National risk prediction model for perioperative mortality in non-cardiac surgery.

BACKGROUND: Many multivariable models to calculate mortality risk after surgery are limited by insufficient sample size at development or by application to cohorts distinct from derivation populations. The aims of this study were to validate the Surgical Outcome Risk Tool (SORT) for a New Zealand population and to develop an extended NZRISK model to calculate 1-month, 1-year and 2-year mortality after non-cardiac surgery. METHODS: Data from the New Zealand National Minimum Data Set for patients having surgery between January 2013 and December 2014 were used to validate SORT. A random 75 per cent split of the data was used to develop the NZRISK model, which was validated in the other 25 per cent of the data set. RESULTS: External validation of SORT in the 360 140 patients who underwent surgery in the study period showed good discrimination (area under the receiver operating characteristic curve (AUROC) value of 0·906) but poor calibration (McFadden's pseudo-R2 0·137, calibration slope 5·32), indicating it was invalid in this national surgical population. Internal validation of the NZRISK model, which incorporates sex and ethnicity in addition to the variables used in SORT for 1-month, 1-year and 2-year outcomes, demonstrated excellent discrimination with AUROC values of 0·921, 0·904 and 0·895 respectively, and excellent calibration (McFadden's pseudo-R2 0·275, 0·308 and 0·312 respectively). Calibration slopes were 1·12, 1·02 and 1·02 respectively. CONCLUSION: The SORT performed poorly in this national population. However, inclusion of sex and ethnicity in the NZRISK model improved performance. Calculation of mortality risk beyond 30 days after surgery adds to the utility of this tool for shared decision-making.

ANTECEDENTES: Muchos modelos multivariados de estimación del riesgo de mortalidad después de la cirugía están limitados por haberse desarrollado a partir de tamaños muestrales insuficientes o por haberse aplicados a cohortes distintas de las poblaciones de derivación. Los objetivos de este estudio fueron validar el Surgical Outcome Risk Tool (SORT) para una población de Nueva Zelanda y desarrollar un modelo NZRISK extendido para calcular la mortalidad al mes y a los 1 y 2 años de una cirugía no cardíaca. MÉTODOS: Para validar el SORT se utilizó el Conjunto Mínimo Básico de Datos de Nueva Zelanda para los pacientes sometidos a cirugía entre enero de 2013 y diciembre de 2014. Se realizó una división aleatoria del 75% de los datos para desarrollar el modelo NZRISK que, posteriormente, se validó en el otro 25% del conjunto de datos. RESULTADOS: La validación externa de SORT en 360.140 pacientes intervenidos en el periodo analizado mostró una buena discriminación (área bajo las curvas de característica operativa del receptor (area under the receiver-operator characteristic curves (AUROC) 0,906)) pero con una mala calibración (pseudo-R2 de McFaddens 0,137 y pendiente de calibración 5,32), lo que indicaba que SORT no era válido para esta población quirúrgica nacional. La validación interna del modelo NZRISK, que incorpora el género y la etnia además de las variables utilizadas en el SORT, para los resultados al mes y a los 1 y 2 años demostró una excelente capacidad de discriminación con una AUROC de 0,921, 0,904, 0,895 respectivamente y una calibración excelente, con una pseudo-R2 de McFaddens de 0,275, 0,308 y 0,312 respectivamente. Las pendientes de calibración fueron de 1,12, 1,02 y 1,02, respectivamente. CONCLUSIÓN: El SORT no fue útil en esta población nacional. Sin embargo, la inclusión del género y la etnia en el modelo NZRISK mejoró sus resultados. El cálculo del riesgo de mortalidad más allá de 30 días después de la cirugía añade utilidad a esta herramienta para la toma de decisiones compartida.

Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery.

BACKGROUND: Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate (CHO) treatment. The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double-blind randomized trial. METHODS: Patients undergoing elective colorectal surgery or liver resection were randomized to oral CHO or placebo drinks to be taken on the evening before surgery and 2 h before induction of anaesthesia. Primary outcomes were postoperative length of hospital stay and fatigue measured by visual analogue scale. RESULTS: Sixty-nine and 73 patients were evaluated in the CHO and placebo groups respectively. The groups were well matched with respect to surgical procedure, epidural analgesia, laparoscopic procedures, fasting period before induction and duration of surgery. Postoperative changes in fatigue score from baseline did not differ between the groups. Median (range) hospital stay was 7 (2-35) days in the CHO group and 8 (2-92) days in the placebo group (P = 0.344). For patients not receiving epidural blockade or laparoscopic surgery (20 CHO, 19 placebo), values were 7 (3-11) and 9 (2-48) days respectively (P = 0.054). CONCLUSION: Preoperative CHO treatment did not improve postoperative fatigue or length of hospital stay after major abdominal surgery. A benefit is not ruled out when epidural blockade or laparoscopic procedures are not used. REGISTRATION NUMBER: ACTRN012605000456651 (http://www.anzctr.org.au).

A possible role for IGE-II: evidence in sheep for in vivo regulation of IGF-I mediated protein anabolism.

Using primed constant infusions of [14C]urea we assessed the effects in castrate male lambs of insulin-like growth factor (IGF) II infusion on protein metabolism during concurrent IGF-I infusion. A 300 minute infusion of IGF-I at 15 micrograms/kg.hour (n = 4) increased (p less than 0.001) the plasma IGF-I concentration from 72.5 +/- 6.4 ng/ml to 213.6 +/- 17.4 ng/ml and decreased (p less than 0.01) the rate of net protein catabolism (NPC) from 1.48 +/- 0.28 g/kg.day to 1.02 +/- 0.18 g/kg.day. Infusion of IGF-II at a dose of 50 micrograms/kg.hour concurrently with IGF-I at 15 micrograms/kg.hour (n = 4) was associated with a similar rise (p less than 0.01) in plasma IGF-I concentration from 79.4 +/- 4.1 ng/ml to 225.2 +/- 32.8 ng/ml. Plasma IGF-II increased (p less than 0.05) from 350.6 +/- 41.6 ng/ml to 746.7 +/- 165.5 ng/ml over the infusion. Coadministration of IGF-II completely blocked (p less than 0.01) the anabolic effect of IGF-I and the rate of NPC remained unchanged throughout the combined IGF-I and IGF-II infusion at a level comparable to saline infused controls (n = 4). This study suggests that IGF-II may play a physiological role as a circulating modulator of the anabolic effects of IGF-I.

Synergistic effect of insulin-like growth factor-I administration on the protein-sparing effects of total parenteral nutrition in fasted lambs.

Using primed constant isotopic infusions, we investigated the effects of recombinant human insulin-like growth factor-I (IGF-I) infusion on protein kinetics in both fasted and parenterally fed (TPN) lambs. Infusion of IGF-I at a dose of 50 micrograms/kg.h in fasted animals increased (P less than 0.005) the mean plasma IGF-I concentration from 77.5 +/- 9.7 to 454.4 +/- 51.4 ng/ml. During IGF-I infusion the rate of net protein catabolism (NPC) was decreased (P less than 0.005) by 17% from 3.5 +/- 0.2 to 2.9 +/- 0.2 g/kg.day, and the rate of appearance (Ra) of leucine in plasma decreased (P less than 0.01) from 5.0 +/- 0.4 to 3.4 +/- 0.4 mumol/kg.min. In addition, the fractional synthetic rate of protein in cardiac and diaphragmatic muscle increased by 100% (P less than 0.05) during the same period. After 3 h of TPN, the rate of NPC was decreased (P less than 0.01) in the TPN animals compared to that in their fasted counterparts (1.89 +/- 2.27 vs. 4.1 +/- 0.2 g/kg.day, respectively). The rate of NPC was further decreased after another 300 min of TPN to 0.76 +/- 0.27 g/kg.day. However, the Ra of leucine was not changed compared to the initial value. Infusion of IGF-I concurrently with TPN reversed (P less than 0.001) the rate of NPC from 1.02 +/- 0.21 g/kg.day after 180 min of TPN alone to a state of net protein gain of 0.14 +/- 0.19 g/kg.day after a further 300 min of combined IGF-I and TPN infusion. The Ra of leucine decreased (P less than 0.01) from 3.9 +/- 0.8 to 2.5 +/- 0.47 mumol/kg.min during IGF-I and TPN infusion. Similarly, the fractional synthetic rates of protein in cardiac muscle, diaphragm, adductor muscle, psoas muscle, and hepatic tissue were increased (P less than 0.05) compared to those in animals that received only TPN. The protein-sparing effects of IGF-I and TPN were synergistic, and the infusion of both agents resulted in the induction of a protein anabolic state within 60 min of commencing IGF-I infusion. In contrast, neither IGF-I nor TPN alone resulted in a state of net protein anabolism, and neither had an effect on protein kinetics until 120 min into the infusion. Consequently, IGF-I shows considerable potential as an anticatabolic agent when used synergistically with nutritional support.

Passive immunization against circulating insulin-like growth factor-I (IGF-I) increases protein catabolism in lambs: evidence for a physiological role for circulating IGF-I.

Primed constant infusions of [14C]urea were used to determine the acute effect of passive immunization against circulating free and protein-bound insulin-like growth factor-I (IGF-I) on the rate of net protein catabolism (NPC) in castrated male lambs fasted for 48 h. Following an intravenous bolus of 50 ml IGF-I antiserum, the rate of NPC increased to a peak 30 min after injection of 1.69 +/- 0.16 g/kg per day from a baseline value of 1.45 +/- 0.22 g/kg per day (P < 0.05, n = 4). In three animals given 50 ml equivalents of the purified immunoglobulin fraction, NPC increased from 1.31 +/- 0.20 to 1.59 +/- 0.16 g/kg per day (P < 0.05). A similar trend was observed in animals given 25 ml antiserum (n = 4). The rate of NPC did not increase following a bolus of non-immune serum in control animals and the rate of NPC in the treated lambs returned to control levels within 60 min of antibody injection. Plasma insulin and glucose concentrations in both the treated and control groups were unchanged throughout the study. These data suggest that circulating IGF-I has a physiological role in regulating whole body protein turnover during starvation and possibly other catabolic states. The effect of immunoneutralization of circulating IGF-I is transient and this suggests that while IGF-I has an endocrine role in the regulation of protein turnover, other regulatory mechanisms are involved.

Leucine kinetics in patients with benign disease, non-weight-losing cancer, and cancer cachexia: studies at the whole-body and tissue level and the response to nutritional support.

We have performed intraoperative isotopic infusions of carbon 14-labeled leucine in 65 patients to define the abnormalities in protein metabolism at both the whole-body and tissue level in patients with weight-losing and non-weight-losing cancer. Eighteen patients had benign disease, 26 had non-weight-losing cancer, and 21 had cancer cachexia. Samples of plasma and expired breath were taken to determine rates of whole-body protein synthesis (WBPS), whole-body protein catabolism (WBPC), net protein catabolism, and albumin fractional synthetic rates. Tissue samples were taken to determine the fractional synthetic rates (FSR) of protein in muscle, liver, cancer, and the tissue in which the cancer arose. In addition, in 14 patients the effect of nutritional support on protein metabolism was assessed. In all parameters examined we were unable to detect any significant differences between patients with no cancer and the patients with non-weight-losing cancer. In contrast, patients with cancer cachexia had a significant elevation (p less than 0.005) in WBPC compared with the other two groups. WBPS was also elevated (to a lesser extent) in the patients with cancer cachexia, and the rate of net protein catabolism was increased significantly (p less than 0.05). Patients with cancer cachexia also had significantly higher values of FSR of protein in muscle (p less than 0.05), liver (p less than 0.05), and albumin (p less than 0.01) compared with the other two groups. In addition, the protein FSR in the cancer rose progressively when the values for the primary cancer were compared with those for nodal and systemic metastases. Further, although nutritional support resulted in an increase in host muscle protein synthesis (p less than 0.04), there was no promotion of FSR of protein in cancer. We conclude that patients with cancer cachexia are actively losing protein as a result of an increase in WBPC that is only partially compensated for by an increase in WBPS. There are compensatory increases in protein synthesis in muscle and liver, but these increases in host protein synthesis are insufficient to keep pace with the combined effect of the accelerated rate of protein synthesis in the cancer per se and the accelerated rate of net protein catabolism at the whole-body level. In response to nutritional support, there is a significant increase in the muscle protein synthesis, but we could not demonstrate any increase in cancer protein synthesis.

Total energy expenditure during total parenteral nutrition: ambulatory patients at home versus patients with sepsis in surgical intensive care.

BACKGROUND: To avoid the complications associated with overfeeding or underfeeding, the energy requirements of patients receiving total parenteral nutrition (TPN) must be accurately prescribed. However, until recently it has not been possible to directly measure the rates of total energy expenditure (TEE) in surgical patients receiving TPN. METHODS: Values for total body water and TEE in four patients with sepsis (mean Acute Physiology and Chronic Health Evaluation [APACHE] score, 10) receiving TPN in surgical intensive care unit and in four patients with chronic intestinal failure receiving long-term TPN at home (HPN) have been determined by using the doubly labeled water technique. The values for TEE have been compared with those of resting energy expenditure obtained with indirect calorimetry (REE CAL) and calculated by using the Harris-Benedict equation (REE HB). RESULTS: In both the patients with sepsis and the patients receiving HPN the proportion of body weight made up of water was normal for patient age and gender. In patients with sepsis the REE HB significantly (p < 0.05) underestimated the REE CAL (15.39 +/- 3.80 kcal/kg/day-1 versus 31.3 +/- 1.23 kcal/kg/day-1) and was significantly less than the TEE derived by using doubly labeled water (44.62 +/- 1.09 kcal/kg/day-1; p < 0.001). In the ambulatory patients receiving HPN no difference was noted between the REE HB and the REE CAL (18.02 +/- 0.41 kcal/kg/day-1 versus 21.37 +/- 0.94 kcal/kg/day-1). The average TEE for these patients was 30.25 +/- 3.42 kcal/kg/day-1, and this was significantly greater (p < 0.006) than both REE CAL and REE HB: CONCLUSIONS: This investigation has shown that in patients with sepsis TEE constitutes 1.4 times the REE CAL or approximately 40 kcal/kg/day, whereas in HPN patients TEE can be estimated by supplying 1.4 times the REE or approximately 30 kcal/kg/day-1.

Parathyroid cancer: biology and management.

A review of all reports in the literature of parathyroid carcinoma (PTC) was undertaken to define an optimal management strategy for this rare condition. PTC is uncommon and its etiology of PTC is largely unknown although patients with familial hyperparathyroidism, multiple endocrine neoplasia type 1 and irradiation to the head and neck are at increased risk for developing the disease. PTC occurs with equal frequency in both sexes and is usually diagnosed in the fifth decade. En bloc resection of the carcinoma and the adjacent structures in the neck is the surgical treatment and is associated with an 8% local recurrence rate and a long term overall survival rate of 89% (mean follow up 69 months). In contrast simple parathyroidectomy results in a 51% local recurrence rate and 53% long-term survival rate (mean follow up 62 months). Adverse prognostic factors for survival were initial management with simple parathyroidectomy alone, the presence of nodal or distant metastatic disease at presentation and non-functioning PTC.

Role of laparoscopy in the initial multimodality management of patients with near-obstructing rectal cancer.

The purpose of this study was to investigate the role of diagnostic laparoscopy in the multimodality management of locally advanced, near-obstructing rectal cancer. Fourteen patients with near-obstructing adenocarcinoma of the rectum (8 men and 6 women; mean age 49 years) underwent staging laparoscopy and formation of a sigmoid loop colostomy (n = 7), transverse colostomy (n = 4), or ileostomy (n = 3). The mean operative time was 78 minutes (range 67 to 94 minutes). All patients began a regular diet on postoperative day 1 and the median time to discharge was 4 days (range 2 to 8 days). Four patients were found to have diffuse peritoneal carcinomatosis not defined on preoperative CT scan. These patients died of disease within 6 months. Ten patients with advanced, localized pelvic disease began preoperative combined-modality treatment (5040 cGy external-beam radiation therapy in conjunction with 5-fluorouracil/leucovorin) between 8 and 13 days (median 9 days) following laparoscopy, and all underwent successful resection with clear margins in a median time of 12 weeks following laparoscopy. In the initial management of patients with near-obstructing advanced rectal cancer, laparoscopy can be both therapeutic and diagnostic by clarifying the site of the primary tumor, identifying patients with unsuspected peritoneal disease, and facilitating the formation of a defunctioning stoma with minimal morbidity. This leads to the early commencement of preoperative combined-modality treatment and does not compromise the prospects of subsequent tumor resection.

Total parenteral nutrition in surgical illness: how much? How good?

Using primed constant infusions of isotopes and indirect calorimetry, we assessed protein, glucose, and fat kinetics in severely ill surgical patients suffering from sepsis, major trauma, gastrointestinal cancer, or nutritional depletion from benign disease. We also assessed the effect of 5 days of total parenteral nutrition (TPN) on abnormal metabolism in these states. In the basal state, patients with sepsis, trauma, or cancer had an elevated rate of net protein catabolism due to an increased rate of whole-body protein catabolism, whereas whole-body protein synthesis was not impaired. TPN had no impact on the elevated rate of whole-body protein catabolism in these conditions but decreased the rate of net protein catabolism, suggesting that increased substrate availability optimizes whole-body protein synthesis. Consequently, few surgical patients became anabolic while receiving TPN. In contrast, patients with nutritional depletion from benign disease had a decreased rate of net protein loss compared with volunteers and could be made anabolic with the administration of TPN. All patients studied had an elevated rate of plasma glucose production, impaired glucose oxidation, and an increased rate of Cori cycling in the basal state. After 5 days of TPN, most surgical patients showed improved ability to oxidize glucose, but the high rates of glucose recycling to lactate persisted. Patients suffering from sepsis, trauma, or cancer had an enhanced rate of lipolysis in the basal state associated with an increased rate of whole body-fat oxidation compared with healthy volunteers. After administration of TPN, whole-body fat oxidation was significantly decreased in patients with trauma but increased in patients with sepsis or cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative importance of amino acid infusion as a means of sparing protein in surgical patients.

We performed isotopic infusions in 51 surgical patients to investigate the effectiveness of different substrates to conserve protein. All patients were initially studied in the basal state and then the effects of glucose infusion (GL, N = 13), lipid infusion (LIP, N = 11), or amino acid infusion (AA, N = 17) were determined. Ten patients receiving total parenteral nutrition (TPN) were also studied. The basal value for net protein catabolism (NPC) in GL patients was 1.53 +/- 0.4 (SEM) g/kg/day decreasing to 1.39 +/- 0.4 g/kg/day during glucose infusion (p less than 0.01). The basal NPC in the LIP group was 2.04 +/- 0.4 g/kg/day decreasing to 1.72 +/- 0.3 g/kg/day during lipid infusion (p less than 0.01). In the TPN patients the NPC was 0.79 +/- 0.46 g/kg/day whereas in the AA patients the basal value for NPC was 1.37 +/- 0.14 g/kg/day decreasing to -0.77 +/- 0.11 g/kg/day during amino acid infusion (p less than 0.0005). From our study we conclude that: (1) All substrates commonly used in intravenous feeding have the capacity to spare protein. (2) Protein sparing was more pronounced when a balanced amino acid infusion was used than with either glucose or lipid infusion alone. (3) This effect is not solely due to insulin secretion as larger insulin responses were seen with both GL and TPN patients. (4) These results may have implications for peripheral vein feeding with amino acid solutions where there is a contraindication for full TPN or the lack of resources for administering it.

Parathyroid cyst and hyperparathyroidism in Auckland.

We have reviewed the clinical and pathological records of 4 patients presenting for treatment of parathyroid cyst in Auckland between 1970 and 1987. The mean age of the patients was 60.5 years and 3 patients presented with symptomatic hyperparathyroidism (2 male and 1 female patient) and 1 female patient presented with a neck mass and tracheal compression. All cysts were unilocular and filled with clear fluid (mean cyst diameter was 1.5 cm and mean cyst weight was 5.55 g). Four out of the 5 cysts were located in the inferior neck. Of the three patients with hyperparathyroidism, 2 patients had associated parathyroid adenoma (1 patient having bilateral cystic adenomas) and 1 patient had hyperplasia of the remaining glandular tissue. We conclude that parathyroid cyst is an uncommon clinical problem of uncertain aetiology affecting middle aged and elderly patients.

Liver resections in Auckland 1998-2001: mortality, morbidity and blood product use.

AIMS: There has been a marked increase in the number of liver resections undertaken at Auckland Hospital since 1998. Low central venous pressure anaesthesia was routinely used for liver resection during this period. The aim of this study was to review this experience, with particular emphasis on the peri-operative outcomes of morbidity, mortality and blood product use. METHODS: All patients undergoing liver resection from January 1998 to May 2001 were included in the review. Standardised data were collated retrospectively from hospital records and transferred to an electronic database for analysis. RESULTS: Of 123 patients undergoing liver resection, 113 were elctive and ten were urgent operations. 65% had major resections and 10% had synchronous extrahepatic surgery. There were three post-operative deaths (mortality 2.4%) due to liver failure and sepsis. One or more complications occurred in 68 patients (morbidity 55%). 72% did not receive a blood transfusion during their hospital stay. Only two of 113 elective patients required a massive blood transfusion (ten or more units). CONCLUSIONS: Mortality in the study period was low but morbidity remains significant. Blood product use was low in elective patients. These results compare well with those of specialised hepatobiliary units internationally.

Acral (volar-subungual) melanoma in Auckland, New Zealand.

We have retrospectively reviewed the charts of 34 acral melanoma patients (melanoma arising from the volar skin of the hands, feet or a subungual site) seen in the Auckland area between 1970 and 1985. These 34 patients constituted 3.5 per cent of the total number of patients (972) reviewed over this period. Six of the thirty-four patients were either Polynesian or Maori. There were 19 men and 15 women, and the mean age of the group was 59 years. The primary lesion arose from the plantar or palmar skin in 25 patients and 9 patients had subungual lesions. All lesions but one were pigmented. Most patients with plantar or palmar lesions presented with clinical stage 1, Clark's level 4 disease, while those with subungual lesions presented most commonly with stage 2, Clark's level 5 disease. Treatment was wide local resection for plantar and palmar lesions and amputation for subungual lesions. Regional lymph node dissection was performed in 10 patients with positive nodes at presentation and in 6 patients who developed metachronous nodal disease. Patients were followed for between 1 and 16 years, and 18 patients died in this period, 15 of metastatic melanoma (mean time 34 months). Subungual melanoma carried a worse prognosis than melanoma arising in palmar or plantar skin.

Surgical management of neutropenic enterocolitis.

Three cases of histologically confirmed neutropenic enterocolitis, each presenting as an acute abdomen in patients with leukaemia are presented. All three patients presented with fever and abdominal pain within 14 days of completing a course of chemotherapy. Signs of peritonitis localized to the right iliac fossa developed in each patient, in spite of aggressive antibiotic therapy and bowel rest. All three patients were found to have non-viable caecum at laparotomy and were treated by right hemicolectomy. Primary ileocolic anastomosis was performed in one patient, who recovered following a stormy postoperative course owing to sepsis. Two patients underwent formation of an ileostomy with distal mucous fistula and each recovered with minimal postoperative complications; secondary anastomosis was performed electively in both cases. The difficulty in diagnosing neutropenic enterocolitis preoperatively is discussed and the place of non-operative management is reviewed but we recommend surgical intervention as a means of ensuring removal of a localized septic focus until marrow regeneration occurs.

The effect of tumor bulk on the metabolic response to cancer.

The derangements in energy/substrate metabolism seen in oncology patients are similar regardless of the tumor's site of origin, and in advanced disease these metabolic derangements can be manifested as cancer cachexia. The relationship between tumor size and the degree of metabolic abnormality, however, remains unclear. Using primed constant infusions of stable and radiolabeled isotopes and indirect calorimetry, the authors have determined the rates of net protein catabolism (NPC), glucose oxidation, Cori cycling of glucose, and oxygen consumption in 85 patients with cancer. They have assessed the association between bulk of tumor and metabolic abnormality using regression analysis. A positive correlation was found between tumor bulk and the rates of NPC (r2 = 0.8), plasma glucose appearance (r2 = 0.72), plasma glucose clearance (r2 = 0.70), the percentage of tissue glucose uptake recycled to lactate (r2 = 0.62), and oxygen consumption (r2 = 0.79). The percentage of tissue glucose uptake oxidized was negatively correlated with tumor bulk (r2 = 0.75). The data indicate that the degree of metabolic abnormality seen in cancer patients is closely related to the quantity of malignant tissue present. Progressive increase in tumor size is associated with an increase in peripheral substrate mobilization, an increase in the rate of hepatic glucose production, an increase in tissue glucose uptake, an increase in energy-expensive glucose cycling to lactate, and an increase in protein loss.

Hepatic artery infusion chemotherapy for metastatic colorectal carcinoma.

Hepatic metastases are a major cause of morbidity and will affect up to 80,000 new patients annually in the United States. Up to 20% of these patients will die with metastatic disease localized to the liver. Hepatic arterial infusion (HAI) therapy has a sound anatomical and pharmacological rationale. A number of randomized clinical trials in patients with unresected metastases have demonstrated that HAI is associated with a complete response rate in 5% of patients and partial responses up to 60%. In comparison, systemic chemotherapy is associated with a partial response in 20% of cases. No investigation comparing systemic chemotherapy with HAI has demonstrated an improvement in survival following HAI, since all investigations either allowed crossover, were under-powered with respect to survival statistics, or included patients with extrahepatic disease in the HAI arm. However, a recent investigation utilizing HAI with systemic chemotherapy following hepatic resection demonstrates improved local and systemic disease control and overall survival. This approach offers new promise for the curative treatment of the patients with metastatic colorectal carcinoma.

Cancer of the tongue and oral cavity in Auckland, New Zealand, 1970-86.

This report comprises a retrospective review of the clinical data on 157 patients seen in the Auckland area having a diagnosis of cancer of the tongue, floor of the mouth, inferior alveolus, or buccal mucosa (retromolar area, vestibule of the mouth, and cheek mucosa) during 1970-86. One hundred patients were male, 95% were European, 85% were cigarette smokers, and 58% had a history of high alcohol intake. All primary tumours were squamous cell carcinomas, 50% were located in the tongue, 27% in the floor of the mouth, and 11.5% each in the buccal mucosa and inferior alveolus. The majority (60%) of patients with tongue cancer were clinically stage I at presentation while other intra-oral tumours were evenly distributed between stages I and IV. Surgical resection of the primary intra-oral lesion produced local control in 90% of stage I tumours, but this fell to below 70% in stage II-IV tumours. Most patients (82%) who recurred locally had positive or 'close' margins, and this rate of local tumour recurrence as a consequence of narrow margins did not decrease with the addition of adjuvant radiotherapy. Of those patients with stage I disease who received only treatment of the primary lesion, 20% later developed regional nodal disease which was controlled in more than half by neck dissection, but control was achieved only in 11% of patients treated with radiation. The presence of regional disease at presentation was associated with a poor prognosis. It is concluded that local control of inferior oral cavity tumours can be achieved if resection is accomplished with clear margins.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic basis for management of the septic surgical patient.

The physiologic events accompanying postoperative septic complications in surgical patients represent a coordinated response to bacterial invasion, which is aimed at maintaining the function of key organ systems. When sepsis is prolonged or overwhelming, physiologic dysfunction and multiorgan failure develop. This review outlines the pathophysiologic response to sepsis and correlates it with recent therapeutic advances in the metabolic management of the postoperative septic patient.