Total Parenteral Nutrition Treatment Research Articles

Disproportionately Low Albumin and High Neutrophil-to-Lymphocyte Ratio in Small Bowel Adenocarcinoma Patients With Long-Duration Crohn's Disease.

Although Crohn's disease (CD) is a known risk factor of small bowel adenocarcinoma (SBA), early diagnosis remains a significant clinical challenge. Identification of biomarkers for SBA may lead to early detection. This is a retrospective study comparing albumin levels and neutrophil-to-lymphocyte ratio (NLR) of patients with long-standing CD who underwent small bowel resection with and without malignancy. Forty-two patients with CD were included in this study (11 with SBA). Median NLR before surgery was 8.5 (interquartile range 6.2-31.3) in patients with SBA and 3.8 (interquartile range 2.8-5.3) for patients without SBA ( P < 0.05). Mean albumin levels before surgery were significantly lower among patients with SBA compared with patients without SBA (2.6 ± 0.6 g/dL vs 3.5 ± 0.6 g/dL, respectively, P < 0.05), despite patients with SBA being under longer total parenteral nutrition treatment duration. CD patients with SBA diagnosis have increased NLR and lower albumin before surgery compared with CD patients without detection of SBA.

The Oral Administration of Honey Recovers the Function of the Small Intestine for Digestion and Absorption of Nutrients in a Rat Model of Total Parenteral Nutrition.

The oral administration of pure monosaccharides is effective for improving intestinal function such as nutrient digestion and absorption. However, day-to-day diets tend not to include high purity monosaccharides for intestinal health. Honey possesses large amounts of monosaccharides including glucose and fructose in the same ratio. In this study, we have evaluated the nutritional properties of honey and examined the effects of its oral ingestion on the recovery of intestinal function in the total parenteral nutrition (TPN) rat model. It was observed that honey remarkably recovered the function of the small intestine including the villous morphology, nutrient digestion, and absorption capabilities. In particular, the expression of disaccharidase was significantly enhanced by the ingestion of honey after TPN treatment. Therefore, oral intake of honey is effective in recovering and maintaining small intestinal functions and can potentially be used as a supplement for promoting small intestinal function recovery.

Evaluation of prognostic factors associated with intensive care unit mortality in patients with hematopoietic stem cell transplantation

Background &amp; objective: Although the outcome of patients admitted to ICUs have considerably improved in recent years, hematopoietic stem cell transplantation (HSCT) continues to be significantly associated with mortality.&#x0D; We studied the prognostic factors associated with ICU mortality after HSCT. The Acute Physiological and Chronic Health Evaluation II (APACHE II) was used as a prognostic scoring system.&#x0D; Methods: Within the scope of the research, the clinical and laboratory data of 52 patients who were admitted to the ICU after undergoing HSCT between 2013 and 2019 were analyzed retrospectively.&#x0D; Results: Mortality risk was found to be 4.22 times higher in patients who received mechanical ventilation (MV) within the first 24 h (P = 0.047), 18.37 times higher in patients who received total parenteral nutrition (TPN) support (P = 0.007), and 158.17 times higher in recipients of vasopressor drug support compared to those who did not (P &lt; 0.001). It was found that a one unit increase in GCS score decreased mortality risk by 0.58 fold (P = 0.015). Additionally, a one unit increase in heart rate was found to increase mortality risk by 1.03 fold (P = 0.010). Whereas, one unit increases in systolic blood pressure or diastolic blood pressure decreased the mortality risk by 0.91 and 0.92 fold, respectively (P = 0.001 and P = 0.002). Mortality was not associated with APACHE II or graft-versus-host disease.&#x0D; Conclusion: Receiving MV, TPN or vasopressor treatment, and having lower GCS, higher heart rate, lower systolic and diastolic blood pressure were associated with an increase in the risk of ICU mortality in HSCT recipients admitted to the ICU.&#x0D; Abbreviations: HSCT - hematopoietic stem cell transplantation; TPN - total parenteral nutrition; APACHE II - Acute Physiological and Chronic Health Evaluation II: GVHT - graft-versus-host disease; ICU - intensive care unit; GCS – Glasgow Coma Scale; MODS - Multiple organ dysfunction syndrome &#x0D; Key words: Hematopoietic stem cell transplantation; Intensive care; Mortality; Mechanical ventilation, parenteral nutrition; MV- mechanical ventilation;&#x0D; Citation: Tunay B, Sadri S. Evaluation of prognostic factors associated with intensive care unit mortality in patients with hematopoietic stem cell transplantation. Anaesth. pain intensive care 2022;26(4):480-487 ; DOI: 10.35975/apic.v26i4.1951&#x0D; Received: Nov 12, 2021; Reviewed: May 11, 2022; Accepted: July 08, 2022

Evaluation of Nutritional Status in Hospitalized Chronic Obstructive Pulmonary Disease Patients and Can C-reactive Protein-to-Albumin Ratio Be Used in the Nutritional Risk Assessment in These Patients.

BackgroundMalnutrition is common in patients diagnosed with chronic obstructive pulmonary disease (COPD). CRP/albumin ratio (CAR) can be used as a parameter to evaluate the inflammatory process and nutritional status together. The aim of this study was to make a general evaluation of the nutritional status of hospitalized patients with COPD and to investigate whether CAR can predict nutritional status in these patients.MethodsPatients who were hospitalized with COPD who were consulted to the nutrition department were included in the study. The patients' Nutritional Risk Score-2002 (NRS), demographic data, diagnoses, body mass indexes (BMI), nutritional support applied to the patients were recorded. CRP, Albumin, and CAR values of the patients were determined. Patients recommended nutritional follow-up, total parenteral nutrition (TPN) or enteral nutrition (EN) initiated, and oral nutritional supplement (ONS) support were identified.ResultsA total of 393 patients with COPD were analyzed. 88.55% of the patients were in the NRS ≥ 3 risk group. TPN treatment was started in 10.2% of the patients, EN in 10.9%, ONS in 76.3%, and nutritional follow-up was recommended in 2.5% of the patients. While albumin level was lower in patients with NRS ≥ 3, CRP and CAR were higher in patients with NRS ≥ 3 (p < 0.05). There was a negative correlation between NRS-2002 and albumin (p < 0.001). A positive correlation was observed between NRS-2002 and CRP and CAR (p < 0.001). Age and CAR were found to be effective in predicting those with NRS-2002 ≥ 3. The cut-off value for CAR was accepted as 3.26.ConclusionsThe need for nutritional support is high in patients hospitalized with COPD. It is important to evaluate nutritional support needs in these patients, regardless of NRS-2002 and BMI. In this respect, the clinician's observation and the decision are as valuable as the scoring that determines malnutrition. We think that the cut-off value of 3.26 determined for CAR can be used in the nutritional risk assessment in patients with COPD.

Total Parenteral Nutrition Treatment Improves the Nutrition Status of Gynecological Cancer Patients by Improving Serum Albumin Level.

BackgroundMalnutrition is often observed in gynecological cancer patients, however its prevalence in these patients remains largely unexplored. Total parenteral nutrition (TPN) is a nutritional intervention method that has controversial treatment outcome on gynecological cancer patients. The present retrospective study is designed to evaluate the nutrition status and TPN treatment outcome on patients diagnosed with endometrial, cervical or ovarian malignant tumors.MethodsMedical records of a total of 263 patients treated at the First Hospital of Shanxi Medical University, China were included. Nutrition status was assessed by patient-generated subjective global assessment (PG-SGA). Patients were grouped based on nutrition status, cancer type or treatment strategy for clinical characteristic comparison. Multivariable logistic regression analysis was used to identify predictors for malnutrition status and hospital stay duration.ResultsPresence of endometrial and cervical cancer, body weight before nutritional intervention and serum albumin level (P < 0.001 for all) were found to be significant predictors for malnutrition status in gynecological cancer patients. In the malnourished patients, those who were treated with TPN had significantly lower serum albumin levels before and after treatment (P < 0.001) and PG-SGA scores after treatment. Also, TPN treatment could significantly increase the serum albumin levels in these patients after 1 week. In addition, shorter hospitalization period was needed for TPN-treated endometrial (P = 0.019) and ovarian (P < 0.001) patients. Moreover, serum albumin levels (P < 0.001), use of TPN treatment (P = 0.025) and nutrition status (P = 0.010) were identified to be independent predictors for hospital stay duration.ConclusionOur results suggest that malnutrition is a significant clinical manifestation in gynecological cancer patients who may benefit from TPN treatment for reduced hospitalization and improved serum albumin levels.

Change in liverfunction tests in patients switched form olive oil based tpn to fish oil containing tpn

Rationale: The Nutritional Support Team of the University Medical Center Groningen ( UMCG ) (consisting of dieticians, registered nurses, nurse practitioners and gastroenterologists) coordinates and monitors an increasing number of adult patients with home Total Parenteral Nutrition (TPN) for mainly type 2 intestinal failure. These patients are initially all treated with olive oil based parenteral nutrition (Olimel N9E, Baxter). When during TPN treatment patients develop signs of liver dysfunction, we change into a fish oil containing TPN (SmofKabiven, Fresenius Kabi). In this study we investigated the course of the liver tests in these patients.

Exploring the malnutrition status and impact of total parenteral nutrition on the outcome of patients with advanced stage ovarian cancer

BackgroundOvarian cancer is a common cancer type in women and is often associated with onset of malnutrition. Total parenteral nutrition (TPN) is a nutritional intervention method that has been reported to have controversial effect on cancer patients. In the present retrospective study, we sought to explore the prevalence of malnutrition assessed by the Nutritional Risk Index (NRI) and its association with survival in advanced stage ovarian cancer patients. We also compared the post-operative outcome of the malnourished patients treated with either TPN or conservative management.ResultsA total of 415 patients with advanced stage ovarian cancer were separated into 4 nutrition groups based on the NRI scores. We found that a number of factors were significantly different among the 4 nutrition groups, including age, serum albumin level, BMI and NRI; among which serum albumin level and NRI were identified to be independent predictors of progression-free and overall survival. In the moderately and severely malnourished patients, those who were treated with TPN had significantly shorter hospitalization period, lower serum albumin level and lower BMI after surgery. In addition, serum albumin level, use of TPN and number of patients with complications were closely related to the hospital stay duration.ConclusionMalnutrition status is closely associated with survival of advanced stage ovarian cancer patients. These patients may benefit from TPN treatment for reduced hospitalization, especially with the onset of hypoalbuminemia.

Total Parenteral Nutrition Management Based on Intravenous Drug Compounding Service

Total parenteral nutrition treatment is complex and has serious and detrimental complications, including catheter-related blood stream infections, fluid and electrolyte imbalance, hyperglycemia and hypercalcemia. This research examines how Intravenous Drug Compounding Service (IDCS) figures in total parenteral nutrition prescriptions reviewed by pharmacists, strengthens hospital clinical care and improves patients&amp;rsquo; health. For this study, a total of 56164 nutritional prescriptions or medical orders from a hospital in Guangdong from 2016 to 2020 were randomly selected. According to whether IDCS was administered, the patients were divided into two experimental groups: the intervention group and the control group. The types and numbers of irrational prescriptions in the two groups were analyzed and compared, and further analysis of the role of IDCS in improving the level of nutritional prescriptions was performed. The results showed that the rate of irrational prescriptions in the intervention group from 2016 to 2020 was significantly lower than that in the control group, and the difference was statistically significant (P&amp;lt;0.01). The total irrational prescription rate in the intervention group was 32.53‱ on average, which was significantly lower than the 156‱ in the control group. The difference was statistically significant (P&amp;lt;0.01). After the administration of IDCS, the incidence rates of both total prescription errors and formulation errors were significantly lower than the incidence rate of irrational prescriptions without pharmacists&amp;rsquo; intervention. The study confirms the importance and necessity of IDCS, so that patients can receive more efficient nutrition and health management services.

Correlation Analysis of Hypercalcemia in Patients Treated with Total Parenteral Nutrition

Total parenteral nutrition treatment is very important for maintain patient&amp;rsquo;s life, but it is complex to understand the correlation between the medical treatment and hypercalcemia. This paper explored the incidence and correlation of hypercalcemia in patients receiving total parenteral nutrition and its related factors. 280 representative patients were selected from one hospital in Guangdong Province, China, as the research objects. Collect the patient&amp;rsquo;s basic attributes, nutritional status before total parenteral nutrition and total parenteral nutrition with the method of medical history retrospective, and use multiple logistic regression to explore important correlations that affect the occurrence of hypercalcemia in hospitalized patients receiving total parenteral nutrition factor. The results showed the percentage of patients with treatment days greater than 14 days that developed hypercalcemia was 7.5% which is significantly related to the occurrence of hypercalcemia. The probability of hypercalcemia in patients with total parenteral nutrition treatment for more than 14 days is higher than that of patients with treatment for less than or equal to 14 days. This study can prevent potentially harmful complications that may be caused by total parenteral nutrition and provide safer health quality.

NON-ALBICANS SPECIES: MAIN ACTORS OF CANDIDEMIA? SEVEN-YEAR EXPERIENCE FROM A SINGLE CENTRE

Objective: Candidemia is a major cause of mortality among healthcare-associated infections. Considering the increase in non-albicans species in recent years, it is important to define the treatment approach by identifying Candida at the species level. The aim of this study was to evaluate the epidemiological characteristics, risk factors and mortality of patients with candidemia in our hospital. Material and Method: Forty-four patients with Candida species isolated from at least one bottle of blood culture taken during hospitalization between January 2013 and October 2019 were included in the study. Patients’ demographic information, comorbidities, duration of hospitalization and ward, neutropenia, total parenteral nutrition (TPN), steroid administration and invasive device use, antimicrobial treatments used in the last month, source of candidemia, acute phase indicators, Candida species and antifungal resistance, antifungal treatment, clinical response and mortality were evaluated retrospectively. Candida species and antifungal susceptibilities were identified using the automated system VITEK®2 (bioMérieux, Marcy l’Etoile, France). Results: A total of 44 patients with candidemia participated; the median age was 57, and 27 (61.3%) were male. The median length of stay was 33.5 days. Forty-two (95.4%) of the cases were accompanied by multiple comorbidities, and the most common aetiology was malignancy (59%). Most (97.7%) of the patients had received broad-spectrum antibiotic treatment in the last month. Central venous catheters (CVCs) were used in 35 (79.5%) of the cases and 50% of them were treated with TPN. Candida albicans (54.6%) was the most common species, followed by Candida tropicalis (18.2%). Non-albicans species were observed to increase over time. Thirty-day mortality was 36.3%.Conclusion: Non-albicans candidemia was found to have increased over the years in our study. The main risk factors for candidemia were determined as the presence of comorbidities, especially malignancy, prior broad-spectrum antibiotherapy use, TPN treatment and the presence of CVC. The mortality rate in this study was also consistent with the literature.

Revisiting Infectious Complications Following Total Parenteral Nutrition Use During Hematopoietic Stem Cell Transplantation

BackgroundTotal parenteral nutrition (TPN) is frequently used to manage caloric needs during hematopoietic stem cell transplantation (HSCT). Previous studies in transplant patients who received TPN have reported widely discordant results with regard to infection and mortality, and risk factors for TPN-related infection remain unclear.MethodWe conducted a retrospective study of all HSCT recipients treated with TPN between 2005 to 2014 at Northwestern Memorial Hospital to determine the incidence and epidemiology of infections. Electronic records were used to identify patients treated with TPN for at least 2 days who developed infection.ResultsAmong 198 patients treated with TPN, 30% developed documented infection. Total parenteral nutrition treatment duration (13 vs. 7 days; p < .0001) and the timing of TPN initiation (> day 9 post HSCT; p < .0001) were significantly higher in patients who received TPN and developed infection. Receipt of an allogeneic transplant was associated with increased risk for infection (p < .0138), and day 60 mortality was significantly higher in TPN-treated patients with infection (p < .0001).ConclusionStem cell recipients who receive TPN, especially from an allogeneic donor, have high rates of infection and mortality. Minimizing TPN exposure may reduce the chance for infection.

Exogenous Secretin Improves Parenteral Nutrition-associated Liver Disease in Rats.

Intestinal failure-associated liver disease (IFALD) is a feared and life-threatening complication in neonates with intestinal failure (IF) receiving long-term total parenteral nutrition (TPN). This study aims to investigate the effect of exogenous secretin on liver pathology and hepatic function in a rat model of PN-associated liver disease (PNALD). Male Sprague-Dawley rats underwent right jugular venous catheterization to receive 14-day continuous TPN therapy. All rats were allocated into 3 groups: the Control group (n = 8) did not have surgery or TPN and was fed standard rat chow ad libitum; the TPN group (n = 8) underwent catheter insertion and TPN treatment; and the TPN/S group (n = 8) also underwent catheter insertion, TPN treatment, and exogenous secretin treatment (2.5 nmol · kg · day) daily. Fourteen days after initial surgery, we collected the animals' liver and blood samples for further test. The TPN/S group had diminished direct bilirubin (TPN, 2.1 ± 0.7 μmol/L; TPN/S, 1.5 ± 0.2 μmol/L) and liver total bile acid levels (TPN, 144.5 ± 21.2 μmol/L; TPN/S, 123.4 ± 10.4 μmol/L) and improved histological outcomes compared with those in the TPN group. Exogenous secretin also enhanced the canalicular transporter (BSEP, 0.5-fold, P = 0.011) and inhibited the basolateral transporter (OSTA, -0.48-fold, P = 0.002; OSTB, -0.6-fold, P = 0.013) of liver bile acid. In this animal model of PNALD, secretin may improve cholestasis by enhancing canalicular transport, inhibiting the basolateral export of liver bile acid, and eventually decreasing the total bile acid level in the liver. Exogenous secretin treatment may potentially prevent and treat IFALD in IF patients relying on long-term TPN therapy.

Ultrashort Bowel Syndrome: long-term survival without ParenteralNutrition

Short Bowel Syndrome (SBS) is a condition in which nutrients are not absorbed (malabsorption) because a large part of the small intestine is missing or has been surgically removed, developing an Intestinal Failure (IF), that is defined as a loss of absorptive capacity secondary to obstruction, dysmotility, surgical resection, congenital defect, or mucosal disease resulting in chronic diarrhea, dehydration, electrolyte abnormalities, micronutrient imbalance, and malnutrition. (1) The long-term survival without parenteral nutrition in patients with the diagnosis of ultrashort bowel syndrome is difficult. This is a case, first reported in the country, of a 63 years old woman with ultrashort bowel syndrome who after three abdominal surgeries was left with only about 35 cm of small intestine with a jejune-transverse anastomosis. During the first surgery the right colon was removed. From the beginning she received Total Parenteral Nutrition (TPN) lasting about three months, at which time she presented a serious reaction after which she refused further TPN treatment. She lived with oral feeding including nutritional supplements for almost five years, and one significant complication,diarrhea, was managed with loperamida and octreotride.

Early downregulation of P-glycoprotein facilitates bacterial attachment to intestinal epithelial cells and thereby triggers barrier dysfunction in a rodent model of total parenteral nutrition.

Intestinal barrier dysfunction is a major complication of total parenteral nutrition (TPN). Our preliminary study revealed that intestinal P-glycoprotein (P-gp) was significantly downregulated under TPN treatment followed by disruption of barrier function, and thus the significance of early downregulation of P-gp needs to be addressed. Herein, we report a pivotal role of P-gp in the development of intestinal barrier dysfunction under TPN. Functional suppression of P-gp may facilitate bacterial attachment to intestinal epithelial cells (IECs) and thereby induce degradation of tight junctions to trigger barrier dysfunction. By using a rat model of TPN, we found early downregulation of P-gp function in ileum after 3-day TPN, followed by disruption of barrier function after 7-day TPN. By using Escherichia coli (E. coli) k88 and DH5α as type strains, we found significantly increased bacterial attachment to IECs in TPN group compared to sham. By using Caco-2 cells as an IEC model in vitro, we found that functional suppression of P-gp remarkably facilitated bacterial attachment to Caco-2 cells, leading to subsequent disruption of intestinal barrier function. Of note, Occludin was significantly downregulated by bacterial attachment when P-gp was functionally suppressed. Mechanistically, changes on Occludin were attributed to enhanced protein degradation instead of suppressed protein translation. Despite the half-life of Occludin protein being unchanged by DH5α treatment alone, it was decreased by about 40% when P-gp was simultaneously suppressed. Taken together, our findings revealed that early downregulation of intestinal P-gp under TPN may be a potential therapeutic target to prevent the development of barrier dysfunction.

Clinical efficacy of Da Vinci robot-assisted radical resection for right colon cancer

Objective To investigate the clinical efficacy of Da Vinci robot-assisted radical resection for right colon cancer. Methods The retrospective cross-sectional study was conducted. The clinical data of 85 patients with right colon cancer who were admitted to the First Hospital Affiliated to Army Medical University from August 2013 to February 2019 were collected. There were 56 males and 29 females, aged from 29 to 84 years, with an average age of 60 years. All patients underwent Da Vinci robot-assisted radical resection of right colon cancer, named right hemicolon D3 + complete mesocolic excision, and received infection prevention and total parenteral nutrition treatment after surgery. According to clinical pathological staging of guideline issued by National Comprehensive Cancer Network, patients underwent postoperative chemotherapy within 1 year after surgery. Observation indicators: (1) treatment status; (2) postoperative pathological examination; (3) follow-up. Follow-up was conducted using outpatient examination, telephone interview and mail every 3 months within 1 year after surgery, every 6 months from 1 to 3 years after surgery, and once a year from 3 to 5 years after surgery up to March 2019. The postoperative tumor metastasis and survival of patients were obtained. Measurement data with normal distribution were represented as Mean±SD, and measurement data with skewed distribution were described as M (range). Count data were expressed as absolute number. Survival rates were calculated using life-table method. Results (1) Treatment status: 85 patients underwent Da Vinci robot-assisted right hemicolon D3 + complete mesocolic excision successfully. The operation time, volume of intraoperative blood loss, time for postoperative out-of-bed activities, time to recovery of gastrointestinal function, time to liquid diet intake were (178±28)minutes, (85±33)mL, (2.9±1.8)days, (3.1± 2.7)days, (3.9±1.9)days, respectively. There was no perioperative death. Eleven patients had postoperative complications including 5 of anastomotic leakage, 2 of anastomotic bleeding, 2 of pulmonary infection, 1 of gastric emptying disorder and 1 of incomplete intestinal obstruction; they were cured and discharged after conservative treatment. All the 85 patients received postoperative infection prevention and total parenteral nutrition support, including 64 receiving systemic intravenous chemotherapy with 6-8 cycles of FOLFOX or XELOX, 7 receiving 6-8 cycles of oral capecitabine, and 14 receiving no chemotherapy. (2) Postoperative pathological examination: the number of harvested lymph nodes was 20±11 and 25 had lymph node metastasis. The length of proximal and distal cutting edge of the specimens was (16±5)cm and (9±5)cm, respectively. There was no cancerous cell on the cutting edge. High-differentiated adenocarcinoma, moderate-differentiated adenocarcinoma, moderate-differentiated tubular adenocarcinoma, low-differentiated adenocarcinoma, mucinous adenocarcinoma, tubular combined with mucinous adenocarcinoma were detected in 2, 40, 14, 16, 9, 4 patients, respectively. There were 8, 28, 24, 5, 12, 8 patients inⅠstage, ⅡA stage, ⅡB stage, ⅡC stage, ⅢB stage, ⅢC stage of TNM staging, respectively. (3) Follow-up: 85 patients were followed up for 1-67 months, with a median follow-up time of 19 months. During the follow-up, 1 of 85 patients had liver metastasis at 14 months after surgery and had survived after radiofrequency ablation treatment up to the end of follow-up. Three cases died of abdominal tumor metastases, 1 of which inⅡC stage died at 32 months after surgery, 1 in ⅢB stage died at 4 months after surgery and 1 in ⅢB stage died at 16 months after surgery. The 1-, 3-year overall survival rates were 97.1% and 94.0%, respectively. Conclusion Da Vinci robot-assisted radical resection of right colon cancer is safe and feasible, with good short- and long-term outcomes. Key words: Colon neoplasms; Right colon cancer; Right hemicolectomy; Da Vinci robotic surgical system; Prognosis

Total parenteral nutrition versus early enteral nutrition after cystectomy: a meta-analysis of postoperative outcomes.

This study aimed to systematically summarize and analyze the current evidence regarding the effect of total parenteral nutrition (TPN) versus early enteral nutrition (EEN) on postoperative outcomes of cystectomy. A comprehensive search of online databases was conducted to identify comparative studies on the postoperative outcomes of patients receiving TPN and EEN after cystectomy. Our subsequent meta-analysis followed the PRISMA Protocol and the Cochrane Handbook. Five studies with 556 participants were included for meta-analysis. EEN was shown to have a significant effect on reducing the overall complications (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.37-0.75, P < 0.01) and infectious complications (OR 0.32, 95% CI 0.21-0.49, P < 0.01) compared with TPN. Additionally, EEN saved €614-€3120 in costs compared to TPN. There were no significant differences between TPN and EEN groups regarding mortality rate (OR 0.47, 95% CI 0.06-3.51, P = 0.46), the incidence of postoperative ileus (OR 0.90, 95% CI 0.55-1.47, P = 0.68), length of hospital stay (mean difference (MD) 2.12, 95% CI - 0.15 to 4.40, P = 0.07), or time to resume a full diet (MD 1.31, 95% CI - 1.15 to 3.77, P = 0.30). EEN was found to have a significant effect on reducing infectious complications and costs compared with TPN treatment after cystectomy. Remarkably, EEN had no significant impact on mortality incidence, postoperative ileus, length of hospital stay, or the time to resumption of full diet.

Comment: Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft.

To the Editor, We read with interest the paper titled “Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft” by Yankol et al. (1). In this case report, the authors describe a successful treatment of a retrohepatic vena cava leiomyosarcoma with resection and polytetrafluoroethylene vascular graft reconstruction. As mentioned in the manuscript surgical resection with negative margins is the gold standard treatment. But after resection, in conjunction with inferior vena cava (IVC) reconstruction options, there also stands another choice which is ligation without reconstruction, which is not discussed in the manuscript. Regarding to this case report, we aimed to present a patient (S.O,prot:806/59,F) from our clinic to whom we performed segmented IVC resection and ligation for diagnosed level 2 vena cava leiomyosarcoma. IVC was ligated above aortoiliac bifurcation and below renal veins. Because of the high graft thrombosis risk this approach was preferred instead of anastomosis. Intermittent pneumatic compression was applied and low dose fractioned heparin was given at therapeutic dosage in order to protect from deep venous thrombosis risk and lower-extremity edema. On postoperative day 3, the patient had underwent a second laparotomy because of intraabdominal bleeding. Perioperative exploration revealed an oozing type bleeding from the proximal caval stump. After hemostasis the patient sent to intensive care unit for close follow-up. On postoperative day 8, chylous drainage was encountered and oral feeding was stopped following total parenteral nutrition (TPN) support. 2 weeks after TPN treatment the drainage was turned to serous character and oral feeding was restarted with abolishment of TPN support. Finally the patient was discharged with compression stocking and 5-mg. coumadin tb./day orally one month after surgery and she did not suffer from renal failure or lower extremity edema during her hospitalization. Pathologic findings revealed a grade 2 leomyosarcoma with negative margins. Immunohistochemistry panel showed that SMA: (+), Desmin: (+), S-100: (−) CD117: (−) Ki-67 index: 30%. Six cycles of chemotherapy was given to the patient following discharge from our clinic. Now the patient is on postoperative 8th month and there is no documented recurrence or metastasis. The proper technique following IVC resection in the literature is lacking. Caval reconstruction is associated with longer operative time and has its own morbidity and mortality rates. On the other hand in the absence of sufficient collateral venous flow or in cases of interruption of vital organ vasculature, it is necessary to make a vascular reconstruction (2). Daylami et al. (3) claimed in their paper that reconstruction of the IVC was not necessary for resection of tumors below the level of the hepatic veins in most if not all cases. They also mentioned lower-extremity edema and acute renal failure as an albeit transient and early postoperative complication. According to their series with 6 patients, 2 of them developed chylous leak and 1 of them was treated with dietary modification and percutaneous drainage and the other with a Denver shunt. We wonder if the authors have checked the patency of graft during follow-up because as Hirohashi et al. (4) suggested in their case report, thrombosis may occur as a late complication in an inferior vena caval graft. In conclusion, we believe that whenever possible, primary IVC resection without reconstruction in the management of lower IVC leiomyosarcoma should be preferred due to its benefits by means of shorter operation time and acceptable morbidity and mortality rates.

Total parenteral nutrition treatment efficacy in adolescent eating disorders.

Management of adolescent patients with severe eating disorders who refuse treatment for weight loss is complicated. Nutritional rehabilitation is most important during the growth period; thus, strong support in the form of total parenteral nutrition (TPN) as soon as possible is necessary in severe cases. No studies involving detailed, long-term follow up have evaluated biochemical markers and gonadotropin in patients undergoing TPN treatment. Twenty-five adolescent female patients admitted to hospital received TPN immediately, and biochemical marker and gonadotropin levels were measured and analyzed. If subsequent weight gain was observed, TPN treatment was gradually reduced and stopped. No patients dropped out of the study. A significant increase in weight was observed during hospitalization (average, 8.0 kg). Under this treatment, serum total bilirubin was significantly decreased at 3 months, total cholesterol was significantly decreased at 2 months, and alkaline phosphatase (ALP) was significantly increased at 3 and 6 months. Follicle-stimulating hormone response significantly preceded both luteinizing hormone response and appetite recovery. After this treatment, nine of the 25 patients were readmitted for recurrence of appetite loss. Two patients required additional TPN treatment, but seven immediately recovered their appetite after hospitalization without TPN treatment. Bodyweight gain per day was significantly lower and ALP on admission was significantly higher in patients with than without recurrence. Most patients had a remarkable recovery of appetite without refusal behaviors and without evidence of malnutrition after admission. Nutrition maintenance with TPN support is particularly important during the growth period.

Ultrashort Bowel Syndrome: long-term survival without Parenteral Nutrition

ABSTRACTShort Bowel Syndrome (SBS) is a condition in which nutrients are not absorbed (malabsorption) because a large part of the small intestine is missing or has been surgically removed, developing an Intestinal Failure (IF), that is defined as a loss of absorptive capacity secondary to obstruction, dysmotility, surgical resection, congenital defect, or mucosal disease resulting in chronic diarrhea, dehydration, electrolyte abnormalities, micronutrient imbalance, and malnutrition. (1)The long-term survival without parenteral nutrition in patients with the diagnosis of ultrashort bowel syndrome is difficult.This is a case, first reported in the country, of a 63 years old woman with ultrashort bowel syndrome who after three abdominal surgeries was left with only about 35 cm of small intestine with a jejune-transverse anastomosis. During the first surgery the right colon was removed. From the beginning she received Total Parenteral Nutrition (TPN) lasting about three months, at which time she presented a serious reaction after which she refused further TPN treatment. She lived with oral feeding including nutritional supplements for almost five years, and one significant complication,diarrhea, was managed with loperamida and octreotride.

Risk Factors for Systemic Candida Infections in Pediatric Small Bowel Transplant Recipients

Fungal infections are an important cause of morbidity and mortality after small bowel transplantation (SBT). Little information about risk factors for Candida infections in pediatric SBT is available. We performed a 1:1 matched retrospective case-control study including 23 Candida culture-positive patients (cases) and 23 culture-negative patients (controls), matched based on age and time of transplantation. Patients' characteristics were compared using Wilcoxon rank-sum, χ, or Fisher exact tests. McNemar test was used to assess discordance between pretransplant and posttransplant fungemia. Univariate and multivariable conditional logistic regression analyses were performed to identify risk factors. The median age of the group was 1.87 years (range, 0.87-17.60); 59% patients were male. Within 1 month before transplant, 8.7% cases had fungemia and within 1-6 months before transplant, 30.4% cases had fungemia, compared with 69.6% within the 12 months after transplantation (P = 0.0001 and P = 0.02). By univariate analysis, total parenteral nutrition (TPN) (odds ratio [OR], 17.0 [95% confidence interval: 2.12, 2198]; P = 0.003) and antibiotic administration (OR, 18.99 [2.42, 2449]; P = 0.002) were risk factors for fungal infections. By multivariable analysis, both remained independent risk factors (TPN: OR, 10.86 [1.23, 1425], P = 0.03; antibiotic administration: OR, 12.83 [1.52, 1672], P = 0.01). Fungemia was significantly more frequent after SBT than before transplantation. Patients receiving TPN and antibiotic treatment had, respectively, 11 and 13 times higher risk of developing Candida infections after SBT.