Search

AIM: To reduce detrimental opioid-related side effects, minimising the postoperative opioid consumption is needed, especially in older patients. Continuous wound infusion (CWI) with local analgesics seems an effective opioid-sparing alternative. However, the added value of CWI to an enhanced recovery protocol after colorectal cancer (CRC) surgery is unclear. The aim of this study was to evaluate the outcomes of CWI after CRC surgery within a strictly adhered enhanced recovery protocol.METHOD: In this multicentre prospective observational cohort study, patients who underwent CRC surgery between May 2019 and January 2021 were included. Patients were treated with CWI as adjunct to multimodal pain management within an enhanced recovery protocol. Postoperative opioid consumption, pain scores and outcomes regarding functional recovery were evaluated.RESULTS: A cohort of 130 consecutive patients were included, of whom 36.2% were ≥75 years. Postoperative opioids were consumed by 80 (61.5%) patients on postoperative day 0, and by 28 (21.5%), 27 (20.8%), and 18 (13.8%) patients on postoperative day 1, 2, and 3, respectively. Median pain scores were CONCLUSION: In patients treated with CWI, low amounts of postoperative opioid consumption, adequate postoperative pain control, and enhanced recovery were observed. CWI seems a beneficial opioid-sparing alternative and may further improve the outcomes of an enhanced recovery protocol after CRC surgery, which seems especially valuable for older patients.

Item does not contain fulltext AIM: Guidance throughout the entire process of ostomy surgery is warranted to improve self-management and reduce healthcare consumption. The aim of this study was to develop an interactive application to educate patients scheduled for ostomy surgery and to evaluate patient satisfaction and implementation. METHOD: A literature study and a cross-sectional study among patients and nurses was performed to evaluate the relevance of different topics (e.g., ostomy materials, self-care, complications, impact) for an interactive application in ostomy surgery. The interactive application, StoManager, was developed in collaboration with patients and healthcare providers. The implementation of the application was evaluated among 30 patients scheduled for ostomy surgery to investigate usability, patient satisfaction, compliance, the need for home nursing care services, and the number of contact moments with the ostomy nurse. RESULTS: StoManager contained all topics considered relevant by patients and healthcare providers, including information on ostomy surgery, ostomy self-care and ostomy-related complications. Patient-reported outcome measures were incorporated to monitor the patient's health status during treatment. The usability scores of StoManager were above average. Patients rated StoManager with an overall score of 7.5 (SD 1.5) out of 10. The response rate to the patient-reported outcome measures was 79.3%. At discharge, 28/30 (93.3%) patients did not need home nursing care services for ostomy care. CONCLUSIONS: An interactive application to support patients throughout the entire process of ostomy surgery is feasible. Patients were satisfied with StoManager and its usability, which might result in improved self-management and decreased healthcare consumption. A more patient-specific approach could further improve the perceived quality and value of the application. 01 juni 2023

Conflicting data about inflammatory bowel disease [IBD] and immunosuppressants are risk factors for severe COVID-19 confuse patients and healthcare providers. Clinical reports with longer follow-up are lacking. A retrospective search was performed for severe COVID-19 (hospital admission and/or mortality) one year after the SARS-CoV-2 outbreak in an IBD cohort from one of the most affected Dutch regions. Cohort characteristics were explored by value-based healthcare data, including immunotherapy. COVID-19 cases were detected by ICD-10 codes and further examined for IBD determinants (including medication) and COVID-19 characteristics (intensive care admission, respiratory support, treatment, mortality). The national mortality register was consulted, ensuring detection of patients that died without admission. Results were compared with regional and national general population registries. The IBD cohort consisted of 1453 patients (51% Crohn’s disease, 54% women, 39.9% using immunotherapy), including children. Biologics use increased during the study. Eight cases (0.55%) had severe COVID-19: seven were hospitalized (0.48%, 95% confidence interval [CI] 0.21–1.04), and two died (0.14%, CI 0.002–0.55). Six patients had comorbidity, one used immunotherapy, and four had no medication. Both deceased patients were older than 80 years, had severe comorbidity, but used no immunotherapy. Hospitalization occurred significantly more in the IBD cohort than regionally (0.18%, CI 0.17–0.19, p = 0.015), but not significantly more than nationally (0.28%, CI 0.279–0.284). Mortality was equal in IBD patients, regionally (0.11%, CI 0.10–0.12) and nationally (0.13%, CI 0.125–0.128). Neither IBD nor immunosuppressants are associated with increased risks of severe COVID-19 in an observational study with one-year follow-up.

Hepatology communications 5(8), 1400-1411 (2021). doi:10.1002/hep4.1728, Published by Wiley, Hoboken, NJ

Background This study aimed to investigate the agreement between magnetic resonance tumour regression grade (mrTRG) and pathological regression grade (pTRG) in patients with locally recurrent rectal cancer (LRRC). Also, the reproducibility of mrTRG was investigated. Methods All patients with LRRC who underwent a resection between 2010 and 2018 after treatment with induction chemotherapy and neoadjuvant chemo(re)irradiation in whom a restaging MRI was available were retrospectively selected. All MRI scans were reassessed by two independent radiologists using the mrTRG, and the pTRG was reassessed by an independent pathologist. The interobserver agreement between the radiologists as well as between the radiologists and the pathologist was assessed with the weighted kappa test. A subanalysis was performed to evaluate the influence of the interval between imaging and surgery. Results Out of 313 patients with LRRC treated during the study interval, 124 patients were selected. Interobserver agreement between the radiologists was fair (k = 0.28) using a two-tier grading system (mrTRG 1–2 versus mrTRG 3–5). For the lead radiologist, agreement with pTRG was moderate (k = 0.52; 95 per cent c.i. 0.36 to 0.68) when comparing good (mrTRG 1–2 and Mandard 1–2) and intermediate/poor responders (mrTRG 3–5 and Mandard 3–5), and the agreement was fair between the other abdominal radiologist and pTRG (k = 0.39; 95 per cent c.i. 0.22 to 0.56). A shorter interval (less than 7 weeks) between MRI and surgery resulted in an improved agreement (k = 0.69), compared with an interval more than 7 weeks (k = 0.340). For the lead radiologist, the positive predictive value for predicting good responders was 95 per cent (95 per cent c.i. 71 per cent to 99 per cent), whereas this was 56 per cent (95 per cent c.i. 44 per cent to 66 per cent) for the other radiologist. Conclusion This study showed that, in LRRC, the reproducibility of mrTRG among radiologists is limited and the agreement of mrTRG with pTRG is low. However, a shorter interval between MRI and surgery seems to improve this agreement and, if assessed by a dedicated radiologist, mrTRG could predict good responders.

Simple Summary Total mesorectal excision is the cornerstone for rectal cancer curation. However, elderly and frail patients may not be able to undergo a surgical procedure. These patients often receive no treatment at all and are at risk for developing debilitating symptoms that impair quality of life. Recent developments in the non-operative management of rectal cancer have increased the possibilities to provide patients with an alternative treatment if surgery is not possible, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The heterogeneity within the elderly and frail population requires a patient-centred approach to optimise treatment. The aim of this narrative review was to discuss a multidisciplinary and patient-centred treatment approach for the personalised non-operative management of elderly and frail rectal cancer patients. The narrative review also provides a practical suggestion of a successfully implemented multidisciplinary clinical care pathway, based on a literature review. Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.

Background: Short-chain fatty acids (SCFAs), fermentation products of undigested fibers, are considered beneficial for colonic health. High plasma concentrations are potentially harmful; therefore, information about systemic SCFA clearance is needed before therapeutic use of prebiotics or colonic SCFA administration. Objective: The aim of this study was to investigate the effect of rectal butyrate administration on SCFA interorgan exchange. Methods: Twelve patients (7 men; age: 66.4 6 2.0 y; BMI 24.5 6 1.4 kg/m 2 ) undergoing upper abdominal surgery participated in this randomized placebo-controlled trial. During surgery, 1 group received a butyrate enema (100 mmol sodium butyrate/L; 60 mL; n = 7), and the other group a placebo (140 mmol 0.9% NaCl/L; 60 mL; n = 5). Before and 5, 15, and 30 min after administration, blood samples were taken from the radial artery, hepatic vein, and portal vein. Plasma SCFA concentrations were analyzed, and fluxes from portal-drained viscera, liver, and splanchnic area were calculated and used for the calculation of the incremental area under the curve (iAUC) over a 30-min period. Results: Rectal butyrate administration led to higher portal butyrate concentrations at 5 min compared with placebo (92.2 6 27.0 mmol/L vs. 14.3 6 3.4 mmol/L, respectively; P < 0.01). In the butyrate-treated group, iAUCs of gut release (282.8 6 133.8 mmol/kg BW 0.5 h) and liver uptake (2293.7 6 136.0 mmol/kg BW 0.5 h) of butyrate were greater than in the placebo group [216.6 6 13.4 mmol/kg BW 0.5 h (gut release) and 16.0 6 13.8 mmol/kg BW 0.5 h (liver uptake); P = 0.01 and P < 0.05, respectively]. As a result, splanchnic butyrate release did not differ between groups. Conclusion: After colonic butyrate administration, splanchnic butyrate release was prevented in patients undergoing upper abdominal surgery. These observations imply that therapeutic colonic SCFA administration at this dose is safe. The trial was registered at clinicaltrials.gov as NCT02271802. JN utr2015;145:2019‐24.

Physiological reports 4(24), (2016). doi:10.14814/phy2.13037, Published by Wiley, [S.l.]

PLoS one 11(11), e0166161 (2016). doi:10.1371/journal.pone.0166161, Published by PLoS, Lawrence, Kan.

Background Manipulation of the liver during liver surgery results in profound hepatocellular damage. Experimental data show that mobilization-induced hepatocellular damage is related to hepatic inflammation. To date, information on this link in humans is lacking. As it is possible to modulate inflammation, it is clinically relevant to unravel this relationship. Aim This observational study aimed to establish the association between liver mobilization and hepatic inflammation in humans. Methods Consecutive patients requiring mobilization of the right hemi-liver during liver surgery were studied. Plasma samples and liver biopsies were collected prior to and directly after mobilization and after transection of the liver. Hepatocellular damage was assayed by liver fatty acid-binding protein (L-FABP) and aminotransferase levels. Hepatic inflammation was determined by (a) immunohistochemical identification of myeloperoxidase (MPO) and CD68- positive cells and (b) hepatic gene expression of inflammatory and cell adhesion molecules (IL-1β, IL-6, IL-8, VCAM-1 and ICAM-1). Results A total of 25 patients were included. L-FABP levels increased significantly during mobilization (301 ± 94 ng/ml to 1599 ± 362 ng/ml, P = 0.008), as did ALAT levels (36 ± 5 IU/L to 167 ± 21 IU/L, P

Hypothesis: The prevalence of and risk factors for incisional hernias among temporary stoma wounds have implications for clinical practice.Design: Retrospective cohort study.Setting: University tertiary care hospital.Patients: All adult patients with a stoma closed between January 1, 2000, and August 1, 2004. Of 150 living patients, 111 (74.0%) were included for analysis after follow-up at the outpatient clinic.Main Outcome Measures: The main outcome was incisional hernia in a temporary stoma wound, defined as a defect within the musculature and fascia detected by ultrasonographic examination. Risk factors for incisional hernias and the diagnostic validity of clinical symptoms and palpation during the Valsalva maneuver were determined.Results: After a median follow-up of 35 months (range, 5-77 months), hernia prevalence was 32.4%. Among patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of less than 30, hernia prevalence was 25.8%; among patients with a body mass index of 30 or higher, hernia prevalence was 59.1%. Palpation demonstrated the highest sensitivity (58.3%). One in 6 patients had discomfort at the temporary stoma site and no palpable defect but showed an incisional hernia on ultrasonographic examination. Obesity was the sole significant risk factor identified in this study (odds ratio, 5.53; 95% confidence interval, 1.72-17.80). The presence of a stoma in situ for less than 6 months showed a trend toward being a risk factor (odds ratio, 2.38; 95% confidence interval, 0.96-5.99).Conclusion: Incisional hernias occur in 1 of 3 temporary stoma wounds, and a body mass index of 30 or higher is a risk factor.

PURPOSE: To investigate whether a collagen fleece kept in place by fibrin glue might seal off a colorectal anastomosis, provide reinforcement, and subsequently improve anastomotic healing. METHODS: Wistar rats underwent a 1-cm left-sided colonic resection followed by a 4-suture end-to-end anastomosis. They were then randomly assigned to one of three treatment groups: no additional intervention (control, n = 20), the anastomosis covered with fibrin glue (fibrin glue, n = 20), the anastomosis covered with a collagen fleece, kept in place with fibrin glue (collagen fleece, n = 21). At either 3 or 7 days follow-up, anastomotic bursting pressure was measured and tissue was obtained for histology and collagen content assessment after which animals were sacrificed. RESULTS: Three rats in the control (15%), three in the fibrin glue (15%), and one in the collagen group (4.8%) died due to anastomotic complications (P = 0.497). Anastomotic bursting pressures were not significantly different between groups at 3 and 7 days follow-up (P = 0.659 and P = 0.427, respectively). However, bowel obstructions occurred significantly more often in the collagen group compared to the control group (14/21 vs. 3/20, P = 0.003). Collagen contents were not different between groups, but histology showed a more severe inflammation in the collagen group compared to the other groups at both 3 and 7 days follow-up. CONCLUSIONS: A collagen fleece kept in place by fibrin glue does not improve healing of colonic anastomoses in rats. Moreover, this technique induces significantly more bowel obstructions in rats, warranting further study before being translated to a clinical setting.

Background & aims: Prebiotics are increasingly used to improve gut integrity. A presumed mechanism of their beneficial action is the synthesis of short chain fatty acids (SCFA: acetate, propionate and butyrate). High systemic concentrations of propionate and butyrate are toxic and can adversely affect the patient. In physiological situations the liver uses propionate and butyrate for energy metabolism. The aim of the present study was to investigate to which extent patients with liver cirrhosis are still able to metabolize portal derived SCFA in the liver. Methods: Twelve patients with liver cirrhosis and an intrahepatic portosystemic shunt (TIPSS) were studied. Blood was sampled from the femoral artery, portal and hepatic vein. Organ plasma flow was measured. Net release or uptake was calculated by multiplying the arteriovenous differences by plasma flow. SCFA plasma concentrations were measured using LC-MS. Results: Arterial concentrations were 124±12, 8±1 and 10±1μmol/l for acetate, propionate and butyrate, respectively. The gut produced 32.5±13.0, 4.8±1.3 and 6.2±2.1μmolkgbw-1h-1 of acetate, propionate and butyrate, respectively. Assuming 70% portosystemic shunting, hepatic uptake of propionate and butyrate was 3.1±0.9 and 5.2±1.4μmolkgbw-1h-1. Hepatic uptake of acetate was non significant (12.1±12.3μmolkgbw-1min-1). As a consequence of shunting, part of total acetate escaped from the splanchnic bed, which equalled 34.9±14.7μmolkgbw-1h-1. Conclusion: The liver of patients with stable cirrhosis is able to use butyrate and propionate, most likely preventing increased systemic concentrations. This suggests that prebiotics can be administered safely, but monitoring butyrate levels may be advisable in patients with diminished liver function. © 2009 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.

PURPOSE: The purpose of this study was to evaluate the impact of postoperative complications and the presence of a stoma on long-term quality of life in patients with rectal cancer. METHODS: Consecutive patients with an adenocarcinoma of the rectum who underwent surgery at Maastricht University Medical Center or VieCuri Medical Center between 2003 and 2005 were included in this study. Data on surgical treatment and complications were collected. Severe postoperative complications were classified according to a standardized complication severity score. Quality of life was assessed by use of the European Organization for Research and Treatment of Cancer core and colorectal cancer-specific quality-of-life questionnaires. RESULTS: One hundred seventy patients received a questionnaire, and 121 (71%) responded. Of the responders, 33 (27.3%) patients suffered from severe postoperative complications. The median follow-up was 36 months. In the univariate analysis, patients with severe postoperative complications had a lower score on physical functioning (73 vs. 85, P = 0.031) and higher scores on pain (17 vs. 0, P = 0.025) and fatigue (33 vs. 22, P = 0.036). Stoma construction (n = 51) was associated with a higher global health status (83 vs. 75, P = 0.019), and these patients reported fewer gastrointestinal problems (P = 0.001). CONCLUSION: Severe postoperative complications seem to be associated with several lower quality-of-life subscores over the long term. In contrast, a stoma is associated with improved global health status and leads to fewer gastrointestinal complaints. In patients prone to complications, it may be sensible to avoid creating a low anastomosis and to construct a permanent stoma immediately.

Summary Background & aims Short chain fatty acids (SCFAs; acetate, propionate and butyrate) are important energy sources for colonocytes and are assumed to play a key role in gut health. Local effects of SCFAs have been investigated, but less is known about whole body metabolism of these SCFAs. The aim of the present study was to quantify the role of the gut and liver in interorgan exchange of SCFAs in humans in vivo. Methods Twenty-two patients undergoing major upper abdominal surgery were studied. Blood was sampled from a radial artery, the portal and a hepatic vein. Portal, splanchnic and arterial blood flow was measured using intra-operative Duplex ultrasonography. SCFAs were measured on a liquid chromatography system combined with mass spectrometry. Results SCFAs were released by the gut, 34.9 (9.1) μmol kg bodyweight −1 h −1 . SCFAs uptake by the liver was significant for propionate and butyrate; −5.6 (1.3) and −3.8 (1.6) μmol kg bodyweight −1 h −1 ( p = 0.0002 and p = 0.03) respectively and counterbalanced gut release. Liver uptake of acetate was not significant, −5.2 (6.6) μmol kg bodyweight −1 h −1 ( p = 0.434). Splanchnic (i.e., gut + liver) SCFAs release was significant for acetate and propionate, 17.3 (7.3) and 1.2 (0.4) μmol kg bodyweight −1 h −1 ( p = 0.027 and p = 0.0038), respectively. Splanchnic release of butyrate was not significantly different from zero (1.9 (1.2) μmol kg bodyweight −1 h −1 , p = 0.129). BMI and previous colonic resection did not affect gut release of SCFAs. Conclusion This is the first in vivo study on the role of the gut and liver in SCFAs exchange in humans in vivo. It is shown that intestinal SCFAs release by the gut is equalled by hepatic uptake.

Short-chain fatty acids (SCFAs), fermentation products of undigested fibers, are considered beneficial for colonic health. High plasma concentrations are potentially harmful; therefore, information about systemic SCFA clearance is needed before therapeutic use of prebiotics or colonic SCFA administration.The aim of this study was to investigate the effect of rectal butyrate administration on SCFA interorgan exchange.Twelve patients (7 men; age: 66.4 ± 2.0 y; BMI 24.5 ± 1.4 kg/m(2)) undergoing upper abdominal surgery participated in this randomized placebo-controlled trial. During surgery, 1 group received a butyrate enema (100 mmol sodium butyrate/L; 60 mL; n = 7), and the other group a placebo (140 mmol 0.9% NaCl/L; 60 mL; n = 5). Before and 5, 15, and 30 min after administration, blood samples were taken from the radial artery, hepatic vein, and portal vein. Plasma SCFA concentrations were analyzed, and fluxes from portal-drained viscera, liver, and splanchnic area were calculated and used for the calculation of the incremental area under the curve (iAUC) over a 30-min period.Rectal butyrate administration led to higher portal butyrate concentrations at 5 min compared with placebo (92.2 ± 27.0 μmol/L vs. 14.3 ± 3.4 μmol/L, respectively; P0.01). In the butyrate-treated group, iAUCs of gut release (282.8 ± 133.8 μmol/kg BW · 0.5 h) and liver uptake (-293.7 ± 136.0 μmol/kg BW · 0.5 h) of butyrate were greater than in the placebo group [-16.6 ± 13.4 μmol/kg BW · 0.5 h (gut release) and 16.0 ± 13.8 μmol/kg BW · 0.5 h (liver uptake); P = 0.01 and P0.05, respectively]. As a result, splanchnic butyrate release did not differ between groups.After colonic butyrate administration, splanchnic butyrate release was prevented in patients undergoing upper abdominal surgery. These observations imply that therapeutic colonic SCFA administration at this dose is safe. The trial was registered at clinicaltrials.gov as NCT02271802.

Background: Plasma interleukin-6 (IL-6) levels increase during liver resection. The source of this IL-6 is hitherto unclear. It has been demonstrated that the hepatosplanchnic area takes up IL-6 but the role of the gut and liver is unknown. The aim of the present study was to investigate the role of the gut and liver in IL-6 homeostasis during liver surgery. Methods: Before and after partial hepatectomy, IL-6 was measured in blood sampled from the radial artery, and the hepatic and portal vein. Blood flow was measured to assess IL-6 fluxes (flow times AV-differences) across the gut, liver and hepatosplanchnic area. Results: In 22 patients undergoing liver resection, IL-6 release from the gut after transection was 90.9 (30.1) ng/min (P < 0.001), whereas net IL-6 uptake by the liver equalled 83.4 (41.7) ng/min (P < 0.01). Overall hepatosplanchnic flux was 7.3 (43.5) ng/min after transection and did not differ significantly from zero. Overall hepatosplanchnic flux was 87.8 (41.5) ng/min in the major resection group and -59.8 (67.5) ng/min in the minor resection group (P < 0.05). Discussion: The gut releases IL-6 and the liver takes up IL-6 before and after liver resection. The loss of IL-6 uptake as a result of a small functional remnant liver could lead to higher IL-6 levels after surgery.

BACKGROUND: A small remnant liver volume is an important risk factor for posthepatectomy liver failure. ImageJ and OsiriX((R)) are both free, open-source image processing software packages. The aim of the present study was to compare ImageJ and OsiriX((R)) in performing prospective computed tomography (CT) volumetric analysis of the liver on a personal computer (PC) in patients undergoing major liver resection. METHODS: Patients scheduled for a right hemihepatectomy were eligible for inclusion. Two surgeons and one surgical trainee measured volumes of total liver, tumor, and future resection specimen prospectively with ImageJ and OsiriX((R)). A radiologist also measured these volumes with CT scanner-linked Aquarius iNtuition((R)) software. Resection volumes were compared with the actual weights of the liver specimens removed during surgery, and differences between the measured liver volumes were analyzed. RESULTS: A total of 15 patients (8 men, 7 women) with a median age of 63 years (48-79 years) were included. There was a significant correlation between the measured weights of resection specimens and the volumes calculated prospectively with ImageJ and OsiriX((R)) (r = 0.89; r = 0.83, respectively). There was also a significant correlation between the volumes measured with radiological software iNtuition((R)) and the volumes measured with ImageJ and OsiriX((R)) (r = 0.93; r = 0.95, respectively). CONCLUSIONS: There were no major differences in total liver volumes, resection volumes, or tumour volumes for these three software packages. Prospective hepatic CT volumetry with ImageJ or OsiriX((R)) is reliable and can be accurately used on a PC by nonradiologists. ImageJ and OsiriX((R)) yield results comparable to the radiological software iNtuition((R)).

INTRODUCTION: Anastomotic leakage is a common clinical complication with incidences up to 10% to 17% in colorectal surgery, leading to high morbidity and mortality. Butyrate is the product of colonic fermentation of indigestible carbohydrates and is considered beneficial to gastrointestinal healing. The aim of this study was to investigate the effect of intraluminal supplementation of butyrate on colonic anastomotic strength in a rat model. METHODS: Wistar rats were randomly assigned to one of 3 groups (18 animals each). All rats underwent a 1-cm left colonic resection and end-to-end anastomosis with 4 interrupted sutures. Group I underwent no other treatment and served as the control, group II received daily 5 mL of 60 mM sodium butyrate enemas postoperatively, and group III received placebo enemas. On the third or seventh postoperative day, rats (n = 9 per time point) were anesthetized and anastomotic bursting strength was assessed. RESULTS: As a consequence of anastomotic leakage, 3 rats (16.6%) in group I, 1 rat (5.6%) in group II, and 2 rats (11.2%) in group III died. Mean anastomotic bursting pressures at day 3 were not significantly different between groups (53, 64, and 68 mm Hg for group I, II, and III, respectively, P = .777). At day 7, bursting pressures were 118, 225, and 129 mm Hg for groups I, II, and III, respectively (P = .0006). Group II showed an increased mature-to-immature collagen ratio (P = .035). CONCLUSION: Postoperative intestinal butyrate supplementation enhances anastomotic bursting strength in a left-sided partial colonic resection rat model, which can be explained by increased collagen synthesis and maturation.

INTRODUCTION: Aminotransferases are commonly used to determine the optimal duration of ischemic intervals during intermittent Pringle manoeuvre (IPM). However, they might not be responsive enough to detect small differences in hepatocellular damage. Liver fatty acid-binding protein (L-FABP) has been suggested as a more sensitive marker. This randomized trial aimed to compare hepatocellular injury reflected by L-FABP in patients undergoing liver resection with IPM using 15 or 30 minutes ischemic intervals. PATIENTS AND METHODS: Twenty patients undergoing liver surgery were randomly assigned to IPM with 15 (15IPM) or 30 (30IPM) minutes ischemic intervals. Ten patients not requiring IPM (noIPM) served as controls. Primary endpoint was hepatocellular injury during liver surgery reflected by systemic L-FABP plasma levels. Between group comparisons were performed using area under the curve and repeated measures two-way ANOVA. RESULTS: The IPM groups had similar characteristics. Aminotransferases did not differ significantly between 15IPM and 30IPM at any time point. L-FABP levels rose up to 1853 +/- 708 ng/mL in the 15IPM and 3662 +/- 1355 ng/mL in the 30IPM group after finishing liver transection and decreased rapidly thereafter. There were no significant differences between 15IPM and 30IPM in cumulative L-FABP level (p=0.378) or L-FABP level at any time point (p=0.149). Blood loss, remnant liver function and morbidity were comparable. CONCLUSION: IPM with 15 or 30 minutes ischemic intervals induced similar hepatocellular injury measured by the sensitive marker L-FABP. The present study confirms the results of earlier trials, suggesting that IPM with 30 minutes ischemic intervals may be used.

A new liquid chromatography-mass spectrometry method is described to determine concentrations of the short chain fatty acids acetic acid, propionic acid and butyric acid (SCFAs) in human blood plasma. The method is based on reversed phase chromatography followed by post-column neutralization of the mobile phase with ammonia and a consecutive measurement of the SCFAs ammonia adducts using negative electro spray ionization. Sample preparation involved simple organic acid deproteinization, resulting in 100% recovery. SCFAs eluted baseline separated within a 25 min run cycle. A linear response was obtained in the range between 0 and 250 micromol/l (R(2) ranged from 0.997 to 0.9999). The limit of detection ranged from 0.05 micromol/l for propionic and butyric acid and 0.1 micromol/l for acetic acid. The method was tested by analyzing plasma of arterial blood, from portal vein and hepatic vein blood from patients undergoing a pylorus-preserving pancreaticoduodenectomy. As expected, the highest SCFA concentrations were found in portal plasma, hepatic vein levels were in between, while arterial concentrations were lowest. This newly developed method is suitable to determine SCFA concentrations in human plasma samples.

Increased lipid peroxidation and inflammation are major factors in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). A lipoxidation product that could play a role in the induction of hepatic inflammation is Ne-(Carboxymethyl)lysine (CML). The aim of this study was to investigate the relationship between steatosis and CML, and to study the role of CML in hepatic inflammation.

Introduction In a recent study we coincidentally showed that mobilisation of the liver was a major cause of liver surgery-induced damage. The magnitude of and mechanisms by which this damage occurs are unknown. Aim (A) To determine the relative contribution of mobilisation during liver surgery to liver damage and (B) To examine whether there is an association between mobilisation-induced liver damage and liver inflammation. Method Consecutive patients undergoing liver surgery requiring full mobilisation of the right hemi-liver were included. Plasma samples and liver biopsies were obtained immediately after induction, prior to and directly after liver mobilisation, and after liver transection. Liver Fatty Acid Binding Protein (L-FABP) and alanine aminotranferase (ALAT) were analysed as markers of hepatocyte injury. Specimens were stained by immunohistochemistry for myeloperoxidase (MPO), human neutrophil peptide (HNP), and caspase-3-mediated cleavage generated neo-epitope of CK18 (M30). Gene expression of interleukin (IL) 1β, 6 and 8, and intercellular adhesion molecule (ICAM) were analysed by q-RT-PCR. Results Nineteen patients were included (11M/8F, median age 64 years [30–79]) who underwent major liver surgery. L-FABP levels increased significantly during liver mobilisation (from 91.7 ng/ml [11.4–2212.5 ng/ml] to 1014.4 ng/ml [141.4–8986.1 ng/ml], p Conclusion Mobilisation of the liver during surgery induces profound hepatocellular damage and inflammation, which is associated with activation and/or infiltration of immune cells. Given the short half-life of L-FABP (14 min), hepatocyte damage predominantly occurred during mobilisation of the liver and not during transaction. These data produce insight into the mechanisms of mobilisation-induced liver damage, and provide indications for designing interventions aiming at prevention of surgery-induced liver damage in the future.