Patients with Barrett's esophagus are hypersensitive to acid but hyposensitive to other stimuli compared with healthy controls.

BACKGROUND: Esophageal hyposensitivity has been observed in Barrett's esophagus and may contribute to its pathophysiology. However, studies are few, in particular those assessing different sensory modalities. We aimed to compare esophageal sensitivity to multimodal stimulation in patients with Barrett's esophagus and in healthy controls. METHODS: Twenty-three patients with Barrett's esophagus and 12 healthy controls were examined. A multimodal probe was placed in the lower esophagus. Mechanical, thermal, and electrical stimulation was applied followed by an acid perfusion test with 0.1 N hydrochloric acid. KEY RESULTS: Compared with controls, patients were hyposensitive to mechanical distension, heat, and electrical stimulation (all P<.05), but hypersensitive to acid (mean tolerated acid volume 57% lower, P=.001). A linear correlation between acid hypersensitivity and lower baseline impedance was found (P<.001). Patients had longer esophageal acid exposure time than controls (median acid exposure time 18 vs 5%, P=.03). Asymptomatic patients (no reflux symptoms at baseline) were hyposensitive to mechanical distension, electrical stimulation, and acid perfusion (all P<.05) compared with symptomatic patients. CONCLUSIONS & INFERENCES: Patients with Barrett's esophagus exhibited acid hypersensitivity but hyposensitivity to other stimuli. Lower mucosal baseline impedance, a likely surrogate marker for impaired mucosal integrity, may explain the selective hypersensitivity to acid. On the other hand, the concurrent hyposensitivity may theoretically be explained by changes in central pain modulation. Patients with Barrett's esophagus seem to compose symptomatic and asymptomatic subgroups, showing different esophageal sensory profiles.

Esophagogastric junction distensibility in hiatus hernia.

Hiatus hernia is known to be an important risk factor for developing gastroesophageal reflux disease. We aimed to use the endoscopic functional lumen imaging probe (EndoFLIP) to evaluate the functional properties of the esophagogastric junction. EndoFLIP assessments were made in 30 patients with hiatus hernia and Barrett's esophagus, and in 14 healthy controls. The EndoFLIP was placed straddling the esophagogastric junction and the bag distended stepwise to 50 mL. Cross-sectional areas of the bag and intra-bag pressures were recorded continuously. Measurements were made in the separate sphincter components and hiatus hernia cavity. EndoFLIP measured functional aspects such as sphincter distensibility and pressure of all esophagogastric junction components and visualized all hiatus hernia present at endoscopy. The lower esophageal sphincter in hiatus hernia patients had a lower pressure (e.g. 47.7 ± 13.0 vs. 61.4 ± 19.2 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the common esophagogastric junction in controls. In hiatus hernia patients, the crural diaphragm had a lower pressure (e.g. 29.6 ± 10.1 vs. 47.7 ± 13.0 mm Hg at 50-mL distension volume) and was more distensible (all P < 0.001) than the lower esophageal sphincter. There was a significant association between symptom scores in patients and EndoFLIP assessment. Conclusively, EndoFLIP was a useful tool. To evaluate the presence of a hiatus hernia and to measure the functional properties of the esophagogastric junction. Furthermore, EndoFLIP distinguished the separate esophagogastric junction components in hiatus hernia patients, and may help us understand the biomechanics of the esophagogastric junction and the mechanisms behind hiatal herniation.

Randomized study of coagulation and fibrinolysis during and after gasless and conventional laparoscopic cholecystectomy.

BACKGROUND: Carbon dioxide pneumoperitoneum may be an important pathophysiological factor stimulating the coagulation system during conventional laparoscopic cholecystectomy. The aim of this study was to test the hypothesis that gasless laparoscopy produces smaller changes in the coagulation and fibrinolytic system than carbon dioxide pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients were allocated randomly to conventional (n = 26) or gasless (n = 24) laparoscopic cholecystectomy. Blood samples were obtained on admission, after induction of anaesthesia, after insufflation or traction, 30 min after introduction of the laparoscope, 10 min after exsufflation of carbon dioxide or traction, 4 h after extubation and 24 h after operation. RESULTS: The two groups were comparable with respect to age, sex, body mass index and duration of operation. Plasma levels of prothrombin fragment 1 and 2 (F1 + 2), soluble fibrin and D-dimer did not differ between the two groups. F1 + 2 levels varied significantly in both groups during and after operation (P < 0.001). Soluble fibrin and D-dimer levels did not change during operation in either group, but after operation the levels increased significantly in both groups (P < 0.001). CONCLUSION: Carbon dioxide pneumoperitoneum does not enhance the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. The coagulation and fibrinolytic systems are activated during and after gasless as well as conventional laparoscopic cholecystectomy.

Randomized comparison of conventional and gasless laparoscopic cholecystectomy: operative technique, postoperative course, and recovery.

The positive CO2 pneumoperitoneum needed to create the working space for laparoscopic surgery induces cardiovascular, neuroendocrine, and renal changes. Concern about these pathophysiologic changes has led to the introduction of a gasless technique. Fifty consecutive patients with symptomatic gallstones were randomized to conventional (CLC) or gasless laparoscopic cholecystectomy (GLC), with special reference to overall patient satisfaction, technical difficulties, duration of surgery, postoperative pain, and recovery. The overall exposure of the operative field was extremely poor in the GLC group, whereas the duration of surgery, steps involved in the cholecystectomy technique, length of hospital stay, and postoperative pain score did not differ significantly. After discharge, the median time to complete relief of pain tended to be shorter in the gasless group (5 days [range 1 to 15]) vs. the conventional group (8 days [range 1 to 15]). The period to return to normal activity was shorter in the GLC group (6 days [range 1 to 15]) compared to the CLC group (8.5 days [range 1 to 15]) (P = 0.031). No differences were found in terms of fatigue, dizziness and nausea, and overall satisfaction with the outcome. This study demonstrates a significantly shorter convalescence after laparoscopic cholecystectomy by means of the gasless technique compared to the conventional CO2 technique. Exposure of the operative field was less than optimal using the gasless technique.

Risk and patterns of bacteraemia after splenectomy: a population-based study.

During a period in which vaccination of splenectomized patients has been recommended, we analysed the patterns of severe post-splenectomy infections (i.e. bacteraemia or meningitis) in a defined population-based cohort. A total of 561 patients undergoing splenectomy were identified during 1984-93 in a Danish county, and the 538 eligible patients were followed for 1731 person-years. After splenectomy, 38 patients contracted a bacteraemia, of which 45% occurred within 30 d (i.e. during the postoperative period). No cases of meningitis were found. Among splenectomized patients the incidence rate of bacteraemia was 2.3 per 100 person-years at risk. Beyond the postoperative period we found an 8-fold increased risk of bacteraemia. Enterobacteria were the predominant cause (45%), and only 1 case due to Streptococcus pneumoniae was recorded. 89 (17%) died during the postoperative period, and the overall mortality rate was 18.4 per 100 person-years at risk. In all, 60% of the patients had been given a pneumococcal vaccination, and a Cox proportional hazard regression model showed that vaccination significantly reduced the risk of bacteraemia of any cause beyond the postoperative period. We conclude that splenectomy increases the risk of severe infections, and that vaccinated patients carry a lower risk of infection than non-vaccinated ones.

Dose relation in the prevention of proximal vein thrombosis with a low molecular weight heparin (tinzaparin) in elective hip arthroplasty.

This is a review of a double-blind, prospective study comparing the thromboprophylactic efficacy and safety of two different prophylactic regimens of a low molecular weight heparin (tinzaparin) in 250 consecutive patients (aged < or 18) undergoing primary elective hip arthroplasty. Regimen 1: 75 U anti-Xa/kg BW (actual range 63 to 91) once daily started 12 hours before operation; and regimen 2: 50 U anti-Xa/kg BW (actual range 41 to 71) once daily started 2 hours before operation. Both regimens were administered in a weight-adjusted fashion and were continued for 7 days after operation or until full mobilization. Efficacy was evaluated by occurrence of postoperative deep vein thrombosis (DVT) diagnosed by bilateral ascending phlebography on day 7 +/- 2 after operation, and the venograms were evaluated in an assessor blind fashion by a panel of three expert radiologists. Safety was evaluated by the amount of blood lost and transfusion requirements during and after the operation; all bleeding complications, reoperations, adverse events and deaths were observed during the study. A 3-month follow-up on survival and occurrence of thromboembolism was performed on all randomized patients. The result was a significantly better protective effect against proximal DVT by regimen 1 compared with regimen 2. This was achieved with improved safety in terms of a significantly decreased need for blood transfusions during operation and fewer wound complications in the postoperative period in favor of regimen 1. Therefore, tinzaparin administered in a dosage of 75 U anti-Xa/kg BW 12 hours before surgery is significantly more protective against proximal DVT and safer than the standard regimen of 50 U anti-Xa/kg BW started 2 hours before surgery in patients undergoing primary elective hip arthroplasty.

[Extramammary Paget's disease interpreted as psoriasis]. / Ekstramammaer Pagets sygdom tolket som psoriasis.

We describe a case of extramammary Paget's disease (EMPD) in the lateral part of the breast of a woman with known psoriasis. The eczema was treated as psoriasis for three years. There were no macroscopic changes of the nipple or areola. Nodular swellings beneath the eczema proved to be infiltrating ductal carcinoma. The eczema showed the pattern of EMPD. A mastectomy was performed. Two foci of ductal carcinoma in situ were found in the mammary body and two foci of Paget's disease were found in the areola and nipple. Fourteen axillary lymph nodes were examined without signs of malignancy.

[Results after surgery of incisional hernias]. / Resultater efter operation for hernia incisionalis.

The purpose of this paper is to describe the subjective results after operation for ventral hernia. Patients operated for ventral hernia in the period from January 1, 1988 to December 31, 1992 were sent a questionnaire with a response rate of 87%. Forty-five percent had lasting discomfort, 30% were absent due to illness more than eight weeks after the operation and 22% were not able to go to work. These factors increase with the number of hernia operations. Regardless of the number of operations, about 70% of the patients wanted a new operation should the hernia recur. It is therefore important to give the patient an objective and detailed information to prevent from unrealistic expectations of the results of ventral hernia operation.

Prophylaxis against pneumococcal infection after splenectomy: a challenge for hospitals and primary care.

OBJECTIVE: To evaluate prophylaxis against pneumococcal infection after splenectomy. DESIGN: Retrospective analysis. SETTING: District hospital, Denmark. SUBJECTS: 555 Patients who underwent splenectomy between 1 January 1984 and 31 December 1993. INTERVENTIONS: Splenectomy, pneumococcal vaccination. MAIN OUTCOME MEASURES: Pneumococcal vaccination rates and the time of vaccination related to different indications for splenectomy. Extent of information in hospital records about measures for prophylaxis against pneumococcal infection. Recording of splenectomy and vaccination in discharge letters. RESULTS: The total vaccination rate was 62% (344/555), but vaccination rates from 47% to 91% in five different groups of indications were observed. Patients undergoing splenectomy during cancer surgery or because of inadvertent intraoperative trauma to the spleen were particularly at risk of not being vaccinated. Vaccination rates increased from 59% to 70% during the period studied. Of the 235 patients alive on 1 April 1995, 87% (205) had been vaccinated. Only 23% of the patients were vaccinated at the appropriate time. Splenectomy had not been recorded in 10%, and vaccination status was mentioned in 35% of the discharge letters. Only 6% of the hospital records and 2% of the discharge letters mentioned one or more precautions to consider for asplenic patients. CONCLUSIONS: The pneumococcal vaccination rates of patients after splenectomy were not satisfactory. Most of patients were vaccinated at an inappropriate time in relation to the splenectomy. The discharge letters often lacked information about the patients' vaccination status. More effort is needed to reach an acceptable level of prophylaxis against pneumococcal infection after splenectomy.

Antibody levels against Streptococcus pneumoniae and Haemophilus influenzae type b in a population of splenectomized individuals with varying vaccination status.

In order to determine antibody levels against Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae type b (Hib) in a population of splenectomized subjects, 561 persons in a Danish county, splenectomized between 1984 and 1993 were identified. Two hundred and thirty-five were alive and 149 participated in the study. Each person donated a blood sample for antibody determination by ELISA. Though vaccine coverage among the 149 persons was 91% only 52% had 'protective' levels of pneumococcal antibodies. Despite recommendations for regular follow-up on pneumococcal antibody levels this had only been carried out in 4% of the subjects. Splenectomized subjects who needed pneumococcal revaccination were significantly more likely to have received their initial vaccination less than 14 days before or after splenectomy, as recommended, than those not requiring revaccination. Therefore, the timing of initial pneumococcal vaccination in relation to splenectomy seems to be important. All persons had Hib antibody levels higher than 0.15 microgram/ml and 60% had levels higher than 1 microgram/ml, which are the levels thought to provide short term and long term protection, respectively. In total, 37% of the 149 persons tested had pneumococcal and Hib antibody levels thought to correlate with protection from serious infections.

[Incisional hernia. A study of morbidity, mortality and bed utilization in a Danish county]. / Hernia incisionalis. En opgørelse af morbiditet, mortalitet og sengedagsforbrug i et dansk amt.

Four hundred and four patients operated for ventral hernia during a five year period were reviewed with special emphasis on morbidity, mortality and number of days in hospital. The patients were divided into 357 patients who had been operated for ventral hernia only once (A) and 47 patients who had been operated more than once for ventral hernia (B). There were no significant differences between the two groups regarding to ages or preoperative condition. The postoperative complications were 21% in group A and 12% in group B, although this was not statistically significant. Of those who suffered a complication after the operation, 76% had a competing illness prior to the operation. The overall mortality was 0.5%. The patients were hospitalized for a total of 4846 days. In view of the results of this material and of the high recurrence rate demonstrated in the literature, a restrictive attitude towards operations for ventral hernia is recommended.

[Chronic volvulus of the stomach]. / Kronisk ventrikelvolvulus.

Gastric volvulus is an abnormal rotation of the stomach. The incidence seems to be equal for men and women, and all ages are represented. Gastric volvulus may present as an emergency or as a chronic condition. Acute volvulus is potentially lethal if unrecognized, while a chronic volvulus may cause symptoms for years if not treated. Gastric volvulus may be more common than previously estimated. Approximately 700 cases have thus far been documented. Two case reports of chronic gastric volvulus are presented, of which one was treated by laparoscopic surgery.

[Early osteosynthesis of fractures of the lower extremities in patients with multiple trauma]. / Tidlig osteosyntese af underekstremitetsfrakturer hos multitraumatiserede.

In the early 1970s, some trauma centres began to perform early operative fixation of lower limb fractures in multiple trauma patients. At that time, no clinical studies were available on this topic. At present, several publications have demonstrated lower mortality, reduction of the incidence of Adult Respiratory Distress Syndrome and sepsis, and a shorter stay in hospital after early operative fracture fixation compared with conservative fracture management or late fracture fixation. The incidence of fracture complications appeared not to increase after early operative fracture fixation. The present paper is a review of the most significant reports concerning timing of operative fracture management of patients with multiple trauma. Prospective randomised trials are needed on this subject.

[Low molecular heparin in prevention of thrombosis in orthopedic surgery]. / Tromboseprofylakse med lavmolekylaert heparin i ortopaedkirurgien.

The review encompasses all published clinical studies of prophylactic treatment with low molecular weight (LMW) heparins marketed in Denmark when used to prevent thrombosis in patients undergoing elective or emergency orthopaedic operations. In elective hip surgery, LMW-heparin was more effective than placebo in reducing the incidence of deep vein thrombosis. There was significantly better anti-thrombotic effect of LMW-heparin, given in recommended doses, than of Dextran 70. When compared to low-dose heparin, the incidence of deep vein thrombosis was lowest using LMW-heparin, but only one study found the difference significant. LMW-heparin compared to low-dose heparin in combination with dihydroergotamine showed no significant difference with respect to either effect of safety. The use of LMW-heparin as prophylactic treatment for patients with either trochanteric or femoral neck fractures is as yet not nearly so well-documented. The relatively few studies that have been carried out show large variation between the different LMW-heparins. There is need for a study comparing the effect of LMW-heparin with that of low-dose heparin in these patients, both with respect to thrombosis prevention and influence on total mortality.

Markers of coagulation and fibrinolysis after fractures of the lower extremities.

The study was performed to detect activation of coagulation and fibrinolysis in terms of prothrombin fragment 1 and 2 (F1 + 2), thrombin-antithrombin III complex (TAT), fibrin degradation products (FbDP), fibrinogen degradation products (FgDP), and soluble fibrin monomers (FM) in plasma from 39 patients with fractures of the lower extremities. We found substantially elevated levels of the molecular markers at admission and on the day after admission (Day 1) compared with control levels. Admission levels of F1 + 2, TAT, FbDP and FgDP were significantly higher compared with levels on day 1, whereas levels of FM were not significantly different between the two days. Generally there were good correlations between all markers of coagulation and fibrinolysis at admission whereas correlations were weaker or absent on day 1. In conclusion we found substantial haemostatic activation as a immediate response to trauma. Increased levels of F1 + 2, TAT, FM, FbDP and FgDP appear to be a normal physiological reaction after fractures of the lower extremities.