The prevention of pulmonary complications after upper abdominal surgery in patients with noncompromised pulmonary status.

Controversy exists regarding the routine use of breathing exercises in the prevention of pulmonary complications after upper abdominal surgery. We prospectively randomized 153 patients who had noncompromised pulmonary status; the control group (84 patients) engaged in no breathing exercises, and the respiratory therapy group (69 patients) engaged in preoperative and postoperative breathing exercises supervised by the physical therapist. Postoperative pulmonary complications were classified using criteria derived from chest roentgenograms, arterial blood gas samples, and temperature registration. The incidences of postoperative complications in the treatment group and in the control groups were 19% and 60%, respectively. In the present study, preoperative lung function tests had no additional or predictive value. We advise preoperative and postoperative breathing exercises as a prophylactic treatment in all patients scheduled for upper abdominal surgery.

[Misdiagnosed rupture of the diaphragm following blunt thoracic-abdominal trauma]. / Verkannte Zwerchfellrupturen nach stumpfem Brust-Bauch-Trauma.

The histories of 67 patients with a diaphragmatic rupture due to blunt trauma were reviewed in four hospitals. In 45 patients the diagnosis was made within 24 hours after the accident, in the other 22 patients the rupture was diagnosed in a later stage. In the first group there were much abdominal injuries and during emergency laparotomy for some other reasons in 29% of these cases the diaphragmatic rupture was found accidentally. Not recognizing a rupture in the acute phase and therefore delaying operation was caused by the fact that the initial chest X-ray was not thoroughly checked for signs of a diaphragmatic rupture. The reasons for operation in the "delayed" group were mainly typical abnormalities for diaphragmatic rupture of the chest X-rays and other investigations proving the diagnosis. Only in one patient the delay in diagnosis has led to a very serious complication: because of incarceration with gangrene of a part of the small bowel it was necessary to remove this part. The other 21 patients in the group where the diagnosis was initially missed did not suffer from any serious complication.

An operative choledochoscopy using the flexible choledochoscope.

In a prospective study, the value of operative choledochoscopy as a completion procedure after standard instrumental exploration of the common bile duct is evaluated. The technique of examination using the flexible scope is described. Operative choledochoscopy was performed upon 320 patients. Retained stones of the biliary tract missed by exploration were detected in 23 patients (7.1 per cent). Stones retained in spite of endoscopic examination were found in five (1.6 per cent) of the patients. The comparison of the personal experience (158 patients) with the experience of other surgeons and registrars performing the biliary tract operations on their own at our institutions (178 patients) allows a conclusion that, if the technique of choledochoscopy is well standardized and correctly learned, no difference in results achieved is to be expect. Operative choledochoscopy is a reliable method of examination supporting valuable diagnostic information, contributing to the operative decision making and reducing efficiently the incidence of retained biliary tract stones.

A retrospective study of surgical common bile-duct exploration: ten years experience.

The results of surgical common bile duct exploration in 1007 patients were evaluated in a retrospective study. Overall mortality was 2%. Under the age of 70 years mortality was 0.9%. Mortality increased significantly in patients older than 80 years (9.5%), including the patients with acute cholangitis. The most frequently encountered complications were wound infection in 7%, severe pulmonary insufficiency in 4%, and cardiovascular problems in 3%. The results of the present series show that in the current state of pre-, intra- and postoperative care surgical common bile-duct exploration has a low morbidity and mortality rate in patients under 80 years of age.

Bristow-Latarjet repair for recurrent anterior shoulder instability; an eight-year study.

A follow-up study was made of 44 patients who underwent 47 should operations as described by Bristow and Latarjet. The group consisted of 32 recurrent shoulder dislocations and 15 so-called spontaneous shoulder instabilities. The average follow-up was 3.7 years. No significant complications occurred either per- or postoperatively and relapse of luxation was not seen. Only one patient had objectively confirmed shoulder instability after the operation. The average limitation of external rotation at 90 degrees abduction was 12 degrees.

Postoperative choledochoscopy. A five-year experience.

In a five-year period postoperative choledochoscopy was used in 85 consecutive patients for therapeutic or diagnostic interventions in the biliary tract. Seventy-three patients underwent postoperative choledochoscopy for removal of retained biliary stones; 67 (92%) had successful removal of 94 retained stones; in 11 stones were located in the intrahepatic ducts; in six postoperative choledochoscopy failed; and in 12 postoperative choledochoscopy was performed for diagnostic or other therapeutic reasons. No serious complications were encountered in this series. The advantage of this simple and effective technique over other instrumental or so-called radiologic techniques is discussed. In our opinion, postoperative choledochoscopy is now the method of choice for diagnostic and therapeutic (re)interventions in the biliary tract by patients with a T tube still in situ.