[Successful treatment of secondary aortoesophageal fistula after thoracic endovascular aortic repair]

HISTORY AND CLINICAL SYMPTOMS: A 58-year-old man was admitted to our hospital with acute chest pain and subfebrile temperatures. Two years ago, endovascular aortic stent-graft placement had been performed for acute type B aortic dissection complicated by malperfusion syndrome.

DIAGNOSTIC ASSESSMENT

CT angiography showed a discrete soft-tissue attenuation mass between the aorta and esophagus. The patient developed progressive swallow disorder and esophago-gastro-duodenoscopy demonstrated deep esophageal ulcerations at the level of the implanted aortic stent-graft. Intravenous treatment with broad spectrum antibiotics was started. The FDG-PET/CT scan showed increased FDG uptake and air entrapment in the affected region establishing the diagnosis of aortoesophageal fistula formation.

THERAPY AND OUTCOME

Given the generally poor condition of the patient and the high risk of any aggressive surgical intervention, a new limited surgical approach was chosen consisting of open transthoracic esophageal resection, blind closure of the stomach and cervical esophagostomy. A percutaneous endoscopic gastrostomy tube was placed. After three months, esophageal continuity was restored by retrosternal colon interposition. The presented therapeutic management resulted in a full recovery of the patient.

CONCLUSION

Aortoesophageal fistula is a rare complication of thoracic aortic stent-graft placement. Patient may present with unspecific symptoms such as fever and rised inflammatory markers, but may also present with massive upper gastrointestinal bleeding. The herein presented limited therapy with esophageal resection represents a promising to the otherwise difficult therapy of aortoesophageal fistula.

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration.

RESULTS

Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively.

CONCLUSIONS

The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

[Frequency of decubitus ulcer in patients of a university medical center. Combination of routine documentation and cross-sectional study]

BACKGROUND AND OBJECTIVE

Pressure ulcer is a relevant issue for quality management and cost containment of hospitals. Cross-sectional studies are the typical design to estimate the frequency of pressure ulcers. The derived point prevalence rate is not as good for a case related reference value as the period prevalence rate. The interdisciplinary pressure ulcer project at the University Clinics in Essen combined a routine documentation with a cross-sectional survey, thus providing both measurements for the first time.

PATIENTS AND METHODS

The routine and computer-based collection of information about pressure ulcers started in March 2003, using the patient administration system medico//s from Siemens. Findings are presented from 49,904 admissions, starting on 91/03/2004, discharged by 31/03/2004. The mean age was 48.7 +/- 22.4 years; 51.2 % were males, 48.8 % females. Additionally, a decubitus team examined patients from randomly selected wards each work-day. The real period prevalence rate was calculated using the observed period prevalence rate, the sensitivity and the point prevalence rate.

RESULTS

In the routine documentation, 700 pressure ulcers had been recorded from 49,904 inpatient cases (period prevalence rate 1.4 %). The decubitus team did 5,415 examinations and 294 times detected at least one pressure ulcer (point prevalence rate 5.4 %). Estimated results in three different period prevalence rates: 3.0 % using sensitivity of the routine documentation, 3.7 % using sensitivity stratified for departments, and 2.3 % using the point prevalence rate for cases with short, medium, and long length of stay.

CONCLUSIONS

The project presents for the first time reference values for pressure ulcer frequency in university clinics. A comparison with international rates is hindered by unpublished sensitivity values. In view of the higher point prevalence rate of 10 % present in the literature, a period prevalence rate of 5 % is a realistic reference value.

Frostbite in a mountaineer

Cold injury is an objective danger in mountain climbing as well as in many outdoor sports. With increasing number of people practising so-called extreme tourisms physicians can be confronted with frostbite. Thus we present a case of frostbite in a 35 year-old female mountaineer. She took part at a demanding high alpine trekking tour in the Himalayan-area requesting well trained mountaineers experienced in ice- and securing-techniques and good physical condition. At day 12, when the group reached the top of the Parchamo (Nepal, 6273 m), she developed frostbite at all toes leading to amputation finally. Risk factors, prognosis and options for initial treatment are discussed.

Pancreatic secretory response to intraileal amino acids: studies in dogs with an in situ neurally isolated ileum

BACKGROUND

Intraileal carbohydrates and lipids affect the pancreatic exocrine secretion, but the effect of intraileal amino acids and the role of the extrinsic nerves of the ileum as mediators of the pancreatic bicarbonate and enzyme output are unknown.

METHODS

Four dogs underwent total extrinsic denervation of the entire ileum. Thomas-like cannulas were placed into the stomach, duodenum (to collect pure pancreatic juice), and at the jejuno-ileal junction. Eight neurally intact control dogs received only the three fistulas. After recovery, in both sets of dogs, dose-response studies of the pancreatic secretory response to intraileal infusion with graded loads of tryptophan (0.12-10.0 mmol/h) were performed, given against an intravenous (iv) background of secretin (20.5 pmol/kg/h) and cerulein (29.6 pmol/kg/h). On separate days, control experiments with intraileal infusion of 0.15 M NaCl were performed.

RESULTS

In both sets of dogs, iv secretin plus cerulein significantly (p < 0.05) increased pancreatic bicarbonate and protein output above basal. Intraileal tryptophan caused a dose-dependent decrease in the pancreatic bicarbonate and protein response to secretin plus cerulein. In the dogs with denervated ileum, this inhibition was significantly stronger than in the intact animals. In both sets of dogs, the 225-min integrated bicarbonate (IBR) and protein response (IPR) to all loads of tryptophan were significantly lower than in control experiments. Both IBR and IPR were significantly lower in the denervated as compared with the intact animals.

CONCLUSIONS

1) Extrinsic denervation of the entire ileum is a valuable preparation to study the role of nerves in the control of pancreatic exocrine secretion; 2) both in the intact and denervated animals the amino acid tryptophan induces an "ileal brake" of the hormonally stimulated pancreatic bicarbonate and protein output; 3) the extrinsic nerves of the ileum are probably not the dominant mediators of the inhibitory action of intraileal tryptophan but rather counteract this effect.

[Assessing the quality of life after pancreas-kidney transplantation]

The pancreas-kidney transplantation strives for a reestablishment both of the physiological regulation of blood glucose levels without external insulin and of kidney function without the need of dialysis. Nevertheless, the postoperative morbidity of the combined transplantation is high. In long lasting diabetes type I, a strict selection of transplant candidates is necessary to minimize the risks of cardio-vascular complications. Between 1990 and 1997 only 17 of 44 patients really were accepted for transplantation in our unit. 13/17 patients are actually independent from external insulin and dialysis. Two other patients are free of dialysis, but the pancreas transplants had to be removed due to thrombosis or infection. In one case therapy-resistant acute rejection occurred and both organs had to be removed after two months. One women died four years after transplantation with a functioning kidney graft from myocardial infarction. 10 patients with stable transplant function are at work again. After normal pregnancy two women gave birth to healthy children, in one case twins. Drug regimen and outpatients visits are not seen as significant restrictions of the quality of life.

Pancreatic secretory response to intrajejunal tryptophan: studies in dogs with an autotransplanted entire jejunoileum

In two sets of dogs with gastric, duodenal, and jejunal fistulas, we studied the effect of atropine (14 nmol/ kg/h) on the pancreatic secretory response to intrajejunal tryptophan (0.12-10.0 mmol/h; given against a secretin background) before (n = 7) and after extrinsic denervation of the jejunoileum (orthotopical autotransplantation; n = 6). Plasma levels of cholecystokinin were determined by radioimmunoassay. The incremental bicarbonate response to tryptophan was not significantly different between the two sets of dogs. Atropine had no effect on the incremental bicarbonate response to tryptophan. In both sets of dogs, intrajejunal tryptophan caused a dose-dependent increase in pancreatic protein output, which was reduced by atropine. The tryptophan-stimulated levels of plasma cholecystokinin were not significantly altered by denervation and or atropine. We conclude that in dogs (1) intrajejunal tryptophan stimulates pancreatic bicarbonate and protein secretion via release of hormones, (2) extrinsic denervation of the jejunoileum does not significantly alter the incremental bicarbonate and protein responses to intrajejunal tryptophan, (3) the cholinergic intrinsic nerves of the jejunoileum and the hormone cholecystokinin are probably involved in control of the pancreatic protein response to tryptophan, and (4) the release of cholecystokinin by intrajejunal tryptophan does not depend on the extrinsic and intrinsic cholinergic nerves of the jejunoileum.

[Results of peripheral arterial vascular injury in polytraumatized patients]

The therapeutic concept of limb salvage or immediate amputation is controversial in patients with multiple trauma. Sixty-three multiple trauma patients (injury severity score ISS > 18 patients) with blunt arterial injuries were investigated. Twenty-seven had injuries of the upper limb and 36 patients of the lower limb. In 33 cases a limb salvage procedure was performed (group I), while in 30 cases the limb was amputated (group II). Neither group showed a significant difference in age (I: 33 +/- 3, II: 30 +/- 3 years), ISS (I: 30 +/- 2, II: 29 +/- 2 patients), time of ischemia (I: 238 +/- 30, II: 203 +/- 20 min) ICU stay (I: 18 +/- 4, II: 19 +/- 4 days). Lethality and morbidity were slightly increased in group I (death: I: n = 8; II: n = 4; MOF: I: n = 5; II: n = 3; Sepsis: I: n = 11, II: n = 4). No differences were found in the incidence of local infections (I: n = 12, II: n = 10). Secondary amputations were performed in 7 patients after 12 +/- 2 days (range 3-40; median: 5 days). We conclude that limb salvage did not increase the risk for severe complications. Lethality and morbidity were related to the severity of the injury. To prevent complications, secondary amputations had to be performed early.

Combined preoperative chemotherapy and radiotherapy in patients with locally advanced esophageal cancer. Interim analysis of a phase II trial

PURPOSE

The prognosis of patients with locally advanced esophageal cancer (LAEC) remains poor when treated with local modalities. An intensive preoperative program with chemoradiotherapy was used to evaluate the curative resection rate, pathologic response, and survival of patients with LAEC.

PATIENTS AND METHODS

Ninety patients with LAEC were treated preoperatively with chemotherapy (three courses of fluorouracil, leucovorin, etoposide, and cisplatin [FLEP]) followed by concurrent chemoradiotherapy (one course of cisplatin plus etoposide in combination with 40 Gy of radiation). Transthoracic esophagectomy was performed 4 weeks after the end of radiation.

RESULTS

Seventy-two patients were included in this evaluation. Forty-four (61%) underwent a complete tumor resection, and 16 (22%) had no tumor in the resected specimen (pathologic complete response [PCR]). The operative mortality rate was 15%. At a median follow-up time of 22 months (range, 12 to 41), the median survival duration of all 72 patients was 17 months (range, 1 to 41+). The calculated survival rates at 3 years were 33%, 42%, and 68% for all patients, patients after complete resection, and patients with PCR, respectively.

CONCLUSION

This combined treatment modality is active in LAEC, with a PCR in 33% of the patients undergoing surgery. The results appear improved compared with those reported with surgery alone, by approximately doubling the 3-year survival rate. The high efficacy of preoperative chemoradiation warrants evaluation of the role of surgery in LAEC.

[Liver complications in HELLP syndrome]

In a 5 years period 5 female patients suffering from a severe HELLP syndrome were treated. The problems concerning diagnostic and treatment are discussed. 3 patients had to be operated on in an emergency state. The operations were performed because of acute and severe abdominal bleeding. Two of the patients needed liver transplantation as an emergency procedure, one of them died after hepatectomy on the list. Another one died 7 weeks after successful transplantation in a state of prolonged sepsis. The two conservatively treated and the one transplanted patient are still alive and well.

Acute liver necrosis in the HELLP syndrome: successful outcome after orthotopic liver transplantation. A case report

We discuss the case of a 30-year-old primipara woman who developed a liver rupture as a complication of the HELLP syndrome. A liver necrosis and bleeding made a hepatectomy necessary. A portocaval shunt was able to maintain the patient until she underwent urgent liver transplantation. In an excellent state of recovery, the woman and her baby were discharged from the hospital 66 days after having been admitted.

Acute liver necrosis in the HELLP syndrome: successful outcome after orthotopic liver transplantation. A case report

We discuss the case of a 30-year-old primipara woman who developed a liver rupture as a complication of the HELLP syndrome. A liver necrosis and bleeding made a hepatectomy necessary. A portocaval shunt was able to maintain the patient until she underwent urgent liver transplantation. In an excellent state of recovery, the woman and her baby were discharged from the hospital 66 days after having been admitted.

[Autotransplantation of the kidney. Indications and results]

Renal autotransplantation is an established but rarely used therapy in cases of renal vessel lesions, tumours of the kidney and ureter, long-distance ureter lesions, complex nephrolithiasis and retroperitoneal fibrosis. The indications and results of renal autotransplantation are discussed using three case reports and compared to the literature. In cases of central intrarenal tumours and aneurysms of the kidney, autotransplantation is indispensible in order to save the organ. For long-distance ureter lesions as well as for retroperitoneal fibrosis, autotransplantation of the kidney gives excellent results. In difficult clinical situations ileum segment interposition is an alternative treatment.

[De novo malignant tumors during drug immunosuppression. The findings following 1245 cadaveric kidney transplants in 1080 patients]

Thirty new malignant tumours were found in 1080 patients (634 men, 446 women; mean age 37.6 +/- 13.6 years) after a median follow-up period of 5 years following 1245 cadaveric kidney transplantations performed between 1972 and 1990. The mean dialysis period before transplantation had been 4.0 +/- 3.1 years. Regarding the type of tumour, carcinomas were by far the most frequent, while there was only one lymphoma. The annual malignancy incidence for renal transplant patients was 0.5%. This is 3.5 times higher for men and 4.2 times for women than in the normal population. Immunosuppression with azathioprine and/or antithymocytic globulin (n = 395) produced the same malignancy incidence (0.54%) as with cyclosporin (n = 685; 0.60%). On the other hand, malignant tumours occurred much earlier under cyclosporin than under azathioprine/antithymocytic globulin (27 and 68 months, respectively).

Patterns of prohormone processing. Order revealed by a new procholecystokinin-derived peptide

An 83-amino acid cholecystokinin peptide with a sulfated tyrosine and an amidated carboxyl terminus (CCK-83) was purified from human intestinal mucosa. The purified peptide was chemically characterized, and its bioactivity was compared to CCK-8. Several post-translational processing steps such as cleavage at basic residues, sulfation, and amidation are necessary to form biologically active cholecystokinin from its nascent prepropeptide. The discovery of CCK-83 gives new insight into the order of preprohormone processing. The processing of prepro-CCK appears to be in the order of: 1) signal peptidase cleavage, 2) tyrosine sulfation, 3) cleavage after a carboxyl-terminal pair of basic residues, 4) carboxypeptidase B-like cleavage of these basic residues, 5) amidation (which results in the formation of CCK-83), and 6) cleavage at monobasic residues by endopeptidases (which results in the smaller molecular forms of cholecystokinin). The characterization of biologically active CCK-83 with a sulfated tyrosine and an amidated carboxyl terminus establishes the site of signal peptidase action and suggests an order of post-translational modifications that give rise to the various molecular forms of cholecystokinin.

The use of OKT3 in steroid-resistant rejections following cadaveric kidney transplantation

OKT3 has been proved to be effective in the treatment of steroid-resistant rejection after renal allograft transplantation. We investigated the clinical course of OKT3 recipients to find out in which cases of steroid resistance OKT3 therapy might be ineffective.

Hormonal control of pancreatic secretion by intrajejunal HCl: studies in dogs with an autotransplanted entire jejunoileum

To elucidate the role of hormones in the control of pancreatic secretion, we developed, in seven dogs, a model of total extrinsic denervation of the jejunoileum by autotransplanting this segment of bowel. A Thomas-like cannula was placed into the stomach, the duodenum (to collect pure pancreatic juice), and the proximal part of the jejunum. Thus, intestinal stimulants could only stimulate the pancreas via release of humoral (= hormonal) mediators. Seven control dogs received only the three fistulas. After recovery, dose-response curves of pancreatic bicarbonate and protein response to perfusion of the extrinsically denervated or innervated jejunoileum with HCl (1.5 to 48 mmol h-1) were performed with and without atropine (14 nmol kg-1 h-1 i.v.). Plasma levels of secretin were determined by radioimmunoassay. The maximal bicarbonate output occurred in response to 24 mmol h-1 of HCl and was significantly (p less than 0.05) higher in intact as compared to denervated animals. Atropine only significantly depressed the bicarbonate response to HCl in dogs with a denervated jejunoileum. HCl caused a dose-dependent increase in plasma levels of secretin, which was not altered by denervation and/or atropine. Irrespective of the innervation of the small bowel, pancreatic protein output was only significantly stimulated above basal when high loads (12-48 mmol h-1) of HCl were given. Atropine significantly reduced these responses.(ABSTRACT TRUNCATED AT 250 WORDS)

[Porto-femoro-subclavian bypass and the rapid infusion technique in orthotopic liver transplantation]

Veno-venous bypass during orthotopic liver transplantation is commonly performed as a porto-femoro-axillary bypass. Right-angle positioning of one patient's arm and surgical preparation of the femoral and axillary veins are necessary. In 17 patients and 20 consecutive orthotopic liver transplant procedures the common porto-femoro-axillary veno-venous bypass was substituted by porto-femoro-subclavian bypass with a percutaneous 20 F cannulation set (LAUB catheter, Cook). The 20 F catheter was introduced into the left subclavian vein by Seldinger's technique before the operation and was connected intraoperatively to the outflow tube of the biopump. Surgical preparation of the axillary vein was not performed. In 10 patients a Y-connector was used to connect up the Rapid Infusion System in addition. Postoperatively the catheter was left in place for 2-4 days. Introduction and removal of the catheter were uneventful in all cases. High blood flow through the catheter could be maintained by a low driving pressure of the pump (4000 ml/min; 100 mmHg). No intraoperative complications were observed. Shunt flows remained stable throughout the surgical procedure during the anhepatic stage. There was no bleeding from the puncture site, especially after removal of the catheter, though several patients had a poor coagulatory status in the early postoperative period. Two postoperative complications were observed: air embolism due to disconnection and formation of a thrombus at the catheter tip, which it was possible to remove together with the catheter itself. Installation of an irrigation infusion in the postoperative period and well-tightened connections help avoid such complications as thrombus formation, bleeding or air embolism.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of the cholecystokinin-receptor antagonist lorglumide on pancreatic enzyme secretion stimulated by bombesin, food, and caerulein, giving similar plasma cholecystokinin concentrations in the dog

This study was undertaken to determine the role of cholecystokinin in pancreatic enzyme secretion stimulated by bombesin and a meal by (a) comparing the pancreatic enzyme output during bombesin infusion and after a meal to output during caerulein infusion and (b) comparing the inhibitory effect of the cholecystokinin-receptor antagonist lorglumide (CR-1409) on enzyme output in response to bombesin and food with the response to caerulein. Bombesin (90 pmol/kg per h) and caerulein (30 pmol/kg per h) were infused into seven dogs in doses giving similar plasma cholecystokinin peak increments as a meal (mean (SEM) 6.8 (0.8), 6.3 (1.2), and 5.7 (0.8) pM, respectively), together with either saline or 2 mg/kg per h of lorglumide. A background infusion of synthetic secretin 20.5 pmol/kg per h was given in each experiment. In addition, gastric acid secretion was determined in the experiments with bombesin and caerulein infusion. Pancreatic protein responses to bombesin (1231 (247) mg/h) and food (1430 (220) mg/h) were similar to the responses to caerulein (1249 (201) mg/h). Lorglumide inhibited pancreatic protein output during stimulation with bombesin by 60%, after the meal by 45%, and during caerulein infusion by 68%. Pancreatic bicarbonate output by bombesin, caerulein, and food was inhibited by lorglumide by 28%, 40%, and 38%, respectively. In contrast, lorglumide significantly increased gastric acid secretion from 1.12 to 7.98 mmol/h during bombesin infusion and from 0.52 to 7.62 mmol/h during caerulein infusion. In conclusion, cholecystokinin plays an important part in the stimulation of pancreatic enzyme secretion by bombesin and a meal in conscious dogs and it is involved in the regulation of gastric acid during stimulation by infusions of caerulein and bombesin.

Intrinsic pancreatic nerves after mechanical denervation of the extrinsic pancreatic nerves in dogs

Little is known about the influence of cutting the extrinsic pancreatic nerves on the morphology and function of the intrapancreatic nerves in dogs. For this reason, intrapancreatic nerves of mongrel dogs were studied, using electron microscopy and immunohistochemistry, after truncal vagotomy, after celiac and superior mesenteric ganglionectomy, and after a combination of both operations, i.e., removing all extrinsic nerves of the pancreas. Dogs with intact extrinsic and intrinsic pancreatic nerves served as controls. Studies were performed 1-2 weeks and up to 5 months after one or both denervation procedures. For immunohistochemical and electron microscopic studies the animals were perfused with glutaraldehyde-formaldehyde-picric acid solution and the tissue was embedded in Epon or paraffin. Both immunohistochemical and electron microscopic studies revealed that signs of degenerating intrapancreatic nerves occurred only in the early phase (up to 30 days) after operation. After 60 days, hypertrophy of pancreatic nerve fibers was observed. The most striking finding was that the integrity of the intrapancreatic ganglia and nerves was almost preserved after complete extrinsic denervation. In controls there was a strong intrapancreatic innervation with vasoactive intestinal polypeptide (VIP) and peptide histidine isoleucine (PHI), substance P (SP), and neuropeptide Y (NPY) nerves. SP and NPY-nerves significantly decreased after the different denervation procedures, but the other peptidergic nerves were not altered by truncal vagotomy, ganglionectomy, or the combination of both procedures. We conclude that the dog pancreas contains extensive intrinsic peptidergic nerves, which, with the exception of SP and NPY-nerves, are greatly independent of the integrity of the extrinsic nerves.

Coeliac ganglionectomy

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Role of cholecystokinin in bombesin- and meal-stimulated pancreatic polypeptide secretion in dogs

This study was undertaken to delineate the role of cholecystokinin (CCK) in bombesin- and meal-stimulated pancreatic polypeptide (PP) secretion in seven conscious dogs by studying: (1) the stimulatory effect of similar plasma levels of CCK induced by a meal and infusions of bombesin and the synthetic CCK analog cerulein on plasma PP, and (2) the inhibition of PP secretion by the CCK-receptor antagonist CR-1409 during these three stimuli. The stimulation of PP secretion during bombesin (11.0 +/- 1.6 nM/hr) and after the meal (8.9 +/- 2.0 nM/hr) were significantly (P less than 0.05) greater than during infusion of the CCK analog cerulein (2.7 +/- 0.4 nM/hr). CR-1409 significantly inhibited the bombesin- and meal-stimulated PP secretion to 2.0 +/- 0.4 nM/hr (81%; P less than 0.05) and 3.1 +/- 1.2 nM/hr (47%; P less than 0.05), respectively, while the cerulein-stimulated PP release was almost abolished to 0.2 +/- 0.1 nM/hr (93%; P less than 0.05) by the drug. These findings point to an important role for CCK in the regulation of bombesin- and meal-stimulated PP secretion.

Characterization of the major form of cholecystokinin in human intestine: CCK-58

Acid extracts of human intestines obtained from surgical samples or from organ donors contain cholecystokinin (CCK) immunoreactivity. From surgical samples, extracted and eluted quickly, greater than 75% of the CCK immunoreactivity eluted in the same region as purified canine CCK-58 during analytical reverse-phase high-pressure liquid chromatography (HPLC). A major portion of the CCK immunoreactivity from donor intestinal extracts also eluted in this region. This immunoreactivity has been purified from human intestinal extracts by a series of several reverse-phase and cation-exchange chromatographies. Amino acid and microsequence analysis showed that this immunoreactivity is human CCK-58. Tryptic digestion of purified human CCK-58 produced another immunoreactive form that eluted in the position of CCK-8 during analytical reverse-phase HPLC. The immunoreactivity of the trypsin-digested material was 2.6-fold higher than that of an identical sample of CCK-58 incubated without trypsin. Thus the carboxyl-terminal antibody used for radioimmunoassay cross-reacts greater than twofold less with human CCK-58. This diminished cross-reactivity would lead to an underestimation of the relative proportions of CCK-58 in tissue and plasma extracts. If CCK-58 is the major circulating form this diminished cross-reactivity would also lead to underestimations of the circulating levels of total CCK. Determination of human CCK-58 structure confirms that one of the major components of human CCK that expresses biological activity is CCK-58.

[Primary malignant melanoma of the esophagus]

We report two cases of primary malignant melanoma of the esophagus. Both were female, 83 and 68 years of age. Both had metastatic spread of the disease at the time of first treatment, either in regional lymph nodes or organ involvement. One patient underwent resection of the tumor (partial esophagectomy). The second patient is alive 22 months postoperatively with metastatic tumor (12/1989), the first died one year after diagnosis. Prognosis of primary melanoma of the esophagus is poor. Though, resection of the tumor is the most promising therapy.

Action of neurotensin on meal-stimulated gastric acid secretion in the dog

In six to nine mongrel dogs the effect of graded doses of intravenous neurotensin (188, 375, 750, and 1500 pmol/kg h) on acid secretion basally or stimulated by distention (by isotonic glucose), peptone (0.5, 1, and 4 g%), and pentagastrin was studied. Neurotensin did not affect acid secretion basally, stimulated by distention, or the maximal peptone dose. However, when submaximal doses (0.5 and 1 g%) of peptone were instilled in the stomach, neurotensin stimulated the secretory response to intragastric peptone. This effect was observed in doses of intravenous neurotensin which mimicked circulating neurotensin concentrations after a standard test meal. Thus, neurotensin could be considered a physiologic stimulant of acid secretion when protein is present in the stomach. The mechanism for this action of neurotensin is unknown but could be partly explained by an enhanced release of gastrin. The potentiating effect of neurotensin on peptone-stimulated acid secretion could play a major role in gastric secretory function of the dog.

A new molecular form of PYY: structural characterization of human PYY(3-36) and PYY(1-36)

A radioimmunoassay was developed using an antibody raised in rabbits against synthetic porcine PYY. This radioimmunoassay was used to detect PYY immunoreactivity in human intestinal extracts. Human colonic mucosa was extracted with acid, centrifuged and the supernatant concentrated by low pressure preparative reverse phase chromatography. A subsequent C-18 reverse phase HPLC step separated two peaks of PYY immunoreactivity. Each peak was purified by sequential steps of ion-exchange FPLC and reverse phase HPLC. In the final purification step single absorbance peaks were associated with PYY immunoreactivity. Microsequence, amino acid, and mass spectral analysis of the intact and tryptic fragments of the two peptides were consistent with the structures: YPIKPEAPGEDASPEELNRYYASLRHYLNLVTRQRY-amide [human PYY(1-36)] and--IKPEAPGEDASPEELNRYYASLRHYLNLVTRQRY-amide [human PYY(3-36)]. Human PYY(1-36) differs from porcine PYY only at position 3, with Ile instead of Ala, and position 18, with Asn instead of Ser. PYY(3-36) may differ in its biological activity from the intact peptide. Its high proportions in the colon suggest that it is released into the circulation where it could act as a partial antagonist of PYY(1-36).

Pancreatic secretory response to intravenous caerulein and intraduodenal tryptophan studies: before and after stepwise removal of the extrinsic nerves of the pancreas in dogs

In two sets of 6 dogs with gastric and pancreatic fistulas, we studied the effect of atropine (14 nmol/kg.h i.v.) on the pancreatic secretory response to intravenous caerulein and to intraduodenal perfusion with tryptophan (both given with a secretin background) before and after stepwise removal of the extrinsic nerves of the pancreas, i.e., celiac and superior mesenteric ganglionectomy alone or truncal vagotomy alone and truncal vagotomy plus celiac and superior mesenteric ganglionectomy. Atropine significantly (p less than 0.05) depressed the protein output in the basal state and in response to secretin at each stage of innervation. The incremental protein response to caerulein was not altered by the various denervation operations nor by atropine. Truncal vagotomy alone significantly decreased the incremental protein response to low (0.12, 0.37, and 1.1 mmol/h) but not high loads of tryptophan. Ganglionectomy in combination with vagotomy did not further depress the incremental protein response to low loads of tryptophan. Atropine significantly reduced the incremental protein response to low loads of tryptophan only in intact innervated animals. Ganglionectomy alone did not alter the incremental protein response to any load of tryptophan. Ganglionectomy, truncal vagotomy, and atropine did not alter basal or tryptophan-stimulated levels of plasma cholecystokininlike immunoreactivity. We conclude that (a) neither the extrinsic nor the intrinsic cholinergic pancreatic nerves modulate the protein response to caerulein; (b) the sympathetic pancreatic nerves do not mediate the response to tryptophan; (c) the protein response to intraduodenal tryptophan is at least in part mediated by long, cholinergic, enteropancreatic reflexes with both afferent and efferent fibers running within the vagus nerves; and (d) release of cholecystokinin by intestinal tryptophan is not under cholinergic or splanchnic control.

Pancreatic bicarbonate response to HCl before and after cutting the extrinsic nerves of the pancreas in dogs

In two sets of dogs with gastric and pancreatic fistulas, we studied the effect of atropine on pancreatic bicarbonate output and release of secretin in response to intraduodenal HCl before and after stepwise removal of the extrinsic nerves of the pancreas, i.e., celiac and superior mesenteric ganglionectomy alone or truncal vagotomy alone and truncal vagotomy plus celiac and superior mesenteric ganglionectomy. Ganglionectomy alone did not alter the incremental bicarbonate response to HCl. Truncal vagotomy alone significantly (P less than 0.05) decreased the incremental bicarbonate response to low (1.5 and 3 mmol/h) but not high (6 to 24 mmol/h) loads of HCl. Additional ganglionectomy restored the bicarbonate response to prevagotomy levels. With the extrinsic nerves intact and after ganglionectomy, but not after truncal vagotomy and truncal vagotomy plus ganglionectomy, intravenous atropine (14 nmol.kg-1.h-1) significantly reduced the incremental bicarbonate response to low (1.5 and 3 mmol/h) but not high loads of HCl. Neither the different surgical procedures nor atropine significantly altered plasma levels of secretin basally and in response to intestinal HCl. We conclude that 1) cholinergic fibers within the vagus nerves but not the splanchnic nerves are important mediators of the pancreatic bicarbonate response to low loads of HCl and 2) release of secretin by intestinal HCl is not under cholinergic and splanchnic control.

Nervous control of gastric and pancreatic secretory response to 2-deoxy-D-glucose in the dog

The relative contribution of the vagus and splanchnic nerves as mediators of the action of 2-deoxy-D-glucose (2-DG) on the stomach and the pancreas is largely unknown. In conscious dogs with gastric and pancreatic fistulas, the effect of 2-DG (100 mg kg-1, given as an intravenous bolus) on gastric acid and pancreatic exocrine secretion was tested before and after bilateral truncal vagotomy and after truncal vagotomy plus celiac and superior mesenteric ganglionectomy (i.e. extrinsic denervation of the stomach and the pancreas). In another set of dogs, only ganglionectomy was performed and the same experiments were done as in the first set of dogs. With the extrinsic nerves intact, 2-DG caused a rapid (within 15 min) and prolonged increase in gastric acid output as well as in pancreatic flow rate, bicarbonate and protein output. Truncal vagotomy abolished the gastric acid and pancreatic secretory response to 2-DG; additional ganglionectomy had no further effect. Ganglionectomy alone did not significantly alter 2-DG-stimulated gastric acid output, pancreatic flow rate and bicarbonate output; protein output, however, was significantly diminished by 57%. These results indicate that (a) intravenous 2-DG is a potent stimulant of gastric acid and pancreatic bicarbonate and protein output; (b) the vagus nerves are the major mediators of the gastric and pancreatic secretory response to 2-DG; (c) the sympathetic nerve fibers running through the celiac and superior mesenteric ganglia are probably not involved in the mediation of the 2-DG-induced gastric acid and pancreatic bicarbonate secretion. The diminished protein response to 2-DG after ganglionectomy is probably due to cut vagal fibers running through these ganglia.

Pancreatic polypeptide response to a meal before and after cutting the extrinsic nerves of the upper gastrointestinal tract and the pancreas in the dog

The role of the sympathetic and parasympathetic innervation in the release of pancreatic polypeptide (PP) basally and in response to a meal was studied after stepwise extrinsic denervation of the pancreas and the upper gastrointestinal tract in conscious dogs with gastric fistulae. One set of seven dogs was fed a meat meal (35 g/kg body weight) before and after truncal vagotomy and after truncal vagotomy plus celiac and superior mesenteric ganglionectomy, ie, extrinsic denervation of the pancreas and the upper gastrointestinal tract. In another set of six dogs, only ganglionectomy was performed. Experiments were repeated in the presence of atropine (50 micrograms/kg body weight, given as an intravenous bolus 60 min prior to the meal). Truncal vagotomy significantly (P less than 0.05) reduced the postprandial 120-min integrated plasma PP response (IPPPR) by 84% as compared to the prevagotomy response. Before truncal vagotomy, atropine significantly reduced the IPPPR by 57%. After truncal vagotomy, atropine completely abolished the residual PP response. Additional celiac and superior mesenteric ganglionectomy did not alter the IPPPR already reduced by truncal vagotomy. With the vagus nerves intact, ganglionectomy alone had no effect on the IPPPR whether or not atropine was given. These findings indicate that (1) the splanchnic nerves do not play a significant role in postprandial PP release and (2) that the vagus nerves are important mediators of the response to a meal. The effect of atropine on postprandial PP release after truncal vagotomy may be due to interruption of short enteropancreatic reflexes, suppression of the intrinsic cholinergic activity of the pancreas, or inhibition of hormonally induced PP release.

[Neural control of pancreatic secretion]

In humans and many laboratory animals, protein and fat digestion products are potent intestinal stimulants of pancreatic enzyme secretion. Both neural and hormonal pathways mediate the enzyme response to these intestinal stimulants. Enteropancreatic, cholinergic, vago-vagal reflexes are probably the most important mediators of the enzyme response to low loads of amino acids, fatty acids and HCl; hormones, such as cholecystokinin, seem to be the major mediators of the response to high loads of amino acids, fatty acids and HCl. Gastric acid is the major regulator of postprandial pancreatic bicarbonate secretion. Secretin released by HCl is probably the most important physiological hormonal mediator of postprandial pancreatic bicarbonate secretion; its effect being potentiated by extrinsic (vagal) and intrinsic (intrapancreatic) cholinergic nerves and release of other hormones, such as cholecystokinin. Under physiological conditions it is probably the interplay of neural and hormonal mechanisms which regulates the pancreatic response to intestinal stimulants. However, this interaction of nerves and hormones is greatly unknown.