Clinical Significance of Post-Operative Hyperglycemia in Nondiabetic Patients Undergoing Definitive Surgery for Gastrointestinal Fistula.

BACKGROUND: To evaluate the association between peri-operative hyperglycemia and adverse events in patients with gastrointestinal (GI) fistulas without a pre-operative diagnosis of diabetes mellitus who were undergoing definitive surgery. METHODS: Pre-operative and all post-operative blood glucose concentrations (BG) were retrieved for 363 consecutive patients undergoing GI reconstruction from September 2012 to December 2015. Normoglycemic (BG <125 mL/dL), mild hyperglycemia (125-199 mL/dL), and severe hyperglycemia (≥200 mL/dL) were defined using the highest BG found within the first 48 h post-operatively. Outcomes of interest included 30-d mortality rate and re-operation, time of enteral nutrition resumption, and infectious and non-infectious complications. RESULTS: More than half of the nondiabetic patients (61.4%) experienced hyperglycemia post-operatively. The degree of hyperglycemia correlated with patient age, American Society of Anesthesiologists class, and surgical interventions. Hyperglycemia was associated with re-operation and post-operative complications, the frequency of these complications increasing in parallel with the degree of hyperglycemia. Additionally, post-operative hyperglycemia was associated independently with surgical site infections (p = 0.014), anastomotic leak (p = 0.010), delayed resumption of enteral nutrition (p < 0.001), and longer hospital stay (p < 0.001). CONCLUSION: Elevated post-operative BG was frequent after surgery in patients with GI fistulas. Post-operative hyperglycemia is significantly associated with unfavorable outcomes, and this risk is related to the degree of BG elevation. Our findings suggest that vigilant post-operative BG monitoring and early appropriate glycemic control are critical for patients, even nondiabetic patients, undergoing definitive surgery for GI fistula.

Assessment of Microbiota and Their Drug Resistance in Chronic Fistulous Tracts.

BACKGROUND: Bacteria colonizing an enterocutaneous fistula tract have not been clarified. The aims of this study were to investigate the pathogen spectra of fistulous tracts and their resistance to antibiotics in patients with chronic fistulas. METHODS: We conducted a one-year prospective single-center study. In the absence of significant sepsis, consecutively stabilized patients with chronic enterocutaneous fistula were included. Microbiology and antimicrobial susceptibility of isolates from the tracts were analyzed. The correlations between the existence of bacteria and various clinical values were investigated further. RESULTS: Forty-one patients were enrolled, of whom eight had a negative culture. A total of 48 bacterial strains were harvested, including 42 strains of gram-negative bacteria and six strains of gram-positive bacteria, most of which were multiple-drug-resistant. The three bacteria cultured most often were Escherichia coli (11 strains; 22.9%), Pseudomonas aeruginosa (eight strains; 16.7%), and Klebsiella pneumoniae (eight strains). Binary logistic regression analysis with forward (conditional) stepwise selection found that fistula length correlated with positive bacterial results (p=0.018). Other variables, namely entire length of hospitalization and fistula duration and location, were unrelated to the presence of micro-organisms in fistula tracts. CONCLUSIONS: Multiple-drug-resistant gram-negative bacteria were the main pathogens colonizing chronic fistula tracts. Fistula length was significantly associated with the presence of pathogens in a multivariable logistic regression model.

Laser speckle contrast imaging for assessment of abdominal visceral microcirculation in acute peritonitis: does sequential impairments exist?

OBJECTIVE: It is believed that the microcirculation of multiple organs is impaired during acute peritonitis, however whether distinct susceptibilities of visceral microvasculature exist is still unknown. The present study aims to verify whether the microcirculatory alterations occur sequentially among multiple abdominal viscera during acute peritonitis. MATERIALS AND METHODS: Acute peritonitis was achieved on 29 Sprague-Dawley rats through colon ascendens stent peritonitis (CASP) model. With laser speckle contrast imaging (LSCI), the microcirculation of the liver, ileum and renal cortex was monitored in each rat at baseline before CASP sepsis and continued monitoring at 4h, 8h, or 12h after the surgery. Another 9 rats served for sham operation. One-way analysis of variance with a post hoc Dunnett's test was used for analysis. RESULTS: The ileum microcirculation was impaired earliest from 342.1±61.0 laser speckle perfusion unit (LSPU) at baseline to 271.7±74.0 LSPU at 4h (P<0.05), while the decline of renal microcirculation was not obvious until 8h after peritonitis (289.1±111.2 vs 376.2±53.4, P<0.05). However hepatic microcirculation was not significantly changed during 12h of observation period. CONCLUSION: The microcirculation of various viscera has shown distinct susceptibilities to acute peritonitis: the ileum is more susceptible than the kidney, while the hepatic microcirculation seems to be the most resistant to peritonitis.