Clinical impact of malnutrition on complication rate and length of stay in elective ENT patients: a prospective cohort study.

Malnutrition is considered as an independent risk factor for morbidity, mortality and a prolonged hospital stay for in-hospital patients. While most available data on the impact of malnutrition on health-related and financial implications refer to gastroenterologic or abdominal surgery patients, little is known about the impact of malnutrition on Ear Nose Throat (ENT)/head and neck surgery patients. The objective of this study was to investigate the impact of malnutrition on morbidity and length of hospital stay in an elective ENT/head and neck surgery patient cohort. The study was performed as a single-center, prospective cohort study at a tertiary referral centre. Nutritional risk at admission was assessed using the NRS-2002 screening tool. Multivariate regression models were used to determine independent risk factors for complications and a prolonged hospitalization. Three hundred fifty one participants were included in the study. A malignant disease was found in 62 participants (17.7 %). 62 patients (17.7 %) were at a moderate to severe risk of malnutrition. A bad general health condition and complications during hospital stay could be identified as independent risk factors for a prolonged hospitalization. Patients with a malignant tumor showed a more than fourfold higher risk of developing at least one complication. Malnutrition, however, was not statistically associated with a higher complication rate or a prolonged hospital stay. Our data suggests that malnutrition does not seem to play such an important role as a risk factor for complications and a prolonged hospital stay in ENT patients as it does in other disciplines like abdominal surgery or gastroenterology.

[Clinical nutrition in surgery. Guidelines of the German Society for Nutritional Medicine]. / Klinische Ernährung in der Chirurgie. S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin e. V.

BACKGROUND: While enhanced recovery after surgery (ERAS) programs are the standard for perioperative management, special nutritional care has to be administered to malnourished patients and those at metabolic risk with special regard to patients with postoperative complications. METHODS: Existing guidelines of the German and European societies of nutritional medicine (DGEM and ESPEN) on enteral and parenteral nutrition in surgery were merged and in accordance with the principles of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, German Association of the Scientific Medical Societies) and Ärztliches Zentrum für Qualität in der Medizin (AeZQ, German Agency for Quality in Medicine) revised and extended. RESULTS AND DISCUSSION: The working group developed 41 consensus-based recommendations for perioperative nutrition. The recommendation strength is: 9x A (recommendation based on significant good quality literature containing at least one randomized controlled trial), 12x B (recommendation based on well-designed trial without randomization), 13x C (recommendation based on expert opinions and/or clinical experience of respected authorities) and 7x CCP (clinical consensus point). CONCLUSION: Even in patients without obvious malnutrition perioperative nutritional support is indicated when oral food intake is not feasible or inadequate for a longer period of time.

A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study.

PURPOSE: Early recovery after surgery concepts have gained wide acceptance in various surgical specialties. However, limited data are available for radical cystectomy. A new early recovery after surgery concept was compared to a more conservative regimen in patients undergoing radical cystectomy for bladder cancer. MATERIALS AND METHODS: A total of 101 consecutive patients were prospectively randomized to early recovery after surgery (62) or a conservative regimen (39) (intended randomization ratio was 2 early recovery after surgery-to-1 conservative regimen). Primary end points were differences in quality of life, and secondary end points included postoperative morbidity, demand for analgesics, time spent in the intermediate care unit, mobility and number of gastrointestinal events during hospital stay. RESULTS: Quality of life parameters, as measured by the EORTC (European Organization for the Research and Treatment of Cancer) Quality of Life questionnaire QLQ-30 did not change significantly between postoperative days 3 and 7 and at discharge from hospital in the conservative regimen group, whereas a significant improvement was observed in the early recovery after surgery group. Postoperative morbidity was lower in the early recovery after surgery group in terms of wound healing disorders (p = 0.006), fever (p = 0.004) and thrombosis (p = 0.027). The demand for analgesics was significantly lower in the early recovery after surgery group. The amount of food consumed in relation to the amount of food offered was significantly higher for the early recovery after surgery group as early as day 3 (p = 0.02). Time spent in the intermediate care unit was significantly shorter for the early recovery after surgery group (p <0.001). There were no significant differences between the groups with respect to gastrointestinal events. The main limitations of this study were the lack of long-term data as well as the single center approach. CONCLUSIONS: Early recovery after surgery of patients who underwent radical cystectomy appears to have significant benefits compared to a conservative regimen in terms of postoperative morbidity, quality of life, use of analgesics and time spent in the intermediate care unit.

Nutritional screening for risk prediction in patients scheduled for abdominal operations.

BACKGROUND: Increased risks related to surgery might reflect the nutritional status of some patients. Such a group might benefit from perioperative nutritional support. The purpose of this study was to identify the relative importance of nutritional risk screening along with established medical, anaesthetic and surgical predictors of postoperative morbidity and mortality. METHODS: This prospective observational study enrolled consecutive eligible patients scheduled for elective abdominal operations. Data were collected on nutritional variables (body mass index, weight loss, food intake), age, sex, type and extent of operation, underlying disease, American Society of Anesthesiologists grade and co-morbidities. A modified composite nutritional screening tool (Nutritional Risk Screening, NRS 2002) currently recommended by European guidelines was used. Relative complication rates were calculated with multiple logistic regression and cumulative proportional odds models. RESULTS: Some 653 patients were enrolled of whom 132 (20.2 per cent) sustained one or more postoperative complications. The frequency of this event increased significantly with a lower food intake before hospital admission. No other individual or composite nutritional variable provided comparable or better risk prediction (including NRS 2002). Other factors significantly associated with severe postoperative complications were ASA grade, male sex, underlying disease, extent of surgical procedure and volume of transfused red cell concentrates. CONCLUSION: In abdominal surgery, preoperative investigation of feeding habits may be sufficient to identify patients at increased risk of complications. Nutritional risk alone, however, is not sufficient to predict individual risk of complications reliably.

Malnutrition and clinical outcome in urological patients.

INTRODUCTION: In a previous study we evaluated the risk for malnutrition among urological patients in a German university hospital. There are published different studies in other surgical fields that could show a correlation between malnutrition and clinical outcome. As data on this issue is still rare in the urological field we aimed to correlate the risk of malnutrition with different parameters regarding clinical outcome. METHODS: In the time from 2007 to 2009 a total of 320 patients were evaluated regarding the risk of malnutrition and occurrence of complications during the time of hospitalization at our Urological department. The Nutritional risk screening 2002 (NRS) by Kondrup et al. was used for the estimation of the risk level for malnutrition. Patients of a German university hospital were included independently of intervention, age or gender. Parameters for clinical outcome were: pulmonary complications (infectious/noninfectious), cardiovascular complications (infectious/noninfectious), other infections (urinary tract infection etc.), wound healing disorders and time of hospitalization. RESULTS: In this evaluation 320 patients were included for analysis. Forty patients (13%) presented with a normal nutritional status (NRS score 0) at the time of admission to the hospital and 212 patients (66%) were at risk for forming malnutrition problems (NRS score 1-2). Sixty eight patients (21%) of this urological cohort were detected with a malnutrition according to the applied NRS Score (≥3). Regarding the occurrence of overall complications in this cohort the rate was rather low compared to other surgical fields. Of 320 patients only 22 patients (7%) presented with relevant complications during their hospitalization. However if data were stratified for peri- and postoperative complications in correlation to nutritional status of patients, an evident trend to a higher complication rate of 9% was obvious. CONCLUSIONS: In our cohort of exclusively urological patients, the risk for post-surgical complications was higher in patients who were malnourished as defined using the Nutritional Risc Screening System (NRS) by Kondrup et al. Further studies need to show whether an adequate nutritional supportive therapy could help to optimize the clinical outcome of malnourished urological patients.

[Fast track approach in radical cystectomy]. / "Fast track" bei der radikalen Zystektomie.

The origins of the fast track concept in the field of elective colon surgery can be traced back to the beginning of the 1990s. The first studies performed by Kehlet et al. sparked interest in this new form of patient management among physicians and hospital administrators. Different fast track programs for patients undergoing radical cystectomy can be found in the current literature. The goal of the prevailing fast track concepts is to reduce the perioperative burden, optimize postoperative convalescence, decrease the postoperative need for analgesics, lower the postoperative morbidity rate, and shorten hospital stays.

[Diabetes mellitus - perioperative management]. / Perioperatives Management bei Diabetes mellitus.

The prevalence of diabetes in hospitalized adults is conservatively estimated at 12-25% and rising. Poor glucose control and presence of diabetes complications (e.g. diabetic nephropathy, diabetic neuropathy, atherosclerosis) are commonly regarded as risk factors for perioperative morbidity and mortality. Thus it is crucial to determine diabetes comorbidities preoperatively in order to avoid perioperative renal and cardiovascular complications. Perioperative glycemic control is challenging due to preoperative changes in diabetes treatment and the effects of surgery-associated stress hyperglycemia. For patients in general surgical units, evidence for specific glycemic goals is based on epidemiologic and physiologic data rather than clinical trials. According to guidelines of the German Society of Nutrition, the approximation of normoglycemia is reasonable as long as hypoglycemia is avoided (suggested range for plasma glucose 80-145 mg/dL).

Complications and monitoring - Guidelines on Parenteral Nutrition, Chapter 11.

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks.

[Elective colon resection in Germany. A survey of the perioperative anesthesiological management]. / Elektive Kolonresektionen in Deutschland. Umfrage zum perioperativen anästhesiologischen Management.

BACKGROUND: Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany. METHODS: In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection. RESULTS: The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia. CONCLUSION: In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

[A survey of perioperative therapy for elective colon resection in Germany, 2006]. / Umfrage zur perioperativen Therapie bei elektiven Kolonresektionen in Deutschland 2006.

BACKGROUND: Despite the evidence that fast-track concepts in colon surgery lead to an enhanced recovery rate, there is no information on the prevalence and utilization of such programs in Germany. METHODS: Based on a conventional sigmoid resection, we asked 1,270 surgical departments in Germany to describe their standard surgical procedures in a questionnaire. RESULTS: The response rate was 385 (30.31%). A total of 96% use a bowel preparation, 83% a vertical incision, 10% use a nasogastric decompression for longer then 1 day, 34% avoid intra-abdominal drains, 51% allow clear fluids on the day of surgery, 13% offer solid food on the first day after surgery, 75% use epidural analgesia and 47% discharge the patients by the seventh day after surgery. CONCLUSION: Although there is an evident benefit using fast-track concepts, they are not yet in wide use as a standard procedure. Further efforts have to be made to ensure that the majority of patients will benefit from these concepts.

[Nutritional therapy. Indication and approaches]. / Enterale Ernährung. Indikation und Zugangswege.

Appropriate nutritional therapy of surgical patients intends to supply calories for the maintenance of essential body functions. Beyond this goal, nutritional support may also significantly reduce nosocomial morbidity if applied properly and to the right patients. In surgical patients, nutritional therapy should start preoperatively by identifying and treating malnutrition and be continued postoperatively as a patient-tailored supportive measure. Oral/enteral nutrition is feasible in the majority of patients. Rare exceptions are patients with intestinal leakage, overt ileus, and circulatory shock. If the upper gastrointestinal tract is not functioning (as in swallowing disorders or after construction of surgical anastomoses), tube systems may be used. They can be placed endoscopically or at the time of surgery (needle catheter jejunostomy) to allow continuous enteral nutrition. If oral/enteral nutrition cannot completely meet caloric requirements of the patient, additional parenteral supply is indispensable to reach the intended caloric goal.

Laparoscopic repair of an extrahiatal hernia caused by congenital dysplasia: a case report.

A 40-year-old woman with complaints of relapse in the upper abdomen and dysphagia was referred for laparascopic hiatal hernia repair. Chest radiograph, barium-swallow, and upper endoscopy revealed a paraesophageal hernia. Esophageal manometry and 24-h-pH study showed no pathological findings. A laparoscopic gastropexy was planned. Intraoperatively, in contradiction to the preoperative findings, an extrahiatal hernia containing most of the stomach was found. After resection of the hernia sac, the beating heart without covering pericardium was seen. These findings were confirmed by an additional thoracoscopy at the end of the operation. The defect was closed by direct suturing. The postoperative course and 2-month follow-up were uneventful. The resected parts of the hernia sac showed an embryonic and dysgenetic etiology. This rare malformation has been reported in combination with complex syndromes, which appear with serious clinical and morphological signs in the neonatal period. In adults, the pericardial aplasia can be observed during diagnostic or surgical interventions. In these patients, complaints are usually not caused by the malformation but may be due to the occasional herniation of abdominal organs. We consider laparoscopic repair to be a gentle and safe procedure for the treatment of extrahiatal hernias.

Effect of elective abdominal surgery on human colon protein synthesis in situ.

OBJECTIVE: To determine the effect of elective abdominal surgery on the rate of human colon fractional protein synthesis in situ. SUMMARY BACKGROUND DATA: Efficient intestinal protein synthesis plays an important role in the physiology and pathophysiology of the intestinal tract, allowing preservation of gut integrity and thereby preventing bacterial or endotoxin translocation. Because of species differences, animal studies have only limited applicability to human intestinal protein metabolism, and because of methodologic restrictions, no studies on colon protein synthesis in situ are available in humans. METHODS: The authors used advanced mass spectrometry techniques (capillary gas chromatography and combustion isotope ratio mass spectrometry) to determine directly the incorporation rate of 1-[13C]-leucine into colon mucosal protein in control subjects and nonseptic postoperative patients. All subjects had a colostomy, which allowed easy access to the colon mucosa, and consecutive sampling from the same tissue was performed during continuous isotope infusion (0.16 micromol/kg per minute). RESULTS: Control subjects demonstrated a colon protein fractional synthetic rate of 0.74 +/- 0.09% per hour. In postsurgical patients, colon protein synthesis was significantly higher and the tissue free leucine enrichment was significantly lower, compatible with an increased colon proteolytic rate. CONCLUSIONS: Elective abdominal surgery followed by an uncomplicated postoperative course is associated with a stimulation of colon protein synthesis and possibly also of protein degradation. The postoperative rate of colon protein synthesis is, compared with other tissues, among the highest measured thus far in humans.

Determination of protein synthesis in human ileum in situ by continuous [1-(13)C]leucine infusion.

Efficient protein synthesis plays an important role in the physiology and pathophysiology of the human gastrointestinal tract. Because of methodological restrictions, no studies on ileal protein synthesis in situ are available in humans. We used advanced mass spectrometry techniques (capillary gas chromatography/combustion isotope ratio mass spectrometry) to determine directly the incorporation rate of [1-(13)C]leucine into ileal mucosal protein in control subjects and postoperative patients. All subjects had an ileostomy, which allowed easy access to the ileal mucosa. To examine changes in ileal protein synthesis during prolonged isotope infusion (0.16 micromol. kg(-1). min(-1), 9.6 micromol/kg prime), studies were performed over a 10-h period. Mucosal biopsies were performed after 3, 6, and 10 h of infusion. Protein synthesis was calculated separately between hour 3 and hour 6 (period 1) and hour 6 and hour 10 (period 2). Control subjects demonstrated an ileal protein fractional synthetic rate of 0.62 +/- 0.06%/h in period 1 and of 0. 52 +/- 0.08%/h in period 2 (not significant). In postsurgical subjects, ileal protein synthesis was significantly higher (1.11 +/- 0.14%/h in period 1, P < 0.01 vs. controls in period 1) but declined markedly in period 2 (0.39 +/- 0.13, P < 0.01 vs. period 1 after surgery). The rate of protein synthesis in the small bowel of control subjects is, thus far, among the lowest measured in mammals and reflects the comparably slow turnover of human ileal mucosa. Postoperative disturbances of gut integrity lead to an accelerated anabolic response. During prolonged isotope infusion, stimulated protein synthesis declines because of diurnal variations or is erroneously reduced by tracer loss due to an accelerated cell turnover.