Laparoscopic fundoplication for gastroesophageal reflux: effects on esophageal motility.

Laparoscopic Nissen-Rossetti fundoplication is now recognized as a valid therapy for the treatment of gastroesophageal reflux disease. This retrospective study evaluates the effects of laparoscopic fundoplication on esophageal motility and correlates these effects to postsurgical symptoms. A total of 123 patients underwent laparoscopic fundoplication at our institution. Pre- and postoperative esophageal manometric data were analyzed with regard to the effect of surgery and postsurgical outcome. Postoperative lower esophageal sphincter pressure was significantly increased compared wtih preoperative values (1.7 +/- 0.8 kPa vs 0.9 +/- 0.7 kPa). Duration and amplitude of esophageal body contractions were not modified. The percentage of deglutition-induced complete peristaltic waves and the velocity of propagation were significantly decreased after surgery (P < 0.05). Postoperative symptoms were significantly correlated with postoperative lower esophageal sphincter pressure only. Laparoscopic fundoplication significantly increases lower esophageal sphincter pressure. It significantly decreases esophageal body peristaltic efficiency, a decrease that is most likely of minor clinical significance.

[Gastric acid secretion in children with duodenal ulcer]. / Sécrétion acide gastrique de l'enfant atteint d'ulcère duodénal.

Gastric acid secretion was studied in 17 children with primary duodenal ulcer (mean age: 10 yrs 4 mo, rang: 4-16). Eight of the 17 children with primary ulcer had chronic evolution and 10 of them had an affected first degree relative. Basal acid output (BAO) and peak acid output under pentagastrin (PAO) were not significantly different in the 17 children (0.094 +/- 0.085 mmol/kg/hr; 0.483 +/- 0.235 mmol/kg/hr) and in 32 adults with duodenal ulcer (0.073 +/- 0.010 mmol/kg/hr; 0.477 +/- 0.021 mmol/kg/hr). BAO and PAO were not significantly different between children with or without chronic ulcer. The BAO and PAO of children with an affected first degree relative were significantly higher than those of children without (p less than 0.05). This study shows that gastric acid secretions are similar in children and adults with duodenal ulcer. The chronicity of duodenal ulcer in childhood is not associated with increased acid secretion. Gastric acid secretion seems to be higher in children with an affected first degree relative than those without.

Long-term results of surgical treatment for gastroesophageal reflux in asthmatic patients.

We report the long-term results of surgical repair of gastroesophageal reflux in 44 asthmatic patients who underwent surgery more than five years earlier (mean = 7.9 +/- 1.5 years). The severe asthma was associated with clinically evident reflux, and repair was attempted by surgical technique Nissen transabdominal gastropexy, with the following results: total cure, 11 cases (25 percent); marked improvement, 7 (16 percent); moderate improvement, 11 (25 percent); no improvement, 15 (34 percent). Cure was attained in intrinsic asthma with a predominance of nocturnal crises, associated with nocturnal tracheitis and with significant reflux, objective signs of which had appeared before the beginning of the asthma. Other results concerned asthmas complicated secondarily by GER in which it was impossible to determine whether the reflux was only a complication, without effect on the respiratory illness, or exacerbating the asthma. The question of surgery in these patients should be considered with care, being reserved for cases of severe asthma, poorly controlled by antiasthmatic drugs, and complicated by a severe reflux that encompasses ulcerative esophagitis.

Assessment of the lactulose-mannitol test in Crohn's disease.

The mannitol-lactulose intestinal permeability test was evaluated in 100 healthy controls and 47 patients with Crohn's disease. These patients were further separated into three subgroups of increased activity (Harvey-Bradshaw index) and in two subgroups, with elective colonic lesions and associated ileal and colonic lesions. Results were given as percentages of urinary recoveries for mannitol (M), lactulose (L), and L/M ratio. As a whole, patients with Crohn's disease have lower mean M and higher mean L and mean L/M ratios than controls. The magnitude of alterations in M, L, and L/M increased with activity. The sensitivity of the test, however, reached interesting figures (67%:L and 86%:L/M) only in subgroup III which was composed of relapsing patients. Mean M was lower in patients with associated ileal lesion but, whatever the criterion (M, L, or L/M), the test does not provide any clue for the detection of a possible infraclinical associated ileal localisation.

Clinical and hormonal effects of a long-acting somatostatin analogue in pancreatic endocrine tumors and in carcinoid syndrome.

Nine patients with pancreatic apudomas (seven gastrinomas, one glucagonoma, one tumor secreting a substance P-like component) and nine with metastasized carcinoid tumors were treated with a somatostatin analogue (SMS 201-995), administered subcutaneously twice daily for 3 days. Treatment was pursued for 2 to 12 months in nine patients in whom SMS was clinically and/or biologically beneficial. In gastrinomas, SMS decreased plasma gastrin in all but one patient, inhibited the residual gastric acid secretion under H2-blockers and improved diarrhea; in the glucagonoma patient, glucagonemia decreased and skin lesions disappeared. In carcinoid syndrome, clinical efficacy was partial and inconstant; daily 5-hydroxyindole acetic acid (5-HIAA) output was slightly decreased. Plasma substance P levels decreased in six patients with initially high concentrations. No antitumoral activity or side effects have been so far evidenced. SMS 201-995 is a useful, well-tolerated agent in secreting pancreatic apudomas and to a lesser extent in carcinoid syndrome, where high-dosage regimens may be required.

Effect of 40749 RP on basal and sham feeding stimulated gastric secretion in man.

40749 RP, a pyridyl-2-tetrahydrothiophene derivative, is known to be a potent inhibitor of the gastric acid response to pentagastrin, betazole and a meal. In 6 healthy young volunteers, a single oral dose of 2 mg.kg-1 greatly reduced the gastric acid secretory response to sham-feeding. By contrast, neither gastric pepsin nor the plasma PP response were altered by the drug. No change was observed in plasma gastrin, motilin, VIP or somatostatin concentrations. The results show that 40749 RP is also active on the pure vagus-stimulated gastric acid secretion. The lack of effect upon gastric pepsin and plasma PP suggests that 40749 RP is not likely to act on the basolateral cholinergic receptor and that it affects further cellular steps involved in hydrogen ion secretion.

Effects of proximal gastric vagotomy on gastric secretory and plasma hormonal responses to sham feeding in patients with duodenal ulcers.

The effects of proximal gastric vagotomy on the gastric secretion of acid and pepsin, and on the release of gastrin and pancreatic polypeptide in response to sham feeding were assessed comparatively within 1-4 months after surgery in 32 male duodenal ulcer patients. Each test comprised three successive periods: basal, modified sham feeding (MSF) and pentagastrin stimulation. In each test period the acid output was strongly correlated with the corresponding pepsin output, both parameters being reduced to similar extents after vagotomy. The percentage of postoperative reduction of MSF-induced acid and pepsin outputs was positively correlated with the preoperative values. MSF resulted in a limited but significant release of gastrin, the response being significantly greater after surgery. The MSF-induced release of pancreatic polypeptide was significantly reduced by proximal gastric vagotomy, the reduction percentage being negatively correlated with the time elapsed since surgery. Neither pre- nor post-operatively did the gastrin and pancreatic polypeptide responses bear any relationship to the other parameters tested. We conclude that the study of sham feeding responses of pepsin, gastrin and pancreatic polypeptide provides no further information than does the measurement of acid secretion for the segregation of duodenal ulcer patients, especially with respect to follow-ups for ulcer recurrence.

Increased effect of multiple doses of 40 749 RP a new long acting gastric antisecretory agent.

40,749 RP, a pyridyl-2-tetrahydrothiophene derivative is known to be a potent gastric antisecretory agent in animals and man. In 27 healthy volunteers in four double-blind cross-over studies, this activity has been examined against basal and pentagastrin stimulated gastric acid secretion. The effect of a single oral dose of 2 mg/kg was still present after 12, 24 and 48 h. The effect of 1 mg/kg was definitely increased after treatment for 7 days as compared to a single dose of 1 mg/kg.

Substrates for cold thermogenesis in thyrotoxic dogs.

The influence of thyrotoxicosis on energy supply during cold exposure was studied in normal and chronically thyroxine (T4)-treated normothermic dogs exposed to neutral (Ta,N = +25 degrees C) or cold (Ta,C = -21 degrees C) ambient temperatures. At Ta,N, T4 treatment significantly increased VO2, glucose turnover, and plasma 3-hydroxybutyrate concentration. The percentage of glucose turnover derived from alanine also increased in spite of lower alanine release. In cold, T4 treatment did not significantly modify O2 consumption, glucose turnover, or plasma alanine concentration, but plasma hydroxybutyrate, alanine clearance, and alanine conversion into glucose were significantly increased compared with control. It is suggested that in cold the main effect of thyrotoxicosis on energy supply, in addition to a trend toward lipid mobilization, is an increase in hepatic alanine extraction and conversion into glucose in the presence of lower muscular alanine delivery.

Effect of cold ambient temperature on glucose and alanine turnover in dogs.

The metabolic effects of acute cold exposure were examined in dogs exposed to either +25 degrees C (TaN) or -21 degrees C (TaC). Simultaneous infusion of D-3-3H glucose and U-14C alanine was used to measure glucose (R Glu) and alanine carbon (R Ala) turnover rates. At the two ambient temperatures the animals remained normothermic and normoglycemic throughout the experiments. Cold exposure provoked a significant increase in VO2 (X 4.5), plasma 3-hydroxybutyrate concentration (X 1.8), R Glu (X 2.3) and alanine metabolic clearance (X 1.7), while plasma alanine concentration (X 0.4) and R Ala (X 0.6) were significantly decreased. At TaN and TaC, significant direct relationships were found between R (Ala) and plasma alanine concentration, the alanine fractional turnover rate being higher at TaC than at TaN. At the two ambient temperatures, inverse relationship was found between R (Ala) and plasma 3-hydroxybutyrate concentration. These experiments indicate that in spite of increased glucose needs, acute cold exposure is accompanied by reduced alanine release. They suggest that alanine plays only a minor role in cold-stimulated gluconeogenesis in dogs.

Effects of endogenous glucagon on glucose kinetics in shivering dogs.

Intravenous infusion of D-[3-3H]glucose at a constant rate was used to measure glucose production (rate of appearance, Ra) and utilization (rate of disappearance, Rd) in normal overnight-fasted dogs exposed to either neutral (TaN = +25 degrees C) or cold (TaC = -21 degrees C) ambient temperature. At TaC the metabolic rate was 4.1 times greater than at TaN and the dogs remained normothermic under both conditions. During control periods, cold exposure provoked a 2.2 times increase in hepatic Ra while plasma glucagon remained unaffected. Between two control periods somatostatin (1 microgram.kg-1.min-1 iv) and insulin (0.5 mU.kg-1.min-1 intraportal) were infused in such a manner that plasma insulin remained fairly constant at basal levels while glucagon dropped by 51% (TaN) and 66% (TaC), these percentages being not significantly different. This selective glucagon deficiency resulted in a 24% (TaN) and 30% (TaC) reduction in plasma glucose concentration, due to a 23% (TaN) and 25% (TaC) reduction in glucose production. There was a significant (r = 0.82, P less than 0.01) correlation between the control Ra and the reduction induced by the glucagon deficiency. At TaN and TaC, two significant parallel relationships were found between hepatic Ra and plasma glucagon concentration suggesting that glucagon has a modulatory effect on more fundamental mechanisms triggered by the cold-increased metabolic needs.

Independence of circulating insulin levels of the increased glucose turnover in shivering dogs.

In dogs, selective insulin deficiency induced by simultaneous somatostatin and glucagon infusion does not alter the high rate of glucose utilization provoked by acute cold exposure. However, both in resting and in shivering dogs, lowering of plasma insulin decreases plasma glucose metabolic clearance significantly.

[Glucose metabolic clearance during acute cold exposure. Effects of insulin and glucagon (author's transl)]. / La clairance métabolique du glucose pendant l'exposition aiguë au froid. Effets de l'insuline et du glucagon.

The glucose metabolic clearance (CMG) was measured by using tritiated glucose in dogs either resting at neutral ambient temperature (TaN = + 25 degrees C) or shivering in the cold (TaC = 21 degrees C). Between two control periods, insulin and/or glucagon deficiencies were provoked by jugular somatostatin infusion without or with portal insulin (glucagon deficiency) or glucagon infusion (insulin deficiency). It was observed that: (1) In absence of hormonal deficiency, CMG was about twice as high at TaC as at TaN; (2) A simultaneous insulin and glucagon deficiency decreased CMG only at TaC; (3) Both at TaN and TaC, the CMG was either decreased or increased by insulin or glucagon deficiency respectively; (4) The magnitude (16-30%) of the hormonal-induced variations were small by comparison with the increase induced by the lowering of the ambient temperature.