Relapse rate of healed duodenal, prepyloric, and gastric ulcers treated either with sucralfate or cimetidine.

A multicenter double-blind study was designed to compare the relapse rates of peptic ulcers after initial healing with a cytoprotective agent and a histamine (H2)-receptor antagonist. Patients with endoscopically verified prepyloric or duodenal ulcers were treated with cimetidine 400 mg twice daily or sucralfate 1 g four times daily for a maximum of eight weeks; gastric ulcers were treated for up to 12 weeks. Patients with healed ulcers were followed up to 12 months, during which time anti-ulcer medication was not permitted. Control endoscopy was performed two to four and nine to 11 months after healing and at the time of symptomatic relapse. A total of 258 patients were followed for 12 months; of these, 143 had been previously treated with cimetidine and 115 had been treated with sucralfate. The relapse rates and the median time to relapse did not differ between the two groups. After 12 months, 71 percent of the previously cimetidine-treated patients and 68 percent of the sucralfate-treated patients had experienced a relapse. Smoking significantly increased the relapse rate and shortened the time to relapse in the total study population and among cimetidine-treated patients; it had no such effect in the sucralfate-treated group.

Prolonged thromboprophylaxis following hip replacement surgery--results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin)

Discontinuation of thromboprophylaxis a few days after surgery may unmask delayed hypercoagulability and contribute to late formation of deep venous thrombosis (DVT). To investigate whether thromboprophylaxis should be prolonged beyond the hospital stay, a prospective, double-blind randomised study was conducted in 308 patients. All patients received initial thromboprophylaxis with dalteparin, dextran and graded elastic stockings. On day 7, patients were randomised to receive dalteparin (Fragmin) 5000 i.u. once daily, or placebo, for 4 weeks. All patients were subjected to bilateral venography, perfusion ventilation scintigraphy and chest X-ray on days 7 and 35. Patients with venographically verified proximal DVT on day 7 were withdrawn from the randomised study to receive anticoagulant treatment. The overall prevalence of DVT on day 7 was 15.9%. On day 35, the prevalence of DVT was 31.7% in placebo-treated patients compared with 19.3% in dalteparin-treated patients (p = 0.034). The incidence of DVT from day 7 to day 35 was 25.8% in the placebo-treated group versus 11.8% in the dalteparin-treated group (p = 0.017). The incidence of symptomatic pulmonary embolism (PE) from day 7 to day 35 was 2.8% in the placebo-treated group compared with zero in the dalteparin-treated group. This included one patient who died from PE. No patients experienced serious complications related to the injections of dalteparin or placebo. This study shows that prolonged thromboprophylaxis with dalteparin. 5000 IU, once daily for 35 days significantly reduces the frequency of DVT and should be recommended for 5 weeks after hip replacement surgery.

Highly selective vagotomy in the treatment of duodenal ulcer in a teaching hospital. A one-to-three year follow-up relating results to the number of operating surgeons, their surgical experience, and training conditions.

In the present series, highly selective vagotomy (HSV) was used in the treatment of duodenal ulcer and the patients were followed up 1 to 3 years after operation. Three months after operation, 57% of the patients had positive insulin tests (early and late positive). Ulcer recurrence rate was approximately 6.5%, whereas 18% of the results were judged to be therapeutic failures. The operations were done during the period of introduction of the method in a general surgical department of a teaching hospital, when the enthusiasm was great and the experience of the individual surgeon with HSV was small. The moderately poor results in this series are thought to be due to too many surgeons operating on a rather limited number of patients. Unrelated to this situation, a statistically significant increase in the frequency of positive insulin tests during the observation period was found, giving an incidence of 80% positive tests 2 years after the operation.

Experimental evaluation of gastric banding for treatment of morbid obesity in pigs.

The effectiveness and complications of gastric banding were evaluated in 15 miniature pigs. A Gore-tex or Dacron graft was employed to encircle the stomach. The animals were divided into five groups, three pigs in each group. Group 1 had a 13 mm pouch stoma with a Gore-tex band, Group 2 had a 16 mm pouch stoma with a Gore-tex band, Group 3 had a 13 mm pouch stoma with a Dacron band, Group 4 had a 16 mm pouch stoma with a Dacron band, and Group 5 had a sham operation. The weight variation in the control group was significantly higher than that in the other groups at the ninth postoperative week (p less than 0.05). There was no significant difference among Groups 1, 2, 3, and 4. The gastric band had migrated distally in seven pigs. It was located in the body of the stomach in four animals and in the pylorus in three. These three pigs died from stenosis of the pylorus. The band had eroded and penetrated all stomach layers in three other animals. There was no difference in the incidence of postoperative complications between the Gore-tex and Dacron band groups. The use of this simple operation in the treatment of the morbidly obese patient should be applied with caution.

The pharmacokinetics of one single preoperative dose of metronidazole or tinidazole.

Eight patients who were subjected to colorectal surgery received 1500 mg metronidazole and another 8 patients 1600 mg tinidazole. The two groups of patients were comparable in respect to age, body size, diagnoses, types of operations, premedication, and anaesthesia. Concentrations of the parent compounds and hydroxy-metronidazole were determined by high pressure liquid chromatography in serum and tissues (subcutaneous fat, rectus abdominal muscle, peritoneum, greater omentum, distal ileum, colon, appendix). The serum and tissue concentrations of metronidazole and tinidazole were within overlapping ranges. Hydroxy-metronidazole but not hydroxy-tinidazole was detected. The total area under the serum curves was 505 (SD: +/- 181) mg . h/l for metronidazole, 137 (+/- 38) mg . h/l for hydroxy-metronidazole, and 810 (+/- 286) mg . h/l for tinidazole. The serum half-life values in the same order were 8.5, 11.2, and 14.2 hours. The distribution volume (Vd,area) were 30.1 liter for metronidazole and 38.8 liter for tinidazole. The range of tissue concentrations were completely overlapping. The two regimens can, consequently, be assessed as pharmacokinetically similar.

Treatment of peptic ulcers--acid reduction or cytoprotection?

In a Swedish multicenter double blind trial cimetidine was compared to sucralfate in the treatment of peptic ulcer. Patients with endoscopically verified gastric, prepyloric and duodenal ulcers were treated with cimetidine 400 mg x 2 or sucralfate 1 g x 4 for four to eight weeks. Gastric ulcers were treated up to 12 weeks. Patients with healed ulcers were followed for up to 12 months. During follow-up without any anti ulcer treatment control endoscopy was performed 2-4 and 9-11 months after endoscopic healing and at symptomatic recurrence. 647 patients were studied (334 cimetidine and 313 sucralfate). 258 patients were included in the 12 months' follow up: of these 143 were previously treated with cimetidine and 115 with sucralfate. Healing rates were 92% in patients treated with cimetidine and 87% in those given sucralfate (ns). Symptomatic relief and ulcer recurrence did not differ between the treatments. Smoking significantly increased recurrence rate and shortened the time to recurrence in the cimetidine treated patients, but not in the sucralfate group. Cimetidine and sucralfate compared well in all aspects of acute peptic ulcer treatment and recurrence during one year of follow up.

Treatment of acute duodenal ulcer--a Swedish multicenter study.

Medical ulcer therapy focuses on enhancing mucosal defence mechanisms or reducing intraluminal acidity. In this Swedish multicenter, randomized double-blind study these two principles were compared in the treatment of acute duodenal ulcerations. Sucralfate (Andapsin 1g X 4) or cimetidine (Tagamet 400mg X 2), together with antacid tablets (Novalucol), were supplied to patients with acute ulcerations in the pyloric ring or duodenal bulb. Endoscopy was performed at inclusion, after four weeks and in some patients also after eight weeks. Besides healing rate, symptoms and antacid intake, smoking and side effects were recorded on a special protocol. 371 patients from 15 centers completed the trial. At inclusion the patient groups did not differ in any essential aspect. At four weeks 71% of 177 patients on sucralfate and 77% of 194 on cimetidine were healed. The corresponding figures for eight weeks were 86% (suc) and 92% (cim). The difference is not significant, the 95% confidence interval for the difference in ulcer healing efficacy of sucralfate compared with cimetidine at eight weeks was -12% to +5%. Antacid intake and symptoms decreased rapidly and equally in both groups. Side effects related to the treatments were uncommon. It is concluded that sucralfate and cimetidine, representing two different principles in medical ulcer treatment, are both very effective and compare well in the short term treatment of acute duodenal ulcer.

Swedish multicenter study on prepyloric and gastric ulcer.

A double-blind, randomized, multicenter study was performed to compare the effects of sucralfate and cimetidine for the short-term treatment of gastric and prepyloric ulcers. Ulcer healing was evaluated endoscopically at 4-week intervals up to 8 weeks in the PPU study and up to 12 weeks in the GU study. A total of 142 PPU and 134 GU patients completed the study. The overall healing rates after 8 weeks in the PPU study were 83% for the sucralfate group and 90% for the cimetidine group (NS), while the cumulative healing rates after 12 weeks in the GU study were 98% for the sucralfate group and 94% for the cimetidine group (NS). The confidence interval means that the 95% confidence limit ranges from 11% in favour of sucralfate to 2% in favour of cimetidine in the GU study and corresponding figures of 4% 19% in the PPU study. There were significantly more patients in the cimetidine group taking antacid tablets after 3 weeks in the GU study. Symptomatic relief did not differ significantly. Reported side effects and symptoms, pooled together with our duodenal ulcer study, were mostly non-specific and in some part related to the ulcer disease. In conclusion, sucralfate and cimetidine are both excellent healing agents for the short-term treatment of PPU and GU. Both give rapid and good symptomatic relief with no side effects of any importance.

Ulcer recurrences following initial ulcer healing with sucralfate or cimetidine.

Ulcer relapses after short-term treatment of duodenal, prepyloric and gastric ulcers with Cimetidine 400 mg b.d. or Sucralfate 1 g q.i.d. were studied in 270 patients over one year. Endoscopic examinations were carried out 2-4 and 9-11 months after ulcer healing or when symptoms occurred. Ulcer relapses were found in 59% of the Cimetidine-treated patients and 51% of those treated with Sucralfate, and a further 21% and 16% respectively had endoscopically verified erosive gastroduodenitis. The cumulative recurrence rate in smokers was 82% and that in non-smokers 51% (p less than 0.001). Relapses among the Cimetidine patients occurred more often in those who smoked or had irregular working hours. The onset of the relapse was not related ulcer healing time. The ulcer relapses appeared in the same region as the initial ulcer in 88% of cases and exactly at the original site in 33%. These results suggest that cytoprotection by Sucralfate did not result in fewer or later relapses than acid reduction by Cimetidine. Cigarette smoking obviously increases the risk of relapse in patients with healed peptic ulcers.

Polyglycolic acid (Dexon) versus Mersilene in repair of inguinal hernia.

In a prospective, randomized study of 520 inguinal hernioplasties, the incidence of early and late complications was compared after suture with Mersilene or Dexon. The respective overall recurrence rates were 5.1 and 4.9%. Persistent neuralgia was more common in the Mersilene group, necessitating late resection of the ilioinguinal nerve in two patients. Suture fistula occurred after one Mersilene repair. The study indicates that Dexon (absorbable polyglycolic acid) suture is reliable for preventing recurrent hernia. No serious complications were associated with its use.

Morphometric studies of the small intestine following jejuno-ileal shunt operation.

In five patients in whom a jejuno-ileal by-pass had been previously performed for massive obesity, a relaparotomy was performed because of subjective complaints or unsatisfactory weight reduction. At the reoperation morphometric studies were made of the functioning segments and the by-passed intestine. Length and circumferential measurements were taken, and the villous height and mucosal thickness were measured from histological biopsies. The results were compared with the findings in a control group. After shunt operation adoptive hypertrophy in the functioning remnant, a considerable length growth and dilatation of the gut, as well as a marked increase in villous height and total mucosal thickness, were demonstrated. These adaptive changes seem to be more marked in the distal part of the small intestine. No atrophy of the mucosa could be demonstrated in the excluded intestinal loop.

Early or delayed endoscopic papillotomy (EPT) in gallstone pancreatitis.

In 29 patients with gallstone pancreatitis, endoscopic papillotomy was performed during the first period (1976-1979) as elective procedure 1-8 weeks after the clinical symptoms had subsided. From 1979, endoscopic investigations and treatment were routinely done within 48 hours after the onset of clinical symptoms. The ERCPs and EPTs were well-tolerated and were performed without serious complications. The results of these series indicate that EPT can be safely performed in the acute stage of gallstone pancreatitis. Acute EPT gives effective drainage and relief of the acute symptoms in patients with obstructive pancreatitis.

Endoscopic papillotomy (EPT) in acute obstructive suppurative cholangitis.

Eight high risk patients, median age 79 years, with a distal obstruction of the common bile duct and serious clinical symptoms of acute obstructive cholangitis were treated by EPT. In seven patients, impaction of a stone in the common bile duct was found and in one patient, an obstructing cancer. EPT was performed without immediate complications and followed by obvious drainage of purulent bile in all patients. Repapillotomy with stone extraction was necessary in three patients 5, 6, and 10 days after the first EPT. The papillotomy was followed by immediate symptom relief, normalization of body temperature, and a decrease in leukocytes and bilirubin and alkaline phosphatase values within the first several postoperative days. Average hospitalization time was 8 days, ranging from 4-17 days. The patient with pancreatic cancer died 3 months after the EPT. One other patient died in pseudomonas sepsis 17 days after an uncomplicated EPT. ERCP controls in the other six patients have been normal and they all remain symptom free. Since early decompression is mandatory in these patients and laparotomy with internal decompression is associated with a high morbidity and mortality, endoscopic decompression should probably be the recommended treatment in patients with obstructive, septic cholangitis prior to employing this therapeutic option.

"Pseudotumor" of the stomach. Endoscopical and operative findings.

Persistent pathological changes at endoscopy are reported in three patients. At explorative laparotomy the changes were seen to be caused by neighbouring organs (splenic artery, pancreas and gallbladder). A correct diagnosis of "pseudotumor" of the stomach is necessary to avoid unwarranted surgery or unnecessary biopsies.

Polyglycolic acid (PGA, Dexon) sutures in neck surgery.

The limitations of catgut, which has been the only available absorbably suture material for surgical work are well known. In the present study, catgut and PGA (Dexon) are compared in 123 patients undergoing neck surgery with respect to wound complications. Dexon appears to offer a favourable alternative since this synthetic, absorbable suture material produces fewer early tissue reactions.

Effect of small bowel bypass on serum gastrin levels and gastric acid secretion in man.

In animals massive resection of the small intestine is followed by increased gastric acid secretion and an increase in serum gastrin levels. Whether hypersecretion occurs in man after intestinal resections or intestinal bypass is unclear, but an increase in fasting gastrin levels has been reported after intestinal resection. In this series a significant increase in basal gastric acid secretion and fasting serum gastrin levels has been demonstrated after intestinal bypass. However, none of the patients developed peptic ulcer or clinical symptoms of hypersecretion after the bypass operation. Whether the increase in basal secretion and the serum gastrin concentration are interrelated or of any clinical importance is uncertain.

[Lack of specialists in gastroenterological surgery]. / Spesialistmangel innen gastroenterologisk kirurgi.

Despite the fact that a prognosis in 1991 predicted a surplus of ten gastroenterological surgeons in 1994, several hospitals are now experiencing a lack of applicants. In order to define the scope of this problem, the Norwegian Gastroenterological Society and The Specialty Committee for Gastroenterological Surgery sent a questionnaire and made a telephone query to all Norwegian Surgical Departments in autumn 1995. There were 21 vacant posts and 27 specialists are still needed to carry out the tasks the hospitals are instructed to perform. An initiative must be taken to increase the capacity and geographical distribution of the education and improve the working conditions, and thereby job satisfaction, of gastroenterological surgeons.