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The malnourishing effects of cancer and its treatments haveprovided a strong clinical incentive for the nutritional support of cancer patients with intravenous hyperalimentation (IVH), but potential enhancement of tumor growth by additional substrate provision has generated concern. Twenty-five patients undergoing surgical treatment for gastrointestinal cancer were studied on one of two preoperative dietary regimens: ad libitum oral diet or intravenous hyperalimentation. Using a stable isotope tracer, N-glycine, in vivo tissue fractional protein synthesis rates were determined from operative specimens of tumor and normal gastrointestinal tissue. Despite substantial advantage in caloric and protein intake, and nitrogen retention, tumors in IVH-fed patients were synthesizing protein no faster (14.2%/day) than those in orally fed patients (15.1/day). Tumor fractional protein synthesis rates (PSRs) correlated (r = + 0.708, P less than 0.005) with the PSR of the tissues from which they arose. IVH maintained gut PSR at the level occurring in the orally fed patients. Parenteral nutritional support in cancer patients does not maintain protein synthesis rates at levels greater than those present with regular oral diets. Although not a direct measure of tumor growth, these data provide preliminary evidence that optimal nutritional support of the cancer patient may be possible without undesirable stimulation of tumor growth.

The substantial prevalence of malnutrition in the hospitalized patient population has only been recently recognized. Preoperative nutritional and immunological assessment was performed prospectively on admission in 64 consecutive surgical patients. Factors measured included weight loss, triceps skinfold, midarm muscle circumference, creatinine-height index, serum albumin level, serum transferrin level, total lymphocyte count, serum complement level, serum immunoelectrophoresis, lymphocyte T rosettes formation, neutrophil migration, and delayed hypersensitivity. Using these criteria for malnutrition, 97% of the patients had at least one abnormal measurement and 35% had at least three abnormal measurements. Patients were monitored for complications during their hospital course. Serum albumin level, serum transferrin level, and delayed hypersensitivity reactions were the only accurate prognostic indicators of postoperative morbidity and mortality. Substantial unrecognized malnutrition exists in the surgical patient population. An isolated indicator of malnutrition should be interpreted with caution. The visceral protein compartment (serum albumin and serum transferrin levels and delayed hypersensitivity) is the most accurate prognostic indicator of postoperative morbidity and mortality. Perioperative nutritional support may reduce operative morbidity and mortality in the malnourished operative candidate.

Kraske's methodology was classic: develop the operation in the laboratory, try it initially on patients as a last resort and, if it works, expand its use to patients with less severe disease. His operation immediately gained acceptance and was popular for the next quarter of a century. It was subsequently modified by Hochenagg, Billroth and Rydygier. These men merely altered the amount or manner of sacral removal. The operation was largely abandoned after Miles (3) showed that the lymphatic spread from carcinoma of the rectum is toward the liver. Kraske's procedure, however, stands as a landmark in preantibiotic operations on the colon. Combined with abdominal exploration, this type of procedure can be used to preserve the anus in certain instances of carcinoma of the rectum today.

Balloon-catheter dilation of arterial stenoses and/or occlusions has been found to be helpful when used both as an adjunct to arterial surgery and as definitive treatment. Used preoperatively, it enables the extent of surgery to be limited and may improve the patient's general condition and ability to undergo surgery; such is seen when renal or mesenteric vessels are dilated preoperatively. During surgery, it can be used to augment the surgery, particularly in an area that is difficult to expose or out of the operative field. Postoperatively, it is often useful in maintaining patency of a graft or its inflow and outflow tract. Judicious use of this modality can enhance arterial surgery and improve results.

The case report of a patient presenting with inferior vena caval obstruction secondary to ruptured abdominal aortic aneurysm is presented. The cause of the obstruction was not diagnosed prior to laparotomy. Management included replacement of the aneurysm, plication of the thrombosed inferior vena cava, and evacuation of the hematoma. So far as the authors are aware, this is the first case of this type to be reported and one which adds another possible diagnostic consideration in managing inferior vena caval obstruction.