Influence of parenteral nutrition on postoperative recovery in an experimental model of peritonitis

BACKGROUND AND AIMS

There seems to be no clear-cut indications for routine TPN support after major elective surgery. The present study was designed to investigate whether TPN could improve the results of standard surgical care for acute peritonitis (laparotomy plus antibiotics).

ANIMALS AND METHODS

Peritonitis was induced in 48 New Zealand rabbits (day -2). On day 0, appendectomy and peritoneal lavage were performed, ceftriaxone (250 mg, i.m./24 h.) was started and animals were randomly assigned to receive regular fluids (RF), glucose-based TPN (G-TPN) or isocaloric fat-based TPN (F-TPN) for 6 days.

MAIN OUTCOME MEASURES

Balance studies (days 1-3), s-albumin, thyroid hormones and urinary catecholamines were determined at various points of the experiment. At postmortem, wound infection, residual intra-abdominal infection and laparotomy wound breaking strength were recorded.

RESULTS

Peritonitis produced a fall in weight, s-albumin and T3. At day 6, weight-loss was more pronounced in RF than in G-TPN or F-TPN (-7 vs 1.5 vs -1.2%;P=0.0001) but s-albumin and T3 concentrations were similar. Diuresis (377 vs 268 vs 269 mL/3 days; P=0.01) was higher and water balance lower (373 vs 511 vs 480 mL/3 days; P=0.01) in Group RF. Although the differences were not statistically significant (P<0.2), persistent infection and wound breaking strength were slightly worse in the pooled TPN groups compared with the RF group (19 vs 6% and 542 vs 701 g, respectively).

CONCLUSIONS

TPN failed to improve relevant biochemical markers and clinical outcome after laparotomy for peritonitis.

Anorexia and the effect of internal biliary drainage on food intake in patients with obstructive jaundice

BACKGROUND

Anorexia is a frequent finding in patients with biliary obstruction (BO). This study investigates the role of biochemical and hormonal factors in the pathogenesis of reduced food intake in BO and the effects of internal biliary drainage.

STUDY DESIGN

Sixty-two patients with BO were prospectively investigated. Transaminases, amylase, cholecystokinin, secretin, bile acids, tumor necrosis factor-alpha, and endotoxin were determined at admission. Caloric intake was quantified by a controlled diet. In a subset of 27 patients, studies were repeated after internal biliary drainage.

RESULTS

Sixty-six percent of patients had spontaneous food intakes below the estimated caloric requirements. Serum bilirubin, alkaline phosphatase, and cholecystokinin plasma levels were independent predictor factors for calorie intake (p = 0.0001). After internal biliary drainage, cholestasis parameters and cholecystokinin concentrations decreased significantly; this was associated with an improvement of spontaneous food intake in both benign and malignant biliary obstruction (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Decreased food intake in BO was associated with the degree of obstruction and with increased cholecystokinin plasma levels. Biliary drainage improved biochemical and food intake derangements.

Factors predicting nutritional derangements in patients with obstructive jaundice: multivariate analysis

Patients with obstructive jaundice (OJ) that requires surgery often have malnutrition associated with increased perioperative morbidity. This study investigated the factors influencing nutritional derangements in these patients. A series of 46 OJ patients were investigated prospectively (28 malignant tumors, 18 benign obstructions). A nutritional risk index of < 83.5 was used to define protein-calorie malnutrition. Liver function, cholecystokinin (CCK), tumor necrosis factor-alpha (TNFalpha), and endotoxin levels were determined. A multivariate analysis was performed, and an obstructive jaundice malnutrition index (OJMI) was obtained. Altogether, 22 (48%) OJ patients had malnutrition (33% with benign obstructions, 57% with malignant disease). Malnourished patients had higher serum bilirubin levels (258 +/- 120 vs. 154 +/- 62 mmol/L; p = 0.005), longer duration of jaundice (16 +/- 9 vs. 9 +/- 5 days; p = 0.03), and higher plasma levels of CCK (4.0 +/- 1.3 vs. 1.7 +/- 1.0 pmol/L; p = 0.005), alanine aminotransferase (ALT) (226 +/- 209 vs. 187 +/- 161 UI/L; p = 0.01), endotoxin (15 +/- 10 vs. 6.5 +/- 7.0 EU/L; p = 0.007), and TNFalpha (69 +/- 82 vs. 23 +/- 15 pg/ml; p = 0.008) than those without malnutrition. However, only serum bilirubin, CCK, ALT, and patient age were predictors for malnutrition by multivariate analysis. Malnutrition might be expected (95% confidence interval) in patients older than 68 years with increased bilirubin (> 290 mmol/L) and ALT (> 210 UI/L) levels that corresponded with an OJMI > 55. It was concluded that nutritional alterations in patients with obstructive jaundice were determined by the intensity of the biliary obstruction correlated with increased plasma CCK levels as well as with liver dysfunction and patient age.

Successful treatment with liposomal amphotericin B of an intraabdomianl abscess due to Candida norvegensis associated with a Gore-Tex mesh infection

There are few reports of severe infections caused by Candida norvegensis. We here describe a case of C. norvegensis-associated intraabdominal abscess and Gore-Tex mesh-associated infection, successfully treated with liposomal amphotericin B and removal of the mesh. This is, to our knowledge, the first report of C. norvegensis causing this type of infection.

Cytokines and acute-phase response markers derangements in patients with obstructive jaundice

BACKGROUND/AIMS

Prolonged acute-phase response and increase of cytokines have been associated with higher mortality and surgical complications. This study investigated the status of cytokines and acute-phase response markers in patients with obstructive jaundice.

METHODOLOGY

Forty-one patients were investigated. Endotoxin, tumor necrosis factor-alpha, interleukin-6, nitric oxide, C-reactive protein, liver enzymes, albumin and percentage of weight loss were determined at admission.

RESULTS

Endotoxin, interleukin-6 and C-reactive protein were significantly elevated in both benign and malignant obstructive jaundice. Increased plasma levels of tumor necrosis factor-alpha were only detected in malignant tumors (68 vs. 24 pg/mL; P < 0.001). Patients with positive acute-phase response (C-reactive protein > mean + 2 SD of controls) had greater weight loss (P = 0.02), endotoxin (P = 0.03) and interleukin-6 plasma levels (P = 0.05) than those with no inflammatory response. Prolonged biliary obstruction (> 10 days) was associated with higher weight loss (P = 0.04), tumor necrosis factor-alpha (P = 0.003) and interleukin-6 (P = 0.05) plasma levels.

CONCLUSIONS

A prolonged high-grade biliary tract obstruction prompted an increase in endotoxin levels, associated with a positive acute-phase response and cytokine elevation.

Strategies for prevention of catheter-related bloodstream infections

Prevention of catheter-related bloodstream infections is critically dependent on an accurate knowledge of the two main routes by which intravascular devices become contaminated: the extraluminal (skin-related) and the intraluminal (hub-related) routes. Extraluminal catheter seeding results from infection of the catheter entry site by microorganisms and leads to bacteremia most often during the week following catheter placement. The main ways of preventing it are appropriate skin disinfection and the adoption of maximal antiseptic barriers at the time of catheter insertion. Avoiding the internal jugular and the femoral veins, whenever possible, will reduce the likelihood of bacteremia. Intraluminal contamination is the consequence of improper handling of the catheter hub at the time of connection and disconnection of the administration set. It is the most common origin of catheter infections after the first week of catheter placement. Multiple-lumen catheters, side-ports and multipurpose catheters particularly increase the risk of endoluminal contamination. To prevent it, strict asepsis should be observed in hub handling and hubs should be protected against environmental soiling with an antiseptic impregnated gauze at all times. New technology is available for prevention of catheter infections: antibiotic and antiseptic-coated catheters, antiseptic hubs, disinfecting caps and flushing solutions are currently undergoing scientific assessment.

Nutritional assessment of patients with benign and malignant obstructions of the biliary tract

OBJECTIVES

the aim of this study was to assess the severity and type of nutritional deficiencies observed in patients with benign and malignant obstructive jaundice (OJ).

METHOD

in this prospective cross-sectional study 51 patients with OJ (21 with benign and with 30 malignant obstruction) were investigated. Nutritional status was assessed by anthropometric parameters (ideal body weight, midarm muscle area and skinfold thickness), visceral proteins, creatinine height index and total lymphocyte count. Observed values in patients with OJ were normalized to the percentage value of the lower limit of normal (obtained from 17 healthy subjects matched for age and sex) and averaged to obtain a total score for protein-energy malnutrition.

RESULTS

forty-two (82%) patients with OJ had protein-calorie malnutrition (PCM). Malnutrition was mild in 55%, moderate in 35% and severe in 10%. Severity of PCM was associated with intensity (p < 0.05) and duration of jaundice (p < 0.01). Kwashiorkor (74%) was the dominant type of malnutrition. PCM was common in benign (71%) as well as in malignant obstruction (90%), but the total score (92 +/- 20 vs 80 +/- 19; p < 0.05) and the proportion of mild PCM in patients with benign obstruction (80% vs 41%, p < 0.01) was significantly higher than in patients with malignant tumors.

CONCLUSIONS

a high percentage of patients with OJ had PCM. The degree of nutritional alteration was associated with the intensity of jaundice. Malnutrition was equally prevalent among patients with benign obstructions and patients with malignant causes of biliary obstruction, although it was more severe in the latter. Acute malnutrition (kwashiorkor) was the dominant type of malnutrition in both groups of patients.

Preoperative assessment of body fluid disturbances in patients with obstructive jaundice

Postoperative renal dysfunction in obstructive jaundice (OJ) patients has been associated with hypovolemia and depletion of the extracellular water compartment (ECW). The aim of the study was to evaluate the preoperative status of body compartments in OJ patients measured by two methods. In a prospective study 39 OJ patients (11 benign and 28 malignant obstructions) were investigated, with 15 healthy subjects used as a control group (CG). Bioelectrical impedance analysis (BIA) determinations and values derived from anthropometric measurements were used to assess body compartment status. The coefficient of variation of BIA was below 4% in both OJ and CG subjects. No differences were found in intracellular water. However total body water (TBW) and ECW were reduced in OJ patients (50.5 +/- 4.6 vs. 56 +/- 8% body weight, p = 0.05; and 21 +/- 4.5 vs. 23.8 +/- 2.5% body weight, p < 0.05, respectively). There were no differences between benign and malignant obstructions. Seventy four percent of OJ patients had an ECW volume below the mean +/- 2 SD in the CG subjects. Anthropometric and BIA determinations correlated closely for TBW measurements in both CG (r = 0.92, p < 0.001) and OJ patients (r = 0.91, p < 0.001). Bland-Altman analysis also showed that for TBW the BIA was in agreement with anthropometry. In the present study, BIA offered a good correlation with anthropometric determinations and was a reliable method for body fluid disturbances assessment in jaundiced patients.

Catheter-related bloodstream infections

Catheter-related bloodstream infections (CBIs) rank among the most frequent and potentially lethal nosocomial infections. Intravascular devices become contaminated on the outer surface during nonaseptic insertion or maintenance of the catheter exit site or endoluminally during hub manipulation. CBI is heralded by spiking fever, malaise and rigors and should be promptly diagnosed to prevent endocarditis and septic metastasis. In about two-thirds of the cases the offending organisms are coagulase-negative staphylococci; Staphylococcus aureus, gram-negative bacilli, and Candida sp. are responsible for one-third of these infections and carry a worse prognosis. Diagnosis of CBI relies on proper bacteriologic techniques, some of which can be performed in situ avoiding withdrawal of the device. Prevention strategies should aim at avoiding extra- and endoluminal contamination and should be based on three main pillars: maximal aseptic barriers at insertion, appropriate site maintenance, and junctional (hub) care and protection. Treatment includes catheter withdrawal and appropriate antibiotic coverage. For long-term cuffed catheters, local treatment with intraluminal administration of antibiotics is effective and can save a significant number of catheters, particularly those colonized by coagulase-negative staphylococci.

Changes in the pattern of visceral protein concentrations after internal biliary drainage in patients with obstructive jaundice

OBJECTIVE

To evaluate the influence of internal drainage on status of nutritional markers in patients with obstructive jaundice. DESSING: Prospective longitudinal study.

SETTING

University hospital, Spain.

SUBJECTS

39 patients with obstructive jaundice (18 benign and 21 malignant obstructions).

INTERVENTIONS

Nutritional state was assessed before and 10 days after endoscopic drainage.

MAIN OUTCOME MEASURES

One anthropometric (body weight <95% of ideal) and two biochemical (albumin <35 g/L and prealbumin < 170 mg/L) as an indication of protein calorie malnutrition. Retinol binding protein and transferrin concentrations, total lymphocyte count, and nutritional prognostic index (NPI) were also measured.

RESULTS

Thirty patients (77%) had protein calorie malnutrition. After internal drainage, 6 patients with benign obstruction and 11 with malignant tumours remained malnourished. No anthropometric variables or concentrations of proteins with long half-lives were affected by drainage. However, prealbumin (p < 0.01) and transferrin (p < 0.01) concentrations, and total lymphocyte count (p < 0.001) increased significantly in both groups. NPI also improved significantly after drainage from 43 (9) compared with 37 (5) in benign obstructions (p < 0.05) and 58.7 (14) compared with 52 (12) in malignant (p < 0.05), although in the latter group the mean nutritional risk index remained high.

CONCLUSIONS

Concentrations of some of the visceral proteins studied (prealbumin and transferrin) improved 10 days after internal biliary drainage for both benign and malignant obstruction. However, many patients with malignant tumours remained malnourished with a high nutritional risk index.

[Evaluation of anorexia in patients with bile duct obstruction]

INTRODUCTION

Obstructive jaundice is often accompanied by protein-caloric malnutrition. The objective of the present study is to analyze the incidence and the degree of alterations in the food ingestion of patients with obstructive jaundice.

MATERIAL AND METHODS

In a prospective, cross-sectional study 50 patients with obstructive jaundice (19 benign and 31 malignant) were evaluated. The anorexia was evaluated using Welch's test (subjective evaluation) and by means of quantifying the caloric ingestion. An anthropometric parameter (ideal weigh < 95%) and two biochemical ones (albumin < 3.5 g/dl and pre-albumin < 17 mg/dl) were used to define the degree of malnutrition.

RESULTS

96% of the patients presented alterations in the Welch test and in 72% of the patients the caloric ingestion was below the estimated needs. Overall, the ingestion of food was reduced by 76.3 +/- 30% of the estimated needs (84.7 +/- 28% in the benign cases and 70.9 +/- 32% in the malignant cases). Both the Welch test (r = 0.59; p = 0.01) and the caloric ingestion (r = 0.53; p < 0.001) were inversely correlated with the serum bilirubin. In patients with malnutrition criteria, the caloric ingestion was reduced by 30% against the 12% reduction in the non-malnourished patients (p < 0.05). There was a direct correlation between the two methods used in the assessment of the anorexia (r = 0.71; p < 0.001).

CONCLUSIONS

Obstructive jaundice is associated with an important reduction in the caloric ingestion, and this is manifested in both biliary obstructions of a benign origin, and in those of neoplasic origins.

Transfusion timing and postoperative septic complications after gastric cancer surgery: a retrospective study of 179 consecutive patients

BACKGROUND

Immunosuppression associated with homologous blood transfusion was first observed in renal allograft transplantation. Clinical effects of transfusion-induced immunosuppression in surgical patients have been debated in the literature for more than a decade with contradictory results.

OBJECTIVE

To investigate whether homologous blood transfusions significantly affect postoperative septic morbidity and mortality in patients undergoing elective surgery for gastric cancer.

DESIGN

Case series.

SETTING

Hospitalized care.

PATIENTS

The hospital records of 209 patients who underwent elective surgery for gastric cancer at the Department of Surgery of the Hospital del Mar, Autonomous University of Barcelona in Spain, and at the Department of Surgery of the Catholic University of Rome in Italy from April 1984 to December 1990 were reviewed, and 179 patients were included in the study.

MAIN OUTCOME MEASURES

The following variables were entered into univariate and multivariate analyses to identify factors potentially affecting postoperative septic morbidity: demographic data, weight loss, preoperative serum albumin level and lymphocyte count, type and duration of operative procedure, amount and timing of blood transfusion, and stage of disease.

RESULTS

Univariate analysis showed that a large quantity of blood transfused (> 1500 mL) and transfusion in the postoperative period (group C) were associated with a worse clinical outcome. Postoperative transfusion was an independent predictor of septic morbidity in multivariate analysis.

CONCLUSIONS

Despite transfusion-induced immunomodulation, homologous blood transfusion should not be considered a risk factor for postoperative septic morbidity in patients undergoing elective major abdominal surgery. The timing-response relationship between transfusions and septic morbidity in multivariate analysis may be the effect of uncontrolled confounders such as variation of volemia induced by stress response in patients who were developing or had just developed infectious complications.

[Prospective randomized trial of meropenem versus cefotaxime and metronidazole in the treatment of intraabdominal infections]

BACKGROUND

The empiric antibiotic treatment of intraabdominal infections is in constant evolution. Monotherapy appears to be a desirable goal because of the simplicity of its administration, lack of toxic effects and wide spectrum.

PATIENTS AND METHODS

A multicentre, prospective, randomized, open study was carried out to compare two antibiotic regimens in the treatment of intraabdominal infections in patients undergoing surgery. Ninety-eight consecutive patients were randomly allocated into two groups. One group (GM, n = 51) received meropenem (1 g/8 h) and the other (GCM, n = 47) a combination of cefotaxime (2 g/8 h) plus metronidazol (0.5 g/8 h). Clinical and bacteriological responses were assessed at the end of treatment and at 2-4 weeks.

RESULTS

The severity of patients as assessed by the APACHE II score was similar in both groups (GM: 7.2 and GCM: 8.1). Three patients in each group could not be evaluated due to premature interruption of treatment or deviation from the protocol. The mean duration of treatment was 7.4 days in GM and 7.9 days in GCM. A satisfactory clinical response was obtained in 95% of patients in both groups. 31 patients (61%) in GM and 26 patients (55%) in GCM were bacteriologically evaluable. Bacteriological erradication was achieved in 94% of patients in GM and in 92% of patients in GCM.

CONCLUSION

Meropenem is a good alternative for single antibiotic therapy in intraabdominal infections of moderate severity.

[Hydatid cyst in the hepatic hilum causing a cavernous transformation in the portal vein]

Portal cavernomatosis consists in the substitution of the portal vein by many fine, twisting venules leading to the liver. This phenomenon is produced as a consequence of anterior thrombosis of the portal vein and is associated with chronic pancreatitis, cancer of the pancreas, intraabdominal sepsis and cholelithiasis. The symptomatology may be nul or present as obstructive jaundice or portal hypertension. Diagnosis is made by Doppler echography. The treatment is portal shunt when symptomatology is produced. In patients with cholelithiasis requiring surgery, the shunt is advised prior to biliary surgery since perioperative hemorrhage, if present, may be incoercible as in the case herein described. We present a 84-year-old woman with portal cavernomatosis the etiology of which was a hydatidic cyst located in the hepatic bifurcation and treated with mebendazol 10 years previously. This etiology has not been previously reported.

Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation

BACKGROUND

Emergency operation in the elderly carries a high risk of death. We investigated the incidence of euthyroid sick syndrome (ESS) and associated nutritional and endocrine abnormalities and their relationship to postoperative outcome in this population.

METHODS

Sixty-six patients older than 70 years of age requiring emergency operations were assessed before any therapeutic intervention. Values for thyroid hormones, catecholamines, cortisol, interleukin-6, interleukin-1, C-reactive protein, and the Acute Physiology and Chronic Health Evaluation II score were determined. Nutritional assessment was carried out. Mortality rates and duration of hospital stay were related to ESS and albumin concentrations.

RESULTS

ESS was diagnosed in 34 patients (51.50%) and was associated with worse Acute Physiology and Chronic Health Evaluation II scores (10.9 vs 8.6; p = 0.004), hypoalbuminemia (34.7 vs 40.8 gm/L; p = 0.0001), lower triceps skinfold (11.8 vs 14.6 mm; p = 0.03), and higher cortisol and norepinephrine levels (937 vs 741 nmol/L [p = 0.04] and 358 vs 250 pg/ml [p = 0.02], respectively), interleukin-6 plasma concentrations (347 vs 113 pg/ml; p = 0.01), death rate (20% vs 0%; p = 0.02), and length of hospital stay (17.2 vs 11.8 days; p = 0.03). A serum albumin level less than 35 gm/L was virtually always associated with ESS.

CONCLUSIONS

ESS is highly prevalent in the elderly with acute surgical problems and is associated with poor nutrition, higher sympathetic response, and worse postoperative outcome. The serum albumin level at admission is a specific marker of ESS.

Circulating bile is the main factor responsible for atrial natriuretic peptide release in experimental obstructive jaundice

BACKGROUND

Biliary obstruction in the rabbit causes increased release of atrial natriuretic peptide (ANP). Circulating bile, raised biliary pressure or absence of bile in the duodenum may be implicated in this hepatocardiac syndrome.

METHODS

An experimental model was developed to elucidate the mechanism linking obstructive jaundice and increased plasma ANP. Hepatic and renal function, biliary tree pressure and ANP plasma concentrations were investigated in conscious rabbits 4 and 24 h after common bile duct ligation, biliovenous shunting or external drainage via a biliary fistula.

RESULTS

Bilirubin concentration increased after bile duct ligation and creation of a biliovenous shunt. Plasma creatinine increased abruptly in rabbits with a biliovenous shunt. At 4 h, the ANP increase in animals with a biliovenous shunt was ninefold that observed after bile duct obstruction while no change was noted after external biliary diversion (mean 350 versus 45 versus 9 fmol/l; P < 0.01). Relief of biliary tree obstruction was associated with a return of ANP levels towards basal normal values.

CONCLUSION

Raised plasma ANP in obstructive jaundice is not the result of an increased biliary pressure per se or absence of bile in the proximal duodenum but of the passage of bile components to the circulation.

Increased plasma levels of atrial natriuretic peptide and endocrine markers of volume depletion in patients with obstructive jaundice

BACKGROUND

Hypovolaemia may cause renal dysfunction in obstructive jaundice. This study investigated whether, in patients with obstructive jaundice: (1) atrial natriuretic peptide (ANP) is increased; (2) fluid-regulating hormones are altered; and (3) biliary drainage improves fluid homoeostasis.

METHODS

Forty-three patients with obstructive jaundice were investigated. A renal profile was obtained and levels of ANP, renin, aldosterone and vasopressin were determined. In a subset of 18 patients, studies were repeated 3 days after endoscopic biliary drainage and changes in extracellular volume were measured.

RESULTS

Creatinine clearance was impaired in ten of 30 patients. Patients with obstructive jaundice had higher mean levels of ANP (118 versus 40 pg/ml, P = 0.0001) and aldosterone (156 versus 43 pg/ml, P = 0.0001) than matched controls. Increased renin levels were observed in ten of the 43 patients and were associated with impaired creatinine clearance. After biliary drainage ANP concentration decreased (110 versus 67 pg/ml, P = 0.004) as well as aldosterone level (182 versus 85 pg/ml, P = 0.0002) and the mean extracellular volume increased (20.5 versus 23.1 per cent of body-weight, P = 0.001).

CONCLUSION

Plasma ANP concentration is increased in obstructive jaundice. Endocrine markers of hypovolaemia are activated in obstructive jaundice. After biliary drainage there is an improvement of endocrine and fluid derangements.

Fluid and sodium problems in perioperative feeding: what further studies need to be done?

Total parenteral nutrition may induce harmful water and sodium retention. Few efforts have been made to elucidate the mechanisms of this deleterious response to total parenteral nutrition. In this review we discuss the different factors involved in its pathophysiology and possible changes in total parenteral nutrition regimes in order to modulate such a response: reduction of the proportion of non-protein calories given as glucose, restriction of water and sodium, and the possible benefits of pharmaceutical nutritional therapy with glutamine and growth hormone.