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For patients undergoing gastrointestinal surgery, new concepts referred to as enhanced recovery after surgery (ERAS) or fast track surgery focus on enhanced recovery and the reduction of postoperative morbidity which include special metabolic and nutritional care. Whenever possible, artificial nutritional support should be withheld. Therefore, early detection and observation of patients with nutritional risks remain essential issues for perioperative management. In cases of inadequate oral intake, which has to be anticipated in risk patients, nutritional support should be started early via the enteral route, maybe in combination with parenteral nutrition. Long-term total parenteral nutrition should be restricted to special indications. This review includes the recent guideline recommendations for surgical patients of the German Society for Nutritional Medicine (DGEM; http://www.dgem.de, http://www.awmf@online.de) and the European Society for Clinical Nutrition and Metabolism (ESPEN; http://www.espen.org) from 2006 and 2009. © Springer-Verlag 2011.


Jonas J.,Klinik fur Allgemein und Visceralchirurgie
European Surgical Research | Year: 2010

Introduction: Newly developed vagal stimulation probes permit continuous intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid resection. Complete signal loss indicates damage of the nerve. There is no other criterion so far to warn before imminent nerve function impairment. Methods: In 100 patients, thyroid resection (188 nerves at risk, 52 thyroidectomies, 21 Dunhill resections, 12 hemithyroidectomies, 5 two-sided subtotal resections) was performed. The vagus electrode V3 was used for continuous stimulation and placed between the carotid artery and the internal jugular vein (V3 electrode; laryngeal adhesive tube electrode; Fa. inomed Medizintechnik GmbH, Teningen, Germany). The signals were recorded via the tube electrode during the complete operation. The signal parameters amplitude, latency and thresholds of nerve conductance were compared at the start of thyroid resection and after completion of thyroid preparation. The changes of these parameters were analyzed. Results: The latencies (right vagal nerve 4.39 ± 0.51 ms; left vagal nerve 6.78 ± 0.75 ms) remained unchanged during the operation. The lower threshold of nerve conduction varied from 0.5 to 2.5 mA, the upper threshold from 1.5 to 5.0 mA. There were no changes between the two measuring points in the majority of cases (lower threshold 92.1%, upper threshold 80.8%). The signal amplitude values were identical in 48% of the cases compared to values at the beginning of operation. A large change in signal amplitude was seen from -58% to +243% after resection. None of the recorded changes of these three parameters were associated with laryngoscopic visible vocal cord disorders. Complete signal loss during operation was documented in 4 cases. Vocal cord palsy was confirmed in 3 cases after operation. In the 4th case, the stimulation signal could be deviated again with diminished amplitude at the end of the operation without vocal cord pareses at laryngoscopy afterwards. Conclusions: The parameters signal amplitude, latency and stimulation threshold cannot be used as reliable warning criteria for nerve function impairment during thyroid resection. Loss of signal remains the most important criterion for the surgeon. The coupling of the signal change to operational procedure may be beneficial in difficult thyroid preparation. This gives the surgeon the possibility to react immediately in the case of signal loss. Copyright © 2010 S. Karger AG, Basel.


Weimann A.,Klinik fur Allgemein und Visceralchirurgie | Rittler P.,Ludwig Maximilians University of Munich
Aktuelle Ernahrungsmedizin | Year: 2011

Next to minimizing complication rate and morbidity, enhanced recovery after surgery (ERAS) has become the focus of perioperative management. The recent ERAS (Enhanced Recovery After Surgery) and Fast Track concepts particularly emphasize the necessity of appropriate perioperative nutritional and metabolic care. Whenever possible, artificial nutritional support should be avoided. Therefore, early detection, observation, and adequate oral treatment of patients with nutritional risk remain an essential part of perioperative management. In risk patients, nutritional support should be started early and primarily via the enteral route, or in combination with parenteral nutrition. Long-term total parenteral nutrition will be limited to special indications. Individually calculated nutritional support is a clinically and economically highly effective support in order to reduce perioperative morbidity and mortality. This review includes the recent guideline recommendations for surgical patients of the German Society for Nutritional Medicine (DGEM) (www.dgem.de; www.awmf.org) and the European Society for Clinical Nutrition and Metabolism (ESPEN) (www.espen.org) from 2006 and 2009. © Georg Thieme Verlag KG Stuttgart · New York.


Haase O.,Charité - Medical University of Berlin | Langelotz C.,Charité - Medical University of Berlin | Scharfenberg M.,Fachabteilung Unfall und Arthroskopische Chirurgie | Schwenk W.,Klinik fur Allgemein und Visceralchirurgie | Tsilimparis N.,Charité - Medical University of Berlin
Langenbeck's Archives of Surgery | Year: 2012

Background: Heart rate variability (HRV) is a sensitive marker of altered sympathetic-parasympathetic function and is reduced in inflammation, illness, and trauma. The effect of major abdominal surgery on the course of HRV parameters is still an issue requiring further investigation. Materials and methods: A prospective, observational study including 40 consecutive patients undergoing elective colorectal surgery under "fast-track" perioperative management. Time and frequency domain parameters of HRV were measured 1 day prior to operation and on days 1-5 postoperatively. General and surgical complications as well as the course of leucocytes and C-reactive protein (CRP) were documented and correlated to the HRV measurements. Results: Time domain parameters of HRV showed a significant decrease compared to the preoperative values on postoperative day 1 and returned to baseline on day 2, demonstrating impaired autonomic regulation in the early postoperative period. No correlation to complications or course of leukocytes or CRP was significant in our study. Conclusions: Colorectal resections significantly influence the HRV course. The autonomic regulation is reduced in the early postoperative time and all parameters return to baseline until the third day. © Springer-Verlag 2011.


Weimann A.,Klinik fur Allgemein und Visceralchirurgie
World Review of Nutrition and Dietetics | Year: 2013

In aiming for enhanced recovery and the reduction of postoperative morbidity, enhanced recovery after surgery concepts have introduced a new era in perioperative management. It is frequently not recognized that the enhanced recovery after surgery protocol does not overcome the necessity for appropriate perioperative nutritional and metabolic care, particularly with those in intensive care. Early detection and preoperative conditioning of patients at nutritional risk remains essential. In patients at risk where inadequate oral intake is anticipated for a longer period, nutritional support should be started early via the enteral route, possibly in combination with parenteral nutrition. For early enteral nutrition in the intensive care unit, a slow increase in the administration rate is recommended while observing the enteral tolerance by abdominal distension and gastric aspirate. While the length of time before combining enteral and parenteral nutrition with the appropriate supplementation is still under debate, immunomodulating substrates and diets have proven benefits in surgical high-risk patients. Copyright © 2013 S. Karger AG, Basel.


Kolln A.,Klinik fur Allgemein und Visceralchirurgie
Coloproctology | Year: 2010

Endorectal sonography is a simple and dynamic procedure that has few side effects and can be performed as often as desired. It facilitates accurate localization of the pathological processes based on knowledge of anatomical structures and is valuable in making treatment decision during pre- and postoperative staging of rectal cancer. Endoanal sonography allows precise planning of sphincter-sparing surgery and planning of multimodal therapy. © 2010 Urban & Vogel, Muenchen Literatur:.


Weimann A.,Klinik fur Allgemein und Visceralchirurgie
Journal fur Gastroenterologische und Hepatologische Erkrankungen | Year: 2012

Focusing on enhanced postoperative recovery and rehabilitation, so-called ERAS or fast-track protocols as a treatment bundle have induced a revolution in surgery. Basic principle is the minimization of perioperative stress with fast mobilization and early oral feeding in order to achieve rehabilitation as early as possible. Successful ERAS is also related to a highly motivated patient. A recent metaanalysis of the available data has clearly shown significant advantages with regard to postoperative complication rate and length of hospital stay.


Weimann A.,Klinik fur Allgemein und Visceralchirurgie | Andra J.,Klinik fur Allgemein und Visceralchirurgie | Sablotzki A.,Klinik fur Allgemein und Visceralchirurgie
Deutsche Medizinische Wochenschrift | Year: 2011

The prognostic impact of inadequate energy and protein supply in malnourished intensive care patients has been recently reemphasized. Consent exists about the beneficial effects of early enteral nutrition in the critically ill. However, gastrointestinal intolerance of the critically ill may be a major problem for the feasibility of enteral nutrition bearing additional risks. In case adequate enteral nutrition cannot be realized, there is controversy about the appropriate time to start total parenteral or combined enteral / parenteral nutrition. Due to potential adverse effects immune-enhancing substrates have to be cautiously administered. For standardization implementation of a guideline based nutritional protocol is recommended. The review refers to the recent guidelines of the European Society for Clinical Nutrition and Metabolism (2009), the American Society for Parenteral and Enteral Nutrition (ASPEN) (2009) and the German Sepsis Society (DSG) (2010). © Georg Thieme Verlag KG Stuttgart - New York.


Weimann A.,Klinik fur Allgemein und Visceralchirurgie
Perioperative Medizin | Year: 2010

Aiming enhanced recovery and the reduction of postoperative morbidity ERAS and Fast Track concepts do not preclude the necessity of appropriate perioperative nutritional and metabolic care. Whenever possible, artficial nutritional support should be avoided. Therefore, the early detection and observation of patients with nutritional risk remains an essential part of perioperative management. In case inadequate oral intake has to be anticipated in risk patients, nutritional support should be started early via the enteral route, may be in combination with parenteral nutrition. Long term total parenteral nutrition will be limited to special indications. This review includes the recent guideline recommendations for surgical patients of the German Society for Nutritional Medicine (DGEM) (www.dgem.de; www.awmf@online.de) and the European Society for Clinical Nutrition and Metabolism (ESPEN) (www.espen.org) from 2006 and 2009. © 2010.


Weimann A.,Klinik fur Allgemein und Visceralchirurgie
Medizinische Klinik | Year: 2013

The review presents the concept of immunonutrition in enteral and parenteral nutrition of the critically ill. The present indications for supplementing immune enhancing and anti-inflammatory substances are summarized and discussed in accordance with the recent literature and guidelines. © 2013 Springer-Verlag Berlin Heidelberg.

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