Some patients are prone to persisting intraabdominal infection regardless of initial eradication of the source of infection. Our aim was to characterize patients who had to undergo relaparotomy for persisting abdominal sepsis using simple clinical parameters and to define those patients who are susceptible to benefit of aggressive surgical treatment by early and repeated reoperations to control multiple organ dysfunction syndrome (MODS) caused by ongoing intraabdominal infection. Persisting abdominal sepsis was the cause of death in all of our patients who had to undergo relaparotomy. Controlling persisting abdominal sepsis should achieve a reduction in the tremendously high mortality rate. Performing a case-control study, we retrospectively reviewed 523 consecutive patients with secondary peritonitis treated from 1986 to 1996 and focused our attention on 105 patients, in whom standard surgical treatment of secondary peritonitis failed and who had to undergo relaparotomy for persisting abdominal sepsis (study group). Overall, there was no significant difference in the postoperative mortality rate between "planned relaparotomy" and "relaparotomy on demand" (54.5% versus 50. 6%). Equally clear risk estimations were given preoperatively by both the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Goris scores. There was a significant difference between patients of the control group and patients of the study group with regard to preoperative APACHE II score, Goris score, age >70 years, albumin <30 g/L, extent of peritonitis, and outcome (p = 0.0001). Reexploration performed more than 48 hr after the initial operation resulted in a significantly higher mortality rate (76.5% versus 28%; p = 0.0001). However, the time of reoperation had no significant impact on survival in patients with an APACHE II score of > or = 26, because physiologic derangement is such that only a few patients could benefit from reoperation. The lowest mortality rate (9%) was achieved in patients who underwent reoperation on demand within 48 hr. We conclude that patients >70 years of age with secondary peritonitis extending over the entire abdomen and a greater degree of physiologic compromise (serum albumin levels <30 g/L, preoperative APACHE II scores >20, and existing organ failure measured by the Goris score) are at high risk for developing persistent intraabdominal infection. Our data show that timely relaparotomy provides the only surgical option that significantly improves outcome. However, aggressive surgical treatment has reached its limit in patients whose source of infection could not be controlled at the initial operation. To improve overall survival the decision to perform a relaparotomy on demand after an initially successful eradication of the source of infection must be made within 48 hr, at least before MODS emerges.

Nonparasitic cysts of the liver (NPHC) are highly variable in respect to appearance and therapeutic approach. The treatment of these cysts varies according to the nature and appearance of the disease. Based on the variable nature of disease and the various therapeutic options, all of which were attempted in our patients, the most suitable mode of treatment for different forms of NPHC are discussed. Ninety-one patients with NPHC who had been treated surgically from 1977 through 1995 were examined retrospectively. Asymptomatic peripheral cysts measuring up to 10 cm do not require further treatment. Computed tomography (CT)-guided aspiration (n = 9) should be regarded as a palliative measure. Within a short period, CT-guided aspiration led to recurrence of symptoms in seven of our patients. Standard treatment of NPHC is fenestration with widest possible excision of the cystic wall, which can be performed laparoscopically (n = 10) or by the conventional surgical mode (n = 54). One patient was initially operated by the laparoscopic technique but developed bleeding, which necessitated conversion to the open mode. Three patients underwent synchronous laparoscopic cholecystectomy. Recurrence rates were similar: 11% in the laparoscopically treated group and 13% in the group that underwent conventional open surgery. Conventional surgical treatment was always successful in cases of solitary cysts. However, in cases of multiple cysts measuring more than 5 cm, conventional surgery was followed by recurrence of symptoms in 26% of patients (7/27), who then had to undergo a second operation. Partial resection of the liver (n = 9) was successfully performed in cases of polycystic disease (n = 5) with concomitant enlargement of the organ as well as in cases of large solitary cysts of the left lobe of the liver (n = 4). In patients in whom we found that the cysts communicated with the ductal system (n = 3), we performed a cystojejunostomy to drain the bile. The complication rate was low. In addition to frequent postoperative ascites, which necessitated no further intervention, we observed infectious complications in four patients. Twenty patients (22%) expired during a mean follow-up period of 6.2 years. Interestingly, deaths were frequently associated with malignancy (11/20). After fenestration of multiple cysts measuring > 5 cm, the patients are at high risk for recurrence. Hence partial resection of the liver is an excellent therapeutic alternative in selected patients with polycystic disease and massive enlargement of the organ in whom the disease could not be controlled by simple fenestration. The results of this study show that laparoscopic fenestration should replace the conventional surgical technique as the gold standard in cases of NPHC because the laparoscopic technique is less stressful for the patient and is associated with a rate of success similar to that of the conventional technique.

Hypothesis: Anastomotic leakage is the most important cost driver in patients who undergo low anterior resection (LAR) for rectal cancer. Creating defunctioning stomas to protect colorectal anastomoses may also have a major effect on the overall costs. Unselected creation of defunctioning stomas in most of these patients may be associated with higher overall costs compared with a program that has a low rate of defunctioning stomas and an acceptable anastomotic leakage rate. Design: Cost-effectiveness analysis. Setting: Secondary referral center. Patients: Performing a cost analysis from the viewpoint of a hospital provider, we reviewed data of 70 consecutive patients who underwent LARs with (n=19) or without (n=51) a defunctioning colostomy. A scenario analysis was performed using data derived from the medical literature to assess a plausible range of leakage and stoma rates. Main Outcome Measure: Costs per treatment option and incremental cost-effectiveness ratio according to various treatment scenarios. Results: Performing an LAR without a stoma and no anastomotic leakage is associated with significantly lowest costs

Limb-preserving resection of sarcoma of the lower extremity can be performed with satisfactory function of the limb maintained, even if it becomes necessary to resect the femoral vessels. Autologous venous graft for vascular reconstruction is the treatment of choice. In spite of the high incidence of metastases, considerable long-term survival is possible.

From 1986 to 1995 a total of 97 patients > 65 years of age underwent hepatic resections at the Department of General Surgery, Hospital Lainz, Vienna, Austria. The population consisted of 39 men and 58 women with a mean age of 74.0 +/- 5.5 years. Primary neoplasia of the liver was the cause of resection in 35 patients, gallbladder cancer in 16 patients, and metastatic disease to the liver (due to colorectal cancer in 70%) in 40 patients. The rate of major resections (> or = 3 liver segments) was 96% for primary neoplasia of the liver, 70% for metastatic disease to the liver, and 50% for gallbladder cancer; the associated mortality rates were 23%, 2.5%, and 25%, respectively. The magnitude of the resection had a significant influence on survival for gallbladder cancer (p = 0.02) and for primary neoplasia of the liver (p = 0.002) but not for metastatic disease to the liver. This reflects the high rate of cirrhosis in hepatocellular and cholangiocellular carcinoma (88%) and gallbladder cancer (37.5%). Both pre- and postoperative severe liver dysfunction had a significantly higher risk for postoperative mortality and morbidity, which showed an incremental risk with age. Another organ system able to predict outcome at the beginning of treatment by its moderate severe dysfunction were the lungs. Overall, only right and extended right lobectomies carried a significantly higher risk for postoperative mortality and morbidity. Postoperative complications were recorded in 43% of our patients, with infection the most frequent problem in nearly all of these patients (95%). Pneumonia was the leading complication associated patient survival. All patients who developed pneumonia as a late complication during a complicated postoperative course died postoperatively. The postoperative Goris score of the patients who died was 6.9 +/- 2.9 (range 3-11), whereas the surviving patients' score averaged 2.2 +/- 1.9 (range 0-9), which was significantly different (p = 0.0003). None of the 54 patients with a GORIS score < or = 2 died postoperatively, whereas 5 of 6 patients with a score > or = 9 died (p = 0.0001). Severe liver dysfunction rather than the extent of resection influences clinical mortality. Patients > 80 years of age with a preoperative severe liver dysfunction showed a postoperative mortality of 57%, and all of these patients developed postoperative complications. Therefore resection cannot be recommended for those patients. Cirrhosis led to an unacceptable mortality of 44% after hepatic resection of > or = 5 liver segments for primary neoplasia of the liver. Major resections cannot be recommended in the aged with gallbladder cancer because 50% of the patients died after such operations. Overall, only resection of > or = 5 liver segments with segments I to III or less remaining were found to pose a major risk for clinical mortality and morbidity, but the cause of death was preexisting liver dysfunction and cirrhosis in all of these patients. Major resections of large neoplasia of the liver can be recommended even in the aged, b...