Percutaneous endoscopic gastrostomy in burn patients.

BACKGROUND: Prolonged enteral feedings are required occasionally in seriously burned individuals. We have employed percutaneous endoscopic gastrostomy (PEG) in selected patients who require particularly prolonged access, thus prompting this review. METHODS: The PEG procedure was performed under general anesthesia in combination with another surgical procedure using a variety of commercially available needle and guidewire kits in 14 patients. RESULTS: These 14 patients had an average age of 55.2 +/- 6.6 years and a burn involving 38 +/- 8% of the body surface. Eleven of these patients had suffered an inhalation injury. The tubes were placed an average of 57 +/- 10.5 days after injury through unburned and unharvested skin in four patients (28%), healed donor sites in five patients (35%), healed burn in one patient (1%), and grafted burn in four patients (28%). One patient, whose catheter was placed through a grafted fascial excision, developed moderate local wound erosion. Tubes were known to have been left in place as long as 155 days. However, most were removed in rehabilitation hospitals, and we were unable to determine how long most were left in place. We are unaware of any problems with the tubes occurring after discharge from the acute care setting. CONCLUSIONS: In selected patients, PEG can provide more comfortable access for prolonged enteral feedings than nasogastric tubes and can be placed with minimal morbidity.

Experience of percutaneous endoscopic gastrostomy at Massachusetts General Hospital--indications and complications.

BACKGROUND: Percutaneous Endoscopic Gastrostomy (PEG) is a relatively new method to deliver nutrition to patients with inadequate caloric intake who have a functionally intact gastrointestinal tract. METHODS: This is a retrospective review of 58 consecutive patients who were referred to the Surgical Endoscopy Unit, Massachusetts General Hospital for placement of PEG in 1996. The current indications, methods, and results of PEG will be discussed. RESULTS: Of this series, all but one patient had the PEG successfully placed. Indications included head and neck cancer (29 patients); neurological disorders (21 patients); burns (3 patients); respiratory failure (2 patients), and aspirations (2 patients). Fifty-four percent of cases were performed with local anaesthesia. There was one complication (2%) with no procedural-related mortality. CONCLUSION: PEG is an easy and safe procedure. It is a good alternative to provide enteral feeding in selected patients.

Quantitative cultures of the mucosal-associated bacteria in the mechanically prepared colon and rectum.

Little is known about the mucosal microflora of the colon and rectum at the time of elective surgery. Our objective was to determine the concentrations of anaerobic and aerobic bacteria associated with the mucosa of the mechanically prepared large bowel. Ten patients were studied after a standard polyethylene glycol-electrolyte lavage preparation. No patient had taken antibiotics in the preceding four weeks. Sterile wire brushes passed through the colonoscope during advancement were used to culture the rectal, transverse colon, and cecal mucosa. Total anaerobic, aerobic, Gram-positive, and enteric bacterial counts were determined along with specific cultures for Bacteroides fragilis, Clostridium difficile, Escherichia coli, Pseudomonas aeruginosa, enterococcus, and staphylococcus species. The results showed that there was a significant increase (P < 0.01) in aerobes, anaerobes, enterics, Gram positives, B. fragilis, and E. coli mucosal counts with proximal progression. Aerobes showed a steady gradient, while anaerobes demonstrated an increase from the rectum to the transverse colon but no change between the transverse colon and cecum. We conclude that, in the prepared bowel, there is an increase in the mucosal bacterial counts in the more proximal portions of the bowel. The results may serve as a baseline for future studies on the mucosal-associated bacteria of the large intestine.

Endoscopic resection of large sessile colorectal polyps.

Colonoscopic removal of large, sessile polyps is difficult, but can be successfully carried out by experienced endoscopists. "Piecemeal" resection with an electrocautery snare was performed at our institution in 108 patients with 132 such lesions. The mean size of the unresected polyps was 3.0 cm. Complications occurred in 3.0% of polypectomies (3.8% of patients), with bleeding necessitating transfusion in 2.3% of polypectomies (2.8% of patients), and microperforation (probable) in the remainder. No patient required emergency surgery due to a complication. In 65 patients (60%), colonoscopic resection and follow-up alone was carried out. Of these, adenomas recurred/persisted in 28%, most of which were successfully re-resected. Nearly half of all recurrent polyps occurred after at least one negative intervening examination. Carcinoma later appeared in 17% of the recurrences despite apparent initial complete resection of a previously benign polyp. Cure was ultimately achieved in 88% of endoscopically managed patients. Surgical resection was required in 27% of patients, mostly following the initial polypectomy when invasive carcinoma was found in the specimen. No residual tumor was later found in 41% of the colon specimens from these patients. Ninety-one percent of cancers were favorable stage, whether discovered early or late. Follow-up colonoscopy was achieved in 77% of patients over an average of 3.7 years. Metachronous polyps were excised in 52 patients (63%) and metachronous carcinoma was diagnosed in 3 patients (3.6%). An aggressive regimen of surveillance colonoscopy is warranted in these patients to detect and manage local recurrences and to remove subsequent adenomas. Endoscopic resection of large sessile adenomas can be safe and effective.

The freckle sign--an endoscopic feature of the cecum.

Mucosal spots, or "freckles," surrounding the appendiceal orifice are an endoscopic feature of the cecum. These are clusters of 1 to 2 mm round or oval slightly raised spots, each with a pale center and an erythematous border. They correlate microscopically with subepithelial and submucosal lymphoid follicles. The freckling pattern, identified in about one third of colonoscopies, was seen best with the videoendoscope and was identified more commonly in patients with systemic illness. Recognition of mucosal freckling around the appendiceal orifice helps identify the cecum and may be useful in the evaluation of cecal and appendiceal pathology.

Burned children from the Bashkir train-gas pipeline disaster. I. Acute management at Children's Hospital 9, Moscow.

Following the Bashkir train-gas pipeline disaster of 4 June 1989, US surgeons and nurses had an opportunity to join their Soviet counterparts at the Burn Unit at Children's Hospital 9 in Moscow in caring for the children. As a result of the joint effort, both the Soviet and US professionals came to understand the strengths and limits of each system of burn care. Joining strengths through mutual willingness to listen and cooperate left an elevated level of burn care at Children's Hospital 9.

Burned children from the Bashkir train-gas pipeline disaster. II. Follow-up experience at Children's Hospital 9, Moscow.

A group of US surgeons and nurses was invited by the Soviet surgeons and nurses of the Burn Unit of Childrens Hospital 9 to return to Moscow to participate in the evaluation and treatment of a group of 25 children burned in the Bashkir train-gas pipeline accident of 4 June 1989. The US group had participated in the acute care of the children 7 months before. Major sequelae observed were hepatitis, cardiomyopathy and severe emotional disorders. Reconstructive surgery for burn scars was jointly planned and carried out during a 2-week period of mutually instructive cooperation.

Increased survival after massive thermal injuries in adults: preliminary report using artificial skin.

Survival of major burn injuries has improved markedly from an expected survival of 10% to 20% in both children and adults to an expected survival of 60% in children with burns greater than 70% BSA. Increased survival for adults after similar burn injuries has been less dramatic than in children because of the profound influences of advancing age and the coexistent processes of aging upon survival after a major injury. Consecutive admissions of patients with massive burn injuries (greater than or equal to 70% BSA) to the Massachusetts General Hospital Adult Burn Unit from 1974 to 1986 were analyzed statistically using univariate and multiple logistic regression analysis to identify factors associated with survival and to identify patient characteristics associated with increases in expected survival. Survival of adults with massive burn injuries has improved markedly, from 24% of adults admitted to the Adult Burn Center in 1974-75 to 48% of adults admitted in 1984-86. An increased likelihood of survival was shown to be associated with the use of artificial skin. Improved survival rates in these massive burn injuries were attributed to multiple factors including wound management of prompt eschar excision and immediate wound closure.

Prompt eschar excision: a treatment system contributing to reduced burn mortality. A statistical evaluation of burn care at the Massachusetts General Hospital (1974-1984).

Mortality at the Adult Burn Center of the Massachusetts General Hospital (MGH) has declined from 24% in 1974 to an average of 7% for 1979-1984. From 1974 to 1976, prompt eschar excision and immediate wound closure therapy was initiated and standardized. After 1976, this therapy was the standard treatment. Detailed statistical analysis is necessary to determine the influence of this treatment on the improved survival. Therefore, logistical regression analysis was used to examine the influence of variables such as burn size, age, and treatment on mortality for 1103 patients during 1974-1984. Survival rates during the treatment development phase (1974-1977) were compared to the survival rates of the last 5 years of standardized excisional treatment (1979-1984). Survival rates for the standardized excisional treatment were also compared to the results of previously published studies from this hospital that were probit analyses of burn mortality for 1939-1955 and 1955-1970. This latter comparison provided 45 years' experience with burn mortality at a single institution. Results of the statistical analysis of the survival data from 1974 to 1984 indicate that mortality strongly depends on burn size, age, and treatment (p less than 0.001 for each independent variable). In addition, length of stay (LOS) for the total group decreased significantly from 32 to 22 days. The improved survival for 1974-1984 occurred independently of changes in the annual distributions of burn size, age, or sex. Comparison of survival rates shows improved survival during standardized excisional treatment when compared to the treatment development phase. The most extensive increases in survival during 1974-1984 were seen in the treatment of elderly patients and patients with massive burn injuries. Survival for the period 1974-1984 was markedly improved as compared to the 1939-1970 published experiences.

Hyperparathyroid crisis reviewed: a role for parenteral cimetidine?

Hyperparathyroid crisis secondary to primary hyperparathyroidism has variously been described as hypercalcemic crisis, parathyroid storm, and parathyroid intoxication as well as other equally descriptive terms. Whatever the nomenclature, all emphasize the seriousness and urgency of the condition. Although fewer than 200 cases have been described since the first report by Hanes in 1939, it is generally agreed that hyperparathyroid crisis is more prevalent than commonly appreciated. The signs and symptoms of the syndrome are believed due not only to the presence of hypercalcemia, but to the toxic effects of parathormone as well. Its wide, but nonspecific clinical spectrum makes it easily confused with other causes of rapidly fatal cardiovascular or renal disease. The mortality in untreated cases is essentially 100 per cent. With combined medical-surgical treatment, it is still reported as high as 60 per cent. Three patients with severe hyperparathyroid syndrome are reported. Effective control of both hypercalcemia and the toxic effects of acute hyperparathyroid crisis was achieved with the use of parenteral cimetidine. Definitive surgical removal of a solitary parathyroid adenoma was performed in all three patients. The intimate relationship of the bioavailability of cimetidine and its effect in primary hyperparathyroidism is clearly demonstrated. An analogy to the use of cimetidine in Zollinger-Ellison syndrome is made. Both are endocrinopathies that require doses of cimetidine in excess of that normally considered therapeutic for peptic ulcer disease. The signs and symptoms of hyperparathyroid crisis as well as current modalities of treatment are reviewed. It is concluded that parenteral cimetidine is an important aid in the management of acute hyperparathyroid syndromes secondary to primary hyperparathyroidism.

Long-term functional results of selective treatment of hand burns.

Four hundred seventy-eight patients with hand burns (786 hands) were treated at the burn service of the Massachusetts General Hospital. Long-term evaluation showed that early incision and immediate autografting of deep second degree, mixed second and third degree, and third degree full-thickness hand burns resulted in 93 percent, 95 percent, and 93 percent, respectively, excellent to good functional results. There was no significant differences in results in patients with superficial second degree burns treated nonsurgically with silver nitrate dressings and early physical therapy compared with results in patients with deep second degree, mixed second and third degree, and third degree hand burns treated with early excision and grafting. No patient with fourth degree burns had excellent to good results. Permanent damage was related to extent of original injury to the extensor tendons and joint capsules. On the basis of this broad experience, it is believed that all burned hands judged unlikely to heal within 3 weeks will benefit from early excision and grafting by experienced surgical personnel.

Colonic polyps.

Carcinoma of the large bowel arises almost exclusively in neoplastic polyps, which are present in 5-10% of the population over age 40. These polyps may be of three histologic types: (a) tubular adenoma (adenomatous polyp), (b) tubulovillous adenoma (villoglandular polyp), and (c) villous adenoma. The tendency for malignant change is greatest in the villous adenoma (41%) and in tubulovillous (villoglandular polyps--23%). In tubular adenomas (simple adenomatous polyps), the incidence of malignancy is 5% over all. The tendency toward malignant change is determined by histologic type, size, and degree of atypicality of adenoma. Early detection and complete removal of neoplastic polyps of the colon are essential to the prevention of cancer of the large bowel, and this may usually be done in most cases with the colonoscope.

The preoperative use of cimetidine as a means of preventing symptomatic hypocalcemia following a parathyroid operation.

Cimetidine has been shown to lower circulating PTH levels effectively by causing an intraglandular rearrangement of PTH peptides in human parathyroid tissue in instances of primary hyperparathyroidism. A state of "euparathyroidism" is established. It has been statistically found at a 98.7 per cent confidence level that preoperative treatment with cimetidine effectively prevents symptomatic hypocalcemia postoperatively after parathyroid operations. It is anticipated that cimetidine has provided a tool for the in depth exploration of parathyroid disease.

Effect of cimetidine on circulating parathyroid hormone in primary hyperparathyroidism.

In twelve patients with primary hyperparathyroidism the raised parathyroid hormone (PTH) levels consistently returned to normal with cimetidine ("Tagamet"), 300 mg four times a day, orally. As PTH levels returned to normal, signs and symptoms improved. Reduction of hypercalcaemia varied with the time, dose, and route of administration of cimetidine. Whenever cimetidine was discontinued, there was a rebound of PTH levels to approximately twice the initial value, which suggests that cimetidine blocks the synthesis and/or secretion of parathyroid hormone, so that parathyroid hormone or its precursor accumulates in the gland. A solitary parathyroid adenoma has been confirmed surgically in the five patients so far operated on. In all surgical patients the PTH levels were brought to normal by cimetidine preoperatively; these levels were maintained postoperatively. The adenomas were unusually large, firm, and congested; there was no atrophy of the rest of the glands. These last two observations further support our hypothesis that cimetidine blocks the synthesis or release of parathyroid hormone; they also support the concept that in primary hyperparathyroidism the parathyroid adenoma becomes autonomous or there is an abnormal hormone.

Operative cholangiography and overlooked stones.

In a series of 100 consecutive common bile duct explorations in which stones were present and operative cholangiography performed, 22 patients were found to have residual stones. The operative cholangiograms showed the missed stones in three fourths of the patients, even though many of the cholangiograms were of poor quality. It is concluded that operative cholangiography is an excellent technique that will demonstrate most common bile duct stones. Closer cooperation with the radiologist and more emphasis on technique should lead to consistently satisfactory films and more appropriate interpretation, thus resulting in fewer overlooked biliary calculi.