Contrasting effects of identical nutrients given parenterally or enterally after 70% hepatectomy

Based on clinical observations, we hypothesized that prolonged parenteral nutrition (in contrast to enteral nutrition) is detrimental after major hepatic resection. Male Sprague-Dawley rats (300 to 380 g) anesthetized with intraperitoneal sodium pentobarbital had 70% hepatic resection and jugular vein and gastrostomy catheterizations using aseptic techniques and were divided randomly into three groups: (1) total parenteral nutrition (TPN) (nutrients via central vein), (2) total enteral nutrition (TEN) (identical nutrients via gastrostomy), and (3) standard oral feeding (SOF) (chow and water ad libitum). Unused catheters were plugged. In the first set of experiments (n = 42), nutrient intake was formulated to approximate the nutritional intake of normal rats, 216 kcal/kg/d. Infusate was 15% glucose, 4.5% amino acids, electrolytes, trace minerals, vitamins, and 20% fat emulsion given half-strength the first day, three-fourths strength the second day, and full strength thereafter. On postoperative day 7, surviving rats were killed. Mortality prior to day 7 was very high (68%) in the TPN group and low in the TEN (9%) and SOF (9%) groups (p < 0.005). Among survivors, the serum albumin level was lowest (p < 0.002) and serum bilirubin level (p < 0.025) and wet weight of regenerated liver (p < 0.002) highest in the TPN group. However, the livers in TPN rats appeared pale and were found to be abnormal histologically with markedly diminished glycogen and amphophylic hepatocyte cytoplasm, and their spleens were enlarged (by a factor of two). The high mortality of TPN rats was seen whether the fat emulsion was given as a bolus daily, continuously as part of the infusate, or not included as part of the TPN regimen. In the next series (n = 70), nutrient concentrations, volumes, and rates of infusion were varied. There was a high correlation between caloric (r2 = 0.831, p < 0.0006), glucose (r2 = 0.598, p < 0.02), and amino acid (r2 = 0.619, p < 0.03) intakes and mortality in the TPN group: at 140 kcal/kg/d, none died; at 178 kcal/kg/d, 50% to 62% died; and at 230 kcal/kg/d, 80% died. No TEN rat died. In conclusion, 70% hepatectomized rats fed enterally with nutrients approximating the intake of normal rats do well and survive. In sharp contrast, mortality is very high when identical nutrients are infused parenterally. By reducing the levels of nutrients given parenterally, survival improves significantly.

Composite reconstruction of the esophagus and hypopharynx after severe caustic injury

The ingestion of caustic materials may cause burns and subsequent strictures of the esophagus. Depending on the extent of the injury, the stricture may require dilation, excision, or bypass with an esophageal replacement. There is also a risk of esophageal dysfunction, perforation, and malignancy. Here is presented a case of a burn so severe that the hypopharynx was deformed and the esophagus destroyed. Composite techniques restored complete gastrointestinal continuity while maintaining excellent swallowing function.

Tube feeding in palliative care: benefits and problems

Percutaneous endoscopic gastrostomy techniques are becoming more widely available and will be considered increasingly for patients with head and neck or upper gastrointestinal malignancies, and for neurological dysphagia, as occurs in motor neurone disease. This case history illustrates some of the practical and ethical issues raised by their use.

Effects of highly selective vagotomy and additional procedures on gastric emptying in patients with obstructing duodenal ulcer

A solid gastric emptying study was conducted on 46 patients more than 1 year after highly selective vagotomy (HSV) and additional procedures for obstructing duodenal ulcer and on 21 patients after HSV alone for uncomplicated duodenal ulcer. The additional procedures included dilatation (n = 14; HSV + D group), Holle pyloroplasty (n = 14; HSV + P group), and Jaboulay gastroduodenostomy (n = 18; HSV + GD group). The test meal consisted of two eggs labeled with 99mTc sulfur colloid, two slices of white bread toast, and 300 ml of orange juice (total 322 kcal). Gastric emptying curves and emptying parameters (t1/2, half emptying time; lag phase, TLAG; emptying rate, k; and beta value) were compared with those of 17 healthy volunteers, the normal control group. The patients after HSV alone had an almost normal gastric emptying. The HSV + D group showed a significant delay from minute 45 to the end of the emptying curve, corresponding to a longer t1/2 (p = 0.02), and a slower emptying rate (p = 0.029). The HSV + P group approached a nearly normal emptying curve, corresponding to an insignificant difference in emptying parameters. The HSV + GD group had significantly faster emptying from minute 15 to the end of the emptying curve, corresponding to a faster t1/2 (p = 0.0005), a shorter lag phase (p = 0.027), and a faster emptying rate (p = 0.021). Recurrent ulcerations were noted in one patient (4.8%) of the HSV alone group, five (35.7%) of the HSV + D group, one (7.1%) of the HSV + P group, and one (5.6%) of the HSV + GD group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of 110 cases of esophagogastrostomy by intraluminal elastic circular ligation with an absorbable supporting tube]

The result of 110 cases of esophagogastrostomy by intraluminal elastic circular ligation (IECL) with an absorbable supporting tube was reported. Postoperative X-ray observation of the tube showed that its supporting effect was satisfactory. The tube-drop time was 14.7 +/- 2.5 days and unaffected by the tube size or the site of anastomosis. The supporting tube could be safely absorbed or partially fragmented and expelled from the alimentary tract. Postoperative anastomotic leakage occurred in one case (0.91%) and the cause was analysed. The use of IECL, with the merits of saving time, anastomosing tightly and leaving no suture materials in the anastomotic site, can be expected to prevent the anastomotic leakage and may provide references for other gastrointestinal anastomosis.

Assessment of alkaline reflux in children after Nissen fundoplication and pyloroplasty

During an eight month period, 22 children less than 15 years of age (mean age of three years and seven months) who underwent operative treatment of gastroesophageal reflux (GER) were selected for study. All were symptomatic and unresponsive to medical therapy. Preoperative evaluation included esophageal pH probe monitoring in 18 patients, gastric isotope emptying study in 18 patients and contrast studies of the upper part of the gastrointestinal tract in ten patients. Four children with severe neurologic disorders who required placement of a feeding gastrostomy tube underwent fundoplication without preoperative evaluation. All 22 patients had GER and 14 had documented delayed gastric emptying (greater than 60 percent residual at 90 minutes) on radionuclide scan with appropriate meal for age. Each child underwent Nissen fundoplication and tube gastrostomy. Sixteen patients also had a modified pyloroplasty with a 2.5 to 4.0 centimeter vertical seromuscular incision on the antrum. When the patients achieved a full feeding schedule (postoperative day range three to 21 days, mean of 6.2 days), they were put on a fast for six hours and an aspirate was obtained from the gastrostomy tube. Analysis of pH and bile acid content served as indicators of alkaline reflux. The six children without pyloroplasty served as the control group. Intragastric pH ranged from 1.91 to 7.00 (mean of 3.71) and bile acid content ranged from 4 to 150 micrometers per liter (mean of 62 micrometers per liter). No significant differences were seen between patients with fundoplication alone and those with fundoplication and pyloroplasty (p = 0.97 for pH; p = 0.66 for bile acid content). Two patients with pyloroplasty showed slight elevation of intragastric bile acid content at the upper limits of normal. At follow-up evaluation from nine to 23 months (mean of 18 months), all patients were asymptomatic, with only two showing rare gagging. Additionally, nine patients have had complete resolution of their pulmonary symptoms. No patients demonstrated diarrhea, gas bloat or dumping. Nissen fundoplication combined with a modified pyloroplasty or "antroplasty" for delayed gastric emptying provides excellent clinical results with minimal demonstrable bile acid reflux and no change in intragastric pH at the one and one-half year follow-up evaluation.

Characteristics of dysphagia in children with cerebral palsy

Videofluoroscopic modified barium swallow (VMBS) examinations may provide clinically relevant information regarding deglutition in children with cerebral palsy and dysphagia. A retrospective review of clinical evaluations and VMBS studies on 90 consecutive children with cerebral palsy and dysphagia was completed. Most children were referred because of concerns regarding airway protection during oral feedings. Most children had multiple disabilities and 93% were nonambulatory. The majority of children were totally dependent for oral feedings (80%). Oral and pharyngeal phase abnormalities were present in almost all patients. Abnormalities of deglutition were observed only while swallowing specific food textures in the majority of patients. Aspiration of specific food textures was significantly more common than aspiration of all food textures (p < 0.0001). Finally, aspiration was silent in 97% of the patients. VMBS studies can provide clinicians with valuable information regarding the most appropriate food textures and rates of oral feeding for children with cerebral palsy and dysphagia.

Gastroesophageal reflux during gastrostomy feeding

BACKGROUND/AIMS

Aspiration pneumonia is one of the most serious complications of gastrostomy tube feeding, with a reported incidence of 10%-20% in nursing home patients. The aims of this prospective study were to examine lower esophageal sphincter (LES) pressure before and after placement of gastrostomy tubes and to examine the effects of rapid intragastric bolus and slow, continuous feeding on LES pressure.

METHODS

Ten subjects were enrolled in the study. Basal LES pressure was measured before and after placement of gastrostomy tubes. Thereafter, LES pressure was measured for 15 minutes during rapid intragastric infusion of 250 mL of an enteral feeding formula and 100 mL water and continuous infusion of the enteral feeding formula at 80 mL/h. Scintigrams evaluating gastroesophageal reflux were obtained during each method of feeding.

RESULTS

Placement of gastrostomy tubes had no effect on basal LES pressure. Rapid intragastric bolus infusion led to a reduction in LES pressure to incompetent levels at 2.1 +/- 2.0 mm Hg (P < 0.001). Free gastroesophageal reflux to the sternal notch was shown by scintigraphy. Slow, continuous gastrostomy feedings did not alter LES pressure (P > 0.05) or show free gastroesophageal reflux by scintigraphy.

CONCLUSIONS

Gastroesophageal reflux and aspiration in patients fed via the gastrostomy tube may be caused by LES relaxation secondary to gastric distention caused by distention of the stomach.

Severe complications following a "barium swallow" investigation for dysphagia

OBJECTIVE

To highlight the risks of investigation of patients with swallowing disorders by "barium swallow", when the disorders may arise from dysfunction of the upper swallowing tract.

CLINICAL FEATURES

An 81-year-old Italian woman presented to her local doctor with a history of dysphagia of five days' duration. A barium swallow resulted in aspiration of a large amount of barium into the right main bronchus, causing severe problems. After a period of intensive respiratory care including intubation and continuous positive airway pressure, she recovered sufficiently to be referred to a rehabilitation unit. She had mild hemiplegia but severe dysphagia, secondary to a brain stem infarct.

INTERVENTION AND OUTCOME

Persisting severe dysphagia was confirmed, with extreme risk of aspiration. The patient underwent percutaneous endoscopic gastrostomy and was discharged to live independently, but requiring long-term gastrostomy feeding.

CONCLUSION

When a patient presents with dysphagia, great care should be taken to exclude upper tract dysfunction with its attendant risk of aspiration, generally by referral to a centre or consultant with expertise in this area, before ordering or carrying out investigations appropriate to disorders of the lower tract.

Intramural haematoma of the duodenum

Intramural duodenal haematoma secondary to blunt abdominal trauma is a rare injury. One case is reported, and the clinical features, diagnosis and management are discussed.

[Gastrostomy instead of gastric intubation for stomach decompression after large urologic operations]

In 31 patients who had undergone extensive intraabdominal urological surgery, a gastrostomy was performed for gastric decompression instead of introduction of a nasogastric tube. There were no complications during the procedure. All patients tolerated the gastrostomy well. Two were fed through the gastrotomy. We conclude, that gastrostomy is a safe method of gastric decompression.

Feeding Roux-en-Y jejunostomy in the management of severely neurologically impaired children

Feeding problems are legion in severely neurologically impaired children. Many patients do well with a gastrostomy with or without fundoplication. Unfortunately, fundoplication is not without complication, emphasizing the need for other options in the management of these difficult patients. Since 1990 six patients (age range, 2 months to 6 years) have been treated by the creation of a permanent Roux-en-Y end-jejunostomy and a gastrostomy. The Roux limb is closed tightly around a mushroom catheter. The gastrostomy is left for gastric decompression, and the jejunostomy tube is used for all nutrition and most medications. One patient died in the postoperative period. All the others have done well, without significant complication and with a high level of parent satisfaction (average follow-up, 12 months). Previously four other patients were treated with a Roux-en-Y jejunostomy in which, rather than closing the Roux limb around the catheter, it was brought out as a catheterizable stoma. Frequent leakage and prolapse make this approach less desirable.

[A rare complication of percutaneous endoscopic gastrostomy: metastasis of adenocarcinoma of the stomach in the area of the gastric stoma]

A percutaneous endoscopic gastrostomy (PEG) was placed by the "pull technique" in a 67-year old patient before initiation of palliative radiation therapy of a gastric adenocarcinoma invading the distal esophagus. A tumor metastasis developed in the peristomal area and around the gastrocutaneous fistula tract; it was most likely caused by implantation of tumor tissue adhering to the PEG tube. This complication of PEG placement appears to be very rare.

Pylorus-preserving pancreatoduodenectomy: technique and indications

Pylorus-preserving pancreatoduodenectomy is accepted as definitive treatment of some malignancies, such as cancer of the duodenal papilla, and cancer of the lower bile duct. However, its use in cancer of the head of the pancreas is controversial. We have applied pylorus-preserving pancreatoduodenectomy combined with extended lymph node dissection as the major technique in cases of malignant disease. Also, when invasion of the portal vein is confirmed or suspected, portal vein resection has been combined. However, when the duodenal bulb or pyloric ring has been invaded by cancer, the classic Whipple operation has been indicated. Our experience over the last 11 years has demonstrated no statistical difference in the 5-year survival rate between patients with pancreatic head cancer treated with the Whipple procedure (n = 25, 34.8%) and pylorus-preserving pancreatoduodenectomy (n = 16, 33.3%). Also, the postoperative quality of life proved to be better in patients with pylorus-preserving pancreatoduodenectomy. These data support the continued application of pylorus-preserving pancreatoduodenectomy for the treatment of cancer of the head of the pancreas.

Percutaneous biliary drainage into the jejunum via a tube gastrostomy in patients with complete biliary obstruction: a report of two cases

In recent years, percutaneous gastrostomy has been used to return bile draining from percutaneous transhepatic drainage catheters in patients with complete biliary obstruction that could not be bypassed surgically or stented either percutaneously or endoscopically. We report our initial experience with two patients in whom the combined percutaneous and endoscopic technique was used to divert the bile back into the jejunum.

Contamination of a prefilled ready-to-use enteral feeding system compared with a refillable bag

The contamination of a refillable bag enteral feeding system was compared with a prefilled, ready-to-use system on four stable patients with gastrostomies in a longterm care facility. Samples were taken from the distal end of the tubing attached to the formula reservoir three times (just before administration to the patient, during the morning medication pass, and just before the reservoir change) during 24 hours for 3 days with use of the refillable bag, the ready-to-use system, and the ready-to-use system with a Y-port added. A Y-port was added to the ready-to-use system to facilitate administration of water, medications, residual checks, and specimen collection without disconnection of the gastrostomy tube from the formula reservoir tubing when it was apparent that the contamination levels of the refillable bag and the ready-to-use system were not different. Forty-one (65%) of the 63 specimens collected while the Y-port was not being used exceeded the acceptable contamination level for grade A pasteurized milk. Five (28%) of the 18 specimens collected while the Y-port was in use exceeded this level. Use of a Y-port is suggested when a prefilled ready-to-use system is used to decrease contamination as well as save nursing time.

Long-term effects of feeding high carbohydrate diet in pre-weaning period by gastrostomy: a new rat model for obesity

In the present study, we report the long-term metabolic consequences of feeding a milk substitute formula that is high in carbohydrate-derived calories during the suckling period. Male Sprague-Dawley rat pups were raised by gastrostomy on a high carbohydrate (HC) formula or a high fat (HF) formula (which mimicked rat milk composition in macronutrients) during the pre-weaning period (day 4 to 24). These rats were then weaned to a laboratory stock diet and subsequently challenged with a high sucrose diet to augment the development of obesity. The pups receiving the HC formula developed obesity in later life, even though there was no change in the body weight of this group compared to mother-fed (MF) controls or HF formula fed animals during the pre-weaning period. The HC rats were hyperinsulinemic and their growth rates were greater than MF rats starting at day 55. The lipogenic capacity of liver as well as adipose tissues (epididymal and omental) was higher in HC animals compared to MF control animals, as reflected by increases in two key lipogenic enzymes (fatty acid synthase and glucose-6-phosphate dehydrogenase) and in vitro synthesis of lipids. An analysis of adipose tissue morphology in adult rats showed an increase in cell size in epididymal adipose tissue of HC rats compared to the MF group. However, there was no significant difference in cell size in omental adipose tissue between the MF and HC rats. The HF group behaved similarly to the MF control group in growth pattern and measured metabolic parameters.

Evaluation of the benefits of gastric tube feeding in an elderly population

OBJECTIVE

To assess the benefits of gastric tube feeding in an elderly community hospital population.

SUBJECTS

One hundred consecutive patients who required feeding gastrostomies from July 1984 through June 1987.

SETTING

Durham (NC) Regional Hospital, a 380-bed community hospital.

METHODS

Patients were evaluated using a quality of life scale (QL scale) adapted from Spitzer's QL Index. The evaluation was based on hospital records at the time of tube placement and interviews with patients or family members at follow-up between June 1991 and March 1992. Subjective evaluation of the benefits of gastric tube feeding were obtained in interviews with patients or their families at follow-up.

RESULTS

Overall there was no significant change in the objective evaluation of quality of life at follow-up. Men, patients over 76 years of age, and patients with chronic illnesses such as multiple strokes or dementia showed the poorest response on the QL scale. Subjective evaluation by patients or their family members was positively correlated with objective evaluation on the QL scale. Family members of patients who showed the poorest response on the QL scale were more likely than other family members to respond no to the question, "Would you want this done to you if you were in his/her situation?"

CONCLUSIONS

Our QL scale provides a good indication of patients' and family members' subjective evaluation of the benefits of gastrostomy tube feeding after 4 to 8 years. Thus, the scale should be helpful to physicians who must consult with patients and their families and make decisions about the use of this procedure. The significant discrepancy between family members' evaluations of the benefit of the procedure to the patient and their refusal of the procedure for themselves if they were in the patient's situation confirms the need for advance directives and the importance of conscientious implementation of the Patient Self Determination Act of 1990.

Pure esophageal atresia: outlook in the 1990s

Eleven newborns with pure esophageal atresia were treated between 1980 and 1989 inclusive; there were six girls and five boys. Their gestational age ranged from 31 to 40 weeks (average, 37 weeks) and weight from 1.1 to 3.0 kg (average, 2.2). The only associated anomalies were Down's syndrome, respiratory distress syndrome, and patent ductus arteriosus. All babies received an immediate gastrostomy. Several radiologic studies were done to see if the distance between the two esophageal pouches was decreasing. Dilatations of the upper pouch were carried out in two patients. After a wait of 1 to 7 months (average, 3 1/2) a primary anastomosis was attempted; the weight of six babies doubled during this time. Eight neonates had a primary repair (two were aided by a circular myotomy). Two had a staged gastric tube constructed, and one baby had a gastric pull-up procedure. Three of the infants with a primary anastomosis required a subsequent antireflux operation, and one needed her anastomosis resected 16 months later. Ten of these 11 newborns are alive and well; one of the gastric tube children died from an adhesive small bowel obstruction at age four years.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of supportive nutritional therapy via percutaneous endoscopically guided gastrostomy on the quality of life of cancer patients

Between April 1987 and May 1990 a total of 212 consecutive patients with tumours in the head and neck region were admitted to a prospective study comparing planned prospective enteral nutrition via percutaneous endoscopically guided gastrostomy (PEG; n = 47) and oral nutrition (n = 134). The nutritional status (anthropometric and laboratory chemical parameters) and the quality-of-life index according to Padilla et al. [Res Nurs Health 6:117-126 (1983)] were determined prior to radiotherapy, 2, 4, 6 weeks later during radiotherapy and 6, 12 and 18 weeks after completion of radiotherapy. The quality-of-life score of the orally nourished patients decreased quickly during radiotherapy and improved only slowly afterwards. Although PEG patients had a worse starting score, their quality-of-life index did not deteriorate during therapy (statistically significant difference between the two groups). The same applies to the nutritional status. These results show that an early and constant enteral nutrition by PEG can stabilize the nutritional state and the quality of life of patients with tumours of the head and neck area during radiotherapy.