In vivo characterization of ischemic small intestine using bioimpedance measurements.

The standard clinical method for the assessment of viability in ischemic small intestine is still visual inspection and palpation. This method is non-specific and unreliable, and requires a high level of clinical experience. Consequently, viable tissue might be removed, or irreversibly damaged tissue might be left in the body, which may both slow down patient recovery. Impedance spectroscopy has been used to measure changes in electrical parameters during ischemia in various tissues. The physical changes in the tissue at the cellular and structural levels after the onset of ischemia lead to time-variant changes in the electrical properties. We aimed to investigate the use of bioimpedance measurement to assess if the tissue is ischemic, and to assess the ischemic time duration. Measurements were performed on pigs (n = 7) using a novel two-electrode setup, with a Solartron 1260/1294 impedance gain-phase analyser. After induction of anaesthesia, an ischemic model with warm, full mesenteric arterial and venous occlusion on 30 cm of the jejunum was implemented. Electrodes were placed on the serosal surface of the ischemic jejunum, applying a constant voltage, and measuring the resulting electrical admittance. As a control, measurements were done on a fully perfused part of the jejunum in the same porcine model. The changes in tan δ (dielectric parameter), measured within a 6 h period of warm, full mesenteric occlusion ischemia in seven pigs, correlates with the onset and duration of ischemia. Tan δ measured in the ischemic part of the jejunum differed significantly from the control tissue, allowing us to determine if the tissue was ischemic or not (P < 0.0001, F = (1,75.13) 188.19). We also found that we could use tan δ to predict ischemic duration. This opens up the possibility of real-time monitoring and assessment of the presence and duration of small intestinal ischemia.

Long-term results of laparoscopic Nissen fundoplication due to gastroesophageal reflux disease. A ten year follow-up in a low volume center.

BACKGROUND AND AIMS: Laparoscopic 360 degrees nissen fundoplication has been our routine surgical procedure since 1995, in the treatment of gastroesophageal reflux disease (GERD). We have reviewed our results of patients treated with laparoscopic Nissen fundoplication (LNF) during 1995-1998. MATERIAL AND METHODS: 170 patients have undergone LNF in our hospital since 1995. during the period of 1995-1998, 33 patients were treated. all patients were asked to return a structured follow-up questionnaire, using a Visick grading scale, after an average of 69 months (2003) and 117 months (2007). 29 questionnaires (90%) were answered in 2003, and 31 questionnaires (97%) were answered in 2007. one patient died at home before the first questionnaire in 2003, and is therefore not included. We present our results on LNF after an observation time of 117 months (range 99-144 months). RESULTS: patient satisfaction after LNF is rated as very good or good (Visick 1-2) in 93% in 2003 and 97% in 2007. 97% of the patients would recommend the same treatment to other patients with similar symptoms at ten year follow up. One patient has undergone resurgery during follow up. Daily gas bloat and flatulence is reported in 52% in 2003 and 39% in 2007, and is the most common reason for reduced satisfaction. Five patients report of reflux symptoms, one patient daily and four patients sometimes, where the first patient still uses proton pump inhibitor (PPI) daily and three patients use PPI occasionally. CONCLUSIONS: patient satisfaction after LNF treatment for gerd is high at long-term (10 years) follow-up. Bloating and flatulence persistently occurred to a great extent and the need for preoperative information regarding these symptoms is important.

[Abdominal metastases from signet cell carcinoma of the appendix vermiformis]. / Metastaser i bukhulen fra signetcellekarsinom i appendix vermiformis.

Signet cell carcinomas are often aggressive tumours. A patient with this tumour, originally located in the appendix, was diagnosed with peritoneal metastases. When she later got abdominal symptoms, computer axial tomography indicated large infiltrating tumour masses in the pelvis. However, when a laparotomy was performed, the only macroscopic tumour masses was localised to the ovaries (Krukenberg tumour). The surgical intervention gave the patient an improved quality of life, and most likely prolonged survival. We stress the importance of thinking of this possibility.

An experimental study on effects of monopolar diathermy on the bile ducts.

OBJECTIVE: To study the effects of monopolar diathermy on the bile ducts in pigs. DESIGN: Experimental study. SETTING: University hospital, Norway. MATERIAL: 18 pigs. INTERVENTIONS: Laparotomy, application of diathermy at standard sites along the cystic duct, the bile ducts, and a cystic duct containing a metal clip, 3 to 12 times of 5 seconds' duration at each site. Temperature was subsequently recorded at standard measurement points on the bile ducts. Twelve pigs were killed after three weeks for assessment of the bile ducts at necropsy. MAIN OUTCOME MEASUREMENTS: Increase in temperature in the bile duct walls and late changes in the bile ducts. RESULTS: Temperature increased by 4-6 degrees C during 6 of 330 diathermy applications along the cystic duct, by 4-18 degrees C in 8 of 126 applications along the common bile duct, and by 4-11 degrees C at the clip in 9 of 54 applications. There were no macroscopic or microscopic changes in the bile ducts. CONCLUSION: Monopolar diathermy induced unexpected distant increases in the temperature of the bile duct walls and at a clip on the cystic duct probably because diathermy current energy was distributed along channels of high current conductivity.

Complications during the introduction of laparoscopic cholecystectomy in Norway. A prospective multicentre study in seven hospitals.

OBJECTIVE: To assess the morbidity of laparoscopic cholecystectomy since its introduction in Norway in the Autumn of 1990. DESIGN: Postal collection of prospectively collected data. SETTING: Practices of 26 surgeons in 7 district and university hospitals. SUBJECTS: 527 patients who underwent laparoscopic cholecystectomy. INTERVENTIONS: 133 patients (25.5%) had endoscopic retrograde cholangiopancreatography before operation, and two had cholangiograms during operation; dissection was by electrocautery in 490 patients and by laser in 37. MAIN OUTCOME MEASURES: Morbidity, number converted to open operation, and number who required reoperation. RESULTS: There were no deaths and a total of 70 complications (13.3%), 8 of which were after laser dissection. There were 59 local complications (11.2%) and 11 general (2.1%); 12 patients (2.3%) required reoperation for bleeding (n = 5), biliary leak (n = 4), and incisional hernia (n = 3). One had a retained stone in the common duct. 42 were converted to open operation (8.0%), 11 because of complications (bleeding, n = 6; damage to the bile duct, n = 3; and bowel perforation, n = 2). Of the 28 patients with acute cholecystitis 5 (17.9%) had to be converted to open operations and 7 (25.0%) developed complications. 2 of these patients had bile duct injury. CONCLUSION: The morbidity during the introductory period of laparoscopic cholecystectomy in Norway is higher than that reported elsewhere, indicating that the risk of complications is increased during the learning period.

Plasma kallikrein generation in endotoxemia is abolished by ultra high doses of methyl-prednisolone: in vivo studies in a pig model.

Thirty-one healthy young pigs were studied to evaluate the effects of methylprednisolone sodium succinate (MP) on cellular, proteolytic, and hemodynamic parameters in normal and endotoxin-exposed animals. Fourteen animals served as controls, whereas 17 test animals received a continuous infusion of endotoxin, 0.01 mg/kg/3hr. Seven of the test animals and seven of the control group received a total of 200 mg/kg body weight over 5 hr of MP, 100 mg/kg as pretreatment before the endotoxin infusion was started. The administration of MP to control animals did not cause changes in the plasma kallikrein-kinin system, as determined with chromogenic peptide substrate assays. Only temporary effects, which normalized during the observation period, were seen in hemodynamic parameters. The pretreatment with MP significantly counteracted the increases in plasma kallikrein activity (KK) and the decreases in functional kallikrein inhibition capacity (KKI) seen after endotoxin infusion in untreated animals. Marked reductions in the number of circulating leukocytes and platelets were observed in untreated endotoxemia, together with increases in hematocrit. Furthermore, increases in pulmonary vascular resistance (PVR) and decreases in cardiac output (CO), left ventricular stroke work (LVSW), and mixed venous oxygen saturation (SvO2) ensued. The changes in circulating cells, PVR, and SvO2 were significantly counteracted by MP treatment, whereas changes in hematocrit, CO, and LVSW were only moderately improved.

Studies on components of the contact phase system in patients with advanced gastrointestinal cancer.

The authors have studied components of the contact system in plasma obtained from patients with advanced gastrointestinal cancer. Plasma samples from 118 healthy blood donors served as controls. Plasma prekallikrein (PKK) values, evaluated by chromogenic peptide substrate technique, were significantly decreased in patients with cancer compared with healthy blood donors. High molecular weight kininogen (HMwK) and Hageman factor (FXII) values, assayed by immunochemical techniques, were also decreased in the patients with cancer. The changes of contact factors were most pronounced in patients with liver metastasis. The most striking observation in our study, however, was the elevated inhibitor values in patients with cancer. Alpha-2-macroglobulin (alpha 2-M) and C1 inhibitor (C1INH) values, determined both by functional and immunochemical techniques, were markedly increased in patients with cancer. In conclusion, this study shows that patients with intestinal cancer have reduced values of contact factors and markedly elevated inhibitor values which indicate that development of malignant tumors in the gastrointestinal tract is associated with changes in the contact system of plasma.

[Surgical treatment of necrotizing fasciitis]. / Kirurgisk behandling ved nekrotiserende fasciitis.

We present nine patients with necrotizing fasciitis. Two of them had Fourniers gangrene. Predisposing factors included diabetes mellitus, alcohol and drug abuse. Local signs were redness, swelling and pain rapidly followed by fever and deterioration in the patient's general condition. Soft tissue-gas was observed in all patients. It was found either clinically, on roentgenograms or by CT. Bacteria were found in blood cultures and/or necrotic tissues in all patients. The dominating treatment was radical surgical excision and early reexplorations. Antibiotics, intensive care support and early parenteral nutrition were given. Four patients were given hyperbaric oxygen treatment. The overall mortality rate was 11%. Amputation of one lower extremity became necessary in three patients. In these cases 4-8 days had elapsed between the onset and the first surgical excision. We find it important to underline early diagnosis and radical surgical excision in patients with necrotizing fasciitis.

Plasma proteolysis and circulating cells in relation to varying endotoxin concentrations in porcine endotoxemia.

Ten juvenile pigs receiving a continuous infusion of 0.01 mg/kg of endotoxin over 3 hr and seven animals infused with sterile saline (serving as controls) were studied for 5 hr. Endotoxin concentrations in plasma as determined with a chromogenic Limulus amoebocyte lysate (LAL) test reached a steady state of about 1,000 ng/liter after 1 hr and declined rapidly as the infusion was discontinued. Preinfusion values were reached at the end of the observation period. Endotoxin concentrations found during the infusion period were comparable with those seen in humans with septicemia. The endotoxin infusion was followed by hemoconcentration, leukocytopenia, and thrombocytopenia. Using chromogenic peptide substrate assays, activation of the plasma kallikrein-kinin, fibrinolytic, and coagulation systems was detected. Although the endotoxin concentrations reached preinfusion values within the last 2 hr of the observation period, changes found in circulating cells and components of the plasma cascade systems did not normalize, and the hemodynamic situation did not change.

Peritoneal lavage efficiently eliminates protease-alpha-2-macroglobulin complexes and components of the contact system from the peritoneal cavity in patients with severe acute pancreatitis.

Trypsin (Try), plasma kallikrein (KK) and plasmin activities together with coagulation factor XII (F XII, Hageman factor), high-molecular-weight kininogen (HMWK), plasma prekallikrein (PKK), alpha 2-macroglobulin (alpha 2-M), C1 inhibitor (C1Inh), and functional plasma kallikrein inhibition (KKI) values were studied in peritoneal fluid and lavage taps of 9 patients with severe acute pancreatitis treated with peritoneal lavage. Both immunochemical methods and functional techniques based on chromogenic peptide substrate assays were used. In the exudate obtained before peritoneal lavage was performed, F XII was 52%, HMWK was 30%, PKK was 40%, alpha 2-M was 29% and C1Inh was 57% of standard plasma pool values, determined by immunochemical technique. Functional plasma KKI values were zero, whereas Try activities determined by chromogenic peptide substrate technique were markedly elevated in the exudate. Using a prepacked HR 10/30 Superose Tm 12 column (Pharmacia, Uppsala, Sweden) and chromogenic peptide substrate assays, Try and KK activities were detected in the alpha 2-M containing fractions of the peritoneal exudate demonstrating KK-alpha 2-M and Try-alpha 2-M complex formation. The peritoneal lavage procedure efficiently eliminated components of the contact system and protease activities. In the first lavage tap, Try activities were markedly reduced compared to values found in the exudate and concentrations of F XII, HMWK, PKK, alpha 2-M and C1Inh were all zero. In consecutive lavage taps Try values were also zero. The study shows that the lavage procedures efficiently clears the peritoneal cavity for protease-alpha 2-M complexes generated during acute pancreatitis. Also, components of the contact system found in peritoneal exudate, and which might serve as substrates for the protease-alpha 2-M complexes, are rapidly eliminated by the procedure.

[New therapeutic alternatives for patients with gallstones]. / Nye alternativer i behandlingen av pasienter med gallesten.

Calculi in the bile ducts are usually removed by surgery or endoscopic papillotomy. When these methods are contraindicated or fail, new and non-surgical alternatives can now be used. Percutaneous transhepatic balloon dilatation of the papilla of Vater enables expulsion of stones in the bile duct. Large stones in the bile ducts can be reduced in size using extracorporeal shock waves or completely dissolved by instillations of Methyl-tertiary-butyl ether in the common bile duct. We report the cases of three patients who were treated successfully for stones in the bile duct using combinations of these techniques.

Sodium taurocholate-induced acute pancreatitis in pigs. Pathomorphological studies of the pancreas in untreated animals and animals pretreated with high doses of corticosteroids or protease inhibitors.

Acute pancreatitis was induced in anesthetized pigs by injection of Na-taurocholate into the pancreatic duct. The pigs were allocated to 4 groups. One group remained untreated while the other groups received either C1-inhibitor, aprotinin or methyl-prednisolone intravenously as pretreatment. Extensive necroses of the pancreatic parenchyma, peripancreatic oedema and accumulation of large amounts of fluid in the abdominal cavity developed within a few hours in all experimental groups. Pretreatment significantly improved hemodynamics and increased the survival rate at 6 hours. It is concluded that the most essential effect of the pretreatments were reduction of proteolytic activities which are secondary to the pancreatic lesions.