Surgery
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We have examined the effects of the somatostatin analogue (SMS 201-995) in 10 patients with gastrinoma syndrome. Four had hepatic metastases, one had a tumor in a peripancreatic lymph node, two had resectable intrahepatic and intraduodenal gastrinomas, and in three the primary tumor was not found. Acutely, SMS 201-995 decreased acid secretion and restored the BAO/MAO ratio to normal in eight of eight patients. ⋯ We conclude that SMS may be useful in the management of gastrinoma patients by decreasing hypersecretion of gastrin and gastric acid and, over a longer term, may even change tumor capacity to release gastrin and gastric acid secretion. SMS may thus be useful as a palliative agent and as an adjunct to conventional treatment of the gastrinoma syndrome. SMS does not appear to shrink tumor mass in patients with very high basal gastrin levels.
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Randomized Controlled Trial Comparative Study Clinical Trial
Enteral nutrition does not prevent multiple organ failure syndrome (MOFS) after sepsis.
Gut malnutrition in patients with persistent hypermetabolism is hypothesized to be an important factor in postseptic multiple organ failure syndrome (MOFS). The hypothesis was made that enteral nutrition (EN) started at the onset of hypermetabolism could reduce the incidence of MOFS. Sixty-six patients with persistent hypermetabolism 4 to 6 days after onset of sepsis were prospectively randomized to receive either parenteral nutrition (PN) or enteral nutrition (EN) at 1.5 gm protein/kg/day and 30 nonprotein calories/kg/day; the EN and TPN were of the same composition. ⋯ A formula with a nonprotein-calorie-to-nitrogen ratio of 100:1 was associated with more nitrogen retention, higher levels of visceral proteins, and better gut tolerance. The route of nutrition administration does not seem to affect the incidence of postseptic MOFS or mortality when hypermetabolism is already present and when commercially available nutritional formulas are used. The relationships among the route of nutrition, the type of enteral formula, and the disease process of hypermetabolism and MOFS appear to be complex and require much more investigation before the role of the gut and enteral nutrition can be defined.
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Randomized Controlled Trial Clinical Trial
A randomized, controlled trial to determine the effectiveness of fascial infiltration of bupivacaine in preventing respiratory complications after elective abdominal surgery.
A randomized, controlled trial was performed to determine whether infiltration of fascia with bupivacaine, a long-acting local anesthetic, at the time of closure after elective laparotomy, is effective in preventing postoperative respiratory complications. At the Toronto General Hospital 415 patients undergoing elective laparotomy were randomly allocated to receive bupivacaine 0.25% (2 ml/cm incision), infiltrated into the fascia evenly along both sides of the incision before wound closure (202 patients), or to have closure without infiltration (213 patients). Chest x-ray (CXR) films of all patients were obtained preoperatively and on the second postoperative day. ⋯ There was no significant difference in the amount of analgesic taken in the first 24 hours, although the time to first analgesic was significantly longer in the treatment group (2.2 vs 1.3 hours, p less than 0.055). We conclude that infiltration of the fascia with 0.25% bupivacaine at a dose of 2 ml/cm of incision is not effective in preventing postoperative atelectasis. It does not reduce use of an analgesic although it may delay its initial requirement.
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Although well accepted in pediatric patients, nonoperative management of blunt hepatic trauma in adults remains controversial. From January 1981 through May 1987, 66 adults were identified with blunt hepatic trauma that had been confirmed by abdominal exploration or abdominal computed tomography (CT): 46 underwent immediate operation, and 20 were initially managed nonoperatively. Patients were considered for nonoperative management only if they were hemodynamically stable and had no significant peritoneal irritation. ⋯ A small amount of blood in either gutter or in the pelvis did not portend failure of nonoperative management. No delayed complications were noted during an average follow-up of 27 months. Nonoperative management of blunt hepatic injury based on abdominal CT findings is a useful alternative in a select group of hemodynamically stable patients.
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To determine the safety and efficacy of a hypertonic solution for hypovolemic resuscitation, we compared the acute and delayed effects of hypertonic sodium lactate solution (514 mOsm) to Ringer's lactate solution (274 mOsm) in a porcine model of hemorrhagic shock. Cardiovascular, pulmonary, renal, and cerebral functions were examined in mature swine after their blood volume had been reduced by 40%. ⋯ HSL produced significant increases in serum sodium and osmolality, which resolved within 48 hours. Hypernatremia and hyperosmolality were not associated with renal or cerebral dysfunction and were corrected through increased sodium excretion, free water intake, and a negative free water clearance.