Annales chirurgiae et gynaecologiae最新文献

Background and aims: Axillofemoral bypass has been used since the 1960's in poor-risk patients with aortoiliac atherosclerotic occlusive disease to improve arterial circulation in the lower extremities. This article describes the outcome of 84 consecutive operations in our hospital.

Material and methods: During the period 1.1.1985-31.5.1996, 84 axillofemoral bypass operations were performed in our hospital. In this retrospective study, information was based on patient records and clinical follow-up examination for surviving patients living in the area of Kuopio province and operated before the end of 1995. Patencies and survivals were established using the life table method.

Results: The primary patency rate was 81.1 % at one year, 64.3 % at three years and 56.7 % at five years. The secondary patency rates were 92.1%, 67.1% and 57.7 %, respectively. The operative mortality rate was 6.0%. Eighty-five percent of the patients were alive one year after the operation, compared to 50 % after five years. Serious complications were rare, but local wound complications occurred in 29 %. Vascular reoperations were needed in 29 %, particularly thrombectomies.

Conclusions: Axillofemoral bypass gives acceptable results in the treatment of lower leg ischaemia in elderly poor-risk patients.

Background and aims: Anal fistula surgery is associated with considerable morbidity, mainly related to anal incontinence. As promising results of the use of fibrin glue in the treatment of complex anal fistulas were recently shown, we planned to do a randomized trial comparing the use of fibrin glue and surgery in the treatment of perianal fistulas. There were no reports of the use of fibrin glue in the management of previously untreated anal fistulas.

Material and methods: Prior to the planned study a pretrial pilot series of 10 patients with different perianal fistulas were treated. Informed consent was obtained from every patient. Under spinal anesthesia, the fistula track was identified and brushed to remove granulous tissue, then washed with hydrogen peroxide and thereafter filled with fibrin glue.

Results: We performed fibrin gluing on 10 patients with perianal fistulas of different etiology and type. The gluing was done once to 7 patients, twice to 2 and three times to one patient. In all but one patient the fistula and symptoms recurred after only one month. One patient with a low trans-sphincteric fistula of which the internal opening was not found, was symptom-free for 6 months. At the one-month follow-up visit the external opening of the fistula was almost unidentifiable, suggesting that the fistula had healed. However, due to recurrence fistulotomy was performed after 6 months.

Conclusions: Fistulas around the anus, with or without associated inflammatory bowel disease, do not seem to heal after fibrin gluing.

Background and aims: Clostridial gas gangrene is one of the most dreaded infections in surgery. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and especially the role of hyperbaric oxygen in the management of clostridial gas gangrene.

Material and methods: 53 patients, 42 of them submitted from other hospitals in Finland. After the diagnosis had been made the patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen (HBO) treatments at 2.5 ATA pressure. The necrotic tissue was excised and incisions were made in the affected areas. Amputations were performed when necessary.

Results: Twelve patients died (22.6%). Hyperbaric oxygen therapy decreased the systemic toxicity and prevented further extension of the infection thereby improving the overall outcome of the patients.

Conclusion: Hyperbaric oxygen therapy of gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy applied promptly. Surgical and antibiotic therapy as well as HBO treatment combined with surgical intensive care must be started as soon as possible.

This paper is confined to the use of human musculoskeletal tissue in the treatment of patients. Its focus is on the safety and quality dimension of human tissue transplantation, including the ethical and legal aspects, the regulations and standards from the European perspective, quality assurance and quality management in tissue banking and as a special subject, tissue sterilisation and the validation of sterilisation methods.

The review paper discusses the conditions for obtaining in vivo a composite from a synthetic, inorganic material and collagen fibres. Bone itself is a composite containing collagen fibres and hydroxoapatite crystals. The crystal size is, however, far smaller than can be made using conventional methods of ceramics technology. The paper discusses therefore the possibilities to synthesize the apatite in a gel. The requirements of initial load bearing can be met by forming the gel on the surface of glass particle, sintered to a porous body. In the pores calcium ions react with the gel to form (= SiO)Ca+ complexes. When the phosphate concentration in the pore is high enough to exceed the solubility product of apatite, the calcium-gel complexes release the calcium and highly dispersed apatite crystallites are precipitated in the gel. These give the gel the osteoconductive properties observed for bioactive glasses. Glass compositions, which give a gel surface enough hydrated to form calcium complexes, are discussed.

Background and aims: Among men, hip fracture is the most common outcome of osteoporosis. The aim of this study was to investigate the clinical characteristics, treatment, complications, short-term outcome and mortality of male hip fracture patients.

Material and methods: Operation theatre logs of all hip fracture patients operated on (1124 patients) at Kuopio University Hospital in 1989-1993 were reviewed. Medical records of the 276 male patients who underwent surgery (25 % of all patients) were studied.

Results and conclusions: 233 hip fractures (86 %) in men were due to low energy trauma. Of these cases, 61 % of the fractures occurred at the femoral neck, 31 % were pertrochanteric and 8 % subtrochanteric. The vast majority (90 %) of these patients had some chronic medical condition, and in 66 % the condition influenced motory or sensory functions. Hemiarthroplasty was most often used for femoral neck fractures (64 %). Internal fixation was used for pertrochanteric (97 %) and subtrochanteric (94 %) fractures. 20 % of the men had post-operative complications during the 1.5 year follow-up. During primary hospitalisation mortality was 3 %. Within 1.5 years of the fracture 40 % of the men had died, resulting in a mortality three times higher than age matched Finnish male population.

Background and aims: The purpose of this study was to evaluate the use of bioabsorbable implants in proximal tibia cancellous bone fixations in 28 patients.

Patients and methods: The implants used were self-reinforced polyglycolide (SR-PGA) or self-reinforced polylactide (SR-PLLA) screws or rods. In six patients a high tibial osteotomy and in 16 patients a proximal tibial plateau fracture were secured with these implants (cancellous bone fixations). In addition, four anterior tibial eminence avulsion fractures and two tibial tuberosity avulsions were fixed (avulsion fractures). The average follow-up time was 3.6 years.

Result and conclusions: In the cancellous bone fixations (15 patients at the follow-up) there were three excellent clinical results, five good, five moderate and two poor results; radiologically there were one excellent result, eight good, five moderate, and one poor result. In the avulsion fracture patients (four patients at the follow-up) there were two excellent and two good clinical results; radiologically all results were excellent. In four cancellous bone fixations redisplacement was noted. In all patients the functional score was 25.6/30 (Rasmussen 1973). The bioabsorbable implants can be used for fixation of proximal tibial cancellous bone osteotomies and fractures and avulsion fractures with good or moderate results.

Background and aims: This retrospective study clarifies the prognosis of surgically treated lung cancer in a teaching university hospital.

Material and methods: During a four year period 141 patients were operated for lung cancer in a teaching university hospital. After five years follow up the case records were analysed. The operative and microscopical findings were classified using the AJC pTNM staging system and WHO's histologic classification of lung tumours. There were 120 (85 %) male and 21 (15 %) female. The median age for males was 62 years and females 64 years; range was 29 to 76 years for both sexes.

Results and conclusions: The perioperative mortality of all patients was 5,0 %, of 84 patients operated with lobectomy 2.4 %, of 32 patients operated with pneumectomy 15,6 %, and of 25 patients operated with explorative thoracotomy 0 %, respectively. The five year survival of all patients was 33 % including perioperative mortality. The survival was significantly better for 83 patients with stage I disease (49 %) than 17 stage II (6 %), 24 stage IIIa (20.8 %), and 17 stage IIIb or IV disease (0 %). The survival was significantly better after lobectomy (44.1 %) than after pneumectomy (25.0 %) or explorative thoracotomy (8.0 %). Our study shows the good effect of surgery in stage I, and confirms it's usefulness in stage IIIa lung cancer. The histologic types of tumours did not affect survival.

Background and aims: This study was carried out to investigate the use of porous bioactive glass implants in promotion of articular cartilage and subchondral bone repair in large osteochondral joint defects.

Material and methods: Two conical osteochondral defects (top diameter 3.0-3.2 mm) were drilled into the patellar grooves of the distal femurs in the rabbit. The defects, extending (approximately 6-7 mm) from the surface of the articular cartilage to the subchondral marrow space, were reconstructed with size-matched porous conical implants made of sintered bioactive glass microspheres (microsphere diameter 250-300 microm, structural implant compression strength 20-25 MPa) using press-fit technique. The implant surface was smoothened to the level of the surrounding articular cartilage. One of the two defects in each femur was left empty to heal naturally and to serve as the control. At 8 weeks, the defect healing was analyzed with use of a semiquantitative histological grading system, histomorphometry of subchondral bone repair, back-scattered electron imaging of scanning electron microscopy (BEI-SEM), and a microindentation test for characterization for the stiffness properties of the cartilage repair tissue.

Results: The porous structure of the bioactive glass implants, extending from the articular defect of the patellar groove into the posterior cortex of the femur, was extensively filled by new bone. Cartilage repair varied from near-complete healing by hyaline cartilage to incomplete healing predominantly by fibrocartilage or fibrous tissue. There were, however, no statistical differences in the histological scores of repair between the glass-filled and control defects, although the sum of the averages of each category was lowest for the bioactive glass filled defects. The indentation stiffness values of all the defects were also significantly lower than that of normal cartilage on the patellar groove.

Conclusions: Porous textures made by sintering bioactive glass microspheres may expand the opportunities in reconstruction of deep osteochondral defects of weight-bearing joints. The implants act mechanically as a supporting scaffold and facilitate the penetration of stromal bone marrow cells and their chondrogenic and osteogenic differentiation. Ionic properties of the bioactive glasses make the substances highly potential even as delivery systems for adjunct growth factor therapy.

Background: Self-reinforced absorbable implants have been developed recently to use in hard tissue reconstructive surgery. Polyglycolide is a biocompatible polymer from which the suture Dexon is made and widely used.

Aims: To study histologically the behaviour of self-reinforced polyglycolide membrane (SR-PGA) in rabbits' ears.

Material and methods: SR-PGA membranes, 0.4 mm thick, were implanted in the subcutis of the ears of 24 New Zealand white rabbits. Sham operations were carried out on the contralateral ear of each rabbit. The rabbits were followed-up for 4, 12 and 20 weeks. Attention was directed towards external macroscopic changes in the rabbits' ears. After sacrifice, the ears were taken as specimens, inspected for any evidence of infection, sinus formation or fluid accumulation and histological examination was carried out.

Results: No complications such as infection, fluid accumulation or sinus formation were observed. Histologically, the membranes induced a foreign-body reaction involving fibrous tissue encapsulation, macrophages and giant cells. Fibrous tissue and inflammatory cells were seen between the PGA fibres. The membranes underwent progressive degradation throughout the follow-up period. However, PGA material could be still seen 20 weeks postoperatively, with a small amount of fibrous tissue and macrophages and giant cells. The implant-cartilage interface comprised fibrous and fatty tissue.

Conclusions: SR-PGA membranes are biocompatible when implanted in the subcutis of the ears of rabbits.