Ageratina adenophora damages the rumen epithelium via inducing the expression of inflammatory factors in goats

The aim of this experiment was to investigate the effects of Ageratina adenophora on the expression of epithelium tight junction proteins and inflammatory factors in the rumen of goats. Twelve goats were randomly divided into three groups. The first group was the blank control group (n = 3, C) which was fed normal diet. The second group was fistulas control group (n = 3, RFC), which was fitted with rumen fistulas, and fed normal diet. The third group was the A. adenophora test group (n = 6, AA), which was fitted with rumen fistulas and fed a mixture of 60% of normal diet and 40% of A. adenophora grass powder. The feeding experiment lasted for 90 d, after which all goats were sacrificed and samples were collected from the rumen dorsal sac and ventral sac. The relative expression of mRNA of inflammatory factors in the rumen epithelium (tumor necrosis factor alpha [TNF-α], interferon gamma [IFN-γ], interleukin 1 beta [IL-1β], IL-2, IL-4, IL-6, and IL-10) and tight junction protein genes (occludin, claudin-1, and ZO-1) was measured by quantitative real-time fluorescence PCR. Expression of tight junction proteins in the rumen epithelium was measured by Western blot. A correlation was established between the expression of inflammatory factors and tight junction protein genes using Graph Pad Prism. The results showed that A. adenophora caused a significant increase in the mRNA expression levels of TNF-α, IFN-γ, IL-1β, IL-2, IL-6, and IL-10 in the rumen epithelial (P < 0.05 or P < 0.01). The expression of tight junction proteins at both gene and protein levels was significantly decreased (P < 0.05 or P < 0.01). Furthermore, the correlation analysis revealed that the changes in tight junction protein expression in the test group were closely related to the upregulation of the expression of inflammatory factors TNF-α and IFN-γ in rumen epithelial cells. In conclusion, the expression of inflammatory factors was increased and the expression of tight junction proteins was decreased in goats after feeding on A. adenophora, which caused some damage to the rumen epithelium.

Hepatic Metabolomic and Transcriptomic Responses Induced by Cecal Infusion of Sodium Propionate in a Fistula Pig Model

Short-chain fatty acids (SCFAs) are the major products of the microbial fermentation of indigestible carbohydrates. SCFAs are known to improve the host metabolism, but their underlying mechanism of action remains elusive. In this study, 16 growing pigs were infused with saline or sodium propionate solution (25 mL, 2 mol/L) through a cecal fistula twice a day during a 28 day experimental period. The results showed that the cecal infusion of the SCFA propionate decreased serum and liver triglyceride levels and increased serum PYY secretion in growing pigs. Hepatic metabolomics identified 12 metabolites that were significantly altered by propionate. These included decreased levels of lipid metabolism-related stearic acid and glycerol-2-phosphate; increased levels of TCA cycle components including malic acid, fructose-6-phosphate, and succinic acid; and decreased levels of the amino acid metabolism products aspartic acid and serine. Hepatic transcriptomics demonstrated that propionate inhibited fatty acid synthesis and promoted the lipid metabolic process. Pathway enrichment analysis showed that propionate accelerated gluconeogenesis and decreased glycolysis. Taken together, these data support a role of the SCFA propionate on host lipid and glucose metabolism.

Iatrogenic inguinal chyle fistula: a rare case report

Chyle fistula may be common in the neck and thorax region but it is a rare entity in the inguinal region. The rarity of the incidence of chyle fistula and the tremendous response to conservative management are the important aspects to be remembered. We hereby report a case of iatrogenic inguinal chyle fistula complicating a femoral vein cannulation.

Diagnostic values of beta-2 transferrin and beta-trace protein as markers for cerebrospinal fluid fistula

INTRODUCTION

During recent decades, beta2-transferrin and beta-trace protein (prostaglandin D synthase) have been used as immunological markers for the diagnosis of CSF fistula. A method for detecting CSF traces should be non invasive, reliable and cheap.

METHODS

The characteristics of the two immunological markers are described based on own experience and a literature review. PubMed (1966-2007) was searched and 39 articles were retrieved from the period 1987-2007.

RESULTS

The beta2-transferrin marker showed a high reliability during the last decades using immunofixation or immunoblotting. The performance of beta2-transferrin assay requires between two and four hours hands-on time in the laboratory depending on the assay. The beta-trace protein protein marker showed a high reliability when assayed using immunoelectrophoresis or laser-nephelometry. Laser-nephelomety is automated, non- time consuming, provides quantitative results and last but not least, is cheap. A cut-off point at 1.11 mg/l for beta-trace protein gave the best trade-off between high sensitivity and high specificity when including the secretion/serum ratio.

CONCLUSION

Both beta2-transferrin and beta-trace protein are reliable immunological markers for the detection of CSF traces. High diagnostic accuracy values were found for both beta2-transferrin and beta-trace protein protein.

Expression of BMI-1 in normal skin and inflammatory and neoplastic skin lesions

BACKGROUND

BMI-1 is involved in the maintenance of stem cells and functions as an oncogene in both lymphomas and solid carcinomas, acting by downregulation of p16ink4a. We have investigated the expression profile of BMI-1 in normal and inflamed skin as well as in basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs).

METHODS

BMI-1 expression was determined by immunohistochemistry and immunofluorescence, and evaluated semiquantitatively.

RESULTS

BMI-1 was weakly expressed in nuclei of basal and sometimes suprabasal keratinocytes, in basal cells of sebaceous glands, weakly to moderately in the bulge area and the external root sheath of hair follicles, and strongly in sweat glands. Whereas BCCs showed strong and diffuse BMI-1 expression, SCCs expressed BMI-1 heterogeneously. Strong cytoplasmic expression of BMI-1 was found in dividing cells.

CONCLUSIONS

BMI-1 expression marks stem cells within the hair follicle. As BMI-1 was also found in suprabasal keratinocytes and a variety of specialized cells, the distribution of BMI-1 only partly reflects the known distribution of stem cell compartments. BMI-1 is strongly overexpressed in BCCs, tumors linked to dysregulation of the sonic hedgehog pathway, which has been shown to upregulate BMI-1, suggesting a contribution of the BMI-1 oncogene in their pathogenesis.

Prednisolone concentration in the cochlea of patients with perilymph fistula

After iv administration of 200 mg prednisolone in patients with perilymph fistula, concentrations of the drug in the cochlea were determined. A specially adapted LC method was used for analysis. Mean concentrations of prednisolone in the perilymphe reached 95 ng/ml after 15-25 min, and 338 ng/ml after 30-45 min. The values reached 8 and 41% of the corresponding serum concentrations, respectively.

3D MRI of the in vivo vestibulo-cochlea labyrinth during Gd-DTPA-BMA uptake

The morphology, time-course and volume of the in vivo uptake of the T1 contrast agent gadolinium (Gd) in the perilymphatic vestibulo-cochlea labyrinth, including the utricle, saccule, semicircular canals and scalae of the guinea pig inner ear were analyzed as Fourier transform signal intensity enhancement levels by 3D MRI at 4.7 T. The uptake of Gd as a function of time in the perilymphatic space of the vestibular labyrinth was shown by ANOVA and PLSD post hoc tests to be significantly less (p < 0.05) than that of the scala tympani of the cochlea 10, 30, 60 and 90 min after i.v. injection. Experimentally induced fistulae resulted in MRI detected morphological and quantitative alterations in Gd concentration in the perilymphatic labyrinthine space. The findings demonstrate that Gd-enhanced 3D MRI of the perilymphatic space may be used to examine the morphology, kinetics and intravenous substance delivery in the in vivo mammalian vestibulo-cochlea labyrinth.

The cell death regulatory protein bak is expressed in endothelial cells in inflamed tissues and Is induced by IFN-gamma in vitro

In the present report, we examined the endothelial expression of the anti- and pro-apoptotic proteins Bcl-2 and Bak in situ and in vitro. Endothelial cells (EC) in regular tissue of the bowel and the skin were essentially negative for both Bcl-2 and Bak. In contrast, EC within the walls of fistulas and abscesses in these organs stained distinctly for Bak, but remained Bcl-2-negative. In tissue culture both unstimulated human dermal microvascular endothelial cells (HDMEC) and human umbilical vein endothelial cells (HUVEC) expressed Bcl-2 and Bak constitutively. Exposure of EC to 200-1000 IU IFN-gamma downregulated Bcl-2 but upregulated Bak. This opposing regulation of Bcl-2 and Bak in vitro and the expression of Bak in EC adjacent to necrotic tissue areas suggests that this pro-apoptotic protein may play a decisive role in regulation of EC survival in vivo.

Severe cervical chyle fistula after radical neck dissection

The case of a chylous cervical fistula detected immediately after radical neck dissection is presented. The flow and metabolic derangements secondary to depletion of fluid, electrolytes, and protein required the ligation of the thoracic duct at the thoracic cavity. The various possible treatments of chylous fistula are reviewed.

Correlation of beta-2 transferrin and middle ear abnormalities in congenital perilymphatic fistula

Congenital perilymphatic fistula (PLF) as a diagnosis for progressive, fluctuating, or sudden sensorineural hearing loss with or without vertigo is still controversial. Beta-2 transferrin is a protein that is unique to cerebrospinal fluid, aqueous humor, and perilymph. A recent pilot study demonstrated that beta-2 transferrin may be an objective test to determine the existence of a congenital PLF. The authors prospectively evaluated and recommended surgery for 43 children with suspected PLF over the past 3 years. A prospective, blinded study was performed by having the attending otolaryngologist evaluate the middle ear at the time of surgery for a PLF and any middle ear abnormalities. Samples of fluid were collected from the oval and round windows and were tested for beta-2 transferrin. Of 16 patients undergoing tympanoplasty or tympanomastoidectomy who served as controls, none were positive for beta-2 transferrin. Of the 43 patients undergoing exploratory tympanoplasty for PLF, 20 (46.5%) were considered to be negative for PLF on microscopic visualization; 23 (53.5%) were found to be positive. Of the 20 patients thought to be negative for PLF, 18 (90%) tested negative for beta-2, but 2 of these patients were positive for beta-2, and both had a congenital middle ear abnormality. Of the 23 patients found to have a PLF at surgery, 6 (26.1%) tested positive for beta-2, and all of these 6 had middle ear abnormalities. Of the 17 patients negative for beta-2, 9 had normal anatomy; 6 had middle ear abnormalities, and 2 had erosive changes. The authors conclude that beta-2 transferrin, an objective test, confirms the existence of congenital PLF in children, which is associated with middle ear abnormalities.

Congenital perilymphatic fistula: computed tomography appearance of middle ear and inner ear anomalies

Congenital perilymphatic fistula is an abnormal communication between the inner ear and middle ear. Inner ear anomalies have been described on computed tomography scans. Middle ear anomalies have been found at surgery; the most frequent are anomalies of the stapes and round window. This retrospective study describes the appearance of the inner and middle ear on computed tomography scans, and of the middle ear at surgery, in 10 patients (15 ears) in whom perilymphatic fistula was found at surgery. Twelve of 15 stapes were abnormal at surgery; 4 of these 12 (33%) could be seen on computed tomography scans. Two stapes normal at surgery were normal on computed tomography. Three round windows were abnormal at surgery; none of these was seen on computed tomography scans. There were also four dysplastic cochleas, four dysplastic vestibules, and three dilated vestibular aqueducts. Computed tomography scans identified an abnormal inner ear, middle ear, or both in 8 (53%) of the 15 ears with perilymphatic fistula. An inner ear or middle ear anomaly on computed tomography may heighten clinical suspicion of congenital perilymphatic fistula.

Protein profile of human perilymph: in search of markers for the diagnosis of perilymph fistula and other inner ear disease

Recent developments in high-resolution two-dimensional polyacrylamide gel electrophoresis, combined with amino acid sequencing and computer-assisted image analysis, have allowed separation of approximately 100 proteins and identification and quantitation of some 30 proteins in human perilymph. The majority of proteins were found to be present in perilymph at levels in basic agreement with the total protein gradient between perilymph and plasma (1:35). However, several striking differences were observed: (1) beta 2-transferrin, known to be absent from normal plasma but present in cerebrospinal fluid, was detected in perilymph at a concentration roughly equal to that in cerebrospinal fluid; and (2) two high-density lipoprotein-associated apolipoproteins--apo D (formerly PLS:33) and apo J or NA1 and NA2 (formerly PSL:29/30), the latter showing identity with SP40/40, or cytolysis inhibitor--were found to be present at concentrations 1 to 2 orders of magnitude higher when examined in terms of total protein and to be comparable with or higher than plasma levels when examined in terms of absolute concentrations. The functional significance of the extremely high levels of the two apolipoproteins is not known at this time. An attempt was made to use beta 2-transferrin, as well as apo D and apo J (NA1/NA2), as markers for the diagnosis of perilymph fistula, one of the most controversial and challenging problems for the otologist today. It was determined that the technique is indeed applicable when relatively pure fistula samples are analyzed. Limitations and potential improvements of the technique are discussed. In addition, the potential usefulness of two-dimensional polyacrylamide gel electrophoresis in other pathologic conditions of the inner ear is discussed briefly.

Chylous fistula: an unusual occurrence after mastectomy with immediate breast reconstruction

Postoperative lymphatic complications of mastectomy and immediate reconstruction are well documented, consisting predominantly of lymphorrhea, lymphocele, and chronic lymphoedema. Chylous fistula is a hitherto undescribed entity complicating breast surgery. It was managed successfully by cessation of oral intake and the use of intravenous fluids, as is recommended in the treatment of chylous fistulas occurring elsewhere in the body. Although these are exceedingly rare, all plastic surgeons doing breast reconstruction should be aware of chylous fistulas and their treatment.

Changes of pulmonary glucocorticoid receptor and phospholipase A2 in sheep with acute lung injury after high dose endotoxin infusion

In a sheep model of acute lung injury induced by an Escherichia coli endotoxin (5 micrograms/kg) with chronic lung lymph fistula (n = 15), we measured the changes in glucocorticoid receptor (GCR) binding capacity in lung tissue by means of radioligand binding assay. The content of cortisol and the activity of phospholipase A2 (PLA2) were also measured. The results showed that the maximal binding capacity (Bmax) of GCR in lung cytoplasma decreased continuously 2 h (113 +/- 3 versus 66 +/- 2 fmol/mg protein, p < 0.01), 4 h (105 +/- 6 versus 52 +/- 3 fmol/mg protein, p < 0.01), and 6 h (105 +/- 5 versus 37 +/- 2 fmol/mg protein, p < 0.01) after endotoxin infusion. Its affinity decreased markedly (p < 0.05) at 6 h after the infusion. The contents of cortisol in plasma elevated at 0.5 h and remained at a high level until 4 h after the infusion. PLA2 activity rose from 97 +/- 25 to 188 +/- 12 U (p < 0.05), 99 +/- 13 to 285 +/- 25 U (p < 0.01), and 106 +/- 14 to 354 +/- 32 U (p < 0.01) at 2, 4, and 6 h after endotoxin infusion, respectively. There was a negative correlation between the Bmax of GCR and PLA2 activity (r = -0.87, p < 0.01). The findings indicate that there was a secondary GCR abnormality and a higher PLA2 activity during endotoxin-induced lung injury. The glucocorticoid hypofunction caused by reduced GCR binding capacity may accelerate the pathologic response of acute lung injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Downregulation of blood and bone marrow neutrophils decreases expression of acute lung injury in sheep

We have shown that infusion of zymosan-activated plasma (ZAP) in sheep causes acute lung injury and downregulates peripheral blood neutrophils in that elicited superoxide release is reduced for at least 24 h after the infusion. The present study was designed to test the following hypotheses: 1) peripheral blood neutrophils are representative of neutrophils marginated in the pulmonary circulation, 2) blood neutrophils are downregulated because neutrophils developing in bone marrow are similarly affected, and 3) downregulated neutrophils have a reduced capacity to produce tissue injury. In a series of experiments in 21 sheep, we showed that elicited superoxide release was similar in peripheral blood neutrophils and in marginated neutrophils washed out of the pulmonary vascular bed. Measurements of superoxide release from blood and bone marrow neutrophils collected 2-24 h after ZAP infusion revealed progressive downregulation with time and greater downregulation of superoxide release in bone marrow neutrophils compared with peripheral blood neutrophils. Finally, after downregulating peripheral blood neutrophils, subsequent infusion of ZAP in conscious sheep produced sequestration of neutrophils in the pulmonary circulation but failed to produce a sustained increase in lung lymph protein clearance. The results suggest that neutrophil downregulation, as measured in vitro, is expressed in vivo as reduced ability of neutrophils to produce tissue injury when challenged by an activating agent.

Perilymphatic fistula: analysis of free amino acids in middle ear microaspirates

High-performance liquid chromatography was used to determine 19 free amino acid concentrations in perilymph, serum/plasma, and red blood cell intracellular fluid. Significant differences were found between perilymph and these fluids. Free amino acid analysis was then used to quantitatively analyze middle ear microaspirates in order to test the hypothesis that perilymph is a potential source of clear fluid in perilymphatic fistulas (PLF). Fourteen unknown samples from patients with visually identified PLF, including patients with no identifiable otic capsule defect, were studied. Six samples on amino acid pattern analysis were correlated most similarly with perilymph (rrho greater than 0.95). Four of these six samples were scored on the basis of quantitative amino acid values as similar to perilymph. However, three samples of clear fluid were more similar to serum/plasma than to perilymph on both amino acid pattern and quantitative amino acid score analysis. These results objectively suggest perilymph as a potential source of clear fluid in some patients with a diagnosis of PLF. Not all clear fluid observed in the middle ear, however, is potentially perilymph.

Prediction and prevention of fistulae after major head and neck surgery: a preliminary report

A method of checking the integrity of mucosal repair after head and neck surgery using wound amylase levels is described. A low wound amylase concentration allows early resumption of oral intake; an increasing amylase concentration is a strong predictor of subsequent wound breakdown and fistula formation. A regimen has been developed which has prevented fistulae from developing in the small number of patients studied thus far.

Sodium chloride depletion in a cat with fistulated meningomyelocele

Decreased serum and CSF chloride concentrations were documented in a 5-year-old Manx cat referred for evaluation of anorexia. Inadequate chloride intake coupled with chloride loss through a fistulated meningomyelocele probably caused chloride deficiency. The inciting cause of anorexia was not determined. The cat was treated with 0.9% NaCl solution. Normal serum and CSF chloride concentrations were restored. Lumbar myelography was performed to delineate the meningocutaneous tract, which then was dissected surgically and was ligated. The cat's body attempted to maintain normal CSF chloride concentration even though the serum chloride concentration was decreased markedly. Calculations made on the basis of rate of CSF production, CSF chloride concentration, and duration of anorexia provided supportive evidence for an active transport system for chloride from plasma to CSF.

Increased systemic microvascular albumin flux in septic shock

Lymph/plasma (L/P) albumin ratios were followed in a patient with a traumatic thoracic duct lymph fistula, during septic shock when lymph flow was high and at recovery when lymph flow was low. Higher albumin ratios were found during the former. On both occasions, the P-L difference of radioactive counts/min per gram was followed for 6 h after i.v. injection of 51Cr human serum albumin (HSA). Equilibration half times between plasma and lymph amounted to 0.85 h during septic shock and 2.49 h at recovery. The data indicate that systemic microvascular albumin flux had increased during shock in our patient. Increased permeability may have been responsible.

Ameloblastoma with hypoproteinemia due to protein leakage

One peculiar case of giant ameloblastoma of the mandible is reported in this paper. This case is characterized by 2 interesting points: large tumor size of an infant's head, hypoproteinemia caused by leakage of serum protein, especially albumin, via fistula formed in the gum and edema of the body. Problems accompanying hypoproteinemia are discussed.

Secretion of bromide by the canine prostate

Four dogs with surgically produced prostatic fistulas were given single oral doses of 1.13 gm of sodium bromide daily for five consecutive days. Two days later the mean (+/- SE) serum level of bromide was 28.0 +/- 4.0 meq/L and the serum chloride level had decreased from a pretreatment value of 112.5 +/- 1.0 meq/L to 86.5 +/- 3.7 meq/L; in the basal prostatic secretion, the mean prostatic fluid to serum (PF/S) ratios for bromide and chloride were 0.56 +/- 0.15 and 0.53 +/- 0.11, respectively, and were not different (P greater than 0.05, paired t-test); at higher rates of secretion provoked by intravenous pilocarpine the corresponding PF/S ratios of 1.48 +/- 0.04 and 1.32 +/- 0.01 were significantly different (P less than 0.05, paired t-test). It is concluded that the processes involved in forming the basal and pilocarpine-induced prostatic secretions must differ and that the ability of the chloride-transporting system to transport bromide is slightly greater than that for chloride. Because it may impair sperm motility, bromide secreted in prostatic fluid potentially could adversely affect reproduction.

Hypertrophy of the rat Golgi complex during enhancement of cholesterol and bile acids synthesis

There are some evidences that the Golgi apparatus could be involved in bile salts transport. In this study we investigate the morphology of the Golgi apparatus in rats with a chronic bile fistula or treated with 4% cholestyramine, a bile salts chelating agent. In both models liver histology was normal by light microscopy. With electron microscopy--compared to sham groups--the only obvious change was the enlargement of the Golgi complex. Morphometric data confirmed that the Golgi rich area volume density was almost doubled after chronic bile fistula or cholestyramine treatment. These data give another support for the participation of the Golgi complex in bile salts transport.

External biliary-pancreatic fistulas

Twenty-seven patients treated for pancreatic and/or biliary-cutaneous fistulas have been reviewed. Four patients died mainly because of cardiopulmonary and septic complications. Spontaneous sealing of the fistula occurred in 81% of the conservatively treated cases (48% of all cases). All the LO fistulas but only 68% of the HO fistulas treated conservatively sealed spontaneously. Eleven patients were treated surgically. There were three deaths and three failures (reappearance of fistula). All the patients who died had been operated on within three months after the appearance of HO fistulas. There was no mortality among the patients with LO fistulas or among patients operated on at a later stage. We have reached the following conclusions: 1. There is a significant difference in prognosis between low output and high output fistulas. 2. In LO fistulas, there is no need for a surgical intervention aimed to close the fistula unless it persists for at least one year. 3. In HO fistulas, if a corrective operation is necessary, it should be withheld for at least three months whenever possible. 4. Roux-en-Y fistulojejunostomy is considered to be the procedure of choice. 5. Infection and premature colsure of the external part of the fistulous tract should be avoided by insertion of drains and repeated surgical drainage, where necessary. 6. High caloric feeding, elemental diet and intravenous hyperalimentation are very important factors that enhance recovery in the surgically and conservatively treated patients.

Increase in myocardial digoxin content associated with circulatory volume overload in the dog

1. Tritiated (12alpha-3H) digoxin (0-05 mg/kg body weight) was administered intravenously to conscious dogs with circulatory volume overload induced by previous creation of aorto-caval fistulae. Dogs were killed after 5 min, 1, or 4 h, and the myocardium sampled. Digoxin was extracted and counted and results compared to those in normal dogs. 2. At each time, myocardial digoxin concentration of all cardiac chambers in test dogs was greater than normal. Plasma digoxin concentration measured 5 min after administration was greater in dogs with fistulae but the subsequent levels were not different. 3. Anaesthetized and open-chest dogs with fistulae studied 5 min after digoxin administration had greater myocardial concentrations than similarly studied normal dogs. Although myocardial concentrations of digoxin were higher in anaesthetized than in conscious dogs the group with fistulae had higher values than did the normal group, as was the case for unanaesthetized dogs. 4. The basis for the effect of fistula is probably multifactorial. Diminised peripheral blood flow and peripheral digoxin delivery and uptake, resulting initially in higher digoxin levels in plasma perfusing the myocardium, may play a role. Increased myocardial mechanical and metabolic activity almost certainly are important. Cardiac hypertrophy, cardiac failure per se and plasma electrolyte changes are probably not. 5. The results are consistent with previously demonstrated reduced digitalis tolerance in the dog with circulatory volume overload.

The role of surgery and hyperalimentation in therapy of gastrointestinal-cutaneous fistulae

Thirty-eight patients with external gastrointestinal fistulas arising from different levels of the gastrointestinal tract, observed and treated at the Massachusetts General Hospital, from December 1970 to April 1973, are analyzed. Surgical complications were the causes of fistulization in 77% of the cases. The treatment program included parenteral nutrition through a subclavian line in all cases. The 38 patients were fed parenterally for a total of 2311 days. Spontaneous fistula closure occurred in only 11 of the 38 patients. Surgical procedures were necessary in 71.05% of the cases to control fistula complications or persistent fistula drainage. Operative success rate was 70.4%. Parenteral nutrition effects on metabolic parameters, fistula secretion, nutritional status, morbidity and mortality of fistulas are discussed. Parenteral nutrition hazards are also presented. Overall mortality in this series was 21%. Roles of parenteral nutrition and surgery in the total management of external gastrointestinal fistulas are suggested.