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1.
Updates Surg ; 75(4): 953-958, 2023 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-37004654

RESUMO

Organ sparing resection of gastrointestinal stromal tumors (GISTs) located in the proximal stomach or esophagogastric junction can be challenging, resulting in proximal or total gastrectomy to facilitate a radical resection without tumor spill. We developed and evaluated a single incision surgical gastroscopy (SISG) procedure to provide a technically feasible alternative for the removal of gastric GISTs at these challenging locations. We developed an endoluminal resection of gastric GISTs through a small single abdominal incision and longitudinal ventral gastrotomy. Patients with a proximal tumor location, in whom a wedge resection was deemed challenging on pre-operative investigation were included in the current series. Safety, short-term oncological and surgical outcome were evaluated. We performed SISG in six consecutive patients with histopathological proven or suspected gastric GIST. In all patients, the procedure was performed successfully with no tumor rupture. The mean operative time was 61 min and there were no significant complications. Pathological examination showed a microscopically radical resection in all patients. Single incision surgical gastroscopy is a feasible technique with excellent short-term oncological and surgical outcomes. This technique serves as a good alternative for complicated resections for gastric GISTs at challenging locations.


Assuntos
Tumores do Estroma Gastrointestinal , Laparoscopia , Neoplasias Gástricas , Humanos , Junção Esofagogástrica/patologia , Gastrectomia/métodos , Tumores do Estroma Gastrointestinal/diagnóstico , Tumores do Estroma Gastrointestinal/cirurgia , Tumores do Estroma Gastrointestinal/patologia , Gastroscopia/métodos , Laparoscopia/métodos , Estudos Retrospectivos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/cirurgia , Neoplasias Gástricas/patologia , Resultado do Tratamento
2.
Endoscopy ; 55(9): 859-864, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-36828030

RESUMO

BACKGROUND : Endoscopic vacuum therapy (EVT) is a novel treatment for esophageal perforations. This study aimed to describe initial experience with EVT of esophageal perforations due to iatrogenic cause, Boerhaave syndrome, or other perforations not related to prior upper gastrointestinal surgery. METHODS : Data from patients treated with EVT for esophageal perforation at five hospitals in three European countries, between January 2018 and October 2021, were retrospectively collected. The primary end point was successful defect closure by EVT, with or without the use of other endoscopic treatment modalities. Secondary end points included mortality and adverse events. RESULTS : 27 patients were included (median age 71 years). The success rate was 89 % (24/27, 95 %CI 77-100). EVT failed in three patients: two deceased during EVT (septic embolic stroke, pulmonary embolism) and one underwent esophagectomy due to a persisting defect. Two adverse events occurred: one iatrogenic defect expansion during sponge exchange and one hemorrhage during sponge removal. Median treatment duration was 12 days (interquartile range [IQR] 6-16) with 1 sponge exchange (IQR 1-3). CONCLUSION : EVT is a promising organ-preserving treatment for esophageal perforations, with a success rate of 89 %. More experience with the technique and indications will likely improve success rates.


Assuntos
Perfuração Esofágica , Tratamento de Ferimentos com Pressão Negativa , Humanos , Idoso , Perfuração Esofágica/etiologia , Perfuração Esofágica/cirurgia , Estudos Retrospectivos , Tratamento de Ferimentos com Pressão Negativa/métodos , Endoscopia/efeitos adversos , Doença Iatrogênica , Fístula Anastomótica/terapia , Resultado do Tratamento
3.
J Thorac Dis ; 12(12): 7182-7192, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33447407

RESUMO

BACKGROUND: CT imaging is the primary diagnostic approach to assess the integrity of the intrathoracic anastomosis following Ivor Lewis esophagectomy. In the postoperative setting interpretation of CT findings, such as air and fluid collections, may be challenging. Establishment of a scoring system that incorporates CT findings to diagnose anastomotic leakage could assist radiologists and surgeons in the postoperative phase. METHODS: Consecutive patients who underwent a CT scan for a clinical suspicion of postoperative anastomotic leakage following Ivor Lewis esophagectomy between 2010 and 2016 in two medical centers were retrospectively included. Scans were excluded when oral contrast was not (correctly) administered. Acquired images were randomized and independently assessed by two experienced gastrointestinal radiologists, blinded for clinical information. For this study anastomotic leakage was defined as a visible defect during endoscopy or thoracotomy. RESULTS: A total of 80 patients had 101 CT scans, resulting in 32 scans with a confirmed anastomotic leak (25 patients). After multivariable backward stepwise logistic regression, a practical 5-point scoring system was developed, which included the following CT findings: presence of extraluminal oral contrast, air collection at the anastomotic site, fluid collection at the anastomotic site, pneumothorax and loculated pleural effusion. Patients with a score of ≥3 were considered at high risk for anastomotic leakage (positive predictive value: 83.3%), patients with scores <3 were considered at low risk for anastomotic leakage (negative predictive value: 84.4%). The scoring system showed a superior diagnostic performance compared to the original CT report and blinded interpretation of two radiologists. CONCLUSIONS: Our CT-based practical scoring system enables a standardized approach in CT assessment and could facilitate early recognition of anastomotic leakage in patients after Ivor Lewis esophagectomy.

4.
Am J Clin Nutr ; 103(2): 435-43, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26762368

RESUMO

BACKGROUND: Jejunal feeding is preferred instead of gastric feeding in patients who are intolerant to gastric feeding or at risk of aspiration. However, the impact of gastric feeding compared with that of jejunal feeding on postprandial circulating plasma glucose and amino acid concentrations and the associated endocrine response in vivo in humans remains largely unexplored. OBJECTIVE: We compared the impact of administering enteral nutrition as either gastric feeding or jejunal feeding on endocrine responses in vivo in humans. DESIGN: In a randomized, crossover study design, 12 healthy young men (mean ± SD age: 21 ± 2 y) received continuous enteral nutrition that contained noncoagulating proteins for 12 h via a nasogastric tube or a nasojejunal tube placed 30-40 cm distal to the ligament of Treitz. Blood samples were collected during the 12-h postprandial period to assess the rise in plasma glucose, amino acid, and gastrointestinal hormone concentrations. RESULTS: No differences were observed in the postprandial rise in circulating plasma amino acid and glucose concentrations between regimens. Jejunal feeding resulted in higher peak plasma insulin concentrations than did gastric feeding (392 ± 53 compared with 326 ± 54 pmol/L, respectively; P < 0.05). The postprandial rise in plasma cholecystokinin, peptide YY (PYY), glucagon-like peptide 1 (GLP-1), and glucagon-like peptide 2 (GLP-2) concentrations was greater after jejunal feeding than after gastric feeding, with higher peak concentrations and a greater postprandial incremental AUC for GLP-1 and cholecystokinin (all P < 0.05). Plasma ghrelin concentrations did not differ between regimens. CONCLUSIONS: Enteral nutrition with gastric or jejunal feeding in healthy young men results in similar postprandial plasma amino acid and glucose concentrations. However, the endocrine response differs substantially, with higher peak plasma cholecystokinin, PYY, GLP-1, and GLP-2 concentrations being attained after jejunal feeding. This effect may result in an improved anabolic response, greater insulin sensitivity, and an improved intestinotropic effect. Nevertheless, it may also lead to delayed gastric emptying. This trial was registered at trialregister.nl as NTR2801.


Assuntos
Colecistocinina/sangue , Nutrição Enteral , Peptídeo 1 Semelhante ao Glucagon/sangue , Peptídeo 2 Semelhante ao Glucagon/sangue , Mucosa Intestinal/metabolismo , Peptídeo YY/sangue , Regulação para Cima , Aminoácidos/sangue , Glicemia/análise , Colecistocinina/metabolismo , Estudos Cross-Over , Digestão , Mucosa Gástrica/metabolismo , Peptídeo 1 Semelhante ao Glucagon/metabolismo , Peptídeo 2 Semelhante ao Glucagon/metabolismo , Humanos , Insulina/sangue , Insulina/metabolismo , Secreção de Insulina , Absorção Intestinal , Intubação Gastrointestinal , Jejuno , Masculino , Peptídeo YY/metabolismo , Período Pós-Prandial , Estômago
5.
J Nutr ; 145(9): 2033-8, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26224751

RESUMO

BACKGROUND: Dietary protein is required to attenuate the loss of muscle mass and to support recovery during a period of hospitalization. Jejunal feeding is preferred over gastric feeding in patients who are intolerant of gastric feeding. However, the impact of gastric vs. jejunal feeding on postprandial dietary protein digestion and absorption kinetics in vivo in humans remains largely unexplored. OBJECTIVE: We compared the impact of gastric vs. jejunal feeding on subsequent dietary protein digestion and amino acid (AA) absorption in vivo in healthy young men. METHODS: In a randomized crossover study design, 11 healthy young men (aged 21 ± 2 y) were administered 25 g specifically produced intrinsically l-[1-(13)C]phenylalanine-labeled intact casein via a nasogastric and a nasojejunal tube placed ~30 cm distal to the ligament of Treitz. Protein was provided in a 240-mL solution administered over a 65-min period in both feeding regimens. Blood samples were collected during the 7-h postprandial period to assess the increase in plasma AA concentrations and dietary protein-derived plasma l-[1-(13)C]phenylalanine enrichment. RESULTS: Jejunal feeding compared with gastric feeding resulted in higher peak plasma phenylalanine, leucine, total essential AA (EAA), and total AA concentrations (all P < 0.05). This was attributed to a more rapid release of dietary protein-derived AAs into the circulation, as evidenced by a higher peak plasma l-[1-(13)C]phenylalanine enrichment concentration (2.9 ± 0.2 vs. 2.2 ± 0.2 mole percent excess; P < 0.05). The total postprandial plasma AA incremental area under the curve and time to peak did not differ after jejunal vs. gastric feeding. Plasma insulin concentrations increased to a greater extent after jejunal feeding when compared with gastric feeding (275 ± 38 vs. 178 ± 38 pmol/L; P < 0.05). CONCLUSIONS: Jejunal feeding of intact casein is followed by more rapid protein digestion and AA absorption when compared with gastric feeding in healthy young men. The greater postprandial increase in circulating EAA concentrations may allow a more robust increase in muscle protein synthesis rate after jejunal vs. gastric casein feeding. This trial was registered at trialregister.nl as NTR2801.


Assuntos
Caseínas/administração & dosagem , Nutrição Enteral/métodos , Absorção Gastrointestinal/efeitos dos fármacos , Absorção Intestinal/efeitos dos fármacos , Jejuno/efeitos dos fármacos , Proteólise , Adolescente , Adulto , Aminoácidos/sangue , Glicemia/metabolismo , Índice de Massa Corporal , Isótopos de Carbono , Caseínas/farmacocinética , Estudos Cross-Over , Dieta , Proteínas Alimentares/administração & dosagem , Humanos , Insulina/sangue , Jejuno/metabolismo , Leucina/sangue , Masculino , Pessoa de Meia-Idade , Atividade Motora , Proteínas Musculares/metabolismo , Fenilalanina/sangue , Período Pós-Prandial/efeitos dos fármacos , Adulto Jovem
7.
Am J Clin Nutr ; 100(5): 1385-91, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25332337

RESUMO

BACKGROUND: Arginine plays a role in many different pathways in multiple cell types. Consequently, a shortage of arginine, caused by pathologic conditions such as cancer or injury, has the potential to disturb many cellular and organ functions. Glutamine is the ultimate source for de novo synthesis of arginine in humans via the intestinal-renal axis. Therefore, we hypothesized that parenteral glutamine supplementation may stimulate the interorgan pathway of arginine production. OBJECTIVES: The objectives were to quantify arginine production from its precursor glutamine and to establish the contribution of the kidneys to de novo synthesis of arginine in patients receiving intravenous supplementation of glutamine dipeptide during major abdominal surgery. DESIGN: Whole-body and renal metabolism of glutamine, citrulline, and arginine was assessed by stable isotope techniques in 7 patients receiving a perioperative supplement of intravenous alanyl-glutamine (0.5 g · kg(-1) · d(-1)). RESULTS: Plasma glutamine, citrulline, and arginine concentrations increased significantly in patients receiving intravenous glutamine dipeptide. At whole-body level, 91% of total citrulline turnover was derived from glutamine, whereas 49% of whole-body citrulline turnover was used for de novo synthesis of arginine. The kidneys were responsible for 75% of whole-body arginine production from citrulline. CONCLUSIONS: Glutamine and citrulline are important sources for de novo arginine synthesis. The kidneys are the main production site for endogenous arginine. After comparison of these results with previous similar studies, our data suggest that an intravenous glutamine supplement doubles renal arginine production from citrulline. This trial was registered at www.trialregister.nl as NTR2914.


Assuntos
Arginina/biossíntese , Suplementos Nutricionais , Dipeptídeos/administração & dosagem , Glutamina/metabolismo , Rim/efeitos dos fármacos , Administração Intravenosa , Idoso , Citrulina/metabolismo , Estudos Transversais , Estudos de Avaliação como Assunto , Feminino , Humanos , Marcação por Isótopo , Rim/metabolismo , Masculino , Pessoa de Meia-Idade
8.
Food Funct ; 5(8): 1866-71, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24943994

RESUMO

A serious complication seen in critically ill patients is the solidification of enteral nutrition causing gastrointestinal obstruction. It has been suggested that enteral nutrition enriched with insoluble fibers may increase the risk of this complication. Therefore, we investigate the effect of soluble and insoluble dietary fibers on the coagulation of a casein-based enteral nutrition in an artificial gastric digestion model. A 100% casein-based enteral nutrition was enriched with increasing concentrations of soluble fibers (acacia fiber, oligofructose and inulin) and insoluble fibers (soy polysaccharide, resistant starch and alpha cellulose). After digestion in an artificial gastric model, the chyme was poured over sequentially placed sieves, separating the coagulate into size fractions of larger than 2 mm, between 1 and 2 mm, and between 0.25 and 1 mm. Of these fractions we measured wet weight, dry weight and protein content. A significant effect on the fraction larger than 2 mm was considered to be clinically relevant. Addition of high concentrations soy polysaccharide and resistant starch to a casein-based enteral nutrition, did not alter the wet weight, whereas dry weight and protein content of the coagulate was significantly reduced. When high concentrations of soy polysaccharide and resistant starch are added to a 100% casein-based enteral nutrition, the coagulate consist of more water and less proteins, which may lead to an increased protein digestion and absorption in a clinical setting. The suggestion that insoluble fibers increase the risk of gastrointestinal obstruction in critically ill patients is not supported by these data.


Assuntos
Caseínas/química , Fibras na Dieta/farmacologia , Digestão , Nutrição Enteral , Modelos Biológicos , Estômago/efeitos dos fármacos , Celulose/farmacologia , Carboidratos da Dieta/farmacologia , Mucosa Gástrica/metabolismo , Conteúdo Gastrointestinal , Inulina/farmacologia
9.
Proc Nutr Soc ; 72(3): 277-87, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23410523

RESUMO

Pharmaco-nutrients have beneficial effects on protective and immunological mechanisms in patients undergoing surgery, which are important for recovery after injury and in combating infectious agents. The aim of this review article was to outline the potential of the administration of nutritional substrates to surgical patients and the underlying mechanisms that make them particularly important in peri-operative care. Surgery causes a stress response, which has catabolic effects on the body's substrate stores. The amino acid glutamine is a stimulating agent for immune cells. It activates protective mechanisms through its role as a precursor for antioxidants and it improves the barrier function of the gut. Arginine also enhances the function of the immune system, since it is the substrate for T-lymphocytes. Furthermore, n-3 PUFA stabilise surgery-induced hyper-inflammation. Taurine is another substrate that may counteract the negative effects of surgical injury on acid-base balance and osmotic balance. These pharmaco-nutrients rapidly become deficient under the influence of surgical stress. Supplementation of these nutrients in surgical patients may restore their protective and immune-enhancing actions and improve clinical outcome. Moreover, pre-operative fasting is still common practice in the Western world, although fasting has a negative effect on the patient's condition and the recovery after surgery. This may be counteracted by a simple intervention such as administering a carbohydrate-rich supplement just before surgery. In conclusion, there are various nutritional substrates that may be of great value in improving the condition of the surgical patient, which may be beneficial for post-operative recovery.


Assuntos
Aminoácidos/administração & dosagem , Ácidos Graxos Ômega-3/administração & dosagem , Procedimentos Cirúrgicos Operatórios/métodos , Humanos
10.
Clin Nutr ; 32(4): 556-61, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23219717

RESUMO

BACKGROUND & AIMS: A carbohydrate (CHO) drink given preoperatively changes the fasted state into a fed state. The ESPEN guidelines for perioperative care include preoperative CHO loading and re-establishment of oral feeding as early as possible after surgery. An intestinal ischaemia reperfusion (IR) animal model was used to investigate whether preoperative CHO loading increases spontaneous postoperative food intake, intestinal barrier function and the catabolic response. METHODS: Male Wistar rats (n = 65) were subjected to 16 h fasting with ad libitum water and: A) sham laparotomy (Sham fasted, n = 24); B) intestinal ischaemia (IR fasted, n = 27); and C) intestinal ischaemia with preoperatively access to a CHO drink (IR CHO, n = 14). Spontaneous food intake, intestinal barrier function, insulin sensitivity, intestinal motility and plasma amino acids were measured after surgery. RESULTS: The IR CHO animals started eating significantly earlier and also ate significantly more than the IR fasted animals. Furthermore, preoperative CHO loading improved the intestinal barrier function, functional enterocyte metabolic mass measured by citrulline and reduced muscle protein catabolism, as indicated by normalization of the biomarker 3-methylhistidine. CONCLUSIONS: Preoperative CHO loading improves food intake, preserves the GI function and reduces the catabolic response in an IR animal model. These findings suggest that preoperative CHO loading preserves the intestinal function in order to accelerate recovery and food intake. If this effect is caused by overcoming the fasted state or CHO loading remains unclear.


Assuntos
Carboidratos da Dieta/administração & dosagem , Ingestão de Alimentos/fisiologia , Trato Gastrointestinal/metabolismo , Animais , Biomarcadores/sangue , Glicemia , Citrulina/sangue , Homeostase , Insulina/sangue , Resistência à Insulina , Mucosa Intestinal/metabolismo , Intestinos/patologia , Masculino , Metilistidinas/sangue , Modelos Animais , Período Pós-Operatório , Cuidados Pré-Operatórios/métodos , Ratos , Ratos Wistar , Traumatismo por Reperfusão/patologia , Traumatismo por Reperfusão/prevenção & controle
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