Management of Peutz-Jeghers syndrome. Experience with patients from the Danish Polyposis Register.

Danish patients with Peutz-Jeghers syndrome are registered in the Danish Polyposis Register. We have initiated a new follow-up programme based on recent literature including our own cases. This has been adjusted to the regrowth rate of the polyps whereby patients with no symptoms and low regrowth rate are followed with few examinations. The programme includes upper and lower gastrointestinal endoscopy, small bowel enema and in cases with large or symptomatic polyps, laparotomy with intraoperative total enteroscopy with polypectomy as required. Pelvic examination, cervical smear, breast and testicular examination are carried out after the age of 30 years.

Exulceratio simplex dieulafoy.

During a three year period, 18 patients with the Exulceratio Simplex Dieulafoy lesion of the stomach were treated (nine males and nine females). Because of intermittent bleeding episodes, lack of chronic ulceration of the gastric mucosa and the location of the lesion (most common in the upper part of the stomach), the lesion is easily overlooked at endoscopy and even at laparotomy with gastrotomy. Our treatment includes repeated endoscopies, attempted hemostasis with a combination of injection sclerotherapy and electrocoagulation and, if this is not successful, emergency surgical treatment with wedge resection using a technique with the TA 90 (U. S. Surgical Corp.) linear stapler. The diagnostic and therapeutic problems are discussed on the basis of patient profiles.

Cancer occurrence in a cohort of patients surgically treated for peptic ulcer.

A cohort of 4107 patients treated surgically for peptic ulcer between 1955 and 1960 was followed up to determine the incidence of cancer by record linkage to the Danish Cancer Registry. A total of 930 cases of cancer were observed during 76,634 person-years. Relative risks of cancer were computed by comparison with the recorded cancer incidence in the Danish population. During the first five years after surgery the relative risk of gastric cancer was slightly increased (RR = 1.43), but 5-15 years after the operation the risk was lower than expected (RR = 0.55). Thereafter, the relative risk of gastric cancer increased steadily and increased more than twofold after 25 years. Lung cancer occurred more frequently in the cohort members than expected (RR = 1.66), but the relative risk was independent of time since surgery. Malignancies other than gastric cancer and cancers related to tobacco smoking were close to the expected numbers. The results do not support the findings of a recent British study of similar size in which increased risks were reported for cancer at other sites.

Food-stimulated cholescintigraphy as a supplement to ERC in patients with suspected bile flow obstruction. A preliminary study.

Cholescintigraphy after food stimulation was carried out in 40 patients (13 patients with biliary enteric bypass, 14 patients with bile duct stenosis, demonstrated by ERC, 5 patients with endoprothesis and 8 patients with clinically suspected post-cholecystectomy syndrome. Biliary-bowel transit time of one hour or less was considered to be normal. In patients with biliary enteric bypass 11 had a normal transit time; however, one with a concomitant anastomotic leakage, and 2 patients had prolonged transit time and a significant obstruction by the anastomosis. All 14 patients with demonstrated biliary stricture had normal transit time. In 5 patients with endoprothesis, 2 had prolonged transit time in spite of patent endoprothesis. Finally, in the 8 patients with suspected post-cholecystectomy syndrome, 4 had normal sphincter of Oddi manometry and normal transit time, and 4 had abnormal sphincter of Oddi manometry, but only one with prolonged transit time. It is concluded that in patients with biliary enteric bypass (hepatico-jejunostomia) or biliary strictures a biliary-bowel transit time of one hour will be discriminatory between normal and abnormal conditions. This is in contrast to patients with endoprothesis and suspected sphincter of Oddi dysmotility, where a transit time of one hour only will have limited predictive value.

Comparison of one dose versus three doses of prophylactic antibiotics, and the influence of blood transfusion, on infectious complications in acute and elective colorectal surgery.

In a randomized prospective controlled trial involving 311 patients undergoing acute or elective colorectal surgery, the efficacy and safety of two different single dose and one triple dose regimen of antibiotic prophylaxis, as well as the influence of blood transfusion on postoperative infectious complications, were studied. Postoperative infectious complications occurred in a total of 59 patients (19.0 per cent). There were no major differences between the three treatment groups. Thirty-four patients (10.9 per cent) developed abdominal wound infection, 17 patients (5.5 per cent) intra-abdominal abscess and 16 patients (5.1 per cent) anastomotic leakage. Of 202 patients (65.0 per cent) requiring blood transfusion during hospitalization 57 (28.2 per cent; 95 per cent confidence limits of 23-36 per cent) developed infectious complications, whereas two non-transfused patients (1.8 per cent; 95 per cent confidence limits of 0.2 to 6 per cent; P less than 0.001) developed infectious complications. It is concluded that one single dose of antibiotic prophylaxis in acute and elective colorectal surgery is as protective as a triple dose regimen. The development of infectious complications despite antibiotic prophylaxis is strongly related to blood transfusion.

Gastric cancer after peptic ulcer surgery. A historic prospective cohort investigation.

In a historical prospective cohort investigation of 4131 patients undergoing peptic ulcer surgery in 53 hospitals in the western part of Denmark from 1955 through 1960, the risk of subsequent gastric cancer development was studied. The patients were followed with regard to gastric cancer development until their death or the end of the year 1982 and the incidence of cancer in this cohort was compared to the incidence in the total population in the same region during the same period. A total of 46 gastric cancers were diagnosed versus 47 expected. Up to 15 years after operation the cancer risk was lower than expected. After 15 years the risk was higher than expected with a 2.1-fold higher incidence after 25 years for the total patient population. The highest risk was observed in male subjects undergoing a Billroth II subtotal gastrectomy with a 3.2 times increase in risk after 25 years. There was no difference between gastric and duodenal ulcer patients; and patients undergoing simple suture for a perforated ulcer showed no increase in cancer incidence. Patients with long-lasting symptoms had the same incidence as patients with briefer symptoms. These observations indicate that the operation per se and not the ulcer disease may be precancerous.

Cefoxitin for one day vs. ampicillin and metronidazole for three days in elective colorectal surgery. A prospective, randomized, multicenter study.

In a multicenter study the prophylactic efficacy of two antibiotic regimens was tested against postoperative septic complications following elective colorectal surgery. The study was conducted in a prospective block-randomized design. Patients were preoperatively allocated to either ampicillin, 1 gm, four times daily, and metronidazole, 0.5 gm, three times daily, for 72 hours, or to cefoxitin, 2 gm, given three times in a period of 10 hours. Both regimens were initiated immediately before surgery. Forty-five patients were withdrawn from the study after randomization. Three hundred fifty two patients (175 receiving ampicillin and metronidazole and 177 receiving cefoxitin) completed the study and were followed for one month postoperatively. The frequency of septic and nonseptic complications was not statistically significant different between the two regimens. About one third of all septic complications appeared more than two weeks after surgery. It is concluded that short-term treatment with cefoxitin is at least as efficient as a three-day treatment with ampicillin and metronidazole.

Venous thrombosis after abdominal surgery. A comparison between subcutaneous heparin and antithrombotic stockings, or both.

In an open controlled study, 248 consecutive patients (age more than 40 yrs) admitted for major abdominal surgery were randomized to one of three prophylactic antithrombotic treatments. Eighty-five patients received subcutaneous heparin, 74 patients had graduated compression stockings to the knee (TED stockings), and 89 patients had both subcutaneous heparin and stockings. Treatment began on the evening before operation and continued to complete mobilization, or for not less than five days postoperatively. On the fourth or fifth postoperative day, the patients underwent a 99mTc-plasmin test of the lower limbs as a test for deep vein thrombosis. There were 29.7% positive tests in the stocking group, 29.4% in the group with heparin prophylaxis, and 25.8% in the combined group. Differences between treatments were not statistically significant.

Risk of colorectal cancer after surgery for benign peptic ulceration.

A historical prospective cohort study has been conducted to determine the incidence of colorectal carcinoma following gastric surgery for benign peptic ulcer disease. A total of 4131 patients from 53 hospitals in the western part of Denmark were operated upon for gastric or duodenal ulcer from 1955 to 1960 inclusive. After exclusion of patients who were diagnosed as having a primary cancer before the ulcer operation and 0.5 per cent of the patients whose present status could not be defined, 2975 men and 943 women survived more than one month after the operation and thus formed the cohort of the study. They were followed up to their death or the end of the year 1982. Eighty-four colorectal carcinomas were observed against the expected 85.9. There was no significant difference between observed or expected number of cancers neither among men nor women.

Transurethral ureteroscopic extraction of stone from the ureter and renal pelvis.

Use of a rigid ureteroscope for extraction of 19 ureteric and 6 renal pelvic stones is reported. One of the 24 patients had bilateral ureteric stone. The extraction was successful in 22 cases, including 9 after ultrasonic disintegration of stone. Surgical removal of stone was required because of failure of the ultrasound apparatus in one case and ureteric perforation in another. One stone was extracted "blind". The method has many advantages over more established procedures. It should be the preferred technique for management of ureteric calculi, and may be an option for some renal pelvic stones.

Distinction by radioisotope technique of a subgroup with increased thrombophilic potential among patients submitted to major abdominal surgery.

Deep vein thrombosis (DVT) detectable by the 99mTechnetium-labeled plasmin test developed in 13 (37%) of 35 sequentially studied patients, all above 40 years, undergoing elective major abdominal surgery. Ten of the 13 patients with DVT had an abnormal pulmonary perfusion scintigram, suggesting pulmonary embolism (PE), but only three had clinical evidence of thrombotic disease.

Gastric cancer with special reference to prognostic factors. A review of 779 cases.

A series of 779 patients with gastric cancer diagnosed in the 20-year period 1960-1979 is presented. Surgery was performed in 86% of the cases, but was judged to be radical in only 28%. The operative mortality in the total period was 14.3%, with a fall in the final 5-year period. Patient age, stage of cancer and radicality of operation were prognostic factors as regards survival time. The overall 5-year survival rate was 12%. The rate was 37% after radical surgery, increasing to 49% when corrected for age and sex. The survival rate was unchanged during the period of the study. The crude 5-year survival among the patients with radical surgery was 41% and was independent of the type of surgery. Median age was significantly lower in the patients with early-stage cancer than in the series as a whole. The numbers of younger patients increased during the last ten years of the study.