Search

A consecutive series of patients with all types of cervical hip fracture (both undisplaced and displaced) were randomised to osteosynthesis with Hansson hook-pins (n = 98) or AO-screws (n = 101). Background parameters, fracture type and reduction of the fracture did not differ significantly between the groups. Fifty-seven percent of the patients were operated on within 6 h of admission to hospital, 74% within 12 h and 92% within 24 h. The mean (median) time for operation was 36 (30) min for the hook-pins and 40 (35) min for the AO-screws. The devices were significantly better positioned in the hook-pin group (81% of cases good) compared to the AO-screws (66% good) (p = 0.04). In all, 72% of the patients had no deficiency either in reduction of the fracture, positioning of the implants or had drill penetration of the femoral head. Direct unrestricted weight bearing was encouraged in 92% of the hook-pin and 90% of the AO-screws group. The mean (median) hospital time was 13 (10) days with no significant difference between the groups. Following treatment, 5% walked without aids, 76% of the patients walked with some aids, and 16% could not walk. The walking ability was not known for 4%. At four months, 59% of the patients were living in their own home (64% before fracture), 18% (25% before) in a nursing home, 5% (11% before) in other accommodation and 18% were dead. After two years, 77% of the hook-pin patients had not needed any re-operation compared to 73% in the AO-screw group. In total a secondary hemi-arthroplasty had been performed in 7% and total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. The difference in the reoperation rates between the two methods was not significant. In the undisplaced fractures, 84% of the patients had not needed any reoperation after two years compared to 70% among the displaced fractures. Major reoperation had been performed in 10% (1% hemi and 9% total hip arthroplasty) in the patients with undisplaced fractures compared to 26% in those with displaced fractures (10% hemi, 16% total hip arthroplasty and 1% Girdlestone operation). The remaining patients had only undergone removal of metalwork. Osteosynthesis thus proved to be a successful operation in many of the patients with displaced fractures. A preoperative, prognostic-based selection between osteosynthesis and arthroplasty is the future goal for optimised femoral neck fracture treatment.

Objective: Jejunoileal (JI) bypass was a widely performed surgical procedure for morbid obesity in the 1970s. The purpose of this study was to assess cardiovascular risk factors and mortality in patients 25 years or more after this operation., Material and Methods: All (n = 36) patients operated on for obesity with JI bypass at Haukeland University Hospital between 1971 and 1976 were evaluated. Survivors (n = 28) participated in a follow-up that included clinical examination and biochemical tests. Preoperative data were compared with data at 1 year (3 years) and 25 years. Causes of death were identified for the deceased., Results: For the 23 patients alive with intact JI shunts at 25 years there was a statistically significant lowering of body mass index (BMI) (p < 0.01), systolic blood pressure (p < 0.05), diastolic blood pressure (p < 0.001) and serum cholesterol (p < 0.05) compared to before the operation. There was no statistically significant change in fasting blood glucose or serum triglyceride. The serum insulin level was normal in all but one (21/22) of the patients examined. Three out of 26 patients with intact JI shunts, and 5 out of 10 patients with reversed JI shunts, had died., Conclusion: For patients with intact shunts there is a persistent reduction in body weight, serum cholesterol and blood pressure, and a reduced insulin resistance 25 years after JI bypass.

Background: Cholecystectomy is intended to relieve symptoms of gallstones, but unfortunately some patients will experience postcholecystectomy symptoms, including pain. There is limited information in the literature on gallstone-related pain and its influence on quality of life. The aim of this study was to examine how pain and quality of life in patients with symptomatic, uncomplicated gallbladder stones were affected by observation of their condition compared with removal of the gallbladder., Methods: One-hundred and thirty-seven patients were randomized to observation (watchful waiting; n = 69) or cholecystectomy (n = 68) and answered questionnaires on pain, quality of life (PGWB index and NHP Part II) at randomization and fixed intervals (6, 12 and 60 months). All gallstone-related events (hospital admission for pain, complications of gallstone disease and cholecystectomy) and crossover between treatment groups were recorded., Results: Of patients randomized to observation, 35 of 69 patients (51%) eventually underwent a cholecystectomy. Significant improvements in quality of life and pain scores were detected regardless of surgical treatment. Patients that subsequently experienced gallstone-related events had significantly higher pain scores at randomization than patients that did not experience any subsequent events, and this difference was maintained throughout follow-up., Conclusions: Unexpectedly, in the majority of patients symptoms did abate without any significant differences between groups in pain and quality of life. Patients that had high intensity and frequency of pain at randomization had a higher risk of experiencing subsequent events.

Objective: The oral direct thrombin inhibitor (oral DTI) ximelagatran and its active form, melagatran, which can be administered subcutaneously, were investigated for the prevention and treatment of thromboembolic complications., Design and Patients: In this randomised, double-blind, double-dummy, parallel-group study in patients (n = 90) undergoing general abdominal and/or pelvic surgery, 8-day and 35-day treatment regimens of postoperatively initiated sub-cutaneous (sc) melagatran (3mg twice daily) followed by oral ximelagatran (24mg twice daily) were compared with standard-duration sc dalteparin (5000IU) initiated preoperatively. Pharmacodynamic and pharmacokinetic parameters, efficacy (number of patients with distal and/or proximal deep vein thrombosis [DVT] verified by bilateral venography on the final day of treatment) and safety were assessed., Results: The pharmacokinetics of melagatran were well described by a one-compartment model with first-order absorption after administration of both sc melagatran and oral ximelagatran. Bioavailability of melagatran was 21% after the first oral dose of ximelagatran and was virtually unchanged throughout the study. Activated partial thromboplastin time increased in a non-linear manner with plasma melagatran concentration. The overall rate of DVT was 11.4% (8/70), with events distributed evenly between treatment groups. Bleeding volumes during surgery tended to be higher in the dalteparin group than in the melagatran/ximelagatran groups. Blood transfusion volumes and numbers of patients transfused were similar in all treatment groups., Conclusions: Good bioavailability of melagatran was achieved following oral administration of ximelagatran. Postoperative sc melagatran followed by oral ximelagatran appeared to be well tolerated, and the efficacy of standard-length or prolonged prophylaxis with sc melagatran and oral ximelagatran may be comparable to that of dalteparin initiated preoperatively.

Background: Jejunoileal (JI) bypass was a widely performed operation for morbid obesity in the 1970s. The aim of this study was to investigate the long-term status for mental and physical health after weight loss induced by this operation., Methods: 20 female patients (age 48-80 y, BMI 23-75 kg/m2) were interviewed 25 years after JI bypass. The Hospital Anxiety and Depression Scale (HAD) and Short Form 36 (SF-36) were used. Scores from the Norwegian female population, and published scores for morbidly obese patients were used for comparison. An assessment was made on whether present demographic and clinical factors influenced the scores., Results: Anxiety and depression scores, and scores for physical functioning, bodily pain, vitality and mental health on the SF-36 were similar to scores in the Norwegian female population used for comparison. The scores from the patient sample were much better than scores published for morbidly obese patients, and implies that weight loss induced by the operation has been of great benefit on mental health and health-related quality of life. Anxiety and depression symptoms improved; however, being socially handicapped by the stools had a negative impact on HAD and SF-36 scores., Conclusion: These results suggest that 25 years after the JI bypass most of these patients have a similar level of mental and physical health as the general Norwegian female population. For individuals with bothersome side-effect(s) of the operation, a negative impact is seen.

Background: Cholecystectomy has been recognized as the treatment of choice for symptomatic gallbladder stone disease. Not all patients are cured by an operation and the reason for having the gallbladder removed may rest on common practice rather than evidence-based medicine. The aim was to compare cholecystectomy with observation (watchful waiting) in patients with uncomplicated symptomatic GBS disease. Three-hundred-and-thirty-eight patients were considered for participation in the study; 45 patients were excluded according to predefined criteria and 156 did not join for other reasons. The remaining 137 were randomized to cholecystectomy (n = 68) or non-operative, expectant treatment (n = 69)., Methods: Randomized patients were contacted regularly and followed for a median of 67 months. All gallstone-related hospital contacts were registered in both randomized and excluded patients., Results: Eight of the patients randomized to cholecystectomy did not undergo operation, while 35 of the patients randomized to observation later had their gallbladders removed. The cumulative risk of having a cholecystectomy seemed to level off after 4 years. Gallstone-related complications occurred in 3 patients in the observation group, 1 in the operation group and 5 of 201 excluded patients. After cholecystectomy, 16 of 222 patients had a major complication and 10 a minor., Conclusions: We found that non-operative expectant treatment carries a low risk of complications. Patients should be informed that watchful waiting is a safe option.

Background: Induction of intestinal malabsorption by jejunoileal (JI) bypass was a widely performed procedure for morbid obesity in the 1970's. The purpose of this study was to evaluate the long-term results., Methods: A total of 36 patients underwent JI bypass from November 1971 to September 1976. At operation the median age was 33 years and median BMI 42 kg/m2. Shunt lengths varied between 45 and 60 cm. The present check-up of the 28 patients still alive included clinical examination, biochemical tests, bone density measurement and measurement of fecal fat excretion., Results: 10 patients (28%) had had their shunt reversed. With one exception these patients quickly regained weight, and 5 (50%) of them were dead. 23 patients with an intact JI shunt are alive, but 5 of them have had the shunt shortened due to weight gain. Their median age today is 56 years, and median BMI is 30. None of these patients were known to have coronary heart disease or diabetes mellitus at follow-up. Malabsorption of fat is still present. Blind loop syndrome, flatulence, foul fecal smell and diarrhea are the most troublesome long-term sequelae. Vitamin and mineral deficiencies are common. 2 of 21 patients (age 80 and 57 years) have osteoporosis., Conclusion: When the optimal shunt length for the individual patient is found, JI bypass maintains a substantially reduced weight for 25 years. Vitamin and mineral deficiencies are common, but no serious clinical deficiency states are seen.

Detection of micrometastatic cells in bone marrow (BM) may potentially be of prognostic value in colorectal cancer (CRC). In the present study, we have evaluated our immunomagnetic detection method in model experiments and on BM samples from CRC patients. In repeated experiments, 11 of 12 CRC cell lines consistently bound MOC31 antibody-coated magnetic particles with an average of 98% of the cells being rosetted with the beads. When different numbers of CRC cells (20, 100, 200, and 1000) were admixed to 1 x 10(7) mononuclear cells (MNCs) from BM, a mean of 77% of the cancer cells was recovered. In BM samples obtained from CRC patients at primary surgery, rosetted tumor cells were detected in 46 of 275 samples (17%) upon screening of 2 x 10(7) MNCs/sample. The fractions positive were: 10% (5 of 49) in Dukes' A; 17% (20 of 115) in Dukes' B; 23% (18 of 78) in Dukes' C; and 9% (3 of 33) in Dukes' D. Of 206 control samples, three (1.5%) contained cells in BM that formed rosettes with the MOC31 beads. In positive samples, a median of eight tumor cells (range, 2-120) were identified per 20-microl examined fraction, representing about one-tenth of the total sample. The results demonstrate the feasibility of using the immunomagnetic method for detection of micrometastatic CRC cells. Furthermore, that screening of 2 x 10(7) MNCs in a BM sample can be completed in <3 h makes the method an attractive alternative to other techniques.

Objective: To assess the effect of piperacillin/tazobactam compared with cefuroxime/metronidazole in the treatment of patients with intra-abdominal infections., Design: Randomised open study., Setting: 16 Swedish and 6 Norwegian hospitals., Subjects: 269 patients with intra-abdominal infections were randomised and treated with at least one dose of each study drug. 205 patients, 105 treated with piperacillin/tazobactam and 100 with cefuroxime, were clinically evaluable for follow up (had been given the full course of treatment)., Intervention: Patients were given piperacillin 4g/tazobactam 0.5 g every 8 hours or cefuroxime 1.5 g every 8 hours plus metronidazole 1.5 g every 24 hours. Each patient was to be treated for a minimum of 3 days and not more than 10 days., Main Outcome Measures: Clinical evaluation of infection at the end of and 4-6 weeks after treatment. Evaluation of safety and tolerance to the drugs and bacteriological susceptibility to the treatment drugs., Results: In the intention to treat analysis treatment was equally successful for piperacillin/ tazobactam (103/140, 74%) and the cefuroxime/metronidazole groups (90/129, 70%) (p = 0.6). Corresponding figures for the clinically evaluable group were 102/105 (97%) and 94/100 (94%) for piperacillin/tazobactam and cefuroxime/metronidazole groups, respectively, at the end of treatment. At late follow up, 92/105 (88%) and 83/100 (83%) in the two groups, respectively, remained free of infection. The side effects of the treatment were mild and evenly distributed between the two groups. Most pathogens were susceptible to the drugs in both treatment groups., Conclusion: Both piperacillin/tazobactam and cefuroxime/metronidazole are well suited to the treatment of patients with intra-abdominal infections, and we found no significant difference between the two. The drugs were safe and well tolerated in the regimens used.

Background: Play-the-Winner (PTW) design was compared with Weighted-Play-the-Winner (WPW) design with regard to sensitivity to discriminate between treatments., Methods: In total, 231 patients undergoing digestive surgery were included in a PTW study comparing safety of enoxaparin and dextran-70 in the prevention of venous thrombo-embolism. In the PTW model each patient was classified as a 'winner' or 'loser'. The treatment was changed when a patient was classified as 'loser', otherwise the same treatment was continued for the next patient. The study was performed by using a PTW design, but with all assessments needed for a WPW simulation. In the WPW design, a 'loser score' was calculated for each patient and summarized to a 'loser index' for consecutive patients given the same treatment. When this index exceeded a predefined value, treatment was changed and the 'loser index' set to zero. The WPW model with inheritance (WPWI) is identical to WPW, except that the overload of 'loser index' from the previous sequence with the same treatment was used as the starting value for the next., Results: The PTW study revealed superiority of enoxaparin. This was enforced in the WPW model and further increased by WPWI., Conclusion: Changing from the PTW to WPW design and further to WPWI increased the sensitivity of the model, but at the same time the complexity of the design.

Background: Symptoms of gastro-oesophageal reflux are common, and currently available methods for diagnosing reflux disease are expensive and uncomfortable for the patient. The diagnostic value of a treatment test with omeprazole is unclear., Methods: Patients with dyspepsia including heartburn admitted for upper gastrointestinal endoscopy were studied in a prospective, randomized, double-blind Scandinavian multicentre study. Before entry 188 patients were enrolled, and 160 were randomized to 1-week treatment with 20 mg omeprazole twice daily or placebo. Gastro-oesophageal reflux disease (GERD) was defined as reflux oesophagitis Savary-Miller grades II-III at endoscopy or pH < 4 exceeding 4% of the total time at 24-h oesophageal pH-monitoring and was found in 135 patients. The treatment test was considered positive when the patient's symptoms improved during the treatment week compared with the pretreatment day., Results: The sensitivity in diagnosing reflux disease was 71-81% with omeprazole as a diagnostic test, compared with 36-47% for placebo during treatment days 3-7. The specificity was similar for the two treatment arms during the first days of the study. During the end of the week a larger proportion of the patients with normal endoscopy and pH test responded to omeprazole treatment, giving omeprazole lower specificity than placebo. The investigators' overall evaluation of whether the patient was a responder to the test had a sensitivity of 75% and a specificity of 55% in the omeprazole-treated patients. The corresponding figures in the placebo group were 17% and 92%, respectively., Conclusion: One week of omeprazole treatment is a simple diagnostic test with a fairly high sensitivity. The specificity is poor owing to the placebo effect and to the lack of a gold standard in diagnosing reflux disease.

Background: The description and understanding of gallbladder stone disease in the medical literature are difficult because an assessment of the natural course of this symptomatic disease, with separation of patients in strictly defined groups, is generally lacking., Method: A multicenter study was carried out with patients randomized to either surgery or conservative, expectant treatment to examine optimal treatment and natural history in well-defined groups of symptomatic gallbladder stone disease with pain, episodes only (study group 1) or acute cholecystitis (study group 2). The patients were between 18 and 80 years of age and had right upper quadrant or midline epigastric pain and ultrasonographic evidence of gallbladder stone, with or without acute cholecystitis. Medical treatment was ordinated on the basis of signs and symptom severity. Patients randomized to surgery were placed on the hospital's waiting list and electively operated on with cholecystectomy as soon as conveniently possible. Preliminary results of follow-up are based on questionnaires mailed at regular intervals and consultations if required by the patients' symptoms. Quality of life and freedom from pain are study end points for evaluation., Results: Five hundred and one patients were considered for the study, 318 patients (63.5%) belonging to group 1 and 183 (36.5%) to group 2. One hundred and eighty-four patients (36.7%) were randomized, 120 (24%) in group 1 and 64 (12.7%) in group 2. Three hundred and seventeen patients (63.3%), with an equal proportion from each study group, were excluded, the largest number of patients because of incapacitating pain or serious presenting symptoms (26%). More women (81%) than men (19%) had pain alone (group 1), but the sex ratio was reduced, 56% women and 44% men, in patients with acute cholecystitis (group 2), with a highly significant difference (P = < 0.001) between the two groups. A significant difference in patient withdrawal from randomized treatment was registered, with 24% from observation and 12% from surgery (P = 0.032), but with an equal distribution in the two study groups., Conclusions: A randomized trial of this nature is feasible but extremely difficult to perform because of the heterogeneous nature of gallbladder stone disease, leading to exclusion of many patients and difficulties in measuring and evaluating outcome variables.

Background: The aim of this study was to measure the efficacy of 150-mg ranitidine effervescent tablets compared with 20-mg famotidine wafers in the management of patients presenting to primary care physicians with episodic symptoms of gastro-oesophageal reflux disease (GORD)., Methods: The study was of a multicentre, open, randomized, parallel-group design in which 32 Norwegian general practitioners participated. After a pre-treatment demographic and symptom assessment, eligible patients were allocated to either ranitidine effervescent tablet or famotidine wafer. Patients were then provided with the study medication, a stopwatch, and a 2-week symptom diary card. Efficacy was primarily determined by the time to adequate symptom relief for the first symptom episode., Results: In total, 377 patients were recruited to the study; 187 patients received ranitidine effervescent, and 190 received famotidine wafer. More than 50% of the patients had daily GORD symptoms before recruitment. Median time to adequate symptom relief was 15 min in the ranitidine group and 18.5 min in the famotidine group (P = 0.005). Adequate symptom relief within 60 min was reported by 165 (92%) ranitidine patients and 156 (84%) famotidine patients (P = 0.02). The number of non-responders after 60 min was twice as great in the famotidine group: 30 (16%) versus 15 (8%). A greater proportion of patients in the famotidine group liked taking the wafer formulation: 173 (94%) versus 126 (70%) (P = 0.001)., Conclusion: There was a statistically significant difference in favour of 150-mg ranitidine effervescent tablets in terms of time to adequate symptom relief and the proportion of patients who achieved adequate symptom relief for the first episode. A greater proportion of patients in the famotidine group liked the type of formulation than in the ranitidine group.

Objective: To assess the effect of preoperative local anaesthesia with ropivacaine and find out if there was a dose-response relationship with postoperative pain after inguinal hernia repair., Design: Randomised, double-blind, placebo-controlled trial., Setting: Two Swedish and two Norwegian hospitals., Subjects: 131 Male patients undergoing elective inguinal hernia repair., Intervention: Infiltration of the inguinal field before operation with 0.5% ropivacaine 40 ml (200 mg), 0.25% ropivacaine 40 ml (100 mg) or saline 40 ml., Main Outcome Measures: Wound pain at rest and during mobilisation, pressure exerted to reach pain threshold and maximum pain tolerance after 3, 6, 10, and 24 hours, and after 7 days; consumption of analgesics; and Quality of Life assessed by two independent questionnaires before and after operation., Results: Pain scores after 3 hours were significantly lower in the ropivacaine groups compared with the saline group for all variables (p < 0.05). At 6 hours pain scores were significantly lower for ropivacaine 0.5% compared with saline for wound pain during mobilisation and pressure exerted to reach maximum pain tolerance. Patients given saline made their first request for analgesics significantly sooner than in the other two groups (p < 0.05), and a significantly larger percentage of them requested analgesics during the first 24 hours (p < 0.05). Evaluation of the Quality of Life questionnaires showed no significant differences between the groups., Conclusion: Ropivacaine has a significant, dose-related pain-reducing effect in the immediate postoperative period but we could find no support for the theory that preoperative infiltration analgesia reduces long term pain.

Discontinuation of thromboprophylaxis a few days after surgery may unmask delayed hypercoagulability and contribute to late formation of deep venous thrombosis (DVT). To investigate whether thromboprophylaxis should be prolonged beyond the hospital stay, a prospective, double-blind randomised study was conducted in 308 patients. All patients received initial thromboprophylaxis with dalteparin, dextran and graded elastic stockings. On day 7, patients were randomised to receive dalteparin (Fragmin) 5000 i.u. once daily, or placebo, for 4 weeks. All patients were subjected to bilateral venography, perfusion ventilation scintigraphy and chest X-ray on days 7 and 35. Patients with venographically verified proximal DVT on day 7 were withdrawn from the randomised study to receive anticoagulant treatment. The overall prevalence of DVT on day 7 was 15.9%. On day 35, the prevalence of DVT was 31.7% in placebo-treated patients compared with 19.3% in dalteparin-treated patients (p = 0.034). The incidence of DVT from day 7 to day 35 was 25.8% in the placebo-treated group versus 11.8% in the dalteparin-treated group (p = 0.017). The incidence of symptomatic pulmonary embolism (PE) from day 7 to day 35 was 2.8% in the placebo-treated group compared with zero in the dalteparin-treated group. This included one patient who died from PE. No patients experienced serious complications related to the injections of dalteparin or placebo. This study shows that prolonged thromboprophylaxis with dalteparin. 5000 IU, once daily for 35 days significantly reduces the frequency of DVT and should be recommended for 5 weeks after hip replacement surgery.

Despite the fact that a prognosis in 1991 predicted a surplus of ten gastroenterological surgeons in 1994, several hospitals are now experiencing a lack of applicants. In order to define the scope of this problem, the Norwegian Gastroenterological Society and The Specialty Committee for Gastroenterological Surgery sent a questionnaire and made a telephone query to all Norwegian Surgical Departments in autumn 1995. There were 21 vacant posts and 27 specialists are still needed to carry out the tasks the hospitals are instructed to perform. An initiative must be taken to increase the capacity and geographical distribution of the education and improve the working conditions, and thereby job satisfaction, of gastroenterological surgeons.

Bilateral infrapatellar tendon rupture is a relatively rare injury. We describe the case of a 32 year old woman who stumbled and sustained a bilateral infrapatellar tendon rupture while jogging. In our opinion, this represents an unusual mechanism of injury, and we also find it unusual that it was a bilateral injury in an otherwise healthy patient. Diagnosis was confirmed by surgical exploration eight days after admission to hospital. Despite repeated clinical, X-ray and ultrasound examinations, the diagnosis was delayed since we initially did not consider the trauma adequate to cause such an extensive injury. The diagnosis of patella tendon rupture should be based on careful consideration of the history of the injury and thorough clinical examination. X-ray and ultrasound can be of diagnostic help.

Objective: To compare enoxaparin and dextran 70 for the prophylaxis of venographically diagnosed deep vein thrombosis (DVT) after gastrointestinal operations., Design: Part 1: randomised double blind trial; Part 2: single blind study with historical controls., Setting: Eight Norwegian hospitals., Subjects: 381 Patients undergoing elective gastrointestinal operations., Interventions: Part 1 (n = 329): enoxaparin 20 mg subcutaneously starting two hours before operation and continuing until the patient was fully mobilised or had had 10 injections and a placebo infusion of 0.9% sodium chloride, or dextran 70,500 ml at the start of the operation, on the evening of operation, and on the first, third, and fifth postoperative days and placebo subcutaneous injections. Part 2 (n = 52): enoxaparin 40 mg in the same regimen as part 1 (compared with 39 historical controls). Venograms 4-6 days post-operatively., Main Outcome Measure: Venographically confirmed DVT., Results: Part 1: Because of the high overall incidence of DVT an interim analysis was done which showed 33/101 DVT (33%) among high risk patients in the enoxaparin 20 mg group and 33/107 (31%) in the dextran 70 group. The corresponding figures for patients at medium risk were 2/27 (7%) for enoxaparin 20 mg and 5/27 (19%) for dextran 70 (95% confidence interval (CI) for the difference--11.9 to 9.8). Part 2: the dose of enoxaparin was therefore increased to 40 mg and prophylaxis restricted to patients with cancer. There were 6/49 DVT (12%), which was compared with a random sample from the dextran 70 group from part 1 (historical controls) in which the incidence was 15/39 (38%, 95% CI of the difference 4.0 to 8.4). There were no pulmonary emboli, only 4 thrombi were above the knee and there were 4, 1 and 3 clinical DVT in the 20 mg and 40 mg enoxaparin, and dextran 70 groups, respectively., Conclusions: Enoxaparin 20 mg and dextran 70 are effective prophylaxis for patients at medium risk, but enoxaparin 40 mg is required for those at high risk.

Background: Stimulation of gastric motility has been supposed to accelerate the healing of gastric ulcer. The combination of the prokinetic drug cisapride and the H2 blocker ranitidine was tested in the treatment of uncomplicated gastric ulcer., Methods: Cisapride, 20 mg twice daily (Cis), and ranitidine, 150 mg twice daily (Ran), were given as monotherapies and in the combination 20 mg cisapride and 150 mg ranitidine daily (Cis + Ran) for a maximum of 8 weeks. The study was multicentre, randomized, and double-blind., Results: A total of 197 patients were included. Healing rates in the per-protocol analysis after 4 and 8 weeks' treatment were 61%/84%, 52%/69%, and 61%/92% for the Cis + Ran (n = 56), Cis (n = 58), and Ran (n = 59) treatment groups. No statistically significant difference in healing rates was seen when comparing Cis + Ran with the monotherapies. Symptom relief at the end of treatment was significantly better in the Ran group than in the Cis + Ran group with regard to epigastric pain (p = 0.01) and vomiting (p = 0.05). Patients' global evaluation of treatment was in favour of Ran in comparison with Cis + Ran treatment (p = 0.04)., Conclusions: Combination of cisapride and ranitidine in the treatment of gastric ulcer did not enhance the healing rate or improve symptom relief in patients treated for uncomplicated gastric ulcer when compared with the monotherapies.

Laparoscopic surgery is rapidly increasing its field of application. We describe the uncomplicated use of peritoneoscopic techniques to remove a benign renal cyst. No previous report of this mini-invasive, patient-friendly and cost-effective method has been found in the literature. It should be considered in the rare cases where surgery is indicated as treatment for this benign condition.

In a Swedish-Norwegian multicentre study patients with endoscopically verified duodenal ulcers (greater than 5 mm) were randomized to 2 or 4 weeks of treatment with either 20 mg omeprazole once daily or 300 mg ranitidine once daily. The aim was to evaluate 2 and 4 weeks' treatment with regard to symptomatic improvement during treatment, relapse after treatment, and safety of the two drugs. Endoscopy was not performed to check healing at the end of treatment. Instead the patients were instructed to contact the investigator in the event of recurrence of symptoms for renewed endoscopy. Follow-up was ended 10 weeks after stopping active treatment. Altogether 450 patients were evaluated at 17 centres. The symptomatic improvement during treatment was good in all groups, with significantly better reductions of daytime pain and heartburn in omeprazole-treated patients. Symptomatic relapse was commonest in the 2-week ranitidine group (57%), significantly more than in the 2-week omeprazole group (31%) (p less than 0.003). In the 4-week groups relapse rates were 34% (ranitidine) and 39% (omeprazole) (NS). It is suggested that in the short-term treatment of acute duodenal ulcer 20 mg omeprazole once daily is most rationally used in a 2- to 4-week regimen, whereas 300 mg ranitidine once daily should not be used for less than 4 weeks.

Four cases of suture line ulcers after gastric surgery caused by nonabsorbable suture material are presented. The literature is reviewed, and a plea ia made for the use of absorbable suture materials in gastrointestinal surgery.

Medical ulcer therapy focuses on enhancing mucosal defence mechanisms or reducing intraluminal acidity. In this Swedish multicenter, randomized double-blind study these two principles were compared in the treatment of acute duodenal ulcerations. Sucralfate (Andapsin 1g X 4) or cimetidine (Tagamet 400mg X 2), together with antacid tablets (Novalucol), were supplied to patients with acute ulcerations in the pyloric ring or duodenal bulb. Endoscopy was performed at inclusion, after four weeks and in some patients also after eight weeks. Besides healing rate, symptoms and antacid intake, smoking and side effects were recorded on a special protocol. 371 patients from 15 centers completed the trial. At inclusion the patient groups did not differ in any essential aspect. At four weeks 71% of 177 patients on sucralfate and 77% of 194 on cimetidine were healed. The corresponding figures for eight weeks were 86% (suc) and 92% (cim). The difference is not significant, the 95% confidence interval for the difference in ulcer healing efficacy of sucralfate compared with cimetidine at eight weeks was -12% to +5%. Antacid intake and symptoms decreased rapidly and equally in both groups. Side effects related to the treatments were uncommon. It is concluded that sucralfate and cimetidine, representing two different principles in medical ulcer treatment, are both very effective and compare well in the short term treatment of acute duodenal ulcer.

Eight high risk patients, median age 79 years, with a distal obstruction of the common bile duct and serious clinical symptoms of acute obstructive cholangitis were treated by EPT. In seven patients, impaction of a stone in the common bile duct was found and in one patient, an obstructing cancer. EPT was performed without immediate complications and followed by obvious drainage of purulent bile in all patients. Repapillotomy with stone extraction was necessary in three patients 5, 6, and 10 days after the first EPT. The papillotomy was followed by immediate symptom relief, normalization of body temperature, and a decrease in leukocytes and bilirubin and alkaline phosphatase values within the first several postoperative days. Average hospitalization time was 8 days, ranging from 4-17 days. The patient with pancreatic cancer died 3 months after the EPT. One other patient died in pseudomonas sepsis 17 days after an uncomplicated EPT. ERCP controls in the other six patients have been normal and they all remain symptom free. Since early decompression is mandatory in these patients and laparotomy with internal decompression is associated with a high morbidity and mortality, endoscopic decompression should probably be the recommended treatment in patients with obstructive, septic cholangitis prior to employing this therapeutic option.

In the period 1977-1983, 21 patients with small tumour of the lower two-thirds of the rectum were treated with local excision, using the posterior trans-sphincteric approach. The operative and postoperative course was uneventful, with no mortality, septic complications, fistula or anal incontinence. In 14 cases the tumour was an adenocarcinoma. These tumours had been preoperatively classified as carcinoma or suspected carcinoma with limited superficial growth. In 12 of them there was no invasion beyond the rectal wall. In follow-up averaging 44 months there has been no local recurrence, but liver metastasis has appeared in two patients. In our experience, local tumour excision via posterior trans-sphincteric rectotomy is a safe alternative for removal of adenoma or small, localized carcinoma of the lower two-thirds of the rectum.

In five patients in whom a jejuno-ileal by-pass had been previously performed for massive obesity, a relaparotomy was performed because of subjective complaints or unsatisfactory weight reduction. At the reoperation morphometric studies were made of the functioning segments and the by-passed intestine. Length and circumferential measurements were taken, and the villous height and mucosal thickness were measured from histological biopsies. The results were compared with the findings in a control group. After shunt operation adoptive hypertrophy in the functioning remnant, a considerable length growth and dilatation of the gut, as well as a marked increase in villous height and total mucosal thickness, were demonstrated. These adaptive changes seem to be more marked in the distal part of the small intestine. No atrophy of the mucosa could be demonstrated in the excluded intestinal loop.

Over a 3-year period continuous intravenous infusion of moderate doses of vasopressin in 13 patients bleeding profusely from hemorrhagic gastritis, was associated with rapid control of the bleeding in 11 patients, while in 2 patients prolonged infusion was required to stop the hemorrhage. In 2 patients there was a relapse of the hemorrhage 3 and 7 days after the initial treatment, which was successfully controlled by renewed vasopressin infusion. There was no mortality and no complications of the vasopressin treatment were encountered. The results compared favourably with the experience from the preceding 3-year period where a comparable group of patients undergoing conventional medical and surgical treatment suffered a mortality of 38%. This study therefore suggests that vasopressin infusion performed continuously with moderate doses over extended periods, improves survival of patients with severe hemorrhagic gastritis through control of bleeding.

The effectiveness and complications of gastric banding were evaluated in 15 miniature pigs. A Gore-tex or Dacron graft was employed to encircle the stomach. The animals were divided into five groups, three pigs in each group. Group 1 had a 13 mm pouch stoma with a Gore-tex band, Group 2 had a 16 mm pouch stoma with a Gore-tex band, Group 3 had a 13 mm pouch stoma with a Dacron band, Group 4 had a 16 mm pouch stoma with a Dacron band, and Group 5 had a sham operation. The weight variation in the control group was significantly higher than that in the other groups at the ninth postoperative week (p less than 0.05). There was no significant difference among Groups 1, 2, 3, and 4. The gastric band had migrated distally in seven pigs. It was located in the body of the stomach in four animals and in the pylorus in three. These three pigs died from stenosis of the pylorus. The band had eroded and penetrated all stomach layers in three other animals. There was no difference in the incidence of postoperative complications between the Gore-tex and Dacron band groups. The use of this simple operation in the treatment of the morbidly obese patient should be applied with caution.

Eight patients who were subjected to colorectal surgery received 1500 mg metronidazole and another 8 patients 1600 mg tinidazole. The two groups of patients were comparable in respect to age, body size, diagnoses, types of operations, premedication, and anaesthesia. Concentrations of the parent compounds and hydroxy-metronidazole were determined by high pressure liquid chromatography in serum and tissues (subcutaneous fat, rectus abdominal muscle, peritoneum, greater omentum, distal ileum, colon, appendix). The serum and tissue concentrations of metronidazole and tinidazole were within overlapping ranges. Hydroxy-metronidazole but not hydroxy-tinidazole was detected. The total area under the serum curves was 505 (SD: +/- 181) mg . h/l for metronidazole, 137 (+/- 38) mg . h/l for hydroxy-metronidazole, and 810 (+/- 286) mg . h/l for tinidazole. The serum half-life values in the same order were 8.5, 11.2, and 14.2 hours. The distribution volume (Vd,area) were 30.1 liter for metronidazole and 38.8 liter for tinidazole. The range of tissue concentrations were completely overlapping. The two regimens can, consequently, be assessed as pharmacokinetically similar.

Endoscopic papillotomy was performed for choledocholithiasis in 22 high-risk patients with gallbladder in situ. The procedure was well tolerated by the patients and was performed without serious complications. Pathologic laboratory findings normalized in most cases during the first week after papillotomy. The median hospital stay was four days. Laparotomy was subsequently performed in five cases, in one because of impaction of a 3 cm stone two days after the papillotomy, and in four because of biliary symptoms during a five-year follow-up period. On the basis of experience with this patient series and recent reports in the literature, primary endoscopic papillotomy is recommended as the sole therapeutic procedure for high-risk patients.

A double blind randomised study was undertaken to compare sucralfate and cimetidine in short term treatment of gastric ulcer. The study included 149 patients with endoscopically confirmed gastric ulcerations. Patients with prepyloric ulcers 2 cm or less from the pyloric ring were not accepted for participation in the trial. Ulcer healing was assessed endoscopically at four week intervals. A total of 134 patients completed the study. The cumulative healing rates after 12 weeks were 98% for sucralfate and 94% for cimetidine treated patients. After four and eight weeks, the healing rates were 61% and 94% for sucralfate and 69% and 94% for the cimetidine-treated group respectively. No statistically significant differences in healing rates were seen. The 95% confidence interval was calculated for the difference between the ulcer healing rates of sucralfate and cimetidine. This interval was found to range between +11% and -2% after 12 weeks of treatment - that is, the healing efficacy of sucralfate was calculated to be at most 11% better or 2% worse than that of cimetidine. No significant differences in symptom relief, side effects or antacid intake were found.

The limitations of catgut, which has been the only available absorbably suture material for surgical work are well known. In the present study, catgut and PGA (Dexon) are compared in 123 patients undergoing neck surgery with respect to wound complications. Dexon appears to offer a favourable alternative since this synthetic, absorbable suture material produces fewer early tissue reactions.

Primary prosthetic replacement in elderly patients with displaced intracapsular fracture of the femoral neck has been used during the last few years with encouraging early results. The prosthetic device preferred has been Christiansen's endoprosthesis. During the past year a new type with separable plastic head and metallic cap has been used. This modification has resulted in the occurrence of a previously unknown complication, a separation of these two parts, necessitating reoperation and insertion of a new head piece. The possible mechanisms causing this separation are discussed.

Metabolic parameters were studied in 6 patients before and for 18 months after jejunoileal bypass for obesity. The postoperative changes in plasma concentration of amino acids were characterized by a decrease in essential amino acids, while the non-essential amino acids were unchanged or elevated, indicating a state of protein-caloric malnutrition. The pattern of fatty acids in serum the first year after operation: an unchanged sum of unsaturated and saturated fatty acids accompanied by a significant fall in linoleic acid and a corresponding increase in oleic acid, showed that even during this period the patients were in a state of essential fatty acid deficiency. The oral glucose tolerance test and the levels of serum immunoreactive insulin activity indicated a general improvement in glucose tolerance and a normalization of preoperative hyperinsulinism. A 40-50% reduction was found both in serum triglycerides and cholesterol levels. Serum iron was reduced by approximately 30%, whereas TIBC levels remained unchanged. The Schilling test showed a significant fall in vitamin B12 absorption postoperatively with subnormal values at 6 and 12 months. Vitamin B12 in serum dropped, but remained within the normal range, suggesting that the preservation of 25 cm of distal ileum is sufficient to secure adequate absorption of vitamin B12. Folic acid levels in serum fell after the bypass, demanding supplementation in 5 of the 6 patients at 6 months postoperatively.

Six cases of fracture of the lateral part of the distal tibial epiphysis are presented. Five were operated on and 1 was treated with a plaster cast only. The results were excellent, and we advocate operative treatment of this fracture if more than minimal dislocation exists.

A double-blind, randomized, multicenter study was performed to compare the effect of sucralfate (1 g qid) and cimetidine (400 mg bid) in the treatment of prepyloric ulcer. Altogether 142 patients (68 in the sucralfate and 74 in the cimetidine group) with endoscopically confirmed ulcer within 2 cm of the pylorus completed the study. Endoscopic follow up was performed after four weeks and, if the ulcer was not healed, after eight weeks of treatment. After four weeks, 65% of the ulcers in the sucralfate group were healed, compared to 70% in the cimetidine group. There was no significant difference between sucralfate and cimetidine at either time point. The 95% confidence interval for the difference in ulcer healing with sucralfate or cimetidine ranged from +4 to -19% at eight weeks. Said another way, with an observed difference of 7% (83% vs 90%), the 95% confidence limit ranged from 4% in favor of sucralfate to 19% in favor of cimetidine. Symptomatic relief, antacid intake, and side effects did not differ significantly between the two groups. The healing rate of prepyloric ulcer in this study is similar to that reported for duodenal ulcer after four and eight weeks when treated with sucralfate or cimetidine. Sucralfate is safe and as effective as cimetidine in the short-term treatment of prepyloric ulcer.