Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue

INTRODUCTION

Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences.

METHODS

TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment.

RESULTS

FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4).

CONCLUSION

Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Distribution of TLR4 and MHC class II molecules of the spleen in broiler chicks treated with and without LPS in the first 2 weeks of the post-hatch period

1. The purpose of this study was to investigate the distribution of Toll-like receptor-4 (TLR4) and major histocompatibility complex (MHC) class II molecules of the spleen in chicks treated with lipopolysaccharide (LPS) during the first 2 weeks of their life. 2. A total of 225 Ross-308 commercial broiler chicks were used. Within the 2-week experimental period, chicks were divided into 5 main groups according to the days of decapitation which were 1, 4, 7, 10 and 14 d after hatch. Each main group had 45 chicks. The main groups were further divided into three subgroups (15 chicks each), which included control chicks (no injection), and phosphate-buffered saline (PBS) and LPS-injected chicks. Spleen samples were collected 1-, 3-, 6-, 12- and 24-h after the PBS or LPS administrations. Tissue sections were stained using streptavidin-biotin-peroxidase complex staining method. 3. From 1 d of age, TLR4 positivity was found in the spleen in diffuse granular form. The cells showing intense TLR4 positivity were observed in periellipsoidal lymphoid tissue in 4-d-old chicks. The same cells were determined in the germinal centre of the spleen in 7-d-old chicks. LPS stimulation led to an increase in the intensity of TLR4 positivity in 14-d-old chicks. 4. From 1 d of age, MHC class II positivity was found in both white pulp and red pulp. This was higher in 14-d-old chicks injected with LPS than in the controls and the chicks injected with PBS. 5. The findings indicate that, from 1 d of age in chicks, the spleen has both non-specific defence elements and the molecules having the information to induce adaptive immunity. In addition, at the end of the 2-week experimental period, it was determined that the spleen had the capacity to recognise antigens.

Effects of formaldehyde and xylene on CD4- and CD8-positive T cells in bronchus-associated lymphoid tissue in rats

The aim of this study was to determine the localization and number of CD4- and CD8-positive T lymphocytes in bronchus-associated lymphoid tissue (BALT) of the embryos and newborns or young and adult rats exposed to formaldehyde (6 ppm), technical xylene (300 ppm), or a combination of these two agents (3 ppm + 150 ppm) for 6 weeks (8 h/day). A total of 96 female Sprague-Dawley rats were used. The CD4-positive cells were localized predominately in area under the epithelium and in the periphery of BALT follicles after the exposure period. However, CD8-positive cells were localized mainly in the periphery of BALT follicles after the exposure period. The number of CD4- and CD8-positive lymphocytes significantly increased in exposed young and adult rats compared to the respective controls. These results suggest that formaldehyde and/or xylene may affect the local immunity in BALT particularly in young and adult rats.

The several elements of intestinal innate immune system at the beginning of the life of broiler chicks

Functional capacity of digestive system and intestinal adaptive immunity are immature at hatching of broiler chicks. Therefore, intestinal innate immunity after hatching is vital to young chicks. The purpose of this study was to investigate expression and tissue distributions of several elements of the innate immune system (i.e., TLR2, TLR4, CD83, and MHC class II expressing cells) in the intestine of one-day-old chicks. For this purpose, ileum and cecum were examined the under different conditions, which included the control and 1, 3, 6, 12, or 24 h after injection of lipopolysaccharide (LPS) and phosphate buffered saline. The findings indicated that regardless of the antigenic stimulation, Toll-like receptor (TLR) 2 and TLR4 expressing cells were present in the intestinal tissues of one-day-old chicks. We noticed that the intestinal segments have different TLR expression levels after LPS stimulation. Dendritic cells were identified, and they left the intestinal tissue after LPS treatment. MHC class II molecules were diffusely present in both the ileum and cecum. This study demonstrates that the intestinal tissue of one-day-old chicks has remarkable defensive material, including histological properties and several elements of the innate immune system. Microsc. Res. Tech. 79:604-614, 2016. © 2016 Wiley Periodicals, Inc.

A Histochemical Investigation of Different Distribution of TSH Cells in Adenohypophsis of Female and Male Rats

The aim of the present study was to investigate histochemically the localization of thyroid-stimulating hormone (TSH) cells and the number of TSH cells in adenohypophysis of ovariectomized adult females, intact females at estrous and diestrous phase of sexual cycles and castrated and non-castrated adult male rats. TSH cells, distributed throughout the pars distalis in all groups, were observed more frequent in areas near to the pars intermedia than other regions. The cells were round, ovoid, stellar-shaped and had contacts with sinusoids. Their nuclei were large and round-shaped. The cells were found mostly single or occasionally in groups of double and triple. The number of TSH cells was higher in estrous than diestrous phase in intact rats. In adenohypophysis of ovariectomized rats, their numbers were less than that of intacts in estrous, but higher than that of found in diestrous phases. Furthermore, the numbers of TSH cells in intact females during estrous phase was higher than those found in intact and castrated male rats. On the other hand, castration reduced the number of TSH cells while ovariectomy had no effect in this respect.