Early gastric cancer in the remnant stomach

BACKGROUND/AIMS: Early gastric cancer in the remnant stomach is rare. Periodical endoscopic examinations are mandatory for patients with partial gastrectomy for a good prognosis. Our goal is to improve the surgical management of gastric cancer in the remnant stomach. We have retrospectively investigated a total of 15 rare cases of early gastric cancer after partial gastrectomy. METHODOLOGY: From 1976 to 1994, a total of 2,102 cases of gastric cancer were resected in our Department. Among these resected cases, 845 cases were histologically diagnosed as having early gastric cancer of the stomach. Of these, 15 patients had previously undergone a partial gastric resection. The time interval between the initial partial gastrectomy and the second resection of the remnant stomach, was more than 10 years for 8 patients (Group 1) and less than 10 years for 7 patients (Group 2). Here we investigate these rare cases of remnant early gastric cancer. RESULTS: The incidence of early gastric cancer in the remnant stomach was 1.8% (15/845). The cancer location in the remnant stomach was around the stoma and suture line in 75% of Group 1 and in 28.6% of Group 2. The incidence rate of mucosal cancer (m-cancer) was 87.5% for Group 1, and 14.3% for Group 2. Total gastrectomy was selected for 37.5% of Group 1, and for 100% of Group 2. No lymph node metastasis was discovered in both groups. The postoperative mortality was zero in both groups. One patient from Group 2, later died of liver metastasis 2 years after the second total gastrectomy, while the other 9 patients continued to live for more than 5 years with no gastric cancer recurrence to date. CONCLUSIONS: The outcome for patients with gastric cancer in the remnant stomach is generally considered poor. However, the outcome of early gastric cancer in the remnant stomach was good without major postoperative complications. Therefore, to improve surgical management of remnant-stump gastric cancer, early diagnosis is most important, using periodic endoscopic follow-up examinations, especially around the stoma. When mucosal cancer around the stoma is diagnosed, subtotal gastrectomy can be selected even in gastrectomized patient for a good prognosis.     

Electromyographic studies on gastric and intestinal motor function following pylorus preserving gastrectomy with jejunal interposition in dogs (author's transl)

The gastric and intestinal motor function following pylorus preserving gastrectomy with jejunal interposition were studied electromyographically in dogs. The action potentials were recorded from the interposed jejunal segment, the preserving pylorus and the duodenum before and after insertion of warm water. Studies were made on the frequency, the propagation velocity of the spike-bursts in the portions mentioned above, and the incidence of the spike-bursts which propagated from the distal porition of the interposed jejunal segment to the preserving pylorus, and from the preserving pylorus to the proximal portion of the duodenum. The results obtained are as follows: 1) The frequency of the spike-bursts found in the interposed jejunal segment, the preserving pylorus, and the duodenum showed a remarkable increase after insertion of warm water. 2) The propagation velocity of the spike-bursts in the interposed jejunal segment, the preserving pylorus, and the duodenum were accelerated after insertion of warm water. 3) There were observed a moderate increase in the incidence of the spike-bursts which propagated from the distal portion of the interposed jejunal segment to the preserving pylorus, and from the preserving pylorus to the proximal portion of the duodenum after insertion of warm water. These findings suggested that the motor function of the interposed jejunal segment, that of the preserving pylorus, and that of the duodenum after pylorus preserving gastrectomy with jejunal interposition might be kept not yet injured enough to transport the contents from the interposed jejunal segment into the duodenum.     

Radiographic diagnosis: arachnoid cyst in a dog

Lauren's intestinal type of gastric cancer was proposed to be dependent on long-term environmental factors and is always preceded by chronic premalignant change. A cohort study was performed and demonstrated an increased cancer risk of gastric remnant after gastric surgery for benign disease. It is generally believed that after gastrectomy the residual stomach has an environmental change and, thus, enters a neoplastic process. Based on the carcinogenic theory of intestinal-type tumour, it would be of interest to know whether the intestinal-type tumour is more common in gastric remnant cancer. Forty patients with gastric remnant cancer had gastrectomy in the Veterans General Hospital-Taipei. Another 683 patients with primary gastric carcinoma underwent resection and were used as controls. The clinical characteristics, tumour stage and intestinal-type tumour were analysed in gastric remnant cancer and were compared with the various portions of primary gastric carcinoma. Although the overall distribution of intestinal-type carcinoma in gastric remnant (45%) was no different to that of any other portion of stomach cancer, intestinal-type carcinoma was more common in the early stage of gastric remnant (73%) and distal stomach (73%), but not in the proximal stomach (50%), which was supposed to have the same characteristics as the gastric remnant because of identical anatomic location. More than expected, intestinal-type carcinoma in early gastric remnant cancer together with a long incubation interval between primary surgery and later tumour occurrence were compatible with the theory of carcinogenesis of intestinal-type carcinoma.     

Antro-pyloric contractile patterns and transpyloric flow after meal ingestion in humans

OBJECTIVE: The present study aimed to evaluate the patterns of antral contractility and pylorus opening and closure in relation to transpyloric flow of a nutrient liquid meal. METHODS: Ultrasound images of the antro-pyloro-duodenal tract were continuously tape-recorded in healthy volunteers for 1 h postprandially and were reviewed twice later by independent observers. Episodes and patterns of pylorus opening and closure, antral-wall contractions, and transpyloric flow were assessed separately and their time relations were identified. RESULTS: Transpyloric flow (forward, 56%+/-13%; retrograde, 19%+/-11%; and to and fro, 25%+/-14%) occurred essentially during episodes of prolonged pylorus opening not associated with occlusive antral or duodenal proximal contraction, which represented the antro-pyloro-duodenal common chamber. The antro-pyloro-duodenal common chamber lasted on average 36+/-12 s and represented 41%+/-12% of the total observation period. Different patterns of antral contractions were identified according to whether they reached or occluded the terminal antrum and pylorus. Preterminal antral contractions (46%+/-12%) did not propagate beyond the proximal two thirds of the antrum. Terminal antral contractions (54%+/-12%) propagated along the entire antrum and could either occlude (20%+/-9%) or not occlude (42%+/-17%) the lumen. Pyloric opening independent of antral contractions and related to nonocclusive antral contractions could occur equally at the onset of the antro-pyloro-duodenal common chamber. Pyloric closure independent of antral contractions put an end to transpyloric flow in 73%+/-6% of the antro-pyloro-duodenal common chamber. CONCLUSIONS: The final passage of contents from the stomach to the duodenum after the ingestion of a caloric liquid meal is the result of one or more episodes of uni- or bi-directional transpyloric flow, which are regulated by several motor events. The contractile states of the antrum and pylorus show specific features that variably interrelate to provide mixing and to regulate the transpyloric flow of ingesta. A crucial regulator of transpyloric flow appears to be the spatio-temporal relation between antral contractions and pyloric closure rather than the contractile events per se. An equal number of pyloric openings related, and unrelated, to antral contractions appears to determine the onset of the antro-pyloro-duodenal common chamber and, thus, of transpyloric flow. Pyloric closure unrelated to antral contractions appears to be the main mechanism that interrupts transpyloric flow. In conclusion, it appears that the antro-pyloro-duodenal tract acts as a functional unit in the digestion of a liquid caloric meal.     

Inhibitory effect of pinaverium bromide on gastrointestinal contractile activity in conscious dogs

The inhibitory effect of 4-(6-bromoveratryl)-4-(2-[2-(6,6-dimethyl-2-norpinyl)-ethoxy]-ethyl)-morpholinium hydroxide (pinaverium bromide), a quaternary ammonium derivative, on the contractile activity of the gastrointestinal tract from the stomach to the colon was investigated in six conscious dogs. Gastrointestinal motor activity was monitored by means of chronically implanted force transducers. Pinaverium bromide was continuously administered i.v. for 30 min in doses of 10 and 20 mg/kg/h during both the digestive and interdigestive states. It was found that pinaverium bromide strongly inhibited gastrointestinal contractile activity during both the digestive and interdigestive states; contractions in the stomach were most strongly inhibited; however, those in the small and large bowels were also significantly inhibited. No significant side effects in the circulatory and respiratory systems and the gastrointestinal tract such as nausea, vomiting or diarrhea were observed during and after the infusion of this agent.     

Physiologic effects of cisapride on gastric emptying after pylorus-preserving gastrectomy for early gastric cancer

Pylorus-preserving gastrectomy (PPG) has been considered reasonable reduction surgery. However, even patients in whom more than 1 year passed after surgery frequently have a feeling of gastric fullness after meals and long-term retention of foods in the residual stomach. To treat this syndrome, cisapride has been administered. We studied the emptying time of a semisolid diet (radioisotope method using 99mTc-tin colloid-labeled rice gruel) and the emptying time of a fluid diet (acetaminophen method with orange juice) before and after oral administration of cisapride (15 mg/day for 1 month) in 14 patients (10 men, 4 women; 32-70 years old, average 60.6 years) who underwent PPG (Billroth I procedure, D2 lymph node dissection, curability A) for treatment of early gastric cancer. Ten healthy volunteers without gastrointestinal symptoms and digestive diseases (7 men, 3 women; 28-61 years old, average 49.8 years) were enrolled as controls. The results showed obviously delayed emptying time of the semisolid diet before administration of cisapride in patients with PPG compared with that of the control group, whereas the emptying curves for the fluid diet showed an almost normal pattern. One month after the start of cisapride administration the emptying time of the semisolid diet was improved, and the emptying curves were close to the patterns in the control group. Emptying of the fluid diet was slightly accelerated compared with that before administration of cisapride, and the emptying curves showed almost the same pattern as in the control group. A postgastrectomy symptom, "gastric fullness," after PPG was alleviated by cisapride. These results showed that cisapride improved delayed emptying of a semisolid diet after PPG and prevented the feeling of gastric fullness after meals due to retention in the residual stomach.     

Curative laparoscopic surgery for early gastric cancer: five years experience

Sixty-one patients who were diagnosed with mucosal gastric cancer have been successfully treated with two laparoscopic techniques at our institute from March 1992 to March 1997. One is laparoscopic wedge resection of the stomach using a lesion-lifting method for lesions of the anterior wall, the lesser curvature, and the greater curvature of the stomach. The other is laparoscopic intragastric mucosal resection for lesions of the posterior wall of the stomach and near the cardia or the pylorus. Indications are as follows: (1) preoperatively diagnosed mucosal cancer; (2) <25 mm diameter elevated lesions; and (3) <15 mm diameter depressed lesions without ulcer formation. Patients were discharged in 4 to 8 days uneventfully. There was no major complication or mortality. The resected specimens had sufficient surgical margins horizontally (16 +/- 5 and 8 +/- 4 mm, respectively) and vertically. In one patient histologic examination revealed slight tumor infiltration into the submucosal layer with lymphatic invasion. He underwent gastrectomy with lymph node dissection 1 month after surgery. Otherwise, histologic examination revealed curative surgery. All patients in the series have survived during the 4- to 65-month follow-up period. There have been two recurrences in the series, both of which were found near the staple line 2 years after the initial surgery and were still mucosal lesions. They were successfully treated by open gastrectomy and laser irradiation. A separate early gastric cancer was found 2 years after the initial surgery in one patient, who then underwent curative open gastrectomy. In conclusion, if the patients are selected properly, these laparoscopic procedures are curative, minimally invasive treatment for early gastric cancer.     

Studies on the relationship between gastric acidity and the development of MRSA. Especially for the prevention of MRSA enterocolitis

Enterocolitis caused by methicillin-resistant Staphylococcus aureus (MRSA) has recently been recognized as one of the severe postoperative complications in surgery on the digestive organs. This disease often occurs in the early days after gastrointestinal operation, especially after gastrectomy. MRSA enterocolitis seems to occur when MRSA has first infected the naso-pharyngeal mucosa preoperatively, and then moved into the stomach, and subsequently proliferated in the higher pH gastric juices. The aim of this experiment was to reveal the relationship between the acidity of gastric juices and bacterial growth in the stomach during the pre and post operative period in an effort to prevent of MRSA enterocolitis. In vitro, MRSA was cultured for various periods at various pH values, and its proliferation was observed. MRSA did not grow in the culture at pH 1 at all, neither did it grow at pH 2 when cultured for more than 8 hours. This data shows the germicidal effect of high acidity in the stomach. Clinically, twenty patients with cancer in the digestive tract had the bacteria in their gastric juices examined in terms of acidity before and after operation. In cases with an increased pH level in the gastric juices after the operation. S. aureus including MRSA, was isolated frequently from the stomach. In vitro, incubation of MRSA with gastric juices collected from those cases showed no development of MRSA when the pH was below 3.98. In order to prevent the onset of MRSA enterocolitis, the remnant stomachs of ten patients with stomach cancer were filled with hydrochloric acid lemonade just after operative reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preservation of normal gastric emptying following gastric surgery by use of a muscle bridge

BACKGROUND: Maintenance of descending antral intramural pathways may be important in normal functioning of the pylorus after pylorus-preserving gastrectomy. METHODS: We examined the effect of a 1-cm bridge of muscle as a means of maintaining pyloric connection to antral intramural motor control pathways in 10 pigs. Antropyloroduodenal pressures and transpyloric flow were measured during gastric emptying of saline before and after either total or subtotal transection and reanastomosis of antrum. RESULTS: Complete antral transection shortened the time interval between antral and subsequent pyloric lumen occlusion, significantly reducing total gastric emptying and volume of transpyloric flow pulses. Subtotal transection maintained pre-transection timing and was associated with normal patterns of transpyloric flow and emptying. CONCLUSIONS: Our results indicate that a muscle bridge is capable of maintaining normal gastric emptying and the coordination of antral with pyloric contractions. We propose that antropyloric coordination is maintained by transmission of neural signals through the muscle bridge.     

GABA receptors in the dorsal motor nucleus of the vagus influence feline lower esophageal sphincter and gastric function

Gamma-aminobutyric acid (GABA) antagonist (bicuculline methiodide, BIC; picrotoxin, PIC) or agonist (muscimol, MUS) microinjections were made into the dorsal motor nucleus of the vagus nerve (DMV), and effects on lower esophageal sphincter pressure (LESP), gastric motility, and gastric acid secretion were determined in chloralose-anesthetized cats. Right or left DMV sites were microinjected with BIC, PIC, MUS, or isotonic tonic saline (140 nl) through a glass micropipette having a tip diameter of 15-21 microns. Esophageal body, LESP, and gastric fundic pressures were measured manometrically. Circular smooth muscle contractions of the antrum and pylorus were recorded with strain-gauge force transducers. Gastric acid secretion was measured every 15 min through a gastric cannula and titrated to pH 7.0. DMV microinjection sites were verified histologically. Direct BIC microinjections (0.275 or 0.550 nmol) into the DMV primarily produced a decrease in LESP (71% of all sites tested), with mean LESP changing from 23.2 +/- 1.7 mmHg to 3.7 +/- 0.7 mmHg (p < 0.01). Tonic LESP increases and phasic LESP contractile activity occurred less frequently. BIC-induced LESP responses were abolished by vagotomy or by microinjections of MUS (0.5 to 10 nmol) into the DMV. Direct PIC microinjection (0.232 nmol) into the DMV produced a pattern of responses similar to those observed with BIC (which were also abolished by vagotomy or by MUS microinjections into the DMV). The antrum and pylorus were also responsive to DMV microinjections of both GABA antagonists. Microinjections of BIC or PIC into the DMV produced increases in gastric circular muscle activity that occurred less frequently than LESP effects, but also were eliminated by vagotomy. The high (0.550 nmol) dose of BIC increased gastric motility significantly more often than the low dose of BIC (p < 0.05). In addition, BIC (0.550 nmol) microinjections into the DMV increased gastric secretory volume (from 0.6 +/- 0.2 to 6.0 +/- 2.5 ml/15 min; p < 0.01) and total titratible acid (from 34.4 +/- 8.9 to 86.0 +/- 19.1 mEq/15 min; p < 0.01), and decreased gastric pH (from 4.63 +/- 0.44 to 3.50 +/- 0.49; p < 0.05). Vagotomy also eliminated the gastric secretory effects of DMV BIC. Direct microinjections of MUS into the DMV also blocked BIC- or PIC-induced changes in gastric motility and/or gastric acid secretion. Isotonic saline microinjected into the DMV did not increase basal or decrease stimulated gastric esophageal motility or gastric secretion. These data indicate that LESP, gastric motility, and gastric secretion are influenced by a tonic DMV inhibition mediated by GABAA receptor stimulation of the DMV. Because disinhibition of these receptors clearly activates the upper gut, future work should focus on identifying the nuclei providing this synaptic input to the DMV that might be involved in the functional regulation of upper gut motor and secretory function.     

The emptying process of the residual stomach after various methods of anastomoses (author''s transl)

Similar to the high pressure zone of the lower esophageal segment (LES) gastric emptying results from alternating intraluminal pressure in the antrum, pylorus and duodenum. Alterations of this antro-duodenal pressure zone depend on hormonal and nervous control mechanisms and are regulated by intraduodenal localized pH-, osmo- and fat-receptors. Experimental investigations in partially gastrectomized dogs emphasize the important role of the duodenum for gastric emptying. After resection of the lower half of the stomach and reconstruction of the orthograde passage between the gastric remnant and the duodenum by gastroduodenostomy (b i-anastomosis), a hormonally controlled gastric emptying comparable to that of the intact organ can be noticed.     

Dystonia

The need for extrinsic neural input to the upper gut in regulation/control of cyclic interdigestive motility and release of motilin remains a topic of controversy. Our aim was to determine whether extrinsic denervation of the upper gut disrupts cyclic release of motilin in relation to the migrating motor complex. Ten dogs underwent transection of all extrinsic innervation and enteric neural input to the stomach, small intestine, colon, pancreas, and liver while enteric neural continuity within this multivisceral complex was maintained. A cyclic pattern of motility occurred during fasting in all dogs in the small bowel (period = 100 +/- 3 min, mean +/- standard error of the mean) and in 8 of 10 dogs in the stomach (period = 98 +/- 4 min). Gastric cycles were temporally coordinated with small bowel cycles. Plasma motilin concentrations cycled temporally with the motility pattern with the greatest concentrations occurring during gastroduodenal phase III-like activity. Exogenous motilin induced a burst of gastric contractions and a premature migrating motor complex in all dogs. Oral meals disrupted cyclic motility and cyclic changes in plasma motilin. Extrinsic innervation to the upper gut is not necessary for cyclic motor activity, for coordinated cyclic release of motilin, or to initiate a premature migrating motor complex-like response to motilin. Central nervous system input (afferent, efferent) is not necessary for cyclic interdigestive activity or cyclic release of motilin.     

Disaster-related psychiatric care system in the United States

We report herein the case of a 57-year-old man in whom malignant lymphoma originating in the gastric remnant was confirmed 25 years after a subtotal gastrectomy with Billroth II reconstruction had been performed for gastric ptosis. Gastroscopy revealed an ulcerated tumor on the fornix, and histologic examination of the endoscopic biopsy specimens demonstrated malignant lymphoma. Thus, total gastrectomy with splenectomy, pancreatectomy, and resection of the previously anastomosed jejunal stoma were performed. Histologic examination of the stomach remnant confirmed a diagnosis of B-cell lymphoma of the large-cell type. Although we were unable to study the surgical specimen from the initial operation, the possible relationship between pseudolymphoma and malignant lymphoma has been presented in the literature, which is reviewed following this case report.     

Enhanced motility of the vagotomized canine stomach by electrical stimulation

Functional impairment of the vagotomized stomach used as a substitute oesophagus seriously deteriorates the quality of life of patients following oesophageal cancer surgery. We speculated that if the enteric neurons of the reconstructed gastric tube survived functionally, the motility of the gastric tube could be facilitated and the recovery process after operation would improve as a consequence. In the present study we investigated whether direct electrical stimulation was effective for facilitating the motility of the canine vagotomized stomach. Dogs underwent truncal vagotomy by transabdominal approach and, in some cases, arteries to the upper stomach and the oesophagus were also ligated and resected to resemble the blood supply and surgical invasion of the reconstructed gastric tube. Electrical stimulation, a few minutes of positive rectangular current pulses, amplitude 20 V (or 15 mA), duration 0.5 ms and frequency between 0.2 and 7 Hz, was delivered on the greater curvature of the mid corpus. Changes in mechanical contractions were recorded using strain gauge force transducers. Electrical stimulation successfully enhanced the mechanical force of the phasic ring contractions of the vagotomized stomach in a frequency dependent manner. Aboral propagation and periodicity of the contractions, impaired by surgical procedures, were restored during stimulation. These excitatory effects were inhibited by atropine, hexamethonium and tetrodotoxin, suggesting that electrical stimulation acts on intramural cholinergic nerves that have survived functionally. These results suggest that electrical stimulation could be an effective method for improving the motility of the vagotomized stomach.     

Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.     

Neuronal control of motility changes in the canine lower esophageal sphincter and stomach in response to meal ingestion

BACKGROUND & AIMS: Neuronal control of motility changes in the lower esophageal sphincter (LES), gastric body (GB) and gastric antrum (GA) in response to meal ingestion is not fully understood. The aim of this study was to investigate the neuronal mechanism of the LES and gastric motility response to meal ingestion in conscious dogs. METHODS: Dogs fitted with force transducers in the LES, GB and GA were given neuronal antagonists before a meal. Motility was assessed for 10 min after feeding and was compared to results without antagonists. RESULTS: In the LES, atropine inhibited tonic contractions, whereas N omega-nitro-L-arginine (L-NAME) significantly enhanced tonic contractions initiated by meal ingestion. In the GB, atropine, hexamethonium or L-NAME inhibited receptive relaxation, and the effect of hexamethonium was significantly greater than that of atropine or L-NAME. In the GA, atropine, hexamethonium or naloxone inhibited postprandial phasic contractions, whereas L-NAME tended to enhance phasic contractions. CONCLUSIONS: Neuronal control of postprandial motility was clearly different in each region: (1) LES tonic contractions are mainly regulated by muscarinic receptors, (2) nicotinic transmission plays an essential role in receptive relaxation, which also involves muscarinic receptors and nitric oxide, (3) cholinergic nerves and opiate receptors are involved in the occurrence of antral phasic contractions, and (4) endogenous nitric oxide may inhibit postprandial contractions in the LES and GA.     

D2 receptor binding in dopa-responsive dystonia

OBJECTIVES: Synchronous gastric tumors (including benign and secondary tumors) associated with esophageal cancer present diagnostic and therapeutic issues. We investigated this synchronous association, and retrospectively determined the frequency of the gastric tumors and the clinical characteristics. METHODS: In a series of 208 patients with esophageal cancer, we investigated the synchronous gastric tumors, as well as the frequency of association, clinicopathological characteristics, diagnosis, treatment, and the clinical outcome after surgery. RESULTS: Twenty-eight gastric tumors were found in 24 patients. Adenocarcinoma was most frequent. Most of these tumors were located at the upper or middle third of the stomach. Eight gastric tumors in six patients could not be detected preoperatively. Six of these tumors including a gastric remnant cancer were detected in the resected stomach, and two leiomyomas were detected during the operation. In one patient in which an endoscope could not pass through the esophagus, a leiomyoma was detected in the resected stomach. For the gastric cancers, total gastrectomy or proximal gastrectomy with lymph node dissections was performed. For the benign tumors, partial resection of the stomach was performed, and endoscopic resection was performed preoperatively for an adenoma. In both the postoperative hospital mortality rate and the survival rate after surgery, there were no significant differences between the patients with and without gastric tumors. CONCLUSIONS: Synchronous gastric tumors associated with esophageal cancer are not rare. When an endoscope cannot pass through the esophagus before surgery, other techniques must be performed to explore the stomach. For these patients, surgical treatment should be adapted positively.     

Variability of plasma HDL subclass concentrations in men and women over time

1. Nitric oxide (NO) has been suggested as a gastrointestinal neurotransmitter, mediating the gastric receptive relaxation and the relaxation in the peristaltic reflex. The aim of the present study was to measure nerve-induced NO formation in vivo in the gastrointestinal tract. 2. Formation of the nitric oxide oxidation products nitrite and nitrate during vagal nerve stimulation were measured in the anaesthetized rabbit. Microdialysis probes were inserted into the wall of the stomach and proximal colon, and nitrite and nitrate in dialysate measured by capillary electrophoresis. 3. During bilateral vagal nerve stimulation there was an increase in nitrite and nitrate formation at the level of the stomach and in nitrite formation at the level of the colon. This increase was inhibited by intravenous administration of the NO synthase inhibitor N omega-nitro-L-arginine methyl ester (L-NAME 30 mg kg-1). Furthermore, L-NAME significantly increased nerve-induced gastric and colonic contractions, as well as spontaneous colonic contractions. 4. In summary, we present a new methodological procedure for quantification of small changes in nitric oxide formation in vivo. This study provides evidence that nitric oxide is released in the stomach and colonic wall during vagal nerve activity, at concentrations able to cause inhibition of smooth muscle contractions in vivo.     

Knee arthroplasty in rheumatoid arthritis. A report from the Swedish Knee Arthroplasty Register on 4,381 primary operations 1985-1995

The aim of this study was to determine whether the use of an ileal Roux limb, rather than a jejunal Roux limb, would prevent the Roux stasis syndrome that can occur after Roux gastrectomy. An ileal Roux limb was constructed in eight dogs and anastomosed to the gastric remnant after distal hemigastrectomy. Flow of chyme through the jejunum was preserved via an ileojejunostomy and a jejunoileostomy. Six dogs with distal gastrectomy and a conventional Roux gastrojejunostomy served as a control group. Chronic enteric recording electrodes and intraluminal, open-tipped pressure catheters were implanted in all dogs. After recovery, the electrical activity and motility of the Roux limbs and the rates of gastric emptying of liquids and solids were measured. Dogs with a Roux gastroileostomy had a slower frequency of pacesetter potentials in the Roux limb, a greater Roux motility index, and a faster rate of gastric emptying of liquids and solids than did dogs with a Roux gastrojejunostomy. Stomal ulcers, however, developed in seven of the eight ileal Roux limbs but in none of the jejunal Roux limbs. It was concluded that Roux gastroileostomy does ameliorate the Roux stasis syndrome, but there is a greater risk of stomal ulceration in the limb.     

Pylorus and pyloric vagus preserving gastrectomy treating 125 cases of peptic ulcer

BACKGROUND: With a view to preventing the sequelae of conventional subtotal resection of stomach, such as dumping syndrome, intestinal fluid reflux and other such complications and maintaining the normal movable physiological function of the remnant stomach, we have designed a pylorus and pyloric vagus preserving gastrectomy (PPVPG). METHODS: As many as 125 cases of peptic ulcer (GU 49, DU 76) were so treated without a single death. Comparative studies were made with 48 cases of operations done at the same period with Billroth. In reducing acid, both modes of operations are identical. RESULTS: 97.9% of the Billroth cases saw more than two degrees of intestinal fluid reflux, 5.8% of the PPVPG cases had only one. Dumping syndrome occurred in the Billroth cases, none in PPVPG cases. In gastric emptying, food digestion and absorption, body weight and life quality, PPVPG proved superior to Billroth. In the subsequent follow-ups for 5.5 years, no recurrence of the disorder has been reported, curative effect proved to be Visik I or II, 98.4%. CONCLUSIONS: Safe and adaptable to a wide variety of indications, PPVPG carves not only a new course for the surgical treatment of peptic ulcer, but also can be applied to other benign gastric lesion such as polyposis, leiomyoma and ectopic pancreas.