[Interdisciplinary position paper "Perioperative pain management"]. / Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement".

Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.

Octreotide combined with goserelin in the therapy of advanced pancreatic cancer--results of a pilot study and review of the literature.

The two hormone analogues octreotide and goserelin have been shown to decelerate growth of human pancreatic cancer in vitro and in vivo. The objective of this pilot study was to investigate the efficacy and toxicity of the combination of these two agents in patients with advanced pancreatic cancer. Octreotide was injected subcutaneously in dosages increasing weekly, starting with 50 micrograms twice daily, until the level of maintenance therapy of 500 micrograms three times a day was reached. In addition, 3.8 mg goserelin acetate was administered subcutaneously at monthly intervals. A median of 7 cycles (range 1-27 cycles) were applied; 13 out of 14 patients entered into the study were evaluable for response and all 14 were evaluated for toxicity. In one patient with initially non-resectable pancreatic cancer, systemic therapy yielded a partial remission lasting 9 months. The degree of tumour regression then allowed a consecutive macroscopic radical tumour resection followed by an additional 6 months of no evidence of disease while the same drug combination was continued. In an additional 9 patients, no change of disease was observed, in some cases for a remarkably long time (up to 27 months). Nevertheless, the objective response rate of 7% (95% confidence interval 0 +/- 21%) was low. In 5 patients a clear improvement in their performance status was seen soon after the start of therapy; 3 patients showed progression of the disease at first evaluation or earlier and 1 patient was not evaluable at the time of study assessment. According to the product-limit method of Kaplan and Meier, the time to progression was 3.0 +/- 1.8 months [median +/- asymptotic standard error (ASE)] and overall survival was 6.0 +/- 1.5 months (median +/- ASE). Toxicity was rare and only of mild to moderate degree. Overall, the regimen under investigation did not meet the criteria for sufficient antitumoural effectiveness. Nevertheless, this study reinforces the concept that pancreatic cancer is principally responsive to endocrine therapy and therefore the further investigation of hormonal manipulation seems worth while in the future.

[Pre- and postoperative diagnosis of an aortic aneurysm by dynamic computed tomography with omission of angiography]. / Prä- und postoperative Diagnostik des Aortenaneurysmas mittels dynamischer Computertomographie unter Verzicht auf die Angiographie.

A study which was prospective with regard to the method, showed 41 cases of aortic aneurysms in a collective of 3597 body-CT-examinations (1.14%). By means of CT and its possibility of reconstruction all morphological details of an aneurysm become visible. The course of the vessels to the bowel and to the kidneys are shown with the same excellence as in angiography. However, additional information which angiography cannot supply, is also given, like non-perfused lumen, changed wall structure and perivascular changes. Measurement of flow can be performed in the vessel and in the organ, the arterial supply of which is involved in aneurysmatic disease. The method is non-invasive. This is important for control after operation. Morphological changes of the vessel prosthesis are detected, as well as bleeding and infection. Functional parameters are determined semiquantitatively.

[MR-Cholangiopancreatography as a single-shot projection: techniques and results of 200 examinations]. / MR-Cholangiopankreatikographie als Einzelschussprojektion: Erfahrungen und Ergebnisse bei 200 Untersuchungen.

PURPOSE: Evaluation of utility and value of a selective projection technique for bile and pancreatic ducts in MRI. MATERIAL AND METHODS: 200 patient examinations of the pancreaticobiliary duct system using a turbo-SE pulse sequence in "single-shot" technique were evaluated in retrospect concerning anatomic display and diagnostic accuracy compared to surgery, ERCP, i.v. cholangiography, ultrasound and clinical course. RESULTS: Non-dilated ducts allowed visualisation of gallbladders in 78%, common bile ducts in 97%, cystic ducts in 80%, intrahepatic main ducts in 71% and pancreatic main ducts in 69%. When dilatation was present, all common bile, intrahepatic main and pancreatic ducts were visible. Display of cystic ducts and gallbladders with a detection rate of 69 and 85%, respectively, did not improve. Sensitivities for diagnosing papillary stenoses (n = 6), pancreatic ductal stenoses and dilatation (n = 13), compressions and dilatations of the biliary tree (n = 33) as well as for one choledochal cyst were 100%. Choledocholithiasis could correctly be predicted in 11/15 cases (73%), cholecystolithiasis in 71/120 cases (59%). CONCLUSION: "Single-shot" MR-cholangiopancreatography is a fast and non-invasive modality which can replace i.v. cholangiography and restrict the indication for ERCP to therapeutic indications and problem cases.

Polydioxanone in vascular surgery. First experience with an absorbable suture in femoro-popliteal bypass.

The use of synthetic absorbable monofilament suture material (polydioxanone, PDS), is described for operative vascular surgery. Six anastomoses in three femoro-popliteal (tibial) vein bypass operations were performed. Angiographical control was carried out, when absorption was in progress (after a period of five months) or totally completed (within six months), and showed no dilatation or aneurysm formation at the suture line. One anastomosis was excised five months after the first intervention. Histological examination showed fragmented suture material and slight tissue reaction. Suture material characteristics in respect of tensile strength, pliability, knotting properties and visibility were judged critically.

[Morphologic changes in artificial prostheses following para-articular knee bypass operations]. / Morphologische Veränderungen an Kunststoffprothesen nach kniegelenksüberschreitenden Bypassoperationen.

A report is presented on two helically reinforced polytetrafluoroethylene vascular prostheses in the femoro-popliteal (below-knee) position which thrombosed in the early postoperative period. Lateral angiography in the 45, 90 and 120 degree position of the knee joint showed short (2 mm) mild stenosis like kinking in case 1. At reoperation in case 2 the prosthesis was kinked in the longitudinal axis. Femoro-popliteal allografts across the knee joint should accomplish the following demands: 1. no kinking on postoperative lateral angiography with the knee joint bent and 2. intact prosthesis at reoperation.

[Indications and results of gastric bypass in the treatment of extreme obesity]. / Indikation und Ergebnisse des Magenbypass in der Behandlung der extremen Fettsucht.

A report is presented on gastric bypass (n = 27) and gastroplasty (n = 2) in patients with morbid obesity. One patient died postoperatively (mortality 3.4%). Mean weight prior to operation was 129 kg (96 to 205 kg), i.e. 117% (63 to 253%) in excess of the ideal weight. During a follow-up period of 6 to 46 months, the mean loss of weight amounted to 38 kg (3 to 77 kg). 86% of the patients judged their condition as being very good to good. Diseases related to obesity were reduced to a remarkable degree: hypertension from 43 to 5%, hypertriglyceridaemia from 50 to 5% and diabetes mellitus from 52 to 13%. Two patients had to be reoperated on due to a peptic jejunal ulcer, five because of an incisional hernia. No patient suffered from diarrhoea, calculi of the biliary or urinary tract or electrolyte disorders. On the basis of these results gastric bypass would appear to be indicated for the treatment of obesity not amenable to conventional therapy.

[Gastric bypass in the management of morbid obesity]. / Der Magenbypass in der Therapie der morbiden Fettsucht.

A report is presented on 82 gastric bypass operations performed from 1979 to 1988. The average preoperative body weight was 132 kg, the body mass index (BMI) 45.0 +/- 7.0. 1 patient died (mortality 1%). 88 per cent of all patients were followed up 2 months to 9 years (2.5 years on average) postoperatively. The mean weight loss was 40.8 kg (reduction of BMI 15.1). Obesity-related diseases decreased remarkably, 3 stomal ulcers and 5 cases of anemia occurred as late complications. On the basis of these results gastric bypass is shown to be an effective and safe treatment of morbid obesity.

[Circular staplers in esophagojejunal and esophagogastric anastomoses]. / Die zirkuläre Klammernaht bei ösophagojejunalen und -gastralen Anastomosen.

A report on 100 consecutive esophagoenteric anastomoses (EEA stapler) following total (esophagojejunostomy) or proximal gastrectomy (esophagogastrostomy) is presented. The following intraoperative problems occurred: insufficiency of the purse string suture [4], lumen of the esophagus too small [1], rupture of the esophageal wall [4], incomplete rings [4]. Fatal postoperative complications included two cases of insufficiency of the esophagojejunostomy, whilst the remaining six postoperative deaths were not linked to the use of the stapler (operative mortality 8%). Follow-up showed no recurrence at the stapler line, but two anastomotic strictures occurred. The EEA stapler is a helpful instrument to reduce leakage at the esophagoenteric anastomosis and, hence operative mortality after total and proximal gastrectomy.

[Tumor diagnosis by immunoscintigraphy with anti-CEA antibodies (Tc-99m MAK BW 431/26)]. / Immunszintigraphische Tumordiagnostik mit Anti-CEA-Antikörpern (Tc-99m MAK BW 431/26).

We evaluated the clinical application of the monoclonal antibody MAb, BW 431/26, which is easy to label with Tc-99m for tumor localization. This is an anti-CEA antibody and a murine immunoglobulin (Ig G1, Isotype). We investigated patients with colorectal carcinoma (n = 14), with colorectal carcinoma recurrences (n = 24), breast carcinoma (n = 2), stomach carcinoma (n = 1), carcinoma of the urinary bladder (n = 3), lung carcinoma (n = 2) and patients with an elevated CEA level. In primary colorectal tumors (n = 14) all carcinomas were correctly localized by IS and ECT technique. In these patients the diagnosis was already known. The planar pictures showed a false negative result in 3 patients. In patients with colorectal recurrences the investigations were performed twice in 2 patients and three times in 1 patient. In these 31 ECT investigations we found 17 true positive results, 12 true negative results, 1 false positive result and 1 false negative result. The lesions were already visualized within 4 to 6 hours, but 24-hour pictures are desirable. SPECT pictures are absolutely necessary because sensitivity is considerably improved thereby. Elevated CEA levels increase the probability of a positive IS low CEA levels do not exclude positive tumor visualization. HAMA was found in only 1 patient, but follow-up investigations are indicated.

[Clinical relevance of extracorporeal shockwave lithotripsy (ESWL) in choledocholithiasis]. / Klinische Relevanz der extrakorporalen Stosswellenlithotripsie (ESWL) bei Choledocholithiasis.

Primary endoscopic removal of bile duct stones is an established method of treatment. However, the extraction of stones is impossible in about 10% of cases despite successful endoscopic papillotomy and manual lithotripsy. Over a period of two years extracorporeal shock-wave lithotripsy (ESWL) was performed in 32 patients. Piezolith 2200, a second generation lithotripter was used, which requires neither analgesia nor anaesthesia for the patient. Localisation of the stones was carried out by means of a 3.5 MH 2 sector scanner. ESWL treatment was successful in 24 of 32 patients (75%). In 6 patients the bile duct stones were too large or too numerous and in 2 patients sonographic localisation was impossible. Out of a total of 131 patients with stones in the biliary tract only 9 (6.8%) needed surgery. Piezoelectric lithotripsy is a safe and effective adjunct procedure for the treatment of bile duct stones which were not extractable by endoscopy.

[Minimally invasive surgery--choledocholithiasis: therapeutic splitting]. / Minimal invasive Chirurgie--Choledocholithiasis: Therapeutisches Splitting.

Patients with cholecysto- and choledocholithiasis may benefit from the advantages of laparoscopic cholecystectomy by intraoperative common bile duct exploration or preoperative endoscopic papillotomy (EPT) with stone removal. We performed therapeutic splitting in 94 patients. Morbidity was 4.2% and mortality was zero. A follow up study of 50 patients shows residual stones in 2% and papillary stenosis in 2%. We believe our results, supported by data on EPT in the literature, show that two-stage endoscopic stone removal prior to laparoscopic cholecystectomy is a safe and effective method for treating cholecystolithiasis combined with choledocholithiasis.

Stapling devices in gastrointestinal surgery.

In a series of 189 patients, 197 operations (251 stapled anastomoses) were performed. U.S. Surgical Corporation instruments (GIA n = 156, EEA n = 36, TA n = 59) were used in surgery of the stomach, pancreas, small and large bowel, and the rates of complications were investigated. The EEA gave 14% complications because of the frequent failure (33%) of the anastomosis after low anterior resection. The reasons for failure were incomplete rings, colonic wall damage and too short rectal stumps. The use of the EEA in esophago-jejunostomy and esophago-gastrostomy was safe and the postoperative course uneventful. The GIA was used in intestinal and colonic surgery and was pleasant and quick to use (right hemicolectomy: 1 hour 40 minutes; sigmoid resection: 1 hour 45 minutes). Complications occurred in the intestine (6%) and colon (7%). Only with GIA stapled anastomoses was there a risk of hemorrhage (2.5%). The incidence of anastomotic leakage (all staplers) was 3.6%; the stapler was responsible for a 2.0% mortality. Weighing up the indications and contraindications of stapling devices, this method presents an advantageous but not indispensable method in gastrointestinal surgery.

[Intraoperative biliary tract injuries]. / Intraoperative Gallengangsverletzungen.

Twelve iatrogene bile duct injuries are reported. Eleven occurred in operations of the bile system, and one in a gastric resection (B II). The injury should be diagnosed immediately, especially by intraoperative cholangiography. Operative treatment is discussed. Eleven patients survived, one died of pulmonary embolism (operative mortality, 8,3%). One patient had to be reoperated because of stenosis of the common bile duct. Choledochoduodenostomy was performed. The follow-up of 11 patients showed good results without any recurrence of jaundice or pain.

[Diagnosis and results of treatment in appendicitis]. / Diagnose und Behandlungsergebnisse der Appendicitis.

In a period of 5 years 3455 appendectomies were performed because of appendicitis. Acute appendicitis (i.e. gangrenous appendicitis, appendiceal abscess, perforated appendicitis) was found in 30% of all appendectomies. Histological finding, sex, age, symptoms, duration of illness until operation, technique of operation and postoperative complications were documented in a form suitable for computer input and analyzed. The lethality of appendectomy was 0.38%.

[Two-stage minimally invasive therapy of cholecysto- and choledocholithiasis]. / Zweizeitige minimal-invasive Therapie bei Cholecysto- und Choledocholithiasis.

Therapeutical splitting consisting of endoscopic sphincterotomy, stone removal and laparoscopic cholecystectomy is a valuable alternative method compared to open cholecystectomy with common bile duct exploration. In our prospective study we performed this procedure in 89 patients (28.7.1990-28.7.1993). Morbidity was 4.5% and mortality was 0. A follow-up study of 50 patients shows residual stones in 2% and papillary stenosis in 2%.

[Repair of internal carotid artery stenosis. Results of reconstruction in 129 patients]. / A. carotis interna-Stenose-Desobliteration. Rekonstruktionsergebnisse bei 128 Patienten.

128 Patients were operated upon consecutively since 1965 for lesions of the carotid bulb (stadium I.: n = 21;stadium II: n = 45;stadium III: n = 33; stadium IV:n - 29), a postoperative neurological deficit was noted in 4,7%, the cerebral lethality was 1,9%. The procedure was done in general anesthesia with moderate elevation of the systemic blood pressure. In case the pressure readings obtained in the stump of the internal carotid artery were below the level of 50 mm of mercury an intraluminal shunt was used. Considered an average lethality of 7% per year 48 patients died during follow-up, 5 for cerebral. 10 for internal medical reasons, in 33 cases the results of post mortem examination was not available. After a mean follow-up time of 7 years 41 patients were re-evaluated 4,8 recurrent stenoses, 2,4% intracranial and 9,4% changes in the contralateral carotid artery were detected. Only 4,8% showed abnormalities on neurological examination, which underscores the importance of non invasive diagnostic tools.