579.2023.2200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Most current predictive models for risk of readmission were primarily designed from non-surgical patients and often utilize administrative data alone. Models built upon comprehensive data sources specific to colorectal surgery may be key to implementing interventions aimed at reducing readmissions. This study aimed to develop a predictive model for risk of 30-day readmission specific to colorectal surgery patients including administrative, clinical, laboratory, and socioeconomic status (SES) data. Patients admitted to the colorectal surgery service who underwent surgery and were discharged from an academic tertiary hospital between 2017 and 2019 were included. A total of 1549 patients met eligibility criteria for this retrospective split-sample cohort study. The 30-day readmission rate of the cohort was 19.62%. A multivariable logistic regression was developed (C=0.70, 95% CI 0.61-0.73), which outperformed two internationally used readmission risk prediction indices (C=0.58, 95% CI 0.52-0.65) and (C=0.60, 95% CI 0.53-0.66). Tailored surgery-specific readmission models with comprehensive data sources outperform the most used readmission indices in predicting 30-day readmission in colorectal surgery patients. Model performance is improved by using more comprehensive datasets that include administrative and socioeconomic details about a patient, as well as clinical information used for decision-making around the time of discharge.
Collapse
Affiliation(s)
- Thomas Clark Howell
- Department of Surgery, Duke University, Durham, NC
- Department of Surgery, University of North Carolina at Chapel Hill, NC
| | - Stephanie Lumpkin
- Department of Surgery, Duke University, Durham, NC
- Department of Surgery, University of North Carolina at Chapel Hill, NC
| | - Nicole Chaumont
- Department of Surgery, University of North Carolina at Chapel Hill, NC
- Department of Surgery, MedStar Health, Baltimore, MD
| |
Collapse
|
3
|
Raje P, Allar BG, Arndt KR, Crowell KT, Messaris E. Early C-reactive protein after colorectal surgery is not predictive of anastomotic leak: a retrospective cohort study. Langenbecks Arch Surg 2023; 408:142. [PMID: 37036567 DOI: 10.1007/s00423-023-02884-7] [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: 11/28/2022] [Accepted: 04/04/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE Prior studies suggest postoperative C-reactive protein (CRP) trends are sensitive for predicting anastomotic leak (AL) after elective colorectal surgery. However, in the setting of enhanced recovery pathways, multi-day CRP trends may not be feasible. This study aimed to assess the realistic and clinical utility of CRP in prediction of AL. METHODS A retrospective review of patients who underwent elective colectomy or proctectomy from January 2019 to October 2020 at a single institution was performed. Comorbidities, operative characteristics, and perioperative outcomes were recorded. CRP was checked routinely on POD1 and on a clinical basis subsequently. The association between 10-point change in CRP-POD1 and AL was evaluated using multivariable logistic regression. The relationships between CRP-POD3, CRP-POD1, and AL were assessed using exploratory analyses. RESULTS Among 332 patients, 23 (6.9%) developed AL, of which 9 cases (39%) were diagnosed upon readmission. AL was not associated with mortality. Median length of stay was 3 days (IQR 2-5). Median days to AL diagnosis was 7 (IQR 4-15). Adjusting for diverting stoma, steroid use, diagnosis, and open surgery, each 10-point increase in CRP was associated with increased odds of AL (OR 1.12, 95% CI 1.03-1.21, p=0.008). CRP-POD1 had poor discriminant utility for detecting AL (AUC 0.62, 95% CI = 0.494-0.746; p=0.061). CONCLUSION CRP on POD1 is not a reliable method to predict a leak, and trending CRP may not be practical with decreasing lengths of stay in colorectal surgery.
Collapse
Affiliation(s)
- Praachi Raje
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA.
| | - Benjamin G Allar
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Kevin R Arndt
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Kristen T Crowell
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| | - Evangelos Messaris
- Division of Colon and Rectal Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA, 02115, USA
| |
Collapse
|
4
|
Pinares-Carrillo HD, Ortega-Checa D, Vergel-Ramírez K, Chilca-Alva ML, Núñez-Vergara M. Proteína C reactiva como biomarcador predictivo de fuga anastomótica en cirugía oncológica colorrectal: estudio de cohorte retrospectivo. REVISTA COLOMBIANA DE CIRUGÍA 2023. [DOI: 10.30944/20117582.2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Introducción. La fuga anastomótica es la complicación más grave del tratamiento quirúrgico del cáncer de colon por su alta morbimortalidad. El diagnóstico evidente, manifestado por la salida de contenido intestinal por drenajes o la herida quirúrgica, ocurre tardíamente (entre el 6º y 8º día). El objetivo de este trabajo fue estudiar la variación de los valores de la proteína C reactiva postoperatoria para hacer un diagnóstico precoz.
Métodos. Estudio observacional, analítico, retrospectivo, de una cohorte de pacientes con neoplasia, en quienes se realizó cirugía oncológica con anastomosis intestinal, entre enero de 2019 y diciembre de 2021. Se midieron los valores en sangre de proteína C reactiva postoperatoria (1°, 3° y 5° días).
Resultados. Se compararon 225 casos operados que no presentaron fuga con 45 casos con fuga. En los casos sin fuga, el valor de proteína C reactiva al 3º día fue de 148 mg/l y al 5º día de 71 mg/l, mientras en los casos con fuga, los valores fueron de 228,24 mg/l y 228,04 mg/l, respectivamente (p<0,05). Para un valor de 197 mg/l al 3º día la sensibilidad fue de 77 % y para un valor de 120 mg/l al 5º día la sensibilidad fue de 84 %.
Conclusión. El mejor resultado de proteína C reactiva postoperatoria para detectar precozmente la fuga anastomótica se observó al 5º día. El valor de 127 mg/l tuvo la mejor sensibilidad, especificidad y valor predictivo negativo, lo cual permitiría el diagnóstico temprano y manejo oportuno de esta complicación.
Collapse
|
5
|
Correa Neto IJF, Nishiyama VKG, Theis C, Schelle G, Robles AG, Robles L. C-REACTIVE PROTEIN AS POSTOPERATIVE COMPLICATIONS PREDICTOR OF COLORECTAL SURGERIES. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:4-10. [PMID: 37194779 DOI: 10.1590/s0004-2803.202301000-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/19/2022] [Indexed: 05/18/2023]
Abstract
BACKGROUND The use of inflammatory markers in order to accurate the diagnosis, decrease the reoperation rate and enable earlier interventions during the postoperative period of a colorectal surgery is increasingly necessary, with the purpose of reducing morbimortality, nosocomial infections, costs and time of a readmission. OBJECTIVE To analyze C-reactive protein level on the third postoperative day of an elective colorectal surgery and compare the marks between reoperated and non-reoperated patients and to establish a cutoff value to predict or avoid surgical reoperations. METHODS Retrospective study based on the analysis of electronic charts of over 18-year-old patients who underwent an elective colorectal surgery with primary anastomoses during the period from January 2019 to May 2021 by the proctology team of Santa Marcelina Hospital Department of General Surgery with C-reactive protein (CRP) dosage taken on the third postoperative day. RESULTS We assessed 128 patients with a mean age of 59.22 years old and need of reoperation of 20.3% of patients, half of these due to dehiscence of colorectal anastomosis. Comparing CRP rates on the third postoperative day between non-reoperated and reoperated patients, it was noted that in the former group the average was of 153.8±76.2 mg/dL, whereas in reoperated patients it was 198.7±77.4 mg/dL (P<0.0001) and the best CRP cutoff value to predict or investigate reoperation risk was 184.8 mg/L with an accuracy of 68% and negative predictive value of 87.6%. CONCLUSION CRP levels assessed on the third postoperative day of elective colorectal surgery were higher in patients who were reoperated and the cutoff value for intra-abdominal complication of 184.8mg/L presented a high negative predictive value.
Collapse
Affiliation(s)
| | | | - Cláudia Theis
- Hospital Santa Marcelina, Departamento Cirurgia Geral, Serviço de Coloproctologia, São Paulo, SP, Brasil
| | - Gabriela Schelle
- Hospital Santa Marcelina, Departamento Cirurgia Geral, Serviço de Coloproctologia, São Paulo, SP, Brasil
| | | | - Laercio Robles
- Hospital Santa Marcelina, Departamento Cirurgia Geral, Serviço de Coloproctologia, São Paulo, SP, Brasil
| |
Collapse
|
6
|
Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis. Surg Today 2022; 53:718-727. [DOI: 10.1007/s00595-022-02603-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/25/2022] [Indexed: 11/18/2022]
|
7
|
Chinda D, Shimoyama T. Assessment of physical stress during the perioperative period of endoscopic submucosal dissection. World J Gastroenterol 2022; 28:4508-4515. [PMID: 36157933 PMCID: PMC9476878 DOI: 10.3748/wjg.v28.i32.4508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/28/2022] [Accepted: 08/01/2022] [Indexed: 02/06/2023] Open
Abstract
The advantage of endoscopic submucosal dissection (ESD) is that it is less invasive than surgery. ESD is one of the best treatments for older patients as surgery in this age group of patients is difficult. However, it is unclear how much lower the physical stress of ESD is compared with that of surgery. Thus, objective methods are required to assess physical stress in patients who have undergone ESD. The current review of ESD aimed to summarize the recent advancements in the assessment of physical stress during the perioperative period, focusing on changes in energy metabolism and serum opsonic activity (SOA). Based on metabolic changes, resting energy expenditure (REE) was measured using an indirect calorimeter. The stress factor calculated from the REE and the basal energy expenditure computed using the Harris-Benedict equation can be used to assess physical stress. SOA was assessed using the chemiluminescence method, wherein the use of chemiluminescent probes (i.e., lucigenin and luminol) allowed quantification of reactive oxygen species generated by neutrophils. Using an auto luminescence analyzer, the results were evaluated based on the maximum light emission and area under the emission curve. These quantifiable results revealed the minimal invasiveness of ESD.
Collapse
Affiliation(s)
- Daisuke Chinda
- Department of Gastroenterology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki 036-8563, Japan
| | - Tadashi Shimoyama
- Department of Gastroenterology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan
- Department of Internal Medicine, Aomori General Health Examination Center, Aomori 030-0962, Japan
| |
Collapse
|
8
|
Rouanet P, Selvy M, Jarlier M, Bugnon C, Carrier G, Mourregot A, Colombo PE, Taoum C. Tailored Management with Highly-Selective Diversion for Low Colorectal Anastomosis: Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort. Ann Surg Oncol 2022; 29:2514-2524. [PMID: 34994889 DOI: 10.1245/s10434-021-11197-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA). METHODS In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded. RESULTS Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p = 0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p = 0.064), disease-free survival was 67.0% and 55.8%, respectively (p = 0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p = 0.084). The long-term, stoma-free rate was 89.1% overall. CONCLUSIONS Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.
Collapse
Affiliation(s)
- Philippe Rouanet
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France.
| | - Marie Selvy
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Marta Jarlier
- Biometrics Unit, Montpellier Cancer Institute, Montpellier, France
| | - Caroline Bugnon
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Guillaume Carrier
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | - Anne Mourregot
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| | | | - Christophe Taoum
- Surgical Oncologic Department, Montpellier Cancer Institute, Montpellier, France
| |
Collapse
|
9
|
Guyard C, de Ponthaud C, Frontali A, Monsinjon M, Giacca M, Panis Y. C-reactive protein monitoring after ileocecal resection and stoma closure reduces length of hospital stay: a prospective case-matched study in 410 patients with Crohn's disease. Tech Coloproctol 2022; 26:443-451. [PMID: 35239097 DOI: 10.1007/s10151-022-02590-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/30/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate a C-reactive protein (CRP)-driven monitoring discharge strategy for patients with Crohn's disease (CD) undergoing laparoscopic ileo-cecal resection (ICR) and if needed, temporary stoma closure (SC). METHODS Four hundred and ten patients who underwent laparoscopic ICR for CD: 153 patients (CRP group) between June 2016 and June 2020 at our department, had a CRP-driven monitoring discharge on postoperative day (POD) 3 and were discharged on POD 4 if CRP < 100 mg/L. These patients were matched (according to age, sex, body mass index, type of CD (and stoma or not) to 257 patients who underwent laparoscopic ICR for CD between January 2009 and May 2016, without CRP monitoring (Control group). For SC, 79 patients with CRP monitoring were matched with 88 control patients. Primary outcome was overall length of hospital stay (LHS). Secondary outcomes were discharge on POD 4 for SC and POD 4 and POD 6 for ICR, 3-month postoperative overall morbidity and severe morbidity rates, surgical site infection, readmission rates, and CRP level in cases of morbidity at 3 months. RESULTS For ICR without stoma, mean LHS was significantly shorter in the CRP group than in the control group (6.9 ± 2 days vs 8.3 ± 6 days, p = 0.017). Discharge occurred on POD 6 (or before) in 73% of the patients (CRP group) vs 60% (Control group) (p = 0.027). For ICR with stoma, LHS was 8 days for both groups (p = 0.612). For SC, LHS was significantly shorter in the CRP group than in the control group (5.5 ± 3 days vs 7.1 ± 4 days; p = 0.002). Discharge occurred on POD 4 in 62% (CRP group) vs 30% (Control) (p = 0.003). Postoperative 3-month overall and severe morbidity, and rehospitalization rates were similar between groups. CONCLUSIONS CRP-driven monitoring discharge strategy after laparoscopic ICR for CD is associated with a significant reduction of LHS, without increasing morbidity, reoperation or rehospitalisation rates.
Collapse
Affiliation(s)
- C Guyard
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - C de Ponthaud
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - A Frontali
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - M Monsinjon
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - M Giacca
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, DMU DIGEST, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University of Paris, 100 boulevard du Général Leclerc, 92118, Clichy, France.
| |
Collapse
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Oxidative Stress Level as a Predictor of Anastomotic Leakage after Rectal Surgery. Mediators Inflamm 2021; 2021:9968642. [PMID: 34257521 PMCID: PMC8261183 DOI: 10.1155/2021/9968642] [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: 04/04/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background Early diagnosis of anastomotic leakage (AL) after rectal surgery can reduce the adverse effects of AL, thereby reducing morbidity and mortality. Currently, there are no accepted indicators or effective scoring systems that can clearly identify patients at risk of anastomotic leakage. Methods A prospective study with assessment of the diagnostic accuracy of oxidative stress level (CAT, SOD, MDA) in serum and drain fluid compared to white blood cell count (WBC), C-reactive protein (CRP), and neutrophil percentage (NEUT) in prediction of AL in patients undergoing elective rectal surgery with anastomosis. Results Most of the oxidative stress indicators we detected are of considerable significance in the diagnosis of anastomotic leakage. The level of MDA on postoperative day (POD)3 (areas under the curve (AUC): 0.831) and POD5 (AUC: 0.837) in the serum and on POD3 (AUC: 0.845) in the drain fluid showed the same excellent diagnostic accuracy as the level of CRP on the POD3 (AUC: 0.847) and POD5 (AUC: 0.896). Conclusions The overall level of oxidative stress in serum and drain fluid is a reliable indicator for the early diagnosis of anastomotic leakage after rectal surgery. More specifically, among the redox indicators analyzed, MDA has almost the same predictive value as CRP, which provides another useful biomarker for the early diagnosis of anastomotic leakage.
Collapse
|
12
|
Ogilvie JW, Qayyum I, Parker JL, Luchtefeld MA. Use of a standardized discharge checklist with daily post-operative C-reactive protein monitoring does not impact readmission rates after colon and rectal surgery. Int J Colorectal Dis 2021; 36:1271-1278. [PMID: 33543391 DOI: 10.1007/s00384-021-03866-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Elevated CRP has been associated with infectious complications after colorectal surgery but has not been evaluated in a prospective fashion as part of a discharge checklist. The objective of this study was to evaluate the effectiveness of a multi-component "discharge criteria checklist" that included daily use of CRP in decreasing hospital readmission rates after colorectal surgery. METHODS This is a prospective before and after study design that included consecutive patients undergoing major colorectal operations at a single university-affiliated community hospital over a 2-year period. The primary outcome was inpatient or emergency department readmission after 30 days. Selected pre- and peri-operative factors associated with readmissions were then examined in a multivariate analysis model. RESULTS The study included a total of 1546 patients. Surgical indications were inflammatory bowel disease (15%), colorectal cancer (24%), and benign disease (60%); 9.5% were emergencies. The readmission rates for each group were similar, 17.3% and 17.0%, for the control and discharge checklist groups, respectively (p=0.88). On multivariate analysis of the discharge checklist group dataset, only age, sex, surgical acuity and operating time were statistically significant risk factors. The difference of median CRP values on the day of discharge of those readmitted compared to those not readmitted (35 vs 32 mg/L) was not statistically significant (p=0.28). CONCLUSIONS The institution of a "discharge checklist" did not impact post-operative hospital readmissions. Not only were readmissions unchanged by the use of a CRP threshold at discharge, but CRP levels at the time of discharge were not associated with readmissions.
Collapse
Affiliation(s)
- James W Ogilvie
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, MI, USA. .,Department of Surgery, Division of Colorectal Surgery, Michigan State University- affiliated hospitals, Spectrum Health, 4100 Lake Dr. SE, Suite 205, Grand Rapids, MI, 49546, USA.
| | - Imad Qayyum
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, MI, USA.,Department of Surgery, Division of Colorectal Surgery, Michigan State University- affiliated hospitals, Spectrum Health, 4100 Lake Dr. SE, Suite 205, Grand Rapids, MI, 49546, USA
| | - Jessica L Parker
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, MI, USA.,Department of Surgery, Division of Colorectal Surgery, Michigan State University- affiliated hospitals, Spectrum Health, 4100 Lake Dr. SE, Suite 205, Grand Rapids, MI, 49546, USA
| | - Martin A Luchtefeld
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, MI, USA.,Department of Surgery, Division of Colorectal Surgery, Michigan State University- affiliated hospitals, Spectrum Health, 4100 Lake Dr. SE, Suite 205, Grand Rapids, MI, 49546, USA
| |
Collapse
|
13
|
Cazelles A, Giacca M, Monsinjon M, Hain E, Frontali A, Panis Y. Monitoring of C-reactive protein decreases length of stay after laparoscopic total mesorectal excision for cancer: a prospective case-matched study in 236 patients. Colorectal Dis 2021; 23:1158-1166. [PMID: 33554408 DOI: 10.1111/codi.15573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/05/2021] [Accepted: 02/01/2021] [Indexed: 12/29/2022]
Abstract
AIM The aim of this study was to evaluate a discharge strategy driven by monitoring of C-reactive protein (CRP) in a homogeneous group of patients undergoing laparoscopic total mesorectal excision with sphincter-saving surgery for rectal cancer (TME). METHOD One hundred and thirteen patients who underwent a TME had CRP monitoring on postoperative day (POD) 5. Patients were discharged on POD 6 if the CRP level was ≤100 mg/L. Patients were matched (according to age, gender, body mass index, neoadjuvant pelvic irradiation and type of anastomosis) to 123 control patients who underwent the same operation with the same postoperative care but without CRP monitoring. RESULTS Postoperative 3-month overall [CRP group 62/113 (55%) vs controls 73/123 (59%); p = 0.487] and severe (i.e. Clavien-Dindo grade 3 and above) [CRP group 17/113 (15%) vs controls 19/123 (15%); p = 0.931] morbidity rates were similar between groups. Mean length of hospital stay (LHS) was significantly shorter in the CRP group (CRP group 9.7 ± 14 days vs controls 11.6 ± 7 days; p < 0.001). Discharge occurred on POD 6 in 55/113 (49%) patients from the CRP group vs 7/123 (6%) from the control group (p < 0.001). The rehospitalization rate [CRP group 19/113 (17%) vs controls 13/123 (11%); p = 0.177] was similar between groups. The CRP level on POD 5 had a diagnostic property to assess an anastomotic leakage with an area under the curve of 0.81. CONCLUSION In patients who underwent TME, a discharge strategy based on CRP monitoring significantly decreased LHS without increasing morbidity, mortality or rehospitalization rates.
Collapse
Affiliation(s)
- Antoine Cazelles
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy cedex, France
| | - Massimo Giacca
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy cedex, France
| | - Marie Monsinjon
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy cedex, France
| | - Elisabeth Hain
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy cedex, France
| | - Alice Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy cedex, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), Clichy cedex, France
| |
Collapse
|
14
|
Kawasaki Y, Park S, Miyamoto K, Ueki R, Kariya N, Tatara T, Hirose M. Modified model for predicting early C-reactive protein levels after gastrointestinal surgery: A prospective cohort study. PLoS One 2020; 15:e0239709. [PMID: 32970767 PMCID: PMC7514002 DOI: 10.1371/journal.pone.0239709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/12/2020] [Indexed: 11/19/2022] Open
Abstract
Background Postoperative serum concentration of C-reactive protein (CRP) is one of the objective quantitative indices integrating the effects of preoperative and intraoperative variables. Higher levels of CRP after gastrointestinal surgery are associated with major postoperative complications. To develop a model for predicting CRP levels on postoperative day (POD) 1 in surgical patients both with and without serious conditions and comorbidities, we modified the previous formula for prediction of CRP levels on POD1, and assessed the accuracy of our modified predictive formula for CRP levels. Material and methods Consecutive patients of all ages undergoing gastrointestinal surgery under general anesthesia were enrolled in this single-institution prospective cohort study. We developed a modified predictive formula in a calculation cohort. Next, associations between measured CRP levels on POD1, predicted CRP levels on POD1 using the previous and modified models, and major complications after surgery were examined in a validation cohort. Results We obtained the following model in the calculation cohort (n = 222): Modified model for predicting CRP levels on POD1 (mg•dL-1) = -10.13 + 0.0025 Duration of surgery (min) + 15.9 Mean Nociceptive Response (NR) + 0.66 Preoperative CRP level (mg•dL-1). In the validation cohort (n = 440), there was a significant association between measured and predicted CRP levels on POD1 (P < 0.001) No significant difference between the measured and predicted CRP levels using the modified model was observed (P = 0.847). There were also significant associations between the predicted CRP levels and major complications after surgery. Conclusion CRP levels predicted using duration of surgery, mean NR, and preoperative CRP levels are likely identical to measured CRP levels on POD1, being associated with major complications after gastrointestinal surgery.
Collapse
Affiliation(s)
- Yui Kawasaki
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Soonhee Park
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazunori Miyamoto
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ryusuke Ueki
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Nobutaka Kariya
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tsuneo Tatara
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Munetaka Hirose
- Department of Anesthesiology and Pain Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
- * E-mail:
| |
Collapse
|
15
|
Shi J, Wu Z, Wang Q, Zhang Y, Shan F, Hou S, Ying X, Huangfu L, Li Z, Ji J. Clinical predictive efficacy of C-reactive protein for diagnosing infectious complications after gastric surgery. Therap Adv Gastroenterol 2020; 13:1756284820936542. [PMID: 32670413 PMCID: PMC7339084 DOI: 10.1177/1756284820936542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/25/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND With the popularization of Enhanced Recovery After Surgery (ERAS), identifying patients with complications before discharging becomes important. This study aimed to explore the efficacy of C-reactive protein (CRP) in predicting infectious complications after gastrectomy. METHODS Patients with gastric cancer who underwent gastrectomy at Beijing Cancer Hospital from March 2017 to April 2018 were enrolled in the training set. Complications were prospectively registered. Receiver operating characteristic analysis was performed to assess the diagnostic accuracy of CRP via evaluating the area under the curve (AUC). Patients who had CRP tested on postoperative day (POD) 5 and accepted gastrectomy from April to December 2018 were included in the validation set to validate the cut-off value of CRP obtained from the training set. RESULTS A total of 350 patients were included (263 patients in the training set and 87 patients in the validation set). Out of these, 24 patients were diagnosed with infectious complications and 17 patients had anastomotic leakage in the training set. The CRP level on POD5 had superior diagnostic accuracy for infectious complications with an AUC of 0.81. The cut-off value of CRP on POD5 at 166.65 mg/L yielded 93% specificity and 97.2% negative predict value (NPV); For anastomotic leakage, the AUC of CRP on POD5 was 0.81. Using the cut-off value of CRP at 166.65 mg/L on POD5 achieved 92% specificity and 98.6% NPV. The optimal cut-off value (CRP 166.65 mg/L on POD5) was validated in the validation set. It achieved 97.5% specificity and 94.0% NPV for infectious complications, and 97.6% specificity and 96.4% NPV for anastomotic leakage. CONCLUSION CRP is a reliable predictive marker for the diagnosis of inflammatory complications following gastric surgery. However, this study was based on preliminary data. The validity of this data needs confirmation by a larger number of cases.
Collapse
Affiliation(s)
| | | | - Qi Wang
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, Beijing, P.R. China
| | - Yan Zhang
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, Beijing, P.R. China
| | - Fei Shan
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, Beijing, P.R. China
| | - Shiyang Hou
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, Beijing, P.R. China
| | - Xiangji Ying
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, Beijing, P.R. China
| | - Longtao Huangfu
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, Beijing, P.R. China
| | | | - Jiafu Ji
- Gastrointestinal Cancer Center, Key Laboratory
of Carcinogenesis and Translational Research (Ministry of Education), Peking
University Cancer Hospital and Institute, No. 52 Fu-Cheng Road, Hai-Dian
District, Beijing 100142, P.R. China
| |
Collapse
|
16
|
What are the risk factors of failure of enhanced recovery after right colectomy? Results of a prospective study on 140 consecutive cases. Int J Colorectal Dis 2020; 35:1291-1299. [PMID: 32361939 DOI: 10.1007/s00384-020-03590-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Nausea and vomiting is the main cause of failure of enhanced recovery protocol (ERP) after right hemicolectomy. METHODS From January 2013 to January 2018, all patients undergoing right hemicolectomy were prospectively included. Patients undergoing emergency surgery, additional complex procedure or temporary stoma, nasogastric tube (NGT) maintenance, or abdominal drainage were excluded. Failure of ERP was defined as nausea/vomiting precluding oral feeding after POD3 and/or the occurrence of postoperative ileus requiring NGT and/or length of stay (LOS) ≥ 8 days except for patients awaiting admission in rehabilitation unit. Risk factors of failure of ERP were identified using univariate and multivariate analysis. RESULTS Among 306 patients undergoing right hemicolectomy, 140 fulfilled the inclusion criteria. Postoperative morbidity was 31%, and the mortality rate was nil. The mean postoperative hospital stay was 7 days (range 2-30). Successful ERP was achieved in 83 patients (59%). Causes of failure were major nausea/vomiting precluding oral feeding after POD3 in 36, postoperative ileus requiring NGT in 16 and LOS ≥ 8 days in 36. On multivariate analysis, preoperative anemia (OR 5.2; CI 95%, 1.3-21.1, p = 0.02) and platelet anti-aggregant/anti-coagulant (OR 4.5; CI 95%, 1.7-12.1, p = 0.003) were associated with the risk of failure of ERP. CONCLUSION This study shows that anemia and medication with antiplatelet/anticoagulation therapy increase the risk of failure of ERP after right hemicolectomy that translates most of the time by nausea/vomiting and postoperative ileus. The presence of these factors should lead to adapt the strategy to improve outcome rather than be considered as contraindication to ERP.
Collapse
|
17
|
Patients' refusal as major limitation of early discharge after colorectal resection in an enhanced recovery program. Langenbecks Arch Surg 2020; 405:337-344. [PMID: 32296935 DOI: 10.1007/s00423-020-01879-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/02/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The reduction of length of hospitalization without compromising the patient's safety constitutes the challenge of the enhanced recovery after surgery (ERAS) programs. Our aim was to evaluate the feasibility and safety of a 3-day hospitalization after colectomy and 5-day hospitalization after proctectomy in the setting of an ERAS program. METHODS An ERAS program was prospectively proposed to all patients who required a colorectal resection (January 2014-December 2018) with a 3- or 5-day discharge objective. The success of the program was defined by a 3-/5-day hospitalization without complications and without readmissions. RESULTS Among 283 patients included, 232 patients had a colectomy (82%) and 51 (18%) patients a proctectomy. Eighty-six patients experienced complications (30%) including fifteen severe complications (5%). Mean hospital stay was 5.1 ± 3.7 (2-33) days. A total of 136 patients (48%) were discharged at 3-/5-day, within 9 were readmitted (3%). Discharge was delayed after 3-/5-day for complications (n = 65, 23%), CRP > 120 (n = 45, 16%) or refusal without medical reason (n = 37, 13%). The success rate of the program was 45% (n = 127). This success rate was similar between colectomy and proctectomy (p = 0.277) and between right and left colectomy (p = 0.450). In multivariate analysis, predictive factors associated with the program success were intraoperative use of lidocaine (OR 2.1 [1.1-4.1], p = 0.022), time to remove perfusion ≤ 2 days (OR 10.3 [5.4-19.6], p = 0.001), time to recover bowel movement ≤ 2 days (OR 4.0 [1.7-9.6], p = 0.002) and time to walk out of the room ≤ 2 days (OR 2.6 [1.1-6.0], p = 0.022). CONCLUSION Integrating a realistic hospitalization duration objective into an ERAS program guarantees its safety, feasibility and effectiveness in reducing hospitalization duration.
Collapse
|
18
|
Can a Local Drainage Salvage a Failed Colorectal or Coloanal Anastomosis? A Prospective Cohort of 54 Patients. Dis Colon Rectum 2020; 63:93-100. [PMID: 31804271 DOI: 10.1097/dcr.0000000000001516] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Local drainages can be used to manage leakage in select patients without peritonitis. OBJECTIVE The aim of this study was to evaluate the efficacy of drainage procedures in maintaining a primary low anastomosis after anastomotic leakage. DESIGN A retrospective observational study was performed on a prospectively maintained database. SETTINGS The study was performed between 2014 and 2017 in a tertiary referral center. PATIENTS Patients undergoing rectal resections with either a colorectal or coloanal anastomosis with diverting stoma were identified. Anastomotic leakages requiring a radiological or transanal drainage without peritonitis were included. MAIN OUTCOME MEASURES The primary outcome was the maintenance of the primary anastomosis after local drainage of an anastomotic leakage and stoma reversal. RESULTS A low anastomosis for rectal cancer with diverting stoma was performed in 326 patients. A total of 77 anastomotic leakages (24%) occurred, of which, 6 (8%) required abdominal surgery, 17 (22%) were treated conservatively (medical management), and 54 (70%) were managed by drainage. Surgical transanal drainage was performed in 21 patients (39%), with radiologic drainage procedures performed in 33 patients (61%). The median interval between surgery and drainage was 13 days (range, 9-21 d). Five patients (9%) required emergency abdominal surgery. Twenty-seven patients (50%) did not require any additional intervention after drainage procedure, whereas 21 patients (39%) underwent redo anastomotic surgery. Forty-three patients (80%) had no stoma at the end of follow-up. Failure to maintain the primary anastomosis after local drainage was associated with increased age (p = 0.04), a pelvic per-operative drainage (p = 0.05), a drainage duration >10 days (p = 0.002), the time between surgery and drainage >15 days (p = 0.03), a side-to-end or J-pouch anastomosis (p = 0.04), and surgical transanal drainage (p = 0.03). LIMITATIONS The small sample size of the study was the main limitation. CONCLUSIONS Local drainage procedures maintained primary anastomosis in 50% of cases after an anastomotic leakage. See Video Abstract at http://links.lww.com/DCR/B57. ¿PUEDE UN DRENAJE LOCAL SALVAR UNA ANASTOMOSIS COLORRECTAL O COLOANAL FALLIDA? UNA COHORTE PROSPECTIVO DE 54 PACIENTES: Los drenajes locales se pueden utilizar para controlar las fugas en pacientes seleccionados sin peritonitis.El objetivo de este estudio fue evaluar la eficacia de los procedimientos de drenaje, para mantener una anastomosis primaria baja, después de una fuga anastomótica.Se realizó un estudio observacional retrospectivo en una base de datos mantenida prospectivamente.El estudio se realizó entre 2014-2017, en un centro de referencia terciaria.Se identificaron pacientes sometidos a resecciones rectales con anastomosis colorrectal o coloanal y estoma de derivación. Se incluyeron fugas anastomóticas sin peritonitis, que requirieron drenaje radiológico o transanal.El resultado primario fue el mantenimiento de la anastomosis primaria, después del drenaje local de una fuga anastomótica y la reversión del estoma.Se realizó una anastomosis baja para cáncer rectal con estoma derivativo en 326 pacientes. Se produjeron 77 (24%) fugas anastomóticas, de las cuales 6 (8%) requirieron cirugía abdominal, 17 (22%) fueron tratadas de forma conservadora (tratamiento médico) y 54 (70%) fueron manejadas por drenaje. Se realizó drenaje transanal en 21 pacientes (39%) y procedimientos de drenaje radiológico en 33 pacientes (61%). La mediana del intervalo entre la cirugía y el drenaje fue de 13 días [9-21]. 5 (9%) pacientes requirieron cirugía abdominal de emergencia. Veintisiete (50%) pacientes no requirieron ninguna intervención adicional después del procedimiento de drenaje, mientras que 21 pacientes (39%) se sometieron a una reparación quirúrgica anastomótica. 43 pacientes (80%) no tuvieron estoma al final del seguimiento. El fracaso para mantener la anastomosis primaria después del drenaje local, se asoció con un aumento de la edad (p = 0.04), un drenaje pélvico preoperatorio (p = 0.05), una duración del drenaje >10 días (p = 0.002), el tiempo entre la cirugía y el drenaje >15 días (p = 0.03), anastomosis termino lateral o bolsa en J (p = 0.04) y drenaje quirúrgico transanal (p = 0.03).El pequeño tamaño de la muestra del estudio fue la principal limitación.Después de la fuga anastomótica, los procedimientos del drenaje local conservaron la anastomosis primaria en el 50% de los casos. Vea el Resumen del Video en http://links.lww.com/DCR/B57.
Collapse
|
19
|
D'Urso A, Komen N, Lefevre JH. Intraluminal flexible sheath for the protection of low anastomosis after anterior resection: results from a First-In-Human trial on 15 patients. Surg Endosc 2019; 34:5107-5116. [PMID: 31802217 DOI: 10.1007/s00464-019-07279-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 11/23/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Defunctioning ostomy is commonly used to protect patients from anastomotic leakage complications after low anterior resection, but is fraught with its own deleterious effects. This first-in-human study examines the safety and preliminary efficacy of Colovac, an anastomosis protection device. The Colovac consists of a flexible bypass sheath, placed in the lumen of colon and anchored above the anastomosis using a vacuum stent. METHODS 15 patients underwent anterior resection (AR) with anastomosis protection by Colovac at 3 European centers. After 14 days, the anastomosis integrity was examined by CT scan and endoscopy. The device was then endoscopically removed. Data regarding demographics, surgical details, 30 day post-operative complications, and patient satisfaction were collected prospectively. RESULTS 15 patients (10 male) underwent laparoscopic AR with Colovac placement. Preoperative neoadjuvant therapy was administered to 54% of patients. Device placement was uneventful in all patients with a median duration of 7 min and placement was judged as easy or very easy in 93% of the cases. Patients did not report major discomfort during the 14 days. Endoscopic removal (10 min) was judged as easy or very easy in 87% of the cases. Absence of feces below the Colovac anchoring site was observed in 100% of the cases. 4 anastomotic leakages were observed (including 3 device migrations). Overall 5 patients (33%) required a planned stoma creation. At 3 months, 1 had already been closed. CONCLUSION Colovac provides a minimally invasive protection of the anastomosis during the healing process by avoiding the need for a diverting ostomy for two-thirds of patients who will not experience anastomotic complications and allowing safe conversion to the standard of care for patients requiring extended anastomotic protection. A larger study is ongoing to confirm these results.
Collapse
Affiliation(s)
- Antonio D'Urso
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Niels Komen
- Department of Abdominal Surgery, University Hospital Antwerp, University of Antwerp, Edegem, Belgium
| | - Jérémie H Lefevre
- Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint-Antoine, 75012, Paris, France.
| |
Collapse
|
20
|
Ho YM, Laycock J, Kirubakaran A, Hussain L, Clark J. Systematic use of the serum C-reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks. ANZ J Surg 2019; 90:109-112. [PMID: 31770827 DOI: 10.1111/ans.15568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/18/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study aimed to characterize the time-dependent relationship between serum C-reactive protein (CRP) and anastomotic integrity in the early post-operative period and to develop a systematic use of CRP and computed tomography. METHODS Patients aged 18 years or over who had the formation of a left-sided colonic or a colorectal anastomosis, in Royal Sussex County Hospital, were included. The post-operative day (POD) CRP cut-off values were calculated according to receiver operating characteristic analysis to evaluate the sensitivities and specificities of the proposed cut-off parameters. RESULTS A total of 125 left-sided colonic and colorectal anastomoses were recruited and analysed. When comparing to POD1 CRP cut-off, the calculated CRP ratio cut-off values of all the rest of PODs (2-5) were highly significant in the laparoscopic group and the overall group (P < 0.001). This statistically significant ratio was also demonstrated in the open group at POD2 (P < 0.0001). CONCLUSION CRP and CRP ratios cut-off values were sensitive to detect an anastomotic leak in the early post-operative period. The cut-off values could facilitate the development of systematic use of CRP and computed tomography.
Collapse
Affiliation(s)
- Yiu Ming Ho
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Juliet Laycock
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Arangan Kirubakaran
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Labib Hussain
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jeremy Clark
- Department of Digestive Disease, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| |
Collapse
|
21
|
Chinda D, Shimoyama T, Arai T, Sawada K, Akitaya K, Kudo S, Yasuda K, Miyazawa K, Akimoto N, Sato S, Hayamizu S, Tatsuta T, Kikuchi H, Hiraga H, Sawaya M, Sakuraba H, Mikami T, Nakaji S, Fukuda S. Usefulness of serum opsonic activity measured by chemiluminescence method to assess the invasiveness of colorectal endoscopic mucosal dissection. Free Radic Res 2019; 54:810-817. [DOI: 10.1080/10715762.2019.1681590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Daisuke Chinda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Community Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | | | - Tetsu Arai
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kaori Sawada
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazuki Akitaya
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Sae Kudo
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kohei Yasuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kuniaki Miyazawa
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Naoki Akimoto
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Satoshi Sato
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shiro Hayamizu
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hidezumi Kikuchi
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hiroto Hiraga
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Manabu Sawaya
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirotake Sakuraba
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki, Japan
| | - Shigeyuki Nakaji
- Department of Social Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| |
Collapse
|