Complications of permanent transvenous cardiac pacing.

Clinical experience with permanent transvenous pacing during a 6 year period at Hannover Medical School is presented. A total of 1,376 pacemaker operations were performed in 799 patients, with a mortality rate of 1.1 per cent. The most common complications were premature battery failure, dislocation of endocardial electrodes, infections of the generator and/or electrodes, and skin ulcerations. In our cumulative follow-up period of 1,225 years, a complication necessitating a reoperation is to be expected after an average function-time of 31 months. Including normal battery exhaustion in this calculation will make reoperation necessary every 21.9 months.

Statistical pattern detection in univariate time series of intensive care on-line monitoring data.

OBJECTIVES: To determine how different mathematical time series approaches can be implemented for the detection of qualitative patterns in physiologic monitoring data, and which of these approaches could be suitable as a basis for future bedside time series analysis. DESIGN: Off-line time series analysis. SETTING: Surgical intensive care unit of a teaching hospital. PATIENTS: 19 patients requiring hemodynamic monitoring with a pulmonary artery catheter. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Hemodynamic data were acquired in 1-min intervals from a clinical information system and exported into statistical software for further analysis. Altogether, 134 time series for heart rate, mean arterial pressure, and mean pulmonary artery pressure were visually classified by a senior intensivist into five patterns: no change, outlier, temporary level change, permanent level change, and trend. The same series were analyzed with low-order autoregressive (AR) models and with phase space (PS) models. The resulting classifications from both models were compared to the initial classification. Outliers and level changes were detected in most instances with both methods. Trend detection could only be done indirectly. Both methods were more sensitive to pattern changes than they were clinically relevant. Especially with outlier detection, 95% confidence intervals were too close. AR models require direct user interaction, whereas PS models offer opportunities for fully automated time series analysis in this context. CONCLUSION: Statistical patterns in univariate intensive care time series can reliably be detected with AR models and with PS models. For most bedside problems both methods are too sensitive. AR models are highly interactive, and both methods require that users have an explicit knowledge of statistics. While AR models and PS models can be extremely useful in the scientific off-line analysis, routine bedside clinical use cannot yet be recommended.

[Computed tomography of malignant stomach tumors]. / Computertomographie bei malignen Tumoren des Magens.

Forty-four patients with malignant disease of the stomach (41 carcinomas, three non-Hodgkin lymphomas) and two patients with chronic gastric ulcers were examined by computer tomography before undergoing surgery. The ulcers, the non-Hodgkin lymphoma and the carcinomas stages pT2 to pT4 were easily demonstrated, as well as 66% of carcinomas in stage pT1. In addition to the primary tumour, it was possible to recognise lymph node and organ metastases. Two of the 46 patients were not submitted for surgery because of extensive metastases.

[Small intestinal transit with radio-opaque markers to localize intermittent small bowel obstruction] . / Magendarmpassage mit röntgendichten Tracerkugeln zur Lokalisation von Dünndarmstenosen bei intermittierenden Obstruktionen.

AIM: In difficult diagnostic cases of partial small bowel obstruction, radiopaque, non-digestible markers were used to challenge and localize the site of obstruction. MATERIAL AND METHOD: 32 patients (19 female, 13 male, 3-80 years) were examined. Each patient received 20 4-mm radiopaque markers orally. Abdominal radiographs were obtained at 4-8 h intervals. Mechanical obstruction was defined as the clustering of at least 3 markers for 4 hours or longer. The transit of radiopaque markers was compared to plain radiography, ultrasound, barium meal, computed tomography, enteroclysis and operative findings. RESULTS: 18 of 32 patients showed small bowel clustering suggestive of obstruction. Diagnostic agreement was found in 12 of 14 cases with ultrasound, in 7 of 13 cases with plain radiography and in 3 of 6 cases with enteroclysis. 13 of the 18 patients with clustering had surgery. All of them (13/13) had adhesions with the need of resection. CONCLUSION: This investigation is an alternative diagnostic method for the decision between conservative and surgical treatment in cases of intermittent partial small bowel obstruction.

[Multiple colorectal cancers: properties and long-term prognosis]. / Colorectale Mehrfachcarcinome: Eigenschaften und Langzeitprognose.

In our own patient population with primary colorectal cancer (n = 1352, 1971-1984) we analyzed the frequency, characteristics and prognosis of multiple carcinomas. The overall incidence was 7.3% (4.5% synchronous and 2.8% metachronous carcinomas). Compared to single cancer synchronous tumors had a worse and metachronous tumors had a better 5 year-prognosis (58%, 43% and 86% respectively). This suggests that synchronous and metachronous colorectal carcinomas may be two biologically separate entities. Conclusions from our observations are discussed in regard to diagnosis, therapy and follow-up.

[Increased wound healing disorders in patients with inguinal hernia caused by administration of antithrombotic agents in the abdominal wall]. / Vermehrte Wundheilungsstörungen bei Leistenhernienpatienten durch Applikation der Thromboseprophylaxe in die Bauchdecken.

In a prospective, randomized study, including 108 patients, we investigated the effect of different locations for the subcutaneous injection of low dosed or low molecular heparin following standard herniotomia. In the group with injection into the contralateral abdominal wall the rate of local surgical complications was four times higher compared to those patients with injections into the thigh. Thus we conclude that after herniotomia low dosed or low molecular heparin should be applied into the subcutis of the thigh.

[Polyposis coli. Comparison between the familial and non-familial form]. / Polypose des Dickdarms. Ein Vergleich der familiären mit der nichtfamiliären Form

Since 1970 16 patients with polyposis coli have been treated at the Department of Surgery, Medical School, Hannover. Of these, 9 patients showed the classic type of familial polyposis, while 7 patients denied a positive family history. Comparing both groups, the nonfamilial type of polyposis coli can be separated as well from the familial polyposis as from multiple adenomas of the large bowel. Operative treatment in both groups of polyposis coli and management of nonfamilial polyposis coli are discussed.

[Hepato-biliary sequence-scintigraphy in pre- and postoperative upper abdominal diagnosis. Studies on 200 patients using the radiopharmacon 99mTechnetium-Solcoscint-Hepatobida]. / Hepato-biliäre Sequenzszintigraphie in prä- und postoperativer Oberbauchdiagnostik. Untersuchungen an 200 Patienten mit dem Radiopharmakon 99mTechnetium-Solcoscint-Hepatobida.

Hepato-biliary dynamic studies with 99mTc-Solcoscint-Hepatobida are suggested in the pre- and postoperative investigation of patients with possible surgical disease of the biliary tract. The equipment used for the studies was a gamma camera. The diagnostic criteria used were those of blood retention, liver, gall bladder, and biliary tree visualisation. Results from findings in 200 patients are presented to demonstrate the ability of the technique; especially to disclose evidence indicating intra- or extrahepatic causes of cholestasis.

[Use of a new method for the determination of the duodeno- and jejunogastral reflux after gastric surgery]. / Die Anwendung einer neuen Methode zur Bestimmung des duodeno- und jejunogastralen Reflux nach Magenoperationen. Vorläufige Mitteilung.

The use of hepato-biliary sequential scintigraphy with 99mTechnetium as a new method to demonstrate duodenogastric or jejunogastric reflux is described. In contrast to other techniques, the benefit of minimal stress for patients, routine practice, and combined measurement of fasting and postprandial reflux is pointed out. First clinical studies in postoperative patients are presented and it is accentuated, that this technique has a special field of application in gastric surgery.

[Selective proximal vagotomy with ulcer excision or Billroth I resection in chronic stomach ulcer. A prospective randomized multicenter study]. / Selektiv-proximale Vagotomie mit Ulcusexcision oder Billroth I-Resektion beim chronischen Ulcus ventriculi. Eine prospektive randomisierte Multicenter-Studie.

In a prospective randomised multicenter study in 41 patients with chronic gastric ulcer type I according to Johnston we compared selective proximal vagotomy (SPV) plus ulcerectomy (21 patients) with a standardised Billroth I gastrectomy (20 patients). The follow-up period was at least 2 years. Preoperative characteristics of both groups did not differ. Intraoperatively, in 5 patients of the SPV group technical problems during dissection of the lesser curvature occurred. The main postoperative complaints were pain and epigastric fullness after SPV and bile vomiting, early dumping or diarrhea after Billroth I gastrectomy. 3 of 21 patients after SPV developed recurrent ulceration, whereas after BI resection no recurrence was observed. This study indicates a higher recurrence rate in gastric ulcer patients after SPV compared to Billroth I gastrectomy.

[The Dufourmentel flap-plasty for treatment of chronic pilonidal sinus]. / Die Dufourmentel-Lappenplastik zur Behandlung des chronischen Sinus pilonidalis.

Thirty-seven patients with chronic sinus pilonidalis were treated after total excision by Dufourmentel flap. We saw seroma complications in three and wound infections in two cases. Patients stayed in hospital 6.3 days on an average and were able to work after 2.5 weeks. The method is easy to use. We have not seen a return to sinus problems in any of this cases.

[Results of preoperative radio-chemotherapy in locally advanced squamous epithelial cancer of the esophagus]. / Ergebnisse der präoperativen Radio-Chemotherapie beim lokal fortgeschrittenen Plattenepithelcarcinom des Oesophagus.

In a 4-year period (1988-1991) 122 patients with a squamous cell carcinoma of the esophagus were studied prospectively and analysed. 64 patients of them could be primary resected (primary resectability rate 52%), 36 patients were in general inoperable and 22 patients had an advanced stage of cancer with local inoperability. Due to a preoperative combined radiotherapy and chemotherapy 16 of the 22 patients with local inoperability had a clinical remission of the tumor (73%). 11 patients (50%) showed a histological verified down staging and 3 cases of them a complete remission (no primary tumor was found, no infiltration of the regional lymphnodes and no metastatic disease). Curative resection was possible in 14 of 16 patients with clinical remission (2 patients refused surgical treatment). So the resectability rate now increases from 52 to 63%. We conclude that there was no increased rate of postoperative complications or mortality in the combined radio-/chemotherapy group compared with the primary resected patients.

[Technic and problems of resection of small intestine segments for free transplantation]. / Technik und Probleme bei der Dünndarmsegmententnahme zur freien Transplantation.

The removal of a segment of the small bowel for free microvascular transplantation corresponds to a small bowel resection in routine abdominal surgery. Attention must be given to the careful preparation of a sufficiently long vascular pedicle, clear separation and marking of the artery and vein, and adaptation of the mesentery to the graft location. According to the author's experience inflammatory small bowel disease and general occlusive vascular disease are contraindications to small bowel transplantation.

[The free jejunal graft for the reconstruction of the hypopharynx and cervical esophagus]. / Das freie Jejunuminterponat zur Rekonstruktion von Hypopharynx und zervikalem Osophagus.

The free jejunal transfer for primary reconstruction of the cervical oesophagus after laryngo-pharyngectomy was described more than 20 years ago. Its popularity as a surgical method has increased in recent years with improvement in microsurgical techniques. Tumour resection and preparation of the jejunal graft are performed synchronously by two surgical teams. After suturing the graft into the defect the mesenteric vessels are usually anastomosed to the superior thyroid pedicle. In this series four patients are presented, in three there were no complications, in the fourth a fistula developed despite adequate vascularisation of the transfer. The jejunal graft has proved to be a good functional replacement for the cervical oesophagus. Experience in other series have shown the risks of necrosis, fistulae, stenosis and abdominal complications to be minimal.

[New aspects of the reconstruction of large defects of the oral mucosa with microvascularly anastomosed small intestinal grafts]. / Neue Aspekte bei der Wiederherstellung von grossen Schleimhautdefekten der Mundhöhle durch mikrovaskulär anastomosierte Dünndarmtransplantate.

Our experience in reconstruction of extensive defects in the oral mucosa with free jejunal grafts in 15 patients is reported. The jejunum provides a well vascularised mucosal lining, which is resistant to mechanical stress and being a thin flap contours well in the mouth. Methods of avoiding technical failure are described. The technique permits radical resection of oral tumours.

[Surgical therapy of esophageal cancer--early results]. / Die operative Therapie des Osophaguskarzinoms--Frühergebnisse.

PATIENTS AND METHOD: A prospective study was undertaken in 230 patients with carcinoma of the esophagus and of the cardia with infiltration of the distal oesophageal part from 1988 to 1993. RESULTS: According to postoperative UICC-classification 3% of patients had stage 0, 43% stage I/II and 54% stage III/IV. 162/230 were resected (resection rate 70.4%). 55% (89/162) of resected patients had thoracoabdominocervical, 38% (62) thoracoabdominal and 8% (11) transhiatal esophagectomy. Rate of anastomotic break-down was 1.9% (3/162). Clinical mortality decreased from 32% in 1988/89 to 11% in 1990/91 to at least 0% in 1992/93 (total 13%). CONCLUSION: Control of the postoperative phase is of decisive importance in decreasing mortality after esophageal resection, while surgical-technical problems seem to be solved. Esophagectomy is possible even as palliative measure in the presence of low mortality.