[Loop ileostomy--the first choice for relief of colon and rectum]. / Loop-ileostomi--første valg ved aflastning af colon og rectum.

In numerous comparative investigations, loop-ileostomy has proved superior to transversostomy. The operative technique is described and experience from 27 loop-ileostomies carried out in a department for organ surgery are reviewed. The qualities of the method as compared with transversostomy are discussed on the basis of the literature and the authors' own results. It is concluded that loop-ileostomy may, in general, be preferred for temporary and palliative relief of the colon.

Benign nevus cells in the lymph nodes. An immunohistochemical study.

Aggregates of nevus cells in the axillary lymph nodes may give rise to a suspicion of metastatic breast cancer. Usually the nevus cells are confined to the capsule or the trabeculae, but in the present case, clusters of nevus cells were also observed in the peripheral sinus. Immunohistochemical analysis for S-100 protein and epithelial membrane antigen established the true nature of the cells.

Reproducibility of the fluorescein dilaurate pancreatic function test.

The indirect pancreatic function test, the fluorescein dilaurate test, was performed twice on nine healthy volunteers. The test is based on the renal excretion of fluorescein liberated from an ingested fluorescein ester by pancreatic enzymes. As a control, fluorescein sodium was ingested under similar conditions. The results of the test are expressed as the ratio of the amount of fluorescein excreted in the test part and the control part, forming the test/control (T/C) ratio. The mean values of excreted fluorescein correlated well with those reported by other authors. The coefficient of variation was 35% in the repeated test and of the same order in the series of individuals. The test cannot be recommended as a quantitative test until further investigation has been performed. Its use as a screening test is found questionable.

Prophylaxis with whole gut irrigation and antimicrobials in colorectal surgery. A prospective, randomized double-blind clinical trial.

In a prospective, randomized double-blind trial, the efficacy of whole gut irrigation as preoperative bowel preparation for elective colorectal surgery was evaluated alone and in combination with two antimicrobial agents in 148 patients. The antimicrobial regimens were metronidazole alone or metronidazole and ampicillin administered systemically preoperatively and continued for 3 days. Whole gut irrigation was completed without any discomfort in 87 percent of the patients. In 3 percent, the irrigation was stopped and the patients were excluded from the study. Abdominal wound infection developed in 32 percent of the patients after whole gut irrigation, and the addition of metronidazole decreased this incidence to 22 percent (not significant). The incidence in wound infections in the group receiving metronidazole as well as ampicillin was 2 percent, and this difference was highly significant compared with both other groups. No significant difference was found for the incidence of intraabdominal abscesses (p = 0.06), infection of the perineal wound, or anastomotic leakage. No difference in the postoperative infection rate was found between a bowel containing fecal fluid or fecal masses, but when a bowel was clean, significantly fewer infectious complications were found. Whole gut irrigation is a rapid, well-tolerated, easily performed, and safe form of preoperative bowel preparation in elective colorectal surgery if combined with systemic antimicrobial prophylaxis consisting of antimicrobial agents effective against anaerobic and aerobic organisms.

Non-absorbable suture material as a nidus for the formation of common bile duct stones.

A patient with double recurrence of common bile duct stones formed around non-absorbable suture material is reported. Clinical evidence from the literature is presented to support the recommendation that non-absorbable suture material should be avoided in the region of the biliary tract.

Arhus County Vagotomy Trial: gastric secretory alterations during the first year after selective gastric and parietal cell vagotomy.

Changes in gastric acid secretion during the 1st year after selective gastric (SGV) and parietal cell (PCV) vagotomy for duodenal ulcer disease were studied. Pentagastrin tests were performed preoperatively and 3 months and 1 year after surgery in 383 SGV and 302 PCV patients. Resting juice pH showed after both operations a trend towards the preoperative distribution from 3 months to 1 year. Basal acid output showed a similar pattern. The initial reduction in pentagastrin-stimulated peak acid output (PAOpg) was most pronounced after SGV, but an increase occurred for both operations during the 1st postoperative year. An exception from this was the minority of patients who had a less than 20% initial reduction. They had a further decrease in their PAOpg. No sex difference and no influence of the duration of symptoms could be demonstrated. The patients with less than 20% initial reduction were younger than the other groups, and this applied for both SGV and PCV. The patterns of change in gastric acid secretion during the first year after vagotomy suggest that biologic factors are active, in addition to the effect of the surgical technique.

Arhus County Vagotomy Trial: ulcer recurrence rate related to alterations in gastric acid secretion after selective gastric and parietal cell vagotomy.

Clinical and secretory data were analysed with respect to the recurrence rate for 685 patients treated with either selective gastric vagotomy (SGV) or parietal cell vagotomy (PCV) for duodenal ulcer disease. The duration of ulcer history before surgery was of no importance for the recurrence risk. Men with recurrence after SGV were significantly younger than men without recurrence, but no difference was found for women with SGV or for men and women with PCV. The recurrence rate was not higher for hypersecretors (pentagastrin-stimulated peak acid output (PAOpg) greater than 45 mmol/h) than for patients with lower PAOpg. Resting, basal, and stimulated secretion 3 months after surgery were higher for the patients with recurrence than for the patients without, but only a few of the secretion values were significantly different. A higher recurrence rate was found for the patients with the lowest initial acid reduction, and this trend was more pronounced in the PCV group. With regard to the change in gastric secretion during the first year after vagotomy a significant rise was seen for the PCV patients who developed recurrence in spite of initial reduction of more than 60%. For all SGV patients and the PCV patients with an initial reduction on the average or less, the change in secretion capacity had no influence on the recurrence rate. The findings are in accordance with reports about anatomical limitations for a sufficient PCV in about 20% of the patients.

Arhus county vagotomy trial. Acid secretory patterns in patients with prepyloric, pyloric, and duodenal ulcer.

Prepyloric (PPU), pyloric (PU), and duodenal bulb ulcers (DU) are traditionally incorporated in the clinical entity 'duodenal ulcer disease'. Clinical and gastric secretory data were analyzed with respect to the ulcer location in a prospective study with complete data from 776 patients. 574 had DU, and the female/male ratio was 0.39. 95 had PU (female/male ratio = 0.61) and 107 PPU (female/male ratio = 0.53). The higher female/male ratio for PU and PPU as compared to DU was significant. The age distribution showed a significant trend to younger age representation of males in the DU group, while the age distribution of the females was equal for the three groups. The duration of symptoms before elective surgery was equal for all three groups. The pentagastrin-stimulated peak acid output was significantly higher for DU compared to PPU, and this applied for both sexes even when the values were corrected for body weight as well as for age differences. Our results indicate DU and PPU to be materially different while PU constitute an intermediary group.

Gastric acid secretion and fasting serum gastrin in patients with duodenal ulcer, prepyloric ulcer or gastric ulcer.

In order to evaluate whether prepyloric ulcer (PPU) could be classified as an intermediate ulcer type between duodenal ulcer (DU) and gastric ulcer (GU), fasting serum gastrin as well as basal and pentagastrin-stimulated acid secretion were studied. The fasting serum gastrin values in the three groups were not significantly different. Patients with PPU and DU showed a higher basal acid output compared to GU patients. The basal acid output in DU patients increased in the last two periods before stimulation, and in the last basal period it was significantly higher compared to PPU patients. Patients with GU showed the lowest basal and stimulated acid output. However, the higher stimulated acid output in DU patients was insignificantly different from that of PPU patients. The results indicate that basal and stimulated gastric acid secretion values in PPU patients are closer to those of DU patients than of GU patients. Furthermore, it is concluded that PPU is a homogeneous ulcer type without secretory overlap with the GU group.

Recovery of gastric acid after vagotomy with and without a drainage.

This study tests the possibility that the difference in acid reduction after parietal cell vagotomy (PCV) and selective gastric vagotomy with a drainage (SGV + D) could be explained by differences in the secretion recovered rather than by real secretory differences. A method for estimating the completeness of aspiration during gastric function tests using the isotope Na251CrO4 as an inert marker is described. The method was used in patients with the two types of vagotomy and the recovery of gastric secretion was more complete after PCV (89.7%) than after SGV + D (75.1%). This difference may substantially account for the apparent difference in reduction of acid secretion after the two operations. The pyloroplasty supplementing the SGV is probably responsible for a pyloric loss causing a lower recovery after this operation.

Pedunculated vagally innervated lesser curve gastric pouch in dogs.

An optimal vagally innervated gastric pouch in dogs is constructed as a pyriform flap from the anterior wall of the stomach. Nerves and vessels are spared in a pedicle from the lesser curvature. The acid secretion pattern is similar to the secretion in nonvagotomized gastric fistula dogs as measured by stimulation with insulin and 2-deoxy-D-glucose. The dogs have been maintained for prolonged periods without deterioration, and the advantages of the model are mentioned.

Dose-response studies of acid secretion after administration of tetragastrin. Studies in duodenal ulcer patients before and after highly selective vagotomy, hemigastrectomy and truncal vagotomy plus antrectomy.

Dose-response studies to tetragastrin were performed in patients with duodenal ulcer before and after highly selective vagotomy, hemigastrectomy and truncal vagotomy plus antrectomy. The calculated maximal response and the dose necessary to elicit 50 percent of that response (D50) were calculated by linear transformation of the results. Both highly selective vagotomy and hemigastrectomy were followed by a significant decrease in the stimulated acid output, characterized by a decrease in the calculated maximal response, but no change in the sensitivity of the parietal cells (D50) was observed. This indicates a noncompetitive reduction in the acid output. The calculated maximal response could not be restored to preoperative values by increasing the dose of stimulant. Truncal vagotomy plus antrectomy was followed by severe alteration in gastric physiology, and no linear transformation of the acid output could be made. This investigation shows that maximal acid output was obtained by the same dose of stimulant before and after all three operations studied. Therefore it is not necessary to increase the dose in postvagotomy acid studies.

Effect of beta 2-sympathomimetic on pentagastrin- and histamine-stimulated gastric acid secretion in vagotomized gastric fistula dogs.

The effect of a beta 2-adrenoceptor agonist on pentagastrin- and histamine-stimulated gastric acid secretion was studied in conscious vagotomized gastric fistula dogs. A dose-dependent inhibition was found after pentagastrin stimulation, whereas minor differences were found after histamine stimulation. No major differences between truncal, selective, and parietal cell vagotomy were found after pentagastrin stimulation, whereas one truncal vagotomy dog showed a high inhibition after histamine stimulation. Dose-response experiments with five doses of pentagastrin or histamine (single-dose studies) and two doses of beta 2-agonist suggested a change after vagotomy in the mechanisms of inhibition of gastric acid secretion: for pentagastrin, from a non-competitive type to an uncompetitive type, and for histamine, from a competitive type to a non-significant inhibition. Furthermore, the dose-response curves for the vagotomized dogs were very similar to the curve from intact innervated dogs inhibited by a beta 2-agonist, from an earlier study. These findings may indicate that a decrease in cholinergic tone and an increase in sympathetic tone have identical effects on pentagastrin- and histamine-stimulated gastric acid secretion, and a counterbalance between the two nervous systems on gastric acid secretion is suggested.

Effect of two types of beta-adrenergic blockade on gastric acid secretion during pentagastrin stimulation in non-vagotomized and in vagotomized gastric fistula dogs.

The effect of beta-adrenoceptor blockade by propranolol and practolol on submaximally pentagastrin-stimulated gastric acid secretion was studied in conscious non-vagotomized and in vagotomized gastric fistula dogs. Propranolol (0.5 mg/kg) intravenously augmented gastric acid output in vagotomized dogs, more after truncal and selective vagotomy than after parietal cell vagotomy. Vagally innervated dogs also showed an increase, but to a lesser degree and not statistically significant. The increase restored the acid output to preoperative levels in the vagotomized dogs. Practolol (1.0 mg/kg) intravenously resulted in a slight and insignificant increase in acid output in dogs with truncal vagotomy and had only a negligible effect in vagally innervated dogs and after selective and parietal cell vagotomy. It is concluded that propranolol augments pentagastrin-stimulated acid output in vagotomized dogs, and this augmentation was most pronounced in the totally vagotomized stomach. Practolol had minor influence on gastric acid secretion. This effect of the two beta-blocking agents indicates that beta 2-blockade is most important for the secretory augmentation. The restoration of postvagotomy acid secretion to preoperative levels suggests that adrenergic influence is important for the decrease in pentagastrin-stimulated acid secretion after vagotomy.

Effects of beta2-sympathomimetic on histamine-stimulated gastric acid secretion in dogs.

The effect of a selective beta2-adrenoceptor agonist on histamine-stimulated gastric acid secretion was studied in conscious gastric-fistula dogs. A dose-dependent inhibition was found, most pronounced for the lowest doses of histamine. The inhibition was on the volume, whereas the acidity was unchanged. The pulse rate was increased by the beta2-agonist and by histamine. Propranolol prevented the inhibition of acid secretion as well as the increase in pulse rate. Practolol had no effect on the inhibition of acid secretion but reduced the increase in pulse rate. Dose-response experiments with six doses of histamine and two doses of the beta2-agonist showed unchanged calculated maximal response and an increase in D50. It is concluded that the beta2-agonist inhibits histamine-induced acid secretion in the dog, but to a lesser degree that pentagastrin-induced acid secretion, as found in earlier experiments. The inhibition follows competitive kinetics, and beta2-receptors are probably involved. The influence of beta2-sympathomimetics on the mechanism of gastric acid secretion is discussed.

Inhibition of gastric acid secretion in dogs by a new sympathomimetic drug.

The effect of salmefamol, a new beta 2-agonist, on pentagastrin-induced gastric acid secretion was studied in conscious gastric fistula dogs. Salmefamol inhibited the acid secretion, an effect which was dose dependent. The volume as well as the acidity was inhibited. Salmefamol caused an increase in the pulse rate. Propranolol prevented the inhibition of acid output as well as the increase in pulse rate. Practolol, a beta 1-adrenoceptor blocker, had no effect on the inhibition of acid secretion but prevented the increase in pulse rate. Dose-response experiments with 6 doses of pentagastrin and 1 dose of salmefamol showed a decrease in calculated maximal response (CMR) and an unchanged D50. It is concluded that salmefamol strongly inhibits pentagastrin-induced acid output in the dog, and the inhibition follows a non-competitive kinetic. The mechanism of gastric secretion probably involves a beta 2-receptor.