Vagal influence on duodenal motor activity

The extrinsic and intrinsic vagal influences on duodenal motor activity in the anesthetized dog were investigated. The following conclusions were derived: (1) Electrical vagal stimulation elicits gastroduodenal contractions. (2) Poststimulatory contractions, or off responses, occur on the antrum and duodenum after termination of the stimulus. (3) Denervation of the extrinsic vagal nerves to the duodenum does not eliminate the above responses. (4) Denervation of the extrinsic nerves to the duodenum and transection of the gastroduodenal junction eliminates stimulated duodenal motility and the occurrence of off responses on the duodenum. Antral responses remain unaffected. (5) The motor innervation to the duodenum is composed of extrinsic vagal fibers and intrinsic vagal nerves which appear to first enter the antrum and then cross the gastroduodenal junction to innervate the duodenum.     

Aorto-Enteric Fistula: a Dilemma for the Endoscopist as a Rare Cause of Gastro-Intestinal Bleeding

A 78-year-old man with a history of aorta-femoral graft operation was admitted to the hospital with symptoms of syncope, melena and haematemesis. He reported several episodes of melena during the previous year for which he underwent repeated gastro-intestinal endoscopic examinations, which were unable to show the site of the gastrointestinal bleeding. The third upper gastro-intestinal endoscopic examination disclosed a yellowish ulcerative lesion with irregular borders in the third part of the duodenum, which was considered to be a fistula, between the aorta and the duodenum. The patient underwent an explorative operation that revealed an intact aortic graft, firmly adherent to the duodenal wall, and the duodenum that was eroded in the third portion. The duodenum was transected and a duodenoduo-denostomy was performed. Although re-bleeding did not occur, the patient died of sepsis eight days after the operation. Aorto-enteric fistulae can be missed due to the common practice of limiting the endoscopic examination to the second part of the duodenum and not considering them in the differential diagnosis of gastro-intestinal bleeding because of their rarity. Possibly, a number of prior endoscopic examinations may be inconclusive until a correct diagnosis is reached in most of the cases.     

Myoelectrical activity of the canine stomach and duodenum after gastric resection

Distal gastric resection has long-lasting effects on the basal electrical rhythm of the canine stomach and duodenum. After Billroth I resection, duodenal fast activity is no longer controlled by the gastric basal electrical rhythm and is excessive and uncoordinated. Segmental resection of the stomach is followed by a high incidence of retrograde conduction of the basal electrical rhythm of the stomach and duodenum. Pylorus-preserving gastrectomy reduces this retrograde activity to a minimum.     

Surgical management of perforated duodenal diverticula

A patient is described who had acute perforation of a duodenal diverticulum and survived after surgical intervention. Various technics for the surgical management of perforated duodenal diverticula are detailed. Choledochotomy, with passage of a catheter or sound into the duodenum, permits identification of the ampulla and safe excision and closure of the diverticulum. T tube drainage seems to be useful, and postoperative cholangiography confirms the integrity of the duodenum prior to feeding. Drainage of the retroduodenal area is recommended.     

THE EFFECT OF DUODENAL DISTENSION UPON ANTRO-PYLORIC MOTILITY AND LIQUID GASTRIC EMPTYING IN PIGS

Background: This study has investigated first the role of the antrum and pylorus in the retardation of gastric emptying during distension of the duodenum, and second whether ascending duodenal intramural nerves contribute to control of both antro-pyloric motility and liquid gastric emptying in response to distension of the duodenum. Methods: Studies were performed on 18 pigs. In six the duodenum was transected 1–2 cm distal to the pylorus, to intempt intramural nerves, in six the pylorus was excised and a further six pigs without any transection or resection acted as controls. Motility of the antrum, pylorus and duodenum was recorded by a sleeve/side hole manometric catheter. Gastric emptying was measured by drainage of the duodenum through a cannula. Results: In control animals distension of the duodenum inhibited antro-pyloric pressure waves (APPW), from 1.52 waves/min at minimum distension to 0.25/min at maximum distension (P = 0.0007), stimulated isolated pyloric pressure waves (IPPW), from 0.56/min to 1.80/min (P = 0.034) and slowed emptying of a 1000 mL load of 5% dextrose over 30 min from 788 mL to 251 mL (P = 0.0001). Duodenum transected animals did not show the duodenal distension-induced stimulation of IPPW (maximum distension: 0.93/min), but both the distension-induced inhibition of APPW (maximum distension: 0.85/min) and slowing of emptying (maximum distension: 52 mL emptied) were unaltered. Similarly in pylorus-excised animals, duodenal distension inhibited APPW (maximum distension: 0.47/min) and slowed liquid emptying (maximum distension: 267 mL), effects which did not differ from control animals. Retardation of gastric emptying by duodenal distension may be due in part to inhibition of antral contractions. Conclusions: Under the conditions of this experiment, increased pyloric resistance to flow does not play a major role in the slowing of emptying by duodenal distension, but the stimulation of the pylorus by duodenal distension depends on duodenal intramural neural pathways. Duodenal distension-induced feedback control of emptying is mediated primarily via pathways other than ascending intraduodenal nerves.     

End to side isoaxial anastomosis in gastrointestinal surgery

This report points out that the incisions used in conventional end to side gastroduodenostomy and ileotransversostomy are perpendicular to the arterial supply of the duodenum and colon. It is suggested that the duodenum and colon be incised parallel to their arterial supply. A more anatomic and physiologic anastomosis can be obtained, with the peristaltic waves and the axes of the organs in the same direction. This method is termed “isoaxial anastomosis.”     

Organ preservation I. kidney and pancreas

The present study was performed to determine the effect of cortisosteroid hormones on the mechanical properties and collagen content of healing wounds in rat stomach and duodenum. Long-term cortisol (hydrocortisone) treatment was started 4 weeks before wounding and continued until sacrifice. Wounds were made in the nonglandular part (rumen) and in the glandular oxyntic part (corpus) of the stomach and in duodenum. The wounds were tested 7 and 20 days after operation. Cortisol treatment decreased the mechanical strength of healing wounds in stomach and duodenum. A reduction was found for breaking strength as well as breaking energy. The inhibition was most pronounced early after (7 days) operation, while an apparently normal increase of wound strength was found between 7 and 20 days of healing. A relation between mechanical strength and total collagen content was shown. These findings indicate that the increase of mechanical strength and collagen content in wounds from stomach and duodenum is impaired by systemic long-term corticosteroid treatment. The effect is a delay of the healing process rather than a real inhibition.     

Books received for reviewSurgery,Creighton University School of Medicine,

The eighth reported case of choledochocele is described. This lesion is a cyst communicating with the terminal portion of the common bile duct. It is characteristically lined with duodenal mucosa and is probably a form of duplication of the duodenum. The surgical treatment is marsupialization of the cyst to the interior of the duodenum.     

The pathogenesis of duodenal and gastric ulcers

The normal gastric content of man and experimental animals is not sufficiently corrosive to prevent the rapid healing of even extensive defects or lesions in the gastric or duodenal mucosa. In marked contrast, pure gastric juice is a very corrosive liquid and is able to destroy and digest living tissue such as spleen, pancreas, and mucosa of the stomach and intestines if these tissues are exposed to its action for a sufficient period of time. Under normal conditions, digestion of the mucosa does not occur because the acid gastric juice is buffered and diluted by the food. The mechanism that regulates gastric secretion provides for an abundant flow of gastric juice when food is in the stomach and also checks further secretion before the gastric content becomes sufficiently corrosive to damage the mucosa. This inhibitory mechanism involves both the antrum and the duodenum. In ulcer patients the corrosive qualities of the gastric content approach that of pure gastric juice. This is due to stimulation of gastric secretion by agencies other than food, by an abnormally prolonged or excessive secretion in response to normal stimuli, or to both factors. The corrosive gastric content is quite able to destroy and digest the normal mucosa of the stomach, duodenum, or jejunum and can be considered a sufficient cause of peptic ulceration.     

Ninety-five percent duodenectomy. An experimental study

Subtotal excision of the duodenum with preservation of the pancreas and bile and pancreatic ducts was achieved in five dogs without complications. Reconstruction was performed by direct anastomosis of the jejunum to the duodenal strip remaining attached to the head of the pancreas. Radiologic, metabolic, and histologic parameters 4 months postoperatively documented the success of this procedure. We suggest that this technique may be used to further investigate the role of the duodenum in digestive physiologic functions and may have clinical applications for benign diseases of the duodenum.     

Multiple atresias and a new syndrome of hereditary multiple atresias involving the gastrointestinal tract from stomach to rectum

Ten patients with multiple intestinal atresias were seen at Ste Justine Hospital from 1962–1971. Two of the seven patients with multiple atresia were unusual, presenting a rarely reported association of atresia of the duodenum, jejunum, and ileum.In addition, we recently treated three of five children with a special type of multiple atresia who came from the same area and born to three related French-Canadian families. These five cases of hereditary atresia involved the stomach, duodenum, jejunum, colon and rectum. Genetic investigation revealed common ancestors in these three families going back to the original settlers in 1654–1663. In addition, consanguinity was present in some of the more recent generations.It is proposed that when extensive multiple atresias occur a rare autosomal recessive gene is the responsible agent for this congenital birth defect. The etiology of such multiple septal atresia is difficult to place into any present theory of pathogenesis.     

局部晚期右半结肠癌侵犯十二指肠的诊断与外科治疗原则

临床工作中局部晚期右半结肠癌侵犯十二指肠的病例并不罕见,需要引起外科医生的重视,使部分确有治愈机会的患者得到应有的治疗。患者的主要症状与右半结肠癌类似,CT和MRI有助于明确十二指肠是否受侵。超声内镜也有着重要的诊断价值。对可疑侵犯十二指肠的病例可先试行新辅助治疗,待降期后再考虑手术治疗。术中探查发现肿瘤侵犯十二指肠时应根据具体情况采用不同的手术方法。     

Clinical evaluation of 99mTc-pyridoxylideneglutamate for hepatobiliary scanning

Clinical evaluation of hepatobiliary scanning using ^99mTc-PG was done in twenty normal volunteers and eighty-three patients with liver and biliary tract disease. Satisfactory images of the biliary tract were obtained using small dosages of this agent. In normal humans, the agent reached the liver in 5 minutes, and the common bile duct, gallbladder, and duodenum in 10 to 20 minutes. The gallbladder was not visualized when the cystic duct was obstructed in patients with acute and chronic cholecystitis. In patients with partial common bile duct obstruction, a distended duct was visualized and there was delay in transit of radioactivity into the duodenum. With complete common bile duct obstruction, no radioactivity was seen in the biliary or gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of the biliary and gastrointestinal tracts. There were no toxic or other untoward effects in any patient.     

Healing of incisional wounds in stomach and duodenum: A biomechanical study

The healing pattern of incisional wounds in the rat stomach and duodenum was determined. A model allowing the biomechanical determinations of complete load-deformation curves is described. Wounds were made in the nonglandular (rumen) and glandular oxyntic (corpus) parts of the stomach and in duodenum. The wounds were tested 5 to 40 days after operation.Of the intact tissues the nonglandular part of the stomach was found to be more extensible and required more energy to be ruptured than the glandular part of the stomach and duodenum. The healing wounds in the glandular part of the stomach and duodenum showed the most rapid increase in mechanical strength, and after 40 days both required more energy to be ruptured than intact tissue. Wounds in the nonglandular part of the stomach reached only 75 percent of intact strength value after 40 days. The process of wound healing resulted in an increase in tissue stiffness.These findings indicate that wound healing in stomach and duodenum is more rapid than that in most other tissues and that the load-strain data give a detailed picture of the healing process. The energy required to rupture a wound represents the most informative assessment of wound healing.     

Villous adenoma of the duodenum: A case report and review of the literature

A case of villous adenoma of the duodenum, with focal in situ carcinomatous changes, has been described with a review of forty-two other case reports from the world literature. Occult bleeding, resulting in anemia, and vague obstructive symptoms appear to be the most common presenting findings. The average age was 56.4 years, which was seven years younger than the average age for villous tumors of the colon. Adequate radiologic studies should establish the diagnosis preoperatively. These tumors obtain relatively large size before causing significant symptoms. Approximately one third showed carcinomatous changes, and approximately one half of these were in situ changes. Local segmental resection for duodenal villous tumors is desirable when possible. However, in areas where this is not feasible, local mucosal excision is acceptable for benign tumors and for those with in situ carcinoma. If invasive carcinoma is found in the excised specimen, pancreatoduodenectomy is recommended. Insufficient evidence is available to adequately evaluate survival for malignant villous tumors of the duodenum, but the available data suggest that the survival after treatment of malignant villous tumors is comparable to other malignant lesions originating in the duodenum.     

Healing of incisional wounds in stomach and duodenum: Collagen distribution and relation to mechanical strength

The present study was performed to determine the changes in and distribution of collagen concentration around a healing incision in rat stomach and duodenum. These concentrations were related to the mechanical properties presented previously. Wounds were made in the nonglandular (rumen) and the glandular oxyntic parts (corpus) of the stomach and in duodenum. Specimens were cut parallel to the incision line and hydroxyproline contents and dry defatted weight were measured. Wounds were investigated 5 to 40 days after operation.Of the intact tissues the nonglandular part of the stomach had twice the collagen concentration of the glandular oxyntic part and duodenum, which did not differ from each other. The healing wounds in the glandular oxyntic part of the stomach and duodenum showed the most rapid increase in collagen concentration in the incision line and 40 days postoperatively both had collagen concentrations significantly greater than those of intact tissues. Wounds in the nonglandular part of the stomach only reached the level of intact tissue after 40 days. The dimensions of the biochemically active zones around incisions in stomach and duodenum remain essentially unchanged for 40 days after operation. A relation between the development of collagen concentration and mechanical strength was shown.These findings indicate that wound healing in stomach and duodenum is rapid, that collagen is the primary factor in the mechanical properties and that the highest activity is limited to a zone close to the incision line. The width of the biochemical zone remains constant.     

Injuries of the duodenum

During 10 years there were 94 patients aged 16-68 years with injuries of the duodenum. Their case histories were studied in order to establish the causes of complications and lethality. Among them there were 48 patients with knife wounds, 5 patients with gunshot wounds, closed trauma of the abdomen was diagnosed in 40 patients, 1 patient had a iatrogenic wound of the duodenum. There were 17 isolated injuries of the gut and 77 combined and multiple injuries. Patients with traumatic perforations in the duodenum made up 89.4%, 31% of them died. In 70 patients suture of the duodenum was put during operation, 10 patients had sutures and intubation of the duodenum, in 6 patients the injured gut was excluded, in 1 patient resection of the duodenum was made and primary anastomosis was formed. 28 patients (29.8%) died. Among the causes of the deaths were non-compensated blood loss resulting from hemorrhage from the vessels of the liver and other organs, combined and multiple injuries. Pyo-septic complications led to death of 12 patients, duodenal fistula was found in 4 patients. An analysis of the material has shown that most patients with traumas of the duodenum could be cured by suturing the incised or lacerated wound of the duodenum. Exclusion of the duodenum is thought to be a helpful addition to operation on the injured duodenum, especially on large wounds. Pancreatoduodenectomy is necessary but seldom in surgery of such traumas.     

Spontaneous rupture of duodenum: case report and review

Although rare, injuries of the duodenum increased in frequency during the past ten years. Careful attention must be paid to them, especially in blunt trauma of the abdomen and lower thoracic regions. Often they occur along with lesions of other related structures in polytraumatized patients. X-rays are the most important mean used in diagnosis. Early diagnosis and surgical treatment are conditio sine qua non for successful results. Complete intraoperative inspection of the duodenum, careful suture of the perforation and a correct placement of drainage are essential for the prevention of postoperative complications. If the duodenal wall had lost its vitality, a gastrojejunal or duodenojejunal anastomosis or gastrostomy are performed; the duodenum is decompressed and drainage of the peritoneal cavity is established. In cases of associated injury of the pancreas or choledochus, the drainage of the extrahepatic bile duct is recommended. The Authors report a case of spontaneous rupture of duodenum in which all of the above mentioned procedures were used; they stress that only suspicion of a duodenum's rupture indicates an immediate laparotomy.     

Pancreas Transplantation After Liver Transplantation: A Case Report

Our aim was to describe the clinical indications, surgical technique, and clinical outcomes of a pancreas transplantation, performed 4 years after liver transplantation, as treatment for new-onset, uncontrolled diabetes mellitus in a 53-year-old man. Liver transplantation was performed for end-stage liver disease secondary to hepatitis B virus infection and hepatocellular carcinoma. The patient had no history of diabetes prior to the liver transplantation. The decision to proceed with a pancreas transplantation was made when the patient's blood sugar levels could not be normalized despite insulin doses >100 IU/d. A modified cadaveric transplantation technique was used, with the recipient's inferior vena cava dissected for anastomosis with the portal vein of the graft, using a diamond-shaped patch procedure. Moreover, the right common iliac artery was anastomosed with a Y-graft in the pancreas graft, and the duodenum remnant of the graft was anastomosed to the recipient's duodenum using a side-to-side procedure. The 6-month postoperative follow-up included repeated endoscopic biopsy of the graft duodenum, with no evidence of thrombosis or rejection of the graft, with glucose level within normal limits without requirement for diabetic drugs. To our knowledge, this is the first reported case of pancreas transplantation after liver transplantation.     

Contact cholangiography

A technic of intraoperative contact cholangiography is described in which a sterile wrapped film is placed behind the mobilized duodenum and common bile duct. In a series of 120 cholecystectomies this technic, in conjunction with conventional cholangiography, allowed a low rate of exploration of the common bile duct (15 per cent) and has detected otherwise unsuspected stones in two patients.