Preoperative oral immunonutrition versus standard preoperative oral diet in well nourished patients undergoing pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy is still associated to high morbility, especially due to pancreatic surgery related and infectious complications: many risk factors have already been advocated. Aim of this study is to evaluate the role of preoperative oral immunonutrition in well nourished patients scheduled for pancreaticoduodenectomy. METHODS: From February 2014 to June 2015, 54 well nourished patients undergoing pancreaticoduodenectomy were enrolled for 5 days preoperative oral immunonutrition. A series of consecutive patients submitted to the same intervention in the same department, with preoperative standard oral diet, was matched 1:1. For analysis demographic, pathological and surgical variables were considered. Mortality rate, overall postoperative morbility, pancreatic fistula, post pancreatectomy haemorrhage, delayed gastric emptying, infectious complications and length of hospital stay were described for each groups. Chi squared test, Fisher's Exact test and Student's T test were used for comparison. Differences were considered statistically significant at p < 0.05. Statistics was performed using a freeware Microsoft Excel (®) based program and SPSS v 10.00. RESULTS: No statistical differences in term of mortality (2.1% in each groups) and overall morbility rate (41.6% vs 47.9%) occurred between the groups as well as for pancreatic surgery related complications. Conversely, statistical differences were found for infectious complications (22.9% vs 43.7%, p = 0.034) and length of hospital stay (18.3 ± 6.8 days vs 21.7 ± 8.3, p = 0.035) in immunonutrition group. CONCLUSION: Preoperative oral immunonutrition is effective for well nourished patients scheduled for pancreaticoduodenectomy; it helps to reduce the risk of postoperative infectious complications and length of hospital stays.

[A serious complication due to liquid silicone injection in the legs for cosmetic purpose]. / Effetto collaterale da iniezione di silicone liquido nelle gambe per uso estetico.

Liquid injectable silicone has been used to increase volume in determined cutaneous districts, particularly in aesthetical reconstructive surgery. Although considered biologically inert for a long time this substance produced various complications as granulomatous foreign body reaction (siliconomas), secondary limphedema, tissue destruction and lethal embolism. A 35-year-old Caucasian woman came to our department with erithema and edema on the right leg, fever and chills. A thorough examination of the patient's history revealed injection of liquid silicone 7 years before for cosmetic volume increase of both legs. A closer observation revealed a small fistulous element from which came out white-yellow puruloid material. Antibiotic therapy and drainage of the abscess were undertaken. Within few days of treatment erithema and swelling essentially improved and the patient was discharged. After two months she came back to our department due to the same disease on her left leg that we treated with the therapy previously used. We highlight the long time, 7 years, elapsed between liquid silicone injection and onset of cutaneous symptoms.

Percutaneous endoscopic gastrostomy: a long-term follow-up.

Percutaneous endoscopic gastrostomy (PEG) is the preferred method of long-term tube feeding, but only a few studies describe a long-term follow-up. The purpose of this study is to analyze the follow-up of PEG enteral feeding patients in the long term, and to report on the complication and survival rates. Between January 1991 and June 1995, we studied 136 patients (49% cancer and 51% non-cancer patients; male = 68%, female = 32%) after PEG insertion. One hundred twenty-eight patients had a long-term follow-up of over 31 d. The mean duration of PEG feeding was 277 +/- 358 d (range 31-1590): 17% of patients returned to oral feeding, 34% continued enteral nutrition, and 49% died. Major complications occurred in 3% of the patients: 1 aspiration pneumonia, 1 subcutaneous abscess. 2 buried bumper syndrome. Minor complications arose in 14% of our cases: 8 tube blockages, 4 tube dislodgements, 6 site infections. For the whole group of 136 patients, survival probabilities after PEG insertion at 1, 6, 12, and 24 mo were 90.5%, 52%, 42%, and 35%, respectively. After 180 d, the difference in survival probabilities between cancer and non-cancer patients became significant (P < 0.02). Median survival probability was 64% for non-cancer and 39% for cancer patients, and this trend did not change over 2 y.

Passively administered antibody suppresses the induction of measles virus antibodies by vaccinia-measles recombinant viruses.

We have used vaccinia-measles recombinant viruses to study vaccination in the presence of pre-existing antibody. When mice were vaccinated with recombinants expressing either the haemagglutinin (H) or fusion (F) measles virus (MV) proteins, the humoral response to the MV protein was suppressed by passively administered polyclonal antibody. However, individual monoclonal antibodies (H or F) did not affect the response. Mice whose anti-MV antibody response to H or F was initially suppressed by passive administration of anti-MV antibody were revaccinated 120 days later and gave a normal humoral response to the MV proteins. The VV-H recombinant induces a strong class I CTL response in Balb/c mice. This was not affected by the presence of levels of anti-MV antibody which inhibited the humoral response.

[Trace nutrients in total enteral nutrition: the basal status and longitudinal course]. / Oligonutrienti in nutrizione enterale totale: stato basale e andamento longitudinale.

INTRODUCTION: Previous studies demonstrated deficiencies of selenium and other micronutrients in patients receiving total enteral nutrition (TEN). The content and bioavailability of trace elements in enteral formulas can be suboptimal. MATERIAL AND METHODS: Basal blood levels of some trace elements (copper, iron, selenium, zinc) and vitamins (B12, folic acid) were determined in twenty patients at the beginning of TEN. Vitamin E was measured in 7 patients. Primary diagnosis was cancer (no. = 13) and organic brain syndromes (no. = 7). Commercially available polymeric and oligomeric enteral formulas were used, containing respectively, as a percent of RDA in 1500 kcal, 65-39% of copper, 180-135% of iron, 80-100% of zinc. Selenium was not indicated; determinations in our laboratory gave a content of 78-63% of the minimum recommended intake. Blood levels of copper and zinc (no. = 6), selenium (no. = 5), iron, transferrin and ferritin (no. = 13) were measured after two months of TEN (mean intake of 30 +/- 3 kcal/kg/day). Copper, selenium and zinc were measured with atomic absorption; iron with the complessometric method: vitamin B12 and folic acid with RIA; vitamin E with HPLC. RESULTS: Mean values, expressed as mean +/- SD (range) were: copper: 129 +/- 23 (82-300) micrograms/dl; iron: 37 +/- 18 (16-89) mg/dl; selenium: 53 +/- 20 (22-93) micrograms/dl; zinc: 85 +/- 34 (44-185) micrograms/dl; vitamin B12: 632 +/- 450 (140-1575) pg/ml); vitamin E: 5.4 +/- 1.5 (3.3-7.8) mg/dl; folic acid: 11 +/- 8 (2-20) ng/ml. Values below the lower normal limit were found in 100% (vitamin E), 89% (selenium), 60% (iron), 35% (zinc), 24% (vitamin B12) and 14% (folic acid) of the patients studied. Copper was higher than the upper normal limit in 31% of cases; no data below normal range was found. Mean blood levels of depleted subjects were at the 28%, 43%, 54% and 63% of the mean normal value respectively for iron, selenium, vitamin E and zinc. Blood iron (p < 0.05) and selenium (p < 0.001) were significantly lower in more malnourished patients (weight loss > 20% vs < 20% on usual body weight). After two months of TEN, a reduction of 33% of mean blood selenium was observed in 4 of 5 patients studied. Blood copper and zinc remained stable in 6 subjects with initial normal or higher than normal values. Blood iron increased nonsignificantly, ferritin remained stable, transferrin increased significantly (p < 0.05). No clinical deficiency syndromes were observed. CONCLUSIONS: A careful monitoring of micronutrients during TEN is recommended. Selenium content of enteral formulas, unless supplemented by the producers, seems to be insufficient to maintain the initial blood level in two months of TEN.

[Percutaneous endoscopic gastrostomy]. / Gastrostomia endoscopica percutanea.

Surgical gastrostomies were first performed in the middle of the 19th century and modified during the following years, but the most important technical improvement was percutaneous endoscopic placement (PEG), in 1980 by Ponsky and Gauderer. This technique doesn't require anesthesia and it in possible also in patients with contraindications to surgical gastrostomy. The simple procedure involves a shorter hospitalization, lower risks and reduced costs. Many authors already reported the good results of this new technique, that can be performed on a day-hospital regimen as well. The main indications are head and neck cancers, neurologic diseases involving food intake capacity, cancer cachexia, obstruction of the GI tract when there is enough space for an endoscopic procedure. Every disease that can compromise food intake for a period longer than 60 days can find an indication in placing a percutaneous gastrostomy. The advantage for the patient is a much better psychological tolerance compared with a naso-gastric tube. Also the incidence of mechanical complications of a PEG is much lower. In our experience from October '90 to July '92 we followed 34 patients with PEG, 22 males and 12 females, with mean age of 69 years (range 41-88). We used 9-French tube placed using the pull-method technique. All patients received antibiotic therapy for 5 days. About 12 hours after PEG placement all patients began using the gastrostomy, initially with the administration of electrolyte solutions and later with enteral polymeric formulas. The constant increase led all patients to a 1500 non protein calories daily intake in 3-4 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Enteral nutrition in the elderly]. / La nutrizione enterale dell'anziano.

Elderly is particularly at risk of malnutrition: he is not able to feed himself adequately, it is then important to attain correct intakes using also artificial enteral nutritional techniques (nasogastric tube, gastrostomy, etc.). These techniques may lead to complications (ab ingestis pneumonia, metabolic complications, alvus disorders): the use of artificially nutrition in the elderly must be carefully evaluated. 257 patients (M = 180, F = 77) aged 65 or more, mainly affected by neoplastic diseases (n 195) and by neurological and vascular diseases (n 62). The feeding route were evaluated in this study: 74% by nasogastric tube, 13% by gastrostomy, 11% by jejunostomy. In a group of 55 patients similar concerning clinical and nutritional conditions we evaluated at the beginning of enteral feeding and four months later, caloric/protein intake, body weight and plasmatic albumin. In patients fed by nasogastric tube a mean intake of 1300 +/- 365 Kcal n.p./die, with a protein rate of 58.5 +/- 16.9 g/die was attained; by gastrostomy 1450 +/- 324 Kcal n.p./die and 65.5 +/- 16 g/die; by jejunostomy 1219 +/- 398 Kcal n.p./die and 53.3 +/- 21 g/die. The compliance to enteral nutrition was well in 37% of patients night administration was performed. Clinical complications: nausea and vomiting were observed in 9 patients with nasogastric tube, in 1 patient with gastrostomy and in 3 patients with jejunostomy; diarrhea has been noticed in 6 patients with nasogastric tube and in 1 patient with jejunostomy. Mechanical complications; nasogastric tube (n 189): 35 displacements, 7 breakages, 4 obstructions; pharyngostomy (n 6): 2 displacements and 1 obstruction; gastrostomy (n 33): 3 displacements; jejunostomy (n 29): 2 misplacements.(ABSTRACT TRUNCATED AT 250 WORDS)

[The role of the intestine in the pathogenesis and treatment of multiple organ failure]. / Il ruolo dell'intestino nella patogenesi e nel trattamento della "multiple organ failure".

Infection and sepsis remain major causes of death in medical and surgical services, despite the availability of potent antibiotics, aggressive surgery and close monitoring of patients in intensive-care units. Actually the terminology to define this type of events in multiple organ failure: we considered the role of intestine in its pathogenesis and its management.

Electromyographic observations in patients with foot pain syndromes.

Abductor hallucis muscle EMGs were performed in control subjects and in patients with chronic foot pain (9 affected by the disease of the metatarsophalangeal joint of the big toe, 6 affected by chronic foot strain) to investigate pathophysiological mechanisms of muscle pain syndromes. Unlike control subjects, patients showed an abnormal involuntary activity when standing. All patients presented a decrease of abnormal EMG activity when postural changes were induced either by variations in body weight distribution on the feet, or by changes of position in the weight-bearing foot achieved by arch supports or by boards of variable thickness applied under the forefeet or the heels. Anaesthesia of the metatarsophalangeal joint of the hallux (injection into the joint cavity of 2-3 ml 0.50% bupivacaine) reduced the abnormal EMG activity only in patients with hallux valgus, whereas it did not affect muscular activity in the other patients. Present results support the idea of the role of abnormal muscular activity in causing and maintaining chronic pain and suggest that alterations of postural mechanisms and of afferent input, in particular that arising from joint receptors, are involved in the genesis of this abnormal muscular activity.