Major Elective Gastrointestinal Surgery Research Articles

Road of recovery in gastrointestinal surgery: From ERAS to FRAS

Enhanced recovery after surgery (ERAS) starts mainly with colorectal surgery and has been shown to improve clinical outcomes and cost savings in almost all major surgical specialties during the implementation and development for more than two decades. On the basis of improving medical quality and perioperative safety strengthened by ERAS, we propose the concept of fastest recovery after surgery (FRAS) and bring it into clinical practice to achieve fastest recovery for patients undergoing elective major gastrointestinal surgery. In this article, we introduce the definition, superiorities, perioperative protocol, and future directions with regard to the practice of FRAS in gastrointestinal surgery.

Impact of common surgical and anaesthetic strategies for pain control after elective gastrointestinal surgery: cohort study

Introduction: Poor pain control after surgery is associated with chronic pain and opioid dependence. This study aimed to determine the incidence of patient reported pain control failure following gastrointestinal surgery, and to evaluate the impact of common preventative surgical and anaesthetic strategies.
 Methods: Data were extracted from an electronic health record that linked real-time, ward-based pain scores with prescribing data. Adults undergoing major elective gastrointestinal surgery in 2011-18 were included. The primary endpoint was early pain control failure (≥1 instances of moderate or severe pain on postoperative days 0-2). Secondary outcomes were late (postoperative days 3-5) and persistent (both early and late) pain control failure.
 Results: Of 2238 patients, half underwent planned open surgery (50.3%, 1126/2238). Patient controlled analgesia (PCA) was initially used in 49.7% (1113/2238) and epidural in 35.0% (784/2238). Early (54%, 1211/2238), late (33.7%, 755/2238), and persistent (24.9%, 557/2238) pain control failures occurred frequently. In multivariable analyses, minimally invasive surgery was associated with fewer early, late, and persistent pain control failures than open surgery. There was no association between initial epidural analgesia and early or persistent pain control failure, but there was an association with increased late failure (OR 1.37, 95% CI 1.08-1.73, p=0.009). Of patients with initial epidural analgesia, 39.3% (308/784) were subsequently converted to PCA.
 Conclusion: Epidural analgesia offered no advantage over PCA, with pain control failure common irrespective of analgesic strategy. Increasing the uptake of minimally invasive surgery, through medical advances to down-stage disease, may offer a path to effectively improve postoperative pain failure.

FTP5.2 Functional deficits in older patients undergoing major gastrointestinal surgery

Abstract Aim Gastrointestinal surgeons face an increasingly complex patient population. Patients are older, often with co-morbidities, frailty, nutritional, functional, and cognitive impairments. The aim of this study was to compare functional outcomes of a cohort of older patients following emergency and elective major gastrointestinal surgery. Methods A prospective cohort study in 3 NHS trusts was performed (NCT04545125). Baseline comprehensive assessment including quality of life, physical activity levels, functional, nutritional, and cognitive status was performed. Functional status (WHODAS v2, & Activities of Daily living questionnaire) and quality of life (EQ-5D-5L) were assessed at baseline, 6 weeks, 3 months, and 6 months following surgery. Results Ninety-eight patients were recruited; median age 74 years, 56% male. Eighty-two patients underwent elective surgery and 16 underwent emergency surgery. At baseline, 13.9% elective vs 68.8% emergency patients were considered vulnerable or frail on frailty testing; 35.9% elective vs 62.5% emergency were identified as malnourished or at risk of malnutrition. Emergency patients had lower Independent Activities of Daily Living score median 6 versus 8 (p=0.007). Baseline activity was lower in emergency patients compared to elective; 1,386 vs 3,882 MET minutes per week (p=0.06). Functional status and quality of life appeared to recover in elective patients by three months, however this was lower at baseline in emergency patients and this persisted over follow-up. Conclusion High levels of baseline functional, cognitive and nutritional deficits were found in this study. Whilst elective patients appear to recover within 3 months, emergency patients have persistent deficits in functional capacity and quality of life.

Factors Predicting Prolonged Postoperative Ileus in Patients Undergoing Major Gastrointestinal Surgery

Objective: This study aimed to investigate the rate of prolonged postoperative ileus (PPOI) and its predictive factors focusing on age, body mass index, smoking status, postoperative mobilization, and preoperative anxiety and depression among patients undergoing major gastrointestinal surgery.Materials and Methods: This prospective observational study included patients who underwent elective major gastrointestinal surgery in a super tertiary hospital in Thailand. The data were collected using a uniform case record form including the Hospital Anxiety and Depression Scale and Fagerstrom Test for Nicotine Dependence. PPOI was defined using criteria of Vather et al. (2013). Predictive factors for PPOI were determined by multivariate analysis.Results: A total of 123 patients were enrolled, with an average age of 59.8 ± 12.7 years. The most common indication for surgery was gastrointestinal malignancy (96 patients, 78%), followed by an open approach (75 patients, 61%) and a combined general and epidural anesthesia (58 patients, 47%). Approximately 30% of patients had a history of smoking. Preoperative anxiety and depression were equally found in nine patients (7%). Twenty-seven patients (22%) experienced PPOI. The significant predictive factors of PPOI were having preoperative anxiety (OR = 6.26, 95% CI = 1.22–44.41, p = 0.046) and being unable to ambulate on postoperative day 1 (OR = 3.26, 95% CI = 1.25–8.50, p = 0.015).Conclusion: Preoperative anxiety and delayed postoperative ambulation were two predictors for PPOI in this study. Some interventions to reduce preoperative anxiety and encourage early postoperative ambulation should be considered in patients undergoing major elective gastrointestinal surgery.

Sucrosomial® Iron Supplementation during Perioperative Period in General Surgery

Anemia frequently occurs in patients undergoing general surgery and in particular for gastrointestinal surgery [1]. The impact of anemia and iron deficiency on abdominal surgery outcomes is well known [1-3] and new preoperative strategies are nowadays considered to improve patient conditions during the perioperative period. Iron supplementation is often administered intravenously, since conventional oral iron therapies are usually less effective [4]. Since Sucrosomial iron, an innovative oral iron formulation where iron is conveyed into a matrix of phospholipids and sucrester, appears to be effective in improving Hb levels and reducing blood transfusion during the perioperative period (5), we aim to determine whether oral Sucrosomial® Iron supplementation enables better results in terms of recovery, length of hospital stay and need of blood transfusions in anemic patients undergoing major elective gastrointestinal surgery.Data from patients scheduled for major gastrointestinal surgery were prospectively collected between October 2016 and July 2017. Supplementation with oral Sucrosomial Iron (1 capsule/day) for 2 to 3 weeks prior to surgery, was recommended to patients, scheduled for colorectal surgery (right and left hemicolectomy, segmental colonic resection or anterior rectal resection) or gastric surgery (total or subtotal gastrectomy), that showed levels of hemoglobin < 13 g/dL for women and < 14 g/dL for men during preoperative visit. The level of hemoglobin was evaluated one week before surgery, during the preoperative follow up visit, and one day after surgery. Moreover, blood transfusion needs and length of hospital stay were also evaluated. Thirty-five patients have been currently enrolled, however 4 patients were excluded due to intraoperative findings of advanced neoplastic disease and 3 due to post-operative anastomotic bleeding. To date, the post-operative results from 10 patients are available and have been analyzed in terms of hemoglobin values, blood transfusions and hospital stay. These preliminary results were compared to an equivalent historical population of 82 patients extrapolated from a pool of patients, who underwent major elective gastrointestinal surgery in 2015. Thus, patients that received palliative intervention and those with hemorrhagic post-operative complications were excluded. The two populations were not pair-matched. This comparable group of patients from 2015 was chosen in order to evaluate the difference in hemoglobin drop recorded after surgery and evaluate a possible preoperative protocol implementation that includes sucrosomial iron supplementation.Preliminary results from patients supplemented with Sucrosomial® iron showed that average hemoglobin levels one week prior to surgery (preOP) were 11.5 ± 1.72 g/dL, which were maintained after surgery (postOP, 11.3 ± 1.45 g/dL). These results showed a smaller decrease in the expected post-operative hemoglobin drop compared to an equivalent and not supplemented population from 2015 (0.2 g/dL vs 1.9 g/dL). Moreover, average blood transfusions decrease of 2 folds to 0.20 ± 0.03 units/patient in patients supplemented with Sucrosomial iron, compare to 2015 patients (0.41 ± 0.07 units/patient). Finally, mean hospital stay appears to be longer in the Sucrosomial iron group, however this result was biased by 2 patients whose longer hospitalization was not due to anemia.Preliminary results show that supplementation with Sucrosomial® iron allows an improvement in perioperative Hb levels and a decrease in blood transfusion compared to a comparable historical population. Thus these finding appear to confirm previous results on Sucrosomial® iron in patients undergoing elective surgery (5). However, these are preliminary results and data collected from all patients still need to be analyzed. Moreover, confirmation on a larger cohort of patients is need.1. Hallet J, et al. Transfus Med Rev. 2014 Oct;28(4):205-11. Review.2. Hogan M, et al. Eur J Cardiothorac Surg. 2015 Feb;47(2):218-26. Review.3. Yohanathan L, et al. J Gastrointest Surg. 2016 Jun;20(6):1106-22.4. Garrido-Martín et al. Interact Cardiovasc Thorac Surg. 2012 Dec;15(6):1013-85. Scardino M. et al. Expert Review of Hematology. 2016;9:1-42. [Display omitted] DisclosuresPera:Pharmanutra S.p.A.: Employment. Tarantino:Pharmanutra S.p.A.: Employment.

Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial: study protocol for a multicentre international trial of cardiac output-guided fluid therapy with low-dose inotrope infusion compared with usual care in patients undergoing major elective gastrointestinal surgery

IntroductionPostoperative morbidity and mortality in older patients with comorbidities undergoing gastrointestinal surgery are a major burden on healthcare systems. Infections after surgery are common in such patients, prolonging hospitalisation and...

Preoperative serum albumin level as a predictor of perioperative outcome in patient undergoing major gastrointestinal surgery

Introduction: Hypoalbuminemia, as a marker of malnutrition and disease, is associated with higher risk of poor postoperative outcomes. However, no study has been reported from our country until now. Our aim was to identify the relationship between preoperative hypoalbuminemia and the development of complications after major gastrointestinal surgery.&#x0D; Methods: A prospective study of 106 patients who underwent major elective gastrointestinal surgery between July 2012 to June 2013 in Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal were considered for the study. Serum albumin was determined preoperatively in all patients. Hypoalbuminemia was defined as albumin less than 35 mg/dl. Thirty-day postoperative complications were analyzed.&#x0D; Results: The patients were 70 males (66 %) and 36 females (34%) with a mean age of 50 years (23-81). Thirty-six patients (34%) had hypoalbuminemia. Overall complication rate was 32%. Hypoalbuminemic patients had a significantly higher rate of postoperative complications (26.4 and 5.6%; P&lt;0.05). In multivariate analysis, age (&gt;50 year), BMI (&lt;18 kg/m2), duration of surgery (&gt;3 hours) and hypoalbuminemia (&lt;35 mg/dl) were the significant risk factors for postoperative complications (P&lt;0.05).&#x0D; Conclusion: Preoperative hypoalbuminemia is an independent predictor of postoperative outcomes in patients with elective major gastrointestinal surgery. Identification and optimization of nutritional status prior to surgery may improve surgical outcomes.

Is there still a need for prophylactic intra-abdominal drainage in elective major gastro-intestinal surgery?

Prophylactic drainage of the abdominal cavity after gastro-intestinal surgery is widely used. The rationale is that intra-abdominal drainage enhances early detection of complications (gastro-intestinal leakage, hemorrhage, bile leak), prevents collection of fluid or pus, reduces morbidity and mortality, and decreases the duration of hospital stay. However, dogmatic attitudes favoring systematic drain placement should be questioned. The aim of this review was to evaluate the evidence supporting systematic use of prophylactic abdominal drainage following gastrectomy, pancreatectomy, liver resection, and rectal resection. Based on this review of the literature: (i) there was no evidence in favor of intra-peritoneal drainage following total or sub-total gastrectomy with respect to morbidity-mortality, nor was it helpful in the diagnosis or management of leakage, however the level of evidence is low, (ii) following pancreatic resection, data are conflicting but, overall, suggest that the absence of drainage is prejudicial, and support the notion that short-term drainage is better than long-term drainage, (iii) after liver resection without hepatico-intestinal anastomosis, high level evidence supports that there is no need for abdominal drainage, and (iv) following rectal resection, data are insufficient to establish recommendations. However, results from the French multicenter randomized controlled trial GRECCAR5 (NCT01269567) should provide new evidence this coming year. Accumulating data support that systematic drainage of the abdominal cavity in digestive surgery is a non-beneficial and obsolete practice, except following pancreatectomy where the consensus appears to indicate the usefulness of short-term drainage. While the level of evidence is high for liver resections, new randomized controlled trials are awaited regarding gastric, pancreatic and rectal surgery.

Pre-surgical Geriatric Syndromes, Frailty, and Risks for Postoperative Delirium in Older Patients Undergoing Gastrointestinal Surgery: Prevalence and Red Flags

ObjectiveWe sought to identify and evaluate red flags for pre-surgical geriatric conditions (geriatric syndromes, frailty, and risks for postoperative delirium) in older patients undergoing gastrointestinal surgery. MethodsOlder individuals (≥65 years) undergoing major elective gastrointestinal surgery from 2009 to 2012 were enrolled and assessed preoperatively. ResultsParticipants (N = 379; mean age = 74.5±5.9 years) primarily underwent colorectal (54.3 %), gastric (21.9 %), and pancreatobiliary (12.6 %) surgery. Overall, 30.9 % had existing geriatric syndromes, 26.7 % were frail, and 22.8 % had >3 risk factors for postoperative delirium. The largest proportion (45.7 %) presented with at least one geriatric condition. Patients with or without geriatric conditions were discriminated with adequate sensitivity (67 %), specificity (84 %), and positive predictive value (77 %) by eight red flags: age ≥75 years (OR, 2.86; P < 0.001), eating soft food (OR, 3.63; P = 0.001), reported hypertension (OR, 2.8; P = 0.001), weight loss >3 kg (OR, 4.79; P < 0.001), fair-to-weak grip strength (OR, 2.53; P = 0.001), sleeplessness (OR, 2.57; P = 0.001), no-better-than-peer perceived health (OR, 1.88; P = 0.022), and short-term inability to recall two of three common words (OR, 1.81; P = 0.025). ConclusionsEight red flags covered as part of history and physical examination are well suited to screen patients for geriatric conditions indicating the need for preoperative geriatric assessments and optimization.

Perioperative blood transfusion is associated with a gene transcription profile characteristic of immunosuppression: a prospective cohort study

IntroductionBlood transfusion in the perioperative period has frequently been associated with an excess of nosocomial infections. Whilst transfused whole blood induces specific host immune alteration that may predispose to nosocomial infections, the immunomodulating properties associated with leukodepleted blood remain incompletely understood. In this study, we explore the hypothesis that the transfusion of leukodepleted allogeneic blood during or following major gastrointestinal surgery is associated with an immunosuppressed phenotype, which may in turn predispose to postoperative infectious complications.MethodsPatients aged over 45 years undergoing scheduled inpatient major gastrointestinal surgery were recruited. Gene expression profiles of specific inflammatory genes were assayed from blood collected preoperatively, at 24 and at 48 hours after surgery. Genes were selected based on their ability to represent specific immune pathways. Gene expression was quantified using quantitative real-time polymerase chain reaction (qRT-PCR) to measure messenger RNA (mRNA) levels. Postoperative infections were documented using predefined criteria.ResultsOne hundred and nineteen patients were recruited. Fifteen (13%) patients required blood transfusion within 24 hours of surgery, 44 (37%) patients developed infections and 3 (2%) patients died prior to discharge. Patients receiving a blood transfusion were more likely to develop postoperative infections (P =0.02) and to have lower tumour necrosis factor alpha (TNFα), interleukin (IL)-12, IL-23 and RAR-related orphan receptor gamma T (RORγt) gene expression in the postoperative period (P <0.05). The TNFα/IL-10 mRNA ratio at 24 hours (P =0.0006) and at 48 hours (P =0.01) was lower in patients receiving a blood transfusion over this period. Multivariable analysis confirmed that these observations were independent of the severity of the surgical insult.ConclusionsAn association between an immunosuppressive pattern of gene expression and blood transfusion following major elective gastrointestinal surgery is described. This gene expression profile includes a reduction in the activity of innate immunity and T helper cell type 1 (Th1) and T helper cell type 17 (Th17) pathways in those patients receiving a blood transfusion. Blood transfusion was also associated with an excess of infectious complications in this cohort. A mechanistic link is suggested but not proven.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0541-x) contains supplementary material, which is available to authorized users.

Perioperative blood transfusion is associated with a gene transcription profile characteristic of immunosuppression: a prospective cohort study

Blood transfusion in the perioperative period has frequently been associated with an excess of nosocomial infections. Whilst transfused whole blood induces specific host immune alteration that may predispose to nosocomial infections, the immunomodulating properties associated with leukodepleted blood remain incompletely understood. In this study, we explore the hypothesis that the transfusion of leukodepleted allogeneic blood during or following major gastrointestinal surgery is associated with an immunosuppressed phenotype, which may in turn predispose to postoperative infectious complications. Patients aged over 45 years undergoing scheduled inpatient major gastrointestinal surgery were recruited. Gene expression profiles of specific inflammatory genes were assayed from blood collected preoperatively, at 24 and at 48 hours after surgery. Genes were selected based on their ability to represent specific immune pathways. Gene expression was quantified using quantitative real-time polymerase chain reaction (qRT-PCR) to measure messenger RNA (mRNA) levels. Postoperative infections were documented using predefined criteria. One hundred and nineteen patients were recruited. Fifteen (13%) patients required blood transfusion within 24 hours of surgery, 44 (37%) patients developed infections and 3 (2%) patients died prior to discharge. Patients receiving a blood transfusion were more likely to develop postoperative infections (P =0.02) and to have lower tumour necrosis factor alpha (TNFα), interleukin (IL)-12, IL-23 and RAR-related orphan receptor gamma T (RORγt) gene expression in the postoperative period (P <0.05). The TNFα/IL-10 mRNA ratio at 24 hours (P =0.0006) and at 48 hours (P =0.01) was lower in patients receiving a blood transfusion over this period. Multivariable analysis confirmed that these observations were independent of the severity of the surgical insult. An association between an immunosuppressive pattern of gene expression and blood transfusion following major elective gastrointestinal surgery is described. This gene expression profile includes a reduction in the activity of innate immunity and T helper cell type 1 (Th1) and T helper cell type 17 (Th17) pathways in those patients receiving a blood transfusion. Blood transfusion was also associated with an excess of infectious complications in this cohort. A mechanistic link is suggested but not proven.

Impact of Perioperative Enteral Immunonutrition on Infectious Complications After Major Gastrointestinal Surgery

Objective: To study the impact of perioperative, enterally administered whey protein concentrate on infectious complications after major elective gastrointestinal surgery in a tertiary care hospital. Materials and Methods: Prospective non-randomized study conducted from June 2008–April 2010, which included 50 consecutive patients who underwent major elective gastrointestinal surgery for benign and malignant diseases. The primary outcome measured was the rate of infectious complications, and the secondary outcome was length of postoperative stay. Results: 50 patients were divided into two equal groups: Group 1 and Group 2 (n=25 each). One group received immune-enhanced enteral nutrition (IMEN) perioperatively, and the control group received standard enteral nutrition (SEN) during the same period. There were no significant differences between the two groups with regard to complications (P=0.26), either infective (P=0.76) or non-infective (P=0.65). There was no significant difference in the duration of postoperative stay (P=0.25) between the two groups. There was also no significant difference in the pre- and postoperative White Blood Cell (WBC) count, C-Reactive Protein (CRP), and albumin levels. However, a subgroup analysis carried out to identify malnourished patients in the immunonutrition group revealed significant reduction in the length of postoperative stay (P=0.03) but not the rate of infectious complications (P=0.20). Conclusion: Perioperatively administered immunonutrition did not decrease the incidence of postoperative infectious complications and the duration of postoperative stay. Malnourished patients given immunonutrition in the perioperative period showed a significant reduction in the length of postoperative hospital stay but not the incidence of infective complications.

Teamwork and communication failures in post-operative care

Introduction Communication failures in surgery are a recognised source of error, however research in this area has primarily focussed on the operating room. We aimed to conduct a detailed examination of failures in post-operative care after elective surgery. Methods We conducted a prospective, ethnographic study of the post-operative care of patients following major elective gastrointestinal surgery. We observed 50 patients from the point of surgery to discharge, representing 659 days of post-operative care. An independent observer attended ward rounds, examined notes and charts and conducted interviews with clinical staff. Ethnographic field notes of any unexpected incident were analysed by two independent assessors, based on the methodologies employed by the Harvard Medical Practice Study, to identify failures in the process of care (reliability: intra-class correlation 0.755, p Results We observed 256 process failures (median 4.5 per patient, range 0-16), of which 74 (29%) were associated with patient harm, 23 (9%) met adverse event criteria and 85% were preventable. Process failures included problems with lines, tubes and drains, medications, blood transfusion and blood and radiological investigations. Poor communication was the cause of these failures in 105/256 (41%) cases, of which 104/105 (99%) were preventable. Communication breakdowns were due to poor written communication in 58/105 (55%) and poor verbal communication in 47/105 (45%) cases. Communication failed primarily between surgeons and nurses (46/105) and within the surgical team (19/105). Conclusions Communication breakdown is a common cause of process failures following surgery. Improving communication has the potential to decrease such failures and therefore enhance both outcomes and patient safety.

A randomised study on the clinical progress of high-risk elective major gastrointestinal surgery patients treated with olive oil-based parenteral nutrition with or without a fish oil supplement

n-3 Fatty acids have clinical benefits. The primary aim of the present study was the assessment of infection in patients who underwent major high-risk elective gastrointestinal surgery receiving postoperatively fish oil (FO)-supplemented parenteral nutrition (PN), compared with those receiving a standard olive oil (OO) emulsion. The secondary aims were the assessment of anti-inflammatory response and evaluation of tolerance and safety of these emulsions. A prospective, randomised, double-blind study was performed in patients requiring at least 5 d of PN. An isoenergetic and isoproteic formula was administered: group A received OO alone, while group B received OO that was partially replaced with FO (16.6 %, w/w). End points were outcome measures (mortality, sepsis, infection, hospitalisation days and PN duration), inflammatory response (C-reactive protein (CRP), prealbumin and leucocytes) and safety (TAG and glucose metabolism, and liver and kidney function). Statistical analysis was done using Student's t test and Fisher's exact test (P < 0.05). Twenty-seven patients were evaluated, with thirteen patients receiving FO. In this group, a significantly lower incidence of infections was found (23.1 v. 78.6 %, P = 0.007). CRP, prealbumin and leucocytes were not significantly different between the groups. There were no differences in safety parameters. We conclude that high-risk surgical patients receiving FO-supplemented PN for 5 d present a lower incidence of infection. Emulsions were safe and well tolerated.

Perioperative Intravenous Glutamine Supplemetation in Major Abdominal Surgery for Cancer

To investigate whether perioperative intravenous glutamine supplementation may affect surgical morbidity. Small-sized randomized trials showed a trend toward a reduction of postoperative infections in surgical patients receiving glutamine. : A randomized, multicentre trial was carried out in 428 subjects who were candidates for elective major gastrointestinal surgery. Inclusion criteria were: documented gastrointestinal cancer, weight loss <10% in previous 6 months, and age >18 years. Patients received either intravenous infusion of L-alanine-L-glutamine dipeptide (0.40 g/kg/d; equal to 0.25 g of free glutamine) (Ala-Glu group, n = 212), or no supplementation (control group, n = 216). Glutamine infusion began the day before operation and continued postoperatively for at least 5 days. No postoperative artificial nutrition was allowed unless patients could not adequately eat by day 7. Postoperative morbidity was assessed by independent observers according to a priori definition. Patients were homogenous for baseline and surgical characteristics. Mean percent of weight loss was 1.4 (2.7) in controls and 1.4 (2.4) in Ala-Glu group. Overall postoperative complication rate was 34.9% (74/212) in Ala-Glu and 32.9% (71/216) in control group (P = 0.65). Infectious morbidity was 19.3% (41/212) in Ala-Glu group and 17.1% (37/216) in controls (P = 0.55). The rate of major complications was 7.5% (16/212) in Ala-Glu group and 7.9% (17/216) in controls (P = 0.90). Mean length of hospitalization was 10.2 days (4.8) in Ala-Glu group versus 9.9 days (3.9) in controls (P = 0.90). The rate of patients requiring postoperative artificial nutrition was 13.2% (28/212) in Ala-Glu group and 12.0% (26/216) in controls (P = 0.71). Perioperative glutamine does not affect outcome in well-nourished GI cancer patients.

Major elective gastrointestinal surgery: does fluid restriction improve outcome?

Controversy regarding fluid therapy for major surgery dates back to the 1950s and is largely based on two differing concepts: the first, that the metabolic and stress response to surgery causes water and sodium retention, and the second, that there is redistribution of fluid into a hypothetical ‘third space’ leading to a fall in intravascular volume. Aggressive perioperative fluid resuscitation is the standard of care provided by many anaesthetists, however, evidence seems to suggest that this is flawed. Unfortunately, the answer is not as simple as following a restrictive fluid regimen.

Less Is Not More: A Lack of Evidence for Intraoperative Fluid Restriction Improving Outcome After Major Elective Gastrointestinal Surgery

Less Is Not More: A Lack of Evidence for Intraoperative Fluid Restriction Improving Outcome After Major Elective Gastrointestinal Surgery

Less Is Not More: A Lack of Evidence for Intraoperative Fluid Restriction Improving Outcome After Major Elective Gastrointestinal Surgery

Less Is Not More: A Lack of Evidence for Intraoperative Fluid Restriction Improving Outcome After Major Elective Gastrointestinal Surgery

Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery

Fluid therapy is one of the most controversial topics in perioperative management. There is continuing debate with regard to the quantity and the type of fluid resuscitation during elective major surgery. However, there are increasing reports of perioperative excessive intravascular volume leading to increased postoperative morbidity and mortality. Recent evidence suggests that judicious perioperative fluid therapy improves outcome after major elective gastrointestinal surgery. The observed benefits may not be solely attributable to crystalloid restriction but also to the use of colloids instead. Some clinically useful guidelines based on the studies discussed in this review include avoidance of deep general anesthesia and elimination of preload for patients who receive epidural analgesia. A balanced approach to fluid management is recommended, with colloids administered to provide hemodynamic stability and maintain urine output of 0.5 mL x kg(-1) x h(-1) and crystalloids administered only for maintenance. In addition, blood loss may be replaced with colloid on a volume-to-volume basis. Furthermore, predetermined algorithms that suggest replacement of third space losses and losses through diuresis are unnecessary. Significant reduction in crystalloid volume can be achieved without encountering intraoperative hemodynamic instability or reduced (i.e., < 0.5 mL x kg(-1) x h(-1)) urinary output just by avoiding replacement of third space losses and preloading. Finally, there is a need for well-controlled studies in a well-defined patient population using clear criteria or end-points for perioperative fluid therapy.

Normal values and differences between intraperitoneal and subcutaneous microdialysis in patients after non‐complicated gastrointestinal surgery

Objective. Visceral ischemia is an early event in the development of shock and organ failure. Microdialysis has been presented as a promising method for detection of visceral hypoxia and ischemia. The aim of this study was to investigate differences in the metabolic response measured by microdialysis between intraperitoneal and subcutaneous locations and to estimate normal values of lactate/pyruvate ratio, glucose and glycerol. Material and methods. Intraperitoneal and subcutaneous metabolic responses were compared regarding lacate/pyruvate ratio, glucose and glycerol, during 45 postoperative hours in 33 patients undergoing various non‐complicated elective major gastrointestinal surgery. Results. Intraperitoneal lactate/pyruvate ratio started around 15 and decreased over time, while subcutaneous levels were stable around 9. Glucose levels were higher intraperitoneally and increased rapidly during the first 9 h to 8.6 mM, while the subcutaneous levels increased during 21 h to 7.5 mM. Intraperitoneal glycerol levels were stable around 100 µM, while subcutaneous values started around 230 µM and then increased. Conclusions. In a non‐complicated postoperative course the lactate/pyruvate ratio and glucose levels are higher intraperitoneally, suggesting a higher postoperative intraperitoneal metabolism. Glycerol levels are higher and increase subcutaneously, suggesting increased postoperative energy demand, particularly in the visceral organs, as being responsible for the lipolysis seen in the subcutaneous tissue.