Minimalinvasive Chirurgie primärer und sekundärer Lebertumoren

Background

Initially, mainly superficial liver lesions were resected laparoscopically but now even major resections are performed using a minimally invasive procedure. Careful selection of suitable patients is of key importance.

Aims and methods

This article describes the current state of the art in patient selection and choice of the appropriate laparoscopic technique based on a review of the recent literature. Perioperative and oncological outcome parameters of laparoscopic liver resection are presented.

Results

Laparoscopic liver resection offers significant benefits compared to open liver resection in terms of reduced intraoperative blood loss, reduced overall and liver-specific complications and length of hospital stay without compromising oncological outcomes.

Conclusion

Lesions in the peripheral anterolateral segments (segments 2, 3, 4b, 5 and 6) are particularly suitable for laparoscopic liver resection. Access to the posterosuperior segments 1, 4a, 7 and 8 is more challenging but safe and feasible in experienced centers.     

28. Primärer und sekundärer Hyperparathyreoidismus

Zusammenfassung Beim primären, autonomen Hyperparathyreoidismus führt die Parathormon (PTH)-Überproduktion zu Symptomen am Skelet und (infolge Hypercalciämie) an Nieren, intestinalen Organen, Zentralnervensystem u. a. Beim sekundären Hyperparathyreoidismus werden die Nebenschilddrüsen durch chronische Hypocalciämie (bei Niereninsuffizienz infolge Phosphatstau und Störung des Vitamin D-Stoffwechsels) stimuliert, Behandlungsbedürftigkeit ergibt sich bei Skeletschäden. Für die Diagnostik stehen Calcium-, PTH- u. a. blutchemische Bestimmungsmethoden zur Verfügung, sie werden ergänzt durch Röntgenologie und Knochenhistologie.Mit Unterstützung der Deutschen Forschungsgemeinschaft, SFB 87 Endokrinologie, Ulm     

Primärer Megaureter

A primary megaureter is an anomaly with a prevesical or overall dilated ureter of more than 6 mm in diameter. It is important to distinguish between cases of primary non-refluxing and primary obstructive-refluxing megaureters, as the treatment of both is completely different. The basic diagnostic work-up includes ultrasonography and voiding cystourethrography. Diuretic renography is used to detect split renal function and the degree of upper urinary tract obstruction. In most cases of primary non-refluxing megaureter surgical treatment is unnecessary due to the high remission rate, whereas obstructive refluxing megaureters commonly only need to be corrected. Antibiotic prophylaxis may be indicated in infants with a primary obstructive megaureter during the first 6 months of life due to a higher risk of complications due to pyelonephritis especially in this age group.     

Primärer Hyperparathyreoidismus

Introduction

Normocalcemic hyperparathyrinemia, i.e. elevated parathyroid hormone (PTH) levels after parathyroidectomy in patients with primary hyperparathyroidism (pHPT) may occur in the course of postoperative recovery without the development of persistence or relapse.

Materials, methods and results

Intraoperative and long-term (7 year) postoperative PTH and calcium levels after curative parathyroidectomy are demonstrated on the basis of a case report of a 62-year-old female patient with severe pHPT and pronounced osseous and renal manifestations. The intraoperative PTH gradient displayed a decrease from 1072 pg/ml to 13 pg/ml (normal range 11–67 pg/ml) followed by an increase of up to 287pg/ml. The hyperparathyoid values decline to subnormal levels on administration of calcium and vitamin D and increase again after tapering these medications. The inverse calcium/PTH correlation in the course of the 7-year observation period suggests an intact feed-back mechanism. Preoperative PTH screening was performed in 316 consecutive normocalcemic thyroid patients to evaluate the rate of incidental hyperparathyroidism in patients with normal serum calcium levels. Of these patients 31 (9.8%) with normocalcemia (average 2.28 mmol/l, normal range 2.1–2.7 mmol/l) exhibited increased PTH levels averaging 84.2 pg/ml. A parathyroid adenoma was found intraoperatively as the cause for normocalcemic pHPT in only 1 of these 31 patients.

Discussion and conclusions

A review of the literature revealed that late postoperative elevated parathyroid hormone levels after successful pHPT surgery occur in 21.5%. Multiple causes are discussed, e.g. reactive hyperparathyroidism in cases of relative hypocalcemia, hungry bone syndrome, vitamin D deficiency, renal dysfunction and ethnic or lifestyle differences. In mild cases of postoperative hyperparathyrinemia observation of the patient may be sufficient. In cases of reactive hyperparathyroidism due to hypocalcemia, administration of calcium is indicated, in symptomatic patients, additional administration of vitamin D or calcitriol is necessary. Vitamin D deficiency per se needs adequate substitution. In cases of ongoing hyperparathyrinemia an interdisciplinary diagnostic and therapeutic approach is required.     

Qualitätssicherung interdisziplinärer Polytraumaversorgung

BACKGROUND: The purpose of this study was to evaluate the quality of interdisciplinary multiple trauma management using routinely taken data. METHODS: A retrospective analysis of all multiple traumatized patients [Injury Severity Score (ISS)>15] in a university hospital (n=172; time period 01.01.1997-31.12.1999) was carried out concerning epidemiological and clinical variables and hospital outcome (p<0.05). RESULTS: The overall mortality was 22% [n=38; expected Trauma Injury Severity Score (TRISS) mortality 29%]. Significant parameters for worse outcome in univariate analysis were age>74 years, hypotension, decreasing hemoglobin level and prothrombin time, decreased Glasgow Coma Scale and the number of erythrocyte or plasma concentrates received in the initial period of treatment. The comparison of our results with the data of the German Association for Trauma Surgery registry demonstrated comparable results with respect to management sequence and outcome. CONCLUSIONS: In the quality management of multiple trauma patients retrospective analysis of routinely registered parameters can be a reliable and practical alternative to time-consuming prospective studies when based on prognostic relevant data. Such a procedure allows a preliminary critical comparison with other centers.     

Primärer vesikoureteraler Reflux

The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy. The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible. Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.     

Nagelung metaphysärer Frakturen

Nailing of metaphyseal fractures demands thorough preoperative planning. The trauma surgeon has to take the specific morphology of the fracture, the individual anatomy of the broken bone, and the design and characteristics of the selected implant into consideration. The fracture has to be precisely reduced and the reduction controlled during nail insertion. The reduction technique and reduction aids must be chosen preoperatively. The nail has to be introduced with care and brought to its correct and ideal position. Only after successful proximal and distal interlocking can the nail become the central weight bearing implant, which holds the fracture stable and reduced. In the following contribution, the specific problems of reduction and nail fixation of metaphyseal fractures of the proximal humerus, proximal and distal femur, and proximal and distal tibia together with the needed reduction and fixation aids are presented.     

Versorgung pertrochantärer Femurfrakturen

Background

The primary aim of surgery for pertrochanteric fractures of the femur is to regain preoperative mobility as quickly as possible. The aim of this study was to investigate whether clinical or radiological differences could be found between proximal femoral nails (PFN) and trochanteric gamma nails (TGN), with particular attention given to technical differences in implantation and early complications.

Patients and methods

This prospective study included 114 patients with PFN or TGN. Their average age was 78.9 years. Clinical and radiological examinations were evaluated over a 24-month period.

Results

The implantation time for PFN was 20 min less than for TGN in patients with 31A1 (AO) fractures, and 78.5% of all operations were complication-free. Problems occurred in 10 cases (seven PFN, three TGN) during nail insertion and were, in the case of TGN, all caused by fragment dislocation. Postoperative dislocation of the implant was observed in 12 cases [eight PFN (7%), four TGN (3.5%)]. Cut-out occurred in four cases with PFN implants, one of which was attributed to z-effect, and in two cases with TGN. Secondary varus deviation without cut-out occurred in one case with TGN and two cases with PFN. No significant differences in complication rates could be found between the two implants (p>0.05).

Conclusions

PFN are better suited to 31A1 fractures because of their higher rotational stability from the use of dual screws. A short femur and high antecurvation can cause insertion problems in PFN because of the nail design. It is advisable to choose the type of implant during preoperative planning after considering fracture type and patient anatomy.     

Revision unikondylärer Knieprothesen

Despite the good midterm survivorship reported for unicondylar knee arthroplasty, an increase in revision surgery has to be expected due to increased replacement rates. The reasons for failure as well as distribution are different for unicondylar knee arthroplasty compared to total knee arthroplasty. The main reasons for revision are aseptic loosening and the progression of osteoarthritis. In most cases, unicondylar knee arthroplasty will be revised to total knee arthroplasty. To obtain good revision results, the cause of implant failure has to be analysed carefully. In the case of contained bone defects, the reconstruction can be supported with bone grafting. For those cases with uncontained defects, implants with augmentation and, in some cases, stem extensions are needed. The modularity of the revision implant should cover different intraoperative requirements.     

Oberarmkorrekturosteotomie bei einem Patienten mit McCune-Albright-Syndrom unter perivaskulärer axillärer Plexusanästhesie nach Weber

Zusammenfassung Bei einem 20-jährigen Patienten mit McCune-Albright-Syndrom und respiratorischer Globalinsuffizienz mit Dauermaskenbeatmung musste eine Intubationsnarkose vermieden werden. Zur operativen Korrektur einer schwergradigen Oberarmfehlstellung erfolgte eine perivaskuläre axilläre Plexusanästhesie nach Weber. Mit der Lagerung des Patienten auf die nichtbetroffene Seite und Kopftieflagerung von 15° (modifizierte Lagerungstechnik) konnte eine Ausbreitung der Analgesie bis auf die Oberarmregion erreicht werden.     

Behandlungsoptimierung fortgeschrittener testikulärer Keimzelltumoren

Testicular germ cell cancer represents the most frequent solid neoplasm in young men aged 20–40 years. Depending on the prognosis according to the IGCCCG classification, the treatment of choice for advanced germ cell tumors consists in three to four cycles of bleomycin, etoposide, and cisplatin (BEP) in accordance with the current European Consensus Guidelines. Although residual tumor resection (RTR) adheres to guidelines as the treatment for residual metastatic lesions, numerous questions remain unresolved, which we intend to systematically answer within the scope of our research group by conducting prospective/retrospective and clinical/molecular investigations in cooperation with national and international project groups.     

Botulinumtoxin-A-Injektion bei therapierefraktärer Giggle-Inkontinenz

A 20-year-old woman reported about giggle incontinence despite antimuscarinic therapy. Therefore we injected botulinum toxin A into the detrusor muscle. The effect of botulinum toxin A appeared about 1 week after injection and no more leakage was observed even during vigorous laughter. A control uroflowmetry showed a good voiding rate without any residual volume. Botulinum toxin A might be an alternative for patients with giggle incontinence after unsuccessful antimuscarinic treatment.     

Stadienspezifische Therapie testikulärer Keimzelltumoren

Testicular germ cell tumours (GCT) represent the most common solid neoplasm of young men aged 20–40 years with an increasing incidence in Western countries during the last 50 years. It is mandatory for all physicians involved in the primary care of testis cancer patients to adhere to the guidelines of stage-specific treatment in order not to impair the high cure rate of about 90% and to prevent long-term toxicities due to inadequate therapy. Risk-adapted therapeutic options in stage I seminoma include active surveillance, retroperitoneal radiation therapy (RT) with 20 Gy or carboplatinum monotherapy depending on the presence of the risk factors tumour size > 4 cm and rete testis invasion. Retroperitoneal RT represents the standard therapeutic approach in stage IIA seminoma, whereas RT and PEB chemotherapy are alternative treatment options in stage IIB tumours. Primary chemotherapy with 3–4 cycles PEB according to the IGCCCG criteria is the treatment of choice in metastatic seminomas ≥ stage IIC. In clinical stage I NSGCT active surveillance is the treatment of choice in low-risk patients, and primary chemotherapy with 1–2 cycles PEB is the preferred treatment for high-risk patients. Treatment of metastatic GCT is performed with 3–4 cycles PEB chemotherapy and postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) in cases of residual disease according to the IGCCCG risk classification. PC-RPLND is best performed in experienced centres due to the complex nature of surgery and the necessity for adjunctive surgery in 25% of the patients. PC-RPLND, primary treatment of patients with intermediate and poor prognosis and salvage therapy should be performed in tertiary referral centres only.     

Osteosynthese dislozierter intraartikulärer Kalkaneusfrakturen

Objective

Anatomic reduction of displaced intra-articular calcaneal fractures with restoration of height, length, and axial alignment and reconstruction of the subtalar and calcaneocuboid joints.

Indications

Displaced intra-articular calcaneal fractures with incongruity of the posterior facet of the subtalar joint, loss of height, and axial malalignment.

Contraindications

High perioperative risk, soft tissue infection, advanced peripheral arterial disease (stage III), neurogenic osteoarthropathy, poor patient compliance (e. g., substance abuse).

Surgical technique

Extended lateral approach with the patient placed on the uninjured side. Reduction of the anatomic shape and joint surfaces according to the preoperative CT-based planning. Reduction of the medial wall and step-wise reconstruction of the posterior facet from medial to lateral. Reduction of the tuberosity and anterior process fragments to the posterior joint block and temporary fixation with Kirschner wires. Internal fixation with an anatomic lateral plate in a locking or nonlocking mode. Alternatively less invasive internal fixation with a calcaneus nail over a sinus tarsi approach for less severe fracture types.

Postoperative management

The lower leg is immobilized in a brace until the wound is healed. Range of motion exercises of the ankle and subtalar joints are initiated on the second postoperative day. Patients are mobilized in their own shoe with partial weight bearing of 20 kg for 6–12 weeks depending on fracture severity and bone quality.

Results

Over a 4-year period, 163 patients with 184 displaced, intra-articular calcaneal fractures were treated with a lateral plate via an extended approach. In all, 102 patients with 116 fractures were followed for a mean of 8 years. A surgical revision was necessary in 4 cases (3.4?%) of postoperative hematoma, 2 (1.7?%) superficial and 5 (4.3?%) deep infections. Of the latter, 2 patients needed a free flap for definite wound coverage, no calcanectomy or amputation was needed. Secondary subtalar fusion for symptomatic posttraumatic arthritis was performed in 9 cases (7.8?%). At follow-up, the AOFAS Ankle/Hindfoot Score averaged 70.2, the Zwipp Score averaged 76.0, the German versions of the Foot Function Index and SF-36 physical component averaged 32.8 and 42.2, respectively. Scores were significantly lower with increasing fracture severity according to the Sanders and Zwipp classifications, bilateral fractures, open fractures, and with work-related injuries. With less invasive fixation using a calcaneal nail, superficial wound edge necrosis was seen in 2 of 75 cases (2.7%).     

Palliative therapie primärer Lebertumoren

Zusammenfassung Primäre Lebertumoren sind in Europa und Nordamerika selten. Ihre einzige kurative Therapiemöglichkeit ist die Resektion. Da aber nor 20–30% der Tumore reseziert werden konnen, muß der große Rest palliativ behandelt werden. In einer retrospektiven Analyse wurden 68 Patienten mit einem hepatozellulären oder cholangiozellulären Karzinom, die seit 1983 an unserer Klinik behandelt wurden, untersucht. 14 Patienten konnten reseziert werden. Bei 28 Patienten führten wir eine Chemoembolisation und bei 26 Patienten eine intraarterielle Chemotherapie der Leber durch. Nach der UICC-Klassifikation bestanden keine Unterschiede zwischen den beiden palliativen Gruppen, aber bei den resezierten Patienten überwogen die niedrigen Stadien. Die Chemoembolisation erfolgte mit einem Gemisch aus Ethibloc, Mitomycin, Adriamycin und Cisplatin. Die intraarterielle Chemotherapie wurde bis 1987 mit Mitomycin und 5-FU und seitdem mit Adriamycin und Cisplatin durchgeführt. Die mediane Überlebenszeit für das Gesamtkollektiv betrug 8 Monate, fur die Chemoembolisation 6,5 Monate, fur die intraarterielle Chemotherapie 6 Monate und für die Resektion 17 Monate. Ein signifikanter Unterschied fand sich zwischen Patienten im Tumorstadium II und Tumorstadium III und IV. Im Vergleich mit den natürlichen Überlebenszeiten konnte in unserem Krankengut keine Verbesserung durch eine palliative Therapie nachgewiesen werden.

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In Europe and North America, primary liver tumors are rare. Resection is the only means of cure, but is possible in only 20–30% of the patients affected, so that in all other patients, i.e. the vast majority, only palliative treatment is possible. In a retrospective analysis we investigated the 68 patients we had treated for hepatocellular or cholangiocellular carcinoma of the liver. In 14 patients resection was possible, while 28 patients were treated by chemoembolization and 26 by intraarterial regional chemotherapy to the liver. There was no difference in tumor stage between the two groups receiving different palliative treatments. The patients in whom resection was performed, in contrast, mostly had less advanced tumors. For chemoembolization we used a mixture of Ethibloc, mitomycin, Adriamycin and cisplatin. Up to 1986, the intraarterial chemotherapy was performed with mitomycin and 5-FU. Since 1986 we have used Adriamycin and cisplatin. The overall median survival time was 8 months: after resection 17 months, after chemoembolization 6.5 months, and after intraarterial chemotherapy 6.5 months. There was a significant difference in survival between patients with tumor stage II and those with tumor stages III and IV. On comparing the survival time achieved with our treatments and that ensuing in the natural course of patients with liver tumor we found no improvement.

     

Minimal-invasive Implantation unikondylärer Prothesen

Knee arthroplasty has become one of the most successful standard procedures in orthopaedic surgery. With a more frequent use in young and active patients bone-saving procedures have become more important. The goal is to save good bone stock for the revision procedure. Therefore, unicompartmental knee arthroplasty is a good example. Instrumentation and minimally invasive surgical techniques have been improved so very good long-term results and early functional results are achieved. The paper describes the surgical technique with true capsule incision and extramedullary alignment technique.In a prospective study, the early functional results with the ZUK implant were excellent. The implant may not be indicated for every knee situation and an exact differential indication and sound surgical technique are necessary. Its use, however, in cases with unicompartmental knee arthritis, contributes to excellent early rehabilitation and to maintaining autologous bone. Therefore, the minimally invasive unicompartmental knee arthroplasty is a sensible alternative to other options.     

Laserbehandlung bei nicht-parasitärer Chylurie

Nonparasitic chyluria is rare. Spontaneous remission occurs in 50% of patients. Conservative treatment includes diet with medium-chain triglycerides, lymphangiography, and the instillation of sclerosing solutions of silver nitrate. If conservative management fails, open or retroperitoneoscopic nephrolysis is the treatment of choice. We present a case of spontaneous recumbent nonparasitic chyluria from the left kidney treated twice by endoscopic application of neodymium-YAG laser. This is new to the literature. The chyluria disappeared for several months. The temporary cessation of chyle flow after local laser application should encourage further use of this treatment modality after failure of conservative treatment.