Assessment of the perfusion in peripheral tissue beds by subcutaneous oximetry and gastric intramucosal pH-metry in elective colorectal surgery.

Gastric intramucosal pH (pHi) and subcutaneous oxygen tension (PscO2) were compared with traditional perfusion parameters in patients undergoing elective colorectal surgery and were related to clinical outcome. Ten patients were studied per- and postoperatively and tissue oximetry studies were also performed in a group of 10 healthy volunteers. The response of PSCO2 to oxygen breathing proved to be the most sensitive predictor of clinical outcome. Of the 10 patients 8 failed to respond to an O2 challenge, while all 10 volunteers in the control group did so. Out of those 8 patients 6 presented with mainly infectious complications while only 3 had an inadequate perioperative urine output and none presented with signs of arterial or of gastric intramural acidosis. The present study suggests a possible relationship between clinical outcome and oxymetric signs of tissue hypoperfusion after O2 challenge in surgical patients, even in the presence of an adequate urine output and a normal gastric wall pH.

The influence of cholecystectomy on the duodenogastric reflux of bile.

The effect of cholecystectomy on postprandial duodenogastric bile reflux was studied by biliary excretion scintigraphy in a group of 20 patients examined before and after gallbladder removal. Dyspeptic complaints were correlated with the presence of postprandial duodenogastric reflux in 37 patients admitted to the hospital for cholecystectomy. The removal of the gallbladder, whether functional or not, in patients presenting with gallstones, did not seem to influence the occurrence of postprandial duodenogastric bile reflux. Dyspeptic complaints were positively correlated with postprandial gastric reflux. This reflux was observed in 90% of dyspeptic patients, while only 7% of the patients without dyspepsia had reflux. The role of duodenogastric reflux in the production of dyspeptic complaints is open to discussion, but the removal of the gallbladder does not seem to interfere with the occurrence of bile reflux into the stomach after a milk meal.

CT-scan diagnosis of bilateral obturator hernias in a patient with chronic chylous ascites.

Bilateral obturator hernias were diagnosed in a 61-year-old woman by CT-scan examination, permitting an elective surgical repair by preperitoneal interposition of Teflon mesh. The condition developed in a patient presenting with a 15-year history of chylous ascites, occasioned by primary hypoplasia of the lymphatic system and cirrhosis of the liver.

Reconstruction of the digestive tract after total gastrectomy.

Reconstruction of the digestive tract after total gastrectomy should be safe and give the patient maximal comfort. Dehiscence of the esophago-enteral anastomosis is the main cause of operative mortality. Stapling and jejunoplication procedures offer the best chances of success. A Roux-en-Y esophagojejunostomy is readily carried out in patients with malignant disease, and avoids distressing reflux esophagitis, which constitutes a major cause of morbidity. The construction of a gastric reservoir has been advocated to prevent malnutrition, weight loss and other functional complaints. This matter is still the subject of much debate and requires further prospective studies. A personal retrospective evaluation of 23 patients provided with a Lygidakis pouch after total gastrectomy shows that this procedure can be performed with an acceptable mortality rate (8.7%). The clinical results look promising as most of the patients studied one year after the operation had no functional complaints and their weight had stabilized.

Is there a place for research in the training of surgeons?

The incorporation of research facilities into the surgical curriculum is a major asset in supporting the scientific aspect of surgery. The dearly won place of surgery in medical science should be preserved and consolidated by encouraging motivated young surgeons to carry out research. It is the task of the universities to set up laboratories and research units, where the necessary know-how and infrastructure are present and accountable research activities can be developed.

[Colon occlusion due to safety belt (authors transl)]. / Colonocclusie door autogordel

The author describes a delayed occlusion of the colon, consecutive to an ischemic constriction, occurring after a car accident in a patient wearing his safety belt. The patient, 49 years old, had undergone urgent laparotomy just after the accident: intraabdominal hemorrhage from hepatic and mesocolic lacerations were discovered and treated. Six weeks after that operation the patient developed an occlusion of the transverse colon necessitating segmental resection and end-to-end anastomosis. Pathology disclosed typical signs of ischemia with constriction. This was considered due to the horizontal part of the safety belt. This should be placed low and tight enough so that the pelvis, rather than the abdominal viscera, receives the shock. After accidents with safety belts the possibility of such complications should be present at mind.

Problems in the surgical treatment of motility disorders occurring after gastric surgery.

Delayed or accelerated gastric emptying and excessive reflux of upper intestinal contents into the stomach are the main disorders of motility occurring after gastric surgery. Most of these syndromes may be treated by conservative measures. When surgical therapy is needed attention must be paid to the possible specific side effects of remedial treatment. Interposition of a reversed jejunal loop in the treatment of dumping after Billroth I gastrectomy may be responsible for the development of an anastomotic ulcer. Roux-en-Y biliary diversion for the surgical treatment of postoperative reflux alkaline gastritis may result in a Roux-en-Y syndrome characterized by severe, delayed gastric emptying. Whenever possible, the pyloric sphincter should be preserved in gastric surgery as the elimination of the pylorus is the main cause of postoperative motility disorders.

A prospective comparative clinical study between monofilament absorbable and non-absorbable sutures for abdominal wall closure.

One hundred and sixty-seven patients undergoing laparotomy were randomly allocated to a continuous layered closure technique with absorbable monofilament polyglyconate (PG) (Maxon*) or non-absorbable polyamide (PA) (Ethilon*). Laparotomy wounds were closely observed during the postoperative hospital course and all patients were reviewed at one month, six months and one year. Any wound complications were noted. Two patients in the PA group (3.0%) presented with burst abdomen and one (1.9%) in the PG group (ns). The incidence of incisional hernia was not statistically different between the two groups (4/64, 6.0% in PA group and 4/65, 6.2% in PG group). The postoperative wound infection rate was 21.0% in the Pa group and 15.4% in the PG group (ns). The present study clearly shows a major increase in incidence of wound failure in patients with infected abdominal wounds in both groups (28.6% vs 3.8% in PA group p less than 0.025; 20% vs 5.5% in Pg group p less than 0.05). This clinical trial confirms the important roles of wound infection and respiratory failure in the occurrence of wound failure; the choice of an absorbable or a non-absorbable suture material seems to play a minor role only.

Single-dose parenteral antibiotic prophylaxis in gastrointestinal surgery.

In the course of two consecutive, double-blind and prospective studies, the authors evaluated the prophylactic effect of a single peroperative intravenous dose of gentamicin (this study included 166 patients) or the combination gentamicin and clindamycin (this study included 127 patients), on the wound infection rate following interventions involving the incision of an abdominal hollow viscus. Antibiotic prophylaxis lowered the post-operative wound sepsis rate, especially following clinically contaminated interventions, but this reduction did not reach statistical significance. It is concluded that a single peroperative parenteral dose of antibiotics does not constitute an entirely satisfactory means of wound infection prophylaxis in digestive surgery.

[The case for more active prevention of deep-vein thrombosis after major surgery (author's transl)]. / Pleidooi voor een meer actieve preventie van postoperatieve diepe veneuze trombose

The frequency of deep-vein thrombosis (DVT) determined by the 125I-fibrinogen test and confirmed by phlebographic studies, is 20 to 30 % in high-risk patients over the age of forty undergoing major surgery. Comparison of this figure with the incidence of clinically detected thrombosis (5 to 10 %) shows that physical signs are unreliable in the detection of this disease. The ultimate fate of these thrombi is unknown. The majority will probably disappear spontaneously; some will be responsible for the development of a "post-phlebitic syndrome" in the extremities and some will propagate and may produce a fatal pulmonary embolus. Besides the currently used physical methods of prophylaxis, some new pharmalogical techniques for the prevention of postoperative deep-vein thrombosis have been tested and advocated in neighbouring countries. Oral anticoagulants have been used routinely for many years by most Dutch surgeons but have never become very popular in other countries. They need extensive laboratory control and, in spite of this, up to 20 % overdosage bleedings have been recorded. As both the administration of low-dose subcutaneous heparin and IV dextran have been reported to provide effective prophylaxis against deep venous thrombosis, we decided to study and compare their efficacy in a randomized clinical trial in order to assess their practical value in daily surgical practice. 119 adult patients undergoing abdominal surgery have been investigated. They have been devided at random in three groups : a dextran 40 group (n=39), a heparin group (n=39) and a control group (n=41 patients). DVT was diagnosed by the fibrinogen uptake test in 21,9 % patients in the control group in 12,8 % patients in the dextran group, and in 10,2 % patients in the heparin group. For the highrisk patients over the age of 70, the administration of low dose SC heparin, as well as the administration of IV low molecular weight dextran significantly reduced the incidence of postoperative DVT in the lower extremities (p less than 0.05). The dextran 40 and heparin groups were not significantly different. The techniques are simple and do not need laboratory control. No deleterious side effects have been noted. A large-scale multicentre international, clinical trial (4121 patients) recently showed that low-dose heparin prophylaxis not only lowered the incidence of postoperative deep-vein trombosis without severely augmenting the risk of bleeding, but also significantly reduced the frequency of fatal pulmonary embolism in the postoperative period. It is suggested that the administration of low-dose subcutaneous heparin should become a routine prophylactic measure in daily surgical practice.

Late recurrence following treatment of anal canal carcinoma.

A late pelvic recurrence of a cloacogenic anal canal carcinoma, occurring eleven years after an abdominoperineal resection, is reported in a 61-year old female patient. The primary tumour, 2.5 cm in diameter had infiltrated the rectal wall but did not show any evidence of local lymph node involvement on pathological examination. Recurrence of this disease is frequently considerably delayed, with several cases recurring after 5 or more years. This tendency to late recurrence clearly limits the reliability of short-term survival data. Current concepts concerning the management of malignant tumours of the anal canal are discussed from this point of view.

[Treatment of anal fistulas]. / De behandeling van anale fistels.

It is generally accepted that laying-open constitutes the only effective cure for anal fistulae. The sacrifice of at least some part of the anal sphincter apparatus is therefore the inevitable consequence of every operation for fistula. In the case of an intersphincteric or low-trans-sphincteric fistula, only the internal sphincter or the lower half of the external sphincter need to be incised. This may usually be performed without endangering postoperative faecal continence. High trans-sphincteric or suprasphincteric fistulae, however, involve the entire external sphincter and/or the puborectalis muscle. Straightforward trans-section of these sphincters would lead to faecal incontinence. For this reason such high fistulae should be progressively laid open in staged procedures, after encircling the sphincters for some weeks with a seton. The same procedure should also be employed for complex horseshoe-shaped fistulae. Contrary to traditional teaching, anal fistulae in Crohn's disease are no exception to these general therapeutic guidelines. Finally, exploration for an underlying fistula and, if possible, immediate fistulotomy are advocated for all patients with an acute perianal abscess.

The use of muscle flaps in leg soft tissue defects.

The use of muscle transpositions following the technique of Ger is discussed in fifteen cases where important soft tissue defects in the leg, some of them combined with complicated fractures, made spontaneous healing or coverage with split skin grafts impossible.

[Indications for total parenteral nutrition in surgery (author's transl)]. / Indicaties voor totaal parenterale voeding in de heelkunde.

The indications for total parenteral nutrition are compared with those for enteral alimentation. The indications for parenteral nutrition (nutrition support and hyperalimentation) in gastro-intestinal surgery, traumatology and burn care are discussed. Prophylactic TPN, supplemental TPN and therapeutic TPN are covered as well as their merit in the treatment of surgical complications.

The Hartmann procedure revisited.

The results of 37 consecutive cases of Hartmann's procedure over a 5-year period (1985-1990) were reviewed. The series consisted of 27 emergency procedures (11 diverticular disease, 13 carcinoma, two trauma and one sigmoid volvulus) and ten elective procedures (nine carcinoma and one peridiverticular abscess). The indications for emergency procedures were obstruction and perforation. All patients presented with faecal peritonitis owing to colonic perforation. The mean (range) age was 79.4 (34-90) years. The postoperative mortality rate was 30 per cent overall (11 of 37), 33 per cent (four of 12) in the diverticulitis group, 23 per cent (five of 22) in the carcinoma group, and 100 per cent in the iatrogenic trauma group. Death was mainly due to sepsis (82 per cent). Postoperative complications were mainly wound infections, which occurred in 43 per cent (16 of 37) cases. In 25 per cent of the surviving patients, re-establishment of continuity was performed in three of 17 (18 per cent) of the carcinoma group and three of seven (43 per cent) of the diverticulitis group. No attempt at restoration of intestinal continuity was made in six cases due to medical risk in two, extensive carcinoma in two and local recurrence with metastatic disease in two. Three patients refused all further intervention. There were no postoperative deaths after the restoration of continuity. This series reflects the severity of the pathology in this high risk group of patients. However, the operation can be life-saving for a selected group of patients and offers good palliation for advanced colorectal tumours.

[Duplication of the colon in the adult (author's transl)]. / Duplicatio coli bij de volwassene.

The authors describe 2 cases of duplication of the colon. One was discovered by accident and not treated. The other occurred in a patient with a long story of abdominal pain and had been operated twice with signs of intestinal obstruction. A partial resection of the duplication with the adjoining bowel segment was performed and the digestive tract was reconstructed bij and end-to-end anastomosis. The different forms of duplication are described with their specific features and the current theories about their mode of formation. Finally a brief description of the symptoms and of the available surgical techniques is given.

The screening value of the amylase-creatinine clearance ratio in acute pancreatitis.

The screening value of the amylase creatinine clearance ratio in acute pancreatitis is studied. A series of 28 patients with pancreatic disease is compared with 80 controls and 82 patients with other intra-abdominal disease. The greatest specificity of the amylase creatinine clearance ratio value is reached at the 3.5 level. The amylase creatinine clearance ratio value proves to be of interest, not only in the diagnosis of acute pancreatitis but also in differentiating mild and heavy forms of pancreatitis.

The value of short-term peripheral parenteral nutrition after colorectal surgery: a comparative study with conventional postoperative intravenous fluid.

The potential beneficial effect of postoperative peripheral parenteral nutrition (PPN) was assessed in ten patients undergoing colorectal surgery and compared with the conventional use of intravenous fluids in ten controls. Clinical and biological parameters were checked. A significant improvement in the nitrogen-balance, which was not positive during the first postoperative days was observed. All other daily measured parameters (lipid metabolism, electrolytes, glucose levels and plasma pH) remained within normal ranges. In our opinion, short-term postoperative PPN may lessen protein losses and is indicated in those patients who may have a prolonged paralytic ileus without risking complications of central venous access. However, peripheral solutions may cause phlebitis and PPN is by no means an alternative to central TPN.

[Our experience of the Vest-Margulis test in the differential diagnosis of mechanical and paralytic ileus (author's transl)]. / Onze ervaring met de test van Vest-Margulis bij de differentiële diagnose tussen mechanische en paralitische ileus.

In order to evaluate the Vest-Margulis test in the differential diagnosis between mechanical and paralytic ileus a retrospective study was undertaken on 51 such tests performed before and after operation. Transit of gastrografin (Sodium amidotrizoate) through the caecum 4 hours after ingestion was controlled through roentgenograms. The diagnostic value of a positive test in pure paralytic ileus can be confirmed. Indeed 23 positive cases proved to have paralytic rather than mechanical ileus. On the contrary a negative test has no diagnostic value. Twenty-eight patients in which the contrast medium had not reached the caecum within 4 hours had either form of intestinal obstruction. The attention is drawn on the interesting therapeutic action of gastrografin in patients with a paralytic ileus and the simplicity of the investigation.

Emergency oesophageal stripping, an aggressive approach to acute, necrotic caustic burns of the oesophagus and stomach.

The authors describe a patient who was admitted with total necrosis of the oesophageal and gastric mucosa after ingestion of concentrated sodium hydroxide solution. An emergency total gastrectomy and blunt, thoracic oesophageal stripping was performed. Three months later, the continuity of the digestive tract was restored by a retrosternal colon interposition. The necessity of an aggressive diagnostic and therapeutic approach after the ingestion of caustics is recommended. An emergency endoscopic evaluation of the upper G.I. tract is mandatory. If a third degree oesogastric mucosal burn is diagnosed urgent laparatomy should be performed to assess transmural wall necrosis. If present an oesophageal gastrectomy should be performed as a life saving intervention.