A CASE REPORT OF H.P.N. DURING 6 YEARS FOLLOWING DISTAL GASTRECTOMY, MASSIVE SMALL INTESTINAL RESECTION, AND RIGHT HEMICOLECTOMY

Abstract

A 71-year-old male with double cancer of the stomach was treated surgically by partial gastrectomy with R- 2 lymph node dissection and gastroduodenostomy to restore continuity of the GI tract (Billroth-I resection). Three months after this first operation the patient underwent an extended enterectomy and right hemicolectomy for thrombosis of the SMA. For postoperative nutritional management TPN was administered and, after treatment for short bowel and malabsorption syndromes proved difficult during both postoperative periods, he was switched to and has since been maintained on HPN for 6 years postoperatively.During these years mechanical complications related to the insertion of subclavian catheters occurred frequently, but the frequency of these episodes was markedly reduced after the nursing staff became familiar with the catheter management and two filters were used in series in the catheter line. Fat emulsions were not administered throughout the period of HPN and, probably because of this, subnormal serum cholesterol levels were noted 6 years postoperatively but there was no overt essential fatty acid deficiency. This suggests the necessity of supplementing HPN with fat emulsions at least by intermittent infusions through a peripheral vein.An analysis of the serum for amino acid fractions revealed that, among the BCAA, valine was decreased while phenylalanine was increased and, consequently, the Fisher ratio was reduced. This points to the necessity for amino acid supplementation.Six years postoperatively, anemia and folic acid deficiency were noted, indicating that the need for iron should always be taken into consideration in patients maintained on long-term home hyperalimentation.The present patient on one occasion developed cutaneous manifestations of trace element deficiencies, and supplementation of the deficient elements resulted in symptomatic improvement He also experienced one episode of cholecystitis during the course of chronic HPN and has since been placed under medical surveillance while receiving UDCA.The patient also developed severe diarrhea requiring antidiarrheal drug administration postoperatively.At the present time the symptom has subsided to the point where any such medication is unnecessary.