Complications of splenic artery aneurysm other than intraperitoneal rupture.

Thirty-eight patients with aneurysms of the splenic artery were identified in the records of 11 years, but only one aneurysm was ruptured. Portal hypertension was found in nine patients (24%); in two of these the reaction surrounding the aneurysm prevented the construction of a patent splenorenal shunt or caused compartmented portal hypertension. One aneurysm encountered during the survey period and another encountered just after its conclusion ruptured into the stomach. There was a twofold overrepresentation of multiparous women. Intraperitoneal rupture is rare, except in pregnancy. If elective therapy is considered, angiography should be performed. Exclusion or resection of the aneurysm is advocated only for patients with symptomatic or ruptured aneurysms or (very rare) large aneurysms and for women of childbearing age. The spleen should be preserved, when possible. In high-risk patients occlusion of the aneurysm via an intra-arterial catheter should be considered. If the splenic artery aneurysm causes compartmented portal hypertension, splenectomy is indicated; if portal hypertension is general, the form of portasystemic decompression chosen should avoid the region of the aneurysm.

[Magnetic resonance cholangiopancreatography: sensitive and specific diagnostic method for suspected choledolithiasis]. / Magnetische-resonantiecholangiopancreatografie: sensitieve en specifieke onderzoeksmethode bij vermoeden van choledocholithiasis.

OBJECTIVE: To evaluate the role of magnetic resonance pancreaticography (MRCP) in the diagnostic process of common bile duct stones. DESIGN: Retrospective. METHOD: All 27 MRCPs performed in the period December 1997-December 1998 in the Deventer Hospital, the Netherlands, were evaluated using chart examination. The group comprised 11 males and 16 females with an average age of 57 years (SD 3.2) with anamnestic or biochemical cholestasis. If at MRCP stones were diagnosed, endoscopic retrograde cholangiopancreaticography (ERCP) was performed. If MRCP was without abnormalities, no further diagnostic procedures were performed. The findings at MRCP were compared with those at ERCP and with the clinical course. The MRCP examinations were performed on a 1.5 Tesla MR unit. RESULTS: In 16 patients MRCP was performed before laparoscopic cholecystectomy and in 5 there after. In 5 MRCP was performed to rule out a biliary cause of acute pancreatitis and in 1 patient because of an elevated alkaline phophatase after laparotomy for an abdominal stab injury. There was one false-positive MRCP result and no false-negative ones. Accordingly, the sensitivity of MRCP for choledocholithiasis was 100% and the specificity 95%.

The treatment of lunatomalacia. Radial shortening or ulnar lengthening?

In 35 patients with lunatomalacia, radial shortening (20 cases) was compared with ulnar lengthening (15 cases) 5 (1-14) years postoperatively. There was no radiographic evidence of recovery of the architecture of the lunate bone. The time of consolidation of the osteotomy with screw and plate fixation averaged 3 months after radial shortening and 4 months after ulnar lengthening. Pseudoarthrosis developed in 1 case of radial shortening and in 3 cases after ulnar lengthening. The two groups were equal with satisfactory results in two thirds of the patients.

Treatment of oesophageal perforation: a multivariate analysis.

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.

Massive retrogastric bleeding caused by neurofibroma. Case report.

A case of massive retrogastric bleeding from a neurofibroma arising from the gastric wall is described. The tumour was removed without opening the gastric mucosa. The possibility of neurofibroma should be borne in mind when there is unexplained bleeding from the digestive tract or the intraperitoneal or retroperitoneal space, particularly in patients with von Recklinghausen's disease.

Acute abdominal pain due to early postoperative elemental feeding by needle jejunostomy.

Early postlaparotomy needle jejunostomy feeding with an elemental diet resulted in a typical clinical entity in six of 160 patients (4 per cent). In all, an acute condition of the abdomen developed with a grossly distended intestine, filled with fluid and gas, and an empty stomach as confirmed roentgenographically or at a second laparotomy. This complication is presumably caused by carbohydrate hyperosmolarity of the elemental diet and carbon dioxide production by fermentation. The complication was seen predominantly in patients with a Roux-en-Y reconstructed pancreatectomy. In two patients, a negative second laparotomy was performed. In two others, a pancreaticojejunostomy suture line blowout followed, resulting in death. One patient died after aspiration of the gastric contents.

Nerve growth factor: acceleration of the rate of wound healing in mice.

Earlier studies have shown that removal of the submandibular glands of mice retards the rate of contraction of experimentally induced wounds and that communal licking of wounds accelerates contraction in intact animals [Hutson, J. M., Niall, M., Evans, D. & Fowler, R. (1979) Nature (London) 279, 793-795]. In the light of the observation that nerve growth factor (NGF) is secreted in high concentrations in mouse saliva, we have studied the effect of topically applied high molecular weight nerve growth factor (HMW-NGF) upon the rate of wound contraction in sialoadenectomized animals. Results show that HMW-NGF significantly accelerates the rate of wound contraction and that this phenomenon is probably dependent upon the enzymic activity of the protein. Neither diisopropyl fluorophosphate-inactivated NGF nor 2.5S NGF [isolated according to Bocchini, V. & Angeletti, P. U. (1969) Proc. Natl. Acad. Sci. USA 64, 787-794] displays this biological activity. Thus, it may be that one of the physiological roles of NGF in saliva is to promote wound healing by the licking process.

Survival after resection for carcinoma of the oesophagus.

During the period 1978-1984, 525 patients referred with cancer of the oesophagus or gastro-oesophageal junction were assessed for operation and cure. After investigation, 276 patients were selected and operated upon, as a rule, 4 weeks after radiotherapy (40 Gy/4 weeks). In 224 patients (81 per cent) the oesophagus and cardia were resected and reconstructed with stomach (69 per cent), colon (21 per cent), free ileal graft (7 per cent) or Roux-en-Y-oesophagojejunostomy (3 per cent). The postresectional hospital mortality was 14 per cent in all patients and decreased to 5 per cent in 1983. Mortality was higher when the colon was used for reconstruction than when the stomach was used. By postresection staging, 82 patients were found to have stages I and II tumours and 142 patients stage III tumours. Estimated 3-year survival after resection for all male patients was 28 per cent and for all female patients was 42 per cent. Estimated 3-year survival for all patients treated for adenocarcinoma was 31 per cent. Survival was better for stages I and II patients with adenocarcinoma (52 per cent) than for stage III patients (18 per cent) (P less than 0.01). Estimated 3-year survival for all patients treated for squamous cell carcinoma was 33 per cent. Estimated 3-year survival was better for stages I and II patients with squamous cell carcinoma (48 per cent) than for stage III patients (25 per cent) (P less than 0.001). It can be concluded from this study that resection of oesophagus and cardia after radiotherapy offers hope for cure in a subgroup of patients with non-advanced oesophageal cancer. The operation can be performed with acceptable mortality by experienced surgeons, especially when the stomach is used for reconstruction.

Fascia closure after midline laparotomy: results of a randomized trial.

Four techniques to close the fascia after midline laparotomy were compared in a prospective randomized multicentre trial. The four techniques were: interrupted closure with polyglactin; continuous closure with polyglactin; continuous closure with polydioxanone-s, and continuous closure with nylon. The early postoperative results in 1491 patients revealed an incidence of wound infection of 8.6 per cent and of wound dehiscence of 2.3 per cent with no statistically significant differences between the four techniques. We reviewed 1156 patients after 1 year. Wound pain was present in 9.7 per cent of the patients, statistically significantly more in the group closed with nylon (16.7 per cent). Suture sinuses developed in 3.5 per cent of the patients, statistically significantly more frequently in the nylon group (7.7 per cent). The total number of incisional hernias detected 1 year postoperatively was high (15.2 per cent) (interrupted polyglactin 16.9 per cent, continuous polyglactin 20.6 per cent, continuous polydioxanone 13.2 per cent and continuous nylon 10.3 per cent). The difference between nylon and continuous polyglactin is statistically significant. The results of this trial indicate that although nylon has the lowest incidence of incisional hernia it also is associated with more wound pain and suture sinuses.

Growth and metabolic alterations after submandibular sialadenectomy in male mice.

Because the submandibular salivary glands of male mice are rich in growth factors such as epidermal growth factor and nerve growth factor, and because there are sporadic reports of sialadenectomized mice showing growth retardation and endocrine abnormalities, we studied oxidative metabolism and fertility after submandibular sialadenectomy. Despite similar intake of food, male mice (n = 60) deprived of submandibular saliva, either by duct ligation or gland excision, initially weighed 12-13% less than the sham controls and had a slower rate of growth (P less than 0.001). After 5 mo, mice with duct ligation caught up with the sham-operated mice, but the differences compared with submandibular-sialadenectomized mice were still apparent at 32 wk (P less than 0.001). The mean respiratory quotient of submandibular-sialadenectomized and duct-ligated mice was 0.71 instead of 0.88 as in the shams at 10, 20, and 30 wk after operation (P less than 0.01). No effect on fecundity was observed in either male or female mice following submandibular sialadenectomy.

Hypersecretion of submandibular saliva in male mice: trophic response in small intestine.

The submandibular salivary gland of the male mouse and its secretions contain growth-promoting factors that accelerate cell proliferation in vitro and also have effects on the gastrointestinal tract in vivo. We therefore stimulated salivary secretion with isoproterenol for studies of the effects of submandibular saliva on intestinal cell proliferation; only submandibular glands respond to isoproterenol by releasing epidermal growth factors and other growth factors into the saliva. Submandibular sialadenectomized and sham sialadenectomized male mice on pair-feeding schedules were given isoproterenol intraperitoneally for 1 wk. A 44% increase in ribonucleic acid and a 13% increase in deoxyribonucleic acid were observed in the jejunum of animals with intact submandibular glands (p less than 0.001). In the ileum, there was a 26% increase in ribonucleic acid, a 47% increase in deoxyribonucleic acid, and a 28% increase in deoxyribonucleic acid specific activity (p less than 0.001). Morphometric measurements showed a 28% increase in villous height (p less than 0.001). No differences were found in colonic mucosa. Submandibular saliva increases the nucleic-acid content of mucosal cells and the villous height in the small intestine of male mice, presumably in part because of the growth factors it contains; a systemic metabolic change could also be present.

Operative approach to cancer of the head of the pancreas and the peri-ampullary region.

A retrospective study was made of 75 consecutive patients treated for a tumour of the head of the pancreas and the peri-ampullary region from January 1978 to August 1981. These patients underwent either pancreatic resection--pancreatoduodenectomy (n = 24) and total pancreatectomy (n = 10)--palliative procedures (n = 29) or exploratory laparotomy (n = 12). Clinical signs and diagnostic procedures, such as ultrasonography and coeliac arteriography, were studied for their value in preoperative assessment of operability. Vaso-invasion, as revealed by arteriography and, to a lesser extent, ultrasonographic signs of a tumour and the absence of jaundice were poor prognostic signs. The operative mortality was 8 per cent for the group as a whole, but somewhat higher (13 per cent) for the group that underwent pancreatoduodenectomy. No patient died after total pancreatectomy. The operative mortality was 27 per cent in all patients aged 70 years or older, but only 3 per cent in patients under 70 years. One-year patient survival was 94 per cent after pancreatoduodenectomy for peri-ampullary cancer and 57 per cent after resection for cancer of the head of the pancreas. The results of this study point to pancreatic resection as the treatment of choice for resectable tumours of the peri-ampullary region and the head of the pancreas in patients under 70 years of age. Coeliac arteriography and ultrasonography have been found to be useful for preoperative classification of tumour stage.

Nerve growth factor potentiates stress-induced gastric ulceration.

Increased salivary flow stimulated by intravenous isoproterenol (IPR) (6 mg/kg) doubled the incidence of gastric stress ulceration in normal male mice, but not after submandibular sialadenectomy. The submandibular salivary glands in these mice secrete large amounts of several growth factors, including epidermal growth factor (EGF) and nerve growth factor (NGF). Intragastric instillation of a quantity of high molecular weight NGF equimolar to that in IPR-stimulated saliva doubled the incidence of stress ulcers after submandibular sialadenectomy. This action of NGF in vivo is not mediated by its nerve growth promoting properties nor its plasminogen activating property.

Differences in healing of skin wounds caused by burn and freeze injuries.

Circular, full-thickness dermal burn- and freeze-produced wounds were produced in rats to compare the difference in healing between the two types of thermal injuries. Contraction did not occur in wounds (n = 30) caused by freezing, while burn wounds (n = 30) contracted to less than one-third of original size by 21 days after injury. If the centers of the freeze-produced wounds (n = 12) were excised, contraction would then occur and proceed at the same rate as an open wound. Histologically, the degree of initial tissue destruction by the two types of injuries was similar. The burn wound contained only half the amount of collagen found in the freeze-produced wound. There was a greater and more rapid replacement of collagen in the burn wounds. With both injuries, the highest concentration of collagen was found on the fifteenth day and returned to normal by the twenty-eighth day. The burn wound contained three times the amount of collagen in normal skin, while the freeze-produced wound contained only 1 3/4 times the amount in normal skin. Contraction does not seem to occur in the healing of the freeze-injured skin because the slow removal and replacement of the residual matrix prevents contraction.

Prospective randomized multicentre trial of proximal gastric vagotomy or truncal vagotomy and antrectomy for chronic duodenal ulcer: results after 5-7 years.

In a prospective, randomized study 145 patients with duodenal ulcer have been followed 5-7 years after proximal gastric vagotomy (PGV) or truncal vagotomy with antrectomy (TVA). Postoperative complications were significantly higher after TVA (P less than 0.0005). There was one death due to anastomotic leakage after TVA. The recurrence rate was significantly higher after PGV (9.9 per cent). Postoperative symptoms were less after PGV (P less than 0.01). Due to the recurrence rate after PGV there was no overall significant difference in the Visick grading, although perfect results (Visick I) were seen significantly more often (P less than 0.01). It is concluded that better results follow PGV.

The influence of preoperative jaundice, biliary drainage and age on postoperative morbidity and mortality after pancreatoduodenectomy and total pancreatectomy.

Details are given of the postoperative course of 56 patients after pancreatoduodenectomy, and 11 after total pancreatectomy. The main indication was adenocarcinoma (56 cases). The most serious complication was leakage from the pancreatojejunostomy, which occurred in nine patients and was fatal in seven of these (10%). This was the only cause of death in the group. The observed mortality was appreciably higher (38%) in the 13 patients aged over 70 years. Contrary to recent reports, jaundice was not found to influence postoperative mortality adversely, nor was preoperative biliary drainage found to reduce mortality.

Transfusion of red cells is associated with increased incidence of bacterial infection after colorectal surgery: a prospective study.

BACKGROUND: Several studies suggest that perioperative blood transfusion is a major independent risk factor for postoperative bacterial infections. Transfusion-induced immunosuppression is thought to mediate this effect. STUDY DESIGN AND METHODS: In a randomized clinical trial comprising 697 patients with colorectal cancer, the relationship between two types of red cell components (buffy coat-depleted packed red cells and white cell-reduced [filtered] packed red cells) and postoperative bacterial infections was analyzed. RESULTS: Both types of red cells appeared to be associated with a greater incidence of postoperative infection than was no transfusion (39 vs. 24%, p < 0.01). A dose-response relationship could be demonstrated: the corrected relative risk was 1.6 for 1 to 3 units of red cells and 3.6 for more than 3 units. Multivariate analyses identified the transfusion of red cells and tumor location as the only significant independent risk factors for postoperative bacterial infection. CONCLUSION: Because allogeneic white cells, plasma, microaggregates, citrate, and platelets could be ruled out as risk factors for transfusion-associated postoperative infections, it is hypothesized that the transfusion of red cells is a potentially detrimental factor that transiently impairs the clearance of bacteria by phagocytic cells.