Long-term nutritional and metabolic consequences of pancreaticoduodenectomy in children.

BACKGROUND: The long-term nutritional and metabolic consequences of pancreaticoduodenectomy in children are unknown. METHODS: Five children were evaluated in a clinical research center 2.5 to 10 years after pancreaticoduodenectomy to assess their nutritional status based on patterns of growth and to assess their gastrointestinal function. Investigation included vitamin levels, a bentiromide study, and serum immunoreactive trypsinogen levels to evaluate pancreatic function and a d-xylose absorption and a radionuclide gastric emptying scan for intestinal absorption and motility. RESULTS: Children were able to grow after pancreaticoduodenectomy. Three remained in low percentile groups for height/weight ratio, and two were near or above normal. Low normal levels of the fat-soluble vitamins were present. Very low levels of pancreatic function were found based on the bentiromide and trypsinogen studies, whereas intestinal absorption of d-xylose was normal except for one patient with extremely rapid gastric emptying. CONCLUSIONS: After pancreaticoduodenectomy children can grow and develop normally if given adequate levels of oral pancreatic supplements to replace the severely decreased level of endogenous pancreatic enzymes after operation. Routine supplementation of the fat-soluble vitamins should be considered.

Anorectal function in children after ileoanal pull-through.

Mucosal proctectomy and ileoanal pull-through is increasingly used in children requiring total colectomy for ulcerative colitis or familial polyposis. Excellent continence can be achieved with this procedure, and it avoids proctocolectomy and permanent ileostomy. We have evaluated prospectively anorectal function in nine consecutively treated children who underwent ileoanal pull-through. Patients were 8 to 17.5 years of age (median, 11.3 years) at the time of surgery; seven had ulcerative colitis, and two had familial polyposis. Anorectal evaluation was performed before colectomy and ileoanal pull-through, following ileoanal pullthrough, after rectal training, and then at yearly intervals. A biofeedback "rectal training" program was instituted 6 weeks after ileoanal pull-through and a contrast study documenting integrity of the pouch. The program consisted of an initial biofeedback session with the motility unit, followed by daily instillations, through a catheter, of progressively larger volumes of water (from 1 to 6 oz, increasing 1 oz per week) into the ileal pouch. Patients were instructed to retain the water and participate in normal activities after the instillation. This protocol acclimated the patient to sensing distension of the pouch and using the sphincters. The follow-up period ranges from 1 to 4.5 years (median, 2.2 years). All patients are continent by day and night. One patient has nocturnal incontinence with episodes of pouchitis. Stool frequency is three to eight movements per day (median, four), with none at night. Preoperative resting rectal sphincter pressures averaged 74.3 +/- 23.1 mm Hg (mean +/- standard deviation), and a maximum squeeze pressure was 93.9 +/- 25.3 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

CT quantitation of tracheal cross-sectional area as a guide to the surgical and anesthetic management of children with anterior mediastinal masses.

Pediatric patients presenting with anterior mediastinal masses between January 1980 and November 1988 were reviewed to assess the correlation between tracheal cross-sectional area and anesthetic risks. Forty-two patients had evaluable computed tomography (CT) scans and underwent a surgical procedure. Thirty-four patients had Hodgkin's disease, six had non-Hodgkin's lymphoma, and two had mediastinal teratoma. Tracheal cross-sectional areas were greater than 75% of expected in 19 cases, greater than 50% to 75% in 16 cases, greater than 25% to 50% in five cases, and less than or equal to 25% in two cases. The presence or extent of symptoms did not correlate well with the degree of tracheal narrowing shown by CT scan except for orthopnea. Local anesthesia was used primarily in patients with significant tracheal narrowing (tracheal size was less than or equal to 56% in 5 of 6 patients). General anesthesia with spontaneous ventilation by mask was performed in four patients with tracheal areas of 33%, 73%, 76%, and 98% of expected. General endotracheal anesthesia was utilized in the remaining 32 patients, only three of whom had tracheal areas of less than 50% of expected (down to 30%, 26%, and 24% of expected) and one received preoperative radiotherapy (26%). None of these 32 patients had symptoms of orthopnea or dyspnea at rest, and only one had dyspnea on exertion. All tolerated anesthesia without difficulty. No patient in this series suffered respiratory or cardiovascular collapse during surgery. Adequate biopsy material was obtained in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective, randomized study of adjuvant parenteral nutrition in the treatment of sarcomas: results of metabolic and survival studies.

A prospective, randomized study was performed to evaluate the use of total parenteral nutrition (TPN) in a group of young patients receiving aggressive chemotherapy for metastatic or locally recurrent sarcomas. Fourteen patients were randomly selected to receive TPN and 18 to receive conventional oral nutritional support (CN). During the study period (from first dose of chemotherapy to recovery from myelosuppression), the TPN patients received between 1020 and 2100 calories/m2/day (median 1650) and between 5.3 and 12.4 gmN/m2/day (median 8.9), while the CN patients received between 380 and 880 calories/m2/day (median 685) and between 0.0 and 3.7 gmN/m2/day (median 1.5). The mean daily nitrogen balance during the study period for the TPN group (-3.0 to + 1.3 gmN/m2/day, median -0.7) was significantly higher (p = 0.005) than that of the CN group (-6.2 to -0.7 gmN/m2/day, median -2.6). Serum protein levels (albumin, total protein, and transferrin) did not differ between the two treatment groups. The proportion of patients responding to therapy and the long-term survival rates were similar in the treatment groups. Thus despite established improvement in nitrogen balance, no survival or therapeutic advantage was demonstrated for the adjuvant parenteral nutrition group. Further studies of the role of parenteral nutrition as an adjuvant to cancer chemotherapy are needed to determine which populations of patients will benefit from its use.

The effect of chemotherapeutic agents on wound healing.

A review of experimental studies of chemotherapeutic agents and wound healing has demonstrated impairment of healing by a wide variety of agents. The extent of impairment by several agents (corticosteroids, Adriamycin, methotrexate, and cyclophosphamide) is dependent upon the interval between administration and wounding. If given within three to four days of wounding significant impairment results, but beyond that interval, impairment is minimal. Studies in animals with some agents (adriamycin, nitrogen mustard, cyclophosphamide, and methotrexate) have shown a dose-dependent impairment of healing, but extrapolation of these doses to regimens employed in man is impossible. Information regarding complications of chemotherapeutic agents in wound healing in man is available from adjuvant studies. No increased frequency of complications from nitrogen mustard, thio-TEPA, or cyclophosphamide occurred, even when these agents were given in the immediate perioperative period. Increased wound complications occurred with 5-fluorouracil when a 60 mg/kg dose was begun seven days after surgery but not when it was begun 14 days after surgery. These results stress the need for continued attention to wound complication occurring in adjuvant studies, and suggest that delay of treatment until seven days after surgery should produce minimal impairment.