Septic complications after splenectomy for sickle cell sequestration crisis.

Patients with sickle cell disease (SCD) are predisposed to infections. There is a paucity of recent information on the incidence of post-splenectomy infectious complications in these patients. The purpose of this study was to determine whether splenectomy increases infectious complications in SCD. Twenty-nine patients with SCD had splenectomy for sequestration crises at our hospital between 1988 and 1992; 16 of them received all of their follow-up care at our institution. These 16 charts were reviewed for infectious-related admissions, hospital days, days of i.v. antibiotics, positive cultures, and episodes of sepsis. For each patient, these parameters in the pre- and postoperative period were compared and expressed as number per year. The mean age at time of splenectomy was 2.5 +/- 0.4 years and the mean follow-up was 4.5 +/- 0.4 years. There was no significant difference in the pre- and postoperative periods for admissions, hospital days, days of i.v. antibiotics, positive cultures, or episodes of sepsis per year. There were also no operative deaths. The incidence of pre-splenectomy sepsis was 0.04 +/- 0.03 episodes per year compared to 0.09 +/- 0.04 (P = ns) episodes/year after splenectomy. Sepsis occurred at an average of 20.8 (range 2-30) months postoperatively; Streptococcus pneumoniae was the most common causative organism. The total mortality after splenectomy in SCD patients was 3.4% (1/29) over a nearly 5-year period. Although infections are common in children with SCD, there was no increase in infections or episodes of sepsis in SCD patients who underwent splenectomy.

Growth hormone, glutamine, and a modified diet enhance nutrient absorption in patients with severe short bowel syndrome.

BACKGROUND: Massive loss of intestinal surface area results in the short bowel syndrome characterized by malabsorption of fluid, electrolytes, and other nutrients. Although the remaining bowel undergoes morphological and functional adaptation, often these changes are inadequate to support the individual by enteral feedings, and parenteral nutrition is required to prevent dehydration, electrolyte disturbances, and malnutrition. Substances such as growth hormone, glutamine, and fiber exert bowel-specific trophic effects and either directly or indirectly influence nutrient absorption. This study was undertaken to determine whether the co-administration of exogenous growth hormone, supplemental glutamine, and a modified fiber-containing diet could enhance nutrient absorption in patients who had undergone massive intestinal resection. METHODS: Ten patients (5 men, 5 women, aged 43 +/- 4 years) with short bowel syndrome were studied 6 +/- 1 years after surgical resection. All patients were admitted to the Clinical Research Center for a 28-day period; the first week served as a control period when nutritional (enteral and parenteral) and medical management simulated usual home therapy. Thereafter, eight patients received exogenous growth hormone, supplemental glutamine, and a modified high-carbohydrate, high-fiber diet. Two patients were treated with the modified diet alone. The efficiency of net nutrient absorption (percent absorbed) for total calories, protein, fat, carbohydrate, water, and sodium was calculated from the measured nutrient intake and stool losses. RESULTS: Three weeks of treatment with growth hormone, glutamine, and a modified diet increased total caloric absorption from 60.1 +/- 6.0% to 74.3 +/- 5.0% (p < or = .003), protein absorption from 48.8 +/- 4.8% to 63.0 +/- 5.4% (p < or = .006), and carbohydrate absorption from 60.0 +/- 9.8% to 81.5 +/- 5.3% (p < or = .02). Fat absorption did not change (61.0 +/- 5.3% to 60.3 +/- 7.9%, p = NS). Water and sodium absorption increased from 45.7 +/- 6.7% to 65.0 +/- 7.3% (p < or = .002) and from 49.0 +/- 9.8% to 69.6 +/- 6.5% (p < or = .04), respectively. These absorptive changes resulted in a decrease in stool output (1,783 +/- 414 g/d control period vs 1,308 +/- 404 g/d third week of treatment, p < or = .05). Treatment with diet alone did not influence nutrient absorption or stool output. CONCLUSIONS: The combined administration of growth hormone, glutamine, and a modified diet enhanced nutrient absorption from the remnant bowel after massive intestinal resection. These changes occurred in a group of patients that had previously failed to adapt to the provision of enteral nutrients. This therapy may offer an alternative to long-term dependence on total parenteral nutrition for patients with severe short bowel syndrome.

Recurrence of sigmoid volvulus after surgical intervention.

Little attention has been focused on the recurrence rate of sigmoid volvulus after surgical therapy. Consequently, we reviewed the longterm post-operative course of 29 patients who underwent surgery for sigmoid volvulus. The overall recurrence rate was 36 per cent, with recurrences occurring in 7 of 19 patients who underwent sigmoid colectomy and anastomosis; 1 of 5 patients undergoing sigmoid colectomy and end colostomy; and 2 of 4 patients undergoing laparotomy without resection. Although the recurrence rate varied slightly according to the operative procedure performed, the major variable was the degree of colonic involvement, since patients whose disease was limited to the sigmoid colon had a 6 per cent recurrence rate compared to 82 per cent for those with associated megacolon (p = .005). In patients with megacolon treated by subtotal colectomy, no recurrences were documented. Therefore, subtotal colectomy should be considered as the surgical procedure of choice in patients with sigmoid volvulus with associated megacolon.

Anabolic therapy with growth hormone accelerates protein gain in surgical patients requiring nutritional rehabilitation.

OBJECTIVE: The authors investigated the effects of exogenous growth hormone (GH) on protein accretion and the composition of weight gain in a group of stable, nutritionally compromised postoperative patients receiving standard hypercaloric nutritional therapy. SUMMARY BACKGROUND DATA: A significant loss of body protein impairs normal physiologic functions and is associated with increased postoperative complications and prolonged hospitalization. Previous studies have demonstrated that standard methods of nutritional support enhance the deposition of fat and extracellular water but are ineffective in repleting body protein. METHODS: Fourteen patients requiring long-term nutritional support for severe gastrointestinal dysfunction received standard nutritional therapy (STD) providing approximately 50 kcal/kg/day and 2 g of protein/kg/day during an initial 7-day equilibrium period. The patients then continued on STD (n = 4) or, in addition, received GH 0.14 mg/kg/day (n = 10). On day 7 of the equilibrium period and again after 3 weeks of treatment, the components of body weight were determined; these included body fat, mineral content, lean (nonfat and nonmineral-containing tissue) mass, total body water, extracellular water (ECW), and body protein. Daily and cumulative nutrient balance and substrate oxidation studies determined the distribution, efficiency, and utilization of calories for protein, fat, and carbohydrate deposition. RESULTS: The GH-treated patients gained minimal body fat but had significantly more lean mass (4.311 +/- 0.6 kg vs. 1.988 +/- 0.2 kg, p < or = 0.03) and more protein (1.417 +/- 0.3 kg vs. 0.086 +/- 0.1 kg, p < or = 0.03) than did the STD-treated patients. The increase in lean mass was not associated with an inappropriate expansion of ECW. In contrast, patients receiving STD therapy tended to deposit a greater proportion of body weight as ECW and significantly more fat than did GH-treated patients (1.004 +/- 0.3 kg vs. 0.129 +/- 0.2 kg, p < 0.05). GH administration altered substrate oxidation (respiratory quotient = 0.94 +/- 0.02 GH vs. 1.17 +/- 0.05 STD, p < or = 0.0002) and the use of available energy, resulting in a 66% increase in the efficiency of protein deposition (13.37 +/- 0.8 g/1000 kcal vs. 8.04 g +/- 3.06 g/1000 kcal, p < or = 0.04). CONCLUSIONS: GH administration accelerated protein gain in stable adult patients receiving aggressive nutritional therapy without a significant increase in body fat or a disproportionate expansion of ECW. GH therapy accelerated nutritional repletion and, therefore, may shorten the convalescence of the malnourished patient requiring a major surgical procedure.

The incidence of recurrent penetrating trauma in an urban trauma center.

In spite of the fact that penetrating trauma is an increasingly frequent cause of death and disability in America, little epidemiologic information is available on the recurrence rate or natural history of patients sustaining such injuries. The current study therefore was carried out to determine the recurrence rate of penetrating trauma in our institution. During the 12-month study period (August 1984 through July 1985), 556 (2%) of the 26,728 patients examined in our surgical emergency department had sustained penetrating trauma. After excluding patients who died at the time of their original injury and patients whose records were incomplete, 389 (70%) of the 556 patients were available for analysis. As of January 1990, 127 (32.6%) of the 389 patients had sustained two or more documented episodes of penetrating trauma. The incidence of recurrent penetrating trauma in the patients treated and released from the emergency department (35%) was similar to that of the patients requiring admission for their index injuries (31%). Based on the fact that the incidence of recurrent trauma was highest in men (p less than 0.01), blacks (p less than 0.01), and the uninsured (p = 0.03), it appears that recurrent penetrating trauma is a major societal as well as a medical problem.

Sodium oxalate corrects calcium interference in Lowry protein assay.

We have previously noted that high levels (10 mM) of calcium interfere with protein determination in the Lowry assay. While there are numerous reports in the literature of substances interfering with the Lowry assay, none of these interfering substances are as ubiquitous as calcium. We hypothesized that physiologic levels of calcium may interfere with the protein determination as measured by the Lowry assay. To test this hypothesis, bovine serum albumin standards from 12.5 to 1600 micrograms/ml were tested in the Lowry assay in the presence of calcium chloride concentrations from 0 to 5 mM. In low protein concentrations (12.5-50 micrograms/ml) 1 to 2 mM calcium induced errors of up to 384%. In samples containing 100 to 400 micrograms/ml protein, 1 to 2 mM calcium induced errors of up to 40%. The addition of sodium oxalate to calcium-spiked protein samples significantly reduced the errors in protein determination at all calcium concentrations tested. This effect also is seen throughout the range of protein concentrations tested (50-1600 micrograms/ml). In most cases sodium oxalate pretreatment of samples used in the Lowry assay reduces errors by 70-95%. Physiologic levels of calcium induce significant errors in the estimation of protein concentration using the Lowry method. Routine pretreatment of Lowry samples with sodium oxalate will provide a more accurate estimation of the protein concentration in biological systems.