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Zhang J, Wang Y, Zhang T, Xu D, Shi C, Wang W. A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy. Surgery 2023; 174:946-955. [PMID: 37495464 DOI: 10.1016/j.surg.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 05/08/2023] [Accepted: 06/18/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Small bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management. METHODS Clinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation. RESULTS The nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775-0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686-0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model's area under the curve was 0.815 (95% confidence interval, 0.683-0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present. CONCLUSION The clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.
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Affiliation(s)
- Jiahui Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Yanjun Wang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Tong Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Dongyao Xu
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Chunfeng Shi
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China
| | - Wei Wang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, China.
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Fujiwara Y, Higashida M, Kubota H, Okamoto Y, Mineta S, Endo S, Ueno T. Perioperative Predictive Markers for Recurrence of Esophageal Cancer after Esophagectomy. Gastrointest Tumors 2021; 8:87-95. [PMID: 33981687 DOI: 10.1159/000513961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction We studied whether perioperative nutritional, immunological factors or postoperative inflammatory responses predicted esophageal cancer (EC) progression and prognosis in patients who received esophagectomies. Methods We evaluated preoperative prognostic nutritional index (PNI), BMI, neutrophil-to-lymphocyte ratio (NLR), intraoperative blood loss, postoperative C-reactive protein (CRP) max, recurrence-free survival (RFS), and overall survival (OS) in 111 patients with pStage I-IV squamous cell EC who received esophagectomies. Optimal cutoff values for each continuous parameter were determined by receiver operating characteristic curves and Youden indices. Univariate and multivariate Cox analyses were used to derive independent prognostic factors. Propensity score matching using inverse probability of treatment weighting was used in groups divided by Youden indices, as appropriate. Results Cutoff values of continuous variables were NLR: 2.27, PNI: 44.2, blood loss: 159 mL, and CRPmax: 21.7 mg/dL. In multivariate analyses, PNI, CRPmax, and intraoperative blood loss were independent prognostic factors for OS and RFS. Among patients with stage II-IV disease, low PNI was associated with shorter RFS. Postoperative respiratory complications were associated with both higher CRP and shorter RFS. Discussion/Conclusions Low preoperative PNI and high postoperative inflammatory response were associated with postoperative EC progression after esophagectomy. Preoperative nutritional interventions or suppression of postoperative inflammatory response, including respiratory complications, may improve patient prognosis.
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Affiliation(s)
- Yoshinori Fujiwara
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Masaharu Higashida
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hisako Kubota
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yuko Okamoto
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Shumei Mineta
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Shunji Endo
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Tomio Ueno
- Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, Japan
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3
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Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy-A Comparison with the Open Approach. J Clin Med 2020; 9:jcm9061896. [PMID: 32560416 PMCID: PMC7355913 DOI: 10.3390/jcm9061896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/23/2022] Open
Abstract
Patients undergoing esophageal cancer surgery are at high risk of developing severe pulmonary complications. Beneficial effects of minimally invasive esophagectomy had been discussed recently, but the incidence of perioperative respiratory impairment remains unclear. This is a retrospective single-center cohort study of patients, who underwent open (OE) or laparoscopically assisted, hybrid minimally invasive abdomino-thoracic esophagectomy (LAE) for cancer regarding respiratory impairment (PaO2/FiO2 ratio (P/FR) < 300 mmHg) and pneumonia. No differences were observed in the cumulative incidence of reduced P/FR between OE and LAE patients. Of note, until postoperative day (POD) 2, P/FR did not differ among both groups. Thereafter, the rate of patients with respiratory impairment was higher after OE on POD 3, 5, and 10 (p ≤ 0.05) and tended being higher on POD 7 and 9 (p ≤ 0.1). Although the duration of LAE procedure was slightly longer (total: p = 0.07, thoracic part: p = 0.004), the duration of surgery (Spearman's rank correlation coefficient (rsp) = -0.267, p = 0.006), especially of laparotomy (rsp = -0.242, p = 0.01) correlated inversely with respiratory impairment on POD 3 after OE. Pneumonia occurred on POD 5 (1-25) and 8.5 (3-14) after OE and LAE, respectively, with the highest incidence after OE (p = 0.01). In conclusion, respiratory impairment and pulmonary complications occur frequently after esophagectomy. Although early respiratory impairment is independent of the surgical approach, postoperative pneumonia rate is reduced after LAE.
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4
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Schizas D, Michalinos A, Syllaios A, Dellaportas D, Kapetanakis EI, Hadjigeorgiou G, Vergadis C, Lasithiotakis K, Liakakos T. Staged esophagectomy: surgical legacy or a bailout option? Surg Today 2019; 50:1323-1331. [PMID: 31612330 DOI: 10.1007/s00595-019-01894-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022]
Abstract
Staged esophagectomy was developed in the mid-twentieth century in an attempt to reduce high rates of postoperative morbidity and mortality. Nowadays, the operation has almost been abandoned due to its significant disadvantages, especially the need for multiple surgeries, inability of patients to feed between operations, and morbidity of esophageal stoma. However, staged esophagectomy is still occasionally useful for very high-risk patients and in particular cases, for example multiple cancers of the aerodigestive tract and emergent esophagectomy. Staged esophagectomy is based on the division of surgical stress into two operations, which gives the patient time to recover before final restoration. Gastric tube ischemic preparation may be a more important mechanism in staged esophagectomy. This approach may survive and expand with the application of ischemic gastric pre-conditioning through embolization or laparoscopic ligation of the gastric arteries, which is a less explored and promising technique.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
| | - Adamantios Michalinos
- Department of Anatomy, European University of Cyprus, Diogenous 6 Str, CY-2404, Engomi, Nicosia, Cyprus.
| | - Athanasios Syllaios
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
| | - Dionysios Dellaportas
- Second Department of Surgery, National and Kapodistrian University of Athens, Aretaieion University Hospital, Vasillisis Sofias 76 str, Athens, Greece
| | - Emmanouil I Kapetanakis
- Department of Thoracic Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Rimini 1 Str. Chaidari, Athens, Greece
| | - Georgios Hadjigeorgiou
- Department of Anatomy, European University of Cyprus, Diogenous 6 Str, CY-2404, Engomi, Nicosia, Cyprus
| | - Chrysovalantis Vergadis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University Hospital of Heraklion, Panepistimiou 12 str, Heraklion, Greece
| | - Theodoros Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital Ag, Thoma 17 str. Goudi, Athens, Greece
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5
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Delko T, Watson DI, Beck-Schimmer B, Immanuel A, Hussey DJ, Zingg U. Cytokine Response in the Pleural Fluid and Blood in Minimally Invasive and Open Esophagectomy. World J Surg 2019; 43:2631-2639. [PMID: 31222636 DOI: 10.1007/s00268-019-05069-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transthoracic esophagectomy for cancer triggers a massive inflammatory reaction. The data whether a minimally invasive esophagectomy (MIE) leads to less pronounced inflammatory response compared to open right-sided transthoracic esophagectomy (OE) are scarce. The aim of this study was to evaluate the extent of the inflammatory reaction, represented by levels of the pro-inflammatory interleukins IL-6 and IL-8, the anti-inflammatory IL-1 RA and the chemokines CINC-1 and MCP-1 in the right pleural fluid and the blood from patients undergoing standard OE or MIE. METHODS Pleural drainage fluid and blood was collected at five different time points during the first 72 h following surgery, and the concentrations of IL-6, IL-8, IL-1 RA, CINC-1 and MCP-1 were analyzed using enzyme-linked immune-sorbent assays in 24 patients undergoing MIE or OE. RESULTS The groups were matched for cancer stage and comorbidities. Pro- and anti-inflammatory mediator levels in the pleural fluid were markedly increased at the end of surgery and on postoperative days 1-3. The pleural inflammatory response of all cyto- and chemokines was lower in the MIE group, reaching significance at some time points. Cyto- and chemokine response levels measured in the blood were overall lower compared to those in the pleural fluid. The chemokines CINC-1 and MCP-1 reacted less pronounced or not at all. Preoperative pulmonary comorbidity, postoperative pulmonary morbidity and length of surgery were associated with an increased reaction in selected mediators. CONCLUSIONS The minimally invasive technique attenuates the inflammatory response, especially locally in the thoracic compartment. Length of procedure, preoperative pulmonary comorbidity and postoperative pulmonary complications are mirrored in an increase in individual inflammatory markers in the pleural fluid. The value of the chemokines CINC-1 and MCP-1 as markers of inflammation in the setting of esophagectomy is unclear.
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Affiliation(s)
- T Delko
- Department of Surgery, Flinders University, Bedford Park, Australia
| | - D I Watson
- Department of Surgery, Flinders University, Bedford Park, Australia
| | - B Beck-Schimmer
- Institute of Anesthesiology, University of Zurich, Zurich, Switzerland
| | - A Immanuel
- Department of Surgery, Flinders University, Bedford Park, Australia
| | - D J Hussey
- Department of Surgery, Flinders University, Bedford Park, Australia
| | - U Zingg
- Department of Surgery, Flinders University, Bedford Park, Australia.
- Department of Surgery, Limmattal Hospital, Urdorferstrasse 100, 8952, Schlieren, Switzerland.
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6
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Jeong H, Choi JW, Ahn HJ, Choi YS, Kim JA, Yang M, Kim JK, Kim DK, Shin BS, Lee SH, Kim YR, Park M, Chung YJ. The effect of preventive use of corticosteroids on postoperative complications after esophagectomy: A retrospective cohort study. Sci Rep 2019; 9:11984. [PMID: 31427671 PMCID: PMC6700144 DOI: 10.1038/s41598-019-48349-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022] Open
Abstract
Corticosteroids have been empirically administered to reduce the rate of acute respiratory distress syndrome (ARDS) after esophagectomy. However, their efficacy remains controversial, and corticosteroids may increase the risk of graft dehiscence and infection, which are major concerns after esophagectomy. Therefore, we compared the incidence of composite complications (ARDS, graft dehiscence and infection) after esophagectomy between patients who received a preventive administration of corticosteroids and those who did not. All patients who underwent esophagectomy from 2010 to 2015 at a tertiary care university hospital were reviewed retrospectively (n = 980). Patients were divided into Steroid (n = 120) and Control (n = 860) groups based on the preventive administration of 100 mg hydrocortisone during surgery. The primary endpoint was the incidence of composite complications. The incidence of composite complications was not different between the Control and Steroid groups (17.4% vs. 21.7% respectively; P = 0.26). The incidence rates of complications in each category were not different between the Control and Steroid groups: ARDS (3.8% vs. 5.0%; P = 0.46), graft dehiscence (4.8% vs. 6.7%; P = 0.37), and infection (12.8% vs. 15.8%; P = 0.36). Propensity score matching revealed that composite complications (20.0% vs. 21.7%; P = 0.75), ARDS (4.3% vs. 5.2%; P = 0.76) and infection (16.5% vs. 15.7%; P = 0.86) were not different between the Control and Steroid group, but the incidence of graft dehiscence was higher in the Steroid group than in the Control group (0.9% vs. 7.0%; P = 0.0175). In conclusions, the preventive use of corticosteroids did not reduce the incidence of ARDS, but may be related to an increased incidence of graft dehiscence. Therefore, routine administration of corticosteroids to prevent ARDS is not recommended in esophagectomy.
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Affiliation(s)
- Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Yong Soo Choi
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jin Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Byung Seop Shin
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Young Ri Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Mihye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Yoon Joo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
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7
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Reichert M, Schistek M, Uhle F, Koch C, Bodner J, Hecker M, Hörbelt R, Grau V, Padberg W, Weigand MA, Hecker A. Ivor Lewis esophagectomy patients are particularly vulnerable to respiratory impairment - a comparison to major lung resection. Sci Rep 2019; 9:11856. [PMID: 31413282 PMCID: PMC6694108 DOI: 10.1038/s41598-019-48234-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/29/2019] [Indexed: 12/15/2022] Open
Abstract
Pulmonary complications and a poor clinical outcome are common in response to transthoracic esophagectomy, but their etiology is not well understood. Clinical observation suggests that patients undergoing pulmonary resection, a surgical intervention with similarities to the thoracic part of esophagectomy, fare much better, but this has not been investigated in detail. A retrospective single-center analysis of 181 consecutive patients after right-sided thoracotomy for either Ivor Lewis esophagectomy (n = 83) or major pulmonary resection (n = 98) was performed. An oxygenation index <300 mm Hg was used to indicate respiratory impairment. When starting surgery, respiratory impairment was seen more frequently in patients undergoing major pulmonary resection compared to esophagectomy patients (p = 0.009). On postoperative days one to ten, however, esophagectomy caused higher rates of respiratory impairment (p < 0.05) resulting in a higher cumulative incidence of postoperative respiratory impairment for patients after esophagectomy (p < 0.001). Accordingly, esophagectomy patients were characterized by longer ventilation times (p < 0.0001), intensive care unit and total postoperative hospital stays (both p < 0.0001). In conclusion, the postoperative clinical course including respiratory impairment after Ivor Lewis esophagectomy is significantly worse than that after major pulmonary resection. A detailed investigation of the underlying causes is required to improve the outcome of esophagectomy.
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Affiliation(s)
- Martin Reichert
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.
| | - Magdalena Schistek
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Johannes Bodner
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Department of Thoracic Surgery, München Klinik Bogenhausen, Englschalkinger Strasse 77, D-81925, Munich, Germany
| | - Matthias Hecker
- Department of Pulmonary and Critical Care Medicine, University of Giessen and Marburg Lung Center (UGMLC), University Hospital of Giessen, Klinikstrasse 33, D-35392, Giessen, Germany
| | - Rüdiger Hörbelt
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Veronika Grau
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany.,Laboratory of Experimental Surgery, German Centre for Lung Research (DZL), Justus-Liebig-University Giessen, Feulgenstrasse 10-12, D-35392, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, D-69120, Heidelberg, Germany
| | - Andreas Hecker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Strasse 7, D-35392, Giessen, Germany
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8
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Hyperbilirubinemia predicts the infectious complications after esophagectomy for esophageal cancer. Ann Med Surg (Lond) 2019; 39:16-21. [PMID: 30899455 PMCID: PMC6402227 DOI: 10.1016/j.amsu.2019.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/03/2019] [Accepted: 02/15/2019] [Indexed: 02/08/2023] Open
Abstract
Background Surgical stress and inflammation can cause hyperbilirubinemia, which sometimes occurs after esophagectomy for esophageal cancer (EC). The aim of this study was to elucidate the clinical significance of postoperative hyperbilirubinemia in the management of EC patients. Materials and methods We retrospectively reviewed records of 81 EC patients who underwent esophagectomy from 2009 to 2014. We compared the clinicopathological and perioperative factors, including the presence of hyperbilirubinemia (total bilirubin ≥1.5 mg/dL), between patients with postoperative infectious complications (PIC group) and those without (Non-PIC group). Results PIC developed in 52 patients (64.2%). There were significant differences in incidence of postoperative hyperbilirubinemia between the PIC group and the non-PIC group (34.6% vs. 3.4%, P = 0.002), as well as the approach of esophagectomy (P = 0.045), the surgical duration (469 vs. 389 min, P < 0.001), the amount of blood loss (420 vs. 300 mL, P = 0.018), the frequency of intraoperative blood transfusions (32.7% vs. 6.9%, P = 0.012) and the peak postoperative C-reactive protein level (17.3 vs. 8.6 mg/dL, P = 0.007). Multivariate analysis revealed hyperbilirubinemia was independently associated with the occurrence of PICs (odds ratio: 38.6, P = 0.010). The median time to the diagnosis of hyperbilirubinemia was significantly shorter than that of PICs (3.0 vs. 4.5 days, P = 0.025). Conclusions Postoperative hyperbilirubinemia was associated with the occurrence of PICs and frequently occurred before any PICs become apparent. More attention should be paid to the serum bilirubin level in the management after esophagectomy for EC.
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Key Words
- CI, confidence of interval
- CRP, C-reactive protein
- Complications
- EC, Esophageal cancer
- Esophageal cancer
- Esophagectomy
- Hyperbilirubinemia
- Infection
- LN, lymph node
- MIE, Minimally invasive transthoracic esophagectomy
- OE, open transthoracic esophagectomy
- OR, odds ratio
- PICs, postoperative infectious complications
- T-bil, total bilirubin
- THE, Transhiatal esophagectomy
- TNM, tumor-node-metastasis
- UICC, International Union Against Cancer
- WBC, white blood cell
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Takeda C, Takeuchi M, Kawasaki Y, Yonekura H, Nahara I, Kuwauchi A, Yoshida S, Tanaka S, Kawakami K. Prophylactic sivelestat for esophagectomy and in-hospital mortality: a propensity score-matched analysis of claims database. J Anesth 2019; 33:230-237. [PMID: 30612210 DOI: 10.1007/s00540-018-2602-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/19/2018] [Indexed: 01/29/2023]
Abstract
PURPOSE Transthoracic esophagectomy is an invasive surgery, and the excessive surgical stress produces inflammatory cytokines, which provoke acute respiratory distress syndrome (ARDS). Sivelestat sodium hydrate-a selective neutrophil elastase inhibitor-is used to treat or prevent ARDS in patients undergoing esophagectomy, although clear evidence is lacking. We investigated the benefits and risk of prophylactic sivelestat. METHODS This retrospective study used an administrative claims database in Japan. Adult patients who underwent transthoracic esophagectomy from 2010 to 2016 were identified and divided into a prophylactic sivelestat use group and a non-prophylactic use group that included both non-users and therapeutic users. The primary outcome was all-cause in-hospital mortality, and a secondary outcome included the proportion of ARDS. We used 1:1 propensity score matching. For sensitivity analyses, we conducted a 1:2 propensity score matching analysis and several analyses with various patient inclusion criteria. RESULTS Of the 3391 patients with esophagectomy, 621 received prophylactic sivelestat. On unadjusted analysis, the sivelestat group had a higher proportion of in-hospital mortality (5.3% vs. 2.9%) compared with the control group. We created a matched cohort of 615 pairs, whose baseline characteristics were well balanced. On adjusted analysis using propensity score matching, prophylactic sivelestat administration was not associated with decreased in-hospital mortality [adjusted odds ratio (aOR) 1.65; 95% confidence interval (CI) 0.95-2.88], ARDS rate (aOR 1.25; 95% CI 0.49-3.17). The findings were also consistent with other sensitivity analyses. CONCLUSION Because mortality and postoperative complications were similar, our findings do not support prophylactic sivelestat administration for patients undergoing esophagectomy.
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Affiliation(s)
- Chikashi Takeda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Anesthesia, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Yohei Kawasaki
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Hiroshi Yonekura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Isao Nahara
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Aki Kuwauchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Shiro Tanaka
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Clinical Biostatistics/Clinical Biostatistics Course, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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10
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Choi H, Cho JH, Kim HK, Choi YS, Kim J, Zo JI, Shim YM, Jeon K. Prevalence and clinical course of postoperative acute lung injury after esophagectomy for esophageal cancer. J Thorac Dis 2019; 11:200-205. [PMID: 30863589 DOI: 10.21037/jtd.2018.12.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Although acute lung injury (ALI) that develops after esophagectomy is associated with significant morbidity and mortality, there is limited information on its overall clinical course. The objective of this study was to investigate the prevalence and clinical course of ALI after esophagectomy. Methods Data were collected from all consecutive patients diagnosed with ALI after esophagectomy for esophageal cancer from January 2012 through March 2017 and retrospectively analyzed. Results During the study period, a total of 1,132 patients underwent esophagectomy for esophageal cancer and 52 (4.6%) patients developed postoperative ALI. At the time of ALI diagnosis, the median lung injury score of all patients was 1.8 (1.0-2.0). Among the patients with ALI, 17 (33%) patients required mechanical ventilation (MV) support, of which two failed to wean from MV and 15 were weaned from MV. The median MV duration was 4 days (interquartile range, 3-8 days). Corticosteroids were used in 33 (63%) patients. During corticosteroid treatment, superimposed infections were observed in 10 (30%) patients and surgical site complications were observed in 9 (27%). Overall in-hospital mortality was 10%. Conclusions The prevalence and mortality of ALI following esophagectomy in our study were lower than those of previous reports. However, the use of corticosteroids in patients with ALI following esophagectomy requires attention to the occurrence of surgical site complications and close surveillance to identify new infections.
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Affiliation(s)
- Hayoung Choi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, South Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Protective effects of continuous positive airway pressure on a nonventilated lung during one-lung ventilation: A prospective laboratory study in rats. Eur J Anaesthesiol 2018; 33:776-83. [PMID: 27139568 DOI: 10.1097/eja.0000000000000460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of one-lung ventilation (OLV) to facilitate intrathoracic surgery is a cause of lung injury. OBJECTIVE We hypothesised that application of continuous positive airway pressure (CPAP) to a nonventilated lung during OLV would prevent alveolar hypoxia and blood flow shift from the nonventilated to the ventilated lung, thereby attenuating lung injury. DESIGN Controlled animal study. SETTINGS University laboratory. STUDY PARTICIPANTS Adult male Sprague-Dawley rats (n = 4 to 8 per group, depending on experiments). INTERVENTIONS Rats were alternately assigned to one of two ventilation protocol groups: control and CPAP groups. Rats received 240 min of OLV followed by 240 min of two-lung reventilation (re-TLV). The nonventilated lungs of rats in the control group were collapsed during OLV whereas rats in the CPAP group received CPAP (5 cmH2O with 100% oxygen) to the nonventilated lungs. MAIN OUTCOME MEASURES Pulmonary blood flow during OLV was measured by quantification of lung radioactivity after intravenous infusion of indium-labelled macroaggregated albumin. Inflammatory cytokines in the lungs after 240 min of OLV, and after the subsequent 240 min of re-TLV were measured. Additionally, we measured lung wet-to-dry weight ratios after re-TLV. We also measured lung malondialdehyde levels after re-TLV as an indicator of reactive oxygen species produced by reoxygenation. RESULTS Application of CPAP attenuated the pulmonary blood flow shift from the nonventilated to the ventilated lung. CPAP decreased the levels of IL-6, CXC chemokine ligand-1 and CC chemokine ligand-2 in both lungs after 240 min of OLV. CPAP also decreased CXC chemokine ligand-1 in the nonventilated lung and CC chemokine ligand-2 in both lungs after re-TLV. Moreover, wet-to-dry weight ratios of both lungs were decreased by application of CPAP. However, lung malondialdehyde concentrations were not affected by CPAP. CONCLUSIONS CPAP applied to the nonventilated lung during OLV suppresses blood flow shift and decreases inflammatory cytokines and water content in both lungs. Application of CPAP may attenuate lung injury during and after OLV.
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Zhang GH, Wang W. Effects of sevoflurane and propofol on the development of pneumonia after esophagectomy: a retrospective cohort study. BMC Anesthesiol 2017; 17:164. [PMID: 29202701 PMCID: PMC5715630 DOI: 10.1186/s12871-017-0458-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 11/24/2017] [Indexed: 12/01/2022] Open
Abstract
Background Postoperative pneumonia (PP) is one of the common complications following esophagectomy and associated with poor short- and long-term outcomes. Sevoflurane and propofol, which have inflammatory-modulating effects, are common used general anesthetics. This study aimed to compare the effects of anesthesia with sevoflurane and propofol on the development of PP after esophageal surgery for cancer. Methods The electronic medical records of patients who underwent elective esophagectomy between July 2013 and July 2016 were reviewed. We conducted univariate and multivariate logistics analysis and propensity score matching analysis to compare the effect of sevoflurane and propofol on the incidence of PP and to identify the risk factors for PP after esophagectomy. Results Overall, the incidence of postoperative pneumonia was 9.5%. There was no significant difference in the rates of PP between sevoflurane group and propofol group either before or after propensity score matching (9.6% vs 8.0%, P = 0.606; 7.7% vs 6.4%, P = 0.754, respectively). Univariate and multivariate analysis revealed that alcohol use (OR 1.513; 95% CI 1.062–2.156), surgical procedure (Sweet: referent; Ivor-Lewis: OR 1.993; 95% CI 1.190–3.337; Three-incision: OR 1.878; 95% CI 1.296–2.722) and surgeon experience (high-volume: referent; low-volume: OR 1.525; 95% CI 1.090–2.135) were significant risk factors of postoperative pneumonia. Conclusions Sevoflurane did not differ from propofol in terms of affecting the risk of PP development after esophagectomy.
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Affiliation(s)
- Guo-Hua Zhang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli Road, Chaoyang District, Beijing, 100021, China.
| | - Wen Wang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuannanli Road, Chaoyang District, Beijing, 100021, China
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Postoperative complications after head and neck operations that require free tissue transfer - prevalent, morbid, and costly. Br J Oral Maxillofac Surg 2017; 55:809-814. [DOI: 10.1016/j.bjoms.2017.07.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/21/2017] [Indexed: 12/31/2022]
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14
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Yasuda M, Saeki H, Nakashima Y, Yukaya T, Tsutsumi S, Tajiri H, Zaitsu Y, Tsuda Y, Kasagi Y, Ando K, Imamura Y, Ohgaki K, Akahoshi T, Oki E, Maehara Y. Treatment results of two-stage operation for the patients with esophageal cancer concomitant with liver dysfunction. THE JOURNAL OF MEDICAL INVESTIGATION 2017; 62:149-53. [PMID: 26399339 DOI: 10.2152/jmi.62.149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSE The aim of this study was to clarify the usefulness of two-stage operation for the patients with esophageal cancer who have liver dysfunction. METHODS Eight patients with esophageal cancer concomitant with liver dysfunction who underwent two-stage operation were analyzed. The patients initially underwent an esophagectomy, a cervical esophagostomy and a tube jejunostomy, and reconstruction with gastric tube was performed after the recovery of patients' condition. RESULTS The average time of the 1(st) and 2(nd) stage operation was 410.0 min and 438.9 min, respectively. The average amount of blood loss in the 1(st) and 2(nd) stage operation was 433.5 ml and 1556.8 ml, respectively. The average duration between the operations was 29.8 days. The antesternal route was selected for 5 patients (62.5%) and the retrosternal route was for 3 patients (37.5%). In the 1(st) stage operation, no postoperative complications were observed, while, complications developed in 5 (62.5%) patients, including 4 anastomotic leakages, after the 2(nd) stage operation. Pneumonia was not observed through two-stage operation. No in-hospital death was experienced. CONCLUSION A two-stage operation might prevent the occurrence of critical postoperative complications for the patients with esophageal cancer concomitant with liver dysfunction.
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Li B, Xiang J, Zhang Y, Hu H, Sun Y, Chen H. Factors Affecting Hospital Mortality in Patients with Esophagogastric Anastomotic Leak: A Retrospective Study. World J Surg 2016; 40:1152-7. [PMID: 26678489 DOI: 10.1007/s00268-015-3372-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We aimed to clarify the association between anastomotic leak and leak-associated mortality to assist decision-making and reduce hospital mortality. BACKGROUND Anastomotic leak is a common complication after esophagectomy, but the nature of its relationship to leak-associated mortality has not been established. METHODS A retrospective review of all esophagogastric anastomotic leaks that had occurred between 2008 and 2012 at our institution (n = 246) was performed. Risk factors for leak-associated mortality were determined using a multivariate logistic regression analysis. RESULTS Of the 246 patients with anastomotic leaks, 14 (5.7 %) died. Leak-associated mortality rates were similar regardless of anastomosis location (cervical vs. thoracic anastomosis), surgical approaches (retrosternal vs. prevertebral reconstruction route) and anastomotic techniques (hand-sewn vs. mechanical anastomosis). When a leak occurred, risk factors for leak-associated mortality as determined by multivariate logistic analysis included patient age >60 years (P = 0.029) and the occurrence of the leak within 1 week of surgery (P = 0.039). When disease worsened after treatment, leak-associated mortality was more frequent in patients requiring reintubation (25.6 vs. 1.4 %, P < 0.001). Fatal bleeding and sepsis were the most common causes of leak-associated mortality. CONCLUSION In patients with anastomotic leaks, patient age >60 years and the occurrence of the leak within 1 week of surgery were risk factors for leak-associated mortality. Increased efforts to reduce the incidence of early anastomotic leaks within 1 week after surgery and prevent the need for reintubation are important for improving patient prognosis.
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Affiliation(s)
- Bin Li
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270#Dong'an Rd, Shanghai, 20032, China
| | - Jiaqing Xiang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270#Dong'an Rd, Shanghai, 20032, China
| | - Yawei Zhang
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270#Dong'an Rd, Shanghai, 20032, China
| | - Hong Hu
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270#Dong'an Rd, Shanghai, 20032, China
| | - Yihua Sun
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, 270#Dong'an Rd, Shanghai, 20032, China
| | - Haiquan Chen
- Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.
- Department of Oncology, Shanghai Medical College, Fudan University, 270#Dong'an Rd, Shanghai, 20032, China.
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Fink-Neuboeck N, Lindenmann J, Bajric S, Maier A, Riedl R, Weinberg AM, Smolle-Juettner FM. Clinical impact of interleukin 6 as a predictive biomarker in the early diagnosis of postoperative systemic inflammatory response syndrome after major thoracic surgery: A prospective clinical trial. Surgery 2016; 160:443-53. [PMID: 27206334 DOI: 10.1016/j.surg.2016.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/29/2016] [Accepted: 04/01/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative systemic inflammatory response syndrome and sepsis are associated with high morbidity and mortality rates. Early detection of postoperative systemic inflammatory response syndrome improves the outcome. The aim of this study was to evaluate the feasibility of interleukin 6 as a predictive biomarker in the early diagnosis of postoperative systemic inflammatory response syndrome after a major thoracic operation. METHODS A total of 94 patients were enrolled in this prospective, clinical, single-center study. The enrolled subjects underwent either lung resection or esophageal operation. Interleukin 6, procalcitonin, C-reactive protein, and leucocytes were measured sequentially before, during, and after the operation. These levels were compared between patients who developed postoperative systemic inflammatory response syndrome and those who did not. RESULTS The enrollees who completed the study included of 55 males (79.7%) and 14 females (20.3%) with a mean age of 60.9 years. Twenty patients (29.0%) developed systemic inflammatory response syndrome at a median time of 33.0 hours postoperatively. In cases of postoperative systemic inflammatory response syndrome, interleukin 6 was the most predictive biomarker, showing a striking increase on the day of operation and preceding the median onset of postoperative systemic inflammatory response syndrome, which occurred the next day (P ≤ .001). Peak procalcitonin and C-reactive protein occurrence were significantly delayed at 24 hours (P = .012) and 48 hours (P = .012). There was no mortality 30 days postoperatively. CONCLUSION Interleukin 6 is a reliable predictor of postoperative systemic inflammatory response syndrome, and it is able to detect postoperative system inflammatory response syndrome before the onset of related clinical symptoms. When identifying patients at high risk, it would be beneficial to include interleukin 6 in conventional postoperative monitoring, particularly after extended surgical resection.
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Affiliation(s)
- Nicole Fink-Neuboeck
- Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Graz, Austria
| | - Joerg Lindenmann
- Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Graz, Austria.
| | - Sedin Bajric
- Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Graz, Austria
| | - Alfred Maier
- Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Graz, Austria
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Wang L, Cang J, Xue Z. Protective effects of thoracic epidural anesthesia on hypoxia-induced acute lung injury in rabbits. Exp Ther Med 2016; 11:2021-2027. [PMID: 27168845 DOI: 10.3892/etm.2016.3151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 10/07/2015] [Indexed: 02/06/2023] Open
Abstract
The mechanism underlying the effect of thoracic epidural anesthesia (TEA) on hypoxia-induced acute lung injury (ALI) is currently unknown. In the present study, a rabbit acute lung injury model was established to investigate the effects of TEA on inflammatory factors, pulmonary surfactant and ultrastructure. A total of 56 rabbits were randomly assigned to four groups (n=14 per group): Control group (Group C), hypoxia group (Group H), sevoflurane group (Group S) and combined sevoflurane-epidural anesthesia group (Group ES). The ALI model was considered to have been successfully induced when the ratio of arterial oxygen partial pressure to fractional inspired oxygen was <300. The correct placement of a catheter for TEA was confirmed using epidurography. ALI was maintained for 3 h. Arterial blood samples were collected from all groups during spontaneous breathing (T0) and at 3 h after ALI induction (T5) in order to evaluate the serum levels of interleukin (IL)-6, IL-8 and IL-10. Bronchoalveolar lavage fluid was harvested to determine the total phospholipid, saturated phosphatidylcholine and total protein levels. Furthermore, the dry/wet weight ratio and the mRNA expression levels of IL-6, IL-8 and IL-10 in the lung tissue were determined using ELISA. In addition, light and transmission electron microscopy and histological techniques were used to examine the morphology of alveolar type II cells in the rat lung tissue. The results indicate that changes of serum IL-6, IL-8 and IL-10 levels following ALI were consistent with the changes in the mRNA expression levels of IL-6, IL-8 and IL-10 in the lung tissue. TEA attenuated these changes and thus reduced the severity of the ALI. In addition, TEA improved the alveolar structure, reduced the number of polymorphonuclear cells and mitigated the damage of lamellar bodies. In summary, the results of the present study indicate that TEA reduces lung tissue damage by inhibiting systemic and local inflammation, decreasing the inactivation of pulmonary surfactant and improving the alveolar ultrastructure following ALI.
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Affiliation(s)
- Lijun Wang
- Department of Anesthesiology, Ear, Eye, Nose and Throat Hospital, Fudan University, Shanghai 200031, P.R. China
| | - Jing Cang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Zhanggang Xue
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
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Takahata R, Ono S, Tsujimoto H, Hiraki S, Aosasa S, Yamamoto J, Hase K. Preoperative chemoradiation therapy for esophageal cancer is a risk factor for the elevation of high mobility group box-1, leading to an increase in postoperative severe pulmonary complications. Dis Esophagus 2016; 29:70-8. [PMID: 25139532 DOI: 10.1111/dote.12261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We herein clarified the time course of changes in the serum high mobility group box chromosomal protein-1 (HMGB-1) concentrations in esophageal cancer patients after esophagectomy, and investigated whether the perioperative serum HMGB-1 levels correlate with the administration of neoadjuvant chemoradiation therapy (NACRT) and the postoperative clinical course, especially the occurrence of pulmonary complications, in such patients. Sixty patients who underwent right transthoracic esophagectomy for esophageal cancer were enrolled in this study. The relationship between the perioperative serum HMGB-1 levels and NACRT, and the postoperative severe pulmonary complications were evaluated. Patients with severe pulmonary complications (n = 44) tended to have undergone NACRT more often than those without severe pulmonary complications (n = 16). The preoperative and postoperative day 7 serum HMGB-1 concentrations were significantly higher in patients with severe pulmonary complications than those in patients without severe pulmonary complications. In the univariate and multivariate analyses, the use of NACRT and the preoperative elevations in the serum HMGB-1 levels (>4.2 ng/mL) were found to be significantly associated with pulmonary dysfunction. Furthermore, the response to NACRT was found to be significantly associated with the preoperative serum HMGB-1 levels. The use of NACRT contributes to preoperative serum HMGB-1 elevation, and these were risk factors for the occurrence of severe postoperative pulmonary complications in patients with esophageal cancer after thoracic esophagectomy.
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Affiliation(s)
- R Takahata
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - S Ono
- Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Saitama, Japan
| | - H Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - S Hiraki
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - S Aosasa
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - J Yamamoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - K Hase
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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Randomized Phase II Study of the Anti-inflammatory Effect of Ghrelin During the Postoperative Period of Esophagectomy. Ann Surg 2015; 262:230-6. [PMID: 25361222 DOI: 10.1097/sla.0000000000000986] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A prospective randomized phase II trial was conducted to evaluate the efficacy of ghrelin administration in reducing systemic inflammatory response syndrome (SIRS) duration after esophagectomy. BACKGROUND Esophagectomy for esophageal cancer is highly invasive and leads to prolonged SIRS duration and postoperative complications. Ghrelin has multiple effects, including anti-inflammatory effects. METHODS Forty patients undergoing esophagectomy were randomly assigned to either the ghrelin group (n = 20), which received continuous infusion of ghrelin (0.5 μg/kg/h) for 5 days, or the placebo group (n = 20), which received pure saline for 5 days. The primary endpoint was SIRS duration. The secondary endpoints were the incidence of postoperative complications, time of a negative nitrogen balance, changes in body weight and composition, and levels of inflammatory markers, including C-reactive protein (CRP) and interleukin-6 (IL-6). RESULTS The ghrelin group had a shorter SIRS duration and lower CRP and IL-6 levels than did the placebo group. The incidence of pulmonary complications was lower in the ghrelin group than in the placebo group, whereas other complications did not differ between the groups. Although time of the negative nitrogen balance was shorter in the ghrelin group than in the placebo group, changes in total body weight and lean body weight did not differ significantly. CONCLUSIONS Postoperative ghrelin administration was effective for inhibiting inflammatory mediators and improving the postoperative clinical course of patients with esophageal cancer.
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Wang ZQ, Chen LQ, Yuan Y, Wang WP, Niu ZX, Yang YS, Cai J. Effects of neutrophil elastase inhibitor in patients undergoing esophagectomy: A systematic review and meta-analysis. World J Gastroenterol 2015; 21:3720-3730. [PMID: 25834341 PMCID: PMC4375598 DOI: 10.3748/wjg.v21.i12.3720] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 06/23/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the benefit and safety of sivelestat (a neutrophil elastase inhibitor) administration in patients undergoing esophagectomy.
METHODS: Online databases including PubMed, EMBASE, the Cochrane Library, Web of Knowledge, and Chinese databases (Wanfang database, VIP and CNKI) were searched systematically up to November 2013. Randomized controlled trials and high-quality comparative studies were considered eligible for inclusion. Three reviewers evaluated the methodological quality of the included studies, and Stata 12.0 software was used to analyze the extracted data. The risk ratio (RR) was used to express the effect size of dichotomous outcomes, and mean difference (MD) or standardized mean difference was used to express the effect size of continuous outcomes.
RESULTS: Thirteen studies were included in this systematic review and nine studies were included in the meta-analysis. The duration of mechanical ventilation was significantly decreased in the sivelestat group on postoperative day 5 [I2 = 76.3%, SMD = -1.41, 95%CI: -2.63-(-0.19)]. Sivelestat greatly lowered the incidence of acute lung injury in patients after surgery (I2 = 0%, RR = 0.27, 95%CI: 0.08-0.93). However, it did not decrease the incidence of pneumonia, intensive care unit stay or postoperative hospital stay, and did not increase the incidence of complications such as anastomotic leakage, recurrent nerve palsy, wound infection, sepsis and catheter-related fever.
CONCLUSION: A neutrophil elastase inhibitor is beneficial in patients undergoing esophagectomy. More high quality, large sample, multi-center and randomized controlled trials are needed to validate this effect.
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Okamura A, Takeuchi H, Matsuda S, Ogura M, Miyasho T, Nakamura R, Takahashi T, Wada N, Kawakubo H, Saikawa Y, Kitagawa Y. Factors Affecting Cytokine Change After Esophagectomy for Esophageal Cancer. Ann Surg Oncol 2015; 22:3130-5. [DOI: 10.1245/s10434-014-4348-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Indexed: 11/18/2022]
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Affiliation(s)
- P R Boshier
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - N Marczin
- Department of Anaesthetics, Pain Medicine and Intensive Care, Chelsea and Westminster Hospital, Imperial College London, London, UK.,Department of Anaesthetics, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, UK.,Department of Anaesthesia and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - G B Hanna
- Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
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McMahon JD, MacIver C, Smith M, Stathopoulos P, Wales C, McNulty R, Handley TP, Devine JC. Postoperative complications after major head and neck surgery with free flap repair—prevalence, patterns, and determinants: a prospective cohort study. Br J Oral Maxillofac Surg 2013; 51:689-95. [DOI: 10.1016/j.bjoms.2013.04.015] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
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Nagai Y, Watanabe M, Baba Y, Iwatsuki M, Hirashima K, Karashima R, Kurashige J, Kinoshita K, Baba H. Preventive effect of sivelestat on postoperative respiratory disorders after thoracic esophagectomy. Surg Today 2013; 43:361-6. [PMID: 23412514 DOI: 10.1007/s00595-013-0508-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 11/07/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE Sivelestat, a selective inhibitor of neutrophil elastase, has been reported to reduce acute lung injury associated with systemic inflammatory response syndrome. This study retrospectively investigated the effect of sivelestat on respiratory function in patients who underwent esophagectomy. METHODS Patients who underwent esophagectomy for thoracic esophageal cancer between 2005 and 2010 were included in this study. Forty-two were treated perioperatively with sivelestat (4.8 mg/kg/day; sivelestat group) and the remaining 35 were not (control group). Sivelestat was administered continuously from the beginning of surgery until postoperative day 3. All patients were administered methylprednisolone for 3 days. The perioperative clinical and laboratory data, total sequential organ failure assessment score, PaO2/FiO2 ratio (P/F ratio) and postoperative complications were compared between the two groups. RESULTS There were no significant differences between the groups in the patients' background data. The P/F ratio immediately after surgery was significantly higher in the sivelestat group than in the control group (p < 0.05). The respiratory rate immediately after surgery and the temperature on postoperative day 2 were significantly lower in the sivelestat group than in the control group (p < 0.05). There were no differences in any of the other clinical data or complications. CONCLUSIONS Perioperative administration of sivelestat improves postoperative respiratory function in patients after esophagectomy.
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Affiliation(s)
- Yohei Nagai
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, Kumamoto 860-8556, Japan.
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Saeki H, Morita M, Harada N, Egashira A, Oki E, Uchiyama H, Ohga T, Kakeji Y, Sakaguchi Y, Maehara Y. Esophageal replacement by colon interposition with microvascular surgery for patients with thoracic esophageal cancer: the utility of superdrainage. Dis Esophagus 2013; 26:50-6. [PMID: 22394201 DOI: 10.1111/j.1442-2050.2012.01327.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Replacing the thoracic esophagus with the colon is one mode of reconstruction after esophagectomy for esophageal cancer. There is, however, a high incidence of postoperative necrosis of the transposed colon. This study evaluated the outcomes of colon interposition with the routine use of superdrainage by microvascular surgery. Twenty-one patients underwent colon interposition from 2004 to 2009. The strategy for colon interposition was to: (i) use the right hemicolon; (ii) reconstruct via the subcutaneous route; (iii) perform a microvascular venous anastomosis for all patients; and (iv) perform a microvascular arterial anastomosis when the arterial blood flow was insufficient. The clinicopathologic features, surgical findings, and outcomes were investigated. The colon was used because of a previous gastrectomy in 18 patients (85.7%) and synchronous gastric cancer in three patients (14.3%). Eight patients (38.1%) underwent preoperative chemoradiotherapy including three (14.3%) treated with definitive chemoradiotherapy. Seven patients (33.3%) underwent microvascular arterial anastomosis to supplement the right colon blood supply. Pneumonia occurred in four patients (19.0%). Anastomotic leakage was observed in five patients (23.8%); however, no colon necrosis was observed. The 3-year and 5-year overall survival rates were both 50.6%. Colon interposition with superdrainage results in successful treatment outcomes. This technique is one option for colon interposition employing the right hemicolon.
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Affiliation(s)
- H Saeki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan.
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Tsujimoto H, Takahata R, Nomura S, Kumano I, Matsumoto Y, Yoshida K, Hiraki S, Aosasa S, Ono S, Yamamoto J, Hase K. Predictive value of pleural and serum interleukin-6 levels for pneumonia and hypo-oxygenations after esophagectomy. J Surg Res 2012. [PMID: 23207169 DOI: 10.1016/j.jss.2012.11.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Pulmonary complications after esophagectomy continue to be a significant cause of morbidity and mortality. Although several factors have been implicated to be associated with pulmonary complications after esophagectomy, the prediction of pulmonary complications remains a challenge. The purpose of this study was to evaluate the predictive value of cytokine levels in sera and pleural drainage fluid for pneumonia and hypo-oxygenations following esophagectomy. METHODS A total of 66 patients who underwent esophagectomy for esophageal cancer were retrospectively evaluated for preoperative status, surgical procedures, and postoperative systemic response and laboratory data up to postoperative day (POD) 7. Interleukin-6 (IL-6) and IL-8 levels were also examined in patient sera and pleural drainage fluid until POD 5. RESULTS Eighteen patients (27.3%) had pneumonia following esophagectomy. Patients with pneumonia had significantly more frequent intraoperative blood transfusions, more frequent re-intubation, longer hospital stays, and higher hospital mortality than those without pulmonary complications. Patients with pneumonia had significantly higher levels of serum and pleural IL-6 immediately after surgery and on POD 1 than those without pneumonia. Univariate and multivariate analyses revealed higher pleural IL-6 levels were associated with postoperative minimum PaO2/FiO2 ratio. CONCLUSIONS The elevation of pleural IL-6 levels immediately after surgery and on POD 1 may predict the incidence of pneumonia and the levels of postoperative impaired oxygenation following esophagectomy.
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Affiliation(s)
- Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan.
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Lee JJ, Kim GH, Kim JA, Yang M, Ahn HJ, Sim WS, Park KJ, Jun BH. Comparison of Pulmonary Morbidity Using Sevoflurane or Propofol-Remifentanil Anesthesia in an Ivor Lewis Operation. J Cardiothorac Vasc Anesth 2012; 26:857-62. [DOI: 10.1053/j.jvca.2012.01.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Indexed: 11/11/2022]
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Derogar M, Orsini N, Sadr-Azodi O, Lagergren P. Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal cancer surgery. J Clin Oncol 2012; 30:1615-9. [PMID: 22473157 DOI: 10.1200/jco.2011.40.3568] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To evaluate the effect of major postoperative complications on health-related quality of life (HRQL) in 5-year survivors of esophageal cancer surgery. PATIENTS AND METHODS This study was based on the Swedish Esophageal and Cardia Cancer register with almost complete nationwide coverage and data on esophageal cancer surgery collected prospectively between 2001 and 2005. Patients who were alive 5 years after surgery were eligible. HRQL was assessed longitudinally until 5 years after surgery by using the validated European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and OES18. Linear mixed models were used to assess the mean score difference (MD) with 95% CIs of each aspect of HRQL in patients with or without major postoperative complications. Adjustment was made for several potential confounders. RESULTS Of 153 patients who survived 5 years, 141 patients (92%) answered the 5-year HRQL questionnaires. Of these individuals, 46 patients (33%) sustained a major postoperative complication. Dyspnea (MD, 15; 95% CI, 6 to 23), fatigue (MD, 13; 95% CI, 5 to 20), and eating restrictions (MD, 10; 95% CI, 2 to 17) were clinically and statistically significantly deteriorated throughout the follow-up in patients with major postoperative complications compared with patients without major complications. Although problems with choking declined to levels comparable with patients without major postoperative complications, sleep difficulties and gastroesophageal reflux progressively worsened during follow-up. CONCLUSION The occurrence of postoperative complications exerts a long-lasting negative effect on HRQL in patients who survive 5 years after esophagectomy for cancer.
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Affiliation(s)
- Maryam Derogar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Bianchi RCG, Ropelle ER, Katashima CK, Carvalheira JBC, Lopes LR, Andreollo NA. Analysis of the physical activity effects and measurement of pro-inflammatory cytokines in irradiated lungs in rats. Acta Cir Bras 2012; 27:223-30. [PMID: 22460252 DOI: 10.1590/s0102-86502012000300004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/20/2012] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To study if the pre-radiotherapy physical activity has radio-protective elements, by measuring the radio-induced activation of pro-inflammatory cytokines as interleukin-6 (il-6), transforming growth factor -β (tgf -β), tumor necrosis factor -α (tnf-α) and protein beta kinase β (ikkβ), through western blotting analysis. METHODS A randomized study with 28 Wistar hannover rats, males, with a mean age of 90 days and weighing about 200 grams. The animals were divided into three groups: (GI, GII and GIII). GIII group were submitted to swimming for eight weeks (zero load, three times a week, about 30 minutes). Then, the groups (except the control group) were submitted to irradiation by cobalt therapy, single dose of 3.5 gray in the whole body. All animals were sacrificed by overdose of pentobarbital, according to the time for analysis of cytokines, and then a fragment of the lower lobe of the right lung went to western blotting analysis. RESULTS The cytokines IKK β, TNF-α and IL-6 induced by radiation in the lung were lower in the exercised animals. However, exercise did not alter the radiation-induced increase in tgf-β. CONCLUSION The results show a lower response in relation to inflammatory cytokines in the group that practiced the exercise pre-radiotherapy, showing that exercise can protect tissues from tissue damage due to irradiation.
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Early Results: Morbidity, Mortality, and the Treatment of Complications. Updates Surg 2012. [DOI: 10.1007/978-88-470-2330-7_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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31
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Breunig A, Gambazzi F, Beck-Schimmer B, Tamm M, Lardinois D, Oertli D, Zingg U. Cytokine & chemokine response in the lungs, pleural fluid and serum in thoracic surgery using one-lung ventilation. JOURNAL OF INFLAMMATION-LONDON 2011; 8:32. [PMID: 22078633 PMCID: PMC3253056 DOI: 10.1186/1476-9255-8-32] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 11/11/2011] [Indexed: 11/12/2022]
Abstract
Background Thoracic surgery mandates usually a one-lung ventilation (OLV) strategy with the collapse of the operated lung and ventilation of the non-operated lung. These procedures trigger a substantial inflammatory response. The aim of this study was to analyze the cytokine and chemokine reaction in both lungs, pleural space and blood in patients undergoing lung resection with OLV with special interest in the chemokine growth-regulated peptide alpha (GROα) which is the human equivalent to the rat cytokine-induced neutrophil chemoattractant-1 (CINC-1). Methods Broncho-alveolar lavage (BAL) fluid of both the collapsed, operated and the ventilated, non-operated lung, respectively, pleural space drainage fluid and blood was collected and the concentrations of interleukin (IL)-6, IL-1RA and GROα were determined with enzyme-linked immunosorbent assays in 15 patients. Results Substantial inter-individual differences in the BAL fluid between patients in cytokine and chemokine levels occurred. In the pleural fluid and the blood these inter-individual differences were less pronounced. Both sides of the lung were affected and showed a significant increase in IL-6 and IL-1RA concentrations over time but not in GROα concentrations. Except for IL-6, which increased more in the collapsed, operated lung, no difference between the collapsed, operated and the ventilated, non-operated lung occurred. In the blood, IL-6 and IL-1RA increased early, already at the end of surgery. GROα was not detectable. In the pleural fluid, both cytokine and chemokine concentrations increased by day one. The increase was significantly higher in the pleural fluid compared to the blood. Conclusion The inflammatory response of cytokines affects both the collapsed, operated and the ventilated, non-operated lungs. The difference in extent of response underlines the complexity of the inflammatory processes during OLV. In contrast to the cytokines, the chemokine GROα concentrations did not react in the BAL fluid or in the blood. This indicates that GROα might not be useful as marker for the inflammatory reaction in complex surgical procedures.
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Affiliation(s)
- Andreas Breunig
- Department of Surgery, University Hospital Basel, Switzerland.
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Clinical significance of salvage esophagectomy for remnant or recurrent cancer following definitive chemoradiotherapy. J Gastroenterol 2011; 46:1284-91. [PMID: 21818602 DOI: 10.1007/s00535-011-0448-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 07/04/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND The purpose of this study was to clarify the effect of preoperative chemoradiotherapy (CRT) for esophageal cancer on the postoperative course, and to determine the clinical significance of salvage esophagectomy after definitive CRT. METHODS Based on their preoperative treatment, 477 patients with esophageal cancer were classified into three groups: 253 patients who received surgery alone (Group I), 197 who received planned CRT (30-45 Gy, Group II), and 27 who received a salvage esophagectomy (radiation ≥60 Gy, Group III). RESULTS Postoperative complications developed in 25, 40, and 59% of the patients in Groups I, II, and III, respectively, with pulmonary complications developing in 10, 15, and 30%, and anastomotic leakage developing in 13, 23, and 37%, respectively. Mortality rates were 2.4, 2.0, and 7.4%, respectively. Multivariate analysis revealed preoperative therapy to be an independent factor associated with postoperative risks: the odds ratios (ORs) of Groups II and III compared to Group I were 1.8 and 4.0 for pulmonary complications, while they were 1.9 and 2.8, respectively, for anastomotic leakage. No critical complications developed in the 14 patients who received salvage surgery performed with strict surgical indications after 2005. The survival of Group III was not significantly different from that of Groups I and II. Most patients who received an R1/R2 resection after definitive CRT died within 2 years after salvage surgery. CONCLUSIONS Preoperative CRT is associated with postoperative complications especially in patients with R2 resection, while long-term survival can be achieved after R0 resections. Salvage surgery should be considered for carefully selected patients in whom R0 resection can be achieved.
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Serum C-Reactive Protein as a Predictor of Morbidity and Mortality in Intensive Care Unit Patients After Esophagectomy. Ann Thorac Surg 2011; 91:1775-9. [DOI: 10.1016/j.athoracsur.2011.02.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 02/10/2011] [Accepted: 02/14/2011] [Indexed: 11/19/2022]
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Makino H, Kunisaki C, Kosaka T, Akiyama H, Morita S, Endo I. Perioperative use of a neutrophil elastase inhibitor in video-assisted thoracoscopic oesophagectomy for cancer. Br J Surg 2011; 98:975-82. [PMID: 21557207 DOI: 10.1002/bjs.7499] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study was undertaken to assess the value of administering perioperative sivelestat sodium hydrate (SSH), a selective neutrophil elastase inhibitor, after video-assisted thoracoscopic oesophagectomy for cancer. METHOD Thirty-one consecutive patients with thoracic oesophageal cancer selected to undergo video-assisted thoracoscopic oesophagectomy with lymph node dissection between March 2007 and March 2009 were assigned randomly to a treatment group that received SSH intravenously for 7 days from the beginning of surgery (16 patients) and a control group that received saline (15). The primary endpoint was pulmonary function based on the arterial partial pressure of oxygen/fraction of inspired oxygen ratio (P/F ratio) during the first 9 days after surgery. Secondary endpoints included platelet count, serum C-reactive protein (CRP) concentration, plasma neutrophil elastase-α(1)-antitrypsin complex level, duration of mechanical ventilation and systemic inflammatory response syndrome (SIRS), and length of intensive care unit (ICU) and hospital stay. RESULTS The mean P/F ratio of patients who received SSH was significantly higher than that of the control group on postoperative days 1-5 and 7. Duration of mechanical ventilation and SIRS, and length of ICU stay were significantly shorter in the treatment group. Serum CRP concentration on postoperative day 9 was significantly lower (P = 0·048), platelet counts on days 2, 3 and 5 were higher (P = 0·012, P = 0·049 and P = 0·006 respectively), and the incidence of postoperative acute lung injury was significantly lower following SSH treatment (P = 0·023). CONCLUSION Perioperative sivelestat may maintain postoperative pulmonary function following video-assisted oesophagectomy.
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Affiliation(s)
- H Makino
- Department of Surgery, Gastroenterological Centre, Yokohama City University, Minami-ku, Yokohama, Japan.
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Morita M, Nakanoko T, Kubo N, Fujinaka Y, Ikeda K, Egashira A, Saeki H, Uchiyama H, Ohga T, Kakeji Y, Shirabe K, Ikeda T, Tsujitani S, Maehara Y. Two-Stage Operation for High-Risk Patients with Thoracic Esophageal Cancer: An Old Operation Revisited. Ann Surg Oncol 2011; 18:2613-21. [DOI: 10.1245/s10434-011-1654-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Indexed: 11/18/2022]
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Morita M, Nakanoko T, Fujinaka Y, Kubo N, Yamashita N, Yoshinaga K, Saeki H, Emi Y, Kakeji Y, Shirabe K, Maehara Y. In-hospital mortality after a surgical resection for esophageal cancer: analyses of the associated factors and historical changes. Ann Surg Oncol 2011; 18:1757-65. [PMID: 21207167 DOI: 10.1245/s10434-010-1502-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Resections for esophageal cancer are invasive, with high mortality and morbidity rates. The object of this study was to clarify the factors associated with in-hospital death while also evaluating any associated historical changes in the characteristics of such deaths. METHODS The factors associated with mortality were examined by logistic regression analysis in 1106 patients who underwent an esophagectomy for esophageal cancer. The historical changes in the characteristics of in-hospital deaths were also evaluated. RESULTS A multivariate analysis revealed that not only undergoing an esophagectomy before 1979, but also a patient's age (odds ratio 1.070 for every increase in age by year) and an incomplete resection (odds ratio 2.265) were independent factors associated with in-hospital death. The in-hospital mortality rates were 16.1%, 5.8%, 2.5%, and 3.1%, while the 30-day mortality rates were 9.2%, 2.2%, 0.8%, and 0.3% during 1964-1979, the 1980s, the 1990s, and the 2000s, respectively. Eight patients had preoperative comorbidities among 11 patients who died in the hospital after 1997. The mortality rate was 5.5% in patients with any comorbidities, while it was 1.3% in patients without any comorbidities (P = 0.026). The most common direct cause of in-hospital death was previous pulmonary complications; however, cancer progression has recently become the most common cause. CONCLUSIONS To prevent in-hospital mortality after an esophagectomy, strict indications for surgery and careful perioperative management are important, especially in high-risk patients with advanced esophageal cancer.
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Affiliation(s)
- Masaru Morita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Kobayashi M, Irinoda T, Akiyama Y, Meguro E, Hayakawa Y, Funato O, Takagane A. Effect of a selective neutrophil elastase inhibitor on early recovery from body water imbalance after transthoracic esophagectomy. Dis Esophagus 2010; 23:565-71. [PMID: 20353442 DOI: 10.1111/j.1442-2050.2010.01053.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The objective of the study was to evaluate the efficacy of sivelestat, a selective neutrophil elastase inhibitor, on body fluid balance after transthoracic esophagectomy. Esophagectomy with elective lymphadenectomy may induce excessive release of neutrophil elastase, which then promotes vascular permeability and an excessive water shift from the intravascular space to the peripheral compartment. Body fluid imbalance after esophagectomy often leads to circular instability, a decrease of urine output, and a delay in the shift to a diuretic state. The study was designed as a case-control study with a historical control group. A retrospective analysis was performed to examine our hypothesis that sivelestat improves abnormal body fluid retention and prevents subsequent pulmonary complications. To reveal the direct influence of sivelestat on the postoperative course, we avoided using steroids or other diuretic agents. Eighty-eight patients who underwent thoracic esophagectomy with extended lymphadenectomy from 2000 to 2008 were divided into two groups: those treated from 2003 to 2008, who all received postoperative administration of sivelestat (n=60); and those treated from 2000 to 2002, who did not receive sivelestat and were used as the control group (n=28). Both groups received fluid management using the same protocol. The time to reach a diuretic state, time until extubation of the tracheal tube, and development of delayed respiratory dysfunction were compared between the groups using univariate and multivariate analysis. The time until a shift to a diuretic state was significantly shorter after treatment with sivelestat (p<0.0001) and with a shorter operation time (p<0.0001). The tracheal tube was extubated significantly earlier in the sivelestat group (p<0.0001) and the incidence of delayed respiratory dysfunction was also significantly lower (p=0.0028) in this group. Multivariate logistic regression analysis showed that a delay in a shift to a diuretic state was a strong independent risk factor for the time to tracheal extubation (odds ratio 2.539, p=0.0056) and occurrence of delayed respiratory dysfunction (odds ratio 1.989, p=0.0104). Sivelestat treatment was not independently associated with reduced pulmonary complications, but the diuretic state was strongly regulated by sivelestat treatment (odds ratio 0.044, p=0.0003). Thus, administration of sivelestat has a beneficial influence on recovery from body water imbalance through a more rapid return to a diuretic state after esophagectomy, which contributes to prevention of subsequent pulmonary complications.
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Affiliation(s)
- M Kobayashi
- Dept. Surgery, Hakodate Goryoukaku Hospital, Goryoukaku-Cho, Hakodate, Japan.
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Impact of perioperative peripheral blood values on postoperative complications after esophageal surgery. Surg Today 2010; 40:626-31. [DOI: 10.1007/s00595-009-4135-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 04/27/2009] [Indexed: 12/18/2022]
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Hypothermia during burn surgery and postoperative acute lung injury in extensively burned patients. ACTA ACUST UNITED AC 2009; 66:1525-9; discussion 1529-30. [PMID: 19509610 DOI: 10.1097/ta.0b013e3181a51f35] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Respiratory dysfunction remains one of the major complications after burn surgery in extensively burned patients. We evaluated the relationship between the invasiveness of burn surgery and acute lung injury (ALI). METHODS Patients admitted to our burn unit between 2006 and 2007 with burns greater than or equal to 30% of the total body surface area without severe inhalation injury were entered into this study. Of sixteen patients (mean age, 49.4 +/- 19.3 years, total body surface area 46.0% +/- 14.9%) who underwent burn surgery (3-6 days postburn), vital signs, hemodynamic parameters, blood gas analysis, and peak inspiratory pressure were recorded. Lung injury severity (LIS) score was serially determined. Bronchoalveolar lavage (BAL) was performed before and 24 hour postoperatively. RESULTS Body temperature and LIS score preoperatively (baseline) were 37.1 degrees C +/- 0.9 degrees C and 3.8 degrees C +/- 2.2 degrees C, respectively. LIS score increased with increased polymorphonuclear neutrophil in BAL 24 hour postoperatively in 7 of 10 patients with intraoperative temperature decreasing more than 1 degrees C. Extent of excision (20.3% +/- 6.7%), transfusion (4.3 +/- 3.0 units), or duration of surgery (147 +/- 49 minutes) alone did not show significant correlation with the development of ALI postoperatively. CONCLUSION In patients with severe burn injury, hypothermia during surgery despite aggressive intraoperative warming is significantly correlated with the development of ALI with increased polymorphonuclear neutrophil in BAL and may reflect the severity of invasiveness.
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