The European journal of surgery = Acta chirurgica最新文献

Objective: To investigate anorectal manometric findings in patients with haemorrhoids and to evaluate the clinical effects and physiological consequences of adding a lateral internal sphincterotomy (LIS) to haemorrhoidectomy.

Design: Randomised prospective study.

Setting: Teaching hospital, Naples.

Patients: 48 consecutive patients with prolapsed piles who had anorectal manometry; 10 healthy volunteers served as controls.

Interventions: Resting and squeeze pressures, sphincter length and rectoanal inhibitory reflex were recorded. 6 patients were excluded because anal pressures were not raised, so 42 patients were randomised. 22 patients had haemorrhoidectomy plus LIS; and 20 had haemorrhoidectomy alone.

Main outcome measures: Morbidity, continence, and anorectal manometry.

Results: Sphincter anomalies were found in 87.5% (n = 42) of patients. Haemorrhoidectomy alone did not affect anal pressures, which returned to the normal ranges after sphincterotomy. Those who had LIS did better postoperatively than those who had did not. 4 patients who did not have a sphincterotomy developed anal strictures. No patient who had LIS developed incontinence of faeces.

Conclusions: High anal pressures are common in patients with haemorrhoids suggesting that they may have a pathogenetic role; anorectal manometry is useful in the investigation of anal pressure patterns; and when indicated, lateral sphincterotomy avoids pain, urinary retention, and stenosis, and is safe.

Objective: To present our experience of cardiac injuries treated at one Swedish emergency department in the 10 years 1988-97.

Design: Retrospective study.

Setting: Teaching hospital.

Subjects: 11 patients (9 men and 2 women, mean age 33 years, range 19-54); in 7 they were penetrating injuries and in 4 blunt.

Main outcome measures: Morbidity and mortality.

Results: The mechanisms of injury were stab wound (n = 7), and car crash, fall, boat crash, and abuse (n = 1 each); drug or alcohol misuse played a part in all those with penetrating injuries. The penetrating wounds involved the left ventricle (n = 3), the right ventricle (n = 2), and the pericardium (n = 2). All 5 patients with ventricular wounds presented with cardiac tamponade, in 1 of whom it was fatal (he bled to death during emergency thoracotomy). The main complications were anoxic brain damage and postpericardiotomy syndrome (1 each). There was no case of myocardial concussion.

Conclusion: Our data reflect the Swedish experience of heart trauma: there are few cases, alcohol and drug misuse is the principal risk factor, and there were no gunshot wounds.

Objective: To find out whether we could manage critical pulmonary haemorrhages in penetrating injuries, and to report our experience with blunt trauma of the lung.

Design: Retrospective study.

Setting: Teaching hospital, Sweden.

Subjects: 81 patients who presented with pulmonary injuries during the period January 1988-December 1997; 6 were penetrating and 75 blunt.

Results: There was only one patient with an isolated lung contusion. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. We correlated grade of lung injury [American Association for the Surgery of Trauma-Abbreviated Injury Scale (AIS)] with mortality. All patients with penetrating injuries survived without serious consequences. There were a mean (SD), of 6 (2) injuries/patient in those with extrathoracic injuries compared with 3 (1) injuries/patient in the group with thoracic lesions (p < 0.001). The corresponding hospital mortality was 6/42 (19%) mainly as a result of the central nervous system lesions (4/6) compared with 0/32. The mean (SD) Injury Severity Score (ISS) was 9.3 (4.8) in patients with thoracic lesions compared with 24.1 (14.7) in patients with extrathoracic lesions (p < 0.0001), and 14.9 (9.5) in all survivors compared with 49.9 (13.6) among those who died (p < 0.0001).

Conclusions: An excellent outcome can be achieved managing penetrating injuries of the lung by an aggressive approach and urgent surgical intervention even when emergency room thoracotomy is essential. Pulmonary contusion is considered to be a relatively benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma. These data may help to decrease the obsession with pulmonary contusion in patients with chest trauma, with or without extrathoracic lesions, and avoid many unnecessary computed tomograms of the chest.

Objective: To study the prognostic factors in patients with differentiated thyroid carcinoma.

Design: Retrospective analysis.

Setting: University hospital, Germany.

Patients: 139 consecutive patients who underwent surgery for follicular (n = 42) and papillary thyroid carcinoma (n = 97).

Main outcome measures: Survival rate, type of operation (systematic lymphadenectomy or no lymphadenectomy).

Results: Median observation time was 72 months (range 1-203). The 5 and 10 year survival rates in patients with papillary carcinoma were 92% and 89% respectively, and in those with follicular carcinoma 88% and 80%, respectively. Prognostic factors for papillary carcinoma were distant metastases, age, and extrathyroidal growth, and for follicular carcinoma they were distant metastases, extrathyroidal extension, and multifocal growth. The Union International contre le Cancer and European Organisation for Research and Treatment of Cancer scores and the age, grade, extent and size score were all highly significant. The extent of lymphadenectomy, primary or secondary thyroidectomy, and partial or total thyroidectomy did not influence survival.

Conclusion: Staging and score systems may be helpful in calculating prognosis in differentiated thyroid carcinoma, but the benefit of systematic lymphadenectomy remains controversial.

Objective: To assess the results of open management of the abdomen and planned re-operations in severe bacterial peritonitis after perforation or anastomotic disruption of the digestive tract.

Design: Retrospective study.

Setting: University Hospital, The Netherlands.

Subjects: 67 consecutive patients.

Interventions: Open management of the abdomen and planned reoperations.

Main outcome measures: Hospital morbidity and mortality, long-term follow-up.

Results: 38 patients developed multiple organ failure (MOF), but 29 needed only ventilatory and inotropic support. The mean number of re-operations was nine. 16 patients developed severe bleeding and 16 fistulas. In-hospital mortality was 42% (n = 28). Long-term morbidity, particularly the number of abdominal wall defects (n = 10), was considerable.

Conclusion: Despite open management of the abdomen and planned re-operations, mortality of severe bacterial peritonitis still continues to be too high, and both short and long-term morbidity are appreciable. The value of open management of the abdomen and planned re-operations rests only on the clinical observation that other conventional surgical treatments of severe bacterial peritonitis often fail.

Objective: To design and implement a hospital trauma registry so as to be able to monitor the care of injured patients.

Setting: Teaching hospital, Greece.

Subjects: All patients admitted with trauma from January 1997.

Main outcome measures: Design of a suitable form, establishment of inclusion and exclusion criteria, injury severity scoring, finding money and personnel, and getting suitable computer hardware and software for reliable collection and analysis of data.

Results: We experienced great difficulty in getting funding, so were unable to employ dedicated staff to collect the data, though we have had a part-time secretary to coordinate the registry whose salary has been paid by a pharmaceutical company. We have to rely on junior doctors to collect the data, which works well when they are enthusiastic (though not all are). We decided to use the data collection form used by the UK Trauma Network. We are trying to collect sufficient data to code severity by more than one system, but at present this is causing problems because busy nurses and doctors do not like filling in forms. Software has also been a problem as most of it is in English and translation is a considerable workload. The calculations are still being done manually while we work with two computer programmers to develop our own. We have submitted a research protocol to the Ministry of Health which has been accepted and this will guarantee our expenses for the next two years.

Conclusions: Implementing a philosophy of continuous quality improvement is never easy, and we expect funding to be a permanent source of anxiety. Our progress so far has been good, but not as good as we hoped; however, we are optimistic that as people see the value of continuous monitoring of the system they will become more enthusiastic and supportive.

Objective: To report our experience in patients with anaplastic thyroid carcinoma and try to establish differences between cases in which the histological study showed that there was an associated thyroid carcinoma and those that were strictly anaplastic or pure.

Design: Retrospective study.

Setting: University hospital, Spain.

Subjects: 14 patients with anaplastic thyroid cancer treated over a period of 26 years; 7 presented with associated thyroid tumours and 7 were pure.

Mean outcome measures: Clinical data (age, sex, symptoms), treatment, histological study (associated thyroid disease, spread, involved lymph nodes) and follow-up.

Results: 13 of the 14 tumours had spread locally. 5 patients were treated by total thyroidectomy, 3 subtotal thyroidectomy, 5 excision of the tumour, and 1 patient had a biopsy alone. There were associated thyroid tumours in 7 cases: 2 follicular, 2 tall cell papillary, 1 solid papillary, 1 medullary and 1 Hurthle cell tumour. 12 patients died. Another 2 are still alive having survived 61 and 70 months respectively, both with associated anaplastic cancers (follicular and solid). The mean survival was 14 months (24 for associated anaplastic carcinoma and 4 for pure anaplastic carcinoma).

Conclusion: There is a subgroup of anaplastic cancers in which a better differentiated thyroid carcinoma coexists with the anaplastic carcinoma. The prognosis in this subgroup is better than that for primary pure anaplastic carcinoma.