Metabolic considerations in management of surgical patients

Evaluating the Impact of Multimodal Prehabilitation with High Protein Oral Nutritional Supplementation (HP ONS) with Beta-Hydroxy Beta-Methylbutyrate (HMB) on Sarcopenic Surgical Patients-Interim Analysis of the HEROS Study

BACKGROUND

Multimodal prehabilitation programs, which may incorporate nutritional supplementation and exercise, have been developed to combat sarcopenia in surgical patients to enhance post-operative outcomes. However, the optimal regime remains unknown. The use of beta-hydroxy beta-methylbutyrate (HMB) has beneficial effects on muscle mass and strength. However, its effect on muscle quality in the perioperative setting has yet to be established. This study aims to explore the impact of a multimodal prehabilitation program using a bundle of care that includes high-protein oral nutritional supplementation (HP ONS) with HMB and resistance exercise on muscle quality and functional outcomes in sarcopenic surgical patients.

METHODS

Sarcopenic adult patients undergoing elective major gastrointestinal surgeries were recruited for this pilot interventional cohort study. They were enrolled in a 2-4-week multimodal prehabilitation program comprising resistance exercise, nutritional supplementation, vitamin supplementation, comorbid optimization and smoking cessation. Participants were provided three units of HP ONS with HMB per day pre-operatively. The primary outcome was changes in intramuscular adipose tissue (IMAT) as a proxy of muscle quality, assessed using Artificial Intelligence (AI)-aided ultrasonography. Secondary outcomes include changes in anthropometric measurements and functional characteristics. Outcomes were measured before prehabilitation, after prehabilitation and 1 month post-operatively.

RESULTS

A total of 36 sarcopenic patients, with a median age of 71.5 years, were included in this study. There was an increase in the IMAT index after two weeks of prehabilitation (p = 0.032) to 1 month after surgery (p = 0.028). Among functional parameters, improvement was observed in gait speed (p = 0.01) after two weeks of prehabilitation, which returned to baseline post-operatively. The median length of hospital stay was 7 (range: 2-75) days.

CONCLUSIONS

The increase in the IMAT index in a sarcopenic surgical cohort undergoing prehabilitation may be due to altered muscle metabolism in elderly sarcopenic patients. A prehabilitation regime in sarcopenic patients incorporating HP ONS with HMB and resistance exercise is feasible and is associated with increased gait speed.

Morphological and functional changes of the geniohyoid muscle in elderly patients after hip fracture surgery: Comparison of ultrasound images with a focus on swallowing function

OBJECTIVE

The purpose of this study was to clarify, using ultrasound imaging, (1) whether the area and contraction of GH change in elderly patients after hip fracture surgery and (2) whether the changes in the area and contraction of GH are related to decline in swallowing function.

METHODS

The participants were 21 female patients over 65 years of age who underwent hip fracture surgery. The patients were divided into two groups based on the results of swallowing assessment by water drinking: One with normal swallowing function (NSF) and the other with suspected decline in swallowing function (DSF). Sagittal cross-sectional area (SA) of GH at rest and the shortening rate (SR) of GH upon contraction during swallowing were compared at two time points: immediately and 2 weeks after surgery. Wilcoxon signed-rank test was used for intra-group comparisons, and Mann-Whitney U-test was used for between-group comparisons.

RESULT

SA of GH decreased significantly at 2 weeks after surgery in both groups, regardless of their swallowing function. In the intra-group comparison, SR significantly decreased (worsened) only in DSF group. SR at 2 weeks after surgery was significantly higher in NSF than in the DSF. In the inter-group comparison, DSF showed a significantly smaller (worse) change of SR than NSF in 2 weeks after surgery.

CONCLUSION

Decrease in muscle mass, or atrophy, of GH observed in both NSF and DSF, did not coincide with the post-operative change in GH contraction of the two groups. The results suggest the importance of continuous swallowing assessment in the elderly individuals during their perioperative period.

Validity of the Global Leadership Initiative on Malnutrition criteria using calf circumference in the prediction of in-hospital mortality in older surgical patients: A secondary analysis of a cohort study

BACKGROUND

Malnutrition is a prevalent condition among older patients and is associated with worse clinical outcomes. Methods such as the Subjective Global Assessment (SGA), the Mini Nutritional Assessment Long Form (MNA-LF), and the Global Leadership Initiative on Malnutrition (GLIM) diagnose malnutrition early. This study aimed to evaluate the performance and validity of these instruments to predict the length of hospital stay (LOS) and in-hospital mortality in older surgical patients.

METHODS

This prospective cohort study was performed in hospitalized older surgical patients. In the first 48 h of admission, general data were collected, and patients were evaluated by SGA, MNA-LF, and GLIM using calf circumference (CC) and mid-upper arm circumference (MUAC) as phenotypic criteria for nutrition diagnoses. Accuracy tests and regression analysis adjusted for sex, type of surgery, and the Charlson Comorbidity Index adjusted for age were performed to assess the criterion validity of instruments to predict LOS and mortality.

RESULTS

A total of 214 patients (age 75.4 ± 6.6 years, 57.3% men, and 71.1% admitted to elective surgery) were evaluated. Malnutrition was diagnosed in 39.7% (SGA), 63% (MNA-LF), 41.6% (GLIMCC ), and 32.1% (GLIMMUAC ) of patients. GLIMCC had the best accuracy (AUC = 0.70; 95% CI, 0.63-0.79) and sensitivity (95.8%) to predict in-hospital mortality. In the adjusted analysis, malnutrition, according to SGA, MNA-LF, and GLIMCC , increased the risk of in-hospital mortality by 3.12 (95% CI, 1.08-11.34), 4.51 (95% CI, 1.29-17.61), and 4.83 (95% CI, 1.52-15.22), respectively.

CONCLUSION

GLIMCC had the best performance and satisfactory criterion validity to predict in-hospital mortality in older surgical patients.

Effect of Visual Exposure versus Obstruction upon Patient's Quantitative and Qualitative Stress Parameters Changes during Minor Oral Surgery

OBJECTIVES

 Dental anxiety is ultimately related to the fear of pain, more evidently seen in surgical dental procedures. This study aimed at comparing the stress parameter differences between patients undergoing minor oral surgery (MOS) with their eyes covered (closed) versus uncovered (open) at our center.

MATERIALS AND METHODS

 Twenty-three MOS patients were draped with eyes covered, while another 23 MOS patients were draped with eyes uncovered. Stress parameters such as systolic and diastolic blood pressures (DBP), mean arterial pressure (MAP), heart rate, random blood glucose, and Spielberger State-Trait Anxiety Inventory (STAI)-6 questionnaire score were recorded accordingly in the different intervals; then statistically analyzed later.

RESULTS

 Closed eyes patients had significantly lower mean DBP and MAP (73.91 ± 6.80/88.94 ± 6.88 mm Hg) as compared with open eyes patients intraoperatively. Though significant only in the postoperative phase, the closed eyes group had a relatively lower mean heart pulse rate than the open eyes group in all surgical intervals. Postoperatively, closed eyes patients had lower mean blood glucose level as compared with open eyes group. STAI mean score revealed a higher psychological stress for closed eyes patients versus open eyes patients.

CONCLUSION

 Closed eyes patients displayed lower quantifiable physiological stress level as compared with patients undergoing MOS draped with eyes uncovered. However, in qualitative psychological context, closed eyes draped MOS patients responded poorly as compared with opened eyes draped patients under similar surgical stress.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection

Objectives  The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design  This is a retrospective regression analysis. Setting  This study was done at a single, multihospital, urban academic medical center. Participants  Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures  Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results  Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p  = 0.015) and reoperation after index admission ( p  = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p  = 0.045) and decreasing but not significant reoperation after index admission ( p  = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion  Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

Recognising the importance of language in effective pain assessment

Pain is a highly personal experience that can be challenging to define. In addition, evidence has indicated that the assessment of pain by healthcare professionals is often suboptimal and its severity often underestimated. In clinical practice, the use of language can be a significant influencing factor in the effective management of pain, with terms such as pain, discomfort and comfort used interchangeably. This article explores how language can both act as a barrier to, and assist, nurses to understand the patient's pain experience.

Effects of physical activity on quality of life and physical function in postoperative patients with gastrointestinal cancer

OBJECTIVES

This study was to clarify changes in physical function and quality of life (QOL) for postoperative, and to examine the influence of the amount of physical activity on these variables.

METHODS

This study included 29 patients who underwent gastrointestinal cancer surgery. The QOL measurement was used to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for preoperative and 2nd and 4th postoperative weeks. Physical function measured knee extension strength, 4 m walk time, 5 times sit-to-stand test, and 6-minute walk for preoperative and 1st and 2nd postoperative weeks. The amount of physical activity score was based on METs-hours, which is estimated from cumulative physical activity. As basic characteristics were investigated cancer stage, comorbidities and complications, and operative. Statistical analysis was repeated measures analysis of variance was performed to observe postoperative changes in physical function and QOL. Furthermore, stepwise multiple regression analysis was used to the parameters of physical function and QOL affected by the physical activity score were investigated.

RESULTS

Physical function decreased postoperatively and generally improved 2nd postoperative week. Though scores on the QOL functional scales improved, some items did not improve sufficiently. Multiple regression analysis showed that physical activity score had an effect on constipation and emotion functioning.

CONCLUSIONS

Improvement in symptom scales is not sufficient in a short period of time, and they need to be followed up by increasing the amount of physical activity and promoting instantaneous exercise.

Preemptive light sedation in intensive care unit may reduce pulmonary complications in geriatrics receiving pancreaticoduodenectomy

BACKGROUND

Patients undergoing pancreaticoduodenectomy (PD) for periampullary lesions are usually elderly with a high risk of postoperative morbidity and mortality. This retrospective cohort study investigated whether postoperative preemptive light sedation aids in recovery of elderly patients following PD.

METHODS

Ninety-nine geriatric patients undergoing PD at one hospital were enrolled from 2009 to 2018. Patients in the sedation group received mechanical ventilation support and preemptively light sedation with fentanyl and propofol or dexmedetomidine in the first 5 days postoperatively in the intensive care unit (ICU). Patients in the control group underwent early extubation and received morphine for pain control but no postoperative sedatives in the ordinary ward. Patients in the two groups were matched 1:1 using propensity scoring. The postoperative complication rate, surgical mortality, and postoperative hospital length of stay (LOS) were recorded. We also tested inflammation in an immortal human bronchial epithelial cell line.

RESULTS

After 1:1 matching, 40 patients in the sedation group were compared with 40 patients in the control group. The sedation group had a significantly lower pulmonary complication rate and fewer patients with postoperative gastroparesis. Both groups had similar postoperative hospital LOS and identical surgical mortality rates. Patients in the sedation group had significantly better postoperative quality of life, including less pain and less heartbeat variation. In vitro cell experiments supported the above clinical observations, showing that adequate use of sedatives could significantly elevate the cell viability rate, protect cells from damage, decrease interleukin-6 production, and reduce inflammation.

CONCLUSION

Postoperative preemptive light sedation in the ICU in geriatric patients following PD may not only reduce the rates of postoperative pulmonary complications and gastroparesis but also improve postoperative quality of life without prolonging the postoperative hospital LOS.

Effect of postoperative hypoalbuminemia and supplement of human serum albumin on the development of surgical site infection following spinal fusion surgery: a retrospective study

PURPOSE

To determine the association between postoperative hypoalbuminemia and the development of surgical site infection (SSI) and evaluate whether the supplement of exogenous human serum albumin (HSA) in patients following spinal surgery would decrease the rate of postoperative SSI.

METHODS

We performed a retrospective review of all patients who underwent lumbar spinal fusion surgery in our institution between January 2014 and December 2018. Patients with postoperative SSI were identified. We reviewed the demographic and clinical records of the patients and performed multiple logistic regression models to clarify the relevance between postoperative hypoalbuminemia, the supplement of HSA and SSI. Statistical adjustment for the potential confounders was also performed to exclude possible variation.

RESULTS

Twenty-four of 602 patients developed SSI after lumbar spinal fusion surgery. No statistical significance was found between postoperative hypoalbuminemia and SSI rate (OR 0.74; 95% CI 0.22-2.48; P = 0.6199). However, the supplement of exogenous HSA was significantly associated with increased postoperative SSI rate (OR 1.21; 95% CI 1.05-1.41; P = 0.0094). Interestingly, stratified analyses showed supplement of HSA in patients without postoperative hypoalbuminemia increased the risk of SSI (OR 2.55; 95% CI 1.01-6.45; P = 0.0475), compared with patients with postoperative hypoalbuminemia (OR 1.17; 95% CI 1.00-1.36; P = 0.0434).

CONCLUSIONS

The present study suggests that postoperative hypoalbuminemia is not associated with the development of SSI after spinal surgery. However, the supplement of HSA following spinal surgery will increase the rate of SSI. These slides can be retrieved under Electronic Supplementary Material.

Hepatic and renal functions and blood cell counts in brain tumor patients during the perioperative period

We aimed to investigate the correlations between biochemical and hematological markers and the clinical conditions of brain tumor patients before and after craniotomy. A retrospective study was conducted in 90 brain tumor patients. Age, gender, underlying diseases, tumor size and intraoperative blood loss were recorded. Red blood cell counts and hepatic and renal markers were analyzed preoperatively and postoperatively. Albumin decreased by 5.6 g/L after surgery (p < 0.001). Older patients (>52 years) and females had lower albumin levels than younger patients and males did. Red blood cell counts and hemoglobin levels decreased significantly on the 1st and increased on the 3rd postoperative day. The blood glucose level increased on the 1st postoperative day and then decreased. Older patients had higher blood glucose levels than younger patients did (p < 0.05). The postoperative serum sodium, potassium and calcium levels were within the normal ranges; 37 patients had hypocalcemia (41.1%) and patients with hypokalemia and hyponatremia increased postoperatively. Albumin and hemoglobin levels were linearly correlated (correlation coefficient 0.559, p < 0.001). Intraoperative blood loss was correlated with tumor size (p < 0.05) but did not affect the decrease in hematological markers. In brain tumor patients, red blood cell counts and hemoglobin and serum albumin levels were significantly decreased after craniotomy; these effects were influenced by gender and age instead of intraoperative blood loss. The postoperative blood glucose level peaked and then decreased; it was affected by age and diabetes mellitus. Electrolytes remained relatively stable. These findings have implications for patient management and postoperative complication prevention.

Prospective pilot trial with combination of propranolol with chemotherapy in patients with epithelial ovarian cancer and evaluation on circulating immune cell gene expression

OBJECTIVE

To determine the feasibility of pharmacologic beta-adrenergic blockade in women with newly diagnosed stage II-IV epithelial ovarian cancer (EOC) throughout primary treatment.

METHODS

Patients initiated propranolol prior to beginning chemotherapy or surgery. Feasibility was assessed as proportion able to complete 6 chemotherapy cycles while on adrenergic suppression. Descriptive statistics summarized surveys, and paired changes were analyzed using signed rank tests. Random-intercept Tobit models examined immune response.

RESULTS

Median age was 59.9; 88.5% were stage IIIC/IV; and 38.5% underwent primary debulking. Thirty-two patients were enrolled; 3 excluded because they never took propranolol; an additional 3 didn't meet inclusion criteria, leaving 26 evaluable. Eighteen of 26 (69%), 90% credible interval (CI) of 53-81%, completed 6 chemotherapy cycles plus propranolol (an 82% posterior probability that the true proportion of success is ≥60%). Among the 23 patients with baseline and six month follow up data, overall QOL, anxiety, and depression improved (P < 0.05) and leukocyte expression of pro-inflammatory genes declined (P = 0.03) after completion of therapy. Decrease from baseline of serum IL-6 and IL-8 preceded response to chemotherapy (P < 0.0014). Change from baseline IL-10 preceded complete response.

CONCLUSION

Use of propranolol during primary treatment of EOC is feasible and treatment resulted in decrease in markers of adrenergic stress response. In combination with chemotherapy, propranolol potentially results in improved QOL over baseline.

Appropriate use of total parenteral nutrition in children with perforated appendicitis

BACKGROUND

Total parenteral nutrition (TPN) is often used in children with perforated appendicitis, despite the absence of clear indications. We assessed the validity of specific clinical indications for initiation of TPN in this patient cohort.

METHODS

Data were gathered prospectively on duration of nil per os (NPO) status and TPN use in a cohort of children treated under a perforated appendicitis protocol during a 19-month period. TPN was started in the immediate postoperative period in patients who had generalized peritonitis and severe intestinal dilatation at operation, or later per the discretion of the attending surgeon. At discharge, TPN was considered to have been used appropriately, according to consensus guidelines, if the patient was NPO≥7days or received TPN≥5days.

RESULTS

During the study period, TPN was initiated in 31 (25.4%) of 122 patients operated for perforated appendicitis. Sixteen (51.6%) received TPN per operative finding indications and 15 (48.4%) for prolonged ileus. The operative indications demonstrated 47% sensitivity, 86% specificity, a positive predictive value (PPV) of 35%, and a negative predictive value (NPV) of 91%, when adherence to TPN consensus guidelines was considered the gold standard.

CONCLUSION

Patients without severe intestinal dilatation and generalized peritonitis at operation should not be placed on TPN in the immediate postoperative period. Refinement of selection criteria is necessary to further decrease inappropriate TPN use in children with perforated appendicitis.

TYPE OF STUDY

Diagnostic Test.

LEVEL OF STUDY

II.

Protein sparing therapies in acute illness and obesity: a review of George Blackburn's contributions to nutrition science

Protein sparing therapies were developed to mitigate the harms associated with protein-calorie malnutrition and nitrogen losses induced by either acute illness or hypocaloric diets in patients with obesity. We review the development of protein sparing therapies in illness and obesity with a focus on the pioneering contributions of George Blackburn, MD, PhD. He recognized that protein-calorie malnutrition is a common and serious clinical condition and developed new approaches to its treatment in hospitalized patients. His work with stable isotopes and with animal models provided answers about the physiological nutritional requirements and metabolic changes across a spectrum of conditions with varying degrees of stress and catabolism. This led to improvements in enteral and parenteral nutrition for patients with acute illness. Blackburn also demonstrated that lean body mass can be preserved during weight loss with carefully designed very low calorie treatments which became known as the protein sparing modified fast (PSMF). We review the role of the PSMF as part of the comprehensive management of obesity.

Stuck in tradition-A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff

AIMS AND OBJECTIVES

To explore the barriers for nutritional care as perceived by nursing staff at an acute orthopaedic ward, aiming to implement evidence-based nutritional care.

BACKGROUND

Previous studies indicate that nurses recognise nutritional care as important, but interventions are often lacking. These studies show that a range of barriers influence the attempt to optimise nutritional care. Before the implementation of evidence-based nutritional care, we examined barriers for nutritional care among the nursing staff.

DESIGN

Qualitative study.

METHODS

Four focus groups with thirteen members of the nursing staff were interviewed between October 2013-June 2014. The interview guide was designed according to the Theoretical Domains Framework. The interviews were analysed using qualitative content analysis.

RESULTS

Three main categories emerged: lacking common practice, failing to initiate treatment and struggling with existing resources. The nursing staff was lacking both knowledge and common practice regarding nutritional care. They felt they protected patient autonomy by accepting patient's reluctance to eat or getting a feeding tube. The lack of nutritional focus from doctors decreased the nursing staffs focus leading to nonoptimal nutritional treatment. Competing priorities, physical setting and limited nutritional supplements were believed to hinder nutritional care.

CONCLUSION

The results suggest that nutritional care is in a transitional state from experience- to evidence-based practice. Barriers for nutritional care are grounded in lack of knowledge among nursing staff and insufficient collaboration between nursing staff and the doctors. There is a need for nutritional education for the nursing staff and better support from the organisation to help nursing staff provide evidence-based nutritional care.

RELEVANCE TO CLINICAL PRACTICE

This study contributes with valuable knowledge before the implementation of evidence-based nutritional care. The study provides an understanding of barriers for nutritional care and presents explanations to why nutritional care has failed to become an integrated part of the daily treatment and care.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis

BACKGROUND

Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear.

OBJECTIVE

To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation.

DESIGN

Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation.

MAIN OUTCOME MEASURE

Mortality.

RESULTS

A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population.

CONCLUSION

Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Intratumoural interleukin 12 gene therapy stimulates the immune system and decreases angiogenesis in dogs with spontaneous cancer

Interleukin 12 (IL-12) is a powerful immunostimulatory cytokine with a strong antitumoural activity. In this work, the immunological, anti-angiogenic and clinical effects of three consecutive intratumoural IL-12 electrogene therapy (EGT) treatments were evaluated in nine dogs with spontaneous cancer. In all the dogs, tumour biopsies and blood samples were taken prior, during and after the intratumoural IL-12 EGT (on days 1, 8, 35 and 1, 3, 8, 15, 35, respectively). An initial decrease in immune cells was followed by an increase above baseline 1-3 weeks after treatment initiation. Interestingly, the decrease in peripheral leukocytes 2 days after the first intratumoural IL-12 EGT coincided with erythema and tumour swelling. Transient increases of IL-12 and interferon γ were measured in the serum and the tumour tissue, whereas IL-10 transiently increased only in the serum. The effect of intratumoural IL-12 EGT on the levels of IL-24 and vascular endothelial growth factor in the sera and tumour biopsies differed per dog. Via contrast-enhanced ultrasound (US) (on days 1, 8 and 35), we demonstrated that intratumoural IL-12 EGT resulted in a significant decrease of the relative blood volume and blood flow speed in the tumour compared with baseline. Metastases were present in two dogs. In one of these dogs, IL-12 EGT of the primary tumour caused a transient partial regression of the metastases, but not of the primary tumour. The second dog with metastases did not survive long enough to complete the entire treatment cycle. Despite encouraging immunostimulatory and anti-angiogenic effects after intratumoural IL-12 EGT, no clinically relevant outcomes were observed in this study, as persistent tumour regression could not be obtained. On the other hand, the laboratory and US results hold great promise for combinatorial strategies of intratumoural IL-12 EGT with conventional antitumour (immuno)therapies.

Short-Term Preoperative Calorie and Protein Restriction Is Feasible in Healthy Kidney Donors and Morbidly Obese Patients Scheduled for Surgery

Introduction. Surgery-induced oxidative stress increases the risk of perioperative complications and delay in postoperative recovery. In mice, short-term preoperative dietary and protein restriction protect against oxidative stress. We investigated the feasibility of a calorie- and protein-restricted diet in two patient populations. Methods. In this pilot study, 30 live kidney donors and 38 morbidly obese patients awaiting surgery were randomized into three groups: a restricted diet group, who received a synthetic liquid diet with 30% fewer calories and 80% less protein for five consecutive days; a group who received a synthetic diet containing the daily energy requirements (DER); and a control group. Feasibility was assessed using self-reported discomfort, body weight changes, and metabolic parameters in blood samples. Results. Twenty patients (71%) complied with the restricted and 13 (65%) with the DER-diet. In total, 68% of the patients reported minor discomfort that resolved after normal eating resumed. The mean weight loss on the restricted diet was significantly greater (2.4 kg) than in the control group (0 kg, p = 0.002), but not in the DER-diet (1.5 kg). The restricted diet significantly reduced levels of serum urea and plasma prealbumin (PAB) and retinol binding protein (RBP). Conclusions. A short-term preoperative calorie- and protein-restricted diet is feasible in kidney donors and morbidly obese patients. Compliance is high and can be objectively measured via changes in urea, PAB, and RBP levels. These results demonstrate that this diet can be used to study the effects of dietary restriction on surgery-induced oxidative stress in a clinical setting.

The intraoperative glycemic response to intravenous insulin during noncardiac surgery: a subanalysis of the DeLiT randomized trial

Patient characteristics may affect patients' response to insulin. We examined the impact of body weight and presence of diabetes on the response to insulin during noncardiac surgery. We studied 202 patients who were enrolled in the DeLiT Trial and received intraoperative intravenous insulin. Univariable and multivariable analyses (Bonferroni corrected) assessed the relationship between patient's response to the initial intraoperative I.V. bolus of regular insulin and the factors of interest. Blood glucose concentrations decreased 8.3 ± 10mg/dL (0.46 ± 0.56mmol/L) per unit of I.V. insulin in 30minutes. The response to insulin was similar in patients with or without diabetes (adjusted mean difference [97.5% confidence interval], 0.2 [-3.9, 4.2] mg/dL, 0.01 [-0.22, 0.24] mmol/L; P = .93). No relationship was found between insulin response and body weight (P=0.38). Our results suggest that adjustment for body weight and the presence of diabetes may not improve intraoperative insulin treatment algorithms.

Nutritional risk index is predictor of postoperative complications in operations of digestive system or abdominal wall?

BACKGROUND

Malnutrition can be considered the most common disease in hospitals due to its high prevalence.

AIM

To investigate the methods of evaluation of the nutritional status that better correlate with postoperative complications and the length of hospital stay in patients submitted to gastrointestinal or abdominal wall surgeries.

METHODS

This is a retrospective evaluation of 215 nutritional assessment records. All were submitted to traditional anthropometry (weight, height, BMI, arm circumference, triceps skinfold thickness and mid-arm muscle circumference), subjective global assessment, serum albumin and lymphocyte count. Nutritional risk index was also calculated.

RESULTS

A total of 125 patients were included. Malnutrition was diagnosed by mid-arm muscle circumference, nutritional risk index and subjective global assessment in 46%, 88% and 66%, respectively. Severe malnutrition was found in 17,6% if considered subjective global assessment and in 42% by the nutritional risk index. Oncologic patients had a worst nutritional status according to this index (5,42 less units). There was a negative correlation between occurrence the noninfectious postoperative complications with the nutritional risk index (p=0,0016). Similarly, lower serum albumin levels were associated with higher non infectious complications (p=0,0015). The length of hospital stay was, in average, 14,24 days less in patients without complications as compared with non infectious postoperative complications (p<0,05).

CONCLUSION

Nutritional risk index and serum albumin are the parameters with the best capacity to predict the occurrence of non infectious postoperative complications and the length of hospital stay was higher to this patients.

Perioperative protocols in colorectal surgery

The reduction in health-care expenditures and more efficient use of medical resources are now overriding health policy priorities with the two-pronged goal of improving patient outcomes while decreasing overall cost. Current reports show colorectal surgery accounting for 25% of all operative complications and an average length of stay of 8 to 12 days for a standard elective colon resection. To combat this, Kehlet and colleagues introduced a concept of enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using current evidence and multimodal therapies to decrease surgical stress, enhance postoperative recovery, and reduce length of stay. The benefits, safety, and cost-effectiveness of fast-track protocols are validated in multiple randomized controlled trials. In this review, the authors focus on the evidence regarding fast-track pathways, use of minimally invasive surgery and its role in fast-track pathways, newer perioperative interventions, and future directions.

Current concepts in the surgical approach to necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the most common surgical emergency occurring in neonatal intensive care unit (NICU) patients. Among patients with NEC, those that require surgery experience the poorest outcomes and highest mortality. Surgical intervention, while attempting to address the intestinal injury and ongoing mulitfactorial physiologic insults in NEC is associated with its own stresses that may compound the ongoing physiologic derangement. Surgery is thus reserved for those patients with clear indication for intervention such as pneumoperitoneum, confirmed stool or pus in the peritoneal cavity, or worsening clinical status. The purpose of this review is to briefly describe the physiologic stress induced by surgical intervention in the preterm, low birth weight patient with NEC and to provide a contemporary overview of available surgical management options for NEC. The optimal surgical plan employed is strongly influenced by clinical judgment and theoretical benefits in terms of minimizing physiologic stressors while providing temporary and/or definitive treatment in a timely fashion. While the choice of operation has not been shown to have a significant effect on any clinically important outcomes, ongoing investigations continue to study both short and long-term outcomes in patients with NEC.

Glucose metabolism in critically ill patients: are incretins an important player?

Critical illness afflicts millions of people worldwide and is associated with a high risk of organ failure and death or an adverse outcome with persistent physical or cognitive deficits. Spontaneous hyperglycemia is common in critically ill patients and is associated with an adverse outcome compared to normoglycemia. Insulin is used for treating hyperglycemia in the critically ill patients but may be complicated by hypoglycemia, which is difficult to detect in these patients and which may lead to serious neurological sequelae and death. The incretin hormone, glucagon-like peptide (GLP) 1, stimulates insulin secretion and inhibits glucagon release both in healthy individuals and in patients with type 2 diabetes (T2DM). Compared to insulin, GLP-1 appears to be associated with a lower risk of severe hypoglycemia, probably because the magnitude of its insulinotropic action is dependent on blood glucose (BG). This is taken advantage of in the treatment of patients with T2DM, for whom GLP-1 analogs have been introduced during the recent years. Infusion of GLP-1 also lowers the BG level in critically ill patients without causing severe hypoglycemia. The T2DM and critical illness share similar characteristics and are, among other things, both characterized by different grades of systemic inflammation and insulin resistance. The GLP-1 might be a potential new treatment target in critically ill patients with stress-induced hyperglycemia.

Preoperative diet impacts the adipose tissue response to surgical trauma

BACKGROUND

Short-term changes in preoperative nutrition can have profound effects on surgery-related outcomes such as ischemia/reperfusion injury in preclinical models. Dietary interventions that lend protection against stress in animal models (eg, fasting, dietary restriction [DR]) impact adipose tissue quality/quantity. Adipose tissue holds high surgical relevance because of its anatomic location and large tissue volume, and it is ubiquitously traumatized during surgery. Yet the response of adipose tissue to trauma under clinically relevant circumstances including dietary status remains poorly defined. We hypothesized that preoperative diet alters the adipose tissue response to surgical trauma.

METHODS

A novel mouse model of adipose tissue surgical trauma was employed. Dietary conditions (diet-induced obesity [DIO], preoperative DR) were modulated before application of surgical adipose tissue trauma in the context of clinically common scenarios (different ages, simulated bacterial wound contamination). Local/distant adipose tissue phenotypic responses were measured as represented by gene expression of inflammatory, tissue remodeling/growth, and metabolic markers.

RESULTS

Surgical trauma had a profound effect on adipose tissue phenotype at the site of trauma. Milder but significant distal effects on non-traumatized adipose tissue were also observed. DIO exacerbated the inflammatory aspects of this response, and preoperative DR tended to reverse these changes. Age and lipopolysaccharide (LPS)-simulated bacterial contamination also impacted the adipose tissue response to trauma, with young adult animals and LPS treatment exacerbating the proinflammatory response.

CONCLUSION

Surgical trauma dramatically impacts both local and distal adipose tissue biology. Short-term preoperative DR may offer a strategy to attenuate this response.

Capillary leak syndrome in trauma: what is it and what are the consequences?

TICS is a complex disease that is clearly multifactorial in the traumatically injured patient (Fig. 2). Although systemic inflammation that occurs directly as a result of injury plays the most prominent role, the local tissue and organ injury effects of trauma not only cause local capillary leak and edema but also further amplify the SIRS response. High volume fluid administration and hypoproteinemic states further exacerbate the problem. All of this leads to organ dysfunction and failure, which is the third leading cause of death following injury. Strategies to treat TICS and attenuate its effects once it occurs by targeting inflammatory pathways have been wholly unsuccessful. The mainstay of therapy for TICS is prevention and minimization of its lethal effects. Newer resuscitation strategies such as hemostatic resuscitation and early goal-directed therapies are currently the best available strategies to combat TICS. Whether these result in better outcomes remains to be seen and the authors anxiously await the results of well-designed prospective trials.