Biomedical subjects
Publications and source records attributed to P Buchmann.
This article studies the self-assessed pre/postoperative course of the psychological condition of 3 patient groups (hernia, aorto-coronary bypass and cancer patients) and healthy controls. Some consequences for clinical work are discussed.
A retrospective study was carried out on 88 hand sewn and 34 stapled anastomoses following anterior resection to evaluate the impact of suture technique on local recurrence rate. The patient groups were comparable with one exception: there were significantly more Dukes C lesions resected and sutured using the stapling gun (35% versus 15%, X2 = 6.33, p less than 0.05). Stage-corrected recurrence rate was similar in both groups, Dukes A: 8%, Dukes B 21%, Dukes C 52%, all recurrences being detected within 24 months following operation. Significantly fewer protective colostomies were needed using the staple gun (15% versus 34%, X2 = 4.50, p less than 0.05). Otherwise, no significant difference or benefit was observed comparing the two suture techniques.
Flexible fiberoptic sigmoidoscopy more and more replaces sigmoidoscopy with a rigid tube. In a retrospective series of 152 rigid sigmoidoscopies we analysed depth of endoscopy and findings. In 36% of patients without anaesthesia endoscopy had to be stopped at 15 cm and in further 31% at 20 cm leading to a highly significant difference to the anesthetized patients (p less than 0.0005). A good history of the present illness allows separating of bleeding carcinoma and polyps proximal to the sigmoid colon which have to be examined by colonoscopy. In routine screening for blood loss per anum it is desirable to achieve in all patients a maximal security not to overlook a finding, because of the medical costs. We have enlarged the list of indications for the rigid sigmoidoscopy by Marks et al. as a practical compromise: delineation of rectal lesions, side localization and critical rectal measurements, surveillance of disease states or anastomoses within its reach, for performing rectal biopsy and rectal polypectomy, in patients with possible contamination of the instrument, endoscopy in the anesthetized patient before a proctological operation if case history excludes a higher sited lesion. In all other cases there is an indication for colonoscopy or barium contrast enema. It is stressed that in patients with blood loss per anum the search for the source always is done by flexible fiberoptic sigmoidoscopy.
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This study deals with 188 consecutive patients who had a radically resected colorectal carcinoma and who were later controlled by colonoscopy. The median interval between resection and endoscopy was 2.5 (0.5-19) years. In 20 patients, a local recurrence was found (10.6%). In 11 of these 20 patients the indication for colonoscopy was the clinical suspicion of a recurrence. The remaining nine patients were asymptomatic, and colonoscopy was done as a routine procedure. In six of nine asymptomatic patients, a potentially curative resection of the recurrent tumor was possible, which was not possible in any of the 11 symptomatic patients. Nineteen of the 20 patients with a local recurrence could be followed up. Five of the six patients with potentially curative resection of the recurrence were asymptomatic for a median time of 38 (12-72) months after surgery; in contrast, 9 of 13 patients without curative operation died after a median survival period of 8 (1-24) months. The results of this study suggest that good long-term prognosis may be expected in patients in whom local recurrence is detected at an early asymptomatic stage with the possibility of potentially curative resection. Therefore, the authors propose regular endoscopic examinations in the first years after curative colorectal cancer surgery.
The mode of action, indications and contraindications of laxatives and bulkage are presented. There are only a few indications for the use of laxatives, centering mainly on bowel preparation for diagnostic and operative purposes. Frequent abuse of laxatives is observed in chronic constipation, a disease which should be treated by a high roughage diet and bulkage, preferably with bran.
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A herniation (with torsion) of the heart trough a dehiscent pericardial suture was observed on the second postoperative day after right-sided pneumonectomy, when shock symptoms developed. Chest x-ray was diagnostic and lead to rethoracotomy with successful reposition of the heart.--Another case showed an atypical bulge of the heart contour after pneumonectomy with partial pericardial resection. It was caused by pericardial fat, sutured on the defect for occlusion.
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The early postoperative results of 1273 operations for inguinal hernia are reported. In addition, the late outcome of 688 operations of patients answering the questionnaires was analysed according to the surgeons stage of training. In group 1, the operator was in the first two years of his training, in group 2, he was older but had not yet achieved his title as a specialist for surgery and in group 3, all are fully trained surgeons. The postoperative complications are distributed equally among the 3 groups. Wound infection was leading in 37% to recurrent inguinal hernia. The overall figure of recurrent inguinal hernia was highest in group 2 with 7.8% (14 out of 179), followed by group 1 with 5.5% (22 out of 399) and group 3 with 4.5% (5 out of 110). Early post-operative recurrence was again highest in group 2 with 7 out of 14 compared with 9 out of 22 in group 1 and 2 out of 5 in group 3. We conclude from these results that inguinal hernia may be performed by a very young surgeon in training; supervision in those who are over the first steps, but have not completed their training has to be intensified and that asepsis has to be observed very carefully.
95% of our patients have a simple fistula in ano. The majority of these fistulas were following a cryptoglandular abscess. No definitive incontinence occurred after laying open the fistula penetrating the anal sphincter and excision of the extrasphincteric part. In only 7% there was a temporary incontinence for faeces or flatus respectively. The recurrence rate was 5%. High fistulas are seldom an indication for a seaton. In 5% we found a complex fistula with supralevator or extrasphincteric extension. Thereby we usually performed a defunctioning colostomy. This became the permanent treatment for more than half of these patients.
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An unusual case of scleroderma with colonic involvement mimicking sigmoid carcinoma is presented. Severe low colonic obstruction was due to stenosis of the large intestine making segmental colonic resection mandatory.
Two out of five patients with a colonic anastomosis stapled with the EEA device, under protection of a diverting colostomy, developed stenosis requiring reoperation. Therefore, a canine experiment was conducted in order to compare the degree of fibrosis in a sutured with that in a stapled anastomosis. A colonic loop excluded from the fecal stream was transsected twice. One anastomosis was done by sutures, the other by an EEA stapling device. The amount of fibrous tissue between the circular muscle layer and the lamina muscularis mucosae was measured on strips of 2-mm length. Immediately after surgery, the submucosal edema was similar in both anastomoses. Marked fibrous thickening of stapled anastomoses developed after two to six months. In contrast, sutured anastomoses elicited very little fibrous thickening of the lamina submucosa. This difference in fibrosis could not be demonstrated following use of the stapling device alone, i.e., without staples. The fibrous thickening, measured in a stapled anastomosis diverted from the fecal stream, exceeds that seen in a sutured anastomosis and may result in stenosis. Therefore, it is suggested that an anastomosis, protected by a diverting colostomy, should be sutured.
Many patients with rectal prolapse and/or fecal incontinence could be helped if they disclosed the ailment to their physician. Thirteen out of 23 patients underwent transabdominal rectopexy and remained recurrence-free, whereas only one out of 10 anal cerclages brought relief of symptoms. Simultaneous incontinence was also eliminated in most cases by rectopexy. Thirty-one patients with incontinence in the absence of traumatic sphincter lesions or urgency grade 2 were treated either by voluntary training of the pelvic floor muscles in combination with faradic stimulation, or by postanal repair. Fifteen patients regained continence or showed some improvement. Thirteen of the remaining 16 patients were healed or improved after postanal repair. The authors therefore recommend transabdominal rectopexy for rectal prolapse. In cases of simultaneous incontinence the rectopexy should be performed first. If a course of training of the pelvic floor muscles produces no improvement, postanal repair is advisable.
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