Maturation of porcine tracheal cholinergic and inhibitory non-adrenergic, non-cholinergic innervation.

It is known that both excitatory cholinergic neural activity and nitric oxide (NO) release from inhibitory non-adrenergic, non-cholinergic (iNANC) nerves are important determinants of adult human airway smooth muscle tone. However, the level of cholinergic and iNANC activity in the newborn is unknown. Therefore, isolated trachealis muscle strips were obtained from neonatal, 10-day-old, and adult pigs. To quantify cholinergic nerve activity, isometric contractions were elicited by stimulating the nicotinic receptors of the cholinergic intramural ganglia with dimethyl-phenyl-piperazinium (DMPP). After ganglionic blockade with hexamethonium, the post-ganglionic cholinergic nerves were subjected to electrical field stimulation (EFS). To assess whether DMPP and EFS were also stimulating nitric oxide release from iNANC nerves, the stimulations were repeated after NO-synthase inhibition with 3 x 10(-5) M NG-monomethyl-L-arginine acetate (LNMMA). All responses were expressed as a percentage of maximal response to 10(-4) M acetylcholine. Although no significant age-related differences in the contractile responses to DMPP were demonstrated between the three age groups, the EFS responses were significantly different. At EFS frequencies of 1 and 2 Hz the responses of all three groups were different (P < 0.05, unpaired t-test). At frequencies of 0.125 and 0.5 Hz the contractile responses in the neonatal and 10-day-old groups were less than in the adult animal tissues (P < 0.05, unpaired t-test). At 4 Hz and above, the responses of the 10-day-old and adult groups became greater than the neonatal (P < 0.05, unpaired t-test). LNMMA did not significantly increase the contractile responses to DMPP at any age. Only in the neonatal rat and 10-day-old groups was a significant increase of the EFS frequency responses by LNMMA demonstrated (140.4 +/- 38.2% and 144.2 +/- 41.2%, respectively, at 0.5 Hz, ANOVA, P < 0.001). In conclusion, the DMPP responses suggest that the neonatal porcine cholinergic innervation is mature at birth. This contrasts with a frequency-dependent increase in EFS responses from birth. This may be due in part to a relative increase in iNANC modulation of post-ganglionic cholinergic activity at birth. This mechanism is not responsible for the increase in higher EFS frequency responses with post-natal maturation. Inhibitory iNANC activity may serve a protective role in the newborn, given the reported hyper-responsiveness of airway smooth muscle, small airway caliber, and high chest wall compliance at this age.

The many uses of the U tube.

U tube placement was employed as an adjunct to complicated biliary procedures in 14 patients. We found the transhepatic tubes to be useful for stenting biliary anastomoses, maintaining biliary drainage, delivering localized irradiation, and acting as permanent external conduits. The tubes remained in placed an average of 15 months and as long as 40 months. The frequency of cholangitis was minimized by frequent tube exchange. The U-shaped configuration makes tube exchange easy and inexpensive to perform.

Operative management of incidental cholelithiasis.

Incidental cholelithiasis was encountered at the time of celiotomy in 56 patients. Thirty-three of the patients underwent concomitant cholecystectomy. The overall morbidity and mortality were 27 and 3 percent, respectively, but only one complication (3 percent) was clearly related to the cholecystectomy. Cholecystectomy was not performed in 23 patients. Within 6 months of primary celiotomy, acute cholecystitis developed in 11 patients, 3 had attacks of biliary colic, and 2 became jaundiced. Fifteen patients (65 percent) underwent cholecystectomy and 6 of the 15 (40 percent) required common bile duct exploration. Concomitant cholecystectomy adds minimal morbidity to the operation and should be performed unless specific contraindications exist. Left untreated, cholelithiasis becomes symptomatic and leads to subsequent operation in most patients, which may require a more extensive procedure producing greater morbidity.

Value of pneumoperitoneum in the diagnosis of visceral perforation.

The presence or absence of pneumoperitoneum may not be as reliable an indicator of visceral perforation as commonly thought. Visceral perforation as commonly thought. Visceral perforation resulted in pneumoperitoneum in only 51 percent of patients in this study. Pneumoperitoneum occurred in 14 percent of patients in whom the extraalimentary intraperitoneal air had sources other than a perforated viscus. These patients' clinical findings were often indistinguishable from those of patients with a perforated viscus, and three patients underwent celiotomy unnecessarily. The routine use of the left lateral decubitus film to detect pneumoperitoneum and the judicious use of gastrointestinal contrast studies should be part of the optimal management of patients with suspected visceral perforation.

Increased incidence of pancreas-related complications in patients with postoperative pancreatitis.

The incidence and significance of pancreas-related complications (pseudocysts, abscesses, and fistulas) were evaluated in 100 patients with acute pancreatitis. Alcoholic (40 percent), biliary (20 percent), and postoperative (15 percent) pancreatitis were seen most frequently. Eighteen patients had severe pancreatitis (3 or more Ranson's criteria). The overall mortality rate was 8 percent, and there were 16 pancreas-related complications. Pancreas-related complications developed in eight patients (53 percent), including two pseudocysts, four abscesses, and two fistulas. The incidence of pancreas-related complications was significantly greater in the postoperative group than in the overall 9 percent incidence in the other groups (p less than 0.005). Half of these patients required operation for their complications. Patients with postoperative pancreatitis are at a markedly increased risk of pancreas-related complications. Since these complications occur even in apparently mild cases of pancreatitis, these patients should be followed closely to detect pancreas-related complications.

Conservative treatment of liver hematoma in the postpartum period. A report of two cases.

Two pregnant women at term had antenatal symptoms of impending preeclampsia (thrombocytopenia, liver dysfunction) and developed clinical signs of a leaking subcapsular liver hematoma in the immediate postpartum period. They were managed conservatively, with blood transfusions and ultrasonic computerized tomographic monitoring of the hematoma. Both did well, and their hospital stays were brief. These cases suggest that immediate celiotomy may not always be necessary for suspected liver hematoma associated with preeclampsia.

Postoperative adjuvant irradiation of rectal and rectosigmoid cancer.

Local recurrence is a major problem for approximately 40% of stage B and C rectal cancer patients following successful complete resection by either anterior (AR) or abdominoperineal resection (APR). We retrospectively analyzed the sites of local recurrence in 138 patients following curative surgery, and evaluated the effect of 5,000 rad adjuvant postoperative pelvic EXRT in reducing the incidence of local recurrence in 40 patients.

Control of hemorrhage following missile wound to the pelvis.

Exsanguination is the immediate problem when dealing with trauma to pelvic blood vessels. A case is presented to demonstrate a systematic approach for successful management. Embolization, arteriography, and externally controlled compression stopped the life-threatening hemmorrhage.

Comparison of the pharmacodynamics of ketamine in the isolated neonatal and adult porcine airway.

Ketamine inhibits contractions of adult airway smooth muscle by actions both within the smooth muscle cell and the vagal intramural ganglia. Its effects in the neonate are unknown, as physiological changes occur after birth in both of these structures. Isolated trachealis muscle strips from neonatal and adult pigs were contracted selectively by stimulation of the vagal intramural ganglia using dimethyl-phenyl-piperazinium (DMPP), the post-ganglionic vagus nerve using electrical field stimulation (EFS) and the smooth muscle cell itself using acetylcholine (ACh) in the presence of tetrodotoxin. The inhibitory effects of clinical concentrations of ketamine at each site were compared both within and between age groups. At both ages, ketamine 10(-4) mol litre-1 abolished (P < or = 0.001) and ketamine 10(-5) mol litre-1 attenuated (P < or = 0.001) the contractile responses to DMPP at the intramural ganglia. The inhibitory effect of ketamine 10(-4) mol litre-1 on ACh responses at the smooth muscle cell was greater in neonatal preparations (P = 0.025). Furthermore, only neonatal EFS and ACh responses were attenuated by ketamine 10(-5) mol litre-1 (P = 0.04 and P = 0.03). Ketamine 10(-4) mol litre-1 attenuated EFS responses in both age groups (P < or = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative pancreatitis.

Our experience with 52 patients who had postoperative pancreatitis develop during a nine year period was reviewed to characterize this group, to determine the incidence of complications and to identify variables predictive of complications. Biliary tract procedures (n = 10), colectomy (n = 9) and intestinal resection (n = 9) were the most frequently performed operations preceding pancreatitis. Thirty of the procedures were near the pancreas. Pancreatitis was detected within seven days of the operation in 26 of the patients. Sixteen patients had complications related to the pancreas, 12 had other nonlethal complications and nine died. Fourteen patients had severe pancreatitis (greater than or equal to 3 Ranson's criteria) and were more likely to have a complicated course (p less than 0.05). Complications related to the pancreas included pancreatic pseudocyst (n = 9), abscess (n = 4), fistula (n = 2) and arterial hemorrhage (n = 1). Age, operation performed, serum amylase level and frequency of hypotension, renal failure and other complications were similar in patients with and without complications related to the pancreas. A high index of suspicion must remain throughout the postoperative period to recognize inflammation of the pancreas and its complications so that prompt diagnosis and management can be undertaken.

Papillary carcinoma of the thyroid and familial polyposis coli.

A 22-year-old white woman in whom multicentric papillary carcinoma of the thyroid developed two years after prophylactic colectomy for intestinal polyposis is reported. This association has been observed by others. Patients with familial polyposis coli are at risk for a variety of malignancies other than colonic, and careful life-long surveillance is necessary.

gamma-Aminobutyric acid plasma levels and brain binding in Eck fistula dogs.

It has been hypothesized that gamma-aminobutyric acid (GABA), the principle inhibitory neurotransmitter of the mammalian brain, contributes to the neural inhibition of hepatic encephalopathy. Eck fistulae were created in seven dogs and celiotomy alone performed in five dogs to determine plasma GABA levels, brain GABA binding, and synaptic membrane changes in dogs after creation of Eck fistulae. Eck fistula dogs lost 19 +/- 9% body weight, lost hair, ate poorly, and developed atrophic livers with classic hepatic histological changes. Control dogs maintained body weight, normal behavior, and normal liver histology. Plasma GABA levels were elevated significantly in the Eck fistula dogs (312 +/- 105.9 nM) both as compared to controls (154.4 +/- 69.8) and to preoperative levels (161.6 +/- 56.7, P less than 0.05). Brain GABA binding for animals sacrificed at 6-9 weeks was not statistically different from sham-operated dogs sacrificed at 6 weeks (1.87 +/- .54 pmole/mg protein vs 1.186 +/- 24, P less than 0.2). Synaptic membrane fluidity and cholesterol were likewise unchanged. Plasma GABA levels are increased significantly following complete portal diversion but do not correlate with the degree of encephalopathy. GABA binding to neural membranes are not significantly increased in Eck fistula dogs. These findings do not support a direct relationship between plasma GABA levels and neurologic impairment in Eck fistula dogs.

Comparison of techniques for growing small bowel neomucosa.

Small bowel neomucosa has been grown on a variety of surfaces. The purpose of this study was to compare the rate of growth and function of neomucosa on colon serosa (CS) and abdominal wall muscle (AM) in New Zealand white rabbits. The terminal ileum was incised for 5 cm and patched with either adjacent CS (23 animals) or AM (19 animals) to create a 2 X 5-cm defect. Gross and histologic examinations of the specimens at 1, 2, 4, and 8 weeks revealed that the rate of growth was similar in both groups. There was minimal lateral ingrowth at 2 weeks, nearly complete coverage of the defects at 4 weeks, and complete coverage of the defect at 8 weeks in more than 85% of animals with mature villi and muscularis mucosae. The ileal diameter at the site of patching increased in both groups from 11.9 +/- 2.6 to 16.3 +/- 3.2 mm in the CS group and 11.3 +/- 2.5 to 15.1 +/- 1.8 mm in the AM group (P less than 0.01). Glucose uptake was similar in both groups being 65.4 +/- 24.1% of control in the CS group and 73.9 +/- 29.8% in the AM group. Brush border enzyme activity of sucrase, maltase, and lactase was similar to controls in the AM group but in the CS group activity of sucrase and maltase were significantly less than controls (P less than 0.01). Average body weight was increased postoperatively in both groups. There was one anastomotic leak in each group and two cases of partial intestinal obstruction in the abdominal wall group.(ABSTRACT TRUNCATED AT 250 WORDS)