Traumatic perforation of duodenal diverticulum.

A fragile 72-year-old female with previous coronary artery disease sustained blunt abdominal trauma in a motor vehicle crash. A ruptured duodenum was identified by computed tomography scanning. Exploratory laparotomy revealed that the duodenal rupture was caused by perforation of a diverticulum in the second portion of the duodenum. The surgical management of the injury to the duodenum is described in detail.

Incidence of necrotizing pancreatitis and factors related to mortality.

Of 348 cases of acute pancreatitis presenting between 1980 and 1985, extensive retroperitoneal necrosis with bacterial or fungal superinfection developed in only 17 (4.8 percent). However, in 14 of the 17 patients (80 percent), multiple surgical interventions and intensive supportive therapy failed to control the process, and they died from complications. Deaths occurred after a prolonged in-hospital course characterized by sequential failure of organ systems. If the salvage of these patients is to be optimized, as in some reports, the timing of the first surgical procedure has to be very carefully made based on the clinical and laboratory findings, and most importantly, the results of computerized tomography. Exploration is probably best carried out through an extended subcostal incision, and a determined attempt must be made to remove all of the necrotic tissue. Little reliance can be placed on the possibility that significant amounts of residual necrotic tissue can be aspirated through sump catheters or evacuated by irrigations. We believe that the poor results in this series lend strong support to those who have already advocated much more universal application of the open abdomen technique in the management of these patients with widespread anterior pararenal space necrosis.

Serial measurement of plasma cholesterol and lecithin:cholesterol acyl transferase activity in adults receiving total parenteral nutrition.

The effect of total parenteral nutrition (TPN) containing approximately 800 ml Nutralipid daily on plasma cholesterol and lecithin:cholesterol acyl transferase (LCAT) activity was studied in 11 adult hospital patients. LCAT was assayed using an endogenous (S/N) and an artificial (ASA) substrate to differentiate between altered plasma substrate composition (which would influence the S/N method) and enzyme quantity (measured by the exogenous ASA method). Total cholesterol levels increased significantly during TPN, but generally remained within normal range. In comparison to laboratory reference values, free cholesterol was elevated and high-density lipoprotein cholesterol and ASA LCAT activity was reduced in patients before the start of TPN and remained unaltered by the TPN regime. S/N LCAT activity was normal and not altered by TPN. Since changes in plasma high-density lipoprotein and free cholesterol and ASA LCAT were present in patients before TPN, it must be concluded that they resulted from the underlying disease rather than the TPN per se. Longitudinal analyses showed that during the first 21 days of TPN nine patients showed a further fall in ASA LCAT and a rise in free cholesterol, thereafter ASA LCAT activity rose and free cholesterol fell despite continuation of TPN. It is suggested that ASA is a more reliable indicator of cholesterol esterification than S/N and that change in LCAT activity, although not caused by TPN, was related to the altered plasma lipid profile in the patients studied.

Management of small bowel fistulas.

Fifty-two patients with fistulas that arose from the small intestine were encountered in the 6 year span between 1975 and 1981. The mortality rate in this group was 38 percent, the average hospital stay was 95 days, and 47 patients were receiving total parenteral nutrition for an average of 56 days. Intraabdominal sepsis and peritonitis forced early reoperation in eight patients in whom exteriorization of the fistula as an ileostomy and mucous fistula and reconstruction after a long interval, was a more successful means of management than were attempts at immediate resection and anastomosis. Nineteen of 44 patients (43 percent) had spontaneous closure while receiving parenteral nutrition without oral feeding. The average time span to spontaneous closure of the fistula was 25 days. Delayed reoperation was carried out after a long interval in patients without spontaneous closure. There was a high rate of success with resection of the fistula and primary anastomosis.

Possible biotin deficiency in adults receiving long-term total parenteral nutrition.

Two adult patients receiving total parenteral nutrition on a long-term home basis presented with severe loss of hair. Both patients had extensive gut resection, consumed no biotin orally and received no biotin parenterally. Supplementation with Berroca-C, one ampule containing 200 micrograms biotin per day resulted in gradual regrowth of healthy hair. The patients now receive a parenteral solution containing biotin and have shown no recurrence of alopecia. It is suggested that biotin deficiency can occur in the adult when no preformed biotin is provided to the body and the contribution of this vitamin from intestinal microbial biosynthesis is compromised.

Cholestasis caused by lipid emulsions.

Liver function was observed in 35 patients receiving intravenous feeding for more than three weeks. A progressive cholestatic jaundice occurred in ten of 18 patients receiving a lipid emulsion in a dose of 3 grams per kilogram per day. Only one of 17 patients receiving a dose of 1 gram per kilogram per day showed evidence of cholestasis. Neither the type of amino acid preparation used nor the dosage appeared to be a factor. Similarly, the contribution to calories from dextrose did not influence the frequency of cholestasis. The cholestatic jaundice improved with the return to normal of liver function when the lipid emulsion dosage was reduced or intravenous feeding was discontinued.

Polytetrafluoroethylene grafts for vascular access for hyperalimentation.

A polytetrafluoroethylene (PTFE) graft from the brachial artery to the axillary vein may provide a safe and trouble-free means of vascular access in selected patients requiring long-term intravenous feeding in the hospital setting. This route for the administration of solutions supplying total parenteral nutrition (TPN) should be considered in persons whose requirement for parenteral feeding is likely to extend over many months and in whom there are other sources of bacteremia which can imitate or be confused with infection of a conventional central venous feeding line. In a 52-year-old man an 8-mm PTFE graft was anastomosed end-to-side to the brachial artery and the axillary vein and brought through a subcutaneous tunnel on the medial aspect of the upper arm. Access to it was obtained by intermittent puncture with a no. 21 butterfly needle. Hyperosmolar TPN solutions flowed easily by gravity drip into the shunt. The graft seemed resistant to infection. This form of vascular access appears to exclude parenteral feeding lines, solutions and catheters as sources of sepsis.

Preoperative parenteral feeding in Crohn's disease: preoperatively, to induce remission, and at home.

Extended courses of preoperative parenteral nutrition were used in eight cases of complicated Crohn's disease. Impressive gains in weight and strength were demonstrated, as well as radiologic improvement in the diseased bowel. It is recommended that preoperative parenteral feeding be carried out for a minimum of 20-30 days, in order that full nutritional benefits be realized, as well as the resolution of inflammatory changes in the bowel and supporting structures.

Symposium on intensive care: 1. Monitoring of the critically ill surgical patient.

The skill and experience of the medical and nursing staff are the factors that have the greatest impact on the quality of monitoring and treatment of the critically ill surgical patient. Basic determinations at the bedside together with periodic evaluation of the whole patient by the medical staff may, in selected cases, be supplemented usefully by more invasive monitoring techniques. The specific complications and technical pitfalls of these techniques should be known, and caution should always be exercised that the values provided are not misinterpreted. A critical care area serving a major teritary referral hospital should be able to measure pulmonary capillary wedge pressure and cardiac output. Mixed venous oxygen content and arterial lactate concentration, as indices of oxygen delivery, are also useful measures.

Parenteral solutions for nutritional support in surgical patients. A comparison of nitrogen gains employing 5 per cent and 10 per cent amino acid solutions.

A 10 per cent amino acid solution accompanied by 10 per cent Intralipid and 50 per cent glucose could be infused by peripheral veins. This safe and practical method induced positive nitrogen balance of 7 to 8 gm daily in five of six septic patients.

Parenteral fluid therapy in septic shock: An evaluation of crystalloid and colloid.

PIP: A retrospective review of 25 patients with bacteremic shock was undertaken to evaluate and compare the quality of resuscitation with infusion of either crystalloid or colloid solutions. The average improvement in systolic pressure in the crystalloid infusion group was 23 mm of Hg, whereas the colloid group achieved a mean rise in pressure of 48 mm. Colloid was also superior to crystalloid in terms of speed and magnitude of response measured. In the group of 8 patients given colloid, central venous pressure was recorded over the 24-hour infusion period with a mean rise of 8 cm of water produced, vs. 2 cm of water in the crystalloid group. Crystalloid administration aggravated arterial hypoxemia, whereas colloid infusion did not worsen respiratory function. All 25 patients were oliguric or anuric before beginning therapy; adequate urine flow was quickly restored by expanding blood volume alone, with the fusion of a large volume of salt and water unnecessary. Hence, it is concluded that salt solutions should not be given in cases of bacteremic shock, unless clear indications of deficits or continuing losses of sodium and water are present. Excessive sodium administration was an unreliable and ineffective blood volume expander, accentuated hypoalbuminemia, and increased pulmonary shunting and hypoxemia. Prompt blood pressure and central venous pressure elevation, and restoration of urine flow, can be achieved with colloid solution.^ieng

Pancreatic secretion in response to jejunal feeding of elemental diet.

The instillation of elemental diet into the proximal jejunum of dogs results in a brisk pancreatic secretory response, but the fluid is watery and "enzyme-poor." The administration of the caloric equivalent in a standard blenderized ward diet induces pancreatic enzyme secretion. Although elemental diet does not "rest" the pancreas, the failure of these preparations to stimulate pancreatic enzyme secretion gives them a theoretical advantage as a nutritional source in the convalescent phase of acute pancreatitis.