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This paper reports on a five year follow-up of 174 morbidly obese patients (132 women) with gastric banding performed between 1981 and 1985. Mean preoperative weight was 122.6 +/- 1.4 kg (s.e.m.) (body mass index (BMI) = 41.8 +/- 0.4 kg/m2) and mean overweight was 73.2 +/- 1.6%. After rapid weight loss during the first six months weight levelled off reaching a nadir at 12-18 months. At 12 months mean weight loss was 36.5 +/- 1.2 kg (BMI = 29.1 +/- 0.4 kg/m2). At 60 months BMI had increased to 32.3 +/- 0.6 kg/m2 (P < 0.05 vs. 12 and 24 months). Mean excess weight at 60 months was 33.5 +/- 2.4% with 47.5% of patients maintaining less than 30% overweight. There were no differences in relative weight loss between men and women and no differences between stomal diameter of 12 or 15 mm 60 months after the operation. Early post-operative complications occurred in 25 patients (14.4%), four of whom required reoperation. Three of these re-operations were for perforations, one of which was fatal. Forty-eight patients (28%) had altogether 60 late complications requiring 26 reoperations (14.9%). There has been a total of four deaths (one clearly unrelated, one unknown) in the series. We conclude that gastric banding is a simple and safe gastric restrictive operation that is effective in about 50% of patients weighing between 90-181 kg (BMI 33-69 kg/m2).

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Pulmonary function and pulmonary gas exchange at rest, and during and after a standard exercise load of 500 kpm in 1 min on bicycle ergometer were studied in 34 women with severe, uncomplicated obesity, aged 37.8 (20-59) years, before and 1 year after gastric banding, resulting in a weight loss from 113.2 (84-156) to 81.7 (60-110) kg. Following the weight loss, TLC and VC rose from 93 and 94 per cent of expected to 98 and 101 per cent, respectively. FRC, ERV and FRC/TLC rose more markedly from 77, 64 and 83 per cent to 98, 109 and 99 per cent. IC fell from 108 to 99 per cent. RV and RV/TLV remained unchanged. FEV1.0 rose from 97 to 103 per cent, while MVV rose from 102 to 112 per cent, i.e. above normal. TLCO and PaCO2 remained unchanged, at 90 and 95 per cent, whereas PaO2 rose from 86 to 91 per cent. Resting O2 intake (VO2) decreased from 147 to 115 per cent of the expected for normal weight women, while VO2/BSA decreased from 113 to 99 per cent, the changes being greater than expected from commonly used formulas for prediction of metabolic rate. O2 cost of work (EO2) decreased from 142 to 105 per cent. Resting ventilation (V) declined from 136 to 113 per cent, while ventilatory cost of work (EV) decreased from 142 to 105 per cent. CO2 recovery time after work (CO2RT) decreased from 121 to 100 per cent, while the ratios CO2RT to EO2 and to extra CO2 output of work (ECO2) rose slightly. Thus, the loss of weight led to increased filling of the lungs, improved dynamic function, reduced ventilation/perfusion disturbances and greater than expected reduction of energy expenditure, both at rest and exercise. In the obese state there was no evidence of alveolar hypoventilation or impaired ventilatory control. The beneficial effect of weight reduction on the exertional dyspnea included a combination of marked reduction of ventilatory demands and moderate rise in ventilatory capacity.

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During the years 1981-85, 163 patients were treated with gastric banding for morbid obesity. Mean preoperative body weight (+/- s.e.m.) was 121.3 kg +/- 1.4, and mean overweight was 71.5% +/- 1.6 according to Broca's formula. Twenty-four patients had postoperative complications during the first 30 days, mostly minor. Four required reoperation and one of these died. Seventeen patients had late complications, six persistent vomiting necessitating reoperation, eight incisional hernia and three penetration of gastric wall by band. The weight loss was rapid during the first 6 months, and thereafter levelled off. After 2 years the weight loss was 33.4 kg +/- 2.4, corresponding to a mean weight loss of 27.6 percent +/- 1.9 of preoperative weight. There was no significant difference in weight loss expressed as a percentage of preoperative weight between patients operated with an outlet of 12 mm (45 patients) or 15 mm (118 patients), nor between males (37 patients) or females (126 patients). We conclude that our technique of gastric banding seems to be a relatively safe and reliable surgical treatment for morbid obesity. But our follow-up period has been limited to 2 years or less, and a longer follow-up is necessary before the method can be fully evaluated.

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Eight patients with perforation of the oesophagus following forced dilatation because of nonmalignant disease were treated conservatively with antibiotics and parenteral nutrition. None had primary leakage to the pleural cavities. Nasogastric suction was employed in three patients, and one had a feeding gastrostomy prior to perforation. Recovery was uneventful in six cases. A single thoracocentesis was required in one case. In the eighth patient there was leakage to the right pleural cavity with massive pleural effusion after two weeks of treatment and thoracotomy was necessary. All the patients survived. The authors conclude that subcervical oesophageal perforation following forced dilatation because of nonmalignant disease should be managed conservatively when there is no leakage to the pleural or peritoneal cavities.

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While guinea-pig stomachs were isolated and oxygenated in organ baths. Continuous pressure recordings were made from separate fundic and antral pouches. Prostaglandin F2 alpha stimulated motor activity in both fundus and antrum mainly by elevation of wall tension, whereas the amplitude or frequency of the rhythmic activity was not significantly affected. The responses were dose-dependent and not significantly inhibited by atropine, mepyramine, or cimetidine. A direct effect mechanism of PGF2 alpha, independent of intramural cholinergic or histaminergic pathways, is indicated for both fundus and antrum.

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A case of acute jejunogastric intussusception is reported. The patient had suffered intermittent attacks for 7 years, and had an acute fulminating attack prior to the present admission. Chronic recurrent jejunogastric intussusception should be considered a possible cause of pain and vomiting in patients who have had gastrojejunostomy or gastric resection.

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Biliary and urinary excretion of hydroflumethiazide (HFT) and its metabolite, 2,4-disulfamyl-5-trifluoromethylaniline (DTA), was investigated in 5 otherwise healthy patients with a T-drain in the common bile duct after cholecystectomy and choledochotomy. After a single oral dose of HFT 302--453 micromoles, a mean of 0.051% (range 0.028--0.075) of the dose was excreted in bile and 34.9% (range 23.7--45.4) in urine during the first 6 hours after administration. Biliary excretion appeared to be of minor importance in the elimination of HFT by man. DTA could not be detected in bile.

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Guinea-pig stomachs were isolated in organ baths, and recordings made of fundal and antral responses. Cholecystokinin (CCK-PZ), 0.38 U/ml, gastrin, 0.05 microgram/ml, and acetylcholine, 10(-4)M, produced typical responses: raised base line in the fundus and increased amplitudes of rhythmic contractions in the antrum. The antral responses to gastrin were too small to quantitate. Both fundal and antral responses to 5 x 10(-4)M histamine consisted of an increase in base line without an alteration in amplitudes. Mepyramine, 3.2 x 10(-5)M, reduced the spontaneous activity in the fundus. It also inhibited fundal responses to gastrin and responses to histamine and CCK-PZ in both pouches. The fundal response to acetylcholine was unaffected by mepyramine, but the antral response seemed to be partially reduced (p less than 0.06). Cimetidine affected neither spontaneous activity nor motor responses. The results indicate that the motor response to histamine is mediated via H1-receptors and that these receptors may also be involved in the fundal response to CCK-PZ and gastrin. The inhibition of the antral responses by mepyramine may be due to unspecific anticholinergic action.

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Pressure responses in guinea-pig antral and fundal pouches were investigated in vitro. Secretin and glucagon in concentrations that did not significantly alter spontaneous activity significantly reduced antral responses to cholecystokinin, but had no depressive effect on the fundal responses. The antral inhibition of CCK-PZ may be specific, since responses to acetylcholine were unaffected by secretin and glucagon. The changes produced by secretin and glucagon in the antral dose-response curve to CCK-PZ suggest that the inhibition might be of a non-competitive type.

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Pressure responses to cholecystokinin (CCK-PZ, approximately 500 U/mg) and gastrin (human synthetic gastrin) were investigated in isolated guinea-pig antral and fundal pouches. Both drugs stimulated motor activity, in the antrum mainly by increasing amplitudes and rhythmic activity, in the fundus by increasing basal tension. Antral responses to gastrin were markedly smaller than to CCK-PZ, while the differences were less pronounced in the fundus. Prestimulation with gastrin, being an agonist by itself, significantly reduced the antral responses to submaximal doses of CCK-PZ, while no inhibition was found in the fundus. When pre-exposed to gastrin, the antral dose-response curve to CCK-PZ was flattened, with reduced maximal response, simulating a non-competitive interaction. It seems that gastrin behaves like a partial agonist to CCK-PZ on guinea-pig antral smooth muscle.

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Both cholecystokinin (CCK-PZ) and gastrin stimulated antral rhythmic activity and raised fundal basal pressure. The antral motor effects were significantly blocked by pretreatment with atropine or tetrodotoxin. The fundal motor responses were almost unaffected. It is concluded that CCK-PZ and gastrin exert their antral motor effects essentially through local cholinergic neural pathways, while the motor responses in the fundus are almost entirely independent of these pathways.

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Graded distension increased the motor response to cholecystokinin and acetylcholine both in antral and fundal pouches. The increase became even more obvious when the pressure responses were converted into changes in wall tension. The responses to cholecystokinin were additive with low doses (10(-7)M) of carbachol, but diminished or abolished by prestimulation with higher doses. The results indicate that the increased response to cholecystokinin after distension is due to increased smooth muscle stretch.

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A new porous ceramic material was tested for possible use as a bone substitute in regions exposed mainly to compressive forces. The porous ceramics were implanted into the medial condyle of the tibia of four sheep and left in position for 3 months. The operated tibia was then removed and sections were made of the implants. The sections were studied by transmitted light microscopy, microradiography and scanning electron microscopy. There was no apparent loss of function of the operated leg and the implants were found to be bound to the adjacent bone by ingrowth of bony tissue, in some regions to a depth of 2-3 mm. It is concluded that the properties of the porous ceramic implants justify a clinical trial, provided that the results of long-term animal experiments are equally satisfactory.

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The plasma binding of quinidine and phenytoin has been studied pre- and postoperatively in nine patients submitted to planned gastric surgery. The binding of phenytoin showed a slight and transient reduction, whilst quinidine binding was markedly increased, on average from 78.5% on the day of operation to a maximum of 87.5%, after 2-4 days. The time course of the increase was strikingly parallel to that of the concentration of certain acute phase proteins.

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Cholecystokinin produced dose-dependent increases in motor activity in antral and fundal pouches of isolated guinea-pig stomachs. The response was immediate; the motor activity increased to a peak within 2 min, then decreased somewhat, but stabilized within 5 min at a value that was higher than before addition of cholecystokinin. In the antral pouches the response consisted of an increase in the amplitude of the rhythmic contractins; in the fundal pouch it was seen as an increase in basal pressure. The antral response was significantly greater in pouches distended to an initial basal pressure of 15-25 cm H2O than in undistended pouches. The fundal reponse was not enhanced by distension.

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Peritoneal lavage with ten hourly repeated instillation-drainages of one litre lavage fluid containing 50 mg doxycycline (Vibramycin Pfizer) was carried out on six patients suffering from diffuse peritonitis due to perforated appendicitis. Bacteriological specimens were obtained both from the perforation in the appendix and the peritoneal fluid at operation and the doxycycline concentrations in blood and lavage fluid were determined at intervals up to 72 hours postoperatively. All the patients recovered, but the lavage was considered a failure in one case as a small abscess and multiple adhesions were found at reoperation 1 1/2 months later. Bacteriological swabs from the perforated appendix and the peritoneal fluid usually contained the same bacteriological species, and as a rule several species were isolated. Doxycycline compared favourably with ampicillin as regards bacterial sensitivity, but the difference was too slight to be of practical importance. Doxycycline was absorbed very rapidly from the peritoneal cavitiy, and due to its slow excretion a cumulation occurred. In this small series doxycycline did not appear to give any real advantage over ampicillin, but it may be considered the drug of choice in patients with penicillin allergy, and in those who fail to respond to ampicillin.

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