Annales chirurgiae et gynaecologiae最新文献

Background and aims: Displacement of internally fixed femoral neck fractures due to implant migration is a common problem. This in vitro study was performed to compare maximum torque and holding power for five different implants.

Material and methods: Synthetic porous material with low, medium or high density was used to simulate cancellous bone. The tested implants included three conventional screws (AO, Olmed, Hansson), one screw with threads and a barb (Hybrid), and a pin with a hook (LIH).

Results: The Hansson screw provided higher maximum torque in low and medium density blocks when compared with the other implants (p < 0.0001) followed by LIH, Hybrid, Olmed, and AO. For high-density blocks there was no significant difference between Hansson and Hybrid screws, both with significantly higher torque than the other implants. The maximal pullout in low-density blocks differed significantly between all five implants with the Hansson screw providing the highest holding power. For medium and high-density blocks the conventional screws had significantly higher pullout resistance compared with the Hybrid and LIH.

Conclusion: The in vitro model used seemed to provide reproducible and clinically relevant results. There was a good correlation between material density and holding power for all implants. Screws inserted without predrilling provided higher maximal torque while maximal pull out load seemed less affected by predrilling being used or not.

Due to their borderline location between the stomach and esophagus the optimal surgical strategy for patients with adenocarcinoma of the esophagogastric junction is controversial. Irrespective of the surgical approach a complete removal of the primary tumor and its lymphatic drainage has to be the primary goal of surgical treatment of such tumors. Based on the experience with surgical resection of more than 1000 patients with adenocarcinoma of the esophagogastric junction we recommend an individualized surgical strategy guided by tumor stage and topographic location of the tumor center or tumor mass. This requires detailed preoperative staging and classification of tumors arising in the vicinity of the esophagogastric junction into adenocarcinoma of the distal esophagus (AEG Type I Tumors), true carcinoma of the gastric cardia (AEG Type II Tumors) and subcardial gastric carcinoma infiltrating the esophagogastric junction (AEG Type III Tumors). In patients with Type I Tumors transthoracic esophagectomy offers no survival benefit over radical transmediastinal esophagectomy, but is associated with higher morbidity. In patients with Type II or Type III tumors an extended total gastrectomy results in equal or superior survival and less postoperative mortality than a more extended esophagogastrectomy. In patients with early tumors, staged as uT1 on preoperative endosonography, a limited resection of the proximal stomach, cardia and distal esophagus with interposition of a pedicled isoperistaltic jejunal segment allows a complete tumor removal with adequate lymphadenectomy and offers excellent functional results. Multimodal treatment protocols with neoadjuvant chemotherapy or combined radiochemotherapy followed by surgical resection appear to markedly improve the prognosis in patients with locally advanced tumors who respond to preoperative treatment. With this tailored approach extensive preoperative staging becomes mandatory for an adequate selection of the appropriate therapeutic concept.

Background and aims: To evaluate the incidence of conduction defects (CDs) following coronary artery bypass grafting (CABG) in three different patient populations, to assess the etiologic factors associated with CDs, and to find out their effect on immediate postoperative outcome of the patient.

Material and methods: Three patient populations were prospectively studied: cohort A consisted of 180 CABG-patients operated between 1990-91, cohort B of 100 patients operated during the year 1993 and cohort C of 118 patients operated from April 1997 to June 1997. Cold crystalloid cardioplegia was used throughout the study years. In the first cohort A, two separate cavae were cannulated and clamped, venting through the right upper pulmonary vein was used, iced cold saline was used in pericardium, and cardioplegia was given until a myocardial temperature of 10-15 degrees of Celcius was attained. In the two later cohorts, two-stage venous cannula and aortic root venting were used and cardioplegia was given only until the activity of the myocardium stopped. Proximal anastomoses were performed after aortic declamping in cohort A, and during aortic occlusion in the two later cohorts.

Results: The incidence of permanent CDs in cohort A was 36%, in cohort B 5% and in cohort C 1%. Permanent atrioventricular (AV-) and left-sided blocks disappeared first. Left main coronary artery stenosis and low myocardial temperatures were associated with CDs. Patients with permanent CDs had more often low cardiac output after the operation, their values of cardiac enzymes were higher, and they had more often postoperative infarction than patients without CDs.

Conclusions: The disappearance of all long lasting AV- and left-sided blocks simultaneously with decreasing plasma levels of cardiac enzymes is evidence that protection of both conduction tissue and myocardium had considerably improved in the two later cohorts. Giving cardioplegia in smaller amounts and more often at the same time when raising the general temperature during perfusion were the main reasons for the disappearance of postoperative CDs.

Background and aims: Intraoperative femoral fractures are a serious complication of total hip replacement. The purpose of this study was to evaluate the risk factors of intraoperative femoral fractures in a retrospective analysis of a series of 3,566 total hip replacements.

Materials and methods: The patients were divided into two groups, A and B. Group A patients had no intraoperative femoral fractures and Group B patients had intraoperative femoral fractures. In Group A there were 3,483 patients (97.7%) and in Group B, 83 (2.3%). The following potential risk factors were evaluated: sex, age, diagnosis, previous surgery at the homolateral hip, surgical approach, fixation type of the femoral component, prosthesis type, surgical stage during which the fracture occurred, and the lead operating surgeon.

Results: The fracture incidence was higher in females (p < 0.005) in uncemented femoral components (p = 0.005), in patients who had previous surgery at the homolateral hip (p < 0.005), and in revision surgery (p < 0.005).

Conclusion: The analysis of intraoperative femoral fracture risk factors should allow the surgeon to improve the surgical performance and therefore reduce the incidence of this severe intraoperative complication.

Background and aims: Relatively many patients with chronic critical limb ischaemia (CLI) have oedema in the afflicted limb. Previous studies in these patients indicate derangement in the Starling forces governing transcapillary fluid balance. An impaired veno-arteriolar reflex (VAR) may cause an increase in capillary pressure and hence increased filtration pressure resulting in oedema. The aim of the present study was to investigate VAR in patients with CLI to come to a better understanding of the pathogenesis of ischaemic oedema.

Material and methods: Sixteen patients (mean age of 78+/-9.4 years) with unilateral CLI and oedema were included. There were two control groups of similar age, one consisted of 8 patients with unilateral CLI but without oedema and the other of 9 healthy subjects. Laser Doppler fluxmeters were used to evaluate the foot skin microcirculation, with the limbs in supine as well as in the dependent position, simultaneously in 4 different areas: the pulp of the first toe (Sitel), at the level of the second metatarsal body (Site 2), at the anterolateral part of ankle (Site 3) and the pulp of the first toe of the contralateral limb (Site 4) as reference. Laser Doppler flux (LDF) values (expressed in perfusion unit, PU) were recorded with the foot dependent (PUd), in the horizontal position (PUh), and the orthostatic response (OR) was calculated at all measuring sites as PUd/PUh.

Results: In none of the measured sites there was a significant difference in OR between the limbs with CLI and oedema and the limbs with CLI but without oedema. The median OR of CLI limbs at site 1 [2.5 (0.61-8.96)] was greater than at sites 2 [0.99 (0.46-2.38), p < 0.01] and 3 [0.95 (0.68-10.31), p < 0.04] respectively, while the differences in OR between site 2 and 3 were not significant. The median OR in the limbs of healthy controls at sites 1, 2 and 3 were 0.58 (0.37-1.43), 0.54 (0.28-1.33) and 0.51 (0.34-0.91), respectively. There were no significant differences in OR between sites 1, 2 and 3 of the control group. The OR of CLI at site 1, 2 and 3 were significantly greater than the corresponding sites in the healthy subjects (p < 0.001, p < 0.008, p < 0.001).

Conclusions: The VAR is disturbed in limbs with CLI, both in the ones with and without oedema. There were regional differences in the OR in these ischaemic feet but there were no differences in OR between those with and without oedema. Thus, disturbances in VAR may play a role in the development of ischaemic oedema, but is probably not the only causative factor.

Background and aims: The use of antibiotic prophylaxis in open reduction and osteosynthesis of closed hip fractures is still controversial. The aim of this study was to demonstrate the effect of antibiotic prophylaxis in osteosynthesis of these fractures.

Material and methods: A total of 224 patients operated on between November 1994 and February 1998 in six hospitals by internal fixation for a fresh hip fracture were prospectively and randomly allocated to either a ceftriaxone antibiotic prophylaxis or no prophylaxis group and followed for one year.

Results: Within 6 weeks after the operation, 2.6% wound infections were recorded in the antibiotic group and 4.7% in the control group. Two (1.9%) of the five infections in the control group were deep infections (both sensitive to ceftriaxone). There were no statistically significant differences between the infection rates in both groups. However, when analyzing all complications recorded within 6 weeks, significantly more complications were found in the control group (p < 0.01). In the multivariate analysis the most important factor predicting postoperative complications was the lack of antibiotic prophylaxis.

Conclusion: In this study the antibiotic prophylaxis group had significantly less postoperative complications than the control group within 6 weeks after the operation.

Background and aims: Preoperative diagnosis of blunt diaphragamatic rupture is difficult and missed injuries can lead to severe late complications. The aim of this study was to assess the value and reliability of initial chest radiographs in diagnosing blunt diaphragmatic rupture.

Material and methods: A retrospective analysis of initial radiographs of 18 patients with blunt diaphragmatic rupture treated at two Greek Trauma Centers was performed. The chest radiograph was the primary diagnostic radiological tool in all of cases, and the findings were confirmed at operation in all cases.

Results: The preoperative diagnosis of blunt diaphragmatic rupture on the basis of chest radiographs was made in 16 out 18 patients (89%). The presence of air-containing viscera and an elevated nasogastric tube above the level of the left hemidiaphragm were the most specific signs. Although elevation of the hemidiaphragm was seen in all 18 cases, it is non-specific. A marked elevation of the right hemidiaphragm (more than 6 cm above the level of the left diaphragm), however, was a strong sign of right diaphragmatic rupture.

Conclusions: In spite of the availability of newer diagnostic imaging techniques, the initial chest radiograph is very reliable in detecting most cases with blunt diaphragmatic rupture, and together with high index of suspicion and sound clinical assessment remain the cornerstone in diagnosing these challenging injuries.

Background and aims: Computed tomography (CT) is still widely used in the staging of patients with carcinoma of the oesophagus. The aim of the study was to evaluate the diagnostic accuracy of CT in a series of patients with carcinoma of the oesophagus or the cardia. Results were compared with findings at surgery or autopsy.

Material and methods: 47 consecutive patients of whom 30 underwent operation while 17 patients were not candidates for surgery due to advanced disease.

Results: Demonstration of tumour invasion on CT in 30 patients who underwent operation had an accuracy of 63%, a nosographic sensitivity of 10% and a specificity of 90%. Diagnosis of metastases to abdominal lymph nodes had an accuracy of 57%, and a nosographic sensitivity and specificity of respectively 37% and 90%. The assessment of tumour invasion and metastases to lymph nodes in patients not candidates for surgery was expectedly more accurate (100 and 67%, respectively, in nine autopsies).

Conclusion: CT may provide valuable information in pretherapeutic staging of oesophageal cancer by identifying patients with advanced disease, who are not candidates for surgery. In patients without signs of dissemination on CT additional information may be obtained from endoscopic ultrasonography and laparoscopy.