Choledochoduodenostomy in choledocholithiasis and benign strictures of the common bile duct

The methods of external and of internal drainages of the bile ducts are alternatives in choledocholithiasis and benign strictures of the choledochus. In the Central Research Institute of Gastroenterology, 349 operations were performed on the common bile duct, stones were found in the choledochus in 259 (74.2%) cases and benign strictures of the terminal part of the choledochus and the major duodenal papilla in 103 (29.5%) cases. Ninety-five operations were secondary or reconstructive in character. A precise diagnosis of affection of the biliary tract can be established only during an operation or by retrograde cholangiopancreatography. External drainage of the common bile duct was conducted in 229 (65.6%) cases. Choledochoduodenostomy was undertaken in 105 patients (55 were operated on for the first time and 50 underwent operation on the biliary tract for a second time). Endoscopic papillosphincterotomy was successful in 28 cases with short strictures of the choledochus and choledocholithiasis. The stones were removed from the ducts with instruments or were expelled spontaneously at days 2 to 5.     

Indications and results of early functional vertebral fracture treatment

Early functional treatment was administered to 213 patients with stable compression fractures of thoracic and lumbar vertebrae between 1975 and 1982. Physiotherapy was carried out according to a uniform schedule. The patients were mobilized after an average of 6 days; hospitalization lasted 2 weeks on an average. Control examinations of 82 of these patients revealed only a slight union of compressed vertebral bodies (on an average, 7% of the initial height), which correlated with the primary compression and the patient's age. Remaining functional restriction of the spine and subjective complaints did not correlate significantly with the extent of vertebral compression.     

Surgical approaches to recurrent choledocholithiasis: Choledochoduodenostomy versus T-tube drainage after choledochotomy

To assess the value of choledochoduodenostomy versus T-tube drainage to manage patients with recurrent choledocholithiasis, a prospective, randomized study was carried out where under strict criteria of selection, 45 patients underwent choledochoduodenostomy after choledochotomy (Group A), and another 45 patients underwent T-tube drainage (Group B). Results revealed that patients in Group A had low early morbidity (8.8 percent), no mortality, and no reoperations due to recurrent choledocholithiasis. In contrast, in Group B patients there was a mortality of 4.4 percent, an early morbidity of 26.6 percent, and a late recurrence and reoperation rate of 20.9 percent. The difference in those elements between patients in Group A and Group B is considered significant (p <0.05, p <0.001, and p <0.0001, mortality and early and late morbidity, respectively). It is recommended that at least for a proportion of patients with recurrent choledocholithiasis who present with clinical and operative findings similar to those in this study, choledochoduodenostomy has to be considered the method of choice.     

Surgical management of pelvic ring disruptions. Indications, techniques and functional results.

In a period of 30 months, we treated 44 pelvic ring fractures by early operative stabilization. The ratio of associated musculoskeletal and intrapelvic lesions was very high, with a mean ISS of 36.2. The perioperative mortality rate (3/44) was acceptable with 6.8%. A second osteosynthesis was performed in fast 8% of type-B and in fast 40% of type-C lesions. The average hospital stay was very short with 42.0 days. We were able to mobilize the patients very early after their admission, thanks to the quick operative stabilization of the pelvic ring and the other skeletal injuries. Of the 39 surviving patients, 35 were reviewed clinically, functionally and radiographically after a mean of 19.3 months. There was a statistically significant difference in the rate of walking difficulties, walking distance, hip mobility, muscle force and the functional end-results between patients with type-B and those with type-C lesions. Lesions of type B are benign and can be adequately treated by the application of an anterior external fixator frame alone. The functional results are excellent or good in the great majority of cases. The type-C lesions are much more difficult to deal with. The anterior external fixator provides insufficient stability in many cases. It must be supplemented by posterior fixation or exchanged for anterior and posterior internal fixation. Even then, many patients with type-C lesions have functional disabilities and subjective complaints after treatment.     

Indications for relaparotomy and its results

For the recent six years 6855 operations on abdominal organs have been performed which were followed by relaparotomies in 104 patients (1.5%). The authors show that the greatest amount of relaparotomies followed operations for ulcer disease, tumors and cholecystitis. The main causes of relaparotomies were peritonitis, intestinal obstructions and bleedings. The group of greater risk consisted of men aged 50-60. The amount of relaparotomies can be reduced due to unification of medical tactics, strict observation of the operation technique and responsible management of the patients in the postoperative period.     

Vascularized joint transfers. Indications and results.

Vascularized joint transfer can be beneficial in restoring joint function and maintaining growth. It is sometimes indicated in patients with painful post-traumatic arthritis, post-traumatic joint instability, and post-traumatic deformity. The best indication for this procedure is in children whose joint injury is associated with damage to growth plates in any of the digits; however, the complications associated with this procedure should not be overlooked. Extensor lag is common. This complication may be prevented during the surgical procedure by using a step-cut osteotomy to preserve the insertion of the extensor tendon, resecting the volar plate of the finger, harvesting the transferred joint with enough length to keep the extensor tendon tight, and placing the transferred joint in a maximally extended position to counteract the flexible trend of the toe joints. We believe this procedure holds promise for the future. Further improvement in surgical technique and clarification of its indications will likely enhance overall results.     

Indications, surgical technique, and long-term functional results of colon interposition or bypass.

Over a 17-year period, 92 patients with esophageal disease underwent colon interposition or bypass, with each operation performed by the same surgeon. The indication was cure of cancer in 20 patients, relief of dysphagia in 55 (cancer in 17 patients and benign in 38), loss of gastrointestinal (G.I.) continuity in ten, and tracheoesophageal fistula in seven patients (malignant in five, benign in 2). The thirty-day operative mortality rate was 5%, and the hospital mortality rate was 9%. Graft necrosis occurred in seven of 92 patients, four of whom later underwent a successful second reconstruction. Thirteen patients required subsequent revisional surgery. In 85 patients, the left colon based on the inferior mesenteric artery was used, and in seven, the right colon was used. Technical insights were gained to help preserve the blood supply to the graft and improve its function in transporting food. Thirty-four patients were available for interview 2-17 years after operation (median of 5 years) 28 of whom had benign disease, and six of whom had malignant disease); 82% of the patients felt they were cured of their preoperative symptoms, 18% improved, and none worsened. Eighty-eight per cent of the patients were able to receive an unrestricted diet. All patients except one were satisfied with the results of surgery, and, asked what they would do if they had to make the choice again, all responded that they would have the operation. Twenty-six of the interviewed patients had their eating ability evaluated with a test meal and the transit time of a liquid and solid barium bolus measured. Compared to controls, patients with colon interpositions consumed a smaller capacity meal over a longer period of time and were not dependent on liquids to flush the food through the colon graft. A colon interposition provides good quality of deglutition, is very durable, and is the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival.     

Endoscopic papillotomy today. Indications and results

The therapeutic possibilities offered by endoscopic papillotomy have improved in comparison with the recent past by virtue of mounting experience and increasingly satisfactory results. The position of the surgeon in the face of this procedure is more serene and objective than those who concern themselves with the endoscopic method as such. In long-term personal experience, endoscopic papillotomy was indicated in 162 cases of biliary lithiasic pathology--associated and otherwise with Odditis--and angiocolitis, with and without the gall-bladder. The reference to endoscopic treatment was mainly confined to patients with associated pathologies, dependent and otherwise, that involved general or specific surgical risk, while evaluations of the lumen of the biliary excretory way, of the coexistence of more or less incisive biliary inflammation, of the age of the patient--all parameters to which are attributed special importance for the choice between derivative intervention and open papillotomy--do not possess particular significance for the endoscopic method. Results obtained and the low incidence of short and long-term morbility support the claim to absolute usefulness of the method when it is proposed on correct indications and carried out with expert technique.     

Indications and results of completion pneumonectomy.

OBJECTIVES: Completion pneumonectomy (CP) is widely known to be associated with a high morbidity and mortality. However, in certain instances, CP offers the only chance for a cure. The results of the following three groups were investigated: progressive or recurrent benign disease, recurrence of a malignant tumour and complication after lung resection. METHODS: Between January 1986 and April 2003, 525 patients underwent pneumonectomy, 86 of these being completion pneumonectomies (16.4%). Six patients suffered from a progression or recurrence of a benign disease, 41 patients had a recurrence of a malignant tumour (local recurrence, secondary carcinoma and recurrent metastases) and 39 patients had a complication after lung resection. Among patients with a complication, the indication for CP was either an emergency or urgent condition. Right CP was carried out in 48 cases and left CP in 38. RESULTS: The overall 30-day mortality was 20.2, 0% in the group with benign disease, 10% in the group with a recurrent malignant tumour and 33.3% in the group with a complication after lung resection. The 30-day mortality of CP was significantly higher (P = 0.014) on the right side (29.8%) than on the left side (7.7%). Differentiation between emergency and urgent indications resulted in 30-day mortalities as follows: 54 and 23%, respectively. This difference is significant (P = 0.002). The 30-day mortality for patients with anastomotic or stump insufficiency was 41% (P = 0.002). Five-year survival of all patients was 28% and in the group of patients with a complication after lung resection 32%. CONCLUSIONS: Lethality of CP remains high, especially after CP for a complication performed in an emergency condition. Possible risk factors are right side of operation, CP performed in an emergency condition and CP for anastomotic or stump insufficiency, either or not involving sepsis. However, considering the long-term survival, CP is certainly justified.     

Indications for and results of surgical therapy for male gynecomastia.

BACKGROUND: The objective of our study was to analyze factors determining diagnostic versus cosmetic indication and postoperative results in the treatment of gynecomastia. PATIENTS AND METHODS: Data from 100 patients and 141 breasts were analyzed retrospectively, and reevaluated by questionnaire (n = 81) and clinical examination (n = 33). Except for 2 patients, all underwent subcutaneous mastectomy through various incisions. RESULTS: Diagnostic surgery was exclusively performed in unilateral, nodular gynecomastia being preferentially of grade I. Higher grade, bilateral gynecomastia led mainly to cosmetic surgery. Minor complications (skin retraction, hypertrophic scars, hypesthesia, skin redundancy) occurred in 53% of patients and significantly more often in grade III or II gynecomastia. Each incision was preferentially associated with specific sequelae. However, 86% of patients were satisfied with surgical results. CONCLUSIONS: Laterality, consistency, grade, and age at onset of symptoms determine surgical indication. Despite the high number of sequelae due to preoperative grade and selected incision, most patients are satisfied with postoperative results.     

Immediate tricuspid valve replacement for endocarditis. Indications and results

Tricuspid valve excision for tricuspid endocarditis in addicts is recommended to avoid early reinfection, continued sepsis, and late reinfection because of the resumption of intravenous drug abuse. Valvectomy is allegedly well tolerated hemodynamically by some, but it leads to heart failure in at least a third of patients. In our experience in 10 addicts with staphylococcal endocarditis who had failed to respond to antibiotic therapy, tricuspid valve replacement allowed all 10 to leave the hospital free of infection and free of heart failure. Resumption of drug addiction in three led to septic death, but not necessarily to tricuspid reinfection. Two returned to jobs requiring a high level of physical labor and tolerated this without difficulty. We find no need to follow the practice of tricuspid valve excision for tricuspid endocarditis in addicts. Those who refrain from drug abuse are well served by valve replacement. Those who do not are doomed with or without a tricuspid valve.     

Indications for and results of coronary artery bypass surgery.

The natural history of angina and the influence of aortocoronary saphenous vein bypass grafting on the relief of symptoms and survival are reviewed. Indications and contraindications for coronary surgery and the complications and results of operation are discussed. Coronary artery surgery is occasionally indicated in situations other than angina, such as in selected cases of unstable angina, arrhythmias and acute myocardial infarction.