The exteriorized anastomosis: its role in surgery of the colon.

Sixty-one patients (59, trauma; two, nontrauma) have been managed at Detroit General Hospital from 1972 to 1976 utilizing an exteriorized colon anastomosis. Healing of the anastomosis was present in 42 (70%) of the patients, and 37 (62%) avoided colostomy. Our experience with this procedure has demonstrated that it is a safe, reliable adjunct to be used in colon surgery when primary intraperitoneal repair is not desirable, that the added operating time (20 to 30 minutes) will not be deleterious to the patient, that the lesion is at least 18 cm above the peritoneal reflection, and that the likelihood of a prolonged septic postoperative course is not high.

The effect of nutritional support on immune competency in patients suffering from trauma, sepsis, or malignant disease.

Thirty-nine patients, 25 of whom were suffering from trauma, sepsis, or malignant disease, were studied prospectively to determine the immunologic value of improved protein-calorie balance in this setting. All were suffering from varying degrees of malnutrition, and 72% (P less than 0.05) of the patients with anergy-inducing disease processes were anergic at the time of evaluation. In the presence of disease-induced anergy, skin test reactivity was not helpful in measuring the therapeutic response to nutritional support; among severely wasted patients, significant elevations in absolute lymphocyte count and serum albumin suggest that these are useful parameters when following the severely wasted patient who has concomitant trauma, sepsis, or malignant disease.

Prophylactic jejunostomy: a reappraisal.

BACKGROUND: The effectiveness of enteral feeding in maintaining postoperative nutrition has led some investigators to recommend prophylactic jejunostomy at the time of any high-risk abdominal operation. A failed procedure in this setting weighs heavily on the side of risk without identifiable benefit. METHODS: A benefit/risk analysis comparing complication rate, avoidance of parenteral nutrition, and discontinuation of jejunostomy feeding was performed in 92 patients. These patients were judged retrospectively to be undergoing either a prophylactic jejunostomy placed at the time of operation for another serious condition (group A) or therapeutic jejunostomy alone (group B) during a 3-year period (1993 to 1996). Classification as prophylactic or therapeutic was determined by the surgeon's preoperative intent. RESULTS: Avoidance of parenteral nutritional support, a goal of prophylactic jejunostomy, was not achieved in 39% of the patients. Patients in group A had a 5-fold increase in the risk of premature discontinuation of enteral feeds when compared with group B (P < .03). The complication rate was higher in group A (41%) than in group B (26%). Four life-threatening complications occurred in group A; all required reversal of the feeding jejunostomy. CONCLUSIONS: This study suggests that the benefit/risk ratio of prophylactic jejunostomy is low. This adds weight to the notion that this procedure be abandoned in favor of other forms of nutritional support.

The therapeutic advantages of a balanced nutritional support system.

Twenty-two critically ill patients were entered into a 21-day prospective study to evaluate the feasibility of relying on a balanced nutritional support system to satisfy the needs of a diverse group of surgical patients. No patient sustained a serious complication related to glucose metabolism, and only two patients required insulin. Twenty-one of the patients achieved positive nitrogen balance during the study, and 13 had a significant weight gain not related to water retention. Documented sepsis was present in 50% of the patients but in spite of this, 91% had a successful course of therapy. The ease of management and metabolic efficiency of this approach encourages the use of fat as a primary energy substrate in a balanced nutritional support system to restore positive energy and nitrogen balance.

Jejunoileal bypass. A legacy of late complications.

Since 1977, we have managed 56 patients (36 Payne and 20 Scott bypasses) with late (one to 18 years) complications resulting from a jejunoileal bypass. All patients underwent a one-stage conversion of the jejunoileal bypass to a gastric bypass. Patients were classified according to postbypass weight, the need for nutritional support, the type and severity of complication, and the time interval between jejunoileal bypass and the onset of the complication and correction of the complication. There were no operative deaths; one patient died 18 months after surgery of cirrhosis. The complication rate was 34%; however, most complications were minor. Our experience with this procedure has shown it to be highly effective in correcting complications other than polyarthritis. When coupled with nutritional support, it is safe even in malnourished patients.

The role of definitive surgery in the management of perforated duodenal ulcer disease.

From 1970 to 1973, 147 patients were treated at Wayne State University Affiliated Hospitals for perforated duodenal ulcer disease. One hundred thirteen were observed for at least 18 months and findings showed that (1) mortality was dependent on the condition of the patient rather than on the choice of operation, (2) current indications (previous ulcer history, degree of peritoneal contamination, and time interval between performation and surgery) were not reliable in choosing the initial operation or in predicting the need for subsequent surgery, and (3) morbidity was high following simple closure. Therefore, we recommend vagotomy and pyloroplasty as the procedure of choice for a perforated duodenal ulcer, unless the patient is in septic shock at admission.

Gastrojejunal disruptions. Changing concepts in management.

From 1973 through 1983, 197 patients were treated at Harper-Grace Hospital, Detroit, according to a protocol designed to minimize the effects of possible gastrojejunal disruption. All had high-risk resections or bypasses of the stomach reconstructed with an end-to-end Roux-en-Y anastomosis using a long (100-cm) jejunal limb. Eighteen anastomoses leaked, producing fever, pain, and mild respiratory distress in 14 patients and peritonitis with shock in four. Nine of the 14 patients without shock avoided surgery, requiring only antibiotics and nutritional support. The other five had a subphrenic abscess, necessitating drainage. The four patients with shock were treated with staged intestinal discontinuity, nutritional support, and reestablishment of gastrointestinal continuity at a later date. Seventeen patients (94%) survived this serious complication, a significant improvement compared with the mortality of historical controls.

Substrate composition and sepsis. Effects on immunity.

A randomized prospective study was performed to determine the effects of substrate composition on immunity in septic malnourished patients. A balanced substrate formula was administered to 11 patients with sepsis and 11 nonseptic patients. This provided 40 kcal/kg/day and 1 to 1.5 g of protein per kilogram each day with a carbohydrate-nitrogen ratio of 50:1. A 25% dextrose and 4.25% protein solution that provided 50 kcal/kg/day and 1 to 1.5 g of protein per kilogram each day with a carbohydrate-nitrogen ratio of 150:1 was provided to ten patients with sepsis and 11 without. Skin test conversion rates were not affected by substrate composition; however, the absolute lymphocyte count was significantly improved in septic patients who achieved positive nitrogen balance, regardless of the nutritional support regimen used. These findings suggest that substrate composition per se has no effect on immunologic responsiveness.

Sepsis, glucose intolerance, and protein malnutrition: a metabolic paradox.

Glucose intolerance and its hormonal influence was examined in patients with sepsis. Eighteen patients were included in the protocol, which studied the response to a standard intravenous glucose tolerance test (GTT) in the postoperative stressed, septic, and septic protein malnourished (depressed albumin level) states. Four groups could be defined: stress (1), sepsis with depressed albumin level and normal glucose tolerance (2), sepsis with mild glucose intolerance and normal albumin levels (3), and sepsis with severe glucose intolerance and depressed albumin (4). Serial hormone levels were measured during the GTT, including insulin, glucagon, epinephrine, and human growth hormone values. Each group demonstrated a characteristic hormone profile. In a comparison with controls, group 2 was associated with mild suppression of insulin; group 3 exhibited mild glucose intolerance, hyperglucagonemia, and increased insulin; and group 4 demonstrated severe glucose intolerance, hyperglucagonemia, and marked suppression of growth hormone production.

Enhancement of mitochondrial function in sepsis.

Recent reports from our laboratory have challenged the concept that sepsis selectively damages or interferes with mitochondrial function. To address the lingering skepticism that mitochondrial assays in surviving animals might not detect this "injury," we injected rats with a lethal dose of Escherichia coli endotoxin and compared hepatic, cardiac, and skeletal muscle mitochondrial function in these animals with that of control rats. Mitochondrial function was serially determined during a four-hour postmortem period by measuring the respiratory control ratio, the adenosine diphosphate-oxygen ratio, and protein levels. Hepatic mitochondria ceased to function within 30 minutes of the time of death. Cardiac and skeletal muscle mitochondria functioned normally up to four hours after death in both septic and control animals. Mitochondria from septic animals had a significantly higher respiratory control ratio than those from control rats. Thus, sepsis appears to enhance rather than damage mitochondrial function up to four hours after death.

The relationship of insulin production to glucose metabolism in severe sepsis.

Basal glucose metabolism was evaluated in eight stable, infected patients by measuring hepatic glucose production rates in relation to stress endocrine profile and by comparing these data to five injured, noninfected patients. All patients exhibited normal total-body oxygen consumptions and cardiac indices. Fasting basal insulin values were similar in both groups (6 microU/cc) despite a significantly higher plasma glucose level in septic patients (106 +/- 14 mg/dL) compared to nonseptic patients (88 +/- 10 mg/dL). Septic patients exhibited splanchnic glucose production and calculated glucose clearance rates, 53% and 34% higher, than injured nonseptic patients, respectively. In addition, septic patients exhibited a decreased pancreatic insulin secretory response to an intravenous glucose tolerance test as evidenced by a significantly depressed peak insulin value (17 microU/cc) relative to injured patients (77 microU/cc). These findings indicate that insulin suppression is evident in sepsis even in the absence of shock and suggest that sepsis-related basal hyperglycemia does not appear to be associated with peripheral insulin resistance.

Motilin excites neurons in the cerebral cortex and spinal cord.

The 22 amino acid polypeptide motilin was tested by iontophoretic application onto neurons in the rat cerebral cortex and by perfusion over the isolated hemisected toad spinal cord. Motilin (25--150 nA) excited identified cortico-spinal neurons and other deep spontaneously firing cortical cells. Excitation developed relatively rapidly and lasted for up to 60 sec after the application. Motilin was a potent excitant (threshold concentration 2.5 x 10(-9) M) of neurons in the amphibian spinal cord, eliciting a depolarization of dorsal root terminals and motoneurons. Its effects were substantially reduced after tetrodotoxin, suggesting a primary site of action on spinal cord interneurons.

Peritoneovenous shunt for palliation of gynecologic malignant ascites.

BACKGROUND: Ascites is a common sequela of advanced or recurrent gynecologic malignancies, such as carcinoma of the ovary, fallopian tube, or endometrium. Symptomatic treatment with repeated paracentesis is the initial management after failure of chemotherapy. STUDY DESIGN: This study was done to evaluate the safety and effectiveness of a peritoneovenous shunt (PVS) in the palliation of these patients with recurrent ascites. A retrospective review of 25 patients having a PVS between 1982 and 1992 was performed. RESULTS: The 25 patients consisted of 21 patients with carcinoma of the ovary, two with primary carcinoma of the peritoneum, one with carcinoma of the endometrium, and one patient with carcinoma of the fallopian tube. The mean weight and abdominal girth decreased after shunt insertion (p < 0.001). Gastrointestinal dysfunction and dyspnea also improved with PVS insertion. There was no change in mean Karnofsky score after placement of a PVS. Two patients died within ten days postoperatively. The median survival period was 80 days and shunt occlusion occurred in four patients. CONCLUSIONS: The insertion of a PVS is effective in relieving refractory malignant ascites in gynecologic malignancies. The impact on quality of life requires further study.

Is clonidine an adenosine antagonist?

Clonidine has been reported to possess the ability to block the depressant actions of purine compounds on the firing of rat cerebral cortical neurons. In studies on rats anaesthetized either with nitrous oxide and methoxyflurane or urethane, it was not possible to confirm this observation. Rather clonidine enhanced the depressant actions of iontophoretically applied adenosine and adenosine 5'-monophosphate (5'-AMP).

The injured colon: therapeutic considerations.

A prospective randomized study was carried out at the Detroit General Hospital over a two year period to evaluate methods of management in 165 patients with colonic injuries. Results of the study show that primary closure is a safe and reiable method of management when rigid criteria are incorporated in an ongoing protocol. Moreover, the technic of exteriorization is a safe adjunct to management and is recommended in any patient with a colonic injury above 18 cm in which one suture line is required and in which the additional operating time of twenty minutes will not compromise the management of secondary injuries. Patients not fulfilling these criteria should have primary colostomy. These principles make it possible to reduce the need for primary colostomy to approximately 50 per cent in a large ongoing group of patients with colonic injury.

Selective versus standard hyperalimentation. A randomized prospective study.

Fifty consecutive surgical patients were included in a randomized prospective study to determine the relative advantages and disadvantages of two types of nutritional support systems: one, selective hyperalimentation, relies on a balanced substrate formula, while the other, standard hyperalimentation, depends on carbohydrate and protein to satisfy the energy requirements of the patient. The patients who received the balanced substrate formula had significantly fewer complications than those receiving standard hyperalimentation, even though both groups achieved positive energy and nitrogen balance. The enhanced safety of selective hyperalimentation suggests its therapeutic superiority as a basic nutritional support system for a busy surgical service.

Alterations in the metabolism of exogenous lipid associated with sepsis.

The responses to an exogenous lipid challenge of nonhypermetabolic surgical patients requiring parenteral nutrition and seriously ill septic patients were compared. All patients received a 500-ml intravenous infusion of a 10% lipid emulsion over a 4-hr period. An early elevation of glycerol and triglyceride was noted during the infusion suggesting chylomicron fractionation. Peak triglyceride levels were higher in the septic group but the rate of lipid clearance appeared essentially identical in both septic and nonseptic patients. Lipoprotein lipase levels remained constant and were equal for both groups. Significant late ketone body production was statistically identical in both groups despite depressed albumin levels in the septic group suggesting adequate hepatic ketogenic capacity in septic as well as nonseptic patients.

Anabolic steroid administration during nutritional support: a therapeutic controversy.

Nitrogen balance was determined in 48 patients who were entered into a randomized prospective double-blind study, comparing anabolic steroids versus placebo in our parenteral nutritional support system. The group included both young and old patients suffering from catabolic illnesses, in whom intravenous feeding ranged from 14-21 days. All participants received the active agent or placebo biweekly throughout the study. During the period of intravenous nutrition, there was statistically significant difference in nitrogen balance and protein conservation in the patients receiving the active agent.

Altered immunologic function and nitrogen metabolism associated with depression of plasma growth hormone.

The specific role of endogenous growth hormone in regulating nitrogen metabolism during surgical stress and infection remains unclear. We have studied splanchnic amino acid uptake and plasma concentrations in patient groups exhibiting growth hormone hypersecretion or relative growth hormone depression in response to stress. Splanchnic amino acid uptake was similar in both groups although plasma levels were significantly higher in the presence of depressed growth hormone production suggesting increased net peripheral proteolysis. In association with this latter observation. T lymphocyte subset analysis revealed a greater incidence of depressed helper to suppressor cell ratios in the presence of depressed growth hormone suggesting a greater impairment of cellular immunity.

Endotoxin and calcium effect on metabolism.

The effects of calcium and endotoxin were investigated in vivo and in vitro using the A/J, retired white male breeder mouse model. Intravenous administration of increasing calcium doses (3.75, 4.37, and 4.75 mg Ca/g-BW) resulted in increasing serum calcium levels (11.4, 14.4, 15.2, respectively vs. animals not injected, 9.5 mg/dl). Mice injected with E. coli bacterial endotoxin after injection of calcium demonstrated significantly (P less than 0.05) lowered serum calcium concentrations (10.5, 12.1, 12.5, respectively). The magnitude of serum calcium reduction was related to the level just prior to endotoxin administration. Mitochondria were incubated using a Percoll purification step. The effect of pretreating the animal in vivo with calcium, endotoxin or calcium plus endotoxin versus control was investigated in both liver and skeletal muscle. When mitochondria were incubated in medium containing EGTA (free Ca less than 1 X 10(-9)). no significant difference between groups was observed in either (RCR) or mitochondrial calcium content. When mitochondria were incubated in EGTA buffers containing calcium (free Ca approximately 7 X 10(-7) liver, 1 X 10(-7) muscle) significant differences in RCR and mitochondrial calcium content were observed. Liver RCR increased significantly with calcium or endotoxin pretreatment (2.20, 2.43 vs. 1.86). Muscle mitochondrial RCR significantly decreased with calcium administration (5.02 vs. 6.79). Both liver and muscle mitochondrial calcium content significantly decreased (2.54 vs. 27.32, and 6.46 vs. 25.82 nMole Ca/mg mitochondrial protein). Preloading with calcium prevented the decline in mitochondrial calcium content. Findings suggest that the reduction in intramitochondrial calcium content during endotoxemia could be an effector of metabolic derangement specifically through calcium-dependent intramitochondrial enzymes.