[Results of resection of the esophagus in cancer]

Since 1964 245 resections of the esophagus because of cancer were performed at the University Hospital of Cologne. Hospital mortality was 27%. It was reduced to 12.1% during the last 5 years. Surgeon's experience turned out to be of major influence upon hospital mortality whereas tumor and organ related risk factors or kind of the operating procedure didn't influence hospital mortality at all. Five year survival rates that included hospital mortality were 15.5% and were 23.2% without. Patient's late outcome was influenced significantly by tumor staging and histological grading. Radical operating procedure--blunt dissection or transthoracal esophagectomy--were of no prognostic value.

[Surgery of bronchial cancer and demands on radiology]

The most important demand the surgeon can make in respect of the radiologist's work is earliest possible diagnosis of lung cancer. Secondly, the surgeon is always grateful for any pointer leading to diagnosis of the type (and status) of the tumor. This supplies decisive information for both operative planning and perioperative technique. For example, it is essential to know, if x-ray reveals a circular focus, whether this represents tuberculosis of a carcinoma. In case of tuberculosis, drug treatment will be prescribed perioperatively, and the site of operation is limited as much as possible, whereas bronchial carcinoma requires immediate surgery which should be as radical as possible.

[Surgical therapy of squamous cell carcinoma of the esophagus--limited radical intervention]

Within 23 years 237 esophageal resections were performed in patients with carcinoma of the esophagus. 115 had epidermoid cell carcinoma. After resection of the esophagus 15.3% survived 5 years. The follow-up rate over the whole period is 96%. In respect to survival only the degree of differentiation, the stage and the hospital lethality significantly influence survival. In historical comparison the blunt dissection was able to lower hospital lethality. This could not be shown in our material within a comparable time. In order to evaluate the outcome after 5 years in regard to radical transthoracic operation and blunt dissection we did a matched-pairs-analysis. There was no difference in both groups.

[Value of preoperative risk factors in patients with resectable esophageal cancers]

Since 1. 1. 1964 245 patients with oesophageal carcinoma underwent resection at the department of surgery of the university of Cologne. A significant correlation between stage, localisation or type of carcinoma and the postoperative mortality was not found. It was possible to develop organ specific scores which were able to detect groups of patients with a high postoperative mortality, but the predictive value of these scores was too small for relevant clinical decision making.

[Spontaneous and other non-tumor-induced esophageal perforations]

The outcome of esophageal perforation is determined by the cause and localisation, but mainly by the time lapse between trauma and therapy. Spontaneous and intraoperative ruptures are most dangerous. Treatment of choice is direct closure and drainage. If this is not possible, esophagectomy or exclusion and diversion in continuity should be considered. The injury may present itself with rather unspecific symptoms. Pathological findings in the plain chest roentgenogram and gastrographin study will confirm diagnosis in nearly all cases.

[Quality assurance in surgery by prospective assessment of the risk of complications by a simple point score]

3654 general surgical interventions were prospectively registered during a 40 month period. Postoperative complications (wound infection, pneumonia, reoperation, mortality) were recorded and were quantified numerically by a complication score which describes the precise number of complications per ten operations. In this way the risk of a single operation can be monitored continuously and quality control programs can do without classification of operations in clean, contaminated and dirty interventions. The length of postoperative hospital stay and the amount of postoperatively applied antibiotics correlated well with the score.

[Limits of cancer surgery]

Cancer patients show special characteristics which the doctor has to know. The therapy is based on the knowledge of the course of common forms of cancer. The documentation, classification and stratification of these forms of cancer is the basis for therapeutic decisions. The latter especially depends on an assessment of probabilities amongst which the quality of life plays a major role. In the advanced stage it is the control of symptoms, the relief of pain and the encouragement of social rehabilitation that are important. The experiences in the treatment of 129 patients over a period of 3 years are described.

[Indications for splenectomy in non-malignant systemic diseases]

The benign systemic disorders with involvement of the spleen are divided into haematologic diseases, thesaurismosis, collagenosis, morbus Boeck, infectious diseases, parasitosis and others. 4/5 of the cases are haematologic diseases of the erythrocytic, the thrombocytic and lymphatic system as well as myeloproliferative and aplastic syndromes. 227 of 1214 splenectomies of the last 20 years were done in benign systemic diseases. The functional and mechanical hypersplenism as a rule is the cause for operation. The specific indications, the medical pretreatment and the combination of surgery and non-surgical measures are discussed.

Oesophageal stenosis--a complication of sclerotherapy of oesophageal varices

A total of 246 non-selected patients with oesophageal variceal haemorrhage were treated with the intravascular high-pressure injection technique. Approximately 200 ml of the sclerosant were injected in three sessions. Reliable destruction of the varices in the absence of necrosis/ulceration along the variceal "column" must be considered doubtful. Owing to misplaced (paravasal) injection, 11 patients (4.4%) developed an oesophageal stenosis. All these stenoses were curatively treated with the ESKA-Buess multiple-diameter bougie. The stenosis can be negotiated under endoscopic vision, and, in the immediately following bougienage procedure, dilated up to 16 mm. The presence of mucosal bridges in the stenotic oesophagus is essential for curative bougienage. The use of a circular paravascular injection technique in the distal oesophageal mucosa is not to be recommended.

[Vagotomy and vagotomy follow-up--results of a survey]

A survey of 1006 surgical clinics in the Federal Republic of Germany in 1984 showed that the general surgical procedure for duodenal ulcers was vagotomy in 65.9%. 21.9% of the clinics checked the effectiveness of vagotomy intraoperatively by either performing electrostimulation (69.6%), leucomethylene-blue staining (20.9%), monitoring of the intragastric pH-value (7.3%), or Congo-red test (1.4%). Postoperative vagotomy controls were performed in 51% of the hospitals. Judging by the present results, application of intraoperative effectiveness control is not necessarily advisable. Evaluating the pre- and postoperative acid production allows the establishment of a quality control, however without any prognostic relevance.

[Functional anatomy of the anorectal sphincter]

Sensory component, reflexes and motor components are responsible for anorectal continence. The most important factors are the extraperitoneal part of the rectum, the M.m. sphincter ani internus and externus, the levator ani muscles and the corpus cavernosum recti. The diagnostic of anal incontinence is usually evident from history and physical examination. Additionally intraluminal pressure recordings and electrical measurements are helpful.

[Results following colorectal interventions--an analysis over 36 years]

The data of 407 patients with colon carcinoma and 346 patients with rectum carcinoma treated in the last 36 years were analysed retro- and prospectively as regards the operative technique, the perioperative treatment and the postoperative complication rates. It was shown that the number of tumour resections increased continuously and that the percentage of deep anterior rectal resections rose since 1981. The mortality rate after tumour resections could be reduced to 1.5%. Most decisively for the improvement of the results was the introduction of a regular quality control system.

[Transanal endoscopic microsurgery]

A new endoscopic surgical method was developed for removal of large sessile adenomas of the rectum and lower sigmoid. Stereoscopic sight and magnifying glasses do allow precise surgery of these tumors. If adenomas are present they can be removed using the technique of mucosa excision; if on the other hand rectum carcinomas have to be removed the complete wall of the rectum in an appropriate extension can be excised. Hemorrhages which occur during preparation always can be stopped by diathermy. The surgical intervention is terminated by a transverse continuous suture of the defect. 33 patients were operated upon in this way from July 1983 to April 1985. Areas with an diameter of up to 10 cm could be removed, even located up to 18 cm in the colon. Suturing of the defect could always be performed without problem. In 1 patient a relapse occurred.

[Experiences with 2 years of quality control following general and vascular surgery in 3193 patients]

3193 general and vascular surgical interventions were prospectively controlled regarding the postoperative complication rates. The examination of all complication data was necessary to define the risk of the various operations. By a regular follow-up system the risk of wound infections and other complications decreased. Although perioperative antibiotic prophylaxis and stapling devices for gastrointestinal end-to-end anastomoses were routinely used, the surgeon still influenced the complication rates.

[Prophylactic immunoglobulin administration after major gastric resections. A prospective randomized study]

Immunoglobulins in a dosage of 0,25 g/kg body weight were administered in a prospective randomised study prophylactically to 90 out of 180 patients with gastric surgery of variable extent on the day of operation and on the first postoperative day. Wound infection rates of the treated group were 4.4%, of the control group 14.4%. In addition, the control group had a pneumonia rate of 21% and the treatment group of 11%. However, there were no differences between both groups as regards other assessments (mortality, further postoperative complications, time of hospitalisation, duration of ventilation, postoperative use of antibiotics). It can be concluded that although immunoglobulins lower the risk of infection prophylactic administration should for reasons of expense be limited to patients with preoperatively increased pulmonary risks. The appropriate therapeutic use is to be evaluated.

[Current status of therapy of liver metastases of colorectal carcinoma]

Surgical removal of liver metastases stemming from colo-rectal carcinoma is the therapy of choice of this disease. Postoperative mortality is 8%, 5 years survival rate ranges between 22 and 52% and can be considered to be good. However in 85% of patients surgery is not possible because of widespread involvement of the liver. Systemic chemotherapy yields remission rates up to 23% without increase of survival time, and therefore is no real alternative. Infusion of cytostatic drug into the hepatic artery yields better results, e.g. remission rates up to 85% and average survival times up to 26 months.

Endoscopic surgery in the rectum

A new transanal endoscopic operative technique permits microsurgery in the rectal cavity and the placing of surgical sutures. Compared with other procedures this one is non-aggressive, and there were not postoperative complications in twelve cases. A stereoscopic optical system, a new operating rectoscope and special surgical instruments, as well as a modification to an insufflation device are necessary for the endoscopic operation.