C-Reactive Protein as Predictor for Infectious Complications after Robotic and Open Esophagectomies.

INTRODUCTION: The value of C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after esophagectomy has been addressed by numerous studies. Despite its increasing application, robotic esophagectomy (RAMIE) has not been considered separately yet in this context. We, therefore, aimed to evaluate the predictive value of CRP in RAMIE. MATERIAL AND METHODS: Patients undergoing RAMIE or completely open esophagectomy (OE) at our University Center were included. Clinical data, CRP- and Procalcitonin (PCT)-values were retrieved from a prospectively maintained database and evaluated for their predictive value for subsequent postoperative infectious complications (PIC) (AL, gastric conduit leakage or necrosis, pneumonia, empyema). RESULTS: Three hundred and five patients (RAMIE: 160, OE: 145) were analyzed. PIC were noted in 91 patients on postoperative day (POD) 10 and 123 patients on POD 30, respectively. Median POD of diagnosis of PIC was POD 8. Post-operative CRP-values in the robotic-group peaked one and two days later, respectively, and converged from POD 5 onward compared to the open-group. In the group with PIC, CRP-levels in the robotic-group were initially lower and started to differ significantly from POD 3 onward. In the open-group, increases were already noticed from POD 3 on. Procalcitonin levels did not differ. Best Receiver operating curve (ROC)-results were on POD 4, highest negative predictive values at POD 5 (RAMIE) and POD 4 (OE) with cut-off values of 70 mg/L and 88.3 mg/L, respectively. CONCLUSION: Post-operative CRP is a good negative predictor for PIC, after both RAMIE and OE. After RAMIE, CRP peaks later with a lower cut-off value.

A novel unconventional T cell population enriched in Crohn's disease.

OBJECTIVE: One of the current hypotheses to explain the proinflammatory immune response in IBD is a dysregulated T cell reaction to yet unknown intestinal antigens. As such, it may be possible to identify disease-associated T cell clonotypes by analysing the peripheral and intestinal T-cell receptor (TCR) repertoire of patients with IBD and controls. DESIGN: We performed bulk TCR repertoire profiling of both the TCR alpha and beta chains using high-throughput sequencing in peripheral blood samples of a total of 244 patients with IBD and healthy controls as well as from matched blood and intestinal tissue of 59 patients with IBD and disease controls. We further characterised specific T cell clonotypes via single-cell RNAseq. RESULTS: We identified a group of clonotypes, characterised by semi-invariant TCR alpha chains, to be significantly enriched in the blood of patients with Crohn's disease (CD) and particularly expanded in the CD8+ T cell population. Single-cell RNAseq data showed an innate-like phenotype of these cells, with a comparable gene expression to unconventional T cells such as mucosal associated invariant T and natural killer T (NKT) cells, but with distinct TCRs. CONCLUSIONS: We identified and characterised a subpopulation of unconventional Crohn-associated invariant T (CAIT) cells. Multiple evidence suggests these cells to be part of the NKT type II population. The potential implications of this population for CD or a subset thereof remain to be elucidated, and the immunophenotype and antigen reactivity of CAIT cells need further investigations in future studies.

Treatment with Ceftriaxone in Complicated Diverticulitis Increases the Incidence of Intra-Abdominal Enterococcus faecium Detection.

Background: Complicated diverticulitis of the sigmoid colon typically is treated by resection after initial antibiotic treatment. Third-generation cephalosporins are the drugs of choice but are not effective against enterococci and can induce colonic colonization by Enterococcus faecium within hours. Infections caused by enterococci, especially E. faecium, are difficult to treat but should be considered in the strategic treatment planning of hospital-acquired peritonitis (e.g., anastomotic leakage), especially in immunocompromised patients. Methods: To determine whether the duration of pre-operative ceftriaxone treatment in complicated diverticulitis increases the incidence of intra-abdominal E. faecium detection, we analyzed all patients operated on for diverticulitis of the sigmoid colon in our department between 2008 and 2016. Results: Analyzing 516 resections performed for complicated diverticulitis, we found that E. faecium generally was detected intra-abdominally more often in the group that underwent longer pre-operative ceftriaxone treatment (≥ 4 days). During primary resection, E. faecium was detected in 2.7%, 11.1%, and 37.0% cases in the group undergoing immediate operation, 1-3 days of antibiotic treatment, and ≥4 days of antibiotic treatment, respectively. Enterococcus faecium was detected in 0, 25.0%, and 70.6% of surgical revisions and 28.6%, 14.3%, and 56.0%, respectively, of incisional surgical site infections with identified pathogens. A multivariable analysis discovered anastomotic leakage and antibiotic treatment lasting ≥4 days to be independent risk factors for intra-abdominal isolation of E. faecium. Conclusion: A ceftriaxone treatment ≥4 days led to a higher incidence of intra-abdominal E. faecium. Our data further suggested that empiric coverage of E. faecium in the treatment of hospital-acquired peritonitis could be beneficial after a long duration of ceftriaxone treatment.

Low Postoperative Levels of C-Reactive Protein Are an Early Predictor for an Uncomplicated Course After Bariatric Surgery: A Retrospective, Validated Cohort Study.

BACKGROUND: Bariatric surgery is popularly used to treat or prevent morbidity in severely obese patients. Severe complications are rare, but their early detection has a significant impact on clinical outcomes. We aimed to determine whether blood tests in the first few postoperative days are reliable predictors for complications. METHODS: We retrospectively analyzed 1073 patients who underwent laparoscopic bariatric surgery between 2009 and 2018 at our center. Clinical outcome was correlated with postoperative serum C-reactive protein (CRP), white blood cell count, and vital signs, analyzed using a receiver operating characteristic (ROC) curve. A total of 570 procedures between 2009 and 2015 were used to calculate the best cutoff values (calculation group), which were validated with 330 different patients operated upon between 2016 and 2018 (validation group). RESULTS: Twenty-four patients (4.2%) developed anastomotic or staple-line leakages in the calculation group. The ROC curve showed a good reliability for CRP levels on day 2 (area under the ROC curve=0.86); the highest Youden index existed for a cutoff of 119 mg/L. White blood cell count and heart rate were poor predictors. Even though several characteristics differed in the validation cohort, test quality of the cutoff was high (sensitivity, 71.4%; specificity, 94.9%; positive predictive value, 23.8%; negative predictive value, 99.3%). The prediction was excellent especially for leakages appearing on days 2 to 9 (sensitivity 100.0%, negative predictive value 100%). Leakages from day 10 were rare and prediction poor (sensitivity 0%). CONCLUSIONS: A CRP level on day 2 <120 mg/L is a good predictor of a postoperative course without leakage, even though the predictive value goes down for late-appearing events. An earlier CRP measurement added no predictive benefit. The cutoff value was validated in an internal cohort and could be applied to different populations.

Drain Amylase or Lipase for the Detection of POPF-Adding Evidence to an Ongoing Discussion.

： Objectives: A postoperative pancreatic fistula (POPF) is defined as a threefold increase in the amylase concentration in abdominal drains on or after the third postoperative day (POD). However, additional lipase fluid analysis is widely used despite lacking evidence. In this study, drain amylase and lipase levels were compared regarding their value in detecting POPF. Methods: We conducted a retrospective study including all patients who underwent pancreatic resections at our center between 2005 and 2016. Drain fluid analysis was performed from day 2 to 5. Results: 990 patients were included in the analysis. Overall, 333 (34%) patients developed a POPF. The median amylase and lipase concentrations at POD 3 in cases with POPF were 11.55 µmol/(s·L) (≈13 ×-fold increase) and 39 µmol/(s·L) (≈39 ×-fold increase), respectively. Seven patients with subsequent POPF (2%) were missed with amylase analysis on POD 3, but detected using 3-fold lipase analysis. The false-positive rate of lipase was 51/424 = 12%. A cutoff lipase value at POD 3 of > 4.88 yielded a specificity of 94% and a sensitivity of 89% for development of a POPF. Increased body mass index turned out as risk factor for the development of POPF in a multivariable model. Conclusions: Threefold-elevated lipase concentration may be used as an indicator of a POPF. However, the additional detection of POPF using simultaneous lipase analysis is marginal. Therefore, assessment of lipase concentration does not provide added clinical value and only results in extra costs.

Colorectal Surgical Site Infections and Their Causative Pathogens: Differences between Left- and Right-Side Resections.

BACKGROUND: Surgical site infections (SSIs), after colorectal resection, pose a significant burden. Recognition of the spectrum of potentially involved pathogens is crucial for determining correct antibiotic prophylaxis. This study aimed to determine whether the distribution of SSI-associated pathogens depends on the location of the colorectal resection. METHODS: We retrospectively categorized 2713 consecutive colon resections as left- or right-side operations, identified patients having concurrent peritonitis or development of postoperative SSIs and peritonitis, and assigned all subcutaneously and intra-abdominally isolated pathogens according to the location of the resection. RESULTS: Gram-positive cocci (especially enterococci) and gram-negative bacilli (especially Pseudomonas aeruginosa) were isolated more frequently from patients in whom SSIs developed after left-side resections than after right-side resections (52.5% vs. 32.6%, p < 0.01 and 15.9% vs. 6.7%, p < 0.01, respectively); enterococci were the causative organisms in a large percentage of SSIs (46.3%). Moreover, intra-abdominal P. aeruginosa and Candida spp. were isolated more frequently during left-side resections than during right-side operations in patients with peritonitis (15.8% vs. 6.3%, p = 0.02 and 14.3% vs. 5.3%, p = 0.02, respectively). CONCLUSIONS: Our results indicate that differences exist in the distribution of pathogens after left- or right-side colorectal resections. Our data further suggest that gram-positive cocci play an important role in SSIs occurring after colorectal resections; therefore, antibiotic prophylaxis should emphasize their coverage. Further, enterococcal coverage may be especially advantageous during left-side resections.

Assessing changes in tissue oxygenation by near-infrared spectroscopy following brachial plexus block for arteriovenous fistula surgery: A prospective observational pilot study.

BACKGROUND: Near-infrared spectroscopy (NIRS) can be used to measure tissue oxygen saturation (StO2) in different sites and in a wide range of clinical scenarios. Peripheral regional anaesthesia induces vascular changes causing increased arterial blood flow and venodilatation, but its effect on StO2 is still under debate. This is especially so for patients undergoing arteriovenous fistula surgery, wherein latest data suggest an improved outcome under brachial plexus block (BPB) compared with local anaesthesia, but no data are available. OBJECTIVE: The aim of this study was to investigate changes in StO2 following BPB prior to arteriovenous fistula surgery using NIRS. DESIGN: A prospective observational study. SETTING: A secondary teaching hospital from August 2016 to March 2017. PATIENTS: Fifteen patients undergoing arteriovenous fistula surgery. INTERVENTION: Ultrasound-guided BPB in 15 patients undergoing arteriovenous fistula surgery. OUTCOME MEASURES: StO2 at baseline and compared with baseline and the contralateral arm following BPB measured using NIRS of the thenar eminence (NIRSth). RESULTS: Baseline values of StO2 assessed by NIRSth were 42.6 ±â€Š7.7% in the arteriovenous fistula arm and 42.7 ±â€Š9.7% in the contralateral arm. There was no significant difference between the two. Five minutes after BPB, there was a significant increase in StO2 of the blocked arm, compared with the control arm expressed as difference of absolute values (7.1 ±â€Š9.7%). At 60 min, an absolute difference of 21.0 ±â€Š13.5% was reached. The absolute increase in StO2 of the blocked arm compared with baseline reached significance after 5 min (8.8 ±â€Š4.6%) and increased up to 23.2 ±â€Š8.2% after 60 min. CONCLUSION: NIRSth indicates that BPB significantly increases StO2 of the arteriovenous fistula arm in patients undergoing haemodialysis. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03044496.

Calcification of the iliac arteries: a marker for leakage risk in rectal anastomosis-a blinded clinical trial.

PURPOSE: Anastomotic leakage (AL) is associated with increased morbidity and mortality after colorectal surgery. Calcification of the arteries has been identified as a risk factor for cardiovascular events and can be reliably measured on computed tomography using software assistance. The aim of this prospective study was to prove the value of calcium scoring of the iliac arteries as a predictor of AL after rectal anastomosis. METHODS: Consecutive patients who underwent colorectal resection with rectal anastomosis were analyzed. Diagnostic computed tomography images were used to detect calcification of the arteries supplying the rectal anastomosis. Logistic regression analysis was used to determine the relationship between vascular calcification and AL. RESULTS: Of 139 included and analyzed patients, AL occurred in 15 (11%). The volume and calcium scores were significantly higher in the infrarenal aorta, the left and right common iliac artery, and the left internal iliac artery. In univariate analysis, calcification of the left internal iliac artery and both internal iliac arteries combined correlated with the occurrence of the primary endpoint. A receiver operating curve analysis led to the cut-off values of 30 and 6 for the volume score and calcium score, respectively. They provide a negative predictive value of 0.97 and a positive predictive value of 0.19. CONCLUSIONS: Calcification in the iliac arteries appears to be a good marker for the risk of leakage after rectal anastomosis. The calcification scoring system is easy to calculate after computed tomography and may aid in patient selection to create a protective ileostomy.

Are routine ultrasound examinations helpful in the detection of bleeding complications following laparoscopic inguinal hernia repair?

PURPOSE: Intraabdominal bleeding is a dreaded complication after laparoscopic transabdominal preperitoneal inguinal hernia repairs. Routine postoperative sonographic (US) examination and hemoglobin measurement have been suggested to identify bleeding after surgery. We retrospectively assessed the value of these tests. METHODS: A total of 995 consecutive patients admitted for laparoscopic inguinal hernia repair to a single teaching hospital were analyzed. US examinations were performed postoperatively on the operative day to identify intraabdominal bleeding. In addition, hemoglobin measurements were obtained on the first postoperative day. RESULTS: Postoperative US examinations were performed on 971 patients (97.6%). Of these, 945 were examined within 24 hours of surgery. Reoperation was necessary in 1.1% (11/995) of the patients because of a persistent seroma in five cases, intraabdominal or inguinal bleeding or hematomas in five cases, and a trocar hernia in one case. In none of the 11 patients requiring reoperation did US examination or hemoglobin measurement indicate acute bleeding or hematoma. CONCLUSIONS: Routine postoperative US examination and hemoglobin measurement within the first 24 hours of surgery are not suitable for identifying patients with intraabdominal bleeding who require a reoperation. Instead, US examination and hemoglobin measurement should be part of the patient workup when there is a clinical suspicion of a postoperative complication. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:145-149, 2017.

Routine ultrasound and blood tests after laparoscopic cholecystectomy-are they worthwhile? A diagnostic accuracy study.

PURPOSE: Delayed recognition of complications can have life-threatening sequelae and is a leading cause of medical litigation. Minimal evidence exists for benefits of postoperative surveillance. This study investigated whether ultrasound (US) and blood tests can detect complications after laparoscopic cholecystectomy. METHODS: A series of 772 laparoscopic cholecystectomies performed between February 2008 and October 2009 was retrospectively analyzed. Routine US was performed within 6 h postoperatively, and a blood sample was taken at the second postoperative day. RESULTS: Postoperative US was performed in 722 patients. Fluid accumulation was documented in 104 patients; only two of these patients had clinically significant findings requiring treatment. The best predictor of infectious complications was elevated postoperative C-reactive protein (≥123 mg/L), with an area under the curve (AUC) of 0.94 and a number needed to misdiagnose (NNM) of 8.7. To predict postoperative choledocholithiasis, a combination of total bilirubin, aspartate aminotransferase and alkaline phosphatase elevations, with cutoff values of 1.3 mg/dL, 37 IU/L, and 136 IU/L, respectively, attained the highest accuracy with a NNM of 29.5. Ultrasonographic detection of bile duct dilation further improved specificity, while lowering sensitivity. CONCLUSIONS: The value of early routine postoperative US is low, unless there is clinical suspicion of complications. Routine blood tests have a high sensitivity for infectious complications and a high specificity for remnant biliary duct stones. Therefore, we recommend avoiding routine US postoperatively and performing routine postoperative blood tests. We also recommend facilitating easy access to postoperative US, as it can aid the decision to take therapeutic measures in symptomatic patients.

Subcutaneous application of gentamicin collagen implants as prophylaxis of surgical site infections in laparoscopic colorectal surgery: a randomized, double-blinded, three-arm trial.

PURPOSE: Despite a standardized prophylaxis with antibiotics, surgical site infections (SSI) are a characteristic problem in colorectal surgery. Local administration of gentamicin-collagen sponges (GCS) has been shown to decrease the infection rate after contaminated procedures. So far, the effect has not been tested for standardized laparoscopic colorectal resections. METHODS: We conducted a randomized, double-blind, placebo-controlled trial to investigate the efficacy of GCS to reduce wound infection after laparoscopic colorectal resections. Patients underwent a standardized operative procedure with standardized incision treatment. The intervention was the application of a GCS in the subcutaneous tissue of the bowel extraction site (GCS group). In the collagen group, a collagen sponge without antibiotics was used, and no sponge was used in the control group. The primary endpoint was SSI within 30 days postoperatively, according to the Center of Disease Control and Prevention definition. RESULTS: We randomly assigned 291 patients to all three groups. There was no difference between the groups regarding demographic characteristics and perioperative course. SSI was diagnosed in 8.2 % (GCS group), 13.5 % (collagen group), and 11.3 % (control group) of patients. No significant difference was found among the groups. CONCLUSION: The local administration of GCS showed no significant benefit regarding wound infection after standardized laparoscopic colorectal resections. However, there was a trend toward reduced SSI in the GCS group. Therefore, a larger trial or meta-analysis is necessary to validate this result.

Effectiveness of triclosan-coated PDS Plus versus uncoated PDS II sutures for prevention of surgical site infection after abdominal wall closure: the randomised controlled PROUD trial.

BACKGROUND: Postoperative surgical site infections are one of the most frequent complications after open abdominal surgery, and triclosan-coated sutures were developed to reduce their occurrence. The aim of the PROUD trial was to obtain reliable data for the effectiveness of triclosan-coated PDS Plus sutures for abdominal wall closure, compared with non-coated PDS II sutures, in the prevention of surgical site infections. METHODS: This multicentre, randomised controlled group-sequential superiority trial was done in 24 German hospitals. Adult patients (aged ≥18 years) who underwent elective midline abdominal laparotomy for any reason were eligible for inclusion. Exclusion criteria were impaired mental state, language problems, and participation in another intervention trial that interfered with the intervention or outcome of this trial. A central web-based randomisation tool was used to randomly assign eligible participants by permuted block randomisation with a 1:1 allocation ratio and block size 4 before mass closure to either triclosan-coated sutures (PDS Plus) or uncoated sutures (PDS II) for abdominal fascia closure. The primary endpoint was the occurrence of superficial or deep surgical site infection according to the Centers for Disease Control and Prevention criteria within 30 days after the operation. Patients, surgeons, and the outcome assessors were masked to group assignment. Interim and final analyses were by modified intention to treat. This trial is registered with the German Clinical Trials Register, number DRKS00000390. FINDINGS: Between April 7, 2010, and Oct 19, 2012, 1224 patients were randomly assigned to intervention groups (607 to PDS Plus, and 617 to PDS II), of whom 1185 (587 PDS Plus and 598 PDS II) were analysed by intention to treat. The study groups were well balanced in terms of patient and procedure characteristics. The occurrence of surgical site infections did not differ between the PDS Plus group (87 [14·8%] of 587) and the PDS II group (96 [16·1%] of 598; OR 0·91, 95% CI 0·66-1·25; p=0·64). Serious adverse events also did not differ between the groups-146 of 583 (25·0%) patients treated with PDS Plus had at least one serious adverse event, compared with 138 of 602 (22·9%) patients treated with PDS II; p=0·39). INTERPRETATION: Triclosan-coated PDS Plus did not reduce the occurrence of surgical site infection after elective midline laparotomy. Innovative, multifactorial strategies need to be developed and assessed in future trials to reduce surgical site infections. FUNDING: Johnson & Johnson Medical Limited.

HAnd Suture Versus STApling for Closure of Loop Ileostomy (HASTA Trial): results of a multicenter randomized trial (DRKS00000040).

OBJECTIVES: The objective of the HASTA trial was to compare hand suture versus stapling loop ileostomy closure in a randomized controlled trial. BACKGROUND: Bowel obstruction is one of the main and the clinically and economically most relevant complication following closure of loop ileostomy after low anterior resection. The best surgical technique for closure of loop ileostomy has not been defined yet. METHODS: HASTA trial is a multicenter pragmatic randomized controlled surgical trial with 2 parallel groups to compare hand suture versus stapling for closure of loop ileostomy. The primary endpoint was the rate of bowel obstruction within 30 days after ileostomy closure. RESULTS: A total of 337 randomized patients undergoing closure of loop ileostomy after low anterior resection because of rectal cancer in 27 centers were included. The overall rate of postoperative ileus after ileostomy closure was 13.4%. Seventeen of 165 (10.3%) patients in the stapler group and 27 of 163 (16.6%) in the hand suture group developed bowel obstruction within 30 days postoperatively [odds ratio (OR) = 1.72; 95% confidence interval (CI): 0.89-3.31 = 0.10]. Duration of surgical intervention was significantly shorter in the stapler group (15 minutes; P < 0.001). Multivariable analysis of potential risk factors did not reveal any significant correlation with development of postoperative ileus. Rate of anastomotic leakage (stapler: 3.0%, hand suture: 1.8%, P = 0.48) did not differ significantly as well as all other secondary endpoints. CONCLUSIONS: Hand-sewn anastomosis versus stapler ileo-ileostomy for ileostomy closure are equally effective in terms of postoperative bowel obstruction, with stapler anastomosis leading to a shorter operation time. Postoperative ileus after ileostomy reversal remains a relevant complication.