Distal decompression and proximal feeding for nutritional support during bowel obstruction.

The treatment for acute mechanical intestinal obstruction is a timely operation. A select group of patients may, however, be nutritionally supported with continual administration of elemental diet proximal to long tube decompression under two sets of circumstances: 1. while awaiting spontaneous or treatment-induced resolution of the underlying process, and 2. while reversing catabolism during evaluation prior to operation. Eleven patients with chronic intermittent bowel obstruction were studied: six with obstruction involving radiated small bowel, three with an acute exacerbation of chronic inflammatory bowel disease, one with obstruction secondary to an intra-abdominal phlegmon and one with a segmental motility problem. They received nutritional support with continual gastrointestinal administration of elemental diet proximal to long tube decompression after initial observation for signs or symptoms of altered intestinal viability and stabilization of fluid and electrolyte status. Six of the 11 patients eventually required operation. All patients maintained body weight and three gained weight. Mean nutritional input was 1,873 calories and 12.6 gm nitrogen/day. There were no complications related to the technique of proximal feeding and distal decompression because of careful patient selection and appropriate administration of elemental diet under carefully controlled guidelines.

Splenectomy: its place in operations for inflammatory disease of the pancreas.

Involvement of the spleen or its vasculature in inflammatory disease of the pancreas may result in life-threatening hemorrhage. Retrospective analysis of six patients having direct splenic involvement and/or occlusion of the splenic vein secondary to pancreatitis or pseudocyst showed that removal of the spleen as a portion of an appropriately timed operation for complications of pancreatitis uniformly resulted in an uncomplicated course and survival (3 patients). Leaving the spleen in place when it was directly involved in a pseudocyst and/or when the splenic vein was occluded resulted in postoperative bleeding, the requirement for reoperation, and death from septic sequelae (2 patients). One patient died of progressive respiratory and renal failure because initial operation was inappropriately delayed. We recommend splenectomy as a portion of an appropriately timed operation for complications of pancreatitis when the splenic vessels are involved and/or when the spleen is directly involved in a pseudocyst or lesser sac collection.

Continual catheter administration of an elemental diet in infants and children.

Elemental diet offers a safe, simple, widely applicable technique for providing nutritional support in infants and children, thus protecting them against the hazards of malnutrition. Continual catheter administration of elemental diet provides an avenue of nutritional support free of many of the complications associated with total parenteral nutrition. Although mechanical and metabolic complications were avoided by rigid protocol compliance in our group of over 150 patients, further metabolic studies may suggest minor compositional changes providing a more optimal diet for premature and newborn infants.

Laparotomy for staging of Hodgkin's and non-hodgkin's lymphoma.

To justify the performance of an invasive technique as an aid to determining diagnosis and therapy in any condition, one must correlate the benefits derived with the adverse effects of performing that procedure. The review of the records of the patient indicates that clinical staging remains a moderately inaccurate means of assessing the extent of the disease in patients with Hodgkin's and non-Hodgkin's lymphoma. Lymphangiogram remains an aid to the surgeon in the localization of suspicious nodes. It is of greater accuracy in the patient with Hodgkin's lymphoma as compared with those with non-Hodgkin's lymphoma. Conversely, laparotomy for staging was not of as great a value in the patients in the non-Hodgkin's group as in those in the Hodgkin's group, and the incidence of complications was higher in the non-Hodgkin's group; especially in the patients with advanced disease. Laparotomy for staging is of significant benefit in the Hodgkin's lymphoma group, and the complication rate is not prohibitive. Laparotomy for staging in the non-Hodgkin's lymphoma group, on the other hand, is of less value than it is in the Hodgkin's group and is associated with a substantially higher complication rate in the face of advanced disease. In non-Hodgkin's lymphoma, individual decisions regarding laparotomy must be used, and the routine use of laparotomy may not be warranted.

Splenectomy in children. A correlative review of indications and complications in fifty patients.

We have reported our experience with splenectomy in fifty patients less than fourteen years old. The indications, results, and complications were enumerated. These data were then correlated with the recent literature regarding pediatric splenctomy. Of special note is the problem of immunologic incompetency associated with splenectomy in the patients less than five years old.

The VIPoma: further confirmation of VIP as the hormonal agent in the WDHA syndrome.

The WDHA syndrome characterized by watery diarrhea, hypokalemia, and achlorhydria is being diagnosed with increasing frequency. The diagnosis has been made to date only due to severe clinical symptomatology. In a review of the literature gastrin, secretin, glucagon, enteroglucagon, gastric inhibitory peptide (GIP), vasoactive intestinal peptide (VIP), and prostaglandins have been variously suggested as a possible etiologic agent for this syndrome. A case of the WDHA syndrome is reported in which hormonal assays of the serum preoperatively and two years postoperatively and tumor for many of the proposed agents is performed. A discussion of possible cross-reactivity among these similary structured polypeptides in the radioimmunoassays systems is used to explain the multitude of possible hormonal agents presented in the literature. Standardization of the VIP assays will result in increasing diagnosis of this diseases state prior to its fulminant clinical presentation.

Factors increasing the probability of malignancy in thyroid nodules.

A series of 348 patients undergoing operative intervention because of thyroid masses is reviewed. The incidence of primary malignancy among these patients is 16.4%. Male sex and the presence of cervical adenopathy significantly increase the probability of malignancy. The presence of multiple nodules or a functional nodule on radioiodine thyroid scan significantly reduces the probability of cancer. A rational approach to thyroid nodules is presented based on these findings and new modalities that have become available.

Continual catheter administration of an elemental diet.

A technique for continual catheter administration of elemental diet is used as the basis for successful nutritional support. There is a rational for early postoperative use of elemental diet as an intrajejunal feeding to provide fluid, electrolytes and nutritional requirements.

Gallbladder disease in the young male.

Eighteen of 2,614 patients undergoing cholecystectomy in two large general hospitals were males between the ages of two and twenty years. The great majority presented with a typical symptoms of cholecystitis. Ten of the eighteen had idiopathic cholelithiasis, with no predisposing factors generally associated with an increased incidence of this disease. This diagnosis must be kept in mind in dealing with patients of this age group.

Liver failure after jejunoileal shunt.

Reports of fatty infiltration of the liver following jejunoileal shunt for obesity and hyperlipemia are frequent. Cases of overt liver failure, in contrast, are rare and poorly documented following the various types of small bowel bypass. Fifteen months after jejunoileal bypass, a 41-year-old nonalcoholic woman whose preshunt liver function was chemically normal was found to have morbidly abnormal liver chemistry values. A biopsy examination demonstrated severe fatty metamorphosis bordering on frank cirrhosis. Reversal of her shunt led to return of her liver chemistry values to normal and reversal of the morphologic changes noted at biopsy examination. Close follow-up of patients subjected to small bowel bypass for obesity or hyperlipemia is mandatory. If liver function abnormalities persist for more than six months, strong consideration should be given to reversal of the shunt.

Thyroid carcinomas arising in thyroglossal ducts.

Six cases of thyroid carcinoma arising in a thyroglossal duct cyst are described and combined with previously reported cases to provide a total of 66 cases for retrospective analysis. Most presented as benign thyroglossal duct cyst, and the malignant nature of the lesion was not recognized until the permanent pathology sections were reviewed. Eight of 10 patients with metastatic disease in retrospect had preoperative indications of malignancy as manifest by clinically suspicious nodes or a thyroglossal cyst larger than the mean for the series. The primary cell type in all cases was papillary thyroid carcinoma. Local resection by the Sistrunk method and suppressive doses of thyroid are recommended for the patient with papillary thyroid carcinoma arising in a thyroglossal duct cyst when there is no evidence of extension of the malignancy beyond the confines of the cyst. The patient presenting with metastatic carcinoma should, of course, be treated with appropriate local resection, hormonal manipulation, thyroid ablation, and lymphadenectomy as indicated by his age and sex, the cell type of the tumor, and the extent of local and metastatic disease.