The obesity paradox in surgical intensive care patients with peritonitis.

PURPOSE: Although obesity is usually regarded as a risk factor in surgical patients, various observations have revealed a better outcome in the obese. This finding is called the obesity paradox. To which group of patients the paradox applies and even whether it exists at all are matters of controversial discussion. MATERIALS AND METHODS: We retrospectively analyzed 253 consecutive patients with surgical peritonitis and sepsis who needed intensive care for more than 2 days postoperative. Patients were assigned to groups according to body mass index (BMI), and groups were compared with respect to outcome parameters. RESULTS: In the 4 BMI groups--less than 21, 21 to 25, 26 to 30, and more than 30 kg/m(2)--mortality rate at 28 days was 73%, 50%, 42%, and 31%, respectively. The relative risk of death at 28 days in the BMI greater than 30 kg/m(2) group compared to the normal weight group (BMI, 21-25.9 kg/m(2)) was 0.66 (95% confidence interval, 0.28-0.94). However, mortality rate at 5 years was 90%, 70%, 69%, and 75%, respectively. Patients in the lowest BMI range were less likely to be discharged home. Intensive care unit and hospital length of stay was longest in the group of highest BMI, and that group had the best mean survival (386 days for BMI >30 kg/m(2) vs 113 days for BMI <21 kg/m(2)). CONCLUSIONS: The "obesity paradox" may exist in patients with surgical peritonitis. Short-term but not long-term outcomes were improved in the obese. Concerns about obesity as a special risk factor in patients with peritonitis are not warranted according to our findings.

Subcutaneous Redon drains do not reduce the incidence of surgical site infections after laparotomy. A randomized controlled trial on 200 patients.

PURPOSE: Surgical site infections (SSI) cause excess morbidity and mortality in modern surgery. Several different approaches to reduce the incidence of SSI have been investigated with variable results. METHOD: This is to our knowledge the first systematic randomized evaluation in patients undergoing laparotomy in visceral surgery to clarify whether widely used subcutaneous drains (Redon) affect wound infection as the primary outcome measure. RESULTS: In 200 patients, we were unable to show a statistically significant impact on the postoperative healing process in patients with the full variety of abdominal surgical interventions. Overall, we observed surgical site infection in 9.5% of all patients (n = 19), of these n = 9 (47.4%) were in the control group without a drain, and 10 (52.6%) were in the experimental group with a Redon drain (not significant). CONCLUSION: As this study could not demonstrate a reduction of SSI by the use of Redon drains, there is no indication for prophylactic subcutaneous suction drains after laparotomy.

Cytokine expression in colon carcinoma.

BACKGROUND: Cytokines reflect the activity of the immune system. We analyzed the local expression of characteristic cytokines indicating the level of activity of unspecific inflammatory cells, Th1-cells and Th2-cells in colon cancer. MATERIALS AND METHODS: In 25 tumor/ mucosa pairs, IL-1alpha, IL-2, IL-4, IL-5, IL-15, TNF-alpha and IFN-gamma were measured by real-time PCR. RESULTS: There was a significant increase in IL-1alpha, IL-4, IL-5 and TNF-alpha and a significant decrease in IL-2 in tumor tissue compared to normal mucosa. DISCUSSION: The cytokine profile in colon cancer indicates a strong unspecific inflammatory reaction in the tumor tissue represented by high levels of IL-1 and TNF-alpha. The comparatively low level of IL-2 suggests suppression of a specific immunological reaction, namely Th1-cells. It can be hypothesized that this is a result and/or cause of local immune escape mechanisms. Furthermore, there is an activation of TH2 cells in the carcinomas.