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He Z, Xiong H, Cai Y, Chen W, Shi M, Liu L, Wu K, Deng X, Deng X, Chen T. Clostridium butyricum ameliorates post-gastrectomy insulin resistance by regulating the mTORC1 signaling pathway through the gut-liver axis. Microbiol Res 2025; 297:128154. [PMID: 40188705 DOI: 10.1016/j.micres.2025.128154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2025] [Revised: 03/23/2025] [Accepted: 03/25/2025] [Indexed: 05/04/2025]
Abstract
Postoperative insulin resistance (IR) is a metabolic disorder characterized by decreased insulin sensitivity and elevated blood glucose levels following major surgery. Our previous clinical study identified a notable correlation between postoperative IR and gut microbiota, particularly butyrate-producing bacteria, yet the mechanisms remain unclear. In this study, we established gastric resection SD rat models to evaluate the impact of Clostridium butyricum NCU-27 (butyrate-producing bacteria) on postoperative IR. The results demonstrated significant reductions in fasting blood glucose (FBG), fasting insulin (FIns) levels, and HOMA-IR (6.64 ± 0.76 vs. 11.47 ± 1.32; 4.27 ± 0.59 vs. 7.40 ± 0.54) in the postoperative period compared to the control group (P < 0.05). Additionally, glucose tolerance and hepatic glycogen content were markedly improved (P < 0.001). Further exploration of butyrate demonstrated effects similar to C. butyricum NCU-27, potentially mediated through the gut-liver axis by inhibiting mTORC1 expression in liver cells, activating the IRS1/AKT pathway, enhancing glucose uptake and glycogen synthesis, suppressing gluconeogenesis, increasing insulin sensitivity, and improving IR. Finally, the use of mTORC1 agonists and inhibitors further confirmed the critical role of the mTORC1 pathway in mediating the beneficial effects of C. butyricum NCU-27 and butyrate on postoperative IR. In conclusion, this study elucidated that C. butyricum NCU-27 improves postoperative IR by regulating butyrate metabolism and inhibiting the mTORC1 pathway, offering new insights for preventing and treating post-gastrectomy IR.
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Affiliation(s)
- Zhipeng He
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China; Jiangxi Province Key Laboratory of Bioengineering Drugs, School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang 330031, China
| | - Huan Xiong
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China
| | - Yujie Cai
- Jiangxi Province Key Laboratory of Bioengineering Drugs, School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang 330031, China
| | - Wenjing Chen
- Jiangxi Province Key Laboratory of Bioengineering Drugs, School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang 330031, China
| | - Meng Shi
- Department of Gastrointestinal Surgery, Sinopharm Dongfeng General Hospital, Hubei University of Medicine, Shiyan, Hubei 442008, China
| | - Lulin Liu
- Department of Vascular Surgery, Heyuan Hospital of Guangdong Provincial People's Hospital, Heyuan, Guangdong 51700, China
| | - Kai Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China
| | - Xi Deng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China
| | - Xiaorong Deng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China.
| | - Tingtao Chen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China; Jiangxi Province Key Laboratory of Bioengineering Drugs, School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang 330031, China; National Engineering Research Center for Bioengineering Drugs and the Technologies, Institute of Translational Medicine, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi 330031, China.
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Carcéles AF, Degani M, Soler C, Serra CI, Fernández-Salesa N, García de Carellán Mateo A, Herrería-Bustillo VJ, Di Franco C, Briganti A. Veterinary Enhanced Recovery After Surgery (Vet-ERAS) Program in Dogs Undergoing Emergency Laparotomy. Vet Sci 2025; 12:377. [PMID: 40284879 PMCID: PMC12030949 DOI: 10.3390/vetsci12040377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2025] [Revised: 04/15/2025] [Accepted: 04/16/2025] [Indexed: 04/29/2025] Open
Abstract
This study aimed to assess the efficacy of a veterinary enhanced recovery after surgery (Vet-ERAS) protocol in dogs undergoing emergency laparotomy (EL). The protocol, adapted from human medicine, encompassed a multidisciplinary approach and interventions such as early goal-directed fluid resuscitation, antibiotic prophylaxis, anti-emetic therapy, multimodal analgesia, and early enteral nutrition. A prospective observational study compared outcomes between dogs managed with the Vet-ERAS protocol (n = 59) and historical controls (n = 82). Implementation of the Vet-ERAS protocol resulted in a significant reduction in perioperative complication rates (p = 0.003) and 15-day mortality (5% vs. 20.7%). Intraoperative complications, including tachycardia and hypothermia, were significantly lower in the Vet-ERAS group. Compliance with the protocol improved over time (p = 0.01). These findings suggest that integrating the Vet-ERAS protocol into perioperative management can improve outcomes in dogs undergoing EL.
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Affiliation(s)
- Aida Fages Carcéles
- Department of Veterinary Sciences, Veterinary Teaching Hospital “M. Modenato”, University of Pisa, 56122 Pisa, Italy
- Doctoral School, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
| | - Massimiliano Degani
- Department of Veterinary Sciences, Veterinary Teaching Hospital “M. Modenato”, University of Pisa, 56122 Pisa, Italy
- Clinical Department of Companion Animal Sciences, Faculty of Veterinary Medicine, University of Liège, 4000 Liège, Belgium
| | - Carme Soler
- Doctoral School, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
- Small Animal Medicine and Surgery Department, Veterinary Teaching Hospital, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
| | - Claudio Iván Serra
- Small Animal Medicine and Surgery Department, Veterinary Teaching Hospital, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
| | - Nuria Fernández-Salesa
- Small Animal Medicine and Surgery Department, Veterinary Teaching Hospital, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
| | - Alejandra García de Carellán Mateo
- Small Animal Medicine and Surgery Department, Veterinary Teaching Hospital, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
| | - Vicente José Herrería-Bustillo
- Small Animal Medicine and Surgery Department, Veterinary Teaching Hospital, Catholic University of Valencia “San Vicente Mártir”, 46018 Valencia, Spain
| | - Chiara Di Franco
- Department of Veterinary Sciences, Veterinary Teaching Hospital “M. Modenato”, University of Pisa, 56122 Pisa, Italy
| | - Angela Briganti
- Department of Veterinary Sciences, Veterinary Teaching Hospital “M. Modenato”, University of Pisa, 56122 Pisa, Italy
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Yang Z, Jiang F, Jian M, Liu Y, Zhang Y, Zhang Z, Yao Z, Zhou B, Chen C, Li M, Jiang L. High glycemic variability serves as an independent risk factor for postoperative infection-related complications in patients undergoing radical surgery for gastric, colon, and rectal cancer. Medicine (Baltimore) 2025; 104:e41602. [PMID: 39960895 PMCID: PMC11835079 DOI: 10.1097/md.0000000000041602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 10/17/2024] [Indexed: 02/20/2025] Open
Abstract
Patients with gastrointestinal surgery have a higher incidence of infection-related complications than the rest of those who undergo clean cut surgery. It can lead to a worse prognosis for patients. This study aimed to assess the association between glycemic variability (GV) and postoperative infection-related complications of gastrointestinal cancer patients. A total of 438 patients were included in this study. Using univariate and multivariate regression analyses, the risk factors for postoperative complications were determined. And nomogram prediction models were constructed through machine learning. The performance of the nomogram was assessed with respect to the calibration curves. Univariate and multivariate regression analysis showed that high GV on post operation day (POD)1 (P < .001), high leukocytes on POD4 (P = .003 < .01) and alcohol consumption (P = .005 < .01) were independent risk factors for postoperative infection-related complications in patients with gastrointestinal cancers. The area under the curve (AUC) showed that these 3 prediction models established through logistic regression (AUC = 0.81), XGBoost (AUC = 0.82) and random forest (AUC = 0.78) all performed well. Our study confirmed that higher GV on POD1 were independent risk factors for postoperative infection-related complications within 30 days of surgery in patients with gastrointestinal cancers. And the nomogram prediction model confirmed its capable for predicting infection-related complications.
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Affiliation(s)
- Zhensong Yang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
- Qingdao Medical College, Qingdao University, Shandong, China
| | - Fangjie Jiang
- Department of Endocrinology, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Mi Jian
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Yang Liu
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Yifei Zhang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Zhenbin Zhang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Zengwu Yao
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Baocai Zhou
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Cheng Chen
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Miaomiao Li
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
| | - Lixin Jiang
- Department of Gastrointestinal Surgery, Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University, Shandong, China
- Department of Surgical Department, The Yeda Hospital of Yantai City, Shandong, China
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Sun M, Ruan X, Zhou Z, Huo Y, Liu M, Liu S, Cao J, Liu YH, Zhang X, Ma YL, Mi W. Effect of intranasal insulin on perioperative cognitive function in older adults: a randomized, placebo-controlled, double-blind clinical trial. Age Ageing 2024; 53:afae188. [PMID: 39216470 DOI: 10.1093/ageing/afae188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 06/18/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Postoperative cognitive impairment are common neural complications in older surgical patients and exacerbate the burden of medical care on families and society. METHODS A total of 140 older patients who were scheduled for elective orthopaedic surgery or pancreatic surgery with general anaesthesia were randomly assigned to Group S or Group I with a 1:1 allocation. Patients in Group S and Group I received intranasal administration of 400 μL of normal saline or 40 IU/400 μL of insulin, respectively, once daily from 5 minutes before anaesthesia induction until 3 days postoperatively. Perioperative cognitive function was assessed using the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment-Basic (MoCA-B) at 1 day before and 3 days after surgery and postoperative delirium (POD) incidence was assessed using the 3-minute Diagnostic Interview for CAM (3D-CAM) on postoperative days 1-3. Serum levels of interleukin-6 (IL-6), tumour necrosis factor α (TNF-α), S100-β and C-reactive protein (CRP) were measured on the first day after surgery. RESULTS Insulin treatment significantly increased postoperative MMSE and MoCA-B scores in group I than in group S (P < 0.001, P = 0.001, respectively), decreased the incidence of POD within the 3-day postoperative period in Group I than in Group S (10.9% vs 26.6%, P = 0.024), and inhibited postoperative IL-6 and S100-β levels in Group I compared to Group S (P = 0.034, P = 0.044, respectively). CONCLUSIONS Intranasal insulin administration is thus suggested as a potential therapy to improve postoperative cognition in older patients undergoing surgery. However, a more standardized multi-centre, large-sample study is needed to further validate these results.
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Affiliation(s)
- Miao Sun
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
- Department of Anesthesiology, The First Affiliated Hospital, Jinzhou Medical University, Jinzhou, Liaoning Province, China
| | - Xianghan Ruan
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Zhikang Zhou
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Yuting Huo
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Min Liu
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Siyuan Liu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Jiangbei Cao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Yan-Hong Liu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Xiaoying Zhang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Yu-Long Ma
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
| | - Weidong Mi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing 100730, China
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Liu D, Ren B, Tian Y, Chang Z, Zou T. Association of the TyG index with prognosis in surgical intensive care patients: data from the MIMIC-IV. Cardiovasc Diabetol 2024; 23:193. [PMID: 38844938 PMCID: PMC11157750 DOI: 10.1186/s12933-024-02293-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The triglyceride-glucose (TyG) index, a tool for assessing insulin resistance, is increasingly recognized for its ability to predict cardiovascular and metabolic risks. However, its relationship with trauma and surgical patient prognosis is understudied. This study investigated the correlation between the TyG index and mortality risk in surgical/trauma ICU patients to identify high-risk individuals and improve prognostic strategies. METHODS This study identified patients requiring trauma/surgical ICU admission from the Medical Information Mart for Intensive Care (MIMIC-IV) database, and divided them into tertiles based on the TyG index. The outcomes included 28-day mortality and 180-day mortality for short-term and long-term prognosis. The associations between the TyG index and clinical outcomes in patients were elucidated using Cox proportional hazards regression analysis and RCS models. RESULTS A total of 2103 patients were enrolled. The 28-day mortality and 180-day mortality rates reached 18% and 24%, respectively. Multivariate Cox proportional hazards analysis revealed that an elevated TyG index was significantly related to 28-day and 180-day mortality after covariates adjusting. An elevated TyG index was significantly associated with 28-day mortality (adjusted hazard ratio, 1.19; 95% confidence interval 1.04-1.37) and 180-day mortality (adjusted hazard ratio, 1.24; 95% confidence interval 1.11-1.39). RCS models revealed that a progressively increasing risk of mortality was related to an elevated TyG index. According to our subgroup analysis, an elevated TyG index is associated with increased risk of 28-day and 180-day mortality in critically ill patients younger than 60 years old, as well as those with concomitant stroke or cardiovascular diseases. Additionally, in nondiabetic patients, an elevated TyG index is associated with 180-day mortality. CONCLUSION An increasing risk of mortality was related to an elevated TyG index. In critically ill patients younger than 60 years old, as well as those with concomitant stroke or cardiovascular diseases, an elevated TyG index is associated with adverse short-term and long-term outcomes. Furthermore, in non-diabetic patients, an elevated TyG index is associated with adverse long-term prognosis.
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Affiliation(s)
- Donghao Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
- Beijing Hospital, Institute of Geriatric Medicine, Peking University Fifth School of Clinical Medicine, Beijing, People's Republic of China
| | - Bingkui Ren
- Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China
- Department of Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Yuqing Tian
- Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Zhigang Chang
- Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China.
- Department of Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Tong Zou
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
- Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China.
- Beijing Hospital, Institute of Geriatric Medicine, Peking University Fifth School of Clinical Medicine, Beijing, People's Republic of China.
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Carlson JP, Peña K, Burjonrappa S. The Obesity Paradox in the Pediatric Trauma Patient. J Pediatr Surg 2024; 59:275-280. [PMID: 37993398 DOI: 10.1016/j.jpedsurg.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Obesity is a chronic disease that adversely impacts patient outcomes and increasingly affecting the pediatric population. According to the CDC, in 2020 the prevalence of obesity among children and adolescents was estimated to be as high as 19.7%. The obesity paradox is the increased survival for overweight and obese adult trauma patients when compared to patients with healthy weights. The aim of this study was to analyze the impact of BMI and outcomes in the pediatric trauma population. METHODS Trauma patients in the 2-18 years age group and reported to the 2017-2019 National Trauma Data Bank were identified. CDC growth charts and z-scores were calculated to categorize patients into four subgroups: underweight (<5th percentile), healthy weight (5th-85th percentile), overweight (85th-95th percentile), and obesity (>95th percentile). Primary outcome studied was the mortality rate. Secondary outcomes included injury severity score (ISS), hospital length of stay (LOS), ICU LOS, and number of days on a ventilator. Continuous and categorical data were analyzed using ANOVA and Chi-squared test, respectively, using the healthy BMI category as reference group. P < 0.05 was considered significant. RESULTS A total of 161,458 patients [Underweight: 9148 (6%), Healthy weight: 88,009 (55%), Overweight: 26,740 (17%), and Obese: 37,561 (23%)] were included. The mean age was 11 years (SD:5.1). Total mortality for the patient set was 1825 (1.13%). The lowest mortality rate was in the obese group. The ISS was lowest in the obese group, while ICU LOS and days on ventilator were no different than control patients. Hospital LOS and transfer to rehabilitation rates were higher in the obese population. CONCLUSION Obesity appears to have a protective effect on mortality and significantly better secondary outcomes in the pediatric trauma population. Further study is necessary to evaluate the interplay between body weight and outcomes in pediatric trauma and disease states. LEVEL OF EVIDENCE III.
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Tarasova IA, Tshkovrebov AT, Bitarov TT, Boeva IA, Ivanova MY, Shestakov AL. [Clinical efficacy of carbohydrate preloading in reconstructive esophageal surgery]. Khirurgiia (Mosk) 2024:83-90. [PMID: 39665350 DOI: 10.17116/hirurgia202412283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2024]
Abstract
OBJECTIVE To evaluate clinical efficacy of preoperative carbohydrate loading as a component of ERAS in esophageal reconstructive surgery. MATERIAL AND METHODS Post hoc analysis included 162 patients who underwent esophageal reconstructive interventions with ERAS principles between 2014 and 2024. The main group (n=61, CHO+) included patients who were metabolically loaded with carbohydrates in preoperative period with 12.5% maltodextrin solution 800 mL the day before and 400 mL 2 hours before surgery per os or enterally. The control group consisted of patients without carbohydrate load (n=101, CHO-). Primary endpoint was length of hospital-stay, secondary control points - postoperative glycemia and complication rate. RESULTS Both groups were comparable in sex, age, character of the main and comorbid diseases, body mass index. Patients with CHO had significant lower incidence of respiratory complications (p=0.034). Both groups did not differ in the incidence of anastomosis failure, morbidity and mortality. CONCLUSION Preoperative carbohydrate loading in esophageal reconstructive surgery positively affects metabolic status and reduces the incidence of respiratory complications without effect on length of hospital-stay.
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Affiliation(s)
- I A Tarasova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A T Tshkovrebov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - T T Bitarov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - I A Boeva
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - M Yu Ivanova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A L Shestakov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Zhu J, Jin XQ, Li XY, Sun L, Peng Y. The association between oral carbohydrate intake before orthopedic surgery for osteoporotic fractures and outcomes in elderly patients. J Orthop Surg Res 2023; 18:966. [PMID: 38098008 PMCID: PMC10722799 DOI: 10.1186/s13018-023-04458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Oral carbohydrate (CHO) intake is a safe method with effective clinical results in various surgical patients before surgery. Nevertheless, due to a lack of adequate clinical data, it is not frequently utilized in older patients undergoing orthopedic surgery for osteoporotic fractures (OPFs), especially in China. The purpose of the present study was to examine the relationship between preoperative oral CHO consumption and outcomes in elderly patients undergoing surgical treatment for OPFs. METHODS This retrospective cohort study was conducted at a single Chinese institution and included a total of 879 elderly patients (median age: 71 years; range: 50-99 years) who underwent OPF surgery. Various exclusion criteria were established as follows: (a) the necessity for urgent surgical intervention; (b) the existence of hypoglycemia, hyperglycemia, or diabetes mellitus with blood glucose levels lower than 2.8 mmol/L; (c) a medical history of gastrointestinal motility disorders or delayed gastric emptying; (d) the utilization of local anesthesia; (e) a Charlson comorbidity index (CCI) score over 2; and (f) an American Society of Anesthesiologists (ASA) score exceeding 3. After propensity score (PS) matching, 264 patients from each cohort were included in the analysis. The primary outcome was the all-cause mortality rate within 60 days post-surgery, while secondary outcomes included the length of hospital stay (LOS), hospitalization costs, intraoperative and postoperative blood transfusions, and the incidence of postoperative nausea and vomiting (PONV) and aspiration. The relationship between preoperative oral CHO intake and outcomes was evaluated using multivariate regression analysis. RESULTS After PS matching, preoperative oral CHO intake was negatively associated with 60-day mortality in the fully adjusted model (odds ratio 0.35; 95% confidence interval 0.12-0.97; P-value: 0.04). Patients who received preoperative oral CHO intake also had a shorter LOS and lower hospitalization costs than those who did not receive CHO intake. However, none of the models showed a significant association between CHO intake and PONV or blood transfusion risk. Furthermore, no cases of aspiration were observed in either cohort. CONCLUSIONS Preoperative oral CHO intake may be associated with reduced mortality risk and improved outcomes in elderly patients undergoing surgical treatment for OPFs. However, it is important to acknowledge the limitations of our study, including its retrospective nature, potential unmeasured confounding variables, the small sample size, incomplete data on important variables such as duration of surgery and inflammatory markers, and the limited generalizability due to the participation of only one institution. Future research with larger sample sizes and a broader range of events is warranted to validate and enhance the validity of our findings, particularly in assessing long-term results and understanding the underlying mechanisms.
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Affiliation(s)
- Jing Zhu
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Xue-Qin Jin
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Xiao-Yan Li
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Li Sun
- Department of Nursing, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Yuan Peng
- Intensive Care Unit, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, Jiangsu, China.
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Irgebay Z, Beiriger JC, Beiriger JW, Matinrazm S, Natali M, Yi C, Smetona J, Schuster L, Goldstein JA. Review of Diet Protocols Following Orthognathic Surgery and Analysis of Postoperative Weight Loss. Cleft Palate Craniofac J 2023; 60:1411-1418. [PMID: 35837697 DOI: 10.1177/10556656221113998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Orthognathic surgery is routinely practiced, yet little comparative data exists to evaluate post-orthognathic surgery diet protocols. OBJECTIVE To evaluate which postoperative diet protocols are recommended and to quantify post-orthognathic surgery weight changes in our institutional cohort. METHODS An internet search was carried out on Google for "orthognathic surgery diet" and the postoperative diet recommendations from centers worldwide were quantified. Additionally, a retrospective analysis of patients that underwent orthognathic surgery at our institution was performed, and their preoperative and postoperative weights were recorded. RESULTS The internet search yielded 58 centers that met our inclusion criteria. Most centers were in the United States (n = 37, 63.8%) and were oral and maxillofacial surgeon (OMFS)-led centers (n = 39, 67.2%). Postoperative diets were categorized into 7 distinct protocols, ranging from most to least restrictive-the most popular was liquid diet for 2 to 4 weeks followed by soft diet for 2 to 6 weeks. There were no significant patterns observed across different geographical regions or specialties.In our institution, 135 patients were identified. Overall, there was an average maximum weight loss of 4.1 kg by week 4, followed by a gradual increase in weight. Linear regression analysis showed that patients with greater preoperative body mass index (BMI) lost more weight postoperatively than patients with lower BMI (R2 = 0.25, P < .001). CONCLUSION There is a significant variability in recommended postoperative diets following orthognathic surgery. Following a moderately restrictive diet at our institution, patients returned to their preoperative weight after approximately 4 months.
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Affiliation(s)
- Zhazira Irgebay
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Justin W Beiriger
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sayna Matinrazm
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Megan Natali
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Cleo Yi
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John Smetona
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lindsay Schuster
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jesse A Goldstein
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Martindale RG. Novel nutrition strategies to enhance recovery after surgery. JPEN J Parenter Enteral Nutr 2023; 47:476-481. [PMID: 36938940 DOI: 10.1002/jpen.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 01/20/2023] [Accepted: 02/08/2023] [Indexed: 03/21/2023]
Abstract
Surgery and traumatic injury set off a cascade of metabolic changes that are becoming better understood. Recently, strategies and protocols have been developed for optimizing outcomes, and this has yielded beneficial results. This brief review evaluates three specific nutrition or metabolic interventions in the postoperative setting that attempt to optimize outcomes. We limited this to three subspecialty areas including oncologic surgery, orthopedic surgery, and cardiac surgery. These agents included fish oils, factors to prevent dysbiosis, and resistance exercise and its role in enhancing protein update. Where these novel agents fit into the basic tenets of postoperative nutrition interventions does not change the narrative: deliver graduated early enteral feeding to attenuate the metabolic response to surgical stress, maintain the gastrointestinal mucosal barrier, use immune/metabolic modulation to enhance immune response while attenuating excessive inflammation, and support the microbiome.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Zhang J, Chi R, Zhang Y, Xie Y, Liu Y, Bao Q, Lv H, Han B, Sun H, Sun P. Preoperative administration of branched-chain amino acids reduces postoperative insulin resistance in rats by reducing liver gluconeogenesis. Nutr Metab (Lond) 2022; 19:78. [PMID: 36447227 PMCID: PMC9706859 DOI: 10.1186/s12986-022-00710-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/30/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Postoperative insulin resistance (PIR) represents an important characteristic of metabolic response following surgical injury. Clinical outcomes are negatively correlated to postoperative insulin resistance and hyperglycemia, indicating a novel treatment for reducing postoperative insulin resistance is urgently needed. The current work aimed to assess the protective effects of branched-chain amino acids (BCAA) on glucose metabolism disorders induced surgically in a rat model, and to explore the underpinning mechanism. METHODS AND RESULTS Rats were randomly assigned to 2 groups, including the control and BCAA groups. Rats were given a compulsory oral 3 mL load by gavage two hours before surgery. The results showed that BCAA remarkably reduced glycemia by suppressing liver gluconeogenesis via reduction of cAMP-response element-binding protein-regulated transcription coactivator 2 (CRTC2) and glucose-6-phosphatase (G6PC) gene and protein expression levels (all Ps < 0.05). CONCLUSIONS This study revealed that BCAA lower blood glucose levels by reducing liver gluconeogenesis without significant elevation of plasma insulin levels. We anticipate that preoperative BCAA supplementation may be a means for preventing postoperative insulin resistance.
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Affiliation(s)
- Jin Zhang
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Rui Chi
- grid.16821.3c0000 0004 0368 8293Department of Pathophysiology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Yunpeng Zhang
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Yi Xie
- grid.16821.3c0000 0004 0368 8293Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Yunxia Liu
- grid.16821.3c0000 0004 0368 8293Department of Pathophysiology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Qun Bao
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Hengyu Lv
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Bo Han
- grid.16821.3c0000 0004 0368 8293Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
| | - Haipeng Sun
- grid.265021.20000 0000 9792 1228NHC Key Laboratory of Hormones and Development, Center for Cardiovascular Diseases, The Province and Ministry Cosponsored Collaborative Innovation Center for Medical Epigenetics, Chu Hsien-I Memorial Hospital and Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, 300134 China ,grid.16821.3c0000 0004 0368 8293Department of Pathophysiology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Hongqiao International Institute of Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Peng Sun
- grid.16821.3c0000 0004 0368 8293Department of General Surgery, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200336 China
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Major Abdominal Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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He Y, Liu C, Han Y, Huang Y, Zhou J, Xie Q. The impact of oral carbohydrate-rich supplement taken two hours before caesarean delivery on maternal and neonatal perioperative outcomes -- a randomized clinical trial. BMC Pregnancy Childbirth 2021; 21:682. [PMID: 34620123 PMCID: PMC8495981 DOI: 10.1186/s12884-021-04155-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/28/2021] [Indexed: 12/17/2022] Open
Abstract
Background To evaluate the impact of oral carbohydrate-rich (Ch-R) supplement taken 2 hours before an elective caesarean delivery (CD) on maternal and neonatal perioperative outcomes. Methods Ninety pregnant women undergoing elective CD were randomized into the Ch-R group, placebo group and fasting group equally. Participants’ blood was drawn at three time points, before intervention, immediately after and 1 day after the surgery to measure maternal and neonatal biochemical indices. Meanwhile women’s perioperative symptoms and signs were recorded. Results Eighty-eight pregnant women were finally included in the study. Women who had drunk Ch-R supplement had lower postoperative insulin level (β = − 3.50, 95% CI − 5.45 to − 1.56), as well as postoperative HOMA-IR index (β = − 0.74, 95% CI − 1.15 to − 0.34), compared with women who had fasted. Additionally, neonates of mothers who were allocated in the Ch-R group also had a higher glucose level, compared with neonates of mothers in the fasting group (β = 0.40, CI 0.17 to 0.62). Conclusion Oral Ch-R solution administered 2 hours before an elective CD may not only alleviate maternal postoperative insulin resistance, but also comfort women’s preoperative thirst and hunger, compared to fasting. Additionally, it may increase neonatal glucose level as well. Trial registration Chinese Clinical Trial Registry, ChiCTR2000033163. Data of Registration: 2020-5-22. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04155-z.
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Affiliation(s)
- Yuanying He
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Chunhong Liu
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Ying Han
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Yun Huang
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Jianhong Zhou
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China
| | - Qigui Xie
- Department of Gynecology and Obstetrics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301, Yanchangzhong Road, Shanghai, 200072, China.
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Moringa Oleifera Seed Extract Concomitantly Supplemented with Chemotherapy Worsens Tumor Progression in Mice with Triple Negative Breast Cancer and Obesity. Nutrients 2021; 13:nu13092923. [PMID: 34578801 PMCID: PMC8472177 DOI: 10.3390/nu13092923] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 12/26/2022] Open
Abstract
Triple negative breast cancer (TNBC) is an aggressive and highly metastatic breast cancer subtype with limited treatment options. Obesity and insulin resistance are associated with a worse prognosis in those with TNBC. Moringa oleifera (moringa) is a tropical edible plant used for both food and medicinal purposes and found to have anti-obesity and anti-cancer effects in vitro and in preclinical models. The anti-cancer effects of moringa seed extract alone and in combination with chemotherapy were evaluated in immunocompromised female mice with diet-induced obesity bearing MDA-MB-231-derived xenograft tumors. Moringa supplementation protected against high-fat diet- and chemotherapy-induced increases in fasting glucose and improved insulin sensitivity. Moringa supplementation alone did not attenuate tumor growth relative to chemotherapy alone, and in combination worsened tumor progression. Moringa supplementation alone reduced angiogenesis, but this effect was abrogated in combination with chemotherapy. Moringa supplementation may be an effective strategy to improve metabolic health in mice with obesity and TNBC and reduce angiogenesis in tumors, but may have a negative interaction when used as a concurrent complementary therapy. Caution should be taken when considering the consumption of moringa seed extracts while receiving chemotherapy for breast cancer treatment. Further investigations of alternative timings of moringa therapy are warranted.
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Enhanced recovery after elective surgery. A revolution that reduces post-operative morbidity and mortality. J Visc Surg 2020; 157:487-491. [DOI: 10.1016/j.jviscsurg.2020.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Thörling J, Ljungqvist O, Sköldenberg O, Hammarqvist F. No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery - A single-centre observational cohort study. Clin Nutr 2020; 40:1348-1354. [PMID: 32896447 DOI: 10.1016/j.clnu.2020.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 07/31/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
RATIONALE Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients. METHODS 160 patients (116 women and 44 men; age 80 ± 10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥ 42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien-Dindo and 1-year mortality was compared between the groups. RESULTS Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥ 48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glycaemic control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien-Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3%), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3%) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4%) respectively, p = NS. There were no differences in 30-day complications (p = 0.55) or 1-year mortality (p = 0.35) between the groups. CONCLUSION Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.
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Affiliation(s)
- John Thörling
- Department of Emergency Medicine, Karolinska University Hospital, Sweden; Department of Clinical Science, Intervention and Technology, (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Olof Sköldenberg
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Division of Orthopaedics, Sweden; Danderyd University Hospital Corp., Department of Orthopaedics, Stockholm, Sweden
| | - Folke Hammarqvist
- Department of Emergency Surgery and Trauma, Karolinska University Hospital, Sweden; Department of Clinical Science, Intervention and Technology, (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Roulin D, Demartines N. Evidence for enhanced recovery in pancreatic cancer surgery. Langenbecks Arch Surg 2020; 405:595-602. [DOI: 10.1007/s00423-020-01921-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022]
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Transcutaneous Stimulation of Auricular Branch of the Vagus Nerve Attenuates the Acute Inflammatory Response After Lung Lobectomy. World J Surg 2020; 44:3167-3174. [DOI: 10.1007/s00268-020-05543-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Roh CK, Son SY, Lee SY, Hur H, Han SU. Clinical pathway for enhanced recovery after surgery for gastric cancer: A prospective single-center phase II clinical trial for safety and efficacy. J Surg Oncol 2020; 121:662-669. [PMID: 31930513 DOI: 10.1002/jso.25837] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/02/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND We aimed to evaluate the safety and efficacy of a clinical pathway (CP) for enhanced recovery after surgery (ERAS) in gastric cancer patients, including early oral feeding and discharge on postoperative day 4. METHODS We performed a prospective, single-center, phase II clinical trial. Based on proposed indications for an ERAS CP in our retrospective study, we enrolled 133 patients younger than 65 years who were undergoing minimally invasive subtotal gastrectomy. The primary endpoint was the ERAS CP completion rate. Secondary endpoints included complication, mortality, hospital stay, and readmission. RESULTS Among 133 patients, six patients were dropped out from this study. The ERAS CP completion rate (77.2%, 98 of 127) was comparable to the historical control group that completed a conventional CP (85.4%, P = .085). The postoperative complication incidence (13.4%, 15 of 127) was also similar to that of the conventional CP group (9.5%, P = .174). We identified reduced hospital stays (4.7 ± 1.3 vs 7.2±2.3 days; P < .001) and lower hospital costs ($7771 vs 8539; P < .001) in the ERAS CP group compared with the conventional CP group. CONCLUSIONS An ERAS CP can be safely and effectively adopted for patients with gastric cancer without increasing the complication rate and could shorten hospital stays. TRIAL REGISTRATION ClinicalTrials.gov (NCT01642953).
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Affiliation(s)
- Chul Kyu Roh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sook Young Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - Hoon Hur
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Arkley J, Dixon J, Wilson F, Charlton K, Ollivere BJ, Eardley W. Assessment of Nutrition and Supplementation in Patients With Hip Fractures. Geriatr Orthop Surg Rehabil 2019; 10:2151459319879804. [PMID: 31667002 PMCID: PMC6801887 DOI: 10.1177/2151459319879804] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/06/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction: Malnutrition is common in older people, is known to interact with frailty, and is a
risk factor for wound complications and poor functional outcomes postoperatively.
Sustaining a hip fracture is a significant life event, often resulting in a decline in
mobility and functional ability. A poor nutritional state may further impede recovery
and rehabilitation, so strategies to improve perioperative nutrition are of considerable
importance. We provide a review of nutritional supplement practices in this vulnerable
and growing population. Method: Systematic review of preoperative oral nutritional supplementation (ONS) in hip
fracture patients. Results: We identified 12 articles pertaining to this important area of perioperative care. The
findings suggest postoperative ONS can improve postoperative outcomes in hip fracture
patients, especially in terms of increasing total serum protein, improving nutritional
status to near-optimum levels, and decreasing postoperative complications. Discussion: There is an absence of evidence specific to preoperative ONS in patients admitted
following hip fracture. Literature relating to other populations is encouraging but is
yet to be robustly studied. It is unclear whether these results are generalizable to the
frailer hip fracture population. There is a need for studies clearly defining outcome
measurement and complication assessment pertaining to preoperative ONS. The potential
benefit is considerable, and this review will provide a means to inform the construction
of meaningful trials in preoperative ONS of patients sustaining hip fracture. Conclusion: Oral nutritional supplementation in hip fracture patients may decrease postoperative
complications while increasing elderly patient’s nutritional state to a near-optimum
level. This is extrapolated from postoperative literature, however with a clear gap in
research pertaining specifically to preoperative care. The need for well-constructed
studies focused on the impact and assessment of early ONS in this population is
transparent.
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Affiliation(s)
- James Arkley
- Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Ján Dixon
- Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | | | - William Eardley
- James Cook University Hospital, Middlesbrough, United Kingdom
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Teo BJX, Chong HC, Yeo W, Tan AHC. The Impact of Diabetes on Patient Outcomes After Total Knee Arthroplasty in an Asian Population. J Arthroplasty 2018; 33:3186-3189. [PMID: 30017216 DOI: 10.1016/j.arth.2018.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/20/2018] [Accepted: 06/15/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetes is implicated with poorer outcomes and more complications after total knee arthroplasty (TKA). We aim to determine whether diabetes affects infection risk, functional outcomes, patient-reported outcome measures, and patient satisfaction in Asian patients after TKA. METHODS Prospectively collected data for 905 patients who underwent unilateral TKA by a single surgeon from February 2004 to July 2014 were reviewed, of which 123 (13.6%) patients suffered from diabetes. At 2-year follow-up, the change in range of motion of the operated knee, body mass index, Knee Society Score, Oxford Knee Score (OKS), and Short Form-36 from baseline was compared between diabetic and nondiabetic patients. We also analyzed the length of hospitalization stay, infection risk, and patient satisfaction between the 2 groups. RESULTS Compared with nondiabetic patients, diabetic patients had significantly poorer preoperative OKS (37.6 on 8.3 to 35.8 .38.0, P = .02) and Short Form-36 Mental Component Score (48.3 Me11.2 to 51.7 1.10.7, P = .01). At 2-year follow-up, diabetes continued to be associated with poorer OKS of 21.2 018.4 and Knee Society Score Function score of 64.7 Fu20.9 compared to 19.1 0.6.2 (P = .02) and 71.8 0220.1 (P = .01) respectively in nondiabetic patients. Interestingly, the difference in mental well-being was no longer significant after TKA. A significantly larger proportion of diabetic patients (50%) had a reduction in body mass index after TKA compared to 36% in nondiabetic patients (P < .01). There was no difference in range of motion, length of hospitalization stay, infection risk, and patient satisfaction. CONCLUSION Despite poorer physical scores throughout, diabetic patients are no less satisfied and had significantly greater improvement in mental well-being and weight reduction after surgery.
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Affiliation(s)
- Bryon J X Teo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Hwei-Chi Chong
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - William Yeo
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
| | - Andrew H C Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Micić D, Stanković S, Lalić N, Đukić V, Polovina S. Prognostic Value of Preoperative Neutrophil-to-lymphocyte Ratio for Prediction of Severe Cholecystitis. J Med Biochem 2018; 37:121-127. [PMID: 30581347 PMCID: PMC6294096 DOI: 10.1515/jomb-2017-0063] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/26/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) in patients with cholecystitis has not been established. The aim of this study was to investigate preoperative NLR in patients with cholecystitis and to identify a relevant NLR value that discriminates between simple and severe cholecystitis. METHODS This study included 136 patients who under went laparoscopic cholecystectomy due to cholecystitis. The Receiver Operating Characteristic (ROC) analysis was performed to identify the most useful NLR cut-off value in relation to the severity of cholecystitis. The patients were di vided into two groups according to the cut-off NLR value: high NLR group (≥4.18, n=23) and low NLR group (<4.18, n=113). Severe cholecystitis was defined as a state which includes inflammation, empyema, gangrene, perforation of gallbladder, adhesions or difficulty in dissecting Calot's triangle. RESULTS In the high NLR group, severe cholecystitis (p<0.0001) and higher C-reactive protein level (CRP) and white blood cells count (WBC) (p<0.0001) were significantly more frequent. There was no difference in homeostatic model assessment-insulin resistance index (HOMA-IR) between both groups before the operation (p<0.634). The incidence of severe cholecystitis was 16.9%. The NLR of 4.18 could predict severe cholecystitis with 78.3% sensitivity and 74.3% specificity. Spearman's correlation revealed significant association between the preoperative NLR and HOMA-IR on day 1, (r=0.254, p=0.030) and between preoperative NLR and CRP on day 1 (ρ=0.355; p<0.0001). CONCLUSIONS NLR ≥4.18 was significantly associated with severe cholecystitis. The preoperative NLR in patients under going cholecystectomy due to cholecystitis could be a useful surrogate marker of severe cholecystitis.
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Affiliation(s)
- Dušan Micić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Emergency Surgery, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Sanja Stanković
- Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia
| | - Nebojša Lalić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Serbia, Belgrade, Serbia
| | - Vladimir Đukić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Emergency Surgery, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Snežana Polovina
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Serbia, Belgrade, Serbia
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Is patient factor more important than surgeon-related factor in sepsis prevention in colorectal surgery? INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bater M, King W, Teare J, D’Souza J. Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference? Br J Oral Maxillofac Surg 2017; 55:1024-1029. [DOI: 10.1016/j.bjoms.2017.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
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Abstract
BACKGROUND/PURPOSE The implications of childhood obesity on pediatric trauma outcomes are not clearly established. Anthropomorphic data were recently added to the National Trauma Data Bank (NTDB) Research Datasets, enabling a large, multicenter evaluation of the effect of obesity on pediatric trauma patients. METHODS Children ages 2 to 19years who required hospitalization for traumatic injury were identified in the 2013-2014 NTDB Research Datasets. Age and gender-specific body mass indices (BMI) were calculated. Outcomes included injury patterns, operative procedures, complications, and hospital utilization parameters. RESULTS Data from 149,817 pediatric patients were analyzed; higher BMI percentiles were associated with significantly more extremity injuries, and fewer injuries to the head, abdomen, thorax and spine (p values <0.001). On multivariable analysis, higher BMI percentiles were associated with significantly increased likelihood of death, deep venous thrombosis, pulmonary embolus and pneumonia; although there was no difference in risk of overall complications. Obese children also had significantly longer lengths of stay and more frequent ventilator requirement. CONCLUSIONS Among children admitted after trauma, increased BMI percentile is associated with increased risk of death and potentially preventable complications. These findings suggest that obese children may require different management than nonobese counterparts to prevent complications. LEVEL OF EVIDENCE Level III; prognosis study.
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Are we ready for the ERAS protocol in colorectal surgery? Wideochir Inne Tech Maloinwazyjne 2017; 12:7-12. [PMID: 28446926 PMCID: PMC5397552 DOI: 10.5114/wiitm.2017.66672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/02/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Modern perioperative care principles in elective colorectal surgery have already been established by international surgical authorities. Nevertheless, barriers to the introduction of routine evidence-based clinical care and changing dogmas still exist. One of the factors is the surgeon. Aim To assess perioperative care trends in elective colorectal surgery among general surgery consultants in surgical departments in Malopolska Voivodeship, Poland. Material and methods An anonymous standardized 20-question questionnaire was developed based on ERAS principles and sent out to Malopolska Voivodeship general surgery departments. Answers of general surgery consultants showed the level of acceptance of elements of perioperative care. Results The overall response rate was 66%. Several elements (antibiotic and antithrombotic prophylaxis, postoperative oxygen therapy, no nasogastric tubes) had quite a high acceptance rate. On the other hand, most crucial surgical perioperative elements (lack of mechanical bowel preparation, preoperative oral carbohydrate loading, use of laparoscopy and lack of drains, early fluid and oral diet intake, early mobilization) were not followed according to evidence-based ERAS protocol recommendations. Surgeons were not willing to change their practice, but were supportive of changes in anesthesiologist-dependent elements of perioperative care, such as restrictive fluid therapy, use of transversus abdominis plane blocks, etc. Conclusions Many elements of perioperative care in elective colorectal surgery in Malopolska Voivodeship are still dictated by dogma and are not evidence-based. The level of acceptance of many important ERAS protocol elements is low. Surgeons are ready to accept only changes that do not interfere with their practice.
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Wijk L, Nilsson K, Ljungqvist O. Metabolic and inflammatory responses and subsequent recovery in robotic versus abdominal hysterectomy: A randomised controlled study. Clin Nutr 2017; 37:99-106. [PMID: 28043722 DOI: 10.1016/j.clnu.2016.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/14/2016] [Accepted: 12/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND & AIMS Surgery causes inflammatory and metabolic responses in the body. The aim of the study was to investigate whether robotic-assisted total laparoscopic hysterectomy induces less insulin resistance than abdominal hysterectomy, and to compare inflammatory response and clinical recovery between the two techniques. METHODS A randomised controlled study at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden. Twenty women scheduled for a planned total hysterectomy with or without salpingo-oophorectomy between October 2014 and May 2015, were randomly allocated to robotic-assisted total laparoscopic hysterectomy or abdominal hysterectomy. Insulin resistance after surgery was measured by the hyperinsulinemic normoglycaemic clamp method, inflammatory response measured in blood samples, and clinical recovery outcomes registered. RESULTS There were no differences in development of insulin resistance between the robotic group and the abdominal group (mean ± SD: 39% ± 22 vs. 40% ± 19; p = 0.948). The robotic group had a significantly shorter hospital stay (median 1 vs. 2 days; p = 0.005). Inflammatory reaction differed; in comparison to the robotic group, the abdominal group showed significantly higher increases in serum interleukin 6 levels, white blood cell count and cortisol from preoperative values to postoperative peak values. CONCLUSIONS Robotic laparoscopic surgery reduced inflammatory responses and recovery time, but these changes were not accompanied by decreased insulin resistance. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov Identifier no NCT02291406.
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Affiliation(s)
- Lena Wijk
- Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Kerstin Nilsson
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Olle Ljungqvist
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden; Department of Surgery, Örebro University Hospital, Sweden.
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Abstract
The enhanced recovery pathway is an evidence-based surgical care pathway that includes preoperative, perioperative and postoperative care and results in fewer complications and a shorter length of stay in hospital. There are a variety of elements associated with this pathway and one is the use of a preoperative carbohydrate-loading drink. The consumption of this drink, which is specifically designed to be safely consumed a few hours before surgery, is discussed with a review of the literature on the topic.
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Affiliation(s)
- Jennie Burch
- Enhanced Recovery Nurse, St Mark's Hospital, Harrow, London
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31
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Hellspong G, Gunnarsson U, Dahlstrand U, Sandblom G. Diabetes as a risk factor in patients undergoing groin hernia surgery. Langenbecks Arch Surg 2016; 402:219-225. [DOI: 10.1007/s00423-016-1519-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/02/2016] [Indexed: 01/27/2023]
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Witt CE, Goldin AB, Vavilala MS, Rivara FP. Effect of body mass index percentile on pediatric gastrointestinal surgery outcomes. J Pediatr Surg 2016; 51:1473-9. [PMID: 27056288 PMCID: PMC5007147 DOI: 10.1016/j.jpedsurg.2016.02.085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/21/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND/PURPOSE Pediatric obesity is an important public health concern, yet its effect on surgical outcomes is poorly understood. The purpose of this study was to determine if age and gender-specific body mass index (BMI) percentile influences complications and hospital resource utilization following pediatric gastrointestinal surgeries. METHODS Patients aged ≥2 to <18years who underwent appendectomy or other gastrointestinal operations were identified in the 2012-2013 Pediatric National Surgical Quality Improvement Program datasets. Age- and gender-specific pediatric BMI percentiles were calculated. Patients who underwent appendectomy (n=9606) and those undergoing all other intestinal operations (n=2664) were evaluated as separate cohorts. RESULTS In the appendectomy cohort, frequency of any complication increased with BMI category (normal weight 4.5%, overweight 5.3%, obese 5.7%, morbidly obese 7.3%, overall 5.0%, p=0.014). In multivariate analysis, there was a quadratic association between BMI percentile and increased frequency of superficial incisional infection, unplanned tracheal intubation, and longer operative duration. In the intestinal surgery cohort, BMI percentile was not a predictor of any individual complication or any measure of hospital utilization. CONCLUSIONS Age- and gender-specific BMI percentile was associated with increased risk of complications and longer operative duration in patients undergoing appendectomy but not other intestinal operations.
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Affiliation(s)
- Cordelie E. Witt
- Department of Surgery, University of Washington, 1959 NE Pacific Street, Seattle, WA, USA 98195,Harborview Injury Prevention and Research Center, 325 9th Ave, Box 359960, Seattle, WA USA 98104
| | - Adam B. Goldin
- Division of General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, USA, 98105
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA, USA 98195,Harborview Injury Prevention and Research Center, 325 9th Ave, Box 359960, Seattle, WA USA 98104
| | - Frederick P. Rivara
- Department of Pediatrics, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA, USA 98195,Harborview Injury Prevention and Research Center, 325 9th Ave, Box 359960, Seattle, WA USA 98104
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Pecorelli N, Nobile S, Partelli S, Cardinali L, Crippa S, Balzano G, Beretta L, Falconi M. Enhanced recovery pathways in pancreatic surgery: State of the art. World J Gastroenterol 2016; 22:6456-6468. [PMID: 27605881 PMCID: PMC4968126 DOI: 10.3748/wjg.v22.i28.6456] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/21/2016] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial in terms of improved postoperative outcomes, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways.
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Ljungqvist O, Fearon K. Nutrition in Surgery and Trauma. Clin Nutr 2015. [DOI: 10.1002/9781119211945.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Moppett IK, Greenhaff PL, Ollivere BJ, Joachim T, Lobo DN, Rowlands M. Pre-Operative nutrition In Neck of femur Trial (POINT)--carbohydrate loading in patients with fragility hip fracture: study protocol for a randomised controlled trial. Trials 2014; 15:475. [PMID: 25472724 PMCID: PMC4289274 DOI: 10.1186/1745-6215-15-475] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/13/2014] [Indexed: 12/20/2022] Open
Abstract
Background Trauma such as hip fracture initiates a neurohumoral stress response that changes the balance between anabolism and catabolism resulting in muscle breakdown and reduced mobilisation. Various studies have demonstrated a reduction in catabolism with pre-operative carbohydrate loading but only in an elective setting. Methods/Design This is a two-centre, randomised double-blinded trial in the United Kingdom. Sample size will be 30 patients (approximately 15 from each centre). Randomisation will be web based using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be >70 years of age, cognitively intact (Abbreviated Mental Score ≥7), able to give informed consent, and admitted directly through the emergency department with fractured neck of femur requiring hemiarthroplasty. Intervention will consist of two carbohydrate drinks (Nutricia pre-Op) given the night before, and the morning of the surgery. The control will receive two placebo drinks of equal volume. All participants will receive standard hospital care at the discretion of the clinical team. The primary outcome is the difference between groups in insulin resistance calculated by a glucose tolerance test administered pre-operatively and 24 hours postoperatively. Secondary endpoints will be changes in muscle carbohydrate metabolism (biopsy), mobility (Cumulative Ambulation Score) and subjective measures of tolerability. Discussion This is a small-scale pilot study, investigating the benefits and tolerability of carbohydrate loading in an emergency setting in a frail elderly group with known high morbidity and mortality. Positive findings will provide the basis for a larger scale study. Trial registration Current Controlled Trials ISRCTN91109766 (7 April 2014); NRES ref: 13/EM/0214 Trial Sponsor: University of Nottingham Ref.13036.
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Affiliation(s)
- Iain K Moppett
- Associate Professor and Honorary Consultant Anaesthetist, Anaesthesia and Critical Care Research Group, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, UK.
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Catecholamine-induced lipolysis causes mTOR complex dissociation and inhibits glucose uptake in adipocytes. Proc Natl Acad Sci U S A 2014; 111:17450-5. [PMID: 25422441 DOI: 10.1073/pnas.1410530111] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Anabolic and catabolic signaling oppose one another in adipose tissue to maintain cellular and organismal homeostasis, but these pathways are often dysregulated in metabolic disorders. Although it has long been established that stimulation of the β-adrenergic receptor inhibits insulin-stimulated glucose uptake in adipocytes, the mechanism has remained unclear. Here we report that β-adrenergic-mediated inhibition of glucose uptake requires lipolysis. We also show that lipolysis suppresses glucose uptake by inhibiting the mammalian target of rapamycin (mTOR) complexes 1 and 2 through complex dissociation. In addition, we show that products of lipolysis inhibit mTOR through complex dissociation in vitro. These findings reveal a previously unrecognized intracellular signaling mechanism whereby lipolysis blocks the phosphoinositide 3-kinase-Akt-mTOR pathway, resulting in decreased glucose uptake. This previously unidentified mechanism of mTOR regulation likely contributes to the development of insulin resistance.
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Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, Carli F, Demartines N, Griffin SM, Lassen K, Fearon KCF, Ljungqvist O, Lobo DN, Revhaug A. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg 2014; 101:1209-29. [PMID: 25047143 DOI: 10.1002/bjs.9582] [Citation(s) in RCA: 479] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/20/2014] [Accepted: 05/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. METHODS An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. RESULTS The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSION The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.
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Affiliation(s)
- K Mortensen
- Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | | | | | | | | | | | | | | | | | | | | | - K C F Fearon
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, UK
| | - O Ljungqvist
- Department of Surgery, Örebro University Hospital, Örebro and Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - A Revhaug
- Department of Gastrointestinal and Hepatopancreaticobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
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Lips MA, de Groot GH, van Klinken JB, Aarts E, Berends FJ, Janssen IM, Van Ramshorst B, Van Wagensveld BA, Swank DJ, Van Dielen F, Willems van Dijk K, Pijl H. Calorie restriction is a major determinant of the short-term metabolic effects of gastric bypass surgery in obese type 2 diabetic patients. Clin Endocrinol (Oxf) 2014; 80:834-42. [PMID: 23711328 DOI: 10.1111/cen.12254] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 05/02/2013] [Accepted: 05/23/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Roux-en-Y gastric bypass (RYGB) and restrictive weight loss interventions, such as gastric banding (GB) and very-low-calorie diets (VLCD) directly impact glucose metabolism, possibly by calorie restriction and/or altered secretion of gut hormones. We aimed to establish the direct endocrine and metabolic effects of RYGB compared to restrictive interventions in obese glucose-tolerant (NGT) subjects and subjects with type 2 diabetes (T2DM). DESIGN Controlled, nonrandomized observational trial. PATIENTS AND MEASUREMENTS Four groups of obese females received a mixed meal at baseline and 3 weeks after intervention; NGT-GB (n = 11), NGT-RYGB (n = 16), T2DM-RYGB (n = 15) and T2DM-VLCD (n = 12). Normal weight controls (n = 12) were studied once. RESULTS At baseline, all obese subjects were hyperinsulinemic. T2DM was associated with hyperglycaemia and decreased GLP-1 levels. RYGB and VLCD reduced glucose levels to a similar extent in T2DM, insulin levels decreased only after VLCD. Comparison of restrictive intervention vs RYGB showed a more pronounced decrease in glucose and insulin AUC after restriction. In NGT and T2DM subjects, RYGB increased GLP-1 and PYY levels and decreased ghrelin levels, whereas VLCD and GB only increased GIP levels. CONCLUSIONS These data indicate that deterioration of glucose metabolism in T2DM is associated with a decline of GLP-1 levels. Calorie restriction facilitates glucose metabolism and blunts hyperinsulinemia in obese (diabetic) humans. Additional duodenal exclusion through RYGB induces gut hormone release and hyperinsulinemia but does not improve postprandial glucose levels any further. Our data thus strongly suggest that calorie restriction underlies the short-term metabolic benefits of RYGB in obese T2DM patients.
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Affiliation(s)
- Mirjam A Lips
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
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Andersson B, Ansari D, Nordén M, Nilsson J, Andersson R. Surgical stress response after colorectal resection. Int Surg 2013; 98:292-299. [PMID: 24229011 PMCID: PMC3829051 DOI: 10.9738/intsurg-d-12-00009.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The human body's response to surgery is correlated with the extent of tissue damage. The aim of the present study was to, over time, map out parameters concerning inflammation, metabolism, nutrition, breathing function, muscle strength, and well-being in elective colorectal surgery. Eighteen patients were prospectively included: colon resection (n = 9) and rectum resection/amputation (n = 9). Postoperative interleukin 10 (IL-10) rose more in the rectum surgery group on day 0 (P = 0.007) and day 3 (P = 0.025). Furthermore, significant differences between groups were detected regarding albumin, prealbumin, and total iron-binding capacity (TIBC). For albumin and TIBC, this difference was seen even on day 7. C-reactive protein, IL-6, IL-8, glucose, cortisol, insulin, pain, fatigue, nausea, grip strength, and forced expiratory volume in 1 second did not show any differences. No correlation was revealed between measured parameters and postoperative complications. Postoperative levels of IL-10, albumin, prealbumin, and TIBC may be used as determinants of surgical stress after colorectal surgery.
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Affiliation(s)
- Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Morgan Nordén
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Johan Nilsson
- Department of Cardiothoracic Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg 2013; 37:259-84. [PMID: 23052794 DOI: 10.1007/s00268-012-1772-0] [Citation(s) in RCA: 842] [Impact Index Per Article: 70.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Oliveira SDS, Cibantos JS, Ripari WT, Aguilar-Nascimento JED. Impact of the aspirated volume of fat tissue in the insulin resistance after liposuction. Rev Col Bras Cir 2013; 40:17-22. [PMID: 23538534 DOI: 10.1590/s0100-69912013000100004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 07/31/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate insulin resistance imposed by liposuction, correlating its intensity with the extent of the operation. METHODS The sample consisted of 20 female patients without comorbidities, aged between 21 and 43 years, body mass index between 19 and 27 kg/m², undergoing liposuction alone or associated with breasts' prosthesis. We assessed insulin resistance at the beginning and end of the procedure by calculating the Homeostasis Model Assessment (HOMA-IR). The operative variables were length of liposuction, breast prosthesis time, body areas submitted to liposuction and total fat aspirated. RESULTS The liposuction time was 94-278 min (mean = 174 min), duration of breast prosthesis 20-140 min (mean = 65 min) and total fat aspirated 680-4280 g (mean = 1778 g). Statistical analysis was performed by considering a division line of 1500 g of aspirated fat and there was a significantly increased insulin resistance by HOMA index greater in the group > 1500 g (123% increase) than in the group d" 1500 g (an increase of 53 %) from the baseline data (p = 0.02). Other operative variables showed no significant correlation. CONCLUSION Insulin resistance shows significant increase in liposuction, and it is correlated to the volume of aspirated fat.
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Affiliation(s)
- Sérgio de Souza Oliveira
- Faculty of Medicine, Federal University of Mato Grosso, Cuiabá, State of Mato Grosso - MT, Brazil
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Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:817-30. [DOI: 10.1016/j.clnu.2012.08.011] [Citation(s) in RCA: 357] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 08/19/2012] [Indexed: 02/06/2023]
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Sato H, Carvalho G, Sato T, Hatzakorzian R, Lattermann R, Codere-Maruyama T, Matsukawa T, Schricker T. Statin intake is associated with decreased insulin sensitivity during cardiac surgery. Diabetes Care 2012; 35:2095-9. [PMID: 22829524 PMCID: PMC3447850 DOI: 10.2337/dc11-2251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Surgical trauma impairs intraoperative insulin sensitivity and is associated with postoperative adverse events. Recently, preprocedural statin therapy is recommended for patients with coronary artery disease. However, statin therapy is reported to increase insulin resistance and the risk of new-onset diabetes. Thus, we investigated the association between preoperative statin therapy and intraoperative insulin sensitivity in nondiabetic, dyslipidemic patients undergoing coronary artery bypass grafting. RESEARCH DESIGN AND METHODS In this prospective, nonrandomized trial, patients taking lipophilic statins were assigned to the statin group and hypercholesterolemic patients not receiving any statins were allocated to the control group. Insulin sensitivity was assessed by the hyperinsulinemic-normoglycemic clamp technique during surgery. The mean, SD of blood glucose, and the coefficient of variation (CV) after surgery were calculated for each patient. The association between statin use and intraoperative insulin sensitivity was tested by multiple regression analysis. RESULTS We studied 120 patients. In both groups, insulin sensitivity gradually decreased during surgery with values being on average ∼20% lower in the statin than in the control group. In the statin group, the mean blood glucose in the intensive care unit was higher than in the control group (153 ± 20 vs. 140 ± 20 mg/dL; P < 0.001). The oscillation of blood glucose was larger in the statin group (SD, P < 0.001; CV, P = 0.001). Multiple regression analysis showed that statin use was independently associated with intraoperative insulin sensitivity (β = -0.16; P = 0.03). CONCLUSIONS Preoperative use of lipophilic statins is associated with increased insulin resistance during cardiac surgery in nondiabetic, dyslipidemic patients.
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Affiliation(s)
- Hiroaki Sato
- Department of Anaesthesia, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:783-800. [PMID: 23099039 DOI: 10.1016/j.clnu.2012.08.013] [Citation(s) in RCA: 459] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/19/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Ersta Hospital, Stockholm, Sweden.
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Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KCH, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CHC. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2012; 37:240-58. [DOI: 10.1007/s00268-012-1771-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Ljunggren S, Hahn RG. Oral nutrition or water loading before hip replacement surgery; a randomized clinical trial. Trials 2012; 13:97. [PMID: 22747890 PMCID: PMC3442968 DOI: 10.1186/1745-6215-13-97] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 07/02/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgery induces insulin resistance that might be alleviated by a nutritional drink given preoperatively. The authors hypothesized that some of the beneficial effects of the drink could be attributed to the volume component (approximately 1 L) rather than to the nutrients. METHODS Sixty patients scheduled for elective total hip replacement under spinal anesthesia were recruited to a clinical trial, and randomly allocated to preoperative fasting, to oral ingestion of tap water, or to oral ingestion of a carbohydrate drink. An intravenous glucose tolerance test calculated glucose clearance and insulin sensitivity on the day before surgery, in the postoperative ward, and on the day after surgery. Other parameters were stress (cortisol in plasma and urine), muscle catabolism (urinary 3-methylhistidine), and wellbeing. RESULTS Fifty-seven patients completed the study. In the postoperative ward, the glucose clearance and the insulin response had decreased from the previous day by 23% and 36%, respectively. Insulin sensitivity did not decrease until the next morning (-48%) and was due to an increased insulin response (+51%). Cortisol excretion was highest on the day of surgery, while 3-methylhistidine increased 1 day later. Follow-up on the third postoperative day showed an average of 1.5 complications per patient. Wellbeing was better 2 weeks after than before the surgery. None of the measured parameters differed significantly between the study groups. CONCLUSIONS Preoperative ingestion of tap water or a nutritional drink had no statistically significant effect on glucose clearance, insulin sensitivity, postoperative complications, or wellbeing in patients undergoing elective hip surgery.
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Affiliation(s)
- Stefan Ljunggren
- Research Unit, Södertälje Hospital, House 18, 581 85 Södertälje, Sweden.
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Intensive versus conventional insulin therapy in nondiabetic patients receiving parenteral nutrition after D2 gastrectomy for gastric cancer: a randomized controlled trial. J Gastrointest Surg 2011; 15:1961-8. [PMID: 21904964 DOI: 10.1007/s11605-011-1654-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 08/08/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study was used to compare the effects of intensive insulin therapy with conventional insulin therapy on postoperative outcomes among nondiabetic patients receiving parenteral nutrition following D2 gastrectomy for gastric cancer. METHOD A total of 248 eligible patients were randomly assigned to receive intensive insulin therapy targeting a blood glucose level between 4.4 and 6.1 mmol/l [intensive group (n = 125)] or conventional insulin therapy targeting a blood glucose level less than 11.0 mmol/l [conventional group (n = 123)] during the postoperative period. RESULTS Mean blood glucose concentrations were lower in the intensive group than in the conventional group. Severe hypoglycemia defined as blood glucose ≤2.2 mmol/l occurred in eight (6.4%) patients in the intensive group vs one (0.8%) patient in the conventional group (P = 0.036). One (0.8%) patient died in the intensive group vs two (1.6%) patients in the conventional group (P = 0.620). However, intensive insulin therapy significantly reduced overall postoperative complications rate (from 25.2% to 13.6%, P = 0.024). Moreover, both insulin resistance indicated as HOMA-IR and HLA-DR expression on monocytes were improved in the intensive group. CONCLUSIONS Intensive insulin therapy significantly reduced the postoperative short-term morbidity but not mortality among nondiabetic patients receiving parenteral nutrition after D2 gastrectomy. The benefits may be due to the suppression of insulin resistance and improvement of HLA-DR expression on monocytes.
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Abstract
PURPOSE OF REVIEW This article reviews the recent research on perioperative nutrition in digestive tract surgery in the light of modern perioperative care principles, that is, enhanced recovery after surgery (ERAS). Four major directions of research emerge: detecting malnutrition, perioperative hyperglycemia/insulin resistance, enteral/parenteral nutrition and immunonutrition. RECENT FINDINGS For preoperative nutritional screening/assessment, current data cannot single out superiority for SGA questionnaire, nutritional risk score, Reilly's nutritional risk score or nutritional risk index in the ability to predict nutrition-related complications. The use of ERAS elements to reduce surgical stress and preclude postoperative insulin resistance has recently been clearly linked to reductions in adverse outcomes. There are specific situations in which enteral nutrition is contraindicated and criterias for preoperative and postoperative parenteral nutrition in undernourished patients are defined in guidelines recently available. Several controlled randomized studies and systematic reviews indicate that immune nutrition formulas reduce both morbidity and length of stay after major abdominal surgery. SUMMARY To reduce surgical stress, insulin resistance, unnecessary protein losses and postoperative complications, the use of an ERAS protocol is important. Current data shows that the use of perioperative immunonutrition diets for major abdominal surgery is beneficial. Further research on nutritional assessment tools to predict who is at risk for postoperative complications is needed.
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