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Plant-associated microorganisms have been shown to critically affect host physiology and performance, suggesting that evolution and ecology of plants and animals can only be understood in a holobiont (host and its associated organisms) context. Host-associated microbial community structures are affected by abiotic and host factors, and increased attention is given to the role of the microbiome in interactions such as pathogen inhibition. However, little is known about how these factors act on the microbial community, and especially what role microbe-microbe interaction dynamics play. We have begun to address this knowledge gap for phyllosphere microbiomes of plants by simultaneously studying three major groups of Arabidopsis thaliana symbionts (bacteria, fungi and oomycetes) using a systems biology approach. We evaluated multiple potential factors of microbial community control: we sampled various wild A. thaliana populations at different times, performed field plantings with different host genotypes, and implemented successive host colonization experiments under lab conditions where abiotic factors, host genotype, and pathogen colonization was manipulated. Our results indicate that both abiotic factors and host genotype interact to affect plant colonization by all three groups of microbes. Considering microbe-microbe interactions, however, uncovered a network of interkingdom interactions with significant contributions to community structure. As in other scale-free networks, a small number of taxa, which we call microbial "hubs," are strongly interconnected and have a severe effect on communities. By documenting these microbe-microbe interactions, we uncover an important mechanism explaining how abiotic factors and host genotypic signatures control microbial communities. In short, they act directly on "hub" microbes, which, via microbe-microbe interactions, transmit the effects to the microbial community. We analyzed two "hub" microbes (the obligate biotrophic oomycete pathogen Albugo and the basidiomycete yeast fungus Dioszegia) more closely. Albugo had strong effects on epiphytic and endophytic bacterial colonization. Specifically, alpha diversity decreased and beta diversity stabilized in the presence of Albugo infection, whereas they otherwise varied between plants. Dioszegia, on the other hand, provided evidence for direct hub interaction with phyllosphere bacteria. The identification of microbial "hubs" and their importance in phyllosphere microbiome structuring has crucial implications for plant-pathogen and microbe-microbe research and opens new entry points for ecosystem management and future targeted biocontrol. The revelation that effects can cascade through communities via "hub" microbes is important to understand community structure perturbations in parallel fields including human microbiomes and bioprocesses. In particular, parallels to human microbiome "keystone" pathogens and microbes open new avenues of interdisciplinary research that promise to better our understanding of functions of host-associated microbiomes.

Aim: Calcitonin (Ctn) measurement in patients with thyroid disease could potentially increase the detection rates of medullary thyroid carcinoma (MTC) but remains a controversial issue. The aim of this study was to evaluate routine preoperative Ctn measurements., Methods: All patients with thyroid surgery documented in the prospective StuDoQ|Thyroid registry between March 2017 and September 2020 were included. Cutoff levels for Ctn were determined with receiver-operating characteristic analyses to assess the preoperative diagnosis of MTC in subgroups for females and males., Findings: In 29 590 of 39 679 patients (75%) participating in the registry, routine preoperative Ctn testing was performed. In 357 patients (227 females and 130 males), histopathology confirmed MTC with a mean tumor size of 14.7 mm (±12.43). Biochemical cure was achieved in 71.4% of the patients. Ctn levels between 11 and 20 pg/mL were seen in 2.6% of the patients, and only 0.7% of the patients had Ctn levels above 21 pg/mL. Cutoff levels for the diagnosis of MTC were 7.9 pg/mL for females and 15 pg/mL for males (P < 0.001). The sensitivity and specificity for females were 95 and 98%, and 96 and 97% for males, respectively., Conclusion: Routine Ctn testing is a reliable predictor for MTC and provides the opportunity for earlier thyroidectomy before lymph node metastases occur, resulting in a better prognosis. Females with Ctn levels >7.9 pg/mL and males >15 pg/mL without any other extrathyroidal sources for an elevated Ctn should be monitored. Thyroid surgery should be considered if Ctn levels are increasing or ultrasound detects suspicious thyroid lesions.

Background: Previous data suggest that the incidence of hypoparathyroidism after surgery for Graves disease (GD) is lower after subtotal thyroidectomy compared to total thyroidectomy (TT). The present study evaluated the incidence of postoperative hypoparathyroidism after near-total (NTT) versus TT in GD., Methods/design: In a multicenter prospective randomized controlled clinical trial, patients with GD were randomized intraoperatively to NTT or TT. Primary endpoint was the incidence of transient postoperative hypoparathyroidism. Secondary endpoints were permanent hypoparathyroidism, transient recurrent laryngeal nerve palsy (RLNP), reoperations for bleeding, inadvertently removed parathyroid glands, and recurrent hyperthyroidism after 12 months., Results: Eighteen centers randomized 205 patients to either TT (n = 102) or NTT (n = 103) within 16 months. According to intention-to-treat postoperative transient hypoparathyroidism occurred in 19% (20/103) patients after NTT and in 21% (21 of 102) patients after TT (P = 0.84), which persisted >6 months in 2% and 5% of the NTT and TT groups (P = 0.34). The rates of parathyroid autotransplantation (NTT 24% vs TT 28%, P = 0.50) and transient RLNP (NTT 3% vs TT 4%, P = 0.35) was similar in both groups. The rate of reoperations for bleeding tended to be higher in the NTT group (3% vs 0%, P = 0.07) and the rate of inadvertently removed parathyroid glands was significantly higher after NTT (13% vs 3%, P = 0.01). An existing endocrine orbitopathy improved in 35% and 24% after NTT and TT (P = 0.61). Recurrent disease occurred in only 1 patient after TT (P = 0.34)., Conclusion: NTT for GD is not superior to TT regarding transient postoperative hypoparathyroidism.

Background: The techniques available for antireflux surgery have expanded with the introduction of the magnetic sphincter augmentation device (MSAD) for gastroesophageal reflux disease (GERD)., Methods: A prospective, multicenter registry evaluated MSAD and laparoscopic fundoplication (LF) in clinical practice (ClinicalTrials.gov identifier: NCT01624506). Data collection included baseline characteristics, reflux symptoms, proton-pump inhibitor (PPI) use, side effects, and complications. Post-surgical evaluations were collected at one year., Results: At report, 249 patients (202 MSAD patients and 47 LF patients) had completed one-year follow-up. The LF group was older and had a greater frequency of large hiatal hernias and Barrett's esophagus than the MSAD group (P < 0.001). The median GERD-health related quality of life score improved from 20.0 to 3.0 after MSAD and 23.0 to 3.5 after LF. Moderate or severe regurgitation improved from 58.2 to 3.1% after MSAD and 60.0 to 13.0% after LF (P = 0.014). Discontinuation of PPIs was achieved by 81.8% of patients after MSAD and 63.0% after LF (P = 0.009). Excessive gas and abdominal bloating were reported by 10.0% of patients after MSAD and 31.9% following LF (P ≤ 0.001). Following MSAD, 91.3% of patients were able to vomit if needed, compared with 44.4% of those undergoing LF (P < 0.001). Reoperation rate was 4.0% following MSAD and 6.4% following LF., Conclusion: Antireflux surgery should be individualized to the characteristics of each patient, taking into consideration anatomy and propensity and tolerance of side effects. Both MSAD and LF showed significant improvements in reflux control, with similar safety and reoperation rates. In the treatment continuum of antireflux surgery, MSAD should be considered as a first-line surgical option in appropriately selected patients without Barrett's esophagus or a large hiatal hernia in order to avoid unnecessary dissection and preserve the patient's native gastric anatomy. MSAD is an important treatment option and will expand the surgeon's role in treating GERD.

Context: Serum calcitonin (hCT) measurement may be useful for detecting medullary thyroid carcinoma (MTC), but the routine use of hCT after pentagastrin stimulation to screen patients with nodular thyroid disease remains controversial., Patients: A total of 1007 patients (567 females and 440 males) with nodular thyroid disease and a mean age of 55+/-14 (mean+/-S.D.) years were included in the study. All patients did not have impaired renal function, bacterial infection, alcohol and drug abuse, pseudohypoparathyroidism, or proton-pump inhibitor therapy. Individuals referred with known elevation of hCT, Graves' disease, or autoimmune thyroid disease were not considered or included in this investigation., Methods: Serum hCT levels were determined under basal conditions, and when basal values were >or=10 and <100 pg/ml, testing was repeated after pentagastrin stimulation. Patients with basal or stimulated levels >100 pg/ml were referred for surgery., Results: hCT levels >10 pg/ml were increased in 17 patients (1.7%). One patient had a basal hCT level of 4400 pg/ml with a histological confirmation of a MTC. In this patient, pentagastrin test was not performed. Sixteen patients with basal hCT between 10 and 100 pg/ml underwent pentagastrin-stimulated hCT measurement. Of 16 patients, 4 had stimulated hCT>100 pg/ml. Of 17 patients with hCT>10 pg/ml, 2 had MTC, and of 17 patients, 3 had C-cell hyperplasia. In total, two patients (0.20%) had a histologically verified MTC., Conclusions: Basal hCT measurement together with pentagastrin-stimulated hCT measurement in cases of basal hCT>10 pg/ml detects MTC in 0.20% of patients with nodular thyroid disease. Whether this high incidence of MTC has major implications or not has to be discussed, but it should be considered as a useful and recommended tool for early detection of MTC and to save patients' life.

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60-80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

Objective: To prove safety and effectiveness of a lipid emulsion enriched with n-3 fatty acids from fish oil (Lipoplus) within the setting of parenteral nutrition of patients after major abdominal surgery and to determine whether there are effects on outcome parameters., Design: Prospective, randomized, double-blind, multicenter trial., Setting: University and surgical teaching hospitals., Patients: After obtaining informed consent, 256 patients undergoing major abdominal surgery were randomized. Parameters of safety, effectiveness, and outcome were routine laboratory parameters, complication rates, length of stay in the intensive care unit, and length of hospital stay. In addition we determined in patient subgroups of 30 patients each, the changes of the content of selected long-chain polyunsaturated fatty acids, the leukotriene synthetic capacity and the antioxidant alpha-tocopherol., Interventions: Participating patients were randomized to receive either Lipoplus (group I; n = 127 patients) or Intralipid (group II; n = 129 patients). Parenteral nutrition was initiated immediately after surgery and ended on day 5 after surgery., Measurements and Main Results: No significant differences between groups I and II were observed when comparing routine laboratory parameters during the perioperative period. Plasma levels of eicosapentaenoic acid, leukotriene B5, and antioxidant content were significantly increased in group I. Furthermore, there was a significantly shorter length of hospital stay of approximately 21% (17.2 vs. 21.9 days; p = .0061) in group I., Conclusions: Our findings indicate that the administration of Lipoplus in the postoperative period after major abdominal surgery is safe and results in a significantly shorter length of hospital stay. Administration of n-3 polyunsaturated fatty acids in the postoperative period can be considered a valuable choice for patients requiring parenteral nutrition after major abdominal surgery.

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Major surgery leads to post-traumatic immune dysregulation which is driven by the activation of potent proinflammatory mediators including the leukotrienes (LTs). The LTs of the four-series derive from arachidonic acid (an omega-6 fatty acid). In contrast, LTs of the five-series are metabolic products of eicosapentaenoic acid (an omega-3 fatty acid) and exert less biological activities. Therapeutical strategies to attenuate proinflammatory signals include the provision of omega-3 fatty acids. Thirty patients with major elective abdominal surgery and an indication for total parenteral nutrition (TPN) were compared in a prospective, double blind, randomized study of two parallel groups. Group 1 (n=14) received an omega-3 fatty acid enriched 20% lipid emulsion (MCT:LCT:fish oil = 5:4:1, MLF541; Lipoplus) for 5 days postoperatively. Group 2 (n=16) received a standard 20% fat emulsion (LCT; Intralipid). The LT release from whole blood leukocytes stimulated with Ca-ionophore was analyzed preoperatively and on postoperative days 1, 6 and 8 by HPLC. There was a significant increase in the generation of LTB(5) (P=0.0035) and in the ratio of LTB(5)/LTB(4) (P=0.0017) the omega-3 group, but not in the reference group after 5 days infusion of the lipid emulsions. The omega-6/omega-3 fatty acid ratio 3:1 of the newly developed MLF541 lipid emulsion is appropriate to increase the synthesis of the biologically less active leukotrienes of the five-series. Nutritive enrichment with omega-3 fatty acids in a balanced ratio with omega-6 fatty acids is an important step to avoid hyperinflammatory situations in patients after major surgery.

The aim was to perform a totally laparoscopic thrombendarterectomy (TEA) of the infrarenal aorta to reduce the trauma connected to the surgical approach. A 52-year-old man was referred to our institution with severe claudication. Angiography revealed a subtotal stenosis of the infrarenal aorta. Because the lesion was not suitable for an interventional procedure, a TEA was planned. The surgery was performed through six ports using a transperitoneal approach with pneumoperitoneum. The laparoscopic TEA was carried out according to the standards of open vascular surgery. The surgery time was 285 minutes, the crossclamping lasted 105 minutes, and the blood loss was 100 mL. The angiographic and functional results were excellent. The patient experienced a rapid recovery and was discharged after 6 days. This case report shows the feasibility of totally laparoscopic TEA of the infrarenal aorta. The well-known advantages of minimally invasive techniques in abdominal surgery with regard to the decrease of surgical trauma may also be valid in aortic surgery for occlusive disease.

Hypothesis: Perioperatively administered enteral immunonutrition will improve early postoperative morbidity and cost-effectiveness after gastrointestinal tract surgery., Design: A prospective, randomized, double-blind, multicenter clinical trial., Setting: Surgical departments in German university and teaching hospitals., Patients: One hundred fifty-four patients with upper gastrointestinal tract malignant neoplasms who were eligible for analysis., Intervention: Preoperatively, patients received 5 days of oral immunonutrition (an arginine-, RNA-, and omega3 fatty acid-supplemented diet) or an isoenergetic control diet (1 L/d). Early postoperative enteral feeding with immunonutrition or an isoenergetic, isonitrogenous control diet using a catheter jejunostomy was performed for 10 days., Main Outcome Measures: Postoperative infectious complications, their treatment costs, and cost-effectiveness of immunonutrition were analyzed. Plasma levels of the fatty acids eicosapentaenoic acid and docosahexaenoic acid were measured., Results: In the immunonutrition group, significantly fewer infectious complication events occurred (14 vs 27; P = .05). The number of patients with complications was significantly lower in the supplemented diet group after postoperative day 3 (7 vs 16; P = .04). The treatment costs of complications in the supplemented diet group were suggestively lower than in the control diet group (DM 75172 vs DM 204273). Cost-effectiveness was DM 1503 in the experimental group vs DM 3587 in the control group, where DM denotes deutsche mark (German currency)., Conclusion: The perioperative administration of an enteral immunonutrition significantly (P = .05) decreased the early occurrence of postoperative infections and reduced substantially the treatment costs of the complications after major upper gastrointestinal tract surgery.

Graft infection continues to be one of the most feared complications in vascular surgery. It can lead to disruption of anastomoses with life-threatening bleeding, thrombosis of the bypass graft, and systemic septic manifestations. One method to ensure adequate limb perfusion after removal of an infected aortofemoral graft is extra-anatomical bypass grafting. We used a minimally invasive, video-assisted approach to implant a crossover iliofemoral obturator bypass graft in a patient with infection of the left limb of an aortofemoral bifurcated graft. This appears to be the first case report describing the use of this technique.

Purpose: The study objective was to apply laparoscopic techniques to conventional bypass procedures for aortoiliac occlusive disease., Methods: From October 1995 to August 1997, we performed seven iliofemoral (IFB), five unilateral aortofemoral (UAFB), and 11 aortobifemoral (AFB) bypass procedures and one aortic endarterectomy (TEA) totally laparoscopic. A transabdominal approach with pneumoperitoneum was preferred, and only laparoscopic vascular instruments were used. Endoscopic intervention followed principles of vascular surgery. As in open surgery, we used Dacron grafts and polypropylene sutures., Results: Twenty procedures were carried out totally laparoscopic; four conversions to open surgery were necessary. Severe complications included one postoperative respiratory failure requiring ventilatory support for four days, and one iliac vein lesion with subsequent open surgery. Mean operating time was 258 +/- 49 minutes for IFB, 218 +/- 54 minutes for UAFB, 279 +/- 69 minutes for AFB, and 290 minutes for aortic TEA. Mean blood loss was 92 +/- 49 ml for IFB, 390 +/- 316 ml for UAFB, 563 +/- 516 ml for AFB, and 100 ml for aortic TEA. Mean postoperative stay was 7.4 days for IFB, 7.8 days for UAFB, and 10.1 days for AFB. After the aortic TEA, the patient was discharged on day 6. At control examination all grafts were patent; two patients had mild claudication because of one progressive disease and one distal suture stenosis., Conclusion: Laparoscopic vascular surgery for aortoiliac occlusive disease is feasible, safe, and effective. At the beginning, a cooperation between experienced laparoscopists and vascular surgeons is needed to overcome procedural challenge, because operating time and conversion rate decrease with growing experience. The advantages observed in the majority of our patients were minimal tissue trauma, decreased blood loss, and faster postoperative recovery when compared with patients who had open aortic surgery at our institution. Further evidence has to be gained by clinical trials to define the role of laparoscopic vascular surgery for aortoiliac occlusive disease.

Objective: To determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT, Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outcome, i.e., reduced infectious and wound complications and decreased treatment costs when compared with an isocaloric, isonitrogenous control diet., Design: A prospective, randomized, placebo-controlled, double-blind, multicenter trial of the clinical outcome and a retrospective cost-comparison analysis., Setting: Surgical intensive care units in three different German university hospitals., Patients: Of 164 patients enrolled in the study, 154 patients were eligible for analysis. They were admitted to the intensive care unit after upper gastrointestinal surgery for cancer and they received an enteral diet via needle catheter jejunostomy. Infectious complications were defined as sepsis or systemic inflammatory response syndrome, pneumonia, urinary tract infection, central venous catheter sepsis, wound infection, and anastomotic leakage. The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth postoperative day) postoperative complications. The treatment costs of each complication were analyzed and compared in both groups., Interventions: Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postoperative day 5., Measurements and Main Results: Clinical examination and adverse gastrointestinal symptoms were recorded on a daily basis. Both groups tolerated early enteral feeding well, and the rate of tube feeding-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs. 24 patients in the control group (NS). Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 patients in the immunonutritional group vs. 11 patients in the control group). However, in the late phase (after postoperative day 5), considerably fewer patients in the experimental diet group experienced complications compared with the control group (5 vs. 13, p < .05). In addition, the frequency rate of complicating events were recorded in each group. In the experimental diet group, a total of 22 complicating events were recorded vs. a total of 32 events in the placebo diet group (NS). However, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced in the immunonutrition group when compared with the control group (8 vs. 17 events, p < .05). The total costs for the treatment of the complications were 83,563 German marks in the experimental diet group vs. 122,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks. (At the end of December 1995, the conversion rate from German marks to U.S. dollars was 1.4365 German marks to $1.00.), Conclusions: Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery. In patients who received the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was observed. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.

In this study mitoxantrone (Mtx) induced DNA strand breaks were measured with the alkaline elution technique in short term cell cultures derived from human gliomas. Glioblastomas or astrocytomas from 5 patients who underwent intracranial surgery were cultured and incubated i h with different concentrations of Mtx (0, 0.01, 0.1 and 1.0 microgram/ml). The alkaline elution method was modified to measure DNA lesions in human gliomas. Mtx induced DNA strand breaks in a dose dependent manner in all cell cultures tested. There was a linear increase of DNA strand break frequency induced by Mtx between 0.01-1.0 microgram/ml. concerning these in vitro data, Mtx might be potentially useful for the treatment of patients with malignant brain tumors.

Objective: Nutritive immunomodulation of patients after major surgery., Design: Prospective, randomized controlled double-blind study., Patients: Forty patients undergoing major intestinal surgery. Patients were divided into two groups: one received a total parenteral nutrition enriched with omega-3 fatty acids for 5 days postoperatively, the other an isocaloric, control nutrition., Materials and Methods: We analyzed the leukocyte ability to release leukotrienes from whole blood leukocytes stimulated with the calcium ionophore A23187 (5 micromol/L) by reverse phase high-performance liquid chromatography and circulating cytokines by enzyme-linked immunosorbent assay., Results: Leukocytes from patients of the omega-3 fatty acids group generated significantly higher amounts of less biologically active leukotriene B5 as compared to the control group (p < or = 0.001). This was accompanied by a significant decrease in the generation of proinflammatory leukotriene B4 (p < or = 0.006) in the study group. In contrast to interleukin-1beta, interleukin-6, and interleukin-10 systemic levels of tumor necrosis factor-alpha (p < or = 0.05) were postoperatively decreased in the study group., Conclusion: Our data provide evidence that a total parenteral nutrition enriched with omega-3 fatty acids modulates the lipid mediator pattern and systemic tumor necrosis factor-alpha levels.

Following severe trauma or major surgery patients develop functional alterations of host defense mechanisms which contribute an enhanced susceptibility towards microbial infections. Several studies have demonstrated that a specialized nutritional regimen may improve immune functions. We analyzed leukocyte functions from 40 patients undergoing major upper gastrointestinal surgery in a randomized placebo-controlled double-blind study. Patients were divided into two groups, one received 5 days pre-operatively an orally given experimental supplement enriched with omega-3-fatty acids, arginine, and ribonucleic acid (RNA), the other an isocaloric, control supplement. The experimental group generated significantly more leukotriene B(5) (LTB(5)) as compared to the control group. In contrast, the capacity to generate leukotriene B(4) (LTB(4)) as well as the synthesis of interleukin-8 (IL-8) was not significantly different in both groups. Additionally, lymphocyte/monocyte proliferation was analyzed and donor specific heterogeneities were observed; but no significant differences were found between the two nutritional regimens.

Objective: To evaluate the effect of early postoperative feeding with a nutritionally complete enteral diet supplemented with the nutrients arginine, ribonucleic acid (RNA), and omega-3 fatty acids on the immune function in patients undergoing surgery for upper gastrointestinal (GI) malignancies., Design: Prospective, randomized, placebo-controlled, double-blind study., Setting: Surgical intensive care unit (ICU) in a German university hospital., Patients: Forty-two consecutive patients receiving an enteral diet via needle catheter jejunostomy after GI surgery for cancer., Interventions: Patients were randomized to receive either the arginine, RNA, and omega-3 fatty acids supplemented diet or an isocaloric and isonitrogenous placebo diet. Early enteral nutrition was started on postoperative day 1 in the surgical ICU with 20 mL/hr and progressed to the optimal goal of 80 mL/hr by postoperative day 5., Measurements and Main Results: Clinical examination and adverse GI symptoms were recorded on a daily basis. Body weight was determined twice weekly. Immunoglobulin concentrations were determined by laser nephelometry. Interferon-gamma concentrations were measured with a modified enzyme-linked immunosorbent assay method. Fluorescence-activated cell scan flow cytometry was performed to analyze B cells, T lymphocytes and their subsets. Clinical patient characteristics and mean caloric intake were similar between the two groups and both formulas were well tolerated. The number of T lymphocytes and their subsets, helper T cells (CD4) and activated T cells (CD3, HLA-DR), were significantly higher in the supplemented diet group on postoperative days 10 and 16 (p < .05). Mean interferon-gamma concentration after phytohemagglutinin stimulation was higher in the supplemented diet group on postoperative day 16. In the supplemented diet group, mean immunoglobulin M concentrations were significantly higher on postoperative day 10 and mean immunoglobulin G concentrations were higher on postoperative day 16 (p < .05) compared with the results in the placebo group. B-lymphocyte indices were significantly higher in the supplemented vs. the placebo diet group on postoperative days 7 and 10 (p < .05)., Conclusions: Supplementation of enteral diet with arginine, RNA, and omega-3 fatty acids in the early postoperative time period improves postoperative immunologic responses and helps to overcome more rapidly the immunologic depression after surgical trauma.

Objective: To find out whether an enteral diet supplemented with arginine, RNA, and omega-3 fatty acids modulated the production of interleukin-1 (IL-1), interleukin-2 (IL-2), IL-2 receptor, interleukin-6 (IL-6), and tumour necrosis factor alpha (TNF-alpha) after operations for upper gastrointestinal cancer., Design: Prospective double blind clinical study., Setting: University hospital, Germany., Subjects: 42 patients randomised into two groups (n = 21 each), one of which was given an isocaloric and isonitrogenous placebo diet and one of which was fed the same diet supplemented with arginine, RNA, and omega-3 fatty acids., Interventions: The cytokines were measured before operation and on postoperative days 1, 3, 7, 10, and 16., Main Outcome Measures: Comparison of concentrations of cytokines in the two groups., Results: Among those receiving the placebo diet (after spontaneous stimulation) IL-6 concentrations were significantly higher on days 3 and 7 (p < 0.05) and TNF-alpha concentrations on day 7. In contrast (after stimulation with phytohaemagglutinin) mean concentrations of IL-2 receptor were significantly higher on days 3 and 7, and of IL-1 beta and IL-2 on day 16 (p < 0.05) in the group receiving the supplemented diet., Conclusion: Supplementation of an enteral diet with arginine, RNA and omega-3 fatty acids can modulate the acute phase reaction as indicated by the reduction in concentrations of TNF-alpha and IL-6 in the group fed the supplemented diet. Patients receiving the supplemented diet also showed accelerated recovery in the concentrations of IL-1 beta and IL-2 receptor.

Background: Gastrointestinal side effects, particularly diarrhea, are still the main reasons for discontinuation of enteral nutrition. Although the causes of diarrhea are diverse, the enteral nutrition solution is frequently suspected of playing a leading role in causing diarrhea., Methods: Our randomized, prospective, double-blind trial with 100 patients assessed the effects of feeding a standard diet (Nutrodrip Standard) vs the same diet supplemented with 20 g of soluble fiber, containing partially hydrolyzed guar gum (Sunfiber), per 1000 mL. Thirty patients received total enteral nutrition postoperatively, and 70 patients received enteral supplementation., Results: The patients receiving total enteral nutrition with soluble fiber had decreased diarrhea but increased flatulence. In none of these patients did enteral feeding have to be discontinued because of gastrointestinal side effects, whereas in four patients who were on a standard diet, enteral feeding had to be interrupted because of diarrhea (p < .05). Similar observations were made in patients receiving enteral supplementation. In both groups, the incidence of diarrhea decreased significantly with the soluble fiber diet compared with the standard diet (6 vs 15, p < .05)., Conclusions: Enteral feeding with a formula supplemented with partially hydrolyzed guar gum reduces the incidence of diarrhea in patients receiving total enteral nutrition as well as in those receiving enteral supplementation, regardless of the cause of diarrhea. The increased hydrogen production and the significantly higher rate of flatulence are likely to result from fermentation of the soluble fiber in the colon, with concomitant production of short-chain fatty acids, which leads to increased absorption of short-chain fatty acids, sodium, and water by the colonocytes. This effect, together with the observed cholecystokinin-mediated decrease in colonic transit time with partially hydrolyzed guar gum, may explain the reduction in the incidence of diarrhea in this study.

The hypothesis that the lipid emulsion of the emulsion formulation of propofol is responsible for the low frequency of nausea, retching, and vomiting after propofol anesthesia was tested. A randomized, prospective, and comparative study was performed to evaluate the antiemetic effect of 10% lipid solution in 60 women, ASA physical status I and II, scheduled for ambulatory laparoscopic procedures. Two groups of patients were studied. Induction of anesthesia (thiopental) and maintenance of anesthesia (enflurane, nitrous oxide) were similar in both groups. At induction the study group received 10% Intralipid (3 mL/min for 20 min). The control group received 5% dextrose in lactated Ringer's solution at the same rate. Other drugs administered during or after anesthesia were similar among the groups. The groups were similar with respect to duration of anesthesia, characteristics of early and intermediate recovery, as well as pain scores in the postanesthesia care unit. There were no differences in the amount of antiemetic medications administered or postoperative nausea, retching, or vomiting when the patients were evaluated objectively by a blinded observer or subjectively by patient self-evaluation. It is concluded that 10% Intralipid, the lipid in the emulsion formulation of propofol, does not possess significant antiemetic effects.