Langenbecks Archiv fur Chirurgie最新文献

The therapeutic concept of programmed lavage has been established in the treatment of severe diffuse peritonitis. This treatment was given to 30 patients from January 1995 to February 1997. The total lethality rate was 30% (11/30 patients). Ten patients had organ failure of three or four organ systems at the time of first laparotomy. In this group the lethality rate was 50%. On average 9.2 programmed relaparotomys were performed per patient. As early complications, small bowel fistulas were observed in three patients, bleeding in three patients and problems due to the laparostomy in four patients.

With standardized operating strategies, a lethality rate of 10.2% was achieved following intra-abdominal administration of taurolidine in 352 cases of severe intra-abdominal infection. The extent and type of antibacterial therapy were determined on the basis of the clinical severity, the patient's age, and the original site of the infection. Local antisepsis includes tactical surgery and the use of locally and systemically acting taurolidine. Antibiotics were used for systemic antibacterial therapy. After laparoscopical clearance of the focus of infection (appendix, gall bladder) the operating time was significantly extended compared with that required for open surgery, while the postoperative complication rate and the length of stay in hospital were significantly reduced.

In recent years, minimally invasive operations in abdominal and thoracic surgery, especially with laparoscopic techniques, have developed rapidly. A multi-purpose retractor system, Jakoscope (Atlantis Surgical, Inc., New Brunswick, NJ, USA), developed by Jako provides a new and interesting alternative for minimally invasive and direct access surgery without pneumoperitoneum. This instrumentarium, apart from its use in various surgical specialties, allows a direct access through a 3- to 6-cm single incision for removal of the gallbladder. We used this instrumentarium with great success in patients not suited for laparoscopic surgery in comparable time. Up to now the Jakoscope has been applied in five patients. We report about our first case.

The objective of this retrospective study was to determine the indications for splenectomy in hematological disorders and to analyze the results depending on the indication leading to surgery. Fifty-six patients with various hematological disorders were splenectomized between 1990 and 1994. The main indication was noted. Operative success was defined as: return to normal platelet counts without further medication in thrombocytopenia, relief of pain and local compression syndrome in painful splenomegaly, hemoglobin levels > 10 g/dl without the need for further transfusions in hemolytic anemia, response to chemotherapy after splenectomy for prior resistance because of massive splenic infiltration, and relief of infection in splenic infection. Morbidity and mortality were noted. Five major indications for splenectomy were found: thrombocytopenia (n = 36, success 78%), painful splenomegaly (n = 8, success 100%), hemolytic anemia (n = 5, success 60%), resistance to chemotherapy because of massive splenic infiltration (n = 5, success 100%). One patient with thrombocytopenia died (mortality 2%). Seven patients had major complications (13%). In hematological diseases, thrombocytopenia, painful splenomegaly and splenic infection are likely to be improved by splenectomy. In hemolytic anemia it can be a helpful approach, while in resistance to chemotherapy because of massive splenic infiltration success is less likely.

From September 1985 to February 1994, 183 patients (arterial occlusive disease n = 108, abdominal aneurysm n = 75) underwent reconstruction of the abdominal aorta. In 120 patients an aorto-bi-iliac or aorto-bi-femoral reconstruction was performed and in 63 patients a tube-type reconstruction. The early and late postoperative complications are described. The complications were dependent on the choice of graft, the distal anastomosis and the preoperative risk factors. The mortality from elective repairs was compared with the mortality in emergency repairs. The role of endovascular reconstructive surgery in comparison to conventional reconstructive procedures is discussed.

Reconstruction after radical tumor resection in the oropharyngeal region still represents an interdisciplinary challenge. Autotransplantation of the jejunum is a popular procedure, in which the abdominal surgeon's main task is that of harvesting enteral tissue. To evaluate this technique, a careful analysis of accompanying perioperative abdominal complications was performed. Additionally, we reexamined 35 of 66 patients still living after a follow-up period of 21 (range 2-63) months on average. The perioperative mortality of 90 patients treated for oropharyngeal malignancy using the described procedure was 7.8%. None of the perioperative deaths was caused by an abdominal complication associated with enteral resection. One abdominal reoperation was performed because of abdominal wall dehiscence. For reasons not related to enteral resection, four further patients had to be relaparotomized, two of them during their hospital stay and two after leaving hospital. In five cases we observed minor complications which could be treated nonsurgically. In the follow-up reexamination we detected no abdominal late-onset complication except small incisional hernias in six cases. Finally, we concluded that despite an elevated overall operative risk in this population, complications owing to jejunal resection were comparably low. The data regarding the rate of complications classify jejunal resection as a safe procedure for reconstructive purposes in patients suffering from oropharyngeal malignancy.

Between April 1993 and December 1996, the data of 3183 patients were recorded and analyzed in a program for internal quality assurance at the Department of General and Abdominal Surgery of the University of Mainz. The measuring of perioperative risk, the finding of intraoperative influences and the objective rating of quality of treatment were achieved by means of eight different operation-specific documentation sheets and the data records of the operation theater. With our system it is possible to measure differences between several surgeons and also differences in comparison to national and international results. By means of prospective collection of patient data and the built-in control mechanisms we obtain a lot of exact and nearly complete data. The information gained not only reflects the performance of a department, but can also be used as an instrument for the planning of work and deduction. Through optimized therapy the program can lead to an improvement of quality.

Common late complications after esophagectomy and gastric tube reconstruction for esophageal carcinoma are symptomatic, benign fibrotic stenoses of the cervical anastomosis, which require dilatation. Since the prognosis of esophageal carcinoma still remains poor, bad functional results such as dysphagia affect quality of life. In a retrospective analysis, our patients were evaluated with regard to the underlying effects of cervical anastomotic stenosis after esophagectomy and gastric tube reconstruction. From 1 January 1989 to 31 July 1995, 173 patients with carcinoma of the esophagus were operated in our institution. Transhiatal esophageal dissection was performed in 133 patients; 40 patients underwent transthoracic en bloc resection. The 30-day mortality rate was 7.5% (13 patients). Postoperative fibrotic stenosis of the cervical anastomosis requiring dilatation occurred in 36.4% (63 patients) 6-12 weeks after operation. Fibrotic stenosis of the cervical anastomosis did not develop in 97 patients. There was a significant difference concerning the incidence of anastomotic leaks within both groups: whereas in 23.8% of the 63 patients who developed a fibrotic stricture of the cervical anastomosis an anastomotic leak preceded this event (P < 0.001), no anastomotic leak occurred in the group of 97 patients with normal healing of the cervical anastomosis. In addition, significantly (P < 0.01) more patients (37.5%, n = 23) with preexisting diabetes mellitus could be found among the 63 patients who developed a fibrotic stricture of the cervical anastomosis, in contrast to the 97 patients without anastomotic stenosis.

In 57 convalescence courses after surgery, temperature, pulse rate and complications recorded daily for 24 days were investigated. Complications were synchronized approximately with temperature. The time structure of the temperature proved to be periodical (reactive periods). The approximately 7-day periods (medium waves) predominated, frequently superimposed by short waves (< or = 4-day periods) and long waves (> or = 14-day periods). There was an intermediate band of approximately 10-day periods. The phases were synchronized with the day of operation, mostly with maxima, otherwise with minima. Periods and phases could jump, the periods preferably in integer ratios, the phases approximately 180 degrees. The long waves yielded a steep drop initially and a reascent of the temperature in the approximately 3rd week. As the number of complications was coincident with the temperature, it also dropped quickly after operation but rose again during the 3rd week. Apart from long waves, temperature and complications descended slowly, synchronizing with the medium waves. The reascent time structure is generally associated with a trophotropic type of patient (late reactive), the gradual descent with an ergotropic type (early reactive). As both of them can be recognized preoperatively, the time structure of the late complications expected can be predicted. Besides the long waves the time structure of the complications is related to the medium waves. Therefore a peak of the complications often occurs at the end of the 1st week.

Annular pancreas is rare congenital malformation of the pancreas. In about 50% of the cases the malformation is asymptomatic until the third to fifth decade. We report on a 52-year-old male patient who presented with subtotal duodenal and gastric outlet stenosis. Duodenohemipancreatectomy (Whipple's procedure) was performed. The histological examination showed an annular pancreas with complicating inflammatory reactions (tryptic sialadenitis) of the pancreatic head causing additional obstruction. Annular pancreas should be taken into account as a possible cause of adult duodenal obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic modality of choice, and in combination with computed tomography the diagnosis can be obtained preoperatively in many patients. However, there are still patients in whom the diagnosis can finally be obtained only intraoperatively especially in cases where inflammatory pseudotumors or subtotal duodenal stenosis make ERCP impossible.