Nasogastric feeding in severe acute pancreatitis may be practical and safe.

BACKGROUND: Severe acute pancreatitis may be protracted and some form of nutritional support is frequently required to maintain the patient's nutritional status. Recent work has suggested that enteral feeding via a jejunal route of delivery may reduce the magnitude of the inflammatory response. Insertion of nasojejunal (NJ) tubes in the patient with severe acute pancreatitis involves both delay and inconvenience. We undertook a prospective, feasibility study to assess the safety and practicability of nasogastric (NG) feeding in patients with severe acute pancreatitis. PATIENTS AND METHODS: Twenty-six patients with objective evidence of severe acute pancreatitis received nasogastric feeding within 48 h of admission to our unit. RESULTS: Etiology was identified as cholelithiasis (18 patients), ethanol (5), and miscellaneous (3). The median Glasgow score was 4 (range 2-7), APACHE II score 10 (4-28), and C-reactive protein concentration 286 mg/L (79-469). Fifteen patients had pancreatic and/or peripancreatic necrosis. Eleven patients developed severe organ failure, necessitating ventilatory support. Six developed multiple organ system failure, requiring inotropic support and/or renal dialysis. There were four deaths (15.3%). Nine patients underwent early, and nine late, ERCP, respectively; six necrosectomy (5 proven infected necrosis, 1 continued deterioration despite maximal support) and 4 patients internal drainage of a pseudocyst. The feed was well-tolerated in 22 patients. In 3 patients gastric stasis proved troublesome. There was no evidence of clinical or biochemical deterioration on commencing nasogastric feeding. CONCLUSION: It would appear that early NG feeding is usually possible in severe acute pancreatitis. In most patients it appears safe, well-tolerated, and worthy of further study.

Emergency sub total colectomy for chronic constipation.

Severe chronic constipation presents a significant management problem which may, occasionally, necessitate surgical intervention. Rarely emergency surgery is required and we report a case in which emergency subtotal colectomy was indicated to treat faecal peritonitis secondary to stercoral ulceration.

Sclerosing cholangitis: a rare etiology for acute pancreatitis.

Primary sclerosing cholangitis as the cause of acute pancreatitis is a rare phenomenon with only one previous case having been found by ourselves in the English literature. Over a period of 2 yr, two patients with acute pancreatitis secondary to primary sclerosing cholangitis were seen in this unit. The first patient is currently being treated with ursodeoxycholic acid and repeat endoscopic sphincterotomies, whereas the second required liver transplantation.

Importance of the profunda femoral artery in distal limb revascularisation.

The profunda femoral artery (PFA) was recognised in the early 1960s as an essential artery to maintain perfusion in the lower limb. The aim of this retrospective study was to analyse the results obtained with aortobifemoral bypass surgery (ABF) where the distal perfusion was solely dependent on the PFA. An evaluation was made of 240 ABFs done between January 1988 and May 1995. This represented a combination of operations done by either the vascular unit at the HF Verwoerd teaching hospital or by Dr Van Marle privately. In 56 cases only the PFA was available for distal anastomoses in one or both limbs, giving a total of 80 PFA anastomoses. Evaluation was based on pre- and postoperative ankle brachial pulse indexes (ABPI). There were 3 deaths and 1 amputation in the early postoperative period. Over an average follow-up period of 32 months (1 month-63 months) 76 limbs were assessed. At initial presentation 30% of the patients had rest pain and 2 already had gangrenous changes. Mean pre-operative ABPI was 0.5. A further femoral-popliteal bypass was required within 1 year for 6 of the patients. The average postoperative ABPI was 0.86, giving a 73.2% average improvement. We therefore concluded that good results can be achieved when the PFA is used for distal anastomosis in ABF bypass surgery.