SHORT PAPERS
Home Parenteral Nutrition in Treatment of Severe Radiation Enteritis DONALD G. MILLER, M.D.; MARIANNE IVEY, RPh; and JEFFRY YOUNG, M.D.; Seattle, Washington
Ten patients with radiation enteritis unresponsive to conventional medical and surgical therapy were put on long-term parenteral nutrition at home. Six of the patients are alive at home; four patients died, two from recurrent cancer. Some of the patients have been able to resume oral intake, but none have been able to discontinue parenteral nutrition. Fistulas healed or had a marked decrease in output. Two patients in our series were given prednisone and sulfasalazine without significant benefit, in contrast to previously reported clinical improvement of radiation enteritis with this therapy.
Each 2-L bottle provides 2040 nonprotein calories and 100 g protein hydrolysate. The solution was infused via a Holter (Extracorporeal Medical Specialties, Inc.; King of Prussia, Pennsylvania) or an I M E D (San Diego, California) pump through a permanent indwelling silastic catheter, such as a Broviac catheter or a Hickman catheter (EVERMED; Seattle, Washington). The catheter was filled with 1.5 to 2.0 mL of heparin, 1000 U / mL, and capped when the patient was not being infused. The patient was responsible for the entire technique, including mixing the parenteral nutrition solution. Details are provided in earlier articles (5, 6).
IN R E C E N T Y E A R S r a d i a t i o n t h e r a p y h a s b e e n u s e d for a n u m b e r o f abdominal a n d pelvic carcinomas, including cervical carcinoma, transitional cell c a r c i n o m a o f t h e bladder, a n d a d e n o c a r c i n o m a o f t h e c o l o n . T h e u s e o f radiation therapy, either as an adjunct t o surgery or as a primary therapy, h a s resulted in an increased cure rate. H o w e v e r , along w i t h this success h a v e been c o m p l i c a tions resulting from t h e radiation therapy. A m o n g these has been t h e reported 1 % t o 2 % incidence o f radiation injury t o t h e small intestine ( 1 , 2 ) . I n m a n y cases t h e s y m p t o m s o f radiation enteritis are transient. I n other cases these s y m p t o m s are m o r e chronic. T h e r e h a v e been reports o f i m p r o v e m e n t w i t h sulfasalazine a n d steroid therapy ( 3 ) . S o m e o f these patients d e v e l o p persistent s y m p t o m s o f intestinal obstruction a n d u n d e r g o successful intestinal resection or bypass surgery ( 2 , 4 ) . A minority o f patients w i t h radiation enteritis d e v e l o p chronic nausea, vomiting, diarrhea, or w e i g h t loss, o r a c o m b i n a tion o f these despite conventional medical or surgical m a n a g e m e n t . A t o u r institution a n u m b e r o f s u c h patients h a v e been treated successfully w i t h h o m e parenteral nutrition.
Case Histories Three representative case histories are as follows.
Materials and Methods All patients with radiation enteritis started on home parenteral nutrition from January 1970 through November 1978 were followed up. Patient characteristics are given in Table 1. There were 10 patients whose ages ranged from 41 to 72 years. There were three men and seven women. Patients were followed up on home parenteral nutrition from 1 to 52 months (average, 15.7 months). N o patients were lost to follow-up. The patients infused 2 L of parenteral nutrients during a 10- to 12-h period at night. The nutrient solution consisted of 1L 6 0 % dextrose, 1L 10% protein hydrolysate (or 1L 8.5% amino acid solution), and the necessary electrolytes, vitamins, and minerals. Trace metals and intravenous fat emulsion were used when necessary. • From the Departments of Medicine and Pharmacy, University of Washington; Seattle, Washington. 858
Annals of Internal Medicine. 1979;91:858-860.
PATIENT 1
A 54-year-old white woman had malabsorption and intractable high ileostomy output from radiation enteritis. The patient was well until May 1977, when she had a left hemicolectomy and left ureterostomy for adenocarcinoma of the left colon adherent to the iliac vessels and the left ureter. Then, in June 1977 the patient received 5000 rad to the abdomen. Profuse diarrhea, crampy abdominal pain, and vomiting developed. In February 1978, because of intestinal obstruction, an ileostomy was done. Postoperatively the patient lost weight. She also had an ileostomy output of 2 to 3 L/d. An upper gastrointestinal and small bowel series showed two more stenotic ileal segments and a 15min transit time through the bowel. She was referred to the University of Washington in April 1978 for institution of home parenteral nutrition. The patient was sent home on 2 L home parenteral nutrition and 2 L saline/d. The patient's weight has increased since that time from 56.7 to 65.0 kg. Because of her obesity, home parenteral nutrition has been decreased to three times a week. She continues to infuse 2 L of normal saline daily. PATIENT 2
A 42-year-old white woman had weight loss and enterocutaneous fistulas secondary to radiation enteritis. In September 1970 she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for serous cystadenoma of the left ovary metastatic to the uterus and right ovary. Postoperatively the patient received radiation therapy, 5000 rad to the abdomen and also intraperitoneal 32 P. In January 1971, the patient began experiencing crampy epigastric pain. In June 1971, she had a laparotomy for perforation of the ileum. The operation was complicated by a pelvic abscess and an enterocutaneous fistula. Later she was started on prednisone and sulfasalazine without any benefit, losing 14 kg between July and October 1971. At that time proctoscopy and gastrointestinal roentgenograms showed changes typical of radiation enteritis. In February 1972, because of continued weight loss and gastrointestinal bleeding, she was started on home parenteral nutrition. The patient died 7 months later of recurrent ovarian carcinoma. PATIENT 3
A 72-year-old white woman had an oopherectomy in December 1976 for grade II granulosis cell carcinoma of the ovary. This was followed by radiation therapy (4500 rad), at which ©1979 American College of Physicians
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Table 1 . Patient Characteristics Patient
Age
Sex
Operations Before Home Parenteral Nutrition
Malignancy
Radiation Treatment
yrs
rad
1
65
M
2
52
F
3 4 5
54 61 41
F M F
6
42
F
7
62
F
8 9
72 60
F F
10
55
M
Transitional cell bladder (3/75). Prostate
Cystectomy with ileal conduit; bilateral lymphadectomy Radical prostatectomy; small bowel resection (0.76 m 7/75 4000 jejunum left) Cervical (1974) Total abdominal hysterectomy, bilateral oophorectomy; colectomy with ileostomy; resection enterovaginal 1975 6000 fistula 6/77 5000 Colon (5/77) Hemicolectomy, left ureterectomy ileal resection Transitional cell bladder (7/75) Exploratory laporotomy 7/76 6000 Colon (1971) Total abdominal hysterectomy, bilateral oophorectomy; left colectomy, resection dome of bladder, 1975 5500 ileotransverse colectomy, bilateral ureostomy Total abdominal hysterectomy, bilateral oophorecOvary (9/70) (serous cystadenoma) tomy; exploratory laporotomy 9/70 5000, 32 P Transitional cell (8/60) bladder Cystectomy with ileal conduit. Inguinal node biopsy, 6/63 6000 small bowel resection (0.51 m small bowel left) 1/77 4500 Ovary (10/76) (granulosa cell) Hysterectomy and resection right ovary Vulva (11/74) Hysterectomy, radical vulvectomy, colectomy with 11/74 5000 colostomy Transitional cell (3/74) bladder; renal cell Cystectomy with ileal conduit. Left heminephrectomy. 6/76 6000 Resection 45 cm ileum
time she started having abdominal cramping, diarrhea, nausea, and vomiting. In June 1977, a laparotomy showed a diffusely thickened atonic small bowel compatible with radiation enteritis. There was no evidence of tumor. The patient was tried on tube feedings and elemental diets, but symptoms and weight loss continued. She was sent, therefore, to the University of Washington for home parenteral nutrition. In June 1977 she was discharged on home parenteral nutrition, 2 L seven times a week. This was reduced later to five times a week, and the patient has maintained her weight on that regime. Results and Comment The results are summarized in Table 2. Of the 10 patients reported here, six are alive and at home. Three of these six patients have not required any further hospitalization (Patients 3, 8, 9). Two patients died of recurrent carcinoma and one from an aspiration pneumonia (after a cerebrovascular accident). At the time of death, the third patient was known to have recurrent carcinoma. The
fourth patient died of ischemic bowel necrosis and pneumonia. All patients who died did so within 1 year of starting home parenteral nutrition. None of the patients who survived more than 1 year from the start of home parenteral nutrition has any evidence of recurrent tumor. The average duration of home parenteral nutrition was 15.7 months (1 to 52 months). The average weight gains and rise in serum albumin were 8.7 kg (-2.1 to 15.0 kg) and 0.44 g/dL (-0.3 to 1.0 mg/dL), respectively. Although some patients have resumed oral intake, none has been able to discontinue parenteral nutrition. Fistula drainage decreased in all patients, but the fistulas did not completely heal in any (five patients). Sulfasalazine and steroids have been described as beneficial in patients with radiation enteritis (3). One patient received sulfasalazine and prednisone with a reported improvement but then had recurrent symptoms requiring parenteral nutrition. A second patient did not respond to
Table 2 . Home Parenteral Nutrition in Patients with Radiation Enteritis*
Pateint Start of Duration Infusions Height HPN of HPN
Weight Initial
1
11/75
mos. 12
no./wk 7
cm 187
2 3 4 5 6 7 8 9 10
2/77 4/78 3/78 3/76 1/72 6/74 6/77 4/78 9/75
20 6 1 31 10 52 16 6 3
4 4 7 4 7
165 170 173 161
3i
170 170 165
5 4 7
Final kg
56.7 37.5 56.7 63.6 39.5 43.6 33.4 61.0 32.5 61.0
54.0 (61.8)t 49.0 68.0 61.5 54.5 45.0 65.0 46.4
Albumin
SGOT
Alkaline Phosphatase
U/L 10
U/L 73
Death
Initial Final g/dL 3.4 2.8 4.2 3.2 3.2 3.1 3.2 2.8 2.8 4.1 2.9
4.7 4.0 3.5 2.9 3.6 3.8 3.8
30 51 35 15 10 38 13
139 137 148 64 138 73 140 246 211
11/76 lung cancer ? metastatic 4/78 CVA, pneumonia 11 /72 ovarian cancer
12/75 ischemic bowel necrosis, penumonia
* HPN = home parenteral nutrition; SGOT = serum glutamic-oxalacetic transaminase; CVA = cerebrovascular accident, t Highest weight achieved by patient. Miller eta/.
• Parenteral Nutrition for Radiation Enteritis
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859
sulfasalazine and prednisone, and a third patient did not respond to steroid therapy. Our experience indicates that home parenteral nutrition offers a selected group of patients with severe radiation enteritis a means of improving nutrition as manifested by a weight gain and an increase in serum albumin level. None of these patients were able to maintain their weight even with elemental diets before starting home parenteral nutrition. Recurrent cancer is a major cause of early mortality. In contrast to an earlier report (2), none of the patients here benefited from prednisone or sulfasalazine, or both. A C K N O W L E D G M E N T S : Grant support: Dr. Miller was supported in part by a Fellowship from the American College of Physicians and by the McGaw Laboratories. • Requests for reprints should be addressed to Jeffry Young, M.D.; Division
860
Annals of Internal Medicine. 1979;91:860-862.
of Kidney Diseases, RM-11, Department of Medicine, University of Washington School of Medicine; Seattle, WA 98195. Received 3 April 1979; revision accepted 31 August
1979.
References 1. G R A H A M JB, VILLALBA RJ. Damage to the small intestine by radiotherapy. Surg Gynec Obstet. 1963;116:665-8. 2. P A L M E R JA, BUSH RS. Radiation injuries to the bowel associated with the treatment of carcinoma of the cervix. Surgery. 1976;80:458-64. 3. GOLDSTEIN F, K H O U R Y J, T H O R N T O N JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids. Am J Gastroenterol. 1976;65:201-8. 4. S W A N RW, F O W L E R WC J R , B O R O N O W R C . Surgical management of
radiation injury to the small intestine. Surg Gynec Obstet. 1976; 142:3257. 5. R A U L T RM, SCRIBNER BH. Parenteral nutrition in the home. In: G L A S S GB, ed. Progress in Gastroenterology. Vol. 3. New York: Grune & Stratton; 1977: 545-62. 6. IVEY M, SCRIBNER BH, M I L L E R DG. Home Parenteral Nutrition Instruction Manual. 2nd ed. Seattle: University of Washington, Department of Hospital Pharmacy; 1979.
©1979 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19553/ by a University of California San Diego User on 02/09/2017
Home Parenteral Nutrition in Treatment of Severe Radiation Enteritis DONALD G. MILLER, M.D.; MARIANNE IVEY, RPh; and JEFFRY YOUNG, M.D.; Seattle, Washington
Ten patients with radiation enteritis unresponsive to conventional medical and surgical therapy were put on long-term parenteral nutrition at home. Six of the patients are alive at home; four patients died, two from recurrent cancer. Some of the patients have been able to resume oral intake, but none have been able to discontinue parenteral nutrition. Fistulas healed or had a marked decrease in output. Two patients in our series were given prednisone and sulfasalazine without significant benefit, in contrast to previously reported clinical improvement of radiation enteritis with this therapy.
Each 2-L bottle provides 2040 nonprotein calories and 100 g protein hydrolysate. The solution was infused via a Holter (Extracorporeal Medical Specialties, Inc.; King of Prussia, Pennsylvania) or an I M E D (San Diego, California) pump through a permanent indwelling silastic catheter, such as a Broviac catheter or a Hickman catheter (EVERMED; Seattle, Washington). The catheter was filled with 1.5 to 2.0 mL of heparin, 1000 U / mL, and capped when the patient was not being infused. The patient was responsible for the entire technique, including mixing the parenteral nutrition solution. Details are provided in earlier articles (5, 6).
IN R E C E N T Y E A R S r a d i a t i o n t h e r a p y h a s b e e n u s e d for a n u m b e r o f abdominal a n d pelvic carcinomas, including cervical carcinoma, transitional cell c a r c i n o m a o f t h e bladder, a n d a d e n o c a r c i n o m a o f t h e c o l o n . T h e u s e o f radiation therapy, either as an adjunct t o surgery or as a primary therapy, h a s resulted in an increased cure rate. H o w e v e r , along w i t h this success h a v e been c o m p l i c a tions resulting from t h e radiation therapy. A m o n g these has been t h e reported 1 % t o 2 % incidence o f radiation injury t o t h e small intestine ( 1 , 2 ) . I n m a n y cases t h e s y m p t o m s o f radiation enteritis are transient. I n other cases these s y m p t o m s are m o r e chronic. T h e r e h a v e been reports o f i m p r o v e m e n t w i t h sulfasalazine a n d steroid therapy ( 3 ) . S o m e o f these patients d e v e l o p persistent s y m p t o m s o f intestinal obstruction a n d u n d e r g o successful intestinal resection or bypass surgery ( 2 , 4 ) . A minority o f patients w i t h radiation enteritis d e v e l o p chronic nausea, vomiting, diarrhea, or w e i g h t loss, o r a c o m b i n a tion o f these despite conventional medical or surgical m a n a g e m e n t . A t o u r institution a n u m b e r o f s u c h patients h a v e been treated successfully w i t h h o m e parenteral nutrition.
Case Histories Three representative case histories are as follows.
Materials and Methods All patients with radiation enteritis started on home parenteral nutrition from January 1970 through November 1978 were followed up. Patient characteristics are given in Table 1. There were 10 patients whose ages ranged from 41 to 72 years. There were three men and seven women. Patients were followed up on home parenteral nutrition from 1 to 52 months (average, 15.7 months). N o patients were lost to follow-up. The patients infused 2 L of parenteral nutrients during a 10- to 12-h period at night. The nutrient solution consisted of 1L 6 0 % dextrose, 1L 10% protein hydrolysate (or 1L 8.5% amino acid solution), and the necessary electrolytes, vitamins, and minerals. Trace metals and intravenous fat emulsion were used when necessary. • From the Departments of Medicine and Pharmacy, University of Washington; Seattle, Washington. 858
Annals of Internal Medicine. 1979;91:858-860.
PATIENT 1
A 54-year-old white woman had malabsorption and intractable high ileostomy output from radiation enteritis. The patient was well until May 1977, when she had a left hemicolectomy and left ureterostomy for adenocarcinoma of the left colon adherent to the iliac vessels and the left ureter. Then, in June 1977 the patient received 5000 rad to the abdomen. Profuse diarrhea, crampy abdominal pain, and vomiting developed. In February 1978, because of intestinal obstruction, an ileostomy was done. Postoperatively the patient lost weight. She also had an ileostomy output of 2 to 3 L/d. An upper gastrointestinal and small bowel series showed two more stenotic ileal segments and a 15min transit time through the bowel. She was referred to the University of Washington in April 1978 for institution of home parenteral nutrition. The patient was sent home on 2 L home parenteral nutrition and 2 L saline/d. The patient's weight has increased since that time from 56.7 to 65.0 kg. Because of her obesity, home parenteral nutrition has been decreased to three times a week. She continues to infuse 2 L of normal saline daily. PATIENT 2
A 42-year-old white woman had weight loss and enterocutaneous fistulas secondary to radiation enteritis. In September 1970 she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for serous cystadenoma of the left ovary metastatic to the uterus and right ovary. Postoperatively the patient received radiation therapy, 5000 rad to the abdomen and also intraperitoneal 32 P. In January 1971, the patient began experiencing crampy epigastric pain. In June 1971, she had a laparotomy for perforation of the ileum. The operation was complicated by a pelvic abscess and an enterocutaneous fistula. Later she was started on prednisone and sulfasalazine without any benefit, losing 14 kg between July and October 1971. At that time proctoscopy and gastrointestinal roentgenograms showed changes typical of radiation enteritis. In February 1972, because of continued weight loss and gastrointestinal bleeding, she was started on home parenteral nutrition. The patient died 7 months later of recurrent ovarian carcinoma. PATIENT 3
A 72-year-old white woman had an oopherectomy in December 1976 for grade II granulosis cell carcinoma of the ovary. This was followed by radiation therapy (4500 rad), at which ©1979 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19553/ by a University of California San Diego User on 02/09/2017
Table 1 . Patient Characteristics Patient
Age
Sex
Operations Before Home Parenteral Nutrition
Malignancy
Radiation Treatment
yrs
rad
1
65
M
2
52
F
3 4 5
54 61 41
F M F
6
42
F
7
62
F
8 9
72 60
F F
10
55
M
Transitional cell bladder (3/75). Prostate
Cystectomy with ileal conduit; bilateral lymphadectomy Radical prostatectomy; small bowel resection (0.76 m 7/75 4000 jejunum left) Cervical (1974) Total abdominal hysterectomy, bilateral oophorectomy; colectomy with ileostomy; resection enterovaginal 1975 6000 fistula 6/77 5000 Colon (5/77) Hemicolectomy, left ureterectomy ileal resection Transitional cell bladder (7/75) Exploratory laporotomy 7/76 6000 Colon (1971) Total abdominal hysterectomy, bilateral oophorectomy; left colectomy, resection dome of bladder, 1975 5500 ileotransverse colectomy, bilateral ureostomy Total abdominal hysterectomy, bilateral oophorecOvary (9/70) (serous cystadenoma) tomy; exploratory laporotomy 9/70 5000, 32 P Transitional cell (8/60) bladder Cystectomy with ileal conduit. Inguinal node biopsy, 6/63 6000 small bowel resection (0.51 m small bowel left) 1/77 4500 Ovary (10/76) (granulosa cell) Hysterectomy and resection right ovary Vulva (11/74) Hysterectomy, radical vulvectomy, colectomy with 11/74 5000 colostomy Transitional cell (3/74) bladder; renal cell Cystectomy with ileal conduit. Left heminephrectomy. 6/76 6000 Resection 45 cm ileum
time she started having abdominal cramping, diarrhea, nausea, and vomiting. In June 1977, a laparotomy showed a diffusely thickened atonic small bowel compatible with radiation enteritis. There was no evidence of tumor. The patient was tried on tube feedings and elemental diets, but symptoms and weight loss continued. She was sent, therefore, to the University of Washington for home parenteral nutrition. In June 1977 she was discharged on home parenteral nutrition, 2 L seven times a week. This was reduced later to five times a week, and the patient has maintained her weight on that regime. Results and Comment The results are summarized in Table 2. Of the 10 patients reported here, six are alive and at home. Three of these six patients have not required any further hospitalization (Patients 3, 8, 9). Two patients died of recurrent carcinoma and one from an aspiration pneumonia (after a cerebrovascular accident). At the time of death, the third patient was known to have recurrent carcinoma. The
fourth patient died of ischemic bowel necrosis and pneumonia. All patients who died did so within 1 year of starting home parenteral nutrition. None of the patients who survived more than 1 year from the start of home parenteral nutrition has any evidence of recurrent tumor. The average duration of home parenteral nutrition was 15.7 months (1 to 52 months). The average weight gains and rise in serum albumin were 8.7 kg (-2.1 to 15.0 kg) and 0.44 g/dL (-0.3 to 1.0 mg/dL), respectively. Although some patients have resumed oral intake, none has been able to discontinue parenteral nutrition. Fistula drainage decreased in all patients, but the fistulas did not completely heal in any (five patients). Sulfasalazine and steroids have been described as beneficial in patients with radiation enteritis (3). One patient received sulfasalazine and prednisone with a reported improvement but then had recurrent symptoms requiring parenteral nutrition. A second patient did not respond to
Table 2 . Home Parenteral Nutrition in Patients with Radiation Enteritis*
Pateint Start of Duration Infusions Height HPN of HPN
Weight Initial
1
11/75
mos. 12
no./wk 7
cm 187
2 3 4 5 6 7 8 9 10
2/77 4/78 3/78 3/76 1/72 6/74 6/77 4/78 9/75
20 6 1 31 10 52 16 6 3
4 4 7 4 7
165 170 173 161
3i
170 170 165
5 4 7
Final kg
56.7 37.5 56.7 63.6 39.5 43.6 33.4 61.0 32.5 61.0
54.0 (61.8)t 49.0 68.0 61.5 54.5 45.0 65.0 46.4
Albumin
SGOT
Alkaline Phosphatase
U/L 10
U/L 73
Death
Initial Final g/dL 3.4 2.8 4.2 3.2 3.2 3.1 3.2 2.8 2.8 4.1 2.9
4.7 4.0 3.5 2.9 3.6 3.8 3.8
30 51 35 15 10 38 13
139 137 148 64 138 73 140 246 211
11/76 lung cancer ? metastatic 4/78 CVA, pneumonia 11 /72 ovarian cancer
12/75 ischemic bowel necrosis, penumonia
* HPN = home parenteral nutrition; SGOT = serum glutamic-oxalacetic transaminase; CVA = cerebrovascular accident, t Highest weight achieved by patient. Miller eta/.
• Parenteral Nutrition for Radiation Enteritis
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19553/ by a University of California San Diego User on 02/09/2017
859
sulfasalazine and prednisone, and a third patient did not respond to steroid therapy. Our experience indicates that home parenteral nutrition offers a selected group of patients with severe radiation enteritis a means of improving nutrition as manifested by a weight gain and an increase in serum albumin level. None of these patients were able to maintain their weight even with elemental diets before starting home parenteral nutrition. Recurrent cancer is a major cause of early mortality. In contrast to an earlier report (2), none of the patients here benefited from prednisone or sulfasalazine, or both. A C K N O W L E D G M E N T S : Grant support: Dr. Miller was supported in part by a Fellowship from the American College of Physicians and by the McGaw Laboratories. • Requests for reprints should be addressed to Jeffry Young, M.D.; Division
860
Annals of Internal Medicine. 1979;91:860-862.
of Kidney Diseases, RM-11, Department of Medicine, University of Washington School of Medicine; Seattle, WA 98195. Received 3 April 1979; revision accepted 31 August
1979.
References 1. G R A H A M JB, VILLALBA RJ. Damage to the small intestine by radiotherapy. Surg Gynec Obstet. 1963;116:665-8. 2. P A L M E R JA, BUSH RS. Radiation injuries to the bowel associated with the treatment of carcinoma of the cervix. Surgery. 1976;80:458-64. 3. GOLDSTEIN F, K H O U R Y J, T H O R N T O N JJ. Treatment of chronic radiation enteritis and colitis with salicylazosulfapyridine and systemic corticosteroids. Am J Gastroenterol. 1976;65:201-8. 4. S W A N RW, F O W L E R WC J R , B O R O N O W R C . Surgical management of
radiation injury to the small intestine. Surg Gynec Obstet. 1976; 142:3257. 5. R A U L T RM, SCRIBNER BH. Parenteral nutrition in the home. In: G L A S S GB, ed. Progress in Gastroenterology. Vol. 3. New York: Grune & Stratton; 1977: 545-62. 6. IVEY M, SCRIBNER BH, M I L L E R DG. Home Parenteral Nutrition Instruction Manual. 2nd ed. Seattle: University of Washington, Department of Hospital Pharmacy; 1979.
©1979 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19553/ by a University of California San Diego User on 02/09/2017
