Biomedical subjects
Publications and source records attributed to P Gatzinsky.
Bilateral spontaneous pneumothorax with almost complete collapse of the lungs in a 29-year-old man is reported. On admission to hospital the patient was in moderate respiratory distress, but the arterial blood gases were normal. Initially he was treated with bilateral tube drainage. Thoracotomy with parietal pleurectomy was later done on the right side to prevent recurrence.
During a 10-year period 28 patients with shrinking pleuritis with atelectasis (SPA) were observed and operated upon. This lesion has been given different names in the literature, for instance rounded atelectasis, pleuroma, pulmonary pseudotumour, and lung folding. All patients except two were operated upon because of a diagnosis of pulmonary tumour. However, at operation no tumour was found. The aetiology and pathogenesis of SPA are discussed on the basis of X-ray, operative, and histopathological findings.
Although oesophagocardiomyotomy has been the method of choice for surgical treatment of achalasia cardiae for several decades, there are still great discrepancies in the technical details of the procedure as performed in different centres. This is one of the main explanations for the diverging results reported, particularly with regard to the incidence of postoperative gastro-oesophageal reflux. Sixty-three patients underwent primary oesophagocardiomyotomy with a total length of 12 cm, including incision of about 2 cm onto the stomach. Forty-one patients were not examined preoperatively for conditions now recognized as predisposing to reflux and were managed with oesophagocardiomyotomy only, except one patient. Eight patients developed severe reflux complications from 1 to 5 years (mean 2 years) after the operation. In 11 out of 22 patients examined preoperatively for such conditions, Heller's operation was combined with an antireflux procedure. The results were good in all patients and pathological gastro-oesophageal reflux was not detected in any of the 22 patients during a follow-up period of 2 to 7 years (mean 4 years). It is concluded that oesophagocardiomyotomy should be combined with an antireflux procedure in selected patients. The indications for an antireflux procedure are discussed.
A series of 44 consecutive patients with oesophageal perforation treated during the ten-year period 1969-1978 has been reviewed. Thirty perforations were caused by oesophagoscopy using a rigid instrument, often combined with dilation and/or biopsy, 4 were caused by a fibreoptic instrument and 10 were spontaneous ruptures. A benign stricture was the most commonly associated lesion in the oesophagus. Six patients with an iatrogenic perforation were treated conservatively without mortality. These patients were characterized by mild symptoms, early recognition, minor leakage from the oesophagus and no communication to the pleural cavity. Fourteen patients were treated with closed thoracic drainage. The overall mortality among these patients was 70%, but for those with a spontaneous rupture it was 100%. Twenty-four patients were treated surgically with a mortality of 20%. Individualized treatment is recommended.
Satisfactory results with open cardiac valve surgery in selected elderly patients have been increasingly reported during recent years. In a series of 17 patients aged 70 or above the operative mortality was 18% and the long-term results were favourable. When selecting elderly patients for heart valve surgery special attention should be paid to left ventricular function and the presence of coronary artery diseases, which have unfavourable influence on the results.
Ninety-seven consecutive patients with hiatal hernia were operated upon with a modified Husfeldt hernia repair during a ten-year period. Thirty-two of the patients had severe reflux complications, such as ulcerative oesophagitis, oesophageal stricture and shortened oesophagus. Ninety patients were carefully followed up postoperatively. The mean duration of follow-up was 5 years. Analysis of the postoperative results in relation to the type of hernia showed no difference between sliding and combined hernia. Recurrence of hernia, unsatisfactory clinical results and gastro-oesophageal reflux were recorded more often in patients with severe reflux complications. The main cause of unsatisfactory results in these patients was found to be a shortened oesophagus. The method proved to be a reliable procedure for surgical treatment of not only uncomplicated hernias, but also cases complicated by oesophageal stricture if the stricture was not associated with shortened oesophagus. It is considered that a shortened oesophagus is a contra-indication for employment of the Husfeldt method.
Gastroplasty, as proposed by Collis, combined with fundoplication of varying degree, has been increasingly used during recent years for management of hiatal hernia complicated by shortened oesophagus and oesophageal stricture. A modification of this procedure using 180 degree fundoplication and the transthoracic-transdiaphragmatic approach is described. Thirty consecutive patients have been subjected to the procedure since 1973. The clinical results and results of X-ray examinations and laboratory investigations of gastro-oesophageal reflux in 29 patients examined postoperatively are analysed. The concept of combining artificial lengthening of the oesophagus with fundoplication is considered to be a promising approach for solving the problems associated with the management of hiatal hernia complicated by shortened oesophagus.
The relationship between GAS and oesophageal reflux complications in patients with hiatal hernia and incompetent antireflux mechanism is a matter of controversy. In a study of 70 patients operated upon for hiatal hernia, BAO and PAO after betazole stimulation were studied preoperatively in relation to oesophageal reflux complications, age and oesophageal motility. No correlation was found between BAO and oesophageal reflux complications. There was no association between PAO and such complications in patients with oesophageal hypomotility whereas PAO was clearly correlated to these complications in patients with normal oesophageal motility. Oesophageal reflux complications were closely correlated to oesophageal hypomotility and age.
The indications for surgical procedures reducing gastric acid secretion in patients with hiatal hernia and symptomatic gastroesophageal reflux remain unclear. In a study of the postoperative results in 40 patients operated upon with modified Husfeldt hernia repair only, the results were assessed in relation to BAO and PAO. No correlation was found between the clinical results and BAO or PAO in patients in whom the reflux was successfully corrected by the procedure. It is concluded that gastric acid-reducing procedures are not indicated in patients in whom correction of reflux is anticipated.
One hundred and sixteen patients operated upon for hiatal hernia with gastro-oesophageal reflux and with or without reflux complications were postoperatively examined by personal interview, X-ray study, pH measurements and study of the oesophageal motility 1 to 10 years postoperatively. The patients without severe reflux complications were operated upon mainly with a modified Husfeldt hernia repair and the patients with complications, such as oesophageal stricture and shortening, underwent various surgical procedures. The main reason for unsatisfactory clinical results, with persistent reflux symptoms, was gastro-oesophageal reflux uncorrected by the surgical procedure. However, gastro-oesophageal reflux was detected even in completely asymptomatic patients. It was found that the reflux symptoms were influenced by the oesophageal motility. The clinical results were better and recurrence of hernia and the occurrence of pathological reflux were lower in patients operated upon for hernia without severe reflux complications. Creation of a competent antireflux barrier between the oesophagus and stomach for control of gastro-oesophageal reflux is much more difficult in patients with severe reflux complications.
During a 10-year period, 1967-1976, 57 patients were operated upon for hiatal hernia and gastro-oesophageal reflux complicated by oesophageal stricture. Forty-four patients were managed by various surgical antireflux procedures combined with dilation of the stricture. In 12 patients the stricture was resected and the oesophageal continuity restored by oesophagogastrostomy. The primary mortality was 3.5%. Fifty-two patients were carefully followed up postoperatively by periodic control examiniations. The results of the treatment are presented. The main cause of unsatisfactory postoperative results was gastro-oesophageal reflux uncorrected by the surgical procedure. In the patients subjected to a hernia repair the failure of the antireflux procedure was due mainly to a shortened oesophagus associated with the stricture. It is concluded that most of these strictures can be successfully treated by dilation after establishment of control of the pathological reflux by means of an antireflux surgical procedure. The location, width, length and rigidity of the stricture, as revealed at the preoperative examination, are not decisive for the choice of therapeutic approach.
The existence of an anatomically shortened oesophagus in patients with hiatal hernia, and its influence on the results of surgical repair of the hernia, is the subject of great controversy. One hundred and forty patients operated upon for hiatal hernia were studied for presence of shortened oesophagus. The method of examination and criteria for evaluation of the oesophageal shortening are described. The oesophagus was found to be anatomically shortened in 52 of these patients. None of the findings obtained at the preoperative examinations employed in the study could be used as a pathognomonic sign for diagnosing a shortened oesophagus. Irreducibility of the cardia below and the diaphragm, as observed radiologically, in association with other severe reflux complications, such as oesophageal stricture and/or ulcerative, makes it presence very likely, however. The incidence of shortened oesophagus in this series was higher in patients with a long history of symptomatic gastro-oesophageal reflux. The influence of the shortened oesophagus on the result of the surgical repairs used in this study, and aimed mainly at restoring the abdominal segment of the oesophagus, was clearly unfavourable.
A series of 43 patients with thymoma was reviewed. The patients were classified with respect to some factors of prognostic significance. The tumors were reclassified histologically, and a staging system with three defined stage-groups was applied to the series on the basis of operative findings and histological examination of surgical specimens. Surgical-pathological staging is of high prognostic and therapeutic importance in thymomas. Complete removal of the tumor was possible in the 25 patients with stage I or II disease and in 14 of the 18 patients with stage III tumors. Pleural metastases were observed in half of the patients with stage III disease. Even patients with extensive local spread or pleural metastases were subject to tumor resection. The treatment of choice is radical resection along in stage I; radical extirpation and, if indicated, postoperative radiotherapy in stage II; and radical resection whenever possible, even in cases of pleural spread, in stage III, with postoperative radiotherapy and chemotherapy. Myasthenia gravis is an indication rather than a contraindication to radical treatment of thymoma, although some patients may deterioratte. The importance of total thymectomy is stressed.
Among 82 patients with a tumor in the thymic region, 17 had a lesion that fulfilled the criteria for Hodgkin's disease of the thymus; the histopathological differentiation of this entity from thymomas is discussed. All patients received surgical treatment and postoperative radiotherapy. After a mean observation time of 10 years there was no local recurrence and no death due to the disease, though 3 deaths were cuased by the treatment. New clinical manifestations occurred in 3 of the 14 long-term survivors: they were treated successfully by operation or irradiation. A very aggressive surgical approach involving extirpation of all tumor tissue, extensive excision of the surrounding tissues and adjacent lymph nodes, and supplementary radiotherapy seems to be the treatment of choice.
In a series of 82 patients with tumors of the thymus and thymic region there were 11 with teratomas and germinal tumors. Four of these patients had benign cystic teratomas, 4 had malignant teratomas, 1 had an embryonal carcinoma, and 2 had seminomas. The benign teratomas were removed by simple extirpation without complications. The malignant teratomas were highly invasive, and despite extensive operations and postoperative radiotherapy, 3 of the 4 patients died within 9 months. One patient with predominantly seminomatous differentation of the teratoma was alive and well more than 3 years after the operation. The patient with an embryonal carcinoma died after 4 months. One of the 2 patients with seminoma remained alive 20 years after radical excision and postoperative radiotherapy. The other, who had a huge seminoma, died during operation. The prognosis in patients with seminomas or with predominantly seminomatous structures in teratomas seems to be good after combined radical excision and radiotherapy, although nonradical resection followed by raditherapy may be justified in high-risk patients.
Intramural oesophageal cysts lined by ciliated columnar epithelium are considered to be lesions which are not prone to serious complications except infection. In contrast to this view, a case of intramural oesophageal cyst recently operated upon by us, in which severe mediastinal bleeding developed, is described.
No method of surgical treatment of carcinoma of the oesophagus and cardia is universally accepted. An approach to the problems of the choice of the side for thoracotomy, the organ for reconstruction of the continuity of the oesophagus and the combination of the abdominal and thoracic stages of the surgical procedure is presented. It is based on the following principles: (1) Selecting the side for the thoracotomy on the basis of the distance from the upper incisors to the upper margin of the tumour, determined by oesophagoscopy. (2) Separation of the laparotomy and the thoracotomy. (3) Starting the operative procedure with the laparotomy. The operative mortality in a series of 44 patients operated upon according to these principles is compared with that in a previous series of 77 patients and the advantages and disadvantages of this approach are discussed.
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