Surgical complications of adrenal steroid therapy

A study on the prevention of hemorrhage and perforation in patients with primary gastric diffuse large-B cell lymphoma during treatment with immunochemotherapy

BACKGROUND

Stomach hemorrhage and perforation are very severe and common complications in patients with primary gastric diffuse large B-cell lymphoma (PG-DLBCL) during treatment with immunochemotherapy. However, no relevant clinical studies have been performed on the prevention of these serious complications.

METHODS

Patients diagnosed with PG-DLBCL were enrolled in this retrospective study. The prevention group received standard rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) treatment without prednisone combined with antacids and anti-Helicobacter pylori (Hp) therapy. These patients received R-CHOP-based treatment until the complete recovery of gastric ulcers, as proven by gastroscopy. The control group received a standard R-CHOP regimen. Toxicity and survival were the main endpoints.

RESULTS

A total of 52 patients received preventative treatment, while 146 patients did not. Among patients with stage I, II-1, and II-2 disease, the prevention group had a lower rate of hemorrhage and perforation (0/40) than the control group (10/78, p = 0.044). At a median follow-up time of 25 months, the 5-year event-free survival (EFS) rates were 97.1% in the prevention group and 66.1% in the control group (p = 0.025), and the 5-year overall survival (OS) rates were 100% and 72.0%, respectively (p = 0.021). However, the differences in the 5-year EFS and OS of patients with disseminated disease were not statistically significant.

CONCLUSIONS

Preventative treatment can decrease the risk of hemorrhage and perforation in patients with localized PG-DLBCL during immunochemotherapy, leading to better EFS and OS in these patients. However, preventative treatment failed to reduce the risk of gastric hemorrhage and perforation and did not improve survival (EFS and OS) in advanced-stage patients.

Colon perforation in multiple myeloma patients - A complication of high-dose steroid treatment

Gastrointestinal complications of multiple myeloma (MM) treatment are common and include nausea, constipation, and diarrhea. However, acute gastrointestinal events like perforations are rare. We aimed to describe the characteristics and outcomes of patients with MM that had colonic perforations during their treatment. This is a retrospective study that included patients from all three Mayo Clinic sites who had MM and developed a colonic perforation. All patients were diagnosed with colonic perforations based on CT scans and were surgically treated. Patients diagnosed with AL amyloidosis, a perforated colon complicating neutropenic colitis during ASCT and those with perforation due to colonic cancer were excluded. A high dose of dexamethasone was defined as ≥40 mg dexamethasone once a week. Thirty patients met inclusion criteria. All patients received steroids at doses ≥10 mg once weekly prior to the perforation, while four (11%) were on high-dose dexamethasone without chemotherapy. Fourteen patients were given high doses of dexamethasone. Twenty-five patients required ostomies with all surviving surgery. Twenty-four perforations (80%) were associated with diverticulitis. Treatment with steroids was resumed in 23 patients with no further gastrointestinal complications. The median OS was 20 months following perforation (IQR 8-59). Within the same timeframe 5854 patients were treated at Mayo Clinic for MM, making the risk of bowel perforation 0.5%. Intestinal perforations in MM are rare and, in our series, always occurred with dexamethasone ≥10 mg per week. Urgent surgery is lifesaving and resumption of anti-myeloma treatment appears to be safe.

Effect of perioperative systemic steroid treatment on patients with obstructive lung disease undergoing elective abdominal surgery

INTRODUCTION

Chronic obstructive pulmonary disease is an independent risk factor of postoperative pulmonary complications (PPCs). It is unknown whether a perioperative systemic corticosteroid would be beneficial in patients with obstructive airway disease.

OBJECTIVES

The present study was conducted to determine the effect of a perioperative systemic corticosteroid on PPCs in patients who showed airway obstruction in preoperative spirometry.

METHODS

Retrospective medical record reviews were performed on records from January 2010 to December 2011 in a referral hospital. We analyzed the data of patients who were referred to pulmonologists before elective abdominal surgery and had a prebronchodilator FEV1/FVC of <70%. We compared the PPCs between the steroid group and the non-steroid group.

RESULTS

A total of 270 patients were referred to pulmonologists and, of these, 86 had a FEV1/FVC of <70% in the preoperative spirometry. In the 30 patients in the steroid group, the mean FEV1 was 52.2% and half of these had previously used a bronchodilator. Use of a perioperative systemic corticosteroid was significantly associated with reduced incidence of PPCs in the multivariate logistic regression with adjustment by propensity score (adjusted odds ratio = 0.036, 95% confidence interval [CI] = 0.003-0.505; P = 0.014).

CONCLUSION

In our retrospective study we showed that those treated with steroids had better outcomes. However, future prospective and randomized controlled trials are needed.

Cushing's disease presenting with gastrointestinal perforation: a case report

Gastrointestinal perforation is a complication associated with steroid therapy or hypercortisolism, but it is rarely observed in patients with Cushing's disease in clinical practice, and only one case has been reported as a presenting symptom. Herein, we report a rare case of Cushing's disease in which a patient presented with gastrointestinal perforation as a symptom. A 79-year-old man complained of discomfort in the lower abdomen for 6 months. Based on the endocrinological and gastroenterological examinations, he was diagnosed with Cushing's disease with a perforation of the descending colon. After consultation with a gastroenterological surgeon, it was decided that colonic perforation could be conservatively observed without any oral intake and treated with parenteral administration of antibiotics because of the mild systemic inflammation and lack of abdominal guarding. Despite the marked elevated levels of serum cortisol, oral medication was not an option because of colonic perforation. Therefore, the patient was submitted to endonasal adenomectomy to normalize the levels of serum cortisol. Subsequently, a colostomy was successfully performed. Despite its rarity, physicians should be aware that gastrointestinal perforation may be associated with hypercortisolism, especially in elderly patients, and immediate diagnosis and treatment of this life-threatening condition are essential. If a perforation can be conservatively observed, endonasal adenomectomy prior to laparotomy is an alternative treatment option for hypercortisolism.

Postoperative gastrointestinal complications after lung volume reduction operations

BACKGROUND

Lung volume reduction operations have been shown to improve the quality of life and functional status of some patients with end-stage emphysema.

METHODS

Because of a perceived increase in the occurrence of postoperative gastrointestinal (GI) complications, we reviewed our experience in 287 patients who had lung volume reduction operations to determine the frequency of GI complications and to identify risk factors.

RESULTS

Using a broad definition of postoperative GI complications (nausea, vomiting, abdominal distension, gastroesophageal reflux, diarrhea, constipation) there were 137 complications in 67 patients (23%). More severe GI complications (bowel ischemia, GI bleeding, perforation, ulceration, ileus, colitis, cholecystitis, pancreatitis) occurred 49 times in 27 patients (9.4%). Seven of the 27 patients required abdominal operations. Risk factors identified as predictive of severe complications include diabetes (p = 0.0003), lower preoperative hematocrit (p = 0.01), steroid use (p = 0.02), and use of parenteral meperidine analgesic (p = 0.002). Stepwise logistic regression demonstrated that diabetes was 7.02 times more likely to produce severe complications. Other risk factors included steroids (2.81), number of different pain medications (2.59), hematocrit decrease of 5% (1.96), and hematocrit decrease of 1% (1.14). In the patients with severe GI complications there were six of 27 (22%) hospital deaths compared with five of 260 (2%) in those without GI complications (p = 0.0001).

CONCLUSIONS

Severe GI complications in patients with emphysema who had lung volume reduction operations are not uncommon (9.4%) and influence the perioperative mortality rate. Heightened awareness to identified risk factors will allow earlier recognition, prevention, and perhaps decrease morbidity and mortality rates in these high-risk patients.

Evaluation and preoperative management of lung volume reduction surgery candidates

The efficacy of lung volume reduction surgery has been demonstrated by improvements in functional status, dyspnea, pulmonary function, alveolar gas exchange, and exercise tolerance. However, surgery has a significant morbidity, mortality, and cost. Surgical outcome is dependent on the clinical, anatomical, and physiological features of the patients and their emphysema. Therefore, the patient evaluation process and the preoperative optimization of medical therapy are crucial for success. Through understanding mechanisms for improvement have added insight to the selection process, patient selection needs further clarification.

Sigmoid diverticular perforation in neurosurgical patients receiving high-dose corticosteroids

Perforation of colonic diverticula is a complication of corticosteroid use that has not been described in the neurosurgical literature. Between 1987 and 1992, 719 patients who underwent surgery for primary and metastatic brain and spinal tumors of the central nervous system received 2246 to 4936 mg of methylprednisolone given over at least 7 days. Five patients in this group (all men, ages 50-69 yr) experienced a sigmoid diverticular perforation at a mean dose of 3947 mg of methylprednisolone (range, 2240-6160 mg). Of these five, two had a known history of diverticular disease. In contrast, during this same period, 3749 patients who underwent neurosurgical procedures for non-neoplastic conditions did not receive corticosteroids and experienced no colonic perforations. All five patients with colonic perforations presented with abdominal pain and had free intraperitoneal air that was revealed on radiographs of the abdomen. Perforation of a sigmoid diverticulum was confirmed in all five at exploratory laparotomy. Four patients had good outcomes, and one died. We conclude the following: 1) patients over age 50 who receive high-dose corticosteroids are at risk for sigmoid colonic perforation, and these medications should be used with caution in such patients; 2) if possible, lower total doses of perioperative corticosteroids should be used in patients with known diverticular disease; and 3) because corticosteroids mask many of the inflammatory signs of perforation, this diagnosis should be considered in any patient with abdominal discomfort, fever of unknown origin, or unexplained leukocytosis.

Unusual gastrointestinal complications in neurosurgery

Nine neurosurgical patients with unusual gastrointestinal complications are presented. Their diagnostic clinical features, as well as pitfalls in their diagnosis are highlighted. A high index of clinical suspicion of these unusual complications is important as patients' decreased level of consciousness and concomitant steroid therapy often complicates the clinical presentation. Progressive abdominal distension and absent or sluggish bowel sounds were the most consistent clinical features in comatose patients with peritonitis, whereas, high fever and markedly elevated white cell counts were often absent.

Immune thrombocytopenia: surgical therapy and predictors of response

We have reviewed 40 patients with immune thrombocytopenia purpura (ITP) to assess current methods of preparation for surgery and to evaluate perioperative complications and response to splenectomy. Twenty-one patients had chronic ITP (greater than 1 year duration) and 19 patients had severe acute thrombocytopenia (platelet counts less than 10,000). A progression of methods of pretreatment was seen in the 10-year period reviewed. Seventeen patients received no treatment before admission for surgery, and 10 of these received platelet transfusions. Seventeen patients received steroids immediately preceding surgery; 16 of these responded and 1 received a platelet transfusion. Recently, 5 patients received intravenous gamma globulin (IgG) preceding surgery with all patients responding and none receiving platelet transfusions. One patient received a combination of steroids and IgG with good response and did not require platelet transfusion. No major postoperative complications occurred (ie, pancreatitis, small bowel obstruction, or sepsis) except for one patient requiring a secondary exploration for an accessory spleen and recurrent thrombocytopenia. Eight patients (20%), 6 with severe ITP and 2 with chronic ITP (5 males and 3 females) developed recurrence of thrombocytopenia following surgery up to 1 1/2 years after splenectomy. These patients all required further medical therapy. Three additional patients (2 chronic and 1 severe) developed thrombocytopenia following viral illnesses, but required no further therapy. Of the 8 surgical failures, 4 failed to respond to prior treatment with steroids, 1 to IgG, and 2 failed to respond to combination therapy, while one surgical failure responded to both steroid and combination therapy. Of the responders to splenectomy (32 patients), only 3 failed to respond to prior treatment with steroids.(ABSTRACT TRUNCATED AT 250 WORDS)

Systemic lupus erythematosus presenting initially with acute pancreatitis and a review of the literature

A patient with systemic lupus erythematosus is reported whose initial clinical presentation was that of acute pancreatitis, confirmed by pancreatic isoamylase elevation and pancreatic enlargement on computerized tomography. A lack of a correlation with steroid therapy and a need to document pancreatitis in a multisystem disease like lupus with radiographic evidence as well as pancreatic isoamylase elevations is emphasized.

Pathologic features of gastrointestinal tract lesions in childhood-onset systemic lupus erythematosus: study of 26 patients, with review of the literature

A review of the gastrointestinal tracts of 26 autopsied cases of childhood-onset systemic lupus erythematosis (SLE) showed the single most common pathologic finding to be chronic nonspecific mucosal infiltration (96%). The most frequent general category was ischemic bowel lesions, attributable to vascular lesions of SLE (60%) or to nonocclusive causes of circulatory insufficiency such as congestive heart failure, uremia, or shock (40%). Complications of ischemic bowel lesions included secondary invasion by opportunistic organisms such as Candida (9 patients), pneumatosis intestinalis (1), and perforation of a gastroesophageal ulcer (1). Colonic ulcers, clearly ischemic in etiology, were noted in 6 patients, none of whom had other bowel lesions resembling those of Crohn's disease or ulcerative colitis. Other relevant findings included ascites (88%), peritoneal inflammation or fibrosis (42%), upper esophageal skeletal muscle fiber atrophy (8%), heterotopic calcification of gastric mucosa (12%), and severe intestinal mucus inspissation (4%). Correlations between the various lesions and clinical manifestations, and possible etiologic and pathogenetic mechanisms of these lesions, are discussed.

Jejunal perforation possibly induced by slow-release potassium in a patient with Crohn's disease

A case of small bowel ulceration and perforation possibly due to therapy with Klotrix in a patient with Crohn's disease is presented. Following emergent surgery with creation of a diverting loop jejunostomy, subsequent reestablishment of intestinal continuity was carried out with excellent clinical results. Gastrointestinal mucosal lesions possibly due to wax-matrix potassium chloride preparations are reviewed.

Oral glucocorticoids and their complications. A review

Glucocorticoid preparations form one of the cornerstones of the modern medical pharmacopeia. This class of medications has been especially useful to dermatologists, who are purported to be among its most prolific users. Oral glucocorticoids, available now for over 30 years, are prescribed to over 7% of hospitalized patients. Of this group, some 17% may experience adverse effects. It behooves any physician who uses these powerful agents to be aware of the potential complications and side effects. In this article we have undertaken to summarize and discuss selective examples of this rapidly growing segment of the literature.

What's new in Osmosin and intestinal perforation?

New formulations of drugs may have unexpected side effects. Osmosin is a new osmotic-pump controlled-release formulation of Indomethacin, designed to prevent gastrointestinal irritation. However, in a small number of cases the use of Osmosin has coincided with perforation of the small and large intestine, probably because passage of the tablet through the gastrointestinal tract was impeded.

Acute perforation of sigmoid diverticula

Forty patients underwent operative therapy for acute perforation of colonic diverticula. The group I patients had some localization of infection, group II had generalized feculent-purulent contamination with free perforation, and group III had free perforation and were treated with chronic steroids for various medical disorders. The retrospective evaluation was directed at evaluating the effect on survival of methods to treat the hole in the colon and methods to treat peritoneal contamination. It is concluded that control of the perforation in the bowel and aggressive peritoneal irrigation may decrease the high morbidity and mortality rates.

Changes in gastric parietal cells during prolonged intermittent corticosteroid treatment

Immature A/J mice were treated for up to 7 weeks with intermittent doses of triamcinolone hexacetonide and were thereafter allowed to recover for 7 weeks. Structural examinations and morphological measurements were performed on the parietal cells in the gastric mucosa. By the 3rd injection a significant decrease was noted in the number of the above cells - a feature that lasted throughout the experimental period. In contrast, the diameter of the parietal cells increased. However, following recovery, the latter returned to their normal size.

Bowel perforation in steroid-treated patients

Gastrointestinal perforation in patients receiving glucocorticosteroid (GCS) therapy has been reported to have mortality rates as high as 100%. From 79 patients seen during a nine-year period, three groups were formed according to GCS dosage: group 1 (steroid perioperative coverage), group 2 (low-dose steroids, prednisone < 20 mg daily), and group 3 (high-dose steroids, prednisone greater than or equal to 20 mg daily). Of 11 clinical presentation factors, only abdominal tenderness was consistently present in group 3. The mean delay from onset of symptoms to treatment for group 3 was 8.3 days and was in marked contrast to that for group 1 or 2, 1.7 and 2.2 days, respectively (p < 0.005). Mortality increased from 11.8% in group 1 to 13.3% in group 2 to 85% in group 3. High-dose GCS therapy decreased the clinical expression of peritonitis to the point that recognition and, therefore, treatment of gastrointestinal perforation were markedly delayed. In a patient receiving high-dose GCS, a high degree of clinical suspicion must accompany any new abdominal discomfort, and aggressive diagnostic efforts should be made to establish the cause. If abdominal pain persists, surgical exploration should be considered.

Perforated stress ulcer in infants: a silent threat

Stress ulcer has become an important clinical entity and its two major complications--bleeding and perforation--are among the most baffling problems, in terms of management, in clinical practice. Perforation, though the less common of the two, is perhaps the most formidable particularly when this occurs in a very sick infant. Four such infants (cyanotic heart disease, gastroenteritis and two severe pneumonias) all developed this severe complication of their illness and after surgery two survived. Two of these infants presented with bleeding prior to perforation of their stress ulcer. The perforation diagnosis was initially not apparent and was first made after radiological examination. Clinical signs of peritonitis were absent as these infants were too sick for such signs to be elicited. All four ulcers were situated in the posterior wall of the duodenum. Two of these infants developed cardiac complications on the operating table, the cause of which was not very clear. It may have been due to the debilitation of these babies with the additional effect of anesthesia perhaps leading to myocardial toxicity. It is therefore recommended that: all sick infants on steroid therapy be placed on prophylactic antacids; abdominal girth measurements be taken frequently in sick infants to appreciate any unexplained increase in girth; such increase in abdominal girth must be evaluated with an upright abdominal x-ray; operative closure of the perforation must be simple and expedient.

Factors which influenced postoperative complications in patients with ulcerative colitis or Crohn's disease of the colon on corticosteroids

A retrospective analysis was undertaken of the records of 107 patients with Crohn's disease of the colon or with ulcerative colitis who underwent 162 operations under steroid cover. The study revealed no correlation between steroid dosage and postoperative morbidity or mortality. The incidence of wound dehiscence and incisional hernia compared favourably with the reports of other unselected series of similar patients. Contamination did significantly influence results. Septic complications were more frequent when the operative field was contaminated and both delayed wound healing and mortality were related to this sepsis. A ;clean and dirty' technique was effective in controlling contamination during elective bowel division but preoperative bowel perforation and accidental entry into the lumen of the bowel during dissection were potentially avoidable sources of contamination. Primary healing of the perineal wound after proctocolectomy was seldom achieved in contaminated patients where a drain tube was brought out through the main perineal incision. When perineal sinuses or fistulae followed a proctocolectomy, patients with Crohn's disease had a significantly slower rate of healing than did patients with ulcerative colitis. However, there was no difference in the healing of abdominal wounds in relation to the primary pathology. Even abdominal incisions which were used on more than one occasion healed as well as those which were used for the first time. A prophylactic antibiotic regime of either ampicillin or tetracycline offered little protection against postoperative sepsis. The organisms which caused such infections were often insensitive to the two antibiotics.

Drug consumption before perforation of peptic ulcer

In a retrospective study of 195 patients with a perforated peptic ulcer 18 per cent of the patients had taken aspirin, phenylbutazone or corticosteroids during the period before the perforation. In a controlled prospective trial, 18 of 22 patients (82 per cent) had taken drugs known to be potentially harmful to the stomach. Aspirin was the drug mainly used. Thirteen of 22 patients had taken the drugs within 12 hours of the perforation, usually because of symptoms not related to the gastro-intestinal tract. Drug consumption and perforation of pre-pyloric ulcers were most closely associated; the latter applies particularly to female patients, who either had only a short history of upper gastro-intestinal dyspepsia or were asymptomatic.

Incidence of stress ulcer formation associated with steroid therapy in various shock states

The use of pharmacologic doses of steroids early in the shock state, within the first hour when possible, for periods of less than forty-eight hours seems to reduce the incidence of gastric ulceration and hemorrhage in low flow states associated with septic, cardiogenic, and hemorrhagic shock.

Pathophysiology of stress ulcer and its prevention. I. Pharmacologic doses of steroid

The efficacy of a large dose of Decadron on stress ulcer formation in restrained rats has been studied using microangiohistologic technics. When a pharmacologic dose of Decadron was administered twenty-four hours prior to the procedure, Dacadron prevented ulcer formation.