1. To establish the speed on onset of jejunal and ileal mucosal hypoplasia and hypofunction in parenterally fed rats, we measured three indices of mucosal mass, three mucosal enzymes and quantitative histology after 3, 6, 10 and 15 days of total parenteral nutrition and compared the results with those in two orally fed control groups, one with and one without intravenous catheters and metabolic cage restraint. The kinetics of galactose absorption in vivo were also measured after 10 days of total parenteral nutrition and in both control groups. 2. The most striking decrease in both jejunal and ileal mucosal wet weight and protein and DNA content per 10 cm length of intestine, occurred after only 3 days of total parenteral nutrition; thereafter the mean values showed only a slight further decrease. 3. The results of the morphometric studies showed that the hypoplasia affected the villi slightly more than the crypts. Within 3 days of starting total parenteral nutrition, mean jejunal mucosal thickness decreased by 16% and after 15 days it had fallen by 28%. The ileum showed similar, although less marked, changes. In the jejunum (not the ileum) modest cellular hypotrophy accompanied the mucosal hypoplasia; there were more epithelial cells/unit length of mid-villus and there was more DNA per g of mucosa in the total parenteral nutrition group than in the control group of rats. 4. Jejunal galactose absorption from the 16, 32 and 64 mmol/l solutions was significantly less in the 10-day total parenteral nutrition rats than in the controls, the apparent Vmax. being five times greater in the orally fed animals. The apparent Michaelis constant (Km) was also significantly less than normal in the jejunum of the parenterally fed rats, suggesting increased affinity of the hypothetical carrier for galactose, perhaps as a result of functionally hypermature cells. 5. Mucosal alkaline phosphatase and catalase activities per unit length of intestine decreased and alpha-D-glucosidase activity increased in the jejunum and ileum of the total parenteral nutrition rats. 6. These results show that during total parenteral nutrition, the ileum and particularly the jejunum show marked reductions in mucosal mass and function after only 3 days of total parenteral nutrition and that there is a more gradual and progressive loss of mucosal mass thereafter up to 15 days.

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Hypothesis:The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial demonstrated that a greater benefit from carotid endarterectomy (CEA) was seen in elderly compared with younger patients. However, no patients older than 89 years were included in either study. We hypothesized that CEA is safe and effective in patients 89 years and older.Design and Setting: This is a retrospective review of 3 neurosurgeons' CEA experience with nonagenarian patients.Participants and Interventions: Of our 1800 patients who underwent CEA, 26 were 89 years or older. Twenty-three patients had had cerebral ischemic symptoms (unilateral hemispheric symptoms in 21 and 2 dizzy spells associated with bilateral high-grade stenosis). Cerebral angiography was performed in 3 patients. Twentythree patients underwent noninvasive imaging. Four patients had bilateral high-grade stenosis and underwent staged bilateral CEA. All procedures were performed after the induction of general anesthesia with electroencephalographic (and, more recently, transcranial Doppler) monitoring and etomidate-induced burst suppression for cerebral protection during cross-clamping.Results: Unusual technical difficulties were frequently noted, including high bifurcations, looping rotated internal carotid arteries, and marked adherence of surrounding soft tissues. In 3 of the 30 procedures, a shunt was used. There were no perioperative cerebral ischemic or cardiac events. The mean hospital stay was 2 days. One patient had a transient vocal cord paresis. Twentytwo patients were alive and well 24 months following the procedure. Four patients died of non-stroke-related causes.Conclusions: Carotid endarterectomy was successfully performed without perioperative cerebral or cardiac complications in our series of 26 patients 89 years and older undergoing 30 CEAs. Extrapolating from reported results from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial, we believe CEA should be considered in nonagenarian patients with high-grade symptomatic carotid stenosis who are otherwise well medically. Our recommendations are less certain in the case of asymptomatic disease.