The prognostic impact of abdominal surgery in cancer patients with neutropenic enterocolitis: a systematic review and meta-analysis, on behalf the Groupe de Recherche en Réanimation Respiratoire du patient d’Onco-Hématologie (GRRR-OH)

Abstract

Neutropenic enterocolitis (NE) is a diagnostic and therapeutic challenge associated with high mortality rates, with controversial opinions on its optimal management. Physicians are usually reluctant to select surgery as the first-choice treatment, concerns being raised regarding the potential risks associated with abdominal surgery during neutropenia. Nevertheless, no published studies comforted this idea, literature is scarce and surgery has never been compared to medical treatment. This review and meta-analysis aimed to determine the prognostic impact of abdominal surgery on outcome of neutropenic cancer patients presenting with NE, versus medical conservative treatment. This meta-analysis included studies analyzing cancer patients presenting with NE, treated with surgical or medical treatment, searched by PubMed and Cochrane databases (1983–2016), according to PRISMA recommendations. The endpoint was hospital mortality. Fixed-effects models were used. The meta-analysis included 20 studies (385 patients). Overall estimated mortality was 42.2% (95% CI = 40.2–44.2). Abdominal surgery was associated with a favorable outcome with an OR of 0.41 (95% CI = 0.23–0.74; p = 0.003). Pre-defined subgroups analysis showed that neither period of admission, underlying malignancy nor neutropenia during the surgical procedure, influenced this result. Surgery was not associated with an excess risk of mortality compared to medical treatment. Defining the optimal indications of surgical treatment is needed.Trial registration PROSPERO CRD42016048952

ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

“…Blood cultures and respiratory cultures should be obtained and sinus, head, chest, and abdominal imaging performed as indicated [14,15]. Abdominal pain or diarrhea associated with fever suggests neutropenic enterocolitis (typhlitis) which can lead to intestinal necrosis [28,29]. In the hemodynamically unstable patient with a central venous catheter, early catheter removal is associated with improved survival [19]; infected or potentially infected catheters should be removed without delay.…”

Neutropenic Enterocolitis in the Treatment of Solid Tumors: A Case Report and Review of the Literature

“…In the absence of clinical benefit and in the presence of hemodynamic changes, the patient should be rapidly discussed with the surgeon for re-evaluation and possible surgery [21,37,38]. It has been reported that the presence of neutropenia should not be considered as a contraindication to surgery [39]. The mortality rate is high (32-50%), although it has been improving in recent years thanks to more efficient medical treatments [13].…”

Factors associated with emergent colectomy in patients with neutropenic enterocolitis

“…Formerly referred to as typhlitis (from the Greek typhlon, or cecum), neutropenic enterocolitis (NEC) is a serious complication of neutropenia. It is characterized by segmental ulceration and intramural inflammation with necrosis of the gut (especially in the ileal-cecum-ascending colon area) [2,3]. NEC was first described in the 1970s as a complication of the treatment of childhood leukemias [4][5][6].…”

“…It occurs most frequently after intensive chemotherapy in acute leukemias [7]. The actual incidence of NEC is unknown, and reports range from 0.8 to 26% [2,3,7]. NEC is considered as the most common gastrointestinal infection related to neutropenia [8].…”

“…The precise pathogenesis of NEC is undefined [8]. The proposed pathogenesis is immunosuppression secondary to neutropenia, in conjunction with chemotherapy cytotoxicity, tumor infiltration, and inflammatory reaction, which lead to direct mucosal injury, loss of gut barrier function, and microbial translocation [2,3]. Following the microbial invasion, production and release of bacterial endotoxins result in inflammation, edema, ulceration, transmural necrosis, perforation, and septic shock [8].…”