title: A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study. Goal-directed intraoperative therapy based on autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. Safety and Usefulness of Intravenous Iron Sucrose in the Management of Preoperative Anemia in Patients with Menorrhagia: A Phase IV, Open-Label, Prospective, Randomized Study Successful use of a single chest drain postlobectomy instead of two classical drains: a randomized study. Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy The effect of nutritional support on the immune function in the acute postoperative period after esophageal cancer surgery: total parenteral nutrition versus enteral nutrition. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial Esophagectomy—It’s Not Just About Mortality Anymore: Standardized Perioperative Clinical Pathways Improve Outcomes in Patients with Esophageal Cancer Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. Omission of Nasogastric Tube Application in Postoperative Care of Esophagectomy Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. Feasibility and effectiveness of pre-operative inspiratory muscle training in patients undergoing oesophagectomy: a pilot study. Pre‐operative carbohydrate loading may be used in type 2 diabetes patients Volume Threshold for Chest Tube Removal: A Randomized Controlled Trial The impact of chest tube removal on pain and pulmonary function after pulmonary resection. Goal-Directed Fluid Therapy Using Stroke Volume Variation Does Not Result in Pulmonary Fluid Overload in Thoracic Surgery Requiring One-Lung Ventilation Intravenous hydration versus naso-jejunal enteral feeding after esophagectomy: a randomised study. The effectiveness of preemptive analgesia varies according to the type of surgery: a randomized, double-blind study. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445] Active or passive chest drainage after oesophagectomy in 101 patients: a prospective randomized study Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective follow-up of 201 patients. Is botulinum toxin injection of the pylorus during Ivor Lewis [corrected] esophagogastrectomy the optimal drainage strategy? Optimal duration of urinary catheterization after thoracotomy in patients under postoperative patient-controlled epidural analgesia. Prospective randomised clinical trial of providing patients with audiotape recordings of their oesophagogastric cancer consultations. Preoperative Epoetin Alfa in Colorectal Surgery: A Randomized, Controlled Study Is Urinary Drainage Necessary During Continuous Epidural Analgesia After Colonic Resection? Erythropoietin to treat head and neck cancer patients with anaemia undergoing radiotherapy: randomised, double-blind, placebo-controlled trial Pain relief after esophagectomy: Thoracic epidural analgesia is better than parenteral opioids. Complications of needle catheter jejunostomy in 2,022 consecutive applications. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively--a randomised clinical trial. A prospective study of the association between drainage volume within 24 hours after thoracoscopic lobectomy and postoperative morbidity. 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Randomized clinical trial comparing feeding jejunostomy with nasoduodenal tube placement in patients undergoing oesophagectomy Computed Tomography Versus Water-Soluble Contrast Swallow in the Detection of Intrathoracic Anastomotic Leak Complicating Esophagogastrectomy (Ivor Lewis): A Prospective Study in 97 Patients Perioperative Erythropoietin Administration in Patients With Gastrointestinal Tract Cancer: Prospective Randomized Double-Blind Study Prospective trial comparing contrast swallow, computed tomography and endoscopy to identify anastomotic leak following oesophagogastric surgery The Effect of Thoracic Epidural Bupivacaine and an Intravenous Adrenaline Infusion on Gastric Tube Blood Flow During Esophagectomy Pre-operative oral iron supplementation reduces blood transfusion in colorectal surgery - a prospective, randomised, controlled trial. Timing of chest tube removal after coronary artery bypass surgery. Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Nutritional Status as a Risk Factor in Esophageal Surgery Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility. Epoetin alfa improves survival after chemoradiation for stage III esophageal cancer: final results of a prospective observational study. Short course pre-operative ferrous sulphate supplementation--is it worthwhile in patients with colorectal cancer? Pre-operative inspiratory muscle training preserves postoperative inspiratory muscle strength following major abdominal surgery - a randomised pilot study. Psychiatric morbidity among patients with cancer of the esophagus or the gastro-esophageal junction: a prospective, longitudinal evaluation. Erythropoietin-alfa during neoadjuvant chemotherapy for locally advanced esophagogastric adenocarcinoma. Allowing Normal Food at Will After Major Upper Gastrointestinal Surgery Does Not Increase Morbidity: A Randomized Multicenter Trial The effects of immediate enteral feeding with a formula containing high levels of omega-3 fatty acids in patients after surgery for esophageal cancer. Less Urinary Tract Infection by Earlier Removal of Bladder Catheter in Surgical Patients Receiving Thoracic Epidural Analgesia Preemptive Analgesia by Intravenous Low-dose Ketamine and Epidural Morphine in Gastrectomy: A Randomized Double-blind Study An enhanced recovery pathway decreases duration of stay after esophagectomy. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations
abstract: CONTEXT Postoperative enteral nutrition is thought to reduce complications and speed recovery after pancreatic resection . There is little evidence on the best route for delivery of enteral nutrition . Currently we use percutaneous transperitoneal jejunostomy or percutaneous transperitoneal gastrojejunostomy , or the nasojejunal route to deliver enteral nutrition , according to surgeon preference . OBJECTIVE To compare morbidity , efficiency , and safety of these three routes for enteral nutrition following pancreaticoduodenectomy . PATIENTS Data were obtained from a prospect ively maintained data base , for all patients undergoing pancreatic resection between January 2007 and June 2008 . One-hundred pancreatic resected patients underwent enteral nutrition : 93 had Whipple 's operations and 7 had total pancreatectomies . INTERVENTION Enteral nutrition was delivered by agreed protocol , starting within 24 h of operation and increasing over 2 - 3 days to meet full nutritional requirement . RESULTS Delivery route of enteral nutrition was : percutaneous transperitoneal jejunostomy in 25 ( 25 % ) , percutaneous transperitoneal gastrojejunostomy in 32 ( 32 % ) and nasojejunal in 43 ( 43 % ) . The incidence of catheter-related complications was higher in percutaneous techniques : 24 % in percutaneous transperitoneal jejunostomy and 34 % in percutaneous transperitoneal gastrojejunostomy as compared to nasojejunal technique ( 12 % ) . Median time to complete establishment of oral intake was 14 , 14 and 10 days in percutaneous transperitoneal jejunostomy , percutaneous transperitoneal gastrojejunostomy , and nasojejunal groups , respectively .  Nasojejunal tubes were removed at median 11 days ( mean 11.5 days ) compared to 5 - 6 weeks for percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy . Commonest catheter-related complication in the percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy was blockage ( n=6 ; 10.5 % ) , followed by pain after removal of feeding tube at 5 - 6 weeks ( n=5 ; 8.8 % ) , whereas in the nasojejunal group it was blockage ( n=3 ; 7.0 % ) , followed by displacement ( n=2 ; 4.7 % ) . Two patients died postoperatively in this cohort , however , there were no catheter-related mortalities . CONCLUSION Enteral nutrition following pancreatic resection can be delivered in different ways . Nasojejunal feeding was associated with fewest and less serious complications . On current evidence surgeon preference is a reasonable way to decide enteral nutrition but a r and omized controlled trial is needed to address this issue Introduction Several studies have shown that goal -directed hemodynamic and fluid optimization may result in improved outcome . However , the methods used were either invasive or had other limitations . The aim of this study was to perform intraoperative goal -directed therapy with a minimally invasive , easy to use device ( FloTrac/Vigileo ) , and to evaluate possible improvements in patient outcome determined by the duration of hospital stay and the incidence of complications compared to a st and ard management protocol . Methods In this r and omized , controlled trial 60 high-risk patients scheduled for major abdominal surgery were included . Patients were allocated into either an enhanced hemodynamic monitoring group using a cardiac index based intraoperative optimization protocol ( FloTrac/Vigileo device , GDT-group , n = 30 ) or a st and ard management group ( Control-group , n = 30 ) , based on st and ard monitoring data . Results The median duration of hospital stay was significantly reduced in the GDT-group with 15 ( 12 - 17.75 ) days versus 19 ( 14 - 23.5 ) days ( P = 0.006 ) and fewer patients developed complications than in the Control-group [ 6 patients ( 20 % ) versus 15 patients ( 50 % ) , P = 0.03 ] . The total number of complications was reduced in the GDT-group ( 17 versus 49 complications , P = 0.001 ) . Conclusions In high-risk patients undergoing major abdominal surgery , implementation of an intraoperative goal -directed hemodynamic optimization protocol using the FloTrac/Vigileo device was associated with a reduced length of hospital stay and a lower incidence of complications compared to a st and ard management protocol .Trial Registration Clinical trial registration information : Unique identifier : CONTEXT Postoperative pulmonary complications ( PPCs ) after coronary artery bypass graft ( CABG ) surgery are a major source of morbidity and mortality , and increase length of hospital stay and re source utilization . The prehospitalization period before CABG surgery may be used to improve a patient 's pulmonary condition . The efficacy of preoperative inspiratory muscle training ( IMT ) in reducing the incidence of PPCs in high-risk patients undergoing CABG surgery has not yet been determined . OBJECTIVE To evaluate the prophylactic efficacy of preoperative IMT on the incidence of PPCs in high-risk patients scheduled for elective CABG surgery . DESIGN , SETTING , AND PATIENTS A single-blind , r and omized clinical trial conducted at the University Medical Center Utrecht , Utrecht , the Netherl and s , with enrollment between July 2002 and August 2005 . Of 655 patients referred for elective CABG surgery , 299 ( 45.6 % ) met criteria for high risk of developing PPCs , of whom 279 were enrolled and followed up until discharge from hospital . INTERVENTION Patients were r and omly assigned to receive either preoperative IMT ( n = 140 ) or usual care ( n = 139 ) . Both groups received the same postoperative physical therapy . MAIN OUTCOME MEASURES Incidence of PPCs , especially pneumonia , and duration of postoperative hospitalization . RESULTS Both groups were comparable at baseline . After CABG surgery , PPCs were present in 25 ( 18.0 % ) of 139 patients in the IMT group and 48 ( 35.0 % ) of 137 patients in the usual care group ( odds ratio [ OR ] , 0.52 ; 95 % confidence interval [ CI ] , 0.30 - 0.92 ) . Pneumonia occurred in 9 ( 6.5 % ) of 139 patients in the IMT group and in 22 ( 16.1 % ) of 137 patients in the usual care group ( OR , 0.40 ; 95 % CI , 0.19 - 0.84 ) . Median duration of postoperative hospitalization was 7 days ( range , 5 - 41 days ) in the IMT group vs 8 days ( range , 6 - 70 days ) in the usual care group by Mann-Whitney U statistic ( z = -2.42 ; P = .02 ) . CONCLUSION Preoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N17691887 Background : The aim of this study was to compare the efficacy , safety and achievement of the target hemoglobin level ( Hb ≥10 g/dl ) in patients with preoperative anemia due to menorrhagia who received intravenous iron sucrose compared with oral iron protein succinylate for anemia management . Methods : Seventy-six patients with Hb levels < 9.0 g/dl who were scheduled to undergo surgical treatment were r and omized to receive either intravenous iron sucrose ( based on the calculated total iron deficit divided into 2 ampoule infusions intravenously 3 times a week , beginning 3 weeks before surgery ) or oral iron ( 80 mg/day of oral iron protein succinylate daily ) . Results : The intravenous iron group had higher increases in Hb ( 3.0 vs. 0.8 g/dl ; p < 0.0001 ) and ferritin levels ( 170.1 vs. 4.1 μg/l ; p < 0.0001 ) than the oral iron group . Achieving the target Hb was also higher in the intravenous iron group than in the oral iron group ( 76.7 vs. 11.5 % ; p < 0.0001 ) . There were tolerable adverse events in both groups . Conclusion : Preoperative intravenous iron sucrose administration is more effective  than oral iron and is as safe as oral iron therapy in the correction of preoperative anemia due to menorrhagia OBJECTIVE To compare surgical results and complications in the immediate postoperative course between the use of a single drain and two-drain post-anatomical pulmonary resections . PATIENTS AND METHODS Between January 2004 and September 2005 , 143 patients were scheduled for pulmonary lobectomy or bilobectomy for non-small cell lung cancer ( NSCLC ) in our department . Pneumonectomies , wedge resection , and nonresectable thoracotomies were excluded from the study . Hundred and nineteen patients were enrolled in this study . Clinical and surgical variables were collected prospect ively . Lobectomy or bilobectomy and systematic mediastinal node dissection were performed in all cases . The patients were r and omly assigned to receive single ( group A ) or two ( group B ) drains , independent of any preoperative or intraoperative variables . Group A consisted of 60 patients who had  one single drain  sited in the mid-position and group B consisted of 59 patients who had  two classical drains ( apical and basal ) . There were no surgical , oncological , or physiological differences between the groups ( p = NS ) . RESULTS There were no statistically significant differences detected between the groups in relation to postsurgical morbidity or mortality and other issues studied , except in analgesia requirements ( group A less than group B , p<0.05 ) . After drain removal there were no significant differences between the groups in terms of subcutaneous emphysema , new drains needed , residual pleural effusion , or residual space ( p>0.05 ) . CONCLUSIONS In our study , we did not find significant differences between the use of one or two drains after lobectomy or bilobectomy in relation to early postoperative outcome . However , the use of only one drain is more economical and is less painful for patients , without any additional adverse consequences Purpose Stoma formation is a well-known cause for delayed discharge  following colorectal surgery . This has been addressed by the enhanced recovery programme ( ERP ) preoperatively through stoma counselling sessions . These aim to promote independent stoma management post-operatively , thus expediting hospital discharge . We compared the numbers of patients with prolonged hospital stay secondary to delayed independent stoma management prior to and following the introduction of an enhanced recovery programme with preoperative stoma education . Methods Data collection on patients undergoing anterior resection with the formation of a loop ileostomy was carried out retrospectively prior to ERP ( January 2006 to August 2008 ) and prospect ively following the introduction of  ERP  ( September 2008 to October 2010 ) . Comparisons were made in patients with prolonged hospital stay ( defined as hospital stay of more than 5 days ) secondary to stoma management . Results Two hundred forty patients underwent elective anterior resection with the formation of a loop ileostomy , 120 prior ERP  and 120 post-ERP . Average length of hospital stay was 14 days before ERP introduction , with a range of 7–25 days . The mean length of stay amongst the ERP patients was 8 days ( p = 0.17 ) , ranging from 3 to 17 days . Twenty-one patients in the pre-ERP group ( 17.5 % ) experienced postponed hospital discharge due to a delay in independent stoma management , compared to one patient experiencing such a delay after the introduction of ERP ( 0.8 % , p < 0.0001 ) . Conclusions Delayed discharge secondary to independent stoma management can be significantly reduced with preoperative stoma management teaching as part of an enhanced recovery programme Background : The oesophagectomy procedure includes the formation of a gastric tube to re‐establish the continuity of the gastrointestinal tract . The effect of thoracic epidural analgesia ( TEA ) on gastric mucosal blood flow ( GMBF ) remains unknown in clinical practice . The aim of this prospect i ve observational study was to assess the microcirculatory changes induced by TEA in the early post‐operative course BACKGROUND Enteral nutrition ( EN ) is now used more frequently than total parenteral nutrition ( TPN ) for nutritional support after resection for esophageal cancer . But consensus regarding which type of nutrition should be used does not exist . We studied the effect of TPN and EN on patients ' nutritional status and immune function in the immediate postoperative period after esophageal cancer resection . METHODS We enrolled 30 patients ( 27 men and 3 women ) who underwent subtotal esophagectomy .  The patients were r and omly assigned to TPN or EN group . Either TPN or EN was begun on postoperative day 1 . On postoperative days 1 , 3 , and 7 , three endpoints were measured : albumin , C-reactive protein , and Th1/Th2 balance . RESULTS All patients completed the study .  Anastomotic leaks occurred in 6 patients in the TPN group and 7 patients in the EN group . Albumin , Th1/Th2 balance , and C-reactive protein did not differ between the groups . Th1/Th2 balance was not different regardless of the preoperative treatment or complications . CONCLUSIONS No differences in immune function , nutritional state , or inflammatory response were seen between patients supported with TPN and those supported with EN . The results of our study suggest that perioperative nutritional support can be safely performed either with TPN or EN BACKGROUND Although current opinion favours the use of enteral over parenteral nutrition , the clinical benefits of early postoperative nutrition in patients undergoing elective surgery have never been clearly shown . We aim ed to test the hypothesis that postoperative enteral nutrition is better ( fewer postoperative complications ) than parenteral nutrition containing similar energy and nitrogen amounts ( 112 kJ kg(-1 ) day(-1 ) and 1.4 g aminoacid kg(-1 ) day(-1 ) ) . METHODS We did a r and omised multicentre clinical trial in patients with gastrointestinal cancer who were malnourished and c and i date s for major elective surgery . 159 patients were assigned to enteral nutrition and 158 to parenteral nutrition .  The primary endpoint was the occurrence of postoperative complications , and secondary endpoints were length of postoperative hospital stay , adverse effects , and treatment crossover . Analysis was by intention to treat . FINDINGS Postoperative complications occurred in 54 ( 34 % ) patients fed enterally versus 78 ( 49 % ) fed parenterally ( relative risk 0.69 , 95 % CI 0.53 - 0.90 , p=0.005 ) . Length of postoperative stay was 13.4 days and 15.0 days in the enteral nutrition and parenteral nutrition groups , respectively ( p=0.009 ) . Adverse effects occurred in 56 ( 35 % ) patients fed enterally versus 22 ( 14 % ) patients fed parenterally ( 2.50 , 1.61 - 3.86 , p<0.0001 ) . 14 ( 9 % ) patients on enteral nutrition had to switch to parenteral nutrition , whereas none of those fed parenterally crossed over to enteral feeding . INTERPRETATION We conclude that early enteral nutrition significantly reduces the complication rate and duration of postoperative stay compared with parenteral nutrition , although parenteral nutrition is better tolerated than enteral nutrition Background Esophageal resection ( ER ) remains the st and ard therapy for early esophageal cancer ; however , because of concerns regarding high levels of morbidity and mortality reported in analyses of national data bases , many patients are relegated to less effective endoscopic or chemotherapeutic approaches . Methods All patients undergoing esophagectomy by a single surgeon for cancer or high- grade dysplasia between 05/91–05/06 were prospect ively entered into an IRB-approved data base . All aspects of work-up and treatment were guided by an evolving st and ardized perioperative clinical pathway . Results Three hundred forty consecutive patients , mean age of 64 ( 33–90 ) , underwent ER for Barrett ’s esophagus ( 17 ) or invasive cancer stages I-87 , II-133 , III-94 , IV-9 . One hundred thirty-nine ( 41 % ) had neoadjuvant therapy .  Sixty-three percent were American Society of Anesthesiologists class III or IV , and five different operative approaches were used . Patient were managed intraoperatively with a “ fluid restriction ” protocol . Mean intraoperative blood loss was 230 cc . 99.5 % of patients were extubated immediately , and mean ICU and hospital stays were 2.25 ( 1–30 ) and 11.5 ( 6–49 ) days , respectively . Postoperative analgesia was managed with patient-controlled epidural analgesia in 98.5 % , and 86 % were mobilized on day 1 after surgery . Complications occurred in 153 patients ( 45 % ) , most commonly atrial dysrhythmia ( 13 % ) , and postoperative delirium ( 11 % ) . Anastomotic leaks occurred in 13 patients ( 3.8 % ) . Mortality occurred in one patient ( 0.3 % ) . No significant differences were seen in length of stay , operative time , blood loss , or complications in patients receiving neoadjuvant therapy . For stages I , II , and III , patients between 1998–2004 Kaplan – Meier 5-year cumulative survival was 92.4 , 57.1 , and 34.5 % , respectively . Conclusions Surgical treatment of esophageal cancer can be done with moderate morbidity and very low mortality , and the expectation of improved levels of survival , especially in early-stage patients . St and ardized perioperative clinical pathways can provide the infrastructure for the treatment of these patients and should include increased efforts to minimize blood loss and transfusions , improve postoperative pain control and extubation rates , and facilitate early mobilization and discharge . ER , as sole therapy or in combination with radiation/chemotherapy , should remain the st and ard of care in patients with early and locoregional esophageal cancer Introduction Several studies have shown that maximizing stroke volume ( or increasing it until a plateau is reached ) by volume loading during high-risk surgery may improve post-operative outcome . This goal could be achieved simply by minimizing the variation in arterial pulse pressure ( ΔPP ) induced by mechanical ventilation . We tested this hypothesis in a prospect i ve , r and omized , single-centre study . The primary endpoint was the length of postoperative stay in hospital . Methods Thirty-three patients undergoing high-risk surgery were r and omized either to a  control group ( group C , n = 16 ) or to an intervention group ( group I , n = 17 ) . In group I , ΔPP was continuously monitored during surgery by a multiparameter bedside monitor and minimized to 10 % or less by volume loading . Results Both groups were comparable in terms of demographic data , American Society of Anesthesiology score , type , and duration of surgery . During surgery , group I received more fluid than group C ( 4,618 ± 1,557 versus 1,694 ± 705 ml ( mean ± SD ) , P < 0.0001 ) , and ΔPP decreased from 22 ± 75 to 9 ± 1 % ( P < 0.05 ) in group I. The median duration of postoperative stay in hospital ( 7 versus 17 days , P < 0.01 ) was lower in group I than in group C. The number of postoperative complications per patient ( 1.4 ± 2.1 versus 3.9 ± 2.8 , P < 0.05 ) , as well as the median duration of mechanical ventilation ( 1 versus 5 days , P < 0.05 ) and stay in the intensive care unit ( 3 versus 9 days , P < 0.01 ) was also lower in group I. Conclusion Monitoring and minimizing ΔPP by volume loading during high-risk surgery improves postoperative outcome and decreases the length of stay in hospital . Trial registration BACKGROUND Operative procedures on the pleural space are usually managed by chest tube drainage . Timing for removing the tube is empirically established , with wide variation among surgeons . Our objective was to evaluate the effectiveness and safety of establishing a volume of 200 mL/d of uninfected drainage as a threshold for removal of chest tube , as compared with more frequently used volumes of 100 and 150 mL/d . STUDY DESIGN A prospect i ve r and omized study was performed in a single institution . Patients ( n = 139 ) su bmi tting to pleural drainage after surgical procedures were r and omized to one of three groups , defined by the planned timing of chest tube removal ( depending on the threshold volume per day of pleural fluid drained ) : G-100 ( < or = 100 mL/d , n = 44 ) ; G-150 ( < or = 150 mL/d , n = 58 ) ; and G-200 ( < or = 200 mL/d , n = 37 ) . Subsequently , another 91 consecutive patients had chest tubes removed when drainage was less than 200 mL/d ( G-val , prospect i ve validation group ) . All patients had similar discharge and 60-day followup .  Drainage time , hospital stay , and reaccumulation rate were registered . RESULTS Drainage time ( median days : 3.5 for G-100 , 3 for G-150 , 3 for G-200 , 3 for G-val ) and hospital stay ( median days : 4 for G-100 , 3 for G-150 , 3 for G-200 , 3 for G-val ) were not statistically different among groups . Radiologic reaccumulation rates were 9.1 % for G-100 , 13.1 % for G-150 , 5.4 % for G-200 , and 10.9 % for G-val , and the thoracenteses rates were 2.3 % , 0.8 % , 2.7 % , and 3.3 % , respectively , with no major differences among groups ( G-100 versus G-150 versus G-200 ; G-200 versus G-val ) . CONCLUSIONS Increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage , hospitalization time , or overall costs , nor did it increase the likelihood of major pleural fluid reaccumulation . This volume ( 200 mL/d ) could be recommended for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks Introduction Surgeons routinely use nasogastric ( NG ) tubes in most esophageal resection surgeries . Considering the numerous complications caused by using the tube and the uncertainty about its usefulness and the scarcity of studies conducted on the subject , particularly in patients with esophageal cancer , the necessity of using the tube in these types of cases is investigated in the present study . Methods In this clinical trial , patients with esophageal cancer were r and omized into groups with NG tube and without NG tube after surgery ; the latter were prescribed Metoclopramide , as well . The variables recorded for each patient included the first day of gas passage , defecation and bowel sounds ( BSs ) auscultation , as well as the duration of postoperative hospitalization , nausea and vomiting , abdominal distension , pulmonary complications , wound complications , anastomosis leak , and the need for placing/replacing the NG tube . Results The incidence of anastomosis leak was significantly higher in the NG-tube group ( 6 vs. 0 ; P = 0.016 ) . Other complications were not different in the two groups . The mean time of gas passage , defecation , BS auscultation , and the duration of postoperative hospitalization did not have meaningful differences in the two groups . The need for placing/replacing the NG tube was the same for both groups . Conclusions The routine application of NG tubes after surgery is not recommended for all patients . We suggest that NG tubes should be used according to the specific problems of each patient BACKGROUND Perioperative epidural analgesia provides continuous pain control and may have advantages over parenteral opiate administration . This study assessed the impact of epidural analgesia on quality of life ( QOL ) of patients undergoing major surgery . METHODS Sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospect ively . Patients were r and omly assigned to receive either thoracic epidural analgesia or patient-controlled i.v . opiate analgesia ( PCA ) after operation .  Visual analogue pain and sedation scores were recorded for the period of the study . QOL health surveys at 24 h ( SF-8 acute form ) and at 1 week ( SF-36 ) were recorded . Results were examined by uni- and multivariate analyses corrected for the effect of multiple comparisons . RESULTS Mean pain scores were significantly lower in the epidural group at most time points . Physical and mental scores in the epidural group were significantly better than the PCA group for both SF-8 and SF-36 QOL health surveys ( P<0.001 ) . CONCLUSIONS Epidural analgesia with local anaesthetic and opioid improves QOL and delivers better analgesia compared with PCA in patients undergoing major thoraco-abdominal surgery BACKGROUND Patients undergoing oesophageal surgery have a high risk for post-operative complications including pulmonary infections . Recently , physical therapy has shifted from the post-operative to the pre-operative phase to diminish post-operative complications and to shorten hospital stay . The purpose of this pilot study was to investigate the feasibility and initial effectiveness of pre-operative inspiratory muscle training ( IMT ) on the incidence of pneumonia in patients undergoing oesophagectomy . METHODS A pragmatic non-r and omized controlled trial was conducted among all patients who underwent an oesophagectomy between January 2009 and February 2010 . Patients in the intervention group received IMT prior to surgery . Feasibility was assessed on the basis of the occurrence of adverse effects during testing or training and patient satisfaction . Initial effectiveness on respiratory function was evaluated by maximal inspiratory pressure ( MIP ) and endurance , the incidence of post-operative pneumonia and length of hospital stay . RESULTS Eighty-three patients were included , of which 44 received pre-operative IMT . No adverse effects were observed .  IMT was well tolerated and appreciated . In the intervention group , the median MIP and endurance improved significantly after IMT by 32 % and 41 % , respectively ( p < 0.001 ) . The incidence of post-operative pneumonia and the length of hospital stay were comparable for the intervention and the conventional care groups ( pneumonia , 25 % vs. 23 % [ p = 0.84 ] ; hospitalization , 13.5 vs. 12 days [ p = 0.08 ] ) . CONCLUSIONS Pre-operative IMT is feasible in patients with oesophageal carcinoma and significantly improves respiratory muscle function . This , however , did not result in a reduction of post-operative pneumonia in patients undergoing oesophagectomy Background : Post‐operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery . Pre‐operative oral carbohydrate loading ( CHO ) reduces post‐operative insulin resistance with a reduced risk of hyperglycaemia during post‐operative nutrition . Insulin‐resistant diabetic patients have not been given CHO because the effects on pre‐operative glycaemia and gastric emptying are unknown Abstract : Background : Despite importance of chest tube insertion in chest trauma , there is no general agreement on the level of daily volume drainage from chest tube . This study was conducted to compare the effectiveness and safety of chest tube removal at the levels of 150 ml/day and 200 ml/day . Methods : Eligible patients ( 138 ) who needed replacement of chest tube ( because of trauma or malignancy ) were r and omized into two groups ; control ( removal of chest tube when drainage reached to 150 ml/day ) and trial ( removal of chest tube at the level of 200 ml/day ) . All patients received st and ard care during hospital admission and a follow-up visit after 7days of discharge from hospital . Patients were then compared in terms of major clinical outcomes using chisquared and t-test . Results : From the total of 138 patients , 70 and 68 patients were r and omized to control ( G150 ) and trial ( G200 ) group , respectively . Baseline characteristics were comparable between the two groups . Although the trial group had a shorter mean for length of hospital stay ( LOS ) ( 4.1 compared to 4.8 , p=0.04 ) , their differences in drainage time did not reach to the level of statistical significance ( p=0.1 ) . Analysis of data showed no statistically significant differences between the rate of radiological reaccumulation , thoracentesis and decrease in pulmonary sounds ( auscultatory ) , one week after discharge from hospital . Conclusions : Compared to a daily volume drainage of 150 ml , removal of chest tube when there is 200 ml/day is safe and will even result in a shorter hospital stay . This in turn leads to a lower cost OBJECTIVE The aim of this study was to assess the immediate influence of chest tube removal on chest pain and forced expiratory volume in 1 s ( FEV1 )  after pulmonary resection . METHODS Prospect i ve longitudinal investigation on 104 consecutive patients ( 53 wedge/segmentectomies and 51 lobectomies ; 69 muscle and nerve-sparing lateral thoracotomy and 35 video-assisted thoracoscopic surgery ( VATS ) ) . Post-operative chest pain was controlled in all patients by a st and ardized combination of oral and intravenous non-opioid analgesics .  All patients had one chest tube ( 24 French ) .  Static and dynamic ( after forced expiratory effort ) pain and FEV1 were assessed before and 1 h after the chest tube removal by the same operator . No additional analgesics were administered before or after the chest tube removal . The pain level was assessed by the numeric pain scale [ range : 0 ( no pain)-10 ( excruciating pain ) ] . FEV1 was assessed by a portable spirometer . Bronchodilators were not used in these patients . Pre- and post-removal measurements were compared by the Wilcoxon signed rank test . RESULTS The average pre-removal static and dynamic pain scores were 2.6 and 4.1 , respectively . The static and dynamic pain scores decreased by 42 and 41 % , respectively , after the tube removal ( P < 0.0001 ) . The average FEV1 before the chest tube removal was 1.5 l or 53 % of the predicted value and increased by 13 % after the tube removal ( P = 0.0004 ) . In total , 56 and 78 % of patients reported static and dynamic pain scores improvement and 67 % showed an FEV1 improvement after the chest tube removal . Similar results were observed in patients operated on through VATS or thoracotomy . Compared with patients whose chest tube was removed later , those who had their chest tube removed before post operative day 3 ( POD3 ) , showed a greater reduction in the static pain score ( 41 vs. 31 % , P = 0.05 ) and greater improvement in FEV1 ( 18 vs. 0.01 % , P = 0.02 ) . CONCLUSIONS The removal of a chest tube reduces pain and improves ventilatory function , independent of surgical access and particularly in the early post-operative phase . A fast track chest tube removal policy may favour patients ' recovery Background . Goal -directed fluid therapy ( GDT ) guided by functional parameters of preload , such as stroke volume variation ( SVV ) , seems to optimize hemodynamics and possibly improves clinical outcome . However , this strategy is believed to be rather fluid aggressive , and , furthermore , during surgery requiring thoracotomy , the ability of SVV to predict volume responsiveness has raised some controversy . So far it is not known whether GDT is associated with pulmonary fluid overload and a deleterious reduction in pulmonary function in thoracic surgery requiring one-lung-ventilation ( OLV ) . Therefore , we assessed the perioperative course of extravascular lung water index ( EVLWI ) and paO2/FiO2-ratio during and after thoracic surgery requiring lateral thoracotomy and OLV to evaluate the hypothesis that fluid therapy guided by SVV results in pulmonary fluid overload . Methods . A total of 27 patients ( group T ) were enrolled in this prospect i ve study with 11 patients undergoing lung surgery ( group L ) and 16 patients undergoing esophagectomy ( group E ) .  Goal -directed fluid management was guided by SVV ( SVV < 10 % ) . Measurements were performed directly after induction of anesthesia ( baseline — BL ) , 15 minutes after implementation OLV ( OLVimpl15 ) , and 15 minutes after termination of OLV ( OLVterm15 ) . In addition , postoperative measurements were performed at 6 ( 6postop ) , 12 ( 12postop ) , and 24 ( 24postop ) hours after surgery . EVLWI was measured at all predefined steps . The paO2/FiO2-ratio was determined at each point during mechanical ventilation ( group L : BL-OLVterm15 ; group E : BL-24postop ) . Results . In all patients ( group T ) , there was no significant change ( P > 0.05 ) in EVLWI during the observation period ( BL : 7.8 ± 2.5 , 24postop : 8.1 ± 2.4 mL/kg ) . A subgroup analysis for group L and group E also did not reveal significant changes of EVLWI . The paO2/FiO2-ratio decreased significantly during the observation period ( group L : BL : 462 ± 140 , OLVterm15 : 338 ± 112 mmHg ; group E : BL : 389 ± 101 , 24postop : 303 ± 74 mmHg ) but remained > 300 mmHg except during OLV . Conclusions . SVV-guided fluid management in thoracic surgery requiring lateral thoracotomy and one-lung ventilation does not result in pulmonary fluid overload . Although oxygenation was reduced , pulmonary function remained within a clinical ly acceptable range OBJECTIVE Patients undergoing esophagectomy are typically nutritionally depleted and can not establish oral feeding for up to a week after surgery . We have investigated the routine use of enteral feeding via a naso-jejunal tube . METHODS Forty consecutive patients undergoing a transthoracic esophagectomy for cancer were r and omised to receive enteral feeding or intravenous crystalloid fluids after surgery . Nutritional indices were obtained prior to surgery and on the 7th post-operative day . RESULTS There were no post-operative deaths . Non-fatal complications occurred in 10 patients , without difference in morbidity between the two groups . Lean body mass did not change in either group over the study period . No differences in any other parameters were identified between the two groups . CONCLUSION Enteral feeding via a naso-jejunal tube is safe and well tolerated after esophagectomy . It is a simple method of providing nutritional support prior to the re- introduction of oral feeding . However it provides no measurable benefit over intravenous hydration only for patients undergoing routine esophagectomy UNLABELLED The reliability of preemptive analgesia is controversial . Its effectiveness may vary among anatomical areas or surgical types . We evaluated preemptive analgesia by epidural morphine in six surgery types in a r and omized , double-blind manner . Pain intensity was rated using a visual analog scale , a verbal report , and a measurement of postsurgical morphine consumption .  Preemptive analgesia  was effective in limb surgery and mastectomy , but ineffective for gastrectomy , hysterectomy , herniorrhaphy , and appendectomy . Relief of postsurgical pain in hemiorrhaphy was more rapid than that in the other surgery types .  Preemptive analgesia  was effective in limb surgery and mastectomy , but not in surgeries involving laparotomy , regardless of whether the surgery was major ( gastrectomy and hysterectomy ) or minor ( herniorrhaphy and appendectomy ) . These results suggest that viscero-peritoneal nociception is involved in postsurgical pain . The abdominal viscera and peritoneum are innervated both heterosegmentally ( in duplicate or triplicate by the vagus and /or phrenic nerves ) and segmentally ( by the spinal nerves ) . Therefore , supraspinal and /or cervical spinal neurons might be sensitized , despite the blockade of the segmental nerves with epidural morphine . The rapid retreat of the pain after hemiorrhaphy suggests that central sensitization remits soon after minor surgery , but that in appendicitis , it may be protracted by additional noxious stimuli , such as infection . IMPLICATION S Epidural preemptive analgesia was reliably effective in limb and breast surgeries but ineffective in abdominal surgery , suggesting involvement of the brainstem and cervical spinal cord via the vagus and phlenic nerves Introduction Goal -directed therapy ( GDT ) has been shown to improve outcome when commenced before surgery . This requires pre-operative admission to the intensive care unit ( ICU ) . In cardiac surgery , GDT has proved effective when commenced after surgery . The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery . Methods This was a r and omised controlled trial with concealed allocation . High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min-1 m-2 or to conventional management . Cardiac output was measured by lithium indicator dilution and pulse power analysis . Patients were followed up for 60 days . Results Sixty-two patients were r and omised to GDT and 60 patients to control treatment . The  GDT  group received more  intravenous colloid  ( 1,907 SD ± 878 ml versus 1,204 SD ± 898 ml ; p < 0.0001 ) and dopexamine ( 55 patients ( 89 % ) versus 1 patient ( 2 % ) ; p < 0.0001 ) . Fewer GDT patients developed complications ( 27 patients ( 44 % ) versus 41 patients ( 68 % ) ; p = 0.003 , relative risk 0.63 ; 95 % confidence intervals 0.46 to 0.87 ) . The number of complications per patient was also reduced ( 0.7 SD ± 0.9 per patient versus 1.5 SD ± 1.5 per patient ; p = 0.002 ) . The median duration of hospital stay in the GDT group was significantly reduced ( 11 days ( IQR 7 to 15 ) versus 14 days ( IQR 11 to 27 ) ; p = 0.001 ) . There was no significant difference in mortality ( seven patients ( 11.3 % ) versus nine patients ( 15 % ) ; p = 0.59 ) . Conclusion Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay . The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission This study evaluates the efficiency and safety of two methods of chest drainage after uncomplicated oesophagectomy OBJECTIVE Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality . Because the choice of analgesic technique may influence outcome , the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy . DESIGN Prospect i ve observational study during January 1996 until January 2002 . SETTING University hospital . PARTICIPANTS All patients undergoing thoracoabdominal esophagectomy during the 6-year period . INTERVENTIONS Patients were prospect ively monitored during a 6-year period . Duration of surgery , intraoperative blood loss , fluid administration , postoperative intubation time , intensive care unit ( ICU ) stay , pain relief and related side effects , postoperative complications , hospital stay , and in-hospital and long-term mortality were compared in relation with the analgesic technique . MEASUREMENTS AND MAIN RESULT Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients , and intravenous morphine analgesia was used in 35 patients .  Postoperative intubation time and ICU stay were similar in both groups . Patients with epidural analgesia experienced less pain . Sedation , respiratory depression , hallucinations , and confusion were more common in the intravenous morphine group . Postoperative weight did not differ between the groups , despite fluid replacement that was higher in the epidural group during the first 24 hours . The in-hospital mortality rate was 0.5 % . CONCLUSIONS No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy . Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia . However , postoperative epidural analgesia was associated with more technical difficulties BACKGROUND The optimal management of the pylorus during  esophagogastrectomy  is unknown . Pyloromyotomy and pyloroplasty cause early edema and risk long-term bile reflux ; however , the lack of pyloric drainage might risk early aspiration . METHODS We performed a retrospective study with a prospect i ve data base on patients with esophageal cancer or high- grade dysplasia who underwent Ivor-Lewis esophagogastrectomy . All had one surgeon and similar stomach tubularization , h and -sewn anastomoses , nasogastric tube duration , and postoperative prokinetic agents .  Outcomes of postoperative gastric emptying , aspiration , and swallowing symptoms were compared . RESULTS Between January 1997 and June 2008 , there were 221 patients . Seventy-one patients had a pyloromyotomy  , and gastric emptying judged on postoperative day 4 was delayed in 93 % ( 52 % had any morbidity and 14 % had respiratory morbidity ) . Fifty-four patients had no drainage procedure , and gastric emptying was delayed in 96 % ( 59 % had any morbidity and 22 % had respiratory morbidity ) . Twenty-eight patients underwent pyloroplasty , and 96 % had delayed gastric emptying ( 50 % had any morbidity and 32 % had respiratory morbidity ) . Sixty-eight patients had botulinum toxin injection into the pylorus . Gastric emptying was delayed in only 59 % ( P = .002 , 44 % had any morbidity and 13 % had respiratory morbidity ) . Hospital length of stay ( P = .015 ) and operative times ( P = .037 ) were shorter in the botulinum toxin group . Follow-up ( mean , 40 months ) showed symptoms of biliary reflux to be lowest in the botulinum toxin group ( P = .024 ) . CONCLUSION Injection of the pylorus with botulinum toxin at the time of esophagogastrectomy is safe and decreases operative time when compared with pyloroplasty or pyloromyotomy . In addition , it can improve early gastric emptying , decrease respiratory complications , shorten hospital stay , and reduce late bile reflux . A prospect i ve multi-institutional r and omized trial is needed BACKGROUND Epidural analgesia is widely used for efficient pain relief after major surgery . However , it may cause urinary retention , leading to delayed removal of bladder catheters with prolonged patient discomfort . Using a specific regimen in patient controlled epidural analgesia ( PCEA ) , we examined the optimal duration of urinary catheterization in patients undergoing major thoracic surgery . METHODS Seventy-eight patients scheduled for elective thoracotomy  were prospect ively r and omized into two groups : Group 1 , removal of the transurethral catheter on the first postoperative day ( n = 38 ) ; Group 2 , removal of the catheter after discontinuation of PCEA ( n = 40 ) . The PCEA regimen was a mixture containing low-dose morphine , bupivacaine and neostigmine and was given for 3 days after surgery in all subjects . Micturition problems , pain scores assessed by the visual analog scale ( VAS ) , and side effects were evaluated during and after PCEA treatment . RESULTS The average duration of urinary drainage after surgery was 30.2 + or - 5.1 hours and 78.5 + or - 7.3 hours in Groups 1 and 2 , respectively . After removal of the bladder catheter , no patient in either group required re-catheterization for urinary retention or encountered catheter-related infection . VAS scores were significantly lower in Group 1 at rest and at 24 , 36 and 48 hours after cessation of PCEA . VAS scores were significantly higher in Group 2 patients , possibly due to catheter-induced pain related to prolonged catheterization . CONCLUSION Routine continuous bladder catheterization may not necessarily be required after thoracotomy in patients with ongoing continuous thoracic epidural analgesia OBJECTIVE To evaluate audiotape-recorded consultations at which a new diagnosis of oesophageal or gastric cancer was given to patients with reference to information retention , psychological outcome and socio-economic deprivation . METHODS Fifty-eight patients were r and omised to receive audiotaped consultations or not .  Thirty-one patients received tapes ( 12 oesophageal and 19 gastric cancers ) and were compared with 27 control patients ( 12 oesophageal and 15 gastric cancers ) . All patients were re-interviewed and completed a hospital anxiety and depression ( HAD ) question naire . Socio-economic deprivation scores were calculated using National Indices of Multiple Deprivation . RESULTS Patients r and omised to receive tapes were more likely to retain information ( 31 patients ) than control patients ( 18 patients , p=0.001 ) . Median ( range ) HAD scores were similar in both groups of patients [ HAD A tape 6 ( 0 - 21 ) vs. no tape 5 ( 2 - 14 ) , HAD D tape 3 ( 0 - 23 ) vs. 4 ( 0 - 10 ) , respectively ] . Deprivation correlated significantly with higher HAD A scores in control patients ( p=0.039 ) but was not associated with information retention ( p=0.667 ) . CONCLUSION Taped consultations were associated with significantly better information retention without adverse psychological outcomes . Providing an audiotape may reduce the effect of socio-economic deprivation on patient anxiety . PRACTICE IMPLICATION S Audiotaping , or its equivalent , would be a valuable tool in the multidisciplinary approach to cancers of the upper gastrointestinal tract Background Colorectal cancer patients are often anemic before surgery , and this leads to an increased requirement for allogeneic blood transfusion . This may result in transfusion-induced immunosuppression , which in turn leads to increased morbidity and possibly an increased rate of tumor relapse . We investigated the possible benefits of perioperative epoetin alfa administration in anemic patients to correct hemoglobin levels and reduce transfusion needs . Methods A total of 223 colorectal cancer patients with anemia scheduled for surgery were r and omized to a group that received epoetin alfa 150 or 300 IU/kg/day subcutaneously for 12 days ( day -10 to + 1 ) or to a control group . All received iron ( 200 mg/day by mouth ) for 10 days before surgery . Hemoglobin levels , hematocrit , and the number of blood units transfused were recorded . Results A total of 204 patients were eligible for analysis .  Mean hemoglobin levels and hematocrit were significantly higher in the 300 IU/kg group than in the control group , both 1 day before surgery ( hemoglobin , P = .008 ; hematocrit , P = .0005 ) and 1 day after surgery ( hemoglobin , P = .011 ; hematocrit , P = .0008 ) . Blood loss during and after surgery was similar in all groups . Patients who received epoetin alfa 300 IU/kg required significantly fewer perioperative transfusion units than control patients ( .81 vs. 1.32 ; P = .016 ) and significantly fewer postoperative units ( .87 vs. 1.33 ; P = .023 ) . There were no significant differences in the number of units in the 150 IU/kg group . Conclusions Preoperative epoetin alfa ( 300 IU/day ) increases hemoglobin levels and hematocrit in colorectal surgery patients . These effects are associated with a reduced need for perioperative and postoperative transfusions Background and Objectives Postoperative urinary retention may occur in between 10 % and 60 % of patients after major surgery . Continuous lumbar epidural analgesia , in contrast to thoracic epidural analgesia , may inhibit urinary bladder function . Postoperative urinary drainage has been common in patients with continuous epidural analgesia , despite the lack of scientific evidence for its indication after thoracic epidural analgesia . This study describes 100 patients who underwent elective colonic resection with 48 hours of continuous thoracic epidural analgesia and only 24 hours of urinary drainage .  Methods This is a prospect i ve , uncontrolled study with well-defined general anesthesia , postoperative analgesia , and nursing care programs in patients with a planned 2-day hospital stay , urinary catheter removal on the first postoperative morning , and epidural catheter removal on the second postoperative morning . Follow-up in the outpatient clinic was on days 8 and 30 . Results Nine patients needed bladder recatheterization , 8 as a single procedure and 1 patient a second recatheterization with removal on day 7 . This patient had urinary infection on day 10 and was readmitted for 5 days because of urosepsis and , subsequently , for cystitis and left-sided epididymitis . Three patients had uncomplicated urinary infection . No patients had urological complaints at 30 days follow-up ( 95 % confidence limit , 0 % to 3.6 % ) . Conclusion The low incidence of urinary retention ( 9 % ) and urinary infection ( 4 % ) suggests that routine bladder catheterization beyond postoperative day 1 may not be necessary in patients with ongoing continuous low-dose thoracic epidural analgesia BACKGROUND Anaemia is associated with poor cancer control , particularly in patients undergoing radiotherapy . We investigated whether anaemia correction with epoetin beta could improve outcome of curative radiotherapy among patients with head and neck cancer . METHODS We did a multicentre , double-blind , r and omised , placebo-controlled trial in 351 patients ( haemoglobin < 120 g/L in women or < 130 g/L in men ) with carcinoma of the oral cavity , oropharynx , hypopharynx , or larynx . Patients received curative radiotherapy at 60 Gy for completely ( R0 ) and histologically incomplete ( R1 ) resected disease , or 70 Gy for macroscopically incompletely resected ( R2 ) advanced disease ( T3 , T4 , or nodal involvement ) or for primary definitive treatment . All patients were assigned to subcutaneous placebo ( n=171 ) or epoetin beta 300 IU/kg ( n=180 ) three times weekly , from 10 - 14 days before and continuing throughout radiotherapy . The primary endpoint was locoregional progression-free survival . We assessed also time to locoregional progression and survival . Analysis was by intention to treat . FINDINGS 148 ( 82 % ) patients given epoetin beta achieved haemoglobin concentrations higher than 140 g/L ( women ) or 150 g/L ( men ) compared with 26 ( 15 % ) given placebo . However , locoregional progression-free survival was poorer with epoetin beta than with placebo ( adjusted relative risk 1.62 [ 95 % CI 1.22 - 2.14 ] ; p=0.0008 ) . For locoregional progression the relative risk was 1.69 ( 1.16 - 2.47 , p=0.007 ) and for survival was 1.39 ( 1.05 - 1.84 , p=0.02 ) . INTERPRETATION Epoetin beta corrects anaemia but does not improve cancer control or survival . Disease control might even be impaired . Patients receiving curative cancer treatment and given erythropoietin should be studied in carefully controlled trials OBJECTIVE To compare postoperative pain relief and pulmonary function in patients after thoracoabdominal esophagectomy treated by continuing perioperative thoracic epidural anesthesia or changing to parenteral  opioids . DESIGN Prospect i ve , r and omized study . SETTING University teaching hospital . PARTICIPANTS Thirty-three patients undergoing thoracoabdominal esophagectomy . INTERVENTIONS General anesthesia was combined with thoracic epidural anesthesia during surgery . The patients either continued with thoracic epidural analgesia ( n = 18 ) or were switched to patient-controlled analgesia with intravenous morphine ( n = 15 ) for 5 postoperative days .  Pain scores were estimated twice daily , at rest and after mobilization . Peak expiratory flow , forced expiratory volume , and vital capacity were measured the day before surgery , postoperative day 2 , and postoperative day 6 . Adverse events and complications were recorded . MEASUREMENTS AND MAIN RESULTS At rest , there were no differences in pain relief between the groups . Pain scores at mobilization showed a significantly lower value in the epidural group ( p < 0.027 ) . No intergroup differences were found regarding pulmonary function , which decreased on postoperative day 2 , but was improved on postoperative day 6 . CONCLUSION Continuation of intraoperative thoracic epidural anesthesia for 5 postoperative days provides better pain relief at mobilization compared with a switch to patient-controlled analgesia with intravenous morphine . There was no intergroup difference in the impact on measures of pulmonary function BACKGROUND We commonly use needle catheter jejunostomy ( NCJ ) for early enteral feeding in selected patients . Review of our approach was prompted by the suggestion that enteral feeding represents a " stress test " for the bowel and may be associated with a high complication rate . MATERIAL S AND METHODS We review ed patients with NCJ inserted over the past 16 years by prospect i ve data base , chart review , and conference minutes , with emphasis on complications . RESULTS During the conduct of 28,121 laparotomies , 2,022 NCJs inserted in 1,938 patients ( 7.2 % ) result ed in 34 NCJ-related complications in 29 patients ( 1.5 % ) The most common complication was premature loss of the catheter from occlusion or dislodgment ( n = 15 ; 0.74 % ) , and the most serious was bowel necrosis ( n = 3 ; 0.15 % ) . CONCLUSIONS Needle catheter jejunostomy may be inserted and used with a low complication rate . Most complications were preventable through greater attention to detail and better monitoring of physical examination of patients with marginal gut function AIM Recent evidence suggests that the provision of energy-containing fluids is safe and may impact positively on markers of recovery . The aims of this study were to assess the tolerance of preoperative carbohydrate fluid administration and to determine its effect on postoperative metabolic and clinical responses . METHODS Patients admitted to the Royal Infirmary of Edinburgh for major , elective abdominal surgery were recruited to this double-blind , r and omised study and received either a placebo drink or carbohydrate ( 12.6g/100ml ) drink ( CHOD ) . Patients consumed 800 ml of their drink on the evening before surgery and 400 ml on the day of surgery 2 - 3 h before the induction of anaesthesia . Nutritional status was determined using body mass index ( BMI ) and upper arm anthropometry ; all measurements were taken preoperatively , postoperatively and at discharge . Blood glucose and insulin concentrations were also measured preoperatively and on the first post operative day . Length of hospital stay ( LOS ) and postoperative complications were recorded . RESULTS Seventy-two patients were recruited and 65 ( 34 male:31 female ) completed this study . Thirty-four patients were r and omised to receive the placebo drink ( control group ) and 31 patients to receive the carbohydrate drink ( CHOD group ) . Groups were well-matched in terms of gender and age . There were no differences between the two groups at baseline for BMI ( control : -25.1+/-1.7 kg/m2 ; CHOD -25.2+/-1.2 kg/m2 ) , upper arm anthropometry or surgical procedure . At discharge loss of muscle mass ( arm muscle circumference ) was significantly greater in the control group when compared with the CHOD group ( control : -1.1+/-0.15 cm ; CHOD : -0.5+/-0.16 cm ; P<0.05 ) . Baseline insulin ( control : 20.7+/-4.9 mU/l ; CHOD : 24.6+/-6.2 mU/l ) and glucose ( control : 6.0+/-1.4 mmol/l ; CHOD 5.7+/-1.4 mmol/l ) were comparable in the two groups and did not differ postoperatively . No complications were recorded as a result of preoperative fluid consumption . Postoperative morbidity occurred in six patients from each group . Median LOS in the control group was 10 days ( IQR=6 ) , and 8 days ( IQR=4 ) in the CHOD group . CONCLUSION Preoperative consumption of carbohydrate-containing fluids is safe . Provision of a carbohydrate energy source prior to surgery may attenuate depletion of muscle mass after surgery . Further studies are required to determine if this preservation of muscle mass is reflected in improved function and reduced rehabilitation time OBJECTIVES We prospect ively analyzed the association between drainage volume and development of complications to clarify the safety of early removal of chest tube after  thoracoscopic lobectomy .  METHODS Between November 2001 and October 2007 , 136 patients with suspected or histologically documented lung cancer were enrolled . Patients with no air leak and increased drainage underwent removal of the chest tube on the day after thoracoscopic lobectomy  independent of the drainage volume . Patients were classified into three groups as tertiles according to the drainage volume . Demographic and perioperative variables were compared among the three groups . Age-sex adjusted odds ratios of the clinical variables associated with development of complications were estimated . In addition , the odds ratios of the drainage volume for development of complications were estimated after adjusting for potentially important factors . RESULTS One hundred patients underwent early removal of the chest tube . Almost all demographic and perioperative variables showed no differences among the three groups ( 0 - 289 mL , n = 33 ; 290 - 399 mL , n = 33 ; and > or=400 mL , n = 34 ) . Tumors in a lower lobe , preoperative stage II or higher , 5 or more anatomic segments resected , and advanced disease were all factors that were associated with higher odds ratios for complications . The drainage volume was not associated with an increased morbidity , even after adjusting for these factors . CONCLUSIONS Early removal of chest tube on the day after thoracoscopic lobectomy , independently of the drainage volume , appears to be safe in well-selected patients Abstract This study was conducted to determine the effects of immediate enteral nutrition ( EN ) on nutritional status , immunological competence , and the suppression of excessive inflammatory responses in patients following esophageal cancer surgery . Twenty-four patients who underwent the same elective operation for thoracic esophageal carcinoma were r and omized into an immediate enteral nutrition ( IEN ) group who received EN from postoperative day ( POD ) 1 and a parenteral nutrition ( PAN ) group . Both groups received comparable volumes and calories on the same POD . Laboratory studies were carried out preoperatively and on PODs 1–7 . Other nutritional and immunological assessment s were repeated on PODs 1 and 7 . Plasma concentrations of nitrate and nitrite were also measured . All of the patients in the IEN group tolerated enteral feeding well . There were no significant differences in the results of nutritional assessment s , lymphocyte function , or plasma nitrate and nitrite levels between the two groups . The IEN group showed a significantly earlier recovery of the total lymphocyte count . The serum levels of total bilirubin and C-reactive protein were significantly attenuated in the IEN group . These results indicate that immediate EN may have beneficial effects on immunological competence and the suppression of excessive inflammatory responses in patients following esophagectomy . Patients undergoing radical esophageal surgery who are subjected to severe surgical stress might benefit the most from early EN Objective : To investigate the feasibility and effects of preoperative inspiratory muscle training on the incidence of atelectasis in patients at high risk of postoperative pulmonary complications scheduled for elective abdominal aortic aneurysm surgery . Design : Single-blind r and omized controlled pilot study . Setting : Gelderse Vallei Hospital Ede , the Netherl and s. Subjects : Twenty high-risk patients undergoing elective abdominal aortic aneurysm surgery were r and omly assigned to receive preoperative inspiratory muscle training or usual care . Main measures : Effectiveness outcome variables were atelectasis , inspiratory muscle strength and vital capacity , and feasibility outcome variables were adverse effects and patient satisfaction with inspiratory muscle training . Results : Despite r and omization , patients in the intervention group were significantly older than the patients in the control group ( 70 ± 6 years versus 59 ± 6 years , respectively ; P = 0.001 ) . Eight patients in the control group and three in the intervention group developed atelectasis ( P = 0.07 ) . The median duration of atelectasis was 0 days in the intervention group and 1.5 days in the control group ( P = 0.07 ) . No adverse effects of preoperative inspiratory muscle training were observed and patients considered that inspiratory muscle training was a good preparation for surgery . Mean postoperative inspiratory pressure was 10 % higher in the intervention group . Conclusion : Preoperative inspiratory muscle training is well tolerated and appreciated and seems to reduce the incidence of atelectasis in patients scheduled for elective abdominal aortic aneurysm surgery BACKGROUND Surgical resection is regarded as the only curative option for resectable oesophageal cancer , but pulmonary complications occurring in more than half of patients after open oesophagectomy are a great concern . We assessed whether minimally invasive oesophagectomy reduces morbidity compared with open oesophagectomy . METHODS We did a multicentre , open-label , r and omised controlled trial at five study centres in three countries between June 1 , 2009 , and March 31 , 2011 . Patients aged 18 - 75 years with resectable cancer of the oesophagus or gastro-oesophageal junction were r and omly assigned via a computer-generated r and omisation sequence to receive either open transthoracic or minimally invasive transthoracic oesophagectomy . R and omisation was stratified by centre . Patients , and investigators undertaking interventions , assessing outcomes , and analysing data , were not masked to group assignment . The primary outcome was pulmonary infection within the first 2 weeks after surgery and during the whole stay in hospital . Analysis was by intention to treat . This trial is registered with the Netherl and s Trial Register , NTR TC 2452 . FINDINGS We r and omly assigned 56 patients to the open oesophagectomy group and 59 to the minimally invasive oesophagectomy group . 16 ( 29 % ) patients in the open oesophagectomy group had pulmonary infection in the first 2 weeks compared with five ( 9 % ) in the minimally invasive group ( relative risk [ RR ] 0·30 , 95 % CI 0·12 - 0·76 ; p=0·005 ) . 19 ( 34 % ) patients in the open oesophagectomy group had pulmonary infection in-hospital compared with seven ( 12 % ) in the minimally invasive group ( 0·35 , 0·16 - 0·78 ; p=0·005 ) . For in-hospital mortality , one patient in the open oesophagectomy group died from anastomotic leakage and two in the minimally invasive group from aspiration and mediastinitis after anastomotic leakage . INTERPRETATION These findings provide evidence for the short-term benefits of minimally invasive oesophagectomy for patients with resectable oesophageal cancer . FUNDING Digestive Surgery Foundation of the Unit of Digestive Surgery of the VU University Medical Centre BACKGROUND There appears to be an emerging consensus that early postoperative nutritional support benefits the high-risk patient by decreasing septic morbidity , maintaining immunocompetence and improving wound healing .  Enteral nutrition via a feeding jejunostomy has been associated with serious complications , with a reported mortality rate as high as 10 % , while total parenteral nutrition has also been associated with a wide variety of complications . METHODS Ninety-seven patients undergoing oesophagectomy or gastrectomy underwent pre-operative nutritional assessment and were r and omized to receive either total parenteral nutrition ( 47 patients ) or enteral nutrition ( 50 patients ) . RESULTS There was no significant difference in the number of catheter-related complications between the two groups , but 9 ( 45 % ) patients in the total parenteral nutrition group had major morbidity ( potentially fatal in two patients ) requiring active intervention . CONCLUSIONS This study demonstrates enteral nutrition to be safe and associated with mainly reversible minor complications . It is probable that immediate postoperative enteral feeding conserves the gut 's integrity . Whether this leads to a reduction in postoperative septic complications has not been demonstrated by this study although there appears to be a trend in this direction , supporting the concept of enteral feeding as ' primary therapy ' . This can be safely , simply and economically achieved using a feeding jejunostomy placed at the time of surgery OBJECTIVE Many patients have their hospital discharge delayed because their chest tube drainage is too high , despite the fact that there are no data to support the commonly used 250 mL/day threshold . METHODS A retrospective cohort study was conducted with a prospect i ve data base and prospect i ve algorithm from one surgeon . All patients underwent elective pulmonary resection .  The last chest tube was removed if there was no air leak and nonchylous drainage of 450 mL/day or less . RESULTS The study comprised 8608 operations and 2077 patients who underwent an elective ( nonpneumonectomy ) pulmonary resection via thoracotomy by one general thoracic surgeon over a 10-year period . Eighty-nine patients went home with a chest tube owing to air leak . The remaining 1988 patients were discharged without a chest tube . Types of pulmonary resection were wedge resection in 729 patients , segmentectomy in 214 , lobectomy in 1104 , and bilobectomy in 30 . The median day of discharge was postoperative day 4 . One hundred one ( 5 % ) were readmitted to the hospital within 60 days of discharge . The most common reason for readmission was dehydration and fatigue . Only 11 ( 0.55 % ) had readmissions owing to recurrent symptomatic effusion and most were treated with video-assisted thoracoscopy . Follow-up was 100 % at 4 weeks and 93 % at 8 weeks . CONCLUSIONS Chest tubes can be removed with up to 450 mL/day of nonchylous drainage after pulmonary resection , and perhaps a higher volume could be accepted . Readmission owing to a recurrent effusion is exceedingly uncommon , and the practice of leaving the tube in longer for drainage less than 450 mL/day is unsupported in the literature Objective This study seeks to evaluate the level of anxiety , recall , and comprehension of the provided information in patients undergoing esophageal and gastrointestinal surgery . Methods Sixty-one patients without cognitive disorders entered a prospect i ve study design ed to assess the effect of a surgical informed consent process . The written informed consent was administered to all patients and was supported by a verbal explanation and a schematic drawing of the operation . The  State Trait Anxiety Inventory test  was used to assess state anxiety and tract anxiety . The test was repeated after the informed consent process . A disease-specific feedback question naire was subsequently administered to assess the actual comprehension of the provided information . Results A significant decrease of the state anxiety scores was documented in most patients ( p < 0.001 ) . This effect was more evident in the elderly ( p = 0.021 ) and in those who used Internet as a previous source of information ( p = 0.032 ) . The mean correct exact answer rate on the disease-specific question naire was 76 % ( IQ range 66.7–85 % ) . No statistically significant relationship was found between the rate of correct answers and the state anxiety scores . Conclusions An exhaustive surgical informed consent process was effective in providing comprehension and decreasing anxiety in patients who are c and i date s to minimally invasive esophageal and gastrointestinal surgical procedures BACKGROUND The provision of perioperative immune modulating enteral feeds after major surgery may result in reduced infective complications , but meta-analyses have not demonstrated a survival advantage . The aim of this study was to determine whether early postoperative immune modulating jejunostomy feeding results in reduced infective complications in patients undergoing resectional surgery for upper gastrointestinal cancer . METHODS A total of 120 patients undergoing resection for cancers of the pancreas , oesophagus and stomach were r and omized in a double-blind manner to receive jejunostomy feeding with an immune modulating diet ( Stresson-Group A ) or an isonitrogenous , isocaloric feed ( 1250 Calories and 75 g protein/l -- Nutrison High Protein-Group B ) for 10 - 15 days . Feeding was commenced 4h postoperatively and continued for 20 h/day . The target volume ( ml/h ) was 25 on day 0 , 50 on day 1 , and 75 thereafter . Outcome measures included complications , hospital stay and mortality . RESULTS A total of 108 patients ( 54 in each group ) were analysed .  Feed delivery , although less than targeted , was similar in both groups . There were 6 ( 11 % ) deaths in each group . Median ( IQR ) postoperative hospital stay was 14.5 ( 12 - 23 ) days in Group A and 17.5 ( 13 - 23 ) days in Group B ( P=0.48 ) . A total of 24 ( 44 % ) patients in each group had infective complications ( P=1.0 ) . A total of 21 ( 39 % ) patients in Group A and 28 ( 52 % ) in Group B had non-infective complications ( P=0.18 ) . Jejunostomy-related complications occurred in 26 ( 48 % ) patients in Group A and 30 ( 56 % ) in Group B ( P=0.3 ) . CONCLUSION Early postoperative feeding with an immune modulating diet conferred no outcome advantage when compared with a st and ard feed Feeding jejunostomy is frequently performed in patients undergoing oesophageal surgery , but can lead to serious complications . This prospect i ve r and omized trial compared the efficacy and complications of feeding jejunostomy with those of nasoduodenal tube feeding in oesophageal surgery Purpose : Water-soluble contrast swallow ( CS ) is usually performed before refeeding for anastomosis assessment after esophagectomy with intrathoracic anastomosis but the sensitivity of CS is low . Another diagnostic approach is based on analysis of computed tomography ( CT ) scan with oral contrast and of CT mediastinal air images . We undertook to compare them prospect ively . Methods : Ninety-seven patients with an esophageal carcinoma operated by intrathoracic anastomosis were included prospect ively in a study based on a CT scan at postoperative day 3 ( without oral and intravenous contrast ) and CT scan and CS at day 7 . CT scan analysis consisted of assessing contrast and air leakage . In case of doubt , an endoscopy was done . Results : A diagnosis of anastomotic leak was made in 13 patients ( 13.4 % ) , in 2 cases before day 7 and in 3 beyond day 7 . At day 3 , 94 CT scans were performed , but the diagnostic value was poor . In 95 patients with both CS and CT scan at day 7 , CS disclosed a leak in 5 of 11 , and CT scan was abnormal in 8 of 11 . Leakage of contrast and /or presence of mediastinal gas had the best negative predictive value ( 95.8 % ) . Endoscopy was done in 16 patients with only mediastinal gas at day 7 CT scan . It disclosed a normal anastomosis in 11 , fibrin deposits in 4 , and a leak in 1 . Conclusions : In comparison with CS only , CT at day 7 improves the sensitivity and negative predictive value for diagnosing an anastomotic leak . In case of doubt endoscopy is advisable . This approach provides an accurate assessment of the anastomosis before refeeding Objective To investigate the effect of recombinant human erythropoietin ( r-HuEPO ) administration on perioperative hemoglobin concentrations and on the number of blood transfusions in patients undergoing surgery for gastrointestinal tract malignancies . Summary Background Data Erythropoietin has been shown to improve the yield of autologously predonated blood and to reduce the subsequent requirements for homologous blood transfusions in cancer patients . Methods In this double-blind placebo-controlled study , 31 cancer patients received subcutaneous r-HuEPO in a dose of 300 IU/kg body weight plus 100 mg iron intravenously ( study group ) and 32 patients received placebo medication and iron  ( control group ) . All patients received the medications daily for at least 7 days before and 7 days after the operation . Results Patients who received erythropoietin received significantly fewer transfusions intraoperatively and postoperatively . Postoperatively , the study group had significantly higher hematocrit , hemoglobin , and reticulocyte count values compared to the control group . The use of erythropoietin was also associated with a reduced number of postoperative complications and improved 1-year survival . Conclusions Patients with gastrointestinal tract cancer and mild anemia benefit from perioperative erythropoietin administration in terms of stimulated erythropoiesis , reduction in the number of blood transfusions , and a favorable outcome BACKGROUND Anastomotic leaks are a major complication of oesophagogastric surgery . We compare contrast swallow fluoroscopy , computed tomography ( CT ) with oral contrast and endoscopy in identifying anastomotic leaks following oesophagogastric surgery . METHODS A prospect i ve trial of 38 patients undergoing oesophagogastric resection  was undertaken with informed consent and institutional review board ( ethics committee ) approval . Patients underwent all three investigations ( over 24 hours ) 1 week postoperatively . RESULTS Eight ( 21 % ) had clinical ly apparent leaks . Three pseudo-leaks were suggested on contrast swallow but were confirmed normal on CT and endoscopy . Contrast swallow and CT missed one anastomotic leak each . Endoscopy identified anastomotic defects in three patients , in whom CT and contrast swallow were either normal or conflicting . CONCLUSIONS Routine tests of anastomotic integrity are unnecessary . When clinical ly suspected , contrast swallow or CT with oral contrast will identify most leaks . Endoscopy is useful in cases where there are incongruous results BACKGROUND : Gastric tube necrosis is a major cause of anastomotic leak after esophagectomy . A correlation has been shown between reduced flux at the anastomotic end of the gastric tube and anastomotic leaks . METHODS : We prospect ively studied the effect of intraoperative thoracic epidural bupivacaine and subsequent adrenaline infusion on hemodynamics and flux in the gastric tube . RESULTS : Administering the epidural bolus significantly decreased flux at the anastomotic end of the gastric tube ( P < 0.01 ) . Gastric flux was returned to baseline by an adrenaline infusion . CONCLUSIONS : The administration of a thoracic epidural bolus may decrease flux at the anastomotic end of the gastric tube INTRODUCTION Allogeneic blood transfusion confers a risk to the recipient . Recent trials in colorectal surgery have shown that the most significant factors predicting blood transfusion are pre-operative haemoglobin , operative blood loss and presence of a transfusion protocol . We report a r and omised , controlled trial of oral ferrous sulphate 200 mg TDS for 2 weeks ' pre-operatively versus no iron therapy . PATIENTS AND METHODS Patients diagnosed with colorectal cancer were recruited from out-patient clinic and haematological parameters assessed . R and omisation was co-ordinated via a telephone r and omisation centre . RESULTS Of the 49 patients recruited , 45 underwent colorectal resection . There were no differences between those patients not receiving iron ( n = 23 ) and the iron-supplemented group ( n = 22 ) for haemoglobin at recruitment , operative blood loss , operation duration or length of hospital stay . At admission to hospital , the iron-supplemented group had a higher haemoglobin than the non-iron treated group ( mean haemoglobin concentration 13.1 g/dl [ range , 9.6 - 17 g/dl ] versus 11.8 g/dl [ range , 7.8 - 14.7 g/dl ] ; P = 0.040 ; 95 % CI 0.26 - 0.97 ) and were less likely to require operative blood transfusion ( mean 0 U [ range , 0 - 4 U ] versus 2 U [ range , 0 - 11 U ] transfused ; P = 0.031 ; 95 % CI 0.13 - 2.59 ) . This represented a cost reduction of 66 % ( 47 U of blood = pound4700 versus oral FeSO(4 ) at pound30 + 15 U blood at pound1500 ) . At admission , ferritin in the iron-treated group had risen significantly from 40 microg/l ( range , 15 - 222 microg/l ) to 73 microg/l ( range , 27 - 386 microg/l ; P = 0.0036 ; 95 % CI 46.53 - 10.57 ) . CONCLUSIONS Oral ferrous sulphate given pre-operatively in patients undergoing colorectal surgery offers a simple , inexpensive method of reducing blood transfusions AIM Assessing the impact of chest tube removal timing following a coronary artery bypass grafting surgery  on the clinical outcome . METHODS Eighty-three consecutive patients were r and omly assigned to either have the chest tube removed 24 hours ( Group A ) or 48 hours ( Group B ) postoperatively . Chest tubes were removed on the condition that drainage was less than 100 cc for the last 8 hours . Pre- and postoperative data were analyzed . RESULTS The following preoperative and intraoperative risk factors were more prevalent among Group A patients : previous MI ( 60.5 % vs 40.7 % , p = 0.11 ) , previous CVA ( 9.1 % vs 0 % , p = 0.11 ) , hypertension ( 72.7 % vs 55.6 % , p = 0.14 ) , pump time ( 111.6 min vs 96.8 min , p = 0.07 ) , and cross-clamp time ( 73.8 min vs 64.4 min , p = 0.07 ) . Postoperatively , there was a lower dem and for analgesics in Group A ( 2.1 times for 12 hours at 36 hours vs 3.6 p = 0.09 ) , lower white blood cell count ( 10,947 at 48 hours vs 11,576 , p = 0.39 ) a higher oxygen saturation ( 91.9 % at 48 hours vs 88.9 % , p = 0.07 ) , higher expiratory volumes ( 594 mL at 36 hours vs 514 mL p = 0.08 ) and earlier mobilization ( 23 % walking at 48 hours vs 4 % , p = 0.01 ) . Pleural effusion and atelectasis were less frequent in Group A in both chest X-rays ( 66 % vs 73 % , p = 0.6 and 64 % vs 75 % , p = 0.47 , respectively ) and CT scans ( 19 % vs 41 % , p = 0.1 and 84 % vs 96 % , p = 0.42 , respectively ) . There was no difference between the two groups in the prevalence of serous wound discharge and the length of hospital stay and there were no reported cases of pneumonia throughout the study . CONCLUSION In cases where no excessive drainage accumulates , early removal of the chest tubes was found to be a policy that improves the postoperative outcome and decreases the need for supportive treatment such as analgetics , physiotherapy , nurse care , and oxygen . This policy did not involve significant residual effusions BACKGROUND Postoperative organ failures commonly occur after major abdominal surgery , increasing the utilization of re sources and costs of care . Tissue hypoxia is a key trigger of organ dysfunction . A therapeutic strategy design ed to detect and reverse tissue hypoxia , as diagnosed by an increase of oxygen extraction ( O2ER ) over a predefined threshold , could decrease the incidence of organ failures . The primary aim of this study was to compare the number of patients with postoperative organ failure and length of hospital stay between those r and omized to conventional vs a protocol ized strategy design ed to maintain O2ER < 27 % . METHODS A prospect i ve , r and omized , controlled trial was performed in nine hospitals in Italy . One hundred thirty-five high-risk patients scheduled for major abdominal surgery were r and omized in two groups . All patients were managed to achieve st and ard goals : mean arterial pressure > 80 mm Hg and urinary output > 0.5 mL/kg/h . The patients of the " protocol group " ( group A ) were also managed to keep O2ER < 27 % . MEASUREMENTS AND MAIN RESULTS In group A , fewer patients had at least one organ failure ( n = 8 , 11.8 % ) than in group B ( n = 20 , 29.8 % ) [ p < 0.05 ] , and the total number of organ failures was lower in group A than in group B ( 27 failures vs 9 failures , p < 0.001 ) . Length of hospital stay was significantly lower in the protocol group than in the control group ( 11.3 + /- 3.8 days vs 13.4 + /- 6.1 days , p < 0.05 ) . Hospital mortality was similar in both groups . CONCLUSIONS Early treatment directed to maintain O2ER at < 27 % reduces organ failures and hospital stay of high-risk surgical patients . Clinical trials.gov reference No. NCT00254150 Background : Nutritional condition is one of the factors determining postoperative outcome in esophageal surgery . This study explored the relation between preoperative nutritional status and postoperative infectious complications . Methods : From a prospect i ve data base , 400 patients who underwent esophageal resection for malignancy were selected .  Preoperative nutritional status was assessed by body mass index , prognostic nutritional index ( PNI ) , nutritional risk index ( NRI ) and weight loss . The association between nutritional parameters and postoperative complications and mortality , gender , age and hospitalization was assessed . Results : PNI and NRI differed between the patients with and without postoperative infectious complications ( p = 0.031 and p = 0.009 , respectively ) . However , receiver operating characteristic curves showed that PNI and NRI have a low predictive value for such complications . Also , no associations were found between nutritional parameters and in-hospital mortality . Although mean nutritional parameters were significantly lower , i.e. worse , in patients with neoadjuvant treatment as compared to no such treatment , the incidence of complications did not significantly differ between these treatment groups . Although PNI and NRI correlated negatively with age , no association was found between age and infectious complications . Multivariate analysis of various factors showed the male gender to be the only significant risk factor for development of infectious complications . Discussion : Preoperative nutritional status established by PNI , NRI , body mass index and weight loss has limited value in predicting complications following esophageal resection A carbohydrate‐rich drink ( CHO ) has been shown to reduce preoperative discomfort . It was hypothesized that it may also reduce postoperative nausea and vomiting ( PONV ) OBJECTIVE The authors set out to determine whether immediate enteral feeding minimizes early postoperative decreases in h and grip and respiratory muscle strength . SUMMARY BACKGROUND DATA Muscle strength decreases considerably after major surgical procedures . Enteral feeding has been shown to restore strength rapidly in other clinical setting s. METHODS A r and omized , controlled , nonblinded clinical trial was conducted in patients undergoing esophagectomy or pancreatoduodenectomy who received immediate postoperative enteral feeding via jejunostomy ( fed , n = 13 ) , or no enteral feeding during the first 6 postoperative days ( unfed , n = 15 ) .  H and grip strength , vital capacity , forced expiratory volume in one second ( FEV1 ) , and maximal inspiratory pressure ( MIP ) were measured before surgery and on postoperative days 2 , 4 , and 6 . Fatigue and vigor were evaluated before surgery and on postoperative day 6 . Mobility was assessed daily after surgery using a st and ardized descriptive scale . Postoperative urine biochemistry was evaluated in daily 24-hour collection s. RESULTS Postoperative vital capacity ( p < 0.05 ) and FEV1 ( p = 0.07 ) were consistently lower ( 18%-29 % ) in the fed group than in the unfed group , whereas grip strength and maximal inspiratory pressure were not significantly different . Postoperative mobility also was lower in the fed patients ( p < 0.05 ) and tended to recover less rapidly ( p = 0.07 ) . Fatigue increased and vigor decreased after surgery ( both p < or = 0.001 ) , but changes were similar in the fed and unfed groups . Intensive care unit and postoperative hospital stay did not differ between groups . CONCLUSIONS Immediate postoperative jejunal feeding was associated with impaired respiratory mechanics and postoperative mobility and did not influence the loss of muscle strength or the increase in fatigue , which occurred after major surgery . Immediate postoperative enteral feeding should not be routine in well-nourished patients at low risk of nutrition-related complications PURPOSE This prospect i ve , nonr and omized study evaluates the effectiveness of epoetin alfa to maintain the hemoglobin levels at 12 to 14 g/dL ( optimal range for tumor oxygenation ) during chemoradiation for Stage III esophageal cancer and its impact on overall survival ( OS ) , metastatic-free survival ( MFS ) , and locoregional control ( LC ) . METHODS AND MATERIAL S Ninety-six patients were included . Forty-two patients received epoetin alfa ( 150 IU/kg , 3 times a week ) during radiotherapy , which was started at hemoglobin less than 13 g/dL and stopped at 14 g/dL or higher .  Hemoglobin levels were measured weekly during RT . RESULTS Both groups were balanced for age , sex , performance status , tumor length/location , histology , grading , T-stage/N-stage , chemotherapy , treatment schedule , and hemoglobin before RT . Median change of hemoglobin was + 0.3 g/dL/wk with epoetin alfa and -0.5 g/dL/wk without epoetin alfa . At least 60 % of hemoglobin levels were 12 to 14 g/dL in 64 % and 17 % of the patients , respectively ( p < 0.001 ) . Patients who received epoetin alfa had better OS ( 32 % vs. 8 % at 2 years , p = 0.009 ) and LC ( 67 % vs. 15 % at 2 years , p = 0.001 ) . MFS was not significantly different ( 42 % vs. 18 % at 2 years , p = 0.09 ) . CONCLUSIONS The findings suggest that epoetin alfa when used to maintain the hemoglobin levels at 12 to 14 g/dL can improve OS and LC of Stage III esophageal cancer patients INTRODUCTION Pre-operative anaemia is well recognised in patients presenting with colorectal cancer ( CRC ) . While the benefits of long-term FeSO4 supplementation on Fe deficiency anaemia are well established , it is not known if short-course supplementation ( 2 - 3 weeks ) impacts significantly on pre-operative haemoglobin ( Hb ) levels . This study examines the impact of short-term , oral FeSO4 supplementation on patients undergoing surgery for CRC . PATIENTS AND METHODS All patients with CRC presenting to a single surgeon were included . At diagnosis , baseline  Hb  and  blood film  were checked on all patients who then received 200 mg tds of FeSO4 . Haemoglobin was rechecked pre-operatively and daily postoperatively . Patients requiring pre-operative blood transfusions were excluded from analysis . RESULTS Between 1 January 2004 and 31 December 2006 , 117 patients were identified , 14 of whom were excluded . Patients received a median of 39 days ' treatment with FeSO4 . Fifty-eight ( 56.3 % ) patients were anaemic at presentation gaining a mean of 1.73 g/dl ( P<0.001 ) from short-course FeSO4 supplementation . Right-sided tumours ( lower mean Hb at presentation ; P=0.008 ) responded more to FeSO4 when compared to left-sided tumours ( P<0.017 ) . Increase in Hb was unrelated to pathological stage . The transfusion rate for all curative resections was 0.69 units/patient . For the historical cohort ( patients undergoing curative resection between 1 January 2001 and 31 December 2003 ) , the mean transfusion rate fell from 1.69 units/patient . CONCLUSIONS Routine short-course supplementation with iron offers improved pre-operative Hb prior to surgery in CRC , especially in right-sided lesions and those with presenting anaemia INTRODUCTION The aim of this pilot study was to assess the effect of pre-operative inspiratory muscle training ( IMT ) on respiratory variables in patients undergoing major abdominal surgery . PATIENTS AND METHODS Respiratory muscle strength ( maximum inspiratory [ MIP ] and expiratory [ MEP ] mouth pressure ) and pulmonary functions were measured at least 2 weeks before surgery in 80 patients awaiting major abdominal surgery . Patients were then allocated r and omly to one of four groups ( Group A , control ; Group B , deep breathing exercises ; Group C , incentive spirometry ; Group D , specific IMT ) . Patients in groups B , C and D were asked to train twice daily , each session lasting 15 min , for at least 2 weeks up to the day before surgery . Outcome measurements were made immediately pre-operatively and postoperatively . RESULTS In groups A , B and C , MIP did not increase from baseline to pre-operative assessment s. In group D , MIP increased from 51.5 cmH(2)O ( median ) pre-training to 68.5 cmH(2)O ( median ) post-training pre-operatively ( P < 0.01 ) . Postoperatively , groups A , B and C showed a fall in MIP from baseline ( P < 0.01 , P < 0.01 ) and P = 0.06 , respectively ) . No such significant reduction in postoperative MIP was seen in group D ( P = 0.36 ) . CONCLUSIONS Pre-operative specific IMT improves MIP pre-operatively and preserves it postoperatively . Further studies are required to establish if this is associated with reduced pulmonary complications Cancer of the esophagus is often diagnosed at a late stage and is related to severe morbidity and a low 5-year survival rate . Previous studies have reported low health-related quality of life and high suicide rates for these patients . The occurrence of psychiatric morbidity and thus the potential need for psychological support may vary over time after diagnosis . This has not been adequately studied in patients with newly diagnosed cancer of the esophagus or gastro-esophageal junction . The present study therefore aim ed to prospect ively evaluate the prevalence of psychiatric morbidity in 94 consecutive patients ( median age 66 , range 45 - 88 years ) with all stages of disease .  Psychiatric morbidity was evaluated with the  Hospital Anxiety and Depression Scale ( HADS ) question naire at inclusion and 1 , 2 , 3 , 6 and 12 months later . At inclusion , 42 % of the patients had HADS scores indicating possible or probable anxiety disorder and /or depression . At all follow-ups except at 3 months , proportions of patients with possible/probable anxiety disorder were significantly lower than at inclusion . Among patients with a duration of tumor-specific symptoms exceeding 6 months pre-diagnosis , larger proportions of patients with a possible/probable anxiety disorder were found at the 1- and 6-month follow ups . The prevalence of possible/probable depression was greater among patients treated with a palliative intent than among those with a curative intent at inclusion . Patients who died during the study period scored worse for depression compared to the survivors . Apart from this , the proportion of patients with possible/probable psychiatric morbidity ( anxiety and /or depression ) was relatively stable over time and was unrelated to patient characteristics or clinical background , including the treatment regime . In conclusion , psychiatric morbidity is common among esophageal cancer patients , both at inclusion and over time , regardless of the cancer therapy given . The findings stress the importance of monitoring the patients ' mental health and of offering adequate psychological care when needed BACKGROUND In a previous study we showed that many patients with esophagogastric adenocarcinoma experience anemia during neoadjuvant chemotherapy . We now investigated the role of erythropoietin in managing anemia during neoadjuvant chemotherapy . METHODS Patients with esophagogastric adenocarcinoma who experienced anemia ( hemoglobin < 12 g/dL ) during neoadjuvant treatment  received  erythropoietin 10,000  IE subcutaneously three times a week . Primary outcomes were the response to erythropoietin , safety , the need for allogeneic red blood cell transfusion , and the rate of postoperative complications . RESULTS Between April 2003 and December 2004 , 24 patients ( median age , 62 years ) were enrolled . The mean hemoglobin level before chemotherapy was 12.5 g/dL and the mean hemoglobin level before patients received erythropoietin was 11.5 g/dL. One year after involvement in the trial , 4 of 17 analyzable patients were still anemic ( hemoglobin level < 12 mg/dL ) . Twenty-two patients received erythropoietin , and 16 ( 73 % ) responded . We could observe a significant increase in hemoglobin concentrations under therapy with erythropoietin to 12.6 g/dL ( p < 0.001 ) . Two patients ( 8 % ) received allogeneic transfusions ; the rate of postoperative complications was 16 % . There were no erythropoietin-related  adverse events . CONCLUSIONS Treatment with erythropoietin is effective and well tolerated in patients with esophagogastric adenocarcinoma who experience anemia during neoadjuvant chemotherapy Objective : The aim of this trial was to investigate whether a routine of allowing normal food at will increases morbidity after major upper gastrointestinal ( GI ) surgery . Summary Background Data : Nil-by-mouth with enteral tube feeding is widely practice d for several days after major upper GI surgery . After other abdominal operations , normal food at will has been shown to be safe and to improve gut function . Methods : Patients were r and omly assigned to a routine of nil-by-mouth and enteral tube feeding by needle-catheter jejunostomy ( ETF group ) or normal food at will from the first day after major upper GI surgery . Primary end point was rate of major complications and death . Secondary outcomes were minor complications and adverse events , bowel function , and length of stay . All patients were invited to a follow-up at 8 weeks after discharge from the hospital . Results : Four hundred fifty-three patients who underwent major open upper GI surgery in 5 centers were enrolled between 2001 and 2006 . Four hundred forty-seven patients were correctly r and omized . Of 227 patients 76 ( 33.5 % ) had major complications in the ETF group compared with 62 ( 28.2 % ) of 220 patients allowed normal food at will ( P = 0.26 , 95 % CI for the difference in rate from −3.3 to 13.9 ) . In the ETF group , 36 ( 15.9 % ) patients were reoperated compared with 29 ( 13.2 % ) in the group allowed normal food at will ( P = 0.50 ) and 30-day mortality was 10 ( 4.4 % ) of 227 and 11 ( 5.0 % ) of 220 patients , respectively ( P = 0.83 ) . Time to resumed bowel function was significantly in favor of allowing normal food at will ( P = 0.01 ) , as were the total number of major complications , length of stay , and rate of postdischarge complications . Conclusions : Allowing patients to eat normal food at will from the first day after major upper GI surgery does not increase morbidity compared with traditional care with nil-by-mouth and enteral feeding BACKGROUND We investigated whether supplementation of enteral nutrition ( EN ) with omega-3 polyunsaturated acids ( PUFAs ) affected platelet aggregation , coagulation activity , and inflammatory response in the early stages after esophageal cancer surgery . METHODS Twenty-eight patients with esophageal cancer who underwent the same surgical procedure were selected for this study . All patients received EN , which was started immediately after the operation and was increased to a maximum volume of 1500 ml/day by the third postoperative day ( POD ) . Eleven patients received a conventional EN formula ( Ensure Liquid ) , while the remaining 17 patients received a different formula rich in omega-3 PUFAs ( Racol [ RAC ] ) . Several markers of coagulation and fibrinolysis were determined in POD 2 , while the concentrations of interleukin (IL)-6 , IL-8 , 6-keto-PGF1alpha and thromboxane B2 were determined on PODs 1 , 3 , and 5 . RESULTS A total of 27 patients completed the study , 11 in the Ensure Liquid group and 16 in the RAC group . Administration of RAC significantly inhibited the postoperative decrease in platelet count . The level of D-dimer was attenuated significantly in the RAC group . Plasma IL-8 levels were decreased significantly in the RAC group on PODs 1 and 3 . The anti-inflammatory effects of omega-3 PUFAs were confirmed by the clinical findings of lower body temperature . The plasma concentration of 6-keto-PFG1alpha also tended to decrease in the RAC group with a significant difference on POD 5 . CONCLUSIONS Early EN with a large amount of omega-3 PUFAs in reduced platelet aggregation , coagulation activity , and cytokine production . All these effects would be expected to be beneficial in patients following esophageal cancer surgery . The clinical significance of the changes in eicosanoid production remains to be established Background and Objectives : It is common practice to catheterize the bladder in the presence of epidural analgesia and to leave the bladder catheter in situ to avoid postoperative urinary retention . However , bladder catheterization carries the risk for urinary tract infection ( UTI ) . The objective of this r and omized control trial was to assess whether the incidence of UTI will differ among patients receiving st and ard care and patients who have the bladder catheterization discontinued on the morning after surgery with the epidural still functioning . Methods : Patients at low risk for postoperative urinary retention , scheduled for thoracic and abdominal surgery and receiving continuous thoracic epidural analgesia , were r and omized on the morning after surgery to 2 groups : in the early removal group ( n = 105 ) , the bladder catheter was removed on the same morning after surgery , whereas in the st and ard group ( SG ) ( n = 110 ) , the bladder catheter was removed when epidural analgesia was discontinued ( 3 - 5 days ) . Urinary bladder volume was assessed by ultrasound . Primary and secondary outcomes were the incidence of UTI and rate of recatheterization . Results : Two hundred fifteen patients were r and omized . There were 17 UTI cases in total , with 15 ( 14 % ) in the SG and 2 ( 2 % ) in the early removal group ( P = 0.004 ) . The incidence of recatheterizations was not different between the 2 groups ( P = 0.09 ) and did not correlate with the site of epidural insertion . When matched for the types of surgery , the duration of hospital stay was longer in the patients who contracted UTI ( P = 0.004 ) . There were more patients older than 65 years in the SG . Conclusions : Leaving the bladder catheter as long as the epidural analgesia is maintained results in a higher incidence of UTI and prolonged hospital stay . Removal of the bladder catheter on the morning after surgery does not lead to higher rate of catheterizations Background Morphine and ketamine may prevent central sensitization during surgery and result in preemptive analgesia . The reliability of preemptive analgesia , however , is controversial . Methods Gastrectomy patients were given preemptive analgesia consisting of epidural morphine , intravenous low-dose ketamine , and combinations of these in a r and omized , double-blind manner . Postsurgical pain intensity was rated by a visual analog scale , a categoric pain evaluation , and cumulative morphine consumption . Results Preemptive analgesia by epidural morphine and by intravenous low-dose ketamine were significantly effective but not definitive . With epidural morphine , a significant reduction in visual analog scale scores at rest was observed at 24 and 48 h , and morphine consumption was significantly lower at 6 and 12 h , compared with control values . With intravenous ketamine , visual analog scale scores at rest and morphine consumption were significantly lower at 6 , 12 , 24 , and 48 h than those in control subjects . The combination of epidural morphine and intravenous ketamine provided definitive preemptive analgesia : Visual analog scale scores at rest and morphine consumption were significantly the lowest at 6 , 12 , 24 , and 48 h , and the visual analog scale score during movement and the categoric pain score also were significantly the lowest among the groups . Conclusion The results suggest that for definitive preemptive analgesia , blockade of opioid and N-methyl-d-aspartate receptors is necessary for upper abdominal surgery such as gastrectomy ; singly , either treatment provided significant , but not definitive , postsurgical pain relief . Epidural morphine may affect the spinal cord segmentally , whereas intravenous ketamine may block brain stem sensitization via the vagus nerve during upper abdominal surgery PURPOSE Enhanced recovery pathways ( ERP ) decrease morbidity and duration of stay after colorectal surgery . There is little information about their role in complex procedures , such as esophagectomy . The purpose of this study was to determine the impact of an ERP on duration of stay , complications , and readmissions after esophagectomy . METHODS Patients undergoing esophagectomy for cancer or high- grade dysplasia from June 2009 to December 2011 were identified from a prospect ively maintained data base . Beginning in June 2010 , all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan , indications for intensive care admission , early structured mobilization , and diet and drain management . Short-term ( 30-day ) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway . Data are expressed as median values [ interquartile range ] . RESULTS We identified 106 patients ; 47 underwent esophagectomy before ERP implementation and 59 after . Patients were similar with respect to age , gender , diagnosis , and operative time .  Hospital stay was shorter in the ERP group ( 8 [ 7 - 17 ] vs 10 [ 9 - 17 ] days ; P = .01 ) . There were no differences in rates of complications ( 59 % vs 62 % ) or readmissions ( 6 % vs 5 % ) . CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay , without an increase in complications or readmissions Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials
target: Overall , there is little direct evidence for components of ERAS , with much derived from nonesophageal thoracoabdominal surgery .
  ERAS in principle seems logical and safe for esophagectomy .
background: OBJECTIVE This article aims to provide the first systematic review of enhanced recovery after surgery ( ERAS ) programs for  esophagectomy  and generate guidelines .
  BACKGROUND ERAS programs use multimodal approaches to reduce complications and accelerate recovery .
  Although ERAS is well established in colorectal surgery , experience after esophagectomy has been minimal .
  However , esophagectomy remains an extremely high-risk operation , commonly performed in patients with significant comorbidities .
  Consequently , ERAS may have a significant role to play in improving outcomes .
  No guidelines or review s have been published in esophagectomy .