Postoperative CD4 counts predict anastomotic leaks in patients with penetrating abdominal trauma

Abstract

Introduction The influence of trauma-and surgical stress-induced decrease of CD4 count on anastomotic leaks after penetrating abdominal trauma has to date not been investigated. A prospective study was performed to explore the effect of CD4 count 24 hours after surgery on the anastomotic leak rate and to identify risk factors for anastomotic leaks. Methods This was a prospective study including 98 patients with small or large bowel resection and subsequent anastomosis due to penetrating abdominal trauma. Univariate analysis identified risk factors for the development of anastomotic leak and also investigated the predictive value of the CD4 count for this complication. Results Of the 98 patients 23 patients (23%) were HIV-infected. The overall leak rate was 13%. Univariate analysis including all potential risk factors with p-values<0.05 identified six factors leading to a significantly higher rate of anastomotic complications: postoperative CD4 count<250 cells/l, postoperative albumin <30 g/L, penetrating abdominal trauma index25, gunshot wound as mechanism of injury, blood transfusion requirement >6units and delayed anastomosis after damage control surgery. Survival rates were analysed with the χ 2 test and did not show a significantly higher mortality rate in patients with low CD4 count. The negative impact of trauma and subsequent surgery on the cell mediated immunity was demonstrated by the fact that 55 (73%) of the HIV-negative patients had a CD4 count less than 500 cells/l 24 hours postoperatively. HIV-infection had no significant influence on the leak rate, however all HIV infected patients that developed an anastomotic leak died. Conclusion A low post-operative CD4 count is a predictor for anastomotic leaks irrespective of HIV-serostatus. Low postoperative serum albumin, high injury severity, gunshot wound as mechanism of injury, blood transfusion requirement >6 units and delayed anastomosis were further risk factors for anastomotic complications. Postoperative CD4 count and serum albumin should be considered in the decision making process of performing an anastomosis or diverting stoma for patients after "clip and drop" of the bowel as part of damage control surgery.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

“…Small bowel continuity is preferable to diversion, however, the occurrence of an anastomotic leak in a trauma patients is linked to a steep increase in mortality (46% versus 1% in patients with or without an anastomotic leak, respectively; p < 0.001) [ 86 ]. The risks must be carefully weighted.…”

[Retracted] Analysis of Expression of Inflammatory Factors and T Cell Lymphocyte in Patients with Orthopedic Trauma after Infection and Risk Factors

“…erefore, when infection occurs, it indicates that the cellular immunity of human body cannot effectively eliminate the invasion of foreign microorganisms, indicating that the overall cellular immune status is poor, so the detected expression rate of CD3 is relatively low [16]. As the main immune response cell, CD4 can assist the body in antitumor immunity to a certain extent [17]. As suppressor T cells, CD8 has the ability to inhibit CD4 and B cells, and at the same time inhibits cellular immune response to a certain extent.…”

Compound volvulus: An unexpected surgical finding

“…Subsequently to the patient's surgery, the HIV status was found with a CD4 count of 29, despite being immunocompromised, there were no complications with regards to his anastomosis. At the same facility a postoperative CD4 count was found to be predictive of anastomotic leak rates regardless of HIV serostatus, however this study was done in patients sustaining penetrating abdominal trauma 8 . At our facility we operate on many HIV positive patients and therefore knowing the status preoperatively may not have changed intra-operative decision making, one has to consider the morbidity of a high output ileostomy and an anastomotic leak as well as the access to healthcare institutions.…”