[Quality control in patient education. Results of a patient survey about the patient education protocol of the Swiss Society of Surgery in 6 Swiss hospitals]. / Qualitätskontrolle der Patientenaufklärung. Resultate der Patientenbefragung über das Aufklärungsprotokoll der Schweizerischen Gesellschaft für Chirurgie (SGC) in sechs Schweizer Spitälern.

In the past years the number of malpractice suits due to lack of patient information has increased. Because there have been no generally accepted guidelines for preoperative patient information, the Swiss Society of Surgery has decided to work out an informative brochure tailored to the needs of patients. It takes into account that the need to know beforehand is increasing rapidly. In collaboration with the judiciary service of the Swiss Medical Federation all the items and points of legal relevance have been compiled to establish an informative brochure. Based on this protocol, patients in surgical departments of 6 Swiss community hospitals were asked before discharge to qualify the preoperative information offered to them. 2660 questionnaires were evaluated. The majority of patients considered the information regarding their diagnosis, the complications, risks, treatment and postoperative care, the sketches describing the operation and the overall degree of information as good or very good. Almost 60% of all patients stated that no alternative treatment had been discussed with them other than the planned procedure. In most of these patients operative procedures were chosen and carried out for which there were few or no other acceptable options. 2/3 of the patients asked for immediate preoperative written information, especially if they had malignant disease. Barely 4% of the patients were not reassured by the information provided to them. The fact that 2/3 of all patients re-read the informative protocol before the operation underlines how important it is to hand out a copy of the protocol to satisfy the informative needs of the patients. To our surprise the vast majority of patients uttered little concern about giving their signature to forms that were presented to them. Only 2% of the patients felt that giving a signature would cause them grave reservations. The informative protocol devised by the Swiss Society of Surgery is well adapted to the informative needs of the patients and allows for a structured conversation. It facilitates documentation and offers valid legal proof for the physician that he/she has provided adequate information.

[Late results of Childs-Phillips mesenteric plication for therapy and prevention of small intestine ileus]. / Spätresultate der Mesenterialplikatur nach Childs-Phillips zur Therapie und Prophylaxe des Dünndarmileus.

During the past 7 years 45 patients have been operated upon using the Childs-Phillips method. Of those, 37 were subsequently examined for the study--7 patients had died in the meantime. None of the deaths occurred as a direct result of transmesenteric small-bowel plication. An early recurrence of intestinal obstruction occurred in 4.4% and a laparotomy was repeated. During the most recent examinations 86.5% of those patients checked had (virtually) no complaints--91.9% based upon the Visick classification. A subtotal intestinal obstruction occurred during the period of the study in 8.1% of cases, but could be conservatively treated. Up until the most recent examination there were still no instances of a late recurrence. Most intestinal obstruction recurrences are due to errors specific to the technique and are early recurrences. On the basis of our results, we are of the opinion that plication in the presence of existing peritonitis, as well as partial plication, is acceptable.

[Thoracic sympathectomy in palmar hyperhidrosis: comparison of open with thorascopic procedure]. / Die thorakale Sympathektomie bei der Hyperhidrosis palmarum: Vergleich / thorakoskopisches Vorgehen.

Between 1976 and 1994 we performed 26 thoracic sympathectomies for treatment of therapy-resistant palmar hyperhidrosis. Until the end of 1992 the operation was performed using an open transaxillary approach, since 1993 sympathectomy was done by video-assisted thoracoscopy. Both procedures consisted in excision of the thoracic ganglia T2 to T5. The only complication was a pneumothorax in the open surgery group (successfully treated by drainage). Compensatory sweating occurred in 70% of our patients, compared to results in the literature of 60-90%. We did not note further complications, e.g. no Horner's syndrome. All of our patients were satisfied with the result of the operation. Comparison of the two collectives shows significant advantages for video-assisted thoracoscopic surgery. the procedure is easier to perform, exposure is better, cosmetic results are favourable, operation-time and hospital stay are reduced.

[Emergency carotid endarterectomy in acute infarction--case report and literature review]. / Notfallmässige Carotisendarterektomie im akuten Infarkt--Case Report und Literaturübersicht.

Elective operation of carotid stenosis over 70% is uncontested since publication of the interim results of NASCET and ECST [1,2] trials. Even though emergency carotid endarterectomy for rapidly progressing cerebral infarction (stroke in evolution) remains very controversial outcome depends on how fast cerebral perfusion is reestablished, complete recovery is possible if carotid thrombendarterectomy is successfully performed in between the first 6-8 hours. We report the case of a female patient developing a cerebral infarction on the first postoperative day after femoropopliteal bypass grafting. Diagnosis of an acute carotid occlusion was established by cerebral duplex sonography, intracerebral hemorrhage was excluded by emergency computed tomography. Emergency thrombendarterectomy successfully reverted all cerebral symptoms. Postoperative course was uneventful, the patient was dismissed on the 12th postoperative day without any neurological residual deficit.

[Surgical treatment of varices at the stage of trophic disorders in chronic venous insufficiency]. / Le traitement chirurgical des varices au stade des troubles trophiques lors d'insuffisance veineuse chronique.

Most ulcers of the lower limbs are caused by existing chronic venous insufficiency. Later on, true social and professional problems will arise, with serious economic and psychological consequences not only for the patient himself, but for the community as well, such as huge medical costs--hence the importance of prevention and treatment, which must in no case be purely symptomatic. The ligation of the arch and of the perforating veins and stripping of the affected vein are part of the classical management of varices. These procedures can may prove to be virtually impossible in case of chronic venous insufficiency, if the patient also presents with subcutaneous liposclerosis or atrophy in an already pregangrenous skin. This preulcerous stage can be aggravated later on if the requirements for surgical repair are not met. Necrosis can then occur, if too aggressive surgery directly or indirectly injures the microcirculatory system of the damaged skin. Omitted or undesirable acts are dangerous at the stage of trophic disorders and surgery may fail to reach its aim, which of course would be to definitively and quickly eliminate the varicose disease.

[Infected vascular prostheses]. / Infizierte Gefässprothesen.

Szilagyi's statement: 'The management of cases with infected arterial implants proves to be a task of grave and sometimes insurmountable difficulty' has kept its validity until today. In spite of restrictive patient selection, perfect surgical skill and perioperative antibiotic prophylaxis, infection of vascular grafts still do occur. Diagnosis has to be established without delay, and treatment of such often fatal infections is an aggressive surgical one.

Swiss adjuvant trial (OSAKO 06/74) with chlorambucil, methotrexate, and 5-fluorouracil plus BCG in node-negative breast cancer patients: nine-year results.

Between 1974 and 1977, a total of 254 patients with stages T1-3a, N0-1, and M0 operable breast cancer (node negative and node positive, stratified) were randomized to either modified radical mastectomy alone or the same surgery and adjuvant chlorambucil, methotrexate, 5-fluorouracil (LMF) plus BCG. After a median follow-up of 9 years (January 1985), we concluded that LMF plus BCG significantly increased relapse-free survival (RFS) in 240 fully evaluated patients, especially postmenopausal women. This gain in RFS ceased to transform into a gain in overall survival (OAS) after 7 years of median follow-up for the whole patient group. In the 122 node-negative patients studied, LMF plus BCG produced a marked increase in RFS up to the fifth year and in OAS up to 8 years after initial surgery, thus prolonging significantly the median disease-free interval compared with surgical control patients. This trend favoring LMF plus BCG-treated patients continues. Although median time to first relapse and to generalized disease were increased in relapsing patients by LMF plus BCG, the subsequent intervals from local relapse to distant disease and from distant metastases to death were equal for both treatment regimens. Subjective and objective acute toxicity from LMF plus BCG was mild. At 9 years of median follow-up, fewer second tumors were noted in the node-negative group receiving LMF plus BCG than in surgical controls.

[The risk of hemorrhaging in the prevention of thromboembolism in general surgery: comparison of low-dose heparin and heparin-dihydergot 2500]. / Das Blutungsrisiko der Thromboembolie-Prophylaxe in der Allgemeinchirurgie: Vergleich von low-dose-Heparin mit Heparin-Dihydergot 2500.

In a prospective randomized double-blind study, the risk of heparin-induced intra- or postoperative hemorrhage in prophylaxis of thromboembolism was studied. 500 general surgical patients were divided into 2 groups; group A receiving a reduced portion of heparin (2 X 2500 IU) in combination with 0.5 mg dihydroergotamine (DHE) was compared to group B with conventional low dose heparin regimen (2 X 5000 IU) with regard to postoperative wound hematomas and reoperation for hematoma. After prophylaxis with heparin dihydroergotamine 2500 wound hematoma and reoperation for hematoma are shown to be reduced in a significant way (p = 0.03).

Adjuvant chemoimmunotherapy with LMF plus BCG in node-negative and node-positive breast cancer - intermediate report at 4 years.

A randomized surgical adjuvant trial in 242 evaluable patients with T1-3a, N0-1, and M0 breast cancer was initiated 4 years ago. The well-tolerated, oral combination chemotherapy with six cycles of Leukeran plus methotrexate plus fluorouracil (LMF) plus repeated BCG skin scarifications was used. After 4 years, the following results were seen: (1) significant increase of relapse-free (RFS) and also overall survival (S) in both pre- and postmenopausal node-negative patients versus surgical controls (RFS 91.1 vs. 701%, P = 0.003; S 96 vs. 88%, P = 0.03); (2) no significant increase of RFS or S in pre- and postmenopausal node-positive patients versus surgical controls (RFS 50.1 versus 44%, P = 0.49; S 70 versus 68 %, P = 0.9, respectively); (3) Patients receiving greater than 90% of the planned LMF dose showed significantly better survival after 4 years; and (4) Nonrandomized comparison with concurrent Swiss adjuvant studies with LMF alone indicate no beneficial or harmful effect of BCG skin scarifications in addition to the six-cycle LMF.

[Antibiotic prophylaxis in elective colon surgery: comparison of the combination of metronidazole (Flagyl)/cefazolin (Kefzol) with cefazolin alone]. / Antibiotikaprophylaxe in der elektiven Kolonchirurgie: Vergleich der Kombination Metronidazol (Flagyl)/Cefazolin (Kefzol) mit Cefazolin allein.

In this prospective trial prevention of infectious complications after elective colonic surgery was studied. 34 patients receiving i.v. cefazolin were compared to 32 patients receiving oral metronidazol and i.v. cefazolin. No significant difference was observed concerning local wound infection, septicemia, anastomotic dehiscence or death. The rate of postoperative infection was 53% in group I, 34% in group II. No side effects of this prophylaxis were observed.

[Follow-up study of B-II-stomachs: clinical, endoscopic and histologic results]. / Spätuntersuchungen des B-II-Magens: klinische, endoskopische und histologische Resultate.

Histological investigation leads to significantly more reliable evaluation of the B-2 stump than do clinical or endoscopic examinations. This is the result of our study, in which follow-up examinations in 58 patients were undertaken 25 to 30 years after B-2 resection for benign ulcer. Of these 58 patients 23 were examined endoscopically and histologically (22 patients). The histological results of interest are: early cancer, dysplasia and intestinal metaplasia. - Carcinoma of the gastric stump occurs only occasionally earlier than 15 years after resection. In order to detect more early cancers, we therefore suggest that a routine endoscopy and histological evaluation of the gastric mucosa should be undertaken 15 years after gastric resection for benign ulcer. Further follow-ups depend on the result of this "staging" of the gastric mucosa.

[Paraganglioma of the glomus caroticum]. / Paragangliom des Glomus caroticum.

Extra-adrenal paraganglioma (chemodectoma) is a rare tumor; the tumor of the carotid body is the most frequently observed chemodectoma. Histochemical analysis of the glomus cell shows catecholamine in all cases, but functional activity of those tumors is an exception. The diagnosis of carotid body tumor can be confirmed by carotid arteriography. Surgery is the treatment of choice. Malignant degeneration of chemodectoma has been observed in a few cases.

Congenital duodenal membrane as cause for hiatus hernia, stricture of the oesophagus, and stricture carcinoma in an adult with Down's syndrome.

The case of a 31 year old male mongoloid patient is reported, where a congenital duodenal membrane, asymptomatic in childhood, had led to hiatal hernia, stricture of the oesophagus, and finally to carcinoma of the stricture (Fig. 1). Observation time until death was 26 months. In a first operation, the membrane was resected (Fig. 2) and Nissen's fundoplication performed. 31/2 months after that stricture, carcinoma was diagnosed. In the second operation, carcinoma was resected and continuity reestablished by oesophagogastrostomy. The patient died 8 months after the second intervention.

Delayed arterial embolectomy: a plea for a more active surgical approach.

In a series of 18 patients delayed embolectomy of the limb was performed 8-63 days after embolism had occurred. Three patients died (2 of them after amputation), and 7 limbs were amputated after surgery. In 10 instances blood flow was fully restored by the operation. Analysis of the 18 cases leads to the conclusion that the success of delayed embolectomy where neuromuscular function is intact depends primarily on surgical technique. Direct embolectomy by local or regional exposure of the obstructed arterial level is shown to produce better results than conventional (distant) balloon catheter embolectomy by proximal incision. This is thought to be due to increased mural adherence of the embolus, with secondary thrombus formation after a delay of 8 days or more. A plea is therefore made for a more aggressive surgical attitude to delayed arterial embolization. Provided that preoperative arteriography has localized the obstructive level and that the patient's general condition allows major vascular surgery, direct removal of the embolus and secondary thrombi by open exposure of the obstructed artery is recommended.