M. Kemen

Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients.

OBJECTIVE To determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT, Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outcome, i.e., reduced infectious and wound complications and decreased treatment costs when compared with an isocaloric, isonitrogenous control diet. DESIGN A prospective, randomized, placebo-controlled, double-blind, multicenter trial of the clinical outcome and a retrospective cost-comparison analysis. SETTING Surgical intensive care units in three different German university hospitals. PATIENTS Of 164 patients enrolled in the study, 154 patients were eligible for analysis. They were admitted to the intensive care unit after upper gastrointestinal surgery for cancer and they received an enteral diet via needle catheter jejunostomy. Infectious complications were defined as sepsis or systemic inflammatory response syndrome, pneumonia, urinary tract infection, central venous catheter sepsis, wound infection, and anastomotic leakage. The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth postoperative day) postoperative complications. The treatment costs of each complication were analyzed and compared in both groups. INTERVENTIONS Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postoperative day 5. MEASUREMENTS AND MAIN RESULTS Clinical examination and adverse gastrointestinal symptoms were recorded on a daily basis. Both groups tolerated early enteral feeding well, and the rate of tube feeding-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs. 24 patients in the control group (NS). Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 patients in the immunonutritional group vs. 11 patients in the control group). However, in the late phase (after postoperative day 5), considerably fewer patients in the experimental diet group experienced complications compared with the control group (5 vs. 13, p < .05). In addition, the frequency rate of complicating events were recorded in each group. In the experimental diet group, a total of 22 complicating events were recorded vs. a total of 32 events in the placebo diet group (NS). However, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced in the immunonutrition group when compared with the control group (8 vs. 17 events, p < .05). The total costs for the treatment of the complications were 83,563 German marks in the experimental diet group vs. 122,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks. (At the end of December 1995, the conversion rate from German marks to U.S. dollars was 1.4365 German marks to

Early postoperative enteral nutrition with arginine-omega-3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact.

1.00.) CONCLUSIONS Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery. In patients who received the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was observed. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.

Evaluation of clinical safety and beneficial effects of a fish oil containing lipid emulsion (Lipoplus, MLF541) : Data from a prospective, randomized, multicenter trial

OBJECTIVE To evaluate the effect of early postoperative feeding with a nutritionally complete enteral diet supplemented with the nutrients arginine, ribonucleic acid (RNA), and omega-3 fatty acids on the immune function in patients undergoing surgery for upper gastrointestinal (GI) malignancies. DESIGN Prospective, randomized, placebo-controlled, double-blind study. SETTING Surgical intensive care unit (ICU) in a German university hospital. PATIENTS Forty-two consecutive patients receiving an enteral diet via needle catheter jejunostomy after GI surgery for cancer. INTERVENTIONS Patients were randomized to receive either the arginine, RNA, and omega-3 fatty acids supplemented diet or an isocaloric and isonitrogenous placebo diet. Early enteral nutrition was started on postoperative day 1 in the surgical ICU with 20 mL/hr and progressed to the optimal goal of 80 mL/hr by postoperative day 5. MEASUREMENTS AND MAIN RESULTS Clinical examination and adverse GI symptoms were recorded on a daily basis. Body weight was determined twice weekly. Immunoglobulin concentrations were determined by laser nephelometry. Interferon-gamma concentrations were measured with a modified enzyme-linked immunosorbent assay method. Fluorescence-activated cell scan flow cytometry was performed to analyze B cells, T lymphocytes and their subsets. Clinical patient characteristics and mean caloric intake were similar between the two groups and both formulas were well tolerated. The number of T lymphocytes and their subsets, helper T cells (CD4) and activated T cells (CD3, HLA-DR), were significantly higher in the supplemented diet group on postoperative days 10 and 16 (p < .05). Mean interferon-gamma concentration after phytohemagglutinin stimulation was higher in the supplemented diet group on postoperative day 16. In the supplemented diet group, mean immunoglobulin M concentrations were significantly higher on postoperative day 10 and mean immunoglobulin G concentrations were higher on postoperative day 16 (p < .05) compared with the results in the placebo group. B-lymphocyte indices were significantly higher in the supplemented vs. the placebo diet group on postoperative days 7 and 10 (p < .05). CONCLUSIONS Supplementation of enteral diet with arginine, RNA, and omega-3 fatty acids in the early postoperative time period improves postoperative immunologic responses and helps to overcome more rapidly the immunologic depression after surgical trauma.

Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease

Objective:To prove safety and effectiveness of a lipid emulsion enriched with n-3 fatty acids from fish oil (Lipoplus) within the setting of parenteral nutrition of patients after major abdominal surgery and to determine whether there are effects on outcome parameters. Design:Prospective, randomized, double-blind, multicenter trial. Setting:University and surgical teaching hospitals. Patients:After obtaining informed consent, 256 patients undergoing major abdominal surgery were randomized. Parameters of safety, effectiveness, and outcome were routine laboratory parameters, complication rates, length of stay in the intensive care unit, and length of hospital stay. In addition we determined in patient subgroups of 30 patients each, the changes of the content of selected long-chain polyunsaturated fatty acids, the leukotriene synthetic capacity and the antioxidant &agr;-tocopherol. Interventions:Participating patients were randomized to receive either Lipoplus (group I; n = 127 patients) or Intralipid (group II; n = 129 patients). Parenteral nutrition was initiated immediately after surgery and ended on day 5 after surgery. Measurements and Main Results:No significant differences between groups I and II were observed when comparing routine laboratory parameters during the perioperative period. Plasma levels of eicosapentaenoic acid, leukotriene B5, and antioxidant content were significantly increased in group I. Furthermore, there was a significantly shorter length of hospital stay of ≈21% (17.2 vs. 21.9 days; p = .0061) in group I. Conclusions:Our findings indicate that the administration of Lipoplus in the postoperative period after major abdominal surgery is safe and results in a significantly shorter length of hospital stay. Administration of n-3 polyunsaturated fatty acids in the postoperative period can be considered a valuable choice for patients requiring parenteral nutrition after major abdominal surgery.

Video-assisted crossover iliofemoral obturator bypass grafting: A minimally invasive approach to extra-anatomic lower limb revascularization

PURPOSE The study objective was to apply laparoscopic techniques to conventional bypass procedures for aortoiliac occlusive disease. METHODS From October 1995 to August 1997, we performed seven iliofemoral (IFB), five unilateral aortofemoral (UAFB), and 11 aortobifemoral (AFB) bypass procedures and one aortic endarterectomy (TEA) totally laparoscopic. A transabdominal approach with pneumoperitoneum was preferred, and only laparoscopic vascular instruments were used. Endoscopic intervention followed principles of vascular surgery. As in open surgery, we used Dacron grafts and polypropylene sutures. RESULTS Twenty procedures were carried out totally laparoscopic; four conversions to open surgery were necessary. Severe complications included one postoperative respiratory failure requiring ventilatory support for four days, and one iliac vein lesion with subsequent open surgery. Mean operating time was 258 +/- 49 minutes for IFB, 218 +/- 54 minutes for UAFB, 279 +/- 69 minutes for AFB, and 290 minutes for aortic TEA. Mean blood loss was 92 +/- 49 ml for IFB, 390 +/- 316 ml for UAFB, 563 +/- 516 ml for AFB, and 100 ml for aortic TEA. Mean postoperative stay was 7.4 days for IFB, 7.8 days for UAFB, and 10.1 days for AFB. After the aortic TEA, the patient was discharged on day 6. At control examination all grafts were patent; two patients had mild claudication because of one progressive disease and one distal suture stenosis. CONCLUSION Laparoscopic vascular surgery for aortoiliac occlusive disease is feasible, safe, and effective. At the beginning, a cooperation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenge, because operating time and conversion rate decrease with growing experience. The advantages observed in the majority of our patients were minimal tissue trauma, decreased blood loss, and faster postoperative recovery when compared with patients who had open aortic surgery at our institution. Further evidence has to be gained by clinical trials to define the role of laparoscopic vascular surgery for aortoiliac occlusive disease.

Laparoscopic thrombendarterectomy of the infrarenal aorta.

Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique.

Effects of Proximal Gastric Vagotomy on the Gastrointestinal Transit Time of a Mixed Solid-Liquid Test Meal through the Stomach, Small Intestine and Colon

The aim was to perform a totally laparoscopic thrombendarterectomy (TEA) of the infrarenal aorta to reduce the trauma connected to the surgical approach. A 52-year-old man was referred to our institution with severe claudication. Angiography revealed a subtotal stenosis of the infrarenal aorta. Because the lesion was not suitable for an interventional procedure, a TEA was planned. The surgery was performed through six ports using a transperitoneal approach with pneumoperitoneum. The laparoscopic TEA was carried out according to the standards of open vascular surgery. The surgery time was 285 minutes, the crossclamping lasted 105 minutes, and the blood loss was 100 mL. The angiographic and functional results were excellent. The patient experienced a rapid recovery and was discharged after 6 days. This case report shows the feasibility of totally laparoscopic TEA of the infrarenal aorta. The well-known advantages of minimally invasive techniques in abdominal surgery with regard to the decrease of surgical trauma may also be valid in aortic surgery for occlusive disease.

Endoskopische Prothesen-Implantation — wann ist das Verfahren indiziert und wie sind die Ergebnisse?

In order to detect the effects of proximal gastric vagotomy on the gastrointestinal transit time during the early and late postoperative periods, a mixed solid-liquid test meal containing 0.5 mCi

Die laparoskopische Anlage aortobifemoraler Bypässe

Mit dem Ziel der Minimierung des Operationstraumas aortoiliacaler Gefasrekonstruktionen werden in unserer Klinik seit 1995 laparoskopische Techniken angewandt, um den Zugang zu den Spendergefasen zu erreichen (1). Wir verfolgen dabei den Grundsatz, das der eigentliche Gefaseingriff mit denselben Materialien und nach denselben Prinzipien erfolgen soll, wie sie in der „offenen“ Gefaschirurgie Anwendung finden und gultig sind.

Laparoskopische Thrombendarteriektomie der Aorta im infrarenalen Abschnitt

ZusammenfassungFragestellung: Entwicklung einer laparoskopischen Technik zur transperitonealen Anlage einer aortobifemoralen Bifurkationsprothese bei AVK. Methode und Patienten: In der Zeit vom 1. 2. 96 bis zum 1. 2. 98 wurden 16 Patienten der laparoskopischen Anlage einer aortofemoralen Bifurkationsprothese zugeführt. Über 6 5–12 mm große Arbeitszugänge konnten Exposition, Ausklemmung und Arteriotomie des infrarenalen Aortensegmentes mittels laparoskopischer Instrumente ausgeführt werden. Der fortlaufende End-zu-Seit-Anschluß der primär dichten Dacronprothese erfolgte ebenso vollständig laparoskopisch. Nach retroperitonealem Durchzug der Prothesenschenkel, wurden diese konventionell an den Leistenschlagadern angeschlossen. Ergebnisse: Der Eingriff konnte 13mal auf laparoskopischem Wege beendet werden; 3mal war eine Konversion zur konventionellen Operationstechnik erforderlich. Ein Patient erfuhr eine 16tägige intensivmedizinische Behandlung wegen einer respiratorischen Insuffizienz. Die mittlere Operationsdauer betrug 292±60 min bei einer Abklemmzeit von 74 ±18 min. Der Blutverlust lag bei 566±434 ml, bei 2 Patienten erfolgte eine Fremdbluttransfusion. Die regelrechte Lage und Durchgängigkeit der Bypässe wurde angiographisch dokumentiert. Die Patienten konnten durchschnittlich 9±5,8 Tage nach dem Eingriff entlassen werden. Bisher wurden 15 von 16 Patienten im nicht-invasiven Gefäßlabor nachuntersucht, alle Rekonstruktionen waren offen. Wegen einer hochgradigen Stenose am femoralen Anschluß, war in einem Fall eine Revision erforderlich. Schlußfolgerung: Die laparoskopische Anlage einer aortofemoralen Bifurkationsprothese ist möglich, sicher und effektiv. Der technisch anspruchsvolle Eingriff wird mit speziellem Instrumentarium durchgeführt, die Entwicklung eines Klammernahtgeräts sowie eines Retraktors für den Darm wird voraussichtlich den Schwierigkeitsgrad sowie die Dauer der Operation wesentlich verringern können. Möglicherweise wird diese Methode einen Beitrag zur Minimierung des Operationstraumas bei aortofemoralen Rekonstruktionen leisten können.AbstractPurpose: The aim of the study was to apply laparoscopic techniques in reconstructive procedures for aortoiliac occlusive disease. Methods: From February 1996 to February 1998, 16 patients underwent a laparoscopic aortobifemoral bypass procedure (ABF) using the transperitoneal approach. Six, 5 to 12 mm ports were needed to dissect, cross-clamp and divide the infrarenal aorta using specific laparoscopic devices. The aortic anastomosis was made end-to-side. A long curved clamp was then passed from each groin to draw the limbs of the graft into the femoral incision. The distal anastomosis was then performed conventionally. Results: The laparoscopic ABF was performed successfully in 13 of 16 cases. Three times a conversion to open surgery was requested. One patient developed respiratory insufficiency requiring prolonged treatment on the ICU. Mean operative time was 292±60 min; the aorta was crossclamped for 74±18 min. Two patients needed transfusions of red blood cells. In the study group, blood loss averaged 566±434 ml. The bypass patency and the correct positioning of the graft were assessed by angiography. The patients were discharged 9±5.8 days after surgery. At follow-up after 4.5±4 months, 15 patients were examined noninvasively in the vascular laboratory. All grafts were patent, and the ischemic symptoms had resolved in 14 patients. One patient with recurrent claudication had severe stenosis of the left distal anastomosis. Conclusions: The laparoscopic aortobifemoral bypass is a feasible, safe and effective procedure. Specific laparoscopic instruments are required for the challenging procedure. The development of vascular staplers and retraction devices will probably reduce the operative time and the technical challenge. In the future this operative technique may gain relevance as a minimally invasive procedure for severe aortoiliac occlusive disease.