Heiko Renner

Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction

After resective and reconstructive surgery in the gastrointestinal tract, oral feeding is traditionally avoided in order to minimize strain to the anastomoses and to reduce the inherent risks of the postoperatively impaired gastrointestinal motility. However, studies have given evidence that the small bowel recovers its ability to absorb nutrients almost immediately following surgery, even in the absence of peristalsis, and that early enteral feeding would preserve both the integrity of gut mucosa and its immunological function. The aim of this study was to investigate the impact of early enteral feeding on the postoperative course following oesophagectomy or oesophagogastrectomy, and reconstruction. Between May 1999 and November 2002, forty-four consecutive patients (thirty-eight males and six females; mean age 62, range 30-82) with oesophageal carcinoma (stages I-III), who had undergone radical resection and reconstruction, entered this study (early enteral feeding group; EEF). A historical group of forty-four patients (thirty-seven males and seven females; mean age 64, range 41-79; stages I-III) resected between January 1997 and March 1999 served as control (parenteral feeding group; PF). The duration of both postoperative stay in the Intensive Care Unit (ICU) and the total hospital stay, perioperative complications and the overall mortality were compared. Early enteral feeding was administered over the jejunal line of a Dobhoff tube. It started 6 h postoperatively at a rate of 10 ml/h for 6 h with stepwise increase until total enteral nutrition was achieved on day 6. In the controls oral enteral feeding was begun on day 7. If compared to the PF group, EEF patients recovered faster considering the duration of both stay in the ICU and in the hospital. There was a significant difference in the interval until the first bowel movements. No difference in overall 30 d mortality was identified. A poor nutritional status was a significant prognostic factor for an increased mortality. Early enteral feeding significantly reduces the duration of ICU treatment and total hospital stay in patients who undergo oesophagectomy or oesophagogastrectomy for oesophageal carcinoma. The mortality rate is not affected.

Protein expression profiles in adenocarcinomas and squamous cell carcinomas of the lung generated using tissue microarrays.

With the appearance of defect‐targeted therapies, the definition of tumour protein expression profiles has gained increasing importance. Two lung carcinoma tissue microarrays, one including 75 primary adenocarcinomas (ACs) and the other comprising 67 primary squamous cell carcinomas (SQCCs), were generated in the present study. On both arrays, each tumour was represented by an average of five cores. In addition, one punch of normal lung parenchyma adjacent to each tumour was included in the array. Immunohistochemical expression of 86 proteins was evaluated and the results were analysed by non‐parametric tests, hierarchical clustering, and principal component analysis. In both tumour entities, parenchyma and tumours were clearly separated by hierarchical clustering. By the same statistical approach, it was possible to distinguish ACs from SQCCs with 98% accuracy and to distinguish parenchyma adjacent to ACs from that adjacent to SQCCs with 96% accuracy. It was also possible to separate ACs into three groups that significantly differed in survival. Cathepsin E and hsp105 were identified as previously unknown predictors of survival in lung AC. In summary, this study has shown that protein profiles are feasible tools for anticipating biological behaviour. Copyright

Self-expandable coated stent after intraluminal treatment of esophageal cancer : A risky procedure?

BACKGROUND Stenting is a well established palliative treatment for stenotic malignant disease of the esophagus. Because of its merely mechanical potential other tumoricidal techniques are often done before stenting. METHODS We did esophageal stenting in 11 patients (9 men and 2 women) using a self-expanding coated stent system. Three tumors were localized in the proximal, four in the middle, and four in the distal third of the esophagus. In 9 patients tumors were locally or functional nonresectable, 1 patient refused an operation, and 1 had a recurrence after esophagojejunostomy. One patient had had pretreatment by repetitive dilatation and local hyperthermia, 9 had had photodynamic therapy followed by endoluminal iridium 192 high-dose rate brachyradiotherapy, and 1 patient was admitted with esophagotracheal fistula. The interval between the last endoluminal treatment and stent insertion was between 3 and 29 days (mean, 11 days). RESULTS In 7 patients (63.7%) no complications were observed. Four patients (36.3%) died of major complications within 1 week. Postmortem examination confirmed that the pressure of the fully expanding stent to the esophageal wall caused the rupture. CONCLUSION The use of self-expanding coated stents in pretreated esophageal tumors is associated with a high risk of perforation due to pressure of the indwelling tube in a less resistant esophageal wall.

Is aggressive surgery in pleural empyema justified

OBJECTIVE High risk and a long hospitalization time are often quoted as negative aspects of aggressive surgery in pleural empyema. We did a retrospective analysis evaluating outcome and duration of hospitalization in patients treated according to an aggressive schedule. METHODS Since 1989 we have treated 101 patients with pleural empyema (72 males, 29 females; mean age 50.3 years, range 11-91 years; 77 metapneumonic empyema, 24 empyema following trauma or abdominal surgery). Sixty-nine patients had had unsuccessful conservative pre-treatment (antibiotics, thorcozentses, drainage/irrigation, VATS). Thirty-one were critically ill patients. In eight cases a seropurulent stage of empyema was present, 17 patients had fibrinous membranes, 30 an organizing stage with and 46 without well identifiable dissection plane. Eighty-five patients proceeded to thoracotomy. Pulmonary abscesses or indurative pneumonia necessitated wedge-resection, lobectomy, or pneumonectomy in 29 cases. In the presence of gross necroses or callosities not amenable to decortication primary open-window thoracostomy (n = 22) was carried out. In six cases a secondary open-window thoracostomy was carried out because of persisting putrid secretion and sepsis persisting after decortication or after drainage. The thoracostomy was closed when clean granulative tissue developed. Sixteen patients underwent only drainage and irrigation because of an early stage or because of a general condition not permitting thoracotomy. RESULTS Three patients died due to severe sepsis not responding to treatment, one had fatal bleeding from a duodenal ulcer (mortality rate 3.9%). The others were able to resume their preoperative activities. The median duration of hospitalization was 14 days (mean 21.1 days; SEM 1.7 days). CONCLUSION Aggressive surgery for pleural empyema beyond the seropurulent stage ensures rapid relief from sepsis at a low mortality rate even in very ill patients.

Creation of a prevascularized site for cell transplantation in rats

Stiegler P, Matzi V, Pierer E, Hauser O, Schaffellner S, Renner H, Greilberger J, Aigner R, Maier A, Lackner C, Iberer F, Smolle‐Jüttner F‐M, Tscheliessnigg K, Stadlbauer V. Creation of a prevascularized site for cell transplantation in rats. Xenotransplantation 2010; 17: 379–390.

Hyperbaric oxygen in the treatment of hydrogen sulphide intoxication

used thromboelastometry (RoTEM) and platelet adhesion was inhibited by pre-treatment with cytochalasin D (FibTEM measurement); therefore, adhesion of the clot to the pin and cup depended on fibrinogen or fibrin constituents. De Lorenzo et al. showed that in FibTEM measurements, fibrinogen could not even correct the effect of a 20% HES hemodilution, in contrast to the ExTEM measurements. This signifies the importance of platelet contribution also in HES dilution coagulopathy, as measured by thromboelastometry. We therefore suggest that platelet adhesion during dilutional consumption coagulopathy influences thromboelastometry and this should be considered. More research on the adhesive properties of blood, the interaction with plastic surfaces and the specific role of platelets herein is, however, necessary.