Insufficiency of local approach regarding treatment of early gastric cancer

Out of 1041 patients who underwent surgery for gastric cancer between 1968 and 1987, 120 patients suffered from early gastric cancer (11.5%). Until 1976, early gastric cancer was treated along the lines of surgical treatment of benign ulcer disease, i.e. by partial 2/3-gastric resection without lymphadenectomy, even though malignancy had been confirmed preoperatively in all cases. Since 1979 oncological criterias (subtotal or total gastrectomy with lymphadenectomy) have gained importance in treating early gastric carcinoma. In the case of mucosal carcinoma, the extent of surgical intervention does not have any influence on the 10-year survival rate. In treating submucosal carcinoma 10-year survival rates of 72.9 (+/- 7.2%) can only be achieved by performing total gastrectomy and lymphadenectomy whereas the 10-year survival rate after performing partial 2/3-gastric resection alone (p = 0.01) is only 17.6 (+/- 9.2%). Since mucosal and submucosal carcinoma cannot accurately be differentiated preoperatively, surgical intervention must be carried out in an oncological sense. The fact that 2/3 partial gastric resection does not generally ensure adequate therapy implies that local procedures are even less sufficient. Even in cases of mucosal infiltration only, local procedures such as laser therapy and local excision of the tumour cannot be considered being a curative approach, since hereby the probability of lymph node metastases (4%) is not taken into account.

Endothelial mediated enhancement of noradrenaline induced vasoconstriction in normal and varicose veins

The role of the endothelium to influence smooth muscle contraction in normal and varicose veins was investigated in vitro using saphenous vein preparations obtained at vascular surgery. Paired control and endothelium-denuded rings were tested simultaneously and contracted with noradrenaline (10(-9)-10(-4) M). Identical experiments were also performed on sheep femoral veins and arteries. Noradrenaline induced maximal tension was 30% lower in varicose compared to normal veins. In normal veins removal of endothelium significantly reduced the maximal response to noradrenaline by 40% whereas in varicose veins no significant reduction could be seen. In the sheep femoral vein removal of the endothelium also resulted in decrease of noradrenaline-induced contraction. It can be concluded that in the human saphenous vein the endothelium has a contraction facilitating effect in response to stimulation with noradrenaline. In varicose veins the endothelial-mediated enhancement of noradrenaline-induced vasoconstriction is reduced probably because of endothelial damage. This observation may be of importance in the pathogenesis of varicose veins.

Doppler echocardiographic findings in coronary-pulmonary fistula

We describe a patient with a coronary-pulmonary fistula who had a syncopal attack. He had also pectus excavatum. Doppler echocardiography revealed late diastolic flow in the left high parasternal region which was not caused by pulmonary insufficiency, but by the jet through the fistulous communication. Selective coronary angiography demonstrated the fistula between the left anterior descending artery and the pulmonary trunk.

Long-term results of highly selective vagotomy for the treatment of duodenal ulcer

Between 1971 and 1987, highly selective vagotomy (HSV) was carried out in 984 patients suffering from duodenal ulcer disease. In 97.3% of these cases, the surgical intervention was uncomplicated, the related mortality being 0.3%. During the follow-up period the postoperative condition of the patients was checked once a year wherever possible; in 92.3%, follow-up was continued until december 1987, the maximum period of postoperative follow-up being 16 years. No prognostically reliable indication of the risk of ulcer recurrence was obtained from an analysis of gastric juice. In 79.1% of the cases who underwent surgery, the result was good to satisfactory, while 11.7% had functional complaints such as dumping or diarrhea. The probability of developing a recurrent ulcer within 16 years after the initial operation was 29.7%. This rate of recurrence is determined among other things, by the discovery of clinically quiescent ulcers during the yearly follow-up examinations, when these are performed carefully, and over a sufficiently long period.

[Quality of life after rectal resection or extirpation. A comparison using different measurement parameters]

Two groups of 41 patients each who had undergone rectal resection or excision were questioned about the quality of their life an average of 4.3 or 3.8 years, respectively, after the operation. Three different measurements were obtained (Karnofsky, Grogono and Spitzer indexes). In addition, the patients provided a subjective estimate of the quality of their life. The quality of life was significantly better after resection than after excision, most clearly so according to the Grogono index, and this was also reflected in the patients' personal assessment. In males rectal excision frequently resulted in inferiority feelings, depression and disorders of sexual activity. Females found it easier to cope: they showed only minor differences in quality of life between resection and excision. Irrigation proved to be the best means of stoma care as far as quality of life was concerned.

Anthropometric parameters for preoperative screening to predict high-risk patients

Prediction of serious postoperative complications by using standard anthropometric variables was attempted in 460 patients undergoing a major surgical procedure. Handgrip dynamometry was also carried out in 249 of the patients. None of the preoperative variables were of predictive value to postoperative complications, relating the method to its specified, sensitivity and validity. Upper arm anthropometry and handgrip dynamometry are rapid and inexpensive tests for detecting malnutrition, but they are not useful for preoperative screening to predict postoperative morbidity because appropriate standards are locking.

A multicentered phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: II. The comparison of bleeding patterns. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation Special Programme of Research, Development and Research Training in Human Reproduction

A multicentered phase III clinical trial was conducted in seven countries to compare two dosages of depot-medroxyprogesterone acetate (DMPA), 100mg and 150mg, given every 90 days. Contraceptive efficacy and side-effects of both regimens were reported previously. Their effect on vaginal bleeding patterns is the object of this paper. A total of 1216 women were randomly assigned to a dose group and 1156 of them provided a menstrual diary. The comparison of the bleeding patterns is made using a 90-day reference period approach and following the guidelines published by WHO. In addition, the longest bleeding/spotting episode and the longest bleeding/spotting-free interval are calculated over the entire diary length. The only difference found between the two dose groups is a higher incidence of amenorrhea with the 150mg regimen. Overall, there is a high degree of consistency between the reasons given by individual women for discontinuing the contraceptive method and their vaginal bleeding pattern during the 90 days preceding discontinuation. However the data revealed large between-centre differences, both in the incidence of specific patterns, and in the identification by women of bleeding problems as reasons for discontinuation. This last point suggests that the life-table analysis underestimates the true incidence of menstrual irregularities. Comments on the reference period analysis method are made.

A multicentred phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: 1. Contraceptive efficacy and side effects. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation. Special Programme of Research, Development and Research Training in Human Reproduction

Two dosages of depot-medroxyprogesterone acetate (DMPA), 100 mg and 150 mg given every 90 days, were compared in two groups of women with regard to effectiveness, reported complaints and reasons for discontinuation. A total of 1216 women were recruited into a seven-centre, multinational, randomized clinical trial. Follow-up was for a period of one year and resulted in a total of 5507 woman-months of experience of 100 mg DMPA and 5429 woman-months of experience of the 150 mg dose. The study showed little difference in efficacy and side effects between the two treatment groups. Two pregnancies occurred in women receiving 100 mg DMPA giving a Pearl Index of 0.44 per 100 woman-years. None occurred in the 150 mg group. There was no difference in the overall continuation rates between the two groups at one year, being 59.3% in the 100 mg group and 58.8% in the 150 mg group. Except for discontinuation of method use for amenorrhea, the rates of all medical and non-medical reasons given for discontinuation were comparable between the two treatment groups. Women's perception of lack of bleeding was reported as amenorrhea and resulted in discontinuation rates at 12 months for amenorrhea of 7.2% for women receiving 100 mg of DMPA and 12.5% for those receiving the 150 mg dose. Three centres, Alexandria, Karachi and Szeged, made the major contributions to this difference.

Seroepidemiology of hepatitis B in a population of children in central Tunisia

The prevalence rate of HBV markers in the overall population was 18.0%. The prevalence rates of HBsAg and anti-HBs were 3.3% and 12.2% respectively. 2.5% of the children were negative for these markers but positive for anti-HBc alone. Of the 17 HBsAg positive children, 10 were HBeAg positive and four were anti-HBe positive. The statistical study using multifactorial correspondence analysis and the chi 2 test showed a positive relationship between the prevalence rate of anti-HBs and age, and a negative relationship between the prevalence rate of 'absence of markers' and age. The male sex and urban dwelling were related to higher prevalence rates of HBsAg and anti-HBc alone and to a lower prevalence rate of 'absence of markers'. No relationship was found between geographical zone, father's education and HBV markers. The implications of these results in terms of prevention are discussed.

Incorporation of radioactivity from amino acids in the presence of cycloheximide demonstrates gluconeogenic activity in Mucor rouxii

Mucor rouxii cells induced for gluconeogenesis incorporated radioactivity from [14C]glutamic acid into trichloroacetic acid-precipitable material in the presence of 200 micrograms of cycloheximide per ml. This metabolic capacity was repressed by hexoses and required amino acids for induction. These results suggest that the incorporation of amino acids in the presence of cycloheximide represents gluconeogenic activity with associated polysaccharide synthesis.

[Transanal endoscopic surgery of the rectum - testing a new method in animal experiments]

Surgery of the lower third of the rectum can be done without difficulty through the anus using an endoscopical approach. Polyps or tumors located in the upper two thirds of the rectum can be removed using the Mason or Kraske procedure, or by the transabdominal approach. A new endoscopic technique has been developed with the aim, to allow surgery in the whole rectum through the anus. The rectum is being dilated by mechanical means and air insufflation. An oblique angle stereoscopic endoscope as well as modified surgical instruments are used. In animals 47 excisions of mucosa were done, and the incisions were closed by continuous suture. Application of this technique in a clinical setting is planned.

Immunohistochemical studies on the effect of capsaicin on spinal and medullary peptide and monoamine neurons using antisera to substance P, gastrin/CCK, somatostatin, VIP, enkephalin, neurotensin and 5-hydroxytryptamine

After neonatal treatment of rats with capsaicin, the spinal cord, the spinal trigeminal nucleus and spinal and trigeminal ganglia were analysed with immunohistochemistry using antisera to several peptides and 5-hydroxytryptamine. A marked decrease was observed in substance P-, cholecystokinin-, somatostatin- and VIP-like immunoreactivity present in the central branches of primary sensory neurons in the spinal cord and in substance P- and somatostatin-like immunoreactivity in sensory ganglion cells. No definite depleting effect of capsaicin could be established on 5-hydroxytryptamine and peptides, such as enkephalin and neurotensin, present in centrally originating fibres in the dorsal horn of the spinal cord. The results demonstrate that the effects of capsaicin are not confined to substance P immunoreactive primary sensory neurons. The possibility is discussed that capsaicin effects specifically functioning rather than chemically specific primary sensory neurons.

Substance P, VIP, enkephalin and somatostatin immunoreactive neurons in intestinal tissue transplanted to the anterior eye chamber

Tissue pieces of small and large intestine from pre- and postnatal and adult rats, respectively, were transplanted to the anterior eye chamber of the rat. Immunohistochemical studies revealed high numbers of substance P-, vasoactive intestinal polypeptide (VIP)- and enkephalin-containing nerve fibers, especially in the circular smooth muscle layer and in the myenteric plexus of the intestinal tissue transplants. A small number of somatostatin-containing fibers were observed. The distribution patterns of the various peptide-containing neurons in the grafts resembled those which have been described in the intact gastro-intestinal wall. Substance P, VIP, enkephalin and somato-statin immunoreactive fibers were seen also in the host irides. No obvious differences in peptide innervation in grafts and host irides were observed between normal and sympathectomized animals and animals lesioned in the trigeminal ganglion. These findings suggest that most of the peptide-containing fibers in the intestinal transplants and the host irides originate in the transplanted tissue. Thus, it is shown that peptide neurons can survive in this transplantation model, which may be useful for functional studies of intestinal physiology including peptidergic mechanisms.

Substance P-, VIP-, and enkephalin-like immunoreactivity in the human vagus nerve

The human vagus nerve has been investigated for the presence of substance P (SP), vasoactive intestinal polypeptide (VIP), and enkephalin (ENK) using immunohistochemistry. After 0.5-4 hr of nerve ligation during surgical operations two right thoracic main truncs, two anterior subdiaphragmal trunks, and four anterior nerves of Latarjet were found to contain accumulation of immunoreactive material in nerve fibers above the ligation. Very high numbers of SP-, medium numbers of ENK-, and low number of VIP-immunoreactive fibers were seen. The relative proportions were similar at all levels studied. These data thus indicate the presence and axonal transport of SP-, ENK-, and VIP-like peptides in the human vagus nerve. Our observations in humans correlate well with results obtained from other species. Thus gastrointestinal vagal sensory mechanisms may be mediated by SP (and possibly VIP) and some motor mechanisms by ENK.

Localization and possible function of peptidergic neurons and their interactions with central catecholamine neurons, and the central actions of gut hormones

The localization of various neuropeptides is described in the gut and in the hypothalamus in the rat. Evidence is given for the presence of material resembling corticotropin-like intermediate peptide in arcuate and periarcuate neurons, projecting to various hypothalamic nuclei, limbic areas and the thalamus. beta-Endorphin and glucagon decrease dopamine turnover in the median eminence, while secretin increases dopamine turnover and vasoactive intestinal polypeptide (VIP) has no effect. beta-Endorphin, VIP, secretin, and glucagon all produce discrete changes in norepinephrine turnover in various hypothalamic nuclei. Mainly increases of norepinephrine turnover were observed. These catecholamine turnover changes appear to cause changes in the secretion of prolactin and growth hormone. The results therefore indicate that gut hormones and opioid peptides may act directly on the hypothalamus on specific types of receptors to participate in the control of hypothalamic functions such as control of hormone secretion from the anterior pituitary and of food intake. It seems possible that gastrointestinal peptides released from the gastrointestinal tract into the circulation under certain circumstances could reach the hypothalamus and modulate its activity via the above-mentioned mechanisms. It may therefore be speculated that disturbances in gastrointestinal functions could lead to pathological changes in food intake via modulation of hypothalamic activity.

VIP-, enkephalin-, substance P- and somatostatin-like immunoreactivity in neurons intrinsic to the intestine: immunohistochemical evidence from organotypic tissue cultures

Small intestine from 18-day fetal mice grown for 3 weeks in organotypic tissue culture was found to contain numerous VIP, enkephalin, substance P and some somatostatin immunoreactive nerve fibers. Since these cultures should be devoid of all afferent or other extrinsic neuronal inputs, it is concluded that there are VIP, enkephalin, substance P and somatostatin containing neurons intrinsic to the intestinal wall. However, all 4 peptides may also be present in neurons originating outside the gastrointestinal tract as well as in the intrinsic neurons.

Watery diarrhea syndrome. Two unusual cases and further evidence that VIP is a humoral mediator

Two unusual cases of the watery diarrhea syndrome are presented. In one patient an adrenal medullary tumor, a pheochromocytoma that produced vasoactive intestinal polypeptide (VIP) was excised with total relief of symptoms. The second patient a 65-year-old man with abrupt onset of massive watery diarrhea that led to acidosis and coma was symptomatically controlled for one year on 10 mg/day of prednisone. Elevated levels of VIP returned to normal after prednisone therapy was started. A benign islet cell tumor not localized by angiography was removed by distal pancreatic resection. Tissue levels of VIP were markedly elevated. VIP is a humoral mediator of the water diarrhea syndrome. Both benign and malignant pancreatic and extrapancreatic tumors may cause the watery diarrhea syndrome. Steroids may cause symptomatic relief of the diarrhea by lowering peptide levels to normal. The term watery diarrhea syndrome may be more accurate than the pancreatic cholera syndrome.