Cisapride enhances the effect of partial posterior fundoplication on esophageal peristalsis in GERD patients with poor esophageal contractility

Partial posterior fundoplication improves esophageal peristalsis in patients with gastroesophageal reflux disease (GERD) associated with poor esophageal body function. The aim of this study was to investigate whether postoperative administration of cisapride enhances the effect of surgery on esophageal peristalsis. Laparoscopic partial posterior fundoplication was performed on 34 consecutive GERD patients with poor esophageal body motility. These patients were randomized in groups without and with postoperative treatment with cisapride 20 mg twice daily for six months. Esophageal manometry was performed preoperatively and six months following surgery. Esophageal body function improved significantly following partial posterior fundoplication without or with postoperative treatment with cisapride. However, this effect was more pronounced in the group of patients receiving cisapride. Partial posterior fundoplication combined with postoperative treatment with cisapride should be the therapy of choice in GERD patients with poor esophageal body motility.

Medical students' personal values and their career choices a quarter-century later

A longitudinal study of 391 physicians tested two hypotheses regarding personal values and career choices: that higher preference for social values would be associated with physicians' being more interested in "people-oriented" rather than "technology-oriented" specialties and that higher preference for economic values would be associated with expectations of high income. The physicians (344 men, 47 women) were graduates of Jefferson Medical College in 1974 and 1975 who completed the Allport-Vernon-Lindzey Study of Values during medical school. Analysis showed that physicians currently in the "people-oriented" specialties scored significantly higher on the Social Value scale than their peers in "technology-oriented" specialties. A moderate but statistically significant correlation was found between scores on the Economic Value scale and expectations of higher income. The findings suggest that physicians' personal values are relevant to their career decisions such as specialty choice and expectations of income. The findings have implications with regard to two major issues in the evolving health care system, namely, the distribution of physicians by specialty and cost containment.

Gastro-oesophageal reflux disease: medical or surgical treatment? Report of an interactive workshop

Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract. With the introduction of proton pump inhibitors medical treatment of GERD has been significantly improved. However, the development of laparoscopic antireflux surgery resulted in an increasing interest of surgeons in this disease. An interactive meeting was organized in order to develop an agreement between gastoenterologists and surgeons regarding therapeutic decisions and this is the main topic of this paper.

Respiratory symptoms in patients with gastroesophageal reflux disease following medical therapy and following antireflux surgery

BACKGROUND

It is not known whether antireflux surgery is more effective than medical therapy to control respiratory symptoms (RS) in gastroesophageal reflux disease (GERD).

METHODS

In 21 GERD patients with RS, reflux was assessed by endoscopy, manometry, and pH monitoring. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 7 patients with normal esophageal peristalsis had a laparoscopic Nissen fundoplication and 14 with impaired peristalsis a Toupet fundoplication. Respiratory symptoms were scored prior to treatment, at 6 months following medical therapy, and at 6 months after surgery.

RESULTS

Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Respiratory symptoms improved in 18 patients (85.7%) following surgery and in only 3 patients (14.3%) following medical therapy (P <0.05). Esophageal peristalsis improved following the Toupet fundoplication.

CONCLUSION

Medical therapy fails to control reflux since it does not inhibit regurgitation. Surgery controls reflux and improves esophageal peristalsis, which contributes to its superiority over medical therapy in the treatment of RS associated with GERD.

Trends in, and transitions to, institutional residence among older people in England and Wales, 1971-91

OBJECTIVES

To compare transitions from private households to institutions between 1971-81 and 1981-91 among elderly people and see whether (1) differentials in the risk of institutionalisation changed and (2) whether the risk was higher in the second period.

DESIGN

Cross sequential analysis of data from the Office of National Statistics longitudinal study, a record linkage study which included individual level data from three national censuses, (1971, 1981, and 1991) and linked vital registration data.

SUBJECTS

Altogether 26,400 people aged 65 and over in 1971-81 and 32,500 persons aged 65 and over in 1981-91. These samples represent 1% of the population of England and Wales.

RESULTS

In both periods models including age, housing tenure, and marital status or household/family type terms fitted the data reasonably well. The effect of age was stronger in the second decade, while that of marital status was reduced. The risk of transition to an institution was nearly 33-52% higher in the second decade after controlling for these factors.

CONCLUSIONS

During the 1980s the availability of state financed institutional care increased substantially; a growth which the 1990 NHS and Community Care Act was designed to reverse. Increased access to institutional care undoubtedly is one factor underlying the higher transition rate to institutions observed in 1981-91 than for the previous decade. During 1981-91, transitions to live with relatives also declined substantially. It is not clear whether this simply represents the continuation of a previous trend or whether the increased availability of institutional care led to some substitution for family care. Either interpretation has worrying implications for policy makers keen to promote care in the community.

Tailored antireflux surgery for gastroesophageal reflux disease: effectiveness and risk of postoperative dysphagia

The Nissen fundoplication is not the proper antireflux procedure for patients with poor esophageal peristalsis as it does not strengthen impaired esophageal peristalsis. The aim of this study was to investigate if tailoring of antireflux surgery according to esophageal contractility is an effective treatment of gastroesophageal reflux disease (GERD) with a low incidence of postoperative dysphagia. The Toupet fundoplication was laparoscopically performed on 32 patients with poor esophageal peristalsis and the Nissen fundoplication on 17 patients with normal peristalsis. After a median follow-up of 15 months, only 1 of the 49 patients (2.04%) complained of heartburn. Acute esophagitis was found in none of them on endoscopy. Of 40 patients tested postoperatively, 2 (5%) underwent pathologic esophageal pH monitoring. Postoperative dysphagia was found in two patients (4.1%) compared with 25 (51%) preoperatively (p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES) significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.

Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs.44%; P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after surgery.

Medical treatment of gastroesophageal reflux disease does not prevent the development of Barrett's metaplasia and poor esophageal body motility

OBJECTIVE

Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barrett's metaplasia or poor esophageal body motility.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

138 GERD patients were analyzed regarding the development of Barrett's metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H2 blockers or omeprazole.

MAIN OUTCOME MEASURES

The rate of patients with Barrett's metaplasia or poor esophageal body motility with or without effective medical treatment.

RESULTS

Barrett's metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P < 0.05), but these patients had a significantly shorter history of GERD.

CONCLUSIONS

Medical treatment with H2 blockers or omeprazole does not prevent the development of Barrett's metaplasia or poor esophageal body motility.

Azole phenoxy hydroxyureas as selective and orally active inhibitors of 5-lipoxygenase

Azole phenoxy hydroxyureas are a new class of 5-lipoxygenase (5-LO) inhibitors. Structure-activity relationship studies have demonstrated that electronegative substituents on the 2-phenyl portion of the oxazole tail increased the ex vivo potency of these inhibitors. Similar substitutions on the thiazole analogs had only minor contribution to the ex vivo activity. The trifluoromethyl-substituted oxazole 24 was the best compound of the oxazole series in both the ex vivo (6 h pretreated rats) and in vivo (3 h pretreated rats) RPAR assay with ED50 values of approximately 1 and 3.6 mg/kg, respectively, but was weakly active in the allergic guinea pig assay. Oxazole 50 was equally active in both the RPAR and guinea pig in vivo models and was similar to zileuton. The unsubstituted thiazole 52 was the best compound of the thiazole series, by inhibiting the leukotriene B4 biosynthesis in the RPAR assay (3 h pretreated rats) by 99%, at an oral dose of 10 mg/kg, and the bronchoconstriction in the allergic guinea pig by 50%, at an intravenous dose of 10 mg/kg. Oxazole 24 demonstrated high and selective 5-LO inhibitory activity in the in vitro assays, with IC50 values ranging from 0.08 microM in mouse macrophages to 0.8 microM in human peripheral monocytes to 1.2 microM in human whole blood. This activity was selective for 5-LO, as concentrations up to 15 microM in mouse macrophages did not affect prostaglandin formation. Oxazole 59 was the most active inhibitor in the human monocyte assay with an IC50 value of 7 nM.

Survival and local recurrence after anterior resection and abdominoperineal excision for rectal cancer

The aim of this retrospective study is to compare the outcome of abdominoperineal excision (APE) and anterior resection (AR) for rectal cancer in 136 patients. Local recurrence rates and 5-year survival probabilities were estimated for the AR and APE group. Further comparisons were carried out between hand-sewn and stapled anastomoses after AR, and between patients after AR and APE for tumours 2 to 6 cm from the dentate line. Local recurrence after AR occurred in 14% and after APE in 10% of these cases. Five-year survival probabilities and local recurrence frequencies showed no statistically significant difference (P > 0.05). Local recurrence rates were 13.5% after hand-sewn anastomoses and 15% after the stapled procedure. No statistically significant difference was observed in the 5-year survival and recurrence rate (P > 0.05). Seventy-four of 136 patients had tumours located 2 to 6 cm from the dentata line. Local recurrence occurred in 21% after AR and 5% after APE, showing a statistically significant difference in frequency (P < 0.05). No significant difference was found in cumulative 5-year survival probabilities. APE for advanced low rectal cancer showed a significant reduction in local recurrences compared to AR.

Etodolac selectively inhibits human prostaglandin G/H synthase 2 (PGHS-2) versus human PGHS-1

The isozymes of prostaglandin G/H synthase (PGHS) are shown to be differentially inhibited in vitro by currently marketed nonsteroidal anti-inflammatory drugs (NSAIDs) using microsomal rhPGHS-1 and rhPGHS-2. Comparison of selectivity ratios (IC50 rhPGHS-1/IC50 rhPGHS-2) demonstrated a 10-fold selectivity of etodolac (Lodine) for rhPGHS-2, whereas the other NSAIDs evaluated demonstrated no preference or a slight preference for inhibition of rhPGHS-1. In vitro enzyme results were supported by a human whole blood assay where etodolac also demonstrated a 10-fold selectivity for inhibition of PGHS-2 mediated TxB2 production. Taken together, these data may be key to explaining the clinically observed gastrointestinal safety of etodolac versus other marketed NSAIDs.

Free radical scavengers prevent reflux esophagitis in rats

Free radical damage in reflux esophagitis of rats induced by 24-hr duodenojejunal ligation was studied. Oxygen free radicals were selectively blocked. Groups were: sham operation, reflux, reflux + superoxide dismutase (SOD), catalase, dimethylthiourea, allopurinol, and inactivated SOD or inactivated catalase alone or in the combination SOD + catalase or SOD + catalase + dimethylthiourea + allopurinol. Macroscopic esophagitis was inhibited only by SOD, alone or in combination with other agents. Esophageal mucosal lipid peroxidation was 10-fold increased in the reflux group compared to the sham group (P < 0.05). This response was damped by SOD > catalase (P < 0.05) but not by the inactivated enzymes, dimethylthiourea or allopurinol. SOD + catalase showed no significant improvement on SOD alone. Total inhibition of lipid peroxidation was achieved by combining all scavengers. Total glutathione (GSH) in the esophageal mucosa was stimulated by reflux. This response was inhibited by scavengers equivalent to their efficacy in preventing lipid peroxidation. It is concluded that reflux esophagitis is associated with free radical release with O2- being the main source. Free radicals appear to stimulate GSH production in this prolonged oxidative stress.

Free radical production in nicotine treated pancreatic tissue

The ability of nicotine to induce oxidative stress in the pancreatic tissue of rats was investigated. Homogenized pancreatic tissue of Sprague-Dawley rats was incubated with nicotine in a dose of 200 ng/mg protein/ml for 15, 30, 45, and 60 min or was incubated for 30 min with nicotine in a dose of 50, 100, 200, 400, and 800 ng/mg protein/ml. Pancreatic tissue was also incubated with 200 ng/mg protein/ml nicotine with or without the scavengers superoxide dismutase (SOD), catalase, SOD+catalase, inactivated SOD, inactivated catalase, or albumin. Incubation with 0.9% NaCl served as control. There was a positive correlation between the duration of nicotine incubation and chemiluminescence (r = 0.6) or lipid peroxidation (r = 0.71) and also between the nicotine dose and chemiluminescence (r = 0.54) or lipid peroxidation (r = 0.66). Thirty minutes incubation of pancreatic tissue with nicotine in a dose of 200 ng/mg protein/ml increased chemiluminescence 5 fold and lipid peroxidation 2.5 fold. This response was dampened by SOD or catalase and abolished by SOD+catalase. Inactivated enzymes or albumin had no scavenging effect. These results demonstrate that nicotine causes oxidative stress to the pancreatic tissue of rats.

In vitro free radical production in rat esophageal mucosa induced by nicotine

Oxidative stress induced by nicotine was investigated in the esophageal mucosa of rats. The homogenized mucosa was incubated for 30 min with 50, 100, 200, 400, and 800 ng/mg protein/ml nicotine or with 200 ng/mg protein/ml nicotine for 15, 30, 45, and 60 min. Esophageal mucosa was also incubated for 30 min with 200 ng/mg protein/ml nicotine with or without the scavengers superoxide dismutase (SOD), catalase, SOD+catalase, inactivated SOD, inactivated catalase, or albumin. Incubation with 0.9% NaCl served as control. There was a strong correlation between chemiluminescence and the nicotine dose (r = 0.75) or the nicotine incubation time (r = 0.77). Thirty-minute incubation of the esophageal mucosa with 200 ng/mg protein/ml nicotine increased chemiluminescence 5.5-fold and lipid peroxidation 3.3-fold. This response was dampened by SOD or catalase and abolished by SOD+catalase. Inactivated enzymes or albumin had no scavenging effect. These results demonstrate that nicotine causes oxidative stress to the esophageal mucosa.

Traumatic bilhemia

BACKGROUND

Retrospective analysis was done of three cases with severe liver trauma and excessive serum bilirubin levels caused by a traumatic biliovenous fistula. The literature is reviewed.

METHODS

Diagnostic measures included laboratory findings, computed tomography, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

The biliovenous fistula was detected by ERCP in two cases. In one case a left hemihepatectomy was carried out, and the patient was cured. The other patient received drainage of a huge necrotic cavity in the center of the liver. Ten months later the patient underwent reoperation, and left hepatic resection was performed. The patient died of liver function failure on postoperative day 7. In the third case the fistula subsided spontaneously.

CONCLUSIONS

An excessively high serum level of direct bilirubin and only moderately elevated liver enzymes indicate bilhemia in trauma patients. ERCP is most reliable in localizing the fistula; computed tomography/ultrasonography are valuable in detecting the extension and localization of the parenchymal destruction. Conservative therapy is justified if the patient is in good condition or if the localization of the fistula is unclear. Spontaneous closure of the fistula may occur. Surgical treatment options are partial liver resection and suture of the fistula and T-tube drainage of the common bile duct and drainage of the rupture site.

Survival after surgical treatment of recurrent carcinoma of the rectum

BACKGROUND

From January 1983 to January 1991, radical surgical treatment for carcinoma of the rectum was performed upon 154 patients in our department. In 30 instances, local treatment failure occurred and patients were treated either conservatively or operatively. Survival times of these 30 patients were compared to evaluate if operation, even in instances in which only palliative resection is possible, can prolong survival and if early diagnosis of recurrence leads to a higher rate of radical resections and subsequent cure.

STUDY DESIGN

Patients were divided into three groups. Group 1 consisted of patients not undergoing an operation, patients in group 2 had a palliative resection and patients in group 3 had radical resections. The median survival time was estimated for each group.

RESULTS

The median survival period was six months for group 1, 17 months for group 2, and 35.5 months for group 3. Four patients who underwent reoperation for cure are still alive: one with recurrent tumor after 28 months, and three without evidence of disease after 32, 42 and 43 months. The most valuable diagnostic mean in the detection of local recurrence was endosonography.

CONCLUSIONS

Surgical treatment for recurrent carcinoma of the rectum is justified not only in cases having radical resection but also as a palliative approach. Compared to other investigative methods, endosonography seems to detect recurrences earlier, at a time when curative retreatment is still possible.

Ultrasonography in the management of blunt abdominal and thoracic trauma

OBJECTIVE

To assess the sensitivity, specificity, and predictive value of ultrasonography in patients with blunt abdominal or thoracic trauma in regard to the indication for immediate operation, delayed abdominal exploration, or conservative treatment.

DESIGN

A retrospective study was conducted after consecutive sampling of 1151 patients in a nonrandomized control trial.

SETTING

The study was conducted at the University Hospital of Innsbruck (Austria), which serves as a general community hospital and a major primary care and referral center.

PATIENTS

All patients with blunt abdominal or thoracic trauma with or without polytraumatization were eligible for the study; a total of 1151 patients were observed from 1980 to 1990. According to the ultrasonographic findings, patients were divided into three groups: immediate operation, primary conservative treatment, and conservative treatment (normal ultrasonographic findings). Ultrasonography was repeated when the clinical findings or laboratory test results showed the development of intra-abdominal hemorrhage or signs of organ laceration.

INTERVENTION

Ultrasonography in the emergency department or intensive care unit.

MAIN OUTCOME MEASURES

Conservative or operative treatment based on ultrasonographic and clinical findings.

RESULTS

Ultrasonography showed a sensitivity of 99%, a specificity of 98%, a positive predictive value of 0.97, and a negative predictive value of 0.99 in regard to the indication for surgery in cases of blunt abdominal or thoracic trauma. Ultrasonography is not reliable in patients with intestinal perforation and large retroperitoneal hematomas.

CONCLUSION

Ultrasonography saves time and money, can be performed in the emergency department, shows high sensitivity and specificity, and is the method of first choice in the evaluation of blunt trauma.

Subcutaneous abscess due to gallstones lost during laparoscopic cholecystectomy

No complications caused by gallstones lost during laparoscopic cholecystectomy have yet been described in the literature. In one animal study in rats, it has been shown that pigment calculi, but not cholesterol stones, lead to severe local inflammation of the abdominal cavity. We present a case of a chronic subcutaneous and subfascial abscess in the lower abdomen, which included multiple pigment calculi, six months after laparoscopic cholecystectomy. During the procedure, multiple small pigment calculi had been lost into the free abdominal cavity.

Simulated operations by pulsatile organ-perfusion in minimally invasive surgery

The rapid amplification of indications and areas of application of laparoscopic or thoracoscopic techniques leads to increasing problems and needs in surgical training. Pulsatile perfusion of organs (POP) and organ groups in laparoscopic training devices (pelvitrainers) aids in creating optimum conditions for the simulation of difficult intraoperative situations and complications. Simple applicability, low cost, and the possibility of a noticeable reduction of the currently required animal experiments render POP an ideal training method for minimally invasive surgery.

Students' psychosocial characteristics as predictors of academic performance in medical school

PURPOSE

To investigate the incremental effects of selected psychosocial measures--beyond the effects of conventional admission measures--in predicting students' academic performances in medical school.

METHODS

In 1989-90, 210 second-year students at Jefferson Medical College were each asked to complete 11 psychosocial questionnaires that were then used as predictors of performance measures in medical school. The students' scores on three subtests of the Medical College Admission Test (MCAT) were also used as predictors. Three composite measures of performance were used as the criterion measures: basic science examination grades, clinical examination grades, and ratings of clinical competence. A multiple regression algorithm (general linear model) was used for statistical analysis.

RESULTS

The response rate was 83% (175 students). When the psychosocial measures were added to the statistical models in which the common variances of the MCAT scores were already determined, significant increments in the common variances were observed for two of the three performance measures: basic science grades and clinical examination grades. Whereas only 4% of the common variance in the ratings of clinical competence could be accounted for by the MCAT scores, 14% could be accounted for by the psychosocial measures.

CONCLUSION

The "noncognitive," or psychosocial, measures increased the magnitude of the relationships between the predictive and criterion measures of the students' academic performances, beyond the magnitude attained when only the conventional admission measures were used. Therefore, psychosocial measures should be considered as significant and unique predictors of performance in medical school.

Treatment of calculi of the common bile duct

Endoscopic sphincterotomy (EST) is regarded as an alternative therapeutic approach to the surgical treatment of choledocholithiasis. To clarify the indication for each of these two methods, a prospective study has been performed comparing patients with calculi of the common bile duct who had undergone endoscopic or surgical treatment. Mortality, morbidity and stone clearance were used as criteria for the evaluation of the dependence of age on results achieved by the two modalities. Of 306 patients with choledocholithiasis, 199 underwent surgical exploration of the duct and 107 underwent endoscopic sphincterotomy. Patients who were more than 60 years of age and had previously undergone cholecystectomy underwent endoscopic sphincterotomy. All other patients had surgical treatment. There were no significant differences among the two groups with regard to mortality rates. The incidence of relevant complications as well as the incidence of surgical revisions related to postoperative complications in the operation group was, however, significantly higher (p less than 0.05). In contrast with this, the incidence of retained stones was significantly lower (p less than 0.01) in the group that underwent surgical treatment (2.5 percent) than in the group that had endoscopy (11.2 percent). When assessing the results in terms of stone clearance, complications and mortality rates, findings seem to indicate that a safe limit for the application of surgical treatment would be 60 years of age, whereas older patients should be primarily considered as candidates for EST.

Morphometry and prognosis in cancer of the pancreatic head

The histological slides of 39 cases of cancer of the pancreatic head were analysed using an interactive image analyser system. Some 14 cases were classified as periampullary, 25 as ductal pancreatic cancer. All cases had undergone radical tumor resection according to Whipple's procedure. Morphometric data, tumor size and metastatic nodal involvement were correlated to prognosis. Univariate statistical analysis showed that the classical differentiation between ductal and periampullary cancer was a weaker prognosticator than morphometric variables. In fact, multivariant statistical analysis showed that the morphometric variable irregularity was the best prognosticator (p = 0.0001). No other variable added significant prognostic information. Irregularity is a newly developed variable describing the nuclear shape corrected for roundness. We conclude that morphometry can be of essential prognostic information for the clinician in cancer of the pancreatic head.

Distinct distributions of D-erythro-neopterin in arteries and veins and its recovery by an enterohepatic circulation

Large amounts of D-erythro-neopterin, a pteridine derivative, are formed from guanosine triphosphate (GTP) by human macrophages upon stimulation with interferon-gamma. In addition, in humans a basal neopterin level in all body fluids is evident also in absence of immunological stimuli. Extremely high concentrations of D-erythro-neopterin were detected in biliary fluid. We therefore investigated, if an enterohepatic circulation might exist for this substance. We quantified concentrations of pteridines in serum obtained from various vessels and in biliary fluid. Samples were collected during surgery of five patients with duodenal ulcer or adenocarcinoma of the stomach. Our data clearly demonstrate the existence of an enterohepatic circulation for the recovery of neopterin which seems to be specific for this substance. The relative distributions of neopterin concentrations in the gastrointestinal tract and vessels were seen invariably in all patients and were consistent with findings in five corpses examined post mortem. In addition, significantly higher neopterin concentrations, were found in arteries than in veins. The data indicate that neopterin derivatives are consumed in the peripheral capillary system and an enterohepatic circulation is established to maintain constant blood levels of neopterin derivatives. Furthermore, we suppose that the liver is the source of constitutive neopterin concentrations.

Combined extracorporeal shock wave lithotripsy and laparoscopic cholecystectomy

For many centers, laparoscopic cholecystectomy (LC) has become the treatment of choice in cholecystolithiasis. Sometimes, however, bile stones with a diameter of 1.5 cm and above can only be removed if the periumbilical incision is enlarged or the stone is crushed with a forceps intraoperatively. To keep the incision as small as possible, to be able to work with the smallest available trocars, and to shorten the operative procedure, patients in our center with stones larger than 1.5 cm are submitted to preoperative extracorporeal shock wave lithotripsy (ESWL). LC is performed the same or the next day. We have used this procedure in eight patients, and LC could be performed in all cases without enlargement of the periumbilical incision. Macromorphological changes of the gallbladder following ESWL, such as hematoma and edema, were not seen.

[Individualized intraoperative radiotherapy of pancreatic cancer]

During the period from 1984-1988 at the University Clinic, Innsbruck (in cooperation with the Department of Radiotherapy and Surgery) 40 patients with pancreas carcinoma were treated with intraoperative radiotherapy. Based upon the preoperative CT's, the operation reports and the patho-anatomic judgement of the operative specimen for 19 patients the quality of the performed IORT (with curative intention combined with partial pancreaticoduodenectomy) was examined. This examination was based upon a standardized concept. In 53% of the cases the chosen irradiation field was too small and, in most cases the applied single dose was from radiooncological point of view not sufficient. These results emphasize the need for preoperative treatment planning depending from the surgical intention, the need for individually shaped cones and direct field control of the applied dose.

[Sigmoid volvulus, diagnosis and feasibility of an interdisciplinary primary therapy]

Sigmoid volvulus is an emergency which requires rapid diagnosis and immediate adequate treatment. Diagnosis is primarily radiological. Emergency laparotomy carries a high mortality and should therefore not be the immediate treatment. In our opinion, detorsion by colonoscopy under radiological control is a promising form of treatment. Selective resection of the sigmoid, thereby removing the cause of the abnormality, should not be forgotten, since this prevents recurrences. For this method, mortality after adequate gut preparation is only 5.4%. An exception to the above is gangrene of the bowel, when an emergency laparotomy cannot be avoided.

Nuclear DNA distribution pattern of the parenchymal cells in adenocarcinomas of the pancreas and in chronic pancreatitis. A study of archival specimens using both image and flow cytometry

The nuclear DNA distribution pattern of the neoplastic parenchymal cells of 100 conventionally formalin-fixed and paraffin-embedded specimens from pancreatic adenocarcinomas and from 8 specimens of chronic pancreatitis was assessed by means of image cytometry. All material originated from pancreatic restrictions. Evaluable DNA histograms could be obtained for 77 carcinomas, and clinical data were available for 71 of these. In these 71 specimens, the nuclear DNA ploidy pattern was also investigated by means of flow cytometry. In 76 of the 77 cases, the image-cytometric DNA ploidy pattern obtained showed a "nondiploid" distribution with modal values as high as 8.5 c. In 21 cases, the neoplastic cells showed modal values in the "triploid" region. The analogous 71 flow-cytometric DNA histograms could only be evaluated in 50 cases because of excessively high amounts of background and/or excessively broad peaks. In 47 cases, the nuclear DNA histogram was nondiploid according to both techniques. The patients with carcinomas whose cell nuclei showed a triploid DNA distribution showed a significantly shorter survival time than those with tumor cell populations of nontriploid DNA distribution patterns. In the 8 specimens of chronic pancreatitis, the parenchymal cells were all equipped with nuclei showing diploid DNA distribution patterns.

Adaptation to bacterial lipopolysaccharide controls lipopolysaccharide-induced tumor necrosis factor production in rabbit macrophages

These experiments provide an explanation for the observation that two intravenous injections of lipopolysaccharide (LPS) spaced 5 h apart in rabbits cause tumor necrosis factor/cachectin (TNF) levels to rise in the blood only after the first LPS injection. Herein we show that treatment of elicited peritoneal exudate rabbit macrophages (PEM) with two doses of LPS given 9 h apart results in a marked reduction in TNF production by the second LPS exposure. This state of hyporesponsiveness is a result of adaptation to LPS, is induced by LPS concentrations that are 1,000-fold less than required to induce TNF production (picograms vs. nanograms), is characterized by a decrease in LPS-induced TNF mRNA without any change in TNF mRNA half-life, is not changed by including indomethacin in cultures, and is specific for LPS since LPS-adapted cells display a TNF response to heat-killed Staphylococcus aureus that is at least as good as that observed in control PEM.

Transesophageal sonography in central bronchial carcinoma

A new application of transesophageal sonography was tested in eight patients suffering from central bronchial carcinoma. Due to ultrasound technology, a real time investigation is feasible which enhances the diagnostic method of computed tomography (CT) by discriminating between tumour and mediastinal organs which cannot be delineated by CT only. Different sonographic densities and the movement between organ and tumour contribute to the diagnostic accuracy of sonography if operability is questionable due to possible organ infiltration by tumour. The method is limited by the air filled organs (trachea, bronchi), as ultrasound does not penetrate adequately.

Colonoscopic treatment of sigmoid volvulus

Sigmoid volvulus commonly presents with signs of bowel obstruction. In the absence of an exact preoperative diagnosis, these patients have to undergo urgent surgery. We report a case of sigmoid volvulus diagnosed radiologically and managed by endoscopic derotation. When the cause of the obstruction is known to be due to sigmoid volvulus, surgery can be avoided by careful endoscopic derotation of the sigmoid colon.

"Reversible gastric banding" in surgical treatment of morbid obesity--results of animal experiments

The basic principle of "reversible gastric banding" as a new surgical approach to morbid obesity treatment is the creation of a small fundus reservoir using a silicone cuff which is coiled around the stomach close to the cardia. The extent of obstruction corresponds to the amount of liquid in the cuff which can be varied by puncture of a valve implanted in the subcutis. The reversibility of gastric obstruction is the great advantage of this method as compared to vertical banded gastroplasty or gastric bypass. We studied this method in animal experiments using seven "Göttinger Minipigs". In two animals the objectives of the study were reached, the observed complications, mostly caused by the nature of the test animal, are analyzed and discussed. To our knowledge, this is the first report in the literature on animal experiments in bariatric surgery.

Synchronous adenocarcinoma of the transverse colon, the gallbladder and the vermiform appendix

According to the literature synchronous adenocarcinomas of both, the colon and the gallbladder or the colon and the appendix are extremely unusual. To our knowledge the simultaneous occurrence of all three tumors has never been published before. Preoperative diagnosis of early stage tumors of the gallbladder and the vermiform appendix is also made very seldom. The following case report records an instance of synchronous adenocarcinomas of the gallbladder, the transverse colon, in a colonic polyp and the appendix. Owing to the patient's advanced age simultane cancer occurrence may be mere coincidence. Nevertheless, this extremely rare entity could also be ascribed to a genetic defect or an unknown carcinogenic agent.

[Intraoperative radiotherapy of malignant pancreatic tumors--initial results]

Thirteen patients suffering from adenocarcinomas of the pancreas were submitted to an intraoperative fast electron "boost" therapy with or without percutaneous photon irradiation. A duodeno-cephalo-pancreatectomy with subsequent irradiation of the tumor bed could be performed in three patients. Ten patients were inoperable because of advanced tumors and formation of metastases. The average survival is 6.5 months, at present six patients are alive without major troubles. An analgetic effect was obtained in ten patients. The first results are encouraging with respect to local control, the little acute and chronic morbidity, and palliation achieved in advanced stages.

[Intraoperative radiation treatment of carcinoma of the pancreas. Initial clinical results]

Intraoperative radiotherapy (IORT) was administered to 13 patients with carcinoma of the pancreas, using high-velocity electrons of a LINAC accelerator in a single dose of maximally 25 Gy applied directly to the tumour or tumour bed with the abdomen open. There were no disorders of wound healing or other serious early complications which could be ascribed to the radiation. Stomach and intestines were excluded from the radiation field to avoid late radiation damage, such as stenoses or ulcers. The method is particularly indicated for locally non-resectable, non-metastasized pancreatic carcinoma, possibly also as tumour-bed radiation during radical surgery. Patients with distant metastases were not given radiation. First results point to IORT providing lasting improvement of pancreatic pain. It is too early to know whether survival time is favourable influenced.

Attenuation by d-ozolinone of l-ozolinone-induced diuresis in rats

The effect of the non-diuretic dextrorotatory isomer of ozolinone on l- ozolinone -induced diuresis was studied in anesthetized rats. After intravenous application d- ozolinone attenuated l- ozolinone -induced increase in renal fluid, sodium, potassium and chloride excretion. Microperfusion experiments of the loop of Henle in vivo revealed that no interaction between the two stereoisomers occurred at this main site of tubular action of l- ozolinone . Since both isomers share the same organic acid transport pathway in the proximal tubule it is assumed that d- ozolinone attenuates the l- ozolinone -induced diuresis because it depresses proximal secretion of l- ozolinone and thereby partially prevents transfer of this diuretic to the tubular fluid.

Psychopathologic patterns in depressed adolescents

Depression in adolescents may be masked by symptoms not commonly found in adults. These symptoms may require, at least initially, a management approach not necessarily in the best interest of treatment of the underlying depression. Suicidal behavior in adolescents can be manipulative and unrelated to depression. Management of such adolescents must differ from the management of patients whose suicidal behavior is the direct result of depression.