Some problems of the surgical treatment of stomach and duodenal ulcer]

The analysis of the results of surgical treatment of the gastric and duodenal ulcer disease in 191 patient under conditions of surgical department of the central district hospital was carried out. It was established that performance of the organ-preserving operation with vagotomy in duodenal ulcer disease permitted to reduce the mean duration of postoperative treatment and temporary invalidity, reduce the lethality. In gastric ulcer, the best result was obtained when using Billroth-I and stepped resection of the stomach.     

Surgical treatment of perforative gastroduodenal ulcer in patients living in a catastrophic flood zone

In a period of catastrophic flood in 1998 and 2001 yrs there was noted the enhancement of general quantity of patients with gastroduodenal ulcer disease as well as with complicated course, including gastroduodenal ulcer perforation. In the period of flood in Zakarpattya in 2001 the quantity of patients, who were admitted to hospital, to Tyachiv and Vinogradiv central district hospitals in particular, too late, was enhanced as twice. In conditions of extreme situation it is expedient to conduct prophylactic treatment of patients, who are staying under the dispensary observation for gastroduodenal ulcer disease. Improvement of the surgical treatment results in patients with gastroduodenal ulcer disease complications in the disaster zone may be achieved due to accurate organization and coordination on all the stages of medical care to population, application of modern endoscopic technologies.     

Diagnosis, pathophysiology and surgical treatment of duodenogastric reflux in peptic ulcer

Results of the examination of 142 patients with ulcer disease were studied. The incidence of DGR was found to be 48% in gastric ulcer and 44% in duodenal ulcer. The unfavorable influence on the gastric mucosa was greater under conditions of the acidic intragastric medium. Special attention to causes of DGR in the surgical treatment of the ulcer disease and the use of areflux anastomoses can improve results of the surgical treatment of such patients.     

Prognosis of gastric ulcer: twenty-five year followup.

Four hundred twenty-two patients with gastric ulcer treated during 1950-1960 were followed up to 25 years with a mean followup of 9 years. Nonoperative treatment was used in 59% with a hospital mortality of 35%, one-third of these deaths being directly due to gastric ulcer perforation or hemorrhage. Operative treatment was used in 41% of patients. The most common operation (86%) was gastric resection without vagotomy. Overall operative mortality was 16%; 34% for emergency procedures and 6% for elective procedures. Cachexia seemed to be the most important factor related to operative mortality. Nonoperative treatment resulted in more than twice the hospital mortality compared to operative treatment. Approximately one-half of all patients treated non-operatively had a recurrent gastric ulcer at some time during this study. The recurrence rate following definitive gastric resection was 1.3% compared with 16% during nonoperative therapy. Three-fourths of recurrences occurred later than two years and nearly half of recurrences after more than 5 years of followup. Patients with a prior history of overt bleeding from gastric ulcer disease particularly were at risk for further bleeding. There were coincidental duodenal ulcers in 10% of our patients and a 0.8% incidence of gastric cancer during followup. Long term followup demonstrates the superiority of operative treatment of gastric ulcer and also reveals the continuous propensity of such ulcers to recurrence following nonoperative treatment. Earlier elective operation in patients with overt bleeding, recurrence or persisting symptoms should decrease overall mortality and result in a lower overall long-term risk of ulcer complications.     

Gastroduodenal ulcer hemorrhage under conditions of Extreme North (Yakut)

Under analysis there were results of treatment of 431 patients with duodenal ulcer bleedings. The authors note that the duodenal ulcer bleedings under conditions of Extreme North (Yakutia) are observed more often in those who come (not in residents). Among specific features of the clinical course of the ulcer disease the authors note a short case history, continuous and severe exacerbation, short remission, frequent development of complications. The authors use in their work active individualized surgical methods and make organ-saving operations aimed at saving the patient's life.     

Plasmapheresis in the complex treatment of nonspecific ulcerative colitis

An experience with using the apparatus plasmacytapheresis in 16 patients with nonspecific ulcer colitis has revealed its high effectiveness mainly in patients with mild and middle-severity forms of the disease. Convincing data were obtained on the improvement of clinical, biochemical and immunological processes. The method can be used in ambulatory conditions for supporting therapy of the patients.     

A Prospective Study in Comparison of Ambulatory Phlebectomy and Duplex Guided Foam Sclerotherapy in the Management of Varicosities with Isolated Perforator Incompetence

Perforators are those which connect the superficial and deep venous system either directly to main veins or indirectly through the muscular and soleal venous plexus. The emergence of minimally invasive techniques like ambulatory phlebectomy (AP) and foam sclerotherapy (FS) has led to increasing interest about the appropriate therapy for the treatment of isolated perforator incompetence. There have been no studies which have compared the effectiveness of these in-office procedures in isolated perforator incompetence due to the low prevalence of cases. The primary goal of this study is to compare the clinical parameters (return to normal activity, primary symptom relief), functional parameters (procedure time, change in disease severity, course of venous ulcer), and duplex parameters (recurrence in treated veins, complete occlusion of treated veins) in the management of leg varicosities having isolated primary perforator incompetence by ambulatory phlebectomy and duplex guided foam sclerotherapy. Though the procedure time was shorter with FS than AP, the other parameters of primary symptom relief such as change in disease severity, faster healing of venous ulcer, complete occlusion of treated veins in follow-up duplex examination, and lower recurrence of treated veins are better with AP than FS. In conclusion, the interruption of perforators is effective in decreasing the symptoms of chronic venous insufficiency and for the rapid healing of ulcers. The interruption of the incompetent perforating veins appears to be essential to decrease ambulatory venous hypertension. It is apparent from this study that ambulatory phlebectomy stands distinct with enormous benefits and serves as a superior alternative to foam sclerotherapy in treating patients with isolated perforator incompetence.     

Ambulatory containment treatment in Perthes' disease

The results of four different ambulatory methods used in the treatment of 248 patients with Perthes' disease were compared in five different hospitals. In each hospital the patient population was selected for the era of treatment policy. Seventy-two patients were treated with crutches alone, 58 with a Scottish Rite orthosis, 48 with a Newington abduction orthosis (a bilateral long-leg brace holding the hips in abduction and internal rotation), and 70 with proximal femoral osteotomy. The end results of treatment were rated according to head sphericity using the MOSE method. Prognostic indicators were recorded, including age of onset of disease, Catterall type, and femoral subluxation. Patients with partial-head involvement under eight years of age at disease onset with minimal lateral subluxation (less than 1.5 lateral subluxation ratios) and no proximal subluxation fared equally well with crutch walking or any of the three ambulatory-containment treatments studied. With greater degrees of subluxation, all three containment groups were superior to crutch walking and all were equally effective. In partial-head involvement, patients between eight and 12 years of age, with or without lateral or proximal subluxation, all three ambulatory containment methods were superior to crutch walking. Femoral osteotomy and the Newington abduction orthosis were equally effective. Only five Scottish Rite patients were in this age group, too small a number to compare with the other treatment methods. Patients with partial-head involvement over 12 years of age at disease onset had poor results. For patients with total-head involvement under eight years of age at disease onset, femoral osteotomy was correlated with a lesser degree of femoral head flattening than either brace or crutch treatment. In whole-head involvement patients over eight years old at disease onset, all three ambulatory containment methods were equally effective and superior to crutch walking; however, there were few crutch walking and Newington abduction arthrosis patients in this age group.     

The catalogue of ambulatory sickness benefits -- realistic? Feasible? Put into practice?

Ambulatory surgery at German hospitals is an underdeveloped field. New legal regulations allow contracts between hospitals and insurance companies which will improve this situation. Besides the establishment of quality parameters and a fixed payment for the operations the contract lists 307 operations which can be performed on an outpatient basis. However, only few operations need to be done obligatory as ambulatory surgery. This reflects just incompletely what is already operated ambulatory outside the hospitals. Due to altered financial structures in case of in-patient treatment and because of a decrease of hospital beds, the listed operations in the contract may be reviewed and ambulatory surgery at the hospitals will increase in the future. The hospitals need to change their structure to establish successfully ambulatory surgery within the hospital setting. Finally, German patients need to be convinced that operations done on an out-patient basis show the same quality standards like procedures under in-patient conditions.     

Patient rehabilitation following the surgical treatment of gastric and duodenal peptic ulcer

On the basis of observation of the ulcer disease of the stomach and duodenum in 970 patients given the restorative treatment in rehabilitation hospitals after being discharged from the surgical hospital the authors recommend the earlier rehabilitative treatment since it gives more rapid reestablishment of their working capacity.     

Adverse effects of delayed treatment for perforated peptic ulcer.

OBJECTIVE: The authors assessed the consequences of delayed treatment for ulcer perforation with regard to short-term and long-term survival, complication rates, and length of hospital stay. SUMMARY BACKGROUND DATA: Important adverse effects of delayed treatment have not been studied previously. Conflicting results have been given with regard to short-term survival. METHODS: One thousand two hundred ninety-two patients operated on for perforated peptic ulcer in the Bergen area between 1935 and 1990 were studied. The effect of delay on postoperative lethality and complications adjusted for age, sex, ulcer site, and year of perforation was analyzed by stepwise logistic regression. The effect of delay on duration of hospital stay adjusted for potential confounding factors was analyzed by Cox proportional hazards regression. Observed survival was estimated by the Kaplan-Meier method, and expected survival was calculated from population mortality data. RESULTS: Adverse effects increased markedly when delay exceeded 12 hours. Delay of more than 24 hours increased lethality sevenfold to eightfold, complication rate to threefold, and length of hospital stay to twofold, compared with delay of 6 hours or less. The reduced long-term survival for patients treated more than 12 hours after perforation could be attributed entirely to high postoperative mortality. CONCLUSIONS: Delayed treatment after peptic ulcer perforation reduced survival, increased complication rates, and caused prolonged hospital stay. To improve outcome after ulcer perforation, an effort should be made to keep delay at less 12 hours, particularly in elderly patients.     

Treatment of acute paraproctitis at a polyclinic setting

The experience with operative treatment of 24 patients with uncomplicated acute paraproctitis under ambulatory conditions was analysed. The radical operation was performed in 21 patients. The disease recurrence developed in 2 patients, who were reoperated on in the in-patient department.     

Death from undiagnosed peptic ulcer complications: a continuing challenge

A 10-year study of all 9653 autopsies performed in the Plymouth Health District, UK from 1977 to 1986 revealed 154 patients who died from undiagnosed peptic ulcer complications. In all, 118 of these patients died suddenly at home and 36 died in hospital. Most patients were elderly although 47 were under 70 years and 2 were under 50 years of age. Anti-inflammatory drugs were being used by 81 of these patients, an incidence of 60 per cent where full drug histories were available. Women who died were much more likely to be using these drugs than men. This study emphasizes the hitherto unrecognized importance of death from undiagnosed peptic ulcer disease and further highlights the potential risk of non-steroidal anti-inflammatory drug use.     

Medico-social prognosis for patients with degenerative-dystrophic lesions of the hip joint after corrective osteotomy in the first year after surgery

A complex clinico-functional examination (clinical, ++roentgenological, electromyographical, functional tests) performed in patients after correcting osteotomy within the terms up to 1 year allowed to objectively assess the efficiency of the prolongation of ambulatory treatment of the patients under conditions of intensive restorative treatment and recognize more than 50% of the patients to be capable of working.     

Surgical tactics in ulcer-related gastroduodenal hemorrhage in middle-aged and elderly patients

Under analysis were immediate results of surgical treatment of ulcer disease of the stomach and duodenum complicated by profuse hemorrhage in 229 patients aged from 60 to 79 who were treated in a specialized gastroenterological department of a regional hospital and district hospital. It has been proved that better results of the surgical treatment of gastroduodenal hemorrhages of ulcerous etiology in elderly and senile patients are dependent on more active and earlier performing operative interventions.     

Evaluation of results and treatment variables for pressure ulcers in 48 veteran spinal cord-injured patients.

This retrospective study of 48 spinal cord-injured patients with pressure ulcers seen at a tertiary referral Veterans Hospital spinal cord injury unit between 1992 and 1997 correlates a number of variables (co-morbid conditions, nutritional status, smoking history, type of repair performed, type of bed used postoperatively, ulcer location and severity, duration of postoperative antibiotic therapy, time elapsed before sitting rehabilitation began, and length of hospital stay) with ulcer repair outcome measures, including postoperative systemic and wound-healing complications, recurrence rates, and the development of new ulcers at different sites. Surgical complication rates were high, occurring in 19 patients (39.6%), and ulcer recurrence or new ulcer development occurred in 38 patients (79.2%). Correlations were found between ulcer location and postoperative wound separation and the length of hospitalization. The hospital course was shorter if the ulcer was new rather than recurrent. Other than the finding that chronic smokers had longer courses of antibiotic therapy, smoking did not correlate statistically with other outcome variables, including wound-healing complications. No significant correlations were found between any postoperative systemic or wound complications, ulcer recurrence, or new ulcer development and patient age, level of spinal cord injury, number of ulcers and grade, laboratory values, mental status, cardiac or pulmonary disease, diabetes, and presence or absence of osteomyelitis.     

Present status of the Taylor method in perforated ulcer of the duodenal bulb

Therapy by Taylor's method was attempted in 61 of 96 patients with perforated ulcer of duodenal cap. Treatment was effective in 50 cases (more than 50%) and morbidity and mortality were low. Most operated cases were recipients of simple treatment for the perforation, more rarely combined with therapy for the ulcer disease. Postoperative mortality was very high (24% of patients operated upon) but appeared to be related mainly to associated risk factors. Only 8 of the patients treated by Taylor's method required recovery surgery, while this was necessary in 4 patients operated upon initially and given simple treatment for the perforation. These findings suggest efficacy of Taylor's method for treatment of perforated duodenal ulcer, avoiding operation or allowing treatment of the ulcer disease once the acute episode has passed.     

Venous ulcers of the lower extremity: Definition,epidemiology, and economic and social burdens

Venous ulcer is a common vascular condition affecting 1% of the population, and a prevalence that increases with age. Venous ulcer is defined by the American Venous Forum as “a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing.” The economic and social burden of this condition is significant to both the affected individual and the health care system. The recurrent nature of venous ulcers underscore the need for treatment of the underlying pathophysiology, that is, ambulatory venous hypertension produced by venous valve reflux alone or in conjunction with venous obstruction.     

Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial

BACKGROUND: The prevalence of venous leg ulcers is as high as 1% to 1.5%, and the total costs of this disease are 1% of the total annual health care budget in Western European countries. Treatment modalities are conservative or surgical. Subfascial endoscopic perforating vein surgery (SEPS) combined with superficial vein ligation is performed in many centers to address vein incompetence in patients with chronic venous leg ulcers. Several reports describe good healing and low recurrence rates, although a randomized trial to compare surgical treatment including SEPS and treatment of the superficial venous system to conservative modalities has never been performed. Therefore, a prospective, randomized, multicenter trial was conducted to study whether ambulatory compression therapy with venous surgery is a better treatment than just ambulatory compression therapy in venous leg ulcer patients. METHODS: Patients with an active (open) venous leg ulcer (CEAP C6) qualified for the study. The study consisted of two treatment groups. All patients were treated by standardized ambulatory compression therapy, and half of the patients received SEPS. Concomitant superficial venous incompetence was also treated in the second group. For allocation to both treatment groups, each patient was assigned by a computer program at the randomization center. The primary goal of the study was to compare the ulcer-free period during follow-up in both study groups. Secondary end points were ulcer healing and recurrence rates. RESULTS: From April 1997 until January 2001, 200 ulcerated legs (170 patients) were included in the study in 12 centers in The Netherlands. A total of 97 ulcers were allocated to the surgical group and 103 to the conservative group. Patient characteristics were similar in the two treatment groups at baseline, with the exception of a higher proportion in the conservative group of diabetes mellitus. Healing rates were 83% in the surgical group and 73% in the conservative group (not significant; median time to healing, 27 months). Recurrence rates were the same in both treatment groups (22% surgical vs 23% conservative). During follow-up of a mean of 29 months (median, 27 months) in the surgical group and 26 months (median, 24 months) in the conservative group, we found that in the surgical group, the ulcer-free rate was 72%, whereas in the conservative group this rate was 53% (P = .11; Mann-Whitney test). Patients with recurrent ulceration or medially located ulcers in the surgical group had a longer ulcer-free period than those treated in the conservative group (P = .02 for both). A first-time ulcer and one of the centers also had a positive effect on the ulcer-free period during follow-up (P < .001 and P = .02), independent of the treatment group. Deep vein incompetence did not affect the ulcer-free period. CONCLUSIONS: In conclusion, we suggest that patients with medial and/or recurrent ulceration should receive surgery combined with ambulatory compression therapy. A dedicated center should provide care for those patients.     

Peritoneal dialysis in Hungary

In 1991 the technical conditions and the number of patients receiving peritoneal dialysis were surveyed in the Hungarian nephrology and dialysing units. Not only the number of patients with chronic uraemia (undergoing dialysis + transplantation) is lower in this country as compared to the European average (106 and 236 per one million people, respectively), but also their distribution according to the type of treatment is different. For several years patients under intermittent peritoneal dialysis make up more than 10% of the cases and those under continuous ambulatory peritoneal dialysis less than 2% (in Europe: <2% and 4–43%, respectively). The survey also included the types of solution, disinfection and connecting devices used in peritoneal dialysis, as well as the incidence of peritonitis and the administration of antibiotics. The principles of biocompatibility, the function of interleukin, as well as the effectiveness and the conditions of continuous ambulatory peritoneal dialysis are summarized.