Peptic ulcer surgery in the nineties: patient profile, immediate results and clinical findings.

The decreasing frequency of elective ulcer surgery and the persisting frequency of emergency surgery for peptic ulcer diseases has often been reported. The reason for the divergent epidemiological behaviour of the two subgroups of surgical candidates is not clear. The present cross-sectional, population-based analysis of patients undergoing peptic ulcer surgery evaluates the mode of preoperative therapy in elective and emergency cases. It also assesses the present frequency of peptic ulcer surgery, ulcer complications, and the immediate results of ulcer surgery in a target population. The evaluation concerned 117 adult patients (F/M ratio 1/1.1, mean age 58.7 +/- 1.8 years) operated on for peptic ulcer disease in Helsinki City between March 1990 and February 1991. The annual frequency of elective surgery was 8.3 and of emergency surgery 20.7 per 10(5) residents in Helsinki. 30% of the patients treated surgically had no preoperative symptoms or antiulcer medication; the others were on on-demand type H2-receptor antagonist therapy. Whereas there was no mortality from the elective surgery the mortality rate for the emergency surgery was 10%, mainly due to cardiopulmonary reasons among elderly, high-risk patients. In conclusion, since our previous report for 1987 for the same target population in Helsinki, the incidence of emergency surgery has additionally increased, while the incidence of elective surgery has continuously decreased.

Benign retroperitoneal schwannoma.

A rare case of benign retroperitoneal schwannoma in a 76-year-old man is reported. Ultrasound and computerized tomography disclosed two cystic retroperitoneal tumors sized 12 cm and 7 cm. The larger tumor was located anterior to psoas muscle and the smaller one was within the muscle. The larger tumor was excised via laparotomy. After 3.5 years follow-up the intramuscular tumor has remained unchanged and the patient has no symptoms.

Primary arterioenteric fistula between common iliac artery and ileum with massive bleeding.

Primary iliac artery aneurysms are rare, and a fistula to the terminal ileum with bleeding is very uncommon. A case with a primary massively bleeding iliaco-ileal fistula is described. In an emergency operation the common iliac artery was ligated and the fistula to the small bowel was resected. Arterial reconstruction was done by extra-anatomical femoro-femoral suprapubic prosthesis. The immediate outcome of the operation was excellent, but the patient died four days later because of acute myocardial infarction.

Peptic ulcer surgery during the H2-receptor antagonist era: a population-based epidemiological study of ulcer surgery in Helsinki from 1972 to 1987.

To evaluate the effects of improvements in medical therapy on the incidence of, indications for and operative methods used in peptic ulcer surgery, all cases of primary peptic ulcer surgery among adults in the city of Helsinki in the years 1972, 1977, 1982 and 1987 were analysed. There was a total of 565 such cases in a population which consisted of 5.2 X 10(5) individuals in 1972 and 4.8 X 10(5) individuals in 1987. The introduction of H2-receptor antagonists in 1979 was associated with a fall in the annual incidence of elective duodenal ulcer operations, from 15.5 to 6.7 per 10(5) individuals, and a fall in the annual incidence of elective gastric ulcer operations, from 9.4 to 3.1 per 10(5) individuals (P less than 0.05). The decrease was greatest among males with duodenal ulcer. In contrast, the annual incidence of emergency surgery for ulcer haemorrhage and perforation (all types of ulcers) remained relatively stable, varying from 7.2 to 10.2 per 10(5) inhabitants over the observation period (n.s.). The mean age of patients undergoing elective surgery remained essentially unchanged. The mean age of patients undergoing emergency surgery increased. The decrease in the annual incidence of elective duodenal ulcer surgery occurred mainly in relation to proximal gastric vagotomy. There was a concomitant relative increase in the incidence of gastric resection. The types of operative procedures used in cases of pyloric, prepyloric and gastric ulcer remained unchanged over the years 1972 to 1987.

Surgical treatment of gastric carcinoma.

To investigate changes in the results of treatment of gastric carcinoma, two 10-year periods between 1963 and 1982 with 641 and 630 patients, respectively, were compared. In the two groups, 94 percent and 92 percent of patients were operated on. The operation was considered curative in 200 and 265 patients in Groups 1 and 2, respectively. There was a shift towards more radical operations, with 215 total or subtotal gastrectomies in Group 2 compared with 76 in Group 1, when distal gastric resection was considered radical enough. Despite the increasing number of curative operations and more radical surgery in Group 2, no progress in the 5-year survival rate was noted. Distal and subtotal gastrectomies gave slightly better results than total gastrectomies, but the most important single factor contributing to the long-term survival was cancerous invasion of the serosa. It is concluded that in the past 20 years, the results of surgical treatment of gastric carcinoma have not improved, despite the more advanced diagnostic methods and more radical surgery.

Effect of PCO2 on intracellular pH in in vitro frog gastric mucosa.

Steady-state intracellular pH (pHi) in 0, 5, and 10% CO2-buffered Ringer solution in sheets of in vitro frog gastric antral or fundic mucosa has been measured using the pH-sensitive fluorescent dye 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein (BCECF). In tissues perfused with N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid (HEPES)-100% O2 buffer [extracellular pH (pHo) = 7.14], steady-state pHi in antral surface cells was 7.08 +/- 0.06 (n = 8), in fundic oxynticopeptic cells 6.91 +/- 0.03 (n = 13), in the muscularis mucosa 7.58 +/- 0.06 (n = 4). In mucosae perfused with 17.8 mM HCO3- -95% O2-5% CO2 buffer (pHo = 7.14), steady-state pHi in antral surface cells was 6.97 +/- 0.02 (n = 22), in fundic oxynticopeptic cells 7.00 +/- 0.04 (n = 18), and in fundic muscularis mucosa 7.39 +/- 0.05 (n = 8). In fundic oxynticopeptic cells perfused with 35.6 mM HCO3- -90% O2-10% CO2 (pHo = 7.14) steady-state pHi was 6.77 +/- 0.07 (n = 4). In tissues equilibrated initially with 100% O2 and changed to 5% CO2, antral surface cells acidified by 0.21 pH units and fundic oxynticopeptic cells by 0.10 pH units, with restoration of pHi to resting levels within 30 and 10 min, respectively. Exposure of tissues initially equilibrated with 5% CO2 to 100% O2 alkalinized antral surface cells by 0.22 pH units and fundic oxynticopeptic cells by 0.23 pH units, with only partial recovery of pHi by 30 min. These data suggest that steady-state pHi is equivalent in surface and oxynticopeptic cells and is lower than in the muscularis mucosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Human epidermal growth factor: renal production and absence from plasma.

Among the unsettled questions in the physiology of human epidermal growth factor (EGF) are (1) does EGF circulate in the blood and (2) what is the source of the abundant urinary immunoreactive EGF (irEGF). Therefore, we monitored the concentration of irEGF by an ultrasensitive assay in blood plasma from 5 healthy subjects every 20 min overnight carefully avoiding activation of platelets. Detectable levels (0.8-3.7 pM) were observed in only one of the subjects, in 5 of 29 samples. In random day-time plasma samples from 18 healthy adults, EGF was undetectable (less than 0.8 pM) in 13 subjects, and in 5 subjects EGF levels ranged from 2.2 to 4.9 pM. Furthermore, in 5 patients with a tumor in a functioning kidney we measured urinary relative irEGF concentration (nmol/mmol creatinine) before and after unilateral nephrectomy. The concentration fell by approximately 50%. Our findings are consistent with (1) blood irEGF residing exclusively in platelets, and (2) urinary irEGF originating from the kidneys.

Carcinoma of the stomach and its heredity in young patients.

The clinical and histopathologic characteristics of gastric carcinoma in young patients (less than 40 years old) were studied retrospectively. The carcinoma was of the diffuse type in 94% of the young patients, and typical features were poor prognosis, an equal sex ratio, and a strong association with blood group A. The family histories of the young patients were studied. There was a highly significant (p less than 0.001) overrepresentation of gastric cancer in the parents of the index cases. In four instances (13%) the findings were compatible with hereditary cancer. One of the patients belonged to a cancer family syndrome (CFS) kindred. The CFS is an autosomal, dominantly inherited trait for adenocarcinomas is well documented. It seems, on the basis of the present study, that CFS should also be added to the list of genetic risk factors for gastric carcinoma. The high incidence of familial cases indicates the importance of studying the family history of every patient with abdominal symptoms.

Effect of ethanol on frog gastric mucosa. Electrophysiologic and morphologic correlations.

The effects of and recovery from luminal ethanol (0%-100%) were assessed in the in vitro chambered frog gastric mucosa. At concentrations of 5%-10%, the potential difference decreased during exposure, but recovered after washout. No gross or light microscopic changes were observed. During exposure to 20%-40% ethanol, potential difference and short circuit current decreased and resistance increased, with only partial recovery after removal of the alcohol. Acid secretion ceased at 20% ethanol and alkalinization of the luminal solution was observed at greater than or equal to 30% ethanol. Microscopy of this group showed discharge of mucus, separation of oxynticopeptic cells from the basal lamina, and slough of surface epithelium. At 60%-100% ethanol, potential difference and short circuit current decreased and resistance increased markedly but there was no recovery. Microscopy showed changes similar to those of the intermediate group (20%-40%), except that surface epithelial cells were fixed to the basal lamina rather than sloughing. The morphologic effects of 100% ethanol in vivo were similar to those in vitro. Pretreatment with 10(-5) M 16,16-dimethyl prostaglandin E2 did not prevent either the electrophysiologic or the histologic changes caused by 20% and 30% ethanol. We conclude that there is a gross discrepancy between the functional and morphologic findings after high concentrations of luminal ethanol.

Near-total gastrectomy for gastric cancer.

Fifty-nine consecutive patients (95 percent) with gastric cancer of the distal portion of the stomach were operated on with 95 percent subtotal gastrectomy between 1975 and 1980. The operations were for cure in all cases. Twenty-five patients were alive after 5 years, for a crude 5 year survival rate of 42 percent. The operative mortality rate was 5 percent (three patients). Twenty-four patients (41 percent) had complications, which consisted of postoperative respiratory infection in 11 patients (19 percent), postoperative ileus in 4 patients (7 percent), and subphrenic abscess in 2 patients (3.4 percent). In addition, there was one wound dehiscence and one liver rupture (with fatal outcome), one deep venous thrombosis, one urinary infection, and one wound infection. Only one patient (1.7 percent) had an anastomotic leak at the gastrojejunostomy site. Seven relaparotomies (12 percent) had to be performed for complications. We have concluded that, in patients with distal gastric cancer, 95 percent subtotal gastrectomy can result in a 5 year survival rate that is comparable to that reported in the literature for total gastrectomy, and it has the advantage of a very low rate of anastomotic leakage between the minute gastric remnant and the jejunum. Therefore, 95 percent subtotal gastrectomy is recommended over total gastrectomy in the treatment of distal gastric cancer.

Urinary epidermal growth factor concentrations in various human malignancies.

We determined the concentrations of immunoreactive epidermal growth factor in the urine (U-irEGF) of 97 adult patients with various malignancies, including carcinomas of the urinary bladder, kidney, stomach, colon, rectum, breast, endometrium, uterine cervix, ovary, vagina, prostate, pancreas and thyroid, liposarcoma and skin melanoma. The relative U-irEGF concentrations (ng m-1 creatinine) were higher (P = 0.002) for the whole series of female patients than for healthy controls matched for sex and age. Such difference did not appear for male patients. The only specific group with a statistically supranormal U-irEGF concentration (P = 0.0005) comprised women with endometrial carcinoma of the uterus.

Local management in primary breast cancer. Our experience of 331 cases.

The peroperative exploration of axillary content gave wrong result from the stage of axillary nodes in every fourth case compared with the final result of axillary evacuation. There were no locoregional recurrences in stage I-patients irradiated after mastectomy. In postoperatively irradiated stage II-patients there were locoregional recurrences in 2.5% of cases, which was 1/8 of recurrences of patients not irradiated postoperatively.

Analysis of 58 patients surviving more than ten years after operative treatment of gastric cancer.

We evaluated 58 patients who were still alive more than ten years after operative treatment of gastric cancer. We reexamined their histologic specimens and compared them with those of matched paired controls of the same sex and age who had died of gastric cancer. Forty-two patients consented to a follow-up study. The age of the patients did not affect survival. For patients with gastric cancer, those with distal cancer or an ulcer simulating cancer had had a better prognosis. Forty percent of the patients had had an early gastric cancer. Only two patients had had lymph node metastases in regional lymph nodes, and macroscopic tumor growth through the serosa had been recorded in only four cases. In 23 cases, a distal resection had proved successful. No significant correlation between intestinal or diffuse types of cancer and prognosis was observed. One recurrence after ten years was found; in one case, there was a new cancer in the gastric remnant. In addition, biopsy specimens from two patients showed grave dysplasia. We suggest that throughout their lives annual follow-up examinations be performed in patients who have undergone radical operations for gastric cancer.

Total and near-total gastrectomy for gastric cancer in patients over 70 years of age.

A total or near-total gastrectomy was performed in 52 patients over 70 years of age in our hospital from 1975 through 1982. The hospital mortality rate was 9.6 percent. The operation was palliative in nine patients. In these patients, the operation was performed because of an obstructing cancer. At last follow-up, 11 patients had survived more than 5 years and 6 patients were alive and free of disease more than 3 years after the operation. Total and near-total gastrectomies seem to be justified in elderly patients in good overall physical condition.

A suggested follow-up time for breast cancer patients.

The data for this study, consisting of 300 females treated for breast cancer in 1951-1961, were evaluated in order to ascertain when excess mortality from breast cancer disappears and what would be an appropriate follow-up period for investigational purposes. The clinical stages of the patients were classified as follows: 23.3%, stage I; 49%, stage II; 20.3%, stage III and 7.3%, stage IV. Halsted's radical mastectomy was performed in 79.7% of the cases. Every patient was given radiotherapy. Two hundred and ninety-eight patients could be followed until death or up to the present. Forty-five patients (16%) were still alive. The survival rate over a 20-year period for the various stages was as follows: stage I, 46.1%; stage II, 22.7% and stage III, 10.9%. Only 26% of the patients with stage I died of breast cancer, while the respective figures for stage II were 57% and stage III, 70%. The death rate from the cancer diminished with time in every stage especially 10 years after primary treatment. After this the observed survival rate curves were almost parallel with the expected curves. Our data show that for follow-up studies a 5-year follow-up is good and a 10-year follow-up is very good to show the trend in the treatment of breast cancer.

Total gastrectomy with esophagojejunostomy. Analysis of 100 consecutive patients.

One hundred consecutive patients treated for gastric cancer by total gastrectomy from 1977 to 1982 at the second department of surgery of the Helsinki University Central Hospital were analyzed. The mean age of the patients was 61.5 years. Gastroscopy proved to be diagnostically superior to roentgenographic examination, particularly in cases of proximally located cancer. The mean length of postoperative hospital stay was 19.7 days, and the hospital mortality was 8 percent. Respiratory complications accounted for nearly half of the complications, and postoperative intraabdominal complications were recorded in 15 patients. Reoperation was performed on eight patients during the initial hospital stay due to complications. The results suggest that total gastrectomy is a safe procedure with an acceptable mortality rate, and it can be recommended both as a curative and a palliative operation in patients with gastric cancer.

Factors influencing 5-year survival in gastric malignancies after total gastrectomy.

One hundred consecutive patients were analysed who had been treated with total gastrectomy in the Second Department of Surgery, Helsinki University Central Hospital, for malignancies of the stomach from 1977 to 1982. Hospital mortality was 8%. The 5-year survival rate in this selected group of patients was 43% and 34% for patients with gastric cancer. Patients with metastases died within 42 months, more than half of them within one year. However, palliative total gastrectomy is recommended in proximally located obstructing tumours. Radical operations on patients with tumour growth to adjacent tissue and organs had no effect on the 5-year survival rates compared to those on patients with metastases. Surgical removal of the primary tumour is recommended in these cases as well. Patients without lymph node metastases had a survival rate of 67% but the prognosis was even better in cases with intact serosa (96%).

Changes in the treatment and prognosis of breast cancer.

The data of 331 women with breast cancer treated in the Second Department of Surgery, Helsinki University, during the period 1976-1980 (patient material, treatment, prognostic factors) is evaluated and compared with an equally large patient material treated during the period 1951-1961 in the same hospital. A breast lump was the main symptom in 94% and the tumour was found by the patient in most cases. Only two patients were younger than 30 years. The median delays to the first medical contact and to operative treatment were 30 and 20 days respectively. The delay had no influence on the prognosis. Also, the age of the patients and the localization of the tumour had no significant effect on the prognosis. Simple mastectomy with axillary lymph node excision was the main operative treatment in the present material whereas Halsted's radical mastectomy was frequently performed in the previous study. Operative radicality was the same in both studies. The prognosis has improved in all clinical stages. The present relative five year survivals in stages I-IV were 95, 83, 53 and 18%, whereas in the previous study they were 75, 58, 41 and 0%, respectively. The improvement in stage II-IV breast cancers is probably due to advances in radio- and chemotherapy. However, the improvement in the prognosis of stage I and to a lesser extent of stage II breast cancers cannot be explained on this basis alone. Neither do the shorter delays in treatment fully explain the differences in the prognosis. The most frequent sites of metastasis were bone and lung/pleura where almost half of the total metastasis occurring during the follow-up were found.