Long-term results of conventional surgical treatment for epilepsy. Delayed recurrence after a period of 10 years

The results of the surgical treatment of epilepsy were studied in 44 patients 10 or more years after operation. Thirty-seven patients underwent operation only once; these patients were observed 11–26 years postoperatively. Seven patients had a recurrence within 5 years after operation and required a second operation; these patients were observed 11–17 years after the second operation. Recovery persisted for 15–27 years in 32 patients. There was a recurrence in 12 cases 11–19 years after operation. With one exception, these recurrences were satisfactorily treated medically.     

Clinical results of laparoscopic fundoplication at ten years after surgery

BACKGROUND: Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery. METHODS: The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years. RESULTS: Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to "wind" problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors. CONCLUSIONS: Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.     

Renin-aldosterone system and atrial natriuretic peptide during anesthesia in orthopedic patients over 80 years of age.

STUDY OBJECTIVES: To investigate the changes in plasma atrial natriuretic peptide, renin activity, and aldosterone during isoflurane anesthesia in patients over 80 years. DESIGN: Prospective, randomized, controlled study. SETTING: Operating rooms and postanesthesia recovery room of Hirosaki University Hospital and Hakodate Watanabe Hospital. PATIENTS: 36 patients undergoing reduction of femur neck fracture (18 patients ranging in age from 80 to 99 years and 18 patients ranging in age from 40 to 59 years as control). INTERVENTION: In all patients, anesthesia was induced with intravenous (i.v.) thiopental sodium 3 to 5 mg/kg succinylcholine 0.5 to 1.0 mg/kg for facilitating tracheal intubation and was maintained with 1.2% to 2.0% isoflurane in 50% oxygen. MEASUREMENTS AND MAIN RESULTS: Plasma atrial natriuretic peptide (ANP), plasma renin activity (PRA), and plasma aldosterone (PA) levels were assayed. Blood samples were obtained on the following occasions: before the induction of anesthesia, 15 minutes after skin incision, 90 minutes after anesthesia induction, and the 60 minutes after the end of surgery. Plasma renin activity and PA levels in patients from 40 to 59 years increased significantly 90 minutes after induction, whereas PRA and PA levels in patients over 80 years were unchanged. There were significant differences in PRA and PA levels between both groups at any time of measurements. Plasma ANP levels of patients over 80 years were significantly elevated at 90 minutes induction. Plasma ANP levels in patients over 80 years at 90 minutes after the induction and 60 minutes after the end of surgery were significantly higher than those of patients from 40 to 59 years. Plasma renin activity in hypertensive patients over 80 years at 90 minutes after the induction was significantly lower than that observed in normotensive patients. The renal loss of sodium was increased in the hypertensive patients. CONCLUSIONS: Orthopedic patients over 80 years of age have decreased PRA and PA, increased ANP, and renal loss of sodium as compared with patients 40 to 59 years, during isoflurane anesthesia. Plasma renin activity at 90 minutes after induction was decreased in hypertensive patients over 80 years, but PA and ANP were not affected by hypertension during anesthesia.     

The rate of recovery following whiplash injury

Summary Fifty consecutive patients with soft-tissue neck injuries following rear end collisions were studied prospectively to assess their rate of recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into one of four groups (A, asymptomatic; B, nuisance; C, intrusive; D, disabling). Fourteen of 15 patients (93%) who were asymptomatic after 3 months remained symptom-free after 2 years. Of 35 patients with symptoms after 3 months, 30 (86%) remained symptomatic after 2 years. After 1 year, 26 (52%) stated that they had recovered completely, but after 2 years this had fallen to 19 (38%). Nine of the 15 patients who had improved between 3 months and 1 year deteriorated to their previous status, or worse, between 1 and 2 years. In asymptomatic cases, a prognosis that is 93% accurate after 2 years can be given after 3 months, and 86% of patients who are symptomatic after 3 months will remain so after 2 years. However, the severity of their symptoms will change during this period and will be at the same degree of severity in less than 50%.     

Rehabilitation of the bilateral amputee

One hundred sixteen patients with bilateral amputation as a result of severe ischemia were reviewed to evaluate their rehabilitation potential. Seventy patients were male and 46 were female; ages ranged from 31 to 92 years (mean 68 years). The operative mortality rate after the second amputation was 9.5% (11 of 116 patients). The time from the first to second amputation ranged from zero to 144 months (mean 23 months). Follow-up from 1 to 14 years was available on all patients. Sixty percent of the patients surviving the postoperative period were alive at 2 years and 40% at 5 years. Of the 105 patients available for follow-up, only 27 (26%) were able to use bilateral prostheses. Twenty-three (85%) of these patients were ambulatory after their first amputation. Four patients not walking after their first amputation became ambulatory after their second. All four had bilateral below-knee amputations. Of the 78 patients unable to use a bilateral prosthesis, 68 (87%) were able to function independently and 10 became bedridden. Successful prosthetic rehabilitation in the bilateral amputee appears primarily dependent on the use of a prosthesis after the first amputation. The acceptable long-term survival and the number of patients who became independent in their activities justify an aggressive approach to the rehabilitation of the bilateral amputee.     

Long-term outlook after atrial correction of transposition of great arteries

Late results were reviewed in 220 survivors after atrial correction of transposition of the great arteries who were operated between 1964 and 1985. Senning's procedure and its various modifications have been used; all patients who survived 30 days after correction were included in this analysis. Average follow-up for the whole group was 10.3 years; 113 patients were observed for 10 years, 26 patients for 15 years, and 8 patients for 20 years. The actuarial survival rate for the whole group was 89% at 10 years, 87% at 15 years, 82% at 20 years. It was higher in simple than in complex transposition (92% versus 84% at 10 years). Sudden deaths (8 patients) and late heart failure (6 patients) were the principal causes of death, predominantly in the complex transposition group (10/13 deaths). Late survival was more common in the latter part of the study, with 95% of patients operated on after 1978 surviving 9 years as opposed to 84% of patients operated on earlier. Late reoperation was necessary in 18 patients (8%), with 12 reoperations occurring within 2 years after correction. Cumulative reoperation rate reached 11.7% after 10 years. Reoperations were more common in complex than in simple transposition (14% versus 6%, p less than 0.05). Late arrhythmias can occur after atrial correction, and the cumulative incidence of pacemaker implantations was 8% at 10 years. Most of the survivors are functionally free of symptoms (83% of the simple and 75% of the complex transposition group). Significant tricuspid valve incompetence was encountered in only three patients, with two valve reconstructions being possible. In summary, long-term outlook for survivors of atrial correction for transposition of the great arteries remains encouraging, although complex transposition does seem to engender more late problems. Atrial correction is still warranted in simple transposition, but close cardiological surveillance is necessary.     

Local Recurrence After Mastectomy for Ductal Carcinoma In Situ

Abstract: Local recurrence after mastectomy for invasive cancer generally carries a poor prognosis. Local recurrence after mastectomy for ductal carcinoma in situ (DCIS) is rare and its impact on survival is unknown. Sixty-eight patients were treated with mastectomy for DCIS at the Fox Chase Cancer Center between 1985 and 1996, and only one of these developed a chest wall recurrence. An additional five patients treated with mastectomy at other institutions and referred to Fox Chase after local recurrence were also identified. These six patients had only DCIS as their primary pathology. Four of the six patients were premenopausal (median age 42 years). The median interval to local recurrence was 5.0 years (2.8–9.3 years). The median follow-up from initial diagnosis was 10.5 years (4.3–26.7 years) and 5.2 years (1.4–17.6 years) from recurrence. All of the recurrences were invasive and treatment included wide local excision with radiotherapy in all of the patients followed by adjuvant chemotherapy for the premenopausal patients. None of the patients had metastatic disease at presentation. The disease-free survival from initial recurrence was 83% and 63% at 5 and 10 years, respectively. The 5- and 10-year survival following local recurrence was 80%. One patient died 3.6 years after recurrence with metastatic disease, while a second patient developed metastatic disease 11.8 years after her initial recurrence. The remaining four patients are alive (NED), ranging from 1.4 to 10.7 years following their local recurrence. Local recurrence following mastectomy for DCIS is rare, usually invasive, and may have a long interval to failure. Salvage using conventional multimodality therapy appears to result in long-term survival.     

Ist die Naht des rupturierten vorderen Kreuzbandes ohne Augmentation sinnvoll?

The five-and ten-years review of 40 patients with primary suture of the anterior cruciate ligament without augmentation showed all patients to have a positive Lachman-Test. Five years postoperatively 14 patients had no complaints, after ten years, only two patients remained free of symptoms. Five years after suture nine patients were limited at work, while after ten years this number had risen to twelve. Ten years after the suture only eleven patients had the same sporting abilities as before the accident; only six patients retained their level of performance. Six patients needed a meniscus-operation between the first and second review (five and ten years postoperatively). Radiologically we found signs of gonarthrosis in 15% at five years and 30% at ten years. 75% of the patients with gonarthrosis had had partial meniscectomy. Our results confirm that instability caused by an insufficient anterior cruciate ligament leads to higher incidence of meniscal tears and osteoarthritis. A primary suture of the anterior cruciate ligament without augmentation almost allways leads to functional instability. This surgical procedure therefore is not recommended.     

What happens after graft loss? A large,long-term,single-center observation

The number of patients returning to dialysis after graft failure increases. Surprisingly, little is known about the clinical and immunological outcomes of this cohort. We retrospectively analyzed 254 patients after kidney allograft loss between 1997 and 2017 and report clinical outcomes such as mortality, relisting, retransplantations, transplant nephrectomies, and immunization status. Of the 254 patients, 49% had died 5 years after graft loss, while 27% were relisted, 14% were on dialysis and not relisted, and only 11% were retransplanted 5 years after graft loss. In the complete observational period, 111/254 (43.7%) patients were relisted. Of these, 72.1% of patients were under 55 years of age at time of graft loss and only 13.5% of patients were ≥65 years. Age at graft loss was associated with relisting in a logistic regression analysis. In the complete observational period, 42 patients (16.5%) were retransplanted. Only 4 of those (9.5%) were ≥65 years at time of graft loss. Nephrectomy had no impact on survival, relisting, or development of dnDSA. Patients after allograft loss have a high overall mortality. Immunization contributes to long waiting times. Only a very limited number of patients are retransplanted especially when ≥65 years at time of graft loss.     

尿微量蛋白检测对移植肾早期功能损害的诊断价值

目的探讨尿微量蛋白检测对肾移植患者术后早期肾功能损害的诊断价值。方法 200例肾移植患者(肾移植组)按移植术后时间长短分层随机抽样,分为5组:术后1～3个月组,术后4～11个月组,术后1～5年组,术后6～10年组,术后10年以上组,每组40例。另随机抽取拟行肾移植术而进行术前检查的尿毒症患者20例为尿毒症对照组。用速率散射比浊法分别对6组患者的清洁新鲜中段尿进行尿微量蛋白测定与尿蛋白定性检测,同时采用全自动生化仪检测血清肌酐(Scr)。结果与术后1～3个月组比较,术后4～11个月组的尿α1-微球蛋白即开始升高(P<0.05),术后1～5年组、6～10年组尿微量白蛋白、尿转铁蛋白明显升高(均为P<0.05)。术后10年以上组尿微量白蛋白、尿α1-微球蛋白、尿转铁蛋白、尿免疫球蛋白(Ig)G均明显升高(均为P<0.05)。术后10年以上组尿蛋白阳性率明显高于其它时间组(均为P<0.05)。肾移植术后不同时间Scr水平比较差异无统计学意义(均为P>0.05)。结论尿微量蛋白的变化较尿蛋白定性及Scr的改变更为敏感,宜作为早期移植肾功能受损的常规监测指标。     

Long-term results of the cementless porous-coated anatomic total hip prosthesis

Between January 1984 and January 1986, 131 porous-coated anatomic total hip replacements were performed in 119 consecutive patients. Of these, 100 patients (110 hips) who were alive at a minimum of 18 years after replacement were included in the study. The mean age of the patients at surgery was 48.4 years and that of surviving patients at the latest follow-up was 67.8 years. The mean duration of the clinical and radiological follow-up was 19.4 years (18 to 20). The mean Harris hip score initially improved from 55 points before to 95 points at two years after operation, but subsequently decreased to 91 points after six years, 87 points after 11.2 years, and 85 points after 19.4 years. At the final follow-up, 23 hips (18%) of the entire cohort and 21% of survivors had undergone revision because of loosening or osteolysis of the acetabular component and eight hips (6%) of the entire cohort and 7% of survivors for loosening or osteolysis of the femoral component. Only four femoral components (4%) were revised for isolated aseptic loosening without osteolysis and two (2%) for recurrent dislocation. On the basis of these long-term results, the porous-coated anatomic femoral component survived for a minimum of 18 years after operation while the acetabular component was less durable. The findings identify the principles of uncemented joint replacement which can be applied to current practice.     

单中心8818例脊柱畸形矫形术后深部感染的处理策略

目的探讨脊柱畸形矫形术后深部感染的发生率及其相应的处理策略。方法回顾性分析1998年1月至2017年12月接受脊柱畸形矫形术治疗8818例患者的病历资料,根据患者术后的临床症状、影像学检查及实验室检查判断是否发生深部感染。将初次手术后3个月之内发生的感染定义为早发性感染,初次手术3个月后发生的感染定义为迟发性感染。所有感染患者行清创灌洗、术后引流冲洗,并静脉应用敏感抗生素。若感染无法根除,如手术后时间不足2年,暂予伤口换药保留内固定;如手术后时间达到2年,评估融合情况满意后可在伤口清创的同时取出内固定。摄站立位全脊柱正、侧位X线片测量冠状面和矢状面参数,评估取出内固定者矫正丢失情况。结果共有60例(0.68%,60/8818)术后发生深部感染,早发性感染11例(发生率为0.12%,11/8818),迟发性感染49例(发生率为0.56%,49/8818)。两组患者在年龄、性别、手术入路及融合节段数方面的差异均无统计学意义。术后2~5年是深部感染发生的高峰期。特发性脊柱侧凸及强直性脊柱炎患者术后感染的发生率最低,综合征性及神经肌源性脊柱侧凸术后感染的发生率较高。初次培养阴性率较高,早发性感染中金黄色葡萄球菌和大肠埃希菌居多;迟发性感染中痤疮丙酸杆菌和凝固酶阴性葡萄球菌占比明显增高。经治疗后早发性感染组中9例保留内固定,2例换药至术后2年取出内固定。迟发性感染组中5例保留内固定,10例换药至术后2年取出内固定,34例手术时间超过2年直接取出内固定;其中1例患者取出内固定后1个月重新植入内固定;另有1例患者因矫正丢失在取出内固定3年后重新植入内固定。末次随访时取出内固定的患者出现了明显的冠状面矫正丢失。结论脊柱畸形矫形术后深部感染的发生率为0.68%,早发性感染发生率较低,迟发性感染较高;神经肌源性脊柱侧凸与综合征性脊柱侧凸患者有着较高的感染风险。如果感染在反复清创后无法根除,推荐在术后2年骨融合后取出内固定,但仍存在矫正丢失的风险。     

Arthroscopic partial meniscectomy: a 12-year follow-up and two-step evaluation of the long-term course

The long-term results after arthroscopic partial meniscectomy of 119 patients with a mean follow-up of 12 years are presented in this study. The same series of patients had an earlier follow-up 4 years postoperatively. Thus, an evaluation of the actual long-term course and not only a single result after partial meniscectomy is presented. Arthroscopic partial meniscectomy is shown to be the definitive means of therapy for meniscal lesion of the knee joint; 91.7% of patients had an excellent or good result 4 years after surgery, and 78.1% rated excellent or good 12 years after surgery. Full recovery regarding ability to work and sports activity level was achieved in a very high percentage of patients. Early results were mostly representative and did not change significantly during the long-term course for the isolated meniscal lesion. The factor with the highest impact on long- term results was damage to the articular cartilage, which did not influence knee function for several years after surgery but became increasingly symptomatic over time after 5 years and more. Only 62% of patients with additional cartilage damage rated excellent and good 12 years after surgery, in contrast with 94.8% good and excellent results in patients with isolated meniscal tears. Similar observations were made for the untreated rupture of the anterior cruciate ligament.Arthroscopy 1998 Mar;14(2):136-42     

Results of surgical treatment for familial polyposis coli

Seventy-seven patients with polyposis coli operated on at The Mount Sinai Hospital in the last 40 years were studied. Forty-two patients had a subtotal colectomy. Sixteen were found to have colon cancer at the time of operation, and a second rectal cancer developed in 50 percent of the survivors within 1 to 13 years after subtotal colectomy. Rectal cancer subsequently developed in only 3 of 23 patients without colon cancer. Thirty-five patients had total proctocolectomy or total colectomy with mucosal proctectomy and ileoanal anastomosis. Recurrent adenomatous polyps developed in two patients after mucosal proctectomy. A villous adenoma with carcinoma in situ of the ileum developed in one patient 30 years after total proctocolectomy and ileostomy. Another patient died from a periampullary carcinoma 24 years after subtotal colectomy. It seems that as the life expectancy of patients with polyposis improves, the incidence of small bowel and duodenal cancers may be expected to increase.     

Long-term results of the Ivalon baffle mitral valve repair.

In the evolution of mitral valve surgery, Ivalon sponge was sutured to the posterior leaflet of the mitral valve to obtain competency. Between August 1959 and October 1962, 18 patients had this procedure. All patients were discharged home. Three patients were lost to follow-up 5 to 10 years after operation. Valve replacement was necessary in 7 patients 10.4 +/- 8.5 years after repair. Bacterial endocarditis causing late death occurred in 5 patients within 4 years. Five embolic episodes occurred. The estimated probability of survival and need for valve replacement at 28 years were 29.2% +/- 12.3% and 12.4% +/- 6.7%, respectively.     

Clinical study of patients with renal carcinoma surviving for more than 10 years after nephrectomy.

Of 207 patients with renal carcinoma we studied 50 who survived for more than 10 years after nephrectomy. These 50 patients were younger than the others at the time of operation and included more females. They had lower stage and lower grade tumours. Recurrence was detected in 18/50 patients and 6 died from cancer. Recurrence developed approximately 10 years after nephrectomy. Eleven patients with recurrences had metastases to a single organ and 9 received multidisciplinary treatment, mainly surgery and radiotherapy. The survival rate 10 years after nephrectomy was lower in patients with recurrences than in those without recurrent tumours and there was a significant decrease in the survival rate 17 years after nephrectomy. Although the patients had low grade and low stage tumours 10 years after nephrectomy, careful follow-up is recommended in such cases as it is possible that they may have dormant tumours.     

The feasibility of closed mitral valvotomy in pregnancy

Rheumatic mitral valve stenosis is an important nonobstetric complication of pregnancy in an African country. Between January 1965 and September 1985 41 closed mitral valvotomies with a Tubbs dilator were performed in 39 pregnant women (two first trimester, 22 second trimester, and 17 third trimester). All patients experienced symptomatic improvement from New York Heart Association Class 3.01 (average) preoperatively to 1.22 postoperatively. There were no deaths related to the operation and delivery. Fetal deaths were due to postoperative spontaneous abortion in two cases (4.9%) or premature labour in three cases (7.3%), for an overall survival of 36 babies (87.8%). Fetal morbidity was due to prematurity or dismaturity in three infants, all of whom survived. Thirty-three normal infants were delivered at term. Nine patients needed subsequent surgical procedures for mitral valve restenosis 5 to 17 years (mean 10.2 years) after the initial closed valvotomy: Repeat closed valvotomy was performed in three patients after 5, 8, and 10 years (the first two during subsequent pregnancies), an open procedure was performed in one after 6 years, and five patients underwent subsequent mitral valve replacement after 11 (two), 12 (two), and 17 (one) years. Two late deaths occurred; one after 10 years, as a result of pneumonia and meningitis, and the other after 12 years, before a mitral valve replacement for restenosis could be performed. None of the remaining patients has required further surgical procedures, but two have moderate symptoms. Closed mitral valvotomy gives satisfactory results in pregnant patients with severe mitral stenosis. When indicated during pregnancy, it should be performed at any stage of the pregnancy.     

Total knee replacement in patients older than 85 years.

Between 1987 and 1995, 62 unilateral total knee replacements performed in patients older than 85 years (mean age, 87 years) were followed up for a minimum of 2 years (range, 2-11 years, mean, 5.4 years). This group represented 3.8% of all the total knee replacements performed during the same time. The majority of the patients were women with osteoarthritis. There was a 70% preoperative cardiac disease comorbidity. Overall, confusion after surgery was greater in this older group than in the patients younger than 85 years of age, however, confusion was lower in the group of patients who had epidural anesthesia as compared with those patients who had surgery under general anesthesia. The mean knee score at followup was 89 points and the mean pain score was 43 points (of 50 points). The mean flexion was 114 degrees. Seventy-five percent of these elderly patients still required the use of a cane for walking outdoors compared with 18% of the patients who were younger than 85 years. More than 855 of the older patients could travel independently to socialize and shop after surgery. Seventy-six percent of the patients were living independently or in senior retirement housing after surgery. Only two of the patients required living accommodations in a nursing home. One third of the patients still could drive their own car after surgery. Quality of life improvement was markedly increased in this elderly group of patients. The results of this study indicate that total knee replacement still is a valuable procedure even for this elderly group, and most of these patients returned to a more functional lifestyle.     

Reconstructive jejuno-gastroplasty in the treatment of operated stomach disease

The results of treatment of 205 patients with operated stomach disease were analyzed. Conservative therapy was effective in 71.7% patients. Surgical treatment was used in 58 (28.3%) patients. Reoperation was performed less than a year after primary surgery in 5.2% patients, 1 to 3 years later -- in 41.4%, 3 to 5 years -- in 36.2%, more than 5 years later - in 17.2% patients. Early after operation complications were observed in 24.1% patients. Clinical and device examinations demonstrate that surgical reconstruction significantly reduces intensity of pathological symptoms in all the patients.     

Esophagectomy for End Stage Achalasia

Esophageal myotomy is the standard primary therapy for achalasia. However, reports on long-term results of myotomy have suggested a deterioration of outcome over time with many patients presenting with end stage disease several years after esophagomyotomy. Eight patients who had previously undergone esophagomyotomy for achalasia presented with recurrent or worsening symptoms, and after preoperative evaluation, were treated by esophagectomy via laparotomy and right thoracotomy. The mean age at the time of myotomy was 52 years (range 18 to 62 years), and the mean time until esophagectomy was 12.5 years (range 2 to 18 years) after the initial myotomy. The median time until esophagectomy was performed after myotomy was 14 years. All patients in this series gained weight (mean, 23 pounds; range, 9 to 42 lbs) following esophagectomy, and none of the patients complained of dysphagia at follow-up or developed stricture. There were no major complications (including anastomotic leak) or deaths in this series. Five of the patients have been followed a mean of six years and remain well. Esophagectomy is a safe and appropriate treatment option in the setting of recurrent and end stage achalasia.