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The records of patients treated for perforation of the gallbladder in 1946-1956 or 1969-1980 (n = 41 and 70) were reviewed to elucidate if changed strategy in acute cholecystitis, i.e. delayed vs. early surgery, had had any effect on the prognosis. The overall mortality declined significantly between the two periods, from 20 to 7%. The mortality was lowest (6%) after cholecystectomy, as compared with cholecystostomy (29%) and conservative treatment (67%). The frequency of chronic biliary fistula, calculated on all gallbladder perforations, decreased significantly (46 vs. 27%), but the frequency of acute free perforation was similar in both periods (27 and 34%). Treatment policy in acute cholecystitis is discussed. The study indicated that early surgery (Cholecystectomy with peroperative cholangiography and, if required, choledochotomy) is the treatment of choice, giving the best results also in patients with perforation of the gallbladder.

Ligation of the hepatic artery was carried out in 23 patients with primary and secondary cancer of the liver. The survival time correlated well with the amount of tumor tissue in the liver. Ligation of the hepatic artery prolonged the survival time of the operated patients when compared with the untreated group, and, in addition, yielded good palliation. In appropriate cases, the most promising result in the treatment of hepatic malignancies was achieved by liver resection two to four months after the initial ligation of the hepatic artery, whereas from our experiences the final value of regional arterial chemotherapy is still unsettled. Very promising results were achieved by ligation in the treatment of liver metastases from lymphosarcoma of the stomach, which responded especially well to this kind of therapy.

Eearly results of a prospective clinical trial of selective proximal vagotomy (SPV) with or without pyloroplasty are reported. The total number of patients was 41, of whom 39 had chronic duodenal ulcer, one gastric ulcer and one heamorrhage gastritis. The follow-up period in our preliminary series now averages 18 months. Recurrent duodenal ulcer appeared in two patients with proved incomplete vagotomy (5%), and two other patients suffered postoperatively from gastric retention. All the symptomatic patients underwent SPV without pyloroplasty. The promising early results warrant continuation of our trial in order to asses the role of SPV in the surgical treatment of duodenal ulcer.

Five patients were succesfully operated upon for tracheal stricture following prolonged assisted ventilation with a cuffed tracheal tube. The operative exposures and techniques to be recommended with relation to site and extent of tracheal stenosis are discussed. Most tracheal resections can be carried out through a low cervical incision. Lesions of the lower part of the trachea (5 cm or less from the carina) are best approached through a right posterolateral thoracotomy incision. A stenosed tracheal segment of 4 cm or less can be resected easily by both routes without undue tension on the anastomotic line. The use of interrupted Prolene sutures is proposed for the tracheal anastomosis, because it produces much less tissue reaction than chromic catgut.

Fourteen patients have been encountered with stercoraceous or idiopathic perforations of the colon. Seven patients had a stercoraceous perforation; four had an idiopathic perforation; and three patients remained without exact classification. All the patients were admitted to hospital because of sudden abdominal pain. All except one patient, who was in an agonal condition, were operated on with a diagnosis of peritonitis. The preoperative clinical, radiologic and laboratory examinations were not specific, and in only one instance, the provisional diagnosis was correct. The main differnece between idiopathic and stercoraceous perforations was the macroscopic and histologic appearance of the perforation. In a perforated stercoraceous ulcer, the perforation was a round or an ovoid hole with necrotic and inflammatory edges, while in the idiopathic form, the perforation was a tear with a normal appearance of the colonic wall. The treatment consisted of a closure of the perforation and a proximally situated stoma, or exteriorization. Four patients of the seven with stercoraceous perforations survived. In idiopathic perforations, the prognosis was poor. All patients died during the first 24 hours after the operation. This possibly is an indication of some basic difference in the pathophysiology of these two diseases.

6 patients whose peptic oesophageal stricture caused by reflux oesophagitis was treated surgically with Nissen fundoplication and oesophageal dilatation are reported. In 5 patients oesophageal dilatation was performed intraoperatively and in one postoperatively 2 months after Nissen fundoplication. One patient whose stricture had been treated for 12 years with repeated dilatation required several dilatations postoperatively as well, but now, 6 months after operation, the need and frequency of dilatations are definitely decreasing. Our results of the Nissen fundoplication operation and simultaneous oesophageal dilatation are very promising. We feel that in the surgical treatment of benign peptic oesophageal stricture, particularly if the aetiology of the stricture isgastro-oesophageal reflux, more conservative operations of this type will displace other procedures consisting of resection of the stricture with or without intestinal interposition.

The aortic area (Torlin) for diseased stenotic aortic valves was calculated in 10 patients using two different methods; data obtained in preoperative cardiac catheterization and by intraoperative flowmetric and aortic and left ventricular pressure-recording measurements, and their mutual correlation was tested. The correlation between the aortic valve areas obtained by these methods was very good (r = 0.992), confirming the valve and reliability of the intraoperative flowmetric and pressure recording measurements in clinical work.

Flow to the right and left coronary arteries was recorded continuously during aortic valve replacement using continous constant-pressure coronary perfusion at 32 degrees C in 13 patients. The initially high coronary flow decreased gradually until a certain level, the so-called resting flow level, was reached and stabilized there as long as perfusion temperature remained unchanged. At 32 degrees C, resting flow was about 50% of the peak hyperaemic flow. The length of preceding anoxia had a significant effect on the duration of reactive hyperaemic response. After a short anoxic period, resting flow level was reached in about 3 min, after moderate period in 15 min and after long anoxia in 35 min, respectively.

Five patients with blunt retroperitoneal injury of the duodenum are presented. In three of them the trauma was caused by a traffic accident, the most common mechanism of such injuries. One patient died. The high index of suspicion is still the best indication for laparotomy in retroperitoneal injuries of the duodenum, because no typical finding or reliably diagnostic test could be demonstrated even in the present study. The proper treatment in less severe injuries of the retroperitoneal duodenum is evacuation of the hematoma or simple suture of the rupture with drainage and naso-gastric suction. Internal drainage as an afferent jejunostomy is sometimes necessary in the treatment of more severe injuries. Pancreatoduodenectomy is to be reserved for only the very severe duodenal injuries, where the head of the pancreas is badly crushed.

Single aortic valve replacement with the Björk-Shiley tilting disc valve prosthesis has been performed in 50 patients since April 1971. None of the total of six deaths (12.0%) was attributable to malfunction of the prosthesis or to embolic complications. Follow-up examination showed insignificant or moderate prosthetic regurgitation in two patients and moderate paravalvular leakage in one patient. A slight intravascular haemolysis was found in two cases, one of them without marked regurgitation, and a slight reversible cerebral thrombo-embolism in two. Clinical improvement was observed in 43 of the 44 survivors during the 6 to 12 months of follow-up. Objective evidence of improvement was verified by cardiac catheterization following the replacement of aortic valve with the Björk-Shiley tilting disc prosthesis.

Heterotopic ossificaton of the upper midline abdominal incision scar is reported in seven patients. This disorder may follow abdominal operations via vertical incisions. The cause is unknown. All patients were men in their fifties. The calcification resembled a "rib" and occurred in upper midline incisions between the peritoneum and fascia, fixed more to the fascia. Excision of the mass was performed in six cases. Excision is recommended only in symptomatic cases, and should be wide enough to avoid recurrence. In the differential diagnosis several other wound complications as well as intra-abdominal malignancy should be considered.

Reactive hyperemic response of individual coronary arteries and of the whole heart to anoxia during coronary cannulation was investigated in 10 patients undergoing aortic valve replacement. Reactive hyperemic response in man is identical to that reported in experimental investigations. The duration of hyperemic response was dependent on the length of the preceding period of anoxia; the longer the period of anoxia, the more prolonged was the hyperemic response. No significant collateral circulation between the coronary arteries could be demonstrated during prolonged anoxia of an individual coronary artery. Blood flow debt was almost always overpaid, but the repayment percentage decreased with the lengthening of the anoxic period, being 460 percent after a short period of anoxia (less than or equal to 2 minutes), 230 percent after an anoxic period of moderate length (3 to 5 minutes), and only 160 percent after a long period of anoxia (greater than or equal to 7 minutes). The total mean repayment of blood flow debt of the whole heart was 195 percent.

The most common etiologies of mesenteric infarction in fifty-one patients were arterial thrombosis (in 42 per cent), bowel infarction without major vessel occlusion (in 28 per cent), and arterial embolus (in 22 per cent), but the etiology also included some very rare vascular diseases--two cases of the malignant atrophic papulosis of Degos. In the group of forty-four operative patients the mortality was 70 per cent. All the patients treated medically died. Mesenteric infarction should be suspected in all elderly cardiac patients with symptoms of acute abdomen. The value of an early diagnosis, fast resuscitation, and aggressive operative treatment cannot be overstated. Bowel resections yielded the best results in this series. However, the operative treatment of the mesenteric infarction should be individual, depending on the etiologic factors and the time which has elapsed from the onset of the symptoms.

A patient with accessory diaphragm, aplasia of the middle lobe and total anomalous right pulmonary venous drainage is reported. Diagnostic difficulties and possibilities in the surgical treatment of cases with anomalous pulmonary venous drainage are briefly discussed.

The changes occurring in plasma renin activity (PRA), tissue oxygen tension of the renal cortex and the change in renal total blood flow were studied during haemorrhagic hypotension in six dogs. The flow was measured with an electromagnetic flowmeter, the plasma renin activity was determined by radioimmunoassay and tissue oxygen tension with IBC oxygen electrodes. Haemorrhagic hypotension led to a significan increase in PRA. The fall in renal total blood flow and cortical tissue oxygen tension were significant after all three epizodes of bleeding (each of 10 ml/kg. Metabolic acidosis increased after every bleed. The correlation between PRA, renal blood flow and cortical tissue oxygen tension is evaluated in the discussion.

Early experiences and results with the EEA stapling instrument for colorectal anastomosis are reported. 39 patients underwent anterior resection or left hemicolectomy with end-to-end anastomosis performed by means of the EEA stapler. Two patients had a clinically recognizable anastomotic leakage, both of which healed spontaneously. One patient died from pulmonary embolism, but at autopsy the anastomosis was intact. No significant problems in the control of anorectal function developed. On follow-up sigmoidoscopic examinations two patients showed a distinct narrowing of the anastomotic site, but both of these stenoses were spontaneously dilated by six months. It seems that an anastomosis performed with the EEA stapler is at least as reliable as a hand sutured one and apparently more so. With this instrument an anastomosis can be achieved at a lower level than would be feasible with conventional hand suture techniques. In addition, it is much more easily and rapidly performed, especially in patients with a narrow pelvis or other anatomical difficulties.

The effect of furosemide on renal function in patients undergoing open heart surgery was investigated, using creatinine clearance, urine flow, sodium and potassium excretion as the parameters. The effect of furosemide (2 mg/kg i.v.) on blood flow in arteria renalis and the tissue oxygen tension of the renal cortex and medulla were also investigated experimentally in six dogs. The flow was measured with an electromagnetic flowmeter and the tissue oxygen tension with IBC tissue oxygen electrodes. Prolongation of the perfusion time to more than 60 minutes resulted in a decline of creatinine clearance to appr. 50% of the initial level. Prophylactic furosemide given prior to the perfusion brought down the creatinine clearance to 64% of the initial level. Furosemide, administered either prophylactically just before the cardiopulmonary bypass or after urine flow had declined below 0.5 ml/kg/h, had no effect on the potassium balance in the long perfusion group (over 60 minutes), though it clearly increased the negative potassium balance in the short perfusion group (below 60 minutes). In an experimental work on dogs, furosemide was found to elevate the tissue oxygen tension in the renal cortex and and medulla, and slightly to increase the blood flow in arteria renalis.

105 valve replacements with the Björk-Shiley tilting-disc prosthesis have been performed in 99 patients with an overall mortality of 12%. The hospital mortality for 73 single aortic valve replacements was 10%, for 24 single mitral valve replacements 13%, and for 5 double valve operations 20%. One late death (1%) occurred in a case with single aortic valve replacement. The follow-up period of the first patients with aortic valve replacement is 4 1/2 years, and that of those with mitral valve replacement over 2 1/2 years. The most common late complication in patients with mitral valve replacement was a paravalvular leak (19%), whereas in patients with aortic valve replacement slight haemolytic anaemia (4%) and late thromboembolism (3%) occurred most frequently. 84 of the 87 survivors showed manifest clinical improvement in their preoperative status and increased exercise tolerance.

Fatal microemboli occurred in 3 of 100 consecutive patients having aortic valve replacement; 2 occurred during perfusion before the microfilter era, and 1 occurred intraoperatively despite the use of in-line filters. In all 3 patients cerebral symptoms were present immediately postoperatively, and each died of severe brain damage. On postmortem examination cerebral calcium microemboli were verified in only 2 patients, although the brain of each patient contained minute infarctions. However, calcium particles were found in the kidneys of all 3 patients. Thus the kidneys proved to be the best place for detection of calcium emboli on postmortem examination. Although the microfilters currently available effectively prevent microemboli during extracorporeal circulation, the surgeon should be aware that embolization can also occur immediately after discontinuation of perfusion. The means of protecting the patient from this are discussed.

A simplified left atrial-distal aorta bypass for operative treatment of extensive dissecting. Type III, aneurysms of the distal thoracic aorta is reported. In this technique the lower part of the body is perfused through a large cannula placed into the true lumen of the several distal aorta. The indications and advantages of the method are discussed.

A patient with acute hemorrhagic pancreatitis treated successfully with total pancreatectomy is reported. Total pancreatectomy is rarely indicated in acute hemorrhagic pancreatitis as suggested by only one surviving patient in the literature so far. Though near total pancreatectomy remains the best surgical treatment in patients with acute hemorrhagic pancreatitis dying from the disease because of failure of nonoperative treatment, total pancreatectomy may be considered as an alternative if circumstances so indicate.

The efficacy of metronidazole, active only against anaerobes, and clindamycin-gentamycin combination, covering both anaerobes and aerobes, in the prevention of infectious complications after elective colonic surgery was compared in a prospective randomized trial over a three-year period. A total of 130 patients were accepted for the trial, 67 receiving metronidazole intrarectally and 63 receiving clindamycin-gentamycin combination. The prophylactic treatment was started on the evening before the operation and continued for 24 hours. One patient out of 67 receiving metronidazole (1.5%) and two patients out of 63 receiving clindamycin-gentamycin (3.2%) developed a wound infection. An intra-abdominal infection occurred in two patients in both groups (3% and 3.2%, respectively). There was no statistically significant difference in postoperative infections between the groups. The authors conclude that metronidazole is as effective as the clindamycin-gentamycin combination and should be preferred to broad-spectrum antibiotics because of its fewer side effects and lower potential of developing resistant bacterial strains.

Ventilatory function, pulmonary diffusion capacity and right heart catheterization were studied in eight patients 2-7 years after pneumonectomy. The operation had been carried out for bronchial carcinoma. Dependence of pulmonary diffusion capacity on pulmonary perfusion rather than on ventilatory changes was characteristic of the elderly patients in the late post-pneumonectomy state. When decreased pulmonary perfusion, produced by cardiac disease or increased pulmonary vascular resistance, severely affects the pulmonary diffusion capacity, a careful assessment of the cardiac state is very important in the pre-operative evaluation of operability. In the absence of coexisting diseases, the cardiopulmonary state of long-term survivors usually remains good.

In a randomized, double-blind, controlled clinical study, the effects of 5 g of guar gum, a dietary fiber composed of galactose and mannose, or placebo added to the diet of 20 patients with duodenal ulcer for 1 wk each were examined. Ten patients derived evident benefit and five some help from guar gum, on comparing symptoms during administration of guar gum with those experienced earlier or during the placebo week, whereas four patients found that neither guar gum nor placebo had any effect (p less than 0.001). The beneficial effect was associated with increased feelings of repletion after meals. Patients with fewest symptoms benefited only slightly, or not at all, from guar gum. In one patient, guar gum abolished pain felt earlier and on placebo, but also caused severe gastric retention after meals. This patient had pyloric stenosis. In patients who were intolerant to berries, fruits, sugar, sweet rolls, and pizza these foodstuffs were better tolerated during guar gum administration. The diarrhea which occurs in some patients ingesting guar gum was avoided by giving low initial doses. In three patients unpalatability of guar gum was a minor complaint. It is concluded that guar gum is helpful to many patients with uncomplicated duodenal ulcer, but that it is harmful to those having increased gastric emptying, eg, pyloric stenosis patients, and that guar gum may exert its effects by increasing gastric emptying time.

Of the 77 cases of renal trauma treated at Oulu University Central Hospital during the years 1965--1975, 60 injuries were minor and 17 severe. 73 of these injuries were closed and 4 penetrating. The rate of operative treatment in severe renal injuries was 88% minor renal injuries being treated conservatively. Primary exploration was done in 18 of the 77 cases and in all patients with penetrating injuries. Only 7 of the 73 patients with blunt trauma and one of the 4 patients with penetrating injury required nephrectomy, including one patient with renal carcinoma. 6 of the 77 patients died, most as a result of severe associated injuries, giving a mortality of 8%. None of the surviving patients treated for renal trauma suffered from major complications. In 13 of the 18 patients operated upon, renal injury was the main indication for operation. Operation was performed in 5 of the 18 patients after immediate radiological evaluation. The advantages of immediate surgical management in severe renal injuries are early and final treatment, short hospital stay, and low incidence of complications. Qualifications for emergency surgery are access to renal angiography and familiarity with reparative renal procedures.

71 patients with traumatic splenic rupture are reported. Most had severe associated injuries. In 44 patients the mechanism of trauma was blunt, in 10 penetrating, and in 17 iatrogenic, occurring most commonly (11/17) during operations for peptic ulcer. Splenectomy gave use to thrombocytosis which reached its peak about 2 weeks and returned to normal within one month after operation. Postoperative complications occurred in 24 of the 60 surviving patients (40%) of which most, 17 patients (30%) were infectious in origin. One patient developed deep venous thrombosis. Mortality was 16%. Associated injuries were the main cause of death in most patients (9/11), the ruptured spleen being responsible for only 2 deaths. None of the 17 patients with injury to the spleen alone died, whether associated with fractures of the left lower ribs or not. Primary unconsciousness, shock on admission, and multiple injuries, especially renal and hepatic, increased the mortality rate markedly. The necessity of drainage, the possibility of increased susceptibility of splenectomized patients to infection and thromboembolic complications and their prevention are briefly discussed.

The possible association between intragastric bile reflux and lower esophageal sphincter (LES) incompetence was elucidated in an experimental work in dogs. Chronic intragestric bile contamination was produced by cholecystogastrostomy. The effect of this procedure on LES competence was evaluated by manometric, radiologic and endoscopic studies two weeks, one month, and then once a month for 6 months after operation. No significant change occurred in LES pressure, and neither radiological reflux nor endoscopic evidence of esophagitis developed during the follow-up period. According to the present study intragastric bile reflux does not have a significant role in the pathogenesis of LES incompetence in the dog, but esophagitis effected by bile reflux seems to require previously existing LES incompetence.

Technique, early experiences and results with the EEA stapling instrument for the reconstruction of intestinal continuity after gastric and esophageal resection in 52 patients are reported. 12 patients with gastric cancer and 4 patients with cardiac cancer underwent total gastrectomy with esophagojejunostomy, 25 patients with gastric cancer underwent subtotal gastrectomy with gastrojejunostomy, 8 patients with esophageal cancer had esophageal resection with esophagogastrostomy and 3 patients with non-resectable gastric or cardiac cancer had palliative by-passing esophagojejunostomy, all performed by means of the EEA stapler. Three anastomotic leakages were detected radiologically, two after esophagojejunostomy and one after gastrojejunostomy. These leaks did not lead to clinical signs or symptoms and healed with parenteral nutrition in three weeks. One patient died of myocardial infarction on the 8th postoperative day, but at autopsy the anastomosis was intact. At follow-up endoscopy three mild anastomotic strictures have been found, but no treatment have been required. In two patients the stricture resolved spontaneously in a few months. According to our experience, esophagojejunal, gastrojejunal and esophagogastric anastomosis performed with the EEA stapling instrument seems to be at least as reliable as a hand sutured anastomosis, obviously even more reliable. The EEA stapler is also time saving, especially after adequate experience with the use of the instrument has been achieved. The difficulties and hazards associated with the use of the stapler are discussed.

This study was undertaken to review our result in the surgical treatment of the axial hiatal hernia-reflux complex with Nissen fundoplication using cineradiologic, manometric, and endoscopic studies and an analysis of objective symptoms of the patients as criteria in evaluation. During the period 1966-1975 86 patients underwent Nissen fundoplication at Oulu University Central Hospital. In 50 of the 86 patients it was possible to carry out thorough pre- and postoperative examinations and a long-term follow-up using the aforementioned methods. There was some discrepancy between objective and subjective postoperative results. During the 10-year follow-up period, mean 5 years, the recurrency frequency was 14% (7/50), but 22% (11/50) of the patients considered the postoperative result subjectively to be poor. On the other hand, 3 patients with a definite recurrence considered the end result subjectively to be good. On the basis of these findings we were able to conclude that the objective postoperative examinations in themselves are not sufficient for thorough, long-term evaluation of postoperative results, but that the patient's subjective postoperative symptoms and his opinion of the success or failure of the operation should also be taken into consideration.

Six consecutive patients with Spigelian hernia treated operatively over a period of ten years are reported. There were no complications, no deaths, and no recurrence in this series. Recognition of this rather rare lesion may be difficult, but it is important because of its quite high predisposition to incarceration and strangulation. The main pathological and clinical features are discussed, and the literature briefly reviewed.

234 patients, 146 with carcinoma of the oesophagus and 88 with carcinoma of the cardia are reported. There were 82 females and 152 males, mean age 62 years. The overall operability and resectability of the whole series was 38% and 23%. In cardiac carcinoma operability was 50% and resectability 32%, while in oesophageal carcinoma it was 31% and 18% respectively. 54 patients underwent resection, 44 received irradiation, and in 136 patients only palliative treatment was possible. The overall hospital mortality after resection was 15%, after oesophageal resection 12%, after cardiac resection 18%, and after palliative procedures 14%. Anastomotic leakage occurred in 9 patients (17%), four of whom died. The overall 5-year survival rate for the whole series was 4%, after resection 11%, and after radiotherapy 4%. No patient in the palliative group survived for 2 years. The mean survival time after irradiation was 11.5 months and after palliative procedures 5.5 months. The 5-year survival rate after oesophageal resection was 13% and after cardiac resection 6%.

A patient with severe blunt liver injury and laceration of the vena cava who underwent a successful extended right hepatic lobectomy is reported. The use of autotransfusion unit saved the patient from exsanguination. His postoperative course was complicated by renal and hepatic failure, bile leakage, and persistent jaundice due to cholangitis. Prolonged choledochal drainage via T-tube obviously acted as a source of infection. The use of autotransfusion, choledochal drainage and the proper timing of its removal, the treatment of vena cava lesions and jaundice due to cholangitis in patients with severe liver trauma are discussed.

The coronary perfusion system used at Oulu University Central Hospital is described and the importance of physiological coronary perfusion stressed. Our method of protecting the myocardium from ischemic injury during aortic valve replacement included the following: phasic constant-pressure coronary perfusion, maintenance of coronary perfusion pressure larger than or equal to 80 mmHg, maintenance of the heart in a beating, empty, oxygenated state, and the use of the largest possible coronary canula. Under these circumstances, autoregulation of the coronary vascular bed was maintained. When small coronary cannulae were used a significant pressure drop occured across the tubing system, especially at high flow rates. Flow measurements recorded by an on-line electromagnetic flowmeter proved reliable.

The cystic duct remnant can be an etiologic factor for distress after cholecystectomy, justifying reoperation and excision of the stump. In connection with cholecystectomy, it is not justified to leave any cystic duct stump unless there is a special reason for it. Stones in the cystic duct remnant, overlooked or newly formed, scar tissues and cystic duct syndrome of whatever cause--inflammation and stasis of the bile, a poorly healing stump end and neuroma--can also be factors producing the discomfort. Unresorbable suture material which provokes foreign body granulomas should be avoided in operations upon the biliary tract since, together with even a normal nerve under pressure, it may cause biliary distress. For the same reason, special attention should be devoted to careful trimming of the cystic nerve in cholecystectomy, and ligation or cautery of nerve tissues should be avoided. The cystic duct remnant is more often visualized in peroperative cholangiography than in an intravenous examination but even then not unfailingly. The cholangiographic finding alone does not justify surgical intervention, since in a number of patients troubles deriving from elsewhere in the biliary tract or from adjacent organs persist and not all cystic stumps apparently produce discomfort.

The effect of open-heart surgery on the drug metabolism of the liver was investigated in 17 patients by using the rate of antipyrine elimination as an index. A correlation was found between the pre-operative heart size and the antipyrine elimination rate. In patients with a markedly dilated heart, the plasma antipyrine half-life was prolonged and apparent clearance significantly impaired. Immediately postoperatively, antipyrine elimination was impaired in all patients. Later, the drug metabolism improved in patients with atrial septal defect, changed temporarily in patients with aortic valve replacement, and remained unchanged in patients with mitral valve replacement. The results indicate that adaptive changes in drug metabolizing capacity occur in patients undergoing cardiac surgery. The changes are related to the type of lesion corrected, the pre-operative functional capacity of the liver, and the time lapse after surgery.

A patient with a spontaneous rupture of the liver, followed by a spontaneous rupture of the spleen and gastrointestinal bleeding, is reported. The patient was operated for both ruptures and survived. We could not find any corresponding reports in the literature. Histological findings both in the liver and in the spleen were suggestive of an acute immunologic reaction and the symptoms of the patient resembled those of an autoimmune disease. Attention is drawn to the possibility that the ruptures of the liver and the spleen might have represented an allergic reaction reminiscent of the general type of Schwartzman reaction. This also could explain the other systemic manifestations of the disease. In the present patient steroid therapy eliminated all symptoms, and this possibility should be kept in mind when treating obscure ruptures of the liver and the spleen.

The etiology of nontraumatic small bowel perforations in 24 operated patients was as follows: strangulation in five, diverticulum in four, foreign bodies in four, idiopathic in three, Crogn's disease in two, malignant atrophic papulosis of Degos (MAP) in two, and tuberculosis, carcinoid tumor, radiotherapy, and iatrogenic in one. The high mortality rate in these patients appeared to be a funciton of the disease process rather than of the means of treatment. In favorable circumstances, as in strictly localized lesions with well known etiology and otherwise normal bowel, a simple closure of perforation is warranted. In more far advanced cases operated upon early enough, we still consider bowel resection and primary anastomosis as the best method of treatment, though it yielded poor results in procedures are advisable to protect the anastomosis.

Fourteen patients operated upon for subcutaneous bladder perforation are reported. The majority of the patients (11/14) had intraperitoneal rupture of the bladder and multiple associated injuries (10/14), most often pelvic fractures (9/14). In 12 patients the injury was caused by a road traffic accident. 2 patients with extraperitoneal rupture presented with a typical history of a blow or kick in the lower abdomen following a drinking session. In doubtful cases cystography was the diagnostic method of choice. The principles of treatment we recommend are well known: urinary drainage with a catheter in all cases, and in intraperitoneal ruptures, prompt surgery.

Arteriosclerotic aneurysm of the thoracoabdominal aorta, involving one or more visceral branches, was successfully operated on in eight patients. Two of the aneurysms had ruptured. The left diaphragm-splitting thoracoabdominal incision through the 8th intercostal space, using a retroperitoneal route, gave unrestricted exposure. A temporary aortofemoral shunt effectively protected abdominal organs and spinal cord from perioperative ischemic damage. The step-by-step reattachment technique into ready-made side limbs in the woven Dacron graft ensured that visceral and renal ischemic times remained within acceptable limits. Perfusion cooling of the abdominal organs was done in one patient in whom shunt could not be used. A standby autotransfusion device was life-saving in another case. All the patients recovered without major complications. Moderate elevation was found as regards serum creatinine levels in seven patients and liver enzymes in four patients, but the values normalized within a month. No paraplegic complications occurred, although all bleeding intercostal and lumbar arteries were ligated intra-aneurysmatically in seven of the eight patients. Seven patients are well 20 to 60 months postoperatively, with patent and well functioning grafts. One patient died of lung cancer after 7 months. Four of the 18 revascularized arteries in three patients were shown by control angiography to be occluded, but without serious sequelae. Our experience suggests that most thoracoabdominal aortic aneurysms are suitable for surgical correction, with acceptable risk. Elective surgery is therefore recommended.