Banana flakes control diarrhea in enterally fed patients.

Diarrhea occurs frequently in the critically ill tube-fed population and may result from a multitude of causes. Despite the availability of antidiarrheal medications, diarrhea associated with enteral feedings remains a problem for clinicians and for the patients affected by it. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving enteral feedings. Thirty-one patients with diarrhea and receiving enteral feedings were randomized to receive either banana flakes or medical treatment for diarrhea. Medical treatments included the use of pharmacological agents according to the discretion of the patient's physician or reducing feeding rates. Both banana flakes and medical treatments reduced the severity of diarrhea in critically ill tube-fed patients. Over the course of treatment, mean diarrhea scores were 21.64 +/- 7.81 for the banana flake group and 25.41 +/- 9.76 for the medical group. These differences were not statistically significant. Both groups achieved similar levels of nutrition support. The banana flake group had less diarrhea clinically, with 57% of the subjects diarrhea free on their last study day as opposed to 24% of the medically treated subjects. This occurred despite a threefold increase in the number of patients testing positive for Clostridium difficile toxin in the banana flake group. We conclude that banana flakes can be used as a safe, cost-effective treatment for diarrhea in critically ill tube-fed patients. Banana flakes can be given concurrently with a workup for C. difficile colitis, thereby expediting treatment of diarrhea.

Complications of laparoscopic cholecystectomy: the experience of a university-affiliated teaching hospital.

BACKGROUND: In most published reports on laparoscopic cholecystectomy, the cases have been accrued from small community hospitals in a multicenter fashion. The purpose of this study was to compare the rate of complication following laparoscopic cholecystectomy performed at a single university-affiliated teaching hospital to those quoted in the literature. STUDY DESIGN: A retrospective review of the first 1300 laparoscopic cholecystectomies performed at the Videoscopic Surgery Center at Pennsylvania Hospital from May 1990 through January 1994 was undertaken. Complications were classified as those related to creation of the initial pneumoperitoneum and those related to cholecystectomy. RESULTS: A 3% conversion rate to open cholecystectomy (n = 40) was noted due to the presence of dense adhesions, gangrenous cholecystitis, or difficult anatomic relationships. There were 18 complications (1.4%) related to creation of the initial pneumoperitoneum and 14 complications (1.1%) related to cholecystectomy. Complications related to laparoscopy included bleeding from the abdominal wall (n = 2), trocar site hernia (n = 11), hollow viscus injury (n = 1), and wound infection (n = 4). Complications related to cholecystectomy included unanticipated retained CBD stone (n = 5), symptomatic bile leak (n = 6), hollow viscus injury (n = 1), intraabdominal abscess (n = 1), and a retained portion of gallbladder (n = 1). There were no perioperative deaths related to laparoscopic cholecystectomy, and the overall morbidity was 2.4%. Long-term follow-up revealed no cases of benign biliary strictures. CONCLUSIONS: With attention to anatomy, technique, and meticulous dissection, laparoscopic cholecystectomy can be safely performed in a university-affiliated teaching hospital setting.

Osteoclastic giant cell tumor of the pancreas: an immunohistochemical study.

A case of an osteoclastic giant cell tumor of the pancreas is presented. Immunohistochemical studies were performed, which showed keratin (CAM, AE1) and epithelial membrane antigen positivity in the tumor cells. The findings support an epithelial origin for this tumor.

Small bowel obstruction following endoscopic extraperitoneal-preperitoneal herniorrhaphy.

Laparoscopic hernia repair has a number of unique potential complications. These include complications of pneumoperitoneum, general anesthesia, trocar injuries and complications of small bowel obstruction related to trocar site fascial defects, intraabdominal adhesions, and reaction with the synthetic mesh. A totally extraperitoneal approach should, in theory, eliminate postoperative small bowel obstruction in that the peritoneal space is never entered. A case of small bowel obstruction following totally extraperitoneal-preperitoneal herniorrhaphy is presented.

Combined laparoscopic-endoscopic gastrostomy.

Since the first report of successful percutaneous endoscopic gastrostomy placement by Gauderer and Ponsky in 1981 [Surg. Gynecol. Obstet. 152: 83-85], many modifications of the original technique have been published. Each reports easier and safer placement of the gastrostomy tube, but all have the same inherent flaw: Access to the gastric lumen is accomplished by a blind needle puncture of the anterior abdominal wall. A new technique, utilizing a newly available microendoscope (Origin Medsystems), is described. Using the microendoscope, direct visualization of the stomach and left upper quadrant of the abdomen allows safer access to the gastric lumen for subsequent tube placement without the need for additional incisions or punctures. The procedure can still be performed with local infiltrative anesthesia and systemic intravenous sedation.

Granular cell tumor of the common bile duct.

Granular cell tumor most commonly appears in the tongue and skin, but has been found in varied locations (10). There are now 14 reported cases of the lesion occurring in the common bile duct. In most of these 14 cases, it has affected black females in their thirties. The lesion is most often benign. It should be considered in the differential diagnosis of obstructive jaundice secondary to bile duct tumors, especially if other granular cell tumors are present. This is the first reported case of pancreaticoduodenectomy for granular cell tumor of the common bile duct.

Artificial pancreas as an aid during insulinoma resection.

Blood glucose control by an artificial pancreas facilitated the intraoperative management of two patients with insulin-secreting pancreatic islet cell tumors (one had a large adenoma, the other diffuse islet-cell hyperplasia). The artificial pancreas is a glucose-controlled insulin and dextrose infusion system uniquely suited for the control of blood glucose concentrations during surgery. The artificial pancreas produced a stable glycemic baseline before surgery, prevented hypoglycemia during palpation of the pancreas and manipulation of the tumor, and indirectly amplified small decreases in the blood sugar level with large increases in the rate of dextrose infusion. The advantages and limitations of continuous glucose monitoring during surgery and the use of this instrument in locating occult insulin-secreting tumors are reviewed.

Malignant fibrous histiocytoma: report of five cases and a review of the literature.

Five cases of malignant fibrous histiocytoma are presented and the relevant literature is reviewed. All the patients had locally extensive tumor or eventual recurrent or metastatic disease. Determining malignancy by histologic criteria is difficult. Therefore, histologic, gross, and clinical behavior of the tumor is important. Though the role of radiation therapy and chemotherapy is not yet established, it appears that at least wide "cancer resection," if possible, is the treatment of choice. The unusually high incidence of nonresectable, recurrent, or metastatic disease in retroperitoneal histiocytomas raises the question as to whether all three modalities of therapy should be used in the treatment of tumors at this particular site.

Operative trauma to the spleen.

A patient is discussed in whom splenic rupture followed an elective uncomplicated cholecystectomy by two weeks. There was no known direct operative or postoperative trauma to the spleen and the spleen was microscopically normal with no evidence of organizing hematoma. Possible mechanisms of operative splenic injury to the spleen are reviewed and the importance of recognition of this entity by surgeons is emphasized.