Pancreaticoduodenectomy due to cancer in the elderly

The elderly have traditionally been excluded from pancreaticoduodenectomy due to the high morbimortality of this procedure. Six cases of pancreaticoduodenectomy) 5 cephalic and 1 total) for periampullary tumors in patients over 70 are reported. There was no mortality. We conclude that, in selected cases, pancreaticoduodenectomy can be performed safely in the elderly.

Choledochoduodenostomy and sphincterotomy in the treatment of choledocholithiasis

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22.6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40.6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21.3 per cent), supraduodenal choledochoduodenostomy in 216 (36.5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1.5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5.6 years, 71.5 per cent of patients who underwent choledochoduodenostomy and 75.2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).

Vagal system involvement in changes in small bowel motility during restraint stress: an experimental study in the dog

Changes in small intestinal motility were studied during restraint stress in fasting animals and after food; the involvement of the vagal system in the pathophysiology of these changes was assessed. Small intestinal motility was recorded in 40 dogs using electromyography with monopolar electrodes and manometry with submucosal microballoons. Twenty animals underwent bilateral truncal vagotomy. Stress increased intestinal motility (percentage of slow waves followed by action potentials in 1 min), both in fasting conditions (P < 0.001) and post-prandially (P < 0.001). It also completely abolished the migrating motor complex-interdigestive myoelectric complex periodicity characteristic of the normal fasting pattern. In dogs subjected to vagotomy, restraint stress increased motility during fasting (P < 0.001) but decreased it after feeding (P < 0.01). Restraint stress thus increases small intestinal motility, both during fasting and after food. The vagal system is partially involved in this hypermotility response.

Long term results of surgical sphincterotomy in the treatment of choledocholithiasis

The present article analyzes the indications for sphincterotomy in the Surgical Department of the University of Murcia, postoperative morbidity and mortality and the long term clinical situation of the patient after a follow-up period averaging 5.8 years. During a ten year period, a total of 2,610 patients underwent operation for biliary lithiasis, with exploratory choledochotomy indicated in 591 (22.6 percent). Surgical exploration of the bile duct finished with sphincterotomy in 135 (22.9 percent); 52 percent of these patients were less than 60 years old. The most frequent preoperative diagnosis was choledocholithiasis (33.3 percent) and cholelithiasis with crises of acute pancreatitis (30.3 percent). If we divide the ten years of the study into two five year periods, we noted a statistically significant decrease (p < 0.001) in the percentage of sphincterotomies compared with the number of choledochotomies performed during the second period. The rate of intra-abdominal complications was 5.1 percent; four intra-abdominal abscesses, one hemorrhaging at the level of the sphincterotomy and two instances of postoperative pancreatitis. Mortality in the series was 1.4 percent (two patients)--one with postoperative pancreatitis that developed torpidly and one with pulmonary embolism. Six years after the operation, 72.9 percent of the patients are still asymptomatic and the remaining patients have some type of symptoms--15.8 percent presented with dyspeptic syndrome; 2.0 percent had crises of colicky pain, and 5.9 percent required hospital admission for cholangitis. All of the patients with symptoms underwent endoscopy and ultrasonographic exploration of the bile duct. There were no pathologic findings in the biliary tree of patients who had dyspeptic syndrome or colicky pain, and all of the patients with cholangitis had a papillary stenosis and required endoscopic sphincterotomy or reoperation.

[Role of the vagal system in changes in small intestinal motility induced by psychological stress. Experimental study on dogs]

The objectives of the present study were: 1) to describe the modifications in motility of the small intestine in response to situations of psychic stress during fasting and postprandial periods. 2) To analyse the possible involvement of the vagal system in these modifications. For this we used a total of 40 dogs. The motility of the small intestine was recorded using electromyography techniques (monopolar electrodes) and manometric techniques (submucous microballons). The stress stimulus consisted in the complete body immobilization of the animal in plaster. We show that stress induced a significant increase in the intestinal motility index (percentage of show waves followed by the action potential) in the three locations of the intestine studied (duodenum, angle of Treitz and proximal part of the jejunum) during the fasting (p less than 0.001) and postprandial periods (p less than 0.001). Finally, we demonstrate that vagotomy prevents the effect of hypermotility causes by the psychic stress. We can conclude that psychic stress does indeed modify the normal motility of the small intestine, both in the fasting and postprandial periods, and the vagus is implicated in this hypermotility response.

Long-term results of choledochoduodenostomy in the treatment of choledocholithiasis: assessment of 225 cases

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8.6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62.2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4.0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1.8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4.6 years, 71.5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15.1 per cent), colicky pain (8.7 per cent) or episodes of cholangitis (4.7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.