The European journal of surgery = Acta chirurgica最新文献

Objective: To study the outcome of treating extensive proximal femoral fractures with the long Gamma nail.

Design: Retrospective study, with a minimum follow-up of a year.

Setting: 24 hospitals throughout The Netherlands.

Subjects: 329 patients with primary proximal femoral fractures.

Main outcome measures: Functional results and complications.

Results: 19 patients died in hospital and 6 were lost to follow-up. Of the remaining 304 who were fully documented, 241 (80%) became fully mobile, 59 (19%) moderately mobile, and 4 remained bedridden. 264 patients had no pain, 38 had moderate pain and used oral painkillers, and 2 had severe pain that was difficult to treat. Major technical complications occurred in 17 patients: alignment and locking gave rise to most problems, 4 patients developed deep infections, and 7 patients needed additional measures before the fracture was solid.

Conclusions: The long Gamma nail in the treatment of extensive proximal femoral fractures gave good functional results with acceptable rates of complications and union problems.

Objective: To assess the incidence, natural course, and possible pathogenesis of dysphagia that is not caused by anastomotic stricture, after transhiatal oesophagectomy and gastric tube reconstruction.

Design: Prospective study.

Setting: District teaching hospital, The Netherlands.

Subjects: 22 patients who had transhiatal oesophagectomy and gastric tube reconstruction for cancer.

Main outcome measures: Incidence of dysphagia that is not caused by anastomotic stricture one week after operation, and presence of this functional dysphagia and correlation with vocal cord palsy at 4, 8, 12, and 16 weeks postoperatively.

Results: The incidence of functional dysphagia was 7 out of 22 (32%); it was self-limiting in 5 out of 7 (71%) of the cases and associated with the incidence of vocal cord palsy (p = 0.0006).

Conclusion: Functional dysphagia after transhiatal oesophagectomy occurs frequently, but is self-limiting in most patients. Injury to branches of the recurrent laryngeal nerve is a likely cause.

Objective: To find out which factors predict recurrence of cancer in the remnant after unilateral thyroid lobectomy for patients with papillary cancer.

Design: Retrospective study.

Setting: Teaching hospital, Japan.

Subjects: One hundred thirty-three patients with a clinically solitary papillary thyroid cancer who had unilateral lobectomy for the primary disease between 1966 and 1990 and were followed up for more than 60 months. Twelve patients had developed recurrences in the remnant gland by the time of the second operation and 121 patients had not as judged by a second operation, an ultrasound examination, or by palpation.

Result: The primary tumour size in those who developed recurrences was significantly larger than in those who did not (p < 0.0001), and clinical signs of regional lymph node involvement or distant metastases were also significantly more common (p = 0.006). No patient died of their cancer.

Conclusion: Size of the primary tumour is an important prognostic factor for recurrence of solitary papillary thyroid cancer in the remnant after unilateral lobectomy. Such recurrences are unlikely to be lethal.

Objective: To assess the uptake of hyaluronic acid (HA) as a marker of microvascular damage in a model of hemihepatectomy in pigs having continuous or intermittent vascular inflow occlusion.

Design: Prospective, animal study.

Setting: Laboratory for experimental surgery, University hospital, The Netherlands.

Interventions: Total liver ischaemia was achieved during 90 minutes by continuous (n = 5) or intermittent (n = 5) occlusion of the portal vein and hepatic artery followed by 120 minutes of reperfusion. In a second series of pigs (n = 8) a left hemihepatectomy was added to the protocol.

Main outcome measures: Uptake of exogenous HA was assessed before ischaemia and after 120 minutes of reperfusion, together with the galactose elimination capacity. Plasma activities of aspartate aminotransferase (AST), alanine amino transferase, and lactate dehydrogenase were measured and specimens of liver were obtained for histopathological examination.

Results: HA uptake was slightly reduced after reperfusion in unresected livers compared with uptake before ischaemia. After hemihepatectomy HA uptake after reperfusion was significantly reduced after both continuous and intermittent occlusion, but more HA was taken up after continuous occlusion (p = 0.02). Release of AST after reperfusion was increased only after hemihepatectomy.

Conclusions: Microvascular damage, as assessed by HA uptake capacity, significantly contributed to normothermic ischaemia and reperfusion injury in porcine liver. Vascular inflow occlusion during 90 minutes in combination with hemihepatectomy resulted in less liver damage when vascular occlusion was continuous rather than intermittent.

Objective: To assess the efficacy of transposition of gracilis muscle in the treatment of chronic recurrent fistulas and unhealed perineal wounds after proctectomy in patients with Crohn's disease.

Design: Retrospective study.

Setting: Academic clinic, United States.

Subjects: 7 patients with Crohn's disease: 3 had unhealed perineal wounds and persistent sinuses; 2 had had several attempts to repair rectovaginal fistulas; 1 had a rectourethral fistula; and 1 a pouch vaginal fistula.

Intervention: Transposition of the gracilis muscle.

Main outcome measure: Healing.

Results: Mean follow up was 18 months (range 3-30). All patients operated on for unhealed perineal wounds had healed completely within 3-6 months. The patients with a rectovaginal fistula and a rectourethral fistula had both healed by 1 month postoperatively. Two fistulas recurred, and the small pouch-vaginal fistula remained but was asymptomatic.

Conclusions: Transposition of the gracilis is a viable option for the treatment of persistent sinus and unhealed perineal wound after proctectomy for Crohn's disease. It could also be an option before proctectomy for patients with other types of Crohn's-related or complicated fistulas for whom other treatments have failed. A larger series will be required before a definite conclusion can be drawn.

Objective: To evaluate the prognostic factors for patients with stage III malignant melanoma and to identify patients at high risk of developing recurrent disease who may benefit from adjuvant therapy.

Design: Retrospective study.

Setting: Specialist hospital, USA.

Subjects: 130 patients with stage III malignant melanoma (according to the TNM classification), treated at the Roswell Park Cancer Institute between 1970 and 1992.

Main outcome measures: Survival and prognostic factors on multivariate analysis.

Results: Four factors were independent prognostic indicators for patients with stage III malignant melanoma: age >51 years (p = 0.008), >3 involved lymph nodes, (p = 0.03), the site of the primary tumour on head or trunk, (p = 0.007), and the presence of palpable lymph nodes (p = 0.004).

Conclusion: These prognostic factors help us to stratify patients into low and high-risk groups. High-risk patients may benefit from more aggressive adjuvant therapy in future trials of treatment of melanoma.

Objective: To assess the efficacy of hydrocolloid dressings in wound management after excision of pilonidal sinus.

Design: Prospective randomised trial.

Setting: District hospital, Spain.

Patients: 38 patients with chronic pilonidal sinus.

Interventions: Open excision with healing by second intention. Divided into three groups: conventional gauze dressing (control, n = 15), Comfeel (n = 12) and Varihesive (n = 11).

Main outcome measures: Median healing time, infection rate, intolerance, pain, comfort, ease of management, leakage, and recurrence.

Results: Median healing time was 68 days (range 33-168) in the control group, compared with 65 days (range 40-137) in the two hydrocolloid groups combined. There were no differences between the hydrocolloid groups. There were no recurrences during the 74 months of follow-up. A third of the postoperative cultures in the control group grew pathogens compared with 1/23 of the patients treated with hydrocolloid dressings (p = 0.03). This was of no clinical relevance. 14/23 in the hydrocolloid group developed leaks. Pain was significantly less in the first four postoperative weeks among the patients in the hydrocolloid group than in the control group (p < 0.05).

Conclusions: Hydrocolloid dressings lessen pain and increase comfort for patients after excision of pilonidal sinus, though time to healing is no shorten than when a conventional gauze dressing is used.

Vascular surgery is in a transitional phase. Standard open repair is being replaced by endovascular and minimally invasive techniques. The techniques developed for elective cases are also applicable for injured patients. The introduction of endovascular treatment for emergencies has consequences for both institutional and regional organisation. Success can be achieved only by the prepared team trained with wide elective experience. Endovascular repair of vascular injuries has many advantages, such as remote approach and limited exposure with less surgical stress to the patient. Because the long term effects are only partially known a word of caution is justified. Endovascular repair of vascular trauma is still a developing form of treatment.