Pneumatosis intestinalis and portal venous air associated with needle catheter jejunostomy

Pneumatosis intestinalis is an unusual postoperative complication. In some cases, immediate surgical intervention may be necessary. This report describes pneumatosis intestinalis with portal venous air attributed to enteral nutritional support via needle catheter jejunostomy. The etiology, radiographic findings, and management of this problem are reviewed.

[Toxic cholestatic hepatitis due to phenytoin]

We report the case of a 51-years-old female who was prophylactically treated with diphenylhydantoin after surgery of an intracranial aneurysm. Twenty-four days after beginning the treatment, a general syndrome appeared, in addition to a diffuse cutaneous exanthema. Four days later, a cholestatic syndrome, compatible with "toxic cholestatic acute hepatitis", was developed. The suppression of the drug, was followed by rapid clinical improvement and gradual normalization of transaminases values, although biochemical cholestasis persisted for months.

Post-operative levamisole may compromise early healing of experimental intestinal anastomoses

There exists growing interest in immediate post-operative local adjuvant therapy after resection of intestinal malignancies. It is therefore necessary to assess it potential effect on the healing of intestinal anastomoses. Five groups (n = 20) of rats underwent resection and anastomosis of both ileum and colon: a control group and four experimental groups receiving intraperitoneal 5-fluorouracil (5-FU), 5-FU plus leucovorin, 5-FU plus levamisole or levamisole alone, on the day of surgery and the next 2 days. Animals were killed 3 or 7 days after operation. Another three groups (n = 6) of animals were used to compare anastomotic collagen synthetic capacity in control rats or rats receiving 5-FU or 5-FU plus levamisole. On the third post-operative day, the average anastomotic bursting pressure in the 5-FU/levamisole group was reduced by 36% as compared with the control group, both in ileum (P = 0.02) and in colon (P = 0.01). Values in the other groups were similar to those in the control group. Anastomotic breaking strength was significantly (P < 0.025) lowered in the ileum from the levamisole group at both days 3 and 7. Anastomotic collagen synthetic capacity was strongly reduced in the 5-FU and 5-FU/levamisole groups. However, there was no significant difference between the control group and the four experimental groups with regard to anastomotic hydroxyproline concentration and content, either 3 or 7 days after operation. Thus, limited use of levamisole, alone or in combination with intraperitoneal 5-FU, may compromise intestinal healing.

[Enteral nutrition in seriously ill patients with digestive tract surgery]

The results of an enteral nutritional pattern used in 40 seriously ill patients who underwent gastrointestinal tract surgery, are described. The most frequently used route of administration (97.5% of the cases) was a jejunal catheter. We review the types of formula used, the method and time of perfusion, and the association with parenteral nutrition. The mean time of perfusion was 8.6 (5) days and the morbidity rate due to enteral nutrition was 20%. In all cases the complications were minor (externalization of the catheter in 2 cases, proximal reflux of the formula in 1 patient, a catheter break, which was eliminated through the stool without any consequences, in 1 case, diarrhoea in 2 patients, and catheter obstruction in 2 cases). The nutritional results, evaluated by means of clinical chemistry (total proteins, albumin, prealbumin, and transferrin), showed a stabilization of the catabolic process in patients with a poor preoperative nutritional state under severe surgical stress. It can be concluded that enteral nutrition is a useful manner of postoperative feeding in seriously ill patients who undergo gastrointestinal surgery, and that it must often be added to parenteral nutrition to ensure an adequate caloric intake.

[A comparative study in rectal adenocarcinoma: preoperative or postoperative radiotherapy]

PURPOSE

To compare the results of preoperative and postoperative radiotherapy in rectal adenocarcinoma, in terms of overall survival and disease-free survival.

PATIENTS AND METHODS

From 1989 to 1993, 52 patients with clinically operable rectal cancer were retrospectively analyzed. Two groups were compared: Patients in Group I received postoperative radiotherapy and those in Group II preoperative radiotherapy. Patients with a Karfnosky index > 70%, no evidence of distant disease and no major systemic problems were included in this study.

RESULTS

The overall 5-year actuarial survival was 75% in Group I and 83% in Group II. The 5-year disease-free survival was 52% in Group I compared to 86% in Group II, a statistically significant difference (p = 0.025). A reduction in all Dukes' stages was observed in the preoperative radiation group, allowing preservation of the anorectal function in an increased number of patients.

CONCLUSIONS

We observed better results with preoperative radiotherapy and conclude that this treatment might be justified in rectal carcinoma.

Post-orchidectomy radiation therapy alone for patients with early stage non-seminomatous germ cell tumours of the testis

The aim of this study was to review the patterns of disease relapse and survival outcomes for patients treated post-orchidectomy with radiotherapy for early stage (I and IIA) non-seminomatous germ cell tumors of the testis (NSGCT). The clinical records were reviewed of 117 men consecutively treated at the Queensland Radium Institute from 1960-90 (inclusive) for stage I or IIA NSGCT. A total of 108 patients received radiotherapy to the para-aortic nodes and ipsilateral hemipelvis following orchidectomy; nine patients received radiotherapy to the para-aortic nodes and whole pelvis. Twenty-two of 99 (22.2%) stage I and eight of 18 (44.4%) stage IIA patients relapsed following definitive radiotherapy. The 5 year overall and recurrence-free survivals were 84 and 75%, respectively. Factors associated with a significantly worse outcome included: (i) patients with stage IIA disease; (ii) the presence of undifferentiated elements in the operative specimen; (iii) a primary tumor < 5 cm size; and (iv) treatment given prior to 1979. Given the unsatisfactory recurrence rate following radiation therapy alone and the availability of cisplatin-based chemotherapy regimens, it is recommended that radiation therapy alone for patients with early stage NSGCT be abandoned in favour of other management strategies.

[The fulminant meningeosis blastomatosa of a medulloblastoma during postoperative chemotherapy]

BACKGROUND

Chemotherapy is currently investigated in young children with medulloblastoma with the objective to omit or even delay craniospinal irradiation.

CASE REPORT

We report a case of very early meningeal progression of medulloblastoma during postoperative chemotherapy in a 2.5-year-old boy. At 2 3/12 years of age, the boy developed ataxia. One month later, a malignant cerebellar tumor was diagnosed by magnetic resonance tomography. The boy underwent a macroscopically complete resection. Histological diagnosis revealed medulloblastoma. Postoperative magnetic resonance scans showed no residual disease or spinal seedings and the patient was classified as T3 M0 according to Chang. Three weeks after surgery, chemotherapy with ifosfamide, VP 16, and methotrexate was started. One month later, a positive Babinski sign developed, computed tomography scans showed no abnormalities. Chemotherapy was continued with cisplatin plus cytosine arabinoside as well as cisplatin plus ifosfamide and methotrexate. After 4 months of chemotherapy, a seizure and weakness of the legs occurred. Magnetic resonance scans revealed massive meningeal seeding and 400 tumor cells/microliters were found in the cerebrospinal fluid. Craniospinal irradiation was initiated, and the neurologic symptoms resolved. The boy died, however, 4 months later due to progressive spinal disease.

CONCLUSIONS

The early and rapid meningeal progression during chemotherapy is uncommon. The case demonstrates the difficulties of diagnosis and differential diagnosis.

A pitfall in the technique of jejunal tube insertion, resulting in jejunal perforation

Enteral feeding by a jejunostomy tube is a reliable and cost-effective method for both long- and short-term nutritional support in selected patients, although a high complication rate has been reported in some series. The authors report on jejunal perforation in an infant, caused by a kinked jejunostomy tube, and emphasize this possible pitfall as a warning to others.

A case of acute myocardial infarction. Intracoronary thrombosis in two major coronary arteries due to hormone therapy

A fifty-four-year-old woman was admitted to the hospital for a sensation of tightness in the chest of one hour's duration. She had undergone surgery for breast cancer two years previously and had been taking 30 mg of tamoxifen and 1200 mg of medroxyprogesterone daily after surgery. Emergency coronary angiography on admission revealed thrombi in both the right coronary artery and the left anterior descending coronary artery. Tissue-type plasminogen activator was injected into both coronary arteries, resulting in diminution of thrombus size. Repeat coronary angiography on the next day disclosed no thrombus in either artery and no significant stenosis. Electrocardiographic and laboratory data indicated myocardial infarction. These findings strongly suggest that the combination hormone therapy altered the patient's blood coagulability and played an important role in the formation of the intracoronary thrombi and subsequent acute myocardial infarction.

[Hypocaloric peripheral parenteral nutrition in postoperative patients (the Europan Project) (II)]

Hypocaloric peripheral parenteral nutrition (HPPN) appears to be indicated in patients in a situation of moderate malnutrition who are to undergo a short period of fasting following surgery. Our aim was to determine the utility of the contribution of parenteral solutions of amino acids (AA) with limited caloric supply in the post-surgical patient, using different nutritional evaluation parameters. We examined 75 post-surgical patients who met at least two of the three criteria established as malnutrition: 1) albumin < 3 g/dl; 2) pre-albumin < 21 mg/dl; 3) bodyweight of less than 95% of the ideal weight. They were divided into four groups: a control group, of 15 patients undergoing standard fluid therapy; Group I, 20 patients with nutritional support of glucose +AA; Group II, 20 patients with glycerol +AA; and Group III of 20 patients with sorbitol-xylitol +AA. The most significant data encountered were a rapid recovery of short half-life proteins (pre-albumin and retinol), a less negative nitrogen balance, and a greater decrease of urinary 3-methylhistidine, when HPPN was used. A notable increase was also obtained in the majority of AAs and of the G and M immunoglobulin plasmatic figures in the groups treated. In terms of complications, a greater percentage of wound dehiscences appeared in the control group than in those treated (13.3 vs 5%) while, on the other hand, there was a higher incidence of catheter-induced phlebitis in groups undergoing HPPN. We conclude that HPPN is a valid nutritional support in post-surgical patients with more or less significant malnutrition, and when the gastro-intestinal tract cannot be used, for whatever reason, during the first week following the operation.

Heparin-induced thrombosis treated with ancrod

Heparin used in the treatment of thromboembolic disease may produce an immune response in the patient, leading to thrombocytopenia and even thrombosis. These complications may arise at any time after the institution of heparin therapy. The authors report a case of heparin-induced thrombocytopenia with thrombosis in a 70-year-old woman. The complication was treated successfully with thrombectomy and the administration of warfarin and ancrod, which is a natural fibrinolytic agent. The nature of heparin-induced thrombosis and the mechanism of action of ancrod are discussed. The authors emphasize that all patients receiving heparin therapy should be closely monitored to detect hematologic disorders and to prevent their sequelae. Ancrod provides a reasonable therapeutic option if thrombosis does occur.

Pressure exerted by head bandages used in otological surgery

The pressure exerted by head bandages at the operation site following ear surgery was measured using a balloon catheter and pressure transducer. The initial pressures achieved, their diminution with time and the relationship of pressure to the induction of headache in the patient were studied. The principal findings were that the standard otological head bandage is rarely tight enough to prevent haematoma formation, bandages have lost their efficacy after the first hour and headaches are associated with a significantly higher initial bandage pressure.

Urological complications in 210 consecutive simultaneous pancreas-kidney transplants with bladder drainage

OBJECTIVE

The urological complications of 210 patients who underwent simultaneous pancreas-kidney (SPK) transplantation over a 7-year period were reviewed.

SUMMARY BACKGROUND DATA

Worldwide, bladder drainage has become the accepted method of exocrine drainage after pancreas transplantation. With the increasing use of bladder drainage, the surgical post-transplant complications have shifted from intra-abdominal complications to urological complications.

METHODS

Two hundred ten diabetic patients received SPK transplants with bladder drainage. A retrospective review was conducted to analyze the incidence, type, and management of urological complications.

RESULTS

The most frequent urological complications were hematuria, leak from the duodenal segment, recurrent urinary tract infections, urethritis, and ureteral stricture and disruption. Complications related to the renal transplant included ureteral stricture and leaks, as well as lymphoceles.

CONCLUSIONS

Despite the high incidence of urological complications, 5-year actuarial patient and graft survival are excellent. Only one graft and one patient were lost secondary to urological complications.

[The administration of intermittent outpatient total parenteral nutrition via a subcutaneous reservoir]

The development of artificial nutrition has made it possible to maintain the nutritional condition and survival of patients with large intestinal resections along with therapeutic support in certain pathological processes. As such patients have become aware of their potential and the prolonged life expectancy offered, they have increased their demands for enhanced comfort and independence. The experience with a patient with short gut syndrome following quasi-total intestinal resection due to necrosis, and with another with post-esophagocoloplasty necrosis, and the administration of intermittent outpatient total parenteral nutrition through a subcutaneous reservoir in both cases, enabled us to appreciate the advantages of the reservoir in administration of the nutrition. The ease of administration, reduced risk of infection and the positive psychological effect seen in these patients, enabled to lead a "practically normal" life, all vindicate the use of this method.

GM-CSF in the treatment of a patient with severe methotrexate intoxication

This case report describes the successful treatment of severe methotrexate intoxication in a 72-year-old female patient. Following two prior uneventful courses of a polychemotherapy regimen including low-dose intravenous (i.v.) methotrexate, the patient presented with fever, polymucositis, incipient pyodermia, acute renal failure and pancytopenia 9 days after the third application. Severe methotrexate overdose was confirmed by serum levels. Using a polypragmatic treatment approach focusing on renal function and including granulocyte-macrophage-colony-stimulating factor (GM-CSF) this life threatening and nearly fatal intoxication was successfully treated. This case report demonstrates that GM-CSF might contribute to rapid reconstitution of leukopoiesis once methotrexate serum levels are in the subtoxic range.

[Solcotrans, a new autotransfusion system]

Thirty-one patients scheduled to undergo aortic reconstruction were studied. 16 had aortic aneurysms and 15 required aortobifemoral grafts. The solcotrans unit comprises a rigid plastic container with an inner lining bag, into which blood is aspirated. When the bag is full (500 ml), the unit is inverted and blood is re-infused through a 40 micron filter. Sixty-three percent of the blood transfused per-operatively and 41% peri-operatively was given with the solcotrans unit. Only minor changes in the coagulation parameters were seen. Blood cultures from ten solcotrans units were all negative. Two patients contracted pneumonia, and one cystitis. We conclude that the solcotrans system is safe to use when two-to four units of blood are transfused. Further studies are required to define its role when multitransfusions of blood are needed.

[Cardiac tamponade: a fatal complication of parenteral nutrition]

Several complications are associated with the use of central venous catheters for total parenteral nutrition; cardiac tamponade is one of the most severe. The recent use of flexible materials made of silastic polymeric silicone has great decreased the incidence of this complication, but has not eliminated wholly. We report the case of a patient with fatal cardiac tamponade, while receiving parenteral hyperalimentation trough a silicone central venous catheter placed in the right jugular internal vein, secondary to superior vena cava perforation. The physiopathological mechanisms, precautionary measures and treatment are discussed.

[2 cases of chylothorax during total parenteral nutrition: the etiopathogenetic considerations]

The authors report the onset of bilateral chylothorax during postoperative total parenteral nutrition. They underline the peculiar origin of the complication. Therefore, attention is payed to the possible pathogenic causes. The overload of fluids, in the elderly with minimal functional reserves, may increase central blood pressure, so to adversely affect lymphatic drainage causing chylothorax.

[The prevention and treatment of suppurative-inflammatory complications in the bronchopulmonary system during prolonged artificial ventilation]

The use of physical methods, namely low frequency magnetic field in critically ill patients under respiratory therapy made it possible to prevent and in case of their development to effectively treat pyoinflammatory bronchopulmonary complications that accompany prolonged controlled lung ventilation. The results obtained were due to the elimination of an unfavourable effect of controlled lung ventilation on natural resistance and immune response of the respiratory tract because of normalization of physicochemical properties of the tracheobronchial tree secretion, enhanced functional capacities of phagocytes, repaired bonds between cellular and humoral local immunity in the lungs.