Hongjin Shim

Perioperative nutritional status changes in gastrointestinal cancer patients.

Purpose The presence of gastrointestinal (GI) cancer and its treatment might aggravate patient nutritional status. Malnutrition is one of the major factors affecting the postoperative course. We evaluated changes in perioperative nutritional status and risk factors of postoperative severe malnutrition in the GI cancer patients. Materials and Methods Nutritional status was prospectively evaluated using patient-generated subjective global assessment (PG-SGA) perioperatively between May and September 2011. Results A total of 435 patients were enrolled. Among them, 279 patients had been diagnosed with gastric cancer and 156 with colorectal cancer. Minimal invasive surgery was performed in 225 patients. PG-SGA score increased from 4.5 preoperatively to 10.6 postoperatively (p<0.001). Ten patients (2.3%) were severely malnourished preoperatively, increasing to 115 patients (26.3%) postoperatively. In gastric cancer patients, postoperative severe malnourishment increased significantly (p<0.006). In univariate analysis, old age (>60, p<0.001), male sex (p=0.020), preoperative weight loss (p=0.008), gastric cancer (p<0.001), and open surgery (p<0.001) were indicated as risk factors of postoperative severe malnutrition. In multivariate analysis, old age, preoperative weight loss, gastric cancer, and open surgery remained significant as risk factors of severe malnutrition. Conclusion The prevalence of severe malnutrition among GI cancer patients in this study increased from 2.3% preoperatively to 26.3% after an operation. Old age, preoperative weight loss, gastric cancer, and open surgery were shown to be risk factors of postoperative severe malnutrition. In patients at high risk of postoperative severe malnutrition, adequate nutritional support should be considered.

Serum selenium and zinc levels in critically ill surgical patients

PURPOSE The authors designed this study to determine how serum selenium and zinc affect the outcomes of critically ill surgical patients. METHODS The medical records of 162 patients admitted to a surgical intensive care unit (ICU) from October 2010 to July 2012 and managed for more than 3 days were retrospectively investigated. RESULTS Overall, the mean patient age was 61.2 ± 15.0 years, and the median ICU stay was 5 (3-115) days. The mean Acute Physiologic and Chronic Health Evaluation II score was 18.0 ± 8.0. Eighteen (11.1%) of the study subjects died in ICU. mean selenium levels were 83.5 ± 23.8 ng/dL in the survivor group and 83.3 ± 29.6 ng/dL in the nonsurvivor group, and corresponding mean zinc levels were 46.3 ± 21.7 and 65.6 ± 41.6 μg/dL, respectively. Mean selenium concentrations were significantly different in patients with and without shock (77.9 ± 25.4 and 87.2 ± 23.1 ng/dL, P = .017). Furthermore, mean serum selenium was lower in patients with sepsis than in traumatic or simply postoperative patients (P < .001 and P = .038). Serum Zn was significantly lower in patients with sepsis than in patients with trauma (43.4 ± 25.4 μg/dL vs 54.8 ± 28.1 μg/dL, P = .038). CONCLUSIONS To determine the effects of serum selenium and zinc levels on critically ill surgical patients, a large-scale prospective study is needed.

Early Feeding Is Feasible after Emergency Gastrointestinal Surgery

Purpose This study was undertaken to assess the feasibility of early feeding in patients that have undergone emergency gastrointestinal (GI) surgery. Materials and Methods The authors retrospectively reviewed 84 patients that underwent emergency bowel resection and/or anastomosis from March 2008 to December 2011. Patients with severe shock, intestinal ischemia, sustained bowel perforation, or short bowel syndrome were excluded. Patients were divided into the early (group E; n=44) or late (group L; n=40) group according to the time of feeding commencement. Early feeding was defined as enteral feeding that started within 48 hours after surgery. Early and late feeding groups were compared with respect to clinical data and surgical outcomes. Results The most common cause of operation was bowel perforation, and the small bowel was the most commonly involved site. No significant intergroup differences were found for causes, sites, or types of operation. However, length of stay (LOS) in the intensive care unit (1 day vs. 2 days, p=0.038) and LOS in the hospital after surgery were significantly greater (9 days vs. 12 days, p=0.012) in group L than group E; pulmonary complications were also significantly more common (13.6% vs. 47.5%, p=0.001) in group L than group E. Conclusion After emergency GI surgery, early feeding may be feasible in patients without severe shock or bowel anastomosis instability.

Correlation of the oxygen radical activity and antioxidants and severity in critically ill surgical patients - study protocol

BackgroundSurgical patients who require an emergent operation commonly have severe sepsis or septic shock, followed by high morbidity and mortality rates.Despite advances in treatment however, no predictable markers are available. In severe sepsis, many pathophysiologic mechanisms are involved in progression to organ failure, and oxygen free radical and antioxidants are known to contribute to this process. Oxygen free radical and antioxidants contribute to progression of organ failure in severe sepsis. In fact, oxygen radical activity has been reported to be correlated with disease severity and prognosis in patients with severe sepsis or septic shock. Accordingly, we aim to assess the usefulness of oxygen free radical and antioxidant concentrations to predict the disease severity and mortality in a cohort of critically ill surgical patients.Methods/DesignThis is a prospective observation study including patient demographic characteristics, clinical information, blood sampling/serum oxygen radical activity, serum antioxidant activity, serum antioxidant concentrations (zinc, selenium and glutamate), disease severity scores, outcomes, lengths of stay in intensive care unit, hospital 30-day mortality.

Feasibility of the Short Hospital Stays after Laparoscopic Appendectomy for Uncomplicated Appendicitis

Purpose The aim of this study was to evaluate the feasibility of short hospital stays after laparoscopic appendectomy for uncomplicated appendicitis. Materials and Methods The records of 142 patients who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 2010 to December 2012 were analyzed retrospectively. Patients were allocated to an early (<48 hours) or a late (>48 hours) group by postoperative hospital stay. Postoperative complications and readmission rates in the two groups were evaluated and compared. Results Overall mean patient age was 50.1 (±16.0) years, and mean hospital stay was 3.8 (±2.8) days. Fifty-four patients (group E, 38.0%) were discharged within 48 hours of surgery, and 88 patients (group L, 62.0%) stayed more than 48 hours. Overall complication rates were similar in the two groups (14.8% vs. 21.6%, p=0.318), and wound complications (13.0% vs. 12.5%), postoperative bowel obstruction (1.9% vs. 2.3%), and abdominal pain (1.9% vs. 3.4%) were not significantly different. Conclusion Patients that undergo laparoscopic appendectomy due to uncomplicated appendicitis may be safely discharged within 48 hours. Further study should be conducted to determine the optimal length of hospital stay after laparoscopic appendectomy to reduce hospital costs.

Serum oxygen radical activity and total antioxidation capacity are related with severities of surgical patient with sepsis: Prospective pilot study

Purpose: The purpose of this pilot study was to evaluate the correlation between clinical severity and serum oxygen radical activity (ORA) and total antioxidation capacity (TAC) in critically ill surgical patients with sepsis. Materials and methods: The prospective observational study was performed in surgical intensive care unit (SICU) patients with intra‐abdominal sepsis. Serum ORA and TAC levels were measured using a spectrophotometry‐based antioxidant assay machine. Serum selenium and zinc levels and plasma glutamine concentrations were also determined. Sequential organ failure assessment (SOFA) and multiple organ dysfunction (MOD) scores were calculated to evaluate the severity. Blood tests and severity scores were assessed on days 1, 3, and 7 in the SICU. Results: Twenty‐seven patients were included. The mean APACHE II score was 22.4. The in‐hospital mortality rate was 14.8%. Serum TAC levels correlated positively with SOFA and MOD scores on SICU days 1, 3 and 7, and serum ORA correlated negatively with SOFA and MOD scores on day 3. Serum zinc and selenium levels were lower than normal throughout the observation period. However, there was no significant relationship in clinical severity. Conclusions: Serum TAC level may be a useful biomarker to predict severity of critically ill surgical patients with sepsis. HighlightsSerum TAC levels correlated positively with sepsis severity on SICU day 1, 3, and 7.Serum ORA correlated negatively with SOFA and MODS scores on day 3.TAC level of SICU day 1, 3, and 7 was significantly higher in non‐survivors than in survivors.

Epidemiology and Microbiology of Secondary Peritonitis Caused by Viscus Perforation: A Single-Center Retrospective Study

BACKGROUND Complicated intra-abdominal infections are serious conditions that require urgent source control and antibiotic treatment. The purpose of this study was to evaluate the epidemiology and bacterial causation of such infections using blood and peritoneal cultures of Korean patients with peritonitis originating from viscus perforation. METHODS The medical records of 419 consecutive patients who underwent emergency surgery because of bowel perforation from January 2007 to December 2011 were analyzed. Clinical characteristics, peri-operative conditions, perforation sites, and mortality data were obtained. Bacterial distributions and antibiotic resistance were evaluated using blood and peritoneal culture reports. RESULTS The most common perforation site was the colon (165; 39.4%), and the overall mortality rate was 11.2%. Blood cultures were performed in 182 patients, and 20 patients (11.0%) had a positive culture. Blood culture positivity was significantly higher for colon perforations (17.7%) than perforations elsewhere (p=0.039). A peritoneal culture was performed for each of 210 patients (50.1%), and 145 of those patients (69.0%) had a positive culture. Enterococcus faecium (35.2%) was the most common gram-positive bacterium, and Escherichia coli was the most common gram-negative organism. There were 276 community-acquired infections (CAI) (65.9%) and 143 hospital-acquired infections (HAI) (34.1%). Escherichia coli producing extended-spectrum β-lactamases were more common in the HAI than in the CAI group (p=0.016). CONCLUSIONS The compositions and antibiotic resistances of micro-organisms found in this study are similar to those reported previously. A multicenter prospective study is needed of this disease state in South Korea.

Application of negative pressure wound therapy in patients with wound dehiscence after abdominal open surgery: a single center experience

Purpose Since the 1990s, negative pressure wound therapy (NPWT) has been used to treat soft tissue defects, burn wounds, and to achieve skin graft fixation. In the field of abdominal surgery, the application of NPWT is increasing in cases with an open abdominal wound requiring temporary wound closure and a second look operation. In the present study, the authors analyzed patients that underwent NPWT for postoperative wound dehiscence. Methods The computerized records of patients that had undergone an abdominal operation from November 2009 to May 2012 were retrospectively analyzed. Results The number of total enrolled patients was 50, and 30 patients (60%) underwent an emergency operation. Diagnoses were as follows: panperitonitis or intra-abdominal abscess (24 cases, 48%), intestinal obstruction (10 cases, 20%), cancer (7 cases, 14%), mesentery ischemia (3 cases, 6%), and hemoperitoneum (1 case, 2%). NPWT was applied at a mean of 12.9 ± 8.2 days after surgery and mean NPWT duration was 17.9 days (2 to 96 days). The 11 patients (22%) with unsuccessful wound closure had a deeper and more complex wound than the other 39 patients (78%) (90.9% vs. 38.5%, P = 0.005). There were two complication cases (4%) due to delayed wound healing. Conclusion Most patients recovered well due to granulation formation and suturing. NPWT was found to be convenient and safe, but a prospective comparative study is needed to confirm the usefulness of NPWT in patients whose wounds are dehisced.

Efficacy and toxicity of high-dose nebulized colistin for critically ill surgical patients with ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii☆

Purpose Few studies have compared nebulized and intravenous (IV) colistin for multidrug‐resistant Acinetobacter baumannii and Pseudomonas aeruginosa pneumonia. This study compared the nephrotoxicity and clinical outcomes for these two delivery routes. Methods This study retrospectively compared 95 critically ill surgical patients who were diagnosed with Acinetobacter baumannii ventilator associated pneumonia and received colistin between March 2013 and January 2016. Results The most common diagnoses were brain hemorrhage (27.4%), traumatic brain injury (20%), traumatic thoracic injury (15.8%), and secondary peritonitis (11.6%). Compared to the IV group, the nebulizer group was significantly older (60.0 vs. 67.5 years, p = 0.010), had higher APACHE II scores (16.3 vs. 19.9, p = 0.001), and more frequently had diabetes mellitus (6.8% vs. 21.6%, p = 0.043). Nephrotoxicity was more common in the IV group (60.5% vs. 15.7%, p < 0.0001). Both groups had similar microbiological and clinical outcomes (p = 0.921 and p = 0.719, respectively). Patients with nephrotoxicity exhibited prolonged IV or nebulized colistin treatment and more frequent combination with vancomycin. Nephrotoxicity was independently associated with IV delivery (odds ratio: 8.48, 95% confidence interval: 2.95–24.39, p < 0.0001). Conclusions Nebulized colistin may have less nephrotoxicity and provide similar clinical results, compared to IV colistin. HighlightsColistin can be used intravenously or as a nebulized mist for treating VAP.This study compared the toxicity and clinical outcomes of these two routes.IV colistin was an independent and significant risk factor for nephrotoxicity.Nebulized and IV colistin provided similar clinical and microbiological outcomes.Nebulized colistin may be useful for treating critically ill surgical patients.

Removal of Aspirated Teeth in a Multiple Trauma Patient, Using Fiberoptic Bronchoscopy With Simultaneous Tracheostomy: Review of 2 Cases

Aspiration of a tooth in facial trauma is a known complication. There have been few reports on the consequences of maxillofacial trauma, especially when the patient is intubated. We report 2 complicated cases of multiple teeth aspiration and their removal in intubated patients. A special technique using flexible bronchoscopy with simultaneous tracheotomy was used for safe and successful removal of aspirated teeth. We suggest that simultaneous tracheostomy is a safe and effective method for removal of a bronchial foreign body in a maxillofacial traumatized patient.