A short-time economic evaluation of various modalities of glutamine dipeptide-enriched parenteral nutrition support in patients undergoing elective surgery for gastrointestinal tumors using decision-tree model / 中华临床营养杂志

Objective To assess the short-time economics of various glutamine dipeptide-enriched parenteral nutrition (PN) for patients undergoing elective surgery for gastrointestinal tumors, with an attempt to provide evidence for decision makers on clinical nutrition support.Methods A prospective cohort study was designed.From payer/disburser''s perspective, a cost-effectiveness decision-tree model was developed to assess the clinical outcomes and short-time economic effects of glutamine dipeptide-enriched PN that used in different time points (early postoperative or perioperative).Cost-effectiveness analysis, cost-utility analysis, and incremental cost-effectiveness analysis were adopted in the decision-tree model.One-way sensitivity analysis was performed to determine the robustness of the results.Results Totally 107 patients were included.There was no significant difference between the perioperative alanine(Ala) glutamine(Gln) nutrition support (group A) and early postoperative Ala-Gln nutrition support (group B) in the ratio of 5％ weight declines on the 8th day after surgery and infection-related postoperative complications (72.1％ vs.78.1％, χ2=0.509, P=0.498 and 2.32％ vs.4.69％, χ2=0.060, P=0.806).The levels of prealbumin (PA) and albumin(Alb) and the level of total lymphocyte count(TLC) also the time of recovering gastrointestinal function, length of stay nutritional discharge index(LOSNDI), and direct costs were significantly different [PA:(208.19±56.92)mg/L vs.(187.97±62.05)mg/L, t=2.283,P=0.039;Alb:(33.82±3.91)×109 vs.(31.96±4.57)×109, t=2.184, P=0.036;TLC:(1.19±0.55)×109 vs.(0.89±0.66)×109, t=2.461, P=0.015;the time of recovering gastrointestinal function(3.06±0.28)d vs.(3.39 ± 0.34)d, t=-3.675, P=0.000;LOSNDI:(16.84±2.92)d vs.(18.52 ±3.47)d, t=-2.613, P=0.011;direct costs:￥(17 029.05±317.28) vs.￥(15 610.64±292.56), t=23.764, P=0.000].When LOSNDI and quality-adjusted life years (QALYs) were estimated as indicators of effectiveness, the incremental cost-effectiveness ratios and incremental cost-utility ratios of group A were ￥844.3 and ￥70 920.5, respectively.Net monetary benefit of group B was more than that of group A.One-way sensitivity analysis showed that parameters had no significant effect on the model.Conclusion When using local per capita gross domestic product as threshold, early postoperative Ala-Gln PN was more economical than perioperative Ala-Gln PN strategy evaluation.

Chemopreventive Action of Anthocyanin-rich Black Soybean Fraction in APC(Min/+) Intestinal Polyposis Model

BACKGROUND: Anthocyanins have been shown to inhibit cancer cell growth by suppressing oxidative stress and inflammatory responses. The purpose of this study was to investigate the effects of an anthocyanin-rich extract (AE) from black soybean coat on intestinal carcinogenesis. METHODS: APC(Min/+) mice were fed a diet of 0.2% or 0.5% AE for 7 weeks. We analyzed the number of intestinal tumors, oxidative stress and inflammatory markers associated with beta-catenin and cytosolic phospholipase A2 (cPLA2) signals. The number of intestinal tumors, and cellular expression of beta-catenin were determined. RESULTS: The number of intestinal tumors was significantly lower in mice fed a 0.5% AE diet compared to those of the other groups. Cytosolic beta-catenin expression was significantly decreased in the AE supplemented groups compared to that of the control animals. In addition, mucosa expression of cyclooxygenase-2 and cPLA2 were also significantly decreased in the 0.5% AE group, by 32% and 62%, respectively, compared to the control group. CONCLUSIONS: These results suggest that dietary AE reduced the development of intestinal tumors, possibly through the ability to suppress oxidative stresses, decreasing inflammatory responses mediated by beta-catenin associated signals.

Neoplasias del intestino delgado / Small intestinal neoplasms

Small intestine tumors are infrequent lesions during the routine clinical practice. They appear sporadically, in association with genetic diseases (e.g familiar adenomatous polyposis or Peutz-Jeghers syndrome), or associated to chronic inflammatory diseases (e.g Crohn’s disease or celiac disease). Benign tumors of small intestine (e.g leiomyomas, lipomas, adenomas, hamartomas or desmoid tumors) are generally asymptomatic, and may show up with intussusception. Primary malignant small intestine tumors (e.g adenocarcinoma, leiomyosarcoma, carcinoid tumor and lymphoma), can appear with intestinal obstruction, jaundice, digestive bleeding or abdominal pain. Small intestine metastatic lesions can appear by nearness, peritoneal metastasis or by hematological way. This last dissemination type is infrequent and more typically of melanoma. Because of its low prevalence, unspecific symptomatology and relative inaccessibility by conventional endoscopy, the diagnostic of small intestine neoplasm is often made several months after the first symptoms. Enteroclysis is a useful imaging technique towards the small intestine neoplasm suspicion. The endoscopic capsule and enteroscopy are actually the best diagnostic and therapeutic methods for this type of neoplasm. The treatment depends in the type of neoplasm, being the tumoral resection the first-line therapy.

Los tumores de intestino delgado son lesiones infrecuentes en la práctica clínica habitual. Aparecen de forma esporádica en asociación con enfermedades genéticas (por ej., poliposis adenomatosa familiar o síndrome de Peutz-Jeghers), o bien asociados a enfermedades inflamatoria crónicas intestinales (por ej., enfermedad de Crohn o enfermedad celíaca). Los tumores benignos de intestino delgado (por ej., leiomiomas, lipomas, adenoma, hamartoma o tumor desmoide) son generalmente asintomáticos, pudiendomanifestarse con intususcepción. Los tumores malignos primarios de intestino delgado (por ej.,adenocarcinoma, leiomiosarcoma, carcinoide y linfoma), pueden presentarse con obstrucción intestinal, ictericia, sangramiento digestivo o dolor abdominal. Las lesiones metastásicas de intestino delgado pueden aparecer por contigüidad, metástasis peritoneal o por vía hematógena. Este último tipo de diseminación es infrecuente y más típico del melanoma. Debido a su baja prevalencia, sintomatología inespecífica y relativa inaccesibilidad por endoscopía convencional, el diagnóstico de las neoplasias de intestino delgado es realizado a menudo varios meses después de iniciado los síntomas. La enteroclisis es una técnica de imagen útil frente a la sospecha de neoplasia de intestino delgado. La cápsula endoscópica y la enteroscopía son los métodos actualmente de mayor rendimiento para el diagnóstico y eventual terapia de este tipo de neoplasias. El tratamiento depende del tipo de neoplasia, siendo la resección tumoral la terapia de primera línea.

Neoplasias duodenais primárias: análise de casuística e conduta cirúrgica / Primary duodenal tumors: clinicopathologic experience and surgical treatment

São apresentados 18 casos de neoplasias primárias do duodeno, salientando-se sua raridade e as dificuldades diagnósticas, a despeito dos modernos recursos endoscópicos e de identificação por imagem. A literatura revela que de 1% a 10% de todos os tumores do aparelho digestório se situam no intestino delgado. A localização duodenal é, por isso, muito pouco freqüente, possui sintomatologia indefinida e implica conduta terapêutica mais complexa do que quando o tumor se situa em outros segmentos do intestino delgado. Os sintomas mais comuns são dor, náusea, vômito e hemorragia. A presente casuística consiste de 11 neoplasias malignase sete benignas. Entre as primeiras o adenocarcinoma é o mais freqüente, sendo os lipomas os mais comuns dosneoplasmas benignos. Enquanto nestes a exérese local representa a conduta mais adequada, a duodenopancreatectomiacefálica foi a cirurgia de escolha nos tumores malignos da segunda porção duodenal, exibindo bons resultados. As lesões malignas da terceira porção e principalmente da quarta porção do duodeno foram tratadas pela ressecção duodenojejunal, também com resultados satisfatórios.

Eighteen primary duodenal tumors, including 11 malignant and 8 benign, are presented, stressing their poorly defined natural history and rare frequency. The most common histological diagnosis was adenocarcinoma. There were 6 adenocarcinomas, 2 carcinoids, 1 linfoma, 1 anaplastic and 1 neuroectodermic carcinoma. Benign lesions were occasionally found during a gastroduodenal or a biliary surgery (n = 4) and during the autopsies (n = 3). They consisted of lipomas (n = 4), adenomatous polyps (n = 2) and leiomyoma (n = 1). Concerning the malignant lesions, 6 pancreaticoduodenectomies, 3 duodenojejunal segmentary resection and one paliation consisting of gastrojejunostomy and biopsy were performed. One carcinoid lesion was found at the duodenal bulb during a gastroduodenectomy for a gastric ulcer. Pancreaticoduodenectomy can be done with acceptable risk and it seems that patients with duodenal adenocarcinoma are more likely to survive longer after radical surgery than those with cancer of the head of pancreas. Every patient of this series treated by pancreaticoduodenectomy or duodenojejunal segmentary resection had an uneventful recovery and the follow-up ranged from 16 months to 7 years. As for the duodenal carcinoids, local resection is usually followed by recurrence, so an agressive surgical management is the best approach. Benign tumors must be treated by local excision when disclosed.