The Association Between Intraoperative Compromised Intestinal Integrity and Postoperative Complications in Cancer Patients.

BACKGROUND: Because of perioperative splanchnic hypoperfusion, the gut wall becomes more permeable for intraluminal microbes to enter the splanchnic circulation, possibly contributing to development of complications. Hypoperfusion-related injured enterocytes release intestinal fatty acid binding protein (I-FABP) into plasma, which is used as proxy of intestinal integrity. This study investigates the occurrence of intestinal integrity loss during oncologic surgery, measured by I-FABP change. Secondary the relationship between compromised intestinal integrity, and related variables and complications were studied. METHODS: Patients undergoing oncologic surgery from prospective cohort studies were included. Urine I-FABP samples were collected preoperatively (T0) and at wound closure (T1), and in a subgroup on Day 1 (D1) and Day 2 (D2) postoperatively. I-FABP dynamics were investigated and logistic regression analyses were performed to study the association between I-FABP levels and patient-related, surgical variables and complications. RESULTS: A total of 297 patients were included with median age of 70 years. Median I-FABP value increased from 80.0 pg/mL at T0 (interquartile range [IQR] 38.0-142.0) to 115 pg/mL at T1 (IQR 48.0-198.0) (p < 0.05). Age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.02-1.08) and anesthesia time (OR 1.13, 95% CI 1.02-1.25) were related to stronger I-FABP increase. When comparing I-FABP change in patients experiencing any complications versus no complications, relative I-FABP change at T1 was 145% of T0 (IQR 86-260) versus 113% (IQR 44-184) respectively (p < 0.05). CONCLUSIONS: A significant change in I-FABP levels was seen perioperatively indicating compromised intestinal integrity. Age and anesthesia time were related to higher I-FABP increase. In patients experiencing postoperative complications, a higher I-FABP increase was found.

Timed up and go test and long-term survival in older adults after oncologic surgery.

BACKGROUND: Physical performance tests are a reflection of health in older adults. The Timed Up and Go test is an easy-to-administer tool measuring physical performance. In older adults undergoing oncologic surgery, an impaired TUG has been associated with higher rates of postoperative complications and increased short term mortality. The objective of this study is to investigate the association between physical performance and long term outcomes. METHODS: Patients aged ≥65 years undergoing surgery for solid tumors in three prospective cohort studies, 'PICNIC', 'PICNIC B-HAPPY' and 'PREOP', were included. The TUG was administered 2 weeks before surgery, a score of ≥12 seconds was considered to be impaired. Primary endpoint was 5-year survival, secondary endpoint was 30-day major complications. Survival proportions were estimated using Kaplan-Meier curves. Cox- and logistic regression analysis were used for survival and complications respectively. Hazard ratios (aHRs) and Odds ratios (aOR) were adjusted for literature-based and clinically relevant variables, and 95% confidence intervals (95% CIs) were estimated using multivariable models. RESULTS: In total, 528 patients were included into analysis. Mean age was 75 years (SD 5.98), in 123 (23.3%) patients, the TUG was impaired. Five-year survival proportions were 0.56 and 0.49 for patients with normal TUG and impaired TUG respectively. An impaired TUG was an independent predictor of increased 5-year mortality (aHR 1.43, 95% CI 1.02-2.02). The TUG was not a significant predictor of 30-day major complications (aOR 1.46, 95% CI 0.70-3.06). CONCLUSIONS: An impaired TUG is associated with increased 5-year mortality in older adults undergoing surgery for solid tumors. It requires further investigation whether an impaired TUG can be reversed and thus improve long-term outcomes. TRIAL REGISTRATION: The PICNIC studies are registered in the Dutch Clinical Trial database at www.trialregister.nl: NL4219 (2010-07-22) and NL4441 (2014-06-01). The PREOP study was registered with the Dutch trial registry at www.trialregister.nl: NL1497 (2008-11-28) and in the United Kingdom register (Research Ethics Committee reference 10/H1008/59).  https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/?page=15&query=preop&date_from=&date_to=&research_type=&rec_opinion=&relevance=true .

Compromised intestinal integrity in older adults during daily activities: a pilot study.

BACKGROUND: Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities. METHODS: Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially. RESULTS: Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak. CONCLUSION: This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently.

Postoperative recovery of accelerometer-based physical activity in older cancer patients.

INTRODUCTION: Recovery of physical activity is an important functional outcome measure after cancer surgery. However, objective data on physical activity for older cancer patients is scarce. The aims of this study were to quantify perioperative physical activity levels, assess recovery of physical activity three months after surgery, and characterise patients who achieved recovery. MATERIALS AND METHODS: This observational cohort study analysed physical activity data collected from patients aged >65 who were scheduled for cancer surgery between May 2018 and July 2019. Perioperative daily step count was measured using a Fitbit device. The primary outcome measure was the percentage of patients who returned to (≥90% of) their preoperative (baseline) physical activity levels three months after surgery. RESULTS: Fifty patients (mean age 73) were recruited, and available Fitbit data was analysed. Median daily step counts at baseline (n = 40), before hospital discharge (n = 40), and three months postoperative (n = 37) were 5,974 (IQR 4,250-7,922), 1,619 (IQR 920-2,839), and 4,674 (IQR 3,047-7,592), respectively. The 15/37 (41%) patients who had reached baseline levels three months after surgery seemed to have more preoperative self-reported physical activity, better anaesthesiologists' physical status classification, and fewer in-hospital complications compared to patients who had not, although the differences were statistically non-significant. CONCLUSION: Perioperative physical activity was quantified for older cancer patients, and 41% returned to baseline levels within three months. Accelerometer-based physical activity provided a valuable outcome measure for postoperative physical recovery. Future studies using objective physical activity measures are needed to evaluate effects of interventional studies aimed at improving physical activity.

Skater's Cramp: A Possible Task-Specific Dystonia in Dutch Ice Skaters.

BACKGROUND: Skater's cramp is an involuntary lower leg movement in skilled speed skaters. We aim to evaluate whether skater's cramp is compatible with task-specific dystonia. METHODS: A case-control study tested 5 speed skaters exhibiting symptoms of skater's cramp and 5 controls. Affected skaters completed a standardized questionnaire and neurological examination. Video analyses included skating normally, intensely, and with extra mass around the skater's ankles. An Inertial Motion Capturing (IMC) device mounted on both skates provided angular velocity data for both feet. RESULTS: Median time of onset of skater's cramp occurred after 12 (range 3-22) years of speed skating. Skater's cramp appeared as task specific; its onset was sudden and correlated to stress and aberrant proprioception. Symptoms presented acutely and consistently during skating, unilaterally in 4 and bilaterally in 1 skater. Visually, skater's cramp was an active, patterned, and person-specific jerking of a skater's foot, either exo- or endorotationally. It presented asymmetrically, repeating persistently as the foot neared the end of the swing phase. The skater's affected leg had a longer swing phase (median, 1.37 [interquartile range {IQR}, 0.35]/1.18 [IQR, 0.24] seconds; P < 0.01), a shorter glide phase (median, 1.09 [IQR, 0.25]/1.26 (IQR, 0.29) seconds; P < 0.01), and higher angular velocity during the jerking motion. Symptoms remained constant irrespective of speed or extra mass around the ankle (P > 0.05). No significant differences between legs were detected in the control group. CONCLUSIONS: Observed clinical, visual, and kinematic data could be an early and tentative indication of task-specific dystonia.