S. Karger GmbHChir Gastroenterol0177–99902032004Ernährung – Sondenernährung173173DEE.RothC.BeglingerEDITORIALCGA200402000317310.1159/000081225

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S. Karger GmbHChir Gastroenterol0177–99902032004Malnutrition as Prognostic FactorMalnutrition als prognostischer Faktor175180DEK.NormanH.LochsM.PirlichCGA200402000317510.1159/000081226Malnutrition as Prognostic Factor Malnutrition is a common problem occurring in patients with chronic or severe disease. Prevalence of hospital malnutrition ranges between 20 and 60%, depending on the method and criteria used in order to determine nutritional status. Nutritional status is known to worsen during hospital stay which is partly due to poor recognition by the medical staff. Clinical malnutrition however is generally associated with increased morbidity and mortality in acute disease – such as stroke or hip fracture – as well as in chronic disease – such as liver failure or chronic renal failure – and has serious implications for recovery from illness and surgery. Length of hospital stay is longer in malnourished patients which in turn implies substantial higher costs. Therefore, nutritional assessment should be part of every medical examination in order to recognize malnutrition early and initiate nutritional therapy if necessary. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004Evaluation of Nutritional StatusBestimmung des Ernährungszustands181186DEJ.M.HacklCGA200402000318110.1159/000081227Evaluation of Nutritional Status In the average population it is common to be overweight (above 30%), while in hospital patients it is more common to show a lack of nutrition (above 40%). Either form of malnutrition leads to an increase in morbidity as well as mortality. Analyzing the nutritional status adequately allows to implement an appropriate therapy regarding nutrition (nutritional team). The nutritional status can be measured by particular parameters or by use of nutritional scores. The aim will be to gather the data easily and inexpensively and to reveal the statements and conclusions in a sensitive and specific manner. Anthropometric, labor chemical and immunological parameters are mostly of no value as they may be affected by the underlying illness; e.g. the body mass index (BMI) is not a very sensitive measure. The significance of stress related parameters is increasing. So far, there is no ‘golden standard’ regarding the score systems, but they are to be executed without too much effort. While the ‘Subject Global Assessment’ (SGA) (‘score of condition’) mainly includes inquired data, the ‘Nutritional Risk Screening’ (NRS) also includes stress related metabolism and weight loss, and the amended ‘Innsbruck Nutrition Score’ (INS) further considers several metabolic laboratory parameters. Key factor is an estimation of the risks involved for the patients in order to allow for an appropriate nutritional therapy. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004Nutritional Aspects in Surgical OutpatientsErnährungsambulanz in der Chirurgie187191DEA.WeimannD.WirthCGA200402000318710.1159/000081228Nutritional Aspects in Surgical Outpatients In surgery, preoperative reduction of length of stay in hospital will be realized by shifting appropriate diagnostic and therapeutic procedures to an outpatient setting. As malnutrition is considered a prognostic factor in hospitalized patients especially after surgery, patients at risk should be identified beforehand. In an outpatient clinic, patients can also be selected and prepared for ‘Fast Track’ surgery programs and obesity surgery. Appropriate preoperative nutritional therapy as well as its continuation and monitoring postoperatively are implemented by outpatient clinics. Therefore, from a nutritional point of view surgical outpatient clinic should achieve at least good cooperation with a nutritional support team. For health care it also opens perspectives for nutritional network formation including hospital, outpatient clinic and specialized practitioners as well as home care services. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004Perioperative HyperglycaemiaPerioperative Hyperglykämie192195DEM.HiesmayrCGA200402000319210.1159/000081229Perioperative Hyperglycaemia Hyperglycaemia is frequently observed during acute illness and after surgery or admission to an intensive care unit. It is observed twice as frequently in diabetic patients than in non-diabetics. The relative risk of a poor outcome is 1.5–6 in patients with ‘stress-hyperglycaemia’. Acute hyperglycaemia induces pathophysiologic changes with consequences even several hours to days after exposure. Hyperglycaemia modifies the function of leucocytes, monocytes, platelets and immunglobulins. Perfusion is reduced, most severely after ischaemia. The area of myocardial infarction is enlarged and prognosis after cerebral ischaemia worsened. In addition hyperglycaemia reduces gastro-intestinal motility. Acute hyperglycaemia is also associated with more frequent rejection episodes after kidney transplantation. The continuous infusion of insulin improved outcome after myocardial infarction, cardiac surgery and burns as well as in intensive care patients. The aim of insulin therapy is to normalise blood sugar levels early after injury. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004New Nutritional Dogmata in Surgical PatientsNeue Ernährungsdogmen beim chirurgischen Patienten197202DEK.-W.JauchP.RittlerCGA200402000319710.1159/000081230New Nutritional Dogmata in Surgical Patients Severe malnutrition in surgical patients is associated with increased perioperative morbidity and mortality. In the past, nutritional support for these patients has focused mainly on the postoperative administration of nutrients. However, there is growing evidence that clinical outcome of severely malnourished patients can be improved by intensified preoperative nutritional support. Therefore, it is important to implement sufficient screening tests (Subjective Global Assessment, SGA; Malnutrition Universal Screening Tool, MUST-Score) to identify those patients at risk of malnutrition who may benefit from adequate preoperative nutritional support. In addition, periods of prolonged preoperative starvation should be avoided in any patient, in order to ameliorate postoperative stress metabolism. Furthermore, traditional concepts of postoperative nutrition are changing. For example, the presence of a gastro-intestinal anastomosis used to be a contraindication for early enteral nutrition. It is now supposed that early postoperative enteral nutrition within 24–48 h after surgery using a catheter jejunostomy, a nasogastric or a nasojejunal tube is beneficial for most patients undergoing surgery of the gastro-intestinal tract. Only if a surgical patient is not able to meet his nutritional needs by enteral nutrition even after few days of adaptation or in the case of severe malnutrition, supplemental hypocaloric parenteral nutrition should be administered. Total parenteral nutrition should be reserved for patients with absolute contraindication for enteral nutrition (mesenteric ischemia, prolonged ileus, prolonged severe diarrhea) or failure of the gastro-intestinal tract with inability to tolerate any amount of tube feeds. For improving clinical outcome, it is important to ensure continuation of adequate nutritional support from the initial postoperative period with the hormonal acute phase response to the time of rehabilitation when regular diet is well tolerated and the clinical signs of malnutrition are disappearing. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004News of Feeding Tube PlacementNeues von der Sondentechnik204209DER.MeierC.BeglingerCGA200402000320410.1159/000081231News of Feeding Tube Placement Nutritional support should be included in each therapeutic concept of patients at risk because of the positive effect on outcome. If oral nutrition, including the use of supplements, is not possible, a tube feeding approach is recommended. For enteral nutrition different tubes and techniques are available. The selection of the tube depends on gut function, the underlying disease, the necessary time of enteral feeding, the availability of the different techniques, and the patient’s wish. Tube feeding is nowadays used in patients with neurological swallow disorders, tumors of the head and neck region, and tumors in the upper gastrointestinal tract as well as in intensive care patients. Moreover, enteral nutrition is increasingly performed in patients after major abdominal surgery. Each tube technique has advantages and disadvantages. Enteral nutrition is cost effective in several diseases if the adequate tube is carefully selected. A well trained nutritional support team is able to choose the best way of enteral nutrition. A nutritional support team is also able to reduce technical problems and complications. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004Parenteral and Enteral ImmunonutritionParenterale und enterale Immunonutrition210215DEE.RothCGA200402000321010.1159/000081232Parenteral and Enteral Immunonutrition In this paper ‘immunonutrition’ is defined as every parenteral or enteral nutrition formula containing at least one immunomodulating nutrient in a concentration higher than necessary to conserve body mass. Commercially available products contain as immunomodulating macronutrients glutamine, omega-3 fatty acids (ω-3 FA), arginine, and/or nucleotides. Moreover, enteral immunonutrition formulas generally contain a higher content of antioxidative micronutrients such as vitamin C and A, β-carotin, selen, zinc and copper. In accordance with the published studies and the recommendation of the Austrian and German Societies of Clinical Nutrition (AKE, DGEM), a recommendation for parenteral or enteral glutamine administration can be given for patients in severe catabolic state and in the immediate postoperative/posttraumatic situation. The enteral administration of a formula containing arginine, ω-3 FA, and nucleotides can be recommended in the pre-and postoperative state and for ICU patients with a low APACHE score. The parenteral administration of ω-3 FA reduces the inflammatory activity of neutrophils and monocytes. Appropriate data demonstrating an improved prognosis of the patients when supplying ω-3 FA are still lacking, however. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004Use of Antioxidants in Intensive Care PatientsDer Einsatz von Antioxidantien beim Intensivpatienten216222DEN.ManhartCGA200402000321610.1159/000081233Use of Antioxidants in Intensive Care Patients This article summarizes the available clinical studies regarding an antioxidative treatment in critically ill patients. There are several lines of evidence showing an increased oxidative stress during critical illness. The oxidative damage to cells and tissues possibly contributes to organ failure. Therefore a prophylactic or preventive treatment with antioxidants should reduce the oxidative stress and lead to an improved pathophysiological situation in critically ill patients. The results of the clinical studies found in the literature are contradictory because of heterogeneous patient populations, different antioxidants (single substances or combinations), different quantities, application times, start and/or duration of the study. From the present clinical data no firm conclusion for antioxidative treatment in critically ill patients can be drawn. Nevertheless, there is sufficient evidence from experimental studies suggesting that antioxidative therapy is an interesting treatment concept during critical illness. Copyright © 2004 S. Karger GmbH, Freiburg

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S. Karger GmbHChir Gastroenterol0177–99902032004Inflammatory Pseudotumor of the Sigmoid Colon by Enterobius vermicularis: A Case Report227229ENO.TopcuE.CanbayM.TuranS.AriciZ.SumerM.SenCGA200402000322710.1159/000081235For the first time, we report a case of an inflammatory pseudotumor of the sigmoid colon originating from an infection withEnterobius vermicularis. A 42-year-old man presented with left lower abdominal pain, weight loss, fever, nausea, and vomiting. Physical examination revealed tenderness and a palpable mass in the left lower quadrant. Laboratory results demonstrated elevated leukocyte count. Colonoscopy showed 25 cm above from the anus a nonobstructive, approximately 4 × 4 cm irregular lesion narrowing the sigmoid colon lumen with erythematous and rough mucosa; a diverticulosis could not be observed. Colonoscopic biopsy showed inflammatory changes. Computerized tomography (of the abdomen showed a 10 × 6 × 6 cm mass at the left lower abdomen. On abdominal exploration, the mass in the sigmoid colon was detected, and anterior resection of the sigmoid colon was performed. Histopathologic examination of the specimen revealed eggs of the E. vermicularis embedded in the granulation tissue and in the submucosa/mucosa of the sigmoid colon. The patient was uneventful in the postoperative period and discharged 7 days after surgery. Copyright © 2004 S. Karger GmbH, Freiburg

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