European Journal of Surgery最新文献

Objective: To investigate the mechanisms and anatomical failures after total laparoscopic fundoplication using the symptoms and findings at reoperation.

Design: Prospective open study.

Setting: University hospital, Sweden.

Patients: Twenty-one patients who were reoperated on a median of 33 (0.5–102) months after laparoscopic fundoplication.

Interventions: The patients were divided into three groups according to the mode of presentation. The first group presented with dysphagia and no gastro-oesophageal reflux (GOR) (n = 6). The second group (n = 11) had recurrent GOR and the third group (n = 4) complained of a sense of excessive fullness.

Results: In the dysphagia group the reason for it in 4 patients was severe fibrosis in the hiatal region including the right part of the fundoplication. One patient had correctly located fundoplication but it was too tight. In the last patient the part of the stomach used was too low down. All patients in the GOR group had a slippage and rupture of the fundoplication. Ten patients also had a recurrent hernia. In 6/11 patients the fundal mobilisation was incomplete. In the last group (excessive fullness) one patient had a postoperative leak from the fundal part, one patient a para-oesophageal hernia, and one patient an intact but herniated repair. One further patient had an intact abdominal oesophagus and crural repair, but a large portion of the stomach had herniated through the left part of the fundoplication and acted as a volvulus.

Conclusions: Dysphagia was caused by hiatal fibrosis or other technical failures rather than a normal tight fundoplication. Using the wrong part of the stomach causes recurrent heartburn. The laparoscopic suturing technique must be improved.

Objective: To find out whether there is any benefit from venous resection during pancreaticoduodenectomy for ductal pancreatic adenocarcinoma.

Design: Retrospective study.

Setting: University Hospital Mannheim/Heidelberg, Germany.

Interventions: 271 patients had resections for ductal adenocarcinoma of the pancreatic head between 1980 and 2001. The outcome of patients who did (n = 68) and who did not (n = 203) have simultaneous resection of major veins (portal vein and/or superior mesenteric vein) were compared.

Main outcome measurement: 5 year survival.

Results: The groups differed significantly regarding stage, perineural infiltration, lymphangiosis carcinomatosa, operating time, blood loss, and blood transfusion. However, there was no difference in perioperative morbidity (27% and 22%), mortality (4% and 3%), and long-term survival (at 5 years 23% and 24%). Subgroup analysis of patients with margins free of tumour (R0 resections) showed that those patients who had venous resections in whom histological examination did not show infiltration of tumour had the most favourable outcome.

Conclusion: There is no reason to exclude patients with suspected venous infiltration from radical pancreaticoduodenectomy including venous resection.

Objective: To find out how injections of botulinum A toxin influence the healing of anal fissures.

Design: Retrospective study.

Setting: Medical University of Lodz, Poland.

Subjects: 13 patients (6 women, 7 men), mean age 49 (range 31–78), treated with injections of botulinum A toxin 50 units on either side of the anal fissure into the internal anal sphincter from May to December 1999.

Main outcome measures: Complications and relapse.

Results: Seven fissures had healed by one month and four by two months. Two remained unhealed but asymptomatic. There was no incontinence of flatus or faeces after three months of treatment. Resting anal pressure was significantly lower in 10 of 13 patients compared with before treatment (p < 0.05). One fissure relapsed after 4 months and this patient had a successful anal stretch.

Conclusion: Injection of botulinum A toxin gives good results in the treatment of anal fissures.

Objective: To investigate the relationship between five-year control of reflux and early postoperative oesophageal function after total fundoplication done either laparoscopically or through a laparotomy in severe and mild reflux disease.

Design: Prospective open study.

Setting: University hospital, Sweden.

Patients: In the group with severe disease 9 patients had a laparotomy and 7 laparoscopy. The corresponding figures for the group with mild disease were 21 and 34 respectively.

Results: The increase in lower oesophageal sphincter pressure 6 months after operation in patients with recurrent disease was significantly less than that for patients with good reflux control (p < 0.01). In patients who had laparotomy, including 30% (9/30) with severe reflux disease, good long-term reflux control was found in 93% (27/29). In patients operated on laparoscopically including 17% (7/41) with severe reflux disease good long-term reflux control was found in 90% (35/39).

Conclusion: The mechanism of recurrence differed between patients with severe disease who had a laparotomy and patients with mild disease operated on laparoscopically. Early postoperative manometry was prognostic for recurrence. Long-term reflux control seems to be similar after laparotomy and laparoscopy. Further randomised studies are needed.

Objective: To evaluate regional differences in the use of a vascular surgical service in the treatment of critical lower limb ischaemia and incidence of amputation in the 1990s in a well-defined geographical area.

Design: Retrospective study.

Setting: One university and five county hospitals, Finland.

Subjects: All referrals to the university hospital vascular surgical unit for chronic critical lower limb ischaemia and the number of major amputations in the region.

Main outcome measures: Numbers of new vascular surgical consultations and amputations in 11 municipalities. Correlation between numbers of consultations and amputations.

Results: Between the subregions the age-standardised incidence of new vascular surgical consultations in the 15–85 year old population varied from 52.4 to 104.7/10⁵ and the incidence of amputation from 10.2 to 24.8/10⁵. There was an inverse correlation between the numbers of consultations and amputations. The most significant inverse correlation was between consultations and below knee amputations in diabetic patients (r = −0.70). For above knee amputations there was no correlation (r = −0.21).

Conclusion: An active referral policy leads to reduced amputation rates.

Objective: To find out if early closure of a defunctioning small bowel stoma (day 10) was feasible and safe.

Design: Prospective non-randomised study.

Setting: University hospital, France.

Interventions: During a 42-month period (January 1998-June 2001), all patients with a temporary small bowel stoma were elected for early closure on postoperative day 10 in a non-randomised prospective study. The procedure was considered only if the patient was not taking steroids, was in good condition, and had not developed wound or general sepsis after the initial operation. Other patients' stomas were closed after the usually recommended delay (>8 weeks).

Main outcome measures: Postoperative complications, delay to recover bowel activity, and to resume oral feeding, and duration of hospital stay.

Results: Thirty-six patients were included in the study: 14 patients in the early group and 22 in the delayed group. There were no postoperative deaths. Three patients developed wound abscesses, two in the early group and one in the delayed group. The median (range) duration of hospital stay was longer in the delayed group: 36 (14–84) days, than in the early group: 22 (18–29) days (p < 0.01).

Conclusions: Small bowel stomas can be closed in selected healthy patients on postoperative day 10 without major complications.

In recent times gastric carcinoid tumours have become the subject of substantial clinical interest as knowledge of their biological background and clinical importance has increased Gastric carcinoid tumours have long been considered rare lesions, amounting to less than 2% of all carcinoid tumours and less than 1% of all stomach neoplasms. New large databases suggest that the prevalence of gastric carcinoid is rising, with a true value now closer to 5% of all carcinoids. A tripartite classification system for gastric carcinoid tumours is now in common use: tumours associated with chronic atrophic gastritis; tumours associated with Zollinger-Ellison syndrome; and sporadic lesions. Gastric carcinoids associated with hypergastrinaemia are relatively benign, while sporadic lesions require aggressive surgical management. Gastric carcinoids, however, can be managed initially by endoscopic excision of accessible tumours, followed by regular endoscopic surveillance.