Transposition of the anorectum to the abdominal wall

A unique procedure is described in which the anorectum is mobilized on the inferior mesenteric vascular pedicle and transposed to the anterior abdominal wall. The aim is to preserve maximal intestinal length in patients with short bowel syndrome and intractable diarrhoea. Unique physiological data provided by the second case demonstrate that the specialized sensory functions of the rectum reside in the rectal wall and are subserved by an autonomic nervous supply that is independent of the pudendal nerves.

Physical measures of recovery from anorexia nervosa during hospitalised re-feeding

OBJECTIVE

To examine the relationship between weight gain, changes in body composition and physiological characteristics of fitness during the recovery from anorexia nervosa.

DESIGN

Longitudinal over eight weeks of intensive inpatient re-feeding (Wk 0-8).

SETTING

The London Hospital Medical College.

SUBJECTS

Ten female patients who agreed to participate. Seven completed the protocol.

INTERVENTIONS

Dual-energy X-ray absorptiometry (dexa) and skinfold thickness measures at Wk 0 and 8. Weekly measures of peak expiratory flow rate and cycle ergometry (several variables relating to aerobic work recorded at rest and during cycling at low loads (0-60 W)). Blood samples for lactate and potassium measures, taken during cycling at Wk 0, 4 and 8 only.

RESULTS

(1) Body composition: Mean weight gain over eight weeks was 9.6 kg, dexa and skinfold measures showing fat gain to contribute 62% and 54%, respectively. Both methods showed significant changes in percentage body fat with refeeding (P < 0.01 and P < 0.001, respectively), however there were significant differences in results between methods before (P < 0.01) but not after (P = 0.2) refeeding. (2) Physiological function: Between weeks 0 and 8, mean peak expiratory flow rate rose to 85% of predicted values, cycle ergometry performance improved in six subjects (three never reached 60 W load), mean respiratory exchange ratio (RER) during cycling fell at 0 W and 20 W loads (both P < 0.05), and oxygen pulse increased at rest and 0 W load cycling (both P < 0.05), Wk 8 values being well below normal. Oxygen uptake at rest and all loads increased in line with body weight gain only. No significant changes were seen in heart rate or blood lactate and potassium levels.

CONCLUSIONS

(1) Lean body and fat mass increased significantly during eight weeks of refeeding. The methodological difference in initial body fat measurements requires further investigation. (2) The women had severely impaired physiological function. Variables studied were only slowly improving with refeeding, and work capacity was still well below normal.

Protein Turnover, Energy Expenditure and Body Composition in Patients with Acute Leukaemia Undergoing Chemotherapy

1. Measurements of whole body protein turnover using the (13)C-leucine tracer technique, of body composition using anthropometric measurements and DEXA scanning, and of resting energy expenditure (REE) assessed by indirect calorimetry were made in 8 patients with acute leukaemia undergoing a single course of chemotherapy. Measurements were made in the post absorptive state immediately before chemotherapy and were repeated close to the time of discharge from hospital (mean days in hospital 31 ± 4.3, range 22-35), a mean of 23 ± 4.8 days after completion of chemotherapy. 2. The mean weight loss was 3.63kg (P < 0.001) with significant reductions in the mean non dominant mid arm circumference (1.29cm, P < 0.01), biceps (0.7mm, P < 0.01) and triceps (1.9mm, P < 0.05) skinfold thicknesses. DEXA scanning showed a reduction of mean body fat (1.22kg, P < 0.05) and lean tissue (1.85kg, P < 0.01). 3. There was a reduction in whole body leucine flux (Q) by 35% (P < 0.01) and synthesis (S) by 40% (P < 0.001) with no change in catabolism (C) over the course of admission. 4. There were no significant changes in REE.

Bed rest decreases whole-body protein turnover in post-absorptive man

1. Whole-body protein turnover was measured using the [15N]glycine tracer technique in 10 post-absorptive healthy volunteers during normal daily activities and a period of bed rest. 2. Bed rest reduced whole-body protein turnover (25%), synthesis (26%) and breakdown (25%), but short-term urinary nitrogen excretion remained unchanged.

Review article: artificial nutritional support for improved patient care

Malnutrition is common and undiagnosed in the majority of affected hospital patients; it is associated with impaired organ function, morbidity, and increased length of hospital stay. Artificial nutritional support in malnourished patients leads to improvement in nutritional status and clinical outcome. Nutritional support is required in malnourished patients, patients who are unable to take normal diet and patients with intestinal failure. Gastroenterologists are required to supervise patients with intestinal failure, to insert endoscopic feeding devices, and increasingly to participate in, or lead, nutritional support teams. Major developments in nutrient delivery have included percutaneous endoscopic feeding devices, the recognition that enteral feeding is possible in patients with gastric stasis, and that nutrient needs can be met by peripheral parenteral nutrition. There is much interest in the use of new substrates, or substrates delivered in pharmacological doses such as glutamine and arginine, to manipulate the response to disease. Many hospitals lack an organized approach to artificial nutritional support. Patients continue to suffer from a lack of treatment or the consequences of inappropriate or inadequate treatment. This article reviews the current status of artificial nutritional support and provides guidelines for patient management.

Malnutrition: incidence, diagnosis, causes, effects and indications for nutritional support

Various methods for the diagnosis of malnutrition, and some of the physical signs commonly associated with it, are discussed. The incidence and possible causes of malnutrition and its effects are then addressed. Finally, the indications for nutritional support, using either the enteral or the parenteral route, are examined.

Whole-body protein turnover in response to hyperinsulinemia in humans postabsorptively with [15N]glycine as tracer

Studies using stable isotopes to determine the effect of insulin on whole-body protein turnover have given conflicting results. The precursor approach to studying healthy subjects in a postabsorptive state shows reductions in breakdown and oxidation; with end product methods in parenterally fed patients no such changes are seen. To explain these discrepancies, we measured protein turnover with and without euglycemic hyperinsulinemic clamping postabsorptively in nine healthy subjects by using single-dose [15N]glycine with calculations based on ammonia and urea end product excretion. With and without clamping, respectively, insulin reduced nitrogen (22.1 and 48.2 mg.kg-1.9 h-1, P < 0.01) and urea (15.8 and 37.5 mg.kg-1.9 h-1, P < 0.05) but increased ammonia (7.7 and 5.0 mg.kg-1.9 h-1, P < 0.05) excretion. Although the urea end product method suggested that insulin tended to reduce both protein breakdown and synthesis, the protein metabolism changes detected with the ammonia end product method tended to be in the opposite direction. The [15N]glycine ammonia end-product method may be inappropriate for studies during insulin infusion because of insulin's effect on ammonia excretion.

Nutritional support in patients with low volume chylous fistula following radical neck dissection

One of the well known complications of radical neck dissection is a chylous fistula, which results from injury to the thoracic duct as it enters the left subclavian vein. Such fistulae may cause considerable increased morbidity to a patient who is already debilitated by malignancy and by the increased catabolic response to surgery. Further surgery may be appropriate for those with a high fistula output but conservative therapy is normally advocated for the remainder. Nutritional and electrolyte support for these patients is essential and poses potential problems in management. We present three such patients. One was fed parenterally and two enterally and in all cases the fistulae closed spontaneously. We examine the known physiological stimuli to chyle production and conclude that the enteral feedings of these patients with fat or an isomolar enteral feed does not, contrary to current belief, increase chyle flow or delay the healing of these fistulae.

High lipid parenteral nutrition improves portasystemic encephalopathy

We have conducted a randomized double crossover study over 4 days in six parenterally fed patients with portasystemic encephalopathy (PSE) in which the nonprotein energy source of otherwise identical feeds was alternately all glucose or predominantly fat. Concentrations of plasma branched chain amino acids (BCAA), plasma insulin, and blood glucose were measured after an initial fast and subsequently after each of the four 24-hr periods of isonitrogenous feeding. The grade of PSE was assessed clinically and by the number connection test, BCAA concentrations were significantly lower during the glucose infusion than during fasting or the lipid infusion. PSE was significantly less with the lipid than with the glucose infusion. Trials testing the effect of infused BCAA must take account of the opposing effect on BCAA concentrations of simultaneous glucose infusion. A high lipid feed may have advantages in the short-term treatment of PSE.

Reproducibility of whole-body protein turnover measurements in an 'ideal' metabolic subject

Whole-body protein turnover measurements using the single dose 15N-glycine technique have been made in a patient completely paralysed by the Guillaine-Barré syndrome. Variation (difference x 100/mean) between the results of the studies was better than 0.75 per cent for protein flux, better than 0.85 per cent for protein breakdown, and better than 5 per cent for protein synthesis.

Protein metabolism in inflammatory bowel disease

Major loss of body protein mass in inflammatory bowel disease is much less common than weight loss, which is often attributable to losses of other body, particularly water and fat. It does occur, however, in a few patients, especially in those with compromised food intake. It is due principally to the combined effects of diminished intake and excessive intestinal losses of amino nitrogen. Nitrogen metabolism is influenced not only by protein nutritional state and net nitrogen intake but also by disease activity. There is some evidence for abnormally low secretion of growth hormone in adolescents with inflammatory bowel disease and growth failure. Low serum albumin concentrations are not necessarily related to protein undernutrition and are the combined result of relatively reduced albumin synthesis, increased intestinal losses, and maldistribution between intravascular and extravascular spaces. Concentrations in the plasma of IgG and acute phase reactants may be raised despite increased losses into the bowel lumen. The prevention of total body protein depletion is achieved principally by maintaining adequate and often not supranormal intakes of a balanced source of amino nitrogen in a balanced diet given orally, enterally, or parenterally, combined with a medical or surgical approach to reduce disease activity: supranormal energy intakes are not beneficial.

Controlled trial of bowel rest in the treatment of severe acute colitis

In a prospective, randomised clinical trial, 47 patients with severe, acute, non-infective colitis treated with 60 mg intravenous prednisolone daily, received either bowel rest with parenteral nutrition or oral diet. Although those who received 'bowel rest' experienced a reduction in daily stool weight, there were no differences in the operation or mortality rates between the groups. Fourteen of the 27 patients with ulcerative colitis, but none of the 16 patients with Crohn's disease required urgent surgery. Bowel rest did not affect the outcome in severe ulcerative colitis treated with intravenous prednisolone. Ulcerative colitis and Crohn's colitis behaved differently in the acute attack.

The effect of insulin infusion on whole-body protein metabolism in patients with gastrointestinal disease fed parenterally

The effect of insulin infusion on whole-body protein metabolism was studied in six non-diabetic patients with gastrointestinal disease receiving constant total parenteral feeding, with each patient as his own control. Insulin added to the parenteral feed significantly raised the plasma insulin concentration and lowered the blood glucose. With insulin infusion there was a significant increase in the rates of urea output and ammonia excretion, but no change in 3-methylhistidine excretion or in the urinary 3-methylhistidine/creatinine ratio. Studies of whole-body protein turnover were performed with a tracer injection of 15N-glycine and both urea and ammonia as end products. Without insulin urea as end product gave an estimate of flux 18 per cent greater than that given by ammonia. With both end products rates of whole-body protein synthesis were significantly greater than rates of breakdown. When insulin was infused the estimate of flux from ammonia increased significantly, resulting in close agreement with the estimate from urea, and there was no longer a significant difference between rates of whole-body protein synthesis and breakdown. Our data, taken with the results of other studies, suggest that insulin infusion is not beneficial as a means of increasing nitrogen retention in non-diabetic parenterally-fed patients.