Structured CT reporting improves accuracy in diagnosing internal herniation after laparoscopic Roux-en-Y gastric bypass

Objectives: To confirm that structured reporting of CT scans using ten signs in clinical practice leads to a better accuracy in diagnosing internal herniation (IH) after gastric bypass surgery, compared with free-text reporting. Methods: In this prospective study, CT scans between June 1, 2017, and December 1, 2018, were included from a cohort of 2606 patients who had undergone laparoscopic gastric bypass surgery between January 1, 2011, and January 1, 2018. The CT scans were made for a suspicion of IH and structured reports were made using a standardised template with ten signs: (1) swirl sign, (2) small-bowel obstruction, (3) clustered loops, (4) mushroom sign, (5) hurricane eye sign, (6) small bowel behind the superior mesenteric artery, (7) right-sided anastomosis, (8) enlarged nodes, (9) venous congestion, and (10) mesenteric oedema. Furthermore, an overall impression of IH likelihood was given using a 5-point Likert scale. CT scans performed in 2011 until 2017, without structured reporting, were included for comparison. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated using two-way contingency tables; the chi-square test was used for calculating p value. Reoperation and 3-month follow-up were used as reference. Results: A total of 174 CT scans with structured reporting and 289 CT scans without structured reporting were included. Sensitivity was 81.3% (95% CI, 67.7–94.8%) and 79.5% (95% CI, 67.6–91.5%), respectively (p = 0.854); specificity was 95.8% (95% CI, 92.5–99.1%) and 88.6% (95% CI, 84.6–92.6%), respectively (p = 0.016); PPV was 81.3% (95% CI, 67.7–94.8%) and 55.6% (95% CI, 43.3–67.8%), respectively (p = 0.014); NPV was 95.8% (95% CI, 92.5–99.1%) and 96.0% (95% CI, 93.5–98.6%), respectively (p = 0.909); and accuracy was 93.1% (95% CI, 88.0–96.2%) and 87.2% (95% CI, 82.7–90.7%), respectively (p = 0.045). Conclusion: Structured reporting for the diagnosis of internal herniation after gastric bypass surgery improves accuracy and can be implemented in clinical practice with good results. Key Points: • Ten signs are used to aid CT diagnosis of internal herniation after gastric bypass surgery. • Structured reporting increases specificity and positive predictive value and thereby prevents unnecessary reoperations in patients without internal herniation. • Structured reporting by means of a standardised template can help less experienced readers

Early decreased neutrophil responsiveness is related to late onset sepsis in multitrauma patients: An international cohort study

<div><p>Background</p><p>Severe trauma can lead to the development of infectious complications after several days, such as sepsis. Early identification of patients at risk will aid anticipating these complications. The aim of this study was to test the relation between the acute (<24 hours) inflammatory response after injury measured by neutrophil responsiveness and the late (>5 days) development of septic complications and validate this in different trauma populations.</p><p>Methods and findings</p><p>Two prospective, observational, cohort series in the Netherlands and South Africa, consisting of severely injured trauma patients. Neutrophil responsiveness by fMLF-induced active FcγRII was measured in whole blood flowcytometry, as read out for the systemic immune response within hours after trauma. Sepsis was scored daily. Ten of the 36 included Dutch patients developed septic shock. In patients with septic shock, neutrophils showed a lower expression of fMLF-induced active FcγRII immediately after trauma when compared to patients without septic shock (P = 0.001). In South Africa 11 of 73 included patients developed septic shock. Again neutrophils showed lower expression of fMLF induced active FcγRII (P = 0.001). In the combined cohort, all patients who developed septic shock demonstrated a decreased neutrophil responsiveness.</p><p>Conclusions</p><p>Low responsiveness of neutrophils for the innate stimulus fMLF immediately after trauma preceded the development of septic shock during admission by almost a week and did not depend on a geographical/racial background, hospital protocols and health care facilities. Decreased neutrophil responsiveness appears to be a prerequisite for septic shock after trauma. This might enable anticipation of this severe complication in trauma patients.</p></div