Make efforts to improve overall levels of clinical nutriology in China / 中华胃肠外科杂志

Clinicians should assume the responsibility of nutritional therapy for satisfactory outcomes. They should master knowledge on nutritional metabolism, and participate in the administration of nutritional support. Clinicians should be acquainted with new concepts and standardized techniques in this field, such as different requirement of energy, understanding of early nutritional support, and optimal regimens of enteral or parenteral nutrition.

Application of enhanced recovery program after surgery(ERAS) in patients undergoing radical resection for colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the enhanced recovery program after surgery (ERAS) with conventional perioperative management in patients undergoing radical resection for colorectal cancer.</p><p><b>METHODS</b>The ERAS protocol included a combination of evidence-based and consensus methodology. A total of 597 consecutive patients undergoing elective colorectal resection were randomized to either the ERAS(n=299) or the control group(n=298). Outcomes related to nutrition and metabolism index, stress index, and recovery index were measured and recorded.</p><p><b>RESULTS</b>Demographics and operative parameters were similar between the two groups(P>0.05). The nutritional status of patients in the ERAS group was improved after surgery compared with that of the control group. On postoperative day (POD) 1, the HOMA-IR in the ERAS group was significantly lower than that in the control group(P<0.01). The cortisol level in the control group was elevated on both POD 1(P<0.01) and POD 5(P<0.01) compared to the preoperative level. However, the cortisol level was not increased until POD 5(P<0.01) in the ERAS group. The levels of TNF-α, IL-1β, IL-6, and IFN-γ were reduced in the ERAS group, indicating less postoperative stress responses compared with the control group. In addition, ERAS group was associated with accelerated recovery of gastrointestinal function. The postoperative length of stay [(5.7±1.6) d vs. (6.6±2.4) d, P<0.01] and expense[(15 998±2655) RMB vs. (17 763±3059) RMB, P<0.01] were reduced in the ERAS group. Twenty-eight patients(9.4%) in the control group and 29(9.7%) in the ERAS group developed complications, while the difference was not statistically significant(P>0.05).</p><p><b>CONCLUSION</b>ERAS protocol alleviates surgical stress response and accelerates postoperative recovery without compromising patient safety.</p>

Assessment of energy expenditure and body composition in cancer patients / 中华外科杂志

<p><b>OBJECTIVE</b>To demonstrate the changes of resting energy expenditure (REE), substrate metabolism and body composition in cancer patients.</p><p><b>METHODS</b>From September 2004 to March 2008, REE, carbohydrate oxidation (CO) and fat oxidation (FO) in 936 cancer patients and 840 control subjects were measured by indirect calorimetry. Bioelectrical impedance appliance was applied to assess intracellular fluid, extracellular fluid, fat mass (FM) and fat free mass (FFM) in the two groups.</p><p><b>RESULTS</b>No difference in REE was found between the cancer patients and non-cancer patients [(1452.2 +/- 196.4) kcal/d vs. (1429.5 +/- 182.6) kcal/d, P = 0.136]. But REE/FFM and REE/pREE were elevated in cancer patients than in controls (all P < 0.05). Of the cancer patients, 48.6% were hypermetabolic, 42.9% normal and 8.5% hypometabolic, while those were 22.5%, 58.5% and 19.0% in controls. Cancer patients had higher FO [(77.8 +/- 11.3) g/min vs. (67.1 +/- 12.1) g/min, P = 0.000], lower CO and npRQ [(68.7 +/- 10.5) g/min vs. (88.8 +/- 12.1) g/min, P = 0.000; 0.782 +/- 0.012 vs. 0.810 +/- 0.014, P = 0.000]. Cancer patients exhibited lower FM and FFM [(14.9 +/- 4.5) kg vs. (18.4 +/- 5.2) kg, P = 0.000; (44.4 +/- 7.2) kg vs. (46.1 +/- 8.1) kg, P = 0.008].</p><p><b>CONCLUSIONS</b>Elevated REE is common in cancer patients. Substrate metabolism of the cancer patients features in increased FO, decreased CO and npRQ, which is correlated with the elevated REE. FM and FFM loses in proportion in cancer patients.</p>

Therapeutic effects of hepatic resection in liver metastasis of colorectal cancer / 中华外科杂志

<p><b>OBJECTIVES</b>To evaluate therapeutic effects of hepatic resection in liver metastasis of colorectal cancer (LMCC).</p><p><b>METHODS</b>The clinical data of 133 cases of LMCC received hepatic resection from January 1, 2000 to December 31, 2005 in Zhongshan Hospital were analyzed retrospectively. The relationship between hepatic resection and survival rate was also concerned.</p><p><b>RESULTS</b>One hundred and thirty-three cases received curative hepatic resection in all 470 LMCC cases, of which 30 cases from synchronous liver metastasis (SLM) group (totaled 196 cases) and 103 cases from metachronous liver metastasis (MLM) group (totaled 274 cases). Mortality rate during operation was 3.3% in SLM and 1.9% in MLM (P < 0.05). All patients were followed-up till June 31, 2006, the 1, 3, 5 year survival rates and median survival time of SLM were similar to those of MLM, but its recurrence rate was higher (36.7% vs 20.4%, P = 0.030). The 1, 3, 5 year survival rate in the 49 patients who were operable but received non-operation treatment were significantly lower than those in operated patients (P = 0.003). In 30 SLM cases, 22 received I stage resection of their primary and liver metastasis tumor and 8 received liver metastasis resection after the primary surgery (II stage operation), 1, 2, 3 year survival and the median survival time were similar in the two groups. With COX multivariate analysis, incision margin > or = 1 cm (P = 0.036) and reoperation after recurrence (P = 0.041) were protective survival factors, and post-operation recurrence (P = 0.023) was survival risk factor.</p><p><b>CONCLUSIONS</b>Curative hepatic resection is the first choice of therapy in liver metastasis of colorectal cancer and it can improve survival.</p>

A randomized controlled trial of postoperative artificial nutrition in malnourished patients with gastrointestinal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the potential benefits of postoperative nutrition in malnourished patients with gastrointestinal cancer.</p><p><b>METHODS</b>A total of 646 malnourished patients with gastrointestinal cancer defined by the subjective global assessment (SGA) were randomly divided into parenteral nutrition group (n=215), enteral nutrition group (n=215) and conventional group (n=216). Two nutritional regimens were designed to be isocaloric 125.5 kJ(30 kcal).kg(-1).d(-1) and isonitrogenous 0.25 g.kg(-1).d(-1) for 7 postoperative days. Conventional group did not receive artificial nutrition before and after surgery. Postoperative complications, mortality and postoperative length of hospital stay were compared.</p><p><b>RESULTS</b>All baseline and surgical characteristics were comparable among 3 groups. Overall postoperative mortality was 1.5%, and no difference was observed among 3 groups. Postoperative complications occurred in 61(28.4%) patients in enteral nutrition group, 72(33.5%) in parenteral nutrition group, and 97 (44.9%) in conventional group (P=0.000 vs enteral nutrition group; P=0.001 vs parenteral nutrition group). Postoperative length of hospital stay was (9.8+/-3.4) d in enteral nutrition group, (11.2+/-5.0) d in parenteral nutrition group, and (14.5+/-7.1) d in conventional group (P=0.001 vs enteral nutrition group; P=0.003 vs parenteral nutrition group).</p><p><b>CONCLUSIONS</b>Postoperative artificial nutrition support is beneficial to the malnourished patients with gastrointestinal cancer, which improves postoperative outcome. Early enteral nutrition significantly reduces the infectious complication rate and length of postoperative hospital stay as compared with parenteral nutrition.</p>

Survival of patients with liver metastasis from colorectal cancer by different modes of therapy: a report of 363 cases / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate the correlation between different therapies and survival of liver metastasis from colorectal cancer ( LMCC) , and to compare the clinical outcome of synchronous liver metastasis (SLM) with that of metachronous liver metastasis (MLM).</p><p><b>METHODS</b>The clinical data of 363 patients with LMCC were retrospectively reviewed with focus on the correlation between different therapy and survival.</p><p><b>RESULTS</b>Of these 363 patients, 160 had SLM and 203 had MLM. Between the SLM and MLM group, there was no significant difference in age, or gender or primary cancer site (P > 0. 05 ), but significant differences were observed in condition of liver metastasis including liver lobe involved, focus number, maximum focus diameters and level of serum CEA and CA199 before therapy(P <0. 05). Ninety-one patients underwent curative hepatic resection, 22 of them in the SLM group and 69 in the MLM group. Mortality rate related to operation was 4. 5% (1/22) in SLM group and 2. 9% (2/69) in MLM group( P < 0.05). All patients were followed until 31/6/2005. The 3-year survival rate was 5. 2% with a median survival time of 10 +/- 1 months for the SLM group, and it wasl6. 4% and 17 +/- 1 months for the MLM group (P<0.01). Regarding to the treatment modalities, the 3-year survival rate was 30. 2% with a median survival time of 26 months for curative hepatic resection group, and it was 0% - 16. 7% and 10 - 17 months for non-operation groups treated by intervention, chemotherapy, radiofrequency therapy, percutaneous ethanol injection and Chinese traditional drugs (P <0. 05, P <0. 01 ).</p><p><b>CONCLUSION</b>Curative hepatic resection is still the first choice for liver metastasis from colorectal cancer improving the survival significantly. Other non-operative methods also can improve phase II resection rate. Metachronous liver metastasis has higher resection rate and better survival than the synchronous liver one.</p>

Effects of glucagon-like peptide 2 on the adaptation of residual small bowel in a rat model of short bowel syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effects of glucagon-like peptide 2 (GLP-2) on the morphology and functional adaptation of the residual small bowel in rat model of short bowel syndrome.</p><p><b>METHODS</b>Twenty rats with 75% of the midjejunoileum removed were randomly divided into two groups, and received intra-peritoneal injection of GLP-2(250 micro*gd*kg-1*d-1) or subcutaneous injection saline(0.5 ml, twice one day) after operation. On postoperative day 6, the morphological changes of the residual jejunum and ileum, the expression of proliferating cell nuclear antigen(PCNA), and the mRNA expressions of Na-D-glucose cotransporters (SGLT1) and peptide cotransporters (PEPT1) were determined. The intestinal glucose absorption data per unit length as well as per unit weight of ileum were measured by in vivo circulatory perfusion experiment.</p><p><b>RESULTS</b>The morphological parameters of the residual gut such as the thickness of mucosa, height of villus, depth of crypt, and PCNA positive index were significantly higher, while the apoptosis rate per unit of mucosal square was significantly lower in GLP-2 treatment group than those in the control group. The expressions of mRNA SGTLl and PEPT1 in the residual ileum were significantly higher than those in the control group. There was no significant difference in glucose absorption rate per gram of mucosal wet weight between the two groups (P > 0.05).</p><p><b>CONCLUSION</b>GLP-2 could improve morphological and functional adaptation of the residual small bowel by stimulating enterocyte proliferation and decreasing enterocyte apoptosis in short bowel syndrome.</p>

Prevalence of malnutrition in general surgical patients: evaluation of nutritional status and prognosis / 中华外科杂志

<p><b>OBJECTIVE</b>To estimate prevalence of malnutrition on admission to hospital and the relationship between nutritional status and prognosis.</p><p><b>METHODS</b>Four thousand and twelve patients admitted to general surgery department were evaluated by a lot of nutrition indexes within 48 h. Operative morbidity and complications were recorded to identify the difference between malnourished and well-nourished patients.</p><p><b>RESULTS</b>Malnutrition rate of all patients according to BMI, TSF, MAC, AMC, albumin, prealbumin, and lymphocyte count was 21.3%, 50.6%, 20.5%, 21.2%, 24.2%, 35.4% and 55.8%, respectively. The prevalence of malnutrition as defined by SGA and MNA were 38.8% and 20.8%. The older patients (> 60 years old) were associated with a higher prevalence of malnutrition (47.6%) compared with those younger than 60 (31.5%). Malnutrition was more frequently occurred in cancer patients than non-oncologic patients (64.5% vs 22.4%). Patients with digestive tract disease had higher rates of malnutrition than those without digestive tract disease (52.6% vs 30.0%). There were large differences in the morbidity and complications between well nourished patients and malnourished patients (4.0% vs 1.1%, P < 0.01 for morbidity; 19.8% vs 5.9% for complications).</p><p><b>CONCLUSIONS</b>The prevalence of malnutrition in hospitalized surgical patients is high. Malnutrition was associated with increased length of stay, higher operative morbidity and complications.</p>

Effect of glutamine and growth hormone on adaptation in short bowel syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To assess the effects of parenteral glutamine and growth hormone supplementation on gut adaptation for patients with short bowel syndrome.</p><p><b>METHODS</b>Twenty-six patients [male 15, female 11, aged (39 +/- 23) years] with short bowel syndrome received parenteral nutrition (PN) 3-52 months after surgical resection. The median length of remnant small intestine was 42.5(0-100)cm. All patients received growth hormone (0.10+/- 0.06) mg.kg(-1).d(-1) plus glutamine (0.30 +/- 0.17) mg.kg(-1).d(-1) for two or three weeks.</p><p><b>RESULTS</b>Among the 26 patients, PN was not required soon after treatment in 34.6% (n=9) of the patients, the frequency and volume of PN decreased from (6.0 +/- 1.0) d to (4.2 +/- 1.0) d, from (13.6 +/- 5.2) L per week to (8.2 +/- 3.3) L per week respectively in 30.8% (n=8) of the patients,while 34.6% (n=9) still required PN after treatment.</p><p><b>CONCLUSION</b>The combined administration of glutamine and growth hormone can promote remnant intestinal adaptation in short bowel patients.</p>