Metin Senkal

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.

Reduction in Diarrhea Incidence by Soluble Fiber in Patients Receiving Total or Supplemental Enteral Nutrition

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.

Supplementation of Ω-3 Fatty Acids in Parenteral Nutrition Beneficially Alters Phospholipid Fatty Acid Pattern:

BACKGROUND Gastrointestinal side effects, particularly diarrhea, are still the main reasons for discontinuation of enteral nutrition. Although the causes of diarrhea are diverse, the enteral nutrition solution is frequently suspected of playing a leading role in causing diarrhea. METHODS Our randomized, prospective, double-blind trial with 100 patients assessed the effects of feeding a standard diet (Nutrodrip Standard) vs the same diet supplemented with 20 g of soluble fiber, containing partially hydrolyzed guar gum (Sunfiber), per 1000 mL. Thirty patients received total enteral nutrition postoperatively, and 70 patients received enteral supplementation. RESULTS The patients receiving total enteral nutrition with soluble fiber had decreased diarrhea but increased flatulence. In none of these patients did enteral feeding have to be discontinued because of gastrointestinal side effects, whereas in four patients who were on a standard diet, enteral feeding had to be interrupted because of diarrhea (p < .05). Similar observations were made in patients receiving enteral supplementation. In both groups, the incidence of diarrhea decreased significantly with the soluble fiber diet compared with the standard diet (6 vs 15, p < .05). CONCLUSIONS Enteral feeding with a formula supplemented with partially hydrolyzed guar gum reduces the incidence of diarrhea in patients receiving total enteral nutrition as well as in those receiving enteral supplementation, regardless of the cause of diarrhea. The increased hydrogen production and the significantly higher rate of flatulence are likely to result from fermentation of the soluble fiber in the colon, with concomitant production of short-chain fatty acids, which leads to increased absorption of short-chain fatty acids, sodium, and water by the colonocytes. This effect, together with the observed cholecystokinin-mediated decrease in colonic transit time with partially hydrolyzed guar gum, may explain the reduction in the incidence of diarrhea in this study.

Blood glucose control in healthy subject and patients receiving intravenous glucose infusion or total parenteral nutrition using glucagon-like peptide 1.

BACKGROUND The clinical safety and the uptake of ω-3 polyunsaturated fatty acids (PUFA) into the serum phospholipids and erythrocyte membranes after administration of fish-oil-supplemented parenteral nutrition (PN) was investigated in colorectal surgical patients. METHODS Forty patients undergoing colorectal surgery (n = 40) and with an indication for PN were enrolled in a prospective, double-blind, randomized study to receive an ω-3 PUFA-supplemented 20% lipid emulsion (Lipoplus; B. Braun Melsungen, Melsungen, Germany; test group, n = 19) for 5 days postoperatively. The control group received a standard 20% fat emulsion (Lipofundin MCT/LCT, B. Braun Melsungen, Melsungen, Germany, control group, n = 21). Clinical outcome parameters and safety were assessed by means of adverse events recording clinical parameters and hematologic analyses. The contents of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as arachidonic acid (AA), in phospholipid fractions in plasma and in erythrocytes were analyzed preoperatively, on postoperative days 1, 6, and 10 using liquid gas chromatography. RESULTS Both fat emulsions were well tolerated, and none of the adverse events was considered to be related to treatment. Postoperative infectious complications occurred in 4 patients of the ω-3 PUFA group vs 7 patients in the control group. As compared with the control group, the ω-3 PUFA group had significantly increased levels of EPA in the membranes of the erythrocytes in postoperative day 6 (2.0% ± 0.9% vs 0.8% ± 0.5% fatty acid methyl esters, [FAME]) and postoperative day 10 (2.1% ± 0.8% vs 0.9%± 0.7% FAME, p < .05). Also, the EPA levels in the serum phospholipids were significantly higher than in the control group on the same postoperative days (7.0% ± 2.6% vs 1.3% ± 0.8% and 3.6%± 1.0% vs 1.0% ± 0.4% FAME, p < .05). The DHA levels in the serum phospholipids were significantly higher in theω -3 PUFA group compared with the control on postoperative days 6 and 10 (11.8% ± 1.9% vs 8.4% ± 1.5% and 11.2% ± 1.6% vs 8.5% ± 1.4% FAME, p < .05). AA levels were not significantly different in the both groups. CONCLUSIONS Ω -3-fatty-acids-supplemented fat emulsions for parenteral administration are safe and very well tolerated. This study demonstrates that parenteral administration of ω-3-PUFA-enriched fat emulsions leads to increased incorporation of EPA and DHA into phospholipids in serum and erythrocytes, whereas AA levels remain unchanged. Thus, postoperative parenteral administration of ω-3-PUFA-enriched lipid emulsions could have an impact on the postoperative inflammatory response after abdominal surgery and could be used in standard postoperative care when PN is indicated.

Preoperative Oral Supplementation with Long-Chain Ω-3 Fatty Acids Beneficially Alters Phospholipid Fatty Acid Patterns in Liver, Gut Mucosa, and Tumor Tissue

AIMS It was the aim of the study to examine whether the insulinotropic gut hormone GLP-1 is able to control or even normalise glycaemia in healthy subjects receiving intravenous glucose infusions and in severely ill patients hyperglycaemic during total parenteral nutrition. PATIENTS AND METHODS Eight healthy subjects and nine patients were examined. The volunteers received, in six separate experiments in randomised order, intravenous glucose at doses of 0, 2 and 5mg kg(-1) min(-1), each with intravenous GLP-1 or placebo for 6 h. Patients were selected on the basis of hyperglycaemia (>150 mg/dl) during complete parenteral nutrition with glucose (3.2+/-1.4 mg kg(-1) min(-1)), amino acids (n=8; 0.9+/-0.2 mg kg(-1) min(-1)), with or without lipid emulsions. Four hours (8 a.m. to 12 a.m. on parenteral nutrition plus NaCl as placebo) were compared to 4 h (12 a.m. to 4 p.m.) with additional GLP-1 administered intravenously. The dose of GLP-1 was 1.2 pmol kg(-1) min(-1). Blood was drawn for the determination of glucose, insulin, C-peptide, GLP-1, glucagon, and free fatty acids. RESULTS Glycaemia was raised dose-dependently by glucose infusions in healthy volunteers (p<0.0001). GLP-1 ( approximately 100-150 pmol/l) stimulated insulin and reduced glucagon secretion and reduced glucose concentrations into the normoglycaemic fasting range (all p<0.05). In hyperglycaemic patients, glucose concentrations during the placebo period averaged 211+/-24 mg/dl. This level was reduced to 159+/-25 mg/dl with GLP-1 (p<0.0001), accompanied by a rise in insulin (p=0.0002) and C-peptide (p<0.0001), and by trend towards a reduction in glucagon (p=0.08) and free fatty acids (p=0.02). GLP-1 was well tolerated. CONCLUSIONS Hyperglycaemia during parenteral nutrition can be controlled by exogenous GLP-1, e.g. the natural peptide (available today), whereas the chronic therapy of Type 2 diabetes requires GLP-1 derivatives with longer duration of action.

Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results

BACKGROUND The uptake of ω-3 polyunsaturated fatty acids (PUFAs) into the liver, gut mucosa, and tumor tissue and plasma levels after preoperative administration of supplemented enteral nutrition was investigated in patients with malignancies of the upper gastrointestinal tract. The objective of the study was to evaluate the incorporation of preoperatively administrated PUFAs, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) into cell phospholipids. METHODS Patients undergoing major gastrointestinal surgery (n = 40) were prospectively randomized to receive a PUFA-supplemented liquid oral diet 5 days preoperatively or an isocaloric control diet. The planned diet intake was 1000 mL/d providing 3.7 g of PUFA. The diet was given in addition to the usual hospital diet. The phospholipid fractions in plasma were analyzed on the day of surgery. Tissue samples of liver, gut mucosa (small intestine), and tumor were taken during surgery and homogenized. EPA and DHA content was analyzed using liquid gas chromatography. RESULTS Both patient groups (PUFA group: n = 20; control group: n = 20) were similar in age, weight, and surgical procedures. As compared with the control group, the PUFA group had significantly increased levels of EPA in liver tissue (0.4 vs 1.3 weight %), gut mucosa (0.3 vs 1.0 weight %), and tumor tissue (0.3 vs 0.8 weight %). Also, the DHA levels in the PUFA group were significantly higher than the control group: liver tissue (4.1 vs 7.5 weight %), gut mucosa (2.1 vs 3.7 weight %) and tumor tissue (1.9 vs 4.2 weight %). CONCLUSIONS This study suggests that administration of PUFA-enriched diets leads to increased incorporation of EPA and DHA not only in liver and gut mucosa tissue, but also in tumor tissue in patients with solid gastrointestinal tumors. Thus, preoperative administration of oral PUFA-enriched diets could have an impact on the postoperative inflammatory response after major abdominal surgery.

Erratum to “Blood glucose control in healthy subject and patients receiving intravenous glucose infusion or total parenteral nutrition using glucagon-like peptide 1” [Regul Pept 118 (2004) 89–97]

Background: We describe a modification of the technique for laparoscopic jejunostomy in patients with stenosis of the upper gastrointestinal tract and assess the patients outcomes with this enteral access. Methods: In a retrospective study of 80 patients, we evaluated the outcome of a modified technique for the laparoscopic placement of a jejunostomy catheter into the proximal jejunum. Standard laparoscopy equipment and ready-to-use jejunostomy catheters were used. After the creation of a pneumoperitoneum, the proximal jejunal loop was fixed to the parietal peritoneum. The jejunum was then punctured with a split needle, and the catheter (9F) was pushed into the jejunum. Finally, the catheter was secured with an additional purse-string suture. The external fixation was performed with nonabsorbable sutures. Enteral nutritional support with a polymeric enteral diet was initiated after fluoroscopic control on the first postoperative day at a rate of 20 ml/h. The flow rate was increased progressively until the nutritional goal of 60–80 ml/h was reached on the 3rd or 4th postoperative day. Results: In all patients (n = 80), the placement site of the catheter was correct, and all patients were able to receive enteral nutrition on the 1st postoperative day. There were no intraoperative complications. The mean operating time was 51 min. Two patients developed a localized infection at the catheter site; one patient developed an abscess; and three patients had catheter obstructions. Conclusions: Patients in need of intermediate or long-term enteral nutrition may benefit from laparoscopic catheter jejunostomy. The technique described is safe, effective, and less invasive than alternative techniques of laparoscopic jejunostomy.

Ist die gehaltene Aufnahme bei frischer fibularer Bandruptur erforderlich

Medizinische Universitats-Klinik, Knappschafts-Krankenhaus Bochum, Klinikum der Ruhr-Universitat Bochum, In der Schornau 23-25, D-44892 Bochum, Germany Medizinische Klinik 1, St. Josef-Hospital, Klinikum der Ruhr-Universitat Bochum, Gudrunstr. 56, D-44791 Bochum, Germany Diabeteszentrum Bad Lauterberg, Kirchberg 21, D-37431 Bad Lauterberg, Germany Chirurgische Klinik I, St. Josef-Hospital, Klinikum der Ruhr-Universitat Bochum, Gudrunstr. 56, D-44791 Bochum, Germany Department of Medical Physiology, Panum Institute, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark

Intra-arterial Application of Ceftizoxime Supports Wound Healing in Infected Ischemic Lesions of the Limbs

ZusammenfassungGrundlagen: Die fibulare Bandruptur am oberen Sprunggelenk ist die häufigste Kapselbandverletzung der großen Gelenke. Zur Diagnosestellung wird noch vielfach die standardisierte, gehaltene Aufnahme im Seitenvergleich gefordert. Ziel unserer Untersuchung war die Überprüfung der Wertigkeit der gehaltenen Aufnahmen gegenüber der Klinischen Diagnose. Methodik: In einer prospektiven Studie wurden 976 Patienten mit einer frischen fibularen Bandruptur untersucht und operiert. Nach radiologischem Frakturausschluß bei allen Patienten erfolgte die weitere Diagnostik bei 655 Patienten durch die klinische Untersuchung, gefolgt von gehaltenen Aufnahmen nachScheuba, bei 321 Patienten nur durch die klinische Untersuchung. Die tatsächliche Läsion am fibularen Bandapparat wurde bei der anschließenden operativen Revision dargestellt. Ergebnisse: Der operative Situs einer Bandruptur bestätigte die präoperative Diagnose bei 618 (94,35%) von 655 klinisch und mit gehaltenen Aufnahmen untersuchten Patienten. In 29 Fällen (4,43%) war die Aussage falsch negativ, in 5 Fällen (0,76%) falsch positiv und bei 3 Patienten richtig negativ (0,46%). Demgegenüber wurde in 321 Fällen der Entscheidungsfindung anhand der klinischen Parameter die Diagnose intraoperativ bei 320 Patienten (99,7%) bestätigt, in 1 Fall (0,3%) erwies sie sich als falsch positiv. Schlußfolgerungen: Zur Sicherung der Diagnose einer frischen fibularen Bandruptur ist die gehaltene Aufnahme des oberen Sprunggelenkes im Seitenvergleich nicht erforderlich, sie wiederholt das Trauma artifiziell. Nach radiologischem Frakturausschluß darf der klinische Befund als wegweisend betrachtet werden. Vor dem Hintergrund der derzeit dominierenden konservativ-funktionellen Therapie der frischen Außenbandläsion ergibt sich die Indikation für die gehaltene Aufnahme bei der chronischen fibularen Instabilität aus vorwiegend forensischen und versicherungsrechtlichen Aspekten.SummaryBackground: The rupture of the lateral ankle ligaments is a very common ligamentous injury. Frequently, a stress X-ray is recommended in comparison to the not injured ankle in order to evaluate talar tilt and drawer sign. The purpose of our study was the evaluation of raliability of stress X-ray after severe ankle sprain versus the sole clinical examination. Methods: In a prospective study 976 patients were examined and operated after a recent rupture of the lateral ankle ligaments. After radiological exclusion of a fracture one group of 321 patients was examined clinically for ligamentous rupture, whereas in the other group of 655 patients additional stress X-ray was performed. All patients were operated for the repair of the ruptured ligaments. The intraoperative state of all ligamentous lesions was documented. Results: In 618 of 655 patients with additional stress X-ray the pre-operative diagnosis was confirmed by intraoperative findings (i.e. 94.35%). Among 29 patients the diagnosis was false negative (4.48%), in 5 cases false positive (0.76%) and in 3 patients right negative (0.46%). In the other group of 321 patients without stress X-ray the ligamentous rupture was confirmed intraoperatively in 320 cases (99.7%). 1 patient had a false positive diagnosis (0.3%). Conclusions: Stress X-ray of the ankle joint is not necessary after a recent injury for the diagnosis of a ligamentous rupture. Moreover, the trauma is repeated by this technique of examination, which may cause additional injury. Clinical assessment is a safe parameter for the diagnosis. According to the actual trend of conservative/functional treatment of the recent rupture of ankle ligaments we see the indication for stress X-ray only for patients with chronic fibular instability for forensic and documentative reasons.