Preoperative Nutritional Optimization of the Oncology Patient: A Scoping Review.

BACKGROUND: Malnutrition is common among patients with cancer and is a known risk factor for poor postoperative outcomes; however, preoperative nutritional optimization guidelines are lacking in this high-risk population. The objective of this study was to review the evidence regarding preoperative nutritional optimization of patients undergoing general surgical operations for the treatment of cancer. METHODS: A literature search was performed across the Ovid (MEDLINE), Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCOhost), and Web of Science (Clarivate) databases. Eligible studies included randomized clinical trials, observational studies, reviews, and meta-analyses published between 2010 and 2020. Included studies evaluated clinical outcomes after preoperative nutritional interventions among adult patients undergoing surgery for gastrointestinal cancer. Data extraction was performed using a template developed and tested by the study team. RESULTS: A total of 5,505 publications were identified, of which 69 studies were included for data synthesis after screening and full text review. These studies evaluated preoperative nutritional counseling, protein-calorie supplementation, immunonutrition supplementation, and probiotic or symbiotic supplementation. CONCLUSIONS: Preoperative nutritional counseling and immunonutrition supplementation should be considered for patients undergoing surgical treatment of gastrointestinal malignancy. For malnourished patients, protein-calorie supplementation should be considered, and for patients undergoing colorectal cancer surgery, probiotics or symbiotic supplementation should be considered.

Long-term functional and echocardiographic assessment after penetrating cardiac injury: 5-year follow-up results.

BACKGROUND: There is almost no data describing the long-term functional outcome of patients after penetrating cardiac injury. METHODS: A retrospective study at a Level I trauma center from 2000 to 2009. RESULTS: Sixty-three patients had penetrating cardiac injuries from 28 stabbings and 35 gunshots. Men comprised 89% (56) of the patients. Overall, there were 21 survivors (33%) and 42 died in the emergency room or perioperative period. The mean age did not significantly differ between survivors (36 years ± 12 years) compared with those who died (30 years ± 11 years; p=0.07). There was an increased chance of survival after being stabbed compared with being shot (17 patients vs. 4 patients; odds ratio=12; p=0.002). Thirteen (62%) had injuries to the right ventricle only. Three patients died during follow-up: one from lung cancer and two other patients died from myocardial infarctions, one 9 years later at the age of 45 years and the other 8 years later at the age of 55 years. The survivors had functional follow-up evaluations from 2 months to 114 months (median, 71; interquartile range, 34-92 months) and echocardiographic follow-up from 2 months to 107 months (median, 64; interquartile range, 31-84 months) after their injuries. Functionally, all patients were in NYHA class 1 status, except one patient in class II who was 54 years old and had a mild exertional limitation. The previously injured area could only be identified by echocardiogram in one patient who had a patch repair of a ventricular septal defect (VSD). The mean ejection fraction improved over time from a mean of 51% ± 8% in the immediate postoperative period to 60% ± 9% after a mean follow-up of 59 months (p=0.01). After surgery, 43% of patients had a mild to moderate pericardial effusion; however, the long-term follow-up studies showed that all these had resolved. Wall motion abnormalities occurred in 33% of patients in the immediate postoperative period and, again, all these resolved during long-term follow-up. CONCLUSIONS: Patients who survive penetrating cardiac injuries, without coronary arterial or valvular disruption, have an excellent long-term functional outcome with minimal subsequent cardiac morbidity related to the injury. Full physiologic recovery and normal cardiac function can be expected if the patient survives.

Evaluation of vascular injury in penetrating extremity trauma: angiographers stay home.

The debate over the use of diagnostic angiography (DA) to exclude arterial injury in penetrating extremity trauma (PET) continues. This review evaluates our current protocol for PET and identifies indications for DA. Patients presenting to our urban Level I trauma center between January 1997 and September 2000 with PET were included. Demographic data, emergency department (ED) course, and patient follow-up were reviewed. ED evaluation directed by physical examination (PE) included Doppler pressure indices (DPI) and DA if indicated. A total of 538 patients had PET injuries. Twenty (4%) patients with hard signs of vascular injury were taken to the operating room. Ninety-one (17%) patients without vascular compromise underwent operative procedures or were admitted for other injuries. One hundred twenty-three (23%) patients with nonproximity wounds were discharged. Four DAs were performed for abnormal DPI with no change in management. Three hundred patients with a negative PE and normal DPI were discharged from the ED. Follow-up was available on 51 per cent of these patients (range 1-49 months) with no missed injuries identified. We conclude that PE with DPI is an appropriate way to identify significant vascular injuries from PET. Patients with normal PE and DPI can be safely discharged. DA is only indicated for asymptomatic patients with abnormal DPI.

Selective management of penetrating truncal injuries: is emergency department discharge a reasonable goal?

We undertook this retrospective review to examine the appropriateness of a protocol for the selective emergency department (ED) workup of asymptomatic penetrating truncal injuries. Records of consecutive patients presenting to our urban Level I trauma center with penetrating truncal injuries between January 1, 1997 and September 2000 were reviewed. Data obtained included: patient demographics, ED workup, ED disposition, complications, and follow-up. Selective ED workup included hospital triple-contrast CT, admission for observation, and local wound exploration for selected anterior abdominal stab wounds. Four hundred fifty-five patients presented with penetrating truncal wounds during the study period. One hundred ninety-four patients were taken directly to the operating room, 136 were discharged based solely on physical examination and plain radiographs, 18 were admitted for observation without ED workup, and 107 had selective ED workup. Sixty-two patients (58% of those selectively worked up) were discharged home after negative ED workup, 18 were managed operatively, and 27 were managed nonoperatively. There were two missed injuries that were later identified and managed with no complications. Follow-up was available on 66 per cent of ED workup patients (range 1-42 months). We conclude that selective management of certain penetrating truncal injuries appears appropriate. Patients having a negative selective ED workup can be safely discharged thereby avoiding the cost and resource utilization associated with hospital admission.

Indicators for tracheostomy in patients with traumatic brain injury.

Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived >7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3+/-7.0 days). Logistic regression analysis identified presenting GCS < or =8, ISS > or =25, and ventilator days >7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days (P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS > or =9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS < or =8, an ISS > or =25, and ventilator days >7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.

Use of human acellular dermal matrix in complex and contaminated abdominal wall reconstructions.

BACKGROUND: Few good surgical options exist for the repair of complex anterior abdominal wall defects, particularly those in which bacterial contamination is present. The use of prosthetic mesh increases complication rates when the mesh is placed directly over viscera or when the surgical site is contaminated from a pre-existing infection or enteric spillage. The use of an acellular dermal matrix (ADM), which becomes vascularized and remodeled into autologous tissue after implantation, may represent a low-morbidity alternative to prosthetic mesh products in these complex settings. This study examined our experience with ADM in the reconstruction of contaminated abdominal wall defects. METHODS: Patients undergoing abdominal wall reconstructions in the face of contamination with ADM between May 2002 and December 2005 underwent retrospective chart review. Demographics, indications for ADM placement, plane of implantation, complications, and follow-up data were evaluated. RESULTS: Sixty-seven patients were identified. The indications for ADM placement included incarcerated hernias, infected mesh, fistulae, early/delayed abdominal wall reconstruction after intra-abdominal catastrophe or trauma, dehiscence/evisceration, and spillage of enteric contents. The ADM was positioned either above the fascia or beneath the fascia or was sutured directly to the fascial edges. Sixteen patients developed a wound infection; the majority of these were superficial and required only local wound care, 5 required some further surgical intervention, and 2 required removal of the ADM. Twelve patients developed recurrent hernias. The mean follow-up time for the study population was 10.6 months. CONCLUSIONS: ADM can be used safely and effectively as an alternative to traditional mesh products for abdominal wall reconstructions, even in the setting of contaminated fields.

Limb loss following lower extremity arterial trauma: what can be done proactively?

We performed a retrospective review of patients admitted to two Level I trauma centres over a 15-year period with arterial injuries (excluding primary amputations). Preoperative factors analysed included mechanism of injury, site and type of arterial and venous injury and repair, time to operating room, initial blood pressure, evidence of ipsilateral limb fracture and/or extensive tissue damage, status of preoperative pulses and angiographic data. One hundred and fifty-one arterial injuries were treated (80 penetrating). Overall mortality was 10 (6.6%) and limb loss 16 (10.6%). Only two factors that might possibly be modified by specific interventions were noted. The incidence of limb loss was higher in patients who developed compartment syndrome (41% versus 7% without, P=0.003) and in those who did not receive intra- or immediately postoperative anticoagulation (15% without versus 3% with, P=0.02). Unfortunately, no factor was found that reliably predicted the risk of compartment syndrome. In addition, patients who did not receive peri-operative anticoagulation were more severely injured than those that did were. Despite this, there were no bleeding complications associated with anticoagulation. These findings suggest that the primary interventions that may improve limb salvage include liberal use of fasciotomy (recognising that any patient may require this) as well as early use of anticoagulation.