Object During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed these cases to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding. Methods These cases were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual postal questionnaires. Conclusions Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.

This paper analyses the early postoperative complications after 285 pancreaticoduodenectomies performed during the past 15 years in the Surgical University Clinic, Mannheim. There were 235 partial (Whipple) and 52 total pancreatectomies performed for pancreatic and periampullary tumors (181 patients) and complicated chronic pancreatitis (104 patients). A total of 92 complications requiring relaparotomy in 42 patients ended fatally in nine patients. The overall operative and hospital mortality rate was 3.1%. The most frequent and most dangerous were complications at or around the pancreaticojejunal anastomosis, which occurred 25 times with five deaths. Postoperative hemorrhage was seen in 16 patients; endoscopic treatment in four patients and operation in 12 patients was successful in stopping the bleeding in all but one patient. Eight biliary fistulae either ceased spontaneously (3 patients) or after operative reintervention (5 patients) without any mortality. Control of these complications depends on four lines of approach: (1) before operation: optimal preparation of the jaundiced patient including endoscopic transpapillary decompression of the common duct; (2) during operation: a meticulous and standardized technique is mandatory; (3) after operation: continuous observation in the surgical intensive care unit is essential for the timely detection of possible complications; and (4) early reintervention can salvage the great majority of these patients with deleterious complications.

Twenty-one years ago, Howard published a paper entitled "Forty-one Consecutive Whipple Resections Without an Operative Mortality." That paper stimulated the present analysis of the last 118 consecutive pancreatoduodenectomies (107 Whipple and 11 total resections) performed at the Surgical University Clinic Mannheim from November 1985 to the present day with no deaths. Ninety-one resections were performed for neoplasms and 27 were for complicated chronic pancreatitis. The preoperative evaluation, operative technique, and postoperative care of these cases is discussed in detail and compared to the experience of Howard. While there was general agreement on operative technique, there were differences concerning preoperative evaluation (modern imaging methods) and postoperative care (simplification). In this series 21 postoperative complications required seven relaparotomies. Long-term survival after resection for carcinoma was analyzed for 133 consecutive patients who were shown to have true ductal adenocarcinoma. In 76 patients, who had radical (R0-) resections, the actuarial 5-year-survival rate was 36%. In 44 patients, whose R0-resections for pancreatic cancer occurred more than 5 years ago, the actual survival rate was 25%.

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Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.

During 7057 conventional cholecystectomies (1972-1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93%, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an "uneventful" cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean follow-up period after surgery was 7.4 +/- 4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.

Sodium valproate (VP) inhibited oxidative phosphorylation in isolated rat liver mitochondria. State 3 rates of oxygen consumption with glutamate as substrate were 80% of control values at a low VP concentration (24 microM). At 240 microM, there was more than 50% inhibition of glutamate and alpha-ketoglutarate state 3 rates. Succinate state 3 rates were 80% of control values, and uncoupling was noted at 2400 microM VP. These VP effects were similar to those of propionate and isovalerate, suggesting a common mechanism of toxicity. Inhibition of mitochondrial oxidative phosphorylation may explain why VP intoxication causes a hepatocerebral disorder that resembles Reye syndrome.