Predictive value of preoperative serum C-reactive protein for recurrence after definitive surgical repair of enterocutaneous fistula

Elevated preoperative suPAR is a strong and independent risk marker for postoperative complications in patients undergoing major noncardiac surgery (SPARSE)

BACKGROUND

Patients undergoing major surgery are often at risk of developing postoperative complications. We investigated whether a preoperative marker of chronic inflammation, soluble urokinase plasminogen activator receptor, can aid in identifying patients at high risk for postoperative complications, morbidity, and mortality.

METHODS

In this prospective observational study (ClinicalTrials.gov identifier: NCT03851965), EDTA blood was collected from consecutive adult White patients scheduled for major noncardiac surgery with expected duration ≥2 hours under general anesthesia. Inclusion criteria were age ≥18 years and American Society of Anesthesiologists physical status I to IV. Plasma soluble urokinase plasminogen activator receptor levels were determined using the suPARnostic quick triage lateral flow assay. The primary endpoint was postoperative complications defined as presence of any complication and/or admission to intensive care unit and/or mortality within the first 90 postoperative days.

RESULTS

Preoperative soluble urokinase plasminogen activator receptor had an odds ratio of 1.50 (95% confidence interval: 1.24-1.82) for every ng/mL increase. When including age, sex, American Society of Anesthesiologists score, C-reactive protein, and grouped soluble urokinase plasminogen activator receptor in multivariate analysis, patients with soluble urokinase plasminogen activator receptor between 5.5 and 10 ng/mL had an odds ratio of 11.2 (confidence interval: 3.1-40.8) and patients with soluble urokinase plasminogen activator receptor >10 ng/mL had an odds ratio of 19.9 (95% confidence interval: 4.3-92.9) compared to patients with soluble urokinase plasminogen activator receptor ≤5.5 ng/mL, respectively. Receiver operating characteristic analysis of soluble urokinase plasminogen activator receptor showed an area under the curve of 0.82 (confidence interval: 0.72-0.91). Receiver operating characteristic analysis combining age, sex, C-reactive protein levels, and American Society of Anesthesiologists score and had an area under the curve of 0.71 (95% confidence interval: 0.61-0.82). Adding soluble urokinase plasminogen activator receptor to this model increased the area under the curve to 0.83 (95% confidence interval: 0.74-0.92) (P = .033).

CONCLUSION

Preoperative soluble urokinase plasminogen activator receptor provided strong and independent predictive value on postoperative complications in White patients undergoing major noncardiac surgery.

The Importance of Abdominal Wall Closure After Definitive Surgery for Enterocutaneous Fistula

INTRODUCTION

The coexistence of an enterocutaneous fistula (ECF) with large abdominal wall defects represent one of the most demanding situations seen by a surgeon. Simultaneous treatment of ECF closure with abdominal wall defect closure has been widely debated. Our objective was to determine if the type of abdominal wall closure was associated with fistula recurrence after definitive surgery for ECF.

MATERIALS AND METHODS

Consecutive patients submitted to fistula resection with primary anastomosis for ECF closure. Among several variables, total abdominal wall closure (primary independent variable) was assessed as a factor related to the recurrence of the ECF (dependent variable). Univariate and multivariate analyses were performed.

RESULTS

One-hundred and fourteen patients were included. Fistula recurred in 39 patients (34%). Total abdominal wall closure was done in 37 patients (32%). ECF recurred in 16% (6 of 37 patients) when abdominal wall closure was performed, compared to 43% (33 of 77 patients) when this was not (p < 0.02). After multivariate analyses, abdominal wall closure was found as a protective factor against recurrence (p < 0.02). Patients with total abdominal wall closure had one-fourth of risk for recurrence compared to patients without it. Other factors associated to recurrence of ECF were multiple fistulas (p < 0.05), intraoperative blood loss >325 mL (p < 0.05) and preoperative C-reactive protein >0.5 mg/dL (p < 0.01).

CONCLUSION

Our results suggest that total abdominal wall closure is a protective factor against fistula recurrence after definitive surgery for ECF.

Effect of Preoperative Administration of Oral Arginine and Glutamine in Patients with Enterocutaneous Fistula Submitted to Definitive Surgery: a Prospective Randomized Trial

BACKGROUND

The use of glutamine and arginine has shown several advantages in postoperative outcomes in patients after gastrointestinal surgery. We determined the effects of its use in patients with enterocutaneous fistula after operative treatment.

PATIENTS AND METHODS

Forty patients with enterocutaneous fistula were randomly assigned to one of two groups. The control group received the standard medical care while the patients of the experimental group were supplemented with enteral administration of 4.5 g of arginine and 10 g of glutamine per day for 7 days prior to the surgery. The primary outcome variable was the recurrence of the fistula and the secondary outcomes were preoperative and postoperative serum concentrations of interleukin 6 and C-reactive protein and postoperative infectious complications.

RESULTS

Twenty patients were assigned to each group. The fistula recurred in two patients (10%) of the experimental group and in nine patients (45%) of the control group (P < 0.001). We found a total of 13 infectious complications in six patients of the control group (all with fistula recurrence) and none in the experimental group. Mean preoperative serum concentrations of interleukin 6 and C-reactive protein were lower in patients from the experimental group. In addition, these levels were lower in patients who had recurrence if compared to patients that did not recur.

CONCLUSION

Preoperative administration of oral arginine and glutamine could be valuable in the postoperative recovery of patients with enterocutaneous fistulas submitted to definitive surgery.

Surgical Repair of Small Bowel Fistulas: Risk Factors of Complications or Fistula Recurrence

Background

Definitive surgical repair of persistent fistulas of the small intestine remains a surgical challenge with a high rate of re-fistulation and mortality. The aim of this study was to evaluate the type and incidence of complications after definitive surgical repair, and to identify factors predictive of severe postoperative complications or fistula recurrence.

Material/Methods

This was a retrospective study of 42 patients who underwent elective surgical repair of a persistent fistula of the small intestine. The analysis included preoperative and intraoperative parameters.

Results

The healing rate after definitive surgery was 71.4%. Postoperative complications developed in 88.1% of patients. The mortality rate was 7.2%. Fistula recurrence was recognized in 21.4% of cases. Overall, 93 complications occurred in 37 patients. The most common complications were septic (48.0%). Hemorrhagic and digestive tract-related complications accounted for 19.0% and 15.0% of all complications, respectively. Severe complications (Clavien-Dindo grade III–V) made up 28.0% of all complications. In univariate analysis, multiple fistulas (p=0.03), higher C-reactive protein level (p=0.01), and longer time interval from admission to definitive surgery (p=0.01) were associated with an increased risk of severe complications or fistula recurrence. In multivariate analysis, only multiple fistulas were an independent risk factor for severe complications or fistula recurrence (OR=8.2, p=0.04).

Conclusions

Fistula complexity determines the risk of severe postoperative complications or fistula recurrence after definitive surgical repair of the persistent small intestine fistulas. Inflammatory parameters should be normalized before definitive surgery.

A Systematic Review and Meta-analysis of Timing and Outcome of Intestinal Failure Surgery in Patients with Enteric Fistula

Background

The timing of intestinal failure (IF) surgery has changed. Most specialized centers now recommend postponing reconstructive surgery for enteric fistula and emphasize that abdominal sepsis has to be resolved and the patient’s condition improved. Our aim was to study the outcome of postponed surgery, to identify risk factors for recurrence and mortality, and to define more precisely the optimal timing of reconstructive surgery.

Methods

PubMed, Embase, and the Cochrane Library were systematically reviewed on the outcomes of reconstructive IF surgery (fistula recurrence, mortality, morbidity, hernia recurrence, total closure, enteral autonomy). If appropriate, meta-analyses were performed. Optimal timing was explored, and risk factors for recurrence and mortality were identified.

Results

Fifteen studies were included. The weighted pooled fistula recurrence rate was 19% (95% CI 15–24). Lower recurrence rates were found in studies with a longer median time and/or, at the minimum of the range, a longer time interval to surgery. Overall mortality was 3% (95% CI 2–5). Total fistula closure rates ranged from 80 to 97%. Enteral autonomy after reconstructive surgery, mentioned in four studies, varied between 79 and 100%.

Conclusions

Postponed IF surgery for enteric fistula is associated with lower recurrence. Due to the wide range of time to definitive surgery within each study, optimal timing of surgery could not be defined from published data.

Results after Definitive Surgical Treatment in Patients with Enteroatmospheric Fistula

As enteroatmospheric fistulas (EAF) lack healthy overlying tissue, spontaneous healing is very unlikely. Our aim was to identify risk factors for recurrence and mortality after definitive surgical treatment for EAF. Sixty-two consecutive patients with a diagnosis of EAF were submitted to definitive surgical repair (fistula resection and primary anastomosis) during a 6-year period. Several patient, disease, and operative variables were assessed as risk factors associated to our endpoints: recurrence and mortality. All patients were followed-up until hospital discharge or death. Univariate and multivariate analysis were performed. There were 24 females and 38 males with a median age of 53 years (interquartile ranges 43–63). EAF recurred in 23 patients. Univariate analysis identified several risk factors for recurrence which included performing more than one anastomosis (20 vs 52%, P = 0.013), failure of achieving total abdominal closure (16 vs 47%, P = 0.025), intraoperative hemorrhage >400 cc (28 vs 65%, P = 0.007), presence of multiple fistulas (25 vs 61%, P = 0.008), and preoperative C-reactive protein >0.5 mg/dL (54 vs 82%, P = 0.029). The latter two remained significant after multivariate analysis. Final EAF closure was attained in 47 patients (76%) and 8 more (13%) had a low-output (<50 mL/day) enterocutaneous fistula. Timing of surgery was not related to fistula recurrence. Eight patients died (13%), and fistula recurrence was the only risk factor found related to mortality both through univariate (26 vs 5%, P = 0.043) and after multivariate analysis. EAF management represents a rather challenging problem. Timing for surgical treatment is controversial and is based mostly on patient status and surgeon's criteria. Recurrence is associated to EAF characteristics and an inflammatory state; it was also the only factor associated to mortality.

Values of procalcitonin and C-reactive proteins in the diagnosis and treatment of chronic obstructive pulmonary disease having concomitant bacterial infection

Objective:

To observe the changes in the levels of C-reactive protein (CRP) and procalcitonin (PCT) in serum of patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and to compare with the values of CRP in combination with PCT in the diagnosis and treatment of infective exacerbation of COPD.

Methods:

One hundred and sixty-four patients who developed acute exacerbation of COPD and admitted to the Binzhou People’s Hospital from March 2014 to December 2015 were selected. They were divided into an infection group (N=98) and a non-infection group (N=66) according to bacterial culture results of sputum and lung computer tomography (CT) examination results. Moreover, 50 healthy people were selected as a normal control group. The levels of PCT and CRP of the three groups were determined respectively; patients in the infection group and non-infection group were determined again after administration of antibacterial drugs for a period of time. The results were all recorded.

Results:

The levels of PCT and CRP of the infection group were significantly higher than those of the non-infection group and the normal control group before treatment, and the difference had statistical significance (P<0.05). The levels of PCT and CRP were (1.97±0.13) μg/L and (7.34±2.66) mg/L respectively in the infection group after treatment, which was much lower than the levels before treatment (P<0.05). The level of PCT of the infection group was remarkably higher than that of the non-infection group after treatment (P<0.05), but the difference of CRP level between the infection group and non-infection group had no statistical significance (P>0.05). The specificity and sensitivity of diagnosing COPD in combination with bacterial infection with PCT or CRP were lower than those of PCT in combination with CRP.

Conclusion:

Levels of CRP in combination with PCT is a reliable index for determining the existence of bacterial infection, which is of great clinical guidance significance to the treatment and prognosis assessment of AECOPD patients.

Effect of Oral ω3-Polyunsaturated Fatty Acids as a Complement Management to Control Fistula Output and Inflammation in Patients With Digestive Fistula

BACKGROUND

The presence of digestive fistula involves chronic inflammation and fibrosis. It has been reported that ω3-polyunsaturated fatty acids stimulate the resolution of inflammation.

AIM

Determine if the administration of oral ω3 reduces fistula output and the time required for fistula closure.

METHODS

Forty-nine patients with postoperative fistula were randomly divided in two groups: 26 received conventional treatment and 23 received the conventional treatment supplemented with ω3 (540 mg eicosapentaenoic acid and 360 mg docosahexaenoic acid) for 35 days. Patients were monitored daily for fistula output and spontaneous closure. Additionally, serum pro-inflammatory cytokines and C-reactive protein were quantified in four patients with conventional and in seven patients with ω3 treatment.

RESULTS

Patients with ω3 had significantly decreased fistula output from days 2 to 27, compared to control (p < 0.05). Spontaneous fistula closure was achieved in 15 patients (65%) in the ω3 group and in 14 (54%) in the control group. ω3-polyunsaturated fatty intake also decreased the serum concentrations of interleukin-6 and C-reactive protein (p < 0.05).

CONCLUSIONS

Our results suggest that ω3 supplementation to conventional medical treatment decreases fistula output and reduces inflammation (interleukin-6 and C-reactive protein), and these effects may increase the efficiency of conventional medical treatment.