Evaluation of the inflammatory markers CCL8, CXCL5, and LIF in patients with anastomotic leakage after colorectal cancer surgery

PURPOSE

Anastomotic leakage constitutes a dreaded complication after colorectal surgery, leading to increased morbidity and mortality as well as prolonged hospitalization. Most leakages become clinically apparent about 8 days after surgery; however, early detection is quintessential to reduce complications and to improve patients' outcome. We therefore investigated the significance of specific protein expression profiles as putative biomarkers, indicating anastomotic leakage.

METHODS

In this single-center prospective cohort study serum and peritoneal fluid samples-from routinely intraoperatively inserted drainages-of colorectal cancer patients were collected 3 days after colorectal resection. Twenty patients without anastomotic leakage and 18 patients with an anastomotic leakage and without other complications were included. Protein expression of seven inflammatory markers in serum and peritoneal fluid was assessed by multiplex ELISA and correlated with patients' clinical data.

RESULTS

Monocyte chemoattractant protein 2 (CCL8/MCP-2), leukemia-inhibiting factor (LIF), and epithelial-derived neutrophil-activating protein (CXCL5/ENA-78) were significantly elevated in peritoneal fluid but not in serum samples from patients subsequently developing anastomotic leakage after colorectal surgery. No expressional differences could be found between grade B and grade C anastomotic leakages.

CONCLUSION

Measurement 3 days after surgery revealed altered protein expression patterns of the inflammatory markers CCL8/MCP2, LIF, and CXCL5/ENA-78 in peritoneal fluid from patients developing anastomotic leakage after colorectal surgery. Further studies with a larger patient cohort with inclusion of different variables are needed to evaluate their potential as predictive biomarkers for anastomotic leakage.

Arterial dissection as a cause of intracranial stenosis: A narrative review

Intracranial artery dissection (IAD) is an underdiagnosed, non-atherosclerotic cause of stroke with various clinical manifestations. To identify all the potential studies investigating the epidemiology, risk factors, symptoms, radiology findings, and treatment methods of IAD, we conducted a literature search screening PubMed, SCOPUS, EMBASE, and BIREME. According to the results of several studies, IAD is the major cause of ischemic stroke in at least one-third of the cervical-cranial artery dissection (CCAD) cases presenting with ischemic stroke. Mechanical causes are associated with cervical artery dissections (CAD) in up to 40 % of the cases. However, the risk factors for IAD are still not completely understood. Antithrombotic therapy with either antiplatelet or classic anticoagulants is the mainstay of treatment for preventing further thromboembolic complication after a stroke. Endovascular or surgical treatment options can be considered when medical therapies are not effective or when there is a high rate of recurrence or increased risk of bleeding. The observational studies have shown that these methods are very effective in preventing recurrence and significantly improving morbidity and mortality in patients with ruptured dissections. Clinical trials are required to establish the best option for each mechanism of ischemic lesion.

Rectal Surgery Evaluation Trial: protocol for a parallel cohort trial of outcomes using surgical techniques for total mesorectal excision with low anterior resection in high-risk rectal cancer patients

AIM

Total mesorectal excision (TME) is the standard of care for rectal cancer, which can be combined with low anterior resection (LAR) in patients with mid-to-low rectal cancer. The narrow pelvic space and difficulties in obtaining adequate exposure make surgery technically challenging. Four techniques are used to perform the surgery: open laparotomy, laparoscopy, robot-assisted surgery and transanal surgery. Comparative data for these techniques are required to provide clinical data on the surgical management of rectal cancers.

METHODS

The Rectal Surgery Evaluation Trial will be a prospective, observational, case-matched, four-cohort, multicentre trial designed to study TME with LAR using open laparotomy, laparoscopy, robot-assisted surgery or transanal surgery in high-surgical-risk patients with mid-to-low non-metastatic rectal cancer. All surgeries will be performed by surgeons experienced in at least one of the techniques. Oncological, morbidity and functional outcomes will be assessed in a composite primary outcome, with success defined as circumferential resection margin ≥ 1 mm, TME Grade III and minimal postoperative morbidity (absence of Clavien-Dindo Grade III-IV complications within 30 days after surgery). Secondary end-points will include the co-primary end-points over the long term (2 years), quality of surgery, quality of life, length of hospital stay, operative time and rate of unplanned conversions.

DISCUSSION

This will be the first trial to study all four surgical techniques currently used for TME with LAR in a specific group of high-risk patients. The knowledge obtained will contribute towards helping physicians determine the advantages of each technique and which may be the most appropriate for their patients.

[Gastric stump carcinoma: frequency, treatment, complications and prognosis]

BACKGROUND

Gastric stump carcinoma develops in the gastric remnant after partial gastrectomy. While the frequency of gastric cancer is declining, the incidence of gastric stump carcinoma has remained stable due to the long latency period. As the surgical treatment of gastric ulcers by partial gastrectomy has become much less important, more and more gastric stump carcinomas develop after oncological resection.

AIM

This study compared the surgical therapy of gastric stump carcinoma with the therapy of primary gastric cancer.

MATERIAL AND METHODS

From 2001 to 2014 a total of 24 patients were surgically treated for gastric stump carcinoma in the University Hospital of Heidelberg. In the same time 428 patients underwent resection due to primary gastric cancer. Both groups were analyzed and compared with a focus on preoperative therapy, intraoperative differences, complications and overall survival.

RESULTS

Patients with gastric stump carcinoma were older at disease onset (68 years vs. 62 years, p = 0.003). Compared with primary gastric cancer, patients with gastric stump carcinoma were more often suspected of having lymph node (cN+) involvement (51.4 % vs. 41.7 %, p < 0.001) but neoadjuvant therapy was applied less often (48.7 % vs. 14.3 %, p < 0.01). For resection of gastric stump carcinoma, extended resections were more often necessary (54.5 % vs. 28.2 %, p < 0.001). There were no significant differences in mean overall survival between the two patient groups (64.4 months vs. 45.8 months, p = 0.34) CONCLUSION: Despite the differences described, the treatment of gastric stump carcinoma does not essentially differ from that of primary gastric cancer. Carcinomas of the gastric stump are more often locally advanced and in our opinion a neoadjuvant therapy should be applied analogue to gastric cancer even if evidence-based data on this point are limited.

Meta-analysis of immunonutrition in major abdominal surgery

Background

The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias.

Methods

A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence.

Results

A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P &lt; 0·001) and shortened hospital stay (mean difference –1·79 (95 per cent c.i. –2·39 to –1·19) days; P &lt; 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01).

Conclusion

Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE: high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE: low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).

Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas)

BACKGROUND

Preoperative nutritional status has an impact on patients' clinical outcome. For pancreatic surgery, however, it is unclear which nutritional assessment scores adequately assess malnutrition associated with postoperative outcome.

METHODS

Patients scheduled for elective pancreatic surgery at the University of Heidelberg were screened for eligibility. Twelve nutritional assessment scores were calculated before operation, and patients were categorized as either at risk or not at risk for malnutrition by each score. The postoperative course was monitored prospectively by assessors blinded to the nutritional status. The primary endpoint was major complications evaluated for each score in a multivariable analysis corrected for known risk factors in pancreatic surgery.

RESULTS

Overall, 279 patients were analysed. A major complication occurred in 61 patients (21·9 per cent). The proportion of malnourished patients differed greatly among the scores, from 1·1 per cent (Nutritional Risk Index) to 79·6 per cent (Nutritional Risk Classification). In the multivariable analysis, only raised amylase level in drainage fluid on postoperative day 1 (odds ratio (OR) 4·91, 95 per cent c.i. 1·10 to 21·84; P = 0·037) and age (OR 1·05, 1·02 to 1·09; P = 0·005) were significantly associated with major complications; none of the scores was associated with, or predicted, postoperative complications.

CONCLUSION

None of the nutritional assessment scores defined malnutrition relevant to complications after pancreatic surgery and these scores may thus be abandoned.

Meta-analysis of prophylactic abdominal drainage in pancreatic surgery

BACKGROUND

Intra-abdominal drains are frequently used after pancreatic surgery whereas their benefit in other gastrointestinal operations has been questioned. The objective of this meta-analysis was to compare abdominal drainage with no drainage after pancreatic surgery.

METHODS

PubMed, the Cochrane Library and Web of Science electronic databases were searched systematically to identify RCTs comparing abdominal drainage with no drainage after pancreatic surgery. Two independent reviewers critically appraised the studies and extracted data. Meta-analyses were performed using a random-effects model. Odds ratios (ORs) were calculated to aggregate dichotomous outcomes, and weighted mean differences for continuous outcomes. Summary effect measures were presented together with their 95 per cent confidence intervals.

RESULTS

Some 711 patients from three RCTs were included. The 30-day mortality rate was 2·0 per cent in the drain group versus 3·4 per cent after no drainage (OR 0·68, 95 per cent c.i. 0·26 to 1·79; P = 0·43). The morbidity rate was 65·6 per cent in the drain group and 62·0 per cent in the no-drain group (OR 1·17, 0·86 to 1·60; P = 0·31). Clinically relevant pancreatic fistulas were seen in 11·5 per cent of patients in the drain group and 9·5 per cent in the no-drain group. Reinterventions, intra-abdominal abscesses and duration of hospital stay also showed no significant difference between the two groups.

CONCLUSION

Pancreatic resection with, or without abdominal drainage results in similar rates of mortality, morbidity and reintervention.

Staging of pancreatic cancer based on the number of positive lymph nodes

BACKGROUND

The International Study Group on Pancreatic Surgery has stated that at least 12 lymph nodes should be evaluated for staging of pancreatic cancer. The aim of this population-based study was to evaluate whether the number of positive lymph nodes refines staging.

METHODS

Patients who underwent pancreatectomy for stage I-II pancreatic cancer between 2004 and 2012 were identified from the Surveillance, Epidemiology, and End Results database. The predictive value of the number of positive lymph nodes for survival was assessed by generalized receiver operating characteristic (ROC) curve analysis and propensity score-adjusted Cox regression analysis.

RESULTS

Some 5036 patients were included, with a median of 18 (i.q.r. 15-24) lymph nodes examined. Positive lymph nodes were found in 3555 patients (70·6 per cent). The median duration of follow-up was 15 (i.q.r. 8-28) months. ROC curve analysis revealed that two positive lymph nodes best discriminated overall survival. Patients with one or two positive lymph nodes (pN1a) and those with three or more positive lymph nodes (pN1b) had an increased risk of overall mortality compared with patients who were node-negative (pN0): hazard ratio (HR) 1·47 (95 per cent c.i. 1·33 to 1·64) and HR 2·01 (1·82 to 2·22) respectively. These findings were confirmed by propensity score-adjusted Cox regression analysis. The 5-year overall survival rates were 39·8 (95 per cent c.i. 36·5 to 43·3) per cent for patients with pN0, 21·0 (18·6 to 23·6) per cent for those with pN1a and 11·4 (9·9 to 13·3) per cent for patients with pN1b disease.

CONCLUSION

The number of positive lymph nodes in the resection specimen is a prognostic factor in patients with pancreatic cancer.

Limits on Momentum-Dependent Asymmetric Dark Matter with CRESST-II

The usual assumption in direct dark matter searches is to consider only the spin-dependent or spin-independent scattering of dark matter particles. However, especially in models with light dark matter particles O(GeV/c^{2}), operators which carry additional powers of the momentum transfer q^{2} can become dominant. One such model based on asymmetric dark matter has been invoked to overcome discrepancies in helioseismology and an indication was found for a particle with a preferred mass of 3  GeV/c^{2} and a cross section of 10^{-37}  cm^{2}. Recent data from the CRESST-II experiment, which uses cryogenic detectors based on CaWO_{4} to search for nuclear recoils induced by dark matter particles, are used to constrain these momentum-dependent models. The low energy threshold of 307 eV for nuclear recoils of the detector used, allows us to rule out the proposed best fit value above.

Phenotypic and phylogenetic segregation of Alternaria infectoria from small-spored Alternaria species isolated from wheat in Germany and Russia

AIMS

To identify the taxonomic differences between phytopathogenic small-spored Alternaria strains isolated from wheat kernels in Germany and Russia by a polyphasic approach.

METHODS AND RESULTS

Ninety-five Alternaria (A.) strains were characterized by their colony colour, their three-dimensional sporulation patterns, mycotoxin production and phylogenetic relationships based on sequence variation in translation elongation factor 1-α (TEF1-α). The examination of toxin profiles and the phylogenetic features via TEF1-α resulted in two distinct clusters, in each case containing Alternaria infectoria isolates (92 and 96% respectively) in the first and the Alternaria alternata, Alternaria arborescens and Alternaria tenuissima isolates (77 and 79% respectively) in the other combined cluster. The production of Alternariol, Altertoxin and Altenuene has not been reported previously in the A. infectoria species group. The isolates from Germany and Russia differ slightly in species composition and mycotoxin production capacity.

CONCLUSIONS

We identified that the A. infectoria species group can be differentiated from the A. alternata, A. arborescens and A. tenuissima species group by colour, low mycotoxin production and by the sequence variation in TEF1-α gene.

SIGNIFICANCE AND IMPACT OF THE STUDY

These results allow a reliable toxic risk assessment when detecting different Alternaria fungi on cereals.

Meta-analysis of surgical outcome after enucleation versus standard resection for pancreatic neoplasms

BACKGROUND

Pancreatic enucleation is a tissue-sparing approach to pancreatic neoplasms and may result in better postoperative pancreatic function than standard pancreatic resection. The objective of this review was to compare the postoperative outcome after pancreatic enucleation versus standard resection.

METHODS

MEDLINE, Embase and the Cochrane Library were searched systematically until February 2015 to identify studies comparing the outcome of enucleation versus standard resection for pancreatic neoplasms. After critical appraisal, meta-analysis was performed and the findings were presented as odds ratios or weighted mean differences with corresponding 95 per cent c.i.

RESULTS

Twenty-two observational studies (1148 patients) were included. Duration of surgery (P < 0.001), blood loss (P < 0.001), length of hospital stay (P = 0.04), and postoperative endocrine (P < 0.001) and exocrine (P = 0.01) insufficiency were lower after enucleation than after standard resection. Mortality (P = 0.44), overall complications (P = 0.74), reoperation rate (P = 0.93) and delayed gastric emptying (P = 0.15) were not significantly different between the two approaches. The overall rate of postoperative pancreatic fistula (POPF) was higher after enucleation than after standard resection (P < 0.001). However, the raised POPF rate did not result in higher mortality or overall morbidity. Sensitivity analysis of high-volume studies (total of more than 20 enucleations and more than 4 per year) showed that, in specialized centres, enucleation can be performed with no increased risk of POPF (P = 0.12).

CONCLUSION

Compared with standard resection, pancreatic enucleation can be performed effectively and with comparable safety in high-volume institutions. Enucleation should be considered instead of standard resection for selected pancreatic neoplasms.

Pitfalls in the diagnostic evaluation of subacute combined degeneration

We report a case of a 43-year-old man presenting with a 2-week history of painless ascending sensory disturbances, suspected to be suffering from acute inflammatory polyneuropathy. On clinical examination, deep tendon reflexes were preserved and muscle strength was 5/5 everywhere. Gait was ataxic with positive Romberg test. Lumbar puncture was normal and electroneurography demonstrated demyelination. With spinal cord involvement centred on the posterior tracts on MRI, differential diagnosis focused on cobalamin deficiency. Initial laboratory work up showed nearly normal holotranscobalamin (43 pmol/L, normal>50) suggesting no vitamin B12 deficiency. Surprisingly, further testing including methylmalonic acid (3732 nmol/L, normal<271) and homocysteine (48.5 µmol/L, normal<10) showed an impairment of vitamin B12-dependent metabolism leading to the diagnosis of subacute combined degeneration. Only after repeated history taking did the patient remember having taken tablets containing cobalamin for 3 days before hospitalisation. In case of B12 deficiency, holotranscobalamin can rapidly normalise during supplementation, whereas methylmalonic acid and homocysteine might help to detect B12 deficiency in patients who recently started supplementation.

Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer

BACKGROUND

Options for reconstruction after low anterior resection (LAR) for rectal cancer include straight or side-to-end coloanal anastomosis (CAA), colonic J pouch and transverse coloplasty. This systematic review compared these techniques in terms of function, surgical outcomes and quality of life.

METHODS

A systematic literature search (MEDLINE, Embase and the Cochrane Library, from inception of the databases until November 2014) was conducted to identify randomized clinical trials comparing reconstructive techniques after LAR. Random-effects meta-analyses were carried out, and results presented as weighted odds ratios or mean differences with corresponding 95 per cent c.i. A network meta-analysis was conducted for the outcome anastomotic leakage.

RESULTS

The search yielded 965 results; 21 trials comprising data from 1636 patients were included. Colonic J pouch was associated with lower stool frequency and antidiarrhoeal medication use for up to 1 year after surgery compared with straight CAA. Transverse coloplasty and side-to-end CAA had similar functional outcomes to the colonic J pouch. No superiority was found for any of the techniques in terms of anastomotic leak rate.

CONCLUSION

Colonic J pouch and side-to-end CAA or transverse coloplasty lead to a better functional outcome than straight CAA for the first year after surgery.

[Surgical options in cancer of unknown primary (CUP)]

BACKGROUND

Cancer of unknown primary site (CUP) comprises a relatively frequently occurring group of heterogeneous malignant tumors in the clinical routine, which currently has an abysmal prognosis for affected patients. Based on the improved diagnostic tools it is now possible to identify subgroups of patients with different clinical prognoses. New therapies adapted to these identified subgroups are becoming increasingly more relevant.

AIM

This review aims to evaluate the role of surgery and different surgical options in the therapy of patients with CUP.

RESULTS

For the treatment of patients with CUP it is important to identify subgroups of patients with a better prognosis. Surgical resection of CUP metastasis is a therapy option leading to a prolonged survival in (1) women with papillary peritoneal adenocarcinomatosis, (2) women with axillary lymph node metastasis of adenocarcinoma, (3) patients with cervical lymph node metastasis of squamous cell carcinoma, (4) patients with inguinal lymph node metastasis, (5) patients with poorly differentiated carcinomas with midline distribution (e.g. extragonadal germ cell syndrome) and (6) patients with small resectable tumors.

CONCLUSION

Surgery is an important therapy option in different subgroups of patients with CUP. Together with multimodal therapy, adjusted according to the identified most likely origin of the primary tumor, it is possible to prolong patient survival.

Incisional hernia rate 3 years after midline laparotomy

BACKGROUND

Incisional hernia is the most frequent long-term complication after visceral surgery, with an incidence of between 9 and 20 per cent 1 year after operation. Most controlled studies provide only short-term follow-up, and the actual incidence remains unclear. This study evaluated the incidence of incisional hernia up to 3 years after midline laparotomy in two prospective trials.

METHODS

Three-year follow-up data from the ISSAAC (prospective, multicentre, historically controlled) and INSECT (randomized, controlled, multicentre) trials focused on the rate of incisional hernia 1 and 3 years after surgery. Differences between the two groups were compared using t tests for continuous data and the χ2 test for categorical data.

RESULTS

Analysis of 775 patients included in the two trials suggested that the incisional hernia rate increased significantly from 12.6 per cent at 1 year to 22.4 per cent 3 years after surgery (P < 0.001), a relative increase of more than 60 per cent.

CONCLUSION

This follow-up of two trials demonstrated that 1 year of clinical follow-up for detection of incisional hernia is not sufficient; follow-up for at least 3 years should be mandatory in any study evaluating the rate of postoperative incisional hernia after midline laparotomy.