European Journal of Surgery最新文献

Objective: To find out the incidence of cholecystectomy and of reintervention after cholecystectomy in Sweden 1987 to 1995, and to compare mortality and reintervention after simple laparoscopic and conventional open cholecystectomy (without exploration of the common bile duct or simultaneous operation).

Design: Analysis of data from Swedish national registers.

Setting: Two hospitals and government department, Sweden.

Main outcome measures: Mortality and reintervention during readmission within one year after cholecystectomy classified as: reoperation on bile duct, endoscopic or percutaneous reintervention, or reoperation for wound complication, bleeding, or unspecified cause.

Results: Incidence of cholecystectomy rose between 1987–89 and 1993–95 from 0.97 to 1.04 for men and from 1.70 to 2.05 operations/1000 inhabitants for women. Reoperation on the bile ducts declined from 1987 to 1991 but returned to previous levels thereafter. Endoscopic reinterventions increased tenfold from 1987 to 1995, whereas those for general complications and mortality did not change significantly. Among simple cholecystectomies laparoscopic surgery was associated with an increased risk of endoscopic reintervention, odds ratio 1.8 (95% CI 1.2 to 2.6), and with a lower risk for postoperative mortality, odds ratio 0.5 (95% CI 0.3 to 0.8).

Conclusions: Incidence, mortality, and readmission with reintervention are important endpoints in gallbladder surgery. Significant changes in these variables were identified after the introduction of laparoscopic cholecystectomy.

Objective: To investigate the effects of the tyrosine kinase inhibitor tyrphostin AG 556 on the course of acute necrotising pancreatitis in rats.

Design: Laboratory study.

Setting: Medical school, Turkey.

Animals: 72 Sprague Dawley rats, 12 in the sham operated (control) group and 20 in each of the three others.

Main outcome measures: Cardiorespiratory measurements, mortality, effect on the activities of various enzymes in serum and tissue of pancreas and lung, and the histological picture.

Results: The four study groups were sham + Ringer's lactate, acute necrotising pancreatitis with Ringer's lactate, tryphostin AG 556, and dimethylsulfoxide (DMSO). There were 12 animals in the first group and 20 in each of the other groups. The induction of pancreatitis increased mortality from 0/12 in the control to 6/20 (30%), 7/20 (35%), 8/20 (40%) in the three experimental groups, respectively. Heart rate, packed cell volume (PCV), serum activities of amylase and alanine aspartate transferase, tissue activity of myeloperoxidase (MPO) and malondialdehyde (MDA) in the pancreas and lung, serum concentrations of urea and calcium, volume of ascites, degree of pancreatic damage, blood pressure, and urine production did no differ between the pancreatitis groups.

Conclusions: Treatment with the tyrphostin kinase inhibitor did not improve the course of acute pancreatitis or reduce the extent of acinar cell injury and is therefore unlikely to be of benefit in patients with pancreatitis.

Objectives: To assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct stones in the preoperative investigation of patients electively referred for gallstone disease, to find out the incidence of asymptomatic common duct stones, and to correlate clinical symptoms and history and liver function tests (LFT) with the actual occurrence of common duct stones.

Design: Prospective study.

Setting: General hospital, Denmark.

Patients: 180 consecutive non-jaundiced patients referred with symptomatic gallstones for elective cholecystectomy.

Interventions: LFT, abdominal ultrasonography, MRCP, endoscopic retrograde cholangiopancreatography (ERCP), questionnaire.

Main outcome measures: Positive and negative predictive values and accuracy of MRCP, number of patients with asymptomatic stones, and correlation of symptoms with the presence of stones.

Results: 26/180 patients had common duct stones (14%). Only one (<1%) had an asymptomatic stone. For detection of such stones, MRCP's positive predictive value was 0.95 (95% confidence interval (CI): 0.86 to 1.00), negative predictive value 0.96 (0.93 to 0.99), and accuracy 0.85 (0.93 to 0.99). MRCP missed 5 stones 11 mm in size in 5 patients; 17/64 patients with raised LFTs had stones (27%). The probability of stones was highest when the patients had both raised LFTs and a dilated common (>7 mm) bile duct (82%). There were no readmissions with ductal stones in the 6-month postoperative period.

Conclusions: The predicive values of MRCP were fairly good, but MRCP misses some small stones <5 mm in size. Asymptomatic stones in the common duct are not common in this population and should not be screened for. The probability of stones increases with the number of predictive factors. Patients should be questioned carefully about signs of biliary obstruction, and only be offered preoperative MRCP should they have a suspicious history, raised LFTs, or a dilated common duct.

Objective: To find out if drugs, position, and endoscopic manipulation during endoscopic retrograde cholangiopancreatography (ERCP) influence the changes in the variability of heart rate.

Design: Single-blind randomised trial.

Subjects: 10 volunteers given butyscopolamine, glucagon, or saline intravenously on three different study days, and 10 patients who had ERCP without butylscopolamine or glucagon.

Main outcome measures: Holter tape analysis for ischaemia and changes in the variability of heart rate.

Results: 5 volunteers developed tachycardia after butylscopolamine, while 2 developed tachycardia after glucagon. During ERCP 9 patients developed tachycardia, and 2 developed myocardial ischaemia. Vagal tone decreased in the volunteers after butylscopolamine, but no changes were seen after glucagon or placebo, or in patients during ERCP.

Conclusions: Butylscopolamine reduced vagal tone in volunteers. Patients who were having ERCP without butylscopolamine had a stable vagal tone. The previously observed reduced vagal tone during ERCP may therefore be primarily the result of giving butylscopolamine.

Objective: To assess the outcome of the surgical treatment of patients who had adrenalectomy for phaeochromocytoma.

Design: Retrospective clinical study.

Settings: University hospital, Germany.

Subjects: 87 consecutive patients with phaeochromocytoma who were operated on.

Interventions: 29 flank and 58 transabdominal adrenalectomies between 1974 and 2000.

Results: The mean tumour diameter was 5 cm (range 2–13), and the mean weight 91 g (range 7–550). The postoperative hospital stay was 11 days. The flank incision entailed the shortest operating time (95 minutes). Two of the phaeochromocytomas were malignant. There were two wound infections but no deaths. With a correct selection of patients, a flank incision is safe. Endoscopic retroperitoneal adrenalectomies should be preferred.

Objective: To identify risk factors for severe hypocalcaemia after surgery for primary hyperparathyroidism.

Design: Retrospective study followed by a prospective study.

Setting: University hospital, Denmark.

Patients: 340 consecutive patients, operated on from 1991 to 1999, and 85 consecutive patients operated on in 2000.

Main outcome measures: Predictive value of identified risk factors.

Results: Incisional biopsy or excision of more than 2 parathyroid glands, thyroid operation together with parathyroidectomy, preoperative serum concentration of parathyroid hormone of more than 25 pmol/L, or a history of previous operations on the neck, were identified retrospectively as risk factors for severe postoperative hypocalcaemia. In the prospective study these factors showed a sensitivity of 100% (9/9), and a specificity of 25% (9/36). We found no risk of severe hypocalcaemia after parathyroidectomy in patients without these risk factors. The risk increased to 37% (7/19) if serum concentration of parathyroid hormone was more than 25 pmol/L, or if thyroidectomy was done together with parathyroidectomy.

Conclusions: Patients with no risk factors for severe hypocalcaemia can be discharged early from hospital. Special attention should be given to patients with one or more risk factors for severe hypocalcaemia.