[Surgical treatment of paraesophageal hiatal hernia with total intrathoracic volvulus of the stomach]. / Le traitement chirugical des hernies hiatales par roulement avec volvulus intrathoracique de la totalité de l'estomac.

UNLABELLED: From 1971 to 1993, we operated 44 patients, 34 females and 10 males with a paraoesophageal hernia in which the entire stomach entered the thorax. Mean age of the patients was 70 years. Seventeen patients underwent emergency surgery for strangulated hernia leading to complete ghastric occlusion, gastric bleeding or necrosis (3 cases). Only 2 patients had a past history of gastro-oesophageal reflux. The following techniques were used: abdominal access in all cases, saccular resection, closure of the widened hiatus or of a left sided hernial hiatus, anterior gastropexy suturing the greater curvature to the abdominal on the left. Several patients were in precarious clinical situations and had to be treated under local or regional anaesthesia alone. Two patients had partial necrosis of the stomach and were treated by partial gastropexy. There were no deaths or major complications. Incomplete recurrence was noted in one patient 2 years after the initial procedure. IN CONCLUSION: 1) abdominal access is much preferable; 2) an antireflux procedure is only indicated when the patients have signs of gastro-oesophageal reflux; 3) most complications are not due to the hernia itself but to gastric volvulus. Consequently, simple reduction of the hernia followed by anterior gastroplexy under local anaesthesia can give excellent results in patients in precarious clinical situations and argues against major operation with general anaesthesia; 4) due to the gravity of paraesophageal hernia, a surgical solution is required as soon as diagnosis has been confirmed.

[Surgical treatment of chronic idiopathic constipation]. / Le traitement chirurgical de la constipation chronique idiopathique.

We review current experience with surgical treatment of severe constipation due to primary inertia of the colon. Over the last 10 years, we have operated 18 patients (14 females and 4 males) with severe constipation. The surgical procedure was either nearly total colonectomy with ascending colon/rectum anastomosis (8 cases) or total colonectomy with ileorectal anastomosis (9 cases). In one patient, coloproctectomy was performed with an ileoanal anastomosi. Indications for surgery were based on results of barium emena and functional evaluation of defecation. Results were satisfactory in all patients. In several patients however, we noted that the motility of other levels of the digestive tract was also impaired. Colonectomy was introduced as a treatment for chronic constipation nearly a century ago and although very few indications have been retained in the recent this procedure has now become an acceptable surgical approach in a limited number of well-though-out cases.

[Ulcerous disease of endocrinal origin caused by a non-gastric substance]. / Maladie ulcéreuse d'origine endocrine véhiculée par une substance non-gastrinique.

The purpose of this paper is to report on a form of duodenal ulceration associated with a major hypersecretion that we described in 1984. This entity belongs to the group of endocrine duodenal ulcer diatheses of which the Zollinger-Ellison Syndrome (ZES) is the prototype. We have recently in 1989 reported a series of patients with clinical and pathologic features indistinguishable from those of the Zollinger-Ellison syndrome but without hypergastrinemia. We have also found that the plasma and the tumor tissues of these patients contains a potent non-gastrin secretagogue.

[Ulcer disease of endocrine origin associated with a non-gastrin substance]. / Maladie ulcéreuse d'origine endocrine véhiculée par une substance non-gastrinique.

The purpose of this paper is to report on a form of duodenal ulceration associated with a major hypersecretion that we described in 1984. This entity belongs to the group of endocrine duodenal ulcer diatheses of which the Zollinger-Ellison Syndrome (ZES) in the prototype. We have recently in 1989 reported a series of patients with clinical and pathologic features indistinguishable from those of the Zollinger-Ellison syndrome but without hypergastrinemia. We have also found that the plasma and the tumor tissues of these patients contains a potent non-gastrin secretagogue.

[Ambulatory surgery in the United States. Reasons of its existence and future]. / La chirurgie ambulatoire aux USA. Ses raisons d'être et son avenir.

Ambulatory surgery has been gaining momentum in the United States over the past decade. This does not result from an initiative taken by the medical profession, but from a government plan aimed at checking the soaring costs of medical care. Since this rise was chiefly caused by hospital costs, the attempted savings have primarily affected our privilege of admitting the patients to hospital as we wanted. It has become impossible to admit a patient to hospital for diagnostic testing. Even for major surgery (such as resection of the esophagus, duodenopancreatotomy, etc.), the patient comes to hospital on the very morning of the operation. In addition, the medical mutual benefit insurance companies, in particular, the HMOs, have decided that some operations must be performed without any stay in hospital. This has resulted in the creation of ambulatory surgery units, which were either integrated in hospital surgery departments, or independent, and of which we discuss the pros and cons. In addition, an infrastructure aimed at facilitating postoperative care at home or in smaller private units has been set up. Laparoscopic surgery has further increased the percentage of ambulatory operations. There certainly will be no retreat now.

Liver injury with alcoholiclike hyalin after gastroplasty for morbid obesity.

Hepatic damage resembling alcoholic hepatitis has been described after jejunoileal bypass surgery for morbid obesity, but has not been previously reported as a complication of gastric partitioning operations (gastric bypass and gastroplasty). A patient who developed an alcoholic hepatitislike clinical picture 8 mo after gastroplasty is described, suggesting that malnutrition superimposed on obesity may be responsible for the injury in both settings. Reversal of the gastroplasty was associated with clinical and biochemical improvement.

Gastric and small intestinal myoelectric dysrhythmia associated with chronic intractable nausea and vomiting.

We describe a patient with symptoms of severe nausea, vomiting, epigastric bloating and pain, and marked weight loss due to a gastrointestinal motility disturbance. Motility abnormalities were characterized by uncoordinated high pressure (as high as 300 mm Hg) contractions and uncoordinated interdigestive motor complexes in the duodenum and small intestine, and tachygastria often associated with tachyarrhythmia in the gastric myoelectric activity recordings. Uncoordinated interdigestive myoelectric complexes again were found in the duodenum and small intestine. These abnormal myoelectric activities observed in the in-vivo study were confirmed in the in-vitro study. After distal hemigastrectomy and gastrojejunostomy, the symptoms of nausea, vomiting, and epigastric pain decreased considerably. Thus, the motility abnormality found in the study appears to be responsible for the symptoms described. This is probably a new clinical entity. The importance of manometric and myoelectric study of a gastrointestinal motility for unexplained nausea and vomiting is emphasized.

Influence of cold on stress ulceration and on gastric mucosal blood flow and energy metabolism.

"Ice-cold" gastric lavage is an important part of the treatment of bleeding from stress ulceration. The purpose of this study was to find out if cooling modifies ischemic injury of the gastric mucosa. Four series of experiments were performed in rabbits. In the first, we studied the influence of cooling on the rate of breakdown of gastric mucosal high energy phosphates during complete, ex vivo ischemia achieved by rapid excision of the stomach. We then studied the influence of cold versus warm gastric lavage on the severity of gastric mucosal injury and on the rate of breakdown of gastric mucosal adenosine phosphates during hemorrhagic shock. In a fourth series of experiments, we examined the influence of cold versus warm gastric lavage on gastric mucosal blood flow measured by injection of radioactive microspheres. Although the rate of breakdown of mucosal high energy phosphates was less rapid during a short period of complete, ex vivo ischemia when the stomach was cooled, this rate was more rapid during hemorrhagic shock under in vivo conditions when the stomach was lavaged with cold solution. The latter also increased the severity of shock-induced gastric mucosal injury. Cold gastric lavage reduced gastric mucosal blood flow before, during and after hemorrhagic shock.

Experiences with the treatment of alkaline reflux gastritis.

Between 1973 and 1978, we have treated 34 patients with alkaline reflux gastritis. All but one had a history of prior gastric surgery. Ten patients had severe diarrhea due to dumping or vagotomy or both. Eleven of the patients had undergone 17 unsuccessful remedial operations. Except for one patient whose gastrojejunostomy was dismantled and two patients who had interposition of a Henle loop between the stomach and the duodenum, all the patients were managed by construction of a 40 cm Roux-en-Y limb. In 10 patients with diarrhea, a 7 to 8 cm antiperistaltic segment was positioned 80 cm distal to the stomach. Ancillary procedures such as vagotomy and Hill hiatal hernia repair were done in some of the patients. Bile gastritis was well controlled by the 40 cm Roux limb. The short reversed segment placed 80 cm from the stomach effectively controlled diarrhea whether it was due to dumping or vagotomy and did not cause any of the problems of gastric stasis that we and others have observed with reversed segments positioned next to the stomach.

Electrogastrographic study of patients with unexplained nausea, bloating, and vomiting.

A method of recording gastric myoelectric activity with a peroral suction electrode was evaluated, and the recording was compared with that obtained by implanted electrodes on the serosal surface of the stomach of laparotomized humans. In a group of patients with unexplained nausea, epigastric bloating, and vomiting, abnormal antral myoelectric activities were found by a peroral electrode, in contrast to a regular pacesetter potential (frequency: 3-4/min) in control subjects. These abnormalities were confirmed by the recordings from the implanted electrodes in the same subjects. The study indicates that peroral recording of gastric myoelectric activity is a useful diagnostic method for the detection of gastric myoelectric activity abnormalities in humans.

On the malignant potential of acquired short esophagus.

Esophageal adenocarcinoma developed in an esophagus lined with columnar epithelium. The malignant potential of columnar metaplasia complicating long-standing gastroesophageal reflux and the implications of surgical management of acquired short esophagus are discussed briefly.

A modified fundoplication which preserves the ability to belch.

This report describes a transabdominal antireflux procedure which combines some of the features of the operations described by Nisse, Belsey, and Hill. From 1972 through 1976, 61 patients underwent a conventional Nissen fundoplication and 54 patients were operated according to the method described in this report. None of the patients who had a Nissen operation was able to belch freely; 15% had a "gas-bloat syndrome". Return of the ability to belch often signified partial or complete brakdown of the plication, which occurred in 11% of the cases. By contrast, all but one of the patients who had modified plication were able to belch freely; there has been only one instance of recurrent reflux.

Mechanism of stress ulcer. Influence of alpha-adrenergic blockade on stress ulceration and gastric mucosal energy metabolism.

In previous reports from this laboratory, it has been proposed that stress ulceration results from a severe gastric mucosal energy deficit due to shock-induced mucosal ischemia. In the experiments described in this report, the hypothesis was further tested by studying stress ulceration and gastric mucosal energy metabolism in rabbits subjected to hemorrhagic shock with or without the concomitant administration of an alpha-adrenergic blocking agent. Our data show that stress ulceration and gastric mucosal energy deficits are significantly less severe when shock is combined with alpha-adrenergic blockade.

Influence of hyperglycemia on survival after hemorrhagic shock.

Terms such as "insulin resistance" and "glucose intolerance" applied to shock-induced hyperglycemia suggest that this state may prejudice survival. However, our data indicate that posthemorrhage hyperglycemia improves short-term survival. Rabbits, either fed until the experiment or fasted for 24 hours, were shocked by rapid removal of 25% of their blood volume (BV) measured by 131IHSA. During the next 60 minutes, blood pressure (BP) was recorded, and the following variables were measured every 10 minutes: plasma volume (PV); arterial and venous plasma osmolality (PO), glucose, lactate, Na, K and hematocrit. Other fasted animals studied similarly received short intravenous pulses of hypertonic xylose after bleeding. The PO of fed animals, who all survived for 60 minutes rose to an extent accounted for by rises in glucose and lactate. A significant PV fluid gain was maintained for 60 minutes. The fasted animals, 42% of whom died before 60 minutes, had a flat glucose curve with a correspondingly small rise in PO. The PV fluid balance, after an initial small gain, became negative. Although a lower blood pressure in fasted rabbits was probably due to lack of PV refill, death resulted from hyperkalemia. Poor tolerance of fasted animals to shock is not attributable only to less glucose for energy metabolism, because when they received xylose, homeostatic features of fed animals were restored. The data suggest that, immediately after hemorrhage, glucose acts as a nonpermeant solute drawing fluid into the circulation. This study also shows that control of the nutritional status of animals used for shock models is important.