Postoperative Follow-up Study Research Articles

A postoperative follow-up study of infantile coarctation of the aorta.

Follow-up investigations were performed in 16 patients operated on for coarctation during infancy. The follow-up period ranged from 4.5 to 11 years (median 5.5 years). Four different surgical techniques were used: resection with end-to-end anastomosis (REE) (4 patients), subclavian flap aortoplasty (SFA) (10 patients), patch aortoplasty (1 patient) and resection and SFA (1 patient). One patient developed recoarctation (6%). She had been operated on by REE at 7 days of age. The other three patients operated on by REE had equal pulses in the arms and legs; none had hypertension and all had normal arm/leg pressure gradients at rest. Seven (58%) of the 12 patients operated on by SFA or aortoplasty had weak radial pulses in the left arm but no limitation of left arm function. The left a rm showed a normal bone age but was smaller and shorter than the right arm in 9 (81%) of the patients. None of the patients operated on by SFA had hypertension and the arm/leg gradient at rest was normal.

Risk of residual rectal mucosa after proctocolectomy and ileal pouch-anal reconstruction with the double-stapling technique. Postoperative endoscopic follow-up study.

This study was designed to assess the risk of retained rectal mucosa after proctocolectomy and ileal pouch-anal anastomosis with the double-stapling technique. A total of 113 patients underwent proctocolectomy with an ileal pouch-anal reconstruction. In 57 patients the anastomosis between pouch and proximal anal canal was performed using the double-stapling technique. In 26 patients the procedure was carried out without a protecting ileostomy. Of the remaining 31 patients with a proximal ileostomy, 15 underwent endoscopy six weeks postoperatively. Circular biopsies were taken just distal from the pouch-anal anastomosis. Histologic examination revealed rectal mucosa in at least one biopsy in 7 of 15 patients. At follow-up (mean 18 months) no (distal) pouchitis was clinically noticed. In one patient with familial polyposis, a few polyps, distal of the anastomosis, had to be endoscopically removed. Double-stapled ileal pouch-anal anastomosis has a considerable risk of residual rectal mucosa, because of combined linear transection and circular stapling with bilateral dog-ear formation of rectal mucosa. Residual rectal mucosa did not seem to influence clinical results at follow-up.

Dilemma in surgical treatment of petrous cholesteatoma

Surgical treatment of petrous cholesteatoma that involves the petrous pyramid and extends beyond the internal auditory canal is often difficult because of the site and extent of the cholesteatoma. Various problems pertaining to the operation are discussed from our experience with fourteen patients who underwent surgery in our hospital. When accompanied with otorrhea, the middle ear was eradicated by radical mastoidectomy before total removal of the cholesteatoma in order to avoid intracranial infection. Staging operation was conducted in 6 patients in which otorrhea could not be stopped by conservative treatment. The surgical approach was translabyrinthine in 10 patients, middle cranial fossa plus transmastoid in 2, and a combination of these methods in 2. The postoperative large cavity was totally exteriorized in 5 cases in which eradication of the cholesteatoma was deemed too risky, although the exposed internal auditory canal and the denuded dura were supplemented locally. In the other 9 cases, the cavity was obliterated with abdominal fat and/or muscle flap. Facial nerve palsy was present preoperatively in 11 patients. They were treated by decompression in 7 cases, nerve-anastomosis in 2 and nerve grafting in one. In one patient, atrophy of the nerve was too severe to perform nerve grafting. Plastic surgery, such as suspension of the eyelid and masseter muscle transfer, was additionally carried out in 6 of the above patients. Postoperative follow-up study with CT and MRI is very important. In 3 of our cases, the cholesteatoma recurred and the reoperation was needed.

顎関節内障クローズドロック症例に対する外科療法の検討 顎関節鏡視下剥離授動術術後成績について

A postoperative follow-up study of internal derangement with persistent closed lock after arthroscopic surgery of the temporomandibular joint was performed in 9 patients, 11 joints.Using a triangulation technique via a second puncture, diagnostic arthroscopy was performed, followed by arthroscopic lysis and lavage operation of the temporomandibular joint to increase mobility of condyle-disk complex. This was accomplished by using power instrumentation (Microdebrider-Small Joint Microelectric Arthroplasty System) in conjunction with an irrigation system.We evaluated the efficiency of this instrument and irrigation system for temporomandibular joint arthroscopic surgery.According to the criteria of the American Society of Oral and Maxillofacial Surgery and those of Takahashi and Shibata, the surgical success rate was 88.9%. Postoperatively, there was no complication or severe discomfort.

Postoperative Recurrence of Perilymphatic Fistulas

Postoperative follow-up study of perilymphatic fistulas (PLFs) showed that recurrence of PLF was not rare and revision was sometimes needed to relieve the symptoms associated with leakage of perilymph. Of the 54 PLF patients surgically treated in our clinic, some sign or symptom of recurrence was found in 9 cases (17%). Vertigo accompanied by spontaneous or positional nystagmus was noted in all 9 cases, while only 3 complained of exacerbation of the existing hearing loss. Revision was indicated in 3 patients since they had no predisposition to spontaneous healing. Various etiological and underlying factors contributed to the incidence of recurrence. Careful operative procedures together with strict postoperative management are required for surgical treatment of PLF.

Clinical significance of arginase in colorectal cancer.

Arginase, a potent immune inhibitor, existed in much greater abundance in the cytoplasm of cancer cells than in normal cells. Serum arginase levels from 31 patients with colorectal adenocarcinoma were determined by using enzyme immunoassay (mean +/- standard error = 18.96 +/- 4.83 ng/ml) and showed to be significantly higher than levels from control subjects (n = 115, 3.09 +/- 0.22 ng/ml) (P less than 0.005). Surgical samples of 15 patients were individually homogenized and assayed by the same method and revealed that the arginase level in tissues with colorectal cancer was two times greater than the level found in normal mucosal tissues (1.74 +/- 0.31 micrograms/g tissue versus 0.77 +/- 0.09 micrograms/g tissue, P less than 0.005). However, the serum arginase levels in patients with colorectal cancer were independent of their carcinoembryonic antigen (CEA) levels (n = 27, arginase 11.81 +/- 1.88 ng/ml, CEA 17.31 +/- 4.24 ng/ml, r = 0.084, P = 0.666). The results suggested that serum arginase level can be a valuable criterion for preoperative evaluation and possibly postoperative follow-up study. It can also combine with CEA determination to intensify the clinical assessment for colorectal cancer.

Bipolar Arthroplasty for 496 Hip Fractures

Four hundred ninety-six bipolar arthroplasties were performed over a 14-year period for the treatment of proximal femur fractures. A historical review, including 71 references from the 19th century to the present, was composed concerning the advances in operative techniques for the treatment of such fractures. Comparisons were then made between this series and those that used internal fixation and one-piece conventional prostheses. Immediate postoperative and long-term follow-up study results confirm findings of a previous smaller study. That previous study showed the bipolar prosthesis offered significant improvement over internal fixation in reducing morbidity and mortality. Additionally, it offered advantages over the one-piece prosthesis in terms of fit, decreased acetabular erosion, and improved function.

ANALYSIS OF COLORECTAL CANCER WITH COMBINED RESECTION OF ADJACENT ORGANS

Of 499 cases of colorectal cancer operated on during a 16-year period, 108 (21.6%) had macroscopic invasion into the surrounding organs. Seventy-one of the 108 patients underwent combined resection of colorectal tumor and the adjacent organs, resulted in curative resection in 54 patients. The invasion was predominantly seen in the small intestine and urine bladder in colon cancers, while in the bladder and uterus in rectal cancers. However, only 22 (40.7%) of them were verified to have the tumor invasion microscopically. In a postoperative follow-up study, 12 cases had recurrence of cancer and 4 out of the 12 had local recurrence. The five-year survival rates were as relatively high as 82.9% in colon cancers and 72.2% in rectal cancers (by Kaplan-Meier method). No significant difference in prognosis was found between patients with direct histological invasion and those without such invasion. From these results, suggest that combined resection of the surrounding organs is recommended for better prognosis in colorectal cancers, if those are suspected to have the direct invasion.

Usefulness of echocardiography in the long-term follow-up study after surgical treatment of annuloaortic ectasia.

From July, 1979 to August, 1987, 10 patients at our institution underwent a repair of annuloaortic ectasia (AAE), either with a separate aortic graft and valve or with Bentall's operation. There were no hospital deaths, although there were two late deaths from unrelated accidental causes. In nine of the patients, echocardiograms were recorded to evaluate the postoperative cardiac function and possible complications. M-mode echocardiography facilitated the evaluation of cardiac function, and two-dimensional echocardiography was better suited to studying the postoperative structures. On the other hand, the real time two-dimensional Doppler flow mapping ensured the diagnosis of dissecting aneurysms through the blood flow pattern. Although the postoperative hemodynamics improved significantly, pseudoaneurysms between the native aortic wall and the graft were detected in three patients, with compression to the composite conduit in one, and residual distal aortic dissection was noted in another three patients. It was thus concluded that the composite graft replacement of the ascending aorta and aortic valve in patients with AAE can be accomplished with a low risk, but pseudoaneurysm formation at the coronary ostial or aortic suture line may be observed late after surgery. Regular postoperative follow-up study is therefore of great importance, and echocardiography would be the most pertinent, non-invasive method of meeting this purpose.

Study and Play with Neuro-ultrasound

Researches on neurosonology of the author performed for 30 years or more are reviewed with episodes of humor that have made him urge to work on ultrasound, both in practice and at laboratory. The postoperative follow-up study with the aid of echodiagnosis of A-mode and of B-mode tomography afforded an accurate and simple method to find the regression and growth of malignant processes of surgery and neurosurgery after treatment, and those results were supported by basic studies of ultrasonic absorption coefficient of human brains and live organs. Pulsatile echoencephalography was studied by the analysis of time factors with a lot of result, which revealed potentials of differentiating occluded locations of cerebral arterial occlusive diseases, as well as of determining the state of brain death. The author has also achieved basic studies and applications of ultrasonic destruction of malignant tumors by making a comparison with the radiation therapy.

Aortic regurgitation after surgical relief of subvalvular membranous stenosis. A long-term follow-up study.

A postoperative follow-up study of 21 cases of discrete membranous subvalvular aortic stenosis is presented. The age at operation was 6-47 (mean 16) years, and the follow-up time 0.6-16 (mean 6.7) years. Preoperatively most patients were in NYHA function class II or III and had high peak systolic pressure gradient, left ventricular hypertrophy and/or cardiothoracic index greater than 0.50. At follow-up all but six patients were in NYHA class I, the Doppler-estimated peak systolic gradient was 0-36 (mean 18) mmHg, the cardiothoracic index unchanged and the mean left ventricular hypertrophy score had declined from 4.3 to 2.3. Of 13 patients without aortic regurgitation preoperatively, eight had regurgitation at follow-up (group I) and five did not (group II). The interval to follow-up was significantly longer and the preoperative peak systolic gradient was greater in group I than in group II. Aortic regurgitation may develop even after surgical relief of discrete membranous subvalvular aortic stenosis, possibly associated with high preoperative pressure gradient and time from operation. Regular postoperative Doppler echocardiography is therefore recommended.

Surgical treatment of hypertensive intracerebral haematoma by CT-guided stereotactic surgery.

Ninety consecutive cases of hypertensive intracerebral haematoma were treated with CT guided stereotactic evacuation. The patients were composed of 61 males and 29 females, ranging from 42 to 87 years old. The location of haematoma was either in the putamen (59 cases) or in the thalamus (31 cases). The average volume of the evacuated haematoma was 21.4 ml in the putaminal haematoma and 14.0 ml in the thalamic haematoma. Postoperative follow-up study in 46 patients showed good recovery of neurological deficits both in putaminal and thalamic group. Criteria of surgical indication of CT-guided stereotactic evaluation of intracerebral haematoma were advocated based on the author's clinical experience.

Urodynamic factors in relation to outcome of prostatectomy

A pre- and postoperative five-year follow-up study on 83 patients undergoing elective prostatectomy for benign hypertrophy revealed good overall symptomatic results in 70 (84 %). Hesitancy and a poor stream were improved more often than were frequency and nocturia. A high preoperative voiding pressure was significantly associated with a good result; less satisfactory results tended to be associated with a higher preoperative flow rate.

Morbid obesity treated with gastric partitioning and gastrogastrostomy.

Between April 1981 and July 1983, 30 patients were operated on for morbid obesity with gastric partitioning and a gastrogastrostomy (GP). The patients were checked 3, 6, 9, 12, and 24 months postoperatively. Radiological investigations were performed on the 5th postoperative day and after 2-32 months. All patients lost weight postoperatively, ranging from 14 to 45 kg after 9 months, but thereafter a slight increase in weight was noted. The weight loss was not correlated with radiologically measured stoma size or volume of the upper gastric pouch. Thus, in contrast studies combined with Gastroluft (sodium bicarbonate, tartaric acid, and dimethicone), pouch distention does not yield prognostic information on anticipated weight loss. More reliable methods for measuring stoma and pouch size are needed, but other factors like patient motivation and a careful postoperative follow-up study with dietetic advice are probably more important for a satisfactory outcome.

Persistence of gastric hypoacidity in uraemic patients after renal transplantation.

To evaluate the effect of renal transplantation on the frequent gastric hypoacidity encountered among uraemic patients, 84 patients (19 with chronic renal failure receiving dietary treatment, 29 receiving regular dialysis treatment, and 36 with a well-functioning renal transplant) were studied for their gastric acid secretory capacity. The mean duration of preoperative dialysis treatment of the dialysed patients was 13.7 months, and the mean length of postoperative follow-up study of the transplant patients was 10.1 months. The mean gastric acid secretory capacity of all three subgroups of renal patients was similar, and all these means fell within the reported reference interval of healthy controls. Gastric hypoacidity was observed in 26% of the non-dialysed and in 17% of the dialysed patients but also in 28% of the patients with a well-functioning renal graft. Thus uraemia seems to result in gastric hypoacidity, which tends to persist for over 10 months after normalization of renal function through transplantation.

Image diagnosis of parathyroid glands in chronic renal failure.

Twenty-two out of 31 patients with chronic renal failure and secondary hyperparathyroidism who underwent parathyroidectomy before operation underwent non-invasive image diagnosis of parathyroid glands by computed tomography (CT), scintigraphy with 201TlCl and 99mTcO4+, and/or ultrasonography. CT visualized 39 of 45 parathyroid glands (86.7%), weighing more than 500 mg. Scintigraphy with a subtraction method using a computer performed the diagnosis in 19 of 27 glands (70.4%). Ultrasonography detected 21 of 27 glands (77.8%). Image diagnosis was also useful in the postoperative follow-up study. The non-invasive image diagnosis of parathyroid glands in patients with chronic renal failure is thus valuable for 1) definite diagnosis of secondary hyperparathyroidism, 2) localization, and 3) diagnosis for effectiveness of conservative treatment.

The effect of highly selective vagotomy on sick-listing in peptic ulcer patients.

The amount of sick-listing in 75 patients operated on with highly selective vagotomy (HSV) was studied during two periods, the first consisting of 12 months and ending 1 year before operation and the second period, also consisting of 12 months, starting 1 year after operation. Patients with suspected ulcer recurrences were excluded and only patients who, at the 1-year postoperative follow-up study, were without symptoms suggestive of ulcer recurrence are included. The median amount of sick days was 31.3 for the period preceding and 37.2 (NS) after the operation. Before operation 60% of all sick-leave diagnoses were ulcer or gastritis, compared with 20% after operation. A 50% increase in infectious diseases and lumbago occurred. Psychiatric disorders rose from 1 to 16 occasions. We therefore conclude that patients apparently cured of chronic ulcer disease change target and develop symptoms elsewhere. The study shows no potential economic benefits of HSV, at least not with regard to a diminishing amount of sick days after operation.

Natural history of glioma.

The natural life history of gliomas is discussed from the viewpoint of early diagnosis of so-called "silent" gliomas and postoperative follow-up study of "inactive gliomas, both types easily detectable by CT scan. On the basis of their functional status, about 10% of 150 histologically proven intracranial gliomas were judged to be silent or inactive gliomas. They were inactive for an average of 8.5 years, and most were fibrillary or gemistocytic astrocytomas except for one grade 3 astrocytoma. cystic formation was seen in two thirds of the cases and calcification in one half. Also, among highly malignant gliomas, a significant difference in the period of survival was seen between the group with very long intervals of 2-3 years, from onset to operation and that with relatively short periods of 2-3 months. Accordingly, treatment policy regarding such silent or inactive gliomas should be carefully determined case by case. Monitoring during postoperative progression-freed intervals is especially useful.

Coarctation of the aorta. Follow-up of 218 patients operated on after 13 years of age.

Twohundred and eighteen patients aged 13 years or more at operation for coarctation of the aorta were selected for a long-term postoperative follow-up study. The mean age of operation was 25,3 years, range 13 to 62 years, and the mean follow-up period was 13 years, range 2 to 28 years. The surgical mortality rate was 1.4%, all 3 patients being in their fourth decade. There were 35 late deaths (16,3%), 26 having cardiovascular disease as the causation; 3 patients developed a dissecting aneurysm of the ascending aorta, and 11 died suddenly of unknown cause. Persisting hypertension was found in approximately one third of the patients. A highly significant correlation was demonstrated between the systolic blood pressures before and after surgery. Aortic valve disease occurred in 31 patients (14,2%). Coarctation of the aorta should be operated on in childhood, and a close postoperative long-term follow-up in all patients is recommended.

Functional bladder neck obstruction. Late results after endoscopic bladder neck incision.

The effect of endoscopic bladder neck incision for functional bladder neck obstruction was assessed in 28 consecutive patients with a follow-up period of up to 50 months. The operation had excellent effect on the patients' symptoms consisting mainly of weak stream and/or recurrent urinary infections. Uroflowmetry at the postoperative follow-up study showed a statistically significant increase in as well maximum flow rate as mean flow rate. The bladder neck incision carried very few complications, and the average postoperative stay in hospital was 2.8 days. It is important to be aware of the condition functional bladder neck obstruction, and the diagnosis should be based upon uroflowmetry and voiding cystourethrography. In borderline cases with only slightly reduced urinary flow rate, additional pressure-flow studies should be applied to demonstrate infravesical obstruction.