Incidence Of Postoperative Infectious Complications Research Articles

Immunonutrition in patients undergoing esophageal cancer resection

Specialized nutritional support containing immunonutrients such as arginine, omega-3 fatty acids, and ribonucleic acid significantly reduces the incidence of postoperative infective complications and hospital length of stay in elective surgery patients. However, immunonutrition use is not standard practice in esophago-gastric units internationally. This review provides a clinical update regarding the use of immunonutrition in patients undergoing major gastrointestinal surgery and, in particular, esophageal cancer resection, and provides direction for future collaborative research. A review of MEDLINE and Cochrane Library databases was conducted for randomized controlled trials or meta-analyses. A recent meta-analysis demonstrated that preoperative immunonutrition use significantly reduces hospital length of stay and the incidence of postoperative complications in patients undergoing major elective surgery, particularly for gastrointestinal malignancies. Only three small randomized controlled trials have evaluated immunonutrition use in patients exclusively undergoing esophageal cancer surgery. These were unable to determine whether immune-enhancing formulae positively influence key clinical outcomes such as mortality, hospital and intensive care unit length of stay, and postoperative morbidity in this patient group. Currently, there is insufficient evidence to recommend routine use of immunonutrition in patients undergoing esophageal cancer surgery. Future collaborative research should evaluate whether: (i) immunonutrition use positively influences key clinical outcomes in this population; (ii) these patients benefit from preoperative supplementation with an immune-enhancing formula or whether they require postoperative continuation (perioperative approach) to combat their risk of complications after surgery; and (iii) these formulae can be used safely in those patients who develop sepsis.

Is Antibiotic Prophylaxis Necessary in Elective Laparoscopic Surgery for Benign Gynecologic Conditions?

Background: The use of prophylactic antibiotics in gynecologic laparoscopic surgery is still popular and many gynecologic surgeons believe that prophylactic antibiotic therapy will decrease the incidence of postoperative infection complications. Aim: The aim of this prospective cohort study was to investigate the opportunity of prophylactic antibiotics to prevent early postoperative infections and febrile morbidity in elective laparoscopic surgery for benign gynecological conditions. Methods: 300 women who underwent laparoscopic surgery for benign gynecological conditions were included in the study. After the patients were included they were divided in two groups (ratio 1:1). Group A (n = 150) received 2 g of cefazolin (Cefamezin®; Pfizer Italia Srl, Italy) 30 min before surgery and group B (n = 150) received no antibiotic prophylaxis. Results: No postoperative infection was diagnosed for a total of 300 study patients. The overall rate of febrile morbidity was 3.3% for a total of 300 patients (1.3% for group A and 2% for group B). No differences in infection complications and febrile morbidity were found between the two groups. Conclusion: Postoperative infection complications in laparoscopic gynecologic surgery without antimicrobial prophylaxis are negligible and overlapping to those obtained with cefazolin prophylaxis.

Optimal dose of preoperative enteral immunonutrition for patients with esophageal cancer

A preoperative immunonutrition pharmaceutics diet (IMPACT) significantly reduced the incidence of postoperative infectious complications, but the optimal regimen still remains unclear. We evaluated the optimal dose of a preoperative IMPACT for patients with esophageal carcinoma and the incidence of postoperative complications based on the dose of IMPACT. This study design was a prospective nonrandomized study. Twenty patients with thoracic esophageal carcinoma who underwent a right transthoracic subtotal esophagectomy were divided into two groups. These patients were administered immunonutrition of 500 ml/day (IMP500) or 1000 ml/day (IMP1000) for 7 days before the operation. The incidence of postoperative mortality and morbidity was not different between the IMP500 group and the IMP1000 group. No difference was observed in the perioperative changes in inflammatory, immunological and nutritional variables between the two groups. There were no adverse effects in the IMP500 group, but four patients (40%) had diarrhea and four patients (40%) had appetite loss in the IMP1000 group. In the IMP1000 group, only four patients (40%) could take 1000 ml, but others reduced the quantity of IMPACT because of diarrhea and discomfort. This study suggests that 500 ml of IMPACT is recommended as an optimal dose for patients with esophageal cancer.

Risk factors and predictors for surgical site infection after hepatic resection

Strict control of blood glucose levels with insulin in a surgical intensive care unit reduces postoperative morbidity and mortality. The aim of this study was to identify risk factors and the predictors for the prevention of surgical site infection (SSI) in a consecutive series of hepatectomised cases in a single institution. The association between SSI and various clinical parameters was investigated in 152 patients who underwent hepatic resection at Kochi Medical School from January 2000 through March 2007. The incidence of SSI in these patients was 14.5%. Multivariate analysis identified four independent parameters correlating with the occurrence of SSI: (i) body mass index >23.6 kg/m(2); (ii) estimated blood volume loss >810 mL; (iii) presence of postoperative bile leakage of organ/space SSI; and (iv) use of the sliding scale method for postoperative glucose control. There was no observed SSI after liver resection in the group whose postoperative blood glucose levels were controlled by an artificial pancreas. This study reveals that lack of postoperative glycaemic control is associated with a significantly higher incidence of postoperative infectious complications and longer hospitalisation. Obesity and the level of intraoperative estimated blood loss and bile leakage after hepatic resection are also risk factors with predictive value for SSI. Artificial pancreas is a safe and beneficial device to perform postoperative strict glycaemic control without hypoglycaemia for patients who undergo hepatic resection for liver diseases.

Attenuation of the Systemic Inflammatory Response and Infectious Complications After Gastrectomy with Preoperative Oral Arginine and ω‐3 Fatty Acids Supplemented Immunonutrition

Past trials have shown perioperative immunonutrition to improve the outcome for patients with gastric cancer. The present study was designed to evaluate the effect of preoperative oral immunonutrition on cellular immunity, the duration of the systemic inflammatory response syndrome (SIRS), and detailed postoperative complications in patients with gastric cancer. Sixty patients with gastric cancer were randomly assigned to two groups: one group received immune-enhanced formulas supplemented with arginine and omega-3 fatty acids (immune-enhancing diet (ID) group, n = 30); the other received standard formulas (conventional diet (CD) group, n = 30) for 7 days before the operation. These groups were well matched in terms of age, sex, operations, cancer stages, and intraoperative variables. The postoperative outcome was evaluated based on clinical variables, including postoperative infectious complications, noninfectious complications, and SIRS duration. In addition, the perioperative state of cellular immunity was evaluated and compared between the two groups. The incidence of postoperative infectious complications in the ID group (6%) was significantly (p < 0.05) lower than that of the CD group (28%). The duration of SIRS in the ID group (0.77 +/- 0.9 days) was significantly (p < 0.05) shorter than that in the CD group (1.34 +/- 1.45 days). The postoperative lymphocyte and CD4(+)T-cell counts significantly decreased (p < 0.05) in both groups. However, the number of CD4(+)T-cells on preoperative day 1 and postoperative day 7 was significantly (p < 0.05) higher in the ID group than in the CD group. Preoperative oral immune-enhanced formulas supplemented with arginine and omega-3 fatty acids enhanced the immune status of the patients, reduced the duration of SIRS, and decreased the incidence of postoperative infectious complications. CD4(+)T-cell immunity likely played an important role in the modulation of the postoperative immune and inflammatory response after gastrectomy.

Randomized Clinical Trial of the Effects of Perioperative Use of Immune‐enhancing Enteral Formula on Metabolic and Immunological Status in Patients Undergoing Esophagectomy

Although perioperative immune-enhancing enteral formula (IEEF) is effective to decrease the rate of infectious complications, it is not clear whether perioperative use of IEEF decreases the incidence of postoperative complications and improves clinical outcome in patients who have undergone esophagectomy. A prospective randomized clinical trial was performed to examine the effects of perioperative IEEF on nutritional and immunological status in patients with esophageal carcinoma who have been treated with esophagectomy. A total of 30 patients were randomly assigned to two groups, each receiving 3 days of preoperative and postoperative enteral nutrition through jejunostomy started within 24 h after operation, either with immune-enhancing enteral formula (group IEEF, n = 16) or with regular polymeric enteral formula (group C, n = 14). Preoperative and postoperative nutritional and immunological parameters and clinical outcome were examined. A significant increase in the serum concentration of ornithine was noted in group IEEF and it peaked at 5 days after surgery. The equivalent values were significantly lower in group C. There was no difference in serum dochosahexaic acid between the two groups. The n-3/n-6 fatty acid ratio in group IEEF was significantly higher than in group C at 7 days after surgery. Peripheral percent lymphocyte fraction and total lymphocyte count in group IEEF were both significantly higher than those in group C. While T cell fraction of peripheral lymphocytes in group IEEF at 3 days after surgery, B cell fraction in group IEEF at 5 and 7 days after surgery was significantly higher than those in group C, suggesting that perioperative IEEF caused a shift towards B cell proliferation. Perioperative use of IEEF caused a significant increase in the total lymphocyte count at 3 and 5 days after operation and caused a shift toward B cell proliferation, which may possibly be beneficial to decrease the incidence of postoperative infectious complications.

Perioperative Synbiotic Treatment to Prevent Postoperative Infectious Complications in Biliary Cancer Surgery

Use of synbiotics has been reported to benefit human health, but clinical value in surgical patients remains unclear. To investigate the effect of perioperative oral administration of synbiotics upon intestinal barrier function, immune responses, systemic inflammatory responses, microflora, and surgical outcome in patients undergoing high-risk hepatobiliary resection. Patients with biliary cancer involving the hepatic hilus (n = 101) were randomized before hepatectomy, into a group receiving postoperative enteral feeding with synbiotics (group A); or another receiving preoperative plus postoperative synbiotics (group B). Lactulose-mannitol (L/M) ratio, serum diamine oxidase (DAO) activity, natural killer (NK) cell activity, interleukin-6 (IL-6), fecal microflora, and fecal organic acid concentrations were determined before and after hepatectomy. Postoperative infectious complications were recorded. Of 101 patients, 81 completed the trial. Preoperative and postoperative changes in L/M ratio and DAO activity were similar between groups. Preoperatively in group B, NK activity, and lymphocyte counts increased, while IL-6 decreased significantly (P < 0.05). Postoperative serum IL-6, white blood cell counts, and C-reactive protein in group B were significantly lower than in group A (P < 0.05). During the preoperative period, numbers of Bifidobacterium colonies cultured from and total organic acid concentrations measured in feces increased significantly in group B (P < 0.05). Postoperative concentrations of total organic acids and acetic acid in feces were significantly higher in group B than in group A (P < 0.05). Incidence of postoperative infectious complications was 30.0% (12 of 40) in group A and 12.1% (5 of 41) in group B (P < 0.05). Preoperative oral administration of synbiotics can enhance immune responses, attenuate systemic postoperative inflammatory responses, and improve intestinal microbial environment. These beneficial effects likely reduce postoperative infectious complications after hepatobiliary resection for biliary tract cancer.

Reduced hepatic acute-phase response after simultaneous resection for gastrointestinal cancer with synchronous liver metastases.

Serum cytokines and hepatic acute-phase responses were studied in seven patients undergoing simultaneous resection of primary gastrointestinal cancer and synchronous metastatic liver tumours and in 12 undergoing partial hepatectomy alone for metachronous hepatic metastases. The incidence of postoperative infectious complications was significantly higher after simultaneous resection than after partial hepatectomy alone (P < 0.05). Although the peak interleukin 6 level was significantly higher after simultaneous resection (P < 0.05), plasma levels of acute-phase proteins were significantly lower (P < 0.05). The results suggest that simultaneous resections further reduce the hepatic acute-phase response and render patients liable to infection compared with partial hepatectomy alone, and result in a higher incidence of postoperative infective complications.

Serum monocyte chemoattractant protein-1 in patients with postoperative infectious complications from gastrointestinal surgery for cancer.

We examined the kinetics of serum monocyte chemoattractant protein-1 (MCP-1) perioperatively and clarified its significance regarding the development of infectious complications. We studied 94 patients who underwent gastrointestinal surgery for gastric or colorectal cancer at Mie University Hospital from 1996 to 2000. Serum concentrations of MCP-1 and interleukin-6 (IL-6) were measured perioperatively. The number of circulating lymphocytes and neutrophils were counted to assess the apoptotic rate of neutrophils. Patients were divided into two groups at the median preoperative MCP-1 level obtained from 40 gender- and age-matched healthy volunteers. The rate of developing infectious complications was significantly higher and tumor size was significantly larger in the low MCP-1 group than in the high MCP-1 group. The increasing IL-6 ratio (postoperative/preoperative IL-6 level) in the low MCP-1 group was about twofold greater than that in the high MCP-1 group. The neutrophil level calculated for the low MCP-1 group was significantly higher than that in the high MCP-1 group on postoperative day 3. We concluded that a decreased level of serum MCP-1 reflected tumor-related immunosuppression. Low MCP-1 levels were associated with an exaggerated postoperative IL-6 response and delayed neutrophil apoptosis, which affected the incidence of postoperative infectious complications developing in patients with gastrointestinal malignancies.

Nutrition support to patients undergoing gastrointestinal surgery.

Nutritional depletion has been demonstrated to be a major determinant of the development of post-operative complications. Gastrointestinal surgery patients are at risk of nutritional depletion from inadequate nutritional intake, surgical stress and the subsequent increase in metabolic rate.Fears of postoperative ileus and the integrity of the newly constructed anastomosis have led to treatment typically entailing starvation with administration of intravenous fluids until the passage of flatus. However, it has since been shown that prompt postoperative enteral feeding is both effective and well tolerated. Enteral feeding is also associated with specific clinical benefits such as reduced incidence of postoperative infectious complications and an improved wound healing response. Further research is required to determine whether enteral nutrition is also associated with modulation of gut function.Studies have indicated that significant reductions in morbidity and mortality associated with perioperative Total Parenteral Nutrition (TPN) are limited to severely malnourished patients with gastrointestinal malignancy. Meta-analyses have shown that enteral nutrition is associated with fewer septic complications compared with parenteral feeding, reduced costs and a shorter hospital stay, so should be the preferred option whenever possible.Evidence to support pre-operative nutrition support is limited, but suggests that if malnourished individuals are adequately fed for at least 7–10 days preoperatively then surgical outcome can be improved.Ongoing research continues to explore the potential benefits of the action of glutamine on the gut and immune system for gastrointestinal surgery patients. To date it has been demonstrated that glutamine-enriched parenteral nutrition results in reduced length of stay and reduced costs in elective abdominal surgery patients. Further research is required to determine whether the routine supplementation of glutamine is warranted.A limitation for targeted nutritional support is the lack of a standardised, validated definition of nutritional depletion. This would enable nutrition support to be more readily targeted to those surgical patients most likely to derive significant clinical benefit in terms of improved post-operative outcome.

Active observation of children with possible appendicitis does not increase morbidity.

Attempts to maximise diagnostic accuracy and reduce unnecessary surgery have led to the hospital observation of children with suspected appendicitis but unconvincing physical signs. However, morbidity associated with perforation necessitates the prompt management of acute appendicitis and increases anxiety concerning prolonged preoperative observation. To assess the preoperative delay and subsequent complications associated with active observation of appendicitis, we reviewed the records of 378 children who had an appendicectomy performed at the Women's and Children's Hospital during a 4-year period. Active observation was associated with an overall diagnostic accuracy of 93%. The mean preoperative hospital time was 12 h. The incidence of gangrene or perforation was 32%, with a mean preoperative hospital time in this group of 7 h. In view of the short preoperative waiting time in this group, we do not believe perforation in hospital to have been a frequent occurrence. The overall incidence of postoperative infective complications was 4%, with an incidence of 12% following perforation. Children with advanced disease often have convincing signs on presentation and are not usually subjected to a significant delay. Active observation is not associated with high postoperative morbidity.

Laparoscopic Appendectomy Does Not Change the Incidence of Postoperative Infectious Complications

Background: It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. Methods: One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position. Results: Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group ( P = 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P = 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA ( P = 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA ( P = 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. Conclusions: Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications.

Blood Transfusion: What Does It Mean to the Surgeon?

In addition to organ transplantation, the immunomodulating effect of allogeneic blood transfusion might also have consequences for patients with malignancies or other surgical patients requiring blood transfusion. It has been suggested that this effect of allogeneic blood transfusion could adversely affect the prognosis of patients with a malignant disorder or increase the susceptibility for postoperative infections. These deleterious effects of allogeneic blood transfusion, which are suspected to be mediated by the induction of immunosuppression are further discussed in this review. We conclude that, whenever a detrimental effect of blood transfusions on cancer prognosis or the incidence of postoperative infectious complications exists, this relationship is not causal, but reflects the circumstances which necessitate the transfusion.

Single-dose cefminox versus triple-dose cefoxitin as antimicrobial prophylaxis in surgical treatment of patients with colorectal cancer

The efficacy of single-dose cefminox versus multiple-dose cefoxitin as antimicrobial prophylaxis in surgical treatment for colorectal cancer was compared in a prospective, randomized, single-masked, Phase III clinical trial. A total of 124 patients were entered into the study, and 31 were withdrawn after randomization. Of the 93 assessable patients, 47 received cefminox (2 g intravenously at induction of anesthesia) and 46 received cefoxitin (2 g intravenously at induction of anesthesia with subsequent doses 4 and 8 hours later). The incidence of postoperative infectious complications was similar in both groups: wound infection, 5 patients (10.6%) with cefminox and 3 (6.5%) with cefoxitin; intra-abdominal infection, 1 (2.1%) in the cefminox group and 1 (2.2%) in the cefoxitin group. Adverse events were few, and we found no statistical difference between antibiotic regimens. We concluded that single-dose cefminox 2-g monotherapy offers good prophylaxis in elective colorectal surgery. In this setting, cefminox is as effective as cefoxitin 6 g (2 g/4 h).

Oral ciprofloxacin as prophylaxis in gastroduodenal surgery

One hundred and fifty patients undergoing gastroduodenal surgery were randomly allocated to receive intravenous (iv) cefuroxime, iv ciprofloxacin or oral ciprofloxacin as prophylaxis. There were no differences in the incidence of postoperative infection complications or duration of stay among the three groups. Oral ciprofloxacin offers obvious advantages in terms of ease of administration and cost.

Post-operative urinary tract infection and wound infection in women undergoing Caesarean section: a comparison of two study periods in 1985 and 1987

In 1985 and 1987 women undergoing Caesarean section were studied for the development of post-catheterization bacteriuria, urinary tract infection and wound infection. In 1985, 34% developed bacteriuria compared to 25% in 1987. Post-catheterization bacteriuria within two days was reduced by improved catheterization techniques. Late urinary tract infection after 5 days occurred in 2% of women in 1985 and 6% in 1987. The commonest bacteria were Escherichia coli and enterococci. Post-catheterization bacteriuria was only confirmed in a second urine specimen in 53%. The incidence of wound infection was 20% in 1985 and 15.8% in 1987 but bacterial pathogens were only isolated from 12.5% and 5.1% respectively. Staphylococcus aureus was isolated in 60%) of infected women. Antimicrobial usage was high in this group of women at 41% in 1985 and 27% in 1987. A significant reduction of usage from 37% to 16% was seen in bacteriologically confirmed infections where the laboratory reports were only issued after examination of a second specimen. However most symptomatic women received treatment. The incidence of post-operative infective complications is high in women having Caesarean section. Careful urethral catheterization techniques are necessary to prevent bacteriuria.

Clinical Characteristics of Anaerobic Bactibilia

During a two-year period, 1,892 patients underwent biliary tract surgery at the Mayo Clinic. Both aerobic and anaerobic bile cultures were performed in 371 patients and 253 of these were positive. Anaerobes were isolated from 100 patients, although only twice in pure culture. Only aerobes grew from cultures from 153 patients. One hundred cases of biliary tract infections involving anaerobes and an equal number involving aerobes only were reviewed in order to determine their clinical characteristics. Prominent features of anaerobic bactibilia included (1) a history of complex, multiple, biliary tract surgeries often involving biliary-intestinal anastomoses and common bile duct manipulation, (2) severe symptoms, (3) high incidence of postoperative infectious complications, especially wound infections. Further analysis of anaerobic biliary infections suggested that Bacteroides fragilis was more often associated with serious pathologic conditions of the biliary tract than was Clostridium.