[Current therapy of complicated appendicitis]. / Zeitgemässe Therapie der komplizierten Appendizitis.

A significant number of complications in acute appendicitis develop due to delayed or even missed diagnosis. Potentially every patient can be affected due to a distinct feature of appendicitis--the rapidity with which the inflammation passes through the different stages. Even after a few hours, gangrenous appendicitis with impending overt perforation can have developed. In many cases, the term complicated appendicitis may be less significant than implied because, e.g., the rapidly developed perforation can be treated by appendectomy, which rarely presents a surgical challenge. However, every perforation of a hollow viscus in the abdomen leads to peritonitis of different degrees, which untreated can end lethally. The often cited statement of Dieu la Foy from the last but one century "no patient has to die from appendicitis" remains a surgical dream not quite fulfilled. Occasionally even today, patients with comorbidity die from the sequelae of appendicitis, i.e., high-risk groups including the very young and the very old and immunosuppressed patients. These patients should receive special attention when the diagnosis of appendicitis is considered. By definition, complicated appendicitis includes perforation of the appendix, empyema or abscess formation, and finally fecal peritonitis. The surgical procedure chosen and when to add supportive measures will depend on the specific complication present. Early or immediate appendectomy, i.e., the urgent indication to operate, is a generally accepted concept in the therapy of acute appendicitis. Even in complicated cases, the aim is just one operative procedure or if need be only the application of antibiotics.

[Tuberculosis of the pancreas--a clinical rarity]. / Tuberkulose des Pankreas--eine klinische Rarität.

Pancreas tuberculosis is a rare diagnosis and is usually associated with miliary spread. Only a few cases are reported in the literature. A female patient was admitted with a history of uncharacteristic abdominal pain, weight loss, weakness, and intermittent fever. CA 19-9 was increased and the CT scan showed an irregular mass in the pancreatic tail. Suspecting the diagnosis of pancreatic cancer, a pancreas tail resection with splenectomy was performed. The histological examination showed pancreas tuberculosis. Mimicking pancreatic cancer or presenting with acute/chronic pancreatitis or obstructive jaundice, the diagnosis of pancreas tuberculosis is very difficult to make and is usually established after surgical treatment. Although pancreas tuberculosis is rare, it should be considered when evaluating a pancreatic mass.

[Treatment of secondary and tertiary hyperparathyroidism--surgical viewpoints]. / Therapie des sekundären und tertiären Hyperparathyreoidismus--chirurgische Standpunkte.

Nearly all patients with chronic renal failure exhibit some degree of secondary hyperparathyroidism (sHPT), defined as parathyroid hyperplasia and elevated serum parathyroid hormone (PTH) levels. Despite improvements in the medical management of patients with sHPT continue to develop progressive bone disease manifested by osteitis fibrosa cystica, soft tissue calcification and myopathy, pruritus, bone and joint pain and calciphylaxis may accompany the bone disorder. When medical therapy fails, parathyroidectomy becomes necessary. This is not sufficiently explained by the failure to administer calcitriol to control serum phosphate and calcium concentration or to deliver sufficient dialysis. The continuous increase of the proportion of patients exhibiting severe uncontrolled HPT with increasing time of dialysis points to a more basic underlying biological problem; an even higher proportion of patients shows also nodular, rather than diffuse hyperplasia. It was commonly believed that after restoration of normal renal function with successful transplantation, the hyperplastic parathyroid glands would involute and return to normal function state. After renal transplantation some patients continue to have a HPT. This disease entity is recognized and termed as tertiary Hyperparathyroidism (tHPT). After establishing a diagnosis of hyperparathyroid bone disease, in patients with sHPT and tHPT a parathyroidectomy (PTX) frequently becomes necessary to decrease the mass of the hyperplastic parathyroid tissue. The surgical procedure remains controversial. Some surgeons prefer subtotal PTX, others prefer total PTX with autotransplantation of a small amount of tissue to the arm, because the transplanted tissue can be removed in the event of a recurrent HPT. Successful surgical intervention for sHPT and tHPT significantly reduces preoperative symptoms and leeds to restoration of bone disease and therefore supports PTX for patients with s and tHPT. In our experience total PTX with autograft has proven to be a satisfactory procedure. Subtotal PTX is also an effective procedure and the choice of operative technique should be left to the surgeon.

[Resection and replacement of the cervical esophagus and hypopharynx--an interdisciplinary responsibility for visceral, micro- and ENT surgeons]. / Resektion und Ersatz der cervikalen Speiseröhre und des Hypopharynx--eine interdisziplinäre Aufgabe für Viszeral-, Mikro- und HNO-Chirurgen.

From 1984 to 1996, 136 carcinomas of the esophagus and 8 of the hypopharynx were resected using 3 different procedures (94 transmediastinal, 36 transthoracic, 14 cervicoabdominal). The hospital mortality rate for cervicoabdominal resection (0%) is unequivocally lower than that of the transmediastinal (17.1%) or transthoracic (14.3%) methods. The 5-year survival rates are not significantly different (24%, 22%, 17%).

[Pyogenic skin infections of the extremities with vascular involvement. Local vascular reconstruction and systemic therapy concepts]. / Pyogene Hautinfektionen der Extremitäten mit Gefässbeteiligung. Lokale gefässrekonstruktive und systemische Therapiekonzepte.

In a 6-year period, we treated 14 patients with severe groin infections involving the femoral artery following drug injection in addicts. In 13 cases, we used autologous material for arterial reconstruction; in one case of massive bleeding the femoral artery had been embolized. Ten patients were treated with full success, two patients had claudication postoperatively, and in two cases above-knee amputations were necessary.

[What may surgical therapy of benign thyroid gland diseases cost? Extreme, moderate and ethically defensible calculations]. / Was darf die chirurgische Therapie benigner Schilddrüsenerkrankungen kosten? Extreme, moderate und ethisch vertretbare Kalkulationen.

Since January 1996, Fallpauschalen (fee for case) and Sonderentgelte (fee for service) lead up to a new dictatorship of economy over surgeons affairs. A detailed economical analysis for the surgical treatment of benign diseases of the thyroid gland was made. Comparing the costs and our financial benefits, it is evident that there are no reserves for complications or longterm patients.

Perioperative use of ampicillin/sulbactam, cefoxitin and piperacillin/metronidazole in elective colon and rectum surgery: a prospective and randomized quality control study in 422 patients.

As previous work has shown, antibiotic prophylaxis is highly effective in lowering wound infection rates in colorectal surgery. In order to establish quality control, the authors investigated the effectiveness of three different prophylactic antibiotic regimes in 422 patients in a prospective and randomized trial. There were no significant differences between the three groups with regard to age, type of operation and risk factors like adipositas and diabetes. The wound infection rate according to the Centers for Disease Control criteria ranged from 7.0% to 9.5%. No significant difference was found between the three antibiotic regimes. It can be concluded, therefore, that under the conditions used in this study each of the three different types of antibiotics is of equal value, hence, the cheapest one can be used.

[Gastrointestinal lymphomas: results of multimodal therapy in 57 patients of one center]. / Gastrointestinale Lymphome: Ergebnisse einer multimodalen Therapie bei 57 Patienten eines Zentrums.

From 1982-1995, 57 patients with primary gastrointestinal lymphoma were treated with a multimodality therapy. Of these patients, 36 were primary operated, 43 were given an isolated or postoperative chemotherapy and 17 were treated with radiation. Primary operated patients have a significantly better chance of relapse-free survival than those only treated conservatively.

[Spiral computerized tomography of acute abdominal aortic aneurysm with optimal 3-D image reconstruction]. / Spiral-Computertomographie des akuten Bauchaortenaneurysmas mit optionaler 3-D-Bildrekonstruktion.

43 of 46 consecutive patients with suspected rupture of abdominal aortic aneurysm could be examined by spiral CT. Rupture of an abdominal vessel was found in 18 patients and proved by surgery. Size and extent of the aneurysm, rupture, dissection and vascular occlusion were demonstrated quickly and precisely by spiral CT, planning of surgical intervention could be optimized. Using spiral CT unnecessary explorative laparotomies could be avoided in 25 patients. In addition spiral CT offers the possibility of multiplanar reconstruction images with spatial visualisation of the vascular system. In 8 patients DSA offered no advantage in comparison with 3-D reconstruction images. Spiral CT meets all requirements for quick and reliable diagnosis in suspected rupture of abdominal vessels. Other imaging modalities like digital subtraction angiography are not necessary for evaluation of abdominal aortic aneurysms.

[Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple's operation]. / Pankreasfunktion und Lebensqualität nach Pankreaskopfresektion bei der chronischen Pankreatitis. Eine prospektive, randomisierte Vergleichsstudie nach duodenumerhaltender Pankreaskopfresektion versus Whipple'scher Operation.

Given an indication for surgery in patients with chronic pancreatitis, such as distal common bile duct obstruction, duodenal stenosis, or dilated pancreatic duct with stones and congestion, the surgeon must decide the type of operation to perform. A duodenopancreatectomy, the Whipple procedure, is widely considered to be the gold standard. It is highly effective in relieving pain and eliminating the structural abnormalities noted above. Duodenum-preserving resection of the head of the pancreas (DPRHP) seems to be an attractive alternative to pancreaticoduodenectomy (PD) in the treatment of chronic pancreatitis. In a clinical prospective randomized trial the efficiency of both operative methods was investigated. Between 7/1987 and 12/1993 43 patients were randomly assigned to undergo either a Whipple procedure (n = 21) or DPRHP (n = 22). Data on postoperative course, mortality, and postoperative morbidity were compiled. As concerns long-term results, postoperative hormonal status (insulin, neurotensin, cholecystokinin, gastrin) was checked, basal and stimulated with a standardized meal, using standard hormonal assay kits. All patients with PD survived, whereas one with DPRHP died from peritonitis. Patients with DPRHP had a significant more rapid convalescence (16.5 vs. 21.7 days). The range for postoperative follow-up is from 36 months to 5.5 years. In the DPRHP group 18 patients are in good condition. Two had diabetes and one developed carcinoma. In the PD group one died from hepatic coma, 14 are in good condition and 6 developed diabetes. All gained body weight with an average of 6.4 vs. 4.9 kg, DPRHP vs. PD. A difference between DPRHP and PD was obvious for the postoperative hormonal status. Results are satisfactory in both groups. For patients with DPRHP however, we see a quicker convalescence and a significant benefit as concerns postoperative hormonal status.

[Palliative surgical and endoscopic therapy of malignant bile duct occlusion]. / Palliative chirurgische und endoskopische Therapie maligner Gallenwegsverschlüsse.

Cholestatic jaundice is the result of a malignancy of the bile duct itself, of the gallbladder, of the ampulla or (as in most cases) of the pancreas. Patients without evidence of metastases or other signs of advanced cancer (e.g. ascites) are candidates for explorative laparotomy. In the vast majority of cases resection of a tumor is not feasible and the surgeon is faced with the objective of providing palliation. To date there exists not only one palliative procedure, and the surgeon has to take into account the following: In patients with pancreatic cancer palliation can be given with biliary bypass with or without gastroenterostomy. This carries an operative mortality of almost 20% and means a survival of only 5-6 months. Nonsurgical procedures as transpapillary stenting play an increasing role in the management of patients with obstructive jaundice due to pancreatic cancer. In some cases however resectable tumors perhaps will be overlooked. The results of controlled studies comparing endoscopic stenting and surgical bypass are encouraging for stenting techniques (lower morbidity and mortality (< 10%), technical success rates exceeding 90%). The availability of different palliative treatment modalities for carcinoma of the bile ducts suggests that no approach is definitely superior. Operative biliary-enteric anastomosis gives a tolerable operative mortality rate in younger patients, less morbidity, than external biliary drainage by better quality of life of the patients. In retrograde placement of prosthetic stents, in patients with high bile duct obstruction difficulties are frequently. In such cases the percutaneous drainage should be reserved for endoscopic failures, in cases the endoscopic and percutaneous approaches can be combined in the 'rendezvous' procedure. In recent years several reports have advocated extensive surgery for biliary neoplasms. Preoperative staging of these patients remains an issue as none of the commonly modalities are accurate in predicting resectability.

[Laparoscopic pancreatocystojejunostomy without entero-entero-anastomosis]. / Laparoskopische Pankreatocystojejunostomie ohne Entero-Entero-Anastomose.

The gradual enlargement of a persistent pancreatic pseudocyst generally requires intervention. When the decision to carry out an operative procedure is made, preference should be given to internal rather than external drainage. We have developed a simple technique in which the pseudocyst is approached directly, to make a pancreatico-cystojejunostomy, which does not require a Braun- or Roux-en-Y anastomosis. We present our laparoscopic method, which opens up new possibilities in the treatment of pancreatic pseudocysts.

Prophylaxis of complications after pancreatic surgery: results of a multicenter trial in Germany.

Major pancreatic resection still carries a considerable risk for morbidity and even mortality. Complications occurring after pancreatic surgery are chiefly linked with exocrine pancreatic secretion. Therefore to inhibit exocrine pancreatic secretion perioperatively seems to be a promising concept in the prevention of complications following pancreatic resection. The hormone somatostatin and its synthetic analogue octreotide have been demonstrated to inhibit exocrine pancreatic secretion profoundly, particularly the secretion of proteases is decreased. In a randomized placebo-controlled multicentric and double-blind trial we analyzed the role of octreotide in the prevention of post-operative complications after major pancreatic surgery. A significant reduction of complications (fistula, abscess, fluid collection, sepsis, pulmonary insufficiency, postoperative acute pancreatitis) could be demonstrated in patients receiving octreotide (3 x 100 micrograms/day s.c.). The effect of octreotide was particularly true in patients undergoing a Whipple resection for cancer.

[Perioperative use of ampicillin/sulbactam, cefoxitin and piperacillin/ metronidazole in elective colon and rectal surgery. A prospective randomized quality assurance study of 422 patients]. / Perioperative Anwendung von Ampicillin/Sulbactam, Cefoxitin und Piperacillin/Metronidazol in der elektiven Colon- und Rectumchirurgie. Eine prospektive randomisierte Qualitätssicherungsstudie bei 422 Patienten.

As has been proved before, antibiotic prophylaxis is highly effective in lowering wound infection rates in colorectal surgery. In order to establish quality control, we checked the effectiveness of three different prophylactic antibiotic regimes in 422 patients in a prospective and randomized trial. Between the three groups were no significant differences as regards age, type of operation and risk factors like adipositas and diabetes. The wound infection rate according to CDC-criteria was from 7.0 to 9.5%. We did not find a significant difference between the three antibiotic regimes. It is therefore our conclusion, that in our setting each of the three different types of antibiotics is of equal value. This means, on the other hand, that the cheapest one is enough.

[Prevention of thromboembolism in surgery--results of a survey in West German hospitals]. / Thromboembolie-Prophylaxe in der Chirurgie--Ergebnis einer Umfrage an westdeutschen Krankenhäusern.

UNLABELLED: In 1990 a questionnaire on methods for prevention of deep venous thrombosis (DVT) and pulmonary embolism (LE) was mailed to 940 surgical centers in West Germany (FRG). The return rate was 60% or 564 answers, covering about 1,200,000 operations/year. The results are as follows: (1) Physical therapeutic measures (early mobilisation, elastic stockings) and drug administration are routinely used in all centers. The duration of prophylaxis is 3-8 days in 36% of centers, up to mobilisation in 31%, 9-16 days after operation in 17% and until demission in 16%. (2) A single drug regime is employed in 60% of centers (49% standard heparin, 9% low molecular heparin in combination with DHE) 40% of centers use all three drugs without clear cut guidelines concerning the indications. (3) The reported rates of thromboembolic complications diagnosed by clinical criteria are 0.55 +/- 0.62% for DVT and 0.22 +/- 0.29% for fatal or nonfatal LE. There is no evidence from the analysed data that the drug regimes influences the clinical outcome. CONCLUSION: The need for administration of drugs prevent DVT is widely accepted. A polypragmatic approach seems to be effective. However, standardized regimes for defined clinical conditions are desirable.

Role of octreotide in the prevention of postoperative complications following pancreatic resection.

Though morbidity and mortality rates following pancreatic resection have improved in recent years, they are still around 35% and 5%, respectively. Typical complications, such as pancreatic fistula, abscess, and subsequent sepsis, are chiefly associated with exocrine pancreatic secretion. In order to clarify whether the perioperative inhibition of exocrine pancreatic secretion prevents complications, we assessed the efficacy of octreotide, a long-acting somatostatin analogue. We conducted a randomized, double-blind, placebo-controlled, multicenter trial in 246 patients undergoing major elective pancreatic surgery. Patients were stratified into a high-risk stratum (limited to patients with pancreatic and periampullary tumors) or low-risk stratum (patients with chronic pancreatitis). Patients received octreotide (3 x 100 micrograms) or placebo subcutaneously for 7 days perioperatively. Eleven complications were defined: death, leakage of anastomosis, pancreatic fistula, abscess, fluid collection, shock, sepsis, bleeding, pulmonary insufficiency, renal insufficiency, and postoperative pancreatitis. Two hundred patients underwent pancreatic head resection, 31 patients underwent left resection, and 15 patients had other procedures. The overall mortality rate within 90 days was 4.5%, with 3.2% in the octreotide group and 5.8% in the placebo group. The complication rate was 32% in the patients receiving octreotide (40 of 125 patients) and 55% in patients receiving placebo (67 of 121 patients) (p less than 0.005). In the patients in the high-risk stratum, complications were observed in 26 of the 68 (38%) patients treated with octreotide and in 46 of 71 (65%) patients given placebo (p less than 0.01). Whereas in patients in the low-risk stratum, the complication rate was 25% (14 of 57 patients) in those treated with octreotide and 42% (21 of 50 patients) in patients given placebo (p = NS). The perioperative application of octreotide reduces the occurrence of typical postoperative complications after pancreatic resection, particularly in patients with tumors.