Long-term surgical outcome of closed mitral commissurotomy.

Seven hundred and fifty-four patients who underwent closed mitral commissurotomy (CMC) between 1958 and 1993 (71% female, 29% male; mean age 39 years) for acquired mitral stenosis were reviewed postoperatively. Particular attention was given to those patients who later required mitral valve replacement (MVR). The total follow up experience was 9,607.9 years. Eighty-two patients (11%) needed a repeat CMC and 30% of these patients had subsequent MVR. In all, 146 patients (19, 3%) required MVR a mean of 17.0 years after commissurotomy (range one to 35 years). Preoperative factors associated with an unsatisfactory postoperative course and with later MVR included preoperative functional class, calcification of the mitral valve and subvalvular fusion. The adequacy of valvulotomy assessed at operation was also related to outcome. Postoperatively, poor functional improvement, congestive heart failure and the necessity for a repeat CMC were associated with late MVR. The indications for MVR were restenosis (59%), residual stenosis with or without mild mitral regurgitation (30%), and moderate to severe regurgitation (11%). Among survivors, 88% improved at least one functional class after MVR and the majority was free of congestive heart failure. It is concluded that CMC provides excellent long term clinical improvement in appropriately selected patients. The mean time interval of 17 years between CMC and late MVR reveals the efficacy of CMC to achieve satisfactory long term results.

[Annular pancreas - complications and therapeutic problems]. / Pancreas anulare - Komplikationen und therapeutische Probleme.

Five cases of annular pancreas with symptoms and signs of high duodenal obstruction are reported. The diagnosis was established during the operation, and four of five patients were complicated by duodenal ulcer and a marked relapse of cholangitis. The results and the operative procedures are discussed.

[Operative treatment of the invasion of Echinococcus cysticus of the liver into the bile ducts]. / Die operative Behandlung des Einbruchs des Echinococcus cysticus der Leber in die Gallengänge.

The basic principles, methods, and results of treatment are reported from personal experience in the treatment of 32 patients with intrabiliary rupture of hydatid cysts of the liver. These patients were treated from 1970-1979 in Surgery I of the University of Thessaloniki. Total cystectomy combined with sphincteroplasty of the sphincter Oddi is the method of choice. The clinical data, special types of treatment, and indications are discussed. Reoperation during the same admission in some complicated cases is strongly recommended.

Did Alexander the Great die of acute pancreatitis?

I propose that Alexander the Great died of acute pancreatitis secondary to heavy alcohol consumption and a very rich meal. The cause of death of prominent historic or artistic figures attracts considerable interest of historians and researchers. This is especially the case for Alexander the Great. More than 20,000 publications, books, or monographs on the life and work of Alexander the Great have been published. There are several theories and hypotheses regarding the cause of his death, that are based on historic descriptions, diaries, notations, and interpretations of events. It is inevitable that history and myth intermingle in any investigative approach, no matter how scholarly. In this article, on the basis of several historic sources. I have made an effort to reconstruct the final 14 days of his life and record the course of medical events that preceded his death with the formulation of a plausible diagnosis.

Adult Hirschsprung's disease. An experience with the Duhamel-Martin procedure with special reference to obstructed patients.

A two-stage management of six adult patients with Hirschsprung's disease of the rectum and rectosigmoid, with obstruction (two patients) or enormous dilatation of the proximal innervated colon is reported. A preliminary transverse loop colostomy was carried out urgently in two patients because of colonic obstruction, and electively in four patients; at the same time, a full-thickness rectal wall biopsy was taken in all patients to establish the diagnosis. Reconstruction was performed four to six months later with Martin's modification of the Duhamel procedure. The postoperative course was uneventful and functional results are excellent three to eight years later. Based on experience, the Duhamel-Martin procedure seems preferable in adult Hirschsprung's disease when a considerable discrepancy exists between the ganglionic and aganglionic segments of the colorectum.

[Rare primary localizations of Echinococcus cysticus]. / Seltene primäre Lokalisationen des Echinococcus cysticus.

Seven cases of unusual location of echinococcus cysts are described. Three of them were located in the muscles, three in the subcutaneous tissue and one in a retroperitoneal position.

[Nonocclusive vascular insufficiency of the bowel (author's transl)]. / Die funktionelle intestinale Perfusionsischämie.

The particular problems of nonocclusive mesenteric vascular insufficiency are discussed on the basis of reports in the literature and 4 patients observed by the authors. Diminution in splanchnic blood flow as a manifestation of splanchnic compensation to low cardiac output seems to be the most common cause. The symptoms are described and the necessity for early diagnosis and immediate treatment are stressed. Our results of treatment in 4 patients with nonocclusive mesenteric vascular insufficiency are presented.

Pathways of lymph node involvement in upper abdominal malignancies: evaluation with high-resolution CT.

The aim of this study was to enhance our understanding of the pathways of lymphatic spread of primary carcinomas in the upper abdomen by recognizing the development, configuration, and frequency of nodal enlargement in discrete anatomic regions. The study included 417 patients with histologically confirmed carcinomas (CC) of the stomach (n = 267), liver (n = 98), gallbladder (n = 25), and bile ducts (n = 27). All patients were studied by high-resolution CT and tumor extension to the lymph nodes of the subperitoneal space was clearly identified in 59 patients [33 with CC of the stomach, 8 with CC of the gallbladder, 3 with CC of the bile ducts, and 15 with hepatocellular carcinoma (HCC)]. In 47 of 59 patients this extension was confirmed by surgery or aspiration biopsy. Three discrete anatomic groups of lymph nodes were recognized producing a relatively distinct CT configuration when involved: (a) the hepatoduodenal seen in 49 patients; (b) the peripancreatic demonstrated in 33 patients; and (c) the aortocaval recognized in 16 patients. These groups of lymph nodes can be seen individually involved or in combination. Recognition of involvement of these nodes is important for correct diagnosis and staging of upper abdominal malignancies. The development of this involvement follows the natural flow of lymph via the lesser omentum to the retroperitoneal space.