Systemic Inflammatory Cytokines Predict the Infectious Complications but Not Prolonged Postoperative Ileus after Colorectal Surgery.

AIM: Postoperative ileus (POI) is common after surgery. Animal studies indicate that the POI mechanism involves an inflammatory response, which is also activated during postoperative complications. This study aimed to determine whether inflammatory biomarkers might facilitate an early detection of prolonged POI (PPOI) or infectious complications. METHODS: Forty-seven adult patients who underwent oncological colorectal surgery were included. They filled out a perioperative diary to report their gastrointestinal symptoms. Blood samples were collected preoperatively, and on postoperative day (POD) 1 and 3. Levels of leucocytes, C-reactive protein (CRP), interleukin (IL)-6, TNF-α, and IL-1ß were analyzed. RESULTS: Patients with PPOI had significantly longer stay in hospital than patients without (13.6 ± 10.5 versus 7.4 ± 3.2 days, p < 0.001); they also had higher levels of IL-6 ratios, leucocytes, and CRP levels, but did not reach significance. Higher levels of postoperative IL-6 and CRP levels (p < 0.05, resp.) were found in patients with infectious complications. The receiver operating characteristic (ROC) analysis found better diagnostic values of IL-6 ratio on both POD 1 and 3 than that of CRP (POD 1: ROC 0.825, p < 0.001). CONCLUSION: Blood levels of inflammatory cytokines cannot predict PPOI after colorectal surgery. Instead, postoperative IL-6 changes may predict the infectious complications with a better diagnostic value than the current leukocytes or CRP tests.

Monocyte subsets in blood correlate with obesity related response of macrophages to biomaterials in vitro.

Macrophages play a key role in the foreign body response. In this study it was investigated whether obesity affects the acute response of macrophages to biomaterials in vitro and whether this response is associated with biomarkers in blood. CD14 + monocytes were isolated from blood from obese and age and gender matched lean persons. Monocyte subsets were determined based on CD14 and CD16 on their surface. C-reactive protein (CRP) was measured in peripheral blood. The response of monocyte-derived macrophages to polypropylene (PP), polylactic acid (PLA), polyethylene terephthalate (PET) monofilament, and PET-multifilament (mPET) in culture was based on cytokine production. More IL-6 (for PET), less CCL18 (all materials) and IL-1ra (for PLA) was produced by macrophages from obese patients than lean subjects. Body mass index, serum CRP and to a lesser extend percentages of monocyte subtypes correlated with IL-6, TNFα, CCL18, and IL-1ra production. Taken together, monocyte-derived macrophages of obese patients respond more pro-inflammatory and less anti-inflammatory to biomaterials than macrophages from lean subjects, depending on the material. These results are a step towards personalized medicine for the development of a model or even a blood test to decide which biomaterial might be suitable for each patient.

Hyperbaric oxygen therapy improves colorectal anastomotic healing.

PURPOSE: Hyperbaric oxygen treatment (HBOT) has been found to improve the healing of poorly oxygenated tissues. This study aimed to investigate the influence of HBOT on the healing in ischemic colorectal anastomosis. METHODS: Forty Wistar rats were randomly divided into a treatment group that received HBOT for 10 consecutive days (7 days before and 3 days after surgery), or in a control group, which did not receive the therapy. Colectomy with an ischemic anastomosis was performed in all rats. In each group, the rats were followed for 3 or 7 days after surgery to determine the influence of HBOT on anastomotic healing. RESULTS: Five rats from each group died during follow-up. No anastomotic dehiscence was seen in the HBOT group, compared to 37.5 % and 28.6 % dehiscence in the control group on postoperative day (POD) 3 and 7, respectively. The HBOT group had a significantly higher bursting pressure (130.9 ± 17.0 mmHg) than the control group (88.4 ± 46.7 mmHg; p = 0.03) on POD 3. On POD 3 and POD 7, the adhesion severity was significantly higher in the control groups than in the HBOT groups (p < 0.005). Kidney function (creatinine level) of the HBOT group was significantly better than of the control group on POD 7 (p = 0.001). Interestingly, a significantly higher number of CD206+ cells (marker for type 2 macrophages) was observed in the HBOT group at the anastomotic area on POD 3. CONCLUSION: Hyperbaric oxygen enhanced the healing of ischemic anastomoses in rats and improved the postoperative kidney function.

Is aortoiliac calcification linked to colorectal anastomotic leakage? A case-control study.

BACKGROUND: Anastomotic leakage in bowel surgery remains a devastating complication. Various risk factors have been uncovered, however, high anastomotic leakage rates are still being reported. This study describes the use of calcification markers of the central abdominal arteries as a prognostic factor for colorectal anastomotic leakage. METHODS: This case-control study includes clinical data from three different hospitals. Calcium volume and calcium score of the aortoiliac tract were determined by CT-scan analysis. Cases were all patients with anastomotic leakage after a left-sided anastomosis (n = 30). Three controls were randomly matched for each case. Only patients with a contrast-enhanced pre-operative CT-scan were included. RESULTS: The measurements of the calcium score and calcium volume of the different trajectories showed that there was one significant difference with regard to the right external iliac artery. Multiple regression analysis showed a significant different negative odds ratio of the presence of calcium in the right external iliac artery. CONCLUSION: This study demonstrates that calcium volume and calcium score of the aortoiliac trajectory does not correlate with the risk of colorectal anastomotic leakage after a left-sided anastomosis.

Nicotine gum chewing: a novel strategy to shorten duration of postoperative ileus via vagus nerve activation.

Postoperative ileus (POI) is a transit cessation of bowel motility after surgery. Substantial evidences suggest that gum chewing accelerate the recovery of bowel motility after surgery. Perioperative nicotine administration reduces postoperative opioid use and prevents postoperative nausea and vomiting. Nicotine gum chewing combines stimulation of the cephalic-vagal reflex by gum chewing, and activation of the cholinergic anti-inflammatory pathway by nicotine administration. We therefore hypothesized that nicotine gum chewing reduces POI and improves patient outcomes such as shortening the length of hospitalization as well as saving medical costs. As nicotine gum is commercially available, inexpensive, and has been in use for many years without any severe side effects, it may have a wide clinical application in POI prevention.

A close look at postoperative fluid management and electrolyte disorders after gastrointestinal surgery in a teaching hospital where patients are treated according to the ERAS protocol.

PURPOSE: To evaluate the routine postoperative fluid management in relation to the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 2008 by the assessment of the fluid overload and electrolyte disorders in patients who were postoperatively treated according to an 'enhanced recovery after surgery' (ERAS) protocol. METHODS: All liver, pancreatic and gastrointestinal surgical patients treated during a 10-week period were consecutively included in this analysis. All patients were treated according to a fast track protocol. Fluid balance charts and electrolyte disorders were recorded. Electrolyte disorders were reported based on the laboratory results. RESULTS: A total of 71 patients with an uncomplicated postoperative course were analysed. Even with restrictive fluid management performed as part of the ERAS protocol, hypervolemia developed in 54 % of all patients on the first postoperative day. There were no cases of excessive peripheral or pulmonary oedema in cases with excessive fluid administration. Twenty-six percent of the patients had electrolyte imbalances, euvolaemia was seen in 22 %, and 85 % of these patients had hypokalemia. CONCLUSION: Postoperative registration of fluid charts is difficult, which results in incomplete charts. This has resulted in more attention being paid to recording the fluid balance at our institution. Concerning electrolyte disorders, we recommend prophylactic potassium administration. However, there is no reason to replace standard 0.9 % NaCl/glucose 5 % by Ringer's lactate, as the British guidelines advice.

Reducing anastomotic leakage by reinforcement of colorectal anastomosis with cyanoacrylate glue.

INTRODUCTION: Technical failure of sutured or stapled anastomoses may lead to anastomotic leakage, which is one of the most important complications after colorectal surgery. Cyanoacrylate glue (CA) provides strong mechanical attachment, making it a good candidate for suture reinforcement. This study aimed to demonstrate that CA is the most important factor in the strength of a sealed colorectal anastomosis, in both normal and insufficient anastomoses. METHODS: Ex vivo porcine colorectal segments were resected. A 1-layer continuous anastomosis or an insufficient 6-interrupted-suture anastomosis was created, and the baseline anastomotic bursting pressure (ABP) was measured. The primary anastomosis was then reinforced either by CA or with 4 additional interrupted sutures, further inverting the anastomosis. After reinforcement a second ABP test was performed. RESULTS: Thirty-two segments were used. Reinforcing the anastomosis by CA significantly increased ABP in both normal and insufficient anastomoses when compared to the primary anastomosis (p < 0.05 for all groups); no significant difference in ABP was found between normal and insufficient anastomosis groups after CA reinforcement. Anastomotic reinforcement with CA was not inferior to the reinforcement with sutures in both normal and insufficient anastomoses, and had significantly fewer ABP variances in normal anastomosis groups (p = 0.042). CONCLUSION: Reinforcing a colorectal anastomosis with CA increases its mechanical strength in both normal and technically insufficient situations, which may contribute to the reduction of anastomotic leakage. CA is promising for anastomotic reinforcement based on mechanical improvement of the anastomosis, and in vivo studies are needed to evaluate its biological effects.