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1.
J Am Coll Surg ; 229(2): 200-209, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30905855

RESUMO

BACKGROUND: Earlier detection of anastomotic leakage (AL) after colorectal procedures could minimize the detrimental clinical impact of AL and thereby reduce morbidity and mortality. STUDY DESIGN: We conducted a prospective study with assessment of the diagnostic accuracy of monocytic HLA-DR (mHLA-DR) expression compared with WBCs, C-reactive protein (CRP), and procalcitonin (PCT) in predicting AL in patients undergoing elective colorectal operation with anastomosis. RESULTS: Comparison of the blood marker values on postoperative day (POD) 4 revealed significant differences for all markers, but the difference for mHLA-DR was highly significant (15% expression of monocytes in AL patients vs 34% in patients without AL; p = 0.001). Together with WBC (p = 0.026), mHLA-DR expression was the only test to show significance on day 3 (14% vs 31%; p < 0.001). Receiver operating characteristic analysis revealed that mHLA-DR expression had superior diagnostic accuracy compared with all other diagnostic markers both on POD 3 (mHLA-DR area under the curve [AUC] 0.928; WBC AUC 0.734; CRP AUC 0.707; PCT AUC 0.672) and POD 4 (mHLA-DR AUC 0.887; WBC AUC 0.738; CRP AUC 0.709; PCT AUC 0.696). Monocytic HLA-DR had a negative predictive value of at least 94% on PODs 3 and 4, as well as specificity and positive predictive values of 100% at a threshold of 23% on POD 3 and 24% on POD 4, respectively. CONCLUSIONS: Expression of mHLA-DR appears to be a more accurate predictor for AL after colorectal operation compared with WBC, CRP, and PCT. It represents a promising test to precisely monitor the perioperative course of high-risk patients and contribute to safer discharge.


Assuntos
Fístula Anastomótica/diagnóstico , Colo/cirurgia , Antígenos HLA-DR/sangue , Monócitos/metabolismo , Reto/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Fístula Anastomótica/sangue , Biomarcadores/sangue , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Sensibilidade e Especificidade , Adulto Jovem
2.
G Chir ; 40(1): 20-25, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30771794

RESUMO

BACKGROUND: Anastomotic leakage (AL) is a dreaded major complication after colorectal surgery. There is no uniform definition of anastomotic dehiscence and leak. Over the years many risk factors have been identified (distance of anastomosis from anal verge, gender, BMI, ASA score) but none of these allows an early diagnosis of AL. The DUtch LeaKage (DULK) score, C reactive protein (CRP) and procalcitonin (PCT) have been identified as early predictors for anastomotic leakage starting from postoperative day (POD) 2-3. The study was designed to prospectively evaluate AL rates after colorectal resections, in order to give a definite answer to the need for clear risk factors, and testing the diagnostic yeld of DULK score and of laboratory markers. Methods and analysis. A prospective enrollment for all patients undergoing elective colorectal surgery with anastomosis carried out from September 2017 to September 2018 in 19 Italian surgical centers. OUTCOME MEASURES: preoperative risk factors of anastomotic leakage; operative parameters; leukocyte count, serum CRP, serum PCT and DULK score assessment on POD 2 and 3. Primary endpoint is AL; secondary endpoints are minor and major complications according to Clavien-Dindo classification; morbidity and mortality rates; readmission and reoperation rates, length of postoperative hospital stay (Retrospectively registered at ClinicalTrials.gov Identifier: NCT03560180, on June 18, 2018). Ethics. The ethics committee of the "Comitato Etico Regionale delle Marche - C.E.R.M." reviewed and approved this study protocol on September 7, 2017 (protocol no. 2017-0244-AS). All the participating centers submitted the protocol and obtained authorization from the local Institutional Review Board.


Assuntos
Fístula Anastomótica/diagnóstico , Proteína C-Reativa/análise , Colo/cirurgia , Pró-Calcitonina/sangue , Reto/cirurgia , Fístula Anastomótica/sangue , Biomarcadores/sangue , Diagnóstico Precoce , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Humanos , Contagem de Leucócitos , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Fatores de Risco , Tamanho da Amostra , Deiscência da Ferida Operatória/complicações
3.
Thorac Cancer ; 10(4): 728-737, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30734487

RESUMO

BACKGROUND: Anastomotic leakage (AL), a serious complication after esophagectomy, might impair patient quality of life, prolong hospital stay, and even lead to surgery-related death. The aim of this study was to show a novel decision model based on classification and regression tree (CART) analysis for the prediction of postoperative AL among patients who have undergone esophagectomy. METHODS: A total of 450 patients (training set: 356; test set: 94) with perioperative information were included. A decision tree model was established to identify the predictors of AL in the training set, which was validated in the test set. A receiver operating characteristic curve was also created to illustrate the diagnostic ability of the decision model. RESULTS: A total of 12.2% (55/450) of the 450 patients suffered AL, which was diagnosed at median postoperative day 7 (range: 6-16). The decision tree model, containing surgical duration, postoperative lymphocyte count, and postoperative C-reactive protein to albumin ratio, was established by CART analysis. Among the three variables, the postoperative C-reactive protein to albumin ratio was identified as the most important indicator in the CART model with normalized importance of 100%. According to the results validated in the test set, the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of the prediction model were 80%, 98.8%, 88.9%, 97.6%, and 96.8%, respectively. Moreover, the area under the receiver operating characteristic curve was 0.95. CONCLUSION: The decision model based on CART analysis presented good performance for predicting AL, and might allow the early identification of patients at high risk.


Assuntos
Fístula Anastomótica/diagnóstico , Proteína C-Reativa/análise , Esofagectomia/efeitos adversos , Albumina Sérica Humana/análise , Idoso , Fístula Anastomótica/sangue , Fístula Anastomótica/etiologia , Árvores de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Valor Preditivo dos Testes , Curva ROC
5.
J Intensive Care Med ; 34(7): 572-577, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28486866

RESUMO

Anastomotic leak was a potentially severe life-threatening complication of esophagectomy, which drew attention in consequence of progressive dyspnea until acute respiratory distress syndrome (ARDS) due to the early asymptomatic presentation. Respiratory failure, caused by ARDS as the severe presentation of anastomotic leak, is the most common organ failure. CRP (C-reactive protein), procalcitonin (PCT), and Blood G (BG) test are the sensitivity markers for inflammatory, sepsis, and fungemia, respectively. Early recognition and intervention treatment of anastomotic leak may alleviate complication and improve outcome. We retrospectively analyzed 71 patients, accepting mechanical ventilation support because of ARDS as the complication after radical resection of esophagus cancer. Clinical data were collected from the patients' electronic medical records, including their clinically hematological examination, drainage fluid cultures, and sputum culture. Accord to appearance of anastomotic leak or not, all patients were divided into 2 groups, leak group and no-leak group. Inflammatory markers, such as CRP, PCT, and the coefficient of BG and PCT, were significantly different between the 2 groups. Respiratory index, white blood cell, hemoglobin (HBG), platelet (PLT), and other clinical factors were not significantly different between the 2 groups. Receiver operating characteristic curves were constructed to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve for various cutoff levels of several factors. Blood G tests presented the better predicting value for anastomotic leak. Blood G tests and PCT should be tested after esophagectomy. The coefficient of PCT and BG (>260) is of great significance, and clinical value to predict anastomotic leak for patients with postesophagectomy ARDS, early PCT and BG test, and especially, dynamic variation may alleviate complication and improve outcome.


Assuntos
Fístula Anastomótica/sangue , Neoplasias Esofágicas/cirurgia , Esofagectomia , Síndrome do Desconforto Respiratório do Adulto/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/fisiopatologia , Biomarcadores Tumorais/sangue , Proteína C-Reativa , Esofagectomia/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Pró-Calcitonina/sangue , Síndrome do Desconforto Respiratório do Adulto/etiologia , Síndrome do Desconforto Respiratório do Adulto/fisiopatologia , Estudos Retrospectivos
6.
Cir Cir ; 86(5): 432-436, 2018.
Artigo em Espanhol | MEDLINE | ID: mdl-30226485

RESUMO

Introducción: La fuga de anastomosis (FA) en cirugía colorrectal es una complicación temida por el incremento de la morbimortalidad. La tasa de FA se reporta desde el 1 hasta el 25%. Realizar el diagnóstico de forma temprana es difícil. Objetivo: Determinar el rendimiento diagnóstico de la proteína C reactiva (PCR) en una cohorte de pacientes sometidos a cirugía colorrectal electiva con anastomosis. Método: Se realizó un estudio prospectivo, comparativo, en 138 pacientes sometidos a cirugía colorrectal con anastomosis de forma electiva, analizando los valores séricos de la PCR los días 1, 3, 5 y 7 del posoperatorio, así como los de leucocitos y otros datos de sepsis abdominal. Resultados: La tasa de FA fue del 6.5%, y los valores de la PCR fueron significativamente más altos en el grupo de pacientes con FA en el tercer día del posoperatorio. Con un punto de corte de 18.5 mg/dl en el tercer día del posoperatorio se obtuvo una sensibilidad del 81%, una especificidad del 91%, un valor predictivo positivo del 45% y un valor predictivo negativo del 98%. Conclusión: La medición de la PCR en el tercer día del posoperatorio en pacientes sometidos a cirugía colorrectal electiva con anastomosis primaria o secundaria permite identificar las complicaciones sépticas, incluida la FA. Introduction: The anastomotic leakage (AL) in colorectal surgery is a complication feared by the increase in morbidity and mortality. The rate of AF is reported from 1 to 25%. Making the diagnosis early is difficult. Objective: To determine the diagnostic performance of the C reactive protein (CRP) in a cohort of patients undergoing elective colorectal surgery with anastomosis. Method: A prospective, comparative study was conducted in 138 patients undergoing elective anastomosis with colorectal surgery, analyzing the serum values of CRP on postoperative days 1, 3, 5 and 7, as well as leukocytes and other abdominal sepsis data. Results: The AL rate was 6.5%, the CRP values were significantly higher in the group of patients with AF on the 3rd postoperative day; with a cut-off point of 18.5 mg/dl on the third postoperative day, it obtained sensitivity 81%, specificity 91%, positive predictive value 45%, negative predictive value 98%. Conclusion: Measurement of CRP on the third postoperative day in patients undergoing elective colorectal surgery with primary or secondary anastomosis allows the identification of septic complications including leakage of anastomosis.


Assuntos
Fístula Anastomótica/diagnóstico , Proteína C-Reativa/análise , Neoplasias Colorretais/cirurgia , Diverticulose Cólica/cirurgia , Adulto , Idoso , Fístula Anastomótica/sangue , Biomarcadores , Doenças do Colo/cirurgia , Diagnóstico Precoce , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças Retais/cirurgia
7.
Pol Przegl Chir ; 90(3): 31-36, 2018 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-30015322

RESUMO

BACKGROUND: This study aims to examine the factors involved in anastomotic leak (AL) following low anterior resection and total mesorectal excision (LAR-TME) and to determine the usefulness of early measurement of the inflammatory biomarkers C-Reactive Protein (CRP) and Procalcitonin (PCT). METHODS: One hundred patients undergoing LAR-TME with a proximal diverting stoma were analyzed between 2013 and 2016. Postoperative CRP and PCT levels were measured on the 3rd and the 6th postoperative days. RESULTS: There were 11 clinical leaks with a negative impact in univariate analysis on AL of male gender, larger and stenotic tumours, intraoperative blood loss > 200 mL, the need for perioperative blood transfusion, postoperative anaemia and an operating time exceeding 180 minutes. On multivariate analysis, only perioperative blood transfusion was an independent AL risk factor. Recorded CRP was higher in AL patients when compared with non-AL cases on both the 3rd postoperative day (152.4 mg/L vs. 93 mg/L, respectively; P < 0.0001) and the 6th postoperative day (130.5 mg/L vs. 68.2 mg/L; P < 0.0001). The PCT levels also significantly differed between AL and non-AL cases on the 3rd postoperative day (0.5 ng/mL vs. 0.2 ng/mL, respectively; P < 0.0001) and the 6th postoperative day (1.16 ng/mL vs. 0.1 ng/mL, respectively; P < 0.0001). Both CRP and PCT showed high negative predictive values (NPV) for the diagnosis of an AL on both postoperative days. CONCLUSION: Following low restorative proctectomy, the high NPV of CRP and PCT measurements for the diagnosis of anastomotic leaks may assist decision-making for early hospital discharge.


Assuntos
Fístula Anastomótica/sangue , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Estomas Cirúrgicos/efeitos adversos , Fístula Anastomótica/etiologia , Biomarcadores/sangue , Proteína C-Reativa/análise , Calcitonina/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/cirurgia , Fatores de Risco , Estomas Cirúrgicos/patologia
8.
J Surg Res ; 228: 100-106, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29907197

RESUMO

BACKGROUND: Early diagnosis of anastomotic leakage is the most important factor in reducing its morbidity and mortality. Anastomotic integrity monitoring of the leukocyte count (WBC), C-reactive protein (CRP), and neutrophil-lymphocyte ratio (NLR) are commonly used laboratory parameters. The availability of follow-up presepsin anastomotic integrity was investigated in this study. MATERIALS AND METHODS: This study included patients who had gastrointestinal anastomosis due to major abdominal surgery between January 2016 and February 2017. Blood samples were collected to determine the WBC, CRP, NLR, and presepsin values before the anastomosis was performed and then taken on postoperative days 1, 3, and 5. RESULTS: This is a prospective nonrandomized study with 100 consecutive patients enrolled in the anastomosis group (male/female, 42:58). WBC, CRP, NLR, and presepsin values are based on certain days in the complication group, and the complication group increased with statistical significance. Presepsin had a specificity of 98.63% in determining anastomotic leak. CONCLUSIONS: Presepsin can be used as a supplemental marker with CRP and NLR for anastomotic integrity.


Assuntos
Fístula Anastomótica/diagnóstico , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Receptores de Lipopolissacarídeos/sangue , Fragmentos de Peptídeos/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/sangue , Fístula Anastomótica/etiologia , Biomarcadores/sangue , Proteína C-Reativa/análise , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Período Pós-Operatório , Período Pré-Operatório , Estudos Prospectivos , Curva ROC , Fatores de Tempo , Adulto Jovem
9.
Esophagus ; 15(2): 95-102, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29892934

RESUMO

BACKGROUND: The aim of the study was to assess serum C-reactive protein (CRP) level immediately after minimally invasive esophagectomy (MIE) as a surrogate of surgical invasiveness in patients who underwent esophagectomy. METHODS: In total, 104 patients were enrolled in the study: 37 patients underwent MIE in the left lateral decubitus position (MIE-LP) and 67 patients underwent MIE in the prone position (MIE-PP). Serum CRP levels were assessed on POD 1, 3, 5, and 7 after MIE, and were compared with surgical outcomes and duration of systemic inflammatory response syndrome (SIRS) to investigate less invasiveness of the MIE. RESULTS: Reduced serum CRP level on POD 1 was associated with PP during MIE (P < 0.001) and decreased blood loss (P = 0.03). MIE-PP was identified as a significant independent predictor of reduced CRP level on POD 1 (odds ratio 3.65, P = 0.042). CRP level on POD 7 was associated with gender (P = 0.02), position of MIE (P = 0.011), blood loss (P = 0.02), and respiratory complications and/or anastomotic leakage (P < 0.001). Postoperative respiratory and/or anastomotic complication was identified as a significant predictor of elevated serum CRP level on POD 7 (odds ratio 3.44, P = 0.048). Shorter duration of SIRS was shown in the patients with reduced serum CRP level on POD 1 and 7 (P = 0.03 and P < 0.001, respectively). CONCLUSION: Serial assessments of serum CRP level immediately after MIE may be a possible indicator that can reflect surgical invasiveness and postoperative complications.


Assuntos
Fístula Anastomótica/sangue , Proteína C-Reativa/metabolismo , Esofagectomia/métodos , Decúbito Ventral , Doenças Respiratórias/sangue , Síndrome de Resposta Inflamatória Sistêmica/sangue , Idoso , Fístula Anastomótica/etiologia , Biomarcadores/sangue , Perda Sanguínea Cirúrgica , Esofagectomia/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Posicionamento do Paciente , Período Pós-Operatório , Doenças Respiratórias/etiologia , Fatores Sexuais , Síndrome de Resposta Inflamatória Sistêmica/etiologia
10.
Zhonghua Wei Chang Wai Ke Za Zhi ; 21(4): 442-447, 2018.
Artigo em Chinês | MEDLINE | ID: mdl-29682717

RESUMO

OBJECTIVE: To investigate the value and feasibility of C reactive protein (CRP) in predicting postoperative anastomotic leakage in rectal cancer patients with enhanced recovery after surgery (ERAS) for safer implementation of this ERAS. METHODS: A cohort study on serum CRP of 455 rectal cancer patients undergoing laparoscopic radical resection according to the ERAS procedure at Gastrointestinal Unit of General Surgery Department, Guangdong General Hospital from August 2014 to June 2017 was retrospectively carried out. The serum CRP level was measured before operation and at postoperative days 1-7, and the serum CRP level of the groups with and without anastomotic leakage was compared to analyze its prediction for anastomotic leakage. Diagnostic standard of anastomotic leakage was based on the definition of postoperative anastomotic leakage in rectal cancer from International Study Group of Rectal Cancer (ISREC): (1) Postoperative localized or diffuse peritonitis occurred, or fecal liquid was found from the abdominal drainage tube; (2) When anastomotic leakage was uncertain, peritoneal or pelvic computed tomography scan should be used to confirm. RESULTS: All the 455 patients underwent surgery successfully, and 41 patients (9.0%) had anastomotic leakage postoperatively. Patients with anastomotic leakage were diagnosed (4.0±2.0) days postoperatively, of whom 8 cases (19.5%) were diagnosed more than 5 days postoperatively. Serum CRP levels in patients with anastomotic leakage continued to increase within 1-4 days postoperatively [(50.04±27.98) mg/L to (122.75±52.98) mg/L] and decreased 5 days postoperatively [(92.02±58.26) mg/L], both were higher than those of non-anastomotic leakage group, and the difference was statistically significant (all P<0.05, except postoperative day 2). The serum CRP level of non-anastomotic leakage group reached the peak on the second postoperative day [(83.10±37.45) mg/L] and decreased 3 days postoperatively [(48.01±27.59) mg/L]. The ROC curve was drawn with the anastomotic leakage as the state variable, and the CRP level as the detection variable. The area under the curve (AUC) at postoperative 1, 2, 4, 5, 6 and 7 days was 0.74, 0.58, 0.83, 0.82, 0.65, and 0.70, respectively. The maximum was at postoperative day 3 [0.93(95%CI: 0.86-0.99)]. The Youden index was 0.72, and the threshold of CRP was 80.09 mg/L, as the cut-off point to predict anastomotic leakage, with sensitivity, specificity, and positive predictive value of 79.3%, 92.3%, and 74.2%, respectively. CONCLUSIONS: Monitoring the postoperative serum CRP level can help predict the occurrence of anastomotic leakage after laparoscopic surgery for rectal cancer. When the serum CRP level is >80.09 mg/L on the third postoperative day, the CRP level has the largest value in predicting postoperative anastomotic leakage, and the safety of ERAS has a certain clinical significance as well.


Assuntos
Fístula Anastomótica/sangue , Proteína C-Reativa/análise , Neoplasias Retais/cirurgia , Anastomose Cirúrgica , Fístula Anastomótica/etiologia , Humanos , Período Pós-Operatório , Estudos Retrospectivos
11.
Langenbecks Arch Surg ; 403(2): 235-244, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29516256

RESUMO

BACKGROUND: Early detection of anastomotic leakage after esophagectomy has the potential to reduce morbidity and mortality. Prompt suspicion of leak may help to exclude patients from fast-track protocols, thereby avoiding early oral feeding and early hospital discharge which could aggravate the prognosis of a clinically occult leak. PATIENTS AND METHODS: Observational retrospective cohort study. Patients with diagnosis of esophageal cancer who underwent elective minimally invasive esophagectomy were included. The following data were collected: age, gender, BMI, comorbidities, ASA score, tumor histology, TNM staging, use of neo-adjuvant therapy, type of operation, operative time, morbidity, and 90-day mortality. A panel of biomarkers including C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC), and percentage of neutrophils (PN) were measured at baseline and on postoperative days 3, 5, and 7. RESULTS: Two hundred forty-three patients operated between 2012 and 2017 were included in the study. Anastomotic leakage occurred in 29 patients. There was a statistical association over time between anastomotic leakage and CRP (p < 0.001), PCT (p < 0.001), WBC (p = 0.019), and PN (p = 0.007). The cut-off value of CRP on POD 5 was 8.3 mg/dL, AUC = 0.818, negative LR = 0.176. CONCLUSIONS: Increased serum CRP, PCT, WBC, and PN after minimally invasive esophagectomy are associated with anastomotic leakage. A CRP value lower than 8.3 mg/dL, combined with reassuring clinical and radiological signs, may be useful to exclude leakage on postoperative day 5.


Assuntos
Fístula Anastomótica/sangue , Biomarcadores Tumorais/sangue , Proteína C-Reativa/análise , Neoplasias Esofágicas/sangue , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/epidemiologia , Fístula Anastomótica/fisiopatologia , Área Sob a Curva , Distribuição de Qui-Quadrado , Estudos de Coortes , Intervalo Livre de Doença , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/mortalidade , Neoplasias Esofágicas/mortalidade , Esofagectomia/mortalidade , Esofagoscopia/efeitos adversos , Esofagoscopia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Estatísticas não Paramétricas , Análise de Sobrevida , Resultado do Tratamento
12.
J Gastrointest Surg ; 22(5): 818-830, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29327310

RESUMO

BACKGROUND: Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications. METHODS: Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis. RESULTS: Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter < 3 mm and serum C-reactive protein ≥ 100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p < 0.01) and pancreatic fistula (p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62-0.82, p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01). CONCLUSIONS: C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.


Assuntos
Abscesso Abdominal/sangue , Fístula Anastomótica/sangue , Proteína C-Reativa/metabolismo , Fístula Pancreática/sangue , Pancreaticoduodenectomia/efeitos adversos , Abscesso Abdominal/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ductos Pancreáticos/patologia , Fístula Pancreática/etiologia , Readmissão do Paciente , Período Pós-Operatório , Valor Preditivo dos Testes , Curva ROC , Fatores de Risco , Fatores de Tempo , Adulto Jovem
13.
Rom J Morphol Embryol ; 59(4): 1075-1081, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30845287

RESUMO

AIM: The aim of this experimental study was to determine if the type of termino-terminal anastomosis of the colon affect the process of healing of the intestinal mucosa and if the severity of the anastomotic leakage (AL) can be predicted based on the circulating level of intestinal fatty acid-binding protein (I-FABP). MATERIALS AND METHODS: In 18 healthy Wistar rats, two types of open colon resection with termino-terminal anastomosis were performed: group A (n=9) - without inversing the vascularization and group B (n=9) - with inversing the vascularization. To assess the intestinal barrier function, circulating level of I-FABP was measured pre- and post-operatively. I-FABP tissue expression was immunohistochemically assessed in the anastomotic and perianastomotic colonic mucosa. The rats were sacrificed at three, five, and seven days after surgery. RESULTS: In both groups, the post-operative serum level of I-FABP increased 3-4 times at 3-5 days and seven times in the seventh post-operative day. In the six cases that showed AL, the increased level was significantly higher: seven times at three days (n=2) or five days (n=2) and 30 times at seven days (n=2). The I-FABP epithelial expression was lost in all cases from group B (as result of prolonged ischemia) and in cases with AL from group A. The I-FABP was translocated in the intraglandular mucus. CONCLUSIONS: The post-operative level of I-FABP can be appreciated based on the pre-operative value only. A 7-8 increased value in first five days might indicate a risk of AL. After seven days, a seven times increased value is an indicator of a proper healing process but an increasing amount higher that 30 times might predict risk for AL, fistula, peritonitis and septic shock. The risk of AL does not depend on the anastomotic method, although the level of ischemia is higher in anastomoses that involve vascular damage.


Assuntos
Fístula Anastomótica/diagnóstico , Colo/cirurgia , Proteínas de Ligação a Ácido Graxo/metabolismo , Fístula Anastomótica/sangue , Fístula Anastomótica/patologia , Animais , Biomarcadores/metabolismo , Colo/patologia , Proteínas de Ligação a Ácido Graxo/sangue , Mucosa Intestinal/patologia , Ratos Wistar
14.
Dig Surg ; 35(1): 77-84, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28132052

RESUMO

PURPOSE: To assess the prognostic value of postoperative C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) in the development of anastomotic leak (AL) in patients after surgery for colorectal cancer (CRC). METHODS: Patients operated on for CRC between 2010 and 2014 were enrolled into the study. The sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPVs) were calculated for the CRP and NLR measured on the 4th postoperative day (POD). RESULTS: Among 724 patients, AL was diagnosed in 33 (4.6%). The accuracy of CRP in the detection of AL using area under curve was 0.83 with the optimal cut-off value of 180 mg/L, sensitivity 75%, specificity 91%, PPV 52% and NPV 87%. Also, NLR on POD4 was higher in the AL group: 9.03 ± 4.13 vs. 4.45 ± 2.25; p = 0.0012; sensitivity 69%, specificity 78%, PPV 49%, NPV 88% at cut-off point of 6.5. Moreover, CRP and NLR on POD4 were significantly higher in patients who died in the postoperative period: 239 ± 24 mg/L vs. 199 ± 41 mg/L; p = 0.034 and 10.71 ± 2.08 vs. 8.65 ± 4.67; p = 0.029, respectively). CONCLUSIONS: CRP and NLR on POD4 possess the ability to predict the development of AL and postoperative mortality after CRC operation. Based on our results, high NPV might be indicative of patients with low risk of AL in their postoperative period.


Assuntos
Fístula Anastomótica/diagnóstico , Proteína C-Reativa/metabolismo , Neoplasias Colorretais/cirurgia , Linfócitos/metabolismo , Neutrófilos/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/sangue , Biomarcadores/sangue , Neoplasias Colorretais/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Sensibilidade e Especificidade
15.
Asian J Surg ; 41(1): 30-38, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27451010

RESUMO

BACKGROUND: Preoperative hypoalbuminemia is a well-known risk factor for anastomotic leakage after colorectal surgery, but the association between perioperative albumin level and anastomotic leakage has not been fully investigated in curative colorectal cancer (CRC) patients. METHODS: In total, 200 CRC patients (Stage I-III) undergoing curative laparoscopic surgery between January 2004 and December 2013 were enrolled in this study. We collected data on surgical factors, perioperative levels of serum albumin and inflammatory markers, and perioperative factors affecting hypoalbuminemia from 196 CRC patients to assess the relation to anastomotic leakage. RESULTS: Anastomotic leakage occurred in 11 cases (5.6%) and the frequency was higher in rectal cancer patients (p = 0.0044). There was no significant difference of preoperative serum albumin level between the anastomotic leakage group (AL) and the nonanastomotic leakage group (NAL). Postoperative serum albumin levels in AL were significantly lower than in NAL [postoperative day (POD) 0, p = 0.0004; POD1, p = 0.0001; POD3, p = 0.0004; and POD7, p = 0.0021]. On multivariate analysis, lower average level of serum albumin on POD1 and POD3 {odds ratio (OR) [95% confidence interval (CI)] = 7.53 (1.60-55.80), p = 0.0095}, higher average level of serum white blood cells on POD1 and POD3 [OR (95% CI) = 7.24 (1.40-59.25), p = 0.0165], and surgery for rectal cancer [OR (95% CI) = 15.18 (3.26-93.99), p = 0.0004] were independent risk factors for anastomotic leakage. CONCLUSION: Lower early postoperative serum albumin levels are a potentially valuable indicator of anastomotic leakage in CRC patients undergoing curative surgery.


Assuntos
Fístula Anastomótica/diagnóstico , Neoplasias Colorretais/cirurgia , Assistência Perioperatória/métodos , Albumina Sérica/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/sangue , Fístula Anastomótica/etiologia , Biomarcadores/sangue , Feminino , Humanos , Hipoalbuminemia/sangue , Hipoalbuminemia/complicações , Hipoalbuminemia/diagnóstico , Laparoscopia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
16.
ANZ J Surg ; 88(3): 223-227, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27457697

RESUMO

BACKGROUND: Post-operative C-reactive protein (CRP) has been investigated as a predictor of anastomotic leak (AL) following colorectal surgery, but its role in oesophago-gastric surgery is not yet established. METHODS: Clinical data and post-operative CRP values of patients who underwent elective oesophago-gastric resection between January 2004 and July 2014 were analysed retrospectively. Only patients with an oesophageal anastomosis were included. AL was defined as leakage of contrast material seen on imaging or a leak confirmed intraoperatively on return to theatre. RESULTS: One hundred and forty-five patients were identified. Of the 145 patients, 13 (9%) developed AL. The CRP on post-operative days (POD) 2, 3 and 6 had the greatest diagnostic accuracy, with an area under the curve of 0.82, 0.80 and 0.91 respectively. Using a cut-off value of 209 mg/L on POD 2, the sensitivity was 100%, the specificity was 61%, the positive predictive value (PPV) was 21% and the negative predictive value (NPV) was 100%. Using a cut-off value of 190 mg/L on POD 3, the sensitivity was 100%, the specificity was 59%, the PPV was 21% and the NPV was 100%. Using a cut-off value of 154 mg/L on POD 6, the sensitivity was 100%, the specificity was 78%, the PPV was 29% and the NPV was 100%. CONCLUSION: Post-operative CRP is an accurate negative predictive test for the development of AL following oesophago-gastric surgery. It may help to discriminate between patients with a high risk of leak and those in which AL is unlikely to occur.


Assuntos
Fístula Anastomótica/sangue , Proteína C-Reativa/metabolismo , Neoplasias Esofágicas/cirurgia , Junção Esofagogástrica/cirurgia , Gastrectomia/métodos , Adulto , Idoso , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Fístula Anastomótica/etiologia , Biomarcadores/metabolismo , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/mortalidade , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Junção Esofagogástrica/patologia , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Queensland , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade , Estatísticas não Paramétricas , Análise de Sobrevida
17.
Cir Esp ; 95(9): 529-535, 2017 Nov.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29061337

RESUMO

INTRODUCTION: Anastomotic leak (AL) is a serious complication in colorectal surgery due to its increase in morbidity and mortality. The aim of this prospective non-randomised study is to determine whether C-reactive Protein (CRP) is useful as a predictor of AL in patients undergoing open versus laparoscopic surgery. METHODS: A total of 168 patients undergoing elective colorectal surgery were included. CRP was measured daily during the first 5postoperative days. Complications, specially AL, were analysed. RESULTS: Following an open approach 32 patients (45.7%) presented complications, 15 (18.7%) in the laparoscopic group and 12 (29.4%) in the converted group (P=0.153). Following open surgery 9 patients experienced AL, 5 were detected in the laparoscopic group and none in those converted (P=0.153). There were significant differences in CRP values between the 3 groups (P=0.03). ROC Curves showed AUC for the open and laparoscopic approach of 0.731 and 0.760 respectively. On day 4 the AUC was 0.867 for the open group and 0.914 for the laparoscopic group. Cut-off points on day 4 were: Open: 159.2mg/L; sensitivity 75%, specificity 89% and NPP 96% (P<0.001). Following laparoscopic surgery the cut-off point was 67.3%; sensitivity 100%, specificity 89.5% and NPP 100% (P=0.016). CONCLUSION: CRP on day 4 is useful to diagnose AL. Different cut-off values should be taken into account depending on the approach used.


Assuntos
Fístula Anastomótica/sangue , Fístula Anastomótica/diagnóstico , Proteína C-Reativa/análise , Doenças do Colo/cirurgia , Laparoscopia , Doenças Retais/cirurgia , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos
18.
Int J Surg ; 46: 7-10, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28803998

RESUMO

BACKGROUND: Anastomotic leak (AL) following oesophagectomy carries a high mortality and morbidity. Early detection and intervention is required for a successful outcome. We have examined the role of a high postoperative serum lactate in predicting which patients are at risk of developing an anastomotic leak(AL). MATERIALS AND METHODS: All patients who underwent transthoracic oesophagectomy over a 3-year period were identified from a prospectively collected database. Medical records were reviewed to identify the highest serum lactate recorded from blood gas analysis over each 24hr post-operative period. Patients who underwent transhiatal and left thoraco-abdominal oesophagectomies were excluded. Patients who developed a chyle leak were excluded. RESULTS: Of a total of 136 oesophagectomies included for analysis, 18 developed an AL (13.2%). Of these patients, 10 underwent thoracoscopic oesophageal mobilization with cervical anastomosis and the rest an Ivor Lewis procedure. Predictive factors for AL included neoadjuvant chemotherapy (15/18 83.3% vs 55/118 46.6% p = 0.0046) and number of positive lymph nodes (mean 4.2 vs control mean 2.3 p = 0.045). Overall net fluid balance was comparable between the 2 groups, although AL patients received slightly more fluid on Day 3. High lactate levels on days 1-3 were associated with an AL. Using a Day 2 lactate of 1.7 mmol/L, the sensitivity of predicting AL was 72% and specificity 88%. The mean lag time using existing diagnostic modalities was 7.9 days. CONCLUSION: A serum lactate of >1.7 mmol/l on day 2 should raise the possibility of a potential AL. Such patients should be selected for more intensive monitoring, optimization and selective gastroscopy.


Assuntos
Fístula Anastomótica/etiologia , Esofagectomia/efeitos adversos , Esôfago/cirurgia , Lactatos/sangue , Estômago/cirurgia , Idoso , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/sangue , Fístula Anastomótica/diagnóstico , Biomarcadores/sangue , Bases de Dados Factuais , Neoplasias Esofágicas/sangue , Neoplasias Esofágicas/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos
19.
Surg Endosc ; 31(12): 5283-5288, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28593411

RESUMO

INTRODUCTION: The performance of most bariatric procedures within an Enhanced Recovery After Surgery program has resulted in significant advantages, including a reduction in the length of hospital stay to 2-3 days. However, some postoperative complications may appear after the patient has been discharged. The aim of this study was to investigate the efficacy of various acute-phase parameters determined 24 h after a laparoscopic sleeve gastrectomy for predicting staple line leak in the postoperative course. PATIENTS AND METHODS: A prospective study of 208 morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between 2012 and 2015 was performed. Blood analysis was performed 24 h after surgery. Acute-phase parameters (C-reactive protein, procalcitonin, fibrinogen, and White Blood Cell count) were investigated. RESULTS: Staple line leak appeared in eight patients (3.8%). Using receiver operating characteristic analysis at 24 h postoperatively, a cutoff level of CRP at 9 mg/dL achieved 85% sensitivity and 90% specificity for predicting staple line leak, a cutoff level of procalcitonin at 0.85 ng/mL achieved 70% sensitivity and 90% specificity, and a cutoff level of fibrinogen at 600 mg/dL achieved 80% sensitivity and 87.5% specificity. CONCLUSION: An elevation of CRP > 9 mg/dL, procalcitonin > 0.85 ng/mL and fibrinogen > 600 mg/dL should alert the surgeon the possibility of occurrence of postoperative staple line leak.


Assuntos
Proteínas da Fase Aguda/análise , Fístula Anastomótica/sangue , Gastrectomia/efeitos adversos , Laparoscopia/efeitos adversos , Obesidade Mórbida/cirurgia , Adulto , Idoso , Fístula Anastomótica/diagnóstico , Biomarcadores/sangue , Proteína C-Reativa/análise , Calcitonina/sangue , Feminino , Fibrinogênio/análise , Gastrectomia/métodos , Humanos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Sensibilidade e Especificidade , Grampeamento Cirúrgico/efeitos adversos , Grampeamento Cirúrgico/métodos
20.
Colorectal Dis ; 19(5): O115-O125, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28214365

RESUMO

AIM: Anastomotic leak is associated with higher rates of recurrence after surgery for colorectal cancer. However, the mechanisms responsible are unknown. We hypothesized that the infection-induced inflammatory response may induce overexpression of tumour progression-related genes in immune cells. The aim was to investigate the effect of postoperative intra-abdominal infection on the gene expression patterns of peripheral blood leucocytes (PBL) after surgery for colorectal cancer. METHOD: Prospective matched cohort study. Patients undergoing surgery for colorectal cancer were included. Patients who had anastomotic leak or intra-abdominal abscess were included in the infection group (n = 23) and matched with patients without complications for the control group (n = 23). PBL were isolated from postoperative blood samples. Total RNA was extracted and hybridized to the Affymetrix Human Gene 1.0 ST microarray. RESULTS: Patients in the infection group displayed 162 upregulated genes and 146 downregulated genes with respect to the control group. Upregulated genes included examples coding for secreted cytokines involved in tumour growth and invasion (S100P, HGF, MMP8, MMP9, PDGFC, IL1R2). Infection also upregulated some proangiogenic genes (CEP55, TRPS1) and downregulated some inhibitors of angiogenesis (MME, ALOX15, CXCL10). Finally, some inhibitors (HP, ORM1, OLFM4, IRAK3) and activators (GNLY, PRF1, FGFBP2) of antitumour immunity were upregulated and downregulated, respectively, suggesting that the inflammatory environment caused by a postoperative infection favours immune evasion mechanisms of the tumour. CONCLUSION: Analysis of PBL shows differential expression of certain tumour progression-related genes in colorectal cancer patients who have a postoperative intra-abdominal infection, which in turn may promote the growth of residual cancer cells to become recurrent tumours.


Assuntos
Neoplasias Colorretais/genética , Infecções Intra-Abdominais/sangue , Leucócitos/metabolismo , Proteínas de Neoplasias/sangue , Complicações Pós-Operatórias , Idoso , Fístula Anastomótica/sangue , Fístula Anastomótica/etiologia , Estudos de Casos e Controles , Colectomia/efeitos adversos , Neoplasias Colorretais/cirurgia , Feminino , Humanos , Infecções Intra-Abdominais/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
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