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Hoffman JT, Heuvelings DJI, van Zutphen T, Stassen LPS, Kruijff S, Boerma EC, Bouvy ND, Heeman WT, Al-Taher M. Real-time quantification of laser speckle contrast imaging during intestinal laparoscopic surgery: successful demonstration in a porcine intestinal ischemia model. Surg Endosc 2024:10.1007/s00464-024-11076-3. [PMID: 39020119 DOI: 10.1007/s00464-024-11076-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/08/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Anastomotic leakage (AL) is a dreaded complication following colorectal cancer surgery, impacting patient outcome and leads to increasing healthcare consumption as well as economic burden. Bowel perfusion is a significant modifiable factor for anastomotic healing and thus crucial for reducing AL. AIMS The study aimed to calculate a cut-off value for quantified laser speckle perfusion units (LSPUs) in order to differentiate between ischemic and well-perfused tissue and to assess inter-observer reliability. METHODS LSCI was performed using a porcine ischemic small bowel loop model with the PerfusiX-Imaging® system. An ischemic area, a well-perfused area, and watershed areas, were selected based on the LSCI colormap. Subsequently, local capillary lactate (LCL) levels were measured. A logarithmic curve estimation tested the correlation between LSPU and LCL levels. A cut-off value for LSPU and lactate was calculated, based on anatomically ischemic and well-perfused tissue. Inter-observer variability analysis was performed with 10 observers. RESULTS Directly after ligation of the mesenteric arteries, differences in LSPU values between ischemic and well-perfused tissue were significant (p < 0.001) and increased significantly throughout all following measurements. LCL levels were significantly different (p < 0.001) at both 60 and 120 min. Logarithmic curve estimation showed an R2 value of 0.56 between LSPU and LCL values. A LSPU cut-off value was determined at 69, with a sensitivity of 0.94 and specificity of 0.87. A LCL cut-off value of 3.8 mmol/L was found, with a sensitivity and specificity of 0.97 and 1.0, respectively. There was no difference in assessment between experienced and unexperienced observers. Cohen's Kappa values were moderate to good (0.52-0.66). CONCLUSION Real-time quantification of LSPUs may be a feasible intraoperative method to assess tissue perfusion and a cut-off value could be determined with high sensitivity and specificity. Inter-observer variability was moderate to good, irrespective of prior experience with the technique.
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Affiliation(s)
- J Tim Hoffman
- Faculty Campus Fryslân, University of Groningen, Wirdumerdijk 34, 8911 CE, Leeuwarden, The Netherlands.
- University Medical Centre Groningen, Optical Molecular Imaging Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
- LIMIS Development, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
| | - Danique J I Heuvelings
- NUTRIM, Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Tim van Zutphen
- Faculty Campus Fryslân, University of Groningen, Wirdumerdijk 34, 8911 CE, Leeuwarden, The Netherlands
| | - Laurents P S Stassen
- NUTRIM, Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Solnavägen 1, Solna, 171 77, Stockholm, Sweden
| | - E Christiaan Boerma
- Faculty Campus Fryslân, University of Groningen, Wirdumerdijk 34, 8911 CE, Leeuwarden, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Wido T Heeman
- University Medical Centre Groningen, Optical Molecular Imaging Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
- LIMIS Development, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Mahdi Al-Taher
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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Gregersen JS, Bazancir LA, Johansson PI, Sørensen H, Achiam MP, Olsen AA. Major open abdominal surgery is associated with increased levels of endothelial damage and interleukin-6. Microvasc Res 2023; 148:104543. [PMID: 37156371 DOI: 10.1016/j.mvr.2023.104543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/19/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To examine changes in biomarkers of endothelial glycocalyx shedding, endothelial damage, and surgical stress following major open abdominal surgery and the correlation to postoperative morbidity. INTRODUCTION Major abdominal surgery is associated with high levels of postoperative morbidity. Two possible reasons are the surgical stress response and the impairment of the glycocalyx and endothelial cells. Further, the degree of these responses may correlate with postoperative morbidity and complications. METHODS A secondary data analysis of prospectively collected data from two cohorts of patients undergoing open liver surgery, gastrectomy, esophagectomy, or Whipple procedure (n = 112). Hemodynamics and blood samples were collected at predefined timestamps and analyzed for biomarkers of glycocalyx shedding (Syndecan-1), endothelial activation (sVEGFR1), endothelial damage (sThrombomodulin (sTM)), and surgical stress (IL6). RESULTS Major abdominal surgery led to increased levels of IL6 (0 to 85 pg/mL), Syndecan-1 (17.2 to 46.4 ng/mL), and sVEGFR1 (382.8 to 526.5 pg/mL), peaking at the end of the surgery. In contrast, sTM, did not increase during surgery, but increased significantly following surgery (5.9 to 6.9 ng/mL), peaking at 18 h following the end of surgery. Patients characterized with high postoperative morbidity had higher levels of IL6 (132 vs. 78 pg/mL, p = 0.007) and sVEGFR1 (563.1 vs. 509.4 pg/mL, p = 0.045) at the end of the surgery, and of sTM (8.2 vs. 6.4 ng/mL, p = 0.038) 18 h following surgery. CONCLUSION Major abdominal surgery leads to significantly increased levels of biomarkers of endothelial glycocalyx shedding, endothelial damage, and surgical stress, with the highest levels seen in patients developing high postoperative morbidity.
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Affiliation(s)
| | - Laser Arif Bazancir
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Pär Ingemar Johansson
- Department of Clinical Immunology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Henrik Sørensen
- Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - August Adelsten Olsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Denmark
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Strandby RB, Secher NH, Ambrus R, Gøtze JP, Henriksen A, Kitchen CC, Achiam MP, Svendsen LB. Mid‐regional plasma pro‐atrial natriuretic peptide and stroke volume responsiveness for detecting deviations in central blood volume following major abdominal surgery. Acta Anaesthesiol Scand 2022; 66:1061-1069. [PMID: 36069352 PMCID: PMC9543860 DOI: 10.1111/aas.14126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/10/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022]
Abstract
Background A reduced central blood volume is reflected by a decrease in mid‐regional plasma pro‐atrial natriuretic peptide (MR‐proANP), a stable precursor of ANP, and a volume deficit may also be assessed by the stroke volume (SV) response to head‐down tilt (HDT). We determined plasma MR‐proANP during major abdominal procedures and evaluated whether the patients were volume responsive by the end of the surgery, taking the fluid balance and the crystalloid/colloid ratio into account. Methods Patients undergoing pancreatic (n = 25), liver (n = 25), or gastroesophageal (n = 38) surgery were included prospectively. Plasma MR‐proANP was determined before and after surgery, and the fluid response was assessed by the SV response to 10° HDT after the procedure. The fluid strategy was based mainly on lactated Ringer's solution for gastroesophageal procedures, while for pancreas and liver surgery, more human albumin 5% was administered. Results Plasma MR‐proANP decreased for patients undergoing gastroesophageal surgery (−9% [95% CI −3.2 to −15.3], p = .004) and 10 patients were fluid responsive by the end of surgery (∆SV > 10% during HDT) with an administered crystalloid/colloid ratio of 3.3 (fluid balance +1389 ± 452 ml). Furthermore, plasma MR‐proANP and fluid balance were correlated (r = .352 [95% CI 0.031–0.674], p < .001). In contrast, plasma MR‐proANP did not change significantly during pancreatic and liver surgery during which the crystalloid/colloid ratio was 1.0 (fluid balance +385 ± 478 ml) and 1.9 (fluid balance +513 ± 381 ml), respectively. For these patients, there was no correlation between plasma MR‐proANP and fluid balance, and no patient was fluid responsive. Conclusion Plasma MR‐proANP was reduced in fluid responsive patients by the end of surgery for the patients for whom the fluid strategy was based on more lactated Ringer's solution than human albumin 5%.
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Affiliation(s)
- Rune B. Strandby
- Department of Surgery and Transplantation, Rigshospitalet Institute for Clinical Medicine, University of Copenhagen, Inge Lehmanns Vej 7 Copenhagen Denmark
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
| | - Rikard Ambrus
- Department of Surgery and Transplantation, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
| | - Jens P. Gøtze
- Department of Clinical Biochemistry, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
| | - Amalie Henriksen
- Department of Surgery and Transplantation, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
| | - Carl C. Kitchen
- Department of Anesthesia, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
| | - Michael P. Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
| | - Lars B. Svendsen
- Department of Surgery and Transplantation, Rigshospitalet, Institute for Clinical Medicine University of Copenhagen Denmark
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Evaluation of the systemic inflammatory response, endothelial cell dysfunction, and postoperative morbidity in patients, receiving perioperative corticosteroid, developing severe mesenteric traction syndrome — an exploratory study. Langenbecks Arch Surg 2022; 407:2095-2103. [DOI: 10.1007/s00423-022-02507-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/01/2022] [Indexed: 01/01/2023]
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Severe mesenteric traction syndrome is associated with increased systemic inflammatory response, endothelial dysfunction, and major postoperative morbidity. Langenbecks Arch Surg 2021; 406:2457-2467. [PMID: 33686490 DOI: 10.1007/s00423-021-02111-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/01/2021] [Indexed: 01/01/2023]
Abstract
This study aimed to determine if mesenteric traction syndrome (MTS) triggers increased systemic inflammation and endothelial cell dysfunction. Patients developing severe MTS had pronounced early IL6 elevations followed by endothelial cell damage. Furthermore, these processes were associated with increased postoperative morbidity. OBJECTIVE To determine whether mesenteric traction syndrome (MTS) leads to increased systemic inflammation and dysfunction of the glycocalyx and endothelial cell and whether this correlates with the degree of postoperative morbidity. INTRODUCTION Severe MTS is associated with increased postoperative morbidity following major gastrointestinal surgery, but the pathophysiological mechanism has not been previously explored. Systemic inflammatory response and impaired glycocalyx and endothelial cells may be responsible for the development of symptoms. METHODS The study analyzed prospectively collected data from two cohorts (n = 67). The severity of the MTS response was graded intraoperatively and blood samples for PGI2, catecholamines, IL6, and endothelial biomarkers obtained at predefined time points. RESULTS Patients undergoing either esophagectomy (n = 45) or gastrectomy (n = 22) were included. Surgery led to significantly increased plasma concentrations of all biomarkers. Yet, patients who developed severe MTS had higher baseline epinephrine levels (p < 0.05) and higher levels of PGI2 (p < 0.05), Syndecan-1 (p < 0.001), and sVEGFR1 (p < 0.001). Peak values of IL6, Syndecan-1, sVEGFR1, and sTM all correlated to peak PGI2. Lastly, patients with high postoperative morbidity had higher baseline epinephrine (p = 0.009) and developed higher plasma IL6 (p = 0.007) and sTM (p = 0.022). CONCLUSION The development of severe MTS during upper gastrointestinal surgery is associated with preoperative elevated plasma epinephrine and further a more pronounced proinflammatory response and damage to the vascular endothelium. The increased postoperative morbidity seen in patients with severe MTS may thus, in part, be explained by an inherent susceptibility towards an inappropriate secretion of PGI2, which leads to an increased surgical stress response and endothelial damage. These findings must be confirmed in a new prospective cohort.
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Strandby RB, Ambrus R, Ring LL, Nerup N, Secher NH, Goetze JP, Achiam MP, Svendsen LB. Hypotension Associated with MTS is Aggravated by Early Activation of TEA During Open Esophagectomy. Local Reg Anesth 2021; 14:33-42. [PMID: 33688249 PMCID: PMC7936689 DOI: 10.2147/lra.s294556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Objective A mesenteric traction syndrome (MTS) is elicited by prostacyclin (PGI2)-induced vasodilation and identified by facial flushing, tachycardia, and hypotension during abdominal surgery. We evaluated whether thoracic epidural anesthesia (TEA) influences the incidence of MTS. Design Randomized, blinded controlled trial. Setting Single-center university hospital. Participants Fifty patients undergoing open esophagectomy. Interventions Patients were randomized to either early (EA, after induction of general anesthesia) or late activation of TEA (LA, after re-established gastric continuity). Plasma 6-keto-PGF1α, a stable metabolite of PGI2 and interleukine-6 (IL6) were measured in plasma during surgery along with hemodynamic variables and MTS graded according to facial flushing together with plasma C-reactive protein on the third post-operative day. Results Forty-five patients met the inclusion criteria. Development of MTS tended to be more prevalent with EA (n=13/25 [52%]) than with LA TEA (n=5/20 [25%], p=0.08). For patients who developed MTS, there was a transient increase in plasma 6-keto-PGF1α by 15 min of surgery and plasma IL6 (p<0.001) as C-reactive protein (P<0.009) increased. EA TEA influenced the amount of phenylephrine needed to maintain mean arterial pressure >60 mmHg in patients who developed MTS (0.16 [0.016–0.019] mg/min vs MTS and LA TEA 0.000 [0.000–0.005] mg/min, p<0.001). Conclusion The incidence of MTS is not prevented by TEA in patients undergoing open esophagectomy. On the contrary, the risk of hypotension is increased in patients exposed to TEA during surgery, and the results suggest that it is advantageous to delay activation of TEA. Also, MTS seems to be associated with a systemic inflammatory response, maybe explaining the aggravated post-operative outcome.
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Affiliation(s)
- Rune B Strandby
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rikard Ambrus
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Linea L Ring
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Secher
- Department of Anesthesia, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars B Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Chen Z, Shao DH, Ma XD, Mao ZM. Dexmedetomidine aggravates hypotension following mesenteric traction during total gastrectomy: a randomized controlled trial. Ann Saudi Med 2020; 40:183-190. [PMID: 32493029 PMCID: PMC7270615 DOI: 10.5144/0256-4947.2020.183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/13/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mesenteric traction syndrome (MTS), which is characterized by arterial hypotension and tachycardia following mesenteric traction (MT), frequently occurs during abdominal surgery. Dexmedetomidine, commonly used in general anesthesia during major surgery, has a sympatholytic effect and attenuates the compensatory response to hypotension. OBJECTIVE Assess the effect of dexmedetomidine on hypotension following mesenteric traction. DESIGN Prospective, randomized, controlled clinical trial. SETTING Department of Anesthesiology, Zhenjiang First People's Hospital in China. PATIENTS AND METHODS Patients were randomly divided into three groups. Dexmedetomidine, 0.5 or 1.0 µg/kg, was intravenously administered over 15 minutes before skin incision followed by a maintenance rate of 0.5 µg/kg/h in groups D1 and D2, respectively; saline was administered in group C. MAIN OUTCOME MEASURE(S) The duration of hypotension, heart rate and plasma norepinephrine level in patients with MTS were recorded within 60 minutes following MT. SAMPLE SIZE 75 patients. RESULTS The duration of hypotension in the MTS patients in group D1 and D2 was significantly longer than that in groups C (D1 vs. C, P<.05; D2 vs. C, P<.01). Significantly more phenylephrine was required to treat hypotension in group D1 and D2 than was required for patients in group C (P<.05). The increase in heart rate during the first 15 minutes of MT in group D2 was significantly attenuated compared to that in group C (P<.0083). The increases in norepinephrine levels during the first 15 minutes of MT in group C were significantly higher than those in groups D1 and D2 (P<.0167). CONCLUSION Adjunctive dexmedetomidine in general anesthesia aggravates hypotension during MTS in open total gastrectomy. LIMITATIONS Postoperative complications were not evaluated. CONFLICT OF INTEREST None.
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Affiliation(s)
- Zheng Chen
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
| | - Dong-Hua Shao
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
| | - Xiao-Dong Ma
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
| | - Zu-Min Mao
- From the Department of Anesthesiology, Zhenjiang First People's Hospital, Zhenjiang, Jiangsu, China
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Development of a severe mesenteric traction syndrome during major abdominal surgery is associated with increased postoperative morbidity: Secondary data analysis on prospective cohorts. Langenbecks Arch Surg 2019; 405:81-90. [PMID: 31820096 DOI: 10.1007/s00423-019-01847-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/28/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE MTS is elicited during open abdominal surgery and is characterized by facial flushing, hypotension, and tachycardia in response to the release of prostacyclin (PGI2) to plasma. MTS seems to affect postoperative morbidity, but data from larger cohorts are lacking. We aimed to determine the impact of severe mesenteric traction syndrome (MTS) on postoperative morbidity in patients undergoing open upper gastrointestinal surgery. METHODS The study was a secondary analysis of data from three cohorts (n = 137). The patients were graded for severity of MTS intraoperatively, and hemodynamic variables and blood samples for plasma 6-keto-PGF1α, a stable metabolite of PGI2, were obtained at defined time points. Postoperative morbidity was evaluated by the comprehensive complication index (CCI) and the Dindo-Clavien classification (DC). RESULTS Patients undergoing either esophagectomy (n = 70), gastrectomy (n = 22), liver- (n = 23), or pancreatic resection (n = 22) were included. Severe MTS was significantly associated with increased postoperative morbidity, i.e., CCI ≥ 26.2 (OR 3.06 [95% CI 1.1-6.6]; p = 0.03) and risk of severe complications, i.e., DC ≥3b (OR 3.1 [95% CI 1.2-8.2]; p = 0.023). Furthermore, patients with severe MTS had increased length of stay (OR 10.1 [95% CI 1.9-54.3]; p = 0.007) and were more likely to be admitted to the intensive care unit (OR = 7.3 [95% CI 1.3-41.9]; p = 0.027), but there was no difference in 1-year mortality. CONCLUSION Occurrence of severe MTS during upper gastrointestinal surgery is associated with increased postoperative morbidity as indicated by an increased rate of severe complications, length of stay, and admission to the ICU. It remains to be determined whether inhibition of MTS enhances postoperative recovery.
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