Complications of abdominal operations for malignant disease

A review of platelet-rich plasma for enteric fistula management

Enteric fistula (EF), a serious complication after abdominal surgery, refers to unnatural communication between the gastrointestinal tract and the skin or other hollow organs. It is associated with infection, massive fluid/electrolyte loss, and malnutrition, resulting in an unhealed course. Despite advances in surgical techniques, wound care, infection control, and nutritional support, EF remains associated with considerable morbidity and mortality. Autologous platelet-rich plasma (PRP) containing elevated platelet concentrations has been proposed to promote healing in many tissues. However, the mechanism of action of PRP in EF treatment remains unclear owing to its complicated clinical manifestations. In this review, we summarized the clinical approaches, outlined the principal cytokines involved in the healing effects, and discussed the advantages of PRP for EF therapy. In addition, we defined the mechanism of autologous PRP in EF management, which is essential for further developing EF therapies.

Aspectos críticos dos pacientes submetidos a peritoneostomia - Destaque para a assistência de enfermagem

Peritoneostomia é uma técnica cirúrgica utilizada no tratamento das peritonites difusas. Consiste em deixar a cavidade abdominal aberta, como se fosse um grande abscesso. O objetivo da peritoneostomia é permitir uma drenagem espontânea, inspeção diária da cavidade abdominal, aspirações de possíveis lojas purulentas, debridamento de tecidos desvitalizados e prevenção da reacumulação do pus; é empregada como um tratamento cirúrgico nas peritonites difusas graves. Pesquisada e modificada através de recursos materiais e técnicas múltiplas nos últimos anos, continua sendo um desafio para toda equipe multidisciplinar em relação à seu prognóstico, pois os índices de mortalidade continuam elevados. Os pacientes portadores de neoplasias submetidos à peritoneostomia constituem um grupo de risco elevado, potencialmente letal, por apresentarem algum tipo de deficiência imunológica com comprometimento de suas defesas, quer pela doença de base ou terapêutica a que foram submetidos e a infecção. Em 38 pacientes submetidos a peritoneostomia no INCA entre 1985 e 1992, veri1camos que a peritonite é geralmente difusa, generalizada, seu exsudato apresenta-se purulento ou fecal; apesar do tratamento com antibióticos a infecção fulminante caminha com insuficiência orgânica múltipla na maioria dos casos (27/38). Pacientes oncológicos peritoneostomizados necessitam de tratamento em Unidade de Terapia Intensiva, requerem terapia pronta, especializada e adequada às mais diversas características do status do paciente e de sua ferida operatória; são pacientes que representam alto custo hospital/dia; maior tempo de internação hospitalar, e prognóstico sombrio com alto índice de mortalidade.

Perioperative nutrition: Recommendations from the ESPEN expert group

BACKGROUND & AIMS

Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

METHODS

This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

RESULTS

Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

CONCLUSIONS

Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

Neutrophil priming as a risk factor for surgical site infection in patients with colon cancer treated by laparoscopic surgery

Background

The purpose of this study is to identify perioperative marker predicting postoperative surgical site infection (SSI) including with anastomotic leakage (AL) in curative colon cancer patients, laparoscopically.

Methods

In total, 135 colon cancer patients (stage I–III) undergoing curative laparoscopic surgery between January 2004 and December 2013 were enrolled in this study. We collected data on clinicopathological factors, laboratory data on pre and postoperative day 3 (POD3) and tumor markers levels to assess the relation to surgical site infection (SSI) including with anastomotic leakage (AL).

Results

SSI and AL occurred in 16 cases (5.6%) and 4 cases (3%), respectively. SSI and AL were not association with clinicopathological factors. Within laboratory data and tumor markers preoperatively, high neutrophil counts were significantly associated with SSI (P < 0.05) and AL (P < 0.01), respectively. Area under curves (AUC) of SSI and AL were 0.656 and 0.854, respectively. In addition, high neutrophil counts on POD3 also were significantly associated with SSI (P < 0.01) and AL (P < 0.01), respectively. Area under curves (AUC) of SSI and AL were 0.747 and 0.832, respectively.

Conclusion

Neutrophil count on pre and POD3 are potentially valuable indicators of SSI including with AL in colon cancer patients undergoing curative surgery laparoscopically.

Nutritional Risk Screening and Assessment

Malnutrition is an independent risk factor that negatively influences patients’ clinical outcomes, quality of life, body function, and autonomy. Early identification of patients at risk of malnutrition or who are malnourished is crucial in order to start a timely and adequate nutritional support. Nutritional risk screening, a simple and rapid first-line tool to detect patients at risk of malnutrition, should be performed systematically in patients at hospital admission. Patients with nutritional risk should subsequently undergo a more detailed nutritional assessment to identify and quantify specific nutritional problems. Such an assessment includes subjective and objective parameters such as medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values. Nutritional care plans should be developed in a multidisciplinary approach, and implemented to maintain and improve patients’ nutritional condition. Standardized nutritional management including systematic risk screening and assessment may also contribute to reduced healthcare costs. Adequate and timely implementation of nutritional support has been linked with favorable outcomes such as a decrease in length of hospital stay, reduced mortality, and reductions in the rate of severe complications, as well as improvements in quality of life and functional status. The aim of this review article is to provide a comprehensive overview of nutritional screening and assessment methods that can contribute to an effective and well-structured nutritional management (process cascade) of hospitalized patients.

The Management of Intestinal Penetrating Crohn's Disease

Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.

Randomized clinical trial of arginine-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing gastric cancer surgery

PURPOSE

Significant malnutrition exists in a high percentage of patients with gastric cancer. It is, therefore, crucial to establish an effective means to provide nutrition for these patients. This prospective, randomized, double-blinded clinical trial aims to assess the long-term survival of arginine-supplementation enteral nutrition versus standard enteral nutrition in malnourished patients with gastric cancer.

METHODS

The control group (36 cases) received postoperative standard enteral nutrition. Meanwhile, the arginine-supplementation group (37 cases) adopted the same nutrition product but enriched with arginine (9.0 g/L). The primary study objective was overall survival (OS). Secondary endpoints were progression-free survival (PFS); serum parameters including total protein, albumin, proalbumin, and transferrin obtained on preoperative day 1, postoperative day 2, and day 12; CD4(+) and CD8(+) T cells, natural killer (NK) cells, immunoglobulin M (IgM), and immunoglobulin G (IgG) obtained on preoperative day 1 and postoperative day 7.

RESULTS

No significant differences in baseline characteristics were observed between groups. The group receiving arginine-enriched nutrition had a significantly better OS (P = 0.03, 41 vs. 30.5 months) and better PFS (P = 0.02, 18 vs. 11.5 months). On postoperative day 7, CD4(+) T cells, NK cells, IgM and IgG levels of the arginine-supplemented group increased prominently and were significantly higher than those of the control group and those on preoperative day 1. There is no significant difference in the serum total protein, albumin, proalbumin, and transferrin levels between the two arms.

CONCLUSIONS

Arginine-supplemented enteral nutrition significantly improves long-term survival and restores immunity in malnourished gastric cancer.

The anabolic effect of perioperative nutrition depends on the patient's catabolic state before surgery

OBJECTIVE

We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patient's preoperative catabolic state.

BACKGROUND

Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown.

METHODS

Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids. Feeding was administered over 72 hours, from 24 hours before until 48 hours after surgery. Glucose provided 50% of the patient's measured resting energy expenditure. Amino acids provided 20% of the resting energy expenditure. Whole-body leucine balance (difference between the incorporation of leucine into protein = protein synthesis and endogenous leucine release = proteolysis) was determined using L-[1-(13)C]leucine kinetics before and 2 days after surgery. We analyzed the association between the postoperative increase in leucine balance and the following factors: preoperative leucine balance, protein breakdown, weight loss, oxygen consumption, circulating concentrations of glucose, free fatty acids, insulin, glucagon, cortisol, albumin, age, duration of surgery, and blood loss.

RESULTS

Of 6 potentially relevant variables, 4 (weight loss, protein breakdown, albumin, and cortisol) were removed because they were not significant during the stepwise linear regression procedure. Leucine balance and age were the remaining 2 factors that remained with the final regression model: Δleucine balance = 19.1 - (0.20 × age [years]) - (0.58) × leucine balance(preOP)).

CONCLUSIONS

We demonstrate a significant association between the degree of preoperative catabolism, the patient's age, and the anabolic effect of hypocaloric nutrition (ClinicalTrials.gov registration ID: NCT01414946).

Is malnutrition still a risk factor of postoperative complications in gastric cancer surgery?

OBJECTIVE & AIMS

The present study aimed at retrospectively evaluating the incidence of mortality and major and minor postoperative complications in patients who underwent surgery for gastric cancer between 2000 and 2006 stratified according to the preoperative percentage weight loss, serum albumin levels and body mass index (BMI).

METHODS

One hundred and ninety-six patients affected by gastric cancer admitted to the Division of Digestive Surgery of the Catholic University of Rome between January 2000 and December 2006 were considered eligible and were included in the study. According to the weight loss, patients were divided into three groups: (1) 0-5%; (2) 5.1-10%; (3) >10%. On the basis of serum albumin levels, were divided into three groups: (1) <3.0 g/dl; (2) 3.0-3.4 g/dl; (3) >3.5 g/dl. According to BMI, were divided into four groups: (1) <18.5 kg/m(2); (2) 18.5-24.9 kg/m(2); (3) 25.0-29.9 kg/m(2); (4) >30.0 kg/m(2). Postoperative complications and mortality were reported. Complications were classified by objective criteria as major or minor, and as infectious or non-infectious.

RESULTS

The postoperative mortality was 0%. Major infectious complications occurred in 20 patients (10.2%), major non-infectious in 18 (9.2%), minor infectious in 21 (10.7%), whereas minor non-infectious complications were absent. The rate of major infectious, major non-infectious and minor infectious postoperative complications was similar in patients with absent or light weight loss (8.8%, 8.8%, 10.6%, respectively), mild weight loss (15.3%, 11.5%, 9.6%, respectively), or severe weight loss (6.4%, 6.4%, 12.9%, respectively). Similarly, the rate of postoperative complications did not differ between patients with serum albumin <3.0 g/dl (10.8%, 8.1%, 8.1%, respectively); between 3.0 and 3.4 (8.8%, 13.3%, 17.7%, respectively) or > or =3.5 g/dl (10.5%, 7.9%, 8,7%, respectively). According to BMI, the rate of postoperative complications was: 11.7%, 5.8%, and 5.8% for BMI <18.5 kg/m(2); 9.4%, 8.2%, and 11.7% for BMI between 18.5 and 24.9 kg/m(2); 10.7%, 10.7%, and 9.2% for BMI between 25 and 29.9 kg/m(2); 10.3%, 10.3% and 13.7% for BMI >30 kg/m(2). Then, we evaluated the postoperative morbidity only in patients who underwent total gastrectomy or distal subtotal gastrectomy associated with extended lymphadenectomy. In this group of patients, the rate of postoperative complications was comparable in patients with 0-5% (8.8%, 7.7%, 10%, respectively), 5.1-10% (14.6%, 9.7%, 9.7%, respectively), and >10% (7.1%, 7.1%, 14.3%, respectively) weight loss. Also stratifying the patients according to the serum albumin levels, the rate of postoperative complications did not differ significantly (serum albumin <3.0 g/dl: 14.8%, 11.1%, 14.8%, respectively; serum albumin between 3.0 and 3.4 g/dl: 6.2%, 12.5%, 15.6%, respectively; serum albumin > or =3.5 g/dl: 10.4%, 5.8%, 7.0%, respectively). According to BMI, the rate of postoperative complications was: 7.6%, 0%, and 7.6% for BMI <18.5 kg/m(2); 9.5%, 9.5%, and 11.1% for BMI between 18.5 and 24.9 kg/m(2); 12.5%, 8.3%, and 10.4% for BMI between 25 and 29.9 kg/m(2); 9.5%, 9.5% and 9.5% for BMI >30 kg/m(2).

CONCLUSION

The present study suggests that weight loss and hypoalbuminemia are not associated with an increased risk of mortality and morbidity in patients who underwent surgery for gastric cancer. This study may represent a stimulus for further studies aiming at evaluating the actual role of malnutrition in the development of postoperative complications in major abdominal surgery.

Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature

BACKGROUND

Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition.

METHODS

A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay.

RESULTS

Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74-0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56-0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47-0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41-0.95; P = 0.03), and duration of hospital stay (weighted mean difference, -0.81; 95% CI, -1.25-0.38; P = 0.02). There were no clear benefits in any of the other complications.

CONCLUSION

The present findings would lead us to recommend the use of EN rather than PN when possible and indicated.

Nutrition and management of enterocutaneous fistula

BACKGROUND

The management of enterocutaneous fistula is challenging, with significant associated morbidity and mortality. This article reviews treatment, with emphasis on the provision and optimal route of nutritional support.

METHODS

Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers.

RESULTS AND CONCLUSION

Management of enterocutaneous fistula should initially concentrate on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output. The routine use of somatostatin infusion and somatostatin analogues remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of increased probability of spontaneous closure. Malnutrition is common and adequate nutritional provision is essential, enteral where possible, although supplemental parenteral nutrition is often required for high-output small bowel fistulas. The role of immunonutrition is unknown. Surgical repair should be attempted when spontaneous fistula closure does not occur, but it should be delayed for at least 3 months.

Intestinal permeability is decreased in anorexia nervosa

Malnutrition and absence of exogenous luminal nutrients in the gastrointestinal tract affect intestinal permeability (IP) leading to an increased penetration of substances that passively cross intestinal epithelium via intercellular pathways. We hypothesised that an increase in IP could occur in patients with anorexia nervosa because of their prolonged fasting and chronic malnutrition. Therefore, we assessed IP in 14 drug-free anorexic women and 19 drug-free age-matched healthy women by means of the lactulose/mannitol (LA/MA) test. To this purpose, after an overnight fast, subjects ingested an oral solution containing 5 g lactulose and 2 g mannitol in 100 ml water. Urine specimens were collected immediately before and 30, 60, 120, 180, 240 and 300 min after the ingestion of the sugar solution. Urinary lactulose and mannitol were determined by high-performance anion exchange chromatography coupled with pulsed amperometric detection. We found that IP, as expressed by the 5-h LA/MA excretion ratio, was significantly decreased in anorexic women because of a lower urinary recovery of lactulose. Moreover, in patients, the time course of lactulose excretion significantly differs from healthy controls. These results do not confirm our hypothesis of increased IP in anorexia nervosa. Since IP reflects the anatomo-functional status of intestinal mucosa, the present findings support the idea that changes in the anatomo-physiology of intestinal mucosa occur in anorexia nervosa.

Patients with postoperative infections have sticky neutrophils before operation

Appropriate polymorphonuclear neutrophil (PMN) recruitment is essential for host defense against infection. We investigated the significance of the preoperative PMN adhesion-migration process, as assessed by the flow chamber method, on postoperative infectious complications. Thirty-one consecutive patients with gastrointestinal malignancies, 21 colorectal and 10 gastric, who were undergoing elective surgery were enrolled. PMNs, isolated preoperatively from each patient's venous blood, were perfused onto a tumor necrosis factor alpha-stimulated human umbilical vein endothelial cell (HUVEC) monolayer through the flow chamber. We evaluated the adherent PMN number, the migrated PMN number, and the stuck PMN number by directly inspecting PMN interactions with a HUVEC monolayer under continuous shear flow simulating postcapillary venules. The expression of adhesion molecules on circulating PMNs was also measured. Patients were grouped into an infectious and a noninfectious group according to the occurrence of postoperative infectious complications defined by the Centers for Disease Control criteria. Eleven patients developed postoperative infectious complications. Although the number of preoperative in vitro adherent PMNs in patients with postoperative infection was significantly higher than in those without postoperative infection (P = 0.01), migrated PMN number was similar in both groups. Stuck PMN number tended to be higher in the infectious group than in the noninfectious group. The migrated PMN number showed a significant positive correlation with the adherent PMN number in the noninfectious group but not in the infectious group. Preoperative CD31 expression on circulating PMNs was significantly lower in the infectious group than in the noninfectious group. Preoperative in vitro derangement of the PMN adhesion-migration process is closely associated with postoperative infectious complications.

Enteral nutrition and surgical patient

Enterai nutrition can be applicated alone or in combination with, parenteral nutrition. Enterai feeding should be applicated as early as possible in preoperative preparation or in postoperative period in respect of contraindications and everyday evaluation of patients. Immunomodulatory substances like arginin, 3-o-fat acids, ribonucleic acid and glutamine are incorporated in "ready to use" solution for enterai feeding. Enterai feedings oral or via tubes are safe if some precautions are taken: like sitting position and control of feeding tubes position. Use of jejunostomy and promotility agents improved enterai feeding after major abdominal surgery and acute pancreatitis. Enterai feeding and immunonutrition improved postoperative course in reduction of hospital stay, incidence of postoperative complications especially infections. The aim of this review article is to validate pro and con for enterai nutrition in preoperative and postoperative course.

Survival and quality of life after palliative surgery for neoplastic gastrointestinal obstruction

OBJECTIVE

The aim was to identify the prognostic factors which relate to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with an occlusion.

METHODS

The files of 109 patients with a neoplasm who were operated on for occlusion between 1990 and 2000 have been re-examined. The prognostic factors studied were age, sex, the location of the primary tumour, the extension of the cancer at the time of the operation, and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of transit and the return home.

RESULTS

The median survival was 64 days and the peroperative mortality was 21%. The quality of life of patients has been improved in 65% of cases. The only factors clearly correlating to survival and the success of the operation are the aetiological diagnosis of the occlusion (local recurrence better than carcinomatosis) and the type of procedure it was possible to carry out (resection better than bypass).

CONCLUSION

Palliative surgery can, in a certain number of cases, improve the quality of life of patients, but it has not been possible for us to demonstrate prognostic factors which would allow the selection of patients who could benefit the most from such surgery.

[Intestinal obstruction in cancer patients: results of palliative surgery]

OBJECTIVE

The study aim was to investigate predictive factors related to the results, in terms of survival and quality of life, of palliative surgery in cancer patients presenting with intestinal obstruction.

METHODS

A total of 109 patients already treated for a neoplasm were operated on for intestinal obstruction between 1990 and 2000. The investigated prognostic factors were age, sex, location of the primary tumour, extension of the cancer at the time of the operation and the surgical procedure carried out. The impact on the quality of life was assessed by the resumption of intestinal transit and the return home.

RESULTS

The median survival rate was 64 days and the postoperative mortality rate 21%. The quality of life was improved in 65% of the patients. The only factors clearly correlated with survival and the success of the operation were the aetiological diagnosis of the intestinal obstruction and the type of procedure which was possible to carry out.

CONCLUSION

Palliative surgery may improve the quality of life of a certain number of patients, but it was not possible to demonstrate predictive factors for the selection of patients who could have the larger benefits of such surgery.

The management of patients with advanced cancer (II)

In this second article in the series, obstruction of hollow viscera in patients with advanced malignant disease is discussed. The obstruction of such structures can be associated with the development of painful and incapacitating symptoms, often in patients who have a limited life expectancy. This obstruction may be caused by the primary tumour, compression from adjacent tumour-draining lymph nodes, the presence of metastases distant from the site of the primary tumour or to adhesions within the abdominal compartment (usually as a result of previous surgery). The organs most often affected are the oesophagus, the intestine (small and large), the biliary tree and the genito-urinary tract. Obstruction of each of these organs and its management is discussed in more detail below.

Nutritional issues in cancer management

The objective of this article was to investigate the relationship between nutrition and cancer, as it relates to the initiation, promotion, and treatment of tumor growth. English-language studies published in the last 25 years were retrieved using MEDLINE, bibliographies, and consultation with experts. MEDLINE search terms included "cancer", "malnutrition," and "nutritional support." In vitro and in vivo controlled studies addressing the impact of nutritional factors on cancer prevention and treatment were selected. Approximately 30% of cancers in the Western countries are diet-related. The presence of malignancy affects patients' nutritional status negatively, leading to increased morbidity and mortality. Standard nutritional support (both enteral and parenteral) is not always effective in significantly improving outcome in malnourished cancer patients, due to characteristic changes in host metabolism. Preliminary studies suggest that newer nutritional-pharmacologic agents may be beneficial in counteracting the derangement of host metabolism, and consequently in ameliorating cancer patients' nutritional status and outcome of malnourishment. This review suggests that dietary manipulations and nutritional-pharmacologic therapy might be highly effective adjuncts in controlling the symptoms of patients with neoplastic disease.

From laboratory to bedside: new strategies in the treatment of malnutrition in cancer patients

The objective of this review is to present and discuss the current and the possible future perspectives of artificial nutrition in preventing and treating cancer cachexia. English-language studies published in the last 25 years were retrieved using MEDLINE, bibliographies and consultation with experts. MEDLINE search terms included "cancer," "malnutrition," and "nutritional support." In vivo and in vitro controlled studies were selected, and data from each study were independently abstracted by the authors. Data obtained indicate that cancer cachexia is a common manifestation of advanced malignant disease, characterized by marasmus due to impaired nutrient metabolism, weight loss, and anemia. In patients, the presence of cachexia increases morbidity and mortality, delays or impedes the delivery of the adequate treatment, reduces the efficacy of anti-neoplastic therapy, and impairs patient's quality of life. Indirect evidence indicates that cancer cachexia is mediated by circulating cytokines, produced by the host in response to the presence of the malignancy. In the past two decades, nutritional support was used to counteract the detrimental effect of cancer cachexia on the host, but with limited success. More recently, the better understanding of the mechanisms of cancer cachexia and the identification of pharmacologic effects provided by specific nutrients, has formed the rationale for a "new" mode of nutrition therapy/nutritional support, adding pharmacotherapy to adjunctive initial care.

Studies on the regulation of food intake using rat total parenteral nutrition as a model

Total parenteral nutrition (TPN) is essential for maintaining the nutritional status of patients who are unable to eat sufficiently to meet their metabolic needs. However, TPN suppresses appetite and ultimately diminishes food intake. Theories concerning the role(s) of peripheral metabolites as signals, acting via the liver and the hypothalamus, for the metabolic control of food intake, have been put forward to explain the anorectic effect of TPN. In addition, it is postulated that changes in peripheral metabolites during TPN may be translated into changes in the levels of brain neurotransmitters known to decrease food intake. This review summarizes studies concerning the effect of TPN on food intake. These studies have involved: (1) characterizing the changes in feeding activity due to TPN; (2) investigating the involvement of the central nervous system; and (3) investigating the role of the periphery and its metabolites in the regulation of food intake during TPN. Some insight into the mechanism of action of TPN on food intake is provided.

Pharmacological management of pain and infection in the surgical oncology patient

Surgical oncology patients are often high-risk patients that require careful perioperative management for a successful outcome. Prophylactic antibiotics are needed to prevent infection in tissues compromised by disease, radiation, or chemotherapy. Pain control is needed to prevent the stress response to surgery from worsening the outcome and to aid in the maintenance of patient comfort.

Intraoperative radiation therapy following pancreaticoduodenectomy

OBJECTIVE

To determine the morbidity and mortality of pancreaticoduodenectomy followed by electron-beam intraoperative radiation therapy (EB-IORT).

SUMMARY BACKGROUND DATA

Local recurrence following pancreaticoduodenectomy occurs in 50% to 90% of patients who undergo a potentially curative surgical resection for adenocarcinoma of the pancreatic head. To improve local disease control, a more aggressive retroperitoneal dissection has been combined with adjuvant EB-IORT.

METHODS

Forty-one patients with malignant neoplasms of the periampullary region underwent pancreaticoduodenectomy followed by EB-IORT between January 1989 and May 1992. EB-IORT was delivered in a dedicated operative suite, eliminating the need for patient relocation. Electron-beam energies of 6 to 12 MeV were used to deliver 10 to 20 Gy to the treatment field following resection but before pancreatic, biliary, and gastrointestinal reconstruction.

RESULTS

Median operative time was 9 hours, blood loss was 1 L, perioperative transfusion requirement was 2 units, and hospital stay was 20 days. One patient died of a postoperative myocardial infarction, and four patients required reoperation, one for an anastomotic leak. No patient failed to receive EB-IORT because of operative complications during the time period of this study.

CONCLUSION

Adjuvant EB-IORT after pancreaticoduodenectomy can be delivered safely, with low mortality and acceptable morbidity.

Dynamics of oral intake resumption after general anesthesia and operation in rats

The influence of general anesthesia and operation on dynamics of postoperative food intake resumption was investigated in eight rats. A laparotomy was performed on each rat under anesthesia induced by intraperitoneally injected chloral hydrate. Spontaneous food intake and feeding indexes were continuously measured using an Automated Computerized Rat Eater Meter (ACREM) before and after operation. Although spontaneous food intake and all feeding indexes were depressed immediately following anesthesia and operation, each feeding index was depressed to a greater degree during the dark vs. the light cycle. Initially, rats fully capable of eating ate fewer, smaller, and shorter meals. The return to normal of each feeding index differed temporally. Thus, although meal number normalized by the third postoperative day, meal size by the sixth postoperative day, and meal duration by the fourth postoperative day, normalization of meal number during the light cycle occurred sooner than during the dark cycle, while the converse occurred with meal size and meal duration.

Nutritional status of surgical patients and the relationship of nutrition to postoperative outcome

A preoperative nutritional assessment including anthropometry, biochemical indices and global subjective assessment was performed for 127 patients admitted for elective gastrointestinal surgery. Of these, 24 were subjected to minor surgery, 65 to intermediate surgery and 38 to major procedures. Patients were followed postoperatively, recording complications or mortality. Intermediate and major surgery patients had lower triceps skinfold thickness and mid-arm circumference and greater weight loss than did minor surgery patients. Thirty-six percent of the patients suffered complications. No association was found between preoperative nutritional status and incidence of postoperative complications. Six patients died and they showed greater preoperative weight loss (21 +/- 6.5 vs 12 +/- 1.4%) and lower serum albumin levels (25 +/- 4 vs 35 +/- 1 g/l) than patients who survived complications. Global subjective assessment classified 43% of survivors as malnourished, compared to 100% of patients who died.

Nutritional assessment and indications for nutritional support

The goal of nutritional assessment is to identify prospectively all those patients who would develop a nutrition-related complication. In practical terms, there is no single test capable of achieving this goal. At present, the best method of nutritional assessment is an organized step-by-step multifactorial approach. This involves assessment of the primary illness, the patient history, and the prognosis. A nutritional status examination is done, and the current intake is compared with the nutritional goals. A decision is then made whether to force feed. If forced feeding is initiated, the effectiveness of the therapy must be monitored frequently until the patient recovers and is able to be sustained by volitional oral intake.

Surgical wound infection and cancer among the elderly: a case control study

Surgical wound infection occurs in fewer than 5% of operations. Nevertheless, it represents the second most common type of hospital-acquired infection and results in increased morbidity and mortality. As with all nosocomial infections, the rate of surgical wound infection increases with age. Patients over 65 years of age run an approximately 15% risk of surgical wound infection. Two-thirds of patients with invasive cancer other than non-melanotic skin cancer are aged 65 years and over. Over half of them are treated surgically for their cancer. Cancer and other chronic diseases have been cited as possible causes of the increased risk of nosocomial infection among the elderly. Using the Foothills Hospital Wound Study Data Base as the sampling frame, we conducted a case-control study of surgical wound infection and cancer among the elderly. Cancer was found not to be a risk factor for surgical wound infection. The results are discussed in relation to the role of immunity in both disorders.

Palliative operations for colorectal cancer

A review of 96 consecutive patients who underwent palliative surgery for primary colorectal cancer was undertaken to clarify the value of palliation achieved with surgical treatment. The overall rate of postoperative mortality was 8 percent (8 of 96) and the overall rate of postoperative morbidity was 24 percent (23 of 96). The mortality rate was 5 percent (3 of 66) after resective surgery and 17 percent (5 of 30) after nonresective surgery. Three deaths were related to the malignant disease, three were related to the intra-abdominal infection, and two were related to formation of intestinocutaneous fistulas. Of the 8 patients who died, 1 had a tumor with local visceral involvement only and 7 had a tumor with more distant spread. Median survival was 10 months for all patients, 15 months for patients treated with resective surgery, and 7 months for nonresected patients. Five patients (5 percent) have survived for longer than 5 years. The median relief of preoperative cancer symptoms was 4 months (4 months after resective surgery and 1 month after nonresective surgery). Twenty-five patients have undergone second surgery. It is concluded that palliative resective surgery for colorectal cancer can improve patient comfort with an acceptable postoperative mortality rate when cancer growth is localized and in favorable cases with more distant spread, whereas nonresective surgery fails to achieve symptom relief.

Home enteral nutrition via gastrostomy in advanced head and neck cancer patients

We investigated whether home enteral feeding via a tube gastrostomy would enable patients with advanced malignant disease, who were unable to maintain themselves nutritionally via the oral route, to be independent of the hospital setting. Thirty-nine patients with advanced upper gastrointestinal and head and neck cancer had a tube gastrostomy placed. Before discharge, the patient was trained in the care and use of the gastrostomy feeding tube. Ten patients died of their disease before they could be discharged. During the 6-month period before gastrostomy insertion, the mean weight loss of the remaining 29 patients was 12.8%, and the mean body weight was less than 90% of ideal body weight. Prior to operation, the mean serum albumin and total lymphocyte count were 3.7 g/L and 1,087/mL, respectively. At discharge the mean caloric intake was 1.48 times resting energy expenditure. Home enteral nutrition was provided for a median of 94 days and resulted in stabilization of nutritional indices. During their median survival of 176 days, the 29 patients were admitted a total of 52 times. Twenty-eight percent of the patients were never re-admitted after gastrostomy and were adequately maintained at home, whereas 24% needed to be re-admitted once. Only 48% were re-admitted twice to assist in their nutritional management. Twenty patients received temporary home nursing services to aid in their transition. Four patients eventually resumed oral intake, and their feeding gastrostomies were removed.(ABSTRACT TRUNCATED AT 250 WORDS)