[Urologic errors in surgical procedures]. / Urologische Behandlungsfehler bei chirurgischen Eingriffen.

BACKGROUND: In the examinations of the appraisal commission of Northern Rhine the third most frequent urologic errors are ascertained after surgical procedures. In order to prevent them, it is adequate to evaluate their causes. MATERIAL AND METHODS: Urologic claims were examined that came before the appraisal commission for treatment errors of the Northern Rhine Physicians' Authority between 1975 and 2005. The results of the first 23 years were compared with those of the last 7 years. The judgment criteria were professional standards and required care. RESULTS: Ninety-five treatment errors were registered in 1975-2005. From 1975 to 1998 there were 60 such errors (2.6 per year) and from 1999 to 2005 there were 35 (5.0 per year). These errors concerned diagnosis in 14.7% of cases (mainly testicular torsion), indication in 7.5%, and explanations of the surgery in 2.1%. About half the cases (46.3%) applied to surgical technique, especially for injuries to the spermatic cord, urinary bladder, ureter, or urethra. In nearly one third of cases (29.4%), errors were found in postoperative care, concerning especially lesions of the spermatic cord and ureter. CONCLUSIONS: There is considerable risk of misjudging or even causing urologic disorders in abdominal and vascular surgery. This applies most strongly to diagnosis, above all for testicular torsion. Hernia surgery and colon resection are the treatments leading to the highest number of injuries to testicular vessels, ureter, bladder, and/or urethra. Such occurrences cannot be tolerated if they can be avoided or, if unavoidable, not recognized promptly and adequately managed.

Perioperative treatment with filgrastim stimulates granulocyte function and reduces infectious complications after esophagectomy.

We investigated the effects of recombinant G-CSF (Filgrastim) on the function of neutrophils and the rate of infectious complications in an open-label, nonrandomized study of patients with esophageal cancer undergoing esophagectomy. In this single-center phase-II trial 20 sequential patients (19 evaluable) received Filgrastim at standard doses (300 microg or 480 microg) subcutaneously for 2 days prior to and up to 7 days after surgery. The phagocytotic activity of neutrophils and the oxidative burst in the study group and in an experimental control group (n=27) were measured on days -2, 2, and 10. Neutrophil function was enhanced in the Filgrastim-treated group by factor 1.2 for phagocytosis (p=0.016) and 1.4 for oxidative burst (p)=0.154). Leukocyte counts increased from 7.6 x 10(9)/l (day -2) to a maximum of 45 x 10(9)/l on day 6. No infection was reported in the study group (mean age 59.7 years; 13 men, seven women) up to 10 days after surgery. In contrast, 23 patients (29.9%) in a historical control group (mean age 56 years; 67 men, ten women) treated at the same center developed infections within the first 10 days (p = 0.008). In addition, no postoperative deaths occurred in the study group, compared with 9.1% in the group of historical controls. Thus, in this study, administration of Filgrastim stimulated neutrophil function in patients undergoing esophagectomy, and it might be effective in reducing infectious complications related to the surgical procedure.

Histopathological subtypes and prognosis of gastric cancer are correlated with the expression of mucin-associated sialylated antigens: Sialosyl-Lewis(a), Sialosyl-Lewis(x) and sialosyl-Tn.

The expression of three sialylated mucin-associated antigens - sialosyl-Lewisa (SLEA), sialosyl-Lewisx (SLEX) and sialosyl-Tn (STN) - and their correlation with the TNM stage, histopathological growth pattern and prognosis was investigated in a series of 127 gastric carcinomas. Various classification systems (pTNM, WHO and Laurén) did not display any correlation with an expression of the sialomucin antigens under study. SLEA reactivity was strongly associated with an unfavorable outcome of the total population, whereas SLEX and STN did not exert such an impact. However, in the subgroups of pTNM stage I as well as pN0 patients, SLEA and SLEX reactivity of the tumors was associated with a worse prognosis. In the subgroup of diffuse-type cancers as defined according to Laurén's classification, the expression of all three antigens indicated a worsening of the prognosis.

Correlation of the immunohistochemical reactivity of mucin peptide cores MUC1 and MUC2 with the histopathological subtype and prognosis of gastric carcinomas.

The expression of MUC1 and MUC2 mucin peptide core antigens in gastric carcinomas was studied by immunohistochemistry to determine correlations with TNM stage and histo-pathological classifications as well as a possible prognostic impact. Paraffin-embedded specimens from 128 gastric carcinomas with a minimal follow-up of 5 years were immunostained. In addition to a polyclonal antiserum generated against polymorphic epithelial mucin (MUC1) from human milk, 2 monoclonal antibodies (MAbs), HMFG2 (anti-MUC1) and 4FI (anti-MUC2), were applied. Reactivity of carcinomas was correlated with the classifications of the UICC (TNM), WHO and Laurén. Correlations with overall survival were analyzed using the Kaplan and Meier product limit method. MUC1 immunoreactivity was associated with an advanced pTNM stage. The demonstration of both mucin species (MUC1, MUC2) displayed a statistically significant correlation with tubular/papillary vs. signet-ring cell differentiation as well as with intestinal-type vs. diffuse-type of tumor growth according to Laurén. In particular, MUC2 was only rarely detectable in signet-ring cell and diffuse-type tumors. MUC1 correlated with poor prognosis in all cases and the subgroup of stage I tumors. According to the histopathological classifications, a similar result was observed in signet-ring cell and diffuse-type carcinomas. In contrast, MUC2 reactivity was associated with a favourable prognosis of intestinal-type carcinomas. In the non-neoplastic gastric mucosa, both peptide cores were recognized in the superficial epithelium, whereas parietal cells contained only MUC1, and intestinal metaplasia almost exclusively MUC2 antigens. We conclude that the mucin peptide core antigens are suitable markers for the tubule-rich gastric carcinomas, which may in part be derived from intestinal metaplasia. In addition, MUC1 may exert a prognostic relevance and appears to be involved in the progression of diffuse-type tumors.

Monoclonal antibody therapy for resected Dukes' C colorectal cancer: seven-year outcome of a multicenter randomized trial.

PURPOSE: As previously shown, antibody treatment increased survival of patients with resected colorectal cancer of stage Dukes' C. Since the 5-year analysis was criticized because of the wide range (2.7 to 7.5 years) of follow-up time, we performed a 7-year analysis with only four of 189 patients monitored for less than 5 years. PATIENTS AND METHODS: A total of 189 patients with resected Dukes' C colorectal cancer were randomly allocated to infusions of a total of 900 mg 17-1A antibody, 500 mg postoperatively followed by 4 monthly doses of 100 mg (n=99), or to observation only (n=90). Primary end points were overall survival and disease-free interval. Patients were stratified by a dynamic randomization according to center, sex, location of tumor, number of affected lymph nodes, and preoperative carcinoembryonic antigen concentration. RESULTS: Randomization produced balanced distribution of risk factors. After 7 years of follow-up evaluation, treatment had reduced overall mortality by 32% (Cox's proportional hazard, P < .01; log-rank, P=.01) and decreased the recurrence rate by 23% (Cox's proportional hazard, P < .04; log-rank, P=.07). The intention-to-treat analysis gave a significant effect for overall survival (Cox's proportional hazard, P < .01; log-rank, P=.02) and disease-free survival (Cox's proportional hazard, P=.02; log-rank, P=.11 ). While distant metastases were significantly reduced (Cox's proportional hazard, P=.004; log-rank, P=.004), local relapses were not (Cox's proportional hazard, P=.65; log-rank, P=.52). This differential effect of 17-1A antibody on disseminated isolated tumor cells versus occult local satellites may explain the increased significance seen in the overall survival. CONCLUSION: The now-matured study shows that 17-1A antibody administered after surgery prevents the development of distant metastasis in approximately one third of patients. The therapeutic effect is maintained after 7 years of follow-up evaluation.

Risk factors, complications, and outcome in surgery: a multivariate analysis.

OBJECTIVE: To correlate variables recorded perioperatively with morbidity and mortality in an attempt to assess the predictive value of these variables for the outcome of individual patients. DESIGN: Prospective study. SETTING: Teaching hospital, Germany. SUBJECTS: 6304 consecutive patients admitted for operation. INTERVENTIONS: Recording of American Society of Anesthesiologists (ASA) class, age, sex, operation class (Hoehn), anaemia, hypertension, bronchopulmonary disease, diabetes mellitus, renal failure, major gastrointestinal disease, type of anaesthesia, operation (and whether emergency or elective), and duration of operation. All these factors were subjected to logistic regression analysis. MAIN OUTCOME MEASURES: Odds ratio (OR), sensitivity, specifity, and positive and negative predictive values. RESULTS: We studied 6304 patients of whom 140 died postoperatively and 1432 developed complications from which they survived. The variable that had most influence on the risk of postoperative complications was the ASA class (ASA class 4, OR 4.2, and ASA class 3, OR 2.2) followed by the severity of the operation (OR 1.86). An uncomplicated course was correctly predicted in 96%, but complications were correctly predicted in only 16%. The positive predictive value was 57%, and negative predictive value 80%. CONCLUSIONS: Despite the fact that we considered a large number of variables we were unable to predict the risk of complications for individual patients with any accuracy.

Hans von Haberer: a forgotten pioneer in vascular surgery.

After carrying out the first free vein graft transplantation on an aneurysm of the axillary vein by Lexer in 1907, many attempts were made to reconstruct arterial injuries with direct vascular suture technique or vein graft transplants during the Balkan War (1912) and the First World War (1914-1918). Hans von Haberer gained wide experience in the reconstructive surgery of traumatic aneurysms at the Department of Surgery at the University of Innsbruck. During this period, he operated on a total of 201 vascular aneurysms, mainly using a direct circular vascular suture technique. In 1914, von Haberer described the first reconstruction of a carotid aneurysm. First experiences with vein bypasses were made, but not pursued in the following years.

[Hans von Haberer--the beginnings of reconstructive carotid surgery]. / Hans von Haberer--Anfänge der rekonstruktiven Carotischirurgie.

Hans von Haberer (1875-1958) gained wide experience in the reconstructive surgery of vascular aneurysms at the universities of Innsbruck, Graz, Düsseldorf and Cologne. In this period he operated on 421 vascular aneurysms--including 30 carotid aneurysms--mainly by means of direct circular vascular suture. In 1914 von Haberer described the first repair of a carotid aneurysm. Therefore he is the pioneer of reconstructive carotid surgery. Based on detailed clinical and operation reports on approximately 16,000 cases, written by Hans von Haberer between 1904 and 1949, and on the contemporary literature, we describe his experience in vascular surgery.

Role of transanal endoscopic microsurgery in the palliative treatment of rectal cancer.

BACKGROUND: Palliative, minimal invasive treatment of rectal cancer is advocated in patients with advanced and incurable disease or poor clinical condition and in those who refuse radical surgery. Several methods have been used during recent years. We report our experience with palliative transanal endoscopic microsurgery. MATERIALS: Between 1983 and 1995, 29 patients underwent transanal endoscopic microsurgery for palliation. Eleven patients had advanced malignant disease, nine were in poor clinical condition, and nine repeatedly refused radical surgery. RESULTS: Intraoperatively one severe complication, an intra-abdominal perforation, occurred. The morbidity rate was 14%. Postoperatively, clinical signs were abolished or improved in all cases. Only three patients required further palliative resections after initial symptom relief. CONCLUSIONS: Transanal endoscopic microsurgery is a successful approach in the palliative treatment of rectal cancer. The technique enables complete resection of rectal tumors. Although anesthesia is needed, the morbidity is low, even in patients with poor clinical condition.

Surgical therapy of esophageal carcinoma: the influence of surgical approach and esophageal resection on cardiopulmonary function.

OBJECTIVE: The effects of the different surgical approaches (transhiatal esophagectomy and right-sided transthoracic esophagectomy) on perioperative cardiopulmonary function in the surgical treatment of esophageal carcinoma are discussed controversially and have not yet been evaluated. METHODS: In a prospective randomized study including 32 patients, we investigated the effects of the surgical approach (blunt dissection (n = 16) versus transthoracic en-bloc resection (EB) (n = 16)) in the treatment of esophagus carcinoma on perioperative cardiopulmonary function. The following parameters were measured in all patients: cardiac index (CI), mean arterial pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), intrapulmonary shunt (QS/QT), arterio-alveolar (aaDO2), arterio-venous oxygen pressure difference (avDO2), and blood gas analyses. Time of measurement were: after induction of anesthesia, beginning and end of esophagus resection, end of surgery, 1 h postoperatively, and then every 12 h until the third postoperative day. RESULTS: Compared to blunt dissection, en-bloc esophagectomy was found to be associated with a transient deterioration of pulmonary function during one-lung ventilation in the left-lateral position, which could already be compensated for during the intervention. No other significant differences in cardiopulmonary effects were seen between the two surgical techniques. The incidence of postoperative complications was identical in both groups. CONCLUSIONS: The results of our study show that en-bloc resection is only associated with an increased intraoperative pulmonary strain that is completely compensated during the operation and that there is no difference in cardiopulmonary functions between the two techniques in the postoperative course.

p53 expression in gastric cancer: clinicopathological correlation and prognostic significance.

For evaluation of the prognostic relevance of p53 expression in gastric cancer, the immunohistochemical tissue status of 133 primary gastric cancer patients was investigated for p53 expression and the association between p53 tissue status and clinicopathological parameters was analyzed. P53 immunoreactivity was detected in the nuclei of cancer cells in 35 cases (26.3%). The nuclear p53 immunoreaction was closely associated with tumor location, lymph node metastasis, and curability. Tumors with positive p53 stain reactions frequently metastasized to lymph nodes (metastatic rate: 91.4%) in contrast to tumors with negative p53 stain reactivity (71.4%, P = 0.021). Immunohistochemical analysis of primary gastric cancer appears to be an accurate and simple method of screening for p53 expression. In combination with common prognostic parameters, determination of p53 tissue status might help to detect prognostically unfavorable subgroups of gastric cancer patients.

Colorectal cancer--a multivariate analysis of prognostic factors.

The data from 1050 patients who had undergone colorectal carcinoma resection at the University of Cologne between 1976 and 1990 were studied. The aim of the study was to determine the concomitant effects on survival of several patient characteristics (sex, age, tumour localization, blood transfusion) and histopathological variables (Dukes' staging). We first calculated survival rates, both including and excluding post-operative mortality. We set up a hierarchical log-linear model for the detection of relationships between selected crossclassified categorial variables. We then used Cox's proportional hazard regression method to study the relationship between survival and different prognostic patterns. Dukes' staging was shown to be a highly discriminating factor in survival (P<0.001). Survival rates were better in women (P<0.001), and better for younger patients (<70 years; P<0.001). Tumour site (colon; P = 0.0362) and blood transfusion (P = 0.0857) also correlated with survival.

Gasless videoendoscopic implantation of an aortobifemoral vascular prosthesis via a transperitoneal versus extraperitoneal approach: an experimental study.

PURPOSE: To report progress in the development of a new minimally invasive surgical technique for aortobifemoral grafting utilizing gasless videoendoscopy. METHODS: In an experimental study, aortobifemoral Dacron vascular prostheses were implanted in 20 human cadavers using videoendoscopic techniques in both transperitoneal and extraperitoneal approaches. Rather than inducing pneumoperitoneum, the abdominal wall was elevated with an electrically powered lifting system. RESULTS: Each approach was utilized in 10 cadavers for implantation of 20 aortobifemoral grafts under endoscopic guidance in a gasless field. Average operative time for transperitoneal approach was 3.8 hours (range 3.0 to 5.5), slightly less than the average 4.1 hours (range 3.0 to 6.0) for the extraperitoneal access. Both access routes provided adequate visualization of the operative field. CONCLUSIONS: Advantages of gasless endoscopy include the use of conventional instruments and the potential benefits associated with a minimally invasive approach. Optical magnification facilitates suturing of the femoral anastomosis, improves examination of the vascular walls, and allows a more accurate suturing technique.

Anastomotic tissue oxygen tension during esophagectomy in patients with esophageal carcinoma.

Submucosal tissue oxygen tension (PtO2) was measured in 20 patients with cervical esophagogastrostomy after resection of esophageal carcinoma, using a Clark-type oxygen electrode. The mean gastric baseline PtO2 was 54.6 +/- 10.7 mm Hg. Following ligature of the vasa brevia and the left gastroepiploic artery PtO2 decreased to 45.8 +/- 9.9 mm Hg, ligature of the left gastric artery caused a decrease to 34.2 +/- 9.7 mm Hg and resection of the lesser curvature and pulling up of gastric tube led to 25.5 +/- 9.0 mm Hg. Clinical value and practicability of intraoperative PtO2 measurements could be proven.

[Effect of surgical trauma on NK cell activity in esophageal carcinoma after transmediastinal dissection vs. transthoracic en bloc resection]. / Einfluss des Operationstraumas auf die NK-Zell-Aktivität beim Osophaguskarzinom nach transmediastinaler Dissektion vs. transthorakaler En-bloc-Resektion.

In order to assess the impact of surgical trauma involved in the therapy of esophageal carcinoma on the cellular immune system, a perspective study was performed involving perioperative hematological parameters. The activity of natural killer cells and the serum concentrations of interleukin-2, interleukin-6 and TNF-alpha were measured in 12 cases of transmediastinal dissection and 10 cases of transthoracic en bloc esophageal resection and compared to values of a control group of thoracic and abdominal surgical patients with non-malignant maladies. Natural killer cells assume a central role in the non-specific immunological response in tumor patients. Their main function is the destruction of tumor cells via cytotoxic activities amplified by the release of interleukin-2 and TNF-alpha. Natural killer cell activity was measured prior to surgery and on postoperative days 4 and 10 using a standardized europium chloride release assay, utilizing K562 target cells. Lymphokines interleukin-2, interleukin-6, and TNF-alpha were also measured on postoperative days 1 and 7 using standardized ELISA assays. The activity of natural killer cells in our patient group sank significantly (P < 0.05) on postoperative day 4 and likewise in the control group and both study groups, activity sank to the original values. In the control group, natural killer cell activity averaged 45% of preoperative values, in comparison with an average of 63% following transmediastinal esophageal carcinoma resection (one cavity procedure), and transthoracic en bloc resection (two cavity procedure). On postoperative day 10, all groups displayed a significant reacceleration of natural killer cell activity (P < 0.05). Whereas transthoracic en bloc resection patients only reached 61% of preoperative values, transmediastinal dissection patients assumed 75%, and 77% was achieved by control group members. Transthoracic en bloc resection of the esophagus led to a more extreme reduction in cytotoxic cellular activity owing to the greater surgical trauma. Suppression of the immunological tumor resistance, especially in the vulnerable perisurgical phase, can have an indirect negative effect on the manifestation risk of hematogenic metastases owing to intraoperative tumor cell dissemination resulting from tumor manipulation and may thus be prognostically relevant.

[The beginnings of reconstructive vascular surgery in Austria]. / Anfänge der rekonstruktiven Gefässchirurgie in Osterreich.

Hans von Haberer (1875-1958) gained wide experience in the reconstructive surgery of traumatic aneurysms during the 1st world war at the Surgical Department of the University of Innsbruck. In the period 1914-1918 he operated on altogether 201 vascular aneurysms, mainly using a direct circular vascular suture. In 1914 von Haberer described the first reconstruction of a carotid aneurysm. On the basis of the detailed case notes and operation reports written by Hans von Haberer between 1904 und 1949 on approximately 16000 cases and from the contemporary literature, we describe his experiences in vascular surgery at the Surgical Department of the University of Innsbruck between 1914 and 1918.