61. Hämodynamische Spätergebnisse nach Ligatur der Vena cava inferior

Zusammenfassung 22 Patienten mit tiefer Beinvenenthrombose (DVT) und direkter operativer Ligatur der Vena cava (LIVC) wurden mit Hilfe der Strain Gauge Plethysmographie durchschnittlich 9 Jahre postoperativ nachuntersucht. Acht Patienten (36%) waren symptomfrei, ein Ulcus cruris trat bei vier Patienten (18%) auf. Patienten LIVC ohne frühere DVT wiesen keinen signifikanten Unterschied im venous reflux auf im Vergleich zu Kontrollpersonen. LIVC-Patienten mit DVT zeigten signifikante Unterschiede im venous reflux. Die Spatmorbidität dürfte eher von durchgemachten DVT als von LIVC herrühren.     

Rupture of splanchnic artery aneurysms

The results of surgical therapy for acute ruptured splanchnic artery aneurysms in 6 patients treated at Helsinki University Central Hospital from 1964 to 1984 were analyzed. There were 3 patients with ruptured splenic, 2 with ruptured hepatic and 1 with ruptured superior mesenteric artery aneurysms. The condition remained undiagnosed in all patients preoperatively, and the diagnosis was obtained only at emergency laparotomy performed for severe shock, abdominal pain, and distension. Five of the 6 patients survived, including a pregnant woman, who gave birth to a living baby by ceserean section. The results indicate that immediate, aggressive surgical approach dictated by the clinical condition of the patient affords good survival in patients suffering from acute rupture of splanchnic artery aneurysms.

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Resumen Se analizan los resultados del tratamiento quirúrgico de la ruptura aguda de aneurismas de arterias esplnicas en 6 pacientes manejados en el Hospital Central de la Universidad de Helsinki en el periodo 1964–1984. Se presentaron 3 pacientes con ruptura de aneurismas de la arteria esplénica, 2 de la hepática y 1 de la mesentérica superior. La condición clínica se mantuvo sin diagnóstico durante la fase preoperatoria, y el diagnóstico sólo fue hecho en el curso de la laparotomía, procedimiento que fue realizado por shock severo, dolor abdominal y distensión. Cinco de los 6 pacientes sobrevivieron, incluyendo una mujer embarazada, quien dio a luz un niño vivo mediante sección cesárea. Los resultados indican que el enfoque quirúrgico inicial agresivo indicado por la condición clínica del paciente ofrece una buena oportunidad de supervivencia en pacientes que presentan ruptura de aneurismas de las arterias esplácnicas.

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Résumé Les résultats du traitement chirurgical de 6 ruptures d'anévrysmes des artères splanchniques traités à l'Hôpital Central Universitaire d'Helsinki de 1964 à 1984 sont étudiés par les auteurs. Ils concernent la rupture anévrysmale de 3 artères spléniques, de 2 artères hépatiques, de 1 artère mésentérique. Le diagnostic ne fut porté qu'au moment de l'intervention d'urgence pratiquée en présence d'un état de choc sévère s'accompagnant de douleur et de distension abdominales. Cinq des 6 opérés ont survécu, dont une femme enceinte chez qui une césarienne fut pratiquée avec succès. Ces résultats plaident en faveur de l'action chirurgicale d'urgence.

     

The association between decision-making skills and subjective decision outcomes among administrative officers in the Swedish Social Insurance Agency

Social insurance administrative officers’ decision-making skills influence their efficiency at work and their general well-being. At work their tasks are characterised by complexity and a need for order and accountability. Moreover, cases should usually be handled and finalised within the imposed time frames. We investigated skills related to decision-making success among social insurance officers. In total, 118 administrative officers at the Swedish Social Insurance Agency (66% response rate) responded to questions on scales and measures relating to cognitive-rational, socio-emotional and time approach features of decision-making skill. In addition, they responded to questions on three scales pertaining to outcomes of everyday decisions in terms of subjective everyday difficulties, tendencies to burnout and depressive symptoms. The results showed that cognitive-rational competence was associated with lower reports of subjective everyday difficulties and depressive symptoms and thereby contributed to the explained variance in decision outcomes. Furthermore, socio-emotional and time approach features of decision-making skills contributed to the explanation for subjective everyday difficulties, tendencies to burnout and depressive symptoms. The results corroborate the basic assumption and usefulness of a broad approach in the definition and assessment of decision-making skills in human service professions in general, and of administrative officers in social insurance agencies in particular. Recommendations for future research and the implications of the results are discussed.     

Functional outcome after laparoscopic or open Nissen fundoplication: a follow-up study

OBJECTIVE: To compare the results of open and laparoscopic fundoplication. DESIGN: Nonrandomized controlled study with a 3-year follow-up. PATIENTS AND METHODS: Fifty-seven consecutive patients with erosive reflux esophagitis underwent laparoscopic (30 patients) or open (27 patients) fundoplication. INTERVENTIONS: Interview by an independent person. In addition, 52 patients (91%) underwent postoperative endoscopy, and 38 patients (67%) underwent esophageal 24-hour pH recording. RESULTS: Temporary dysphagia was reported by 20 patients (67%) after laparoscopic and by 11 (41%) after open fundoplication (P = .05). There were no differences between groups concerning incidence of persistent dysphagia (20% vs 18%, respectively) and mild to no reflux symptoms (97% vs 100%, respectively). In addition, bloating (50% vs 63%, respectively) and increased flatus (77% vs 78%, respectively) were equally common. Visual analog scale scores for dysphagia, bloating, and increased flatus were 0.6, 2.4, and 4.3, respectively, in the laparoscopic and 0.6, 3.5, and 3.4, respectively, in the open groups. Normal belching ability was reported by 12 patients (40%) after laparoscopic and by 20 (74%) after open fundoplication (P = .01). Visick grade 1 or 2 was reported by 21 patients (70%) after laparoscopic and by 24 (89%) after open fundoplication (P = .08). Defective fundic wrap was detected in 4 patients (13%) in the laparoscopic and in none in the open group. In addition, abnormal results of 24-hour pH recording were found in 4 patients (22%) after laparoscopic and in 2 (10.5%) after open fundoplication. CONCLUSION: From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia.     

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS: The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs. MATERIAL AND METHODS: 110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model. RESULTS: Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard). CONCLUSIONS: Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.     

Survival and developmental disability in infants with birth weights of 501 to 800 grams, born between 1979 and 1994

OBJECTIVE: Because the survival rate has increased for extremely low birth weight neonates, many have raised the concern that the rate of developmental disability among survivors will also increase. To address this concern, we analyzed changes over time in survival and major neurosensory impairment in a sample of extremely low birth weight infants born between July 1, 1979, and June 30, 1994. METHODS: The study sample included 513 infants with birth weights of 501 to 800 g who were cared for in either of the two neonatal intensive care units that serve a 17-county region in northwest North Carolina and who were born to mothers residing in that region. At 1 year of age (corrected for gestation), survivors were examined by a pediatrician and were tested using the Bayley Scales of Infant Development. Major neurosensory impairment was defined as cerebral palsy, a Bayley Mental Developmental Index <68, or blindness. A total of 209/216 (97%) of survivors were examined at 1 year of age. Epoch of birth was defined as follows: epoch 1, July 1, 1979 to June 30, 1984; epoch 2, July 1, 1984 to June 30, 1989; and epoch 3, July 1, 1989 to June 30, 1994. RESULTS: Survival rates for epochs 1, 2, and 3 were, respectively, 24/120 (20%), 63/175 (36%), and 129/218 (59%). In contrast, the proportions with a major neurosensory impairment did not increase over time; rates for successive epochs were 6/24 (25%), 17/61 (28%), and 26/124 (21%). Rates of cerebral palsy were 3/24 (13%), 12/61 (20%), and 9/124 (7%); rates of delayed mental development were 4/24 (17%), 12/61 (20%), and 17/124 (14%); and rates of blindness were 2/24 (8%), 0/62, and 5/124 (4%), respectively. CONCLUSIONS: This analysis suggests that the increasing survival of extremely low birth weight neonates since the late 1970s has not resulted in an increased rate of major developmental problems identifiable at 1 year of age.