[Volume manometry for determination of rectal compliance].
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Compliance↗
Biomedical subjects
H P Bruch
Publications and source records attributed to H P Bruch.
Prospective multicenter study of the quality of oncologic resections in patients undergoing laparoscopic colorectal surgery for cancer. The Laparoscopic Colorectal Surgery Study Group.
PURPOSE: Laparoscopic colorectal surgery for cancer is currently under discussion. Results of large, randomized studies will not be available for a number of years yet. This study analyses the results of such resections in consecutive patients operated on by unselected surgeons. METHODS: A prospective, observational, multicenter study was initiated on August 1, 1995, in the German-speaking countries of Europe. One year after initiation of the study, findings are presented with respect to the quality of oncologic resections. RESULTS: Of 500 operations, 231 (46 percent) were performed for cancer, 167 (33 percent) with a curative intent. The most common curative resections were as follows: 63 anterior rectum resections (38 percent), 51 sigmoid resections (30 percent), and 27 abdominoperineal resections (16 percent). Segmental resections were performed in 20 patients (12 percent). Intraoperative tumor spillage was reported in 2 percent. Mean number of lymph nodes harvested was 13 (confidence interval, 5-95 percent; range, 11.5-14.6) and positive lymph nodes harvested was 2.2 (confidence interval, 5-95 percent; range, 0.9-3.4). Significant differences were noted between participating centers in terms of number of lymph nodes resected (P < 0.0001). Distal and proximal resection margins were tumor-free in every case. Lateral margins were tumor free when examined. In the case of 63 curative anterior resections, the mean distal resection margin was 39 (confidence interval, 5-95 percent; range, 33-45) mm, and in 8 of these resections, it was less than 20 min. Mean blood loss was 344 (confidence interval, 5-95 percent; 292-396) ml, and 21 percent of patients received blood transfusion. CONCLUSIONS: These data document that the average quality of laparoscopic colorectal procedures for cancer is satisfactory but differs among surgeons.
Aged↗
Blood selenium and glutathione peroxidase status in patients with colorectal cancer.
PURPOSE: It is still controversial whether a low selenium level and a reduced activity of the selenium-dependent enzyme, glutathione peroxidase, in blood are associated with an increased risk and poor prognosis of cancer in humans. This study evaluates whether colorectal cancer patients have lower serum selenium and glutathione peroxidase levels than a gender-matched and age-matched control group and whether there is a correlation to clinical data and prognosis. METHODS: In a retrospective study, serum selenium and glutathione peroxidase activity of 106 patients with colorectal cancer were determined. Clinical data were provided by our long-term follow-up program for colorectal cancer patients. RESULTS: Patients with a selenium level <70 microg/l had a significantly lower mean survival time and a lower cumulative cancer-related survival rate than patients with a selenium level >70 microg/l (P = 0.0009). When considering the different tumor stages, a decline of the mean selenium level in the T4 carcinoma group was found in the analysis of variance (P < 0.05). The lowest selenium level was found for patients with advanced tumor disease and in a preoperative situation, ie., high tumor burden. In comparison with the control group, the cancer group showed a significant reduction of serum glutathione peroxidase activity (P < 0.01) but no significant difference in selenium level. CONCLUSIONS: These results support the hypothesis of an association between low selenium level and advanced tumor disease. From our data, it cannot be decided whether this phenomenon is more likely to be a consequence or a causative factor for development and course of the disease.
Adult↗
["Streptococcal toxic shock-like syndrome"].
Since the mid-1980s increasing numbers of severe group A streptococcal infections (Streptococcus pyogenes) have been reported worldwide. Younger, healthy patients after minor local trauma are most commonly afflicted. The infection is characterized by a rapid course with shock, sepsis, multiorgan failure, soft-tissue infection and a high mortality rate. This special disease has been termed "streptococcal toxic shock-like syndrome". The M-proteins, especially types 1 and 3, and the streptococcal pyrogenic exotoxin A (speA) might play an important role in the pathogenesis of the infection. High dose therapy with antibiotics, monitoring in the intensive care unit and early, aggressive and often multiple debridement of necrotic soft tissue are necessary to save the patient's life.
Adult↗
[Laparoscopic sigmoid resection in diverticulitis].
Between September 1992 and May 1997 in the Department of Surgery at the Medical University of Lübeck 240 colorectal procedures were performed by laparoscopic techniques. Fifty-seven patients underwent laparoscopic colectomy for diverticulitis. In 52 cases sigmoid resections were performed laparoscopically, including 4 cases with simultaneous laparoscopic rectopexy. Anterior resections were necessary in 3 patients, whereas 2 patients with extended localization of diverticula required left hemicolectomies. Using atraumatic instruments and an ultrasound dissector, laparoscopic resection involved tubular dissection and preperitoneal anastomosis. The mean operative time was 234 min. In 8 cases (14%) conversion to an open procedure was necessary. Complications occurred in 6 patients (10.5%). One patient died because of an anastomotic leakage. In conclusion, with increasing experience laparoscopic resection for diverticulitis can be performed without additional morbidity in comparison to open colectomy. In particular, the benefits of the minimally invasive method are quicker reconvalescence with reduced postoperative pain and improved cosmesis.
Adult↗
Molecular mechanisms of sepsis.
Today a great number of problems in the field of bacterial sepsis remain to be solved. Understanding the molecular mechanisms of one of the most important bacterial products in the pathogenesis of sepsis - endotoxin may contribute to innovative and more effective therapies. Therefore, this review focuses on the structural and functional elements of endotoxin, its interaction with immune cells, and its biological activity. Finally, other bacterial components and their impact on sepsis are discussed.
Endotoxins↗
Assessment of the proliferation index in gastric carcinomas with the monoclonal antibody MIB 1.
Our study aimed to reveal whether the proliferation index of tumor cells, calculated with the monoclonal antibody (mAb) MIB1, is of prognostic relevance in patients with a gastric carcinoma and shows any correlation to well-known clinicopathological factors (TNM categories, stage, grade, Laurén type). We examined formalin-fixed, paraffin-embedded tissue blocks of samples from 94 patients, who underwent surgery for an adenocarcinoma of the stomach between 1988 and 1991. Specimens were immunohistochemically stained using the mAb MIB1 in combination with the alkaline-phosphatase/anti-(alkaline phosphatase) technique. The proliferation index (PI) was estimated in various areas of interest (tumor center and periphery and in lymph node metastases of compartments I and II), by always counting 200 tumor cells in three different high-power fields per specimen, and calculated as the percentage of MIB1-positive tumor cell nuclei relative to all tumor cell nuclei in the area examined. The total PI in the primary tumor was 47.2% and slightly higher in the center (49.1%) compared to the periphery (44.7%). Surprisingly in lymph node metastases the PI was lower than in the primary tumor (compartment I: 39.5%, compartment II: 33.6%). Tumors with distant metastases revealed a higher proliferative activity (55.1%) than tumors without (44.3%). The PI increased significantly from well to poorly differentiated carcinomas (P < 0.01), whereas the intestinal Laurén type showed a lower PI than the diffuse type. No difference in survival was found between patients with a median PI or less and those with a PI above the median (47.2%). Our results show that the proliferation index in gastric carcinomas has no prognostic relevance and therefore is of low clinical value.
Adenocarcinoma↗
Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery. Laparoscopic Colorectal Surgery Study Group (LCSSG).
BACKGROUND: Prospective randomized multicenter studies comparing laparoscopic with open colorectal surgery are not yet available. Reliable data from prospective multicenter studies involving consecutive patients are also lacking. On the basis of the personal caseloads of specialized surgeons or of retrospective analyses, it is difficult to judge the true effectiveness of this new technique. This study aims to investigate the results of laparoscopic colorectal surgery in consecutive patients operated on by unselected surgeons. METHODS: This observational study was begun August 1, 1995, in the German-speaking part of Europe (Germany and Austria) and 43 centers initially agreed to participate. All consecutive cases were documented. All data were rendered anonymous. Analysis was performed on an intention-to-treat basis. The study committee was blinded to the participating center. RESULTS: By the end of the 1st year, 500 patients (M:F ratio 0.83, mean age 62.9 years) had been treated by 18 centers; 269 operations were performed for benign indications and 231 for cancer (palliative and curative). Most operations were done on the distal colon or rectum. An anastomosis was performed in 84%, with an overall leakage rate of 5.3% (colon 3.6% and rectum 11.8%), which required surgical reintervention in 1.7%. The mean operating time was 176 min and showed a decreasing tendency over the period under study. The conversion rate was 7.0% and the overall complication rate 21.4%. The reoperation rate was 6.6%; the most common cause was bleeding. There was one ureteral lesion (0.2%), but urinary tract infections were fairly common (4.8%). A postoperative pneumonia was diagnosed in 1.6% of the cases. No thromboembolic complications were reported. The 30-day mortality rate was 1.4% and overall hospital mortality 1.8%. CONCLUSIONS: Laparoscopic colorectal operations are still rare (about 1% of all colorectal operations in Germany). Laparoscopic procedures are more common on the left colon and rectum than on the right colon. The surgical complication rate is acceptable, comparable with rates reported by others for open surgery. Cardiopulmonary and thromboembolic complications were rarely seen. Mortality and surgical morbidity rates do not differ significantly among participating centers. A learning curve, reflected by a shortening of the operating time and a somewhat lower conversion rate, was observed over the observation period.
Aged↗
[Detection of hL6-mRNA: new possibilities in serologic tumor diagnosis of colorectal carcinomas].
A study was performed to detect circulating tumor cells in patients with colorectal cancer using mRNA coding for the tumor associated antigen L6. The mRNA was determined by Reverse Transcriptase Polymerase Chain Reaction and gel-electrophoresis. The L6 results were compared with the CEA levels. Peripheral blood samples were taken from 109 patients with histologically verified colorectal cancer. Statistics were carried out using CHI Square and Sokal and Rohlf's-test. Preoperatively 81.65% showed positive L6 mRNA, whereas only 58.7% had elevated CEA titers (p < 0.05). In all patients of the control group (n = 52) no L6 was detectable. Concerning our results L6 seems to be a sensitive and precise tool for diagnosing circulating tumor cells in colorectal cancer.
Antigens, Surface↗
[Laparoscopically assisted surgery in Crohn disease].
UNLABELLED: From Jan. 1993 to Apr. 1997 intestinal resections in Crohn's disease have been performed in 275 patients. 89 patients have been operated on laparoscopic assisted. The following parameters were analyzed: previous laparotomies, extent of resection, steroid medication, conversionrate, complications, operative time and postoperative stay. Endpoints were: conversionrate, complications, reconvalescence and overall satisfaction with the laparoscopic technique. RESULTS: The duration of the disease ranged from 1 to 16 years (x = 6). 47 patients were under steroid medication at the time of surgery. 30 patients had undergone previous laparotomies. In 10 patients the operation had to be converted into open surgery. The following procedures have been performed: ileocaecal resections (45), anastomotic resections (14), small bowel resections (4), hemicolectomies (12), colectomies (9), loopileostomies (4), adhesiolysis (1). Minor complications occurred in 6.7% of patients, major complications in 5.6%. Operative time ranged from 70 to 420 minutes (x = 173.7). The postoperative hospital stay was 13.3 days in the average. CONCLUSION: The morbidity of 12.3% is not higher than in open surgery. When complications do not occur the patients benefit from early convalescence, better cosmetics and shorter hospital stay.
Adolescent↗
[Quality in hospital treatment. How is it assured and who determines the guidelines?].
BACKGROUND: Internal quality control of medical performance in the interest of patient safety is not a new idea. In fact it has been implemented in varying degrees since the beginnings of medicine. ACTUAL SITUATION AND METHODS: Ever since hospitals are compelled by law to apply methods of quality assurance and external quality control, the question arises as to whether this law can achieve a concrete increase in quality of patient care or whether it rather serves to support economically motivated goals of health care policies, in the sense of an increase in efficiency of performance by physicians. Seen in the light of the overall situation of hospital care, the attempt to create mandatory quality standards is problematical. A reduction of hospital beds and a decrease in the average length of hospital stay contrasts the growing number of treated patients. This presents a problem which must be compensated for, despite cutbacks in budget and personnel. Methods of quality analysis are of the implicit as well as of the explicit type. Implicit methods are based on retrospective data analysis lacking previously set standards of comparison. These methods harbor the danger of viewer-dependent subjectivity (restricted reliability). Explicit methods are based upon comparison to previously defined standards. These methods are more objective, but often fail to give consideration to individual situations (restricted validity). The infrastructure necessary in order to sensibly apply quality control in the hospitals is not yet present in Germany. The software required in order to record and analyse data is still in a stage of development in many places. CONCLUSION: It is of importance not to leave external quality control to politicians and economists unfamiliar with the subject matter, but rather that quality control is implemented by experts in the medical field.
Economics, Hospital↗
Prognostic relevance of occult tumor cells in lymph nodes of colorectal carcinomas: an immunohistochemical study.
PURPOSE: Whereas lymph node metastases in colorectal carcinoma are an important prognostic factor, the prognostic relevance of occult tumor cells in lymph nodes is not elucidated at present. Therefore, our study intended to assess the rate of patients with occult tumor cells in histopathologically negative lymph nodes. Furthermore, we tried to evaluate an eventual influence of these occult tumor cells on patients' prognoses. METHODS: For examination, we used paraffin blocks of lymph nodes, tumor-negative by conventional histopathology, from 49 patients with colorectal carcinoma (Stage I-III) after a curative (R0) tumor resection in 1987. After preparation of tissue blocks using the serial sectioning technique, the specimens were stained with the alkaline phosphatase, antialkaline phosphatase method and two monoclonal antibodies (AE1/AE3 and Ber-EP4). RESULTS: In 13 of 49 patients (26.5 percent), we disclosed tumor cells, mostly located in subcapsular sinuses as single cells or in groups. There was a good correlation between the detection rate and N category, tumor stage, and grading. Moreover, 33 percent of patients in Stage I/II with occult tumor cells (N0+) developed a local relapse and/or distant metastases in contrast to 12 percent of patients without tumor cells (N0-). With a median follow-up of 84 months, we found no difference in disease-free survival between the tumor cell negative and positive groups in Stage I/II patients. CONCLUSION: The results show that occult tumor cells might increase the risk for development of a local tumor relapse and/or distant metastases but do not influence patients' prognoses at all.
Adult↗
[Abdominal pain of uncertain origin--value of laparoscopy. "If in doubt, carry it out"].
Surgeons treating a patient with lower abdominal pain of uncertain etiology are caught between the extremes of conservative and operative treatment. After clinical examination and ultrasonography, explorative laparoscopy has been shown by several studies to solve this therapeutic dilemma. Using laparoscopy prolonged observation, the incidence of perforation and unnecessary laparotomies can be reduced dramatically, in particular, the rate of negative appendectomies is lowered from 30-40% to about 15%. This leads to shortened stay in hospital, increased efficiency and decreased financial costs.
Abdominal Pain↗
[Results of deep rectum resection and intersphincteric rectum excision].
Low resection and intersphincteric extirpation of rectal cancer in the distal third of the rectum has become an accepted sphincter-saving method. From December 1990 to December 1994, 42 patients (17 women and 25 men) with a mean age of 67.2 years had a low resection or extirpation of the rectum at our institution. Eighteen patients received a transanal sutured anastomosis, 24 a stapler anastomosis. We had a lethality rate of 2.5% and a anastomotic insufficiency rate of 14%.
Aged↗
[Treatment strategy in inguinal injection abscess and complications].
From 1994 to March 1997, 12 patients with 15 drug-related abscesses of the groin were treated at the Surgical Department of Lübeck Medical University. Besides laboratory, serological and microbiological examinations, the standard diagnostic investigation consisted of sonography or duplex sonography. If indicated, the diagnosis was extended to include, for example, clarification of the retroperitoneum by CT. The most common accompanying disease was deep femoral vein thrombosis. Substitution was planned individually. After surgical débridement and perioperative administration of a beta-lactam-protected acylaminopenicillin, open wound treatment was successfully carried out in 13 cases; secondary closure was performed four times in cases of good compliance. One abscess led to necrotising of the femoral artery; saphenous vein was interposed because of erosion bleeding and formation of aneurysm. In a second case, the bifurcation was reconstructed with saphenous vein after external resection of an infected false aneurysm and early occlusion. Both defects were covered by rotation of sartorius muscle and mesh graft. On the basis of the treatment concept, a rapid and successful intervention was possible; complications such as sepsis, amputation or withdrawal delirium did not occur. Resistance against the antibiotic was not observed. In the case of infected aneurysm, we prefer the autogenous saphenous vein graft followed by rotation of sartorius muscle and mesh graft. Ligation or excision leads to high rates of claudication or amputation; extended reconstructions are threatened by insufficient compliance of the patients; the use of synthetic grafts is endangered by further bacteraemia or infections.
Abscess↗
[Kinetic therapy within the scope of treating septic surgical patients].
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Adult↗
[Patient anxiety before surgery].
At present time we have to face a new quality of fear and anxiety rooted in a social change of fundamental values. Disease and death are being increasingly ruled out from the pattern of everyday life. Therefore, disease and death represent an extreme emotional stress for today's human beings, who find it difficult to assess their significance. Against this background we must view human fear and anxiety before surgery. Nowadays, people have lost the ability of dealing with themselves and their own problems. There is no place for disease in a world dominated by materialism. Accordingly, it is an extreme challenge for any human remain psychologically stable, whereas, anxiety appears increasingly irrational. Both anaesthesiologists and surgeons are responsible for removing anxiety and affording assistance to patients expecting surgery. Consequently, contemporary strategies of therapy include both surgical and psychosocial aspects. Therefore, confidence concerning the relationship between surgeon and patient, consideration of psychosocial factors, and an interdisciplinary approach are essentially necessary to cure the patients from their disease. However, to alleviate and even remove the patients' preoperative anxiety, we must approach and meet the patient on an equal level: from human being to human being.
Adaptation, Psychological↗
Laparoscopic implantation of Oreopoulos-Zellermann catheters for peritoneal dialysis.
For the implantation of continuous ambulatory peritoneal dialysis (CAPD) catheters, both the laparoscopic technique and the use of an Oreopoulos-Zellermann catheter have been suggested to be preferable to the open technique using Tenckhoff catheters. Building on advantages of known techniques, we here describe a procedure for the laparoscopic implantation of the Oreopoulos-Zellermann catheter. The procedure is quick, efficient and unstressful to the patient. After nearly 10,000 patient-days of catheter use, we find positive results with regard to permanently good inlet and outlet flows, low incidence of exit site infections and leaks from the catheter tunnel.
Adult↗