Proximal Pouch Research Articles

Absorption of Oral Penicillin before and after Gastroplasty for Morbid Obesity

Gastroplasty for morbid obesity results in a small proximal pouch with a narrow stoma to the distal stomach. Absorption of phenoxymethylpenicillin given in tablets and liquid form was evaluated in 8 females before and 3 months after gastroplasty. Penicillin absorption was not affected to any significant extent. Oral penicillin can therefore safely be given for the treatment of infections in patients after gastroplasty.

Transcervical myotomy for wide-gap esophageal atresia

A primary end-to-end anastomosis of the esophagus can be accomplished in the wide-gap esophageal atresia by obtaining extra esophageal length through circular myotomy of the proximal esophageal pouch. However, a very short proximal esophageal pouch may not be accessible through the standard thoracic incision, precluding this procedure. An infant is reported in whom the inaccessible proximal pouch was exteriorized into the neck through a concomitant cervical incision, allowing three circular myotomies to be performed with ease. The proximal esophagus was then reintroduced into the chest cavity and a primary esophagoesophagostomy performed without difficulty.

Endoscopy of the partitioned stomach.

Fiberoptic endoscopy is an important diagnostic modality for evaluation of the patient with upper gastrointestinal (GI) tract symptoms following gastric bypass and gastroplasty. During a 3-year period, 182 patients underwent gastric partitioning procedures and 22 patients (12%) developed upper GI symptoms requiring endoscopic evaluation. Eight patients had undergone Mason vertical banded gastroplasty, 12 patients had undergone Gomez gastroplasty, and two patients had undergone Roux-en-Y gastric bypass. In four of five patients with abdominal pain, gastritis of the proximal pouch was observed. Of the two patients with symptoms of obstruction of the proximal gastric outlet, one patient was found to have a cherry pit occluding the channel. Intraoperative endoscopy was performed in one patient who developed upper GI bleeding after Roux-en-Y gastric bypass, the pylorus was scarred and stenotic and multiple superficial ulcerations were seen in the excluded distal stomach. In eight patients with symptoms suggestive of channel stenosis, four were found to have a stenotic channel and underwent endoscopic dilation of the channel. Upper GI endoscopy was performed in eight patients with Gomez gastroplasty to confirm suspected dilatation of the channel between the upper and lower gastric pouches. Upper GI contrast studies did not estimate accurately the diameter of the channel as determined during endoscopy. No complications were observed following any of the endoscopic procedures. As the collective experience with gastric partitioning procedures increases, the need for endoscopic examinations of the upper GI tract will also increase. Endoscopists should be familiar with the altered gastric anatomy and with the spectrum of upper GI lesions that develop following these operations.

Semen Quality and Fertility After Heat Stress in Boars

Sperm morphology and the fertilizing capacity of ejaculated spermatozoa were examined in 6 Swedish Landrace boars before and after heat stress. The boars were exposed to 35° C during 100 h in a climatic room. Fertility was measured by insemination of gilts before and at various times after heat stress. Each gilt (n = 44) was inseminated with a total of 5×109 spermatozoa diluted to 10O ml with EDTA-glucose diluent and fertilization was assessed by examining recovered ova 2 days after insemination. Changes in semen quality varied among the boars from a very weak response in 2 boars to pronounced semen alterations occurring 2–6 weeks after heat stress in the other boars. A close relationship was found between seminal changes and fertilization rates, all ejaculates which had high fertilization rates being of the same quality as the pre-exposure ejaculates. The ejaculates that had poor fertility were characterized by lowered sperm motility and increased numbers of spermatozoa with abnormal heads, proximal cytoplasmic droplets and nuclear pouch formations.

ULTRASONIC ANATOMY OF THE TENDONS AND LIGAMENTS IN THE DISTAL METACARPAL‐METATARSAL REGION OF THE EQUINE LIMB

In a two‐phase study, ultrasound was used to delineate the normal sonographic anatomy of soft tissues of the equine distal limb. The study was limited to the soft tissues of the palmar surface of the limb just proximal to the fetlock joint. In the first phase, cadavers were evaluated with a B‐mode ultrasound machine, † Then the limbs were radiographed and dissected to compare their gross, radiographic, and ultrasonographic appearances. In the second phase, nine normal adult horses were ultrasonographically scanned. The sonographic appearance of the normal animals was compared with that of the cadavers. Front and rear limbs of all horses had similar ultrasonographic appearances. Flexor tendons and the suspensory ligament were easily identified as having linear, uniformly intense ecogenicity. The borders of the digital sheath and of the proximal palmar pouch of the fetlock joint had a less organized and less intense ecogenic appearance than the flexor tendons and suspensory ligament, and they were poorly delineated unless distended with fluid. Ultrasonography was used in three lame horses and aided the diagnoses of synovial proliferation in the fetlock joint, tendosynovitis, and bowed tendon. Diagnostic ultrasonography was effective in identifying and characterizing soft‐tissue structures of the distal equine limb. It is a valuable, noninvasive diagnostic aid.

Difference in kinetics between the distal and proximal parts of the canine parietal cell mass in response to histamine.

Dogs provided with one denervated gastric pouch in the distal part of the corpus fundus and another of equal size in the proximal part, were studied during histamine stimulation. Dose-response curves were determined for acid output and mucosal blood flow, which was measured with the Neutral Red technique. Maximum acid output was significantly higher for the distal (mean 234.0 mumol min-1) than for the proximal pouch (120.0 mumol min-1). ED50 for acid output was significantly higher for the distal (105.0 micrograms kg-1 h-1 of histamine) than for the proximal pouch (57.0 micrograms kg-1 h-1). ED50 for blood flow did not differ significantly between the distal (40.5 micrograms kg-1 h-1) and the proximal pouch (29.0 micrograms kg-1 h-1). For both pouches ED50 for blood flow was significantly lower than that for simultaneous acid output. This indicated that the rise in blood flow precedes that in acid output. Regression analysis showed a significantly higher ratio between maximum mucosal blood flow and maximum acid output for the distal (0.30 ml mumol-1) than for the proximal pouch (0.15 ml mumol-1). The finding that ED50 for acid output in response to histamine was lower for the proximal pouch is contrary to earlier results obtained with pentagastrin, which showed that ED50 was lower for the distal pouch. There is no valid explanation for these differences in ED50 between the pouches, but a difference at receptor level could be hypothesized. The difference in maximum acid output between the two pouches is explained by the known difference between distal and proximal parts in volume fraction of the parietal cells. The possibility that these differences in acid production depend on dissimilarities in mucosal blood flow can be excluded.

Difference in kinetics between the distal and proximal parts of the canine parietal cell mass in response to pentagastrin.

1. Dogs were provided with one denervated gastric pouch in the distal and another of equal size in the proximal part of the corpus fundus. Dose-response curves for pentagastrin were determined for acid output and mucosal blood flow, which was measured with the Neutral Red technique. 2. Maximum acid output was significantly higher for the distal (mean 165.4 mumol min-1) than for the proximal pouch (53.8 mumol). ED50 for acid output was significantly higher for the proximal (5.10 micrograms kg-1 h-1 of pentagastrin) than for the distal pouch (1.98 micrograms). 3. ED50 for blood flow did not differ significantly between the distal (0.48 microgram) and the proximal pouch (1.23 micrograms). For both pouches ED50 for blood flow was significantly lower than that for simultaneous acid output. This indicated that the rise in blood flow precedes that of acid output. 4. Regression analysis indicated similar ratios between maximum mucosal blood flow and maximum acid output for the distal (0.17 ml mumol-1) and the proximal (0.14 ml mumol-1)pouch. 5. The difference in maximum acid output between the two pouches correlates well with the known difference between distal and proximal parts in volume fraction of the parietal cells, while there is no valid explanation for the difference in ED50 for acid output. It can be excluded that these differences in acid production depend on dissimilarities in mucosal blood flow.

Meal stimulated gastrin and pancreatic polypeptide levels before and after partial gastric transection for morbid obesity.

The aim of the study was to determine the basal and meal stimulated plasma gastrin and pancreatic polypeptide levels in six morbidly obese patients before and after partial gastric transection (gastroplasty), an operation which results in the distention of the stomach with a small volume of food. The partial gastric transection involved the creation of a proximal gastric pouch of approximately 100 ml, with a 1.2 cm diameter lumen between the proximal and distal gastric pouch. Basal gastrin and pancreatic polypeptide were not altered by the operation. The magnitude of the pancreatic polypeptide response to the mean was significantly depressed, although the time course was not changed. Inhibition of pancreatic secretion is thought to be a physiological function of pancreatic polypeptide, hence its decreased release warrants further investigation in relation to the effect of partial gastric transection on pancreatic function.

Radiographic abnormalities after gastric bypass.

Postoperative radiographic findings in the gastrointestinal tract were analyzed in 43 of 72 patients with gastric bypass for morbid obesity. In 15 patients studied because of early postoperative vomiting or abdominal pain, two showed leak from the proximal gastric pouch and six showed impairment of proximal pouch emptying at the anastomosis or proximal efferent loop. In four of the six, the impaired emptying was due to transient postoperative edema and improved spontaneously. Three patients had impairment of distal gastric pouch emptying due to pylorospasm. Five patients studied in the late postoperative period showed dehiscence of the gastric staple line, which can be difficult to demonstrate radiographically. Familiarity with the normal and the abnormal radiographic appearance after gastric bypass is important in elucidating the nature of the problems that can arise after this operation.

Gastroplasty in morbid obesity: a progress report.

AbstractThe lower mortality and morbidity rates of the gastric partitioning operations seem to be the primary reason for their increasing popularity among surgeons everywhere. Two hundred patients in our series underwent gastroplasty for morbid obesity. A measured 60‐ml proximal gastric pouch is formed as the TA‐90 is doubly applied across the upper stomach, just distal to the esophagogastric junction. The egress channel is located on the greater curvature, supported by a continued seromuscular inverting layer using 2‐0 polypropylene suture and a second interrupted inverting layer using 4‐0 Dacron® sutures. There were 154 females and 46 males in the series. The mean age was 34.2 years and the mean kg overweight, 67.4. The early postoperative complication rate was 19%, including 1 cardiac death, for a 0.5% mortality rate. Twelve percent revision rate included 15 staple line disruptions, 3 enlarged channels, 4 channel stenoses, and 2 enlarged pouches. Staple line dehiscence continues to be of concern with stapling in continuity. Liquid or pureed diet restriction for the first 12 postoperative weeks decreases the incidence of this complication. The second application of TA‐90 and the preservation of adequate blood supply to the pouch are important factors in the preservation of the integrity of the staple line. Ninety percent of total weight loss occurred at 12 months. Weight loss was maintained at 18 and 24 months.

Wide gap esophageal atresia with inaccessible upper pouch

Circular myotomy of the proximal esophageal pouch has allowed end-to-end esophagoesophagostomy in infants with wide gap esophageal atresia. Occasionally, the proximal pouch ends so high in the thorax that the circular myotomy is technically impossible under conventional means. Exteriorization, mobilization, and myotomy of the proximal esophageal pouch via a separate cervical incision has allowed us to overcome this limitation of an inaccessible upper pouch and has permitted esophagoesophagostomy. This technique has been performed successfully in two infants with good results and no morbidity over a follow-up period of 1 1/2 to 3 1/2 years.

Inhibition of canine interdigestive proximal gastric motility by cholecystokinin octapeptide.

Feeding abolishes cyclic interdigestive motility and decreases intraluminal pressure in autotransplanted pouches of canine proximal stomach. Our aim was to determine whether cholecystokinin might be the hormonal messenger involved. In four conscious dogs with autotransplanted proximal gastric pouches and chronic duodenal electrodes, intrapouch pressure and duodenal myoelectric activity were measured during fasting, while cholecystokinin octapeptide (CCK-OP) was infused intravenously for 4 h at doses 0, 15, 31, 62, 125, and 250 mg . kg-1 . h-1. Each dose was given five times to each animal. Cholecystokinin octapeptide inhibited the interdigestive cycles in both pouch and duodenum and decreased the pressure in the pouch. The threshold for these effects was 31 ng . kg-1 . h-1, and the ED50 was 62 ng . kg-1 . h-1. The dose of 125 ng . kg-1 . h-1 suppressed the cycles nearly completely and decreased mean +/- SE intrapouch pressure from 15.3 +/- 1.1 to 6.3 +/- 2.8 cmH2O . min (P less than 0.001). After the infusions were stopped, cyclic activity and intrapouch pressure returned promptly to control values. We concluded that CCK-OP at "physiological" doses abolished interdigestive cycles and decreased intraluminal pressure in autotransplanted pouches of canine proximal stomach.

Esophageal atresia and tracheoesophageal fistula: Review of thirteen years’ experience

A review of the treatment of esophageal atresia (EA) was undertaken to examine current methods of management and to ascertain the influence of prematurity and associated medical defects on survival. One hundred patients with EA presented at The Children's Orthopedic Hospital and Medical Center, Seattle, between 1967 and 1979. Eighty-two percent had a blind proximal esophageal pouch and distal tracheoesophageal fistula (TEF). Ninety-two patients were initially treated by gastrostomy. Fifty-nine patients were born at term and had no major medical problems. They underwent either primary or delayed (up to 1 week) repair of the esophagus. The survival rate was 93% and surgical mortality was 3%. Twenty-two patients born prematurely or having major medical problems underwent a staged repair. Survival in the staged group was 55% with a surgical mortality of 27%. Overall survival for the entire series was 79% (79/100). The use of air rather than contrast material for the radiographic diagnosis of EA was associated with fewer subsequent pulmonary abnormalities. There was an 18% incidence of minor anastomotic leaks, regardless of technique. The route of approach (transpleural, retropleural) did not influence mortality or morbidity in this series. There were more than three times as many significant strictures among patients who had double-layer anastomoses (18%) as among those who had single-layer repairs (5%). The surgical treatment of infants with EA has reached a level in which associated illness, anomalies, or prematurity are now the most significant determinants of survival.

Postprandial hormonal inhibition of canine interdigestive gastric motility.

Our aim was to determine whether hormones other than gastrin inhibit cyclic interdigestive motility in the proximal stomach. In four conscious dogs with autotransplanted proximal gastric pouches, excluded gastric antrums, and chronic duodenal electrodes, intraluminal pressure of the pouch and electrical activity of the duodenum were monitored before and after gastric instillation of 250 ml of 154 mM NaCl alone or 154 mM NaCl plus 15 kcal/kg of either dextrose, olive oil, casein hydrolysate, or a mixture containing 5 kcal/kg of each of the three nutrients. Dextrose, olive oil, casein, and the mixture abolished the interdigestive cycles in both pouch and duodenum and decreased intrapouch pressure compared with the saline control. The duration of the inhibition was longest with oil (5 h) and shortest with casein (3 h), and the decrease in mean intrapouch pressure was greatest with the mixture (11.8 cmH2O . min) and least with dextrose (9.3 cmH2O . min). Serum gastrin was unchanged by any of the instillates. We concluded that hormones other than gastrin inhibited cyclic interdigestive motility in the proximal stomach.

Can endogenous gastrin inhibit canine interdigestive gastric motility?

Our aim was to determine whether endogenously released gastrin inhibits cyclic interdigestive motility in the proximal stomach. In 4 dogs with chronic duodenal electrodes and isolated innervated antral pouches, we constructed proximal gastric pouches, the external neural connections of which were completely severed by autotransplanting the pouches to the left pelvis. After recovery, the antral pouch was irrigated with 0.2% acetylcholine for 3.7 hr at 90 ml/hr, while intraluminal pressure was monitored in the proximal gastric pouch and myoelectric activity was recorded from the duodenum. Blood was collected concurrently for radioimmunoassay of gastrin. The antral irrigations increased serum gastrin from a mean ± SEM of 85 ± 14 pg/ml before irrigation to a mean ± SEM of 350 ± 54 pg/ml after 30 min of irrigation (P < 0.001), and the increased levels continued throughout the remaining 3.2 hr of irrigation. The irrigations also suppressed the cycles of interdigestive motor activity in the proximal gastric pouch and the cycles of interdigestive myoelectric activity in the duodenum. The cycles had a mean duration ± SEM of 105 ± 5 min before irrigation in both the proximal gastric pouch and duodenum, but were abolished in every test during irrigation. Irrigation inhibited the cycles even when cimetidine was given intravenously at 200 mg/hr to block gastrinstimulated secretion of HCl, duodenal acidification, and subsequent release of duodenal hormones. However, cimetidine alone had no effect on the interdigestive cycles. We concluded that antral irrigation with acetylcholine inhibited interdigestive cyclic motility in the proximal stomach via a hormonal mechanism and that gastrin was likely the hormone involved.

Does motilin regulate canine interdigestive gastric motility?

Our objective was to determine whether motilin increases the frequency of cyclic interdigestive motor activity in the canine proximal stomach. In 4 conscious dogs with autotransplanted proximal gastric pouches and gastrointestinal electrodes, intravenous infusions of motilin (0.6 microgram/kg body wt/hr) increased the frequency of the interdigestive cycles by 30% both in the pouch and in the main gastrointestinal tract. However, the 3-min interval between the end of a cycle in the pouch and the end of a cycle in the duodenum was unchanged by motilin. In control experiments, without motilin infusion, the concentration of endogenous motilin in the plasma during the intense contractile phase of the cycles (overall mean 385 pg/ml) was greater in each dog (P less than 0.01) than the concentration during the quiescent phase (overall mean, 256 pg/ml). The concentration of plasma motilin was also greater in the contractile phase (mean, 717 pg/ml) than in the quiescent phase (mean, 587 pg/ml) during exogenous infusions of motilin in two of three dogs (P less than 0.01). We concluded that motilin increased the frequency of cyclic interdigestive motor activity in the canine proximal stomach and that the increase was not dependent on intact proximal gastric extrinsic innervation.

Release of Gastric Somatostatin-Like Immunoreactivity During Acidification of the Duodenal Bulb

This study was designed to determine if gastric somatostatin is released during the acidification of the duodenal bulb or distal duodenum. A proximal duodenal pouch was per f used with HCl in normal laparotomized anesthetized dogs during an intravenous infusion of saline, pentagastrin (5 µg/kg/hr), or histamine (20 µg/kg/hr). Bulb acidification during i.v. saline was accompanied by a slight increase in antral vein somatostatin-like immunoreactivity (SLI), but no change in fundic vein SLI or inferior vena caval SLI levels occurred. Acidification of the bulb during i.v. pentagastrin elicited an increase in fundic vein SLI from a baseline level of 593 ± 205 pg/ml to a peak level of 1,554 ± 510 pg/ml (P

Roentgenographic findings in a spectrum of uncommon tracheo-oesophageal anomalies

Roentgenographic and clinical findings in a spectrum of malformations of the trachea and oesophagus are discussed. Five previously unreported patients representing four rare anomalies of tracheal agenesis, laryngotracheo-oesophageal cleft, oesophageal atresia with a tracheo-oesophageal (T-E) fistula to the proximal oesophageal pouch, and T-E fistula without oesophageal atresia (H-type fistula) are presented. These anomalies can be characterised by a failure in separation of the oesophagus and trachea and by atresia of either organ. All of the patients were diagnosed roentgenographically. Since the incidence of associated abnormalities is high in babies with these anomalies, a generalised embryological defect must be a basic assumption in any theory to explain the development of T-E anomalies.

The flaccid trachea and tracheoesophageal congenital anomalies

The patient with an esophageal atresia associated with a distal tracheoesophageal fistula, is often found to have an abnormally soft trachea. The use of contrast material as an aid in the diagnosis of this congenital anomaly demonstrates radiologically the compressive effect that a dilated and hypertrophied proximal esophageal pouch has on the trachea of the newborn. It is postulated that this chronic compressive force plays a part in retarding the development of the trachea during fetal life. The important decompressive effect of a distal tracheoesophageal fistula allowing nonphysiologic escape of lung fluid, supplements this effect. Attention is drawn to the fact that tracheal compression plays an important part in the respiratory distress seen in these patients, both before and after surgical correction of the tracheoesophageal anomaly.

The suprasternal fossa on chest radiographs in newborns

Visualization of the suprasternal fossa in the newborn is due to suprasternal retraction. It is seen in 59% of patients with respiratory distress syndrome of the premature prior to intubation, and in 5% of patients with conditions such as pneumonia, meconium aspiration, and transient tachypnea of the newborn. The lower compliance of the lungs in patients with respiratory distress syndrome and increased compliance of the chest wall in premature infants accounts for the higher incidence of accentuation of the fossa. Visualization of the suprasternal fossa can simulate the distended proximal pouch of esophageal atresia. The two can be differentiated in the lateral view where the pretracheal location of the fossa can be appreciated.