What is the value of available risk-scores in predicting postoperative complications after aorto-iliac surgery? A prospective non randomized study.

AIM: With an aging population, atherosclerotic manifestations are steadily increasing. Beside the anatomical and pathophysiological preoperative risk-factors accompanying perioperative risk-factors like patient's age, length of operation, blood loss and skill of the surgeon, all need to be accounted for when assessing the risk of morbidity and mortality after vascular surgery. The demand for cost effectiveness may make a risk-score system useful. The aim of the present study was, therefore, to prospectively apply various scoring systems in order to estimate outcome in patients undergoing aortobifemoral surgery due to arterial occlusive disease at the aorto-iliac level. METHODS: A prospective non randomized study was carried out. The SPSS 9.0 statistical package for Windows and, for nominal data, chi-squared-tests were used to compare rates between groups. For continuous data analysis of variance (ANOVA) was performed. When appropriate, a multivariate analysis with binary-regression by Wald was used. Sensitivity and specificity was done using ROC-curves. P < 0.05 was considered significant. From May 1996 to June 2000, 107 patients were included in the study. Besides basic data, all postoperative complications were noted according to a specific definition. Four different risk-scoring systems were used: ASA-classification; the acute physiology and chronic health evaluation (APACHE-II) system; the physiological and operative severity score for enumeration of mortality and morbidity (POSSUM) classification and, finally, the simplified acute physiology score (SAPS) classification. RESULTS: We found no significant correlation between risk-scores and outcome. None of the scoring systems used was able to predict mortality. The independent factors that influenced the postoperative complication rate were operating time, blood loss, intraoperative assisted ventilation time and age. The endpoint using the relative operating characteristic (ROC) curves analysis was either mortality or morbidity. CONCLUSIONS: It can be concluded that none of the systems analyzed separately was useful for determining morbidity and mortality. We still lack a system, that can be used preoperatively in an individual case and the vascular surgeon still has to build up his own clinical judgement or to transfer a clinical judgement.

[Heterotopic gastric pancreas: a rare cause of abdominal complaints]. / Heterotopes Pankreasgewebe der Magenwand. Seltene Ursache abdominaler Beschwerden.

Heterotopic pancreas is an uncommon cause of gastrointestinal complaints such as epigastric pain, nausea, vomiting, and upper gastrointestinal bleeding. Despite the development of modern diagnostic procedures, it is still difficult to differentiate heterotopic pancreatic tissue from other benign or malignant gastric tumors. Local excision of the gastric wall is regarded as the diagnostic and therapeutic procedure of choice. We present two cases and an overview of the literature.

[Risk evaluation in German clinics. Results of a survey]. / Zum Stand der Risikoevaluation an Kliniken in Deutschland. Ergebnisse einer Umfrage.

INTRODUCTION: Risk evaluation is essential for the choice of individual surgical therapy. The aim of this survey was to examine whether preoperative risk analysis is routine in surgical therapy. METHODS: A questionnaire was sent to 1,159 clinics to assess how preoperative risk was evaluated and who carried out the evaluation. In addition, the factors used to determine the postoperative course and the way in which postoperative complications were observed were established. RESULTS: A total of 636 clinics filled out the questionnaire. Preoperative risk factors substantially influenced the postoperative course. The ASA classification was the most commonly used. Anesthesiologists together with surgeons evaluated the preoperative risk in 67% of cases. No preoperative risk evaluation was made in 12% of the clinics, and 21% did not record the postoperative complications regularly. CONCLUSIONS: Risk evaluation and control of postoperative complications are an important part of good clinical practice.

[Development of ultrasonography in a radiological university department from 1994 to 2001]. / Entwicklung der sonographischen Diagnostik in einer Radiologischen Universitätsklinik von 1994 bis 2001.

BACKGROUND: In 1994, 5 % of a total of 25 718 examinations and 7 % of all 4630 B-mode sonograms performed in the Radiology Department, University of Cologne was classified as not indicated. In light of these results, the health care policy guidelines for sonographic indications have been amended. PURPOSE: The aim of this study was to establish the current rate of non-indicated sonographic examinations performed in routine diagnostics by radiology departments at university hospitals, to determine the reasons for such over-diagnosis and identify which regulatory mechanisms can be implemented to prevent his. METHOD: We counted the number of 1) B-mode and 2) color-flow Doppler ultrasound imaging procedures carried out in patients who had had no change in symptoms within the previous 4 weeks or who were scheduled without reference to an existing sonogram (double examinations). 3) The reasons for over-diagnosis were analyzed. 4) The 1994 survey was repeated in 2000 with an identical protocol and 5) additionally, a modified survey of the diagnostic questions was conducted. RESULTS: 1) Out of 4,119 patients presenting for the first time to receive a B-mode sonogram, 443 prior sonograms (11 %), 305 CT scans (7 %) and 57 MRI scans (1 %) were documented. 2) Double sonograms were carried out in 6 % of the 1,118 patients presenting for the first time for color-flow Doppler ultrasounds and in 16 % of the 651 patients assigned to receive catheter angiographies with arterial color-flow Doppler. 2) 41 out of 55 (75 %) prior sonograms from non-university settings stated by 94 surgery patients were listed in the medical records. 36 out of 43 (84 %) prior sonograms from the university hospital were repeated in the same patients despite the fact that the medical report with the findings was available. None of the 48 sonograms indicated to confirm a plausible finding yielded any information that was additionally relevant to therapy. 4) In the period April - June, 2000, 12 % of all 15,921 tests and interventions, 26 % of 3,569 B-mode sonograms and 58 % of 1,033 abdominal sonograms performed in adults were classified as having not been indicated. 5) Staging and follow-up were stated as the most common reasons that a sonography was carried out in 46 % of the 1,017 adults who were given B-mode sonograms conducted from Jan - Mar, 2000 and comprised 62 % of the 410 sonograms classified as not or probably not medically indicated. CONCLUSION: The results showed that a multidisciplinary consensus was required to establish the diagnostic value of sonographic procedures. Therefore, this research group drafted a hospital-internal interdisciplinary guideline for "abdominal transcutaneous B-mode sonography in oncological questions".

Inadequacies of repeated radiological examinations in a university hospital.

PURPOSE: To establish why 16% of 1,045 patients undergoing abdominal and/or vascular surgery referred to the University Department of Radiology for a B-image sonogram reported that a US of the same regions of the body had been conducted during the previous 6 weeks without any changes in the clinical status. STATEMENT OF THE PROBLEM: Evaluation of the reasons for these superfluous examinations and analysis of the consequences that the US follow-up examinations implied for the patient. MATERIAL AND METHODS: One senior resident radiologist and one senior resident surgeon reviewed the medical records of the patients reporting previous examinations and examinations scheduled at the time of the questioning of the patients. RESULTS: One hundred and eight (63%) of the 171 medical records were available. Data on previous examinations mentioned in the report forms were incorrect in 14 cases (13%). Therefore, further evaluations were based on 94 patients. Ten (8%) out of 121 sonograms, 4 (10%) out of 40 CT and 2 (20%) out of 10 MR investigations documented in the medical records had not been mentioned by the patients. As many as 41 (75%) of the 55 preliminary sonograms performed by general practitioners and specialists in private practice were not documented in the medical records. Even though records existed of clinically plausible findings, 36 (84%) of the 43 preliminary US investigations performed by doctors in the University Hospital were repeated to verify the diagnosis without any further diagnostic benefit. CONCLUSION: A cross-speciality consensus over the diagnostic value of B-image sonography and management of the findings obtained is of paramount importance.

[Do guidelines bring an improvement in the perioperative course? A study of perioperative antibiotic prophylaxis]. / Bewirken Leitlinien eine Verbesserung des perioperativen Ablaufs?--Untersuchung anhand der perioperativen Antibioticaprophylaxe.

INTRODUCTION: Although the effectiveness of perioperative antibiotic prophylaxis is proven, it is not used adequately. The aim of this study was to evaluate whether hospital-based guidelines are useful tools to improve the management of perioperative antimicrobial prophylaxis. MATERIAL: In a retrospective study the actual quality of perioperative antibiotic prophylaxis as given by the criteria choice of drugs, dosage, timing, continuation and 2nd dose after > 3 h was evaluated. After information and establishment of adequate guidelines we started a prospective analysis to test compliance and rate of adequate prophylaxis. Differences were calculated according to the chi 2-test with P < 0.05 significance niveau. RESULTS: The percentage of cases in which antibiotics were indicated but not administered was reduced from 15.5% to 8.4%. Compared to the result of the retrospective analysis, the prospective study showed a significantly higher percentage of adequately administered antibiotics (35.7% vs. 63.5%). This was mainly due to the compliance with dosage recommendations and to the 2nd dose in longer surgical procedures. DISCUSSION: Guidelines lead to a significant improvement in perioperative antibiotic prophylaxis. To increase this effect, further approaches such as integration of guidelines into computer-based systems should be evaluated.

Apoptosis and expression of bcl-2 protein are inverse factors influencing tumour cell turnover in primary carcinoid tumours of the lung.

AIMS: This study evaluates potential regulating factors in primary pulmonary carcinoid tumours, 16 typical and four atypical samples, with special emphasis on apoptosis and the bcl-2 gene family. Furthermore, p53-related oncogenes were analysed in a search for associated biological parameters. METHODS AND RESULTS: The in-situ end-labelling technique (ISEL) was used to determine apoptotic cells, in addition to immunohistochemical methods, which were used to investigate the expression of the Ki67 antigen (avidinbiotin complex (ABC) method) and bcl-2, bcl-x, p53, p21/waf1, p27 and mdm-2 proteins (catalysed reporter deposition (CARD) technique). The incidence of apoptotic tumour cells was significantly enhanced in typical carcinoids. The bcl-2 protein was expressed to a higher degree in atypical carcinoids, which displayed a higher proliferative capacity as well. In contrast, bcl-x was observed predominantly in so-called typical carcinoids. The tumour cell turnover index was the most distinguishing parameter between both entities. All carcinoid tumours failed to show a staining for p53, p21/waf. p27 and mdm-2 proteins. CONCLUSIONS: The different biological behaviour of the carcinoid tumours under study seems to be influenced by the bcl-2 gene family preventing programmed cell death. We speculate that this results in a more aggressive course in atypical carcinoid tumours.

[Is the type of vessel wall change a risk factor in implantation of prostheses in the aortofemoral segment? Dilatative versus obliterating arteriopathy]. / Ist die Art der Gefässwandveränderung ein Risikofaktor bei Implantation von Prothesen im aortofemoralen Abschnitt? Dilatative versus obliterierende Arteriopathie.

The question of what effect role obliterative vessel disease has on postoperative outcome was analysed with the help of uni- and multivariate analysis. The univariate analysis showed significantly more preoperative risk factors in patients with obliterative vessel disease. Our multivariate analysis found three independent factors: ASA class, age, duration of surgery. Obliterative vessel disease seems to be a disadvantageous factor, but may be influenced by preoperative existing risk factor.

[Treatment strategies in malignant pleural effusion of breast carcinoma]. / Behandlungsstrategien bei malignen Pleuraergüssen des Mammakarzinoms.

Symptoms are dyspnea, pain and reduced common feeling. Aine of the study was, to compare our results of talc pleurodesis with the literature. In a prospective trial we performed talc pleurodesis via a chest tube in 41 patients. All patients had radiologically proven pleural effusions. No additional therapy was permitted 30 days before or after entry into the study. Response was assessed monthly. Seven patients dies because of tumor progress. We examined 34 patients. Treatment was successful in 31 patients adverse effects we saw only a few times. Application of iodized talc for therapy of malignant pleural effusions is effective and cheep. We did not see major adverse effects or complications.

Risk factors, complications, and outcome in surgery: a multivariate analysis.

OBJECTIVE: To correlate variables recorded perioperatively with morbidity and mortality in an attempt to assess the predictive value of these variables for the outcome of individual patients. DESIGN: Prospective study. SETTING: Teaching hospital, Germany. SUBJECTS: 6304 consecutive patients admitted for operation. INTERVENTIONS: Recording of American Society of Anesthesiologists (ASA) class, age, sex, operation class (Hoehn), anaemia, hypertension, bronchopulmonary disease, diabetes mellitus, renal failure, major gastrointestinal disease, type of anaesthesia, operation (and whether emergency or elective), and duration of operation. All these factors were subjected to logistic regression analysis. MAIN OUTCOME MEASURES: Odds ratio (OR), sensitivity, specifity, and positive and negative predictive values. RESULTS: We studied 6304 patients of whom 140 died postoperatively and 1432 developed complications from which they survived. The variable that had most influence on the risk of postoperative complications was the ASA class (ASA class 4, OR 4.2, and ASA class 3, OR 2.2) followed by the severity of the operation (OR 1.86). An uncomplicated course was correctly predicted in 96%, but complications were correctly predicted in only 16%. The positive predictive value was 57%, and negative predictive value 80%. CONCLUSIONS: Despite the fact that we considered a large number of variables we were unable to predict the risk of complications for individual patients with any accuracy.

[Effectiveness of preoperative diagnosis in scintigraphically cold thyroid nodule]. / Effizienz der präoperativen Diagnostik bei szintigraphisch kalten Schilddrüsenknoten.

PURPOSE: To compare the diagnostic efficacy of different imaging procedures carried out in patients with scintigraphically cold thyroid nodules. METHODS: The preoperative imaging procedures carried out in all patients operated on for cold thyroid lesions at the Department of Surgery of the University of Cologne were recorded in prospective manner for 1 year. Special attention was paid to the difference between in-patient and out-patient management. Diagnostic accuracy was assessed by comparison with the intraoperative findings and histology. RESULTS: The combination of ultrasonography and fine needle aspiration cytology proved effective. Computed tomography should be reserved for the preoperative assessment of large thyroid tumors. Repeat examinations seldom gave additional information. CONCLUSION: Standardized preoperative investigations may be performed on an out-patient basis, provided attention is paid to quality assurance.

Colorectal carcinoma--aspects of surgery in the elderly.

In accordance with the aging of the German population an increasing number of surgical procedures are performed on patients of advanced age. Perioperative data from 441 patients (223 women, 218 men, mean age 64.1 +/- 11.7 years) undergoing colorectal carcinoma resection 133 were aged 70 years and older, 308 were younger than 70 years-were prospectively recorded. Risk factors were found more frequently in the elderly (hypertonus 49% vs. 34%; coronary artery disease 18% vs. 8%; pulmonary disease 39% vs. 31%, gastrointestinal disease 30% vs. 23%). No differences were found in operative (loss of blood, duration of operation, ventilation) and postoperative parameters (intensive care, hospitalization) neither age dependent nor between elective and emergency surgery. Postoperative complications in electively treated patients, such as pneumonia, wound infection, urinary tract infection, pulmonary complications, and anastomotic leakages were not age dependent. Although cardial complications were recorded five times as often in electively treated elderly patients perioperative mortality was unchanged (0.8% vs. 0.9%). After emergency operations the rate of anastomotic leakage after perforating peritonitis was increased in the elderly (5.5%). In particular, cardial complications during emergency surgery in 50% of the elderly had a causal connection with perioperative mortality that was substantially increased by up to 28.6%.

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.

ASA classification and perioperative variables as predictors of postoperative outcome.

In a prospective study of 6301 surgical patients in a university hospital, we examined the strength of association between ASA physical status classification and perioperative risk factors, and postoperative outcome, using both univariate analysis and calculation of the odds ratio of the risk of developing a postoperative complication by means of a logistic regression model. Univariate analysis showed a significant correlation (P < 0.05) between ASA class and perioperative variables (intraoperative blood loss, duration of postoperative ventilation and duration of intensive care stay), postoperative complications and mortality rate. Univariate analysis of individual preoperative risk factors demonstrated their importance in the development of postoperative complications in the related organ systems. Estimating the increased risk odds ratio for single variables, we found that the risk of complication was influenced mainly by ASA class IV (risk odds ratio = 4.2) and ASA class III (risk odds ratio = 2.2). We conclude that ASA physical status classification was a predictor of postoperative outcome.

Gender related survival in colorectal cancer.

The importance of patient characteristics to long term survival in colorectal carcinoma is the subject of much debate. The importance of female gender as an advantagous factor in prognosis is difficult to determine. A retrospective study based on data from 1050 patients resected for colorectal carcinoma was carried out. A complete follow-up and survival data were available. Categorical variables such as age, sex, tumor stage and location, perioperative blood transfusions, and postoperative complications were used. Standard univariate and multivariate descriptive analysis was applied. In addition to tumor staging patients' sex was a strong significant factor on prognosis. When analysed independently of tumor location, blood transfusions, and severe complications, sex was revealed to be a statistically significant independent prognostic factor in longterm survival. The 5-year survival rate for men was 43.5 % and 54.7 % for women. When the observed survival was compared with sex related life expectancy of a representive population, similar differences of survival were seen for both sexes.

[Geriatric surgery--stomach carcinoma in patients older than 70]. / Alterschirurgie--Das Magenkarzinom bei Patienten ab dem 70. Lebensjahr.

In a prospective study the results of surgery for gastric carcinoma were analysed comparing patients under 70 years of age (n = 384) and patients over 70 years of age. The surgical treatment for gastric cancer resulted in increased mortality in patients over 70 years of age due to severe risk factors. Optimization of anociassociation and stageoriented cancer treatment may further prolong survival of patients over 70 years of age with this malignancy.

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.

Esophageal tuberculosis: a differential diagnostic challenge.

Esophageal tuberculosis is a rare clinical picture. It is typically secondary to tuberculous infection of other organs. There are neither diagnostic signs or symptoms nor typical x-ray or laboratory findings. Histology, too, often fails to establish a reliable diagnosis, so that esophageal tuberculosis might be mistaken for esophageal carcinoma. We report the case of a woman with secondary esophageal tuberculosis to illustrate the clinical course and diagnostic problems of this condition.

[Tuberculosis of the esophagus]. / Tuberkulose des Oesophagus.

Tuberculosis of the esophagus is a rare disease, occurring in most cases secondary to tuberculous infection of other organs. There are neither characteristic symptoms or diagnostic signs, nor typical X-ray or laboratory findings. Histology, too, often fails to establish a reliable diagnosis, so that esophageal tuberculosis may be mistaken for esophageal carcinoma. Most cases can be successfully treated with antituberculous therapy, although patients with esophageal tuberculosis in the presence of AIDS do not respond as well to anti-tuberculous therapy.

Prospective randomized study of preoperative bowel cleansing for patients undergoing colorectal surgery.

Three different methods of preoperative bowel preparation were tested in a prospective randomized trial examining efficacy and morbidity. In all, 163 patients were treated by gut irrigation with Ringer's lactate, Prepacol or polyethylene glycol (PEG). Fluid retention, cleansing effect, postoperative complications and subjective acceptance were documented. Relevant weight gain and decrease in haematocrit indicating fluid retention were seen only after the use of Ringer's lactate. There were no significant differences in bowel cleansing. In the Prepacol group the postoperative complication rate was significantly increased. Prepacol was tolerated best, with few side-effects. PEG was better tolerated than Ringer's lactate, but vomiting occurred in 2 and 21 per cent of patients respectively. PEG is most suitable for bowel preparation in patients undergoing colorectal surgery.