Ivan Ceconello

Effects of continuous versus bolus infusion of enteral nutrition in critical patients

PURPOSE Enteral alimentation is the preferred modality of support in critical patients who have acceptable digestive function and are unable to eat orally, but the advantages of continuous versus intermittent administration are surrounded by controversy. With the purpose of identifying the benefits and complications of each technique, a prospective controlled study with matched subjects was conducted. PATIENTS AND METHODS Twenty-eight consecutive candidates for enteral feeding were divided into 2 groups (n = 14 each) that were matched for diagnosis and APACHE II score. A commercial immune-stimulating polymeric diet was administered via nasogastric tube by electronic pump in the proportion of 25 kcal/kg/day, either as a 1-hour bolus every 3 hours (Group I), or continuously for 24 hours (Group II), over a 3-day period. Anthropometrics, biochemical measurements, recording of administered drugs and other therapies, thorax X-ray, measurement of abdominal circumference, monitoring of gastric residue, and clinical and nutritional assessments were performed at least once daily. The principal measured outcomes of this protocol were frequency of abdominal distention and pulmonary aspiration, and efficacy in supplying the desired amount of nutrients. RESULTS Nearly half of the total population (46.4%) exhibited high gastric residues on at least 1 occasion, but only 1 confirmed episode of pulmonary aspiration occurred (3.6%). Both groups displayed a moderate number of complications, without differences. Food input during the first day was greater in Group II (approximately 20% difference), but by the third day, both groups displayed similarly small deficits in total furnished volume of about 10%, when compared with the prescribed diet. CONCLUSIONS Both administration modalities permitted practical and effective administration of the diet with frequent registered abnormalities but few clinically significant problems. The two groups were similar in this regard, without statistical differences, probably because of meticulous technique, careful monitoring, strict patient matching, and conservative amounts of diet employed in both situations. Further studies with additional populations, diagnostic groups, and dietetic prescriptions should be performed in order to elucidate the differences between these commonly used feeding modalities.

Fatores prognósticos de pacientes com câncer de cólon direito tratados cirurgicamente: experiência de 10 anos de uma instituição universitária

RACIONAL: Câncer colorretal e o tipo mais comum das neoplasias gastrointestinais. Ha muitas controversias na literatura acerca do valor prognostico do sitio da neoplasia. Muitos estudos revelam maiores taxas de sobrevida para tumores em colon direito, com piora do prognostico a medida que as lesoes se situam mais distalmente. OBJETIVO: Analisar os resultados do tratamento cirurgico de pacientes com câncer de colon direito estadios I-IV operados em um periodo de dez anos e identificar os fatores prognosticos que foram associados com menor sobrevida global. METODOS: Em 10 anos, 187 pacientes foram submetidos a colectomia direita com intencao curativa. Foram estudados os seguintes fatores: genero, idade, localizacao do tumor, o numero de linfonodos obtidos no especime, comprometimento linfonodal, estadio T e presenca de metastases a distância. Estes fatores foram avaliados quanto a possibilidade de serem indicadores prognosticos na sobrevida em cinco anos. RESULTADOS: A idade media foi de 65 (±12) anos e 105 (56,1%) eram mulheres. A localizacao, mas comum foi o colon ascendente (48,1%), seguido do ceco (41,7%) e o ângulo hepatico (10,2%). A media de tempo de internacao hospitalar foi 14 (±2.8) dias. A distribuicao do estadio T foi T1 (4,8%), T2 (7,5%), T3 (74,9%) e T4 (12,8%). Acometimento linfonodal ocorreu em 46,0% e metastases a distância em 3,7%. Um minimo de 12 linfonodos ressecados foram obtidos em 87,2% dos especimes cirurgicos. Em 84.5% os tumores eram nao-mucinosos. A media de sobrevida foi de 38,3 (±30.8) meses. A sobrevida geral foi afetada pelo estadio T, N, M e pelo estadio final. O acometimento linfonodal (RR=2,06) e os estadios III/IV (RR=2,81) foram fatores prognosticos negativos independentes. CONCLUSOES: Estadio avancado e envolvimento linfonodal foram os fatores associados com a pior sobrevida em longo prazo.

Prognostic factors of surgically-treated patients with cancer of the right colon: a ten years' experience of a single universitary institution

Background Colorectal cancer is one of the most common malignancies in the world. There are many controversies in the literature about the prognostic value of primary tumor location. Many studies have shown higher survival rates for tumors in the right colon, and worse prognosis for lesions located more distally in the colon. Aim To analyze the results of surgical treatment of right-sided colon cancers patients operated in one decade period and identify the prognostic factors that were associated with lower overall survival in stages I-IV patients. Methods A retrospective review from the prospectively collected database identified 178 patients with right-sided colon cancer surgically treated with curative intent. Demographic factors (gender and age), tumor factors (site, T stage, N stage, M stage, histological type and tumor differentiation), and lymph node yield were extracted to identify those associated with lower overall survival. Results Mean age was 65 (±12) years old, and 105 (56.1%) patients were female. Most common affected site was ascending colon (48.1%), followed by cecum (41.7%) and hepatic flexure (10.2%). Mean length of hospital stay was 14 (±2.8) days. T stage distribution was T1 (4.8%), T2 (7.5%), T3 (74.9%), and T4 (12.8%). Nodal involvement was present in 46.0%, and metastatic disease in 3.7%. Twelve or more lymph nodes were obtained in 87.2% of surgical specimens and 84.5% were non-mucinous tumors. Mean survival time was 38.3 (±30.8) months. Overall survival was affected by T stage, N stage, M stage, and final stage. Lymph node involvement (OR=2.06) and stage III/IV (OR=2.81) were independent negative prognostic factors. Conclusion Right-sided colon cancer presented commonly at advanced stage. Advanced stage and lymph node involvement were factors associated with poor long term survival.

Endoscopic colostomy with percutaneous colopexy: an animal feasibility study

BACKGROUND Indications for colostomy in colorectal diseases are obstruction of the large bowel, such as in cancer, diverticular disease in the acute phase, post-radiotherapy enteritis, complex perirectal fistulas, anorectal trauma and severe anal incontinence. Some critically ill patients cannot tolerate an exploratory laparotomy, and laparoscopic assisted colostomy also requires general anesthesia. OBJECTIVE To evaluate the feasibility, safety and efficacy of performing colostomy assisted by colonoscopy and percutaneous colopexy. MATERIALS AND METHODS Five pigs underwent endoscopic assisted colostomy with percutaneous colopexy. Animals were evaluated in post-operative days 1, 2, 5 and 7 for feeding acceptance and colostomy characteristics. On day 7 full colonoscopy was performed on animals followed by exploratory laparotomy. RESULTS Average procedure time was 27 minutes (21-54 min). Postoperative mobility and feeding of animals were immediate after anesthesia recovery. Position of the colostomy, edges color, appearance of periostomal area, as well as its function was satisfactory in four animals. Retraction of colostomy was present in one pig. The colonoscopy and laparotomy control on the seventh day were considered as normal. A bladder perforation that was successfully repaired through the colostomy incision occurred in one pig. The main limitation of this study is its experimental nature. CONCLUSION Endoscopic assisted colostomy with percutaneous colopexy proves to be a safe and effective method with low morbidity for performing colostomy in experimental animals, with possible clinical application in humans.