Changes in hospital costs for an appendectomy: 1955, 1965, and 1975

A reduction in the number of postoperative bed days for patients who underwent appendectomy led to a study of changes in hospital costs of appendectomies for the years 1955, and 1965, and 1975. No significant changes were found in the total hospital costs. However, the postoperative costs decreased by 36 percent from 1955 to 1975 due to a decrease in the mean duration of hospital stay. During the same period of time, the perioperative costs increased by 90 percent due to increased length of operation time correlated with an increasing proportion of inexperienced operating surgeons. At present, there seem to be few possible ways to increase the cost efficiency of treating appendicitis.     

Role of obstruction in the pathogenesis of acute appendicitis

The role of obstruction in the pathogenesis of acute appendicitis was studied by measuring the pressure in the appendix perioperatively in 24 patients operated on with an appendectomy because of suspected acute appendicitis. The technique used involved inserting a fine needle through the apex into the appendix lumen and measuring the hydrostatic pressure required to inject saline solution. In three patients with a gangrenous appendix found at operation, and in two patients with a phlegmonous appendix, there were signs of obstruction of the appendix lumen as revealed by increased pressure within it. In 14 patients with a phlegmonous appendix found at operation, no signs of obstruction were found. These experimental data suggest that obstruction is not an important causative agent of acute appendicitis, but might develop as a result of the inflammatory process.     

Natural history of patients with untreated liver metastases from colorectal cancer

One hundred fifty-five patients, laparotomized because of colorectal cancer, were retrospectively evaluated with special attention given to the natural course of untreated synchronous liver metastases. The median survival time for patients with synchronous liver metastases was 4.5 months. The survival time was mainly influenced by the extent of tumor involvement in the liver. Patients with elevated levels of serum-alkaline phosphatase at the time of operation had a significantly shorter survival time than those with normal values. Serum alkaline phosphatase levels are a good indication of prognosis. The incidence of synchronous liver metastases was 16 percent. This low rate is partly explained by the development of metachronous liver metastases in five patients within 1 year. Comparison with previous reports, often more than 10 years old, revels that the poor prognosis of patients with untreated liver metastases from colorectal cancer has remained unchanged.     

Ambulatory inguinal hernia repair compared with short-stay surgery

Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time.     

Prophylactic oophorectomy in colorectal carcinoma

It is a well established fact that women with recurrent colorectal carcinoma have a high frequency of ovarian metastases. This study was undertaken to see if microscopic metastases could be found in serial sections of ovaries removed at the time of primary operation. Of 58 patients, 4 had microscopic metastases and an additional 2 patients had macroscopic metastases. This finding, plus the risk of the development of a primary ovarian carcinoma, favors prophylactic oophorectomy in women with colorectal carcinoma.     

Herniography in athletes with groin pain

In the years 1974 to 1981, herniography was performed in 78 athletes with groin pain. The investigation comprised 101 painful groin sides in 23 athletes with bilateral symptoms. Before herniography, a hernia was palpated in only eight (7.9 percent) groins with pain. Hernias were found at herniography in 84.2 percent of the symptomatic groin sides and in 49.1 percent of the asymptomatic groin sides. Sixty-three hernia operations were performed. The herniographic and operative diagnoses corresponded well. Direct hernias dominated among the operated athletes, and were found in 55.6 percent of those below 30 years of age. Altogether 69.8 percent of the operated patients were cured by hernia repair and another 20.6 percent were improved. Tenoperiostitis of the adductor muscles was the most frequent diagnosis in those not cured by operation and among the nonoperated patients. Herniography was of great value in selecting those patients who needed a repair. A broad differential diagnostic approach when examining these patients is of the utmost importance.     

Changes in blood clotting and fibrinolysis after liver ischemia in pigs

Ten pigs were subjected to fifteen minutes of liver ischemia and four pigs to sixty minutes of liver ischemia. After fifteen minutes of ischemia three of ten animals showed a significant prolongation in the recalcification time. There was no decrease in clotting factors to explain the prolongation. The increase in fibrinolytic activity was similar in the three pigs with and the seven pigs without a prolonged recalcification time. There were no changes in fibrinogen concentration in any of the animals. Dilution tests for determining the circulating anticoagulants strongly indicated the presence of an anticoagulant in the plasma samples with a prolonged recalcification time.All four animals subjected to sixty minutes of liver ischemia showed a moderate prolongation in the recalcification time of longer duration but not of the same magnitude as that of the animals having fifteen minutes of liver ischemia. The prolongation in the recalcification time in this group was probably a result of a decrease in clotting factors.     

Intraarterial infusion chemotherapy (5-fluorouracil) in patients with inextirpable or locally recurrent rectal cancer.

A retrospective analysis of the results of treatment of advanced rectal cancer of the pelvis with regional intraarterial infusion of 5-fluorouracil (5-FU) is reported. A special technic for positioning the catheters selectively in the internal iliac arteries justifies this analysis. Four patients with primary inextirpable rectal cancer and 10 patients with locally recurrent rectal cancer have been treated. No immediate mortality was noted. Relief of pain was noted in two-thirds of the patients. An objective tumor response was noted in three patients with locally recurrent disease. In one patient with primary inoperable cancer it was possible to extirpate the tumor after infusion therapy. An improvement in quality of life during the first 2 months after therapy was achieved in half of the patients as judged by their performance. Complications were not serious. Hematomas with infection were seen in one patient, two patients had septicemia, and three patients had transient oliguria. Transient thrombocytopenia was reported in two patients. The results indicate that infusion therapy produces a reasonable response such as palliation of pain. Only minor complications were seen and easily controlled. The advantages of infusion therapy are that it can be given in a reasonable time with only a short hospital stay.     

Microflora and deconjugation of bile acids in alkaline reflux after partial gastrectomy

It has been postulated that reflux of bile into the stomach promotes gastric carcinogenesis. Bilestained aspirates from 50 asymptomatic patients, partially gastrectomized more than 10 years earlier, were examined bacteriologically and with regard to conjugated and deconjugated bile acids. Endoscopic biopsies showed atrophic gastritis in all patients, cancer in two and severe dysplasia in another two. pH in the reflux aspirates was 7.3 ± 0.4 (mean ± standard deviation). Bacterial cultures were positive in all patients studied. Fecal type flora, mostly E. coli, klebsiella and Clostridium perfringens, was found in 85 percent of the patients. Total bile acids were found to be 2.6 ± 2.0 mg/ml, 23 percent of which were deconjugated. Deoxycholic acid, known to promote carcinogenesis in animals, amounted to 27 percent of total bile acids and deconjugated deoxycholic acid was 5 percent of total bile acids. The mostly anaerobic microflora and the presence of mainly free secondary and primary bile acids may contribute to the high incidence of cancer in the gastric remnant observed after Billroth I or II operations.     

Treatment of liver cancer with regional intraarterial 5-FU infusion.

The results of a retrospective three year study of forty-six patients with cancer of the liver treated with regional intraarterial infusion of 5-FU are reported. No primary mortality was noted. Oblective overall remission rate was 43 per cent. Overall median survival from onset of treatment was six months. The one year survival rate was 33 per cent and the two year survival rate 11 per cent. Patients with an objective response had a significantly prolonged survival as compared with nonresponders, especially in the colorectal group: sixteen months versus four months. Survival was not related to tumor size and involvement of the liver. During treatment 42 per cent of the patients developed extrahepatic metastases. Quality of life was improved in 63 per cent of the patients. The results indicate that infusion therapy induces reasonable response and palliation but is inadequate for the control of extrahepatic tumor growth.     

Relationship between postoperative temperature and survival in patients resected for colorectal cancer

The present study suggests that the prognosis of patients undergoing resection for colorectal carcinoma might be improved if there is an increase in body temperature during the postoperative period.     

Breaking strength of small intestinal anastomoses

The breaking strength of standardized small bowel anastomoses at different times after surgery was studied in the rat. The anastomotic strength with sutures in place successively decreased during the first 3 postoperative days to approximately 15 percent of the immediate postoperative value. This indicates a rapid decrease in the suture holding capacity of the gut wall in the early postoperative course. From the fourth day onward a rapid increase in strength was recorded. This could be due not only to deposition of collagen in the tissue bridging the anastomosis but also to the regained capacity of the gut wall to withstand tearing forces. After 14 days the strength of the anastomosis was due mainly to healing, and the relative contribution from the sutures was negligible. It may be that tearing of sutures through the tissue is more important than defective healing for anastomotic complications.     

Effect of bile acid gavage or vagotomy and pyloroplasty on gastrointestinal carcinogenesis

Possible promotion of MNNG-induced gastrointestinal carcinogenicity was evaluated in male Wistar rats exposed to unconjugated bile acid given as gavage or as obtained through truncal vagotomy plus pyloroplasty. No significant difference was found compared with the relevant control groups. Even though gastroduodenal erosions were found more frequently in the bile acid gavage and MNNG groups than in MNNG-treated controls, secondary deconjugated bile acids apparently did not reach optimal promoting concentrations. In contrast to partial gastrectomy, vagotomy and pyloroplasty does not increase the tumor yield in the rat.     

Deficient collagen formation by obese mice in a standard wound model.

Poor healing was demonstrated in two different experimental models of diabetes mellitus. In one model, there was an absolute lack of insulin and in the other, a resistance to insulin. A review of the history of the results of surgery in diabetic patients shows that in the clinical situation, wound failure is associated with both a lack of insulin and a resistance to insulin. Thus, the causes of wound failure in diabetic patients include a failure of insulin to perform its normal role in healing. This does not exclude other causes such as "small vessel disease" as etiologic factors, but it does suggest that control of metabolic derangements is beneficial to healing in diabetic patients who undergo operation.     

Healing of experimental colonic anastomoses: III. Collagen metabolism in the colon after left colon resection

In a previous study it was shown that resection and anastomosis of the left colon is accompanied by a marked reduction of collagen concentration in the colon. These changes were not confined to the immediate vicinity of the anastomosis but extended a considerable distance along the bowel and were more marked proximally than distally. Whether the decrease in collagen concentration is due to decreased synthesis or increased breakdown of collagen was studied in the present work by measuring the rate of collagen synthesis and comparing the observations with changes in net amounts of collagen.Synthesis of collagen was studied using pulse labeling with ³H-proline. Studies on the time course of incorporation showed a biphasic pattern with maximal specific activities of collagen 4 and 24 hours after injection of the precursor. The maximal labeling occurred after 24 hours. At that time 75 to 90 percent of the label was present in insoluble collagen, indicating a high rate of turnover. Comparison of net amounts with the rate of synthesis indicates an increased breakdown of collagen. The reaction was clearly most pronounced proximal to the anastomosis. During the first 4 postoperative days breakdown (lysis) dominated. On the 7th day increased net amounts of collagen indicate that synthesis had begun to outbalance processes that break down collagen. The results indicate that the entire colon reacts to the trauma of resection and anastomosis and that in healing of the colon a delicate balance exists between the synthesis and breakdown of collagen.     

Surgical treatment of thyroid carcinoma in a defined population: 1960 to 1977. Evaluation of the results after a conservative surgical approach

Ninety patients from a demographically well-defined area of, on an average, 243,000 inhabitants were surgically treated for thyroid carcinoma during an 18 year period. Sixty-five of the patients had papillary carcinoma, 20 follicular carcinoma, 4 medullary carcinoma, and 1 anaplastic carcinoma. Seventy-eight patients were operated on for cure, and among them, 23 had total thyroidectomy and 55 partial thyroidectomy. Additional therapy with thyroxine was given to all patients postoperatively. None of the patients treated for cure died from thyroid carcinoma at follow-up 2 to 20 years after diagnosis. One of 42 patients (2.4 percent) primarily treated for cure with lobectomy for papillary carcinoma had local recurrence in the thyroid bed which was excised successfully. No patient treated for cure of follicular carcinoma had local recurrence. All verified recurrences except one were diagnosed within 5 years of primary operation. We conclude that local recurrence after procedures less than total thyroidectomy that are considered to be curative is unusual provided that thyroxine is given postoperatively. Thus it seems that the reported high rates of microscopic carcinoma in the contralateral lobe in patients with unilateral cancer have little clinical significance. A conservative approach in most patients with localized thyroid carcinoma is indicated because it reduces the risk of postoperative complications.     

Combined fractures of the femoral and tibial shafts in the same limb

This paper reports a study of ipsilateral fractures of the femoral and tibial shafts in 21 patients treated according to a detailed plan including shock treatment, prophylaxis against fat embolism, soft-tissue and fracture treatment. Death due to hypovolaemic shock was eliminated and the incidence of fat embolism (9.5 per cent) reduced in comparison with an earlier series. The tibial fracture was stabilized by plaster or internal fixation as soon as conditions allowed. In most cases the femoral fracture was treated by medullary nailing. Results have improved compared with earlier series. All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89 per cent).     

Effect of diverting colostomy on collagen metabolism in the colonic wall. Studies in the rat

The effect of total bowel rest by colostomy on collagen metabolism was studied. Fecal diversion led to a marked decrease of collagen and protein synthesis in the excluded colon. These changes were accompanied by a decrease in the amount of collagen and noncollagenous components. In the colonic part proximal to the colostomy site, a less marked decrease in collagen content was observed. It was concluded that stimulation of intraluminal bulk might be important as a regulating factor for collagen turnover. It remains to be determined if the observed changes in collagen metabolism affect colonic healing.     

Avulsion fracture of the lateral malleolus in children

Five girls under the age of 13 years with recurrent symptoms after ankle injuries were found on radiography to have a bony fragment close to the tip of the fibula. At operation it was found that the fragment was attached to the proximal end of the anterior talofibular ligament except in one case in which the fragment had no ligamentous attachment. In the latter case a rupture of the anterior talofibular ligament itself was also found. There was no sign of ankle instability. Removal of the fragments relieved the symptoms in each girl and it is suggested that the symptoms in such cases are due to the bony fragment rather than to ligamentous injury.