Harry C. Sax

Early total parenteral nutrition in acute pancreatitis: Lack of beneficial effects

To determine the effect of early aggressive parenteral support in pancreatitis, 54 patients with acute pancreatitis were randomized to receive either conventional therapy (control group) or conventional therapy plus the institution of total parenteral nutrition within 24 hours. The two groups were similar demographically. The total parenteral nutrition group had a significantly higher rate of catheter-related sepsis than did an additional group of contemporaneous patients without pancreatitis who received total parental nutrition (10.5 percent and 1.47 percent, respectively; p less than 0.01). There was no advantage to the use of early total parenteral nutrition; that is, there was no difference in the number of days to oral intake, total hospital stay, or number of complications of pancreatitis. Patients with zero or one Ransons criterion on admission were more likely to be eating by the seventh hospital day than were those with two or more Ransons criteria (80 percent and 54 percent, respectively; p less than 0.05). The early institution of total parenteral nutrition in patients with acute pancreatitis did not appear to improve the outcome. Its use should be limited to prolonged periods of no oral intake or treatment of a specific complication, such as a pseudocyst.

Predicting success after gastric bypass: the role of psychosocial and behavioral factors

BACKGROUND Success after bariatric surgery requires behavioral modification. This study analyzes outcomes after Roux-en-Y gastric bypass surgery performed by a single surgeon between 1994 and 2002, and correlates preoperative factors with long-term outcome. METHODS A bariatric database has been maintained since 1994. Beginning in April 1997, patients completed preoperative and annual postoperative questionnaires that collected an array of psychosocial information. We hypothesized that certain attributes are predictive of success after surgery. RESULTS Of the 243 patients in our database, 181 enrolled after 1997. A total of 149 were seen for follow-up at 1 year. Life Experiences Survey (LES) scores and sexual satisfaction improved significantly. Perceived obesity-related health problems, motivation unrelated to social distress about obesity, a Sense of Coherence (SOC) score >110, and an LES score <-1 each independently predicted better weight loss (P<.05). A history of sexual abuse correlated with poorer weight loss (P<.05). Patients with more confidants, multiple previous dieting attempts, and greater anticipated postoperative diet-related stress tended toward better weight loss, but these data did not reach significance. CONCLUSIONS Intrinsic motivational factors appear to predict greater weight loss after surgery. Ongoing follow-up will help determine the utility of preoperative evaluations and the role of preoperative intervention in those with poor predictive factors.

Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation.

Routine transpyloric placement of feeding tubes reduces aspiration in intensive care unit patients. Spontaneous passage eliminates the need for radiologic or endoscopic intervention. It is unclear whether the addition of a weight to the end of the tube or the use of the prokinetic agent metoclopramide in the conventional dose (10 mg) improves spontaneous transpyloric placement. In a randomized, prospective trial, 39 intensive care unit patients (age > 2 years) had a total of 50 nasoenteral tubes placed after intravenous metoclopramide (20 mg in adults, 0.2 mg/kg in children). The tubes were 8 French in diameter with either a weighted end or an unweighted bullet tip. Tip position was confirmed radiographically within 4 hours after blinded placement and at 1 and 2 days if spontaneous passage had not occurred. At 4 hours, 36% of the weighted tubes and 84% of the unweighted tubes (p < .002) had passed through the pylorus. At 1 day, 48% of the weighted tubes and 86% of the unweighted tubes (p < .007) had achieved transpyloric position. At 2 days, 56% and 92% of the weighted and unweighted tubes, respectively, had passed through the pylorus (p < .009, chi 2). The occurrence of transpyloric passage and the rapidity at which it occurred was significantly greater for the unweighted tube during all time periods. A poststudy trial was conducted to evaluate the effect of the normal dose of metoclopramide (10 mg in adults and 0.1 mg/kg in children) and the transpyloric passage of the unweighted feeding tube. Twenty-five patients received 10 mg of metoclopramide before the insertion of the unweighted tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Extrapelvic endometriosis: Diagnosis and treatment

BACKGROUND Young women with nondescript abdominal pain can be difficult to diagnose. Although extrapelvic endometriosis is infrequent, we have treated 7 patients over the past 3 years with endometriosis in the abdominal wall, inguinal canal, or surgical incisions as the etiology of their symptoms. PATIENTS AND METHODS We reviewed the medical records of patients whose final pathology report confirmed a diagnosis of extrapelvic endometriosis. Seven women who were treated at the University of Rochester Strong Memorial Hospital from May 1, 1991 through April 30, 1994 were identified. RESULTS All patients were premenopausal with no history of pelvic endometriosis. In 4 patients, symptoms were cyclical. Surgical excision was initially curative in 5 patients. Two women required reexcision. The diagnosis of endometriosis was established at exploration by gross appearance and by frozen section. CONCLUSIONS Endometriosis should be included in the differential diagnosis of a symptomatic mass in a celiotomy scar, the abdominal wall, or the inguinal canal. Principles of management include obtaining an accurate diagnosis and performing an adequate excision to prevent recurrence.

Hepatic complications of total parenteral nutrition

Elevations in serum hepatic enzyme levels and alterations in hepatic morphology have been noted in patients on total parenteral nutrition, in some cases progressing to fatal hepatic failure. Various factors such as toxins, inappropriate substrates, overfeeding, deficiency states, and gut hormone alterations have been implicated. It would appear that the tailoring of nutritional support to meet patient needs and the maintenance of normal gut integrity will be of increasing importance in reducing the incidence of this potentially fatal complication.

Can Aviation-Based Team Training Elicit Sustainable Behavioral Change?

OBJECTIVE To quantify effects of aviation-based crew resource management training on patient safety-related behaviors and perceived personal empowerment. DESIGN Prospective study of checklist use, error self-reporting, and a 10-point safety empowerment survey after participation in a crew resource management training intervention. SETTING Seven hundred twenty-two-bed university hospital; 247-bed affiliated community hospital. PARTICIPANTS There were 857 participants, the majority of whom were nurses (50%), followed by ancillary personnel (28%) and physicians (22%). MAIN OUTCOME MEASURES Preoperative checklist use over time; number and type of entries on a Web-based incident reporting system; and measurement of degree of empowerment (1-5 scale) on a 10-point survey of safety attitudes and actions given prior to, immediately after, and a minimum of 2 months after training. RESULTS Since 2003, 10 courses trained 857 participants in multiple disciplines. Preoperative checklist use rose (75% in 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports related to environment as opposed to actual events increased from 15.9% prior to training to 20.3% subsequently (P < .01). Perceived self-empowerment, creating a culture of safety, rose by an average of 0.5 point in all 10 realms immediately posttraining (mean [SD] rating, 3.0 [0.07] vs 3.5 [0.05]; P < .05). This was maintained after a minimum of 2 months. There was a trend toward a hierarchical effect with participants less comfortable confronting incompetence in a physician (mean [SD] rating, 3.1 [0.8]) than in nurses or technicians (mean [SD] rating, 3.4 [0.7] for both) (P>.05). CONCLUSIONS Crew resource management programs can influence personal behaviors and empowerment. Effects may take years to be ingrained into the culture.

Growth factor regulation of enterocyte nutrient transport during intestinal adaptation

BACKGROUND Intestinal adaptation occurs in response to injury or alteration in nutrient availability. It is both morphologic and physiologic in nature and can be mediated by growth factors and nutrients. Pathologic conditions such as short-bowel syndrome and inflammatory bowel disease lead to derangements in nutrient absorption that may exceed the bodys regenerative and adaptive capacity. Failure to fully adapt often results in long-term dependence on parenteral nutrition, leading to decreased quality of life and excessive medical expenses. The therapeutic use of appropriate growth factors may increase the adaptive capabilities of the gut. DATA SOURCE Medline and current literature review. CONCLUSIONS The major known nutrient transporters present in the gut and the mechanisms by which growth factors alter transport activity during intestinal adaptation are summarized. Growth factors have the potential to improve nutrient absorption in some bowel diseases.

Growth Factors Regulation of Rabbit Sodium-Dependent Neutral Amino Acid Transporter ATB0 and Oligopeptide Transporter 1 mRNAs Expression after Enterectomy

BACKGROUND Sucessful intestinal adaptation after massive enterectomy is dependent on increased efficiency of nutrient transport. However, midgut resection (MGR) in rabbits induces an initial decrease in sodium-dependent brush border neutral amino acid transport, whereas parenteral epidermal growth factor (EGF) and growth hormone (GH) reverse this downregulation. We investigated intestinal amino acid transporter B0 (ATB0) and oligopeptide transporter 1 (PEPT 1) mRNA expression after resection and in response to EGF and/or GH. METHODS Rabbits underwent anesthesia alone (control) or proximal, midgut, and distal resections. Full-thickness intestine was harvested from all groups on postoperative day (POD) 7, and on POD 14 from control and MGR rabbits. A second group of MGR rabbits received EGF and/or GH for 7 days, beginning 7 days after resection. ATB0 and PEPT 1 mRNA levels were determined by Northern blot analysis. RESULTS In control animals, ileal ATB0 mRNA abundance was three times higher than jejunal mRNA, whereas PEPT 1 mRNA expression was similar. By 7 and 14 days after MGR, jejunal ATB0 mRNA abundance was decreased by 50% vs control jejunum. A 50% decrease in jejunal PEPT 1 message was delayed until 14 days after MGR. Treatment with EGF plus GH did not alter ATB0 mRNA expression but doubled PEPT 1 mRNA in the jejunum. CONCLUSION The site of resection, time postresection, and growth factors treatment differentially influence ATB0 and PEPT 1 mRNA expression. Enhanced sodium-dependent brush border neutral amino acid transport with GH plus EGF administration is independent of increased ATB0 mRNA expression in rabbit small intestine after enterectomy.

Epidermal growth factor receptor is increased in rabbit intestinal brush border membrane after small bowel resection.

A defective epidermal growth factor receptor (EGFR) abrogates adaptation, while overexpression of EGFR or exogenous epidermal growth factor (EGF) enhances adaptation following small bowel resection (SBR). EGFR is predominantly located on the enterocyte basolateral membrane, yet luminal EGF is increased in injured mucosa. We hypothesized that EGFR is both increased and redistributed to the enterocyte brush border membrane (BBM) after SBR and that parenteral EGF will reverse this redistribution. Rabbits (N = 20) were subjected to sham operation or SBR. EGF or vehicle were administrated one week postoperatively to SBR rabbits, and the gut was harvested one week later. EGFR levels in intestinal crude extracts and purified BBM were determined by Western blot analysis. No difference in EGFR level was detected in the crude extract among any of the groups. SBR more than doubled EGFR amount in BBM (P < 0.006). Parenteral EGF did not influence this redistribution. Thus, EGFR is partially redistributed to the BBM in the mucosa of SBR rabbits, and parenteral EGF does not reverse this redistribution.

EARLY NUTRITIONAL SUPPORT IN CRITICAL ILLNESS IS IMPORTANT

The hypermetabolic state in critically ill patients is characterized by wasting of lean body mass and immunosuppression. The gut is among the most metabolically active organs. Failure to maintain gut function by way of early enteral nutrition can lead to increased infectious complications. Early enteral nutrition improves outcomes and may maintain muscle mass by blunting the cytokine-mediated hypermetabolic response.