[Surgical Indications for Diverticulitis in Germany: Are All Operations Justified?]. / Operationsindikation der Sigmadivertikulitis in Deutschland: Sind alle Operationen gerechtfertigt?

INTRODUCTION: Pathological changes of preexisting sigma diverticulosis into a state of sigma diverticulitis are possible. Treatment of sigma diverticulitis accounts for a significant proportion of emergency treatments in clinics. The number of patients treated for sigma diverticulitis has risen steadily in recent years. Although it can be observed that operated cases making 7 % compared with 14 % to all stationary admissions, there is a less marked increase. Nevertheless, the question should be clarified as to how high the proportion of complicated surgical cases is in relation to non-complicated cases. It is important to clarify, in this context, if each operation is justified or whether in some cases there is over-treatment. MATERIAL AND METHODS: All data relating to Germany, were prospectively collected by the treating hospitals using the DRG and evaluated by the Federal Statistical Office. The treatment numbers from Erlangen were prospectively collected from the encrypted DRG and analysed retrospectively by the coding officer. The investigated period lasted from 2005 to 2010. To demonstrate some treatment options, the following possible forms of therapy were examined with reference to the Hansen/Stock classification. RESULTS: In Germany, about 40 % of stationary patients with sigma diverticulitis are treated surgically. It is striking that in about two thirds of all operated patients uncomplicated forms of diverticulitis were present. The remainder consisted of covered or free perforations. For these complicated forms, various treatment approaches have been established. Ultimately, in dependence of timing these are always surgically treated. In the milder forms the general indication for surgery has come into discussion as the recommendation for a surgical approach after the second relapse in the symptom-free interval is being questioned by several groups based on the age of the studies on which the recommendations are based. CONCLUSION: A significant increase in hospital admissions and surgically treated patients is demonstrated. Striking was that a closer analysis of data revealed that mainly non-complicated cases were surgically treated. This should be seen as a clear indication for an over-treatment. Therefore, possibly not all surgeries performed are justified. In the case of complicated forms, in consideration of various treatment paths, surgery is inevitable in most cases.

The pathological assessment of mesorectal excision: implications for further treatment and quality management.

BACKGROUND AND AIMS: Most clinical practice guidelines today recommend total mesorectal excision (TME) for carcinoma of the middle and lower rectal thirds and partial mesorectal excision (PME) for the upper rectal third. However, these procedures may not always fulfill the oncological requirements. The pathological examination of resected rectal carcinomas should always include a visual assessment of the mesorectal excision to ensure oncological adequacy and appropriate quality. The clinical practice guideline of the German Cancer Society recommends reporting of the distal extent of mesorectal excision (total or partial without coning) and the excision in an inviolate fascial envelope. PATIENTS AND METHODS: Reporting schemas of assessment and documentation for daily use and for studies are presented. RESULTS: Careful macroscopic evaluation of the resection specimen should be standardized. This may be supplemented by stain marking after postoperative filling the inferior mesenteric or superior rectal artery with ink or methylene blue solution. Photodocumentation is highly desirable. The pathological assessment of adequacy of mesorectal excision should be taken into account in selection for adjuvant radiotherapy. Objective macro- and microscopic assessment of mesorectal excision by pathologists is essential for quality management throughout patient care and in clinical trials.

[The surgeon as a cost factor. Cost analysis exemplified by surgical treatment of rectal carcinoma]. / Der Chirurg als Kostenfaktor. Kostenanalyse am Beispiel der chirurgischen Behandlung des Rektumkarzinoms.

INTRODUCTION: Besides quality, costs play an increasingly important role. For rectal carcinoma, the cost of the surgical treatment of the disease (including after-care) was analysed under variable clinical conditions. METHODS: Eleven patients (eight men, three women, median age 57 years) with curative resection of rectal carcinoma between 1991 and 1995 were selected: Five patients with an uneventful course remaining recurrence-free, three patients who developed an anastomotic leakage and three patients with locoregional recurrence during their further course. In three patients, adjuvant radiochemotherapy was performed after resection of the primary tumor. For each patient, costs from the first postoperative day until the end of an assumed after-care of 5 years' duration were analysed. RESULTS: Costs for the postoperative period of the primary treatment ranged between 3.162 DM and 149.988 DM, in case of development of an anastomotic leakage between 14.699 DM and 149.988 DM. Adjuvant radiochemotherapy increased costs by 12.265 DM up to 23.259 DM, locoregional recurrence caused additional costs between 9.461 DM and 27.301 DM. Cost group analysis showed the costs for nursing care to be the highest (30% of total costs), followed by the expense for drugs and medication. Total costs of treatment ranged from 7.361 DM to 160.833 DM. CONCLUSIONS: Costs as well as the patient's prognosis depend to a great extent on the quality of the procedure and consequently on the individual operating surgeon. A complicated course is associated with a considerable increase in costs. A complete cost analysis of rectal carcinoma has to include the cost of a potential locoregional recurrence which would lead to the additional prolonged after-care for these patients.

[CT-guided percutaneous core biopsy: Effective accuracy, diagnostic utility and effective costs]. / CT-gesteuerte perkutane Schneidbiopsie: effektive Genauigkeit, diagnostischer Nutzen und effektive Kosten.

PURPOSE: The value of a diagnostic technique does not only depend on its sensitivity, specificity and accuracy, but also on how its results affect clinical management. This effect is represented by the values effective accuracy and the diagnostic utility which were determined for CT-guided coaxial core biopsies in this study. MATERIALS AND METHODS: 180 consecutive biopsies were analyzed. The results were analyzed with the help of a logistic regression analysis with regard to the organ regions biopsied, the size of the needle used, and the number of tissue cores taken. Correct results that were not accepted as diagnostic clinically and resulted in additional biopsies were scored together with the false results under negative utility coefficients. RESULTS: The sensitivity, specificity and accuracy of all the tests amounted to 91.1 %, 100 %, and 93.3 %, respectively. The diagnostic utility of the biopsies varied between 66 % for the liver and pancreatic lesions, and 88 % for the non-organ related retroperitoneum. In those cases where more than three tissue cores were taken the results were statistically significantly better in terms of effective accuracy and diagnostic utility. No significant differences were found with regard to different needle sizes in the biopsied organ regions. The lowest clinical acceptance was observed for the histological findings "scar tissue" and "inflammation". CONCLUSION: CT-guided coaxial biopsies offer a high degree of sensitivity, specificity and accuracy, as well as a low rate of therapeutically relevant complications. With increasing use of differentiated strategies in therapy for malignomas percutaneous biopsies play a very important role in the management of these diseases. Prospective studies should further evaluate the effective accuracy and diagnostic utility of core biopsies also in comparison to fine needle aspiration biopsies (FNAP).

Percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) for decompression in the upper gastrointestinal tract. Initial experience with palliative treatment of gastrointestinal obstruction in terminally ill patients with advanced carcinomas.

BACKGROUND: Signs of gastrointestinal obstruction, with intractable vomiting and an inability to take oral food, are common symptoms in terminally ill cancer patients with advanced primary tumors or peritoneal carcinomatosis. The application of percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEJ) instead of the usual nasoenteral tube is a simple method of achieving permanent decompression in the upper gastrointestinal tract. The goals of this study, in addition to establishing indications and outcome, were to identify specific aspects of tube placement and to determine the incidence of complications. METHOD: Over a period of 3 years, a total of 24 consecutive patients (mean age, 64 years; range, 37-83 years) underwent either a PEG (17/71%) or a PEJ (seven/29%). RESULTS: In all patients, PEG/PEJ obviated the need for the nasoenteral tube. A total of 22 patients (92%) were enabled to take liquids orally, and 20 (83%) were discharged to home care. With the exception of a single spontaneous dislodgement of the PEG tube, no major complications were observed. CONCLUSION: We believe that PEG/PEJ represents an effective, minimally invasive, and cost-effective method for gastrointestinal decompression in patients with advanced incurable cancer.

[Regional cooperation in molecular biology topics]. / Regionale Zusammenarbeit für eine molekularbiologische Fragestellung.

Research on rare events, such as the occurrence of port-site metastases, can be speeded up by pooling patients from different hospitals. Multidisciplinary approaches, involving surgeons, pathologists and molecular biologists, allow more detailed experimental results to be obtained. Research costs are kept low by using existing infrastructures over a short period of time.

[Verifying routine preoperative diagnosis between private practice and the surgical university clinic]. / Abstimmung der präoperativen Routinediagnostik zwischen niedergelassener Praxis und Chirurgischer Universitätsklinik.

In an attempt to shorten the preoperative in-patient period and to avoid unnecessary investigations, a cooperative patient management model was established for a number of surgical operations at the University Department of Surgery, Anaesthesiology and their referring Specialist and General Practitioners. The latter were requested to carry out the previously defined preoperative routine investigations, which allowed for a marked reduction in hospital diagnostics. Ambulatory preoperative patient management and a new admission routine resulted in a 57% decrease of the average preoperative in-patient stay for the observed procedures.

[Electronic data processing in ward management--possibilities for rationalization and cost control]. / EDV-Stationsmanagement--Möglichkeiten zur Rationalisierung und Kostendämpfung.

Electronic data processing in ward management increases cost and time efficiency. Nurses and doctors will have more time to concentrate their genuine rather than administrative duties. Therefore the presented model has gained high acceptance.

[Optimizing a conventional documentation system on the surgical intensive care unit--a contribution to cost reduction and preventive quality management?]. / Optimierung eines konventionellen Dokumentationssystems auf der chirurgischen Intensivstation--ein Beitrag zu Kostenreduktion und präventivem Qualitätsmanagement?

In Intensive Care Units (I.C.U.), the lack of staff and funds require the mobilisation of organisational reserves in order to ensure high-quality patient care. Traditional occupational-group organised documentation systems are burdened with lack of clarity, limited utilisation by the staff, insufficient information content and difficulties in synoptic patient monitoring. They cannot meet the demands of modern intensive-care medicine. At the inauguration of our Surgical I.C.U. in June 1992, an occupational-group oriented documentation system was introduced and put into operation. Because of negative repercussions on patient care, it was replaced by a patient-centered, conventional prescription and documentation system in April 1993. In April 1994, an evaluation of the patient-centered system was carried out. We report on our initial problem analysis, the subsequent developmental and introductory phases, and the results after having used the system in our I.C.U. for one year. Data condensation, standardised data recording, as well as structured prescription, examination, assessment and decision processes, saved 730 working hours for medical and nursing staff per year, reduced the cost for documentation materials by 58% and improved the extent of data recording. In our experience, improving a conventional documentation system is a suitable instrument to support cost reduction and preventive internal quality management in the I.C.U.

[Performance and cost analysis of surgical therapy of stomach carcinoma--results and sequelae]. / Leistungs- und Kostenanalyse der chirurgischen Therapie des Magenkarzinoms--Ergebnisse und Folgerungen.

In order to identify opportunities for cost containment in gastric cancer surgery, and analysis of pre-, peri-, and postoperative cost profiles was performed for 60 gastric cancer patients who underwent curative resections (76.6%), explorative laparotomies (18.3%), and palliative gastrojejunostomies (5%). While pre- and perioperative phases only offer limited opportunities for cost reduction, postoperative complications raised the mean length of hospital stay by 47%, the mean length of intensive care treatment by 865%, and the total treatment costs by 84-248% compared to an uncomplicated clinical course. Pre-, peri-, and postoperative cost-containment efforts must focus on the prevention of postoperative complications.