In recent years new techniques for the investigation of colonic motility and defaecation mechanism have been developed. On the basis of the results of these studies it has been suggested that there might be an indication for a surgical approach to the distressing problem of constipation. Because this approach is still controversial, it seems to be appropriate to review the suggested indications for the use of surgery in the treatment of constipation and to discuss the results as reported in the literature so far.
The case history is reported of a patient with a carcinoma of the duodenum 30 years after blunt abdominal trauma at the site of the 'scar' in the duodenum. Thirteen years after the trauma the patient was treated with chemotherapy and abdominal irradiation for a relapse of Hodgkin's disease. At follow-up, 25 months after the operation, he had no local recurrence of Hodgkin's disease or duodenal cancer. The possible relation between the cancer and the abdominal trauma, chemotherapy and abdominal irradiation is discussed.
The case report is presented of a patient with a potentially lethal embolism secondary to thrombosis of a supraceliac distal thoracic aorta to femoral artery bypass. In view of this serious complication, wide use of this type of extra-anatomic bypass does not seem to be warranted.
The case history is reported of a patient with an invasion of the inferior vena cava by metastases of a non-seminomatous testicular tumour. He was treated with combination chemotherapy, followed by laparotomy and resection of residual tumour tissue. Fourteen months after this operation he is in good health. For every retroperitoneal lymph node dissection it is necessary to be on the look-out for invasion of the vena cava, because of the risk of a sudden pulmonary embolism.
A pedicled omentoplasty is a simple and safe method to reconstruct soft-tissue defects. A pedicled omentoplasty can also be used as an adjuvant surgical procedure in preventing anastomotic leakage and radiation damage. The way a pedicled omentoplasty should be performed is described in detail with special attention to transposing techniques.
Computed tomography, ultrasound, nuclear scintigraphy, and laboratory tests (lactic dehydrogenase, alkaline phosphatase, and 5-nucleotidase) were compared in 135 patients with gastro-intestinal carcinoma to define the most useful test to detect hepatic metastases. Thirty-six patients (26.7 per cent) had hepatic metastases at laparotomy. Sensitivities were low: 46.2 per cent for nuclear scintigraphy, 57.6 per cent for ultrasound, 67.7 per cent for computed tomography and 62.9 per cent for lactic dehydrogenase. Accuracies ranged from 62.9 (lactic dehydrogenase) to 77.6 per cent (nuclear scintigraphy). No significant differences were found. Accurate and efficient detection of hepatic metastases is hampered by relatively low sensitivity, specificity and accuracy of the conventional imaging tests and laboratory tests.
In surgery, the omentum is used as a very potent tissue in wound healing. This suggests, besides a good vascularization pattern, an important immunological function in which milky spots might be involved. Therefore, we investigated the characteristics of the milky spots in the omentum of an animal model after several immunization procedures. Our results showed that milky spots must be regarded as strongly reactive structures originating from perivascular effusions in the omentum. Moreover, milky spots can firstly be a local source of potent immune effector cells i.e. peritoneal macrophages and secondly can, after specific immunization, be qualified as a lymphoid organ that is, produce a specific (lymphocyte) mediated response. This may shed new light on the reason why the omentum works so well in wound healing.
Popliteal artery aneurysms are dangerous and limb threatening; they can present with various ischemic symptoms. Surgical treatment is advised to avoid thromboembolic complications. In most cases the aneurysm is bypassed with a tunnelled reversed saphenous vein or with a prosthetic graft followed by ligation of the popliteal artery. In the popliteal fossa, the close relation between the graft and the aneurysm may cause graft failure. Four patients with symptomatic popliteal artery aneurysms were treated with an extra-popliteal in-situ saphenous vein graft, so far without failures. An additional advantage of an in-situ graft is the better result in case of a distal anastomosis.
The concept that constipation derives from an isolated abnormality of one muscle group or mechanism is probably naive, and stems from an inability to assess the colon, rectum and anal mechanism as an integrated unit.
Herniation of the abdominal wall is seldom encountered after harvesting cancellous bone from the iliac crest. The case history is presented of a patient with the symptoms, diagnostic work-up and repair of the hernia using a Goretex sheet.
The case history is presented of two patients with attacks of cherry-red urine after strenuous exercise. Both had varicosity of the long saphenous veins. Haemoglobinuria disappeared after crossectomy of the long saphenous vein and resection of the convolutes. After one and two years, they have no recurrence.
Two patients with venous obstruction of the arm are reported. Obstruction in one patient was caused by a congenital web of the subclavian vein, in the second by granulomatous thrombophlebitis of the brachiocephalic vein. Both patients were successfully treated by operation. All obstructive symptoms subsided completely. Control phlebography one week and three months postoperatively showed patent reconstructions.
The only effective treatment of an aortocaval fistula is the surgical closure of the fistula opening with insertion of an aortic prosthesis to restore the arterial continuity. The diagnosis of this distinct but infrequent clinical entity is often missed because of lack of suspicion. Proper preoperative evaluation facilitates the choice of surgical approach and reduces the morbidity. Three patients are presented with an aortocaval fistula: two with spontaneous rupture of an atherosclerotic abdominal aneurysm into the inferior vena cava and one with a traumatic fistula following intervertebral disk surgery 33 years before. All three patients suffered from pain in the abdomen and back, a palpable pulsatile abdominal mass and an audible continuous harsh bruit. Cardiac failure was present in two of them. Successful surgical closure could be accomplished in two patients although the perioperative course was complicated by ventricular arrhythmia, profuse blood loss and an inferior vena cava syndrome. One patient with a spontaneous aortocaval fistula passed away due to intraoperative exsanguination.
Two patients with Crohn's disease confined to the appendix are described. The condition may present as acute appendicitis or appendiceal infiltrate. Therapy of either manifestation includes appendectomy. Concurrent Crohn's disease elsewhere in the gastrointestinal tract may be found in 25 per cent of the patients. A recurrence rate of 10 to 15 per cent in the remaining patients justifies a follow-up of some three years.
A 61-year-old diabetic woman was admitted with high fever, dehydration and acidosis caused by fasciitis necroticans of the forehead. The electrolytes and blood sugar level were corrected, broad spectrum antibiotics started and extensive débridement performed, followed by a second-look operation the next day. After the bacterial culture was known, the antibiotics were adapted. A split-skin graft gave an acceptable result.
