G. Lepsien

Gastric emptying 16 to 26 years after treatment of infantile hypertrophic pyloric stenosis

Long-term follow-up was performed 16 to 26 years after conservative (group I, n = 18) and operative (group II, n = 38) treatment of 56 patients who had infantile hypertrophic pyloric stenosis (IHPS). The study encompassed the scintigraphic determination of gastric emptying rates for solids and liquids, an interview to obtain medical history and ascertain whether a current disorder of the upper gastrointestinal tract was present, and a clinical examination. Gastric emptying rates were measured on two different days for solids and liquids. The standard solid meal consisted of two scrambled eggs, two slices of toast, and 20 g of margarine. The gastric emptying rate for liquids was measured using 300 mL of apple juice. The scrambled eggs and apple juice were each marked with 2.2 MBq technetium 99m-sulphur-colloid. Two control collectives were used in this study; one group (physicians) served to create a reference curve for gastric emptying, and the other group, with the same age and gender distributions as those of the patients, served to evaluate the frequency of gastrointestinal complaints, by means of a questionnaire. There was no significant rate difference for gastric emptying between the patients treated conservatively or surgically and the controls. No association could be construed between the frequency of gastrointestinal symptoms or disorders and the gastric emptying rates for solids and liquids. The results presented here substantiate that clinically relevant disturbances of stomach motility after IHPS appear to be rare.

Effects of gastrin-releasing peptide (GRP) on the mechanical activity of the human ileocaecal region in vitro.

Mechanical activity was recorded in muscle preparations isolated from the human ileocaecal region. Gastrin‐releasing peptide (GRP, 10−9− 10−7 mol L−1) produced two types of response in the different muscle layers. Longitudinally cut strips showed a concentration‐dependent increase in the rhythmic activity, whereas the circularly orientated layers generally reacted with a small decrease in tone. These effects could not be influenced by blockade of adrenergic or cholinergic receptors or nerve blockade with tetrodotoxin (TTX). Application of pentagastrin did not mimic the action of GRP. These findings suggest a direct action of GRP on smooth muscle via distinct receptors which have already been demonstrated to exist in human gastrointestinal tract. The opposite effects on circular and longitudinal strips might indicate a modulatory role of GRP in the control of ileocolonic transit.

Laparoscopic resection of pheochromocytoma

SummaryThe following case report presents the diagnostic procedures, laparoscopic therapy, and postoperative course of a 48-year-old patient with pheochromocytoma. During the previous 15 years, he had occasionally presented with hypertension, intermittent attacks of severe perspiration, and tachycardia; no diagnostic measures were performed at the time. During an ultrasound examination of the abdomen performed due to gastrointestinal complaints, a 5-cm adrenal tumor was discovered incidentally. Further diagnostic procedures then indicated the presence of a pheochromocytoma which was resected laparoscopically. The anesthesia was tolerated well, although isolated systolic blood pressure peaks to 200 mmHg were observed. The laparoscopic tumor resection presented no problems, although identifying the tumor proved to be difficult and resulted in an extended operation time of 4 h and 20 min. The postoperative course was unremarkable. This case report presents our laparoscopic technique and confirms that techniques proven in the “open” resection of a pheochromocytoma can also be utilized in the laparoscopic approach.

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.

Sonographical findings in whipple's disease : a case report with regard to the literature

SummaryWe present a case report of a 60-year-old male patient and subsequently discuss sonographical findings in Whipples disease. This particular patient showed an intraabdominal tumorous mass. Symptoms of a malabsorption disorder were absent. Computer-assisted tomography and radiological examination could not determine the origin of the tumor. Sonography demonstrated a polycyclic hyperechoic mass in the root of the mesentery. The small intestine was not distended and showed normal peristalsis. Its wall was hyperechoic concentrically thickened. Final diagnosis was established from a diagnostic laparotomy showing enlarged lymph nodes and distended lymphatic vessels. Based on the literature the described sonographical findings seem to be typical in cases of Whipples disease.

Kardiafunktion nach proximal-gastrischer Vagotomie

SummaryIn 36 patients with chronic duodenal ulcer disease LES-function before and after proximal-gastric vagotomy was examined manometrically and by determining pH-values in a prospective study. In addition, esophagus biopsies were taken 5 cm proximal of the cardia. 12 healthy volunteers served as controls. A direct effect of proximal-gastric vagotomy on LES-function could not be shown. On the contrary, in 38,9 % of the patients examined, preoperatively proven esophagitis disappears nearly completely 12 months following proximal gastric vagotomy. This positive effect of vagotomy is to be interpreted as a beneficial effect on regurgitated intestinal juice, more so than an effect on cardia function itself.ZusammenfassungIn einer prospektiven Studie wurde an 36 Patienten mit chronisch-rezidivierenden Ulcera duodeni die Kardiafunktion vor und nach proximal-gastrischer Vagotomie manometrisch und pH-metrisch untersucht. Zusätzlich wurden 5 cm oral der Kardia Oesophagusbiopsien entnommen. Als Kontrollkollektiv dienten 12 gesunde Probanden. Ein direkter Einfluß der proximal-gastrischen Vagotomie auf die Kardiafunktion ließ sich dabei nicht nachweisen. Im Gegenteil, eine bei 38,9% der untersuchten Ulcus-Patienten präoperativ nachweisbare Oesophagitis heilt 12 Monate nach proximalgastrischer Vagotomie weitgehend aus. Dieser positive Effekt der Vagotomie ist eher über eine günstige Beeinflussung des Regurgitates als über einen Effekt auf die Kardiafunktion zu deuten.

Causes of Death in Hemorrhagic Necrotizing Pancreatitis

Hemorrhagic necrotizing pancreatitis still carries high mortality. The prognosis in cases of pancreatic autodigestion not only depends on local tissue damage but also on the toxic effects of inflammation, involving the whole organism [1, 6, 9]. Both local and systemic damage are thus responsible for death in this disease [6, 7, 9, 11].

NEUROTENSIN-RELATED REGULATION OF THE POSTPRANDIAL LOWER-OESOPHAGEAL-SPHINCTER PRESSURE

Abstract Background: Ingestion of food has been shown to modulate the lower-oesophageal-sphincter pressure (LESP). Fat is especially effective in decreasing the postprandial LESP. As there is good evidence that neurotensin (NT) is able to decrease the LESP, we conducted the present trial to determine whether NT could possibly be a mediator of the fat-induced decrease of the LESP. Methods: Six half-breed dogs were fitted for cervical side-to-side oesophagostomy to allow repeated oesophageal intubation; plasma NT immunoactivity was recorded during infusion of NT and after intragastric instillation of 200 ml of a fat solution. Experiments were repeated, with the specific NT antibody GN25 administered intravenously. Results: The optimal dose of NT required to simulate a postprandial situation was 50 pmol/kg/h. Infusion of this NT dose led to a statistically significant decrease of the LESP. Simultaneous administration of the NT antibody (immunoneutralisation) significantly inhibited this effect. Intragastric fat decreased the LESP and increased plasma NT. Immunoneutralisation of endogenously released NT led to an earlier restoration of baseline LESP, but this effect was not statistically significant. Conclusions: NT and intragastric fat modulate the LESP. NT appears to mediate the postprandial, fat-induced decrease of the LESP. Research with specific NT-receptor antagonists is necessary to determine the exact role of NT and other regulatory peptides in this context.

Real-time sonography of the mediastinum in adults: a study in 100 healthy volunteers

SummaryReal-time sonography has proved to be a valuable tool in the evaluation of the mediastinum in children. In the literature there is a paucity of information on ultrasound examination of the mediastinum in adults. Using a 3.5-MHz sector scanner, we evaluated a new method for the examination of mediastinal organs in adults, which is practicable in routine as well as emergency diagnosis. The endpoints of this study were the visibility of mediastinal organs and the discomfort of the patient. In 100 healthy volunteers aged 20–40 years, the normal anatomy of the anterior and middle mediastinum was investigated. Neither the height nor the weight of the volunteers limited the examination. We found that this method causes no discomfort to the subject. Via the supra-, infra- and left parasternal approaches, anatomical structures of the mediastinum are visible in a high percentage of cases. To date, this method has proved its practicability in more than 250 patients suffering from blunt thoracic trauma, primary and metastatic tumours, and infections of the mediastinum.

[Therapeutic results of peptic stenosis in the esophagus (author's transl)].

Of 118 patients treated for peptic stenosis between 1970 and 1979, 89 cases (75.4%) had developed in connection with endobrachyesophagus, i. e., as the result of primary reflux disease; 26 cases were the consequence of secondary reflux disease without endobrachyesophagus. In three cases the peptic stenosis had to be explained as the result of a local acid secretion. The treatment which followed was conservative (bougienage + Cimetidine/Antacids) or operative (bougienage + fundoplication). The results of the therapy varied according to the type of stenosis. In cases where the stenosis was located in the upper part (endobrachyesophagus), good results could be achieved with conservative therapy in 38.3% and with operative therapy, in 67.3%. The results were worse in terminal stenosis (conservative therapy, 45.5%; operative therapy, 60%). Retrospective analysis of unsuccessful treatment shows that predominantly scarred stenosis shows worse results than florid stenosis with recent esophagitis.SummaryOf 118 patients treated for peptic stenosis between 1970 and 1979, 89 cases (75.4%) had developed in connection endobrachyesophagus, i. e., as the result of primary reflux disease; 26 cases were the consequence of secondary reflux disease without endobrachyesophagus. In three cases the peptic stenosis had to be explained as the result of a local acid secretion. The treatment which followed was conservative (bougienage + Cimetidine/Antacids) or operative (bougienage + fundoplication). The results of the therapy varied according to the type of stenosis. In cases where the stenosis was located in the upper part (endobrachyesophagus), good results could be achieved with conservative therapy in 38.3% and with operative therapy, in 67.3%. The results were worse in terminal stenosis (conservative therapy, 45.5%; operative therapy, 60%). Retrospective analysis of unsuccesful treatment shows that predominantly scarred stenosis shows worse results than florid stenosis with recent esophagitis.ZusammenfassungVon 118 peptischen Stenosen, die zwischen 1970 und 1979 zur Behandlung kamen, waren 89 (75,4%) im Zusammenhang mit einem Endobrachyoesophagus, d. h. im Verlauf einer primären Refluxkrankheit, entstanden, 26 als Folge einer sekundären Refluxkrankheit ohne Endobrachyoesophagus. In drei Fällen mußte die peptische Stenose als Resultat einer lokalen Säureproduktion gedeutet werden. Die Therapie erfolgte konservativ (Bougierung und Cimetidin/Antacida) oder operativ (Bougierung und Fundoplicatio). Die Therapieergebnisse waren je nach Stenosetyp unterschiedlich. Bei hochsitzenden Stenosen (mit Endobrachyoesophagus) waren gute Ergebnisse unter konservativer Therapie in 39,3%, unter operativer Therapie in 67,3% der Fälle erreichbar. Die Ergebnisse bei den terminalen Stenosen waren vergleichbar (konservative Therapie 45,5%, operative Therapie 60%). Die retrospektive Analyse der Therapieversager zeigt, daß vorwiegend narbige Stenosen schlechtere Ergebnisse zeigen als floride Stenosen mit frischer Oesophagitis.