M. Braga

metabolic and Functional Results After Laparoscopic Colorectal Surgery : a Randomized, Controlled Trial

AbstractPURPOSE: This study was designed to compare metabolic and functional results after laparoscopic and open colorectal resection. METHODS: Seventy-nine patients were randomly assigned to laparoscopic (n = 40) or open (n = 39) colorectal resection. Before and after operation, the following parameters were determined: respiratory function (spirography and blood gas); serum level of cortisol, lactate, and C-reactive protein; total lymphocyte count; and CD4 and CD8 lymphocyte subsets. Intraoperative core temperature was measured by a bladder probe. Postoperative pain and analgesic consumption were also monitored. RESULTS: Mild operative hypothermia, a trend to postoperative reduction of total lymphocyte count, and significant impairment of respiratory function early after surgery were found in both groups. Laparoscopy showed a higher CD4/CD8 ratio (P = 0.01) on postoperative Day 1 and a faster return of C-reactive protein to preoperative values (P = 0.01) than in the open colorectal resection group. Morphine consumption in the first 48 hours after surgery was lower in the laparoscopic than in the open group (P = 0.02). CONCLUSIONS: Laparoscopy was associated with a less pronounced immunosuppression and inflammatory response and a lower consumption of analgesic drugs than open surgery. Moreover, our data did not show any additional detrimental effect of laparoscopy on either operative core temperature or early postoperative respiratory function.

Immunonutrition in Gastric Cancer Surgical Patients

The aim of this study was to evaluate the potential advantages of perioperative versus postoperative administration of an enteral immune-enhancing diet on host defense and protein metabolism. Thirty subjects, candidates for gastrectomy for cancer, were randomly allocated into two groups. The first group (n = 15) received an enteral formula enriched with arginine, omega-3 fatty acids, and RNA 7 d before and 7 d after surgery; the second group (n = 15) received the same diet but only 7 d after surgery. Postoperative immune and inflammatory responses were investigated by phagocytosis ability of polymorphonuclear cells, interleukin-2 receptors (IL-2R), lymphocyte subsets, interleukin-6 (IL-6), and delayed hypersensitivity response (DHR). Prealbumin (PA), retinol binding protein, albumin, and transferrin were determined as protein synthesis indicators. Perioperative immunonutrition prevented the early postoperative impairment of phagocytosis, DHR, total number of lymphocytes, and CD4/CD8 ratio (P < 0.05 versus postoperative group). The IL-2R levels were significantly higher in the perioperative group (P < 0.05 versus postoperative on postoperative day [POD] 4 and 8). Perioperative group also showed lower levels of IL-6 (P < 0.05 versus postoperative on POD 1, 4, and 8) and higher levels of PA (P = 0.04 versus postoperative on POD 8). The perioperative administration of immunonutrition ameliorated the host defense mechanisms, controlled the inflammatory response, and improved the synthesis of short half-life constitutive proteins.

Benefits of Early Postoperative Enteral Feeding in Cancer Patients

OBJECTIVE To evaluate the effect of the early postoperative administration of an enriched enteral diet in cancer patients. DESIGN Randomised controlled study. SETTING Surgical intensive care unit of a university hospital. PATIENTS 77 consecutive patients undergoing curative surgery for gastric or pancreatic cancer. INTERVENTIONS Patients were randomised into 3 groups to receive: a standard enteral formula (n=24); the same formula enriched with arginine, RNA, and omega-3 fatty acids (n = 26), isonitrogen isocaloric total parenteral nutrition (n = 27). Enteral nutrition was started within 12 h following surgery. Infusion rate was progressively increased reaching the full regimen on postoperative day (POD) 4. On admission and on POD 1 and 8, the following measurements were performed: serum level of total iron-binding capacity, albumin, prealbumin, retinol-binding protein (RBP), and cholinesterase. Delayed hypersensitivity response (DHR), IgG, IgM, IgA, lymphocyte subsets. and monocyte phagocytosis ability were also evaluated. Bioelectrical impedance analysis was performed preoperatively and on POD 2, 7, and 11. The rate and severity of postoperative infections and the length of hospital stay were evaluated. RESULTS In all patients, a significant drop of nutritional and immunologic parameters was observed on POD 1. A significant increase of prealbumin (p<0.02), RBP (p<0.005), monocyte phagocytosis ability (p<0.001), and DHR (p<0.005) was found on POD 8 only in the group fed with the enriched diet. A significant reduction of severity of postoperative infections and length of postoperative stay was found in the group with the enriched diet compared to the other groups. CONCLUSIONS These data are suggestive of an improvement of the nutritional and immunologic status and clinical outcome in cancer patients who receive an enriched enteral diet in the early postoperative course.

Erythropoiesis after Therapy with Recombinant Human Erythropoietin: A Dose–Response Study in Anemic Cancer Surgery Patients

Background and Objectives: Preoperative treatment with 600 U/kg of recombinant human erythropoietin (r‐HuEPO) effectively increases erythropoiesis in cancer patients. The aim of this study was to evaluate the erythropoietic response after different doses of r‐HuEPO in order to find the minimum effective dose. Materials and Methods: Twenty anemic sideropenic patients (hemoglobin ≤ 110 g/l; serum iron <600 μg/l) with cancer of the gastrointestinal tract were randomly allocated to two groups: the first (n = 10) received 400 U/kg of r‐Hu EPO divided in 4 doses (100 U/kg each, every 4 days); the second (n = 10) received 200 U/kg of r‐HuEPO (50 U/kg each, every 4 days). Both groups were given intravenous iron gluconate (125 mg) every day for 15 days. Results: After treatment, the serum iron level significantly rose in both groups. The production of new red blood cells was 176.3±90.8 ml in the 200 U/kg group and 268.4±79.4 ml in the 400 U/kg group (p = 0.036). The increase of hemoglobin was significantly higher in the 400 U/kg group (22.3±2.0 g/l) than in the 200 U/kg group (14.1±2.7 g/l) (p = 0.017). Conclusion: The r‐HuEPO dose of 400 U/kg appears significantly more effective than the 200 U/kg to stimulate erythropoiesis in anemic sideropenic cancer patients.

Experimental gut-derived endotoxaemia and bacteraemia are reduced by systemic administration of monoclonal anti-LPS antibodies

This study aimed to investigate the effects and mechanisms of action of systemic administration of monoclonal antibodies, anti-endotoxin (HA-1A), in an animal model of gut-origin sepsis. In the first experiment, Balb/c mice were transfused with allogeneic blood (C3H/HeJ mice). Five days post-transfusion the animals were gavaged with 1 x 10(9) Escherichia coli and randomized into three groups (n = 22 each) to receive a sham burn (SB group) or a 20 per cent TBSA thermal injury, immediately followed by the systemic administration of monoclonal antibodies (3 mg/kg) (HA-1A group) or aliquots of sterile saline (Control group). The animal survival rate was observed for 10 days postburn. In the second experiment transfusion and burn injury were reproduced but the mice (n = 8/group) were gavaged with 10(9) E.coli labelled with 111indium oxine. Four hours after the burn the mesenteric lymph nodes, liver, lungs and blood were harvested to determine plasma endotoxin levels and the magnitude of translocation of labelled bacteria measured by the residual radioactivity in the organs. Circulating endotoxin levels were determined by limulus assay. The mortality rate of the HA-1A group (9 per cent) was similar to the SB group (0 per cent) and significantly lower than the control group (59 per cent) (P < 0.05). Both plasma endotoxin levels and degree of bacterial translocation in all extraintestinal tissues were significantly lower (by approximately 50 per cent) in the HA-1A group than in the control group (P < 0.05). Systemic administration of HA-1A exerts a beneficial effect by reducing the circulating levels of endotoxin and by increasing the gut barrier function to translocating microorganisms.

Role of bioelectrical impedance analysis in acutely dehydrated subjects

15 young healthy volunteers were studied to assess the reliability of bioelectrical impedance analysis (BIA) to determine body composition during acute dehydration. Body weight (BW), resistance and reactance measurements were performed before and 4h after a 40 mg intravenous administration of furosemide. BW decreased on average from 69.09 +/- 9.83 kg to 67.43 +/- 9.72 kg (p < 0.001), while resistance, reactance, and phase angle showed significant increases. The individual variations in bioelectrical parameters were not related to the BW loss. Formulae to derive body composition predicted poorly the true water loss (mean individual error: 40% of real loss). The errors in body composition prediction were unrelated to basal percentage of fat free mass, to body mass index, or to BW loss after furosemide administration. In conclusion, BIA proved unreliable in calculating the body composition of acutely dehydrated subjects.