Biomedical subjects
Publications and source records attributed to D A August.
Proximal biliary tract cancer carries a dismal prognosis. Few patients have a curative option. However, worthwhile palliation can be achieved in many patients by relieving obstructive jaundice. An overview is presented to place in perspective the treatment methods described and the results obtained.
Often, maintenance of fluid and electrolyte homeostasis is the most challenging dilemma posed by short bowel syndrome. This report describes the management of a patient with intractable, dehydrating, salt-wasting diarrhea after small and large bowel resection for Crohn's disease complicated by rectal cancer. Intraperitoneal fluid and electrolyte therapy delivered through a Tenckhoff catheter was used to achieve long-term outpatient stability without chronic intravenous therapy. The concept of intraperitoneal fluid and electrolyte therapy is discussed and its potential role in the treatment of short bowel syndrome is described.
Death from colorectal cancer frequently results from manifestations of recurrent local or metastatic disease following initial 'curative' therapy. Presently, the attempted curative treatment of recurrent colorectal cancer lays in the hands of the surgeon. This paper reviews the natural history of surgically treated large bowel cancer and summarizes published and National Cancer Institute experience with the surgical therapy of recurrent disease. A schema with rationale is offered for follow-up of the patient following 'curative' bowel resection. The treatment of recurrent disease incorporating the use of CEA initiated second-look laparotomy is advocated. Hepatic and pulmonary resections for metastatic disease are accepted as important therapeutic endeavours, and are discussed in some detail. It is concluded that of all patients diagnosed as having large bowel cancer, roughly 70% are resectable for cure at time of presentation, and 45% will indeed be cured by primary resection. Of the 25% who fail primary therapy, approximately 20% (5% of all colorectal cancer patients) can be cured by local re-resection or hepatic or pulmonary resection.
The use of home parenteral nutrition (HPN) in patients with inoperable malignant bowel obstruction (IMBO) is controversial. The efficacy, safety, and indications for HPN in these patients is uncertain, and its benefit is difficult to demonstrate. The records of 17 patients (9, ovarian cancer; 4, colon cancer; 4, other) with IMBO receiving HPN managed by the Nutrition Support Team (NST) at Yale-New Haven Hospital from 1980 to 1989 were reviewed. Median survival was 53 days and was longest in the two patients with appendiceal carcinomatosis (208 and 159 days), intermediate in patients with colon cancer (median 90 days), and shortest in patients with ovarian cancer (median 39 days). Survival was unrelated to age or sex. All patients died of their underlying disease; 82% of deaths occurred at home. Only one treatment-related complication requiring readmission occurred. Fourteen patients and their families (82%) perceived their therapy as highly beneficial or beneficial. The NST agreed with this assessment in 11 patients but did not share this perception in three patients. These three patients had a short duration of HPN (less than 25 days) or minimal rehabilitation. It is concluded that HPN for patients with IMBO is associated with a low complication rate, may be most beneficial for those patients with gastrointestinal tract primary tumors, and is usually perceived by patients and care providers as beneficial. HPN has palliative benefit and facilitates compassionate home care for carefully selected patients with IMBO.
BACKGROUND: There is a compelling need to determine the benefits of sophisticated, costly, and potentially hazardous nutrition support interventions. The clinical efficacy and cost effectiveness of specialized nutrition support must be quantitatively defined. Creation of a national outcomes research consortium to study the use of specialized nutrition support can meet these objectives. METHODS: Nutrition support and outcomes research literature were reviewed to develop a model for the application of outcomes research methods to clinical, professional, administrative, and financial problems currently challenging the discipline of nutrition support. RESULTS: A multi-institutional nutrition support outcomes research consortium involving creation of a large, practice-based data base is proposed. Relevant clinical, administrative, methodologic, and implementation issues are discussed. CONCLUSIONS: A multi-institutional nutrition support outcomes research consortium offers the means to collect rigorous data that can be used to improve patient outcomes, improve the cost-effectiveness of nutrition support, establish a firm scientific basis for the discipline of nutrition support, and assist nutrition support clinicians in the cost-cutting climate that currently characterizes health care in the United States. Given the timeliness of these objectives and the human, professional, and financial costs of not achieving them in a timely fashion, it is fair to ask of a nutrition support outcomes research consortium, "If not now, when?"