Annales chirurgiae et gynaecologiae最新文献

Background and aims: Restorative proctocolectomy with mucosectomy and handsewn J-pouch-anal anastomosis is the curative operation of choice for ulcerative colitis. The aim of this study was to determine frequencies of various complications at perioperative time (within 30 days after surgery) with this operative method. We also evaluated the chances of failure of this restorative operation and the trends in operative management.

Material and methods: Evaluation was based on a register containing data on all patients operated for ulcerative colitis at our department since the beginning of 1985. Statistical analysis was made for all adult patients (over 18 years) who underwent an operation for ulcerative colitis during the 11 years' time period.

Results: A total of 170 adult patients underwent an elective operation for ulcerative colitis between March 1985 and December 1995. In 154 cases a restorative procedure was intended. In 142 (92%) cases this proved possible, and in 136 of these a handsewn J-pouch-anal anastomosis was created. The chance of failure in the restorative operation was higher in men (p = 0.0314). During the latter five years' period IAA operations were performed more often as a second-stage procedure. Uneventful recovery was reported in 62 (45.5%) cases. One or more complications were encountered in 74 (55.1%) patients. Corticosteroid treatment did not affect leakage frequency. In spite of the high morbidity there were no perioperative deaths.

Background and aims: In the era of magnetic resonance cholangiopancreaticography (MRCP) and laparoscopic biliary surgery, indications for endoscopic retrograde cholangiopancreaticography (ERCP) should be profoundly considered in the light of ERCP related complication rate.

Material and methods: To evaluate the frequency of complications associated with diagnostic and therapeutic ERCP, all endoscopic procedures from 1991 to 1996 were retrospectively reviewed.

Results: A total of 813 cannulations were performed on 590 patients. Endoscopic sphincterotomy (EST) was performed on 223 patients out of 230 attempted. Common bile duct stones were removed from 134 patients, an endoscopic stent was inserted in 69 patients and a benign stricture was dilated in 11 patients. After diagnostic ERCP, the complication rate was 1.8% with no mortality, after EST the complication rate was 9.1% with a mortality rate of 0.9%. Pancreatitis was the most common complication with a rate of 1.5% after diagnostic ERCP and 3.9% after EST. In three patients the pancreatitis was severe and resulted in the deaths of two of them. Other complications were haemorrhage after EST (2.6%), duodenal wall or bile duct perforation (0.7% of the cannulations and 2.2% of EST) and cholangitis (0.6% of all cannulations). All of these patients survived.

Conclusion: Complication rates were comparable with large series from clinics specialised in endoscopic procedures.

The duration of spinal cord ischemia is probably the most important single factor in the pathogenesis of paraplegia after repair of descending thoracic aortic aneurysms. We describe a modification of open distal anastomosis technique originally presented by Dr. Cooley, in which we use partial cardiopulmonary bypass with femoral cannulation and mild hypothermia. Cardiopulmonary bypass is interrupted after lowering patient's temperature to 32 degrees C and the aorta is clamped using one proximal clamp. During the suturing of the distal anastomosis blood is sucked to reservoire and returned oxygenated to the patient via the venous line using a shunt which is installed between the arterial and venous lines. After completion of the distal anastomosis the graft is clamped and cardiopulmonary bypass reinstituted. Rewarming is started as bleeding intercostal arteries are sutured and proximal anastomosis performed. This modification shortens the distal ischemia time, but supports the circulation of the kidneys and splanchnic area immediately after the distal anastomosis is finished. Lowering the temperature should give additional protection for the spinal cord and the blood can be returned oxygenated to the patient. In our opinion, this combination of femoro-femoral perfusion, mild hypothermia, and open distal anastomosis offers several benefits and can be used in dissections and aneurysms, which extend up to aortic hiatus.

Background and aims: This investigation was made to elucidate the outcome of conservatively treated scaphoid fractures.

Material and methods: 63 patients with a scaphoid fracture were treated initially conservatively and examined retrospectively. The mean follow up time was 54 months.

Results: In this group bone union was achieved in 56 cases (89%). Three of the patients ended up to operation because of delayed union soon after conservative treatment and three nonunions were found in the follow up appointment. One fracture did not heal because of dislocation during cast treatment and was treated with operation. Incidence of osteoarthrosis and residual symptoms were studied in the group with totally conservative treatment. Osteoarthrosis was found in 19 (32%) wrists, but no correlation with wrist problems (pain, reduced grip strength or problems at work) was found. 20 (34%) of the patients complained residual symptoms. Most of the symptoms were mild and did not impair their ability to work or cause serious problems during free time.

Conclusion: According to the present study conservative treatment is a safe method for the treatment of undislocated stabile scaphoid fractures.

Background and aims: In a prospective study, Bard BTA (bladder tumour antigen) test was compared to voided urine cytology (VUC) in detecting primary and recurrent bladder cancer (BC).

Materials and methods: 407 control cystoscopies, BTA test and VUC were performed on 150 patients, of which 96 (23.6%) recurrent tumours were found, and 43 patients with a new BC were noticed.

Results: BTA test was superior to VUC in detecting superficial Ta (23% vs. 3%, p < 0.001) and grade 1 (16% vs. 0%, p < 0.001) as well as grade 2 (35% vs. 11%, p < 0.01) tumours. In Tis and T2-T4 tumours as well as in grade 3 tumours both tests performed similarly. The sensitivity of BTA test compared to VUC in detecting recurrent tumours was higher (24 % vs. 9%, p < 0.01), but VUC had more specificity than BTA test (99% vs. 80%, p < 0.001).

Conclusions: BTA test was superior to VUC in detecting BC and its recurrence. The simultaneous use of the BTA test and VUC did not add any information in detecting tumour growth in the bladder as compared to the BTA test alone.

Endoprosthetic treatment of intracapsular, subcapital displaced femoral neck fracture in the elderly patients is widely accepted. According to increase in total number of femoral neck fractures in the last decades, there will be about 5 500 femoral neck fractures in Finland suitable for endoprosthetic treatment in the year 2020. Uncemented or cemented unipolar, bipolar or total hip replacements have been alternatives to internal fixation. For active elderly patients with a much younger physiologic than actual age and living a fully independent life, cemented bipolar or total hip arthroplasty should be preferred to unipolar arthroplasty in the year 2 000.

Background and aims: MRI has proven to be the most effective method for demonstrating suspected postoperative discitis. The prognosis of discitis varies markedly in different series. The purpose of this study was to analyze the clinical outcome and late MRI findings of the patients with postoperative discitis.

Material and methods: The medical records of ten patients with discitis and of ten patients without infectious findings following lumbar discectomy in 1993 to 1995 were reviewed. A clinical follow-up investigation with a detailed questionnaire and MRI was performed. Without knowledge of the clinical history, a radiologist selected the cases of discitis based on evaluation of the MRI pictures, and thereafter after a combined analysis of preoperative CT scans and of the MRI pictures.

Results: The follow-up MRI demonstrated characteristic findings in every discitis case. However, similar changes were seen in four cases of the control group. The discitis group had more symptoms, a longer sick leave and less return to previous occupation than the control group.

Conclusion: As a late examination, MRI is insufficient in itself for diagnosis of earlier discitis. Postoperative discitis lengthens the sick leave markedly. Patients with postoperative discitis are rarely capable to return to a physically strenuous work. Every effort, including antibiotic prophylaxis, should be undertaken to reduce the risk of this serious complication.

The purpose of this paper is to evaluate in an animal model the long term results obtained with a prosthetic stem fully coated with hydroxyapatite. The cup was manufactured in polyethylene and was cemented. Six arthroplasties were performed in six sheep. After twelve months, the animals were euthanized and the femurs were harvested and processed for undecalcified sectioning. Twelve cross sections were cut perpendicularly to the longitudinal stem axis. Sections one to five corresponded to the area of the stem which, at the time of surgery, had a full initial contact between the bone and the prosthesis; sections six to ten corresponded to the area of the stem which, at the time of surgery, had a gap from 0 to 2 mm between the bone and the prosthesis; sections eleven and twelve had an initial gap larger than 2 mm. At one year after implantation, in the sections one to five, morphological analyses showed extensive direct contact between the bone and the hydroxyapatite coating. Bone prosthesis contact was lower in the sections six to ten. No contact was seen in sections eleven and twelve. Comparing bone to prosthesis contact of each subsequent section, from proximal to distal, the difference becomes significant with section five compared to section six (p < 0.00005). No detachment of the hydroxyapatite coating from the metallic substrate was observed in any section. In conclusion, this study shows that a conic shaped femoral stem, fully coated with hydroxyapatite gives very good histological and histomorphometric results at one year. Prosthesis osteointegration showed to be influenced by the initial bone to prosthesis contact. No direct bone to prosthesis contact was achieved if the initial bone to prosthesis gap was larger than 2 mm.

A perforation of distal oesophagus in benign cases occurs usually as a complication of endoscopic procedures or due to perforating external trauma. Perforations caused by blunt trauma are rare and usually involve high-energy accidents. The time of diagnosis, severity of the perforation, degree of mediastinal and pleural contamination and treatment are the most important factors predicting the outcome. Treatment may be conservative, comprise primary suturation or include oesophageal resection. We present three cases with a benign oesophageal perforation, which we have treated with a coated stent. One of the cases suffered from a thoracic oesophageal perforation due to a lesser trauma, while the other two cases are perforations caused by complications of endoscopy.