A five year experience with laparoscopic falope ring sterilization

This report presents the results of a 5-year series of Laparoscopic Falope Ring tubal sterilizations performed consecutively at a private hospital by the author. It was seen that no special requirements for patient selection were necessary and previous abdominal surgery was not a contraindication for the operation. Laparoscopic tubal occlusions were accomplished in all but one of the 447 cases and banding was not attempted in this case because of bilateral hydrosalpinges. After follow-up of 6 months to 5.5 years, there have been no pregnancies other than one well documented luteal phase pregnancy. The few complications encountered were mostly of a technical nature and considered minor. With 90% of the patients available for follow-up there has been no evidence of long-term adverse effects such as menstrual dysfunction. Thus Laparoscopic tubal occlusion is seen to be a safe, simple and effective means of female sterilization which can be performed by gynecologists trained in laparoscopy.

Digests of protein augment acid-induced canine pancreatic secretion

To study interactions between intraluminal acid and protein digests, six dogs with chronic gastric and pancreatic fistulas received three sets of intestinal perfusates. The first set contained HCl (1, 2, or 4 mmol/50 ml) and 64 mM D- or L-phenylalanine. The second set contained HCl plus either intact or pepsin-digested bovine serum albumin (BSA); the BSA and HCl were varied so that each 50 ml contained 1, 2, or 4 meq of acid titratable from an initial pH of 2.0 to an end-point pH of 4.5. The third set was identical to the second set except for an initial pH of 3.5. All perfusates were adjusted to 300 mosM and randomly infused at 200 ml/h. L-Phenylalanine enhanced acid-induced bicarbonate and protein outputs, as did pH 2.0 BSA digests. At pH 3.5, only acid-induced protein output was augmented by BSA digests. In additional studies, undigested or digested BSA at pH 7.0 was infused with secretin (82 pmol.kg-1.h-1). Only digested BSA enhanced secretin-induced pancreatic secretion. We conclude that there is an important, albeit complex, interaction between the intestinal acid stimulus and the protein digest stimulus on pancreatic secretion.

Search for resistances controlling canine gastric emptying of liquid meals

Previous work has indicated that a chemoselective resistance controls gastric emptying. By use of meals of glucose or oleate, which were shown to empty spontaneously from dogs' stomachs half as fast as saline, we sought to locate this resistance by studying flow under controlled pressures in various regions of the gastrointestinal tract. In intact dogs, gastric outflow of glucose or oleate rose one-third as fast as outflow of saline as gastric pressure was raised, and this increased resistance to outflow of nutrients was unaffected by truncal vagotomy and pyloroplasty. In fistula dogs, gastroduodenal outflow rose linearly with gastroduodenal pressure gradients; outflow was markedly inhibited in a dose-related manner by intestinal oleate but not glucose. Inhibition by oleate was abolished by pyloroplasty. Glucose or oleate flowed into the small bowel from a barostat only slightly slower than saline. However, there was a strong inhibition of intestinal inflow of all three meals by gastric distension, an effect unaltered by truncal vagotomy. The findings suggest that gastric emptying is controlled by complex interactions among pressures and resistances, both within and beyond the stomach.

Peptic ulcer: new therapies, new diseases

Although hospitalizations and deaths attributable to peptic ulcer have decreased notably during the past decade, it is not certain whether this decrease is because of reduced incidence of new cases or changes in other factors, such as the severity of the disease. Several genetic traits associated with peptic ulcer have been recognized. Hyperpepsinogenemia I is the most prevalent. Peptic ulcer is a heterogeneous group of disorders with multiple genetic and environmental causes. One manifestation of the diversity of ulcer disease is the variety of physiologic abnormalities seen in patients. The use of endoscopy has enabled more reliable evaluation of new treatments. Histamine H2-receptor antagonists are the dominant mode of treatment, but increasing attention is being given to agents that enhance the resistance of the mucosa to injury, such as prostaglandins. Because of the lower frequency of side effects, proximal gastric vagotomy is gradually replacing truncal vagotomy with drainage. The possibility that endoscopic treatments, such as laser coagulation, may reduce mortality from bleeding ulcers is being investigated.

Simultaneous gastric emptying of two solid foods

A variety of radionuclide-labeled, solid foods have been used to measure gastric emptying. Implicit is the idea that the nuclide label identifies the rate of emptying of meal contents. The present studies tested whether different foods empty from the human stomach at different rates. Eight volunteers were fed meals of 200 ml of water + 213 g of beef stew + 52 g of chicken liver, with half the liver as 0.25-mm particles and half as 10-mm chunks, labeled with 99mTc and 113mIn, respectively, or the reverse. Another 8 subjects ingested 200 ml of water + 75 g of noodles, labeled with 123I, + 30 g of liver, labeled with 113mIn. Gastric emptying of each radionuclide was determined for 3 h by measuring the decline of counts in the gastric region of interest, using an Ohio Nuclear S410 gamma camera interfaced to a DEC computer. In each case, appropriate corrections were made for nuclear decay, down-scatter from 113mIn, and septal penetration. Seven of 8 subjects emptied 0.25-mm liver particles more quickly than 10-mm chunks of liver, while 1 subject emptied the two sizes of liver at the same rate. The t 1/2 for the 0.25-mm liver was 70 +/- 10 min; and for the 10-mm liver, 117 +/- 19 min (p less than 0.05). Six of 8 subjects emptied noodles much faster than liver, while 2 emptied the two foods at similar rates. The t 1/2 for the noodles was 52 +/- 8 min; and for the liver, 82 +/- 5 min (p less than 0.02). Since different foods in the same meal were found to empty at different rates, we conclude the gastric emptying of every food in a meal is not accurately represented by the emptying of a single, nuclide-labeled food. The different t 1/2s for the emptying of 10-mm liver in the two meals (p less than 0.05) probably reflected the influence of other meal components on gastric motility.

Gastric emptying of ordinary food: effect of antrum on particle size

The lack of reliably quantitative methods has delayed understanding how the stomach empties and processes foods. Rapid refinement of gamma cameras has prompted the development of several methods for labeling of ordinary foods with radionuclides. These methods allow rapid labeling with tightly adherent nuclides and are safe for studies both in animals and humans. Nuclide-labeled foods have also permitted detailed analyses of gastric emptying in animals prepared with chronic duodenal fistulas. Early results indicate that the stomach retains foods until these are fragmented into particles smaller than 0.5 mm in diameter, and that this sieving is achieved in the antral region of the stomach. The speed of fragmentation of foods into particles of this size as well as the speed of emptying appear to be closely regulated by chemoceptive mechanisms in the small intestine, which can inhibit these processes. Thus, chemical composition of the meal regulates gastric emptying as well as the physical nature of the food, which determines how easily it can be fragmented by the stomach.

Effect of peptic digestion on emptying of cooked liver in dogs

By speeding the fragmentation of meat, peptic digestion might accelerate gastric emptying. To examine this possibility, mongrel dogs prepared with chronic duodenal fistulas were fed steak and 99mTc-labeled chicken liver, measuring 99mTc in all chyme exiting from the stomach out the duodenal fistula allowed quantitation of the gastric emptying of 99mTc-liver. Emptying was studied during relatively uninhibited gastric propulsion when the proximal bowel was perfused with chyme or fat. When chyme was diverted, the speed of emptying varied with peptic activity in the stomach--that is, it was increased by orogastric perfusion with acid-pepsin (vs. a control perfusion of pH 7 buffer) or, alternately, was decreased from the unperfusion stomach by i.v. cimetidine (vs. i.v. saline). By contrast, no effect of altering peptic conditions was observed when chyme was allowed access to the proximal bowel (the more normal situation), or when the duodenum was perfused with fat. We conclude that duodenal inhibition may override the effect of peptic digestion on the emptying of liver. We postulate that inhibition of gastric contractions limits the grinding of liver into particles susceptible to peptic digestion.

How gastric emptying of carbohydrate affects glucose tolerance and symptoms after truncal vagotomy with pyloroplasty

It is commonly assumed that both abnormal glucose tolerance and postcibal symptoms after truncal vagotomy with pyloroplasty (V&P) are the result of rapid gastric emptying of carbohydrate; yet such correlations have not been established. These studies measured gastric emptying in symptomatic patients with V&P and normal subjects and sought correlations between rates of emptying and the time-courses of serum glucose and insulin as well as between emptying and symptoms. Gastric emptying in the V&P varied widely with different isocaloric meals of hypertonic glucose, taken in the erect vs. supine position, or of hypotonic starch taken in the erect posture as a solution or as solid balls of paste. Glucose and starch solutions were emptied abnormally rapidly in the erect posture, while glucose taken supine, and the starch balls were emptied more slowly. By contrast, all four meals emptied at about the same rates in the normal subjects. In both the V&Ps and the normals, there were weak correlations evident between the amount of carbohydrate emptied in the first 30 postcibal minutes and the rises in serum glucose or insulin. However, the presence or absence, the timing, and the qualitative nature of postcibal symptoms observed in the V&Ps did not correlate well with either the speed of emptying or the osmolarity of the carbohydrate meals.

Gastric, pancreatic, and biliary secretion and the rate of gastric emptying after parietal cell vagotomy

We compared the gastric, pancreatic, and biliary secretory responses to a liquid test meal and the rates of gastric emptying of liquid and solid test meals in six patients at least 1 year after parietal cell vagotomy with eight unoperated subjects, one with duodenal ulcer disease and seven normal control subjects. Parietal cell vagotomy decreased gastric acid secretion to one third of normal, but total trypsin and bile salt secretion during the first 150 postcibal minutes were normal. The liquid test meal emptied from the stomach faster after parietal cell vagotomy, the pattern of emptying being exponential in the vagotomy patients and linear in the normal subjects. The rate of gastric emptying of a liquid meal, although faster than normal, was less precipitous after parietal cell vagotomy than after truncal vagotomy plus drainage or subtotal gastrectomy, and trypsin and bile salt concentrations were not diluted to abnormal levels, as occurs after these other procedures. Furthermore, emptying and dispersion of solid food remained normal after parietal cell vagotomy. These findings probably explain, at least in part, the decreased incidence of postprandial dumping and diarrhea that accompanies parietal cell vagotomy compared with the other popular operations for duodenal ulcer.

Sieving of solid food by the canine stomach and sieving after gastric surgery

Present concepts on the gastric emptying of solid materials derive from experiments with plastic spheres now known to be emptied differently than food. Accordingly, experiments were undertaken with radiolabeled chicken liver to assess (a) the size of meat particles passed by the normal canine stomach and (b) the effects of ulcer surgery on the rate of emptying and the size of emptied meat particles. Control or ulcer-operated dogs were prepared with chronic duodenal fistulas from which chyme was collected after a standard meal of beefsteak + radioliver + water. Collected chyme was sieved over a stack of sieves of decreasing pore size, and the percent of radioactivity recovered on each sieve was determined each postcibal hour for 5 hr. Control dogs emptied the meal slowly, and virtually all recovered meat was emptied in particles equal to or less than 2.0 mm. Dogs with vagotomy (V), pyloroplasty (P), vagotomy + pyloroplasty (V + P), or antrectomy with end-to-end (A-BI) or end-to-side (A-BII) gastroduodenostomy did not empty the meal faster than the control dogs. In all ulcer-operated dogs except those with P, there were significant upward shifts in the size of meat particles emptied from the stomach; but changes were marked only dogs with V + P or A-BII. Although the experiments verify the antral sieving mechanism noted in earlier work with plastic spheres, the trituration of solid food is probably more complex than previously envisioned.

Pancreatic response to intestinal perfusion with lactic acid or acidified albumin

To test the hypothesis that the permeability of weak acids across the intestinal mucosa affects their ability to stimulate pancreatic bicarbonate output, we compared pancreatic bicarbonate secretion in response to intestinal perfusion with an acid presumed to be permeable to cell membranes, lactic acid (90 daltons), and an acid presumed to be impermeable, acidified bovine serum albumin (about 70,000 daltons). These two substances have similar titration curves from pH 2.00 to pH 4.50. In four conscious dogs with pancreatic fistulas, solutions of these weak acids were perfused at 50 ml/15 min into the intestine at concentrations adjusted to deliver 1, 2, or 4 mmol/15 min of acid titratable to pH 4.50 (threshold pH for bicarbonate stimulation) from an initial pH of 2.00 or 3.50. At both pH 2.00 and 3.50 and at all titratable acid loads, bicarbonate secretory responses to lactic acid and acidified albumin were not significantly different. Equal titratable acid loads of HCl produced much larger secretory responses. The data do not support the hypothesis that permeability of weak acids is a factor, but confirm the observation that weak acids are less potent than strong acids in stimulating pancreatic bicarbonate secretion.

Further clinical experiences of a phase I study with the hypoxic cell radiosensitizer misonidazole

Since April 1976 we have performed clinical investigations with multiple doses of the hypoxic cell radiosensitizer misonidazole in 21 patients. A significant side effect of the drug was the development of peripheral sensory neuropathies in 13 patients (8 mild, 5 severe) and of a transient acute organic psychosyndrome in 2 of the 5 patients with a severe polyneuropathy. The severity of the polyneuropathies is related to the total dose of misonidazole and the overall time of drug administration. Treatment schedules designed to obtain the desired sensitizing effect without neurological side effects are under investigation.

Gastric emptying rates of solid food in relation to body size

The relationship of body size to rates of gastric emptying of solid food was investigated in order to obtain data that may allow this variable to be considered when populations of varying size are studied. Rates of gastric emptying were measured using a beef stew meal to which were added pieces of chicken liver tagged with [99mTc]sulfur colloid, and following the passage of the isotope through the gastrointestinal tract with intermittent gamma-imaging. Results showed an inverse linear relationship between gastric emptying rates and body surface area, and between gastric emptying rates and body weight. The variable of body size must be taken into account when measurements of gastric emptying of solid food are measured.

Cimetidine versus intensive antacid therapy for duodenal ulcer: a multicenter trial

In a randomized double blind multicenter trial, patients treated with cimetidine (800 or 1200 mg daily) or an intensive regimen of Al-Mg antacid (210 ml daily) had similar rates of duodenal ulcer healing and pain relief. After 4 weeks of treatment, the proportion of patients with ulcer healing by endoscopy were: cimetidine (1200 mg), 21 of 33 (64 percent); cimetidine (800 mg), 19 of 32 (59 percent); and antacids, 15 of 29 (52 percent). These proportions did not differ significantly. Eighty per cent of cimetidine-treated patients became asymptomatic by week 4, as did 63 percent of antacid-treated patients (P greater than 0.1). No untoward effects were observed during cimetidine treatment. Twenty-seven per cent of antacid-treated patients reported diarrhea.

Gastric emptying of liquid meals and pancreatic and biliary secretion after subtotal gastrectomy or truncal vagotomy and pyloroplasty in man

Pancreatic and biliary secretion and gastric emptying rates of a liquid test meal (LTM) were determined in normal persons, in patients with subtotal gastrectomy with gastroduodenostomy (STG-BI) or with gastrojejunostomy (STG-BII), and in patients with truncal vagotomy and pyloroplasty (V&P). In all operated persons, rapid gastric emptying diluted intraluminal contents, with consequent abnormally low concentrations of trypsin and bile salts initially, a pattern that was not corrected by addition of intravenous hormones to the meal stimulus. Trypsin output in V&P's after the LTM was significantly depressed to 40% of normal, but was normal in the STG groups. The delay in reaching normal values for trypsin and bile salt concentrations, was more marked in STG-BII owing to sequestration of secretions in the afferent loop. The low luminal concentrations of digestive secretions for the first 60 to 80 min after a LTM are therefore attributable to rapid gastric emptying in all operated groups, and in V&P to a depressed pancreatic enzyme response also. In STG-BII, afferent loop sequestration exaggerates the delay in attainment of normal intraluminal concentrations. The combined disturbance in STG-BII produces greater abnormalities than seen in STG-BI.

Gastric emptying of solid food in normal man and after subtotal gastrectomy and truncal vagotomy with pyloroplasty

Alterations in gastric emptying are considered contributory to many sequelae of peptic ulcer surgery. The application of a validated method of firmly tagging solid food has enabled the measurement of the rates and patterns of gastric emptying in normal subjects, subtotal gastrectomy, and vagotomy and pyloroplasty (V&P). Normal persons emptied with a linear pattern at a mean rate of 27.96% per hr. Subtotal gastrectomy patients showed up to three phases in their emptying pattern, which, over all, approximated an exponential pattern with a mean rate constant of 0.030 min-1 and calculated t1/2 of 23.3 min. V&P subjects divided into two groups: (1) slow emptying with a linear pattern and mean rate of 17.64% per hr; (2) rapid emptying with exponential pattern and mean rate constant of 0.039 min-1, t1/2 of 17.7 min. The slow gastric emptying rate and slow passage of chyme through the small intestine in one-half of the V&P group presumably allows greater efficiency of digestion and absorption and may account for the over-all less severe nutritional disturbances after V&P.