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

Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines

BACKGROUND

Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis.

STUDY DESIGN AND METHODS

Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation.

RESULTS

The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused.

INTERPRETATION

Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.

Association Between Postoperative Decrease of Albumin and Outcomes in Patients Undergoing Craniotomy for Brain Tumors

BACKGROUND

Serum albumin reflects nutritional status and is associated with postoperative complications and mortality. Delta albumin (ΔAlb), defined as the difference between preoperative and lowest postoperative levels, could predict complications and mortality, even with postoperative levels above 30 g/L prompting albumin infusions. This study aimed to assess how ΔAlb relates to outcomes in craniotomy patients with brain tumors.

METHODS

This retrospective study screened patients diagnosed with a brain tumor who underwent cerebral surgery from a single Chinese hospital between December 2010 and April 2021. Patients were divided into 4 groups based on their ΔAlb levels: <5 g/L (normal), 5-9.9 g/L (mild ΔAlb), 10-14.9 g/L (moderate ΔAlb), and ≥15 g/L (severe ΔAlb). The primary outcome was postoperative 30-day mortality.

RESULTS

Among the 9660 patients undergoing craniotomy for brain tumors, the median ΔAlb level after craniotomy was 7.3 g/L. ΔAlb was associated with increased postoperative 30-day mortality; odds ratios for mild, moderate, and severe ΔAlb were 1.93 (95% confidence interval [CI], 1.17-3.18, P = 0.01), 2.21 (95% CI, 1.28-3.79, P = 0.004), and 7.26 (95% CI, 4.19-12.58, P < 0.01), respectively. Significantly, ΔAlb >5 g/L was found to have a strong association with a higher risk of mortality, even when the nadir Alb remained greater than 30 g/L (odds ratio, 1.84; 95% CI, 1.13-3.00, P = 0.014).

CONCLUSIONS

Among patients undergoing craniotomy for brain tumor resection, a mild degree of ΔAlb was associated with increased 30-day mortality, even if the nadir Alb remained greater than 30 g/L. Moreover, ΔAlb was associated with postoperative complications and longer lengths of stay.

Assessing the perioperative gain of weight (Δweight) as a determinant of morbidity after kidney transplantation: a retrospective exploratory study

Kidney transplantation (KT) is associated with a substantial risk of postoperative complications (POC) for which performant predictors are lacking. Data showed that a perioperative gain of weight (ΔWeight) was associated with higher risk of POC, but it remains unexplored in KT. This retrospective study aimed to investigate the association between ΔWeight and POC after KT. ΔWeight was calculated on postoperative day (POD) 2. POC were graded according to the Dindo-Clavien classification. Primary endpoint was overall POC. A total of 242 patients were included and 174 (71.9%) complications were reported. Patients showed a rapid gain of weight after KT. Mean ΔWeight was 7.83 kg (± 3.20) compared to 5.3 kg (± 3.56) in patients with and without complication, respectively (p = 0.0005). ΔWeight showed an accuracy of 0.74 for overall POC. A cut-off of 8.5 kg was determined. ΔWeight ≥ 8.5 kg was identified as an independent predictor of overall POC on multivariable analysis (OR 2.04; 95% CI 1.08-3.84; p = 0.025). ΔWeight ≥ 8.5 kg appeared as an independent predictor of POC after KT. These results stress the need to monitor weight in KT and to further investigate this surrogate with future studies assessing its clinical relevance.

Association between admission albumin levels and 30-day readmission after hip fracture surgery in geriatric patients: a propensity score-matched study

PURPOSE

This study aimed to evaluate the correlation admission albumin levels and 30-day readmission after hip fracture surgery in geriatric patients.

METHODS

In this retrospective cohort study, 1270 geriatric patients admitted for hip fractures to a level I trauma center were included. Patients were stratified by clinical thresholds and albumin level quartiles. The association between admission albumin levels and 30-day readmission risk was assessed using multivariate logistic regression and propensity score-matched analyses. The predictive accuracy of albumin levels for readmission was evaluated by ROC curves. The dose-response relationship between albumin levels and readmission risk was examined.

RESULTS

The incidence of 30-day readmission was significantly higher among hypoalbuminemia patients than those with normal albumin levels (OR = 2.090, 95%CI:1.296-3.370, p = 0.003). Furthermore, propensity score-matched analyses demonstrated that patients in the Q2(35.0-37.9 g/L) (OR 0.621, 95%CI 0.370-1.041, p = 0.070), Q3(38.0-40.9 g/L) (OR 0.378, 95%CI 0.199-0.717, p < 0.001) and Q4 (≥ 41 g/L) (OR 0.465, 95%CI 0.211-0.859, p = 0.047) quartiles had a significantly lower risk of 30-day readmission compared to those in the Q1(< 35 g/L) quartile. These associations remained significant after propensity score matching (PSM) and subgroup analyses. Dose-response relationships between albumin levels and 30-day readmission were observed.

CONCLUSIONS

Lower admission albumin levels were independently associated with higher 30-day readmission rates in elderly hip fracture patients. Our findings indicate that serum albumin may assist perioperative risk assessment, and prompt correction of hypoalbuminemia and malnutrition could reduce short-term readmissions after hip fracture surgery in this high-risk population.

Rural Women Have a Prolonged Recovery Process after Esophagectomy

BACKGROUND

Gender and geographic access to care play a large role in health disparities in esophageal cancer care. The aim of our study was to evaluate disparities in peri-operative outcomes for patients undergoing esophagectomy based on gender and geographic location.

METHODS

A retrospective cohort of prospectively collected data from patients who underwent esophagectomy from 2003 to 2022 was identified and analyzed based on gender and county, which were aggregated into existing state-level "metropolitan" versus "rural" designations. The demographics, pre-operative treatment, surgical complications, post-operative outcomes, and length of stay (LOS) of each group were analyzed using chi-squared, paired t-tests and single-factor ANOVA.

RESULTS

Of the 1545 patients, men (83.6%) and women (16.4%) experienced similar rates of post-operative complications, but women experienced significantly longer hospital (p = 0.002) and ICU (p = 0.03) LOSs as compared with their male counterparts, with no differences in 30-day mortality. When separated by geographic criteria, rural women were further outliers, with significantly longer hospital LOSs (p < 0.001) and higher rates of ICU admission (p < 0.001).

CONCLUSIONS

Rural female patients undergoing esophagectomy were more likely to have a longer inpatient recovery process compared with their female metropolitan or male counterparts, suggesting a need for more targeted interventions in this population.

Biochemical implications of robotic surgery: a new frontier in the operating room

Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.

Association between early postoperative hypoalbuminaemia and outcome after orthotopic heart transplantation

OBJECTIVES

In patients undergoing heart transplantation (HTX), preoperative liver impairment and consecutive hypoalbuminaemia are associated with increased mortality. The role of early postoperative hypoalbuminaemia after HTX is unclear. This study investigated the association between early postoperative hypoalbuminaemia and 1-year mortality as well as 'days alive and out of hospital' (DAOH) after HTX.

METHODS

This retrospective cohort study included patients who underwent HTX at the University Hospital Duesseldorf, Germany, between 2010 and 2022. The main exposure was serum albumin concentration at intensive care unit (ICU) arrival. The primary endpoints were mortality and DAOH within 1 year after surgery. Receiver operating characteristic (ROC) curve analysis was performed and logistic and quantile regression models with adjustment for 13 a priori defined clinical risk factors were conducted.

RESULTS

Out of 241 patients screened, 229 were included in the analysis (mean age 55 ± 11 years, 73% male). ROC analysis showed moderate discrimination for 1-year mortality by postoperative serum albumin after HTX [AUC = 0.74; 95% confidence interval (CI): 0.66-0.83]. The cutoff for serum albumin at ICU arrival was 3.0 g/dl. According to multivariate logistic and quantile regression, there were independent associations between hypoalbuminaemia and mortality/DAOH [odds ratio of 4.76 (95% CI: 1.94-11.67) and regression coefficient of -46.97 (95% CI: -83.81 to -10.13)].

CONCLUSIONS

Postoperative hypoalbuminaemia <3.0 g/dl is associated with 1-year mortality and reduced DAOH after HTX and therefore might be used for early postoperative risk re-assessment in clinical practice.

Identifying the best candidates for reduced port gastrectomy

BACKGROUND

Previous studies have focused on the non-inferiority of RPG compared with conventional port gastrectomy (CPG); however, we assumed that some candidates might derive more significant benefit from RPG over CPG.

METHODS

We retrospectively analyzed the clinicopathological and perioperative parameters of 1442 patients with gastric cancer treated by gastrectomy between 2009 and 2022. The C-reactive protein level on postoperative day 3 (CRPD3) was used as a surrogate parameter for surgical trauma. Patients were grouped according to the extent of gastrectomy [subtotal gastrectomy (STG) or total gastrectomy (TG)] and lymph node dissection (D1+ or D2). The degree of surgical trauma, bowel recovery, and hospital stay between RPG and CPG was compared among those patient groups.

RESULTS

Of 1442 patients, 889, 354, 129, and 70 were grouped as STGD1+, STGD2, TGD1+, and TGD2, respectively. Compared with CPG, RPG significantly decreased CRPD3 only among patients in the STGD1+ group (CPG: n = 653, 84.49 mg/L, 95% CI 80.53-88.45 vs. RPG: n = 236, 70.01 mg/L, 95% CI 63.92-76.09, P < 0.001). In addition, the RPG method significantly shortens bowel recovery and hospital stay in the STGD1+ (P < 0.001 and P < 0.001), STGD2 (P < 0.001 and P < 0.001), and TGD1+ (P = 0.026 and P = 0.007), respectively. No difference was observed in the TGD2 group (P = 0.313 and P = 0.740).

CONCLUSIONS

The best candidates for RPG are patients who undergo STGD1+, followed by STGD2 and TG D1+, considering the reduction in CRPD3, bowel recovery, and hospital stay.

Exploring ideal operative time for best outcomes in gastric cancer surgery: A multi-institutional study based on KLASS-07 database

Objective

While a rushed operation can omit essential procedures, prolonged operative time results in higher morbidity. Nevertheless, the optimal operative time range remains uncertain. This study aimed to estimate the ideal operative time range and evaluate its applicability in laparoscopic cancer surgery.

Methods

A prospectively collected multicenter database of 397 patients who underwent laparoscopic distal gastrectomy were retrospectively reviewed. The ideal operative time range was statistically calculated by separately analyzing the operative time of uneventful surgeries. Finally, intraoperative and postoperative outcomes were compared among the shorter, ideal, and longer operative time groups.

Results

The statistically calculated ideal operative time was 135.4-165.4 min. The longer operative time (LOT) group had a lower rate of uneventful, perfect surgery than the ideal or shorter operative time (IOT/SOT) group (2.8% vs. 8.8% and 2.2% vs. 13.4%, all P<0.05). Longer operative time increased bleeding, postoperative morbidities, and delayed diet and discharge (all P<0.05). Particularly, an uneventful, perfect surgery could not be achieved when the operative time exceeded 240 min. Regardless of ideal time range, SOT group achieved the highest percentage of uneventful surgery (13.4%), which was possible by surgeon's ability to retrieve a higher number of lymph nodes and perform ≥150 gastrectomies annually.

Conclusions

Operative time longer than the ideal time range (especially ≥240 min) should be avoided. If the essential operative procedure were faithfully conducted without compromising oncological safety, an operative time shorter than the ideal range leaded to a better prognosis. Efforts to minimize operative time should be attempted with sufficient surgical experience.

Albumin and fibrinogen synthesis rates in advanced chronic liver disease

Synthesis of plasma proteins is an important function of the liver that has sparsely been investigated by modern techniques in patients with advanced chronic liver disease (CLD). Twenty-eight well-characterized patients with CLD under evaluation for liver transplantation were included. Albumin and fibrinogen synthesis rates were measured by the flooding dose technique using stable isotope-labeled phenylalanine. Transcapillary escape rate of albumin and plasma volume were assessed by radioiodinated human serum albumin. The absolute albumin synthesis rates were low (65 mg/kg/day, range: 32-203) and were associated with impaired liver function, as reflected by the risk-scores Child-Pugh (P = 0.025) and model for end-stage liver disease (rs = -0.62, P = 0.0005). The fibrinogen synthesis rate (12.8 mg/kg/day, range: 2.4-52.9) was also negatively associated with liver function. The synthesis rates of albumin and fibrinogen were positively correlated. Plasma volume was high (51 ± 9 mL/kg body wt), which contributed to an almost normal intravascular albumin mass despite low plasma concentration. Autoimmune inflammatory etiologies to CLD were associated with higher fibrinogen synthesis. De novo synthesis rates of albumin and fibrinogen in advanced chronic liver failure were negatively correlated to prognostic scores of liver disease. Albumin synthesis rate was low and associated with both liver failure and autoimmune inflammation, whereas fibrinogen synthesis was often normal and positively associated with chronic inflammation. This is different from acute inflammatory states in which both albumin and fibrinogen synthesis rates are high.NEW & NOTEWORTHY Albumin and fibrinogen synthesis were positively correlated, but the high variation indicates that these are probably influenced by different mechanisms. There might be a limited metabolic reserve for the liver to increase both albumin and fibrinogen synthesis in response to longstanding inflammation in CLD and fibrinogen seems to be prioritized.

The role of comorbidity indices and histochemical markers in surgically resected and non-resected primary central nervous system lymphoma

The role of surgical resection in primary central nervous system lymphoma (PCNSL) was not recognized until recently. However, prognostic factors for surgically treated PCNSL remain unclear. In the present study, we aimed to identify and compare the prognostic value of comorbidity indices and immunohistochemical markers in patients with surgically and non-surgically treated PCNSL. This retrospective single-center study analyzed patients who underwent either surgical resection or stereotactic biopsy for newly diagnosed PCNSL between January 2012 and December 2021. Clinical demographics, comorbidity indices, and immunohistochemical markers were analyzed. We included 23 and 18 patients who underwent stereotactic biopsy and surgical resection, respectively. The median overall survival (OS) was 11.05 months. Using multivariate Cox regression, we identified pretreatment prognostic nutritional index (PNI) (p = 0.009), positive BCL2 staining (p = 0.026), and infratentorial involvement (p = 0.004) as independent prognostic factors of OS. Predictors of progression-free survival (PFS) included PNI (p = 0.040), infratentorial involvement (p = 0.021), and surgical resection for PCNSL (p = 0.048). Subgroup analyses revealed that positive BCL2 (p = 0.048) and PD-L1 (p = 0.037) staining were associated with worse OS in the biopsy group. PNI and infratentorial involvement could significantly impact both OS and PFS in patients with PCNSL. Surgical resection could predict favorable PFS but not OS. Moreover, BCL2 and PD-L1 expression can be employed as prognostic markers in these patients.

A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy

BACKGROUND

Small bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management.

METHODS

Clinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation.

RESULTS

The nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775-0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686-0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model's area under the curve was 0.815 (95% confidence interval, 0.683-0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present.

CONCLUSION

The clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.

Predictive markers in estimating the need for early intensive care in patients with adhesive small bowel obstruction in the emergency department

Introduction

Adhesive small-bowel obstruction (ASBO) is a common condition requiring emergency room admission, and predicting the need for intensive care unit (ICU) hospitalisation is crucial for optimal patient management. This study aimed to investigate the predictive value of various scores and indices in determining ICU requirements in patients with ASBO.

Patients and Methods

Seventy patients diagnosed with ASBO and managed nonoperatively were included in the study. Data on patient demographics, laboratory values, imaging findings, previous hospitalisations and comorbidities were collected. The Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index (CCI) score and C-reactive protein (CRP)/albumin ratio were calculated. Patients were categorised into ICU and non-ICU groups for analysis.

Results

The ICU group comprised patients with higher number of previous ASBO hospitalisations and longer hospitalisation days. Serum albumin levels were significantly lower and the maximum small-bowel horizontal diameter was significantly higher in the ICU group. The SOFA score and CCI score were significantly higher in the ICU group. The CRP/albumin ratio showed a trend towards significance.

Conclusion

The number of days since the last stool discharge, SOFA score and CCI score demonstrated significant associations with ICU requirements in ASBO patients. These findings highlight the importance of assessing organ dysfunction, comorbidities and gastrointestinal function during patient triage. Our study provides valuable insights into predicting ICU need in ASBO patients, aiding in resource allocation and patient management.

Predictive Value of Risk Factors for Pharyngocutaneous Fistula After Total Laryngectomy

OBJECTIVES

To assess the predictive value of various risk factors for pharyngocutaneous fistula (PCF) after total laryngectomy.

METHODS

The characteristics of each study were collected from six databases up to January of 2022. Risk for bias was assessed using the QUADAS-2 tool.

RESULTS

A total of 58 studies in 9845 patients were included in the analysis. The incidence of PCF was 21.69%, 95% confidence intervals (CI) [0.20; 0.24] in the included studies. Age (OR = 1.33, 95% CI [1.12; 1.58]), postoperative anemia (OR = 2.29, 95% CI [1.47; 3.57]), diabetes mellitus (OR = 1.81, 95% CI [1.20; 2.71]), tumor site (above or below the glottis) (OR = 1.47, 95% CI [1.15; 1.88]), previous radiation therapy (OR = 2.06, 95% CI [1.56; 2.72]), previous tracheostomy (OR = 1.26, 95% CI [1.04; 1.53]), surgery timing (salvage vs. primary) (OR = 2.08, 95% CI [1.46; 2.97]), extended total laryngectomy (including pharyngectomy) (OR = 1.96, 95% CI [1.28; 3.00]), primary tracheoesophageal puncture (OR = 0.61, 95% CI [0.40; 0.93]), and postoperative hypoproteinemia (OR = 9.98, 95% CI [3.68; 27.03]) were significantly associated with the occurrence of PCF. In view of predictive ability, postoperative hypoproteinemia showed the highest accuracy (sensitivity = 51%, specificity = 90%, area under the curve = 0.84).

CONCLUSION

Multiple patient-, disease-, and surgery-related factors are risk factors for PCF. In particular, postoperative hypoproteinemia could be a good predictive factor for PCF in patients undergoing total laryngectomy. Laryngoscope, 133:742-754, 2023.

Relative decline in serum albumin help to predict anastomotic leakage for female patients following sphincter-preserving rectal surgery

BACKGROUND

Patients with normal preoperative serum albumin still suffer from a significant reduction in serum albumin after major abdominal surgery. The current study aims to explore the predictive value of ∆ALB for AL in patients with normal serum albumin and examine whether there is a gender difference in the prediction of AL.

METHODS

Medical reports of consecutive patients undergoing elective sphincter-preserving rectal surgery between July 2010 and June 2016 were reviewed. Receiver operating characteristic (ROC) analysis was adopted to examine the predictive ability of ∆ALB and determine the cut-off value according to the Youden index. The logistic regression model was performed identify independent risk factors for AL.

RESULTS

Out of the 499 eligible patients, 40 experienced AL. Results of the ROC analyses showed that ΔALB displayed a significant predictive value for females, and the AUC value was 0.675 (P = 0.024), with a sensitivity of 93%. In male patients, the AUC was 0.575 (P = 0.22), but did not reach a significant level. In the multivariate analysis, ∆ALB ≥ 27.2% and low tumor location prove to be independent risk factors for AL in female patients.

CONCLUSIONS

The current study suggested that there may be a gender difference in the prediction of AL and ∆ ALB can serve as a potential predictive biomarker for AL in females. A cut-off value of the relative decline in serum albumin can help predict AL in female patients as early as postoperative day 2. Although our study needs further external validation, our findings may provide an earlier, easier and cheaper biomarker for the detection of AL.

Development and validation of a user-friendly risk nomogram for the prediction of catheter-associated urinary tract infection in neuro-intensive care patients

OBJECTIVE

This study aimed to develop a user-friendly nomogram model to evaluate the risk of catheter-associated urinary tract infections in neuro-critically ill patients.

METHODS

A retrospective cohort analysis was conducted on 537 patients with indwelling catheters admitted to the neuro-intensive care unit. Patients' general information, laboratory examination findings, and clinical characteristics were collected. Multivariate regression analysis was applied to develop the nomogram for the prediction of catheter-associated urinary tract infections in this group of patients. The discriminative capacity, calibration ability, and clinical effectiveness of the nomogram were evaluated.

RESULTS

The occurrence of catheter-associated urinary tract infections was 3.91 % and Escherichia coli was the major causative pathogen. Multivariate regression analysis showed that age ≥ 60 years (odds ratio: 35.2, 95 % confidence interval: 2.3-550.8), epilepsy (39.3, 5.1-301.4), a length of neuro-intensive care stay > 30 days (272.2, 8.3-8963.5), and low albumin levels (<35 g/L) (12.1, 2.1-69.9) were independent risk factors associated with catheter-associated urinary tract infection in neuro-intensive care patients. The nomogram demonstrated good calibration and discrimination in both the training and the validation sets. The model exhibited good clinical use since the decision curve analysis covered a large threshold probability.

CONCLUSIONS

We developed a user-friendly nomogram to predict catheter-associated urinary tract ibfection in neuro-intensive care patients. The nomogram incorporated clinical variables collected on admission (age, admission diagnosis, and albumin levels) and the length of stay and enabled the effective prediction of the likelihood of catheter-associated urinary tract infections.

Hypoalbuminemia within One Hour After Surgery as a Predictor of Post-Operative Urosepsis in Patients Undergoing Flexible Ureteroscopy Lithotripsy: A Retrospective Study

Abstract Background: To investigate retrospectively whether changes in serum albumin levels within one hour of flexible ureteroscopy (fURS) lithotripsy can be used as a predictor of post-operative urosepsis. Patients and Methods: Eligible patients with unilateral upper urinary calculi who underwent fRUS lithotripsy performed by a single surgeon at our center were included in the analysis. The patients were divided into sepsis and non-sepsis groups. The change ratio of albumin and white blood cell (WBC) count was calculated by post-operative/pre-operative index*100%. Univariable and multivariable logistic regression analyses were used to assess whether there was a correlation between risk factors and post-operative urosepsis. The receiver operating characteristic (ROC) curve was used to analyze factors that showed significant differences in multivariable logistic regression analysis. Results: A total of 314 patients were included in the analysis, 20 of whom had post-operative urosepsis and five developed septic shock; no deaths occurred. Multivariable logistic regression analysis showed that urine culture results, WBC counts within one hour after surgery, post-operative albumin levels, and the degree of albumin changes after surgery were independent predictors of post-operative urosepsis. Receiver operating characteristic curve analysis showed that noteworthy hypoalbuminemia after surgery and positive pre-operative urine culture could help screen high-risk patients for post-operative urosepsis effectively. Conclusions: Hypoalbuminemia shortly after operation can be utilized as a predictor for early diagnosis of post-operative urosepsis in patients undergoing fURS lithotripsy.

Preoperative Risk Factors for Predicting Postoperative Human Serum Albumin Infusion after Hip Fracture Surgery: Development and Validation of a Nomogram

Background

As one of the adverse events after hip fracture surgery, hypoalbuminemia is usually treated using human serum albumin infusion. However, the application of human serum albumin may cause complications such as postsurgical infection and increased mortality.

Aims

To examine the preoperative risk factors of human serum albumin infusion after hip fracture surgery, establish a nomogram prediction model, and verify its accuracy.

Study Design

A retrospective cross-sectional study.

Methods

Eligible patients who underwent hip fracture surgery were divided into the infusion and non-infusion groups according to whether human serum albumin was infused or not. All patients were divided randomly into a training set and a testing set in line with the ratio of 7:3. In the training set, independent risk factors of postoperative human serum albumin infusion were determined by univariate logistic regression analysis, LASSO regression, and multivariate logistic regression analysis. Then, a nomogram model was established. Furthermore, the receiver operating characteristic curve and calibration curve were plotted, and decision curve analysis was performed for the training and testing sets to assess the predictability, discriminative ability, and clinical usefulness of the model.

Results

This study included a total of 1,339 eligible patients, 141 of whom were injected with human serum albumin postoperatively. Altogether, the training set incorporated 939 patients, and the testing set included 400 patients. Multivariate logistic analysis indicated five independent risk factors, including chronic lung disease (odds ratio, 95% confidence interval, 2.618, 1.413-4.849, p = 0.002), (albumin; odds ratio, 95% confidence interval, 0.842, 0.787-0.900, p < 0.001), prothrombin time (odds ratio, 95% confidence interval, 1.252, 1.071-1.463, p = 0.005), red blood cells (odds ratio, 95% confidence interval, 0.370, 0.228-0.602, p < 0.001), and type of anesthesia (odds ratio, 95% confidence interval, 0.553, 0.327-0.937, p = 0.028). Fracture type, a clinically significant factor, was also considered. Finally, the nomogram model was built based on these seven predictors. The areas under the curve of the nomogram were 0.854 (95% confidence interval, 0.811-0.898) and 0.767 (95% confidence interval, 0.686-0.847) in the training and testing sets separately. As shown in the calibration curve, the predicted result was consistent with the observed one. The decision curve analysis indicated that the nomogram has good clinical value.

Conclusion

Low preoperative serum albumin levels, low preoperative red blood cell counts, prolonged preoperative prothrombin time, history of chronic lung disease, and general anesthesia were independent risk factors for postoperative human serum albumin infusion. Besides, the fracture type, clinically significant factor, was also included. The nomogram that combined these six predictors could accurately predict the risk of postoperative human serum albumin infusion.

What are Risk Factors of Postoperative Pneumonia in Geriatric Individuals after Hip Fracture Surgery: A Systematic Review and Meta-Analysis

Postoperative pneumonia (POP) is a common postoperative complication. Negative consequences associated with POP included prolonged hospital length of stay, more frequent intensive care unit (ICU) stays, and a higher rate of sepsis, readmission, and mortality. This meta-analysis aimed to assess the incidence and risk factors associated with POP after hip fracture surgery in elderly patients. PubMed, Web of Science, and Cochrane Library were searched (up to March 31, 2022). All studies on the risk factors for POP after hip fracture surgery in elderly patients, published in English, were reviewed. The qualities of the included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled, and a meta-analysis was performed. Ten studies, including 12,084 geriatric patients undergoing hip fracture surgery, were included. Of these 12,084 patients, POP occurred in 809 patients. The results indicated that age (mean difference [MD] = 4.95, 95% confidence interval [CI]: 3.22-6.69), male (odds ratio [OR] = 1.41, 95% CI: 1.02-1.93), the American Society of Anaesthesiologists classification ≥3 (OR = 3.48, 95% CI: 1.87-6.47), dependent functional status (OR = 5.23, 95% CI: 2.18-12.54, P = 0.0002), smoking (OR = 1.33, 95% CI: 1.07-1.65), chronic obstructive pulmonary disease (OR = 3.76, 95% CI: 2.07-6.81), diabetes mellitus (OR = 1.19, 95% CI: 1.01-1.40), coronary heart disease (OR = 1.74, 95% CI: 1.23-2.46), arrhythmia (OR = 1.47, 95% CI: 1.01-2.14), cerebrovascular disease (OR = 1.88, 95% CI: 1.56-2.27), dementia (OR = 2.36, 95% CI: 1.04-5.36), chronic renal failure (OR = 1.85, 95% CI: 1.29-2.67), hip arthroplasty (OR = 1.30, 95% CI: 1.08-1.56), delayed surgery (OR = 6.40, 95% CI: 3.00-13.68), preoperative creatinine (MD = 5.32, 95% CI: 0.55-10.08), and preoperative serum albumin (MD = -3.01, 95% CI: -4.21 - -1.80) were risk factors for POP. Related prophylactic measures should be provided in geriatric patients with the above-mentioned risk factors to prevent POP after hip fracture surgery.

Personalized diagnostic approach and indirect quantification of extravasation in human anaphylaxis

BACKGROUND

Anaphylaxis is the most acute and life-threatening manifestation of allergic disorders. Currently, there is a need to improve its medical management and increase the understanding of its molecular mechanisms. This study aimed to quantify the extravasation underlying human anaphylactic reactions and propose new theragnostic approaches.

METHODS

Molecular determinations were performed in paired serum samples obtained during the acute phase and at baseline from patients presenting with hypersensitivity reactions. These were classified according to their severity as Grades 1, 2 and 3, the two latter being considered anaphylaxis. Tryptase levels were measured by ImmunoCAP, and serum protein concentration was quantified by Bradford assay. Human serum albumin (HSA) and haemoglobin beta subunit (HBB) levels were determined by Western blot and polyacrylamide gel electrophoresis, respectively.

RESULTS

A total of 150 patients were included in the study. Of them, 112 had experienced anaphylaxis (83 and 29 with Grade 2 and 3 reactions, respectively). Tryptase diagnostic efficiency substantially improved when considering patients' baseline values (33%-54%) instead of the acute value threshold (21%). Serum protein concentration and HSA significantly decreased in anaphylaxis (p < .0001). HSA levels dropped with the severity of the reaction (6% and 15% for Grade 2 and 3 reactions, respectively). Furthermore, HBB levels increased during the acute phase of all hypersensitivity reactions (p < .0001).

CONCLUSIONS

For the first time, the extravasation underlying human anaphylaxis has been evaluated based on the severity of the reaction using HSA and protein concentration measurements. Additionally, our findings propose new diagnostic and potential therapeutic approaches for this pathological event.

Laparoscopic liver resection is associated with less significant muscle loss than the conventional open approach

BACKGROUND

Laparoscopic liver resections (LLR) have been shown a treatment approach comparable to open liver resections (OLR) in hepatocellular carcinoma (HCC). However, the influence of procedural type on body composition has not been investigated. The aim of the current study was to compare the degree of skeletal muscle loss between LLR and OLR for HCC.

METHODS

By using propensity score matching (PSM) analysis, 64 pairs of patients were enrolled. The change of psoas muscle index (PMI) after the operation was compared between the matched patients in the LLR and OLR. Risk factors for significant muscle loss (defined as change in PMI > mean change minus one standard deviation) were further investigated by multivariate analysis.

RESULTS

Among patients enrolled, there was no significant difference in baseline characteristics between the two groups. The PMI was significantly decreased in the OLR group (P = 0.003). There were also more patients in the OLR group who developed significant muscle loss after the operations (P = 0.008). Multivariate analysis revealed OLR (P = 0.023), type 2 diabetes mellitus, indocyanine green retention rate at 15 min (ICG-15) > 10%, and cancer stage ≧ 3 were independent risk factors for significant muscle loss. In addition, significant muscle loss was associated with early HCC recurrence (P = 0.006). Metabolomic analysis demonstrated that the urea cycle may be decreased in patients with significant muscle loss.

CONCLUSION

LLR for HCC was associated with less significant muscle loss than OLR. Since significant muscle loss was a predictive factor for early tumor recurrence and associated with impaired liver metabolism, LLR may subsequently result in a more favorable outcome.

An algorithm based on the postoperative decrease of albumin (ΔAlb) to anticipate complications after liver surgery

Background

Perioperative decrease of albumin (ΔAlb) appeared as a promising predictor of complications after digestive surgery, but its role after liver surgery remains unclear. This study aimed to analyze whether and how ΔAlb can be used to predict complications after liver surgery.

Methods

A bicentric retrospective analysis of patients undergoing liver surgery (2010–2016) was performed, following TRIPOD guidelines. The preoperative and postoperative difference of albumin was calculated on POD 0 and defined as ΔAlb. Patients with any missing variable were excluded. The primary endpoint was overall complications according to the Clavien classification. A multiparametric algorithm based on ΔAlb was generated to optimize prediction performance.

Results

A total of 110 patients were analyzed. At least one complication occurred in 66 (60%) patients. Patients with and without complication showed a ΔAlb of 15.8 vs. 9.5 g/L (p<0.001). Area under ROC curve (AUC) of ΔAlb was 0.75 (p<0.01.). The ΔAlb-based algorithm showed an AUC of 0.84 (p<0.01), significantly improving performance (p=0.03). Multivariable analysis identified ΔAlb as independent predictor of complications (HR, 1.12; 95% CI, 1.01–1.07; p = 0.002).

Conclusions

ΔAlb appeared as a promising predictor independently associated with the risk of complication after liver surgery. The study presents a novel decision-tree based on ΔAlb to anticipate complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00285-w.

The Association between Serum Albumin and Post-Operative Outcomes among Patients Undergoing Common Surgical Procedures: An Analysis of a Multi-Specialty Surgical Cohort from the National Surgical Quality Improvement Program (NSQIP)

While studies have demonstrated an association between preoperative hypoalbuminemia and adverse clinical outcomes, the optimal serum albumin threshold for risk-stratification in the broader surgical population remains poorly defined. We sought define the optimal threshold of preoperative serum albumin concentration for risk-stratification of adverse post-operative outcomes. Using the American College of Surgeons National Surgical Quality Improvement Program Database, we identified 842,672 patients that had undergone a common surgical procedure in one of eight surgical specialties. An optimal serum albumin concentration threshold for risk-stratification was determined using receiver-operating characteristic analysis. Multivariable logistic regression analysis was used to evaluate the odds of adverse surgical events; a priori defined subgroup analyses were performed. A serum albumin threshold of 3.4 g/dL optimally predicted adverse surgical outcomes in the broader cohort. After multivariable analysis, patients with hypoalbuminemia had increased odds of death within 30 days of surgery (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.94–2.08). Hypoalbuminemia was associated with greater odds of primary adverse events among patients with disseminated cancer (OR 2.03, 95% CI 1.88–2.20) compared to patients without disseminated cancer (OR 1.47, 95% CI 1.44–1.51). The standard clinical threshold for hypoalbuminemia is the optimal threshold for preoperative risk assessment.

The effect of pre-operative carbohydrate loading in femur fracture: a randomized controlled trial

BACKGROUND

Femur fracture is a major burden among elderly people, leading patients to be bedridden for a long time in the hospital. The body is more likely to be in a catabolic state as a result of the prolonged fasting period required for surgery, leading to an increase in insulin resistance. Pre-operative carbohydrate loading has been shown to improve postoperative outcomes in several countries. The study aimed to evaluate the effect of pre-operative carbohydrate loading in femur fracture surgery.

METHODS

This study was single-center, hospital-based, open-label, parallel-group randomized controlled trial conducted between August 2020 and November 2021. A total of 66 participants, aged 50 years and above having femur fractures planned for surgery were included in this study and assigned to the control (n = 33) and study (n = 33) groups through computer-generated random numbers. The control group was kept fasting from midnight to the next morning as in existence while the study group was intervened with carbohydrate loading according to the Enhanced Recovery After Surgery (ERAS) protocol. The pre-operative nutritional status was identified and the postoperative outcomes were measured using the Visual Analogue Score (VAS), Cumulative Ambulatory Score (CAS), and Modified Barthel Index (MBI) scoring systems. Statistical analyses were performed using the Chi-square test and the Student's two-sample t-test to compare the outcomes between the two groups.

RESULTS

All the participants completed the study. There was a significant reduction in the average postoperative pain in the carbohydrate loading group (VAS: 4.8 (SD ± 1.8), 95% CI: 4.7-5.4) as compared to the control group (VAS: 6.1 (SD ± 2.1), 95% CI: 5.3-6.8). The average CAS showed a significant improvement in regaining the mobility function of participants in the study group (CAS: 8.1 (SD ± 2.8), 95% CI: 7.1-9.1) than that of the control group (CAS: 6.8 (SD ± 2.8), 95% CI: 5.8-7.8). The mean MBI score of the participants at the time of discharge from the hospital was higher in the study group (MBI:13.1 (SD ± 2.3), 95% CI: 12.2-13.9) compared to the control group (MBI: 11.8 (SD ± 3.1), 95% CI:10.6-12.9). Similarly, the length of hospital stay after surgery had decreased in the study group than in the control group.

CONCLUSIONS

The uptake of carbohydrate loading showed reduced post-operative pain, enhanced functional mobility, and decreased length of hospital stay. This study warrants larger trials to show the effect of pre-operative carbohydrate loading in a clinical setting.

TRIAL REGISTRATION

NCT04838366, first registered on 09/042021 ( https://clinicaltrials.gov/ct2/show/NCT04838366 ).

Fibrinogen to Albumin Ratio as Early Serum Biomarker for Prediction of Intra-Hospital Mortality in Neurosurgical Intensive Care Unit Patients with Spontaneous Intracerebral Hemorrhage

Background: The prognostic value of the fibrinogen to albumin ratio on intrahospital mortality has been investigated in patients with cardiovascular disease, cancer, sepsis, and ischemic stroke; however, it has not been investigated for neurosurgical patients with spontaneous intracerebral hemorrhage (ICH). The present study investigates the impact of the fibrinogen to albumin ratio upon admission for intrahospital mortality in neurosurgical intensive care unit (ICU) patients with spontaneous ICH. Methods: A total of 198 patients with diagnosis of spontaneous ICH treated from 10/2008 to 12/2017 at our ICU were retrospectively analyzed. Blood samples were drawn upon admission, and the patients’ demographic, medical data, and cranial imaging were collected. Binary logistic regression analysis was performed to identify independent prognostic factors for intrahospital mortality. Results: The total rate of intrahospital mortality was 35.4% (n = 70). In the multivariate regression analysis, higher fibrinogen to albumin ratio (OR = 1.16, CI = 1.02−1.31, p = 0.03) upon admission was an independent predictor of intrahospital mortality in neurosurgical ICU patients with ICH. Moreover, a fibrinogen to albumin ratio cut-off level of >0.075 was related to increased intrahospital mortality (Youden’s index = 0.26, sensitivity = 0.51, specificity = 0.77). Conclusion: A fibrinogen to albumin ratio > 0.075 was significantly associated with increased intrahospital mortality in ICH patients.

C-Reactive Protein/Albumin Ratio on the First Day after Surgery Predicts Short-Term Complications of Gastrectomy for Gastric Cancer

Postoperative complications of gastrectomy for gastric cancer affect the efficacy of surgery. It is of clinical significance to identify high-risk patients with postoperative complications as early as possible. A total of 206 patients who underwent gastrectomy were enrolled in this study. Univariate and multivariate analyses were used to determine the risk factors for postoperative complications. The cutoff value and diagnostic accuracy of the C-reactive protein/albumin ratio were calculated by receiver operating characteristic curves. A total of 64 (31.1%) patients developed postoperative complications. Multivariate analysis confirmed that the C-reactive protein/albumin ratio on the first day after operation was an independent risk factor for postoperative complications (OR = 2.538, 95%CI: 1.346-4.785, P = 0.004). The cutoff value of the C-reactive protein/albumin ratio on the first day after operation was 2.105 calculated by receiver operating characteristic curves. Patients with a C-reactive protein/albumin ratio greater than 2.105 had a higher incidence of postoperative complications (43.2% vs 22.0%, P = 0.001) and longer postoperative hospital stay (15.3 ± 1.2 vs 13.0 ± 0.5, P = 0.042) than patients with less than 2.105. Patients with C-reactive protein/albumin ratio greater than 2.105 on the first day after operation are more likely to have postoperative complications.

Peri-Operative Fall in Serum Albumin Levels Correlate Well With Outcomes in Children Undergoing Emergency Abdominal Surgery: A Prospective Study From a Resource-Limited Setting

Background

Albumin is a negative acute-phase protein as its levels fall after injury, sepsis, and surgical stress. A review of the literature suggests that serum albumin level drops rapidly after surgery in adults and correlates well with the outcomes. However, there is limited data on the use of peri-operative fall in serum albumin levels as an outcome predictor in children undergoing emergency abdominal surgeries. We aim to investigate the correlation between the degree of peri-operative fall in serum albumin levels and the outcomes in children undergoing emergent abdominal surgeries.

Materials and methods

This prospective study included all children aged 2-15 years undergoing emergent abdominal surgeries between January 2019 to June 2020 at our center. Preoperative serum albumin level (A1) was recorded for all children. Postoperative day 0 serum albumin level (A2) was sent 4-6 hours following the surgery. The degree of peri-operative fall in serum albumin level (∆A) was calculated by subtracting A2 from A1. Patients were then grouped on the basis of ∆ A, i.e. groups 1 and 2 with ∆ A < 0.5 and ≥ 0.5 gm/dl respectively. Additional data like diagnosis, surgical procedure, duration of surgery, complications, and length of hospital stay were also recorded. Recorded parameters in group 1 were then compared to group 2 statistically.

Results

Fifty-six children (male to female ratio {M:F} = 1.5:1), who met the inclusion criteria during the study period, were included in the study. Groups 1 and 2 comprised 38 and 18 children respectively. The postoperative serum albumin levels were significantly lower in group 2 (p = 0.0005). Duration of surgery was significantly higher in group 2 (p = 0.0474). Complications and length of hospital stay were significantly higher in group 2 (p = 0.0107 and p = 0.0375 respectively).

Conclusion

The present study evaluated the fall in peri-operative serum albumin level (∆A) in children undergoing emergent abdominal surgery as a marker of stress. Higher values of ∆A (≥ 0.5 gm/dl) depicted a significant correlation with complications requiring re-laparotomy and a longer length of hospital stay. 

What Level Should Preoperative Albumin of Thoracic and Lumbar Tuberculosis Patients Be Reached: A Case-Controlled Study

Objective

To explore the risk factors of hypoalbuminemia in patients with thoracic and lumbar tuberculosis and develop a scoring scale, according to which the patients with thoracic and lumbar tuberculosis were divided into 2 groups to, respectively calculate the perioperative albumin changes and to find out the preoperative albumin recommended value.

Methods

A total of 166 patients with thoracic and lumbar tuberculosis, who underwent spinal focus debridement between January 2012 to May 2020, were identified into 2 groups: with and without postoperative hypoalbuminemia (n = 131 and n = 35, respectively), recording and analyzing clinical characteristics by multivariate analysis to establish a scoring scale. Using this scale, patients with spinal tuberculosis were divided into a high-risk group and a low-risk group, and then, calculated the average decrease of postoperative albumin in both groups. Combined with the diagnostic threshold of hypoalbuminemia, we proposed the preoperative albumin safe values of the patients with thoracic and lumbar tuberculosis.

Results

A total of 131 of 166 patients experienced postoperative hypoalbuminemia after spinal focus debridement. Multivariate binary logistic regression analysis identified pulmonary tuberculosis (adjusted odds ratio = 0.270, p = 0.012), pre-operative serum albumin value (adjusted odds ratio = 0.754, p < 0.001), and operation time (adjusted odds ratio = 1.017, p = 0.002) as independent risk factors for the occurrence of postoperative hypoalbuminemia in patients with thoracic and lumbar tuberculosis. According to the OR value, the risk factors are assigned to make the scoring scale, the receiver operating characteristic (ROC) curve indicates that postoperative hypoalbuminemia rises when the score is greater than or equal to 4 points. The scoring scale is tested in the derivation set (166 patients) showed: sensitivity-51.9%, specificity-91.4%, and in the validation set (102 patients) showed: sensitivity-63.6% and specificity-86.1%. The perioperative albumin decreased value is 4.71 ± 2.66 g/L in the low-risk group and 8.99 ± 3.37 g/L in the high-risk group (p < 0.001).

Conclusion

Complicated with pulmonary tuberculosis, low preoperative albumin value and long operation time can lead to postoperative hypoalbuminemia in patients with thoracic and lumbar tuberculosis. The scoring scale can effectively assist physicians to evaluate whether patients with thoracic and lumbar tuberculosis develop hypoalbuminemia after surgery. The scale is simple and reliable and has clinical guiding significance. For low-risk patients and high-risk patients, preoperative albumin values should reach 40 and 44 g/L, respectively, to effectively avoid postoperative hypoalbuminemia.

Difference between delayed anastomosis and early anastomosis in damage control laparotomy affecting the infusion volume and NPWT output volume: is infusion restriction necessary in delayed anastomosis? A single-center retrospective analysis

Objectives

During temporary abdominal closure (TAC) with damage control laparotomy (DCL), infusion volume and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure. The same may also hold true for anastomosis. The aim of this research is to evaluate whether the difference between early anastomosis and delayed anastomosis in DCL is related to infusion volume and NPWT output volume.

Methods

This single-center retrospective analysis targeted patients managed with TAC during emergency surgery for trauma or intra-abdominal sepsis between January 2011 and December 2019. It included patients who underwent repair/anastomosis/colostomy in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity.

Results

Seventy-three patients were managed with TAC using NPWT, including 19 cases of repair, 17 of colostomy, and 37 of anastomosis. In 16 patients (trauma 5, sepsis 11) with early anastomosis and 21 patients (trauma 16, sepsis 5) with delayed anastomosis, there was no difference in the infusion volume (p=0.2318) or NPWT output volume (p=0.7128) 48 hours after surgery. Additionally, there was no difference in the occurrence of suture failure (p=0.8428). During the second-look surgery after 48 hours, the anastomosis was further postponed for 48% of the patients who underwent delayed anastomosis. There was no difference in the infusion volume (p=0.0783) up to the second-look surgery between the patients whose delayed anastomosis was postponed and those who underwent delayed anastomosis, but there was a tendency toward a large NPWT output volume (p=0.024) in the postponed delayed anastomosis group.

Conclusion

Delayed anastomosis may be managed with the same infusion volume as that used for early anastomosis. There is also the option of postponing anastomosis if the planned delayed anastomosis is complicated.

Level of evidence

Therapeutic/Care Management, Level IV.

Serum Albumin Kinetics in Major Ovarian, Gastrointestinal, and Cervico Facial Cancer Surgery

Hypoalbuminemia in major cancer surgery can lead to postoperative short and long-term complications. Our study was designed to detect albumin variations in three major cancer surgeries: ovarian debulking (DBK), major abdominal gastrointestinal surgery (ABD), and major cervico-facial, or ear, nose and throat cancer surgery (ENT). Single-center prospective study inclusion criteria were non-emergency procedures scheduled to last at least five hours. We performed hourly perioperative monitoring of the patients’ albuminemia and hemoglobinemia. Electronic charts were followed for at least five years for survival analysis. Sixty-three patients were analyzed: 30 in the DBK group, 13 in the ABD group, and 20 in the ENT group. There was a significant difference in albumin decrease between the ENT group and the two others (−19% at six hours in the ENT group versus -49% in the debulking group and −31% in the ABD group (p < 0.05). There was no significant difference between the DBK and ABD groups. The decrease in hemoglobin was not significantly different between the groups, and no significant difference was observed in long-term survival. DBK and ABD surgery yielded significant hypoalbuminemia. Therefore, the extent of decrease in serum albumin is probably not the only etiology of the specific postoperative complications of these major surgeries. No significant difference was noticed in five-year mortality, and no correlation was found in relation to the degree of intraoperative albumin kinetics.

Impact of prehabilitation during neoadjuvant chemotherapy and interval cytoreductive surgery on ovarian cancer patients: a pilot study

Background

Cytoreductive surgery followed by systemic chemotherapy is the standard of treatment in advanced ovarian cancer where feasible. Neoadjuvant chemotherapy (NACT) followed by surgery is applicable where upfront cytoreductive surgery is not feasible because of few certain reasons. Nevertheless, surgical interventions and the chemotherapy itself may be associated with postoperative complications usually entailing slow postoperative recovery. Prehabilitation programs consist of the patient’s preparation before surgery to improve the patient’s functional capacity. The aim of this study was to evaluate the impact of a prehabilitation program during neoadjuvant treatment and interval cytoreductive surgery for ovarian cancer patients.

Methods

A retrospective observational pilot study of patients with advanced ovarian cancer treated with NACT and interval cytoreductive surgery was conducted. The prehabilitation group received a structured intervention based on physical exercise, nutritional counseling, and psychological support. Nutritional parameters were assessed preoperatively and postoperatively, and functional parameters and perioperative and postoperative complications were also recorded.

Results

A total of 29 patients were included in the study: 14 in the prehabilitation group and 15 in the control group. The patients in the prehabilitation program showed higher mean total protein levels in both preoperative (7.4 vs. 6.8, p = 0.004) and postoperative (4.9 vs. 4.3, p = 0.005) assessments. Up to 40% of controls showed intraoperative complications vs. 14.3% of patients in the prehabilitation group, and the requirement of intraoperative blood transfusion was significantly lower in the prehabilitation group (14.3% vs. 53.3%, p = 0.027). The day of the first ambulation, rate of postoperative complications, and length of hospital stay were similar between the groups. Finally, trends towards shorter time between diagnosis and interval cytoreductive surgery (p = 0.097) and earlier postoperative diet restart (p = 0.169) were observed in the prehabilitation group.

Conclusion

Prehabilitation during NACT in women with ovarian cancer candidates to interval cytoreductive surgery may improve nutritional parameters and thereby increase postoperative recovery. Nevertheless, the results of this pilot study are preliminary, and further studies are needed to determine the clinical impact of prehabilitation programs.

Postoperative decrease of albumin (ΔAlb) as early predictor of complications after gastrointestinal surgery: a systematic review

Background

Postoperative complications are frequent after gastrointestinal surgery and early prediction remains an unmet need. Serum albumin shows a rapid decrease after surgery, and this decline (ΔAlb) may reflect the intensity of the surgical stress response and thereby be a predictor of postoperative complications. This study aimed to comprehensively review the available data on ΔAlb in gastrointestinal surgery.

Methods

PRISMA guidelines were followed to conduct a systematic review of the literature in MEDLINE and Embase. Studies assessing the role of ΔAlb to predict complications after gastrointestinal surgery were included.

Results

A total of 1256 articles were screened, and 16 studies were included in the final analysis: 7 prospective and 9 retrospective trials. Sensitivity of ΔAlb to predict postoperative complications ranged from 63 to 84%, whereas specificity ranged from 61 to 86%. Nine out of the 16 included studies established a threshold of ΔAlb to predict morbidity (range: 5–11 g/l or 14–27%).

Conclusion

ΔAlb appeared as a valuable and promising biomarker to anticipate complications after gastrointestinal surgery. Future efforts are needed to determine whether and how ΔAlb may be integrated in clinical practice to guide clinicians in the perioperative management of patients.

Value of Postoperative Serum Albumin to Predict Postoperative Complication Severity in Spinal Tuberculosis

Background

Many complications occur after surgery in patients with spinal tuberculosis (STB); however, the severity varies in different patients. The complications' severity is evaluated from grades I to V by the Clavien–Dindo classification (CDC), and grade V is the most severe. Most complications are mild, and only severe complications are life threatening, and thus, it is important to identify severe complications in patients with STB. The purpose of this study was to identify the risk factors of postoperative complication severity in patients with STB.

Methods

Between January 2012 and May 2021, a retrospective study included 188 patients that underwent STB debridement surgery. The patients were divided into three groups based on postoperative complication severity. Clinical characteristics measured included age, sex, body mass index (BMI), comorbidities of diabetes mellitus and pulmonary tuberculosis, alcohol use and smoking history, course of disease, preoperative hemoglobin, preoperative serum albumin, preoperative lymphocytes, preoperative erythrocyte sedimentation rate (ESR), preoperative C-reactive protein (CRP), surgical approach, operating time, blood loss during surgery, postoperative hemoglobin, and postoperative serum albumin. The clinical characteristics of patients with STB who developed postoperative complications were evaluated using logistic regression analysis.

Results

188 patients suffered at least one postoperative complication; 77, 91, and 20 patients experienced grade I, II, and III-IV complications, respectively. In the univariate analysis, sex, diabetes mellitus, postoperative hemoglobin, and postoperative albumin are statistically significant. In the multivariable analysis, postoperative albumin (adjusted odds ratio (OR) = 0.861, P < 0.001) was an independent risk factor of the postoperative complication severity in patients with STB. Receiver operating characteristic (ROC) analysis showed that the optimal cutoff values for postoperative albumin were 32 g/L (sensitivity: 0.571, specificity: 0.714, area under the ROC curve: 0.680) and 30 g/L (sensitivity: 0.649, specificity: 0.800, area under the ROC curve: 0.697) for grade II and grade III-IV complications, respectively.

Conclusions

Postoperative albumin is an independent risk factor for postoperative complication severity in patients with STB. The improvement of postoperative albumin levels may reduce the risk of severe complications in patients with STB.

Red cell distribution width/albumin ratio and 90-day mortality after burn surgery

Background

Red cell distribution width (RDW) and serum albumin concentration are associated with postoperative outcomes. However, the usefulness of the RDW/albumin ratio in burn surgery remains unclear. Therefore, we evaluated the association between RDW/albumin ratio and 90-day mortality after burn surgery.

Methods

Between 2013 and 2020, a retrospective review of patients in a burn intensive care unit (ICU) was performed. Receiver operating characteristic curve, multivariate Cox logistic regression, multivariate logistic regression and Kaplan–Meier analyses were conducted to evaluate the association between RDW/albumin ratio and 90-day mortality after burn surgery. Additionally, prolonged ICU stay rate (>60 days) and ICU stay were assessed.

Results

Ninety-day mortality was 22.5% (210/934) in burn patients. Risk factors for 90-day mortality were RDW/albumin ratio at postoperative day 1, age, American Society of Anesthesiologists physical status, diabetes mellitus, inhalation injury, total body surface area burned, hypotensive event and red blood cell transfusion volume. The area under the curve of the RDW/albumin ratio at postoperative day 1 to predict 90-day mortality, after adjusting for age and total body surface area burned, was 0.875 (cut-off value, 6.8). The 90-day mortality was significantly higher in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (49.2% vs 12.3%, p < 0.001). Prolonged ICU stay rate and ICU stay were significantly higher and longer in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (34.5% vs 26.5%; 21 [11–38] vs 18 [7–32] days).

Conclusion

RDW/albumin ratio >6.8 on postoperative day 1 was associated with higher 90-day mortality, higher prolonged ICU stay rate and longer ICU stay after burn surgery.

Effect of Pre-operative Nutritional Protocol Implementation on Postoperative Outcomes Following Gastrointestinal Surgeries: A Randomized Clinical Trial

Introduction: A significant proportion of patients undergoing major gastrointestinal operations suffer from malnutrition. Although the benefit of postoperative nutritional support is well established, the effects of energy intake during pre-operative period is less reported. The present study was designed to test the effect of structured pre-operative nutritional therapy on the postoperative recovery of patients undergoing major gastrointestinal operations.

Methods: A randomized clinical trial was conducted among 80 patients of the surgical gastroenterology department of a tertiary care center in south India. A simple random sampling method was used. The nutritional status of all participants was assessed by subjective global assessment (SGA). While control group received standard energy intake nutrition, the experimental group received calculated nutrition with an extra 50 g of soy protein for seven days pre operatively. Data were analysed using SPSS version 20.

Results: The median day of removal of abdominal drainage tube was 3 (0-5) compared to 5 (2.5-7.5) in the control group. In the intervention group, the median time for the appearance of bowel sounds and starting of enteral feeding was 1.1 (0.5) days and 2 (1-2) days, while in the control group, it was 1.6 (0.9) days, 3 (1-4) days, respectively which was significant at P < 0.05. Similarly, the mean (SD) postoperative serum albumin on third day was 3.6 (0.4) g/dL vs 3.4 (0.4) g/dL experimental and in the control group.

Conclusion: Preoperative nutrition protocol improved the patients’ clinical outcomes in terms of post-operative serum albumin, the timing of bowel sounds, and early initiation of enteral feeds.

A novel robust nomogram based on preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) for predicting lymph node metastasis of gastric cancer

BACKGROUND

Accurate assessment of lymph node status in gastric cancer (GC) patients can help to select appropriate treatment strategies for GC, but the diagnostic accuracy of conventional methods needs to be improved. The aim of this study was to investigate the predictive value of preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) on lymph node status in GC patients and to construct a risk prediction model.

METHODS

This study retrospectively analyzed the clinicopathological characteristics of 349 patients with GC who underwent radical gastrectomy, among which 250 patients were recruited in the training cohort and 99 patients in the independent validation cohort. Significant risk factors in univariate analysis were further identified as independent variables in multivariate logistic regression analysis, which were then incorporated and presented in a nomogram. Receiver operating characteristic (ROC) curves, Calibration curve and decision curve analysis (DCA) curves were used to evaluate the discrimination, prediction accuracy and clinical effectiveness of the model.

RESULTS

Multifactorial logistic regression analysis showed that alcohol use (OR =2.203, P=0.036), Depth of invasion (OR =7.756, P<0.001), differentiation (OR =2.252, P=0.018), carcinoembryonic antigen (CEA) (OR =2.443, P=0.017), carbohydrate antigen 19-9 (CA199) (OR =2.715, P=0.008) and HALP (OR =2.276, P=0.032) were independent risk factors for lymph node metastasis (LNM) in GC. We used these factors to construct a nomogram for predicting LNM in GC patients, and the ROC curves showed good discrimination of the model with AUC values of 0.854 (training cohort) and 0.868 (validation cohort), respectively, and the calibration curves showed good predictive ability of the nomogram, in addition to the DCA curves results showed the clinical usefulness of the model.

CONCLUSIONS

In conclusion, we established a nomogram for predicting LNM in patients with GC.

Beneficial effects of preoperative oral nutrition supplements on postoperative outcomes in geriatric hip fracture patients: A PRISMA-compliant systematic review and meta-analysis of randomized controlled studies

BACKGROUND

Geriatric hip fracture patients often present malnutrition during admission, which leads to higher morbidity and mortality. Protein-based oral nutrition supplements may improve nutritional status. We conducted this systematic review and meta-analysis of randomized controlled trials (RCTs) according to the PRISMA guidelines to elucidate whether preoperative nutrition supplements can improve postoperative outcomes in geriatric hip fracture patients.

METHODS

Only RCTs conducted to compare postoperative outcomes between geriatric hip fracture patients (>60 years old) receiving preoperative oral protein-based nutrition supplement (ONS group) and those who receiving regular diet (Control group) were included. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception until August, 2021. Postoperative outcomes, including complications, length of hospital stay, and in-hospital mortality, were assessed.

RESULTS

A total of 5 RCTs with 654 geriatric hip fracture patients (ONS group: 320 subjects; Control group 334 subjects) were included. Our data revealed that postoperative complications risk in the ONS group was significantly lower than in the Control group (odd's ratio: 0.48, 95% confidence intervals [CI]: 0.26-0.89, P = .02, I2 = 64%). However, no significant differences in the length of hospital stay (standardized mean difference: -0.35 days, 95% CI: -1.68 to 0.98 days, P = .61, I2 = 0%) and the risk of having postoperative in-hospital mortality (odd's ratio: 1.07, 95% CI: 0.43-2.63, P = .89, I2 = 54%) between these 2 groups were observed. Quality assessment revealed high risk of bias and significant data heterogeneity (I2>50%) in most included RCTs.

CONCLUSION

Preoperative protein-based oral nutrition supplements exert beneficial, but limited, effects on postoperative outcomes in geriatric patients with hip fracture undergoing surgery.

The effects of cardiovascular and orthopaedic surgery on vitamin concentrations: a narrative review of the literature and mechanisms of action

Given the rise in worldwide chronic diseases, supplemented by an aging population, the volume of global major surgeries, encompassing cardiac and orthopedic procedures is anticipated to surge significantly. Surgical trauma can be accompanied by numerous postoperative complications and metabolic changes. The present review summarized the results from studies assessing the effects of orthopedic and cardiovascular surgery on vitamin concentrations, in addition to exploring the possible mechanisms associated with changes in concentrations. Studies have revealed a potentially severe depletion in plasma/serum concentrations of numerous vitamins following these surgeries acutely. Vitamins C, D and B1 appear particularly vulnerable to significant depletions, with vitamin C and D depletions consistently transpiring into inadequate and deficient concentrations, respectively. The possible multifactorial mechanisms impacting postoperative vitamin concentrations include changes in hemodilution and vitamin utilization, redistribution, circulatory transport and absorption. For a majority of vitamins, there has been a lack of investigation into the effects of both, cardiac and orthopedic surgery. Additionally, studies were predominantly restricted to short-term postoperative investigations, primarily performed within the first postoperative week of surgery. Overall, results indicated that further examination is necessary to determine the severity and clinical significance of the possible depletions in vitamin concentrations that ensue cardiovascular and orthopedic surgery.

A Comparative Study of Modulation of Neuroendocrine Stress Response by Dexmedetomidine versus Fentanyl Premedication during Laparoscopic Cholecystectomy

Introduction:

Surgical stress is the systemic response to surgical injury. Analyzing these surgical stress responses and pharmacologically modulating them can be of immense use to an anesthetist for optimal patient care.

Aim:

The aim of the present study was to investigate the influence of dexmedetomidine and fentanyl premedication on the modulation of neuroendocrine stress response during laparoscopic cholecystectomy under general anesthesia.

Methods:

After obtaining approval from the institutional ethical committee [Date - 05/11/2020, Ethical Clearence Number - 133/2018], 60 patients undergoing laparoscopic cholecystectomy under general anesthesia were randomized into three study groups of 20 patients each. Group D patients were given intravenous (i.v.) dexmedetomidine 1 μg.kg⁻¹, Group F patients fentanyl 2 μg.kg⁻¹ and Group C patients 10 mL of normal saline. All patients received the same anesthetic drugs and surgical procedure. Patients were assessed for changes in hemodynamic parameters such as heart rate (H) and mean arterial pressure (MAP). Blood samples were analyzed for glucose, serum albumin, C-reactive protein (CRP), and serum cortisol levels at various time intervals.

Results:

H and MAP differed among the groups after intubation, 5 min after pneumoperitoneum (POT), and 10 min after POT. The increase in these parameters from their baseline values was less in the dexmedetomidine group when compared to other groups. Among the biological markers, the increase in serum cortisol levels and decrease in albumin levels could be detected 6 h after induction while blood glucose levels rose immediately after the incision. CRP levels started significantly rising only after 24 h of induction. All these changes were much less pronounced in patients receiving dexmedetomidine premedication as compared to other groups.

Conclusion:

i.v. dexmedetomidine 1 μg.kg⁻¹ is better than injection fentanyl 2 μg.kg⁻¹, in the modulation of neuroendocrine response in patients undergoing laparoscopic cholecystectomy under general anesthesia.

Preoperative laboratory testing in elderly patients

PURPOSE OF REVIEW

Preoperative testing in elderly patients is performed to examine the patient's current medical condition in the context of evaluating vulnerabilities and predicting postoperative complications to ensure that all functions recover before surgery. This review focused on preoperative laboratory tests in geriatric patients.

RECENT FINDINGS

Preoperative complete blood count, electrolyte testing, and blood chemistry can predict postoperative complications. Preoperative elevated morning/evening salivary cortisol secretion ratio, C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratios, and preoperative decreased serum albumin level or 25-hydroxyvitamin D levels can predict postoperative cognitive dysfunction. Elevated brain-type natriuretic peptide or serum alkaline phosphatase levels can be biomarkers of major postoperative adverse cardiac events. Decreased preoperative estimated glomerular filtration rates and serum albumin levels can predict acute kidney injury. Hyponatremia, hypocalcemia, and low albumin/fibrinogen ratio predict postoperative complications. Hypoalbuminemia can predict surgical site infection or postoperative mortality after hip fracture surgery. A high CAR can predict anastomotic site leakage and is a risk factor for one-year mortality after hip surgery.

SUMMARY

Preoperative laboratory testing helps predict postoperative adverse complications; thus, a plan of care can be initiated.

Post-embolization outcomes of splenic artery pseudoaneurysms: A single-center experience

PURPOSE

Splenic artery pseudoaneurysms (PSA) are relatively rare but associated with high mortality/morbidity when presenting acutely. Embolization has emerged as the treatment of choice. We aim to evaluate the outcomes of embolization for the treatment of splenic artery PSAs.

METHODS

From 2007 to 2019, all patients that underwent embolization for splenic artery PSAs were included in this IRB-approved review. Evaluated outcomes included complications, morbidity/mortality rates, and 30-day white blood cell count. Student t-tests were performed to compare laboratory values before and after embolization. 5-year survival rates were estimated using Kaplan Meier methodology.

RESULTS

A retrospective analysis of 24 patients (14 males, mean age 51 ± 19 years) who underwent splenic artery PSA embolization was performed. Fifteen PSA embolizations were performed in an emergent setting. There was technical success in 23/24 patients. Etiologies included trauma (10), pancreatitis (9), post-surgical (3), and malignancy (2). Post-embolization patients had a mean length of stay of 19 days and within 30 days, 9 patients developed leukocytosis (median of 14,800/μl). The 5-year survival rate of these patients was 89% [95% CI 75% - 100%]. Post-procedure, 4 patients developed grade 2 complications. Grade 3 complications were observed in 5 patients. One (4.2%) splenic abscess was identified. Of the 19 patients with follow-up imaging, 14 patients had splenic infarcts (5 infarcts were >50% of splenic volume).

CONCLUSIONS

Splenic artery PSAs are encountered in the emergent setting and are most frequently secondary to trauma or pancreatitis. Embolization can be life-saving in these critically ill patients.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.

Real-time point-of-care total protein measurement with a miniaturized optoelectronic biosensor and fast fluorescence-based assay

Measurement of total protein in urine is key to monitoring kidney health in diabetes. However, most total protein assays are performed using large, expensive laboratory chemistry analyzers that are not amenable to point-of-care analysis or home monitoring and cannot provide real-time readouts. We developed a miniaturized optoelectronic biosensor using a vertical cavity surface-emitting laser (VCSEL), coupled with a fast protein assay based on protein-induced fluorescence enhancement (PIFE), that can dynamically measure protein concentrations in protein-spiked buffer, serum, and urine in seconds with excellent sensitivity (urine LOD = 0.023 g/L, LOQ = 0.075 g/L) and over a broad range of physiologically relevant concentrations. Comparison with gold standard clinical assays and standard fluorimetry tools showed that the sensor can accurately and reliably quantitate total protein in clinical urine samples from patients with diabetes. Our VCSEL biosensor is amenable to integration with miniaturized electronics, which could afford a portable, low-cost, easy-to-use device for sensitive, accurate, and real-time total protein measurements from small biofluid volumes.

Hypoalbuminemia as Surrogate and Culprit of Infections

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.

THE ROLE OF MARKERS OF SYSTEMIC INFLAMMATORY RESPONSE IN THE POSTOPERATIVE PERIOD. REVIEW

Despite all the achievements of modern surgery, the number of postoperative infectious complications in the world remains high. Their occurrence leads to a longer period of patients’ hospitalization, requires the use of additional medical and diagnostic measures, which ultimately leads to higher treatment costs and significant financial losses in the health care system. Therefore, it is important to identify postoperative complications at an early stage, even before the development of pronounced clinical symptoms, and to predict their possible development in a certain category of patients. For these purposes, scientists try to use various laboratory markers. In this paper, we analyzed both well-known indicators of the inflammatory response, such as: C-reactive protein, albumin, their ratio, procalcitonin and interleukin-6, and relatively new parameters that research teams are trying to apply for these purposes: neutrophil granularity intensity and neutrophil reactivity intensity, pancreatic stone protein and pancreatitis-associated protein. We tried to collect the most complete information available at the moment, evaluate the opinions of researchers, identify contradictions in their works and try to explain their cause. As a result, it turned out that even the markers of inflammation known for many years are not absolutely specific for postoperative infectious complications. We concluded that most of the laboratory parameters described in this article can be used to some extent in the early diagnosis of postoperative infectious complications, but if we want to obtain more complete information in this area of knowledge, it is necessary to conduct new largescale studies.

The Systemic Inflammation-Based Prognostic Score Predicts Postoperative Complications in Patients Undergoing Pancreaticoduodenectomy

Background

Although many studies have confirmed the correlation between inflammation-based or nutritional markers and postoperative complications in patients undergoing colorectal cancer surgery, their correlation after undergoing pancreaticoduodenectomy (PD) remains unclear.

Methods

We retrospectively reviewed the clinical data of patients who underwent PD in Beijing Friendship hospital between 2018 and 2020. Univariate analysis, multivariate analysis, and receiver operating characteristic curve (ROC) were performed. We assessed the preoperative modified Glasgow Prognostic Score (mGPS), C-reactive protein/albumin ratio (CAR), C-reactive protein (CRP), postoperative Glasgow Prognostic Score (poGPS), CRP on postoperative day 3 (POD3) and CAR on POD3. The optimal cut-off values were determined by performing logistic regression analysis.

Results

Of the 172 patients who underwent PD, 74 (43.0%) developed complications, of whom 27 (15.7%) had clinically relevant postoperative pancreatic fistulas (CR-POPF) and 36 (20.9%) had positive drainage fluid cultures. Elevated levels of preoperative mGPS (P<0.001), poGPS (P<0.001), CRP (P<0.001) and CAR on POD3 were associated with postoperative complications. CRP on POD3 (OR=1.028, 95% CI=1.017-1.039, P<0.001) was an independent risk factor associated with postoperative complications in both univariate and multivariate analyses. CAR on POD 3 showed the largest area under the curve (AUC=0.883, P<0.001). Compared with CAR<4.86, CAR ≥4.86 on POD3 was associated with a higher probability of complications (85.5% vs 14.6%, P<0.001), especially CR-POPF (33.3% vs 4.9%, P<0.001), intra-abdominal infection (36.2% vs 10.7%, P<0.001) with a positive drainage fluid culture.

Conclusion

CAR, an inflammatory response-based marker, can effectively predict early postoperative complications in patients undergone PD.

Albumin and the fibrinogen-to-albumin ratio: Biomarkers for the acute phase response following total knee arthroplasty

PURPOSE

Complications following total knee arthroplasty (TKA) lead to patient morbidity and cost. While acute phase reactants, such as c-reactive protein (CRP) and fibrinogen, have been used to predict complications following TKA, the extent and duration of changes in albumin levels following TKA are unknown. It is hypothesized that like CRP and fibrinogen, albumin, and the fibrinogen/albumin ratio (FAR) represent useful measures of the acute phase response (APR) following TKA. The purpose of this study was to describe the longitudinal course of albumin and FAR in healthy patients following TKA, relative to established biomarkers, and examine if the variance in albumin or FAR correlates with patient comorbidities.

METHODS

This retrospective cohort study of patients undergoing TKA at a tertiary medical center. CRP, fibrinogen, and albumin values were collected pre- and post-operatively. An age-adjusted Charlson comorbidity index (CCI) was utilized as a measure of patient comorbidity status.

RESULTS

The median preoperative albumin value was 4.3 g/dL, which dropped to 3.6 g/dL on postoperative day 1 following TKA. The albumin value returned to 93% of the baseline by postoperative week 2. The course of albumin inversely mirrored the course of CRP (r = -0.41). Median preoperative FAR was 0.087 g/L, which rose to 0.130 g/L by postoperative week 2 and returned to baseline by postoperative week 6. While preoperative FAR strongly correlated with postoperative week 2 values (r = 0.74), there was a weak positive correlation between age-adjusted CCI and pre-operative FAR (r = 0.24) in patients undergoing primary TKA.

CONCLUSION

Albumin levels follow a predictable postoperative decline that inversely correlates with CRP in healthy patients following TKA. Given the low cost and abundance of laboratories offering albumin levels, direct albumin levels and/or albumin ratios such as FAR may be underutilized biomarkers for monitoring the APR following TKA.

High-Throughput Microbore Ultrahigh-Performance Liquid Chromatography-Ion Mobility-Enabled-Mass Spectrometry-Based Proteomics Methodology for the Exploratory Analysis of Serum Samples from Large Cohort Studies

The deployment of proteomic analysis in clinical studies represents a significant opportunity to detect and validate biomarkers in translational medicine, improve disease understanding, and provide baseline information on population health. However, comprehensive proteome studies usually employ nanoscale chromatography and often require several hours of analysis/sample. Here, we describe a high-throughput liquid chromatography tandem mass spectrometry (LC/MS/MS) methodology using 1 mm scale chromatography requiring only 15 min/sample, coupled to ion mobility-enabled mass spectrometry. The short run time effected a 6-fold increase in productivity compared with nanoscale LC/MS. The method demonstrated excellent reproducibility with retention time coefficient of variations of less than 0.05% and peak area reproducibility ranging from 5 to 15%. The 1 mm system produced similar chromatographic peak capacity values to the nanoscale miniaturized system, detecting 90% of the Escherichia coli proteins identified by the 75 μm LC/MS system (albeit based on only 75% of the peptides found by the latter). Application to the analysis of serum samples from a human prostate cancer study group resulted in the identification of a total of 533 proteins revealing the differential expression of proteins linked to patients receiving hormone-radiotherapy or undergoing surgery.

Serum albumin concentrations are associated with disease severity and outcomes in coronavirus 19 disease (COVID-19): a systematic review and meta-analysis

Coronavirus disease 2019 (COVID-19), an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is responsible for the most threatening pandemic in modern history. The aim of this systematic review and meta-analysis was to investigate the associations between serum albumin concentrations and COVID-19 disease severity and adverse outcomes. A systematic literature search was conducted in PubMed, from inception to October 30, 2020. Sixty-seven studies in 19,760 COVID-19 patients (6141 with severe disease or poor outcome) were selected for analysis. Pooled results showed that serum albumin concentrations were significantly lower in patients with severe disease or poor outcome (standard mean difference, SMD: - 0.99 g/L; 95% CI, - 1.11 to - 0.88, p < 0.001). In multivariate meta-regression analysis, age (t =  - 2.13, p = 0.043), publication geographic area (t = 2.16, p = 0.040), white blood cell count (t =  - 2.77, p = 0.008) and C-reactive protein (t =  - 2.43, p = 0.019) were significant contributors of between-study variance. Therefore, lower serum albumin concentrations are significantly associated with disease severity and adverse outcomes in COVID-19 patients. The assessment of serum albumin concentrations might assist with early risk stratification and selection of appropriate care pathways in this group.