[Surgery in para-esophageal hiatal hernia: technic and results]

40 patients with paraesophageal hiatus hernia have undergone surgery over a period 25 years' period. Surgery consisted of gastropexy in 38 patients (ventral corpopexy in 32, fundophrenicopexy in 19), narrowing of the hiatus in 24 and fundoplication in 14. There was one operative death (2.5%). On follow-up 3 to 24 years later (mean 12.5 years) 17 of 20 patients (85%) have good or excellent results. 2 patients without additional antireflux surgery had to be reoperated later because of severe reflux disease (secondary fundoplication). 1 patient with gastropexy and fundoplication has recurrent reflux disease. X-ray studies in 18 patients showed recurrent paraesophageal hiatus hernia in 9 (50%). After operation for paraesophageal hiatus hernia a good clinical long-term result can be expected. To reduce the frequency of recurrent hernia, technical modifications should be considered.

[Long-term results following fundus plication and vagotomy in reflux disease. Complaints after 10-20 years]

In 109 patients with primary reflux disease in whom combined fundoplication and vagotomy had been performed, the clinical results were evaluated by questionnaire 10-20 years (median 15.7 years) after operation. Indication for additional vagotomy was severe reflux disease and/or increased gastric acid output in 56 (A) and coexistent ulcer disease in 53 (B) patients. Vagotomy was truncular (with pyloroplasty) in 49, selective gastric (with pyloroplasty) in 50, and proximal gastric in 10 patients. Follow-up was available from 64 patients (59.6%). The results were as follows: 17.2% (A 19.4%, B 7.1%) had reflux symptoms, while 9.5% (A 11.4%, B 7.1%) needed medical antireflux therapy. Dysphagia was present in 28.2% (A 13.9%, B 35.7%), and gas-bloat in 54.7% (A 55.5%, B 53.6%). Typical postvagotomy symptoms were diarrhea in 23.5% (A 30.6%, B 14.3%) and dumping in 25.0% (A 22.2%, B 28.6%). Using the Visick classification criteria we found grade I and II in 73.4%, grade III in 17.2% and IV in 9.4%. Symptoms are frequent after fundoplication and vagotomy. The clinical result is more favourable in group B and for the combination of fundoplication with proximal gastric vagotomy.

[Pain-free piezoelectric extracorporeal shock wave lithotripsy in gallbladder stones. Initial experiences]

Efficacy and side effects of lithotripsy of gallbladder stones with a piezoelectric lithotriptor are assessed. 16 treatments were performed in 8 patients (1-3 per patient). Patients required no premedication, analgesia, infusion or monitoring. Gallstone fragmentation was achieved with all treatments. Laboratory findings remained unchanged after treatment, with the exception of one patient with mild pancreatitis. With adjuvant oral bile acid treatment, 6 of the 8 patients were stone-free within 3 days to 3 months. Extracorporeal shockwave lithotripsy with piezoelectric shock waves provides painless and efficient gallstone fragmentation. Repeated treatments may speed complete fragment dissolution.

[Palliative biliodigestive anastomosis in non-resectable cancer of the head of the pancreas--with or without preventive gastroenterostomy?]

In 226 patients with malignant obstructive jaundice over a 10-year period (1975-1984) 92 presented with an unresectable carcinoma of the head of the pancreas and were treated with a palliative bilioenteric diversion: in 52 cases alone, in 20 cases with a therapeutic gastroenterostomy because of early duodenal obstruction, and in 20 cases with a simultaneous prophylactic gastroenterostomy. The latter did not increase perioperative morbidity (25% vs. 50% in bilioenteric diversion alone), mortality (5% vs. 19%) nor length of hospital stay (19.9 vs. 20.6 days). Later on patients with a prophylactic gastroenterostomy showed a decreased incidence of chronic vomiting (15% vs. 42%). No secondary gastroenterostomy was performed in this group, vs. 14% (6 patients) in cases with bilioenteric diversion alone (mortality 33%). We recommend the simultaneous prophylactic gastroenterostomy which does not increase morbidity, mortality and length of hospital stay and helps avoiding a risky secondary gastroenterostomy.

[Therapy and prognosis in 102 liver injuries]

Case histories of 102 patients with liver trauma were analyzed. 88% sustained blunt and 12% penetrating liver injury. 71% of all patients had a polytrauma. The liver injuries were classified in 4 types. With 25 patients primary resuscitation was unsuccessful, in 12 of these cases even though immediate laparotomy and aortic clamping was performed in the emergency room. In 62 of the remaining 77 patients haemostasis was accomplished with minor surgical procedures (lethality 16%), in 13 cases major surgery had to be performed (lethality 62%). Packing was used in one patient only. Prognosis of liver trauma depends mainly on associated injuries and on severity of liver trauma.

[Can recurrent reflux disease following fundoplication be prevented by adding a vagotomy?]

Recurrent reflux disease is one of the main problems after fundoplication. Reducing gastric acid secretion by adding a vagotomy could theoretically be of beneficial value in controlling reflux. The clinical results of 109 patients were assessed 10 to 20 years after combined fundoplication and vagotomy for primary reflux disease. Indication for an additional vagotomy was severe reflux disease or increased gastric acid output in 56 and coexistent ulcer disease in 53 patients. Data from 64 patients (59.6%) were analyzed. Results were as follows: 17.2% had persistent or recurrent reflux disease, 9.5% needing medical treatment. The results were similar with different types of vagotomy: 18.5% and 14.8%, respectively for truncular vagotomy and pyloroplasty (27 pts.) 17.9% and 7.4%, respectively for selective gastric vagotomy and pyloroplasty (28 pts.), and 11.1% and 0%, respectively for proximal gastric vagotomy (9 pts.). Compared with the results after fundoplication alone, an additional vagotomy does not seem to prevent recurrent reflux disease.

[Long-term results following fundus plication. Symptoms after 10 to 20 years]

10 to 20 years (median 15.1 years) after fundoplication for primary reflux disease, 257 patients were asked to complete a questionnaire concerning their symptoms. Data of 163 patients (64.3%) were analyzed. Results were as follows: 21.4% of the patients had persistent or recurrent reflux symptoms, about half (9.8%) needing medical treatment. Adverse side effects of fundoplication were frequent (dysphagia in 28.2% and gas-bloat in 50.3%). Using the Visick classification criteria we found Visick grade I and II in 75.5%, grade III in 17.2%, and IV in 7.4%.

[Hiatal hernia and reflux disease--long-term results following fundoplication and consequences in therapeutic failures]

10 to 20 years (median 15.1 years) after fundoplication for primary reflux disease 257 patients were questioned about their symptoms. Data of 163 patients could be analyzed.

RESULTS

21.4% of the patients have persistent or recurrent reflux symptoms, about half of them (9.8%) need medical treatment. Adverse side-effects of the fundoplication are frequent: dysphagia in 28.2%, gas-bloat in 50.3%. Using the Visick criteria for classification we found Visick grade I and II for 75.5%, grade III for 17.2%, and IV for 7.4%. Diagnostic and therapeutic concepts in case of failed reflux control are discussed.

The stability of parenteral fat emulsions in nutrition mixtures

The effect of dilution, dextrose, amino acids and electrolytes on the stability of two parenteral fat emulsions (Travamulsion and Intralipid) were investigated. It was found that dilution of intravenous emulsions with water for injection had a different influence on the stability of the two emulsions. In addition, a dextrose concentration of 15-20% and higher, in the absence of amino acids caused coagulation of the fat droplets after storage (4 degrees C for 24 h followed by 24 h at room temperature). The addition of amino acids increased the stability of emulsions in the presence of dextrose. The differences found in the particle size distribution of the different emulsions investigated were reflected in their stability in the presence of electrolytes. Critical aggregation concentrations (monovalent cation) of 240 mmol/l for Travamulsion 10% and 156 mmol/l for Intralipid 10% were determined.

[Long-term results of thoracic truncal vagotomy and pyloroplasty in complicated reflux disease]

In advanced cases of esophagitis with acquired short esophagus and stricture, operative treatment to eliminate gastroesophageal reflux may be difficult or impossible. 24 such patients were treated by transthoracic truncal vagotomy and pyloroplasty. In a long-term follow-up 9--11 years later 12 patients were examined by X-ray and esophagoscopy. In 9 patients symptoms due to reflux or obstruction had improved, 5 of them were symptom-free. At endoscopy and barium-swallow 2 patients showed back-formation of their stricture, the other patients had generally unchanged findings. Transthoracic truncal vagotomy with drainage seems to be able to prevent progression of severe esophagitis and to improve its symptoms.