Showing papers in "Acta chirurgica Scandinavica in 1981"

Comparative influences of epidural and general anaesthesia on deep venous thrombosis and pulmonary embolism after total hip replacement.

Abstract: In an investigation on deep venous thrombosis and pulmonary embolism, where neither dextran nor antithrombotic drug prophylaxis were employed, 30 patients undergoing total hip replacement were randomly allotted to one of two groups receiving either epidural or general anaesthesia. The epidural group (n = 15) was given 0.5% bupivacaine with epinephrine (5 micrograms/ml) and this was prolonged into the postoperative period for pain relief. The general anaesthesia group (n = 15) was operated on under artificial ventilation with nitrous oxide/oxygen via an endotracheal tube and intravenously administered fentanyl and pancuronium bromide. In this group of patients narcotic analgesics (ketobemidone) were given intramuscularly on demand for pain relief postoperatively. The frequency of deep venous thrombosis involving the femoral veins, as observed at phlebography, was significantly lower in patients receiving continuous epidural block (3 of 15; 20%), than in those receiving general anaesthesia and parenteral analgesics postoperatively (11 of 15; 73%). Further, the frequency of pulmonary embolism, as determined by pulmonary perfusion lung scanning, was lower in patients receiving continuous epidural block (2 of 15) than in the general anaesthesia group (7 of 15). Possible explanations for these findings are discussed, including a hyperkinetic lower limb blood flow and lower fibrinolysis inhibition activity in patients given epidural block. Lower blood transfusion requirements in patients given epidural block might also play a role, as well as a "stabilizing" effect of local anaesthetics on platelets, leukocytes and endothelial cells.

The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy.

Abstract: The occurrence of deep vein thrombosis (DVT) was studied by the 125-I-fibrinogen uptake test in 38 patients subjected to retropubic prostatectomy. The patients were randomly allocated to two groups: continuous lumbar epidural analgesia for up to 24 hours and general anaesthesia with intermittent positive pressure ventilation. Two of the 17 patients in the epidural group (12%) developed DVT in contrast 11 of the 21 patients in the general anaesthetic group (51%). The difference between the groups was significant. It is concluded that epidural analgesia offers a protection against postoperative DVT and is worth further investigation.

Fibronectin in early phases of wound healing in children.

Abstract: Fibronectin, an adhesive glycoprotein, was demonstrated with the Cellstic device in healing wounds of 13 children after routine surgery. An indirect immunofluorescent method was adapted to cytological and histological specimens made from the Cellstic sponges 1 to 92 hours after operation. As early as one hour after Cellstic implantation some bright fluorescent spots could be seen in the cytological specimens, although cell morphology still fully resembled to that of peripheral blood. The intensity of the fibronectin fluorescence increased rapidly until the maximum was reached 24-48 hours after surgery. Thereafter the fluorescence gradually decreased to the level of the first hours. Rapid appearance of fibronectin, its abundance on the second day and gradual diminution upon the activation of type I collagen synthesis indicate its role as a biological guide for localization of cellular activity in wound repair.

Continent ileostomy. An account of 314 patients.

Abstract: Continent ileostomies were created in 314 patients between 1967-1979. Approximately 50% of the patients were provided with the continent ileostomy in connection with proctocolectomy and the others were converted from a conventional ileostomy to the continent ileostomy. In the majority of patients the indication for proctocolectomy was ulcerative colitis, but 51 patients with Crohn's disease were also included. There was 2.5% operative mortality overall, but when the material was divided into two groups operated upon during two consecutive time periods, no mortality was recorded in 152 patients operated upon during the latter period. The non-fatal complication rate had also decreased from 24% in the early series to 7% in the group operated upon during the latter period. Revisional surgery because of malfunction of the nipple valve has consecutively decreased with the present technique for construction of the nipple from 54% in the original series to 6%. At the follow up, 94% of the patients were continent and never used ileostomy appliances.

Protein turnover in acute and chronic liver disease.

Abstract: The method of constant infusion of U14C tyrosine tracer was used to measure whole body protein turnover in 24 patients with liver disease of varying severity. Whilst on a basic diet of glucose alone (5 g/hr), protein turnover and endogenous breakdown was significantly elevated in patients with cirrhosis and fulminant hepatic failure (F.H.F.), breakdown rising to 700 g/d greater than normal in F.H.F. In addition plasma aromatic aminoacids were significantly elevated and positively associated with the increases in endogenous protein breakdown (r = 0.78, p less than 0.05). Fourteen patients had a second infusion after dietary supplementation with either complete aminoacids (3 g/hr, n = 8) or branched chain aminoacids (BCAA, 4 g/hr, n = 6). The complete mixture did not worsen encephalopathy, improved the plasma aminoacid pattern, reduced protein breakdown and resulted in positive aminoacid balance. The BCAA supplements significantly reduced protein oxidation and endogenous breakdown. The results indicate that protein restriction in cirrhosis and fulminant hepatic failure will not significantly affect the load of aminoacids on the liver, nor their accumulation in plasma. Nutritional support of such patients should therefore include 40 - 60 g. protein per day to prevent protein depletion, and hypertonic glucose and insulin to suppress catabolism. BCAA supplementation may play a useful supportive role in increasing the utilisable nitrogen content of the diet and further suppressing catabolism.

Comparison of rubber band ligation and sclerosant injection for first and second degree haemorrhoids-- a prospective clinical trial.

Abstract: Fifty patients with first or mild second degree haemorrhoids were randomly allocated to sclerosant injection (26) or rubber band ligation (24). One year after treatment 24 injection and 22 rubber band ligation patients were assessed. All patients presented with rectal bleeding; injection relieved 14 and rubber band ligation relieved 17 of this symptom (N.S.). Three of seven patients with prolapsing haemorrhoids who had sclerosant injections and five of seven who had rubber band ligation were relieved of this prolapse. However, a further six patients in the injection group developed prolapse for the first time during the one year follow-up period (p less than 0.05). Rubber band ligation relieved anal pain in 10 out of 14 patients whereas injection relieved only one patient of this symptom (p less than 0.05). Neither treatment influenced pruritus ani or faecal soiling. Although rubber band ligation caused more treatment discomfort, it is an effective management for first and mild second degree haemorrhoids and it should be considered as the procedure of choice.

Tracheal stenosis after tracheostomy and after orotracheal cuffed intubation.

Abstract: Tracheal stenosis occurred in 9 cases in a series of 812 tracheostomized patients, an incidence of 1.1%. Two additional stenoses had developed after orotracheal cuffed intubation. Two suprastomal, two stomal and seven infrastomal stenoses were confirmed. The stenosis was diagnosed within 10 weeks of extubation in 10 patients and 5 months after extubation in 1 case. The airway results were good after segmental resection and end to end anastomosis in 5 patients; satisfactory in 4 patients after various dilatation procedures and poor in 1 case after removal of granulation tissue. The mortality rate was 18%. One patient died on account of missed diagnosis and another of tracheo-innominate artery erosion with massive bleeding after tracheal resection. The present report indicates that the best airway results are achieved by segmental resection. Various dilatation procedures, however, produced satisfactory airway results and should be used as primary treatment when the stage of the stenosis makes resection inappropriate. When planning surgical treatment, X-ray examinations, tomography or tracheo-graphy are necessary for evaluation of the site and length of the stenosis. The stage of the stenosis can best be evaluated by tracheoscopy. The use of large, low-pressure thin-walled cuffs and avoidance of overinflation of the cuff are the most important measures for preventing the cuff-induced tracheal injury which may lead to tracheal stenosis.

Arteriovenous communications in varicose veins localized by thermography and identified by operative microscopy.

Abstract: By thermography the hottest spots of varicosities were localized. At surgery they were found to correlate well to the sites of small pulsating arteries joining the varicosities but did not show correspondence to incompetent perforating veins. At peroperative measurements these arteriovenous communications (AVC) ranged from 0.1-2 mm. Most of them (79%) were within 0.2-0.8 mm with a median value of 0.6 mm. Unexpectedly, direct communication of an arteriovenous nature between perforating veins and adjacent arteries was frequently seen at the fascial level or immediately beneath it. AVC to varicose and perforating veins were demonstrated in 64% (100/157) of explorations performed. The continuity of the suggested AVC was visually confirmed by microscopical anatomical isolation of the affluent artery or by observation of pulsatile bleeding on the inadvertent division of such a vessel. Operative microscopy was performed in 35 and magnifying glasses were used in a further 16 patients. Overall 79% of subfascially isolated perforating veins were equal to or smaller than 2.4 mm and 61% equal to or smaller than 1.8 mm. Perforating veins were missing in totally 47% (74/157 explorations) which means a frequent occurrence of clearly well-defined hot varicosities which could not be explained by retrograde flow through either incompetent perforating veins or by saphenous trunk insufficiency. The unexpected incongruity between the occurrence of well-defined hot varicosities and incompetent perforating veins discredits the traditional concept of their import with respect to varicose development. The only plausible explanation to the pooling of hot varicose blood was the identified arteries, inevitably supporting the role of arteriovenous communication in varicose development.

Randomised trial comparing Proximate stapler with conventional skin closure.

Abstract: The Proximate stapler was compared with usual skin closure in a randomized trial, with 137 patients having elective abdominal and breast surgery. The median duration of skin closure with the Proximate stapler was 80 seconds, which was significantly shorter than the median of 242 seconds with conventional closure. No difference was found with regard to wound infection, but pain was more frequent after stapling.

Growth and nitrogen utilization in rats on continuous and intermittent parenteral nutrition with and without fat (Intralipid 20

Abstract: A rat model relevant to paediatric praxis was designed in order to evaluate possible differences between total parenteral nutrition (TPN) with fat (Intralipid 20%), and isocaloric TPN without fat and also to compare continuous TPN (24 hours/day) versus intermittent TPN (12 hours/day). TPN with fat resulted in better growth and nitrogen utilization. Continuous TPN with fat resulted in statistically significant better nitrogen utilization. The results suggest that TPN in paediatric praxis should be continuous and include fat.

Cancer of the head of the pancreas and choledochoduodenal junction: a clinical study of 88 Whipple resections.

Abstract: The results of 88 pancreaticoduodenectomies performed at one institution over a period of 15 years (1960-1974) have been reviewed. Resection was undertaken in 62 patients with carcinoma of the head of the pancreas (HP) and in 26 patients with carcinoma of the choledochoduodenal junction (CDJ), with an operative mortality of 10% and 15% respectively. The 5-year survival rate for patients without positive lymph node histology was 13% for those with HP carcinoma and 21% for those with CDJ carcinoma. With positive nodes, the 5-year survival rates were 3% and 33% respectively, which suggests that a Whipple resection in patients with CDJ carcinoma has a relatively favourable prognosis even in the presence of lymph node metastases. In patients with HP carcinoma, on the other hand, resection was associated with a poor prognosis.

The celiac compression syndrome: myth or reality?

Abstract: Fifteen patients were operated on for compression of the celiac artery with division of the median arcuate ligament. Initially most patients were released from their preoperative abdominal pain. At follow-up after 1 1/2-9 1/2 years only two patients were asymptomatic. Our results corroborate the nonentity of the celiac compression syndrome. The existence and identification of a subgroup of patients with symptomatic compression of the celiac artery is discussed.

Changes in nitrogen metabolism in catabolic patients given three different parenteral nutrition regimens.

Abstract: Nitrogen metabolism was investigated in 24 catabolic patients (15 men and 9 women) given three different parenteral nutrition regimens for 10-12 days. Energy was supplied as either carbohydrates alone (glucose group) or as carbohydrates and fats (lipid group) and nitrogen as amino acids. In the third group (amino acid group) amino acids were given in excess and less energy was supplied as carbohydrate. Each patient served as his own control. On the basis of daily urinary urea excretion all infused amino acid was retained in the body in the glucose and lipid groups during parenteral nutrition, but in the amino acid group 54% of infused amino acids were metabolized in gluconeogenesis apparently for energy production. In the glucose and lipid groups nitrogen balance rose to a "plateau" within 2-4 days but in the amino acid group within 5-7 days. The increment of nitrogen balance, 0.169 +/- 0.030 g N/kg/day, in the glucose group was greater than that, 0.140 +/- 0.037 g N/kg/day, in the lipid group (p less than 0.05) and that, 0.122 +/- 0.044 g N/kg/day, in the amino acid group (p less than 0.01). The initially low values of serum and liver protein did not change in the glucose and lipid groups, but in the amino acid group serum protein rose from 53.7 +/- 6.5 g/l to 61.1 +/- 5.9 g/l (less than 0.01) and liver protein from 47.4 +/- 7.2 mg/mgDNA to 65.0 +/- 22.6 mg/mgDNA (p less than 0.05). It seems tht a parenteral nutrition program rich in amino acids stimulates the vital protein synthesis of the liver more than regimens with abundance of non-nitrogen energy sources and poorer in amino acids. Nitrogen balance does not reveal information about the important protein metabolism of the liver. The results of this study support the opinion that during parenteral nutrition carbohydrates improve nitrogen balance more than isocaloric amount of fat.

Splenectomy after blunt abdominal trauma. A retrospective study of 413 children.

Abstract: Splenectomies performed in children aged 0-14 during the period 1968-1977 have been reviewed. In 413 cases traumatic rupture of the spleen had occurred. The trauma causing the rupture, preoperative examinations, operative findings and complications have been studied. Most frequently traffic accidents had caused the splenic rupture. Many ruptures were not bleeding at the time of operation. Consequently surgical repair saving the spleen had been possible in several cases. Splenectomized children have a significant increased risk of overwhelming sepsis. In this retrospective material 10 children (2.4%) developed sepsis within eight years. Five of these cases had a fatal outcome. The need for a more conservative attitude in children with splenic rupture is emphasized.

Respiratory complications after upper abdominal surgery. The incidence of chest X-ray abnormalities, arterial hypoxemia and clinically recorded pulmonary complications.

Abstract: The incidence of postoperative chest X-ray abnormalities, arterial hypoxemia and clinically recorded pulmonary complications was studied in fifty-two 40-75-year-old men admitted for elective surgery for peptic ulcer or gallbladder disease. Twenty-eight (54%) patients had an abnormal chest X-ray and twenty-three (43%) arterial hypoxemia, whereas only four patients (8%) were identified with clinical signs and symptoms of respiratory complications. Forty-one patients (79%) were found with pulmonary complications by at least one of the three methods. Twelve patients had both an abnormal chest X-ray and arterial hypoxemia. Only two of these were identified with clinical signs indicating pulmonary complications. The great discrepancy between results based on clinical signs and symptoms noted in the patients' records and results based on postoperative chest X-ray and measurements of the arterial oxygen tension, respectively, should be of great importance when comparing the incidence of pulmonary complications after different forms of surgery and when assessing risk factors and clinical consequences of respiratory complications.

Haemorrhage into a pheochromocytoma in an anticoagulant-treated patient.

Abstract: Bleeding in a pheochromocytoma after anticoagulant therapy is described. The symptomatology, diagnosis, treatment and prognosis are surveyed. The importance of computed tomography, possibly with the addition of angiography, in the diagnosis of this rare condition is emphasized.

Urokinase or heparin in the management of patients with deep vein thrombosis

Abstract: Twenty patients with clinical signs of deep vein thrombosis of a duration not exceeding 72 hours, and with the condition confirmed phlebographically, were randomly allocated to one of two groups in a double-blind study. In group 1 the patients received urokinase in a low-dose regimen of 200 000 Ploug units during the first 24 hours, followed by infusion of heparin, 40 000 units daily during the next 5 days. Patients in group 2 received heparin only, 40 000 units daily for 6 days. The clinical course was assessed daily. When the infusion period was completed, the phlebography was repeated, and the results of the two examinations were compared with respect to extent of filling defects and the degree of non-filling of the deep veins. We found no superiority in the regimen consisting of urokinase preceding heparin infusion, compared with that of heparin infusion alone. Most of the patients improved clinically during the 6-day infusion period, but the degree of thrombosis, evaluated phlebographically, was unaltered or even deteriorated during the period in all patients except two. Overt bleeding was noted in 6 patients.

The outcome of staged management of complicated diverticular disease of the sigmoid colon.

Abstract: In a retrospective study, 83 consecutive patients with indication for a staged treatment of complicated diverticular disease were reviewed. There was a considerable overall morbidity rate following construction of the colostomy, colonic resection, and colostomy closure. However, only 58% underwent a resection of the diseased segment, and even fewer (46%) obtained an eventual restoration of the colon continuity. This was primarily due to an unacceptable high mortality rate when patients with general peritonitis were managed by a proximal colostomy and drainage only. Subsequently, advanced age and associated major illness in patients with a planned three-stage management were the most important factors, determining the deficient completion of the staged treatment. Due to the permanence of many transverse colostomies but also to the fact that serious anastomotic complications, including fatal consequences, occurred despite a defunctioning colostomy, one should re-evaluate the need for a proximal colostomy in patients at high risk, considering resection and an end sigmoid colostomy which is the superior permanent stoma if reconstruction fails to come.

Liver changes in rats on continuous and intermittent parenteral nutrition with and without fat (Intralipid 20

Abstract: The possible advantages of including fat in a regimen of total parenteral nutrition (TPN) have long been debated. In order to investigate the role of fat in liver function during different intravenous regimens, two groups of rats received a regimen including fat (Intralipid 20%) during 12 and 24 hours/day, respectively and two groups received a fat-free regimen, isocaloric and isonitrogenous, during the same intervals, all for a period of 10 days. A control group received for 10 days the fat-including regimen orally and libitum. The liver was investigated biochemically and morphologically. Fatty infiltration of the parenchymal liver cells, a low content of linoleic acid and a high content of palmitic and oleic acid among the liver lipids were found in the rats receiving the fat-free regimen. Fat pigments in the cells of the reticuloendothelial system of the livers and values of fatty acid among the liver lipids comparable to those found in orally-fed rats were seen in rat receiving the fat-including regimen. This study underscores the physiological importance of including intravenous fat emulsion in the TPN regimen. Our results also indicate that essential fatty acid deficiency in tissue may develop rapidly.

Regional, portal hypertension in chronic pancreatitis.

Abstract: Because of a close anatomical relationship to the splenic vein chronic pancreatitis can cause obstruction to the splenic outflow. Regional portal hypertension develops and collateral flow sometimes gives rise to gastric and oesophageal varices which can cause life-threatening bleeding. Three cases with regional portal hypertension secondary to chronic pancreatitis are presented. Two of them were treated with surgical splenectomy and the third had an embolization of the splenic artery. Regional portal hypertension should be suspected in a patient with a history of chronic pancreatitis who is bleeding from gastric of oesophageal varices. The treatment of choice is surgical splenectomy. In high risk patients embolization of the splenic artery can be tried.

Effect of carotid endarterectomy on the antihypertensive properties of the carotid sinus reflex.

Abstract: In eight patients subjected to carotid reconstructive surgery, the reflex effect on systemic pressure of an increase in carotid sinus transmural pressure was studied, before and two months after endarterectomy. The increase in carotid sinus transmural pressure was obtained by applying subatmospheric pressure to the neck. It was found that the closed loop gain of the carotid sinus reflex, calculated as the ratio of change in systemic pressure to change in carotid sinus transmural pressure, was 0.53 before and 0.52 two months after endarterectomy. It is thus concluded that carotid endarterectomy has no persisting effect on the antihypertensive properties of the carotid sinus reflex.

Metabolic studies in multiple injured patients. Clinical features, routine chemical analyses and nitrogen balance.

Abstract: The effect of three different isocaloric parenteral nutritional regimes has been investigated in the early postoperative period in 19 patients with severe multiple injuries. Clinical course, biochemical analyses and nitrogen balance were monitored. The first group received glucose and insulin (n = 7), the second group fat and glucose (n = 6) and the third group fat, glucose and 24 g aminoacid-nitrogen (n = 6). The clinical course was similar in the three groups and all patients survived. The biochemical changes showed a typical pattern for trauma and there were no differences between the groups except for urea, which was significantly higher in the group receiving amino acids. The cumulative nitrogen balance was markedly less negative one week after trauma (-45 g N +/- 8) in the group given amino acids, glucose and fat compared to those given isocaloric amounts of glucose (-84 g N +/- 12) or glucose and fat (-95 g N +/- 10). This improvement in nitrogen balance was probably mainly due to an increase in protein synthesis.

Complications to subtotal parathyroidectomy.

Abstract: Seventy-three patients were operated on for confirmed hyperparathyroidism. Identification of all glands was done by 1/3 biopsies for histopathologic examination on frozen section during the operation. In cases of adenoma only, the adenoma was removed except for the biopsies. In cases of hyperplasia, subtotal resection was made, leaving between a half-gland and a whole gland. The frequency of complications was analysed. Temporary hypocalcemia occurred in a similar frequency in both adenoma and hyperplasia groups. Permanent hypocalcemia was present in only one patient. At follow-up 3-5 years after operation, 98.6% of the patients were normocalcemic. Ionized and total serum calcium were normalized 3 months after operation and remained so for the rest of the follow-up period. Serum phosphate, serum magnesium and serum parathormone also remained normal. Thus identification of parathyroid glands with biopsies or subtotal parathyroidectomy in cases with hyperplasia did not increase the risk of postoperative complications.

Gut structure changes in rats on continuous and intermittent complete parenteral nutrition.

Abstract: Diarrhoea is often seen as a complication in infants when shifting from a few weeks of complete parenteral nutrition (CPN) to enteral feeding. In this experimental study, the intestinal structure during CPN was investigated, whereby rats received a 10-day regimen of CPN continuously or for 12 hours per day. A third groups of rats received the same regimen enterally ad libitum. The weight and nitrogen content of the intestine decreased in the intravenously fed rats. Marked mucosal changes were seen particularly in the proximal part of the small intestine, where the height of villi and the nitrogen content decreased most. The decreased height of the villi seemed to be caused mainly by a decrease in the number of mucosa cells. No obvious advantages were seen by giving the regimen for 12 hours per day.

Collagen synthesis in cultured mesothelial cells. Response to silica.

Abstract: Mesothelial cells were isolated from the peritoneal surface of rats using trypsinization. The cells were polygonal-shaped and proliferated rapidly forming confluent cultures. Application of colloidal silica to mesothelial cell cultures in doses known to induce peritoneal adhesion disease was injurious to the cells and reduced their synthesis of total proteins and collagen. This effect was dose dependent. Media from silica-treated mesothelial cells and granulation tissue fibroblasts were applied to similar but non-treated mesothelial cell and granulation tissue fibroblast cultures. Media from SiO2-treated mesothelial cells increased collagen synthesis markedly both in the mesothelial cell and fibroblast cultures compared with the control cultures as estimated from the incorporation of radioactive proline into hydroxy-proline-containing proteins. However, no stimulation of collagen synthesis was induced by media from the SiO2-treated granulation tissue fibroblasts. Similar effects are known to be induced in fibroblast cultured by media from silica-treated peritoneal macrophage cultures. The alkaline ribonuclease activities of the media were decreased in silica-treated mesothelial cell and macrophage cultures but not in the media of fibroblast cultures. These results suggest that mesothelial cells, like macrophages, can interfere with the protein synthesis of fibroblasts and thus contribute to the regeneration of mesothelium after injury and to the formation of adhesions.

Local antibiotic irrigation in the treatment of arterial graft infections.

Abstract: A retrospective study was made of 7 patients with infected vascular grafts treated by local debridement, drainage and continuous antibiotic irrigation in combination with systemic antibiotics. The long-term results were excellent in 4 patients in whom infection had occurred along Dacron grafts without involvement of anastomoses but involved a risk of rebleeding. Some general principles in the management of patients with infected vascular grafts are suggested.