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1.
Program of gastrointestinal rehabilitation and early postoperative enteral nutrition: a prospective study.
Martos-Benítez, FD, Gutiérrez-Noyola, A, Soto-García, A, González-Martínez, I, Betancourt-Plaza, I
Updates in surgery. 2018;(1):105-112
Abstract
Nutritional depletion is commonly observed in patients undergoing surgical treatment for a gastrointestinal malignancy. An appropriate nutritional intervention could be associated with improved postoperative outcomes. The study was aimed to determine the effect of a program of gastrointestinal rehabilitation and early postoperative enteral nutrition upon complications and clinical outcomes in patients who experienced gastrointestinal surgery for cancer. This is a prospective study (2013 January-2015 December) of 465 consecutive patients submitted to gastrointestinal surgery for cancer and admitted to an Oncological Intensive Care Unit. The program of gastrointestinal rehabilitation and early postoperative enteral nutrition consisted on: (1) general rules: pain relive, early mobilization, antibiotic prophylaxis, deep vein thrombosis prophylaxis and respiratory physiotherapy; and (2) gastrointestinal rules: gastric protection, control of postoperative nausea and vomiting, early nasogastric tube remove and early enteral nutrition. The most frequent surgical sites were colorectal (44.9%), gynecological with intestinal suturing (15.7%) and esophagus/stomach (11.0%). Emergency surgery was performed in 12.7% of patients. The program of intestinal rehabilitation and early postoperative enteral nutrition reduced major complications (19.2 vs. 10.2%; p = 0.030), respiratory complications (p = 0.040), delirium (p = 0.032), infectious complications (p = 0.047) and gastrointestinal complications (p < 0.001). Intensive care unit mortality (p = 0.018), length of intensive care unit stay (p < 0.001) and length of hospitalization (p < 0.001) were reduced as well. A program of gastrointestinal rehabilitation and early postoperative enteral nutrition is associated with reduced postoperative complications and improved clinical outcomes in patients undergoing gastrointestinal surgery for cancer.
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2.
Appropriate use of total parenteral nutrition in children with perforated appendicitis.
Yousef, Y, Youssef, F, Homsy, M, Dinh, T, Stagg, H, Petroze, R, Baird, R, Larberge, JM, Poenaru, D, Puligandla, P, et al
Journal of pediatric surgery. 2018;(5):991-995
Abstract
BACKGROUND Total parenteral nutrition (TPN) is often used in children with perforated appendicitis, despite the absence of clear indications. We assessed the validity of specific clinical indications for initiation of TPN in this patient cohort. METHODS Data were gathered prospectively on duration of nil per os (NPO) status and TPN use in a cohort of children treated under a perforated appendicitis protocol during a 19-month period. TPN was started in the immediate postoperative period in patients who had generalized peritonitis and severe intestinal dilatation at operation, or later per the discretion of the attending surgeon. At discharge, TPN was considered to have been used appropriately, according to consensus guidelines, if the patient was NPO≥7days or received TPN≥5days. RESULTS During the study period, TPN was initiated in 31 (25.4%) of 122 patients operated for perforated appendicitis. Sixteen (51.6%) received TPN per operative finding indications and 15 (48.4%) for prolonged ileus. The operative indications demonstrated 47% sensitivity, 86% specificity, a positive predictive value (PPV) of 35%, and a negative predictive value (NPV) of 91%, when adherence to TPN consensus guidelines was considered the gold standard. CONCLUSION Patients without severe intestinal dilatation and generalized peritonitis at operation should not be placed on TPN in the immediate postoperative period. Refinement of selection criteria is necessary to further decrease inappropriate TPN use in children with perforated appendicitis. TYPE OF STUDY Diagnostic Test. LEVEL OF STUDY II.
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3.
Unfavourable risk factor control after coronary events in routine clinical practice.
Sverre, E, Peersen, K, Husebye, E, Gjertsen, E, Gullestad, L, Moum, T, Otterstad, JE, Dammen, T, Munkhaugen, J
BMC cardiovascular disorders. 2017;(1):40
Abstract
BACKGROUND Risk factor control after a coronary event in a recent European multi-centre study was inadequate. Patient selection from academic centres and low participation rate, however, may underscore failing risk factor control in routine clinical practice. Improved understanding of the patient factors that influence risk factor control is needed to improve secondary preventive strategies. The objective of the present paper was to determine control of the major risk factors in a coronary population from routine clinical practice, and how risk factor control was influenced by the study factors age, gender, number of coronary events, and time since the index event. METHODS A cross-sectional study determined risk factor control and its association with study factors in 1127 patients (83% participated) aged 18-80 years with acute myocardial infarction and/or revascularization identified from medical records. Study data were collected from a self-report questionnaire, clinical examination, and blood samples after 2-36 months (median 16) follow-up. RESULTS Twenty-one percent were current smokers at follow-up. Of those smoking at the index event 56% continued smoking. Obesity was found in 34%, and 60% were physically inactive. Although 93% were taking blood-pressure lowering agents and statins, 46% were still hypertensive and 57% had LDL cholesterol >1.8 mmol/L at follow-up. Suboptimal control of diabetes was found in 59%. The patients failed on average to control three of the six major risk factors, and patients with >1 coronary events (p < 0.001) showed the poorest overall control. A linear increase in smoking (p < 0.01) and obesity (p < 0.05) with increasing time since the event was observed. CONCLUSIONS The majority of coronary patients in a representative Norwegian population did not achieve risk factor control, and the poorest overall control was found in patients with several coronary events. New strategies for secondary prevention are clearly needed to improve risk factor control. Even modest advances will provide major health benefits. TRIAL REGISTRATION Registered at ClinicalTrials.gov (ID NCT02309255 ).
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4.
Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase.
Sutcliffe, RP, Hamoui, M, Isaac, J, Marudanayagam, R, Mirza, DF, Muiesan, P, Roberts, JK
World journal of surgery. 2015;(8):2023-30
Abstract
INTRODUCTION The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF). PATIENTS AND METHODS Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal. RESULTS 81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP. CONCLUSION Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.
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5.
Intraperitoneal microdialysis in the postoperative surveillance of infants undergoing surgery for congenital abdominal wall defect: A pilot study.
Risby, K, Ellebæk, MB, Jakobsen, MS, Husby, S, Qvist, N
Journal of pediatric surgery. 2015;(10):1676-80
Abstract
PURPOSE This study aims to investigate the safety and clinical implication of intraperitoneal microdialysis (MD) in newborns operated on for congenital abdominal wall defect. PATIENTS AND METHODS 13 infants underwent intraperitoneal microdialysis (9 with gastroschisis and 4 with omphalocele). MD samples were collected every four hours and the concentrations of lactate, glycerol, glucose and pyruvate were measured. The results of MD were compared between the group of infants with gastroschisis and the group with omphalocele. The duration of parenteral nutrition and tube feeding were compared for high and low levels of intraperitoneal lactate, glycerol, and glucose and lactate/pyruvate ratio respectively. High and low levels were defined as above or below the median value on day one. RESULTS Results from intraperitoneal MD showed a significantly higher mean lactate concentration in the group of infants with gastroschisis compared with the group of infants with omphalocele. The median values were 6.19 mmol/l and 2.19 mmol/l, respectively (P=0.006). The results from MD in the six infants in the gastroschisis group who underwent secondary closure after Silo treatment were similar to those who underwent primary closure. None of the infants with omphalocele received parenteral nutrition whereas all of the infants with gastroschisis did. There was no significant difference in duration of parenteral nutrition or tube feeding, respectively, when comparing the gastroschisis children with high versus low intraperitoneal lactate values. Placement of the MD catheter in the intraperitoneal cavity was feasible and without any major complications. CONCLUSION Intraperitoneal MD is a safe procedure and an applicable method in surveillance of inflammatory changes in the peritoneal cavity in infants after operation for congenital abdominal wall defect. The true clinical value in infants with congenital wall defect remains unknown.
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6.
[Adherence to and satisfaction with oral outpatient thromboembolism prophylaxis compared to parenteral: SALTO study].
Peidro-Garcés, L, Otero-Fernandez, R, Lozano-Lizarraga, L
Revista espanola de cirugia ortopedica y traumatologia. 2013;(1):53-60
Abstract
INTRODUCTION Prolongation of drug-based thromboembolism prophylaxis after discharge from hospital is clearly recommended following total hip and knee replacement. The aim of this study was to evaluate and compare adherence to and satisfaction with outpatient thromboembolism prophylaxis (by injection and oral) under routine clinical practice conditions. MATERIAL AND METHOD We analysed two consecutive cohorts of patients (480 and 366, respectively) who had undergone total hip or knee replacement surgery in 120 Spanish hospitals, and were prescribed outpatient thromboembolism prophylaxis, by injection and orally, respectively. Information on adherence to and satisfaction with both treatments, sociodemographic data and treatment compliance was collected using specific questionnaires. RESULTS The drop-out rate (9.49 vs. 4.14%), general satisfaction (37 vs. 83.38%), and the TSQM satisfaction scale were better in the oral prophylaxis cohort and, although the differences between the two routes of administration were not significant, treatment compliance was also better in the oral cohort (Morisky-Green test: 53.49 vs. 59.05%). CONCLUSIONS Adherence to and satisfaction with the oral thromboembolism prophylaxis were better than for prophylaxis by injection in the context of outpatient prolongation. Nevertheless, suboptimal treatment compliance was found in both cohorts, which could result in lack of efficacy of the prophylaxis. Both patients and doctors have to be made aware of the importance of post-discharge extension of thromboprophylaxis in orthopaedic surgery with high thrombotic risk. Moreover, strategies should be developed to encourage compliance.
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7.
Combining early postoperative parathyroid hormone and serum calcium levels allows for an efficacious selective post-thyroidectomy supplementation treatment.
Raffaelli, M, De Crea, C, Carrozza, C, D'Amato, G, Zuppi, C, Bellantone, R, Lombardi, CP
World journal of surgery. 2012;(6):1307-13
Abstract
BACKGROUND Optimal treatment protocol to prevent symptomatic hypocalcemia following total thyroidectomy is still matter of debate. We prospectively evaluated the efficacy of a selective supplementation protocol based on both early postoperative intact parathyroid hormone (iPTH) and serum calcium levels. METHODS Two hundred thirty consecutive patients were divided in three different groups of treatment according to iPTH levels 4 h after total thyroidectomy (4 h-iPTH) and serum calcium levels in the first postoperative day (1PO-Ca): group A (4 h-iPTH > 10 pg/ml, 1PO-Ca ≥ 8.5 mg/dl), no treatment; group B (4 h-iPTH > 10 pg/ml, 1PO-Ca < 8.5 mg/dl), oral calcium (OC) 3 g per day; and group C (4 h-iPTH ≤ 10 pg/ml), OC 3 g + calcitriol (VD) 1 μg per day. Development of biochemical and/or symptomatic hypocalcemia was evaluated. RESULTS Fifty-nine patients (25.6%) had subnormal 4 h-iPTH levels (≤10 pg/ml) (group C). Among patients with normal 4 h-iPTH levels, 25 (10.9%) had subnormal 1PO-Ca (<8.5 mg/dl) (group B). The remaining 146 patients (63.5%) had normal 4 h-iPTH and 1PO-Ca levels (group A). One patient in group A, 2 in group B, and 18 in group C developed biochemical hypocalcemia. Only one patient in group C experienced major symptoms. Treatment was discontinued within 1 month in all the patients in group B. At a mean follow-up of 303 days, five patients in group C were still under supplementation treatment. CONCLUSION The proposed supplementation protocol seems efficacious in preventing symptomatic hypocalcemia. It could allow a safe and early discharge of most patients, thus avoiding the constraints and the costs of routine supplementation.
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8.
Fast track postoperative management after elective colorectal surgery: a controlled trail.
Feo, CV, Lanzara, S, Sortini, D, Ragazzi, R, De Pinto, M, Pansini, GC, Liboni, A
The American surgeon. 2009;(12):1247-51
Abstract
In the attempt to reduce postoperative complications and costs and improve outcomes, the concept of fast track surgery has been proposed. Improvements in anesthesia techniques and a better understanding of the pathophysiologic events occurring during and after surgery have made it possible. A group of patients undergoing colorectal resections with a fast track approach were investigated; specifically, the effects on postoperative morbidity, resumption of intestinal function, and duration of hospitalization. Fifty patients were managed according to a protocol, which included epidural analgesia, early ambulation, and oral feeding (fast track group); they were compared with 50 patients managed with a different protocol: no epidural analgesia, early ambulation, and early oral diet (control group). Primary outcome end-points reported include morbidity, time to passage of flatus and stool, and length of hospital stay. Fourteen complications occurred in the fast track group and 13 in the control group (P = not significant (NS)). Resumption of intestinal function occurred after 3 days, and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients (P = NS, P < 0.01). Patients undergoing elective colorectal resections can be managed safely with fast track protocols reducing hospital stay.
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9.
[The importance of recombinant human thyroid stimulating hormone in the follow-up and treatment of disseminated thyroid cancer after thyroidectomy].
Skoura, E, Rontogianni, P
Hellenic journal of nuclear medicine. 2007;(1):40-7
Abstract
In patients operated for differentiated thyroid cancer (DTC), before thyroid remnant ablation and treatment of metastatic disease, thyroid hormones are withdrawn four to six weeks in order to induce an increase in serum thyroid stimulating hormone (TSH) of more than 25-30 microU/mL and thus to stimulate thyroid gland uptake and retention of iodine-131 ((131)I), given therapeutically. Secretion of thyroglobulin (Taug) is also increased. However, thyroid hormone withdrawal frequently causes clinical hypothyroidism. Recombinant human TSH (rhTSH) can provide TSH stimulation without withdrawal of thyroid hormones. The primary clinical utility of rhTSH has been for the post-surgical monitoring in patients with DTC but is currently an aid in thyroid remnant ablation and treatment of thyroid tumors with encouraging results. In this review we have briefly described the findings reported during the period 1994-2006 concerning the diagnostic and therapeutic usefulness of rhTSH in patients with DTC after total or near total thyroidectomy.
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10.
Influence of nutritional treatment on the postoperative course in patients with gastric cancer.
Karcz, W, Głuszek, S, Kot, M, Matykiewicz, J
Advances in medical sciences. 2006;:278-82
Abstract
PURPOSE Malnutrition occurs in ca. 60% of all patients with gastric cancer. The obligatory standard for a curative radical oncological procedure is gastrectomy inclusive of regional lymph nodes. Nutritional treatment is expected to decrease possibilities of postoperative complications in patients subjected to curative surgery. The study is aimed at comparing treatment results in patients with gastric cancer subjected to radical surgery, nutritional and non-nutritional treatment respectively. MATERIAL AND METHODS The study included 176 patients qualified for curative surgery of a total or subtotal gastrectomy. Analysed were 2 groups of patients: group I--not subjected to nutritional treatment, group II--subjected to nutritional treatment, both in the circumoperative period. The groups were compared in respect to: 1) age, 2) sex, 3) nutritional condition, 4) degree of clinical cancer development, 5) histopathological cancer type, 6) kind of surgical procedure performed, 7) antibiotic and antithrombotic prevention. All complications observed in the patients were divided into four kinds: surgical of a high or low risk and general of a high or low risk. RESULTS Given the above-mentioned estimation parameters, no statistically significant differences between both groups were recorded. Of 176 patients, 27% showed surgical complications and 40% had general complications. No difference (p = 0.60) in the incidence of a high and low risk surgical complications between groups I and II in the circumoperative period was observed, a significant difference (p = 0.03) was recorded in the incidence of general complications. Low risk general complications (respiratory infections) were shown to occur significantly more often (p = 0.005) in patients receiving either parenteral or enteral nutrition after surgery. CONCLUSIONS A significant part of the patients with a medium degree and a medium to heavy degree of malnutrition subjected to a curative gastrectomy can pass through the postoperative period without using either parenteral or enteral nutrition and with no violations of all the other principles of the postoperative procedure as well as without provoking any significant increase of surgical complications. In case surgical complications should occur and delay resuming natural feeding, it is necessary that parenteral and/or enteral nutritional treatment be undertaken according to clinical circumstances and condition of the patient concerned; such proceedings increase chances of cure.