Thrombocyte decrease and hemoglobin level as simple non-inflammatory predictors of anastomotic leakage in rectal-cancer surger.

PURPOSE: The study aimed to determine a simple diagnostic test that could predict the risk of anastomotic leakage in early postoperative period. METHODS: A single-center, retrospective study was conducted. The electronic medical records of patients who underwent resection for rectal tumor between January 1, 2016, and December 31, 2021, in University Hospital Olomouc, were reviewed. The data included risk factors for leakage and laboratory parameters commonly obtained. RESULTS: The decrease in platelets was significant as for the possibility of being a marker of anastomotic leakage; OR = 0.980 (p = 0.036). A decrease of 34 or higher predicts leakage with a sensitivity of 45 % (95 % CI: 23.1-68.5 %) and specificity of 81.1 % (95 % CI: 75.2-86.1 %). Postoperative leukocyte blood level (OR = 1.134; p = 0.019) and leukocyte level on postoperative day 1 (OR = 1.184; p = 0.023) were significant predictors for leakage. WBC values ≥ 8.8 predict leakage with a sensitivity of 70.0 % (95 % CI: 45.7-88.1 %) and specificity of 55.3 % (95 % CI: 48.4-62.0 %).  Hemoglobin blood level ≤ 79.5 predicts leakage with a sensitivity of 70.0 % (95 % CI: 45.7-88.1 %) and specificity of 62.2 % (95 % CI: 55.5-68.7 %). CONCLUSION: Despite the fact that the specificity and sensitivity of the followed parameters are low, they could serve as markers useful for early diagnosis or suspicion for leakage (Tab. 5, Fig. 3, Ref. 14).

Effect of reinforcement suture on anastomotic healing in rectal and sigmoid tumor resections, single-center experience: a retrospective case-controlled study.

PURPOSE: Healing of colorectal anastomosis is burdened with a number of risk factors and the development of leak carries with it higher morbidity and mortality associated not only with worse quality of life but also worse oncological outcomes. The purpose of the study was an evaluation of the effect of reinforcement suture in the healing of stapler rectal anastomosis and risk factors for anastomotic leakage in mid, upper rectal and sigmoid tumors. METHODS: A total of 357 patients who underwent curative resection for rectal or sigmoid tumor over 5 years were analyzed. Risk factors, baseline demographic and clinical data, and presence of leak were recorded. All statistical analyses were carried out at a significance level of P<0.05. RESULTS: One hundred fifty-one patients met the inclusion criteria for the study. The overall incidence of leak was 2.8% in the group with reinforcement suture and 6.3% in the group without reinforcement suture. Because of the low incidence of leak the results were not statistically significant. Further results also show that none of the monitored parameters (age, weight, body mass index, tumor distance, preoperative radiotherapy, tumor stage, type of surgery) were significant predictors of anastomotic leakage. CONCLUSION: Although the reinforcement suture is a safe and simple option for anastomosis protection after rectal or sigmoid resections, its statistical significance was not demonstrated in our study.

Toxic Megacolon Burdened with COVID-19 Coinfection-Worsening of an Unfavorable Diagnosis: A Single-Center Retrospective Study.

INTRODUCTION: This study primarily sought to evaluate the risk factors for toxic megacolon development and treatment outcomes in Clostridium difficile-positive COVID-19 patients, secondarily to determining predictors of survival. METHODS: During the second COVID-19 wave (May 2020 to May 2021), we identified 645 patients with confirmed COVID-19 infection, including 160 patients with a severe course in the intensive care unit. We selected patients with Clostridium difficile infection (CDI) (31 patients) and patients with toxic megacolon (9 patients) and analyzed possible risk factors. RESULTS: Patients who developed toxic megacolon had a higher incidence (without statistical significance, due to small sample size) of cancer and chronic obstructive pulmonary disease, a higher proportion of them required antibiotic treatment using cephalosporins or penicillins, and there was a higher rate of extracorporeal circulation usage. C-reactive protein (CRP) and interleukin-6 values showed significant differences between the groups (CRP [median 126 mg/L in the non-toxic megacolon cohort and 237 mg/L in the toxic megacolon cohort; p = 0.037] and interleukin-6 [median 252 ng/L in the group without toxic megacolon and 1127 ng/L in those with toxic megacolon; p = 0.016]). As possible predictors of survival, age, presence of chronic venous insufficiency, cardiac disease, mechanical ventilation, and infection with Candida species were significant for increasing the risk of death, while corticosteroid and cephalosporin treatment and current Klebsiella infection decreased this risk. CONCLUSIONS: More than ever, the COVID-19 pandemic required strong up-to-date treatment recommendations to decrease the rate of serious in-hospital complications. Further studies are required to evaluate the interplay between COVID-19 and CDI/toxic megacolon.

Prognostic Significance of Simple Scoring Systems in the Prediction of Diffuse Peritonitis Morbidity and Mortality.

INTRODUCTION: Diffuse peritonitis is a serious disease. It is often addressed within urgent management of an unstable patient in shock. The therapy consists of treatment of the source of peritonitis, decontamination of the abdominal cavity, stabilization of the patient and comprehensive resuscitation care in an intensive care unit. A number of scoring systems to determine patient prognosis are available, but most of them require complex input data, making their practical application a substantial problem. OBJECTIVE: Our aim was to assess simple scoring systems within a cohort, evaluate the level of mortality, morbidity, and duration of hospital stay, followed by a comparison of the acquired data with the literature and determination of an easily implementable scoring system for use in clinical practice. MATERIAL AND METHODS: We evaluated a group of patients with diffuse peritonitis who underwent surgery in the 2015-2019 period. Medical history, surgical findings, and paraclinical examinations were used as the input for four scoring systems commonly used in practice-MPI, qSOFA, ECOG, and ASA. We compared the results between the systems and with the literature. RESULTS: Our cohort included 274 patients diagnosed with diffuse peritonitis. Mortality was 22.6%, morbidity 73.4%, with a 25.2 day average duration of hospital stay. Mortality and morbidity increased with rising MPI and qSOFA, well-established scoring systems, but also with rising ASA and ECOG, similarly to MPI and qSOFA. CONCLUSIONS: The utilized scoring systems correlated well with the severity of the condition and with predicted mortality and morbidity as reported in the literature. Simple scoring systems primarily used in other indications (i.e., ASA and ECOG) have a similar predictive value in our cohort as commonly used systems (MPI, qSOFA). We recommend them in routine clinical practice due to their simplicity.

The role of CRP in the diagnosis of postoperative complications in rectal surgery.

Postoperative complications of rectal resections classified as grade III or higher according to Clavien-Dindo system, which also include anastomotic leaks, are usually life-threatening conditions. Delayed diagnosis may account for almost 18% of deaths. Due to nonspecific clinical signs in the early postoperative period, diagnosing these complications may truly be a challenge for clinicians. Nowadays, with the implementation of the ERAS protocol (enhanced recovery after surgery) and efforts concentrated on quickly delivered treatment to patients suffering from the above-mentioned complications, an appropriate marker with high specificity is required. Postoperative levels of C-reactive protein in blood serum seem promising in this aspect. The presented study aimed to determine the cut-off level of serum C-reactive protein as a possible predictive factor for early diagnosis of serious postoperative complications associated with rectal resections. This could also lead clinicians to the diagnosis of anastomotic leak after other possible options are ruled out. This study is a retrospective observational analysis of patients who underwent open resection of rectal cancer during a one-year period. Collected data included risk factors (age, gender, BMI, bowel preparation), record of complications and C Reactive Protein (CRP) serum levels. The study included 162 patients. Uncomplicated postoperative course was observed in 58 patients (35.8%). Complications were present in 104 cases (64.2%), including surgical site infections (16.7%) and anastomotic leak (9.9%). The mortality rate was 2.5%. Serum CRP threshold predicting relevant complications reached a sensitivity of 83.3% and specificity of 82.7% on POD 4, with a 175.4 mg/L cut-off value, burdened with a 95.7% negative predictive value. Postoperative serum C-reactive protein may be used as a good predictor of infectious complications, including anastomotic leaks. Measuring CRP levels in the early postoperative period may facilitate identification oflow-risk patients ensure early and safe discharges from hospital after rectal resections.

A biliary tract obstruction complicated by acute appendicitis and portal vein thrombosis-a case report and review of literature.

INTRODUCTION AND IMPORTANCE: Acute appendicitis is one of the most common surgical diagnoses in clinical practice. In case of uncomplicated course, diagnosis and treatment do not cause significant difficulties. On the other hand, unrecognized or complicated appendicitis can rarely bring unusual complications that threaten the patient with delayed treatment rather than the course itself. Portal vein thrombosis, also known as pylephlebitis, with an incidence of 1/1000 acute admissions, certainly meets this statement. CASE PRESENTATION: In this study, we present a successful treatment of advanced acute appendicitis complicating treatment of biliary obstruction. Due to the advanced inflammation with forced intestinal resection in the extent of right-sided hemicolectomy. And then successful conservative treatment of portal vein thrombosis in the surgical facility lasting a total of 6 weeks when the patient was discharged to home care without sequelae. CLINICAL DISCUSSION: The epidemiology, presentation, diagnosis and strategy of treatments as well as their outcomes were discussed. CONCLUSION: Portal vein thrombosis after acute appendicitis is rare. In case of unfavorable postoperative course with high inflammatory markers, temperatures, discomfort and abdominal pain, a CT scan is in order, which can easily establish the diagnosis and subsequently target the treatment in the right direction. Treatment of pylephlebitis is conservative and long term. It consists in the application of low molecular weight heparin and targeted antibiotic treatment. The mortality rate is 32%.

Necrotizing pelvic infection after rectal resection. A rare indication of endoscopic vacuum-assisted closure therapy. A case report.

INTRODUCTION: Anastomotic leak after colorectal surgery is a major problem associated with higher morbidity and mortality. In most cases of contained leaks, treatment recommendations are clear and effective. However, in rare cases like necrotizing pelvic infection, there is no clear treatment of choice, despite the mortality rate almost 21%. We present successful management with endoscopic vacuum-assisted closure therapy. THE PRESENTATION OF A CASE: A 68-year-old female patient with BMI 26, hypothyroidism and high blood pressure was indicated to low anterior rectal resection because of high-risk neoplasia of lateral spreading tumor type of the upper rectum. Four days after the primary operation, sepsis (SOFA 12) with diffuse peritonitis and unconfirmed leak according to CT led to surgical revision with loop ileostomy. On postoperative days 6-10, swelling, inflammation and subsequent necrosis of the right groin and femoral region communicating with the leak cavity developed. The endoscopy confirmed a leak of 30% of the anastomotic circumference with the indication of debridement and endoscopic vacuum-assisted closure therapy. EVAC sessions with 3-4 day intervals healed the leak cavity. Secondary healing of the skin defects required 4 months. CONCLUSION: Necrotizing pelvic infection after a leak of the colorectal anastomosis is a very rare complication with high morbidity and mortality. Endoscopic vacuum-assisted closure therapy should be implemented in the multimodal therapeutic strategy in case of major leaks, affecting up to 270° of the anastomotic circumference.

Epidemiology of hospital-acquired pneumonia: Results of a Central European multicenter, prospective, observational study compared with data from the European region.

BACKGROUND: Hospital-acquired pneumonia (HAP) is associated with high mortality. In Central Europe, there is a dearth of information on the prevalence and treatment of HAP. This project was aimed at collecting multicenter epidemiological data on patients with HAP in the Czech Republic and comparing them with supraregional data. METHODS: This prospective, multicenter, observational study processed data from a database supported by a Czech Ministry of Health grant project. Included were all consecutive patients aged 18 and over who were admitted to participating intensive care units (ICUs) between 1 May 2013 and 31 December 2014 and met the inclusion criterion of having HAP. The primary endpoint was to analyze the relationships between 30-day mortality (during the stay in or after discharge from ICUs) and the microbiological etiological agent and adequacy of initial empirical antibiotic therapy in HAP patients. RESULTS: The group dataset contained data on 330 enrolled patients. The final validated dataset involved 214 patients, 168 males (78.5%) and 46 females (21.5%), from whom 278 valid lower airway samples were obtained. The mean patient age was 59.9 years. The mean APACHE II score at admission was 21. Community-acquired pneumonia was identified in 13 patients and HAP in 201 patients, of whom 26 (12.1%) had early-onset and 175 (81.8%) had late-onset HAP. Twenty-two bacterial species were identified as etiologic agents but only six of them exceeded a frequency of detection of 5% (Klebsiella pneumoniae 20.4%, Pseudomonas aeruginosa 20.0%, Escherichia coli 10.8%, Enterobacter spp. 8.1%, Staphylococcus aureus 6.2% and Burkholderia cepacia complex 5.8%). Patients infected with Staphylococcus aureus had significantly higher rates of early-onset HAP than those with other etiologic agents. The overall 30-day mortality rate for HAP was 29.9%, with 19.2% mortality for early-onset HAP and 31.4% mortality for late-onset HAP. Patients with late-onset HAP receiving adequate initial empirical antibiotic therapy had statistically significantly lower 30-day mortality than those receiving inadequate initial antibiotic therapy (23.8% vs 42.9%). Patients with ventilator-associated pneumonia (VAP) had significantly higher mortality than those who developed HAP with no association with mechanical ventilation (34.6% vs 12.7%). Patients having VAP treated with adequate initial antibiotic therapy had lower 30-day mortality than those receiving inadequate therapy (27.2% vs 44.8%). CONCLUSIONS: The present study was the first to collect multicenter data on the epidemiology of HAP in the Central European Region, with respect to the incidence of etiologic agents causing HAP. It was concerned with relationships between 30-day patient mortality and the type of HAP, etiologic agent and adequacy of initial empirical antibiotic therapy.