The European journal of surgery = Acta chirurgica最新文献

Objective: To compare our results of open and laparoscopic mesh repair of incisional hernias.

Design: Retrospective cohort study.

Setting: Teaching hospitals, The Netherlands.

Subjects: All patients who had had a laparoscopic (n = 25) or an open (n = 76) mesh repair of incisional hernia between January 1996 and January 2000.

Interventions: Physical examination at the time of the study.

Main outcome measures: Morbidity and recurrence.

Results: The groups were comparable. 11 patients (14%) developed postoperative infections after open repair and 1 (4%) after laparoscopic repair (p = 0.29). Median hospital stay was 5 days (range 1-19) in the open group and 4 (range 1-11) in the laparoscopic group (p = 0.28). The 2-year cumulative incidence of recurrence was 18% after open repair (median follow-up of 17 months (range 1-46) and 15% after laparoscopic repair (median follow-up of 15 months, range 1-44). Recurrences in the laparoscopic group were all among the first 7 cases in which the mesh was fixed with staples alone.

Conclusion: There were fewer infections and hospital stay was shorter in the laparoscopic group, but not significantly so. Recurrence rates were comparable.

Aberrant cutaneous scar formation is a substantial cause of postoperative morbidity. There is at present no clear consensus on the best way to prevent or treat such scarring, although recently there has been considerable progress in developing an understanding of the mechanisms of tissue repair and scarring. We carried out a literature review using Medline to establish the current understanding of the key events occurring during tissue repair and to identify potential causes of scarring. We now review the key events during tissue repair and the pathogenesis of fibroproliferative disease. Tissue repair is achieved through a multistranded, elegantly coordinated process within which the balance between synthesis and breakdown of matrix is upset during fibrotic disease. Scars form because the signals directing tissue repair are not correctly terminated, and while the initiation and propagation of repair is well understood the signals that direct its cessation have yet to be elucidated.

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 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 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 104.7/10(5) and the incidence of amputation from 10.2 to 24.8/10(5). 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.