P-070 SYNTHETIC MESH VERSUS BIOLOGICAL IMPLANT TO PREVENT INCISIONAL HERNIA AFTER LOOP-ILEOSTOMY CLOSURE: A RANDOMIZED FEASIBILITY TRIAL

Aim

The aim of this study was to evaluate the safety and efficiency of synthetic mesh compared to a biological mesh in incisional hernia prevention after loop-ileostomy closure.

Material & Methods

Up to one third of patients experience incisional hernia after loop-ileostomy closure, justifying hernia prevention procedures. Although biological meshes have been widely used in contaminated surgical sites instead of synthetic ones due to complication concerns, previous data on the subject does not support this practice. A randomized, controlled, multi-center non-inferior feasibility trial was conducted from April 2018 – November 2021. Patients (n=102) were randomized 1:1 to receive either a light-weight synthetic polypropylene mesh (Parietene MacroTM, Medtronic) (SM) or a biological mesh (PermacolTM, Medtronic) (BM) to the retrorectus space at loop-ileostomy closure after anterior resection for rectal adenocarcinoma. The primary outcome was rate of surgical site infections (SSI) at 30-day follow-up.

Results

In total, 102 patients were randomized, of which 97 received the intended allocation. At 30-day follow-up, 94 patients (97%) were evaluated. Of patients in the SM group, 1/46 (2%) had SSI and in the BM group 2/48 (4%) had SSI (p>0.90). Uneventful wound healing was recorded in 38/46 (86%) and 43/48 (90%) patients in the SM and BM groups, respectively. One patient from each group underwent reoperation requiring mesh removal (p>0.90).

Conclusions

Both a synthetic mesh and biological mesh were safe in incisional hernia prevention after loop-ileostomy closure. Hernia prevention efficiency will be reported after long-term patient follow-ups.

Redo ventral rectopexy: is it worthwhile?

BACKGROUND

Minimally invasive ventral mesh rectopexy (VMR) is a widely used surgical treatment for posterior pelvic organ prolapse; however, evidence of the utility of revisional surgery is lacking. Our aim was to assess the technical details, safety and outcomes of redo minimally invasive VMR for patients with external rectal prolapse (ERP) recurrence or relapsed symptoms of internal rectal prolapse (IRP).

METHODS

This is a retrospective cohort study of patients with recurrent ERP or symptomatic IRP who underwent redo minimally invasive VMR between 2011 and 2016. The study was conducted at three hospitals in Finland. Data collected retrospectively included patient demographics, in addition to perioperative and short-term postoperative findings. At follow-up, all living patients were sent a questionnaire concerning postoperative disease-related symptoms and quality of life.

RESULTS

A total of 43 redo minimally invasive VMR were performed during the study period. The indication for reoperation was recurrent ERP in 22 patients and relapsed symptoms of IRP in 21 patients. In most operations (62.8%), the previously used mesh was left in situ and a new one was placed. Ten (23.3%) patients experienced complications, including 2 (4.7%) mesh-related complications. The recurrence rate was 4.5% for ERP. Three patients out of 43 were reoperated on for various reasons. One patient required postoperative laparoscopic hematoma evacuation. Patients operated on for recurrent ERP seemed to benefit more from the reoperation.

CONCLUSIONS

Minimally invasive redo VMR appears to be a safe and effective procedure for treating posterior pelvic floor dysfunction with acceptable recurrence and reoperation rates.

Outcomes of sacral neuromodulation for chronic pelvic pain: a Finnish national multicenter study

BACKGROUND

The aim of this study was to report the outcomes of sacral neuromodulation (SNM) in chronic pelvic pain (CPP) patients in the Finnish national cohort.

METHODS

This was a register-based retrospective study, involving all the centers that provide SNM treatment in Finland. The data of all patients treated with SNM for CPP were gathered from Oulu-, Turku-, Tampere- and Helsinki University Hospitals, as well as Jyväskylä and Seinäjoki Central Hospitals. All patients who had been tested for SNM implantation prior to April 2017 were included in the study.

RESULTS

A total of 51 patients were selected for SNM treatment due to CPP from 2004 until 2017. The mean follow-up time was 13.8 months (SD 22.9 months). A total of 28 patients (57%) advanced from testing to permanent stimulator implantation. There were 21 patients (41%) who had a working modulator implanted at the end of follow-up. Patients with endometriosis-related pain had a significantly higher permanent implantation rate than the overall implantation rate (88% vs. 57%; p = 0.01). The endometriosis patients also had a higher overall success rate by the end of the follow-up (75% vs. 41%; p = 0.026) CONCLUSIONS: SNM may be a viable treatment option for patients with CPP due to endometriosis. Further research on SNM treatment for endometriosis patients with refractory CPP is needed.

Outcomes of treatment of faecal incontinence with sacral nerve stimulation - a Finnish multicentre study

AIM

The aim of this multicentre study is to report the results of sacral nerve stimulation (SNS) treatment for faecal incontinence (FI) in Finland and determine factors that could influence SNS treatment outcomes.

METHOD

This is a national multicentre study, involving all patients tested for SNS implantation in Finland from 1999 to 2017. Data were collected retrospectively from electronic patient archives and analysed for possible effects on treatment outcome.

RESULTS

Of the 432 patients with FI tested for SNS, 365 were women. Three hundred and thirteen (72.5%) of the tested patients advanced to permanent implantation of a stimulator. A successful final treatment outcome, with subjective alleviation of FI, was reported by 59.3% of the patients at the end of follow-up (mean 2.4 years, range 8 days to 13.3 years). Patients with obstetric sphincter injury and idiopathic FI had more permanent stimulator implantations than patients with iatrogenic injury (P = 0.012). Male patients had significantly worse test phase outcomes than female patients (P < 0.001). Age did not influence treatment outcome (P = 0.446) CONCLUSION: Subjective final success of SNS treatment for FI was achieved in 59.3% of patients at a mean of 2.4 years. Gender and the aetiology of FI influenced the test phase and final treatment outcome of SNS treatment.

Laparoscopic Wide Mesocolic Excision and Central Vascular Ligation for Carcinoma of the Colon

Background and Aims:

The principle of complete mesocolic excision for colon cancer has been introduced to improve oncologic outcome. However, this approach is scantily discussed for laparoscopic surgery and there is a lack of randomized trials. This study examined oncologic and clinical outcome after laparoscopic wide mesocolic excision and central vascular ligation for colon cancer.

Material and Methods:

This is a review of prospectively gathered data from a single-institution colorectal cancer database. This study was conducted in the Central Hospital of Central Finland. From January 2003 to December 2011, 222 patients underwent laparoscopic colonic resections with wide mesocolic excision and central vascular ligation in the multimodal setting. The main measures of outcome were cancer recurrence and survival, with early recovery, 30d-mortality and morbidity, reoperation, readmission, and late complications as secondary outcomes.

Results:

The median follow-up was 5.5 (interquartile range (IQR) = 3.7–8.0) years. The 5-year overall survival for all 222 patients was 80.2% and disease-specific survival was 87.5%, and for those 210 R0-patients with stage I–III disease, 83.9% and 91.3%, respectively. The 5-year disease-free survival was 85.8%: stage I was 94.7%, stage II was 90.8%, and stage III was 75.6% ( p = 0.004). Increasing lymph node ratio significantly decreased the 5-year disease-free survival. Conversion rate to open surgery was 12.2%. Thirty-day mortality was 1.3% and morbidity, 19.7%. Median postoperative hospital stay was 5 (IQR = 3–7) days.

Conclusion:

Laparoscopic wide mesocolic excision and central vascular ligation for colon cancer resulted in good long-term oncologic outcome. Randomized trials are needed to show that laparoscopic complete mesocolic excision technique would become the standard of care for the carcinoma of the colon.

The Role of Biofeedback Therapy in Functional Proctologic Disorders

Background and Aims:

The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation.

Material and Methods:

Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database.

Results:

Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes.

Conclusions:

Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.

Evaluation of a fast-track protocol for patients undergoing colorectal surgery

BACKGROUND AND AIMS

Fast-track protocols have been used to optimize the perioperative care and to enhance postoperative recovery. This study examined short-term clinical outcomes and determinants affecting the length of postoperative hospital stay.

MATERIAL AND METHODS

From 2007 to 2009, 180 patients underwent laparoscopic or open bowel resection (N = 138) or sacrocolporectopexy (N = 42) in the Central Hospital of Central Finland for various colorectal diseases in the fast-track setting. The main measures of outcome were time to functional recovery, 30-day morbidity, and readmission rates, with hospital stay and patient satisfaction as secondary outcomes.

RESULTS

There were no deaths. Time to functional recovery was median 2 (interquartile range 2-3) days. The overall 30-day postoperative morbidity was 14.5% after bowel resection and 0% after sacrocolporectopexy. Relaparotomy rate was 3.6% and 30-day readmission rate 7.2%. Postoperative hospital stay was median 3 days after small bowel and ileo-colic resection, 4 days after segmental colectomy, and 6 days after rectal resection and subtotal colectomy. Patient's body mass index > 30 kg/m², malignant disease, complexity of surgery, recovery of bowel function later than 2 days after surgery, time to functional recovery > 2 days and postoperative morbidity were patient- and treatment-related determinants increasing postoperative hospital stay. Protocol compliance-related determinants increasing postoperative hospital stay were intake of normal food and mobilization ≥ 6 h/day later than 2 days after surgery and removal of urinary catheter later than 1 day after surgery.

CONCLUSION

Postoperative functional recovery was fast, morbidity and readmission rates were low, and postoperative hospital stay short indicating that fast-track care should form the mainstay of elective colorectal surgery.

Tumour regression grading in the evaluation of tumour response after different preoperative radiotherapy treatments for rectal carcinoma

BACKGROUND AND AIMS

Preoperative radiotherapy (PRT) for rectal carcinoma has been shown to cause tumour regression and increase local control and patient survival. The aim of this study was to examine the usefulness of tumour regression grading (TRG) in quantifying the effect of PRT.

METHODS

Depending on the tumour stage (uT), as defined by preoperative endorectal ultrasound (ERUS), fixity and distance from the anal verge, 126 patients with rectal cancer underwent either surgery alone, or received short-course 25-Gy radiotherapy or long-course 50-Gy radiotherapy combined with 5-fluorouracil (5-FU) before surgery. TRG in each group was assessed and compared with the downstaging, defined as a change in preoperative uT stage and pathologic stage (pT).

RESULTS

Complete response (no residual tumour, TRG 1) was seen in 7% of the patients (3/44) and total or major regression (TRG 1-3) in 73% of the patients (32/44) treated with 50-Gy chemoradiation. Of those treated with 25-Gy PRT, 21% (9/42) showed major tumour regression. Of the patients who underwent ERUS and PRT, 32% (26/83) were downstaged when comparing uT with pT, but 53% (14/26) of the downstaged tumours showed no response by TRG. In comparison, 50% (28/57) of the tumours with no downstaging showed a marked response by TRG (p=0.05).

CONCLUSIONS

Tumour regression grading offers detailed information of the effect of PRT and shows that tumour regression is more marked after long-term chemoradiation than after short-course radiotherapy (p=0.02). In contrast, T-stage downstaging was similar in both groups and did not correlate with the TRG results (p=0.05).

Outcome of temporary stomas. A prospective study of temporary intestinal stomas constructed between 1989 and 1996

PURPOSE

The purpose of this study was to examine the outcome of patients to whom a temporary stoma was constructed in our institution.

METHOD

The outcome of patients operated on over an 8-year period was prospectively examined. Special attention was given to the influence of age on complications and closure of stomas.

RESULTS

Between 1989 and 1996, a total of 349 intestinal stomas were constructed in 342 patients. In 141 of these patients, the stoma could be considered as temporary. The 30-day mortality rate was 7%. The overall complication rate was 50%. Pure stoma-related complications were observed in 12% of the patients. The final closure rate of temporary stomas was 67%. The closure rate was significantly higher if the temporary stomas were of the double-barrel type. There was no significant difference in the closure rate between patients with benign and malignant diseases, but the rate decreased significantly in age groups over 70 years.

CONCLUSIONS

Forty percent of stomas constructed are considered as temporary, but only two-thirds of temporary stomas are closed subsequently. Especially end stomas tend to become permanent in patients over 70 years of age, although the morbidity rates of stoma closure do not differ from those of younger patients.

Laparoscopic repair of rectal prolapse: surgical technique

Technical features of laparoscopic rectopexy include complete rectal mobilization without division of the lateral stalks to avoid parasympathetic denervation and postoperative problems with defecation. Suture rectopexy is equally effective as posterior mesh rectopexy in preventing recurrences and eliminates the use of foreign material which is sometimes associated with intense fibrosis, sepsis and increased constipation. According to two randomised studies constipation seems to be less after resection rectopexy than suture or posterior mesh rectopexy alone perhaps by eliminating possible kinking at the rectosigmoid region by falling of the redundant sigmoid colon in the pouch of Douglas. Randomized studies are, however, needed to validate the need for colonic resection and to determine its optimal extent in patients who suffer from rectal prolapse, constipation and slow transit.

Superselective intra-arterial chemotherapy with mitomycin C in hepatic metastases from colorectal cancer

BACKGROUND

Mitomycin C has been found clinically useful in the treatment of colorectal cancer when administered via the hepatic artery. In a prospective therapeutic trial, we studied the effect of superselective intra-arterial chemotherapy with mitomycin C in patients with hepatic metastases from colorectal cancer.

METHODS

Forty-six patients with hepatic metastases from colorectal cancer received intra-arterial chemotherapy with mitomycin C (SIAC) between 1981 and 1991. The results of a 5-year follow-up were compared with 46 control patients standardized by sex, age, and tumor distribution.

RESULTS

The overall response rate to intra-arterial chemotherapy was 20%. The median survival time for responders was 26 months and that for nonresponders 12 months (P < 0.003). The median survival period after intra-arterial chemotherapy was 15 months, compared with 9 months in controls (P < 0.004). The cumulative 5-year survival rate was 6% for patients treated by SIAC and 5% for controls. Cessation of chemotherapy was necessary in 39 of the 46 patients: in 28 because of tumor progression, in 9 because of toxicity, in 1 because of catheterization difficulties, and in 1 because of patient refusal.

CONCLUSIONS

Superselective intra-arterial mitomycin C therapy had a poor effect on hepatic metastases from colorectal cancer because of the low response and long-term survival rates.

Human and mouse liver coumarin 7-hydroxylases do not metabolize warfarin in vitro

1. The contribution of human P450 2A6 and mouse P450 2a-5 isoenzymes, both highly active in coumarin 7-hydroxylation, to the metabolism of warfarin was studied in several in vitro systems with human and mouse liver preparations. 2. The reconstituted P450 2a-5 purified from DBA/2 mouse liver did not metabolize warfarin. 3. An anti-P450 2a-5 antibody did not consistently inhibit any of the warfarin biotransformation reactions catalyzed by human or mouse liver microsomes, although coumarin 7-hydroxylation was inhibited by over 90%. 4. In some human microsomal samples, 4- and 8-hydroxylations of warfarin were inhibited to some extent by the anti-P450 2a-5 antibody. 5. Warfarin (less than 1 mM) did not inhibit coumarin 7-hydroxylation by human or mouse liver microsomes in vitro. 6. We conclude that mouse and human coumarin 7-hydroxylases do not oxidise warfarin.

Inhibition of human hepatic and placental xenobiotic monooxygenases by imidazole antimycotics

Three imidazole antimycotic drugs, ketoconazole, clotrimazole and miconazole, were studied to characterize the inhibition of aryl hydrocarbon hydroxylase (AHH), 7-ethoxycoumarin O-deethylase (ECDE) and 7-ethoxyresorufin O-deethylase (ERDE) activities in human liver and placenta in vitro in comparison with liver enzymes from control, phenobarbital (PB) and 3-methylcholanthrene (MC) pretreated rats. All three compounds inhibited rat liver enzymes, although MC pretreatment seemed to lead to a resistance of inhibition relative to PB-treated and control animals. There were large differences in the extent of inhibition of human hepatic and placental activities. Furthermore, while the type of inhibition of the hepatic ERDE was competitive or mixed, that of the placental enzyme cannot be described in ordinary terms of inhibition kinetics. Ketoconazole and clotrimazole were relatively potent inhibitors of maternal cigarette smoking-induced placental ECDE activities (IC50 values from 0.5 microM to 5 microM), whereas much less inhibition of the placental AHH activity was obtained with ketoconazole and miconazole (IC50 values from 50 microM to 500 microM). In most cases, hepatic enzymes were less sensitive to antimycotics than placental activities. This was in contrast with results from rat enzyme studies, in which MC pretreatment seemed to decrease the inhibitory response.

Inhibitor panel studies of human hepatic and placental cytochrome P-450-associated monooxygenase activities

1. A panel of nine inhibitors displaying some P-450 isozyme specificity was used to characterize aryl hydrocarbon hydroxylase (AHH) and 7-ethoxyresorufin 0-deethylase (ERDE) activities in human liver and placenta in vitro in comparison with liver enzymes from control, phenobarbital (PB) and 3-methylcholanthrene (MC) treated rats. 2. SKF 525A and cimetidine inhibited more potently hepatic AHH than the placental enzyme. 7,8-Benzoflavone inhibited more efficiently placental AHH than the hepatic enzyme, whereas ERDE was inhibited at the same level in both tissues. Quinine, quinidine, SKF 525A and metyrapone inhibited ERDE almost to the same extent in both tissues, but the variability was larger with the liver enzyme. Aminoglutethimide, debrisoquine or tetrahydrofuran did not inhibit AHH or ERDE significantly in either tissue. 3. When compared with inhibition profiles obtained with rat liver microsomes, the human hepatic and placental ERDE resembled most that of MC-treated rat liver enzyme. Inhibition profile of placental AHH activity was also similar, but the inhibition characteristics of hepatic AHH activity resembled more closely control or PB-induced rat liver. It also seems that isozymes for alcohol induction or debrisoquine hydroxylation do not contribute significantly to hepatic or placental AHH or ERDE. 4. The inhibitor panel selected on the basis of known pretreatment and isozyme specificity might be useful in the characterization of enzymes and metabolic biotransformations participating in the metabolism of new substrates.

Methylprednisolone in acute canine hemorrhagic pancreatitis

The effect of methylprednisolone on hemodynamics and oxygen transport was investigated in acute hemorrhagic pancreatitis in 13 dogs randomly allocated to a fluid treatment group, a methylprednisolone prophylaxis (MPP) group and a methylprednisolone therapy (MP) group. Methylprednisolone (30 mg/kg) was given as a bolus dose, starting 30 min before induction of pancreatitis in the MPP group and 30 min after induction in the MP group. Acute hemorrhagic pancreatitis was induced with a mixture of trypsin and sodium taurocholate, and hemodynamics and blood gases were monitored for 4.5 hours. MPP improved cardiac output significantly and prevented the initial increase in the arteriovenous oxygen content difference. In the MP group there were no significant differences from the control group in hemodynamics or oxygen transport. Prophylactically administered methylprednisolone thus partially attenuated the hemodynamic changes caused by acute hemorrhagic pancreatitis. It seemed especially to improve cardiac performance, assessed from changes in cardiac output.

Prostacyclin and thromboxane in acute hemorrhagic pancreatitis in dogs

To study the role of the vasodilatory, antiaggregatory prostacyclin (PGI2) and its endogenous antagonist thromboxane A2 (TxA2) in acute pancreatitis, we measured serum thromboxane B2 (TxB2, which indicates platelet TxA2 production) and plasma 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha, which indicates systemic PGI2 production) from sequential blood samples in trypsin and taurocholate induced acute canine hemorrhagic pancreatitis (AHP). In addition the effect of a prostaglandin synthesis inhibitor, ibuprofen, was studied and systemic (MAP) and pulmonary artery pressure (MPAP) were recorded for 4.5 hr. The animals were divided into a sham-operated group, an AHP group, an ibuprofen prophylaxis group, and an ibuprofen therapy group. In the sham group the parameters remained stable throughout the experiment. In the AHP group MAP decreased steadily and 6-keto-PGF1 alpha rose significantly from 80.0 +/- 7.8 to 956.0 +/- 287.0 pg/ml (P less than 0.001), whereas serum TxB2 and MPAP remained unchanged. Ibuprofen prophylaxis eliminated the initial fall in MAP and the rise of 6-keto-PGF1 alpha. Ibuprofen therapy normalized the initially decreased MAP and depressed the level of 6-keto-PGF1 alpha. We conclude that PGI2 may at least partly mediate the initial hypotension in canine AHP, whereas platelet TxA2 production obviously has a negligible role in the development of hemodynamic changes in AHP.

The effect of cigarette smoking on 7-ethoxyresorufin O-deethylase and other monooxygenase activities in human liver: analyses with monoclonal antibodies

Four cytochrome P-450 enzyme activities, 7-ethoxyresorufin O-deethylase (ERDE), coumarin 7-hydroxylase (CH), 7-ethoxycoumarin O-deethylase (ECDE) and aryl hydrocarbon hydroxylase (AHH) were measured in human liver needle biopsy samples from smokers and non-smokers. Cigarette smoking was verified and quantitated by measuring plasma cotinine levels. Enzyme inhibitory monoclonal antibodies (MAb) to a 3-methylcholanthrene-induced (MAb 1-7-1) and phenobarbitone-induced (MAb 2-66-3) rat hepatic cytochrome P-450 were used to measure the contribution of MAb-defined, epitope-specific cytochromes P-450 to the total reaction measured for each of the above activities. ERDE activity was significantly elevated in the livers of cigarette smokers, whereas AHH, CH or ECDE activities were not affected by cigarette smoking. No correlation was observed between plasma cotinine concentration and ERDE activity. MAb 1-7-1 inhibited hepatic ERDE activity to a variable extent (from 0 to 65%), but had very little or no effect on AHH, CH or ECDE activities. The inhibitory effect of MAb 1-7-1 on ERDE activity was greater than 50% in the non-smokers. MAb 2-66-3 had no inhibitory effect on any of the enzyme activities studied. In contrast to liver both ERDE and AHH on human placental microsomes from cigarette smokers were inhibited by MAb 1-7-1. The MAb 2-66-3 was without effect. Cigarette smoking induces a form of P-450 in human liver, responsible for ERDE activity, that contains an epitope recognized by MAb 1-7-1. This form of cytochrome P-450 is insensitive to MAb 2-66-3 and is not contributing to AHH, CH or ECDE activities of human liver.

Thyrotropin-releasing hormone in acute pancreatitis. A preliminary report

The effect of thyrotropin-releasing hormone (TRH) in continuous infusion (a bolus of 400 micrograms followed by 200 micrograms/hour for 6 hours) was studied in 35 patients (17 TRH, 18 placebo) with acute pancreatitis in a double-blind investigation. Three hours after the start of infusion, significantly more patients were pain-free in the TRH group than in the placebo group, but not thereafter. TRH also significantly reduced the serum amylase and lipase levels, but did not influence the clinical course of pancreatitis.

Carbohydrate intolerance associated with reduced hepatic glucose phosphorylating and releasing enzyme activities and peripheral insulin resistance in alcoholics with liver cirrhosis

Carbohydrate intolerance was investigated in 8 alcoholics with liver cirrhosis and in controls. Indices of carbohydrate metabolism, glucose and insulin levels after glucose loading, were compared with glucose phosphorylating (glucokinase, hexokinase) and releasing (glucose-6-phosphatase) enzymes. Comparison was also made with pericellular collagen in liver biopsies and with insulin sensitivity assessed by the euglycemic clamp technique and with conventional liver function tests including oral antipyrine test. Glucokinase activity was low or absent, hexokinase activity increased and the GK/HK ratio reduced. Glucose-6-phosphatase activity was lowered and insulin sensitivity decreased. Pericellular collagen was increased (P less than 0.001) and related to the fasting glucose (r0.593) and insulin levels (r0.526). Blood glucose was related to antipyrine metabolism (r-0.727) but not to the other liver tests. Glucose intolerance in cirrhosis seems to be associated with reduced glucose phosphorylating and liberating enzyme activities. Hyperinsulinaemia, developing secondarily, may then lead to insulin resistance.

Haemodynamic comparison of dopamine and dobutamine in normovolaemic and hypovolaemic dogs

The haemodynamic effects of dopamine and dobutamine in doses of 1-106 micrograms/kg/min were compared in dogs, first in the normovolaemic state and then after bleeding (10 ml/kg). In normovolaemia, dopamine caused a dose-dependent rise in systolic, mean and diastolic aortic pressures, while dobutamine caused a rise only in systolic pressure. In hypovolaemia, a rise in all three aortic pressures, was caused by both drugs, but to a lesser extent by dobutamine. Heart rate and cardiac output were similarly increased by both drugs, as was pulmonary artery pressure with high doses, in both states. Renal blood flow and diuresis increased in the middle-dose area. Both inotropic drugs caused an elevation in Paco2 and a drop in Pao2 and O2-saturation in both normovolaemia and hypovolaemia. The results agree with current opinion on the dose-dependent alpha-sympathomimetic action of dopamine and the relatively pure beta-action of dobutamine.

Ultrasound and computed tomography of small asymptomatic haemangiomas of the liver

Gray-scale ultrasound examinations were performed in 13 patients with 18 small asymptomatic haemangiomas of the liver and computed tomography in 10 of these patients. Different types of ultrasound images were found. One of them appeared as a well-demarcated area of increased echoes with an echo-free halo consisting of vessels, is probably characteristic for haemangioma. The other types of images are considered non-specific. The native CT scans demonstrated a well-demarcated spherical area with low attenuation in 8 cases and an area with attenuation similar to the liver in 4. After contrast medium injection, areas with lower attenuation were found in 7 cases, with irregular accumulation of contrast medium in the periphery in 4, and with distinct vessels in the periphery in one case, 2 haemangiomas had the same attenuation as the liver parenchyma.

Isoniazid, quinidine, and sulphafurazole absorption in patients with jejunum transposition 15 years earlier

Gastric surgery has formerly been shown to affect drug absorption. The absorption of oral isoniazid (INH), quinidine, and sulphafurazole (sulfisoxazole) was therefore studied in 19 ulcer patients operated on some 15 years earlier with resection of the ventricle combined with jejunum transposition. Twelve medical inpatients served as controls. The operated patients had all experienced relief of their ulcer symptoms, and there was no evidence of clinical malabsorption. In operated patients the peak serum levels of all three drugs were reached earlier than in controls. At 1 and 6 h the INH serum levels were increased in operated patients, but the sulphafurazole serum levels were at no time different in operated and control patients. As measured by the 24-h urinary excretion, jejunum transposition did not modify the total amounts of INH or sulphafurazole absorbed. In contrast, the quinidine absorption was decreased by about 50% in operated patients, which seems to be the result of increased gastric pH in the operated patients, leading to a poor dissolution and/or precipitation of quinidine in the gastric contents. Obviously, the jejunum transposition per se may not affect the total amounts of drugs absorbed, provided the physiochemical effects resulting from, for example, pH changes due to antrectomy and/or vagotomy are taken into account.

Symptoms of carcinoma of the oesophagus

Cancer of the oesophagus in its early stages is relatively asymptomatic, and the establishment of the diagnosis may be delayed because of the failure of the patient to seek early medical attention, or because the initial examining physician made an incorrect diagnosis. A good knowledge of the symptoms of the disease as well as an active role in diagnostic studies aid the physician in rapidly achieving the diagnosis. The most common symptoms in 162 patients with cancer of the oesophagus were: difficulty in swallowing (96%), loss of weight (42%), vomiting (25%), pain in the upper part of the abdomen (20%) and retrosternal pain (20%). The mean duration of symptoms before first presentation for medical attention was 3.1 months, and the correct diagnosis was generally established four to six weeks after the initial visit at the doctor's office. In 21.6% of cases, the initial visit did not lead to the correct diagnosis.

Experiences with the EEA stapling instrument for anastomoses of the upper gastrointestinal tract

Technique, early experiences and results with the EEA stapling instrument for the reconstruction of intestinal continuity after gastric and esophageal resection in 52 patients are reported. 12 patients with gastric cancer and 4 patients with cardiac cancer underwent total gastrectomy with esophagojejunostomy, 25 patients with gastric cancer underwent subtotal gastrectomy with gastrojejunostomy, 8 patients with esophageal cancer had esophageal resection with esophagogastrostomy and 3 patients with non-resectable gastric or cardiac cancer had palliative by-passing esophagojejunostomy, all performed by means of the EEA stapler. Three anastomotic leakages were detected radiologically, two after esophagojejunostomy and one after gastrojejunostomy. These leaks did not lead to clinical signs or symptoms and healed with parenteral nutrition in three weeks. One patient died of myocardial infarction on the 8th postoperative day, but at autopsy the anastomosis was intact. At follow-up endoscopy three mild anastomotic strictures have been found, but no treatment have been required. In two patients the stricture resolved spontaneously in a few months. According to our experience, esophagojejunal, gastrojejunal and esophagogastric anastomosis performed with the EEA stapling instrument seems to be at least as reliable as a hand sutured anastomosis, obviously even more reliable. The EEA stapler is also time saving, especially after adequate experience with the use of the instrument has been achieved. The difficulties and hazards associated with the use of the stapler are discussed.

Experiences with the EEA stapling instrument for colorectal anastomosis

Early experiences and results with the EEA stapling instrument for colorectal anastomosis are reported. 39 patients underwent anterior resection or left hemicolectomy with end-to-end anastomosis performed by means of the EEA stapler. Two patients had a clinically recognizable anastomotic leakage, both of which healed spontaneously. One patient died from pulmonary embolism, but at autopsy the anastomosis was intact. No significant problems in the control of anorectal function developed. On follow-up sigmoidoscopic examinations two patients showed a distinct narrowing of the anastomotic site, but both of these stenoses were spontaneously dilated by six months. It seems that an anastomosis performed with the EEA stapler is at least as reliable as a hand sutured one and apparently more so. With this instrument an anastomosis can be achieved at a lower level than would be feasible with conventional hand suture techniques. In addition, it is much more easily and rapidly performed, especially in patients with a narrow pelvis or other anatomical difficulties.

Gray-scale ultrasonography and jaundice

Forty-nine consecutive jaundiced patients were examined with ultrasonography as the initial imaging method. In 90% could surgical and medical jaundice be differentiated and in 51% the correct specific diagnosis reached.

The diagnostic accuracy of gray-scale ultrasonography compared with ERP and arteriography in the detection of pancreatic carcinoma

Forty patients who underwent ultrasound, endoscopic retrograde pancreatography (ERP), and selective arteriography examinations and who had a finding of or were suspected of having pancreatic carcinoma in one or several of these examinations form the basis of the study. Nineteen pancreatic carcinomas were verified at operation. Eighteen of these could be detected with ERP, 18 with arteriography, and 15 with sonography. ERP had no, arteriography one and sonography one false-negative finding. All methods had difficulties in distinguishing carcinoma from other pancreatic diseases, and therefore there were many false-positive findings.

The effect of furosemide on renal function in open heart surgery

The effect of furosemide on renal function in patients undergoing open heart surgery was investigated, using creatinine clearance, urine flow, sodium and potassium excretion as the parameters. The effect of furosemide (2 mg/kg i.v.) on blood flow in arteria renalis and the tissue oxygen tension of the renal cortex and medulla were also investigated experimentally in six dogs. The flow was measured with an electromagnetic flowmeter and the tissue oxygen tension with IBC tissue oxygen electrodes. Prolongation of the perfusion time to more than 60 minutes resulted in a decline of creatinine clearance to appr. 50% of the initial level. Prophylactic furosemide given prior to the perfusion brought down the creatinine clearance to 64% of the initial level. Furosemide, administered either prophylactically just before the cardiopulmonary bypass or after urine flow had declined below 0.5 ml/kg/h, had no effect on the potassium balance in the long perfusion group (over 60 minutes), though it clearly increased the negative potassium balance in the short perfusion group (below 60 minutes). In an experimental work on dogs, furosemide was found to elevate the tissue oxygen tension in the renal cortex and and medulla, and slightly to increase the blood flow in arteria renalis.

[Blood sugar level in surgical patients]

Serum glucose levels of six different patient groups were investigated preoperatively, during operation, postoperatively and in the first postoperative days: Group A, 10 cholecystectomy patients with 5% glucose infusion 2000 ml/day at a constant infusion rate; group B, 10 cholecystectomy patients with 10% constant rate glucose infusion; group C, 20 cholecystectomy or hernia patients with saline infusion; group D, 34 patients with 5% free rate glucose infusion 2000 ml/day; group E, 15 atrial septal defect patients with 5% constant rate glucose infusion 1500 ml/day and group f, 14 valvular surgery patients with 5% constant rate glucose infusion. Serum glucose increased in all groups during the study, most in the group B and least in the group C. There were no significant differences between the groups A and D, so constant or "free" infusion rate are the same from this viewpoint. The differences between the saline group (C) and all other groups was per- and postoperatively and in the postoperative day significant (p less than 0.001). There were no significant differences between the open heart surgery groups (E and F) and general surgery groups (A and D).

Effects of open-heart surgery on carbohydrate and lipid metabolism

The concentrations of blood glucose, serum insulin, free fatty acids, and triglycerides were examined preoperatively, during anesthesia, during extracorporeal circulation, and during the following 3 postoperative days in 29 patients. The patients were divided into three groups according to the duration of extracorporeal circulation and the use of hypothermia: short perfusion group (SPG, bypass time shorter than 60 minutes, 15 patients), long perfusion group in normothermia (LPGN, bypass time longer than 60 minutes, 8 patients), and long perfusion group in hypothermia (LPGH, temperature during bypass below 33 degrees C., 6 patients). In all three groups, the concentrations of free fatty acids and blood glucose rose significantly because of anesthesia (p less than 0.001). After cardiopulmonary bypass, the concentrations of free fatty acids diminished significantly. The blood glucose remained at high level until the second postoperative day and was significantly higher in the LPG than in the SPG (p less than 0.05). The serum insulin level remained low during anesthesia and extracorporeal circulation in the SPG and LPGH but rose during the postoperative period; the maximal values were recorded on the first postoperative day. There were no significant differences between the groups with regard to serum insulin during the study. These changes and their metabolic background are discussed.

Spontaneous rupture of liver tumours

Five geriatric patients with spontaneous rupture of the liver caused by hepatic malignancies were operated upon without mortality. Liver resection seems to be the treatment of choice, but in selected cases with unresectable tumours ligation of the hepatic artery alone is preferable to an attempt to control haemorrhage by packing and suture.

Effects of ethanol on the cyclic AMP system of the dog gastric mucosa

The effect of ethanol on the cyclic AMP system of the dog fundic mucosa was studied in vitro. The gastric mucosal content of cyclic AMP was increased by 2.5% ethanol, whereas 10 and 20% ethanol decreased the mucosal content of cyclic AMP. The activity of adenylate cyclase was increased by 2.5 and 5% ethanol, whereas 10% ethanol did not significantly affect it. The activity of cyclic AMP phosphodiesterase was inhibited by ethanol in a competitive manner. The increase in the gastric mucosal content of cyclic AMP, induced by low concentrations of ethanol, is apparently due to the stimulation of adenylate cyclase and inhibition of phosphodiesterase. Changes in the phosphodiesterase or adenylate cyclase activites do not explain the decrease of the mucosal content of cyclic AMP by higher concentrations of ethanol. The mechanism of the decrease is discussed.

Effects of ethyl alcohol on the adenosine 3', 5'-monophosphate system of the human gastric mucosa

The effect of ethyl alcohol on the cyclic AMP system of the human gastric mucosa was studied in vitro. Corporic gastric mucosa was obtained from patients operated on for gastric or duodenal ulcers. Under the in vitro conditions used, ethanol at concentrations of 5% (v/v) or less stimulated the activity of adenylate cyclase and induced a dose-dependent rise of the gastric mucosal content of cyclic AMP. However, 10% ethanol increased the activity of adenylate cyclase but did not affect the gastric mucosal content of cyclic AMP. At the concentrations of 5 or 10%, ethanol inhibited the activity of cyclic AMP phosphodiesterase in a competitive manner. Reports in the literature indicate that oral ethanol stimulates the output of gastric acid at low but not at higher concentrations. The present results are consistent with the conception that the stimulatory effect of ethanol on the output of acid is mediated by an increase of the content of cyclic AMP in the gastric mucosa.