Efficacy and benefit of mediastinal computed tomography as a selection method for mediastinoscopy.

In 95 consecutive patients with proven or suspected bronchial carcinoma, computed tomographic evaluation of the upper mediastinum for N2 disease was performed prospectively. Patients with positive results underwent mediastinoscopy. Patients with perinodal N2 or N3 disease at mediastinoscopy were not considered candidates for operation. The mediastinum was declared negative only when intraoperative mediastinal lymph node dissection showed tumor-free nodes. Of the 95 patients, 12 had benign lesions, 14 were excluded from further evaluation because the lymph node status of the mediastinum was not proven intraoperatively, and 6 others were excluded from the final evaluation because of violation of the protocol. Twenty-two of the 75 remaining patients had a positive computed tomographic scan and underwent mediastinoscopy. Fourteen patients with positive results were considered to have inoperable disease. Fifty-three patients (70.7%) did not undergo mediastinoscopy. We performed seven probably incomplete resections, two for palliative reasons, and two thoracotomies without resection in patients with N2 disease. A policy of routine mediastinoscopy would have prevented only 5% of the thoracotomies performed in patients with lung cancer.

Evaluation of tomography and mediastinoscopy for the detection of mediastinal lymph node metastases.

In a prospective study of 88 patients seen consecutively with proven or suspected bronchial carcinoma, the validity of x-ray tomography and routine mediastinoscopy was tested for the detection and evaluation of mediastinal lymph node metastases. Positive mediastinum was defined as malignant tissue found in the mediastinum and negative mediastinum as mediastinoscopy with negative results plus a negative intraoperative mediastinal lymph node dissection. Thirty-four patients were eliminated from the analysis because carcinoma was not found or because mediastinal evaluation was incomplete by these criteria. Twenty-eight of the remaining 54 patients had mediastinal metastases. Sensitivity was 67% for tomography and 79% for mediastinoscopy. Specificity was 92% for tomography and 100% for mediastinoscopy. The differences were not significant. Sixty-six of 85 mediastinoscopies were unnecessary or unhelpful in the decision to exclude a patient from surgical intervention. Among 19 patients with lesions presumed to be inoperable based on results of mediastinoscopy (i.e., perinodal metastatic growth suspected by palpation or histologically proven), 14 patients had positive tomographic scans and 1 could not be evaluated radiographically because of right upper lobe atelectasis. We conclude that tomography of the upper mediastinum should be used to select patients for mediastinoscopy.

[The early urogram in experimental acute stenosis of a renal artery (author's transl)]. / Das Frühurogramm bei experimenteller akuter Stenosierung der Nierenarterie.

1. Renal excretion as seen in the urogram does not parallel changes in blood flow. The significance of the early urogram as a test of function is therefore very limited. 2. Following acute stenosis of one renal artery, there is simultaneous excretion by both kidneys until flow is reduced to 60%; exretion is delayed, with values of 0.5 to 7.5 minutes, following reduction to 30 to 60% of the original; there is no excretion below 30%. 3. Unilateral delay in excretion occurs at about the level of "critical occlusion pressure". 4. Delayed excretion is observed at the level of the so-called "critical stenosis" of the renal artery. A reduction of flow above 20% follows a reduction of the artery in excess of 66%, corresponding with a reduction of the lumen of more than 90%. 5. These findings indicate that delayed excretion in the early urogram is to be expected only as a result of severe stenosis of the renal artery and represents a late feature of renal vascular disease.

[The haemodynamic effects of renal artery stenosis (author's transl)]. / Zur hämodynamischen Wirksamkeit der Nierenarterienstenose.

Three reasons are suggested for the difficulty of judging the haemodynamic effects of renal artery stenosis: 1. The flow characteristics in the renal arteries of dogs indicate that, at the critical level of reduction to one third of normal diameter, a further change of only 0.5 mm. will cause a 50% alteration in flow volume. Variations of this order of magnitude cannot be reliably measured on the angiogram. 2. The production of turbulence, which can increase the effect of a stenosis considerably, depends, amongst other things, on the nature of the surface of the stenosis and this cannot be judged. 3. The effect of a stenosis depends on peripheral resistance in the kidney.

[Rhabdomyosarcoma of the pulmonary artery (author's transl)]. / Rhabdomyosarkom der Arteria pulmonalis.

A case of a 55-year-old man with the histological diagnosis rhabdomyosarcoma of the left pulmonary artery has been seen. Lung scanning and pulmonary arteriography are the clues for the diagnostical procedure. 55 cases from the literature are reviewed and clinical findings of the early and late stages of the diseases are discussed. Surgical treatment is the therapy of choice if ever possible; aggressive chemotherapy might be an acceptable alternative.

Surgery for cure followed by combined modality treatment for small cell bronchial carcinoma. ISC Lung Cancer Study Group.

For patients with small cell lung cancer (SCLC) at early stages (TNM I, II) surgery for cure is used to eliminate the primary tumour and its regional lymph-nodes followed by intermittent chemotherapy and radiotherapy within the first six postoperative months. After the pathohistological examination of the operation-specimen a two-arm-randomization is performed: standard chemotherapy compared with sequential chemotherapy using three different drug-combinations. Thereafter tumour-free patients only receive prophylactic cranial irradiation. In preliminary evaluations of March 1988, of 121 patients from 20 cooperating departments it was found that the projected life-table survival rate, three years postoperatively, of 47 patients with SCLC at stages pT1-3 N0 M0 was 65%, of 46 patients at stages pT1-3 N1 M0, 56% and of 28 patients at stages pT1-3 N2 M0, 34%. The indication for surgery were emphasized for pTNM-stages I+II. For N2-lesions surgery would not be recommended in general, but the survival rate seemed to indicate that this treatment was not detrimental, but rather more favourable compared with chemotherapy or radiotherapy only. The continuation and enlargement of these studies seem not only justified but emphatically indicated. Multicentre cooperation has to be organized to collect within a reasonable period of time a sufficient number of patients to enable subdivisions to be made according to various prognostic factors.

The importance of surgery as the first step in multimodality treatment of small cell bronchial carcinoma. The ISC Lung Cancer Study Group.

For patients with small cell lung cancer (SCLC) in their early stages (TNM I, II), surgery for cure was used to eliminate the primary tumour and its regional lymph-nodes followed by intermittent chemotherapy and radiotherapy within the first six postoperative months. After the pathohistological examination of the operation-specimen a two-arm-randomization was performed: standard chemotherapy (1000 mg/m2 cyclophosphamide, 50 mg/m2 doxorubicin, 1.4 mg/m2 vincristine) compared with sequential chemotherapy using three different drug-combinations (A: 1500 mg/m2 cyclophosphamide, 100 mg/m2 lomustine, 15 mg/m2 methotrexate; B: 1000 mg/m2 cyclophosphamide, 40 mg/m2 doxorubicin, 1 mg/m2 vincristine; C: 5 x 1.6 g/m2 ifosfamide plus mesna, 5 x 120 mg/m2 etopside). Thereafter disease-free patients only received prophylactic cranial irradiation (PCI: administering 3600 TD Gy/18 fractions) according to the protocols of the International Society of Chemotherapy Studies I and II. Preliminary evaluations in March 1990 of 170 patients from 24 cooperating departments for thoracic surgery showed that the projected life-table four-year-survival rate of 63 patients with SCLC at pTNM-stage I was 61%, of 54 patients at pTNM-stage II was 35%, of 13 patients at stage pT3, 4 NO, 1 MO was 59% and of 40 patients at stage pT N2 MO was 35%. The indication for surgery is emphasized for pTNM-stages I + II. For N2-lesions surgery would not be recommended in general, but the survival rate seems to indicate that this treatment was not detrimental, being rather more favourable compared with chemotherapy or radiotherapy alone. The continuation and enlargement of these studies seem not only justified, but emphatically indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Manometric studies of the anal canal in chronic primary fissure before and after management using dilatation or sphincterotomy]. / Manometrische Untersuchungen des Analkanales bei der primär-chronischen Fissur vor und nach der Behandlung durch Dehnung oder Sphincterotomie.

Manometric investigations in patients with primary chronic fissure in ano were performed before and after stretching or sphincterotomy in a randomized clinical trial. Length of the functional anal canal was not influenced by the procedures. At a six-month follow-up, the maximum resting anal pressure was significantly lower in both groups. After stretching and sphincterotomy, the site of maximum pressure in the anal canal had moved orally. This demonstrates that an elevated resting anal pressure is one of the pathogenetic mechanisms for the development of a primary chronic fissure. It is successfully cut off by either stretching or sphincterotomy.

[Recurrent laryngeal nerve paralysis after thyroid gland operations. Etiology and consequences]. / Recurrenslähmungen nach Schilddrüsenoperationen. Ursachen und Konsequenzen.

In the period of 1 January 1990 to 31 December 1996 the thyroidectomy cases we performed were immediately followed by vocal cord evaluation using a flexible bronchoscope while the patient was still on the operating table. If an obvious cord paralysis was discovered, an exploration of the recurrent laryngeal nerve, to the level of the larynx, was performed. If the nerve was found to be intact, no further measures were taken. A severed nerve underwent suture repair. If an otolaryngologist diagnosed a vocal cord paralysis 1-5 days after surgery, a reoperation was recommended except in the cases where postoperative bronchoscopy had shown an easily mobile cord or the recurrent nerve was completely dissected during the operation. Within this 7-year period, we performed 3492 thyroidectomy operations. The diagnosis of subsequent unilateral postoperative vocal cord paralysis occurred in 48 cases. In 33 of these cases the status of the nerve in the surgical field was known: 4 patients had an intact nerve proved by complete dissection during thyroidectomy, in two patients the lesions of the nerve were detected intraoperatively (1 transsection, 1 partial resection), and 27 cases were followed by reoperation. Of the 33 patients mentioned above, in 19 instances the recurrent laryngeal nerve was found to be intact; 3 displayed signs of local trauma, and 11 were found to be severed with total discontinuity. Those patients with an intact nerve, or local nerve trauma only, went on to develop normal function within 6 months in 20 (91%) of 22 cases. Of the 11 with a severed nerve, 8 showed "autoparalysis" with good voice within 4-8 months, after suture repair in 10 cases. The patient with partial resection had no repair of the nerve. If immediate postoperative evaluation showed mobility of the vocal cords but a paralysis was detected later by an otolaryngologist and repeat intervention was not done, vocal cord function was spontaneously restored in 9 of 11 patients. Four patients refused reoperation. From 1990 to 1991, the recurrent laryngeal nerve was not always dissected during our thyroidectomy operations. However, this was done routinely from 1991 to 1996. Routine intraoperative dissection of the vocal cord nerve reduced the rate of postoperative cord paralysis from 2.0% to 1.2%. It also reduced the frequency of intraoperative nerve injury with total discontinuity from 0.58% to 0.23%.

[Incidence of carcinoma in follicular neoplasia of the thyroid gland]. / Carcinomincidenz bei folliculären Neoplasien der Schilddrüse.

Within four years 1376 thyroid operations were performed. In 152 = 11% a follicular or oncocytic tumor was found, 20 = 13% of these were classified as carcinoma. Seven of these were of the grossly invading type, raising suspicion of malignancy already pre- and intraoperatively while 13 encapsulated tumors were found by the pathologist only. If preoperatively a cold nodule or a nodular goitre was described, the carcinoma incidence was about 16%, while warm or hot nodes showed a carcinoma in 2%. Besides tumors of < 1 cm in diameter where we found no carcinoma the size of follicular tumors had no influence on the incidence of carcinomas.

[Modification of the oxygen supply of the small intestine demonstrated on the ileus model]. / Die Beeinflussung der Sauerstoffversorgung des Dünndarmes im Ileusmodell

Elevation of the intraluminar pressure of rabbit ileum lowers the oxygen supply of the bowel wall in a pressure dependent manner. After decompression local PO2 exceeds the initial values. The infusion of Rheomacrodex-Sorbit induces an increase of local PO2 in the nondistended ileum. The reaction is enhanced in the distended bowel. The application of glucagon does not influence tissue PO2 significantly in either the distended or the undistended bowel. The infusion of Rheomacrodex-Sorbit as well as decompression of the distended bowel are recommended to improve oxygen supply of bowel wall in ileus.

[Mediastinal lymphadenectomy in bronchus carcinoma--techniques and problems]. / Die mediastinale Lymphadenektomie beim Bronchuskarzinom--Techniken und Probleme.

Mediastinal lymph node dissection in bronchial carcinoma patients means an additional procedure to the tumor resection. The en-bloc dissection is only possible if an upper lobe resection or a pneumonectomy is performed; otherwise, an isolated lymph node mapping is necessary. According to the different anatomical structures, mediastinal lymph node dissection is more easily performed on the right than on the left side, where mobilisation of the aortic arch or a longitudinal sternotomy is mandatory to sample the pre- and paratracheal lymph nodes. Up to now it is uncertain whether lymph node dissection improves the prognosis. But undoubtedly it is the basis for an exact staging.

[Therapy and course of disease in spontaneous esophageal perforations]. / Chirurgische Therapie und Verlauf nach spontaner Osophagusruptur.

INTRODUCTION: Esophageal perforations occur spontaneously or as a complication of endoscopic procedures. Especially in spontaneous perforation there is ongoing debate regarding the best treatment options. METHODS: 24 patients that were treated at two surgical centers (University Halle, City-hospital Bielefeld) after spontaneous esophageal perforations between 1996 and 2005 were analysed retrospectively. RESULTS: All patients but one underwent surgical treatment with in 2 cases additional stent implantation. Average stay in hospital was 53 days. In-hospital-lethality was 25% (overall lethality 37.5%). Concerning the therapeutic outcome there was no link between patients' age, localization or size of the perforation and the time interval between perforation and treatment. In 22 patients diagnosis was made > 12hrs after the event. CONCLUSIONS: Main problem of the Boerhaave-syndrome is the septic-toxic disease. Prognostic criteria are the patients' health-state and not factors like size of perforation, time of delay or localization of the perforation. Since in case of survival esophageal resection shows good long-term-results, in doubt a radical surgical procedure should be recommended as primary option. Implanting an esophageal stent might become a useful mean of treating patients with spontaneous perforations.

[Etiology and therapy of spontaneous pneumothorax. Discussion of conservative or surgical procedure based on personal results]. / Atiologie und Therapie des Spontanpneumothorax. Diskussion des konservativen oder chirurgischen Vorgehens anhand eigener Ergebnisse.

The treatment of spontaneous pneumothorax is discussed on the basis of the experience we have gained in 78 patients. Therapy is determined by the pathophysiology and aetiology of the condition. The treatment and follow-up results are compared with those reported in the literature, and the rationale of our own procedure is explained. It is emphasized that surgical treatment that takes account of the aetiology, produces good results with respect to freedom from recurrence and pulmonary function. Particular attention is drawn to the higher mortality rate of pneumothorax in the aged when surgical treatment is required, so that in these patients, it is justified to proceed as conservatively as possible, making use of the less aggressive procedures indicated here.

[Barium sulfate and water-soluble contrast medium--a suitable mixture for contrast radiography in acute small bowel obstruction]. / Bariumsulfat und wasserlösliches Kontrastmittel--ein geeignetes Gemisch zur radiologischen Diagnostik der akuten Passagestörung des Dünndarms.

Experiences with a mixture of two different contrast media for radiography in acute small bowel obstruction are reported. Due to different physical and chemical properties, barium sulfate and a water-soluble, high-osmolar contrast medium provided high contrast density in all segments of the small bowel and a shortening of the transit time to the colon. This method proved to be effective and accurate in predicting which patients with suspected small bowel obstruction required surgical intervention. No complications caused by the contrast media were observed intraoperatively or in the postoperative period.