Thomas Steffen

Safe and early discharge after colorectal surgery due to C-reactive protein: a diagnostic meta-analysis of 1832 patients.

Objective:To assess the predictive value of C-reactive protein (CRP) level for postoperative infectious complications after colorectal surgery. Background:Postoperative infectious complications after colorectal surgery are frequent and associated with relevant short- and long-term sequelae. Therefore, the identification of a diagnostic tool for early recognition of postoperative infectious complications is of cardinal importance. Methods:A meta-analysis was performed for diagnostic studies evaluating CRP as a predictor for postoperative infectious complications on days 1 to 5 after colorectal surgery. Results:Six studies including a total of 1832 patients were identified. The best performance of CRP to predict postoperative infectious complications was on postoperative day 4, on which the mean CRP cutoff value was 135 mg/L (SD: 10 mg/L), the pooled sensitivity 68% (95% CI: 57%–79%), the specificity 83% (95% CI: 77%–90%) and the negative predictive value 89% (95% CI: 87%–92%). The pooled area under the receiver operating characteristic curve was 0.81 (95% CI: 0.73–0.89). Conclusions:This diagnostic meta-analysis of 1832 patients-–the first in the literature–-provides compelling evidence that C-reactive protein on postoperative day 4 has a high negative predictive value for infectious complications of 89%. Therefore, CRP measurement allows safe and early discharge of selected patients after colorectal surgery.

Diagnostic accuracy of C-reactive protein and white blood cell counts in the early detection of inflammatory complications after open resection of colorectal cancer: a retrospective study of 1,187 patients.

Purpose nAlthough widely used, there is a lack of evidence concerning the diagnostic accuracy of C-reactive protein (CRP) and white blood cell counts (WBCs) in the postoperative period. The aim of this study was to evaluate the diagnostic accuracy of CRP and WBCs in predicting postoperative inflammatory complications after open resection of colorectal cancer.

Functional outcome and quality of life after stapled transanal rectal resection for obstructed defecation syndrome.

PURPOSE: Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure. METHODS: Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey. RESULTS: Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9–22) to 5 (range, 2–10) and the severity of symptoms score, from 16 (range, 9–21) to 4 (range, 0–9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components. CONCLUSION: Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.

Rectocele and intussusception: is there any coherence in symptoms or additional pelvic floor disorders?

BackgroundPatients with a rectocele often suffer from such symptoms as obstructed defaecation, urine or stool incontinence and pain. The aim of this study was to assess other concomitant pelvic floor disorders and their influence on pelvic function.MethodsIncluded in the study were 37 female patients with a significant rectocele and defaecation disorder. Medical history and symptoms were analysed in terms of validated functional scores. All patients underwent open magnetic resonance defaecography (MRD) in a sitting position. Imaging was analysed for the presence and size of the rectocele, intussusception and other pelvic floor disorders.ResultsPatients with a higher body mass index tended to have a larger rectocele, whereas age and vaginal birth did not correlate with the size of the rectocele. In 67.5% of the patients with a previously diagnosed recto cele, an intussusception was diagnosed on MRD. This group suffered from significantly worse urine incontinence (p=0.023) and from accessory enteroceles 64%, compared with 17% (p=0.013) for those with a simple rectocele. Patients with higher grade intussusception suffered more frequently from incontinence than from constipation.ConclusionPatients with a symptomatic rectocele frequently have other pelvic floor disorders that significantly influence the pattern of symptoms. Knowledge of all the afflictions is essential for determining the optimal treatment for each individual patient.

Perioperative blood transfusions do not impact overall and disease-free survival after curative rectal cancer resection: a propensity score analysis.

Objective:To assess the putative impact of perioperative blood transfusions on overall and disease-free survival in patients undergoing curative resection of stage I–III rectal cancer by applying propensity-scoring methods. Background:Whether perioperative blood transfusions negatively impact survival remains a matter of great debate. Methods:In a single-center study, 401 patients undergoing open curative resection of stage I–III rectal cancer between 1996 and 2008 were assessed. The median follow-up was 34.2 months. Patients who did and did not receive perioperative blood transfusions were compared using Cox regression and propensity score analyses. Results:Overall, 217 patients (54.1%) received blood transfusions. Patients characteristics were highly biased concerning transfusions (propensity score 0.77 ± 0.23 vs. 0.28 ± 0.25; P < 0.001). In unadjusted analysis, blood transfusions were associated with a 119% increased risk of mortality [hazard ratio (HR): 2.19, 95% confidence interval (CI): 1.34–3.57, P = 0.001]. In propensity score-adjusted Cox regression (HR: 1.02, 95% CI: 0.65–1.58, P = 0.970), blood transfusions did not increase the risk of overall survival. Similarly, in propensity score-adjusted Cox regression (HR: 0.86, 95% CI: 0.60–1.23, P = 0.672), blood transfusions were not associated with an increased risk of recurrence. Conclusions:This is the first propensity score-based analysis providing compelling evidence that worse oncological outcomes after curative rectal cancer resection in patients receiving perioperative blood transfusions are caused by the clinical circumstances requiring transfusions, not due to the blood transfusions themselves. Therefore, concerns about overall and disease-free survival should be no issue in the decision-making regarding perioperative blood transfusions in patients undergoing curative rectal cancer resection.

Bilateral Superficial Cervical Plexus Block in Combination with General Anesthesia Has a Low Efficacy in Thyroid Surgery: A Meta-Analysis of Randomized Controlled Trials

BACKGROUNDnA combination of bilateral superficial cervical plexus block (BSCPB) and general anesthesia is recommended for thyroid surgery. Proof of the efficacy of this combination remains weak. Furthermore, data on the safety of this regimen are lacking. Therefore, a meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy and safety of BSCPB as an adjunct to general anesthesia in patients receiving thyroid surgery was performed.nnnMETHODSnA meta-analysis of RCT was performed that included interventional groups evaluating the efficacy of BSCPB 6 and 24 hours after thyroid surgery.nnnRESULTSnEight RCT, including a total of 799 patients (463 who underwent BSCPB and 336 controls), were analyzed. A meta-analysis demonstrated a reduction in pain scores 6 hours (Hedges g: -0.46 [95% CI: -0.74 to -0.19]; p=0.001) and 24 hours postoperatively (Hedges g: -0.49 [95% CI: -0.71 to -0.27]; p<0.001) in patients who had undergone BSCPB. The relative risk for postoperative nausea and vomiting (PONV) was 0.80 (95% CI: 0.58 to 1.09, p=0.159) in patients receiving BSCPB. Procedure-related adverse events were reported in three of the 476 patients who had undergone BSCPB (0.6%; 95% CI: 0.1% to 2.0%). These three patients had transient paresis of the brachial plexus, combined with a diaphragmatic paresis in one case, and all spontaneously resolved.nnnCONCLUSIONnThe combination of BSCPB and general anesthesia has a significant benefit in reducing pain 6 and 24 hours after thyroid surgery. However, the effect on pain reduction is too small to be of clinical relevance. Although it is a safe procedure, the existing evidence allows for no recommendation concerning the application of BSCPB in thyroid surgery. Further trials should evaluate a dose-response relationship and the incidence of PONV with this regimen.

Safety and reliability of Radio Frequency Identification Devices in Magnetic Resonance Imaging and Computed Tomography.

BackgroundRadio Frequency Identification (RFID) devices are becoming more and more essential for patient safety in hospitals. The purpose of this study was to determine patient safety, data reliability and signal loss wearing on skin RFID devices during magnetic resonance imaging (MRI) and computed tomography (CT) scanning.MethodsSixty RFID tags of the type I-Code SLI, 13.56 MHz, ISO 18000-3.1 were tested: Thirty type 1, an RFID tag with a 76 × 45 mm aluminum-etched antenna and 30 type 2, a tag with a 31 × 14 mm copper-etched antenna. The signal loss, material movement and heat tests were performed in a 1.5 T and a 3 T MR system. For data integrity, the tags were tested additionally during CT scanning. Standardized function tests were performed with all transponders before and after all imaging studies.ResultsThere was no memory loss or data alteration in the RFID tags after MRI and CT scanning. Concerning heating (a maximum of 3.6°C) and device movement (below 1 N/kg) no relevant influence was found. Concerning signal loss (artifacts 2 - 4 mm), interpretability of MR images was impaired when superficial structures such as skin, subcutaneous tissues or tendons were assessed.ConclusionsPatients wearing RFID wristbands are safe in 1.5 T and 3 T MR scanners using normal operation mode for RF-field. The findings are specific to the RFID tags that underwent testing.

Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction

Background and aimsAnastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage.Materials and methodsFifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3–4xa0cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively.Results/findingsNo influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (Pu2009=u20090.023).Interpretation/conclusionPatient’s safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.

Blood transfusion does not adversely affect survival after elective colon cancer resection: a propensity score analysis

PurposeThe aim of this study was to assess the putative impact of perioperative blood transfusions on overall survival in patients undergoing curative resection for stage III colon cancer by applying propensity scoring methods.MethodsIn a single-center study, a total of 309 patients who underwent open curative resection for stages I–III colon cancer from 1996–2008 were assessed. The mean follow-up period was 47u2009±u200938xa0months. Transfused and non-transfused patients were compared using both Cox regression and propensity score analyses.ResultsOverall, 148 patients (47.9xa0%) received blood transfusions. The patient characteristics were highly biased toward transfusions (propensity score 0.68u2009±u20090.22 vs. 0.30u2009±u20090.22, p <0.001). In the unadjusted analysis, blood transfusions were associated with a 90xa0% increased risk of overall mortality (hazard ratio 1.90, 95xa0% CI: 1.19–3.04, pu2009=u20090.001). The 5-year survival for patients receiving blood transfusions was 64.5xa0% (95xa0% CI: 56.0–74.3xa0%) compared with 80.1xa0% (95xa0% CI: 72.8–88.2xa0%) in those not receiving blood transfusions. In the propensity score-adjusted Cox regression analysis (hazard ratio: 0.85, 95xa0% CIu2009=u20090.53–1.37, pu2009=u20090.501), blood transfusions did not increase the risk of overall mortality. After risk adjustment, the 5-year survival rate for patients receiving blood transfusions was 66.6xa0% (95xa0% CI: 57.4–77.3xa0%) compared with 61.8xa0% (95xa0% CI: 51.9–73.7xa0%) for those who did not.ConclusionThis study is the first propensity score-based analysis that provides evidence that poor oncological outcomes after curative colon cancer resection in patients receiving perioperative blood transfusions are due to the clinical circumstances that require the transfusions and are not due to the blood transfusions.

The More the Better—Lower Rate of Stage Migration and Better Survival in Patients With Retrieval of 20 or More Regional Lymph Nodes in Pancreatic Cancer: A Population-Based Propensity Score Matched and Trend SEER Analysis

Objective The aim of this study was to assess the influence of regional lymph node (RLN) retrieval on stage migration and survival in pancreatic cancer. Methods A total of 7685 stage I and II pancreatic cancer patients were identified in the Surveillance, Epidemiology, and End Results database in 2004–2011. The impact of RLN was assessed using Cox regression, propensity score methods, and joinpoint regression. Results In 3079 patients, 1 to 10 RLNs were retrieved; in 2799 patients, 11 to 19 RLNs, and in 1807 patients, 20+ RLNs. The rate of node-positive pancreatic cancer increased with the number of retrieved RLN. This trend continued beyond 10 retrieved RLN (P < 0.001). In unadjusted analysis, retrieval of RLN did not influence survival (P = 0.178). When adjusting for significant bias in staging variables (P < 0.001), retrieval of 20+ RLNs compared to 11 to 19 RLNs was associated with an increased survival in node-negative (hazard ratio, 0.78; 95% confidence interval, 0.62–0.98; P = 0.033) and node-positive cancer (hazard ratio, 0.83; 95% confidence interval, 0.74–0.93; P = 0.002). Conclusions This population-based propensity score–adjusted investigation demonstrated that more retrieved RLNs in pancreatic cancer decreases the rate of stage migration and improves the oncological outcome in node-negative and positive cancer. Contradictory results may be explained by a bias in the cancer characteristics for a different extent of RLN retrieval.