Husfeldt hernia repair: indications and results. A follow-up study.

Ninety-seven consecutive patients with hiatal hernia were operated upon with a modified Husfeldt hernia repair during a ten-year period. Thirty-two of the patients had severe reflux complications, such as ulcerative oesophagitis, oesophageal stricture and shortened oesophagus. Ninety patients were carefully followed up postoperatively. The mean duration of follow-up was 5 years. Analysis of the postoperative results in relation to the type of hernia showed no difference between sliding and combined hernia. Recurrence of hernia, unsatisfactory clinical results and gastro-oesophageal reflux were recorded more often in patients with severe reflux complications. The main cause of unsatisfactory results in these patients was found to be a shortened oesophagus. The method proved to be a reliable procedure for surgical treatment of not only uncomplicated hernias, but also cases complicated by oesophageal stricture if the stricture was not associated with shortened oesophagus. It is considered that a shortened oesophagus is a contra-indication for employment of the Husfeldt method.

Hiatal hernia complicated by oesophageal stricture. Surgical treatment and results. A follow-up study.

During a 10-year period, 1967-1976, 57 patients were operated upon for hiatal hernia and gastro-oesophageal reflux complicated by oesophageal stricture. Forty-four patients were managed by various surgical antireflux procedures combined with dilation of the stricture. In 12 patients the stricture was resected and the oesophageal continuity restored by oesophagogastrostomy. The primary mortality was 3.5%. Fifty-two patients were carefully followed up postoperatively by periodic control examiniations. The results of the treatment are presented. The main cause of unsatisfactory postoperative results was gastro-oesophageal reflux uncorrected by the surgical procedure. In the patients subjected to a hernia repair the failure of the antireflux procedure was due mainly to a shortened oesophagus associated with the stricture. It is concluded that most of these strictures can be successfully treated by dilation after establishment of control of the pathological reflux by means of an antireflux surgical procedure. The location, width, length and rigidity of the stricture, as revealed at the preoperative examination, are not decisive for the choice of therapeutic approach.

Hiatal hernia and shortened oesophagus.

The existence of an anatomically shortened oesophagus in patients with hiatal hernia, and its influence on the results of surgical repair of the hernia, is the subject of great controversy. One hundred and forty patients operated upon for hiatal hernia were studied for presence of shortened oesophagus. The method of examination and criteria for evaluation of the oesophageal shortening are described. The oesophagus was found to be anatomically shortened in 52 of these patients. None of the findings obtained at the preoperative examinations employed in the study could be used as a pathognomonic sign for diagnosing a shortened oesophagus. Irreducibility of the cardia below and the diaphragm, as observed radiologically, in association with other severe reflux complications, such as oesophageal stricture and/or ulcerative, makes it presence very likely, however. The incidence of shortened oesophagus in this series was higher in patients with a long history of symptomatic gastro-oesophageal reflux. The influence of the shortened oesophagus on the result of the surgical repairs used in this study, and aimed mainly at restoring the abdominal segment of the oesophagus, was clearly unfavourable.

Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas.

A series of 43 patients with thymoma was reviewed. The patients were classified with respect to some factors of prognostic significance. The tumors were reclassified histologically, and a staging system with three defined stage-groups was applied to the series on the basis of operative findings and histological examination of surgical specimens. Surgical-pathological staging is of high prognostic and therapeutic importance in thymomas. Complete removal of the tumor was possible in the 25 patients with stage I or II disease and in 14 of the 18 patients with stage III tumors. Pleural metastases were observed in half of the patients with stage III disease. Even patients with extensive local spread or pleural metastases were subject to tumor resection. The treatment of choice is radical resection along in stage I; radical extirpation and, if indicated, postoperative radiotherapy in stage II; and radical resection whenever possible, even in cases of pleural spread, in stage III, with postoperative radiotherapy and chemotherapy. Myasthenia gravis is an indication rather than a contraindication to radical treatment of thymoma, although some patients may deterioratte. The importance of total thymectomy is stressed.

Tumors of the thymus and thymic region: II. Clinicopathological studies on Hodgkin's disease of the thymus.

Among 82 patients with a tumor in the thymic region, 17 had a lesion that fulfilled the criteria for Hodgkin's disease of the thymus; the histopathological differentiation of this entity from thymomas is discussed. All patients received surgical treatment and postoperative radiotherapy. After a mean observation time of 10 years there was no local recurrence and no death due to the disease, though 3 deaths were cuased by the treatment. New clinical manifestations occurred in 3 of the 14 long-term survivors: they were treated successfully by operation or irradiation. A very aggressive surgical approach involving extirpation of all tumor tissue, extensive excision of the surrounding tissues and adjacent lymph nodes, and supplementary radiotherapy seems to be the treatment of choice.

Tumors of the thymus and thymic region: III. Clinicopathological studies on teratomas and tumors of Germ Cell type.

In a series of 82 patients with tumors of the thymus and thymic region there were 11 with teratomas and germinal tumors. Four of these patients had benign cystic teratomas, 4 had malignant teratomas, 1 had an embryonal carcinoma, and 2 had seminomas. The benign teratomas were removed by simple extirpation without complications. The malignant teratomas were highly invasive, and despite extensive operations and postoperative radiotherapy, 3 of the 4 patients died within 9 months. One patient with predominantly seminomatous differentation of the teratoma was alive and well more than 3 years after the operation. The patient with an embryonal carcinoma died after 4 months. One of the 2 patients with seminoma remained alive 20 years after radical excision and postoperative radiotherapy. The other, who had a huge seminoma, died during operation. The prognosis in patients with seminomas or with predominantly seminomatous structures in teratomas seems to be good after combined radical excision and radiotherapy, although nonradical resection followed by raditherapy may be justified in high-risk patients.

An approach to the surgical treatment of carcinoma of the oesophagus and cardia.

No method of surgical treatment of carcinoma of the oesophagus and cardia is universally accepted. An approach to the problems of the choice of the side for thoracotomy, the organ for reconstruction of the continuity of the oesophagus and the combination of the abdominal and thoracic stages of the surgical procedure is presented. It is based on the following principles: (1) Selecting the side for the thoracotomy on the basis of the distance from the upper incisors to the upper margin of the tumour, determined by oesophagoscopy. (2) Separation of the laparotomy and the thoracotomy. (3) Starting the operative procedure with the laparotomy. The operative mortality in a series of 44 patients operated upon according to these principles is compared with that in a previous series of 77 patients and the advantages and disadvantages of this approach are discussed.

Intrapleural streptokinase in the treatment of haemothorax and empyema.

Thirty-eight patients with haemothorax or empyema, in whom conventional drainage treatment had proved ineffective were treated with streptokinase instillations. An increased yield of fluid was noted in all cases, up to 1300 ml after one instillation. Re-expansion of the lung was observed radiologically in 30 cases. No serious complications occurred. The method seems very useful and is recommended.