Highly selective vagotomy plus Jaboulay: a possible alternative in patients with benign stenosis secondary to duodenal ulceration.

BACKGROUND: The treatment of patients with duodenal ulcers has undergone radical changes in recent years. Symptomatic stenotic obstruction of the gastric outlet, however, has remained a specific indication for elective operation, with gastric resection (Billroth I or II) and vagotomy often used as options for intervention. STUDY DESIGN: The present report describes the results of highly selective vagotomy (HSV) in combination with lateral Jaboulay gastroduodenostomy in the treatment of patients with benign stenosis secondary to duodenal ulceration. Functionality of results and patient satisfaction have been focal aspects in our assessment. RESULTS: During a period of five years, HSV plus Jaboulay was performed upon 19 patients (14 men and five women, with an average age of 55 years). No operative mortality was seen. The postoperative follow-up period ranged from 12 to 60 months. There were no ulcer recurrences, the functional results (roentgenographic double-contrast technique) were excellent, and patient satisfaction was high (Visick grade I, 67 percent; Visick grade II, 33 percent). CONCLUSIONS: As evidenced by the results, HSV plus Jaboulay seems to represent a convincing alternative to gastric resection in the treatment of patients with benign stenosis secondary to duodenal ulceration.

Clinical outcome two years after implantation of a transjugular intrahepatic portosystemic shunt for recurrent variceal bleeding.

OBJECTIVE: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a relatively new therapy for variceal bleeding. The aim of this study was to assess clinical course 2 years after TIPS procedure. DESIGN: The study was designed as a prospective, uncontrolled cohort study. METHODS: Forty-six patients who underwent successful TIPS implantation were followed prospectively by clinical examinations, duplex sonography and portal venography. Mean follow-up in surviving patients was 24.1 +/- 9.0 months. RESULTS: The cumulative rate of survival was 80.4% at 1 year and 70.2% at 2 years. The cumulative rebleeding rate was 12.4% at 1 year and 21.3% at 2 years. The mortality rate of episodes of variceal rebleeding was 22.2%. Variceal rebleeding was associated with shunt abnormalities, and successful shunt revision resulted in control of the bleeding. The cumulative incidence of shunt stenosis or occlusion was 41.2% at 1 year and 54.9% at 2 years. Of those patients without shunt abnormalities after 1 year, 23.3% developed shunt stenosis or occlusion during the second year after TIPS procedure. Shunt revision was successful in 96.6% of cases. Secondary patency rate was 88.1% after 2 years. CONCLUSION: Successful TIPS implantation results in a low rate of morbidity and mortality from variceal rebleeding over 2 years. TIPS creation in combination with careful follow-up examinations represents an effective long-term treatment of recurrent variceal bleeding. Even in patients in whom no shunt abnormality is detected during the first year, routine duplex follow-up examinations should be continued at 3-month intervals.

Motivating drivers to correctly adjust head restraints: assessing effectiveness of three different interventions.

Three types of driver educational strategies were tested to determine the most effective approach for motivating drivers to adjust their head restraints to the correct vertical position: (1) a human interactive personal contact with a member of an ICBC-trained head restraint adjustment team, (2) a passive video presentation of the consequences of correct and incorrect head restraint adjustment, and (3) an interactive three-dimensional kinetic model showing the consequences of correct and incorrect head restraint adjustment. An experimental pretest-posttest control group design was used. A different educational treatment was used in each of three lanes of a vehicle emissions testing facility, with a fourth lane with no intervention serving as a control group. Observational and self-reported data were obtained from a total of 1,974 vehicles entering and exiting the facility. The human intervention led to significantly more drivers actually adjusting their head restraints immediately after the intervention than the passive video or interactive kinetic model approaches, which were both no different from the control group. The human intervention was recommended as the most effective and was implemented successfully on a limited basis during 3 months of 1995 and again during 3 months of 1996.

Swallowing function and gastric emptying in patients undergoing replacement of the esophagus.

In order to assess functional changes after esophagectomy, esophageal transit scintigraphy and gastric emptying measurements were performed in a group of 10 patients after esophagus substitution by the tubulized stomach, and in a group of 12 patient with an interposed colon. The swallowing function of the rest of the esophagus was preserved in 15 out of 22 patients. The best results were obtained on using a liquid bolus in an upright position, the worst function was found on using a solid bolus in a supine position. Reflux at the level of the anastomosis with the esophagus was detected in only 7 out of 22 patients. The gastric emptying rate was normal in 4 out of 12 examined patients. Scintigraphic methods proved to be suitable for the detection of functional changes after surgery. The function tests performed proved that substitution of the esophagus by either tubulized stomach or interposed colon provides the patient with adequate comfort, provided that he adopts certain habits.

Metacognitive and frontal lobe processes: at the interface of cognitive psychology and neuropsychology.

During the past several decades, research in both cognitive psychology and neuropsychology has become increasingly concerned with the processes that monitor and control human cognition. In the area of cognitive psychology, this research has focused on metacognition or metacognitive processes, and in the area of neuropsychology, it has focused on frontal lobe processes. It is evident that both areas have been referring to very similar concepts, with some variations, but with notably little acknowledgement of each other. The principal purpose of this study was to conduct an analysis of the main research within each of these areas and to examine the continuities and discontinuities in the theoretical premises and empirical results between the two areas. Results indicated that the two areas are remarkably similar in both theoretical premises and empirical results, but that cognitive psychology emphasizes monitoring and control, whereas neuropsychology tends to emphasize control only. A synthesis that unites the work in cognitive psychology and neuropsychology would supply many new directions for research.

[Thyroid gland function after short-term administration of amiodarone and digoxin]. / Funkcia stítnej zl'azy po krátkodobom podávaní amiodaronu a digoxínu.

The authors administered to 13 patients with auricular fibrillation amiodarone (Cordarone), 1200 mg/day, by the oral route from the 4th to the 10th day of the trial, 600 mg per day from the 11th to the 13th day of the trial. Simultaneously the patients were given digoxin, 1 mg, by the i.v. route: on the first day 1 mg i.v., 2nd to 5th day 0.5 mg i.v., and on the 6th to 10th day of the trial 0.25 mg. They assessed the serum digoxin concentration on the 1st, 4th, 11th and 14th day, the serum concentration of triiodothyronine (T3), thyroxine (T4) and thyrotropic hormone (TSH) on the 1st and 14th day of the trial. The authors revealed that after ten days administration of amiodarone T4 does not change (102.4 +/- 28.2 nmol/l vs. 101.3 +/- 13.4 nmol/l, NS), T3 declines significantly (2.47 +/- 0.85 nmol/l vs. 1.86 +/- 0.54 nmol/l, p less than 0.001) and TSH rises insignificantly (2.82 +/- 1.18 mU/l vs. 3.34 +/- 1.43, NS). Consistent with data in the literature on the effect of several weeks administration of amiodarone on thyroid function, the authors assume inhibition of 5'monodeiodization of T4 with a reduced formation of T3 and increased formation of rT3. The drop of T3 may play a part also in the antiarrhythmic action of amiodarone in the treatment of auricular fibrillation.

[Diabetic ketoacidosis--personal experience with treatment using low (physiologic) doses of insulin]. / Diabetická ketoacidóza--nase skúsenosti s liecbou malými (fyziologickými) dávkami inzulínu.

The authors present an account on their experience with treatment of diabetic ketoacidosis with small (physiological) doses of insulin in a group of patients who were hospitalized in the course of four years at the intensive metabolic care unit. Diabetic ketoacidosis is in spite of therapeutic advances still a serious matter. It calls for monitoring of vital functions, intensive treatment and regular checks of laboratory indicators. Treatment of diabetic ketoacidosis with small (physiological) insulin doses proved effective and safe and the incidence of complications was minimal.

[Acute abdomen as a postoperative complication]. / Náhlé príhody brisní jako pooperacní komplikace.

The authors describe 11 cases of acute abdomen they observed during a two-year period mainly after abdominal operations. The male/female ratio was 6:5, the mean age 59 years with a range from 20 to 75 years. The mean period which had elapsed after the primary operation was 18.5 days. The authors describe four cases with ileus due to adhesions, three cases of volvulus of the small intestine, a stress ulcer, gangrenous appendicitis, acute cholecystitis and adnexitis. In general it is assumed that the most frequent acute abdomen during the post operative period is ileus due to adhesions, postoperative pancreatitis or stress ulcers are less frequent. Extremely rarely the cause of complaints is inflammatory acute abdomen of a different nature which is an unexpected finding during surgical revision. It is dangerous due to the atypical course and the fact that symptoms are masked by manifestations of the receding postoperative state. In the literature the aetiopathogenesis of such rare conditions is most frequently associated with impaired tissue perfusion due to an inadequate blood flow, general tissue hypoxia due to hypovolaemia, protracted postoperative shock, rigid vascular walls which are incapable of adequate reaction to acute deviations of circulatory demands. Despite this these conditions develop more rarely than corresponds to the coincidence of these general relatively frequent adverse factors. Severe immunosuppression is also observed much more frequently in surgical patients than these rare complications. The authors observed the incidence of these cases of acute abdomen at a ratio of 1:2000 which corresponds roughly to data in published work. Seeking the solution in immunity disorders does not explain this problem.(ABSTRACT TRUNCATED AT 250 WORDS)

[The Jurasz surgical procedure in an unusual situation]. / Pouzití operace podle Jurasze v neobvyklé situaci.

The authors present an account on the use of Jurasz' operation for drainage of an abscess of the omental bursa after a piercing injury of the abdomen within a relatively short interval after development of this complication.

[Surgical aspects of treatment of esophageal achalasia]. / Nekteré chirurgické aspekty lécení jícnové achalázie.

Based on experience assembled with surgical treatment of 88 patients with achalasia of the oesophagus in 1980-1988 the authors assume that patients in the second stage of the disease where dilatation treatment produced only temporary relief lasting several weeks and all patients in the third stage of the disease are indicated for treatment. The authors prefer the abdominal approach to the cardia and distal oesophagus as the cardia has an intraabdominal localization. It is also possible to treat other intraabdominal diseases and an antireflux operation can be easily performed. Patients tolerate laparotomy better than thoracotomy. In the author's opinion myotomy extending over 8 cm is sufficient Its protraction to the dilated portion of the oesophagus is not necessary. The antireflux operation is made only when before operation gastrooesophageal reflux was present or where during operation the oesophageal mucosa is open or where mobilization in the area of the oesophageal hiatus damaged several anatomical antireflux structures. Resection of the oesophagus in the IIIrd stage of the disease is exceptional in the authors' opinion.

[Surgery of external hernias at the 3rd Surgical Clinic from 1993 to 1997]. / Operace zevních kýl na III. chirurgické klinice v letech 1993 az 1997.

In 1993 to 1997 at the IIIrd Surgical Clinic of the First Medical Faculty Charles University 1271 patients with the diagnosis of external hernia were operated. For classical operations the term herniorrhaphia (HR) is used, for operations with a mesh hernioplasty (HP). For the present study 204 patients were selected operated in 1996 (half the operations were done by the "classical" method, the other half using a supporting mesh). The mean age of the patients was 57 years. For evaluation the sex, age, height, body weight, employment, risk factors, site and type of hernia, number of recurrences before operation, type and period of administered antibiotic, prevention of thrombosis, type of anaesthesia, complications, duration of operation and hospitalization were recorded. After analyzing the results the authors reached the following conclusions: 1. At present there practically does not exist any patient with hernia contraindicated for surgery. 2. For treatment of external hernias a polypropylene net (Prolen) is suitable and its price is reasonable. 3. In obese patients we indicate surgery using a net. 4. In risk patients antibiotic prophylaxis is indicated. 5. Heparinization increases the risk of development of haematomas, therefore in heparinized patients drainage of the wound is recommended. 6. Patients after surgery for hernias in the Czech Republic were hospitalized in 1996 for an unnecessarily long time according to the authors' experience.

Personality and risk-taking: a brief report on adolescent male drivers.

Risky driving is a major contributing factor in adolescent injuries and deaths, particularly for young males. In the present study, the relationship between personality characteristics and increased crash risk was investigated by comparing scores of high- and low-risk drivers on the Personality Research Form and the Jackson Personality Inventory. The role of personality factors in accident risk is discussed in terms of different theoretical accounts of adolescent risk-taking.

[Changes in strategy and technics in the surgical treatment of hernias]. / Zmeny strategie a techniky chirurgického resení kýl.

During last five years, 1,271 patients with the diagnosis of hernia were operated at the IIIrd Surgical clinic, 1st Faculty of Medicine, Charles University in Prague. Types of hernia were not differentiated. The patients group includes primary inguinal hernias and their relapses, hernias in other localizations as well as hernias in cicatrices. Ligation of the hernia sac as a separated intervention was used in no case. Herniorrhaphy was performed in 52% of cases, hernioplasty in 48%. The hernioplasty/herniorrhaphy ratio increases every year. While the hernioplasty was performed in 34% of patients in 1993, in 1997 was used already in 53% of cases. During that period of time, prolene mesh fixed in the defect with prolene suture was almost exclusively used as implant. In very complicated cases, Goretex was applied with a very good result. Polytetrafluoroethylene is the best implant material at the present time, but its price restrains its general use. Prolene is available for a moderate price and complies sufficiently with requirements on mechanical strength and non-irritability.

[Importance and reliability of preoperative localization in primary hyperparathyroidism]. / Otázka nutnosti a spolehlivosti predoperacních lokalizacních vysetrení u primární hyperparatyreózy.

On the basis of experience with a group of 176 performed operations for primary hyperparathyreosis at the 3rd Surgical Clinic of 1st Medical Faculty of Charles University in Prague in cooperation with the 3rd Internal Clinic of 1st Medical Faculty of Charles University in Prague, we together share the opinion to perform necessary preoperative localization examinations. Sonography is routinely performed and after evaluation of its objective result scintigraphy and MRI is individually indicated. Preoperative localization of adenomas shortens the time of operative procedure. Sufficient experience with preoperative localization examinations become more important especially in the diagnosis before reoperations of parathyroidal adenomas which are sometimes necessary.

[Surgical problems in primary hyperparathyroidism with concomitant nodular goiter]. / Problematika operací pro primární hyperparatyreózu v terénu nodózní strumy.

In our group of 176 performed operations with diagnosis of primary hyperparathyreosis during the period of 1994-1999 present thyreopathy has been established peroperatively as well as postoperatively in altogether 47% of patients. Due to high percentage of coincidence of these diagnoses the condition of establishing indication for surgical therapy appears to be necessary not only on parathyroidal glands, but also determining the extent of resection on the thyroidal gland. In terms of preoperative screening, besides usual investigation of sonography and scintigraphy, we can recommend MRI test, which is highly positive for patients with thyreopathy, particularly in the area of nodular thyroid mass. The advantage of MRI investigation enables more precise localization of ectopic parathyroidal adenoma.

Changes in abdominal wall after mesh implantation in rats.

On an incisional hernia model, we evaluated tissue reactions to three types of non-absorbable foreign materials, Prolene, Gore-Tex and flax, used for covering defects of the abdominal wall muscles in Wistar strain rats. The examinations were carried out in five 14-days intervals between the 35th and 91st days after the intervention. Our results with Gore-Tex showed the lowest tissue response, the lowest inflammatory cellular as well as fibroplastic reaction, it also completely covers the artificially made wall defect and induces no considerable peritoneal adhesion. In defects filled with Prolene mesh, we also observed no considerable cellular response and scarring. However, considerable peritoneal adhesions were found and the defect was filled to a great extent with lipidic tissue with irregularly distributed Prolene fibres. The use of flax material is least suitable since it induces extensive inflammatory reactions, which occur even after a very long time after the operation. Prolene was, as a matter of fact, second to Gore-Tex in the experimental evaluation of the biological tolerance. However, with respect to its ten times lower price, it can be recommended as a material of the first choice for covering defects of the abdominal wall in clinical use.

Acute and chronic complications after implantation of a transjugular intrahepatic portosystemic shunt--a prospective study in 53 patients.

Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is associated with a broad spectrum of acute and chronic complications. Data concerning incidence and prognosis of these complications are conflicting but of great importance toward defining the role of TIPS relative to other therapeutic options. We conducted a prospective, uncontrolled cohort study in 53 patients to assess incidence, management and clinical outcome of complications occurring after TIPS procedure. Mean follow-up was 21.1 +/- 9.0 months. Technique-related mortality was 2%; 9% of patients died within 30 days after TIPS procedure. The overall survival rate after 18 months was 74%. The overall incidence of primary hepatic encephalopathy (HE) within the first year was 25%, and 77% of episodes could be managed successfully by medical treatment or implantation of a reducing stent. The rate of patients without rebleeding after 18 months was 84%. Rebleeding was associated with shunt abnormalities, and the bleeding was controlled by revision of the stent. Two patients died of variceal hemorrhage. The cumulative incidence of shunt stenosis or occlusion was 47% after 18 months. The technical success rate of shunt revision was 97%. TIPS implantation is associated with a considerable risk of HE and shunt stenosis or occlusion. Nevertheless most episodes of HE can be managed by medical treatment or implantation of a reducing stent. Angiographic revision of the stent is successful in nearly all cases of stenosis or occlusion. We therefore conclude that TIPS implantation in combination with careful follow-up examinations constitutes effective medium-term treatment of portal hypertension in a considerable proportion of patients.

Course of platelet counts in cirrhotic patients after implantation of a transjugular intrahepatic portosystemic shunt--a prospective, controlled study.

BACKGROUND/AIMS: The pathogenesis of thrombocytopenia associated with advanced liver disease is still controversial. To study the impact of portal decompression on this hematologic complication, we conducted a prospective, controlled study to compare the course of platelet counts in patients after implantation of a transjugular intrahepatic portosystemic shunt (TIPS) with matched controls without shunts. METHODS: Fifty-five TIPS patients and 110 controls matched for age, sex, Child-Pugh class, etiology of liver disease and baseline platelet count were included, and followed for 1 year. Follow-up visits were scheduled after 1 month, after 3 months, and at 3-month intervals thereafter. RESULTS: Nonparametric Mann-Whitney U-tests revealed significantly higher platelet counts for TIPS patients as compared to controls from the 1st through the 12th month (p<0.01). During the study period, the median platelet count of TIPS patients increased by 19.7%, from 104.0/nl (IR: 68.0) to 124.5/nl (IR: 41.0). In contrast, during the same period the median platelet count of controls decreased by 17.1%, from 102.5/nl (IR: 66.0) to 85.0/nl (IR: 67.5). In the group of cases with baseline platelet counts < or =100/nl, platelet counts had increased by at least 25% at month 12 in 65% of TIPS patients, but in only 5% of controls (p<0.001). However, normalization of platelet counts, i.e. > or =150/nl, was not achieved in any case. Neither the portosystemic pressure gradient after TIPS implantation, nor the percentage of portosystemic pressure gradient reduction during the procedure was predictive of platelet response. CONCLUSIONS: TIPS implantation increases platelet counts significantly. However, portal hypertension is clearly not the only mechanism contributing to thrombocytopenia in advanced liver disease.