Treatment of the dumping syndrome with the somatostatin analogue SMS 201-995.

In six patients suffering from severe early dumping and six patients with late dumping after peptic ulcer surgery, the effect of the somatostatin analogue SMS 201-995 was compared with placebo. In early dumpers subcutaneous administration of 50 micrograms SMS 201-995 prior to meal ingestion induced a strong improvement of dumping symptoms as reflected by a decrease of the Sigstad dumping score from 12 +/- 2 during placebo to 5 +/- 2 (p less than 0.05). Furthermore, the postprandial increase of pulse rate was abolished; maximum pulse rate decreased from 85 +/- 7 beats/min to 67 +/- 7 beats/min (p less than 0.05). SMS 201-995 did not significantly affect postprandial changes in packed cell volume. In late dumpers 50 micrograms SMS 201-995 reduced peak plasma insulin after oral glucose from 173 +/- 16 mU/L during placebo to 35 +/- 9 mU/L during SMS 201-995 (p less than 0.05) and increased individual plasma glucose nadirs from 1.9 +/- 0.3 mmol/L to 7.5 +/- 3.3 mmol/L (p less than 0.01). Both in early and late dumpers SMS 201-995 improved postprandial expiratory breath hydrogen excretion indicating slowing of gastrointestinal hurry. SMS 201-995 is a powerful therapeutic agent for the management of patients suffering from the dumping syndrome after gastric surgery.     

Pulmonary valve insertion during reoperation for tetralogy of Fallot

Our experience with pulmonary valve insertion during reoperation for residual lesions after initial open repair of tetralogy of Fallot in 15 patients is reported. Preoperatively, 14 patients were in moderate to severe congestive heart failure, and all 15 had decreased right ventricular (RV) function at cardiac catheterization. All 15 patients had pulmonary insufficiency but not as an isolated finding. The most common residual lesions encountered were ventricular septal defect in 9, tricuspid insufficiency in 11, and peripheral pulmonary arterial stenosis in 6. Tissue valves were inserted in all patients. Mean peak RV-left ventricular pressure ratio measured in the operating room decreased from 0.61 +/- 0.10 (+/- the standard deviation) to 0.47 +/- 0.17 (p less than 0.05). There were no operative deaths. At follow-up (mean, 33 months), all but 1 patient were in New York Heart Association Class I or II. Pulmonary valve insertion should be considered during reoperation for tetralogy of Fallot when pulmonary insufficiency and RV failure are present.     

APACHE II score and abdominal sepsis. A prospective study

Therapeutic trials for intra-abdominal sepsis require pretreatment stratification; physiologic scoring has been recently proposed for this purpose. We have prospectively tested the validity of one such scoring system, namely, the Acute Physiology and Chronic Health Evaluation (APACHE II). As part of a larger database, we correlated APACHE II scores with mortality in 100 patients hospitalized for generalized peritonitis or abdominal abscess. Use of steroids was recorded because of our suspicion that steroids increase mortality but blunt the physiologic response to sepsis. Thirty-one patients died, including 12 of 19 patients receiving steroids. Stepwise discriminant analysis revealed that the APACHE II score and steroid use were each independently associated with the rate of mortality. We report a prospective validation of pretreatment APACHE II scoring in abdominal sepsis. Steroid use is an independent risk factor.     

Choledochal cyst: case reports and current concepts

Choledochal cyst is an unusual but serious condition which most commonly affects Oriental people. Recent experience of three patients with this condition in whom diagnosis was made by ultrasound examination is reported. Cholangiography (ERCP or PTC) was performed in two of the cases to define the anatomy. All three cases were successfully managed by cyst excision and biliary reconstruction by Roux-en-Y hepaticojejunostomy. The rationale for and importance of cyst excision are discussed.     

Isolated penile burns: a plea for early excision

We report our experience of eight cases of isolated full thickness burns of the penis. Early excision of burns of the penile shaft and repair with a preputial flap or mesh split skin graft produces excellent results, with a reduction in complications and an early re-establishment of sexual function. Conservative treatment of burns of the glans, on the other hand, is appropriate and results in minimal scarring.     

Is additional epidural sympathetic block in microvascular surgery contraindicated? A preliminary report

The use of additional epidural sympathetic block during and after microvascular surgery in the lower extremities to prevent vasospasm is generally agreed on. However, a significant fall in the perfusion rate of the transplants was seen after application of bupivacaine (Marcain) via the epidural catheter. This effect has, to our knowledge, not been described before and is probably caused by the sympathectomy effect of this type of analgesia.     

Operative treatment of median cervical cysts

Median cervical cysts are congenital anomalies arising from remaining thyroglossal duct epithelium. A major problem in the surgical treatment of these cysts is the high frequency of recurrence. Embryonic considerations indicate an important causal role for the hyoid bone in these recurrences. We studied the relationship between operative techniques and the number of recurrences in 36 patients treated in our hospital. Fourteen patients sent from other hospitals had a recurrent fistula; in thirteen cases the hyoid bone was still in place. All patients who had the central part of the hyoid bone excised were cured. In 14 patients without adequate excisions of the hyoid bone we found four recurrences. To prevent recurrence a total excision of thyroglossal duct epithelium is necessary.     

The value of sonography in the diagnosis and follow-up of patients with blunt renal trauma

Eighty-eight patients with blunt renal trauma were examined sonographically. Rupture of the kidney was diagnosed in 41 patients and contusion of the kidney in 45. The correlation between operative findings, sonography and urography showed positive sonographic findings to be correct in all patients with rupture of the kidney. In 4 patients with normal sonograms, the diagnosis of a contusion was based on the urographic results. Three patients underwent angiography. An intimal lesion was seen in 2 and a tear of the renal artery in 1. The results of our investigation suggest that sonography should be applied in the first place in the evaluation of blunt renal trauma. It is the investigation of choice during follow-up after surgical as well as conservative therapy.