OBJECTIVES:To quantify immunological dysfunction in surgical patients with presence/absence of sepsis using a droplet digital polymerase chain reaction (ddPCR) transcriptomic analysis. The study also ...aims to evaluate this approach for improving identification of sepsis in these patients.
BACKGROUND:Immune dysregulation is a central event in sepsis. Quantification of the expression of immunological genes participating in the pathogenesis of sepsis could represent a new avenue to improve its diagnosis.
METHODS:Expression of 6 neutrophil protease genes (MMP8, OLFM4, LCN2/NGAL, LTF, PRTN3, MPO) and also of 5 genes involved in the immunological synapse (HLA-DRA, CD40LG, CD3E, CD28, ICOS) was quantified in blood from 101 surgical patients with sepsis, 53 uninfected surgical patients, and 16 blood donors by using ddPCR. Areas under receiver operating characteristic curves (AUROC) and multivariate regression analysis were employed to test individual genes and gene ratios to identify sepsis, in comparison with procalcitonin.
RESULTS:Sepsis-induced overexpression of neutrophil protease genes and depressed expression of immunological synapse genes. MMP8/HLA-DRA, LCN2/HLA-DRA outperformed procalcitonin in differentiating between patients with sepsis and surgical controls in the AUROC analysisLCN2/HLA-DRA0.90 (0.85–0.96), MMP8/HLA-DRA0.89 (0.84–0.95), procalcitonin0.80 (0.73–0.88) (AUROC, confidence interval 95%), and also in the multivariate analysisLCN2/HLA-DRA8.57 (2.25–32.62); MMP8/HLA-DRA8.03 (2.10–30.76), procalcitonin4.20 (1.15–15.43) odds ratio (confidence interval 95%). Gene expression levels of HLA-DRA were an independent marker of hospital mortality.
CONCLUSIONS:Quantifying the transcriptomic ratios MMP8/HLA-DRA, LCN2/HLA-DRA by ddPCR is a promising approach to improve sepsis diagnosis in surgical patients.
Postoperative anastomotic leaks remain a common and serious complication of colorectal surgeries and are a major cause of mortality and morbidity of these procedures. Anastomotic leaks (AL) have been ...extensively studied; however, there has been no significant reduction in their prevalence over time. In addition, there is a significant economic burden from AL attributed to the need for repeat surgery, radiologic intervention and lengthened hospital stay. We conducted a comparative cost analysis of patients undergoing colorectal surgery with anastomosis, with the application of fibrin sealant (FS) to the sutured anastomosis versus not treating the sutured anastomosis with FS.
The deterministic decision-tree model was populated with clinical data including operating room time, hospitalization days, occurrence of AL, need for revision surgery, blood products and radiologic interventions to treat the AL in lower colorectal surgery. A systematic literature review was conducted to identify appropriate studies with these variables.
The average cost per case treated lower colorectal surgery with fibrin sealant glue 10 mL Tisseel
and those not treated with a fibrin sealant after suturing the anastomoses was €3233 and €4130, respectively, for resource expenses paid by the healthcare system. This would suggest potential savings of €897 per surgery, achieved through the application of FS to the sutured anastomosis for preventing AL following colorectal surgery.
Application of FS to the sutured anastomosis in lower colorectal surgery resulted in a decrease in post-operative AL, and cost savings based on a reduction in hospitalization days, a reduction needing: revision surgery, radiologic intervention and blood products to treat AL.
Amyand hernia is a rare entity that is generally an unexpected intraoperative finding. The decision to perform prophylactic appendectomy, must take into account individual factors that may increase ...morbidity in a short, medium or long term future.
Diverticular disease of the colon has a high global prevalence. The guidelines suggest performing a colonoscopy 4-6 weeks after the acute episode to exclude colorectal cancer (CRC). However, these ...recommendations are based on old studies, when computed tomography was not used to diagnose acute diverticulitis (AD). There are currently some studies showing that CRC incidence is low in uncomplicated AD (UAD). Therefore, we decided to perform this study to determine the CRC incidence after an AD episode and the diagnostic efficacy of colonoscopy in these patients.
This was a retrospective cohort study that included patients with AD between July 2016 and December 2017.
One hundred seventy-four patients had AD. Of these, 46 patients were excluded and we analyzed 128 patients, 72 (56.3%) women and 56 (43.7%) men. Ninety (70.3%) had UAD and 38 (29.7%) complicated AD (CAD). The colonoscopy showed lesions in 18 (14.06%), 5 (3.9%) being CRC. The patients with CRC had shown CAD and were >70 years old (P=0.0001 and P=0.002 respectively).
Routine colonoscopy in patients with UAD appears not have many benefits as a diagnostic tool. However, it has a higher efficacy if the patients have CAD and are >70 years old.
Abstract
Background
The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied.
...Methods
Patients from 216 centres and 45 countries with anastomotic leak after rectal cancer resection between 2014 and 2018 were included. Treatment was categorized as salvage surgery, faecal diversion with passive or active (vacuum) drainage, and no primary/secondary faecal diversion. The primary outcome was 1-year stoma-free survival. In addition, passive and active drainage were compared using propensity score matching (2 : 1).
Results
Of 2470 evaluable patients, 388 (16.0 per cent) underwent salvage surgery, 1524 (62.0 per cent) passive drainage, 278 (11.0 per cent) active drainage, and 280 (11.0 per cent) had no faecal diversion. One-year stoma-free survival rates were 13.7, 48.3, 48.2, and 65.4 per cent respectively. Propensity score matching resulted in 556 patients with passive and 278 with active drainage. There was no statistically significant difference between these groups in 1-year stoma-free survival (OR 0.95, 95 per cent c.i. 0.66 to 1.33), with a risk difference of −1.1 (95 per cent c.i. −9.0 to 7.0) per cent. After active drainage, more patients required secondary salvage surgery (OR 2.32, 1.49 to 3.59), prolonged hospital admission (an additional 6 (95 per cent c.i. 2 to 10) days), and ICU admission (OR 1.41, 1.02 to 1.94). Mean duration of leak healing did not differ significantly (an additional 12 (−28 to 52) days).
Conclusion
Primary salvage surgery or omission of faecal diversion likely correspond to the most severe and least severe leaks respectively. In patients with diverted leaks, stoma-free survival did not differ statistically between passive and active drainage, although the increased risk of secondary salvage surgery and ICU admission suggests residual confounding.
The optimal treatment strategy for anastomotic leakage after restorative rectal cancer surgery remains unknown. This large, international collaborative study investigated various outcomes after four predefined treatment strategies for anastomotic leakage. Substantial differences were observed in patient and leakage characteristics, as well as outcomes following the four treatment strategies. However, no statistically significant differences were reported in stoma-free survival rates between active (vacuum) drainage and passive drainage.
Torsion of the Gallbladder Peñacoba, Luis María Merino; de Andrés Asenjo, Beatriz; Gandiaga, Juan García-Castaño ...
Journal of gastrointestinal surgery,
10/2016, Letnik:
20, Številka:
10
Journal Article
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