Pancreaticoduodenectomy for periampullary cancer in patients more than 70 years of age.

BACKGROUND/AIMS: To assess the indications for and results of pancreaticoduodenectomy in patients more than 70 years old with periampullary cancer. METHODOLOGY: Thirty-four consecutive patients older than 70 years with periampullary cancer. The surgical procedure was pancreaticoduodectomy (Whipple's operation) with an extensive dissection of lymph nodes and the connective tissue in the peripancreatic region. Main outcome measures were postoperative morbidity and mortality, median and 5-year survival rates. RESULTS: Postoperative medical complications occurred in 24% and surgical complications in 53% of the patients. Four patients (12%) died in the postoperative period (within 30 days), and 3 patients (9%) died later in the postoperative course. The cumulative and age corrected 5-year survival rate for the remaining patients was 26%. Fifteen patients died of recurrence, and 7 patients of other causes. Five patients are still alive more than 5 years after surgery. In patients with noncurative operation the median survival time was 1 1/2 years, which is longer than would be expected from other palliative procedures. Apart from a moderately increased postoperative mortality the results were similar to those reported for younger patients. CONCLUSIONS: Pancreaticoduodenectomy should be considered in patients older than 70 years with resectable periampullary cancer. A 5-year survival rate of 20-35% can be obtained. Palliative resection may be indicated in patients in good general condition, as resection gives the best palliation and longer survival than other palliative methods.

Clinical efficacy of micronized purified flavonoid fraction: an overview.

Flavonoids are widely used for the treatment of chronic venous insufficiency (CVI). In clinical trials, micronized purified flavonoid fraction (MPFF, 450 mg diosmin plus 50 mg hesperidin, Daflon 500 mg) has demonstrated its activity in CVI by improving venous tone and vein elasticity assessed by plethysmography. Randomized, double-blind, placebo-controlled clinical studies have shown an improvement in signs and symptoms related to CVI and a decrease in leg circumferences at the levels of the ankle and calf. The effect of MPFF on microcirculatory parameters suspected of participating in the pathophysiological process of venous ulceration has been investigated in patients. These include hemorheological parameters and transcutaneous oxygen tension measurements, which were shown to improve after treatment with MPFF. Finally, a randomized double-blind, placebo-controlled clinical study has shown that MPFF treatment for 2 months, in addition to standard compression therapy, accelerates leg ulcer healing in patients with ulcers

[Pancreaticoduodenectomy--Whipple's operation--for periampullary cancer in patients over 70 years of age]. / Pankreatikoduodenektomi--Whipples operation--for periampullaer cancer hos patienter over 70 år.

Thirty-four consecutive patients with an age over 70 years with periampullary cancer were operated on with pancreaticoduodenectomy (Whipple's procedure). The operative procedure included an extensive dissection of the regional connective tissue and lymph nodes including the retroperitoneum. Postoperative medical complications occurred in 24% and surgical complications in 53% of the patients. Four patients (12%) died in the postoperative period (within 30 days), and three patients (9%) died later in the postoperative course. The cumulative and age corrected five-year survival for the remaining patients was 26%. Fifteen patients died from recurrence, and seven patients from other causes. In patients with a non-radical operation the median survival was 1 1/2 years, which is longer than could be expected with other palliative procedures. Apart from a moderately increased postoperative mortality the results were similar to those reported for younger patients. In conclusion, pancreaticoduodenectomy may be considered in patients with an age over 70 years with operable periampullary cancer. A five-year survival rate of 20-35% can be obtained. Palliative resection is indicated in patients in good general condition, as resection gives the best palliation and longer survival than other palliative methods.

[Transjugular intrahepatic portosystemic shunt. Treatment of patients with recurrent bleeding from esophageal varices]. / Transjugular intrahepatisk portosystemisk shunt. Behandling af patienter med recidiverende esophagusvariceblødning.

We report the results of transjugular intrahepatic portosystemic shunt (TIPS) procedure in six patients with liver cirrhosis and recurrent bleeding or acute intractable bleeding from oesophageal varices in spite of multiple sessions of sclerotherapy. Median follow-up was 15 months (range 1-24 months). The procedure was technically successful in all patients without procedure-related morbidity or mortality. Four of the procedures were performed electively and two as an emergency procedure. The portosystemic pressure gradient decreased to below 12 mmHg following TIPS implantation and the shunt bloodflow was one quarter to three-quarters of the portal bloodflow determined by Doppler ultrasound. Recurrent bleeding occurred in one patient but was amenable to endoscopic sclerotherapy. In this patient the shunt had developed a stenosis that was treated by balloondilatation and insertion of an additional stent six months following the initial procedure, and no further bleeding occurred. The remaining five patients had no rebleeding episodes. Repeated Doppler examinations in the followup period demonstrated patency of all shunts. None of the patients developed portosystemic encephalopathy. One patient died of cerebral haemorrhage, unrelated to TIPS, 16 months following implantation. Another patient died 14 months following TIPS due to acute mesenteric occlusion and septicaemia. We conclude that TIPS is feasible and effective in selected patients with liver cirrhosis and persistent or recurrent variceal bleeding following repeated endoscopic therapy.

[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.

[Augmentation ileo-cystoplasty in women with disabling urge incontinence]. / Augmentationsileocystoplastik hos kvinder med invaliderende imperiøs vandladningstrang.

The results after "clam"-augmentation cystoplasty are assessed in 11 consecutively operated women aged 35-78. All were suffering from severe urgency. Eight were urge-incontinent and six of these stress-incontinent as well. Nine patients had been operated before with a total of 14 operations. Bladder distension and parasympatholytic medication had been tried in two and seven instances respectively. One patient died of a pulmonary embolism three weeks postoperatively. Follow-up ranged from 12-52 months, mean 29 months. Eight (80% (44-97)%) of the remaining 10 patients were cured with respect to urgency. One patient was improved, and one unchanged. Three (60% (15-95)%) out of five previously stress-incontinent patients were dry, one was improved and one unchanged in spite of a subsequent stamey urethrosuspension. Eight patients (80% (44-97)%) had spontaneous micturition, one used self-catheterisation once daily and one patient was retained on an indwelling catheter. It is concluded that augmentation cystoplasty is a procedure of considerable value in patients with disabling non-neurogenic urgency, where conservative therapy and previous surgery has failed.

Flavonoids. A review of the pharmacology and therapeutic efficacy of Daflon 500 mg in patients with chronic venous insufficiency and related disorders.

Daflon 500 mg consists of 450 mg diosmin and 50 mg flavonoid expressed as hesperidin. The authors describe its effects on the microcirculation in chronic venous insufficiency: improvement of venous tone, inhibition of prostaglandin synthesis, protection against free radicals, activation of the complement system, and increased lymphatic drainage. The authors summarize studies of its therapeutic efficacy in reducing venous capacitance, distensibility, and emptying time; reducing capillary permeability; and increasing capillary resistance.

[Computed tomographic detection of air in the portal vein--a case report]. / Computertomographischer Nachweis von Luft in der Pfortader--Ein Fallbericht.

Two cases of portal venous gas (PVG) are presented. One case due to bowel infarction and another due to duodenal ulcer perforation complicated by a subphrenic abscess. The diagnosis was suggested from plain abdominal radiographs and confirmed by unenhanced computed tomography (CT) of the abdomen which is superior to demonstrate gas in the portal venous system. The distinction between PVG and biliary gas is briefly discussed.

Ambulatory strain-gauge plethysmography and blood volume scintimetry for quantitative assessment of venous insufficiency.

In the present study, a strain-guage plethysmographic method (ASGP) is compared to an isotope plethysmographic method (ABVS), in order to evaluate how an externally recorded volume change corresponds to blood displacement within the leg during exercise. The coefficient of correlation for RT (venous return time) was 0.67 (P less than 0.001) and for EV (expelled volume) it was 0.61 (P less than 0.001). The RT values were similar by the two methods both in healthy controls and in patients with Chronic Venous Insufficiency (CVI). The corresponding EV values showed the same pattern in controls and patients but the values differed substantially. By ASGP the value was approximately 2 ml per 100 ml tissue compared to 33 ml per 100 ml blood by the ABVS method. Both methods could clearly distinguish normal controls from patients with chronic deep venous insufficiency, but ABVS could only make this distinction when the ankle area of measurement was applied.

The treatment of female bladder neck dysfunction.

During the period 1981-88, 38 women who eventually had the diagnosis of bladder neck obstruction established, were treated by bladder neck incision. Their age range was 28-85 years. The preoperative investigations included a full urodynamic examination and urethro-cystoscopy. The gynecologic examination was normal. The most constant finding was an elevated, rigid bladder neck seen by endoscopy. The treatment included a bladder neck incision either at 4 or at 8 o'clock. The results four weeks postoperatively were good, the symptoms had disappeared or the patients were improved in most cases, and the flow curves were normalized. Mean observation time was 55 months. After a longer period of time the symptoms in some cases returned, and then the incision was repeated. After the final control, we found 76% of the patients symptomatically improved.

Venous muscle pump function during pregnancy. Assessment by ambulatory strain-gauge plethysmography.

The venous muscle pump function was quantitatively assessed through pregnancy weeks 16, 30, 38 and 3 months (week 53) following delivery, in 24 pregnant women who completed a normal pregnancy. A statistically significant increase was found in the mean venous reflux (P less than 0.01), which was restored to initial values postpartum. Expelled calf volume remained stable throughout pregnancy but increased following delivery. Venous outflow from the legs was significantly reduced in the third trimester. Subjective symptoms of venous insufficiency increased through pregnancy, but, these symptoms had virtually disappeared post partum, corresponding to the muscle pump normalization. No statistical correlation was found between venous muscle pump values and changes in hormone concentrations of estradiol, estriol and progesterone. It is suggested that venous insufficiency development in pregnancy is caused primarily by mechanical obstruction, or hormonal influence other than that of estradiol, estriol or progesterone. 17% (4.7-37%) of the women with a normal pregnancy developed a pathological venous muscle pump function.

Late cosmetic results of wound closure, strips versus suture.

Following 264 non-contaminated abdominal operations, skin closure was performed after randomization to Steri-Strip tape suture or conventional continuous 3-o or 4-o Dermalon suture. The cosmetic results were evaluated six and 46 months after the operation. In the six-month review Steri-Strip tape suture showed advantages over conventional suturing. However, follow-up of 217 patients revealed no significant differences in late cosmetic results after about four years.

Assessment of venous muscle pump function by ambulatory calf volume strain gauge plethysmography after surgical treatment of varicose veins: a prospective study of 21 patients.

A prospective study of the improvement in leg muscle pump function after radical surgery was performed for treatment of varicose veins. Venous muscle pump function was assessed in 21 patients with primary varicose veins by means of ambulatory strain gauge plethysmography immediately before surgery and 3 months and 60 months after surgical treatment of varicose veins. The physiologic documentation of the operative efficacy was provided by the mean venous reflux, which was reduced by 54% (p less than 0.001), and the mean expelled volume, which was increased by 58% (p less than 0.001). Initially, all patients had improved venous muscle pump function. This improvement was still present 60 months after surgery. At clinical assessment 3 months after surgery, it was noted that 90% of the patients were without residual varicose veins (p less than 0.01). Sixty months after surgery, 71% of the patients were without apparent varicose veins (p less than 0.05). Subjective symptoms had virtually disappeared 3 months after surgery (p less than 0.001) but were found to a variable extent in 80% of the patients at the 60-month control follow-up. It is concluded that ambulatory strain gauge plethysmography may quantitate the effect of surgery in patients with venous valvular incompetence; in addition to measurements of refilling time, it is able to measure the muscle-pump-generated expelled volume because of in-place electrical calibration.