Parenteral administration of medium-, but not long-chain lipid emulsions, modulates human neutrophil and mononuclear cell counts

modulation of leukocyte populations suggests that MCT-containing emulsions, in contrast with pure LCT, elicit an immune response in humans. The fact that lipid effects on the function of peripherally sampled neutrophils were not observed might be due to the selective disappearanceof activated leukocytesfrom the circulation, thus explaining the contradicting results of previous in vivo and vitro studies.

1361 Percutaneous Trans-Esophageal Gastro-tubing:A New Technique of Enteral Nutrition for Cases with Difficult Status to Create PercutaneousEndoscopicGastrostomy Hideto Oishi, Hironari Shindou, Aoyama Hosp, Tokyo Women's Medical Univ, Tokyo Japan; Noriyasu Shirotani, Shingo Kameoka,Tokyo Women's Medical Univ, Tokyo Japan PURPOSE: We established a less invasive method of esophagostomy with a rupture-free balloon: RFBwhich we inventedto be used in conjunction with PercutaneousTrans-Esophageal Castro-tubing: PTEG.PTEGwith RFBallows the surgeonto createan esophagostomysafelyand simply even in cases with complicationsthat would make it difficult to create a Percutaneous Endoscopic Gastrostomy: PEG. METHOD/MATERIALS:The control group consisted of eleven patients who underwent an esophagostomyby PTEGwith a normal balloon from October 1994 to May 1997. Thirteen cases were done with a regular balloon catheter to dilate the gastrointestinal tract in place of an RFB for PTEGfrom June 1997 to December 1997 as a preliminary study. This prospective study was based on fifty patients with informed consent for PTEO,who underwent the PTEGprocedure with the RFB, invented in January 1998, and who neededan indwelling catheterfor feedingfor a long term, from January 1998 to December 2000. 1. Insert an RFB through the nose into the esophagus and inflate it. 2. Puncture the RFB percutaneouslyaided by uitrasonography.3. Insert a guide wire. 4. Insert a dilator with a sheath.5. Insert an indwelling catheterinto the digestivetract through the sheath. RESULTS: We treated fifty patients by creating an esophagostomywith PTEGwith an RFB without any major trouble as might occur when creating a PEG. This method only took about fifteen minutes. The averageperiods for the indwelling catheterare 146.5+_103.0days.The Indwelling catheter may be used for the long term affording easy maintenanceat the bedsideand home care. The patients' complaints subsided, and the quality of life was improved for them all. CONCLUSIONS:When it is difficult to create a PEG, PTEGwith RFB is a safe, simple and less invasive method than PEG and just as effective.

1364 Parenteral Administration of Medium-, But Not Long-Chain Lipid Emulsions, Increases the Risk for Infections by Candida Albicans. Geert J. Wanten, Mihai G. Netea,Ton H. Naber, Jo H. Curfs, Liesbeth Jasobs, Trees Verver-Jansen, Bart-Jan Kullberg, Univ Medical Ctr St Radboud, Nijmegen Netherlands It remains unclear whether lipid emulsions contribute to the increased risk for infectious complicatons that is associatedwith the use of total parenteralnutrition (TPN). We evaluated structurally different lipids for their effects on two important aspects of the pathogenesisof infections by the fungal pathogen Candidaalbicans: i) yeast growth and it) the balance of pro- and anti-inflammatory cytokines, which trigger the innate immune system, the major component of the anti-fungal defense. Emulsions containing long-chain triglycerides (LCT), mixed long- and medium-chaintriglycerides (LCT/MCT)or placebo(saline) were administered to eight volunteers in a crossover study design. A triglyceride clamp was set up to stabilize plasma concentrationsat a physiological concentration of 3-5 retool/L, seen with the clinical use of TPN. Before and after four hours of lipid administration, growth of Candida in cellfree serum and Candida-inducedex vivo cytokine production by peripheralblood mononuclear cells, both preparedfrom venous whole blood of study subjects, were evaluated.The growth of Candida in serum samples increasedat least nine-fold after administration of LCT/MCT, while LOT showed no effect comparedwith placebo.When comparedwith placebo, LCT/MCT, contrary to LCT, also significantly modulated the Candida-induced production of various cytokines by mononuclearcells in a way that favors fungal infections (increased production of tumor necrosis factor-u, interleukins-lft,-6, -8 and -10, decreasedproduction of interferon~,). The results of the present study suggest that parenteral administrationof MCT-containing lipid emulsions, contrary to pure LCT, increasesthe risk for infections by Candidaalbicans.

1362 Perioperative Parenteral Nutrition: A Meta-analysis. Ronald L. Koretz, Olive View-UCLA Medical Ctr, Sylmar, CA; Timothy O. Lipman, Veterans Affairs Medical Ctr, Washington, OC; Samuel Klein, Washington Univ Sch of Medicine, St. Louis, MO

1365

Objective:To assessthe efficacy of perioperativeparenteralnutrition (PN) on clinical outcome (mortality, morbidity, or duration of hospitalization) Methods: Meta-analysisof randomized controlled trials (RCTs)meetingthe following criteria: 1) study group receivedPN (intravenous nitrogen source and >10 kcal/kg/d non-nitrogenous calories) 2) control group received no more nutritional support than food ad lib and/or 5% dextrose as maintenancefluid 3) RCT reported -> 1 clinical outcome. The analysis employed Cochrane Collaboration software (Revman 4.0.4, MetaView 3.1, random effects model). Results: 41 RCTs were identified. In many trials, patients believedto be "severely malnourished" were not included. The various outcomes are summarized in the table. Subgroup analyses indicated: 1) Modest reductions in total complication rates were associated with the use of PN solutions containing lipid or when PN was provided to nonmalnoorishedpatients. 2) PreoperativePN reduced the major complication rate by 8% (CI -14%, -2%) 3) PN reduced the major complication rate by 18% (Cl -31%, -6%) in patients with upper gastrointestinal (UGI) cancer. Conclusions: 1) Perioperative PN did not effect postoperative survival. 2) PN may decrease postoperative complications, particularly in patients with UGI cancer. 3) The utility of PN in "severely malnourished" patients could not be assessed. Outcome

ARD~

Mortality Complications: Total Infectious Major Wound Intra-abdominal Pneumonia Dur'n hosp'n

0% -6% -2% -3% -2% 0% -2% -O.5d2

95% CI

Splanchnic Haemodinamic in Short Bowel Syndrome (SBS): Color-Doppler Evaluation in Fasting and Post-Prandial Conditions Carla Serra, Lofts Pironi, Cecilia Merit, Antonio Maria Morselli Labate, Laura Volpe, Cristina Morelli, FedericaPaganelli, Mario Miglioli, Dept of Internal Medicine and Gastroenterology, Bologna Italy Background and Objective.The changes in splanchnic blood flow in SBS are unknown.We evaluated the superior mesenteric artery (SMA) and portal vein (PV) blood flow in fasting and postprandial conditions. Methods. A color-Doppler examination (Hitachi EUB 525) of SMA and PV blood flow were performed in 10 adult pts with SBS (Crohn's disease :4 pts; mesenteric ischemia: 5 pts; voivolus:l pts)and in 10 adult healthy controls (C). The following parameters were analyzed immediately before (baseline)and 30,60,90,120 minutes after a standard meal: peak systolic velocity (PSV), end diastolic velocity (EDV), mean velocity (MV), pulcatility index (PI), resistive index (RI) of SMA and MV of PV. Results. SMA. At baseline PSV (P
# RCTs(patients)

-2%, +2%

37 (2164)

-13%, +1% -8%, +3% -9%, +3% -6%, +2% -5%, +4% ~1%,*2% -2.2d, +1.2d

32 (2062) 29 (1612) 22 (1648) 29 (1800) 21 (1375) 23 (1684) 12 (449)

1366 Pediatric Intestinal Transplantation: The Mount Sinai Experience. Arian Tschernia, Mount Sinai Sch of Medicine, New York, NY; Lei Yu, Univ of Maryland, Baltimore, MD; Neal Leteiko, Stuart Kaufman, Thomas Fishbein, Mount Sinai Sch of Medicine, New York, NY

t Absoluterisk difference(Rate~ ~oup-Rate,=~,~) 2Weightedmeandifference

Intestinal transplantation is now an acceptedtherapeutic intervention for the managementof children with intestinal failure unable to tolerate total parenteral nutrition. We report our experience with combined small bowel and liver transplantation as well as isolated bowel transplantation in children. Pediatric patient referred with documented intestinal failure on 65% parenteralnutrition or greater were listed for transplantation. From July 1999 to August 2000, 10 children were transplanted; ages ranged 9 rag. - 18 years, with a median of 125 years. Underlying etiologies included necrotizing enterocolitis (n=t), gastroschisis (n=2), intestinal atresia (n=l), motility disorder including total colonic Hirschsprung's disease (n = 3), volvulus (n = 3) and Gardner's syndrome (1). Out of 10 patients, 3 patients received isolated small bowel grafts and 7 were transplanted with liver-small bowel composite grafts. Overall survival post transplantation was 73%. 2 out of the 3 patients receiving isolated intestinal graft developed graft failure requiring explantation, with one child going on to successful re-transplantation and one being maintained on parenteral nutrition. All patients receivedimmunosuppressionincluding prednisone,tacrotimus and either basiliximab or daclizumab. The last 2 patients of this group also received rapamycin, which is currently part of our protocol. Enteral feeds were started on average on postoperative day 5 (range: 1-12 days). The meantime to discontinuation of total parenteralnutrition was 44 days (range: 2370 days). Although patients with isolated bowel transplantation seemed to progress faster towards full enteralfeeds, no statistical differencewas detected.Partial hydrolysateand amino acid based formulas were used when initiating feeds, with no difference detected in mean time to full enteralfeeds. In our experience,pediatric small bowel transplantation has become

1363 Parenteral Administration Of Medium-, But Not Long-Chain Lipid Emulsions, Modulates Human Neutrophil And Mononuclear Cell Counts. Geert J. Wanten, Theo B. Geijtenheek,Ton H. Naber, Univ Medical Ctr St Radboud, Nijmegen Netherlands The use of total parenteral nutrition (TPN) is associatedwith an increased risk for infectious complications, mostly due to catheter-relatedproblems. It remains unclear however whether immune-modution by the lipid component of TPN plays a role. To test the hypothesis that structurally different lipid emulsions distinctively modulate human immane responses, we administered emulsions containing long-chain triglycerides (LCT), mixed long- and mediumchain triglycarides (LCT/MCT) or placebo (saline) to eight volunteers in a crossover study design. A triglyceride clamp was set up to stabilize plasma concentrations at a physiological concentration of 3-5 retool/I, seen with the clinical use of TPN. Before and after four hours of lipid administration, leukocytepopulation counts and various aspectsof neutrophil function (production of superoxide and hydrogen peroxyde oxygen radicals, function of/32 integrin adhesion molecules)andphenotype(expressionof adhesion and dngranu[ationmarkers)were evaluated.While LCT had no effect compared with placebo, LCT/MCTsignificantly increased absolute neutrophil counts (+ 114+_47%) and decreasedperipheral blood monunuclearcell counts (-60+_6%), in a lipid-concentrationdependentmanner. None of the emulsions significantly affected functions or phenotype of peripherally sampled neutrophils. The differential

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