Acta chirurgica Scandinavica最新文献

Vascular injury is a rare complication of anterior dislocation of the shoulder joint. Two cases, both in elderly persons (65 and 74 years) were treated in our Department during a 5-year period. Atherosclerotic changes of the axillary artery and previous shoulder dislocation are predisposing factors for such injury.

Ten patients had their large bowel continuity restored (5 after Hartmann resection and 5 after defunctioning left colostomy) by an improved, essentially aseptic, stapling technique with the premium CEEA stapler. There were no deaths and no complications.

In seven patients with high-volume enterocutaneous fistula following gastric surgery, a new method of treatment was used. Fibrin tissue adhesive was applied transintestinally under endoscopic guidance, in one or multiple sessions, to occlude the anastomotic dehiscence and the perianastomotic cavity. Fistula output diminished rapidly in all cases, and complete closure was endoscopically confirmed. There were no complications related to the method. Because of the simplicity and safety of this procedure compared with the complexity of surgical treatment and the persistently high mortality associated with conservative management, interventional endoscopic approach is suggested as an option for treatment of high-volume alimentary fistula.

The repair of recurrent inguinal hernias can be a complex problem. This study examines the results of 52 difficult recurrent inguinal hernias repaired with an expanded PTFE patch. Patients were selected because the hernia had either multiple defects, a single large defect that could only be repaired with excessive tension, or the surrounding tissues were unable to support a sutured repair. The number of previous hernia repairs ranged from 1 to 7 with a mean of 2.5 repairs. Hernias recurred in 5 patients (10%) after a mean follow up of almost 2 years. Three of these recurrences were inguinal, around the patch, and 2 were through the femoral canal. There was no association between postoperative wound complications and hernia recurrence.

To establish the degree of oedema after thromboembolectomy ad modum Fogarty, leg volume changes were recorded daily in 56 patients. Significant increase was found in the volume of the ipsilateral leg, maximally 12.9 +/- 12% after c. 1 week. The swelling was significantly greater if the popliteal artery had been explored than if it had not. The volume increase was weakly correlated to the duration of ischaemia, but this could be explained by higher incidence of below-knee incisions in patients with longer preoperative ischaemia. Compartment syndrome occurred in one case. The outcome of the operation correlated to leg volume changes on postoperative day 1, but not significantly to the maximal volume increase. It is suggested that the early volume changes represent increased microvascular permeability, and that to this relatively modest oedema is in some cases later added more severe swelling due to impairment of the lymphatic outflow.

Between 1971 and 1986 532 proximal gastric vagotomies were carried out at the Pelgulinna Hospital. The five-year recurrence rate was 5.5% (n = 29). We have studied 40 patients with chronic duodenal ulceration, 20 patients who had effective proximal gastric vagotomy, and seven patients who presented with recurrent ulcers after proximal gastric vagotomy. Patients who had positive Hollander tests after vagotomy, and those with disorders of gastric motility, were excluded. In the group with recurrent ulcers the concentration of neutral mucopolysaccharides in the gastric juice was significantly lower than in the other two groups, and it correlated with the amount of material showing a positive reaction to periodic acid Schiff (PAS) in the gastric mucosa. This group also had significantly higher mean serum gastrin concentrations and mast cell degranulation rates in the mucosa of the fundus and the antrum. We conclude that qualitative changes in the production of gastric mucus lead to defective functioning of the mucosal barrier in patients with recurrent ulcers and may be one of the causes of recurrences.

A latex-agglutination test (Rapi-Tex) was used for semiquantitative estimation of myoglobin concentration in 89 serum samples obtained from ten patients undergoing lower-limb arterial embolectomy. Each serum sample was tested with Rapi-Tex both undiluted and after 1:50 dilution with saline. The myoglobin concentration was additionally measured with enzyme-immunoassay. In the undiluted samples there were five 'false negative' Rapi-Tex results--two in the myoglobin concentration interval 0-300 micrograms and three in the samples with myoglobin exceeding 25,000 micrograms/l--and four 'false positive' results. None of the diluted samples gave rise to false classification. Using 1:50 diluted serum, the negative predictive value of the Rapi-Tex test for identification of a myoglobin concentration greater than 5,000 micrograms/l was 0.99 (95% confidence limits 0.94-1.00), and the positive predictive value was 1.00 (0.61-1.00). Rapi-tex is concluded to be a useful emergency test for severe hypermyoglobinemia.

An approximately steady state of bacterial density intraperitoneally has been observed in bacterial peritonitis. This state, which follows an initial (0-4 h) phase of rapid elimination of bacteria, was now studied in a model of porcine peritonitis. Twelve pigs were intra-abdominally infected with 10(10) CFU each of Escherichia coli and Bacteroides fragilis. Six of the pigs received no antibiotic and six were given two doses of fosfomycin (anti-aerobic), 1 g i.v., with the aim of disturbing possible equilibrium between rapid proliferation and destruction of the sensitive E. coli. Levels of fosfomycin up to 90 times the minimum inhibitory concentration (1 mg/l) were detected in the peritoneal exudate, but the antibiotic had no discernible effect on E. coli density or elimination pattern compared with B. fragilis in the same pig or with observations in controls. The results favoured the concept of slow-replicating E. coli and hence declining activity of the defence mechanisms a few hours after the induction of peritonitis.

The results of diagnostic imaging procedures, macroscopic and microscopic findings and clinical follow up data of 20 mucinous cystic neoplasms of the pancreas were retrospectively reviewed to determine the grade of malignancy and its surgical implications. The largest mean diameter was 8.9 cm for 10 malignant cases, 5.0 cm for two premalignant cases, and 3.1 cm for eight benign tumours. Ultrasonography or computed tomography or both, corresponded well with macroscopy. The 10 malignant and two premalignant lesions had intracystic mural nodules or extracystic solid components, while the eight benign specimens had neither nodules nor solid portions. Structural complexity seen on ultrasonography or computed tomography, which reflected the irregularity in size and shape of the cysts, internal septa, walls, and solid components, was severe in the 10 malignant and two borderline tumours and mild or moderate in the eight benign lesions. Angiography showed that five of the nine malignant tumours were hypervascular, while the two premalignant and four benign lesions were all avascular. Five of 10 patients with malignant tumours died of local recurrence or remote hematogenous metastases, and one with malignant disease was still alive with liver metastases at the time of writing. We propose that a careful preoperative estimate of the malignant potential of such cysts should be made based on the size of the tumour, the presence of mural nodules and solid areas, and the structural complexity on ultrasonography or computed tomography, as well as the amount of vascularity seen on angiography. Attention should be paid at follow up to the presence of local recurrence and haematogenous metastases in cases of malignant disease.