Action of gastrointestinal hormones on the myoelectric activity of the sphincter of Oddi in living rabbit.

The aim of this work was to compare the action of gastrointestinal (GI) hormones on the myoelectrical activity of the sphincter of Oddi. Using an experimental design previously described, we studied the electrical activity of the sphincter of Oddi and compared the percentage variation in the number of spikes before and after injection of hormones. Increasing doses of the following hormones were injected i.v. at random: CCK, OP-CCK, caerulein, bombesin, gastrin, secretin and glucagon. CCK and caerulein (as previously found), and also bombesin, OP-CCK and gastrin increased the spikes activity of the sphincter of Oddi. Secretin had no effect and glucagon decreased this activity. There was no tachyphylaxis, but a good dose-effect relationship for each hormone. Compared on a molar basis caerulein is 8 times more effective than CCK and OP-CCK which in turn are more potent than bombesin. Gastrin acts only at pharmacological doses.

Surgical treatment of chronic pancreatitis. Report of 134 cases treated by resection or drainage.

One hundred thirty-four patients (123 men and 11 women) were operated on for chronic pancreatitis (69 pancreaticojejunostomies, 20 cytopancreaticojejunostomies, 22 left pancreatectomies, and 23 Whipple operations). Half of these patients were followed up for 5 years or more. Four patients died from cancer of the pancreas. The operative mortality rate was 4.2 percent after anastomosis, 13.5 percent after pancreatectomy, and 8.7 percent after a Whipple operation. Relief of pain was the main aim of operation. The rate of good results after pancreaticojejunostomy (85 percent) was higher than after resection (71 percent after right pancreatectomy or Whipple operation and 66.6 percent after left pancreatectomy). The mortality rate after 5 years 26 percent after anastomosis, 30 percent after Whipple operation, and 45 percent after left pancreatectomy. Alcoholic intake did not appear to influence the operative result but improved the quality of life of the patient. Postoperative complications are more common and more serious after resection than after anastomosis. If dilated, the common bile duct must be drained as well as the pancreatic duct after anastomosis. Whenever the pancreatic duct is dilated more than 8 mm it must be drained rather than resected.

[Effect of somatostatin on the rabbit Oddi's sphincter in vivo. Interrelation of somatostatin and cholecystokinin]. / Action de la somatostatine sur le sphincter d'Oddi du lapin "in vivo". Inter-relations somatostatine-cholécystokinine.

The action of somatostatin on the myoelectrical activity of the sphincter of Oddi was studied in anesthetized rabbits equipped with bipolar electrodes. The activity of the sphincter was recorded at the basal state and during 30 min after injection of somatostatin. After a bolus injection of somatostatin (1 to 8 micrograms/kg), the myoelectrical activity of the sphincter of Oddi decreased between the 2nd and the 10th min with a parallel decrease of the biliary pressure. These modifications were significant at the doses of 4 and 8 micrograms/kg only. There was a good dose-effect relationship. Moreover, the infusion of somatostatin (60 micrograms/kg/h) led to a decrease in sphincter activity. Bolus injection of cholecystokinin (2 UD/kg) under somatostatin infusion (60 micrograms/kg/h) induced an increase in the activity of the sphincter of Oddi. However, this activity never returned to basal levels.

[Biofeedback as a complementary treatment in surgery for anal incontinence]. / Biofeedback como tratamiento complementario de la cirugía de la incontinencia anal.

Anal incontinence is a severe condition which may be treated by surgery, with unpredictable results. Biofeedback technique is designed to re-educate the function of the anal sphincter; it employs a probe for anorectal manometry, connected to the screen of an oscilloscope. The use of this technique in 43 patients with incontinence, treated with surgery resulted in 48.1% of total continence, 39.53% of partial continence and 11.62% of null response.

[Result of surgical treatment of exteriorized rectal prolapse in adults. Experience of 21 years]. / Résultats du traitement chirurgical du prolapsus rectal extériorisé de l'adulte. Une expérience de 21 ans.

Between 1971 and 1992, 89 patients (57 women, 32 men; mean age: 61 years) underwent surgical treatment for total rectal prolapse. 68.5% were constipated, and 12.3% had a solitary rectal ulcer, 46% were incontinent (3 grades 2, 11 grades 3, 27 grades 4). Twelve patients (21%) had been previously, but unsuccessfully operated. Manometry showed low resting pressures in the upper part of the anal canal, particularly in incontinent patients. Voluntary contraction was lower in incontinent patients. The resting anorectal angle was obtuse (113 degrees). Orr-Loygue operation (n = 53), modified rectopexy (n = 22), rectopexy to the left inguinal ligament (n = 6), Delorme operation (n = 4), and posterior rectopexy (n = 4) were performed. There was no operative mortality. Intraoperative and postoperative morbidity rates were 3.4% (n = 3) and 29%. Rectal prolapse recurred in 3 cases (3.4%). Solitary rectal ulcer healed in all patients. Only 8 patients were incontinent after operation, but control was better in 6 cases; in other both patients, preoperative electromyography showed grade III denervation. Bowel habit was postoperatively better (68.5% of patients were constipated before operation, 51.7% after operation). Resting pressures increased in preoperatively incontinent patients in the upper part of the anal canal; resting external sphincter pressures always increased. There was no change in the resting anorectal angle (112 degrees).

[Immediate and late results of surgical treatment for chronic pancreatitis. Apropos of 127 operated cases]. / Résultats immédiats et tardifs du traitement chirurgical des pancréatites chroniques. A propos de 127 cas opérés.

From 1960 to 1987, 127 patients (105 males and 22 females, mean age: 45.9 years) underwent surgical treatment for CP. The aim of this study was to assess the results of surgical treatment intentionally oriented towards conservative surgical procedures (CPS). Ninety-one patients benefited from either pancreato-intestinal bypasses (84 cases) sometimes associated with other intestinal bypasses and/or transhiatal splanchnicotomy (THS) or isolated biliary (5 cases) or gastric (2 cases) bypasses. Thirty-one resections were carried out: 26 pancreatoduodenal resections (PDR) associated 3 times with TSH and 5 distal pancreatectomies. Other types of conservative treatment were performed in 5 cases. There were 5 post-operative deaths (3.9%): 1 after resection (6.6%) and 4 after CSP (p greater than 0.7). Postoperative complications occurred twice after resections (6.6%) and in 13 cases (16.2%) after CSP (p greater than 0.3). A further surgical procedure was required in 3 cases after pancreatic resection (3/25.12%) and in 14 cases after CSP (14/71, 19.7%) (p greater than 0.5). In the late postoperative course 15 deaths occurred but only 6 of them were directly related to the course of the pancreatitis. Five and 10 year overall survival probability after surgical treatment was respectively 81.5% and 64.7%. This probability was 70.4 and 60.4% after resections and 87.1% and 68.8% after CSP (p = 0.29). After CSP 75% of good functional results were observed between 1 and 4 years and 60% afterwards. Although non statistically significant these results suggest that: CSP and resections have the same operative risk, late reoperations are more frequent after CSP, the chance of late survival rate is better after CSP than after resection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cancer of the rectum in elderly patients over the age of seventy-five years. Results of the surgical treatment]. / Le cancer du rectum chez les sujets âgés de plus de soixante-quinze ans. Résultats du traitement chirurgical.

The authors reviewed 122 rectal cancers observed over a period of 14 years in patients over the age of 75 years. Sixty-eight patients underwent extensive rectal resection, 17 were treated by local excision, and 28 only underwent a colostomy. Eight patients were excluded for surgery. The analysis of all of these groups showed that perioperative mortality was greater for large resections than for local resections, but with a lower recurrence rate and a higher survival at 3 years. Survival at 5 years after large resections was very close to the natural life expectancy for people of the same age. Moreover, survival was the quality of more comfortable than after local excision, and operative mortality was generally due to organ failure rather than to age itself. Radical surgery does not have to be systematically refused for very old patients, but he discussed in terms of the patients general status.

[Treatment of low rectovaginal fistula by pulling down a rectal mucosal curtain]. / Cure des fistules recto-vaginales basses par abaissement d'un rideau muqueux rectal.

The most delicate stage in the repair of low rectovaginal fistulae is closure of the rectal opening. To the numerous and complex procedures proposed, the authors oppose a simple technique which consists of separating the rectal mucosa, which can then be pulled down like a curtain to effectively and completely obturate the opening without attending to the muscular breach. This technique has been successfully used in 9 cases of low recto-vaginal fistulae of obstetrical or infectious origin.

[Anorectal asynchronism. Clinical, manometric and therapeutic data]. / Dyssynergie anorectale. Données cliniques, manométriques et thérapeutiques.

OBJECTIVES: Anorectal asynchronism is a frequent and unrecognized cause of terminal constipation. The aim of this study was to describe clinical and instrumental findings, and results of biofeedback therapy. METHODS: From 1987 to 1991, 18 patients with anorectal asynchronism were studied then treated by biofeedback training. RESULTS: We found high rates of pelvic and perineal trauma (77.7%), of psychogenic factors (6.5%), of urinary incontinence (27.8%). The manometrical study confirmed puborectalis paradoxical contraction during defecation straining, and all the patients could not expel a rectal balloon containing 50 ml of air; non-specific manometrical abnormality was found in 44.5% patients. Excessive stamp of puborectalis muscle was always found at defecography; 77.7% of the patients had incomplete rectal evacuation, and 61.1% had an associated pelvic floor disorder. Biofeedback training was successful, and 88.9% of the patients were cured by 5 or 6 sessions. There was no predictive parameter in our study, but recovery rate seemed to be lower for patients from 45 to 55 years old. CONCLUSION: The diagnosis of the anorectal asynchronism is easily made with manometry and defecography. Treatment with biofeedback gives very good results in almost all patients.

[Is there a correlation between dietary habits and hemorrhoidal disease?]. / Y a-t-il une corrélation entre les habitudes alimentaires et la maladie hémorroïdaire?

OBJECTIVES: It is empirically accepted that certain foods play a role in the pathogenesis of hemorrhoids or their acute exacerbation. The aim of this work was to determine whether there is a relationship between hemorrhoids and certain food-related or common toxin-related factors. PATIENTS AND METHODS: Two groups of 50 subjects were compared. Group I was composed of 50 patients with hemorrhoid symptoms. Fifty volunteers with no proctologic abnormality were included in group II. We used a diet survey to compare total calorie, protein, carbohydrate, fat, food fiber, water, alcohol, salt, pepper, pimento, tea, and coffee intake was well as smoking habits. Episodes of constipation were also noted. RESULTS: Overall calorie intake, as well as protein, carbohydrate and fiber intake were similar in the two groups as were use of salt, coffee and tea. Dietary intake in group I was higher for fat (p = 0.02), alcohol (p = 0.01), pepper (p = 0.04, and pimento (p = 0.001). Subjects in group I drank less water (p = 0.008), smoked more (p = 0.01) and were more often constipated (p < 0.001) than those in group II. CONCLUSION: Our findings provide further arguments suggesting that dietary imbalance or smoking could be involved in the development of hemorrhoids. These factors should be evaluated in appropriate dietary inquiries. Epidemiological surveys would be required to confirm their possible causal effect.

[Primary odditis. Clinical features, therapy, and possible pathogenesis (author's transl)]. / Les oddites primitives. Etude clinique et thérapeutique. Essai d'interprétation pathogénique.

Primary odditis, a rare affection, was observed in 28 patients (15 women and 13 men) with a mean age of 56.4 years. Epigastric or right hypochondrial pain was the presenting symptom in 13 cases, while in 13 others the onset was heralded by jaundice, either of a chronic nature (2 cases) or of the pseudo-lithiasic type (11 cases). The pancreatic form is much less frequent (2 cases). Radiological and histological findings are compared with those described in the published literature. All patients demonstrated a specific psychosomatic profile. Primary odditis can be reproduced experimentally in dogs by chronic irritation of the right splanchnic nerve, this acting on a nerve circuit which includes the right splanchnic and left vagus nerves. It is suggested that such lesions are secondary to a "nervous irritation" (Reilly's phenomenon). Treatment of primary odditis is by surgery only, sphincterectomy giving the best results, though choledochoduodenal anastomosis is also effective in elderly patients.

[Leiomyosarcoma of the anal canal]. / Les léimyosarcomes du canal anal.

Leiomyosarcoma originating in the anal canal internal sphincter is an extremely rare malignant tumor of often late diagnosis, since usually asymptomatic, and with malignancy criteria that are sometimes difficult to define. These tumors affect men and women with equal frequency, usually in the 6 th decade. Two cases are reported in patients aged 67 and 65 respectively in whom the tumor was revealed by a painful perianal mass shown on rectoscopy to be due to a submucous tumor projecting into anal canal, Prognosis and treatment of these tumors is discussed, diagnosis being confirmed only after excision biopsy. Tumoral extension was both local and regional by continuity but blood dissemination had occurred with metastases more frequently in liver (1 case) but also in lungs. Glandular extension was exceptional. Limited local exeresis of small tumors appears justified if sufficiently wide, since malignancy of leiomyosarcoma appears to remain circumscribed over long periods. However, this limited procedure runs the risk of local recurrence with the need for abdominoperineal amputation (the case in the 2 patients reported), although long-term results appear to be similar whether excision is or is not extensive, the abdominoperineal amputation failing to avoid the unfavorable course. Complementary radiotherapy or chemotherapy is ineffective, and prognosis is related more to the degree of tumoral differentiation than to the operative treatment itself.

[Place of ampullectomy in the surgical treatment of tumors in Oddi's sphincter]. / Place de l'ampullectomie dans le traitement chirurgical des tumeurs Oddiennes.

Ampoulectomy is rarely used for exeresis of tumours of the Oddi ampoula due to the risk of incomplete exeresis and postoperative complications. We performed 10 ampoulectomies between 1981 and 1990 (8 males, and 2 females: mean age 59 years). The operative procedure included wide resection followed by reimplantation of the biliary and pancreatic canals. The operative indications were based on converging evidence proficed by pathological examination of pre- and peroperative biopsies. There were 4 adenomas, 2 villous tumours, 2 ectopic pancreases, 1 somatostatinoma and 1 villous tumour with in situ carcinoma. Post-operative mortality was nil: the only post-operative complication was 1 stress ulcer. In one case, the benign nature of the tumour was infirmed by the pathological examination of the surgical specimen (invasive adenocarcinoma). This patient refused duodenopancreatectomy and died at recurrence 72 months later. For the other patients, mean post-operative follow-up was 60 months. Clinical, biological, endoscopic and pathological follow-up have not revealed relapse in any of the other patients. These results show that complete exeresis of benign Oddi tumors can be achieved by ampoulectomy without specific post-operative complications. Progress in echoendoscopy will probably lead to very precise evaluation of the local invasion of these tumours and thus to wider indications and better follow-up in operated patients.

[Chronic postoperative rectal fistulae. Treatment by transanal colo-anal anastomosis. Apropos of 4 cases]. / Les fistules rectales chroniques post-opératoires. Traitement par anastomose colo-anale transanale. A propos de 4 cas.

In a few cases, the postoperative rectal fistulas progress towards chronicity despite correct treatment and left iliac derivation. In 4 cases of such fistulas (3 females and 1 male, mean age 46 years), developed after rectal surgery and persisting for 2 to 16 months in young subjects, in good general condition and with a good long-term prognosis, we performed rectal resection with transanal colo-anal anastomosis according to the Parks technique. This procedure led to healing of the course of the fistulas, then closure of the derivation anus in the 4 patients. The functional results proved to be satisfactory, following short-term rehabilitation with biofeedback. After discussing the other surgical possibilities, the authors estimate that such a radical cure must be decided upon without delay, in case of chronic rectal fistula.

[Early postoperative morbidity after hemorrhoidectomy using the Milligan-Morgan technic. A retrospective studies of 1,134 cases]. / Morbidité post-opératoire précoce après hémorroïdectomie selon la technique de Milligan et Morgan. Une étude rétrospective de 1,134 cas.

Milligan and Morgan's procedure is commonly used for the surgical management of haemorrhoids. The aim of our study was to evaluate short term postoperative morbidity. Between 1975 and 1990, 1,134 patients were operated on. Two patients died after operation. The most frequent complications were pain (71%) and urinary retention (16.4%). Hemorrhages (7.6%) resulting in a re-operation occurred in 1% of cases. Other complications were rare and always cured by a specific treatment (stenosis: 2.9%, anal fissure: 0.5%, abscess: 0.6%, fistula in ano: 1.2%). Two patients had anal incontinence partially improved by biofeedback. Hemorrhoidal was 2%. Short term postoperative morbidity is generally low after Milligan and Morgan hemorrhoidectomy, with careful supervision in a surgical department and repeated postoperative care.

[Urinary disorders following anorectal surgery]. / Les troubles urinaires après chirurgie ano-rectale.

Troubles of micturition are common after anorectal surgery. They range from transient slight dysfunction to protracted retention necessitating catheterization. Surgical procedures for hemorrhoids are the main cause regardless of technique. Anesthesia and age of the patient are of minor importance. Men are more often affected than women. Innervation of the vesical sphincter is connected to that of the anorectal region be it by common innervation or by shared reflexes. Two mechanisms prevail: surgical trauma can lead to early sphincter contraction and atonia of the bladder or constipation after surgery may play a role. Psychologic environment and administration of sedatives play an important role in the treatment of postoperative micturition disorders. Parasympathomimetics are often successful. Catheterization can not always be avoided. It should not be used within first 18 hours after surgery. Rapid institution of intestinal motility has a preventive effect.