[Surgical treatment of hip fractures in 90-year-olds]. / Operatieve behandeling van heupfracturen bij 90-jarigen.

During 1973-1987 178 patients of 90 years and over were operated for a fracture of the hip in the Diaconesseninrichting 'Bronovo', The Hague. Fifty patients were suffering of senile dementia which made reactivation difficult and contributed to 43% of the mortality. The overall in-hospital mortality was 18% and the survivors were discharged after 35 days on average. Patients with lateral and pertrochanteric fractures were treated according to McLaughlin (6), to Ender (74) and with a dynamic hip screw (17) and medial fractures with a dynamic hip screw (54) or a prosthesis (27). The in-hospital mortality rates were 16, 28, 6, 11 en 11% respectively. Postoperatively 7 Ender pins sagged out and 6 patients treated with a dynamic hip screw secondarily needed a prosthesis, 3 of them after discharge. It is advised to use Ender pins in lateral or pertrochanteric fractures in inactive patients only, and a dynamic hip screw in active patients; in medial fractures a dynamic hip screw only in inactive patients and in others a prosthesis. An increase in the number of very old people with hip fractures is to be expected in the near future.

[False aneurysm in prosthesis of the abdominal aorta]. / Valse aneurysmata bij prothesen van de aorta abdominalis.

A false aneurysm in the suture line of a vascular prosthesis is reported in 4 patients. The complications encountered in these patients are discussed. In patients with an aortic bifurcation prosthesis and with unexplained pain, fever or intestinal bleeding further analysis is indicated to exclude a false aneurysm.

Carcinoma of the duodenum.

Primary carcinoma of the duodenum is an uncommon tumor of the gastrointestinal tract. We reviewed the histories of ten patients seen between 1976 and 1986. Some of the patients with tumors in the second part of the duodenum presented with clinically evident jaundice. The symptom complex of all other patients was compatible with many benign diseases and made the diagnosis difficult. At laparotomy, seven patients had resectable disease. Two patients had advanced disease so that no curative resection could be done. In one patient, a resection was technically impossible. A modified Whipple procedure (in which the pylorus is saved) is the method of choice for tumors of the second part of the duodenum. We perform a segmental resection for other tumors. In five patients, there was no involvement of the lymph nodes and these patients are well--two more than 30 months postoperatively and one patient almost ten years postoperatively. In two patients, one or more lymph nodes were involved, but they are still well 30 months postoperatively. As the prognosis of carcinoma of the duodenum, once metastasized, is poor, a greater awareness of the possibility of a duodenal tumor must accompany aggressive diagnostic and surgical procedures. That will be the only way to a higher percentage of cures.

Achalasia of the cardiac sphincter and the pylorus?

A patient with a recurrent achalasia of the cardia was found, after a Heller cardiomyotomy, also to have pyloric insufficiency necessitating gastric resection. The pylorus appeared to contain virtually no ganglia at all. On the basis of an experiment with rabbits, in which vagotomy was shown to have no appreciable effect on the ganglion cells in the pylorus, it was concluded that the abnormality demonstrated in this patient could not be attributed to a possible injury of the vagus nerves but was probably due instead to achalasia of the pylorus.

Ulceration and necrosis of the gastric wall after highly selective vagotomy.

With reference to the case-histories of nine patients with necrosis of the gastric wall and to other data culled from the literature, the hypothesis is advanced that occasionally the gastric ulcer may be the result of ischemia of the lesser curvature caused by the devascularization which is part of the HSV procedure, and that such an ulcer and necrosis of the gastric wall are both consequences of ischemia, differing only in degree.

Surgical treatment of the bleeding peptic ulcer.

Sixty-six patients were subjected to operation for a bleeding ulcer, 14 of them died. There was little difference between the results of truncal vagotomy and resection, in contrast to reports in the literature that vagotomy gave better results especially in duodenal ulcer. Emphasis is laid on the importance of locating the hemorrhage preoperatively. The mortality rate of the operation is determined to a significant extent by the patient's condition at the time of onset of the hemorrhage.

Fractures of the hip in the tenth decade of life. Findings in 25 cases.

A report is given of the results of treatment of 25 patients with a fracture of the hip who were over 90 years of age. Twenty three patients were subjected to operation: 5 of these died in hospital, but not as a direct consequence of operation. Of the 18 patients discharged after an average hospital stay of 32 days, 13 were able to walk independently at home, on the average for over two years. It is concluded that surgical treatment of fractures of the hip in very old people is advisable and useful, provided they are in reasonable general condition and do not exhibit dementia.