Is ERCP manometry useful in the choice of treatment of stones of the common bile duct?

Summary To verify the appropriateness of sphincterotomy as the treatment of choice of choledocholithiasis, since 1980 we have been using endoscopic retrograde cholangiopancreatographic (ERCP) manometry of the sphincter of Oddi (SO). This method allows direct investigation of SO motor activity and provides useful information regarding the presence of benign papillary stenosis (BPS). Thirty-four patients were investigated because the radiological examination indicated BPS might be present. Of these, 20 had common bile duct (CBD) stones, while the remaining 14 presented with biliarylike pain and one or more of the following: CBD dilation (larger than 12 mm); emptying of the ERCP contrast medium took longer than 45 min; abnormal liver function tests. Moreover, 8 healthy volunteers served as controls. Our results show that the incidence of SO motor anomalies is very low in the presence of choledocholithiasis, while it is substantial in patients with suspected SO dysfunction. These observations would suggest that, unlike the traditional view, BPS is rarely secondary to biliary lithiasis. Therefore, most of the sphincterotomies performed that are based on the assumption of underlying SO pathology should be considered unnecessary. Under these circumstances, the physiological role of a functioning SO has induced us to advocate sphincterotomy, surgical or endoscopic, in selected cases only.     

Good outcome in prune-belly syndrome despite associated severe anomalies

A boy aged 4.5 years with prune-belly syndrome (PBS) and associated urethral stenosis, oligohydramnios, imperforate anus and vesicosigmoid fustula is described. In contrast to the anticipated poor prognosis, vesicostomy and divided transverse colostomy performed after birth followed by prophylaxis of infection and bicarbonate supplementation have resulted in a good outcome. The vesicosigmoid fistula might have served in utero as a natural diversion protecting from pressure-induced renal damage. It is suggested that the main determinant of prognosis in PBS is the presence and degree of kidney dysplasia at birth as reflected by the neonatal renal function after performance of an indicated urinary diversion procedure rather than the presence of severe associated anomalies.Supported in part by grants from the National Institute of Health AM 37223-01 and the Medical School and Graduate School Research Committees of the University of Wisconsin and a Research Career Development Award KO4 AM 00421 (RWC), by the Pearl M. Stetler Foundation (SD) and by a National Kidney Foundation fellowship (IZ)     

Influence of a single dose of captopril on pulmonary haemodynamics and right ventricular function in mitral stenosis with pulmonary hypertension

Summary The response of the pulmonary circulation to captopril 75 mg has been examined in 21 patients with pulmonary hypertension secondary to mitral stenosis. The effects of captopril were measured every 15 min up to 2 h by recording pressures in the pulmonary and systemic circulations and by measuring cardiac output.Pulmonary artery systolic pressure fell significantly by 21.6% (from to 42.8 mm Hg), pulmonary artery diastolic pressure by 23.3% (from 26.2 to 20.1 mm Hg), and the pulmonary artery mean pressure by 23.2% (from 36.9 to 28.3 mm Hg). Right ventricular end-diastolic pressure also fell significantly by 7% (8.1 to 7.5 mm Hg). Heart rate decreased by 6.5% (from 76.3 to 71.3 beats·min^–1). Cardiac index and stroke volume index did not change. The total and vascular pulmonary resistance dropped significantly by 23.2% (from 721 to 553.7 dyn·s·cm^–5) and 40% (from 287.2 to 172 dyn·s·cm^–5), respectively. The right ventricular stroke work index fell by 33% (from 15.1 to 10.1 g/beat/m²). Systemic systolic pressure decreased by 10.5% (from 124.5 to 111.4 mm Hg). Thus, captopril lowered pulmonary pressures and resistances and no deterioration in right ventricular function was observed.     

Anaesthetic experience with paediatric interventional cardiology

Anaesthetic and sedation techniques, complications and outcomes were reviewed in 176 children undergoing 184 interventional cardiologic procedures. Techniques included sedation only, and ketamine, inhalational or narcotic anaesthesia. Ketamine infusion was the technique most frequently used. Ketamine was associated with a higher incidence of respiratory complications (P < 0.05) than the other techniques. The higher incidence of hypercarbia (15.6 per cent), which did not affect outcome, may be attributable to the use of supplemental sedatives. The incidence of upper airway obstruction (7.8 per cent) was similar to that of previous studies. Vascular compromise resulted from the procedure in 33 patients, necessitating surgical correction in 16. Cardiac perforation occurred in four cases, causing one death. Pulmonary valve stenosis was most amenable to balloon dilatation and aortic valve stenosis least amenable. Ketamine was the anaesthetic agent preferred by cardiologists for use in the catheterisation suite when general anaesthesia was required. Vigilant monitoring by anaesthetic staff is necessary during the procedure, and avoidance of concomitant narcotics is recommended if a ketamine technique with spontaneous ventilation is used. Les techniques anesthésiques et de sédation ainsi que les complications et les issues ont été revues chez 176 enfants subissant 184 procedures cardiaques. Les techniques ont inctu soil la sédation seulement, soit l’anesthésie à la kétamine, aux agents d’inhalation ou aux narcotiques. La perfusion de kétamine était la technique la plus fréquemment utilisée. La ketamine était associée à une plus grande incidence de complication respiratoire (P < 0.05) comparativement aux autres techniques. La plus grande incidence d’hypercarbie (15.6 pour cent), n’ayant pas affecté l’issue, pourrait être attribuée à l’utilisation additionnelle de sédatifs. L’incidence d’obstruction des voies aériennes supérieures (7.8 pour cent) était similaire aux études préalables. Un problème vasculaire suite à la procédure fut observé chez 33 patients dont 16 ont requis une correction chirurgicale. Une perforation cardiaque est survenue dans quatre cas provoquant le décès d’un seul patient. La sténose de la valve pulmonaire était la procédure la plus susceptible d’être dilatée et la sténose de la valve aortique la moins susceptible. La kétamine était l’agent anesthésique préféré par les cardiologistes lors des cathétérisations quand une anesthésie générate était requise. Une surveillance vigilante par une équipe anesthésique fut nécessaire durant la procedure. Il faut aussi éviter l’administration de narcotiques si la kétamine est administrée en respiration spontanée.

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Presented in part at the Canadian Anaesthetists’ Society annual meeting in Halifax, June 1988.     

Identification of the three-element windkessel model incorporating a pressure-dependent compliance

A new one-step computational procedure is presented for estimating the parameters of the nonlinear three-element windkessel model of the arterial system incorporating a pressure-dependent compliance. The data required are pulsatile aortic pressure and flow. The basic assumptions are a steadystate periodic regime and a purely elastic compliant element. By stating two conditions, zero mean flow and zero mean power in the compliant element, peripheral and characteristic resistances are determined through simple closed form formulas as functions of mean values of the square of aortic pressure, the square of aortic flow, and the product of aortic pressure with aortic flow. The pressure across as well as the flow through the compliant element can be then obtained so allowing the calculation of volume variation and compliance as functions of pressure. The feasibility of this method is studied by applying it to both simulated and experimental data relative to different circulatory conditions and comparing the results with those obtained by an iterative parameter optimization algorithm and with the actual values when available. The conclusion is that the proposed method appears to be effective in identifying the three-element windkessel even in the case of nonlinear compliance.     

Some epidemiological aspects of pyloric stenosis in British Columbia

The records of an ongoing Health Surveillance Registry that utilizes multiple sources of ascertainment were used to study the incidence rate of infantile hypertrophic pyloric stenosis (IHPS) in liveborn children in British Columbia during the period 1966–1977 inclusive. The incidence was 4.6 males/1,000 livebirths and 1.2 females/1,000 livebirths, giving a male to female ratio of 3.1 to 1. No significant overall incidence variations with time could be shown during the study period. There was suggestive evidence of independent sex-incidence variation in different geographical regions, which clearly warrants further investigation.     

动脉导管溶栓治疗急性肢体动脉栓塞14例分析

目的 探讨动脉导管溶栓治疗急性肢体动脉栓塞的方法和疗效。方法回顾性分析14例肢体动脉栓塞的诊断方法和介入手术治疗方案。结果治愈11例，治愈率78．6％(11／14)；2例好转。无患肢缺血坏死或截肢，无术后因肾功能衰竭死亡。结论动脉导管溶栓是治疗急性肢体动脉栓塞有效的方法，值得进一步开展和探索。     

Hydrocephalus induced by immunological blockage of the subcommissural organ–Reissner's fiber (RF) complex by maternal transfer of anti-RF antibodies

Stenosis of the cerebral aqueduct seems to be a key event for the development of congenital hydrocephalus. The causes of such a stenosis are not well known. Overholser et al. in 1954 (Anat Rec 120:917-933) proposed the hypothesis that a dysfunction of the subcommissural organ (SCO) leads to aqueductal stenosis and congenital hydrocephalus. The SCO is a brain gland, located at the entrance of the cerebral aqueduct, that secretes glycoproteins into the cerebrospinal fluid that, upon release, assemble into a fibrous structure known as Reissner's fiber (RF). By the permanent addition of new molecules to its rostral end, RF grows and extends along the aqueduct, fourth ventricle, and central canal of the spinal cord. The immunological blockage of the SCO-RF complex has been used to test Overholser's hypothesis. The following was the sequence of events occurring in pregnant rats that had been immunized with RF glycoproteins: the mother produced anti-RF antibodies and transferred them to the fetus through the placenta and to the pup through the milk, and the antibodies reached the brain of the fetus and pup and blocked the SCO-RF complex. This resulted in a permanent absence of RF that was followed by stenosis of the cerebral aqueduct, and then by the appearance of hydrocephalus. The latter was patent until the end of the 6-month observation period. The chronic hydrocephalic state appeared, in turn, to induce new alterations of the SCO. It is concluded that a selective immunological knock out of the SCO-RF complex leads to hydrocephalus.     

Gestörte alpha2-Adrenozeptorfunktion bei Hämodialysepatienten mit renaler Anämie — eine mögliche Ursache der Blutdrucksteigerung unter rekombinantem humanem Erythropoietin?

Summary Nine patients on maintenance hemodialysis and transfusion-demanding renal anemia (group A) were treated with rHuEPO 120 IU/kg i.v. three times per week. Hemoglobin-content was raised from 7.2±0.9 to 10.4±0.8 g/dl. In all patients blood pressure rose, three patients developed arterial hypertension. Mean diastoloic blood pressure was 66±12 and 78±16 mmHg (p<0.001) before and after rHuEPO. Rise in blood pressure was accompanied by a significant fall in plasma-noradrenaline-levels (from 498±100 to 383±75 pg/ml;p<0.05) and alpha₂-adrenoceptor-density (from 574±76 to 384±49;p<0.05). Compared to nine patients on maintenance hemodialysis and hematocrit over 30% (group B), patients with severe renal anemia (group A before treatment) had higher densities of alpha₂-adrenoceptors (574±76 vs. 218±32;p<0.001) despite higher plasma-noradrenaline-levels (498±100 vs. 399±63; n.s.). We suppose a anemia-related disturbance of alpha₂-receptor-function with the result of abolished receptor down-regulation and impaired vascular reagibility to vasoconstricting stimuli. With the correction of anemia receptor-function improves, receptor down-regulation as well as vascular reagibility is re-established resulting in augmented vascular resistance and higher blood pressure.

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Abkürzungen rHuEPO rekombinantes humanes Erythropoietin - teMAP mittlerer arterieller Blutdruck - RR Blutdrucknach RIVA-ROCCI - RBF regionaler Blutfluß - RPR regionaler peripherer Widerstand