P Ketonen’s research while affiliated with Helsinki University Central Hospital and other places

Two cases of primary small bowel tumors causing an acute intussusception are presented. In one case two polyps were found and in the other case a lipoma in the wall of the jejunum. In both cases there were symptoms of recurrent bowel obstruction for several months before the acute condition. Although intussusception caused by a benign tumor of the small bowel is a rare condition it should be taken into consideration in the differential diagnosis of abdominal pain of doubtful origin.

Fourteen patients suffering from abdominal angina have been operated on with different revascularization techniques. Preoperatively all of them had classical symptoms: postprandial pain and all except two had remarkable weight loss. There were six patients with isolated coeliac axis stenosis and in eight cases there were two or three diseased vessels. Liberation and reconstruction of the coeliac axis were carried out in six cases. Aorto-hepatic by pass graft was performed in three patients. Reinsertion of SMA was done in four and reinsertion of IMA in one case. Reconstruction of SMA with a by pass graft was carried out also in one case. There was no operative mortality. One of the patients died five weeks postoperatively at home from myocardial infarction. Another patient operated on in 1965 died seven years later at the age of 78 from myocardial infarction. He had had no further symptoms of abdominal angina postoperatively. The remaining 12 patients were relieved of their symptoms after the operation. They have been followed up for a mean of 5.5 years. The good long term results of arterial reconstructions in contrast to the poor prognosis without operation, favours early operation. The importance of early diagnosis and the importance of early operative treatment are emphasized.

The writers report a clinical series of 50 patients with traumatic diaphragmatic hernia. There were 36 hernias on the left side and 14 on the right. Stab or bullet wound was the cause of the hernia in 27 cases. The other 23 cases were due to traffic accidents or other blunt injuries. Immediate operative repair was done in 30 cases; in 20 cases the operation was carried out after a time interval of 11.5 years post trauma on an average. Plain chest X-ray, barium meal or enema and pneumoperitoneum were the most valuable diagnostic tools. Visceral injuries were discovered in 53% of cases caused by traffic accidents. The omentum, stomach, colon and spleen were the organs most frequently herniated. In two cases perforation of the stomach occurred before the operation. There were three cases of pericardial rupture associated with the diaphragmatic hernia in the series. The repair was done via thoracotomy in 28 cases, via laparotomy in 4 cases; and both thoracotomy and laparotomy were carried out in 18 cases. The hospital mortality was 2%. One of the patients died of peritonitis and renal failure following perforation of the stomach and intestines on the 9th postoperative day. Recurrence of the hernia occurred twice in one case. Re-examination revealed striction of the diaphragmatic movement in 11 cases. The clinical features, diagnosis and operative treatment are discussed.

A case of a desmoid tumor is presented. The tumour was initially found in an appendectomy scar. Excision of the tumour was not radical enough and it recurred. During the second operation, a tumour weighing 940 g was excised. A segment of the right ureter and right iliac vessels were also resected and reconstructed. Recovery was uneventful. Moderate swelling due to lymphoedema in the right lower extremity persisted after the second operation. There has been no recurrence after the second operation eight years ago.

The follow-up study consists of 121 surgically treated atherosclerotic patients. The average age was 49 years and the male: female ratio 7:5. There were 165 obstructions or occlusions in this series. 59 of them suffered from a subclavian steal syndrome. Altogether 146 reconstructive procedures were perdormed. 78 of them were endarterectomies, 51 bypass graft operations, 15 transpositions of the subclavian artery to the common carotid artery and 2 were other procedures. Operative mortality occurred in 3 patients (2.5 %). Non fatal complications occurred in 26 patients, the most frequent of which was thrombosis ot the reconstructed artery (12 cases). In the follow-up study (mean follow-up time 3.5 years) data on 118 patients was available. During the follow-up time 15 patients had died of other reasons than cerebral ischaemia. 42 % of the patients considered the operative result good and 51 % satisfactory. 25 % of the patients were ar work before operation and 50 % after.

One hundred consecutive patients have been subjectes to 134 carotid artery reconstructive procedures. 81 patients had TIA syndrome, 2 had acutely progressing stroke and 17 had symptomless stenosis at the carotid artery bifurcation. In 121 instances a bifurcation endarterectomy was performed, in 6 cases the internal or common carotid artery was resected and reconstructed, in 5 cases allograft- and in 2 cases autologous vein was used for the reconstruction. An intraluminal shunt was used in 93 operations. Operative mortality occurred in 4 patients, one was a case of acutely progressing stroke. Late mortality occurred in 16 patients. A follow-up study was carried out in the remaining 80 patients. According to the patients' own judgement symptomatic relief was good in 52.5 %, satisfactory in 40 % and unchanged in 7.5 %.

A report is made of a case of left diaphragmatic and pericardial rupture with luxation of the heart from the pericardial sac, resulting from a steering wheel injury. The patient was successfully treated surgically. In the treatment of this injury, correcting the hemodynamic derangement caused by incarceration and torsion of the heart is stressed. A review of the literature on pericardial ruptures is presented.

Three cases of pulmonary sequestrations are reported, one associated with tuberculosis, another with aspergillosis and a third cases associated with pseudomycosis (bothryomycosis). All the patients had a localized infection. They were treated surgically and had an uneventful recovery from their disease.