Fat absorption and gastroenteric pH profile in postsurgical pancreatic insufficiency: role of the association of H2-receptor antagonists with pancreatic enzymes.

The complete control of steatorrhea in post-surgical exocrine pancreatic insufficiency is difficult. The aim of this study was to evaluate the effect of the association of ranitidine with pancrelipase om fecal fat excretion in patients who had undergone a pancreatoduodenectomy with suppression of the exocrine pancreatic secretion by Neoprene injection. Ten patients were studied 1 year after surgery. Steatorrhea was measured as an integrated test of 3-day stools, while patients were kept on a diet of 100 g lipid/day, with their usual enzyme supplementation therapy (16,050 USP units of lipase/meal). A basal 24-h gastroenteric pH profile was also obtained. In the following month, patients had ranitidine (150 mg twice a day) in addition to pancrelipase. Then steatorrhea and gastroenteric pH were reassessed. Mean fecal fat was 26.9 (SD 13.7) g/day without ranitidine and 30.5 (SD 13.9) g/day during combined treatment. Body weight and nutritional parameters did not show any significant variation after ranitidine administration. Even in the absence of ranitidine, postprandial gastroenteric pH values were always > 4; the H2-receptor antagonist only reduced fasting gastric acidity. In conclusion, the gastroenteric pH and fecal fat determinations showed that ranitidine is not useful in patients with total postsurgical exocrine pancreatic insufficiency.

Early and late results of laparoscopic choledochotomy without biliary drainage.

On account of dissatisfaction with the two-staged approach to stones in the common bile duct, and the risks associated with endoscopic papillotomy, one-stage laparoscopic duct exploration was commenced. The initial experienced with 20 cases is presented. In 13 cases the transcystic approach to the main duct was not successful, so a choledochotomy was performed, and closed without biliary drainage. The postoperative course was similar to laparoscopic cholecystectomy and was uncomplicated in all patients. The follow-up examination of 12 patients demonstrated a mild stenosis of the main duct in our first case; however, this resolved spontaneously within six months. When indicated, the laparoscopic "ideal" choledochotomy with fibroscopic exploration gives very good early and long term results.

[The usefulness of dietetic supplementation in feeding after gastric and pancreatic surgeries]. / Utilità di un integratore dietetico nella rialimentazione dopo chirurgia gastrica e pancreatica.

We evaluated the efficacy of an oral artificial supplementation in 22 patients who underwent surgery for gastric or pancreatic cancer. From 8th to 14th postoperative day, 11 patients (cases) received a diet consistent in their REE, and an oral integrator (40% of REE); controls received only the diet. On 7th and 15th day, nutritional and anthropometric parameters were evaluated, and bioelectrical impedance analysis (BIA) was performed to assess body composition. The dietary caloric input was similar in cases (1154 kcal, 86.0% of REE) and controls (1393 kcal, 92.3% of REE). Due to the integrator, cases reached 121.4% of REE (p less than 0.001). The nutritional and anthropometric parameters studied did not show significant variations in the two groups, but BIA showed a decrease of fat mass in controls with respect to cases (p less than 0.02). Our results demonstrate that the oral artificial supplementation was well tolerated, and did not reduce food intake, but induced a significant increase of total caloric input.

Role of bioelectrical impedance analysis in acutely dehydrated subjects.

15 young healthy volunteers were studied to assess the reliability of bioelectrical impedance analysis (BIA) to determine body composition during acute dehydration. Body weight (BW), resistance and reactance measurements were performed before and 4h after a 40 mg intravenous administration of furosemide. BW decreased on average from 69.09 +/- 9.83 kg to 67.43 +/- 9.72 kg (p < 0.001), while resistance, reactance, and phase angle showed significant increases. The individual variations in bioelectrical parameters were not related to the BW loss. Formulae to derive body composition predicted poorly the true water loss (mean individual error: 40% of real loss). The errors in body composition prediction were unrelated to basal percentage of fat free mass, to body mass index, or to BW loss after furosemide administration. In conclusion, BIA proved unreliable in calculating the body composition of acutely dehydrated subjects.

Evaluation of the predictive performance of nutritional indicators by receiver-operating characteristic curve analysis.

Four hundred twenty-two cancer patients who underwent major surgery were studied. At admission, nutritional status was evaluated in all patients by assessing serum albumin (SA), total iron-binding capacity (TIBC), total lymphocyte count (TLC), serum cholinesterase activity (CHE), and weight loss (WL). All patients received perioperative short-term antibiotic prophylaxis and postoperative total parenteral nutrition. Prognostic ability of nutritional indicators was assessed by receiver-operating characteristic (ROC) curve analysis. The area beneath the ROC curve (Az) is an index of predictor performance when its value ranges from 0.5 (chance performance) to 1 (perfect prediction). Specificity, sensitivity, Youden index, and predictive values were determined for each nutritional parameter within a wide range of potential threshold values. Postoperative septic complications were observed in 85 (20.14%) patients. The Az values for the considered nutritional parameters ranged from 0.52 to 0.57 and that showed the low predictive ability of the parameters. When sensitivity and specificity for each nutritional parameter were examined at different thresholds, a clearly more predictive cutpoint was not observed, but ranges of values with a similar predictivity were observed. Significant ranges of predictivity were found for SA (33 to 35 g/L), for TIBC (2200 to 2300 micrograms/L), for TLC (2100 to 2200 million/L), for CHE (1700 to 1900 U/L), and for WL (7% to 12%). The higher values of Youden index were as follows: 1.183 for WL (cutoff 11%), 1.150 for TLC (cutoff 2100 million/L), and 1.145 for SA (cutoff 35 g/L). In conclusion, ROC curve analysis showed that the nutritional parameters had a low predictive ability.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative management of patients with total exocrine pancreatic insufficiency.

The occurrence of maldigestion and malnutrition was studied in 14 patients who had undergone pancreaticoduodenectomy and occlusion of the Wirsung duct with Neoprene. Before discharge patients were put on a 70 g/day dietary fat intake. Mean faecal fat excretion was 32.9 g/day without enzyme replacement and fell to 14.2 g/day with pancrelipase supplementation. At discharge all patients were underweight (88 per cent of the usual mean body-weight) and nine patients showed alteration in laboratory nutritional parameters. At the time of discharge a low-fat diet (50 g/day) was prescribed. Six months after surgery, mean faecal fat excretion decreased further to 8.3 g/day (P less than 0.01) and all patients but one gained weight, reaching 93 per cent of the usual mean body-weight with normalized nutritional parameters. Our data show that the combination of enzyme replacement therapy and low-fat diet allows good correction of steatorrhoea and a significant improvement in nutritional status.