Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Epicardial Adipose Tissue Changes After Bariatric and Metabolic Surgery: a Systematic Review and Meta-analysis

Epicardial adipose tissue (EAT) is a visceral fat depot located between the myocardium and visceral epicardium. Emerging evidence suggests that excessive EAT is linked to increased risk of cardiovascular conditions and other metabolic diseases. A literature search was conducted from the earliest studies to the 26th of November 2022 on PubMed, Embase, and the Cochrane. All the studies evaluating changes in EAT, pericardial adipose tissue (PAT), or total cardiac fat loss before and after BS were included. From 623 articles, 35 were eventually included in the systematic review. Twenty-one studies showed a significant reduction of EAT after BS, and only one study showed a non-significant reduction (p = 0.2).

Quality of Care Transition During Hospital Discharge, Patient Safety, and Weight Regain After Bariatric Surgery: a Cross-Sectional Study

PURPOSE

Bariatric surgery is established as the gold standard in the treatment of severe obesity. However, a significant proportion of patients experience a substantial weight regain afterwards. Previous research focused predominantly on patients' personal factors. Yet, critical discharge process factors that contribute to patient's adherence after surgical interventions are rarely examined. This study investigated whether high quality of care transitions in discharge management influences weight regain and the likelihood of experiencing adverse patient safety incidents.

MATERIALS AND METHODS

A cross-sectional study with 578 patients after bariatric surgery was conducted. Participants answered a standardized assessment on the quality of care transition from hospital to home-, surgery-, and nutrition-related characteristics as well as patient safety incidents.

RESULTS

Significant weight regain was observed 24 months after surgery. The association between time since surgery and weight regain was weaker in patients with high quality of care transitions (B = 2.27, p < .001). Higher quality of care transition was also significantly related to a lower likelihood of unplanned hospital readmissions (OR = 0.67) and fewer medication complications (OR = 0.48) after surgery.

CONCLUSION

This study sheds first light on the key influence of high quality of care transitions after bariatric surgery. Improvement efforts into effective discharge processes may establish smoother care transitions and help patients to assume responsibility and compliance with behavioral recommendations after surgery. Moreover, adverse patient safety incidents are less frequent after high quality care transitions indicating both high quality of health services for patients and reducing costs for the health care system.

[Obesity from the Perspective of Surgical Oncology]

Up to 40% of all adults worldwide are overweight or obese. Besides the established obesity-related comorbidities, such as type 2 diabetes mellitus, hypertension or NAFLD (non-alcoholic fatty liver disease), the focus of interest is shifting towards the influence of increased body weight as a risk factor for the development of malignant diseases. For more than 20 different types of malignancies, interactions between increased body weight and cancer risk have been established. Pathophysiological influences of obesity on carcinogenesis are diverse, including factors such as chronic inflammation, hyperinsulinaemia and insulin resistance, various changes in growth factor and changes in sex hormones. In cohorts of visceral oncology patients, malignancies such as colorectal carcinomas, hepatocellular carcinomas, adenocarcinomas of the pancreas, oesophageal and gastric carcinomas are also linked to an increased disease risk with increasing body weight. Since obesity must be considered a preventable or at least treatable cause of cancer, this review examines the influence of obesity in the field of visceral oncology, examining the effects of obesity on tumour prevalence, prevention and diagnostic testing, as well as its influence on treatment and prognosis. Furthermore, this review explores the current evidence on the influence of bariatric surgery on the prevalence of these obesity associated tumours. For example, in the case of colorectal carcinomas, the evidence base following bariatric surgery is mixed, painting an inhomogeneous picture. On the other hand, significantly lower prevalence of pancreatic adenocarcinoma and hepatocellular carcinomas is to be noted. The latter effect can be explained by the decrease in non-alcoholic fatty liver disease (NAFLD) associated with weight loss. Despite the justified concern that bariatric procedures (especially gastric sleeve resection) lead to increased prevalence of malignancies of the oesophageal junction, the currently available epidemiological data does not seem to identify a relevant increase in the incidence of these malignancies.

Acute inflammation and psychomotor slowing: Experimental assessment using lipopolysaccharide administration in healthy humans

Data from clinical and cross-sectional studies suggest that inflammation contributes to psychomotor slowing and attentional deficits found in depressive disorder. However, experimental evidence is still lacking. The aim of this study was to clarify the effect of inflammation on psychomotor slowing using an experimental and acute model of inflammation, in which twenty-two healthy volunteers received an intravenous injection of lipopolysaccharide (LPS, dose: 0.8 ​ng/kg body weight) and of placebo, in a randomized order following a double-blind within-subject crossover design. A reaction time test and a go/no-go test were conducted 3 ​h after the LPS/placebo injection and interleukin (IL)-6 and tumor necrosis factor (TNF)-α concentrations were assessed. No effect of experimental inflammation on reaction times or errors for either test was found. However, inflammation was related to worse self-rated performance and lower effort put in the tasks. Exploratory analyses indicated that reaction time fluctuated more over time during acute inflammation. These data indicate that acute inflammation has only modest effects on psychomotor speed and attention in healthy subjects objectively, but alters the subjective evaluation of test performance. Increased variability in reaction time might be the first objective sign of altered psychomotor ability and would merit further investigation.

Immunological and behavioral responses to in vivo lipopolysaccharide administration in young and healthy obese and normal-weight humans

Obesity is associated with an increase prevalence of neuropsychiatric symptoms and diseases, such as depression. Based on the facts that pro-inflammatory cytokines are able to modulate behavior, and that obesity is characterized by a chronic low-grade inflammatory state, inflammation has been hypothesized to contribute to the neuropsychiatric comorbidity in obese individuals. However, a causal link between inflammation and the development of neuropsychiatric symptoms is hard to establish in humans. Here, we used an inflammatory stimulus, i.e. the intravenous injection of lipopolysaccharide (LPS), in a double-blind placebo-controlled design, to determine the vulnerability of obese individuals to inflammation-induced behavioral changes. The hypothesis was that obese individuals would show heightened behavioral response compared to normal-weight subjects for the same inflammatory stimulus, reflecting an increased sensitivity to the behavioral effects of pro-inflammatory cytokines. LPS (dose 0.8 ng/kg body weight, adjusted for estimated blood volume in obese subjects) and placebo (saline) were intravenously injected in 14 obese healthy subjects and 23 normal-weight healthy subjects in a within-subject, randomized, crossover design. LPS administration induced, in both groups, an acute increase in blood concentrations of cytokines (interleukin-6, tumor necrosis factor-α, and IL-10), as well as in body temperature, cortisol, norepinephrine, sickness symptoms, fatigue, negative mood, and state anxiety. There were little differences in the immune and behavioral responses to LPS between obese and normal-weight subjects, but the cortisol response to LPS was strongly attenuated in obese individuals. Higher percentage of body fat was related to a lower cortisol response to LPS. Taken together, the population of young and healthy obese individuals in this study did not exhibit an increased behavioral sensitivity to cytokines, but an attenuated cortisol response to the immune challenge. Future studies will need to determine whether additional physiological and psychological factors interact with the state of obesity to increase the risk for inflammation-induced neuropsychiatric symptoms.

The Impact of Psychological Resources on Body Mass Index in Obesity Surgery Candidates

BACKGROUND

Obesity surgery is the therapy of choice for severely obese patients. The results are promising, but at the same time obesity surgery represents a physical and psychological challenge for patients and care givers. In order to give psychosocial support adequately, more knowledge of effects of psychological profiles is required. Research is often deficit and symptom oriented. Psychological resources (competences) of individuals are often neglected. However, after surgery patients have to cope with the altered anatomic condition and therefore psychological resources are essential for a successful development and my influence also the surgical outcome. The interplay of eating behavior, depression, and psychological resources and their influence on weight are yet undetermined.

METHODS

A cross-sectional study in consecutive obesity surgery candidates was performed. One hundred twenty-seven participants were included (90 female, 37 male; mean BMI 49.85 kg/m²; range 36.7-84.2 kg/m²). After conducting semi-structured clinical interviews psychological resources, depression and eating behavior were assessed via three questionnaires: Essener Ressourcen-Inventar (ERI), Patient Health Questionnaire depression module (PHQ-d), and Eating Disorder Examination-Questionnaire (EDE-Q). To evaluate the influence of psychological resources on BMI mediation models and path analyses were performed.

RESULTS

Psychological resources do not influence BMI directly. Path analyses revealed depression as well as depression/eating behavior as mediating dimension. A first path showed that higher psychological resources are associated with less depressive symptoms and lower BMI. On the other side, a second path showed that higher psychological resources are related to less depression and by means of more conscious and controlled eating behavior to a lower BMI.

CONCLUSION

Psychological resources seem to be relevant in the context of obesity surgery. Good psychological resources show plausible associations with less depression and a more adequate eating behavior. The evaluation of psychological resources in obesity surgery candidates allows the identification of patients at risk. Competences of patients should be addressed in the context of surgery. Our findings build a foundation for a more individualized supportive treatment for obesity surgery candidates. Improving impaired psychological resources may help in the coping process after surgery and is supposed to lead to an even higher weight loss.

Postoperative changes in body composition--comparison of bioelectrical impedance analysis and magnetic resonance imaging in bariatric patients

BACKGROUND

Roux-en-Y gastric bypass (RYGB) result in a marked reduction of body fat and also visceral fat (VF) decrease up to 36 % in 16 weeks. This leads to positive effects on cardiometabolic risks, which are known to be correlated with the occurrence of VF. This study analyzed the validity of bioelectrical impedance analysis (BIA) for determining VF in the postoperative course. In addition, magnetic resonance imaging (MRI) was performed for prediction of whole VF in bariatric patients on the basis of a single slice.

METHODS

Eighteen patients, who underwent RYGB (18), were included in this study. MRI and BIA measurements were performed 1 day before surgery, as well as 6, 12, and 24 weeks after surgery.

RESULTS

During the postoperative observation period, we found a significant decrease of both subcutaneous fat (SF) and VF. SF measured by MRI was highly correlated with the level of body fat shown by BIA. In contrast, the VF volume, as determined by MRI, showed no correlation with the body fat measured by BIA. In addition, we were able to show a significant correlation between MRI measured VF volume and the particular single-layer fat area.

CONCLUSIONS

Compared to the widely used bioelectrical impedance analysis to measure changes in body composition after bariatric procedures, a single-layer MRI was superior in determining VF. Single-layer MRI may be a better tool to recognize changes of VF after bariatric procedures.

Handgrip strength as a predictor for post bariatric body composition

BACKGROUND

After bariatric surgery, the postoperative quality of weight loss is variable. The aim of weight loss treatment is to reduce fat mass while keeping fat free mass, in particular body cell mass (BCM), constant. Detection of low BCM is an important aspect of surgical follow up. Handgrip dynamometry is a rapid and inexpensive test to measure static muscle strength, which is an independent outcome indicator of various medical conditions. The objective of this study is to examine the change in handgrip strength after bariatric surgery and its predictive value for postoperative body composition. Furthermore, this study was carried out at the University Hospital, Germany.

METHODS

Twenty-five patients who underwent a bariatric procedure (laparoskopic Roux-Y gastric bypass n=16 or sleeve resection n=9) were included in this study. Bioelectrical impedance analysis and hand-grip strength were measured preoperatively and repeated every 6 weeks for 4 months. An analysis of variance was performed to observe the changes in these individual parameters.

RESULTS

Postoperatively, all patients showed a significant decrease in the body mass index and body fat. The extracellular mass, BCM, and the lean mass of the patients remained constant. Handgrip strength showed no significant changes during the postoperative course. Nevertheless, the preoperative hand-grip strength showed a strong positive correlation with the postoperative body composition.

CONCLUSIONS

This study showed no changes in the static muscle force after bariatric surgery. The preoperative handgrip strength was strongly correlated with postoperative body composition and may be used to identify patients who need more attention before surgery and in the early postoperative phase.

The diagnosis and treatment of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the liver manifestation of metabolic syndrome and frequently accompanied with obesity, insulin resistance, hyperlipidemia and hypertension. NAFLD comprises a variety of clinical conditions ranging from simple steatosis (NAFL) to non-alcoholic steatohepatitis (NASH), with significant hepatic injury and possible progression to cirrhosis and hepatocellular carcinoma. The traditional "second hit" and the recent "multiple parallel hit" theories are the most popular explanations for the pathogenesis of NASH. NAFLD is usually diagnosed by ultrasonographic examination of the liver. For specific diagnosis of the extent and severity of NAFLD, in particular to determine NASH, the gold standard is still liver biopsy. Though, there are some promising non-invasive markers emerging for NAFLD diagnosis and assessment. Currently there is no specific therapy for NAFLD or NASH itself. Thus management of NAFLD mainly relies on initiating weight loss and on treatment of accompanying factors e.g. insulin resistance, hypertension or hyperlipidemia. In the present overview we aimed to summarize options for diagnosis and treatment of NAFLD and NASH based on the current literature.

The effect of a clinical pathway for enhanced recovery of rectal resections on perioperative quality of care

PURPOSE

There is ample evidence of the benefits of clinical pathways (CPs), but this study is the first to investigate the potential additional benefits of a CP for rectal resections in a setting with an already established policy of enhanced postoperative recovery.

METHODS

We compared 36 patients who underwent rectal resections with ileostomy placement and were treated according to a CP (CP group) with 67 patients treated before CP implementation (prepathway group). Indicators of process quality were placement of central venous line and epidural catheter, day of removal of Foley catheter in relation to removal of the epidural catheter, day of first mobilization, day of resumption of regular diet, day of first passage of stool through the stoma, and length of stay. Outcome quality was assessed by morbidity, mortality, reoperation, and readmission rates.

RESULTS

We found that patients in the CP group resumed regular diet significantly sooner (p = 0.001). There were no significant differences regarding the day of first mobilization (p = 0.69), epidural catheter (p = 0.74), central venous line placement (p = 0.92), and removal of Foley catheter (p = 0.23). The first stool was passed through the stoma earlier (p = 0.04) in the prepathway group. Median length of hospital stay was significantly shorter in the CP group (12.5 vs. 15.0 days; p = 0.008). There were no significant changes in outcome quality, except for a significantly higher need for revisional surgery in the CP group (13.9 vs. 3%, p = 0.05).

CONCLUSIONS

After implementation of a CP for rectal resections, one parameter of process quality improved and length of stay decreased.

Healthy obese and post bariatric patients - metabolic and vascular patterns

OBJECTIVE

Obesity and the metabolic syndrome (MetS) are associated with endothelial dysfunction (ED). An established method to determine ED is retinal vessel analysis. Obesity is associated with MetS, but obese patients not matching all criteria of the MetS and therefore defined as metabolically healthy obese subjects (MHOS) exist. Bariatric surgery may be an appropriate option to treat morbid obesity. The aim of this study was to compare MetS, MHOS and post bariatric patients in adipocytokine -patterns and ED.

METHODS

Arterio-venous ratio (AVR) and vessel diameters from retinal photographs (IMEDOS™), parameters of MetS (IDF) and obesity-associated factors (hsCRP, TNF, Il-6, MCP-1, sICAM, sVCAM, IGF-BP3, RBP 4 and adiponectin) were assessed in 51 obese patients with MetS, 20 obese patients without MetS and 21 patients pre and post bariatric surgery.

RESULTS

Bariatric surgery improved ED as reflected by AVR and venous diameters (p<0.05 for both). These improvements were associated with lower levels of fasting plasma glucose, insulin, HOMA-IR, LDL-C, triglycerides, cholesterol, hsCRP, sICAM, and higher levels of adiponectin and RBP4 (p<0.05 for each parameter). MHOS differed from MetS by neck circumference, fasting plasma glucose, HOMA-IR, triglycerides, HDL-C, sICAM, and adiponectin (p<0.05), but not by RRs, RRd, insulin, LDL-C, hsCRP, Il-6, TNF, MCP-1, sVCAM, RBP-4, IGF-BP3, and retinal ED.

CONCLUSION

These data indicate that improved insulin-sensitivity and reduced inflammatory mediators characterize the metabolic outcome of postbariatric patients in comparison to MHOS. Thus, MHOS characterizes an intermediate state between MetS and postbariatric patients.

Effect of different liver resection methods on liver damage and regeneration factors VEGF and FGF-2 in mice

BACKGROUND

Different approaches to study liver regeneration in murine models have been proposed. We investigated the effect of different liver resection models on liver damage and regeneration parameters in mice.

METHODS

We compared the technical aspect of the 2 most commonly used techniques of 50% and 70% liver resection. Liver damage, as determined by the change in serum alanine aminotransferase and aspartate aminotransferase, as well as the regeneration parameters VEGF and FGF-2 were analyzed at 6 time points. A postoperative vitality score was introduced.

RESULTS

Cholestasis was not observed for either technique. Both resection techniques resulted in full weight recovery of the liver after 240 hours, with no significant difference between sham and resection groups. Postoperative animal morbidity and total protein levels did not differ significantly for either method, indicating early and full functional recovery. However, comparing the mitogenic growth factors FGF-2 and VEGF, a significant increase in serum levels and, therefore, increased growth stimulus, was shown in the extended resection group.

CONCLUSION

Extended resection led to a greater response in growth factor expression. This finding is important since it shows that growth factor response differs acdording to the extent of resection. We have demonstrated the need to standardize murine hepatic resection models to adequately compare the resulting liver damage.

Improved arteriole-to-venule ratio of retinal vessels resulting from bariatric surgery

Obesity causes increased morbidity and mortality from metabolic and cardiovascular disease (CVD). We investigated the effect of bariatric surgery on endothelial dysfunction (ED) in retinal vessels as a marker of metabolic and cardiovascular risk in patients with obesity WHO III.Thirty consecutive patients (19/11, w/m) were evaluated by anthropometry, lipid profile, and oral glucose tolerance test before and after bariatric surgery (Mannheim Obesity Study (MOS); NCT 00770276). Risk stratification was performed by the presence of metabolic syndrome (MetS) according to ATP-III (adult treatment panel-III). Subclinical atherosclerosis was assessed by measurement of intima-media thickness (IMT). Flicker light response of retinal vessels was used as measures of ED. We measured their arteriole-to-venule ratio (AVR) for evaluation of vascular pathology. After a median of 9 months following bariatric surgery, mean weight loss was 39.4 kg (37.3%). Remission of impaired glucose metabolism was achieved in 53.3% of affected patients. Dyslipidemia improved significantly (triglycerides -61.3 mg/dl, P < 0.0001, total cholesterol -28.2 mg/dl, P = 0.002, and low-density lipoprotein cholesterol were reduced -24.5 mg/dl, P = 0.008). This resulted in a significant reduction of patients classified for MetS (27 vs. 9, P < 0.0001). Adiponectin increased by 2.08 µg/l (P = 0.032) and high sensitivity C-reactive protein (hs-CRP) and soluble intercellular cell adhesion molecule (sICAM) decreased (-7.3 mg/l, P < 0.0001 and -146.4 ng/ml, P = 0.0006). AVR improved significantly (+0.04, P < 0.0001), but neither Flicker light response nor IMT changed significantly. Retinal AVR is ameliorated after bariatric intervention. As an increased AVR results from either or both widening retinal arteriolar caliber and narrowing retinal venular caliber, an improvement in small vessel profile is evident 9 months after bariatric surgery.

High prevalence of retinal endothelial dysfunction in obesity WHO class III

BACKGROUND

The extent of retinal endothelial dysfunction (ED) in patients with obesity is unknown. We evaluated markers of endothelial dysfunction to assess cardiovascular risk in patients with obesity WHO III° and their interrelation with classical cardiovascular risk factors.

METHODS

120 patients (mean age 42.7±10.6 years, 87 women) were prospectively evaluated for metabolic and cardiovascular risk using anthropometry, cardiovascular risk factors, lipid and glucose profiles. Intima media thickness (IMT) as marker of subclinical atherosclerosis, ED of retinal vessels, and the arteriole-to-venule ratio (AVR) of retinal vessels were assessed.

RESULTS

The mean BMI in our cohort was 48.7 kg/m(2). We diagnosed an overall prevalence of impaired glucose metabolism of 69.2%. 71.6% and 65.2% presented with arterial hypertension or dyslipidemia, respectively. Prevalences of retinal ED, pathologically reduced AVR, and enlarged IMT were 62.7%, 56.6% and 30%, respectively. Markers of endothelial function demonstrated correlation of neck to height ratio with dilatation of arteries (r=-0.333, p=0.01) and HDL cholesterol with dilatation of veins (r=-0.393, p=0.002). AVR was significantly related to neck circumference (r=-0.269, p=0.004).

CONCLUSION

Retinal ED, AVR, and IMT as direct noninvasive surrogate measures of cardiovascular risk showed a high prevalence in patients with obesity WHO III°. We found no association of classical parameters for metabolic or cardiovascular risk with markers of endothelial dysfunction. Therefore, we have to hypothesize that other factors also play a pivotal role in the development of vascular pathology in patients with obesity.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]

BACKGROUND

Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany.

MATERIAL AND METHODS

A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively.

RESULTS

The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years.

CONCLUSIONS

Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon

PURPOSE

Clinical pathways (CPs) are increasingly used to improve quality of care. However, evidence if such improvements are also feasible in fast-track colorectal surgery is lacking. This study evaluates effects of a CP for fast-track colonic resections with respect to process and outcome quality.

METHODS

We compared 78 consecutive patients undergoing colonic resections in 2008 and being treated with a CP (CP group) with 133 consecutive patients treated without CP between 2006 and 2007 (pre-CP group). Indicators for process quality were epidural catheter placement, postoperative mobilisation, resumption of solid diet, Foley catheter removal and length of stay. Outcome quality was measured through morbidity, mortality, re-operations and readmissions.

RESULTS

In the CP group, patients received epidural analgesia significantly more often (87.2% vs. 75.2%; p =0.04), were mobilized (38.9% vs. 20.6% on the day of surgery; p = 0.03) and resumed a solid diet earlier (60.5% vs. 49.6% on day 1; p = 0.002). Foley catheter removal and length of stay did not differ between the groups. There were no significant differences regarding morbidity (28.2% vs. 32.3%), mortality (1.2% vs. 2.3%), re-operations (6.4% vs. 9.0%) and readmissions (2.6% vs. 3.8%).

CONCLUSIONS

After CP implementation for fast-track surgery of the colon, several indicators of process quality improved while others such as length of stay remained unaltered. There were no significant changes in outcome parameters. CPs are a viable instrument to improve specific aspects of perioperative process management, but their selective benefits have to be critically weighed against the infrastructural and personal efforts required for design and implementation.

Association between EGF, TGF-{beta}1, TNF-{alpha} gene polymorphisms and cancer of the pancreatic head

BACKGROUND

To date, EGF 61*A/G, TGF-β1 -509*T/C and TNF-α -308*A/G gene polymorphisms have been not been analysed in pancreatic carcinoma. This study investigated the frequency of these gene polymorphisms among patients with cancer of the pancreatic head.

PATIENTS AND METHODS

A total of 73 pancreatic head cancer patients and 117 cancer-free healthy people were recruited at the Surgical Department of the University Hospital Mannheim. Genomic DNA was isolated from peripheral blood and gene polymorphisms were analysed by PCR-RFLP.

RESULTS

The distribution of EGF 61*G/G homozygotes among pancreatic head cancer patients was more frequent than that in the control group (24.7% vs 11.1%, odds ratio (OR) = 2.618, 95% confidence interval (CI) = 1.195-5.738). In addition, the frequency of the G allele in the pancreatic head cancer patient group was also higher than that in the control group (45.9% vs. 33.3%, OR = 1.696, 95% CI = 1.110-2.592). No difference was found for the TGF-β1 -509 and TNF-α -308 genotypes among pancreatic head cancer patients and healthy controls.

CONCLUSION

The frequencies of the EGF 61*G/G genotype and G allele are significantly increased among patients with pancreatic head cancer. TGF-β1-509*T/C and TNF-α -308*A/G gene polymorphisms are not related to this cancer entity.

Early supplementation of parenteral nutrition is capable of improving quality of life, chemotherapy-related toxicity and body composition in patients with advanced colorectal carcinoma undergoing palliative treatment: results from a prospective, randomized clinical trial

AIM

Patients suffering from advanced colorectal cancer can experience unintended weight loss and/or treatment-induced gastrointestinal toxicity. Based on current evidence, the routine use of parenteral nutrition (PN) for patients with colorectal cancer is not recommended. This study evaluates the effect of PN supplementation on body composition, quality of life (QoL), chemotherapy-associated side effects and survival in patients with advanced colorectal cancer.

METHOD

Eighty-two patients with advanced colorectal cancer receiving a palliative chemotherapy were prospectively randomized to either oral enteral nutrition supplement (PN-) or oral enteral nutrition supplement plus supplemental PN (PN+). Every 6 weeks body weight, body mass index (BMI), chemotherapy-associated side effects and caloric intake were assessed, haemoglobin and serum albumin were measured. Body composition was assessed by body impedance analysis, and QoL was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQC30 questionnaire.

RESULTS

No differences were evident at baseline between the groups for age, sex, diagnosis, weight, BMI or QoL. A difference in BMI was observed by week 36, whereas differences of the mean body cell mass could be observed from week 6, albumin dropped significantly in the PN- group in week 36 and QoL showed significant differences from week 18. Chemotherapy-associated side effects were higher in PN-. The survival rate was significantly greater in the PN+ group.

CONCLUSION

A supplementation with PN slows weight loss, stabilizes body-composition and improves QoL in patients with advanced colorectal cancer. Furthermore, it can reduce chemotherapy-related side effects.

Association between EGF, TGF-beta1, VEGF gene polymorphism and colorectal cancer

INTRODUCTION

Up to the present, EGF 61 A/G, TGF-beta1 -509 T/C, and VEGF 936 T/C gene polymorphisms have been analyzed in other cancer entities than colorectal cancer. We have now investigated the frequency of these gene polymorphisms among colorectal cancer patients.

MATERIAL AND METHODS

A total of 157 colorectal cancer patients and 117 cancer-free healthy people were recruited at the Surgical Department of the Universitätsklinikum Mannheim. All patients and healthy people are Caucasians. Genomic DNA was isolated from peripheral blood, and gene polymorphisms were analyzed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

The distribution of EGF 61 G/G homozygotes among colorectal cancer patients was more frequent than that in the control group (33.1% versus 11.1%; Odds Ratio [OR]=3.962; 95% Confidence Interval [CI]=2.036-7.708). The frequency of the "G" allele in the colorectal cancer patient group was also higher than that in the control group (51.3% versus 33.3%; OR=2.105; 95% CI=1.482-2.988). No difference could be found for the TGF-beta1 and VEGF genotypes among colorectal cancer patients and healthy controls.

CONCLUSIONS

The EGF 61 G/G genotype and the G allele are significantly related to colorectal cancer. The TGF-beta1 -509 T/C and VEGF 936 T/C gene polymorphisms are not related to colorectal cancer.

'Fast-track' colonic surgery in Austria and Germany--results from the survey on patterns in current perioperative practice

OBJECTIVE

'Fast-track' rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Despite this evidence, there is no information on the acceptance and utilization of these concepts among the entirety of Austrian and German surgeons.

METHOD

In 2006, a questionnaire concerning perioperative routines in elective, open colonic resection was sent to the chief surgeons of 1270 German and 120 Austrian surgical centres.

RESULTS

The response rate was 63% in Austria (76 centres) and 30% in Germany (385 centres). Mechanical bowel preparation is used by the majority (Austria, 91%; Germany, 94%); the vertical incision is the standard method of approach to the abdomen in Austria (79%) and Germany (83%), nasogastric decompression tubes are rarely used, one-third of the questioned surgeons in both countries use intra-abdominal drains. Half of the surgical centres allow the intake of clear fluids on the day of surgery and one-fifth offer solid food on that day. Epidural analgesia is used in three-fourths of the institutions.

CONCLUSION

Although there is an evident benefit of fast-track management, the survey shows that they are not yet widely used as a routine in Austria and Germany.

[Association between tumor necrosis factor alpha gene polymorphism and colorectal cancer]

OBJECTIVE

To elucidate the association of TNF-alpha-308G/A gene functional polymorphism with the development and progression of colorectal cancer.

METHODS

PCR-RFLP was employed to detect the TNF-alpha-308 G/A genotypes in 157 colorectal cancer patients and 117 healthy controls.

RESULTS

The frequency of TNF-alpha-308 genotype and allele were not significantly different between colorectal cancer patients and healthy controls (genotype chi(2)=1.054, P=0.591, allele chi(2)=0.404, P=0.525). The frequency of A/A genotype and A allele in III+IV stage (62 patients in total) were higher than those in I+II stages (85 patients in total) (A allele: 22.6% vs 12.9%, A/A genotype: 8.1% vs 1.2%), and the differences were significant (genotype P=0.048, OR=7.368, 95% CI=0.839-64.743, allele chi(2)=4.720, P=0.03, OR=1.962, 95% CI=1.061-3.628). The frequency of TNF-alpha-308 genotype were not significantly different among different colorectal cancer grades (chi(2)=3.009,P=0.591).

CONCLUSION

TNF-alpha-308G/A gene polymorphism is not associated with the development of colorectal cancer, but TNF-alpha-308 A/A genotype and A allele are related to the progression of colorectal cancer.

Enteral vs parenteral nutrition in reconstructive anal surgery--a prospective-randomized trial

OBJECTIVE

Early defecation after reconstructive anal surgery may influence the outcome negatively. Different methods are used to avoid bowel movements in the early postoperative period. We questioned whether stool behaviour is influenced by total parenteral nutrition as opposed to enteral nutrition with resorbable sip feeds. Furthermore, satisfaction of patients with each nutrition regime, cost differences and influence of the postoperative outcome were evaluated.

METHOD

Between January and October 2004, 32 patients were evaluated in a prospective randomized, surgeon-blinded trial. The parenteral group (PG, n = 16) received 1250 ml Nutriflex lipid basal (B. Braun Comp., Melsungen, Germany) intravenously. The enteral group (EG, n = 16) was offered a total amount of three cups of Clinutren fruit (Nestle Nutrition GmbH, Frankfurt, Germany), two boxes of OPD (oligopeptide diet) Elemental 028 extra (SHS, Liverpool, UK) and two cups of OPD Peptamen (Nestle Nutrition GmbH). Both groups received 1000 ml of isotonic cristalloid solution and were allowed to drink up to 1000 ml of tea or water per 24 h.

RESULTS

The satisfaction of patients was significantly higher in the EG. In regard to stool behaviour both groups showed no differences, in the number of bowel movements or in the time to the first postoperative defecation. Enteral feeding resulted in a minimum saving of 220 euros. Postoperative results in the case of plastic fistula closure did not differ between both groups.

CONCLUSIONS

Sufficient bowel confinement during the early postoperative period after anal reconstructive surgery may be achieved by using resorbable sip feeds rather than parenteral nutrition.

[A survey of perioperative therapy for elective colon resection in Germany, 2006]

BACKGROUND

Despite the evidence that fast-track concepts in colon surgery lead to an enhanced recovery rate, there is no information on the prevalence and utilization of such programs in Germany.

METHODS

Based on a conventional sigmoid resection, we asked 1,270 surgical departments in Germany to describe their standard surgical procedures in a questionnaire.

RESULTS

The response rate was 385 (30.31%). A total of 96% use a bowel preparation, 83% a vertical incision, 10% use a nasogastric decompression for longer then 1 day, 34% avoid intra-abdominal drains, 51% allow clear fluids on the day of surgery, 13% offer solid food on the first day after surgery, 75% use epidural analgesia and 47% discharge the patients by the seventh day after surgery.

CONCLUSION

Although there is an evident benefit using fast-track concepts, they are not yet in wide use as a standard procedure. Further efforts have to be made to ensure that the majority of patients will benefit from these concepts.

Elektive Kolonresektionen in Deutschland

BACKGROUND

Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany.

METHODS

In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection.

RESULTS

The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia.

CONCLUSION

In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

Intestinal barrier dysfunction in developing liver cirrhosis: An in vivo analysis of bacterial translocation

AIM

Transmucosal passage of bacteria across the intestine, the essential step for bacterial translocation, has been identified as a key event in the pathogenesis of life-threatening infections in cirrhosis. Existing animal models of liver cirrhosis only provide indirect information about the pathogenesis of such infections. The aim of this study has been to assess transmucosal passage and bacterial translocation directly in vivo using a rat model of developing liver cirrhosis.

METHODS

Male Sprague Dawley rats were randomly assigned to two groups: controls and animals with developing liver cirrhosis induced by s.c. injection of carbon tetrachloride. In anesthetized animals a suspension of green fluorescent protein (GFP)-tagged E. coli was administered into the terminal ileum. Time intervals necessary for translocation of E. coli into the mucosa and muscularis were assessed by intravital microscopy and translocation of E. coli in mesentery, liver and spleen was determined microbiologically.

RESULTS

Bacterial kinetics at the level of the mucosa and muscularis showed significant enhancement in cirrhotic rats compared to the controls (P < 0.001). GFP-expressing E. coli were detected in the mesentery, liver and spleen of animals with cirrhosis taken one hour after E. coli administration. However, cultures of control animals remained sterile.

CONCLUSION

Intravital microscopy of fluorescent bacteria represents a novel approach to studying bacterial translocation in vivo. Here we report that this technique can be used to visualize bacterial transit in in vivo and gives further support to the transmucosal passage of bacteria across the intestine correlating with bacterial translocation in CCl(4)-induced liver cirrhosis.

[Association between vascular endothelial growth factor gene 936 T/C polymorphism and colorectal cancer together with anastomotic leakage]

OBJECTIVE

To investigate the association between VEGF gene 936 T/C polymorphism and colorectal cancer together with anastomotic leakage.

METHODS

Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to detect the VEGF 936 T/C genotypes in colorectal cancer patients and healthy controls.

RESULTS

There was no significant difference in the frequency of VEGF 936 C/C genotype or C allele between colorectal cancer patients and healthy controls (P > 0.05). The C/C genotype or C allele in colorectal cancer patients with anastomotic leakage was less frequently found than in the group without anastomotic leakage (P < 0.05).

CONCLUSIONS

VEGF 936 C/C genotype or C allele is not related to the development of colorectal cancer, but they can reduce the risk of anastomotic leakage after surgery in colorectal cancer patients.

An European survey of structure and organisation of nutrition support teams in Germany, Austria and Switzerland

BACKGROUND & AIMS

Nutritional support teams (NST) have been demonstrated to be an excellent mechanism for identifying patients in need of nutrition support, improving the efficacy of nutrition support in a variety of hospital environments. Focus of this study was the investigation of function, structure and organisation of NST in Germany (D), Austria (A) and Switzerland (CH).

METHODS

Prospective investigation of the function, structure and organisation of NST in D, A and CH, using standardised questionnaires.

RESULTS

From a total of 3071 hospitals in D, A and CH, NST have been established at 98 hospitals (3.2%). Their main activities were creating nutritional regimes (100%), education (87%) and monitoring nutrition therapy (92%). In general, the NST are not independently operating units but are affiliated to a special discipline. Seventy-one per cent of the physicians, 40% of the nurses and 69% of the dieticians in the NST held a nutrition-specific additional qualification. A total of 12% of the physicians, 37% of the nurses and 46% of the dieticians are exclusively responsible for the NST. A reduction of complications (88%) and cost saving (98%) were indicated since their establishment. The NST received in 32% funding support.

CONCLUSION

In D, A, CH neither a uniform nor comprehensive patient care by NST existed in 2004. Standards of practice, development of guidelines in clinical nutrition and better documentation in NSTs are necessary. Special efforts should be aimed at education of NST members and financing of teams.

Imaging Epidermal Growth Factor Receptor Phosphorylation in Human Colorectal Cancer Cells and Human Tissues

In tumor cells, high phosphorylation levels of receptor tyrosine kinases may occur in the absence of exogenous ligands due to autocrine signaling or enhanced tyrosine kinase activity. Here we show that the phosphorylation state of the endogenous epidermal growth factor receptor (EGFR) can be quantitatively imaged in tumor cells and tissues by detecting fluorescence resonance energy transfer between fluorophores conjugated to antibodies against the receptor and phosphotyrosine, respectively. Five different human colorectal cell lines were analyzed for activity and expression of EGFR. All cell lines exhibited basal EGFR phosphorylation under serum starvation conditions. Phosphorylation levels increased after stimulation with EGF or pervanadate, dependent on the level of basal EGFR phosphorylation in the respective cell lines. This basal activity correlated inversely with receptor expression. Using the acceptor photobleaching fluorescence resonance energy transfer imaging approach, a significantly higher phosphorylation state of EGFR was also found in resected human colorectal tumor samples as compared with adjacent healthy tissue. Imaging of EGFR phosphorylation may thus serve as a valuable tool to investigate the role of receptor tyrosine kinase activity in malignant cell growth.

Altered apoptotic response and different liver structure during liver regeneration in FGF-2-deficient mice

BACKGROUND/AIMS

To investigate postulated differences related to FGF-2 in liver morphology and expression of apoptosis-related factors after partial hepatectomy (PH).

METHODS

Homogenous FGF-2-deficient mice (C57BL/6J) with their FGF-2-(+/+) littermates (control) were used to examine the structure of regenerating livers after PH with light and electron microscopy. The regenerative response and BrDu incorporation were monitored. The expression of BclX-l, Bax, Fas, TNF-alpha, and Caspase-3 were measured by reverse transcription PCR (RT-PCR) and Northern blot analysis.

RESULTS

In the FGF-2-(-/-) group, hepatocytes and endothelial cells contain mitochondria with atypical cristae and fragmented endoplasmic reticulum structures compared to control. Sinusoids show irregular basal laminae. These changes are in accordance with a differential expression of apoptosis-related factors: FasL was expressed throughout the entire observation span (days 0 to 10 post-PH). Following PH, tumor necrosis factor alpha (TNFalpha)-mRNA levels were higher in FGF-2-(+/+) animals, while Fas as well as Bax and BclXl were overexpressed in FGF-2-(-/-) mice. Caspase-3-mRNA was similarly expressed in both groups, but Caspase-3 activity was elevated for 4 days in FGF-2-(-/-) mice.

CONCLUSION

Despite morphologic differences, differences in the time schedule of DNA synthesis and differences in apoptotic response, the dynamics of liver regeneration in FGF-2-(-/-) mice were not impaired.

Day-night variation in the in vitro contractility of aorta and mesenteric and renal arteries in transgenic hypertensive rats

TGR(mREN2)27 (TGR) rats develop severe hypertension and an inverted circadian blood pressure profile with peak blood pressure in the day-time rest phase. The present study investigated the in vitro responsiveness of different arteries of TGR rats during day and night. Twelve-week-old TGR rats and normotensive Sprague-Dawley (SPRD) controls, synchronized to 12h light, 12h dark (LD 12:12) (light 07:00-19:00), were killed at 09:00 (during rest) and 21:00 (during activity), and endothelium-dependent relaxation by acetylcholine and vascular contraction by angiotensin II were studied by measuring isometric force in ring segments of abdominal aorta and mesenteric and renal arteries. In SPRD rats, consistent day-night variation was found, with greater responses to angiotensin II during the daytime rest span. In TGR rats, biological time-dependent differences were found in the renal vasculature, but not in the aorta and mesenteric artery. Relaxation of SPRD rat aorta and mesenteric artery by acetylcholine was greater at 09:00, whereas in TGR rats, day-night variation was absent (mesenteric artery) or inverted (aorta). In conclusion, based on the study of two time points, day-night variation in vascular contractility of aorta and mesenteric artery is blunted in TGR rats, whereas renal artery segments showed an unchanged day-night pattern compared to SPRD controls.