The prognosis of the severity of the early postop period in patients operated for gastrointestinal bleeding

The oxygen metabolism was studied up in patients, operated on for gastrointestinal haemorrhage after conduction of an urgent measures for hypovolemia elimination. While favourable course of an early postoperative period the systoles rate (SR) was less than 116 in a minute. Sensitivity of the symptom (frequency of the symptom revealed in the patients of this group) was 94.54%, specificity (the absence of the symptom in the patients of other groups)--53.31%. Constant tachycardia (SR more than 116 in a minute) is a prognostic symptom of exitus lethalis. Its sensitivity is 100%, specificity--83.14%. Moderate loss of xi-potential of erythrocytes is complementary symptom, permitting exitus lethalis prognostication conduction. The increase of ratio of lactic acid and piruvate contents in the blood up to more than 5.25 conventional units is characteristically for the complicated but favourable for life an early postoperative course. Sensitivity of the feature is 91.17%, specificity--60.29%.     

Alterations in fibrinolytic and protein C pathways in gynaecological surgery: low molecular weight heparin prophylaxis

Several parameters of fibrinolytic and protein C pathways were evaluated in three groups of patients with high (HR), moderate (MR) and low (LR) postoperative thrombotic risk undergoing major gynaecological surgery. The HR and MR groups were subjected to low molecular weight heparin (LMW) prophylaxis. A significant increase in plasminogen activator inhibitor type 1 (PAI-1) antigen and activity levels was observed in the HR patient group in comparison with the MR and LR groups in the preoperative and early postoperative period. In all the groups studied, the maximum increase in the levels of PAI-1 was seen on day 1 after surgery. However, the D-dimeric levels reached the highest level on day 7. A significant increase in activated protein C:alpha 1 antitrypsin (APC:alpha 1AT) complex levels was observed in the HR group in comparison with the LR group, and a strong decrease in protein C inhibitor in the early postoperative period was detected in all the groups. In spite of heparin prophylaxis, 2 HR patients were diagnosed as deep vein thrombosis (DVT) during the postoperative period. Both patients showed pre-operative levels of PAI-1 antigen or activity and APC:alpha 1AT complexes above the mean + 1 SD of the pre-operative levels in the HR group. In conclusion, in HR patients a hypofibrinolytic and hypercoagulable state was detected in the pre-operative and early postoperative periods. The prophylactic LMW heparin dose used in the present report (20 mg/day x 7) was insufficient to prevent DVT in the HR group. At present our HR patients are given higher doses of LMW heparin (40 mg/day x 7).     

Ketamine for pediatric cardiac anesthesia

Eighty-five patients ranging from 12 h to 7 years of age were included in this study. In the first group 35 cases received ketamine, gallamine and oxygen for surgery on the great vessels. Ketamine provided satisfactory analgesia and amnesia. Heart rate did not change significantly. Gallamine gave additional safety in the prevention of bradycardia. One hundred per cent oxygen increased oxygen saturation and made more oxygen available for the tissues. The combination secured favorable conditions even in cases of sevre right to left shunt. Seven patients developed some degree of bradycardia, requiring treatment. All but one responded to epinephrime infusion. The one who did not improve died on the table. There were 6 additional deaths during the first 48 postoperative hours. Fifty infants and children received pentobarbital and morphine premedication and ketamine, pancuronium, nitrous-oxide oxygen anesthesia for open heart surgery. Cardiovascular stability with good operating conditions characterized the course of anesthesia. The increase in systolic and diastolic blood pressures and heart rate was small after induction. Further changes in these parameters during anesthesia were statistically insignificant. Perfusion pressure during cardio-pulmonary bypass was well maintained. The addition of 50 per cent nitrous oxide to inhaled oxygen significantly potentiated the duration of hypnosis and analgesia proved by ketamine. Mechanical ventilation was facilitated in both groups by the analgesia extending well into the postoperative period. There were 6 deaths in the first 48 postoperative hours in this group. The state of consciousness at the end of anesthesia and postoperative conditions of all 85 patients were comparable with that found with other agents. The techniques described provided suitable alternatives to the anesthetic management pediatric cardiac surgery.     

Magnitude of cervico-uterine cancer in Mexico]

We studied 30 male patients in the early postoperative period to assess the efficacy, safety and feasibility of a patient-demand, target-controlled infusion (TCI) of remifentanil. All patients received the same TCI-based propofol-remifentanil anaesthetic for elective orthopaedic surgery. At the end of surgery, infusion of remifentanil was reduced progressively until patients were breathing spontaneously. After extubation and transfer to the post-anaesthesia care unit, patients were given control of a hand-set and were able to increase the target remifentanil blood concentration by increments of 0.2 ng ml-1. If there were no demands, the TCI controller automatically reduced the target concentration. Pain scores, sedation level, ventilatory frequency, oxygen saturation and nausea were assessed. Mean time to onset of satisfactory analgesia (VAS < or = 3, out of 10) was 18.9 (95% confidence interval (Cl) 15.8-21.9) min at a mean target remifentanil concentration of 2.02 (Cl 1.87-2.16) ng ml-1. There were no episodes of hypoxaemia and the lowest ventilatory frequency was 9 bpm. Nausea occurred in 26.6% of patients and 10% vomited. The majority of patients were only slightly sedated. These results imply an effective tool without respiratory side effects in the early postoperative period after anaesthesia using remifentanil as the analgesic component.     

Bleomycin associated pulmonary toxicity: is perioperative oxygen restriction necessary?

PURPOSE: We delineate predictive factors of pulmonary morbidity in patients who receive combination chemotherapy with bleomycin and undergo surgical resection of residual disease, and establish updated guidelines for perioperative management. MATERIALS AND METHODS: A total of 77 patients with high volume stage II to IV nonseminomatous germ cell tumors underwent 97 major surgical procedures a mean of 6.4 months following high dose combination chemotherapy, including bleomycin (mean 437.5 units per 8.2 courses), between 1988 and 1995 at the University of Texas M. D. Anderson Cancer Center. The importance of preoperative pulmonary status, anesthesia time, fraction of inspired oxygen, fluid balance, bleomycin dose, number of acute toxicity episodes, oxygen saturation problems and pulmonary symptoms was examined. Cases were divided into groups according to whether there were postoperative oxygen saturation problems (19) or not (58). RESULTS: There were no significant differences in age, weight, bleomycin dose, number of acute toxicity episodes, cardiac ejection fraction or preoperative pulmonary symptoms between the 2 groups. Restrictive spirometry patterns were seen in 26 of 74 patients (35%), only 9 of whom had postoperative oxygen saturation problems. Mean induction fractional inspired oxygen was 87% (median 100%) for an average of 56 minutes. Intraoperative fractional inspired oxygen averaged 40% for a mean duration of 8.1 hours. Postoperative oxygen saturation problems, consisting of prolonged intubation, pulmonary edema, dyspnea, tachypnea or desaturation requiring diuresis, occurred in 19 patients (25%). Surgery/anesthesia time, amount of blood transfused, estimated blood loss, fluid balance, type of fluid given (all p < 0.0001) and preoperative forced vital capacity (p = 0.012) were significant predictors of postoperative oxygen saturation problems on univariate analysis. On multivariate analysis only the amount of blood transfused, preoperative forced vital capacity and surgical time in descending order remained significant. Maintained intraoperative fractional inspired oxygen was not significant on either analysis. There were no deaths. CONCLUSIONS: Perioperative oxygen restriction in patients treated with bleomycin is not necessary. Intravenous fluid management, including transfusion, appears to be the most significant factor affecting postoperative pulmonary morbidity and overall clinical outcome. In addition, post-chemotherapy forced vital capacity and operative time are significant predictive factors of procedure related pulmonary morbidity.     

Early assessment of diaphragmatic dysfunction in children in the ITU: chest radiology and phrenic nerve stimulation

Diaphragmatic dysfunction is a common postoperative complication of cardiac surgery in children, with important effects on respiratory morbidity. Its early diagnosis, followed by prompt surgical intervention, has been shown to reduce morbidity. However, the commonest method of diagnosis, based on hemi-diaphragmatic elevation on the chest radiograph, may be less accurate than direct techniques for assessing phrenic nerve function. We have compared electrophysiological and radiological diagnoses of diaphragmatic abnormality in 100 children (aged 3 days to 17.5 yrs) undergoing cardiac surgery, looking at respiratory morbidity as assessed by the duration of ventilation, the time spent on the cardiac intensive care unit (CICU), and the requirement for reintubation. Despite showing good reproducibility, radiological diagnosis was neither sensitive nor specific in identifying patients with electrophysiological phrenic nerve damage. Analysis of the measures of outcome supported the electrophysiological technique. Patients with electrophysiological evidence of damage had a longer duration of ventilation, spent longer on the CICU, and had a greater incidence of reintubation than either radiologically abnormal or "normal" patients. Chest X-rays are not a good method for diagnosing phrenic nerve damage in the early postoperative period in children. If early diagnosis is needed, then direct assessment of phrenic nerve function, such as the measurement of phrenic latency, may be a better technique.     

Acute severe asthma treated by mechanical ventilation: a comparison of the changing characteristics over a 17 yr period

Recorded cases of asthma have increased in recent years. It is unclear, however, whether this apparent increase in prevalence is accompanied by an increase in severity of the disorder. One potential measure of asthma severity is the requirement for mechanical ventilation. This paper examines those patients ventilated for severe asthma in a district general hospital over a 17 yr period. Since the methods used to assess asthma attacks and the criteria for instituting mechanical ventilation in this hospital did not alter between 1973 and 1992 (Jones criteria), it was possible to compare directly characteristics of all ventilated patients during the study period. The comparison showed that there was a significant increase between the two study periods in the number of patients who required mechanical ventilation. Moreover, in the more recent period both the subjective speed of onset of the asthma attack and the objective time between admission and ventilation were significantly shorter. However, despite this increase in asthma severity the mortality and morbidity in the more recent study period were lower. Overall the results of this study support the view that, in the population served by our district general hospital, asthma has increased in severity. This increased severity is indicated by an increase in the number of patients requiring mechanical ventilation and in the rapidity with which attacks evolved. However, for patients in whom ventilation was required, improved care has lowered both morbidity and mortality.     

Laparoscopic esophagomyotomy without an antireflux procedure for the treatment of achalasia

Various gastroenteric surgical procedures have been attempted laparoscopically. Laparoscopic esophagomyotomy (LE) with or without fundoplication, performed for achalasia, has gained popularity. In our clinic, LE (Heller's myotomy) was performed on six patients with achalasia. All patients underwent barium esophagography, endoscopy, and esophageal manometry for diagnosis. Extramucosal myotomy was started 6 cm above the cardioesophageal junction on the left anterolateral aspect of the esophagus and continued 1 cm below this area. Endoscopic control of the distal esophageal mucosa and the stomach was carried out under direct laparoscopic visualization following the completion of myotomy during the operation. LE was completed without complication in five patients. In one patient (16%), mucosal perforation occurred after myotomy during endoscopic control and was repaired with endostitches. There were no postoperative complications. The average hospital stay was 3 days. Three of the six patients agreed to 24-h pH monitoring, the results of which showed no evidence of reflux. All patients were completely symptom free in the postoperative period. The average preoperative lower esophageal sphincter pressure was 44 mm Hg, whereas in the early postoperative period and 6 months later, it was 11 mm Hg. There was no dysphagia or reflux esophagitis during the follow-up period (range 12 to 24 months). LE is associated with low morbidity and a high success rate, comparable with an open procedure, and can be done without an antireflux procedure.     

Two days' hospital stay after laparoscopic colon resection

In order to reduce surgical stress-induced dysfunction and morbidity in the postoperative period after colon cancer surgery in old people, we performed the operations laparoscopically and optimized the postoperative regime especially as regards to treatment of pain, early oral intake and mobilisation. The patients were treated with continuous epidural infusion of local anaesthetic for 48 hours postoperatively. Morphine was avoided. Normal oral intake was allowed immediately after operation and active mobilisation was ensured. Twenty patients with a median age of 81 years (71-92 years), who preoperatively were able to take care of themselves at home, entered the study. In four the operation was converted to open surgery due mainly to growth of the cancer into neighbouring organs. One patient had to have an open reoperation due to small bowel strangulation. Fifteen followed the scheduled programme. They all had normal bowel function on day one or two and were mobilised for eight hours on day two and 12 hours on day three. Accordingly postoperative hospital stay was only two days (median), and the high level of activity continued at home after discharge. The combination of laparoscopic mini-invasive surgical technique and a postoperative regime that optimized pain treatment, early oral intake and active mobilisation considerably reduced postoperative convalescence after colon cancer surgery in old patients.     

Changes in the mechanics of respiration and lung perfusion following partial lung resection

The authors have shown that in early postoperative period pronounced changes in the mechanics of respiration were observed in patients subjected to a partial lung resection. The dynamic pliability of lungs was considerably decreased, general pulmonary resistance became higher, the specific and minute respiration work was increased respectively. The degree of arterial hypoxemia was closely associated with the increasing general lung shunt of the blood. It was concluded that such disorders in the early postoperative period could be considerably reduced by methods of active sanitation of the tracheobronchial tracts.     

Utility of adenoviral-mediated Fas ligand gene transfer to modulate islet allograft survival

We examined the perioperative balance between oxygen delivery and oxygen consumption under hemodilution in 24 patients who underwent head and neck surgery of long duration and with massive blood loss. Intraoperative mixed venous oxygen saturation (SVO2), which decreased according to a decrease in hematocrit (Hct), was almost always kept above 60% when Hct was more than 20%. The longer the duration of surgery, the lower was SVO2 at the end of surgery. Postoperative SVO2 correlated positively with SVO2 at the end of surgery, and negatively with the duration of surgery and blood loss, but did not correlate with Hct. In 9 cases, SVO2 at the recovery from anesthesia decreased to below 60%, because oxygen consumption increased remarkably with shivering. These results suggest that in highly invasive head and neck surgery, the intraoperative minimum acceptable Hct level is 20%. On the other hand, there is no general postoperative minimum acceptable Hct level, because postoperative oxygen demand and supply balance depends on the degree of surgical invasion and increase of VO2. SVO2 at the end of surgery is useful in predicting postoperative oxygen demand and supply balance.     

Suppression by coffee cherry of the growth of spontaneous mammary tumours in SHN mice

Acute arterial occlusion in the lower extremities of patients with gynecologic cancers may not be immediately recognized in the postoperative period, despite the known risk of hypercoagulability associated with malignancy. Such delays in recognition and treatment can result in irreversible but potentially preventable tissue injury. This report describes three cases of acute arterial occlusion of the femoral and/or external iliac arteries in the immediate postoperative period following radical pelvic surgery. Two patients lost the involved limb due to irreversible changes resulting from prolonged ischemia. One patient was diagnosed while the involved limb was still viable and surgical revascularization was successfully performed. These cases illustrate the potential morbidity in unrecognized acute limb ischemia and the case with which it may be overlooked. Systematic documentation of arterial patency is recommended in the postoperative period, noting peripheral pulses and patient complaints related to the lower extremities. Rapid diagnosis and surgical intervention significantly increase the chance of maintaining viability of the involved limb.     

Ward versus intensive care management of high-risk surgical patients

BACKGROUND: Selection of high-risk surgical patients for preoperative and perioperative admission to an intensive therapy unit (ITU) for enhancement of oxygen delivery may reduce postoperative morbidity and mortality rates. Limited resources may prevent admission of all suitable patients. This audit study examined whether it is possible to select patients most at risk and thus reduce surgical morbidity and mortality rates when ITU services are limited. METHODS: This was a retrospective audit comparing the actual outcomes of complications and death with predicted outcomes using the POSSUM score (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) for 101 general surgical and vascular patients who would have fulfilled previously suggested criteria for preoperative admission to the ITU. Main outcome measures were the number of preoperative ITU admission criteria, American Society of Anesthesiologists (ASA) and POSSUM scores, preoperative oxygen delivery values, intravenous fluid therapy, length of ITU stay, length of hospital stay, postoperative complications and 28-day mortality. RESULTS: Medical staff allocated patients appropriately. There was a lower mortality rate than predicted from individual POSSUM scores. Patients who were admitted to the ITU before operation had the highest ASA scores, admission criteria and POSSUM scores; they also had significantly lower mortality and morbidity rates than predicted by the POSSUM scoring system. CONCLUSION: Patients with the greatest reduction in mortality and morbidity rates were admitted to the ITU before operation and had cardiovascular physiology 'optimized' before surgery.     

A case of de novo translocation 16;21: trisomy 16q phenotype and origin of the aberration

We reviewed our experience over a 12 month period with using minimally invasive direct coronary artery bypass (MIDCAB) for the management of high-risk patients with three-vessel coronary artery disease. Twenty patients (4 females, mean age 67 years) received left internal mammary artery (LIMA) grafts to the left anterior descending (LAD) coronary artery. Associated co-morbidity included: severe chronic renal failure, severe extensive arteriopathy, chronic obstructive airway disease, poor general condition and severely impaired left ventricular function. There was one early postoperative mortality and no other cardiac-related morbidity. Graft patency investigated, using angiography was 90%, and 5 patients underwent follow-up angioplasty to other coronary arteries. All patients remain entirely angina free at a follow-up period between 3 and 12 months. We conclude that MIDCAB is a safe and effective approach for managing high-risk patients with three-vessel coronary artery disease.     

Prevention of respiratory complications after abdominal surgery

Abdominal surgery, especially upper abdominal surgical procedures are known to adversely affect pulmonary function. Pulmonary complications are the most frequent cause of postoperative morbidity and mortality. This review article aimed to analyse the incidence and risk factors for postoperative pulmonary morbidity and their prevention. The most important means for preoperative assessment is the clinical examination; pulmonary function tests (spirometry) are not reliably predictive for postoperative pulmonary complications. Age, type of surgical procedure, smoking and nutritional state have all been identified as potential predictors for postoperative complications. However, usually there is not enough preoperative time available to obtain beneficial effects of stopping smoking and improvement of nutritional state. In patients with COPD, a preoperative multidisciplinary evaluation including the primary care physician, pulmonologist/intensivist, anesthesiologist and surgeon is required. Consensus as to preoperative physiologic state, therapeutic preparation, and postoperative management is essential. Simple spirometry and arterial blood gas analysis are indicated in patients exhibiting symptoms of obstructive airway disease. There are no values that contra-indicate an essential surgical procedure. Smoking should stop at least 8 weeks preoperatively. Preoperative therapy for elective surgery with antibiotics, beta2-agonist, or anticholinergic bronchodilator aerosols, as well as training in cough and lung expansion techniques should begin at least 24 to 48 hours preoperatively. Postoperative therapy should be continued for 3 to 5 days. Usually, anaesthesia is responsible for early complications, whereas surgical procedures are often associated with delayed morbidity. Laparoscopic procedures are recommended, as postoperative morbidity and hospital stay seem reduced in patients without COPD. Regional anaesthesia is given as having less adverse effects on pulmonary function than general anaesthesia. However, for unknown reasons these benefits are not associated with a decrease in postoperative respiratory complications. Moreover, the quality or the type of postoperative analgesia does not influence postoperative respiratory morbidity. Postoperatively, oxygen administration increases SaO2, but cannot abolish desaturation due to obstructive apnea. The various techniques of physiotherapy (chest physiotherapy, incentive spirometry, continuous positive airway pressure breathing) seem to be equivalent in efficacy; but intermittent positive pressure breathing has no advantages, compared with the other treatments and could even be deleterious. Chest physiotherapy and incentive spirometry are the most practical methods available for decreasing secretion contents of airways, whereas continuous positive airway pressure breathing is efficient on atelectasis. In stage II or III COPD patients, admission in a intensive therapy unit and prolonged mechanical ventilation may be required.     

Significance of retrograde blood flow in the posterior tibial and deep plantar veins of the foot in the pathogenesis of decompensated varicose disease

The problems of enteral and parenteral nutrition of patients with gastroenteric diseases, peritonitis in early postoperative period are considered. A degree of efficiency of specialized food mixes as one of the forms of basic therapy of a number of surgical and therapeutic of diseases is shown.     

Identification of human and rabbit cytochromes P450 1A2 as major isoforms involved in thiabendazole 5-hydroxylation

OBJECTIVE: To determine perioperative predictors of morbidity and mortality in patients > or =75 yrs of age after cardiac surgery. DESIGN: Inception cohort study. SETTING: A tertiary care, 54-bed cardiothoracic intensive care unit (ICU). PATIENTS: All patients aged > or =75 yrs admitted over a 30-month period for cardiac surgery. INTERVENTION: Collection of data on preoperative factors, operative factors, postoperative hemodynamics, and laboratory data obtained on admission and during the ICU stay. MEASUREMENTS AND MAIN RESULTS: Postoperative death, frequency rate of organ dysfunction, nosocomial infections, length of mechanical ventilation, and ICU stay were recorded. During the study period, 1,157 (14%) of 8,501 patients > or =75 yrs of age had a morbidity rate of 54% (625 of 1,157 patients) and a mortality rate of 8% (90 of 1,157 patients) after cardiac surgery. Predictors of postoperative morbidity included preoperative intraaortic balloon counterpulsation, preoperative serum bilirubin of >1.0 mg/dL, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >120 mins (aortic cross-clamp time of >80 mins), return to operating room for surgical exploration, heart rate of >120 beats/min, requirement for inotropes and vasopressors after surgery and on admission to the ICU, and anemia beyond the second postoperative day. Predictors of postoperative mortality included preoperative cardiac shock, serum albumin of <4.0 g/dL, systemic oxygen delivery of <320 mL/ min/m2 before surgery, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >140 mins (aortic cross-clamp time of >120 mins), subsequent return to the operating room for surgical exploration, mean arterial pressure of <60 mm Hg, heart rate of >120 beats/min, central venous pressure of >15 mm Hg, stroke volume index of <30 mL/min/m2, requirement for inotropes, arterial bicarbonate of <20 mmol/L, plasma glucose of >300 mg/dL after surgery, and anemia beyond the second postoperative day. During the study period, the study cohort used 6,859 (21.5%) ICU patient-days out of a total 31,867 ICU patient-days. Nonsurvivors used 2,023 (30%) ICU patient-days and patients with morbidity used 5,903 (86%) ICU patient-days. CONCLUSIONS: Severe underlying cardiac disease (including shock, requirement for mechanical circulatory support, hypoalbuminemia, and hepatic dysfunction), intraoperative blood loss, surgical reexploration, long ischemic times, immediate postoperative cardiovascular dysfunction, global ischemia and metabolic dysfunction, and anemia beyond the second postoperative day predicted poor outcome in the elderly after cardiac surgery. Postoperative morbidity and mortality disproportionately increased the utilization of intensive care resources in elderly patients. Future efforts should focus on preoperative selection criteria, improvement in surgical techniques, perioperative therapy to ameliorate splanchnic and global ischemia, and avoidance of anemia to improve the outcome in the elderly after cardiac surgery.     

The value of early transjugular liver biopsy after liver transplantation

Conventional percutaneous liver biopsy in the early postoperative period, within 30 days, following liver transplantation may be impossible due to coagulopathy and/or ascites. The use of transjugular liver graft biopsy (TJLB) in this setting is an attractive alternative in that a tissue diagnosis can be obtained despite the relative contraindications for percutaneous biopsy during this period. During the early posttransplant period, 124 TJLBs were performed in 105 liver patients, the majority (89%) of whom had standard liver transplantation without preservation of the native inferior vena cava; the others (11%) had the native inferior vena cava intact. The technical success rate was 87%, with adequate specimen for definitive diagnosis in most instances (86%), which included both rejection (61%) and nonrejection (39%) diagnoses on final histopathology. The biopsy diagnosis influenced clinical management in the majority of cases (65%), with decisions made to perform retransplantation (3%), to influence initiation of antirejection therapy (59%), and to institute antiviral therapy (3%). There was no morbidity or mortality associated with TJLB and it is feasible, safe, and effective in the early period after liver transplantation.     

Adjuvant preoperative radiotherapy in patients with rectal carcinoma. Adverse effects during long term follow-up of two randomized trials

BACKGROUND: Adjuvant preoperative radiotherapy of patients with primary rectal carcinoma improves local control and survival, but also may increase the risk of early postoperative morbidity and mortality. In addition, the possible late adverse effects of this treatment are largely unknown. METHODS: The present study was based on 1027 curatively operated patients included in 2 prospective randomized trials of preoperative radiotherapy for rectal carcinoma patients (Stockholm I and Stockholm II Trials). The goal was to assess whether long term intercurrent morbidity and mortality were increased in patients allocated to the preoperative treatment. A computerized linkage of the randomized patients to a population-based registry of the Stockholm County Council was used to study hospital admissions for six groups of a priori defined diseases, putatively related to late adverse effects of the radiation. RESULTS: Preoperative radiotherapy significantly increased the incidence of venous thromboembolism (P = 0.01), femoral neck and pelvic fractures (P = 0.03), intestinal obstruction (P = 0.02), and postoperative fistulas (P = 0.01). For arterial disease and genitourinary tract diseases, no difference in risk was found between irradiated and non irradiated patients. Radiotherapy significantly reduced rectal carcinoma deaths in both trials and also improved overall survival in the Stockholm II trial. The late intercurrent mortality was similar in irradiated and nonirradiated patients. CONCLUSIONS: Although high dose, short term, preoperative radiotherapy can improve outcome after surgery for rectal carcinoma, there also may be an increased risk for long term morbidity. Refinement of the radiotherapy technique and a more accurate selection of patients suitable for the treatment will probably further improve the results, at least in regard to treatment-related complications.     

An evaluation of splenopancreatic disconnection as a modification of the distal splenorenal shunt, studied in nonalcoholic patients by sequential angiography

To evaluate the validity and complications of modifying the distal splenorenal shunt (DSRS) by performing splenopancreatic disconnection (SPD), hemodynamic changes in the portal system were assessed by visceral angiography in 93 patients with nonalcoholic portal hypertension during early postoperative follow-up after DSRS. There were 40 patients who underwent DSRS alone and 53 who underwent DSRS plus SPD. Early follow-up angiography showed that portal vein perfusion was well maintained, and that the diameter of the portal vein had decreased significantly by the same degree in both groups. Hepatofugal collaterals for the shunt had developed to a greater extent in the DSRS group, while they were almost completely absent in the DSRS with SPD group. Nevertheless, partial portal vein thrombosis was not detected in the DSRS group, although it was seen in seven (13.2%) of the patients who underwent DSRS plus SPD, in whom the left proximal splenic vein was not visible. The proximal splenic vein was seen in significantly less of the DSRS with SPD patients (47.2%) than the DSRS group patients (85%). In conclusion, SPD more effectively prevented the early postoperative development of collateral pathways for the shunt compared with standard DSRS; however, the possible stagnation of blood flow in the left proximal splenic vein may predispose to a risk of partial portal vein thrombosis developing during the early postoperative period after DSRS with SPD.