[Surgery in patients over 80 years of age--a retrospective analysis of 642 general surgery patients]. / Chirurgie bei über 80-jährigen--eine retrospektive Analyse an 642 allgemeinchirurgischen Patienten.

We evaluated the data on 642 patients over 80 years of age who underwent general surgery within the preceding 10 years. Lethality in elective surgery was higher compared to younger patients and showed a threefold increase in emergency procedures. Preexisting co-diseases strongly determined survival, which emphasises the fact that a thorough preoperative risk-assessment is essential for elective surgery. Age itself is not a contraindication for elective surgery.

Minitracheotomy: a new interventional technique for treatment of sputum retention.

Sputum retention causing pulmonary atelectasis, secondary pneumonia, and respiratory failure is a frequent complication particularly in patients recovering from abdominal and thoracic surgery. Physiotherapy and conventional therapeutic means like blind tracheobronchial and bronchoscopic suction applied to prevent and treat postoperative respiratory complications have been shown to not be completely effective. Minitracheotomy is a new alternative method for the treatment of sputum retention. Endobronchial suction can be performed as often as required, using a thin uncuffed tube (ID 4.5 mm) which is inserted into the trachea through the cricothyroid membrane under local anaesthesia. Since respiration occurs normally through the nose, mouth, and larynx these patients retain speech and the ability to cough. Complications are rare. Endobronchial suction via minitracheotomy is minimally invasive, more comfortable, and at least as effective as conventional bronchoscopic suction. It therefore has become a routine method used in the treatment of postoperative sputum retention in high-risk patients in many intensive-care units.

[Surgical therapy of chest wall tumors]. / Die chirurgische Therapie der Brustwandtumoren.

Tumors of the chest wall may occur as both primary and secondary tumors. Diagnosis is established by clinical examination, conventional and/or computed tomography. In most cases of chest wall tumors resection is the treatment of choice. It should be performed with a safe distance to the tumor, if necessary with bloc resection of another intrathoracic part or adjacent tissues. For skeletal reconstruction non-absorbable and absorbable mesh is available; even complete replacement of the sternum is possible. Large full thickness defects can be covered with sliding flaps or myocutaneous flaps from adjacent locations.

Results of surgical treatment of pulmonary metastases.

Surgical removal of one or several metastases with a potentially curative aim is possible in the case of isolated pulmonary metastases. Surgery is part of a combined oncological concept. Between 1972 and 1986, surgical resection was indicated in 368 patients and 419 thoracotomies were carried out. Of the patients, 38% had more uni- or bilateral metastases than expected even after the most careful preoperative diagnostic examinations. The 5-year survival probability of all patients operated on was 33%. Corresponding to a differentiation between potentially curative and non-curative resections, the operation was classified as potentially curative in 73%. In this group, the 5-year survival was 39%. Differentiation into tumour groups (carcinomas of caval type, carcinomas of portal type and sarcomas) revealed no statistically significant differences in prognosis. Due to the excellent chemotherapeutical regimens, testicular teratomas achieved the best results in the early postoperative years. Long-term survival is decisively influenced by the removal of all visible and palpable metastases. If complete removal of all tumour tissue is possible, the number of metastases does not influence survival significantly. Besides radicality, the duration of the disease-free interval showed prognostic differences which were statistically significant (P less than 0.001). Considering the metastatic route and the type of primary tumour, there were slight prognostic differences which were not statistically significant. Recently, the median sternotomy has become the preferred method of access. Predominating resection procedures are wedge and segmental resections which yield the best survival rates.

[Surgical therapy of primary chest wall tumors--experiences with 98 patients]. / Die chirurgische Therapie primärer Brustwandtumoren--Erfahrungen an 98 Patienten.

Between 1973 and 1985, 98 patients with primary tumor of the chest wall have been operated at the Clinic for Thoracic Medicine in Heidelberg Rohrbach. 71 tumors were benign, 27 malignant. Three objectives have priority in surgical therapy: 1) complete (wide) resection of tumor, 2) reconstruction of the chest wall to allow adequate spontaneous ventilation, and 3) cosmetically acceptable coverage with integument. Today almost any defect caused by resection can be repaired. Coverage of the defect with Marlex mesh is recommended. Long-time prognosis depends on the primary disease. Functional and cosmetic results are very satisfactory.

Late results of surgical treatment of pulmonary metastases.

Surgical removal of one or several metastases with a potentially curative aim is possible in the case of isolated pulmonary metastases. The surgery is always part of an overall oncological concept. Between 1972 and 1984, surgery was indicated in 295 cases in 261 patients and 304 thoracotomies were performed. The procedure was classified as potentially curative in 76% of the cases. The 5-year survival probability in this patient group amounted to 38% for all organic tumors. The definitely best prognosis with 5-year survival rates of 42% is observed for caval metastatic carcinoma. Due to the excellent chemotherapeutical regimens, testicular teratomas reach the best individual result with a 3-year survival probability of 71%. Decisive for the long-term prognosis is the removal of all visible and palpable metastases. If radical resectability is possible, the number of metastases is only of secondary importance. Besides radicality, metastatic route and type of the primary tumor, duration of the disease-free interval and the size of the metastases are also of prognostic significance. Predominating resection procedures are the atypical and segment resection and the enucleation which yield the best survival rates.

Local tumor inflammation, lymph node metastasis, and survival of operated bronchus carcinoma patients.

Three hundred and fifty-three resection specimens with primary lung carcinomas were cut into serial sections, and the tumor volume was computed. Resected lymph nodes were cut into 0.3-mm serial sections and analyzed for metastasis. The inflammatory reaction of lung tissue was analyzed by grading the amount of inflammatory infiltrations of a complete tumor cross section. Survival of patients was evaluated by consulting the house physician every 3 months after surgical treatment. Percentage of specimens with severe inflammatory reaction of host tissue increased remarkably in tumors with a volume of 35-60 cm3. Percentage of patients with detectable lymph node metastasis increased with tumor volume but decreased at the tumor volume of 35-45 cm3. Mean tumor volume in patients with no detectable lymph node metastasis was increased if severe inflammatory response of host tissue existed. Survival of patients with severe inflammatory infiltrations was superior to survival of patients with no inflammatory infiltrations if grouped for tumor volume. Data indicated that inflammatory infiltrations in primary lung carcinoma may partly be related to the immunologic response of host tissue to tumor growth. Inflammatory infiltrations may delay tumor cell propagation into lymph nodes or may be even able to destroy small tumor cell agglutinations.

Surgical resection and adjuvant chemotherapy for small cell carcinoma.

Poor long-term results following the surgical management of small cell carcinoma have contributed to the opinion that small cell carcinoma is a non-surgical disease; polychemotherapy is generally given preference. As nowadays adequate therapy (chemotherapy) achieves control of local tumor growth as well as of extended metastases, surgical resections should be discussed from a different viewpoint: "Does surgery profit from modern chemotherapy?" In our clinic, 1332 patients have been operated on for bronchogenic carcinoma from 1973 to 1983: 170 (12.8%) suffered from small cell carcinoma. The indications for surgery were either non-histologically classified tumors (e.g. peripheral coin lesions) or small cell carcinomas stage I, and only in rare cases for palliative reasons. Lobectomy, including bronchoplastic and arterioplastic resections (n = 108), was the most common procedure. The postoperative mortality was 15%, the average survival 341 days, the latter having improved significantly since 1979 when a postoperative polychemotherapy (ACO) was instigated. Recent results of surgical resection after primary chemotherapy are encouraging. Nevertheless, this new concept is reserved for the few cases of strictly limited disease and must be controlled by future studies.

Defense mechanism and macroscopic tumor growth in lung tissue.

A total of 126 resection specimens from malignant lung tumors were cut into serial sections, and tumor volume and macroscopic growth pattern were computed. Four characteristic tumor growth patterns could be separated: Tumors growing in bizarre, irregular shapes; Tumors growing in spheroid shapes; Tumors growing in ellipsoid shapes; Tumors growing in mixed growth pattern. The immunologic response of the host tissue was analyzed grading the number of lymphocytes, plasma cells, macrophages in and at the boundary of the tumor tissue. Lymphocytic subpopulations were analyzed in 46 cases using monoclonal antibodies (BS3/BS4; T3, OKT4, OKT8, OKT11, OKT14). The majority of lymphocytes were T-lymphocytes and monocytes in cases with inflammatory response of host tissue. The ratio of inducer/helper subset (OKT4+) compared to suppressor/cytotoxic subset (OKT8+) was similar in expression as reported for circulating peripheral T-lymphocytes. The different growth patterns depend upon cell type of tumor, immunologic response of the host tissue, and tumor volume. The findings indicate that tumor progression into lung tissue is partly due to "localized metastatic growth" of different tumor cell subpopulations.

[Indications and results of the surgical treatment of small-cell bronchial cancer]. / Indikation und Ergebnisse der chirurgischen Behandlung des kleinzelligen Bronchialcarcinoms.

From 1973 to 1983 170 patients underwent surgical treatment of small cell lung cancer. In 2/3 of the cases we performed lobectomy resp. bilobectomy including bronchoplastic and arterioplastic resections, the other third of patients underwent pneumonectomy. 26 patients (15%) died within 30 days. Postoperative mortality in patients with pneumonectomy was 17% and in patients undergoing lobectomy 7%. Since 1978 lethality rate dropped from 20% to 7%. Due to polychemotherapy, estimated time of survival (according to Kaplan and Meier) has increased significantly, adding up to 3-years- and 5-years-survival rates of 31% and 20% respectively.

[Significance of the nutritional status of surgical patients]. / Zur Bedeutung des Ernährungsstatus chirurgischer Patienten.

In recent years nutritional status gained greater attention as a surgical risk factor. This study analyzes the frequency of malnutrition in surgical patients with solid and operable tumors, the relation to the type of tumor and stage of the disease. In addition, the clinical value of the measurements carried out is discussed. The analysis was performed in 100 cancer patients (34 gastric cancer, 56 colorectal cancer, and 10 breast cancer). The nutritional assessment included individual dietary habits, ideal weight/height, triceps skinfold, arm muscle circumference, creatinine-height index, serum protein, albumin, prealbumin, cholinesterase, transferrin, total peripheral lymphocytes, and skin tests. The results were compared with international standards or normal plasma concentrations respectively. Most patients suffered from an alternation of the nutritional parameters indicating malnutrition, mostly Kwashiorkor-Marasmus Mix. Patients with gastrointestinal cancer, especially gastric cancer showed more often a decline of the nutritional status than patients with breast cancer. Malnutrition became more severe with advanced disease. The parameters examined revealed varying significance with respect to the assessment of the nutritional status. Some measurements showed little clinical importance; the reasons are discussed.

[Reduced nutritional status of the surgical tumor patient--a risk factor for postoperative complications?]. / Der reduzierte Ernährungszustand des chirurgischen Tumorpatienten--Ein Risikofaktor für postoperative Komplikationen?

In recent years nutritional status gained greater attention as a surgical risk factor. In 100 patients with solid and operable tumours nutritional assessment with different types of measurements (dietary habits, ideal weight/height, triceps skinfold, arm muscle circumference, creatinine-height index, serum protein, albumin, prealbumin, cholinesterase, transferrin, total peripheral lymphocytes, and skin tests) was performed. Individual abnormal nutritional measurements were compared with the incidence of complications postoperatively, which were found in 32 out of 95 patients. These complications appeared more often in correlation with the decline of nutritional status. However, we could not prove a statistically significant correlation between the examined parameters themselves and the incidence or lack, respectively, of postoperative complications. Possible reasons are discussed.

[Immediate postoperative enteral tube feeding following resection of the large intestine. Experiences with a controlled clinical study]. / Die unmittelbare postoperative enterale Sondenernährung nach Dickdarmresektion. Erfahrungen mit einer kontrollierten klinischen Studie.

In a prospective randomized study 40 patients after elective colonic surgery were investigated to assess the value of early postoperative enteral feeding versus parenteral feeding. Twenty patients received from the first postoperative day until the sixth postoperative morning a diet consisting of carbohydrates, fat, and short-chain peptides via a fine bore feeding tube placed in the proximal jejunum. Twenty patients of the control group were treated with standard intravenous fluids consisting of carbohydrates and aminoacids via infusion into a central vein. The general condition of the enterally fed patients was satisfactory, the diet was tolerated well and severe side-effects were not seen. The metabolic parameters showed no severe disturbance, a positive nitrogen balance was achieved within the second postoperative day. Body composition measurements were similar in both groups. The enteral route for the application of nutrients is a definite alternative to parenteral nutrition in patients after elective colonic surgery.

[The role of enteral and parenteral feeding in cancer therapy]. / Die Rolle der enteralen und parenteralen Ernährung in der Krebstherapie.

The role of nutrition support as an adjunct to cancer treatment is discussed. Many patients with advanced cancer have demonstrable nutritional deficits, the reason is still unclear. Anorexia, taste abnormalities, pain and obstruction of the gastrointestinal tract can lead to malnutrition. Different modes of therapy, like surgery, radiotherapy and chemotherapy, sometimes deteriorate nutritional status. Several investigators have indicated, that nutritional support provides some benefit. There is no indication at the present time of any disadvantage of this method of treatment in relation to tumor growth. The potential indications and methods of nutritional support are pointed out.