[Economic consequences of complications in abdominal and thoracic surgery in the German DRG payment system]. / Betriebswirtschaftliche Bedeutung von Komplikationen in der Viszeral- und Thoraxchirurgie im DRG-System.

BACKGROUND: The Surgical Department of the University Hospital Grosshadern has been making a systematic record of complications since 2005. With respect to the ongoing problem of under-financing from DRG reimbursements, an analysis of the relationship between surgical cases with severe complications and insufficient reimbursement warranted a detailed analysis. MATERIAL AND METHODS: Out of 16 762 in-house patients during 2005-2007 we assigned 6707 cases into four divisions - hepato-pancreato-biliary, colorectal, minimal invasive and general abdominal surgery as well as 1469 cases of thoracic surgery, for costs and reimbursement. In all groups patients with mandatory treament of complications were compared to the remaining cases without complications. Within these, further subgroups were analysed: patients with a need for artificial ventilation (partition A of the G-DRG system), cases with excessive loss (underfunding above 10 000 Euro) and their intersections. RESULTS: With the exception of minimal invasive surgery, each division featured 10-15 % of serious complications. Losses for these cases ranged from 159 % (thoracic surgery) to 102 % (other abdominal surgery) of the overall loss in each division. Cases with excessive losses, representing 1.5 % of all patients, caused 80 % to 100 % of this deficit. Complicated cases alloted to DRGs for artificial ventilation still represented 50 % of the under-fund-ing. CONCLUSION: Cases with mandatory complication treatment can be discerned as separate economic entities. They are considerably overlapping cases with excessive underfunding, so further analysis might lead to an improved reimbursement policy. In addition, the connection between quality management and economic efficiency is highlighted.

[Visceral and thoracic surgical interventions in patients over 80 years old. Evaluation of cost coverage]. / Viszeral- und thoraxchirurgische Eingriffe bei über 80-Jährigen : Bewertung der Kostendeckung.

Due to the higher incidence of malignant tumours with increasing age, cancer is the second most common cause of death among those aged over 65 years old. Consequently, demographic changes in Germany have resulted in a rising demand for oncological operations in elderly patients which is more cost-intensive. Objective of the present study in the setting of a university surgical department is whether oncological operations on patients over 80 years old is cost-effective in the era of diagnosis-related groups. The revenue and expenditure of 116 cases of patients over 80 years old documented for the years 2005-2007 were collated and evaluated. The calculated average proceeds were compared with cases of patients under 80 years old.The average return was -1493.50 EUR/case for over 80-year olds and was not cost-effective. The presence or absence of complications had a significant impact on proceeds, because the mean return/case without complications was profitable (1297.30 EUR). Medical care of patients over 80 years old was on average cost-effective and generated a profit. Oncological operations in patients under 80 years old were not sufficiently remunerated by the current DRG system. Therefore, there is an economical risk associated with oncological operations in elderly patients.

The dark side of the moon: impact of moon phases on long-term survival, mortality and morbidity of surgery for lung cancer.

OBJECTIVE: Superstition is common and causes discomfiture or fear, especially in patients who have to undergo surgery for cancer. One superstition is, that moon phases influence surgical outcome. This study was performed to analyse lunar impact on the outcome following lung cancer surgery. METHODS: 2411 patients underwent pulmonary resection for lung cancer in the past 30 years at our institution. Intra- and postoperative complications as well as long-term follow-up data were entered in our lung-cancer database. Factors influencing mortality, morbidity and survival were analyzed. RESULTS: Rate of intra-operative complications as well as rate of post-operative morbidity and mortality was not significantly affected by moon phases. Furthermore, there was no significant impact of the lunar cycle on long-term survival. CONCLUSION: In this study there was no evidence that outcome of surgery for lung cancer is affected by the moon. These results may help the physician to quiet the mind of patients who are somewhat afraid of wrong timing of surgery with respect to the moon phases. However, patients who strongly believe in the impact of moon phase should be taken seriously and correct timing of operations should be conceded to them as long as key-date scheduling doesn't constrict evidence based treatment regimens.

The University of Munich lung cancer group database: design, profile of cohort and outcome analysis.

OBJECTIVE: Changes in therapeutic concepts can only be justified by a significant improvement of outcome parameters. Furthermore, detailed statistics of complications are needed to guarantee high quality of treatment. This study describes the new University of Munich Lung Cancer Group Database. METHODS: The MLCG-Database contains all patients who underwent surgery for lung cancer at the Department of Surgery, University of Munich Medical Centre since 1978. Data were database recorded on the patient's ward, or directly imported from other departments performing medical examinations on the patient. Data could be entered online at the time of surgery in the operating room. Relevant information from the Munich Tumour Registry was imported via encrypted data communication. Both epidemiological background and influence of preoperative risk factors on morbidity and mortality as well as on long-term survival were analysed. RESULTS: Median follow-up time was 45 months (1-295 months). Overall 5- and 10-year survival was 36% and 28% respectively. Preoperative risk factors were arterial hypertension in 43% of patients, COPD in 34%, abuse of nicotine in 26% and therapy with corticosteroids in 25%. Surgical procedure consist of lobectomy or bilobectomy in 69%, pneumonectomy in 16% and lesser resections in 15%. Intra- and postoperative complications occurred in 1.4% and 32% of patients, respectively. CONCLUSIONS: This paper provides an overview of our MLCG-Database, which allows performing statistics for outcome analysis and quality management reports as well as medical assessment on a huge collection of patient data on a day-to-day basis. In addition, impact analysis of risk factors on postoperative morbidity and mortality as well as investigation of long-term survival underlines results reported internationally.

[Acute limb ischemia from the general surgeon's point of view. How much knowledge of vascular surgery is necessary?]. / Akute Extremitätenischämie aus allgemeinchirurgischer Sicht. Wie viel gefässchirurgische Kenntnis ist erforderlich?

The diagnosis of acute peripheral ischemia can be obtained based on clinical presentation, inspection, and palpation of the affected extremity. Unfractionated heparin as a single shot is immediately given followed by continuous infusion when diagnosis is clinically evident and contraindications are excluded. Thromboembolectomy using a Fogarty catheter is immediately performed in patients with evidence of arterial embolization and signs of advanced ischemia (TASC IIb/III) followed by intraoperative angiography. Patients with evidence of arterial thrombosis require urgent angiography followed by thrombectomy and probably subsequent endovascular or surgical interventions and vascular reconstruction. For patients with moderate ischemia (TASC IIa), initial diagnostic angiography is recommended followed by primary thrombectomy with subsequent intraoperative angiography and immediate endovascular or operative treatment of remaining vascular problems. As an alternative therapeutic option initial catheter-guided local thrombolysis can be performed in selected patients with the intention of subsequent limb revascularization or unmasking relevant vessel alterations leading to specific endovascular or surgically performed vascular reconstruction. Possible development of muscle ischemia because of increased compartment pressure should be considered and fasciotomy performed when indicated. Primary amputation of the severely ischemic limb after initial thrombectomy might be recommended in patients with life-threatening organ failure related to muscle necrosis.

Gender differences in long-term survival of patients with colorectal cancer.

BACKGROUND: Significant differences exist in the immunological response to surgery. This raises the possibility that gender differences exist concerning the outcome after curative colorectal cancer resection. METHODS: To study this hypothesis, a database of patients with colorectal cancer was analysed prospectively. RESULTS: Some 894 patients were included, 500 (55.9 per cent) were men and 394 (44.1 per cent) were women. Median follow-up was 54.5 months for the entire group and 63.3 months for survivors. The mean(s.e.m.) patient age was 65.3(0.4) years (women 66.1(0.6), men 64.7(0.5) years; P < 0.05). Women lived significantly longer after cancer resection than men (57.8(1.5) versus 52.0(1.3) months; P < 0.05, log rank 0.009). Disease-free survival was significantly longer in women than in men (51.6(1.7) versus 46.0(1.4) months; P < 0.05). Subgroup analysis revealed significant gender differences in Union Internacional Contra la Cancrum (UICC) stages I (n = 195, log rank 0.01) and UICC IV (n = 38, log rank 0.021). Survival analysis after rectal cancer resection revealed significant advantages for women (log rank 0.02), while no gender differences were detected when comparing patients after resection for colonic cancer. Moreover, patients older than 50 years (n = 635) showed significant gender-related survival differences (log rank 0.015). CONCLUSION: Significant gender differences following curative rectal cancer resection were observed. In women disease-free and overall survival were significantly longer. Whether or not these gender differences are related to gender-specific immune functions or to other gender-related local or systemic factors remains to be determined.

The role of carcinoembryonic antigen for the detection of recurrent disease following curative resection of large-bowel cancer.

BACKGROUND AND AIMS: During recent years, a discussion about cost-effectiveness and importance of follow-up evaluation after curative resection of large-bowel cancer has developed. It is not known whether the determination of carcino-embryonic antigen (CEA) plays a crucial role in the early detection of recurrent disease. PATIENTS/METHODS: We conducted an analysis of the prospective follow-up database of 1321 patients after curative resection of colorectal cancer in our institution between 1990 and 1998 to evaluate the role of CEA in the early detection of recurrent disease. RESULTS: Of the 1321 patients included in our study, 306 developed recurrent disease following curative resection (23.2%). These patients with recurrent disease were divided into: Group I. No pre-operative CEA determination/insufficient follow-up (n=47; 15.4%). Group II. No elevation of CEA with primary cancer (n=156; 51.0%): (IIa) elevation with recurrent disease (n=62); (IIb) no elevation at any time point (n=53); and (IIc) role of CEA not completely elucidated (n=41). Thirteen patients of group II underwent curative relapse surgery (8.3%). Group III. Elevated CEA with primary cancer (n=103; 33.7%): (IlIa) no increase with recurrent disease (n=21); (IIIb) increase with other symptoms of recurrent disease (n=45); and (IIIc) increased values as an early symptom of recurrent disease (n=37). Sixteen patients of group III underwent curative relapse surgery (15.5%). In patients after relapse surgery, recurrent disease developed again after a median time of 12 months (mean 17.9+/-3.8 months). CONCLUSIONS: Our findings indicate that 2.8% of all patients (12.1% of patients with recurrent disease) who underwent curative resection of colorectal cancer profit from follow-up CEA determinations. With careful observation of CEA kinetics, 6.2% (n=82) of all patients or 26.8% of patients with recurrent disease could profit from routine follow-up CEA determinations. In 9.5% of patients with recurrent disease, curative resection of relapse was achieved and these patients remained disease free for a median time of 12 months. Regular CEA measurements remain an important part of routine patient care after curative resection of colorectal cancer.

Carcinoembryonic antigen for the detection of recurrent disease following curative resection of colorectal cancer.

BACKGROUND: During recent years a discussion about cost-effectiveness and importance of follow-up determination of carcinoembryonic antigen (CEA) after curative resection of large bowel cancer has developed. PATIENTS AND METHODS: Between 1990 and 1998 follow-up CEA levels of 1,321 patients after curative colorectal cancer resection were prospectively collected in cooperation with family physicians, CEA determinations were made with different assays by various laboratories. The reported findings were adjusted for the different methods used. RESULTS: 306 patients developed recurrent disease following curative cancer resection (23.2% of all patients). Regarding the role of follow-up CEA determination, they were divided into: I. no preoperative CEA determination/insufficient follow-up (N = 47); II. no elevation of CEA with primary cancer, a) elevation with recurrent disease (N = 62), b) no elevation at any time point (N = 53), c) role of CEA not completely elucidated (N = 41); III. elevated CEA levels with primary cancer, a) no increase with recurrent disease (N = 21), b) increase with other symptoms of recurrent disease (N = 45), c) increased levels as early symptom of recurrent disease (N = 37). 30 patients (9.8% of all patients with recurrent disease; 2.3% of all patients) with increased CEA levels at the time of recurrent disease underwent surgical resection with curative intention (R0 resection). CONCLUSIONS: Our findings indicate that up to 47% of the patients with recurrent disease and 11% of all patients (N = 144, groups IIa + IIIb + IIIc) could benefit from routine follow-up CEA determinations after curative colorectal cancer resection. Nonetheless, only 2.3% of all patients with elevated CEA levels underwent R0 resection of recurrent disease. Despite these detection and R0 resectability rates, CEA plays a crucial role in the early detection of recurrent disease and remains an important part of routine patient care after curative resection of colorectal cancer.

Accuracy and uncertainty of single-shot, nonresonant laser-induced thermal acoustics.

We study the accuracy and uncertainty of single-shot nonresonant laser-induced thermal acoustics measurements of the speed of sound and the thermal diffusivity in unseeded atmospheric air from electrostrictive gratings as a function of the laser power settings. For low pump energies, the measured speed of sound is too low, which is due to the influence of noise on the numerical data analysis scheme. For pump energies comparable to and higher than the breakdown energy of the gas, the measured speed of sound is too high. This is an effect of leaving the acoustic limit, and instead creating finite-amplitude density perturbations. The measured thermal diffusivity is too large for high noise levels but it decreases below the predicted value for high pump energies. The pump energy where the error is minimal coincides for the speed of sound and for the thermal diffusivity measurements. The errors at this minimum are 0.03% and 1%, respectively. The uncertainties for the speed of sound and the thermal diffusivity decrease monotonically with signal intensity to 0.25% and 5%, respectively.

An intranet-based system for quality assurance in surgery.

Quality assurance in surgery relies on precise medical records about surgical procedures and outcomes. Data quality is crucial for statistical evaluation; missing values cannot be avoided but must be minimized. The quality assurance system must be accessible from many locations within the clinic; given the complex and heterogeneous computing infrastructure this is a technological challenge. Intranet-technology--the application of internet-tools in local networks--can help to solve the technical problems. We designed, implemented and evaluated a generic Intranet-based quality assurance system in surgery. The basic concept is multi-purpose data entry with predefined textblocks, i.e. the same data is used for clinical reports as well as scientific evaluations. Our first instance were reports on laparoscopic cholecystectomies consisting of 41 Items and 132 textelements. Because of the good clinical acceptance of the system it will be expanded to other surgical procedures.

Beam misalignments and fluid velocities in laser-induced thermal acoustics.

Beam misalignments and bulk fluid velocities can influence the time history and intensity of laser-induced thermal acoustics (LITA) signals. A closed-form analytic expression for LITA signals incorporating these effects is derived, allowing the magnitude of beam misalignment and velocity to be inferred from the signal shape. It is demonstrated how instantaneous, nonintrusive, and remote measurement of sound speed and velocity (Mach number) can be inferred simultaneously from homodyne-detected LITA signals. The effects of different forms of beam misalignment are explored experimentally and compared with theory, with good agreement, allowing the amount of misalignment to be measured from the LITA signal. This capability could be used to correct experimental misalignments and account for the effects of misalignment in other LITA measurements. It is shown that small beam misalignments have no influence on the accuracy or repeatability of sound speed measurements with LITA.

Femoral insertion of the ACL. Radiographic quadrant method.

The optimal femoral insertion or footprint for an anterior cruciate ligament (ACL) graft is the anatomic site. This study was designed to determine the radiographic localization of the femoral insertion of the ACL on a lateral roentgenogram using a quadrant method. Ten human cadaveric knees with intact ACL were dissected. The most anterior, posterior, proximal, and distal borders of the femoral insertion of the ACL were marked with K-wires that were shortened at the bone level of the intercondylar fossa. A roentgenogram was obtained in the strictly lateral position. The end of the K-wires determined the projection of the femoral ACL insertion on the lateral roentgenogram. The center of the radiographically marked area was defined as point K, then four distances were measured on the lateral roentgenogram: distance t (representing the total sagittal diameter of the lateral condyle measured along Blumensaat's line), distance h (representing the maximum intercondylar notch height), distance a (representing the distance of point K from the most dorsal subchondral contour of the lateral femoral condyle), and distance b (representing the distance of point K from Blumensaat's line). Distance a is a partial distance of t and distance b is a partial distance of h, and distances a and b are expressed as length ratios of t and h. The center of the femoral insertion of the ACL was located at 24.8% of the distance t measured from the most posterior contour of the lateral femoral condyle and at 28.5% of the height h measured from Blumensaat's line. Based on these results, the ACL can be found just inferior to the most superoposterior quadrant, which means in anatomic terms it is localized from the dorsal border of the condyle at approximately a quarter of the whole sagittal diameter of the condyle and from the roof of the notch at approximately a quarter of the notch height. By using this radiographic quadrant method combined with fluoroscopic control during surgery, we were able to reinsert the ACL at its anatomic insertion site. This method is independent of variation in knee size or film-focus distance, easy to handle, and reproducible.

The treatment of idiopathic scoliosis in adolescents: rotation or in situ bending?

Rotation alone is not fully efficient in order to correct all types of scoliotic curvatures. We report a series of 30 cases instrumented with the EUROS spine system and analyse reductions obtained with in situ rotation or bending alone or with combined maneuvres. The average age of surgery is 17 years for this series composed of 24 female and 6 male patients. The average follow-up is 2.3 years. The curve patterns are displayed with 6 major thoracic, 5 genuine double major, 4 double major thoracic predominant, 6 double major lumbar predominant and 9 double thoracic curves. Combination of both reduction techniques is advisable and is to be made according to the type of curvature and its reducibility in situ bending is made easier with this system without lockers and by reduced diameter of the rod.

Measurement of gas-phase sound speed and thermal diffusivity over a broad pressure range using laser-induced thermal acoustics.

We report on the detection and analysis of signals generated from gas-phase laser-induced gratings over a large range of static pressure (0.04-100 atm). We employed the experimental technique of laser-induced thermal acoustics and performed measurements on mixtures of NO(2) in air and CO(2) as a function of pressure. Accurate analysis of the acquired data was obtained from a full theory, including beam size effects. The theory fully reproduces the observed data for a ratio of molecular mean free path to grating wavelength extending from 1 to 4 x 10(-4). Nonlinear, least-squares f its between modeled and experimental signals provided accurate values of the sound speed and thermal diffusivity.

Laser-induced thermal acoustics (LITA) signals from finite beams.

Laser-induced thermal acoustics (LITA) is a four-wave mixing technique that may be employed to measure sound speeds, transport properties, velocities, and susceptibilities of fluids. It is particularly effective in high-pressure gases (>1 bar). An analytical expression for LITA signals is derived by the use of linearized equations of hydrodynamics and light scattering. This analysis, which includes full finite-beam-size effects and the optoacoustic effects of thermalization and electrostriction, predicts the amplitude and the time history of narrow-band time-resolved LITA and broadband spectrally resolved (mulitplex) LITA signals. The time behavior of the detected LITA signal depends significantly on the detection solid angle, with implications for the measurement of diffusivities by the use of LITA and the proper physical picture of LITA scattering. This and other elements of the physics of LITA that emerge from the analysis are discussed. Theoretical signals are compared with experimental LITA data.

[Surgical treatment of panaritium articulare with the external minifixator]. / Die operative Behandlung des Panaritium articulare mit dem Minifixateur externe.

Septic interphalangeal arthritis can cause severe damage to the joint affected. Two patients treated by the appropriate operative procedure are presented. After interphalangeal distraction by external fixation two drains are placed in the joint and saline solution is infused regularly. The distraction improves the catheter irrigation and the prospects of success. At follow-up examination we saw no negative consequences of the joint distraction.

Is the Cotrel-Dubousset really universal in the surgical treatment of idiopathic scoliosis?

We reviewed the results of 22 cases of Cotrel-Dubousset (C-D) instrumentation, 16 cases of anterior approach, and 200 cases of posterior approach by Harrington instrumentation and modifications of Harrington procedure. Posterior spinal fusion and instrumentation by C-D gives better correction and stabilization in thoracic and balanced double major curves. We no longer use the Harrington procedure and its modification. In lumbar and short thoracolumbar curves, VDS is still preferred. In some double major curves combined procedures, VDS and C-D are used to obtain more correction with a shorter fusion area.

[Surgical treatment of congenital dislocation of the hip in older children; analysis of the results. Apropos of 46 cases]. / Traitement chirurgical de la luxation congénitale de hanche du grand enfant; analyse des résultats. A propos de 46 cas.

The results of surgical treatment of 46 congenital dislocations of the hip in children older than 4 years are analysed. Several techniques were used; progressive traction for a short time, stabilisation by plaster cast immobilisation or surgical reduction, pelvic osteotomy with or without combined femoral rotation osteotomy with shortening. Apart from other means of assessment, 3 radiological signs were used to determine the results - sphericity of the femoral head, coverage of the femoral head and centering of the femoral head. A new classification is proposed by the authors. Only 25 p. 100 of the results were excellent or good. The other hips had at least one radiological anomaly and 17.5 p. 100 of the hips had a non-spherical head. Cases with poor coverage of the femoral head did well when this was the only defect because this anomaly was easily corrected. In contrast, excentration of the femoral head was poorly tolerated in the long term. The degree and direction of excentration had to be assessed in the frontal plane.