Over a 28 month period, 124 patients with a unilateral inguinal hernia were recruited into a randomized controlled trial comparing open (OH) to laparoscopic inguinal heruiorraphy (LH).The primary endpoint was duration of convalescence.There was no difference in baseline parameters across groups with respect to: Age, Sex, Body mass index, American Society of Anaesthetists score, Employment status, incidence of symptoms, hernia type, or quality of life scores ((QOL), using two validated instruments).Sixty five patients underwent OH and 59 LH.Before operation, LH patients anticipated a significant shorter duration of convalescence than OH (14.2 + 9.6 days vs. 18.4-+ 10.8 days p=0.027).The mean duration of operating room time utilization was 73.5 -+ 26.2 rain for OH and 88.8 -+ 34 rain for LH (p=0.007).Only 39% of OH patients and all LH patients underwent general anesthesia.Eighty one percent of LH repairs were performed using a trans-abdominai properitoneal technique, whereas 50% of OH patients had a tension-free repair.The median duration of hospital stay was one day in both groups.The total does of morphine equivalents required was 41.4_+ 33 mg in OH and 27.9 _+ 34.7mg in LH (p=0.0035).The duration of time till return to work (for employed patients) and return to full activities (for unemployed or retired patients) was 11.4-+ 7.7 days in OH and 9.8 + 7.4 days in LH (NS).This result was confirmed by survival analysis of the percentage of activities which could be performed at the time of post-operative follow-up interviews.There was a significant greater proportion Of LH patients willing to undergo the same procedure (95% Odds ratio = 2.9-17.6,p<0.001).There was no difference however in QOL or morbidity between groups.After a median follow-up of 3 years one OH and three LH patients exhibited an asymptomatic recurrent hernia.Conclusions: Although no difference in convalescence or QOL could be demonstrated across groups, LH patients reported significant benefits in post-OP pain and procedural satisfaction.

Two techniques of duodenum-preserving resections of the head of the pancreas have been described by Beger and Frey for treatment of chronic pancreatitis. These techniques were compared in a prospective randomized trial following a pilot study. The course of 31 patients with chronic pancreatitis was prospectively documented with 25 patients having undergone Beger's and 6 Frey's procedure. Thereafter 38 patients were randomly allocated to either Beger's or Frey's group. The mean interval between symptoms and surgery was 5.4 years in the pilot study and 5.6 years in the randomized study. 17 adjacent organs (13 common bile duct stenoses, 4 duodenal stenoses) were affected in 13 patients in the pilot study, and 35 adjacent organs (28 common bile duct stenoses, 6 duodenal stenoses, 1 pancreatopleural fistula) in 28 patients in the randomized study. The mean follow-up was 4.8 years in the pilot study and 1.5 years in the randomized study (minimum 6 months). In both series there was no mortality. Morbidity was 26% in the pilot study (28% Beger, 17% Frey) and 16% in the randomized study (21% Beger, 11% Frey). In the pilot study complete pain relief was achieved in 92 and 83% of patients after Beger's and Frey's procedure, and in the randomized trial in 95 and 89% of patients' after Beger's and Frey's procedure. Associated affection of adjacent organs was definitively resolved in 94% (16 of 17) in the pilot study (92% Beger, 100% Prey) and in 94% (33 of 35) in the randomized study (90% Beger, 100% Prey). Both techniques of duodenum-preserving pancreatic head resection are equally safe and effective with regard to pain relief and definitive control of complications affecting adjacent organs.

In the present study the effects of local bowel perfusion on anastomotic healing of experimental colonic anastomoses were evaluated in 54 female chinchilla rabbits. Local ischemia was induced by devascularization of the sigmoid colon. Animals were randomly allocated to 4 operative groups. In the animals of group 1 a colo-colonic anastomosis was performed in an area graded as ischemia grade A (intact perfusion). Animals of group 2 received a colo-colonic anastomosis in the sigmoid colon segment, graded as ischemia grade B (marginal perfusion). Group 3 received pretreatment with neomycin and was otherwise treated like group 2. Animals of group 4 a colo-colonic anastomosis was performed in the ischemia grade-C region (total ischemia). The rate of anastomotic leakage was monitored by periodic double contrast enemas. The experiment was terminated on the 8th postoperative day, and microangiography to assess revascularization was performed followed by assessment of perianastomotic adhesions. The rate of anastomotic failure as well as the occurrence of anastomotic failure over time highly depended on the severity of ischemia. Bowel sterilization by neomycin significantly reduced the rate ot anastomotic leakage. The development of perianastomotic adhesions correlated with the severity of ischemia. Microangiography suggested that revascularization originated in the perianastomotic adhesions.

Human pneumococcal septicemia, the prominent postsplenectomy complication, was as yet difficult to study in the porcine model, since this species appeared to be fairly resistant against pneumococcal infections. We have used two strains of pneumococci (serotype 1 and 6B) both of which had been isolated from patients with systemic infection and both of which were maintained in a virulent state by regular mouse passage. After challenge with 10(9) type 1 pneumococci, however, only one of the 5 pigs developed fever, none showed profound hematological alterations and each animal exhibited a rapid clearance of bacteria from peripheral blood. By contrast, challenge of 7 animals with type 6B pneumococci resulted in a slower and incomplete bacterial clearance with persistent bacteremia for up to 24 hours. All animals developed fever and a profound leukopenia with less than 5,000 leukocytes/ml and 3 of the 7 animals died after injection of type 6B pneumococci. The results show that potentially the type 6B pneumococci can be successfully employed for studies of gram positive septicemia in the miniature swine.

OBJECTIVE To formulate a score system that would make the preoperative diagnosis of acute appendicitis more accurate. DESIGN Retrospective then prospective study. SETTING City University Hospital. SUBJECTS 536 patients who had their appendixes removed between 1981 and 1986 (retrospective study), and 150 consecutive patients admitted with a presumptive diagnosis of appendicitis between 1987 and 1988 (prospective study). MAIN OUTCOME MEASURES Correlation between the histological diagnosis of appendicitis and variables representing history, clinical examination, and laboratory investigations. RESULTS The rate of histologically proven negative appendicectomies in the retrospective series was 40% and in the prospective series 33%. The variables that were thought to be predictive were: male sex, white cell count of greater than 11 x 10(9)/l, history of less than 24 hours with no previous complaints, rebound tenderness, shift of pain from the epigastrium, and localised guarding, but all criteria had low specificities and sensitivities when applied prospectively, and combining the scores did not improve them. CONCLUSION The accurate diagnosis of appendicitis depends largely on the experience of the surgeon and is not improved by the application of a score system that includes the above variables.

There is an increasing demand for accurate preoperative and intraoperative staging of bronchial carcinoma with respect to neoadjuvant therapy protocols and parenchyma-sparing operations. This study prospectively evaluated accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma in 108 consecutive patients. The stage of the primary tumor (T stage) was correctly determined in 85% of the patients, and surgical evaluation correctly determined the T stage in 92%. Invasion of major mediastinal structures posed a major problem for computed tomographic scan. On a node-by-node basis, computed tomographic scan predicted involvement of lymph nodes in 81% (sensitivity 29%, specificity 93%, positive predictive value 49%, negative predictive value 85%). The surgeon correctly determined the lymph node status in 69% of lymph nodes (sensitivity 90%, specificity 63%, positive predictive value 39%, negative predictive value 96%). On a patient-by-patient basis, computed tomographic scan correctly predicted the nodal status in 58% of patients. Accuracy of computed tomographic scan and surgical assessment in determination of the lymph node status strongly depended on tumor type and lymph node region (hilar or mediastinal region) studied. This was partly due to the fact that adenocarcinomas exhibited a high proportion of tumor-positive normal-sized lymph nodes, whereas squamous cell carcinomas showed a high proportion of enlarged tumor-free lymph nodes. In conclusion, computed tomographic scan and surgical assessment are sufficiently accurate for determination of the tumor stage but are insufficient in determining the nodal status.

The only curative treatment for proximal bile duct cancer with involvement of both main hepatic ducts is liver transplantation. Most patients do not fulfill the requirements for liver transplantation. Our treatment strategy in appropriate cases is palliative tumor resection and reconstruction of the biliary passage by sutureless bilioenteric anastomosis. We have treated 12 patients, 5 in combination with intraluminal and percutaneous radiotherapy. Our results indicate that this strategy leads to effective palliation in some cases provided that only microscopic residual tumor is left in-situ. Our survival times compare favourably with survival after liver transplantation.

After resecting procedures to the parenchyma of the lung the resection site was sealed with a collagen vleece combined with fibrin glue in 26 patients. No patient exhibited rebleeding. An air leak was present up to the first postoperative day in 19 patients, up to the third postoperative day in 5 patients. In two patients, duration of air leak extended beyond the third postoperative day, this was defined as therapeutic failure. The use of collagen vleece combined with fibrin glue represents a valuable contribution in thoracic surgery.

The existence of the overwhelming postsplenectomy infection syndrome in adults after traumatic splenectomy is discussed controversely. In this study the effects of splenectomy and spleen-preserving operations on outcome of experimental pneumococcemia of the pig were analyzed. Furthermore, the effect of the monocyte activator MTP-PE was assessed. Splenic operations had no influence on the used criteria of sepsis. Pretreatment with MTP-PE protected animals against development of septic leukocytopenia and led to an enhanced bacterial clearance. In addition, mortality of experimental sepsis was significantly decreased. Splenic preservation in adults after posttraumatic splenectomy does not seem to be warranted. On the other hand, the activator of the monocyte-macrophage-system seems to represent an effective regimen to prevent development of sepsis in high-risk patients.

In a porcine model of pneumococcal septicemia, animals were pretreated with 1 mg of liposome-encapsulated muramyl tripeptide phosphatidylethanolamine (MTP-PE) or with liposomes alone. After 24 h each animal received an injection of either 10(9) or 10(10) pneumococcal serotype 6B cells. MTP-PE pretreatment resulted in less pronounced leukocytopenia, with a nadir of 6,700 (versus 4,100) leukocytes per mm3 after injection of 10(9) bacteria and a nadir of 4,400 (versus 3,800) leukocytes per mm3 after injection of 10(10) bacteria. At the same time bacterial clearance was substantially improved by MTP-PE pretreatment. Finally, pretreatment with MTP-PE dramatically reduced mortality; the average death rates for both series of animals used were 55% for liposome-pretreated animals and 3% for animals pretreated with MTP-PE-containing liposomes. These results in a preclinical model suggest that treatment with MTP-PE-containing liposomes might be beneficial in controlling septicemia in patients at risk.

The existence of the overwhelming postsplenectomy infection syndrome in adults after traumatic splenectomy is discussed controversially. In this study the effects of splenectomy and spleen-preserving operations on outcome of experimental pneumococcemia of the pig were analyzed. Furthermore, the effect of the monocyte activator MTP-PE was assessed. Splenic operations had no influence on the used criteria of sepsis. Pretreatment with MTP-PE protected animals against development of septic leukocytopenia and led to an enhanced bacterial clearance. In addition, mortality of experimental sepsis was significantly decreased. Splenic preservation in adults after posttraumatic splenectomy does not seem to be warranted. On the other hand, the activator of the monocyte-macrophage-system seems to represent an effective regimen to prevent development of sepsis in high-risk patients.

We evaluated the accuracy of computed tomography (CT) and of surgical assessment for lymph node staging prospectively in 108 patients with bronchogenic carcinoma. For CT/surgical assessment a sensitivity of 29/90%, a specifity of 93/63%, a positive predictive value of 49/39% and a negative predictive value of 85/96% were calculated on a node-by-node basis. Sensitivity and specifity of CT were highly influenced by the lymph node region studied and by typing of the tumor. Adenocarcinomas showed a high proportion of normal-sized metastatic lymph nodes whereas squamous cell carcinomas exhibited a high proportion of enlarged tumor-free lymph nodes. The diagnostic accuracy in predicting the correct N-stage by CT was determined with 54% for squamous cell carcinoma and 56% for adenocarcinoma. The surgeon predicted the N-stage correctly in 39% of squamous cell carcinoma and 69% of adenocarcinoma. In conclusion, accuracy of CT-scan is too low to renounce mediastinoscopy for routine use in preoperative staging of bronchogenic carcinoma.

After resecting procedures to the parenchyma of the lung the resection site was sealed with a collagen vleece combined with fibrin glue in 26 patients. No patient exhibited rebleeding. An air leak was present up to the first postoperative day in 19 patients, up to the third post-operative day in 5 patients. In two patients, duration of air leak extended beyond the third postoperative day, this was defined as therapeutic failure. The use of collagen vleece combined with fibrin glue represents a valuable contribution in thoracic surgery.

The existence of the overwhelming postsplenectomy infection syndrome in adults after traumatic splenectomy is controversial. Due to the similarity of the porcine immune system to man we chose the pig to study subsets of peripheral mononuclear cells after splenectomy and resistance to experimental Pneumococcal infection after splenic surgery and specific immunization.Female miniature pigs were assigned to four operative groups: sham operation, splenectomy, splenic resection, and heterotopic splenic autotransplantation. Hematologic and flow cytometric analysis of mononuclear cells and their subsets revealed a marked leukocytosis following splenectomy and autotransplantation but no significant shift in monocyte and B-cell numbers.Response of leukocytes to septicemia, bacterial elimination from peripheral blood, and mortality were not affected by splenectomy or spleen-preserving operations. Mortality of splenectomized animals was 18%, compared to 42% in sham-operated controls (difference not significant). Immunization protected animals from development of leukopenia, and led to an enhanced bacterial elimination, and a significantly decreased mortality of 5%, compared to 48% in nonimmune animals. Thus our data do not show significant effects of splenectomy on subsets of porcine mononuclear cells or on resistance to experimental Pneumococcal septicemia.

About 50% of all patients with pelvic fractures present with associated injuries. Diagnostic and therapeutic guidelines follow the step-by-step regimen used in polytraumatized patients. Whereas lifesaving emergency operations are rarely necessary, most associated injuries are operated on after completion of the first diagnostic phase in order to preserve organ function. Injuries of the pancreaticoduodenal system and ruptures of the digestive tract are particularly difficult to diagnose. Stabilization of pelvic fractures will take place in the phase of delayed reconstruction, usually several days after the accident.

We evaluated the accuracy of computed tomography (CT) and of surgical assessment for lymph node staging prospectively in 108 patients with bronchogenic carcinoma. For CT/surgical assessment a sensitivity of 29/90%, a specificity of 93/63%, a positive predictive value of 49/39% and a negative predictive value of 85/96% were calculated on a node-by-node basis. Sensitivity and specificity of CT were highly influenced by the lymph node region studied and by typing of the tumor. Adenocarcinomas showed a high proportion of normal-sized metastatic lymph nodes whereas squamous cell carcinomas exhibited a high proportion of enlarged tumor-free lymph nodes. The diagnostic accuracy in predicting the correct N-stage by CT was determined with 54% for squamous cell carcinoma and 56% for adenocarcinoma. The surgeon predicted the N-stage correctly in 39% of squamous cell carcinoma and 69% of adenocarcinoma. In conclusion, accuracy of CT-scan is too low to renounce mediastinoscopy for routine use in preoperative staging of bronchogenic carcinoma.

Using amino acid arylamides as substrates, proteolytic activities with a strong correlation to tumor growth were detected in serum and tumor extracts of rats with benzopyrene sarcoma. In a subsequent experiment in rats with azoxymethane-induced intestinal carcinoma, the serum activities of these enzymes were studied from the administration of the carcinogen up to 100% incidence of colon carcinoma after 25 weeks. The activity patterns were compared with labeling index, mucosal edema, incidence of dysplastic crypts and tumor frequency, and conclusions on the involvement of the proteolytic activities in carcinogenesis were drawn. A preliminary study in human patients with colorectal cancer supported the results of the rat models.