Gastric emptying and duodeno-gastro-oesophageal reflux in gastro-oesophageal reflux disease.

BACKGROUND: Previous studies present conflicting results regarding relationship between gastric emptying and gastro-oesophageal reflux disease. Reflux of duodenal content to oesophagus is generally considered to be associated with more severe disease. AIM: To assess presence of a gastric emptying disorder in persons with reflux of duodenal contents to oesophagus and to identify any correlation with gastric emptying and oesophageal motility. METHODOLOGY: A total of 15 subjects with (B+) and 15 subjects without (B-) bile reflux to oesophagus determined by 24-hour bilirubin monitoring were studied with scintigraphic solid gastric emptying and 24-hour oesophageal manometry. RESULTS: There was no difference in lag phase [median 23.7 (range 10.8-44.0) vs 24.6 (8.1-40.1) min], half emptying time [74.6 (48.0-93.6) vs 82.8 (54.4-153.9) min] or emptying rate [0.89 (0.59-1.34) vs 0.83 (0.36-1. 15)%/min] for B- and B+ subjects, respectively. In addition, there was no difference in emptying rate of gastric fundus between B- and B+ subjects. Subjects with bile reflux had less effective oesophageal contractions of oesophageal body [9.4(3.3-37)%] compared to subjects without bile reflux [32(19-47)%, p = 0.002]. However, there was no correlation between oesophageal motility and gastric emptying. CONCLUSION: Results suggest that a gastric emptying disorder is a less likely contributing cause of bile reflux to the oesophagus, but bile reflux is associated with less effective oesophageal motility.

A Swedish study of chemoradiation in squamous cell carcinoma of the esophagus.

This multicenter study describes the development of a chemoradiation protocol for the treatment of non-metastatic squamous cell carcinoma of the esophagus. Eighty patients were treated with three courses of chemotherapy (cisplatinum and 5-fluorouracil) with concomitant radiotherapy (40 Gy) during the last two courses of chemotherapy. Esophagectomy was performed, when feasible. If no operation was performed, patients were planned to receive a target dose of 64 Gy. Toxicity was mainly attributable to hematological impairment and led to two adjustments of the treatment protocol (addition of filgrastim and lowering of the 5-fluorouracil dose). These changes made it possible to administer the planned treatment in a gradually higher proportion of patients (13/23 [57%] before changes of treatment compared with 30/36 [83%] after changes). Treatment-related mortality was 3.75% (3 patients, associated with leucopenic septicemia after chemotherapy). Fifty-four patients were resected. No per- or postoperative mortality was encountered. The complete response (pathological CR) rate in operated patients was 46% (27/59 patients) after chemoradiation. In the whole series the CR rate (including clinical CR for non-resected patients) was 44%. With a minimum follow-up of 37 months, the 3-year survival for the whole group was 31% compared with 57% for the CR patients. Total 5-year survival thus far (July 1999) is 26%.

Percutaneous endoscopic gastrostomy for nutrition in patients with oesophageal cancer.

OBJECTIVE: To evaluate the technical aspects and risks of using percutaneous endoscopic gastrostomy (PEG) in the treatment of patients with oesophageal cancer. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 229 consecutive patients who presented with oesophageal cancer between January 1990 and the end of December 1999. INTERVENTION: Insertion of a PEG after diagnosis and before treatment. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: PEGs were successfully inserted in 222/229 (97%), and the tumour required dilatation in 103 (45%). There was 1 oesophageal perforation and 1 tear of the stomach wall, both of which resulted in death (mortality 0.9%). In 1 operated patient the right gastroepiploic artery was injured by the PEG, but this did not prevent the stomach being used successfully as the oesophageal substitute. PEGs were removed because of leaks in 2 patients. There was 1 possible implantation metastasis. CONCLUSION: PEG is a safe and a well tolerated way of ensuring enteral nutrition in patients with oesophageal cancer. The risk of the PEG complicating any later operation is minimal.

Neurochemical and cellular markers in human cervix of late pregnant, postpartal and non-pregnant women.

BACKGROUND: The aim was to evaluate the peptidergic innervation and the dendritic cell content in the cervix uteri. METHODS: Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to protein S-100 (S-100), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), human peptide histidine isoleucine amide (PHM 27), neuropeptide tyrosine (NPY), and human histocompatibility complex class II subregion DR (HLA-DR). RESULTS: Nerve fibers positive for protein S-100, and dendritic cells positive for S-100 and HLA-DR were abundant in the cervix, especially at late pregnancy. CGRP, VIP, PHM-27 and NPY positive nerve fibers were present in non-pregnant, short nerve fibers and scattered immunoreactivity at term, and further scattered immunoreactivity after parturition. NPY positive nerve fibers were decreased at term, and after parturition a scattered immunoreactivity was observed. CONCLUSIONS: The abundant protein S-100 positive nerve fibers implies an impact of myelinated nerves in the cervix uteri during pregnancy. The abundant dendritic cells, positive for HLA-DR and S-100, especially at term, indicates a general activation of the immune system until late pregnancy and parturition. The changed occurrence and distribution of immunoreactivity for CGRP, VIP and PHM-27 suggest a release of these neuropeptides until term. The changes in NPY immunoreactivity indicate a release of NPY around parturition.

Caesarean section in previously untreated acute promyelocytic leukaemia. Report of two patients.

Acute promyelocytic leukaemia (APL) is characterised by a life-threatening hemorrhagic diathesis which is attributed to a DIC-like coagulopathy. This report describes the problems of childbirth in two patients with untreated APL. It is concluded that caesarean section can be performed without major complications. A prerequisite is an active treatment of the coagulopathy and a close collaboration between the obstetrician and the haematologist.

Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia.

Congenital high-airway obstruction syndrome (CHAOS) is due to rare malformations and has been reported previously in only few cases. If the diagnosis can be made prenatally, the ex utero intrapartum treatment (EXIT) procedure may be life-saving. A healthy 28-year old nulli-para was referred because of isolated ascites found at gestational week 16 during routine ultrasound scan. Repeated scans showed overdistended hyperechogenic lungs with inverted diaphragm and a dilated trachea, which was interpreted as a CHAOS resulting from laryngeal atresia. The ascites eventually disappeared. An EXIT procedure was performed at 35 weeks of gestation. Anesthesia of the mother was induced with thiopental, succinylcholine and fentanyl followed by intubation, and maintained with isoflurane and nitrous oxide. A low abdominal midline incision was performed followed by a low transverse incision of the uterus. The fetal head, right arm and shoulder were delivered and intramuscular anesthesia was administered to the fetus. Immediate laryngoscopy confirmed the diagnosis and a tracheostomy was therefore performed. Surfactant was given after a few minutes of ventilation. Compliance improved and when the fetus was easy to ventilate, it was delivered. The baby is developing normally at 18 months of age. Surgical correction of the malformation will be performed after two years of age. It is concluded that some fetuses with a prenatal diagnosis of CHAOS can benefit from the EXIT procedure at delivery. This necessitates a multidisciplinary management team.

Three-year results of laparoscopic vertical banded gastroplasty.

BACKGROUND: Despite the development of pharmacologic agents for the treatment of massive obesity, surgery remains the only treatment option that has been shown to offer long-term weight reduction. Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity. The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (lap VBG) in 60 obese patients. PATIENTS AND METHODS: 60 massively obese patients (50 female) with a mean +/- SEM body mass index (BMI) of 44.4 +/- 1.0 kg/m2 were followed up prospectively for an average of 23.0 +/- 1.5 months. Lap VBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line, and a stretched polytetrafluoroethylene (Gore-Tex) band was used to reinforce the outlet. The patients were seen postoperatively 2, 6, 12, 24, and 36 months after surgery. RESULTS: Conversion to open surgery was performed in 15 cases. Preoperative median BMI and postoperative hospital stay were higher in the open group than in the laparoscopic group: 47.8 kg/m2 (37.7-65.7) and 5 days (3-13), and 41.9 kg/m2 (32.5-57.3) and 3 days (2-6), respectively (P < 0.01 for both). After 36 months of follow-up, the median BMI was 36.9 kg/m2 (24.6-50.7) (n = 9) in the open group and 37.0 kg/m2 (25.8-53.3) (n = 14) (NS) in the laparoscopic group. The number of conversions to open surgery and the median operating time were higher in the first 30 cases than in the last 30 cases: 11 and 137.5 min (96-225) and 4 and 115.0 min (85-190), respectively, with similar preoperative BMI: 44.1 kg/m2 (33.8-65.8) and 41.2 kg/m2 (32.4-57.8). CONCLUSIONS: Lap VBG can be performed safely and results in a shorter postoperative stay than does open surgery. Weight loss was maintained over the 3-year follow-up period. There is a learning curve, resulting in fewer conversions to open surgery and shorter operating time. Long follow-up studies are needed to ascertain that long-term weight loss equals that of open VBG.

Protein gene product 9.5-immunoreactive nerve fibers and cells in human cervix of late pregnant, postpartal and non-pregnant women.

BACKGROUND: The aim of this study was to examine the occurrence and distribution of the general neuronal marker protein gene product (PGP) 9.5 in the cervix uteri. METHODS: Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to PGP 9.5. RESULTS: Nerve fibers were found consistently in all biopsies. There were differences in the occurrence and distribution of PGP 9.5 immunoreactive nerve fibers and cells between the three groups. Immunoreactive nerve fibers were observed at a moderate to abundant frequency in the stroma and around arterial vessel walls, in all groups. Immunoreactive nerve fibers were also observed at high frequency within and around glandular epithelium in the late pregnant and postpartal groups. PGP 9.5 immunoreactive cells were seen occasionally in the stroma of the non-pregnant group, but at a high frequency in the stroma, around arterial blood vessel walls, around and within the glandular epithelium in the late pregnant and postpartal groups. The total frequency of immunoreactive nerve fibers and cells was the highest in the late pregnant group, slightly lower in the postpartal group, and the lowest in the non-pregnant group. CONCLUSIONS: These findings show that changes in the general innervation take place during human cervical ripening until late pregnancy and parturition.

Diagnostic accuracy in 2,351 patients undergoing appendicectomy for suspected acute appendicitis: A retrospective study 1986-1993.

AIMS: To investigate the pre-operative findings, accuracy, perforation rate and complication rate in 2,351 patients who underwent appendicectomy during 1986-1993. METHOD: The 2,351 records from patients who underwent surgery were analysed to determine whether the pre-operative investigations introduced can improve the diagnostic accuracy when analysed in total. RESULTS: The total diagnostic accuracy which was 70.9% in 1986 increased to a statistically significant figure of 87.1% in 1993. In female patients, the figure increased from 61.7 to 82.4% and in males from 82.0 to 91.2% during the studied period. The complication rate was in total 10.4% including a mortality of 0.21% (5 patients). CONCLUSION: We believe that with a combination of increased interest in patients with acute appendicitis, a wider use of active in-hospital observation, a more standardised pre-operative laboratory investigation and the use of ultrasonography, a high diagnostic accuracy could be reached without an increased rate of complications and perforations.

Treatment of perforated appendicitis: an analysis of 362 patients treated during 8 years.

BACKGROUND AND METHOD: In a retrospective study 2,351 records from patients who underwent surgery for acute appendicitis during 1986-1993 were analysed. During this period, there were 362 patients with perforated appendicitis. The aim of this study was to analyse the complication rate, the period of antibiotic treatment and whether the complication rate decreased when intravenous treatment was followed by oral antibiotic treatment. RESULTS: The complication frequency was 18% which was significantly higher than that for non-perforated appendicitis of 10%. The complication rate was 15% in the group receiving additional oral antibiotics compared to 19% in the group receiving only intravenous antibiotics. This difference is not significant. CONCLUSION: Perforated appendicitis is however still associated with increased mortality and morbidity.

[Biliary reflux can be a contributory cause of esophagitis]. / Gallreflux kan vara bidragande orsak till esofagit.

In recent years duodenogastric reflux has been recognised as a possible cause of oesophagitis. Alone or in combination, bile salts, trypsin, pepsin, and hydrochloric acid have all been shown to cause oesophagitis. Duodenal content in the oesophagus can be measured by means of a new fibre-optic sensor, Bilitech 2000, a device measuring the occurrence of bilirubin and yielding 24-hour readings from the distal oesophagus. Studies in which the device has been used have shown oesophageal bilirubin to be increased in patients with oesophagitis, especially in the subgroup with such complications as oesophageal stricture or ulceration, or Barrett's oesophagus. The evidence suggests that unsatisfactory response to proton pump inhibitors in reflux patients might be due to an increase in duodenal reflux, and should be treated surgically with fundoplication or biliary diversion. This may also be true of oesophagitis patients with complications, though this remains to be shown in clinical studies.

An adjustable vertical banded gastroplasty does not eliminate the risk of staple-line disruption.

BACKGROUND: The two main reasons for reoperation after vertical banded gastroplasty (VBG) in the treatment of obesity are staple-line disruption and stomal stenosis. PATIENTS: Seven morbidly obese patients of mean (+/-SEM) body mass index (BMI) 43.7 +/- 1.9 kg/m2 treated with an adjustable vertical banded gastroplasty (AVBG). RESULTS: No complications of the band system were reported. Weight-loss [BMI at 2 years follow-up 33.9 +/- 6.9 kg/m2 (n = 5)] was equivalent to that seen after VBG with a fixed band. Two of the patients developed staple-line disruption at 18 and 24 months after surgery. CONCLUSION: AVBG allows adjustment of the stoma, but staple-line disruption was common in this small series. It is possible that an excessive filling of the band in order to achieve excess weight loss results in a high pressure in the upper pouch which increases the risk of staple-line disruption.

Cervical fetal fibronectin correlates to prostaglandin E2-induced cervical ripening and can be identified in cervical tissue.

OBJECTIVE: Our purpose was to investigate whether prostaglandin E2-induced cervical ripening can be related to changes in fetal fibronectin levels and whether fetal fibronectin can be detected by immunohistochemistry in amniotic and cervical tissue. STUDY DESIGN: Fetal fibronectin levels in cervical mucus were quantitated in 28 nulliparous term pregnant women with unfavorable cervical states before and after intracervical application of prostaglandin E2 gel. The concentration of fetal fibronectin was determined with use of an enzyme immunoassay. Cervical biopsy specimens and amniotic tissue for immunohistochemical analysis were obtained from three term pregnant women and after parturition in three women. Cervical biopsy specimens from two nonpregnant women served as controls. Immunohistochemical analysis was performed with antibodies directed toward fetal fibronectin. RESULTS: The fetal fibronectin level in cervical mucus was low in all women before prostaglandin E2 application. In women with a successful prostaglandin E2-induced ripening (i.e., an increase of cervical score with > or =3 points), a tenfold increase in the fetal fibronectin level was registered. In women with an insufficient cervical ripening after prostaglandin E2 treatment no significant increase in the fetal fibronectin level was registered. The immunohistochemical analyses have identified fetal fibronectin in the epithelial cells of the cervix uteri. CONCLUSION: Successful prostaglandin E2-induced cervical ripening seems to be related to a significant increase in cervical fetal fibronectin levels. Fetal fibronectin can be detected immunohistochemically in the pregnant human cervix.

Interleukin-8 is a mediator of the final cervical ripening in humans.

OBJECTIVE: The aim of the present study was to investigate the presence of interleukin-8 (IL-8) in the human cervix and whether the levels of interleukin-8 could be related to the ripening process during pregnancy. STUDY DESIGN: Cervical biopsies were obtained in twelve term pregnant and in eight vaginally delivered women. Seven non-pregnant fertile women served as controls. After homogenisation and centrifugation, IL-8 levels were determined in the supernatant by an enzyme-immunoassay (EIA). RESULTS: In women at term, the concentration of IL-8 increased six-fold from median 330 pg/ml to median 2190 pg/ml (P < 0.001). After the final cervical ripening it increased in additional 11-fold to median 26,100 pg/ml (P < 0.001). These changes are highly significant. CONCLUSION: To our knowledge, this is the first time IL-8 has been identified in human cervix. Our results support the involvement of IL-8 in the connective tissue remodelling during the final cervical ripening just before onset of labour.

Seven year results of vertical banded gastroplasty for morbid obesity.

OBJECTIVE: To present our experience with a group of obese patients treated by vertical banded gastroplasty. DESIGN: Open prospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 198 Morbidly obese patients operated on between 1986 and April 1994. INTERVENTIONS: Modified Mason vertical banded gastroplasty. MAIN OUTCOME MEASURES: Weight loss, mortality, early and late morbidity, and reoperation. RESULTS: The mean (SEM) age was 40 (0.7) and 149 of the 198 were women (75%). 22 Patients (11%) were lost to follow-up. Five patients died (3%), one soon after operation. Mean (SEM) body mass index (BMI) was 44.4 (0.5) preoperatively and this decreased to 32.6 (0.6) after four years (n = 99) and 33.8 (1.3) after seven years (n = 20). 21 patients developed 24 early postoperative complications, and 31 patients were reoperated on 41 times for late complications. CONCLUSION: All patients lost weight after vertical banded gastroplasty, and their weight continued to decrease during a seven-year follow-up. This was somewhat offset by the high rate of reoperations required.

White blood cell count, leucocyte elastase activity, and serum concentrations of interleukin-6 and C-reactive protein after open appendicectomy.

OBJECTIVE: To investigate the kinetics of interleukin-6 (IL-6), leucocyte elastase complex (elastase), C-reactive protein (CRP), and total white blood cell count (WBC) after open appendicectomy. DESIGN: Prospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 21 patients with suspected acute appendicitis who underwent appendicectomy. INTERVENTIONS: Serum samples were taken preoperatively and postoperatively on days 1, 2, 6, 10, and 30. MAIN OUTCOME MEASURES: Changes in IL-6, elastase, and CRP concentrations and WBC postoperatively, and their correlation with complications. RESULTS: The highest IL-6 concentrations and WBC were found preoperatively, while postoperatively elastase peaked on day 1, and CRP on day 2. One patient developed a suspected deep infection resulting in secondary peaks of IL-6, WBC, and CRP on day 6. Two patients with perforated appendicitis had high preoperative values of IL-6, elastase, and CRP. CONCLUSIONS: Concentrations of IL-6, elastase, and CRP, and WBC increase after surgical trauma, and can remain high for up to 10 days. It is important to understand the postoperative kinetics for each test. Postoperative complications might best be detected by measuring IL-6 and CRP concentrations, and WBC.

Analgesic efficacy of intravenous morphine in labour pain: a reappraisal.

The aim of the present study was to investigate the dose-related analgesic effect of intravenous (i.v.) morphine during spontaneous term first stage labour. This was an open study in 17 parturients who requested analgesia for severe labour pain. All women were given morphine i.v. in repeated doses of 0.05 mg/kg following every third contraction until a final dose of 0.20 mg/kg was reached. The decrease in overall pain intensity, from median visual analogue scale (VAS) 85 (range 52-100) to median VAS 70 (range 46-99), was clinically insignificant. The number of women experiencing back pain, however, decreased significantly following morphine. The most striking effect of morphine (7.2-18 mg) was pronounced sedation. No adverse reactions related to morphine were noted in the neonates. We conclude that i.v. morphine does not significantly reduce overall labour pain intensity. Thus, if a real analgesic effect is desired, systemically given morphine seems inappropriate and other techniques should be used.

Deafferentation leads to a down-regulation of nitric oxide synthase in the rat visual system.

To test the hypothesis that monocular enucleation can cause a decrease in nitric oxide synthase (NOS) in subcortical visual centers, serial sections of superior colliculi and lateral geniculate nuclei from normal and enucleated rats were processed for NOS immunohistochemistry and NADPH-diaphorase histochemistry. Adjacent sections were also reacted for cytochrome oxidase, a metabolic marker, to demonstrate the change in energy demands. We found that both visual centers normally contained moderate levels of NOS, and eye removal caused a consistent down-regulation of NOS, NADPH-diaphorase and cytochrome oxidase on the deprived contralateral side. Optical densitometric values supported these findings (P < 0.01). Thus, the level and the activity of NOS are regulated by neuronal activity in the rat subcortical visual centers.

Six Cases of Barrett's Esophagus after Gastric Restrictive Surgery for Massive Obesity: An Extended Case Report.

OBJECTIVE: The purpose of this study is to report and characterize six patients who have developed Barrett's esophagus after; a gastric restrictive procedure for massive obesity. METHOD: Retrospective analysis of patients operated with gastric banding (GB) and vertical banded gastroplasty (VBG) between 1981 and 1994. RESULTS: Four patients (4/92) initially operated with GB have developed Barrett's esophagus a mean of 9 years post-operatively. Two patients (2/198) operated with VBG developed Barrett's esophagus 18 and 47 months postoperatively. The histopathological type of Barrett's esophagus was cardia-like in three cases, gastric-like in two cases and intestinal-like columnar epithelium in one case. None of the biopsies showed signs of dysplasia. CONCLUSION: Gastric banding is again gaining popularity with the development of adjustable bands that can be placed laparoscopically. The development of Barrett's esophagus after GB and VBG, a premalignant lesion, is cause for some concern. Prospective long-term studies are needed to further address this complication.