[Management of duodenal stump after gastrectomy].
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A new method to evaluate and dilate pyloric stenosis in the presence of peptic ulcer is presented. The pylorus is explored by means of a probe (26 to 38 Ch) which is inserted orogastrically. This procedure is used in association with highly selective vagotomy (HSV). Healing of the ulcer and the pyloric stenosis was observed in 12 patients.
A case is reported of acute gastric dilatation associated with chronic duodenal ulceration and pyloric stenosis. Death was due to mechanical impedance of venous return, resulting from grossly increased intra-abdominal pressure.
The trial of a gastrointestinal tube in gastroduodenal ulcer indicates its high efficiency for enteral tube feeding in serious ulcer cases and as a therapeutic modality in noncomplicated cases. The tube introduction in 55 patients out of 89 promoted the defect healing within 2-3 weeks, in 30 out of 36 cicatrization occurred on week 3-5. The presence of the tube produced no effect on acid production in the stomach, cicatrization of the ulcer took place without basic therapy in remaining hypo-achlorhydria and hyperchlorhydria. Clinico-endoscopic evidence and data on gastroduodenal motility and evacuation suggest the conclusion on the neuro-reflex mechanism of the tube action which eliminates painful syndrome and motor-evacuatory abnormalities which are believed essential in pathogenesis of peptic ulcer.
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Present methods for collection of duodenal bile may be difficult to perform and may involve the use of sedation and roentgenograms. The string test (Entero-Test Pediatric, HDC Corporation, Mountain View, CA) has replaced the need for intestinal intubation for diagnosis of giardiasis and bacterial overgrowth. The present study investigated the use of the string test for collection of duodenal bile. Fifteen children were administered string tests. No complications were encountered. The distal end of the string had yellow pigmented fluid that contained bilirubin conjugates in quantity and quality compatible with duodenal bile. The study demonstrates that the string test is a useful procedure for collection of duodenal bile samples in infants and children.
The role of the adrenergic system in normal gastric function was assessed in five healthy volunteers by measuring gastric secretion and emptying after a mixed meal containing a non-absorbable marker, [14C]-PEG 4000, with and without 100 mg of metoprolol, a beta 1-adrenoceptor antagonist. Intraduodenal perfusion of PEG 4000, and gastric and jejunal sampling was achieved by means of a gastrointestinal intubation technique. Gastric function was assessed from the degree of dilution of the duodenal marker. Analysis of acid content by titration allowed the gastric acid secretory rate to be determined. Gastric emptying of a meal over 4 h was similar with and without metoprolol, the time to 50% emptying being 100 min. In the presence of metoprolol, gastric acid content was significantly increased during the late postprandial period producing a corresponding increase in acid load delivered to the duodenum. beta 1-adrenoceptor blockade appears to prolong the gastric secretory response to food without altering gastric emptying.
We determined if changes in the irregular motor activity of phase II, the dominant motility phase in awake fasting humans, are associated with fluctuations in pancreatic secretion by intubating the upper gastrointestinal tract of 15 healthy humans and recording antral and duodenal motility and obtaining duodenal samples for one or two interdigestive motility cycles. Antral phase II activity was graded as having low, intermediate, or high frequency of contractions and related to duodenal trypsin output and plasma concentrations of motilin and human pancreatic polypeptide (HPP), a marker of vagal cholinergic tone. Low, intermediate, and high phase II motor activities were significantly associated with trypsin outputs (U/10 min; mean +/- SE) of 576 +/- 137, 1,441 +/- 225, and 3,621 +/- 521, respectively (P less than 0.001). Plasma motilin levels did not vary with the grades of phase II motility (P greater than 0.1), but levels of plasma HPP and the grades of phase II motility were positively correlated (P less than 0.001). The close correlation among motility, pancreatic secretion, and plasma HPP during phase II suggests that vagal cholinergic pathways are involved in the common regulatory mechanism controlling phase II interdigestive motility and pancreatic secretion.
Feedback inhibition of basal pancreatic enzyme secretion by luminal pancreatic enzymes appears to be an important regulator of pancreatic secretion in some laboratory animals. To determine whether pancreatic enzymes in the jejunum influence pancreatic or gastric functions in healthy man, we intubated six subjects with a gastric sump tube and a four-lumen duodenal tube which provided (1) a duodenal perfusion site, (2) a duodenal aspiration site, (3) an inflatable balloon immediately distal to the aspiration site, and (4) a jejunal perfusion site immediately beyond the balloon. In this way, the gastroduodenal segment could be functionally separated from the remainder of the intestine. The jejunum was exposed to normal saline, active pancreatic-biliary secretions, or pancreatic-biliary secretions in which the enzymes had been inactivated by heat. Ten minutes after initiation of each jejunal perfusion, normal saline was instilled into the stomach. No differences in trypsin secretion, gastric acid secretion, or gastric emptying occurred with the different jejunal perfusates. We therefore conclude that normal man, in the absence of intraluminal nutrients, does not exhibit a jejunal pancreatic enzyme-dependent feedback control mechanism for pancreatic enzyme or gastric secretion. However, our study does not exclude the possibility of a duodenal feedback regulatory mechanism.
The absorption of dl-methadone from the gastrointestinal tract of the Sprague-Dawley rat was examined by the in vivo segment technique. Duodenal absorption, measured as a function of time and dose, followed first-order kinetics with a half-life of 15.6 min. Absorption was not influenced by prior or concomitant administration of a variety of drugs. Absorption from other regions of the intestine was similar to that from the duodenum; in contrast, absorption from the stomach was markedly slower. Gastric absorption was increased by alkalinization of stomach contents but was still considerably slower than from the duodenum. Gastric emptying of methadone appears to be the rate-limiting step in the overall gastrointestinal absorption of the drug, since the rate of emptying following intubation of the drug into the stomach was also considerably slower than the rate of duodenal absorption.
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A 2-year-old horse with signs of colic, reflux on nasogastric intubation, and large colon distention on transrectal palpation was found to have a leiomyoma involving the duodenum. The mass was excised without penetration of the lumen of the small intestine, and the horse recovered without complications.
OBJECTIVE: To demonstrate our experience with self-expanding nitinol duodenal stents in the treatment of inoperable malignant gastroduodenal obstructions. MATERIALS AND METHODS: Seventy two (72) patients with malignant gastroduodenal obstruction, 42 men and 30 women, were treated with peroral application of a gastroduodenal nitinol stent. The average age was 61.3 years (range of 21 to 92 years). The gastroduodenal obstructions was caused by gastric tumors (38 patients), pancreatic tumors (15), gallbladder tumors (8), bile duct tumors (5), metastatic tumors (4) and two cases of duodenal invasion by regional tumor (colon and hypernephroma). These conditions were considered inoperable in all the patients. Using a flexible 20 Fr. intubator and assisted by endoscopy and fluoroscopy, 3 uncovered stents, 7 fully covered stents and 62 partially covered stents were inserted. RESULTS: A stent was inserted in 67 of the 72 patients (93%) and no patient showed any duodenal perforation nor needed surgery. As to the symptoms, of the 12 patients who did not tolerate any type of oral treatment, 10 improved after the duodenal stents were introduced. Stent migration was observed in 6 cases, 4 of these with fully covered stents. In these cases, the stents were removed by endoscopy and then replaced by a partially covered stent. Tumor colonization was observed in five cases, two of them with the uncovered stents initially used. Out of the 62 procedures with partially covered stents, migration was observed in two cases and only two stents were colonized by the tumor. Patients died between 1 and 96 weeks after introducing the stents (average survival was 20.7 weeks). CONCLUSIONS: Peroral placement of nitinol stents is an effective and easy method of mitigation for most patients with malignant gastro-duodenal obstructions. Migration of fully covered stents and tumor colonization of uncovered stents are important limitations, which can be avoided by using partially covered stents.
A review of 100 consecutive patients admitted with simple, mechanical small-bowel obstruction secondary to adhesions and treated for at least 24 hours with nonoperative intestinal intubation showed that of 76 patients admitted with partial small-bowel obstruction, 49 (65%) were successfully treated without operation. Of those with complete small-bowel obstruction (CSBO), 18 of 24 (75%) subsequently required surgical intervention; however, six of 24 (25%) were safely treated by nonoperative intubation. The 24-hour delay in surgery for CSBO did not increase morbidity or mortality in the 18 requiring operations. Major indications for surgical intervention were suspected strangulated obstruction or persistent obstruction, which frequently was associated with unsuccessful tube passage. Administration of antibiotics preoperatively was associated with a significant reduction in wound infections in patients requiring resection or enterotomy.