Pre-, intra- and postoperative staging of gastric carcinoma and clinical outcome.

BACKGROUND: We compared preoperative (combined clinical and radiological staging and endoscopical Borrmann classification), intraoperative (by the surgeon: curative/palliative; R0/R1/R2-resection; intraoperative stage I to IV) and postoperative staging including histological results (pTNM) in respect of resectability and prognosis. METHODS: All patients with adenocarcinoma of the stomach were prospectively and consecutively included in the study protocol and were staged during the hospitalisation by the different specialists. Out of 215 patients with malignant tumors of the stomach, 153 were finally evaluated for the study. We excluded 62 patients with other malignancies or with a follow up of less than 6 months. Preoperative endoscopic Borrmann classification was done by the gastroenterologist, preoperative TNM-classification by the radiologist and surgeon, intraoperative classification by the surgeon and postoperative classification by the pathologist. All results were immediately described in the protocol. Follow-up and survival curves were performed by the Regional Tumor Registry and statistics by the Statistical Department of the University using Kaplan-Meier survival curves and Log-Rank and Wilcoxon Test for significance. RESULTS: Preoperative staging was unreliable and there was no relationship between preoperative and postoperative staging nor survival. In opposite intra- and postoperative staging correlated significantly between the different groups and with survival (p < 0.001). CONCLUSIONS: As long as preoperative staging systems are not improved (which may be in the future the case with endosonography), all operable patients with gastric carcinoma should undergo a laparotomy or laparoscopy, because only intraoperative evaluation of the surgeon allows a decision on a possible curative resection. Patients with stages I-III should be resected radically with complete dissection of lymph node compartments 1 and 2. This policy is justified especially in view of a minimal hospital mortality (3%).

[Hemorrhage-induced rupture of the pancreatic pseudocyst]. / Die blutungsbedingte Ruptur der Pankreaspseudozyste.

Hemorrhage from pseudocyst may be the most serious complication of chronic pancreatitis: the mortality from such hemorrhage approaches 80%. The bleeding arises from a major artery--the artery is eroded by the basic process of autodigestion, and the pseudocyst is converted into a pseudoaneurysm. The wall of the pseudoaneurysm is subjected to arterial pressure and may perforate into the peritoneal cavity, an adjacent segment of the gastrointestinal tract, or the pancreatic ductal system. Clinical signs and indications of complicated pseudocyst are sudden abdominal pain, hypotension, sudden increase in abdominal tenderness, decrease of hematocrit and sudden disappearance of the mass. Sonography, CT and angiography accurately define the bleeding lesion and greatly aid in planning operative strategy. Surgery, angiographic embolisation, or a combination of both may be employed. Transcystic arterial ligation and internal drainage of the pseudocyst or distal pancreatectomy are the operative procedures of choice and give the best results.

[Choledochal cyst as an unexpected intraoperative finding]. / Die Choledochuszyste als unerwarteter intraoperativer Befund.

In adulthood, choledochal cysts often surprisingly are discovered during cholecystectomy. Abdominal ultrasonography incorrectly identified the cyst as a dilated or septated gallbladder. Once suspected preoperatively, confirmation of the diagnosis is obtained by ultrasonography or computerized axial tomography, which define its relationship to the vascular structures in the porta. The rapidity and accuracy of ultrasonography favour its use as the initial investigative procedure. Direct cholangiography is the preferred modality for accurate definition of the type of choledochal cyst, ductal strictures, intrahepatic ductal configuration, and polypoid filling defects suggesting cholangiocarcinoma. The well known risk of development of ascending cholangitis as well as cystic cancer, mainly in the adult, indicates the excisional operation for preventing these complications. Cyst excision and Roux-en-Y hepaticojejunostomy is the definitive treatment of choice.

[Injuries of the urogenital system]. / Die Verletzung des Urogenitalsystems.

Ultrasonography is accepted as a valuable screening method for the detection of renal trauma, although it does not make any functional contribution. Computerized tomography has replaced excretory urography for the evaluation of blunt renal trauma, because it makes more precise diagnosis possible. Arteriography is mandatory when injuries of the renal branch are suspected. The management of renal trauma should restore normal circulation and renal function and should preserve as much functioning renal tissue as possible. For renal contusion and minor cortical lacerations, even when there is a small extravasation of urine, conservative management is sufficient, while major cortical lacerations and injuries of the renal vessels require prompt operative methods. The classification of urethral ruptures is based on rectal palpation of the prostate, distribution and size of hematomas and urethrography. A primary catheter for diagnostic purposes is strictly contraindicated. Urinary diversion proximal to the urethral lesion is the primary therapeutic procedure, while the definite management of the ruptured urethra can be postponed. Injuries to the organs of the urogenital system are rarely life threatening, and in the case of multiple trauma their management can be adapted to fit in with the treatment of injuries to other vital organs. Nevertheless, diagnosis and adequate treatment of injured urogenital organs must not be neglected as long-lasting or permanent damage could result.

[Acute mesenteric ischemia]. / Die akute mesenteriale Ischämie.

83 patients with acute intestinal ischemia are presented. The aim of the study is to characterize anamnestic and clinical signs of this severe disease. Mainly old people with various cardiac illnesses suffer from acute intestinal ischemia. Precise anamnesis sometimes leads to the etiology of the obstruction. Clinical examination may show the extent of the disease. Angiography is mandatory for correct diagnosis. Early recognition and aggressive therapy significantly improve prognosis.

[Cystadenoma of the pancreas]. / Zystadenome des Pankreas.

We report on a patient with a microcystic adenoma of the head of the pancreas. Cystic neoplasms of the pancreas comprise only about 2% of all exocrine tumours. They can be divided into two distinct groups with different prognoses: the microcystic glycogen containing tumours, which are always benign and the mucinous cystic tumours, the majority of which shows malignant dysplasia. Clinically they manifest as a palpable abdominal mass with unspecific upper abdominal pain. Preoperative diagnosis is difficult to achieve. Computer-tomography and ultrasound are the main radiological facilities that allow some degree of differentiation. During operation a frozen section is mandatory to differentiate between a pseudocyst and a real cyst with epithelial wall. Resection of the tumour is the therapy of choice. The prognosis of the microcystic adenoma is good, the prognosis of the mucinous cystadenoma-cystadenocarcinoma is much better than the prognosis of the adenocarcinoma of the pancreas.

Prophylactic treatment of acute gastroduodenal stress ulceration. Low-dose antacid treatment without and with additional ranitidine.

Low-dose antacid treatment without and with additional ranitidine in the prevention of acute gastroduodenal stress ulceration in high-risk patients was compared in a randomized, double-blind clinical trial with endoscopic examination of the upper gastrointestinal tract before entry and after the 7-day study period. Of 67 patients who entered the study, 56 could be evaluated. Only one patient, allocated to antacid and placebo, had massive acute upper gastrointestinal bleeding, arising from a gastric ulcer. Although gastric intraluminal pH was better controlled with additional ranitidine treatment, the occurrence of mucosal lesions did not depend on the assigned treatment. We conclude that there is no significant difference between the two regimens in terms of endoscopically visible lesions and clinical outcome.

The role of computerized tomography in fever, septicemia and multiple system organ failure after laparotomy.

Fifty-two patients with postoperative sepsis were studied by abdominal and pelvic computerized tomography (CT) for the presence and location of septic foci. CT mapping of infected fluid collections had direct therapeutic consequences as it allowed the selection of patients for percutaneous drainage, local operative drainage or relaparotomy. As soon as sepsis is suspected, an abdominal and pelvic CT study should be performed so that therapeutic procedures may be carried out at a stage at which no organ is yet failing, that is, in a period of lowest mortality.

Colonic hemorrhage from a solitary minute ulcer. Report of three cases.

Three patients with massive lower gastrointestinal bleeding are reported. In all cases, the bleeding source was localized by emergency selective mesenteric angiography. The histologic lesion found in the resected specimen consisted of a minute mucosal ulcer with an abnormally large eroded submucosal artery without evidence of true angiodysplastic changes. The clinicopathological picture is similar to the rare solitary stomach ulceration, described as "Exulceratio simplex Dieulafoy."

[Mirizzi syndrome: anamnesis, diagnosis and therapy based on 5 cases]. / Das Mirizzi-Syndrom: Anamnese, Diagnostik und Therapie anhand von 5 Fällen.

It is reported on 5 patients with Mirizzi syndrome. This syndrome is defined by the trias "chronic cholecystitis, cholelithiasis and benign stenosis of the hepatic duct with jaundice". The biliobiliary fistulas are the more severe forms of this syndrome. There is no typical anamnesis. The diagnosis can be assumed by sonography or computed tomography. A biliobiliary fistula can be demonstrated by direct cholangiography (ERC or PTC). The malignant tumor of the gallbladder or the bile duct is a difficult differential diagnosis. The cholecystectomia simplex is the therapy of choice in the uncomplicated Mirizzi syndrome. In case of a biliobiliary fistula one should try to close the defect of the hepatic duct with a "cuff of the gallbladder". If this procedure is technically impossible, several methods of biliodigestive anastomosis can be chosen.

Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography.

Preoperative recognition of the Mirizzi syndrome permits avoidance of several serious pitfalls at surgery. The typical diagnostic signs of the Mirizzi syndrome are (1) dilatation of the common hepatic duct above the level of (2) a gallstone impacted in the cystic duct, with (3) normal duct width below the stone. Since jaundice is the leading clinical symptom, sonography and computed tomography (CT) are now the primary radiologic tests. The syndrome does not regularly have typical features, however, and therefore cannot be detected routinely on sonography or CT. Direct cholangiography is often necessary, especially since a cholecystobiliary fistula secondary to stone penetration into the common bile duct can be demonstrated only by cholangiography. On the other hand, direct cholangiography should follow either sonography or CT because these imaging methods are superior for demonstrating extraluminal signs of malignancy, which is the most important differential diagnosis. The findings at preoperative examinations (sonography, six; CT, four; endoscopic retrograde cholangiography, five) in seven patients with surgically confirmed Mirizzi syndrome are analyzed retrospectively.

[Perioperative antibiotic prophylaxis in colon surgery. Metronidazole and tobramycin versus metronidazole alone. A prospective randomized study]. / Perioperative Antibiotikaprophylaxe in der Kolonchirurgie. Metronidazol und Tobramycin versus Metronidazol allein. Eine prospektive randomisierte Studie.

97 patients scheduled to undergo elective surgery for colorectal carcinoma were randomized to receive either three doses of intravenous metronidazole-e and tobramycin or three doses of intravenous metronidazole alone. The first dose was given after induction of general anesthesia, the second at 9 p.m. and the third at 6 a.m. the following day. The study was double-blind, with patients in the metronidazol-alone group given a placebo infusion instead of tobramycin. The overall postoperative infection rate was 19.6% with no statistically significant difference between the two groups. It is concluded that the addition of an aminoglycoside does not afford better protection than prophylaxis with metronidazole alone.