Unfallchirurgie—Chancen,Herausforderungen und Risiken in der Zukunft aus Sicht des niedergelassenen Chirurgen

There is a future for trauma surgery outside the hospital environment in a modern healthcare system, despite attempts to bring political influence to bear. The shorter periods of subsequent bed rest with the introduction of the diagnosis-related groups (DRG) has made the work of surgeons in private practice increasingly significant. Competent treatment outside the hospital is what patients want, and it saves on costs (lowest effective care level; LECL). Performance of surgical operations outside the hospital setting will become increasingly significant for patients in all age groups. New methods of diagnosis and treatment must be subjected to more rigorous testing. In this context a high level of importance attaches to evidence-based medicine. The performance of surgery outside hospitals must be given greater emphasis in professional training courses, and specialising in such operations must be a real professional option. The authors take a critical look at the increasing pressure to reduce costs and fees. The model proposed by the employers' liability insurance association is one possible solution.     

Standortbestimmung und Fortentwicklung der Heilverfahren aus der Sicht der Unfallversicherungsträger und aus ärztlicher Sicht

The new contract that came into force since 1 May 2001 between doctors and accident insurance companies brought several important innovations with it that affect the implementation of treatments accepted for remuneration by the employers’ accident insurance associations. Complementing the newly formed and intensified contractual conditions for “D-Arzt” and “H-Arzt” doctors and for hospitals approved for different sorts of injuries, particular mention is made of the newly regulated duties of assignment and the modified regulations concerning the further treatment of seriously traumatized patients after their primary treatment in the approved hospitals. New projects that are intended to improve hand surgery and occupational injuries with psychic damage are also presented as important. As a way of looking into future applications of imaging techniques that will prepare the way for more quality in the treatment with rational use of the available financial resources, attention is drawn to the conclusions of a consensus conference on “Imaging Techniques in Trauma Surgery” and questions concerned with the preparation of core spin tomograms are discussed in detail.     

Chirurgie im Alter aus Sicht der Krankenkassen

The increasing proportion of elderly persons presents one of the most urgent problems to European societies and has a decisive effect on social insurance systems. Costs are rising rapidly due to longer life and the falling number of births. Health care is especially hard-hit because of medical progress and growing numbers of procedures during old age. Despite these problems, the German health care system is still effective. In contrast to neighboring European states, there are neither waiting lists nor rationing of services. With respect to financing, future developments cannot be predicted. Planning scenarios taking enormously higher costs into account often result in demands for rationing, which the German health insurance companies do not accept. This study examines economic figures from the largest German health insurer and attempts to draw a picture of future health care for old people. New possibilities for prevention and resourcing and the need for rationing are discussed. The first, promising projects in these respects have already been started, with the aim of better health and quality of life for the elderly.     

Organisationsformen im Heilverfahren aus Sicht der BG-Administration

The legally required accident insurance institutions are required by the Code of Social Law (SGB) VII to take all steps needed to ensure appropriate treatment and, if required, special trauma. The standard to be applied is treatment “by all appropriate means”. The insurance institutions determine these in the individual case after due consideration of the circumstances, with reference to the type, extent and implementation of the treatment and to the units that can supply it. They also test what benefits are appropriate and reasonable. All they do must be subject to this legally prescribed standard. The accident insurance is now entitled to approve or use any organisational forms except those that comply with this standard.     

Standortbestimmung und Fortentwicklung der Heilverfahren aus der Sicht der Unfallversicherungsträger und aus ärztlicher Sicht

Trauma und Berufskrankheit - Der seit 1.5.2001 geltende neue Vertrag Ärzte-Unfallversicherungsträger brachte einige, die Durchführung der berufsgenossenschaftlichen Heilverfahren...     

Traumanetzwerk aus Sicht der Leitstellen und Rettungsorganisationen

The demands of a regional control centre and its related rescue organizations on a trauma network, as well as the experience gained since establishing such an organization in the Hannover area, are presented here. There are approximately 170,000 deployments per year in this field, of which some 95,000 are emergency rescue deployments (i.e., 260 emergencies/day). The incident-management system at the control centre is divided into: (1) Emergency call and query centre, (2) report-based decision-making, (4) alerting and dispatching rescue services, (4) supervision of rescue services, (5) receiving and protocoling feedback, (6) locating “free beds” and, where relevant, clinic registration of patients, (7) recording patient data and relieving rescue services. In the absence of a trauma network, clinic registration is often a time-consuming problem requiring considerable resources. The situation is significantly improved when a clinic, with an emergency hotline manned by a trained doctor, is connected to a trauma network. The trauma centre in Hannover has proved its value from the perspective of the rescue control centre and the rescue organizations. It is important to mention that these groups were already involved at the planning stage of the network and had their requirements taken into consideration.     

Traumanetzwerk aus Sicht der Leitstellen und Rettungsorganisationen

Posttraumatic axis deviations and pseudarthroses are frequent complications following femur fractures. In addition to varus/valgus and ante/recurvation deformities, rotational changes and length deviations may occur. Combined axis deviations are particularly frequent after comminuted diaphyseal fractures. In the context of corrective osteotomy, both internal and external osteosynthetic methods are available. Osteotomy by means of oscillating saw and osteosynthesis by means of angled blades plates are still considered“classic techniques” in the proximal and distal femur; intramedullary nail fixation is more commonly used in the diaphyseal region. Regardless of the method or implant chosen, such multi-dimensional corrections are often very demanding surgical procedures. In contrast to many of the internal methods, external osteosynthetic procedures offer the potential to extend an extremity, as well as other postoperative corrective possibilities. It must be borne in mind, however, that these can lead to extended treatments times and complications, such as pin track infections.     

Der epidurale Blut-Patch – Goldstandard in der Therapie postpunktioneller Kopfschmerzen und originäre Aufgabe der geburtshilflichen Anästhesie

Die Anaesthesiologie -     

Diagnostik und Definition der Nahtinsuffizienz aus chirurgischer Sicht

The leak rates of different gastrointestinal anastomoses vary considerably but despite this there are common and general concepts for diagnosis and management. Early diagnosis and timely consistent therapy must guide management to prevent harm to the patients. Diagnosis of anastomotic leaks is coupled to clinical signs of the patients and should be initiated promptly. Dependent on the localization of the leak, computed tomography with administration of oral or rectal contrast dye and endoscopy are of high diagnostic value. Both procedures guarantee the option of drainage or stenting through interventional drains or stent placement. Only the implementation of uniform definitions of anastomotic leaks enables surgeons to compare and to improve surgical treatment. Over recent years consensus definitions of postoperative complications including bile leak, pancreatic fistula and colorectal leak have been formulated. These definitions are based on a 3-fold increase of bilirubin (bile leak) or amylase levels (pancreatic fistula) in abdominal drainage fluid compared to serum levels or on an intestinal wall defect with communication of the intraluminal and extraluminal compartments (colorectal anastomosis). The definitions each describe three severity grades A?CC. A change of clinical management is required in grade B whereas grade C usually requires a re-operation. Comparable consensus definitions for anastomotic leaks following esophagogastrostomy or esophagojejunostomy or following small bowel anastomosis have not been established. The authors strongly recommend implementation of the presented consensus definitions into clinical and academic daily practice.     

210. Arbeitsteilung und Verantwortung aus der Sicht der Chirurgie

Zusammenfassung Der Sinn der Arbeitsteilung liegt darin, dem Arzt den notwendigen Freiraum für die Erfüllung seiner spezifischen Aufgaben zu verschaffen. Gefahrenquellen beruhen in: Mängeln der Qualifikation, der Kommunikation, der Koordination, der Organisation und der Einschätzung des eigenen Könnens. Die medizinischen und juristischen Probleme bewegen sich auf den Ebenen: leitender Arzt und ärztliche Mitarbeiter, Fachärzte verschiedener Gebiete, niedergelassener Arzt und Krankenhausarzt, Arzt und medizinische Assistenzberufe. Arbeitsteilung verheißt zugleich Erfolg und Gefahr, sie entläßt niemanden aus der Verantwortung.     

Diagnostik und Definition der Nahtinsuffizienz aus radiologischer Sicht

Anastomotic leakage is a typical complication in gastrointestinal surgery. The frequency of occurrence and symptoms depend on the location of the intervention in the gastrointestinal tract. Consensus definitions have been published for bile leakage, pancreatic fistulas and colorectal leakage but there is still no overall standard classification for anastomotic leakage after surgical intervention in the gastrointestinal tract. Hence, there are also no standard guidelines for a diagnostic algorithm. Radiological techniques for the diagnosis of an anastomotic leakage include sonography, X-ray, fluoroscopy and computed tomography (CT). Percutaneous transhepatic cholangiography (PTC) could be helpful for the diagnosis of a leakage of a biliary enteric anastomosis. Magnetic resonance imaging (MRI) plays a subordinate role in the diagnosis of anastomotic leakage.     

Benigne und maligne Neoplasien der Nebenniere aus der Sicht der Pathologie

Die Chirurgie - Bei bildgebend und klinisch unklaren Neoplasien der Nebenniere fallen die Indikationsstellung zur Operation, aber auch die nachfolgende Klärung von Entität und...     

Organisationsformen der Notfallmedizin aus Sicht der DGCH und des BDC

Due to logistic, organizational and economic advantages, interdisciplinary emergency centers are gaining more and more acceptance compared to established, discipline-specific and independent emergency rooms. Organizational concepts for interdisciplinary emergency centers need to consider the mandate for comprehensive patient care and the consequential performance spectrum. Thus, the implementation of generally accepted guidelines and specifications is demanding. Currently developed concepts of the accordant interdisciplinary working groups try to fulfill these premises. Further fundamental criteria to be met are the quality and education of medical and nursing staff, which are predominantly doing their jobs within the interdisciplinary emergency centers. The concept of the German surgical societies and connected organizations is not the implementation of a new definition of the role of emergency specialized physicians but rather a substantial advancement of the existing and established regulations for further education. Therefore, a further advanced-training program for clinical emergency medicine has to be implemented in addition to the existing emergency education within the common trunk, which every physician has to pass through during discipline-specific education. Furthermore, this program should complement the existing pre-clinical emergency education, which can be acquired after specialization. The accordant criteria to be developed and the coordination with the German Medical Association (Bundes?rztekammer) are currently prioritized on the agenda of the interdisciplinary working group. Due to reasons of compatibility with the regulations for further education, specific management skills for future heads and directors of such interdisciplinary emergency centers should not be stipulated within the advanced-training program for clinical emergency medicine but should be gained through specific course concepts beyond this program.     

Grundregeln und Problematik der Mamma-Reduktionsplastik aus der Sicht eigener Erfahrungen

Zusammenfassung Aus der Sicht eigener Erfahrungen bei mehr als 500 Brustplastiken, die nach verschiedenen Methoden operiert wurden, werden Ergebnisse analysiert, schlechte Resultate auf ihre Ursachen untersucht und typische Fehler aufgezeigt, die nicht die Folge bestimmter Methoden sind, sondern bei jedem Operationsverfahren das postoperative Ergebnis beeinträchtigen können. Eigene Gesichtspunkte in der Auswahl der Operationsmethode für die verschiedenen Formen der Deformitäten der weiblichen Brust werden dargelegt und auf einige für den Erfolg der Operation maßgebende Details wird hingewiesen.

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Basic rules and problems with reduction-mammaplasty in the light of personal experience

Summary During the past 20 years the writer has performed more than 500 reduction-mammaplasties, and various methods have been used. From this experience the conclusion is drawn that there is no single ideal method, and that good results can be obtained whether the operation is performed according to Biesenberger, Dufourmentel-Mouly, Pitanguy, Ragnell or Strömbeck.The proper performance of the essential details is more important than the type of reduction procedure used. Regarding the position of the nipple and areola, the common recommendation of a 16 to 18 cm distance between the sternal notch and the nipple in a standing patient, results in a position which is too high and which can hardly be corrected postoperatively (Fig. 1); it should be abandoned. Instead, a distance of 22 to 24 cm, depending on the size of the patient and the weight of the breasts, is appropriate. The distance between the areola and the submammary fold should not exceed 7 cm postoperatively.To prevent tension in the vertical scars, preliminary mattress-sutures are used before the resection of the skin. The use of the curved McIndoe-forceps is not recommended, because it may lead to disappointing results.If the position of the areola is correct and tension of the skin is prevented, a slight asymmetry of the form and size of the breasts at the end of the operation disappears by itself in the first few months, and bulging of the lower part of the breast (Figs. 2 and 3) will occur less frequently. An overlarge and deformed areola, which is mainly produced by tension-sutures, gives an aesthetically bad result. Therefore the areola should have a diameter of only 4 cm and it should be sutured without any tension.With the advent of Strömbeck's method, the free nipple-transplantation procedure has become only rarely necessary (Figs. 4–7). The scars and the shape of the breast after Strömbeck's operation make this method unsatisfactory in other than very large mammary hypertrophies.In mild or moderate hypertrophies the technique described by Dufourmentel and Mouly has been preferred more recently. Special care is taken for the proper positioning of the nipple, which tends to lie too far medially with this method (Figs. 8 and 9). The lateral incision has to be completed as an L-shaped one (Figs. 10–12), if the resection of the parenchyma exceeds more than 250 gr. In any case, the vertical incision should end 2 to 3 cm above the submammary fold, because otherwise the L-shaped scar would come too far down.

     

96. Humanitas im Krankenhaus —aus der Sicht des Seelsorgers

Ohne Zusammenfassung     

3. Antisepsis und Asepsis aus der Sicht des Chirurgen

Zusammenfassung Die Gefährlichkeit der verschiedenen Infektionsquellen und der verschiedenen Übertragungswege ist unterschiedlich. Infektübertragung durch die Hand des Personals ist häufig, Luftinfektionen sind selten. Schulung des Personals in aseptischem Verhalten ist wirksam, Verringerung des Luftkeimgehaltes ist von geringerer Bedeutung. Strenge und Ausmaß der notwendigen aseptischen Maßnahmen richten sich nach der Operationsart. Antiseptische Lösung als Ersatz für Lokal-Antibiotica gewinnt bei offenen Wunden wieder größere Bedeutung. Ein Optimum an Asepsis kann nur in einer pragmatischen Zusammenarbeit zwischen Kliniker und Krankenhaushygieniker erreicht werden.     

Qualitätssicherung und Management von Handverletzungen aus der Sicht der Verwaltung

Meticulous monitoring and control of the treatment offers patients injured in accidents the best conditions for healing and leads to cost reductions in terms of compensation for injury, vocational aid measures and pensions. The accident and emergency hospital maintained by the employers’ liability insurance association in Hamburg is currently conducting a project entitled “Hand Injuries” in collaboration with the professional association for health services and welfare’s Hamburg regional office, which is aimed at realizing and documenting this aim.