0
selected
-
1.
Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS).
Hamilton, E, Ravikumar, R, Bartlett, D, Hepburn, E, Hwang, MJ, Mirza, N, Bahia, SS, Wilkey, A, Bodenham Chilton, H, Handley, K, et al
Trials. 2013;:249
Abstract
BACKGROUND Postoperative nausea and vomiting is one of the most common complications affecting patients after surgery and causes significant morbidity and increased length of hospital stay. It is accepted that patients undergoing surgery on the bowel are at a higher risk. In the current era of minimally invasive colorectal surgery combined with enhanced recovery, reducing the incidence and severity of postoperative nausea and vomiting is particularly important. Dexamethasone is widely, but not universally used. It is known to improve appetite and gastric emptying, thus reduce vomiting. However, this benefit is not established in patients undergoing bowel surgery, and dexamethasone has possible side effects such as increased risk of wound infection and anastomotic leak that could adversely affect recovery. DESIGN DREAMS is a phase III, double-blind, multicenter, randomized controlled trial with the primary objective of determining if preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing elective gastrointestinal resections. DREAMS aims to randomize 1,350 patients over 2.5 years.Patients undergoing laparoscopic or open colorectal resections for malignant or benign pathology are randomized between 8 mg intravenous dexamethasone and control (no dexamethasone). All patients are given one additional antiemetic at the time of induction, prior to randomization. Both the patient and their surgeon are blinded as to the treatment arm.Secondary objectives of the DREAMS trial are to determine whether there are other measurable benefits during recovery from surgery with the use of dexamethasone, including quicker return to oral diet and reduced length of stay. Health-related quality of life, fatigue and risks of infections will be investigated. TRIAL REGISTRATION ISRCTN21973627.
-
2.
Delayed primary serial transverse enteroplasty as a novel management strategy for infants with congenital ultra-short bowel syndrome.
Wales, PW, Jancelewicz, T, Romao, RL, Piper, HG, de Silva, NT, Avitzur, Y
Journal of pediatric surgery. 2013;(5):993-9
Abstract
BACKGROUND Congenital ultra-short bowel syndrome (USBS) is a challenging problem with a poor outcome. We report a new management approach for USBS infants that attempts to optimize gut growth potential. METHODS We report five neonates with USBS in whom no correction was performed at primary surgery except placement of a gastrostomy (G) tube. Sham feeds were started with intermittent G-tube clamping to induce bowel dilatation/growth. Serial fluoroscopy was done until bowel caliber reached 5 cm. STEP was performed and continuity established to the colonic remnant. Small bowel length (SBL) and enteral caloric intake were tabulated. RESULTS Patients were born with a mean residual SBL of 19 ± 7.6 cm (14.8% of expected). Median duration of sham feeds prior to STEP was 108 (range 27-232)days. Mean SBL at STEP was 47 ± 12.1cm, which increased post-STEP to 70 ± 12.7 cm (a mean increase of 296% from birth, representing 36.4% ± 13.1% of expected gut length). With a median follow-up time of 20 months (range 8-28), 4/5 achieved >50% enteral calories and have normal liver function. One has undergone liver transplantation. CONCLUSIONS In USBS patients, delayed surgical correction with sham feeds accelerates gut growth, optimizing potential for autologous reconstruction. This approach may offer greater opportunity for intestinal adaptation than traditional options.
-
3.
Glucose and protein kinetics in patients undergoing colorectal surgery: perioperative amino acid versus hypocaloric dextrose infusion.
Lugli, AK, Schricker, T, Wykes, L, Lattermann, R, Carli, F
Metabolism: clinical and experimental. 2010;(11):1649-55
Abstract
Surgical injury provokes a stress response that leads to a catabolic state and, when prolonged, interferes with the postoperative recovery process. This study tests the impact of 2 nutrition support regimens on protein and glucose metabolism as part of an integrated approach in the perioperative period incorporating epidural analgesia in 18 nondiabetic patients undergoing colorectal surgery. To test the hypothesis that parenteral amino acid infusion (amino acid group, n = 9) maintains glucose homeostasis while maintaining normoglycemia and reduces proteolysis compared with infusion of dextrose alone (DEX group, n = 9), glucose and protein kinetics were measured before and on the second day after surgery using a stable isotope tracer technique. Postoperatively, the rate of appearance of glucose was higher (P < .001) and blood glucose increased more (P < .001) in the DEX group than in the amino acid group. The postoperative increase in the appearance of leucine from protein breakdown tended to be greater (P = .077) in the DEX group. We conclude that perioperative infusion of a nutrition support regimen delivering amino acids alone maintains blood glucose homeostasis and normoglycemia and tends to have a suppressive effect on protein breakdown compared with infusion of dextrose alone.
-
4.
Chronic kidney disease--a common and serious complication after intestinal transplantation.
Herlenius, G, Fägerlind, M, Krantz, M, Mölne, J, Olausson, M, Gäbel, M, Friman, V, Oltean, M, Friman, S
Transplantation. 2008;(1):108-13
Abstract
BACKGROUND Chronic kidney disease after organ transplantation is a serious complication that negatively impacts on long-term patient survival. We describe long-term renal function after intestinal transplantation by serial measurements of glomerular filtration rates (GFR) with Chromium EDTA clearance. MATERIALS AND METHODS Ten patients with at least 6 months survival form the basis of this report. Glomerular filtration rate measurements were performed at baseline, 3 months posttransplantation, and yearly thereafter. Median follow-up time for the cohort was 1.5 years (0.5-7.8 years). Tacrolimus (Prograf) was discontinued in four patients because of impaired renal function. These four patients were switched to sirolimus (Rapamune) at 11, 18, 24, and 40 months posttransplantation. RESULTS Median baseline GFR was 67 (22-114) mL/min/1.73 m. In the adult patients, GFR 3 months posttransplantation had decreased to 50% of the baseline. At 1 year, median GFR in the adult patients was reduced by 72% (n=5). Two patients developed renal failure within the first year and required hemodialysis. One of the pediatric patients fully recovered her renal function, the second pediatric patient lost 20% of her baseline GFR at 6 months posttransplantation. Glomerular filtration rate calculated with the modified diet in renal disease formula consistently overestimated GFR by approximately 30% compared with measured GFR. CONCLUSION Chronic kidney disease and renal failure are common after intestinal transplantation. These two factors significantly contribute to poor long-term survival rates. Measurements of GFR may help to identify those individuals at risk for developing chronic kidney disease to implement renal sparing strategies.
-
5.
[Cholagenic diarrhea].
Parfenov, AI, Krums, LM, Lychkova, AE, Poleva, NI
Terapevticheskii arkhiv. 2008;(2):33-8
Abstract
AIM: To characterize cholagenic diarrhea as a nosological entity with its specific features of etiology, pathogenesis, clinical picture and treatment. MATERIAL AND METHODS A total of 167 patients with chronic diarrhea (CD) participated in the trial. Of them, 25 patients have undergone resection of the small intestine, 98--cholecystectomy for cholelithiasis, 44 had concurrent hypokinesia of the gall bladder caused by celiac disease (n = 30) or biliary dyskinesia (n = 14). The examination included estimation of cholic acid in the duodenal content (40% glucose solution or cholecystokinin were used as stimulators); 24-h fecal mass; fecal mass for 24 hours, fat, potassium and sodium content in the feces; electromotor activity (EMA) of the gall bladder, small intestine and colon. RESULTS Duodenal intubation with 40% glucose in patients with extensive resection of the small intes- tine detected a fall in cholic acid content in vesical bile to 408 +/- 58.39 mg compared to normal (910 +/- 97.29 mg%). In intravenous administration of cholecystokinin cholic acid concentration rose insignificantly (547.0 +/- 94.7 mg%) and was accompanied with bile loss with feces, polyfecalia, steatorrhea and high sodium concentration in feces. In celiac disease patients bile with high cholic acid concentration was secreted only in administration of cholecystokinin (1673 +/- 175.9 mg/%, normal 1701 +/- 140.6 mg/%). In patients after cholecystectomy colon EMA was primarily slow-wave and middle-amplitude, typical for hypermotor dyskinesia. CONCLUSION CD develops after extensive resection and in inflammatory ileac diseases, suppression of contractile function of the gall bladder and after cholecystectomy. CD after cholecystectomy can be considered as a variant of postcholecystectomy syndrome. The treatment of CD should include drugs binding excessive bile acids in the colon, in hypokinesia of the gall bladder the treatment should include stimulators of its contractile function.
-
6.
Nutrient induced thermogenesis during major colorectal excision--a pilot study.
Chandrasekaran, TV, Morgan, RN, Mason, RA, Mangat, PS, Watkins, AJ, Carr, ND
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2005;(1):74-8
Abstract
OBJECTIVE Hypothermia may occur during general anaesthesia and is associated with postoperative coagulopathy, ischaemic cardiac events, wound infections and increased metabolic expenditure due to shivering. The purpose of the present pilot study was to determine whether the administration of certain amino acids (Vamin 18) during general anaesthesia could prevent postoperative hypothermia. PATIENTS AND METHODS Two groups of patients were studied. The study group comprised 10 patients who underwent complex major colorectal operations. In this group an infusion of 500 mls of Vamin 18 (Fresenius Kabi Ltd) was commenced immediately after induction of anaesthesia but prior to the skin incision. In a control group (n=10) who underwent similar surgical procedures Vamin 18 was not administered. In both groups core body temperature, using an oesophageal probe was recorded during the procedure and recovery period. Ambient theatre and recovery room temperature and other body warming techniques were standardized for all patients. Statistical analysis was performed using t-test for comparison of linear temperature changes at different times during the procedure for both groups of patients. RESULTS The body temperature was statistically significantly reduced in both groups at skin incision when compared with temperature prior to induction of anaesthesia. ( STUDY GROUP mean 0.74 degrees C, SD=0.38, P =<0.001; CONTROL GROUP mean 0.54 degrees C, SD=0.43, P=0.003]. The increase in body temperature between the time of skin incision and recovery period was statistically significant (P=0.012) in the study group but not so in the control group (P=0.730). CONCLUSION The results of the present pilot study demonstrate that complex colorectal operations are associated with a decrease in body temperature which is most marked immediately after the induction of anaesthesia. The perioperative administration of Vamin 18 appears to increase the rate of recovery of body temperature. The impact of this thermogenic effect on perioperative morbidity and mortality should be studied in a prospective randomised clinical trial.
-
7.
Prospective comparison of short- and long-term effects of pelvic floor exercise/biofeedback training in patients with fecal incontinence after surgery plus irradiation versus surgery alone for colorectal cancer: clinical, functional and endoscopic/endosonographic findings.
Allgayer, H, Dietrich, CF, Rohde, W, Koch, GF, Tuschhoff, T
Scandinavian journal of gastroenterology. 2005;(10):1168-75
Abstract
OBJECTIVE The influence of irradiation on the clinical severity of incontinence, sphincter function, morphologic features and short/long-term treatment effects of sphincter training therapy is still insufficiently understood in irradiated patients with fecal incontinence after surgery for colorectal cancer. These parameters were compared in irradiated and non-irradiated patients and followed prospectively with regard to short- and long-term training effects. MATERIAL AND METHODS Forty-one patients having been irradiated after surgery (50.0+/-5.0 Gy) and 54 non-irradiated patients with fecal incontinence participated in this prospective, non-randomized trial. Baseline evaluation included a semiquantitative severity assessment score of fecal incontinence (modified Cleveland Incontinence Score (MCIS)), rectal manometry and endoscopy. After 3 weeks (short term) of intensive in-hospital pelvic floor exercise combined with biofeedback training, a second evaluation was made. In addition, anal endosonography (EUS) was performed in cases of treatment failure. After one year (long term) a third evaluation was made clinically (MCIS score). RESULTS Irradiated patients presented with a significantly higher degree of fecal incontinence (lower MCIS) compared to non-irradiated patients: 7.4+/-2.2 versus 8.7+/-2.7 points (p<0.001). Rectosigmoidal inflammation was more frequent in irradiated than non-irradiated patients (26.9% versus 9.3%) (p<0.03). Sphincter pressure, sensation/pain threshold and the rectoanal inhibitory reflex were similar in both groups. A significant short-term training effect was observed in both groups following sphincter training therapy in terms of an increase in MCIS from 7.4+/-2.2 to 9.4+/-2.7 points in the irradiated group and from 8.7+/-2.7 to 11.4+/-2.5 points in the non-irradiated group (p<0.0001). After one year the scores were 8.2+/-3.8 and 10.7+/-4.4 points, respectively (p<0.0001). There was a significant correlation (p<0.001) between baseline MCIS and the short- and long-term MCIS. In patients with short-term treatment failure (16.6%) anal EUS revealed structural defects of the external sphincter in four patients. There was no association of sphincter diameter with sphincter pressure, sensation/pain threshold and short/long-term MCIS. CONCLUSIONS The main result of this study is that irradiated patients show short- and long-term training effects comparable with those of non-irradiated patients despite the higher degree of incontinence at baseline. The correlation between the initial MCIS and short- and long-term treatment effects may be regarded as an important clinical predictor for treatment outcome. Functional and morphologic features are less suitable for this purpose.
-
8.
Enteral versus parenteral nutrition following resection in malnourished patients with gastrointestinal cancer.
Buchman, AL
Current gastroenterology reports. 2002;(4):322-3