Organ injuries are a frequent occurrence: The Surgical Department of Wuerzburg University treated 270 patients between 1983 and 1987. More than one-fifth of these patients had undergone primary surgery at other hospitals and came to us for reoperation or intensive care. The successful treatment of such severe and often multiple, simultaneous injuries depends on well-trained surgeons whose undelayed consultation with specialists is not impeded by bureaucratic hospital organization.
There is no correlation between the number of places for surgical education and the real demand for surgeons. In Bavaria 86.7% of all surgeons licensed to train surgeons between 1-6 ys. took part in an inquiry. They asked for 25-30% surgeons in their residency staff but got only 8-24% in reality. In addition 60.2% of all resident wait for a place to finish their surgical training in fully licensed hospitals. In a big community hospital there are no problems for residents to get the needed number of operations. Beside this surgical education should include 6 months clinical training in ICU, 2.5 ys. general, 1.5 trauma and 1 year vascular-thoracis surgery. Basic science and research can be done only in universities, but clinical control of patients outcome, i.e. in tumor patients is mandatory.
Looking for medical errors in clinical practice we reviewed several cases from our daily indication and case conference, 6 cases discussed in the lethality conference and 9 which were treated by legal institutions. The points of criticism were analysed. We discriminated between diagnostic, therapeutic failures and those of organisation. The basis were 4045 patients with 4583 operations during the year 1989. The overall lethality was 1.2%. The instruments of avoiding medical errors in individual and general sense were shown.
Asymptomatic patients with carotid stenoses exceeding 75% have an elevated ischemic cerebrovascular event rate of 18% per year (5% strokes). Our combined perioperative stroke and death rate (1980-1990: 1123 operations) is 1.85%. Thus prophylactic surgery may be indicated in the following cases: hemodynamically significant stenoses of 75% and more, especially with marginal or reduced autoregulatory reserve, rapidly progressing lesions in medically treated patients, lesions with a high risk of embolization (ulcerations on B-scan), clear interrelation between arterial lesions and positive (asymptomatic) intracranial findings (CT, NMR, TC, USD).
Even in the era of efficient methods for diagnosis of disturbances of thyroidal function and morphology, the diagnostic program starts with inquiry of history and physical examination. Today, high resolution sonography is the basic method for assessment of thyroidal morphology whereas scintigraphy exclusively gives informations on topography of function. In-vitro determinations of TSH with sensitive assays are the most sensitive and efficient procedures for the clinically most relevant question, namely the exclusion of disturbances of global thyroidal function.
The diagnosis of hyperinsulinism in our 47 patients could be confirmed by clinical signs, blood sugar, insulin and C-peptide estimation. The preoperative localisation of the insulinoma was reached by angiography in 60%, by CT in 50% and by sonography in 10%. Intraoperative tumor localisation by measurement of incorporated P32 was effective in 70%. In 37 patients we enucleated one or more adenomas. In 5 children with Nesidioblastosis the left sided pancreas resection was performed. 5 patients with islet cell carcinoma were treated by duodenopancreatectomy and Streptozotocin. The longest survival time was 6 years.
Surgery of colorectal cancer is also surgery of lymph node compartments and tissue planes. It is essential in such surgery to avoid tumor dissemination and inoculation while observing safety margins. If surgical procedures are strictly standardized according to the rules of surgical oncology R0-resection will yield extraordinarily favourable results not only for stage I but also for stages II and III tumors. There are distinct differences between colon and rectal carcinoma in stage II disease, indicating a different biologic behaviour of these tumors. The possibility of further improvement of the good results of R0-resection by adjuvant therapy should be addressed in future studies.
Management of up-to-date cancer therapy in strict accordance with histology and stage warrants more than ever a competent co-operation of the pathologist. For this reason the surgical pathologist has to act in dual roles as a diagnostician and consultant. With reference to the internationally acknowledged histological grading and classification of malignant tumors and further the refined principles of the TNM-classification, diagnostic requirements for surgical pathology have considerably been extended in the field of interdisciplinary oncology.
The principal aim of a practical diagnostic strategy is rapidly identify the organ injury following blunt abdominal trauma. A general diagnostic strategy and special technical investigations are described and their relative values discussed. From 1 January 1986 to 31 December 1989, 440 patients were treated for blunt abdominal trauma which had resulted in 166 organ injuries. Ultrasound was used in the initial investigation. Its sensitivity was 96% and specificity 98%. Following examination by ultrasound the rate of negative laparotomies was 1.3%.
Acute thrombotic arterial occlusion is a complication of chronic vascular arterial disease. The arteriogram usually reveals a sudden occlusion and the collateral vessels. Treatment with low-dose fibrinolytic therapy is widely accepted. A combination of low-dose fibrinolysis, aspiration embolectomy and angioplasty yields the best primary success rate. In cases of sudden popliteal occlusion and dilating arteriopathy ultrasound sonography should be used to exclude the presence aneurysm which is a contraindication for fibrinolysis. There is a high risk of peripheral embolisation, in the presence of an aneurysm and this may cause severe deterioration of the arterial blood supply.
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