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1.
Preoperative Oral Carbohydrate Load Versus Placebo in Major Elective Abdominal Surgery (PROCY): A Randomized, Placebo-controlled, Multicenter, Phase III Trial.
Gianotti, L, Biffi, R, Sandini, M, Marrelli, D, Vignali, A, Caccialanza, R, Viganò, J, Sabbatini, A, Di Mare, G, Alessiani, M, et al
Annals of surgery. 2018;(4):623-630
Abstract
OBJECTIVE To explore whether preoperative oral carbohydrate (CHO) loading could achieve a reduction in the occurrence of postoperative infections. BACKGROUND Hyperglycemia may increase the risk of infection. Preoperative CHO loading can achieve postoperative glycemic control. METHODS This was a randomized, controlled, multicenter, open-label trial. Nondiabetic adult patients who were candidates for elective major abdominal operation were randomized (1:1) to a CHO (preoperative oral intake of 800 mL of water containing 100 g of CHO) or placebo group (intake of 800 mL of water). The blood glucose level was measured every 4 hours for 4 days. Insulin was administered when the blood glucose level was >180 mg/dL. The primary endpoint was the occurrence of postoperative infection. The secondary endpoint was the number of patients needing insulin. RESULTS From January 2011 through December 2015, 880 patients were randomly allocated to the CHO (n = 438) or placebo (n = 442) group. From each group, 331 patients were available for the analysis. Postoperative infection occurred in 16.3% (54/331) of CHO group patients and 16.0% (53/331) of placebo group patients (relative risk 1.019, 95% confidence interval 0.720-1.442, P = 1.00). Insulin was needed in 8 (2.4%) CHO group patients and 53 (16.0%) placebo group patients (relative risk 0.15, 95% confidence interval 0.07-0.31, P < 0.001). CONCLUSIONS Oral preoperative CHO load is effective for avoiding a blood glucose level >180 mg/dL, but without affecting the risk of postoperative infectious complication.
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2.
Sagittal Abdominal Diameter does not Predict Metabolic Traits Better than Waist Circumference-Related Measures of Abdominal Obesity in Obese Subjects.
Zazai, R, Wilms, B, Ernst, B, Keppler, R, Thurnheer, M, Schmid, SM, Schultes, B
Experimental and clinical endocrinology & diabetes : official journal, German Society of Endocrinology [and] German Diabetes Association. 2018;(10):619-627
Abstract
BACKGROUND Recently, we showed that in subjects with a body mass index (BMI) >35 kg/m2 waist circumference (WC) is associated with metabolic traits but associations were weaker in men than in women. AIMS To confirm our previous observation that anthropometric measures of abdominal obesity are closer linked to metabolic traits in obese women than obese men. To test whether sagittal abdominal diameter (SAD) provides a better prediction of metabolic traits in obese subjects than WC related measures. METHODS SAD and WC along with metabolic traits were assessed in 204 women and 69 men (BMI 30.1-64.0 kg/m2). RESULTS In women, abdominal obesity measures were associated with glycated hemoglobin levels (HbA1c), fasting serum glucose, insulin, triglycerides (TG), total cholesterol (Chol), high-density lipoprotein (HDL), and uric acid levels as well as Chol/HDL ratio and homeostatic model assessment of insulin resistance (HOMA-IR) independently of age and BMI. SAD predicted serum insulin and Chol better than WC, whereas WC was superior to SAD in predicting HbA1c, glucose, HOMA-IR, TG, HDL, Chol/HDL, and uric acid. Of note, the combination of SAD and WC provided a better prediction of insulin, HOMA-IR, TG, and uric acid than each of these anthropometric alone. In men, only fasting glucose, Chol, and uric acid levels were associated with abdominal obesity markers. CONCLUSION Data show various associations between anthropometric measures of abdominal obesity and metabolic traits in obese women but overall much less in obese men. Most metabolic traits are better predicted by WC than by SAD.
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3.
PREVENTT: preoperative intravenous iron to treat anaemia in major surgery: study protocol for a randomised controlled trial.
Richards, T, Clevenger, B, Keidan, J, Collier, T, Klein, AA, Anker, SD, Kelly, JD
Trials. 2015;:254
Abstract
BACKGROUND Anaemia is common in patients undergoing major surgery. The current standard of care for patients with low haemoglobin in the peri-operative period is blood transfusion. The presence of preoperative anaemia is associated with an increased likelihood of the patient receiving peri-operative transfusion and worsened outcomes following surgery, more post-operative complications, delayed recovery and greater length of hospital stay. Intravenous iron, if applied in the preoperative setting, may correct anaemia by the time of surgery and reduce the need for blood transfusion and improve outcomes. METHODS/DESIGN PREVENTT is a phase III double-blind randomised controlled trial that will compare the use of intravenous ferric carboxymaltose (dose 1000 mg) with placebo 10-42 days before major open abdominal surgery in 500 patients with anaemia (haemoglobin < 120 g/L). The primary outcome measure will be the need for blood transfusion and secondary endpoints will include post-operative recovery, length of hospital stay, health care utilisation and cost analysis. TRIAL REGISTRATION ISRCTN67322816--registered 9 October 2012. ClinicalTrials.gov identifier: NCT01692418.
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4.
Contrast enhanced transabdominal ultrasound in the characterisation of pancreatic lesions with cystic appearance.
Beyer-Enke, SA, Hocke, M, Ignee, A, Braden, B, Dietrich, CF
JOP : Journal of the pancreas. 2010;(5):427-33
Abstract
CONTEXT Contrast enhanced ultrasound (CEUS) has been established for detection and characterisation of liver tumours and differential diagnosis of solid pancreatic lesions. The role of transabdominal CEUS in cystic pancreatic disease is less obvious. OBJECTIVE We prospectively evaluated CEUS for characterization of undetermined cystic pancreatic lesions with respect to the differential diagnosis of pseudocysts and cystic neoplasia and differentiation between benign and malignant disease (gold standard: histology or cytology). PATIENTS One-hundred and fourteen patients (63 males, 51 females; median age: 62 years, range: 33-87 years) were prospectively examined. INVESTIGATIONS Conventional B-mode and transabdominal CEUS. MAIN OUTCOME MEASURES Conventional B-mode (criteria: solid nodules, septae), and contrast enhancing features of cystic pancreatic lesions (microperfusion of solid nodules) were analysed. Final diagnoses were made by surgery (47 patients) or histology/cytology and follow-up of at least one year (67 patients). RESULTS Fifty patients proved to have neoplastic lesions (37 malignant, 13 of benign origin). Sixty-four patients had pseudocysts caused by acute (27 patients) or chronic pancreatitis (37 patients). Conventional B-mode had a sensitivity of 94% and a low specificity of 44% in the differentiation of pseudocysts versus neoplasia. CEUS had a higher specificity of 77% with the same sensitivity of conventional B-mode ultrasound. The combination of conventional ultrasound and CEUS improved the specificity even more to 97% with an unchanged sensitivity. CEUS was not reliable in the differentiation of benign and malignant neoplasia. CONCLUSION CEUS improves the differentiation between pseudocysts and pancreatic neoplasia in comparison to the conventional B-mode imaging. The microvascularisation visualised using CEUS even in small nodules (with or without septae) associated with cystic lesions is an indicator for cystic pancreatic neoplasia.
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5.
Helical tomotherapy as a new treatment technique for whole abdominal irradiation.
Rochet, N, Sterzing, F, Jensen, A, Dinkel, J, Herfarth, K, Schubert, K, Eichbaum, M, Schneeweiss, A, Sohn, C, Debus, J, et al
Strahlentherapie und Onkologie : Organ der Deutschen Rontgengesellschaft ... [et al]. 2008;(3):145-9
Abstract
PURPOSE To describe a new intensity-modulated radiotherapy (IMRT) technique using helical tomotherapy for whole abdominal irradiation (WAI) in patients with advanced ovarian cancer. MATERIAL AND METHODS A patient with radically operated ovarian cancer FIGO stage IIIc was treated in a prospective clinical trial with WAI to a total dose of 30 Gy in 1.5-Gy fractions as an additional therapy after adjuvant platinum-based chemotherapy. The planning target volume (PTV) included the entire peritoneal cavity. PTV was adapted according to breathing motion as detected in a four-dimensional respiratory-triggered computed tomography (4D-CT). Inverse treatment planning was done with the Hi-Art tomotherapy planning station. Organs at risk (OARs) were kidneys, liver, bone marrow, spinal cord, thoracic and lumbosacral vertebral bodies, and pelvic bones. Daily control of positioning accuracy was performed with megavoltage computed tomography (MV-CT). RESULTS Helical tomotherapy enabled a very homogeneous dose distribution with excellent sparing of OARs and coverage of the PTV (V90 of 93.1%, V95 of 86.9%, V105 of 1.9%, and V110 of 0.01%). Mean liver dose was 21.57 Gy and mean kidney doses were 9.75 Gy and 9.14 Gy, respectively. Treatment could be performed in 18.1 min daily and no severe side effects occurred. CONCLUSION Helical tomotherapy is feasible and fast for WAI. Tomotherapy enabled excellent coverage of the PTV and effective sparing of liver, kidneys and bone marrow.
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6.
The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively--a randomised clinical trial.
Yuill, KA, Richardson, RA, Davidson, HI, Garden, OJ, Parks, RW
Clinical nutrition (Edinburgh, Scotland). 2005;(1):32-7
Abstract
AIM: Recent evidence suggests that the provision of energy-containing fluids is safe and may impact positively on markers of recovery. The aims of this study were to assess the tolerance of preoperative carbohydrate fluid administration and to determine its effect on postoperative metabolic and clinical responses. METHODS Patients admitted to the Royal Infirmary of Edinburgh for major, elective abdominal surgery were recruited to this double-blind, randomised study and received either a placebo drink or carbohydrate (12.6g/100ml) drink (CHOD). Patients consumed 800 ml of their drink on the evening before surgery and 400 ml on the day of surgery 2-3 h before the induction of anaesthesia. Nutritional status was determined using body mass index (BMI) and upper arm anthropometry; all measurements were taken preoperatively, postoperatively and at discharge. Blood glucose and insulin concentrations were also measured preoperatively and on the first post operative day. Length of hospital stay (LOS) and postoperative complications were recorded. RESULTS Seventy-two patients were recruited and 65 (34 male:31 female) completed this study. Thirty-four patients were randomised to receive the placebo drink (control group) and 31 patients to receive the carbohydrate drink (CHOD group). Groups were well-matched in terms of gender and age. There were no differences between the two groups at baseline for BMI (control: -25.1+/-1.7 kg/m2; CHOD -25.2+/-1.2 kg/m2), upper arm anthropometry or surgical procedure. At discharge loss of muscle mass (arm muscle circumference) was significantly greater in the control group when compared with the CHOD group (control: -1.1+/-0.15 cm; CHOD -0.5+/-0.16 cm; P<0.05). Baseline insulin (control: 20.7+/-4.9 mU/l; CHOD 24.6+/-6.2 mU/l) and glucose (control: 6.0+/-1.4 mmol/l; CHOD 5.7+/-1.4 mmol/l) were comparable in the two groups and did not differ postoperatively. No complications were recorded as a result of preoperative fluid consumption. Postoperative morbidity occurred in six patients from each group. Median LOS in the control group was 10 days (IQR=6), and 8 days (IQR=4) in the CHOD group. CONCLUSION Preoperative consumption of carbohydrate-containing fluids is safe. Provision of a carbohydrate energy source prior to surgery may attenuate depletion of muscle mass after surgery. Further studies are required to determine if this preservation of muscle mass is reflected in improved function and reduced rehabilitation time.
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7.
Comparison of indirect methods of measuring intra-abdominal pressure in children.
Davis, PJ, Koottayi, S, Taylor, A, Butt, WW
Intensive care medicine. 2005;(3):471-5
Abstract
OBJECTIVE To determine the most accurate indirect method of measuring intra-abdominal pressure (IAP) in children. DESIGN AND SETTING Single-centre, prospective, clinical study in a 23-bed specialist paediatric intensive care unit in Australia. PATIENTS AND PARTICIPANTS 20 children admitted to paediatric intensive care with a peritoneal dialysis catheter in situ following congenital cardiac surgery. INTERVENTIONS IAP was measured directly via the peritoneal dialysis catheter and by intragastric manometry via an indwelling nasogastric tube, and by intravesical manometry via an indwelling transurethral urinary catheter, using volumes of 0, 1, 3 and 5 ml/kg body weight of sterile saline instilled into the bladder. MEASUREMENTS AND RESULTS Across the range of IAPs of 1-8 mmHg the Bland-Altman method for assessing agreement between two methods of clinical measurement showed bladder pressure measured via the urinary catheter with 1 ml/kg body weight of saline instilled to be the most accurate indirect measurement technique, tending to give pressures between 0.07 and 1.23 mmHg higher than the direct measurement (95% CI for bias). Measuring bladder pressure with either no saline instilled or more saline per kilogram body weight instilled was less accurate over the same range of pressures, as was measuring the gastric pressure. CONCLUSIONS The most accurate indirect method of measuring IAP in children over the normal range of IAPs involves measuring bladder pressure via a transurethral urinary catheter with 1 ml/kg body weight of sterile saline instilled into the bladder.
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8.
Twice-weekly progressive resistance training decreases abdominal fat and improves insulin sensitivity in older men with type 2 diabetes.
Ibañez, J, Izquierdo, M, Argüelles, I, Forga, L, Larrión, JL, García-Unciti, M, Idoate, F, Gorostiaga, EM
Diabetes care. 2005;(3):662-7
Abstract
OBJECTIVE To evaluate the influence of a twice-weekly progressive resistance training (PRT) program, without a concomitant weight loss diet, on abdominal fat and insulin sensitivity in older men with type 2 diabetes. RESEARCH DESIGN AND METHODS Nine older men (aged 66.6 +/- 3.1) with type 2 diabetes participated in a 16-week PRT supervised program (50-80% of the one repetition maximum), for all main muscle groups. Basal glycemia, HbA(1c), diet, habitual physical activity, body composition, and upper/lower maximal strength were measured. Insulin sensitivity was determined according to Bergman's minimal model procedure and abdominal fat was obtained by computed tomography. The measurements were taken 4 weeks before training (-4), immediately before training (0), and at 8-week intervals (i.e., weeks 8 and 16) during the 16-week training period. RESULTS No significant variation was observed in any of the above selected parameters during the 4-week control period. After PRT, both leg and arm maximal strength increased significantly by 17.1 and 18.2%, respectively. Visceral and subcutaneous abdominal fat decreased significantly by 10.3% (from 249.5 +/- 97.9 to 225.6 +/- 96.6 cm(3), P < 0.01) and by 11.2% (from 356.0 +/- 127.5 to 308.6 +/- 118.8 cm(3), P < 0.01), respectively, while no changes were observed in body mass. PRT significantly increased insulin sensitivity by 46.3% (from 2.0 +/- 1.2 to 2.8 +/- 1.6 . 10(4) . min(-1) . muU(-1) . ml(-1), P < 0.01), whereas it significantly decreased (-7.1%, P < 0.05) fasting blood glucose (from 146.6 +/- 28.3 to 135.0 +/- 29.3 mg/dl). Finally, a 15.5% increase in energy intake (from 2,287.1 +/- 354.7 to 2,619.0 +/- 472.1 kcal/day, P < 0.05) was observed. CONCLUSIONS Two sessions per week of PRT, without a concomitant weight loss diet, significantly improves insulin sensitivity and fasting glycemia and decreases abdominal fat in older men with type 2 diabetes.
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9.
The effects of exercise training on abdominal visceral fat, body composition, and indicators of the metabolic syndrome in postmenopausal women with and without estrogen replacement therapy: the HERITAGE family study.
Green, JS, Stanforth, PR, Rankinen, T, Leon, AS, Rao Dc, Dc, Skinner, JS, Bouchard, C, Wilmore, JH
Metabolism: clinical and experimental. 2004;(9):1192-6
Abstract
The purpose of this research was to investigate the effects of apriori estrogen replacement therapy (ERT) and endurance exercise training in postmenopausal women on abdominal visceral fat (AFV) and other selected variables related to body composition and the metabolic syndrome (MS). Forty-eight healthy and previously sedentary postmenopausal women (mean age, 54.3 years) who were enrolled in the HERITAGE Family Study (HFS) served as subjects. Of these 48 women, 18 were currently taking ERT and the remaining 30 were taking no supplemental estrogen (NHRT). Computed tomography (CT) scans were used to assess AVF as well as total abdominal fat (TAF) and abdominal subcutaneous fat (ASF). Body mass index (BMI) and waist-to-hip ratios (WHR) were calculated while body fat percentage (%FAT) and total fat mass (FATM) was assessed using underwater weighing. Blood assays for HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C), and triglycerides (TG) were conducted at a Centers for Disease Control (CDC) certified laboratory, while blood pressure measurements were assessed using an automated system. All measurements were obtained in duplicate before and after a regimen of endurance exercise training. Analysis of variance (ANOVA) showed AVF to be an average of 31.6 cm(2) less in the women receiving ERT, but lost statistical significance when AVF was adjusted for FATM. Mean values for TAF, ASF, and waist girth were also less in the women receiving ERT, but only waist girth achieved statistical significance. No differences were found in BMI or %FAT, but mean WHR was 5% smaller in the ERT group. Baseline values for HDL-C was higher and LDL-C lower in the ERT group. Prevalence of the MS tended to be greater in the NHRT group, but did not achieve statistical significance. There were no differences in training responses in any of the body composition variables between groups, however, in the ERT group LDL-C decreased with training while TG increased. It was concluded that postmenopausal women taking ERT tended to have lower values of AVF and other indicators of body composition, a more favorable lipid profile, and a slightly reduced risk of the MS when compared with women not taking supplemental hormones. Also exercise training did not improve the overall MS status of either group, as LDL-C status improved in the ERT group while TG decreased in the NHRT group.
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10.
Improvement of pain treatment after major abdominal surgery by intravenous S+-ketamine.
Argiriadou, H, Himmelseher, S, Papagiannopoulou, P, Georgiou, M, Kanakoudis, F, Giala, M, Kochs, E
Anesthesia and analgesia. 2004;(5):1413-8, table of contents
Abstract
UNLABELLED The use of intraoperative racemic ketamine for pain prevention after abdominal surgery is controversial. We compared one preincisional i.v. injection of S(+)-ketamine with its preincisional and repeated intraoperative use in 45 patients undergoing surgery with epidural and general anesthesia. S(+)-ketamine is a new drug formulation that contains the more potent S(+)-stereoisomer of ketamine. Patients were randomized to receive placebo, 0.5 mg/kg preincisional S(+)ketamine, or 0.5 mg/kg preincisional and 0.2 mg/kg intraoperative S(+)-ketamine repeated at 20-min intervals. In the postoperative period, epidural ropivacaine (2 mg/mL; 0.12 mL.kg(-1).h(-1)) was infused for pain therapy. Patients who received repeated S(+)-ketamine reported smaller pain scores than those who received placebo after awakening and 3 and 6 h later (P < or = 0.05). Fewer patients with repeated S(+)-ketamine required additional analgesics than those with placebo (P < or = 0.05). Cumulative consumption of additional diclofenac and dextropropoxyphene at 24 h was less after single (P < 0.05) and repeated (P < 0.05) S(+)-ketamine versus placebo. After awakening, patients who received repeated S(+)-ketamine reported being in a better mood than those in the other groups (P < 0.05). No psychotomimetic side effects were noted. In conclusion, preincisional and repeated intraoperative small-dose S(+)-ketamine added to general and epidural anesthesia causes better postoperative pain relief than general and epidural anesthesia alone. IMPLICATIONS After major visceral surgery, preincisional and repeated intraoperative small-dose S(+)-ketamine added to general and epidural anesthesia causes better postoperative pain relief than general and epidural anesthesia alone.