Pulmonary problems in esophageal surgery can result from the resection itself (intraoperative pulmonary trauma), the reconstruction procedure (intrathoracic organ interposition) and aspiration due to postoperative impairment of swallowing. Therapeutic strategies include postoperative ventilation, deflation of the interponate and a special dietary plan. Our rate of 5.2% postoperative pulmonary complications underlines the efficiency of our treatment modalities.
Reduced cardiac output is the pathogenetic principle of non-occlusive disease. Prerequisites for early diagnosis include anamnesis, clinical and laboratory findings, sonography, mesentericography, contrast enema, and coloscopy. Conservative treatment with vasoactive drugs is promising in early stages. As the abdominal symptoms develop latently, laparotomy is indicated in most cases in order to identify necrosis or perforation and to allow surgery according to the intraoperative findings. Despite indisputable progress made during the past years, the death rate in our patients (n = 42) is still 43%. Only early diagnosis and consequential therapy can achieve better results.
External compression and kinking of the celiac axis is caused by the enlarged and fibrous median arcuate ligament of the diaphragm. The pathogenetic cause may be a functional ischemia or an irritation of the squeezed celiac ganglion. This painful syndrome is an unusual condition, which occurs at a maximum age of about 40 years and mostly in women. The diagnosis is established by exclusion of all other abdominal sources of pain and lateral aortography. The therapy can often be limited to longitudinal incision of the ligament; reconstructive procedures of the coeliac artery are sometimes necessary.
The value of imaging modalities in abdominal malignancies is discussed. Ultrasound is the first method to perform in hepatic tumors--HCC and liver metastases--, followed by CT and/or MRI. CT and ERCP are the diagnostic procedures of choice in pancreatic cancer. MRI is inferior to bolus-enhanced CT. CT and MRI are still equal in colorectal cancers for differentiating between scar and local recurrence after abdominal-perineal amputation.
Surgical threads of a variety of resorbable suture materials (Cat plain and Chrom Cat, Serag Wiessner, Polyglactin 910 and Polydioxanon, Ethicon and polyglycolic acid, Dexon) were incubated up to 7 days at 37 degrees C in Varidase-containing media (Lederle Cyanamid, 1000 IU/ml in 0.9% NaCl or citrated human plasma). Thereafter the knot-breaking strength remained within 90.0 and 108.2% of the respective control threads (incubation in Varidase-free media, n = 7, n.s.). The dose-dependent lysis of fibrin glue by Varidase is effectively inhibited by small amounts of aprotinin (15 KIU/ml as compared with 1000-3000 KIU/ml in routine application). The inhibitor is bound to the matrix and not readily eluted.
Splanchnic blood flow is regulated by cardiovascular factors, the autonomic nervous system, circulating vasoactive agents and local mechanical factors. Typical physiologic phenomena such as "autoregulation", "autoregulatory escape" and "countercurrent exchange" are discussed. Aspects of therapy especially for acute mesenteric infarction, are elucidated with reference to the circulating vasoactive agents, the effects of bowel distension on intestinal blood flow and reperfusion injuries.
The major shortcomings of formal decision analysis derive from the complexity of the clinical problem, behavioral qualities of the investigator and the method itself. It seems difficult to translate study results into a probability estimate for the problem in an individual patient. Therefore, probability assessments from the medical literature, one's own clinical experience and data sources should be combined. Decision analysis is not itself clinical reality but provides a model for thinking explicitly about the problem.
From November 1988 to February 1990 157 patients with gallbladder stones haven been treated by a laparoscopic surgical procedure. They are 28 males and 129 females from 13 to 81 years old. 18 have had a cholecystostomy after intracorporeal lithotripsy (Lus Ultrasonic Olympus). They were placed on bue acids during 3 months. The average follow up time is 11 months. The mortality is zero and 2 mild complications occurred medically cured. 3 patients have a recurrent stone 6 months after surgery. 139 patients have had a cholecystectomy 89 after the same lithotripsy procedure seen above, 50 without prior lithotripsy. In 3 cases the laparoscopic procedure was abandoned, twice because of a sever bleeding, one for too compact surrounding adhesions. The mean follow up is 9 months. 123 were drained 1 day 16 had no drain. The mortality is zero. 2 patients without drainage developed a sub hepatic and douglas pouch abscess. They were cured by a lavage drainage laparoscopically made. 1 patient with drainages had a 7 days bile leak, which disappeared spontaneously. The 136 others have had a short stay in the hospital (2-4 days) a painless post operative time. They could go back to work and sport within 1 week. They have minimal scars and no danger of incisional herriae. The magnification of the optical system enables the dissection of the cystic duct and artery easier and safer than it is by mini laparotomy mostly in obese people. At the beginning of our experience only the patients with frequent biliary colics have been selected for the laparoscopic procedure. At that time 13 patients with subacute cholecystitis and 9 patients with stones in the commun bile duct have had a laparoscopic cholecystectomy associated with an endoscopic sphincterotomy in the last cases without complications.
A total of 274 patients (mean age 67.1 +/- 8.2 years) with asymptomatic stenosis of the internal carotid artery greater than 70% was treated by desobliteration and patchplasty; 332 reconstructions were performed either uni- or bilaterally. In this group only 29% revealed a one vessel disease. Lethality within 30 days was 1.5%; the incidence of complete stroke amounted to 0.9%. In a mean follow up period of 30.8 +/- 20.2 month to lethality rate was 4.4%; 7.8% developed a completed stroke and only 3.8% were related to the operated site. The 5-year-survivalrate was 88.9% and 93.2% of this cohort was neurological free of symptoms.
From 1 January 1982 to 30. June 1986, 436 operations on the internal carotid artery were performed: 164 were asymptomatic (37.6%). Morphologic indication was stenoses greater than 70% only. Supra-aortic multivessel disease played a major role. The operative mortality amounted to 0.6% (total 0.9%) and the perioperative mortality, 1.8%. The cumulative morbidity was 1.6% after the first and 1.8% after the second year, whereas the cumulative survival rate measured 89.8% after one and 80.4% after three years. Therefore surgery for asymptomatic carotid internal stenoses is justified under conditions of the restrictive indication. It also seems to be more favorable as regards early and late results.
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