The European journal of surgery = Acta chirurgica最新文献

Objective: To standardise a direct method for measuring intra-abdominal pressure (IAP), to correlate the results with intrarectal pressure, and to compare the results in various conditions.

Design: Prospective open study.

Setting: Teaching hospital, Egypt.

Subjects: 34 Subjects in 4 groups: control (n = 11), hernia (n = 8; 6 umbilical and 2 incisional), mass (n = 7; 6 enlarged spleen and 1 carcinoma of sigmoid), and obese (n = 8; a mean of 40% above expected weight).

Interventions: Measurement of IAP with a Verres needle connected to a pressure transducer with the patient at rest, straining, supine, erect, and before and after anaesthesia. Intrarectal pressure was measured simultaneously.

Main outcome measures: Reproducibility and correlation between the two measurements.

Results: The hernia group had significantly lower IAP than controls both at rest and on straining (mean (SD) 2.7 (1.5) cm H2O compared with 7.0 (5.09) and 6.1 (2.7) compared with 20.5 (7.9), p < 0.01 in each case). Neither the mass nor the obese group differed from the controls at rest, but the pressure was higher on straining (31.2 (1.4) and 33.5 (2.07) cm H2O, respectively, compared with 21.9 (7.3), p < 0.05 in each case). There was a significant drop in IAP after anaesthesia in all groups, and no significant difference between intrarectal pressure and IAP in any group.

Conclusion: The method of measuring IAP is reproducible. Intrarectal pressure is similar to IAP and can therefore be used instead of it.

Objective: To evaluate the effect of albendazole combined with surgery on the incidence of recurrent hydatid disease.

Design: Prospective open study.

Setting: Teaching hospital, Turkey.

Subjects: 25 patients who presented with hepatic hydatid disease between December 1992 and October 1995.

Interventions: Albendazole 10 mg/kg/day for a month before ultrasonography and then excision, and then albendazole for a further two months.

Results: 2 patients were excluded because the albendazole caused disturbance of liver enzyme activities. Of the remaining 23 patients only 7 had viable cysts on ultrasonography. In 15 patients (65%) the germinal layer was partially or totally destroyed, and in 15 the fluid was either cloudy or stained with bile. During a mean follow up period of 29 months only one patient developed recurrent disease.

Conclusion: Perioperative treatment with albendazole resulted in fewer recurrences than expected. A longer preoperative period of treatment may increase the success rate; this requires further study.

Objective: To assess the value of covering colostomy for patients undergoing low anterior resection for rectal neoplasms.

Design: Prospective randomised study.

Setting: Two university hospitals, Finland.

Subjects: 38 patients with air-tight stapled end-to-end anastomoses and complete anastomotic tissue rings were randomly allocated to have a covering colostomy (n = 19) or not.

Main outcome measures: Postoperative mortality, anastomotic leaks, reoperations for leaks.

Results: The clinical leak rate was 24% (9/38) and six patients (16%) had radiological leaks. The total number of leaks (clinical and radiological together) was similar in the two groups, 7/19 compared with 8/19, respectively. There were fewer clinical leaks in the colostomy group (3/19; 16% compared with 6/19; 32%), but the difference was not significant. Reoperations for leaks were necessary more often in patients who did not have a covering colostomy (6/19; 32% compared with 1/19; 5%, p = 0.09). Two patients who did not have a stoma died from the infective complications of their leaks and one died of heart failure in the colostomy group. One patient who had not been given a stoma initially was left with a permanent colostomy after a leak.

Conclusions: Our results suggest that a covering colostomy does not reduce the leak rate after low anterior resection, but prevents most of the severe infective consequences of the leaks.

Objective: To report our experience of early thymectomy in patients with myasthenia gravis.

Design: Retrospective study.

Setting: University department of surgery, Greece.

Subjects: 76 Patients with myasthenia gravis.

Interventions: Transcervical thymectomy in all cases, additional left thoracotomy in four cases.

Main outcome measures: Mortality, morbidity, and early (6 months) and late (mean follow-up 4.8 years) response to thymectomy.

Results: 20 Patients had thymomas (26%). There was no postoperative mortality; morbidity was 11% (n = 8). There was complete remission in 19 (25%), improvement in 49 (65%) no change in 7 (9%), and impairment in 1 (1%) of the patients at 6 months. Patients who had had symptoms for less than 5 years (p < 0.001), were in an earlier stage of disease (p = 0.006), and who did not have thymomas (p = 0.006) responded better. 3 Patients died of invasive thymoma at 2 1/2, 3, and 5 1/2 years postoperatively and 25/76 (33%) were lost to follow-up. Of the 51 patients available for late follow-up, 19 (37%) were in remission, in 26 (51%) the symptoms had improved, 3 (6%) were unchanged, and 3 (6%) had died of the disease.

Conclusions: Transcervical thymectomy should be considered in patients with early myasthenia gravis.

Objective: To assess the accuracy of preoperative localisation of abnormal parathyroid glands in patients with primary hyperparathyroidism by comparing results of echography and 201thallium and (99m)technetium subtraction scans with the operative findings.

Design: Retrospective study.

Setting: Teaching hospital, Taiwan.

Subjects: 84 Patients with primary hyperparathyroidism, 83 of whom had bilateral exploration of the neck and thymus and one mediastinotomy. Seventy-three patients (69 with adenomas and 4 with hyperplasia) had high-resolution echography and 56 (52 with adenomas and 4 with hyperplasia) had 210Tl/99mTc subtraction scans.

Main outcome measures: Results of follow-up.

Results: 78 Patients had parathyroid adenomas and 6 had hyperplasia. Parathyroid echography had a sensitivity (> or = 0.5 cm) of 55%, a specificity (< 0.5 cm) of 100%, a positive predictive value of 90%, and an accuracy of 77%. 210Tl/99mTc subtraction scanning had a sensitivity (> or = 0.5 cm) of 70%, a specificity (< 0.5 cm) of 100%, a positive predictive value of 100%, and an accuracy of 86%. The double tracer scan was slightly but not significantly more accurate than echography (p = 0.09). There were few postoperative complications except for transient hypocalcaemia, which usually lasted less than two weeks. All but one of the operations was successful. That one developed permanent hypocalcaemia, but it might have been caused by previous thyroid surgery and parathyroid injury.

Conclusion: To increase the success rate of parathyroid surgery, we recommend preoperative localisation with 210Tl/99mTc subtraction scan instead of echography, and routine bilateral exploration of the neck and thymus.

To assess the developments in the prognosis and treatment of patients with primary gastric non-Hodgkin's lymphoma we reviewed 178 papers in English, German, and French on the subject that were listed on MEDLINE between January 1974 and April 1995. We analysed the results of 3157 patients, and during that period the overall survival increased from 37% to 87%. Overall survival by Ann Arbor stage was 57%. 998/1296 (77%) for stage IE, 231/330 (70%) for stage II1E, 107/290 (37%) for stage II2E, 53/172 (31%) for stage IIIE, and 122/451 (27%) for stage IV. Over half the publications recommended resection alone. Only 12 (15%) thought that radiotherapy or chemotherapy, alone or in combination, was adequate. The results of all treatments were similar in 1296 patients with stage IE disease. For stage IIE-IVE disease, however, 66 (82%) of authors suggested a treatment protocol that included resection, and of these 39 (49%) recommended a combination of resection, local radiotherapy, and systemic chemotherapy. The number of patients reported was too small for us to be able to give precise recommendations for treatment of gastric non-Hodgkin's lymphoma, and we have been able to give only an evaluation of current treatments.

Objective: To examine the effect of different temperatures and exposure times in interstitial laser thermotherapy.

Design: Controlled laboratory study.

Setting: University hospital, Sweden.

Material: 48 male Wistar FU rats with dimethylhydrazine-induced adenocarcinoma transplanted into the liver.

Intervention: Treatment was given with an Nd:YAG laser and a feedback system for temperature regulation. Light was delivered into the centre of the tumour and the feedback thermistor probe was placed 3 mm from the tumour margin. Rats were treated at steady-state temperatures at the feedback thermistor of 43, 46, or 50 degrees C for 30 minutes, and at a steady-state temperature of 46 degrees C at the feedback thermistor also for 10 and 20 minutes.

Main outcome measurement: Tumour control as assessed 6 days after treatment using light microscopical examination including immunohistochemical determination of bromodeoxyuridine (BrdU) incorporation into DNA as a measure of cell viability.

Results: Complete tumour necrosis was achieved in all rats treated for 30 minutes, in 6/8 rats treated for 10 minutes and in 6/8 rats treated for 20 minutes at 46 degrees C. During steady-state thermotherapy, temperatures at the tumour margin were about 11 degrees higher than at the feedback thermistor (range 54-61 degrees C). The surrounding liver tissue also became necrotic so that the total necrosis volume exceeded the pretreatment tumour volume.

Conclusion: Interstitial laser thermotherapy at temperatures ranging from 54-61 degrees C at the tumour margin ensures total necrosis of a transplanted rat liver carcinoma provided that treatment is given for 30 minutes.