[Preoperative cognitive function in very old patients : Influence on the complication rate and length of hospitalization]. / Präoperative kognitive Funktion hochbetagter Patienten : Einfluss auf die Komplikationsrate und die Krankenhausverweildauer.

BACKGROUND: Gastrointestinal cancer is a frequent diagnosis in older patients. A curative resection, possibly in combination with radiotherapy and/or chemotherapy, is the standard therapy. The advanced age of the patients with an increasing number of comorbidities and often the presence of cognitive impairment represents a high risk for perioperative complications and a longer stay in hospital. The challenge in the clinical routine is to recognize a cognitive impairment in older patients and to prepare these patients for the operative intervention in the best possible way. OBJECTIVE: This retrospective analysis was carried out to find out whether preoperative cognitive impairment is a prognostic factor for the postoperative outcome. METHODS: In patients over the age of 75 years who were prepared for abdominal surgery of gastrointestinal cancer in the preoperative consultation, the mini mental state examination (MMSE) and the clock test were carried out. The results of the tests were retrospectively compared with the complication rate and the duration of hospital stay. RESULTS: Low MMSE values were significantly associated with the complication rate and the development of a severe complication (Clavien-Dindo grade ≥ 3a). A cut-off value of 24 points in the MMSE was predictive for the development of complications and a longer hospital stay. The age of the patients was not associated with the MMSE. CONCLUSION: Cognitive impairment is an important prognostic factor for the development of perioperative complications and the duration of the hospital stay in patients undergoing extensive abdominal surgery for gastrointestinal cancer. Therefore, a preoperative assessment, for example with the MMSE, is recommended in order to identify high-risk patients.

[Special situations of preconditioning and prehabilitation in oncological visceral surgery]. / Spezialsituationen der Präkonditionierung und Prähabilitation in der onkologischen Viszeralchirurgie.

BACKGROUND: Prehabilitation prior to complex visceral oncological surgery is playing an increasingly important role. OBJECTIVE: The aim of this review article is to present special situations of preconditioning in visceral oncological patient cohorts. The following conditions were defined as special situations with subsequently increased risk profile: cardiopulmonary comorbidities, geriatric patients, neoadjuvant therapy and simultaneous fatigue. MATERIAL AND METHODS: A selective literature review based on a search in the electronic databases MEDLINE, PubMed, Cochrane Library and the International Standard Randomization Controlled Trial Number (ISRCTN) was performed. RESULTS: The identification of high-risk patients is an essential part of the preoperative evaluation conducted by the anesthesiologist prior to surgery. The cardiovascular and the pulmonary risk profile are determined by means of prediction indices evaluating patient-specific and surgery-related risk factors. The increased use of new oral anticoagulants and dual platelet aggregation inhibition requires individualized treatment strategies. Numerous studies have shown clinically relevant effects of exercise therapy interventions throughout all phases of oncological treatment. In addition to positive effects on therapy-associated side effects, sport can also counteract the effects of sedentary behavior in cancer patients and improve the health-related quality of life. The effectiveness of sport and exercise therapies as well as psychological interventions in oncological patients with fatigue (CRF) is broad, with important components being motivation and compliance. DISCUSSION: In high-risk patients an interdisciplinary approach to planning and conduction of prehabilitation is essential for the early detection and optimization of perioperative risk factors and potential complications. The aim is faster recovery, reduced morbidity and mortality and the possibility to improve long-term survival and quality of life.

[Preconditioning prior to visceral oncological surgery : A paradigm shift in visceral surgery?] / Präkonditionierung vor viszeralonkologischen Operationen : Ein Paradigmenwechsel in der Viszeralchirurgie?

BACKGROUND: Postoperative complications after complex visceral oncological surgery can lead to substantial impairment of patients. In addition, preoperative physical performance and the severity of postoperative complications determine the long-term recovery process of physical function. Therefore, preconditioning in the preoperative period should be an important part of the preoperative/neoadjuvant treatment. OBJECTIVE: The aim of this article is a critical appraisal of current concepts of prehabilitation as well as their development potential and applicability in visceral surgery. MATERIAL AND METHODS: Based on a selective literature review, current studies and implemented concepts are presented and therapy algorithms are provided. RESULTS: This study differs in primary outcome, design and temporal framework of the intervention. The study results showed positive effects of an active increase in physical fitness in the preoperative period with respect to the quality of life, convalescence and postoperative pulmonary complication rate. DISCUSSION: In addition to the assessment of the individual risk of complications by means of spiroergometry, a targeted nutrition and exercise program can increase the individual performance level prior to visceral surgery and, thus, influence the postoperative risk of complications. The performance should be understood as a modifiable risk factor, which can also be positively influenced in the preoperative phase, even in a short time period. Individual preoperative care optimizes the physical and psychological situation of patients. To ensure the required individual care, approaches must be created and pursued, which can be implemented in a decentralized way.

ESPEN expert group recommendations for action against cancer-related malnutrition.

Patients with cancer are at particularly high risk for malnutrition because both the disease and its treatments threaten their nutritional status. Yet cancer-related nutritional risk is sometimes overlooked or under-treated by clinicians, patients, and their families. The European Society for Clinical Nutrition and Metabolism (ESPEN) recently published evidence-based guidelines for nutritional care in patients with cancer. In further support of these guidelines, an ESPEN oncology expert group met for a Cancer and Nutrition Workshop in Berlin on October 24 and 25, 2016. The group examined the causes and consequences of cancer-related malnutrition, reviewed treatment approaches currently available, and built the rationale and impetus for clinicians involved with care of patients with cancer to take actions that facilitate nutrition support in practice. The content of this position paper is based on presentations and discussions at the Berlin meeting. The expert group emphasized 3 key steps to update nutritional care for people with cancer: (1) screen all patients with cancer for nutritional risk early in the course of their care, regardless of body mass index and weight history; (2) expand nutrition-related assessment practices to include measures of anorexia, body composition, inflammatory biomarkers, resting energy expenditure, and physical function; (3) use multimodal nutritional interventions with individualized plans, including care focused on increasing nutritional intake, lessening inflammation and hypermetabolic stress, and increasing physical activity.

[Impact of perioperative nutritional therapy on risk and complication management in patients undergoing esophagectomy for cancer]. / Bedeutung der perioperativen Ernährungstherapie beim Risiko- und Komplikationsmanagement von Patienten mit Ösophaguskarzinom.

Esophagectomy is considered to be a high risk procedure regarding postoperative morbidity and mortality. Therefore, in Germany, these operations are limited to hospitals fulfilling a minimum quantity. This systematic review focuses on risk and complication management regarding the impact of perioperative nutritional therapy, including the recent S3-guideline recommendations and comments of the German Working Group of Medical Societies (AWMF) which were established with contributions from the authors.

[Clinical nutrition in surgery. Guidelines of the German Society for Nutritional Medicine]. / Klinische Ernährung in der Chirurgie. S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin e. V.

BACKGROUND: While enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications. METHODS: Existing guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Ärztliches Zentrum für Qualität in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended. RESULTS AND DISCUSSION: The working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point). CONCLUSION: Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

[Endoscopic and surgical procedures for enteral nutrition]. / Endoskopische und chirurgische Techniken zur enteralen Ernährung.

Standardized management of oncology patients necessarily includes screening for nutritional risk. Weight loss of > 5 kg within 3 months and diminished food intake are warning signals even in overweight patients. In case oral nutrition is neither adequate nor feasible even by fortification or oral nutritional supplements, the implantation of a percutaneous endoscopic gastrostomy (PEG) or fine needle catheter jejunostomy (FNCJ) offers enteral access for long-term nutritional support. Although the indications derive from fulfilling caloric needs, endoscopic or operative measures are not considered to be an urgent or even emergency measure. The endoscopist or surgeon should be fully aware and informed of the indications and make a personal assessment of the situation. The implantation of a feeding tube requires informed consent of the patient or legal surrogates. The review summarizes recent indications, technical problems and complications.

Co-morbid mental health conditions in cancer patients at working age--prevalence, risk profiles, and care uptake.

OBJECTIVE: This study examined the prevalence of mental health conditions in cancer patients, the role of socioeconomic position in relation to that, and the use of professional mental health care. METHODS: Prospective cohort with measurements at the beginning of inpatient treatment (baseline) and 3, 9, and 15 months after baseline using structured clinical interviews based on DSM-IV, questionnaires, and medical records. RESULTS: At baseline, 149 out of 502 cancer patients (30%) were diagnosed with a mental health condition. Prevalence was associated with unemployment (odds ratio [OR] 2.0), fatigue (OR 1.9), and pain (OR 1.7). Of those with mental health conditions, 9% saw a psychotherapist within 3 months of the diagnosis, 19% after 9 months, and 11% after 15 months. Mental health care use was higher in patients with children ≤18 years (OR 3.3) and somatic co-morbidity (OR 2.6). There was no evidence for an effect of sex on the use of mental health care. CONCLUSION: Few cancer patients with psychiatric disorders receive professional mental health care early enough. If patients are unemployed or if they suffer from fatigue or pain, special attention should be paid because the risk of having a mental health condition is increased in these patients.

Glutamine and alanine-induced differential expression of intracellular IL-6, IL-8, and TNF-α in LPS-stimulated monocytes in human whole-blood.

To investigate the effects of the commonly-used immunomodulators l-glutamine, l-alanine, and the combination of both l-alanyl-l-glutamine (Dipeptamin(®)) on intracellular expression of IL-6, IL-8, and TNF-α during endotoxemia, lipopolysaccharide (LPS)-stimulated human monocytes in a whole blood system were investigated by flow cytometry. Whole blood of twenty-seven healthy volunteers was stimulated with LPS and incubated with three different amino acid solutions (1. l-glutamine, 2. l-alanine, 3. l-alanyl-l-glutamine, each concentration 2 mM, 5 mM, incubation time 3 h). CD14(+) monocytes were phenotyped in whole-blood and intracellular expression of cytokines was assessed by flow cytometry. Our investigations showed for the first time in whole blood probes, imitating best physiologically present cellular interactions, that l-glutamine caused a dose-independent inhibitory effect on IL-6 and TNF-α production in human monocytes stimulated with LPS. However, l-alanine had contrary effects on IL-6 expression, significantly upregulating expression of IL-6 in LPS-treated monocytes. The impact of l-alanine on the expression of TNF-α was comparable with glutamine. Neither amino acid was able to affect IL-8 production in LPS-stimulated monocytes. The combination of both did not influence significantly IL-6 and IL-8 expression in monocytes during endotoxemia, however strongly reduced TNF-α production. For the regulation of TNF-α, l-glutamine, l-alanine and the combination of both show a congruent and exponentiated downregulating effect during endotoxemia, for the modulation of IL-6, l-glutamine and l-alanine featured opposite regulation leading to a canceling impact of each other when recombining both amino acids.

[Perioperative nutrition - a nationwide web-based survey of German surgery departments]. / Perioperative Ernährung aus Sicht von Chirurgen - Eine deutschlandweite Online-Umfragen.

BACKGROUND: Insufficient nutrition in surgical patients increases perioperative morbidity, mortality, length of stay and therapy costs. Therefore, guidelines declare the integration of nutrition into the overall management as one of the key aspects of perioperative care. This study was conducted to evaluate the current clinical practice of clinical nutrition in surgical departments in Germany. METHODS: In 2009 German Surgical Society (DGCH) members in leading positions were surveyed with a standardised online questionnaire concerning their perioperative nutritional routines in elective surgery. RESULTS: From the addressed physicians n = 156 (6.24 %) answered. Of those, 86.9 % consider the nutritional status of their patients. Only 6 % use standardised nutritional screening tools. Short preoperative fasting for solid and liquid food is practiced by 65 % and 40 %, respectively. After the operation, 65 % allow intake of clear fluids on the day of surgery and 78 % initiate solid food on the day of surgery or the first postoperative day. Oral nutritional supplements are given only "sometimes" or "rarely" by 53.9 % of the respondents. CONCLUSION: The low response rate may imply the dilemma that the evidence-based benefit of perioperative nutrition does not meet sufficient interest. Even in case of a positive selection of "pro-nutrition respondents", standardised preoperative malnutrition screening is also rare. Aspects such as shorter perioperative fasting are already practiced more progressively. However, still greater efforts are needed to promote guideline-based clinical nutrition in surgical care in Germany.

[Diverticulitis and indication for surgery--are there new data?]. / Operationsindikation bei Divertikulitis--Gibt es neue Daten?

The treatment in acute diverticulitis has undergone a considerable shift from an offensive to a more restrictive and individual indication for surgery. This review of the very recent literature with special regard to long-term observation of conservatively treated patients clearly shows that surgery is not required in any case of a first episode of severe diverticulitis, but should be recommended in high-risk patients under immunosuppression or chronic renal failure. In all other groups of patients the indication for surgery should be weighed on an individual basis after each episode, again aiming for the laparoscopic procedure. A therapeutic algorithm is proposed according to the Hansen-Stock classification.

Complex fractures of the proximal humerus in the elderly--outcome and complications after locking plate fixation.

Open reduction and internal fixation (ORIF) with locking plates or primary arthroplasty remains a controversial issue in the management of complex proximal humerus fractures. Aim of this study was to evaluate the surgeon- and patient-based outcome of patients older than 65 years who underwent ORIF using locking plate fixation of a 3- or 4-part fracture of the proximal humerus. Twenty-seven patients older than 65 years were treated with locking plate fixation (PHILOS, Fa. Synthes, Umkirch, Germany). At an average follow-up of 44 months, the clinical and the subjective outcome were evaluated, and complications were analyzed. The mean age- and gender-related Constant score was 70% (30­100%) compared with 92% (47­108%) of the contralateral non-injured shoulder. The mean DASH score was 29 points (0­71). Five patients (18.5%) showed clinical signs of an impingement, which was related to malpositioning of the plate in 3 cases. Screw cutout was seen in 22.2% (6 patients). Avascular necrosis of the head or the tubercula was found in 8 patients (29.6%). The revision rate was 29.6%. However, the patients considered the functional status of their shoulder as "good" or "satisfactory." The functional and patient-orientated results of the locking plate fixation of complex displaced proximal humerus fractures in the elderly are comparable to those of primary arthroplasty and minimally invasive treatment. Proper surgical technique (screw length, plate position) is mandatory for reducing the revision rate.

ESPEN Guidelines on Parenteral Nutrition: surgery.

In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18.

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60-80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

Combined automated cell and flow cytometric analysis enables recognition of persistent polyclonal B-cell lymphocytosis (PPBL), a study of 25 patients.

Persistent polyclonal B-cell lymphocytosis (PPBL) is an extremely rare disorder, which occurs almost exclusively in smoking women and is characterized by a lymphocytosis with circulating binucleated lymphocytes. We analyzed 25 PPBL patients with respect to immunophenotype and by adaptive cluster analysis system (ACAS). Furthermore, HLA type, presence of Epstein-Barr virus (EBV) DNA in B cells, and clinical data were evaluated. Overall, the median percentages of B cells in PPBL patients with expression of CD5(dim), CD23(dim), CD25, CD27, and FMC7 were 21%, 38%, 16%, 74%, and 93%. Compared to normal controls, ACAS revealed a subset of nucleic-acid-rich lymphocytes located between the regular lymphocyte and regular monocyte region. Sixteen (64%) of 25 patients carried a HLA DR7 phenotype. Quantitative real-time polymerase chain reaction analysis did not detect relevant amounts of EBV DNA in circulating B cells of any patient. During a median follow-up of 5 years, a single patient developed lymphoplasmacytic lymphoma. The abnormal morphology and frequent, albeit dim, expression of CD5 and CD23 in PPBL may result in erratic diagnostic assignment of this benign disorder. However, incorporation of immunophenotyping and ACAS into the diagnostic algorithm allows recognition of PPBL in routine analysis and its differentiation from malignant B cell lymphoproliferative diseases. We found that an infection of a significant percentage of PPBL cells by EBV is unlikely. The observation of malignant lymphoma in a single patient implicates that evolution into a clonal malignant transformation may occasionally occur in PPBL.