Total duodenal diversion for treatment of reflux esophagitis uncontrolled by repeated antireflux procedures

The operations of Nissen, Hill, and Belsey are adequate in controlling esophaegeal reflux in the majority of patients. In a small percentage however, objective and subjective evidence of esophagitis persists in spite of repeated operations to restore lower esophageal sphincter competency. These failures are then usually treated by operative procedures of great magnitude involving organ interposition. Repeated antireflux operations directed to the gastroesophageal area may in some instances result in impairment of blood supply with an increased risk of both esophageal and gastric fistulae. In the past many observers have felt that reflux esophagitis resulted solely from the effects of acid-pepsin secretions bathing the distal esophagus. Recently experimental and clinical data have indicated the importance of duodenal contents in the etiology and perpetuation of reflux esophagitis. During a recent two year period, 6 patients with persistent reflux esophagitis uncontrolled by repeated antireflux procedures have been seen on our service. These 6 patients, underwent 12 unsuccessful antireflux operations elsewhere. Three of the 6 patients had also been subjected to vagotomy-antrectomy for a coexisting duodenal ulcer. A marked lowering of gastric acidity took place but esophageal reflux and esophagitis persisted. These three patients were treated on our service by takedown of the Billroth I anastomosis, closure of the duodenal stump and diversion of the duodenal contents into a Roux-en-Y limb. Three other patients who had undergone unsuccessful antireflux procedures alone were subjected to antral resection, Roux-en-Y diversion and transthoracid vagotomy. This simplified appraoch to the treatment of persistent esophageal reflux uncontrolled by repeated antireflux procedures has given satisfactory results. The operation should be considered when technical considerations preclude further surgical attempts to perform another effective antireflux operation. Total duodenal diversion should, however, not be considered as the primary operation for the patient suffering from reflux esophagitis. However, in circumstances discussed above this direct approach appears preferable to major resectional procedures.     

Hemodynamic determinants of the time-course of fall in canine left ventricular pressure

The hemodynamic determinants of the time-course of fall in isovolumic left ventricular pressure were assessed in isolated canine left ventricular preparations. Pressure fall was studied in isovolumic beats or during prolonged isovolumic diastole after ejection. Pressure fall was studied in isovolumic relaxation for isovolumic and ejecting beats (r less than or equal to 0.98) and was therefore characterized by a time constant, T. Higher heart rates shortened T slightly from 52.6 +/- 4.5 ms at 110/min to 48.2 +/- 6.0 ms at 160/min (P less than 0.01, n = 8). Higher ventricular volumes under isovolumic conditions resulted in higher peak left ventricular pressure but no significant change in T. T did shorten from 67.1 +/- 5.0 ms in isovolumic beats to 45.8 +/- 2.9 ms in the ejecting beats (P less than 0.001, n = 14). In the ejecting beats, peak systolic pressure was lower, and end-systolic volume smaller. To differentiate the effects of systolic shortening during ejection from those of lower systolic pressure and smaller end-systolic volume, beats with large end-diastolic volumes were compared to beats with smaller end-diastolic volumes. The beats with smaller end-diastolic volumes exhibited less shortening but similar end-systolic volumes and peak systolic pressure. T again shortened to a greater extent in the beats with greater systolic shortening. Calcium chloride and acetylstrophanthidin resulted in no significant change in T, but norepinephrine, which accelerates active relaxation, resulted in a significant shortening of T (65.6 +/- 13.4 vs. 46.3 +/- 7.0 ms, P less than 0.02). During recovery from ischemia, T increased significantly from 59.3 +/- 9.6 to 76.8 +/- 13.1 ms when compared with the preischemic control beat (P less than 0.05). Thus, the present studies show that the time-course of isovolumic pressure fall subsequent to maximum negative dP/dt is exponential, independent of systolic stress and end-systolic fiber length, and minimally dependent on heart rate. T may be an index of the activity of the active cardiac relaxing system and appears dependent on systolic fiber shortening.     

The thromboembolic risk of the pill

In this review, the clinical reality, the statistical risk, and the frequency of thromboembolism in pill users are evaluated, 6 cases described, and premonitory signs, treatment, and etiology are discussed. Clinically these thromboembolisms appear in unlikely subjects and unusual bodily locations such as the mesenteric veins, without warning. The risks are 8-11 times higher for pulmonary thrombosis, 3-6 times higher for myocardial infarction, based on previously used higher dosed pills. The frequency is about .5-1/1000, or 500-1000/year in France. Some of the cases described used pills with less than .05 mg estrogen, some were heavy smokers, 1 woman died, 1 had a lower extremity amputation, and 1 woman had demonstrated IgG lamda antibodies against ethinyl estradiol. Premonitory signs are rare, and unsually ignored. The immediate action is to stop the pill and start anticoagulants. The cause of these disorders is not known in detail, but is presumed to be estrogens, therefore, low-dose pills, i.e., those with .05 or .03 mg ethinyl estradiol, should be used if possible. Other risk factors are surgery, age, immobilization, history of vein disorders, smoking, hyperlipidemia, hypertension, especially since the pill potentiates hypertension, hyperlipidemia, and hypercoagulation. Some mechanisms proposed are hyperlipidemia, disturbed blood coagulation factors, decreased fibrinolysis, alterations in the blood vessel endothelium and immunity against the estrogen in the pill.     

Computerized tomography in the diagnosis of cerebral atrophy

Computerized tomograms were studied of 67 adults whose lumbar pneumoencephalograms were normal or showed ventricular dilatation with or without widening of the sulci. The maximum ventricular area, measured from 80 x 80 matrix printouts, correlates well with measures of ventricular size on the pneumoencephalogram. An area of 10 cm2 is suggested as the upper limit of normal. The correlation between measures of sulcal width on computerized tomography and pneumoencephalography is less precise, but normal sulci and gross degrees of cortical atrophy can be identified.     

Long tube implants in the management of glaucoma

The design, surgical insertion and results of a plastic draining implant for severe glaucoma are reported. The need for pharmacological control of bleb inflammation is stressed and the favourable long-term outlook for patients with such implants is discussed.     

Cathepsin D from horse spleen. I. Purification and study of certain physicochemical properties

Horse spleen cathepsin D (3.4.23.5.) was purified from crude extract by sodium chloride and ethanol precipitation, column chromatography fractionation on DEAE cellulose and CM Sephadex, re-chromatography on DEAE cellulose and gel filtration. The enzyme has been purified about 3.000 folds with a yield of 30 per cent. The purified enzyme seems to be homogeneous on Sephadex G100, one protein band is apparent on disc electrophoresis. Determined by dansylation the N-terminal amino acid is glycine. A molecular weight of 42,500 +/- 3,000 was obtained with Sephadex G100 gel filtration and light scattering measurements. Amino acid analysis and chemical determinations were performed: cathepsin D is a glycoprotein (2 or 3 osamine residues) including 344 amino acids and 4 disulfide bonds. Spectrophotometric data show that E1cm/1 mg/ml = 1.01 at lambda = 280 nm. ORD measurements indicate about 20 per cent of helicoidal content in the molecule.     

Mothers as volunteers in an oncology clinic

Mothers of children who had died of cancer were successfully utilized as volunteers in a pediatric oncology clinic to provide emotional support and practical assistance to other children afflicted with the same disease and to their families. At the start of the program these volunteers were carefully interviewed to determine their willingness and their emotional ability to participate on a consistent basis. Following an eight-week training program with a psychiatrist, a social worker, and a nurse, they began working in a large pediatric oncology clinic one day a week. Over an 18-month period they have become valuable members of the oncology team by helping to improve communications, to alleviate frustrations, and in giving additional emotional support to the children and their families.