bluuebunny/crossref_metadata_2025 huggingface dataset:
The pathophysiology of enterocutaneous fistulas
Authors: Fischer Josef E.
Published: May 2005

The patient with an enterocutaneous fistula represents a high‐risk situation with overall mortality rates of up to 20%, depending on the series. Treatment of these patients to a successful outcome requires attention to detail and, if necessary, meticulous operative technique.

For convenience, care of these patients is divided into 5 phases:

Stabilization. Resuscitation with crystalloid colloid and/or blood. Drainage of only obvious abscesses. Beginning of local wound care. Initiation of nutritional support.

Investigation. Radiographic investigation of local fistula area, principally by sinography and, if necessary, other contrast studies. Purpose of these studies is to determine likelihood of spontaneous closure with nutritional support.

Decision. Is operation indicated and, if so, when? A decision must be made as to the necessity for operative closure in situations in which the fistula appears anatomically favorable but shows no signs of closure.

Definitive therapy—either spontaneous closure or operation. If the latter, careful preparation is required. Resection and end‐to‐end anastomosis gives the best results.

Healing phase. Nutritional support should not be discontinued too soon for fear of breakdown of newly laiddown protein.

With experience and proper management, relatively high success rates can be achieved.
Elemental diet and enterocutaneous fistula
Authors: Deitel Mervyn
Published: May 2005

Nutritional support is important in the healing of enterocutaneous fistulas. Total parenteral nutrition (TPN) has been a most significant advance in this provision. However, elemental diet may be used effectively with proximal gut fistulas (if delivered distally) or with low intestinal fistulas.
Alimentary tract fistula: Stomatherapy techniques of management
Authors: Devlin H. Brendan , Elcoat Catherine
Published: May 2005

Skin care of enterocutaneous fistulas is demanding but rewarding work, and there is considerable benefit if these cases are referred to centers in which the interests and skills are already developed. Management must include nutritional support, skin care, and morale improvement. The details of the principles of skin care are outlined in this report. The variety of materials utilized in stoma care and indications and instructions for their utilization are discussed.
Operative strategy in the treatment of enterocutaneous fistulas
Authors: Hill Graham L.
Published: May 2005

An overall plan for the management of patients with enterocutaneous fistulas is presented. It comprises 4 sequential but frequently overlapping stages which include control of the fistula output, drainage of sepsis, intravenous nutrition, and excision of the fistula if there is no spontaneous closure.

When the fistula persists, radiological investigations usually reveal the cause, and definitive surgery is required. This is conducted 6–8 weeks after all signs of sepsis have gone and the patient has been restored to nutritional health. For fistulas of the distal duodenum, jejunum, and ileum, the surgical procedure is a radical one involving complete dissection of the entire small intestine, resection of the segment of bowel involved, and primary anastomosis. Occasionally, especially when there has been abdominal irradiation, it is not possible to excise the diseased bowel, and bypass is preferred. Fistulas of the second part of the duodenum are treated by the serosal patch technique in which the jejunal wall is sutured directly to the opening of the fistula.

Surgery is also often required early in the course of treatment when abscesses are drained and proximal diversion (with or without excision of the involved segment of bowel) may be required to control the fistula output. Definitive surgery at this stage frequently results in recurrence of the fistula and carries a high mortality rate.
Postoperative liver insufficiency: Prevention and management
Authors: Bismuth H. , Houssin D. , Mazmanian G.
Published: May 2005

Postoperative hepatic insufficiency is a rare cause of liver failure. Consequences of this usually predictable complication can be limited by appropriate preventive measures and careful postoperative management. This report reviews the current experimental and clinical literature with regard to postoperative hepatic insufficiency.
Acute pancreatitis after cardiac transplantation
Authors: Adiseshiah M. , Wells F. C. , Cory‐Pearce R. , Wallwork J. , English T. A. H.
Published: May 2005

Three cases of acute pancreatitis, which occurred in the early postoperative period after heart transplantation, are reported. This represents an incidence of 10% of a total of 30 cases. The disease was relatively mild and the serum amylase not grossly elevated. The diagnostic importance of laparotomy is stressed.
Effect of trauma on malaria infection
Authors: Aina A. Olufemi
Published: May 2005

Specific malaria antibody concentrations in the sera of Nigerian patients were estimated before and after elective surgery by the microplate version of the enzyme‐linked immunoabsorbent assay (ELISA). Parasitized erythrocytes per 100 leukocytes in Leishman‐stained tail blood smears were also counted on the pre‐ and early post‐trauma days in traumatized and non‐traumatized (control) laboratory mice previously inoculated withPlasmodium berghei malaria parasites.

On the 1st, 2nd, and 3rd postoperative days, specific malaria antibody levels in the sera of Nigerian patients were significantly depressed (p<0.02;p<0.01;p<0.001, respectively) while parasitemia was significantly elevated in laboratory mice with fractured femur (p<0.02;p<0.01;p<0.05, respectively).

Increased susceptibility to malaria after severe injury is suggested.
The radiocephalic fistula as vascular access for chemotherapy
Authors: Wobbes Theo , Slooff Maarten J. H. , Lichtendahl Dagna H. E. , Vriesendorp Robert , Mulder Nanno H.
Published: May 2005

In 110 patients 127 radiocephalic arteriovenous fistulas were performed as vascular access for chemotherapy. If patients did not receive cytostatic agents prior to the operation or were treated for less than 4 weeks, the success rate of the operation was 75%. If chemotherapy was administered for longer than 4 weeks, it was possible to construct a functioning fistula in only 28% of patients. The radiocephalic arteriovenous fistula is considered to be a convenient access for chemotherapy provided the operation is performed before the start of the treatment.
Preoperative transhepatic biliary decompression in pancreatic and periampullary cancer
Authors: Ellison E. Christopher , Van Aman Michael E. , Carey Larry C.
Published: May 2005

Pancreatic resection for pancreatic and periampullary cancer between 1969 and 1975 at The Ohio State University Hospitals had an associated operative mortality rate of 30% and a morbidity rate of 80%. Transhepatic biliary decompression (THD) has been accepted as a method of preoperative risk reduction in the deeply jaundiced patient and an alternative to surgical biliary decompression. The use of preoperative THD in pancreatic and periampullary cancer was examined. Of 44 patients with bilirubin greater than 10 mg/100 ml, 17 had radical resection (THD=7, no THD=10), and 27 had palliative operation (THD=17, no THD=10). Preoperative serum bilirubin in the THD group was 7.3±1.0 compared to 16.3 ±1.5 in the no THD group (p< 0.05). Operative morbidity rate was: radical surgery: THD (40%), no THD (70%); palliative surgery: THD (18%), no THD (20%). Operative mortality rate was: radical surgery: THD (28%), no THD (60%); palliative surgery: THD (6%), no THD (0%). Catheter‐related complications were minimal. Preoperative THD tends to reduce the risk of curative resection for pancreatic and periampullary cancer, but does not alter the outcome of palliative surgery. Long‐term THD may be an alternative if palliative surgical biliary decompression either fails or is not technically possible in the patient with unresectable cancer.
Cancer of the pancreas: Palliative operation, Whipple procedure, or total pancreatectomy
Authors: Longmire William P.
Published: May 2005

Current reviews of the treatment of cancer of the pancreas, most of which evaluate cases treated in the past one or two decades, continue to present discouraging results. The advantages and disadvantages of performing a resection must be carefully evaluated for each patient. The dilemma of resection should be discussed with the patient before operation and when capable he or she should influence the decisions the surgeon anticipates facing during the operation. Pancreatoduodenectomy is the treatment of choice for carefully selected cases of carcinoma of the head of the pancreas and other periampullary carcinomas. Total pancreatectomy has not, at this point, been shown to provide sufficient advantages to warrant routine adoption as the treatment of choice when resection is to be performed.
Surgical treatment of pancreatic cancer
Authors: Kümmerle F. , Rückert K.
Published: May 2005

From 1964 to 1982, there were 782 patients treated for carcinoma of the pancreas. In 174 patients pancreaticoduodenal resection was possible (22%). Until 1977 we performed Whipple procedures, while from 1978 to 1982 total pancreatectomy was preferred. Comparing the results of both methods, we did not find any advantages of total pancreatectomy. Operative mortality did not decrease, survival time did not extend, and the higher resection rates (up to 26%) for more advanced tumor stages were accompanied by greater morbidity. With respect to the patients with inoperable cancer of the pancreas, we found over the last 5 years that the rate of those not undergoing surgery has climbed from 8% to 25%, while the rate of exploratory laparotomies was reduced from 28% to 5%. With the advent of preoperative percutaneous transhepatic cholangio‐drainage (PTCD), the mortality rate of our palliative procedures dropped to 12%. Biliodigestive anastomosis of choice is the hepaticojejunostomy.
Pancreatoduodenectomy with preservation of the pylorus
Authors: Braasch John W. , Gongliang Jin , Rossi Ricardo L.
Published: May 2005

We report 45 consecutive pylorus‐preserving pancreatic resections performed from September, 1979, to August, 1983, for chronic pancreatitis or a variety of periampullary malignancies without an operative death. Of these, 36 patients had pancreatoduodenectomy with pancreatic anastomosis. The most common cause of postoperative morbidity was delay in gastric emptying, which extended beyond 10 days in 13 patients. Twenty‐eight patients could be evaluated for digestive function. Of these, 2 had mild dumping symptoms, and 14 required pancreatic exocrine supplements. A marginal ulcer developed in only 1 patient and was successfully treated by histamine H2‐receptor blockers. Food capacity was normal in 23 of 28 patients and 50–90% of normal in 5. A mean body weight of 93% of pre‐illness weight and 106% of preoperative weight had been regained. Ten of 11 patients with adenocarcinoma of the pancreas were dead of disease (median survival, 12 months), but 19 of 20 other patients with other periampullary malignancies were alive and free of disease up to 42 months postoperatively. Pylorus‐preserving pancreatectomy is the operation of choice for most lesions requiring removal of the periampullary area.
Intraoperative radiation therapy for patients with pancreatic carcinoma
Authors: Shipley William U. , Tepper Joel E. , Warshaw Andrew L. , Orlow Erica L.
Published: May 2005

The results of treatment with intraoperative and external beam radiation for patients with carcinoma of the pancreas are presented. Among patients treated with125I implants for localized unresectable disease, local control rates ranged from 67% to 93% and median survival ranged from 7 to 12 months. In a series using intraoperative electron beam boosts, a 59% local control rate with a median survival of 16 months was achieved. Good palliation rates were achieved, although a high proportion of fatal complications occurred in one125I series. Less promising results were seen in patients receiving intraoperative radiation following resections, with a local control rate of 50% and a median survival of 7 months in a series of 10 patients.
Malignant islet‐cell tumors of the pancreas
Authors: Thompson Norman W. , Eckhauser Frederic E.
Published: May 2005

Although malignant islet‐cell tumors are uncommon, they are an important group of pancreatic neoplasms because appropriate treatment can often result in effective palliation even though cure is infrequent. In general, these tumors are relatively slow growing so that a combination of surgical and chemotherapeutic measures may prove very beneficial. In some patients with tumors hypersecreting insulin, gastrin, glucagon, or vasoactive intestinal polypeptide (VIP), the hormonal effects of the neoplasm can be life‐threatening. Surgical treatment must, therefore, consider both the functional and malignant characteristics of the individual tumor. In many patients with functional tumors, surgical debulking of the primary tumor may be indicated even when a curative resection cannot be accomplished. Some malignancies may be cured by an appropriate pancreatic resection even when peripancreatic lymph nodes are already involved. Although a Whipple procedure is not indicated when hepatic metastases are present, this procedure may cure tumors localized to the pancreatic head and/or peripancreatic lymph nodes. Because hepatic metastases are usually multiple and involve both lobes, liver resections, other than wedge excisions of peripherally located functional metastases, are not indicated. Malignant nonfunctioning islet‐cell tumors are probably best treated with systemic or regional chemotherapy when metastatic. Surgical resections or bypass procedures may be infrequently useful in those cases in which the primary tumor causes either duodenal or bile duct obstruction. The most effective methods used to control hepatic metastases are systemic and hepatic arterial chemotherapy. An alternative is selective hepatic artery embolization. Recently, an implantable hepatic arterial infusion pump has been used with encouraging results in this group of patients. The chemotherapeutic agents that have been most effective in the treatment of hepatic metastases include streptozotocin, DTIC, and fluorouracil.
The future in treatment of pancreatic cancer
Authors: Dietzen Charles D. , Cohn Isidore
Published: May 2005

The mortality rate for pancreatic cancer continues to rise. Despite advances in surgery, radiotherapy, and chemotherapy, the survival rate remains dismal. Future treatment will depend on further epidemiologic, diagnostic, and pathologic studies, as well as controlled clinical trials. Application of new areas of oncologic research to pancreatic cancer is a worthwhile endeavor. Promotion, publication, and dissemination of such research on pancreatic cancer are the goals of the National Pancreatic Cancer Project.
Radiothallium scintigraphy in solitary nonfunctioning thyroid nodules
Authors: Höschl R. , Murray I. P. C. , McLean R. G. , Choy D. , Indyk J. S.
Published: May 2005

The role of radiothallium201Tl chloride scintigraphy was evaluated in 117 patients with solitary thyroid nodules, demonstrated as nonfunctioning with99mTc pertechnetate, and in which histologic diagnosis was obtained. The nodules were malignant in 25 patients and benign in 92. In an attempt to improve the initial diagnostic discrimination between malignant and benign lesions, the degree of accumulation of201Tl by the nodule was assessed semiquantiatively. The uptake was graded by comparing the accumulation by the nodule with that in the paranodular tissue (PN) (1‐absent; 2‐minimal uptake but lower than in PN; 3‐uptake equal to PN; 4‐mildly preferential uptake in comparison with PN; 5‐markedly increased uptake). None of the patients with grade 1 or grade 2 uptake had malignant disease. Of 25 patients with histologically confirmed cysts, 21 had uptake of grade 1 and 4 of grade 2. Benign adenomas (67 patients) were associated with all grades, 45% having grade 3 uptake. Uptake of201Tl in malignant lesions was in all instances at least equal to paranodular tissue or higher (grades 3–5). The incidence of malignancy was 17% in grade 3, 15% in grade 4, and 67% in grade 5 uptake. It is considered that thallium scintigraphy is not by itself a definitive investigation for thyroid cancer but, since the predictive value of malignancy with strict decision threshold (grades 1–4 considered normal and grade 5 abnormal) is 67%, and predictive value of a negative test is 90%, the procedure does have a useful role in investigation of nonfunctioning solitary thyroid nodules either by heightening the suspicion of malignancy or by indicating a very low probability of malignant change.
The use of PMMA beads in recurrent high anal fistula: A preliminary report
Authors: Kupferberg Arie , Zer Michael , Rabinson Souzane
Published: May 2005

Five patients with recurrent high anorectal fistula, in which traditional methods had failed to give complete recovery, were successfully treated by a new technique consisting of partial excision of the fistula, insertion of PMMA beads (Septopal®) and primary closure of the wound, followed by gradual removal of the beads, beginning 7 days after operation and extending over at least 3 weeks (partly on an ambulatory basis). In all these patients, there was eventual complete healing of the problematic fistula. This safe, easily performed method is recommended as being a useful means for combating infection, making possible complete healing, and preventing future recurrence in similar challenging cases.
Repair of ventricular septal defects
Authors: Doty Donald B. , Lamberth Wade C.
Published: May 2005

Primary closure of large ventricular septal defects was performed in 57 patients ranging in age from 1 to 24 months during an 11‐year period. Weight of patients ranged from 2.5 to 12.2 kg (mean, 6.6±0.9 kg). Shunt flow was large with mean Qp/Qs, 3.5±0.5. It was possible to close the defect by the transatrial approach in 86% of patients using a prosthetic patch attached to the ventricular septum by continuous polypropylene suture (89%). Early mortality of 5% and late mortality of 2% and excellent functional results in 93% suggest that this approach is appropriate.
Obstructions to left ventricular outflow
Authors: Weldon Clarence S.
Published: May 2005

Modern techniques of cardiopulmonary bypass combined with methods for myocardial protection make the conventional operations of prosthetic patch aortoplasty, aortic valvotomy, and transvalvular resection of subaortic membranes dependable and accurate procedures which can provide the obliteration or successful reduction of systolic gradients with rare mortality or morbidity. Sonography provides a technique for the diagnosis of critical aortic stenosis in the newborn, permitting expeditious surgical intervention, while prostaglandin therapy provides a technique for the restoration of systemic blood flow and the reversal of acidemia in preparation for surgical intervention. Hypothermic techniques provide protection of ischemic myocardium which is thought to be a principal cause for earlier failures in the management of critical aortic stenosis. An appreciation that critical aortic stenosis need not be cured but only relieved for infant survival has led to the application of dilatation techniques using mechanical dilators and angioplasty balloon catheters. Successful repair of such complex malformations as atrioventricular septal defect, aortic arch interruptions, and the coarctation syndrome in the neonate has uncovered a variety of new fibrous, muscular, and fibromuscular left ventricular outflow tract obstructions which appear to be acquired and progressive and not solely congenitally determined. Sonography provides a technique for the detection and the serial assessments of these lesions. Radical operative approaches have been devised for enlarging, reconstructing, exposing, and replacing the left ventricular outflow tract. These operations, which have thus far found their principal use for the relief of complex and combined left ventricular outflow tract obstructions in older children and for reoperations on the left ventricular outflow tract, will achieve a fuller potential when the procedures are miniaturized and adapted to the use in surgery of the neonate and young infants.
Valve replacement in children
Authors: Elliott Martin J. , de Leval Marc
Published: May 2005

With increasing experience in the surgical management of children with congenital heart disease has come an increasing use of prosthetic valves. They have been employed in a wide variety of conditions ranging from simple congenital stenosis or incompetence to an essential part of repair of more complex disorders. As in adult cardiac surgery, there has been considerable debate over the exact prostheses that should be used in individual circumstances. As we point out in this article, experience has varied both geographically and with time. Our own experience at Great Ormond Street, for example, has been of initial satisfaction with results of mechanical valves followed by enthusiasm for, sequentially, the Hancock and the Ionescu prostheses. Now we have turned full circle and predominantly use mechanical valves, primarily owing to the extraordinary incidence of premature, degenerative calcification of bioprosthetic valves in children. The exact rates of degeneration of these valves are variable; thus it is difficult to relate prosthesis survival to the growth rate of the child. The experience with homograft valve replacements is encouraging, since they do not seem to degenerate so rapidly. Valve replacement in children carries a high risk. The younger the child, the higher the risk, with mitral valve replacement being the most dangerous procedure of all. We conclude that valve replacement in children is a procedure that should not be taken lightly and for which, at present, mechanical valves offer the best prognosis, despite the small risk of anticoagulation.
Repair of complete atrioventricular canal in infancy
Authors: Castaneda Aldo R. , Mayer John E. , Jonas Richard A.
Published: May 2005

Results of operative repair of complete atrioventricular canal defects (CAVCD) are improving due to: general advances in pre‐, intra‐, and postoperative care; a better understanding of the relevant pathological factors, principally of the left atrioventricular (A‐V) valve; a clearer definition of the path of the specialized conduction tissue; and the recognition of associated defects such as single left ventricular papillary muscles, ventricular hypoplasia, with or without malalignment of the common A‐V valve, coexistent ventricular septal defects, and double orifice left A‐V valves. Forty‐eight patients underwent repair from July 1980 through July 1984. Three patients died early and 2 late after the operation. One patient with an additional posterior ventricular septal defect (VSD) remained in complete heart block. Three patients required reoperation for residual left A‐V valve regurgitation and 1 for a residual VSD. In 20 recatheterized patients, mitral regurgitation was moderate in 4 and severe in 2. Pulmonary artery pressure (pulmonary/systemic arterial systolic pressure ratio) remained unchanged in only 1 patient with significant A‐V valve regurgitation. To avoid the development of pulmonary vascular obstructive disease, and based also on the trend of decreasing operative mortality and morbidity rates, primary repair of CAVCD is recommended within the first year of life.
Gastrointestinal myoelectric activity following abdominal operations in the opossum
Authors: Coelho Julio C. U. , Gouma Dirk J. , Moody Frank G. , Li Young F.
Published: May 2005

Gastrointestinal myoelectric activity of the opossum, both in fasting and fed states, was studied after abdominal operations. Five different procedures were performed: a 5‐min, a 1‐hour, and a 3‐hour laparotomy with intestinal handling, enteroenterostomy, and gastrojejunostomy. Electromyographic recordings from the stomach, duodenum, jejunum, ileum, and sphincter of Oddi were obtained from unanesthetized animals. A normal fasting pattern after abdominal operations was observed from immediately after surgery to the fifth postoperative day and depended on the type and duration of the surgical procedure. A fed pattern did not occur in the experiments in which food was instilled before the appearance of the myoelectric migrating complex. A normal fed pattern was observed after the myoelectric migrating complex appearance in all but 2 experiments, one of which occurred in an animal with an intra‐abdominal abscess.
Prophylactic regimens in colorectal surgery: Comparisons between metronidazole used alone or with ampicillin for one or three days
Authors: Roland Magne , Bergan Tom , Bjerkeset Tormod , Erichsen Hans , Hoel Roar , Johansen Svein , Liavåg Ivar , Reinertsen Sverre , Rosseland Arne , Teigan Tor , Thorsen Glen , Wiig Johan
Published: May 2005

The purpose of this study was to compare as anti‐infectious prophylaxis in elective colorectal cancer surgery the effect of metronidazole alone and in combination with ampicillin, and the effect of a duration of 1 or 3 days of prophylaxis. The prophylactic regimens designated regimens A‐D given in randomized order were metronidazole 500 mg used alone or with 2.0 g ampicillin administered every 8 hours as separate but simultaneous infusions. All patients studied received preoperative mechanical evacuation of bowel contents. Eight surgical departments participated in the study. Two hundred thirty‐three patients were studied. The distribution of sex, age, and type of operation was similar among the groups of patients receiving each regimen, except that there were more cases of sigmoidectomy, low anterior resection, or rectal amputation in the group receiving regimen D. The duration of the operations was comparable, even for each type of operation considered separately. Samples for bacteriological examination were obtained by abscess punctures when relevant. The pus was taken and transported to the laboratory under anaerobic conditions. Moderate or severe infections were observed in 6 (10.3%) of 58 patients on regimen A, in 2 (3.5%) of 58 patients on regimen B, in 4 (7.0%) of 57 receiving regimen C, and in 2 (3.3%) of 60 given regimen D. The highest incidence of postoperative infections was observed in rectal amputation. The bacteria causing postoperative infections were similar in the regimens A and C receiving only metronidazole for 1 and 3 days, respectively and in regimens B and D in which ampicillin was added. Only one anaerobe, aClostridium perfringens, was recovered from regimen C; twenty‐two strains of anaerobic bacteria were recovered from regimen A. The number of aerobic bacteria was 25 in regimen A and 16 in regimen C. The yield of bacteria was much more sparse when metronidazole was combined with ampicillin. Eleven isolates (2 anaerobes) were recovered from regimen B, only one isolate was recovered from patients on regimen D, an indole positiveProteus. In conclusion, th'is study indicates that a combination of metronidazole and ampicillin is particularly useful in rectal surgery. Metronidazole alone may suffice in colonic surgery, but a combination with an agent against aerobes is recommended in rectal surgery. The difference between 1‐day prophylaxis and 3‐day prophylaxis was insignificant for metronidazole plus ampicillin; a single day of this prophylactic regimen would appear advisable.
Cushing's syndrome and pheochromocytoma caused by an adrenal tumor, also containing met‐enkephalin and somatostatin: A case report
Authors: Bruining Hajo A. , Ong Eveline G. L. , Gershuny Anthony R. , Lamberts Steven W. J.
Published: May 2005

The simultaneous occurrence of hypercorticolism and increased plasma catecholemia due to pheochromocytoma does not fit into the concept of the known combinations of multiple endocrine adenomatosis. In this paper we communicate the very rare picture of a adrenocorticotropic (ACTH)‐producing pheochromocytoma, giving rise to both clinical entities simultaneously. It is hypothesized that the severity of the clinical picture of this patient was caused by hypercorticolism, which affects the metabolism of catecholamines resulting in a relatively increased production of dopamine.
Nutritional assessment and severity of illness classification systems: A critical review on their clinical relevance
Authors: Dionigi Renzo , Cremaschi Riccarda Erica , Jemos Vassili , Dominioni Lorenzo , Monico Roberto
Published: May 2005

Several studies have attempted to define nutritional parameters that can be used to select undernourished hospitalized patients and identify those who present higher risk of postoperative septic complications. Nevertheless, the majority of these studies do not take into consideration the severity of infectious episodes. Systems for scoring the severity of illness are of critical importance in hospital practice and clinical research. In fact, they could be used for the following purposes: (a) a more correct stratification of patients in clinical studies; (b) monitoring the evolution of the infectious complication; (c) prediction of survival; (d) optimization of the criteria for admission to and discharge from intensive care units; and (e) evaluation of quality, quantity, and costs of nutritional therapy in critically ill patients. In this article, the authors present a critical review on the clinical relevance of the methods of nutritional assessment more commonly used in clinical practice; and, moreover they discuss the more recently proposed systems for scoring the severity of illness.
Protein‐sparing therapy in the postoperative period
Authors: Keller Ulrich , Clerc Didier , Kränzlin Marius , Heberer M.
Published: May 2005

Surgical trauma leads to increased nitrogen loss which may result from increased protein breakdown, diminished protein synthesis, or both. Increased protein breakdown is predominant after surgical trauma, whereas protein synthesis has been reported to be either unchanged or increased. Attempts to improve nitrogen balance should be directed toward both mechanisms; protein breakdown is diminished by avoiding tissue damage, and by prevention of sepsis which results in release of catabolic peptides, e.g., of interleukin 1. Protein breakdown may also be diminished by avoidance of stress hormones, particularly of cortisol, and by providing energy substrates, i.e., glucose, long‐ or medium‐chain fatty acids. Protein synthesis is enhanced by providing nutrition, including supply of energy and amino acids. Data obtained in human volunteers demonstrated that transient elevation of plasma cortisol to stress levels resulted in sustained elevation of plasma amino acids, indicating increased proteolysis. Four hours after plasma cortisol elevation, glucose “clamp” studies indicated insulin resistance of peripheral and hepatic glucose metabolism. In contrast, insulin action on plasma amino acids was unimpaired suggesting that hyperinsulinemia was capable of reverting the cortisol‐induced protein breakdown. The effect of postoperative amino acid therapy was studied in 60 patients after major surgery who received either amino acids or carbohydrates, or both by peripheral venous administration. Postoperative nitrogen balance during 6 days was not significantly improved when amino acids were administered in spite of different plasma concentrations of glucose, insulin, and ketone bodies during the various nutrition regimens. Thus, measures to diminish protein breakdown and to increase protein synthesis should be integrated into the management of the postoperative patient, in order to diminish nitrogen loss and thus to decrease postoperative morbidity.
Parenteral nutrition by peripheral vein, portal vein or central venous catheter?
Authors: Bodoky Andras
Published: May 2005

Different venous accesses used for parenteral nutrition are described. The most important complications and possibilities for prevention are discussed according to both literature and personal experience. As a result, peripheral venous access is recommended for short‐term parenteral nutrition (up to 8 days), whereas central venous access should be used to deliver high caloric loads during extended periods of time. Portal venous access does not appear to have a place in parenteral nutrition to date.
Indications and effects of preoperative parenteral nutrition
Authors: Müller J. M. , Keller H. W. , Brenner U. , Walter M. , Holzmüller W.
Published: May 2005

Malnutrition can be an important risk factor, especially in patients undergoing major gastrointestinal surgery. With 7–10 days of adequate preoperative parenteral nutrition, we are able to improve the nutritional status of most patients. Concentrations of several parameters of the protein compartment and immunocompetence increase significantly. The effect of preoperative parenteral nutrition on postoperative outcome has been tested in only a few properly designed comparative trials. The results were not unanimous. If the postoperative complication rate was high, preoperative parenteral nutrition significantly reduced it. Improvement in surgical technique limited the value of preoperative parenteral nutrition. However, as long as the postoperative complication rate is not zero, preoperative parenteral nutrition is indicated, especially in patients with cancer of the upper gastrointestinal tract, when a major operation is planned.
Alternative methods of nutrition in the postoperative phase
Authors: Heberer Michael , Harder Felix
Published: May 2005

Enteral nutrition as the natural alternative to parenteral feeding offers a wide range of choices with respect to access to the intestinal tract, type of substrate, and mode of application. For most enteral feeding problems in general surgery, nasogastric tubes and the catheter jejunostomy can be regarded as well standardized, cost‐effective, safe and simple solutions. Enteral feeding should be preferred when nutritional support is required for extended periods of time, whereas parenteral nutrition is preferred when nutritional or metabolic imbalances need to be compensated within short periods of time or when enteral nutrition is contraindicated.
Choledochal cyst: Complications of anomalous connection between the choledochus and pancreatic duct and carcinoma of the biliary tract
Authors: Nagata Eiichi , Sakai Katsuji , Kinoshita Hiroaki , Hirohashi Kazuhiro
Published: May 2005

We have done a retrospective study of the clinical features, complications, surgical treatment, histological findings, and outcome of 27 adults with choledochal cyst (congenital biliary dilatation) whom we have encountered in the past 11 years. In 24 (88.9%) of them, an anomalous connection between the choledochus and the pancreatic duct was found by direct cholangiography, or during operation or autopsy; three also had carcinoma of the biliary tract. In congenital biliary dilatation, this anomalous connection seems to be a major factor in causing cholangitis and carcinoma of the biliary tract. For this reason, congenital biliary dilatation must be treated surgically. This involves resection of the dilated bile duct and the gallbladder to remove the place where bile stasis had been present, and reconstruction of the biliary tract to stop reflux of pancreatic juice in the bile duct.
Effect of parathyroid surgery on cartilage calcification
Authors: Van Geertruyden Jean , Kinnaert Paul , Frederic Nany , Fuss Michel , Corvilain Jacques
Published: May 2005

The incidence of chondrocalcinosis in 4 locations (knees, wrists, lumbar discs, and symphysis pubis) has been compared on x‐rays made before and after parathyroid surgery in patients operated on for primary and secondary hyperparathyroidism. Before parathyroid surgery, the overall incidence of chondrocalcinosis in primary and secondary hyperparathyroidism is comparable. However, the distribution by age, the number of joints affected, and the locations are different. Parathyroid surgery changes neither the incidence nor the severity of chondrocalcinosis, in patients with primary or secondary hyperparathyroidism.
The current status of biliary tract surgery: An international study of 1072 consecutive patients
Authors: DenBesten Lawrence , Berci George
Published: May 2005

An international study to determine the practice patterns and outcome of operations for stone‐related biliary tract disorders was commissioned by the International Biliary Association in 1981. Twenty‐one institutions generated 69,700 data bits from 1,072 consecutive patients over an 18‐month period. These data were analyzed for approach to diagnosis, conduct of operation, and outcome. Of the 1,072 operations (412 United States, 660 international), 986 (92%) were primary and 86 (8%) were secondary or repeat procedures. Although elective cholecystectomy was preceded by 2 or more diagnostic tests in 25% of patients, institutional patterns ranged from a single test in 60% of patients to 94% of patients having more than 3 preoperative diagnostic tests. Elective cholecystectomy included operative cholangiography in 83% of patients and choledochotomies in 17% (182 of 1,072). The incidence of negative duct exploration and retained stones was 18.5% and 4.5%, respectively. Choledochoscopy was done before duct exploration in 25% (30.4%‐U.S.A.; 19.5%‐international) and prior to T‐tube insertion in 38% (29%‐U.S.A.; 43%‐international). Repeat operations for choledocholithiasis included a drainage procedure in 72% of American and 46% of European patients. Complications after primary procedures were 17% in the United States (12.4% biliary, 4.4% nonbiliary) and 35% (25% biliary, 9.1% nonbiliary) in the international series. Complications after secondary procedures were 48% (40% biliary, 8% nonbiliary). The mortality rate for all patients was 1.6% for primary procedures (0.6% for cholecystectomy alone) and 2.3% for secondary procedures. These data indicate that: (a) duplication of diagnostic procedures is frequent and characteristic of certain institutions; (b) cholangiography decreases the incidence of negative choledochotomy, and choledochoscopy reduces the incidence of retained stones; and (c) diagnosis, operative management, and outcome vary greatly among institutions.
Total gastrectomy: Is the early postoperative morbidity and mortality influenced by the choice of surgical procedure?
Authors: Hassler H. , Bochud R. , Nöthiger F. , Stafford A.
Published: May 2005

From 1973 to 1982, seventy‐two total gastrectomies were performed. The Siewert‐Peiper gastric replacement procedure was used in 48 cases, while the Rou‐xen‐Y method was performed in 24 cases. Retrospective analysis showed no significant statistical difference between the 2 methods with regard to postoperative morbidity and mortality. There was an overall mortality rate of 11% and a morbidity rate of 45% (10% anastomosis breakdown, 27% pulmonary complications, 1% bowel obstruction, 7% other complications). As the Roux‐en‐Y anastomosis is technically easier to perform compared to the Siewert‐Peiper gastric replacement and as the functional results from the literature are similar, we will, in the future, favor using the Roux‐en‐Y method in our department.
Gastrointestinal perforations in renal transplant recipients immunosuppressed with cyclosporin
Authors: Rigotti Paolo , Van Buren Charles T. , Payne William D. , Peters Charles , Kahan Barry D.
Published: May 2005

Gastrointestinal perforations frequently represent a lethal complication of immunosuppression. Of 325 renal transplant recipients treated with cyclosporin (CsA), 4 patients (1.2%) developed gastrointestinal perforation: 1 from gastric ulcer and 3 from colonic diverticula. All patients underwent operative treatment and all survived without complications. Three patients maintained a well‐functioning allograft. In comparison to azathioprine, CsA does not seem to greatly affect the immune response to bacterial infections, thus representing a considerable advantage in the management of serious gastrointestinal complications.
Rapid progressive dissemination of hemangiosarcoma of the spleen following spontaneous rupture
Authors: Simansky David A. , Schiby Ginette , Dreznik Zeev , Jacob Erwin T.
Published: May 2005

Hemangiosarcoma of the spleen is a rare entity with only 58 reported cases. It is a highly malignant tumor and, in 80% of the cases, metastases are already present at the time of diagnosis. Thirty percent of the patients present with spontaneous rupture of the spleen. This event is catastrophic and results in rapid dissemination of the disease, deterioration, and death. An additional case of hemangiosarcoma of the spleen presenting as spontaneous rupture is described. Despite repeated laparotomies, the histopathological diagnosis was made at a late stage of the disease.
Inotropic agents in the treatment of cardiogenic shock
Authors: Mueller Hiltrud S.
Published: May 2005

The pharmacological therapy of cardiogenic shock is determined by the underlying pathophysiology. In pump failure, secondary to severe obstructive coronary artery disease with a large compartment of ischemic myocardium at risk, coronary reserve is severely impaired. Any attempt to improve cardiac performance must consider the delicate balance between oxygen supply and requirement. Coronary blood flow is dependent on coronary perfusion pressure. Agents increasing arterial blood pressure improve coronary perfusion, but do not increase cardiac output and, thus, interfere with perfusion of vital organs. Inotropic agents, improving cardiac performance, may increase myocardial oxygen requirements in excess of availability; improvement of peripheral perfusion occurs at cost of a deteriorating pump. Contrarily, in pump failure due to primary myocardial impairment, as myocardiopathy or depression of ventricular function by extracorporal circulation, impairment of energy utilization by the myocardium, of contractility, and of neuro‐humoral responses are primary factors. Measures to improve cardiac performance are less limited by considerations of increasing myocardial oxygen requirements. Dobutamine, a relatively selective beta1, agonist, and dopamine, a nonselective beta, alpha, and dopaminergic agonist, are the most frequently applied vasoactive agents in the treatment of cardiogenic shock. Their effects are highly dose dependent. Both catecholamines improve cardiac performance and peripheral perfusion. The major differences between the two drugs are related to the effect on heart rate, cardiac filling pressure, and systemic vascular resistance. At clinically tolerated doses, dobutamine is a more potent inotropic agent than dopamine. The decrease in vascular resistance, unloading the left ventricle, is beneficial for the failing heart. Heart rate remains essentially unchanged. In contrast, dopamine increases arterial pressure, left ventricular filling pressure and, at higher doses, heart rate. If blood pressure cannot be maintained by dobutamine, dopamine is preferable. Moreover, the combination of both vasoactive agents has been proven beneficial, supplemented by I‐norepinephrine, if necessary. An aggressive approach to unstable angina and complicated myocardial infarction, identification of the patient at high risk for sudden cardiac events, introduction of myocardial preservations during surgery, and improved techniques have contributed to the decreased frequency of cardiogenic shock.
Experience with the pierce‐Donachy ventricular assist device in postcardiotomy patients with cardiogenic shock
Authors: Pennington D. Glenn , Samuels Larry D. , Williams George , Palmer Diane , Swartz Marc T. , Codd John E. , Merjavy John P. , Lagunoff David , Joist J. Heinrich
Published: May 2005

In order to assess the current status of ventricular assist device (VAD) support of patients with postcardiotomy ventricular failure, we evaluated the data from 17 patients treated over a 2‐year period with a Pierce‐Donachy paracorporeal pneumatic sac‐type VAD using atrial cannulation and asynchronous pumping. All patients had severe ventricular failure refractory to intra‐aortic balloon (IAB) and drug therapy. The effects of the VAD on left ventricular function were evaluated by nuclear ventriculography and hemodynamic measurements during brief pump on/pump off periods. Eight patients received only left VAD's, 5 received right VAD's and IAB, and 4 received 2 VAD's. All patients were weaned from cardiopulmonary bypass with VAD flows ranging from 1.55 to 2.78 L/min per m2.Eight patients died of bleeding, biventricular failure, or multiple organ failure without improvement in cardiac function. However, 9 patients (53%) had improved cardiac function, 8 were weaned from the VAD, and 7 (41%) were discharged. Five of the last 6 patients survived. Two patients with isolated left ventricular failure survived with left VAD alone. However, of 15 patients with biventricular failure, 5 of 9 receiving biventricular assistance were weaned, while only 1 of 6 receiving left VAD alone was weaned. Although activation of the left VAD decreased left ventricular ejection fraction, left atrial pressure, and left ventricular volume, it concomitantly increased left ventricular afterload. The Pierce‐Donachy VAD provided salvage of patients with severe ventricular failure after cardiac operations. The majority of patients had biventricular failure, which was best treated with biventricular mechanical support. Although the VAD reduced left ventricular preload, ejection fraction decreased as afterload increased, suggesting that asynchronous left atrial pumping does not unload the left ventricle.
The Pennsylvania State University paracorporeal ventricular assist pump: Optimal methods of use
Authors: Gaines Wayne E. , Pierce William S. , Donachy James H. , Rosenberg Gerson , Landis Donald L. , Richenbacher Wayne E. , Waldhausen John A.
Published: May 2005

A ventricular assist device (VAD) has been developed for clinical use at The Pennsylvania State University that can be inserted with standard surgical technique, is capable of completely supporting either the systemic or pulmonary circulation, and does not require anticoagulation. Since 1976, this device has been used in 29 patients following cardiac surgical procedures who were not able to be weaned from cardiopulmonary bypass (CPB) with conventional techniques. From 1976 through 1979, we used ventricular assist pumping in 14 patients. Four of these patients were weaned from the assist pump and 2 were discharged from the hospital, yielding a 14% survival rate. From 1980 to the present, 16 patients required use of the assist pump from which 9 patients were weaned and 7 patients were discharged yielding a 44% survival rate. During the 8 years of clinical experience with this device, a program designed to optimize results has evolved with respect to patient selection, insertion technique, and postoperative care that has resulted in significant improvement in patient survival.