摘要:

Theodor Kocher was born in Bern on August 5, 1841, attained his medical degree in 1865 after studying medicine at the local university, and became the Professor of Surgery there in 1872. By the turn of the century, he was famed as one of the innovative experimental surgeons of his time and, in 1909, was awarded the Nobel Prize for his seminal contributions to thyroid surgery. Both H. Cushing and W. Halsted benefited intellectually and technically from their interactions with Kocher and Bern. Kocher provided the academic template and personal motif upon which Cushing molded his subsequent neurosurgical career. Halsted’s relationship with Kocher was more of a mutual personal admiration supported by an exchange of clinical and scientific information. Overall however, the Swiss influence on American surgery reflected interactions at many levels and included H. Banga, N. Senn, A. Ochsner and M. Stamm. These Swiss-American surgeons all well recognized in their own right provided significant contributions which included the introduction of antisepsis, innovative surgical techniques, educational reforms and the formation of the American College of Surgeon

ISSN:0253-4886    

DOI:10.1159/000172596

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

A time-oriented approach is the key to management of enterocutaneous fistulas. During the 2 initial days the diagnosis and classification should be completed. Then, stabilization of the patient including maintenance of the hydroelectrolytic balance, assessment of the nutritional status and treatment of sepsis must be accomplished. The third week is usually devoted to giving appropriate nutritional support, fully characterizing the fistula anatomy and, if indicated, starting pharmacological treatment. If medical treatment fails, planned reintervention is on order. Nutritional support is of paramount importance for the spontaneous closure of enterocutaneous fistulas. Treatment with octreotide is only effective in accelerating fistula closure and only when it has already stabilized, usually after the first 2 weeks. Fistulas arising from large bowel defects or draining through wound dehiscence are poor candidates for spontaneous closure. With correct treatment, 70-80% spontaneous closure may be expected, with a mortality rate of 5-12%.

ISSN:0253-4886    

DOI:10.1159/000172597

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Complete mechanical obstruction is a frequent complication of radiation enteritis, necessitating hospital admission and usually leading to unavoidable surgery. To alleviate obstruction, resection of variable lengths of intestine is the usual treatment. This option has the risk of potential anastomotic dehiscence in radiation-injured bowel. In this paper, a new technique of extramucosal stricturoplasty is introduced. It is a method to relieve small bowel obstruction without breaking mucosal continuity, consisting of a double plasty, limited to the serosal and muscular layers, that re-establishes adequate width to the bowel lumen and allows restoration of normal transit.

ISSN:0253-4886    

DOI:10.1159/000172598

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Chronic pancreatitis is a medical disease and surgery should only be used to correct an anatomic problem or to relieve pain that has been refractory to medical therapy. Both pancreatic resection and pancreatic duct drainage can relieve pain in chronic pancreatitis. But pancreatic duct drainage is our preferred operation because it does not sacrifice endocrine and exocrine function. In order to achieve the best chance for pain relief, strict attention to the technical details of pancreaticojejunostomy must be kept. Side-to-side pancreaticojejunostomy will provide substantial or complete relief of pain in 65-85% of patients. It has a low operative mortality and reasonable rate of morbidity. Pancreaticojejunostomy is a safe and effective way to treat patients with disabling pain from chronic pancreatitis who have a dilated pancreatic duct.

ISSN:0253-4886    

DOI:10.1159/000172599

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Survival of patients with esophageal carcinoma (EC) can be improved by preoperative neoadjuvant chemoradiation followed by esophageal resection. We introduced this treatment modality in 1994. Treatment results of 25 patients presenting with stage Ila/b or III EC (UICC 1987) were analyzed. After assessment of operability and clinical staging, all patients received radiation therapy (36 Gy, 1.8 Gy/day, days 1-5, weeks 1-4) and chemotherapy (cisplatin 20 mg/m2, days 1-5, weeks 1 and 4, and 5-fluorouracil 500 mg/m2, days 1-5, weeks 1-4). Patients were operated upon 8-10 weeks after treatment initiation and clinical restaging. In 3 patients thoracotomy demonstrated inoperability due to local tumor progression into the tracheobronchial tree. Major postoperative morbidity was observed in 72%, 2 patients died after resection while in hospital (8%). The comparison of pretreatment clinical staging with restaging after neoadjuvant therapy revealed tumor down-staging (UICC) in 12 patients, no change in 11 patients and up-staging in 2. Comparison of restaging after neoadjuvant therapy and pathohistological staging after resection demonstrated down-staging in 2 patients, no change in 8 patients and up-staging in 15 patients. Complete pathohistological remission was observed in 3 patients. Pathohistological findings revealed a different tumor stage (UICC) in 21 patients (11 × up-staging, 10 × down-staging) when compared with pretreatment clinical staging. Mean 2-year survival was 87.5% in patients with remission and 16.5 % in patients without remission or progress of disease. The data demonstrate the feasibility of neoadjuvant preoperative chemoradiation in EC. On the basis of staging results some patients benefit from neoadjuvant therapy while others show progress of disease. The impact of neoadjuvant therapy needs to be carefully evaluated to exclude pitfalls due to clinical misstagin

ISSN:0253-4886    

DOI:10.1159/000172600

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Background: The increasing incidence of carcinoma of the gastro-oesophageal junction and oesophagus implies an increasing future challenge in the management of patients with these tumours. Methods: From 1988 to 1995, 53 patients were operated on for carcinoma of the gastro-oesophageal junction (n = 17) or the oesophagus (n = 36) in the Department of Surgery at the University Hospital in Uppsala. In 81 % of the patients the tumour was in an advanced stage. A thoracotomy was performed in 46 (87%) of the patients and in the rest the tumour was resected without this procedure. Results: Postoperative complications occurred in 60% of the patients. Of these, anastomotic leakage (26%) and stricture (34%) were the most common. The overall in-hospital mortality was 13% and was positively correlated with the age of the patient. Conclusion: Surgical treatment of advanced carcinoma of the oesophagus or the gastro-oesophageal junction is associated with substantial postoperative morbidity and mortality.

ISSN:0253-4886    

DOI:10.1159/000172601

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Circulating alimentary hormones were measured following a standardized meal in 10 patients after partial distal gastrectomy and 12 patients after total gastrectomy, both groups reconstructed by Billroth-II anastomosis, and in 9 age-matched healthy controls. Patients underwent resection for gastric cancer and were studied 45 ± 10 months after surgery. At the time of study, the patients had adapted well to surgery and no longer exhibited the symptoms of dumping seen immediately postoperatively. In contrast, the total gastrectomy patients exhibited severe symptoms of reflux esophagitis. The nutritional states of the patients, evaluated by measurement of rapid turnover proteins in serum, was impaired in proportion to the degree of gastric resection. Basal gastrin levels were reduced by partial (p < 0.05) and total gastrectomy (p < 0.01). Postprandial responses of both gastrin and pancreatic polypeptide were abolished following either partial gastrectomy or total gastrectomy (all p < 0.001). Glucose-dependent insulinotropic peptide and motilin were relatively normal after both procedures. In contrast, early cholecystokinin responses were increased 2-fold after partial gastrectomy (p < 0.05) and 3-fold after total gastrectomy (p < 0.001). Postprandially, a large increase in neurotensin levels and a moderate increase in peptide YY were seen after both partial and total gastrectomy (all p < 0.01). Fasting peptide YY levels were also increased after total gastrectomy (p < 0.01). The late adaptive changes in alimentary hormone secretion may help to compensate for loss of gastric motor function which accompanies gastric resection. On the other hand these hormonal changes may exacerbate the esophageal reflux seen following gastrectomy

ISSN:0253-4886    

DOI:10.1159/000172602

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Aim: Evaluate the role of primary definitive surgery on the treatment of perforated peptic ulcer. Methods: Patients with a perforated peptic ulcer occurring in the period from 1983 until 1993 were studied retrospectively by evaluating inpatient and outpatient records in combination with a general practitioners’ inquiry. Short-term and long-term results were assessed with regard to type of surgical treatment, i.e., simple closure (SC) alone versus highly selective vagotomy (HSV) with SC. Results: Forty out of 81 patients (49%) that were available for long-term follow-up had recurrent ulcer disease (complaints), of which 28 out of 61 of the SC group (46%) and 12 out of 20 of the HSV group (60%). Moreover, in 17 patients treated with SC, but preoperatively judged to need a HSV or meeting the criteria for a HSV, only 7 patients (41%) had recurrent ulcer disease. Conclusion: Primary definitive surgery in perforated peptic ulcer disease has no advantages over SC. Treatment should thus consist of SC of the perforatio

ISSN:0253-4886    

DOI:10.1159/000172603

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Operative treatment of benign biliary strictures, particularly those caused by iatrogenic injuries, is burdened by a relatively high risk of recurrent strictures. We have analyzed late results of Roux-en-Y hepaticojejunostomies, the most common surgical procedure for benign biliary strictures. The results of 74 hepaticojejunostomies performed in 62 patients in the years 1965-1995 are presented in this work. Fifty-five patients (67 operations) were subjected to long-term follow-up. The mean observation period was 12.5 years (1-31 years). Since 1976 up to now, the patients have been under careful, periodic assessments, with emphasis on the first 5 postoperative years. The main aim of these systematic examinations was to diagnose early a possible operative failure and to make a quick decision for reoperation. We have found that duration of cholangitis was on average 2 times shorter before reoperation than in the case of primary hepaticojejunostomy. None of 12 reoperations resulted in death. Effectiveness of particular hepaticojejunostomies, as judged by cumulative patency rate, was 75% (83% for I and II Bismuth type, and 60.5% for III and IV Bismuth type). The distant cumulative patency rate increased to 92%, assuming the second successful reconstruction as continuation of effective treatment. All hepaticojejunostomies according to Hepp for hilar stricture were successful, although only in 5 cases among 15 patients, follow-up was longer than 10 years. Our long-term results indicate that careful, periodic postoperative follow-up of patients after hepaticojejunostomy for benign biliary stricture, especially of iatrogenic origin, has a positive influence on final outcome of surgical treatment.

ISSN:0253-4886    

DOI:10.1159/000172604

出版商:S. Karger AG    

年代:1997

数据来源: Karger

摘要:

Background and Aim: latrogenic biliary injuries are among the most serious complications of biliary surgery. Reparative surgery is challenging, especially in recurrent patients. The aim of this study was to evaluate the success of high hepaticojejunostomy in the management of various types of iatrogenic injuries, both as primary repair and after previous failed attempts at surgical repair. Patients and Methods: Twenty-two patients (13 females, 9 males) with a mean age of 44.7 years were included and injury had occurred during: open cholecystectomy in 19 patients; laparoscopic cholecystectomy in 2 patients, and repair of an incisional hernia in 1 patient. Eight patients had had previous repair attempts with bilioenteric anastomosis in 6 and primary repair over a T tube in 2 patients. The last previous surgery was 1 week to 6 years earlier. The level of injury was diagnosed by endoscopic retrograde cholangiopancreaticography in 15 patients, and by percutaneous transhepatic cholangiography in 7 patients. The patients underwent Roux-en-Y hepaticojejunostomy at the confluence in 15 (68%) and just below the confluence in 7 (32%). The mean follow-up period was 25 ± 15 months. Results: Eighteen patients (82%) had an uneventful recovery and good outcome during follow-up, whereas 4 patients (18%) had moderate or poor outcome. There was no correlation between the duration of biliary injury or previous repair attempts and the outcome of surgery. Conclusion: High hepaticojejunostomy offers good results in the management of complicated iatrogenic biliary injuries. Failed previous attempts at repair do not alter the success of reparative surgery

ISSN:0253-4886    

DOI:10.1159/000172605

出版商:S. Karger AG    

年代:1997

数据来源: Karger