[Quality assurance and cost benefit analysis of viscerosynthesis].
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Abdomen↗
Biomedical subjects
A Thiede
Publications and source records attributed to A Thiede.
[Practical and theoretical aspects of cost-benefit relations in viscerosynthesis].
The necessity of limiting health care costs requires adequate service recording and quality control even in visceral surgery. In this field, the safety of the anastomoses is of greatest importance. Anastomoses at risk are esophageal connections to jejunum or colon and deep rectal anastomoses. At these locations expensive suture devices, such as stapling instruments, can be used in a cost saving aspect, if they help to increase anastomotic safety, time saving and expansion of surgical indication. Manual sutures thus represent the cheapest anastomotic technique as continuous sutures would cost between DM 10.- to 20.- and single stitch sutures between DM 60.- and 100.-. A surgical school should prevalently aim at training manual anastomoses, while special anastomotic techniques should only complete the skill for selected indications. The overall staff expenditure for extended operations amounts around DM 600.- per hour respectively DM 10.- per minute. Time for surgery might be shortened by auxiliary tools as much as to perform an additional operation. However, a circular stapler anastomosis that costs between DM 650.- to 850.- is twice as expensive as manual sutures notwithstanding the double time needed. In the past years, the necessity for a rational use of different anastomotic techniques has shown to be mandatory since, increasingly, financial aspects of health economy require cost benefit calculations in visceral surgery.
Abdomen↗
[Massive hemorrhage from jejunal varices].
A 21-year-old male presented with melaena and signs of hemorrhagic shock. In the following days several episodes of hematochezia occurred requiring the transfusion of nine units of blood. Findings at gastroscopy were normal, at colonoscopy fresh blood was noted from the ileocecal valve. Angiography performed in a bleeding-free interval showed no abnormalities. At repeat angiography, bleeding (from a left lateral branch of the superior mesenteric artery) was provoked by instillation of plasminogen activator. Subsequently, hemostasis was achieved by superselective embolization using coils. At operation one week later, a polypoid tumor of 1 cm diameter was resected along with a 4 cm segment of adjacent jejunum (40 cm distal to the ligament of Treitz). Histologically, a jejunal varix with superficial ulceration was diagnosed.
Adult↗
[Gardner syndrome and thyroid gland carcinoma].
We report on the case of a 23-year-old female with a 5-year history of Gardner's syndrome, who developed a bifocal, papillary carcinoma of the thyroid. The combination of familial adenomatous polyposis with a thyroid cancer is a rare but well-documented association. Typically, histology reveals a multifocal, papillary tumour with a predominantly good prognosis. This type of carcinoma is almost exclusively confined to females in their second decade of life, and it may, in fact, precede the onset of the polyposis manifestation. Patients suffering from familial adenomatous polyposis should therefore undergo regular clinical examination of the thyroid gland. If a neoplastic lesion is suspected, immediate scintigraphic evaluation should be carried out, with fine-needle aspiration of equivocal foci if necessary, and/or intraoperative frozen section. When a carcinoma is found, total thyroidectomy with dissection of the central lymph compartments should be considered the treatment of choice because of the high likelihood of the tumour being multicentric.
Adult↗
[Current and controversial aspects of minimal invasive surgery].
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Cost Control↗
[Laparoscopic interventions in gastroesophageal reflux--a cost-benefit analysis].
On the basis of a cost analysis of conservative and surgical therapy of gastroesophageal reflux disease in 70 patients health economic aspects are discussed. In a prospective documented series of reflux patients a retrolective analysis of medication cost and duration of conservative therapy is performed. In addition, the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization as well as costs for complications with necessary additional treatment and readmissions are assessed. For the conservative treatment of 70 reflux patients a total of more than DM < 700,000 had to be spent during preoperative 5 years. A major part of this sum was spent for patients who needed to increase the initial 20 mg dosage of Omeprazol within 5 years. A mean of approximately DM 2,000 per patient was spent for conservative treatment. Surgical treatment without complications was calculated with DM 5,425 per case. However, in 7 patients complications occurred causing prolonged or even rehospitalization with necessary further treatment summing up to about DM 486,000 for surgical therapy in 70 patients including complications. Cost relevant factors are therefore in conservative treatment patients who need increasing dosages, while, in surgical treatment, the cost relevant patients are those with complications and necessary additional treatment.
Adolescent↗
[Effect of modern instrumental diagnosis on surgical indications for resection of colorectal liver metastases].
In order to select those patients with colorectal liver metastases who may have benefit from an operation, preoperative detection and localization of tumors in the liver is necessary. In this study, the specificity and sensitivity of a CT arterial portography and magnetic resonance imaging with contrast media was compared with the results of operative findings and intraoperative ultrasonography. The combination of both preoperative methods led to an accuracy rate of more than 90%, and all patients who underwent laparotomy were resected or treated with an arterial infusion port system. Negative laparotomies were excluded completely.
Colorectal Neoplasms↗
[Open surgical therapy of functional disorders of the rectum and pelvic floor].
An overview is given of common transabdominal procedures for functional disorders of the rectum and pelvic floor which are caused by degenerative morphological changes, and termed pelvic floor insufficiency. Only the transabdominal approach permits a comprehensive and pathophysiological repair of changes associated with the disorder. Own results and a review of the literature confirm a superior functional outcome and low recurrence rates with a combined procedure consisting of rectopexy, colonic resection and pelvic floor repair.
Colectomy↗
[How expensive is treatment of reflux disease?].
In a prospective documented series of reflux patients, a retroelective analysis of medication cost and duration of conservative therapy as well as the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization, and costs for complications with necessary additional treatment and readmissions is assessed. Cost-relevant factors are in conservative treatment cost-relevant factors are those patients who need increasing dosages, while in surgical treatment the cost-relevant patients are those with complications who need additional treatment.
Anti-Ulcer Agents↗
[Simultaneous intervention in vascular surgery. Risk assessment and cost-benefit analysis].
Thirty-four simultaneous vascular operations were performed from 1993 to 1996. Postoperative complications were similar to additive complication rates of carotid endarterectomies and other vascular operations undertaken during this period. Operation time and postoperative hospital stay was significantly shorter, and cost-benefit analysis revealed clear advantages for the simultaneous group.
Comorbidity↗
Expression pattern of extracellular matrix proteins in the pancreas of various domestic pig breeds, the Goettingen Minipig and the Wild Boar.
UNLABELLED: In spite of progress in biotechnology, isolation of porcine pancreatic islets remains a difficult task with unpredictable results. One reason could be the lack of knowledge as to the expression of extracellular matrix proteins in porcine exocrine and endocrine tissues, particularly in "islet capsules". Such proteins are subject to digestion by proteases, yet they might have a protective function for the fragile islets. OBJECTIVE: Of our study was a detailed histological analysis of the extracellular matrix proteins in various pig breeds. A broad panel of commercial, human-specific antibodies were used, since antibodies against porcine tissue were not available. METHODS: Frozen pancreatic tissue section of 7 domestic pig breeds, the Goettingen Minipig and the Wild Boar were stained with antibodies against collagen types I, II, III, IV, V, VI, VII, IX, laminin, fibronectin, vitronectin and elastin. Binding of antibodies was detected by immunoperoxidase and evaluated microscopically. Human and rat tissue was treated in the same way. RESULTS: (1) With the exception of anti-collagen type II, type VII and vitronectin, all antibodies revealed distinct binding patterns in the pancreas of the different pig breeds. However these antibodies bound on human cartilage and skin. (2) Collagen types I, III, IV, laminin and fibronectin are expressed on porcine pancreatic "islet capsules". (3) Expression levels of these proteins on "islet capsules" vary in the different pig breeds. However, no significant differences could be found in the expression pattern of collagen types I, III, IV, laminin and fibronectin, comparing domestic, experimental and wild type pigs. (4) Older individuals (Goettingen Minipig) appear to express higher levels of proteins on "islet capsules" than younger ones. CONCLUSIONS: Antibodies with specificity for human extracellular matrix proteins can be used successfully in the porcine pancreas. Thus, analysis of the structure and composition of porcine pancreatic tissue can be performed even without pig-specific antibodies. Particularly, the effects of various proteases and collagenases on the pancreatic tissue can now be monitored by immunohistochemical analysis allowing a rational design of protease mixtures for the isolation of pancreatic islets.
Animals↗
The mode of Roux-en-Y reconstruction affects motility in the efferent limb.
OBJECTIVES: To compare motility of a Roux-en-Y esophagojejunostomy after total gastrectomy with normal jejunal motility and to determine the effect on motility of the incorporation of a pouch in the reconstruction. DESIGN: Jejunal motility in normal subjects was compared with jejunal motility in the Roux-en-Y reconstruction with and without a Hunt-Lawrence pouch. SETTING: The case were collected during a 4-year period at a university hospital. The mean time from resection to study was 14 months (range, 4 to 49 months). PATIENTS: Seven control patients were compared with 10 patients with a Roux-en-Y reconstruction and 17 with a Roux-en-Y and Hunt-Lawrence pouch. OUTCOME MEASURE: The fasting-state motility of the jejunum used for reconstruction was measured by a water-perfused manometric system for 2 to 4 hours with the subject in the supine position. RESULTS: Compared with normal subjects, patients with a Roux-en-Y esophagojejunostomy without a pouch had an increased number of phases of the interdigestive motor complex per hour (P < .05). The phases were of shorter duration with a random sequence and increased total time spent in the quiescent phase 1 (P < .05). In patients with a pouch, no differences were detected between the motility in the pouch and the efferent limb. Compared with those without a pouch, there were significantly fewer orthograde interdigestive motor complex phase 3 fronts and more total time spent in phase 1 (P < .05). CONCLUSIONS: Construction of a gastric substitute from jejunum leads to substantial motility changes. The addition of a pouch decreases the overall activity, which may contribute to the storage function of the pouch.
Adult↗
Fiberoptic technique for 24-hour bile reflux monitoring. Standards and normal values for gastric monitoring.
Physiologic bile reflux was assessed in 27 in vivo test with healthy volunteers to define a standardized protocol and normal values for 24-hour enterogastric bile reflux monitoring (protocol with supine, upright, and meal phases and a free diet avoiding alcohol, smoking, and coffee, evaluation with different thresholds of absorbance units: 0.14, 0.25). In vitro tests with bile-sodium solutions demonstrated a linear dependence of absorbance for bilirubin up to 600 mumol/liter (range of the fiberoptic device: 0.0-1.0). Fluids and food might interfere with absorbances below 0.25 (exception: coffee). In vivo bile often remains in the stomach for more than 1 hr; these events were defined as reflux episodes. The upper limits for physiologic bile reflux are a percentage of total time of bile reflux of 28.2% and an average absorbance during a reflux episode of 0.62 (95th percentile with threshold 0.25). Comparing bile with pH monitoring (absorbance > 0.25 and/or pH > 4), an increase of bilirubin was found most frequently with constant pH (45%) or an increase of pH with constant bilirubin (36%). The hypothesis was drawn that bile and duodenal or pancreatic secretions may separately contribute to duodenogastric reflux.
Adult↗
[Primary extragenital manifestation of a malignant mixed Mullerian tumor of the major omentum].
Malignant mixed Müllerian tumours (MMMT) are tumours of the female genital tract which rarely occur in extragenital sites. We report a case of a 46-year-old female with MMMT with primary occurrence in the greater omentum. Only 19 cases of primary extragenital manifestations of this tumour are described in literature. The clinical appearance, diagnosis, therapy, histological evaluation and histogenesis are discussed.
Diagnosis, Differential↗
[Differential concept on use of laparoscopic anti-reflux operations].
The introduction of laparoscopic technique in antireflux surgery has created hope for an improvement in patient outcome. Initial experience with minimally invasive procedures show that the application in antireflux surgery depends more on a differentiated indication for operation and an operative procedure designed to remove or compensate the underlying pathophysiologic functional defect. The method of access is of lesser priority. The promising results of this series may encourage continuation of the demonstrated protocol and operative technique.
Adult↗
[The risk of needle-stick-injuries during abdominal closure].
A randomized study is being presented, which compares closure of laparotomy with 2 different needles (sharp: HR48, blunt: HR48PP = protect point). Handling and glove perforation rate is to be compared. 400 gloves in 100 laparotomies have been tested. Slightly more effort was reported from the surgeon to perforate the fascia with the blunt needle, but there was also a significantly lower perforation rate in the glove of his non-dominant hand. To avoid a contamination during operation the use of blunt needles has to be recommended.
Abdomen↗
[Etiology and epidemiology of anal incontinence].
Current epidemiological data about fecal incontinence are reviewed. Anatomy and physiology of the anal sphincter are described, and it is shown that continence relies on several interdependent anatomical and functional factors. Etiology of fecal incontinence is discussed and illustrated by clinical examples.
Diagnosis, Differential↗