Effects of gastrin-releasing peptide (GRP) on the mechanical activity of the human ileocaecal region in vitro.

Mechanical activity was recorded in muscle preparations isolated from the human ileocaecal region. Gastrin-releasing peptide (GRP, 10(-9)-10(-7) mol L-1) produced two types of response in the different muscle layers. Longitudinally cut strips showed a concentration-dependent increase in the rhythmic activity, whereas the circularly orientated layers generally reacted with a small decrease in tone. These effects could not be influenced by blockade of adrenergic or cholinergic receptors or nerve blockade with tetrodotoxin (TTX). Application of pentagastrin did not mimic the action of GRP. These findings suggest a direct action of GRP on smooth muscle via distinct receptors which have already been demonstrated to exist in human gastrointestinal tract. The opposite effects on circular and longitudinal strips might indicate a modulatory role of GRP in the control of ileocolonic transit.

Idiopathic intestinal perforations in premature infants without evidence of necrotizing enterocolitis.

In the past three years five premature very low birth weight infants (VLBW, birth weight 720-1,300 g) developed spontaneous localized perforations of the small intestine during the second week after birth. There was no evidence of intestinal obstruction or necrotizing enterocolitis (NEC). The clinical presentation and laboratory values as well as the radiologic, intraoperative and histologic findings were different from those of NEC. In four cases the initial symptoms presented as a gray-green discoloration of the flank and inguinal region with an otherwise unremarkable general condition. All patients exhibited a leukocytosis (range 14,700-19,300) and increased neutrophil count (range 9,900-14,800). Additionally, a pronounced increase in the activity of alkaline phosphatase (> 2.000 U/l in 3 cases) and a renewed increase of serum bilirubin was observed. Four of the five infants survived following laparotomy with ileostomy (n = 2) or primary anastomosis (n = 3).

Laparoscopic resection of pheochromocytoma.

The following case report presents the diagnostic procedures, laparoscopic therapy, and postoperative course of a 48-year-old patient with pheochromocytoma. During the previous 15 years, he had occasionally presented with hypertension, intermittent attacks of severe perspiration, and tachycardia; no diagnostic measures were performed at the time. During an ultrasound examination of the abdomen performed due to gastrointestinal complaints, a 5-cm adrenal tumor was discovered incidentally. Further diagnostic procedures then indicated the presence of a pheochromocytoma which was resected laparoscopically. The anesthesia was tolerated well, although isolated systolic blood pressure peaks to 200 mmHg were observed. The laparoscopic tumor resection presented no problems, although identifying the tumor proved to be difficult and resulted in an extended operation time of 4 h and 20 min. The postoperative course was unremarkable. This case report presents our laparoscopic technique and confirms that techniques proven in the "open" resection of a pheochromocytoma can also be utilized in the laparoscopic approach.

Long-term analysis of ultrasonic features of the antropyloric region 17-27 years after treatment of infantile hypertrophic pyloric stenosis.

Long-term follow-up was performed 17 years to 27 years after conservative (n = 12) and operative (n = 36) treatment in 48 patients with infantile hypertrophic pyloric stenosis (IHPS). The follow-up examination included an interview to define any existing gastrointestinal symptoms and to determine whether a current disorder of the gastrointestinal tract was present; a clinical examination, including a scintigraphic determination of gastric emptying; as well as--for the first time--abdominal sonography emphasizing the antropyloric region. The sonographical examination included measurements of pyloric diameter and length, as well as wall and muscle thickness in the antropyloric region. The results were compared with data from a control group with the same age and gender distribution. No association was found between the sonographic parameters obtained, reported gastrointestinal symptoms, or altered gastric emptying times for solids and liquids. Clinically relevant disorders of stomach motility after IHPS appear to be a rare occurrence.

Gastric emptying 16 to 26 years after treatment of infantile hypertrophic pyloric stenosis.

Long-term follow-up was performed 16 to 26 years after conservative (group I, n = 18) and operative (group II, n = 38) treatment of 56 patients who had infantile hypertrophic pyloric stenosis (IHPS). The study encompassed the scintigraphic determination of gastric emptying rates for solids and liquids, an interview to obtain medical history and ascertain whether a current disorder of the upper gastrointestinal tract was present, and a clinical examination. Gastric emptying rates were measured on two different days for solids and liquids. The standard solid meal consisted of two scrambled eggs, two slices of toast, and 20 g of margarine. The gastric emptying rate for liquids was measured using 300 mL of apple juice. The scrambled eggs and apple juice were each marked with 2.2 MBq technetium 99m-sulphur-colloid. Two control collectives were used in this study; one group (physicians) served to create a reference curve for gastric emptying, and the other group, with the same age and gender distributions as those of the patients, served to evaluate the frequency of gastrointestinal complaints, by means of a questionnaire. There was no significant rate difference for gastric emptying between the patients treated conservatively or surgically and the controls. No association could be construed between the frequency of gastrointestinal symptoms or disorders and the gastric emptying rates for solids and liquids. The results presented here substantiate that clinically relevant disturbances of stomach motility after IHPS appear to be rare.

Interdisciplinary treatment of necrotizing enterocolitis and spontaneous intestinal perforations in preterm infants.

From January 1986 to December 1992, 13 patients with necrotizing enterocolitis (NEC) (Grade II-III; Bell) were treated. The incidence was highest in the very immature infants with birth weight < 1000 g: 6/148 (4%). From onset, NEC was associated with clinical symptoms such as abdominal distension, bloody stools, retained gastric contents and septicemia. Indications of inflammation were seen in only 6 out of 13 patients at the time of diagnosis. No complications were seen in 10 patients during the acute phase. Two infants developed a bowel perforation and another one a gangrene. Immediate surgery was performed. In three other infants, elective surgery was performed because of colonic strictures. Twelve (92%) patients survived NEC. Five other VLBW infants developed spontaneous perforations of the bowel. The clinical presentation, laboratory and radiological findings differed greatly from those with NEC. Four infants survived. A primarily conservative therapeutic regime with close cooperation between the surgeon and pediatrician may be an alternative to early surgical intervention in NEC.

[Necrotizing enterocolitis: symptomatology, diagnosis and therapeutic consequences]. / Nekrotisierende Enterokolitis (NEC): Symptomatologie, Diagnostik und therapeutische Konsequenzen.

Within a 6-year period ten patients with necrotizing enterocolitis (grade II-III; Bell) have been treated at the University Hospital, Göttingen. The following NEC incidences were calculated: birth weight < 1000 g: 2.4% (3/123); 1000-1500 g: 0.6% (2/308); 1501-2000 g: 0.7% (3/436); > 3000 g: approximately 0.006% (2/30,000 live births). In all patients onset of necrotizing enterocolitis (NEC) was associated with typical clinical symptoms such as abdominal distension, feeding problems, bloody stools. Only four out of ten patients had positive blood tests of various inflammatory parameters when diagnosed (C-reactive protein, neutrophil count, I/T-ratio). However, increased CRP levels were observed in all patients during the course of the disease (maximum levels: day 2-4 after diagnosis). During primarily conservative therapeutic management only one out of ten patients developed bowel perforation (day 6 after diagnosis) and immediate surgical treatment was carried out. In addition, in three patients who acquired strictures with obstruction of the colon, elective surgery was performed at a postnatal age of 51-77 days. All patients survived NEC without longterm sequelae. We conclude that a primarily conservative therapeutic regimen-whenever perforation and gangrene are absent-may be an alternative to early surgical intervention in NEC.

[New trends in biliary surgery]. / Neue Tendenzen in der Gallenchirurgie.

On the basis of the experience gained in 893 laparoscopic procedures performed on the gallbladder, and with increasing frequency on the bile-ducts, and on the basis of a comprehensive review of the literature from 1992 and 1993 pertaining to this subject, a critical analysis of laparoscopic gallbladder surgery has been accomplished. As substantiated by recent publications, laparoscopic cholecystectomy has achieved wide acceptance in surgical practice. Over the course of the last two years, discussion has focussed on the avoidance of injury caused by Veress needle and trocar puncture and specific pneumoperitoneum-associated complications, as well as the minimisation of overlooked and/or spilled bile-duct calculi and the avoidance of iatrogenic bile-duct injuries. Procedures to be taken in order to achieve the necessary improvement in laparoscopic cholecystectomy are described.

[Intraoperative cholangiography and anterograde bile duct exploration in laparoscopic cholecystectomy--technique, results, perspectives]. / Intraoperative Cholangiographie und anterograde Gallenwegsexploration bei laparoskopischer Cholezystektomie--Technik, Ergebnisse, Perspektiven.

The avoidance of (unrecognized) bile duct injuries (1) and the management of bile duct stones (pre-, intra- or postoperatively?) (2) are believed to be the main problems in laparoscopic cholecystectomy (LCE) at present. They must be a challenge for surgery to develop and improve the concepts of minimally invasive therapy for treatment of cholelithiasis. Intraoperative cholangiography (IOC) plays a very important role and is the basis of innovative, laparoscopically assisted procedures (3) for single session therapy of gallbladder and bile duct stones. (1) A detailed analysis of the literature proves the value of IOC for avoidance or early recognition of iatrogenic bile duct injuries. IOC is of most importance to compensate fundamental restrictions of the laparoscopic technique (missing possibility for palpation or anterograde preparation). IOC adds additional safety to the laparoscopic procedure and detects unsuspected bile duct stones. (2) At present, surgical management of cholecysto-/choledocholithiasis is split in two independent procedures: LCE and pre- or postoperative endoscopic retrograde cholangiography (ERC) with optional endoscopic papillotomy (EPT). A critical analysis of the literature and of the results of 623 LCE performed between 10/91 and 9/93 in the own institution leads to the following conclusions: Preoperative ERCs are performed unnecessary in about 50% of cases. They could be avoided by routine use of IOC. The combination of two independent procedures (LCE and ERC/PT) for treatment of cholelithiasis increases mortality and morbidity. Thus, the outcome of "therapeutic splitting" is not clearly superior to conventional treatment by open surgery.2+ common bile duct exploration allows final diagnosis and treatment in a single session. Additional risks and costs caused by choledochotomy as well as by pre- or post-operative endoscopic retrograde procedures (ERC, EPT) are avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

[Initial experiences with laparoscopic fundoplication]. / Erste Erfahrungen mit der laparoskopischen Fundoplikatio.

Over the past decade decreasing numbers of anti-reflux surgical procedures have been performed. The two main reasons are improved pharmacotherapeutics and the complication rate associated with anti-reflux surgery. But in patients who are medically refractory or in those requiring long-term medications the Nissen-Rossetti fundoplication still has its place in the therapy of reflux disease. Laparoscopic procedures have begun to replace many conventional operations and have pushed surgeons to use this technique in antireflux surgery. Since April '92 we planned laparoscopic Nissen-Rossetti fundoplications in 22 patients. 21 operations were carried out laparoscopically (1 conversion). There were no intraoperative complications. 1 patient suffered from 10 weeks dysphagia. Oesophagitis was healed in 19 patients and improved (grade IV to I) in 2 after 12 weeks. Our results demonstrate that laparoscopic fundoplication is a proven alternative to open surgery. In the future the possibility of avoiding costs and risks of lifelong drug therapy will help to establish well indicated laparoscopic fundoplication.

The 13C-urea breath test--detection of Helicobacter pylori infection in patients with partial gastrectomy.

The 13C-urea breath test (13C-UBT) for diagnosis of Helicobacter pylori (Hp) infection was evaluated in 41 patients after partial gastrectomy and was used for determination of the Hp-prevalence after two different procedures of reconstruction of the gastrointestinal tract, i.e. Billroth's II operation and Roux-en-Y anastomosis. Breath samples were taken at various time points within 30 minutes after a motility inhibiting liquid test meal with citric acid followed by 75 mg of 13C-urea. The 13CO2/12CO2-ratio (delta-value) was measured using isotope ratio mass spectrometry and the recovery of tracer in the exhaled breath was calculated (UBT-value). In all patients and in the corresponding control groups comparison of established reference methods (culture, CLO test, and Fuchsin staining) with the 4 point breath analysis for detection of Hp was investigated. In patients with partial gastrectomy, the sensitivity of the 13C-UBT to detect the presence of Hp and the negative predictive values were 100%, whereas the specificity and the positive predictive values were about 80%. In patients without gastric surgery quality control parameters were not significantly different. Hp-prevalence in postoperative patients was about 45%. All results were independent of their expression either as delta-value or as UBT-value and were not significantly different between the patients with Billroth's II operation and the patients with Roux-en-Y anastomosis. In conclusion, the 13C-UBT is a suitable method for diagnosis and therapeutic monitoring of Hp-status in patients after partial gastrectomy.

The role of pancreatic innervation and cholecystokinin in the intestinal phase of pancreatic polypeptide release in conscious dogs.

Besides vagal cholinergic mechanisms, pancreatic polypeptide (PP) secretion is thought to be mediated by hormones. This study was performed to delineate the role of extrinsic pancreatic innervation and cholecystokinin (CCK) in amino acid- and fat-stimulated PP secretion. In ten mongrel dogs, pancreatic denervation was performed by the method of Debas et al. [3]. Total denervation of the pancreas did not alter PP response to intraduodenal application of amino acids (integrated output 24,434 +/- 3260 pmol/1 x 120 min before vs 22,797 +/- 2470 pmol/1 x 120 min after operation) and to intraduodenal fat solution (19,595 +/- 2121 pmol/1 x 120 min vs 19,983 +/- 2031 pmol/1 x 120 min). Also, no significant differences were measured in CCK release (491 +/- 71 pmol/1 x 120 min vs 430 +/- 57 pmol/1 x 120 min for amino acids, 571 = 63 pmol/1 x 120 min vs 563 +/- 89 pmol/1 x 120 min for fat solution). Plasma PP and CCK levels were compared by linear regression analysis. Correlations between PP and CCK were high in the intact pancreas (amino acids, r = 0.92; fat, r = 0.99) as well as in the denervated pancreas (r = 0.93 amino acids and r = 0.98 fat). These results show that extrinsic pancreatic innervation does not influence PP and CCK release after intraduodenal amino acids or fat solution and that PP secretion seems to be mediated to some extent through the release of CCK.

[Specifics of anesthesiology in laparoscopic surgery in infancy]. / Anästhesiologische Besonderheiten bei laparoskopischen Operationen im Säuglingsalter.

No data exist in the literature pertaining to the problems of laparoscopic surgery in infants and children. However it is reasonable to assume that minimal invasive surgery will find increasing application in these patients in the future. The anesthesiological problems met during surgery are representatively demonstrated and discussed in the context of a case report. It is shown that in infants a reduction of functional residual capacity due to the pneumoperitoneum and consequently increased intraabdominal pressure (IAP) cause alveolar collapse, increased venous admixture and oxygen desaturation more rapidly than in adults. This can be prevented by ventilating with a sufficient level of PEEP. On the other hand, the reduction of venous return caused by increased IAP and aggravated by the necessarily high PEEP can compromise circulation. Adequate volume substitution is essential.

[Endoscopic hernia repair]. / Endoskopischer Hernienverschluss.

A laparoscopic procedure for surgical hernia repair is reported. In comparison to other methods we do not only remove the peritoneal sac, but close although the inguinal canal with a nonresorbable marlex mesh. Up to now we practiced this technique in 35 patients. First post-operative results are encouraging but nothing can be said about longterm results, especially the recurrence rate.

Effect of total extrinsic denervation and atropine on HCl-stimulated pancreatic exocrine secretion and CCK release in conscious dogs.

In 10 dogs with pancreatic fistulas, we studied the effect of extrinsic pancreatic innervation and atropine on protein and bicarbonate secretion and cholecystokinin (CCK) release after intraduodenal perfusion with HCl. Before and after extrinsic denervation of the pancreas, the dogs were given 0.05 M HCl in increasing doses (1.5-48 mmol/h). Tests were repeated with atropine. Increasing doses of HCl resulted in a dose-dependent release of protein and bicarbonate output in both the intact and the denervated pancreas. However, pancreatic denervation significantly decreased pancreatic secretion in response to low loads but not to high loads of HCl. HCl-stimulated CCK release was not altered by pancreatic denervation. In the intact pancreas, atropine significantly reduced bicarbonate and protein response to low loads but not to high doses of HCl. In the denervated gland, atropine had no further inhibitory effect on exocrine pancreatic secretion. Furthermore, atropine showed no influence on HCl-stimulated CCK release under either condition.

The simplified 13C-urea breath test--one point analysis for detection of Helicobacter pylori infection.

A 13C-urea breath test for detection of Helicobacter pylori infection was validated in 306 patients. Breath samples (four, two or one) were taken at various time points within 30 minutes after a motility inhibiting liquid test meal with citric acid followed by 75 mg of 13C-urea. The 13CO2/12 CO2-ratio (delta-value) was measured using isotope ratio mass spectrometry and the recovery of tracer in the exhaled breath was calculated (UBT-value). In 172 patients a comparison of established reference methods (culture, CLO test, and Fuchsin staining) with the 4 point breath analysis for detection of Helicobacter pylori showed high values of quality parameters (greater than 80% for sensitivity, specificity, positive and negative predictive value), independent of expression of the results as delta-value or as UBT-value. In 134 patients a reduction of samples to one single breath sample taken 30 minutes after ingestion of the tracer showed no significant differences in the quality parameters when compared with the standard 4 point breath analysis. This indicates that the analysis of a single breath sample is suitable for detection of Helicobacter pylori status in man.