[Urologic errors in surgical procedures]. / Urologische Behandlungsfehler bei chirurgischen Eingriffen.

BACKGROUND: In the examinations of the appraisal commission of Northern Rhine the third most frequent urologic errors are ascertained after surgical procedures. In order to prevent them, it is adequate to evaluate their causes. MATERIAL AND METHODS: Urologic claims were examined that came before the appraisal commission for treatment errors of the Northern Rhine Physicians' Authority between 1975 and 2005. The results of the first 23 years were compared with those of the last 7 years. The judgment criteria were professional standards and required care. RESULTS: Ninety-five treatment errors were registered in 1975-2005. From 1975 to 1998 there were 60 such errors (2.6 per year) and from 1999 to 2005 there were 35 (5.0 per year). These errors concerned diagnosis in 14.7% of cases (mainly testicular torsion), indication in 7.5%, and explanations of the surgery in 2.1%. About half the cases (46.3%) applied to surgical technique, especially for injuries to the spermatic cord, urinary bladder, ureter, or urethra. In nearly one third of cases (29.4%), errors were found in postoperative care, concerning especially lesions of the spermatic cord and ureter. CONCLUSIONS: There is considerable risk of misjudging or even causing urologic disorders in abdominal and vascular surgery. This applies most strongly to diagnosis, above all for testicular torsion. Hernia surgery and colon resection are the treatments leading to the highest number of injuries to testicular vessels, ureter, bladder, and/or urethra. Such occurrences cannot be tolerated if they can be avoided or, if unavoidable, not recognized promptly and adequately managed.

Monoclonal antibody therapy for resected Dukes' C colorectal cancer: seven-year outcome of a multicenter randomized trial.

PURPOSE: As previously shown, antibody treatment increased survival of patients with resected colorectal cancer of stage Dukes' C. Since the 5-year analysis was criticized because of the wide range (2.7 to 7.5 years) of follow-up time, we performed a 7-year analysis with only four of 189 patients monitored for less than 5 years. PATIENTS AND METHODS: A total of 189 patients with resected Dukes' C colorectal cancer were randomly allocated to infusions of a total of 900 mg 17-1A antibody, 500 mg postoperatively followed by 4 monthly doses of 100 mg (n=99), or to observation only (n=90). Primary end points were overall survival and disease-free interval. Patients were stratified by a dynamic randomization according to center, sex, location of tumor, number of affected lymph nodes, and preoperative carcinoembryonic antigen concentration. RESULTS: Randomization produced balanced distribution of risk factors. After 7 years of follow-up evaluation, treatment had reduced overall mortality by 32% (Cox's proportional hazard, P < .01; log-rank, P=.01) and decreased the recurrence rate by 23% (Cox's proportional hazard, P < .04; log-rank, P=.07). The intention-to-treat analysis gave a significant effect for overall survival (Cox's proportional hazard, P < .01; log-rank, P=.02) and disease-free survival (Cox's proportional hazard, P=.02; log-rank, P=.11 ). While distant metastases were significantly reduced (Cox's proportional hazard, P=.004; log-rank, P=.004), local relapses were not (Cox's proportional hazard, P=.65; log-rank, P=.52). This differential effect of 17-1A antibody on disseminated isolated tumor cells versus occult local satellites may explain the increased significance seen in the overall survival. CONCLUSION: The now-matured study shows that 17-1A antibody administered after surgery prevents the development of distant metastasis in approximately one third of patients. The therapeutic effect is maintained after 7 years of follow-up evaluation.

The immediate function of the kidney after 24-to 72-hr preservation. Hypothermic storage versus mechanical perfusion.

Seventy-two dog kidneys were stored under hypothermia as described by Collins and Sacks between 24 and 72 hr and then transplanted. The immediate function of the kidneys was measured by p-aminohippuric acid and inulin clearances. Twenty-four hr proved to be the maximum safe preservation time with both methods. The immediate function of the kidneys stored under hypothermia could not be improved by the addition of furosemide to the flushing solution. These results were compared with those gained by mechanical perfusion of the organ. Kidney function after 72 hr of hypothermic mechanical perfusion was significantly better than after 24 hr of hypothermic storage.

Effect of hypotension on the results of kidney storage and the use of dopamine under these conditions.

The influence of the length and severity of hypotension on the results of kidney preservation was examined in dogs. Successful 24-hr hypothermic kidney storage was possible, if the donor animal was subjected to hypovolemic hypotension (mean blood pressure 60 mm Hg) for a duration 1 to 4 hr. If the blood pressure was lowered to 50 mm Hg, successful kidney preservation could not be obtained. It was concluded that the level of hypotension was of more importance than its duration. After 24 hr of cold ischemia, the function of kidneys from hypotensive donors could be improved significantly if dopamine was given to the recipient. The preservation injury itself could not be counteracted by dopamine because dopamine did not improve the function of kidneys which were removed from normotensive donors but were stored for 24 hr under hypothermia.

Technique and clinical results of endorectal surgery.

At the Surgical Department of the University of Cologne, a new system has been developed for transanal endoscopic surgery that allows all the conventional surgical techniques within the entire rectal cavity. The method has been in clinical use since 1983. The main indication is the removal of sessile adenomas. Early rectal carcinomas with favorable histologic grading (grades 1 and 2) and staging (Mason I and II) are also suitable for the method. Advanced cancers can also be removed endoscopically in one session, but we perform local excisions of advanced cancers only in cases in which the patient is unwilling to undergo extensive surgery. During the period from July 1983 to December 1990, this method has been employed on 233 patients in 251 cases. The intraoperative and postoperative course of 236 (94%) operations out of 251 was free from any complications. Early postoperative complications consisted of intraperitoneal perforations (five cases), rectovaginal fistulas (four cases), hemorrhages (four cases), and death as a result of cardiopulmonary failure (two cases). The recurrence rate of adenomas is 4.9%. Endorectal surgery allows endoscopic local transanal excision of large adenomas and early cancers with minimal morbidity and excellent presentation of specimens for complete histologic analysis.

Replacement of the inferior vena cava and iliac veins with heterologous grafts in animal tests.

The use of a modified bovine collagen graft as a low-pressure conduit was investigated by implantation into the iliocaval system of dogs. In the 210 day observation period, a patency rate of 87.5% was achieved. Nearly all graft failures occured within the first 14 days following implantation; failure after that time did not seem to be dependent upon length of time of implantation. Progressive organization of the neointima was seen histologically. New smooth muscle fibers were observed in the neointima with electron microscopic evidence of reconstitution of the subendothelial membrane. Continuing resorption of graft collagen coincided with its replacement by newly developed collagen type III fibers in a surface-parallel orientation.

Analysis of the optimal perfusion pressure and flow rate of the renal vascular resistance and oxygen consumption in the hypothermic perfused kidney.

Thirty-six dog kidneys were perfused with different perfusion pressures (between 15 and 60 mm. Hg) for 72 hours and then transplanted. Hypothermic human albumin was the perfusion fluid. Enzyme release, kidney weight, and renal oxygen consumption were measured during perfusion. Kidneys perfused with a flow rate of 0.8 ml. per gram per minute (21 mm. Hg mean perfusion pressure) showed the smallest increase in kidney weight and the best function after transplantation. Renal vascular resistance was independent of the level of the perfusion pressure and renal oxygen consumption was independent of the applied flow rate. It is concluded that the perfusion pressure applied with hypothermic perfusion should be as low as possible because in this way kidney damage caused by perfusion can be avoided most easily.

Relationship between the prolongation of warm ischemia and the maximum available preservation period.

Fifty dog kidneys had hypothermic perfusion for 12 to 72 hours and then were transplanted. Prior to perfusion the kidneys were subjected to 15, 30, 45, and 60 minutes of warm ischemia. Fifteen minutes of warm ischemia was well tolerated (successful 72 hour preservation), but after 30 minutes successful preservation could be achieved for 24 hours only. Enzyme release and lactate formation were related to the prolongation of warm ischemia, and the highly significant concentration differences of these substances, between well functioning kidneys and those with small or no function, indicated the viability of the organ.

Middle and lower third rectum carcinoma: sphincter saving or abdominoperineal resection?

Sphincter saving resections (SSR) are performed with increasing frequency in carcinoma of the lower and middle third of the rectum. In this retrospective study local and distant recurrence and survival were compared to abdominoperineal resection (APR). In 71 women and 71 men (mean age: 64 years) with a primary adenocarcinoma between 5 and 10 cm from the anal verge 89 SSR, and 53 APR, were performed (Dukes stages--SSR--A 19%; B 30.3%; C 50.7% vs APR--A 15%; B 45.3%; C 39.6%). Patients have been followed up for a minimum of 24 months (mean time 62 months). There were no differences in intraluminal diameters of the tumours in each operative procedure. The distal tumour-free distance was more than 6 cm in 52% after APR (SSR: 10%) and less than 3 cm in 43% after SSR. Survival was not different between procedures in Dukes stages A and B. A survival advantage for patients with Dukes C carcinoma after APR did not reach statistical significance. No differences in distant spread were found for SSR (Dukes stage A 0%; B 7%; C 18%) and APR (Dukes stage A 0%; B 8%; C 14%) for local recurrence in Dukes stages A and B after SSR (A and B 0%) and APR (A 0%; B 8%) whereas a significant increase in local recurrence rate was seen in Dukes stage C after SSR (24% vs, APR 5%). Although a further resection could be performed in almost all of these patients a negative effect of local recurrence on survival occurred (25.4 months with and 80 months without local recurrence). While SSR seems to be favourable in Dukes stages A and B, APR should be considered in carcinoma of the lower and middle third of the rectum with lymphatic spread. Effective preoperative staging determines selection of the appropriate operation.

Colorectal cancer--a multivariate analysis of prognostic factors.

The data from 1050 patients who had undergone colorectal carcinoma resection at the University of Cologne between 1976 and 1990 were studied. The aim of the study was to determine the concomitant effects on survival of several patient characteristics (sex, age, tumour localization, blood transfusion) and histopathological variables (Dukes' staging). We first calculated survival rates, both including and excluding post-operative mortality. We set up a hierarchical log-linear model for the detection of relationships between selected crossclassified categorial variables. We then used Cox's proportional hazard regression method to study the relationship between survival and different prognostic patterns. Dukes' staging was shown to be a highly discriminating factor in survival (P<0.001). Survival rates were better in women (P<0.001), and better for younger patients (<70 years; P<0.001). Tumour site (colon; P = 0.0362) and blood transfusion (P = 0.0857) also correlated with survival.

Immunostimulation by propionibacteria--effects on immune status and antineoplastic treatment.

Experimental studies were performed to investigate further the effects of immunotherapy with Propionibacterium avidum KP-40 on thymocyte proliferation, maturation and emigration in BALB/c-mice. Thymus weight and thymocyte counts, especially cells presenting the immature or cytotoxic/suppressor phenotype were significantly increased. Due to enhanced emigration, peripheral blood lymphocyte and monocyte counts as well as expression of activation markers were significantly upregulated. The antimetastatic effect of Propionibacterium avidum KP-40 was demonstrated in BALB/c-mice, where RAW 117-H10 lymphosarcoma liver colonization was significantly reduced after immunostimulation. Clinical investigations proved that surgical treatment of colorectal carcinoma induced an evident decrease of peripheral blood lymphocytes as compared with preoperative counts. However, single preoperative Propionibacterium avidum KP-40 administration induced a considerable increase of peripheral white blood cell counts, especially lymphocytes. Clinical effects of preoperative immunostimulation by Propionibacterium granulosum KP-45 were investigated in a prospective randomized trial in colorectal carcinoma patients. Positive effects on survival time, local tumor recurrence and distant metastasis could be demonstrated in stages I and II, whereas no advantage of immunotherapy was found in advanced stages III and IV. A recent prospective randomized clinical trial was initiated on the quality of life of colorectal carcinoma patients. Three months after surgical treatment negative effects could not be determined after immunotherapy. Quality of life even proved to be better in patients with abdominoperineal resection as compared to non Propionibacterium avidum KP-40 treated control patients.

Preoperative immunostimulation by Propionibacterium granulosum KP-45 in colorectal cancer.

In order to improve the perioperative resistance to the spread of cancer during operation the effect of preoperative stimulation of the immunesystem by Propionibacterium granulosum KP-45 was investigated in patients with colorectal carcinoma. In a prospective randomized trial 101 patients were allocated to either treatment (n = 51) or control (n = 50). In the treatment 10 mg of Propioni bacteria were administered intravenously between the seventh and third day prior to surgical treatment. At the time of operation 21 tumours were classified as stage I (treatment n = 12, control n = 9), 22 as stage II (treatment n = 10, control n = 2). Postoperatively wound infections requiring treatment were more prevalent in the control group (n = 4) than in the treated group (n = 0). All patients were subsequently followed up for 76 months. For stage I carcinoma the survival rates, excluding perioperative deaths, were 91% in the treated and 63% in the control group respectively. One case of tumour metastasis was seen in the control group. For stage II carcinoma the survival rate was 90% for the treated group with distant spread in 1 case and 45% in the control group where the rate of recurrence was 55%. For stages III and IV there was no statistically significant difference in survival between the treated and the control groups.

Isolated hyperthermic perfusion with mitoxantrone of melphalan in malignant melanoma of the limb.

BACKGROUND: Melphalan administered by isolated hyperthermic perfusion of the affected limb is an accepted treatment for malignant melanoma of the extremities. In contrast, pharmacologic and phase I studies suggest that, because of its high uptake, mitoxantrone may give even better local control, but data on survival, onset of metastases, and local and systemic toxicities have not yet been reported. METHODS: A matched-pairs comparison was performed to examine differences in the tolerability and effectiveness of isolated hyperthermic extremity perfusion with mitoxantrone (n = 44) and melphalan (n = 44) in high risk and locoregionally (P < 0.41) metastatic malignant melanoma. Criteria evaluated were local and systemic complications, and recurrence-free and overall survival. RESULTS: Local complications, such as delayed wound healing, were more frequent in the mitoxantrone (27.9%) than in the melphalan group (9.8%) (P < 0.05). Systemic toxicity, in particular bone marrow toxicity, was also more severe with mitoxantrone (78.6% versus 15.4%, P < 0.001). Hepatotoxic effects were more frequent among patients in the melphalan group who were older and has lower tissue perfusion temperatures (P < 0.05). There was no difference between the two groups in overall or recurrence-free survival (P < 0.41). CONCLUSIONS: Local and systemic toxicity seem to be higher with mitoxantrone. Survival rates were similar with both drugs. The data obtained suggest a randomized phase II study with an appropriate number of patients.

Surgical therapy of esophageal carcinoma: the influence of surgical approach and esophageal resection on cardiopulmonary function.

OBJECTIVE: The effects of the different surgical approaches (transhiatal esophagectomy and right-sided transthoracic esophagectomy) on perioperative cardiopulmonary function in the surgical treatment of esophageal carcinoma are discussed controversially and have not yet been evaluated. METHODS: In a prospective randomized study including 32 patients, we investigated the effects of the surgical approach (blunt dissection (n = 16) versus transthoracic en-bloc resection (EB) (n = 16)) in the treatment of esophagus carcinoma on perioperative cardiopulmonary function. The following parameters were measured in all patients: cardiac index (CI), mean arterial pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), intrapulmonary shunt (QS/QT), arterio-alveolar (aaDO2), arterio-venous oxygen pressure difference (avDO2), and blood gas analyses. Time of measurement were: after induction of anesthesia, beginning and end of esophagus resection, end of surgery, 1 h postoperatively, and then every 12 h until the third postoperative day. RESULTS: Compared to blunt dissection, en-bloc esophagectomy was found to be associated with a transient deterioration of pulmonary function during one-lung ventilation in the left-lateral position, which could already be compensated for during the intervention. No other significant differences in cardiopulmonary effects were seen between the two surgical techniques. The incidence of postoperative complications was identical in both groups. CONCLUSIONS: The results of our study show that en-bloc resection is only associated with an increased intraoperative pulmonary strain that is completely compensated during the operation and that there is no difference in cardiopulmonary functions between the two techniques in the postoperative course.

Quality of life after surgical therapy of bronchogenic carcinoma.

Quality of life (QL) after the "curative" resection of non-small cell bronchogenic carcinoma was assessed by patients using the EORTC QL questionnaire (QLQ) and by a psychologist using the Spitzer Index. Quality of life was assessed in 52 patients on one occasion 12 months postoperatively and in 20 patients regularly starting with a preoperative assessment. Self- and external evaluation showed a significant correlation (r = 0.41), but QL was assessed as being higher by the external observer. After surgery it was mainly affected by restrictions related to physical activities, job and household tasks, and disease symptoms, whereas limitations in emotional, social, and financial domains were found less frequently and less severely. Of the different medical (surgical procedures, tumor recurrence) and social factors (sex, marital and employment status), only tumor recurrence was determined to have a significant and negative influence on postoperative QL (P < 0.02). When compared to the preoperative assessment, QL had deteriorated on discharge from hospital but was restored within 3-6 months postoperatively in disease-free patients.

Closure of partial median sternotomy with absorbable sutures: a practical and safe option.

A technique for the closure of upper median sternotomy with absorbable polyglycolid acid sutures is described. In a consecutive series of 130 refixations, no major complications occurred. After a mean follow-up period of 66 +/- 61 months, the long-term results concerning sternotomy closure were determined in 86 patients: 84 (98%) sternotomies were completely consolidated, in 75 cases (87%) without any dislocation and in nine cases (11%) with a minor dislocation in the transverse osteotomy. In two patients (2%) who had received postoperative radio- and chemotherapy, an isolated pseudarthrosis of the transverse osteotomy was observed, whereas the median sternotomy was consolidated completely. As a result of our clinical experience, we consider the closure of partial upper sternotomy with absorbable polyglycoid acid sutures as a practical and safe technique.

Long-term results of highly selective vagotomy for the treatment of duodenal ulcer.

Between 1971 and 1987, highly selective vagotomy (HSV) was carried out in 984 patients suffering from duodenal ulcer disease. In 97.3% of these cases, the surgical intervention was uncomplicated, the related mortality being 0.3%. During the follow-up period the postoperative condition of the patients was checked once a year wherever possible; in 92.3%, follow-up was continued until december 1987, the maximum period of postoperative follow-up being 16 years. No prognostically reliable indication of the risk of ulcer recurrence was obtained from an analysis of gastric juice. In 79.1% of the cases who underwent surgery, the result was good to satisfactory, while 11.7% had functional complaints such as dumping or diarrhea. The probability of developing a recurrent ulcer within 16 years after the initial operation was 29.7%. This rate of recurrence is determined among other things, by the discovery of clinically quiescent ulcers during the yearly follow-up examinations, when these are performed carefully, and over a sufficiently long period.

Results of esophagectomy and gastric bypass for cancer of the esophagus.

Improvements in operative technique and perioperative management have lowered hospital mortality of esophageal resection at our department from 31% to 8% during the past decade. Cumulative 5-year-survival rate depending on the tumor stage only remained unchanged at 21%. Neither extended resection nor perioperative chemo- or radio-therapy show any advantage compared to conventional resection or blunt dissection regarding long-term survival.

[The beginnings of reconstructive vascular surgery in Austria]. / Anfänge der rekonstruktiven Gefässchirurgie in Osterreich.

Hans von Haberer (1875-1958) gained wide experience in the reconstructive surgery of traumatic aneurysms during the 1st world war at the Surgical Department of the University of Innsbruck. In the period 1914-1918 he operated on altogether 201 vascular aneurysms, mainly using a direct circular vascular suture. In 1914 von Haberer described the first reconstruction of a carotid aneurysm. On the basis of the detailed case notes and operation reports written by Hans von Haberer between 1904 und 1949 on approximately 16000 cases and from the contemporary literature, we describe his experiences in vascular surgery at the Surgical Department of the University of Innsbruck between 1914 and 1918.

[Metabolic changes after transperitoneal vascular interventions]. / Stoffwechselveränderungen nach transperitonealen Gefässeingriffen.

Thirty patients who had undergone transperitoneal vascular surgery were examined for hormonal disturbances and alterations of energy and protein metabolism. Of all hormonal alterations only the increased level of insulin activity in the early postoperative period is clinically important. The higher oxygen consumption and carbon dioxide production together with the increased protein turnover indicate an elevated energy expenditure. In order to prevent decompensation of the hypermetabolic metabolism, a reduced nutritional support after major vascular surgery is justified.