Analysis of Later Stage Morbidity and Mortality after Pancreatic Surgery Because of Abdominal Trauma.

Background: Pancreatic trauma surgery is a complicated surgical procedure for severe pancreatic injuries, accompanied by a high incidence of complications and mortality. This study was designed to explore the long-term prognosis of pancreatic surgery because of abdominal trauma. Patients and Methods: The clinical data of 103 patients who were admitted to Jinling Hospital between August 2012 and August 2019 who had pancreatic trauma surgery were analyzed retrospectively. Results: All admissions involved pancreatic trauma surgery performed at an outside hospital network, which later transferred patients to our institution because of post-operative later-stage complications. Eight patients received American Association for the Surgery of Trauma (AAST) grade 1 or 2 pancreatic injuries and 95 received AAST grade 3, 4, or 5 pancreatic injuries. The primary surgical management of pancreatic injuries included drainage of the pancreatic injury (n = 28), repair of the pancreas (n = 35), partial pancreatectomy (n = 15), pancreaticojejunostomy (n = 6), and pancreaticoduodenectomy (n = 19). The most common mechanism of trauma was motor vehicle collision (n = 72), crush injury (n = 26), and stab wound (n = 5). Of 103 patients suffered varying degrees of gastrointestinal fistulae and intra-abdominal infections, there were 66 cases of pancreatic fistulae (64.1%), 49 cases of enteric fistulae (47.6%), 26 cases of colonic fistulae (25.2%), 14 cases of gastric or gastrointestinal anastomotic fistulae (13.6%), and 13 cases of biliary fistulae (12.6%). Ninety-five patients survived and eight patients died after therapy; the mean length of intensive care unit stay was 33 days. The number of patients who underwent emergency pancreaticoduodenectomy (EPD), the incidence of blood transfusion, the number of fistulae per patient, and the duration of mechanical ventilation and bacteremia in the mortality group were substantially higher than in the survival group (p < 0.05 each). The patients who underwent EPD had more grade 5 pancreatic injuries, more blood transfusions, higher peak total bilirubin, greater numbers of fistulae and open abdomen, and longer duration of mechanical ventilation and mortality than other patients (p < 0.05 each). Conclusions: The grade of pancreatic injury was associated with mortality and post-operative complications. The post-operative mortality and occurrence of complications of EPD because of abdominal trauma were significant; use of damage control surgery could potentially reduce the morbidity and mortality related to this procedure.

Preoperative prognostic nutritional index predicts postoperative surgical site infectious in gastrointestinal fistula patients / 中华普通外科杂志

Objective To explore the predictive value of prognostic nutritional index (PNI) in surgical site infections (SSIs) for intestinal fistula patients undergoing bowel resections.Methods Clinical data of 290 gastrointestinal fistula patients who underwent intestinal resections between 2012 and 2015 were retrospectively reviewed.Univariate and multivariate analyses were conducted to identify risk factors for SSIs,and receiver operating characteristic (ROC) curve was used to quantify the effectiveness of PNI.Results SSIs were diagnosed in 99 (34.1％) patients.ROC curve analysis defined a PNI cut-off level of 45 corresponding to postoperative SSIs (area under the curve =0.72,76％ sensitivity,55％ specificity).Furthermore,a multivariate analysis indicated that the PNI ＜ 45 (OR:2.24,95％ CI:1.09-4.61,P =0.029) and preoperative leukocytosis (OR:3.70,95 ％ CI:1.02-13.42,P =0.046) were independently associated with postoperative SSIs.Conclusions Preoperative PNI is useful to predict SSIs in intestinal fistulae patients after enterectomies.

Predictive value of non-thyroidal illness syndrome before definitive operation on postoperative surgical site infection in patients with enterocutaneous fistula / 中华消化外科杂志

Objective To investigate the predictive value of non-thyroidal illness syndrome (NTIS) before definitive operation on postoperative surgical site infection (SSI) in patients with enterocutaneous fistula (ECF).Methods The retrospective case-control study was conducted.The clinical data of 264 ECF patients (181 with euthyroidism and 83 with NTIS) who underwent definitive operation in the Nanjing General Hospital of Nanjing Military Command between April 2014 and November 2016 were collected.After definitive operation,86 with SSI and 178 without SSI were respectively allocated into the SSI group and non-SSI group.Observation indicators:(1) risk factor analysis of postoperative SSI;(2) effect of preoperative NTIS on postoperative SSI;(3) predictive power of serum free triiodothyronine 3 (FT3) level on postoperative SSI.Measurement data with normal distribution were represented as x-± s and was analyzed using the t test.Count data were described as absolute number or percentage,and were analyzed using the chi-square test.The comparison of ordinal data was done by the nonparamentric test.The multivariate analysis was done using the logistic regression model.The receiver operating characteristic (ROC) curve was drawn,and area under the curve (AUC) was calculated for analyzing predictive power of serum FT3 level on postoperative SSI.Results (1) Risk factor analysis of postoperative SSI:cases with volume of preoperative intestinal fluid loss through fistula stoma ＜ 200 mL/24 hours,from 200 to 500 mL/24 hours and ＞ 500 mL/24 hours,preoperative hemoglobin (Hb) level,cases with surgical site located in stomach and duodenum,small intestine,ileocolon and colorectum,cases with open surgery and laparoscopic surgery were respectively 65,15,6,(119±36)g/L,5,50,31,36,58,28 in the SSI group and 135,27,16,(125±39)g/L,11,91,53,71,127,51 in the non-SSI group,with no statistically significant difference between groups (x2 =0.471,t =1.202,x2 =0.332,0.422,P＞0.05).Cases with preoperative single.and multiple fistula stoma,serum albumin (Alb) level,cases with preoperative NTIS,volume of intraoperative blood loss ＜ 300 mL and ≥ 300 mL,operation duration ＜ 3 hours and ≥ 3 hours were respectively 57,29,(35±.8)g/L,36,67,19,53,33 in the SSI group and 146,32,(37±9)g/L,47,161,17,140,38 in the non-SSI group,with statistically significant differences between groups (x2 =8.089,t =2.422,x2 =6.426,7.746,8.547,P＜0.05).Results of multivariate analysis showed that preoperative multiple intestinal fistula and NTIS were independent factors affecting occurrence of postoperative SSI in ECF patients (odds ratio =1.873,2.464,95％ confidence interval:1.052-2.671,1.120-4.392).(2) Effect of preoperative NTIS on postoperative SSI:incidence of preoperative multiple intestinal fistula,proportion of cases with preoperative enteral nutrition time ＞3 months,incidence of postoperative SSI,postoperative superficial and deep incision infection rates and organ/space infection rate were respectively 31.3％ (26/83),72.3％ (60/83),43.4％ (36/83),9.6％ (8/83),21.7％(18/83),7.2％ (6/83) in patients with NTIS and 19.3％(35/181),57.5％(104/181),27.6％(50/181),11.6％(21/181),3.9％(7/181),8.8％ (16/181) in patients with euthyroidism,with statistically significant differences in incidence of multiple intestinal fistula,proportion of cases with preoperative enteral nutrition time ＞ 3 months,incidence of postoperative SSI,superficial and deep incision infection rates (x2 =4.603,5.319,6.426,4.256,4.377,P＜0.05),and no statistically significant difference in organ/space infection rate (x2=0.193,P＞0.05).(3) Predictive power of serum FT3 level on postoperative SSI:the ROC curve showed that optimal cut-off point of serum FT3 predicting postoperative SSI was 3.5 pmol/L,AUC,sensibility and specificity were respectively 0.75,72.6％ and 68.7％.Conclusion The presence of NTIS is associated with occurrence of postoperative SSI in patients with ECF before definitive operation,and optimal cut-off point of serum FT3 predicting postoperative SSI is 3.5 pmol/L.

Predictive value of procalcitonin in postoperative intra-abdominal infections after definitive operation of intestinal fistulae / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the predictive value of procalcitonin(PCT) in postoperative intra-abdominal infections (IAI) after definitive operation of intestinal fistulae(IF).</p><p><b>METHODS</b>With the exclusion of emergence operation, preoperative clinical infection, preoperative renal or hepatic dysfunction, and age less than 18 years, a total of 356 consecutive patients who underwent elective digestive tract reconstruction of intestinal fistulae from February 2012 to December 2015 at Intestinal Fistula Center of Jinling Hospital were prospectively enrolled in the study. All the patients were divided into IAI group (26 cases, 21 of anastomosis leakage and 5 of peritoneal abscess) and non-IAI group (330 cases) based on the existence of postoperative IAI. The non-IAI group was then divided into two subgroups of other infection (93 cases) and non-infection(237 cases) according to the presence of other infections. Plasma PCT level, serum CRP concentration and WBC count were assessed preoperatively and on postoperative days (PODs) 1, 3, 5, 7 by immunofluorescence, turbidimetry and automatic blood analyzer, respectively. The predictive value of each marker for IAI was calculated by receiver operating characteristic (ROC) curve.</p><p><b>RESULTS</b>There was no significant difference in general clinical data between IAI and non-IAI group (all P>0.05). The proportions of multi-IF (53.8%, 14/26) and colectomy (61.5%, 16/26) in IAI group were higher than those of non-IAI group [20.0% (66/330), χ=15.847, P=0.000 and 31.2%(103/330), χ=9.961, P=0.002]. Differences of preoperative PCT, CRP and WBC levels among IAI, other infection and non-infection groups were not significant. These three markers all increased obviously and immediately after surgery. PCT and WBC values reached the peak point on POD 1, whereas CRP on POD 3. In IAI group, mean PCT values were (5.4±4.2) μg/L, (2.9±1.9) μg/L and (1.6±1.8) μg/L on POD 1, POD 3 and POD 5, respectively, which were higher than those of other infection group [(4.2±8.7) μg/L, (1.9±3.8) μg/L and (0.6±0.8) μg/L] and non-infection group [(2.7±5.8) μg/L, (1.1±1.7) μg/L and (0.5±0.7) μg/L, all P<0.05]. Mean CRP values in IAI group were 99.4 mg/L and 183.9 mg/L respectively on POD 1 and POD 3,and mean WBC values of IAI group on POD 1, POD 3 and POD 5 were 16.0×10/L, 10.8×10/L and 8.7×10/L, respectively, which were all significantly higher than those in the other 2 groups (all P<0.05). No significant differences were obtained between other infection group and non-infection group in all these three markers (all P>0.05). ROC curve demonstrated that PCT had the biggest area under the curve (AUC) of 0.86 and 0.84 on POD 3 and POD 5, with the cut-off value of 0.98 μg/L and 0.83 μg/L, 92.0% sensitivity and 74.0% specificity, 91.0% sensitivity and 73.0% specificity, respectively. The highest AUC was 0.72 on POD 3 for CRP and 0.71 on POD 3 for WBC, with 80.0% sensitivity and 54.0% specificity, 56.0% sensitivity and 73.0% specificity, respectively.</p><p><b>CONCLUSION</b>The value of procalcitonin above 0.98 μg/L on POD 3 and 0.83 μg/L on POD 5 can predict the occurrence of IAI after definitive operations of intestinal fistulae.</p>

Effect of postoperative hyperglycemia on clinical outcome of gastrointestinal fistula patients undergoing gastrointestinal reconstruction / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of hyperglycemia within postoperative 48 hours on gastrointestinal (GI) fistula patients without preoperative diagnosis of diabetes undergoing selective GI reconstruction.</p><p><b>METHODS</b>Clinical data of GI fistula patients with age of 18 to 70 years and without diffuse peritonitis and systemic infection undergoing definitive GI reconstruction at Intestinal Fistula Center of Jinling Hospital from September 2012 to December 2015 were retrospectively analyzed. According to the highest blood glucose (BG) value detected within postoperative 48 hours, patients were divided into normoglycemia (BG<6.9 mmol/L), mild hyperglycemia (6.9 to 11.4 mmol/L) and severe hyperglycemia (BG≥11.5 mmol/L) groups. Clinical manifestations were compared among three groups. Effects of postoperative hyperglycemia on associated parameters, including postoperative surgical site infection, anastomotic leakage, intestinal nutrition recovery, hospital stay and hospitalization cost were investigated.</p><p><b>RESULTS</b>A total of 314 patients were enrolled, of whom postoperative gastric fistula occurred in 6 cases, small intestinal fistula in 95 cases, ileocolonic anastomotic fistula in 116, and colorectal fistula in 97 cases. One hundred and ninety-three (61.5%) patients experienced hyperglycemia, including 148 cases of mild hyperglycemia group and 45 cases of severe hyperglycemia group, the other 121 cases were of normoglycemia group. There were no significant differences in gender, BMI, ratio of smoking, ratio of alcohol user and primary diseases among 3 groups (all P>0.05). Older patients were vulnerable to postoperative hyperglycemia and patients who developed hyperglycemia were also prone to have increased ASA score (all P=0.000). Hyperglycemia patients had significantly higher ratio of postoperative ileocolonic anastomotic fistula (mild hyperglycemia group: 40.5%, 60/148; severe hyperglycemia group: 44.4%, 20/45) than normoglycemia cases (29.8%,36/121). Compared to normoglycemia group, ratio of intra-operative transfusion case was higher (P=0.001), operative time was longer (P=0.026), ratio of number of anastomosis >2 was higher (P=0.001), ratio of receiving laparoscopic-assisted operation was lower (P=0.005), ratio of postoperative surgical site infection was higher (P=0.006), incidence of anastomotic leakage was higher (P=0.004), ratio of re-operation was higher (P=0.004), intestinal nutrition recovery time was longer (P=0.001), ICU stay was longer (P=0.001), total hospitalization time was longer (P=0.000) and hospitalization cost was more expensive (P=0.000) in both two hyperglycemia groups. Multivariate regression analysis showed that mild hyperglycemia and severe hyperglycemia were independent risk factors to predict surgical site infection (OR=1.99, 95%CI: 1.12 to 3.54, P=0.019; OR=3.02, 95%CI: 1.36 to 6.70, P=0.007) and anastomotic leakage (OR=7.59, 95%CI: 1.68 to 34.34, P=0.009; OR=13.4, 95%CI: 2.50 to 71.65, P=0.002). Multivariate linear regression analysis indicated that intestinal recovery time of normoglycemia group was 2 days shorter and 3 days shorter, and hospitalization time of normoglycemia group was 2 days shorter and 10 days shorter as compared with mild hyperglycemia and severe hyperglycemia group, respectively.</p><p><b>CONCLUSIONS</b>Elevated postoperative BG is common in GI fistula patients receiving selective GI reconstruction. Postoperative hyperglycemia is significantly associated with surgical site infection, anastomotic leakage and prolonged intestinal recovery. BG control treatment should be recommended for those patients with postoperative hyperglycemia.</p>

The role of mitochondrial DNA in the regulation of innate immune responses / 医学研究生学报

Mitochondria is the main production site of oxidative phosphorylation and ATP, and it is famous as energy factory of the cell.In addition, mitochondria also participates in the process of cellular proliferation, differentiation and apoptosis, and signal transduction.Recent studies have revealed that pathophysiological functions of mitochondria beyond traditional energetic metabolism in cells.Mitochondria-released DAMPs, particularly mtDNA, could activate innate immune responses by involving TLR9, NLRP3 and cGAS-STING signaling pathways.In addition to facilitating antibacterial immunity and regulating antiviral signaling, mounting evidences suggest that mtDNA contributes to inflammatory diseases following cellular damage and apoptosis.In addition to its well-appreciated roles in cellular metabolism and ATP production, mtDNA appears to function as a key member in the innate immune system.Therefore, we highlight the emerging roles of mtDNA in innate immunity.