Randomized clinical trial comparing bipolar coagulating and standard great saphenous stripping for symptomatic varicose veins.

BACKGROUND: Typical side-effects of saphenous stripping for symptomatic varicose veins include painful thigh haematomas, which a new bipolar coagulating electric vein stripper (EVS) may reduce. METHODS: In a randomized, single-blind trial at three vascular centres, 99 patients were assigned to EVS and 101 to conventional stripping. The primary outcome was postoperative pain at rest and following physical exercise (climbing stairs). Haematomas were quantified by ultrasonography. Further endpoints were duration of postoperative compression, sick leave and quality of life (measured by the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ) and Short Form 36 (SF-36). RESULTS: Mean resting visual analogue scale for pain 24 h after surgery was 1.6 in the EVS group and 3.3 in the conventional stripping group (mean difference 1.7, 95 per cent confidence interval (c.i.) 1.4 to 1.9, P < 0.001). Mean ratings following exercise were 3.3 and 5.5 (mean difference 2.3, 95 per cent c.i. 2.0 to 2.6, P < 0.001) respectively. No patient in the EVS group had a measurable thigh haematoma, compared with 74 patients after conventional stripping (P < 0.001). The EVS significantly decreased the length of compression therapy and sick leave, and produced superior CIVIQ and SF-36 ratings. CONCLUSION: The EVS was safe and effective in avoiding painful haematomas following varicose vein surgery.

Surgical anatomy of the upper vertebral artery.

A surgical approach to the upper vertebral artery between C1 and C2 is described. Following dissection of the posterior border of the sternocleidomastoid and the anterior border of the splenius capitis the two muscles are held apart and the levator scapulae is transected at its origin from C1. The cranial end of the vertebral artery can now be connected with the common carotid or external carotid arteries.

[Experiences with intraoperative radiotherapy in inoperable pancreatic carcinoma]. / Erfahrungen mit der intraoperativen Radiotherapie beim inoperablen Pankreaskarzinom.

From January 1983 to April 1985 six patients suffering from unresectable pancreatic cancer underwent intraoperative irradiation therapy (IORT) followed by external radiotherapy. All tumors showed T4-stages except one tumor staged as T2N2. From the onset of symptoms to IORT the median time of hospitalization was 26.5 days. After surgery, treatment (external irradiation included) required a median hospitalization period of 43.5 days. Follow up, complications and the terminal hospital stay of the patients who died lead to another median hospitalization period of 30 days. Altogether hospitalization required an average of 90 days which represented 38.5% of the mean life-expectancy of 234 (SE = 57.4) days. 47.3% of the survival time did not show discomfort, in 31.6% there were reversible and in 21.1% irreversible complaints. Therefore, patients suffering from unresectable pancreatic cancer had to pay a heavy price for prolonging life expectancy by IORT and following percutaneous irradiation.

[Value of preoperative study methods in midrectal cancer. Microscopy versus macroscopy]. / Der Aussagewert präoperativer Untersuchungsmethoden beim Midrectum-Karzinom. Mikroskopie versus Makroskopie.

A retrospective analysis was made of data pre-operatively obtained from 110 patients who had undergone curative, palliative or exploratory surgery for midrectal carcinoma, between 1972 and 1983. Macroscopic tumour findings obtained from rectoscopy, in that context, were found to provide a clue to loco-regional spread (p = between 0.0001 and 0.0162). On the other hand, no information as to loco-regional spread proved to be recordable by histological typing of mid-rectum carcinomas, but for tubulo-papillary carcinoma (p = 0.0153). Grading could provide a clue as to possible lymph node involvement (p = 0.0205). A clearly differentiated prognosis could be usually made by macroscopic tumour appearance (p = 0.0001 to 0.0657). Histological typing was of no value for prognostication (p larger than 0.337), while the value of grading proved to be extremely low (p = 0.1819). Incidence of locally delimited recurrences could not be safely forecast at all, neither by macroscopic assessment (p larger than 0.119) nor by microscopy (p larger than 0.161). The information obtainable from macroscopic findings on both present phase and prognosis was generally greater than that recorded from histological processing of biopsy material (p = 0.0470) and should, therefore, by no means be neglected in pre-operative reconnaissance.

[Surgical anatomy of the internal carotid artery]. / Chirurgische Anatomie der Arteria carotis interna.

Starting from the carotid trigone, a surgical approach to the parapharyngeal part of the internal carotid artery is described. The retrostyloidal part of the lateropharyngeal space is opened up from laterocaudal after resecting the posterior belly of the digastric muscle and the styloidal muscles. Vulneration of the cranial nerves (VII, IX, X) has to be prevented.

[Space-occupying rectal cancer. Concept of the operation and early results in 15 patients]. / Das organüberschreitende Rectumcarcinom. Operationskonzept und Frühergebnisse bei 15 Patienten.

In 1982 and 1983, 15 patients (14 women, 1 man) suffering from large tumors of the rectum and of the rectosigmoidal junction totally filling the small pelvis, underwent operation. Depending on the extent of the tumor, 8 patients underwent a hysterectomy (53.3%), 7 a resection of the small intestine (46.6%), five a resection of part of the bladder (33.3%), three a resection of the vagina (20%), two an extirpation of the bladder (13.3%), and one each a nephrectomy, a resection of the ureter, a resection of the pelvic vein, and a resection of the abdominal wall. In two cases an ileal conduit was applied, in three an ureter splint. Hospital lethality rate was 20% (3 patients) with an average hospital stay of 53 days. After an average observation period of 18.3 months, 8 patients were still alive. The probability of surviving 12 months was 63%. - The surgical concept applied is presented.

[Comparison between the biochemical and histochemical determination of hormone receptors in breast carcinomas]. / Vergleich zwischen biochemischer und histochemischer Hormonrezeptorenbestimmung bei Mammakarzinomen.

The hormonal sensitivity of breast cancer on one hand indicates the prognosis and on the other determines the therapeutical procedure when metastases appear. It also seems to be important in the choice of adjuvant therapy. Therefore the analysis of hormonal receptors in our opinion is at least as important as the histological typification of the carcinoma. As there was a trend recently showing up the so-called histochemical steroid-receptor-assay which is much less complicated than the biochemical (quantitative) method, we investigated the value of this fluorescence-microscopical assay by means of parallel determinations. In the results of 157 patients of the last three years we found differences in 45% of all oestrogen-receptor-determinations and in 50% of 29 progesterone-receptor-determinations. This indicates that the histochemical assay is most probably not representative. There is serious doubt about the possibility to document the hormone receptor by this method at all. Therefore it does not seem advisable at the moment to waive the biochemical receptor determination.

[Prognostically unfavorable factors in esophagus cancer. II. Value of diagnostic significance]. / Prognostisch ungünstige Faktoren beim Oesophaguscarcinom. II. Der Wert diagnostischer Aussagen.

The analysis of data of 121 patients with esophageal carcinoma treated at the Department of Surgery, Landeskrankenhaus Klagenfurt, between 1969 and 1982 revealed that neither histological type nor tumor grading had any significant influence on survival time (p = greater than 0,158). However, tumor localization and length influenced the chance of survival; the more proximal the tumor the poorer the chance to survive more than one year (p = 0,0008); patients with tumors less than 6 cm in length had a better chance of survival (p = 0,031). Cures were achieved only after resection for stage I. Resections for stage II and III did not show any difference in prognosis (p = 0,879). Although no cures could be achieved by surgery, the 1-year survival chance was increased threefold (p = 0,041). In the absence of contraindications, resection should be carried out even when mediastinal lymphnodes are involved by tumor.

[Prognostically unfavorable factors in esophagus cancer. III. Operative therapy of esophagus cancer--effect of preoperative measures on prognosis in curative resection]. / Prognostisch ungünstige Faktoren beim Oesophaguscarcinom. III. Operative Therapie des Oesophaguscarcinoms--Einfluss präoperativer Massnahmen auf die Prognose bei kurativer Resektion.

Between 1969 and 1982, 121 patients were treated for esophageal carcinoma at the Department of Surgery, Landeskrankenhaus Klagenfurt. 38 patients (31.4%) had palliative surgery, 23 patients underwent a curative resection. Hospital mortality after resection was 39%, overall adjusted survival rate at 7 years was 11.2%. An analysis of data shows that a higher resection rate (p = 0.0045) will not improve long-term results. A preoperative parenteral nutrition seems to decrease postoperative mortality (p = 0.069). Preoperative radiotherapy does not improve long-term results (p = 0.788).

[Carotid artery surgery with local anesthesia. Experiences with a series of 181 operations]. / Karotischirurgie in Lokalanästhesie. Erfahrungen mit einer Serie von 181 Operationen.

Between 1982 and 1984, 181 operations of the carotid artery were performed--180 of these in primary awake patients--36 in stage I (19.9%), 72 in stage II (39.8%), 72 in stage IV (39.8%) and only one in stage III (0.6%). 144 patients (79.6%) tolerated clamping of the carotid artery very well. In 37 patients (20.4%) clamping was not tolerated (two patients, in whom the control of cerebral function was not possible, were submitted to the latter group). In three of 181 patients clamping-intolerance started at the end of operation, more than 30 minutes after clamping. Clamping intolerance in these cases was found to be confined to pulmonary and cardiac factors, no shunt was used, but operation was brought to an end as quickly as possible. Complications were present in 15 patients (8.3%), three of them resulting in death (hospital mortality rate 1.7%), 2 of them in permanent loss of function (morbidity rate 1.1%). Only in 2 patients (asystolism with consecutive successful reanimation in one case, and thoracotomy due to enlargement of surgical procedure in the other case) a primary general anaesthesia would have facilitated surgery. Surgery of the carotid artery under local anaesthesia is considered to be a guarantee for a secure intraoperative surveillance followed by a low postoperative complication rate. In a few cases more difficult surgical procedures have to be accepted in account of that.

[Operative therapy of esophageal cancer. Palliative surgical methods and results]. / Operative Therapie des Osophaguskarzinoms. Palliative Operationsmethoden und ihr Ergebnis.

Between 1969 and 1982, 38 out of 121 patients with oesophageal carcinoma underwent palliative surgery. Operatively in 22 patients a Celestin- or Häring-tube was inserted, gastrostomy was performed 10 times, palliative resection two times. Four times the obstruction was bypassed. 17 patient achieved additional radiation therapy. An analysis of data showed, that all operative palliative procedures had nearly the same bad prognosis (p greater than 0.265). A longer survival could be achieved by additional radiation therapy (p = 0.044). Postoperative mortality rate was higher in patients with additional diseases (p = 0.018). Lethal aspiration-pneumonitis was a common (30%) and typical (p = 0.031) complication, when gastrostomy was performed. Because oft the high mortality rate of the first and because of the missing crude palliation of the second operation, palliative resection and gastrostomy were considered to be not indicated in most cases.

[Prognosticly unfavorable factors in esophageal carcinoma. I. The importance of anamnestic data]. / Prognostisch ungünstige Faktoren beim Oesophaguscarcinom. I. Die Bedeutung anamnestischer Angaben.

The analysis of data of 121 patients with esophageal carcinoma treated at the Department of Surgery, Landeskrankenhaus Klagenfurt, between 1969 and 1982 revealed that neither sex nor age, environment, delay of treatment or additional disease had any significant influence on survival time. Weight loss, however, significantly shortened survival time (p = 0.0002). In addition, weight loss suggests an advanced tumor stage (p = 0.0279). After curative resection, rate of survival was significantly lower in patients with weight loss (p = 0.042). In the presence of weight loss and additional risk factors resection is probably not indicated.

[Chronic circulatory disorders]. / Die chronischen Durchblutungsstörungen.

For all parts of the body the clinical picture of obstructive vascular disease is decisive. Invasive diagnostic techniques are only advisable if surgical treatment is considered. Angiography reveals only the site of the obstruction and the run-off-situation in operable cases. In cerebral and in coronary surgery operations can only be recommended if the tissue behind the obstruction is still alive; whether necrotic brain nor dead myocardium can be reanimated by revascularisation. Cerebral and coronary vascular surgery have therefore more prophylactic intentions. In peripheral arterial obstructions an operation should save the leg but not treat intermittent claudication.

[Combined surgical and radiological therapy of pancreatic cancer--case report--future aspects]. / Chirurgisch-radiologisch kombiniertes Therapieverfahren beim Pankreaskarzinom--Falldemonstration--Zukunftsaspekte.

On the basis of the literature [1, 3-5], combined surgical management and intraoperative radiotherapy of carcinoma of the pancreas is demonstrated and illustrated by a case report and further aspects are discussed.

[About the so-called ischemic-ulcerative innerwall lesion of the bowels proximal to intestinal stenoses (author's transl)]. / Uber die sogenannte ischämisch-ulzeröse Darminnenwandläsion proximal stenosireender Darmprozesse.

The ischemic ulceration resp. the ischemic necrosis of the intestine's internal wall located proximal to an obstruction is a rare complication. At present this diagnosis is established by the radiologist alone. The knowledge of this disease--which is at the time being abscure in its origin--is of great importance to the surgeon, who has to try to resect both, the obstructes and the ischemic-ulcerative regions, in order to avoid insufficiency of the anastomosis postoperatively. The oral border of the alteration can be determined by a frozen section during the operation. In this connection the fatal complications of total necrosis of the large and small intestines resp. is demonstrated for the first time.

[Causes of death in lightning strokes (author's transl)]. / Zur Frage der Todesursache beim Blitzunfall

On the basis of the literature and of their own investigations, including animal experimentation, the authors attempt to show the possible causes of death following lightning strokes. Animal experiments give evidence of the important role of cardiac arrhythmias, in particular of asystolia and ventricular fibrillation. Cardiac arrest, respiratory standstill, burns, fractures, mechanical lesions of internal organs and hemorrhages are stated as causes of death. Moreover, autopsy fails to reveal recognizable changes in some of the victims.