Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK)

BACKGROUND AND AIMS

Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime.

METHODS

A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting.

RESULTS

Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided.

CONCLUSION

Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis

Objective

Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods

The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results

Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions

The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Diagnostic and treatment options for skin and soft tissue abscesses in injecting drug users with consideration of the natural history and concomitant risk factors

OBJECTIVE

Skin and soft tissue abscesses are common findings in injecting drug users (IDUs) who present to the surgical emergency department for evaluation and treatment. Although most cases can be managed by incision and drainage, they do require special considerations as compared to abscesses which are not caused by intravenous drug abuse.

METHODS

Skin and soft tissue abscesses treated in the emergency department between 2005 and 2007 were reviewed and a systematic literature search of skin and soft tissue abscesses in IDUs was conducted, including the etiology, occurrence, risk factors, and treatment options, thus providing the rationale for the treatment algorithm presented herein.

RESULTS

The drugs injected, the technique by which they were injected, the attendant circumstances, as well as the immunological status of the IDUs were major factors for the development of abscesses. Skin and soft tissue abscesses in IDUs should be incised and drained under local or general anesthesia depending on the size, location, and association with neurovascular structures. Different factors have been taken into account when treating soft tissue abscesses in this population which predict their specific risks and therefore further therapy needs. The incidence of tetanus is high among IDUs compared to the general population, giving rise to the recommendation for a strict booster policy if the vaccination status is unclear when the patient presents to the emergency department. The presence of fever requires hospitalisation and evaluation for the presence of endocarditis. Foreign bodies, such as broken needles, should be ruled out by radiography, and duplex sonography should be performed to identify the presence of vascular complications. Prior to incision and drainage, prophylactic antimicrobial agents should be administered to every patient and as therapy for high-risk patients, such as immunocompromised patients and patients with fevers and chills.

CONCLUSIONS

IDUs presenting with skin and soft tissue abscesses can be managed safely if some special issues are taken in account. The presented algorithm may help facilitate the decision-making in this context.

Natural history and surgical treatment of brown tumor lesions at various sites in refractory primary hyperparathyroidism

OBJECTIVE

Nowadays, the occurrence of brown tumor lesions or osteitis fibrosa cystica caused by long-lasting primary hyperparathyroidism are very rare, since measuring serum calcium became available routinely in the mid-1970s. It is a tumor-like lesion that may affect the entire skeleton, often presenting with diffuse focal bone pain or by pathological fracture.

METHODS

We describe our experience of brown tumor lesions at different skeletal sites that were treated at our trauma centre within the last two years. This included surgical therapy for the indications (i) pain at the pelvis, (ii) increased risk for pathological fracture at the tibia and (iii) acute radicular symptoms at the lumbar spine. The literature was reviewed for the current understanding of the pathophysiology as well as therapy of brown tumor lesions in primary hyperparathyroidism.

RESULTS

Curettage of a left-sided iliac crest brown tumor terminated focal pain. A less invasive stabilisation system and bone cement decreased both patient pain and the fracture risk of brown tumor lesion sites of the shinbone; and internal fixator including laminectomy at the lumbar spine ended radicular symptoms.

CONCLUSION

Patients with refractory primary hyperparathyroidism should be monitored closely by endocrinologists and the patient's serum calcium level should be adjusted as far as possible. Radiography is required only if focal bone pain or pathological fractures or radicular symptoms occur. Surgery should be considered if large bone defects with spontaneous fracture risk or increasing pain are present. Tumor curettage, Palacos plombage and less invasive stabilisation systems have proved to be acceptable surgical options.

[Intraoperative monitoring of intact parathyroid hormone during surgery for primary hyperparathyroidism]

The aim of the present study was to evaluate a new immunometric assay for intraoperative parathyroid hormone monitoring. The test was applied in 70 patients who underwent surgery for primary hyperthyroidism (pHPT) between 6/1999 and 6/2001. Among these patients, 61 showed a solitary adenoma, eight a hyperplasia and one a double adenoma. Intraoperative iPTH samples were taken at the beginning of the operation and 5, 10 and 15 min after removal of the parathyroid gland. Criterion for a successful operation were a decrease of iPTH levels of more than 50 % within 5 min and of more than 60 % within 15 min after parathyroidectomy. Following the removal of a solitary adenoma, iPTH levels decreased by 63 % (+/- 13 %) after 5 min and by 76 % (+/- 10 %) after 15 min respectively. In case of hyperplasia, a significant decrease of iPTH levels was not observed until a subtotal parathyroidectomy had been carried out. In the present study there were 2 false negative and one false positive results corresponding with a sensitivity of 97 % and a specificity of 89 % for prediction of a solitary adenoma. In our opinion, intraoperative iPTH monitoring using this new assay allows the safe distinction between adenoma and multiglandular disease. It represents a valuable adjunct to surgical skill as it permits minimally invasive operations for solitary adenomas, and in case of recurrent surgery helps to detect the region of interest by selective venous sampling for parathyroid hormone.

[Laparoscopic adrenalectomy with lateral approach--a comparison with the conventional dorsal technique]

OBJECTIVES

Minimal invasive techniques are gaining more and more acceptance in adrenal gland surgery. In a matched case control study laparoscopic transabdominal adrenalectomy in the lateral position (LA) was compared to the conventional open dorsal technique (DA) with resection of the 11th or 12th rib.

METHODS

Between July 1998 and March 2000, 26 LA in 24 patients (two bilateral) were prospectively documented and compared to 25 DA in 23 matched patients (two bilateral), who had been operated on between January 1995 and June 1998. Indications for adrenalectomy in all patients were benign adrenal lesions < 6 cm.

RESULTS

Age, gender, average tumor size (3.5 cm/3.6 cm) and tumor types (Conn adenoma: 10/7; Cushing: 8/7, including 2 bilateral in each group; pheochromocytoma: 3/6, incidentaloma: 2/2; others: 3/3) were distributed in both groups (LA/DA) without statistical differences. However, statistically significant differences (P < 0.05) were present (LA vs DA) comparing intraoperative blood loss (200 vs 360 ml), postoperative narcotic equivalents (1.1 vs 6.2), morbidity (8 vs 30%), and length of hospital stay (5.5 vs 9 days). Average operating time was significantly longer in LA (130 vs 105 min), but decreased during the last LA cases to the DA level. One LA had to be converted to open surgery due to diffuse bleeding. Following LA we observed two minor complications (small retroperitoneal hematoma, nerve irritation below the 12th rib); following DA there were 6 minor (2 dorsal subcutaneous hematomas, 2 nerve irritations, dystelectasis, pleural effusion) and one major complication (wound infection).

CONCLUSION

LA represents a safe procedure with all the common advantages of minimal access surgery. Based on our experience and that of others, laparoscopic adrenalectomy has become the gold standard for adrenalectomy in most cases of benign adrenal disease. As adrenal surgery is rare, at present LA should be restricted to centers with a special interest in endocrine and laparoscopic surgery.

[Duodenosigmoidal fistula in a patient with Crohn's disease]

The development of enteral fistulas - internal and external - is common in Crohn's disease with a frequency of about 45 % in large series of patients. Most internal fistulas arise in the small bowel, but internal large bowel fistulas occur in about one fourth of all patients with fistulas in Crohn's disease. Colonic gastroduodenal fistulas do occur, but are very rare. Of the 35 cases of colonic-duodenal fistulas that we found in the literature, most have been described to involve either a previous ileocolostomy site or the ascending or transverse colon. There are only three cases displaying sigmoidoduodenal fistulas. To these we add a fourth case with this report. A 42-year-old woman presented with upper abdominal pain, loss of appetite and regurgitations with a foul smell as well as abdominal gas complaints. A duodenosigmoidal fistula was diagnosed by local application of contrast and the fistula tract was excised in typical fashion by resection of the colonic fistula and primary closure of the duodenum. The patient experienced a good recovery with relief of symptoms.

[Intraoperative monitoring of intact parathyroid hormone (iPTH) in surgery of primary hyperparathyroidism with a new rapid test]

OBJECTIVES

Intraoperative differentiation between adenoma and hyperplasia during surgery for primary hyperparathyroidism (pHPT) is sometimes difficult, but essential for good results. The aim of our study was to evaluate a new highly sensitive electrochemiluminescence immunoassay (ECLIA) for intraoperative monitoring of intact parathyroid hormone (iPTH) following parathyroidectomy as an adjunct for identification of solitary adenoma in patients with pHPT.

METHODS

Thirty consecutive patients with pHPT (2 with recurrent pHPT) were examined following a standardized protocol: Immediately before and 5, 10 and 15 min following parathyroidectomy of the enlarged gland, iPTH was measured with a new ECLIA (Roche-Diagnostics, Mannheim, Germany). The results were available within 15-20 min. Besides 20 conventional bilateral neck explorations, parathyroidectomy was carried out in a minimally invasive video-assisted technique (MI-VAP) in 10 patients.

RESULTS

Among the 30 patients we found 24 with solitary adenoma (80%), 5 with hyperplasia (17%) and one with a double adenoma (3%). Five minutes after removal of a solitary adenoma the level of iPTH had decreased by 65 (12)% [mean (+/- SD)], after 10 min by 76 (8)% and after 15 min by 81 (8)%. All patients with multiple gland disease could be clearly identified, as iPTH after 15 min did not fall below 50% of basal value. Only after removal of all hyperplastic glands did iPTH decrease to the normal range. Sensitivity and specificity for prediction of a solitary adenoma were 92% and 100% (decline of iPTH more than 50% from baseline value 5 min after parathyroidectomy). In one patient with recurrent pHPT intraoperative sampling from different sites in both internal jugular veins could predict the quadrant of the enlarged gland. Correlation (r) between the results of the quick and the conventional assay, which requires 24 h of incubation, was 0.955. All patients had normal or low calcium levels postoperatively.

CONCLUSIONS

(1) Intraoperative monitoring of iPTH with this new quick assay allows safe identification of patients with solitary adenoma during surgery for pHPT. (2) It represents a valuable adjunct to surgical skill not only in primary operations for pHPT but especially in cases of recurrent surgery for pHPT. (3) With this test available minimally invasive techniques for parathyroidectomy may be employed in cases of preoperatively localized adenoma (ultrasound, sesta-mibi scan), avoiding bilateral neck exploration with its higher potential for complications.

[The use of an underlay polypropylene mesh in complicated incisional hernias: sucessful French surgical technique]

BACKGROUND

Incisional hernia repair with conventional techniques is associated with high recurrence rates of 30-50%. Surgical repair using different prosthetic biomaterials is becoming increasingly popular. On the basis of the favourable results by French surgeons, the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias have been studied.

METHODS

After preparation and excision of the entire hernia sac, the peritoneum and posterior rectus sheath are closed with a continuous looped polyglyconate suture. The prosthesis used for the midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. Between January 1997 and September 1998 a total of 57 incisional hernia repair (25 primary hernias, 32 recurrent hernias) have been performed using this technique (28 women, 29 men, mean age 56+/-13 years).

RESULTS

Local complications occurred in 6 patients (11%). One patient suddenly died on the 3rd postoperative day from severe pulmonary embolism (mortality 1,7%). Thirthy-seven patients with a minimum follow-up of 6 months were reexamined clinically (follow up time 6-33 months). Till now one recurrent hernia has been observed. There were only minor complaints like a feeling of tension in the abdominal wall (n = 3) and slight pain under physical stress (n = 9).

CONCLUSIONS

The aforementioned technique of underlay prosthetic repair allows an anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates especially in high risk patients and complicated hernias.

Laparoscopic loop colostomy for advanced ovarian cancer, rectal cancer, and rectovaginal fistulas

OBJECTIVES

The objectives of this study were to present a minimal invasive technique of intestinal diversion for selected cases of advanced inoperable ovarian cancer, rectal cancer, and rectovaginal fistulas, and to discuss indications, pitfalls, and potential complications.

METHODS

The technical features of laparoscopic colostomy are described.

RESULTS

Between August 1995 and July 1997 laparoscopic colostomy was successfully carried out in 12 patients with advanced ovarian cancer, inoperable carcinoma of the rectum, or rectovaginal fistulas. There were no intraoperative or postoperative complications and postoperative recovery was rapid, with all patients having function of the colostomy within 24 h and regaining their preoperative state of mobility on the second postoperative day.

CONCLUSION

The laparoscopic approach allows careful selection of the colostomy site and easy mobilization of the colon, causing only little disruption to intestinal function and, hence, improving postoperative recovery. From our experience, laparoscopic colostomy is in most cases a simple and safe operation and can be used as the preferred technique of intestinal diversion.

[Open and laparoscopic liver resection with a new ultrasound scalpel]

We report on our experience with a new ultrasonically activated scalpel that has been developed for laparoscopic surgery. It works by means of a longitudinally vibrating blade or scissors and can be used for tissue dissection, coagulation and preparation. The high-frequency vibration causes denaturation of protein and thus allows coagulation of small vessels up to 2-3 mm. The most important advantages compared to electrocautery are very limited heat generation, no production of smoke and the lack of current flow through the patient. Because of this, the ultrasonically activated scalpell is an excellent instrument for different types of laparoscopic surgery, as well as for open liver resection.

[Recurrent abdominal colic, myalgia and mononeuritis multiplex]

The case of a 30-year-old male, who presented with a three months history of fever, night sweats, weight loss and myalgia is reported. Subsequently abdominal cramps, bloody diarrhea and mononeuropathy multiplex developed. An abdominal and renal angiogram showed changes of vascular structures diagnostic for polyarteritis nodosa. An immunosuppressive treatment (Prednisolon 100 mg/day and Cyclophosphamid 200 mg/day) was started. However, diffuse peritonitis as the aftermath of bowel infarction, which comprised the total length of the jejunum and the proximal parts of the ileum, developed at the third week of this treatment. Despite immediate surgical resection of the ischemic bowel septic complications occurred and the patient died.

[Bone regeneration stimulated by bone substitute materials]

Prompted by severe problems in autogeneic and allogeneic bone transplantation, intensive efforts were made to find sufficient substitutes. A main demand on these materials, especially in healing of osseous defects, is to achieve results comparable to those of auto- or allografts. These must be related to their biomechanical and particularly to their biological properties, i.e. the ability to form new bone, osseous integration and physiological remodeling. Within different trials in the tibiae of sheep we investigated bone substitutes like hydroxyapatite ceramics (HA) or partially demineralized bone matrix (pDBM) and compared them to the gold standards of autogeneic and allogeneic bone transplantation. Therefore we used two different models: the drill hole model with small size defects of 6 mm in diameter and the shaft defect model as a true-to-life defect with a 5 cm large diaphyseal defect. Evaluation was done by X-rays, histology, microradiography, fluorescent microscopy and morphometry of the small size defects. HA showed only small effects on new bone formation and works merely as an osteoconductor. However, excellent new bone formation was regularly achieved by pDBM in the small defects, whereas it was limited in the large size defects. But considering their mechanism of action, it is possible to bridge large bone defects by pDBM.

[Management of large abdominal wall hernias with foreign implant materials (Gore-Tex patch)]

OBJECTIVE

Incisional hernia repair with conventional techniques (simple closure, Mayo) is associated with high recurrence rates in the range of 30-50%. Surgical repair using different prosthetic biomaterials gains more and more acceptance. Therefore we wanted to evaluate our own results of hernia repair and analyze the results of a mesh hernioplasty using an expanded polytetrafluoroethylene patch (ePTFE).

PATIENTS AND METHODS

1. During the study period (1984-1992) a total of 205 hernia repairs (148 primary repairs, 57 repairs for recurrent hernia) were done in 173 patients at our institution using the following techniques: Mayo technique n = 90, simple one layer suture n = 56, absorbable mesh n = 25, ePTFE n = 17, other mesh techniques n = 17. In a retrospective study 135 of these patients (78%) could be examined clinically. The average follow up time was 44 months (10-105). 2. Since 1988 we used the ePTFE patch (Gore-tex Soft Tissue Patch) in selected cases for incisional hernia repair. In a second retrospective analysis the course of 26 patients, who were operated between 1988 and 1994, is reported.

RESULTS

1. Local wound complications occurred in 3-6% with conventional techniques and in 11-13% after different types of mesh repair (n.s.). Overall recurrence rates were 30% for primary hernia repair and 38% for recurrent hernia repair without statistically different rates for the various techniques. The presence of two or more patient dependent risk factors (obesity, obstructive lung disease etc.) (p < 0.05) and hernia diameter > 5 cm (p < 0.05) were identified as risk factors for hernia recurrency. 2. In the ePTFE group one patient (4%) developed a superficial wound complication, in another three patients (12%) the patch had to be removed due to deep wound infections. All three patients had revealed septic wound complications after previous surgery. The recurrence rates (17% for primary repair and 20% for repeated repair) were clearly lower compared to conventional techniques.

CONCLUSIONS

The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high risk patients (obesity, obstructive lung disease). Beside the most often used polypropylene mesh, the ePTFE patch (Gore-tex-Soft-Tissue-Patch) represents a valuable alternative in selected cases with direct contact of the prosthesis to abdominal viscera. Any previous septic wound complication or a contaminated operating field (e.g. colostomy) seems to be a contraindication for its use.

[Perioperative standards for prevention of anastomotic insufficiency]

Anastomotic leakage is a major cause of morbidity and mortality in gastrointestinal surgery. Its incidence varies in the different segments of the GI tract being highest in the distal rectum. The rate of anastomotic leakages was reduced considerably within the last 20 years. Perioperative measures have contributed to this reduction in addition to improvements and standardization in operative technique. Perioperative nutrition, perioperative antibiotic prophylaxis and mechanical bowel preparation are widely used in colorectal surgery. Therefore they can be considered as standards. High-caloric parenteral feeding is used commonly perioperative. Its efficiency to reduce postoperative septic complications has been proven until now only for malnourished patients. The aim of perioperative antibiotic prophylaxis is to reduce the bacterial count after intraoperative contamination. Therefore tissue levels must be in the therapeutic range to cover for the expected bacteria. The efficiency to reduce postoperative wound infection has been proven, however the influence on the rate of anastomotic leakages is still controversial. Mechanical bowel preparation can reduce the bowel load but not bacterial concentration inside the bowel. Orthograde lavage with polyethylenglycol solution is feasible unless bowel obstruction is present, but its influence on anastomotic healing is still under discussion. Although all of these procedures are widely used, their influence on anastomotic healing has still to be proven by prospective, controlled trials.

[Lymphangioleiomyomatosis--a rare disease of the lymphatic system]

Lymphangioleiomyomatosis is a rare disease with proliferation of smooth muscle cells within the lymphatics, mediastinal and retroperitoneal lymph nodes and in the lungs. The clinical symptoms are increasing dyspnea, chylous effusion, intestinal obstruction and thoracic or abdominal pain. The authors report the case of a 42-year-old woman who primarily suffered from thoracic pain, dyspnea and chylous effusion. In further examinations we discovered a leftsided retroperitoneal tumor and a tumor in the mesentery. The diagnostic difficulties experienced are described and the necessity of explorative laparotomy for definite diagnosis is demonstrated. Furthermore, the article provides a review of the latest developments in pathology, diagnostics and therapy.

[Diagnostic problems in acute appendicitis and indications for laparoscopic appendectomy]

A retrospective study analyzing the outcome of 400 appendectomies for acute appendicitis in two different hospitals revealed a negative appendectomy rate of over 25%. As a consequence we altered the operative strategy by employing diagnostic laparoscopy in combination with laparoscopic appendectomy in all uncertain cases while still carrying out a conventional appendectomy when there was diagnostic certainty. Preliminary results show that laparoscopic appendectomy is a safe procedure and that the new concept reduces the negative appendectomy rate.

Perioperative management in thoracic surgery

The quality of perioperative treatment for patients undergoing thoracic surgery is of the utmost importance for postoperative morbidity and mortality. Hence, it was the purpose of this study to examine various aspects of our own procedure. The clinical course following 812 successive thoracotomies in 792 patients over a period of 3 years was documented and analysed. The overall complication rate was found to be 19.7%, with a mortality of 3.8% over a 30-day period. Secretostasis, atelectasis and pneumonia were the most common complications. Owing to the predeposition of autologous blood, the percentage of patients requiring allogeneic blood transfusion was reduced from 27% to 9%. There was no evidence suggesting an increase in the complication rate or a longer stay in hospital. Perioperative antibiotic prophylaxis has reduced postoperative wound infection significantly. Similar reductions in the FEV1 are recorded following thoracic surgery, irrespective of the amount of lung tissue resected. This observation indicates that the remaining lung tissue is severely compromised throughout the postoperative period and that the surgical trauma alone is a major factor influencing postoperative pulmonary function for at least 2 weeks.

[Differed autologous blood transfusion and its effects during pulmonary lobectomy]

The aim of our study was to determine the value of preoperative autologous blood donation and its importance with regard to pulmonary lobectomies. Over the course of three years and a total number of 220 operations, autologous blood was preoperatively deposited in 74 cases. 21 patients did not meet the criteria for autologous blood donation and were excluded from the study. It was found that only 6.8% of the patients who had donated autologous blood required a homologous blood transfusion versus 27.2% in the non-donor group. This would imply, that the necessity for homologous blood transfusion is reduced by approximately 75% in patients depositing autologous blood prior to surgery. While we observed similar haemoglobin levels in both groups at admission, it was found that autologous blood donors went into surgery with an Hb 1.5 g% lower than non donors; the levels however adjusted themselves immediately postoperatively. No increased complication rate was found as a result of preoperative autologous blood donation. The data indicate that only 30% of patients undergoing pulmonary lobectomy require homologous blood transfusions. 80% of these patients could benefit from preoperative autologous blood donation. For 70% of all patients the procedure would be of no benefit. Bearing in mind the immunosuppressive effect of homologous blood transfusions, which may result in a higher rate of tumor recurrence, we find preoperative autologous blood donation a justifiable procedure even under these circumstances. It would however be beneficial if studies were conducted to investigate to what extent similar results could be achieved by preoperative acute isovolemic hemodilution.

[Perioperative preventive use of antibiotics in thoracic surgery--results of a controlled randomized study with optocillin]

There seems to be general agreement that antibiotic prophylaxis should be provided for patients undergoing resections of the lung. In order to obtain further information about the extent of resection beyond which this is necessary, and also to establish the type of prophylaxis that is meaningful over the long term, we carried out a controlled study involving two groups of 100 patients each. In the first group, who received minor resections, ultrashort-term prophylaxis was compared with an 0 group. We were able to show that in high-risk patients with prior pulmonary diseases, prophylaxis is indeed meaningful. In the second group of patients undergoing major resections, antibiotic prophylaxis must be provided; a one-day administration suffices, and long-term administration fails to offer any further advantages.

[Perioperative management of thoracic surgery patients]

Immediate postoperative extubation of patients submitted to chest surgery is possible in almost all cases. The intensive care unit responsible for these patients should have good facilities for bronchoscopy, and the indication for this procedure should be made, postoperatively, on a broad basis. The introduction of peri-operative antibiotic prophylaxis has led to a substantial decline in disturbances of wound healing. Due to the use of autologous blood transfusion, the need for homologous blood transfusions has been reduced significantly.

[Osteoid induction]

Osteoinduction is a biological principle. The implantation of tissue with inductive properties results in the proliferation and differentiation of undifferentiated cells to cartilage and bone. This process, which is similar to a cascade-type mechanism, is controlled by a series of humoral and local growth factors. It was possible to isolate a number of macromolecular substances with osteoinductive, mitogenic, or chemotactic properties specifically from the extracellular bone matrix. A deeper understanding of the regulative mechanisms as well as the greater availability of growth factors may lead to new therapeutic approaches in bone surgery.