Role of spleen density in predicting postoperative complications in patients with acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia (AMI) is a life-threatening surgical emergency with a poor prognosis. This study assessed the association of diffuse reduction of spleen density (DROSD) with postoperative complications and identified risk factors for adverse outcomes in AMI patients after surgery. METHODS: Patients who were diagnosed with AMI and underwent surgical operations between April 2006 and July 2021 were enrolled. Spleen density was assessed using preoperative non-enhanced computed tomography. The lowest quartile of spleen density in all patients was regarded as the cutoff value for DROSD. Univariate and multivariate analyses were performed to determine the risk factors related to postoperative outcomes after surgery. RESULTS: According to the diagnostic cutoff, patients with a spleen density ≤49.07 HU were defined as DROSD. In a cohort of 97 patients, 34.0% developed complications within 30 days of surgery. The multivariate analysis illustrated that DROSD was an independent risk factor for prognostic outcomes in AMI patients after surgery. CONCLUSION: Patients with low spleen density were prone to postoperative complications. As an imaging method, preoperative assessment of spleen density is a novel predictor that can be used clinically to identify high-risk AMI patients with poor prognosis.

Role of Platelet to Lymphocyte Ratio and Red Cell Distribution Width in Predicting Postoperative Complications in Patients with Acute Mesenteric Ischemia.

BACKGROUND: The predictive values of the platelet to lymphocyte ratio (PLR) and red cell distribution width (RDW) have been demonstrated in different types of abdominal surgery. The aim of this study was to investigate the interest of the preoperative PLR and RDW as predictors of 30-day postoperative complications in patients with acute mesenteric ischemia (AMI). METHODS: Clinical data of 105 AMI patients were retrospectively reviewed. Postoperative complications were evaluated by the Clavien-Dindo classification. The cutoff values for neutrophil to lymphocyte ratio (NLR), PLR, and RDW were determined by receiver operating characteristic curves. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. RESULTS: In the univariate analyses, advanced age, female, anemia, high white blood cell (WBC), high PLR, high NLR, high RDW, Charlson comorbidity index (CCI) score ≥2, and bowel resection were associated with the postoperative complications. A multivariable analysis revealed that advanced age, high PLR, high RDW, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS: The PLR and RDW might play important roles in evaluation of the risk of postoperative complications in AMI patients. The preoperative PLR and RDW are simple and useful predictors of postoperative complications in AMI patients.

The psoas muscle density as a predictor of postoperative complications and 30-day mortality for acute mesenteric ischemia patients.

OBJECTIVE: Low muscle mass and quality is associated with poor surgical outcomes. Psoas muscle density (PMD)is a validated surrogate for muscle quality that can be easily measured from a clinical computed tomography (CT) scan. The objective of this study was to investigate the association between PMD and short-term postoperative outcomes in patients with acute mesenteric ischemia (AMI). METHODS: From April 2006 and September 2019, the clinical data of all patients who underwent surgical intervention with a preoperative diagnosis of AMI and had preoperative non-contrast CT images available were retrospectively reviewed. PMD was measured by CT at the third lumbar vertebra. The lowest quartile of PMD for men and women in all patients was used as sex-specific cut-off values for low PMD. Univariate and multivariate analyses evaluating risk factors of postoperative complications and 30-day mortality were performed. RESULTS: The cohort consisted of 88 patients with a mean age of 58.8 ± 16.2 years, of whom 21 (23.9%) patients had low PMD based on the diagnostic cut-off values (40.5 HU for men and 28.4 HU for women), 35 (39.8%) patients developed complications within 30 days of the operation, and 10 (11.3%) patients died within 30 days of surgery. Low PMD patients had a higher risk of postoperative complications and 30-day mortality than patients without low PMD patients. In a multivariate analysis, low PMD and low psoas muscle area (PMA) were independent predictors of postoperative complications. However, only low PMD remained an independent risk factor for 30-day mortality. CONCLUSIONS: Preoperative assessment of the PMD on CT can be a practical method for identifying AMI patients at risk for postoperative complications and 30-day mortality.

Role of Frailty and Comorbidity Status in Predicting Morbidity and Mortality in Patients with Acute Mesenteric Ischemia.

BACKGROUND: This study was performed to determine the association of frailty and comorbidity status with postoperative morbidity and mortality in patients with acute mesenteric ischemia (AMI). METHODS: Patients diagnosed with AMI between April 2006 and September 2019 were enrolled in this study. Frailty was evaluated by sarcopenia which was diagnosed by third lumbar vertebra psoas muscle area (PMA). Comorbidity status was evaluated by the Charlson Comorbidity Index (CCI) score. Univariate and multivariate analyses evaluating the risk factors for postoperative morbidity and mortality were performed. RESULTS: Of the 174 patients, 86 were managed conservatively and 88 underwent surgery. In surgically managed patients, 39.8% developed complications within 30 days of surgery. Ten patients died within 30 days of the operation. In the univariate analyses, white blood cell >10 g/L, low PMA, CCI score ≥2, and bowel resection were associated with postoperative complications. Multivariate analysis revealed that low PMA, CCI score ≥2, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS: This study demonstrated that low PMA, CCI score ≥2, and bowel resection were independent risk factors for postoperative complications in patients with AMI. Preoperative assessment of frailty using PMA and the evaluation of comorbidity status using CCI may serve as helpful tools in preoperative risk assessment and should be integrated into scoring systems for surgically treated AMI.

Role of frailty and nutritional status in predicting complications following total gastrectomy with D2 lymphadenectomy in patients with gastric cancer: a prospective study.

PURPOSE: This study was performed to determine the association of frailty and nutritional status with postoperative complications after total gastrectomy (TG) with D2 lymphadenectomy in patients with gastric cancer. METHODS: Patients undergoing TG with D2 lymphadenectomy for gastric cancer between August 2014 and February 2016 were enrolled. Frailty was evaluated by sarcopenia which was diagnosed by a combination of third lumbar vertebra muscle index (L3 MI), handgrip strength, and 6-m usual gait speed. Nutritional status was evaluated by the nutritional risk screening 2002 (NRS 2002) score. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. RESULTS: A total of 158 patients were analyzed, and 27.2 % developed complications within 30 days of surgery. One patient died within 30 days of the operation. In the univariate analyses, NRS 2002 score ≥3 (OR = 2.468, P = 0.012), sarcopenia (OR = 2.764, P = 0.008), and tumor located at the cardia (OR = 2.072, P = 0.046) were associated with the postoperative complications. Multivariable analysis revealed that sarcopenia (OR = 3.084, P = 0.005) and tumor located at the cardia (OR = 2.347, P = 0.026) were independent predictors of postoperative complications. CONCLUSIONS: This study showed a significant relationship between postoperative complications and geriatric frailty using sarcopenia in patients with gastric cancer after TG with D2 lymphadenectomy. Frailty should be integrated into preoperative risk assessment and may have implications in preoperative decisionmaking.

Sarcopenia Adversely Impacts Postoperative Clinical Outcomes Following Gastrectomy in Patients with Gastric Cancer: A Prospective Study.

BACKGROUND: Sarcopenia is characterized by decreased skeletal muscle plus low muscle strength and/or physical performance. This study was performed to determine the association of sarcopenia with short-term postoperative outcomes after gastrectomy for gastric cancer. METHODS: We conducted a prospective study of 255 consecutive patients with gastric cancer who underwent curative gastrectomy. The sarcopenia elements, including lumbar skeletal muscle index, handgrip strength, and gait speed, were measured before surgery. Patients were followed up after gastrectomy to gain the actual clinical outcomes. Factors contributing to postoperative complications were analyzed by univariate and multivariate analysis. RESULTS: Sarcopenia was present in 32 of 255 patients (12.5 %), and was significantly correlated with advance age, lower body mass index, higher nutritional risk screening (NRS) 2002 score, and lower preoperative serum albumin and hemoglobin. Compared with non-sarcopenic patients, sarcopenic patients had a higher risk of postoperative complications, longer postoperative hospital stay, and more hospital costs. In univariate analysis, sarcopenia (p < 0.001), nutritional risk (NRS 2002 score ≥3; p = 0.003), advanced age (≥75 years; p = 0.014), anemia (p = 0.012), hypoalbuminemia (p = 0.029), and diabetes (p = 0.014) were associated with postoperative complications. Multivariable analysis revealed that sarcopenia (p < 0.001) and diabetes (p = 0.006) were independent predictors of postoperative complications. CONCLUSIONS: Sarcopenia is an independent predictor of postoperative complications in patients with gastric cancer after gastrectomy.

Feasibility of Total Gastrectomy with D2 Lymphadenectomy for Gastric Cancer and Predictive Factors for Its Short- and Long-Term Outcomes.

BACKGROUND: The aim of this study was to evaluate the short- and long-term outcomes after total gastrectomy (TG) with D2 lymphadenectomy. METHODS: Patients undergoing TG with D2 lymphadenectomy for gastric cancer between December 2008 and December 2011 were enrolled. Univariate and multivariate analyses were performed to evaluate the risk factors for the short- and long-term outcomes. RESULTS: A total of 229 patients were analyzed, and 22.3 % developed complications within 30 days of surgery. No patient died within 30 days, while 2.6 % died within 90 days of the operation. In the multivariate analysis, age ≥65 years and cardiopulmonary comorbidities were associated with morbidity, whereas hypoproteinemia and tumor-node-metastasis (TNM) stage III were associated with the disease-free survival (DFS) and overall survival (OS). The number of preoperative risk factors stratified the morbidity from 10.3 % in those without any risk factors to 40.5 % in patients with both risk factors. Similarly, 5-year survival rates decreased from 68.9 % (DFS) and 71.1 % (OS) in those without risk factors to 20.2 % (DFS) and 22.9 % (OS) in patients with both risk factors. CONCLUSION: TG with D2 lymphadenectomy has acceptable short- and long-term outcomes. Patient risk stratification may allow for more rational selection of patients and therapeutic strategies for gastric resection.

Prediction of Prolonged Postoperative Ileus After Radical Gastrectomy for Gastric Cancer: A Scoring System Obtained From a Prospective Study.

Currently, there is a paucity of study investigating postoperative ileus in gastric cancer surgery. This prospective study aims to identify the risk factors for prolonged postoperative ileus (PPOI) and to use these risk factors to generate a risk stratification scoring system for the occurrence of PPOI.Patients who underwent radical gastrectomy for gastric cancer were included in this study. A multivariate logistic analysis was applied to identify independent risk factors for PPOI and to generate the scoring system. A receiver operating characteristic curve was generated and the area under the curve was calculated to demonstrate the predictive power of the scoring system.Finally, 296 patients were included and analyzed, of whom 96 (32.4%) developed PPOI. The multivariate analysis showed that age ≥65 years, operative duration ≥4 hours, tumor-node-metastasis (TNM) stage = III, open/converted operative technique, and total postoperative opiates dose (TOD) ≥0.3 mg/kg were independent risk factors for PPOI. Based on these factors, a risk stratification scoring system was generated, classified by low-risk (score 0-2), moderate-risk (score 3-4), and high-risk (score 5-6) groups. The incidence of PPOI increased by 7.5-fold from low-risk to high-risk group. The area under the curve of the scoring system was 0.841 (95% CI, 0.793-0.890), indicating a good predictive capability for the occurrence of PPOI.We have identified independent risk factors for the occurrence of PPOI and used these factors to construct a risk stratification scoring system.

Mitochondrial energy metabolism disorder and apoptosis: a potential mechanism of postoperative ileus.

AIM: To explore whether mitochondrial energy metabolism disorder and apoptosis of smooth muscle cells in intestinal muscularis are participated in pathogenesis of postoperative ileus (POI). METHODS: Rats were randomized into three groups: naive controls (NC) group, sham controls (SC) group and intestinal manipulation (IM) group. Gastrointestinal transits were analyzed. Reactive oxygen species (ROS), malondialdehyde (MDA) and adenosine triphosphatases (ATPases) activity in intestinal muscularis were determined. The levels of aldehyde dehydrogenase 2 (ALDH2), Bcl-2 and Bax in intestinal muscularis were measured by real-time PCR assays and western blot analysis. The levels of ATP, ADP and AMP in intestinal muscularis were determined by high performance liquid chromatography. Transmission electron microscopic was used to observe ultrastructure of smooth muscle cells and mitochondria in intestinal muscularis. RESULTS: Delayed gastrointestinal transitoccurred only in IM groups. After IM, increased levels of ROS and MDA were observed in intestinal muscularis. In IM groups, we also observed decreased levels of ALDH2 and Bcl-2/Bax ratio. The levels of ATP and ADP were decreased and level of AMP was increased in IM groups. The activity of ATPases was decreased in IM groups. Abnormal morphological architecture of smooth muscle cells and mitochondria were found in intestinal muscularis of IM groups. CONCLUSION: Our results suggest that mitochondrial energy metabolism disorder and apoptosis of smooth muscle cells in intestinal muscularis may participate in the development of POI.

Impact of different surgical traumas on postoperative ileus in rats and the mechanisms involved.

The degree of postoperative ileus and the underlying pathophysiological mechanism among different types of surgical traumas have not been examined. The aim of this study was to investigate the inflammatory and oxidative stress changes in rat intestinal muscularis and gastrointestinal transit among three types of surgical traumas. Rats were randomized assigned to four groups: control group, intestinal manipulation (IM) group, intestinal ischemia/reperfusion injury (IR) group and peritoneal air exposure (AE) group. Gastrointestinal transit was measured 24 hours after surgery. Malondialdehyde (MDA), glutathione (GSH) and inflammatory mediators in intestinal muscularis were measured. Influx of neutrophil in intestinal muscularis was also determined. The degree of gastrointestinal motility impairment was equal between the IM and AE groups. However, the IR group was subject to a less impairment of gastrointestinal motility compared with the IM and AE groups. The IM group showed the most significant increase of inflammatory response, while the AE group showed the most significant increase of oxidative stress. The IR group showed a moderate increase of inflammatory response and oxidative stress. Rats subjected to IM, IR and AE could all develop into POI. We speculate that oxidative stress should be an equally important pathophysiological mechanism of POI as inflammation.

Prevention of postoperative fatigue syndrome in rat model by ginsenoside Rb1 via down-regulation of inflammation along the NMDA receptor pathway in the hippocampus.

Postoperative fatigue syndrome (POFS) is a common complication which decelerates recovery after surgery. The present study investigated the anti-fatigue effect of ginsenoside Rb1 (GRb1) through the inflammatory cytokine-mediated N-methyl-D-aspartate (NMDA) receptor pathway. A POFS rat model was created by major small intestinal resection and assessed with an open field test. Real-time quantitative polymerase chain reaction, western blot analysis, high performance liquid chromatography and a transmission electron microscopic analysis were used to determine typical biochemical parameters in the hippocampus. Our results showed that POFS rats exhibited fatigue associated with an increased expression of inflammatory cytokines and NMDA receptor 1, higher (kynurenine)/(tryptophan) and (kynurenine)/(kynurenic acid) on postoperative days 1 and 3, and an increased expression of indoleamine 2,3-dioxygenase (IDO) on postoperative day 1. Degenerated neurons were found in the hippocampus of POFS rats. The NMDA receptor antagonist MK801 had a significant effect on central fatigue on postoperative day 1. GRb1 had no effect on IDO or tryptophan metabolism, but exhibited a significant effect on POFS by inhibiting the expression of inflammatory cytokines and NMDA receptor 1. These data suggested that inflammatory cytokines could activate tryptophan metabolism to cause POFS through the NMDA receptor pathway. GRb1 had an anti-fatigue effect on POFS by reducing inflammatory cytokines and NMDA receptors.

Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases. The purpose of this systemic review was to examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs. METHODS: PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS: Five randomized clinical trials encompassing 598 patients were included in the final analysis. Two of them were multicenter trials. The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs. Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) -1.92 days; 95 % confidence interval (CI) -2.61--1.23 days; P < 0.00001) and number of complications (relative risk (RR) 0.78; 95 % CI 0.66-0.94; P = 0.007) compared with open surgery in the setting of ERAS programs. No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality. The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality. CONCLUSIONS: Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs.