Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery.

INTRODUCTION: Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals. PATIENTS AND METHODS: The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ). RESULTS: Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived. CONCLUSIONS: The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

Timing Noise in SGR 1806-20.

We have phase-connected a sequence of Rossi X-Ray Timing Explorer Proportional Counter Array observations of SGR 1806-20 covering 178 days. We find that a simple secular spin-down model does not adequately fit the data. The period derivative varies gradually during the observations between 8.1x10-11 and 11.7x10-11 s s(-1) (at its highest, approximately 40% larger than the long-term trend), while the average burst rate as seen with the Burst and Transient Source Experiment drops throughout the time interval. The phase residuals give no compelling evidence for periodicity, but more closely resemble timing noise as seen in radio pulsars. The magnitude of the timing noise, however, is large relative to the noise level typically found in radio pulsars (Delta8=4.8; frequency derivative average power approximately 7x10-20 cycles(2) s(-3)). Combining these results with the noise levels measured for some anomalous X-ray pulsars, we find that all magnetar candidates have Delta(8) values larger than those expected from a simple extrapolation of the correlation found in radio pulsars. We find that the timing noise in SGR 1806-20 is greater than or equal to the levels found in some accreting systems (e.g., Vela X-1, 4U 1538-52, and 4U 1626-67), but the spin-down of SGR 1806-20 has thus far maintained coherence over 6 yr. Alternatively, an orbital model with a period Porb=733 days provides a statistically acceptable fit to the data. If the phase residuals are created by Doppler shifts from a gravitationally bound companion, then the allowed parameter space for the mass function (small) and orbital separation (large) rule out the possibility of accretion from the companion sufficient to power the persistent emission from the SGR.

Statistical Properties of SGR 1806-20 Bursts.

We present statistics of SGR 1806-20 bursts, combining 290 events detected with the Rossi X-Ray Timing Explorer/Proportional Counter Array, 111 events detected with the Burst and Transient Source Experiment, and 134 events detected with the International Cometary Explorer. We find that the fluence distribution of bursts observed with each instrument are well described by power laws with indices 1.43, 1.76, and 1.67, respectively. The distribution of time intervals between successive bursts from SGR 1806-20 is described by a lognormal function with a peak at 103 s. There is no correlation between the burst intensity and either the waiting times until the next burst or the time elapsed since the previous burst. In all these statistical properties, SGR 1806-20 bursts resemble a self-organized critical system, similar to earthquakes and solar flares. Our results thus support the hypothesis that the energy source for soft gamma repeater bursts is crustquakes due to the evolving, strong magnetic field of the neutron star, rather than any accretion or nuclear power.

Hard Burst Emission from the Soft Gamma Repeater SGR 1900+14.

We present evidence for burst emission from SGR 1900+14 with a power-law high-energy spectrum extending beyond 500 keV. Unlike previous detections of high-energy photons during bursts from soft gamma repeaters (SGRs), these emissions are not associated with extraordinarily bright flares. Not only is the emission hard, but the spectra are better fitted by D. Band's gamma-ray burst (GRB) function rather than by the traditional optically thin thermal bremsstrahlung model. We find that the spectral evolution within these hard events obeys a hardness/intensity anticorrelation. Temporally, these events are distinct from typical SGR burst emissions in that they are longer ( approximately 1 s) and have relatively smooth profiles. Despite a difference in peak luminosity of greater, similar1011 between these bursts from SGR 1900+14 and cosmological GRBs, there are striking temporal and spectral similarities between the two kinds of bursts, aside from spectral evolution. We outline an interpretation of these events in the context of the magnetar model.

Statistical Properties of SGR 1900+14 Bursts.

We study the statistics of soft gamma repeater (SGR) bursts using a database of 187 events detected with BATSE and 837 events detected with the Rossi X-Ray Timing Explorer Proportional Counter Array; all events are from SGR 1900+14 during its 1998-1999 active phase. We find that the fluence or energy distribution of bursts is consistent with a power law of index 1.66, over 4 orders of magnitude. This scale-free distribution resembles the Gutenberg-Richter law for earthquakes and gives evidence for self-organized criticality in SGRs. The distribution of time intervals between successive bursts from SGR 1900+14 is consistent with a lognormal distribution. There is no correlation between burst intensity and the waiting times till the next burst, but there is some evidence for a correlation between burst intensity and the time elapsed since the previous burst. We also find a correlation between the duration and the energy of the bursts, but with significant scatter. In all these statistical properties, SGR bursts resemble earthquakes and solar flares more closely than they resemble any known accretion-powered or nuclear-powered phenomena. Thus, our analysis lends support to the hypothesis that the energy source for SGR bursts is internal to the neutron star and plausibly magnetic.

Reduction of Platelet Thrombi and Emboli by L-Arginine during Cardiopulmonary Bypass in a Pig Model.

We wanted to test the hypothesis that NO generation by L-arginine (LA) infusion will be beneficial in increasing blood flow to all organs to counteract the process of global ischemia during cardiopulmonary bypass (CPB) and to reduce platelet emboli by platelet inhibition. The effect of LA infusion on NO formation, vasodilation, and reduction of thromboembolic burden in organs and tissues after CPB was quantified with In-111-labeled autologous platelets in two major groups: 180 minutes CPB (CPB) and 90 minutes CPB plus 90 minutes reperfusion (RP). Platelets labeled with In-111 tropolone (650-780 µCi) were administered 24 hours before CPB and LA infusion (bolus, 10 mg/kg and infusion at 2 mg/kg/min, 21 pigs for 180 minutes CPB) in 8 groups of 30 Yorkshire pigs (30-35 kg, 6 pigs; LA 2 mg/kg/min, 3 pigs; sham-thoracotomy control, 6 pigs; unoperated control, 6 pigs). Two groups of 9 pigs (control CPB, 6 pigs; LA 2 mg/kg/min, 3 pigs) underwent 90 minutes of CPB and 90 minutes of reperfusion. All pigs were heparinized (ACT > 400 seconds); CPB was instituted with a roller pump, an oxygenator (OX: Bentley Univox, 1.8 m2), and an arterial filter (AF: 0.25 m2, Bentley) at a blood flow of 2.5-3.5 l/min. Radioactive thrombi in OX and AF and emboli in viscera, brain, and connective tissues were imaged with a gamma camera and were finally measured with an ion chamber and a gamma counter. The percent of injected platelets (mean +/- SD) in the organs and tissues of all pigs was calculated. Cerebral emboli were mapped in 25 regions of both hemispheres of pig brain. Flow cytometry with antibodies to CD61 (GPIIIa) and CD62P (GMP-140:control) of porcine platelets was carried out with blood samples taken before, during, and after CPB. Coronary bypass with LA infusion decreased the amount of adherent thrombi in OX and AF (p < 0.07). The embolic burden in brain and lung also decreased. Regional cerebral mapping of In-111 platelets showed reduced emboli in almost all regions, including the medulla, hip pocampus, and posterior cerebral cortex in both LA-treated groups. Flow cytometry of blood samples demonstrated the shift of equilibria from single platelet to platelet-aggregate-microparticle during CPB and steady-state level after the first 5-10 minutes of initiation of CPB. The L-arginine infusion reduced thrombi and emboli during CPB in the pig model.

Effect of Thoracotomy and Cardiopulmonary Bypass on Activated Platelet and Neutrophil Dynamics and Platelet Emboli in a Pig Model.

The effects of thoracotomy and components of extracorporeal circuits on dynamics of platelets and neutrophils were quantified with autologous In-111-labeled platelets (INPLT) and neutrophils (INN) during cardiopulmonary bypass (CPB) operations in Yorkshire pigs. Cardiopulmonary bypass was carried out with a hollow-fiber oxygenator and an arterial filter in 48 pigs (30-35 kg; 12 unoperated controls for platelets and neutrophils; 12 sham operated controls; 12 with 180 minutes of CPB with platelets and neutrophils; 12 with 90 minutes of CPB and 90 minutes of reperfusion at 2.5-3.5 one/min. Platelets and neutrophils were labeled with In-111 tropolone and were injected intravenously: platelets at 24 hours and neutrophils at 15 minutes before CPB. All pigs were systemically heparinized [activated coagulation time (ACT) > 400 seconds]; CPB was instituted with a roller pump, oxygenator (OX; Bentley Univox, 1.8 m2), and arterial filter (AF; 0.025 m2) for durations of 180 minutes and 90 minutes of bypass, followed by 90 minutes of reperfusion. The kinetics and pooling of platelets and neutrophils were monitored by a Geiger probe. The adherent thrombi and neutrophils in the OX, AF, viscera, and brain were imaged with a gamma camera and were measured with an ion chamber and a gamma counter. The percentile distribution of labeled platelets and neutrophils expressed as the mean +/- standard deviation of injected dose in eight groups was calculated and statistical analyses were performed (ANOVA and paired t-test). Sham operation alone increased platelet retention in the lung, heart, and brain significantly (p < 0.001) over that of unoperated pigs. Neutrophil margination to lung immediately after injection was high; CPB and reperfusion altered the distribution in blood, viscera, and connective tissues. During CPB, an equilibrium among single platelets, platelet thrombi, and emboli was reached in the blood, oxygenator, arterial filter, perfused organs, and tissues. After CPB, the pulmonary neutrophil retention increased significantly (p < 0.001). Reperfusion of 90 minutes following 90 minutes of CPB decreased the level of neutrophils and increased the level of platelets in the lung. Only a small amount of platelets and neutrophils was retained in the oxygenator and arterial filter. Neutrophil retention in the OX and AF was higher than that of platelets. The small amount of retained neutrophils in the heart, kidneys, and brain suggested that cytokines, rather than marginated neutrophils alone, may play a major role in inflammatory insult to these organs during and after CPB. OX thrombi increased with the time of CPB; AF thrombus in both groups was almost similar. During CPB, AF functioned minimally as a thrombus trap with a small percent of retained thrombi; reperfusion post-CPB did not change the amount. Thoracotomy alone has a significant effect on platelet and neutrophil kinetics, and on the subsequent effect of thrombus formation, embolization, and neutrophil margination in organs during the CPB procedure.