title: Decreased endotoxin immunity is associated with greater mortality and/or prolonged hospitalization after surgery.
abstract: BACKGROUND
  Patients undergoing noncardiac surgery often develop postoperative morbidity, potentially attributable to endotoxemia and the systemic inflammatory response syndrome. Endogenous antibodies to endotoxin may confer protection from endotoxin-mediated toxicity. The authors sought to determine the association of preoperative antiendotoxin immunity and death or prolonged hospitalization in a broad population of general surgical patients undergoing major surgery.
  
  
  METHODS
  To test the hypothesis that low preoperative serum antiendotoxin core antibody (EndoCAb) concentration is an independent predictor of adverse outcome after general surgery, 1,056 patients undergoing routine noncardiac surgery were enrolled into a prospective, blinded, cohort study. Immunoglobulin M EndoCAb, immunoglobulin G EndoCAb, total inmunoglobulin M, and immunoglobulin G concentrations were measured in serum obtained preoperatively. A physiologic risk score using the established POSSUM criteria was assigned preoperatively to each patient. The primary predefined composite end point (postoperative complication) was either in-hospital death or postoperative length of stay greater than 10 days. Multivariate logistic regression was used to test the study hypothesis.
  
  
  RESULTS
  Overall, postoperative complication occurred in 234 of the 1,056 patients (22.1%). Lower immunoglobulin M EndoCAb concentration (P = 0.006) predicted increased risk of postoperative complication independent of POSSUM physiologic risk score (P < 0.001). In contrast, total immunoglobulin M and total immunoglobulin G concentrations did not predict adverse outcome. Complications involved multiple organ systems and were generally unrelated to the type or site of surgery, consistent with the systemic inflammatory response syndrome.
  
  
  CONCLUSIONS
  Adverse outcome after routine noncardiac surgery is common and is predicted in part by low concentrations of EndoCAb. The authors' findings suggest that endotoxemia may be a cause of postoperative morbidity after routine noncardiac surgery.
authors.affiliation: Department of Anesthesiology, The Mount Sinai School of Medicine, New York, New York, USA. eb413@columbia.edu
authors.forename: E
authors.initials: E
authors.lastname: Bennett-Guerrero
authors.forename: M H
authors.initials: MH
authors.lastname: Panah
authors.forename: G R
authors.initials: GR
authors.lastname: Barclay
authors.forename: C A
authors.initials: CA
authors.lastname: Bodian
authors.forename: W J
authors.initials: WJ
authors.lastname: Winfree
authors.forename: L A
authors.initials: LA
authors.lastname: Andres
authors.forename: D L
authors.initials: DL
authors.lastname: Reich
authors.forename: M G
authors.initials: MG
authors.lastname: Mythen
mesh_terms: D000328:Adult; D000368:Aged; D000906:Antibodies / Q000032:analysis*; D004311:Double-Blind Method; D004731:Endotoxins / Q000276:immunology*; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000032:analysis / Q000276:immunology; D007075:Immunoglobulin M / Q000032:analysis / Q000276:immunology; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000276:immunology* / Q000401:mortality*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome
chemical_list: D000906:Antibodies; D004731:Endotoxins; D007074:Immunoglobulin G; D007075:Immunoglobulin M