Postoperative intussusception: increasing frequency or increasing awareness?

Postoperative intussusception in children is a rare but well recognized phenomenon. The diagnosis is often delayed due to the protean manifestations of the disorder (ileus, distention, and nausea and vomiting) which, when encountered shortly after an abdominal operation, usually result in a low index of suspicion because they are common after laparotomy. Experience with two cases of postoperative intussusception within 24 hours heightened our index of suspicion. Review of our records indicated we had diagnosed and treated postoperative intussusception in 14 children during the preceding 4 years. Patient ages ranged from 4 months to 12 years (mean 39 months, median 20 months), and symptoms appeared on postoperative days 3 to 36 (mean 10 days, median 6 days). Initial operations included excision of a retroperitoneal or abdominal tumor (five cases), Nissen fundoplication and gastrostomy (three), ileal resection (two), Ladd procedure (one), Duhamel operation (one), and operative reduction of ileocolic intussusception (the two most recent cases). Eleven patients had appendectomy (five by the inversion technique), and three had placement of a transgastric small bowel feeding tube. Nine children had had either barium enema or upper gastrointestinal studies because of the postoperative suspicion of obstruction; one patient had both. Diagnostic studies were not done in four patients. Operative reduction was successful in all but one child, who required bowel resection.

Detergent enema: a cause of caustic colitis.

A 5-year-old boy developed acute colitis followed by stricture formation as a result of a detergent enema. The acute phase of the caustic induced colitis was reproduced in the dog and the rat using full strength and diluted detergent enemas. The severity of the experimental colitis was shown to be directly related to the concentration of the detergent.

Essential fatty acid deficiency in surgical patients.

Parenteral nutrition may protect patients unable to eat from malnutrition almost indefinitely. If fat is not also given EFAD will occur. This outlines a prospective study of 28 surgical patients on total intravenous fat-free nutrition to determine the developmental course of EFAD and the response to therapy. Twenty-eight patients ranging from newborn to 66 years receiving parenteral nutrition without fat had regular determinations of the composition of total plasma fatty acids and the triene/tetraene ratio using gas liquid chromatography. Physical signs of EFAD were looked for also. Patients found to have evidence of EFAD were treated with 10% Intralipid. Topical safflower oil was used in three infants. Total plasma fatty acid composition was restudied following therapy. In general, infants on fat-free intravenous nutrition developed biochemical EFAD within two weeks, but dermatitis took longer to become evident. Older individuals took over four weeks to develop a diagnostic triene/tetraene ratio (greater than 0.4; range 0.4 to 3.75). Therapeutic correction of biochemical EFAD took 7 to 10 days but dermatitis took longer to correct. Cutaneous application of safflower oil alleviated the cutaneous manifestations but did not correct the triene/tetraene ratio of total plasma fatty acids. These studies indicate that surgical patients who are unable to eat for two to four weeks, depending upon age and expected fat stores, should receive fat as a part of their intravenous regimen.

The use of a crystalline amino acid mixture for parenteral nutrition in low-birth-weight infants.

Thirty-six preterm, sick, low-birth-weight neonates were given either total or partial parenteral nutrition. The patients were divided into three groups according to their birth weights: group A -less than 1,000 gm, 12 patients: group B--between 1,000 and 1,500 gm, 15 patients: group C--more than 1,500 gm, 9 patients. The solution for total parenteral nutrition contained 20% glucose and 2.6% crystalline amino acids plus appropriate amounts of vitamins and minerals. The volume of infusate given was usually 125 ml/kg/day, but varied depending on the clinical condition of the patient; occasionally it was as high as 150 to 175 ml/kg/day. Infusate of one-half strength was administered initially; its concentrations of glucose and amino acids were increased to three quarters and full strength gradually, if tolerated. The solution for total parenteral nutrition was infused into the superior vena cava via a central venous catheter; that for partial parenteral nutrition was given into a peripheral vein to supplement inadequate oral feedings. The period of parenteral nutrition lasted from 5 to 49 days, with an average of 13.2 days. The intake of 500 mg of nitrogen as crystalline amino acids and 100 kcal as glucose was capable of achieving body weight gain. Positive nitrogen balance of various degrees was also observed. Hyperglycemia of a slight to moderate degree was observed in nine patients; only three required insulin therapy. Two patients had thrombotic occlusion of the central venous catheter. The conclusion was reached that total parenteral nutrition or partial parenteral nutrition, when properly managed, is a safe procedure in small, premature infants. The amino acid solution given as a nitrogen source along with adequate calories was effective in promoting weight gain and nitrogen balance; it was apparently well tolerated by low-birth-weight neonates.