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Failure to Develop a Physiologic Postoperative Inflammatory Response is Associated with Infectious Complications Following Cancer Surgery
*Tristen T Chun, *Andrew M Blakely, William G Cioffi, Thomas J Miner, Daithi S Heffernan
Rhode Island Hospital, Providence, RI
Objective: Normal physiological responses to stress include the development of post-operative leukocytosis, a component of the SIRS response. Cancer, an immunosuppressive state, may preclude normal physiological responses to surgical stress, thereby making cancer patients more susceptible to post-operative infectious complications. We hypothesized that cancer patients displaying attenuated or absent post-operative leukocytosis are prone to developing infectious complications after surgery.
Design: Five-year retrospective review of demographics, co-morbidities, pre- and post-operative white cell counts (WCC). Pneumonia was diagnosed by bronchoalveolar lavage >10,000cfu, UTI by culture >100,000cfu, other infections by CDC criteria and cultures.
Setting: Tertiary referral hospital.
Patients: Cancer patients across all surgical specialties who underwent operation, excluding those who received neoadjuvant chemotherapy.
Interventions: None.
Main Outcome Measures: Post-operative infectious complications.
Results: 592 patients were reviewed; 62% manifested post-operative leukocytosis. Overall infection rate was 13.6% (most commonly UTI, SSI). Patients who did versus did not develop leukocytosis did not differ by age (67.9+/-1.1 versus 70.4+/-1.4; p=0.2) or male gender (59% versus 55%; p=0.5). Patients who failed to develop leukocytosis had markedly higher rate of post-operative infections (22% versus 10.3%; p=0.02). Furthermore, patients who developed post-operative infections had significantly diminished increase in WCC from pre-operative level to postoperative-day 1 (3.9+/-0.7 versus 5.5+/-0.3; p=0.049). Adjusting for age, gender and pre-existing diabetes, failure to develop early post-operative leukocytosis was associated with increased risk of infectious complications (OR 2.3 [95%CI=1.1-5.1]).
Conclusions: Dampened or absent post-operative inflammatory response to surgical stress in cancer patients is associated with subsequent infectious complications. Future surgical oncology research must better characterize immune reserves. Current efforts to maximize immune reserve, such as diet, exercise and avoidance of unnecessary blood transfusion and antibiotics use should be emphasized.
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