Volume 67 - 2004 - Fasc.3 - Original articles
Perioperative immunonutrition ameliorates the postoperative immune depression in patients with gastrointestinal system cancer (prospective clinical study in 42 patients)
Cancer surgery is a major challenge for patients to develop immune depression in postoperative period. Several cytokines can depress immune cell subpopulations. Increased cytokine response after surgery is assumed to arise mainly from lipooxygenase path- way acting on membrane arachidonic acid. Therefore ; investiga- tors focused their efforts to alter the membrane fatty acid profile by changing the nutritional regimen with e-3 fatty acid supple- mentation and encouraging results were obtained after surgery. Despite the theoretical and clinical advantage of enteral nutrition many surgeons remain committed to parenteral nutrition for feed- ing of patients due to maintain bowel rest and fear of anastomosis leakage at the postoperative period. Several studies investigating role of the postoperative immunonutrition reported that beneficial immunological changes were associated with reduction of infec- tious complications. Interestingly ; these findings were observed at least five days after the surgery in which the highest incidence of complications was seen. In this prospective study including 42 patients eligible for curative gastric or colon cancer surgery ; we investigated the beneficial effect of enteral immunonutrition (EEN) compared to total parenteral hyperalimentation (TPN) beginning from the preoperative period. Cortisol and CRP levels as stress parameters significantly increased one day after surgery in both groups but they rapidly returned to (on POD1) preopera- tive baseline level in EEN group whereas these values remained high in the TPN group. Additionally a significant decrease in nat- ural killer (NK) cells and CD8+ levels were observed in both groups. However they recovered on POD3 in EEN group and on POD6 in TPN group. CD4+ subset remained almost same as pre- operative value in the TPN group whereas it increased from (%) 40.14 to 46.40, 51.29 and 54.7 on PO 6th hr, POD3 and POD6 in the EEN group. Our findings suggest that preoperative nutrition via the enteral route provided better regulation of postoperative immune system restoration than parenteral nutrition. On the basis of our findings we recommend enteral immunonutrition to be started at the preoperative period rather than postoperatively before a major operation whenever the enteral route is feasible. (Acta gastroenterol. belg., 2004, 67, 250-254).
Abdominal tuberculosis in children Report of 10 cases
Background : Abdominal tuberculosis is a rare location of this infection with a lot of diagnostic difficulties. The aim of this study was to review our experience of pediatric abdominal tuberculosis with that of the literature data.
Patients and methods : A retrospective study was conducted over a 7- year period ; 10 cases of abdominal tuberculosis in children were reviewed (6 girls and 4 boys, mean age : 11 years, extremes 4-14). Eight patients enrolled in this study satisfied the following criteria : a positive culture for mycobacterium tuberculosis on samples of ascites fluid, sputum, urine, abscess puncture and/or caseating granulomas on histologic examination of biopsies obtained by endoscopy, percutaneous aspiration or needle biopsy or exploratory laparotomy. Two other patients (patients N° 1 & 5) had a favorable response within 10 weeks of antituberculous ther- apy.
Results : We observed 8 cases of peritoneal tuberculosis and 2 cases of intestinal tuberculosis. Extra-abdominal tuberculosis was found in 4 of those patients. Two patients had a contact with a tuberculosis positive individual. Nine children had BCG immu- nization.
The main clinical features were abdominal distension (6 cases) and abdominal pain (6 cases). Abdominal ultrasonography visual- ized mesenteric lymphadenopathies (6 cases), an abdominal mass (5 cases), free (1 case) and localized ascites (1 case). Barium enema and small bowell series showed small bowel stenosis (1 case) and ileal ulcerations (1 case).
Exploratory laparotomy, performed in 3 patients, showed whitish granulations and peritoneal abscesses with caseous necro- sis on histology. Quadruple therapy with tuberculostatic agents was prescribed in all patients, associating isoniazid, rifampicin, pyrazinamide combined at the start of the treatment with strepto- mycin (7 cases) and ethambutol (3 cases). Short term outcome was favorable with no deaths. The long term outcome was complicat- ed by persistent ascites (1 case) and the development of portal hypertension (1 case).
Conclusion : Abdominal tuberculosis remains a rare localiza- tion with a lot of diagnostic difficulties. (Acta gastroenterol. belg., 2004, 67, 245-249).
Percutaneous endoscopic gastrostomy in cystic fibrosis : patient acceptance and effect of overnight tube feeding on nutritional status
Background : Malnutrition remains a common problem in cys- tic fibrosis (CF) patients, despite pancreatic enzymes and hyper- caloric diet advice. When oral supplementation fails, additional overnight gastrostomy tube-feeding is a therapeutic option.
Methods : In our centre gastrostomy tube feeding is proposed when weight for height drops below 85% despite intensive dietetic counselling. All the CF patients at our centre (n = 11) receiving gastrostomy tube feeding were evaluated for changes in nutrition- al status and pulmonary function. Complications of percutaneous endoscopic gastrostomy were inventarised and patients older than 7 years and all the parents were asked to fill in a questionnaire concerning subjective well-being with gastrostomy supplemental feeding.
Results : The patients received 40% of the recommended daily allowances (RDA) for energy by tube feeding. Total daily energy intake increased by 30%. Within 3 months this resulted in a sig- nificant improvement in nutritional status expressed as percentage of ideal weight for height or body mass index z-score. After 6 months a significant catch-up growth was detectable. Pulmonary function remained stable. The complications were local irritation (n = 4), night sweating (n = 1) and bed-wetting (n = 1). The gastro- stomy was well accepted.
Conclusion : Gastrostomy appears to be a good and safe way to improve nutritional status, growth and mood of the CF child. As decreased pulmonary function plays a crucial role in the growth of the CF child, full normalisation of growth pattern is not achieved despite catch-up. Gastrostomy tube feeding should perhaps be used earlier to optimalise growth. (Acta gastroenterol. belg., 2004, 67, 241-244).
