Surgical treatment of ileus in late radiation sequelae of the intestine

Between 1971 and 1988 74 operations for intestinal complications following radiotherapy were performed on 67 patients at the Second Surgical Department, University of Vienna. The lesions were located in the small bowel (n = 41) and in the sigmoid colon/rectum (n = 33). 98.5% of the patients were females, the most frequent cause for irradiation being ovarian cancer. Bowel stenosis with resultant chronic or acute ileus was the most frequent indication for operation, occurring in 31 cases (76%) of the small bowel lesions and in 15 cases (46%) of the colon lesions. Percutaneous irradiation resulted in a significantly higher proportion of small bowel lesions (77%, p = 0.001), whilst endocavitary irradiation was followed in 67% of cases by colorectal lesions. Different application modality of irradiation also resulted in completely different symptoms for small and large bowel lesions. The operative mortality was 9.5%. Peritonitis following anastomotic leakage was the cause of death in 6 of 7 cases. In the treatment of small bowel ileus mortality following bowel resection (9%, one of 11 cases) was comparable to that of the bypass operation (6%, one of 18 cases). Both operation methods seem to be justified. Single-layer anastomosis resulted in zero mortality (21 cases) for ileus operation compared with 19% mortality (16 cases) in double-layer anastomosis and should be preferred for operations on the irradiated bowel.     

Surgical therapy of carcinoid tumors of the gastrointestinal tract]

More than 70% of all carcinoids are localized in the gastrointestinal tract. Carcinoids of the upper, middle and lower intestines have to be distinguished ontogenetically. The classification according to Capella takes into account the size of the tumor (< 0.9 cm; 1-2 cm; > 2 cm), the grade of invasion of other structures, the grade of angioinvasion, the biologic behaviour, the grade of differentiation and the hormonal activity of the tumor. A carcinoid-syndrome is rarely found. Carcinoids of the small intestine occur multiple in 30-50% and in 20-30% a second malignant tumor is seen. In carcinoids of the colon this percentage is even higher (25-40%). The therapy of carcinoids depends on the size of the tumor and consecutively on the risk of metastasis. A local excision or non-oncologic radical operative procedure is justified in carcinoids smaller than 1 cm. In tumors 1-2 cm in size an individual decision has to be made. Larger tumors should be operated according to oncologic standards. Palliative resections, even of the liver, may be indicated to relieve the symptoms of a carcinoid-syndrome or, to prevent ileus or bleeding in the gastrointestinal tract. The prognosis of gastrointestinal carcinoids is heterogenous: The five-year-survival-rate of appendix-carcinoids is 85.9% over all stages. In rectal carcinoids this rate amounts to 72.2%, in carcinoids of the small intestines to 55.4% and in colon-carcinoids to 41.6%. Carcinoids of the stomach have a five-year-survival-rate of 64.3% in the absence of metastases. Within carcinoids of the stomach type III-tumors have the worst prognosis with a median survival time of 6.5 months.     

Surgical stress and the gastrointestinal tract

Surgery on any part of the body results in a wide spectrum of alterations in normal body homeostasis. The gastrointestinal tract is extremely sensitive to surgical stress, even at remote locations. It is now evident that the G.I. tract also plays an important role in development of postoperative complications, such as the systemic immune response syndrome and multiple organ failure syndrome. The amount of information available on the cellular and subcellular changes occurring in the gastrointestinal tract after surgical stress is scant. These changes are important since they would act as initiators of tissue damage seen at a later stage, which in turn lead to postoperative complications. This review looks at the information available on the effect of surgical stress on the small intestine, the role of oxygen free radicals in this process, and the changes occurring at the cellular level.     

Surgical correction of late sequelae from facial bone fractures

This study has described the UCLA experience over a 5 year period in the treatment of secondary traumatic deformities utilizing the craniofacial techniques originally proposed by Tessier. Because of scarring, absent parts, and the malposition of segments, correction of long-standing traumatic deformities remains difficult and treatment results remain less than ideal. Primary correction utilizing the principles we have described herein still provides the best functional and aesthetic results. Facial fractures can no longer be considered as an independent and unrelated entity when dealing with the traumatized patient. If primary reconstruction continues to be compromised, correction of residual disfigurement will result in unnecessary patient morbidity and disturbances of facial form and function.     

Alterations in the urinary tract after spinal cord injury—diagnosis,prevention and therapy of late sequelae

Summary The life expectancy and quality of life of patients with injuries to the spinal cord greatly depend on the condition of the urinary tract. It is hence necessary that specially trained urologists participate in the treatment of these patients from the beginning. In the last 15 years, excellent diagnostic methods have been developed (especially urodynamic procedures), resulting in the feasibility of individual therapeutic measures on the basis of urodynamic findings. Conservative and surgical methods to improve bladder emptying and thus to reduce the danger to the upper urinary tract are presented and critically evaluated with reference to a large patient population comprising >3000 spinal cord-injured patients in the course of 13 years. Conservative measures such as the specific use of reflex activity, pharmacotherapy, intermittent self-catheterization, as well as graduated operations to lower bladder outlet resistance to a physiological level, were sufficient to attain a compensated situation in >90% of the patients. A part of the remaining problem group profits from more recent surgical methods, with transformation, enlargement, elimination and electrostimulation of the bladder. Today, the vast majority of patients with spinal cord injuries can receive sufficiently definitive treatment with regard to both their life expectancy and their quality of life, with relatively little material effort and inconvenience, even over long periods of time.     

Surgical policy in gastrointestinal tract foreign bodies]

66 patients (45 males and 21 females) who have swallowed 157 foreign bodies (fragments of wire, nails, needles, hafts of spoons, et were treated). If the objects were located in the stomach and the duodenum in the absence of complications endoscopic method of treatment was preferable, with the help of which 31 objects were successfully removed and the terms of treatment were significantly decreased. Conservative treatment (diet rich in fiber and protective substances, barium sulfate administration) resulted in elimination of 58 objects by vias naturals, 53 from which were not more that 8 cm long. Evacuation of the foreign bodies was carried out only during the first 3 weeks after the swallowing. Operative treatment was carried out in 21 patients, in whom 68 foreign bodies were extracted. An urgent operation in the first 6 hours in complications due to foreign bodies (perforation, incarceration, gastrointestinal bleeding) was carried out in 13 patients. An urgent operation in terms from 6 to 24 hours of hospitalization was carried out in 6 patients with large (more that 8 cm) swallowed objects, conglomerates and bunches of foreign bodies. Early removal of these objects prevented development of complications. Elective operation was carried out in failure of conservative treatment as was in 2 patients. No lethality was registered.     

Skeletal sequelae of radiation therapy for malignant childhood tumors

One hundred forty-three patients who received radiation therapy for childhood tumors, and survived to the age of skeletal maturity, were studied by retrospective review of oncology records and roentgenograms. Diagnoses for the patients were the following: Hodgkin's lymphoma (44), Wilms's tumor (30), acute lymphocytic leukemia (26), non-Hodgkin's lymphoma (18), Ewing's sarcoma (nine), rhabdomyosarcoma (six), neuroblastoma (six), and others (four). Age at the follow-up examination averaged 18 years (range, 14-28 years). Average length of follow-up study was 9.9 years (range, two to 18 years). Asymmetry of the chest and ribs was seen in 51 (36%) of these children. Fifty (35%) had scoliosis; 14 had kyphosis. In two children, the scoliosis was treated with a brace, while one developed significant kyphosing scoliosis after laminectomy and had spinal fusion. Twenty-three (16%) patients complained of significant pain at the radiation sites. Twelve of the patients developed leg-length inequality; eight of those were symptomatic. Three patients developed second primary tumors. Currently, the incidence of significant skeletal sequelae is lower and the manifestations are less severe than reported in the years from 1940 to 1970. The reduction in skeletal complications may be attributed to shielding of growth centers, symmetric field selection, decreased total radiation doses, and sequence changes in chemotherapy.     

Drug therapy of carcinoids of the gastrointestinal tract]

Carcinoid tumors are rare and slowly growing neuroendocrine tumors of the foregut, midgut and hindgut. Drug therapy is of special importance in patients with inoperable metastasising disease. This palliative therapy is aimed at reduction of the hormone-dependent symptoms and inhibition of tumor growth. Somatostatin analogues, alpha-interferon and various chemotherapeutic agents are used for this purpose. Drug therapy can be supplemented by surgical and radiological intervention through interdisciplinary cooperation of the surgeon, radiologist, endocrinologist and gastroenterologist.     

Surgical tactics in cases of foreign bodies of the gastrointestinal tract

The experiments on 30 dogs and observation over 186 patients suggest that the indications for the operation in case of foreign bodies in the gastrointestinal tract depend on the shape and size of the foreign body and on the time during which it has been fixed in one place.     

Surgical treatment of sequelae of chemical burns of the upper segments of the digestive tract

An experience with the treatment of 210 patients with consequences of associated chemical burns of the esophagus and stomach (174 of them were operated on the stomach at early terms after burn for impassability) allowed recommendation of operation with the least risk--shunting interventions on the stomach and esophagus. Ante-thoracal lateral jejunostomy is thought to be indicated to patients with massive injuries of the stomach or complications of gastrostomy.     

Role of radiation therapy in gastrointestinal cancer

The intradiation techniques in the last several decades has resulted in a wider application of radiation therapy to the treatment of gastrointestinal cancer. Controlled and uncontrolled clinical trials have shown benefit for preoperative and/or postoperative irradiation in carcinoma of the rectum and rectosigmoid. Endocavitary radiation techniques have been employed successfully in early, accessible rectal cancers as an alternative to abdominal perineal resection. High-dose external beam irradiation with and without concomitant chemotherapy has produced encouraging results in locally advanced, unresectable pancreatic carcinoma. Benefit for radiotherapy in locally advanced gastric carcinoma has been demonstrated as well. In carcinoma of the esophagus, radiotherapy has resulted in long-term control in selected patients and also has been employed with modest success in combination with surgery. Interstitial radiation techniques, intraoperative electron beam therapy, and fast neutrons, heavy charged particles, and other forms of high linear energy transfer radiation are being investigated and may eventually find greater application.     

Long-term functional sequelae of the urinary tract following radical surgical treatment of carcinoma of the cervix with and without extended radiation therapy

Organic and functional lesions of the urinary tract following radical surgery and radiation therapy for gynecologic cancer are complications well known in the literature. The irreversible anatomic and neurologic damage, which often manifests itself many years after the original therapy, is the cause of serious pathology which affects the quality of life of cancer-free patients. In order to delineate those predisposing factors which if corrected or changed would permit the prevention or reduction of such complications, the authors report their experience in 20 patients who had undergone surgical treatment for carcinoma of the cervix, of whom 14 had radiation therapy at least 10 years prior to investigation. Problems of voiding and reduction of bladder compliance with an increase of detrusor pressure were mostly present in the irradiated patients. Low compliance and reflux was significantly correlated with deterioration of the upper urinary tract, especially in the presence of excessively high urethral pressures. The resulting problems are often difficult to treat owing to the diminished effectiveness of drugs and the possibility that surgical treatment may also be inadequate due to tissue damage. Follow-up studies of bladder function must be continued indefinitely so as to guarantee early recognition of alterations in the voiding phase and of occurrence of the ureterorenal reflux which can eventually compromise kidney function.