[Geriatric surgery or geriatrisation of surgical medicine]. / Gerontochirurgie oder die Geriatrisierung der operativen Medizin.

In the western industrial nations the proportion of old people (according to WHO definition people over 75 years) has been rising for many years and with it the amount of surgical treatment on this group of the population. High age does not automatically mean a risk too high for surgical treatment. Very often the reasons for this age group being high-risk patients are hospital admission in an advanced stage of illness or complications due to the illness. Old people are biologically younger than they were years ago. Often they express their perfectly understandable wish for suitable treatment. New treatments and strategies in surgery such as minimal-invasive surgery, endoluminal techniques for heart and vascular surgery, fast-track-concepts, anaesthetising techniques like spinal anaesthesia or the use of better controllable narcotics, improves alleviation of pain, quick mobilisation and early oral nutrition contribute to a minimisation of the risk. Age-related multimorbidity defines the risks of major operations and requires an individual weighing up of benefit and risk. The decision for or against an operation must take the elderly patient's wishes into account. The most important aspect is not only to help the people survive but to enable them to participate in life. In this paper we try to give an overview of geriatric surgery with all its aspects relevant to insurance.

[From guilt and shame to professional handling of mistakes--risk management in surgical medicine]. / Von Schuld und Scham zu einem professionellen Umgang mit Fehlern--Risikomanagement in der operativen Medizin.

Medical advances in diagnosis and therapy, especially in medical technology, lead to differenciated and more complex strategies in therapy with higher risks. Patients show higher expectations concerning the results of a therapy and claim more often that a mistake in treatment has been made. This makes patients turn to arbitration boards more often. They may also want to bring civil action against physicians and hospitals, claiming for compensation and damages. Personal liability insurances have to pay more for damages. Medical insurances have more recourse demands due to mistake in treatment. Hospital and especially operative medicine do have high chances of risks and mistakes. The implementation of a modern risk management system in the hospitals is becoming more and more important, for patients as well as for the surgical departments. A structured reporting system of critical incidents can produce indicators of potential sources of mistakes, which appears to be a successful approach to reduce or avoid typical risks and mistakes in medical treatment. Risk management in medical treatment must be more than just a trendy word, because its roots are in the medical principles of "primum nihil nocere". It is a challenge to today's and tomorrow's medicine. This article is a general overview of current strategies for avoiding mistakes: It is meant to be the basis of a new culture of mistake avoidance as a part of a future quality competition.

[Quality assurance by routine data (QAR)--a new dimension in quality management of inpatient treatment?]. / Qualitätssicherung mit Routinedaten (QSR)--eine neue Dimension im Qualitätsmanagement der stationären Behandlung?

Patients, admitting doctors and payers want to have more and more valid information about the medical results in hospitals really are. The quality of medical care in hospitals is demonstrated in the quality reports through structure and process data, data of volume about the most common main diagnoses and procedures and, in the current version, also through data of external quality assurance. For patients and payers, this means that it may be difficult to obtain sufficient information on relevant quality criteria for different therapies in hospital departments. It may also mean that it is difficult to choose between hospitals. The project "Quality assurance of inpatient treatment by routine data" (QAR) is a new and extended attempt in quality management. By changing the reimbursement procedures of hospitals to DRG, one receives data from which one can easily deduce marks of quality. For special treatment the QAR marks of quality provide patients, insurance companies and the internal quality management of hospitals with information on the quality of the hospitals and their departments. In this paper, the opportunities and prospects of quality assurance by using routine date will be discussed.

[Surgery on the fast track--"fast track" concepts in abdominal-/pediatric surgery and urology]. / Operative Medizin auf der Schnell- oder Uberholspur--"Fast Track" Konzepte in Chirurgie, Kinderchirurgie und Urologie.

In surgical medicine there are traditions, myths, rites and dogmas which define concepts of treatment and strategies. Upheld and passed on without being examined or confirmed in further studies, these concepts and strategies include preoperative intestinal lavage and fasting, postoperative long-term drainage, tubes und catheters, long-term relaxation of the intestine after abdominal surgery or immobilisation for some days. New techniques and procedures in surgery and anaesthesia, including postoperative pain management like laparoscopic surgery and partial anaesthesia, reduce the need for surgery and minimize morbidity of treatment. For more than ten years now, the Copenhagen abdominal surgeon Henrik Kehlet and his team have systematically dealt with the question of how to reduce perioperative stress and improve postoperative conditions of recovery. The resulting concepts of an "enhanced recovery after surgery" (ERAS) seek to overcome handed-down myths und fix new clinical pathways. In current prospective studies of elective surgery, the clinical use of these fast track concepts have been confirmed in colon surgery, pediatric surgery and urology. Here, examples of some of these studies are discussed together with problems like general complications and length of stay, while aspects of insurance are also taken into consideration.

[Predictive genetic testing for hereditary breast cancer and hereditary nonpolyposis colorectal cancer]. / Prädiktive Gentests bei familiärem Brust- und nicht-polypösem Darmkrebs. Wissenschaftliche Grundlagen--klinische Studien--versicherungsmedizinische Aspekte.

Genetic tests are no longer used exclusively for diagnostic purposes, but they serve in increasing numbers to assess the predisposition for illnesses. Predictive genetic testing of this kind includes screening for genetic predispositions towards tumours. Of special significance are familial breast and ovarian cancer caused by BRCA1 - and BRCA2- mutations and hereditary nonpolyposis colorectal cancer (HNPCC). The observation of such conditions constitutes a considerable burden for the individuals concerned as well as their families. So far it has not been sufficiently established to what extent methods of prevention and early diagnosis can offer effective protection against the risk of tumours. While prophylactic organ resections lower the morbidity and mortality associated with cancer, they are also responsible for a loss of physical and emotional well-being. Therefore, an awareness of hereditary predispositions towards tumours causes considerable need for competent medical advice and clinical research. Interdisciplinary projects can offer the suitable organisational base for these tasks. Doctors, universities and health insurances are faced with the challenge of developing and financing corresponding structures of medical care and research.

[Interstitial brachytherapy--a minimal invasive urological option for treatment of prostate cancer of increasing importance]. / Interstitielle Brachytherapie--eine minimal invasive urologische Therapieoption des Prostatakarzinoms mit zunehmender Bedeutung.

As an alternative to a radical prostatectomy with complications reducing the quality of life because of incontinence of urine and erectile dysfunction, the insertion of radioactive sources into the prostate was established in the USA and evaluated by accompanying studies at the beginning of the eighties. The patient has the advantage of minimal-invasive character, the possibility of outpatient treatment and the lower operative morbidity as well as reduced complications. In the locally limited "low-risk" stage (pT1a - pT2c), the American Society for Urology judges it equieffective as a curative treatment as regards the survival period. Although there are long-term studies with a follow-up of 13 years, in Germany we are not able to give our opinion finally, but it can be assumed to be as equally good. Considering the demographic development, one has to expect an increase in this cancer, which today already has the highest cancer rate in men in Germany. The improved diagnosis will lead to an increase in treatments and younger men will be examined. As a result there will be more curable cases and an improvement or even prolongation of the survival period. The trend seen in the USA indicates a rise in this treatment in Germany as well. After a terminological definition of the expression and a presentation of the brachytherapy-technique, the range of actual therapeutical options of prostate cancer and the variations of brachytherapy are shown and compared as far as their efficiency is concerned. Uncertainties in the evaluation of medical necessity are discussed but also contradictions and diversities in the opinions on the mode of accounting.

Outcome analysis of pyeloplasty in infants.

The study examined the outcome of pyeloplasties done for decompensated ureteropelvic junction (UPJ) obstruction in infancy over a 13-year period. In a retrospective study, 186 children who underwent pyeloplasty in infancy were analysed with particular emphasis on the pre- and postoperative findings of 123I hippuran scintigraphy/diuretic renograms. The pre- and postoperative management is outlined in detail. The 186 patients underwent a total of 203 pyeloplasties during the period from January 1983 to 31 December 1996. Three children died; one required a nephrectomy. The postoperative scintigrapic results of 156 children (85%) done about 12 months after surgery were available for evaluation: 101 (64%) showed stable renal function and 43 (27%) revealed more than 5% improvement of renal function. In 12 cases (7%) renal function deteriorated after pyeloplasty by more than 5% compared to the preoperative scintigram. It is concluded that pyeloplasty in infants is a low-risk procedure. The encouraging results of this series support early correction of UPJ obstruction.

Quality of life more than 20 years after repair of esophageal atresia.

PURPOSE: To examine the quality of life after repair of esophageal atresia, follow-up studies were performed in 58 of 71 surviving patients (81.7%). METHODS: Fifty patients with primary anastomosis and all eight surviving patients with colon interposition were seen. The mean age was 25.3 years (range, 20 to 31). Symptoms were evaluated by a standardized interview. Quality of life assessment was performed using a visual analogue scale (0 to 100 points), the Spitzer Index (5 dimensions, 10 points), and the Gastrointestinal Quality of Life Index (GIQLI, 5 dimensions, 128 points). RESULTS: After primary anastomosis the estimated meal capacity was unrestricted in 46 patients (92%), but numerous symptoms such as recidivating cough (60%), hold up (48%), and short breath (30%) were reported. All symptoms except cough were seen more frequently in patients with colon interposition, and all of these patients suffered from periods of short breath. Quality of life scores were higher in patients with primary anastomosis compared with colon interposition. The difference in the visual analogue scale score did not reach statistical significance, but the mean Spitzer Index was 9.7 compared with 8.8 after colon interposition (P < .05). The GIQLI after primary anastomosis was similar to that in healthy controls and was significantly lower in patients with colon interposition. This was because of specific symptoms, which scored 49.3 after colon interposition compared with 61.7 after primary anastomosis (P < .05) and to 54.8 (SD 5) in healthy controls (P < .05). Physical and social functions, emotions, and inconvenience of a medical treatment scored similar in patients with primary anastomosis, colon interposition, and healthy volunteers. CONCLUSIONS: The long-term quality of life after primary anastomosis was excellent. Patients with colon interposition suffer more frequently from various gastrointestinal and respiratory symptoms, but they lead an otherwise normal life.

Long-term functional results and quality of life after colon interposition for long-gap oesophageal atresia.

Out of a series of 146 patients with oesophageal atresia 9 (6.2%) underwent colon interposition from 1963 to 1971. All eight surviving patients were seen at follow-up after a mean of 22 years. Three patients were free of specific symptoms according to the criteria of DeMeester, two had moderate and three severe distress. The mean time for consuming a standardized test meal was 15 minutes, compared to 8 minutes in healthy controls. Patients required 1-9 minutes to transport liquid barium through the transplant, compared to < 10 seconds in control subjects. Histological evaluation revealed a normal architecture of the colonic and ileal epithelium in three patients who underwent endoscopy. In none of these patients were contractions in the colon graft related to the act of swallowing recorded on manometry. Unimpaired quality of life was indicated by the Spitzer index which scored a mean of nine out of ten points. However, on a 100point visual analogue scale patients scored their global quality of life 66 and the mean Gastrointestinal Quality of Life Index was 92.2, compared to 107.6 in healthy control subjects (p < 0.05). This impairment was exclusively due to specific symptoms which scored 49.3 in patients and 59 in healthy individuals (p < 0.05). Physical and social functions, emotions, and inconvenience of a medical treatment were similar to control subjects. We conclude that colon interposition for long-gap oesophageal atresia achieves acceptable long-term functional results. However, specific symptoms lead to a considerable impairment in quality of life.

[Tracheal instability in tracheo-esophageal abnormalities]. / Trachealinstabilität bei tracheo-ösophagealen Fehlbildungen.

The clinical pattern of signs and symptoms of respiratory complications due to flaccid trachea has been analysed in 83 children treated in our hospital between 1983 and 1988 for tracheo-oesophageal malformations. These signs and symptoms are classified according to endoscopic findings, and are thus arranged according to various degrees of severity. Of the surviving children who were followed up and who were suffering from oesophageal atresia Vogt III B, only 5 of 57 were without a pointer towards flaccid trachea, whereas in oesophageal atresia Vogt II there were two of three. The two children with an isolated tracheo-oesophageal fistula showed abnormal findings both clinically and via endoscopy. 16 of the 20 children with very severely pronounced flaccid trachea--defined by the occurrence of life-threating apnoeas and an endoscopically identifiable tracheal collapse of more than two-thirds of the lumen--were subjected to surgery via aortosternopexy. A marked and identifiable improvement was obtained in 15 cases. Complications caused by surgery consisted of temporary phrenicus lesions in two cases.

[Cecil-Duplay/Cecil-Leveuf urethral reconstruction in severe hypospadias]. / Harnröhrenaufbau bei schwergradigen Hypospadien nach der Methode von Cecil-Duplay/Cecil-Leveuf.

A total of 199 boys with severe hypospadias were subjected to surgery during 1981 to 1984 at the Department of Surgery of the Red Cross Paediatric Hospital in Siegen and from 1971 to 1984 at the Department of Surgery of the Municipal Paediatric Hospital in Cologne. Plastic reconstruction of the urethra was performed according to a multiple-stage technique after Cecil-Duplay/Cecil-Leveuf. It is evident that good results can be obtained in such severe forms of hypospadias by means of differentiated multistep surgery. A fistula rate of 14% is an essential improvement over the results previously obtained by the urethral reconstruction method after Denis-Browne.

[Pediatric psychotherapy within the scope of dermatology]. / Kinderpsychotherapie im Rahmen der Dermatologie

The possibilities of psychotherapy of children with psychosomatic skin diseases on an outpatient basis are reported. Twenty children in their pre-school and school years were treated over a period of one to two years using conversational therapy and the Sceno test (from G. v. Staabs). The results underline the necessity of identification and working up of conflicts in order to prevent recurrences or shifting of the disease.