L. Gianotti

Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak

PURPOSE: The aim of this study was to evaluate the reliability of intraoperative laser-Doppler measurements in predicting the occurrence of anastomotic leak in patients with colorectal cancer undergoing stapled straight anastomosis to the rectum. METHODS: A prospective study was undertaken on 55 patients with rectal cancer or distal sigmoid cancer programmed for elective curative surgery. In all patients transmural colonic blood flow was measured by laser-Doppler flowmetry technique before bowel manipulation (baseline measurement) and after vascular ligation and division. Comorbidities at admission, intraoperative events, associated surgical procedures, and clinical outcome were tested for any association with anastomotic leak. RESULTS: Postoperative mortality was 1.8 percent (1/55 patients), and the overall morbidity was 21.3 percent. Anastomotic leak occurred in eight patients (14.5 percent). After colonic division a blood flow reduction at the rectal stump was observed in 42 patients (76.3 percent) as compared with baseline measurement. The mean rectal stump flow reduction was 6.2 percent in patients without anastomotic leak, whereas in patients who developed anastomosis breakdown it was 16 percent (P<0.001). Mean proximal stump flow reduction was 5.1 percent in the uncomplicated patients, whereas in patients who had an anastomosis breakdown it was 12.9 percent (P<0.01). A positive linear correlation was found between decrease in blood flow and rate of anastomotic leak. CONCLUSION: Blood flow reduction at the rectal stump is associated with an increased risk of anastomotic leak.

Complications of Pancreatic Surgery and the Role of Perioperative Nutrition

Background: According to international guidelines, artificial nutrition may be indicated after pancreaticoduodenectomy (PD). This clinical study was designed to evaluate whether the route of administration and the composition of the postoperative nutritional support could affect outcome. Methods: One hundred patients who underwent PD for cancer of the pancreatic head were prospectively studied. Patients were randomized to receive a standard enteral formula (SEN; n = 35) or immunonutrition with an enteral formula enriched with arginine, ω-3 fatty acids, and RNA (IEN group; n = 33), or total parenteral nutrition (TPN; n = 32). Postoperative feeding was started within 12 h after surgery. The three regimens were isoenergetic and isonitrogenous. Tolerance of enteral feeding, rate and severity of postoperative complications, and length of hospital stay (LOS) were evaluated. Results: Full nutritional goal (25 kcal/kg) was achieved in 84% of enterally fed patients versus 96% in the parenteral group (p = NS). The rate of postoperative complications was lower in the IEN group (33%) than in the SEN (40%) and TPN groups (59%). The severity of infectious complications (sepsis score) was lower in the IEN (5.5) than the SEN (7.9) and TPN groups (10.4; p < 0.05). LOS was shorter in the IEN than in the SEN and TPN groups (16.3 vs. 17.8 vs. 19.3 days, respectively; p < 0.05). Conclusions: In patients undergoing PD the established nutritional goal can be obtained by enteral feeding. Immunonutrition seems to improve outcome.

Artificial nutrition after pancreaticoduodenectomy.

Patients undergoing pancreaticoduodenectomy (PD) often require postoperative artificial nutrition. This trial was undertaken to evaluate whether the route of administration and the composition of the postoperative nutritional support could affect the immunometabolic response and outcome. A prospective, randomized trial was carried out in 212 subjects who underwent PD. Patients were randomized to receive a standard enteral formula (standard group, n = 73) or an enteral formula enriched with arginine, omega-3 fatty acids, and RNA (immunonutrition group, n = 71), or total parenteral nutrition (parenteral group, n = 68). Postoperative feeding started 6 hours after surgery. The three regimens were isocaloric and isonitrogenous. Assessed parameters were phagocytosis ability of polymorphonuclear cells, plasma interleukin-2 receptors, C-reactive protein, retinol binding protein, tolerance of enteral feeding, rate of postoperative complications, and length of hospital stay (LOS). Full nutritional goal (25 kcal/kg) was achieved in 87% of enterally fed patients versus 95% in the parenteral group. Subjects receiving immunonutrition had a significantly better recovery of the immunometabolic parameters on postoperative day 8 compared to the other two groups. The rate of postoperative complications was lower in the immunonutrition group (33.8%) than in either the standard (43.8%) or parenteral group (58.8%) (p = 0.005 immunonutrition vs. parenteral). Also, the mean LOS was shorter in the immunonutrition group than in the standard and parenteral groups (15.1 vs. 17.0 vs. 18.8 days, respectively;p < 0.05). Early postoperative enteral feeding may safely and effectively replace parenteral nutrition in patients undergoing PD. Immunonutrition ameliorates the immunometabolic response and improves outcome compared to parenteral feeding.

Health care resources consumed to treat postoperative infections: cost saving by perioperative immunonutrition

The objectives of the study were to calculate the costs of postoperative complications and to evaluate whether the use of perioperative enteral immunonutrition, may lead to a saving in health care resources consumed. The economic analysis was based on data from a randomized double-blind trial that include 206 cancer patients who received perioperatively either enteral immunonutrition (treatment group, n = 102) or a standard enteral diet (control group, n = 104). Estimates of costs were based on resource use for treatment of complications, which were valued according to the National List of Sanitary Costs of the Italian Ministry of Health and on the medical Diagnosis-Related-Group (DRG) reimbursement rates. Costs of nutrition were also calculated. Cost comparison and cost effectiveness analyses were then carried out. Intent-to-treat analysis showed that the total costs of 52 postoperative complications were 322,218 euros, with a consumption of the DRG reimbursement rate of 15.4%. The costs of nutrition were 35,437 euros in the treatment group versus 10,768 euros in the control group. The total costs (nutrition plus treating complications) amounted to 113,778 euros in the treatment group versus 254,450 euros in the control group. The mean total costs per patient were 1,115 euros in the treatment group versus 2,447 euros in the control group (P = 0.04). Effectiveness was 83.3% in the treatment group versus 68.3% in the control group (P = 0.009). Cost effectiveness analysis showed a net saving of 2,386 euros per complication-free patient in favor of the treatment group. In conclusion, the perioperative use of immunonutrition appears cost effective due to a substantial saving of resources used to treat postoperative complications.

A single unit of transfused allogeneic blood increases postoperative infections

The aim of this prospective study was to evaluate if there was a statistical correlation between allogeneic blood transfusion and postoperative infections, and if this could have a dose‐dependent pattern. The evaluation was based on multiple logistic and receiver operating characteristics (ROC) curve analyses. On hospital admission the following parameters were determined in 267 consecutive patients with colorectal cancer: hemoglobin, serum albumin, serum cholinesterase activity, total iron binding capacity and weight loss. Duration of operation, operative blood loss, amount of transfused blood, Dukes’ cancer stage and occurrence of postoperative infections were also recorded. One hundred and thirty‐two patients (49.4%) were given perioperatively allogeneic blood. Postoperative infections developed in 47 (17.6%) patients. Multivariate analysis identified allogeneic blood transfusion as the only variable related to the occurrence of postoperative infections (p < 0.05). ROC curve analysis showed that the risk for the occurrence of infection was significantly higher in patients transfused one unit of blood (p < 0.01). Moreover, a significant trend between increasing number of transfused blood units and susceptibility to infection was found (p < 0.00019).

Impact of enteral nutrition on intestinal bacterial translocation and mortality in burned mice

The aim of these experiments was to study the effect of early enteral nutrition with either standard or enriched (arginine, n-3 fatty acids, RNA) enteral formulas on translocation of bacteria from the gut and acute mortality rate following thermal injury. In the first experiment 60 Balb c mice were gavaged with 10(10)Escherichia coli and received a 20% burn injury. In 40 mice enteral nutrition (20 standard, 20 enriched) was started immediately after injury and stopped 36 h later. In the control group (n = 20) aliquotes of Ringers solution was administered intragastrically. Mortality rate was observed for 10 days post-injury. In the second experiment 60 Balb c mice were gavaged with 10(10)E. coli labelled with biotin(111) Indium and then burned. In 40 mice enteral nutrition (20 standard, 20 enriched) was started immediately after burn. The control group (n = 20) received aliquotes of Ringers solution. 4 h after injury all animals were sacrificed and liver, lungs, kidneys, spleen and systemic blood were harvested, and radionuclide counts were measured. No animal died after day 3 post-burn. The mortality rate was significantly lower at day 1 in the groups infused with both enteral solutions (15%) compared to controls (30%; p = 0.05). At day 3 the animals fed with the enriched diets showed a lower mortality (5%) versus the standard and control groups (10%). Bacterial translocation to the liver and lungs was significantly higher in Ringers group than in both enterally fed groups. Early post-burn enteral nutrition reduces both translocation and acute mortality. Supplementation of the diets with specific nutrients appears to exert additional advantages on outcome.

In vivo evaluation of timing, degree, and distribution of bacterial translocation following experimental small bowel transplantation

These studies were designed to evaluate the correlation between morphologic and functional changes after heterotopic auxiliary small bowel isograft with systemic venous drainage and two ostomies in 20 Lewis rats. Morphologic damage of the graft was scored by full-thickness biopsies before surgery and 1, 3, 5, and 7 days after transplant. Functional evaluation of the graft was done, at the same time points, by urinary excretion of lactulose and mannitol injected in the proximal ostomy. The intestinal permeability was also studied by injecting Escherichia coli labeled with indium-111 oxine in the proximal ostomy. Translocation of radiolabeled bacteria was quantitated in extraintestinal tissues by radionuclide counts and number of viable organisms and in vivo by scinti-graphic imaging. One day after transplant, significant graft damage (score 17.2±4.2) was observed when compared with the pretransplant value (7.3±2.6). The degree of tissue injury was similar on days 3 (15.8±3.5) and 5 (16.1 ±3.9) after transplant and remained high on day 7 (11.8±2.8). The lactulose to mannitol ratio showed a significantly increased permeability on day 1 (17.5) versus pretransplant values (2.6), remained high on day 3 (8.6), and returned to normal values on day 5 (2.8). Translocation of bacteria to distant organs, as measured by both radionuclide counts and number of viable organisms, was strikingly enhanced on day 1 after transplantation, compared with control animals, but returned to the pretransplant value on day 3. A good qualitative and quantitative correlation was observed between radionuclide counts in the extraintestinal organs and in vivo images obtained by scintigraphic scanning. In conclusion, in this model, timing and degree of bacterial translocation do not seem to correlate well, with the exception of the acute posttransplantation phase, with morphologic and perme ability changes of the graft. Evaluation of translocation by scintigraphic imaging appears a suitable approach to study in vivo the kinetics and distribution of this process.

Radical oncologic surgery affects the circulatory levels of interleukin 10

Interleukin 10 (IL‐10) has been shown to be elevated in the plasma of cancer‐bearing patients. The source of systemic IL‐10 may be the tumor microenvironment. We therefore tried to evaluate if ablative surgery for gastrointestinal cancer could affect the levels of circulating IL‐10.

Evaluation of the Predictive Performance of Nutritional Indicators by Receiver-Operating Characteristic Curve Analysis

Four hundred twenty-two cancer patients who underwent major surgery were studied. At admission, nutritional status was evaluated in all patients by assessing serum albumin (SA), total iron-binding capacity (TIBC), total lymphocyte count (TLC), serum cholinesterase activity (CHE), and weight loss (WL). All patients received perioperative short-term antibiotic prophylaxis and postoperative total parenteral nutrition. Prognostic ability of nutritional indicators was assessed by receiver-operating characteristic (ROC) curve analysis. The area beneath the ROC curve (Az) is an index of predictor performance when its value ranges from 0.5 (chance performance) to 1 (perfect prediction). Specificity, sensitivity, Youden index, and predictive values were determined for each nutritional parameter within a wide range of potential threshold values. Postoperative septic complications were observed in 85 (20.14%) patients. The Az values for the considered nutritional parameters ranged from 0.52 to 0.57 and that showed the low predictive ability of the parameters. When sensitivity and specificity for each nutritional parameter were examined at different thresholds, a clearly more predictive cutpoint was not observed, but ranges of values with a similar predictivity were observed. Significant ranges of predictivity were found for SA (33 to 35 g/L), for TIBC (2200 to 2300 micrograms/L), for TLC (2100 to 2200 million/L), for CHE (1700 to 1900 U/L), and for WL (7% to 12%). The higher values of Youden index were as follows: 1.183 for WL (cutoff 11%), 1.150 for TLC (cutoff 2100 million/L), and 1.145 for SA (cutoff 35 g/L). In conclusion, ROC curve analysis showed that the nutritional parameters had a low predictive ability.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutritional Approach in Malnourished Surgical Patients: A Prospective Randomized Study

HYPOTHESIS Perioperative administration of a supplemented enteral formula may decrease postoperative morbidity. DESIGN Randomized clinical trial. SETTING Department of surgery at a university hospital. PATIENTS One hundred ninety-six registered malnourished patients (weight loss > or = 10%) who were candidates for major elective surgery for malignancy of the gastrointestinal tract. INTERVENTION After randomization (n = 150), one group received postoperative enteral feeding with a standard diet within 12 hours of surgery (control group; n = 50). Another group orally received 1 L/d for 7 consecutive days of a liquid diet enriched with arginine, omega-3 fatty acids, and RNA (preoperative group; n = 50). After surgery, patients were given the same standard enteral formula as the control group. A third group orally received 1 L/d for 7 consecutive days of the enriched liquid diet. After surgery, patients were given enteral feeding with the same enriched formula (perioperative group; n = 50). MAIN OUTCOME MEASURES Postoperative complications and length of hospital stay. RESULTS The 3 groups were comparable for baseline demographics, biochemical markers, comorbidity factors, and surgical variables. The intent-to-treat analysis showed that the total number of patients with complications was 24 in the control group, 14 in the preoperative group, and 9 in the perioperative group (P =.02, control group vs perioperative group). Postoperative length of stay was significantly shorter in the preoperative (13.2 days) and perioperative (12.0 days) groups than in the control group (15.3 days) (P =.01 and P =.001, respectively, vs the control group). CONCLUSION Perioperative immunonutrition seems to be the best approach to support malnourished patients with cancer.