Health-related quality of life and hospital costs following esophageal resection: a prospective cohort study.

BACKGROUND: The incidence rates for adenocarcinoma of the esophagus are increasing while the prognosis has only improved slightly. There is no apparent benefit in short- and long-term survival after different surgical strategies, but surgery is associated with significant morbidity. The goal of this study is to prospectively assess the quality of life and hospital costs after esophageal resections depending on the development of complications. METHODS: Prospective data was collected from 47 patients undergoing an esophageal resection for esophageal cancer participating in the prospective LAParotomy or LAParoscopy and Adhesions (LAPAD) study (clinicaltrials.gov registration number: NCT01236625). A comparison was made between patients who developed major complications and minor or no complications regarding quality of life and hospital costs. RESULTS: Thirteen patients developed major complications while 34 patients developed only minor or no complications. Patients with major complications had a mean hospital cost of $16,369 vs $12,409 for patients without or with minor complications. We found no difference in quality of life between the two groups 6 months after surgery. CONCLUSIONS: In our cohort, major complications did not seem to have a detrimental effect on postoperative quality of life 6 months after surgery but they increased costs associated with esophageal resection.

Preoperative nomogram to predict risk of bowel injury during adhesiolysis.

BACKGROUND: Inadvertent bowel injury during adhesiolysis is a major cause of increased morbidity and mortality following abdominal surgery. Identification of risk factors predicting this complication would guide preoperative counselling and surgical decision-making. The aim of this study was to identify predictive preoperative factors for inadvertent bowel injury occurring during adhesiolysis. METHODS: All patients undergoing elective abdominal surgery between June 2008 and June 2010 were evaluated prospectively as part of the LAPAD study. Data on adhesiolysis and inadvertent organ injury were gathered by direct observation during operation. Univariable logistic regression was used to investigate factors that increased the risk of inadvertent bowel injury. Independent predictors of bowel injury were identified using multivariable logistic regression and used to create a clinical nomogram. RESULTS: Of 715 patients eligible for analysis, 48 (6.7 per cent) had inadvertent bowel injuries. In 42 patients the defect was detected during operation and in nine at a later time (3 patients had both). Bowel resection was required for almost two-thirds of the enterotomies. The number of previous laparotomies, anatomical site of the operation, presence of bowel fistula and laparotomy via a pre-existing median scar were independent predictors of bowel injury. A clinical scoring system was constructed using a nomogram incorporating these risk factors; this had a predictive discrimination, measured as the area under the receiver operating characteristic curve, of 0.85. CONCLUSION: A nomogram based on four independent factors predicted the risk of inadvertent bowel injury. REGISTRATION NUMBER: NCT01236625 (http://www.clinicaltrials.gov).

The emulsified lipid Fabuless (Olibra) does not decrease food intake but suppresses appetite when consumed with yoghurt but not alone or with solid foods: a food effect study.

The lipid emulsion Fabuless (Olibra) has been shown in some studies to decrease short/medium term energy intake (EI) and prevent weight regain. The purported mechanism is the ileal brake. Whether Fabuless is efficacious under a range of dietary conditions is unknown since studies have administered the emulsion within a fermented, semi-liquid dairy yoghurt, and outcomes have been inconsistent. To determine whether Fabuless suppresses post-ingestive satiety and short-term food intake under a range of dietary conditions and forms we administered the emulsion co-presented with 185 mL water, stirred into a semi-liquid dairy yoghurt, and co-presented with a solid food breakfast muffin. This was a cross-over study in 18 lean men randomised to 6 treatments: (i) lipid emulsion, LE (15 g Fabuless, containing 4.2g lipid, 0.2 MJ)+water, (ii) lipid control, LC (15 g non-emulsified lipid/water, containing 4.2g lipid, 0.2 MJ)+water, (iii) lipid emulsion+yoghurt, LE+Y (1.2 MJ), (iv) lipid control+yoghurt, LC+Y (1.2 MJ), (v) lipid emulsion+muffin, LE+M (1.2 MJ), (vi) lipid control+muffin, LC+M (1.2 MJ), each given as a test breakfast at 8.30 am. Participants rated postprandial appetite sensations using visual analogue scales (VAS), and ad libitum energy intake was measured at a lunch meal 3.5h later. The lipid emulsion increased fullness compared with an energy-matched lipid control but only when administered within the semi-liquid fermented yoghurt (P<0.05). There were no effects on satiety ratings when co-presented with water or with the solid food muffin. Energy and macronutrient intake were not significantly decreased by any of the emulsion treatments. We conclude that effects are small, the format in which lipid emulsions are consumed influences postprandial satiety, and there is no evidence that this emulsion alters eating behaviour at the subsequent meal.

Fatty acid chain length, postprandial satiety and food intake in lean men.

High-fat diets are associated with obesity, and the weak satiety response elicited in response to dietary lipids is likely to play a role. Preliminary evidence from studies of medium (MCT) and long chain triglycerides (LCT) supports greater appetite suppression on high-MCT diets, possibly a consequence of direct portal access, more rapid oxidation and muted lipaemia. No data is as yet available on high-SCT diets which also have direct hepatic access. In this study SCT- (dairy fats), MCT- (coconut oil) and LCT-enriched (beef tallow) test breakfasts (3.3 MJ) containing 52 g lipid (58 en% fat) were investigated in a randomized, cross-over study in 18 lean men. All participants were required to complete the 3 study days in randomised order. Participants rated appetite sensations using visual analogue scales (VAS), and energy intake (EI) was measured by covert weighing of an ad libitum lunch meal 3.5 h postprandially. Blood samples were collected by venous cannulation. There were no detectable differences between breakfasts in perceived pleasantness, visual appearance, smell, taste, aftertaste and palatability (P>0.05). There was no significant effect of fatty acid chain length on ratings of hunger, fullness, satisfaction or current thoughts of food, nor did energy (mean, sem: SCT: 4406, 366 kJ; MCT: 4422, 306 kJ; LCT: 4490, 324 kJ; P>0.05) or macronutrient intake at lunch differ between diets. The maximum difference in EI between diets was less than 2%. Postprandial lipaemia also did not differ significantly. We conclude that there was no evidence that fatty acid chain length has an effect on measures of appetite and food intake when assessed following a single high-fat test meal in lean participants.

Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs are associated with reduced hospital morbidity and mortality. The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery. In a cohort study, mortality, morbidity, and length of stay were compared between ERAS patients and carefully matched historical controls. METHODS: Patients were matched for their type of disease, the type of surgery, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) Physiological and Operative Score for Enumeration of Mortality and Morbidity (POSSUM), gender, and American Society of Anesthesiologists (ASA) grade. The primary outcome measures of this study were mortality and morbidity. Secondary outcome measures were fluid intake, length of hospital stay, the number of relaparotomies, and the number of readmissions within 30 days. Data on the ERAS patients were collected prospectively. RESULTS: Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care. The two groups were comparable with respect to age, ASA grade, P-Possum (Portsmouth-Possum), CR-Possum (Colorectal-Possum) score, type of surgery, stoma formation, type of disease, and gender. Morbidity was lower in the ERAS group compared to the control group (14.8% versus 33.6% respectively; P = <0.01). Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital (median 6 days, range 3-50 vs. median 9 days, range 3-138; P = 0.032). There was no difference between the ERAS and the control group for mortality (0% vs. 1.6%; P = 0.55) and readmission rate (3.3% vs. 1.6%; P = 0.60). CONCLUSION: Enhanced Recovery After Surgery program reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery.

No effect of an oleoylethanolamide-related phospholipid on satiety and energy intake: a randomised controlled trial of phosphatidylethanolamine.

BACKGROUND: Phosphatidylethanolamine (PE) is a phospholipid which is biosynthesized into long chain N-acylethanolamines (NAEs) including oleoylethanolamide (OEA), a known inhibitor of food intake. The aim of this study was to investigate whether PE-containing lipids can also inhibit intake. This was a 4 treatment intervention where 18 male participants were given a high-fat test breakfast (2.5 MJ, 53 en% fat) containing (i) high-phospholipid, high-PE lipid (ii) high-phospholipid, medium-PE lipid (iii) no-phospholipid, no-PE control lipid or (iv) water control, in a randomised cross-over. Visual analogue scales (VAS) were used to assess post-ingestive hunger and satiety, and energy intake (EI) was measured at an ad libitum lunch meal after 3.5 hours. RESULTS: When compared with the water control, the 3 lipid treatments resulted in lower levels of hunger and thoughts of food, greater fullness and satisfaction (all, treatment*time interaction, P<0.001), and a lower EI (P<0.05). However, there was no difference in any of the VAS measures when the 2 PE lipid treatments were compared with no-PE control lipid, nor when medium-PE was compared with high-PE. Unexpectedly participants ate significantly more energy at the lunch meal when the 2 PE lipid treatments (medium-PE:5406 kJ, 334 sem; high-PE:5288 kJ, 244 sem) were compared with the no-PE control lipid (5072 kJ, 262 sem, P<0.05), although there was no dose effect between the medium- and high-PE treatments. CONCLUSION: Despite the close relationship of PE with OEA, there was no evidence from this acute study that dietary phospholipids containing PE can favourably modify eating behaviour.

The effect of the dietary supplement, Chitosan, on body weight: a randomised controlled trial in 250 overweight and obese adults.

CONTEXT: Chitosan, a deacetylated chitin, is a widely available dietary supplement purported to decrease body weight and serum lipids through gastrointestinal fat binding. Although evaluated in a number of trials, its efficacy remains in dispute. OBJECTIVE: To evaluate the efficacy of chitosan for weight loss in overweight and obese adults. DESIGN AND SETTING: A 24-week randomised, double-blind, placebo-controlled trial, conducted at the University of Auckland between November 2001 and December 2002. PARTICIPANTS: A total of 250 participants (82% women; mean (s.d.) body mass index, 35.5 (5.1) kg/m(2); mean age, 48 (12) y) INTERVENTIONS: Participants were randomly assigned to receive 3 g chitosan/day (n=125) or placebo (n=125). All participants received standardised dietary and lifestyle advice for weight loss. Adherence was monitored by capsule counts. MAIN OUTCOME MEASURES: The primary outcome measure was change in body weight. Secondary outcomes included changes in body mass index, waist circumference, body fat percentage, blood pressure, serum lipids, plasma glucose, fat-soluble vitamins, faecal fat, and health-related quality of life. RESULTS: In an intention-to-treat analysis with the last observation carried forward, the chitosan group lost more body weight than the placebo group (mean (s.e.), -0.4 (0.2) kg (0.4% loss) vs +0.2 (0.2) kg (0.2% gain), P=0.03) during the 24-week intervention, but effects were small. Similar small changes occurred in circulating total and LDL cholesterol, and glucose (P<0.01). There were no significant differences between groups for any of the other measured outcomes. CONCLUSION: In this 24-week trial, chitosan treatment did not result in a clinically significant loss of body weight compared with placebo.

Slow rhythmic oscillations in intracranial CSF and blood flow: registered by MRI.

Since Lundberg first described slow oscillations as so called B-waves during ICP-monitoring, similar oscillations have been found in various physiological systems. Thus, the detection of slow waves in intracranial CSF- and blood-flow with MR-techniques seemed very likely. We examined the interventricular CSF-flow and cerebral blood flow of 11 healthy volunteers with dynamic echo-planar imaging by simultaneous registration of respiration and peripheral pulse. The spectral analysis was restricted to slow waves, which were divided into B-waves (0.008-0.05 Hz), Mayer- or C-waves (0.05-0.15 Hz) and respiration-related waves (0.15-0.6 Hz). In the CSF, the integrated amplitude of B-waves accounted for 18.2%, Mayer- or C-waves for 26.9% and respiration-related waves for 55.0%. Proportional values were recorded in the artery and peripheral pulse. In the venous sinus, a higher percentage of B- and Mayer-/C-waves and a lower percentage of respiration related waves were found. In conclusion, with MR-EPI technique, slow rhythmic oscillations in the cerebral blood- and CSF-flow can be analysed non-invasively and independently from the cardiac cycle. The comparable distribution of slow waves in the pulse, arteries and CSF may reflect an origin in autoregulation, whereas divergent patterns like in the incompressible venous sinus may be of a passive origin.

Detection of a relation between respiration and CSF pulsation with an echoplanar technique.

The flow of cerebrospinal fluid (CSF) through the aqueduct was studied with an echoplanar imaging technique. Images (1024) of a slice perpendicular to the aqueduct were acquired with a repetition time of 107 msec and a flip angle of 90 degrees. This imaging technique is very sensitive for flow into the selected slice, although a quantitative assessment of flow velocities is not possible. Simultaneously with the image data acquisition, data from a pulse oximeter and a respiration belt were recorded. For each data point, a delay time to the preceding cardiac pulse was determined from the recorded pulse wave. The signal intensities could then be assigned to the cardiac cycle. Each cardiac interval was assigned to one of eight respiratory phases, and an average signal curve during the cardiac interval was calculated for each respiration phase. The evaluation showed to signal maxima within the cardiac interval, which could be identified as a downward flow at 10% and an upward flow at 80% of the cardiac pulse interval by measurements with additional saturation pulses. In examinations of 22 healthy volunteers, an influence of respiration on the flow through the aqueduct was found. In spite of interindividual variability, comparable effects could be observed in all volunteers. In the late expiration phase the caudally directed flow was at its maximum, whereas the cranially directed flow was maximal in the post-inspiration phase.