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PURPOSE: The aim of this study was to discover if the cellular immunological response is different in patients receiving early postoperative enteral nutrition compared to patients who only receive "water". METHODS: In a random double-blind prospective trial, 30 patients received Nutridrink® and 30 patients received placebo (water) through a nasoduodenal tube from the day of operation to the fourth postoperative day. Leukocyte differential count was examined preoperatively, and on the first, third, and seventh postoperative days. Subpopulations of lymphocytes were flow cytometrically analysed. IL-1ra and soluble IL-2R were investigated by use of an enzyme-linked immunosorbent assay. RESULTS: In the enteral nutrition group, a significantly larger number of circulating monocytes and NK-cells and a significantly larger expression of HLA-DR were found. In the nutrition group, a tendency to larger numbers of T-lymphocyte subpopulations was found. No difference in IL-1ra and soluble IL-2R was found between the groups. CONCLUSION: Early postoperative enteral nutrition has an important influence on the immediate unspecific cellular immunity and an activating effect on the specific cellular immunity compared to "no food".

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BACKGROUND: In Ethiopia training tutors in the health system are part of a major health programme. A previous study disclosed that tutors felt they lacked sufficient teaching skills. AIM: The Teaching Methodology Course (TMC) described here was designed to correct these deficiencies. The aim of the study was firstly to evaluate the usefulness of questionnaires in terms of TMC quality control and secondly to evaluate whether the subcourses differed in terms of self-progress evaluation and course evaluation. CONTENT: The TMC consists of eight subcourses and is evaluated according to a quality circle described previously. METHODS: Two questionnaires were used as part of the TMC quality control, one to assess tutors' self-progress and the other to examine tutors' opinion about the course instructors' pre-defined teaching skills. RESULTS: In the questionnaires a distinction was made between 'good' and 'bad' subcourses. Moreover, the quantitative evaluation of subcourses was in accord with the tutors' written qualitative comments. CONCLUSION: The questionnaires can be used for TMC quality control in order to improve at least some subcourses.

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BACKGROUND: Patients who become anergic after surgery have a very high death rate, mainly due to infectious complications. It has earlier been shown that preoperative skin testing has predictive value for the clinical outcome in gastrointestinal surgery. This study investigated the effect of early postoperative enteral nutrition versus placebo on cell-mediated immunity with the Multitest CMI and correlated the results to the clinical outcome and to the preoperative nutritional status. METHODS: Sixty patients were randomized to receive either enteral nutrition or placebo. All patients were stratified in accordance with preoperative nutritional status. CMI tests were applied 2 days before surgery and days 1 and 5 postoperatively. All tests were applied and recorded by the same investigator. RESULTS: No significant differences in the score were seen between the groups. Nine patients were malnourished. No significant difference was seen preoperatively with regard to nutritional status, but the malnourished patients had a lower median value on the 3rd postoperative day. In patients with complications the preoperative median CMI score was 17.0 mm (95% confidence limits, 10.5-24 mm), and in patients without complications 9.5 mm (95% confidence limits, 5.5-16 mm). This result is significant and unexpected. Ten patients were anergic preoperatively, and three of these developed complications (30%). The overall complication rate was 27 of 60 (45%). A change in immunologic status from responding preoperatively to anergy postoperatively was significantly associated with severe complications (P = 0.043). CONCLUSIONS: Early enteral nutrition does not influence the CMI score. Preoperative anergy was not related to increased mortality/morbidity, whereas the change in CMI response towards anergy was significant.

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We undertook this study to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. In a randomized double blind prospective trial 30 patients received Nutridrink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml nutrition/placebo, 60 ml/h. On the first postoperative day the patients received median 1000 ml nutrition/placebo, second day median 1200 ml nutrition, 1400 ml placebo, third postoperative day median 1000 ml nutrition, 1150 ml placebo and 4th postoperative day median 1000 ml nutrition, 800 ml placebo. All patients were followed for 30 days by the same investigator. The two groups were not different with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, 2/30 compared to 14/30 in the placebo group (p = 0.0009). We conclude that early enteral nutrition given to patients after major abdominal surgery is followed by a major reduction in infectious complications.

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BACKGROUND: This study was undertaken to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. METHODS: In a randomised double blind prospective trial 30 patients received Nutri-drink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml of either nutrition or placebo, 60 ml per hour. On the first postoperative day the patients received either 1000 ml (median) of nutrition or placebo, on day 2 1200 ml (median) nutrition, 1400 ml placebo, on day 3 1000 ml (median) nutrition, 1150 ml placebo, and on day 4 1000 ml (median) nutrition, 800 ml placebo. All patients were followed up for 30 days by the same investigator. RESULTS: The two groups were similar with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, two of 30 compared with 14 of 30 in the placebo group (p = 0.0009). CONCLUSION: Early enteral nutrition given to patients after major abdominal surgery results in an important reduction in infectious complications.

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'Clam' enterocystoplasty has been performed in 23 patients in the treatment of lower urinary tract dysfunction. Twenty patients had neurogenic disorder while three were neurologically normal. Patients were evaluated urodynamically pre- and postoperatively. A significant change from a high pressure bladder to a low pressure bladder was found. Most patients had detrusor instability/hyperreflexia but 7 were operated due to poor bladder compliance. Only 2 patients had postoperative detrusor instability. Three patients later had a urinary diversion. Nineteen patients became dry giving a total success rate of 87% although 14 had to do clean intermittent self catheterization.

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Urine from patients with interstitial cystitis has been reported to be more cytotoxic than urine from healthy subjects when tested in vitro against cells from a normal urothelial cell line. The purpose of the present study was to develop a method to measure urinary cytotoxicity and so make it possible to estimate the toxicity of urine from interstitial cystitis patients. The study included 10 women with interstitial cystitis and 10 healthy controls. Urine specimens were obtained from both groups and urine cytotoxicity was measured by a modified 51Cr-release assay: A range of urine dilutions was added to suspensions of target cells with intracellular bound 51Cr, and cellular death was recorded by measuring the 51Cr-release from the target cells. The transitional cell bladder cell lines T24 and Hu609 and the erythroleukemia K562 cell line were used as target cells. There was no difference in urine cytotoxicity between interstitial cystitis patients and healthy controls. Urine cytotoxicity was increased by dilution in both groups.

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This study was carried out to examine the efficacy of extraperitoneal pelvioscopy in detecting pelvic metastasis in patients scheduled to undergo radical cystectomy without preoperative chemo- or radiotherapy. The results of pelvioscopy were compared with those obtained by laparotomy. 54 consecutive patients underwent pelvioscopy without complications. Three were technically insufficient. Lymphatic tissue was biopsied in 29 (54%). Pelvioscopy demonstrated tumor dissemination in 5 patients (9.3%): 2 had pT4b tumor, 2 pelvic nodal metastases and 1 both. The remaining 49 patients with benign pelvioscopy were scheduled for laparotomy but 7 patients did not undergo the procedure: 3 had extrapelvic metastasis, 1 bronchial carcinoma, 1 aortic aneurysm, 1 refused surgery and 1 had pulmonary insufficiency. Accordingly, 42 patients underwent open exploration which demonstrated pelvic metastasis in 11: 9 had nodal metastasis, 1 a pT4b tumor and 1 both. Consequently the sensitivity of pelvioscopy in detecting pelvic metastasis was calculated at only 31%. This result indicates that extraperitoneal pelvioscopy should be considered a screening procedure rather than an accurate staging procedure for pelvic metastasis.

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Ten patients have been reviewed in whom urethral stents were implanted for treatment of urethral stricture. Their urethral strictures had been treated with a median of 4.2 endoscopic urethrotomies under direct vision without success. The patients were first treated with optical urethrotomy, and dilatation to 30 F--after which the stents were inserted under direct endoscopic control. A total of 12 stents were inserted. All patients had a 30 mm stent inserted first, and two patients had an additional 20 mm stent inserted because of recurrent stricture at the distal or proximal end of the first stent. One patient had a urethrotomy 12 months after insertion of the stent because of a short recurrent stricture at its distal end. The median length of follow up was 24 months. The median preoperative maximum flow rate was 6.5 ml/s, and the median postoperative maximum flow rate was 20.3 ml/s. Half the patients had postmicturition dribbling postoperatively. The stents were covered with epithelium after 6-18 months, most between 12 and 18 months.

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Labetalol (Trandate) 50 mg i.v. was administered to a pre-eclamptic primigravida with an asphytic fetus prior to cesarean section, in order to reduce the risk of excessive increase in blood pressure during induction of anesthesia. Blood pressure fell rapidly from 170/110 to 115/85 mmHg. A dead infant was born. Oral labetalol is arguably a suitable remedy for pre-eclampsia, but if i.v. administration is necessary, an initial dose of 5-10 mg is recommended.

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On the 3rd day after a cesarean section, because of pre-eclampsia, blood pressure was still high, oral labetalol 100 mg with an 8-hour interval was given, followed by 50 mg i.v. administered over 10 min, twice with a 5-hour interval. The last injection was immediately followed by an atrio-ventricular tachycardia with massive decrease in blood pressure. The reason for this is discussed.

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A 32-year-old woman with multiple sclerosis had an uncomplicated pregnancy and labour two years after successful "clam" ileocystoplasty for urge incontinence and frequency of micturition. She remained well after three years following.

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The therapeutic results in eight patients with congenital myelomeningocele and neuromuscular dysfunction of the lower urinary tract are presented. Urodynamic assessment was performed preoperatively and post-operatively. Ileocystoplasty was performed on all of the patients. The postoperative results were good in seven out of eight patients in whom urodynamic assessment reveals a low-pressure reservoir which functions well. All of the patients employ clean intermittent self catheterization and, employing this treatment, they are continent with stable renal function.

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A total of 1,065 men 60 to 70 years old completed a questionnaire regarding the voiding pattern. At the time of the questionnaire 81 men had already undergone an operation for prostatic hypertrophy (postoperatively queried, group 1) and 29 subsequently underwent an operation (preoperatively queried, group 2). The remaining 955 men were not referred for an operation before March 1987 (healthy, group 3). Approximately a third of the healthy men accepted the symptoms of frequency, post-micturition dribbling and weak stream as not requiring special medical attention, while group 1 men had the same symptom frequency as the untreated men and the symptom frequency was considerably higher in group 2. Post-micturition dribbling was not a specific characteristic of prostatism.

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A total of 1,065 men aged 60-70 years replied to a questionnaire about their micturition patterns. At the time of the study, 81 men had already been treated operatively for prostatic hypertrophy and 29 men were submitted to operation at a later date. The remaining 955 men remained untreated until March 1987. Approximately 1/3 of the untreated men accepted the symptoms of pollakisuria, after-drip and weak flow. The men who had been treated previously showed the same frequency of symptoms as the untreated men but the frequency of symptoms was considerably increased in men requiring treatment. After-drip is not a specific symptom of prostatism.

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A continuous record of postoperative surgical infections was carried out by electronic data processing (EDP) of 4340 orthopaedic and general operations. The overall infection rate was 6.3%, ranging from 2.3% (clean wounds) to 27.1% (dirty wounds). The corresponding deep infection rates were 1.6%, 0.4% and 4.6%. Employing a multiple logistic regression analysis, 10 risk factors were evaluated. Factors found to be significant were: wound contamination, department, duration of operation, date of operation and age, and in addition for the department of general surgery: surgeon, planning of operation, length of preoperative stay and anatomic groups. A statistical model for identification of risk patients is described. Postoperative stay was on average 20.5 days longer in infected patients. We find that EDP-recording may result in an annual cost reduction of at least 175,000 pounds for our hospital.

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A case of common bile duct cyst, type 1, is presented. On account of the risk of development of cancer, excision of the cyst and the gall bladder is recommended. The duct system is then reestablished by means of hepato-jejunostomy. Scandinavian gastroenterologists should bear this condition im mind in patients of Asiatic origin with signs of biliary disease.

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