Should CT scan be performed when CRP is elevated after colorectal surgery? Results from the inflammatory markers after colorectal surgery study.

INTRODUCTION: Serum concentration of C-reactive protein (CRP) that exceeds a pre-defined threshold between the 3rd and 5th postoperative day is a reliable marker of infectious complications after colorectal surgery. However, the optimal strategy to follow when a high CRP is found has not been defined. The aim of this study was to analyze the usefulness of computed tomography (CT) scan in this situation in a prospective cohort of patients following colorectal surgery. METHODS: Between November 2011 and April 2015, patients at two surgical centers who had undergone elective colorectal resection with anastomosis and who had a CRP>12.5mg/dL on the 4th postoperative day (POD) were prospectively included in a database. Data were collected concerning all complications occurring during the 30days following surgery, method of diagnosis, management and clinical course. The decision to perform a CT scan between POD 4 and POD 6 day was guided only by the elevation of CRP in the absence of any other clinical signs; results were analyzed to evaluate the diagnostic value of elevated CRP. Uni- and multivariable analyses were performed to identify risk factors for postoperative infection. RESULTS: The study included a total of 174 patients: 56 (32.1%) had a CT between POD 4 and 6, and this helped detect a postoperative complication in 55.4% of cases. Patients who did not undergo CT had lower CRP values (16.3 vs. 18.5, P=0.02). Among the 118 patients who did not undergo CT, 50.8% eventually developed an infectious complication. The sensitivity of CRP-guided CT was 76.7% with a negative predictive value of 78.8%. CONCLUSION: If an elevated CRP is found on POD 4, an abdominopelvic CT should be performed. A normal result does not formally eliminate the existence of intra-abdominal complication. A study protocol should be set up to evaluate whether systematic revisional surgery or repeat CT scan is the appropriate management if CRP in the next two days reveals persistent inflammation.

Isolated hepatic perfusion: principles and results.

INTRODUCTION: Isolated hepatic perfusion allows the delivery of high dose chemotherapy while decreasing extra-hepatic toxicity, and is used mainly for patients with surgically unresectable liver tumors. PRINCIPLES: Vascular exclusion of the liver is performed after obtaining satisfactory hemodynamic tolerance, occasionally after cavocaval shunt and/or porto-systemic shunt. Perfusion entry can be arterial and/or portal while the exit is portal or caval. The perfusion circuit can be open or closed, using a circulation pump with or without oxygenation. The chemotherapy regimens used are high dose melphalan (with or without TNF-alpha), oxaliplatin, cisplatin and mitomycin, sometimes associated with moderate hyperthermia. The duration of perfusion ranges between 30 and 90 minutes according to the different protocols used. A percutaneous technique with incomplete liver vascular exclusion is also possible. RESULTS: The larger series in the literature show a response rate (partial or complete stabilization) between 60 and 80%, with approximately 5% complete morphologic responses. Morbidity and mortality are 40 and 5%, respectively, including specific morbidity related to the perfusion procedure as well as to chemotherapy. CONCLUSION: Chemotherapy delivered through isolated hepatic perfusion is a new therapeutic alternative, still under development, and can be proposed to patients with surgically unresectable primary or secondary liver tumors within clinical trials. These results seem to be promising, but are still associated with a non-negligible morbidity rate.

Endoprosthetic replacement after extra-articular resection of bone and soft-tissue tumours around the knee.

We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan-Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%). These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection.

Radiation-induced pancreatitis: search for the neoplasm!

The management of a patient with a post-radiation pancreatitis is reported. Several biopsies and imaging failed to diagnose the radiation-induced carcinoma revealed during emergency laparotomy. This diagnosis must be kept in mind, and repeated biopsies are necessary.

[Open pelvic fracture. Treatment strategy and results for 12 patients]. / Die offene Beckenfraktur. Behandlungsstrategie und Resultate anhand von 12 Patienten.

This article presents treatment priorities for open pelvic fracture and the results of 12 patients. In a retrospective study we analyzed 12 patients treated at a level 1 trauma center between 1994 and 1998 of whom eight were male and four female with an average age of 29.6 years. Six type C (6 x III degrees open) and six type B (4 x II degrees and 2 x III degrees open) were identified. On average, 15 EKs were necessary within the first 12 h of treatment (type C=17, type B=13). All type C fractures underwent emergency stabilization with the pelvic C-clamp. Early laparotomy was performed in 60%. Perineal laceration was identified in 58%, followed by nerve and plexus lesions in 42%, injuries of the genitourinary tract in 33%, and lesions of the fecal stream in 25%. Altogether, there were more peripelvic injuries associated with type C fracture than with type B (12 vs 8). On average, there were 27 second-look operations necessary with 3-.2 operations per patient. The average stay in the ICU was 82 days (80-360); 25% died. Control of hemorrhage is fundamental; therefore, emergency stabilization of the pelvis is essential followed by surgical procedures. Early surgical definitive stabilization of the fracture decreases septic complications. Such complex injuries should be treated at specialized trauma centers.

Characterization of two forms of cadmium phosphide by magic-angle spinning 31P NMR.

Annealing of commercial grade cadmium phosphide (CD3P2) at 600 K produces a material which, in magic-angle spinning spin-lattice 31P NMR relaxation experiments, has broad lines and multiple T1 values. By contrast, sublimation at 900 K results in a crystalline material with narrow lines and a single T1. However, both materials have the same Cd-P lattice spacings as determined by rotational-echo, double-resonance 31P NMR with 113Cd dephasing. Both materials also have closely similar X-ray diffraction powder patterns. These results are interpreted in terms of a distribution of lattice vacancies in the annealed material, creating structural heterogeneity but with no substantial change in lattice parameters from those of the sublimed cadmium phosphide.

Solid-state NMR analysis of crosslinking in mussel protein glue.

Solid-state 13C and 15N NMR spectra have been obtained of intact adhesive plaques from the mussel Geukensia demissa labeled by L-[6-13C,6-15N]lysine. The plaques are rich in a polyphenolic protein glue which has 50 or more repeats of a nonapeptide sequence with one lysine per repeat. The average isotopic 15N enrichment of lysyl epsilon nitrogens in the plaques was 4%. These lysyl amines are not involved in ionic complexes and do not form observable concentrations of covalent crosslinks.

Comparison of black coral skeleton and insect cuticle by a combination of carbon-13 NMR and chemical analyses.

Cross-polarization, magic-angle spinning 13C NMR spectra of skeletal components of individual colonies of the New Zealand black coral, Antipathes fiordensis, have a marked similarity to spectra of the sclerotized exoskeleton of the adult tobacco hornworm, Manduca sexta. NMR analysis estimates the organic content of the load-bearing skeletal base of A. fiordensis as 70% protein, 10% chitin, 15% diphenol, and 5% lipid by weight, and that of M. Sexta moth cuticle as 60% protein, 20% chitin, 15% diphenol, and 5% lipid. The younger pinnules or tips of A. fiordensis are less than 3% diphenol by weight. The only diphenols extracted from coral skeleton by hydrochloric acid are 3-(3,4-dihydroxyphenyl)-DL-alanine (DOPA) and 3,4-dihydroxybenzaldehyde (DOBAL), while the predominant diphenols in acid extracts of insect cuticles are N-acyldopamines. More DOPA is found in the base than in the tips of A. fiordensis and it appears to be a peptidyl component of coral skeletal protein. The oxidation of DOPA and DOBAL to quinones may provide mechanical stabilization of the coral skeleton by cross-linking of structural proteins to other proteins or to chitin.