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We report a case of spinal epidural abscess formation after short-term epidural catheter placement for analgesia during labour and delivery. The patient was previously healthy and did not have any predisposing factors. Increasing back pain was the only complaint. A contrast-enhanced CT study on day 5 was inconclusive. Magnetic resonance imaging was performed and showed a large triangular-shaped abscess with adjacent inflammation of the paravertebral muscles. One day later, the patient developed a sensory deficit in the left lower limb. The neurological deficit completely resolved after surgical decompression and debridement, which was followed by antibiotic treatment.

Background: Since prolongation of survival by chemotherapy has been questioned, palliation balanced with an acceptable quality of life is the primary aim in treating patients with metastatic breast cancer. Patients and Methods: 224 patients from 11 centers were randomized to treatment with 40 mg/m2 of Adriamycin or with 40 mg/m2 of epirubicin or with 12 mg/m2 of mitoxantrone each in combination with 600 mg/m2 of cyclophosphamide every 3 weeks. A special monitoring system including follow-up until death guaranteed valid information on response criteria, survival and quality of life. Results: Treatment outcome was not statistically different between the three groups in terms of best response rate, response duration, time to progression or survival. There were, however, statistically significant differences between the three treatment groups in terms of toxicity and quality of life. Most important, treatment outcome was influenced by the following negative prognostic factors: disease-free interval less than 18 months; metastases at more than one organ site; performance status according to WHO > 1; prior adjuvant chemotherapy; age less than 40 years. Conclusions: This meticulously monitored prospectively randomized study shows that prognostic factors are more important than the chosen treatments for the outcome in metastatic breast cancer patients.

For prophylaxis of enterocele and of prolapse of the vagina following hysterectomy, the vaginal stump is fixed in at-risk patients to the sacro-uterine ligaments (known as McCall's suture) or to the sacro-spinal ligament (Amreich-Richter method). We report on the indications and results obtained in 101 sacro-spinal fixations and 211 McCall sutures in vaginal hysterectomy and 118 McCall sutures in abdominal hysterectomy. From 1975 to 1981 sacro-spinal fixation was only occasionally employed in prophylaxis of enterocele. After introduction of the McCall suture in 1982, the use of this method has been steadily increasing and has largely replaced sacrospinal fixation for prophylactic purposes. Nevertheless we are still using this often in cases of total prolapse, since in that situation, the fixation of the vaginal stump to the sacrouterine ligaments (in most cases weakly developed) is insufficient and does not offer enough support. Of a total of 350 McCall sutures performed to date, postrenal anuria occurred twice after kinking of the ureters, a typical complication that requires removal of the McCall suture. In a total of 174 sacro-spinal fixations of the vaginal stump for prophylactic or therapeutic indications, pronounced intraoperative haemorrhage took place in about 5% of the cases, whereas in one case, there was an abscess formation due to an infected haematoma. Technical details on both methods and on avoiding complications are discussed.

Two hundred and twenty-four patients with advanced breast cancer were enrolled in a multicenter prospective randomized clinical study and received either doxorubicin (40 mg/m²), or epirubicin (40 mg/m²) or mitoxantrone (12 mg/m2) each combined with cyclophosphamide (600 mg/m²) i.v. In the patient collective the following response rates were observed: complete response 12.1%; partial response 30.6%; stable disease 40.5%; progressive disease 16.8%. A complete response was observed significantly less often in patients where more than one organ site was involved as compared to those patients with only one metastatic site. The mean time period required to reach a best response was 3.7 months. There was no significant difference between the response rates in the three arms. In comparing the observed toxicities in 1,434 treatment cycles, there was a significant difference with regard to leukocytopenia (mitoxantrone arm exhibiting more than either epirubicin and doxorubicin) although infections did not occur more frequently in the mitoxantrone arm; with regard to alopecia, mitoxantrone and epirubicin arms both exhibited less than doxorubicin. It is noteworthy that no patient who had previously received adjuvant chemotherapy achieved a complete response (p = 0.006). The overall significance of these findings can only be clearly evaluated when survival times can be measured.

51 women asking for refertilization were evaluated by means of a half-standardized questionnaire before laparoscopy. Special attention was directed towards the psychological situation at the time of sterilisation as well as the reasons for refertilization desired. In addition the Giessen-test was performed as standardized psychological personality inventory. In general, the sterilization was initiated by the women because of social, financial or marital difficulties. In 2/3 of the females sterilization was performed in association with other gynecological or obstetrical procedures. Most of the women did not have any kind of adequate psychological or social counseling. The desire for refertilization was mainly caused by changes in the personal situation. 29 of 51 women reported to have a new partner, 27 of them after divorce or separation, two after the previous partner's death. Ten women reported the loss of a child, however, 12 women desired refertilization without any obvious change in their private situation. In conclusion, it appeared that refertilization was desired and experienced as a real need as well as a result of a conflict in the women's self-understanding expressed by a tendency towards depression.

All controlled studies which were available by computer search from the literature were evaluated regarding the efficiency of preventive antibiotics for post-operative infections following hysterectomies and Cesarian sections. All controlled studies were evaluated by identical criteria. In 41 out of 46 studies (89.1%) on vaginal hysterectomies, febrile morbidity showed a significant decrease. In abdominal hysterectomies, 15 of 26 studies (57.7%) and in Cesarian sections 47 of 53 studies (88.7%) showed a significant decrease. Following vaginal hysterectomies and Cesarian sections, the preventive antibiotics decreased the febrile morbidity by 26 or 26.9 percentage points and pelvic or uterine infections by about 20 percentage points. In abdominal hysterectomies, the decrease was only 10.4 or 4.4 percentage points. Cesarian sections after the onset of labour and or rupture of the membranes have a high risk of infection and show the best decrease of febrile morbidity following preventive antibiotics.

Worldwide, the incidence of nonruptured tubal pregnancy has increased, and so has the feasibility of conservative management of this condition. Following conservative surgery the rate of intrauterine pregnancy is significantly higher than after salpingectomy. The rate of ectopic pregnancy has not (or hardly) increased. For a surgeon skilled in this technique, the laparoscopic approach has advantages because it avoids laparotomy. For the time being, medical treatment of ectopic pregnancy with methotrexate, prostaglandins, and antiprogesterone should be confined to clinical studies. For nonviable, nonruptured tubal pregnancy with decreasing HCG titers expectant management seems possible; following conservative treatment, monitoring of HCG until it becomes undetectable is mandatory.