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Atomura D, Osaki T, Iwae S, Sakakibara S. Early Predictors of Fistula Formation Following Head and Neck Reconstruction. J Reconstr Microsurg 2024; 40:466-472. [PMID: 38176428 DOI: 10.1055/a-2238-7591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation. METHODS We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula. RESULTS In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value. CONCLUSION CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.
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Affiliation(s)
- Daisuke Atomura
- Department of Plastic Surgery, Kobe University Hospital International Clinical Cancer Research Center, Kobe, Japan
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan
| | - Takeo Osaki
- Department of Plastic Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Shigemichi Iwae
- Department of Head and Neck Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Shunsuke Sakakibara
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Japan
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Gielen AHC, Schoenmakers M, Breukink SO, Winkens B, van der Horst J, Wevers KP, Melenhorst J. The value of C-reactive protein, leucocytes and vital signs in detecting major complications after oncological colorectal surgery. Langenbecks Arch Surg 2024; 409:76. [PMID: 38409295 PMCID: PMC10896856 DOI: 10.1007/s00423-024-03266-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE To assess the association of postoperative C-reactive protein (CRP), leucocytes and vital signs in the first three postoperative days (PODs) with major complications after oncological colorectal resections in a tertiary referral centre for colorectal cancer in The Netherlands. METHODS A retrospective cohort study, including 594 consecutive patients who underwent an oncological colorectal resection at Maastricht University Medical Centre between January 2016 and December 2020. Descriptive analyses of patient characteristics were performed. Logistic regression models were used to assess associations of leucocytes, CRP and Modified Early Warning Score (MEWS) at PODs 1-3 with major complications. Receiver operating characteristic curve analyses were used to establish cut-off values for CRP. RESULTS A total of 364 (61.3%) patients have recovered without any postoperative complications, 134 (22.6%) patients have encountered minor complications and 96 (16.2%) developed major complications. CRP levels reached their peak on POD 2, with a mean value of 155 mg/L. This peak was significantly higher in patients with more advanced stages of disease and patients undergoing open procedures, regardless of complications. A cut-off value of 170 mg/L was established for CRP on POD 2 and 152 mg/L on POD 3. Leucocytes and MEWS also demonstrated a peak on POD 2 for patients with major complications. CONCLUSIONS Statistically significant associations were found for CRP, Δ CRP, Δ leucocytes and MEWS with major complications on POD 2. Patients with CRP levels ≥ 170 mg/L on POD 2 should be carefully evaluated, as this may indicate an increased risk of developing major complications.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands.
| | - Maud Schoenmakers
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Stephanie O Breukink
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Jischmaël van der Horst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Kevin P Wevers
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
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Anees K, Faizan M, Siddiqui SA, Anees A, Faheem K, Shoaib U. Role of C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy. Surg Innov 2024; 31:26-32. [PMID: 37926929 DOI: 10.1177/15533506231212595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Cholelithiasis is one of the most common diseases encountered in gastroenterology. Laparoscopic cholecystectomy can be labelled as difficult if the surgery continues for more than 60 minutes or if the cystic artery is injured before ligation or clipping. Predicting difficult laparoscopic cholecystectomy can help the surgeon to be prepared for intraoperative challenges such as adhesions in triangle of Calot, injury to cystic artery or gall stone spillage; and improve patient counseling. METHODS In this cross-sectional study, we evaluated 269 patients with diagnosed cholelithiasis and planned for laparoscopic cholecystectomy in the general surgery department of Civil Hospital Karachi. After approval of the institution review board of the Civil Hospital, the data of all the patients was collected along with informed consent. The patients were selected via nonprobability, consecutive sampling. RESULTS The prevalence of difficult LC during procedure was 14.5% (39/269). Contingency table showed the true positive, negative and false positive and negative observation and using these observation to compute accuracy. Sensitivity, specificity, PPV, NPV and accuracy of serum c-reactive protein (CRP) in predicting the difficult laparoscopic cholecystectomy in patients of cholelithiasis was 87.2%, 97%, 82.9%, 97.8% and 95.5% respectively. Effect modifiers like age, gender and BMI were controlled by stratification analysis and observed that diagnostic accuracy was above 90% in all stratified groups as presented in the following tables. 175 (65.06%) of 279 patients were females indicating female predominance. In general, 41 patients (15.05%) had CRP serum levels greater than 11 mg/dL out of which 34 patients had to undergo difficult laparoscopic cholecystectomy (DLC), while 223 out of 228 patients with serum CRP levels of less than 11 mg/dL did not face any difficulty during their cholecystectomy. Similar results have been acquired across all age groups and both genders. CONCLUSION C Reactive Protein is a potent predictor of difficult laparoscopic cholecystectomy and its conversion preoperatively. Patients with preoperatively high C Reactive Protein CRP levels in serum have more chances of complication intraoperatively and increased chances of conversion from laparoscopic to open surgery. Preoperative C Reactive Protein (CRP) with values >11 mg/dL was associated with the highest odds of presenting difficult laparoscopic cholecystectomy (DLC) in our study. This value possesses good sensitivity, specificity, PPV, and NPV for predicting DLC in our population.
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Affiliation(s)
- Khadija Anees
- Department of General Surgery, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Faizan
- Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Ayesha Anees
- dow medical college, Dow University of Health Sciences, Karachi, Pakistan
| | - Komal Faheem
- Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan
| | - Umer Shoaib
- Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan
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Lee JH, Lee DH, Lee BK, Ryu SJ. The association between C-reactive protein to albumin ratio and 6-month neurological outcome in patients with in-hospital cardiac arrest. World J Emerg Med 2024; 15:223-228. [PMID: 38855379 PMCID: PMC11153364 DOI: 10.5847/wjem.j.1920-8642.2024.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/12/2024] [Indexed: 06/11/2024] Open
Affiliation(s)
- Ji Ho Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
| | - Seok Jin Ryu
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
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Saravi B, Ülkümen S, Lang G, Couillard-Després S, Hassel F. Case-matched radiological and clinical outcome evaluation of interlaminar versus microsurgical decompression of lumbar spinal stenosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07551-5. [PMID: 36729245 DOI: 10.1007/s00586-023-07551-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/12/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023]
Abstract
PURPOSE Endoscopic spine surgery is a globally expanding technique advocated as less invasive for spinal stenosis treatment compared to the microsurgical approach. However, evidence on the efficiency of interlaminar full-endoscopic decompression (FED) vs. conventional microsurgical decompression (MSD) in patients with lumbar spinal stenosis is still scarce. We conducted a case-matched comparison for treatment success with consideration of clinical, laboratory, and radiologic predictors. METHODS We included 88 consecutive patients (FED: 36/88, 40.9%; MSD: 52/88, 59.1%) presenting with lumbar central spinal stenosis. Surgery-related (operation time, complications, length of stay (LOS), American Society of Anesthesiologists physical status (ASA) score, C-reactive protein (CRP), white blood cell count, side of approach (unilateral/bilateral), patient-related outcome measures (PROMs) (Oswestry disability index (ODI), numeric rating scale of pain (NRS; leg-, back pain), EuroQol questionnaire (eQ-5D), core outcome measures index (COMI)), and radiological (dural sack cross-sectional area, Schizas score (SC), left and right lateral recess heights, and facet angles, respectively) parameters were extracted at different time points up to 1-year follow-up. The relationship of PROMs was analyzed using Spearman's rank correlation. Surgery-related outcome parameters were correlated with patient-centered and radiological outcomes utilizing a regression model to determine predictors for propensity score matching. RESULTS Complication (most often residual sensorimotor deficits and restenosis due to hematoma) rates were higher in the FED (33.3%) than MSD (13.5%) group (p < 0.05), while all complications in the FED group were observed within the first 20 FED patients. Operation time was higher in the FED, whereas LOS was higher in the MSD group. Age, SC, CRP revealed significant associations with PROMs. We did not observe significant differences in the endoscopic vs. microsurgical group in PROMs. The correlation between ODI and COMI was significantly high, and both were inversely correlated with eQ-5D, whereas the correlations of these PROMs with NRS findings were less pronounced. CONCLUSIONS Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach. Although FED was associated with higher complication rates in our single-center study experience, the distribution of complications indicated surgical learning curves to be the main factor of these findings. Future long-term prospective studies considering the surgical learning curve are warranted for reliable comparisons of these techniques.
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Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Centre - Albert-Ludwigs-University of Freiburg, Albert-Ludwigs-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany. .,Department of Spine Surgery, Loretto Hospital, Freiburg, Germany.
| | - Sara Ülkümen
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Centre - Albert-Ludwigs-University of Freiburg, Albert-Ludwigs-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.,Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Centre - Albert-Ludwigs-University of Freiburg, Albert-Ludwigs-University of Freiburg, Hugstetterstrasse 55, 79106, Freiburg, Germany.,Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
| | - Sébastien Couillard-Després
- Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Institute of Experimental Neuroregeneration, Paracelsus Medical University, 5020, Salzburg, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, Freiburg, Germany
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De Cicco Nardone C, De Luca C, Plotti F, Fabris S, Rossini G, Montera R, Luvero D, Angioli R, Terranova C. C-reactive protein "at first sight": Standard postoperative trend in gynecological surgery and a comparative analysis with white blood cell levels. Int J Gynaecol Obstet 2023; 160:237-243. [PMID: 35749082 PMCID: PMC10084365 DOI: 10.1002/ijgo.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/04/2022] [Accepted: 06/20/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE There is a lack of information about the normal trend of C-reactive protein (CRP) blood levels in the postoperative days after gynecological benign surgery. We investigated the impact of different surgical techniques on CRP trend. We performed a comparative analysis between a CRP and white blood cell (WBC) trend in postoperative monitoring. METHODS We studied 207 surgical patients for benign gynecological pathology. We analyzed CRP and WBC levels after surgery in the total number of women and separately by approaches. RESULTS CRP mean log scores showed a typical behavior. Moreover, results from chi-square test underline that the proportion of women with this result is independent from the type of surgery they underwent. Log score mean values of CPR differed between all groups and between times. No difference in the mean number of white cells between the second and the third day was found, as observed for CRP. CONCLUSIONS Our study shows a trend reference model in postoperative monitoring of patients with benign gynecological surgery. The comparative analysis between the CRP and WBC trend in the postoperative days provided us data demonstrating the superiority of CRP in postsurgical patient outcomes monitoring.
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Affiliation(s)
| | - Cristiana De Luca
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
| | - Francesco Plotti
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
| | - Silvia Fabris
- Unit of Medical Statistics and Molecular Epidemiology, Campus Bio Medico University, Rome, Italy
| | - Gianmarco Rossini
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
| | - Roberto Montera
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
| | - Daniela Luvero
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
| | - Roberto Angioli
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
| | - Corrado Terranova
- Gynecology and Obstetrics, Campus Bio Medico University, Rome, Italy
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Saravi B, Zink A, Ülkümen S, Couillard-Despres S, Hassel F, Lang G. Performance of Artificial Intelligence-Based Algorithms to Predict Prolonged Length of Stay after Lumbar Decompression Surgery. J Clin Med 2022; 11:jcm11144050. [PMID: 35887814 PMCID: PMC9318293 DOI: 10.3390/jcm11144050] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Decompression of the lumbar spine is one of the most common procedures performed in spine surgery. Hospital length of stay (LOS) is a clinically relevant metric used to assess surgical success, patient outcomes, and socioeconomic impact. This study aimed to investigate a variety of machine learning and deep learning algorithms to reliably predict whether a patient undergoing decompression of lumbar spinal stenosis will experience a prolonged LOS. Methods: Patients undergoing treatment for lumbar spinal stenosis with microsurgical and full-endoscopic decompression were selected within this retrospective monocentric cohort study. Prolonged LOS was defined as an LOS greater than or equal to the 75th percentile of the cohort (normal versus prolonged stay; binary classification task). Unsupervised learning with K-means clustering was used to find clusters in the data. Hospital stay classes were predicted with logistic regression, RandomForest classifier, stochastic gradient descent (SGD) classifier, K-nearest neighbors, Decision Tree classifier, Gaussian Naive Bayes (GaussianNB), support vector machines (SVM), a custom-made convolutional neural network (CNN), multilayer perceptron artificial neural network (MLP), and radial basis function neural network (RBNN) in Python. Prediction accuracy and area under the curve (AUC) were calculated. Feature importance analysis was utilized to find the most important predictors. Further, we developed a decision tree based on the Chi-square automatic interaction detection (CHAID) algorithm to investigate cut-offs of predictors for clinical decision-making. Results: 236 patients and 14 feature variables were included. K-means clustering separated data into two clusters distinguishing the data into two patient risk characteristic groups. The algorithms reached AUCs between 67.5% and 87.3% for the classification of LOS classes. Feature importance analysis of deep learning algorithms indicated that operation time was the most important feature in predicting LOS. A decision tree based on CHAID could predict 84.7% of the cases. Conclusions: Machine learning and deep learning algorithms can predict whether patients will experience an increased LOS following lumbar decompression surgery. Therefore, medical resources can be more appropriately allocated to patients who are at risk of prolonged LOS.
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Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany;
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020 Salzburg, Austria;
- Correspondence:
| | - Alisia Zink
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
| | - Sara Ülkümen
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
| | - Sebastien Couillard-Despres
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020 Salzburg, Austria;
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany;
- Department of Spine Surgery, Loretto Hospital, 79108 Freiburg, Germany; (A.Z.); (S.Ü.); (F.H.)
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One-Year Clinical Outcomes of Minimal-Invasive Dorsal Percutaneous Fixation of Thoracolumbar Spine Fractures. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050606. [PMID: 35630022 PMCID: PMC9144472 DOI: 10.3390/medicina58050606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/15/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Introduction: Minimal-invasive instrumentation techniques have become a workhorse in spine surgery and require constant clinical evaluations. We sought to analyze patient-reported outcome measures (PROMs) and clinicopathological characteristics of thoracolumbar fracture stabilizations utilizing a minimal-invasive percutaneous dorsal screw-rod system. Methods: We included all patients with thoracolumbar spine fractures who underwent minimal-invasive percutaneous spine stabilization in our clinics since inception and who have at least 1 year of follow-up data. Clinical characteristics (length of hospital stay (LOS), operation time (OT), and complications), PROMs (preoperative (pre-op), 3-weeks postoperative (post-op), 1-year postoperative: eq5D, COMI, ODI, NRS back pain), and laboratory markers (leucocytes, c-reactive protein (CRP)) were analyzed, finding significant associations between these study variables and PROMs. Results: A total of 68 patients (m: 45.6%; f: 54.4%; mean age: 76.9 ± 13.9) were included. The most common fracture types according to the AO classification were A3 (40.3%) and A4 (40.3%), followed by B2 (7.46%) and B1 (5.97%). The Median American Society of Anesthesiologists (ASA) score was 3 (range: 1−4). Stabilized levels ranged from TH4 to L5 (mean number of targeted levels: 4.25 ± 1.4), with TH10-L2 (12/68) and TH11-L3 (11/68) being the most frequent site of surgery. Mean OT and LOS were 92.2 ± 28.2 min and 14.3 ± 6.9 days, respectively. We observed 9/68 complications (13.2%), mostly involving screw misalignments and loosening. CRP increased from 24.9 ± 33.3 pre-op to 34.8 ± 29.9 post-op (p < 0.001), whereas leucocyte counts remained stable. All PROMs showed a marked significant improvement for both 3-week and 1-year evaluations compared to the preoperative situation. Interestingly, we did not find an impact of OT, LOS, lab markers, complications, and other clinical characteristics on PROMs. Notably, a higher number of stabilized levels did not affect PROMs. Conclusions: Minimal-invasive stabilization of thoracolumbar fractures utilizing a dorsal percutaneous approach resulted in significant PROM outcome improvements, although we observed a complication rate of 13.2% for up to 1 year of follow-up. PROMs were not significantly associated with clinicopathological characteristics, technique-related variables, or the number of targeted levels.
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Vilhav C, Fagman JB, Holmberg E, Naredi P, Engström C. C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage. Langenbecks Arch Surg 2022; 407:1949-1959. [PMID: 35306601 PMCID: PMC9399186 DOI: 10.1007/s00423-022-02440-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
Background Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C. Methods Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C. Results High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started. Discussion High postoperative CRP levels are related to an increased risk of PPH C.
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Affiliation(s)
- C Vilhav
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - J B Fagman
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Holmberg
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Naredi
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Engström
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Shetty S, Ethiraj P, Shanthappa AH. C-reactive Protein Is a Diagnostic Tool for Postoperative Infection in Orthopaedics. Cureus 2022; 14:e22270. [PMID: 35350520 PMCID: PMC8931842 DOI: 10.7759/cureus.22270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/12/2022] Open
Abstract
Background Orthopedic fracture-associated infection is a prevalent complication with a huge burden on the healthcare infrastructure. C-reactive protein (CRP) is a widely used serum inflammatory marker in patients with infections in orthopaedics. It could be difficult to distinguish between CRP elevation caused by surgical site infection and CRP elevation caused by surgery and trauma in orthopaedic procedures. In most situations, a clinical diagnosis of post-surgical infection is sufficient, however, the use of a biomarker with predictive value for acute post-op complications could prompt an earlier diagnosis. This study, therefore, aims at assessing CRP levels in post-operative orthopaedic trauma patients and determining the reliability of CRP as an early indicator of postoperative infection. Materials and methods A prospective study was conducted between December 2020 and November 2021 in the department of orthopaedics in Sri Devaraj Urs medical college, Kolar. Patients with an open and closed fracture of the upper and lower extremities treated by osteosynthesis on an elective or emergency basis were included. The clinical parameters were studied on the day of trauma, postoperative days first, third and seventh. Blood samples for CRP were taken prior to the surgical procedure and on the same days as clinical monitoring. The CRP levels were compared between patients with postoperative infection and patients without postoperative infections using independent samples t-test. A p-value of < 0.05 was considered statistically significant. Results A total of 51 patients were included in the study meeting the inclusion criteria, of which mean standard deviation for age was 37.5 (15.7%), 44 were men (86.2%) and seven were women (13.7%), Patients according to Tscherene classification grade I were 10 (19.6%), grade II were eight (15.6%), grade III were 15 (29.4%) and grade IV was 18 (35.2%), type of fracture surgery diaphyseal were 27 (52.9%), proximal was 11 (21.5%) and distal were 13 (25.4%). 15 patients developed postoperative infection with CRP levels of 96 µg/mL in nine (17.6%), 48 µg/mL in four (7.8%) and 24 µg/mL in two (3.9%). Thirty-six patients who did not develop post-operative infection had CRP levels of 6 µg/mL in 31 (60.8%) and 12 µg/mL in five (9.8%). The p-value for the first postoperative day was 0.289 and statistically insignificant and on the third and seventh postoperative days was <0.001 and was found to be statistically significant. Conclusion C-reactive protein is a useful parameter to detect and monitor post-operative infections in orthopaedic trauma surgeries. The rise in C-reactive protein on the third and seventh postoperative days can be used as a reliable predictor of post-operative infections.
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Chalkias A, Laou E, Kolonia K, Ragias D, Angelopoulou Z, Mitsiouli E, Kallemose T, Smith-Hansen L, Eugen-Olsen J, Arnaoutoglou E. Elevated preoperative suPAR is a strong and independent risk marker for postoperative complications in patients undergoing major noncardiac surgery (SPARSE). Surgery 2021; 171:1619-1625. [PMID: 34736789 DOI: 10.1016/j.surg.2021.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients undergoing major surgery are often at risk of developing postoperative complications. We investigated whether a preoperative marker of chronic inflammation, soluble urokinase plasminogen activator receptor, can aid in identifying patients at high risk for postoperative complications, morbidity, and mortality. METHODS In this prospective observational study (ClinicalTrials.gov identifier: NCT03851965), EDTA blood was collected from consecutive adult White patients scheduled for major noncardiac surgery with expected duration ≥2 hours under general anesthesia. Inclusion criteria were age ≥18 years and American Society of Anesthesiologists physical status I to IV. Plasma soluble urokinase plasminogen activator receptor levels were determined using the suPARnostic quick triage lateral flow assay. The primary endpoint was postoperative complications defined as presence of any complication and/or admission to intensive care unit and/or mortality within the first 90 postoperative days. RESULTS Preoperative soluble urokinase plasminogen activator receptor had an odds ratio of 1.50 (95% confidence interval: 1.24-1.82) for every ng/mL increase. When including age, sex, American Society of Anesthesiologists score, C-reactive protein, and grouped soluble urokinase plasminogen activator receptor in multivariate analysis, patients with soluble urokinase plasminogen activator receptor between 5.5 and 10 ng/mL had an odds ratio of 11.2 (confidence interval: 3.1-40.8) and patients with soluble urokinase plasminogen activator receptor >10 ng/mL had an odds ratio of 19.9 (95% confidence interval: 4.3-92.9) compared to patients with soluble urokinase plasminogen activator receptor ≤5.5 ng/mL, respectively. Receiver operating characteristic analysis of soluble urokinase plasminogen activator receptor showed an area under the curve of 0.82 (confidence interval: 0.72-0.91). Receiver operating characteristic analysis combining age, sex, C-reactive protein levels, and American Society of Anesthesiologists score and had an area under the curve of 0.71 (95% confidence interval: 0.61-0.82). Adding soluble urokinase plasminogen activator receptor to this model increased the area under the curve to 0.83 (95% confidence interval: 0.74-0.92) (P = .033). CONCLUSION Preoperative soluble urokinase plasminogen activator receptor provided strong and independent predictive value on postoperative complications in White patients undergoing major noncardiac surgery.
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Affiliation(s)
- Athanasios Chalkias
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece; Outcomes Research Consortium, Cleveland, OH.
| | - Eleni Laou
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece
| | - Konstantina Kolonia
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece
| | - Dimitrios Ragias
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece
| | | | - Eleni Mitsiouli
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Denmark
| | - Lars Smith-Hansen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Denmark
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Denmark
| | - Eleni Arnaoutoglou
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece
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12
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Archer N, Zebic L, Turton N, Higginson J, Idle M, Praveen P, Martin T, Parmar S, Breik O. An evaluation of the clinical utility of C-reactive protein and antibiotic use in patients undergoing major head and neck reconstructive surgery with outcome assessment. Oral Maxillofac Surg 2021; 26:455-461. [PMID: 34599697 PMCID: PMC8486958 DOI: 10.1007/s10006-021-01001-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 09/02/2021] [Indexed: 12/01/2022]
Abstract
Purpose This ambispective observational study aims to evaluate the local utility of peri-operative CRP testing and prophylactic antibiotics in relation to post-operative complications in patients who have undergone major head and neck oncological reconstructive surgery. Results A total of 79 patients were identified for inclusion; CRP testing was undertaken within the first 3 days postoperatively in 78/79 cases. Results demonstrated no benefit of extended prophylactic antibiotic use in reducing post-operative infection. Forty-two post-operative complications arose. In the prospective arm, CRP did not influence the decision to commence antibiotic therapy for any of the surgical site infections. Age, diabetes, smoking, or high body mass index (BMI) did not appear to affect the incidence of postoperative infection (p > 0.05). There is no evidence that more than 24 h of antibiotic prophylaxis is indicated for patients undergoing head and neck reconstructive surgery. Conclusion Everyone who is involved in peri-operative patient care should be educated regarding the appropriate use of CRP testing, with the implementation of protocols required to standardize CRP testing and prophylactic antibiotic prescription.
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Affiliation(s)
- Natalie Archer
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Lara Zebic
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Natalie Turton
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - James Higginson
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Matthew Idle
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Prav Praveen
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Timothy Martin
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Sat Parmar
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
| | - Omar Breik
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Birmingham, B15 2GW UK
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13
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Schultz-Swarthfigure CT, McCall P, Docking R, Galley HF, Shelley B. Can soluble urokinase plasminogen receptor predict outcomes after cardiac surgery? Interact Cardiovasc Thorac Surg 2021; 32:236-243. [PMID: 33236082 DOI: 10.1093/icvts/ivaa239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/03/2020] [Accepted: 09/20/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker that has been implicated in several cardiac pathologies and has been shown to be elevated in critically ill populations. We measured plasma suPAR in a cohort of cardiac surgical patients to evaluate its ability to predict prolonged intensive care unit (ICU) and hospital length of stay and development of complications following surgery. We compared suPAR against EuroSCORE II and C-reactive protein (CRP). METHODS Ninety patients undergoing cardiac surgery were recruited with samples taken preoperatively and on postoperative days 1, 2 and 3. suPAR was measured using enzyme-linked immunosorbent assay. Area under the receiver operator curve (AUROC) was used to test predictive capability of suPAR. Comparison was made with EuroSCORE II and CRP. RESULTS suPAR increased over time (P < 0.001) with higher levels in patients requiring prolonged ICU and hospital stay, and prolonged ventilation (P < 0.05). suPAR was predictive for prolonged ICU and hospital stay, and prolonged ventilation at all time points (AUROC 0.66-0.74). Interestingly, this association was also observed preoperatively, with preoperative suPAR predicting prolonged ICU (AUROC 0.66), and hospital stay (AUROC 0.67) and prolonged ventilation (AUROC 0.74). The predictive value of preoperative suPAR compared favourably to EuroSCORE II and CRP. CONCLUSIONS suPAR increases following cardiac surgery and levels are higher in those who require prolonged ICU stay, prolonged hospital stay and prolonged ventilation. Preoperative suPAR compares favourably to EuroSCORE II and CRP in the prediction of these outcomes. suPAR could be a useful biomarker in predicting outcome following cardiac surgery, helping inform clinical decision-making. CLINICAL REGISTRATION West of Scotland Research Ethics Committee Reference: 12/WS/0179 (AM01).
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Affiliation(s)
- Chase T Schultz-Swarthfigure
- University Department of Anaesthesia, Pain and Intensive Care Medicine, New Lister Building, Glasgow Royal Infirmary, Glasgow, UK
| | - Philip McCall
- University Department of Anaesthesia, Pain and Intensive Care Medicine, New Lister Building, Glasgow Royal Infirmary, Glasgow, UK.,Department of Anaesthesia, Golden Jubilee National Hospital, Glasgow, UK
| | - Robert Docking
- Department of Anaesthesia, Queen Elizabeth University Hospital, Glasgow, UK
| | - Helen F Galley
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Benjamin Shelley
- University Department of Anaesthesia, Pain and Intensive Care Medicine, New Lister Building, Glasgow Royal Infirmary, Glasgow, UK.,Department of Anaesthesia, Golden Jubilee National Hospital, Glasgow, UK
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14
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. Inflammatory response, fluid balance and outcome in emergency high-risk abdominal surgery. Acta Anaesthesiol Scand 2021; 65:730-739. [PMID: 33548067 DOI: 10.1111/aas.13792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The main disease etiologies requiring emergency high-risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology. METHODS The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013-2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre- and postoperative C-reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology. RESULTS A total of 418 patients were included. Pre- and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non-significant (P = .716 and P = .816 respectively). There was significant association between both pre- (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction. CONCLUSIONS In this explorative study, a high pre- and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Morten L. Lauritsen
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Katrine Kanstrup
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Nicolai B. Foss
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
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15
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Alsaif SH, Rogers AC, Pua P, Casey PT, Aherne GG, Brannigan AE, Mulsow JJ, Shields CJ, Cahill RA. Preoperative C-reactive protein and other inflammatory markers as predictors of postoperative complications in patients with colorectal neoplasia. World J Surg Oncol 2021; 19:74. [PMID: 33714275 PMCID: PMC7956109 DOI: 10.1186/s12957-021-02142-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/20/2021] [Indexed: 12/11/2022] Open
Abstract
Background Inflammatory markers are measured following colorectal surgery to detect postoperative complications. However, the association of these markers preoperatively with subsequent postoperative course has not yet been usefully studied. Aim The aim of this study is to assess the ability of preoperative C-reactive protein (CRP) and other inflammatory marker measurements in the prediction of postoperative morbidity after elective colorectal surgery. Methods This is a retrospective study which catalogs 218 patients undergoing elective, potentially curative surgery for colorectal neoplasia. Preoperative laboratory results of the full blood count (FBC), C-reactive protein (CRP) and carcinoembryonic antigen (CEA) were recorded. Multivariable analysis was performed to examine preoperative variables against 30-day postoperative complications by type and grade (Clavien-Dindo (CD)), adjusting for age, sex, BMI, smoking status, medical history, open versus laparoscopic operation, and tumor characteristics. Results Elevated preoperative CRP (≥ 5 mg/L) was significantly predictive of all-cause mortality, with an OR of 17.0 (p < 0.001) and was the strongest factor to predict a CD morbidity grade ≥ 3 (OR 41.9, p < 0.001). Other factors predictive of CD morbidity grade ≥ 3 included smoking, elevated preoperative platelet count and elevated preoperative neutrophil-lymphocyte ratio (OR 15.6, 8.6, and 6.3 respectively, all p < 0.05). CRP values above 5.5 mg/L were indicative of all-cause morbidity (AUC = 0.871), and values above 17.5 mg/L predicted severe complications (AUC = 0.934). Conclusions Elevated preoperative CRP predicts increased postoperative morbidity in this patient cohort. The results herein aid risk and resource stratification and encourage preoperative assessment of inflammatory propensity besides simple sepsis exclusion.
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Affiliation(s)
- Sufana H Alsaif
- University College Dublin School of Medicine, Belfield, Dublin 4, Ireland
| | - Ailín C Rogers
- Department of Surgery, Mater Misericordiae University Hospital (MMUH), 46-47 Eccles Street, Dublin 7, D07 A8NN, Ireland.,Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland
| | - Priscilla Pua
- University College Dublin School of Medicine, Belfield, Dublin 4, Ireland
| | - Paul T Casey
- University College Dublin School of Medicine, Belfield, Dublin 4, Ireland
| | - Geoff G Aherne
- University College Dublin School of Medicine, Belfield, Dublin 4, Ireland
| | - Ann E Brannigan
- Department of Surgery, Mater Misericordiae University Hospital (MMUH), 46-47 Eccles Street, Dublin 7, D07 A8NN, Ireland.,Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland
| | - Jurgen J Mulsow
- Department of Surgery, Mater Misericordiae University Hospital (MMUH), 46-47 Eccles Street, Dublin 7, D07 A8NN, Ireland.,Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland
| | - Conor J Shields
- Department of Surgery, Mater Misericordiae University Hospital (MMUH), 46-47 Eccles Street, Dublin 7, D07 A8NN, Ireland.,Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland
| | - Ronan A Cahill
- Department of Surgery, Mater Misericordiae University Hospital (MMUH), 46-47 Eccles Street, Dublin 7, D07 A8NN, Ireland. .,Section of Surgery and Surgical Specialties, School of Medicine, University College Dublin, Dublin, Ireland.
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16
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Parama Adi M, Gede Widnyana IM, Pramana Suarjaya IP, Agung Senapathi T, Ryalino C. Comparison of C-reactive protein levels, neutrophil count, and clinical outcomes between low-dose ketamine given at the end of surgery and at induction in laparotomy. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_248_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Bouassida M, Zribi S, Krimi B, Laamiri G, Mroua B, Slama H, Mighri MM, M'saddak Azzouz M, Hamzaoui L, Touinsi H. C-reactive Protein Is the Best Biomarker to Predict Advanced Acute Cholecystitis and Conversion to Open Surgery. A Prospective Cohort Study of 556 Cases. J Gastrointest Surg 2020; 24:2766-2772. [PMID: 31768828 DOI: 10.1007/s11605-019-04459-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND White blood cell levels (WBC) is the only biologic determinant criterion of the severity assessment of acute cholecystitis (AC) in the revised Tokyo Guidelines 2018 (TG18). The aims of this study were to evaluate the discriminative powers of common inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP)) compared with WBC for the severity of AC, and the risk for conversion to open surgery and to determine their diagnostic cutoff levels. METHODS This was a prospective cohort study. Over 3 years, 556 patients underwent laparoscopic cholecystectomy for AC. Patients were classified into two groups: 139 cases of advanced acute cholecystitis (AAC) (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis), and 417 cases of non-advanced acute cholecystitis (NAAC). Multiple logistic regression and receiver-operating characteristic curve analysis were employed to explore which variables (WBC, CRP, and neutrophil-to-lymphocyte ratio (NLR)) were statistically significant in predicting AAC and conversion to open surgery. RESULTS On multivariable logistic regression analysis, male gender (OR = 0.4; p = 0.05), diabetes mellitus (OR = 7.8; p = 0.005), 3-4 ASA score (OR = 5.34; p = 0.037), body temperature (OR = 2.65; p = 0.014), and CRP (OR = 1.01; p = 0.0001) were associated independently with AAC. The value of the area under the curve (AUC) of the CRP (0.75) was higher than that of WBC (0.67) and NLR (0.62) for diagnosing AAC. CRP was the only predictive factor of conversion in multivariate analysis (OR = 1.008 [1.003-1.013]. Comparing areas under the receiver operating characteristic curves, it was the CRP that had the highest discriminative power in terms of conversion. CONCLUSION CRP is the best inflammatory marker predictive of AAC and of conversion to open surgery. We think that our results would support a multicenter-international study to confirm the findings, and if supported, CRP should be considered as a severity criterion of acute cholecystitis in the next revised version of the Guidelines of Tokyo.
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Affiliation(s)
- Mahdi Bouassida
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia. .,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.
| | - Slim Zribi
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Bassem Krimi
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Ghazi Laamiri
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Bassem Mroua
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Helmi Slama
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Mohamed Mongi Mighri
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Mohamed M'saddak Azzouz
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Depatment of Gastroenterology, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia
| | - Lamine Hamzaoui
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.,Depatment of Gastroenterology, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia
| | - Hassen Touinsi
- Depatment of Surgery, Mohamed Tahar Maamouri Hospital, Nabeul, Tunisia.,Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
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18
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Kirdak T, Uysal E, Sezgin E, Cecen GS, Cavun S. Inflammatory response markers in rats undergoing abdominal surgical procedures. Ann Gastroenterol 2020; 33:528-535. [PMID: 32879601 PMCID: PMC7406820 DOI: 10.20524/aog.2020.0511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background The aim of this study was to determine the effectiveness of cortisol, interleukin (IL)-6, C-reactive protein (CRP), and white blood cell (WBC) count as inflammatory markers to evaluate the postoperative inflammatory response associated with various abdominal surgical procedures in rats. Methods Wistar albino rats (N=152) were randomly assigned to 7 groups: control, hepatectomy, splenectomy, nephrectomy, colectomy, gastrectomy, and sham. Apart from the control group, each group was then divided into 3 subgroups: 6th, 24th and 48th h. Thus, a total of 19 groups were defined, each including 8 rats. At the 6th, 24th and 48th h following the surgical procedures blood samples from each rat were collected. The plasma concentrations of IL- 6, cortisol, CRP, and WBC were measured. Results Both the surgery category and the elapsed time after the surgery had a significant effect on IL-6 levels (P<0.0001). Blood CRP levels were primarily determined by the surgery category (P<0.0001). Neither surgery nor the elapsed time had a significant effect on the cortisol levels. The elapsed time after surgery was the major factor that influenced the differences in WBC count among the surgery groups (P<0.0001). Conclusions Our results cumulatively indicate that the levels of IL-6, CRP, and cortisol and WBC count change at different time points after several abdominal surgical procedures. Cortisol level is not related to the type of surgical procedure or the elapsed time, while WBC count decreases with the elapsed time. None of the changes in the markers investigated in this study is specifically related to the category of abdominal surgical procedure.
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Affiliation(s)
- Türkay Kirdak
- Department of General Surgery, Uludag University School of Medicine, Bursa
| | - Erdal Uysal
- Department of General Surgery, Gaziantep, Sanko University School of Medicine
| | - Efe Sezgin
- Department of Food Engineering, Izmir, lzmir lnstitute of Technology, Laboratory of Nutrigenomics and Epidemiology
| | - Gülce Sevdar Cecen
- Department of Medical Pharmacology, Uludag University School of Medicine, Bursa, Turkey
| | - Sinan Cavun
- Department of Medical Pharmacology, Uludag University School of Medicine, Bursa, Turkey
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19
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Paradis T, Zorigtbaatar A, Trepanier M, Fiore JF, Fried GM, Feldman LS, Lee L. Meta-analysis of the Diagnostic Accuracy of C-Reactive Protein for Infectious Complications in Laparoscopic Versus Open Colorectal Surgery. J Gastrointest Surg 2020; 24:1392-1401. [PMID: 32314233 DOI: 10.1007/s11605-020-04599-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION C-reactive protein may predict anastomotic complications after colorectal surgery, but its predictive ability may differ between laparoscopic and open resection due to differences in stress response. Therefore, the objective of this study was to perform a systematic review and meta-analysis on the diagnostic characteristics of C-reactive protein to detect anastomotic leaks and infectious complications after laparoscopic and open colorectal surgery. METHODS A systematic review was performed according to PRISMA. Studies were included if they reported on the diagnostic characteristics of postoperative day 3-5 values of serum C-reactive protein to diagnose anastomotic leak or infectious complications specifically in patients undergoing elective laparoscopic and open colorectal surgery. The main outcome was a composite of anastomotic leak and infectious complications. A random-effects model was used to perform a meta-analysis of diagnostic accuracy. RESULTS A total of 13 studies were included (9 for laparoscopic surgery, 8 for open surgery). The pooled incidence of the composite outcome was 14.8% (95% CI 10.2-19.3) in laparoscopic studies and 21.0% (95% CI 11.9-30.0) for open. The pooled diagnostic accuracy characteristics were similar for open and laparoscopic studies. However, the C-reactive protein threshold cutoffs were lower in laparoscopic studies for postoperative days 3 and 4, but similar on day 5. CONCLUSIONS The diagnostic characteristics of C-reactive protein in the early postoperative period to detect infectious complications and leaks are similar after laparoscopic and open colorectal surgery. However, thresholds are lower for laparoscopic surgery, suggesting that the interpretation of serum CRP values needs to be tailored based on operative approach.
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Affiliation(s)
- Tiffany Paradis
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Anudari Zorigtbaatar
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Maude Trepanier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Gerald M Fried
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.
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20
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Parama Adi M, Agung Senapathi T, Pramana Suarjaya IP, Gede Widnyana IM. The effectiveness and clinical outcomes of low-dose ketamine on the inflammatory stress response in digestive laparotomy surgery: A case series. BALI JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.4103/bjoa.bjoa_18_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Rodriguez-Acevedo OI, Elstner K, Jacombs A, Martins RT, Craft C, Robinson S, Cosman P, Mikami DJ, Read J, Ibrahim N. The macquarie system for comprehensive management of complex ventral hernia. Hernia 2019; 24:509-525. [DOI: 10.1007/s10029-019-02092-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 11/17/2019] [Indexed: 12/18/2022]
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22
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Scharrenberg JS, Yagdiran A, Brinkmann J, Brune M, Siewe J, Jung N, Mahabir E. The diagnostic value of soluble urokinase-type plasminogen activator receptor (suPAR) for the discrimination of vertebral osteomyelitis and degenerative diseases of the spine. J Orthop Surg Res 2019; 14:367. [PMID: 31727136 PMCID: PMC6854784 DOI: 10.1186/s13018-019-1420-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022] Open
Abstract
Background There is still a challenge in discriminating between vertebral osteomyelitis and degenerative diseases of the spine. To this end, we determined the suitability of soluble urokinase-type plasminogen activator receptor (suPAR) and compared the diagnostic potential of suPAR to CRP. Methods Patients underwent surgical stabilization of the lumbar and/or thoracic spine with removal of one or more affected intervertebral discs, as therapy for vertebral osteomyelitis (n = 16) or for erosive osteochondrosis (control group, n = 20). In this prospective study, we evaluated the suPAR and CRP levels before (pre-OP) and after surgery (post-OP) on days 3–5, 6–11, 40–56, and 63–142. Results The suPAR levels in vertebral osteomyelitis patients were significantly higher than those from controls pre-OP, 3–5 days post-OP, and 6–11 days post-OP. Significantly higher CRP levels were observed in the vertebral osteomyelitis group than in the controls pre-OP and 6–11 days post-OP. Levels of suPAR and CRP correlated positively in all patients in the pre-OP period: r = 0.63 (95% CI: 0.37–0.79), p < 0.0001. The values for the area under the receiver operating characteristics curve (AUC) for pre-OP and the overall model post-OP were 0.88 (95% CI: 0.76–1.00) and 0.84 (95% CI: 0.71–0.97) for suPAR, 0.93 (95% CI: 0.85–1.00) and 0.77 (95% CI: 0.62–0.93) for CRP, and 0.98 (95% CI: 0.96–1.00) and 0.91 (95% CI: 0.82–1.00) for the combination of suPAR and CRP. The AUC for suPAR pre-OP revealed an optimum cut-off value, sensitivity, specificity, NPV, and PPV of 2.96 ng/mL, 0.69, 1.00, 0.80, and 1.00, respectively. For CRP, these values were 11.58 mg/L, 0.88, 0.90, 0.90, and 0.88, respectively. Conclusion The present results show that CRP is more sensitive than suPAR whereas suPAR is more specific than CRP. Moreso, our study demonstrated that improvement in the diagnostic power for discrimination of vertebral osteomyelitis and degenerative diseases of the spine can be achieved by a combination of both suPAR and CRP. Trial registration ClinicalTrials.gov, NCT02554227, posted Sept. 18, 2015, and updated Aug. 13, 2019
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Affiliation(s)
- Jan Simon Scharrenberg
- Comparative Medicine, Center for Molecular Medicine, University of Cologne, Robert-Koch-Straße 21, 50931, Cologne, Germany
| | - Ayla Yagdiran
- Department of Orthopedic and Trauma Surgery, University of Cologne, Cologne, Germany
| | - Julia Brinkmann
- Comparative Medicine, Center for Molecular Medicine, University of Cologne, Robert-Koch-Straße 21, 50931, Cologne, Germany
| | - Maik Brune
- Department of Medicine I and Clinical Chemistry, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Siewe
- Faculty of Medicine, University Hospital, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Cologne, Germany
| | - Esther Mahabir
- Comparative Medicine, Center for Molecular Medicine, University of Cologne, Robert-Koch-Straße 21, 50931, Cologne, Germany.
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The role of C-reactive protein after surgery for obesity and metabolic disorders. Surg Obes Relat Dis 2019; 16:99-108. [PMID: 31784329 DOI: 10.1016/j.soard.2019.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/17/2019] [Accepted: 10/08/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND C-reactive protein (CRP) rise might be different in patients with obesity due to chronic inflammation. OBJECTIVES The aim was to analyze postoperative CRP rise and its role as an early prognostic marker of infectious complications. SETTING Center of maximum care in Germany. METHODS Patients who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic one-anastomosis gastric bypass as primary treatment for severe obesity were included. Serum CRP and leukocyte count were measured preoperatively, on postoperative days (POD) 1 and 4 and were analyzed regarding sex, body mass index, waist circumference, obesity-associated diseases, laboratory measurements (glycosylated hemoglobin, triglycerides, cholesterol), surgical procedure, infectious complications, and infectious with anastomotic leakage. RESULTS Four hundred seventy-one patients underwent surgery. Postoperative CRP rise was similar across sexes but lower in the super-super obese group (P < .05) and higher in the gastric bypass groups (P < .05). Linear regression model showed, that the higher preoperative value of waist circumference, the higher the preoperative CRP (beta value: .159, P = .006) and the lower the postoperative CRP rise on POD1 (beta value: -.171, P = .004) and 4 (beta value: -.170, P = .003). Only in the laparoscopic one-anastomosis gastric bypass group did a higher glycosylated hemoglobin predict a higher postoperative CRP rise (POD1: beta value: .434, P = .012; POD4: beta value: .513, P = .006). Fourteen patients (3%) developed infections, 7 of whom (1.5%) had anastomotic leakage. Leukocyte count was no predictor of infectious complications. The cut-off for CRP was 80.5 mg/L (POD1) and 164 mg/L (POD4), with 57.1% and 85.7% sensitivity and 97.9% and 99.6% specificity for anastomotic leakage. CONCLUSION Standard postoperative CRP rises less in patients with higher waist circumference and super-super obesity, but more after gastric bypass procedures. CRP but not leukocyte count predicts early anastomotic healing after obesity surgery. These findings should be considered when interpreting CRP values in the routine clinical setting.
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Charani E, de Barra E, Rawson TM, Gill D, Gilchrist M, Naylor NR, Holmes AH. Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study. Antimicrob Resist Infect Control 2019; 8:151. [PMID: 31528337 PMCID: PMC6743118 DOI: 10.1186/s13756-019-0603-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Qualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice. Methods We prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 – May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy. Results Surgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine. Conclusions Across both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.
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Affiliation(s)
- E Charani
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - E de Barra
- 2Royal College of Surgeons in Ireland, RCSI Education & Research Centre, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - T M Rawson
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - D Gill
- 3Department of Biostatistics and Epidemiology, School of Public Health, Imperial College London, London, W2 1PG UK
| | - M Gilchrist
- Department of Pharmacy, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W12 1NY UK
| | - N R Naylor
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - A H Holmes
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
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C-reactive protein: what to expect after bony hip surgery for nonambulatory children and adolescents with cerebral palsy. J Pediatr Orthop B 2019; 28:309-313. [PMID: 30925527 DOI: 10.1097/bpb.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bony hip reconstruction surgery in children with severe cerebral palsy is associated with high complication rates, usually postoperative chest and urinary tract infections. C-reactive protein (CRP) level is commonly used as an indication of infection; an understanding of its normal postoperative trends is crucial to allow early identification of abnormal levels and possible infection. Our aim was to describe the trends in CRP following bony hip surgery in children who had an uneventful postoperative course, on the basis that the children for whom CRP does not follow this course are likely to have a bacterial infection. A retrospective review was performed of 155 children with CP having bony hip surgery between 2012 and 2016. The median age was 9.9 years (interquartile range: 6.6-12.7). One hundred (64.5%) patients had a Gross Motor Function Classification System rating of V. All CRP levels measured in routine postoperative care were recorded, and medical records were examined for postoperative infective complications. The CRP levels of patients with clinically proven infections were excluded in order to describe what to expect in the absence of infection. Mean CRP peaked on the third postoperative day at 81 mg/l in those who had no postoperative infection. Twenty-five (16.1%) patients had a postoperative infection; their mean CRP was higher on all postoperative days and peaked at 128 mg/l on the third postoperative day. An understanding of the normal postoperative trends in CRP allows identification of those with abnormally raised levels. Postoperative CRP is consistently higher in children with an infective complication. We recommend that the CRP should be routinely checked following bony hip surgery in children with CP, and a careful search for infection undertaken in those with a raised level.
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Gregory GC, Kuzman M, Sivaraj J, Navarro AP, Cameron IC, Irving G, Gomez D. C-reactive Protein is an Independent Predictor of Difficult Emergency Cholecystectomy. Cureus 2019; 11:e4573. [PMID: 31281756 PMCID: PMC6605972 DOI: 10.7759/cureus.4573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The objective of this study was to identify variables that predict a difficult laparoscopic cholecystectomy performed in an emergency setting. The secondary aim was to devise a pathway for patients admitted acutely that required a cholecystectomy. Methods Patients admitted to the Emergency General Surgery Department at Nottingham, the United Kingdom that had an emergency cholecystectomy performed during the one-year period from May 2016 to June 2017 were identified. Collected data included patient demographics, clinical presentation, biochemical analysis, radiological findings, subsequent interventions, surgical data, and clinical outcome. A difficult cholecystectomy was defined as operative time >60 minutes, conversion to an open procedure, or sub-total cholecystectomy performed. Results A total of 149 patients were included. Cholecystitis was the most common diagnosis (n = 86, 57.7%), followed by acute pancreatitis (n = 36, 24.1%). Fifty-five (36.9%) patients had an elevated C-reactive protein (CRP) >100 mg/dL. One hundred and twenty-one (81.2%) patients who had an emergency cholecystectomy were defined as “difficult”. The overall morbidity rate was 15.4% (n = 23), and there was no post-operative in-hospital mortality. Univariate analysis showed that age >60 years (p = 0.012), underlying diagnosis (p = 0.010), presence of heart rate >90 (p = 0.027), and an elevated pre-surgery CRP >100 (p < 0.001) was associated with a difficult emergency cholecystectomy. Multi-variate analysis demonstrated that an elevated pre-surgery CRP >100 was an independent predictor of a difficult emergency cholecystectomy (p = 0.041). Conclusions An elevated pre-operative CRP is an independent predictor of a technically more difficult cholecystectomy in the emergency setting.
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Affiliation(s)
- Gordon C Gregory
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Matta Kuzman
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Jayaram Sivaraj
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Alex P Navarro
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Iain C Cameron
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Glen Irving
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
| | - Dhanwant Gomez
- Hepato-Pancreato-Biliary Surgery, Nottingham University Hospitals, Nottingham, GBR
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Tottas S, Fiska A, Kougioumtzis I, Ververidis A, Tilkeridis K, Drosos GI. Muscle Damage in Different Approaches in Total Hip Arthroplasty According to Serum Markers. Open Orthop J 2019. [DOI: 10.2174/1874325001913010097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:Total Hip Arthroplasty (THA) is the final treatment of end-stage hip osteoarthritis. Nowadays, THA has become very common, cost- effective and one of the most successful orthopaedic procedures. Recently, surgeons have shifted their interest to approaches according to Minimally Invasive Surgery (MIS). These approaches are either modifications of conventional approaches or they are designed from the beginning as MIS approaches. Muscle damage and soft tissue damage are issues that concern researchers who perform studies on THA.Objective:The aim of this study is to review the literature concerning studies by comparing different approaches using serum and inflammatory markers for muscle and soft tissue damage.Methods:We searched the PubMed database in the English language systematically for clinical studies or reviews, comparing muscle damage according to serum markers between two or more approaches in primary total arthroplasty.Results:In total, twenty-one studies were included in this review. Although the results are controversial, it seems that MIS approaches in most of the studies were related to lower levels of inflammation markers contrasting with conventional approaches. Nevertheless, this difference in muscle damage is not correlated with a difference in functional scores or other perioperative data and clinical outcomes in all studies.Conclusion:The existing literature does not lead to a safe consensus about the superiority of any approach. Therefore, there is still a need for further research with well-designed studies.
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Barnes J, Hunter J, Harris S, Shankar-Hari M, Diouf E, Jammer I, Kalkman C, Klein AA, Corcoran T, Dieleman S, Grocott MPW, Mythen MG. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: infection and sepsis. Br J Anaesth 2019; 122:500-508. [PMID: 30857606 DOI: 10.1016/j.bja.2019.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/26/2018] [Accepted: 01/08/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials. METHODS We undertook a systematic review to identify measures of infection and sepsis used in the perioperative literature. A multi-round Delphi consensus process that included more than 60 clinician researchers was then used to refine a recommended list of outcome measures. RESULTS A literature search yielded 1857 titles of which 255 met inclusion criteria for endpoint extraction. A long list of endpoints, with definitions and timescales, was generated and those potentially relevant to infection and sepsis circulated to the theme subgroup and then the wider StEP-COMPAC working group, undergoing a three-stage Delphi process. The response rates for Delphi rounds 1, 3, and 3 were 89% (n=8), 67% (n=62), and 80% (n=8), respectively. A set of 13 endpoints including fever, surgical site, and organ-specific infections as defined by the US Centres for Disease Control and Sepsis-3 are proposed for future use. CONCLUSIONS We defined a consensus list of standardised endpoints related to infection and sepsis for perioperative trials using an established and rigorous approach. Each endpoint was evaluated with respect to validity, reliability, feasibility, and patient centredness. One or more of these should be considered for inclusion in future perioperative clinical trials assessing infection, sepsis, or both, thereby permitting synthesis and comparison of future results.
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Affiliation(s)
- Jonathan Barnes
- Department of Anaesthesia, Great Western Hospital, Swindon, UK
| | - Jennifer Hunter
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK
| | - Steve Harris
- Bloomsbury Institute of Intensive Care Medicine, University College London Hospital, London, UK.
| | - Manu Shankar-Hari
- School of Immunology & Microbial Sciences, Kings College London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Elisabeth Diouf
- Anesthesia and Intensive Care Unit, Le Dantec Hospital, Cheikh Anta DIOP University, Dakar, Senegal
| | - Ib Jammer
- Department of Anaesthesiology and Intensive Care, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Cor Kalkman
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridgeshire, UK
| | - Tomas Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Stefan Dieleman
- Department of Anaesthesia & Perioperative Medicine Westmead Hospital, Sydney, Australia
| | - Michael P W Grocott
- Anaesthesia and Critical Care Research Group, NIHR Biomedical Research Centre, UK; Faculty of Medicine, University of Southampton, Southampton, UK; Department of Anaesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Michael G Mythen
- Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, UK; National Institute of Health Research Biomedical Research Centre, London, UK
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Hering S, Wiegand S. Systemic inflammatory response after endoscopic surgery of Zenker's diverticulum. ACTA OTORHINOLARYNGOLOGICA ITALICA 2019; 39:230-234. [PMID: 30745590 PMCID: PMC6734204 DOI: 10.14639/0392-100x-1576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 12/01/2017] [Indexed: 11/23/2022]
Abstract
Zenker’s diverticulum can be treated with a carbon dioxide laser or linear stapling device. A retrospective study on patients undergoing elective surgery for Zenker`s diverticulum with carbon dioxide laser or stapler was performed to analyse possible differences in inflammatory responses during the postoperative period. Leucocyte counts and C-reactive protein levels in peripheral blood were measured before and on days 1, 2, 3 and 5 after the operation. Statistical analysis was performed using the Mann-Whitney U-test. Of 34 patients, 16 were treated by laser and 18 by stapler. Age, sex ratio and ASA grade did not differ between the groups. Postoperative leukocytosis was significantly milder in the stapler group compared with patients who were treated by carbon dioxide laser. The mean C-reactive protein (CRP) level on day 1, 2 and 3 after surgery was significantly higher in the CO2 laser group than in the stapler group. Leukocyte counts recovered on day 3 after surgery in both groups while CRP levels did not decline to preoperative levels at day 5 after the operation in either group. No inflammatory complications such as mediastinitis or pneumonia occurred. In conclusion, the inflammatory response in the early period after carbon dioxide laser diverticulotomy of Zenker’s diverticulum is higher than after stapler-assisted surgery of Zenker’s diverticulum.
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Affiliation(s)
- S Hering
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - S Wiegand
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Leipzig, Leipzig, Germany
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Shin WC, Do MU, Woo SH, Choi SH, Moon NH, Suh KT. C-reactive protein for early detection of postoperative systemic infections in intertrochanteric femoral fractures. Injury 2018; 49:1859-1864. [PMID: 30082110 DOI: 10.1016/j.injury.2018.07.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/10/2018] [Accepted: 07/26/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND This retrospective cohort study investigated perioperative C-reactive protein (CRP) value for early detection of postoperative systemic infective complications in elderly patients with intertrochanteric femoral fracture. METHODS A total of 250 patients aged ≥65 years, with intertrochanteric femoral fractures that were surgically treated between January 2011 and December 2015 were included. CRP value was measured preoperatively and on postoperative day (POD) 3, 5, and 10, and analyzed with regard to postoperative systemic infections, delirium, and death within 1 year. The patients were divided into two groups according to postoperative systemic infection, and perioperative CRP responses between the two groups were comparedusing t-test (or Man-Whitney test where appropriate). The receiver operator characteristic (ROC) curves of CRP value were used to determine the best-supported cut-off values for identifying postoperative systemic infections. Systemic infections were reclassified as pulmonary and extra-pulmonary infections. RESULTS The mean CRP values preoperatively and on POD 3, 5, and 10 were 2.82, 10.10, 3.74, and 1.89 mg/dL, respectively. Postoperative systemic infections, delirium, and death within 1 year were noted in 35 (14.0%), 30 (12.0%), and 45 (18.0%) patients, respectively. The CRP value in patients with postoperative systemic infections significantly elevated on POD 5 and 10 (p < 0.001, p < 0.001), and cut-off values were 4.71 and 1.59 mg/dL on POD 5 and 10, respectively. Postoperative delirium and death within 1 year were observed more often in the group with postoperative systemic infections (p = 0.003, p = 0.014). Although preoperatively elevated CRP values did not influence the postoperative CRP responses, they were significantly associated with delirium (p = 0.015). CONCLUSIONS The CRP value on POD 5 is the earliest predictor of postoperative systemic infections in elderly patients with intertrochanteric femoral fractures that are managed surgically. Moreover, when the CRP value on POD 5 is >4.71 mg/dL, the possibility of postoperative systemic infections should be considered. LEVEL OF EVIDENCE III, Retrospective cohort study.
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Affiliation(s)
- Won Chul Shin
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea.
| | - Min Uk Do
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea.
| | - Seung Hun Woo
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea.
| | - Sung Hoon Choi
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea.
| | - Nam Hoon Moon
- Department of Orthopaedic Surgery, Pusan National University Hospital, Busan, Republic of Korea.
| | - Kuen Tak Suh
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea.
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Cytokines as biomarkers of inflammatory response after open versus endovascular repair of abdominal aortic aneurysms: a systematic review. Acta Pharmacol Sin 2018; 39:1164-1175. [PMID: 29770795 DOI: 10.1038/aps.2017.212] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/31/2017] [Indexed: 01/01/2023] Open
Abstract
The repair of an abdominal aortic aneurysm (AAA) is a high-risk surgical procedure related to hormonal and metabolic stress-related response with an ensuing activation of the inflammatory cascade. In contrast to open repair (OR), endovascular aortic aneurysm repair (EVAR) seems to decrease the postoperative stress by offering less extensive incisions, dissection, and tissue manipulation. However, these beneficial effects may be offset by the release of cytokines and arachidonic acid metabolites during intra-luminal manipulation of the thrombus using catheters in endovascular repair, resulting in systemic inflammatory response (SIR), which is clinically called post-implantation syndrome. In this systematic review we compared OR with EVAR in terms of the post-interventional inflammatory response resulting from alterations in the circulating cytokine levels. We sought to summarize all the latest evidence regarding post-implantation syndrome after EVAR. We searched Medline (PubMed), ClinicalTrials.gov and the Cochrane library for clinical studies reporting on the release of cytokines as part of the inflammatory response after both open/conventional and endovascular repair of the AAA. We identified 17 studies examining the cytokine levels after OR versus EVAR. OR seemed to be associated with a greater SIR than EVAR, as evidenced by the increased cytokine levels, particularly IL-6 and IL-8, whereas IL-1β, IL-10 and TNF-α showed conflicting results or no difference between the two groups. Polyester endografts appear to be positively correlated with the incidence of post-implantation syndrome after EVAR. Future large prospective studies are warranted to delineate the underlying mechanisms of the cytokine interaction in the post-surgical inflammatory response setting.
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Díaz-Flores A, Cárdenas-Lailson E, Cuendis-Velázquez A, Rodríguez-Parra A, Trejo-Ávila ME. C-Reactive Protein as a Predictor of Difficult Laparoscopic Cholecystectomy in Patients with Acute Calculous Cholecystitis: A Multivariate Analysis. J Laparoendosc Adv Surg Tech A 2017. [DOI: 10.1089/lap.2017.0139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Aarón Díaz-Flores
- Department of General and Endoscopic Surgery, Hospital General “Dr. Manuel Gea González,” Mexico City, Mexico
| | - Eduardo Cárdenas-Lailson
- Department of General and Endoscopic Surgery, Hospital General “Dr. Manuel Gea González,” Mexico City, Mexico
| | - Adolfo Cuendis-Velázquez
- Department of General and Endoscopic Surgery, Hospital General “Dr. Manuel Gea González,” Mexico City, Mexico
| | - Andrés Rodríguez-Parra
- Department of General and Endoscopic Surgery, Hospital General “Dr. Manuel Gea González,” Mexico City, Mexico
| | - Mario E. Trejo-Ávila
- Department of General and Endoscopic Surgery, Hospital General “Dr. Manuel Gea González,” Mexico City, Mexico
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Pearce A, Thornton L, Sutton PA, Walsh CJ. Post-operative C-reactive protein profile following abdominal wall reconstruction with transversus abdominis posterior components separation. Int J Surg Case Rep 2017; 40:17-19. [PMID: 28917217 PMCID: PMC5602949 DOI: 10.1016/j.ijscr.2017.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/06/2017] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Abdominal wall reconstruction using posterior component separation with transversus abdominis release (AWTAR) produces a unique post-operative CRP profile, when compared to routine elective colorectal operations. Therefore, we aim to establish the normal post-operative C-reactive protein (poCRP) profile following AWRTAR and reduce the unnecessary invasive interventions in patients already at greater risk of septic complications. METHODS A retrospective analysis of daily poCRP levels was performed both for patients who underwent uncomplicated AWRTAR (n=12), and a comparator group of uncomplicated open right hemicolectomies (RH) matched for age and sex (n=24). All operations in both groups were performed by a single surgeon from 2013 to 2015. RESULTS The median (IQR) age was 62 (16) and 67 (16) years respectively, with a higher proportion of males to females in both groups (10:2 vs. 17:7). The poCRP profile follows an initial steep rise, peaking at day 2 followed by a gradual washout phase. The poCRP peak is significantly greater in the AWRTAR group compared to the RH group (274 [95%CI ±25] vs. 160 [95%CI±27]; p=0.0001), with a positive correlation between day 2 CRP levels and operative length (r=0.56). CONCLUSIONS We have demonstrated that uncomplicated AWRTAR provokes a significantly greater poCRP rise (>200) compared to that well described in the literature for uncomplicated open colectomy. As poCRP is an important marker of post-operative recovery with abnormally high levels associated with septic complications, these data should help clinicians interpret the post-operative clinical course after AWRTAR.
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Affiliation(s)
- A Pearce
- Department of Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, United Kingdom
| | - L Thornton
- Department of Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, United Kingdom
| | - P A Sutton
- Department of Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, United Kingdom
| | - C J Walsh
- Department of Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, United Kingdom.
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Intravenous lidocaine for effective pain relief after a laparoscopic colectomy: a prospective, randomized, double-blind, placebo-controlled study. Int Surg 2016; 100:394-401. [PMID: 25785316 DOI: 10.9738/intsurg-d-14-00225.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A perioperative intravenous lidocaine infusion has been reported to decrease postoperative pain. The goal of this study was to evaluate the effectiveness of intravenous lidocaine in reducing postoperative pain for laparoscopic colectomy patients. Fifty-five patients scheduled for an elective laparoscopic colectomy were randomly assigned to 2 groups. Group L received an intravenous bolus injection of lidocaine 1.5 mg/kg before intubation, followed by 2 mg/kg/h continuous infusion during the operation. Group C received the same dosage of saline at the same time. Postoperative pain was assessed at 2, 4, 8, 12, 24, and 48 hours after surgery by using the visual analog scale (VAS). Fentanyl consumption by patient-controlled plus investigator-controlled rescue administration and the total number of button pushes were measured at 2, 4, 8, 12, 24, and 48 hours after surgery. In addition, C-reactive protein (CRP) levels were checked on the operation day and postoperative days 1, 2, 3, and 5. VAS scores were significantly lower in group L than group C until 24 hours after surgery. Fentanyl consumption was lower in group L than group C until 12 hours after surgery. Moreover, additional fentanyl injections and the total number of button pushes appeared to be lower in group L than group C (P < 0.05). The CRP level tended to be lower in group L than group C, especially on postoperative day 1 and 2 and appeared to be statistically significant. The satisfaction score was higher in group L than group C (P = 0.024). Intravenous lidocaine infusion during an operation reduces pain after a laparoscopic colectomy.
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Thomas O, Rein H, Strandberg K, Schött U. Coagulative safety of epidural catheters after major upper gastrointestinal surgery: advanced and routine coagulation analysis in 38 patients. Perioper Med (Lond) 2016; 5:28. [PMID: 27777753 PMCID: PMC5067910 DOI: 10.1186/s13741-016-0053-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The risk of spinal haematoma in patients receiving epidural catheters is estimated using routine coagulation tests, but guidelines are inconsistent in their recommendations on what to do when results indicate slight hypocoagulation. Postoperative patients are prone to thrombosis, and thromboelastometry has previously shown hypercoagulation in this setting. We aimed to better understand perioperative haemostasis by comparing results from routine and advanced tests, hypothesizing that patients undergoing major upper gastrointestinal surgery would be deficient in vitamin K-dependent coagulation factors because of malnutrition, or hypocoagulative because of accumulation of low molecular weight heparin (LMWH). METHODS Thirty-eight patients receiving epidural analgesia for major upper gastrointestinal surgery were included. We took blood at the time of preoperative epidural catheterization and at catheter withdrawal. Prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT) and platelet count (Plc) were analysed, and also albumin, proteins induced by vitamin K absence (PIVKA-II), rotational thromboelastometry (ROTEM®), multiple electrode aggregometry (Multiplate®) and activities of factors II, VII, IX, X, XI, XII and XIII. RESULTS Postoperative coagulation was characterized by thrombocytosis and hyperfibrinogenaemia. Mean PT-INR increased significantly from 1.0 ± 0.1 to 1.2 ± 0.2 and mean aPTT increased significantly from 27 ± 3 to 30 ± 4 s. Activity of vitamin K-dependent factors did not decrease significantly: FIX and FX activity increased. FXII and FXIII decreased significantly. Mean Plc increased from 213 ± 153 × 106/L while all mean ROTEM-MCFs (maximal clot firmnesses) especially FIBTEM-MCF increased significantly to above the reference interval. All mean ROTEM® clotting times were within their reference intervals both before and after surgery. ROTEM® (HEPTEM minus INTEM) results were spread around 0. There were significant correlations between routine tests and the expected coagulation factors, but not any of the viscoelastic parameters or PIVKA-II. Multiplate® area under curve and EXTEM-MCF correlated significantly to Plc as did EXTEM-MCF to fibrinogen, FIX, FX and FXIII; and FIBTEM-MCF to Plc, FII, FXI and FXIII. CONCLUSIONS The increase in PT-INR may be caused by decreased postoperative FVII while the elevated aPTT may be caused by low FXII. The mild postoperative hypocoagulation indicated by routine tests is not consistent with thromboelastometry. The relevance of ROTEM® and Multiplate® in the context of moderately increased routine tests remains unclear. Trial registration number is not applicable since this is not a clinical trial.
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Affiliation(s)
- Owain Thomas
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Department of Paediatric Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
| | | | - Karin Strandberg
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Coagulation Laboratory, Department of Clinical Chemistry, Division of Laboratory Medicine, Skåne University Hospital, 21428 Malmö, Sweden
| | - Ulf Schött
- Faculty of Medicine, University of Lund, 22100 Lund, Sweden ; Department of Anaesthesia and Intensive Care, SUS Lund University Hospital, 22185 Lund, Sweden
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Senapathi TGA, Widnyana IMG, Wiryana M, Aribawa IGNM, Aryabiantara IW, Hartawan IGAGU, Sinardja IK, Suarjaya IPP, Nada IKW, Jaya AGPS. Effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia. J Pain Res 2016; 9:689-692. [PMID: 27703393 PMCID: PMC5036542 DOI: 10.2147/jpr.s109616] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Cesarean section is a surgical procedure. Surgical procedures will induce stress responses, which may have negative impact on postoperative recovery. Ketamine plays a role in the homeostatic regulation of inflammatory response in order to attenuate stress response. We tried to determine the effectiveness of low-dose intravenous ketamine to attenuate stress response in patients undergoing emergency cesarean section with spinal anesthesia. PATIENTS AND METHODS Thirty-six pregnant women undergoing emergency cesarean section with spinal anesthesia were randomly divided into two groups (n=18). Ketamine 0.3 mg/kg (KET group) or NaCl 0.9% (NS group) was administered intravenously before the administration of spinal anesthesia. C-reactive protein (CRP) and neutrophil levels were measured preoperatively and postoperatively. RESULTS Elevation of CRP stress response was lower in the KET group and significantly different (P≤0.05) from that in the NS group. Neutrophil level was elevated in both the groups and hence not significantly different from each other (P>0.05). Postoperative visual analog scale pain score was not significantly different between the two groups (P>0.05), but there was a statistically significant (P≤0.05) positive and weak correlation between visual analog scale and CRP level postoperatively. CONCLUSION Low-dose intravenous ketamine effectively attenuates the CRP stress response in patients undergoing emergency cesarean section with spinal anesthesia.
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Affiliation(s)
- Tjokorda Gde Agung Senapathi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | - I Made Gede Widnyana
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | - Made Wiryana
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | | | - I Wayan Aryabiantara
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | | | - I Ketut Sinardja
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | - I Putu Pramana Suarjaya
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | - I Ketut Wibawa Nada
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
| | - Aa Gde Putra Semara Jaya
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Sanglah Hospital, Bali, Indonesia
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Jessica Mok KW, Goh YL, Howell LE, Date RS. Is C-reactive protein the single most useful predictor of difficult laparoscopic cholecystectomy or its conversion? A pilot study. J Minim Access Surg 2016; 12:26-32. [PMID: 26917916 PMCID: PMC4746971 DOI: 10.4103/0972-9941.158963] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Both converted and difficult laparoscopic cholecystectomies (LC) have impact on operating time and training of juniors. The aim of this study is to evaluate parameters that predict difficult LC or conversion (C), and find predictive values for different cut-off points of C-reactive protein (CRP) for conversion. MATERIALS AND METHODS A retrospective cohort study of cholecystectomies performed from January 2011 to December 2012 at NHS trust was undertaken. Association of intra-operative difficulties or conversion with the following factors was studied: Age, gender, CRP, white blood cell count (WBC), history of pancreatitis, and endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Two hundred and ninety one patients were analysed (222 laparoscopic, 45 difficult LC and 24 C). Only 141 patients had a recorded CRP. Median CRP was highest for patients who were converted (286.20) compared to those who had difficult LC (67.40) or LC (7.05). Those patients who did not have preoperative CRP (8/150, 5.3%) had less chance of conversion than those who had CRP (16/141, 11.34%) (P = 0.063). Patients with CRP of ≤220 (3/91, 3.2%) had significantly less chance of conversion than those with CRP >220 (13/21, 61.9%) (P < 0.001). High preoperative CRP, WBC count and ERCP, were predictors of conversion. These factors were only marginally better than CRP alone in predicting conversion. CONCLUSION CRP can be a strong predictor of conversion of LC. Further validation of the results is needed.
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Affiliation(s)
- Kam Wa Jessica Mok
- Department of Upper GI Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Chorley PR7 1PP, United Kingdom
| | - Yan Li Goh
- Department of Upper GI Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Chorley PR7 1PP, United Kingdom
| | - Laura E Howell
- School of Health, University of Central Lancashire, Preston, PR1 2HE, United Kingdom
| | - Ravindra S Date
- Department of Upper GI Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Chorley PR7 1PP, United Kingdom
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Watt DG, Horgan PG, McMillan DC. Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review. Surgery 2015; 157:362-80. [PMID: 25616950 DOI: 10.1016/j.surg.2014.09.009] [Citation(s) in RCA: 223] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 09/08/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations. METHODS A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure. RESULTS A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L). CONCLUSION Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.
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Affiliation(s)
- David G Watt
- Academic Unit of Colorectal Surgery, School of Medicine-University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland.
| | - Paul G Horgan
- Academic Unit of Colorectal Surgery, School of Medicine-University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Donald C McMillan
- Academic Unit of Colorectal Surgery, School of Medicine-University of Glasgow, Glasgow Royal Infirmary, Glasgow, Scotland
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Weimann K, Zimmermann M, Spies CD, Wernecke KD, Vicherek O, Nachtigall I, Tafelski S, Weimann A. Intensive Care Infection Score--A new approach to distinguish between infectious and noninfectious processes in intensive care and medicosurgical patients. J Int Med Res 2015; 43:435-51. [PMID: 25850686 DOI: 10.1177/0300060514557711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 10/03/2014] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Clinicians regularly encounter substantial time delays in diagnosing sepsis and administering appropriate antibiotic treatment. This study investigated the ability of the Intensive Care Infection Score (ICIS) to distinguish between infectious and noninfectious processes, and to assess the justified commencement of antibiotic therapy retrospectively, in line with hospital actual best practice and applied laboratory parameters. METHODS Intensive-care unit (ICU) patients were enrolled in this retrospective, observational study. Clinical data and laboratory parameters were determined daily. The cohort was divided into infected and noninfected patient groups. RESULTS Out of 172 ICU patients, including 72 postoperative patients, the predictive value for infection throughout the first 5 days in 'all patients' and the 'postoperative patient' group was highest for ICIS. An ICIS cut-off value of three could predict infection in postoperative patients with 82.9% sensitivity and 75.1% specificity. ICIS showed the lowest rate of potentially 'falsely encouraged' and 'discouraged' antibiotic therapies for noninfected and for septic postoperative patients, respectively, compared with C-reactive protein, procalcitonin and white blood cell levels. CONCLUSIONS In the ICU, particularly for postoperative patients, ICIS is a reliable marker for the timely identification of infection. ICIS may qualify as a new decision support tool for antibiotic therapy, when interpreted within the clinical context.
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Affiliation(s)
- Karin Weimann
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, University Medical Centre, Berlin, Germany
| | - Mathias Zimmermann
- Department of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany Labor Berlin - Charité Vivantes Services, Berlin, Germany
| | - Claudia D Spies
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, University Medical Centre, Berlin, Germany
| | | | - Oldrich Vicherek
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, University Medical Centre, Berlin, Germany
| | - Irit Nachtigall
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, University Medical Centre, Berlin, Germany
| | - Sascha Tafelski
- Department of Anaesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, University Medical Centre, Berlin, Germany
| | - Andreas Weimann
- Department of Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany Labor Berlin - Charité Vivantes Services, Berlin, Germany
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Akashi M, Furudoi S, Hashikawa K, Sakakibara A, Hasegawa T, Shigeta T, Minamikawa T, Komori T. Postoperative abnormal response of C-reactive protein as an indicator for infectious complications after oral oncologic surgery with primary reconstruction. J Otolaryngol Head Neck Surg 2015; 44:13. [PMID: 25888882 PMCID: PMC4387578 DOI: 10.1186/s40463-015-0066-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 03/20/2015] [Indexed: 11/13/2022] Open
Abstract
Background C-reactive protein (CRP) screening has been reported to be reliable for detection of infectious complications. Postoperative abnormal response of CRP can predict wound infection in colorectal surgery. This study aimed to determine the efficacy of CRP monitoring to detect infectious complications in oral oncologic surgery. Methods One hundred patients who underwent oral cancer resection with primary reconstruction were enrolled. Postoperative kinetics of CRP were classified into a normal or abnormal response. Results A normal CRP response after surgery was observed in 61 patients and an abnormal response was observed in 39. There were postoperative infectious complications in 21 patients, with surgical site infections in 13 patients (early onset in six and late onset in seven). Non-wound infections were found in nine patients. Sensitivity, specificity, the positive predictive value, and the negative predictive value for abnormal CRP response as a predictor for early infectious complications were 100%, 70.1%, 35.9%, and 100%, respectively. Conclusion Postoperative serial CRP screening is a useful test as an indicator of infectious complications in oral oncologic surgery. Normal CRP responses can rule out almost all early infectious complications.
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Affiliation(s)
- Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Shungo Furudoi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Kazunobu Hashikawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Akiko Sakakibara
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takumi Hasegawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takashi Shigeta
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Tsutomu Minamikawa
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takahide Komori
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-1, Chuo-ku, Kobe, 650-0017, Japan.
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Skrøvseth SO, Augestad KM, Ebadollahi S. Data-driven approach for assessing utility of medical tests using electronic medical records. J Biomed Inform 2015; 53:270-6. [DOI: 10.1016/j.jbi.2014.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 10/27/2014] [Accepted: 11/23/2014] [Indexed: 11/25/2022]
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Selby J, Prabhudesai A. Can C-reactive protein predict the severity of a post-operative complication after elective resection of colorectal cancer? Int J Colorectal Dis 2014; 29:1211-5. [PMID: 25060219 DOI: 10.1007/s00384-014-1977-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 02/04/2023]
Abstract
AIMS To explore if post-operative day 3 C-reactive protein (CRP), the ratio of pre-operative to day 3 white cell count (WCC) and platelet count can be used to predict the risk of post-operative complication and stratify the severity of complications as defined by the Clavien-Dindo classification. METHODS Data was obtained retrospectively on 127 patients who had elective bowel resection for malignancy between 2011 and 2013. Baseline demographics and clinical details were obtained including pre-operative and day 3 WCC and platelets and day 3 CRP. Ratio of pre-operative to day 3 WCC and platelets was calculated. Outcome measures were if a complication occurred (death included) and complication as defined by the Clavien-Dindo clasification. Mann-Whitney U test and Kruskal-Wallis were used to test for significance. RESULTS Of 127 patients, 57 % (n = 73) were male with a total median age of 72 and the commonest histology result T3N0 (40.6 %, n = 52). CRP was found to predict a complication (p < 0.0005) and the severity of complication as per the Clavien-Dindo classification (p < 0.0005). Day 3 CRP over 285 suggested a life-threatening complication (Clavien-Dindo score 4). There was no statistical significance between the ratio of WCC and platelets to any of the outcome measures. CONCLUSIONS WCC, platelets and CRP are routinely performed in the post-operative period. Previous research has shown CRP to be a good predictor of a complication. This paper has shown that day 3 CRP can not only predict but can also stratify the severity of post-operative complications.
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Affiliation(s)
- James Selby
- Foundation School, Hillingdon Hospital, Pield Heath Road, Uxbridge, UB8 3NN, UK,
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Yon JH, Choi GJ, Kang H, Park JM, Yang HS. Intraoperative systemic lidocaine for pre-emptive analgesics in subtotal gastrectomy: a prospective, randomized, double-blind, placebo-controlled study. Can J Surg 2014; 57:175-82. [PMID: 24869609 DOI: 10.1503/cjs.009613] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pre-emptive intravenous lidocaine infusion is known to improve postoperative pain in abdominal surgery. We assessed the effect of intravenous lidocaine infusion in patients who underwent subtotal gastrectomy. METHODS We conducted a double-blind, placebo-controlled study with patients undergoing subtotal gastrectomy for early gastric cancer divided into 2 groups: 1 group received intravenous lidocaine infusion preoperatively and throughout surgery, and the other received normal saline infusion (placebo). We assessed postoperative outcomes, including pain scores on a visual analogue scale (VAS), administration frequency of patient-controlled analgesia (PCA) and the amount of consumed fentanyl. Postoperative nausea and vomiting, length of hospital stay (LOS), time to return to regular diet and patient satisfaction at discharge were evaluated. RESULTS There were 36 patients in our study. Demographic characteristics were similar between the groups. The VAS pain scores and administration frequency of PCA were significantly lower in the lidocaine group until 24 hours after surgery, and fentanyl consumption was significantly lower in this group until 12 hours postoperatively compared with the placebo group. The total amount of consumed fentanyl and the total administration frequency of PCA were significantly lower in the lidocaine than the control group. No significant differences were detected in terms of nausea and vomiting, return to regular diet, LOS and patient satisfaction, and there were no reported side-effects of lidocaine. CONCLUSION Intravenous lidocaine infusion reduces pain during the postoperative period after subtotal gastrectomy.
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Affiliation(s)
- Jun H Yon
- The Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Geun J Choi
- The Departments of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Hyun Kang
- The Departments of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Joong-Min Park
- The Department of Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Hoon S Yang
- The Department of Otolaryngology and Head-Neck Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
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Min JJ, Nam K, Kim TK, Kim HJ, Seo JH, Hwang HY, Kim KB, Murkin JM, Hong DM, Jeon Y. Relationship between early postoperative C-reactive protein elevation and long-term postoperative major adverse cardiovascular and cerebral events in patients undergoing off-pump coronary artery bypass graft surgery: a retrospective study. Br J Anaesth 2014; 113:391-401. [PMID: 24829443 DOI: 10.1093/bja/aeu099] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Inflammation plays a key role in the pathogenesis of vascular occlusive diseases, such as myocardial infarction and stroke. Additionally, these conditions are predicted by C-reactive protein (CRP), a general inflammation marker. We hypothesized that the inflammation induced by surgery itself augments vascular occlusive disease. We retrospectively evaluated the relationship between postoperative CRP elevation and postoperative major adverse cardiovascular and cerebral events (MACCE) in patients undergoing off-pump coronary artery bypass surgery (OPCAB). METHODS The electronic medical records of 1046 patients who underwent OPCAB were reviewed retrospectively. The relationship between postoperative serum CRP and long-term postoperative MACCE (median follow-up 28 months) was investigated. RESULTS Patients were divided into quartiles according to maximum postoperative CRP levels (<18, 18-22, 22-27, ≥27 mg dl(-1)). The adjusted hazard ratios (HRs) were 2.15, 2.45, and 2.81, respectively (P=0.004), compared with the lowest quartile (<18 mg dl(-1)). In the multivariate analysis, the postoperative CRP quartile (HR 2.81; P=0.004), postoperative non-use of statins (HR 1.86; P=0.003), and postoperative maximum troponin I (HR 1.02; P<0.001) independently predicted postoperative MACCE, while preoperative CRP did not (P=0.203). Several parameters were correlated with postoperative maximum CRP level: body temperature (P=0.001) and heart rate (P<0.001) at the end of surgery; intraoperative last lactate (P<0.001) and base excess (P<0.001); and red blood cell transfusion (P=0.019). CONCLUSIONS Postoperative CRP elevation was associated with long-term postoperative MACCE in OPCAB patients. This was mitigated by postoperative statin medication. Furthermore, postoperative CRP elevation was associated with intraoperative parameters reflecting hypoperfusion and inflammation.
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Affiliation(s)
- J J Min
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - K Nam
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - T K Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - H J Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J H Seo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - H Y Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Daehakro 101, Jongno-gu 110-744, Seoul, Republic of Korea
| | - K B Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Daehakro 101, Jongno-gu 110-744, Seoul, Republic of Korea
| | - J M Murkin
- Department of Anesthesiology and Perioperative Medicine, Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - D M Hong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Y Jeon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Dede O, Bosch P, Bowles AJ, Ward WT, Roach JW. Clinical Decision Making in Early Wound Drainage Following Posterior Spine Surgery in Pediatric Patients. Spine Deform 2014; 2:104-109. [PMID: 27927376 DOI: 10.1016/j.jspd.2013.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 12/03/2013] [Accepted: 12/08/2013] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective. OBJECTIVES To identify the clinical factors suggestive of infected and non-infected drainage to help clinical decision making. SUMMARY OF BACKGROUND DATA Differentiating between drainage caused by a benign seroma and deep spinal infection may be difficult in the early postoperative period. METHODS Institutional spine surgery database was searched to identify the cases that were taken back to the operating room for drainage from the surgical wound in the early postoperative period between 2000 and 2012. RESULTS A total of 38 cases of early wound drainage (within 6 weeks postoperatively) were identified that were treated with opening all layers, irrigation, and debridement. Intraoperative cultures were sent in all cases. Twenty-five patients proved to have non-infected drainage and did not require further treatment. In 13 patients, infection was confirmed with intra-operative findings and cultures; these patients were treated with serial debridements. In 4 cases, implants had to be removed after multiple debridements (after a quiescent period). The group with non-infected drainage differed from the infection group in that most patients (21 of 25) had non-neuromuscular deformities, whereas 77% of the infected group had neuromuscular etiology (10 of 13) (p = .0004). Average number of days to revision was 8.5 (range, 5-14 days) for the non-infected group. Of the 25 patients, 23 presented in the first 10 days. In the infected group, average number of days to revision was 19. Ten of the 13 patients presented on postoperative day 14 or later. Logistic regression analysis showed a significant association between increased likelihood of infection and increased time from the index procedure (p = .0085). CONCLUSIONS The findings suggest that early presenting drainage in pediatric idiopathic spine deformity is often not infected. Drainage, especially presenting after the second postoperative week in neuromuscular patients, proved to be mostly deep spinal wound infections.
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Affiliation(s)
- Ozgur Dede
- Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Patrick Bosch
- Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Austin J Bowles
- Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - William Timothy Ward
- Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - James W Roach
- Department of Orthopaedic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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Roosinovich E, Reay-Jones N. Use of blood tests in the diagnosis of acute appendicitis. Br J Hosp Med (Lond) 2013; 73:C183-5. [PMID: 23519065 DOI: 10.12968/hmed.2012.73.sup12.c183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Marcus H, Nandi D. C-reactive protein in neurosurgery: valuable marker of post-operative infection or unnecessary over-investigation? Br J Neurosurg 2011; 25:788. [PMID: 22115020 DOI: 10.3109/02688697.2011.577919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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48
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C-reactive protein in the diagnosis of postoperative infection in pediatric patients: a prospective observational study of 103 patients. J Pediatr Surg 2011; 46:1726-31. [PMID: 21929981 DOI: 10.1016/j.jpedsurg.2011.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 02/10/2011] [Accepted: 03/13/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical stress elicits a systemic inflammatory response syndrome that contributes to the development of septic complications. C-reactive protein (CRP) is an acute phase protein released in inflammatory states. To analyze the usefulness of CRP as a marker of infection in surgical pediatric patients, we analyzed its kinetics in these patients in comparison with usual markers, such temperature, leukocytes, or fibrinogen. METHODS One hundred three pediatric patients undergoing major surgery were enrolled consecutively in this observational study. C-reactive protein, leukocytes, neutrophils, platelets, fibrinogen, glycemia, and temperature were determined daily after surgery. Patients were classified as infected or not infected. Sensitivity, specificity, positive predictive value, negative predictive value, efficiency, precocity, positive likelihood ratio, and number of subjects to be treated were calculated. RESULTS Peak in CRP was detected at 48 ± 24 hours. C-reactive protein was higher in the infected group from the first day, with significant differences between groups from the second day. Best cutoff for detecting infection was increases in CRP of 11 mg/dL in 48 hours, with a sensitivity of 87%, specificity of 89%, precocity of 1.7 days (0.82-2.54), number of subjects to be treated of 1.7 (1.4-2.6), and positive likelihood ratio of 7.9. Application of other markers alone or in combination did not surpass the sensitivity, specificity, or precocity for increases in CRP of 11 mg/dL in 48 hours. CONCLUSIONS Increases of CRP constitute an easy and cheap prognostic alert system and may be used to establish strategies aimed to detect infection in surgical pediatric patients.
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Wong K, Shahab Y, Gill PG. Diagnostic value of an initial C-reactive protein level in acute surgical patients. ANZ J Surg 2011; 82:52-5. [PMID: 22507496 DOI: 10.1111/j.1445-2197.2011.05668.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In surgical patients, C-reactive protein (CRP) levels are often measured as a marker of inflammation and infection. However, the diagnostic and prognostic value of a single initial CRP measurement in the acute presentation has not been well established. This study was performed to investigate the usefulness of measuring CRP in such a setting. METHODS CRP levels were measured retrospectively in 473 surgical patients who presented to the Royal Adelaide Hospital emergency department. This was correlated with patient outcomes, defined by the need for imaging tests and/or surgical interventions, the length of hospital stay and 30-day mortality. Spearman's rank correlation and one-way analysis of variance were used for statistical analysis. RESULTS Of 473 patients, 42% had a CRP test in the emergency department within 24 h of admission. Approximately 80% of patients required imaging for diagnosis and 40% required surgery, regardless of the initial CRP level. No correlation was evident between initial CRP level and length of hospital stay (r= 0.06). One-way analysis of variance revealed no variation in levels between patients who required imaging or had surgery compared to those who did not, with P-values of 0.76 and 0.85, respectively. Two patients died within 30 days of presentation. CONCLUSIONS CRP has poor diagnostic and prognostic capabilities as a single initial measurement in acute surgical patients. The statistical analyses imply that CRP levels are unable to accurately predict outcomes of such patients. Therefore, we suggest that CRP should not be used as a routine screening tool.
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Affiliation(s)
- Keith Wong
- University of Adelaide, South Australia, Australia.
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50
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Fellahi JL, Piriou V, Longrois D. [Cardiac biomarkers in perioperative risk stratification]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:126-140. [PMID: 21282034 DOI: 10.1016/j.annfar.2010.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 11/25/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The field of new cardiac biomarkers has triggered physicians' enthusiasm because of their potential diagnostic and prognostic values for routine clinical practice in the surgical setting. The objective of the present article is to review the role of new cardiac biomarkers and their potential additive clinical value in predicting short- and long-term risk following cardiac and non-cardiac surgery. DATA SOURCES A PubMed(®) database research in English and French languages published until June 2010. Keywords were cardiac biomarkers, troponins, cardiac troponin I (cTnI), natriuretic peptides, B-type natriuretic peptide (BNP), C-reactive protein (CRP), multiple markers approach, risk stratification, clinical risk scores. DATA SYNTHESIS Numerous publications deal with the diagnostic and prognostic values of new cardiac biomarkers in cardiac and non-cardiac surgical settings and provide an increasing evidence of their interest, validating different hierarchical steps which are mandatory before recommending a wide use of biomarkers for routine practice. Even if the first studies demonstrating an additional prognostic value of serum postoperative cTnI and/or preoperative BNP when compared with clinical predictive models are now available, we still lack data concerning an actual positive impact of new biomarkers measurements on clinical decision making or practice, as well as patient care and outcome. CONCLUSIONS While use of new cardiac biomarkers in the perioperative period appears to be a simple and objective tool for risk stratification at the bedside, we still need to remain cautious concerning their additional clinical value on existing predictive models for routine practice.
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Affiliation(s)
- J-L Fellahi
- Pôle anesthésie-réanimation-Samu-hémovigilance-coordination hospitalière, CHU de Caen, UFR de médecine, université de Caen-Basse Normandie, avenue de la Côte-de-Nacre, Caen cedex 9, France.
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