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Nineteen patients had a Silastic (silicone rubber) catheter placed into the inferior vena cava (IVC) by way of a vein of a lower extremity. All patients needed long term venous access but had conditions precluding access to the superior vena cava (SVC) or access sites of the upper torso. Precautions regarding operative technique for the placement of the catheter include incisions through healthy skin, maintenance of aseptic technique at the site of access, an atraumatic subcutaneous tunnel at least 25 centimeters in length and a long acting local analgesic effect. Catheters were in situ for a total of 2,215 days (a mean of 111 days per catheter). Catheters were also used to administer intravenously medications, blood and blood products, chemotherapeutic agents, parenteral nutrition and for sampling of blood. Four complications occurred: one instance each of catheter sepsis and infection of the subcutaneous tract and two of thromboses of the IVC. No deaths occurred. The complication rate was 0.18 per cent per catheter-day. Long term access to the IVC is feasible without undue concern in conditions in which access to the SVC is precluded but long term central access is essential.

We have reviewed the data that indicate that protein depletion is an important problem in cancer patients. An incomplete, yet useful, idea of the underlying mechanisms emerges. Further, we have seen that the provision of nutritional support may have a beneficial effect on patients with cancer, and we have explored areas of recent advances in nutritional formulation as regards energy and nitrogen source. Finally, data regarding micronutrients affecting nitrogen metabolism were reviewed. The extent to which tumor metabolism and changes secondary to the tumor-bearing state are influenced by micronutrients is not known. Traditional regimens based on the requirements of normal subjects or noncancer patients may not be relevant to the metabolic needs of the cancer patient. This could explain in part the failure of nutritional intervention trials to demonstrate a consistent benefit of nutritional support to the cancer patient. Further information regarding micronutrient needs in normal humans and cancer-bearing patients and their utilization by malignant tumors will have to be obtained.

The effect of nutritional status on the morbidity and mortality of major gastrointestinal surgery for benign disease was studied in 32 patients. Malnutrition was defined as a serum albumin less than 3.5 g/dl and a recent weight loss greater than 10%, in addition to any two of the following: weight for height, midarm circumference or triceps skin-fold thickness less than 10th percentile. The morbidity and mortality in the 17 malnourished patients was 59% and 29%, respectively, compared with 20% and 7% in 15 well-nourished patients matched for age and operative procedure (p less than 0.05). After operation, the mean duration of inadequate oral nutritional intake period (IONIP, defined as a caloric intake greater than 60% requirement) was 11.9 days +/- 2.9 (SEM) in well-nourished patients compared with 30.5 days +/- 3.7 in the malnourished group. The longer IONIP in malnourished patients was a consequence of the higher morbidity in this group, thus warranting the consideration of supportive (postoperative) parenteral nutrition in malnourished patients who undergo major gastrointestinal surgery for benign disease.

The incidence of morbidity and mortality in 365 consecutive patients with a mean age of 60 years who underwent intraabdominal operation for a variety of cancers involving different organ systems over a recent 2-year period was analyzed. The primary tumor sites were the esophagus (21 patients), gastroduodenum (33 patients), liver and gallbladder (6 patients), pancreas (15 patients), colorectum (101 patients), lymphoproliferative disorders (35 patients), abdominal carcinomatosis (45 patients), genitourinary and gynecologic systems (94 patients), and other sites (15 patients). One hundred eighty-two patients (49 percent) had 1 or more complications (grouped as gastrointestinal, septic, cardiopulmonary, and nonseptic) and 47 patients died (12.9 percent). The 145 patients who underwent a palliative procedure had the highest morbidity and mortality rates (41 percent and 21 percent, respectively). In the 168 patients who had curative resection, the morbidity and mortality rates were 39 percent and 9 percent, respectively, and in 51 patients with a diagnostic laparotomy, 20 percent and 4 percent, respectively. Age was not a contributory factor. The 177 malnourished patients had a significantly higher incidence of complications (72 percent) and postoperative death (23 percent) than the well-nourished patients (29 percent and 4 percent, respectively; p less than 0.001). These differences also existed with each form of complication. Of those patients without complications, the majority resumed consuming 60 percent of their caloric requirements by postoperative day 9. In the majority of patients with complications, resumption of adequate oral intake occurred by postoperative day 20.

The most common metabolic complications of total parenteral nutrition (TPN), glucose intolerance and abnormal liver function, can be significantly reduced when 30% of the glucose calories are replaced by fat. We gave 88 patients either conventional TPN (CON-TPN, 25% dextrose and 4.25% amino acids) or modified TPN (MOD-TPN, 15% dextrose, fat, and 5% amino acids). The treatment groups were as follows: group A, no surgery with TPN only; group B, postoperative TPN; and group C, preoperative and postoperative TPN. Serial blood samples were analyzed for glucose, albumin, triglycerides, and insulin, and for liver function values. Nine patients manifested hyperglycemia and were removed from the study; seven patients had received CON-TPN and two had received MOD-TPN. In group A, the insulin level rose 50% less with MOD-TPN. There was a 50% smaller rise in the triglyceride, SGOT, and SGPT levels in patients who received MOD-TPN. Replacing one third of the TPN glucose calories with fat leads to better glucose tolerance and fewer hepatic complications.

Nine infants underwent operations for perforation of a Meckel's diverticulum over a 21-yr period. All of the infants were acutely ill when initially seen by the surgical service. Lethargy, irritability, anorexia, fever, abdominal tenderness, and passage of blood in the stools were common clinical manifestations. The preoperative diagnosis of perforated Meckel's diverticulum was not made in any of the cases. Skilled preoperative and postoperative management is important for the survival of these infants. There was no mortality and minimal morbidity. In retrospect, the peptic etiology of perforation in this age group is a key to early recognition. The past history of most of the patients includes previous episodes of blood in the stools and episodic abdominal complaints.

Enhanced nitrogen utilization occurs when adults with gastrointestinal disease are fed partially hydrolyzed proteins instead of isonitrogenous, isocaloric crystalline amino acids. A controlled trial was conducted to determine if this difference was also seen in malnourished stressed cancer patients and to gain an understanding of the underlying mechanism. Sixteen malnourished patients with head and neck cancer were prospectively randomized to either crystalline amino acid-glucose (CAA-G) or partially hydrolyzed protein-glucose (PHP-G) diets. Patients were fed via an enteral tube for 10 days starting on the second postoperative day. Blood SMA-6 and amino acid levels were measured on Days 1 and 10. Daily calorie counts and fluid balance were obtained. Daily 24-hr urine and stools were analyzed for total N during the last 5 days of the study period. The daily positive N balance with both diets was the same (CAA-G = +7.8 +/- 0.8 vs PHP-G = +8.2 +/- 1.0 g; mean +/- SE) and 3-methylhistidine:creatinine ratio did not differ. Patients on PHP-G diet gained significantly more weight (+0.5 vs - 1.5 kg; P less than 0.01) and had significantly higher serum albumin (3.2 +/- 0.2 vs 2.8 +/- 0.1 g/dl; P = 0.5) by the end of the 10th study day. Weight changes were not due to fluid retention: serum Na+, K+, creatinine and mean fluid intake for the two groups remained the same during the study period. A significantly greater rise in BUN occurred on the CAA-G diet (from 9.2 +/- 1.7 to 15.4 +/- 1.4 mg/dl; P less than 0.05) while BUN remained unchanged on the PHP-G diet.(ABSTRACT TRUNCATED AT 250 WORDS)

A further refinement of the improved Seldinger technique of central venous cannulation is described. The method entails inserting the guidewire through a previously created side hole in a standard 5ml plastic syringe. The problems of needle dislodgement, air embolism and blood loss are virtually eliminated with this technique.

The limitations of glucose-based TPN solutions are high glucose concentration, high osmolality, lack of fat, and essential fatty acids, which result in glucose intolerance and hepatotoxic effects. We replaced one-third of the calories in a standard amino acid-glucose solution with Liposyn 10% for 14 days in 23 critically ill men who needed total parenteral nutrition. Serial measurements included weight, albumin, glucose, triglyceride concentrations, and liver function tests. Serum osmolality was calculated, and found to remain constant. Body weight and serum albumin were maintained. Minor changes occurred in hepatic enzymes which were physiologically insignificant. Glycosuria occurred in 15%. Adverse side effects of hypoglycemia, hyperosmolar coma, and hypertriglyceridemia were avoided. Our results show that the addition of fat reduced glucose and hepatic related metabolic complications.

Sixteen elderly postoperative patients were randomized in a crossover study comparing isocaloric volumes of 20% and 10% fat emulsions used for total parenteral nutrition (TPN). The caloric intake was maintained constant during the two 7-day periods of each infusion. The indices measured after each period were total volume of fluid administered, change in body weight, hematocrit, serum sodium, creatinine, albumin, blood urea nitrogen, glucose, inorganic phosphate, and cholesterol. The total volume of 10% isocaloric nutrient solution was significantly (p less than .05) greater than that of the 20% solution. A rise in body weight and a fall in serum indices of hydration status were observed; five patients developed clinical signs of overhydration while on the 10% solution. These changes did not occur with the 20% solution. Thus, isocaloric substitution of a 20% fat emulsion for a 10% fat emulsion with TPN prevented overhydration and hemodilution without compromising nutrient intake.

Assessment and correction of malnutrition is a major contribution to the improvements in the pre- and postoperative management of patients with head and neck cancer over the past 20 years. These patients are often in a poor nutritional status and thereby are at a higher operative risk secondary to the local and systemic effects of the tumor and its treatment. This article reviews current data emphasizing preoperative nutritional assessment, modalities available for nutritional therapy in head and neck cancer patients, and indications for perioperative use of these modalities.

Nutritional status of surgical patients is widely assessed using anthropometrics, visceral proteins, and urinary nitrogen losses. Since assay of muscle-specific marker 3-methylhistidine (3MH) is currently limited to research laboratories, routine use of serum creatinine phosphokinase (CPK) and myoglobin is potentially useful in monitoring nutritional repletion of stressed patients. An acute and a temporal phase human studies were done to test this hypothesis. After an overnight fast, nondiabetic, noncardiac patients were given an IVGTT (0.5 g/kg) 3 days after a standard abdominal midline operation. Glucose, insulin, total CPK, myoglobin, and 3-methylhistidine were measured serially. Baseline CPK was elevated threefold above normal range of upper limits, whereas myoglobin was at the upper limit of normality. After the IVGTT insulin rose, (P less than 0.005) and CPK and 3MH fell (P less than 0.005) whereas myoglobin rose and remained elevated throughout the study (P less than 0.05). As long as insulin levels remained elevated, CPK remained depressed. With sufficient TPN to induce positive nitrogen balance (35 kcal and 0.2 g N/kg/day), elevated CPK levels fell and remained depressed in direct correlation with elevated insulin. Greater than 95% of total serum CPK consisted of the isoenzyme CPK-MM. These initial studies indicate that total serum CPK is useful in monitoring the short-term responses of postoperative catabolic patients who receive nutritional repletion.

In contrast with the prevailing view, we report the inability of non-human primate platelets or arterial tissue to complete the biosynthesis of [14C]cholesterol from [14C]mevalonic acid in vitro or in vivo, or from performed [14C]lanosterol in vivo. The latter observation suggests that these tissues lack one or more components of the methyl sterol demethylase system.

Twelve young men, six subjects in each group studied in two phases, participated in an experiment to explore the relationships between valine intake, plasma valine concentrations, and valine kinetics, using 1-[13C]valine as a tracer. Below a valine intake of about 20 mg.kg-1.day-1 plasma valine concentrations reached a low and relatively constant level. The rate of valine oxidation fell with the decline in the intake of amino acid. Below valine intakes of 16 mg.kg-1.day-1, the mean daily rate of oxidation was estimated to be generally higher than the intake level, implying a negative valine balance during the 24 h day. These findings indicate that an intake of 10 mg valine kg-1.day-1 would not be adequate to maintain protein nutritional status. Our results are discussed in relation to the currently accepted 1973 FAO/WHO value of 10 mg.kg-1.day-1 as being the upper range of the valine requirement in healthy adult humans.

To explore the possibility that the half-life of insulin changes after trauma, five control subjects and 19 severe trauma patients received intravenous glucose (0.5 gm/kg) in 5 minutes to raise rapidly the insulin levels, followed immediately by 300 mg of intravenous diazoxide over 5 minutes to inhibit any further insulin secretion. Serial blood samples were analyzed for immunoreactive insulin, and insulin half-life was calculated. The baseline insulin level was 13.4 +/- 3.8 microU/ml in the trauma group 10.4 +/- 3.1 microU/ml in the control group. During the glucose infusion, insulin levels rose to 177.0 +/- 56.0 microU/ml in the controls and to 127.0 +/- 27.0 microU/ml in the trauma group. The rise in the control subjects was greater (P less than 0.03) than the rise in the trauma patients. After diazoxide, insulin levels fell to 25.0 +/- 6.2 microU/ml and 25.0 +/- 6.6 microU/ml, respectively. Insulin half-life in the control subjects was 5.2 +/- 0.3 min and 3.9 +/- 0.2 min in the trauma group (P less than 0.019).

Effects of tumor, operative stress and tumor removal, and postoperative TPN of varying amino acid compositions on brain levels of tryptophan or tyrosine as predicted by their brain influx rates were studied in normals and in malnourished cancer patients. Concentrations of the large neutral amino acids (LNAA) were determined in patients before and after tumor removal, and in postoperative patients before and after receiving either a standard TPN solution (STD-TPN), or a branched-chain amino acid solution (BCAA-TPN). The LNAA were altered in all groups versus normals. Brain influx rates showed the following: in preoperative patients, predicted brain tryptophan levels were below normal (P less than 0.001), whereas tyrosine levels were within or above normal; no significant differences between pre- and postoperative tryptophan or tyrosine levels; postoperative STD-TPN did not change predicted brain tryptophan concentration from preinfusion values, but BCAA-TPN decreased it (P less than 0.001), underscoring the common transport carrier; and preinfusion predicted brain tyrosine levels were decreased (P less than 0.001) by both types of TPN solutions. These results imply low substrate levels for brain serotonin and catecholamine synthesis, possibly affecting functions dependent on their control.

We previously showed that providing 30% of nonprotein calories as lipid eliminated glucose intolerance and ameliorated the other troublesome metabolic complications of total parenteral nutrition (TPN): hepatic abnormalities and hypertriglyceridemia. Whether such a mixed-fuel system is as effective as a hypertonic glucose-only TPN fuel system in achieving an anabolic state was tested in 88 consenting patients randomized to either conventional TPN (25% dextrose and 4.25% amino acids) or modified TPN (15% dextrose, fat, and 5% amino acids). Treatment groups were: group A, no surgery, TPN only; group B, postoperative TPN starting 48 hours after surgery; and group C, preoperative TPN, surgery on day 7 and with continued postoperative TPN. In all groups TPN was given for 14 days while patients were given nothing by mouth. Changes in the indexes of body protein metabolism, reflected by nitrogen balance, serum albumin, blood urea nitrogen, and weight, were measured on days 1 and 14. Nitrogen balance improved in patients randomized to either regimen, but there was no significant difference in the degree of improvement. Albumin levels were maintained, and differences between initial and final values were not significant. Blood urea nitrogen increased in all groups (p less than 0.05); however there was no significant difference between regimens. Patients maintained their weight, and fluid balance data indicated no water retention. Observed weight changes were not statistically significant. In each treatment group an anabolic state occurred and gains in measured protein indexes were similar. Isocaloric replacement of 30% of TPN glucose calories with fat was as effective as glucose-only TPN in achieving an anabolic state without the metabolic complications associated with glucose-only TPN.

Overt malnutrition is seen in about 40% of patients hospitalized for treatment of cancer. In patients whose primary treatment modality is surgical, morbidity and mortality is twice as high in the malnourished group as in the normally nourished patients. This clinically important malnutrition is a consequence of obligatory parasitism by the tumor, which grows at its own genetically determined rate and which competes effectively with the host for the limited available nutrients. Administration of extra nutritional support as total parenteral nutrition (TPN) can alter the tumor-host nutritional balance so that host repletion may occur. Provision of a significant proportion of TPN calories as fat diminishes the incidence of glucose intolerance and reduces the incidence of abnormal liver function. In vitro and in vivo studies both show that leucine is the significant controlling branched-chain amino acid in the TPN mixture, and adequate leucine content is a crucial component of effective TPN. Variations in TPN content of large neutral amino acids have important effects on brain tyrosine and tryptophan availability and hence may also effect neurotransmitter activity. Although the usefulness of TPN for correcting malnutrition in cancer patients is clear, the optimal choices of constituents for the TPN mixture continue to evolve.

The effect of Intralipid on the natural killer (NK) cell activity of healthy male Fisher 344 adult rats was investigated. They were cannulated via the right jugular vein and continuously infused for five days with: normal saline plus heparin, 5% Intralipid plus heparin, or 10% Intralipid plus heparin. Control groups comprised of cannulated rats receiving no infusion and rats undergoing no operative procedures. Following the five-day infusion, rats were exsanguinated under ether anesthesia and mononuclear cells (MNC) harvested from the peripheral blood. NK activity was measured in a standard four hour 51Cr release assay against YAC-1 target cells. NK cell activity in rats infused with 5% Intralipid did not differ significantly from rats in both control groups or rats infused with saline. Infusion of rats with 10% Intralipid resulted in a significant increase in NK activity compared with all other groups.

Nasogastric intubation is a routine procedure, performed daily by both medical and nursing staff. It is a simple procedure, but not without complications which can be life threatening. We present an unusual, life threatening complication which occurred when nasogastric intubation using a no. 8 polyurethane tube with its metal stilet resulted in a pneumothorax after intubation of the endotracheal tree in the presence of a cuffed endotracheal tube. We emphasize that the presence of a cuffed endotracheal tube should not be considered a safeguard against pulmonary intubation during nasogastric placement of a feeding catheter.

To test whether oral carbohydrate would provide greater conservation of body protein than would intravenous carbohydrate, healthy normal human subjects were infused with high doses of glucose either continuously intravenously or by nasogastric tube in both continuous and intermittent regimes. Metabolic responses to high calorie, nitrogen-free infusions in normal man were documented in the blood hormone and substrate changes, and protein sparing was assessed by urinary nitrogen excretion. Continuous glucose produced a lower urinary "nitrogen floor" than did the intermittent regime, and intravenous glucose was more effective than was oral glucose. The insulin responses to continuous nasogastric and continuous intravenous glucose were similar, and nitrogen excretion did not differ between those two groups. The increased insulin levels seen with intermittent glucose were not accompanied by greater protein sparing.

With continued interest and increasing awareness of nutritional support to patients, both hospitalized and at home, many new developments in the field of devices and methods of delivering nutritional support have occurred. The indications, methods of use, and the associated complications related to feeding via nasogastric tube, tube esophagostomy, gastrostomy, and jejunostomy in the light of new devices and methods are outlined. The authors' experience shows that postoperative enteral feeding is a reliable and efficient method of providing supportive nutrition, provided the appropriate patients are selected. Home enteral nutritional support via gastrostomy allows stable cancer patients to maintain their nutritional status and enjoy life independent of the hospital setting for an extended period of time. When feeding via the gastrointestinal tract is neither feasible nor desirable, for both short-term and long-term nutritional support, access to the central venous system becomes necessary because peripheral vein feeding has limited cost-effectiveness. Delivery of nutrients into the superior vena cava by long antecubital catheters has been advocated, and the use of Hickman/Broviac catheters, instead of conventional subclavian catheters, is becoming an increasingly common practice. Experience with the use of arteriovenous fistulae and the Infuse-A-Port (Infusaid Corp.) are reviewed; the method used for declotting infected and thrombosed catheters is outlined. Current trends in the use of three-liter bags containing a fat emulsion with glucose and amino acids are mentioned.

We have reported a case of carcinoma of the breast in a patient that occurred after bilateral prophylactic subcutaneous mastectomy. We recommend that the patient and physician be aware of the limitations of prophylactic mastectomy in terms of cancer prevention and that patients who undergo prophylactic mastectomy continue to be carefully followed.

Six trauma patients and five healthy volunteers were given an intravenous glucose infusion (5 Gm. per hour) for 6 hours. The serum insulin response and urine insulin excretion were measured and compared in the two groups. Glucose intolerance and serum insulin levels which were elevated but inappropriately low for the degree of glycemia characterized the trauma patients. Urine insulin concentrations and total urine insulin were increased significantly in the trauma patients. Renal function was similar in both groups, as determined by serum creatinine, blood urea nitrogen, and creatinine clearance. The increase in urine insulin concentration in the trauma patients reflected the higher serum insulin concentrations, but no correlation existed between serum insulin and urine insulin concentrations. A negative correlation was found between "insulin clearance" and serum insulin in both groups, indicating altered renal handling of insulin following injury which may be a contributory factor to the relative hypoinsulinemia of trauma.