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PubMed1987

[Surgical treatment of obesity].

Morbid obesity is a disease of modern society. Surgery is indicated when there is no endocrinopathy, medical treatment failed and Body Mass index (W/H2) is more than 40 (III degree obesity of Garrow). Many different methods were suggested in connection with the type of obesity, the associated diseases and the psychical state of the patient. Jejuno-ileal by-pass intend to produce a generic malabsorption syndrome. Personal experience is however good, possibly due to the blind loop jejunostomy that we always prepare as a conclusion of the operation and which gives an excellent support for the early post-operative time.

Adult↗
PubMed1975

[Liver damage following intestinal by-pass surgery for weight reduction].

The jejuno-ileal bypass for weight reduction can hardly be considered a non-specific treatment: 3-4% of the patients develop chronic hepatic damage, 1-2% suffer hepatic failure due to massive fatty liver, rapidly progressing liver cirrhosis or hepatic fibrosis. Fatty liver is an invariable sequel of this operation. Once the above-mentioned symptoms set in or an incipient cirrhosis or fibrosis is diagnosed, immediate restoration of normal passage is required. The intestinal bypass syndrome observed in the patient (fem.) (viz. table 1) does not wholly coincide with the enteral bile acid loss syndrome occurring in extensive ileum resection (56) where usually there is no evidence of fatty liver, icterus, cholestasis or encephalopathy. Animal experiments seem to confirm that the blind loop in the broadest sense of the term is responsible for the sometimes fatal hepatic damage. Possibly we are confronted here with a pattern of hepatic damage due to toxic nutritive effects similar to cirrhosis as a sequel of low-protein and low-calorie intake or to the phenomenon observed in animal experiments. The cholestasis confirmed by biopsy and chemical methods is a manifestation of these hepatic disorders. The clinical aspects resemble the Reye syndrome that we know in pediatrics. Patients have to be carefully selected and informed about possible postoperative damage; a continuous clinical follow-up with biopsy of the hepatic tissue is also indicated.

Adult↗
PubMed1989

The influence of small bowel contamination on the pathogenesis of bowel obstruction.

Altered motility of the intestine after laparotomy, adynamic bowel segments, blind bowel loops following bypass operations, or diverticula may cause pathological growth of intestinal microflora and thus lead to contaminated small bowel syndrome (CSBS). As a result of malabsorption in the jejunum and ileum, loss of weight, growth arrest, diarrhea, steatorrhea, megaloblastic anemia, and hypoproteinemia may occur. In addition to these, the acute symptoms of small bowel contamination, intestinal obstruction and secretory diarrhea, are less well known. A stenosis in the terminal ileum was experimentally created in Göttingen minipigs and the bacterial flora of the small bowel assessed by quantitative cultures. After 3 months the number of aerobic and anaerobic bacteria in the pre- and poststenotic region had increased by a factor of 10(2)-10(5). The acute form of CSBS was diagnosed by microbiological examination of gastric samples in 14 children. After the children were treated with orally and intravenously administered antibiotics, the symptoms disappeared within 12-36 h. Reoperations for small bowel obstruction can be avoided by conservative treatment of CSBS with antibiotics.

Bacterial Infections↗
PubMedDate not supplied

Metabolic problems after gastric surgery.

The findings on dumping syndrome (DS) are not consistent considering its relations with age, sex, weight/height, smoking habits, race, dose of oral glucose, the time elapsed since surgery, the function of exocrine pancreas nor the duration of ulcer symptoms. The patients after total gastrectomy (TG) may present relative postprandial lack of insulin. As a sign of long-term hyperglycemia elevated HbA1 has been measured in DS patients. Oral galactose test may reveal new features of DS. Abnormalities in splanchnic blood circulation as well as release of intestinal hormones are involved with DS. Dietary habits including fibers, pectin and guar gum, play a central role in the prevention and treatment of DS. In unresponsive cases several operative methods have been applied with success. Alkaline reflux gastritis is most often seen after B II and I reconstructions and after pyloroplasty. Chronic diarrhea follows mostly after truncal vagotomy. Ten to 50% of patients after gastrectomy (GE) waste 10 to 20% of their body weight because of decreased food, energy, vitamin and mineral intake caused by eating-related symptoms. Vitamin and mineral supplements, a small snack 20 min before the major meal, digestive enzymes, treatment of colonization with antibiotics and protein foods may help. About 50% of GE patients show iron deficiency anemia. Easily dissolved iron between meals with ascorbic acid give the most effective response. Deficiency of vitamin B12 or of folate may develop as megaloblastic anemia. B12 supplement and antibiotics are effective in bacterial overgrowth, but surgical correction is necessary in troublesome blind loop. Folic acid deficiency is corrected by oral folic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

Dumping Syndrome↗
PubMed1991

Effect of enteric pacing on intestinal motility and hormone secretion in dogs with short bowel.

The present study was designed to examine the role of electrode position during retrograde pacing in dogs with short bowel syndrome and unsevered intact duodenum. In nine beagle dogs a subtotal resection of the small bowel and jejunoileostomy was performed. In five of these dogs, an isolated blind loop (jejunum) with preserved mesenteric connections was left in situ as an additional place for a stimulation electrode. Small intestinal motility and plasma levels of insulin, glucagon, gastrin, somatostatin, and glucose were examined during pacing of the residual jejunum or the isolated loop, respectively, compared with control experiments in the same dogs without pacing. During pacing of the loop a significant (P less than 0.05-0.01) decrease in the postprandial small intestinal motility index was observed combined with a significant (P less than 0.05) increase in plasma insulin levels, whereas the postprandial increase in glucagon, somatostatin, gastrin, and glucose levels was not different from that in controls. In contrast, pacing of the jejunum increased postprandial small intestinal motility index (less than or equal to 68%), whereas the levels of the four hormones and plasma glucose were not different from those in controls. The data suggest that in dogs with intact duodenum, pacing on an excluded loop is required to obtain the desired effect of reduced intestinal motility and improved anabolic pancreatic hormone secretion.

Animals↗
PubMedDate not supplied

Blind pouch syndrome secondary to gastrojejunostomy. Report of a case.

A case of blind pouch syndrome following a Roux-en-Y reconstruction after gastrectomy is presented. The patient had a history of pain, anaemia and weight loss and the diagnosis was made on the basis of upper gastrointestinal barium contrast radiography. The surgical procedure was an entero-entero anastomosis between the blind loop and the efferent loop. The postoperative course was uneventful. No symptomatic recurrence was found at one-year follow-up. We advocate this procedure as a valid alternative to resection in cases where the blind loop is not damaged by chronic dilatation. The aim of this operation is to maintain the preferential gastric emptying route via the blind loop in order to prevent recurrence on the stump, and reduce loop isolation in order to minimise ischemic or stenotic damage to the anastomosis.

Adult↗
PubMed1988

[Studies on the relation between late dumping syndrome and glucagon responses to glucose].

This study was planned in pursuit of the relation between glucagon responses to glucose and the late dumping syndrome. Clinically, 75 g oral glucose tolerance test to seven late dumpers, ten gastrectomized patients and ten normal subjects were performed. And experimentary, 20 ml 25% glucose was put into small intestinal blind loops prepared in dogs, which were made the jejunum region and then the ileum region. 1. The mean oral glucose tolerance curve in gastrectomized patients was oxyhyperglycemic, and this tendency was seen in late dumpers. But, for only late dumpers, the low blood glucose concentration which was under 50 mg/dl appeared within one and half to three hours after oral glucose load. 2. The change of serum IRI in gastrectomized patients displayed the initial hyperinsulinemia, that was similar in late dumpers. 3. Pancreatic glucagon (GI) levels were within normal limits in normal subjects and late dumpers, but were significantly increased in gastrectomized patients. 4. Enteroglucagon (gutGLI) levels were not so increased in normal subjects, but were significantly increased in gastrectomized patients and late dumpers as well. 5. GutGLI levels were increased only by putting into the ileum loop. But hypersecretion of gutGLI did not affect the blood glucose curve and the change of serum IRI significantly. These results described above suggest that the pathogenesis of the hypoglycemia in the late dumping syndrome may be responsible for no hypersecretion of GI, for some reason, to prevent hypoglycemia against hyperinsulinemia with oxyhyperglycemia, and that gutGLI may not play so important part in the regulation of the blood glucose level.

Aged↗
PubMed1998

Clinical models of intestinal adaptation.

Mucosal adaptation of the small intestine is morphologically restricted to only three different patterns, namely, atrophy, hyperplasia, and hyperregeneration. The hyperplastic mucosa in the experimental short bowel syndrome exhibits unchanged epithelial barrier properties and a differential functional adaptation with a 150% increase in Na-glucose cotransport but no change in electroneutral NaCl cotransport. In the hyperregeneratively transformed mucosa of the self-filling blind loop of rat jejunum, absorption is seriously impaired, as indicated by the 80% decrease in Na-glucose cotransport. To compensate for this, epithelial barrier function is upregulated by an increase in tight junction complexity to prevent leak flux of ions and substrates. In contrast, the hyperregeneratively transformed mucosa in celiac sprue shows reduced tight junction complexity. Possible candidates responsible for the heterogeneity of tight junction adaptation in these conditions could be cytokines, because tumor necrosis factor-alpha can specifically downregulate the tight junction, as indicated in the intestinal HT-29/B6 cell model.

Animals↗
PubMed1980

[Roentgenologic aspects after (total) gastrectomy for malignant tumours (author's transl)].

Pre-operatively, radiological examination is important for the diagnosis of malignant tumours in the stomach. Postoperatively, it can be used to demonstrate the state of the anastomosis and possible defects of the suture, for the early recognition of recurrences or other abnormalities, and for the diagnosis of reflux oesophagitis and the dumping syndrome. Changes in the oesophagus following various types of reconstruction were examined, both clinically and radiologically, in 40 patients who had had gastrectomies. Following jejunal interposition with a proximal end-to-side anastomosis and a long blind segment, there may be reflex into the oesophagus, but symptoms of reflux oesophagitis only occur if there is also duodeno-jejunal reflux. Patients with a Roux loop show few symptoms, while the worst radiological and clinical results were achieved with a double-barrelled jejunal loop, despite a low anastomosis.

Adult↗
PubMed2004

Vaginal construction using sigmoid colon in children and young adults.

OBJECTIVE: To evaluate the age at which patients who required vaginal replacement (an uncommon procedure in children) were diagnosed, and the cause of their anomaly, and to relate these variables to the surgical outcome. PATIENTS AND METHODS: Patients who had vaginal replacement at the author's institution between 1990 and 2002 were reviewed retrospectively. Depending on the age at reconstructive surgery, patients were divided into pre- and postpubertal groups. RESULTS: A neovagina was constructed in 23 patients during the study period; sigmoid colon was used in 20 but not in two patients with cloacal exstrophy and in one with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS). These cases were excluded from the analysis of outcomes and complications. Group 1 comprised patients diagnosed and treated before puberty and group 2 those diagnosed and/or treated afterward. In group 1 the presenting diagnoses included androgen insensitivity syndrome (AIS) in six patients, MRKHS in two, cloacal exstrophy in two, vaginal tumour in one, Müllerian duct renal aplasia cervicothoracic somite dysplasia, vertebral abnormalities, anal atresia, cardiac anomalies, tracheo-oesophageal fistula, and/or oesophageal atresia, renal abnormalities and limb defects syndromes in one each. In group 2 the presenting diagnoses included MRKHS in seven, AIS in two, and congenital adrenal hyperplasia in one. Complications included superficial wound infection (two patients), recurrent introital stenosis, and blind loop mucocele, complete stenosis of perineal neovaginal opening (one each) and dyspareunia in three. Neither age nor pelvic habitus (android vs gynaecoid) influenced the outcome, and the cosmetic results were excellent in all the patients. CONCLUSION: Isolated sigmoid neovaginal construction appears to be applicable to many diagnoses and in patients at any age. Although an android pelvis can present technical challenges, in this experience it was not associated with a greater complication rate. The long-term satisfaction with the sigmoid neovagina for intercourse, especially in those constructed before puberty, still requires long-term evaluation.

Adolescent↗
PubMed1979

Measurement of 4-hydroxyphenylacetic aciduria as a screening test for small-bowel disease.

We evaluted measurement of urinary 4-hydroxyphenyl acetic acid as a potential screening method for small-bowel disease and bacterial overgrowth syndromes in 360 unselected acutely ill infants and children. Control data were obtained on 120 healthy children, ages 1.5 to 15 years, from a general medical practice, 48 healthy infants, ages one to five years, from local day nurseries, and 150 healthy babies, ages less than one to eight days. Comparative data were from 300 acutely ill hospitalized babies and children, ranging in age from less than one day to 15 years and without clinical evidence for small-bowel disease and bacterial overgrowth syndrome. No false-negative results and only 2% false-positive results were observed. Among the 10 patients whose urinary excretion of the analyte was considered to be abnormal were patients with Giardia lamblia infestation, ileal resection with blind loop, and other diseases of the small intestine associated with bacterial overgrowth. We conclude that measurement of 4-hydroxyphenylacetic acid excretion is useful in screening for such diseases.

Adolescent↗
PubMed1975

Clostridium septicemia following biliary surgery in a gastrectomized patient.

A 75-year-old woman was subjected to biliary surgery 38 years after partial gastrectomy for ulcer. There was a history of gallstones of 10 years duration, pentagastrin-resistant achylia, cholecystolithiasis and choledocholithiasis complicated by stenosis of papilla of vater, cholecystitis and pancreatitis. Peroperative cholangiography and biliary tract surgery were performed. On the third postoperative day heavy jaundice and hemolysis developed, leading to death of the patient. Culture of bile taken at operation revealed strains of Clostridium perfringens and Escherichia coli. Autopsy showed a picture of gas gangraena of the liver and Clostridium septicemia. The role of achylia, blind loop, and biliary obstruction in bile surgery is stressed.

Aged↗
PubMed1976

Effectiveness of bumetanide in nephrotic syndrome: a double-blind crossover study with furosemide.

A double-blind crossover study was undertaken to delineate the renal tubular sites of action of bumetanide and to compare its effects upon electrolyte excretion to that of furosemide in six nephrotic patients with various degrees of renal insufficiency. Bumetanide was found to be a potent oral natriuretic agent without producing changes in either GFR or effective renal plasma flow. The natriuresis was associated with inhibition of proximal tubular transport as evidenced by an increased distal delivery (CH2O+CNA+K) and inhibition of sodium transport in the loop of Henle as shown by a fall in CH2O/CH2O+CC1 during sustained water diuresis and an unchanged TCH2O with continued hydropenia. The increases in free-water clearance induced by furosemide and bumetanide were equivalent, but bumetanide produced significantly higher flow rate, greater solute delivery from the proximal tubule, and a greater natriuresis. The data indicate that at the dosages used, bumetanide has a proportionately greater inhibitory effect than furosemide in both the proximal tubule and the ascending limb of the loop of Henle.

Adolescent↗
PubMed1986

Diagnostic significance of nailfold capillary patterns in patients with Raynaud's phenomenon. An analysis of patterns discriminating patients with and without connective tissue disease.

Nailfold capillary patterns were systematically evaluated in 51 controls and 107 patients with Raynaud's phenomenon (RP) by 2 observers. Fifty patients had primary RP, 18 RP with minor signs of connective tissue disease, and 39 secondary RP (scleroderma, CREST syndrome or mixed connective tissue disease [MCTD]). Nailfolds of all 10 fingers were photographed and blindly evaluated. Qualitative and quantitative scoring of patterns was reproducible. The 4th finger showed the fewest nonevaluable photomicrographs and best distinguished primary from secondary RP. Capillary morphology in primary RP did not differ from controls. A decrease in capillary loops best distinguished primary from secondary RP. Addition of the scores for bushy patterns, extravasates, or giant loops led to better discrimination. No item allowed distinction between different connective tissue diseases. The number of enlarged loops was inversely related to the total number of capillary loops (r = 0.55; p less than 0.01).

Adult↗
PubMed1986

Determination of the earliest site of ventricular activation in Wolff-Parkinson-White syndrome: application of digital continuous loop two-dimensional echocardiography.

Surgical and transcatheter ablation of accessory atrioventricular (AV) connections (Wolff-Parkinson-White syndrome) requires accurate localization of the accessory pathway. In a canine model of endocardial pacing, a continuous loop two-dimensional echocardiographic technique was developed for determining the earliest site of ventricular activation. This technique was then used to localize accessory AV connections in patients. Echocardiographic images were acquired on videotape and converted to a digital continuous loop format, from which the earliest site of systolic motion was determined. In six dogs, using six distinct endocardial sites, two blinded observers accurately identified the earliest site of ventricular activation in 31 (86%) of 36 and 32 (89%) of 36 locations. Determination of the earliest site of ventricular activation with the continuous loop digital technique was superior to standard analog analysis in overall accuracy (p less than 0.02) and in intraobserver variability (p less than 0.004). After validation of this technique, 21 patients with 22 accessory AV connections with anterograde conduction were studied. The earliest site of mechanical activity was determined during sinus (10 patients) or atrial paced (11 patients) rhythms by two blinded observers and compared with electrophysiologic mapping and surface electrocardiograms. Digitally processed echocardiograms correctly localized the earliest site of ventricular activation in 18 of 22 connections and predicted an adjacent location in the remaining 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2004

The calcium sensitizer levosimendan improves the function of stunned myocardium after percutaneous transluminal coronary angioplasty in acute myocardial ischemia.

OBJECTIVES: We assessed the effects of levosimendan on left ventricular (LV) function in patients with acute myocardial ischemia and after coronary angioplasty. BACKGROUND: The calcium sensitizer levosimendan improves the function of myocardium in experimental stunning. METHODS: Twenty-four patients with an acute coronary syndrome underwent angioplasty followed by double-blinded, randomized treatment with 24 microg/kg of levosimendan (n = 16) or placebo (n = 8). Left ventricular pressures and volumes were recorded by cineventriculography and micromanometer-tipped catheters 10 min after angioplasty before drug administration (baseline) and 20 min after drug administration. Left ventricular function was assessed by the pressure-volume loop, and regional function analysis by the Slager method. RESULTS: The number of hypokinetic segments decreased with levosimendan, from 8.9 +/- 0.9 to 6.5 +/- 1.1 (mean +/- SEM), as compared with an increase from 7.8 +/- 1.0 to 8.5 +/- 1.1 with placebo (p = 0.016). A leftward and/or upward shift of the systolic part of the pressure-volume loop, indicating improved systolic function, was observed in eight of 16 of the levosimendan-treated and one of eight of the placebo patients (p = 0.178). In addition, the single-beat elastance was increased by levosimendan (p = 0.045). The pressure-volume area (p = 0.001), end-systolic pressure (p = 0.002), and volume index (p < 0.001) were decreased by levosimendan, but there was no change in the end-systolic pressure-volume ratio. End-diastolic pressure remained unchanged, whereas the end-diastolic volume index was decreased by levosimendan (p = 0.002). The time constant of isovolumic LV pressure fall decreased with levosimendan (p = 0.001). CONCLUSIONS: Levosimendan improved the function of stunned myocardium without obvious impairment of diastolic function.

Acute Disease↗
PubMed1979

[Heitis terminalis promoting cancer (author's transl)].

The increasing number of publications about the incidence of cancer in small intestine with Crohn's disease shows Ileitis terminalis as an affection promoting cancer. Main problems are early diagnosis and differential diagnosis concerning intestinal stenosis caused by Crohn's recidivation or blind loop after resection. Regular scrutiny of patients with Crohn's disease is of special significance; because of the few present case reports early resection as prophylaxis is not justified.

Adenocarcinoma↗
PubMed1994

[Motility disorders in the blind loop after Roux-en-y reconstruction. Electromyography studies in the animal experiment].

Disturbances of intestinal motility, bacterial overgrowth and pancreocibal asynchrony are frequent findings in patients after Roux-en-y reconstruction (RYR). In dogs (n = 6) electromyographic recording of motility after partial gastrectomy with Roux-en-y reconstruction revealed no significant differences from controls in the Roux limb. However, changes in intestinal motility were extensively in the blind loop. The electromyographic pattern was characterized by an extreme loss of activity in the fasted and postprandial state. The activity front of the migrating motility complex occurred only in 25% of the fasting studies and was not correlated in time with motility patterns of connected small intestine. Food intake led to a significant increase in the motility index in the Roux limb (60.2 +/- 10.5), but not in the blind ending loop (27.8 +/- 4.1). Pharmacological stimulation of the hypomotile blind loop with cisapride is successful: increase of the motility index to 111.2 +/- 16.5. It might be useful in the treatment of symptomatic patients after RYR.

Anastomosis, Roux-en-Y↗