Incidence of vein thrombosis in peripheral intravenous nutrition: effect of fat emulsions.

The relative risk of thrombophlebitis induced by either Long-chain Triglycerides (LCTs) or Medium-chain Triglycerides (MCTs) during peripheral i.v. nutrition (PIN) was evaluated. A total of 76 patients were randomly assigned into group A (n=40) and group B (n=36). The nutritional requirements in both groups were covered by a standardized regime of osmolality 1130 mOsm and pH 5.2, which provided 14 kg/day(-1) nitrogen, 600 kcal/day(-1) of carbohydrates and 1000 kcal/day(-1) of lipids. Group A received the lipids as pure LCTs while group B received a mixture of LCTs/MCTs at a ratio 1:1. The infused nutritional volume was 2000 ml and was delivered via a suitable vein in a proximal forearm, using a fine bore polyurethane 22G catheter. The two standardized regimes were evaluated over a 10 day period regarding the incidence of thrombophlebitis. The cumulative risk of thrombophlebitis was documented to be significantly lower in group A compared to group B (17.5% versus 44.4%, P < 0.05). LCTs appear to prolong peripheral vein feeding by lessening the reaction of venous endothelium to the irritating nutritional infusate.

Imaging findings in primary carcinoid tumour of the liver with gastrin production.

We present a 57-year-old man with Zollinger-Ellison syndrome who had undergone total gastrectomy 12 years previously. At that time, a cystic mass in the left lobe of the liver was palpated but was not removed. The patient currently had high serum gastrin levels. Abdominal ultrasound, CT and MR images showed a well defined liver mass with solid and cystic components. The lesion was resected and a primary hepatic carcinoid tumour was diagnosed. Post-operatively, serum gastrin levels were normal. A primary liver carcinoid may appear as multicystic liver mass with solid components. Careful exclusion of a primary tumour elsewhere is required to establish the diagnosis of this rare entity.

Long chain versus medium chain lipids in patients with ARDS: effects on pulmonary haemodynamics and gas exchange.

OBJECTIVE: To compare pulmonary haemodynamic and gas exchange alterations in septic patients with ARDS receiving long-chain triglycerides (LCT) versus medium-chain triglycerides (MCT). DESIGN: Prospective, randomised, clinical study. SETTING: Surgical ICU patients in a University Hospital. PATIENTS: Twenty-one septic patients with ARDS were randomly assigned to receive 50 % of their non-protein caloric requirements as either 20 % LCT (group 1, n = 10) or 20% 1:1 mixture of LCT/MCT (group 2, n = 11). INTERVENTION: Intravenous infusion of LCT and LCT/MCT combinations at a rate of 12 g x h(-1). MEASUREMENTS AND RESULTS: The LCT infusion was associated with an increase of pulmonary venous admixture (Qva/Qt) from 24 % +/- 5 % to 37 % +/- 6 %, an increase of mean pulmonary artery pressure (MPAP) from 25 +/- 5 to 33 +/- 4 mmHg and decrease of PaO2/FIO2 from 240 +/- 30 to 180 +/- 35. LCT/MCT administration was only associated with an elevation of oxygen consumption (VO2) from 329 +/- 14 to 396 +/- 12 ml/ min. During lipid infusion group 1 patients presented higher Qva/Qt (37% +/- 6% vs 25% +/- 4%), MPAP (33 +/- 4 vs 27 +/- 3 mmHg) and VO2 (359 +/- 11 vs 396 +/- 12 ml/min) and lower PaO2/FIO2 (180 +/- 35 vs 235 +/- 30) values compared to group 2. CONCLUSION: In conclusion, we have shown that, in septic patients with respiratory failure, LCT administration was associated with more significant changes of Qva/Qt, MPAP and PaO2/FIO2 compared to infusion of an LCT/MCT 1:1 emulsion. Clinically, these transient alterations might cause serious problems in patients with marginal arterial oxygenation and cardio-respiratory impairment.

Aggressive angiomyxoma of the pelvis: a clinicopathologic study of a case.

A case of aggressive angiomyxoma in a 38-year-old pregnant woman is described. These clinicopathologically distinctive soft tissue tumors comprise a quite rare entity. They are usually located in the pelvic or perineal soft parts and occur predominantly in women. On gross inspection, these lesions are typically soft bulky masses, frequently with a multilobulated contour and of gelatinous appearance. They are characterized by slow growth, infiltration of adjacent structures, absence of distant metastases and a tendency to recur locally, probably secondary to incomplete excision. Therefore, treatment should consist of wide surgical excision, as complete as technically possible. This is the second case of aggressive angiomyxoma of the pelvis occurring in a pregnant woman.

Perforated diverticulitis: a surgical dilemma.

Thirty-eight patients, 18 males and 20 females (mean age 61 years) have been operated on for perforated diverticulitis, over the past 14 years. We assigned the patients into stage A (n = 12) when the inflammation was confined to the mesosigmoid folds, stage B (n = 16) when an intraabdominal abscess was walled off and stage C (n = 10) when a generalized peritonitis had developed. Resection of the perforated sigmoid was carried out in 24 patients either as Hartmann's procedure (n = 18) or with primary anastomosis (n = 6). The mortality rate in this setting was 0.0% and 16.6% respectively. In 14 patients, no resection was carried out in 24 patients either drainage and colostomy (n = 10) or only drainage (n = 4) with corresponding mortality rate 30% and 25%. Mortality rate in relation to the stage was: Stage A 16.16%, Stage B 12.5% and Stage C 10%. The higher mortality rate in stage A and B was due to the fact that less radical operations were carried out. Four of our five deaths in all stages occurred in patients in whom the perforated sigmoid was not resected. In conclusion resection of the perforated sigmoid with or without primary anastomosis regardless of the stage of the disease is recommended.

Glucose-based versus fat-based total parenteral nutrition (TPN): effects on hepatic function in septic patients complicated with cholestatic jaundice.

A prospective study of two types of total parenteral nutrition (TPN) was carried out in 34 patients suffering from sepsis and complicated liver dysfunction. Group 1 (18 patients) received non-protein energy as glucose plus fat emulsion in a caloric ratio of 19:1, while group 2 (16 patients) received the same energy intake but with a ratio of 1:1. Group 1 exhibited higher levels of bilirubin and alkaline phosphatase with values of 93.5 +/- 25.5 mumol/l and 160 +/- 30 IU/l respectively compared to Group 2, in which the corresponding values were 81.6 +/- 32.3 mumol/l and 120 +/- 10 IU/l (p < 0.05). On the other hand, group 1 had lower levels of serum albumin and serum transferrin with values 25 +/- 1.3 g/l and 40 +/- 20% of normal, compared to group 2 in whom the corresponding values were 28 +/- 8 g/l and 48 +/- 30% of normal (p < 0.05). There were no differences between the two groups, in the absolute number of T-lymphocytes and in transaminase levels. In sepsis complicated by liver dysfunction a 50:50 glucose: fat regimen caused less disturbance of liver function than one consisting almost entirely of glucose.

EEA stapler in oesophagogastrectomies.

A retrospective study was conducted to evaluate the use of the EEA circular stapler in the construction of oesophagogastric anastomoses. Eighty five consecutive patients were subjected to oesophageal resections. There were 58 males and 27 females. The age ranged between 38 and 77 (mean 62) years and between 49 and 84 (mean 69) years respectively. In the first 19 patients the surgical approach was carried out via a Lewis' procedure and in the remaining 66 via a low left thoracotomy. The overall hospital mortality was 20%. Leakage related to mortality was found to be 4.7%. Mean operative time was estimated at a rate of 168 min (range: 120-360) and mean blood loss 434 ml (range: 250-1200). The mean postoperative stay was 15.3 days (range: 9-41). Benign anastomotic strictures occurred in 22% of the operated patients, all of whom responded well to dilation. By the aid of the EEA stapler, high and safe anastomoses can be carried out via a low left thoracotomy with acceptable morbidity and mortality.

Plasma level of the creatine phosphokinase BB isoenzyme during experimental intestinal ischemia.

Changes in the serum of CPK-BB isoenzyme were investigated in dogs with intestinal ischemia in order to determine their use as an enzymatic diagnostic test for bowel infarction. The study consisted of 12 mongrel dogs. Group I (n = 6) was assigned as a control and was subjected to lumen obstruction of a jejunal segment 50-60 cm in length. Group II (n = 6) had an intestinal infarction created by ligation of the arteries of a jejunal segment 50-60 cm in length. A catheter was placed into the right atrium through the left jugular vein for blood sampling and monitoring. Blood samples were withdrawn every three hours for biochemical assays. CPK-BB measurements were performed by electrophoresis in agarose gel. CPK-BB remained unchanged in Group I during the course of the study (median range 17 to 20 IU) showing no significant difference from normal levels. Significant elevation of CPK-BB occurred three hours after establishing the ischemia in Group II (median 50 IU) as compared to Group I (p less than 0.05). The highest levels were determined to be 96 and 80 IU at the sixth and ninth hour, respectively. From hour 15 until completion of the experiment, no significant difference was detected between Groups I and II. We conclude that CPK-BB elevation in serum signifies its release from the smooth muscles of the bowel due to ischemic cellular damage.

Postvagotomy diarrhoea put into perspective.

Truncal vagotomy and drainage is still the commonest operation for duodenal ulcer in the United Kingdom, despite its known association with diarrhoea. The frequency and severity of diarrhoea were compared in 102 randomly selected men 10 or more years after truncal vagotomy and pyloroplasty (TVP) and a control group of 62 men taking long-term maintenance cimetidine treatment 2 or more years after healing of duodenal ulcer. 53% of the TVP group still had diarrhoea attacks compared with only 7% of the cimetidine group (p less than 0.001). Of the TVP patients, 11% had continuous diarrhoea and a further 22% at least one attack a week. 24% were displeased with the change in bowel function, and 8% complained that diarrhoea still seriously affected their lives. This side-effect is unacceptable and truncal vagotomy should now be avoided whenever possible.