[The infammatory pseudotumour -- an unusual liver tumour]. / Der inflammatorische Pseudotumor -- eine schwierige Differenzialdiagnose.

We report on a 49-year-old male patient who was suspected to have a malignant liver tumour with enlarged perihepatic lymph nodes because of CT and ultrasound scanning. To verify the diagnosis and procure a histological specimen, the patient underwent laparotomy. Histologically, an inflammatory pseudotumour could be confirmed. This is a rare disease which can present with fever, abdominal pain, vomiting and weight loss indicating malignancy or abscess. The definite diagnosis is often only verified by surgery.

[Longitudinal study on quality of life after gastrectomy for gastric cancer and starting points for intensified care]. / Longitudinaluntersuchung zur Befindlichkeit von Magenkarzinompatienten mit Gastrektomie: Ansatzpunkte zur Intensivierung der Betreuung?

UNLABELLED: This prospective longitudinal study on gastric carcinoma patients with gastrectomy was designed to answer the question about changes in several determinants of the quality of life (QL) at various times before and after surgery and to obtain evidence for specific approaches of therapeutic intervention. METHODS AND PATIENTS: 36 patients were given a questionnaire structured according to Eypasch et al. (self- assessment) before surgery, at discharge from the hospital, and after 3 and 6 months. The dual structure of the questions makes it possible to determine whether a single item is present at all (prevalence) and to what extent it impairs the quality of life (no impairment/some/moderate/strong impairment--corresponding to 0-3). The data were evaluated per domain of QL as well as item-related. RESULTS: Postoperatively, 14 patients had to be excluded from the study because of non-radical surgery, complications, recurrences, etc. After 6 months the items of all QL-determinants showed the lowest prevalence with the exception, however, of the somatic determinants, the items of which showed a prevalence of 27 % preoperatively, 64 % at discharge from the hospital, 58 % after 3 months, and 46 % after 6 months. The average degree of QL-impairment increased continuously from 1.17 preoperatively to 1.61 after 6 months. Preoperatively the psychic domain was predominantly impaired, postoperatively the somatic domain. CONCLUSION: Analysis of the subjective quality of life can reveal care deficits. Gastrectomy-associated symptoms seem to influence the quality of life considerably in the first 6 months after surgery. More attention has to be paid to the sequelae of surgery. The high pre- and postoperative frequency of psychic impairment makes it desirable to provide special psychooncological offers of care.

[Surgery and long-term follow-up of hepatic echinococcosis outside endemic regions]. / Die chirurgische Behandlung der Leberechinokokkose ausserhalb von Endemiegebieten und ihre Spätergebnisse.

UNLABELLED: The aim of the study was to characterize the therapeutic pathways in patients with echinococcal hydatids in an institution outside the endemic areas but with a high frequency of oncological hepatic surgery. PATIENTS AND METHODS: 44 patients with echinococcosis from 1987-1997 were reviewed. To evaluate the long-term results, clinical examination, chest x-ray, serology and liver ultrasound were performed. According to the study protocol 39 patients were evaluable. 89.7 % of the patients suffered from a primary disease, whereas 7.7 had a local recurrence and another 2.5 of patients showed a second site of manifestation after former operation. E. cysticus occurred in 82.5 %, E. alveolaris in 17.5 %. RESULTS: In 66.7 % of all cases a resecting procedure (pericystectomy, atypic resection, regular and extended hemihepatectomy) was performed. One patient underwent an orthotopic liver transplantation and in 10 % the surgical procedure included only an open drainage of the cysts. A simple cystectomy was performed in 23 %. One patient died from multiple organ failure as a consequence of local bleeding complications. The overall complication rate was 38.5 %, including the postoperative death and 7.7 % reoperations. The complication rate following pericystectomy was much higher than after simple cystectomy. At the time of follow-up (median 66 months) no patient showed a recurrent disease. CONCLUSION: Compared to reports from endemic regions the rate of resective procedures was much higher. The therapeutic strategy lead to excellent long-term results. Simple cystectomy should be preferred as pericystectomy showed a higher morbidity.

[Primary lymphoma of the stomach. An interdisciplinary challenge]. / Das primäre Magenlymphom. Eine interdisziplinäre Herausforderung.

Non-Hodgkin-lymphomas of the stomach are mostly of mucosal origin. The lymphoma derives from the acquired lymphatic tissue due to an infection with helicobacter pylori. Beside the grade of malignancy (low/high grade) the extent of the disease is the basis for therapy. It can be limited to the stomach and the lymph node compartments I and II or disseminated to both sides of the diaphragm. Therefore, pre-therapeutic diagnostic procedures have to cover all these localisations including the bone marrow. In case of a tumor limited to the stomach and of low grade malignancy an eradication therapy is the treatment of choice. More advanced tumors, but only involving stomach and lymph node compartments I and II, should be treated by subtotal or total gastrectomy plus lymphadenectomy according to the gastric cancer standards (D2). After R0-resections no adjuvant radio- or chemotherapy is necessary. R1/2 resections require radio- and/or chemotherapy which are the treatment of choice in a priori advanced stages and/or high grade lymphomas. The total 5 year survival rate is about 60-70%. Gastric lymphomas are an outstanding example of interdisciplinary disease management.

A prospective, randomised comparison of single- vs. multiple-dose antibiotic prophylaxis in penetrating trauma.

UNLABELLED: This study was designed to compare the clinical efficacy of a single dose of ceftriaxone with cefoxitin given 3 times a day for 3 days. METHODS: Patients had to have a penetrating injury to only one part of the body, reach the hospital within 2 h and be operated on within 16 h after the trauma. Patients were excluded if it appeared likely that they would require mechanical ventilation for more than 24 h. The same applies to open or grade II/III craniocerebral trauma. The end point was the occurrence of infections within 10 days. The costs of antibiotic treatment were also calculated. RESULTS: 96% of the ceftriaxone patients (n = 97) and 95% of the cefoxitin group (n = 98) remained infection-free. In neither treatment group was deep infection, abscess, phlegmon or sepsis seen. No additional surgery or intensive care due to infection was required. At $41.83 vs. $172.16, the average total cost of delivering antibiotic treatment was significantly lower in the ceftriaxone group (p < 0.001). CONCLUSION: Prophylaxis in penetrating trauma with a single dose of ceftriaxone is safe and has considerable practical and economic advantages.

[Prospective study of spontaneous medical utilization of antibiotics on the normal surgical ward--rationale and economic aspects]. / Prospektive Untersuchung des spontanen ärztlichen Umganges mit Antibiotika auf der chirurgischen Normalstation--rationale und ökonomische Aspekte.

For 8 months, the spontaneous behaviour of the surgeons concerning the use of antibiotics (AB) was studied. The study focused on the indication itself, the chosen substance, the method of drug administration, and the treatment duration. It was evaluated whether the use of AB was rational and what the economic consequences of inadequate use of AB are. Of a total of 1168 pts 21.1% received AB, 88% of them i.v. The intention of AB treatment was therapy in 56.3%, and prophylaxis in 43.7% beside the regular perioperative single shot regimen. More than every second AB prescription was irrational. More rational behaviour (indication, therapy once daily, sequential therapy, no postoperative prophylaxis, less i.v. AB) by the prescribing surgeons would have led to a saving of more than 60% of the total costs of DM 215,000 without any loss of antiinfective efficacy. Moreover, a more rational use of AB would mean prevention of infectious hospitalism and would save a lot of staff time.

[Reliability of intraoperative macroscopic evaluation of lymph node metastasis and effectiveness of lymphadenectomy in stomach carcinoma]. / Zuverlässigkeit der intraoperativ-makroskopischen Evaluation der Lymphknotenmetastasierung und der Effektivität der Lymphadenektomie beim Magenkarzinom.

The aim of this prospectively performed study was to evaluate the accuracy of macroscopic intraoperative lymph node staging by the operating surgeon. 65 patients with histologically proven gastric carcinoma and without previous abdominal operations were included. Carcinomas of the cardia and malignant lymphomas were excluded. Due to the study protocol the surgeon evaluated the lymph node status before beginning the resection. For exact exploration of the compartments II and III the omental bursa had to be opened through the gastrocolic ligament and the lesser omentum had to be cut off from the liver. The resection itself consisted of en bloc total gastrectomy, D2 lymphadenectomy and removal of the lesser and the greater omentum. The operation was completed by the removal of the spleen if necessary. The surgeon thought 85.2% of the N0-patients to be N > 0 and overlooked lymphatic occupation of compartment I in 8.8%, of compartment II in 14.3% and of compartment III in 50%. The histological examination of the resection specimen showed that the surgeon's impression concerning the extent of the lymph node occupation of the complete situs was correct in only 16.9%. The allocation of the macroscopically determined lymph node status to the TNM scheme was correct in 33.8%. It should be concluded from the study that intraoperative macroscopic staging procedures as a basis for therapeutic decisions are to be avoided strictly.

[Acute disease of the pelvis: differentiation between gynecologic and surgical cause]. / Akute Erkrankung im Unterbauch: Differenzierung zwischen gynäkologischer und chirurgischer Ursache.

An acute disorder of the lower abdomen requires early clarification, whether or not it is of gynaecological or surgical origin. With non-gynaecological affections, beside diverticulitis, Crohn's disease, perforations, bowel obstructions, yersiniosis, vascular diseases (acute embolism, thrombosis or dissection), urological disorders or hernias, acute appendicitis has firstly to be considered. The systematic use of the different diagnostic instruments is discussed.

[Differentiation between a gynecologic and surgical origin in pathological pelvic resistance]. / Differenzierung zwischen gynäkologischer und chirurgischer Genese bei pathologischen Unterbauchresistenzen.

Besides typical gynaecological tumours colorectal neoplasms, Crohn's disease, dystopic kidneys, mesenteric cysts, tumours of the small bowel, perityphlitic abscesses, retroperitoneal sarcomas, lymphomas of the ileocoecal region and, in aged patients, aneurysmatic lesions of the iliac arteries have to be considered as source of the symptoms. The systematic use of various diagnostic procedures is discussed.

[Spectrum and effectiveness of emergency care by surgeons acting as rescue unit surgeons in a large city]. / Spektrum und Effektivität der Notfallversorgung durch Chirurgen als Notarztwagenärzte in der Grossstadt.

From 1.1. 1985 to 31. 12. 1990 n = 10,569 emergency cases were prospectively documented. The aim of the study was to evaluate, whether surgeons on a mobile emergency care and rescue unit were able to treat surgical and non-surgical emergencies sufficiently during the prehospital period. 16.8% of the patients were trauma patients while 47% suffered from medical disorders, e.g. myocardial infarction (12%), other cardiocirculatory disorders (7%) and acute opiate and multidrug poisoning (16%). Additionally, other problems out of the broad spectrum of emergency medicine such as disorders from pediatrics, neurology/neurosurgery, gynecology, toxicology, pulmonology, endocrinology etc. had to be solved. More than 50% suffered from life-threatening emergencies, 5.6% required cardio-pulmonary resuscitation, 45% of which were primarily successful. In-field deaths where emergency treatment was not successful occurred in 3.2%. The mortality rate during transport to the next available hospital was 0.1%. It can be concluded from the study that well trained surgeons are very capable to perform high efficient in-field emergency treatment for various disorders.

[Soft tissue sarcoma in adulthood]. / Weichgewebssarkome im Erwachsenenalter.

Soft tissue sarcomas (STS) represent a heterogenous group of malignant tumors arising in mesenchymal tissue and in the autonomal and peripheral nervous systems. Only 1% of all malignancies in adults are STS. Most of them are localized at the extremities, but they also occur in the abdomen and the thorax as well as at the abdominal and chest wall. They are usually surrounded by a pseudocapsule which contains tumor cells and they can exhibit a discontinuous growth pattern. Macroscopically undetectable branches might grow along given anatomical structures. Thus the whole sarcoma-related anatomic compartment should be judged as tumor-contaminated. The high rate of local failure is often caused by insufficiently extended primary resections. Lymph node metastases are rare. The main prognostic factors are histological grading, tumor size and surgical radicality. Diagnosis of STS is often made at a rather late state of tumor progression often too late for curative therapy. Early histological diagnosis is thus of great importance. The operation aims at the removal of the whole tumor bearing anatomic compartment. Even wide excisions of the sarcoma surrounded by 3 cm of tumor free tissue will lead to at least 60% local recurrencies. Excisions along the pseudocapsule (enucleation) will most likely leave parts of the tumor behind. Insufficient surgical radicality cannot be compensated for by adjuvant therapies. The resection should be carried out without compromises.

[C-reactive protein in the recognition of postoperative infectious complications]. / C-reaktives Protein zur Erkennung postoperativer infektiöser Komplikationen.

The postoperative levels of C-reactive protein (CRP) of 384 patients were studied prospectively. Infectious complications occurred in 50 patients. 92% of these patients showed a postoperative CRP increase. The CRP increase could be detected in 67.5% prior to the clinical signs of the septic complication, whereas 32.5% of the patients showed the CRP increase at the time of clinical symptoms. In 8 patients with rising CRP levels no septic focus could be detected. CRP seems to be a helpful parameter in the postoperative management especially in the early diagnosis of septic complications whereas the erythrocyte sedimentation rate and white blood cell count, which were detected simultaneously to CRP, lack reliability concerning early detection of postoperative complications.

Total gastrectomy and oesophagojejunostomy--a prospective randomized trial of hand-sutured versus mechanically stapled anastomoses.

Eighty patients undergoing total gastrectomy for malignant disease were entered into a prospective randomized study, comparing anastomoses constructed mechanically (staples) with hand-sewn (single layer Maxon) anastomoses. The groups were matched with respect to clinical features, medical risk factors and were staged for tumour. Only one anastomotic leak was observed after operation and this was in the group of stapled anastomoses. One patient died in each group (owing to cardiac infarction and multiorgan failure). Operating time, morbidity and hospital stay showed no significant differences between groups. These results indicate that hand-sewn and mechanically stapled oesophagojejunostomy anastomoses allow the same high standard of performance.

[Endoscopic palliative tube and laser therapy in advanced cancer of the esophagus and cardia]. / Endoskopisch-palliative Tubus- und Laser-Therapie bei fortgeschrittenem Carcinom von Oesophagus und Kardia.

The treatment of patients with advanced carcinomas of esophagus and gastric cardia endoscopic palliation should restore the passage for normal oral uptake. We compared the results of two methods: endoscopic neodym-YAG-laser-therapy (group I: 24 patients) and endoscopic perturbation (group II: 56 patients). An initial recanalisation was achieved after 1-4 sessions in group I and after 1-2 sessions in group II. Recurrence of dysphagia caused in median 5 endoscopic interventions in group I and 2 in group II. We observed no complications in group I and 5 complications in group II. The median survival times were not significantly different. The results and the follow-up show no definite superiority of one of the two methods, the selection of treatment modality depends on the technical possibilities and the personal experience of the physicians.

[Postoperative ileus]. / Der postoperative Ileus.

When the causes and pathophysiology of the various types of ileus are known there are numerous possibilities of preventing them and logical therapeutic approaches, in particular in the case of functional ileus. Careful postoperative monitoring is obligatory! With regard to stimulation of bowel function, the principle of elimination of inhibition of motility by sympathicolysis has a place alongside the well-known nonspecific measures and direct stimulation. If conservative measures fail laparotomy must be repeated as soon as possible to procure relief. In the treatment of ileus associated with peritonitis the numerous new methods of flushing the abdomen, the involvement of anaerobes in some cases, and the possibilities offered by new antibiotics should be kept in mind. The involvement or predominance of mechanical ileus factors in the clinical picture must be recognized early and surgery performed without delay. Early consultation of an abdominal surgeon is recommended.

[Controlled study comparing mechanical and manual esophago-jejunostomy following gastrectomy]. / Kontrollierte Studie zum Vergleich maschineller und manueller Oesophago-Jejunostomie nach Gastrektomie.

40 patients with gastric malignancies were entered into a prospective randomised study of mechanical stapling (EEA) vs. manual single layer suturing of the esophago-jejunostomy following total gastrectomy. The groups were well matched with respect to clinical features, medical risk factors and tumor stage. Following manual technique, no anastomotic leak was observed. In the group with automatic mechanical suturing one technical failure and one insufficiency was seen. This difference, however, is not statistically significant. One patient died (cardiac infarction). The analysis of operating time, morbidity and hospital stay showed no significant differences. These results indicate that by use of a precise standardized conventional suture technique the same security performing an esophago-jejunostomy can be achieved as with mechanical staplers.

3H-estradiol and 3H-R5020 binding in cytosols of normal and neoplastic human ovarian tissue.

High-affinity cytoplasmic estrogen and progesterone receptors in normal and abnormal ovarian tissues were studied. Estradiol receptor was detectable in 65% and progesterone receptor in 36% of the malignant tumors; 39% of all malignant ovarian tissues were estradiol- as well as progesterone-receptor-positive. Tumors were said to be receptor-positive when the receptors bound greater than 5 fM steroid/mg cytosol protein. No correlations were found between receptor status and histopathological diagnosis. In normal ovarian tissues collected at various phases of the menstrual cycle no changes in [3H]-estradiol and [3H]-R5020 binding could be detected. Analysis of the receptor concentration for both steroid hormones with regard to the menopausal status demonstrated highest levels in postmenopausal women. No significant difference could be found when two groups of patients with advanced ovarian carcinoma associated with the cytosol estrogen receptor status were compared in terms of two different therapeutic schemes (cytosolic chemotherapy with and without tamoxifen).