[Risk management to control increased and more costly malpractice suits]

Considerable increase of premium for risk-insurance demands now risk management (RM) in German hospitals. RM is more than quality management and has other goals. The method we are using to analyse the risk in hospitals is given in detail. By this way we cover the main groups of potential personal damage of patients and reasons and fundamentals to sue the hospital. There is no total quality management (TQM) in hospitals without RM in the medical field. RM can be successful only with the awareness of medical and nursing staff for risks and liability claims. In our experience there is a lot of potential damages and sources of liability demands even in hospitals which seem to be well managed.

[Splenectomy--a strictly aseptic intervention?]

To determine the factors causing wound infections after splenectomy, 211 patients undergoing surgery during 1982-1991 were studied in two groups:--Patients with clean-contaminated or contaminated operations with additional splenectomy in the same session;--Patients with elective splenectomy only. While in the first group the rate of disorders of wound healing (DWH) was 31.6%, the second group had a rate of 8.15%. This rate was higher than for other clean operations in our hospital and was as high as for clean-contaminated operations such as cholecystectomy. Among the patients older than 60 years, 38.2% had DWH, as against 8.9% of the patients younger than 60 years. The mean operating time in patients with wound infections was 223 min, while the mean operating time in patients without infections was 125 min. In patients with wound infections the gamma-GT was higher than in patients who had no infection. After these results we have given 2 g ceftriaxon as single-shot prophylaxis before every splenectomy. Since starting this, we have performed 28 splenectomies, and DWH has been observed in only 1 (3.57%). We therefore recommend antibiotic prophylaxis.

[Intra-abdominal cystic lymphangioma and mesenteric cysts as a cause of abdominal discomfort]

Although intra-abdominal lymphangioma and mesenteric cysts are rare benign tumours, they have to be considered in the differential diagnosis of abdominal pain. Differentiation of these lesions is important, because lymphangiomas may follow a proliferative and invasive course. From 1979 to 1993 four patients with intra-abdominal cystic lymphangiomas and two with mesenteric cysts underwent operations in our surgical department. Five of these six patients had abdominal symptoms, ranging from unspecific abdominal pain to acute clinical abdomen. In all cases surgical enucleation or resection and histological classification were necessary before final diagnosis was possible.

[Do abuse of nicotine and alcohol have an effect on the incidence of postoperative bacterial infections?]

In a prospective study we evaluated patients with the diagnosis of 1. groin hernia (n1 = 57), 2. gall bladder stones (n2 = 80) and 3. carcinoma of the colon (n3 = 76). The whole group included 213 patients who underwent clean, clean-contaminated or contaminated operations. All wound infections and post-operative bacterial infections like pneumonia or urinal infection were registered. The patients were asked for risk factors at the time of hospitalisation. 7.1% of all patients admitted an intake of alcohol of more than 60 g/day and 15.6% of the patients smoked more than 20 cigarettes a day. We found a four times higher risk to get a postoperative infection for patients with an intake of more than 60 g alcohol a day. The rate of infection for smokers of more than 20 cigarettes a day is two times higher than for non smokers or persons who smoke less than 20 cigarettes a day.

[Do nicotine and alcohol abuse effect the occurrence of postoperative bacterial infections?]

In a prospective study we evaluated patients with diagnoses of (1) inguinal hernia (n = 57), (2) gall bladder stones (n = 80), and (3) carcinoma of the colon (n = 76). The whole group included 213 patients who underwent clean, clean-contaminated or contaminated operations. All wound infections and postoperative bacterial infections such as pneumonia or urinary infection, were recorded. The patients were asked for risk factors at the time of hospitalization: 7.1% of all patients admitted an intake of alcohol of more than 60 g/day, and 15.6% of the patients smoked more than 20 cigarettes/day. We found a four times higher risk of postoperative infection for patients with an intake of more than 60 g alcohol/day. The rate of infection for smokers of more than 20 cigarettes/day is twice as high as for non-smokers or persons who smoke fewer than 20 cigarettes/day.

[What value does laboratory diagnosis have in acute abdomen?]

1. We found in a prospective study with routine laboratory tests: As a single test only amylase is of certain value, but there are 27% false positive results in peritonitis and intestinal obstruction. 2. Our standardized program can help to evaluate disturbed vital functions and so far improve pre- and postoperative treatment. 3. A high risk is given by simultanously alterated acid-base-balance, blood sugar and creatinine; but these findings are showing shock, not acute abdomen. 4. Laboratory procedures are of no help to the practitioner; they must not delay the early lifesaving operation.