[Routine drainage following uncomplicated, elective cholecystectomy? A prospective, randomized study]. / Routinedrainage nach unkomplizierter, elektiver Cholecystektomie? Eine prospektive, randomisierte Studie.

A prospective randomized and controlled study of prophylactic drainage after simple, elective cholecystectomy was carried out. From March 1988 to June 1991 80 patients received an Easy-Flow drain and 80 did not. Operation and perioperative management were standardized. The endpoint of the study was postoperative morbidity, especially postoperative pyrexia and subhepatic fluid collection. The latter was identified by ultrasonography performed daily on postoperative day 1-4. No patient died. The morbidity including postoperative pyrexia revealed no difference between drained and undrained patients. In 19 of the patients with (23.8%) and in 25 of the patients without drainage (31.3%) a subhepatic fluid collection could be demonstrated by ultrasonography. This difference was not statistically significant either. We conclude that prophylactic drainage after elective, simple cholecystectomy is of no use for the patient. As subhepatic fluid collections can be seen in drained as well as in undrained patients it has to be accepted that drainage does not guarantee the removal of subhepatic fluid. Therefore its indicatory function (bleeding) and the ability to prevent the patient having biliary peritonitis or local abscess has to be put in doubt.

[Laparoscopic cholecystectomy and continuing surgical education]. / Laparoskopische Cholezystektomie und chirurgische Weiterbildung.

The rapid spread of laparoscopic cholecystectomy as standard operative treatment of cholelithiasis raises the question whether this new technique can be learned as prescribed for the traditional training of surgeons. To answer this question traditional methods of instruction were used for the first consecutive 100 laparoscopic cholecystectomies after the instructors had seen the method elsewhere and learned by operations on animals. 15 surgeons operated on these 100 patients (23 men and 77 women; mean age 50 [20-79] years). In accordance with the concept of early integration of laparoscopic cholecystectomy into surgical training, two trainee surgeons who had not yet performed a conventional cholecystectomy also took part in laparoscopic cholecystectomies. There were one serious (damage to the hepatocholedochal duct) and two mild (postoperative colics) complications. The median duration of operation was 95 (30-240) min. In eight patients the intervention was continued as a conventional cholecystectomy. This experience demonstrates that training in laparoscopic surgery can follow the same path as that for conventional surgery. A prerequisite is responsible assistance by an experienced operator, after the method has been introduced into the hospital.

[Ultrasonic diagnosis in suspected acute appendicitis: probable or certain indications for surgery?]. / Sonographie bei Verdacht auf akute Appendicitis: Möglichkeit oder Notwendigkeit für den Chirurgen?

The diagnostic accuracy and the clinical impact of routine ultrasonography performed by 4 surgeons, were prospectively studied in 366 unselected patients admitted for suspected acute appendicitis. Clinical and sonographic findings on admission were correlated with laparotomy findings, pathological outcome and clinical as well as follow-up data. The overall sensitivity, specificity and accuracy of the clinical diagnosis of acute appendicitis were 55.3%, 94.6% and 84.2% respectively (positive predictive value (PPV) 75.8%, negative predictive value (NPV) 87.3%). Ultrasound enabled visualization of the disease in 67 of 85 (prevalence 23.3%) patients with a histologically confirmed acute appendicitis; false positive results were recorded in 7 cases (sensitivity 78.8%, specificity 97.5%, accuracy 93.1%, PPV 90.5%, NPV 93.8%). Ultrasound was particularly useful in patients presenting with equivocal or highly unsuspective signs of acute appendicitis: of 38 patients with an acute appendicitis in this group ultrasonography enabled to make the diagnosis in 26. The combined approach of clinical evaluation and routine ultrasonography markedly improved the diagnostic accuracy (sensitivity 85.9%, specificity 96.4%, accuracy 94%) and substantially reduced the negative laparotomy rate (7.9%) in patients with suspected acute appendicitis. It is concluded, that ultrasonographic evaluation of the patient with suspected acute appendicitis performed by surgeons is of great assistance in surgical practice.

Histamine and the stomach: chemical histamine assays.

Histamine assays in gastroduodenal tissues and body fluids are not an absolute objective of scientific interest but are related to the role of histamine in health and disease. Hence, the reliability of histamine assays has to be assessed in relation to this aim. Sensitivity and specificity of the chemical histamine assays are similar in tissues and body fluids. The modern developments in a fluorometric-fluoroenzymatic assay guarantee the highest sensitivity and specificity, especially by tests that monitor specificity in each single run of histamine determinations. Precision and accuracy of histamine measurement were especially investigated for the fluorometric assay. They included tests on the coefficient of variation over the whole concentration range, long-term precision with double-sample standard control charts, comparison of several methods for histamine assay including bioassay, and long-term accuracy with the use of Cusum charts. Finally, appropriate sample preparation, sample-taking, relevant body fluids and tissues, and the right time for sample-taking were evaluated in extended methodologic studies. Histamine assays are not just methods for a normal routine laboratory. Extended knowledge about histamine release and metabolism will be necessary to analyse data in this particular field with reasonable validity.

[Stress ulcer or pneumonia: effect of prevention with H2 blockers on gastric juice pH]. / Stressulkus oder Pneumonie: Einfluss der H2-Blockerprophylaxe auf den Magensaft-pH.

In a study with 30 consecutive ventilated patients in a surgical ICU, the course of gastric pH was measured for 24 h. Cimetidine, 1.2 g per 24 h, was given to prevent stress bleeding. In the course of the evaluation period complete alkalization was found in only 4/30 patients (high responders); 10/30 patients showed no alkalization of gastric juice to above pH 4; and in 16/30 patients irregular pH changes were observed. These results suggest that the risk of developing pneumonia under this regimen will only be elevated in the high responder group. Although the alkalization of gastric juice was incomplete in our group, we saw no evidence of upper gastrointestinal bleeding. There is evidence that alkalization is not the only mechanism involved in successful prevention of bleeding.

[Is simultaneous cholecystectomy and choledochal exploration obsolete?]. / Ist die einzeitige Cholezystektomie mit Choledochusrevision obsolet?

Perioperative data on 284 patients who had simultaneously undergone cholecystectomy and surgical exploration of the bile duct were analysed. The procedures had been performed electively in 234 patients (145 females, 89 males; median age 61.5 [20-84] years). Freedom from stone was achieved in 96.2%; complication rate was 25.2% and death rate 2.6%. There was no death among patients without any or only one risk factor, while the morbidity rate for them was 18%. There were five deaths among 34 patients with four or more risk factors, and 13 (38.2%) had complications. Three of the patients who had died had been operated on because of septic, obstructive cholangitis with fever greater than 37.5 degrees C and bilirubin levels greater than 5 mg/dl. The operation was performed as an emergency in 50 patients (32 females, 18 males; median age 71.5 [24-93] years. 94% of them were free of stone afterwards; death rate was 10%, complication rate 44%. These data suggest that indications for the double surgical procedure in case of cholecysto-choledocholithiasis should be related to risk factors. In an emergency and in patients at risk, endoscopic papillotomy and stone extraction should precede cholecystectomy. But the one-time and thus definitive double surgical procedure remains the management of choice for patients with few or no risk factors.

[Computer-assisted documentation in upper gastrointestinal endoscopy: experiences with routine use at 3 clinics]. / Computerunterstützte Dokumentation bei der oberen gastrointestinalen Endoskopie: Erfahrungen bei der Routineanwendung in drei Kliniken.

The introduction of powerful and inexpensive personal computers (PC) enabled us to develop a documentation system for upper gastrointestinal endoscopy. The system was programmed using the database management system dBASE III. It works on-line, and no computer knowledge or additional staff is needed to run the system. It is now routinely used in the endoscopic units of three different hospitals. Features of performance are a menu-driven data input, automatic report generation and record retrieval, listing according to different criteria as well as other dBASE III facilities. This paper deals with the quality, time effort and user acceptance of the PC-aided system in clinical routine. The analysis showed a good data quality with respect to completeness and adequate use of terminology. Reliability and validity of the documentation were satisfactory considering the methodological problems encountered at their determination. The system was generally judged useful, but time effort was increased compared to conventional documentation.