Laparoscopic obturator nerve neurolysis after pelvic lymphadenectomy

Postoperative neuropathy is a known complication of major pelvic oncologic surgery. Obturator nerve injury complicating pelvic lymph node dissection has been reported in the literature. Severity and duration of symptoms are determined by the severity of the initial nerve lesion. Different management options have been described in the literature. We report here on a patient who developed right obturator neuropathy after pelvic lymphadenectomy. Initial management by physical therapy was unsuccessful, and the patient underwent a successful laparoscopic surgical neurolysis. Whereas preventive measures remain essential to avoid any nerve injury, this case illustrates the use of laparoscopy to perform neurolysis with a favorable outcome; therefore, persistent pain or motor loss should motivate at least surgical exploration that can be done with low morbidity by laparoscopy.

Vaginal hysterectomy for benign disorders in obese women: a prospective study

OBJECTIVE

To compare the morbidity of vaginal hysterectomy in obese and non-obese women in a single institution.

DESIGN

Obese and non-obese women with benign uterine disorders matched for age, parity and race underwent vaginal hysterectomy without laparoscopic assistance. Peri-operative outcome complications were compared. Thirty-eight women had a BMI over 30 kg/m(2) (study group) and 178 women had a BMI below 30 kg/m(2) (control group).

SETTING

Gynaecologic department of a university hospital.

POPULATION

Women who were referred to our department with an indication of vaginal hysterectomy for benign disorders.

METHODS

Case control study.

MAIN OUTCOME MEASURES

Peri-operative complications, the fall in the haemoglobin concentration, the duration of the procedure, the length of the hospital stay and uterine weight were analysed.

RESULTS

Mean BMI was 33.2 and 23.7 kg/m(2) in the study and control groups, respectively. None of the obese women had severe co-morbidity contraindicating surgery. There were no significant differences in surgical or anaesthetic risk factors, including parity, hormonal status, pre-existing disease and estimated mean uterine weight. The overall complication rates were 14% and 16% in the obese and non-obese groups, respectively (P= 0.7). Obesity did not increase the duration of the procedure (48 [7] minutes vs 50 [10] minutes, P= 0.1) or the length of hospitalisation (5.8 [1.4] days vs 5.5 [1.2] days, P= 0.2).

CONCLUSION

Vaginal hysterectomy can be successfully performed, with acceptable morbidity, in obese women.

Previous abdominal surgery and closed entry for gynaecological laparoscopy: a prospective study

OBJECTIVES

To assess the morbidity from closed laparoscopic access and define the role of previous surgery on the occurrence of these complications.

DESIGN AND METHODS

We prospectively recorded data on all laparoscopic procedures between January 2000 and January 2001. We compared results from patients without previous abdominal surgery (group I) with patients with prior abdominal surgery (group II). The insertion site for the Verres needle was trans-umbilical for patients in group I and in the left upper quadrant for patients in group II.

SETTING

Gynaecology department of a University Hospital.

POPULATION

All laparoscopic procedures between January 2000 and January 2001.

MAIN OUTCOME MEASURES

We compared results from patients without previous abdominal surgery (group I) with patients with prior abdominal surgery (group II). The insertion site for the Verres needle was trans-umbilical for patients in group I and the left upper quadrant for patients in group II.

RESULTS

Four hundred and seventy-seven laparoscopies were carried out during the study period, 368 women without previous surgery were included in group I, and 109 women were included in group II. We recorded 1 complication (overall complication rate of 0.2% and 31 incidents (6.4%). One complication (small bowel injury) was related to the insertion of the Verres needle (0.2%). The incidents and complications occurred only in group II (P < 0.05). All the complications were treated by laparoscopy.

CONCLUSION

The complication rate of the entry step is low in gynaecological laparoscopy. A previous history of laparotomy increases the risk of these complications and incidents. Safety rules and other access method should be investigated for these patients.

Sonography in prenatal diagnosis of congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder with an incidence of 1/15 000. More than 90% of CAH cases result from mutations of CYP21, leading to 21-hydroxylase deficiency. In its classical form, CAH is severe and consists of the virilizing (increase of androgens) and salt-wasting (lack of aldosterone) phenotype. When a proband exists, early prenatal diagnosis for CAH can be performed by direct molecular analysis in the first trimester. We describe herein two cases suggesting that the prenatal diagnosis of CAH can be initiated by the sonographic appearance of the adrenal gland at the second-trimester scan in the absence of a family history.

[Embolization of uterine arteries for uterine fibroids: state-of-the-art]

Embolization of uterine arteries for fibroids is a modern minimally invasive method for treatment of uterine fibroids. Results from published data show a substantial short-term uterine reduction, an improvement in menorrhagias, and a reduction in fibroid related pain. Hospital stay and recovery are shortened compared with hysterectomy. One randomised comparative trial EAU vs hysterectomy has showed a reduction in hospital stay length and in the rate of major complications, but an increased rate of minor complications. Pregnancies and uneventful deliveries have been reported after uterine arteries embolization. Rare but severe complications have been described. Embolization of uterine arteries can be considered as a safe alternative to hysterectomy or myomectomy in selected cases. It cannot be a routine method for treating fibroids with women of childbearing age.

Tension-free vaginal tape and associated procedures: a case control study

OBJECTIVES

We compare objective and subjective cure rates after tension-free vaginal tape procedures performed alone or in conjunction with vaginal procedures.

METHODS

One hundred eighty-six women underwent a tension-free vaginal tape procedure for stress or mixed urinary incontinence. One hundred women treated with tension-free vaginal tape alone (group 1) were compared with 40 women treated with tension-free vaginal tape and concomitant vaginal hysterectomy (group 2), and 46 patients treated with tension-free vaginal tape and pelvic floor reconstruction (group 3). Patient outcomes, surgical difficulties and complications are reported. Postoperative voiding diaries, standing stress-test results, and patient satisfaction were compared.

RESULTS

There were no significant differences among the three groups in terms of age, menopausal status, BMI, previous incontinence surgery, or the type and degree of incontinence. Parity was significantly higher in the group treated with tension-free vaginal tape and pelvic floor reconstruction ( p=0.04 ). The overall perioperative complication rate was 15.6%. Women treated with tension-free vaginal tape and hysterectomy (group 2), and those treated with tension-free vaginal tape and pelvic floor reconstruction (group 3) had a significantly higher incidence of bladder injury (17.9% and 13%, respectively, versus 5% in group 1; p=0.05 ). Estimated blood loss and the frequencies of postoperative urgency and voiding disorders did differ significantly between women treated with tension-free vaginal tape alone and those who underwent associated procedures. The mean follow-up time was 24.5+/-2.6 months. No difference in the objective cure rate was found between the tension-free vaginal tape group and the other two groups (93% versus 97.5% and 91.1%; p=0.3 ). No difference in the subjective cure rate was found between the tension-free vaginal tape group and the groups undergoing associated procedures (72% versus 72.5% and 68.8%; p=0.4).

CONCLUSION

Pelvic floor defects, benign uterine disorders and stress urinary incontinence can be safely treated with tension-free vaginal tape and vaginal procedures during the same surgical procedure.

Sclerosing stromal tumor of the ovary: color Doppler findings

The sclerosing stromal tumor (SST) of the ovary is a distinct benign neoplasm that differs from fibromas, thecomas, luteinized tumors and lipoid cell tumors. It accounts for 6% of ovarian stromal tumors and tends to occur at an earlier age. On gray-scale ultrasound examination, SSTs of the ovary are solid or cystic and multilocular. We describe here, we believe for the first time, the findings on color Doppler imaging of an SST of the ovary. A 29-year-old woman presented with an organic ovarian mass. She underwent a transvaginal ultrasound examination that revealed an echogenic cyst with acoustic shadowing. Color Doppler demonstrated marked peripheral vascularization. Findings on computed tomography and magnetic resonance imaging strongly suggested the preoperative diagnosis of SST of the ovary, which was confirmed at pathology. Association of an echogenic ovarian mass with acoustic shadowing and a high degree of peripheral vascularization may strongly suggest the diagnosis of SST of the ovary.

A French multicenter clinical trial of SPARC for stress urinary incontinence

OBJECTIVE

To evaluate the safety and efficacy of the SPARC procedure in women with genuine stress urinary incontinence.

METHODS

We conducted a prospective multicenter trial of a suprapubic approach to suburethral polypropylene (SPARC) taping for the treatment of genuine stress urinary incontinence. Between June 2001 and June 2002, 104 consecutive women (mean age 58.7 years) underwent SPARC in three centers. All the women had urethral hypermobility preoperatively. Detrusor instability was ruled out by cystometry. The women were evaluated 1, 3, 6 and 12 months postoperatively. The objective cure rate was evaluated by clinical and urodynamic examination, and the subjective cure rate was assessed using the Kings and Bristol questionnaire.

RESULTS

The mean follow-up time was 11.9+/-1.9 months (range 8 to 20 months). The mean operating time was 30 min (25-50 min). Most of the patients received general anesthesia (48%). The overall complication rate was 44.2% (46/104). The perioperative complication rate was 10.5%, including 11 bladder injuries. A significant difference in the bladder injury rate was observed between women with and without previous incontinence surgery (respectively 4/11, 36.3% versus 7/93, 7.5%; p<0.001). No hemorrhaging occurred. The early postoperative complication rate was 22.1%. The main complication was voiding disorders (11 patients), which necessitated intermittent self-catheterization for less than 15 days (1.3+/-1.1 days, range 1 to 10 days). The late postoperative complication rate was 11.5%, including de novo urge symptoms in 12 women. The objective cure rate was 90.4%. No difference was found between patients with genuine stress incontinence and those with mixed incontinence. The subjective cure rate was 72%. The objective and subjective cure rates differed significantly (p<0.05). The subjective cure rate among patients with de novo urge symptoms was 58%.

CONCLUSION

The SPARC procedure is a safe and effective treatment for women with stress urinary incontinence, despite a high incidence of de novo urge symptoms.

Morbidity of vaginal hysterectomy for benign tumors as a function of uterine weight

OBJECTIVE

To evaluate the relationship between uterine weight and morbidity in women undergoing vaginal hysterectomy.

STUDY DESIGN

A prospective study of vaginal hysterectomy was carried out in women with benign uterine tumors. The only exclusion criteria were a suspected adnexal mass, a very narrow vagina and an immobile uterus. The women were stratified into 3 groups according to uterine weight. The groups were compared as regards indications, operative time, complication rates, analgesia requirements and postoperative recovery.

RESULTS

A total of 214 women underwent vaginal hysterectomy: group 1, n = 114, uteri < 180 g; group 2, n = 73, uteri 180-500 g; group 3, n = 27, uteri > 500 g (maximum 1,350 g). The groups differed with respect to mean age (P = .003) and menopausal status (P = .002) but not gravidity, parity, previous pelvic surgery or preoperative hemoglobin levels. Concerning the indications for hysterectomy, only the incidence of pelvic compression differed between the groups (P = .04). There was no difference in the frequency of concomitant surgical procedures (e.g., adnexectomy) between the groups. Morcellation rate was 30% in group 1, 73% in group 2 and 100% in group 3. The overall complication rate was not significantly different between the groups: 20.1%, 15.0% and 22.2%, respectively. The only major complication was an injury to the in-fundibulopelvic ligament in a group 1 patient. Operative time increased significantly with uterine weight (82 +/- 35.4, 91.8 +/- 35.4 and 94.8 +/- 36.5 minutes, respectively; P = .01). There were no significant differences between the groups as regards perioperative hemoglobin loss, analgesia requirements, time to flatus and stool return or length of hospital stay.

CONCLUSION

Vaginal hysterectomy can be performed successfully even in the case of greatly enlarged uteri; nulliparity and a history of pelvic surgery are not absolute contraindications.

Predictive value of two-dimensional and three-dimensional multiplanar ultrasound evaluation of the cervix in preterm labor

OBJECTIVE

To compare the predictive value of conventional two-dimensional ultrasound measurement of cervical length and three-dimensional multiplanar volume assessment of the cervix for delivery at < 37 weeks of gestation among patients with preterm labor.

MATERIALS AND METHODS

This preliminary prospective study was conducted in 28 patients hospitalized for preterm labor between 24(+0) and 33(+6) weeks of gestation, defined by regular and painful uterine contractions (at least two per 10 min), intact membranes and a cervical length of < or = 26 mm measured by two-dimensional transvaginal ultrasonography at admission with a Voluson 530 (Kretz, France) machine using a 7.5-MHz transvaginal transducer. The cervical volume was then assessed by the three-dimensional triplan technique. It was automatically calculated after drawing of the cervix outlines in mid-sagittal and median axial plane images. As the border between the cervix and the lower uterine segment is virtual, it was defined by a perpendicular line to the line joining the external os and the internal os. The result of the latter measurement was not disclosed to the obstetric team. The primary outcome was the rate of deliveries at < 37 weeks. We constructed a receiver operator characteristic (ROC) curve to determine the optimal cut-off point of the cervical volume, to predict preterm delivery.

RESULTS

Sixteen (57%) patients delivered at < 37 weeks. Mean (+/- SD) gestational ages at admission and delivery were 28.2 (+/- 3.2) weeks and 35.9 (+/- 4.1) weeks, respectively. Mean cervical length and volume at admission were 20.1 (+/- 9.9) mm and 23.1 (+/- 14.6) mm3, respectively. The ROC curve showed that the optimal cut-off point was 20 mm3. The predictive values of cervical length and of cervical volume on delivery at < 37 weeks were: sensitivity, 87.5% (14/16) and 75% (12/16); specificity, 50% (6/12) and 75% (9/12); positive predictive value, 70% (14/20) and 80% (12/15); negative predictive value, 75% (6/8) and 69.2% (9/13), respectively.

CONCLUSIONS

The three-dimensional multiplanar volume assessment of the cervix probably increases the positive predictive value of cervical ultrasonography in predicting preterm delivery. Screening high-risk women could be achieved by conventional two-dimensional transvaginal ultrasound and the diagnosis of true preterm labor may be improved by three-dimensional multiplanar transvaginal ultrasound assessment of the cervix.

Body mass index and outcome of tension-free vaginal tape

OBJECTIVES

To assess the effectiveness of tension-free vaginal tape (TVT) in women with high body mass indices (BMIs).

METHODS

Thirty-eight consecutive patients with BMIs exceeding 30 who underwent tension-free vaginal tape were compared with 149 consecutive patients with BMIs of 30 or less who underwent the same procedure. Body mass index was calculated pre-operatively and at follow-up. Women were classified as being of normal weight (BMI 20-25), overweight (BMI 26-30), or obese (BMI >30). Patient characteristics, operative and post-operative complications, reported continence rates were analyzed according to BMI.

RESULTS

There were no significant differences between groups in terms of age, parity, menopausal status, previous surgery, type and degree of incontinence. Estimated blood loss, operative times, bladder injuries, post-operative urgency and voiding disorders did not differ significantly between women with high BMIs and those with low BMIs. Women with BMIs exceeding 30 had a significantly higher incidence of post-operative urge urinary incontinence (17.9 versus 3.4 and 6.4% p = 0.02) without any effects on the objective and subjective cure rates (82 versus 88.7 and 93% p = 0.1, 71.7 versus 72.1 and 74% p = 0.9).

CONCLUSION

We did not find pre-operative obesity to be a risk factor for failure of tension-free vaginal tape.

Sigmoid endometriosis in a postmenopausal woman

Bowel obstruction resulting from endometriosis is an infrequently observed phenomenon in postmenopausal women. A 69-year-old woman without hormone replacement had clinical and radiologic findings consistent with a pelvic tumor invasive into the wall of the sigmoid colon. The patient underwent resection of the sigmoid colon and total hysterectomy. Histologic examination revealed endometrioma. This case documents the possible occurrence of symptomatic bowel endometriosis after years of a hormonally castrated state.

[Uterine morcellation during vaginal hysterectomy: apropos of a series of 216 prospective cases]

OBJECTIVE

The purpose of this study was to compare the surgical outcomes of women undergoing vaginal hysterectomy with and without morcelation.

PATIENTS AND METHOD

Between December 1999 and December 2000, 216 women underwent vaginal hysterectomy without laparoscopic assistance at the Department of Gynecology of Hôtel-Dieu hospital in Paris. The patients were divided into two groups: 114 of them underwent vaginal hysterectomies with morcelation whereas 102 underwent vaginal hysterectomies without morcelation. The two groups were compared as to demographic data, total complications, operative time, hospital stay length and peri-operative hemoglobin concentration change.

RESULTS

Although women undergoing morcelation were significantly younger (mean 49 versus 52, p = 0.01) and less parous (mean 1.9 versus 2.3, p = 0.03), there were no significant differences in other surgical or anesthetic risks factors, including weight, BMI, nulliparity and preexisting surgical diseases. Mean uterine weight was significantly greater in those undergoing morcelation (331 versus 110 g, p < 0.001); operative time was increased in the group which had undergone morcelation (331 versus 110 g, p < 0.001). There were no significant differences between the two groups with respect to peri-operative hemoglobin concentration change or hospital stay length. Finally, the rate of surgical complication was similar in the two groups (17.5 versus 21.5%).

CONCLUSION

Although vaginal hysterectomy requires an increase in operative time, morcelation at the time of vaginal hysterectomy is safe and facilitates the vaginal removal of enlarged uteri without increasing peri-operative morbidity.

[Prolapse in the young woman: study of risk factors]

OBJECTIVE

To determine the risk factors for genital prolapse in a group of 37 young women less than 45 years old.

PATIENTS AND METHODS

We studied 37 young women who had been operated for genital prolapse, whereas the control group consisted of women operated for benign gynaecologic disorders.

RESULTS

In the study group the number of pregnancies and deliveries, the babies' weight, the positive family history of prolapse were heavier than in the control group. The women with prolapse had more often chronic pulmonary diseases, asthma, as well as operations for abdominal hernias. The mode of delivery, be it a cesarean section or the use of forceps, and the active second stage of labor had no effect whatever on the occurring of genital prolapse in young women.

CONCLUSION

Our data support the suggestion that multiparity, babies' weight and congenital factors are responsible for a higher rate of genital prolapse in young women.

[Pubo vaginal and sub urethral slings: review]

BACKGROUND

Sling surgery is considered to be the gold standard for treatment of female stress urinary incontinence resulting from sphincter deficiency. A century of experience is reviewed and evolving new concepts and techniques are presented.

METHODS

This article reviews 34 retrospective studies involving 2 967 interventions.

RESULTS

and discussion. Sub urethral sling procedures have been reserved traditionally for the treatment of recurrent stress incontinence, autologous or heterologous slings are used and the success rate varies between 65 and 98%. Objective long term results have been excellent but the rate of voiding disorders and de novo detrusor instability is respectively from 12.8% and 16.6%. The TVT procedure (Tension free vaginal tape) was described by U. Ulmsten in 1996. The mesh is placed under the uretra and supports the integral theory of Ulmsten and Papapetros. Its success is bound by its efficacy, its reproducibility and restricted morbidity.

CONCLUSION

The pubovaginal sling remains an excellent operation for the cure of stress urinary incontinence related both to sphincter deficiency alone or existing with urethral hypermobility. About Prolene tape, the present review of adverse outcomes may simply reflect an overall increase in the number of sling procedures being performed. Although decreased operative time and morbidity have been attributed to the use of TVT tape, it is essential to ensure that long-term safety and efficacy will not be jeopordised before accepting it as a new standard of care.

[New physiological, diagnostic and therapeutic concepts in the management of rectoceles in women]

Anterior rectocele is not only a herniation of the anterior rectal wall into the vagina, but rather a complex anatomical and functional abnormality which may be isolated or associated with other pelvic floor disorders. It could result in rectal obstruction with dyschezia, manual extraction of feces, and fecal or gas incontinence. The purpose of this review is to describe and to assess the most useful methods for the diagnosis and for the treatment of the rectocele. Data from physical examination may be improved by defecography. Surgery remains the main treatment: several surgical ways (perineal, anal, abdominal, laparoscopic) are described. Analysis of the anatomical and functional results allows to assess these techniques and to determine the best therapeutic option.

Inherited interleukin-12 deficiency: IL12B genotype and clinical phenotype of 13 patients from six kindreds

Interleukin-12 (IL12) is a cytokine that is secreted by activated phagocytes and dendritic cells and that induces interferon-gamma production by natural-killer and T lymphocytes. It consists of two subunits, p35 and p40, which are encoded by IL12A and IL12B, respectively. The first reported patient with a genetic cytokine disorder was a Pakistani child, who was homozygous for a large loss-of-function deletion (g.482+82_856-854del) in IL12B. This IL12-deficient child suffered from infections caused by bacille Calmette-Guérin (BCG) and Salmonella enteritidis. We herein report 12 additional patients from five other kindreds. In one kindred from India, the same large deletion that was described elsewhere (g.482+82_856-854del) was identified. In four kindreds from Saudi Arabia, a recessive loss-of-function frameshift insertion (g.315_316insA) was found. A conserved haplotype encompassing the IL12B gene suggested that a founder effect accounted for the recurrence of each mutation. The two founder mutational events-g.482+82_856-854del and g.315_316insA-were estimated to have occurred approximately 700 and approximately 1,100 years ago, respectively. Among a total of 13 patients with IL12 deficiency, 1 child had salmonellosis only and 12 suffered from clinical disease due to BCG or environmental nontuberculous mycobacteria. One patient also had clinical disease caused by virulent Mycobacterium tuberculosis, five patients had clinical disease caused by Salmonella serotypes, and one patient had clinical disease caused by Nocardia asteroides. The clinical outcome varies from case to case, since five patients (aged 2-11 years) died of overwhelming infection, whereas eight patients (aged 3-12 years) are still in good health and are not currently taking antibiotics. In conclusion, IL12 deficiency is not limited to a single kindred, shows significant variability of outcome, and should be considered in the genetic diagnosis of patients with mycobacteriosis and/or salmonellosis. To date, two founder IL12B mutations have been identified, accounting for the recurrence of a large deletion and a small insertion within populations from the Indian subcontinent and from the Arabian Peninsula, respectively.

Novel polymorphism in the FMR1 gene resulting in a "pseudodeletion" of FMR1 in a commonly used fragile X assay

The fragile X syndrome is the most commonly inherited cause of mental retardation. Genetic diagnosis of this disease relies on the detection of triplet repeat expansion in the FMR1 gene on the X chromosome. Although the majority of disease in fragile X patients is due to mutations involving triplet repeat expansion, deletion of various portions of FMR1 has also been described in association with the fragile X syndrome. Here we describe a rare polymorphism in the noncoding region of FMR1 that mimics detection of a deletion in a commonly used assay for fragile X syndrome, which can result in misdiagnosis of the disease.

Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients

OBJECTIVE

Pain-relieving effects of lidocaine/bupivicaine local anesthetic (LA) and saline (S) block of sympathetic ganglia (stellate block, 4 patients; lumbar sympathetic block, 3 patients) were compared in 7 complex regional pain syndrome (CRPS) patients on a double-blind crossover basis to evaluate the diagnostic and therapeutic value of local anesthetic sympathetic blocks.

DESIGN

Patients rated their pain on a visual analog scale before and after blocks and were tested for mechanical allodynia one-half hour after blocks. Thereafter, they rated their pain intensity in diaries four times a day for 7 days. Each patient received two blocks, S and LA, and served as his own control.

RESULTS

Both S and LA injections of sympathetic ganglia produced large reductions in pain intensity in 6 of 7 patients 30 minutes after block. These large reductions were accompanied by the reversal of mechanical allodynia in both S and LA. The mean difference between initial peak reduction in pain intensity produced by saline (68.7%) and active local anesthetic (74.4%) did not approach statistical significance. In striking contrast, the mean duration of pain relief was reliably longer in the case of LA (3 days, 18 hours) as compared with S ( 19.9 hours), a difference that occurred in all 7 patients. In a larger sample of 41 CRPS patients, signs of sympathetic efferent blockade, including Homer' s syndrome or skin surface temperature change, were not predictive of initial peak magnitude of pain relief from sympathetic blockade but were predictive of duration of pain reduction.

CONCLUSION

The combination of these results provides evidence that duration of pain relief is affected by injection of local anesthetics into sympathetic ganglia. These results indicate that both magnitude and duration of pain reduction should be closely monitored to provide optimal efficacy in procedures that use local anesthetics to treat CRPS.

Potentiation of systemic morphine analgesia in humans by proglumide, a cholecystokinin antagonist

Proglumide, a cholecystokinin antagonist, potentiates analgesia produced in rats by morphine and endogenous opiates, and appears to reverse tolerance in rats to opiate analgesia. Therefore, proglumide and other cholecystokinin antagonists may be clinically valuable. We have tested proglumide's possible opiate analgesic potentiating effects by examining, in volunteers, the effects of morphine and proglumide on human pain visual analogue scale responses to 45-51 degrees C skin temperature stimuli. Proglumide (50-100 micrograms intravenously) potentiated both the magnitude and duration of analgesia produced by small doses of morphine. This study provides indirect evidence for a cholecystokinin-opiate interaction in humans. Therefore, cholecystokinin antagonists such as proglumide may serve to potentiate exogenous or endogenous opiate action.