Abstract
BackgroundThere is increasing epidemiological evidence of etiological links between general surgery and sporadic Creutzfeldt-Jakob disease (sCJD) with long incubation periods. The purpose of this study was to identify specific surgical procedures potentially associated with sCJD to be targeted for preventive presurgical-intervention guidance.ResultsWe propose a three-step clinical guidance outline where surgical procedures associated with sCJD clinical onset – potentially more contaminant - are taken into account. Data on hospital discharges and surgical procedures were obtained from Danish and Swedish national in-patient hospital registries for 167 sCJD cases, onset 1987–2003, and for 835 matched and 2,224 unmatched population controls. Surgery was allocated to different life-time periods as previously reported, and frequencies were compared using logistic regression analysis. In the year preceding clinical onset, persons with sCJD underwent a statistically significant higher number of minor surgical interventions (OR (95% CI): 17.50 (3.64-84.24)), transluminal endoscopies (OR: 2.73 (1.01–7.37)) and gastrointestinal operations (OR: 3.51 (1.21–10.19)) compared to matched controls. Surgical discharges clustered towards clinical onset. These differences increased during the clinical period, with statistically significant higher frequencies for both endoscopies and minor surgery (OR: 13.91 (5.87-32.95), and for main surgical procedures (OR: 2.10 (1.00-4.39)), particularly gastrointestinal surgery (OR: 6.00 (1.83-19.66)), and surgery contacting skeletal muscle. Comparisons with unmatched controls yielded similar results for neurosurgery in the clinical period (OR: 19.40 (2.22-168.34)).ConclusionsThese results suggest that some types of surgical procedures are associated with sCJD, after clinical onset or particularly just before onset. Selective planning of such surgery to minimize instrument/device contamination or quarantining might be feasible. Conditional to progress in sCJD etiological research, results are relevant for guidance development.
Highlights
There is increasing epidemiological evidence of etiological links between general surgery and sporadic Creutzfeldt-Jakob disease with long incubation periods
Surgical transmission of Creutzfeldt-Jakob disease (CJD) by tainted instruments has been experimentally demonstrated [2], and exposure to neurosurgical instruments recently used on a patient with CJD or incubating the disease constitutes a diagnostic criterion of iCJD in surveillance. vCJD has been linked to both dietary exposure to bovine spongiform encephalopathy (BSE) and transfusion of blood from infected donors [3,4,5], but not to general or dental surgery [4,6]
Outline of guidance Algorithms used for planning any type of surgery having the potential to contaminate instruments incorporate the following two main variables: 1) patient-related infectious risk level, and, 2) the putative contaminating power of the planned procedure [13,19]
Summary
There is increasing epidemiological evidence of etiological links between general surgery and sporadic Creutzfeldt-Jakob disease (sCJD) with long incubation periods. A recent report shows that a majority of EU Member States had official guidelines that included specific preventive measures covering situations where symptomatic and asymptomatic CJD patients or persons at potentially higher risk of CJD had to undergo surgery [13]. These included written advice for single-use equipment, destruction of contaminated equipment, decontamination of reusable instruments, use of protective clothing, storing and quarantining surgical instruments, as well as organizational recommendations. This report suggests that, should the new risk factors for sCJD be confirmed [8,9,10,11], further guidance will be needed [13]
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