The addition of branched chain amino acids (BCAA) to total parenteral nutrition (TPN) solutions of balanced aminoacid composition has been reported to result in improved nitrogen balance, preservation of plasma protein levels, and improved immune function; however, only a few large clinical studies have been performed, yielding conflicting results. We, therefore, studied in a prospective, randomized double blind trial, the effects of BCAA enrichment of an otherwise isonitrogenous and isocaloric TPN solution on plasma protein levels in 101 traumatized and septic patients. TPN-derived nitrogen intake was similar in both study groups. Nitrogen balances in the BCAA group (n = 49) were not different from those in the standard group (n = 52). Plasma total protein levels increased significantly in the standard group resulting in a significant difference between study groups on day 7. Pre-albumin levels increased significantly in the BCAA group and in the standard group. The number of neutrophils (rods) was significantly lower in the standard group compared to the BCAA group on day 7. Lymphocytes increased significantly in the standard group as did the number of platelets, resulting in a significant difference between study groups on day 7. We conclude that BCAA enrichment of standard TPN solutions does not result in more efficient nitrogen metabolism in septic or traumatized patients.
Lanschot JJB, Obertop H. Laparoscopic ultrasonography for staging of gastrointestinal malignancy. Scand J Gastroenterol 1996;31 Suppl 218:4349.Background: Diagnostic laparoscopy has been used frequently as a preoperative staging procedure for different gastrointestinal malignancies. The assessment of solid abdominal organs and retroperitoneal ingrowth or detection of lymph-node metastasis is limited, however. A recent development, laparoscopic ultrasonography, will probably increase the preoperative evaluation of these lesions and thus further improve the preoperative staging. Method: Since 1993 diagnostic laparoscopy combined with laparoscopic ultrasonography has been performed as an additional diagnostic procedure in patients who have already been selected for curative resection of different GI malignancies. In this prospective study, staging after conventional work-up is compared with the tumour stage after laparoscopy. All patients underwent exploratory laparotomy except those with histologically proven metastaseslingrowth. Results: For patients with cancer of the esophagus and gastric cardia (n = 56) the preoperative stage was altered in 17% but laparotomy could only be avoided in 5 % (for a subgroup of patients with a tumour of the gastric cardia laparotomy was avoided in 11%). Additional findings during laparoscopy showed that laparotomy could be avoided in 55% of the patients (n = 44) with primary liver tumours, liver metastasis or proximal bile duct tumours. For patients with pancreatic head tumours (n = 73) the preoperative stage of the tumour changed in 40%; the strategy of treatment was changed in 26% and laparotomy could be avoided in 20%. Conclusions: Laparoscopy combined with laparoscopic ultrasonography is effective (more accurate) in the staging of gastrointestinal malignancies, in particular for patients with liver, biliary and pancreatic tumours. The preoperative tumour stage changed between 15 and 60% for the different gastrointestinal malignancies and laparotomy could be avoided in 5-55%. The procedure is highly operator-dependent and has a learning curve.
Veress needle and trocar-related accidents have caused many surgeons to adopt the Hasson technique for establishment of pneumoperitoneum, but this technique also has drawbacks. A modification of the sharp trocar has been developed that overcomes the disadvantages of the Veress needle and Hasson trocar.
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