Aggressive management of surgical emergencies

Abstract

Increasing evidence suggests that two factors significantly influence outcome in a surgical emergency - premorbid health and the degree of inflammation during the first 24 h following trauma. Repeat observations suggest that the depth of post-trauma immunoparalysis reflects the height of early inflammatory response. Administration to surgical emergencies, as was routine in the past, of larger amounts of fluid and electrolytes, fat, sugar and nutrients seems counterproductive as it increases immune dysfunction, impairs resistance to disease and, in fact, increases morbidity. Instead, strong efforts should be made to limit the obvious superinflammation, which occurs during the first 24 h after trauma and, thereby, reduce the subsequent immunoparalysis. Several approaches show efficacy in limiting early superinflammation such as strict control of blood glucose, avoidance of stored blood when possible, supply of antioxidants, live lactic acid bacteria and plant fibres. This review focuses mainly on use of live lactic acid bacteria and plant fibres, often called synbiotics. Encouraging experience is reported from clinical trials in liver transplantation, severe pancreatitis and extensive trauma. Immediate control of inflammation by enteral nutrition and supply of antioxidants, lactic acid bacteria and fibres is facilitated by feeding tubes, introduced as early as possible on arrival at the hospital.

Figure 1

Histological sections of lungs 24 h after caecal ligation and puncture. (A) After placebo treatment; (B) after treatment with bioactive fibres; and (C) after treatment with live lactic acid bacteria and bioactive fibres. Reproduced with the permission of Dr Ozer Ilkgul, Izmir, Turkey.

Figure 1

Histological sections of lungs 24 h after caecal ligation and puncture. (A) After placebo treatment; (B) after treatment with bioactive fibres; and (C) after treatment with live lactic acid bacteria and bioactive fibres. Reproduced with the permission of Dr Ozer Ilkgul, Izmir, Turkey.

Figure 1

Histological sections of lungs 24 h after caecal ligation and puncture. (A) After placebo treatment; (B) after treatment with bioactive fibres; and (C) after treatment with live lactic acid bacteria and bioactive fibres. Reproduced with the permission of Dr Ozer Ilkgul, Izmir, Turkey.

Figure 2

The Bengmark flocare autopositioning regurgitation-resistant tube. (A) Photograph of the tube; (B) X-ray showing the tube in situ; (C) photograph of expanding tube coil in the small intestine; and (D) photograph at laparotomy showing the end of the tube and its coil anchored in the upper jejunum. (A) Reproduced with the permission of Nutricia BV, Amsterdam, The Netherlands; (B,C) reproduced with the permission of Dr Gerardo Mangiante, Verona, Italy.

Figure 2

The Bengmark flocare autopositioning regurgitation-resistant tube. (A) Photograph of the tube; (B) X-ray showing the tube in situ; (C) photograph of expanding tube coil in the small intestine; and (D) photograph at laparotomy showing the end of the tube and its coil anchored in the upper jejunum. (A) Reproduced with the permission of Nutricia BV, Amsterdam, The Netherlands; (B,C) reproduced with the permission of Dr Gerardo Mangiante, Verona, Italy.

Figure 2

The Bengmark flocare autopositioning regurgitation-resistant tube. (A) Photograph of the tube; (B) X-ray showing the tube in situ; (C) photograph of expanding tube coil in the small intestine; and (D) photograph at laparotomy showing the end of the tube and its coil anchored in the upper jejunum. (A) Reproduced with the permission of Nutricia BV, Amsterdam, The Netherlands; (B,C) reproduced with the permission of Dr Gerardo Mangiante, Verona, Italy.

Figure 2

The Bengmark flocare autopositioning regurgitation-resistant tube. (A) Photograph of the tube; (B) X-ray showing the tube in situ; (C) photograph of expanding tube coil in the small intestine; and (D) photograph at laparotomy showing the end of the tube and its coil anchored in the upper jejunum. (A) Reproduced with the permission of Nutricia BV, Amsterdam, The Netherlands; (B,C) reproduced with the permission of Dr Gerardo Mangiante, Verona, Italy.