Venous mesenteric infarction: a particular entity

Ninety-eight patients with documented mesenteric infarction during a 19-year period were reviewed. In 13 patients infarction was due to a mesenteric venous thrombosis (MVT). Patients with MVT distinguished themselves from those having another aetiology by: (1) longer history of pain before admission (median 8 days, P less than 0.0001); (2) typical appearance of the bowel at laparotomy (10/13); (3) a localized segment of ischaemic jejunum or ileum of less than 120 cm in length (12/13) allowing better operability at the first laparotomy (P = 0.006). In hospital the mortality was lower for venous mesenteric infarction (5/13, 38 per cent) than for mesenteric infarction of other aetiologies (70/85, 82 per cent) (P = 0.002). Patients with primary venous mesenteric infarction showed a better survival rate (one death in eight patients) than patients with associated diseases such as liver cirrhosis, sepsis or previous operation who had a poor prognosis with a mortality comparable to other aetiologies of acute bowel ischaemia (four deaths in five patients). Since the high recurrence rate of this disease in the early postoperative period was due to residual venous thrombosis and to a hypercoagulable state, a wide bowel resection is recommended followed by early and long-term anticoagulation. Thrombectomy is probably inefficient since it removes only centrally located thrombi and leaves peripheral occlusion, which is responsible for the recurrence.     

Dietary preparation for hemorrhoidectomy. Advantages of a nutritionally complete, chemically defined low residue diet.

Two hundred patients undergoing vagotomy for duodenal ulceration over a period of forty-three months were randomly given Heineke-Mikulicz or Finney pyloroplasty. One died of a myocardial infarction twenty-four fhours after operation, six-teen died within seven years from conditions unrelated to surgery, nine were lost to follow-up study, and 174 were followed up an average of 5.2 years. These patients were evaluated for signs and symptoms of recurrent ulceration or complications of their operation. A majority underwent postoperative secretoay and gastric emptying studies. The proved rate of ulcer recurrence was higher in patients with Heineke-Mikulicz pyloroplasty (4 per cent versus 2 per cent); however, over-all recurrence (proved, probable, and possible) was 13 per cent in each category. The dumping syndrome, seen in 14.4 per cent with Heineke-Mikulicz and 10.7 per cent with Finney pyloroplasty, was the most common complication...     

The morbidity of carotid endarterectomy.

The results of 72 carotid endarterectomy operations carried out by three consultant surgeons were analysed. Thirty-eight operations (32.8 per cent) were performed in patients with mild or resolving stroke and 33 operations (45.9 per cent) in patients with transient ischaemic attacks and/or amaurosis fugax. Five patients (7 per cent) died in the early postoperative period, 2 as a result of strokes and the others from cardiac causes. Seventy-six per cent of patients had a satisfactory long term result, remaining free from storke, blindness or recurrent transient ischaemic attacks over the follow-up period of 1--7 years. There were 10 patients (13.8 per cent), including 2 who died, who developed early postoperative neurological deficits; 4 (5.5 per cent) had transient defects and 6 (8.3 per cent) had permanent deficits. Of these patients, 4 had proved occlusions of the reconstructed artery. In 3 patients, cerebral embolization during operation was suspected as the cause. There were, in addition, 2 asymptomatic patients whose reconstruction was shown to be occluded on follow-up postoperative angiography. The continued absence of symptoms, therefore, is no guarantee that the reconstruction is patent and some more objective method of assessment is necessary if the results of carotid endarterectomy are to be critically analysed. The incidence of neurological deficits could, it is believed, be reduced by greater experience with the operation, the routine use of peroperative intra-arterial shunting and peroperative angiography to confirm the patency of the reconstruction.     

Operative treatment of benign gastric ulcers

Between the years 1953 and 1963, 1,583 patients at the Henry Ford Hospital were recorded as having gastric ulcer. Of this number 150 (9.4 per cent) underwent operative treatment. Failure to respond favorably after medical treatment and suspicion of malignancy prompted surgical intervention most often.Two operative approaches were commonly employed. Gastric resection plus vagotomy with Billroth I reconstruction was utilized in fifty-three patients. Gastric resection with vagotomy and Billroth II reconstruction was the procedure of choice in twenty-nine patients. Thus, eighty-two patients had gastric resection with vagotomy. There were four recurrences in this group (5 per cent). The second largest group of patients were those upon whom gastric resection was performed without vagotomy. The Billroth I reconstruction was performed thirty-one times and the Billroth II procedure was employed twenty-one times. There were nine recurrences in fifty-two patients, a recurrence rate of nearly 17 per cent. Clearly, in this study, gastric resection with vagotomy gave better results (5 per cent recurrence) than did gastric resection alone (17 per cent recurrence). The over-all recurrence rata for 150 patients was approximately 11 per cent.In eight patients the clinical diagnosis was benign ulcer when, in fact, malignancy was present. In two patients, the tumor was lymphoma. Only one of ten patients died of tumor. Excellent follow-up studies were possible in every patient with a malignant lesion. Adequate gastric resection is effective for these small, unsuspected ulcerocarcinomas.There were four postoperative deaths, a mortality rate of 2.7 per cent. Two patients died of myocardial infarction and two died of pulmonary emboli.     

Surgical treatment of unstable angina by saphenous vein and internal mammary artery bypass grafting.

During a 3 year period, direct myocardial revascularization was performed on an urgent basis in 48 patients with intermittent resting chest pain which persisted more than 24 hours despite in-hospital medical therapy and was accompanied by electrocardiographic changes representative of ischemia. Sixteen patients had saphenous vein (SV) grafts exclusively, and 32 patients each had one or two internal mammary artery (IMA) grafts with or without additional vein grafts. Follow-up ranges from 5 to 41 months (mean, 22 months). Twelve patients had single grafts to the left anterior descending coronary artery (LAD), 18 had double grafts, 16 had triple grafts, and 2 had quadruple grafts. The LAD required grafting in every patient. There was one operative death (2 per cent) and one late death from noncardiac causes. There were two (4 per cent) early postoperative myocardial infarcts and no late infarcts. Actuarial analysis projects a survival rate of 96 per cent 3 years postoperatively. Eighty-one per cent of the survivors are in Functional Class I, 17 per cent are in Class II, and 2 per cent are in Class III. All patients had postoperative angiography 2 weeks after operation. Eighty-six per cent of the SV grafts and all IMA grafts were open. No significant differences were observed between mean preoperative and postoperative left ventricular end-diastolic pressures or ejection fractions, but these parameters were noted to improve after operation in several patients. The remarkably high early and late survival rates, the low incidence of myocardial infarction, and the excellent functional results after rather long follow-up indicate that emergency coronary revascularization provides an effective therapy for unstable angina. The use of IMA grafts, when feasible, is a safe and possibly preferable approach in these patients.     

Mesenteric infarction

The most common etiologies of mesenteric infarction in fifty-one patients were arterial thrombosis (in 42 per cent), bowel infarction without major vessel occlusion (in 28 per cent), and arterial embolus (in 22 per cent), but the etiology also included some very rare vascular diseases—two cases of the malignant atrophic papulosis of Degos. In the group of forty-four operative patients the mortality was 70 per cent. All the patients treated medically died.     

Mesenteric infarct--when is the vascular surgeon needed?

The treatment of acute mesenteric infarction is a therpeutical challenge. The mortality rate of these, mainly beyond 70 year old patients has remained extraordinary high despite diagnostic and therapeutic efforts and progress in intensive care medicine. Additionally to the initial hypoxaemia of the bowel a more severe tissue damage is induced via the "reperfusion injury", with increase of the vital risk. Besides the detection of occlusive vascular lesions of different etiology, which have to be treated immediately, "non occlusive mesenteric ischemia" can be identified. Visceral biplane angiography is the diagnostic tool of choice, giving basic informations on concomitant lesions, for a rational vascular surgical intervention and additionally the opportunity to administer vasoactive drugs. Despite increasing treatment modalities influencing the severity of the "reperfusion injury" the most important criteria for the patients' survival is the early diagnosis and immediate treatment. Therefore, close cooperation of general practitioners, internists, radiologists, angiologists, general surgeons and vascular surgeons is required. The support of a vascular surgeon is necessary for complex arterial reconstructions as success and patency rate are significantly influenced by experience. Reocclusion and "redo"-surgery increase the risk substantially.     

Amylase and gut infarction

Serum amylase has been determined on admission in 63 (52 per cent) of 122 patients with acute mesenteric infarction. Amylase levels were normal in 34 (54 per cent) and reached greater than twice normal in 15 patients (24 per cent). In 5 patients (3 on admission) amylase levels were in the diagnostic range of acute pancreatitis (greater than 1200 units/l) leading to inappropriate non-operative treatment in 4. Hyperamylasaemia was found in association with all aetiologies of infarction. The magnitude of the hyperamylasaemia appeared to be related to the extent of the bowel infarction, the highest levels occurring when infarction involved the small bowel and colon. The mechanism of hyperamylasaemia in acute mesenteric infarction is discussed.     

Five year results of a randomized trial of adjuvant 5-fluorouracil and levamisole in colorectal cancer

Following curative surgery for colorectal cancer 141 patients were randomized to receive a 6 month course of 5-fluorouracil (5FU) with or without postoperative levamisole or supportive treatment only. The patients have been followed up for a minimum of 5 years and 52 per cent of patients in the control group, 44 per cent of the 5FU group and 32 per cent of the 5FU/levamisole group have died of tumour recurrence. This represents a significant survival advantage in the patients receiving levamisole, even when other patient and tumour factors are allowed for.     

Postoperative outcome and sites of recurrence in patients following curative resection of gastric cancer

BACKGROUND: Recurrence occurs in a variety of forms and in different organs after 'curative resection' of gastric cancer. This study investigated the postoperative prognosis for each type of recurrence. METHODS: From 1969 to 1988, 939 patients with gastric cancer underwent curative resection; data on 130 of 207 patients who died with recurrence were analysed. Attention was focused on the site of recurrence and the postoperative outcome. RESULTS: Haematogenous recurrence was evident in 54 per cent (70 of 130 patients), peritoneal recurrence in 43 per cent (56 of 130), lymph node recurrence in 12 per cent (16 of 130) and local recurrence in 22 per cent (29 of 130). Thirty-three patients (25 per cent) had recurrences at multiple sites. Peritoneal and local recurrences were related to infiltrative growth, in contrast to haematogenous and lymphatic recurrences. There were no statistical differences in survival time among each type of recurrence and survival was not related to the number of sites of recurrence. Survival did not depend on factors of sex, age, tumour location, tumour size, depth of invasion, tissue differentiation, histological growth pattern, lymphatic and vascular involvement, lymph node metastasis and extent of lymph node dissection. CONCLUSION: The clinicopathological characteristics of gastric cancer determine the type of recurrence, although the clinical outcome is the same for each type of tumour and is not related to the number of sites of recurrence.     

Treatment outcomes for female octogenarians with breast cancer

Scant information is available comparing the treatment outcomes of minor surgery (lumpectomy) versus extensive treatment (radical and simple mastectomy or lumpectomy and radiation) in octogenarians with breast cancer. Medical records of women (ages 80-89) who received treatment for breast cancer from 1984 through 1994 were reviewed. All patients were stage T1 or T2, and none had palpable lymph nodes. The recurrence rate, disease-free interval, and death rate for both groups were compared. Of the 41 patients representing 43 minor surgeries, 12 per cent (5 of 41) of patients developed recurrence, all of which were related to the primary breast tumor. The mean disease-free interval was 28.6 +/- 24.7 months (range, 6-65). Forty-six per cent (18 of 39) of patients died, 10 per cent (4 of 39) from recurrence and metastatic disease from breast cancer and 36 per cent (14 of 39) from other causes. Of those who underwent extensive treatment, 14.6 per cent (7 of 48) of patients experienced recurrence, all related to the primary breast tumor. The mean disease-free interval was 24.0 +/- 21.9 months (range, 2-71). Forty-eight per cent (23 of 48) of patients died, 10 per cent (5 of 48) from recurrence and metastatic disease from breast cancer and 37 per cent (18 of 48) from other causes. None of the differences between the minor surgery versus extensive treatment groups were statistically significant. The recurrence rate, disease-free interval, and death rate from recurrent disease are similar for patients undergoing minor surgery compared with those undergoing extensive treatment.     

Laparoscopic incisional hernia repair with a self-centring suture

BACKGROUND: Open incisional hernia repair is associated with high morbidity and recurrence rates. Laparoscopic approaches offer improved long-term results with low complication rates. METHODS: Laparoscopic repair was attempted in 117 consecutive patients (median age 68 (range 31-91) years, 50 men) undergoing 122 operations. A novel mesh centralization technique was employed. Data were recorded prospectively. Follow-up was by clinical review or telephone consultation. RESULTS: One hundred and eighteen procedures (96.7 per cent) were completed laparoscopically; four required conversion. Forty-one patients (35.0 per cent) had additional, unsuspected defects. The median mesh size was 225 (range 42-600) cm2. Median follow-up was 42 months. Small bowel enterotomy occurred in six patients. Fourteen postoperative seromas were successfully aspirated. Recurrence was detected in nine patients (7.7 per cent). One patient was readmitted with small bowel obstruction that settled with conservative management. There were no enterocutaneous fistulas. One patient died after operation from myocardial infarction. CONCLUSION: Laparoscopic incisional hernia repair using a self-centring suture provides good long-term results with low complication rates.     

Damage control surgery and angiography in cases of acute mesenteric ischaemia

BACKGROUND: Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60-80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia. METHODS: A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed. RESULTS: Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel. CONCLUSIONS: Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2-3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available.     

Acute superior mesenteric ischaemia

A review of case records and post-mortem reports from Glasgow Royal Infirmary over the past 12 years identified 102 patients with acute superior mesenteric ischaemia, 53 (52 per cent) of whom were first diagnosed at post mortem. Overall mortality was 92 per cent and mortality in the 49 patients diagnosed in life was 84 per cent. Fourteen patients (14 per cent) underwent exploratory laparotomy only with no survivors, 26 (25 per cent) had bowel resection alone with 7 surviving, and 9 (9 per cent) had a revascularization procedure, 5 requiring additional bowel resection, with only one surviving. Survivors were usually younger, had a shorter history and less extensive bowel infarction. Improvements in intensive care and nutritional support with the greater use of revascularization procedures in the past 6 years have barely influenced mortality. Delays in diagnosis and treatment contribute to the poor results. Earlier diagnosis might be aided by measuring serum inorganic phosphate and, coupled with the more widespread use of emergency angiography and revascularization procedures, holds out the best hope for future improvement.     

急性肠系膜血管缺血性疾病误诊分析

目的探讨急性肠系膜血管缺血性疾病的误诊原因、诊断和治疗.方法回顾性分析1965～1999年急性肠系膜血管缺血性疾病20例临床资料.结果20例均经病理证实.初诊时多因表现为急腹症、症状与体症不符和缺乏特异性检查而误诊.19例行手术治疗,其中11例治愈,8例死亡;另1例因误诊时间过长,未能及时手术,终导致死亡.结论该病少见,症状和体征无特异性,易造成误诊.选择性动脉造影和D-二聚体检测是较敏感的检查,对诊断有积极作用.早期适当范围切除坏死肠段和术后抗凝治疗是防止复发、降低病死率的重要措施.     

Surgical tactics in acute mesenteric artery occlusion

Operations were performed on 52 patients for acute mesenteric embolism, between 1980 and 1988. The average age of 48 of them was 75.8 +/- 7.3 years. Only four patients were below 60 years of age. Only exploratory laparotomy was possible in 20 cases, and all of these patients died. Six of eight patients (75 per cent) did not survive embolectomy from the superior mesenteric artery. Seven of twelve patients (58 per of eleven patients (27 per cent) died after embolectomy and resection of subtotal parts of the small intestine. Death occurred also to one patient with acute iliaco-mesenteric bypass. Hence, total mortality of all 52 patients amounted to 71.1 per cent. The mortality rate for 32 patients with attempted restitutional surgery amounted to 53.1 per cent, exploratory laparotomy unconsidered. This was certainly attributable to 73 per cent of survivors of embolectomy combined with removal of somewhat extended intestinal sections. Follow-up checks in short intervals of serum lactate have proved to provide reliable diagnostic parameters and means for postoperative appraisal with a view to making an informed estimate of changes of a second-look operation for acute intestinal ischaemia. The lactate mean value for mesenteric embolism was 8.88 +/- 4.43 mmol/l. However, lactate values were normal, between 1 mmol/l and 2 mmol/l, in acute abdominal processes with non-ischaemic causes and in cases of ischaemia of extremities.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bladder cancer in men and women treated by radiation therapy and/or radical cystectomy

Four-hundred fifty-one patients with bladder cancer, 348 men and 103 women, were treated by radiation therapy and/or radical cystectomy during the last two decades at Memorial Sloan-Kettering Cancer Center. Radical cystectomy alone was the treatment in 98 men and 39 women. Radical radiation therapy to an average tumor dose of 6,000 rad in six weeks was given to 79 men and 30 women ± one year before salvage cystectomy was done for recurrent or persistent tumors. Planned preoperative irradiation was delivered to the true pelvis either 4,000 rad in four weeks in 95 men and 24 women or 2,000 rad in one week in 76 men and 10 women ± six weeks and two days, respectively, before radical cystectomy. Over-all survival and recurrence results in both sexes were similar; 40 per cent of men and 36 per cent of women were alive at five years without recurrence, 45 per cent of men and 48 per cent of women died in five or more years with local and/or distant recurrences, and 21 per cent of men and 15 per cent of women died before five years from causes other than cancer recurrence. Higher five-year survival for high clinical stage B₂ to D₁ tumors was noted similarly in the irradiated men (30 per cent) and women (37 per cent) than in the cystectomy alone patients (19 per cent in men and 4 per cent in women). Similar survival rates (52 to 57 per cent) were observed in men and women with low clinical stage O to B1 tumors treated with or without irradiation.     

The impact of coronary artery bypass on late myocardial infarction.

Two hundred consecutive patients undergoing coronary artery bypass for stable and unstable angina pectoris were followed clinically 3 to 53 months (mean 27) and with serial electrocardiograms (ECG's) 3 to 43 months (mean 18.5) postoperatively. Complete (twelve lead) resting ECG data including preoperative, early postoperative (in hospital), and late (post hospital) studies were available in 98 per cent (196/199) of hospital survivors. A total of 2,304 ECG's were examined by two cardiologists for a total follow-up of 3,629 patient months. Myocardial infarction was defined as the appearance of a new, significant (Minnesota Code) Q wave. Fifty-four per cent (108/200) had triple vessel disease and 24 per cent (47/200) preinfarction angina pectoris by strict criteria. There was one hospital death for an operative mortality of 0.5 per cent (1/200). There was one late fatal and three late nonfatal myocardial infarctions. Seventeen patients developed new Q waves in the early postoperative period, a perioperative infarction rate of 8.5 per cent (17/200). The 43 month cumulative myocardial infarction rate, including all early and late postoperative new Q waves and three late deaths from cardiac disease, was 14 per cent. Twenty-two per cent (20/91) showed disappearance of Q waves present at the time of hospital discharge. These data suggest that the late myocardial infarction rate is low in surgically managed patients.     

Perioperative and postoperative complications from bilateral pelvic lymphadenectomy and radical retropubic prostatectomy

The complications experienced by 692 consecutive patients who underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy from 1978 through 1984 were analyzed. Four patients (0.6 per cent) died in the perioperative or early postoperative period. Pulmonary embolus developed in 19 patients (2.7 per cent) and severe to total urinary incontinence occurred in 34 (5 per cent). Our large series suggests that radical retropubic prostatectomy with staging bilateral pelvic lymphadenectomy can be performed in a safe manner with minimal postoperative morbidity.     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.