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Weight discordance is very rare in monozygotic (MZ) twin pairs; when found, however, such pairs are advantageous in the search for either environmental or epigenetic causes and consequences of obesity. We analyzed the growth patterns of young adult MZ pairs discordant and concordant for obesity. Screening 5 consecutive birth cohorts (1975-1979) of 22- to 27-year-old Finnish twins (the FinnTwin16 study), we found 14 obesity discordant (Body Mass Index [BMI] difference > or = 4 kg/m2) MZ pairs out of 658. Ten pairs participated in clinical studies. Nine concordant pairs (BMI difference < or = 2 kg/m2) were examined as controls. Lifetime measured heights and weights recorded in hospitals and health centers were traced manually. Height development was similar in all the co-twins of both groups. The weight differences between the co-twins of the discordant pairs began to emerge at 18 years leading to an average discordance of 16.4 kg, 5.6 kg/m2 (p for both = .005) at 25.7 years. The heavier co-twin weighed 221 g (p = .066), 1.0 kg/m2 (p = .01) more already at birth than the leaner, but the differences waned by 6 months of age and reappeared only after adolescence. Both the leaner and the heavier co-twins of the discordant pairs weighed more than expected by the singleton reference values (Cole et al., 1998) after 8 years. The concordant co-twins, on the other hand, grew similarly and after 6 months, their mean growth was not distinguishable from the singleton patterns. Young adulthood represents a critical period of gaining weight irrespective of genetic background in this twin sample.

Ninety patients with esophageal perforations were operated on at our institutions between 1970 and 1992. Thirty-four of them were seen after delayed diagnosis (> 24 hours) with mediastinal sepsis caused by perforation of the thoracic esophagus. There were 18 patients with spontaneous ruptures, 11 with instrumental perforations (including one caused during laparotomy), and 3 perforations caused by foreign bodies. One patient had perforation of an esophageal ulcer into the pericardium and another had perforation of an esophageal diverticulum into the mediastinum. Nineteen patients underwent primary repair of the perforation with cleansing and drainage of the mediastinum and the pleural cavity. The remaining 15 had primary extirpation of the thoracic esophagus, irrigation of the mediastinum with antibiotics, cervical esophagostomy, gastrostomy, and drainage of the mediastinum and pleural cavity. Nineteen of the 34 patients survived (hospital mortality 44%). Of patients with primary repair, only six survived (in-hospital mortality 68%), whereas only two patients treated with esophagectomy died (in-hospital mortality 13%). The difference was highly significant (p = 0.001). The most common cause of death was multiorgan failure resulting from sepsis. Postoperative complications developed in four patients treated with primary repair (two sepsis, one empyema, and one anuria) and in seven patients treated with esophagectomy (two empyema, two sepsis, one pneumonia, one mediastinal abscess, and one brain abscess). After healing of the mediastinitis, the esophagogastric continuity was reconstructed with colon in 11 patients and stomach in two patients. In the management of delayed esophageal perforation with mediastinal sepsis, esophagectomy is superior to primary repair alone, which often leads to mediastinal leakage, continued sepsis, and death.

The peripheral parts of the phrenic nerve are healthy in some of the patients who require permanent or intermittent care in a respirator owing to reduced respiratory function of central aetiology. In such cases, continual care in a mechanical respirator can be avoided, and diaphragm function maintained by means of functional electrical stimulation (FES) of the phrenic nerve with carefully controlled electrical impulses. The method is suitable for use in certain cases of quadriplegia, or in patients with sleep apnoea. Experience with the method has shown that health care costs can be reduced and the patients' quality of life improved. In some cases, the patient may even regain partial work capacity.

Thirty-six patients, subjected to colon interposition for benign esophageal disease or carcinoma of the esophagus or gastric cardia, were studied by endoscopy for signs of mucosal disease in the interposed colon. Five months to 15 yr (mean 57 months) after the operation, endoscopic finding of the interposed colon was macroscopically normal in 28 patients. Signs of inflammation, including hyperemia or hyperemia and friability, were observed in seven patients. Histologic specimens obtained at endoscopy were examined microscopically, and the findings were compared with those seen in the preoperative graft. In two patients, chronic inflammatory changes were observed in the graft mucosa, consisting of mononuclear cell infiltration of the lamina propria accompanied by crypt dilatation and deformation. In one of these patients, the inflammation was in the proximal third of the graft, and it was also seen at the endoscopy. In the remaining 34 patients, the graft mucosa was microscopically comparable to normal. The alterations were unexpectedly few and mild considering the marked change in the location and function of the colonic segment.

A multi-channel phrenic nerve stimulator developed in Tampere has been implanted into seven patients with C2-tetraplegia and into three patients with central sleep apneas. Six bipolar cuff electrodes were implanted bilaterally into the neck. Two four-pole cuff and 14 four-pole noncuff electrodes were used in seven patients and to replace one bipolar electrode. Four-pole electrodes were implanted within the thorax. Seven patients achieved total independence from conventional ventilators within 4 months of implantation, and one for 18 hours each day. Two patients died 12 days and 3 months after implantation and two patients after having achieved independence from mechanical ventilators from causes unrelated to the stimulators. Reoperations were necessary because of dislocation of receivers, electrodes, electrode lesions, nerve injuries, and technical failures in seven patients. Most of the problems appeared in two patients with obesity and in three patients with very thin phrenic nerves. Single unit prototypes failed technically more frequently than units of prototype serial fabrication. New electrode design, progress in the manufacture of receivers, and improved implantation technique should help to diminish failures in future.

Kirschner pins are widely used for fixation of bone, with few and very rarely serious complications. A case is described in which a Kirschner pin migrated in 10 days from the sternal end of the left clavicle into the lumen of the ascending aorta. The exact location of the pin remained unknown until right thoracotomy, during which X-ray examination revealed the unexpected situation. The pin was simply extracted by pushing it through the vessel wall. The patient recovered uneventfully. The complication could have been prevented by bending the outer part of the pins. The possible route of migration is discussed.

Fifteen cases of carcinoma of the esophagus associated with a history of lye ingestion are presented. They compromised 3% of the total patients treated for esophageal carcinoma in 1964-1986. The mean age of the ten women and five men was 57 years and the average time from corrosion injury to diagnosis of carcinoma was 58 years in the men and 47 years in the women. Most of the patients had accidentally swallowed liquid lye at 2-3 years of age. All 15 tumors were squamous cell carcinoma, and 11 were located at the level of the tracheal bifurcation. Esophageal resection was possible in ten cases. The survival rate in the total series was 40% at 1 year and 13% at 5 years. Because of the high carcinoma risk, patients with corrosion injury to the esophagus should be kept under surveillance that includes regularly repeated esophagoscopy, cytologic study of washings and biopsy at least when the time from the injury exceeds 20 years.

The role of surgery in the treatment of acute hemorrhagic or necrotizing pancreatitis is discussed on the basis of a series of 996 patients with all types of acute pancreatitis who were treated in the years 1967--1976. Pancreatic resection was performed in 29 patients with hemorrhagic or necrotizing pancreatitis during the past 3 years. The extent of resection ranged from 60 to 100% of the pancreas. Eight patients died, for a mortality rate of 28%. Eight of 21 surviving patients developed diabetes requiring substitution therapy. During a follow-up period of 6 to 36 months, 17 patients were able to resume work, 3 are still convalescing, and 1 has retired.

Previously in world literature there have been reports of 40 pregnancies in women with untreated Cushing's syndrome. The perinatal mortality in these series has been 12.9%. This paper reports on a case in which low serum oestriol excretion was the first abnormal laboratory value in a patient with only a few signs of Cushing's syndrome habitus and adrenal adenoma.

Enterogastric reflux was studied using the scintigraphic method in 20 patients with colonic interposition for benign esophageal disease. The state of the transplanted colonic mucosa was evaluated by endoscopy. In 16 patients, reflux of the duodenal contents into the stomach could be seen. In eight, reflux of the duodenal contents into the interposed colon could be demonstrated. There were no differences in the occurrence of reflux into the colonic graft between the isoperistaltic and antiperistaltic interpositions. In three patients, signs of colitis on the mucosa on the lower part of the graft were observed by endoscopy. Each of these patients had a reflux of the duodenal contents into the colonic graft. In monitoring the 24 hour pH of these three patients, one patient had marked acid reflux. Alkaline reflux was not observed. It is concluded that enterogastric reflux is frequent in patients with colonic interposition. Its role in the development of lower colonic graft colitis changes is discussed.

A case of corrosion and necrosis of the esophagus and stomach after ingestion of fluid containing copper sulfate, ethylene glycol and methanol is presented. Esophagectomy and gastrectomy were performed in a primary stage. Four months later reconstruction was carried out, using a right-sided isoperistaltic segment of colon. The mechanism of caustic chemical ingestion injuries and their treatment are discussed.

Colon interposition was carried out in 12 patients with oesophageal carcinoma and on 38 patients with benign oesophageal disease an average of 71 months before the radiographic examination. Various ischaemic changes including "jejunization", loss of haustration and stricture formation were observed in 15 cases. In 12 patients one or several diverticula were seen in the colon graft. Reflux was observed in 17 cases in supine position. Double contrast technique in the examination of interposed colon is recommended.

The stomach is the organ most used for restoring esophageal continuity after esophageal resection for malignancy. In the present series, we report our experience over a 20-year period (1965 through 1984) with an alternative method, colon interposition. Two hundred forty-eight patients (124 men and 124 women) underwent colon interposition. Seventy-one percent (175) of the tumors were squamous cell carcinomas, and 23% (58) were adenocarcinomas in the gastric cardia and lower esophagus. The left colon was the substitute of first choice and was used in 54% of the patients. Of the interpositions, 59% were antiperistaltic. Esophagectomy without thoracotomy was the method in 146 patients. The operative mortality was 16% (40 patients), and 3% (8 patients) sustained colon graft necrosis. Leakage in the upper anastomosis occurred in 4% (10). No dysphagia was experienced by 85%, 80%, and 76% of the patients during reexaminations 3, 6, and 12 months, respectively, after operation. The 1-year and 5-year survival for patients with squamous cell carcinoma was 40% and 10%, respectively, and for patients with adenocarcinoma, 50% and 12%, respectively. The data from this study suggest that colon interposition offers a good alternative for long-term relief of dysphagia in patients with carcinoma of the esophagus. The rate of complications is acceptable.

Pancreatic vessel wall alterations were studied in tissue material obtained from six patients subjected to resection of the gland for acute necrotizing pancreatitis. Special attention was paid to elastic tissue damage, which was studied using special stains in light and electron microscopy. Vascular wall elastic laminae showed changes varying from fragmentation to complete dissolution. The outer elastic lamina was more consistently affected. Elastic tissue damage was observed in pancreatic areas with minor acinar alterations and in vessels with otherwise relatively well-preserved walls. These observations suggest 1/ an early participation of elastase in the production of tissue damage in human acute pancreatitis and 2/ a primary role for elastic tissue injury in the vascular alterations leading to haemorrhage and tissue necrosis through ischaemia.

Recurrent ulceration and colopericardial fistula as late complications of colon interposition occurred in a 48-year-old man who had undergone left colon antiperistaltic interposition for esophageal stricture caused by lye corrosion. To our knowledge, this complication has not been reported previously. Although its etiological process remains to be elucidated, this rare entity should be kept in mind after colonic interposition.

Reflux stricture of the oesophagus was surgically treated in 27 patients. Oesophageal resection and colon interposition were performed in 18 cases, and peroperative fiberoptic endoscopic dilatation with Nissen fundoplication in nine. There was one perioperative death (resection group). Postoperative complications arose in four of that group and one of the dilatation-fundoplication group. At follow-up averaging 86 months after resection and colon interposition, no patient was dysphagic; 44% experienced regurgitation, but most could avoid this by modifying living habits. Further dilatations were required by four of nine patients during follow-up averaging 30 months after dilatation-fundoplication. Fiberoptic endoscopic dilatation with fundoplication is well tolerated by fitter patients with reflux stricture of the oesophagus. In poor-risk patients the treatment should be dilatation and medical antireflux control. Due to higher complication rates oesophageal resection and colon interposition are warranted when other treatment has failed.

Esophagectomy with colon interposition for nonmalignant esophageal stricture was evaluated in 41 patients, 18 with peptic and 23 with lye stricture. Four of the 41 patients died in the postoperative period and 12 had nonfatal complications of surgery. At long-term evaluation, 25 of 31 patients complained of postural regurgitation and 9 had disturbing symptoms related to retention in the graft. The long-term clinical and radiologic results showed no deterioration from the immediate postoperative period. The complications associated with colon interposition clearly restrict indications for its use in benign conditions. Interposition should be used in peptic stricture only when other methods have failed. In chronic lye stricture, interposition is justified by the irreversible nature of the lesion and its predisposition to malignant change.

Between 1970 and 1973, 94 patients underwent Nissen fundoplication for gastroesophageal reflux; 60 of the 94 patients returned for follow-up study in 1982. The same surgeon operated on all the patients, and another physician who did not participate in the treatment interviewed the attending patients. Four patients (7 percent) had persistent symptoms, 7 patients had recurrent symptoms (in 3, during the first postoperative year, and in four, 2 to 10 years postoperatively), and 47 (78 percent) had postfundoplication symptoms which were moderate in most but disturbing in some. Some technical details in the performance of the fundoplication could reduce the frequency of the fundoplication symptoms. Because recurrent symptoms may appear late, even 10 years or more after operation, a definitive evaluation of the results of Nissen fundoplication is impossible to perform.

To assess radionuclide transit in interposed segments of the colon, we examined 25 patients with colon interposition for benign esophageal disease. No such assessment has been reported previously. The most common indications for operation were esophageal strictures that developed after lye ingestion and reflux strictures not responding to other treatment. The operations were performed without thoracotomy by blunt esophageal dissection in 80% of the patients. There were 18 antiperistaltic and seven isoperistaltic colon grafts. A large-field gamma camera and computer system were used. Data were collected at time intervals of 0.5 second during the first 30 seconds and at intervals of 30 seconds up to 20 minutes. The 5% and 90% stomach filling times, times to 50% and 25% activity levels, and residual activity levels as a percentage of the maxima were calculated in the upper, middle, and lower thirds of the colon grafts and of the normal esophagus of 10 healthy control subjects. The examinations were performed with the subject in a sitting position. All parameters showed that emptying of the colon graft was markedly slower than that of the normal esophagus. The intra-abdominal third of the graft had a residual activity of 50.5% +/- 15.7% after 20 minutes' observation. No differences between antiperistaltic and isoperistaltic grafts were observed. Reconstruction with proximal cologastric anastomosis and a short intra-abdominal colon graft segments is suggested.

Colon interposition was performed on 22 patients for benign esophageal disease which had not responded to medical or other surgical treatment. Left colon was used as the interposed segment in 17 cases, transverse colon in two and right colon in three cases. All left colon grafts were positioned antiperistaltically. Manometric studies showed no basal or stimulated motor activity in any of the 22 grafts. The peristaltic activity in the esophageal remnant could be demonstrated in four patients. Thirteen patients were studied with 24-hour pH measurements. Distinct acid reflux to the lower colon graft was observed in only one case. Interposed colon thus was confirmed to function as a passive conduit without motor response to swallowing stimuli. The rarity of acid reflux after colon replacement of esophagus probably is due to the vagotomy usually performed during the operation and to the alkalinity of colon mucus.

To assess gastrointestinal symptoms after colon interposition, 12 patients with colon interposition for malign disease and 33 for benign esophageal disease were interviewed. A 7-day diary, including time of eating and gastrointestinal symptoms experienced by patients during and between meals, was kept by every patient. The observations of the interview and diary were compared. No patient had swallowing difficulties or heartburn. All could also eat solid foods; 24% had no gastrointestinal gastrointestinal symptoms during follow-up. Regurgitation, vomiting, and dumping symptoms were common, being observed in 22, 31, and 18% of the cases. There were no differences with these symptoms between patients with anti- or isoperistaltic colon grafts. The information from interviews agrees with the information recorded in the diaries. We conclude that various degree reflux symptoms are common after colon interposition, being experienced by almost half of the patients.