Effect of Fish Oil Parenteral Emulsion Supplementation on Inflammatory Parameters after Esophagectomy.

(Background) Esophagectomy (EPG) presents high morbidity and mortality. Omega-3 fatty acids (ω-3FA) are a pharmaconutrient with benefits for postoperative morbidity. Studies of ω-3FA administered parenterally after esophagectomy are scarce. This study proposes to investigate the effect of combining fish oil lipid emulsions (LE) administered parenterally with enteral nutrition support. (Methods) Randomization was 1:1:1 in three groups: Group A received a LE mixture of 0.4 g/kg/day of fish oil and 0.4 g/kg/day of LCT/MCT 50:50, Group B received 0.8 g/kg/day of fish oil LE, and Group C received 0.8 g/kg/day of LCT/MCT 50:50. Variables were measured at recruitment time and day +1, +3, and +5. Inflammatory variables studied were Interlukin-6, C-reactive protein (CRP), tumoral necrosis factor-α (TNF-α), IL-10, IL-8 and CD25s. Safety, nutritional parameters and complications were analyzed. (Results) Administration of ω-3LE in the immediate postoperative period did not modulate the earlier inflammatory response. Statistically significant differences were found in IL-6 and CRP overall temporal evolution but were not found when studying the type of LE administered or in patients needing critical care. Administration of ω-3 resulted in safe and improved hypertriglyceridemia, depending on the dose. (Conclusions) ω-3FA has no impact on the early inflammatory postoperative response assessed for a short period but was safe. More studies for longer periods are needed.

Phytosterolemia and γ-glutamyl transferase in adults with parenteral nutrition: Fish versus vegetal lipids: A randomized clinical trial.

OBJECTIVES: Fish oil (FO)-based lipid emulsions (LEs) have been reported to prevent hepatic dysfunction in patients treated with parenteral nutrition (PN). We studied patients with alterations of γ-glutamyl transferase (GGT) associated with the administration of PN containing olive/soybean (O/S)-based LE. The aim of this study was to determine whether the strategy of reducing the lipid dose by 50%, by changing to an FO-based LE, reduced plasma levels of phytosterols (PS) and GGT more effectively and safely, than the strategy of reducing lipid contribution by 50% while maintaining the same LE composition. METHODS: A randomized double-blind clinical trial was carried out in patients with normal initial GGT, who after a minimum of 1 wk of daily PN (0.8 g/kg of O/S-based LE) presented with GGT values twice the upper normal value. At the time of randomization 1:1, lipids were reduced to 0.4 g/kg daily. Group A maintained O/S LE and group B changed to FO LE. The primary endpoints were reduction of plasmatic PS and GGT on day 7 after randomization, performed in the study population per protocol by Student's t test and simple linear regression. Secondary outcomes included alkaline phosphatase (AP), alanine transaminase (ALT), and total bilirubin (BIL), and safety variables. RESULTS: Nineteen patients were included. On day 7 after randomization, GGT and AP values were higher in the O/S group (n = 10; GGT: median [Med], 4.99; interquartile range [IQR], 4.09; AP: Med, 2.59 µkat/L; IQR 1.74) than in the FO group (n = 9; GGT: Med, 2.26 µkat/L; IQR, 1.07; AP: Med, 1.2 µkat/L; IQR 1.44). Although there were no differences in ALT and BIL values, the ALT decrease was larger and more statistically significant in the FO group than in the O/S group (P = 0.009). Total PS (Med, 21.10 µg/mL; IQR, 5.50) in the O/S group was higher than in the FO group (Med, 13.4 µg/mL; IQR, 10.65; P = 0.002). Significant decreases in PS and their fractions were observed, with the exception of campesterol and stigmasterol. CONCLUSION: Plasma accumulation of PS and high values of GGT, AP, and ALT can be prevented with the exclusive administration of FO-based LE.

Cirugía mínimamente invasiva y robótica en el tratamiento quirúrgico de las neoplasias de la unión esofagogástrica / Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer

La cirugía mínimamente invasiva permite el tratamiento de los tumores de la unión esofagogástrica en condiciones de seguridad, reduciendo las complicaciones respiratorias y parietales y mejorando la recuperación postoperatoria, manteniendo además los principios de la cirugía oncológica que permitan obtener unos resultados óptimos de efectividad a largo plazo. Para ello, es necesario un volumen de actividad suficiente y avanzar en la curva de aprendizaje de forma tutelada, para poder garantizar una resección R0 y una linfadenectomía adecuada. La mínima invasión no puede ser un objetivo en sí misma. En caso de gastrectomía total, el riesgo de afectación del margen proximal obliga a verificarlo mediante biopsia intraoperatoria, sin descartar la cirugía abierta de entrada. Por su parte, la esofagectomía mínimamente invasiva se ha ido imponiendo progresivamente. Su principal dificultad, la anastomosis intratorácica, puede realizarse mediante una sutura laterolateral mecánica o manualmente asistida por robot, gracias a la visión tridimensional y a la versatilidad del instrumental

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer. / Cirugía mínimamente invasiva y robótica en el tratamiento quirúrgico de las neoplasias de la unión esofagogástrica.

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.

A randomised study on the clinical progress of high-risk elective major gastrointestinal surgery patients treated with olive oil-based parenteral nutrition with or without a fish oil supplement.

n-3 Fatty acids have clinical benefits. The primary aim of the present study was the assessment of infection in patients who underwent major high-risk elective gastrointestinal surgery receiving postoperatively fish oil (FO)-supplemented parenteral nutrition (PN), compared with those receiving a standard olive oil (OO) emulsion. The secondary aims were the assessment of anti-inflammatory response and evaluation of tolerance and safety of these emulsions. A prospective, randomised, double-blind study was performed in patients requiring at least 5 d of PN. An isoenergetic and isoproteic formula was administered: group A received OO alone, while group B received OO that was partially replaced with FO (16.6 %, w/w). End points were outcome measures (mortality, sepsis, infection, hospitalisation days and PN duration), inflammatory response (C-reactive protein (CRP), prealbumin and leucocytes) and safety (TAG and glucose metabolism, and liver and kidney function). Statistical analysis was done using Student's t test and Fisher's exact test (P < 0.05). Twenty-seven patients were evaluated, with thirteen patients receiving FO. In this group, a significantly lower incidence of infections was found (23.1 v. 78.6 %, P = 0.007). CRP, prealbumin and leucocytes were not significantly different between the groups. There were no differences in safety parameters. We conclude that high-risk surgical patients receiving FO-supplemented PN for 5 d present a lower incidence of infection. Emulsions were safe and well tolerated.

[Second time esophageal reconstruction surgery: coloplasty and gastroplasty]. / Reconstrucción esofágica en un segundo tiempo: coloplastia y gastroplastia.

OBJECTIVE: To analyze the morbidity and mortality of second time esophageal reconstruction in an Esophagogastric Unit. PATIENTS AND METHOD: Second time esophageal reconstruction surgery with coloplasty and gastroplasty was performed on 20 patients, from January 2001 to October 2006. The morbidity and mortality of each technique has been analyzed retrospectively. RESULTS: The mean age of the 16 males and 4 women operated on was 54.3 +/- 17.5 years. The diagnoses at the first surgery were: 7 caustic ingestions, 7 Boerhaave syndrome, 3 iatrogenic perforations, 1 tracheal-esophageal fistula, 1 esophageal-jejunal dehiscence and 1 necrosis of the gastroplasty after transhiatal oesophagectomy. There were 14 (70%) right coloplasties, 4 (20%) left coloplasties and 2 (10%) gastroplasties with gastric conditioning. In 11 of the 20 patients gastroplasty was ruled out due to gastrectomy (8 cases) or previous gastric surgery (3 cases). It was noted on analyzing the morbidity: pleural effusion (65%), respiratory failure (45%), atelectasis (35%) and cervical anastomosis dehiscence (35%). Five patients were re-intervened: 3 due to intra-abdominal sepsis and 2 due to hemoperitoneum. Mortality was 10% (2 cases). In subsequent follow up there was 5% (1 case) of stenosis of the anastomosis. CONCLUSIONS: Esophageal reconstruction technique which in specialist units has an acceptable mortality rate (10%) and an insignificant morbidity. Coloplasty was the technique most used on these patients.

Reconstrucción esofágica en un segundo tiempo: coloplastia y gastroplastia / Second time esophageal reconstruction surgery: coloplasty and gastroplasty

Objetivo. Analizar la morbimortalidad de la reconstrucción esofágica en un segundo tiempo en una unidad de cirugía esofagogástrica. Pacientes y método. Desde enero de 2001 a octubre de 2006 se intervino a 20 pacientes a los que se realizó reconstrucción esofágica en un segundo tiempo con coloplastia o gastroplastia. Se ha analizado retrospectivamente la morbimortalidad de cada técnica. Resultados. Se intervino a 16 varones y 4 mujeres con una media de edad de 54,3 ± 17,5 años. Los diagnósticos de la primera cirugía fueron: 7 por ingesta de cáusticos, 7 por síndrome de Boerhaave, 3 por perforación iatrogénica, 1 por fístula traqueoesofágica, 1 por dehiscencia esofagoyeyunal y 1 por necrosis de la gastroplastia tras esofagectomía transhiatal. Se realizaron 14 (70%) coloplastias derechas, 4 (20%) coloplastias izquierdas y 2 (10%) gastroplastias con acondicionamiento gástrico. En 11 de los 20 pacientes se desestimó la gastroplastia por gastrectomía (8 casos) o cirugía gástrica previa (3 casos). Analizando la morbilidad destacan: derrame pleural (65%), insuficiencia respiratoria (45%), atelectasia (35%) y dehiscencia de anastomosis cervical (35%). Se reintervino a 5 pacientes: 3 por sepsis intraabdominal y 2 por hemoperitoneo. La mortalidad fue del 10% (2 casos). En el seguimiento posterior destaca 1 (5%) caso de estenosis de la anastomosis. Conclusiones. La reconstrucción esofágica es una técnica que en unidades especializadas presenta una mortalidad aceptable (10%) y una morbilidad no despreciable. La coloplastia es la técnica más utilizada en estos pacientes (AU)

Objective. To analyze the morbidity and mortality of second time esophageal reconstruction in an Esophagogastric Unit. Patients and method. Second time esophageal reconstruction surgery with coloplasty and gastroplasty was performed on 20 patients, from January 2001 to October 2006. The morbidity and mortality of each technique has been analyzed retrospectively. Results. The mean age of the 16 males and 4 women operated on was 54.3 ± 17.5 years. The diagnoses at the first surgery were: 7 caustic ingestions, 7 Boerhaave syndrome, 3 iatrogenic perforations, 1 tracheal-esophageal fistula, 1 esophageal-jejunal dehiscence and 1 necrosis of the gastroplasty after transhiatal oesophagectomy. There were 14 (70%) right coloplasties, 4 (20%) left coloplasties and 2 (10%) gastroplasties with gastric conditioning. In 11 of the 20 patients gastroplasty was ruled out due to gastrectomy (8 cases) or previous gastric surgery (3 cases). It was noted on analyzing the morbidity: pleural effusion (65%), respiratory failure (45%), atelectasis (35%) and cervical anastomosis dehiscence (35%). Five patients were re-intervened: 3 due to intra-abdominal sepsis and 2 due to hemoperitoneum. Mortality was 10% (2 cases). In subsequent follow up there was 5% (1 case) of stenosis of the anastomosis. Conclusions. Esophageal reconstruction technique which in specialist units has an acceptable mortality rate (10%) and an insignificant morbidity. Coloplasty was the technique most used on these patients (AU)