Endoluminal and transluminal surgery: current status and future possibilities

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include "incisionless," "endoluminal," "transluminal," and "natural orifice" transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.

Intraoperative cholangiography: past, present, and future

The extrahepatic biliary tree was first visualized in 1918 when Reich injected bismuth and petrolatum and defined a biliary fistula, thus opening the field for further studies of the biliary tree. Mirizzi recorded the first series of intraoperative cholangiography in 1932 using static films. Later, the mobile C-arm image intensifier using a TV monitor was reported in a series by Berci and colleagues in 1978. They emphasized the importance of using routine cholangiography in all laparoscopic cholecystectomies. This procedure can be performed through the cystic duct or through the gallbladder with excellent visualization of the anatomy of the extrahepatic biliary tree, including the potential of finding bile duct stones, stricture, and tumor, as well as defining the function and anatomy of Oddi's sphincter. Numerous benefits of this technique can be observed, including early definition of a bile duct leak or injury. X-ray resolution will continue to improve as well as three-dimensional imaging, and intraoperative magnetic imaging cholangiopancreatography may be developed as the future intraoperative cholangiogram.

Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy

BACKGROUND

The incidence of deep vein thrombosis and pulmonary embolism following laparoscopic surgery is unknown and studies on alterations of hemostasis after laparoscopy are inconclusive.

METHODS

In this study we prospectively evaluated changes in prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (Fg), antithrombin III (ATIII), prothrombin fragment F 1 + 2, beta-thromboglobulin (betaTG) and D-dimer (D-D), preoperatively and 24 h after laparoscopic surgery in 16 patients.

RESULTS

Comparing pre- and postoperative values, no statistical differences were observed in aPTT, F1 + 2, and ATIII measurements. Postoperative PT values increased slightly (p approximately 0.05) after surgery. Conversely, Fg, betaTG, and D-D values were statistically higher in the 24-h evaluation (p = 0.008, 0.01, and 0.045, respectively).

CONCLUSIONS

These data suggest that laparoscopic surgery induces activation of coagulation and fibrinolytic pathways and, additionaly, betaTG elevation, which has never been reported and might account for postoperative platelet activation and a greater risk of thrombogenicity. Therefore, routine thromboembolic prophylaxis in patients undergoing laparoscopic surgery is recommended.

Ultrasonic dissectors and minimally invasive surgery

As increasingly complex operations are performed laparoscopically, new problems arise regarding basic tasks such as dissection and retraction. Emerging technologies continue to reduce the technical demands of minimally invasive surgery. Recent studies have shown that ultrasonic devices have the potential to replace electrocautery without compromising safety in minimally invasive operations. With the combination of several functions into a single instrument, significant reductions in operative time and expense are possible and should increase the acceptance of this new technology.

Laparoscopic cholecystectomy: an analysis on 114,005 cases of United States series

114,005 cases from 40 United States series of laparoscopic cholecystectomies (LC) were reviewed. Indications, conversion rates, rates of intra-operative cholangiography (IOC), and incidence of bile duct stone and iatrogenic bile duct injuries were assessed. Indications included acute cholecystitis in 11.6% and gallstone pancreatitis in 2.1% of reported cases. Conversion rate was to be primarily related to inflammation. Unsuspected bile duct stones were detected intra-operatively in 7.8% of cases. 561 major bile duct injuries (BDI) and 401 bile leaks (BL) were recorded and acute or chronic inflammation was their most important potential predisposing factor. In series with a high rate of IOC performed during LC, BDJ and BL were slightly lower and lesions recognized intra-operatively were much higher than in series with low rate of IOC. BDJ occurred in the first 50 patients of the surgeon's experience in about 91% of the cases.

The clinical management and results of surgery for acute cholecystitis

The laparoscopic approach to acute cholecystitis is not only feasible, but it is also a cost-effective, safe, and beneficial treatment option in selected patients. Patients undergoing laparoscopic surgery for acute cholecystitis seem to enjoy the same benefits of diminished pain and shorter hospitalization as those patients undergoing an elective laparoscopic cholecystectomy. The complication rates are also comparable with those for an open cholecystectomy. An early laparoscopic cholecystectomy within 4 days of the onset of symptoms has been shown to reduce the number of major complications and conversion rate, thus resulting in a decreased hospital stay. A low threshold for conversion to laparotomy also seems to be an important factor in maintaining a low incidence of operative complications. The conversion to laparotomy is therefore considered to be a good surgical option for experienced surgeons. Patients who are in the high-risk category or who have severe disease are best managed initially by gallbladder drainage unless they have perforated disease, which thus requires an emergency laparotomy.

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Bile duct injury: management options during and after gallbladder surgery

Proper management of iatrogenic bile duct injuries is mandatory to avoid immediate or late life threatening sequelae. Results of surgery depend mainly on the type of injury, the detection of the injury, and the timing of the surgery. Lesions detected during cholecystectomy should be repaired immediately, preferably with an end-to-side biliary anastomosis, a Roux-en-Y bilio-enteric anastomosis, or by the insertion of a T-tube. Bile duct injuries detected in the postoperative phase require a multidisciplinary approach and an algorithm for treatment of each type of lesion is proposed. In bile peritonitis with biliary obstruction and/or transection and in tight long strictures, which develop several months after cholecystectomy, a Roux-en-Y hepatico-jejunostomy is the most commonly performed operation. Other surgical techniques include a "mucosal graft" procedure and intrahepatic biliary enteric anastomoses, which may be required in difficult high-biliary lesions. Endoscopy and/or interventional radiology offer the best treatment options in bile duct leaks and in short ductal strictures that involve less than 50% of the bile duct lumen. In these injuries, surgical management should be performed only in the failure of nonsurgical methods. Because these lesions involve complicated biliary surgery, therapeutic endoscopy, and interventional radiology, treatment should be performed where there is expertise in all three areas.

Bile duct injury after laparoscopic cholecystectomy. The United States experience

BACKGROUND

Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed. A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (61.1%) and only 1.4% of the patients had complete transection.

METHODS

When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically percutaneously, or operatively.

RESULTS

The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%.

CONCLUSIONS

It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle, the cystic duct-gallbladder junction, and the cystic duct-common bile duct junction.

Gallbladder cancer and trocar site recurrences

BACKGROUND

Critics of laparoscopic surgery cite an increased incidence of tumor recurrence at the trocar sites following laparoscopic cholecystectomy in patients incidentally found to have carcinoma of the gallbladder. The purpose of this review was to determine if laparoscopic cholecystectomy performed in patients with gallbladder cancer results in an increased incidence of abdominal wall recurrences.

METHODS

The charts of all patients with gallbladder cancer registered at the University of Texas M. D. Anderson Cancer Center from January 1991 through April 1996 were retrospectively reviewed. Data were collected on initial and subsequent surgical procedures, tumor grade and histology, T stage, adjuvant therapy, and survival. These data were analyzed with regard to abdominal wall recurrences and outcome.

RESULTS

Ninety-three patients with gallbladder cancer were seen during this period; 79 patients with complete follow-up information comprised the study population. Comparison of the incidence of abdominal wall recurrences among the categories of surgical procedure (laparoscopic versus open versus laparoscopic converted to open) did not reveal any statistically significant differences. Overall 5-year survival was 10%.

CONCLUSIONS

Gallbladder cancer is an aggressive malignancy with few long-term survivors. In addition, these data show that the incidence of abdominal wall implantation is not increased with laparoscopic surgery but is more likely a manifestation of the aggressive nature of this tumor.

Endoscopic jejunal access for enteral feeding

Enteral (gut) alimentation appears to offer greater benefit for patients than calories delivered via a parenteral (intravenous) route. Enteral alimentation prevents mucosal atrophy, maintains normal gut flora, decreases bacterial translocation, and enhances enteral immunological competence. Reliable delivery into the jejunum without the placement of an operative feeding tube is difficult, however. We have been interested for some time in endoscopically placing a jejunal tube for enteral nutrition early (within 24 hours) after trauma resuscitation or operation. A simplified technique is described for the endoscopic placement of a jejunal feeding tube, with or without a concomitant percutaneous endoscopic gastrostomy.

The economic considerations in laparoscopic surgery

There has been increasing concern in the medical, business, and insurance communities and government agencies about the rising cost of health care. Since 1980 the cost of medical care has increased from $280 billion dollars per year to $670 billion dollars in 1990, and was estimated at $900 billion in 1993. Several factors have contributed to this increase, including the high cost of hospitalization and new expensive technology, such as laparoscopic cholecystectomy. This present cost analysis was undertaken to determine the cost variables in laparoscopic cholecystectomy to see if changes in physician, nursing, and administration work activities could decrease the cost of hospitalization. Fifty-four patients who had an uncomplicated elective cholecystectomy during a five-month period in 1993 were assessed in terms of cost components of hospitalization, including nursing unit labor costs, surgery personnel labor costs, supply/instrument cost, and ancillary costs. Nine general surgeons participated in this study, four of whom accounted for 71% of the annual volume of cases. This analysis was performed with the help of Baxter Corporate Consulting, a Division of Baxter Healthcare Corporation. From this study, it was found that the average cost for uncomplicated laparoscopic cholecystectomy patients was $1589 +/- $223. The operating room and supply/instrument component costs were the two largest expenses, accounting for 42% of the total cost. Reimbursement from various insurance agencies were also evaluated, and it was determined that a contract made with a local HMO caused the hospital to lose an average of $443.00 per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of laparoscopic herniorrhaphy

Anterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Cooper's ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Status evaluation: endoscopic ultrasonography. American Society for Gastroenterology Endoscopy. Technology Assessment Committee

Endoscopic ultrasound is a new technology that improves the local staging of esophageal, gastric, and rectal carcinomas. In addition, EUS may provide useful information which will affect management in individual patients with subepithelial masses (e.g., varices, leiomyomas) and pancreatic diseases. Other imaging studies such as transcutaneous ultrasonography and CT are still necessary to detect distant metastatic disease. At present, EUS may be best reserved for use by individuals who have sufficient patient materials to provide broad experience with the technique. Physicians at centers where large numbers of patients with gastrointestinal cancer are evaluated may find this technology most useful. Even in patients with malignancy, however, studies are needed to show that the improved local staging by EUS will translate into changes in patient management and improved outcome.

Status evaluation: hot biopsy forceps. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee

Monopolar hot biopsy forceps were developed for simultaneous tissue biopsy and electrocoagulation. Many endoscopists used these forceps for coagulation of diminutive polyps of the colon. The rationale for diminutive polyp eradication is to destroy neoplastic tissue and possibly prevent colon cancer. However, convincing data to document a reduction in the incidence of colorectal cancer or even complete obliteration of all treated diminutive polyps with hot biopsy forceps are lacking. Complications of hot biopsy include hemorrhage, perforation, and post-coagulation syndrome. Tissue injury is deeper with monopolar hot biopsy forceps than bipolar forceps. The right colon is particularly susceptible to transmural injury and perforation. For small polyp obliteration, comparative studies of hot biopsy (monopolar and bipolar) with other techniques such as cold biopsy combined with thermal probes, large cup cold biopsy removal, and snare electrocoagulation are warranted. The necessity to biopsy typical appearing angiomata does not seem warranted on a routine clinical basis. The expected obliteration rates of small angiomata or rates of controlling lower gastrointestinal bleeding from colon angiomata after monopolar hot biopsy electrocoagulation have not been well documented. Heater probe or bipolar electrocoagulation have been safely and effectively applied to bleeding colon angiomata. These newer coagulation probes are recommended as an alternative to hot biopsy forceps for treatment of bleeding colonic angiomata.

Concomitant placement of percutaneous endoscopic gastrostomy and jejunostomy

Percutaneous endoscopic gastrostomies have gained wide use for long-term enteral nutrition. However, gastroesophageal reflux and aspiration pneumonia have occurred following this procedure. Initial enthusiasm concerning the ability of intrajejunal feeding to negate the risk of aspiration has been challenged by some reports. In this report, a new method is described for concomitant placement of endoscopic gastrostomy and feeding jejunostomy wherein the tip of the feeding jejunostomy is placed at least 40 cm distal to the pylorus while the gastrostomy tube is used for drainage. Twenty critically ill patients underwent the procedure utilizing general or local anesthesia. Sixty-day follow-up showed one uneventful episode of pulmonary aspiration (5%) after retrograde migration of the jejunal tube into the duodenum. All but two patients (90%) tolerated their tube feedings well. This technique can be easily performed with accurate placement of the PEJ tube distal to the pylorus and is associated with minimal risk of aspiration.

Status evaluation: hot biopsy forceps. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee

Monopolar hot biopsy forceps were developed for simultaneous tissue biopsy and electrocoagulation. Many endoscopists used these forceps for coagulation of diminutive polyps of the colon. The rationale for diminutive polyp eradication is to destroy neoplastic tissue and possibly prevent colon cancer. However, convincing data to document a reduction in the incidence of colorectal cancer or even complete obliteration of all treated diminutive polyps with hot biopsy forceps are lacking. Complications of hot biopsy include hemorrhage, perforation, and post-coagulation syndrome. Tissue injury is deeper with monopolar hot biopsy forceps than bipolar forceps. The right colon is particularly susceptible to transmural injury and perforation. For small polyp obliteration, comparative studies of hot biopsy (monopolar and bipolar) with other techniques such as cold biopsy combined with thermal probes, large cup cold biopsy removal, and snare electrocoagulation are warranted. The necessity to biopsy typical appearing angiomata does not seem warranted on a routine clinical basis. The expected obliteration rates of small angiomata or rates of controlling lower gastrointestinal bleeding from colon angiomata after monopolar hot biopsy electrocoagulation have not been well documented. Heater probe or bipolar electrocoagulation have been safely and effectively applied to bleeding colon angiomata. These newer coagulation probes are recommended as an alternative to hot biopsy forceps for treatment of bleeding colonic angiomata.

Status evaluation: sphincter of Oddi manometry. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee

SO manometry appears to be helpful in defining a group of patients with biliary pain or idiopathic recurrent pancreatitis who may benefit from endoscopic or surgical treatment. It is a procedure that requires considerable time and endoscopic expertise along with knowledge of the manometric interpretation of sphincter of Oddi dysfunction. The diagnostic accuracy of SO manometry and criteria for basing therapeutic decisions on manometric findings need further study and verification.

Laparoscopic repair of duodenal ulcer and gastroesophageal reflux

The low morbidity and early recovery associated with laparoscopic procedures have heralded a new era for many types of surgery. In addition to the initial promising reports for duodenal ulcer disease and gastroesophageal reflux discussed above, there is a growing body of reports of gastric procedures performed laparoscopically, including omentopexy for perforated duodenal ulcer and laparoscopic repair of full-thickness stomach injury. Laws et al recently described the use of transthoracic vagotomy in recurrent peptic ulcer disease for four patients who had previously undergone a gastric drainage procedure. As with any new procedure, laparoscopic techniques for duodenal ulcer and Nissen fundoplication reviewed in this section need to be evaluated further for long-term effectiveness and comparability to existing therapy. At least one controlled multicenter trial is ongoing to compare the long-term results and cost-effectiveness of laparoscopic surgery for duodenal ulcer with those of standard medical therapy, and as surgeons gain more experience with these laparoscopic procedures, it is likely that other similar trials will be initiated.

Percutaneous endoscopic gastrostomy with jejunal extension: a new technique

Percutaneous endoscopic gastrostomies (PEG) with jejunal extensions are placed in patients at risk for aspiration of gastric contents. Current methods used are difficult and often ineffective in preventing aspiration, and frequently result in substantial morbidity and mortality. In this study, a new method of jejunal extension from a PEG was evaluated with regard to efficacy and prevention of aspiration of gastric contents while providing adequate enteral nutrition. Twelve patients with recent aspiration pneumonitis underwent PEG placement with a jejunal extension by this new method. The technique was accomplished rapidly and without difficulty in an average time of 26.2 min (range 17-31 min). In all instances, the jejunal extension remained functional for the first 8 wk after placement, and there were no instances of aspiration of gastric contents while nutritional requirements were met. None of the patients died from complications of the procedure. The method described was effective in preventing aspiration of gastric contents, was easily performed, and was associated with minimal complications.

Percutaneous cholecystostomy and lithotripsy of gallstones

Extracorporeal lithotripsy has a high incidence of postprocedure biliary colic and slow disappearance of gallstones. This situation has led to the development of a new technique which has been successful in four patients and consists of percutaneous cholecystostomy, direct stone visualization, and fragmentation of gallstones with a percutaneous lithotripter. All patients had a functioning gallbladder, stone diameter less than 30 mm, and abdominal pain secondary to cholelithiasis. The procedure was performed in a two day hospitalization. Initially, under general anesthesia, the gallbladder was intubated with a 21 gauge needle and guidewire and the tract dilated to #30 French. A nephroscope was advanced into the gallbladder through a rigid sheath. All gallstones were visualized, fragmented with a percutaneous lithotripter, and extracted. After a postoperative cholecystocholangiogram, an self-retaining catheter was placed in the gallbladder for an average of 2.5 days. Three of the four patients were discharged from the hospital in two days without any complications. A fourth patient had a small bile leak treated with antibiotics. After an average of 13 months follow-up, all patients had a normal ultrasound or oral cholecystogram and no biliary tract symptoms. This technique is safe and efficient in removing gallstones and has no recurrence of gallstones in the 13 month follow-up period.

Endoscopic and histologic correlates of intestinal ischemia in a canine model

The purpose of this study was to correlate endoscopic, microscopic and gross changes in an isolated ischemic segment of canine jejunum. Three experiments were devised. The arterial and venous blood supply to a 20 cm segment of distal jejunum in mongrel dogs was isolated and the bowel divided. External and endoscopic photography and intestinal biopsies were obtained at 0, 5, 15, 30, 60, 120, 180 and 360 minutes after vascular occlusion. Arterial occlusion was characterized by initial blanching of the mucosa, hyperperistalsis, edema, spasm and serosal pallor within 5 minutes. Microscopically, capillaries became congested at 5 minutes; epithelial sloughing occurred in 1-2 hours; necrosis of the tips of the villi occurred at 4 hours; and necrosis of muscle fibers was observed at 18 hours. Venous occlusion was characterized by marked mucosal and edema and hemorrhages within 5 minutes. At 15 minutes serosal hemorrhages were observed. Mucosal sloughing with hemorrhage and infarction were observed at 3 hours. Microscopically, mucosal capillary congestion was severe at 5 minutes and widespread hemorrhages were seen at 15 minutes. Mucosal sloughing began at 30 minutes and was severe by 60 minutes. Complete mucosal necrosis occurred by 3 hours. Combined arterial and venous occlusion was similar to arterial occlusion alone except for the early appearance of punctate mucosal hemorrhages. Massive submucosal hemorrhages did not occur. Results demonstrate that arterial and venous occlusion can be differentiated endoscopically; venous occlusion appears to be more readily injurious; and endoscopy and biopsy are valuable in diagnosis and management.

Effect of elective surgical procedures on tissue protein synthesis

The purpose of the study was to examine whether an early decrease in protein synthesis rates occurred in any tissues after abdominal surgery in postprandial rats. Leucine-specific radioactivity in mixed protein and on tRNA was determined after continuous infusion of L-[3H]leucine. Synthesis rates of mixed protein were significantly decreased in the gastrocnemius muscle, but not in the jejunum, liver, or heart, of rats 1-2 hr after splenectomy and ovariectomy or after combining the groups that had various types of abdominal surgery. These results suggest that a very early decrease in the protein synthesis rate of the gastrocnemius muscle occurs after laparotomy.

Serum zinc levels in lung cancer patients

Serum zinc concentrations were determined in 26 extensive squamous cell lung cancer patients and were tested for correlations with survival, response to therapy, nutritional status indices, and various host defense characteristics. Subnormal serum zinc levels were found in 24 of the 26 patients. The mean serum zinc concentration was 43.2/micrograms 100 ml +/- 3.6 S.E.M. (normal = 80-100 micrograms/100 ml). A significant (P = 0.007) survival advantage was demonstrated for those patients with pretreatment zinc concentrations greater than 45 micrograms%, but serum zinc levels did not correlate with response to chemotherapy (also significantly affecting survival). Decreased serum zinc concentrations were significantly associated with decreased neutrophil migration measured by the skin window technique and with decreased triceps skin fold thickness but not with any of the other host defense and nutritional induces measured. These data suggest that further studies are indicated to examine the role of serum zinc concentration as a possible sensitive prognostic characteristic and to determine if zinc administration may be of therapeutic benefit in cancer patients.

A vest for ambulatory patients receiving hyperalimentation

There have been no significant complications related to the use of this ambulatory hyperalimentation vest. The potential positive impact that increased use of this vest at home might have upon hospital stay and cost containment is obvious. It is further anticipated that, as advances are made in the technology of plastic bags, tubing, miniature pumps and microprocessors, ambulatory or home hyperalimentation delivery systems exemplified by this vest will achieve a much higher degree of sophistication, practical application, economy and favorable clinical results.

Parenteral nutrition techniques in cancer patients

If a patient is expected to respond optimally to one or more forms of oncologic therapy, he should simultaneously be in the best possible nutritional and metabolic condition. When the alimentary tract cannot be used effectively for feeding cancer patients, parenteral nutrition can be lifesaving. Moreover, patients who are poor candidates or noncandidates for any antineoplastic therapy because of their debility or cachexia can be converted to reasonable candidates following a course of i.v. hyperalimentation. This i.v. hyperalimentation can significantly reduce the morbidity and mortality of cancer patients without stimulating tumor growth when applied conscientiously according to the established principles and techniques and when integrated with specific tumor therapy. With the use of ambulatory or home hyperalimentation techniques, normal nutritional status can be restored or maintained during prolonged periods of antineoplastic therapy on a practical and relatively economical outpatient basis. It is anticipated that specific nutrient substrate formulas and parenteral therapy techniques will be developed to maintain optimal host nutrition while adversely affecting the neoplasm.

Intravenous hyperalimentation as an adjunct to radiation therapy

Radiation therapy may induce anorexia with resultant weight loss and inanition that can limit the dose of radiation therapy administered. The purpose of this study was to evaluate 39 nutritionally-depleted patients who had a variety of malignant diseases treated with radiation therapy and concomitant nutritional support with intravenous hyperalimentation (IVH). The average dose of radiation delivered was 3827 rads in an average of 3.5 weeks. Ninety-five percent of the patients completed their planned course of radiation therapy and improved symptomatically. Fifty-four percent of the patients responded with a greater than 50% reduction in tumor size. Responding patients gained an average weight of 13.0 +/- 6.5 lbs. during IVH (av. 36.2 days) and radiation therapy (av. 3832 rads), whereas non-responding patients gained only 4.9 +/- 8.8 lbs. (p less than 0.001) during IVH (av. 42.8 days) and radiation therapy (av. 3819 rads). Serum albumin concentrations rose from 3.12 +/- 0.49 gm/100 ml to 3.51 +/- 0.68 gm/100 ml (p less than 0.05) during treatment in responding patients but did not rise significantly from 3.09 +/- 0.48 gm/100 ml in non-responding patients. In conclusion, IVH allowed a planned course of radiation therapy to be delivered to a group of poor-risk, malnourished cancer patients, and a positive correlation between tumor response and nutritional status was identified. Moreover, IVH was a valuable adjunct in the treatment of six patients who had enteric fistulas that originated from radiated bowel.

Hyperalimentation in infants

Experiences gained in 150 newborns and infants receiving a complete parenteral nutrition are summarized. An infusion pattern for the complete parenteral nutrition of newborns is presented. Technical questions of parenteral nutrition are discussed. Finally the treatment of 2 newborns with inborn errors of the gastrointestinal tract is reported.

Intravenous hyperalimentation in patients with head and neck cancer

Intravenous hyperalimentation was utilized to support nutritionally 23 malnourished patients with major head and neck tumors during surgical treatment, radiotherapy, or the convalescent period. Fifteen patients were treated during the perioperative period and 12 survived. Six patients received convalescent nutritional support successfully 4 to 24 months following operation or radiation treatment. Two patients received treatment with hyperalimentation throughout a protracted course of radiation therapy. Weight gain, wound healing, and recovery were achieved in all but 3 patients. Subclavian vein thrombosis occurred in 1 patient, and catheter-related sepsis occurred in 2 patients. Otherwise, hyperalimentation was safe and efficacious in the debilitated patients. These patients may now become acceptable risks for surgical treatment or radiation therapy by nutritional repletion with intravenous hyperalimentation.

Intravenous hyperalimentation as an adjunct to cancer chemotherapy

A 36 per cent response rate was obtained in fifty-eight nutritionally depleted patients with cancer who would otherwise have been denied adequate antitumor therapy because of the fear of complications from malnutrition and inanition. A positive correlation between the nutritional status of the patient and the chemotherapeutic tumor response was identified. Intravenous hyperalimentation can be a valuable adjunct to cancer chemotherapy by improving the nutritional status, increasing the total deliverable dose of anticancer agent per unit of time, and reducing the incidence and severity of the toxic gastrointestinal side effects without adversely stimulating malignant cell growth or producing septic complications.