Early combined parenteral and enteral nutrition for pancreaticoduodenectomy - Retrospective cohort analysis

Background

Suggested guidelines for nutritional support after pancreaticoduodenectomy are still controversial. Recent evidence suggests that combining enteral nutrition (EN) with parenteral nutrition (PN) improves outcome. For ten years, patients have been treated with Early Combined Parenteral and Enteral Nutrition (ECPEN) after PD. The aim of this study was to report on rationale, safety, effectiveness and outcome associated with this method.

Methods

Consecutive PD performed between 2003 and 2012 were analyzed retrospectively. Early EN and PN was standardized and started immediately after surgery. EN was increased to 40 ml/h (1 kcal/ml) over 24 h, while PN was supplemented based on a daily energy target of 25 kcal/kg. Standard enteral and parenteral products were used.

Results

Sixty-nine patients were nutritionally supplemented according to ECPEN. The median coverage of kcal per patients related to the total caloric requirements during the entire hospitalization (nutrition balance) was 93.4% (range: 100%–69.3%). The nutritional balance in patients with needle catheter jejunostomy (NCJ) was significantly higher than in the group with nasojejunal tube (97.1% vs. 91.6%; p < 0.0001). Mortality rate was 5.8%, while major complications (Clavien-Dindo 3–5) occurred in 21.7% of patients. Neither the presence of preoperative malnutrition nor the application of preoperative immunonutrition was associated with postoperative clinical outcome.

Conclusion

This is the first European study of ECPEN after PD. ECPEN is safe and, especially in combination with NCJ, provides comprehensive coverage of caloric requirements during the postoperative phase. Clinical controlled trials are needed to investigate potential benefits of complete energy supplementation during the early postoperative phase after PD.

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ECPEN is one possible nutritional technique after pancreaticoduodenectomy.

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The coverage of caloric requirements per patient was 93.4%.

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The coverage was higher in patients with needle catheter jejunostomy.

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With ECPEN malnutrition or immunonutrition did not affect outcomes.

Nutritional Risk in Major Abdominal Surgery: Protocol of a Prospective Observational Trial to Evaluate the Prognostic Value of Different Nutritional Scores in Pancreatic Surgery

BACKGROUND

The influence of patients' preoperative nutritional status on their clinical outcome has already been proven. Therefore, patients with malnutrition are in need of additional therapeutic efforts. However, for pancreatic surgery, evidence suggesting the adequacy of existing nutritional assessment scores to estimate malnutrition associated with postoperative outcome is limited.

OBJECTIVE

The aim of the observational trial "Nutritional Risk in Major Abdominal Surgery (NURIMAS) Pancreas" is to prospectively assess and analyze different nutritional assessment scores for their prognostic value on postoperative complications in patients undergoing pancreatic surgery.

METHODS

All patients scheduled to receive elective pancreatic surgery at the University Hospital of Heidelberg will be screened for eligibility. Preoperatively, 12 nutritional assessment scores will be collected and patients will be assigned either at risk or not at risk for malnutrition. The postoperative course will be followed prospectively and complications according to the Clavien-Dindo classification will be recorded. The prognostic value for complications will be evaluated for every score in a univariable and multivariable analysis corrected for known risk factors in pancreatic surgery.

RESULTS

Final data analysis is expected to be available during Spring 2016.

CONCLUSIONS

The NURIMAS Pancreas trial is a monocentric, prospective, observational trial aiming to find the most predictive clinical nutritional assessment score for postoperative complications. Using the results of this protocol as a knowledge base, it is possible to conduct nutritional risk-guided intervention trials to prevent postoperative complications in the pancreatic surgical population.

TRIAL REGISTRATION

germanctr.de: DRKS00006340; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00006340 (Archived by WebCite at http://www.webcitation.org/6bzXWSRYZ).

Stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy

BACKGROUND

Resections of the pancreatic body and tail reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are elective treatments for chronic pancreatitis, benign or malignant diseases, and they have high morbidity rates of up to 40%. Pancreatic fistula formation is the main source of postoperative morbidity, associated with numerous further complications. Researchers have proposed several surgical resection and closure techniques of the pancreatic remnant in an attempt to reduce these complications. The two most common techniques are scalpel resection followed by hand-sewn closure of the pancreatic remnant and stapler resection and closure.

OBJECTIVES

To compare the rates of pancreatic fistula in people undergoing distal pancreatectomy using scalpel resection followed by hand-sewn closure of the pancreatic remnant versus stapler resection and closure.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Biosis and Science Citation Index from database inception to October 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and extracted the data. Taking into consideration the clinical heterogeneity between the trials (e.g. different endpoint definitions), we analysed data using a random-effects model with Review Manager (RevMan), calculating risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

In two eligible trials, a total of 381 participants underwent distal pancreatic resection and were randomised to closure of the pancreatic remnant either with stapler (n = 191) or scalpel resection followed by hand-sewn closure (n = 190). One was a single centre pilot RCT and the other was a multicentre blinded RCT. The single centre pilot RCT evaluated 69 participants in five intervention arms (stapler, hand-sewn, fibrin glue, mesh and pancreaticojejunostomy), although we only assessed the stapler and hand-sewn closure groups (14 and 15 participants, respectively). The multicentre RCT had two interventional arms: stapler (n = 177) and hand-sewn closure (n = 175). The rate of postoperative pancreatic fistula was the main outcome, and it occurred in 79 of 190 participants in the hand-sewn group compared to 65 of 191 participants in the stapler group. Neither the individual trials nor the meta-analysis showed a significant difference between resection techniques (RR 0.90; 95% CI 0.55 to 1.45; P = 0.66). In the same way, postoperative mortality and operation time did not differ significantly. The single centre RCT had an unclear risk of bias in the randomisation, allocation and both blinding domains. However, the much larger multicentre RCT had a low risk of bias in all domains. Due to the small number of events and the wide confidence intervals that cannot exclude clinically important benefit or harm with stapler versus hand-sewn closure, there is a serious possibility of imprecision, making the overall quality of evidence moderate.

AUTHORS' CONCLUSIONS

The quality of evidence is moderate and mainly based on the high weight of the results of one multicentre RCT. Unfortunately, there are no other completed RCTs on this topic except for one relevant ongoing trial. Neither stapler nor scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy showed any benefit compared to the other method in terms of postoperative pancreatic fistula, overall postoperative mortality or operation time. Currently, the choice of closure is left up to the preference of the individual surgeon and the anatomical characteristics of the patient. Another (non-European) multicentre trial (e.g. with an equality or non-inferiority design) would help to corroborate the findings of this meta-analysis. Future trials assessing novel methods of stump closure should compare them either with stapler or hand-sewn closure as a control group to ensure comparability of results.

Percutaneous versus surgical strategy for tracheostomy: protocol for a systematic review and meta-analysis of perioperative and postoperative complications

BACKGROUND

Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches to form a tracheostoma are the open surgical tracheotomy (ST) and the interventional strategy of percutaneous dilatational tracheotomy (PDT). It is particularly important to the critically ill patients that both procedures are performed with high success rates and low complication frequencies. Therefore, the aim of this systematic review is to summarize and analyze existing and relevant evidence for peri- and postoperative parameters of safety.

METHODS/DESIGN

A systematic literature search will be conducted in The Cochrane Library, MEDLINE, LILACS, and Embase to identify all randomized controlled trials (RCTs) comparing peri- and postoperative complications between the two strategies and to define the strategy with the lower risk of potentially life-threatening events. A priori defined data will be extracted from included studies, and methodological quality will be assessed according to the recommendations of the Cochrane Collaboration.

DISCUSSION

The findings of this systematic review with proportional meta-analysis will help to identify the strategy with the lowest frequency of potentially life-threatening events. This may influence daily practice, and the data may be implemented in treatment guidelines or serve as the basis for planning further randomized controlled trials. Considering the critical health of these patients, they will particularly benefit from evidence-based treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015021967.

[Evidence-based surgery - The Study Center of the German Surgical Society]

The Study Center of the German Surgical Society (SDGC) assists surgeons to develop research questions and conduct clinical trials. Development (sample size calculation, protocol, funding application), implementation (submission to ethics committee, data management, monitoring) and analysis (statistical analysis, publication) are supported by SDGC specialists such as biometricians and project managers. Currently approximately 4,800 patients have been included in 15 trials. Systematic reviews with meta-analyses are the basis of valid sample size calculation by aggregating the results of existing studies systematically. In 2005, a work group for the development of systematic reviews has been established at the SDGC. Sixteen publications have so far been completed, and eight more are underway. Using clinical trials and systematic reviews as the fundamental cornerstones in evidence-based medicine, the SDGC has developed an effective network for clinical research in surgery.

Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy

Background

Postoperative pancreatic fistula is one of the most important and potentially severe complications after partial pancreaticoduodenectomy. In this context, the reduction of postoperative pancreatic fistula by means of a dual-loop (Roux-en-Y) reconstruction with isolation of the pancreaticojejunostomy from biliary drainage has been evaluated in several studies. This systematic review and meta-analysis summarizes evidence of effectiveness and safety of the isolation of the pancreaticojejunostomy compared with conventional single-loop reconstruction.

Methods

Randomized clinical trials (RCTs) and controlled clinical trials (CCTs) comparing outcomes of dual-loop reconstruction with isolated pancreaticojejunostomy and single-loop reconstruction were searched according to PRISMA guidelines. Random-effects meta-analyses were performed and the results presented as weighted risk ratios or mean differences with their corresponding 95 per cent c.i.

Results

Of 83 trials screened for eligibility, three RCTs and four CCTs including a total of 802 patients were finally included. Quantitative synthesis showed no significant statistical difference between the two procedures regarding postoperative pancreatic fistula, delayed gastric emptying, haemorrhage, intra-abdominal fluid collection or abscess, bile leakage, wound infection, pneumonia, overall morbidity, mortality, reinterventions, reoperations, perioperative blood loss and length of hospital stay. Duration of surgery was significantly longer in patients undergoing dual-loop reconstruction.

Conclusion

Dual-loop (Roux-en-Y) reconstruction with isolated pancreaticojejunostomy after partial pancreaticoduodenectomy is not superior to single-loop reconstruction regarding pancreatic fistula rate or other relevant outcomes. Additional superiority trials are therefore not warranted, although a high-quality trial may be justified to prove equivalence or non-inferiority.

Association of industry sponsorship and positive outcome in randomised controlled trials in general and abdominal surgery: protocol for a systematic review and empirical study

BACKGROUND

Industry sponsorship has been identified as a factor correlating with positive research findings in several fields of medical science. To date, the influence of industry sponsorship in general and abdominal surgery has not been fully studied. This protocol describes the rationale and planned conduct of a systematic review to determine the association between industry sponsorship and positive outcome in randomised controlled trials in general and abdominal surgery.

METHODS/DESIGN

A literature search in the Cochrane Library, MEDLINE and EMBASE and additional hand searches in relevant citations will be conducted. In order to cover all relevant areas of general and abdominal surgery, a new literature search strategy called multi-PICO search strategy (MPSS) has been developed. No language restriction will be applied. The search will be limited to publications between January 1985 and July 2014. Information on funding source, outcome, study characteristics and methodological quality will be extracted.The association between industry sponsorship and positive outcome will be tested by a chi-squared test. A multivariate logistic regression analysis will be performed to control for possible confounders, such as number of study centres, multinational trials, methodological quality, journal impact factor and sample size.

DISCUSSION

This study was designed to clarify whether industry-sponsored trials report more positive outcomes than non-industry trials. It will be the first study to evaluate this topic in general and abdominal surgery. The findings of this study will enable surgical societies, in particular, to give advice about cooperation with the industry and disclosure of funding source based on empirical evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010802.

Study methods in evidence-based surgery: methodological impediments and suggested approaches for the creation and transfer of knowledge in surgery

BACKGROUND

Since its introduction more than 20 years ago, evidence-based medicine has become an important principle in the daily routine of clinicians around the globe. Nevertheless, many surgical interventions are still not based on high-quality evidence from clinical trials. This is partially due to the fact that surgical trials pose some specific obstacles, which have to be overcome during the planning and conduct of such a trial.

OBJECTIVE

In this study, we will highlight specific challenges and discuss explicit obstacles of surgical clinical research. Moreover, potential solutions will be substantiated by the experience of the Study Centre of the German Surgical Society (SDGC) in surgical clinical research.

CONCLUSIONS

Surgical researchers should be equipped with a basic knowledge of research methodology to be able to overcome the common impediments posed by surgical trials. Collaborations between surgeons and methodologists as well as trial networks have proven to be useful in accomplishing high-quality surgical research in various randomized controlled trials. By maintaining and refining this work and with sufficient and prompt translation of investigational knowledge into daily practice, the treatment of surgical patients should result in an improved outcome in the future.

Vertebral discitis after laparoscopic resection rectopexy: a rare differential diagnosis

Vertebral discitis usually arises from haematogenous spread of pathogens to the discs and bones. Vertebral discitis can rarely occur as a complication after laparoscopic operations with fixating sutures on the promontory. We report the case of an 81-year-old woman who underwent a laparoscopic resection rectopexy because of rectal prolapse. Weeks after the operation, the patient developed lower back pain with radiation to both legs not responding to symptomatic therapy. Two months later, a magnetic resonance imaging of the lumbar spine showed vertebral osteomyelitis and discitis. A fixation on the promontory may be sufficiently traumatic to the spine to pave the way for subsequent infection. A high index of suspicion should be raised in patients with persistent, severe back pain. Anamnesis, imageing and an adequate specimen from the affected area for microbiological analysis are crucial for timely diagnosis and appropriate management involving targeted and prolonged antimicrobial therapy.

The antibody-based targeted delivery of TNF in combination with doxorubicin eradicates sarcomas in mice and confers protective immunity

Background:

Soft-tissue sarcomas are a group of malignancies of mesenchymal origin, which typically have a dismal prognosis if they reach the metastatic stage. The observation of rare spontaneous remissions in patients suffering from concomitant bacterial infections had triggered the clinical investigation of the use of heat-killed bacteria as therapeutic agents (Coley's toxin), which induced complete responses in patients in the pre-chemotherapy era and is now known to mediate substantial elevations in serum TNF levels.

Methods:

We designed and developed a novel immunocytokine based on murine TNF sequentially fused to the antibody fragment F8 (specific to extra-domain A of fibronectin). The antitumor activity was studied in two syngeneic murine sarcoma models.

Results:

The L19 antibody (specific to extra-domain B of fibronectin) has shown by SPECT imaging procedures to selectively localise on sarcoma in a patient with a peripheral nerve sheath tumour, and immunohistochemical analysis of human soft-tissue sarcoma samples showed comparable antigen expression of EDA and EDB. The antibody-based pharmacodelivery of TNF by the fusion protein ‘F8–TNF' to oncofetal fibronectin in sarcoma-bearing mice leads to complete and long-lasting tumour eradications when administered in combination with doxorubicin, the first-line drug for the treatment of sarcomas in humans. Doxorubicin alone did not display any therapeutic effect in both tested models of this study. The cured mice had acquired protective immunity against the tumour, as they rejected subsequent challenges with sarcoma cells.

Conclusion:

The findings of this study provide a rationale for the clinical study of the fully human immunocytokine L19-TNF in combination with doxorubicin in patients with soft-tissue sarcoma.

[Brucellosis as a differential diagnosis of cancer of the testes]

Brucellosis has become a rarity in industrialized countries. The manifestation as a granulomatous inflammation of the testes is described with an incidence of 5-40% in the literature and therefore is a relatively common complication of brucellosis. In cases of pain of the testes combined with B symptoms, a systemic inflammation with a local complication should also be considered besides cancer of the testes.

Long-term outcome after thrombectomy in acute myocardial infarction

BACKGROUND

Current data appear in favour of thrombectomy for ST-elevation myocardial infarction (STEMI). However, information on long-term outcome after thrombectomy is limited. We performed a retrospective long-term study to assess the risk of cardiac re-hospitalizations and survival after discharge from the index hospitalization for STEMI.

METHODS

Patients originally randomized to percutaneous coronary intervention (PCI) with thrombectomy vs. standard PCI were included in a retrospective long-term observational study. The primary study endpoint was the combined risk for all-cause death or cardiac re-hospitalization after index discharge under optimal medical therapy. The cumulative number of cardiac hospitalization days and ventricular remodelling assessed by echocardiography and plasma biomarkers were secondary endpoints.

RESULTS

Of 94 STEMI patients who had been randomized between 11/2000 and 03/2003, 89 patients consented to long-term follow-up. A total of 43 patients had been allocated to thrombectomy and 46 to standard primary PCI. The minimum follow-up time was 1115 days. There was a significantly lower risk for death or cardiac re-hospitalization for patients of the thrombectomy group (hazard ratio = 0.69, 95% CI: 0.49-0.98, P = 0.036). The incidence of recurrent myocardial infarction was not different (P = 0.343). No differences in cardiac remodelling were detected by echocardiography, with the exception that heart-type fatty acid binding protein at 53.2 +/- 17 months was lower in the thrombectomy group (P = 0.045).

CONCLUSION

Thrombectomy in STEMI may decrease the long-term risk for death or cardiac re-hospitalization.

Comparison of transesophageal Doppler coronary flow reserve measurements with thallium-201 single-photon emission computed tomography imaging in assessment of left anterior descending artery stenoses

BACKGROUND AND HYPOTHESIS

Recent studies demonstrate the feasibility of coronary flow reserve measurements by transesophageal echocardiographic (TEE) Doppler recordings of coronary sinus or left anterior descending (LAD) coronary artery flow velocity for detecting stenoses of the LAD artery. This study compares coronary flow reserve measurements by Doppler TEE with thallium-201 (201Tl) single-photon emission computed tomography (SPECT) in patients with proximal single-vessel LAD stenosis.

METHODS

Nineteen patients with various degrees of LAD stenosis (mean area stenosis 71 +/- 24%; range 24-96%) were studied. Area stenosis by quantitative coronary angiography was < 75% in 7 patients and > 75% in 12 patients. Transesophageal LAD and coronary sinus Doppler measurements were performed at baseline and after intravenous dipyridamole. Coronary flow reserve was calculated as the ratio of hyperemic to baseline average peak velocities. Predefined coronary flow reserve cut-off values of 1.8 for the coronary sinus method and of 2.0 for the LAD method were used for diagnosis of significant LAD stenosis. Results were compared with qualitative 201Tl dipyridamole SPECT.

RESULTS

Overall predictive accuracy for diagnosis of > 75% LAD stenosis was 79% for 201Tl SPECT, 77% for the transesophageal LAD and 79% for the transesophageal coronary sinus technique. Concordant results between 201Tl SPECT and the LAD and coronary sinus Doppler methods were observed in 79% and 71% of patients, respectively.

CONCLUSIONS

Thallium-201 SPECT and transesophageal Doppler assessment of coronary flow reserve have similar accuracy for diagnosing significant proximal LAD stenosis. Therefore, both transesophageal Doppler techniques might constitute another widely available, noninvasive method for assessment of left coronary artery disease, if disease location is proximal.

Cerebral microembolism during transcatheter closure of patent foramen ovale

BACKGROUND

Although transcatheter closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has become a commonly performed intervention, the incidence of cerebral embolism with or without neurological deficits during such procedures has not been studied.

METHODS

We monitored the middle cerebral artery in two different depths (48 mm and 53 mm) by continuous transcranial Doppler ultrasound during transcatheter PFO closure in 35 consecutive patients (F/M 20/15, mean age 47 +/- 11 years) and during ASD closure in 8 patients (F/M 7/1, mean age 45 +/- 5 years). All automatically detected high intensity transient signals (HITS) were manually reviewed to eliminate artifacts.

RESULTS

HITS were detected in 33 of 35 patients (96%) with a median rate of 8 (interquartile range 4-19, range 2-29) HITS. The highest rates were observed when the septum was crossed with the guide wire (median 2; IQR 0-12; range 0-25) and when the left atrial disc was deployed (median 2; IQR 1-4; range 0-13). Despite this high rate of cerebral microembolism no clinically apparent neurological or neuropsychological deficit was observed.

CONCLUSIONS

Silent cerebral embolism frequently occurs during transcatheter PFO and ASD closure. The peak of HITS at the time of crossing the septum with the guide wire may support the hypothesis that cerebral emboli in patients with PFO may originate from the septum itself. This may represent an alternative mechanism to the generally assumed paradoxical embolism.

Stent implantation in acute myocardial infarction using a heparin-coated stent: a pilot study as a preamble to a randomized trial comparing balloon angioplasty and stenting

Preliminary experience with primary stenting in myocardial infarction has suggested a greater benefit in clinical outcome than has been obtained with direct balloon angioplasty. However, subacute thrombosis (SAT) remains a limitation for this new mode of therapy. In the BENESTENT II Pilot and main trials, the incidence of SAT with the heparin-coated Palmaz-Schatz stent was only 0.15%. Therefore, as a preamble to a large randomized trial, the feasibility and safety of the use of the Heparin-Coated Palmaz-Schatz trade mark Stent in Acute Myocardial Infarction (AMI) was tested in 101 patients enrolled between April and September 1996 in 18 clinical centres. In 101 stent-eligible AMI patients, as dictated by protocol, a heparin-coated stent was implanted. The primary objectives were to determine the in-hospital incidence of major adverse cardiac events (MACE: death, MI, target lesion revascularization) and bleeding complications, while the secondary objectives were the procedural success rate and the MACE, the restenosis and reocclusion rates at 6.5 months. Stent implantation (n 3 129 stents) was successful in 97 patients of the 101 who were included in this trial. During their hospital stay, two patients died and no patient experienced re-infarction, ischaemia prompting re-PTCA or CABG. Four patients suffered a bleeding complication, three major and one minor, of whom three required surgical repair. At 210 days follow-up, 81% of the patients were event free. At 6.5 months restenosis was documented in 18% of the 88 patients who underwent follow-up angiography, including three total occlusions. The results, both with respect to QCA and the occurrence of MACE, compare favourably with studies using elective stenting in both stable and unstable angina patients. As a result of this pilot study, a large randomized trial comparing direct balloon angioplasty with direct stenting in 900 patients with AMI was initiated in December 1996.

Chlamydial antigens colocalize within IncA-laden fibers extending from the inclusion membrane into the host cytosol

Chlamydial IncA localizes to the inclusion membrane and to vesicular fibers extending away from the inclusion. Chlamydial outer membrane components, in the absence of developmental forms, are found within these fibers. This colocalization may explain how chlamydial developmental form antigens are localized outside of the inclusion within infected cells.