Video-assisted thoracoscopic surgery in the diagnosis of lung disease. The Cretan experience.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been recently utilised in the diagnosis and management of thoracic diseases. In this report we reviewed our VATS experience for biopsy of diffuse or localised lung diseases in 51 cases focusing on indications, operative procedures, complications or failures rates. PATIENTS AND METHODS: Over the last 5 years we performed 51 VATS procedures for diagnostic purposes in 32 men and 19 women. The specific indications for VATS were lung biopsy for undiagnosed diffuse or localised lung disease. In all patients the postoperative pain was controlled with the use of non-narcotic analgesics and was measured according the visual analogue scale (VAS). RESULTS: There was no operative mortality. Postoperative non-fatal complications were seen in 3 cases (6%). The overall median duration of chest tube drainage was 2 days and the mean postoperative stay 3 days. In the diffuse lung disease a tissue diagnosis was obtained in all the cases. Conversion to thoracotomy was needed in 1 case (2%), owing to extensive adhesions. All patients expressed a postoperative pain control effect of less than 50% of VAS. CONCLUSIONS: VATS should be considered as a safe and effective procedure, with low postoperative pain and morbidity. Should be recommended in patients who require a histological diagnosis of diffuse or localised lung diseases.

Erythromycin enhances solid-phase gastric emptying in induced-hyperglycemia in patients with truncal vagotomy and pyloroplasty.

Erythromycin has been found to be a gastrointestinal prokinetic agent while acute hyperglycemia has been associated with delayed gastric emptying in healthy controls and diabetics. The aim of this study was to investigate whether hyperglycemia, per se, alters gastric motility, during erythromycin-induced acceleration of gastric emptying of solids in patients with truncal vagotomy and pyloroplasty (TVP) and the role of vagus nerves. Eight TVP patients and six controls underwent scintigraphic measurement of gastric emptying of a solid meal, during placebo in normoglycemia (5-8.9 mmol/liter glucose) or 200 mg intravenous erythromycin lactobionate in normo- or hyperglycemia (16-19 mmol/liter glucose) induced by intravenous glucose infusion, on separate days in random order. In the TVP patients during normoglycemia, the erythromycin compared to placebo accelerated the meal gastric half-emptying time (T1/2), (37.12 +/- 6.87 vs 91.88 +/- 11.53, P < 0.001) and decreased the lag-phase duration (P < 0.001) and the percentage of meal retained in the stomach at 120 min (P < 0.001). Erythromycin in hyperglycemia compared to normoglycemia increased T1/2 (61.25 +/- 10.67 vs 37.12 +/- 6.87, P < 0.001), prolonged lag-phase duration (P < 0.001), and the percentage of isotope retained in the stomach at 120 min (P < 0.001). The T1/2, the lag phase duration, and the meal retained in the stomach at 120 min, after giving placebo was significantly increased, compared to erythromycin administration in hyperglycemia (P < 0.001). Significant differences among patients and controls were found during gastric emptying after giving placebo and after erythromycin in hyperglycemia (P = 0.04 and P = 0.007, respectively), while nonsignificant differences were found after giving erythromycin in normoglycemia. We conclude that the effect of erythromycin-induced acceleration on gastric emptying is related to the plasma glucose level. Hyperglycemia reduces the erythromycin-induced acceleration of gastric emptying of solids in both controls and TVP patients. A significant increase in the delay of gastric emptying was achieved in TVP patients compared to controls after giving erythromycin in hyperglycemia and after placebo. Despite the inhibitory effect of induced hyperglycemia on gastric emptying, erythromycin is still able to accelerate the emptying rate and could prove to be a useful prokinetic agent under hyperglycemic conditions. Hyperglycemia may indicate a cholinergic-antagonist pathway that delays the erythromycin-induced acceleration of gastric emptying of solids and is more evident in vagotomized patients than controls, who retain the functional integrity of the vagus nerves.

Anterior lesser curve seromyotomy using a stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: longterm results.

BACKGROUND: Recently, gastric stapling with posterior truncal vagotomy has been performed, either by conventional or laparoscopic surgery, as an alternative to highly selective vagotomy and the Taylor procedure for the treatment of chronic duodenal ulcer. Our aim was to investigate the longterm effects after a stapling-modified Taylor procedure, conventional and laparoscopic, on gastric secretion and emptying and on clinical indices and recurrence rates in patients treated for duodenal ulcer before 1994. STUDY DESIGN: Thirty-one patients, aged 40 to 76 years (mean 53 years), were treated between 1986 and 1993, 21 by conventional and 10 by a laparoscopic stapling-modified Taylor procedure. Outcomes were studied for gastric acid secretion, solid and liquid gastric emptying, euterogastric reflux, endoscopic findings, and clinical indices using the Visick grading. RESULTS: Endoscopy revealed a healing ulcer in 29 patients. Two patients showed signs of chronic ulcerative disease with mild symptoms, without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis, and were classified as Visick III. Twenty-four patients were classified as Visick I and 5 as Visick II. The enterogastric reflux index ranged from 0% to 27%, and basal and peak acid output were 1.5+/-0.6 mmol H+/h and 12.2+/-6.4 mmol H+/h, respectively. The half-emptying time of solid and liquid meals was 78+/-9 minutes and 18+/-6 minutes, respectively. These results are likely to be similar to those obtained from the series of patients who underwent highly selective vagotomy or Taylor procedure and are close to those achieved in healthy controls. CONCLUSIONS: This modification of the original Taylor operation (conventional and laparoscopic) allows a more rapid, technically easier, and radical performance of the operation with excellent longterm results and should be considered an effective alternative for the treatment of duodenal ulcer.

Induced-hyperglycemia attenuates erythromycin-induced acceleration of hypertonic liquid-phase gastric emptying in type-I diabetic patients.

BACKGROUND: Erythromycin has been found to be a gastrointestinal prokinetic agent of hypertonic liquids, while acute hyperglycemia has been associated with delayed gastric emptying in diabetic patients. AIM: To investigate whether hyperglycemia, per se, reduces gastric motility during erythromycin-induced acceleration on gastric emptying of hypertonic liquids in diabetic patients. METHODS: In 12 type-I diabetic patients following a hypertonic radiolabeled liquid meal, gastric emptying was measured scintigraphically during normoglycemia (5-8.9 mmol/l glucose) or hyperglycemia induced by intravenous (16-19 mmol/l) glucose infusion. The tests were performed on 4 separate days in random order after administering either placebo or 200 mg i.v. erythromycin. RESULTS: In the hyperglycemic state compared to normoglycemia, the gastric emptying of the hypertonic liquid was reduced after placebo or erythromycin administration. The lag-phase duration (17.8+/-5.5 and 7.8+/-4.5 vs. 10.8+/-3.4 and 3.7+/-2.5 min, respectively, p<0.001), the overall gastric emptying time of the half meal (52.8+/-13 and 24.9+/-5.5 vs. 42.5+/-10.5 min and 16.6+/-6 min, respectively, p<0.001) and the retained percentage of liquid meal in the stomach at 60 and 100 min postprandially (p<0.001) were significantly increased. CONCLUSIONS: The erythromycin-induced acceleration on gastric emptying of hypertonic liquids in diabetic patients is related to the plasma glucose level. The induced hyperglycemia reduces the erythromycin-induced acceleration of liquid-phase gastric emptying, decreasing the overall gastric emptying rate. In spite of the inhibitory effect of induced hyperglycemia on the gastric emptying of hypertonic liquids, erythromycin is still able to accelerate the emptying rate and could prove to be a useful prokinetic agent under hyperglycemic conditions.

Laparoscopic modified taylor procedure in the treatment of duodenal ulcer: technique and outcome after 5-year follow-up.

BACKGROUND: Recently, gastric stapling with posterior truncal vagotomy has been performed by laparoscopic surgery, as an alternative to highly selective vagotomy (HSV) and the Taylor procedure for the treatment of chronic duodenal ulcer. AIM: To investigate, after a mean 5-year follow-up, the effect of the stapling-modified laparoscopic Taylor procedure, on gastric secretion, emptying and reflux as well as clinical parameters and recurrence rates in patients treated for duodenal ulcer. METHODS: 16 patients, aged 38-66 years, were treated from January 1993 to January 1996 (median 60.5 months), by the laparoscopic stapling-modified Taylor procedure, using the Endo-GIA stapler device. Assessment of the results of gastric acid secretion, solid and liquid gastric emptying, enterogastric reflux, endoscopic findings and clinical parameters, using the Visick grading, was performed. RESULTS: Endoscopy found healing ulcer in 15 patients. One patient showed signs of chronic ulcerative disease without gastritis or pyloric stenosis indicative of progressive ulcerative diathesis and was classified as Visick III. 14 patients were classified as Visick I and 1 as II. The enterogastric reflux index ranged from 0 to 26%, basal and peak acid output were 1.4 +/- 0.6 and 11.7 +/- 6.1 mmol H(+)/h, respectively. The half-emptying times of the solid and liquid meal were 82 +/- 7 and 16 +/- 6 min, respectively. These results are likely to be similar to those obtained from series of patients who underwent HSV or Taylor procedure and are closed to those from healthy controls. CONCLUSIONS: The laparoscopic modified Taylor procedure, using the Endo-GIA stapler device allows a more rapid, technically easier and radical performance of the operation with excellent long- term results and should be included in the armamentarium of the treatment of chronic duodenal ulcer.

Effect of nifedipine on rectoanal motility.

PURPOSE: Based on the rationale that the calcium channel blocker, nifedipine, decreases lower esophageal sphincter pressure in achalasia, a prospective controlled trial was performed to evaluate the effect of sublingual nifedipine on the anal sphincter of controls and patients with high anal resting pressures. METHODS: Ten age-matched and sex-matched controls without evidence of anal disorder and ten patients with hemorrhoids and/or fissure-in-ano were included in the study. Anorectal manometry, with an eight-channel, water-perfused catheter was performed on all patients before and 30 minutes after administration of 20 mg of sublingual nifedipine. RESULTS: Nifedipine significantly reduced anal resting pressure in both controls and patients by approximately 30 percent (P < 0.001 and P < 0.0001, respectively). A significant reduction was also noted in the length of high-pressure zone of the anal sphincter (P < 0.02 for both groups) and in the frequency (controls, P < 0.05; patients, P < 0.03) and amplitude (controls, P < 0.03; patients, P < 0.009) of slow waves in both groups, whereas the presence, frequency, and amplitude of ultraslow waves were significantly reduced only in the patient group (P < 0.05; P < 0.01; P < 0.0005, respectively). CONCLUSION: Nifedipine reduces the activity of the internal anal sphincter both in controls and patients with high anal resting pressure. The drug might be of some use in relieving symptoms in patients with hemorrhoids or anal fissure.