The progressive Zollinger-Ellison syndrome in multiple endocrine neoplasia.

The problem of hypergastrinemia in patients with the syndrome of multiple endocrine neoplasia (MEN type 1) has become increasingly controversial since the introduction of the antisecretory H2 antagonists for the treatment of the Zollinger-Ellison syndrome (ZES). One of the questions in the management of ZES is whether the malignant potential of the gastrinomas or the recurrent complications of ulcer will be the ultimate cause of death. Another problem is whether the association of MEN is a favorable or unfavorable factor to the prognosis of patients with ZES. Hypercalcemia contributes to excessive gastrin secretion, thereby casting doubt on the diagnosis of ZES in the presence of MEN. Patients with MEN are also more likely than patients with ZES not to have gastrinoma on an exploratory laparotomy. The existing controversy concerns the choices of therapy in instances of progressive ZES associated with MEN or when there is a failure to detect a primary gastrinoma when exploration is performed. To highlight the debate, the clinical courses of two patients, observed during two and three decades, respectively, are presented. These patients were receiving high doses of cimetidine; in addition, conventional surgical treatment for ulcer and repeated biopsies for gastrinoma were performed. After total gastrectomies (as life saving procedures), both patients are well.

A simplified one stage modification of portoazygos disconnection for massive variceal hemorrhage.

A one stage, complete abdominal portoazygos disconnection procedure is a safe and efficient method for the treatment of acute variceal bleeding. This method was performed upon five patients who were bleeding due to severe cirrhosis of the liver, with no operative mortality. No recurrence of bleeding occurred during a follow-up study of one to four years.

The triangular island skin flap for treatment of anal ectropion.

Another method for repair of anal ectropion is reported. Two triangular island flaps, deeply based, are advanced medially to cover the excised area, thus resurfacing the anal canal with normal skin. The technique is recommended because of its simplicity, reliability, and satisfactory results.

Maintenance of colloid osmotic pressure in critically ill surgical patients on total parenteral nutrition.

The effect of total parenteral nutrition (TPN) on plasma colloid osmotic pressure (COP) was investigated in critically ill and stable surgical patients. Normal COP ranged from 22 to 26 mm Hg (mean +/- SD 24 +/- 2). In critically ill patients COP levels dropped as low as 14 mm Hg (mean 17 +/- 2.4), and remained at these low levels despite aggressive nutritional support with 2,500 to 4,000 kcal and 100 to 170 g protein/day given as central vein parenteral nutrition. A group of stable surgical patients receiving TPN as supportive therapy was investigated as a comparison with the critically ill group. The mean COP level in this stable group was 21.8 +/- 0.6 mm Hg, at the low-normal level. Only when the critically ill patients became less catabolic, sometimes coincident with the resumption of oral intake, did COP levels rise toward normal. As long as a patient is critically ill, the low COP levels should be corrected by the addition of plasma and albumin, as TPN seems to be inadequate for this task in these surgical patients.

Cysts of the adrenal gland.

3 cases of adrenal cysts are reported. The incidence of cyst originating in the adrenal gland was found to be 0.02-0.06% in autopsies. Adrenal cysts are usually symptomless making the diagnosis difficult. The cases described here were diagnosed and removed at operation. One of them was associated with hypertension, and another with pregnancy, considered to be exceptional. Two of these cysts were calcified. All of them were benign. The definite preoperative diagnosis is difficult and the surgical procedure recommended is resection of the cyst with preservation of as much adrenal tissue as possible if malignancy is excluded by frozen section. Since the number of operated cases diagnosed preoperatively are too small, the possibility of treating adrenal cyst by percutaneous aspiration and injection of opaque material to eventually avoid surgery could not be established.

Long term total parenteral nutrition through peripheral veins.

Most complications of total parenteral nutrition are directly related to the use of hypertonic glucose and central venous catheters. We describe a system in which hypertonic glucose is omitted from the total parenteral nutrition regimen and is replaced by Intralipid as the main source of calories. Protein hydrolysate and lipid solutions are infused simultaneously via peripheral veins. This method proved to be simple and efficient with no deleterious effects in 22 patients who were treated for periods of three to 14 weeks.

Role of peritoneal absorption in ascites.

The movement of water, electrolytes and protein across the peritoneum was studied experimentally and clinically in ascites. In the experimental and clinically in ascites. In the experimental studies, large amounts of solutions of various osmolar and colloid osmolar concentrations were infused rapidly into the peritoneal cavities of 32 dogs. In 26 of these dogs, the ureters were ligated before the experiment was begun; the other six dogs served as controls. The clinical studies were done in five patients with ascites. Tritium, 35S and RISA dilution techniques were used to study the kinetics of the different components of peritoneal fluid. Osmolarity changes were measured in plasma and peritoneal fluid by the freezing point depression method. Volume changes of peritoneal fluid were measured serially up to 24 hours for the assessment of the peritoneal absorption rate. The rate of fluid movement across the peritoneal membrane seems to be influenced, among others, by the composition of the intraperitoneal fluid, as well as by the properties of the membrane itself. An asymmetric pattern of peritoneal absorption rate of the different compositional elements of ascitic fluid was observed in this study which seems to interrelate with dynamic equilibrium which develops between ascites and the physiologic body fluid compartments. No cessation of peritoneal fluid absorption or a maximal reabsorption rate was observed in this study; nevertheless, variations in the rate of peritoneal absorption due to miscellaneous influences are possible.