An apparent excess of operative site infections: analyses to evaluate false-positive diagnoses.

OBJECTIVE: To investigate an apparent excess of operative site infections (OSI) reported according to doctor's diagnosis (presumptive OSI) by applying objective criteria for classification (documented OSI). To examine potential consequences of habitual overdiagnosis of OSI. DESIGN: A case-control design was used to examine the clinical course of 18 case patients (12 presumptive OSI, six documented OSI) and 18 matched controls. Comparisons also were made between presumptive and documented OSI patients. SETTING: A nonteaching community hospital. PATIENTS: Thirty-six patients having laminectomies done by the same surgeon. INTERVENTION: Implementation of objective criteria for diagnosis of confirmed OSI and reclassification of presumptive OSI patients. RESULTS: Postoperatively, the frequency of specific adverse events within the operative site (including postoperative hematoma or bleeding; wound necrosis, dehiscence, or sinus tract; and dural tear) was 83% for documented OSI patients, contrasted with 16.7% for presumptive OSI patients (P < .01) and controls (P = .007). Median days of inpatient stay were 27 for documented OSI, contrasted with 9.5 for presumptive OSI (P = .01) and 7 for controls (P < .001). CONCLUSION: Documented OSI patients were found to have significantly more adverse findings and longer lengths of stay than presumptive OSI patients or controls. The similarity of findings for presumptive OSI patients and controls suggests that the apparent excess frequency of OSI was caused by incorrect diagnosis. Whereas doctor's diagnosis may be useful as an initial screen for OSI, use of objective criteria for confirming OSI may avert the consequences of overdiagnosis including excessive length of stay and unnecessary therapy, which lead to elevated healthcare costs and threaten a physician's practice.

[The treatment of male infertility by selective catheterisation of the spermatic vein. Technique, indications, complications, results (author's transl)]. / Perkutane Behandlung männlicher Infertilität im Rahmen der selektiven der selektiven Spermatikaphlebographic mit Katheter.

Sclerosis of the spermatic vein for male infertility and varicoceles was carried out in 84 patients by a percutaneous method. If the catheter is correctly placed in the spermatic vein, sclerosis is possible in almost all cases, as was shown by controlled examinations after periods of more than three months. Together with the radiologic changes, there was also an improvement in the spermatologic parameters. 58% of the patients examined after three months were regarded as fertile.

[Special complications in leg phlebography]. / Spezielle Komplikationen der Beinphlebographie.

Some rare, but serious, complications during leg and pelvic phlebography are described. One fatal pulmonary embolus and six cases of necrosis of the dorsum of the foot due to phlebography were encountered. The causes, pathogenetic factors and other possible complications are discussed. Extravasation of contrast due to puncture on the lateral side of the foot, or near the ankle joint, leads to the formation of a contrast bleb which may proceed to tissue necrosis.

[The technique and results of spermatic vein phlebography in 136 men with primary sterility (author's transl)]. / Technik und Ergebnisse der Spermatica-Phlebographie bei 136 Männern mit primärer Sterilität.

The results of selective phlebography of the spermatic vein in patients with primary sterility and suspected varicoceles are reported. In 60% of those examined there was left-sided, and in 8.8% right-sided, spermatic vein insufficiency or a varicocoele. The value of spermatic vein phlebography is borne out by the large number of anomalies of the venous system (67%) and by the finding of 82 left-sided varicoceles.

Peripheral percutaneous transluminal laser angioplasty in humans: in vitro investigations and clinical results with a novel laser catheter system.

Percutaneous transluminal laser angioplasty has become an accepted method of treatment of peripheral arterial occlusive disease. To minimize the risk of arterial wall perforation during laser angioplasty, a novel laser catheter system was developed. In 113 obliterated postmortem human arteries the perforation rate was 0.9%. The mean degree of stenosis was reduced from 89 +/- 9% before, to 53 +/- 11% after laser irradiation. Clinical Nd:YAG laser angioplasty was performed in 19 patients suffering from peripheral arterial occlusive disease. The Fontaine stage improved in 16 patients; in no case did it deteriorate. The mean degree of stenosis was reduced by laser angioplasty from 91 +/- 12% to 31 +/- 19%. A further reduction down to 13 +/- 18% was achieved by subsequent percutaneous transluminal balloon angioplasty. The systolic Doppler ankle-arm pressure gradient was improved from 0.58 +/- 0.26 to 0.89 +/- 0.25. In 7 patients microembolisms were detectable on the final angiogram. There was no acute reocclusion and no perforation. Within a follow-up period of 12 months, four restenoses were diagnosed by digital subtraction angiography. On average, the Doppler index was 0.75 +/- 0.32.

[Renovascular hypertension: invasive percutaneous diagnosis and therapeutic possibilities]. / Renovaskuläre Hypertonie: Invasive perkutane Diagnose- und Therapiemöglichkeiten.

Under the current conditions of improved pharmacological therapy of arterial hypertension there is a danger that the physician may overlook considering the possibility of underlying renovascular causes for the hypertension. However, the diagnosis and treatment of these conditions are simple and easily accessible. Digital subtraction angiography is a simple technique which enables the diagnosis of renal artery stenosis or stenosis of the aorta to be made as a cause of hypertension in more than 90% of cases. Dependent on the type, extent and location of obliteration in the renal arteries, percutaneous transluminal-renal dilatation with a balloon-catheter is quite frequently the intervention of choice. In fibromuscular dysplasia the results are excellent, with a cure rate exceeding 90%, the patients being predominantly younger and females dominating. In stenosis of atherosclerotic origin, 40-60% show improvement or even normalization of blood pressure. A sudden recurrent increase in blood pressure during long-term follow-up requires angiography in order to perform either dilatation again or surgical reconstruction. In all cases of renovascular hypertension, interdisciplinary cooperation between surgeons and interventional radiologists is essential and all patients with renal insufficiency require close contact to a dialysis centre.

[Radiology of acute phlebothrombosis (author's transl)]. / Die Röntgendiagnostik der akuten Phlebothrombose.

The difference in technique of phlebography in acute phlebothrombosis and that in chronic venous insufficiency is demonstrated. Since acute phlebothrombosis can be cured with good results by thrombectomy and fibrinolysis in the first few days of the disease, phlebography should be performed early, preferably the day on which the presence of acute thrombosis is suspected.

Selective sclerotherapy of the internal spermatic vein in patients with varicoceles.

Percutaneous occlusion therapy of insufficient internal spermatic veins was performed successfully as an outpatient procedure in 155 patients with varicoceles. The administration of the sclerosing agent (Varicocid) through a catheter selectively introduced into the spermatic vein caused therapeutic occlusion. Follow-up studies, both clinical and phlebographic, confirmed the effectiveness of the treatment.

[Phlebography of the internal spermatic vein (author's transl)]. / Phlebographie der Vena spermatica interna.

Phlebography of the internal spermatic vein in male patients suffering from infertility is a diagnostic procedure of low risk. In 432 patients examined for this condition, varicoceles were found, 67.5% of which occurred on the left, 13.8% on the right side. This fairly high number of varicoceles on the right side was surprising. It may be due to the technique, which requires standardisation and an experienced examiner in order to achieve a high rate of success. The possibility of a connection between unsatisfactory examination technique and unsatisfactory therapeutic results is discussed.

New technical trends in coronary laboratories.

Increasing experience and improvement of the techniques used in coronary angiography and left ventriculography, have advanced patient safety and the proper assessment of coronary heart disease. High-resolution image intensifiers, coupled with the use of 50 or 25 frames-per-second cinematography or 100 mm spot film technique, offer diverse possibilities for optimal documentation of the morphologic findings. For an evaluation of both hemodynamics and cinematography, computer-assisted units increasingly simplify work and offer greater safety in procedures that assess ventricular function.

[Percutaneous peripheral laser angioplasty: initial clinical results]. / Perkutane periphere Laserangioplastie: erste klinische Ergebnisse.

Laser angioplasty has developed as a new method for the treatment of peripheral arterial occlusive disease. In 19 patients with high grade stenoses or obstructions of the superficial femoral, popliteal or posterior tibial arteries (Fontaine stage IIa-IV) percutaneous transluminal laser angioplasty was performed using a novel laser catheter system. The laser catheter itself is made of polyethylene. Its distal tip is formed ovally and marked X-ray densely. A silica fiber (core diameter 0.6 mm) for delivering the laser energy is inserted into the laser catheter. Through a sheath with hemostatic valve, laser catheter and silica fiber are introduced into the artery and then advanced to the stenosis over a guide wire. During laser angioplasty, laser catheter and silica fiber are rotated around the guide wire. We use a cw-Nd: YAG laser with a wavelength of 1064 nm. The mean degree of stenosis decreased from 92 +/- 12% before to 31 +/- 19% after laser angioplasty. By conventional balloon angioplasty a further reduction of the degree of stenosis down to 15 +/- 20% was achieved. The mean systolic Doppler ankle-arm pressure ratio improved from 0.56 +/- 0.25 before laser angioplasty to 0.89 +/- 0.24 after combined laser and balloon angioplasty. In seven patients, clinically non-significant distal embolization occurred. In no patient there was a perforation of the arterial wall. Up to now, digital subtraction angiography 3 months after laser angioplasty has been performed in five patients and showed patency of all lesions. The mean systolic Doppler ankle-arm pressure ratio was 0.84 +/- 0.20.

[Results of percutaneous transluminal angioplasty]. / Ergebnisse der perkutanen transluminalen Angioplastie.

Percutaneous transluminal angioplasty (PTA) can be subdivided into three epochs: 1. from its inception by Dotter and Judkins up to the first coronary artery stenosis dilatation with the Grüntzig balloon catheter system; 2. from the introduction of coronary stenosis dilatation by Grüntzig up to its unequivocal acceptance; 3. the period of influence of low-risk coronary dilatation on peripheral angioplasty and the search for techniques to compliment or obviate the need for balloon dilatation. The Grüntzig double-lumen balloon catheter system contributed to the lower rate of complications and higher success rate. The clinical acceptance appeared greater for the coronary arteries since, in contrast to the peripheral vascular system, the indication for treatment is established by the physician performing the dilatation. PTA implies percutaneous puncture of a vessel with Seldinger technique and introduction of devices such as guidewires, Dotter or Grüntzig catheters among others, catheters with fiberglass for laser conduction and instruments for fractionating, drilling and cutting. The goal of PTA is to completely or partially eliminate, without surgery, intraluminal vascular narrowing in the presence of peripheral arterial disease in stage II, III or IV. Prerequisite to the use of PTA are: 1. adequate fluoroscopic and angiographic facilities; 2. adequate instrumentation; 3. experience with at least 200 procedures; 4. knowledge of the pathophysiology and adjunctive treatment; 5. knowledge of the treatment of complications; 6. cooperation with a vascular surgery service. A number of factors may influence the results of treatment. Adjunctive medical treatment: the use of platelet aggregation inhibitors and heparin influences the rate of early rethrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Indication for chemoembolization of liver tumors. An interdisciplinary concept and initial results]. / Indikation zur Chemoembolisation maligner Lebertumoren. Ein interdisziplinäres Konzept und erste Ergebnisse.

We present a new concept after Schultheis which is based on the results of experimental studies on cell cultures. Local chemoembolization in liver tumours including liver metastases is usually performed via the angiographic route. Embolisation of the most peripheral branches of the hepatic artery prevents early formation of collateral vessels. The method also comprises the additional infusion of cytostatic agents via the portal vein. The procedure is usually repeated after an interval of about four weeks. In this paper we will describe our method in liver metastases and present the preliminary results obtained from 19 patients treated to date.

Results of percutaneous transluminal angioplasty.

Percutaneous transluminal angioplasty (Dotter technique) was used in 2,942 cases of iliofemoral atheromatous disease. Results varied with the characteristics of the obstructing lesion (length and location) and the clinical stage of ischemia (claudication, rest pain, gangrene). Based on the foregoing, angioplasty is done either as the preferred primary treatment or for the relief of clinically advanced disease in patients unsuitable for high risk surgery. Success is favored by the use of aggregation inhibitors and single-use Teflon or balloon catheters; complications are few.

[Chemoembolization of colorectal liver metastases]. / Chemoembolisation kolorektaler Lebermetastasen.

In the Center of Surgery of the Justus-Liebig-University Giessen and in the General Hospital in Nuremberg from 1983 to 1987 21 patients with metastases of a colorectal carcinoma were treated with chemoembolization (CHE). The on average survival period of patients treated with chemoembolization after non-successful application of regional chemotherapy amounted to 6 months. The total survival period of these patients amounted to 17.4 months. Since March 1987 chemoembolization has been applied as initial therapy. The on average survival period of the patients, initially treated with cheomoembolization at present amounts to 14 months. 4 of these patients additionally got chemotherapy by the portal vein after CHE. The survival period of 2 patients, having been resected several times after CHE, at present comes to 27 months. These results are the base for a clinical study, in which CHE is combined with the portal venous infusion of a cytostatic agent (Folin acid 5-FU).