Vernix caseosa peritonitis. An infrequent complication of cesarean section with distinctive histopathologic features.

The authors report two cases of vernix caseosa peritonitis, an infrequent complication of cesarean section with distinctive histopathologic findings. Both patients underwent exploratory laparotomy for unexplained abdominal pain after cesarean section. Histopathologic evaluation of surgically removed tissue revealed an organizing peritonitis, which included prominent collections of anucleate squamous cells in association with a foreign body-type granulomatous response. In both cases, the surgical pathologist suggested that the abdominal pain was likely a result of peritoneal reaction to spillage of keratinous material (vernix caseosa) derived from amniotic fluid contents during cesarean section. Surgical pathologists should be aware of this entity and include it in the differential diagnosis of acute abdominal pain.

Circulating prosomatostatin-derived peptides. Differential responses to food ingestion.

Prosomatostatin (pro-S) and its bioactive posttranslational products, somatostatin-14 (S-14), somatostatin-13 (S-13), and somatostatin-28 (S-28), were measured in human plasma by the use of immunoglobulins to the NH2-terminus of S-28 conjugated with agarose to separate them and, thereafter, by RIA with an antiserum recognizing the COOH-terminus of pro-S, and by specific RIA for the NH2-terminus of S-14 and pro-S. In healthy men, mean basal levels of pro-S were 4 pg equivalent S-14/ml; S-14/S-13 combined were 9 pg equivalent S-14/ml; and S-28 levels were 16 pg/ml. After a 700-kcal meal, pro-S, S-14, and S-14/S-13 did not change, whereas S-28 levels doubled by 120 min and remained elevated for 240 min. To evaluate the origins of these peptides, their levels were compared in peripheral, portal, gastric, and mesenteric veins of anesthetized patients and in patients with total resection of stomach and pancreas before and after nutrient intake. The stomach and small intestine were sources of both peptides; however, most S-28 originated in the small intestine. These findings suggest that, in contrast to S-14, S-28 is a hormone and may modulate postprandial nutrient absorption and use.

Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial.

Although enteral nutrition is considered more 'physiologic' than parenteral nutrition, there is greater published experience with parenteral nutrition in trauma patients. To compare the efficacy of these two techniques, we prospectively randomized multiple trauma patients during their admission laparotomy to receive either central venous parenteral nutritional (TPN: n = 23) or enteral nutrition by jejunostomy (Jej: n = 23). Nutritional support began on the first postoperative day; the study period continued a maximum of 14 days. There were no significant differences between the two groups in age, sex, injury severity, estimated caloric needs (3,322 TPN; 3,114 Jej), hours to achieve full prescription (77 PTN; 79 Jej), or the number of days on nutritional support (22 TPN; 25 Jej). Average daily caloric intakes, nitrogen balance results, and complication rates were also comparable. These results suggest that early postoperative jejunostomy feeding is a safe and efficacious choice for multiple trauma patients undergoing laparotomy.

Cimetidine clearance in the obese.

Six subjects with normal weight (mean weight = 62 kg) and six obese subjects (mean weight = 140 kg) were given a single intravenous cimetidine infusion of 600 mg over 10 to 15 minutes. Both groups of subjects had normal serum creatinine levels and were matched with respect to age, desirable body weight, height, renal function, and sex. Compared with subjects of normal weight, obese subjects had higher cimetidine systemic (1147 and 637 ml/min) and renal (808 and 318 ml/min) clearances. Volume of distribution at steady state was of the same order for the two groups (82 and 84 L), but the t 1/2 was shorter in the obese group (1.2 and 1.9 hr). Obese subjects had lower cimetidine sulfoxide serum concentrations and greater cimetidine sulfoxide renal clearance (856 and 509 ml/min). Cimetidine systemic clearance and cimetidine sulfoxide renal clearance values were of the same order in the two groups when normalized by the value of weight raised to the 0.76 and 0.5 powers. Under the assumptions of an average weight of 70 kg and that average serum concentrations produced by cimetidine, 300 mg iv every 6 hours, are appropriate, people with normal renal function and body weight usually receive 48 mg/day/weight0.76. This same dosage in obese individuals with normal serum creatinine values should result in the same average steady-state serum concentrations. In our obese subjects, the mean cimetidine dose would have been approximately 500 mg iv every 6 hours.

Anaesthesia in the morbidly obese. A comparison of anaesthetic and analgesic regimens for upper abdominal surgery.

Seventy morbidly obese patients presented for upper abdominal surgery; 17% had pre-existing cardiovascular disease and 23% pre-existing respiratory disease. Twenty-eight patients received general anaesthesia, plus narcotic analgesia postoperatively, and 42 general anaesthesia plus thoracic epidural analgesia intra- and postoperatively. Aspects of anaesthetic management are discussed and compared with previous similar reports. Doses of local anaesthetic for induction of epidural analgesia were less than those for the non-obese but doses of local anaesthetic for maintenance of epidural analgesia were similar to those in non-obese patients. Patients who had thoracic epidural analgesia required less volatile anaesthesia than the group who had general anaesthesia and narcotic analgesics. Postoperative respiratory complications were more common in patients with pre-existing cardiovascular and respiratory disease, and occurred less frequently in patients who had thoracic epidural analgesia.

Effect of acute ethanolism on the hospital course and outcome of injured automobile drivers.

Acute ethanolism in automobile drivers is purported to be both protective and detrimental in susceptibility to injury from an accident. The potential influence of acute intoxication (serum ethanol greater than 100 mg/dl) on pattern and severity of injury, hospital course, and long-term outcome, including mortality, was examined in 182 consecutive automobile drivers requiring admission to a regional university trauma center during 1980. Significantly more drivers were intoxicated than not, 61% vs. 39%. Similarly, more than 75% of the intoxicated drivers were young males and more than 80% of the intoxicated drivers were felt to be negligent and at cause for the accident. However in this series, the patterns and severity of injuries, hospital course, and late outcome were unaffected by the patient's blood alcohol level. Acute alcohol intoxication apparently neither protected nor hindered the response to injury in these motor vehicle drivers.

Influence of weight on aminoglycoside pharmacokinetics in normal weight and morbidly obese patients.

Aminoglycoside pharmacokinetics were determined in 30 normal weight patients and 30 morbidly obese patients (greater than 90% overweight). All had normal renal function and a gram-negative infection (documented by cultures, fever and elevated white blood cell counts) which was treated only with aminoglycoside antibiotics. The normal weight and morbidly obese patients were matched with respect to the following criterion: age, sex, ideal body weight (IBW), serum creatinine, site of infection, and type of aminoglycoside antibiotic (gentamicin, tobramycin, or amikacin). The results were similar for all 3 drugs. Average half-life was 2 h for both the morbidly obese and normal weight patients. The mean volumes of distribution and clearances were significantly larger in the morbidly obese (23.3 l and 135.8 ml/min for gentamicin, 29.9 l and 162.4 ml/min for tobramycin, and 26.8 l and 157.3 ml/min for amikacin) than in normal weight patients (17.0 l and 95.9 ml/min for gentamicin, 18.3 l and 101.3 ml/min for tobramycin, and 18.6 l and 99.2 ml/min for amikacin). As a result of altered aminoglycoside pharmacokinetics, morbidly obese patients required significantly larger mean doses (540 mg/d for gentamicin, 690 mg/d for tobramycin and 1970 mg/d for amikacin) when compared to the normal weight patients (380 mg/d, 420 mg/d and 1420 mg/d, respectively; p less than 0.005) in order to achieve comparable serum concentrations.

Anergy in high-risk surgical patients: the role of parenteral nutrition.

The finding of delayed hypersensitivity on skin testing has been used to predict the outcome following operations, traumas or severe illnesses and has been correlated with nutritional status in some reports. To test these hypotheses, we did weekly skin tests with a battery of four antigens on 98 high-risk patients referred to the nutritional support service. Anergy persisted or developed in 72 patients, whereas 26 patients remained or became reactive. These two groups were comparable in number of days in hospital, age and amount and duration of parenteral nutrition. Infectious complications (68 percent versus 23 percent, P<.001), sepsis (35 percent versus 12 percent, P<.01) and mortality (33 percent versus 0 percent, P<.001) were more prevalent in anergic than in reactive patients. There was no correlation between nitrogen balance studies and skin test results. In most instances conversion of skin test results occurred as a consequence of appropriate surgical care rather than nutritional support. Whereas nutritional support is required in these high-risk patients, anergy should not be the sole indicator for giving nutritional support or delaying an operation.

Pancreatitis associated with primary hyperparathyroidism.

Two series of patients treated for primary hyperparathyroidism are reviewed for the incidence of associated pancreatitis. In an earlier series of 150 hyperparathyroid patients, six had documented pancreatitis as one of the primary clinical manifestations. Review of a more recent series failed to uncover a single case of pancreatitis in 26 patients with primary hyperparathyroidism. The incidence of pancreatitis associated with hyperparathyroidism appears to be steadily decreasing, possibly reflecting the earlier diagnosis of parathyroid disease, which is due to widespread screening testing methods currently available.

Use of op site as an occlusive dressing for total parenteral nutrition catheters.

A retrospective study of standard hyperalimentation catheter dressing compared to the use of Op Site has demonstrated that Op Site is cost and time effective and is efficacious for attaining a low catheter sepsis rate. It is easy for nursing personnel to apply and comfortable for the patients to wear. Op Site may be contraindicated in diaphoretic patients.

Complications of emergency stoma formation.

Emergency stoma formation in the high-risk patient is a morbid procedure. In a series of 51 stomas in 49 nonelective operative procedures, a morbidity of more than 50% was retrospectively identified. Nine (18%) of 49 patients died, and four (8%) of these patients died of complications directly related to stomal failure or formation. The unplanned nature of the operation and technical difficulties during formation contribute to this overall result. Attention to detail during and after the operative event may help improve the complication rate associated with emergency intestinal stoma formation.

Gastroplasty in patients with symptoms of reflux esophagitis.

Forty-one patients underwent gastroplasty by the technique of Gomez and has at least one year of follow-up study. Fifteen patients had symptoms of reflux esophagitis preoperatively. At present, only two have symptoms of reflux esophagitis and both were free of symptoms until reversal of the gastroplasty. pH studies of the proximal pouch were performed preoperatively and postoperatively in 14 patients. There was a significant increase in proximal pouch pH after gastroplasty. Following gastroplasty, there is an immediate decrease in acid reflux and symptom reduction is observed to last at least one year. Patients with reflux esophagitis should not necessarily be excluded from consideration for gastroplasty.

Natural history of incidental appendectomy in patients with Crohn's disease who required subsequent bowel resection.

The records of 20 patients with Crohn's disease who underwent incidental appendectomy and later required bowel resection were reviewed and the following conclusions ascertained. If the patient had had abdominal pain for less than 1 week, appendectomy is followed by minimal problems. If the patient has had abdominal pain for longer than 1 week, incidental appendectomy is followed by an 83 percent incidence of fistula or sinus tract, arising not from the appendiceal stump but from the terminal ileum. The natural history of patients with resection after appendectomy includes more medication and a higher symptom recurrence rate and perhaps operative recurrence rate than their counterparts who have not undergone incidental appendectomy.

Boerhaave syndrome. Successful conservative management in three patients with late presentation.

Three patients with Boerhaave syndrome were successfully managed with nonoperative treatment. The diagnosis was delayed 5 days in one patient and 10 days in the other two. None of the patients appeared septic. Their conditions had been misdiagnosed as myocardial infarction, pneumonia and pulmonary embolism. Treatment consisted of intravenous hyperalimentation and administration of antacids and antibiotics. Cimetidine was also used in one patient. Two patients were discharged 14 days after diagnosis and the third on the 20th hospital day. Follow-up barium swallows showed complete healing in 2 months in all three patients. Conservative management of spontaneous esophageal perforation is feasible when (1) the perforation is already 5 days old, (2) there are no signs of severe sepsis, (3) esophageal barium study shows a wide-mouthed cavity draining freely back into the esophagus, and (4) the pleural space is not contaminated. When the diagnosis is made promptly, surgical therapy remains the treatment of choice, and patients managed conservatively who show signs of sepsis should be operated on without hesitation. Follow-up esophageal evaluation should be performed to confirm complete healing and to evaluate underlying disease.

Gastric pH monitoring as a prognostic indicator for the prophylaxis of stress ulceration in the critically III.

Previous studies have documented the efficacy of prophylaxis in the prevention of stress ulceration and bleeding in critically ill patients. In an effort to determine whether all critically ill patients require prophylaxis, 144 patients admitted to an intensive care unit were monitored by continuous indwelling nasogastric or gastrostomy tubes. Any patient with a measured gastric pH of less than 4 was treated with prophylactic cimetidine or antacids to maintain a pH of 4 or greater. One hundred twenty-three (85 percent) met this criterion. The gastric pH of 21 patients (15 percent) never fell below 4 during continuous monitoring for 26+/- 4.2 hours. There was a significantly lower incidence of hypotension and respiratory failure in this group ( pl < 0.05). Mortality was higher in the patients who required prophylaxis (15 percent) than in those who did not (0 percent). No bleeding was encountered in any patient in either group. These data suggest that patients who do not require prophylaxis may be determined by continuous monitoring of intragastric pH. If, within 24 hours, intragastric pH does not fall below 4, minimal indications for prophylaxis exist. Intragastric pH monitoring is a simple, effective tool in the care and management of critically ill or traumatized patients.

Trauma to major visceral veins: an underemphasized cause of accident mortality.

In the period 1970-1978, a mortality rate of 44% resulted in 45 patients who suffered major intra-abdominal venous injuries. An especially grave prognosis accompanied wounds to the inferior vena cava and the hepatic and portal venous systems. Management of damage to major veins presents several difficulties. Exposure is poor; veins tear easily when clamped or sutured; exsanguination can occur as rapidly as with arterial trauma; because of low intraluminal pressure, postoperative chances of thrombosis and occlusion are high; veins (unlike arteries) have no intrinsic vasomotor capabilities to halt bleeding. Finally, the misconception persists that venous wounds are less serious than comparable arterial injuries. Simple pressure by packs or hand often controls bleeding: otherwise clamps, balloons, hemostats, or ligation can be selectively chosen. Our experience suggests that atrial-caval shunting without prior identification and control of the bleeding site is doomed to failure.

Preoperative CEA level: a prognostic test in patients with colorectal carcinoma.

Preoperative and postoperative carcinoembryonic antigen (CEA) levels were evaluated in 42 patients with colorectal carcinoma. Preoperative CEA values correlated inversely with survival at a statistically significant level and provided prognostic information not available by pathologic staging. Postoperative plasma CEA can accurately predict recurrent disease and may, when serial values are elevated, serve as an indication for a second-look procedure.

Randomized prospective evaluation of cimetidine and antacid control of gastric pH in the critically ill.

One hundred forty-four critically ill patients admitted to an intensive care setting were randomly assigned to cimetidine or antacid treatament groups. Gastric pH was monitored hourly. One hundred twenty-three (85%) patients demonstrated a fall in pH to less than 4 and were considered to require prophylaxis. Prophylaxis was considered adequate if the measured pH could then be maintained at greater than or equal to 4. Fifty-eight patients received antacids alone, the average requirement being 41 cc/hour. Sixty-five patients received cimetidine. Seventeen (26%) of the cimetidine prophylaxis patients failed to raise their pH and were than placed on hourly administration of antacid with successful elevations of pH to greater than or equal to 4 in all cases on an average supplementary dose of 53 cc/hour. Risk factors, including sepsis, hypotension, head injury, respiratory failure, degree of trauma, and age, were not statistically different in the two treated groups. Using these same criteria, responders to cimetidine could not be differentiated from nonresponders. All patients were protected from significant stress bleeding while on this study. Significant complications of either treatment were minimal. Antacids offered consistent protection against gastric acidity and were 100% effective. A routine schedule of 300 mg every six hours of cimetidine was effective in only 47% of patients, and the maximum dose of cimetidine was effective in only 74% of patients. Hourly measurement of intragastric pH is required for monitoring the response to prophylaxis of stress bleeding in severely ill patients.

Crohn's disease in the older patient.

The progress of 141 consecutive patients with Crohn's disease, operated upon by the same surgeons, was examined. Patients were compared by age of onset of the disease. Few patients with Crohn's disease were older than 50 years of age and even less had a diagnosis after this age. Nevertheless, there are certain features that appear to single out these patients. It appears that Crohn's disease in patients older than 50 years in whom the disease was diagnosed before the age of 50 years, mimics that of the younger patients. An operative recurrence is not common and the mortality minimal. Patients in whom the disease is diagnosed after the age of 50 years have a relatively short duration of symptoms, no fistulas and no hydronephorosis; hemorrhage was a more common indication for operation than was intractability. These patients have just as severe a course, if not more so, than the younger patients with a marked operative recurrence and complications requiring reoperation and a significant mortality. Subsequent to all operations, all these older patients still require medical treatment and, yet, are symptomatic.