Gallstone ileus. A retrospective study.

Eight patients have been admitted with gallstone ileus (GSI) to the Herning Central Hospital during the period 1960--1977. All of the patients were subjected to enterolithotomy only. One patient died postoperatively. On follow-up examination 6 months to 11 1/2 years after operation, one patient complained of a recurrence of cholecystitis, but refused operation. The other patients had no biliary tract complaints. We still consider, due to the above, that enterolithotomy alone is a sufficient primary procedure, and that only in cases of new biliary tract complaints can cholecystectomy and closure of an eventual fistula be considered.     

The value of sonography in the diagnosis of appendicitis. A prospective study of 100 patients

Between October 1988 and July 1989 100 consecutive patients with suspected appendicitis were seen at the surgical clinic, University Hospital of Aachen. All patients underwent ultrasonographic examination corresponding to a prospective study protocol in order to determine the value of ultrasound for the diagnosis of acute appendicitis. The sonographic findings were correlated with the histologic diagnosis or the clinical course, respectively. We found a sensitivity of 100% for appendiceal mass, of 88% for phlegmonous appendicitis and of 25% for catarrhal appendicitis. The overall sensitivity was 49% and the overall specificity rate was 97%. The overall accuracy rate was 64%. The predictive value of a positive test was 97% and the predictive value of a negative finding was 46%. The morphologic changes during the progress of inflammation of the appendix and their sonographic visualisation were discussed. A differentiated concept was developed to integrate the sonographic findings in the therapeutic decision.     

Spondylodiscitis. A retrospective study of 163 patients

Background and purpose?Spondylodiscitis may be a serious disease due to diagnostic delay and inadequate treatment. There is no consensus on when and how to operate. We therefore retrospectively analyzed the outcome of a large series of patients treated either nonoperatively or surgically.

Patients and methods?Between 1992 and 2000, 163 patients (101 males) were hospitalized due to spondylodiscitis. The mean age was 56 (1–83) years. The infection was located in the cervical spine in 13 patients (8%), in the thoracic spine in 62 patients (38%), at the thoracolumbar junction in 10 patients (6%), and in the lumbo-sacral spine in 78 patients (48%). In 67 patients (41%), no microorganisms were detected. Most of the other patients had Staphylococcus aureus infection (53 patients) and/or Mycobacterium tuberculosis (22 patients). The patients were divided into 3 groups: (A) 70 patients who had nonoperative treatment, (B) 56 patients who underwent posterior decompression alone, and (C) 37 patients who underwent decompression and stabilization.

Results?At 12-month follow-up, nonoperative treatment (A) had failed in 8/70 patients, who had subsequently been operated. 24/56 and 6/37 had been reoperated in groups B and C, respectively. Group A patients had no neurological symptoms. In group B, 11 had neurological deficits and surgery was beneficial for 5 of them; 4 remained unchanged and 2 deteriorated (1 due to cerebral abscess). 11 patients in group C had altered neurogical deficits, which improved in 9 of them. 20 patients had died during the 1-year follow-up, 3 in hospital, directly related with infection.

Interpretation?Nonoperative treatment was effective in nine-tenths of the patients. Decompression alone had high a reoperation rate compared to decompression and internal stabilization.     

Hartmann's procedure. A retrospective study of 86 cases]

The purpose of this retrospective study is to define current indications and results of Hartmann's procedure (H). From 1978 to 1989, 86 H were performed, 52 (60%) as emergency surgery. Indications were: colo-rectal cancer (37): 15 complicated and 22 as an elective procedure, diverticular disease acute or complicated (24), ischemic colitis (10), volvulus of the pelvic colon (5), inflammatory bowel disease (4), colonic perforation (3), traumatic hematoma of the sigmoid mesocolon (1). Fourteen patients died after operation (mean age: 79). There was no death after elective H for cancer. Post-operative complications were numerous: pulmonary (25%), abdominal would sepsis or disruption (21%), rectal strump leakage (14%), the later being harmless due to the associated Mickulicz drainage. Seven patients were reoperated on for necrosis of the colonic stoma. Mean initial hospital stay was 31 days. Restoration of the gastrointestinal continuity was done in 27 cases (37% of the surviving patients, 76% of the diverticular diseases). The authors conclude that for complicated diverticular disease H procedure improves survival without preferable continuity. For cancer, H procedure is permanently compromising gastrointestinal in the elderly to hazardous low anastomosis, and to palliative abdomino-perineal resection.     

Importance of Doppler sonography in urology

There have been major advances in Doppler technology over the last 5 years which are particularly useful in the field of urology. In the early 1980s the clinical significance of Doppler was limited to the diagnosis of testicular torsion and its use was primarily intraoperative. Today, however, new advances, i.e. pulsed Doppler, duplex sonography, and color-coded duplex sonography (angiodynography), have cleared the way for totally new approaches to vascular impotence, renal artery stenosis, renal artery embolus, intratumor flow measurement, and control of renal transplants. These new technical advances will be exemplified in typical pathological states.     

Ultrasound diagnosis in ileus

Unspecific clinical symptoms and negative general X-ray findings from the abdominal region have often been characteristic of early ileus stages and have caused delay in prognosis-enhancing surgery. These early stages can be more reliably identified by means of abdominal sonography. Ileus was detected by means of general abdominal sonography from three of 14 of the authors' own patients from whom negative findings had been recorded by X-ray examinations. Their ileus was eliminated by immediate surgical intervention.     

Economic aspects of ultrasound diagnosis. A retrospective study exemplified by cholecystolithiasis

Cholecystolithiasis is a good example to show the economic effects of using ultrasonography consequently as one of the first diagnostic procedures. In this way it is possible to reduce the examination costs about 50% for the out-patient as well as for the diagnosis during the hospital stay.     

Perforated gastric ulcers. A retrospective study of 32 patients

During the last 6 years the authors have treated 99 patients with perforated peptic ulcers. Sixty-six patients had perforated pyloro-duodenal ulcers, while 32 patients were treated for perforated gastric ulcers, a ratio of 2:1. This article deals with the gastric ulcers treated by a surgical unit in an urban, 600-bed multidisciplinary hospital. The mean age of the patients was 58.7 years. In 71.8 per cent of the patients, the perforation was the first major manifestation of the ulcer disease. Seven patients (21.8%), all in the high-risk group according to the criteria of Boey et al. died. There was no death among the low-risk patient group. Eleven patients, all high-risk, had excision and/or biopsy of the ulcer followed by simple closure; three of these patients died (27.2%). Twenty patients, of whom seven were in the high-risk group, underwent gastrectomy; three deaths occurred (15%). The authors conclude that the underlying general health of the patient is a major determinant of the outcome following gastric ulcer perforation.     

Colonic cancers. A retrospective study of 1122 surgically-treated patients

A retrospective study of 1122 cancers of the colon operated by the same surgical team from 1973 to 1989 makes a number of statements possible: In spite of the improved diagnostic means, 66 (5.8%) only of the cancers were of Dukes' type A. 116 patients had complications, ie. perforation in 9 cases and obstruction in 107, among which 59 were operated within 24 hours. The rate of resection is very high: 93.8%. In 8.1% of all cases the excision was extended because of invasion of neighboring tissues. Curative resection was performed in 844 patients, while surgery was palliative in 278, including 205 excisions. The total operative mortality was 5.8%, sinking to 3.9% for curative surgery. It is as high as 22% in emergent surgery. Since 1981, it has been lower than 1% and only caused by general factors. The survival rate of 557 patients after more than 5 years is 46.6%. This rate was studied according to various parameters (sex, location, features of excision, Dukes' stage, involvement of lymph nodes). Lymph node involvement and Dukes' stage are the only factors having a significant influence on survival. In 90.0% of cases, the long-term death of patients followed up for more than 5 years is caused by hepatic metastases (66.6%), local recurrence (13.3%) or both (20%). The occurrence of local recurrence or hepatic metastases can sometimes be treated by second surgery, which has been performed in 20 patients: 11 hepatic resections with a 26.8% survival at 5 years, and 9 excisions for local recurrence with 12.4% survival at 5 years.     

Continuous venovenous hemofiltration after cardiac surgery. A retrospective study in 16 patients with multiple organ failure]

As intermittent haemodialysis in critically ill patients is often associated with circulatory instability and hypotension, pumped continuous veno-venous haemofiltration (CVVH) has been proposed as an alternative. This technique was used postoperatively in 16 cardiac surgery patients with cardiogenic shock (cardiac index < 2.2 l.min-1.m-2), anuria and multiple organ failure. A mean haemofiltration rate of 0.5 to 1 l.h-1 was used. Average length of treatment was 57 +/- 38 h. Two patients were improved and weaned from CVVH after 96 and 144 h respectively. The other fourteen died. A mean 200 +/- 50 ml of liquid were removed every hour. The technique was well tolerated by the cardiovascular system. The systolic arterial pressure, heart rate and cardiac index remained unchanged. Body weight had decreased by 3 +/- 1 kg after 48 h of use. Similarly, serum creatinine concentration was lowered from 337 +/- 32 mmol.l-1 to 252 +/- 27 mmol.l-1 (p < 0.001). At that time, urea and creatinine clearances were 18 +/- 2 ml.min-1, and 15 +/- 1 ml.min-1 respectively. After 24 h of CVVH, both serum sodium and potassium concentrations had been decreased, from 148 +/- 3 mmol.l-1 to 142 +/- 2 mmol.l-1 (p < 0.001), and from 5.7 +/- 0.3 to 4.2 +/- 0.15 mmol.l-1 (p < 0.001) respectively. In addition, pH increased significantly from 7.13 +/- 0.1 to 7.30 +/- 0.04 (p < 0.001). These results were comparable with these of other authors regarding safety and efficiency of CVVH. The low patient survival rate (12.5%) was due to the severity of cardiac impairment.(ABSTRACT TRUNCATED AT 250 WORDS)     

A method of modeling strangulation ileus]

A method for modeling of strangulation ileus consisting in passing the intestinal loop through a strip of cycle rubber nipple with a diameter of 2 mm, width of 4 mm is suggested. Advantages of the method were confirmed by the findings of angioscopy and morphologic study in ileus modeling in 175 rats. The method suggested permits easy and prompt creation of a standard model of strangulation ileus in rats in all the cases, and study after the nipple transection of the changes characteristic of the postischemic period.     

Colonic involvement in acute pancreatitis. A retrospective study of 16 patients

BACKGROUND: Diagnosis of colonic pathology complicating acute pancreatitis is difficult. Several pathogenetic mechanisms have been proposed. The treatment of choice is resection of the affected segment. Current theories on diagnosis, pathogenesis, and treatment were reviewed. METHOD: Retrospectively, 16 patients with severe acute pancreatitis and colonic complications (1988-2001) were included. Preoperative CT scans and specimens of removed colonic segments were reviewed by a blinded radiologist and pathologist respectively. RESULTS: Sixteen patients underwent partial colectomy for suspected imminent or overt perforation, based on the outer aspect of the colon. Four patients had a macroscopic perforation during surgery. Retroperitoneal spread of the necrotizing process to the colon was seen in all 10 reviewed CT scans. All 14 microscopically examined specimens showed fat necrosis and pericolitis. Of these, 4 had ischemia and 6 showed subserosal hemorrhage. Eight specimens had intact mucosa, submucosa and smooth muscle layers. Eleven patients died. Secondary anastomosis in surviving patients did not induce further mortality. CONCLUSION: Spread of pancreatic enzymes and necrosis is the major cause for colonic pathology in acute pancreatitis. Outside inspection of the colon during surgery is unreliable to detect ischemia or imminent perforation. To prevent colonic complications during follow-up, low-threshold colonic resection seems justified.     

Angiographic staging in renal cell carcinoma. A retrospective study of 96 patients

The International Union Against Cancer (UICC) recommends renal angiography to T-stage renal cell carcinoma. 96 angiograms were reviewed, staged and compared with the histopathologic staging. 55% of renal cell carcinomas were overstaged and 4% were under-staged. We conclude that renal angiography cannot be used for precise preoperative staging of renal cell carcinoma.     

A retrospective group study on post-thymectomy myasthenia gravis]

Retrospective group study on post-thymectomy myasthenia gravis (post-Tm MG) was carried out. Five hundred and twenty-seven resected thymoma cases (133 cases with MG and 394 cases without MG) were collected from 9 hospitals. Post-Tmx MG occurred in 18 out of 394 cases -4.6% of thymoma without MG-, and these 18 patients with post-Tmx MG were investigated retrospectively. As to surgical procedures, the mode of operation, either thymectomy or thymo-thymectomy was not thought to be an important factor in the pathogenesis of post-Tmx MG. These 18 patients could be divided into 7 with early onset and 11 with late onset. In the early onset group, post-Tmx MG occurred within 6 months after the operation, and these 7 patients may have had subclinical MG at the time of the initial operation. In the late onset group, post-Tmx MG was noted in 5 patients when recurrence of the tumor was confirmed, the latest being 11 years after operation. The pathogenesis of post-Tmx MG could not be clarified in the other 6 patients (33.3%). For further evaluation of these 6 cases, a prospective studies with large scale are needed.     

Free radial antebrachial flap. A retrospective study of 48 cases. Practical applications]

The authors have studied 48 chinese forearm free flaps operated since 1982 at St-Louis, Hospital Paris. Analysis of early complications and failures shows that the few problems that occurred seem to involve hemodynamics more than technical problems. The results support the hemodynamic theory about radial forearm free flaps: low-flow flap which contrasts with the wide diameter of the radial artery. This kind of free flap may not support interpositional vein graft for arterial bridging (stasis, distension of the graft then thrombosis), which must be taken into account in the operating procedure. When the radial artery needs to be lengthened, we therefore systematically reduce the risk of thrombosis by re-establishing radial artery outflow for safety: either by distal radial artery anastomosis, or with an arteriovenous shunt.