Ureteral Stents Do Not Increase the Risk for Acute Kidney Injury After Colorectal Surgery.

BACKGROUND: Ureteral stents are thought to prevent or help identify ureteral injuries. Studies suggesting that ureteral stents increase the risk of postoperative acute kidney injury show inconsistent conclusions. The large ureteral stenting volume at our institution provided a unique opportunity for granular analysis not previously reported. OBJECTIVE: To determine whether prophylactic ureteral stenting at colorectal surgery increases acute kidney injury. DESIGN: Retrospective analysis of colorectal operations with prophylactic ureteral stents was compared to operations without stents. Adjusted analysis was performed with inverse probability treatment weighting. SETTINGS: Single institution enhanced recovery colorectal surgery service. PATIENTS: Prospective institutional database between July 1, 2018, and December 31, 2021. MAIN OUTCOME MEASURE: The primary outcome was acute kidney injury, defined as increase in creatinine ≥0. 3 mg/dL (definition 1) and 1.5-fold increase in creatinine (definition 2) within 48 hours postoperatively. RESULTS: There were 410 patients in the study population: 310 patients in the stent group and 100 in the no-stent group. There were 8 operative ureteral injuries: 4 (1.29%) in the stent group and 4 (4.0%) in the no-stent group ( p = 0.103). Unadjusted analysis revealed no significant difference in acute kidney injury between groups. After adjustment, there was still no significant difference in acute kidney injury between groups when defined as definition 1 (no-stent 23.76% vs stent 26.19%, p = 0.745) and as definition 2 (no-stent 15.86% vs stent 14.8%, p = 0.867). Subgroup analysis showed that lighted stents were associated with significantly more acute kidney injury than no-stent patients when defined as definition 1 ( p = 0.017) but not when defined as definition 2 ( p = 0.311). LIMITATIONS: Single-institution results may not be generalizable. CONCLUSION: Prophylactic ureteral stenting does not increase the risk of acute kidney injury for patients undergoing enhanced recovery colorectal surgery, although caution and further study may be warranted for lighted stents. Studies further examining contrasting roles of ureter stenting and imaging in open and minimally invasive colorectal surgery are warranted. See Video Abstract. LOS STENTS URETERALES NO AUMENTAN EL RIESGO DE LESIN RENAL AGUDA DESPUS DE LA CIRUGA COLORECTAL: ANTECEDENTES:Se cree que los stents ureterales previenen o ayudan a identificar las lesiones ureterales. Los estudios que sugieren que los stents ureterales aumentan el riesgo de lesión renal aguda post operatoria muestran conclusiones contradictorias. El gran volumen de endoprótesis ureterales en nuestra institución brindó una oportunidad única para el análisis granular que no se informó anteriormente.OBJETIVO:Determinar si la colocación de stent ureteral profiláctico en cirugía colorrectal aumenta el daño renal agudo.DISEÑO:El análisis retrospectivo de operaciones colorrectales con stents ureterales profilácticos se comparó con operaciones sin stents. El análisis ajustado se realizó con ponderación de tratamiento de probabilidad inversa.AJUSTES:Cirugía colorrectal de recuperación mejorada de una sola instituciónPACIENTES:Base de datos institucional prospectiva entre el 01/07/2018 y el 31/12/2021.MEDIDA DE RESULTADO PRINCIPAL:El resultado primario fue la lesión renal aguda definida como un aumento en la creatinina ≥ 0,3 mg/dL (Definición n.° 1) y un aumento de 1,5 veces en la creatinina (Definición n.° 2) dentro de las 48 horas posteriores a la operación.RESULTADOS:Hubo 410 pacientes en la población de estudio: 310 pacientes en el grupo Stent y 100 en el grupo No-Stent. Hubo 8 lesiones ureterales operatorias, 4 (1,29%) en el grupo Stent y 4 (4,0%) en el grupo No-Stent (p = 0,103). El análisis no ajustado no reveló diferencias significativas en la lesión renal aguda entre los grupos. Después del ajuste, todavía no hubo una diferencia significativa en la lesión renal aguda entre los grupos cuando se definió como Definición n.º 1 (sin stent 23,76 % frente a stent 26,19 %, p = 0,745) y por definición n.º 2 (sin stent 15,86 % frente a stent 14,8 %, p = 0,867). El análisis de sub grupos mostró que los stents iluminados se asociaron con una lesión renal aguda significativamente mayor que los pacientes sin stent cuando se definieron como Definición n.º 1 (p = 0,017), pero no cuando se los definió como Definición n.º 2 (p = 0,311).LIMITACIONES:Los resultados de una sola institución pueden no ser generalizables.CONCLUSIÓN:La colocación profiláctica de endoprótesis ureterales no aumenta el riesgo de lesión renal aguda en pacientes que se someten a cirugía colorrectal de recuperación mejorada, aunque es posible que se requiera precaución y estudios adicionales para las endoprótesis iluminadas. Se justifican estudios que examinen más a fondo las funciones contrastantes de la colocación de stents de uréter y las imágenes en la cirugía colorrectal abierta y mínimamente invasiva. (Traducción-Dr. Mauricio Santamaria ).

A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use.

BACKGROUND: Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. METHODS: Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90-180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. RESULTS: Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of 'any opioids' (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90-180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. CONCLUSION: Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use.

The impact of obesity and morbid obesity on urgent/emergency colorectal resections: a regional database analysis.

BACKGROUND: The obesity rate is projected to reach 50% by 2030. Obesity may be modifiable prior to elective colorectal surgery, but there is no opportunity for weight loss when patients present for urgent/emergency operations. The impact of obesity focused on urgent/emergent colorectal operations has not been fully characterized. The study aim was to determine outcomes of obese patients who undergo urgent/emergency colorectal surgery and differences when compared with elective outcomes. METHODS: This is a retrospective cohort study of 30-day outcomes for normal (BMI 18.5-25), obese (BMI 30-39.9), and morbidly obese (BMI > 40) patients in the Michigan Surgical Quality Collaborative between 1/1/2009 and 12/31/2018. Propensity score weighting was used to derive adjusted rates for overall morbidity, mortality, and specific complications. Primary outcome was postoperative complications (any morbidity). RESULTS: The study included 5268 urgent/emergency and 10,414 elective colorectal surgery patients. Postoperative complications were significantly more common in morbidly obese and obese than the normal BMI group for both urgent/emergency (morbidly obese 42.76% vs 33.75%, p = 0.003; obese 36.46% vs 33.75%, p = 0.043) and elective (morbidly obese 18.17% vs 13.36%, p = 0.004; obese 15.45% vs 13.36%, p = 0.011) operations. Surgical site infections are were significantly more common in morbidly obese and obese BMI groups as compared to normal BMI for both urgent/emergency and elective cases. Mortality was significantly higher in the morbidly obese (14.93% vs 11.44%, p = 0.013) but not obese BMI groups as compared to the normal BMI group for urgent/emergency cases. Mortality for all groups undergoing elective operations was < 1% and with no significant differences. CONCLUSIONS: Morbid obesity and obesity are associated with complications that are largely driven by surgical site infections after both urgent/emergency and elective colorectal surgery. Obesity is a risk factor difficult to modify prior to urgent/emergency surgery. Managing complications related to obesity after colorectal surgery will be a continued challenge with projected increasing obesity rates.

Challenging the 48-Hour Rule-Out for Central Line-Associated Bloodstream Infections in the Pediatric Intestinal Failure Population: A Retrospective Pilot Study.

INTRODUCTION: While parenteral nutrition (PN) has revolutionized the management of patients with intestinal failure (IF), central line-associated bloodstream infections (CLABSIs) remain a leading cause of mortality and morbidity in this population. The objective of this study is to characterize the presentation of CLABSIs in pediatric IF and to determine the time to positivity of blood cultures. METHODS: A retrospective cohort study of children with IF who presented to our institution for evaluation of a possible CLABSI from January 1, 2012, to December 31, 2012, was performed. RESULTS: Sixty patients with IF were identified. There were 33 cases of CLABSI in 16 patients, with a rate of 1.5 infections per 1000 catheter days. There were no significant differences in age, growth parameters, or catheter days between patients with or without CLABSI. Fever was documented in 85% of patients with CLABSI. These patients demonstrated an increased percentage of neutrophils and higher C-reactive protein levels compared with patients without CLABSI. The mean time to culture positivity was 13.2 hours, and 97% of cultures were positive within 24 hours. CONCLUSION: Our data suggest that most pediatric patients with IF who have CLABSI develop positive cultures within 24 hours, and the absence of fever and leukocytosis does not necessarily indicate the absence of infection. These findings may support clinical practice guidelines in favor of shorter hospital stay when CLABSI is suspected; however, a prospective analysis of CLABSI in this population is recommended to determine the safety and appropriate setting prior to any practice change.

A review of the impact of biologics on surgical complications in Crohn's disease.

Anti-tumor necrosis factor therapy has revolutionized the treatment of Crohn's disease. Despite the increased use in the past decade and a half, a majority of patients with Crohn's disease with ultimately require operative management of their disease. No clear consensus has been made in the literature regarding the surgical outcomes in patients who have been exposed to anti-tumor necrosis factor therapy. This review highlights the most recent and relevant literature regarding the safety and effects of anti-tumor necrosis factor use in the perioperative period.

Elevated Alkaline Phosphatase in Infants With Parenteral Nutrition-Associated Liver Disease Reflects Bone Rather Than Liver Disease.

BACKGROUND: Elevated serum alkaline phosphatase (ALP) in infants with intestinal failure (IF) can be due to parenteral nutrition-associated liver disease (PNALD) or metabolic bone disease (MBD). The purpose of the study was to determine the utility of serum ALP in the diagnostic criteria for PNALD by measuring tissue-specific levels in infants with IF and PNALD. METHODS: A retrospective review of patient data for 15 infants diagnosed with PNALD between December 2012 and August 2013 was performed. PNALD was defined as the presence of 2 consecutive direct bilirubin (DB) levels >2 mg/dL. Fractionated serum alkaline phosphatase was measured in each patient, while the DB was >2 mg/dL. Parathyroid hormone (PTH), vitamin D3, calcium, and phosphate levels were recorded where available. RESULTS: In 15 infants with PNALD, elevation in total ALP was due to marked elevations in bone-specific ALP. The median liver-specific ALP remained within the normal range. PTH, vitamin D3, calcium, and phosphate levels were within normal limits. CONCLUSION: While elevated ALP can reflect biliary stasis, the ALP elevation observed in infants with IF and PNALD is predominantly of bone rather than hepatic origin. An elevated unfractionated ALP in infants with PNALD should therefore raise suspicion of underlying bone disease, rather than being attributed to liver disease alone.

The natural history of cirrhosis from parenteral nutrition-associated liver disease after resolution of cholestasis with parenteral fish oil therapy.

OBJECTIVE: To determine the natural history of cirrhosis from parenteral nutrition-associated liver disease (PNALD) after resolution of cholestasis with fish oil (FO) therapy. BACKGROUND: Historically, cirrhosis from PNALD resulted in end-stage liver disease, often requiring transplantation for survival. With FO therapy, most children now experience resolution of cholestasis and rarely progress to end-stage liver disease. However, outcomes for cirrhosis after resolution of cholestasis are unknown and patients continue to be considered for liver/multivisceral transplantation. METHODS: Prospectively collected data were reviewed for children with cirrhosis because of PNALD who had resolution of cholestasis after treatment with FO from 2004 to 2012. Outcomes evaluated included need for liver/multivisceral transplantation, mortality, and the clinical progression of liver disease. RESULTS: Fifty-one patients with cirrhosis from PNALD were identified, with 76% demonstrating resolution of cholestasis after FO therapy. The mean direct bilirubin decreased from 6.4 ± 4 mg/dL to 0.2 ± 0.1 mg/dL (P < 0.001) 12 months after resolution of cholestasis, with a mean time to resolution of 74 days. None of the patients required transplantation or died from end-stage liver disease. Pediatric End-Stage Liver Disease scores decreased from 16 ± 4.6 to -1.2 ± 4.6, 12 months after resolution of cholestasis (P < 0.001). In children who remained PN-dependent, the Pediatric End-Stage Liver Disease score remained normal throughout the follow-up period. CONCLUSIONS: Cirrhosis from PNALD may be stable rather than progressive once cholestasis resolves with FO therapy. Furthermore, these patients may not require transplantation and show no clinical evidence of liver disease progression, even when persistently PN-dependent.

The addition of medium-chain triglycerides to a purified fish oil-based diet alters inflammatory profiles in mice.

OBJECTIVE: Parenteral nutrition associated liver disease (PNALD) is a deadly complication of long term parenteral nutrition (PN) use in infants. Fish oil-based lipid emulsion has been shown in recent years to effectively treat PNALD. Alternative fat sources free of essential fatty acids have recently been investigated for health benefits related to decreased inflammatory response. We hypothesized that the addition of medium-chain triglycerides (MCT) to a purified fish oil-based diet would decrease the response to inflammatory challenge in mice, while allowing for sufficient growth and development. MATERIALS/METHODS: Six groups of ten adult male C57/Bl6 mice were pair-fed different dietary treatments for a period of twelve weeks, varying only in fat source (percent calories by weight): 10.84% soybean oil (SOY), 10% coconut oil (HCO), 10% medium-chain triglycerides (MCT), 3% purified fish oil (PFO), 3% purified fish oil with 3% medium-chain triglycerides (50:50 MCT:PFO) and 3% purified fish oil with 7.59% medium-chain triglycerides (70:30 MCT:PFO). An endotoxin challenge was administered to half of the animals in each group at the completion of dietary treatment. RESULTS: All groups demonstrated normal growth throughout the study period. Groups fed MCT and HCO diets demonstrated biochemical essential fatty acid deficiency and decreased IL-6 and TNF-α response to endotoxin challenge. Groups containing PFO had increased inflammatory response to endotoxin challenge, and the addition of MCT to PFO mitigated this inflammatory response. CONCLUSION: These results suggest that the addition of MCT to PFO formulations may decrease the host response to inflammatory challenge, which may pose potential for optimized PN formulations. Inclusion of MCT in lipid emulsions given with PN formulations may be of use in therapeutic interventions for disease states resulting from chronic inflammation.

Neonatal intestinal physiology and failure.

The neonatal intestine is a complex organ that regulates the absorption of nutrients essential for growth and development. Intestinal failure results from insufficient or functionally inadequate bowel and can lead to failure of neonatal growth and development. Current literature on neonatal intestinal physiology and failure was reviewed and summarized. A homeostatic interplay of electrolytes, enzymes, and hormonal regulators is essential to achieve the physiologic balance needed for adequate intestinal performance. Physiologic consequences of intestinal failure are dependent on the length and anatomic location of the diseased or surgically resected bowel. Intestinal failure leads to disruption of normal intestinal physiology and may have long-term consequences for growth and development if inadequately treated. Parenteral nutrition remains the mainstay of treatment for neonatal intestinal failure.

Treatment of parenteral nutrition-associated liver disease: the role of lipid emulsions.

Parenteral nutrition is a life-saving therapy for infants with intestinal failure. However, long-term parenteral nutrition carries the risk of progressive liver disease. Substantial data has implicated components of parenteral soybean oil in the pathogenesis of parenteral nutrition-associated liver disease (PNALD). Elevated serum concentrations of phytosterols, an abundance of omega-6 polyunsaturated fatty acids, and a relative paucity of α-tocopherol have been associated with the risk of cholestasis and hepatic injury observed in PNALD. Currently available treatment strategies include the reduction of the dose of administered parenteral soybean oil and/or the replacement of parenteral soybean oil with alternative parenteral lipid emulsions. The purpose of this review is to provide an overview of the pathogenetic mechanisms associated with the development of PNALD and the data evaluating currently available treatment strategies.

Role of parenteral lipid emulsions in the preterm infant.

Parenteral nutrition (PN) is necessary for infants unable to receive adequate calories enterally due to prematurity, decreased bowel length, or functional intestinal disorders. While PN can be life saving, its use is associated with significant risks of sepsis from catheter-associated infections and progressive liver dysfunction from prolonged use. The preterm infant population is at highest risk for these complications due to the presence of multiple comorbidities and immaturity of the biliary system. Strong data has implicated parenteral lipids in the multifactorial pathogenesis of PN-associated liver disease (PNALD). However, lipids are essential in early infant development, particularly in the neurocognitive development of preterm infants. Substitution of the lipid source from soybean oil to fish oil has emerged as a safe and efficacious treatment of PNALD, with marked improvements in morbidity and mortality. Knowledge of the developmental needs and physiologic limitations of preterm infants is crucial to optimizing parenteral lipid administration to nurture growth, and minimize and treat associated complications. The purpose of this review is to provide an overview of lipid requirements of the preterm infant and discuss the role of parenteral lipid emulsions in the management of PNALD and other diseases of prematurity.

The use of fish oil lipid emulsion in the treatment of intestinal failure associated liver disease (IFALD).

Since 2004, fish oil based lipid emulsions have been used in the treatment of intestinal failure associated liver disease, with a noticeable impact on decreasing the incidence of morbidity and mortality of this often fatal condition. With this new therapy, however, different approaches have emerged as well as concerns about potential risks with using fish oil as a monotherapy. This review will discuss the experience to date with this lipid emulsion along with the rational for its use, controversies and concerns.

Single-molecule analysis of human immunodeficiency virus type 1 gp120-receptor interactions in living cells.

A quantitative description of the binding interactions between human immunodeficiency virus (HIV) type 1 envelope glycoproteins and their host cell surface receptors remains incomplete. Here, we introduce a single-molecule analysis that directly probes the binding interactions between an individual viral subunit gp120 and a single receptor CD4 and/or chemokine coreceptor CCR5 in living cells. This analysis differentiates single-molecule binding from multimolecule avidity and shows that, while the presence of CD4 is required for gp120 binding to CCR5, the force required to rupture a single gp120-coreceptor bond is significantly higher and its lifetime is much longer than those of a single gp120-receptor bond. The lifetimes of these bonds are themselves shorter than those of the P-selectin/PSGL-1 bond involved in leukocyte attachment to the endothelium bonds during an inflammation response. These results suggest an amended model of HIV entry in which, immediately after the association of gp120 to its receptor, gp120 seeks its coreceptor to rapidly form a new bond. This "bond transfer" occurs only if CCR5 is in close proximity to CD4 and CD4 is still attached to gp120. The analysis presented here may serve as a general framework to study mechanisms of receptor-mediated interactions between viral envelope proteins and host cell receptors at the single-molecule level in living cells.

Cdc42 mediates nucleus movement and MTOC polarization in Swiss 3T3 fibroblasts under mechanical shear stress.

Nucleus movement is essential during nucleus positioning for tissue growth and development in eukaryotic cells. However, molecular regulators of nucleus movement in interphase fibroblasts have yet to be identified. Here, we report that nuclei of Swiss 3T3 fibroblasts undergo enhanced movement when subjected to shear flows. Such movement includes both rotation and translocation and is dependent on microtubule, not F-actin, structure. Through inactivation of Rho GTPases, well-known mediators of cytoskeleton reorganization, we demonstrate that Cdc42, not RhoA or Rac1, controls the extent of nucleus translocation, and more importantly, of nucleus rotation in the cytoplasm. In addition to generating nuclei movement, we find that shear flows also causes repositioning of the MTOC in the direction of flow. This behavior is also controlled by Cdc42 via the Par6/protein kinase Czeta pathway. These results are the first to establish Cdc42 as a molecular regulator of not only shear-induced MTOC polarization in Swiss 3T3 fibroblasts, but also of shear-induced microtubule-dependent nucleus movement. We propose that the movements of MTOC and nucleus are coupled chemically, because they are both regulated by Cdc42 and dependent on microtubule structure, and physically, possibly via Hook/SUN family homologues similar to those found in Caenorhabditis elegans.