An alternative classification of incisional hernias enlisting morphology, body type and risk factors in the assessment of prognosis and tailoring of surgical technique.

Incisional hernias occur in 5-10% of patients who have undergone laparotomy and are associated with a high morbidity and significant socioeconomic costs. Better understanding of the anatomy and improved methods for reinforcement of the abdominal wall with alloplastic meshes have reduced the recurrence rate to 1-10% depending on the type of hernia and the technique employed. A number of surgical repair techniques and mesh types are available. However, precise criteria for incorporating patient body type, risk factors for recurrence, hernia morphology, and the available biomaterials into planning of the surgical approach (open versus laparoscopic) have yet to be established. The elaboration of such criteria would require comparative evaluation of long-term results in a sufficiently large number of patients, e.g. in multicentre trials or meta-analyses of standardised data from different centres. Current classifications have the drawback that they fail to take account of prognostically relevant risk factors for recurrence and are not self-explanatory. The authors present a classification of incisional hernias that is self-explanatory and practicable in routine clinical practice. Based on the cornerstones of morphology (M), hernia size in cm (S), and risk factors for recurrence (RF), the scheme enables easy description and documentation of the hernia, and provides evidence for the indications and limitations of the main surgical repair techniques. Since randomised studies can scarcely be conducted on incisional hernias due to the numerous morphological variables, the classification presented here may offer an alternative means for comparative data analysis.

[Usefulness of anal endosonography in the assessment of fistula-in-ano]. / Wertigkeit der analen Endosonographie in der Diagnostik anorektaler Fisteln.

AIM: The purpose of the present study was to define the diagnostic value of anal endosonography in the diagnostic work-up of fistula-in-ano. METHODS: A retrospective study was carried out on 191 consecutive patients (m: 121; f: 70; mean age: 44.0 +/- 12.5 years; range: 0.5-77 years) who were diagnosed to suffer from fistula-in-ano by performing anal endosonography in an outpatient setting. All images were obtained with a Combison 310A ultrasound scanner (Kretz GmbH, Zipf, Osterreich) and 5-Mhz and 7.5-MHz transducer. 131 patients underwent surgery. According to the endosonographic findings fistulas were classified as transsphincteric in 44 %, intersphincteric in 22 %, subanodermal in 16 %, anovaginal in 8 %, suprasphincteric in 5 %, extrasphincteric in 1 % and others in 4 %. RESULTS: In 125 patients (95 %) the preoperative diagnosis was confirmed intraoperatively. This cohort included 12 patients with a complex fistula system. In only 6 patients the preoperative ultrasound finding was misinterpreted. CONCLUSION: In conclusion this study has shown that anal endosonography is a useful and reliable tool in the preoperative evaluation of uncomplicated and complicated anorectal fistulas.

[Adjusting a surgery department to new conditions in the German health service: day surgery, short-stay surgery, vascular centers and wound centers]. / Anpassung einer chirurgischen Klinik an die Herausforderungen im GesundheitswesenDie Tageschirurgie, die Kurzzeitchirurgie, das Gefässzentrum und die Wundsprechstunde.

In April 1994, after the preconditions for ambulatory surgery came into effect, the day surgery ward was opened in the Hamburg-Harburg General Hospital. Besides ambulatory operations, this ward provides all surgical pre- and postoperative care. In addition to the surgical sections, different departments (urology, gynecology, dentistry, radiology, ophthalmology) take advantage of the ward. As preoperative diagnostics also could be completed ambulatorily, we were then able to establish a short-stay surgery department. This ward was opened in June 1996. One year later, the vascular center ("Gefässcentrum Harburg") was established by the departments for surgery, radiology, and angiology. This structure has been integrated into the day and short-stay surgery wards functionally and spatially. With the organizational structures mentioned and by setting up a wound consultation service, it is possible to optimize the capacity for admissions, operations, and beds. Government and health insurance demands for better processing can be filled and efficiency is increased.

[Practical and theoretical aspects of cost-benefit relations in viscerosynthesis]. / Praktische und theoretische Aspekte der Nutzen-Kosten-Relation in der Viszerosynthese.

The necessity of limiting health care costs requires adequate service recording and quality control even in visceral surgery. In this field, the safety of the anastomoses is of greatest importance. Anastomoses at risk are esophageal connections to jejunum or colon and deep rectal anastomoses. At these locations expensive suture devices, such as stapling instruments, can be used in a cost saving aspect, if they help to increase anastomotic safety, time saving and expansion of surgical indication. Manual sutures thus represent the cheapest anastomotic technique as continuous sutures would cost between DM 10.- to 20.- and single stitch sutures between DM 60.- and 100.-. A surgical school should prevalently aim at training manual anastomoses, while special anastomotic techniques should only complete the skill for selected indications. The overall staff expenditure for extended operations amounts around DM 600.- per hour respectively DM 10.- per minute. Time for surgery might be shortened by auxiliary tools as much as to perform an additional operation. However, a circular stapler anastomosis that costs between DM 650.- to 850.- is twice as expensive as manual sutures notwithstanding the double time needed. In the past years, the necessity for a rational use of different anastomotic techniques has shown to be mandatory since, increasingly, financial aspects of health economy require cost benefit calculations in visceral surgery.

The value of endorectal ultrasound in the assessment of adenomas, T1- and T2-carcinomas.

In a prospective study we examined the value of endorectal ultrasound (ERUS) in the preoperative staging of potentially locally excisable tumours. During the study period from 1.1.1991 to 1.3.1996 a total of 160 rectal tumours in 152 patients were staged endosonographically (uT/uN) and compared postoperatively with the histologic result (pT/pN) at the University Hospital of Würzburg. Thirty-eight (24%) patients had an adenoma and 15 (9%) a T1-carcinoma. In 29 (18%) cases a T2-cancer was diagnosed, further 67 (42%) and 11 (7%) patients presented with a T3 and T4 tumour, respectively. The sensitivity for adenomas and T1-Ca (uT0/1) was 81%, the specificity 98%. For T2 tumours, the sensitivity was only 41% and the specificity 92% as the majority (17 of 29) of pT2 neoplasias were overstaged (uT3). The overall staging accuracy (T1-4) was 77.5%. Two patients with a pT1-Ca and seven with a pT2-Ca had lymph node metastases which were detected preoperatively in five. The accuracy for lymph node staging was 83%. We conclude that adenomas and T1 tumours can be assessed with a high grade of accuracy using ERUS. In these tumours ERUS can be used to assist clinical decision-making (transanal vs. abdominal operation). Owing to the lack of sensitivity ERUS is of no help in the assessment of T2 carcinomas.

[How expensive is treatment of reflux disease?]. / Wie teur ist die Behandlung der Refluxkrankheit?

In a prospective documented series of reflux patients, a retroelective analysis of medication cost and duration of conservative therapy as well as the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization, and costs for complications with necessary additional treatment and readmissions is assessed. Cost-relevant factors are in conservative treatment cost-relevant factors are those patients who need increasing dosages, while in surgical treatment the cost-relevant patients are those with complications who need additional treatment.

[Simultaneous intervention in vascular surgery. Risk assessment and cost-benefit analysis]. / Simultaneingriffe in der Gefässchirurgie Risikobewertung und Kosten-Nutzen-Analyse.

Thirty-four simultaneous vascular operations were performed from 1993 to 1996. Postoperative complications were similar to additive complication rates of carotid endarterectomies and other vascular operations undertaken during this period. Operation time and postoperative hospital stay was significantly shorter, and cost-benefit analysis revealed clear advantages for the simultaneous group.

[Laparoscopic interventions in gastroesophageal reflux--a cost-benefit analysis]. / Laparoskopische Eingriffe bei gastroösophagealer Refluxkrankheit--eine Nutzen-Kosten-Analyse.

On the basis of a cost analysis of conservative and surgical therapy of gastroesophageal reflux disease in 70 patients health economic aspects are discussed. In a prospective documented series of reflux patients a retrolective analysis of medication cost and duration of conservative therapy is performed. In addition, the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization as well as costs for complications with necessary additional treatment and readmissions are assessed. For the conservative treatment of 70 reflux patients a total of more than DM < 700,000 had to be spent during preoperative 5 years. A major part of this sum was spent for patients who needed to increase the initial 20 mg dosage of Omeprazol within 5 years. A mean of approximately DM 2,000 per patient was spent for conservative treatment. Surgical treatment without complications was calculated with DM 5,425 per case. However, in 7 patients complications occurred causing prolonged or even rehospitalization with necessary further treatment summing up to about DM 486,000 for surgical therapy in 70 patients including complications. Cost relevant factors are therefore in conservative treatment patients who need increasing dosages, while, in surgical treatment, the cost relevant patients are those with complications and necessary additional treatment.