Cessation Of Oral Intake Research Articles

Conservative Management in a Patient with Recurrent Boerhaave Syndrome

Boerhaave syndrome (BS) is a full thickness oesophageal tear. Most cases require surgical correction. In rare cases, conservative management can be attempted. This case describes a 30-year-old patient with a history of BS 9 months prior, managed conservatively at that time, presenting with 2 days of vomiting. Their vitals and physical examination were within normal limits. Imaging revealed extensive air tracking along the mediastinum, oesophagus, and bilateral neck and chest wall consistent with BS. Gastrographin and barium oesophagrams showed no contrast extravasation. The patient was successfully treated with conservative measures including pantoprazole, piperacillin-tazobactam, cessation of oral intake, and parenteral nutrition. This case represents one of only two documented cases of recurrent BS in an adult patient in which both cases were managed conservatively. Of these two cases, this is the first report with the second episode of BS occurring more than 4 weeks after the first episode. Additionally, unlike the other recurrent BS case that was conservatively managed, this patient lacked any known comorbid risk factors for development of BS. While the management of this case resembles the care provided in some prior case reports, the significant variation and lack of standardisation in the approach of conservative BS treatment posed a significant challenge in developing a therapeutic plan. Given the absence of high-quality studies about conservatively managed BS, an increased sample size of case reports detailing their non-procedural management approaches and their subsequent outcomes would hopefully eventually clarify an optimal treatment regimen, and allow for standardisation of conservative BS treatment.

Examining antidepressant use in palliative care patients by risk of antidepressant discontinuation syndrome.

Antidepressant drugs, which are widely used in palliative care patients for both management of psychiatric disorders and non-psychiatric symptoms, may cause a cluster of distressing symptoms on discontinuation. In dying patients, cessation of oral intake may occur either temporarily or permanently for reasons related to disease or its treatment, as well as in the days before death. We examined antidepressant use in palliative care patients by risk of antidepressant discontinuation syndrome (ADDS). Strategies for reducing the risk of ADDS, and for managing it that should occur, are discussed.

The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions.

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.

Conservative management in hypertriglyceridemia-associated pancreatitis.

Severe hypertriglyceridemia (serum triglyceride >10mmolL-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis. We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach. A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia. Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4mmolL-1 on presentation to 13.3mmolL-1 within 48h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6h. Findings were similar for NPO-only and insulin infusion subgroups. Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.

Concurrent retroperitoneal, mediastinal, cervical and subcutaneous emphysema secondary to iatrogenic sigmoid colon perforation

A 76-year-old woman patient without a remarkable medical history underwent colonoscopy because of diarrhoea and black stool for 1 month. Colonoscopy was aborted at 23 cm from the anal verge...

Gebelik Esnasında Hipertrigliserideminin İndüklediği Akut Pankreatit

Acute pancreatitis is a sudden inflammation of the pancreas. It is related with severe complications and high mortality despite treatment. One of the most common causes of acute pancreatitis is hypertriglyceridemia (HTG) that is defined as triglyceride levels more than 150 mg/dl. There are effective treatment choices during pregnancy such as dietary restriction of fat, intravenous heparin and insulin and plasmapheresis. We presented a patient with severe HTG induced pancreatitis during pregnancy. She was consulted with hypertension and epigastric pain in the 31st weeks of gestation. After birth, she was treated successfully with heparin, insulin and cessation of oral intake and total parenteral nutrition.

A rare case of oesophageal rupture: Boerhaave's syndrome.

A 70-year-old patient was referred to our emergency department with severe retrosternal pain after forceful vomiting. Computed tomography (CT) scan revealed a left-sided oesophageal rupture with accompanying pneumomediastinum and bilateral pleural effusions. Conservative treatment with cessation of oral intake, intravenous broad-spectrum antibiotics, parenteral fluids and nutrition and left sided tube thoracostomy was initiated initially. After 5 days, however, the patient deteriorated. Follow-up CT scan demonstrated a mediastinal fluid collection as well as loculated pleural empyema. Open thoracotomy with mediastinal debridement and pleural drainage was performed, after which he made a slow but full recovery. Spontaneous oesophageal rupture due to an abrupt rise in intraluminal pressure caused by vomiting is also known as Boerhaave's syndrome. It is a rare but potentially life-threatening condition. Many patients present with atypical symptoms, and therefore, physicians should have a high index of suspicion in any patient presenting with vomiting and retrosternal pain. When Boerhaave's syndrome is suspected, a CT scan of the thorax and upper abdomen should be performed since treatment depends on clinical and radiological findings. Conservative management (cessation of oral intake, nasogastric decompression, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum antibiotics and proton pump inhibitors and tube thoracostomies) may only be considered in patients with a contained rupture without systematic symptoms of infection. In these patients, endoscopic bridging of the tear with a self-expandable stent is also an option. Primary surgical repair (either by thoracotomy or by video assisted thoracoscopy (VATS)) should be considered when patients present with sepsis and/or large non-contained leaks or with severe mediastinal decontamination.

The Incidence and Management of Postoperative Chylothorax After Pulmonary Resection and Thoracic Mediastinal Lymph Node Dissection

Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND). This is a retrospective review of patients who underwent pulmonary resection with MLND. Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 μg subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation. Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.

Approach to Patients with Chylothorax Complicating Pulmonary Resection

Mediastinal lymph node dissection, an important part of surgery for non-small cell lung cancer, is associated with a risk of chylothorax. Although mortality has significantly decreased in recent years, it still worries thoracic surgeons. In this report we reviewed our experience on chylothorax with 26 cases and assessed the outcomes after conservative and surgical approaches. Between January 2000 and June 2010, twenty-six patients developed chylothorax after pulmonary resection performed for non-small cell lung cancer. Initially, all cases were treated conservatively with cessation of oral intake and the application of talc poudrage. If the conservative method failed, a surgical approach was used, which consisted either of suturing the leak or of mass ligation. The mean age of patients was 56 ± 9.05 years, and 3 were female. Chylothorax was more common on the right side, in lobectomy cases, in cases with adenocarcinoma, and in patients with advanced stage lung cancer, but the difference did not reach statistical significance. Conservative treatment was successful in 19 of 26 (73 %) patients, four of whom had undergone pneumonectomy. Seven out of 26 cases (27%) required thoracotomy to control the chylous leak. Though thoracotomy was required mostly for the right side (6 right vs. 1 left, p = 0.15), and in patients who had had pneumonectomy as their first operation (4 patients vs. 3, p = 0.18), this did not reach statistical significance. No patient died as a result of surgical intervention. In conclusion, chylothorax is not rare after pulmonary resection performed for lung cancer. But it is not as dangerous as it used to be. Talc pleurodesis has increased the success of conservative management and minimized the need for surgical intervention. In cases of high output leak the surgeon should not hesitate to perform surgery. VATS can be performed instead of open surgery in suitable cases.

Options in the management of esophageal perforation: analysis over a 12-year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.

Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent

Leaks of the esophagus are associated with a high mortality rate and need to be treated as soon as possible. Therapeutic options are surgical repair or resection or conservative management with cessation of oral intake and antibiotic therapy. We evaluated an alternative approach that uses self-expandable metallic stents (SEMS). Between 2002 and 2007, 31 consecutive patients with iatrogenic esophageal perforation (n = 9), intrathoracic anastomotic leak after esophagectomy (n = 16), spontaneous tumor perforation (n = 5), and esophageal ischemia (n = 1) were treated at our institution. All were treated with endoscopic placement of a covered SEMS. Stent removal was performed 4 to 6 weeks after implantation. To exclude continuous esophageal leak after SEMS placement, radiologic examination was performed after stent implantation and removal. SEMS placement was successful in all patients and a postinterventional esophagogram demonstrated full coverage of the leak in 29 patients (92%). In two patients, complete sealing could not be achieved and they were referred to surgical repair. Stent migration was seen in only one patient (3%). After removal, a second stent with larger diameter was placed and no further complication occurred. Two patients died: one due to myocardial infarction and one due to progressive ischemia of the esophagus and small bowl as a consequence of vascular occlusion. Stent removal was performed within 6 weeks, and all patients had radiologic and endoscopic evidence of esophageal healing. Implantation of covered SEMS in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.

Medical management of iatrogenic esophageal perforations

Esophageal perforation is an uncommon, potentially disastrous occurrence with high mortality rates even when managed with surgery. Over the past few decades, several case series have shown that nonoperative management is a feasible option in some patients, although the criteria for selecting such patients are neither firmly established nor accepted by all those who manage these critical patients. The decision to manage a patient without surgery should be made collaboratively with a surgeon. No single criterion, with the possible exception of sepsis and shock, mandates surgical management. Randomized, prospective studies comparing surgical and nonsurgical therapy have not been performed. Factors that can affect the decision to proceed nonoperatively include the perforation's site and size, the patient's underlying comorbidities, and the patient's hemodynamic status on presentation. Healthy patients with small, contained perforations who present without sepsis tend to be the best candidates for nonoperative management. Intravenous antibiotics and cessation of oral intake should be instituted immediately, even before confirming the diagnosis. Mediastinal fluid collections and pleural effusions often coexist with esophageal perforations and must be managed concomitantly. Percutaneously placed drains are an important adjunct to therapy when collections are identified. Endoscopic stenting has been introduced as a means to seal the perforation. After embarking on a nonoperative course, patients still may deteriorate and require surgery, so close follow-up is warranted for every patient. When proper nonoperative management strategies are followed, outcomes have been shown to be at least equivalent to those of surgical management in most series. In this review, the principles of patient selection and medical therapy for iatrogenic esophageal perforations are discussed.

Quilotórax bilateral masivo en postoperatorio de gastrectomía subtotal

Chylothorax is a lymphatic effusion of chylous in the pleural space due to thoracic duct obstruction or injury. The most frequent aetiology is cancer; it is also related to chest trauma and iatrogenic. We describe the case of bilateral chylothorax in a 76-year-old woman, right predominant, during the post-operational phase of gastric surgery. This presented itself with respiratory insufficiency and tachycardia without initial haemodynamic compromise. It presented a favourable evolution after conservative treatment, cessation of oral intake and TPN and chest tube during 10 to 14 days.

Immuno-histochemical study of the expression of Bcl-2 in the Leydig's interstitial cells and primary spermatocyte cells of adult male rabbit under the effect of oral Gossypol intake

Gossypol is a natural compound extracted from the seeds of some species of cotton plants (Gossypium species). Gossypol displays various drug properties, including male antifertility, anti- proliferative activity on tumor cells (leukemia, prostate, adrenal, etc.) and endometriosis. Recently, the action of gossypol has been thought to induce apoptosis in the target cells especially male testicular tissue. The current study was planned to evaluate the effect of oral intake of gossypol on the expression of anti-apoptotic Bcl-2 gene in the interstitial cells of Leydig and primary spermatocyte cells of adult rabbit. Thirty adult male rabbits were used, subdivided into 5 equal groups. Group1 represented control group, groups 2, 3, and 4 represented rabbits intubated with 1.05mg/day gossypol suspended in 1ml. olive oil for 3,6 and 9 weeks respectively. Group5 rabbits were subjected to gossypol oral intake in the same manner for 9weeks and were left for another 9weeks as recovery periods. All rabbits were sacrificed after 24hrs from last dose except group5 rabbits, testes were extracted fixed in neutral buffered formol and histologically processed for 5um paraffin sections. Detection of Bcl-2 protein was done by using labeled streptavidin biotin technique with the monoclonal Bcl-2 antibody. The evaluation of Bcl-2 expression in the interstitial cells of Leydig and primary spermatocyte cells, as an optical density, were done by the aid of image analysis system. The obtained data were statistically analyzed by using student t-test. The study showed that there was a positive Bcl-2 expression in the interstitial cells of Leydig in all study groups, and there were statistically significant increase in the Bcl-2 expression in groups 2, 3 and 4 in comparison to control rabbits values (p<0.001). The recovery group rabbits showed a statistically significant decrease in the Bcl-2 expression (p<0.001) in comparison to control rabbits values. The primary spermatocyte cells showed a very weak Bcl-2 expression in control group rabbits and rabbits of groups 2 and 3. After 9weeks gossypol administration there was a positive Bcl-2 expression in some primary spermatocyte cells (p<0.001) and the overexpression of Bcl-2 was continued in the recovery group rabbits (p<0.001). The study concluded that gossypol may trigger Bcl-2 expression in interstitial cells of Leydig, which started after 2weeks of oral administration and this effect is diminished after cessation of oral intake. Also there was an increase in Bcl-2 protein expression in primary spermatocyte cells after 9weeks of oral gossypol intake and that increase persisted even after cessation of gossypol. The study recommends further study about the role of gossypol on the relation between apoptosis inducing gene and apoptosis inhibiting gene in the testicular tissues.

Immuno-histochemical study of the expression of Bcl-2 in the Leydig's interstitial cells and primary spermatocyte cells of adult male rabbit under the effect of oral Gossypol intake

Gossypol is a natural compound extracted from the seeds of some species of cotton plants (Gossypium species). Gossypol displays various drug properties, including male antifertility, anti- proliferative activity on tumor cells (leukemia, prostate, adrenal, etc.) and endometriosis. Recently, the action of gossypol has been thought to induce apoptosis in the target cells especially male testicular tissue. The current study was planned to evaluate the effect of oral intake of gossypol on the expression of anti-apoptotic Bcl-2 gene in the interstitial cells of Leydig and primary spermatocyte cells of adult rabbit. Thirty adult male rabbits were used, subdivided into 5 equal groups. Group1 represented control group, groups 2, 3, and 4 represented rabbits intubated with 1.05mg/day gossypol suspended in 1ml. olive oil for 3,6 and 9 weeks respectively. Group5 rabbits were subjected to gossypol oral intake in the same manner for 9weeks and were left for another 9weeks as recovery periods. All rabbits were sacrificed after 24hrs from last dose except group5 rabbits, testes were extracted fixed in neutral buffered formol and histologically processed for 5um paraffin sections. Detection of Bcl-2 protein was done by using labeled streptavidin biotin technique with the monoclonal Bcl-2 antibody. The evaluation of Bcl-2 expression in the interstitial cells of Leydig and primary spermatocyte cells, as an optical density, were done by the aid of image analysis system. The obtained data were statistically analyzed by using student t-test. The study showed that there was a positive Bcl-2 expression in the interstitial cells of Leydig in all study groups, and there were statistically significant increase in the Bcl-2 expression in groups 2, 3 and 4 in comparison to control rabbits values (p<0.001). The recovery group rabbits showed a statistically significant decrease in the Bcl-2 expression (p<0.001) in comparison to control rabbits values. The primary spermatocyte cells showed a very weak Bcl-2 expression in control group rabbits and rabbits of groups 2 and 3. After 9weeks gossypol administration there was a positive Bcl-2 expression in some primary spermatocyte cells (p<0.001) and the overexpression of Bcl-2 was continued in the recovery group rabbits (p<0.001). The study concluded that gossypol may trigger Bcl-2 expression in interstitial cells of Leydig, which started after 2weeks of oral administration and this effect is diminished after cessation of oral intake. Also there was an increase in Bcl-2 protein expression in primary spermatocyte cells after 9weeks of oral gossypol intake and that increase persisted even after cessation of gossypol. The study recommends further study about the role of gossypol on the relation between apoptosis inducing gene and apoptosis inhibiting gene in the testicular tissues.

Postoperative chylothorax

Between July 1987 and May 1995, 11,315 patients underwent general thoracic surgical procedures at our institution. In 47 of these patients (0.42%), postoperative chylothorax developed. There were 32 men and 15 women with a median age of 65 years (range 21 to 88 years). Initial operation was for esophageal disease in 27 patients, pulmonary disease in 13, mediastinal mass in six, and thoracic aortic aneurysm in one. All patients were initially treated with hyperalimentation, cessation of oral intake, medium chain triglyceride diet, or a combination. Nonoperative therapy was successful in 13 cases (27.7%), and oral intake was resumed a median of 7 days later (range 2 to 15 days). Reoperation was required in the remaining 34 cases. The reoperation rate varied according to the type of initial operation. Twenty-four of the 27 patients (88.9%) who had undergone an esophageal operation required reoperation, versus only five of 13 patients (38.5%) who had undergone pulmonary resection ( p < 0.001). Lymphangiography was performed in 16 patients and identified the site of the leak in 13. The thoracic duct was ligated in 32 of the 34 patients who required reoperation (94%). The remaining two patients were treated with mechanical pleurodesis and fibrin glue. Reoperation was successful in 31 of the 34 patients (91.2%). The single death among the 47 patients (2.1%) occurred in the reoperated group. Complications occurred in 18 patients (38.3%). Factors that predicted the need for reoperation were initial esophageal operation and average daily postoperative drainage greater than 1000 ml/day for 7 days. We conclude that postoperative chylothorax is an infrequent complication. Some cases can be managed without operation; however, we recommend early reoperation when drainage is greater than 1000 ml/day or if the chylous fistula occurs after an esophageal operation. The fistula can usually be controlled by ligation of the thoracic duct. (J T HORAC C ARDIOVASC S URG 1996;112:1361-6)

Chylous Fistula

Postoperative lymphatic complications of mastectomy and immediate reconstruction are well documented, consisting predominantly of lymphorrhea, lymphocele, and chronic lymphoedema. Chylous fistula is a hitherto undescribed entity complicating breast surgery. It was managed successfully by cessation of oral intake and the use of intravenous fluids, as is recommended in the treatment of chylous fistulas occurring elsewhere in the body. Although these are exceedingly rare, all plastic surgeons doing breast reconstruction should be aware of chylous fistulas and their treatment.

Complications of antireflux surgery

In order to determine the in-hospital morbidity and mortality rates of antireflux surgery in a community hospital setting, a retrospective 10-year review of 355 antireflux procedures was conducted. A modified Nissen fundoplication, with an incomplete fundal wrap, was the most common operation performed. Concomitant procedures, usually biliary or gastric, were undertaken in 93 patients. Thirty-nine patients had previously undergone an operation involving hiatal dissection. Overall morbidity was 17%, and mortality was 1% (three deaths). Patients with previous hiatal surgery had higher morbidity (44%, p < 0.0001) and mortality rates (3%, p < 0.21). Wound infection occurred in 5% of patients and wound dehiscence in 1%. Splenic repair or splenectomy for iatrogenic injury was required in 2%. Postoperative gastroesophageal leaks occurred in six patients (2%). Patients with previous hiatal surgery had a higher incidence of gastroesophageal leaks (8%, p < 0.002). Three of six patients had contained leaks that resolved with antibiotics, cessation of oral intake, and nutritional support. Two of three patients with noncontained leaks died despite surgical intervention.

Sclerosing Encapsulating Peritonitis: Report of a Case With Small Bowel Obstruction Managed by Long-Term Home Parenteral Hyperalimentation, and a Review of the Literature

Sclerosing peritonitis has recently emerged as a complication of peritoneal dialysis associated with a high morbidity and mortality. These patients experience the characteristic syndrome of nausea, vomiting, abdominal pain, partial small bowel obstruction, and impaired ultrafiltration. A pathologic finding is the replacement of mesothelial cells with a thick layer of nondistensible fibroconnective tissue. We report here a 58-year-old white woman who developed peritoneal sclerosis after 4 years of peritoneal dialysis, including 3 years of continuous ambulatory peritoneal dialysis. Risk factors included peritoneal exposure to low concentrations of formaldehyde and a 1-week exposure to long-dwell acetate dialysate. Laparotomy for partial small bowel obstruction with resection of the involved segment was complicated by enterocutaneous fistulae, which improved only on cessation of oral intake and treatment with home parenteral nutrition. We have reviewed the literature to find 20 cases of sclerosing peritonitis in patients on peritoneal dialysis. A 78% mortality rate is reported in cases that had surgical intervention. We conclude that the use of long-term parenteral nutrition with cessation of oral intake may be necessary in the management of sclerosing encapsulating peritonitis.

Essential fatty acid deficiency in critically III surgical patients

Plasma fatty acid profiles of 33 critically ill surgical patients receiving fat-free parenteral nutrition were examined at weekly intervals up to 28 days. While plasma total fatty acid concentration remained relatively constant and within the normal range, marked compositional alterations were apparent. Levels of linoleate (18:2ω6), the major essential fatty acid in man, fell below normal values (754 ± 259 μg/ml) in 67 percent of patients within 1 week after cessation of oral intake. Decreases in other ω6 unsaturated fatty acids, derived from linoleate, were also apparent. In contrast, gradual increases were observed in levels of endogenously synthesized fatty acids, palmitate (16:0), palmitoleate (16:1) and oleate (18:1ω9). A fatty acid unique to essential fatty acid deficiency, 5,8,11 eicosatrienoate (20:3ω9), appeared in 25 percent of the patients during the first week and in all patients by the third week of study. Considering the rapid appearance and progression of these bio-chemical changes, early initiation of linoleate supplementation appears justified to forestall the development of related clinical sequelae.