Intravenous fluid requirements for patients with permanent end-jejunostomy syndrome often exceeds 3 L/d, making rehabilitation difficult. The effect of the somatostatin analogue, octreotide (100 micrograms TID, subcutaneously) in reducing requirements was measured in 10 patients established on home parenteral nutrition. After 10 days of treatment, 72-hour balance measurements demonstrated significant reductions in stomal fluid and electrolyte losses from (mean +/- SE) 8.1 +/- 1.8 to 4.8 +/- 0.7 L/d (p < .03), sodium from 510 +/- 71 to 340 +/- 41 mEq/d (p < .03), chloride from 533 +/- 70 to 315 +/- 32 mEq/d (p < .002), and potassium from 101 +/- 41 to 79 +/- 34 mEq/d (p < .02), permitting an average reduction in intravenous fluid requirements of 1.3 L/d (p < .0003), 118 mEq Na+/d (p < .03), 41 mEq K+/d (p < .02), and 178 mEq Cl-/d (p < .01). This meant that daytime intravenous infusions could be stopped in all patients. Fecal nitrogen losses were decreased (p < .05), but overall there was no significant change in fat and caloric absorption. In addition, hormonal stimulated gastric acid and pancreatic lipase secretions were significantly reduced (p < .05). The effect was most marked in those patients with massive stomal losses and uncontrollable thirst. Continuation of treatment for more than 1 year in 8 of the patients suggested preservation of potency and good tolerance, with the possible exception of accelerated gallstone formation and subacute intestinal obstruction. In conclusion, octreotide has the potential to improve the quality of life of those end-jejunostomy syndrome patients with massive stomal losses, resistant to conventional medical treatment.

In general, the metabolic sequelae of sepsis and trauma are now widely accepted. However, the optimal mixture of energy substrates in parenteral and enteral nutrition solutions remains controversial, and whether glucose or lipid is the preferred substrate in critically ill patients is still hotly debated. In this issue of the Journal of Parenteral and Enteral Nutrition, Raguso and colleagues' have presented us with yet another potential energy substrate that could be included in nutritional feeding regimens. In this article the authors examine the alterations in insulin-mediated glucose uptake and the circulating hormonal milieu in humans infused with sebacic acid, a 10-carbon aliphatic dicarboxylic acid. Their conclusions concerning the suitability of sebacate as an alternative fuel source will undoubtedly add to the debate. This article represents the most recent entry from a group of investigators whose interest in dicarboxylic acids as an energy substrate dates back 5 years and includes at least nine publications. Originally, the short-term infusion of azelaic acid (a 9-carbon dicarboxylic acid) was evaluated as a possible alternative substrate in parenteral nutrition.2-4 As enumerated by the authors, this and other medium-chain dicarboxylic acids possess a number of advantages, compared with lipids, in the formulation of total parenteral nutrition (TPN). These include (1) the apparent lack of toxic and teratogenic effects; (2) high water solubility of the disodium salts, making their preparation relatively inexpensive; and (3) mitochondrial oxidation that is carnitine-independent, which might be important in pathophysiological conditions in which intramitochondrial carnitine levels are reduced. Evaluation of postabsorptive normal volunteers by indirect calorimetry suggests that azelaic acid exhibits a metabolic profile similar to that of long-chain triglycerides, as evidenced by the reduction in respiratory quotient. However, pharmacokinetic analysis also revealed that the majority of the infused azelaic acid (50% to 77% depending on dose) was excreted in the urine and unavailable for oxidation by the body's tissues. Thus, the authors concluded that this particular dicarboxylic acid seems unsuitable as an alternative energy substrate in TPN.More recently, the attention of this group has been focused on the metabolic response of individuals to sebacate (C 10). A comparison of some of the metabolic effects produced by sebacate with those observed after infusion of long-chain triglycerides is presented in Table I. This dicarboxylic acid has all the advantages described above and, in addition, its urinary excretion rate is lower than that of azelate. However, it is important to understand that the excretion of sebacate is proportional to the dose administered. At an infusion rate of 2.5 g/h only 12% is excreted, whereas at 10 g/h almost 50% of the injected dose is lost in the urine. 5-8The sebacate that is available to tissues has been reported to undergo ¡3-oxidation in the mitochondria and peroxisomes. In vitr...