The clear liquid diet is no longer a necessity in the routine postoperative management of surgical patients.

The reinstitution of oral intake in patients who have undergone intra-abdominal surgery has traditionally progressed in a stepwise fashion. Various retrospective studies and anecdotal reports have suggested that a "regular" diet as the first postoperative meal is well tolerated. Although clear liquids are accepted as the standard first postoperative meal, there appears to be little scientific data to support their use. The current study was undertaken to determine whether there is any difference in tolerance to clear liquids versus a regular diet as the first postoperative oral intake. This study is not intended to suggest that clear liquid diets harm patients but to attempt to support our hypothesis that a regular diet as the first postoperative meal is not associated with and increased morbidity. A total of 241 patients undergoing abdominal operations were prospectively randomized to receive either routine clear liquids (N=135) or regular diet (N=106) as the first oral intake. They were followed for any symptoms or signs of dietary intolerance. The group receiving a regular diet was not found to have any statistically significant increase in dietary intolerance in comparison with the clear liquid group. Nutritional data collected in a subset of patients revealed a higher caloric intake in those assigned to a regular diet. These results suggest that the routine use of clear liquids as the initial postoperative diet may be unnecessary and nutritionally suboptimal when compared with a regular diet.

Laparoscopic gastrostomy using four-point fixation.

Percutaneous endoscopic gastrostomy (PEG) has become an effective alternative to surgical gastrostomy in patients who require enteral access or gastric decompression. Technical considerations, however, limit the application of PEG in selected patients and those who have contraindications to PEG. Laparoscopic gastrostomy tube placement has been introduced as an alternative to PEG. A technique for laparoscopic gastrostomy tube placement that emphasizes four-point fixation of the anterior gastric wall is presented.

Cisplatin, 5-fluorouracil, mitomycin C, and concurrent radiation therapy with and without esophogectomy for esophageal carcinoma.

Twenty-nine patients with carcinoma of the esophagus were treated with 5-fluorouracil (5-FU) (1000 mg/m2/d as a continuous intravenous [IV]infusion on days 1 through 4), cisplatin (100 mg/m2 IV on day 1), mitomycin C (10 mg/m2 IV on day 1), and concurrent radiation therapy (4500 cGy/4.5 wk). If no disease progression was observed, operable patients underwent surgery 4 to 6 weeks after completion of radiation therapy. A thoracotomy with a gastric pull-through operation was performed in the first six patients. Subsequently, a transhiatal ("blunt") esophagectomy was used. Twenty-five patients had squamous cell histology and four had adenocarcinoma. Of 25 patients with squamous cell carcinoma, 13 underwent esophagectomy. The clinical complete response rate was 61% (eight of 13 patients), with a pathologic complete remission documented in five of 13 patients (38%). The overall local tumor sterilization rate was 53% (seven of 13 patients). In the 12 patients who did not undergo surgery after chemoradiotherapy, four had a complete clinical response (33%) and five had a partial response (41%). Symptoms or signs of local disease recurrence or stricture were noticed in ten of 12 patients who did not undergo surgery (83%), compared with 28% of patients who underwent surgery. The median survival time of the group receiving surgery was 10 months, compared with 5 months for those who did not undergo operation (P = 0.027). Patients undergoing transhiatal esophagectomy had shorter postoperative hospital stays and fewer serious complications, compared with patients undergoing transthoracic esophagectomy. The use of chemoradiotherapy and transhiatal esophagectomy for esophageal carcinoma should be evaluated using alternative sequences of treatment (e.g., postoperative therapy) to reduce toxicity while maintaining local control of disease.