No abstract

An autopsy study was performed to quantify diagnostic fallibility in clinical surgery. Autopsy results in 312 surgical patients were compared with clinical findings. The primary clinical diagnosis was correct in 93 per cent of patients; complications had been correctly diagnosed in 60 per cent and error in treatment was found in 16 per cent. Error in treatment had an adverse impact on the course of disease in 11 per cent of patients. Infective complications such as abdominal sepsis and bronchopneumonia were encountered most often. Sensitivity was low for the clinical diagnosis of pulmonary embolism, bronchopneumonia, myocardial infarction and terminal haemorrhage. Statistical analysis showed that sudden unexpected death is the most obvious condition in which a high yield is expected from a post-mortem examination. Autopsy remains a valuable means of quality control in clinical surgery and could be a basis for surgical audit.

Limiting degradation of collagen during the initial phase of wound healing is expected to improve postoperative intestinal strength and thereby decrease chances for anastomotic dehiscence. We studied the influence of four nonsteroid anti-inflammatory drugs on the healing of intestinal anastomoses in rats, with special regard to changes of collagen levels around the anastomoses. Four experimental groups of 20 rats each received daily oral doses of piroxicam, ibuprofen, aspirin, or indomethacin and were compared with a control group. Animals were sacrificed 3 or 7 days after operation. Both morbidity and mortality rate in the experimental groups were high. Collagen, measured as hydroxyproline, levels in anastomotic and adjoining 1-cm intestinal segments were compared with concentrations in control segments resected during operation. After an initial decrease on day 3, hydroxyproline concentrations increased on day 7. In the colon the lowering of hydroxyproline concentrations, which was more pronounced than in the ileum, was significantly reduced by administration of piroxicam and ibuprofen, both in the anastomosis and its proximal segment. On day 7, the increase of hydroxyproline concentrations in the ileum was inhibited by administration of anti-inflammatory drugs. It is concluded that nonsteroidal anti-inflammatory drugs may limit postoperative degradation of collagen in colonic anastomoses, but at the same time may increase the rat's susceptibility to surgical infections.

Although steroids are generally thought to impair intestinal anastomotic healing, this effect has never been proven unequivocally in either clinical or experimental studies. We have investigated the influence of methylprednisolone (2.5 or 10.0 mg kg-1 day-1) given from 2 days before operation onwards, on 3-day-old and 7-day-old ileal and colonic anastomoses in rats. Anastomotic abscesses occurred more frequently in the ileum, but not in the colon, after steroid medication. However, methylprednisolone did not lower anastomotic bursting pressures in either of the bowel segments. Comparison of the hydroxyproline content of the anastomotic segment yielded no significant difference between control and methylprednisolone groups in either small or large bowel. Thus, healing of experimental colonic anastomoses remains unaffected by short-term administration of this corticosteroid.

Since 1971, 151 nonpalpable breast cancers (100 invasive carcinomas, 39 in situ ductal carcinomas, and twelve lobular carcinomas in situ) have been diagnosed and treated at the St. Radboud University Hospital. Of the 100 clinically occult invasive carcinomas, 53 had pathologic diameters of more than 10 mm, 29 were of sizes between 6 and 10 mm, and 18 were tumors of 5 mm or less. Residual tumor outside the "excisional" biopsy cavity was encountered in 76 of the 118 mastectomy specimens (64.4%) fully capable of evaluation. Invasive residual tumor would have been left behind in 34 of 86 mastectomy specimens (39.5%). Of 27 axillas studied, no patient with in situ carcinoma had evidence of axillary lymph node metastases. Invasive carcinoma, however, showed axillary lymph node involvement in 7.7% of mastectomy specimens when the size of the primary tumor was not more than 5 mm, in 12.5% when the size was between 6 and 10 mm, and in 29.5% when the primary tumor was more than 10 mm in diameter. The 10-year recurrence-free survival (RFS) of patients with clinically occult invasive carcinomas greater than 10 mm in size was 71.9% and differed significantly from the 90.9% for patients with the invasive tumors less than or equal to 5 mm, as well as from the 100% RFS of patients with invasive tumors of between 6 and 10 mm and noninvasive tumors. Although the 10-year RFS was 92.6% for the patients with negative axillary nodes and 80.0% for the patients with positive axillary nodes, this difference did not reach statistical significance. However, the disease-specific overall survival after 10 years was significantly different between node-negative patients (96.4%) and node-positive patients (78.8%). Multivariate analysis disclosed that the relationship between size of the primary tumor and RFS was independent of the presence of axillary lymph node metastases. In conclusion, the validity of the concept of minimal breast cancer has been re-enforced. However, the results of this study suggest that the upper limit of the original definition of minimal breast cancer is too narrow and should be extended, so that, apart from the noninvasive tumors--regardless of their size--all invasive tumors having a maximum diameter less than or equal to 10 mm should be regarded as minimal breast cancers.