A randomized controlled trial comparing a standard postoperative diet with low-volume high-calorie oral supplements following colorectal surgery.

AIM: Postoperative oral nutritional supplementation is becoming a part of most patient care pathways. This study examined the effects of low-volume high-calorie prescribed supplemental nutrition on patient outcome following elective colorectal surgery. METHOD: Patients undergoing elective colorectal resections were randomized to a prescribed nutritional supplementation group (SG) [standard diet + 6 × 60 ml/day of Pro-Cal (60 ml = 200 kcal + 4 g protein)] or conventional postoperative diet group (CG) (standard diet alone). Preoperative and daily postoperative hand-grip strengths were measured using a grip dynamometer after randomization. Daily food intake, return of bowel activity, nausea score for the first 3 days and postoperative length of hospital stay (LOS) were prospectively recorded. Micro-diet standardized software was used to analyse food diaries. Nonparametric tests were used to analyse the data. RESULTS: Fifty-five patients were analysed (SG 28, CG 27). There was no difference in median preoperative and postoperative handgrip strengths at discharge within each group (SG 31.7 vs 31.7 kPa, P = 0.932; CG 28 vs 28.1 kPa, P = 0.374). The total median daily calorie intake was higher in SG than CG (SG 818.5 kcal vs CG 528 kcal; P = 0.002). There was no difference in median number of days to first bowel movement (SG 3 days vs CG 4 days, P = 0.096). The median LOS was significantly shorter in SG than CG (6.5 vs 9 days; P = 0.037). CONCLUSION: Prescribed postoperative high-calorie, low-volume oral supplements in addition to the normal dietary intake are associated with significantly better total daily oral calorie intake and may contribute to a reduced postoperative hospital stay.

Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults.

BACKGROUND: Secondary peritonitis is associated with a high mortality rate and if not treated successfully leads to development of abscesses, severe sepsis and multi-organ failure. Source control and adjunctive antibiotics are the mainstay of treatment. However, no conclusive evidence suggest that one antibiotic regimen is better than any other but at the same time have a lower toxicity. OBJECTIVES: To ascertain the efficacy and adverse effects of different antibiotic regimens in treating intra-abdominal infections in adults. Outcomes were divided into primary (clinical success and effectiveness in reducing mortality) and secondary (microbiological success, preventing wound infection, intra-abdominal abscess, clinical sepsis, remote infection, superinfection, adverse reactions, duration of treatment required, effectiveness in reducing hospitalised stay, and time to defervescence). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SR-COLOCA. Bibliographies of identified studies were screened for further relevant trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing different antibiotic regimens in the treatment of secondary peritonitis in adults were selected. Trials reporting gynaecological or traumatic peritonitis were excluded from this review. Ambiguity regarding suitability of trials were discussed among the review team. DATA COLLECTION AND ANALYSIS: Six reviewers independently assessed trial quality and extracted data. Data collection was standardised using data collection form to ensure uniformity among reviewers. Statistical analyses were performed using the random effects model and the results expressed as odds ratio for dichotomous outcomes, or weight mean difference for continuous data with 95% confidence intervals. MAIN RESULTS: Fourty studies with 5094 patients met the inclusion criteria. Sixteen different comparative antibiotic regimens were reported. All antibiotics showed equivocal comparability in terms of clinical success. Mortality did not differ between the regimens. Despite the potential high toxicity profile of regimens using aminoglycosides, this was not demonstrated in this review. The reason for this could be the inherent bias within clinical trials in the form of patient selection and stringency in monitoring drug levels. AUTHORS' CONCLUSIONS: No specific recommendations can be made for the first line treatment of secondary peritonitis in adults with antibiotics, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. Future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.

Sequential physiology scoring facilitates objective assessment of resuscitation in patients with an intra-abdominal emergency.

BACKGROUND: Patients who present with an intra-abdominal emergency often require urgent surgery. Before surgery a period of resuscitation is undertaken pre-emptively, or to correct any overt physiological derangement. The assessment of response to resuscitation and the decision when to operate is subjective. This study examined the role of sequential physiology scores in assessing the response to resuscitation objectively. METHODS: Sequential physiology scores were recorded in 92 patients with abdominal pathology that subsequently required urgent or emergency surgery. The physiology component of the Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM), Acute Physiology And Chronic Health Evaluation (APACHE) II and III, and Simplified Acute Physiology Score (SAPS) II were determined at presentation, during resuscitation and immediately before surgery. RESULTS: There were 76 survivors;16 patients died. All scoring systems showed an improvement during resuscitation but subsequent deterioration before surgery. The POSSUM, and APACHE II and III physiology scores differentiated more effectively between survivors and patients who died than SAPS II. CONCLUSION: Sequential physiology scores may facilitate the assessment of patients' response to resuscitation. Patients who fail to respond to resuscitation when identified may benefit from more expedient surgery.