The European journal of surgery = Acta chirurgica最新文献

Objective: To compare the effectiveness of medical (antacids, histamine antagonists and proton pump inhibitors) and surgical (fundoplication) treatment of chronic GORD.

Subjects: Patients with objective (endoscopic or pH) evidence of chronic reflux reported in 6 randomised trials and 3 cohort studies, 1966-1999.

Methods: Systematic review of comparative studies identified from electronic searches, citations, manual searches of journals, and correspondence with authors and experts.

Main outcome measures: Improvements in prevalence or severity of symptoms, oesophagitis, pH reflux duration, lower oesophageal sphincter pressure, patients' satisfaction, and side-effects.

Results: Improved outcomes were more common after surgical than medical treatment with significant differences in objective outcomes in 5/6 randomised trials and in 2/3 cohort studies. Subjective outcomes (symptoms and patients' satisfaction) were also more common among surgical patients in all but one study that assessed them. Odds ratios for improvement with surgical rather than medical treatment ranged from 1.2 to 200, and numbers needed to treat ranged from 1.2 to 58, where these could be calculated. Studies were too heterogeneous for meta-analysis.

Conclusions: In trials of chronic severe GORD, surgery is consistently more effective than medical treatment in relieving symptoms and objective oesophagitis, although omeprazole can give similar symptom relief with adjustment of the dose.

Objective: To find out whether intraoperative ultrasound (IOUS) of the liver should still be considered a routine procedure for patients having hepatic resections as their preoperative investigation has become so much better with the standard use of triphasic spiral computed tomograms (CT).

Design: Retrospective study.

Setting: University medical centre, Utrecht, The Netherlands.

Patients: 26 consecutive patients undergoing liver resection.

Main outcome measures: How much additional information was given by IOUS, and its influence on operative strategy; how IOUS facilitated the hepatic resection.

Results: IOUS revealed additional information over triphasic CT in 13/26 patients, which led to a change in the surgical procedure in 4 (15%). For all 4 patients the change in surgical approach proved to be correct as judged by histology and clinical outcome. In 12 patients IOUS facilitated the resection by providing helpful three-dimensional anatomical insight.

Conclusion: Despite recent improvements in preoperative investigation, IOUS should still be recommended as a routine procedure in patients having hepatic resections. In addition to aiding the ultimate decision about which part to resect, it also gives insight into the hepatic anatomy.

Objective: To investigate the role of two approaches to the operative treatment of hepatic hydatid cysts.

Design: Prospective study.

Setting: University and teaching hospital, Turkey.

Subjects: 108 patients with single uncomplicated hydatid cysts who were operated on in two clinics between 1990 and 1995.

Intervention: Introflexion and omentoplasty or external drainage after partial cystectomy in single uncomplicated hydatid cysts more than 5 cm in size.

Main outcome measures: Morbidity, mortality, and hospital stay.

Results: The median hospital stay after introflexion and omentoplasty was 8 days (range 3-15), which was significantly shorter than that after external drainage (12 days, range 7-20). There were 2/35 postoperative complications in the former group compared with 17/73 in the drainage group (p = 0.03). There was one death after introflexion and omentoplasty.

Conclusion: Introflexion and omentoplasty after partial cystectomy for a single uncomplicated hydatid cyst caused significantly fewer complications than external drainage, and patients left hospital sooner.

Objective: To compare the results of stabilising impending and actual pathological femoral fractures using the long Gamma nail with the published results of other methods.

Design: Retrospective study.

Setting: 20 hospitals throughout The Netherlands.

Patients: 101 patients with metastases in 110 femurs, which were stabilised with a long Gamma nail.

Main outcome measures: Functional results and complications.

Results: Minimum follow-up was 1.5 years or until death, Mean survival was 12 months (range 0-82). 14 patients died in hospital; 5 had technical complications and fat embolism was suspected in 3 patients. 92% of the patients became mobile and pain was absent or acceptable in 93%.

Conclusion: The use of the long Gamma nail produces better functional results, fewer technical complications, and an incidence of general complications no different from those reported for other methods.

Objective: To compare outcome of unilateral and bilateral laparoscopic hernia repair.

Design: Prospective consecutive trial.

Setting: University hospital, Sweden.

Subjects: 380 patients who had unilateral hernias repaired laparoscopically and 64 patients who had bilateral hernias repaired. The median (range) age in the two groups was 56 (21-86) and 61 (30-85) years, respectively and the median (range) follow-up was 42 (24-58) months.

Main outcome measures: Operating time, hospital stay, complications, and time to recovery.

Results: The median (range) operating time was 70 (25-240) minutes in the unilateral and in the bilateral group 113 (55-330) minutes. The complication rate, recurrence rate, and time to full recovery did not differ between the groups.

Conclusion: The laparoscopic approach seems to be a good option for patients with bilateral inguinal hernias.

Objective: To compare safety, outcome, and feasibility of laparoscopic assisted and conventional laparotomy for ileocolic resection in Crohn's disease.

Design: Retrospective study.

Setting: Private clinic, USA.

Subjects: 74 patients who had ileocolic resection and anastomosis for Crohn's disease between August 1991 and July 1996, 48 through conventional laparotomy and 26 in whom it was laparoscopically assisted.

Main outcome measures: Age, operating time, duration of hospital stay, early and late morbidity, and patients' subjective assessment.

Results: The mean age was 42 (+/- 17) in the conventional group and 40 (+/- 15) in the laparoscopically assisted group. The mean operating time was significantly shorter in the conventional group, 90.5 +/- 3.7 minutes, compared with 150 +/- 1.2 minutes in the laparoscopic-assisted group (p < 0.0001), but they stayed in hospital significantly longer, 9.6 +/- 0.6 days in the conventional group, compared with 7 +/- 0.8 days in the laparoscopic-assisted group (p < 0.0001). There were no differences between the groups in the incidence of early complications or the cost of admission, but at a mean follow up of 30 months (range 2-59) significantly more patients in the conventional group had developed symptomatic bowel obstruction (15/48 compared with 2/26, p = 0.02). 31 patients in the conventional group (65%) and 16 in the laparoscopically assisted group (62%) returned their subjective assessments. There were no differences between the groups in the number with changed bowel habits, use of drugs for bowel movement, or restricted diet, but patients in the laparoscopically assisted group returned to work more quickly (3.7 +/- 1.2 weeks) compared with 8.2 +/- 1.1 weeks in the conventional group, had better cosmetic results (14/16 compared with 13/31, p = 0.004), and were more likely to have improved social and sexual lives (8/16 compared with 5/31, p = 0.02).

Conclusion: Laparoscopically assisted ileocolic resection for Crohn' s disease is safe and has less morbidity than conventional laparotomy.