Neurotensin-related regulation of the postprandial lower-oesophageal-sphincter pressure.

BACKGROUND: Ingestion of food has been shown to modulate the lower-oesophageal-sphincter pressure (LESP). Fat is especially effective in decreasing the postprandial LESP. As there is good evidence that neurotensin (NT) is able to decrease the LESP, we conducted the present trial to determine whether NT could possibly be a mediator of the fat-induced decrease of the LESP. METHODS: Six half-breed dogs were fitted for cervical side-to-side oesophagostomy to allow repeated oesophageal intubation; plasma NT immunoactivity was recorded during infusion of NT and after intragastric instillation of 200 ml of a fat solution. Experiments were repeated, with the specific NT antibody GN25 administered intravenously. RESULTS: The optimal dose of NT required to simulate a postprandial situation was 50 pmol/kg/h. Infusion of this NT dose led to a statistically significant decrease of the LESP. Simultaneous administration of the NT antibody (immunoneutralisation) significantly inhibited this effect. Intragastric fat decreased the LESP and increased plasma NT. Immunoneutralisation of endogenously released NT led to an earlier restoration of baseline LESP, but this effect was not statistically significant. CONCLUSIONS: NT and intragastric fat modulate the LESP. NT appears to mediate the postprandial, fat-induced decrease of the LESP. Research with specific NT-receptor antagonists is necessary to determine the exact role of NT and other regulatory peptides in this context.

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.

Volume shifts, unfolding and rolling of haustra in the isolated guinea pig caecum.

The large intestine extracts water from chyme and compacts chyme into faecal conglomerates; it is unclear what role the special pockets known as colonic haustra have in these events. Here we monitored the movements of haustra in isolated preparations of guinea pig caecum using videocamera and ultrasound and related them to contractions of muscle flaps and movements of glass beads in haustral pockets. We found that in partially filled caecal loops localized contractions of taeniae shift volume back and forth between adjacent haustra; volume unfolds haustral walls in a characteristic sweep with sequential intrahaustral folds popping out; cyclic contractions and relaxations of the fold then produce the caterpillar-like movement known as haustral rolling; ultrasound showed that haustral rolling made the haustral flow channel narrower and longer as haustral folds increase their height from 7.5 +/- 1.5 mm to 16 +/- 4 mm and their distance from 4.1 +/- 0.2 mm to 7.9 +/- 0.3 mm; luminal contents were alternatively shaken off the haustral wall, whirled around the lumen or left to settle. We also suspended the row of haustra between two taeniae inside a frame and attached flaps of taeniae and haustral folds to strain gauges to record their mechanical activity; both taeniae and haustral folds produced an undulating baseline tension; during rolling, folds produced phasic contractions at 17 +/- 2 cycles min-1 which propagated distally across haustral septa; rolling constantly shuffled around glass beads placed inside the haustra. When we stimulated the intramural nerves to the caecum through bipolar electrodes, all contractile activity was temporarily inhibited and haustral septa flattened; a rebound contraction then propagated aborally from the caecal pole and swept the glass beads ahead of it. Thus, tonic contractions of taeniae shift caecal contents back and forth across haustral septa; expansion of haustra triggers haustral rolling which shuffles contents; both these movements produce local flow within and between haustra which might enhance the separation of solid and liquid colonic contents.

Cecum of guinea pig is a reservoir and sigmoid is a high-resistance conduit.

We compared the filling responses of the cecum and the sigmoid of the guinea pig using volumes up to 60 ml and 2.5 ml, respectively. In the isolated cecum, each 1-cm increment of hydrostatic pressure above zero led to accommodation of 10 ml volume; in the sigmoid, the yield pressure (at which accommodation first occurred) was 6 cm H2O, and pressure increments up to 20 cm H2O produced volume increments of less than 0.5 ml. Resting pressure at half-maximal filling was 5.0 +/- 0.7 cm H2O for the sigmoid and 1.7 +/- 0.6 cm H2O for the cecum. K+ depolarization led to a significant upward shift in the pressure curves of both segments. Ca2+ withdrawal decreased sigmoid and cecal pressures at some volumes. Distension of the cecum triggered intermittent contractions, which began with the shortening of the teniae and were associated with low-amplitude pressures and expulsion of a 5- to 10-ml volume. Distension of the sigmoid produced propagating contractions that were associated with high-amplitude pressures and lengthening; compartmentalization in the sigmoid prevented efflux from it, and volume inflow was not affected by pressure waves. Our observations indicate that its large capacity and great distensibility make the cecum suitable for reservoir functions, whereas its narrowness and lack of distensibility make the sigmoid a high-resistance conduit.

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.

[Laparoscopic hernioplasty]. / Laparoskopische Hernioplastik.

We report our experience with laparoscopic repair of inguinal hernias since Dec. 1990. The initially used "plug & patch-technique" was abandoned because of high recurrence rates for primary hernias and other disadvantages. In Feb. 1992 we started with a transperitoneal-preperitoneal repair using closure of the defect with sutures as well as posterior wall reinforcement with polypropylene mesh. Based on established conventional techniques, the procedure has evolved and results in quick recovery and low recurrence rates. As compared to anterior techniques, a superior repair of large posterior wall defects, bilateral, femoral and especially recurrent hernias is achieved. Disadvantages are the transabdominal approach and the need of general anesthesia. The technique used in Göttingen is presented in detail. Between 2/92 and 9/93 we repaired 249 hernias (including 44 recurrences) in 207 patients. Major complications were observed in 1.6%. Up to now, we found 4 recurrences (1.6%, follow-up 87%, 5-24 months).

[The Chang mesocaval side-to-side shunt, an alternative shunt form after previous operations and portal vein thrombosis]. / Der mesokavale Seit-zu-Seit-Shunt nach Chang, eine alternative Shuntform nach Voroperationen und bei Pfortaderthrombose.

Over the time period from July 01, 1983 to June 01, 1993, 15 patients with portal hypertension and relapsing bleedings from esophageal varicosis were treated with Chang's mesocaval side-to-side shunt at the Department of General Surgery, University Hospital of Göttingen. All patients were pre-operated in the upper abdomen or exhibited thrombosis of the portal vein. While five cases revealed a prehepatic block, ten patients had an intrahepatic block, based on cirrhosis of the liver (Child classification A or B). The time required for operations was 180 +/- 32 minutes; the pressure in the portal circulation decreased by 56%. In three cases, patients suffered relapsing bleedings despite of regular shunt conditions. Complications which were due to the procedure were seen in two patients (one revealed intraabdominal posthemorrhage, followed by therapy-resistant coagulopathy; the other patient exhibited stenosis of the anastomosis). One patient developed encephalopathy. Given a rigid indication, we regard the procedure described herein an alternative to the mesocaval interposition shunt, and we consider the low rate of thrombosis (so far < 10%) without continued postoperative anticoagulant therapy as well as the avoidance of an interposition as important advantages of this technique.

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.

[Critical evaluation of laparoscopic hernia surgery]. / Kritische Würdigung der laparoskopischen Hernienchirurgie.

The success of the laparoscopic cholecystectomy was remarkable and well-founded, thus it seems necessary to examine whether this procedure could be also used for other general surgical operations. Since Dec. 29th, 1990 the transperitoneal repair of hernias by laparoscopy has been performed in 177 patients. The patients were followed up in regular intervals. The first 100 patients were treated with the "plug repair" technique of Schultz and Corbitt. In this group one recurrence (4 month after operation) and one dislocation of a mesh roll (2 weeks after the operation) were observed. In the middle of April 92 we changed the laparoscopic operation technique to a preperitoneal mesh fortification analogous to the procedure of Stoppa. This requires a detailed preparation of all possible positions of the hernia (medial and lateral compartment). A cutting through all layers of the abdominal wall can be avoided. After the preparation all abdominal wall defects can be fortified effectively and clearly. In this group we have treated 77 patients, so far without complications. With the exception of scrotal hernias and adhesions the laparoscopic hernioplastique can be used in any indication of inguinal hernia repair. An evaluation of the long-term results can only be performed in the future although the early results are encouraging.

Clinical and radiological findings in Gardner's syndrome: a case report and follow-up study.

Gardner's syndrome is characterized by colorectal adenomas, multiple osteomas, especially of the skull, and various soft-tissue tumours. The disease is inherited as an autosomal dominant disorder and all untreated patients will develop colorectal adenocarcinomas. Since the clinical and radiological stigmas in the maxillofacial area, such as exosteal and endosteal osteomas, skin cysts, atypical skin pigmentation and abnormal dental findings or radiopaque lesions can precede the often symptomless adenomas for many years, dentists, maxillofacial surgeons and radiologists should be familiar with the manifestations of this disease. A case is reported to illustrate the dentist's role in the diagnosis of Gardner's syndrome. In a follow-up study of 11 patients with colorectal adenomas, the typical triad of features of Gardner's syndrome was found in eight. In six patients, bony changes were demonstrated by panoramic radiography. It is proposed that radiography of the jaws may serve as a valuable tool for the early detection of carriers of Gardner's syndrome.

Sonographical findings in Whipple's disease. A case report with regard to the literature.

We present a case report of a 60-year-old male patient and subsequently discuss sonographical findings in Whipple's disease. This particular patient showed an intraabdominal tumorous mass. Symptoms of a malabsorption disorder were absent. Computer-assisted tomography and radiological examination could not determine the origin of the tumor. Sonography demonstrated a polycyclic hyperechoic mass in the root of the mesentery. The small intestine was not distended and showed normal peristalsis. Its wall was hyperechoic concentrically thickened. Final diagnosis was established from a diagnostic laparotomy showing enlarged lymph nodes and distended lymphatic vessels. Based on the literature the described sonographical findings seem to be typical in cases of Whipple's disease.