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A multicentre randomized prospective trial compared minimal surgery (under-running the vessel or ulcer excision and adjuvant ranitidine) with conventional ulcer surgery (vagotomy and pyloroplasty or partial gastrectomy) for the treatment of bleeding peptic ulcer. This report is based on 137 patients (eight withdrawn through misdiagnosis or lost data), of whom 62 received conservative surgery and 67 conventional operation. Twenty-nine patients died, 16 (26 per cent) after conservative surgery and 13 (19 per cent) after conventional operations. The only significant difference between the groups was the incidence of fatal rebleeding, which occurred in six patients after conservative surgery compared with none after conventional surgery (P less than 0.02, Fisher's exact test).

The high incidence of clinical remission after faecal diversion for Crohn's colitis suggests the faecal stream may play a part in the inflammatory mechanism. The effect of faecal diversion (n=22) and restoration of intestinal continuity (n=10) was assessed in patients with Crohn's colitis and compared with controls. Faecal diversion produced significant improvement in the disease activity index mean (SEM) (before 176 (9); after 114 (9), p

SUMMARY The effects of intragastric infusion of 10% Intralipid and 10% dextrose on the intraluminal pressures in the antrum, pylorus and duodenal bulb have been examined. Ten studies with each infusate have been performed in 10 normal subjects and the results compared with those obtained previously in 22 studies during intragastric infusion of isotonic saline. During saline infusion, contractile activity varied. In six studies fasting motor activity persisted; in the remainder, variable activity, without recognisable pattern was recorded. With saline, the gastroduodenal region usually functioned as a unit and the pylorus was the least autonomous part. Neither a sustained rise of basal pressure nor rhythmic, independent contractions were recorded from the pylorus. The contractile activity of the gastroduodenal region with Intralipid and dextrose was more uniform than with saline. Fasting motor activity was always abolished. The gastroduodenal region ceased to contract as a unit and the pylorus acquired autonomous activity. Rhythmic, independent contractions of the pylorus were recorded in nine of 10 studies during Intralipid infusion and six of 10 studies with dextrose. In addition, a sustained rise in pyloric basal pressure was recorded in eight of 10 studies with Intralipid and three of 10 studies with dextrose. Pyloric motility indices were significantly greater with fat than with dextrose. The observed differences in gastroduodenal motility are consistent with a role for the pylorus in the control of emptying of liquid from the stomach.Disagreement persists concerning the motility of the pylorus and gastroduodenal region. In dogs' and man2 3a raised basal pressure which was increased by intraduodenal infusion of fat or acid, has been recorded from the pylorus by some workers. Using the same techniques, however, others have failed to reproduce these results.-8 Berger,9 using a photoelectric device to register closure of the pylorus, showed that the normal human pylorus was usually open and contracted only when a contraction passed through the gastroduodenal region. Thus the pylorus does not appear to have an independent action and the whole gastroduodenal region acts as a unit.In a recent studyl we have used a different technique to obtain recordings of intraluminal pressure simultaneously from the antrum, pylorus, and duodenal bulb of normal subjects during intragastric infusion of isotonic saline. Under these Address for correspondence: Mr J Alexander-Williams FRCS, The General Hospital. Steelhouse Lane, Birmingham B4 6NH. Received for publication 25 February 1983 conditions the pylorus did not have an independent action. The studies with saline represent the effects of distension of the gastroduodenal region by an inert liquid. We have now used the same technique to examine the effects of distension with two nutrient liquids, 10% Intralipid and 10% dextrose. The effects of saline, fat and dextrose on gastroduodenal motility have been compared. Methods SUBJECTSAll subjects were healthy volunteers. In the ...

SUMMARY Three groups of patients studied after operations which had cured their duodenal ulcer were compared with a control group (no operation, n=8). The surgical procedures included: proximal gastric vagotomy (n=7), truncal vagotomy and pyloroplasty (n=7), truncal vagotomy and antrectomy (n=8). Samples of gastric juice were aspirated half hourly or hourly over 24 hours for measurement of pH, counts of all identified bacteria, nitrite and total N-nitrosocompounds. Although the pH over 24 hours was significantly higher after proximal gastric vagotomy (p<005) and truncal vagotomy and antrectomy (p<0001) than controls, there was no difference between truncal vagotomy and pyloroplasty and controls. Counts of nitrate reducing bacteria over 24 hours were also significantly higher after truncal vagotomy and antrectomy than controls (p<01) but no differences were observed between the other groups. Only after truncal vagotomy and antrectomy was nitrite over 24 hours significantly increased compared with controls (p<0-01). Despite these higher values after truncal vagotomy and antrectomy, there was no significant difference in total N-nitrosocompounds between any of the four groups. Whereas bacterial counts and nitrite increased with pH, no correlation was found between total N-nitrosocompounds and pH. These results provide no evidence that exposure to total N-nitrosocompounds is increased after operations for duodenal ulcer.

1. The excretion of piperacillin sodium in bile was studied after intravenous injection of 2 g (n = 5) and 4 g (n = 7). All patients had undergone cholecystectomy and exploration of the common bile duct for cholelithiasis. Bile, serum and urine concentrations were measured by a microbiological technique. 2. Peak concentrations of piperacillin were found in bile at 150 minutes after 4 g and at 210 minutes after 2 g. 3. Both the concentration of piperacillin in bile at the end of a 6 1/2 hour study and the calculated mean bile concentration of piperacillin were above the minimum inhibitory concentration (MIC) of this drug for organisms commonly found in acute biliary tract infections. We believe piperacillin may be useful in the management of such conditions.

No abstract

A method of recording continuously and simultaneously the intraluminal pressure in the antrum, pylorus, and duodenal bulb has been used to study gastroduodenal motility during intragastric infusion of saline. Twenty-two studies were performed in 15 normal individuals. Two types of contraction were recorded: (1) independent contractions of the individual parts of the gastroduodenal region, and (2) related contractions of the antrum, pylorus, and duodenal bulb, resulting in a concerted contraction of the whole region. The majority of pyloric contractions were part of a concerted contraction of the whole gastroduodenal region during which the pylorus behaved as the terminal part of the antrum. The majority of duodenal contractions were not associated with pyloric contractions, only 21.7% of duodenal contractions coincided with closure of the pylorus. This suggests that under the conditions of this study the pylorus was not acting as a barrier to reflux. An elevated basal pressure was never recorded from within the pylorus; apart from a brief closure during contraction, the pylorus is always open.