Home visits as part of a new care pathway (iAID) to improve quality of care and quality of life in ostomy patients: a cluster-randomized stepped-wedge trial.

AIM: Morbidity in patients with an ostomy is high. A new care pathway, including perioperative home visits by enterostomal therapists, was studied to assess whether more elaborate education and closer guidance could reduce stoma-related complications and improve quality of life (QoL), at acceptable cost. METHOD: Patients requiring an ileostomy or colostomy, for any inflammatory or malignant bowel disease, were included in a 15-centre cluster-randomized 'stepped-wedge' study. Primary outcomes were stoma-related complications and QoL, measured using the Stoma-QOL, 3 months after surgery. Secondary outcomes included costs of care. RESULTS: The standard pathway (SP) was followed by 113 patients and the new pathway (NP) by 105 patients. Although the overall number of stoma-related complications was similar in both groups (SP 156, NP 150), the proportion of patients experiencing one or more stoma-related complications was significantly higher in the NP (72% vs 84%, risk difference 12%; 95% CI: 0.3-23.3%). Although in the NP more patients had stoma-related complications, QoL scores were significantly better (P < 0.001). In the SP more patients required extra care at home for their ostomy than in the NP (60.6% vs 33.7%, respectively; risk difference 26.9%, 95% CI: 13.5-40.4%). Stoma revision was done more often in the SP (n = 11) than in the NP (n = 2). Total costs in the SP did not differ significantly from the NP. CONCLUSION: The NP did not reduce the number of stoma-related complications but did lead to improved quality of care and life, against similar costs. Based on these results the NP, including perioperative home visits by an enterostomal therapist, can be recommended.

A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer.

BACKGROUND: Rectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5 %. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5-20 %) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients. METHODS/STUDY DESIGN: In this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients. DISCUSSION: The results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery. TRIAL REGISTRATION: NCT02371304 , registration date: February 2015.

Conversion of failed laparoscopic adjustable gastric banding to Roux-en-Y gastric bypass is safe as a single-step procedure.

BACKGROUND: Several different procedures have been proposed as a revisional procedure for treatment of failed laparoscopic adjustable gastric banding (LAGB). Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been advocated as the procedure of choice for revision. In this study, we compare the single- and two-step approaches for the revision of failed LAGB to LRYGB. METHOD: All patients who underwent bariatric surgery were included in a prospective database. For the purpose of this study, patients who underwent revisional surgery from LAGB to LRYGB were selected. Records for individual patients were completed by data review. Complication rates and weight development were recorded until 2 years postoperatively. Data were compared between both procedures and with complications rates reported in literature. RESULTS: Revisional gastric bypass surgery was performed in 257 patients. This was done as a planned single-step procedure in 220 (86 %) patients without indications for acute band removal and in 32 patients as a planned 2 step procedure. Five patients were planned as a single-step procedure but were intraoperatively converted to a 2-step procedure based on poor pouch tissue quality. No postoperative mortality occurred in both groups. No differences in early major morbidity and stricture formation were seen between the two groups. Gastric ulceration was more frequently observed after 2-steps procedure (8.5 vs. 1.7 %, p < 0.05). In comparison with data reported in literature, the single-step procedure had similar to lower complication rates. Percentage excess weight loss two years after revisional gastric bypass procedure was, respectively, 53 versus 67 % (p = 0.147) for single- and two-step procedure. CONCLUSION: In patients without indications for acute band removal, the planned conversion of gastric banding to Roux-Y gastric bypass can be safely done in a single-step procedure without increase in morbidity and no difference in postoperative weight loss.

High 1-year complication rate after anterior resection for rectal cancer.

BACKGROUND: Surgical options after anterior resection for rectal cancer include a primary anastomosis, anastomosis with a defunctioning stoma, and an end colostomy. This study describes short-term and 1-year outcomes of these different surgical strategies. METHODS: Patients undergoing surgical resection for primary mid and high rectal cancer were retrospectively studied in seven Dutch hospitals with 1-year follow-up. Short-term endpoints were postoperative complications, re-interventions, prolonged hospital stay, and mortality. One-year endpoints were unplanned readmissions and re-interventions, presence of stoma, and mortality. RESULTS: Nineteen percent of 388 included patients received a primary anastomosis, 55% an anastomosis with defunctioning stoma, and 27% an end colostomy. Short-term anastomotic leakage was 10% in patients with a primary anastomosis vs. 7% with a defunctioning stoma (P = 0.46). An end colostomy was associated with less severe re-interventions. One-year outcomes showed low morbidity and mortality rates in patients with an anastomosis. Patients with a defunctioning stoma had high (18%) readmissions and re-intervention (12%) rates, mostly due to anastomotic leakage. An end colostomy was associated with unplanned re-interventions due to stoma/abscess problems. During follow-up, there was a 30% increase in patients with an end colostomy. CONCLUSIONS: This study showed a high 1-year morbidity rate after anterior resection for rectal cancer. A defunctioning stoma was associated with a high risk for late complications including anastomotic leakage. An end colostomy is a safe alternative to prevent anastomotic leakage, but stomal problems cannot be ignored. Selecting low-risk patients for an anastomosis may lead to favorable short- and 1-year outcomes.

Effective and efficient learning in the operating theater with intraoperative video-enhanced surgical procedure training.

BACKGROUND: INtraoperative Video Enhanced Surgical procedure Training (INVEST) is a new training method designed to improve the transition from basic skills training in a skills lab to procedural training in the operating theater. Traditionally, the master-apprentice model (MAM) is used for procedural training in the operating theater, but this model lacks uniformity and efficiency at the beginning of the learning curve. This study was designed to investigate the effectiveness and efficiency of INVEST compared to MAM. METHODS: Ten surgical residents with no laparoscopic experience were recruited for a laparoscopic cholecystectomy training curriculum either by the MAM or with INVEST. After a uniform course in basic laparoscopic skills, each trainee performed six cholecystectomies that were digitally recorded. For 14 steps of the procedure, an observer who was blinded for the type of training determined whether the step was performed entirely by the trainee (2 points), partially by the trainee (1 point), or by the supervisor (0 points). Time measurements revealed the total procedure time and the amount of effective procedure time during which the trainee acted as the operating surgeon. Results were compared between both groups. RESULTS: Trainees in the INVEST group were awarded statistically significant more points (115.8 vs. 70.2; p < 0.001) and performed more steps without the interference of the supervisor (46.6 vs. 18.8; p < 0.001). Total procedure time was not lengthened by INVEST, and the part performed by trainees was significantly larger (69.9 vs. 54.1 %; p = 0.004). CONCLUSIONS: INVEST enhances effectiveness and training efficiency for procedural training inside the operating theater without compromising operating theater time efficiency.

The learning effect of intraoperative video-enhanced surgical procedure training.

BACKGROUND: The transition from basic skills training in a skills lab to procedure training in the operating theater using the traditional master-apprentice model (MAM) lacks uniformity and efficiency. When the supervising surgeon performs parts of a procedure, training opportunities are lost. To minimize this intervention by the supervisor and maximize the actual operating time for the trainee, we created a new training method called INtraoperative Video-Enhanced Surgical Training (INVEST). METHODS: Ten surgical residents were trained in laparoscopic cholecystectomy either by the MAM or with INVEST. Each trainee performed six cholecystectomies that were objectively evaluated on an Objective Structured Assessment of Technical Skills (OSATS) global rating scale. Absolute and relative improvements during the training curriculum were compared between the groups. A questionnaire evaluated the trainee's opinion on this new training method. RESULTS: Skill improvement on the OSATS global rating scale was significantly greater for the trainees in the INVEST curriculum compared to the MAM, with mean absolute improvement 32.6 versus 14.0 points and mean relative improvement 59.1 versus 34.6% (P=0.02). CONCLUSION: INVEST significantly enhances technical and procedural skill development during the early learning curve for laparoscopic cholecystectomy. Trainees were positive about the content and the idea of the curriculum.

Interoperative efficiency in minimally invasive surgery suites.

BACKGROUND: Performing minimally invasive surgery (MIS) in a conventional operating room (OR) requires additional specialized equipment otherwise stored outside the OR. Before the procedure, the OR team must collect, prepare, and connect the equipment, then take it away afterward. These extra tasks pose a thread to OR efficiency and may lengthen turnover times. The dedicated MIS suite has permanently installed laparoscopic equipment that is operational on demand. This study presents two experiments that quantify the superior efficiency of the MIS suite in the interoperative period. METHODS: Preoperative setup and postoperative breakdown times in the conventional OR and the MIS suite in an experimental setting and in daily practice were analyzed. In the experimental setting, randomly chosen OR teams simulated the setup and breakdown for a standard laparoscopic cholecystectomy (LC) and a complex laparoscopic sigmoid resection (LS). In the clinical setting, the interoperative period for 66 LCs randomly assigned to the conventional OR or the MIS suite were analyzed. RESULTS: In the experimental setting, the setup and breakdown times were significantly shorter in the MIS suite. The difference between the two types of OR increased for the complex procedure: 2:41 min for the LC (p < 0.001) and 10:47 min for the LS (p < 0.001). In the clinical setting, the setup and breakdown times as a whole were not reduced in the MIS suite. Laparoscopic setup and breakdown times were significantly shorter in the MIS suite (mean difference, 5:39 min; p < 0.001). CONCLUSION: Efficiency during the interoperative period is significantly improved in the MIS suite. The OR nurses' tasks are relieved, which may reduce mental and physical workload and improve job satisfaction and patient safety. Due to simultaneous tasks of other disciplines, an overall turnover time reduction could not be achieved.

Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines.

BACKGROUND: With minimally invasive surgery (MIS), a man-machine environment was brought into the operating room, which created mental and physical challenges for the operating team. The science of ergonomics analyzes these challenges and formulates guidelines for creating a work environment that is safe and comfortable for its operators while effectiveness and efficiency of the process are maintained. This review aimed to formulate the ergonomic challenges related to monitor positioning in MIS. Background and guidelines are formulated for optimal ergonomic monitor positioning within the possibilities of the modern MIS suite, using multiple monitors suspended from the ceiling. METHODS: All evidence-based experimental ergonomic studies conducted in the fields of laparoscopic surgery and applied ergonomics for other professions working with a display were identified by PubMed searches and selected for quality and applicability. Data from ergonomic studies were evaluated in terms of effectiveness and efficiency as well as comfort and safety aspects. Recommendations for individual monitor positioning are formulated to create a personal balance between these two ergonomic aspects. RESULTS: Misalignment in the eye-hand-target axis because of limited freedom in monitor positioning is recognized as an important ergonomic drawback during MIS. Realignment of the eye-hand-target axis improves personal values of comfort and safety as well as procedural values of effectiveness and efficiency. CONCLUSIONS: Monitor position is an important ergonomic factor during MIS. In the horizontal plain, the monitor should be straight in front of each person and aligned with the forearm-instrument motor axis to avoid axial rotation of the spine. In the sagittal plain, the monitor should be positioned lower than eye level to avoid neck extension.

To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands.

BACKGROUND & AIMS: It was shown that patients in the Netherlands remain exposed to unnecessarily prolonged starvation after abdominal surgery. The present study examined whether a structured collaborative effort would help to implement the early start of oral nutrition after colorectal surgery. METHODS: In 2006, twenty-six Dutch hospitals signed up to a "breakthrough project" concerning the implementation of the enhanced recovery after surgery (ERAS) programme with early oral feeding as one of the key elements. Each hospital determined the usual start of food intake by analyzing 50 patients who underwent a colorectal resection in 2004 (n=1126). Subsequently, over the course of one year 861 colorectal surgery patients were treated according to the ERAS programme. The first day that patients were eating before and after the breakthrough project was compared using Kaplan-Meier analyses and Cox regression models. RESULTS: Patients treated according to the ERAS programme were eating 3 days earlier than the patients traditionally treated (p<0.000). Two days after surgery 65% of the ERAS patients were eating normal food versus 7% of the pre-ERAS patients. CONCLUSIONS: The present nationwide collaborative effort was successful in implementing a change towards an early start of oral nutrition after abdominal surgery.

Life and death of the nasogastric tube in elective colonic surgery in the Netherlands.

BACKGROUND & AIMS: There is abundant evidence that the routine use of nasogastric decompression following elective abdominal surgery is ineffective in achieving any goals it is intended for. Nevertheless its use is still standard of care. The aim of the present study was to investigate whether it is possible to ban nasogastric decompression after elective colonic surgery. METHODS: At first baseline measurements concerning elements of perioperative care, including nasogastric tubes, were recorded retrospectively over the year 2004. In 2006-2007 the implementation of a fast-track colonic surgery project was guided by the Dutch Institute for Quality of Healthcare CBO, using Berwick's Breakthrough approach. RESULTS: A total of 2007 patients were enrolled. The baseline measurement showed that the use of nasogastric drainage is still common practice in the Netherlands. 953 patients (88.3%) had a nasogastric tube postoperatively. That tube was removed after a median of 2.5 days (range 1-3 days). After the implementation of the Perioperative Care Breakthrough project the percentage of patients having a nasogastric tube postoperatively dropped to 9.6% (p<0.0001). CONCLUSIONS: Our results show using the Breakthrough Methodology it is possible to eradicate the inappropriate routine use of NG tubes.

Ergonomic assessment of neck posture in the minimally invasive surgery suite during laparoscopic cholecystectomy.

BACKGROUND: With the expanding implementation of minimally invasive surgery, the operating team is confronted with challenges in the field of ergonomics. Visual feedback is derived from a monitor placed outside the operating field. This crossover trial was conducted to evaluate and compare neck posture in relation to monitor position in a dedicated minimally invasive surgery (MIS) suite and a conventional operating room. METHODS: Assessment of the neck was conducted for 16 surgeons, assisting surgeons, and scrub nurses performing a laparoscopic cholecystectomy in both types of operating room. Flexion and rotation of the cervical spine were measured intraoperatively using a video analysis system. A two-question visual analog scale (VAS) questionnaire was used to evaluate posture in relation to the monitor position. RESULTS: Neck rotation was significantly reduced in the MIS suite for the surgeon (p = 0.018) and the assisting surgeon (p < 0.001). Neck flexion was significantly improved in the MIS suite for the surgeon (p < 0.001) and the scrub nurse (p = 0.018). On the questionnaire, the operating room team scored their posture significantly higher in the MIS suite and also indicated fewer musculoskeletal complaints. CONCLUSIONS: The ergonomic quality of the neck posture is significantly improved in the MIS suite for the entire operating room team.

Growth and bone mineralization in children born prematurely.

OBJECTIVE: To study the growth and bone mineralization of children born prematurely. STUDY DESIGN: A cohort of healthy children who were born prematurely with birth weight less than 1.5 kg were compared by weight and height to a national reference. Bone mineral status of preterm infants was compared with children who were born at term gestation. The average follow-up was 7 years. A sample of children who were born prematurely was recalled from an infant nutrition study. Children born at term gestation who had similar body weight for age were recruited from the community. Bone mineral evaluation was conducted in a group of 20 children born prematurely with birth weight less than 1.5 kg and in 15 children born at term gestation. Body weight for age was similar between the groups. All children were born of appropriate size for gestational age at birth. All children had their body weight and height measured. Comparisons for growth assessment status were made with the NHANES III database and published standards. Dietary intakes and food frequency were analyzed. The bone mineral status was measured at two sites, lumbar spine and distal third radius bone. RESULTS: The average age was 7 years, with a range of 5 to 9 years. Compared with the reference population, children who were born prematurely on the average had lower weights, heights and body mass index. Preterm children had a lower lumbar bone mineral content than term children, 12.8+/-3.0 and 14.7+/-2.2 g cm(-1) (P<0.05). The lumbar bone mineral density was lower in the preterm group than in the term group, 0.525+/-0.062 and 0.574+/-0.073 g cm(-2), respectively (P<0.04). Three of the preterm children had a history of fracture whereas none of the term children reported any fractures. CONCLUSION: Children who were born prematurely with birth weights less than 1.5 kg tend to be significantly smaller for age and have lower lumbar spinal bone mineral content and density compared with children born at term gestation.

Prospective evaluation of quality of life and sexual functioning after laparoscopic total mesorectal excision.

PURPOSE: This study was designed to investigate how the quality of life of patients with rectal cancer changes with time after laparoscopic total mesorectal excision. METHODS: Patients completed the Medical Outcomes Study Short Form 36 and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and a colorectal-specific European Organisation for Research and Treatment of Cancer quality of life questionnaire before laparoscopic total mesorectal excision, on discharge from the hospital and at 3, 6, and 12 months postoperatively. Patients were treated by laparoscopic low anterior resection or laparoscopic abdominoperineal resection. RESULTS: Fifty-one patients (mean age, 64 years; 29 males (57 percent)) participated in this study, of whom 38 (75 percent) underwent laparoscopic low anterior resection and 13 (25 percent) laparoscopic abdominoperineal resection. Compared with preoperative scores on the Medical Outcomes Study Short Form 36, patients reported a deterioration in physical functioning (74 vs. 80; P = 0.009), and improved mental functioning (76 vs. 70; P = 0.007) at three months. Improvement in emotional well-being was reported both on the Medical Outcomes Study Short Form 36 (78 vs. 53; P = 0.006) and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (84 vs. 69; P < 0.001). At one year, improvements in global quality of life (82 vs. 68; P = 0.001) and symptoms, such as fatigue (18 vs. 32; P < 0.001), pain (5 vs. 12; P = 0.009), and appetite loss (3 vs. 13; P = 0.01), were reported. Sexual functioning was worse from three months onward until one year after surgery (47 vs. 66; P = 0.004). Patients who underwent low anterior resection experienced less sexual dysfunction than patients after abdominoperineal resection (21 vs. 56; P = 0.004). CONCLUSIONS: One year after laparoscopic total mesorectal excision for rectal cancer, patients reported improvement in some important quality of life outcomes, including global quality of life, despite a decrease in sexual functioning.

Technique for laparoscopic autonomic nerve preserving total mesorectal excision.

With the introduction of total mesorectal excision (TME) for treatment of rectal cancer, the prognosis of patients with rectal cancer is improved. With this better prognosis, there is a growing awareness about the quality of life of patients after rectal carcinoma. Laparoscopic total mesorectal excision (LTME) for rectal cancer offers several advantages in comparison with open total mesorectal excision (OTME), including greater patient comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure. Moreover, laparoscopy allows good exposure of the pelvic cavity because of magnification and good illumination. The laparoscope seems to facilitate pelvic dissection including identification and preservation of critical structures such as the autonomic nervous system. The technique for laparoscopic autonomic nerve preserving total mesorectal excision is reported. A three- or four-port technique is used. Vascular ligation, sharp mesorectal dissection and identification and preservation of the autonomic pelvic nerves are described.

Costs and complications of hospitalizations for children with cerebral palsy.

BACKGROUND: Although many children with cerebral palsy (CP) develop secondary conditions requiring hospitalization, in-patient hospital utilization by this population has not been characterized. OBJECTIVE: To characterize hospitalizations in children with CP and to compare them with hospitalizations of those without CP using a large national data set. METHODS: Analysis of the Healthcare Utilization Project Kid Inpatient Database, a weighted survey of paediatric discharges from US hospitals in 1997. RESULTS: In 1997, 37,000 children with CP were hospitalized, generating charges approaching 600 million dollars. Children with CP demonstrated longer lengths of stay (6.3 vs 4.1 days, p < 0.001), higher total charges (16,024 vs 9952 dollars, p < 0.001), more diagnoses (5.6 vs 3.0, p < 0.001) and more procedures (1.7 vs 1.1, p < 0.001) per admission. Five major diagnostic categories accounted for 83.2% of the discharge diagnoses for children with CP (48.6% for those without CP, p < 0.001). Children with CP were more often transferred to other facilities (p < 0.001) or prescribed home health care (p < 0.001) upon discharge. CONCLUSIONS: Hospitalization of children with CP represents a major expenditure for health care systems. Studies to improve the management of conditions associated with CP could result in better outcomes for children and families and potentially decrease costs associated with hospitalization.

Case-control study of the muscular compartments and osseous strength in neurofibromatosis type 1 using peripheral quantitative computed tomography.

Skeletal anomalies are observed in neurofibromatosis type 1 (NF1), but the pathogenesis is unknown. Given that muscle mass is important in the development of the strength of bone, peripheral quantitative computed tomography (pQCT) was utilized to compare measurements of muscle compartments between NF1 individuals and controls. Forty individuals with NF1 (age 5-18 years) were evaluated. Cross-sectional measurements, at the 66% tibial site, were obtained using pQCT (XCT-2000, Stratec) and variables were compared to controls without NF1 ((age 5-18 years, N=380) using analysis-of-covariance controlling for age, height, Tanner stage, and gender. The NF1 cohort showed decreased total cross-sectional area [p<0.001], decreased muscle plus bone cross-sectional area [p<0.001], decreased muscle cross-sectional area [p<0.001], and decreased Stress Strain Index [p=0.010]. These data indicate that NF1 individuals have decreased muscle cross-sectional area and decreased bone strength than individuals without NF1.

Laparoscopic versus open total mesorectal excision: a case-control study.

BACKGROUND AND AIMS: Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains unproven. The aim of this prospective non-randomised study was to assess the feasibility and short-term outcome of laparoscopic total mesorectal excision (LTME) after 25--30 Gy preoperative radiotherapy and to compare the results with a matched-control group of open TME (OTME). MATERIALS AND METHODS: A series of 41 patients with primary rectal cancer underwent LTME for rectal cancer and were matched with a historical control group of 41 patients who underwent OTME. Both groups received preoperative short-term radiotherapy. RESULTS: There was no mortality in the LTME group and 2% mortality in the OTME group. The overall postoperative morbidity was 37% in the LTME group and 51% in the OTME group, including an anastomotic leakage of 9 and 14% in the LTME and OTME groups respectively. A positive circumferential margin was found in 7% of patients in the LTME group and in 12% of the patients in the OTME group. CONCLUSION: This study shows that LTME is technically feasible and can be performed safely. We show at least a similar surgical completeness using a laparoscopic technique compared with open surgery.

Laparoscopic vs open total mesorectal excision for rectal cancer: an evaluation of the mesorectum's macroscopic quality.

BACKGROUND: Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated. METHODS: A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum. RESULTS: A three-grade scoring system showed no differences between the LTME and OTME groups. CONCLUSION: The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.

Reduction of postprandial hyperglycemia in patients with type 2 diabetes reduces NF-kappaB activation in PBMCs.

AIMS/HYPOTHESIS: Short-lasting hyperglycemia results in activation of the transcription factor NF-kappaB in peripheral blood mononuclear cells. We therefore studied whether the postprandial increase in glucose is sufficient to induce mononuclear NF-kappaB activation and whether blunting postprandial hyperglycemia with the alpha-glucosidase inhibitor acarbose reduces NF-kappaB activation. METHODS: 20 patients with type 2 diabetes were included in a double-blind randomized trial receiving 100 mg acarbose or placebo three times a day over a period of eight weeks. Peripheral blood mononuclear cells were isolated before and 120 minutes after a standardized breakfast. NF-kappaB binding activity was estimated by electrophoretic mobility shift assay and NF-kappaB-p65; translocation was determined by Western blot. RESULTS: Eight weeks of treatment with acarbose significantly reduced postprandial hyperglycemia (p = 0.004 when compared to placebo), postprandial mononuclear NF-kappaB-binding activity (p = 0.045) and nuclear translocation of NF-kappaB-p65 (p = 0.02). CONCLUSION: Reduction of postprandial glucose peak levels by acarbose reduces postprandial mononuclear NF-kappaB activation.