Hinrich Böhner

Predicting Delirium After Vascular Surgery: A Model Based on Pre- and Intraoperative Data

Objective The aim of the study was to determine pre- and intraoperative risk factors for the development of postoperative delirium among patients undergoing aortic, carotid, and peripheral vascular surgery to predict the risk for postoperative delirium. Summary Background Data Although postoperative delirium after vascular surgery is a frequent complication and is associated with the need for more inpatient hospital care and longer length of hospital stay, little is known about risk factors for delirium in patients undergoing vascular surgery. Methods Pre-, intra-, and postoperative data were prospectively collected, including the first 7 postoperative days with daily follow-up by a surgeon and a psychiatrist of 153 patients undergoing elective vascular surgery. Delirium (Diagnostic and statistical Manual of Mental Disorders IV) was diagnosed by the psychiatrist. Multivariate linear logistic regression and a cross validation analysis were performed to find a set of parameters to predict postoperative delirium. Results Sixty patients (39.2%) developed postoperative delirium. The best set of predictors included the absence of supraaortic occlusive disease and hypercholesterinemia, history of a major amputation, age over 65 years, a body size of less than 170 cm, preoperative psychiatric parameters and intraoperative parameters correlated to increased blood loss. The combination of these parameters allows the estimation of an individual patients’ risk for postoperative delirium already at the end of vascular surgery with an overall accuracy of 69.9%. Conclusions Postoperative delirium after vascular surgery is a frequent complication. A model based on pre- and intraoperative somatic and psychiatric risk factors allows prediction of the patients risk for developing postoperative delirium.

Risk factors for postoperative delirium in vascular surgery.

The aim of this study was to identify psychiatric and somatic risk factors associated with the development, severity and duration of postoperative delirium after vascular surgery. Forty-seven patients underwent aortic, carotid artery and peripheral artery surgery. Both, surgeon and psychiatrist, monitored patients preoperatively with daily follow up. Preoperative psychiatric assessment included standardized psychopathological scales for the detection of psychiatric symptoms and cognitive deficits. We diagnosed delirium using DSM IV criteria. Delirium Rating Scale was used to estimate delirium severity. Surgical parameters included patient history, diagnoses, medication and laboratory parameters. A statistical analysis was performed using multivariate regression analyses to find factors significantly associated with delirium development, severity, and duration. Thirty-six percent of the patients developed postoperative delirium after surgery. Comparison of different parameters revealed that especially preoperative depression symptoms and perioperative transfusions/infusions had significant predictive value for the development as well as for the severity of postoperative delirium.

Ultrasonography for Diagnosis of Acute Appendicitis: Results of a Prospective Multicenter Trial

A prospective multicenter observational trial was performed to assess the performance and clinical benefit of ultrasonography of the appendix in the routine clinical examination. Included in the study were 2280 patients with acute abdominal pain from 11 surgical departments in Germany and Austria. Ultrasonography of the appendix was performed in 870 (38%) of the patients (range 16-85%). The overall sensitivity of ultrasonography of the appendix was 55% (13-90%), the specificity 95% (range 82-100%), positive predictive value 81% (50-100%), and negative predictive value 85% (68-96%). With respect to single ultrasound scan findings, adequate sensitivity (44%) was achieved only with the target phenomen, not with the other criteria. There were no correlations between the ultrasound findings of the appendix and the diagnostic accuracy of the clinician, the negative appendectomy rate, or the perforated appendix rate. From the study it can be concluded that there is no proven clinical benefit of ultrasound scanning of the appendix in the routine clinical diagnosis.

Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain

OBJECTIVE To assess the value of plain abdominal radiographs and of data from the medical history and physical examination in the diagnosis of acute abdominal pain in general and of bowel obstruction in particular. DESIGN Prospective study. SETTING 4 university and 2 community hospitals, Germany. SUBJECTS 1254 patients with acute abdominal pain lasting less than 7 days, and with no history of abdominal injury including surgery. INTERVENTIONS Standardised and structured medical history and physical examination, study of results of plain abdominal radiographs. MAIN OUTCOME MEASURES Positive predictive value and sensitivity of clinical variables and abdominal film with respect to the diagnosis at discharge. RESULTS 48 patients (3.8%) had bowel obstruction. 704 patients (56.1%) had plain abdominal films taken at the time of initial presentation. 111 studies (15.8%) showed important findings leading to diagnosis or immediate treatment, 455 (64.7%) showed unimportant or no findings. In 138 (19.6%) results of films were not reported. 16 of 45 single variables were of help in diagnosing bowel obstruction. The six with the highest sensitivity were distended abdomen, increased bowel sounds, history of constipation, previous abdominal surgery, age over 50, and vomiting. If only patients presenting with any two of these symptoms had had radiographs taken, 300 (42.6%) could have been avoided without loss in diagnostic accuracy. CONCLUSION A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction.

Primary malignant tumors of the aorta: clinical presentation, treatment, and course of different entities

OBJECTIVE The objective of this study was to analyze possible correlations between the clinical presentation and the course of patients with different types of primary malignant aortic tumors. METHODS A single academic centers experience was reviewed retrospectively. RESULTS Four patients with primary malignant tumors of the aorta were treated in an 11-year period. Three different histologic entities were found: malignant fibrous histiocytoma, epitheloid angiosarcoma, and unclassified sarcoma. Two female patients presenting with clinical symptoms of vasculitis proved to have epitheloid aortic sarcoma. Both developed diffuse metastasis to bone and skin with initial lymphatic disease in the groin. The other patients developed local recurrence and pulmonary metastasis. Survival of the 4 patients was 11, 20, and 51 months, 1 patient with metastatic disease is still alive 6 months after surgery. CONCLUSION Different types of malignant aortic tumors seem to have different clinical presentation and course.

A Left Nonrecurrent Inferior Laryngeal Nerve in a Patient with Right-Sided Aorta, Truncus Arteriosus Communis, and an Aberrant Left Innominate Artery

The identification and prevention of injury to the inferior laryngeal nerve is one of the main issues in thyroid surgery. Sound knowledge of anatomic variants of the nerve is of major importance. In rare cases the nerve does not run the recurrent way and it is therefore difficult to identify the nerve. Abnormal developments of the aortic arch during embryogenesis include malformation of the great vessels and can be the reason for anatomic abnormalities. A cause for a nonrecurrent nerve on the right side is the so-called lusorian artery, a right retroesophageal subclavian artery. Left-sided nonrecurrent nerves are seldom if ever documented. Only two cases have been published so far of patients with situs inversus viscerum, where left nonrecurrent nerves were associated with inverse, left-sided lusorian arteries.

Endoscopic ultrasound in routine clinical practice for staging adenocarcinomas of the stomach and distal esophagus

AbstractProblem. Endoscopic ultrasound (EUS) is an important diagnostic tool for determining the best therapeutic strategy (primary resection, neoadjuvant therapy or palliation only) to offer esophageal or gastric cancer patients. Patients and Methods. In the present study (1992–2001),we evaluated the accuracy of EUS in adenocarcinomas of the distal esophagus and stomach and compared our results with pathologists findings as the gold standard. Results. Of the 222 patients studied, the precise examination of 11% EUS was not completely possible due to severe tumor stenosis.The accuracy of EUS with respect to T, N+/− and TN+/− amounted to 51%, 65% and 34% in 131 patients with adenocarcinomas of the esophageal gastric junction and to 50%, 66% and 37% in 91 patients with adenocarcinomas located in the fundus, corpus or antrum of the stomach respectively.With respect to T-stage, the overstaging of tumors was more common than understaging, especially in pT2b-carcinomas. The subgroup analysis of the 131 EGJ adenocarcinoma patients showed that the results obtained by EUS were slightly better in type I (distal esophageal cancer) than in type II and III cardia carcinomas (proximal gastric cancer).When comparing two observation periods (1992–1996 and 1997–2001), the accuracy of endoscopic ultrasound staging was very similar in both periods for T-category (51% vs 49%) and N-category (63% vs 64%) as well as for combined TN-staging (36% vs 35%) respectively. Conclusions. In clinical routine examinations of adenocarcinomas of the stomach and the distal esophagus, the accuracy of EUS is not as good as the excellent results in the past – mostly obtained under study conditions – may suggest.ZusammenfassungProblem. EUS-Befunde beeinflussen bei Ösophagus- und Magenkarzinompatienten Therapiekonzepte (primäre Resektion, neoadjuvante Therapie,Palliation). Sind die guten – in Studien erzielten – Ergebnisse auf den klinischen Routinebetrieb übertragbar? Patienten und Methode. Wir evaluierten die Aussageverlässlichkeit der EUS hinsichtlich T, N und TN (Zeitraum: 1992–2001), indem diese Befunde mit denen der pathologisch-anatomischen Untersuchung, die als “gold standard” diente, verglichen wurden. Ergebnisse. Die Untersuchung schließt 222 nicht neoadjuvant vorbehandelte Patienten mit Adenokarzinomen des Magens und distalen Ösophagus ein.Bei 11% der Patienten blieb die Untersuchung bedingt durch nicht passierbare Stenosen unvollständig.Bei den 131 Patienten mit Karzinomen des ösophagogastralen Übergangs betrug die Richtigkeit der EUS für T,N+/− und TN+/− 51%,65% bzw.34% und für die 91 Patienten mit Magenkarzinomen im Fundus,Korpus und Antrum 50%,66% bzw. 37%.Die EUS wies beim T-Stadium,besonders bei pT2b-Tumoren,eine Tendenz zum “Overstaging” auf.Bei der Analyse der Kardiakarzinome waren die Ergebnisse beim Typ I (distales Ösophaguskarzinom) etwas besser als die beim Typ II und III (proximale Magenkarzinome).Es bestanden keine Unterschiede in der Häufigkeit der Übereinstimmung zwischen EUS und Pathologie beim Vergleich von Patienten in der ersten (1992–1996) und zweiten Hälfte (1997–2001) des Beobachtungszeitraums. Schlussfolgerung. Das präoperative endosonographische Staging maligner Tumoren im klinischen Routinebetrieb ist weniger zuverlässig, als es die guten – meist unter Studienbedingungen in der Vergangenheit ermittelten – Ergebnisse annehmen lassen.

Endosonographie in der klinischen Routine beim Adenokarzinom des distalen Ösophagus und Magens

AbstractProblem. Endoscopic ultrasound (EUS) is an important diagnostic tool for determining the best therapeutic strategy (primary resection, neoadjuvant therapy or palliation only) to offer esophageal or gastric cancer patients. Patients and Methods. In the present study (1992–2001),we evaluated the accuracy of EUS in adenocarcinomas of the distal esophagus and stomach and compared our results with pathologists findings as the gold standard. Results. Of the 222 patients studied, the precise examination of 11% EUS was not completely possible due to severe tumor stenosis.The accuracy of EUS with respect to T, N+/− and TN+/− amounted to 51%, 65% and 34% in 131 patients with adenocarcinomas of the esophageal gastric junction and to 50%, 66% and 37% in 91 patients with adenocarcinomas located in the fundus, corpus or antrum of the stomach respectively.With respect to T-stage, the overstaging of tumors was more common than understaging, especially in pT2b-carcinomas. The subgroup analysis of the 131 EGJ adenocarcinoma patients showed that the results obtained by EUS were slightly better in type I (distal esophageal cancer) than in type II and III cardia carcinomas (proximal gastric cancer).When comparing two observation periods (1992–1996 and 1997–2001), the accuracy of endoscopic ultrasound staging was very similar in both periods for T-category (51% vs 49%) and N-category (63% vs 64%) as well as for combined TN-staging (36% vs 35%) respectively. Conclusions. In clinical routine examinations of adenocarcinomas of the stomach and the distal esophagus, the accuracy of EUS is not as good as the excellent results in the past – mostly obtained under study conditions – may suggest.ZusammenfassungProblem. EUS-Befunde beeinflussen bei Ösophagus- und Magenkarzinompatienten Therapiekonzepte (primäre Resektion, neoadjuvante Therapie,Palliation). Sind die guten – in Studien erzielten – Ergebnisse auf den klinischen Routinebetrieb übertragbar? Patienten und Methode. Wir evaluierten die Aussageverlässlichkeit der EUS hinsichtlich T, N und TN (Zeitraum: 1992–2001), indem diese Befunde mit denen der pathologisch-anatomischen Untersuchung, die als “gold standard” diente, verglichen wurden. Ergebnisse. Die Untersuchung schließt 222 nicht neoadjuvant vorbehandelte Patienten mit Adenokarzinomen des Magens und distalen Ösophagus ein.Bei 11% der Patienten blieb die Untersuchung bedingt durch nicht passierbare Stenosen unvollständig.Bei den 131 Patienten mit Karzinomen des ösophagogastralen Übergangs betrug die Richtigkeit der EUS für T,N+/− und TN+/− 51%,65% bzw.34% und für die 91 Patienten mit Magenkarzinomen im Fundus,Korpus und Antrum 50%,66% bzw. 37%.Die EUS wies beim T-Stadium,besonders bei pT2b-Tumoren,eine Tendenz zum “Overstaging” auf.Bei der Analyse der Kardiakarzinome waren die Ergebnisse beim Typ I (distales Ösophaguskarzinom) etwas besser als die beim Typ II und III (proximale Magenkarzinome).Es bestanden keine Unterschiede in der Häufigkeit der Übereinstimmung zwischen EUS und Pathologie beim Vergleich von Patienten in der ersten (1992–1996) und zweiten Hälfte (1997–2001) des Beobachtungszeitraums. Schlussfolgerung. Das präoperative endosonographische Staging maligner Tumoren im klinischen Routinebetrieb ist weniger zuverlässig, als es die guten – meist unter Studienbedingungen in der Vergangenheit ermittelten – Ergebnisse annehmen lassen.

Rekonstruktion der aortoiliakalen Strombahn bei Patienten nach Nierentransplantation Strategien zur Vermeidung einer ischämischen Transplantatschädigung

AbstractIntroduction. The rising life expectancy of patients undergoing kidney transplantation and the improvement in the function rate of the allografts have led to an increasing number of patients suffering from arteriosclerosis-related diseases of the aortoiliac arteries. In these particular cases, an interruption of the blood supply of the allograft is always necessary for operative repair of the aortic and iliac arteries. This means a high risk of ischemic damage to the transplanted kidney. Patients and methods. Between 1987 and 2000, 1,076 kidney transplantations were performed in our department. During this time, 14 reconstructive operations of the aortoiliac arteries were performed in 12 patients (6 women, 6 men, average age 55.2 (45–71) years). Operations were indicated in patients suffering from occlusive disease with imminent extremity or allograft loss, and symptomatic or asymptomatic aneurysms with a maximum diameter of more than 4 cm. In patients presenting with thoracoabdominal (1) and abdominal aortic aneurysms (3), protection of the transplanted kidney was performed by axilloiliac or axillofemoral bypass. Hypothermic flush-perfusion of the allograft containing PGE1 and heparin was performed in seven of nine operations for occlusive disease. Results. None of the patients presented with a permanent decrease in kidney function, six patients showed temporary creatinine elevation, and in nine patients creatinine levels at discharge were lower than they were preoperatively. None of the patients died. Conclusion. Reviewing all reported methods of allograft protection, we recommend a three-step strategy including sequential clamp technique (ischemia < 30 min.), hypothermic flush-perfusion (ischemia ≤ 60 min.), and temporary axilloiliac/femoral shunt (ischemia >60 min), depending on the expected renal ischemia time.ZusammenfassungHintergrund. Die Versorgung aortaler und iliakaler Aneurysmen und Verschlusserkrankungen bei Nierentransplantierten ist mit einer Unterbrechung der Blutzufuhr zur transplantierten Niere verbunden. Hieraus erwächst die Gefahr einer ischämischen Nierenschädigung. Patienten und Methoden. Von 1987–2000 wurden in unserer Klinik 1.076 Nierentransplantationen durchgeführt. Dabei erfolgten 14 rekonstruktive Eingriffe an der aortoiliakalen Strombahn bei 12 Patienten. Die Operationsindikationen ergaben sich aus extremitäten- oder nierenbedrohenden Verschlusserkrankungen, symptomatischen und asymptomatischen Aneurysmen. Bei Patienten mit thorakoabdominalem und abdominalem Aortenaneurysma erfolgte die Ischämieprotektion der Transplantatniere durch extrakorporalen temporären axilloiliakalen bzw. -femoralen Bypass. Sieben von 9 Eingriffen bei Verschlusserkrankungen wurden mit einer hypothermen Flushperfusion der Transplantatniere unter Zusatz von PGE1 und Heparin durchgeführt. Ergebnisse. In keinem Fall kam es zu einer dauerhaften Verschlechterung der Nierenfunktion, 6 Patienten wiesen eine passagere Kreatininerhöhung auf, bei 9 Patienten lagen die Kreatininwerte bei Entlassung unter dem präoperativen Wert. Kein Patient verstarb. Schlussfolgerung. Unter Berücksichtigung aller bekannten Verfahren empfehlen wir ein dreistufiges Therapiekonzept der Transplantatnierenprotektion, das sequenzielle Klemmtechnik, hypotherme Flushperfusion und temporären axilloiliakalen/-femoralen Shunt in Abhängigkeit von der Art des Eingriffs und der damit verbundenen zu erwartenden renalen Ischämiezeit umfasst.

Delirium increases morbidity and length of stay after vascular surgery operations. Results of a prospective study

ZusammenfassungFragestellungZiel dieser Studie war es, den Einfluss postoperativer Delirien auf die postoperative Morbidität und die Liegedauer gefäßchirurgischer Patienten zu analysieren.Patienten und MethodenDie prospektive Studie umfasste 153 Patienten mit elektiven arteriellen Eingriffen (aortoiliakaler Eingriff, peripherer Bypass, Karotisrekonstruktion) Postoperativ wurden die Patienten täglich von Tag 1–7 psychiatrisch untersucht; ein Delir wurde nach standardisierten Kriterien der American Psychiatric Association (Diagnostic and Statistical Manual of Mental Disorders. Fourth edition, DSM IV) diagnostiziert. Die Schwere eines Delirs wurde nach der Delirium Rating Scale (DRS) quantifiziert. Verglichen wurden Patienten ohne Delir mit solchen mit postoperativem Delir mittels univarianter Analyse (t-Test, χ2-Test, Fisher-Test).Ergebnisse60 Patienten (39,2%) entwickelten ein postoperatives Delir. Patienten mit Delirien entfernten sich Katheter signifikant häufiger als Patienten ohne Delir, hatten häufiger katheterassoziierte Infektionen. Der Intensivaufenthalt war bei deliranten Patienten länger als bei nicht deliranten, so auch der postoperative Gesamtaufenthalt.SchlussfolgerungenPatienten mit postoperativen Delirien haben signifikant erhöhte Komplikationsraten sowie Liegedauern auf Intensiv- und Normalstationen.AbstractObjectiveWe intended to analyse the influence of postoperative delirium on postoperative morbidity and length of hospital stay.Patients and method153 patients undergoing elective arterial surgery were studied prospectively. Patients were examined postoperatively by a psychiatrist daily from days 1 to 7. Delirium was diagnosed according to standardised criteria (Diagnostic and Statistical Manual of Mental Disorders). The severity of delirium was quantified using the Delirium Rating Scale. We compared patients without delirium to those who developed postoperative delirium using univariate statistical analysis (t-test, χ2 test, and Fishers test).ResultsSixty patients (39.2%) developed postoperative delirium. They removed catheters significantly more frequently than patients without delirium and had more catheter-related infections. Their length of stay in intensive care units was higher, as was their total postoperative length of stay in hospital.ConclusionsPatients who develop postoperative delirium have significantly more complications and increased postoperative length of stay in hospital and intensive care units.