Postoperative sepsis in cancer patients undergoing major elective digestive surgery is associated with increased long-term mortality

Cancer and sepsis: future challenges for long-term outcome

PURPOSE OF REVIEW

The purpose of this review is to investigate the long-term outcomes of cancer patients who experience sepsis or septic shock.

RECENT FINDINGS

Sepsis is a frequent cause of ICU admission in cancer patients, accounting for approximately 15% of such cases. Short-term mortality rates among these patients vary widely across studies, but they are consistently found to be slightly higher than those of noncancer patients. However, there is a lack of evidence regarding the long-term outcomes of cancer patients who have experienced sepsis or septic shock. The few available studies have reported relatively high mortality rates, reaching around 80% in a few cohort studies. Although several observational studies have noted a decrease in 1-year mortality rates over time, observational data also suggest that sepsis may increase the risk of cancer in the long run.

SUMMARY

As cancer is becoming a chronic disease, there is an urgent need for studies on the quality of life of cancer patients who have experienced sepsis. The relationship between sepsis and cancer extends beyond its impact on the progression of cancer, as sepsis might also contribute to the development of cancer.

Association of Preoperative Immune Checkpoint Inhibitor Therapy With Cardiopulmonary Instability and Organ Injury After High-Risk Surgery

OBJECTIVES

To assess the relationship between prior exposure to immune checkpoint inhibitors (ICIs) and the risk of postoperative complications in cancer patients.

DESIGN

Single-center retrospective cohort study.

INTERVENTIONS

The main exposure was treatment with an FDA-approved ICI within 6 months before surgery.

MEASUREMENTS AND MAIN RESULTS

Exposure to ICIs and covariates was determined from the electronic health record. The primary outcome was a composite of postoperative complications, including prolonged pressor or oxygen dependence, kidney injury, or myocardial injury. Secondary outcomes included each subcomponent of the primary outcome. Of 7674 subjects with cancer admitted to the ICU after surgery, 247 were exposed to one or more ICIs in the 6 months before surgery. After propensity score matching, 197 ICI-exposed subjects were matched to 777 nonexposed. The composite outcome occurred in 70 of 197 (35.5%) ICI-exposed subjects and 251 of 777 (32.3%) nonexposed. There was no difference between exposed and nonexposed groups in the primary composite outcome (odds ratio [OR], 1.12; 95% CI, 0.80-1.58) by conditional logistic regression. Risk of the secondary outcome of prolonged pressor dependence was significantly higher in ICI-exposed subjects (OR, 1.64; 95% CI, 1.01-2.67). Risks of oxygen dependence (OR, 1.13; 95% CI, 0.75-1.73), kidney injury (OR, 1.15; 95% CI, 0.77-1.71), and myocardial injury (OR, 1.76; 95% CI, 1.00-3.10) were not significantly different. There was no difference between groups in the time to hospital discharge alive (p = 0.62).

CONCLUSIONS

Exposure to ICIs within 6 months before high-risk surgery was not associated with the composite outcome of cardiopulmonary instability or organ injury in patients with cancer. The potential for an association with the secondary outcomes of cardiac instability and injury is worthy of future study.

Clinical features and outcomes of patients with pancreatic cancer requiring unplanned medical ICU admission: A retrospective multicenter study

BACKGROUND

We sought to describe the reasons for intensive care unit (ICU) admission and outcomes of patients with pancreatic cancer requiring unplanned medical ICU admission.

PATIENTS AND METHODS

Retrospective cohort study in five ICUs from 2009 to 2020. All patients with pancreatic cancer admitted to the ICU were included. Patients having undergone recent surgery were excluded (< 4 weeks).

RESULTS

269 patients were included. Tumors were mainly adenocarcinoma (90%). Main reason for admission was sepsis/septic shock (32%) with a biliary tract infection in 44 (51%) patients. Second reason for admission was gastrointestinal bleeding (28%). ICU and 3-month mortality rates were 26% and 59% respectively. Performance status 3-4 (odds ratio OR 3.58), disease status (responsive/stable -ref-, newly diagnosed OR 3.25, progressive OR 5.99), mechanical ventilation (OR 8.03), vasopressors (OR 4.19), SAPS 2 (OR 1.69) and pH (OR 0.02) were independently associated with ICU mortality. Performance status 3-4 (Hazard ratio HR 1.96) and disease status (responsive/stable -ref-, newly diagnosed HR 2.67, progressive HR 4.14) were associated with 3-month mortality.

CONCLUSION

Reasons for ICU admissions of pancreatic cancer patients differ from those observed in other solid cancer. Short- and medium-term mortality are strongly influenced by performance status and disease status at ICU admission.

Splenectomy as Part of Maximal-Effort Cytoreductive Surgery in Advanced Epithelial Ovarian Cancer

INTRODUCTION

A splenectomy is frequently performed during debulking surgery for advanced ovarian cancer. Its impact on perioperative and survival outcomes remains questionable as current evidence is conflicting. In the present study, we sought to determine the factors that affect survival rates in ovarian cancer patients that undergo a splenectomy as part of maximal-effort cytoreduction.

PATIENTS AND METHODS

A retrospective chart review was conducted that included all epithelial ovarian cancer patients that had surgical cytoreduction for advanced epithelial ovarian cancer. Differences among splenectomized and non splenectomized patients were evaluated as well as the impact of known risk factors on survival outcomes of splenectomized patients.

RESULTS

Overall, 245 patients were identified and 223 were included in the present series, of whom 91 had a splenectomy. Recurrence rates as well as death rates were comparable among splenectomized and non-splenectomized patients; however, both the disease-free survival (log-rank = 0.001), as well as the overall survival of splenectomized patients (log-rank = 0.006), was shorter. Thrombotic events as well as rates of pulmonary embolism were comparable. Sepsis was more common among splenectomized patients. The site of splenic metastases did not influence patients' survival. Among splenectomized patients, those offered primary debulking had longer progression-free survival (log-rank = 0.042), although their overall survival did not differ compared to patients submitted to interval debulking. Complete debulking significantly improved the overall survival compared to optimal debulking (log-rank = 0.047). Splenectomized patients that developed sepsis had worse overall survival (log-rank = 0.005).

DISCUSSION

The findings of our study support the feasibility of splenectomy in advanced epithelial ovarian cancer; however, its impact on patients' survival is considerable. Therefore, every effort should be made to avoid splenic injury which will result in unintended splenectomy for non-oncological reasons.

Factors Associated with 1-Year Mortality in Elderly Patients (Age ≥ 80 Years) with Cancer Undergoing Major Abdominal Surgery: A Retrospective Cohort Study

BACKGROUND

The number of elderly patients undergoing major abdominal surgery is increasing, but the factors affecting their postoperative outcomes remain unclear. This study aimed to identify the factors associated with 1-year mortality among elderly patients (age ≥ 80 years) with cancer undergoing major abdominal surgery.

METHODS

This retrospective cohort study was conducted from March 2009 to December 2020. The study enrolled 378 patients 80 years old or older who underwent major abdominal surgery. The main outcome was 1-year mortality, and the factors associated with mortality were analyzed.

RESULTS

Of the 378 patients, 92 died at 1 year (24.3%), whereas the 30-day mortality rate was 4% (n = 15). In the multivariate analysis, the factors independently associated with 1-year mortality were preoperative Eastern Cooperative Oncology Group (ECOG) performance status (PS) score higher than 1 (odds ratio [OR], 3.189; 95% confidence interval [CI], 1.595-6.377; p = 0.001), preoperative weight loss greater than 3 kg (OR, 2.145; 95% CI, 1.044-4.404; p = 0.038), use of an intraoperative vasopressor (OR, 3.090; 95% CI, 1.188-8.042; p = 0.021), and postoperative red blood cell units (OR, 1.212; 95% CI, 1.045-1.405; p = 0.011). Survival was associated with perioperative management according to an enhanced recovery after surgery (ERAS) protocol (OR, 0.370; 95% CI, 0.160-0.854; p = 0.006) and supramesocolic surgery (OR, 0.371; 95% CI, 0.158-0.871; p = 0.023).

CONCLUSION

The study identified several factors associated with an encouraging 1-year mortality rate in this setting. These results highlight the need for identification of suitable targets to optimize pre-, intra-, and postoperative management in order to improve outcomes for this vulnerable population.

Alarming correlation between multidrug-resistant bacteriobilia and morbidity after pancreatic surgery

BACKGROUND

Pancreatic surgery is characterized by high morbidity and mortality. Biliary colonization may affect clinical outcomes in these patients.

AIMS

This study aimed to verify whether bacteriobilia and multidrug resistance (MDR) detected during and after pancreatic surgery may have an impact on post-operative outcomes.

METHODS

Data from patients undergoing pancreatic surgery involving bile duct transection (2016-2022) in two high-volume centers were analyzed in relationship to overall morbidity, major morbidity and mortality after pancreato-duodenectomy (PD) or total pancreatectomy (TP). Simple and multivariable regressions were used.

RESULTS

227 patients submitted to PD (n=129) or TP (n=98) were included. Of them, 133 had preoperative biliary drainage (BD; 56.6%), mostly with the employment of endoscopic stents (91.7%). Bacteriobilia was detected in 111 patients (48.9%), and remarkably, observed in patients with BD (p=0.001). In addition, 25 MDR pathogens were identified (22.5%), with a significant prevalence in patients with BD. Multivariable regression analysis showed BD was strongly related to MDR isolation (odds ratio [OR]: 5.61; p=0.010). MDR isolation was the main factor linked to a higher number of major complications (OR: 2.75; p=0.041), including major infection complications (OR: 2.94; p=0.031).

CONCLUSIONS

Isolation of MDR from biliary swab during PD or TP significantly increases the risk of a worse post-operative outcome. Pre-operative precautions could improve patient safety.

Identifying Effective Biomarkers for Accurate Pancreatic Cancer Prognosis Using Statistical Machine Learning

Pancreatic cancer (PC) has one of the lowest survival rates among all major types of cancer. Consequently, it is one of the leading causes of mortality worldwide. Serum biomarkers historically correlate well with the early prognosis of post-surgical complications of PC. However, attempts to identify an effective biomarker panel for the successful prognosis of PC were almost non-existent in the current literature. The current study investigated the roles of various serum biomarkers including carbohydrate antigen 19-9 (CA19-9), chemokine (C-X-C motif) ligand 8 (CXCL-8), procalcitonin (PCT), and other relevant clinical data for identifying PC progression, classified into sepsis, recurrence, and other post-surgical complications, among PC patients. The most relevant biochemical and clinical markers for PC prognosis were identified using a random-forest-powered feature elimination method. Using this informative biomarker panel, the selected machine-learning (ML) classification models demonstrated highly accurate results for classifying PC patients into three complication groups on independent test data. The superiority of the combined biomarker panel (Max AUC-ROC = 100%) was further established over using CA19-9 features exclusively (Max AUC-ROC = 75%) for the task of classifying PC progression. This novel study demonstrates the effectiveness of the combined biomarker panel in successfully diagnosing PC progression and other relevant complications among Egyptian PC survivors.

Influence of Hemorrhagic Complications of Pancreatoduodenectomy in Patients with Cancer on Short- and Long-Term Mortality

BACKGROUND

With a mortality rate of up to 30%, post-pancreatectomy hemorrhage (PPH) remains a serious complication after pancreatoduodenectomy (PD) for cancer. Little is known about the long-term survival of patients after PPH. This retrospective study aimed to evaluate the impact of PPH on long-term survival after PD.

METHODS

The study included 830 patients (PPH, n = 101; non-PPH, n = 729) from two centers, who underwent PD for oncological indications. PPH was defined as any bleeding event occurring within 90 days after surgery. A flexible parametric survival model was used to determine the evolution of the risk of death over time.

RESULTS

At postoperative day 90, PPH significantly increased the mortality rate (PPH vs. non-PPH: 19.8% vs. 3.7%, p < 0.0001) and severe postoperative complication rate (85.1% vs. 14.1%, p < 0.0001), and decreased median survival (18.6 months vs. 30.1 months, p = 0.0001). PPH was associated with an increased mortality risk until the sixth postoperative month. After this 6-month period, PPH had no more influence on mortality.

CONCLUSIONS

PPH had a negative impact on the short-term overall survival beyond postoperative day 90 and up to six months after PD. However, compared to non-PPH patients, this adverse event had no impact on mortality after a 6-month period.

LATE POSTPANCREATICODUODENECTOMY HEMORRHAGE: INCIDENCE, RISK FACTORS, MANAGEMENT AND OUTCOME

ABSTRACT

Background:Postpancreaticoduodenectomy (PD) hemorrhage (PPH) is a life-threatening complication after PD. The main objective of this study was to evaluate incidence and factors associated with late PPH as well as the management strategy and outcomes. Methods: Between May 2017 and March 2020, clinical data from 192 patients undergoing PD were collected prospectively in the CHIRPAN Database (NCT02871336) and retrospectively analyzed. In our institution, all patients scheduled for a PD are routinely admitted for monitoring and management in intensive/intermediate care unit (ICU/IMC). Results: The incidence of late PPH was 17% (32 of 192), whereas the 90-day mortality rate of late PPH was 19% (6 of 32). Late PPH was associated with 90-day mortality (P = 0.001). Using multivariate analysis, independent risk factors for late PPH were postoperative sepsis (P = 0.036), and on day 3, creatinine (P = 0.025), drain fluid amylase concentration (P = 0.023), lipase concentration (P < 0.001), and C-reactive protein (CRP) concentration (P < 0.001). We developed two predictive scores for PPH occurrence, the PANCRHEMO scores. Score 1 was associated with 68.8% sensitivity, 85.6% specificity, 48.8% predictive positive value, 93.2% negative predictive value, and an area under the receiver operating characteristic curves of 0.841. Score 2 was associated with 81.2% sensitivity, 76.9% specificity, 41.3% predictive positive value, 95.3% negative predictive value, and an area under the receiver operating characteristic curve of 0.859. Conclusions: Routine ICU/IMC monitoring might contribute to a better management of these complications. Some predicting factors such as postoperative sepsis and biological markers on day 3 should help physicians to determine patients requiring a prolonged ICU/IMC monitoring.

The new SUMPOT to predict postoperative complications using an Artificial Neural Network

An accurate assessment of preoperative risk may improve use of hospital resources and reduce morbidity and mortality in high-risk surgical patients. This study aims at implementing an automated surgical risk calculator based on Artificial Neural Network technology to identify patients at risk for postoperative complications. We developed the new SUMPOT based on risk factors previously used in other scoring systems and tested it in a cohort of 560 surgical patients undergoing elective or emergency procedures and subsequently admitted to intensive care units, high-dependency units or standard wards. The whole dataset was divided into a training set, to train the predictive model, and a testing set, to assess generalization performance. The effectiveness of the Artificial Neural Network is a measure of the accuracy in detecting those patients who will develop postoperative complications. A total of 560 surgical patients entered the analysis. Among them, 77 patients (13.7%) suffered from one or more postoperative complications (PoCs), while 483 patients (86.3%) did not. The trained Artificial Neural Network returned an average classification accuracy of 90% in the testing set. Specifically, classification accuracy was 90.2% in the control group (46 patients out of 51 were correctly classified) and 88.9% in the PoC group (8 patients out of 9 were correctly classified). The Artificial Neural Network showed good performance in predicting presence/absence of postoperative complications, suggesting its potential value for perioperative management of surgical patients. Further clinical studies are required to confirm its applicability in routine clinical practice.

Does Pancreatic Fistula Affect Long-Term Survival after Resection for Pancreatic Cancer? A Systematic Review and Meta-Analysis

Simple Summary

The real influence of postoperative pancreatic fistula (POPF) on long-term survival after pancreatic cancer resection is unclear. The purpose of the present study was therefore to conduct a systematic review and meta-analysis of the impact of POPF on the disease-free and overall survival of patients with pancreatic cancer. Our results highlighted that clinically relevant POPF after surgery for PDAC seems to be significantly associated with shorter DFS and OS. Confirmation, with future studies, of a negative impact of POPF on survival may encourage the widespread use of risk-stratification tools for assessing fistula, centralization of patients, and probably a closer oncological follow-up.

Abstract

Background: The impact of postoperative pancreatic fistula (POPF) on survival after resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: The MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting on survival in patients with and without POPF. A meta-analysis was performed to investigate the impact of POPF on disease-free survival (DFS) and overall survival (OS). Results: Sixteen retrospective cohort studies concerning a total of 5019 patients with an overall clinically relevant POPF (CR-POPF) rate of 12.63% (n = 634 patients) were considered. Five of eleven studies including DFS data reported higher recurrence rates in patients with POPF, and one study showed a higher recurrence rate in the peritoneal cavity. Six of sixteen studies reported worse OS rates in patients with POPF. Sufficient data for a meta-analysis were available in 11 studies for DFS, and in 16 studies for OS. The meta-analysis identified a shorter DFS in patients with CR-POPF (HR 1.59, p = 0.0025), and a worse OS in patients with POPF, CR-POPF (HR 1.15, p = 0.0043), grade-C POPF (HR 2.21, p = 0.0007), or CR-POPF after neoadjuvant therapy. Conclusions: CR-POPF after resection for PDAC is significantly associated with worse overall and disease-free survival.

Clinical impact of perioperative atrial fibrillation on long-term recurrence of malignancy

Perioperative complications have been reported to be associated with a lower incidence of cancer-free survival. Perioperative atrial fibrillation (POAF) is one of occasionally observed complications in patients with malignancies who undergo noncardiac surgeries. However, the long-term clinical impact of POAF on those with malignancies have remained unknown. This was a prospective, single-center, observational study. Patients who underwent noncardiac surgeries for definitive malignancies between 2014 and 2017 were included. The primary and secondary endpoints were 3-year recurrence of malignancies and cancer death, respectively. The present study included consecutive 752 patients (mean age, 68 ± 11 years; males, 62%), and POAF was observed in 77 patients. The follow-up duration was 1037 (interquartile range, 699-1408) days. The 3-year recurrence of malignancies was observed in 239 (32%) patients (POAF, 32 [42%]; non-POAF, 207 [31%]) and 3-year mortality was 130 patients (17%). Cardiac, noncardiac, and cancer deaths were observed in 4 (0.5%), 126 (17%), and 111 (15%) patients, respectively. Multivariate Cox regression analysis demonstrated that POAF was associated with 3-year recurrence of malignancies (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.15-2.52). Landmark analysis demonstrated that POAF tended to be correlated with the incidence of 3-year cancer death (HR, 1.79; 95% CI, 0.96-3.31). In conclusion, POAF is associated with the subsequent recurrence of malignancies. The association of arrhythmia with cancer death may be revealed under longer follow-up durations.Clinical Trial Registration: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000018270 . UMIN ID: UMIN000016146.

Postoperative morbidity following pancreatic cancer surgery is significantly associated with worse overall patient survival; systematic review and meta-analysis

BACKROUND

The influence of postoperative morbidity on survival after potentially curative resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear.

METHODS

Medline, Web of Science and Cochrane Library were searched for studies reporting survival in patients with and without complications, defined according to the Clavien-Dindo classification, after primary, potentially curative resection for pancreatic cancer followed by adjuvant treatment. Meta-analysis was performed using a random-effects model.

RESULTS

Fourteen retrospective cohort studies comprising a total of 7.604 patients with an overall complication rate of 40.8% (n = 3.103 patients) were included. Median overall survival for the entire patient cohort ranged from 15.5 to 24 months. Overall survival in patients with severe postoperative complications ranged from 7.1 to 37.1 months and was significantly worse compared to the overall survival in patients without severe complications ranging from 16.5 to 38.2 months. Postoperative complication rates ranged from 24.3% to 64%, severe (Clavien-Dindo ≥ III) complication rates from 4.2% to 31%. Results sufficient for meta-analysis were reported by ten studies, representing 6.028 patients. Meta-analysis showed reduced overall survival following any complication (summary adjusted HR 1.47; 95% CI 1.23-1.76, p < 0.0001). Hazard of death was 1.5 times higher in patients experiencing severe postoperative complications than in patients without severe complications (summary adjusted HR 1.45; 95% CI 1.13-1.85, p = 0.003).

CONCLUSIONS

Postoperative complications after potentially curative resection of PDAC are significantly associated with worse overall patient survival.

Predicting Individual Survival after Curative Esophagectomy for Squamous Cell Carcinoma of Esophageal

BACKGROUND

Esophageal cancer is one of the leading causes of cancer-related death worldwide. Despite the significant progress in the overall treatment of esophageal cancer in recent years, the prognosis for patients who require surgery remains poor.

METHODS

The present study investigated the clinicopathological features of 503 patients who underwent radical esophagectomy at Huashan Hospital of Fudan University between January 2005 and January 2015. Nomograms that predicted the esophageal squamous cell carcinoma (ESCC) survival rates were established using the Cox proportional hazard regression model. Discrimination and calibration, which were calculated after bootstrapping, were used as a measure of accuracy.

RESULTS

Multivariate analyses were used to select five independent prognostic variables and build the nomogram. These variables were pathological T stage, pathological N factor, rate of positive LNs, history of chronic obstructive pulmonary disease (COPD) and postoperative sepsis. The nomogram was built to predict the rates for overall survival (OS) and disease-free survival (DFS). The concordance index for the nomogram prediction for OS and DFS was 0.720 and 0.707, respectively. Compared to the conventional TNM staging system, the nomogram had better predictive accuracy for survival (OS 0.720 vs. 0.672, P < 0.001; DFS 0.707 vs. 0.667; P < 0.001).

CONCLUSIONS

The present study incorporated pathological T stage, pathological N factor, rate of positive LNs, history of COPD, and postoperative sepsis into a nomogram to predict the OS and DFS of ESCC patients. This practical system may help clinicians in both decision-making and clinical study design. The assessment of lung function for patients with COPD preoperative, and the control of disease progression are needed. Furthermore, the postoperative infection of patients should be controlled. Further studies may help to extend the validation of this method and improve the model through parameter optimization.

Sepsis and Cancer: An Interplay of Friends and Foes

Sepsis and cancer share a number of pathophysiological features, and both result from the inability of the host's immune system to cope with the initial insult (tissue invasion by pathogens and malignant cell transformation, respectively). The common coexistence of both disorders and the profound related alterations in immune homeostasis raise the question of their mutual impact on each other's course. This translational review aims to discuss the interactions between cancer and sepsis supported by clinical data and the translation to experimental models. The dramatic improvement in cancer has come at a cost of increased risks of life-threatening infectious complications. Investigating the long-term outcomes of sepsis survivors has revealed an unexpected susceptibility to cancer long after discharge from the ICU. Nonetheless, it is noteworthy that an acute septic episode may harbor antitumoral properties under particular circumstances. Relevant double-hit animal models have provided clues to whether and how bacterial sepsis may impact malignant tumor growth. In sequential sepsis-then-cancer models, postseptic mice exhibited accelerated tumor growth. When using reverse cancer-then-sepsis models, bacterial sepsis applied to mice with cancer conversely resulted in inhibition or even regression of tumor growth. Experimental models thus highlight dual effects of sepsis on tumor growth, mostly depending on the sequence of insults, and allow deciphering the immune mechanisms and their relation with microorganisms.

The Relative Role of Bile Bacterial Isolation on Outcome in Stent-Bearing Patients Undergoing Pancreatoduodenectomy

BACKGROUND

Biliary stenting leads to antimicrobial-resistant (AMR) microorganism retrievement in bile cultures. However, the impact of intraoperative bile colonizations on post-pancreaticoduodenectomy complications remains unclear. Aims of our study were to characterize the bile flora of stented patients in comparison with postoperative cultures and to analyze whether patterns of drug resistance affected postoperative outcomes.

METHODS

We analyzed records from stent-bearing pancreaticoduodenectomy patients at 3 European centers. Intra- and postoperative cultures were compared and classified as multidrug sensitive (MDS), multidrug resistant (MDR), and extensively drug resistant (XDR). Thirty-day complications were graded according to international standards.

RESULTS

Out of 270 patients, intraoperative cultures were positive in 219 (81.1%) cases. In 36.7%, MDS species were isolated; in 35.9%, MDR; and in 8.5%, XDR species. A solid correspondence between the species isolated intra- and postoperatively (p < 0.001) was observed. Intraoperative MDR/XDR isolation was associated with an increased rate of surgical (p = 0.043) and infectious complications (p = 0.030), but not severe complication rate (p = 0.973). Postoperative MDR/XDR isolation was associated with higher risk of major complications (45.6% vs. 15.8%, p < 0.001), postoperative pancreatic fistula (p < 0.001), and post-pancreatectomy hemorrhage (p = 0.002). By multivariate analysis, intraoperative AMR isolation was associated with high likelihood of postoperative AMR infections. However, only in 43/121 cases, intraoperative MDR/XDR microorganisms turned into the occurrence of postoperative infections.

CONCLUSION

Intraoperative AMR isolates do not translate into severe outcomes, despite being significantly associated with surgical and infectious complications.

Impact of pretreatment asymptomatic renal dysfunction on clinical course after esophagectomy

PURPOSE

Recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with an increased risk of postoperative complications after esophagectomy; however, it remains unclear whether asymptomatic renal dysfunction affects the postoperative course after esophagectomy.

METHODS

The subjects of this retrospective study were 177 patients who underwent esophagectomy between May, 2009 and December, 2018. Renal function was evaluated based on the pretreatment estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the eGFR cut-off value of 55 ml/min per 1.73 m².

RESULTS

There were 17 patients in the low eGFR group and 160 patients in the normal group eGFR group. The rate of severe complications was significantly higher in the low eGFR than in the normal eGFR group. A low eGFR was the only significant complication risk factor identified; however, there were no marked differences in mortality or survival between the low and normal eGFR groups.

CONCLUSION

Our findings demonstrate that pretreatment asymptomatic renal dysfunction may be a significant risk factor for severe morbidity after esophagectomy.

Does postoperative inflammation or sepsis generate neutrophil extracellular traps that influence colorectal cancer progression? A systematic review

BACKGROUND

Colorectal cancer is the third most common cancer worldwide. Almost half of those that have a potentially curative resection go on to develop metastatic disease. A recognized risk for recurrence is perioperative systemic inflammation and sepsis. Neutrophil extracellular traps have been implicated as promotors of tumor progression. We aimed to examine the evidence in the literature for an association between neutrophil extracellular traps and postoperative metastasis in colorectal cancer.

MATERIALS AND METHODS

Studies published between 2000 and December 2018 that examined the role of neutrophil extracellular traps in sepsis and inflammation in colorectal cancer and in relation to tumor-related outcomes were identified through a database search of Cochrane, CINAHL, and MEDLINE. Quality and bias assessment was carried out by 2 reviewers.

RESULTS

Of 8,940 screened and of the 30 studies included, 21 were observational, 5 were in vivo experimental, 1 was in vitro, and 3 used a combination of these approaches.

CONCLUSION

There is clear evidence from the literature that presence of a preoperative systemic inflammatory response predicts cancer recurrence following potentially curative resection, but the evidence for association of sepsis and progression is lacking. There is robust experimental evidence in murine models showing that neutrophil extracellular traps are present in sepsis and are associated with cancer progression. Some human observational studies corroborate the prognostic significance of neutrophil extracellular traps in progression of colorectal cancer. Further human studies are needed to translate the experimental evidence and to definitively associate sepsis and neutrophil extracellular traps with poor colorectal cancer-specific outcomes.

Intraoperative Hemorrhagic Shock in Cancer Surgical Patients: Short and Long-Term Mortality and Associated Factors

BACKGROUND

Management of hemorrhagic shock is well codified by international guidelines. These guidelines are predominantly based on trauma patients. We aimed to evaluate factors associated with 30-day mortality and long-term survival after intraoperative hemorrhagic shock during major oncological surgery.

METHODS

This retrospective study was conducted in a cancer referral center from January 2013 to February 2018. All adult cancer patients admitted in the operative room for scheduled or emergency oncological surgery associated with an intraoperative hemorrhagic shock were included.

RESULTS

Eighty-four patients were included in this study. The 30-day mortality rate was 26% (n = 22), the mean follow-up from the time of ICU admission was 20 months (95% CI, 15-25 months), 39 (46%) patients died during this period. Using logistic regression for multivariate analysis, factors independently associated with 30-day mortality were SAPS II score (odds ratio (OR) =1.056, 95% confident interval (CI) =1.010-1.1041), delta SOFA (SOFA score at day 3 - SOFA score at day 1) (OR= 1.780, 95% CI 1.184-2.677) and ISTH-DIC score (OR = 2.705, 95% CI 1.108-6.606). Using Cox multivariate analysis, factors associated with long-term mortality were delta SOFA (hazard ratio (HR) =1.558, 95% CI 1.298-1.870), ISTH-DIC score (HR = 1.381, 95% CI 1.049-1.817), hepatic dysfunction (HR = 7.653, 95% CI 2.031-28.842), and Charlson comorbidity index (HR = 1.330, 95% CI 1.041-1.699).

CONCLUSION

The worsening of organ dysfunctions during the first 3 days of ICU admission as well as intraoperative coagulation disturbances (increased ISTH-DIC score) are independently associated with short and long-term mortality. Comorbidities (Charlson comorbidity index) and postoperative hepatic dysfunction were independently associated with long-term mortality. Early perioperative bundle strategies should be evaluated in order to improve patient's survival in this specific situation.

Impact of postoperative complications on disease recurrence and long-term survival following oesophagogastric cancer resection

Background

Postoperative complications after resection of oesophagogastric carcinoma can result in considerable early morbidity and mortality. However, the long-term effects on survival are less clear.

Methods

All patients undergoing intentionally curative resection for oesophageal or gastric cancer between 2006 and 2016 were selected from an institutional database. Patients were categorized by complication severity according to the Clavien–Dindo classification (grades 0–V). Complications were defined according to an international consensus statement. The effect of leak and severe non-leak-related complications on overall survival, recurrence and disease-free survival was assessed using Kaplan–Meier analyses to evaluate differences between groups. All factors significantly associated with survival in univariable analysis were entered into a Cox multivariable regression model with stepwise elimination.

Results

Some 1100 patients were included, with a median age of 69 (range 28–92) years; 48·1 per cent had stage III disease and cancer recurred in 428 patients (38·9 per cent). Complications of grade III or higher occurred in 244 patients (22·2 per cent). The most common complications were pulmonary (29·9 per cent), with a 13·0 per cent incidence of pneumonia. Rates of atrial dysrhythmia and anastomotic leak were 10·0 and 9·6 per cent respectively. Patients with a grade III–IV leak did not have significantly reduced overall survival compared with those who had grade 0–I complications. However, patients with grade III–IV non-leak-related complications had reduced median overall survival (19·7 versus 42·7 months; P &lt; 0·001) and disease-free survival (18·4 versus 36·4 months; P &lt; 0·001). Cox regression analysis identified age, tumour stage, resection margin and grade III–IV non-leak-related complications as independent predictors of poor overall and disease-free survival.

Conclusion

Beyond the acute postoperative period, anastomotic leak does not adversely affect survival, however, other severe postoperative complications do reduce long-term overall and disease-free survival.

Major Complications Independently Increase Long-Term Mortality After Pancreatoduodenectomy for Cancer

BACKGROUND

Postoperative major morbidity has been associated with worse survival gastrointestinal tumors. This association remains controversial in pancreatic cancer (PC). We analyzed whether major complications after surgical resection affect long-term survival.

METHODS

Records of all PC patients resected from 2007 to 2015 were reviewed. Major morbidity was defined as any grade-3 or higher 30-day complications, per the Clavien-Dindo Classification. Patients who died within 90 days after surgery were excluded from survival analysis.

RESULTS

Of 616 patients, 81.7% underwent pancreatoduodenectomy (PD) and 18.3% distal pancreatectomy (DP). Major complications occurred in 19.1% after PD and 15.9% after DP. In patients who survived > 90 days, the likelihood of receiving adjuvant treatment was 43.9% if major complications had occurred, vs. 68.5% if not (p < 0.001), and those who received it started the treatment median 10 days later compared with uncomplicated patients (median 60 days (50-72) vs. 50 days (41-61), p = 0.001). By univariate analysis, in addition to the conventional pathology-related prognostic determinants and the receipt of adjuvant treatment, major complications worsened long-term survival after PD (median OS 26 months vs. 15, p = 0.008). A difference was also seen after DP, but it did not reach statistical significance, likely related to the small sample size (median OS 33 months vs. 18, p = 0.189). At multivariate analysis for PD, major postoperative complications remained independently associated with worse survival [HR 1.37, 95%CI (1.01-1.86)].

CONCLUSIONS

Major surgical complications after pancreaticoduodenectomy are associated with worse long-term survival in pancreatic cancer. This effect is independent of the receipt of adjuvant treatment.

Postoperative ward monitoring - Why and what now?

The postoperative ward is considered an ideal nursing environment for stable patients transitioning out of the hospital. However, approximately half of all in-hospital cardiorespiratory arrests occur here and are associated with poor outcomes. Current monitoring practices on the hospital ward mandate intermittent vital sign checks. Subtle changes in vital signs often occur at least 8-12 h before an acute event, and continuous monitoring of vital signs would allow for effective therapeutic interventions and potentially avoid an imminent cardiorespiratory arrest event. It seems tempting to apply continuous monitoring to every patient on the ward, but inherent challenges such as artifacts and alarm fatigue need to be considered. This review looks to the future where a continuous, smarter, and portable platform for monitoring of vital signs on the hospital ward will be accompanied with a central monitoring platform and machine learning-based pattern detection solutions to improve safety for hospitalized patients.

Risk factors for anastomotic leak after esophagectomy for cancer: A NSQIP procedure-targeted analysis

BACKGROUND

Anastomotic leak is the most common major complication after esophagectomy. We investigated the 2016 American College of Surgeons National Surgical Quality Improvement Program esophagectomy targeted database to identify risk factors for anastomotic leak.

METHODS

Patients who underwent esophagectomy for cancer were included. Patients experiencing an anstomotic leak were identified, and univariate and multivariable logistic regression was performed to identify variables independently associated with anastomotic leak.

RESULTS

Of 915 patients included, 83% were male and the median age was 64 years. Patients with anastomotic leak more frequently had additional complications (87% vs 36%, P < .001). Rates of reoperation (64% vs 11%, P < .001) and mortality (8% vs 2%, P = .001) were higher in patients with anastomotic leak. After adjusting for patient and procedure characteristics, prolonged operative time (for each additional 30-minutes; adjusted odds ratios (AOR) 1.068, 95% CI, 1.022-1.115, P = .003), increased preoperative WBC count (for each 3000/µL increase; AOR 1.323, 95% CI, 1.048-1.670, P = .019), pre-existing diabetes (AOR 1.601, 95% CI, 1.012-2.534, P = .045), and perioperative transfusion (AOR 1.777, 95% CI, 1.064-2.965, P = .028) were independently associated with anastomotic leak.

CONCLUSION

Both patient and procedure-related factors are associated with anastomotic leak. Though frequently non-modifiable, these findings could facilitate risk stratification and early detection of anastomotic leak to reduce associated morbidity.

Postoperative complications increase the risk of long-term chronic kidney disease after nephron-sparing surgery in patients with renal cancer and normal preoperative renal function

OBJECTIVES

To investigate whether postoperative complications affect long-term functional outcomes of renal patients treated with nephron-sparing surgery (NSS).

MATERIALS AND METHODS

We performed an observational study, enrolling 596 patients with preoperative normal renal function treated with NSS for clinical T1abN0M0 renal masses. Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for chronic kidney disease (CKD) including as covariates age, comorbidity (scored according to the Charlson comorbidity index), hypertension, tumour size, preoperative estimated glomerular filtration rate (eGFR), eGFR < 60 mL/min/1.73 m² at discharge, and ischaemia time.

RESULTS

A total of 137 patients (23%) developed postoperative complications. At a median (interquartile range) follow-up of 53 (26-91) months, CKD risk was 19% for patients with postoperative complications and 11% for those without complications. Patients experiencing postoperative complications (HR 1.90, 95% CI 1.26-2.86) were at increased risk of developing CKD during the follow-up at multivariable analysis, after accounting for confounders.

CONCLUSIONS

Our data outline how postoperative complications might have a detrimental impact on postoperative renal function in patients submitted to NSS. Improper patient selection, increasing the risk of postoperative complications, could limit the benefit in terms of renal function brought by NSS.

Impact of a hospital-wide sepsis pathway on improved quality of care and clinical outcomes in surgical patients at a comprehensive cancer centre

PURPOSE

Sepsis is a significant complication following cancer surgery. Although standardised care bundles improve sepsis outcomes in other populations, the benefits in cancer patients are unclear. The objectives of this study were to describe the epidemiology of sepsis in cancer patients post-surgery, and to evaluate the impact of a clinical sepsis pathway on management and clinical outcomes.

METHODS

A standardised hospital-wide sepsis pathway was developed in 2013, and all cases of sepsis at the Peter MacCallum Cancer Centre in 2014 were retrospectively evaluated. Inclusion criteria were sepsis onset during the 100-day period following a surgical procedure for cancer diagnosis. Patients were identified using ICD-10-AM sepsis discharge codes, audit documentation and the hospital's antimicrobial approval system. Sepsis episodes were classified as managed on- or off-pathway.

RESULTS

A total of 119 sepsis episodes were identified. Of these, 71 (59.7%) were managed on the sepsis pathway. Episodes managed on-pathway resulted more frequently in administration of appropriate antibiotics compared to those off-pathway (94.4% vs. 66.7%, p < 0.001), and had shorter time to first-dose antibiotics (median 85 vs. 315 min, p < 0.001). Pathway utilisation was associated with significant reductions in need for inotropes (7% vs. 13%, p = 0.023), ventilation (3% vs. 10%, p = 0.006) and length of hospitalisation (median 15 vs. 30 days, p = 0.008). The most frequent source of infection was organ-space surgical site infection (24.4% of instances).

CONCLUSIONS

A dedicated hospital-wide sepsis pathway had significant impact on the quality of care and clinical outcomes of sepsis in cancer surgery patients. Cost-benefit analysis of sepsis pathways for cancer patients is required.

Continuous vital sign monitoring after major abdominal surgery-Quantification of micro events

INTRODUCTION

Millions of patients undergo major abdominal surgery worldwide each year, and the post-operative phase carries a high risk of respiratory and circulatory complications. Standard ward observation of patients includes vital sign registration at regular intervals. Patients may deteriorate between measurements, and this may be detected by continuous monitoring. The aim of this study was to compare the number of micro events detected by continuous monitoring to those documented by the widely used standardized Early Warning Score (EWS).

METHODS

Fifty patients were continuously monitored with peripheral arterial oxygen saturation (SpO₂ ), heart rate (HR), and respiratory rate (RR) the first 4 days after major abdominal cancer surgery. EWS was monitored as routine practice. Number and duration of events were analyzed using Fisher's exact test and Wilcoxon rank sum test.

RESULTS

Continuous monitoring detected a SpO₂ <92% in 98% of patients vs 16% of patients detected by EWS (P < .0001). Micro events of SpO₂ <92% lasting longer than 60 minutes were found in 58% of patients by continuous monitoring vs 16% by the EWS (P < .0001). Fifty-two percent of patients had micro events of SpO₂ <85% lasting longer than 10 minutes. Continuous monitoring found tachycardia in 60% of patients vs 6% by the EWS. Frequency of events for bradycardia, tachypnea, and bradypnea showed similar patterns.

CONCLUSION

Very low SpO₂ and tachycardia in post-operative patients are common and under-diagnosed by the EWS. Continuous monitoring can discover these micro events and potentially contribute to earlier detection and, potentially, result in prevention of clinical complications.

Post-operative immune suppression is mediated via reversible, Interleukin-10 dependent pathways in circulating monocytes following major abdominal surgery

Introduction

Post-operative infections occur frequently following major surgery. The magnitude of the post-operative immune response is associated with an increased risk of post-operative infections, although the mechanisms driving post-operative immune-dysfunction and the potential reversibility of this response with immune stimulants are not well understood. This study aims to describe the immediate immune response to major surgery and establish links to both post-operative infection and functional aspects of immune dysregulation. We also investigate the potential of clinically available immune stimulants to reverse features of post-operative immune-dysfunction.

Methods

Patients over 45 years old undergoing elective gastro-intestinal surgery with planned post-operative surgical ICU admission were recruited. The expression of selected genes was determined pre-operatively and at 2, 24 and 48 hours post-operatively using qRT-PCR. Circulating levels of Interleukin-10 protein were determined by ELISA. Peri-operative cell surface monocyte HLA-DR (mHLA-DR) expression was determined using flow cytometry. Gene expression and mHLA-DR levels were determined in healthy monocytes cultured in peri-operative serum with and without neutralising antibodies and immune stimulants.

Results

119 patients were recruited; 44 developed a post-operative infection. Interleukin-10 mRNA and protein increased 4-fold post-operatively (P<0.0001), peaking within 2 hours of the procedure. Higher post-operative Interleukin-10 mRNA (P = 0.007) and protein (P = 0.001) levels were associated with an increased risk of infection. Cell surface mHLA-DR expression fell post-operatively (P<0.0001). Reduced production, rather than intracellular sequestration, accounted for the post-operative decline in cell surface mHLA-DR expression. Interleukin-10 antibody prevented the decrease in mHLA-DR expression observed when post-operative serum was added to healthy monocytes. GM-CSF and IFN-γ prevented the decline in mHLA-DR production through distinct pathways.

Conclusions

Monocyte dysfunction and features of immune suppression occur frequently after major surgery. Greater post-operative Interleukin-10 production is associated with later infection. Interleukin-10 is an important mediator of post-operative reductions in mHLA-DR expression, while clinically available immune stimulants can restore mHLA-DR levels.

Apoptosis-induced lymphopenia in sepsis and other severe injuries

Sepsis and other acute injuries such as severe trauma, extensive burns, or major surgeries, are usually followed by a period of marked immunosuppression. In particular, while lymphocytes play a pivotal role in immune response, their functions and numbers are profoundly altered after severe injuries. Apoptosis plays a central role in this process by affecting immune response at various levels. Indeed, apoptosis-induced lymphopenia duration and depth have been associated with higher risk of infection and mortality in various clinical settings. Therapies modulating apoptosis represent an interesting approach to restore immune competence after acute injury, although their use in clinical practice still presents several limitations. After briefly describing the apoptosis process in physiology and during severe injuries, we will explore the immunological consequences of injury-induced lymphocyte apoptosis, and describe associations with clinically relevant outcomes in patients. Therapeutic perspectives targeting apoptosis will also be discussed.

Risk Factors for Postoperative Complications Following Diverting Loop Ileostomy Takedown

INTRODUCTION

Diverting loop ileostomies are frequently created to divert the fecal stream in an effort to protect downstream anastomoses. These are later reversed to restore intestinal continuity. The goal of this study is to evaluate risk factors for postoperative complications following diverting loop ileostomy takedown.

MATERIALS AND METHODS

Patients who underwent diverting loop ileostomy takedown between January 1, 2010 and April 28, 2015 were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified and a hierarchical logistic regression model was used to identify risk factors for postoperative complications.

RESULTS

1,737 patients met the inclusion criteria. Rates of postoperative complications were generally low. Mean length of stay (LOS) was 5.6 (± 4.5) days. Outcomes of interest were the following: overall morbidity, serious morbidity, extended LOS, SSI, UTI, pneumonia, readmission, reoperation, and mortality. Risk factors for these outcomes included the following: ASA class, bleeding disorder, prolonged operative time, race, tobacco use, gender, steroid use, peripheral vascular disease, weight loss, and functional status.

CONCLUSIONS

Diverting loop ileostomy takedown has a complication rate of approximately 20%. Higher ASA class, longer operative times, history of bleeding disorder, and functional status were identified as risk factors for most complications.

Major postoperative complications after pancreatic resection for P-NETS are not associated to earlier recurrence

BACKGROUND

The oncological impact of surgical complications has been studied in visceral and pancreatic cancer.

AIM

To investigate the impact of complications on tumour recurrence after resections for pancreatic neuroendocrine tumours.

METHODS

We have retrospectively analysed 105 consecutive resections performed at the Royal Free London Hospital from 1998 to 2014, and studied the long-term outcome of nil-minor (<3) versus major (≥3) Clavien-Dindo complications (CD) on disease-free (DFS) and overall survival (OS).

RESULTS

The series accounted for 41 (39%) pancreaticoduodenectomies, two (1.9%) central, 48 (45.7%) distal pancreatectomies, eight (7.6%) enucleations, four (3.8%) total pancreatectomies. Sixteen (15.2%) were extended to adjacent organs, 13 (12.3%) to minor liver resections. Postoperative complications presented in 43 (40.1%) patients; CD grade 1 or 2 in 23 (21.9%), grades ≥3 in 20 (19%). Among 25 (23.8%) pancreatic fistulas, 14 (13.3%) were grades B or C. Thirty-four (32.4%) patients developed exocrine, and 31 (29.5%) endocrine insufficiency. Seven patients died during a median 27 (0-175) months follow up. Thirty-day mortality was 0.9%. OS was 94.1% at 5 years. Thirty tumours recurred within 11.7 (0.8-141.5) months. DFS was 44% at 5 years. At univariate analysis, high-grade complications were not associated with shorter DFS (p = 0.744). At multivariate analysis, no parameter was independent predictor for DFS or OS. The comparison of nil-minor versus major complications showed no DFS difference (p = 0.253).

CONCLUSION

From our series, major complications after P-NETs resection are not associated to different disease recurrence; hence do not require different follow up or adjuvant regimens.

Does postoperative morbidity worsen the oncological outcome after radical surgery for gastrointestinal cancers? A systematic review of the literature

PURPOSE

The impact of postoperative complications on survival after radical surgery for esophageal, gastric, and colorectal cancers remains controversial. We conducted a systematic review of recent publications to examine the effect of postoperative complications on oncological outcome.

METHODS

A literature search of PubMed/MEDLINE was performed using the keywords "esophageal cancer," "gastric cancer," and "colorectal cancer," obtaining 27 reports published online up until the end of April 2016. Articles focusing on (i) postoperative morbidity and oncological outcome; and (ii) body mass index (BMI), postoperative morbidity, and oncological outcome, were selected. Univariate and multivariate analyses (Cox proportional hazards model) were performed.

RESULTS

Patients with postoperative complications had significantly poorer long-term survival than those without complications. Complications were associated with impaired oncological outcomes. The hazard ratios for overall survival were 1.67 (95% confidence interval [CI], 1.31-2.12), 1.59 (95% CI, 1.13-2.24), and 1.55 (95% CI, 1.28-1.87) in esophageal, gastric, and colorectal cancers, respectively. High BMI was associated with postoperative morbidity rate but not with poor oncological outcome. Low BMI was significantly associated with inferior oncological outcome.

CONCLUSIONS

Complications after radical surgery for esophageal, gastric, and colorectal cancers are associated with patient prognosis. Avoiding such complications might improve the outcomes.

The impact of post-operative sepsis on mortality after hospital discharge among elective surgical patients: a population-based cohort study

Background

Our aim in the present study was to assess the mortality impact of hospital-acquired post-operative sepsis up to 1 year after hospital discharge among adult non-short-stay elective surgical patients.

Methods

We conducted a population-based, retrospective cohort study of all elective surgical patients admitted to 82 public acute hospitals between 1 January 2007 and 31 December 2012 in New South Wales, Australia. All adult elective surgical admission patients who stayed in hospital for ≥4 days and survived to discharge after post-operative sepsis were identified using the Admitted Patient Data Collection records linked with the Registry of Births, Deaths, and Marriages. We assessed post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year and compared them with those of patients without post-operative sepsis.

Results

We studied 144,503 survivors to discharge. Of these, 1857 (1.3%) had experienced post-operative sepsis. Their post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year were 4.6%, 6.7%, 8.1% and 13.5% (vs 0.7%, 1.2%, 1.5% and 3.8% in the non-sepsis cohort), respectively (P < 0.0001 for all). After adjustment for patient and hospital characteristics, post-operative sepsis remained independently associated with a higher mortality risk (30-day mortality HR 2.75, 95% CI 2.14–3.53; 60-day mortality HR 2.45, 95% CI 1.94–3.10; 90-day mortality HR 2.31, 95% CI 1.85–2.87; 1-year mortality HR 1.71, 95% CI 1.46–2.00). Being older than 75 years of age (HR 3.50, 95% CI 1.56–7.87) and presence of severe/very severe co-morbidities as defined by Charlson co-morbidity index (severe vs normal HR 2.05, 95% CI 1.45–2.89; very severe vs normal HR 2.17, 95% CI 1.49–3.17) were the only other significant independent predictors of increased 1-year mortality.

Conclusions

Among elective surgical patients, post-operative sepsis is independently associated with increased post-discharge mortality up to 1 year after hospital discharge. This risk is particularly high in the first month, in older age patients and in the presence of severe/very severe co-morbidities. This high-risk population can be targeted for interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1596-7) contains supplementary material, which is available to authorized users.

Mechanism and effect of excessive inflammatory response in perioperative period of abdominal surgery

Inflammation is an important pathophysiological change in the perioperative period of abdominal surgery. Moderate inflammatory plays a positive role in wound healing, but excessive inflammation is harmful to the body and is a major cause of postoperative complications and the common pathway of multiple organ dysfunction syndrome. Therefore, intervention of excessive inflammation response in the perioperative period can reduce the morbidity and mortality of patients. However, the current understanding of the pathophysiological process of excessive inflammatory response during the perioperative period is still in the primary stage. This article systematically reviews the induced factors, mechanism and pathophysiological changes of excessive inflammatory response during the perioperative period of abdominal surgery as well as its harm to and influence on the body.

Severity of Acute Respiratory Distress Syndrome in haematology patients: long-term impact and early predictive factors

Severe forms of acute respiratory distress syndrome in patients with haematological diseases expose clinicians to specific medical and ethical considerations. We prospectively followed 143 patients with haematological malignancies, and whose lungs were mechanically ventilated for more than 24 h, over a 5-y period. We sought to identify prognostic factors of long-term outcome, and in particular to evaluate the impact of the severity of acute respiratory distress syndrome in these patients. A secondary objective was to identify the early (first 48 h from ICU admission) predictive factors for acute respiratory distress syndrome severity. An evolutive haematological disease (HR 1.71; 95% CI 1.13-2.58), moderate to severe acute respiratory distress syndrome (HR 1.81; 95% CI 1.13-2.69) and need for renal replacement therapy (HR 2.24; 95% CI 1.52-3.31) were associated with long-term mortality. Resolution of neutropaenia during ICU stay (HR 0.63; 95% CI 0.42-0.94) and early microbiological documentation (HR 0.62; 95% CI 0.42-0.91) were associated with survival. The extent of pulmonary infiltration observed on the first chest X-ray and the diagnosis of invasive fungal infection were the most relevant early predictive factors of the severity of acute respiratory distress syndrome.

Anterior approach for perihilar cholangiocarcinoma (with video)

BACKGROUND

To evaluate the significance of the anterior approach without the Pringle maneuver during right hepatectomies with caudate lobectomies for perihilar cholangiocarcinomas (PHCs).

MATERIALS AND METHODS

From January 2011 to 2015, 25 consecutive patients underwent right hepatectomies with caudate lobectomies using the anterior approach without the Pringle maneuver for PHC (group A). Between 2003 and 2011, 44 patients were operated on for PHC using the classic right approach (group B). We compared the groups with respect to the patients' characteristics and the short-term surgical outcomes.

RESULTS

Group A had significantly lower postoperative mean maximum levels of aspartate aminotransferase (294 U/L versus 453 U/L; P = 0.044), lower frequencies of maximum aspartate aminotransferase or alanine aminotransferase levels that exceeded 500 U/L (8.0% versus 32%; P = 0.036), shorter total Pringle maneuver times (7.1 versus 46.3 min; P < 0.001), lower Pringle maneuver frequencies (0.76 maneuvers versus 5.1 maneuvers; P < 0.001), less bleeding (1237 mL versus 1646 mL; P = 0.025), and shorter postoperative systemic inflammatory response syndrome durations (2.3 h versus15.4 h; P < 0.001) compared with group B.

CONCLUSIONS

This approach can be performed safely, and it seems to limit the hemodynamic disturbance of the remnant left liver.