Surgery For Upper Gastrointestinal Cancer Research Articles

Simultaneous surgery for upper gastrointestinal cancer and cardiovascular diseases

To analyze the immediate and long-term results of simultaneous surgical treatment in patients with upper gastrointestinal cancer and cardiovascular diseases. There were 9 patients with upper gastrointestinal cancer and cardiovascular diseases who underwent simultaneous surgical treatment. We assessed safety and efficacy of this approach. Mean age of patients was 65.7±5.7 years. Coronary artery disease was diagnosed in 3 patients, aortic valve disease - 1 patient, abdominal aortic aneurysm - 2; 4 patients suffered from isolated mitral valve disease, stenosis of the left vertebral artery, internal and external carotid arteries and Leriche syndrome. Considering immediate and long-term postoperative results, we can emphasize advisability of simultaneous surgeries in appropriate patients.

Health service nutrition practices and associations with clinical outcomes in patients undergoing resection for upper gastrointestinal cancer: Results from the multi-centre NOURISH point prevalence study.

The present study aimed to investigate health service nutrition practices of sites providing care to patients undergoing surgery for upper gastrointestinal cancer within Australia, including the provision of perioperative nutrition support services and outpatient clinics, as well as the use of evidence-based nutrition care pathways/protocols. Secondary aims were to investigate associations between the use of a nutrition care pathway/protocol and patient outcomes. Principal investigator dietitians for the sites (n = 27) participating in the NOURISH point prevalence study participated in a purpose-built site-specific survey regarding perioperative nutrition practices and protocols. Data from the 200 patients who participated in the study (including malnutrition prevalence, preoperative weight loss and receipt of dietetics intervention, intraoperative feeding tube insertions, provision of nutrition support day 1 post surgery, length of stay, and complications) were investigated using multivariate analysis to determine associations with the sites' use of a nutrition care pathway/protocol. The majority of sites (>92%) reported having dietetics services available in chemotherapy/radiotherapy. Eighty-five percent of sites reported having some form of outpatient clinic service; however, a routine service was only available at 26% of sites preoperatively and 37% postoperatively. Most preoperative services were embedded into surgical/oncology clinics (70%); however, this was reported for only 44% of postoperative clinics. Only 44% had a nutrition care pathway/protocol in place. The use of a nutrition care pathway/protocol was associated with lower rates of malnutrition, as well as higher rates of preoperative dietetics intervention, intraoperative feeding tube insertions, and European Society of Clinical Nutrition and Metabolism (ESPEN) guideline compliant care day 1 post surgery. The results of the present study demonstrate varied perioperative outpatient nutrition services in this high-risk patient group. The use of nutrition care pathways and protocols was associated with improved patient outcomes.

The impact of arginine-containing postoperative immune modulating nutrition on survival in patients undergoing surgical resection for upper gastrointestinal cancer: the long-term follow-up of a randomized controlled trial

Rationale: Malnutrition and weight loss of varying severity is prevalent in cancers of the upper gastrointestinal tract and have been shown to independently predict poorer oncological treatment outcomes and lower quality of life. There is evidence of benefit for the use of immune modulating nutrition (IMN) in patients undergoing surgery for gastrointestinal cancers. In particular, IMN reduces infective complications and hospital length of stay. There have also been suggestions that arginine-containing IMN may result in improved survival and progression-free survival in patients undergoing surgery for head and neck cancers1,2. This study analysed long-term data from a previous randomised controlled trial3 and evaluated the impact of postoperative IMN on the long-term survival of patients undergoing surgery for upper gastrointestinal cancer when compared with an isocaloric, isonitrogenous control feed.

Early postoperative feeding following surgery for upper gastrointestinal cancer: A systematic review.

Nutrition post major upper gastrointestinal (UGI) cancer surgery is a significant consideration known to affect postoperative recovery and the ability to tolerate adjuvant treatment. This systematic review assessed the effect of early oral feeding (EOF), compared to traditional timing of oral feeding, following major surgery for UGI cancer on postoperative complications, postoperative length of hospital stay (LOS), nutritional status and quality of life (QOL). The literature was searched up to March 9th 2020 using CINHAL, PubMed, MEDLINE, Embase, Scopus and Web of Science databases. Quality assessment was completed using the Academy of Nutrition and Dietetics quality criteria checklist. Fifteen articles were included, consisting of seven randomised controlled trials, six cohort studies and two non-randomised trials, with a total of 2517 participants. The type and timing of EOF varied considerably across studies with limited reporting of energy and protein intakes from oral or enteral feeding. Fourteen studies assessed postoperative complications of which 13 reported no difference between EOF and standard care. Fourteen studies assessed postoperative LOS and of these, 13 reported a reduced length of stay in the EOF group. Four of 15 studies assessing nutritional status found no difference between groups. Three of 15 studies assessed QOL with inconsistent findings. This review found EOF reduced postoperative LOS and did not increase postoperative complications. However, the optimal timing for the introduction of EOF could not be established. Furthermore, the type of EOF varied considerably making comparison across studies challenging and demonstrates a need for internationally standardised definitions.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period.

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4–6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

Phase II randomized clinical trial of endosonography and PET/CT versus clinical assessment only for follow-up after surgery for upper gastrointestinal cancer (EUFURO study)

Upper gastrointestinal malignancies have a poor prognosis. There is no consensus on how patients should be followed after surgery. The authors hypothesized that a structured follow-up programme including endoscopic ultrasonography (EUS) and [18 F]fluorodeoxyglucose (FDG) PET/CT would detect cancer recurrences, leading to more patients being eligible for therapy. After surgery with curative intent for adenocarcinomas in the gastro-oesophageal junction, stomach or pancreas, patients were randomized 1 : 1 to standard clinical assessment in the outpatient clinic at 3, 6, 9, 12, 18 and 24 months after operation, or clinical assessment plus imaging including [18 F]FDG PET/CT and EUS. The primary endpoint was number of patients receiving oncological treatment for recurrence. Secondary endpoints were overall and progression-free survival, survival after recurrence detection of isolated locoregional recurrences and risk factors affecting survival. In total, 183 patients were enrolled, including 93 who underwent standard follow-up and 90 who had follow-up plus imaging. A recurrence was detected in 84 patients within 2 years after surgery (42 in each group), including 33 of 42 patients in the imaging group who were asymptomatic. Some 25 of 42 patients in the imaging group and 14 of 42 in the standard group received chemotherapy (P = 0·028). Although survival after detection of recurrence in asymptomatic patients was significantly longer than that for symptomatic patients (P < 0·001), overall survival from date of surgery in the two treatment groups was comparable. Follow-up after surgery for upper gastrointestinal cancer with EUS and PET/CT leads to detection of more asymptomatic cancer recurrences and patients referred for treatment without prolonging overall survival. Registration number: NCT02209415 ( http://www.clinicaltrials.gov).

Information is the key to successful participation for patients receiving surgery for upper gastrointestinal cancer.

Fast-track programmes are aimed at improving perioperative care. The purpose of this study was to identify and explore patient participation among patients who had surgery for liver, bile duct or pancreatic cancer and followed a fast-track programme. A total of 116 questionnaires to investigate patient participation were analysed. Information was important for the patients, as was having the opportunity to ask questions and express personal views. The results showed differences by sex; men responded to a greater extent that they did not want to make decisions as a patient (p=0.044) and that they had been motivated to take more responsibility for their future health (p=0.011). Patients with pancreatic cancer discussed treatment goals with doctors to a greater extent than did patients with liver cancer (p=0.041). Half of the patients perceived that they had not been involved in their care planning after discharge but had a desired to be involved. This seems to be an important point to improve in future care, and also that professionals should be aware of patients' needs for information and participation, especially at discharge.

Urinary diagnostic proteomic markers for dynapenia in cancer patients.

Dynapenia is defined as the age-related loss of muscle strength, and plays a significant role in the loss of physical function and increased risk of disability among older individuals. The need for an early diagnosis supports the search for a biomarker that reflects muscle 'weakening'. This has previously proven difficult due to patient heterogeneity at presentation and lack of understanding of the underlying molecular mechanisms. The aim of the present study was to identify potential urinary biomarkers of dynapenia in patients undergoing potentially curative surgery for upper gastrointestinal cancer. Maximum isometric knee extensor strength (strain gauge) and maximum leg extensor power (Nottingham power rig) measurements were taken. Cut-off values for dynapenia were based on the Allied Dunbar national fitness survey. Values below the 5th percentile for the population matched for age and sex on the Allied Dunbar national fitness survey were used to stratify the cohort into dynapenic or normal. Urine samples taken at induction of anaesthesia were analysed by SELDI-TOF mass spectrometry using CM10 and IMAC30 chip-types to establish statistically significant m/z peak fingerprint patterns, followed by in-gel LC-MS/MS to identify molecular constituents. Statistical analysis of decision-tree calculations using Biomarker Pattern software resulted in models with sensitivities of 86 and 96%, specificities of 81 and 89%, and overall correctness of 84 and 93%, when applied to the entire cohort for power and strength measurement-based stratifications using the IMAC30 chip-type and the CM10 chip-type, respectively. The molecular identities of 10 peaks of interest were further investigated. After subtraction of potentially unrelated proteins, they were identified as fragments of Annexin A1, collagen α-1 (XV), perlecan and myotrophin. These results demonstrate that urinary screening can be used to define cancer-associated muscle weakness, and the identification of potential biomarkers could be invaluable in establishing a rapid test to measure and assess dynapenia in the clinical setting.

In-hospital clinical outcomes after upper gastrointestinal surgery: Data from an international observational study

AimsPrevious research suggests that patients undergoing upper gastrointestinal surgery are at high risk of poor postoperative outcomes. The aim of our study was to describe patient outcomes after elective upper gastrointestinal surgery at a global level. MethodsProspective analysis of data collected during an international seven-day cohort study of 474 hospitals in 27 countries. Patients undergoing elective upper gastrointestinal surgery were recruited. Outcome measures were in-hospital complications and mortality at 30-days. Results are presented as n(%) and odds ratios with 95% confidence intervals. Results2139 patients were included, of whom 498 (23.2%) developed one or more postoperative complications, with 30 deaths (1.4%). Patients with complications had longer median hospital stay 11 (6–18) days vs. 5 (2–10) days. Infectious complications were most frequent, affecting 368 (17.2%) patients. 328 (15.3%) patients were admitted to critical care postoperatively, of whom 161 (49.1%) developed a complication with 14 deaths (4.3%). In a multivariable logistic regression model we identified age (OR 1.02 [1.01–1.03]), American Society of Anesthesiologists physical status III (OR 2.12 [1.44–3.16]) and IV (OR 3.23 [1.72–6.09]), surgery for cancer (OR 1.63 [1.27–2.11]), open procedure (OR 1.40 [1.10–1.78]), intermediate surgery (OR 1.75 [1.12–2.81]) and major surgery (OR 2.65 [1.72–4.23]) as independent risk factors for postoperative complications. Patients undergoing major surgery for upper gastrointestinal cancer experienced twice the rate of complications compared to those undergoing other procedures (224/578 patients [38.8%] versus 274/1561 patients [17.6%]). ConclusionsComplications and death are common after upper gastrointestinal surgery. Patients undergoing major surgery for cancer are at greatest risk.

Robotic surgery for upper gastrointestinal cancer: Current status and future perspectives.

Robotic surgery with the da Vinci Surgical System has been increasingly applied in a wide range of surgical specialties, especially in urology and gynecology. However, in the field of upper gastrointestinal (GI) tract, the da Vinci Surgical System has yet to be standard as a result of a lack of clear benefits in comparison with conventional minimally invasive surgery. We have been carrying out robotic gastrectomy and esophagectomy for operable patients with resectable upper GI malignancies since 2009, and have demonstrated the potential advantages of the use of the robot in possibly reducing postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy, even though there have been a couple of problems to be solved including longer duration of operation and higher cost. The present review provides updates on robotic surgery for gastric and esophageal cancer based on our experience and review of the literature.

Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature.

Minimally invasive surgery (MIS) for upper gastrointestinal (GI) cancer, characterized by minimal access, has been increasingly performed worldwide. It not only results in better cosmetic outcomes, but also reduces intraoperative blood loss and postoperative pain, leading to faster recovery; however, endoscopically enhanced anatomy and improved hemostasis via positive intracorporeal pressure generated by CO2 insufflation have not contributed to reduction in early postoperative complications or improvement in long-term outcomes. Since 1995, we have been actively using MIS for operable patients with resectable upper GI cancer and have developed stable and robust methodology in conducting totally laparoscopic gastrectomy for advanced gastric cancer and prone thoracoscopic esophagectomy for esophageal cancer using novel technology including da Vinci Surgical System (DVSS). We have recently demonstrated that use of DVSS might reduce postoperative local complications including pancreatic fistula after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. In this article, we present the current status and future perspectives on MIS for gastric and esophageal cancer based on our experience and a review of the literature.

Habitual Myofibrillar Protein Synthesis Is Normal in Patients with Upper GI Cancer Cachexia.

Skeletal muscle wasting and weight loss are characteristic features of cancer cachexia and contribute to impaired function, increased morbidity, and poor tolerance of chemotherapy. This study used a novel technique to measure habitual myofibrillar protein synthesis in patients with cancer compared with healthy controls. An oral heavy water (87.5 g deuterium oxide) tracer was administered as a single dose. Serum samples were taken over the subsequent week followed by a quadriceps muscle biopsy. Deuterium enrichment was measured in body water, serum alanine, and alanine in the myofibrillar component of muscle using gas chromatography-pyrolysis-isotope ratio mass spectrometry and the protein synthesis rate calculated from the rate of tracer incorporation. Net change in muscle mass over the preceding 3 months was calculated from serial CT scans and allowed estimation of protein breakdown. Seven healthy volunteers, 6 weight-stable, and 7 weight-losing (≥5% weight loss) patients undergoing surgery for upper gastrointestinal cancer were recruited. Serial CT scans were available in 10 patients, who lost skeletal muscle mass preoperatively at a rate of 5.6%/100 days. Myofibrillar protein fractional synthetic rate was 0.058%, 0.061%, and 0.073%/hour in controls, weight-stable, and weight-losing patients, respectively. Weight-losing patients had higher synthetic rates than controls (P = 0.03). Contrary to previous studies, there was no evidence of suppression of myofibrillar protein synthesis in patients with cancer cachexia. Our finding implies a small increase in muscle breakdown may account for muscle wasting.

Mo1925 Prognostic Significance of CT Muscle Density in Upper GI Cancer

Introduction: Upper gastrointestinal (UGI) surgery is by definition high risk and frequently performed in malnourished patients with a significant incidence of sarcopenia (age-associated loss of skeletal muscle mass and function). Nutritional support is an integral component of enhanced recovery protocols (ERP) to mitigate post-operative risk, and the aim of this study was to investigate the prognostic significance of sarcopenia as defined by CT density of muscle mass in UGI cancer. Methods: One hundred and seven consecutive patients undergoing surgery for UGI cancer [median age 66 yr, 79 m, 55 esophageal (46 ACA, 9 SCC), 52 gastric cancer] were studied prospectively. The axial CT slice at the upper border of the fourth lumbar vertebra was identified and a region of interest was drawn around each psoas muscle. The mean psoas muscle CT density (PMD) was calculated within the region in Hounsfield units (HU) by the Agfa PACS system, and the greater of the two density measurements was used for analysis. The primary outcome measure was survival. Results: Median PMD was 49.25 (range -5.55 to 73.73) HU. Nineteen patients (17.8%) had low PMD ( 40 HU 70.4%, p<0.001). On multivariate analysis only rTNM stage was independently associated with survival (HR 2.157, 95% CI 1.450-3.209, p<0.001). Conclusion: CT defined psoas muscle density (PMD) and by implication sarcopenia, is an important and new prognostic indicator in UGI cancer. Patients identified as such should enter targeted strategic ERP protocols.

Mo1926 Selenium Supplement Ameliorates Chemotherapy-Induced Mucositis in Rat Small Intestine

Introduction: Upper gastrointestinal (UGI) surgery is by definition high risk and frequently performed in malnourished patients with a significant incidence of sarcopenia (age-associated loss of skeletal muscle mass and function). Nutritional support is an integral component of enhanced recovery protocols (ERP) to mitigate post-operative risk, and the aim of this study was to investigate the prognostic significance of sarcopenia as defined by CT density of muscle mass in UGI cancer. Methods: One hundred and seven consecutive patients undergoing surgery for UGI cancer [median age 66 yr, 79 m, 55 esophageal (46 ACA, 9 SCC), 52 gastric cancer] were studied prospectively. The axial CT slice at the upper border of the fourth lumbar vertebra was identified and a region of interest was drawn around each psoas muscle. The mean psoas muscle CT density (PMD) was calculated within the region in Hounsfield units (HU) by the Agfa PACS system, and the greater of the two density measurements was used for analysis. The primary outcome measure was survival. Results: Median PMD was 49.25 (range -5.55 to 73.73) HU. Nineteen patients (17.8%) had low PMD ( 40 HU 70.4%, p<0.001). On multivariate analysis only rTNM stage was independently associated with survival (HR 2.157, 95% CI 1.450-3.209, p<0.001). Conclusion: CT defined psoas muscle density (PMD) and by implication sarcopenia, is an important and new prognostic indicator in UGI cancer. Patients identified as such should enter targeted strategic ERP protocols.

PP156-SUN CHYLE LEAKS AND UPPER GASTROINTESTINAL SURGERY

Rationale: Recent advances in surgery, pioneered in Japan, involve increased lymph node harvest (lymphadenectomy) in patients with upper gastrointestinal cancer. An audit was undertaken to determine if the incidence of chyle leaks had increased after changes in surgical technique; whether the length of stay differed in patients with chyle leaks; and whether the type of nutrition affected recovery time. Methods: 113 patients who underwent surgery for upper gastrointestinal cancer (oesophagectomy, total gastrectomy with Roux-en-Y and subtotal gastrectomy with Roux-en-Y) at Imperial College Healthcare NHS Trust were identified. Dietetics records were reviewed to determine chyle leak occurrence and duration, length of stay, route and type of nutrition used, and clinical course including any change in the method of nutrition support. Four records were unavailable and three patients were excluded due to insufficient information, leaving 106 for analysis. Results: The rate of chyle leaks increased from 7.8% to 22% (p = 0.06) following increasingly radical lymphadenectomy, patients with chyle leaks experienced prolonged lengths of stay 16 vs 24 days (p = 0.003). 73% of patients with chyle leaks resolved with specialized oral (27%) or enteral feeding (72%); 27% required parenteral nutrition (TPN); of which one required surgery despite conservative measures. Those on oral intake had a reduced duration of chyle leak and hospital stay. 100% of patients fed enterally received MCT feed. Conclusion: The incidence of chyle leaks has increased with increasingly radical surgery as hypothesized. Patients with chyle leaks stay longer as the leak must be resolved before building up to a normal diet and surveillance is required. The majority of patients’ leaks resolve with specialized oral or enteral nutritional measures; a very low fat or MCT diet, as previously reported. Nevertheless a minority of patients still required TPN to enable the leak to heal.

Determinants of global quality of life before and after major cancer surgery: an exploratory study

To explore whether determinants of global quality of life (QOL) change before and after major cancer surgery. Consecutive patients (n = 145) undergoing surgery for upper gastrointestinal cancer were prospectively studied and asked to complete the EORTC QLQ-C30 before and after 6 months. Excluded were patients found to be inoperable (n = 12) and those with missing second questionnaires (because of death n = 20, poor health (n = 10), administrative failure (n = 7) or patient refusal (n = 4)). Multivariable linear regression models investigated associations between global QOL and other scales and items of QOL adjusting for clinical variables. Some 87 patients completed both questionnaires. Before surgery the main predictors of global QOL were physical and emotional function, with adjusted increases in global QOL of 0.55 (95% CI 0.26-0.84; P < 0.001) and 0.30 (95% CI 0.14-0.45; P < 0.001) per unit increase of physical and emotional function, respectively. Six months after surgery, however, fatigue and dyspnea most strongly predicted global QOL, with adjusted differences in global QOL of -0.24 (95% CI -0.44 to -0.04; P = 0.02) per unit increase of fatigue and -6.28 (95% CI -12.64 to 0.07; P = 0.05) for those experiencing any symptoms of dyspnea. Further work is needed to test these findings, but the results suggest that the global QOL scale in the QLQ-C30 is difficult to interpret and it should be considered within the context of other clinical and patient reported outcomes.

Gastrointestinal cancer:developing an information booklet for patients

To ascertain from patients and their relatives the advice they would like to receive on dealing with the post-operative symptoms associated with oesophagectomy and gastrectomy. The findings would be used by the Oesophageal Patients Association to update its information booklet. A literature review was undertaken to investigate what information is available. Qualitative methodology using focus groups with patients and healthcare professionals informed the study. The focus group proceedings were tape recorded and transcribed. Inductive thematic analysis was used, with words being grouped into categories to explore recurrent themes and overlapping concepts. Themes were labelled and the transcripts re-explored for items relevant to each theme. The literature search produced 604 articles. Many were irrelevant to upper gastrointestinal (GI) cancer but useful information was obtained from others, leading to a first draft of the updated booklet. The focus groups' data were crucial in developing the booklet. The updated booklet will assist patients who have had surgery for upper GI cancer to manage their nutrition.

Do Data Support Nutrition Support? Part I: Intravenous Nutrition

Intravenous (parenteral) nutrition has been advocated widely as adjunctive care in patients with a variety of underlying diseases. However, the enthusiasm for this therapeutic intervention was based largely on expert opinion. Because the best way to assess the efficacy of any treatment is to test it in a randomized controlled trial, this review will focus on data that was derived from such studies. Using established search strategies, randomized controlled trials were sought that compared one of two forms of intravenous nutrition: parenteral nutrition (nitrogen and ≥10 kcal/kg/day of non-protein calories for ≥5 days) or protein-sparing therapy (nitrogen and fewer non-protein calories) with no type of artificial nutrition beyond regular food and/or standard (5%) dextrose. The randomized controlled trials were stratified by the underlying disease state. The clinical outcomes of interest were mortality, morbidity (total/infectious complications), and/or duration of hospitalization. More than 100 randomized controlled trials failed for the most part to demonstrate that intravenous nutrition had any effect on clinical outcome. There were a few exceptions. In patients undergoing attempted curative surgery for upper gastrointestinal cancer, the use of preoperative parenteral nutrition seemed to reduce the incidence of major postoperative complications. However, this benefit was only found in low-quality randomized controlled trials. Findings conflict regarding the use of parenteral nutrition in patients with acute pancreatitis or undergoing bone marrow transplantation. Parenteral nutrition was harmful when provided to patients undergoing radiation or chemotherapy for cancer. Although no randomized controlled trials exist, it is assumed that parenteral nutrition is useful in patients with an inadequate gastrointestinal tract (“short gut”). Thus, for the most part, randomized controlled trials comparing intravenous nutrition to no artificial nutrition have not shown that this medical intervention is of benefit.

Early postoperative jejunostomy feeding with an immune modulating diet in patients undergoing resectional surgery for upper gastrointestinal cancer: A prospective, randomized, controlled, double-blind study

The provision of perioperative immune modulating enteral feeds after major surgery may result in reduced infective complications, but meta-analyses have not demonstrated a survival advantage. The aim of this study was to determine whether early postoperative immune modulating jejunostomy feeding results in reduced infective complications in patients undergoing resectional surgery for upper gastrointestinal cancer. A total of 120 patients undergoing resection for cancers of the pancreas, oesophagus and stomach were randomized in a double-blind manner to receive jejunostomy feeding with an immune modulating diet (Stresson-Group A) or an isonitrogenous, isocaloric feed (1250 Calories and 75 g protein/l--Nutrison High Protein-Group B) for 10-15 days. Feeding was commenced 4h postoperatively and continued for 20 h/day. The target volume (ml/h) was 25 on day 0, 50 on day 1, and 75 thereafter. Outcome measures included complications, hospital stay and mortality. A total of 108 patients (54 in each group) were analysed. Feed delivery, although less than targeted, was similar in both groups. There were 6 (11%) deaths in each group. Median (IQR) postoperative hospital stay was 14.5 (12-23) days in Group A and 17.5 (13-23) days in Group B (P=0.48). A total of 24 (44%) patients in each group had infective complications (P=1.0). A total of 21 (39%) patients in Group A and 28 (52%) in Group B had non-infective complications (P=0.18). Jejunostomy-related complications occurred in 26 (48%) patients in Group A and 30 (56%) in Group B (P=0.3). Early postoperative feeding with an immune modulating diet conferred no outcome advantage when compared with a standard feed.

Lack of correlation between failure of gut barrier function and septic complications after major upper gastrointestinal surgery.

To determine the influence of abnormal gut barrier function on the risk of septic complications in patients undergoing major resectional surgery for upper gastrointestinal cancer. A failure of the gut mucosal barrier to exclude bacteria and endotoxin from the portal and systemic circulation is incriminated in the development of sepsis and multiple organ failure. Although the experimental data is compelling, corroborative evidence from studies in humans is sparse. This study attempted to correlate both preoperative gut barrier dysfunction and the pattern of change after surgery with septic outcome. Sixty-eight patients undergoing curative resectional surgery for upper gastrointestinal cancer were monitored for 30-day septic morbidity (intraabdominal abscesses/empyema and pneumonia). Intestinal permeability, serum IgM and IgG anti-endotoxin antibodies (EndoCAb), and serum C-reactive protein were measured before surgery and on postoperative days 1 and 7. Increased intestinal permeability before surgery did not predict septic outcome. Major surgery was associated with increased intestinal permeability and evidence of endotoxin exposure. Comparing sepsis and nonsepsis groups, however, there was no significant difference in intestinal permeability, endotoxin exposure, and the acute phase response after surgery. This study demonstrates that gut barrier dysfunction occurs after surgery, but the magnitude of change does not differentiate patients in whom sepsis develops and those in whom it does not. Preoperative increased intestinal permeability had no predictive value for sepsis. This study failed to support the thesis that gut barrier dysfunction is directly linked to sepsis.