Motility of the canine pyloric ring following a pylorus-preserving pancreatoduodenectomy

Recently, function-preserving operations have become popular, and pylorus-preserving pancreatoduodenectomy (PPPD) is frequently performed for diseases of the head of the pancreas. However, there are only a few basic studies on the pyloric function after PPPD. Using strain gauge force transducers (SGTs), we studied the pyloric motility of normal and PPPD dogs. We prepared three normal and three PPPD dogs in which the SGTs were implanted onto the antrum and pyloric ring, etc. In conscious dogs, the spontaneous gastrointestinal motility was recorded, and the plasma motilin concentration was measured during the interdigestive state. Following the administration of exogenous Leu13-motilin, the motility was again recorded. The relaxation and opening of the pyloric ring was observed synchronously with intense contractions of the antrum during the phase III of normal dogs. Phase III-like motility was recorded in the PPPD dogs, which was not a typical periodic motility. The plasma motilin concentration of one PPPD dog could be measured, and the motilin levels during the phase III-like motility were higher than during phase I. The phase III-like motility was induced by Leu13-motilin in both normal and PPPD dogs. The phase III-like motility recorded in the PPPD dogs was not a typical periodic one, and this aberrant motility was considered to be one of the causes of delayed gastric emptying. Phase III-like motility was induced by the administration of Leu13-motilin; therefore, it is possible that Leu13-motilin improved the motility of the pyloric ring after PPPD.     

Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy

OBJECTIVE: The effect of a cyclic versus a continuous enteral feeding protocol on postoperative delayed gastric emptying, start of normal diet, and hospital stay was assessed in patients undergoing pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Delayed gastric emptying occurs in approximately 30% of patients after PPPD and causes prolonged hospital stay. Enteral nutrition through a catheter jejunostomy is used to provide postoperative nutritional support. Enteral infusion of fats and proteins activates neurohumoral feedback mechanisms and therefore can potentially impair gastric emptying and prolong postoperative gastroparesis. METHODS: From September 1995 to December 1996, 72 consecutive patients underwent PPPD at the Academic Medical Center, Amsterdam. Fifty-seven patients were included and randomized for either continuous (CON) jejunal nutrition (0-24 hr; 1500 kCal/24 hr) or cyclic (CYC) enteral nutrition (6-24 hr; 1125 kCal/18 hr). Both groups had an equal caloric load of 1 kCal/min. The following parameters were assessed: days of nasogastric intubation, days of enteral nutrition, days until normal diet was tolerated orally, and hospital stay. On postoperative day 10, plasma cholecystokinin (CCK) levels were measured during both feeding protocols. RESULTS: Nasogastric intubation was 9.1 days in the CON group (n = 30) and 6.7 days in the CYC group (n = 27) (not statistically significant). First day of normal diet was earlier for the CYC group (15.7 vs. 12.2 days, p < 0.05). Hospital stay was shorter in the CYC group (21.4 vs. 17.5 days, p < 0.05). CCK levels were lower in CYC patients, before and after feeding, compared with CON patients (p < 0.05). CONCLUSIONS: Cyclic enteral feeding after PPPD is associated with a shorter period of enteral nutrition, a faster return to a normal diet, and a shorter hospital stay. Continuously high CCK levels could be a cause of prolonged time until normal diet is tolerated in patients on continuous enteral nutrition. Cyclic enteral nutrition is therefore the feeding regimen of choice in patients after PPPD.     

A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy

The high death rate for those patients undergoing pancreatoduodenectomy, which is a result of leakage of biliary and pancreatic anastomoses in most instances, justifies the study of this technique for rebuilding the alimentary tract. The use of two separate intestinal loops for the biliary and pancreatic anastomoses is the basis of this method. This technique reduces the morbidity and the death rates which are the result of leakage in either anastomosis because it separates biliary and pancreatic fistulas.     

Patterns of symptoms in functional dyspepsia: role of Helicobacter pylori infection and delayed gastric emptying

OBJECTIVE: Functional dyspepsia (FD) is a syndrome in which several causes are probably involved. Our aim was to investigate the association between specific dyspeptic symptoms and Helicobacter pylori infection or delayed gastric emptying. METHODS: Nine hundred thirty-five consecutive outpatients with unexplained dyspepsia were studied. After appropriate investigation, 304 patients were diagnosed as affected by chronic FD and were tested for H. pylori infection and gastric emptying of solids by means of 13C-urea and 13C-octanoic acid breath tests. Four dyspeptic symptoms (epigastric pain or burning, postprandial fullness, nausea, and vomiting) were scored as absent, mild, moderate, or severe (0-3) according to their influence on the patients' activities. Symptoms of irritable bowel syndrome and gastroesophageal reflux disease were also assessed. On the basis of symptom scores, three groups were identified: "prevalent pain" (10.5%), "prevalent discomfort" (32.6 %), and "unclassifiable" dyspepsia (56.9%). RESULTS: Of the 304 patients with FD, 208 (68.4 %) were H. pylori-positive on urea breath test. Gastric emptying was delayed in 99 subjects (32.6%). Patients with "prevalent pain" were infected significantly more often (81.2% vs 59.6%; p = 0.026) and less frequently had delayed gastric emptying (6.2% vs 40.4%; p = 0.0001) than those with "prevalent discomfort." H. pylori infection was independently associated with age > or =40 yr and epigastric pain or burning > or =2 (odds ratio [OR] and 95% confidence interval [CI] 4.09 [2.39-7.00] and 1.70 [1.04-2.77], respectively). Delayed gastric emptying was independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (OR [95% CI]: 3.13 [1.06-9.18]). H. pylori status had no influence on gastric emptying. Logistic regression analysis showed that delayed gastric emptying, female sex, and concomitant symptoms of inflammatory bowel syndrome were independently associated with a cumulative score > or =6 for postprandial fullness, nausea, and vomiting (p = 0.0281, p = 0.0387, and p = 0.0316, respectively). Moreover, concomitant symptoms of gastroesophageal reflux disease, female sex, and H. pylori infection were independently associated with epigastric pain or burning > or =2 (p = 0.002, p = 0.0001, and p = 0.0875, respectively). CONCLUSIONS: Two subsets of FD patients have been identified on the basis of symptoms. One subgroup is mainly characterized by "prevalent pain," H. pylori infection, and normal gastric emptying; the other one demonstrates "prevalent discomfort" and delayed gastric emptying. These findings shed some light on possible etiopathogenetic mechanisms of FD.     

Postoperative ultrasound biomicroscopic evaluation of the haptic position in transsclerally sutured posterior-chamber lenses as compared with the intraoperative endoscopic position

Our objective was to evaluate the long-term stability of transsclerally sutured posterior-chamber lens (PCL) haptics. A total of 22 patients (26 eyes) were examined 29-50 months postoperatively by ultrasound biomicroscopy (UBM) to determine the exact haptic position in relation to the iris base, ciliary sulcus, pars plicata, and pars plana. In all eyes, endoscopy had been performed intraoperatively immediately after PCL insertion and suture fixation of the haptic. We could locate all 52 haptics by UBM. Intraoperative haptic localization was compared with the postoperative position. UBM confirmed the endoscopic position in 81% of cases; 19% of the haptics showed a clinically undetectable dislocation. Secondary dislocations were analyzed in correlation with the intraoperative endoscopic transscleral suture penetration site and the primary position of the two haptics of one PCL. Loosening of the fixation suture together with primary asymmetry of the two haptics of one PCL apparently contributes to a slight dislocation.     

A comparison of the effects of tramadol and morphine on gastric emptying in man

In a previous study using an electrical bioimpedance technique and the paracetamol absorption test, we demonstrated that 0.09 mg.kg-1 of morphine delayed gastric emptying in healthy human volunteers. The aim of this study was to investigate whether analgesic doses of tramadol would cause a delay in gastric emptying similar to conventional opioids. Using the same volunteers and techniques as in our previous study, placebo or tramadol (1 mg.kg-1) was given in a randomised, double-blinded, cross-over placebo-controlled study. Gastric emptying was measured concurrently by a noninvasive epigastric bioimpedance technique and by the paracetamol absorption test. After the ingestion of 500 ml of deionised water plus paracetamol 1.5 g, the mean (SEM) time taken for gastric volume to decrease to 50% (t0.5) was recorded. No difference in gastric emptying rates (t0.5) between placebo, 7.7 (1 min), and tramadol, 9.5 (2 min), was noted. In our previous study, morphine prolonged t0.5 to 21 (3) min (p < 0.03). The maximum concentration and area under the curve of serum paracetamol concentrations following morphine were significantly different from placebo (p < 0.05) and tramadol (p < 0.05). We conclude that tramadol at a dose of 1 mg.kg-1 does not delay gastric emptying in humans.     

Emptying of colon prior to colonoscopy. A comparison between emptying using peroral polyethylene glycol-electrolyte and conventional emptying with dietary restrictions, laxatives and water lavage

The purpose of the study was to compare the degree of bowel emptying at colonoscopy after preparation with either traditional water enema, dietary restrictions and laxatives or after oral lavage solution (Klean-Prep). Colonoscopy was performed in 104 patients over a two month period, 56 patients being allocated to the conventional preparation and 48 to Klean-Prep. The quality of bowel emptying was evaluated visually during endoscopy and by the proportion of incomplete colonoscopies. Bowel emptying was less satisfactory after Klean-Prep (p = 0.018) and seven incomplete colonoscopies resulted in contrast to two after conventional preparation. The results were obtained from a surgical department with a permanent small staff of motivated nurses preparing a huge number of patients for colonoscopy. No economic advantages could be demonstrated by the use of Klean-Prep.     

Breast reconstruction after mastectomy: problems in position, size, and shape

Having learned that healed mastectomy wounds will stretch sufficiently to accommodate an implanted prosthesis, we must pay more attention to the position, and shape of the breast mound created by the prosthesis. We have briefly discussed our methods and the considerations we feel are important in this regard, but, even after extensive experience, we confess that the problems are still with us. Clearly, surgical methods and prostheses must improve.     

Effects of cetirizine on the delayed K+ currents in cardiac cells: comparison with terfenadine

On direct cell-cell contact, stimulated T lymphocytes potently trigger the production of pro-inflammatory factors such as interleukin-1beta (IL-1beta) and matrix metalloproteinases (MMP-1 and MMP-9), as well as anti-inflammatory factors such as IL-1 receptor antagonist (IL-1Ra) and the tissue inhibitor of metalloproteinases (TIMP-1) in peripheral blood monocytes and the monocytic cell line THP-1. Such mechanisms might play an important part in many inflammatory diseases where tissue destruction occurs. To assess whether anti-inflammatory agents such as dexamethasone (DEX) and leflunomide (LF) would affect contact-activation of monocytic cells, T lymphocytes were stimulated by PMA and PHA in the presence or absence of increasing concentrations of drug. LF and DEX (10- 4 M) inhibited the ability of stimulated T lymphocytes to activate monocytic cells by 66-97% and 43-70%, respectively, depending on the readout product. Upon contact with T lymphocytes stimulated in the presence of 10- 5 M LF, the molar ratio of IL-1Ra/IL-1beta and TIMP-1/MMP-1 produced by THP-1 cells was enhanced 3.6- and 1.9-fold, respectively, whereas it was enhanced only 1.3- and 1.4-fold upon contact with T lymphocytes stimulated in the presence of 10- 4 M DEX. Therefore, LF tends to favor the inhibition of pro-inflammatory and matrix-destructive factors over that of anti-inflammatory factors and metalloproteinase inhibitors, thus interfering with both inflammation and tissue destruction. These experiments indicate that LF and DEX have the potential to affect the capacity of stimulated T lymphocytes to activate, on direct cell-cell contact, monocytic cells. Furthermore, flow cytometric analysis revealed that surface molecules of T lymphocytes that were partially involved in contact-signaling of monocytes (i.e., CD69 and CD11) were not modulated by either LF or DEX, suggesting that factors which remain to be identified were mainly involved in the activation of monocytes on direct cell-cell contact.     

Effects of the potassium channel blockers, apamin and 4-aminopyridine, on scopolamine-induced deficits in the delayed matching to position task in rats: a comparison with the cholinesterase inhibitor E2020

The effects of the muscarinic antagonists, scopolamine HBr and MeBr, a cholinesterase inhibitor, E2020, and K+ channel blockers, 4-aminopyridine (4-AP) and apamin, on the performance of rats in a delayed matching to position (DMTP) task were examined. The percentage of correct choices (choice accuracy), number of trials completed and intertrial intervals were measured. Discriminability and response bias were also calculated, using signal detection analysis. Scopolamine HBr (0.1 mg/kg), but not scopolamine MeBr (0.1 mg/kg), significantly and consistently reduced the choice accuracy and discriminability, but neither affected the other measurements. E2020 (0.03-1.0 mg/kg) had no effect on the baseline performance in the DMTP task, but at 1.0 mg/kg, it significantly attenuated the deficits in choice accuracy induced by scopolamine. 4-AP (0.001-0.1 mg/kg) had no effect on either baseline performance or deficits induced by scopolamine. Apamin (0.1-0.4 mg/kg) had no effect on choice accuracy and discriminability. Apamin also failed to attenuate the scopolamine-induced deficits. When administered in combination with scopolamine, apamin at 0.4 mg/kg significantly decreased the number of trials completed and increased the intertrial interval relative to that of the control group. Taken together, these results demonstrate that K+ channel blockers (4-AP and apamin), unlike a cholinesterase inhibitor (E2020), fail to reverse the scopolamine-induced deficits in the DMTP task.     

Ultrasonic evaluation of gallbladder emptying with ceruletide: comparison to oral cholecystography with fatty meal

Assessment of gallbladder function is required prior to nonsurgical treatment of gallstones. In order to develop a practical and reproducible method of evaluation, gallbladder emptying was studied by ultrasound (US) in 55 gallstone patients after intramuscular administration of ceruletide (0.3 micrograms/kg). In 27 of these subjects, the US procedure was compared to oral cholecystography (OCG) with fatty meal. Maximal percent gallbladder contraction was reached 30 min after ceruletide in all patients. Maximal percent contractions were 47.5 +/- 27.7 during US with ceruletide and 33.9 +/- 16.3 during OCG with fatty meal (p = 0.03). A significant linear relationship was found between the results obtained with the two different procedures (r = 0.57; p = 0.002). Serial US determinations of gallbladder emptying were performed in 16 patients. Individual variation was below 20% in 11 subjects, and in five subjects it ranged between 20 and 40%. Minor, self-limiting side effects were observed in 13 patients. US determination of gallbladder emptying after ceruletide appears to be a practical and reliable method to assess gallbladder function.     

Gastric emptying after gastric interposition for esophageal carcinoma: comparison between the anterior and posterior mediastinal approaches

BACKGROUND/AIMS: Close observation and evaluation of the function of the transposed stomach after esophagectomy is essential. The present study uses the sulfamethizole capsule meal test to evaluate differences in gastric emptying between the anterior and posterior mediastinal approaches in patients undergoing esophagectomy. METHODOLOGY: Thirty-eight patients who underwent the esophagectomy and esophagogastrostomy for esophageal cancer were randomly divided into 2 groups: Group 1: anterior mediastinal approach, and Group 2: posterior mediastinal approach. Gastric emptying was studied using the sulfamethizole capsule meal test. Patients received sulfamethizole food capsules, 65 g of bread, and 150 ml of water. Plasma sulfamethizole levels were determined by high performance liquid chromatography (HPLC). RESULTS: Gastric emptying in both groups was significantly accelerated compared to healthy volunteers. Gastric emptying did not differ significantly between groups 1 and 2. CONCLUSIONS: The present data show that the sulfamethizole capsule meal test is an effective means of evaluating the emptying of the transposed stomach. Furthermore, when the stomach is used as an esophageal substitute following esophagectomy, gastric emptying does not differ according to the access route.     

3D CT of fractures: comparison of volume and surface reconstruction

Melatonin is a hormone primarily produced by the pineal gland at night and is suppressed by exposure to light. Experimental studies have indicated that melatonin may protect against cancer development. In the majority of totally blind people, melatonin is never suppressed by light exposure. The aim of this study was to test the hypothesis that blind people have a decreased cancer incidence, and that this effect is more pronounced in the totally blind than in the severely visually impaired. We identified a cohort of 1,567 totally blind and 13,292 severely visually impaired subjects and obtained information about cancer incidence from the Swedish Cancer Registry. We calculated standardized incidence ratios (SIRs) based on the number of person-years and incidence rates specific for national age, sex, and calendar year. Totally blind people had a lower incidence of all cancers combined [SIR = 0.69; 95% confidence interval (CI) = 0.59-0.82]. The risk reduction was observed in both men and women and was equally pronounced in hormone-dependent tumors as in other types of cancer. In the severely visually impaired, SIR was 0.95 (95% CI = 0.91-1.00). The findings support the hypothesis that blind people have a lower cancer incidence, although other explanations than the higher melatonin exposure must also be considered.     

Cyclic motor activity of the gallbladder maintained in a pylorus-preserving gastrectomy in dogs

The gallbladder has cyclic motor activity (CMA), which is impaired after a conventional gastrectomy. We conducted experiments to determine whether or not a pylorus-preserving gastrectomy (PPG) could maintain gallbladder CMA. Six strain gauge force transducers were implanted into the gastrointestinal tract and gallbladder of six dogs, respectively. The motor activity of the gastrointestinal tract and gallbladder was recorded as a control. PPG was then carried out. The phasic contractions of the gallbladder, which were correlated with the antral contractions in the control state, were synchronized with contractions of the pylorus after PPG. Intravenous administration of CCK-OP (40 ng/kg) induced phasic contractions of the gallbladder at 4.6 +/- 0.2 c/min in 3 of the 6 days with gastric contractions. After PPG, the gallbladder had phasic contractions (4.5 +/- 0.2 c/m), which were synchronized with the contractions of the pylorus in all dogs regardless of the contractions in the remnant stomach. These findings suggest that gallbladder CMa has a closer relationship with the CMA of the pylorus than with the remnant stomach after PPG. Thus, a preservation of the pylorus at the time of gastric surgery will help in maintaining gallbladder function and coordination with the remnant stomach.     

International stratification and the health of women: an empirical comparison of alternative models of world-system position

Women's health status is investigated in the context of stratification in the world-system. We investigate three alternative conceptualizations of the world-system for their effects on women's health status, using country-level data. The models investigate the effects of world-system position, military expenditures, and health resources on women's health status. Comparison of the alternative conceptualizations of world-system position indicate that a continuous model is only negligibly better than three- or five-block models at explaining women's health status. Regardless of how it is measured, world-system position has dramatic effects on women's health.     

Assessment of postoperative digestive function after pancreatico-duodenectomy: a comparison of reconstruction techniques

BACKGROUND/AIMS: Malabsorption is a frequent complication following pancreatico-duodenectomy (PD) for pancreatic carcinoma. Gastrojejunostomy followed by Billroth I type of reconstruction (PD III) has been advanced to prevent this disorder. We compared postoperative digestion and absorption determined by 131I-triolein, D-xylose and pancreatic function diagnostant (PFD) after extensive PD followed by one of two reconstructive procedures. MATERIAL AND METHODS: Postoperative digestive and absorptive functions in patients operated by Child's method (PD II) were compared with patients in whom the stomach emptied proximal to the pancreas and bile duct (PD III). RESULTS: The absorption of D-xylose was significantly higher (1.24 +/- 0.36 g vs. 0.72 +/- 0.21 g) in the PD III group. No difference was noted in pancreatic endocrine secretion between the two groups. Biliary scintigraphy revealed increased bile secretion in the PD III group. CONCLUSIONS: These results suggest that PD III is superior to PD II following extensive PD.     

Delayed puberty in obese boys: comparison with constitutional delayed puberty and response to testosterone therapy

OBJECTIVE: To evaluate the results of a brief course of testosterone therapy in boys with delayed puberty and to compare the responses seen in boys with constitutional delayed puberty (CDP), boys with obesity, and boys with possible gonadotropin deficiency. Design and setting: A retrospective chart review was done for 36 boys aged 14 years or older, seen between 1983 and 1996 because of delayed puberty, who were given 4 monthly injections of testosterone, 100 mg/mo, and had adequate follow-up. RESULTS: There were 23 boys whose findings before and after treatment were consistent with a diagnosis of CDP. Testosterone treatment increased the growth rate from 4.3 cm/y to 11.2 cm/y (P <.00001), and mean testis length increased 0.6 to 0.8 cm in all (from a mean of 2.9 to 3.6 cm, P <.00001) in the 4 months after testosterone treatment. Serum testosterone 4 months after therapy was higher than that before therapy (P =.00003). Of 5 boys with growth hormone deficiency but unknown gonadotropin status, 2 had lack of progression after testosterone therapy and were believed to have permanent gonadotropin deficiency. Seven of the 36 boys were obese (body mass index, >25), and 6 had a response to testosterone similar to boys with CDP with clear pubertal progression. One obese boy and one nonobese boy were diagnosed as having isolated gonadotropin deficiency. CONCLUSIONS: Monitoring the growth and genital responses to a 4-month course of testosterone injections helps to differentiate CDP from gonadotropin deficiency in boys with delayed puberty. Obese boys constitute a distinct category of boys with pubertal delay in terms of their growth, but their response to testosterone is similar to that observed in boys with classic CDP.     

Results in the reconstruction of the pyeloureteral segment using the Anderson-Hynes method

In an introduction the authors take into consideration the term Hydronephrosis and then they reviewed indications for a correction-repair of a pyelo-ureteral segment. There is shortly presented what is to be expected from an "ideal" procedure for a such reconstruction and then the operative technique of Anderson-Hynes method is described. They have operated on 37 patients using this procedure and according to X-ray finding (Degree of dilatation of calices and pyelon) patients were divided into four groups. Of primary importance in the evaluation of end results are: X-ray finding, urine analysis and subjective feeling. According to these criteria an excellent result has been attained in 15 patients, very good in 5, rather good in 8, while in 4 the result was bad; 5 patients were lost to follow-up.