[Adequate management of stab and gunshot wounds]. / Adäquates Management von Stich- und Schussverletzungen.

BACKGROUND: It is difficult to verify the treatment of stab and gunshot wounds with prospective randomized studies. That is why the results of observational studies are so important. MATERIAL: From 1 January 1989 to 31 December 1998, we saw 74 patients because of stab (64) and gunshot (ten) wounds. RESULTS: Most of the patients, whose injuries were caused mainly for criminal reasons (criminal 54, autoaggressive 14, accidental 4, unknown 2), came to hospital on weekends. We saw 38 abdominal, 23 thoracic, and 13 mixed injuries. On average, 3.8 h passed between the time of injury and getting first aid. Concerning abdominal injuries, we counted 21 negative intraoperative results. Two of 12 thoracic injuries showed no further damage. The patients stayed in hospital for 13.1 days on average. The morbidity was 28.38%, and mortality was 5.41%. CONCLUSIONS: Abdominal gunshot wounds need immediate surgical treatment. Concerning stab wounds, obligatory as well as selective surgical methods are both acceptable. Because of valid diagnostic options, thoracic stab wounds allow several ways of treatment.

[Psoas abscess. Etiology and treatment]. / Psoasabszess Atiologie und Behandlung.

Psoas abscess is in general a syndrome with low incidence. In the following, two cases are presented which describe the etiology, diagnosis, and treatment of primary and secondary retroperitoneal manifestations. The article mainly focuses on the different respective surgical procedures. Because of its rareness, an overview of further cases discussed in the literature is provided.

Frequency of the Amsterdam criteria in a regional German cohort of patients with colorectal cancer.

Estimates of the colon cancer burden associated with hereditary nonpolyposis colorectal cancer (HNPCC) vary from less than 1 % to more than 5 %. Amsterdam criteria fulfilled within a kindred (classic Amsterdam and Amsterdam II criteria) are widely used to identify patients prone to HNPCC. The present study was initiated to assess the frequency of the Amsterdam criteria within a regional German cohort of 207 patients with a history of colorectal cancer (CRC). Data on individual and family cancer histories were available in 154 patients (73 women, 81 men; mean age at diagnosis 62.4 +/- 13.3 years). A total of 843 first degree relatives have been identified within the kindreds of whom 121 had verified cancers. In 28 of 154 families (18 %), at least one first degree relative of the index patient had CRC. With respect to a typical family history, five kindreds (3.2 %) were likely to suffer from HNPCC on a clinical basis (4 kindreds met the classic Amsterdam criteria and one kindred the Amsterdam II criteria). Testing for microsatellite instability could additionally be performed in 4 of 5 patients who met the Amsterdam criteria and revealed DNA instability in 3 cases. Moreover, a missense mutation of MSH2 (Gly965Asp) was detected in one patient with microsatellite instability. Based on the classic Amsterdam and Amsterdam II criteria approximately 3 % of a regional German cohort of patients with CRC are likely to suffer from HNPCC. However, the final diagnosis of HNPCC can only be established by detection of pathogenic germline mutations within the DNA mismatch repair genes.

[Intraoperative radiotherapy--progress with a CT-assisted navigation system]. / Intraoperative Strahlentherapie--Fortschritt durch ein CT-gestütztes Navigationssystem.

INTRODUCTION: The fact that conventional intraoperative radiotherapy (IORT) does not give the opportunity for exact documentation of the applied radiation volume and dose distribution has been criticised. We would like to introduce a system for surgical navigation and documentation of the flab positioning for intraoperative brachytherapy in afterloading flab technique. METHODS: Our system consists of an electromagnetic 3D digitizer and a PC workstation. Preoperatively taken spiral CT scans of the tumour region are used for navigation and documentation of the flab positioning, analogous to the procedure in neuronavigation. Registration is done via an external reference system attached to the iliac bone of the patient. RESULTS: The mean accuracy of digitalization of the 100 spheres in a pelvis model is about 2.6 +/- 0.5-3.7 +/- 0.9 mm. Mean navigation accuracy is 2.4 +/- 0.8-3.3 +/- 0.8 mm. These figures correspond to the clinical experience of our surgeons. CONCLUSIONS: The optimization of the flab positioning by CT-guided navigation and the more accurate documentation of the dose volume and distribution in the patient is an important step towards improving the quality of individual radiotherapy. We are of the opinion that surgical navigation in the pelvic region should be subject to additional investigation in order to optimize the procedure.

CT-based navigation systems for intraoperative radiotherapy using the afterloading-flab technique.

INTRODUCTION: The fact that conventional intraoperative radiotherapy does not give the opportunity to exactly document the radiation volume applied and the dose distribution has been criticized in many ways. We would like to introduce a system for surgical navigation and documentation of flap positioning in intraoperative brachytherapy using the afterloading flap technique. METHODS: Our system consists of an electromagnetic 3D-digitizer and a PC workstation. Spiral CT scans of the tumor region taken preoperatively are used for navigation and documentation of flap positioning, analogous to the procedure in neuronavigation. Registration is done via an external reference system which is attached to the iliac bone of the patient. RESULTS: The mean accuracy of digitalization of the 100 spheres in a pelvis model is about 2.6 +/- 0.5 to 3.7 +/- 9.9 mm. The mean navigation accuracy is 2.4 +/- 0.8 to 3.3 +/- 0.8 mm. These figures correspond to the clinical experience of our surgeons. DISCUSSION: The optimization of flab positioning by CT-guided navigation and the more accurate documentation of the dose volume and distribution in the patient is an important step on the way to improving the quality of individual radiation therapy. We are of the opinion that surgical navigation in the pelvic region should be subject to additional investigation in order to optimize the procedure.

Reconstruction and navigation system for intraoperative brachytherapy using the flab technique for colorectal tumor bed irradiation.

PURPOSE: To present the development of a new navigation and reconstruction system based on an electromagnetic free-hand tracker and on CT imaging for treatment planning of intraoperative high-dose-rate brachytherapy (IORT-HDRB) in the sacral region. Our aim is to improve accuracy and to enable individualized treatment planning and dose documentation to be performed for IORT-HDRB using a flab technique. METHODS AND MATERIALS: The material consists of an electromagnetic 3D tracker system, a PC workstation with Microsoft Windows NT 4.0 operating system, and a recognition program for continuous speech. In addition, we designed an external reference system constructed of titanium and Perspex, which is positioned in the pelvis, and a special digitizer pen for reconstruction of the flab geometry. The flab design incorporates a series of silicon 10-mm-diameter spherical pellets. Measurements were made with a pelvic phantom in order to study the accuracy of the system. The reconstruction results are stored and can be exported via network or floppy to our different treatment planning systems. RESULTS: Our results for the reconstruction of a flab with six catheters and a total of 100 spherical pellets give mean errors in the range (2.5 +/- 0.6) mm to (3.5 +/- 0.8) mm depending on the positions of the pelvic phantom and transmitter relative to the operation table. These errors are calculated by comparing the reconstruction results of our system with those using a CT-based reconstruction of the flab geometry. For the accuracy of the navigation system for the pelvic phantom, we obtained mean errors in the range (2.2 +/- 0.7) mm to (3. 1 +/- 1.0) mm. CONCLUSIONS: The new system we have developed enables navigation and reconstruction within the surgical environment with a clinically acceptable level of accuracy. It offers the possibility of individualized treatment planning and effective documentation of the 3D dose distribution in IORT-HDRB using a flab technique.

Introduction of proton pump inhibitors--consequences for surgical treatment of peptic ulcer.

BACKGROUND/AIMS: This retrospective study analyzes the influence of different factors on morbidity and mortality after surgical treatment of peptic ulcer. METHODOLOGY: At the Municipal Hospital of Offenbach, Germany, from 1985-1996, 485 patients underwent surgery. RESULTS: Of the 485 patients, 70.7% (343) were diagnosed to have duodenal ulcer and 29.2% (142) had suffered from gastric ulcer. During this period, 79.2% (384) of the operations were performed under emergency conditions because of acute complications (56% of these with perforation, 20% with penetration, 24% with ulcer bleeding), whereas the rest was done electively. Two hundred and ninety-one (60%) patients were male, the average age was 59 years and 71.7% (348) of the patients had certain concomitant diseases. We observed complications in 48% of the cases with a total postoperative mortality of 21%. CONCLUSIONS: Between 1985 and 1996 the total number of ulcer surgeries performed at the Municipal Hospital Offenbach per year has stayed almost constant. However, a definite increase of acute operations in addition to a decrease of elective interventions was noticed. The dissatisfying results of surgical treatment of peptic ulcer after the introduction of proton pump inhibitors seems to be the consequence of the negative selection of patients mentioned above. A connection could be proved between the age and condition of the patient, the type of the surgical intervention (acute or elective) and the morbidity and mortality after the surgery.

Colorectales Carcinom--Behandlungsalternative durch intraoperative Radiotherapie mittels Afterloading-flab-Technik?

Intraoperative radiotherapy (IORT) is a new concept in the treatment of recurrent and primary advanced colorectal tumors. Between October 1994 and December 1997 27 patients (primary tumor: 8, first recurrent tumor: 12, second recurrent tumor: 7) received IORT (32 applications). Chemotherapy and percutaneous radiotherapy had already been given to all patients with advanced and recurrent colorectal tumors. The intraoperative irradiation was performed through HDR iridium afterloading. A flexible flab--individually adapted to the "tumor bed"--was used as applicator. The contact dose ranged from 10 to 15 Gy. The mean operation time (rectum resection: 5, rectum amputation: 14, debulking: 8) increased by 30 min on average. Eight patients had postoperative complications: perianal wound infections (3), sacrovesical fistulas (3), leakage of anastomosis (1) and neural ureter dysfunction (1). To date--on average 17.1 months (range: 3-33) after operation--13 patients are free of tumor recurrence or show stable disease. Ten patients--all of them had macroscopic residual tumor--have local tumor progression combined with good quality of life. Only 4 patients died (acute kidney failure, stroke, marasmus, systemic progression). The afterloading flab technique represents a technically simple, minimally harmful procedure in the therapy of colorectal tumor. Even when IORT with electrons is not feasible or the patients have already been irradiated, a higher radiation dose is possible. Given the demonstrated rate of local tumor recurrence, the afterloading flab technique seems to be a valuable treatment alternative to extended, high-risk resections. Long-term follow-ups will be necessary.

[Mechanical duodenal stump suture. Report of experiences: metal staples versus resorbable staples]. / Der maschinelle Duodenalstumpfverschluss. Erfahrungsbricht: Metallklammern versus resorbierbare Klammern.

The main observation criterion of the present retrospective study is the insufficiency rate after machine closing of the duodenal stump (TA-clip seam device, Auto-Suture), as a consequence of gastrectomy, resection of the stomach with Billroth II respective Roux-Y reconstruction, depending on the used type of clip. Between January 1, 1985 and October 2, 1989 the closing of the duodenal stump was routinely carried out with metal clips (n = 253) in the City Hospital Offenbach. Between October 3, 1989 and December 31, 1991 polysorb staples (n = 96) were exclusively used. The patient collectives were comparable regarding age, sex, health status, basic diseases, accompanying diseases and surgical methods. Closing of the duodenal stump by polysorb staples demonstrated with 13.5% more dehiscent seams than with metal clips (4.7%). As a result of the present study, we cannot recommend the use of polysorb clips for the closing of the duodenal stump.

[Colorectal carcinoma. Which factors are decisive for development of postoperative complications?]. / Kolorektales Karzinom. Welche Faktoren sind für das Auftreten postoperativer Komplikationen entscheidend?

This retrospective study analyses the prognostic effect of different factors on morbidity and lethality based on selected, primarily resecting colon carcinoma operations (n = 222). In all, 12.2% of our operations were performed under emergency conditions. The total complication rate was 31.5%, the lethality rate 7.7%. The left hemicolectomy cases showed the highest morbidity (48.4%), the rectum amputation the highest lethality (11.8%). Tumour staging tumour differentiation and the sex of the patient showed no significant influence on the postoperative morbidity and lethality. However, a correlation was proved between the age of the patient, tumour localisation, co-morbidity, duration of operation and the conditions under which the operation was performed (emergency or elective), on the one hand, and morbidity and lethality on the other.

[Endoscopic ultrasound in TN staging of stomach cancer. A comparison with computerized tomography and conventional ultrasound]. / Endoskopischer Ultraschall im TN-Staging des Magenkarzinoms. Ein Vergleich mit der Computertomographie und der konventionellen Sonographie.

64 patients with histologically proven gastric carcinoma were investigated by endosonography (EUS), computed tomography (CT) and conventional transcutaneous sonography (US). In 50 patients a resection of the stomach was performed and the histological findings were compared with the results of preoperative staging. In all cases EUS was successful in demonstrating the tumour. With CT tumour visualisation was possible in 17 (35.4%), with US in 7 (14.6%) cases. The pT-stage was correctly determined preoperatively by EUS in 40 (81.6%) with CT and US in only 12 (25%) and 4 (8.3%) patients, respectively. The staging accuracy of EUS amounted to 80% in T1-, 81% in T2-, 100% in T3-, and 67% in T4-stage. The sensitivity in demonstrating lymph node metastases was 81.3% for EUS, 25.8% for CT and 9.7% for US. The specificity in this regard was 72.2% for EUS, 83.3% for CT and 100% for EUS. The overall accuracy for determination of pN-stage was 78% for EUS, 47.9% for CT and 41.7% for US. EUS is clearly superior to CT and US in the locoregional TN-staging of gastric carcinoma.

[Primary retroperitoneal tumors]. / Primär retroperitoneale Tumoren.

73 patients, 41 males and 32 females, were treated for primary retroperitoneal tumours between 1974 and 1984. Mean age of the patients was 45.9 years (range: 1 day-79 years). Early symptoms of the tumours were atypical. Initial diagnosis showed a palpable abdominal tumour in 47 patients. Computed tomography is the most important radiologic tool for the diagnosis. In 32 patients the tumour could be removed completely. Intraoperatively, at least one additional organ had to be removed in all patients to ensure radicality of extirpation. Histology showed most tumours to be lymphomas or sarcomas. At the time of diagnosis, 21 patients were found to have metastases. Operative mortality rate was 11%. The overall prognosis in patients with primary retroperitoneal tumours is poor; the 5-year survival rate for malignant tumors was 9%. Combination of radio- and chemotherapy has somewhat improved this dim prognosis in recent years.

[Indications and results of transdiaphragmatic stomach transposition (without thoracotomy) in advanced hypopharyngeal and esophageal cancer]. / Indikation und Ergebnisse der transdiaphragmalen Magentransposition (ohne Thorakotomie) beim fortgeschrittenen Hypopharynx- und Oesophaguskarzinom.

During the period between 1980 and 1985 the technique of pharyngo-oesophageal reconstruction with gastric pull up was used in 7 late-stage cases with carcinomas of the hypopharynx and cervical oesophagus. In one patient the colon was connected with the pharynx. Oral ingestion of food was achieved 3 weeks after operation in 7 patients. The blunt dissection method of the oesophagus allowed a radical resection of the tumor as well as a one-step reconstruction of the nutritional pathway. Palliative therapy is often achieved. The significance of the operation should be evaluated both from the viewpoint of the length of survival as well as of the palliative purpose desired.

[Transdiaphragmatic esophagus resection--a procedure for the curative and palliative treatment of esophageal cancer]. / Die transdiaphragmale Oesophagusresektion--Ein Verfahren zur kurativen und palliativen Behandlung des Oesophaguscarcinoms.

From 12/80 to 1/85 133 patients with a carcinoma of the esophagus were admitted to the hospitals in Düsseldorf and Würzburg. 105 (7 total, 98 subtotal) of them were resected (79%). 14 were treated with a substernal bypass (average age: 60 years). 76% of all tumors were found in stage III and IV. The esophagus was replaced with stomach (98) and colon (7). For bypass the stomach (12) and jejunum (2) were used. The hospital mortality was 17.6% (all operations), 16.2% (resection) and 28.2% (bypass). The 2-year-survival-rate was only 15% (due to 76% of stage II and IV).

[Gas gangrene--still a diagnostic and therapeutic problem]. / Der Gasbrand--weiterhin ein diagnostisches und therapeutisches Problem.

From 1970 to 1980 132 patients were admitted to our Dept. under the diagnosis of gas gangrene. In 54 cases there was no bacteriological evidence of clostridium perfringens. In all patients surgery was performed immediately, followed by hyperbaric oxygen therapy. The overall mortality rate among 78 patients with proven gas gangrene came up to 38%, the amputation after limb injuries to 55%. In our experience we can not state a clear cut advantage of hyperbaric oxygenation as far as the death rate is concerned.

[Postgastrectomy syndromes with special reference to reflux esophagitis]. / Syndrome nach Gastrektomie unter besonderer Berücksichtigung der Refluxoesophagitis.

60 patients without suspicion of recurrence of stomach cancer have had a follow-up by mean of 65 months after the procedure of a total gastrectomy. In 16 cases an additional esophagomanometric and endoscopic-bioptic examination was performed. Up to 1975 the operative procedure of stomach replacement was a jejunal interposition, afterwards the technique of a jejunoplicationn. Clinical signs of an esophageal reflux were found in one half of the patients with a jejunoplicatio and in a third of the cases with a jejunal interposition. Endoscopic-bioptic evidence of a reflux-esophagitis has been found in 13 of 16 patients. A functioning sphincter mechanism of the lower esophagus could be demonstrated in 5 of 16 cases. There was no proof of a correlation between the results of endoscopic-bioptic and manometric examinations. A prevention or reduction of esophageal reflux is as well possible by the technique of jejunal interposition as by jejunoplication.