Luca Gianotti

ESPEN Guidelines on Parenteral Nutrition: Pancreas

Assessment of the severity of acute pancreatitis (AP), together with the patients nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5-7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided. PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased. When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered. In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction

BackgroundThe efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.MethodsSubjects admitted to the authors’ department with colorectal obstruction (nxa0=xa0134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: nxa0=xa049) or for definitive palliation (nxa0=xa034). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.ResultsPlacement of SEMS was technically successful in 95.3xa0% and clinically successful in 98.7xa0% of cases. The short-term complications in the SEMS group were perforation (nxa0=xa01, 1.2xa0%), migration (nxa0=xa04, 4.9xa0%), occlusion (nxa0=xa04, 4.9xa0%), colon bleeding (nxa0=xa03, 3.7xa0%), and abdominal pain (nxa0=xa06, 7.4xa0%). The postoperative complication rate was 32.7xa0% in the SEMS group versus 60.8xa0% in the NO-SEMS group (Pxa0=xa00.005), with a significant reduction in wound infections (26.5 vs 54.9xa0%; Pxa0=xa00.004), abdominal abscess (14.3 vs 39.2xa0%; Pxa0=xa00.006), respiratory morbidity (10.2 vs 37.3xa0%; Pxa0=xa00.002), and intensive care treatment (10.2 vs 33.3xa0%; Pxa0=xa00.007). The median postoperative hospital stay was 10 versus 15xa0days (Pxa0=xa00.001). The in-hospital mortality rate in both groups was 2xa0%. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0xa0%; Pxa0=xa00.04) and definitive stoma formation (6.3 vs 26.0xa0%; Pxa0=xa00.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan–Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8xa0%. The hospital readmission rate for SEMS complications was 34.4xa0%. Overall clinical success was 81.2xa0%.ConclusionsIn case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Fast-track surgery: procedure-specific aspects and future direction

IntroductionFast-track (FT) surgery can be defined as a coordinated perioperative approach aimed at reducing surgical stress and facilitating postoperative recovery. The objective of this review was to examine the literature on the procedure-specific application of FT surgery.DiscussionThe concept of FT rehabilitation has been applied mainly in colorectal surgery, but positive data have appeared also in other areas such as orthopedic, hepatopancreaticobiliary, urological, upper gastrointestinal, gynecological, thoracic, vascular, endocrine, breast, and pediatric surgeries. There is very little experience with comprehensive FT programs in cardiac surgery or trauma. Quantitative analysis from randomized trials and cohort studies suggest that FT is effective in reducing hospital stay without increased adverse events. Other benefits of the FT approach include a reduction in complications, ileus, fatigue, pain, and hospital expenses. However, despite clear benefits of FT care, implementation in daily practice has been slow. Further efforts must be undertaken to secure implementation in routine clinical practice. Standardized FT protocols should be provided on a procedure-specific basis.

Duodenal fistula after elective gastrectomy for malignant disease : an italian retrospective multicenter study

BackgroundDuodenal fistula (DF) after gastrectomy continues to be a life-threatening problem. We performed a retrospective multicenter study analyzing the characteristics of DF after elective gastrectomy for malignant disease.MethodsThree thousand seven hundred eighty-five patients who had undergone gastrectomy with duodenal stump in 11 Italian surgical units were analyzed.ResultsSixty-eight DFs occurred, with a median frequency of 1.6% and a mortality rate of 16%. Complications were mainly septic but fistulas or bleeding of surrounding organs accounted for about 30%. Reoperation was performed in 40% of patients. We observed a correlation between mortality and age (hazard ratio 1.09; 95% CI 1.00–1.20) and serum albumin (hazard ratio 0.90; 95% CI 0.83–0.99). The appearance of further complications was associated with reoperation (Pu2009<u20090.001) and death (Pu2009=u20090.054), while the preservation of oral feeding was related to DF healing (Pu2009<u20090.001).ConclusionsThis paper represents the largest series ever published on DF and shows that its features have changed in the last 20xa0years. DF alone no longer leads to death and some complications observed in the past have disappeared, while new ones are emerging. Nowadays, medical therapy is preferred and surgery is indicated only in cases of abdominal sepsis or bleeding.

Surgical treatment of liver metastases of gastric cancer: state of the art

BackgroundThe prognosis of patients with liver metastases from gastric cancer (LMGC) is dismal, and little is known about prognostic factors in these patients; so justification for surgical resection is still controversial. Furthermore the results of chemotherapy for these patients are disappointing. The purpose of this study was to review recent outcomes of hepatectomy for LMGC and to determine the suitable candidates for surgery, assessing the surgical results and clinicopathologic features. Moreover we compare these results with those obtained with alternative treatments.

Acute cholecystitis: the golden 72-h period is not a strict limit to perform early cholecystectomy. Results from 316 consecutive patients

PurposeEarly laparoscopic cholecystectomy (ELC) is the treatment of choice for acute cholecystitis (AC), but the optimal surgical timing is controversial. The aim of this study was to retrospectively verify the outcome of patients with AC according to different timing of cholecystectomy.MethodsPatients undergoing cholecystectomy for AC from 2006 to 2012 were stratified into two groups: initial admission cholecystectomy (IAC) and delayed cholecystectomy (DC, after at least 4xa0weeks). Among IAC, a subgroup undergoing immediate cholecystectomy (IC, within 72xa0h of symptom onset) was further analyzed.ResultsThree-hundred and sixteen consecutive patients were studied. IAC group included 262 patients (82.9xa0%) and DC group included 54 patients (17.1xa0%). The two groups were similar in conversion rate, operation length, and overall complication rate. The total length of hospitalization was longer in DC patients (pu2009=u20090.005). Among DC patients, 25.9xa0% required re-hospitalization while waiting an elective procedure. In the group undergoing IC (66 patients), conversion rate, length of operation, and postoperative morbidity were similar to that of the IAC group. Length of stay was shorter in IC group (pu2009<u20090.001). Multivariate analysis identified moderate–severe AC grading and ASA scoreu2009≥u20093 as predictors of postoperative complications.ConclusionsThe timing of cholecystectomy for AC does not seem to affect conversion rate and postoperative morbidity. Therefore the 72-h period should not be considered a strict limit to perform LC, provided that the operation is carried out during the initial hospital admission.

Metastatic liver disease from non-colorectal, non-neuroendocrine, non-sarcoma cancers: a systematic review

BackgroundHepatic resection of liver metastases of non-colorectal, non-neuroendocrine, and non-sarcoma (NCNNNS) primary malignancies seems to improve survival in selected patients. The aims of the current review were to describe long-term results of surgery and to evaluate prognostic factors for survival in patients who underwent resection of NCNNNS liver metastases.MethodsWe identified 30 full texts (25 single-center and 5 multicenter studies) published after year 1995 and published in English with a total of 3849 patients. For NCNNNS liver metastases, 83.4xa0% of these subjects were resected.ResultsNo prior systematic reviews or meta-analyses on this topic were identified. All studies were case series without matching control groups. The most common primary sites were breast (23.8xa0%), genito-urinary (21.8xa0%), and gastrointestinal tract (19.8xa0%). The median 5- and 10-year overall survival were 32.3xa0% (range 19–42xa0%) and 24xa0% (indicated only in two studies, range 23–25xa0%), respectively, with 71xa0% of R0 resections.ConclusionsThere is evidence suggesting that surgery of NCNNNS metastases is safe, feasible, and effective if treatment is part of a multidisciplinary approach and if indication is based on the prognostic factors underlined in literature analysis.

Effect of glutamine dipeptide supplementation on primary outcomes for elective major surgery: systematic review and meta-analysis.

To evaluate if glutamine (GLN) supplementation may affect primary outcomes in patients undergoing major elective abdominal operations, we performed a systematic literature review of randomized clinical trials (RCTs) published from 1983 to 2013 and comparing intravenous glutamine dipeptide supplementation to no supplementation in elective surgical abdominal procedures. A meta-analysis for each outcome (overall and infectious morbidity and length of stay) of interest was carried out. The effect size was estimated by the risk ratio (RR) or by the weighted mean difference (WMD). Nineteen RCTs were identified with a total of 1243 patients (640 receiving GLN and 603 controls). In general, the studies were underpowered and of medium or low quality. GLN supplementation did not affect overall morbidity (RR = 0.84, 95% CI 0.51 to 1.36; p = 0.473) and infectious morbidity (RR = 0.64; 95% CI = 0.38 to 1.07; p = 0.087). Patients treated with glutamine had a significant reduction in length of hospital stay (WMD = −2.67; 95% CI = −3.83 to −1.50; p < 0.0001). In conclusion, GLN supplementation appears to reduce hospital stay without affecting the rate of complications. The positive effect of GLN on time of hospitalization is difficult to interpret due to the lack of significant effects on surgery-related morbidity.

The Role of the Enteral Route and the Composition of Feeds in the Nutritional Support of Malnourished Surgical Patients

In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks.

Axillary lymphadenectomy for breast cancer. A randomized controlled trial comparing a bipolar vessel sealing system to the conventional technique

AIMnTo compare safety and efficacy of a bipolar vessel sealing system (BVSS) to the conventional technique in axillary node dissection.nnnMETHODSn116 women with breast cancer were randomized to conventional node dissection surgical technique (control; n = 58) by scalpel and monopolar cautery or using an electrothermal BVSS (study group; n = 58).nnnRESULTSnThe median (range) total volume of fluid collected by drain and aspirations was 305 (30-1420) mL in the study group and 335 (80-1070) mL in the control group (p = 0.325). The median (range) total volume of lymph collected by percutaneous aspirations was 207.5 (40-1050) mL in the study group and 505 (270-705) mL in the control group (p = 0.010). The incidence of seroma was similar in both groups (p = 0.845). The axillary drain was removed earlier in the study group than in controls (p = 0.046).nnnCONCLUSIONnThe use of a BVSS offers marginal advantages when compared to the conventional technique.