Toby O. Graham

Comparison of laparoscopic versus open repair of paraesophageal hernia

BACKGROUND Recent reports suggest that laparoscopic paraesophageal hernia repair (LPHR) is feasible, but no direct comparisons with the standard open paraesophageal hernia repair (OPHR) have been reported. The purpose of this study was to compare the short-term outcome of LPHR versus OPHR at a single institution. METHODS The operative and postoperative courses of 95 consecutive patients undergoing open or laparoscopic repair of a paraesophageal hernia (PEH) were retrospectively reviewed, and outcomes of LPHR versus OPHR were compared. RESULTS PEH was associated with advanced age and significant comorbidity. Although the operative time was increased for LPHR, there was a significant reduction in blood loss, intensive care unit stay, ileus, hospital stay, and overall morbidity associated with LPHR compared with OPHR. CONCLUSIONS PEH is associated with significant comorbidity that increases the operative risk. Short-term outcomes for LPHR are superior to OPHR, suggesting that the laparoscopic approach is the preferred approach to paraesophageal hernia repair.

Quality of Life After Small Intestinal Transplantation and Among Home Parenteral Nutrition Patients

BACKGROUND The purpose of the study was to quantify changes in the quality of life of small bowel recipients before and after transplantation and of home parenteral nutrition (HPN)-dependent patients before and after therapy. We examined quality of life across multiple areas of function including physical, social, and emotional indices. METHODS The Quality of Life Instrument in the form of a self-administered questionnaire was completed voluntarily by the recipients of small intestinal transplants and by a cohort of HPN-dependent patients. RESULTS Small intestinal transplant recipients reported significant improvement in the quality of their life and function. They also rated their quality of life and function during the pretransplant, TPN-dependent period to be worse than before the development of chronic intestinal failure. Similarly, HPN recipients reported significant worsening across most areas of quality of life when they compared their premorbid period to the HPN-dependent state. CONCLUSIONS TPN dependence causes significant impairment in the quality of life in most areas of functioning. In contrast, small intestinal transplantation restores the quality of life among recipients with functioning grafts.

QUALITY OF LIFE OF PATIENTS AFTER INTESTINAL TRANSPLANTATION

BACKGROUND Quality of life is an important consideration in evaluating new medical or surgical treatments. Intestinal transplantation is now available for patients with irreversible intestinal failure. We compared quality of life among patients with intestinal failure receiving home parenteral nutrition (HPN) to that among patients who underwent intestinal transplantation (ITx) at the University of Pittsburgh Medical Center. METHODS The results of the Quality of Life Inventory, a self-administered questionnaire, were compared among 10 ITx recipients and 10 HPN patients. Change in quality of life was examined longitudinally over a 2-year period with repeat testing in four patients in each group. RESULTS ITx recipients were evaluated at mean time of 2.7 years after transplantation and after a mean period of 5.3 years of intestinal failure. HPN patients were evaluated after a mean period of 5.1 years of intestinal failure and were similar to the transplant recipients in age, gender, race, social status, education, etiology, and duration of disease. Assessed quality of life was markedly similar between HPN-dependent patients and ITx recipients, with significant differences in only 2 of 25 domains, despite the difficult early postoperative course and complex management that accompany intestinal transplantation. In longitudinal follow-up (n=4), ITx recipients reported significant improvement in anxiety (P=0.02), sleep (P=0.03), and impulsiveness/control (P<0.001), reflecting a progressive adjustment to their posttransplant status. CONCLUSION The quality of life in ITx recipients is similar to that in HPN-dependent patients. Quality of life among ITx recipients improves over time with decreased anxiety over physical functioning. Further research and efforts to improve quality of life in transplant recipients are needed.

Comparative studies of esophageal function in systemic sclerosis

Three modalities for assessing esophageal dysfunction in patients with systemic sclerosis were prospectively compared. Seventeen patients underwent (a) esophageal manometry with measurement of distal esophageal peak contraction pressure amplitude, percentage of peristaltic waves, and lower esophageal sphincter pressure; (b) cine-esophagography with scoring based on residual contrast and the character of visualized waves; and (c) esophageal transit scintigraphy with quantification of residual swallowed tracer. Highly significant correlations were found between scintigraphic residual and cine-esophagography score, between scintigraphic residual and manometric amplitude, and indeed between all pairs of measured esophageal function parameters except those involving lower esophageal sphincter pressure. In addition, scintigraphy and cine-esophagography showed comparable ability to discriminate between patients with abnormal and normal esophageal motor function. Symptoms did not significantly correlate with quantitative parameters, nor did they have diagnostic discriminating ability. Induction of Raynauds phenomenon in a subgroup of patients had no detectable effect on esophageal function. It was concluded that these three diagnostic modalities are approximately equivalent in their ability to detect esophageal dysmotility in systemic sclerosis and measure its severity.

Ethanol, a Leydig cell toxin: Evidence obtained in vivo and in vitro

The available evidence which suggests that ethanol is a Leydig cell toxin is presented. Both in vivo and in vitro data are reviewed. The minor differences obtained in vitro as compared to those obtained in vivo are discussed. As a result of information obtained during the last decade, there can be little doubt that ethanol and possibly acetaldehyde are clinically important environmental Leydig cell toxins.

Intestinal and multivisceral transplantation: dynamics of nutritional management and functional autonomy

OBJECTIVE The objective of this study was to describe the dynamics of nutrition management of intestinal transplant recipients and allograft functional autonomy. METHODS Intestinal absorptive functions and recipient nutritional status were monitored during the 12-month study period. Absorption was evaluated with D-xylose absorption and fecal fat excretion. Indices for nutrition were body weight, anthropometric measures, and serum albumin. RESULTS Before transplant, all patients were total parenteral nutrition (TPN) dependent and well nourished. By the first postoperative month, all 22 recipients were tolerating enteral feeding. By 3 months, all recipients had begun oral feeding, with 13 off TPN and 7 off enteral feeds. By 6 months, 16 recipients were off TPN, and by the end of the 12th month, 17 (77%) were free of TPN. Although all 22 recipients were completely weaned off TPN during the first posttransplant year, 10 required temporary reinstitution of therapy at different points. Full nutritional autonomy was achieved at 3 months by 3 recipients, at 6 months by 8 recipients, and at 12 months by 12 (55%) recipients. CONCLUSIONS These results reflect our early experience that led to surgical refinement of the operation and evolution of the recipient postoperative management. Nonetheless, even in this initial cohort, most of the engrafted intestines restored the recipient nutritional autonomy, and all survivors remained well nourished.

Early Jejunal Feeding Initiation and Clinical Outcomes in Patients with Severe Acute Pancreatitis

BACKGROUND Compared with parenteral nutrition, enteral nutrition reduces infectious complications and mortality in patients with severe acute pancreatitis (SAP). This study used clinical outcomes to investigate the association between time to initiation of distal jejunal feeding (DJF) and time to achievement of goal enteral feeding with clinical outcomes. METHODS A retrospective chart review was performed on all patients with SAP admitted to the medical intensive care unit (ICU) during a 1-year period. Collected data included demographic information, body mass index (BMI; kg/m(2)), Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission, time of onset of DJF, time to goal feeding, ICU length of stay, and mortality. RESULTS Time to starting DJF was longer in nonsurvivors (n = 4) than in survivors (n = 12) (17 vs 7 days, P < .05). All nonsurvivors had BMI >30 kg/m(2) (50% had BMI > 50 kg/m(2)). ICU length of stay was significantly associated with achievement of goal feeding. Three patients never reached goal feeding and spent 45.3 ± 19.6 days in the ICU; 7 patients reached goal feeding within 3 days of initiating DJF and spent 18 ± 1.7 days in the ICU; and 4 patients reached goal feeding within 3 days and spent 10.5 ± 3.5 days in the ICU. APACHE II scores were not significantly different among the 3 groups (16.7 ± 1.5, 12 ± 0.7, and 16.2 ± 1.2, respectively, P > .05). CONCLUSIONS Early initiation of DJF in the ICU was associated with reduced mortality in this cohort of patients with SAP. Early achievement of jejunal feeding goal early was associated with a shorter ICU length of stay, irrespective of the severity of SAP.

Nutritional factors in inflammatory bowel disease.

Dietary antigens may act as important stimuli of the mucosal immune system and have led to the study of nutritional therapy for IBD. Patients with active CD respond to bowel rest, along with total enteral nutrition or TPN. Bowel rest and TPN are as effective as corticosteroids at inducing remission for patients with active CD, although benefits are short-lived. Enteral nutrition is consistently less effective than conventional corticosteroids for treatment of active CD. Use of palatable, liquid polymeric diets in active CD is controversial, but these diets are of equal efficacy when compared with elemental diets. UC has not been treated effectively with either elemental diets or TPN. Fish oil contains n-3-PUFA, which inhibits production of proinflammatory cytokines and has some benefit in the treatment of CD. Topical applications of short-chain fatty acids have benefited diversion colitis and distal UC, whereas probiotics hold promise in the treatment of pouchitis.

Enteral Feeding Patients With Gastric Outlet Obstruction

Patients with upper gastrointestinal obstructions were previously managed with gastric decompression and parenteral feeding. The authors present their experience in 50 patients with obstructions chiefly due to complicated severe acute (n = 31) or chronic cystic pancreatitis (n = 11) using a double-lumen nasogastric decompression and jejunal feeding tube system (NGJ) held in place with a nasal bridle that passes through the obstructed gastroduodenal segments, allowing distal jejunal feeding, and at the same time decompresses the stomach to prevent vomiting and aspiration. The tip of the jejunal tube was placed approximately 40 cm down the jejunum to maintain pancreatic rest. Duration of feeding ranged from 1-145 days (median 25 days); 19 patients were discharged home with tube feeds. Only 1 patient could not tolerate feeding and needed to be converted to parenteral feeding. Average tube life was 14 days, with replacement being needed most commonly for kinking or clogging of the jejunal tube (56%) or accidental dislodgement (24%). The obstruction resolved spontaneously in 60%, allowing resumption of normal eating. Of the patients with severe acute pancreatitis or pancreatic pseudocysts, pancreatic rest resulted in resolution of the disease without surgery in 87%, and need for surgery in the remainder was put off for 31-76 days. Seven patients died predominantly of complications of acute pancreatitis between 1 and 31 days. In conclusion, NGJ feeding provides a relatively safe conservative management for critically ill patients with upper gastrointestinal obstructions, reducing the need for surgery and parenteral feeding.

What is the significance of a physician shortage in nutrition medicine

The practice of clinical nutrition is distributed across a wide spectrum of medical and surgical specialties. As a result, silos of nutrition activity tend to exist in isolation. Coincident with this process is a progressive shortage of physicians practicing nutrition medicine. Not surprisingly, physician membership in leading professional nutrition societies has been decreasing over the past 10 to 20 years. The number of physicians in the American Society for Parenteral and Enteral Nutrition in 2009 was barely one-third the number seen in 1990 (now <13% of the total membership). While The Obesity Society saw phenomenal growth this decade by more than 1,000 members (a nearly 70% increase), the number of physician members actually decreased by more than 100 (a 20% reduction in between the total membership). Two years ago, the number of physicians in the American Society for Nutrition fell to a range of between 100 to 150 members. The number of physicians sitting for board examinations in nutrition also decreased, such that over the past 4 years, only between 27 and 31 physicians have sat for 1 of 3 exams in clinical nutrition. This summit was convened to address the myriad issues that face the physician nutritionist and contribute to this shortage-issues related to education, board certification, research, and practice management. To correct this problem, and ultimately increase the number of physicians in the field of nutrition, Summit participants were charged with developing short term and long-term strategies with specific recommendations for change. A consortium or council for collaboration among professional nutrition and medical/surgical societies is needed to pursue these initiatives and foster ongoing communication among vested parties.