Ultrasonographic Findings after Conservative Treatment of Acute Appendicitis and Open Appendicectomy

In a randomized study we investigated the effects of antibiotics as the only treatment in acute appendicitis. Forty patients were examined, 19 after antibiotic treatment (one operated due to perforation) and 21 after surgery. All patients were examined prior to randomization, after 10 days and after 30 days. Of the positive ultrasonographic (US) findings, 18 (86%) of the 21 operated patients had histologically proven acute appendicitis. At the 10th day, 9 patients had a seroma under the scar, which had disappeared a month after surgery in all patients. In the 19 patients conservatively treated with antibiotics, the appendix could be visualized in 8 symptom-free cases on the 10th day. In 5 of the 8 patients the appendix was still visualized after 1 month. Three of these 5 had recurrent appendicitis within a year. It is concluded that US can be used not only in diagnosing acute appendicitis, but also in the evaluation of treatments such as antibiotics.

Gastric emptying and duodeno-gastro-oesophageal reflux in gastro-oesophageal reflux disease

BACKGROUND

Previous studies present conflicting results regarding relationship between gastric emptying and gastro-oesophageal reflux disease. Reflux of duodenal content to oesophagus is generally considered to be associated with more severe disease.

AIM

To assess presence of a gastric emptying disorder in persons with reflux of duodenal contents to oesophagus and to identify any correlation with gastric emptying and oesophageal motility.

METHODOLOGY

A total of 15 subjects with (B+) and 15 subjects without (B-) bile reflux to oesophagus determined by 24-hour bilirubin monitoring were studied with scintigraphic solid gastric emptying and 24-hour oesophageal manometry.

RESULTS

There was no difference in lag phase [median 23.7 (range 10.8-44.0) vs 24.6 (8.1-40.1) min], half emptying time [74.6 (48.0-93.6) vs 82.8 (54.4-153.9) min] or emptying rate [0.89 (0.59-1.34) vs 0.83 (0.36-1. 15)%/min] for B- and B+ subjects, respectively. In addition, there was no difference in emptying rate of gastric fundus between B- and B+ subjects. Subjects with bile reflux had less effective oesophageal contractions of oesophageal body [9.4(3.3-37)%] compared to subjects without bile reflux [32(19-47)%, p = 0.002]. However, there was no correlation between oesophageal motility and gastric emptying.

CONCLUSION

Results suggest that a gastric emptying disorder is a less likely contributing cause of bile reflux to the oesophagus, but bile reflux is associated with less effective oesophageal motility.

A Swedish study of chemoradiation in squamous cell carcinoma of the esophagus

This multicenter study describes the development of a chemoradiation protocol for the treatment of non-metastatic squamous cell carcinoma of the esophagus. Eighty patients were treated with three courses of chemotherapy (cisplatinum and 5-fluorouracil) with concomitant radiotherapy (40 Gy) during the last two courses of chemotherapy. Esophagectomy was performed, when feasible. If no operation was performed, patients were planned to receive a target dose of 64 Gy. Toxicity was mainly attributable to hematological impairment and led to two adjustments of the treatment protocol (addition of filgrastim and lowering of the 5-fluorouracil dose). These changes made it possible to administer the planned treatment in a gradually higher proportion of patients (13/23 [57%] before changes of treatment compared with 30/36 [83%] after changes). Treatment-related mortality was 3.75% (3 patients, associated with leucopenic septicemia after chemotherapy). Fifty-four patients were resected. No per- or postoperative mortality was encountered. The complete response (pathological CR) rate in operated patients was 46% (27/59 patients) after chemoradiation. In the whole series the CR rate (including clinical CR for non-resected patients) was 44%. With a minimum follow-up of 37 months, the 3-year survival for the whole group was 31% compared with 57% for the CR patients. Total 5-year survival thus far (July 1999) is 26%.

Percutaneous endoscopic gastrostomy for nutrition in patients with oesophageal cancer

OBJECTIVE

To evaluate the technical aspects and risks of using percutaneous endoscopic gastrostomy (PEG) in the treatment of patients with oesophageal cancer.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

229 consecutive patients who presented with oesophageal cancer between January 1990 and the end of December 1999.

INTERVENTION

Insertion of a PEG after diagnosis and before treatment.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

PEGs were successfully inserted in 222/229 (97%), and the tumour required dilatation in 103 (45%). There was 1 oesophageal perforation and 1 tear of the stomach wall, both of which resulted in death (mortality 0.9%). In 1 operated patient the right gastroepiploic artery was injured by the PEG, but this did not prevent the stomach being used successfully as the oesophageal substitute. PEGs were removed because of leaks in 2 patients. There was 1 possible implantation metastasis.

CONCLUSION

PEG is a safe and a well tolerated way of ensuring enteral nutrition in patients with oesophageal cancer. The risk of the PEG complicating any later operation is minimal.

Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia

Congenital high-airway obstruction syndrome (CHAOS) is due to rare malformations and has been reported previously in only few cases. If the diagnosis can be made prenatally, the ex utero intrapartum treatment (EXIT) procedure may be life-saving. A healthy 28-year old nulli-para was referred because of isolated ascites found at gestational week 16 during routine ultrasound scan. Repeated scans showed overdistended hyperechogenic lungs with inverted diaphragm and a dilated trachea, which was interpreted as a CHAOS resulting from laryngeal atresia. The ascites eventually disappeared. An EXIT procedure was performed at 35 weeks of gestation. Anesthesia of the mother was induced with thiopental, succinylcholine and fentanyl followed by intubation, and maintained with isoflurane and nitrous oxide. A low abdominal midline incision was performed followed by a low transverse incision of the uterus. The fetal head, right arm and shoulder were delivered and intramuscular anesthesia was administered to the fetus. Immediate laryngoscopy confirmed the diagnosis and a tracheostomy was therefore performed. Surfactant was given after a few minutes of ventilation. Compliance improved and when the fetus was easy to ventilate, it was delivered. The baby is developing normally at 18 months of age. Surgical correction of the malformation will be performed after two years of age. It is concluded that some fetuses with a prenatal diagnosis of CHAOS can benefit from the EXIT procedure at delivery. This necessitates a multidisciplinary management team.

Treatment of perforated appendicitis: an analysis of 362 patients treated during 8 years

BACKGROUND AND METHOD

In a retrospective study 2,351 records from patients who underwent surgery for acute appendicitis during 1986-1993 were analysed. During this period, there were 362 patients with perforated appendicitis. The aim of this study was to analyse the complication rate, the period of antibiotic treatment and whether the complication rate decreased when intravenous treatment was followed by oral antibiotic treatment.

RESULTS

The complication frequency was 18% which was significantly higher than that for non-perforated appendicitis of 10%. The complication rate was 15% in the group receiving additional oral antibiotics compared to 19% in the group receiving only intravenous antibiotics. This difference is not significant.

CONCLUSION

Perforated appendicitis is however still associated with increased mortality and morbidity.

Caesarean section in previously untreated acute promyelocytic leukaemia. Report of two patients

Acute promyelocytic leukaemia (APL) is characterised by a life-threatening hemorrhagic diathesis which is attributed to a DIC-like coagulopathy. This report describes the problems of childbirth in two patients with untreated APL. It is concluded that caesarean section can be performed without major complications. A prerequisite is an active treatment of the coagulopathy and a close collaboration between the obstetrician and the haematologist.

Neurochemical and cellular markers in human cervix of late pregnant, postpartal and non-pregnant women

BACKGROUND

The aim was to evaluate the peptidergic innervation and the dendritic cell content in the cervix uteri.

METHODS

Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to protein S-100 (S-100), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), human peptide histidine isoleucine amide (PHM 27), neuropeptide tyrosine (NPY), and human histocompatibility complex class II subregion DR (HLA-DR).

RESULTS

Nerve fibers positive for protein S-100, and dendritic cells positive for S-100 and HLA-DR were abundant in the cervix, especially at late pregnancy. CGRP, VIP, PHM-27 and NPY positive nerve fibers were present in non-pregnant, short nerve fibers and scattered immunoreactivity at term, and further scattered immunoreactivity after parturition. NPY positive nerve fibers were decreased at term, and after parturition a scattered immunoreactivity was observed.

CONCLUSIONS

The abundant protein S-100 positive nerve fibers implies an impact of myelinated nerves in the cervix uteri during pregnancy. The abundant dendritic cells, positive for HLA-DR and S-100, especially at term, indicates a general activation of the immune system until late pregnancy and parturition. The changed occurrence and distribution of immunoreactivity for CGRP, VIP and PHM-27 suggest a release of these neuropeptides until term. The changes in NPY immunoreactivity indicate a release of NPY around parturition.

Three-year results of laparoscopic vertical banded gastroplasty

BACKGROUND

Despite the development of pharmacologic agents for the treatment of massive obesity, surgery remains the only treatment option that has been shown to offer long-term weight reduction. Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity. The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (lap VBG) in 60 obese patients.

PATIENTS AND METHODS

60 massively obese patients (50 female) with a mean +/- SEM body mass index (BMI) of 44.4 +/- 1.0 kg/m2 were followed up prospectively for an average of 23.0 +/- 1.5 months. Lap VBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line, and a stretched polytetrafluoroethylene (Gore-Tex) band was used to reinforce the outlet. The patients were seen postoperatively 2, 6, 12, 24, and 36 months after surgery.

RESULTS

Conversion to open surgery was performed in 15 cases. Preoperative median BMI and postoperative hospital stay were higher in the open group than in the laparoscopic group: 47.8 kg/m2 (37.7-65.7) and 5 days (3-13), and 41.9 kg/m2 (32.5-57.3) and 3 days (2-6), respectively (P < 0.01 for both). After 36 months of follow-up, the median BMI was 36.9 kg/m2 (24.6-50.7) (n = 9) in the open group and 37.0 kg/m2 (25.8-53.3) (n = 14) (NS) in the laparoscopic group. The number of conversions to open surgery and the median operating time were higher in the first 30 cases than in the last 30 cases: 11 and 137.5 min (96-225) and 4 and 115.0 min (85-190), respectively, with similar preoperative BMI: 44.1 kg/m2 (33.8-65.8) and 41.2 kg/m2 (32.4-57.8).

CONCLUSIONS

Lap VBG can be performed safely and results in a shorter postoperative stay than does open surgery. Weight loss was maintained over the 3-year follow-up period. There is a learning curve, resulting in fewer conversions to open surgery and shorter operating time. Long follow-up studies are needed to ascertain that long-term weight loss equals that of open VBG.

Protein gene product 9.5-immunoreactive nerve fibers and cells in human cervix of late pregnant, postpartal and non-pregnant women

BACKGROUND

The aim of this study was to examine the occurrence and distribution of the general neuronal marker protein gene product (PGP) 9.5 in the cervix uteri.

METHODS

Cervical biopsies were obtained from late pregnant (n=5), postpartal (n=5) and non-pregnant (n=5) women. The samples were prepared for immunohistochemistry using antibodies to PGP 9.5.

RESULTS

Nerve fibers were found consistently in all biopsies. There were differences in the occurrence and distribution of PGP 9.5 immunoreactive nerve fibers and cells between the three groups. Immunoreactive nerve fibers were observed at a moderate to abundant frequency in the stroma and around arterial vessel walls, in all groups. Immunoreactive nerve fibers were also observed at high frequency within and around glandular epithelium in the late pregnant and postpartal groups. PGP 9.5 immunoreactive cells were seen occasionally in the stroma of the non-pregnant group, but at a high frequency in the stroma, around arterial blood vessel walls, around and within the glandular epithelium in the late pregnant and postpartal groups. The total frequency of immunoreactive nerve fibers and cells was the highest in the late pregnant group, slightly lower in the postpartal group, and the lowest in the non-pregnant group.

CONCLUSIONS

These findings show that changes in the general innervation take place during human cervical ripening until late pregnancy and parturition.

Diagnostic accuracy in 2,351 patients undergoing appendicectomy for suspected acute appendicitis: A retrospective study 1986-1993

AIMS

To investigate the pre-operative findings, accuracy, perforation rate and complication rate in 2,351 patients who underwent appendicectomy during 1986-1993.

METHOD

The 2,351 records from patients who underwent surgery were analysed to determine whether the pre-operative investigations introduced can improve the diagnostic accuracy when analysed in total.

RESULTS

The total diagnostic accuracy which was 70.9% in 1986 increased to a statistically significant figure of 87.1% in 1993. In female patients, the figure increased from 61.7 to 82.4% and in males from 82.0 to 91.2% during the studied period. The complication rate was in total 10.4% including a mortality of 0.21% (5 patients).

CONCLUSION

We believe that with a combination of increased interest in patients with acute appendicitis, a wider use of active in-hospital observation, a more standardised pre-operative laboratory investigation and the use of ultrasonography, a high diagnostic accuracy could be reached without an increased rate of complications and perforations.

[Biliary reflux can be a contributory cause of esophagitis]

In recent years duodenogastric reflux has been recognised as a possible cause of oesophagitis. Alone or in combination, bile salts, trypsin, pepsin, and hydrochloric acid have all been shown to cause oesophagitis. Duodenal content in the oesophagus can be measured by means of a new fibre-optic sensor, Bilitech 2000, a device measuring the occurrence of bilirubin and yielding 24-hour readings from the distal oesophagus. Studies in which the device has been used have shown oesophageal bilirubin to be increased in patients with oesophagitis, especially in the subgroup with such complications as oesophageal stricture or ulceration, or Barrett's oesophagus. The evidence suggests that unsatisfactory response to proton pump inhibitors in reflux patients might be due to an increase in duodenal reflux, and should be treated surgically with fundoplication or biliary diversion. This may also be true of oesophagitis patients with complications, though this remains to be shown in clinical studies.

An adjustable vertical banded gastroplasty does not eliminate the risk of staple-line disruption

BACKGROUND

The two main reasons for reoperation after vertical banded gastroplasty (VBG) in the treatment of obesity are staple-line disruption and stomal stenosis.

PATIENTS

Seven morbidly obese patients of mean (+/-SEM) body mass index (BMI) 43.7 +/- 1.9 kg/m2 treated with an adjustable vertical banded gastroplasty (AVBG).

RESULTS

No complications of the band system were reported. Weight-loss [BMI at 2 years follow-up 33.9 +/- 6.9 kg/m2 (n = 5)] was equivalent to that seen after VBG with a fixed band. Two of the patients developed staple-line disruption at 18 and 24 months after surgery.

CONCLUSION

AVBG allows adjustment of the stoma, but staple-line disruption was common in this small series. It is possible that an excessive filling of the band in order to achieve excess weight loss results in a high pressure in the upper pouch which increases the risk of staple-line disruption.

Seven year results of vertical banded gastroplasty for morbid obesity

OBJECTIVE

To present our experience with a group of obese patients treated by vertical banded gastroplasty.

DESIGN

Open prospective study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

198 Morbidly obese patients operated on between 1986 and April 1994.

INTERVENTIONS

Modified Mason vertical banded gastroplasty.

MAIN OUTCOME MEASURES

Weight loss, mortality, early and late morbidity, and reoperation.

RESULTS

The mean (SEM) age was 40 (0.7) and 149 of the 198 were women (75%). 22 Patients (11%) were lost to follow-up. Five patients died (3%), one soon after operation. Mean (SEM) body mass index (BMI) was 44.4 (0.5) preoperatively and this decreased to 32.6 (0.6) after four years (n = 99) and 33.8 (1.3) after seven years (n = 20). 21 patients developed 24 early postoperative complications, and 31 patients were reoperated on 41 times for late complications.

CONCLUSION

All patients lost weight after vertical banded gastroplasty, and their weight continued to decrease during a seven-year follow-up. This was somewhat offset by the high rate of reoperations required.

White blood cell count, leucocyte elastase activity, and serum concentrations of interleukin-6 and C-reactive protein after open appendicectomy

OBJECTIVE

To investigate the kinetics of interleukin-6 (IL-6), leucocyte elastase complex (elastase), C-reactive protein (CRP), and total white blood cell count (WBC) after open appendicectomy.

DESIGN

Prospective study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

21 patients with suspected acute appendicitis who underwent appendicectomy.

INTERVENTIONS

Serum samples were taken preoperatively and postoperatively on days 1, 2, 6, 10, and 30.

MAIN OUTCOME MEASURES

Changes in IL-6, elastase, and CRP concentrations and WBC postoperatively, and their correlation with complications.

RESULTS

The highest IL-6 concentrations and WBC were found preoperatively, while postoperatively elastase peaked on day 1, and CRP on day 2. One patient developed a suspected deep infection resulting in secondary peaks of IL-6, WBC, and CRP on day 6. Two patients with perforated appendicitis had high preoperative values of IL-6, elastase, and CRP.

CONCLUSIONS

Concentrations of IL-6, elastase, and CRP, and WBC increase after surgical trauma, and can remain high for up to 10 days. It is important to understand the postoperative kinetics for each test. Postoperative complications might best be detected by measuring IL-6 and CRP concentrations, and WBC.

Analgesic efficacy of intravenous morphine in labour pain: a reappraisal

The aim of the present study was to investigate the dose-related analgesic effect of intravenous (i.v.) morphine during spontaneous term first stage labour. This was an open study in 17 parturients who requested analgesia for severe labour pain. All women were given morphine i.v. in repeated doses of 0.05 mg/kg following every third contraction until a final dose of 0.20 mg/kg was reached. The decrease in overall pain intensity, from median visual analogue scale (VAS) 85 (range 52-100) to median VAS 70 (range 46-99), was clinically insignificant. The number of women experiencing back pain, however, decreased significantly following morphine. The most striking effect of morphine (7.2-18 mg) was pronounced sedation. No adverse reactions related to morphine were noted in the neonates. We conclude that i.v. morphine does not significantly reduce overall labour pain intensity. Thus, if a real analgesic effect is desired, systemically given morphine seems inappropriate and other techniques should be used.

Six Cases of Barrett's Esophagus after Gastric Restrictive Surgery for Massive Obesity: An Extended Case Report

OBJECTIVE: The purpose of this study is to report and characterize six patients who have developed Barrett's esophagus after; a gastric restrictive procedure for massive obesity. METHOD: Retrospective analysis of patients operated with gastric banding (GB) and vertical banded gastroplasty (VBG) between 1981 and 1994. RESULTS: Four patients (4/92) initially operated with GB have developed Barrett's esophagus a mean of 9 years post-operatively. Two patients (2/198) operated with VBG developed Barrett's esophagus 18 and 47 months postoperatively. The histopathological type of Barrett's esophagus was cardia-like in three cases, gastric-like in two cases and intestinal-like columnar epithelium in one case. None of the biopsies showed signs of dysplasia. CONCLUSION: Gastric banding is again gaining popularity with the development of adjustable bands that can be placed laparoscopically. The development of Barrett's esophagus after GB and VBG, a premalignant lesion, is cause for some concern. Prospective long-term studies are needed to further address this complication.

Gastro-oesophageal reflux before and after vertical banded gastroplasty in the treatment of obesity

OBJECTIVE

To study the long term effect of vertical banded gastroplasty on lower oesophageal sphincter pressure.

DESIGN

Prospective study.

SETTING

University hospital, Sweden.

SUBJECTS

21 morbidly obese patients (mean body mass index 42.5).

INTERVENTIONS

Vertical banded gastroplasty, together with measurements of endoscopic grade, oesophageal manometry, and 24 hour pH before, and a mean of 38 months after, operation.

MAIN OUTCOME MEASURES

Weight, grade of oesophagitis according to the Savary-Miller classification, number of episodes of reflux, percentage of time that the pH was < 4, and lower oesophageal sphincter pressure.

RESULTS

Before operation 5/14 patients (36%) had evidence of oesophagitis, and 12/21 (57%) had evidence of reflux disease. Two patients had abnormally low lower oesophageal sphincter pressure ( < 10 mm Hg). A mean (SEM) of 32 months after operation (range 6-49) the mean body mass index was 32.7 (1.2), and after a mean of 38 months paired data showed that there had been no significant changes in manometric (n = 11) or 24 hour pH (n = 10) measurements, or in endoscopic grading (n = 7).

CONCLUSION

Vertical banded gastroplasty used in the treatment of morbid obesity does not affect the antireflux function of the lower oesophageal sphincter.

Premature rupture of the membranes (PROM) at term in nulliparous women with a ripe cervix. A randomized trial of 12 or 24 hours of expectant management

OBJECTIVE

To compare maternal and neonatal outcomes after 12 or 24 hours of expectant management in healthy nulliparous women with a ripe cervix and PROM at term.

DESIGN

A prospective, randomized study.

LOCATION

Karolinska Hospital, Stockholm, Sweden.

SUBJECTS

Two hundred and five healthy nulliparous women with singleton pregnancies, cephalic presentation, gestational duration 36 to 42 weeks, randomized to 12 or 24 hours of expectant management after evaluation of the cervical score (> 5). If spontaneous labor did not occur, induction was performed with oxytocin after 12 or 24 hours, respectively. MAIN PARAMETERS: Maternal early morbidity and neonatal infections, obstetric intervention rate (cesarean section or instrumental delivery).

RESULTS

The cesarean section rate was 4% in each group. The vacuum extraction rate was 21% in each group. Induction of labor was performed in 47% of the women allocated to 12 hours of expectant management vs 17% of the women allocated to 24 hours of expectant management (p < 0.05). The maternal morbidity rate was almost negligible. Only a few fetal infections occurred and no difference was noted between the groups.

CONCLUSIONS

In healthy nulliparous women at term with a ripe cervix, expectant management over 24 hours vs 12 hours resulted in fewer inductions of labor and no increase in instrumental deliveries, without any increase in neonatal or maternal morbidity.

Leucocyte elastase as a marker in the diagnosis of acute appendicitis

OBJECTIVE

To investigate the value of measuring the activity of the leucocyte elastase complex in plasma in the diagnosis of acute appendicitis, either as a single or four-hourly test.

DESIGN

Open study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

165 consecutive patients admitted with suspected acute appendicitis.

MAIN OUTCOME MEASURES

Correlation of concentrations of leucocyte elastase complex (elastase) and total white blood cell count (WBC) with C-reactive protein concentration and histological appearance of the appendix.

RESULTS

Of 165 patients, 101 patients had their appendixes removed, and of these 86 had histologically confirmed appendicitis. An elastase value of less than 54 micrograms/l was considered to be the reference range. Elastase activity measured on admission gave a sensitivity of 61% and a specificity of 43% for acute appendicitis compared with the WBC which had a sensitivity of 81% and a specificity of 36%. The above blood tests were taken on two or more occasions four hourly after admission in 29 patients. Appendicitis was found in 25 of the 29 cases (87%), in which repeated tests showed a significant reduction in WBC together with a definite but not significant reduction in the elastase activity during the preoperative period. Repeated tests were of no value.

CONCLUSIONS

Measurement of the leucocyte elastase complex in plasma does not increase the accuracy of the diagnosis of acute appendicitis. There was no significant correlation between the leucocyte elastase activity and the total white cell count.

Does the Size of the Upper Pouch Affect Weight Loss after Vertical Banded Gastroplasty

BACKGROUND: The importance of creating a small 10-20 ml upper pouch when performing a vertical banded gastroplasty (VBG) is often stated in the literature. In order to test the hypothesis that weight loss is superior in patients with a small upper pouch, we examined the weight loss curves for three different pouch sizes in our patients operated with VBG. METHOD: Retrospective analysis of patients operated with VBG at our institution between November 1986 and April 1994 was done. A modified Mason VBG was performed with intraoperative balloon measurements of the size of the upper pouch. Three groups were identified according to different pouch volumes: 20 ml (n = 65), 30 ml (n = 46), and >/= 40 ml (n = 47). RESULTS: Of the 198 patients operated with VBG, pouch volume measurement was successful in 158 patients. Mean pouch volume was 32 ml at 50.5 cm of water. Loss of body mass index at 6, 12, 24, 48, 60 months did not significantly differ in the three groups. The rate of late reoperative procedures was also similar in the three groups. The incidence of staple-line breakdown (SLB) and endoscopically verified esophagitis was higher in the >/= 40 ml group. CONCLUSION: We have been unable to demonstrate a difference in weight loss after VBG for differing pouch volumes. There is an increased rate of SLB and esophagitis in the group with largest pouch volume; however, length of follow-up was longest for this group.

Cervical fetal fibronectin correlates to cervical ripening

AIM OF STUDY

It is well established that the cervical ripeness is of great prognostic value at labor induction. The available methods of measuring the cervical ripeness are not satisfactory. This study was therefore initiated to investigate if there is any correlation between cervical fetal fibronectin and cervical ripening at term.

METHOD

Three groups were included in this study: women with unripe cervices, women with spontaneous cervical ripening and those with PGE2-induced cervical ripening. Fetal fibronectin was measured by ELIZA after sampling from the cervical canal.

RESULTS

The cervical fetal fibronectin was low in women with unripe cervices. In women with favorable cervices a ten fold higher level was found. The fibronectin level was even higher after PGE2-induced ripening.

CONCLUSION

Conclusively an increased amount of cervical fetal fibronectin is registered during the cervical ripening process. A level of > 0.80 microgram/ml of cervical fetal fibronectin seems to indicate a favorable cervix.

Serial antenatal monitoring compared with labor induction in post-term pregnancies

OBJECTIVE

In view of the increased risk of obstetric and perinatal complications in post-term pregnancy, and the lack of consensus regarding clinical routines for fetal surveillance and labor induction, the aim of this prospective controlled study was to compare obstetric and perinatal outcome after serial monitoring until 43 weeks of gestation with that after labor induction at 42 gestational weeks.

MATERIALS AND METHODS

A study group of 193 gravidae scheduled for serial monitoring until 43 weeks of gestation was compared with a control group of 205 gravidae admitted for induction of labor at 42 weeks. A third, high-risk, group comprised gravidae (from either of the foregoing groups) who had to be admitted for emergency induction of labor owing to increased fetal risk (i.e., the presence of oligohydramnios or a small-for-gestational-age fetus).

RESULTS

The frequency of labor induction was significantly lower in the study group than among controls (p < 0.001), but the two groups did not differ in obstetric or perinatal outcome. As compared with these two low-risk groups, the high-risk group was characterized by significantly higher frequencies of instrumental delivery (p < 0.01), operative delivery for fetal distress (p < 0.001) and infants requiring neonatal intensive care (p < 0.001).

CONCLUSION

As the wait-and-see policy with serial monitoring resulted in a lower rate of labor induction, but not in a lower rate of instrumental delivery or perinatal complication, medically the two routines would appear to be comparable. However, an individual approach with intensified fetal surveillance is to be recommended, as it is vital to identify post-term pregnancies where the fetus is at increased risk. The use of such new techniques as umbilical artery flow velocimetry would no doubt improve the management of high-risk post-term pregnancies.

Ultrasonographic findings after conservative treatment of acute appendicitis and open appendicectomy

In a randomized study we investigated the effects of antibiotics as the only treatment in acute appendicitis. Forty patients were examined, 19 after antibiotic treatment (one operated due to perforation) and 21 after surgery. All patients were examined prior to randomization, after 10 days and after 30 days. Of the positive ultrasonographic (US) findings, 18 (86%) of the 21 operated patients had histologically proven acute appendicitis. At the 10th day, 9 patients had a seroma under the scar, which had disappeared a month after surgery in all patients. In the 19 patients conservatively treated with antibiotics, the appendix could be visualized in 8 symptom-free cases on the 10th day. In 5 of the 8 patients the appendix was still visualized after 1 month. Three of these 5 had recurrent appendicitis within a year. It is concluded that US can be used not only in diagnosing acute appendicitis, but also in the evaluation of treatments such as antibiotics.

Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis

In a prospective controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated. Of 40 patients admitted with a duration of abdominal pain of less than 72 h, 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were randomized to surgery. All patients treated conservatively were discharged within 2 days, except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis. Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery, when appendicitis was confirmed. The diagnostic accuracy within the operated group was 85 per cent. One patient had perforated appendicitis at operation. Antibiotic treatment in patients with acute appendicitis was as effective as surgery. The patients had less pain and required less analgesia, but the recurrence rate was high.

Sensitivity of interleukin-6 and C-reactive protein concentrations in the diagnosis of acute appendicitis

OBJECTIVE

To evaluate the interleukin-6 (IL-6) concentration in the diagnosis of acute appendicitis, either as a single or four-hourly test.

DESIGN

Open study.

SETTING

Teaching hospital, Sweden.

SUBJECTS

165 consecutive patients admitted with suspected acute appendicitis.

MAIN OUTCOME MEASURES

Correlation of concentrations of IL-6 and C-reactive protein with white cell count, duration of symptoms, and histological appearance of the appendix.

RESULTS

Of 165 patients, 101 patients had their appendices removed, and of these 86 had histologically confirmed appendicitis. An IL-6 concentration of less than 15 ng/l was accepted as the reference. On admission IL-6 concentrations above 15 ng/l gave a sensitivity of 66% and a specificity of 31% for acute appendicitis. Repeated tests were of no value. When the patients operated on were divided in groups depending on the duration of symptoms, C-reactive protein was the most valuable test after 24 hours' abdominal pain. Total white cell count has the most sensitive in patients with abdominal pain of less than 24 hours' duration.

CONCLUSIONS

Measurement of IL-6 concentrations does not increase the accuracy of the diagnosis of acute appendicitis. There was no significant correlation between IL-6 and C-reactive protein concentrations.

The diagnostic value of repetitive preoperative analyses of C-reactive protein and total leucocyte count in patients with suspected acute appendicitis

BACKGROUND

Studies have shown that C-reactive protein (CRP) and total leucocyte count (WBC) in suspected acute appendicitis analysed only on admission gave valuable information to guide the surgeon. The aim of this study was to investigate the usefulness of CRP and WBC measured repetitively before operation.

METHODS

During a 1-year period 227 patients were studied before emergency appendicectomy. CRP and WBC were analysed every 4th h. The upper limits of the reference intervals used were 9.0 x 10(9)/l for WBC and 10 mg/l for CRP.

RESULTS

Of the 227 appendicectomized patients, 170 (75%) had acute appendicitis. Sixty-six of the patients were tested on two or more occasions every 4th h. Forty-six of these patients had appendicitis; repetitive tests showed a continuing rise in CRP values but a continuing decrease in WBC. The negative appendicectomy rate among these 66 patients was 30%, which theoretically would have fallen to 19% if patients with normal results had not been subjected to surgery.

CONCLUSIONS

Repeated laboratory tests for CRP and WBC should be performed in patients with suspected acute appendicitis requested to stay for further observation. If these test results are normal, the surgeon should preferably refrain from operating but consider other differential diagnoses.

Marlex Mesh Gastric Banding: A 7-12 Year Follow-up

This paper presents a 7-12 year (mean 9.8 years) follow-up of 92 extremely obese patients treated with Marlextrade mark mesh gastric banding (GB). The follow-up rate was 92% (85 patients). Weight loss was initially good (an average reduction in BMI of 13 during the first year), but late weight gain has been a common complaint and a reason for reoperation. Other complications that necessitated reoperation were severe vomiting and esophagus not amenable to medical treatment. Four patients have developed signs of Barrett's esophagus at late follow-up. Forty-six patients (50%) were reoperated 70 times for correction of the band or conversion to vertical banded gastroplasty (VBG). The most common reoperative procedure was conversion to VBG (38 patients). Only 25 (31%) of the 80 patients with long-term follow-up have an intact band. Our results show the need of long follow-up and that this GB cannot be recommended for the treatment of morbid obesity.

Hepatic esterification rate of cholesterol and biliary lipids in human obesity

Obesity is often associated with an increased hepatic secretion rate of cholesterol and saturated gallbladder bile. In order to evaluate the role of hepatic esterification of cholesterol in this phenomenon, we assayed the activity of acyl CoA:cholesterol acyl transferase (ACAT), which catalyzes the esterification of cholesterol, in liver microsomes obtained from 19 morbidly obese patients without gallstones undergoing vertical banded gastroplasty. Gallbladder bile was obtained and analyzed for lipid composition, cholesterol saturation, nucleation time, and occurrence of cholesterol crystals. Fourteen non-obese gallstone-free subjects undergoing cholecystectomy because of suspected polyp or adenomyoma in the gallbladder served as controls. The hepatic content of esterified cholesterol was increased by about 70% in the obese patients (P < 0.05). Still, the mean levels of the ACAT activity were equal in the obese and non-obese patient groups (11 +/- 1 and 11 +/- 2 pmol/min per mg protein, respectively). When exogenous cholesterol was added to the assay system, the activity was increased markedly in both groups. The ACAT activity was higher in obese patients with steatosis of the liver compared with those displaying normal liver morphology (12 +/- 1 vs 8 +/- 1 pmol/min per mg, P < 0.05). Obese patients did not have significantly more saturated gallbladder bile than the non-obese controls (84 +/- 7 and 77 +/- 8%, respectively). They had a normal nucleation time and their gallbladder bile did not contain any cholesterol crystals. We conclude that obese patients without gallstones usually have a normal esterification rate of cholesterol in the liver. Steatosis of the liver was associated with increased ACAT activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Monofilament versus multifilament absorbable sutures for abdominal closure

This study compares monofilament continuous absorbable sutures with multifilament interrupted absorbable sutures for abdominal closure. Before closure of an abdominal incision, 988 patients were randomized to receive either a monofilament polyglyconate (Maxon) or a multifilament polyglactin 910 (Vicryl) suture. At 1 year after operation, 684 patients (69 per cent) were examined for the presence of incisional hernia, sinus and other wound-healing problems; 179 (18 per cent) had died and 125 (13 per cent) did not attend for follow-up. Incisional hernia occurred in 8 per cent of patients receiving monofilament continuous sutures compared with 6 per cent of those having multifilament interrupted closure (P not significant). Wound dehiscence occurred in 1 per cent of both groups. The mean time for suturing was 7.1 min for monofilament continuous and 8.7 min for multifilament interrupted sutures (P < 0.001). It is concluded that closure of an abdominal incision can be effected by a monofilament continuous absorbable suture more quickly than by multifilament interrupted absorbable sutures without an increased risk of wound dehiscence or incisional hernia.

Aortic valve replacement in octogenarians with aortic stenosis: a case-control study

OBJECTIVES

This study was designed to compare the results of aortic valve replacement in patients greater than or equal to 80 years old with those in patients 65 to 75 years old.

BACKGROUND

Aortic valve replacement may be potentially more complicated and require the use of more resources when performed in octogenarians rather than in younger patients. Few hard data on this possibility are available.

METHODS

The study group comprises all 44 patients greater than or equal to 80 years old (mean age 82 years) who underwent aortic valve replacement at our institution between January 1981 and July 1989. A control group of 83 patients with a mean age of 70 years was matched with the study group for gender and approximate date of valve replacement. Before operation, 86% of the older patients versus 36% of the younger patients were in New York Heart Association functional class III or IV (p less than 0.001). Data were retrospectively collected from hospital records and a self-assessment telephone interview was conducted.

RESULTS

The early mortality rate was 14% in the older group versus 4% in the younger group (p = 0.045). The duration of respirator support, intensive care and the total duration of the hospital stay did not differ significantly between groups. The incidence of postoperative low cardiac output syndrome was higher in the older group (p = 0.049), but the incidence of late valve-related complications was similar in the two groups. The 2-year survival rate (including data on patients who died early) was 73% in the older group and 90% in the younger group (p = NS). Six months postoperatively all patients but one were in functional class I or II.

CONCLUSIONS

Although the patients greater than or equal to 80 years old had a poorer preoperative status than that of younger patients, aortic valve replacement in this group did not require more use of hospital resources and resulted in a clinical improvement comparable to that of younger patients.

Inflammatory response to subcutaneously implanted Marlex and GORE-TEX in massively obese patients

In both vertical banded gastroplasty and in gastric banding, synthetic bands are used to reinforce the outlet from the pouch to the rest of the stomach. Two materials commonly used for these bands are polypropylene (Marlex) and polytetrafluoroethylene (GORE-TEX). As a measure of their suitability, human inflammatory response to subcutaneous implants was investigated. In a randomized series of 17 superobese patients a patch of GORE-TEX was implanted subcutaneously in one groin under local anaesthesia and Marlex mesh was implanted in the other groin. After about 2 months the implants were exstirpated and investigated in a single blind procedure by an experienced pathologist. Marlex gave a significantly greater chronic inflammatory reaction and fibrosis than GORE-TEX. The foreign body giant cell reaction was, however, significantly greater with GORE-TEX. The possible implications of these results are discussed.

Insufficient remodelling of the uterine connective tissue in women with protracted labour

OBJECTIVE

To investigate the association between a slow progress of labour and insufficient remodelling of the uterine connective tissue.

DESIGN

An open comparative study.

SETTING

Danderyd Hospital, Department of Obstetrics and Gynaecology, referral centre.

SUBJECTS

Eleven women (study group) in oxytocin augmented labour but with an unripe cervix in whom vaginal delivery could not be accomplished and 12 women (normal labour group) in normally progressing spontaneous labour and a favourable cervix but who needed to be delivered by caesarean section due to signs of fetal distress.

INTERVENTIONS

At caesarean section tissue specimens were obtained from the fundus, the isthmus and the cervix uteri.

MAIN OUTCOME MEASURES

Collagen concentration and extractability, collagenolytic activity expressed as DNP-peptide hydrolytic activity and the concentrations of sulphated glycosaminoglycans (S-GAG) and hyaluronic acid (HA) in the tissue specimens.

RESULTS

Statistically significantly higher concentrations and lower extractability of collagen in the isthmus and the cervix uteri was found in women with slow progress of labour compared with those with normal labour.

CONCLUSIONS

An insufficient remodelling of the connective tissue in the cervix and isthmus uteri may contribute to slow progress of labour.

Jejunoileal Bypass Operations With a Side-to-side Anastomosis in the Treatment of Morbid Obesity

In order to avoid a stagnant loop syndrome in intestinal bypass operations for morbid obesity, we have tried a jejunoileal bypass with a side-to-side anastomosis in a pilot study. Seven patients were operated on with this method, which resulted in a very high incidence of liver damage. The study puts a question mark to the blind loop syndrome as an etiological factor in producing liver damage.

Eosinophilic gastroenteritis--a rare cause of severe abdominal pain. Case report

A 48-year-old man with a long history of recurrent severe abdominal pain developed moderate drug dependence before the diagnosis of eosinophilic gastroenteritis was established. The symptoms quickly responded to corticosteroid treatment.

Preinductive cervical ripening with PgE2 gel in term pregnant women with ultrasonically diagnosed intra-uterine growth-retarded fetuses

Intra-uterine growth retardation (IUGR), often combined with other pregnancy-related complications, constitutes a rather common indication for labor induction. The objective of this prospective study was to evaluate a strict intracervical application of 0.5 mg PgE2 in gel for cervical ripening and labor induction. Eighty term pregnant women with an ultrasonically diagnosed IUGR (less than -2 SD) and an unripe cervix were given PgE2-gel. The main indication for labor induction was IUGR, but 26 women had other complications. IUGR was verified at delivery in 50 women (study group), whereas 30 women (control group) gave birth to infants of normal birth weight (greater than -2 SD). The cervical ripening effect did not differ between the groups. In the study group, 19 nulliparous and 15 parous women out of 50 had a favorable cervix after 12 h and were delivered within 24 h of gel application. The corresponding result for the control group was 11 nulliparous and 8 parous women out of 30. Failed induction was registered in 2 and one woman respectively. On the other hand, the number of instrumental deliveries was greater in the study group, 11 caesarean sections (CS) and seven ventouses, compared with one CS and three ventouses in the control group (p less than 0.05). The frequency of operative deliveries for fetal distress (ODFD) was higher among the women with verified IUGR (14/50) than in the controls, where the corresponding figure was 3/30. No side effects were observed. We conclude that strict intracervical application of 0.5 mg PgE2 is a safe and effective method for cervical ripening and labor induction in women with IUGR.

Myometrial activity after local application of prostaglandin E2 for cervical ripening and term labor induction

Twelve pregnant women at term with unfavorable cervices (less than or equal to 5 points according to Bishop score) were given prostaglandin E2 for cervical priming and labor induction. Prostaglandin E2 was given in the following manner: 0.5 mg in gel strictly intracervically (n = 4), extraamniotically (n = 4), or prostaglandin E2 (4 mg) in gel vaginally (n = 4). The myometrial activity was registered over a period of 30 minutes before and at least 3 hours after gel application by means of an extraamniotic microtransducer catheter. After both extraamniotic and vaginal gel application, myometrial activity was significantly increased compared with intracervical application. All the women had favorable cervical states 6 hours after treatment and were delivered vaginally within 24 hours. All infants were delivered in good condition with 1-minute Apgar scores greater than 7. From these results we conclude that proper intracervical prostaglandin E2 gel application, in contrast to extraamniotic or vaginal application, induces cervical ripening without significant myometrial activity. Because careful intracervical application appears to avoid or minimize the risks of myometrial hyperstimulation, this technique should be considered particularly in women with unfavorable cervices and delicate fetuses.

Fetal growth retardation after gastric banding

A 35-year-old woman became pregnant 15 months after gastric banding, during which time she lost 55 kg in weight. During the third trimester, severe vomiting was noted and she lost a further 6 kg. Ultrasound examination showed oligohydramnions and fetal growth retardation of 38%. Enteral nutrition was given until delivery and ultrasound verified normalization of the oligohydramnions and weight gain for the fetus. The woman was delivered by cesarean section of a female infant with birthweight 2,470 g. It is concluded that special care must be taken with regard to the nutritional status of pregnant women who have previously been operated on with gastric procedures for obesity, in order to diminish the risk of fetal growth retardation. Ultrasound examinations should be performed on wide indications and enteral nutrition must start immediately once fetal growth retardation is discovered.

Changes in the connective tissue of corpus and cervix uteri during ripening and labour in term pregnancy

The composition of the connective tissue of human cervix and corpus uteri was studied in tissue specimens from seven nonpregnant women and 14 pregnant women, delivered at term by section, to examine spontaneous cervical ripening and labour-induced changes in both the uterine and the cervical connective tissue. The main finding in both the cervix and the corpus was a large (40-60%) decrease of the collagen concentration. The collagen extractability, obtained by pepsin digestion, was increased twofold, suggesting a change of the organization of the collagen fibrils. This reorganization process could also be demonstrated by a large increase of the collagenolytic activity demonstrated with an artificial DNP-peptide substrate. The concentrations of sulphated glycosaminoglycans was lower in pregnant women than in non-pregnant women. The results show that both the cervix and the corpus uteri contain substantial amounts of connective tissue components (collagen, sulphated glycosaminoglycans and hyaluronic acid) and that during ripening, reconstruction of the connective tissue components occurs in both sites. This indicates that the cervical state reflects that of the myometrium.

Changes in the connective tissue of corpus and cervix uteri during ripening and labour in term pregnancy

The composition of the connective tissue of human cervix and corpus uteri was studied in tissue specimens from seven nonpregnant women and 14 pregnant women, delivered at term by section, to examine spontaneous cervical ripening and labour-induced changes in both the uterine and the cervical connective tissue. The main finding in both the cervix and the corpus was a large (40-60%) decrease of the collagen concentration. The collagen extractability, obtained by pepsin digestion, was increased twofold, suggesting a change of the organization of the collagen fibrils. This reorganization process could also be demonstrated by a large increase of the collagenolytic activity demonstrated with an artificial DNP-peptide substrate. The concentrations of sulphated glycosaminoglycans was lower in pregnant women than in non-pregnant women. The results show that both the cervix and the corpus uteri contain substantial amounts of connective tissue components (collagen, sulphated glycosaminoglycans and hyaluronic acid) and that during ripening, reconstruction of the connective tissue components occurs in both sites. This indicates that the cervical state reflects that of the myometrium.

Laboratory tests in patients with suspected acute appendicitis

The clinical usefulness of preoperative determination of total and differential white blood cell count and C-reactive protein was studied in 113 patients undergoing emergency appendectomy for suspected acute appendicitis. The diagnosis was confirmed in 86 (76%) of the patients. In all 86 cases at least one of the three laboratory tests gave an abnormal result. The highest incidence of abnormal results was found in the most advanced stages of inflammatory reaction in the appendix. In nine of the 27 patients with histologically normal appendix all three laboratory parameters were normal. The "negative appendectomy rate" would have fallen from 24% to 16% in this study if the patients with negative results in all three tests had not been operated on.

Elevated plasma levels of oxytocin in obese subjects before and after gastric banding

Impaired glucose tolerance and hyperinsulinaemia are common features of obesity. Since oxytocin has been shown to influence glucose metabolism and insulin secretion, the objective of the present study was to investigate whether the plasma level of oxytocin is elevated in obese subjects and if so, whether it is affected by weight reduction following gastric banding. Repeated blood samples were collected in connection with ingestion of a liquid test meal from subjects weighing about 130 kg. Normal weight subjects were tested likewise. Further tests were performed on obese subjects 6 months after operation with gastric banding and a subsequent weight reduction of about 30 kg. Plasma levels of oxytocin were measured by radioimmunoassay. It was found that plasma levels of oxytocin were 4-fold higher in the obese subjects when compared to the control subjects. Analysis with high performance liquid chromatography demonstrated that the oxytocin-like material, as determined by radioimmunoassay, in extracted plasma from one obese subject coeluted with synthetic oxytocin standard. Ingestion of a test meal did not seem to influence oxytocin levels. The mean oxytocin level was equally elevated in male and female obese subjects. Following operation oxytocin levels decreased significantly, but were still significantly higher than in the control subjects. The mechanism behind the hyperoxytocinaemia and possible consequence of it remain obscure.