Bruno Geier

Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients.

OBJECTIVE To determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT, Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outcome, i.e., reduced infectious and wound complications and decreased treatment costs when compared with an isocaloric, isonitrogenous control diet. DESIGN A prospective, randomized, placebo-controlled, double-blind, multicenter trial of the clinical outcome and a retrospective cost-comparison analysis. SETTING Surgical intensive care units in three different German university hospitals. PATIENTS Of 164 patients enrolled in the study, 154 patients were eligible for analysis. They were admitted to the intensive care unit after upper gastrointestinal surgery for cancer and they received an enteral diet via needle catheter jejunostomy. Infectious complications were defined as sepsis or systemic inflammatory response syndrome, pneumonia, urinary tract infection, central venous catheter sepsis, wound infection, and anastomotic leakage. The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth postoperative day) postoperative complications. The treatment costs of each complication were analyzed and compared in both groups. INTERVENTIONS Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postoperative day 5. MEASUREMENTS AND MAIN RESULTS Clinical examination and adverse gastrointestinal symptoms were recorded on a daily basis. Both groups tolerated early enteral feeding well, and the rate of tube feeding-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs. 24 patients in the control group (NS). Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 patients in the immunonutritional group vs. 11 patients in the control group). However, in the late phase (after postoperative day 5), considerably fewer patients in the experimental diet group experienced complications compared with the control group (5 vs. 13, p < .05). In addition, the frequency rate of complicating events were recorded in each group. In the experimental diet group, a total of 22 complicating events were recorded vs. a total of 32 events in the placebo diet group (NS). However, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced in the immunonutrition group when compared with the control group (8 vs. 17 events, p < .05). The total costs for the treatment of the complications were 83,563 German marks in the experimental diet group vs. 122,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks. (At the end of December 1995, the conversion rate from German marks to U.S. dollars was 1.4365 German marks to

Supplementation of Ω-3 Fatty Acids in Parenteral Nutrition Beneficially Alters Phospholipid Fatty Acid Pattern:

1.00.) CONCLUSIONS Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery. In patients who received the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was observed. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.

Pelvic Venous Incompetence: Reflux Patterns and Treatment Results

BACKGROUND The clinical safety and the uptake of ω-3 polyunsaturated fatty acids (PUFA) into the serum phospholipids and erythrocyte membranes after administration of fish-oil-supplemented parenteral nutrition (PN) was investigated in colorectal surgical patients. METHODS Forty patients undergoing colorectal surgery (n = 40) and with an indication for PN were enrolled in a prospective, double-blind, randomized study to receive an ω-3 PUFA-supplemented 20% lipid emulsion (Lipoplus; B. Braun Melsungen, Melsungen, Germany; test group, n = 19) for 5 days postoperatively. The control group received a standard 20% fat emulsion (Lipofundin MCT/LCT, B. Braun Melsungen, Melsungen, Germany, control group, n = 21). Clinical outcome parameters and safety were assessed by means of adverse events recording clinical parameters and hematologic analyses. The contents of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as arachidonic acid (AA), in phospholipid fractions in plasma and in erythrocytes were analyzed preoperatively, on postoperative days 1, 6, and 10 using liquid gas chromatography. RESULTS Both fat emulsions were well tolerated, and none of the adverse events was considered to be related to treatment. Postoperative infectious complications occurred in 4 patients of the ω-3 PUFA group vs 7 patients in the control group. As compared with the control group, the ω-3 PUFA group had significantly increased levels of EPA in the membranes of the erythrocytes in postoperative day 6 (2.0% ± 0.9% vs 0.8% ± 0.5% fatty acid methyl esters, [FAME]) and postoperative day 10 (2.1% ± 0.8% vs 0.9%± 0.7% FAME, p < .05). Also, the EPA levels in the serum phospholipids were significantly higher than in the control group on the same postoperative days (7.0% ± 2.6% vs 1.3% ± 0.8% and 3.6%± 1.0% vs 1.0% ± 0.4% FAME, p < .05). The DHA levels in the serum phospholipids were significantly higher in theω -3 PUFA group compared with the control on postoperative days 6 and 10 (11.8% ± 1.9% vs 8.4% ± 1.5% and 11.2% ± 1.6% vs 8.5% ± 1.4% FAME, p < .05). AA levels were not significantly different in the both groups. CONCLUSIONS Ω -3-fatty-acids-supplemented fat emulsions for parenteral administration are safe and very well tolerated. This study demonstrates that parenteral administration of ω-3-PUFA-enriched fat emulsions leads to increased incorporation of EPA and DHA into phospholipids in serum and erythrocytes, whereas AA levels remain unchanged. Thus, postoperative parenteral administration of ω-3-PUFA-enriched lipid emulsions could have an impact on the postoperative inflammatory response after abdominal surgery and could be used in standard postoperative care when PN is indicated.

MR Venography in the Detection of Pelvic Venous Congestion

OBJECTIVE To assess reflux patterns and the results of endovascular obliteration of ovarian veins in patients with symptomatic pelvic venous incompetence (PVI). METHODS A total of 71 female patients (mean age 49 years) with signs of PVI on selective phlebography of the pelvic veins were included in the study. In 53 cases (75%), recurrent varicose veins following previous surgery and stripping of the great saphenous vein were present and 51 patients (72%) were multiparous (> or = 2 children). Symptoms were scored on a visual analogue scale (VAS) assessing pelvic and lower limb pain. After duplex ultrasonography of the lower limb veins, in cases of suspected PVI, the presence of any reflux in the ovarian and pelvic veins was demonstrated by phlebography. In selected cases, endovascular treatment with embolisation was used. Follow-up assessment of symptoms was carried out at 1, 2 and 3 years. RESULTS The left ovarian vein (OV) and the right internal iliac vein (IIV) were most frequently affected by reflux (n=41, 58% each). In about half the number of patients, reflux was demonstrated in more than one of the main pelvic veins (n=38, 54%). An extension of reflux into varicose veins of the groin or lower limb was demonstrated in 44 patients (62%); 35 patients (49%) received treatment for their PVI by coil embolisation. Fifty-five patients (77%) completed follow-up. Patients with isolated ovarian vein incompetence, who were treated by embolisation, experienced a significant improvement of symptoms (mean symptom score 5.2 standard deviation (SD) 3.5 before and 1.2 SD 0.9 after embolisation treatment; p<0.0001), while patients with untreated incompetence did not show improvement in symptoms (mean score 4.5 SD 1.6 before and 5.1 SD 1.5 after conservative treatment; non-significant (N.S.)). Improved symptoms were detected in patients with isolated IIV incompetence, who underwent embolisation treatment (mean symptom score 5.1 SD 2.5 before and 2.1 SD 1.6 after treatment; N.S.) although this did not reach statistical significance. Conservative treatment of patients with isolated IIV incompetence resulted in no relevant changes (mean score 4.2 SD 2.0 before and 4.5 SD 2.1 after treatment; N.S.). Worsening of symptoms was found in patients with combined reflux who underwent conservative treatment (mean score 5.3 SD 2.0 before and 6.5 SD 2.5 after treatment, N.S.). In case of combined OV and IIV reflux, isolated interventional treatment of incompetent ovarian veins did not improve symptoms at each interval of the follow-up (mean score 5.2 SD 2.1 before and 5.1 SD 2.6 after treatment, N.S.), while coiling of all reflux pathways resulted in symptom reduction; but this did not reach statistical significance due to the small numbers of patients (mean score 5.6 SD 2.2 before and 3.2 SD 2.1 after treatment, N.S.). CONCLUSIONS Combined reflux in more than one pelvic vein is common. In these cases, isolated treatment of ovarian veins or conservative treatment is associated with a poor midterm clinical outcome. A clinical improvement was achieved only in patients with isolated ovarian vein incompetence.

Residual Stumps Associated with Inguinal Varicose Vein Recurrences: A Multicenter Study

PURPOSE To investigate the feasibility of using magnetic resonance venography (MRV) to detect pelvic venous congestion (PVC). METHODS A prospective study of 23 female patients with signs and symptoms of PVC, who underwent duplex sonography, MRV and phlebography (P). Examinations were interpreted in a blinded fashion. Visualization of venous anatomy, presence of venous incompetence and congestion grade were evaluated. Sensitivity and specificity of MRV using P as reference were calculated. RESULTS MRV agreed with P in 96% (Cohen-K-value 0.646) and in 70% (K 0.555) of the cases respectively in the venous anatomy and congestion grade. Sensitivity and specificity of MRV were 88% and 67% for ovarian veins, 100% and 38% for hypogastric veins and 91% and 42% for the pelvic plexus. CONCLUSIONS In this prospective study MRV showed high sensitivity in the evaluation of patients with suspected PVC. Routine use of this diagnostic method requires further studies in larger patient cohorts.

Ultrasound elastography for the age determination of venous thrombi: Evaluation in an animal model of venous thrombosis

PURPOSE It is unclear whether a residual sapheno-femoral stump left in place after stripping of the great saphenous vein can contribute to the formation of late inguinal varicose vein recurrence. In order to obtain information about the time course of recurrence development, patients with histologically proven residual stumps were recruited and asked about the interval between the initial operation and the first clinical signs of varicose vein recurrence. METHODS A multi-centre study involving 7 centres was conducted amongst patients undergoing redo-surgery for inguinal varicose vein recurrences. The sapheno-femoral stumps resected during the redo-surgery were classified histologically. Patients with a proven long residual sapheno-femoral stump were asked to describe the first signs of varicose vein recurrence with the help of a standardised questionnaire. From these data the symptom-free interval, consisting of the time frame between the initial operation and the first signs of recurrence, was determined. RESULTS In 279 legs of 251 patients a long residual sapheno-femoral stump was present. Most patients had experienced a symptom-free interval after the initial operation with a mean duration of 7.4 S.D. 5.5 years. Recurrent varicose veins became apparent after a mean time interval of 6.3 S.D. 5.3 years and congestion symptoms occurred after a mean interval of 8.5 S.D. 5.7 years. CONCLUSIONS In patients with symptomatic groin recurrences, a long residual sapheno-femoral stump was found in about two thirds of cases. The first clinical signs of varicose vein recurrence can be expected 7-8 years after the initial treatment at the earliest. Long term follow up is required reliably to asses the outcome of treatment for varicose veins.

Long-term results after transfemoral venous thrombectomy for iliofemoral deep venous thrombosis.

The exact age determination of venous thrombi is important if thrombolytic therapy or surgical thrombectomy is considered. Clinical symptoms as well as duplex-ultrasound and phlebography are unreliable in this respect and do not allow an exact age estimation. Ultrasound elastography can provide information about the elastic properties of thrombi. Since thrombus elasticity decreases with age due to the organisation process, it should be possible to use elastography to stage the degree of organisation and thereby determine the age of venous thrombi. Experimental venous thrombi aging 1, 3, 6, 9, 12 and 15 days were created in a porcine model by laparoscopic ligation of the infrarenal Vena cava in combination with transfemoral infusion of thrombin. The thrombosed iliac veins were explanted and embedded in gelatine, after that they underwent examination by ultrasound elastography. In addition, histological evaluation of the thrombi was performed. Elastography demonstrated a decline in thrombus elasticity between days 6 and 12 with the 12-day-old thrombi being about 3 times harder then the 6-day-old thrombi. This correlated with the histological findings, which demonstrated a marked increase in fibroblast and collagen production in the clots during this time, with the 12- and 15-day thrombi showing signs of advanced organisation. In conclusion, in an experimental setting, ultrasound elastography was helpful in determining the exact age of venous thrombi. The differences in elasticity were most pronounced between days 6 and 12, which is also the most relevant time frame when considering invasive therapies in human venous thrombosis.

Oestradiol Levels in Varicose Vein Blood of Patients with and without Pelvic Vein Incompetence (PVI): Diagnostic Implications

OBJECTIVE In patients presenting with extensive venous thrombosis affecting the pelvic veins, transfemoral venous thrombectomy has been suggested as an effective treatment in selected patients. We present our experience of this technique as well as its long-term results. PATIENTS AND METHODS Between January 1998 and January 2008, a total of 83 patients underwent transfemoral venous thrombectomy in our Department of Vascular Surgery. In 22 cases, this was combined with angioplasty and stenting of an iliac vein stenosis. Isolated intra-operative thrombolysis was performed in eight cases to treat deep venous thrombosis (DVT) affecting veins distal to the common femoral vein. All patients suffered from a DVT involving the pelvic veins. A DVT involving all venous segments from the pelvis to the calf was present in 63% of cases. Patients were followed up at 3 months, 6 months and yearly thereafter by clinical and duplex ultrasound examination. RESULTS In all patients, the procedure was successful in achieving re-canalisation of the pelvic veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Life-table analysis showed that, after a mean duration of 60 months following treatment, approximately 75% of the treated venous segments remained patent. Moderate post-thrombotic syndrome (PTS; clinical severity, etiology, anatomy and pathophysiology (CEAP) C2-C4) was present in 20% of cases; severe PTS (CEAP C5 and C6) did not occur in any of the treated patients. CONCLUSIONS It is safe and effective to treat extensive iliofemoral DVT using transfemoral venous thrombectomy and this prevents the development of severe PTS in the long term. The procedure is only feasible in a subset of patients with DVT, depending on the extent and the age of the thrombosis.

Validity of duplex-ultrasound in identifying the cause of groin recurrence after varicose vein surgery

PURPOSE To assess the difference in the oestradiol levels of blood taken from varicose veins in patients with and without pelvic vein incompetence (PVI). MATERIALS AND METHODS Women of child-bearing age with symptomatic primary or recurrent varicose veins of the great saphenous vein (GSV) were included in a prospective study. Patients underwent duplex ultrasonography and pelvic vein phlebography. They were divided into a group with PVI (PVI group) and a control group with GSV reflux alone (VV group). Blood samples were collected from the GSV at the sapheno-femoral junction or lower in the thigh as well as from the arm. Oestradiol levels were determined by electroluminescence. RESULTS Between January and December 2007, 40 women were studied, of which 19 showed phlebographic evidence of PVI (PVI group), while 21 were included in the VV group. Phlebography revealed an incompetent ovarian vein in 14 (74%) patients of the PVI group, dilated uterine and ovarian plexuses in 12 (63%) and an incompetent internal iliac vein in six cases (32%). In the PVI group, the median oestradiol level in GSV samples was 121 pgml(-1) (range: 12-4300), while in the VV group the median level was 75 pgml(-1) (range: 9-1177). In the upper limb, the PVI group patients had a median level of 78 pgml(-1) (range: 15-121) and the VV group patients 68 pgml(-1) (range: 13-568). The ratio of lower limb/upper extremity was significantly higher (p<0.002) in patients of PVI group (median: 1.9; range: 0.7-33) than in those of the VV group (median: 1.1; range: 0.8-13). A threshold ratio of 1.4 showed the highest combined sensitivity and specificity in differentiating patients with PVI from those without. CONCLUSIONS In patients with varicose veins arising from the GSV, oestradiol levels were significantly higher in the lower limb than in the upper extremity in the subgroup with associated PVI. It may be possible to use this observation as a diagnostic test in patients with suspected PVI. This deserves further study.

Classification of venous thrombosis combining ultrasound elastography and tissue characterization

INTRODUCTION Often groin recurrences after varicose vein surgery are diagnosed and classified with the help of a duplex ultrasound scan. There are, however, no studies indicating if duplex ultrasound scans can reliably distinguish between the different forms of recurrent vessels, ie, neovascularization or a residual stump. To address this issue, we have conducted a prospective study in which ultrasound scan assessment of groin recurrences was compared to the histological classification of the recurrent groin veins. MATERIALS AND METHODS All patients undergoing redo-surgery for symptomatic groin recurrences after previous stripping of the greater saphenous vein (GSV) during a 1-year period (May 2006-May 2007) were included in the study. Preoperatively, all patients had a duplex-ultrasound scan examination of the groin vessels. Based on the duplex scan findings, the recurrent veins in the groin were classified as either a residual stump or neovascularization. During the redo-surgery, a specimen of the recurrent groin veins was obtained and underwent histologic evaluation. Based on histologic criteria, the recurrence was also classified as a residual stump or neovascularization. RESULTS During the 1-year study period, 125 groin recurrences in 95 consecutive patients (74 female, 21 male, mean age 58.7 years, standard deviation [SD] 10.3 years) were included. In the 119 cases where both duplex-ultrasound scan and histological evaluation were available, a residual stump was seen at the histological examination in 80.7% of cases, a neovascularization in 10.9% of cases, and a combination of both entities in 8.4% of cases. Duplex-ultrasound scan classified the recurrent groin veins as a residual stump in 68.1% of cases, as neovascularization in 26.1%, and as a combination of both in 5.8% of cases. With histological classification as the gold-standard, duplex ultrasound scans reached a sensitivity of 77.1% and a positive predictive value of 91.4% in correctly identifying a residual stump as the cause of recurrence. For the correct classification of neovascularization, sensitivity was 61.5% and the positive predictive value 25.8%, while a combination of both was recognized with a sensitivity of 10% and a positive predictive value of 14.3%. CONCLUSION While duplex-ultrasound scan is a reliable tool to diagnose groin recurrences after varicose vein surgery, its validity in classifying the different types of recurrent groin vessels is limited. Especially the correct identification of neovascularization which is poor with a sensitivity of 62% and a positive predictive value of 26%. Histological examination should still be regarded as the gold-standard when trying to differentiate between different types of groin recurrences.