The effect of post-discharge oral nutritional supplements on outcomes after gastrointestinal surgery: A systematic review and meta-analysis.

BACKGROUND: Malnutrition is a risk-factor for adverse postoperative outcomes. This systematic review and meta-analysis evaluated the impact of post-discharge oral nutritional supplements (ONS) on outcomes in patients undergoing gastrointestinal surgery. METHODS: The Medline and Embase databases were searched for randomised clinical trials in patients undergoing gastrointestinal surgery who had received ONS for at least two weeks after discharge from hospital. The primary endpoint was weight change. Secondary endpoints included quality of life, total lymphocyte count, total serum protein and serum albumin. Analysis was performed using RevMan5.4 software. RESULTS: Fourteen studies with 2480 participants (1249 ONS/1231 controls) were included. Pooling of results revealed that a reduction in postoperative weight loss in patients taking ONS, when compared with control: overall weighted mean difference (WMD) -1.69 kg, 95% CI -2.98 to -0.41, P = 0.01. Serum albumin concentration was increased in the ONS group: WMD = 1.06 g/L, 95% CI 0.04 to 2.07, P = 0.04. Haemoglobin was also increased: WMD = 2.91 g/L, 95% CI 0.58 to 5.25, P = 0.01. Total serum protein, total lymphocyte count, total cholesterol and quality of life did not differ between the groups. Patient compliance was relatively poor across the studies and there was variability in the composition of ONS, volume consumed and surgical procedures performed. CONCLUSIONS: There was a reduction in postoperative weight loss and an improvement in some biochemical parameters in patients receiving ONS after gastrointestinal surgery. Future RCTs with more consistent methodologies are needed to investigate the efficacy of ONS after discharge from hospital following gastrointestinal surgery.

Laparoscopic Cholecystectomy Versus Percutaneous Cholecystostomy: Suitability of APACHE-II Score, ASA Grade, and Tokyo Guidelines 18 Grade as Predictors of Outcome in Patients With Acute Cholecystitis.

INTRODUCTION: Intervention options in acute cholecystitis (AC) include drainage (percutaneous/endoscopic) or surgery. Several scoring systems have been used to risk stratify acute surgical patients, but few have been validated. This study investigated the suitability of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, American Society of Anesthesiologist (ASA) grade, and Tokyo Guidelines 2018 (TG18) grade as predictors of outcome and assess laparoscopic cholecystectomy versus percutaneous cholecystostomy (PC) as treatment options in patients with AC. MATERIALS AND METHODS: Retrospective data was collected from patients that underwent acute inpatient cholecystectomy (index admission), urgent interval cholecystectomy (2 to 4 wk) and PC between 2016 and 2018. Data included baseline demographics, co-morbidities, ASA grade, APACHE-II score, TG18 grade, morbidity, and mortality. A P-value of <0.05 was statistically significant. Area under the receiver operating characteristic curve was calculated to compare accuracy of APACHE-II, ASA and TG18 in predicting morbidity. RESULTS: A total of 344 consecutive patients (266 cholecystectomies and 84 PC) were included in the study. Significant difference in co-morbidities [median Charlson Co-Morbidity Index (CCI) 1 surgery and 4 cholecystostomy (PC) (P<0.05)], median APACHE-II score (3 surgery and 9 PC), median TG18 grade (1 surgery and 2 PC) and mortality rate [0% surgery and 7% cholecystostomy (PC)]. TG18 grade alone predicted postoperative/postprocedure morbidity (receiver operating characteristic; AUC=0.884; 95% confidence interval: 0.845-0.923; odds ratio: 4.38, 96% confidence interval, P<0.05). DISCUSSION: Utilization of the TG18 grade have shown to be more accurate in risk stratifying and predicting outcomes in patients with AC and therefore may appropriately guide biliary intervention.PC can be utilized in a select group of septic and co-morbid patients (myocardial infarction <6 weeks, chest infection and acute cerebrovascular accident) unable to withstand surgical intervention or in those with complex biliary disease (Mirizzi Syndrome). In a proportion, PC drains sepsis to improve critical state of the patient enough to consider an interval cholecystectomy with satisfactory outcomes.

Hypertriglyceridaemia as a risk factor for critical care admission in acute pancreatitis: A prospective study.

BACKGROUND AND AIMS: Hypertriglyceridaemia is both a primary cause of acute pancreatitis and an epiphenomenon. This study aimed to define the associations between hypertriglyceridaemia and clinical outcomes in patients admitted with acute pancreatitis. METHODS: This single-centre prospective observational study included patients with a confirmed clinical, biochemical or radiological diagnosis of acute pancreatitis from August 2017 to September 2018. Baseline demographics, aetiology of pancreatitis, and fasting triglyceride concentrations were recorded and assessed against the surrogate markers of severity: admission to critical care, length of stay (LOS), readmission to hospital, and mortality. RESULTS: In total, 304 patients with a mean ± SD age of 56.1 ± 19.7 years met the inclusion criteria. There were 217 (71.4%) patients with normotriglyceridaemia (<150 mg/dL or <1.7 mmol/L), 47 (15.5%) with mild hypertriglyceridaemia (150-199 mg/dL or 1.7-2.25 mmol/L) and 40 (13.2%) with moderate-to-severe hypertriglyceridaemia (≥200 mg/dL or >2.25 mmol/L). The underlying aetiologies of acute pancreatitis were gallstones (55%), alcohol (18%), idiopathic (15%), hypertriglyceridaemia (9%), iatrogenic (2%) and bile duct abnormalities (1%). Patients with hypertriglyceridaemia were younger than those with normotriglyceridaemia (p < 0.05). On multivariate regression, moderate-to-severe hypertriglyceridaemia (OR 5.66, 95% CI: 1.87 to 17.19, p = 0.002) and an elevated C-reactive protein concentration ≥120 mg/L (OR 1.00, 95% CI: 1.00-1.01, p = 0.040) were associated with admission to critical care. Moderate-to-severe hypertriglyceridaemia was also associated with an increased LOS (p = 0.002) but not readmission (p = 0.752) or mortality (p = 0.069). CONCLUSION: Moderate-to-severe hypertriglyceridaemia in all aetiological causes of acute pancreatitis was predictive of admission to critical care and prolonged LOS but not readmission or mortality.

The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials.

BACKGROUND: Chewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking. METHODOLOGY: A comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality. RESULTS: Sixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD - 0.31, 95% CI - 0.36, - 0.26, p < 0.00001) and time to defecation (WMD - 0.47, 95% CI - 0.60, - 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality. CONCLUSION: The use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting.

Perioperative Probiotics or Synbiotics in Adults Undergoing Elective Abdominal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To define the impact of perioperative treatment with probiotics or synbiotics on postoperative outcome in patients undergoing abdominal surgery. BACKGROUND: Postoperative surgical infection accounts for a third of all cases of sepsis, and is a leading cause of morbidity and mortality. Probiotics, prebiotics, and synbiotics (preparations that combine probiotics and prebiotics) are nutritional adjuncts that are emerging as novel therapeutic modalities for preventing surgical infections. However, current evidence on their effects is conflicting. METHODS: A comprehensive search of the PubMed, Embase, and WHO Global Index Medicus electronic databases was performed to identify randomized controlled trials evaluating probiotics or synbiotics in adult patients undergoing elective colorectal, upper gastrointestinal, transplant, or hepatopancreaticobiliary surgery. Bibliographies of studies were also searched. The primary outcome measure was incidence of postoperative infectious complications. Secondary outcomes included incidence of noninfectious complications, mortality, length of hospital stay, and any treatment-related adverse events. Quantitative pooling of the data was undertaken using a random effects model. RESULTS: A total of 34 randomized controlled trials reporting on 2723 participants were included. In the intervention arm, 1354 patients received prebiotic or symbiotic preparations, whereas 1369 patients in the control arm received placebo or standard care. Perioperative administration of either probiotics or synbiotics significantly reduced the risk of infectious complications following abdominal surgery [relative risk (RR) 0.56; 95% confidence interval (CI) 0.46-0.69; P < 0.00001, n = 2723, I = 42%]. Synbiotics showed greater effect on postoperative infections compared with probiotics alone (synbiotics RR: 0.46; 95% CI: 0.33-0.66; P < 0.0001, n = 1399, I = 53% probiotics RR: 0.65; 95% CI: 0.53-0.80; P < 0.0001, n = 1324, I = 18%). Synbiotics but not probiotics also led to a reduction in total length of stay (synbiotics weighted mean difference: -3.89; 95% CI: -6.60 to -1.18 days; P = 0.005, n = 535, I = 91% probiotics RR: -0.65; 95% CI: -2.03-0.72; P = 0.35, n = 294, I = 65%). There were no significant differences in mortality (RR: 0.98; 95% CI: 0.54-1.80; P = 0.96, n = 1729, I = 0%) or noninfectious complications between the intervention and control groups. The preparations were well tolerated with no significant adverse events reported. CONCLUSIONS: Probiotics and synbiotics are safe and effective nutritional adjuncts in reducing postoperative infective complications in elective abdominal surgery. The treatment effects are greatest with synbiotics.

Twelve Tips for Developing Clinical Reasoning Skills in the Pre-Clinical and Clinical Stages of Medical School.

Clinical reasoning (CR) is a complex skill required in future clinicians. The best way to develop CR has not been fully elucidated in existing literature. Barriers to CR development include content, environmental, and teacher or expert physician factors. We have reviewed literature, interviewed medical students and teaching staff at the University of Nottingham, and evaluated our teaching delivery. We identified twelve strategies to combat barriers to CR learning at our university. The foundation for CR must be built early through lectures and case-based learning. We emphasize the irreplaceable nature of ward-based learning and add on methods of optimizing time on wards. Placement on acute wards with trained teaching staff to facilitate CR teaching was suggested. Ward time should be supplemented with symptom-focused teaching, patient workshops, simulation sessions, virtual case banks, and clinical skills practice. However, ward time is the utmost priority and must not be replaced.