Effects of resection or bypass of the distal ileum on the lithogenicity of bile

Changes in the composition and lithogenicity of gallbladder bile after resection and bypass of the distal ileum were investigated in the prairie dog. In animals fed a trace cholesterol diet, both ileal resection and ileal bypass increased the cholesterol saturation of bile. In animals fed a cholesterol-enriched diet, the cholesterol saturation was increased by ileal resection but not by ileal bypass. In the animals fed the trace cholesterol diet, both ileal resection and ileal bypass induced the formation of bilirubinate gallstones.     

Prospective evaluation of gray scale ultrasonography in the diagnosis of pancreas cancer

One hundred thirty-four patients suspected of having pancreas cancer successfully underwent gray scale ultrasound examination of the pancreas. The prospective ultrasound findings were correlated with the final diagnoses, laparotomy findings, and pathology findings. Fifty-four patients had pancreas cancer, confirmed by resection or biopsy in all cases. On ultrasonography, the pancreas was correctly reported to have abnormalities in sixty-one of seventy-eight patients (78 per cent) and correctly reported to have no abnormalities in thirty-eight of fifty-six patients (68 per cent). A correct ultrasound diagnosis of pancreas cancer was made for forty-four of fifty-four patients (81 per cent), and there were thirteen false-positive reports. Ninety-four per cent of cancers confined to the head of the pancreas and 70 per cent of cancers at other locations within the gland were detected by ultrasound examination. The correct ultrasound diagnosis was given for fifteen of seventeen patients with resectable pancreas cancer, the degree of associated pancreatitis ranging from minimal to severe.Analysis of the predictive values of positive and negative ultrasound examinations suggests that this test could be used to screen a population of patients with symptoms mildly suggestive of pancreas cancer. The importance of preselecting the level of confidence of a positive test result, above which further investigation is indicated, is emphasized.     

The continuing challenge of gallbladder cancer. Survey of thirty years' experience at the University of Chicago.

The current concepts of the etiologic factors and spread of carcinoma of the gallbladder are discussed. The experience at the university of Chicago with this condition over a period of thirty years is reviewed. Of eighty-two cases diagnosed during this time, 88 per cent of the patients died within one year of diagnosis and the five year survival rate was 5 per cent. The difficulties in diagnosis of cholecystic neoplasms are considered, and the possibility of increasing diagnostic accuracy by the use of celiac axis angiography, immunologic tests for tumor-associated antigens, peptide hormone assays, and cytologic study of duodenal juice is discussed. The place of palliative surgery in the management of cancer of the gallbladder is outlined. Means of improving the current high mortality of this condition are evaluated, and a plea is made for a controlled trial of the various forms of treatment that have been suggested.     

Is glucagon a choleretic hormone at physiologic blood levels?

The mechanism of action and possible physiologic implications of glucagon-induced choleresis were investigated in two groups of dogs. Group I demonstrated, in chronic animal models, that glucagon-induced choleresis was not associated with increased bile acid output and was not blocked by somatostatin or Piptal, suggesting a direct stimulatory effect on bile acid-independent canalicular flow. In acute animal models (group II), glucagon infusion at rates which produced postprandial levels in the portal vein induced significant choleresis, implying that glucagon may have a physiologic role in the regulation of bile secretion. No consistent relation between bile secretion and portal venous blood flow could be demonstrated.     

Gastrointestinal hemorrhage from left-sided portal hypertension: An unappreciated complication of pancreatitis

Eleven of 16 patients with splenic vein thrombosis subsequent to pancreatitis had variceal hemorrhage. Variceal development tends to occur in the stomach, although esophageal varices may also occur, and is a result of left-sided or segmental portal hypertension. The antecedent pancreatitis may be quite mild and produce minimal symptoms. Angiography is required to establish the diagnosis as endoscopic detection of gastric varices is difficult and unreliable. Splenectomy is the definitive treatment, although transgastric ligation of varices must be added if active bleeding is taking place.     

Hemorrhage from ileal varices after total proctocolectomy

We report two cases of hemorrhage from ileal varices developing after total proctocolectomy for chronic ulcerative colitis. Intermittent peristomal bleeding preceded life-threatening hemorrhage from true ileal varices proximal to the stoma. Management by portacaval shunting was effective and has not resulted in encephalopathy.     

New approaches to the management of severe acute pancreatitis.

A recent experience with seventy-seven patients admitted to Boston City Hospital for acute pancreatitis permitted us to identify thirteen patients (17 per cent) whom we diagnosed as having severe protracted acute pancreatitis. These alcoholic patients obviously had fulminant pancreatitis similar to that reported by others in two instances and pancreatic abscesses in two additional instances, but nine of the patients did not fulfill the criteria usually used by others as a basic for surgical intervention. Specific preoperative diagnosis was obtained in these patients by the aggressive use of endoscopic cannulation of the pancreatic ducts, which documented the presence of surgically correctable lesions. These patients had sustained significant malnutrition, which was corrected only by protracted therapy extending an average of two months and involving all modalities currently available for nutritional support of the severely ill patient. After proper preoperative identification of a specific lesion and correction of the malnutrition, the eleven patients without fulminant disease were operated on with no deaths or significant complication. Nine of the patients had elective procedures, which included six distal pancreatectomies and one total pancreatectomy. Thus, severe protracted acute pancreatitis can be identified, and once categrorized, it can have therapeutic implications.     

Current medical and surgical opinions on important therapeutic issues in inflammatory bowel disease: A special 1979 survey

A survey was made in 1979 of 31 gastroenterologists and 25 surgeons on currently important medical and surgical therapeutic issues in inflammatory bowel disease. Opinions about issues such as intractability, indications for surgery in ulcerative colitis and Crohn's disease, the approach to various medical and surgical complications, and bowel malignancy were more concordant than might have been anticipated.     

Diagnostic considerations in acute alcoholic and gallstone pancreatitis

Comparison of a group of patients with acute alcoholic pancreatitis with a group with gallstone pancreatitis has established the serum amylase level on admission as one of the most useful laboratory tests in aiding to differentiate the two entities. A serum amylase level greater than 1,500 IU was most often due to gallstone pancreatitis, as was elevation of the serum bilirubin and alkaline phosphatase levels.     

Clinical and in vitro analysis of determinants of gastroesophageal competence. A study of the principles of antireflux surgery.

The analysis of esophageal manometry and 24 hour esophageal pH monitoring in 266 consecutive patients indicates that the competency of the cardia depends upon the amplitude of the distal esophageal high pressure zone and the length of the abdominal esophagus. These two determinants of competency were examined using human esophagi in a unique in vitro model which allowed control of these parameters, as well as intraabdominal, intragastric, and intrathoracic pressures. The following principles of the function of the abdominal esophagus were graphically illustrated: (1) Competency of a segment of intraabdominal esophagus without intrinsic tone occurs only when intraabdominal pressure is equal to or greater than intragastric pressure. (2) Competency of a segment of intraabdominal esophagus without intrinsic tone is directly related to its length. (3) The length of intraabdominal esophagus necessary to maintain competency is indirectly related to variations in intraabdominal pressure. (4) Competency of a segment of intraabdominal esophagus is augmented by the presence of intrinsic tone, and the shorter the length, the greater the intrinsic tone needed. (5) Competency of a segment of intraabdominal esophagus is augmented by negative intrathoracic pressure. These findings beautifully illustrate the mechanical valvelike function of the abdominal esophagus and the objectives to be accomplished in the surgical treatment of gastroesophageal reflux.     

Alkaline gastroesophageal reflux.

Twenty-four hour monitoring provides a continuous record of the pH of the lower esophagus in a near physiologic setting. The upper level of physiologic reflux was determined from the percentage of time and the number of episodes that the pH was less than 4 or more than 7 and the mean duration of each episode in fifteen asymptomatic subjects. One hundred patients with symptoms of gastroesophageal reflux were divided into four groups on the basis of twenty-four hour pH monitoring: those with abnormal acid but normal alkaline reflux, termed acid refluxers (51 patients); those with both abnormal acid and alkaline reflux, termed acid-alkaline refluxers (25); those with normal acid and abnormal alkaline reflux, termed alkaline refluxers (6); and those with both normal acid and alkaline reflux, termed nonrefluxers (18).Nonrefluxers had a similar incidence of heartburn, regurgitation, and dysphagia as acid and acid-alkaline refluxers, proving the inaccuracy of symptoms for detecting reflux. Alkaline refluxers had a lesser incidence of heartburn but a greater incidence of regurgitation, and four alkaline reflux patients presented with severe pulmonary disease secondary to aspiration. Similar incidence and degree of esophagitis was seen in acid, acid-alkaline, and alkaline refluxers. All three groups of symptomatic refluxers had a mean distal esophageal sphincter pressure significantly lower than that of the control asymptomatic subjects. There was no difference in the distal esophageal sphincter pressure between controls and symptomatic nonrefluxers.Nine of the patients with acid-alkaline reflux and one of the patients with alkaline reflux underwent an antireflux procedure and were restudied three months postoperatively. All ten patients had a 24 hour pH acid score within normal limits, but two had an abnormal 24 hour pH alkaline score. In both patients, reflux was demonstrated after placing an acid load in the stomach.It is concluded that symptomatic gastroesophageal reflux in patients with an intact gastrointestinal tract is a mixture of both acid and alkaline secretions, with one or both abnormal due to different degrees of acid production and pyloric regurgitation. Patients with alkaline reflux may develop serious complications of reflux in the absence of typical symptoms of heartburn. Twenty-four hour pH monitoring of the esophagus is useful in the identification of these patients and in evaluating the ability of an antireflux procedure to control both abnormal acid and alkaline reflux.     

Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastroesophageal competence

This study defines the components of distal esophageal sphincter function which predict gastroesophageal competence and examines the mechanisms by which three antireflux procedures restore competence to the cardia. In a prospective study, the reflux status of 391 patients was determined by 24 hour pH monitoring. Distal esophageal sphincter pressure and length of sphincter exposed to the positive pressure environment of the abdomen was measured by esophageal infusion manometry. Similar pre- and postoperative studies were performed in 45 patients who were randomized to three equal groups for the Hill, Belsey and Nissen antireflux procedures.Two hundred sixty-seven (68 percent) of the 391 patients had a positive 24 hour pH test. Competence of the cardia was related to pressure in the distal esophageal sphincter, to the length of sphincter in the abdomen and to an interaction between both (all p < 0.05). Thus, competence of the cardia requires an adequate pressure and length of sphincter in the abdomen. In determining competence, the pressure and length effects are not additive, but have an interacting relationship.Sphincter pressure and abdominal length are independently corrected by surgery. Restoration of competence requires increases in both. The gastric fundic wrap best augments distal esophageal sphincter pressure by application of normal functioning smooth muscle to the lower esophagus. Sphincter dynamics are normal after a wrap as the gastric fundus and distal esophageal sphincter share the functions of synchronous contraction and simultaneous relaxation on deglutition.     

Mesenteric vascular disease

In a patient with acute abdominal pain, the diagnosis of acute mesenteric vascular disease should be suspected immediately if there is a history of previous embolization, atrial fibrillation, or generalized atherosclerosis. Supportive therapy should be instituted promptly and should include treatment for congestive heart failure, hypotension, and dehydration. Heparin should be given intravenously to prevent extension of the occlusion. Angiography is essential in selecting those patients with superior mesenteric artery occlusion who should undergo immediate operation. At surgery, scanning of the revascularized intestine after aortic injection of ⁹⁹Te-labeled microspheres permits immediate determination of intestinal viability. If angiography demonstrates patency of the superior mesenteric artery, nonocclusive arteriosclerotic disease, venous thrombosis, or inferior mesenteric ischemic colitis is suspected and further supportive therapy and close observation are given. If abdominal findings progress to include peritonitis, laparotomy with intestinal resection is performed in any of these groups. Patients found to have an embolus are carefully evaluated for later corrective cardiac surgery. Patients with extensive atherosclerosis who recover from an acute episode are considered for subsequent elective bypass to avoid future ischemic episodes. This program is clinically practical and offers the hope of greater salvage of patients with decreased operative risk in a disease that has thus far yielded poor clinical results.     

Evaluation of the nissen antireflux procedure by esophageal manometry and twenty-four hour pH monitoring

Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.     

Evidence for a role of the stomach in serum calcium regulation

Gastrin, histamine, cholecystokinin, and the cholecystokinin-octapeptide all result in hypocalcemia in the rat. A gastric factor, and not the release of calcitonin from the thyroid gland, seems most important in mediating these changes in serum calcium concentration. Neither the administration of secretin, V.I.P., G.I.P., nor highly purified insulins resulted in any significant change in serum calcium concentrations in this animal.We conclude that under certain circumstances the stomach may play a role in serum calcium regulation.     

Management of esophageal perforation

Early diagnosis of esophageal perforation is critical. The importance of performing sufficient surgery at the first procedure whenever possible is emphasized. If early primary closure cannot be achieved, then the initial therapeutic method of choice is resection or diversion followed by reconstruction. Drainage of the perforated esophagus alone does not appear to be satisfactory treatment. Our experience indicates that later elective surgery for the management of patients undergoing successful initial resuscitation from esophageal perforation may be accomplished with an acceptable mortality rate.