Effect of Timing of Pharmaconutrition (Immunonutrition) Administration on Outcomes of Elective Surgery for Gastrointestinal Malignancies

Background: Pharmaconutrition has previously been reported in elective surgery to reduce postoperative infective complications and duration of hospital length of stay. Objective: To update previously published meta‐analyses and elucidate potential benefits of providing arginine‐dominant pharmaconutrition in surgical patients specifically with regard to the timing of administration of pharmaconutrition. Design: Randomized controlled trials comparing the use of pharmaconutrition with standard nutrition in elective adult surgical patients between 1980 and 2011 were identified. The meta‐analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta‐Analyses (PRISMA) recommendations. Results: Twenty studies yielding 21 sets of data met inclusion criteria. A total of 2005 patients were represented (pharmaconutrition, n = 1010; control, n = 995), in whom pharmaconutrition was provided preoperatively (k = 5), perioperatively (k = 2), or postoperatively (k = 14). No differences were seen in postoperative mortality with the provision of pharmaconutrition irrespective of timing of administration. Statistically significant reductions in infectious complications and length of stay were found with perioperative and postoperative administration. Perioperative administration was also associated with a statistically significant reduction in anastomotic dehiscence, whereas a reduction in noninfective complications was demonstrated with postoperative administration. Preoperative pharmaconutrition demonstrated no notable advantage over standard nutrition provision in any of the clinical outcomes assessed. Conclusions: This meta‐analysis highlights the importance of timing as a clinical consideration in the provision of pharmaconutrition in elective gastrointestinal surgical patients and identifies areas where further research is required.     

Impact of early endovascular aneurysmal occlusion on outcome of patients in poor grade after subarachnoid haemorrhage: a prospective, consecutive study

Patients in poor grade (WFNS IV and V) after aneurysmal subarachnoid hemorrhage (SAH) often have a bad outcome. To evaluate early GDC embolisation on such patients a prospective observational study, with comparison to a historical cohort was performed. From January 1996 to December 1998 113 patients were admitted to the Department of Clinical Neurosciences in poor grade after SAH (45 WFNS IV and 68 WFNS V). Eighty-one patients were managed actively with endovascular occlusion of the aneurysm (n = 42) where possible and delayed clipping (n = 16) where not. On an intention to treat basis, 46% had a favourable outcome (Glasgow Outcome Score IV or V) and 48% had died by 3 months. Compared to an historical cohort managed in the same unit between 1992 and 1995 (n = 62, 52% favourable outcome) these results suggest that early GDC aneurysmal occlusion has had a minimal impact on overall outcome.     

Increasing antidumping effect of intestinal pacing with motor-active agents

The aim was to determine whether cholecystokinin-octapeptide (CCK-OP), bethanechol Cl, or metoclopramide HCl would increase the antidumping effect of intestinal pacing in five dogs with truncal vagotomy and Roux gastrectomy. While recording electrical activity from the conscious animals, the amount of a 100-ml, 25% dextrose gastric instillate emptied in 20 min was determined during control tests, during tests with CCk-OP (500 ng/kg/hr), bethanechol (80 g/kg/hr), or metoclopramide alone (600 g/kg/hr) given intravenously or during tests using combinations of pacing and drugs. In other tests, intraluminal gastrointestinal pressure was measured during control and drug infusions. CCK-OP, which relaxed the proximal stomach, slowed emptying of the dextrose instillates (mean±sem emptied, no pacing, no drug=74±5 ml; CCK-OP alone=34±5 mlP<0.05). CCK-OP also enhanced the slowing effect produced by pacing (pacing alone=41±7 ml; pacing plus, CCK-OP=19±8 ml;P<0.05). In contrast, bethanechol and metoclopramide, which did not alter proximal gastric motility, did not alter emptying or augment or diminish the effect of pacing. The conclusion was that the combination of pacing and CCK-OP slowed gastric emptying of the dextrose more than pacing alone and thus had a greater antidumping effect. In contrast, neither bethanechol nor metoclopramide enhanced the pacing effect.Supported by USPHS NIH grants AM18278 and TW03296, Medtronic Inc., and the Mayo Foundation.     

Is Focused Minimally Invasive Parathyroidectomy Appropriate for Patients With Familial Primary Hyperparathyroidism?

Background  

The aim of this study was to determine whether a focused minimally invasive parathyroidectomy (MIP) for patients with primary hyperparathyroidism and concordant pre-operative localization studies is appropriate for patients with a family history of the disease. Familial hyperparathyroidism may be seen as a chronic disease in which recurrence is inevitable. Patients frequently undergo subtotal or total parathyroidectomy for perceived 4-gland parathyroid hyperplasia in an attempt to reduce this risk. Controversy remains regarding whether a MIP is appropriate in this setting.     

CAUSTIC SODA BURNS TO THE EXTREMITIES: DIFFICULTIES IN MANAGEMENT

SUMMARY Alkali burns to the extremities are unusual, but they are also a cause of significant morbidity, often because of their late presentation. Their management centres around water lavage, burn debridement and split-skin grafting; there is controversy over the timing of surgery. Three unusual cases of caustic soda burn in adults, and the difficulties encountered in their management, are described, and the literature is reviewed.