Randomized double-blind placebo-controlled trial of early octreotide in patients with postoperative enterocutaneous fistula.

Somatostatin and octreotide both enhance closure of gastrointestinal fistulas. The present trial was undertaken to test whether early combined treatment with parenteral nutrition and octreotide 100 micrograms every 8 h by subcutaneous injection had a beneficial effect compared with parenteral nutrition plus placebo. Thirty-one patients with post-operative gastrointestinal or pancreatic fistula were randomly assigned to receive parenteral nutrition plus octreotide (14 patients) or placebo (17) within 8 days of fistula onset. The percentage reduction in output and rate of spontaneous closure within 20 days were analysed. Mean(s.d.) reduction in output was similar after octreotide and placebo at 24 h (66(43) versus 68(47) per cent, P = 0.9), 48 h (60(46) versus 57(43) per cent, P = 0.8) and 72 h (62(50) versus 66(49) per cent, P = 0.9) after starting the combined treatment. Closure within 20 days was observed in eight of 14 fistulas in patients given octreotide and in six of 17 in those receiving placebo (P = 0.4). Administration of octreotide, within 8 days of fistula onset, associated with parenteral nutrition does not significantly increase the spontaneous fistula closure rate compared with parenteral nutrition plus placebo.

[Role of preoperative nutritional status on postoperative morbidity]. / Influence de l'état nutritionnel préopératoire sur la morbidité postopératoire.

Correlations between preoperative nutritional status on the one hand and postoperative morbidity and mortality on the other hand were reviewed in articles from literature. The inclusion criteria for analysis were the following: large series, well defined nutritional status, major surgery, objective evaluation of postoperative complications and relevant statistical analysis. This study considered factors supposed to alter this correlation, namely the type of primary disease, intensity of denutrition, obesity, site and grade of cancer and age. There was a highly significant correlation between preoperative denutrition and postoperative morbidity and mortality. This correlation was existing whether operation was performed on the gastrointestinal tract or not, whether the primary disease was a cancer or not. The more important the denutrition, the more frequent the postoperative complications and deaths. Morbidity and mortality rates were linearly correlated to denutrition. After head and neck surgery for malignant diseases, malnourished elderly patients had poor prognosis. Obesity had the same prognostic value as denutrition.

Influence of epidermal growth factor and interferon gamma on healing of oesophageal corrosive burns in the rat.

A study was performed to attempt to modify the healing response to severe oesophageal corrosive burns to prevent complications. The study was performed on four groups each of 15 Wistar rats: a control group, an untreated group and groups given epidermal growth factor (EGF) alone or EGF for 5 days and interferon (IFN) gamma from the sixth to 20th day. In the last three groups an oesophageal lesion was induced with 2.5 mol l-1 sodium hydroxide solution. The efficacy of treatment was assessed on days 2, 5 and 20 by measurement of weight gain, oesophageal internal lumen, stenosis index (wall thickness: lumen diameter) and collagen production. On day 5, collagen synthesis was significantly (P < 0.05) higher in rats given EGF than in the untreated group. On day 20, no significant difference was seen in weight gain between the control rats and either treated group and stenoses were present in all untreated rats and in none of the treated group. The stenosis index on day 20 was lower in the groups given EGF and EGF-IFN-gamma than in untreated rats (P < 0.05) and collagen production was significantly (P < 0.05) lower in the group given EGF and IFN-gamma than in the other animals. The sequential use of EGF and IFN-gamma significantly reduced the frequency of residual stenosis.

[Treatment of caustic burns of the esophagus with interferon gamma. Comparison with epidermal growth factor. Experimental study in rats]. / Traitement des brûlures caustiques de l'oesophage par l'interféron gamma. Comparaison avec l'epidermal growth factor. Etude expérimentale chez le rat.

OBJECTIVES: Effects of sequential use of epidermal growth factor followed by interferon gamma on healing response after severe oesophageal corrosive burns has been demonstrated. This sequential treatment improves the inflammatory response of the initial phase and prevents residual stenosis. The aim of this study was to evaluate the use of interferon gamma alone in the same condition. METHODS: The study was performed in 5 groups (n = 15) of Wistar rats: control, placebo, epidermal growth factor alone, interferon gamma alone and epidermal growth factor for 5 days followed by interferon gamma from the 6th to 20th day. The last 4 groups had an oesophageal injury caused by a solution of 2.5 N NaOH. The efficacy of treatment was assessed on days 2, 5 and 20 on: weight gain, oesophageal internal lumen, stenosis index: wall thickness/lumen diameter, collagen production. RESULTS: Interferon gamma significantly reduced residual stenosis frequency while it did not improves the initial healing process. A complete effect on the two healing phases was only observed in animals having the sequential treatment. CONCLUSIONS: These results could lead to clinical trial in man to evaluate efficacy of sequential treatment with epidermal growth factor-interferon gamma in oesophageal corrosive burns.

[Vitamins A and E in digestive cancers]. / Vitamines A et E dans les cancers digestifs.

Vitamins A and E, transthyretin (TT) and retinol binding protein (RBP) plasma levels were assayed in 70 patients having a recently diagnosed digestive cancer and in 116 controls. After adjustment for sex and age, vitamin A or RBP and TT were found lowered in digestive cancer but vitamin E was lowered only in esophagus cancer. The relationship of vitamin levels to the relative risk of digestive cancer was calculated by multiple logistic conditional regression. TT level remained the only significant parameter. Since TT levels are strongly influenced by the nutritional status of patients, our results suggest that the decreased blood levels of vitamin A and its carriers observed in digestive cancer are the consequence of nutritional alterations evoked by the disease.

Vitamin A, vitamin E, retinol binding protein (RBP), and prealbumin in digestive cancers.

The existence of a relation between vitamin A and vitamin E and human cancers is supported by epidemiologic investigations. The aim of this study is to link the level of these vitamins to those of plasmatic protein carriers like retinol binding protein (RBP) and prealbumin (TTR), in three groups of subjects: healthy patients (n = 78), polyp (n = 34) and digestive cancer patients (n = 70). A paired t-test did not reveal any significant variation in any parameter between the polyp group and controls, but did evidence a significant decrease in serum levels of retinol (p less than 2.10(-4], RBP (p less than 2.10(-4), TTR (p less than 10(-5), and alpha-tocopherol (p less than 2.10(-3), in cancer cases as against control subjects. Comparison of RBP renal clearance and retinol tissue clearance in cancer and healthy patients indicates that the decrease in circulating retinol levels cannot be attributed to an increase in peripheral consumption. The simultaneous reduction of RBP and TTR serum levels is to be considered as a sign of protein denutrition. Thus our results suggest that the decrease serum levels of vitamins A and E observed in digestive cancers are a consequence of this nutritional deficiency.

Mechanism of thrombogenesis during total parenteral nutrition: role of catheter composition.

Catheter material is considered as one of the main factors of deep venous thrombosis during parenteral nutrition. The effects of five types of catheters (polyethylene, polyurethane, silicone, TFE Teflon, and FEP Teflon) on the vein wall and on the blood flow were compared. Experiments were performed on rabbits in which catheters were inserted into the vena cava. Five series of experiments were performed, each including five animals with the same type of catheter. After 10 days, venograms of the vena cava were performed, animals were then killed and the vena cava was removed with the catheter in situ. The vein and the catheter were macroscopically examined; in cases with thrombosis the clot was weighed. The vein wall and the catheter were examined by conventional microscopy and by electron microscopy, respectively. Obstruction of the venous lumen were significantly more frequent with the rigid catheters than with the soft catheters (p less than 0.001). The most extensive thromboses occurred with the Teflon catheters. The incidence of fibrin sleeves was significantly higher with the soft catheters than with the rigid ones (p less than 0.01). The venographic and macroscopic findings were in agreement in 60-100% of the cases according to the degree of venous obstruction. Catheter surfaces remained unchanged in all cases. The polyethylene catheters induced the most severe intimal inflammatory reactions. Thrombus formation was caused by two mechanisms depending on catheter composition: (1) turbulence caused by the catheter in the blood stream, and (2) platelet aggregation and subsequently, fibrin deposition on the surface of the catheter.

Treatment of external gastrointestinal fistulas by a combination of total parenteral nutrition and somatostatin.

Thirty-seven patients with external gastrointestinal fistulas were treated with a combination of total parenteral nutrition (TPN) and somatostatin (ST). There was a significant fall in fistula output within the first day of treatment (p less than 0.001). On the first day of combined therapy, the reduction of fistula output was 70%, and in 68% of the cases, the fistula output fell to less than 50% of the initial level. Spontaneous closure was observed in 82% of the cases, and the time taken to close the fistula ranged between 1 and 14 days of starting therapy [5.4 +/- 0.7 days (mean +/- SEM)]. The response to TPN-ST treatment occurred, irrespective of age and sex of patients, duration and daily output of the fistulas before ST use, and their location in the gastrointestinal tract. Infection of fistula output was a factor of adverse prognosis. In all cases, and in the absence of mechanical obstacles, treatment that combines TPN and ST could be tried and continued up to 14 days in cases in which the fistula output falls more than 50% on the first day of treatment.

Ultrasonographic study of gallbladder motility during total parenteral nutrition.

Gallbladder sludge during total parenteral nutrition may be related to abnormal gallbladder motility. To test this hypothesis, gallbladder motility was assessed in 15 parenterally fed patients and in 22 controls using ultrasonography. Parenteral infusion was continuous in 10 cases and cyclic in 5 cases (6 PM to 10 AM). Gallbladder was simulated to a cone and gallbladder volume was calculated after ultrasonographic measurement of the greatest length and diameter. Six to 12 gallbladder volume measurements were performed between 8 AM and 11 PM in the parenteral nutrition group. In controls gallbladder volume was measured hourly between 8 AM and 8 PM. Thus maximal diurnal gallbladder volume and maximal diurnal gallbladder emptying, expressed as a percentage of maximum gallbladder volume, were determined. Maximal gallbladder volume was identical in the two groups. Gallbladder emptying was significantly reduced in parenterally fed patients (p less than 10(-9)) during both continuous and cyclic infusion.

Experimental approach to prevention of catheter-related central venous thrombosis.

The role of catheter material in the formation of deep venous thrombosis during parenteral nutrition has been widely emphasized. Systematic venograms show central venous thrombosis in 20 to 33% of cases with polyethylene catheters and in 4% of cases with silicone catheters. Heparin infusion through the catheter diminishes but does not totally eliminate the risk of thrombosis. The aim of this study was to define the conditions under which the risk of thrombophlebitis was minimal. Four series of experiments were carried out, each on five rabbits. Catheters were inserted into the vena cava and, after 10 days, venograms were performed. The animals were then sacrificed, and the vena cava was macroscopically and microscopically studied. Plastic catheters were used in the first series, heparin-Benzalkonium-bonded plastic catheters in the second, silicone catheters in the third, and heparin-Benzalkonium-bonded silicone catheters in the fourth. The results revealed thrombosis of the vena cava and a fibrin sleeve around the catheters in series 1; thrombosis of the vena cava in series 2; a fibrin sleeve around the catheters in series 3; and neither thrombosis nor a fibrin sleeve in series 4. In conclusion, heparin-Benzalkonium-bonded silicone catheters appear to provide the best protection against thrombophlebitis by reducing the damage caused to the intima by the catheters and by slowing down platelet-aggregation around them.

[Prognostic nutritional index in digestive surgery]. / Indice nutritionnel pronostique en chirurgie digestive.

It is difficult to select and combine the nutritional parameters most useful in predicting the outcome of major gastrointestinal surgery. The aim of this study was to define retrospectively a multifactorial prognostic nutritional index adapted to this purpose. Seventy-eight patients on whom one or more total or partial visceral resection were performed in nonemergency conditions were included in this study. Statistical analysis was carried out to determine correlations between the preoperative nutritional parameters and the postoperative complications such as: a) wound rupture and anastomotic leakage; b) severe sepsis; c) death. Delayed hypersensitivity, assessed as normal or abnormal, together with plasmatic albumin and transferrin levels, the thresholds of which were respectively determined at 35 g/l and 2.2 g/l, were selected as the factors with the greatest predictive value. For the prognosis of postoperative severe complications and death, the sensitivity and specificity of an index using the association of these three parameters were respectively 82.7 p. 100 and 51 p. 100 with positive and negative predictive values of 50 p. 100 and 83.3 p. 100.

[Etiological diagnosis of hepatic masses by percutaneous puncture guided by ultrasonics. Study carried out in patients without known neoplasms]. / Diagnostic étiologique des masses hépatiques par la ponction percutanée guidée par les ultra-sons. Etude réalisée chez des malades sans néoplasie connue.

Ultrasonically guided liver puncture was carried out in 26 patients without overt carcinoma, who presented with a small intrahepatic mass giving an ultrasonographic image of primary or secondary tumour. Puncture was performed with a lumbar or a Chiba needle under local anaesthesia, and a real-time ultrasound apparatus with guide was used. The specimens collected were fixed on slides for histological examination. An aetiological diagnosis was made in 73% of the cases (16 carcinomas and 3 liver abscesses). No abnormal cells were detected and further investigations were conducted in 15%. The failure rate was 12% (2 punctures without specimens and 1 false-negative result). No infectious or haemorrhagic complication was observed.

Venous thrombosis during total parenteral nutrition with central venous catheters--role of nutritive solutions.

Contrast venograms were performed after removal of the catheter in 17 cases with isolated fever during a study of 187 patients treated by total parenteral nutrition with silicone central venous catheters. Thrombosis of the superior vena cava or of one of its collaterals was present in 7 cases and comparison with the 10 cases who had normal venograms showed a significant difference in the composition of the nutritive solutions infused. Patients with thrombosis received more hypertonic solutions with higher concentrations of glucose and nitrogen in their daily infusions.

Total parenteral nutrition with fat emulsions during pregnancy--nutritional requirements: a case report.

After a corrosive burn of the upper gastrointestinal tract leading to a severe dysphagia and to a weight loss of 15 kilograms, a 21-year-old female was treated by total parenteral nutrition (TPN) during the last 7 weeks of pregnancy. TPN by complete nutritive mixtures comprised daily crystalline amino acid solutions and as energy sources glucose plus lipids, the latter representing 43% of the nonprotein calories. A term normal 2800 gram female was delivered by cesarian section. This case report demonstrates the absence of any side effects on pregnancy related to fat emulsions used in usual proportions. Among the nutritional parameters studied here, the variations of weight and creatinine height index seem to be the best indicators of the maternal nutritional status in these cases. Approximately 50 kilocalories and 220 milligrams of nitrogen per kilograms body weight daily seem to be sufficient to restore and to maintain the maternal nutritional conditions and fetal growth.

[Prevention of gastroduodenal complications in coronary surgery. Usefulness of preoperative fiberoscopy]. / Prévention des complications gastro-duodénales de la chirurgie coronarienne. Intérêt de la fibroscopie pré-opératoire.

Fiberoscopic examination of the oesophagus, stomach and duodenum was carried out in 60 coronary disease patients prior to aorto-coronary bypass. Lesions of the upper digestive tract were detected in one-third of the patients; half of them were asymptomatic. The management of these cases depended upon the urgency of the cardiovascular operation. In 17 cases, a 1-month treatment of the digestive lesions with antacids and cimetidine was instituted immediately after fiberoscopy, and revascularization was performed 8 days later. In 3 cases, the cardiovascular operation was postponed; after 1 month of treatment only one patient had active lesions on control fiberoscopy and had to undergo digestive surgery prior to aorto-coronary bypass. No gastroduodenal complications of cardiovascular surgery was observed in this series.