Postoperative inflammation and insulin resistance in relation to body composition, adiposity and carbohydrate treatment: A randomised controlled study.

BACKGROUND & AIMS: The aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin resistance, with and without preoperative treatment with carbohydrate drinks. METHODS: Thirty-two adults (16 obese/16 non-obese) undergoing elective major open abdominal surgery participated in this 2 × 2 factorial, randomised, double-blind, placebo-controlled study. Participants received Nutricia preOp® or placebo (800 ml on the night before surgery/400 ml 2-3 h preoperatively) after stratifying for obesity. Insulin sensitivity was measured using the hyperinsulinaemic-euglycaemic clamp preoperatively and on the 1st postoperative day. Vastus lateralis, omental and subcutaneous fat biopsies were taken pre- and postoperatively and analysed after RNA extraction. The primary endpoint was within subject differences in insulin sensitivity. RESULTS: Major abdominal surgery was associated with a 42% reduction in insulin sensitivity from mean(SD) M value of 37.3(11.8) µmol kg-1 fat free mass (FFM) to 21.7(7.4) µmol kg-1 FFM, but this was not influenced by obesity or preoperative carbohydrate treatment. Activation of the triggering receptor expressed on myeloid cells (TREM1) pathway was seen in response to surgery in omental fat samples. In postoperative muscle samples, gene expression differences indicated activation of the peroxisome proliferator-activated receptor (PPAR-α)/retinoid X-receptor (RXR-α) pathway in obese but not in non-obese participants. There were no significant changes in gene expression pathways associated with carbohydrate treatment. CONCLUSION: The reduction in insulin sensitivity associated with major abdominal surgery was confirmed but there were no differences associated with preoperative carbohydrates or obesity.

Results of laparoscopic colorectal surgery from a national training center.

BACKGROUND/PURPOSE: Trials have shown laparoscopic colorectal surgery to be safe. We aim to analyze the long-term results from a single national training center for laparoscopic surgery, especially in patients with high predicted mortality scores as well as in octogenarians. We also aim to explore the trend in the length of the learning curve among consultants and colorectal trainees, and determine whether or not laparoscopic colorectal surgery is amenable to surgical training. METHODS: All patients between July 2003 and July 2011 having laparoscopic colorectal surgery were included in a prospectively maintained database and analyzed retrospectively. We collected operative data (operation time, conversion), postoperative 30-day morbidity/mortality, cancer survival (including local/distant recurrences), postoperative incisional/port site hernia rates, and rates of reoperation. RESULTS: A total of 508 patients (258 males and 250 females) were enrolled in the study. The mean age of patients was 65.5 years and median body mass index (BMI) 27 kg/m(2); 70% of cases were malignant. Conversion rate was 15%, mean operation time was 175 minutes, and mean blood loss was 220 mL. The mean postoperative length of stay was 5.8 days, 30-day morbidity 23% (leak rate 1.38%), and 30-day mortality 1.57%. Operating time and conversion rates were significantly lower in right-sided resections compared to left-sided and rectal resections, and lymph node retrieval was significantly higher. Readmission and reoperation rates were 4.9% and 2.8%, respectively. The overall mean follow-up period was 1.8 years, rate of incisional/port site/parastomal hernia was 5.7% (n = 30), and readmission secondary to adhesions was <1% (n = 4). Readmission rates and 30-day surgical morbidity were significantly higher in patients with non-neoplastic disease compared to those with benign or malignant lesions. The mean follow-up period for cancer patients was 2.3 years. Local and distant recurrence rates were 4.2% and 13.2%, respectively. Overall death from cancer was 10.4%. Among the study participants, 74 were octogenarians and 23 had a predicted mortality of >5% (P-Possum tool). No statistically significant increases were observed in conversion, morbidity, or mortality rates in these groups (p > 0.05), but length of stay was statistically longer-7 days for octogenarians and 8 days for patients with >5% predicted mortality (p < 0.05). In 2003, two consultants operated on all cases; currently, twice as many procedures are performed by supervised trainees instead of consultants, with no change in outcome. Operating time was significantly higher in the consultant-led cases, but no other differences were noted in short- or long-term outcomes between consultant- and junior/senior trainee-led cases. CONCLUSION: We conclude that laparoscopic colorectal surgery should be the standard treatment option offered to all patients regardless of age and comorbidities and it is amenable to training.