Association of hypoalbuminemia on the first postoperative day and complications following esophagectomy

Comparison of perioperative outcomes following hybrid minimally invasive versus open Ivor Lewis esophagectomy for esophageal cancer

BACKGROUND

The outcomes of various minimally invasive esophagectomy (MIE) procedures for esophageal cancer have been reported; however, those of the hybrid approach are lacking. This study aimed to assess the impacts of hybrid minimally invasive Ivor Lewis esophagectomy (HIL, laparoscopy and right thoracotomy) for esophageal cancer on perioperative outcomes compared with the open approach.

METHODS

This was a retrospective study of 153 patients who underwent Ivor Lewis esophagectomy for squamous cell carcinoma between January 2008 and December 2016. Patients who received neoadjuvant treatment prior to surgery (n=22) and underwent complete minimally invasive procedures (n=16) were excluded. Clinical characteristics and perioperative outcomes of patients who underwent HIL (n=53) were compared with findings in patients who underwent open Ivor Lewis esophagectomy (OIL, n=62).

RESULTS

There were 112 men (97.4%) and 3 women (2.6%) with a median age of 66 years (range, 45-83 years). The HIL and OIL groups were comparable with respect to age, sex, preoperative pulmonary function, location of the tumor, and preoperative laboratory findings. There was no significant difference between the two groups regarding surgical data, except for pyloric management. Postoperative complications occurred in 17 (32.1%) and 23 (37.1%) patients in the HIL and OIL groups, respectively (P=0.573); in-hospital mortality rates were 3.8% and 8.1%, respectively (P=0.337). HIL group patients had higher albumin (3.3 vs. 2.9 g/dL; P<0.001) and lower C-reactive protein (6.4 vs. 8.1 mg/L; P<0.001) postoperatively. The length of hospital stay was shorter in the HIL group (13.5 vs. 19.2 days; P=0.002).

CONCLUSIONS

Compared with the conventional open approach, HIL for esophageal cancer showed better postoperative nutritional and inflammatory status, resulting in shorter hospital stays. However, further studies are required to evaluate the long-term oncologic outcomes of this hybrid approach.

Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours

Long-term all-cause mortality and dependency after complex surgical procedures have not been assessed in the framework of value-based medicine. The aim of this study was to investigate the postoperative and long-term outcomes after surgical procedures lasting for more than six hours. Retrospective cohort study of patients undergoing a first elective complex surgical procedure between 2004 and 2013. Heart and transplant surgery was excluded. Mortality and dependency from the healthcare system were selected as outcome variables. Gender, age, ASA, creatinine, albumin kinetics, complications, benign vs malignant underlying condition, number of drugs at discharge, and admission and length of stay in the ICU were recorded as predictive variables. Some 620 adult patients were included in the study. Postoperative, <1year and <5years cumulative mortality was 6.8%, 17.6% and 45%, respectively. Of patients discharged from hospital after surgery, 76% remained dependent on the healthcare system. In multivariate analysis for postoperative, <1year and <5years mortality, postoperative albumin concentration, ASA score and an ICU stay >7days, were the most significant independent predictive variables. Prolonged surgery carries a significant short and long-term mortality and disability. These data may contribute to more informed decisions taken concerning major surgery in the framework of value-based medicine.

Postoperative decrease of serum albumin predicts short-term complications in patients undergoing gastric cancer resection

AIM

To find an accurate and simple predictor for postoperative short-term complications after gastrectomy.

METHODS

Two hundred and twenty-three patients undergoing gastric cancer resection between October 1, 2015 and September 30, 2016 were enrolled in this study. Univariate and multivariate analyses were used to identify risk factors for complications after gastrectomy. The cutoff values and diagnostic accuracy were examined by receiver operating characteristic curves.

RESULTS

Sixty-two (27.8%) patients had short-term complications after gastric cancer resection. The postoperative decrease in serum albumin (∆ALB) was an independent risk factor for complications (OR = 17.957, 95%CI: 6.073-53.095, P < 0.001). The cutoff value was 14.0% and the area under the curve was higher than that of C-reactive protein on postoperative day 3 (area under the curve: 0.806 vs 0.709). Patients with ∆ALB ≥ 14.0% were more likely to have short-term complications after gastrectomy (46.7% vs 5.0%, P < 0.001), prolonged hospital stay (17.2 ± 10.8 d vs 14.1 ± 4.2 d, P = 0.007) and higher comprehensive complication index (P < 0.001) than those with ∆ALB < 14.0%.

CONCLUSION

Postoperative ∆ALB with a cutoff of 14.0% can be used to recognize patients who have high risk of short-term complications following gastric cancer resection.

Evidence for a Role of Nerve Injury in Painful Intervertebral Disc Degeneration: A Cross-Sectional Proteomic Analysis of Human Cerebrospinal Fluid

Intervertebral disc degeneration (DD) is a cause of low back pain (LBP) in some individuals. However, although >30% of adults have DD, LBP only develops in a subset of individuals. To gain insight into the mechanisms underlying nonpainful versus painful DD, human cerebrospinal fluid (CSF) was examined using differential expression shotgun proteomic techniques comparing healthy control participants, subjects with nonpainful DD, and patients with painful DD scheduled for spinal fusion surgery. Eighty-eight proteins were detected, 27 of which were differentially expressed. Proteins associated with DD tended to be related to inflammation (eg, cystatin C) regardless of pain status. In contrast, most differentially expressed proteins in DD-associated chronic LBP patients were linked to nerve injury (eg, hemopexin). Cystatin C and hemopexin were selected for further examination using enzyme-linked immunosorbent assay in a larger cohort. While cystatin C correlated with DD severity but not pain or disability, hemopexin correlated with pain intensity, physical disability, and DD severity. This study shows that CSF can be used to study mechanisms underlying painful DD in humans, and suggests that while painful DD is associated with nerve injury, inflammation itself is not sufficient to develop LBP.

PERSPECTIVE

CSF was examined for differential protein expression in healthy control participants, pain-free adults with asymptomatic intervertebral DD, and LBP patients with painful intervertebral DD. While DD was related to inflammation regardless of pain status, painful degeneration was associated with markers linked to nerve injury.

The Predictive Value of Coefficient of PCT × BG for Anastomotic Leak in Esophageal Carcinoma Patients With ARDS After Esophagectomy

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.

Is postoperative decrease of serum albumin an early predictor of complications after major abdominal surgery? A prospective cohort study in a European centre

OBJECTIVE

To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes.

DESIGN

Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS).

SETTING

Department of abdominal surgery in a European tertiary centre.

PARTICIPANTS

Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded.

RESULTS

The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p<0.001). ΔAlb also correlated to overall complications (r=0.485, p<0.001), CCI (r=0.383, p<0.001) and LoS (r=0.468, p<0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1% and a specificity of 67.2% (AUC: 78.3%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications.

CONCLUSIONS

Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk.

Early Postoperative Decrease of Serum Albumin Predicts Surgical Outcome in Patients Undergoing Colorectal Resection

BACKGROUND

A simple and accurate predictor of postoperative complications is needed for early and safe discharge after surgery. A decrease in serum albumin is commonly observed early after surgery, even in patients with normal preoperative levels. However, whether it predicts patient postoperative outcome is unknown.

OBJECTIVE

The purpose of this study was to evaluate whether the reduction in serum albumin within 2 postoperative days compared with the preoperative level could serve as an independent predictor of postoperative complications after colorectal surgery.

DESIGN

This was a retrospective study from a single institution.

SETTINGS

The study was conducted in a tertiary referral hospital.

PATIENTS

A total of 626 patients undergoing major colorectal surgery between December 2012 and January 2016 were eligible for this study.

MAIN OUTCOME MEASURES

Univariate and multivariate analyses were performed to identify risk factors for postoperative complications and to identify the factors associated with Δalbumin. Receiver operating characteristic curves were developed to examine the cutoff value of the change in albumin in predicting postoperative complications.

RESULTS

Among all of the patients, the median Δalbumin after surgery was 15%. ΔAlbumin was an independent risk factor for overall complications (p < 0.01). The cutoff value was 15%, and an increased area under the curve compared with C-reactive protein occurred on postoperative day 3 or 4. Patients with a Δalbumin ≥15% experienced more postoperative major complications, a higher comprehensive complication index, a longer postoperative stay, and increased surgical site infections (p < 0.05) than those <15%. ΔAlbumin correlated with sex, type of surgery, stoma creation, C-reactive protein on postoperative day 3 or 4, and intraoperative blood transfusion. Postoperative C-reactive protein remained independently associated with Δalbumin (p < 0.01).

LIMITATIONS

The study was limited by its retrospective nature.

CONCLUSIONS

A cutoff value of a 15% reduction in serum albumin within 2 postoperative days could help to identify patients with a high probability of postoperative complications and permit safe and early discharge after colorectal surgery.

Predictive factors for effectiveness and safety of enoxaparin for total knee arthroplasty in aged Japanese patients: a retrospective review

BACKGROUND

The aims of this study were to investigate predictive factors involved in effectiveness and safety of enoxaparin for prevention of postoperative venous thromboembolism in aged Japanese total knee arthroplasty (TKA) patients.

METHODS

Japanese patients over 65 years old who were administered enoxaparin for TKA were enrolled in this study. Their medical records were retrospectively reviewed. Data were corrected at the Izumi Regional Medical Center, from September 2009 to March 2014. Patients were stratified into groups according to whether enoxaparin was effective (no deep vein thrombosis event up to postoperative day 7) or not, and whether they had an adverse drug event (ADE) or not.

RESULTS

A total of 128 patients were included in this study. One hundred five (82.0%) patients were in the effective group and 20 (15.6%) in the adverse drug event (ADE) group. Anemia (13 patients), abnormalities in liver function tests (4 patients), clinically relevant non-major bleeding (4 patients) and urticaria (1 patient) were observed as ADEs. Multivariate logistic regression analysis showed that the serum total protein level at postoperative day 1 (POD1, before enoxaparin administration), was associated with effectiveness of enoxaparin, while the serum total protein and hemoglobin level at POD1 were involved in ADE caused by enoxaparin.

CONCLUSIONS

Although further large scale studies will be warranted, our results suggest that serum total protein level just before enoxaparin treatment for TKA relates to the effectiveness and safety of enoxaparin in a Japanese aged population. In addition, the results indicate that the development of anemia should be carefully monitored during enoxaparin treatment for TKA, particularly in patients with lower levels of serum hemoglobin before treatment.

Overview of Albumin and Its Purification Methods

As the most frequent plasma protein, albumin constitutes more than 50% of the serum proteins in healthy individuals. It has a key role in oncotic pressure maintenance and it is known as a versatile protein carrier for transportation of various endogenous and exogenous ligands. Reduced amounts of albumin in the body will lead to different kinds of diseases such as hypovolemia and hypoproteinemia. It also has various indications in shocks, burns, cardiopulmonary bypass, acute liver failure and etc. Further applications in research consist of cell culture supplement, drug delivery carrier and protein/drug stabilizer. So, the demand for albumin increased annually worldwide. Due to different applications of albumin, many efforts have been accomplished to achieve albumin during a long period of time. In this review, an overview of serum albumin and different purification methods are summarized.

Nutritional intervention in cognitively impaired geriatric trauma patients: a feasibility study

Background

Most studies focusing on improving the nutritional status of geriatric trauma patients exclude patients with cognitive impairment. These patients are especially at risk of malnutrition at admission and of worsening during the perioperative fasting period. This study was planned as a feasibility study to identify the difficulties involved in including this high-risk collective of cognitively impaired geriatric trauma patients.

Patients and methods

This prospective intervention study included cognitively impaired geriatric patients (Mini–Mental State Examination <25, age >65 years) with hip-related fractures. We assessed Mini Nutritional Assessment (MNA), Nutritional Risk Screening (NRS 2002), body mass index, calf circumference, American Society of Anesthesiologists’ classification, and Braden Scale. All patients received parenteral nutritional supplementation of 800 kcal/d for the 96-hour perioperative period. Serum albumin and pseudocholinesterase were monitored. Information related to the study design and any complications in the clinical course were documented.

Results

A total of 96 patients were screened, among whom eleven women (median age: 87 years; age range: 74–91 years) and nine men (median age: 82 years; age range: 73–89 years) were included. The Mini–Mental State Examination score was 9.5 (0–24). All patients were manifestly undernourished or at risk according to MNA and NRS 2002. The body mass index was 23 kg/m² (13–30 kg/m²), the calf circumference was 29.5 cm (18–34 cm), and the mean American Society of Anesthesiologists’ classification status was 3 (2–4). Braden Scale showed 18 patients at high risk of developing pressure ulcers. In all, 12 patients had nonsurgical complications with 10% mortality. Albumin as well as pseudocholinesterase dropped significantly from admission to discharge. The study design proved to be feasible.

Conclusion

The testing of MNA and NRS 2002 was feasible. Cognitively impaired trauma patients proved to be especially at risk of malnutrition. Since 96 hours of parenteral nutrition as a crisis intervention was insufficient, additional supplementation could be considered. Laboratory and functional outcome parameters for measuring successive supplementation certainly need further evaluations involving randomized controlled trials.

Leakage of albumin in major abdominal surgery

Background

The time course of plasma albumin concentration (P-alb) and cumulative perioperative albumin shift as a measure of albumin extravasation in major abdominal surgery is not well described. Knowledge of these indices of the vascular barrier and vascular content are important for our understanding of fluid physiology during surgery and anesthesia.

Methods

Patients (n = 10) were studied during esophageal or pancreatic surgery. P-alb was repeatedly measured over 72 h, and the mass balance of albumin and hemoglobin were obtained from measures of P-alb, blood hemoglobin and hematocrit.

Results

P-alb decreased rapidly from baseline (32.8 ± 4.8 g/L) until the start of surgical reconstruction (18.7 ± 4.8 g/L; p < 0.001), and was thereafter stable until postoperative day 3. Cumulative perioperative albumin shift increased until 1 h after the end of surgery, when 24 ± 17 g (p < 0.001) had been lost from the circulation.

Conclusions

The rapid fall in P-alb of more than 40 % consistently occurred during the first part of the surgical procedure, but albumin leakage progressed until 1 h after the end of surgery. After the initial drop, P-alb was stable for 72 h.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1283-8) contains supplementary material, which is available to authorized users.

Postoperative Albumin Drop Is a Marker for Surgical Stress and a Predictor for Clinical Outcome: A Pilot Study

Background. Surgical stress during major surgery may be related to adverse clinical outcomes and early quantification of stress response would be useful to allow prompt interventions. The aim of this study was to evaluate the acute phase protein albumin in the context of the postoperative stress response. Methods. This prospective pilot study included 70 patients undergoing frequent abdominal procedures of different magnitude. Albumin (Alb) and C-reactive protein (CRP) levels were measured once daily starting the day before surgery until postoperative day (POD) 5. Maximal Alb decrease (Alb Δ min) was correlated with clinical parameters of surgical stress, postoperative complications, and length of stay. Results. Albumin values dropped immediately after surgery by about 10 g/L (42.2 ± 4.5 g/L preoperatively versus 33.8 ± 5.3 g/L at day 1, P < 0.001). Alb Δ min was correlated with operation length (Pearson ρ = 0.470, P < 0.001), estimated blood loss (ρ = 0.605, P < 0.001), and maximal CRP values (ρ = 0.391, P = 0.002). Alb Δ min levels were significantly higher in patients having complications (10.0 ± 5.4 versus 6.1 ± 5.2, P = 0.005) and a longer hospital stay (ρ = 0.285, P < 0.020). Conclusion. Early postoperative albumin drop appeared to reflect the magnitude of surgical trauma and was correlated with adverse clinical outcomes. Its promising role as early marker for stress response deserves further prospective evaluation.

Postoperative hypoalbuminemia following surgery related to craniosynostosis

BACKGROUND

An episode of postoperative phenytoin toxicity in a patient undergoing surgery related to craniosynostosis highlighted the presence of hypoalbuminemia. We believe that hypoalbuminemia contributed to the altered pharmacokinetics of phenytoin in this case.

OBJECTIVES

To establish the incidence of postoperative hypoalbuminemia in patients undergoing surgery related to craniosynostosis and to investigate the likely etiology.

METHODS

Data on 114 patients undergoing surgery for craniosynostosis over a 2-year period at Oxford Children's Hospital, between May 2011 and May 2013, were retrospectively reviewed. Twenty-two patients were excluded due to incomplete data. This cohort represents the entire population for whom transfusion data had been formally collected at our institution. Preoperative and day 1 postoperative serum albumin levels were collected from the hospital laboratory database. Data regarding blood loss and intra-operative fluid management were reviewed from the anesthetic database. Linear regression analysis was used to establish the relationship between percentage drop in serum albumin with: (i) milliliters per kilogram (ml·kg(-1)) volume of albumin-poor fluids used intra-operatively and (ii) percentage estimated red cell mass loss.

RESULTS

All patients experienced a statistically significant drop in serum albumin. The mean difference in albumin was 17.1 g·l(-1), 95% CI (16.1-18.0) (P < 0.001). Expressed as a percentage, the mean reduction was 37.9% (range 16-61%), SD 9.7. The decrease in albumin was associated with an increase in estimated red cell mass loss (P < 0.001) and an increased ml·kg(-1) volume of albumin-poor fluids given (P < 0.001).

CONCLUSION

Hemodilution due to large volume blood loss and transfusion with albumin-poor fluids is strongly associated with postoperative hypoalbuminemia in patients undergoing surgery related to craniosynostosis. Practitioners should be aware of this risk and the implications of postoperative hypoalbuminemia in this population.

Inflammatory response related scoring systems in assessing the prognosis of patients with pancreatic ductal adenocarcinoma: a systematic review

BACKGROUND

Various scoring systems based on assessment of the systemic inflammatory response help assessing the prognosis of patients with pancreatic ductal adenocarcinoma. In the present systematic review we evaluated the validity of four pre-intervention scoring systems: Glasgow prognostic score (GPS) and its modified version (mGPS), platelet lymphocyte ratio (PLR), neutrophil lymphocyte ratio (NLR), and prognostic nutrition index (PNI).

DATA SOURCES

MOOSE guidelines were followed and EMBASE and MEDLINE databases were searched for all published studies until September 2013 using comprehensive text word and MeSH terms. All identified studies were analyzed, and relevant studies were included in the systematic review.

RESULTS

Six studies were identified for GPS/mGPS with 3 reporting statistical significance for GPS/mGPS on both univariate analysis (UVA) and multivariate analysis (MVA). Two studies suggested prognostic significance on UVA but not MVA, and in the final study UVA failed to show significance. Eleven studies evaluated the prognostic value of NLR. Six of them reported prognostic significance for NLR on UVA that persisted at MVA in 4 studies, and in the remaining 2 studies NLR was the only significant factor on UVA. In the remaining 5 studies, all in patients undergoing resection, there was no significance on UVA. Seven studies evaluated PLR, with only one study demonstrated its prognostic significance on both UVA and MVA, the rest did not show the significance on UVA. Of the two studies identified for PNI, one demonstrated a statistically significant difference in survival on both UVA and MVA, and the other reported no significance for PNI on UVA.

CONCLUSIONS

Both GPS/mGPS and NLR may be useful but further better-designed studies are required to confirm their value. PLR might be little useful, and there are at present inadequate data to assess the prognostic value of PNI. At present, no scoring system is reliable enough to be accepted into routine use for the prognosis of patients with pancreatic ductal adenocarcinoma.

Risk factors of postoperative acute kidney injury in patients undergoing esophageal cancer surgery

OBJECTIVE

The purpose of this study was to identify perioperative risk factors for postoperative acute kidney injury (AKI) in patients undergoing esophageal cancer surgery.

DESIGN

A retrospective analysis of the prospectively collected medical data.

SETTING

A tertiary care university hospital.

PARTICIPANTS

All consecutive adult patients (n=595) who underwent elective esophageal surgery for cancer between January 2005 and April 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

AKI was defined by the AKI Network criteria based on serum creatinine changes within the first 48 hours after esophageal cancer surgery. The relationship between perioperative variables and AKI was evaluated using multivariate logistic regression. Postoperative AKI developed in 210 (35.3%) patients. Risk factors for AKI were body mass index (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.01-1.14), preoperative serum albumin level (OR 0.52; 95% CI 0.33-0.84), use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (OR 1.35; 95% CI 1.05-1.75), colloid infusion during surgery (OR 1.11; 95% CI 1.06-1.18), and postoperative 2-day C-reactive protein (OR 1.05; 95% CI 1.01-1.09). Postoperative AKI was associated with prolonged length of hospital stay.

CONCLUSIONS

Postoperative AKI is common in patients undergoing esophageal surgery for cancer. Closer evaluation and monitoring in patients with risk factors for AKI may be warranted.

Postoperative hypoalbuminemia as a risk factor for surgical site infection after oral cancer surgery

OBJECTIVES

Postoperative surgical site infection (SSI) is a frequent postoperative complication in patients with oral cancer and significantly affects patient recovery and medical expenses. The aim of this study was to examine the predictors of SSI in patients undergoing major surgery for oral or oropharyngeal squamous cell carcinoma (OSCC) and to determine the relationship between perioperative albumin and the development of SSI.

SUBJECTS AND METHODS

In 337 consecutive patients who underwent clean-contaminated surgery for OSCC, serum albumin, glucose, and hemoglobin levels were perioperatively measured. Differences between the groups were examined using Fisher's exact test, Mann-Whitney U-test, and multiple logistic regression analysis.

RESULTS

Surgical site infection was detected in 88 (26.1%) patients with median time to development of 10 (2-25) days. Multiple logistic regression analysis showed that only postoperative serum albumin < 2.5 g dl(-1) was an independent variable predictive of SSI (P = 0.003). The duration of hospital stay was negatively correlated with postoperative albumin (R(2) = -0.302, P < 0.001).

CONCLUSION

Early postoperative hypoalbuminemia <2.5 g dl(-1) is an independent risk factor for the development of SSI in patients undergoing oral cancer surgery. Clinicians should be aware of the implications of postoperative hypoalbuminemia and consider more intensive postoperative care in these patients.

Evaluation of albumin structural modifications through cobalt-albumin binding (CAB) assay

Human serum albumin (HSA) is the most abundant protein in the human body. HSA injections prepared by fractionating human blood have mainly covered the demand for albumin to treat hypoalbuminemia, the state of low concentration of albumin in blood. HSA in solution may exist in various forms such as monomers, oligomers, polymers, or as mixtures, and its conformational change and/or aggregation may occur easily. Considering these characteristics, there is a great chance of modification and polymer formation during the preparation processes of albumin products, especially injections. The albumin cobalt binding (ACB) test reported by Bar-Or et al. was originally designed to detect ischemia modified albumin (IMA), which contains the modified HSA N-terminal sequence by cleavage of the last two amino acids. In this study, we developed a cobalt albumin binding (CAB) assay to correct the flaws of the ACB test with improving the sensitivity and precision. The newly developed CAB assay easily detects albumin configuration alterations and may be able to be used in developing a quality control method for albumin and its pharmaceutical formulations including albumin injections.

Treatment strategies for esophageal cancer

The treatment of esophageal cancer has evolved considerably in the past decade and depends largely on the extent of disease at the time of presentation. For disease confined to the esophageal mucosa, endoscopic therapy is replacing esophagectomy as the standard of care. For locoregional disease, neoadjuvant chemoradiation followed by esophagectomy is the best strategy for optimizing long-term survival. In the minority of patents who present with metastatic disease, the prognosis is poor. Palliative therapies available for these patients include chemotherapy, radiation, endoscopic therapies to ameliorate obstruction or bleeding, and surgical intervention to optimize nutritional status or to relieve obstruction.

Serum blood urea nitrogen and serum albumin on the first postoperative day predict pancreatic fistula and major complications after pancreaticoduodenectomy

INTRODUCTION

Pancreaticoduodenectomy (PD) has a high morbidity rate. Previous work has shown that hypoalbuminemia on postoperative day 1 (POD) to be contributory to post-esophagectomy complications. We set out to determine the impact of blood urea nitrogen (BUN) and albumin on POD 1 for patients undergoing PD.

METHODS

We examined 446 consecutive patients who underwent PD at the Thomas Jefferson University Hospital between January 1, 2000 and December 31, 2008. Complications were graded using the Clavien scale. We examined the incidence of complications based on POD 1 albumin <2.5 versus ≥2.5 mg/dl, as well as POD 1 BUN <10 vs. ≥10 g/dL.

RESULTS

Patients with a BUN <10 had a significantly decreased risk of any complication (p < 0.001), serious complication (p < 0.001), and pancreatic fistula (p = 0.011). On multivariate analysis, BUN ≥ 10 was the most significant predictor of grade III or above complication (p = 0.0019, hazard ration (HR) = 2.7) and pancreatic fistula (p = 0.016, HR = 2.6). POD 1 albumin <2.5 mg/dl was also an independent predictor of serious complication (p = 0.01, HR = 2.3). Patients with both risk factors had a 31 % chance of developing serious complications and 18.5 % risk of developing pancreatic fistula, while those patients with neither risk factor had a 6.5 and 3.6 % risk, respectively.

CONCLUSION

Serum albumin and BUN on POD 1 are important predictors of perioperative morbidity following PD. These low-cost and easily accessible tests can be used as a prognostic tool to predict adverse surgical outcomes.

Nutrition therapy issues in esophageal cancer

Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.

Evaluation of prognostic value of selected biochemical markers in surgically treated patients with acute mediastinitis

BACKGROUND

Monitoring of biochemical markers of inflammation in acute mediastinitis (AM) can be useful in the modification of treatment. This study was a retrospective evaluation of selected biochemical parameters with negative impact on the prognosis in surgically treated patients.

MATERIAL/METHODS

There were 44 consecutive patients treated surgically due to AM of differentiated etiology. Selected biochemical markers (WBC, RBC, HGB, HCT, PLT, CRP, PCT, ionogram, protein and albumins) were assessed before surgery and on the 3rd day after surgery. ANOVA was applied to find factors influencing observations. Numerical data [laboratory parameters] were compared by means of medians.

RESULTS

The overall hospital mortality rate was 31.82%. In the group of dead patients, there were observed statistically significant lower mean preoperative values of RBC [p=0.0090], HGB [p=0.0286], HCT [p=0.0354], protein [p= 0.0037], albumins [p=0.0003] and sodium [p<0.0001] and elevated values of CRP [P=0.0107] and PCT p<0.0001]. High level of inflammatory markers on day 3 after surgery was found to increase the risk of death - for WBC (by 67%), for CRP (by 88%) and for PCT (by 100%).

CONCLUSIONS

Poor prognosis was more frequent in patients with preoperative high levels of CRP, PCT, anemia, hypoproteinemia and hyponatremia. The risk of death increases significantly if in the immediate postoperative period no distinct decrease in WBC count and of the CRP and PCT level is observed. In such a situation the patients should be qualified earlier for broadened diagnostic workup and for reoperation.

Risk assessment using a novel score to predict anastomotic leak and major complications after oesophageal resection

BACKGROUND

Oesophagectomy is associated with significant morbidity and mortality. A simple score to define a patient's risk of developing major complications would be beneficial.

METHODS

Patients who underwent upper gastrointestinal resections with an oesophageal anastomosis between 2005 and 2010 were reviewed and formed the development dataset with resections performed in 2011 forming a prospective validation dataset. The association between post-operative C-reactive protein (CRP), white cell count (WCC) and albumin levels with anastomotic leak (AL) or major complication including death using the Clavien-Dindo (CD) classification were analysed by receiver operating characteristic curves. After multivariate analysis, from the development dataset, these factors were combined to create a novel score which was subsequently tested on the validation dataset.

RESULTS

Two hundred fifty-eight patients were assessed to develop the score. Sixty-three patients (25%) developed a major complication, and there were seven (2.7%) in-patient deaths. Twenty-six (10%) patients were diagnosed with AL at median post-operative day 7 (range: 5-15). CRP (p = 0.002), WCC (p < 0.0001) and albumin (p = 0.001) were predictors of AL. Combining these markers improved prediction of AL (NUn score > 10: sensitivity 95%, specificity 49%, diagnostic accuracy 0.801 (95% confidence interval: 0.692-0.909, p < 0.0001)). The validation dataset confirmed these findings (NUn score > 10: sensitivity 100%, specificity 57%, diagnostic accuracy 0.879 (95% CI 0.763-0.994, p = 0.014)) and a major complication or death (NUn > 10: sensitivity 89%, specificity 63%, diagnostic accuracy 0.856 (95% CI 0.709-1, p = 0.001)).

CONCLUSIONS

Blood-borne markers of the systemic inflammatory response are predictors of AL and major complications after oesophageal resection. When combined they may categorise a patient's risk of developing a serious complication with higher sensitivity and specificity.

Comparative study of complete and partial omentectomy in radical subtotal gastrectomy for early gastric cancer

PURPOSE

Curative surgery for patients with advanced or even early gastric cancer can be defined as resection of the stomach and dissection of the first and second level lymph nodes, including the greater omentum. The aim of this study was to evaluate the short- and long- term outcomes of partial omentectomy (PO) as compared with complete omentectomy (CO).

MATERIALS AND METHODS

Seventeen consecutive open distal gastrectomies with POs were initially performed between February and July in 2006. The patients' clinicopathologic data and post-operative outcomes were retrospectively compared with 20 patients who underwent open distal gastrectomies with COs for early gastric cancer in 2005.

RESULTS

The operation time in PO group was significantly shorter than that in CO group (142.4 minutes vs. 165.0 minutes, p=0.018). The serum albumin concentration on the first post-operative day in PO group was significantly higher than CO group (3.8 g/dL vs. 3.5 g/dL, p=0.018). Three postoperative minor complications were successfully managed with conservative treatment. Median follow-up period between PO and CO was 38.1 and 37.7 months. All patients were alive without recurrence until December 30, 2009.

CONCLUSION

PO during open radical distal gastrectomy can be considered a more useful procedure than CO for treating early gastric cancer. To document the long-term technical and oncologic safety of this procedure, a large-scale prospective randomized trial will be needed.

Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience

BACKGROUND

Surgical treatment of chronic pancreatitis is indicated for intractable pain. Frey's procedure is an accepted treatment for this disease. The aim of the present study was to describe a single-centre experience in the treatment of chronic pancreatitis using Frey's procedure.

METHODS

A retrospective analysis of 73 patients who underwent a Frey's procedure between 1991 to 2007 and had at least 1 year of follow-up. Demographics, indication for surgery, peri-operative complications and late outcomes were analysed.

RESULTS

The median age was 39.9 years. Seventy out of the 73 (95.8%) patients were male. The median pre-operative body mass index (BMI) was 19.1 kg/m(2). All patients had abdominal pain, 34 (46.6%) of them daily and 13 (17.8%) weekly, with moderate or severe intensity in 98.6% (n= 72). The aetiology was secondary to alcohol in 70 patients (95.9%), with a median consumption of 278 g per day. The surgical morbidity rate was 28.7%; there were no deaths. Median post-operative follow-up was 77.0 months; 64 patients (91.4%) had complete pain relief and post-operative BMI was 22.4 kg/m(2) (P<0.001). All patients with pre-operative endocrine and exocrine insufficiencies showed no reversal of the situation. New onset insufficiencies appeared late.

CONCLUSIONS

Frey's procedure was a safe and effective therapeutic option for the surgical treatment of patients with intractable pain caused by chronic pancreatitis.

Nutritional predictors of postoperative outcome in pancreatic cancer

BACKGROUND

Nutritional status plays an important role in the incidence of postoperative complications and the prognosis of various tumours. The prognostic value of preoperative nutritional factors in patients with pancreatic cancer is not known.

METHODS

This retrospective study included 268 patients who underwent resection for adenocarcinoma of the pancreas. The predictive value of preoperative nutritional status for postoperative outcome (survival, complications) was assessed. Nutritional factors included the three constitutional indices, serum albumin and Onodera's prognostic nutrition index (PNI), calculated as 10 × serum albumin (g/dl) + 0·005× total lymphocyte count (per mm(3)).

RESULTS

In multivariable analysis preoperative low PNI (but not low albumin) was an independent prognostic factor for poor survival: hazard ratio (HR) 1·73 (95 per cent confidence interval (c.i.) 1·21 to 2·47). The accuracy of a PNI value of less than 45 as cut-off for clinically significant preoperative malnutrition in predicting 1- or 2-year survival after surgery was, however, limited (66·4 and 56·3 per cent respectively). Low preoperative albumin concentration and PNI were significantly associated with postoperative complications: odds ratio 1·98 (95 per cent c.i. 1·18 to 3·32) and 2·14 (1·23 to 3·73) respectively. Low PNI and low body mass index were independently associated with pancreatic fistula: HR 2·52 (1·37 to 4·63) and 0·40 (0·17 to 0·93) respectively.

CONCLUSION

The PNI is associated with overall survival and postoperative complications, in particular pancreatic fistula, in patients with pancreatic cancer. The moderate accuracy of PNI as a predictor of survival limits its clinical use.

Influência do trauma cirúrgico no comportamento dos níveis séricos de albumina após cirurgia da coluna vertebral

OBJETIVO: avaliar a variação da concentração da albumina nas cirurgias de coluna vertebral e relacioná-la às repercussões clínicas no pós-operatório. MÉTODOS: estudo prospectivo observacional sobre os valores do nível sérico da albumina de 55 pacientes submetidos à cirurgia na coluna vertebral. As amostras de sangue foram coletadas um dia antes da cirurgia e 24 horas após o procedimento. Foi aplicado o teste t pareado na avaliação da variação (pré versus pós) nos parâmetros albumina, hemoglobina e hematócrito. A presença de associação entre grau de variação nos níveis de albumina (<1 g/dL ou >1 g/dL) e as variáveis de interesse: presença de complicações, necessidade de transfusão, procedimento realizado, idade e gênero do paciente e diagnóstico foram avaliadas pelo teste do χ2 de Pearson ou teste do χ2 da razão de verossimilhança quando apropriado. RESULTADOS: a redução média dessa proteína foi de 0,58 g/dL, variando de 0 a 1,8 g/dL. Dos pacientes, 78,2% apresentaram valores da albumina no período pós-operatório abaixo da faixa considerada normal. Somente dois pacientes da amostra apresentaram complicações durante os 30 dias de seguimento. O grupo com correção de deformidades apresentou 100% de pacientes com variação >1 g/dL. CONCLUSÃO: houve influência do trauma cirúrgico na redução sérica da albumina, em média, de 0,58 g/dL nas cirurgias da coluna vertebral. Não foi possível associar essa queda às complicações no período pós-operatório após seguimento de 30 dias desses pacientes.

Postoperative hypoalbuminemia is associated with outcome in patients undergoing off-pump coronary artery bypass graft surgery

OBJECTIVE

The authors aimed to investigate whether immediate postoperative hypoalbuminemia could be associated with outcomes after off-pump coronary artery bypass graft (OPCAB) surgery.

DESIGN

A retrospective analysis of the medical data.

SETTING

Cardiac operating room and adult cardiovascular intensive care unit at a single institution.

PARTICIPANTS

Six hundred ninety adult patients underwent elective OPCAB surgery over a 30-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

To evaluate the clinical relevance of immediate postoperative hypoalbuminemia, the lowest serum albumin level measured over the first 12 hours postoperatively was recorded. A cutoff point was calculated by the area under the curve in the receiver operating characteristic plot for 30-day adverse events including death. Patients were classified according to the cutoff value, and outcomes were compared between groups using propensity score-matching analysis. The impact of immediate postoperative hypoalbuminemia on OPCAB outcome was investigated using multivariate analysis. The cutoff value for immediate postoperative albumin concentration for predicting 30-day adverse events was 2.3 g/dL. Immediate postoperative hypoalbuminemia (<2.3 g/dL) was associated independently with postoperative respiratory failure (odds ratio [OR] = 8.85, p = 0.04), wound infection (OR = 4.44, p = 0.04), the need for an intra-aortic balloon pump after the operation (OR = 13.7, p = 0.02), renal failure (OR = 7.98, p = 0.01), reoperation for bleeding (OR = 4.33, p = 0.05), and the need for inotropes in the intensive care unit (OR = 1.79, p = 0.02).

CONCLUSIONS

Immediate postoperative hypoalbuminemia was associated with poorer outcomes in OPCAB patients. Monitoring of albumin levels after OPCAB could identify patients at risk for short-term adverse events.

Hypoalbuminemia in critically ill patients with cancer: incidence and mortality

PURPOSE

The aim of this study was to investigate the incidence of hypoalbuminemia in critically ill patients with cancer and to describe the relationship of serum albumin levels to mortality.

DESIGN

An observational cohort study. There were no interventions.

RESULTS

During the study period, 200 patients were eligible for inclusion. A total of 164 (82%) patients had a serum albumin concentration below 35 g/L, of which 91 (55.5%) patients had levels of albumin ≤20 g/L. The mean serum albumin was 18.17 g/L. The crude mortality rate was 22.5%. The highest mortality rate (73%) was seen in the group of patients whose serum albumin levels were <20 g/L.

CONCLUSION

The incidence of hypoalbuminemia in critically ill patients with cancer admitted to ICU was high.

Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study

BACKGROUND

Surgical site infection (SSI) is an infection occurring in an incisional wound within 30 days of surgery and significantly effects patient recovery and hospital resources.

OBJECTIVE

This study sought to determine the relationship between preoperative serum albumin and SSI.

METHODS

A study of 524 patients who underwent gastrointestinal surgery in 4 institutions was performed. Patients were identified using a prospective SSI database and hospital records. Serum albumin was determined preoperatively in all patients. Hypoalbuminemia was defined as albumin <30 mg/dL. Data are presented as median (interquartile range) and a difference between groups was examined using Mann-Whitney U and Fisher exact test and multiple logistic regression analysis.

RESULTS

A total of 105 patients developed a SSI (20%). The median time to the development of SSI was 7 (5-10) days. Having an emergency procedure (P = 0.003), having a procedure over 3 hours in duration (P = 0.047), being American Society of Anaesthetics grade 3 (P = 0.03) and not receiving preoperative antibiotics (P = 0.007) were associated with SSI while having a laparoscopic procedure reduced the likelihood of SSI (P = 0.004). Patients who developed a SSI had a lower preoperative serum albumin (30 [25-34.5] vs. 36 [32-39], P < 0.001). On multivariate analysis, hypoalbuminemia was an independent risk factor for SSI development (relative risk, RR = 5.68, 95% confidence interval: 3.45-9.35, P < 0.001). Albumin <30 mg/dL was associated with an increased rate of deep versus superficial SSI (P = 0.002). The duration of inpatient stay was negatively correlated with preoperative albumin (R = -0.319, P < 0.001).

CONCLUSIONS

Hypoalbuminemia is an independent risk factor for the development of SSI following gastrointestinal surgery and is associated with deeper SSI and prolonged inpatient stay.

How do we predict the clinically relevant pancreatic fistula after pancreaticoduodenectomy?--an analysis in 244 consecutive patients

BACKGROUND

The most important problem in pancreatic fistula is whether one can distinguish clinical pancreatic fistula, grade B + C fistula by the International Study Group on Pancreatic Fistula (ISGPF), from transient pancreatic fistula (grade A), in the early period after pancreaticoduodenectomy (PD). It remains unclear what predictive risk factors can precisely predict which clinical relevant or transient pancreatic fistula when diagnosed pancreatic fistula on POD3 by ISGPF criteria.

METHODS

We analyzed the predictive factors of clinical pancreatic fistula by logistic regression analysis in 244 consecutive patients who underwent PD. Pancreatic fistula was classified into three categories by ISGPF.

RESULTS

The rate of pancreatic fistula was 69 of 244 consecutive patients (28%) who underwent PD. Of these, 47 (19%) had grade A by ISGPF criteria, 17 patients (7.0%) had grade B, and five patients (2.0%) had grade C. The independent risk factor of incidence of pancreatic fistula is soft pancreatic parenchyma. However, soft pancreatic parenchyma did not predict underlying clinically relevant pancreatic fistula. The independent predictive factors of clinically relevant pancreatic fistula were serum albumin level <or=3.0 g/dl on postoperative day (POD) 4 and leukocyte counts >9,800 mm(-3) on POD 4. Positive predictive value of the combination of two predictive factors for clinical relevant pancreatic fistula was 88%.

CONCLUSIONS

The combination of two factors on POD4, serum albumin level <or=3.0 g/dl and leukocyte counts >9,800 mm(-3), is predictive of clinical relevant pancreatic fistula when diagnosed pancreatic fistula on POD 3 by ISGPF criteria.

Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database

INTRODUCTION

This report describes the case mix and outcomes of patients with oesophageal cancer admitted to adult critical care units following elective oesophageal surgery in England, Wales and Northern Ireland.

METHODS

Admissions to critical care following elective oesophageal surgery for malignancy were identified using data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. Information on admissions between December 1995 and September 2007 were extracted and the association between in-hospital mortality and patient characteristics on admission to critical care was assessed using multiple logistic regression analysis. The performance of three prognostic models (Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II and the ICNARC physiology score) was also evaluated.

RESULTS

Between 1995 and 2007, there were 7227 admissions to 181 critical care units following oesophageal surgery for malignancy. Overall mortality in critical care was 4.4% and in-hospital mortality was 11%, although both declined steadily over time. Eight hundred and seventy-three (12.2%) patients were readmitted to critical care, most commonly for respiratory complications (49%) and surgical complications (25%). Readmitted patients had a critical care unit mortality of 24.7% and in-hospital mortality of 33.9%. Overall in-hospital mortality was associated with patient age, and various physiological measurements on admission to critical care (partial pressure of arterial oxygen (PaO2):fraction of inspired oxygen (FiO2) ratio, lowest arterial pH, mechanical ventilation, serum albumin, urea and creatinine). The three prognostic models evaluated performed poorly in measures of discrimination, calibration and goodness of fit.

CONCLUSIONS

Surgery for oesophageal malignancy continues to be associated with significant morbidity and mortality. Age and organ dysfunction in the early postoperative period are associated with an increased risk of death. Postoperative serum albumin is confirmed as an additional prognostic factor. More work is required to determine how this knowledge may improve clinical management.

Preoperative risk assessment and prevention of complications in patients with esophageal cancer

In this review the preoperative risk assessment and prevention of complications in patients undergoing esophagectomy for cancer is discussed. Age, pulmonary and cardiovascular condition, nutritional status, and neoadjuvant chemo(radio)therapy are known predictive factors. None of these factors is a valid exclusion criterion for esophagectomy, but may help in careful patient selection. Both anesthetists and surgeons play an important role in intraoperative risk reduction by means of appropriate fluid management and application of optimal surgical techniques.

Low plasma albumin linked to fluid overload in postoperative epidural patients

INTRODUCTION

Hypotension is commonly associated with epidural use in postoperative patients and is usually treated with fluid or vasopressor therapy. The former can result in fluid overload, associated with significant morbidity. This study aimed to identify factors increasing the likelihood of fluid overload in elective patients.

PATIENTS AND METHODS

A prospective audit of fluid therapy in elective, postoperative, epidural patients was carried out over a 6-week period in a teaching hospital in England. Demographic, biochemical, and fluid balance data were collected and analysed to determine which factors had the strongest correlation with fluid overload. Fluid overload was calculated as the percentage of net fluid input relative to pre-operative body weight (%FO).

RESULTS

Thirty-two patients were included in this study. An overload of 10% of the patients' pre-operative body weight was considered significant. The mean fluid overload incurred by patients in this study was 8.17 l (range, 2.89-14.62 l); %FO was 11.32% (range, 3.67-26.10%). The strongest independently correlating factor to fluid overload was initial, postoperative plasma albumin. Patients with a plasma albumin less than 27 g/l developed significant overload: mean overload 9.75 l (range, 2.89-14.62 l), %FO 15.12% (range, 4.81-26.10%), whilst those with an albumin level greater than 27 g/l did not: mean overload 6.77 l (range, 3.34-11.48 l), %FO 7.96% (range, 3.67-13.93%); P = 0.0001.

CONCLUSIONS

Patients receiving epidurals with initial, postoperative, plasma albumin levels below 27 g/l are at increased risk of significant fluid overload. Earlier instigation of vasopressor therapy in this subgroup of patients may help prevent this.

Relevance of albumin in modern critical care medicine

The relevance of albumin administration in the critical care setting remains controversial. We know that albumin has numerous important physiological effects and many potentially beneficial effects in critical illness. We also know that hypoalbuminaemia is common in critically ill patients and is associated with worse outcomes. And we know that routine administration of albumin for fluid resuscitation is not warranted. Albumin may be useful in some patients, especially those with hypoalbuminaemia at risk of complications or those with liver insufficiency. Further studies are needed to clarify what precise role albumin has in today's ICU.

Role of platelets on liver regeneration after 90% hepatectomy in mice

BACKGROUND/AIMS

Mortality after 90% partial hepatectomy in mice was associated with severe acute liver failure. Recently, we revealed that platelets have a strong promotional effect on hepatic regeneration. In the present study, we investigated the effect of thrombocytosis on liver regeneration after 90% hepatectomy in mice.

METHODS

For thrombocytosis induction PEG-rHuMGDF was injected 5 days before operation. Hepatectomy, sparing only the caudate lobe, was performed in normal and thrombocytotic BALB/c mice. Survival rate, platelet number, liver weight/body weight ratio, proliferating cell nuclear antigen, serum parameters, signal transduction and overexpressed genes were examined.

RESULTS

Platelet number was significantly higher in thrombocytotic group. All mice in normal group died within 30 h after hepatectomy. Survival rate in thrombocytotic group was 6/11 at 30 h and 3/11 one week after hepatectomy. Activation of Akt and STAT3 signaling pathways in thrombocytotic group was observed earlier and recognized to be stronger compared to normal group. Cell cycle, signaling pathways, metabolism and transport genes were significantly overexpressed in thrombocytotic group up to 24h after hepatectomy.

CONCLUSIONS

Under the thrombocytotic condition, liver regeneration occurred even in 90% hepatectomized mice. Platelets contribute to cell cycle progression and metabolic pathways in addition to preventing acute liver failure.

Pre-operative hypoalbuminemia is a major risk factor for postoperative complications following rectal cancer surgery

AIM: To determine the relationship between pre-operative hypoalbuminemia and the development of complications following rectal cancer surgery, as well as postoperative bowel function and hospital stay.

METHODS: The medical records of 244 patients undergoing elective oncological resection for rectal adenocarcinoma at Siriraj Hospital during 2003 and 2006 were reviewed. The patients had pre-operative serum albumin assessment. Albumin less than 35 g/L was recognized as hypoalbuminemia. Postoperative outcomes, including mortality, complications, time to first bowel movement, time to first defecation, time to resumption of normal diet and length of hospital stay, were analyzed.

RESULTS: The patients were 139 males (57%) and 105 females (43%) with mean age of 62 years. Fifty-six patients (23%) had hypoalbuminemia. Hypoalbuminemic patients had a significantly larger tumor size and lower body mass index compared with non-hypoalbuminemic patients (5.5 vs 4.3 cm; P < 0.001 and 21.9 vs 23.2 kg/m²; P = 0.02, respectively). Thirty day postoperative mortality was 1.2%. Overall complication rate was 25%. Hypoalbuminemic patients had a significantly higher rate of postoperative complications (37.5% vs 21.3%; P = 0.014). In univariate analysis, hypoalbuminemia and ASA status were two risk factors for postoperative complications. In multivariate analysis, hypoalbuminemia was the only significant risk factor (odds ratio 2.22, 95% CI 1.17-4.23; P < 0.015). Hospitalization in hypoalbuminemic patients was significantly longer than that in non-hypoalbuminemic patients (13 vs 10 d, P = 0.034), but the parameters of postoperative bowel function were not significantly different between the two groups.

CONCLUSION: Pre-operative hypoalbuminemia is an independent risk factor for postoperative complications following rectal cancer surgery.