The selective management of penetrating wounds of the back.

Fifty patients with penetrating wounds of the back were prospectively evaluated and managed selectively on the basis of physical examination. Despite the theoretic problems of evaluating the retroperitoneum, physical examination was found to be a reliable method of determining the need for laparotomy. Every patient who had a significant injury had evidence for this on initial physical examination and no patient judged to have a normal examination required laparotomy. The negative laparotomy rate was 4% and no patients died as a result of delayed surgical intervention. Careful physical examination and surgical judgment allow for safe management of penetrating back wounds.

Nutritional parameters in urban and rural Zulus.

Anthropometric, biochemical and haematological nutritional parameters were measured in 103 (65 men, 38 women) Durban Zulu adults (urban) and 109 (41 men, 68 women) Tugela Ferry Zulu adults (rural). Men conformed to an ideal weight for height whereas women were 18% overweight in Tugela Ferry and 30% so in Durban. Mean arm muscle circumference in men was between the 10th and 20th centiles. Other nutritional parameters were similar to those accepted internationally as normal. In particular the serum albumin level was normal in both urban and rural Zulus. There was little change in the parameters with age except that hand grip as measured by dynamometry fell with age (P less than 0,05). Serum albumin levels fell with age in women (P less than 0,01) but not in men. Nine mothers of babies suffering from kwashiorkor showed normal nutritional profiles.

Nutritional assessment by hand grip dynamometry.

Hand grip dynamometry was studied in 109 normally nourished and 26 malnourished patients. The grip strength was 37,5 +/- 9,9 kg/m2 in normal men, 30,5 +/- 14,4 kg/m2 in men with carcinoma of the oesophagus (starvation-adapted) and 22,0 +/- 9,2 kg/m2 in catabolic men (P less than 0,001). Normal women had a grip strength of 31,6 +/- 7,5 kg/m2 compared with 22,3 +/- 7,0 in catabolic women (P = 0,083). Hand grip dynamometry fell with age (r = 0,69 men; r = 0,57 women), although the correlation was only statistically significant in women (P less than 0,05). There was a strong correlation between right and left hand grip (r = 0,84 men; r = 0,86 women), but hand grip did not correlate well with other indices of nutritional status. Although hand grip dynamometry is a quick, easy and reproducible test, and grip strength is reduced in malnutrition, it cannot replace other tests of nutritional status.

Esophageal transection versus injection sclerotherapy in the management of bleeding esophageal varices in patients at high risk.

In a prospective randomized trial of 76 patients at high risk with bleeding esophageal varices, transection of the esophagus with the EEA stapling apparatus was compared with injection sclerotherapy in the management of patients with Child's class B and C liver status. Thirty-nine patients underwent transection and 37 patients, sclerotherapy with a total of 92 injection procedures (2.4 per patient). The perioperative mortality (less than 30 days) was 28.9 per cent overall; 33.3 per cent for esophageal transection and 24.3 per cent for injection sclerotherapy (chi 2 = 0.375, p greater than 0.05). Gross ascites, severe encephalopathy and emergency operations were associated with a high mortality in the transection group, but other risk factors such as age and hypersplenism did not influence the outcome in either group. Only patients in Child's class C died after transection, but patients who died in the sclerotherapy group (mainly from recurrent bleeding) included patients from both Child's class B and C. Early recurrence of nonfatal bleeding affected one of 39 patients (2.5 per cent) after transection but was evident in 18 of 37 patients (48.6 per cent) after sclerotherapy (chi 2 = 19.12, p greater than 0.0005) and six patients died. Hemorrhage did not recur after transection during a follow-up period of two years, but a further 22 episodes of bleeding were recorded in 13 patients receiving sclerotherapy with five deaths. Postoperative complications and long term morbidity were similar in the two groups. Including readmissions for bleeding and repeat procedures, the mean hospital stay per patient was shorter for transection (14.5 versus 19.1 days) and the requirements for blood were less (1.9 units per patient versus 3.6 units per patient) than for sclerotherapy. It is concluded that esophageal transection effectively protects against short term recurrence of bleeding. Preoperative control of gross ascites will further reduce the mortality and comatose patients should be excluded from operation. Sclerotherapy provides little if any protection against recurrent bleeding and its use in the management of variceal hemorrhage in patients with advanced liver disease remains questionable. It is recommended as a temporary measure in patients at high risk until such time that more effective surgical treatment can be performed.

Total parenteral nutrition by peripheral venous infusion in patients with oesophageal carcinoma.

The safety and efficacy of pre-operative intravenous feeding using a peripheral venous infusion technique was evaluated in 15 black patients with oesophageal carcinoma. Energy requirements were based on individual energy expenditure at rest calculated from oxygen consumption and the respiratory quotient. Patients received 7 600 non-protein kJ and 9,4 g nitrogen daily for 14 days. Although no measurable improvements in nutritional status were noted after intravenous feeding, peripheral venous alimentation using the dual energy system proved an effective method of preventing progressive weight loss and depletion of the lean body cell mass. The infusion technique was safe and without serious metabolic or infectious complications. Total parenteral nutrition by peripheral venous infusion is a viable alternative to the central venous approach in patients with oesophageal carcinoma when their clinical and metabolic status demands early establishment of a positive nitrogen balance.

Stapled anastomosis after colorectal resection for benign and malignant disease.

Low anastomosis using the EEA stapling device was performed in 60 patients after resection for benign and malignant colorectal disease. There were no procedure-related deaths. The anastomosis leaked in 11 patients (18%), and there was abscess formation in 7 patients (12%) in whom the anastomosis was performed 5-8 cm from the anus. Certain technical innovations are recommended to minimize anastomotic disruption.

Fournier's gangrene.

Over a 5-year period 43 men with severe classic Fournier's gangrene of the scrotum and perineum and in some cases of the abdominal wall were treated at King Edward VIII Hospital, Durban. There were 8 deaths, an overall mortality rate of 18,6%. The mortality rate was high (33%) when associated with diabetes mellitus and lower (14,7%) among non-diabetic patients. There was also an increased mortality rate when there was a delay in presentation (of over 6 days in the case of all the patients who later died). We have adopted a policy of aggressive surgical debridement and frequent revision, coupled with the use of broad-spectrum antibiotics.

Air tamponade. A case report.

A 29-year-old man with post-traumatic cardiac tamponade resulting from the development of a tension pneumopericardium is described. To our knowledge this is the first such case reported in the literature.

Segmental artery occlusion for sequential renal injuries. A case report.

We report on a patient who experienced life-threatening haemorrhages in 1974 and 1980 after receiving stab wounds to the same kidney. Treatment by means of segmental artery occlusion was successful. Nephrectomy would have been necessary to control exsanguinating bleeding in both instances. Successful evasion of nephrectomy on two occasions for trauma to the same kidney has not been reported previously.

Retrosternal gastric bypass for the palliative treatment of unresectable oesophageal carcinoma. A simple technique.

A simple and effective technique of retrosternal gastric bypass of the excluded oesophagus for the palliative treatment of unresectable carcinoma of the upper thoracic oesophagus is described. It was used in 60 patients, of whom 5 (8,3%) died. Postoperative morbidity was considerable, complications including chest infection in 20 patients (33,3%), wound infection in 8 (13,3%) and anastomotic leakage in 5 (8,3%); the latter caused 2 deaths. All of the patients who survived the operation were able to swallow solid food and saliva satisfactorily.

E-rosette inhibition and tumour recurrence in early breast cancer.

The relationship of serum blocking activity and susceptibility to tumour recurrence using E-rosette inhibition by normal allogenic lymphocytes was evaluated before and after operation in 20 patients with early breast cancer. Preoperative serum inhibition levels did not predict recurrent tumour. The mean postoperative inhibition in patient with recurrence was significantly greater than in those without recurrence. Postoperative testing only in a group of 124 patients showed that the development of local tumour recurrence was preceded by significantly greater inhibition of E-rosetting than occurred in patients without recurrence. The application of a threshold level of serum inhibition of 15 per cent distinguishes patients who are unlikely to develop tumour recurrence over a 4-year follow-up period. Serial measurements of serum inhibition at 6-monthly intervals over 2 years did not add to the predictive value of this test.

Pulsion intubation v. restrosternal gastric bypass for palliation of unresectable carcinoma of the upper thoracic oesophagus.

The optimum method of restoring the ability to swallow in patients with oesophageal carcinoma remains controversial. This prospective randomized study evaluates the palliative potential of pulsion intubation v. retrosternal gastric bypass of the excluded oesophagus in 106 patients with unresectable carcinoma; 55 patients were intubated and 51 patients treated by gastric bypass. The operative mortality and morbidity, palliation of dysphagia and postoperative nutritional status were compared in the 2 groups. Intubation resulted in 3 deaths (5.5 per cent) and gastric bypass in 4 deaths (7.8 per cent). Intubation was complicated by chest infection in 13 patients (24 per cent) but complications related to the procedure occurred in only 5 patients and included tube migration (2), respiratory obstruction (1), bleeding (2) and oesophageal perforation (1). Gastric bypass was complicated by chest infection in 14 patients (27 per cent), but procedure-related complications were common and included pneumothorax (3), wound infection (6), subphrenic abscess (2), anastomotic leak (5) and purulent neck discharge (3). Palliation of dysphagia was achieved in 93 per cent of patients following intubation and 92 per cent of patients following bypass. Nutritional status improved more rapidly following bypass. Nutritional status improved more rapidly following intubation. Pulsion intubation is the preferred palliative procedure because of fewer complications and a lesser degree of postoperative catabolism.

Total parenteral nutrition--progress with the 3-litre bag.

Recently a disposable 3-litre plastic bag in which the 24-hour nutrient requirements for total parenteral nutrition can be mixed to provide a single solution was introduced to South Africa. We report our initial experience with the 3-litre bag (379 'catheter days'), comparing it with the conventional multiple-bottle system (267 days) in a series of 10 patients. The 3-litre bag system proved easier to administer and also reduced nursing supervision, improved metabolic control and reduced complications. In particular, the control of blood sugar levels in glucose-intolerant patients was significantly better. The 3-litre bag appears to be a major advance in the field of parenteral nutrition, resulting in improved patient care and management.

Nutritional support of the hospitalized patient. Part II. Clinical indications.

The first part of this review dealt with the background, methodology and techniques of nutritional support. As a significant proportion of hospitalized patients suffer from various forms of unrecognized and untreated malnutrition, nutritional support is essential for the maintenance of body mass and function until specific treatment is able to influence the course of disease. The following review highlights various medical and surgical conditions in which nutritional support, in particular total parenteral nutrition, has been advocated in adult patients. Nutritional repletion as a therapeutic modality is still in its infancy, and consequently its true role in patient management is still undergoing evaluation.

Acid secretion and duodenal ulcer healing in patients on medical treatment.

The relationship between gastric acid secretion and ulcer healing was analysed in 168 patients with endoscopically proven duodenal ulceration. One hundred and three patients received active treatment with various therapeutic agents and 65 received placebo. The mean maximal acid output in patients with unhealed ulcers was significantly higher than that in patients with endoscopically confirmed ulcer healing in both the actively treated and the placebo groups (P less than 0,001). In patients with normosecretory acid status the rate of ulcer healing on active treatment was significantly higher than that achieved with placebo (P less than 0,001). However, no significant difference in ulcer healing was evident following active treatment or placebo administration in patients with hypersecretion of acid. Acid secretory profiles warrant consideration when the results of clinical trials are interpreted.