Effect of guar gum added to the diet of patients with duodenal ulcer.

In a randomized, double-blind, controlled clinical study, the effects of 5 g of guar gum, a dietary fiber composed of galactose and mannose, or placebo added to the diet of 20 patients with duodenal ulcer for 1 wk each were examined. Ten patients derived evident benefit and five some help from guar gum, on comparing symptoms during administration of guar gum with those experienced earlier or during the placebo week, whereas four patients found that neither guar gum nor placebo had any effect (p less than 0.001). The beneficial effect was associated with increased feelings of repletion after meals. Patients with fewest symptoms benefited only slightly, or not at all, from guar gum. In one patient, guar gum abolished pain felt earlier and on placebo, but also caused severe gastric retention after meals. This patient had pyloric stenosis. In patients who were intolerant to berries, fruits, sugar, sweet rolls, and pizza these foodstuffs were better tolerated during guar gum administration. The diarrhea which occurs in some patients ingesting guar gum was avoided by giving low initial doses. In three patients unpalatability of guar gum was a minor complaint. It is concluded that guar gum is helpful to many patients with uncomplicated duodenal ulcer, but that it is harmful to those having increased gastric emptying, eg, pyloric stenosis patients, and that guar gum may exert its effects by increasing gastric emptying time.

Effect of guar gum on gastric emptying after gastric resection.

Gastric emptying after a conventional semisolid meal containing 5 g of guar gum granules or placebo was measured in a double-blind, controlled trial, using a radioisotopic (technetium Tc-99m DTPA) technique, in 11 patients who had undergone gastric resection, and who were experiencing the dumping syndrome. Guar gum clearly slowed gastric emptying in five of the 11 patients, and the results suggest that the addition of guar gum to normal meals, especially those rich in monosaccharides or disaccharides, may be helpful to post-gastrectomy patients suffering from the dumping syndrome.

Surgery of thoracoabdominal aortic aneurysms.

Arteriosclerotic aneurysm of the thoracoabdominal aorta, involving one or more visceral branches, was successfully operated on in eight patients. Two of the aneurysms had ruptured. The left diaphragm-splitting thoracoabdominal incision through the 8th intercostal space, using a retroperitoneal route, gave unrestricted exposure. A temporary aortofemoral shunt effectively protected abdominal organs and spinal cord from perioperative ischemic damage. The step-by-step reattachment technique into ready-made side limbs in the woven Dacron graft ensured that visceral and renal ischemic times remained within acceptable limits. Perfusion cooling of the abdominal organs was done in one patient in whom shunt could not be used. A standby autotransfusion device was life-saving in another case. All the patients recovered without major complications. Moderate elevation was found as regards serum creatinine levels in seven patients and liver enzymes in four patients, but the values normalized within a month. No paraplegic complications occurred, although all bleeding intercostal and lumbar arteries were ligated intra-aneurysmatically in seven of the eight patients. Seven patients are well 20 to 60 months postoperatively, with patent and well functioning grafts. One patient died of lung cancer after 7 months. Four of the 18 revascularized arteries in three patients were shown by control angiography to be occluded, but without serious sequelae. Our experience suggests that most thoracoabdominal aortic aneurysms are suitable for surgical correction, with acceptable risk. Elective surgery is therefore recommended.

Perforation of the gallbladder. A retrospective comparative study of cases from 1946-1956 and 1969-1980.

The records of patients treated for perforation of the gallbladder in 1946-1956 or 1969-1980 (n = 41 and 70) were reviewed to elucidate if changed strategy in acute cholecystitis, i.e. delayed vs. early surgery, had had any effect on the prognosis. The overall mortality declined significantly between the two periods, from 20 to 7%. The mortality was lowest (6%) after cholecystectomy, as compared with cholecystostomy (29%) and conservative treatment (67%). The frequency of chronic biliary fistula, calculated on all gallbladder perforations, decreased significantly (46 vs. 27%), but the frequency of acute free perforation was similar in both periods (27 and 34%). Treatment policy in acute cholecystitis is discussed. The study indicated that early surgery (Cholecystectomy with peroperative cholangiography and, if required, choledochotomy) is the treatment of choice, giving the best results also in patients with perforation of the gallbladder.

The effects of gastric surgery on serum ferritin concentrations.

Changes in serum ferritin concentrations were monitored for three months after gastric operation, in 25 patients. In 23 patients, the serum ferritin concentration was seen to be increased, one week postoperatively, as compared with the preoperative level. Thereafter, in most patients, the serum ferritin concentration gradually decreased to the initial preoperative level. Preoperatively, 13 of the total 25 patients had low serum ferritin concentrations, indicating depleted iron stores. In eleven of these patients, the serum ferritin concentrations followed the above-mentioned course and normal values of serum ferritin concentration were seen postoperatively, indicating normal body iron stores. In six of the ten patients with normal preoperative serum ferritin concentrations, there was a temporary increase within the limits of the normal range. The temporary postoperative increase of serum ferritin concentration was more marked in the patients who underwent total or partial gastrectomy than highly selective vagotomy or fundoplication. We conclude that measurement of serum ferritin concentration may give a false impression of normal body iron stores in the postoperative state.

Efficacy of guar gum in preventing the dumping syndrome.

The occurrence of dumping symptoms during 1 wk of use of 5 g of guar gum or placebo in meals was examined in a double-blind study in 11 patients, who had undergone gastric resection and were suffering from the dumping syndrome. The results show that guar gum prevented the dumping syndrome and increased tolerance to foods not previously tolerated in nine of the 11 patients.

Isoniazid, quinidine, and sulphafurazole absorption in patients with jejunum transposition 15 years earlier.

Gastric surgery has formerly been shown to affect drug absorption. The absorption of oral isoniazid (INH), quinidine, and sulphafurazole (sulfisoxazole) was therefore studied in 19 ulcer patients operated on some 15 years earlier with resection of the ventricle combined with jejunum transposition. Twelve medical inpatients served as controls. The operated patients had all experienced relief of their ulcer symptoms, and there was no evidence of clinical malabsorption. In operated patients the peak serum levels of all three drugs were reached earlier than in controls. At 1 and 6 h the INH serum levels were increased in operated patients, but the sulphafurazole serum levels were at no time different in operated and control patients. As measured by the 24-h urinary excretion, jejunum transposition did not modify the total amounts of INH or sulphafurazole absorbed. In contrast, the quinidine absorption was decreased by about 50% in operated patients, which seems to be the result of increased gastric pH in the operated patients, leading to a poor dissolution and/or precipitation of quinidine in the gastric contents. Obviously, the jejunum transposition per se may not affect the total amounts of drugs absorbed, provided the physiochemical effects resulting from, for example, pH changes due to antrectomy and/or vagotomy are taken into account.

Effect of surgery on liver function in patients with liver cancer.

The effect of hepatic resection, hepatic artery ligation (HAL), and artery ligation combined with regional infusion of 5-fluorouracil (HAL + 5-FU) on liver function was investigated by liver tests including antipyrine in 20 patients with liver cancer. One month after resection the conventional liver tests except serum albumin were normalized, but the rate of antipyrine elimination was still significantly reduced. This suggests that the oral antipyrine test may be a sensitive reflector of the reserve capacity of the liver. Palliative procedures (HAL +/- 5-FU) had a transient effect on conventional liver tests and a negligible effect on functional liver capacity as determined by the antipyrine test or serum albumin concentration. On the basis of our results it remains unknown whether antipyrine determination provides any additional advantage over serum albumin as a measure of functional liver capacity in localized liver diseases, such as liver tumours.

Experiences with the EEA stapling instrument for anastomoses of the upper gastrointestinal tract.

Technique, early experiences and results with the EEA stapling instrument for the reconstruction of intestinal continuity after gastric and esophageal resection in 52 patients are reported. 12 patients with gastric cancer and 4 patients with cardiac cancer underwent total gastrectomy with esophagojejunostomy, 25 patients with gastric cancer underwent subtotal gastrectomy with gastrojejunostomy, 8 patients with esophageal cancer had esophageal resection with esophagogastrostomy and 3 patients with non-resectable gastric or cardiac cancer had palliative by-passing esophagojejunostomy, all performed by means of the EEA stapler. Three anastomotic leakages were detected radiologically, two after esophagojejunostomy and one after gastrojejunostomy. These leaks did not lead to clinical signs or symptoms and healed with parenteral nutrition in three weeks. One patient died of myocardial infarction on the 8th postoperative day, but at autopsy the anastomosis was intact. At follow-up endoscopy three mild anastomotic strictures have been found, but no treatment have been required. In two patients the stricture resolved spontaneously in a few months. According to our experience, esophagojejunal, gastrojejunal and esophagogastric anastomosis performed with the EEA stapling instrument seems to be at least as reliable as a hand sutured anastomosis, obviously even more reliable. The EEA stapler is also time saving, especially after adequate experience with the use of the instrument has been achieved. The difficulties and hazards associated with the use of the stapler are discussed.

Comparison of metronidazole with clindamycin-gentamycin combination in the prevention of infectious complications after elective colonic surgery.

The efficacy of metronidazole, active only against anaerobes, and clindamycin-gentamycin combination, covering both anaerobes and aerobes, in the prevention of infectious complications after elective colonic surgery was compared in a prospective randomized trial over a three-year period. A total of 130 patients were accepted for the trial, 67 receiving metronidazole intrarectally and 63 receiving clindamycin-gentamycin combination. The prophylactic treatment was started on the evening before the operation and continued for 24 hours. One patient out of 67 receiving metronidazole (1.5%) and two patients out of 63 receiving clindamycin-gentamycin (3.2%) developed a wound infection. An intra-abdominal infection occurred in two patients in both groups (3% and 3.2%, respectively). There was no statistically significant difference in postoperative infections between the groups. The authors conclude that metronidazole is as effective as the clindamycin-gentamycin combination and should be preferred to broad-spectrum antibiotics because of its fewer side effects and lower potential of developing resistant bacterial strains.

Heterotopic ossification in upper midline abdominal scars.

Heterotopic ossificaton of the upper midline abdominal incision scar is reported in seven patients. This disorder may follow abdominal operations via vertical incisions. The cause is unknown. All patients were men in their fifties. The calcification resembled a "rib" and occurred in upper midline incisions between the peritoneum and fascia, fixed more to the fascia. Excision of the mass was performed in six cases. Excision is recommended only in symptomatic cases, and should be wide enough to avoid recurrence. In the differential diagnosis several other wound complications as well as intra-abdominal malignancy should be considered.

Experiences with the EEA stapling instrument for colorectal anastomosis.

Early experiences and results with the EEA stapling instrument for colorectal anastomosis are reported. 39 patients underwent anterior resection or left hemicolectomy with end-to-end anastomosis performed by means of the EEA stapler. Two patients had a clinically recognizable anastomotic leakage, both of which healed spontaneously. One patient died from pulmonary embolism, but at autopsy the anastomosis was intact. No significant problems in the control of anorectal function developed. On follow-up sigmoidoscopic examinations two patients showed a distinct narrowing of the anastomotic site, but both of these stenoses were spontaneously dilated by six months. It seems that an anastomosis performed with the EEA stapler is at least as reliable as a hand sutured one and apparently more so. With this instrument an anastomosis can be achieved at a lower level than would be feasible with conventional hand suture techniques. In addition, it is much more easily and rapidly performed, especially in patients with a narrow pelvis or other anatomical difficulties.

Liver drug metabolism in patients undergoing open-heart surgery.

The effect of open-heart surgery on the drug metabolism of the liver was investigated in 17 patients by using the rate of antipyrine elimination as an index. A correlation was found between the pre-operative heart size and the antipyrine elimination rate. In patients with a markedly dilated heart, the plasma antipyrine half-life was prolonged and apparent clearance significantly impaired. Immediately postoperatively, antipyrine elimination was impaired in all patients. Later, the drug metabolism improved in patients with atrial septal defect, changed temporarily in patients with aortic valve replacement, and remained unchanged in patients with mitral valve replacement. The results indicate that adaptive changes in drug metabolizing capacity occur in patients undergoing cardiac surgery. The changes are related to the type of lesion corrected, the pre-operative functional capacity of the liver, and the time lapse after surgery.

The effect of furosemide on renal function in open heart surgery.

The effect of furosemide on renal function in patients undergoing open heart surgery was investigated, using creatinine clearance, urine flow, sodium and potassium excretion as the parameters. The effect of furosemide (2 mg/kg i.v.) on blood flow in arteria renalis and the tissue oxygen tension of the renal cortex and medulla were also investigated experimentally in six dogs. The flow was measured with an electromagnetic flowmeter and the tissue oxygen tension with IBC tissue oxygen electrodes. Prolongation of the perfusion time to more than 60 minutes resulted in a decline of creatinine clearance to appr. 50% of the initial level. Prophylactic furosemide given prior to the perfusion brought down the creatinine clearance to 64% of the initial level. Furosemide, administered either prophylactically just before the cardiopulmonary bypass or after urine flow had declined below 0.5 ml/kg/h, had no effect on the potassium balance in the long perfusion group (over 60 minutes), though it clearly increased the negative potassium balance in the short perfusion group (below 60 minutes). In an experimental work on dogs, furosemide was found to elevate the tissue oxygen tension in the renal cortex and and medulla, and slightly to increase the blood flow in arteria renalis.

Intraoperative changes in coronary resistance during aortic valve replacement.

Coronary vascular resistance was investigated in 10 patients undergoing aortic valve replacement using continuous constant-pressure coronary perfusion at 32 degrees C. After coronary flow was initiated, resistance was low but increased steadily until it reached a certain resting level. The plateau was attained faster after a short period of anoxia than after a longer period. The initial postischemic resistance was dependent on the duration preceding anoxia, being of the same magnitude after short and moderate periods of anoxia but significantly higher after a long period. This resistance difference between the groups lasted for the whole perfusion. The total coronary resistance and flow reached a plateau in 30 minutes, while resistance increased threefold but flow decreased to half of the initial postanoxia flow. Our results indicate the importance of initiating coronary perfusion soon after aortic cross-clamping to avoid increase in the initial vascular resistance and subsequent inadequate myocardial flow.

Myocardial reactive hyperemia caused by initial myocardial anoxia during aortic valve replacement.

Reactive hyperemic response of individual coronary arteries and of the whole heart to anoxia during coronary cannulation was investigated in 10 patients undergoing aortic valve replacement. Reactive hyperemic response in man is identical to that reported in experimental investigations. The duration of hyperemic response was dependent on the length of the preceding period of anoxia; the longer the period of anoxia, the more prolonged was the hyperemic response. No significant collateral circulation between the coronary arteries could be demonstrated during prolonged anoxia of an individual coronary artery. Blood flow debt was almost always overpaid, but the repayment percentage decreased with the lengthening of the anoxic period, being 460 percent after a short period of anoxia (less than or equal to 2 minutes), 230 percent after an anoxic period of moderate length (3 to 5 minutes), and only 160 percent after a long period of anoxia (greater than or equal to 7 minutes). The total mean repayment of blood flow debt of the whole heart was 195 percent.

Chronic intragastric bile contamination and lower esophageal sphincter competence. An experimental study in dogs.

The possible association between intragastric bile reflux and lower esophageal sphincter (LES) incompetence was elucidated in an experimental work in dogs. Chronic intragestric bile contamination was produced by cholecystogastrostomy. The effect of this procedure on LES competence was evaluated by manometric, radiologic and endoscopic studies two weeks, one month, and then once a month for 6 months after operation. No significant change occurred in LES pressure, and neither radiological reflux nor endoscopic evidence of esophagitis developed during the follow-up period. According to the present study intragastric bile reflux does not have a significant role in the pathogenesis of LES incompetence in the dog, but esophagitis effected by bile reflux seems to require previously existing LES incompetence.

Effect of intragastric bile on canine lower oesophageal sphincter pressure.

The effect of intragastric bile on lower oesophageal sphincter (LES) pressure was studied in 7 dogs. Five ml of fresh canine bile was instilled into the stomach, and its effect on LES pressure and intragastric pH was observed for one hour. In a control study 5 ml of physiological saline was used instead of bile. Bile instillation led to a statistically significant increase in LES pressure, which reached its maximum in 20 min. LES pressure returned to the resting level in 60 min. Saline instillation produced no signficant change in LES pressure. The rise in intragastric pH was slight and equal in both groups. The results suggest that bile contamination of gastric juice, at least one of short duration, does not have any immediate harmful effect on LES competence in the dog.