Biomedical subjects
Publications and source records attributed to M J Heslin.
Sclerosing mesenteritis is an uncommon benign condition that should be included in the differential diagnosis of abdominal masses. We present the first reported case of this condition in association with idiopathic bile duct fibrosis simulating Klatskin's tumor. A review of the literature regarding both clinical entities is presented.
Closed suction drains after pancreaticoduodenectomy are theoretically used to drain potential collections and anastomotic leaks. It is unknown whether such drains are effective, harmful, or affect the outcome after this operation. Eighty-nine consecutive patients underwent pancreaticoduodenectomy for presumed periampullary malignancy and were retrospectively reviewed. Thirty-eight had no intra-abdominal drains and 51 had drains placed at the conclusion of the operation. We analyzed patient, nutritional, laboratory, and operating room factors with end points being complications and length of hospital stay. Intra-abdominal complications were defined as intra-abdominal abscess and pancreatic or biliary fistula. Postoperative interventions were defined as CT-guided drainage and reoperation. Analysis was by Student's t test and chi-square test. Two of eight surgeons contributed 92% of the patients without drains. The groups were equivalent with respect to demographic, nutritional, and operative factors. Time under anesthesia was significantly shorter in the group without drains (P = 0.0001). There was no statistical difference in the rate of fistula, abscess, CT drainage, or length of hospital stay. Intra-abdominal drainage did not significantly alter the risk of fistula, abscess, or reoperation or the necessity for CT-guided intervention after pancreaticoduodenectomy. Routine use of drains after pancreaticoduodenectomy may not be necessary and should be subjected to a randomized trial.
BACKGROUND: Patients with upper gastrointestinal (GI) tract malignancies are at risk for malnutrition and postoperative morbidity and mortality. We examined the protein kinetic effects of early enteral feeding in this population and compared it with results in patients receiving IV fluid. METHODS: Twenty-nine patients undergoing resection of an upper GI tract malignancy were prospectively randomized to either enteral feeding starting on postoperative day (POD) 1 via a jejunostomy tube (FEED, n = 12) or IV fluid (IVF, n = 17). On POD5, all patients underwent a protein metabolic study using [3H]phenylalanine to determine forearm skeletal muscle (nmol phenylalanine/100 g/min) protein net balance. Free fatty acids (FFA, mEq/dL) and insulin levels (mU/mL) were measured. RESULTS: Protein net balance was significantly less negative in the FEED group compared with the IVF group (-1.4 +/- 0.8 vs -5.0 +/- 1.4, p < .05). Respiratory quotient was significantly increased in patients receiving enteral feeding (0.85 +/- 0.02 vs 0.78 +/- 0.02 FEED vs IVF, p < .05). FFA levels were significantly decreased in the FEED group (0.36 +/- 0.04 vs 0.85 +/- 0.07, p < .05). Insulin levels were significantly elevated in the FEED group (19.8 +/- 4.5 vs 9.3 +/- 0.8, p < .05). Insulin levels correlated with amino acid fluxes. CONCLUSIONS: Postoperative enteral nutrition in upper GI cancer patients results in an improvement in protein kinetic net balance and amino acid flux across peripheral tissue. In addition, insulin levels are elevated, and this elevation correlates with amino fluxes across the forearm. By improving peripheral protein kinetics, early postoperative enteral nutrition may potentially contribute to a decrease in postoperative morbidity and mortality in upper gastrointestinal cancer patients.
BACKGROUND: Increased intestinal permeability may lead to sepsis in resected upper gastrointestinal (GI) cancer patients. This study sought to determine whether these patients demonstrated increased intestinal permeability and if early postoperative enteral nutrition would alter this result. METHODS: Nineteen patients undergoing complete resection of upper GI malignancy were randomized into two groups: the nonfed group received IV crystalloid, and the fed group started enteral nutrition by jejunostomy on postoperative day (POD) 1. Six nonoperative volunteers were controls. The lactulose/mannitol test was performed on PODs 1 and 5. Ten grams of lactulose and 5 g of mannitol were given, and urine was collected for 6 hours. RESULTS: All patients (nonfed, 1.895+/-0.34; fed, 0.893+/-0.24) had elevated lactulose/mannitol ratios on POD 1 vs controls (0.262+/-0.1; p < .008 and p = .05). These elevated levels returned toward control levels in both groups by day 5 (nonfed, 0.533+/-0.1, p = .06; fed, 0.606+/-0.12, p = .08). CONCLUSIONS: Major upper GI surgery for malignancy resulted in a significant increase in intestinal permeability on POD 1. With or without enteral nutrition, this measure of intestinal permeability returned to normal on POD 5 in well-nourished patients.