Ondansetron is effective to treat spinal or epidural morphine-induced pruritus.

BACKGROUND: Spinally and epidurally administered morphine is frequently associated with pruritus. Isolated case reports indicate that ondansetron may be effective in this context. This study aims to investigate the effectiveness of ondansetron to treat this side effect. METHODS: In a prospective, randomized, double-blind, placebo-controlled study, 100 patients with pruritus (> 4 on a visual analog scale, on which 0 represents no pruritus and 10 represents worst pruritus imaginable) after spinal or epidural administration of morphine, received either 8 mg ondansetron intravenously (ondansetron group) in 100 ml NaCl 0.9% or vehicle (placebo group). A decrease of more than 4 points on the visual analog scale 60 min after treatment was considered a success. Changes in levels of pain and sedation, hemodynamic values, and other side effects were checked regularly. The presence or absence of pruritus was assessed for the last time 24 h later. RESULTS: The two groups were similar for demographic characteristics, the route of administration of morphine, and severity of pruritus at the beginning of the study. The ondansetron group showed a success rate of 70% versus 30% for the placebo group (P > 0.05). Among the successfully treated patients, three (9%) in the ondansetron group and six (40%) in the placebo group reported the recurrence of pruritus (P < 0.05). Among the successfully treated patients, none complained of residual pruritus 24 h later. No changes in pain or sedation levels were noted. Hemodynamic values remained stable, hemoglobin oxygen saturation did not decrease, and no other side effects were observed. CONCLUSION: The administration of 8 mg ondansetron intravenously is an effective treatment for spinally or epidurally administered morphine-induced pruritus. In this clinical condition the treatment is safe and well tolerated.

[Antiemetic effect of propofol]. / Antiemetische Wirkung von Propofol.

Propofol is known to possess direct antiemetic effects. Its use for induction and maintenance of anaesthesia has been shown to be associated with a lower incidence of postoperative nausea and vomiting (PONV) when compared to any other anaesthetic drug or technique. However, its mechanism of action in this context is still not well understood. In this article, the best ways to take advantage of propofol's antiemetic properties are emphasized. The possible effects of propofol on the cerebral cortex, its interactions with the dopaminergic and the serotoninergic systems are evaluated by the known clinical and basic science results. Finally, the advantages and disadvantages of using propofol to decrease the incidence of PONV in clinical practice are discussed.

[Long-term follow-up of acute pancreatitis--significance of cholecystectomy for the biliary form]. / Langzeitverlauf nach akuter Pankreatitis--Bedeutung der Cholezystektomie für die biliäre Form.

Of 83 patients with acute pancreatitis it was possible to control 79 of them 5-16 years later, 33 on the basis of case histories and 46 personally. In 43 cases (54.4%) it was pancreatitis caused by gallstones. After an operative procedure, there followed in each case an auspicious progress without recurrence. By the patients who were not operated, there was a recurrence rate of 45.5%. In cases of pancreatitis not caused by gallstones the late progress is marked by a high recurrence and complication rate.

[The mobile cecum syndrome: appendectomy and cecopexy or only appendectomy?]. / Das Coecum mobile-Syndrom: Appendektomie und Cöcopexie oder nur Appendektomie?

1159 patients underwent appendectomy via a McBurney incision from 1972 to 1983 at our institution. 115 patients (10%) had a mobile cecum syndrome (CMS) as defined by Nicole, without evidence of appendicitis or other pathologic findings at operation. 102 patients were followed up to 15 years after the operation. 82% of the 102 patients were free of symptoms at assessment. 36 patients underwent appendectomy and 63 appendectomy and cecopexy. The two cohorts were comparable with respect to sex, age at operation, duration of right lower abdominal pain, operative findings and length of follow-up. There was no significant difference in the postoperative result of patients with appendectomy alone and those with appendectomy and cecopexy. Moreover, we were not able to identify patients who may benefit from an additional cecopexy, on the basis of patient related factors or intraoperative findings.

[How great is the risk of cancer and recurrence following benign breast biopsy?]. / Wie gross ist das Karzinom- und Rezidivrisiko nach gutartiger Mammabiopsie?

Four hundred and thirty-eight patients with biopsy-proven benign breast disease were followed annually in a prospective manner for 4-17 years, to analyze breast cancer risk, correlations with cancer development and recurrence during follow-up. Twelve breast cancers developed in 12 patients during follow-up, giving a 2.6 fold increased cancer risk over the reference population. No association was found between patients who developed cancer and those who did not with respect to the initial histologic feature (p = 0.9), the age at entry by decades (p = 0.4) and relative to menopause (p = 0.3), the presence of cysts (p = 0.5) or calcification (p = 0.2) in the biopsy specimen, a family history of breast cancer (p = 0.7) or the follow-up time (p = 0.9). Benign breast disease does not inevitably lead to recurrence. Moreover, 47% of the 438 patients never had any recurrence and were free of symptoms during follow-up, and 84% never required a further operation. We conclude that an aggressive approach to benign breast disease is not justified, for any type of lesion as defined in this report.

[Long-term results following surgery of varicose veins]. / Langzeitresultate nach Varicenoperation.

In a long-term follow-up after operation for primary varicose vein disease, patients were revisited 5, 10 and 15 years after their operation, in an attempt to define the goal of the treatment and the result. The results were analyzed as well as those factors which had a significant influence on the findings at assessment. The long-term results were good with respect to the patient's self-judgement and relative to improvement of trophic disturbances, especially of venous ulceration, however recurrent superficial varicose veins increase significantly with increasing follow-up time. The outstanding role of incompetent communicating veins is discussed with respect to trophic disturbances and recurrent varicose veins.

Long-term follow-up of patients with biopsy-proven benign breast disease.

Three hundred sixty-five patients with biopsy-proven benign breast disease were followed annually in a prospective manner for 4-15 years to analyze breast cancer development, recurrence, and efficacy of management during follow-up. Eleven breast cancers developed in 11 patients during follow-up, giving a 2.6-fold increased cancer risk over the reference population. No association was found between patients who developed cancer and those who did not with respect to the initial histologic feature (p = 0.62), the age at entry by decades (p = 0.40), and relative to menopause (p = 0.54), the presence of cysts (p = 0.87), or calcification (p = 0.74) in the biopsy specimen, a family history of breast cancer (p = 0.80), or the number of observation years (p = 0.27). We conclude that an aggressive approach to benign breast disease is not justified for any type of lesion as defined in this report. Benign breast disease does not inevitably lead to recurrence. Moreover, 41% of our patients never had any recurrence and were free of symptoms during follow-up; 67% never had a mammogram and 82% never required a further operation. There was no association with initial histologic feature in patients who had clinical examination only and those who had mammogram, biopsy, or both during follow-up (p = 0.93). Mammograms were mainly used to clarify a clinical recurrence than as a screening tool, regardless of histologic feature (p = 0.76). Mammograms were mainly used in premenopausal patients (p less than 0.001) having lumps (p less than 0.001), namely, the most difficult patients for radiologic interpretation. This may be one important reason for the rather low sensitivity (75%) and specificity (40%) of mammography in this report. In conclusion, clinical examination is the outstanding investigational tool to follow patients with biopsy-proven benign breast disease, especially in young premenopausal patients.

[10 years' experience using a modified Shouldice surgical technic for inguinal hernia in adults. II. Which factors modify the recurrence of inguinal hernia?]. / 10 Jahre Erfahrung mit einer modifizierten Operationstechnik nach Shouldice für Inguinalhernien bei Erwachsenen. II. Welche Faktoren beeinflussen die Rezidivgenese von Inguinalhernien?

Many factors seem to influence the recurrence rate after adult inguinal hernia repair. A statistical analysis of data derived from 726 transversalis fascia repairs examined by the authors (with a follow-up rate of 82.5% and a mean follow-up time of 5.5 years) revealed a significantly higher recurrence rate in patients with chronic bronchitis (p less than 0.05) or with postoperative complications (p less than 0.001). Lower recurrence rates were found after resection of lipomas of the cord (p less than 0.01) or cremasteric muscle resection (p less than 0.05). No significant difference of recurrence rate could be established for following parameters: Sex, side, age distribution, profession, prostatism, obesity, type of hernia (direct, indirect, combined, sliding), suture material (silk, polyglycolic acid), surgeon, anesthesia (local, spinal, full), elective or emergency operation, and whether the repair was unilateral or simultaneously bilateral. Recurrent repairs showed no significantly higher recurrence rate than primary repairs.

[10 years' experience using a modified Shouldice surgical technic for inguinal hernia in adults. I. Method and results in 726 operations with follow-up]. / 10 Jahre Erfahrung mit einer modifizierten Operationstechnik nach Shouldice für Inguinalhernien bei Erwachsenen. I. Methode und Resultate bei 726 nachkontrollierten Operationen.

Since 1973 we have used a modified Shouldice repair to treat inguinal hernias in adults. The repair was performed on unselected patients. The procedure was performed by both senior surgeons and surgeons in training. Over a 10-years period, 880 transversalis fascia repairs were done and 726 (82.5%) were examined by the authors 12-142 months after the operation (mean time 66.1 months). In 94.2% of the 726 repairs the patients were satisfied with the result. Follow-up studies revealed testicular atrophy in 0.6%, deep wound infection in 0.8% and an overall recurrence rate of 5.8%. The recurrence rate was not significantly different after direct, indirect, combined or sliding hernias. In 25% of recurrences the patients were asymptomatic and unaware of the recurrence.

[Bile duct revision, yes or no? Reliability of selection criteria for choledochotomy, tested on the basis of late results following gallbladder operations]. / Gallenwegsrevision, Ja oder Nein? Die Zuverlässigkeit von Selektionskriterien zur Choledochotomie, geprüft anhand von Spätresultaten nach Gallenblasenoperationen.

A series of 346 patients with cholelithiasis were followed up 6, 12, 24, and 48 months after the operation and the results were determined by self-assessment and objective criteria (Visick grading) The results were good in over 80% of the patients. The more serious, painful and threatening the situation was before the operation, the better seem to be the later results. The frequency of the postoperative complications and the number of choledochotomies is dependent on the age of the patient. The type of operation and sex has no effect on the duration of postoperative unemployment. On the average the younger patients return to work more rapidly. From the preoperative criteria which may lead to revision of the choledochus the frequency of pain, duration of history and attacks of fever in the history were unreliable, whereas increased age of patient, icterus or pancreatitis in the previous history were increasingly associated with pathology of the choledochus. Intraoperatively numerous small stones, enlarged choledochus and poor flow ( debit ) suggested strongly a stone in the choledochus or stenosis of the papilla. The stones which were palpable intraoperatively were always found, whereas almost one third of the stones in the bile ducts were not palpable. The intraoperative X-ray picture is an useful but not an absolute reliable auxiliary help. Several of the pre- and intraoperative criteria and tests used for the selection of patients for choledochotomy have statistically significant reliable results for the presence of choledocholithiasis or papillary stenosis. Singularly however, there is always the possibility of a false positive or false negative result.

[Is preventive epilation following sacral dermoid operation useful or ineffective?]. / Ist die Epilationsprophylaxe nach Sacraldermoidoperation nützlich oder wirkungslos?

Following operation for pilonidal sinus, 79 patients were followed up for 1-10 years. The ratio male/female was 6 to 1. The majority of the patients had overweight. After primary closure of the wound, 62% healed without and 38% with infection. There were 15 recurrencies (19%) noted in this series. Consequent regular epilation was advised following the operation. One half of all patients neglected our recommendation and only 2/3 of the remaining patients practiced this regularly for a shorter or longer period of time. There were more recurrencies among the patients with regular epilation than the others who neglected epilation. In our study the practice of consequent regular epilation was not successful in preventing recurrent pilonidal sinus.

[What determines the prognosis following cholecystectomy: anamnesis, surgical findings, postoperative complications?]. / Was bestimmt die Prognose nach Cholezystektomie: Anamnese, Operationsbefunde, postoperative Komplikationen?

In 346 patients followed up 6, 12, 24 and 48 months after cholecystectomy the clinical results (VISICK and self-assessment) were very good in over 80%, 1% had symptoms due to organic disturbances and 15-20% had mostly mild symptoms (pain, fullness, food tolerance) without detectable causes. These functional disorders were found frequently in female patients with long preoperative history and frequent attacks of pain. Age of patient, character of pain, therapy before the operation, postoperative complications or change of body weight showed no correlation with later results. The results were almost always good in patients with acute pancreatitis or acute cholecystitis before the operation, or who underwent choledochotomy.

[The Spigelian hernia: missed? rare? puzzling diagnosis?]. / Die Spigelische Hernie: Verpasst? Selten? Verlegenheitsdiagnose?

During a period of six years 24 patients with a clinical diagnosis of spigelian hernia were operated in our department (3% of all abdominal wall hernias). The Spigelian hernia could be verified intraoperative in 12 of these patients and in 12 cases there was no evidence of hernia but other findings which could partially cause the pre-operative complaints. It was possible to follow-up on 22 of the patients over a period of 1-6 years postoperative. Those patients with definite Spigelian hernia showed for the most part, good results while the patients with other problems were less satisfactory.

[Results following surgical repair of the ankle ligaments]. / Resultate nach Bandnaht am Aussenknöchel.

From a total of 133 patients with acute traumatic rupture of the lateral ligaments of the ankle 118 patients (88%) have been followed up for a period of 6 months to 8 years (average 2 years) after operative repair. According to the patients own statements, 88% reported good or very good results (minimal or no complaints). 12% referred to occasional pain and/or swelling. The objective results obtained by clinical and radiological examinations were excellent in 79% and unsatisfactory in 21%. The operative risk is minimal, thus we recommend early operative treatment of acute traumatic rupture of the lateral ligaments of the ankle.

[Hydrops of the gallbladder]. / Hydrops der Gallenblase.

Of 739 cholecystectomies carried out from 1971 to 1978, 40 cases revealed intraoperatively a hydrops of the gallbladder. This hydrops was caused in all cases by a stone located in the gallbladder neck or the cystic duct. In 37 cases, the gallbladder contents were examined: clear "white bile" was present in 29 (78%); this was always very viscous. With one exception, all biles were found to be sterile. The pressure in the gallbladder averaged 61.5 cm saline, ranging from 15 to 115 cm. The osmolality of bile was on the average 295 mosmol/kg, thus being roughly isotonic with blood. In three cases, where chemical analysis of the bile was perfomed, bilirubin-, bile salts, cholesterol-, phospholipids, and protein-content were reduced to non-measurable amounts or to concentrations below 1 mg%. It is suggested that the mucosal inflammation following the obstruction to bile flow leads to disturbances in reabsorptive processes, secretion of mucous and a subsequent increase in intraluminal pressure.