Lethality of standard total parenteral nutrition following major liver resection in rats is prevented by high arginine and high branched chain amino acids but not by glutamine.

Standard total parenteral nutrition (TPN), with or without fat, in amounts approximating the ad libitum intake of normal rats is highly lethal for rats following 70% hepatectomy. Because of significant metabolic changes including alterations of branched chain amino acids (BCAA), arginine (ARG), and glutamine (GLN) associated with serious injury, sepsis, and liver dysfunction, we hypothesized that (1) increasing concentrations of BCAA and ARG in TPN and (2) including glutamine in the TPN may diminish the lethality. Male Sprague-Dawley rats with 70% hepatectomy and jugular vein catheterization were divided into groups. Two sets of experiments were conducted. In Experiment 1, the effects of varying concentrations of BCAA and ARG in the TPN infusate, singly and together, were assessed: Group 1, Standard TPN (19% BCAA, 4.8 g ARG/L); Group II, High BCAA TPN (35% BCAA, 4.8 g ARG/L); Group III, High ARG TPN (19% BCAA, 9.6 g ARG/L); Group IV, High ARG, High BCAA TPN (35% BCAA, 9.6 g ARG/L; Group V, chow and tap water ad libitum. In experiment 2, the effect of 2% GLN in TPN was evaluated: Group A, Standard TPN and Group B, 2% GLN TPN. All infusates were isocaloric (216 Kcal/Kg/d) and isonitrogenous (1.94 g N/Kg/d) delivered at half concentration on postoperative day 1, 3/4 concentration on postoperative day 2, and at full concentration thereafter. Experiment 1: Thirty-three to 36% of rats in Groups I (Standard TPN) (4/11), II (High BCAA TPN) (4/11) and III (High ARG TPN) (4/12) died within 6 days. In sharp contrast, none died in Groups IV (High BCAA, High ARG TPN) and V (rat chow and tap water) (P < 0.05 in each comparison). Among rats in the 4 TPN groups surviving 7 days, there were no significant differences in body weight change (minus 3-4%), spleen or lung weight, extent of liver regeneration (61-66%). Serum total protein and albumin were significantly higher in Group V (chow-fed) (similar to values in normal rats) than in Groups I-IV, P < 0.05 in each case. Serum total bilirubin was significantly higher in Group I than in normals and in Groups II, III, and V. Serum lactate dehydrogenase levels were similar in normals and all 5 groups. Serum aspartate amino transferase level was higher in Group I than in normals but not significantly different from those groups II-V; the latter were similar to normals. Experiment 2: Thirty percent of rats in Groups A (Standard TPN) (3/10) and B (GLN TPN) (3/10) died within 6 days. Among rats surviving for 7 days, body weight change (minus 3-5%), liver regeneration (67-70%), and liver tests were similar in both groups. TPN modified to contain high concentrations of both BCAA and ARG (but not of either alone) prevented the high frequency of lethality induced by standard TPN in rats with 70% hepatectomy. No such salutary effect was shown by modifying the TPN to contain 2% GLN. The striking benefit observed when TPN containing high BCAA and high ARG was infused may be due to the high BCAA leading toward normalization of serum amino acid levels, reducing proteolysis, increasing protein synthesis, and accelerating early liver regeneration, combined with the high ARG likely reducing serum ammonia and leading to increased host defense, and perhaps, thereby, preventing bacterial translocation and bacteremia.

Gastroesophageal reflux disease: surgical considerations.

Technical advances are changing the attitude toward surgery as a last-resort treatment option for gastroesophageal reflux disease (GERD). Although a number of effective medications are currently available to manage GERD, surgery is definitive therapy, and its results are long-term, eliminating both medication compliance problems and the high cost of lifelong drug therapy. Numerous procedures are available for GERD; laparoscopic Nissen fundoplication is emerging as highly suitable and successful for most patients with simple GERD. For the best clinical result, however, the procedure must be tailored to the patient's disease and to the preoperative study results of esophageal pathology and function. The multidisciplinary collaboration of the gastroenterologist, radiologist, and surgeon will be key to the future management of GERD.

Contrasting effects of identical nutrients given parenterally or enterally after 70% hepatectomy: bacterial translocation.

High mortality occurs in rats with 70% hepatectomy fed intravenous (IV) total parenteral nutrition (TPN; 13.9% glucose, 4.17% amino acids, 1.46% fat, electrolytes, trace minerals, and vitamins providing 216 kcal.kg-1.d-1) but not when the identical nutrients are given at the same rate enterally (gastrostomy). We hypothesized that a difference in bacterial translocation (BT) was a contributing factor to this phenomenon. Forty-five male Sprague-Dawley rats (300-360 g) were divided into five groups and underwent the following: control (no operation), sham (intraperitoneal [IP] pentobarbital anesthesia, central venous and gastrostomy catheters, laparotomy, sham hepatectomy), standard oral feeding (SOF), TPN (IV nutrients), and total enteral nutrition (TEN; gastrostomy). The SOF, TPN, and TEN groups had IP pentobarbital anesthesia, central venous and gastrostomy catheters, and 70% hepatectomy. Postoperatively, control and SOF (both catheters plugged) rats ate a commercial rat chow and drank tap water ad libitum pre- and postoperatively. The sham, TPN, and TEN groups were given the identical infusate composition as above, but the nutrient concentrations were cut in half (110 kcal/kg) and three-quarters (165 kcal/kg) on postoperative days 1 and 2, respectively. At the end of postoperative day 2, all rats were euthanized. BT to mesenteric lymph nodes (MLNs), liver, spleen, and lungs was significantly higher in the TPN rats compared with all other groups, except that BT to the MLNs was similar in the TPN and TEN groups. Bacteremia was found only in the TPN rats. BT in TPN rats with 70% hepatectomy was significantly greater 48 h after operation than in those fed the identical nutrients enterally at the same rate; this correlates with the previously reported significantly greater mortality in rats with 70% hepatectomy receiving TPN.

Appendicitis: trends and risks, 1996.

Current changes in the clinical diagnosis and management of acute appendicitis relate to managed care policies and procedures, newer diagnostic techniques, laparoscopy, scoring analysis of clinical data, and nonoperative treatment. Analysis of results of studies using ultrasonography, computed tomography, radionuclide scanning, and diagnostic scoring continues with the intent of developing improved sensitivity and specificity in predicting the presence of acute appendicitis, but it is still not possible to achieve an accurate, uniform, definitive preoperative diagnosis of the disease. The addition of current diagnostic procedures has probably shortened the period of observation for doubtful cases of acute appendiceal inflammation and has established the presence of the disease by means other than clinical examination, interpretation of symptoms, and laboratory tests. Diagnostic scoring systems have been described with enthusiasm, but they are not generally popular and require considerable effort to be clinically useful. The use of laparoscopy and laparoscopic appendectomy is exciting and very in tune with the modern trend in abdominal surgery. However, increasing concern has been expressed that diagnostic advances will be paralleled by delays in patient treatment. Since some delays have been described for management and treatment of acute appendicitis, any delays related to new trends in health care system organization should be monitored carefully.

Traumatic pancreatitis: method and effects of i.v. fluids and Sandostatin.

UNLABELLED: Somatostatin and its analogs are used clinically to treat patients with pancreatitis. To evaluate the effects of i.v. Sandostatin (SNST) on rats with trauma-induced acute pancreatitis, 130 male Sprague-Dawley rats (300-350 g) underwent celiotomy, controlled direct pancreas contusion, and central i.v. line insertion under ip sodium pentobarbital anesthesia. The rats were divided randomly into control (IA, IIA, and IIIA) and SNST-treated (IB, IIB, and IIIB) groups. The basic infusion solution contained 4.8% glucose, vitamins, and electrolytes. For groups IA and IB, the infusion rate was 24 ml/kg/day, while it was 240 ml/kg/day for groups IIA, IIB, IIIA, and IIIB. SNST administration was 6 micrograms/kg/hr i.v. for groups IB and IIB during the first postoperative day, while group IIIB received 6 micrograms/kg/hr i.v. for 4 days. Surviving rats were euthanized after 4 days. All survivors and nonsurvivors were autopsied. In all groups, severity of pancreatitis, fat necrosis, and ascites were greater in the nonsurvivors (P < 0.005 in each case). Mortality rates were consistently lower in the SNST groups: IA (76%) vs IB (52%), IIA (71%) vs IIB (50%), and IIIA (63%) vs IIIB (50%). Because individual group mortality rates were not affected by volume of infusate given or length of time SNST was administered, the results of all control and all SNST rats were combined; there was a statistically significant lower mortality in the SNST-treated rats (51 vs 71%, P < 0.04). CONCLUSION: Intravenous administration of Sandostatin to rats following induction of severe acute traumatic pancreatitis significantly ameliorates the course of the disease.

Contrasting effects of identical nutrients given parenterally or enterally after 70% hepatectomy.

Based on clinical observations, we hypothesized that prolonged parenteral nutrition (in contrast to enteral nutrition) is detrimental after major hepatic resection. Male Sprague-Dawley rats (300 to 380 g) anesthetized with intraperitoneal sodium pentobarbital had 70% hepatic resection and jugular vein and gastrostomy catheterizations using aseptic techniques and were divided randomly into three groups: (1) total parenteral nutrition (TPN) (nutrients via central vein), (2) total enteral nutrition (TEN) (identical nutrients via gastrostomy), and (3) standard oral feeding (SOF) (chow and water ad libitum). Unused catheters were plugged. In the first set of experiments (n = 42), nutrient intake was formulated to approximate the nutritional intake of normal rats, 216 kcal/kg/d. Infusate was 15% glucose, 4.5% amino acids, electrolytes, trace minerals, vitamins, and 20% fat emulsion given half-strength the first day, three-fourths strength the second day, and full strength thereafter. On postoperative day 7, surviving rats were killed. Mortality prior to day 7 was very high (68%) in the TPN group and low in the TEN (9%) and SOF (9%) groups (p < 0.005). Among survivors, the serum albumin level was lowest (p < 0.002) and serum bilirubin level (p < 0.025) and wet weight of regenerated liver (p < 0.002) highest in the TPN group. However, the livers in TPN rats appeared pale and were found to be abnormal histologically with markedly diminished glycogen and amphophylic hepatocyte cytoplasm, and their spleens were enlarged (by a factor of two). The high mortality of TPN rats was seen whether the fat emulsion was given as a bolus daily, continuously as part of the infusate, or not included as part of the TPN regimen. In the next series (n = 70), nutrient concentrations, volumes, and rates of infusion were varied. There was a high correlation between caloric (r2 = 0.831, p < 0.0006), glucose (r2 = 0.598, p < 0.02), and amino acid (r2 = 0.619, p < 0.03) intakes and mortality in the TPN group: at 140 kcal/kg/d, none died; at 178 kcal/kg/d, 50% to 62% died; and at 230 kcal/kg/d, 80% died. No TEN rat died. In conclusion, 70% hepatectomized rats fed enterally with nutrients approximating the intake of normal rats do well and survive. In sharp contrast, mortality is very high when identical nutrients are infused parenterally. By reducing the levels of nutrients given parenterally, survival improves significantly.

Use of biodegradable (PGA) fabric for repair of solid organ injury: a combined institution experience.

A fabric constructed of biodegradable mesh was used in the operative repair of injured intra-abdominal organs in 60 patients at two Level I Trauma Centres. Splenorrhaphy was performed in 44 patients, hepatorrhaphy in eight, renorrhaphy in five and one combined repair of spleen and liver and one kidney and liver. The age range for the patients was 5 to 61 years. Multiple-organ injury occurred in 21 patients. Mean emergency room systolic BP for the patient series was 120 +/- 24 mmHg (SD), Glasgow Coma Scale 14.3 +/- 1.9, haematocrit 37.2 +/- 6.4 per cent, Injury Severity Score (ISS) 28.1 +/- 16.3, Abdominal Trauma Index (ATI) 15.5 +/- 7.5. Postoperative complications occurred in 36.7 per cent of patients. Time for the operation averaged 165.1 + 72.1 min and preoperative and operative transfusion volume averaged 2248 ml. There were three deaths (5.4 per cent). The mesh organ repair technique is an alternative to conventional surgical procedures used to control bleeding from injured organ surfaces and to close organ parenchymal defects.

The high cost of hospital trauma care: an analysis of hospital length of stay, injury severity score, case mix index, and reimbursement-to-cost ratio.

We conducted a study to evaluate reimbursement characteristics for an urban hospital providing a high volume of trauma care. Complete clinical and financial data for 209 trauma patients admitted to the Bronx Municipal Hospital Center during September 1990 were entered into a trauma registry. Patients were categorized into three groups. Group 1 fulfilled criteria for reimbursement using the New York State Major Diagnostic Category 25 (NYSMDC 25) for trauma. Group 2 patients fulfilled New York City Emergency Medical Service 911 criteria for transport to a level 1 trauma center. Group 3 patients did not fit either category. Analysis included age, race, sex, length of stay, injury severity score, case mix index, payer source, and reimbursement-to-cost ratio. Of the patients studied, 77.5% were men. Hispanic, African-American, and white patients constituted 40.2%, 26.3%, and 17.2%, respectively, of the study population. The payer mix was 36.6% Medicaid; 20.8% self-pay; 19.1% no fault; 9.6% Blue Cross; 5.5% Medicare; 5% commercial; and 3.3% other. The study demonstrated that criteria for group 1 and group 2 define patients who constitute a distinct clinical group by injury severity score. As expected, the length of stay and case mix index were significantly higher for group 1, but they did not differ between group 2 and group 3. Group 1 was a small proportion (7.7%) of trauma patients admitted to the Bronx Municipal Hospital Center level 1 trauma center. Trauma admissions were treated at a net loss, with a projected high annual deficit of $5.3 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Murphy's Button revisited. Clinical experience with the biofragmentable anastomotic ring.

Use of the biofragmentable anastomosis ring (BAR) was attempted in 33 patients at two New York City institutions and employed in 31 instances. Anastomoses performed were end-to-end enterocolic (n = 15), colocolic (n = 15), and side-to-side colocolic (n = 1). Patients ranged in age from 27 to 86 years, with the following diagnoses: primary colon cancer, 15; sessile adenoma, four; colostomy, five; diverticulosis, two; metastatic cancer with obstruction, multiple polyposis, perforated appendiceal mass, malignant carcinoid of appendix, intussuscepting right colon mass, one each. In two instances use of the device was aborted because of concern with the blood supply to the bowel wall in one and tissue edema in another. The average duration of postoperative ileus was 4.7 days. Two patients were subsequently treated for small bowel obstruction thought unrelated to use of the anastomotic device. There were no deaths and no evidence of stricture.

Nutritional support by tube jejunostomy.

Access to the jejunum by orogastric intubation or insertion of a surgical tube provides a method for nutrient infusion in clinical conditions that involve abnormal upper gastrointestinal function. Despite the physiologically extraordinary nature of jejunostomy intubation-with enteral infusions beyond the stomach, biliary tract, pancreas, and duodenum--the current view is that jejunal feeding is an acceptable alternative to parenteral nutritional support. Because jejunostomies utilize the gastrointestinal tract, administering feedings by this route can minimize some of the major adverse effects of total intravenous nutrition. The problems with jejunal intubation relate to the technical difficulty of the procedure itself, indications for its general use, and its adaptation as an adjunct in the management of the surgical patient. The timing, composition, and metabolic effects of jejunal nutrient infusions are the subject of continuing debate and study.

Diagnostic tests for intestinal ischemia.

Mesenteric ischemia is a devastating disease. Without early diagnosis and intervention, the process proceeds to intestinal gangrene with its associated high morbidity and mortality rates. Although newer operative techniques and better intensive care unit management may improve patient outcome, it is only by obtaining an earlier diagnosis that greater patient survival rates will be possible. In an attempt to improve diagnostic accuracy, many modalities have been explored. These include serum biochemical markers, peritoneal fluid analysis, tonometry, radionuclide imaging, laparoscopy, and endoscopic techniques. At present, no single test has enabled the clinician to improve the patient's outcome. We are hopeful that the newer techniques, including radionuclide-labeled antibodies, tonometry, and reflectance spectrophotometry, may in the future be of assistance in improving the results for patients sustaining intestinal ischemia.

Infusion of enteral vs parenteral nutrients using high-concentration branch-chain amino acids: effect on wound healing in the postoperative rat.

Starting total parenteral nutrition (TPN) the day after acute surgical stress has beneficial effects on body weight, nitrogen balance, and colonic anastomosis bursting pressure in normally nourished rats. In view of the reported favorable utilization of high-concentration branch-chain amino acids (BCAA) following severe stress, we compared enteral (TEN) to parenteral (TPN) nutrient infusions containing increased BCAA starting the day of operation. Twenty-four male Sprague-Dawley rats, in two groups paired by weight under IP pentobarbital anesthesia underwent jugular vein catheter (CVP) insertion, laparotomy, gastrostomy, colon anastomosis, dorsal skin incision and SC polyvinyl alcohol sponge insertion. The rats were maintained for 6 days with continuous IV infusion in the TPN group (gastrostomy plugged) and continuous gastric infusion for the TEN group (CVP plugged). Urine and feces were collected daily. The infusions contained 1000 to 1002 Kcal, 847 to 845 nonprotein Kcal, 38 to 39 g of amino acids, 206 to 209 g of carbohydrates, and 2.8 to 2.9 g of rat per liter in the TEN and TPN, respectively, with identical ratios of dietary essential amino acids to nonessential amino acids (52/48), and 28.34% BCAA in the TPN and 33.10% BCAA in the TEN. There were 491 mg/100 mL of glutamine in the TEN and 170 mg of glutamic acid in the TPN. Amino acids were infused at 8.59 g/kg per day for TEN and 8.34 g/kg per day for TPN. The vitamins, minerals, and trace minerals were essentially the same in the TEN and TPN except for the absence of iron, iodine, selenium, and molybdenum in the TPN.(ABSTRACT TRUNCATED AT 250 WORDS)

Spare the spleen: rationale and techniques.

For many years, a role for splenic function could not be established. Myths and folklore took the place of fact when it came to the spleen. Currently, splenic function is known to be important enough to justify surgical efforts that repair rather than excise the spleen after traumatic injury. Various repair techniques have been described, including many procedures that are appropriate to severe fragmenting splenic trauma. In a review of the experiences of 48 patients following splenorrhaphy using a variety of repair procedures, satisfactory results were achieved in 16 cases using a polyglycolic acid mesh wrap for splenic envelopment and parenchymal tamponade. There were no treatment failures or intra-abdominal infections associated with this newly described procedure.

Effect of early postoperative nutritional support on skin wound and colon anastomosis healing.

Improved healing occurs in nutritionally depleted rats given early postoperative compared with delayed feeding. The present study was designed to test the hypothesis that delay in postoperative feeding of rats normally nourished at the time of operation would also be detrimental to wound healing. Fully nourished rats weighing 288 to 342 g were divided into three groups (10 rats per group). All rats had central vein catheters inserted, celiotomy with division and reanastomsis of the colon and dorsal skin incisions, under ip pentobarbital anesthesia. With no oral intake allowed postoperatively, group 1 rats were maintained in iv 5% Dextrose electrolytes and vitamins (5% DSV); group 2 was given the 5% D/SV until the third postoperative day when they were placed on TPN (4.5% amino acids 15% Dextrose, 10% Intralipids); and group 3 was given TPN from the first postoperative day. Rats were sacrificed 6 days postoperatively and final weight, skin wound breaking strength (WBS) and colon anastomosis bursting pressure (CBP) were measured. Findings were % weight change -27.8 +/- 1.5 for Group 1, -12.6 +/- 1.0 for Group 2, and -6.9 +/- 8 for group 3 (p less than 0.0001). Wound measurements for STS on fresh specimens were 88.6 +/- 10.0 g for group 1, 89.1 +/- 8.4 g for group 2, and 87.1 +/- 11.1 g for group 3. WBS for formalin-fixed specimens were 313.5 +/- 29.7 g for group 1, 323.4 +/- 38.4 g for group 2, and 382 +/- 25.2 g for group 3 (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

CT appearance in tuberculous pancreatic abscess.

We report a case of a tuberculous pancreatic abscess in a 47-year-old human immunodeficiency virus positive intravenous drug abuser. She had a prolonged febrile course and persistent abdominal pain. On CT and sonography the lesion lacked the usual ancillary features of an abscess such as diffuse pancreatic enlargement and a peripancreatic fluid collection, and more closely resembled a necrotic neoplasm.

Limited role of arteriography in penetrating neck trauma.

Of the patients with penetrating neck wounds treated between 1979 and 1986, 61 patients with 65 injuries had arteriography during their evaluation. Twenty-seven patients had stab wounds and 34 had gunshot wounds, with a relatively equal distribution between the zones of injury. Fifty-seven arteriograms were normal and six were abnormal. Of the six arteriographic defects, three were thought to be spurious on subsequent review, two were clinically insignificant, and one required surgery. No significant arterial injuries were identified by arteriography in the absence of suggestive physical findings. No major arterial injuries were discovered during neck surgery that were missed preoperatively. Neither abnormal nor normal angiograms significantly altered the course of management, including the approach to neck exploration. These data suggest that arteriography for penetrating neck trauma is usually unnecessary for observation of patients in stable condition without suggestive physical findings. Thorough neck exploration with dissection of the carotid sheath in patients with physical diagnostic criteria for surgery eliminates the need for angiography in most cases and avoids the consequences of a possible false-negative study.