Results of carotid endarterectomy in patients 75 years of age and older.

From April 1980 to September 1989, 69 patients over 75 years of age (mean 78 years, range 75 to 86) underwent 81 carotid endarterectomies. Twenty three percent were asymptomatic, 56.5% had symptoms appropriate to lesion location and 20.5% had a non hemispheric syndrome. Nine patients required an associated procedure (combined cardiac surgery 6 pts; vascular surgery 3 pts). Perioperative mortality was 3.7%. The combined early lethal and non lethal stroke rate was 6.1%. Actuarial survival, at 10 years, was 58.4% +/- 10, and the incidence of freedom from stroke at 10 years was 86.2% +/- 5. Despite the fact that the hospital mortality of patients over 75 years undergoing carotid endarterectomy is more than three times that of patients operated on under 75 years of age (1.2%), the combined stroke and neurologic mortality rate is similar to that of patients under 75 years (5.3%). Carotid surgery in patients over 75 years of age does not increase life expectancy but does improve the quality of survival which depends mainly on cardiac events.     

Laparoscopic Hiatal Hernia Repair in the Elderly Patient

Background

Hiatal hernias (HH) are more common among elderly patients, with an increase in incidence with advancing age. Elderly patients frequently suffer from comorbidity, causing them to have an increased risk of perioperative mortality and morbidity. The aim of this study is to assess the safety of this procedure within elderly patients.

Methods

We performed a retrospective analysis of all patients with HH operated between July 2009 and May 2015 at two hospitals in the Netherlands specialized in antireflux surgery and HH repair. Mortality rates and short- and long-term morbidity rates were compared between patients aged under 70 years and aged over 70 years.

Results

A total of 204 consecutive patients underwent laparoscopic HH repair at our institutions, of whom 121 were aged under 70 years and 83 were aged over 70 years. There was no mortality intraoperatively, nor during 30-days follow-up. Intraoperative complications occurred in 7 patients aged 70 years and over, with no significant differences compared to the patients aged under 70. The 30-day morbidity rate did not significantly differ between the age groups, with an overall postoperative complication rate of 9.3 %. Only length of stay (LOS) was significantly longer in the elderly patients. Performing univariate analysis, only the occurrence of intraoperative complications was associated with 30-day morbidity.

Conclusion

In the present study, age was not associated with increased 30-day morbidity or mortality following HH repair. Therefore, in carefully selected patients, age should not be used as an argument to withhold laparoscopic HH repair.

     

Selective segmental colectomy in diverticular sigmoiditis. The surgical risk is not increased after 70 years of age]

Segmental colectomy for complicated diverticulitis is often indicated, between attacks, in elderly patients. We report a retrospective study of operated patients over the age of 70. The aim of this retrospective study was to evaluate the age risk of consecutive patients operated between diverticular attacks by segmental colectomy, and whether such a surgical procedure is justified, as the life expectancy of these patients was 74 years for men and 81.9 years for women in 1996. PATIENTS AND METHOD: From January 1990 to December 1996, 117 patients were operated, between attacks, for complicated sigmoid diverticulitis; 31% (n = 37) were over the age of 70 years. They were 16 men and 21 women with an overall mean age of 77 (range: 70-85 years). Indications for surgery were repeated attacks (n = 17), large bowel stenosis (n = 14) and colovesical fistula (n = 6). The operation was performed an average 8 weeks after the last infectious episode (3-10 weeks). RESULTS: Among patients over the age of 70 years, the postoperative morbidity rate was 40% and there was no mortality. One patient was reoperated for an anastomotic abscess and was managed by protective colostomy and pelvic drainage with conservation of the anastomosis. CONCLUSION: This retrospective study shows that in our experience, one third of patients operated for a complication of diverticulitis were over the age of 70 years. In this subgroup, left colectomy, when performed between attacks carries an acceptable specific morbidity and no mortality. A further study could compare the percentage and outcome of operated patients with those who were denied surgery.     

Hernias of the abdominal wall in patients over the age of 70 years.

OBJECTIVE: To find out if the patients' age affects the treatment of abdominal hernias and the results in relation of the age increase. DESIGN: Retrospective and prospective study. SETTING: University hospital, Spain. SUBJECTS: 664 patients aged 70 years or more operated on for abdominal hernia between 1986-1998. Patients were divided into three groups: 443 aged 70-79; 202 aged 80-89; and 19 patients aged 90 years or more. MAIN OUTCOME MEASURES: Perioperative risk, type of surgery and deaths. RESULTS: 117 women (52%) had femoral hernias, compared with 32 men (7%) (p = 0.0001). The incidence of femoral hernia over 80 years of age was 79/221 (36%) compared with 70/443 (16%) among patients in their seventies (p = 0.0001). 97 of the patients aged 70-79 (22%) were operated on as emergencies, 107 of those aged 80-89 (53%), and 17 in patients 90 or older (89%, p = 0.0001). The mortality rate was 1% in the 70-79 group (n = 6), 5% (n = 10) in the 80-89 group, and 3/19 died in the over 90 group (p = 0.0001). No deaths were reported after elective surgery. CONCLUSION: Emergency operations in elderly patients with abdominal wall hernias are increasingly more common as the patient get older. As result, there is an unacceptable increase in postoperative mortality.     

Elective abdominal aortic aneurysm operations--the results of a single surgeon series of 243 consecutive operations from a district general hospital

BACKGROUND: There are few data on the morbidity and mortality of planned elective surgery for infrarenal abdominal aortic aneurysm (AAA) as a single surgeon series. This audit is of a consecutive series of AAA operations performed by one surgeon in one district general hospital over a 13-year period. METHODS: 243 patients were operated on for AAA between 1985 and 1998. Data were collected on the majority of patients prospectively. A reliable method was devised to identify all patients. Any missing complication and mortality data were then collected retrospectively. RESULTS: 13 patients died as a result of their operation (5.3%). In patients over the age of 80 years (36), five patients died (14%) and in the 207 patients under the age of 80 years, eight died (3.8%). Cardiac deaths were the most frequent cause (38%); 82 patients had recorded complications (34%). The operative mortality rate has increased in later years, (2.2% to 7.1%), largely due to an increase in the very elderly accepted for operation (12% to 16%), and a possible increase in co-morbidity. CONCLUSIONS: An acceptable and comparable mortality rate can be achieved in a district general hospital. The complication rate is high indicating the need for very intense medical and nursing care for these patients postoperatively. There is a considerable variance in mortality rates with age and risk even in the practice of one surgeon, indicating a need to be very knowledgeable and cautious in interpreting postoperative mortality data. This is the largest single surgeon series to date in the UK.     

Carotid endarterectomy in patients aged 75 and over: early results and late outcome.

BACKGROUND: The mean age of patients in the European Carotid Surgery Trial with greater than 70% stenosis was 62 years. With changing demographics older patients are increasingly being referred for carotid endarterectomy (CEA). OBJECTIVES: To assess the complications and survival (stroke-free and overall) of patients over the age of 75 undergoing CEA. METHODS: Analysis of a database, clinical records and cause of death of patients undergoing CEA in a single regional unit over a 7 year period (1/4/1993 until 1/4/2000), with follow-up to April 2002. The rates of further neurological events were obtained from the Scottish Morbidity Record 1 (SMR 1) of hospital discharges. Patients referred from outside the region were excluded. Differences between groups were assessed by the Chi-squared test, with Yates correction and log-rank tests. RESULTS: Of the 235 patients undergoing CEAs, 55 (23%) were 75 years or older. The post-operative neurological complication rate was 1.7% in the under 75's and 5.4% in the older group (p < 0.05). The 30 day mortality was 1.1% (two patients) and 1.8% (one patient) respectively. The Kaplan-Meier estimated survival for the under 75's and older were 93 and 75% at 3 years and 80 and 59% at 5 years respectively (p < 0.001). The Kaplan-Meier estimated neurological event-free 5 year survival for the under 75's and older patients were 96 and 82% respectively (p < 0.001). CONCLUSION: CEA in patients aged 75 years and over is associated with a significantly increased risk of stroke and death. CEA may not benefit elderly patients with a reduced life expectancy.     

Early operative mortality after surgical treatment of bronchogenic carcinoma

Background A retrospective analysis of the results of pulmonary resection over a 7 years period for bronchogenic carcinoma was performed. Methods Three hundred and eleven patients with primary bronchogenic carcinoma were operated upon at Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, between January 1996 to June 2002. There were 62 pneumonectomies (19.93%), 174 lobectomies (55.94%) and 75 lesser resections (24.11%). Results The overall operative mortality was 4.82%. The mortality rate for pneumonectomy, lobectomy and lesser resections were 9.6%, 4.5% and 1.3% respectively. There was no significant difference in operative mortality between pneumonectomy and lobectomy, and between lobectomy and lesser resections. Post operative mortality rate increased as the age of patient increased. Mortality was 2.3;2.9;5.0;7.41; and 14.2 in the age groups of <50 years, 50–59 years, 60–69 years, 70–79 years and 80 years and above respectively. Pneumonia and respiratory failure caused most deaths (46.66%). Conclusions Pulmonary resections can be performed with satisfactory mortality and morbidity in bronchogenic carcinoma.     

Results of surgical treatment of cancer of the common bile duct as a function of age

The aim of this study was to determine whether an age greater than 70 years constitutes a risk factor in subjects who undergo surgery for cancer of the common bile duct. From a total population of 758 cases, 216 patients belonged to this age group. Tumour lesions did not appear to be more progressive in patients over 70 years, however there was a significantly higher incidence of visceral involvement in the latter group. The rate of palliative procedures was comparable in the under 70 and over 70 years groups. However, hepatectomy and hepatic transplantation were only carried out in patients under 70 years. Mortality increased with age both for palliative and curative surgery. The mortality rates were respectively 10% and 10.1% under 70 years and 41% and 49.1% over 70 years. These results should therefore lead to the choice of endoscopic drainage procedures in more elderly patients. However, in the absence of a contraindication to anaesthesia, surgery remains indicated when curative resection is envisaged, in cases of distal stenosis of the bile duct or for failure of other methods.     

Mortality in Severely Injured Elderly Trauma Patients—When Does Age Become a Risk Factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) > or = 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46-55 years of age) to 13.0% (patients ages 56-65 years) in patients with ISS 16-24; from 23.8% to 32.1% in those with ISS 25-50; and from 62.2% to 82.1% in those with ISS 51-75 (P < or = 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P < or = 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P < or = 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma-an increase that was independent of trauma severity.     

The influence of age on the outcome of primary coronary artery bypass grafting.

BACKGROUND: With the steady increase in the number of elderly patients requiring coronary artery bypass grafting (CABG), scepticism still exists as to whether this operation is justified in older patients or not, and whether there is an upper age limit. The aim of this study was to examine the effects of increasing age on the outcome of CABG. METHODS: A retrospective review was performed on 2127 consecutive patients undergoing primary CABG from January 1990 through June 1996. The patients were arbitrarily divided into age groups: 69 years or less (n=1607), 70-75 years (n=371), 76-80 years (n=129) and older than 80 years (n=20). Mortality, morbidity and long-term survival for each group was compared. RESULTS: The groups containing the elderly patients showed an over-representation of women, as well as a higher frequency of arterial hypertension, hyperlipidemia, previous infarction and diabetes. More patients, amongst the elderly, had unstable angina and diffuse coronary disease requiring urgent surgery and coronary thrombendarterectomy compared to those <70 years. Hospital mortality did not differ between the groups, 1.8, 3.0, 2.3 and 5.0%. There was an increased incidence of low postoperative cardiac output and a higher incidence of gastro-intestinal complications amongst the elderly. The 5-year survival was 92.2% (<70 years), 87.0% (70-75 years) and 86.3% (76-80 years) and the cardiac event-free survival was 87.5% (<70 years), 78.4% (70-75 years) and 80.8% (76-80 years) at 5 years. CONCLUSIONS: An acceptable early mortality and medium-term survival (5 years) together with excellent functional medium-term results support the justification of primary CABG in older patients irrespective of age.     

70岁以上高龄食管癌外科治疗体会

目的探讨70岁以上食管癌患者手术切除的可行性及手术效果。方法对我院2004至2008年的54例70岁以上高龄食管癌患者手术治疗的临床资料进行分析。结果手术切除率100％，并发症发生率48．15％，2例死亡，死亡率3．70％。结论70岁以上高龄食管癌患者严格掌握手术适应证，选择恰当的术式，采取正确的围手术期处理，能够获得满意的效果。     

Long term results of cardiac valve replacement in patients aged 75 years and older.

From June 1978 to December 1989, 158 patients over 75 years of age (mean: 78 years; range 75 to 86 years) underwent 164 valve replacements: 134 in the aortic, 18 in the mitral and 6 in double mitral and aortic positions. One hundred and seven of these valves (66%) were bioprostheses, 93 aortic and 14 mitral and 57 valves (34%) were mechanical prostheses; 47 aortic and 10 mitral. Hospital mortality (less than or equal to 30 days) was 7% (11 patients, all in NYHA class III or IV) but was higher in patients who had undergone associated procedures (9.8%; 6/61 patients) or in patients who had mitral valve replacements (11%) and in double valve replacement (16.6%). Because of a minimal delay of one year, long term follow-up information (100%) was only obtained from the first 110 patients discharged from hospital. Late mortality has been 13.6% and actuarial survival at 11 years was 71.5% +/- 5. Therefore, despite a hospital mortality of more than twice that of patients operated upon under 75 years of age (3.3%), an actuarial survival at 11 years, similar to that of patients under 75 years (77 +/- 5%) and the functional improvement obtained (95% of survivors are NYHA class I or II) certainly justify surgery in these patients. Because of the incidence of anticoagulant related hemorrhages in these patients (1.7% patient year) and since, structural deterioration of the bioprostheses was non existent in this series, a bioprosthesis appears to be the best valvular substitute in patients over 75 years of age.     

Permanent Loss of Preoperative Independence in Elderly Patients Undergoing Hepatectomy: Key Factor in the Informed Consent Process

Purpose

Major (>3 segments of the liver) or minor hepatectomy has been demonstrated to provide the most definitive chance for long-term remission and disease-free survival in hepatic malignancies. However, concerns remain in regards to the ability of the elderly (>70 years old) and older (>80 years old) patients to “tolerate” this type of resection. Thus, the aim of this study was to determine the short- and long-term effects of hepatectomies in the elderly patient population.

Methods

An Institutional Review Board approved a prospectively maintained, single-institution HPB database with 663 consecutive hepatectomies from 2003 to 2013 was reviewed. Patients were separated into elderly (>70 years old) and older. Short-term effects were defined as a 30-day morbidity/mortality, and long-term effects were defined as a 90-day morbidity/mortality and the ability to regain preoperative functional independence. Comorbidities were compared using the Charleston Comorbidity Index (CCI). The log-rank and Wilcoxon tests were used to evaluate postoperative outcomes.

Results

A total of 663 patients were reviewed, 480?<?70y/o, 183 were 70 or older, 104 were 75 or older, and 41 were 80 or older. Patients over 70, 75, and 80 years of age showed a higher incidence of preoperative comorbidities than younger patients when compared using CCI (P?<?0.05). Non-elderly patients had more liver lesions than elderly patients (median numbers only 3 vs. 1, P?=?0.005). Patients over 70, 75, and 80 years old showed a higher 90-day mortality rate patients (11, 13, 17 %, respectively) to patients less than 70, 75 and 80 (3, 5, 5 %, respectively, P?<?0.05) (Table). Patients over 70, 75, and 80 years old showed increased morbidity (53, 57, 66 %, respectively) than patients less than 70, 75, and 80 (39, 34, 41 %, respectively, P?<?0.05). The severity of complication in elderly patients was similar to younger patients. Patients older than 70, 75, and 80 years showed an increased incidence of discharge to rehabilitation facilities (13, 15, 17 %, respectively) than patients less than 70, 75, and 80 (2, 3, 5 %, respectively, P?=?<0.001). Logistic regression demonstrated a significant risk of morbidity with an inability to return to preoperative function with a CCI?>?5, major hepatectomy, and >75 years of age (HR 3.8, CI 2.1–5.6)

Conclusions

This study demonstrates an increased rate of a 30- and 90-day postoperative mortality in >75-year old patients. Permanent loss of preoperative function (i.e., ability to live independently or alone) remains a significant risk and a subset of older patients. Communicating this loss of function as well as morbidity/mortality is key to the informed consent process for older patients as well as their families.

     

Favorable results of coronary artery bypass grafting in patients older than 75 years

There is controversy whether the short-term and long-term results of coronary artery bypass grafting in elderly patients justify performing the procedure. Between January 1977 and December 1986, 4580 patients underwent coronary artery bypass grafting, of whom 222 (4.9%) were 75 years old or older (mean 77 years). There were 143 men and 79 women and 139 (63%) were in New York Heart Association class IV. One hundred forty-six patients (66%) had had at least one preoperative myocardial infarction. Myocardial revascularization was performed under emergency conditions in 17 patients (18%). The mammary artery was used in 43%, 96% of the patients received two or more grafts. The mean number of bypass grafts was 3.1 per patient. The overall hospital mortality rate was 10.8% (24/222), 3.6% for elective procedures, 14.9% in urgent cases, and 35% in emergencies. In contrast, the overall early mortality rate was 3.1% in 4358 patients less than 75 years old. Complications occurred in 83 patients (37%). Of the patients discharged from the hospital, 198 were followed up for a mean of 48 months (1 to 130). Actuarial probability of survival was 75% at 48 months. Postoperatively 70% were in New York Heart Association class I or II and only 21% were rehospitalized for cardiac problems. During the follow-up period 77% of the patients were free from angina, and of those experiencing angina the mean time from operation to the first episode was 75 months. Although elderly patients have a somewhat increased operative mortality rate, particularly if operated on urgently or emergently, long-term survival and freedom from angina are excellent and justify continued performance of coronary bypass grafting in selected patients over 75 years of age.     

Influence of age on the mortality from acute pancreatitis

The influence of age on the mortality rate of 268 patients with acute pancreatitis was studied. The hospital mortality rate for patients aged below 50 years was 5.9 per cent. The figure increased to 21.3 per cent in patients aged over 75; the high mortality was accounted for by a higher incidence of deaths related to concomitant medical or surgical diseases in the same hospital admission rather than to complications resulting directly from the pathological process of acute pancreatitis. When only deaths due to complications of acute pancreatitis were analysed, the mortality rate was not significantly different between the young and elderly groups. Moreover, the complication rate and the proportion of patients having severe disease (judged by the number of prognostic signs) were not higher in the elderly. Thus acute pancreatitis was intrinsically not more serious were it not for the presence of concomitant diseases with advanced age.     

Surgical treatment for esophageal cancer in elderly patients over 75 years of age

We performed 127 esophageal resections for the esophageal cancer patient from December 1995 to September 2001. It was separated to under 70 years old patients group (group I), 71-74 years old patients group (group II), and over 75 years old patients group (group III). RESULTS: Postoperative complication was occurred in 53 cases (41.7%) within all of 127 esophageal resected cases. It was 33.7% in group I, 53.6% in group II, 62.5% in group III. Four years survival rate of each group is 38.3% in group I, 44.6% in group II, 31.3% in group III. It is significantly better in group II rather than in group III. Operative death rate is 12.5% (2 cases) in group III, 7.1% (2 cases) in group II, 3.6% (3 cases) in group I, and it is gradually higher and higher by patient's age. CONCLUSIONS: (1) In the esophageal cancer patient over 75 years old, postoperative complication rate is higher than under 74 years old patients, and prognosis is significantly poor rather than in 70-74 years old patients group. (2) In the esophageal cancer patient over 75 years old, we considered it is good indication of esophagectomy for stage I and stage II patient without preoperative complication, however, there are no operative indication for stage III and stage IV patient.     

Pancreaticoduodenectomy in elderly patients--a safe operation?

The aim of this study was to analyze the impact of age in mortality and morbidity after duodenopancreatectomy (DPC), setting the age of 70 as a cut-off. A retrospective study was made of two groups of patients (under 70 and over 70 years old) who underwent DPC in the Center of General Surgery and Hepatic Transplantation, Fundeni, Bucharest between 2001 and 2006 for malignant and benign tumors of the pancreatic head, distal biliary tract, duodenum, Vater's ampulla and chronic pancreatitis. 245 DPC were performed, 207 in patients under 70 years old (group A) and 38 in patients over 70 years old. Postoperative global morbidity rate was 58% in group B vs 49,9 % in group A. Postoperative mortality rate was 5,2% in group B and 4,8 % in group A. No significant differences were recorded in survival when comparing the two groups, both in pancreatic head cancer or distal biliary tract cancer. Under these circumstances, increased age is not determining an increase in postoperative mortality after DPC, but is associated with a higher risk of postoperative medical complications.     

Outcome of VATS Lobectomy for Elderly Non-Small Cell Lung Cancer: A Propensity Score-Matched Study

Purpose: To analyze the short-term and long-term outcome of video-assisted thoracic surgery (VATS) lobectomy for elderly patients with non-small cell lung cancer.Methods: 105 patients aged ≥75 years with resected non-small cell lung cancer were matched with 105 younger patients by propensity score. Survival rates were calculated by the Kaplan-Meier method. The cumulative incidence functions of conditional survival rate according to the age of the patients were calculated by competing risk analysis.Results: patients ≥75 years was associated with higher postoperative complication rate (p <0.001), but similar perioperative death rate (p = 0.006). Patients ≥75 years were less likely to receive adjuvant chemotherapy (p <0.001). The 5-year overall survival rates were 54.6% for patients ≥75 years and 74.1% for patients <75 years (p = 0.001). No difference was seen in disease-free survival rate (59.5% vs. 71.9% respectively = 0.117). The cumulative incidence functions of 5-year cancer-specific death were similar between the two groups (28.7% vs. 24.6% respectively, p = 0.106). The cumulative incidence functions of 5-year non-cancer-specific death was significantly higher in the elderly group (18.7% vs. 1.0%, p <0.001).Conclusions: VATS lobectomy for non–small-cell lung cancer in patients ≥75 years were feasible with increased morbidity but similar mortality. The resected elderly patients were more frequently associated with non-cancer-specific death.     

Outcome of temporary stomas. A prospective study of temporary intestinal stomas constructed between 1989 and 1996

PURPOSE: The purpose of this study was to examine the outcome of patients to whom a temporary stoma was constructed in our institution. METHOD: The outcome of patients operated on over an 8-year period was prospectively examined. Special attention was given to the influence of age on complications and closure of stomas. RESULTS: Between 1989 and 1996, a total of 349 intestinal stomas were constructed in 342 patients. In 141 of these patients, the stoma could be considered as temporary. The 30-day mortality rate was 7%. The overall complication rate was 50%. Pure stoma-related complications were observed in 12% of the patients. The final closure rate of temporary stomas was 67%. The closure rate was significantly higher if the temporary stomas were of the double-barrel type. There was no significant difference in the closure rate between patients with benign and malignant diseases, but the rate decreased significantly in age groups over 70 years. CONCLUSIONS: Forty percent of stomas constructed are considered as temporary, but only two-thirds of temporary stomas are closed subsequently. Especially end stomas tend to become permanent in patients over 70 years of age, although the morbidity rates of stoma closure do not differ from those of younger patients.     

Acute abdominal disease in the elderly: Experience from two series in Stockholm

Two series from greater Stockholm consisting of 726 (1960 to 1968) and 1,000 (1977 to 1978) patients over age 70 years with acute abdominal complaints are presented. Almost two thirds were women. Acute cholecystitis dominated both series, but its incidence decreased from 40.8 to 26 percent in the later series. The incidence of malignant disease increased from 3 to 13.2 percent. About one third of the patients were operated on; 50 percent had postoperative complications. Some frequently occurring aberrations of the usual symptoms and signs in acute appendicitis, ileus, and perforated gastric duodenal ulcer are discussed. The overall therapeutic results improved, as judged by postoperative mortality (series I,23.1; series II, 16 percent) and mortality associated with individual diseases (except for acute pancreatitis). However, total mortality only decreased from 14 to 11.3 percent due to the large number of malignant diseases in series II, which were associated with a mortality of 37.9 percent. In series II the median duration of stay was 10.5 days and 75 percent of the patients were discharged home.