Acta chirurgica Scandinavica最新文献

The effect of low molecular weight (LMW) heparin given once daily as prophylaxis against venous thrombosis was compared with that of dextran 70 in an open randomised trial of 100 patients undergoing elective total hip replacement. Four patients were withdrawn after randomisation and thus 96 were included in the final analysis. The development of thrombus was surveilled by the 125I fibrinogen test, and positive readings were verified by venography. Nine of 47 patients given LMW heparin developed thromboses (19%) compared with 18 of 49 given dextran (37%) (p = 0.09). Two further patients who received LMW heparin developed thromboses after leaving hospital (clinical signs became apparent on days 13 and 17, respectively), giving an overall rate of thrombosis in this group of 23%. Minor wound haematomas occurred in two of 47 in the LMW heparin group and three of 49 in the dextran group (4% and 6%, respectively), and blood loss, transfusion requirements, and reduction in postoperative haemoglobin concentration did not differ between the two groups. The studied LMW heparin given subcutaneously once a day was no less safe or effective than dextran in preventing thromboembolism after total hip replacement.

Sixty-four patients undergoing elective operations for cancer of the colon and rectum were given mechanical bowel preparation in the form of whole gut irrigation with polyethylene glycol electrolyte solution. When their colonic cleansing scores were compared, it was found that the preparation was significantly less effective in the left colon (n = 49) than in the right (n = 15), the mean (SEM) scores being 3.8 (0.56) and 2.65 (1.01), respectively, p less than 0.001. We then compared the scores of 26 patients with stenosing lesions with those of 38 that were not: in the right colon the score for stenosing tumours was 3.9 (0.14) compared with 3.8 (0.25) for non-stenosing tumours. In the left colon, however, they were 2.3 (0.23) and 2.9 (0.18), respectively (p less than 0.01). We conclude that stenosis of the colon caused by malignant lesions reduces the efficacy of mechanical bowel preparation with polyethylene glycol electrolyte solution in the left colon but not in the right colon.

Two cases of abdominal tuberculosis complicated by portal hypertension are reported. Both presented with haematemesis, melaena, night sweats, anorexia and weight loss. Tuberculous lymph nodes at the porta hepatis compressed the portal vein in one case, and the other had disseminated tuberculosis involving the liver and spleen. The mechanism of such portal hypertension is discussed.

We report 4 patients who presented with occult blood loss, from a small bowel adenocarcinoma, in whom there was considerable delay in diagnosis. The difficulty in diagnosis and the role of CT scanning is discussed. We recommend a careful laparotomy when endoscopic and radiological investigations fail to reveal the source of blood loss.

Fatal pneumococcal bacteremia, disseminated intravascular coagulation and Waterhouse Friderichsen syndrome in a vaccinated, splenectomized adult were caused by serotype 22F (Danish classification), which was not included in the vaccine. Revaccination with a 23-valent pneumococcal vaccine and antibiotic prophylaxis are advocated for patients who have undergone splenectomy.

The possible association of pancreatitis with primary sclerosing cholangitis was studied in 17 patients. At endoscopic retrograde cholangiopancreatography (ERCP) four patients (24%) were found to have pancreatic changes in addition. The secretin test was abnormal in one patient, who also had morphological signs of pancreatitis at ERCP. One patient had raised basal serum concentrations of amylase and lipase, and another had decreased pancreatic amylase; these two patients had normal findings on ERCP and normal secretin tests. The findings suggest that pancreatic changes are present in a proportion of patients with primary sclerosing cholangitis despite the lack of clinical suspicion of pancreatitis. The pancreatic damage, however, seems to be confined to alterations in ductal morphology rather than including functional impairment.

Two cases of small-bowel infarction preoperatively diagnosed with 99mTc-HMPAO labelled leucocyte imaging are reported. Uptake in the affected gut was positive in images recorded after only 30 min, which is helpful for early diagnosis and therapeutic strategy.

A prospective, randomized trial of adjuvant portal infusion of 5-fluorouracil in combination with mitomycin C was conducted on 469 patients with operable colorectal cancer. A single postoperative course of the cytotoxic agents was compared with radical surgery alone. The actuarial 5-year survival (median follow-up 48 months) was 70 +/- 3% in the chemotherapy group and 57 +/- 4% in the control group (p = 0.10). The respective figures for disease-free survival were 62 +/- 4% and 53 +/- 4% (p = 0.09). Among the 195 cases with strict adherence to the protocol for adjuvant chemotherapy there were 59 recurrences and 44 deaths in the follow-up period, whereas in the 274 with no or incomplete chemotherapy there were 120 recurrences and 99 deaths (p less than 0.05). Perioperative adjuvant chemotherapy via portal infusion proved to be feasible in a multicenter setting. Follow-up will be continued, in order to provide definitive information on survival according to randomization.

A primary conservative approach was used in treatment of 42 patients with 45 external small-bowel fistulas. Closure of fistula was achieved in 29 patients but failed in 13 (10 died and 3 discharged with open fistula). There was no time-related improvement in closure rate or mortality, probably because of a general shift towards more serious cases. To evaluate this concept more specifically, groups of simple (19) or complicated (23) fistula were distinguished. The 23 patients with complicated fistula were more severely ill, had more sepsis, e.g. intra-abdominal abscess, and were more often treated in the intensive care unit (p less than 0.01) than the 19 with simple fistula. The respective mortality rates were 7/23 and 3/19. All six patients who died of sepsis had complicated fistula. Mortality in the simple fistula group was related to the primary disease. Especially in cases of complicated fistula, further improvements in management of septic complications should be aimed for, to permit success in delayed definitive surgery.