| 1. |
- Currie, Andrew, et al.
(author)
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Enhanced Recovery After Surgery Interactive Audit System : 10 Years' Experience with an International Web-Based Clinical and Research Perioperative Care Database
- 2019
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In: Clinics in Colon and Rectal Surgery. - : Thieme Medical Publishers. - 1531-0043 .- 1530-9681. ; 32:1, s. 75-81
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Research review (peer-reviewed)abstract
- The Enhanced Recovery After Surgery (ERAS) is a managed care program that has shown the ability to reduce complications following elective colorectal surgery. In 2006, the ERAS (R) Society developed the ERAS (R) Interactive Audit System (EIAS), which has allowed centers in over 20 countries to enter perioperative patient data to benchmark against international practice within the audit system and act as a stimulus for quality improvement. The de-identified patient data are coded in SQL (a relational database), stored on secure servers, and data governance aspects have been secured in all involved countries. A collaborative approach is undertaken within involved units toward research questions with published cohort data from the audit system having demonstrated the importance of overall compliance on improving patient outcomes and less cost of care. The EIAS has shown that collaborative clinical effort can drive quality improvement in a short time frame in an international context.
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| 2. |
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| 3. |
- Currie, Andrew, et al.
(author)
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The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection Results From an International Registry
- 2015
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In: Annals of Surgery. - : Lippincott Williams & Wilkins. - 0003-4932 .- 1528-1140. ; 261:6, s. 1153-1159
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Journal article (peer-reviewed)abstract
- Background: The ERAS (enhanced recovery after surgery) care has been shown in randomized clinical trials to improve outcome after colorectal surgery compared to traditional care. The impact of different levels of compliance and specific elements, particularly out with a trial setting, is poorly understood.Objective: This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection.Methods: The international, multicenter ERAS registry data, collected between November 2008 and March 2013, was reviewed. Patient demographics, disease characteristics, and perioperative ERAS protocol compliance were assessed. Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication.Findings: A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries. Median length of stay for colorectal resections was 6 days, with readmissions in 216 (9.2%), complications in 948 (40%), and reoperation in 167 (7.1%) of 2352 patients. Laparoscopic surgery was associated with reduced complications [odds ratio (OR) = 0.68; P < 0.001] and length of stay (OR = 0.83, P < 0.001). Increasing ERAS compliance was correlated with fewer complications (OR = 0.69, P < 0.001) and shorter primary hospital admission (OR = 0.88, P < 0.001). Shorter hospital stay was associated with preoperative carbohydrate and fluid loading (OR = 0.89, P = 0.001), and totally intravenous anesthesia (OR= 0.86, P < 0.001); longer stay was associated with intraoperative epidural analgesia (OR = 1.07, P = 0.019). Reduced postoperative complications were associated with restrictive perioperative intravenous fluids (OR = 0.35, P < 0.001).Conclusions: This analysis has demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.
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| 4. |
- Degens, Hans, et al.
(author)
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Post-operative effects on insulin resistance and specific tension of single skeletal muscle fibres
- 1999
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In: Clinical Science. - : Lippincott Williams & Wilkins. - 0143-5221 .- 1470-8736. ; 97:4, s. 449-455
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Journal article (peer-reviewed)abstract
- Surgery and accidental trauma are associated with a transient period of insulin resistance, substrate catabolism and muscle weakness. In the present study, we evaluated the changes in the force-generating capacity of chemically skinned single muscle fibresfollowing abdominal surgery. Biopsies of the m. vastus lateralis were obtained in three patients 1 day before and 3 or 6 days after surgery. Part of the biopsy was frozen for histochemical analysis of the fibre cross-sectional area (FCSA) and myofibrillar protein content, and another part was used for single-fibre contractile measurements. All patients developed insulin resistance following surgery. The maximum velocity of unloaded shortening of single muscle fibres did not change following surgery. The FCSA did not decrease after surgery, as determined either from histochemical sections or from singlefibres measured at a fixed sarcomere length of 2.76+/-0.09 microm (mean+/-S.D.). Further, the force-generating capacity of the single fibres, measured as maximal Ca(2+)-activated force (P(0)) or as P(0) normalized to FCSA (specific tension), remained unchanged, as did the myofibrillar protein content of the muscle. In conclusion, the muscle weakness associated with post-operative insulin resistance is not related to a decreased specifictension or a loss of myofibrillar proteins. Other potential cellular mechanisms underlying post-operative weakness are discussed.
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| 5. |
- Gustafsson, Ulf O., et al.
(author)
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Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery
- 2011
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In: Archives of surgery (Chicago. 1960). - : American Medical Association (AMA). - 0004-0010 .- 1538-3644. ; 146:5, s. 571-577
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Journal article (peer-reviewed)abstract
- Objectives: To study the impact of different adherence levels to the enhanced recovery after surgery (ERAS) protocol and the effect of various ERAS elements on outcomes following major surgery. Design: Single-center prospective cohort study before and after reinforcement of an ERAS protocol. Comparisons were made both between and across periods using multivariate logistic regression. All clinical data (114 variables) were prospectively recorded. Setting: Ersta Hospital, Stockholm, Sweden. Patients: Nine hundred fifty-three consecutive patients with colorectal cancer: 464 patients treated in 2002 to 2004 and 489 in 2005 to 2007. Main Outcome Measures: The association between improved adherence to the ERAS protocol and the incidence of postoperative symptoms, complications, and length of stay following major colorectal cancer surgery was analyzed. Results: Following an overall increase in preoperative and perioperative adherence to the ERAS protocol from 43.3% in 2002 to 2004 to 70.6% in 2005 to 2007, both postoperative complications (odds ratio, 0.73; 95% confidence interval, 0.55-0.98) and symptoms (odds ratio, 0.53; 95% confidence interval, 0.40-0.70) declined significantly. Restriction of intravenous fluid and use of a preoperative carbohydrate drink were major independent predictors. Across periods, the proportion of adverse postoperative outcomes (30-day morbidity, symptoms, and readmissions) was significantly reduced with increasing adherence to the ERAS protocol (>70%, >80%, and >90%) compared with low ERAS adherence (<50%). Conclusion: Improved adherence to the standardized multimodal ERAS protocol is significantly associated with improved clinical outcomes following major colorectal cancer surgery, indicating a dose-response relationship.
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| 6. |
- Lassen, Kristoffer, et al.
(author)
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Consensus review of optimal perioperative care in colorectal surgery : Enhanced Recovery After Surgery (ERAS) Group recommendations
- 2009
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In: Archives of surgery (Chicago. 1960). - : American Medical Association (AMA). - 0004-0010 .- 1538-3644. ; 144:10, s. 961-969
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Research review (peer-reviewed)abstract
- OBJECTIVES: To describe a consensus review of optimal perioperative care in colorectal surgery and to provide consensus recommendations for each item of an evidence-based protocol for optimal perioperative care. DATA SOURCES: For every item of the perioperative treatment pathway, available English-language literature has been examined. STUDY SELECTION: Particular attention was paid to meta-analyses, randomized controlled trials, and systematic reviews. DATA EXTRACTION: A consensus recommendation for each protocol item was reached after critical appraisal of the literature by the group. DATA SYNTHESIS: For most protocol items, recommendations are based on good-quality trials or meta-analyses of such trials. CONCLUSIONS: The Enhanced Recovery After Surgery (ERAS) Group presents a comprehensive evidence-based consensus review of perioperative care for colorectal surgery. It is based on the evidence available for each element of the multimodal perioperative care pathway.
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| 7. |
- Ljungqvist, Olle, 1954-, et al.
(author)
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Metabolic perioperative management : novel concepts
- 2005
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In: Current Opinion in Critical Care. - Philadelphia, USA : Lippincott Williams & Wilkins. - 1070-5295 .- 1531-7072. ; 11:4, s. 295-9
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Research review (peer-reviewed)abstract
- Purpose of review: This review summarizes novel information regarding the role of metabolic control in the perioperative period.Recent findings: Managing perioperative metabolism has recently been shown to be an important way to improve outcomes in surgical care. In particular, postoperative insulin resistance and hyperglycemia have been linked to many common complications. Recent studies have explored the toxicity of hyperglycemia and suggest a causal relation between insulin resistance and complications in the postoperative state. Controlling glucose concentrations with insulin has been shown to also improve protein balance and fat metabolism. In addition, insulin may affect other hormones including insulinlike growth factor-I during surgical stress. Lastly, recent data suggest that hyperglycemia plays an important role in aggravating the inflammatory response, in that overflow of substrates in the mitochondria causes the formation of excess free oxygen radicals and may also alter gene expression to enhance cytokine production. Although overcoming insulin resistance by insulin infusion is one way of combating hyperglycemia, prevention of its development can also be achieved by using epidural blockade to reduce the release of adrenal stress hormones and to control pain, by preoperative carbohydrates instead of overnight fasting, and by minimal invasive surgical techniques.Summary: Minimizing the effects of insulin resistance has been shown to substantially improve outcome after surgical stress.
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| 8. |
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| 9. |
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| 10. |
- Myrelid, Pär, et al.
(author)
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Surgical Planning in Penetrating Abdominal Crohns Disease
- 2022
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In: Frontiers in Surgery. - : Frontiers Media SA. - 2296-875X. ; 9
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Research review (peer-reviewed)abstract
- Crohns disease (CD) is increasing globally, and the disease location and behavior are changing toward more colonic as well as inflammatory behavior. Surgery was previously mainly performed due to ileal/ileocaecal location and stricturing behavior, why many anticipate the surgical load to decrease. There are, however, the same time data showing an increasing complexity among patients at the time of surgery with an increasing number of patients with the abdominal perforating disease, induced by the disease itself, at the time of surgery and thus a more complex surgery as well as the post-operative outcome. The other major cause of abdominal penetrating CD is secondary to surgical complications, e.g., anastomotic dehiscence or inadvertent enterotomies. To improve the care for patients with penetrating abdominal CD in general, and in the peri-operative phase in particular, the use of multidisciplinary team discussions is essential. In this study, we will try to give an overview of penetrating abdominal CD today and how this situation may be handled. Proper surgical planning will decrease the risk of surgically induced penetrating disease and improve the outcome when penetrating disease is already established. It is important to evaluate patients prior to surgery and optimize them with enteral nutrition (or parenteral if enteral nutrition is ineffective) and treat abdominal sepsis with drainage and antibiotics.
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| 11. |
- Nygren, Jonas, et al.
(author)
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An enhanced-recovery protocol improves outcome after colorectal resection already during the first year : a single-center experience in 168 consecutive patients
- 2009
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In: Diseases of the Colon & Rectum. - 0012-3706 .- 1530-0358. ; 52:5, s. 978-985
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Journal article (peer-reviewed)abstract
- PURPOSE: This study was designed to investigate the clinical outcome and recovery before and immediately after implementation of the enhanced recovery after surgery enhanced recovery after surgery protocol in colonic and rectal resection. METHODS: One hundred and sixty-eight consecutive patients in a single center underwent colorectal surgery before (traditional, n = 69) and immediately after implementing enhanced recovery after surgery (n = 99). Rectal surgery was performed in 77 patients. Postoperative food and fluid intake, mobilization, physiologic function, and clinical outcome were measured prospectively. RESULTS: Resumption of oral diet was achieved on postoperative day postoperative day 1 in the enhanced recovery after surgery group. In the enhanced recovery after surgery group, mobilization more than 6 hours daily was achieved on postoperative day 2 to 3 and passage of stool occurred on postoperative day 2 vs. postoperative day 5 in the traditional group (P < 0.0001). Muscle strength and lung function were less reduced in the enhanced recovery after surgery group (P < 0.05). Median hospital stay was reduced by 2 days (P < 0.01). Readmission rates increased (4 percent vs. 15 percent, P < 0.01) but total hospital stay was still lower in the enhanced recovery after surgery group (P < 0.01). After colonic resection, postoperative complications decreased in enhanced recovery after surgery (37 percent vs. 18 percent, P < 0.05), whereas no change was found after rectal resection. CONCLUSION: Immediately after implementing enhanced recovery after surgery, recovery was improved and length of hospital stay was reduced. Notably, postoperative morbidity decreased only in patients undergoing colonic resection.
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| 12. |
- Nygren, Jonas O., et al.
(author)
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Perioperative insulin and glucose infusion maintains normal insulin sensitivity after surgery
- 1998
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In: American Journal of Physiology. - : American Physiological Society. - 0002-9513 .- 2163-5773. ; 275:1 Part 1, s. E140-E148
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Journal article (peer-reviewed)abstract
- Elective surgery was performed after overnight fasting, a routine that may affect the metabolic response to surgery. We investigated the effects of insulin and glucose infusions before and during surgery on postoperative substrate utilization and insulin sensitivity. Seven patients were given insulin and glucose infusions 3 h before and during surgery (insulin group), and a control group of six patients underwent surgery after fasting overnight. Insulin sensitivity and glucose kinetics (D-[6,6-2H2]glucose) were measured before and immediately after surgery using a hyperinsulinemic, normoglycemic clamp. Glucose infusion rates and whole body glucose disposal decreased after surgery in the control group (-40 and -29%, respectively), whereas no significant change was found in the insulingroup (+16 and +25%). Endogenous glucose production remained unchanged in both groups. Postoperative changes in cortisol, glucagon, fat oxidation, and free fatty acids were attenuated in the insulin group (vs. control). We conclude that perioperative insulin and glucose infusions minimize the endocrine stress response and normalize postoperative insulin sensitivity and substrate utilization.
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| 13. |
- Nygren, Jonas, et al.
(author)
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Preoperative oral carbohydrate administration reduces postoperative insulin resistance
- 1998
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In: Clinical Nutrition. - : Elsevier. - 0261-5614 .- 1532-1983. ; 17:2, s. 65-71
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Journal article (peer-reviewed)abstract
- Infusions of carbohydrates before surgery reduce postoperative insulin resistance. We investigated the effects of a carbohydrate drink, given shortly before surgery, on postoperative metabolism. Method: Insulin sensitivity, glucose turnover ([6,6, 2H2]-D-glucose) and substrate utilization were measured using hyperinsulinemic normoglycemic clamps and indirect calorimetry in two matched groups of patients before and after elective colorectal surgery. The drink group (n = 7) received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation (100 g carbohydrates), as well as another 400 ml (50 g carbohydrates) 2 h before the initiation of anesthesia. The fasted group (n = 7) was operated after an overnight fast. Results: After surgery, energy expenditure increased in both groups. Endogenous glucose production was higher after surgery and the difference was significant during low insulin infusion rates in both groups (P < 0.05). The supressibility of endogenous glucose production by the two step insulin infusion was similar pre- and postoperatively in both groups. At the high insulin infusion rate postoperatively, whole body glucose disposal was more reduced in the fasted group (-49 ± 6% vs -26 ± 8%, P < 0.05 vs drink). Furthermore, during high insulin infusion rates, glucose oxidation decreased postoperatively only in the fasted group (P < 0.05) and postoperative levels of fat oxidation were greater in the fasted group (P < 0.05 vs drink). Only minor postoperative changes in cortisol and glucagon were found and no differences were found between the treatment groups. Conclusions: Patients given a carbohydrate drink shortly before elective colorectal surgery displayed less reduced insulin sensitivity after surgery as compared to patients who were operated after an overnight fast.
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| 14. |
- Nygren, Jobas, et al.
(author)
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Preoperative oral carbohydrates and postoperative insulin resistance
- 1999
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In: Clinical Nutrition. - : Elsevier. - 0261-5614 .- 1532-1983. ; 18:2, s. 117-120
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Journal article (peer-reviewed)abstract
- Infusions of carbohydrates before surgery have been shown to reduce postoperative insulin resistance. Presently, we investigated the effects of a carbohydrate drink, given shortly before surgery, on postoperative insulin sensitivity. Methods: Insulin sensitivity and glucose turnover (16, 6, 2H2]-D-glucose) were measured using hyperinsulinemic, normoglycemic clamps before and after elective surgery. Sixteen patients undergoing total hip replacement were randomly assigned to preoperative oral carbohydrate administration (CHO-H, n = 8) or the same amount of a placebo drink (placebo, n = 8) before surgery. Insulin sensitivity was measured before and immediately after surgery. Patients undergoing elective colorectal surgery were studied before surgery and 24 h postoperatively (CHO-C (n = 7), and fasted (n = 7), groups). The fasted group underwent surgery after an overnight fast. In both studies, the CHO groups received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation (100 g carbohydrates), as well as another 400 ml (50 g carbohydrates) 2 h before the initiation of anesthesia. Results: Immediately after surgery, insulin sensitivity was reduced 37% in the placebo group (P < 0.05 vs. preoperatively) while no significant change was found in the CHO-H group (-16%, p = NS). During clamps performed 24 h postoperatively, insulin sensitivity and whole-body glucose disposal was reduced in both groups, but the reduction was greater compared to that in the CHO-C group (-49 ± 6% vs. -26 ± 8%, P < 0.05 fasted vs. CHO-C). Conclusions: Patients given a carbohydrate drink shortly before elective surgery displayed less reduced insulin sensitivity after surgery as compared to patients undergoing surgery after an overnight fast.
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| 15. |
- Soop, Mattias
(author)
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Effects of perioperative nutrition on insulin action in postoperative metabolism
- 2003
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Doctoral thesis (other academic/artistic)abstract
- Surgical operations are a fundamental part of contemporary treatment of disease. For example, 43 % of in-patients in Sweden undergo a surgical operation. Surgery is not yet without significant risks. Infectious complication rates following abdominal surgery, for instance, remain at 9-25 %. It has recently been recognised that hyperglycaemia is a significant risk factor for postoperative infectious complications. Hyperglycaemia in the postoperative patient occurs on the basis of postoperative insulin resistance, a transient state of reduced sensitivity to the anabolic effects of insulin. This state, similar to type 2 diabetes mellitus, is not traditionally treated in routine perioperative care. Development of methods to attenuate postoperative insulin resistance may improve outcome of surgical care. One such method is preoperative oral carbohydrate treatment. In surgical patients, insulin resistance is best quantified by measuring insulin sensitivity before and after surgery using the hyperinsulinaemic-euglycaemic clamp method. However, reproducibility of the clamp method has not been conclusively demonstrated. Therefore, seven healthy volunteers underwent three two-h hyperinsulinaemic (60 µmol·l 1)-euglycaemic (4.5 mmol·l 1) clamps on days 0, 2 and 14, respectively. The mean intra-individual coefficient of variation of measured whole-body insulin sensitivity between the first and second clamp was 7.0 (2.8) % (mean (SEM)) and, between the first and third clamp, 8.0 (2.4) %. The clamp method was therefore considered reproducible. To study the effects of preoperative oral carbohydrate treatment on postoperative insulin resistance in the absence of postoperative confounding factors such as hypocaloric nutrition and bed rest, 15 patients were studied before and immediately after total hip replacement. They were double-blindly treated with either a preoperative carbohydrate-rich beverage (12.5 %, 800+400 ml, n=8) or placebo (n=7). Glucose kinetics (6, 6 D2 D glucose), substrate utilisation (indirect calorimetry) and insulin sensitivity (clamp) were measured. Whole-body insulin sensitivity decreased in both groups, but significantly less in carbohydrate-treated patients (18 (6) vs 43 (9) %, P<0.05 vs placebo, ANOVA). The attenuation of immediate postoperative insulin resistance was attributable to an attenuated reduction in whole-body glucose disposal and accelerated glucose oxidation rates. Effects of preoperative oral carbohydrate treatment later in the postoperative course were also examined. Fourteen patients undergoing total hip replacement were double-blindly treated with either oral carbohydrates (n=8) or placebo (n=6). Insulin resistance was measured on the third day after surgery, and whole-body nitrogen balance was measured. Whole-body insulin sensitivity decreased similarly in carbohydrate-treated vs placebo-treated patients (36 (10) % vs 49 (7) %, P=0.33). In placebo-treated patients, the decrease in whole-body insulin sensitivity was associated with a significant increase in endogenous glucose release, suggesting a shift of the site of postoperative insulin resistance from the periphery to the liver three days after surgery. Preoperative oral carbohydrate treatment significantly attenuated this postoperative increase in endogenous glucose release as well as mean whole-body nitrogen losses (136 (4) vs 161 (10) mg·kg 1·day 1, P<0.05 vs placebo). Recently, so-called enhanced-recovery after surgery protocols have been introduced, integrating a number of perioperative interventions individually shown to improve outcome. To investigate the metabolic stress responses in enhanced-recovery protocols, insulin resistance and whole-body nitrogen balance were measured in 18 patients four days after major colorectal surgery. An enhanced-recovery protocol was implemented incorporating preoperative carbohydrate treatment, postoperative multimodal pain control based on epidural analgesia and early postoperative mobilisation. Moreover, to assess the role of immediate postoperative complete enteral nutrition in enhanced-recovery protocols, patients were double-blindly treated with either an energy-dense residue-free enteral nutritional solution (1.5 kcal·ml 1, 49 energy-% carbohydrates, 35 energy-% fat, 9.6 mg N·ml 1, n=9) or a hypocaloric placebo solution (glucose 50 mg·ml 1, n=9) given immediately postoperatively for four days. Postoperative metabolic responses were strikingly limited in both treatment groups. Urinary nitrogen losses were low (10.7 (1.0) and 10.5 (0.7) g·day 1, in fed and placebo-treated patients, respectively) and insulin resistance was insignificant (20 (7) and 27 (11) %). Complete enteral feeding was given without hyperglycaemia (mean plasma glucose concentration 6.8 (0.4) during feed vs 6.0 (0.4) mmol·l 1, ns vs placebo) and resulted in a neutral whole-body nitrogen balance (0.1 (0.8) vs 12.6 (0.6) g N·day-1, P<0.001 vs placebo). In conclusion, preoperative oral carbohydrate treatment attenuates postoperative insulin resistance and whole-body nitrogen losses within three days after surgery. An enhanced-recovery protocol including preoperative oral carbohydrate treatment minimises metabolic stress responses after major colorectal surgery, and allows for immediate postoperative complete enteral nutrition without significant hyperglycaemia and with a neutral nitrogen balance.
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| 16. |
- Soop, Mattias, et al.
(author)
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Optimizing perioperative management of patients undergoing colorectal surgery : what is new?
- 2006
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In: Current Opinion in Critical Care. - Philadelphia, USA : Lippincott Williams & Wilkins. - 1070-5295 .- 1531-7072. ; 12:2, s. 166-70
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Research review (peer-reviewed)abstract
- Purpose or review: This review highlights recent developments in individual perioperative interventions in colorectal surgery, and progress in so-called fast-track or enhanced-recovery programmes.Recent findings: A new survey from five northern European countries has revealed that best clinical practice in perioperative care, based on previously published high-grade evidence, is only partially in use in daily clinical practice. Recently, a number of trials contrasting clinical results in enhanced-recovery protocols versus traditional care clearly show that such protocols indeed enhance recovery, although effects on morbidity are less obvious. Further evidence supporting preoperative oral carbohydrate treatment, avoidance of oral bowel preparation and wound drainage in elective colonic surgery and avoidance of intraoperative fluid excess has emerged. The oral opioid antagonist alvimopan has recently been shown to limit postoperative gastrointestinal paralysis. The role of laparoscopic surgery in the era of enhanced-recovery programmes is unclear.Summary: There is strong evidence on how to enhance recovery after colorectal surgery, but many interventions are not utilized in daily practice. Further evidence has emerged supporting several perioperative treatments, and successful experiences of enhanced-recovery programmes have now been reported from several centres.
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| 17. |
- Soop, Mattias, et al.
(author)
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Stress-induced insulin resistance : recent developments
- 2007
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In: Current opinion in clinical nutrition and metabolic care. - Philadelphia, USA : Lippincott Williams & Wilkins. - 1363-1950 .- 1473-6519. ; 10:2, s. 181-6
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Research review (peer-reviewed)abstract
- Purpose of review: Interest in stress-induced insulin resistance has increased during the past 5 years. Relevant clinical and mechanistic investigations during the past year will be reviewed.Recent findings: Recent trials of intensive insulin therapy in intensive care units have brought attention to a high incidence of hypoglycemic episodes with such treatment. The clinical relevance of such hypoglycemia has been shown to be minor, however. Furthermore, animal and in-vitro work further supports the finding that glucose control, rather than glycemia-independent effects of insulin, is the primary mechanism of action of intensive insulin therapy. In elective surgery, cohort studies show an association between intraoperative hyperglycemia and postoperative morbidity. Beneficial effects of preoperative oral carbohydrate treatment on immunocompetence and cardiac contractility have been demonstrated. Laparoscopic segmental colectomy was associated with considerably attenuated derangements in glucose metabolism compared with conventional, open surgery.Summary: Better methods of insulin dosing and administration and glucose monitoring are warranted to further minimize the risks of intensive insulin therapy. In elective surgery, perioperative measures such as preoperative oral carbohydrate treatment and laparoscopic techniques attenuate metabolic and other physiological derangements and such methods should be integrated into perioperative care protocols to minimize morbidity and enhance recovery.
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| 18. |
- Svanfeldt, Monika, et al.
(author)
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Effect of "preoperative" oral carbohydrate treatment on insulin action : a randomised cross-over unblinded study in healthy subjects
- 2005
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In: Clinical Nutrition. - Edinburgh, United Kingdom : Churchill Livingstone. - 0261-5614 .- 1532-1983. ; 24:5, s. 815-21
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Journal article (peer-reviewed)abstract
- Background and aims: Preoperative intake of a clear carbohydrate-rich drink reduces insulin resistance after surgery. In this study, we evaluated whether this could be related to increased insulin sensitivity at the onset of surgery. Furthermore, we aimed to establish the optimal dose-regimen.Methods: Six healthy volunteers underwent hyperinsulinaemic (0.8 mU/kg/min), normoglycaemic (4.5 mmol/l) clamps and indirect calorimetry on four occasions in a crossover-randomised order; after overnight fasting (CC), after a single evening dose (800 ml) of the drink (LC), after a single morning dose (400 ml, CL) and after intake of the drink in the evening and in the morning before the clamp (LL). Data are presented as mean+/-SD. Statistical analysis was performed using the Student's t-test and ANOVA.Results: Insulin sensitivity was higher in CL and LL (9.2+/-1.5 and 9.3+/-1.9 mg/kg/min, respectively) compared to CC and LC (6.1+/-1.6 and 6.6+/-1.9 mg/kg/min, P<0.01 vs. CL and LL).Conclusions: A carbohydrate-rich drink enhances insulin action 3 h later by approximately 50%. Enhanced insulin action to normal postprandial day-time level at the time of onset of anaesthesia or surgery is likely to, at least partly, explain the effects on postoperative insulin resistance.
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| 19. |
- Thorell, Anders, et al.
(author)
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Intensive insulin treatment in critically ill trauma patients normalizes glucose by reducing endogenous glucose production
- 2004
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In: Journal of Clinical Endocrinology and Metabolism. - Chevy Chase, USA : The Endocrine Society. - 0021-972X .- 1945-7197. ; 89:11, s. 5382-6
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Journal article (peer-reviewed)abstract
- Critical illness is associated with insulin resistance and hyperglycemia. Intensive insulin treatment to normalize blood glucose during feeding has been shown to improve morbidity and mortality in patients in intensive care. The mechanisms behind the glucose-controlling effects of insulin in stress are not well understood. Six previously healthy, severely traumatized patients (injury severity score > 15) were studied early (24-48 h) after trauma. Endogenous glucose production (EGP) and whole-body glucose disposal (WGD) were measured (6,6-(2)H(2)-glucose) at basal, during total parenteral nutrition (TPN), and during TPN plus insulin to normalize blood glucose (TPN+I). Six matched volunteers served as controls. At basal and TPN, concentrations of glucose and insulin were higher in patients (P < 0.05). During TPN+I, insulin concentrations were 30-fold higher in patients. At basal, WGD and EGP were 30% higher in patients (P < 0.05). During TPN, EGP decreased in both groups but less in patients, resulting in 110% higher EGP than controls (P < 0.05). Normoglycemia coincided with reduced EGP, resulting in similar rates in both groups. WGD did not change during TPN or TPN+I and was not different between the groups. In conclusion, in healthy subjects, euglycemia is maintained during TPN at physiological insulin concentrations by a reduction of EGP, whereas WGD is maintained at basal levels. In traumatized patients, hyperglycemia is due to increased EGP. In contrast to controls, normalization of glucose concentration during TPN needs high insulin infusion rates and is accounted for by a reduction in EGP, whereas WGD is not increased.
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