The European journal of surgery = Acta chirurgica最新文献

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.

Objective: To report the urological complications after simultaneous renal and pancreatic transplantation.

Design: Retrospective study.

Setting: Teaching hospital, Italy.

Subjects: 143 consecutive patients having simultaneous renal and pancreatic transplantation by one of three techniques. 33 segmental pancreas with duct occlusion, 77 whole pancreas with bladder diversion, and 33 enteric diversion with systemic (n = 26) or portal venous drainage (n = 7). Urological complications were related to the pancreatic transplant, to the renal transplant, or unrelated to the transplant.

Main outcome measures: Morbidity.

Results: After occlusion of the duct and enteric diversion, there were no urological complications related to the pancreatic transplant. On the other hand, among the 77 patients with pancreatic drainage into the bladder, urological complications were common (56/77; 73%). Complications related to the renal transplant were recorded in 6/33 (18%), 26/77 (34%) and 12/33 (36%), respectively. Complications unrelated to the transplant occurred in 6/77 patients (8%) in the bladder drainage group. Five patients after bladder drainage required cystoenteric conversion.

Conclusions: Enteric diversion is a safe alternative to bladder diversion and results in significantly fewer urological complications.

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.

Objective: To record the current standards of management and education in trauma surgery in 12 geographically and socioeconomically diverse countries in Europe.

Design: Questionnaire study.

Setting: Teaching hospital, Austria.

Intervention: Questionnaire sent to experts on trauma in Austria, France, Germany, Italy, The Netherlands, Norway, Portugal, Romania, Spain, Sweden, Turkey, and the United Kingdom.

Main outcome measure: Comparison of management of patients before, during, and after admission to hospital, and opportunities for initial and in-service training.

Results: Management of patients and opportunities for training varied considerably from country to country, ranging from an organised trauma service throughout with specialised training to a haphazard and variable service that depended more on individual hospitals, doctors and patients.

Conclusions: Standardisation of management and training would be desirable, and should be possible at least in countries that are members of the European Union.

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 audit the effect of changes in treatment of inguinal hernias on recurrence rate.

Design: Retrospective analysis of consecutive patients operated on in 1990 and prospective analysis of consecutive patients operated on in 1996. Follow up with questionnaire followed by selective clinical examination.

Setting: County hospital, Sweden.

Subjects: 144 patients with 147 inguinal hernias operated on in 1990 and 154 patients with 165 inguinal hernias operated 1996. on in

Interventions: In 1993, we changed many aspects of the treatment of inguinal hernia. We introduced new techniques such as Shouldice, Lichtenstein, and laparoscopic hernia repair. Non-absorbable polypropylene sutures replaced the braided absorbable sutures previously used. Inguinal herniorrhaphy went from a "low status" operation to a high status operation and became a primary teaching operation for surgical residents.

Main outcome measures: Recurrence rate at 5 year follow up.

Results: The 5 year recurrence rate decreased from 28% in 1990 to 3% in 1996 (p < 0.001). The m edian operating time increased from 35 minutes in 1990 to 78 minutes in 1996 (p < 0.001).

Conclusion: Changing the strategy of inguinal hernia surgery by introducing uniform operating techniques and new materials dramatically improved the results and allowed us to achieve recurrence rates comparable to those seen in specialised hernia centres.

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.

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.

Objective: To evaluate a simple working procedure for recording postoperative complications.

Design: Prospective cohort study.

Setting: Teaching hospital, Denmark.

Subjects: 218 of 312 patients who were operated on from March to July 1996.

Interventions: Follow up 30 days after operation by looking up the local register of complications, review of medical records and by structured telephone interview with the patient.

Main outcome measures: Morbidity.

Results: All the patients were recorded in the local register, showing a complication rate of 21% (n = 49). However the medical record and the telephone interview showed complication rates of 68 (31%) and 76 (33%), respectively.

Conclusion: It is possible to improve the quantity of the recording by a simplified working procedure, while the quality is still a challenge.