Acute phase proteins as predictors of post-operative infections in cirrhotic patients undergoing major abdominal surgery

Tissue injury and infection leads to local production of interleukin-6 and other cytokines that mediate most of the systemic aspects of inflammation. We conducted this study to 1-Evaluate the effect of hepatic cirrhosis on the time course of acute phase proteins [APPs] following major surgery; and 2- Assess this effect in confirming or refuting the suspicion of postoperative infection in these patients during their stay in the surgical intensive care unit [SICU]. We prospectively studied 40 patients scheduled for major abdominal surgery, of whom 21 were non-cirrhotic [control group] and 19 had either known history or clinical evidence of hepatic cirrhosis [study group]. Central venous samples were obtained from all patients for laboratory assessment at induction of anaesthesia, at the end of surgery and at 24 h, 48 h and 72 h postoperatively [PO]. On the fourth PO day, patients from both groups were categorized into infected and non-infected sub-groups [using criteria of Centers for Disease Control] and another blood samples were obtained Laboratory assay: the collected blood samples were analyzed for the serum levels of APPs namely: interleukin-6 [IL-6], C-reactive protein [C-RP], serum amyloid A [SAA] and serum albumin. Liver functions were also assessed by serum concentrations of alanine aminotransferase [ALT], lactic dehydrogenase [LDH], total bilirubin [TB] and prothromhin time [PT]. IL-6 reacted fast in non-cirrhotic patients and reached a peak concentration at 2 h PO [400 +/- 122 pg.ml[-1], P<0.001]. In cirrhotic patients, the reaction of IL-6 was delayed and peak concentrations were not achieved except at 48 h PO [220 +/- 72 pg.ml[-1], P<0.001]. Sera levels of IL-6 were significantly lower in cirrhotic as compared with non-cirrhotic patients at 2,24,48 and 72 hrs PO. C-RP and SAA increased slower and later than IL-6. In both groups, peak concentrations of C-RP and SAA were recorded at 48 and 72h PO, respectively. Serum concentrations of CRP and SAA were not significantly different between the 2 groups throughout the study period [P >0.05]. Serum albumin levels in cirrhotic patients were significantly lower than those in non-cirrhotic at all measured times [P<0.05]. On the fourth postoperative day, patients who developed infection showed significantly higher serum IL-6 levels as compared with non-infected patients in both cirrhotic and non-cirrhotic patients. Serum albumin levels in patients who developed PO infection were significantly lower compared with non-infected patients in both groups. PO infection rate correlated positively with serum IL-6 concentrations and negatively with serum albumin levels in both cirrhotic and control groups. The serum concentrations of C-RP and SAA were not significantly different between infected and non-infected patients of either group [P>0.05]. ALT, LDH, TB and PT were higher in cirrhotic as compared with non-cirrhotic patients at all times [P<0.01], but did not differ significantly between infected and non-infected patients of either group. Major surgery causes substantial increase of the plasma concentrations of APPs in both cirrhotic and non-cirrhotic patients. Among the studied parameters, IL-6 showed the most rapid change, and appears to be a good marker for the early detection of acute phase reaction. Both IL-6 increase and albumin decrease correlated well with postoperative infection rate, and may be used as early predictors of sepsis in these groups of patients

Coagulation and fibrinolytic changes after laparoscopic cholecystectomy: a prospective clinical study

Laparoscopic surgery appears to be less traumatic to the patient than open surgery, but its influence upon haemostatic parameters is incompletely elucidated. The aim of this study was to investigate changes in coagulation and fibrinolysis following laparoscopic cholecystectomy [LC] as compared to open cholecystectomy [OC], to determine whether changes occur after LC that may indicate a risk of thrombosis. Forty-one patients who underwent either LC [22 patients, study group] or OC [19 patients, control group] for uncomplicated cholelithiasis were prospectively enrolled. Prothrombin time [PT], activated partial thromboplastin time [aPTT], fibrinogen, antithrombin III [AT III], thrombin-antithrombin complexes [TAT], fibrin monomers [FM], prothrombin fragment 1+2 [F1+2] and d-dimer were measured before and at 6, 12, and 24 hrs after operation in all patients. No statistical difference was found comparing pre- and post-operative values of PT, aPTT or AT III at all determinations in either group or in-between the two groups. There were significant increases of serum concentrations of fibrinogen, TAT, FM, F1+2, and D-dimer in all post-operative determinations as compared to pre-operative values in LC and OC with no significant differences between the 2 groups. The data of this study suggest that LC induces activation of coagulation and fibrinolytic pathways similar to those following OC. Laparoscopic cholecystectomized patients should be considered at risk for thromboembolism. Therefore, it is recommended that deep vein thrombosis prophylaxis should be utilized in laparoscopic as in conventional open cholecystectomy patients