A. Schafmayer

Treatment of iatrogenic common bile duct injury during laparoscopic cholecystectomy through the laparoscopic insertion of a T-tube stent.

SummaryIatrogenic injury to the common bile duct during laparoscopic cholecystectomy has previously necessitated an immediate laparotomy to alleviate bile leakage. In the course of 171 laparoscopic cholecystectomies performed at our hospital, intraoperative common bile duct injuries occurred in 2 patients. Each case was successfully treated using a laparoscopically placed T-tube, thus avoiding the need for a laparotomy. This novel intraoperative procedure successfully treated common bile duct injuries without resulting in postoperative complications.

Role of the Small Bowel in Regulating Serum Gastrin and Gastric Inhibitory Polypeptide (GIP) Levels and Gastric Acid Secretion

An increase in gastric acid secretion after resection or bypass of the small bowel has been described by several authors in man and dogs1,2,3. Furthermore, a high incidence of peptic ulcer disease has been observed in patients with small bowel resection4,5. The mechanism which induces gastric hypersecretion after exclusion of large parts of the small bowel from food passage is still poorly understood. Several authors have described hypergastrinemia after small bowel exclusion or bypass, which may be caused by either a decrease in catabolism or a diminished release of inhibitors from the small intestine6,7,8. One of the physiologically important inhibitors of gastric acid secretion may be the gastric inhibitory polypeptide (GIP) which is released from the duodenum and jejunum after food intake and shows besides its insulinotropic effect a strong inhibition of stimulated acid secretion in dogs9.

The adaptive response of the rat small intestine after resection and segmental transplantation during the early postoperative phase

Organ harvesting from a living donor or spatial constraints in the recipients abdominal cavity are the main factors to be considered in the segmental transplantation of the small intestine. It was the aim of the following study to gain insight into the functional characteristics of different portions of the small intestine either after partial resection or syngeneic and allogeneic transplantation during the early postoperative period. Nutritional parameters (serum albumin levels, serum triglyceride levels, maltose absorption, excretion of fecal fat) and fat-stimulated neurotensin release were determined in Lewis rats that underwent small bowel resection (n=21), syngeneic (Lewis→Lewis,n=21), or allogeneic transplantation (Brown Norway→Lewis,n=24). The length of the remnant, isograft, or allograft was 27 cm (i.e. one third of the rat small intestine) and consisted of the proximal (n=7), middle (n=7), or distal (n=7) portion. Three postoperative deaths were due to ileus or pneumonia. After allotransplantation, cyclosporine (15 mg/kg BW s.c.) was administered for graft acceptance. Controls were unoperated, weight- and age-matched Lewis rats (n=7). We found that resection of two-thirds of the small intestine led to significantly lower levels of albumin and triglycerides in all the three portions investigated (P<0.01) but did not affect maltose absorption. Excretion of fecal fat was elevated after distal resection (P<0.05). When compared to resected animals, syngeneic transplantation did not affect the nutritional parameters, but caused a significantly higher hormone release (P<0.05) in all three different intestinal grafts. Allogeneic transplantion was successful when the middle or distal portion was grafted. All recipients of proximal allografts showed a severe loss of body weight and died between day 8 and 10 after transplantation. Postmortem examination revealed no signs of acute rejection. When transplantation of short intestinal segments is considered, it is of vital importance to take into account the functional differences and the influence of immunosuppressive drug therapy in the regulatory bowel function.

85. Operationstaktik und -technik bei Peritonitis nach Oberbaucheingriffen

SummaryPeritonitis occurs in 5–7 % of surgical procedures in the upper abdomen and is accompanied by high mortality. The therapeutic approach consists of treatment of the underlaying complication, mostly by extensive external or internal drainage, rarely by reconstruction, and of general treatment of peritonitis. In diffuse peritonitis, surgical intervention is always indicated; in local peritonitis with sufficient drainage, conservative treatment is possible.ZusammenfassungPeritonitische Komplikationen nach Eingriffen an den Oberbauchorganen sind in 5–7 % zu erwarten und von einer hohen Letalität begleitet. Die Therapie besteht in der Sanierung der zugrunde liegenden Komplikation, meist durch ausgedehnte innere und äußere Drainage, selten durch Rekonstruktion sowie der Allgemeinbehandlung der Peritonitis. Bei diffuser sich ausbreitender Peritonitis ist eine Indikation zur Operation nahezu immer gegeben, lediglich bei lokal begrenzter Peritonitis mit ausreichender Drainage kann der Chirurg zuwarten.

Die Freisetzung gastrointestinaler Hormone beim Dumping-Syndrom vor und nach Wiederherstellung der Duodenalpassage

Die Bedeutung der gastrointestinalen Hormone fur das Auftreten des Dumpingsyndroms ist Gegenstand zahlreicher Untersuchungen gewesen. Fur eine unkoordinierte Freisetzung der gastrointestinalen Hormone wird vor allem die fehlende Duodenalpassage angeschuldigt (1). In der vorliegenden Untersuchung haben wir bei Patienten mit schwerem Postgastrektomie-Syndrom (Dumping-Syndrom) vor und nach Umwandlungsoperation in der Modifikation von Henley-Soupault das Verhalten der basalen und postprandialen Serumgas-trinkonzentration von Gastrin, GIP (gastric inhibitory polypeptide) und Insulin untersucht und mit der von Normalpersonen verglichen.

Fat-stimulated cholecystokinin release following transplantation of the entire small bowel or of different intestinal segments in rats

This study presents data on the fat-stimulated release of cholecystokinin (CCK) in conscious rats 11 and 84 days after one-stage transplantation of the entire small bowel, or of jejunal, jejunoileal, or ileal segments, under syngeneic and allogeneic conditions. After allotransplantation, ciclosporin (CsA) was administered for graft acceptance. The results were compared with those in unoperated controls and in animals that had undergone small-bowel resections leaving jejunal, jejunoileal, or ileal remnants. When the entire small bowel was grafted under syngeneic (92.5±8.3; 106.6±7.5) or allogeneic (110.5±5.5.; 101.2±6.9) conditions, CCK release (pg/ml per 60 min) was similar (P>0.05) to that of the controls (110.3±9.0; 94.7±6.8) at both measurement points. Recipients of jejunal or ileal segmental isografts showed a significantly elevated (P<0.05) output of CCK (jejunal graft: 176.4±18.5; 125.5±10.1—ileal graft: 55.9±9.0; 30.1±5.4) compared with corresponding small-bowel resections (jejunal remnant: 69.0±7.9; 93.5±3.9—ileal remnant: 16.7±3.7; 6.6±1.3). In contrast the difference was not significant (P>0.05) when jejunoileal segments were grafted (jejunoileal graft: 74.4±19.6; 47.0±10.4—jejunoileal remnant: 50.7±11.0; 47.0±11.9). All recipients of jejunal allografts died between day 8 and day 10 after transplantation, due to functional impairment. Two-stage segmental jejunal allotransplantation, with insertion of the graft into the continuation of the gastrointestinal tract in an accessory, non-functional position after 28 days was successful. Due to this technique, we could gather data on day 84. Recipients of jejunal (118.2±7.6), jejunoileal (87.1±19.7; 48.6±9.3), or ileal (48.1±6.7; 21.6±4.6) allografts showed no significant (P>0.05) differences in CCK output compared with isografts, either on day 11 or on day 84. Our data indicate that transplantation of the entire small bowel affects the fat-stimulated CCK release neither in the early postoperative period nor 3 months after transplantation. In contrast, transplantation of jejunal or ileal segmental isografts caused a significantly elevated output of CCK compared with corresponding resection remnants. Immunosuppression with CsA did not affect CCK release after transplantation, but led to functional impairment with fatal outcome when a short jejunal segment was grafted. This could be prevented by applying the two-stage technique.

Einfluß der pankreasinnervation auf die exokrine sekretionsleistung der bauchspeicheldruse

SummaryIn the present study we examined the influence of extrinsic pancreatic innervation on exocrine pancreatic response to secretin, caerulein, tryptophan and fat, and furthermore the amino acid- and fat-stimulated release of neurotensin and CCK in dogs. Denervation of the pancreas did not alter secretory response to secretin and caerulein, whereas transsection of the extrinsic nerves significantly diminished the protein response to tryptophan and fat. Release of CCK was not altered by pancreatic denervation. However, fat-evoked neurotensin plasma levels were significantly increased after denervation of the pancreas.ZusammenfassungIn der vorliegenden Studic wurde der Einfluß des extrinsischen Nervensystems des Pankreas auf die exokrine Pankreassekretion nach Stimulation mit Sekretin, Zärulein, Tryptophan and Fett sowie die Aminosäure-und Fett-stimulierte Freisetzung von Neurotensin und CCK beim Hund untersucht. Die Denervation der Bauchspeicheldrüse führte zu keiner Veränderung der exokrinen Antwort auf Sekretin and Zärulein, dagegen bewirkte die Ausschaltung der extrinsischen Nerven eine signifikante Verminderung der Proteinantwort auf Tryptophan and Fett. Die Freisetzung von CCK wurde nicht verändert. Die Fett-stimulierten Neurotensinplasmaspiegel waren nach Denervation signifikant erhöht.

VIP-Konzentrationen im Plasma und Tumor bei Patienten mit Verner-Morrison-Syndrom

VERNER und MORRISON beschrieben 1958 ein Syndrom, das gekennzeichnet ist durch profuse wassrige Diarrhoen, Hypokalamie und Achlorhydrie. Das Verner-Morrison-Syndrom (watery diarrhea, hypocalemia, hypochlorhydria, WDHH) wird durch benigne oder maligne endokrine Tumoren des Pankreas hervorgerufen, die vasoaktives intestinales Polypeptid (VIP) produzieren. In den vorliegenden Untersuchungen haben wir bei 4 Patienten mit Verner-Morrison-Syndrom die Plasma-VIP-Spiegel vor und nach einem operativen Eingriff bestimmt, sowie den Gehalt an VIP in diesen Tumoren ermittelt.

The role of pancreatic innervation and cholecystokinin in the intestinal phase of pancreatic polypeptide release in conscious dogs

SummaryBesides vagal cholinergic mechanisms, pancreatic polypeptide (PP) secretion is thought to be mediated by hormones. This study was performed to delineate the role of extrinsic pancreatic innervation and cholecystokinin (CCK) in amino acid- and fat-stimulated PP secretion. In ten mongrel dogs, pancreatic denervation was performed by the method of Debas et al. [3]. Total denervation of the pancreas did not alter PP response to intraduodenal application of amino acids (integrated output 24434±3260 pmol/1×120 min before vs 22797±2470 pmol/1×120 min after operation) and to intraduodenal fat solution (19595±2121 pmol/1×120 min vs 19983±2031 pmol/1×120 min). Also, no significant differences were measured in CCK release (491±71 pmol/1×120 min vs 430±57 pmol/1×120 min for amino acids, 571=63 pmol/1×120 min vs 563±89 pmol/1×120 min for fat solution). Plasma PP and CCK levels were compared by linear regression analysis. Correlations between PP and CCK were high in the intact pancreas (amino acids,r=0.92; fat,r=0.99) as well as in the denervated pancreas (r=0.93 amino acids andr=0.98 fat). These results show that extrinsic pancreatic innervation does not influence PP and CCK release after intraduodenal amino acids or fat solution and that PP secretion seems to be mediated to some extent through the release of CCK.

Stoffwechselparameter und Neurotensinfreisetzung nach Dünndarmresektion, syngener und allogener Segmenttransplantation an der Ratte

The aim of the following study was to gain some insight into the functional characteristics of different portions of the small intestine after either partial resection or syngeneic and allogeneic transplantation 3 months postoperatively. Nutritional parameters (serum albumin levels, serum triglyceride levels, maltose absorption, excretion of fecal fat) and fat-stimulated neurotensin release were determined in Lewis rats that underwent small-bowel resection (n = 21), syngeneic (Lewis→Lewis, n = 21), or allogeneic transplantation (Brown Norway→Lewis, n = 24). The length of the remnant, isograft, or allograft was 27 cm (i.e., one-third of the rat small intestine) and consisted of the proximal (n = 7), middle (n = 7), or distal (n = 7) portion. Three postoperative deaths were due to ileus or pneumonia. After allotransplantation cyclosporine (15 mg/kg body wt. s.c.) was administered for graft acceptance. The control group was not operated upon, but was composed of weight- and age-matched Lewis rats (n = 7). We found that resection of two-thirds of the small intestine led to significantly lower levels of albumin and triglycerides in all three portions investigated (P < 0.01), but did not affect maltose absorption. Excretion of fecal fat was elevated significantly only after distal resection (P < 0.05). When compared to resected animals, syngeneic transplantation did not affect the nutritional parameters, but caused a significantly higher hormone release (P < 0.05) in all three different intestinal grafts. Allogeneic transplantation was successful when the middle or distal portion was grafted. All recipients of proximal allografts showed a severe loss of body weight and died between day 8 and 10 after transplantation. Postmortem examination revealed no signs of acute rejection. We conclude that when transplantation of short intestinal segments is considered, it is of vital importance to take into account the functional differences and the influence of immunosuppressive drug therapy in the regulation of bowel function.ZusammenfassungDie vorliegende Studie hatte zum Ziel, die Adaptation verschiedener Dünndarmabschnitte nach Resektion und Transplantation an der Ratte zu untersuchen. Stoffwechselparameter (Serumalbumin, Serumtriglyceride, Maltoseabsorption, Stuhlfettausscheidung) und Fett-stimulierte Neurotensinfreisetzung wurden 3 Monate postoperativ in Lewis-Ratten bestimmt, bei denen eine 2/3-Resektion (n = 21), eine syngene (Lewis→Lewis, n = 21) oder eine allogene (Brown Norway→ Lewis, n = 24) Segmenttransplantation durchgeführt worden war. Letale postoperative Komplikationen traten bei 3 Tieren nach allogener Transplantation auf (Ileus in 2 Fdllen, Pneumonie in einem Fall). Betrachtet wurde jeweils der proximale, mittlere oder distale Abschnitt (27 cm, etwa ein Drittel des Rattendünndarms) und zu nicht operierten Tieren (Kontrollen, n = 7), sowie zu Isotransplantaten (n = 7) und zu Allotransplantaten (n = 7) des gesamten Dünndarms in Beziehung gesetzt. Nach Allotransplantation wurde Cyclosporin (15 mg/kg KG i.m. Tag 0–2, 15 mg/kg KG s.c. Tag 3–14, 10 mg/kg KG s.c. Tag 15–28) verabreicht. Die Dünndarmresek-tion führte unabhdngig vom verbliebenen Anteil zu einer signifikanten Verringerung der Alnumin- und Triglyzeridwerte (p < 0,01) im Vergleich zum nicht operierten Tier, während die Maltoseabsorption unbeeinflulßt blieb. Die Stuhlfettausscheidung war lediglich nach distaler 2/3-Resektion signifikant erhöht (p < 0,05). Verglichen mit der Resektion ergab die syngene Transplantation keine Veränderung im Hinblick auf die Stoffwechselparameter, führte jedoch zu einer signifikanten Erhöhung der Hormonausschüttung (p < 0,05). Nach Allotransplantation verstarben alle Empfänger proximaler Dünndarm anteile zwischen Tag 8 und 10 nach Transplantation, ohne daß sich Hinweise auf eine akute Abstoßung oder chirurgische Komplikationen ergaben. Allotransplantationen mittlerer oder distaler Dünndarmanteile verliefen erfolgreich und zeigten keinerlei Nachteile im Vergleich zu Allotransplantaten des gesamten Dünndarms Bowie zu Isotransplantaten. Unsere Ergebnisse deuten darauf hin, daß im Fall einer Segmenttransplantation die unterschiedliche Adaptation verschiedener Dünndarmab-schnitte unter dem Einfluß einer immunsuppressiven Therapie beachtet werden sollte.