Intragastric proteolysis after vagotomy in perforative duodenal ulcer

The examination of intragastric proteolysis in patients operated on the perforative duodenal ulcer has been performed in 80 patients in the period up to 16 years after the surgery. The selective proximal vagotomy was performed in 65 of the patients, the trunk vagotomy--in 15 of the patients. In 55 patients the vagotomy was combined with ulcerrraphy, in 25 patients--with draining operations. The 30-35% decrease of the intragastric pepsin proteolysis was detected in patients after the vagotomy. There was no any signs of restoration of the suppressed proteolytic activity in the time period up to 16 years after the surgery. The draining operations lead to suppression of pepsin proteolysis in long-term period after the surgery and to its substitution with digestion with the pancreatic proteinases.     

Morphological changes in parietal peritoneum in children with appendicular peritonitis

The system of objective estimation of children severity state before and after an urgent operations conduction for the acute disease of abdominal cavity and retroperitoneal space. Three types of the disease course were delineated on the basis of 200 patients, ageing from 3 months to 15 years, examination. While stable course the conservative therapy conduction is indicated, while instable--the intensive therapy, incorporating the extrarenal depuration methods, and the operations when indicated; while the progressing, testifying the incomplete sanation of abdominal cavity--the relaparotomy and intensive therapy.     

Molecular beacon sequence analysis for detecting drug resistance in Mycobacterium tuberculosis

Strictureplasty for treatment of symptomatic intestinal strictures secondary to Crohn's disease is being performed with increasing frequency. To determine the overall clinical results after strictureplasty for Crohn's disease, all patients undergoing this procedure were prospectively studied. Between 6/1/89 and 2/1/97, 57 Crohn's disease patients underwent 60 operations utilizing strictureplasties. A total of 109 strictureplasties were performed (90 Heineke-Mikulicz, 6 Finney, and 13 side-to-side isoperistaltic). The 30-day perioperative morbidity was 12%, with complications being less common for patients undergoing elective versus unscheduled operations (p < 0.002). Recurrence of Crohn's disease requiring operation was seen in seven patients after a mean follow-up of 38 months. The estimated cumulative recurrence rate after 2 years was 15 +/- 6% (+/- standard error) and 22 +/- 10% at 5 years. A recurrence developed at the site of the previous strictureplasty in only five cases. Strictureplasty is a safe, effective means of providing long-term surgical palliation to selected patients with Crohn's disease. Perioperative complication rates are comparable to those seen with standard surgical treatment, and recurrences are not excessive.     

Surgery in patients with HIV infection: indications and outcome

We reviewed the records of 12 patients with HIV infection (one stage I, three stage II, two stage III, six stage IV) who received 15 surgical procedures under general or lumbar/epidural anesthesia. We discussed surgical indications, their poor wound healing and precautions for preventing the risk of transmission of HIV to health care workers. Six emergency and nine elective operations were performed. Postoperative complications developed after three emergency and three elective operations. Ten patients showed delay of wound healing which was not directly correlated with the CD4+ cell count. No operative deaths occurred. In any stage of HIV infection, not only palliative but also curative operations can be performed as long as HIV infection, opportunistic infections and HIV-related neoplasms can be controlled. Late stage wound healing is poor, but the wound will heal without keloid formation, although it takes two to three times longer than usual. For operating on patients with HIV infection precautions for preventing needle sticks, sharp injuries and blood exposure should be learned and used by health care workers. As a result, surgical staff members will be able to perform operations safely on HIV-infected patients to improve both quality of life and the prognosis of their disease.     

Up-to-date approach to the treatment of rectal cancer

During the last 15 years 2404 radical operations of various types were carried out for cancer of the rectum. The rate of postoperative complications made up 28.3% and mortality--2.9%. The tendency to increase of locally spread forms of cancer up to 96.2% with metastases to regional lymph nodes up to--52.3% was detected. The use of adequate chemotherapy, updated suturing devices and new variants of radical operations, combined and extended ones in particular havw much contributed to carrying out radical interventions with complete restoration of bowel continuity in 70% of patients. 5 year survival rate of patients after sphincter saving plastics and restorative procedures made up 60.2-65.3%, after extirpations with colostomy--54.2%. Promising results of improvement the indices of 5 year survival were obtained when preoperative irradiation in regime of multifractioning SOD 45-55 Gy was used together with administration of 5-fluorouracil (5-7.5 g).     

Alfentanil-oxygen anaesthesia for coronary artery surgery

The anaesthétic properties of alfentanil were evaluated in 15 patients undergoing coronary artery bypass grafting operations. Alfentanil was infused at a rate of 3.0mg min-1 until the patients (breathing pure oxygen) became unconscious. Additional alfentanil 2.5-5.0mg i.v. was given if systolic arterial pressure increased by 15% or more from control values. Alfentanil produced unconsciousness in 75 +/- 18s, but muscle rigidity occurred in 27% of patients. Cardiovascular dynamics were minimally altered during the induction of anaesthesia and throughout most of the operation, although 60% of patients became hypertensive during sternotomy and 73% during sternal spread. Recovery from anaesthesia was rapid with patients regaining consciousness after 1.4 +/- 0.6h and fulfilling out criteria for extubation of the trachea 4.1 +/- 1.2h after operation. No patient was aware of laryngoscopy, endotracheal intubation or any aspect of the operation.     

Ulcer surgery and anti-ulcer agents. Changes in surgical activities and sale of anti-ulcer agents in Nord-Tr?ndelag 1975-89

During recent decades the number of operations for peptic ulcer has decreased significantly. The incidence of operations for peptic ulcer or related complications during the period 1975-89 in persons older than 15 years was investigated in the Nord-Tr?ndelag region of Norway, with a population of approximately 100,000. The number of elective surgical procedures decreased by 72% from 1975 to 1989. The greatest reduction was found for duodenal ulcers. The incidence of acute operations decreased by 35%. The main reason was fewer surgical interventions in patients with haemorrhage, since the number of operations for perforation remained almost constant during the period of 15 years. The reduction in surgical treatment can be explained mainly by the introduction of new H2-antagonists in the seventies, leading to more successful pharmacological treatment of peptic ulcer.     

Comparative assessment of Fontan operation in modifications of atriopulmonary and total cavopulmonary anastomoses

OBJECTIVES: The optimal technique of the Fontan operation remains disputable. This investigation was aimed at the comparison of atriopulmonary and total cavopulmonary anastomoses. METHODS: The results of 81 operations of total cavopulmonary and 69 operations of atriopulmonary anastomosis, performed from 1983 to 1995 were analysed. A control study was carried out 1-10 (3.7 + 0.2) years after the operation in 80 patients (36 after total cavopulmonary and 44 after atriopulmonary anastomoses). 70 patients were studied several times. Cardiac catheterization was done in 70 patients. In 78 patients central hemodynamical indices were studied during exercise. RESULTS: Preoperative hemodynamical indices were not reliably different in the two groups. Early mortality after total cavopulmonary anastomosis was 15%, after atriopulmonary anastomosis 23%. The highest mortality was seen when the criteria of Choussat et al. (Choussat et al. Pediatric Cardiology. Edinburgh: 1977:559-566) were surpassed. In the early postoperative period after total cavopulmonary anastomosis circulatory insufficiency was less marked, transsudation from pleural cavities was reliably lower (15.3 + 1.2 versus 25.5 + 1.8 ml/kg/day, P < 0.01). Arrhythmias were more common after total cavopulmonary anastomosis (18.5 versus 12%). Late mortality after total cavopulmonary anastomosis was 6%, after atriopulmonary anastomosis 12%. 82% of patients after atriopulmonary anastomosis and 81% after total cavopulmonary anastomosis were in NYHA classes 1 and 2.7% of patients after total cavopulmonary anastomosis and 11% after atriopulmonary anastomosis were reoperated. Physical tolerance rose stepwise in both groups and by the third post-operative year reached 75% of normal level. At this time we saw the most optimal hemodynamical indices during exercise. However, the best hemodynamics during exercise were seen after atriopulmonary anastomosis. CONCLUSIONS: Total cavopulmonary anastomosis is accompanied by lower mortality rate and a more favourable course of early postoperative period. However, the best long-term functional results are obtained after atriopulmonary anastomosis.     

Cardiac surgery for grown-up congenital heart patients: survey of 307 consecutive operations from 1991 to 1994

The cardiac surgery performed from 1991 to 1994 in a unit dedicated specifically for grown-up congenital heart (GUCH) patients was reviewed to determine the frequency of various procedures, incidence of first and reoperations, early mortality, and its determinants. The 295 patients, aged 16 to 77 years (31 +/- 13), had 307 operations. First operations (n = 128, 42%) were most commonly for closure of atrial septal defect (n = 40), aortic valve replacement (n = 31) or repair of aortic coarctation (n = 14). Reoperations were more frequent (n = 179, 58%) and divided among first corrective repair (n = 49), reoperation after corrective repair (n = 115), and further palliation (n = 15). First corrective surgery was mainly for aortic valve disease (n = 17), Fallot (n = 7), and lesions needing a Fontan procedure (n = 5). Reoperations after corrective repair were needed for aortic valve disease (n = 43), right-sided conduit (n = 30), or recoarctation (n = 11). Early mortality was influenced by presence of central cyanosis (9 of 49, 18% in cyanotic patients; 12 of 258, 5% in acyanotic; p <0.001), increased number of previous operations (0 = 4%, 1 = 7%, 2 = 11%, >2 = 13%; p = 0.003), and increasing age of patients. Cyanotic patients had more serious postoperative complications: pleural and pericardial effusions, severe bleeding, renal insufficiency, and sepsis, and their hospital stay was longer compared with acyanotic patients (20 +/- 17 vs 11 +/- 8 days; p <0.001). In GUCH patients, reoperations cause the largest demand on cardiac surgical services. Increased survival of patients with complex cardiovascular malformations brings difficult challenges not only to cardiologists but also to cardiovascular surgeons. There is a need to provide continued highly specialized care. Resources, patients, and funding should be concentrated in a few designated centers.     

Seven abdominal assessment signs every emergency nurse should know

BACKGROUND: Open or laparoscopic surgery for gastroesophageal reflux disease gives longterm freedom from symptoms in 83-100% of cases but has a certain percentage of complications. This study was undertaken to evaluate the early and late complication rates after primary or repeat antireflux operations. STUDY DESIGN: The records of all patients who underwent surgery for gastroesophageal reflux disease during a 32-year period at a university teaching hospital were reviewed retrospectively. Records for 793 adults (448 men and 345 women) aged 16-85 years (mean, 51) were retrieved for calculation of complication rates and statistical analysis. RESULTS: A total of 827 operations were performed: 793 primary and 41 for recurrent disease (2 patients were each reoperated on twice). There were 49 laparoscopic operations. Only two patients died (mortality, 0.3%), both after open operation. Morbidity was 24% after open surgery and 14% after laparoscopic operation. The total (early and late) complication rate was higher after reoperations than that after open or laparoscopic procedures. The overall complication rate in the open operations was similar in the first and the third decade of the study, namely, 24.6% and 26.1%, respectively. CONCLUSIONS: Surgical treatment of gastroesophageal reflux disease carries very low mortality when performed in a specialized unit. The main causes of morbidity after open operation are infectious complications. The incidence of complications is substantially lower after laparoscopic surgery than after open operation. Reoperation is seldom required, but it carries higher morbidity than the primary operations.     

A sensitive assay for measuring alpha-Gal epitope expression on cells by a monoclonal anti-Gal antibody

BACKGROUND: The distinction between solitary parathyroid adenoma and hyperplasia can sometimes be difficult during surgery for primary hyperparathyroidism (pHPT), especially in patients who have undergone previous thyroid or parathyroid surgery. The use of intraoperative parathyroid hormone (PTH) monitoring as a possible diagnostic tool was therefore investigated. METHODS: Intraoperative levels of PTH were measured in 119 patients during 121 operations (including 14 reoperations) for pHPT. The mean(s.d.) preoperative serum calcium level was 2.79(0.21) mmol/l. Blood samples were drawn before, and at 5 and 15 min after, excision of the first enlarged parathyroid gland. PTH was analysed electively in 61 patients and on-line by a modified assay for intact PTH in 48 patients. Both procedures were used in ten patients. RESULTS: The mean(s.d.) decline in PTH concentration in 101 patients with primary exploration due to solitary adenoma was 63(17) per cent after 5 min (n=84) and 83(10) per cent after 15 min. The patients with primary exploration because of multiglandular disease (n=6) were correctly predicted not to have parathyroid adenoma. CONCLUSION: Measurement of PTH levels during surgery for pHPT is a highly sensitive method for differentiating between single and multiple gland disease. The on-line monitoring of PTH is clinically useful in patients who have undergone previous neck surgery. Its role in pHPT surgery at primary exploration should be evaluated in prospective trials.     

Clinical aspects, diagnosis and surgical treatment in injuries of the iliofemoral venous segment in children

In 1985-1991 forty patients aged from 12 days to 14 years were treated for sequelae of iatrogenic injury to the iliofemoral venous segment. Twenty-five various operations for autovenous shunting were performed: cross shunt after Palma in 15, autovenous shunt in the anatomical projection in 3, phlebolysis and ligation of the collaterals in 5 cases, extravasal correction with A. N. Vedensky's casing spiral in one case, and direct anastomosis in a newborn infant.     

Laparoscopic fundoplication

The experience in treatment of 278 patients with extensive traumatic injuries of the shin complicated by purulent infection is represented. Multistage treatment typical for such category of patients in which reconstructive-restorative stage is performed late after elimination of inflammatory process is not optimal. Owing to the complex of treatment measures based on the principles of active surgical treatment of festering wounds primary operations were a success in 24.6% of patients. In 75.4% of patients early dermoplastic and osteoplastic operations were carried out to 1 month after primary surgical treatment. Good and favourable results obtained in 98.6% of patients demonstrate effectiveness of the above policy of treatment.     

Effects of ketorolac on bone repair: A radiographic study in modeled demineralized bone matrix grafted rabbits

The treatment of instability of the multiply reoperated knee is a complex problem. The causes for failure are numerous and include repeated trauma, insufficient fixation and non-anatomic placement of the graft, inadequate replacement material, isolated anterior cruciate ligament (ACL) reconstruction in complex knee instability or the use of a ligament prosthesis. With every surgical procedure, however, the anatomical and technical conditions become worse. Problems like degenerative changes, joint stiffness and gait abnormalities occur and often become a more focal point than the instability itself. The purpose of this paper is to present the problems and the dilemma of instability of the multiply reoperated knee and the possible solutions. Between 1976 and 1996, a total of 1752 ACL reconstructions were carried out in Munich and Hannover. Of these, 228 (13%) were revision, mostly of failed ACL reconstructions performed elsewhere. Since 1989, we have chosen the severest cases from this group (more than three operations on the same knee) for this study. Seventeen patients were investigated who had undergone up to 25 operations. The mean number of operations was 7. All primary operations were performed in other hospitals. In 10 cases only the ACL reconstruction was performed as a final procedure, mostly in combination with other procedures like medial meniscus replacement, extra-articular stabilization or arthrolysis. In the other cases operations such as osteotomies, arthrodesis or amputation were necessary. The results present the main dilemma in instability of the multiply reoperated knee since they were not successful in all patients. Finally, 15 patients report still having instability, pain or swelling in isolation or in combination. Nine patients were satisfied with their subjective results. Even after the socalled definitive procedures, certain complications arose. The main goal in the treatment of instability of the multiply reoperated knee is to avoid a series of operations, hospitalization and history of illness. General revision surgery for the entire complaint is not the aim of the treatment. The specific problem of the patient should be extracted from the complex situation, and this should be solved with the most limited procedure possible only.     

Convulsions with meningiomas: incidence and significance

In a study of a consecutive series of 127 surgically treated meningiomas, it was found that 29% of the patients had reported with convulsions as their initial symptom. In this group, surgical excision of the meningioma stopped the convulsions in about half of the patients, but the others continued to have seizures after their operations. Among those patients with meningiomas who did not have preoperative convulsions, about one-sixth (15 patients) developed postoperative seizures. Patients in both groups required prolonged anticonvulsant medication. Factors predisposing to the occurrence of postoperative seizures were the site of the tumor, faulty surgical technique, and a preoperative history of seizures.     

The surgical results in patients with different forms of torsion dystonia

The paper describes stereotactic operations made in 278 patients with different forms of torsion dystonia during 20 years. Late outcomes were studied and assessed in 130 patients. The duration of follow-ups was 3 to 23 years. The patients' mean age at surgery was 30.5 years. The indications for surgical treatment were ineffective medical treatment and progressive disease. Positive early and late postoperative outcomes were achieved in 93 and 70% of patients, respectively. Complications developed in 3.2 and 12.3% of patients after the first and second operations, respectively. The positive outcome depends on the form, etiology, the destructible structure or a complex of structures. Surgical treatment of patients with torsion dystonia by stereotactic operations on basal ganglia is an effective treatment that provides a steady-state positive result in 70% of patients in the late period.     

Posterior sagittal anorectoplasty in the treatment of anorectal malformations

Posterior sagittal anorectoplasty is a marked change in treatment of anorectal malformations and differs fundamentally from previous techniques. In 1991-1996 86 patients (51 boys and 35 girls) aged 1 day to 22 years were operated. A primary operation was performed in 65 patients, a secondary one in 21 patients. In primary operations posterior sagittal anorectoplasty was used in 50 patients, in 3 cloacal malformations it was extended by reconstruction of the vagina and urethra. Fifteen patients were operated by other techniques. Posterior sagittal anorecto (vaginourethro) plasty was used in all 21 reoperated patients. Of 65 patients with primary operations one patient died from aspiration bronchopneumonia four years after operation. The patient had also an operation on account of oesophageal atresia. Three patients were reoperated. The continence of patients after primary operations is satisfactory, 5-6 points on Kelly's scale. In 19/21 reoperated patients the continence is 3-5 points according to Kelly. In two patients no substantial changes were recorded, one was reoperated twice. As compared with pull-through techniques the posterior surgical method of anorecto (vaginourethro) plasty is excellent. It cannot be used however without adequate experience.     

A review of 10 patients of nephrectomy through laparoscope video

Ten patients were subjected to nephrectomy through laparoscope video. Compared with routine nephrectomy, it has such merits as slight trauma, less bleeding and pain during the operation as well as quick recovery and short hospitalization. In 6 male patients and 4 female patients the oldest one was 75 years old, and the youngest one was 15 years old. Seven patients suffered from nephrohydrosis and 3 from polycystic kidney. Before the operation, the patients were found the loss of function of the diseased kidney. The video scope was inserted into the abdominal cavity through an operating hole under the navel making the exploration in the cavity; the other operations are as basical as routine operations. The ill kidney was cut off and put into a special pocket, then it was cut into pieces, and taken out. The abdominal membrane was enclosed by the emanometer, the drainage tube kept. In the 10 patients the operations were successful and satisfactory.     

An analysis of radiating pain at lumbar discography

Internal illiac and ovarian artery ligation was performed in 7 patients as a life saving measure (group I) and in 12 patients as a prophylactic procedure (group II) in 116 pelvic operations for gynaecological malignancy. The author presents own surgical technique for internal iliac and ovarian arteries ligation. The purpose of analysis was to identify a surgical complications after the ligation in the study groups. Surgical complications in the group of prophylactic ligation were statistically significant low. It is advisable to adopt this procedure as a routine in all difficult pelvic operations, particularly radical operations for gynaecological malignancy.     

Persistent gastroesophageal reflux disease after antireflux surgery in children: I. immediate postoperative evaluation using extended esophageal pH monitoring

PURPOSE: There is a paucity of quantitative and reproducible follow-up data on childhood operations for gastroesophageal reflux disease (GERD). With the development of minimally invasive techniques for antireflux operations in children, there is a need to quantitatively determine immediate outcomes for such operations performed by laparotomy for comparison. METHODS: A retrospective review of 385 children (age range, 1 week to 15 years) who had a primary antireflux operation in a Children's or University Hospital performed by laparotomy between 1983 and 1997, and who also had an extended esophageal pH study performed within the first 12 postoperative weeks, was conducted. The operations performed included Nissen fundoplication (n = 135), Thal fundoplication (n = 195), and Boerema gastropexy (n = 55). An immediate postoperative failure of the operation to control GERD was defined as an abnormal esophageal pH score persisting up to the twelfth postoperative week. RESULTS: Eleven patients (2.9%) were classified as having an immediate postoperative failure of their operation to control GERD. An additional three patients had an abnormal esophageal pH score 2 weeks postoperatively, which subsequently reverted to a normal esophageal pH score by 12 weeks. The immediate postoperative failure rate was 1.5% (2 of 135) for the Nissen fundoplication, 1.5% (3 of 195) for the Thal fundoplication, and 10.9% (6 of 55) for the Boerema gastropexy. A higher failure rate (five patients, 36%) was seen for the first 14 patients who underwent a Boerema gastropexy during the learning curve period for this operation before 1985, and by excluding these patients the failure rate was 2.4% (1 of 41) after 1985. There was no significantly increased probability of immediate postoperative failure in patients with central nervous system disorders, prematurity, repaired esophageal atresia, or gastric emptying abnormalities. Only 5 (36%) of the 14 children with persisting symptoms suggestive of GERD had immediate postoperative failure of their operation. CONCLUSIONS: Extended esophageal pH monitoring during the first 12 postoperative weeks is a helpful tool to assess the immediate outcome of antireflux operations in children because clinical symptoms alone may be unreliable. The immediate failure rate for an antireflux operation performed in children by laparotomy is very low and seems to be unaffected by comorbid factors.