Results of geriatric surgery in primary care

An analysis was made of surgical interventions from 1967 to 1987, with patients above 65 years of age accounting for something between 19 and 24 per cent. Detailed investigations were conducted into 1,346 operations, with most of these having been performed on patients aged 70 to 74 (27.9 per cent). The overall lethality amounted to 25.2 per cent. The lethality risk increased with leapwise significance beyond the 75th year of age for both elective and emergency operations. Urgency of intervention, concomitant diseases, and age were found to be the major factors to determine prognosis and lethality. Reference is made to improved medical action in the perioperative phase as well as to consideration of ethical aspects.     

Surgical indications, timing and method in acute pancreatitis

Treatment for acute pancreatitis was received by 462 patients at the Surgical Hospital of Greifswald University, between 1976 and 1986. Surgical therapy was applied to 117 of 141 patients with necrotising pancreatitis. Lethality rates were 46 per cent in a group with partial necrosis and 86 per cent in another with total necrosis. The Ranson approach was used in operations on 63 of 90 patients with partial necrosis. Their lethality amounted to 23 per cent. 27 patients were given surgical treatment, in spite of unfavourable prognosis, only up to ten days from onset of acute pancreatitis. Lethality in this group was 78.5 per cent. Proper localisation of the necrotic focus is important to prognosis, just as good timing of surgical intervention. Lethality rates were 25 per cent for resection in the caudal region and 38 per cent for necrosectomy of the pars lienalis. Necrosis in the head region entailed a lethality rate of 90 per cent in response to necrosectomy and a rate of 64 per cent with additional lavage. The prognosis of pancrease necrosis is affected by timing and method of surgery. Timing should depend on the clinical pattern, laboratory parameters as well as on findings recorded by computed tomography and ultrasound. Aetiological aspects and location of the process must be considered for choice of surgical techniques. Necrectomy, lavage, and revision of bile ducts seem to be adequate surgical methods.     

Comparative evaluation of various surgical and combined methods of treatment of patients with esophageal cancer

The work gives a comparative analysis of the results of treatment of 267 patients with carcinoma of the thoracic esophagus by different variants of surgical intervention and preoperative irradiation. The results show that separation of surgical treatment into two or more stages fails to reduce postoperative lethality. Preoperative irradiation does not lead to increase of postoperative lethality and increases 5-year survival of patients as compared to the survival of patients treated by surgery alone. Five-year survival after radical operations was 12.3 +/- 1.2 per cent and after combined treatment it was 24.5 +/- 2.8 per cent. None of the patients who were subjected to palliative operations lived for more than 5 years.     

Perforation of gastroduodenal ulcer. Risk factors and choice of procedure

The well known surgical risk factors, such as age, time of perforation as well as size and localisation of necrosis, were confirmed in retrospective and prospective analyses of perforation of gastroduodenal ulcers (n = 504). Incidence was unchanged in the two different time-related groups, with 3.2 or 3.7 cases in one month. There was a clear-cut need for excision of the ulcer or necrotic margin. Perforation was attributable to malignant tumours in 2.1 per cent of the cases. The authors have definitely adopted the concept of earlier primary surgery (23 per cent of all cases, as compared to 10.4 per cent before). The risk associated to it was found to be lower than linked to palliative operations. The lethality rate was as low as 7.6 per cent, once due consideration was given to the above risk factors for adequate choice of surgical methods. Particular attention was given to ulcer localisation and clinical course. Hence, lethality has clearly dropped below earlier data.     

40 years biliary surgery at the surgical clinic of the Charité

Evaluation of 4,374 bile operations performed between 1945 and 1984 revealed drop in lethality from 4.0 to 0.8 per cent. The average age distribution of patients who had undergone surgery from 1945 to 1954 was identical with that for the period between 1975 and 1984. Case histories were probably shortened owing to earlier diagnosis. The rate of choledochotomy dropped from 11.5 per cent (1945 to 1954) to 7.9 per cent (1975 to 1984). The rates of choledochotomy and surgical papillotomy declined, ever since endoscopic papillotomy had been introduced more than ten years ago. Endoscopic lithotripsy and shock-wave lithotripsy are new approaches to cholelithotherapy.     

Incidence of complications and surgical risk in biliary tract surgery

Locally delimited complications originating from the surgically treated organ were recorded in 7.8 per cent of 7,640 bile duct operations, between 1970 and 1984, while systemic complications accounted for 4.6 per cent. Overall lethality was 0.8 per cent. Inflammatory gall bladder as well as choledochus findings calling for therapeutic action and advanced age together with age-related diseases were factors of relevance to prognosis. Lethality among males was higher with significance than that among females. Postoperative pancreas necrosis, pulmonary embolism, and cardiac failure were predominant causes of death. Target-oriented perioperative antibiotic prophylaxis, broader postoperative use of medicamentous thrombosis prophylaxis, and limitation of papillary dilatation to widths up to 6 mm are considered to be possible approaches to reducing the surgical risk.     

Risk factors for morbidity and mortality in resection of cancer of the cardia

Operations were performed on 166 patients for adenocarcinoma of the cardia, between 1970 and 1986, with resections being applied to 102 of them (6.1 per cent), including 87 curative approaches with complete removal of tumours and no macroscopic evidence of metastases. Total gastrectomy with oesophagectomy was performed on 36 patients and proximal oesophagogastrectomy on 66, in 43 of these via left thoracic incision. Regional lymph nodes were free of tumour in 29 patients (28 per cent). The other approaches to proximal resection were thoracoabdominal in eight cases, abdominal in 13, and transmediastinal in two. Leakage of oesophageal anastomosis occurred in 19 cases and was followed by septicaemia and death in 13. Overall mortality during hospitalisation amounted to 22.5 per cent, including two patients who died on the 30th postoperative day as a result of dehiscence and septicaemia. Mortality figures were 17 per cent following total gastrectomy and 19 per cent in the wake of proximal gastrectomy by thoracic incision. Mortality amounted to 48 per cent in the 23 cases on which abdominal, thoraco-abdominal, and transmediastinal operations had been performed. Multiple logistic regression was used to determine age, ECG, spread of lymph nodes, and surgical techniques as potential risk factors. Emphasis in the context of surgical techniques was laid on proximal versus total gastrectomy, incision on both sides of the diaphragm, palliative resection, and anastomotic suturing (using one-layer or two-layer techniques or mechanical staples). Tumour spread to lymph nodes and proximal resection were the only independent variables associated with dehiscence. Electrocardiogram (ECG), lymph node involvement, and palliative resection proved to be of relevance to prognostication of lethality. No statistical correlations were found to exist between lethality, on the one hand, and surgical approach, age of patient, incision on either side of the diaphragm or suturing, on the other. The conclusion was drawn that in cases of cardia carcinoma total gastrectomy does not aggravate the risk of lethality, as compared to cardia resection.     

The epidural hematoma--diagnostic peculiarities, clinical courses and therapeutic results in a 12-year-study

Over the past twelve years, diagnoses were applied to and operations performed on 71 patients exclusively for epidural haematoma. A retrospective classification and assessment was made of clinical courses, preoperative angiography as well as of findings recorded from computed tomography and direct clinical examination. The pattern of epidural haematoma was found to be characterised by different clinical courses. Highly useful findings were obtained from direct clinical examination, including fracture in 89 per cent of the above cases and injuries to soft tissue in 85 per cent. A correlation was found to exist between development of haematoma (degree of compression) and postoperative neurological condition. Six operations had to be repeated for postoperative haemorrhage or residual haematoma. The lethality amounted to 15.4 per cent.     

Results of early operation of acute cholecystitis

Acute cholecystitis is a frequent complication of cholelithiasis. Patients in advanced age are more often affected than others. Early operation has been widely accepted for treatment of acute cholecystitis, as it has proved to be effective as prophylaxis against perforation, sepsis, recurrent inflammation, and long-term sequels, such as enterocolic fistulae and abscesses. It should be acceptable to everyone, provided short-time individual preparation. Patients in advanced age are likely to draw particular benefit from no-delay surgery, since soon removal of the source of inflammation as well as short-time immobilisation and hospitalisation are good prerequisites for soon, definite healing. Operations for acute cholecystitis were performed von 257 patients, between 1977 and 1987. They accounted for 8.4 per cent of 3,059 gall surgery patients during the period under review. The lethality rate associated with early operations amounted to 1.6 per cent and was thus slightly below overall gall surgery lethality of 1.9 per cent during that period.     

Arguments for regional centralized treatment of stomach cancer. A statistical study of national results

An analysis was made of therapeutic results obtained from 6,220 cases of primary gastric carcinoma and from 1,308 cases of radical surgery, as listed in the 1976 National Cancer Record of the GDR. Results were examined relative to the number of radical operations per annum. Involved in the above treatment of gastric carcinoma were 237 surgical wards throughout the GDR. Numbers of radical operations were between one and four per annum in 56.1 per cent of all wards (Group I), between 5 and 19 in 40.5 per cent (Group II), and 20 or more in only 3.4 per cent (Group III). Radical removability accounted for 13.2 per cent of all cases in Group I, 28.2 per cent in Group II, and 38.5 per cent in Group III. Better therapeutic results relative to the number of radical operations per annum were reflected in the following absolute five-year survival rates: 3.4 per cent in Group I, 6.8 per cent in Group II, and 10.6 per cent in Group III. These findings are likely to support the advisability of regional centralisation of treatment for stomach carcinoma.     

Prognosis in mechanical ileus

A retrospective analysis was made of 160 patients who had undergone surgical treatment for complete mechanical ileus over a period of ten years. These 160 account for 2.18 per cent of all surgical patients in the period under review, which suggested that complete mechanical ileus had been the most common surgical emergency. Primary lethality was as high as 24.4 per cent. Age, time of occlusion, and accompanying diseases were substantive factors of prognosis. Prognosis can be improved by early diagnosis.     

Esophageal cancer from the german point of view

Although there are no differences worth mentioning between esophageal cancer in Japan and in Europe regarding epidemiology, tumor stages at the beginning of therapy and surgical selection. In Japan, early esophageal squamous cell carcinoma is more often diagnosed than in Europe where esophageal adenocarcinoma, especially that of the endobrachyesophagus, is becoming more and more relevant. For a long time, the limiting factor for the prognosis of esophageal cancer was the postoperative lethality. However, by carefully analysing the factors influencing this operative lethality over the last few years, the lethality following esophagectomy has been decreased to approximately 15 per cent. In fact, in some specialized centers, the lethality is now less than 10 per cent and in selected patient groups even 3 per cent has been reached. It is only through this achievement that the prognosis for esophageal cancer has been able to be markedly improved. The results of this analysis can be detailed as follows: 1) The preoperative definition of tumor stage by CT or MRI is not reliable, the validity being between 45 per cent and 73 per cent. Therefore, no therapeutical decisions can be made on the basis of these diagnostic procedures. Hopefully the intraluminal ultrasound will improve this situation in the future. 2) The analysis of preoperative nutritional status did not allow a definition of risk groups. 3) Decisive improvements were able to be achieved by the standardising of surgical procedures and indications. Enbloc resection is indicated for all intrathoracic squamous cell carcinomas and accounts for a high percentage of RO-resections. The blunt dissection is especially appropriate for distal adenocarcinomas. 4) Endobronchial onesided ventilation during the operation and prophylatic assisted ventilation have both decreased the pulmonary risk considerably. A further improvement in the prognosis of esophageal carcinoma can possibly be achieved by the preoperative identification of advanced tumors (T₃/T₄) and preoperatively treating these tumor types accordingly. From our own experience, we believe combined radio-chemotherapy could be successful.     

Esophageal cancer from the German point of view

Although there are no differences worth mentioning between esophageal cancer in Japan and in Europe regarding epidemiology, tumor stages at the beginning of therapy and surgical selection. In Japan, early esophageal squamous cell carcinoma is more often diagnosed than in Europe where esophageal adenocarcinoma, especially that of the endobrachyesophagus, is becoming more and more relevant. For a long time, the limiting factor for the prognosis of esophageal cancer was the postoperative lethality. However, by carefully analysing the factors influencing this operative lethality over the last few years, the lethality following esophagectomy has been decreased to approximately 15 per cent. In fact, in some specialized centers, the lethality is now less than 10 per cent and in selected patient groups even 3 per cent has been reached. It is only through this achievement that the prognosis for esophageal cancer has been able to be markedly improved. The results of this analysis can be detailed as follows: 1) The preoperative definition of tumor stage by CT or MRI is not reliable, the validity being between 45 per cent and 73 per cent. Therefore, no therapeutical decision can be made on the basis of these diagnostic procedures. Hopefully the intraluminal ultrasound will improve this situation in the future. 2) The analysis of preoperative nutritional status did not allow a definition of risk groups. 3) Decisive improvements were able to be achieved by the standardising of surgical procedures and indications. Enbloc resection is indicated for all intrathoracic squamous cell carcinomas and accounts for a high percentage of RO-resections. The blunt dissection is especially appropriate for distal adenocarcinomas. 4) Endobronchial one-sided ventilation during the operation and prophylatic assisted ventilation have both decreased the pulmonary risk considerably. A further improvement in the prognosis of esophageal carcinoma can possibly be achieved by the preoperative identification of advanced tumors (T3/T4) and preoperatively treating these tumor types accordingly. From our own experience, we believe combined radio-chemotherapy could be successful.     

Results of the treatment of bleeding gastroduodenal ulcer

Treatment was applied to 243 patients for bleeding gastro-duodenal ulcer, over a period of ten years. In recent years, conventional radiographic diagnosis has been replaced by emergency gastroscopy. Particular importance is attributed to surgical therapy. Prognosis of bleeding ulcer is substantively affected by intensity of bleeding, age of patient, and multi-morbidity. Therapeutic early elective surgery has so far yielded the best results. The overall lethality of 20.5 per cent included 19.2 per cent after conservative therapy and 21.9 per cent following surgical treatment.     

The surgeon as a prognostic factor after the introduction of total mesorectal excision in the treatment of rectal cancer

BACKGROUND: With conventional blunt surgical resection of rectal cancer, local recurrence rates are high and the individual surgeon putatively influences patient outcome. With total mesorectal excision (TME) local recurrence rates have been reduced and intersurgeon variability may be less important. The 'TME project' was a collaborative project that included surgical workshops in Stockholm between 1994 and 1997. The aim of this study was to assess the impact of the project on the practice of rectal cancer surgery in Stockholm and to analyse whether surgeon case volume and participation in the workshops influenced patient outcome. METHODS: All 652 patients who had an abdominal resection for rectal cancer in Stockholm between 1995 and 1997 were included. Outcome was compared in patients operated on by teams that included high-volume surgeons (more than 12 operations per year) with teams that included low-volume surgeons (12 operations or fewer per year), as well as between teams that including workshop participants and non-participants. RESULTS: Forty-six surgeons operated on the 652 patients. Five high-volume surgeons operated on 48 per cent of the patients. In these, outcome was significantly better than in patients treated by low-volume surgeons (local recurrence rate 4 versus 10 per cent (P = 0.02); rate of rectal cancer death 11 versus 18 per cent (P = 0.007)). Twenty-six surgeons were workshop participants and performed 93 per cent of the operations. Radiotherapy, TME and sphincter-preserving surgery were more common among patients treated by workshop participants. CONCLUSION: The TME project has had an impact on rectal cancer surgical practice in Stockholm. Variability in patient outcome was mainly related to case volume, with better results obtained in patients treated by high-volume surgeons.     

Rupture of the diaphragm--a frequently undetected injury

Traumatic ruptures of the diaphragm are acquired separations of the diaphragm which are aetiologically divided into indirect and rare direct ruptures. The force required to produce indirect ruptures will usually lead to additional intraabdominal lesions of liver and spleen as well as to rib fractures and fractures at the lower extremity. Hence the sequels of these accompanying lesions are often prominent in the clinical pattern to such an extent that 50 to 70% of the diaphragmatic ruptures remain primarily unrecognised. Abdominal and/or cardiorespiratory signs and symptoms become manifest only if there is an evisceration. Hence surgical strategy in preoperatively identified diaphragmatic ruptures depends on the localisation of the rupture, on the severity of the accompanying lesions, and the time until surgical treatment can be effected. Depending on the type and severity of the accompanying lesions an average lethality of 33% must be taken into account in fresh diaphragmatic ruptures. In chronic uncomplicated eviscerations the operations lethality is about one per cent.     

Indications and prognosis of preventive and simultaneous operations of the abdominal cavity

The potential risk implied in prophylactic operations is just as high as that elective interventions. Indications must be subject to stringent deliminating criteria. Required are thorough elucidation and documentation as well as comprehensive substantiation. Operations of that kind may be performed even without elaborate advance planning, if indications are urgent. Simultaneous operations are accompanied by higher risk in cases of major surgery or if one of the interventions is septic. High risk factors were recordable from combined stomach and bile duct surgery, when performed simultaneously. Morbidity amounted to 13 per cent (pulmonary embolism and pneumonia) and lethality to 15 per cent. Simultaneous operations should be performed by an experienced surgeon who should be a fast worker.     

Urological operations in the United States: 1979 to 1984

With data from the National Center for Health Statistics an in-depth analysis of numbers of urological operations from 1979 to 1984 was performed. During the 5-year study period there was an increase in total numbers of urological operations of 7 per cent, while the number of urological surgeons increased 18 per cent. In 1983 urologists performed 1,680,000 operations. Prostatectomy (357,000) was the most common urological procedure and the tenth most frequent operation in this country. The 20 most common urological operations constitute 69 per cent of all urological operations. In 1983 urological operations represented 9 per cent of all procedures completed in this country. These figures illustrate the dynamics of urological surgical practice. The numbers of urological operations have increased minimally during the last 5 years despite constantly increasing numbers of urologists. The belief that urological operative rates will inevitably increase as the number of urologists increases is not supported by this study.     

Long-term results following femoro-popliteal vascular reconstruction

All in all, 330 thromboendarterectomies (TEA) and 354 venous bypass operations (VBP) were performed on 550 patients. In 11.01 per cent of all cases in which VBP had been planned, veins were not in optimum condition. Repetitive interventions had to be applied to 111 patients. Successful reoperations could be performed on six cases with immediate TEA-closures (1.8 per cent) and another two after immediate VBP-closures (0.56 per cent). Postoperative lethality figures were 0.6 per cent after TEA and 0.28 per cent following VBP. Twenty-nine early TEA-closures (8.9 per cent) were corrected by secondary VBP in 16 cases (4.8 per cent). Three were corrected by femoral ablation and two by toe amputation in the border zone (1.7 per cent). Thirty-nine early VBP-closures (11.0 per cent) required repetitive VBP in two cases (0.5 per cent) and toe amputation in the border zone in another three instances (0.84 per cent). Eight patients each died within the first postoperative year from TEA (2.4 per cent) and after VBP (2.2 per cent). The following cumulative patency rates were recorded according to the life table method: after one year (TEA: 90.9 per cent, VBP: 88.9 per cent), after five years (TEA: 73.4 per cent, VBP: 84.6 per cent), after ten years (TEA: 38.2 per cent, VBP: 73.7 per cent), after 15 years (TEA: 9.8 per cent, VBP: 24.2 per cent). These differences were significant as early as five years from surgery. Late amputation rates were 2.1 per cent for TEA and 2.9 per cent for VBP. Late lethality rates were 28.8 per cent for TEA and 7.6 per cent for VBP.     

Treatment of acute cholecystitis

A retrospective investigation was conducted to give an account in this paper of clinical diagnoses, intra-operative findings, and therapeutic results obtained from 453 patients who had received surgical treatment for acute cholecystitis, between 1975 and 1986. The benefits of the approach may be seen from the overall lethality which had been as low as 4.2 per cent. Conservative treatment was found to be indicated only for high-risk cases.