Primary and repeated perineal stapled prolapse resection.

BACKGROUND: Previous studies of the outcome after perineal stapled prolapse resection (PSPR) have included a limited number of patients with a short follow-up and high recurrence rates. The present study was designed to assess the initial results, complications, recurrence rate, and outcomes up to 4 years after PSPR, as well as the need for a repeated procedure. METHODS: Fifty-four consecutive patients with rectal prolapse (mean age 77.2 years, range 46-93 years; n = 3 men) were selected for PSPR between May 2009 and February 2015. Prolapse length was measured at baseline and after surgery. Patients were asked to grade intensity of symptoms as a satisfaction score of 1-10, 10 representing being symptom-free. RESULTS: The mean operation time was 45.3 min (SD = 17.5, range 25-95 min). The mean rectal prolapse length was reduced significantly from 9.5 cm (SD = 5.0, range 4-30 cm) to 1.2 cm (SD = 2.6, range 0-10 cm; p < 0.0001). Bleeding requiring surgical intervention occurred in two patients (3.7%). Postoperative satisfaction score increased from a mean of 2.2 (SD = 0.9) to a mean of 6.4 (SD = 2.8, p ≤ 0.0001). After a mean follow-up of 13.4 months (SD = 14.1), six patients with recurrence underwent a new PSPR and five patients underwent colostomy, mainly because of incontinence, resulting in a recurrence rate of 20.4%. There were no complications after redo PSPR, and after a median of 10-month follow-up (range 6-37), there were no recurrences. CONCLUSIONS: PSPR is a rather new surgical procedure for external rectal prolapse. Immediate complications are few and not serious. Although recurrences can be treated with a second PSPR, the operation may only be the best option for old and fragile patients with comorbidities and a short life expectancy.

[Massive gastrointestinal hemorrhage from the jejunum caused by Dieulafoy's lesion]. / Massiv gastrointestinal blødning fra jejunum forårsaget af Dieulafoys laesion.

A 54-year old woman was admitted to the hospital because of massive haematochezia. Emergency surgical exploration was performed and by a simple method the source of bleeding was localized and treated. We discuss one of the major problems in all GI-bleeding that lies in establishing the diagnosis. With localization in the small bowel the problem is even bigger because this part of the bowel isn't examined by conventional endoscopy. This case-story should be a reminder of the small bowel as a source of bleeding when conventional upper and lower endoscopy does not reveal the bleeding source.

Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial.

OBJECTIVE: To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day. DESIGN: Randomised controlled trial. SETTING: Copenhagen, Denmark. SUBJECTS: 42 alcoholic patients without liver disease admitted for elective colorectal surgery. INTERVENTIONS: Withdrawal from alcohol consumption for 1 month before operation (disulfiram controlled) compared with continuous drinking. MAIN OUTCOME MEASURES: Postoperative complications requiring treatment within the first month after surgery. Perioperative immunosuppression measured by delayed type hypersensitivity; myocardial ischaemia and arrhythmias measured by Holter tape recording; episodes of hypoxaemia measured by pulse oximetry. Response to stress during the operation were assessed by heart rate, blood pressure, serum concentration of cortisol, and plasma concentrations of glucose, interleukin 6, and catecholamines. RESULTS: The intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm2 v 12 mm2, P=0.04), but not after surgery (3 mm2 v 3 mm2). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P

Lack of relationship between serum and gallbladder bile calcium in patients with gallstone disease.

BACKGROUND: Recent studies suggest that alternation in serum calcium influences the level of gallbladder bile ionized calcium (Ca2+). Theoretically, this could increase the risk of calcium precipitation in the gallbladder. METHODS: We therefore measured serum and gallbladder bile minerals in patients with gallstones (n = 27) and without (n = 10, controls). The serum samples were taken just prior to induction of anaesthesia and gallbladder bile was aspirated before any manipulation of the gallbladder. RESULTS: The active molality of Ca2+ in gallbladder bile was not statistically significant different between cases and controls (0.44 +/- 0.16 vs. 0.40 +/- 0.10 mmol/kg), whereas pH was significantly lower (6.94 +/- 0.31 vs. 7.36 +/- 0.28, p < 0.0001) and cholesterol higher (4.37 +/- 2.70 vs. 1.79 +/- 1.33 mmol/l; p < 0.01) in gallbladder bile obtained from cases. Serum Ca2+ at actual pH, magnesium and phosphate were significantly higher among cases than in controls. Gallbladder bile active molality of Ca2+ was significantly correlated with bile total calcium in both groups (r = 0.72; p < 0.001 and r = 0.91; p < 0.001, respectively). In controls only, we observed a positive relationship between serum Ca2+ at actual pH and the active molality of Ca2+ in bile (r = 0.61; p < 0.05). CONCLUSION: Our study demonstrates that Ca2+ in gallbladder bile does not differ between cases and controls. The lack of correlation between serum and gallbladder bile constituents in cases compared to controls suggests that changes in calcium equilibration between bile and serum in patients with gallstone disease might be of importance for the formation of gallstones.

[Liver trauma]. / Levertraumer.

Over a 15-year period 43 patients were treated for liver trauma in a surgical department, subspecialized in liver surgery. The trauma mechanism was blunt in 88% and penetrating in 12%. According to the Organ Injury Scale system of liver trauma, they consisted of 10 in class I, three in class II, 16 in class III, 11 in class IV and three in class V. Thirty-seven patients were treated operatively while six patients were treated conservatively. The overall mortality rate was 9% and liver related mortality 7%. Other organ lesions were present in 53% of the patients. Patients treated conservatively met initial criteria of which the most important was haemodynamic stability. The most important diagnostic method was CT. If strict criteria are followed, a large proportion of liver trauma patients can be treated nonoperatively, provided there is adequate surveillance facilities including CT, and operative capacity to meet unexpected late bleeding complications.

[Hepatic metastases disclosed by laparoscopy and echographic laparoscopy. Impact of ultrasound-guided biopsy]. / Métastases hépatiques découvertes par laparpscopie et écho-laparoscopie. Impact de la biopsie échoguidée.

UNLABELLED: The aim of this prospective study was to study the impact of biopsies of liver metastases guided by laparoscopic ultrasound (LUS) and to evaluate various biopsy techniques. MATERIAL AND METHODS: Laparoscopy with LUS was performed on 18 consecutive patients with liver metastases considered to be surgically curable. Any new liver lesion which could lead to a therapeutic modification was biopsied, with a forceps or guided by LUS using four different techniques. RESULTS: Of 17 patients successfully examined, a biopsy was indicated in 12 cases (71%), extension of the surgical procedure was decided in four cases (24%), and laparotomy was avoided in six cases (35%). The preoperative staging was correct in 15 stages (88%) and incorrect in two cases (12%). The positioning of the puncture needle in the axis of the scanning plane by "free hand" or in association with an abdominal transducer was effective, without complications. CONCLUSION: Any liver lesion discovered by LUS which could lead to a modification or abstention of surgery should be biopsied, with LUS-guidance in the case of deep lesions. However, an optimal and universal guiding system for LUS-probes, has not yet been developed.

[Liver resection of metastases from colorectal cancer]. / Leverresektion for metastaser fra kolorektal cancer.

From 1978 to the end of 1991, 66 patients were operated on for liver metastases from colorectal cancer. All patients had had a curative resection of their colorectal cancer. Forty resections of the liver were major anatomic resections. This study was undertaken to determine the indications for and value of liver resection for metastases from colorectal cancer. Five patients died in the postoperative period. All resections were intended to be curative, but in 16 of the patients the resection became noncurative. None of these patients lived more than two years after liver resection. Fifty patients with a curative resection had a three-year survival rate of 36 percent, postoperative death included. Recurrence in the liver was observed in 30 patients (60 percent) from three to 33 (median 11) months after the liver resection. Four patients had repeated resections performed. Two of them are alive without recurrence at respectively 34 and 60 months after the first liver resection. The difference in survival between curative and noncurative liver resection was highly significant (p = 0.01). Sex, age, Dukes' stage of primary colorectal cancer, synchronous or metachronous appearance of metastases, or number of metastases could not predict long-term prognosis. The only factors of predictive value were tumour size, a free resection margin, and no extrahepatic tumour. If it is possible to perform a curative resection, there should be few contraindications against liver surgery as it is the only treatment that can demonstrate long-term survival for approximately one-third of the patients, and it is the only possibility of cure. Palliative resection is not recommended.

Resection of liver metastases from colorectal cancer. Indications and results.

PURPOSE: This study was undertaken to determine the indications for and value of liver resection for metastases from colorectal cancer. METHODS: From 1978 through 1991, 66 patients were operated on for liver metastases from colorectal cancer. All patients had had a curative resection of their colorectal cancer. Forty resections of the liver were major anatomic resections. RESULTS: Five patients died in the postoperative period. All resections were intended to be curative, but in 16 of the patients the resection became noncurative. None of these patients lived more than two years after liver resection. Fifty patients with a curative resection had a three-year survival rate of 36 percent, postoperative death included. Recurrence in the liver was observed in 30 patients (60 percent) from 3 to 33 (median, 11) months after the liver resection. Four patients had repeated resections performed. Two of them are alive without recurrences 34 and 60 months after the first liver resection, respectively. The difference in survival between curative and noncurative liver resection was highly significant (P = 0.01). CONCLUSIONS: Sex, age, Dukes stage of primary colorectal cancer, synchronous or metachronous appearance of metastases, or number of metastases could not predict long-term prognosis. The only factors of predictive value were tumor size less than 4 cm in diameter, a free resection margin, and no extrahepatic tumor. If it is possible to do a curative resection, there should be few contraindications against liver surgery as it is the only treatment that can demonstrate long-term survival for approximately one-third of the patients, and it is the only possibility of a cure.

Single stage pancreaticoduodenectomy (Whipple's procedure), radical cystectomy and bladder substitution with the urethral Kock reservoir. Case report.

Single stage radical cystectomy and pancreaticoduodenectomy (Whipple's procedure) was carried out in a 59-year old man for a benign pancreatic tumour (ancient schwannoma) and multifocal invasive bladder cancer. Urinary diversion was carried out using the urethral Kock reservoir.

Contrast radiography in small bowel obstruction. A randomized trial of barium sulfate and a nonionic low-osmolar contrast medium.

Thirty-six adult patients clinically suspected of small bowel obstruction underwent small bowel contrast radiography with either barium sulfate or a nonionic low-osmolar contrast medium after randomization. Films were taken after 2, 4, and 8 hours and later when needed. No difference as regards visualization and diagnostic quality was found between the 2 media. It is concluded that a nonionic low-osmolar contrast medium is an alternative to barium sulfate for small bowel contrast radiography where small bowel obstruction is suspected.

[Femoro-popliteal bypass surgery in Denmark 1983-1987]. / Femoro-popliteal bypass-kirurgi i Danmark 1983-1987.

In a retrospective study of femoro-popliteal bypass surgery in Denmark during the period 1983 to 1987, a total of 1,532 operations were performed. Approximately 2/3 of the patients were operated upon for limb salvage, the remainder for severe disabling claudication. The perioperative lethality was below two per cent in all departments. Early occlusion rate was found to be between 21 and 11 per cent, leading to major amputation in about half of the patients.

[Cimetidine treatment of stomach cancer]. / Cimetidinbehandling ved cancer ventriculi.

The effect of cimetidine treatment in cancer of the stomach was investigated in a double-blind, multicentre study comprising eight departments in Greater Copenhagen. Immediately after operation (or the decision not to operate) 181 patients were subdivided at random to treatment with a placebo or cimetidine in a dosage of 400 mg twice daily for two years or until death. Compliance control was carried out every third month. The mean survival in the cimetidine group (450 days, 1-1,826) was significantly longer (p = 0.02) than in the placebo group (316 days, 1-1,653).

A study of the physiological variation in anal manometry.

The physiological variation in anal manometry using a perfused catheter with radiating sideholes was studied in 78 healthy volunteers. The maximum intraindividual variation in the length of the anal high pressure zone, resting pressure and squeeze pressure was 10 mm, 26 mmHg and 68 mmHg respectively. The median 95 per cent confidence interval for length of the pressure zone was 4 mm; for resting pressure it was 15 mmHg and for squeeze pressure it was 48 mmHg. Day-to-day variation did not exceed the intraindividual variation. Constant recording with the catheter fixed in the high pressure zone revealed slow waves and ultraslow waves with amplitudes of 6-24 mmHg which could account for most of the intraindividual variation. No sex difference was found in the length of the high pressure zone whereas resting pressure and squeeze pressure were higher in men than in women. Although a tendency towards a decrease in the length of the high pressure zone, resting pressure and squeeze pressure was observed with increasing age, no significant age-related difference could be demonstrated.

Effect of cimetidine on survival after gastric cancer.

The effect of cimetidine on survival was investigated in 181 patients with gastric cancer. Immediately after operation or the decision not to operate, the patients were randomised in double-blind fashion to placebo or cimetidine 400 mg twice daily for two years or until death, with review every three months. Median survival in the cimetidine group was 450 days (range 1-1826) and in the placebo group 316 days (1-1653). The relative survival rates (cimetidine/placebo) were 45%/28% at 1 year, 22%/13% at 2 years, 13%/7% at 3 years, 9%/3% at 4 years, and 2%/0% at 5 years. Survival in the cimetidine group was significantly longer than in the placebo group.

A randomized study on hemorrhoidectomy combined with anal dilatation.

Forty patients with third-degree hemorrhoids were randomized in two groups. Seventeen patients had a Milligan hemorrhoidectomy combined with anal dilatation and 23 had hemorrhoidectomy only. Anal manometry was carried out preoperatively at three, six, and 12 months postoperatively. Maximum resting pressure decreased significantly in both groups after surgery, although a small increase in maximum resting pressure was noticed after six months. A significant decrease in anal pressure was measured in both groups after one year. After one year, three patients in the dilatation group had minor degrees of incontinence compared to none in the nondilated group. In both groups three patients complained of recurrent symptoms of hemorrhoids. It is concluded that the combination of hemorrhoidectomy and anal dilatation does not improve cure rate compared to hemorrhoidectomy alone, but may increase the risk of continence disturbances.

Traumatic anal incontinence. Results of surgical repair.

The results after surgical repair of traumatic anal incontinence in 23 patients, 12 with simple lesions and 11 with complicated lesions, were analyzed. Overlapping suture was the standard technique in simple lesions, whereas additional procedures were necessary in complicated lesions. Fifteen patients (65 percent; 95 percent confidence limits: 43-83) had excellent results and seven (30 percent; 13-53) had acceptable results. In patients with simple lesions, the result was excellent in nine (75 percent; 43-94), and was excellent also in six patients with complicated lesions (55 percent; 23-83).