Diagnose und Therapie des Frühstadiums der akuten Appendicitis

Ohne Zusammenfassung (Mit 9 Kurven.) Referat, erstattet am 3. Sitzungstage der Versammlung der Deutschen Gesellschaft für Chirurgie zu Berlin, April 1910.     

Therapie der akuten AC-Gelenk-Instabilität

Background

A variety of surgical procedure are desrcibed for the treatment of acute acromioclavicular (AC-) joint injuries. Beside open techniques arthroscopic assisted procedures spread widely. Each surgical technique offers advantages and disadvantages, but none is currently accepted as a gold standard. Therefore, the study aims to review the evidence for arthroscopic and open surgical procedures in the treatment of acute AC joint instabilities.

Material and methods

According to the Cochrane Handbook for Systematic Reviews of Interventions we conducted a defined search of Medline and Embase database for articles publisher over the last ten years.

Results

The search resulted in 961 studies of which 32 were included in this review and 3 studies were suitable for a meta-analysis. The functional outcome (Constant score) showed a tendency towards better results after arthroscopic procedures (weighted mean difference 5.60, 95?% confidence interval 0.36–10.64). There were no significant differences with respect to complication rates, secondary dislocation in the vertical plane, revision surgery and AC joint instability.

Conclusion

There is insufficient evidence to inform the surgical management of acute AC joint instability. Due to inconsistent study designs there is no evidence for a general superiority of any of the open or arthroscopic procedures. Randomized, controlled studies are necessary to demonstrate whether arthroscopic techniques show a potential benefit in terms of a better functional outcome.

     

Stellenwert der Sonographie in der Frühdiagnostik des Nierenzellkarzinoms

The importance of ultrasonography in early detection of renal cell carcinoma was analyzed for 1854 patients, who were operated from 1975 to 1997. The 5-year survival rate of all patients amounts to 75%, the 10- and 20-year survival rate was 68% and 64%. While from 1975 to 1986 tumor symptoms like hematuria (30%), abdominal pain (19%) and palpable mass (3%) lead to diagnosis of renal cell carcinoma in 56% of all cases, there were only 26% from 1987 to 1997. 83% of asymptomatical tumors from 1987 to 1997 were accidentally detected by means of ultrasonography in a kidney independent examination. These tumors are significantly smaller (5.5 cm) than the tumors of symptomatical patients (7.8 cm) and show often a significantly lower local tumor stage, a better tumor grade, frequently lymph nodes, which are free of tumor infiltration and more rarely distant metastasis. The 5-year survival rate of patients with incidental tumors, detected by ultrasonography (82%) was significantly better (log rank < 0.001) in comparison with the symptomatical patients (72%). These results verify 1. The effectivity of ultrasonography in early diagnosis of renal cell carcinoma and 2. The advantage of survival on patients with early tumor detection. That's why asymptomatic patients, who selected under risk factors should be examinated by ultrasonography consistently too.     

Medikamentöse Therapie der akuten Herzinsuffizienz

Background

The aim of treating acute heart failure is to reduce pulmonary and/or systemic congestion. Rapid diagnosis and initiation of treatment are important. Triggering causes should be sought as they offer additional specific treatment options.

Method

Research and analysis of the literature.

Results

Because acute heart failure is a heterogeneous syndrome, fine-tuning the treatment strategy according to the clinical profile is warranted. The current guidelines recommend primary treatment with oxygen for oxygenation, possibly supplemented by noninvasive ventilation, intravenous furosemide to reduce preload, and nitrates to reduce preload and afterload.

Conclusions

These measures achieve a substantial improvement of symptoms and clinical signs of heart failure in the majority of patients. Unfortunately, large clinical studies that show the best possible use of currently available drugs in order to also reduce hard clinical endpoints such as mortality and morbidity (rehospitalization) are lacking.     

Die Therapie der Blasenüberaktivität bei älteren und alten Menschen

Overactive bladder syndrome is a widespread disorder that leads to considerable impairment of quality of life. Besides behavioural therapy (bladder training), methods used in physiotherapy, electrotherapy and instrumental biofeedback have also proved to be successful approaches to treatment. With their good clinical and urodynamic efficacy, substances with antimuscarinic action at M3 receptors in particular and possibly also at M2 receptors have proved successful as first-line agents for the treatment of overactive bladder (OAB). Despite the frequently high level of suffering and severe impairment of quality of life, however, compliance is poor. Muscarine receptors do have a significant effect on detrusor function, but numerous other mechanisms and receptor entities also play a role. Whether patient acceptance can be significantly increased by the development of selective M-receptor antagonists, improved bladder selectivity or formulating innovations remains to be proven by broad-based clinical testing and independent, comparative, scientific studies. At present, it is not possible to estimate with absolute certainty the risk of an anticholinergic-induced deterioration in cognitive abilities, in particular in elderly individuals. Initial data suggest that primarily M3-selective receptor blockage with darifenacin could be beneficial.     

Wandlungen in der Therapie entzündlicher Erkrankungen der Bauchspeicheldrüse

Ohne ZusammenfassungMit 1 TextabbildungBericht über ein Jahr Therapie und Prophylaxe mit dem Kallikrein-und Trypsin-InaktivatorTrasylol (Bayer).     

Der Schlüsselbeinbruch in der Unfallversicherung

Ohne Zusammenfassung     

Wandlungen in der Therapie entzündlicher Erkrankungen der Bauchspeicheldrüse

Ohne Zusammenfassung     

Ergebnisqualität der Therapie des akuten Lungenversagens

Progress in intensive care (ICU) treatment of acute respiratory distress syndrome (ARDS) over the last 20 years includes the introduction of extracorporeal membrane oxygenation (ECMO) for CO₂ removal and the widespread use of evidence-based lung-protective ventilatory strategies. Little is known, however, about whether these changes have resulted in improvements in short-term and long-term outcome of acute respiratory distress syndrome (ARDS) within the two decades after introduction. In a retrospective study 167 long-term survivors of severe ARDS who were transferred to the clinic for anesthesiology of the University of Munich, Campus Großhadern by means of specialized intensive care unit (ICU) transport teams and treated over a period of 20 years (1985–2005) were evaluated to investigate whether significant improvements in outcome as a consequence of the above mentioned progress in ARDS therapy have occurred. The ARDS patient cohort studied was characterized with regard to demographic variables, initial acute physiology and chronic health evaluation (APACHE) II score, duration of ICU treatment, the duration of mechanical ventilation and mortality. Data on long-term outcome were collected in a subcohort (n?=?125) of patients who responded to mailed questionnaires and included health-related quality of life (HRQL, SF-36 questionnaire), symptoms of post-traumatic stress disorder (PTSD), traumatic memories from ICU treatment (PTSS-10 instrument) and current state of employment. During the observation period no significant changes regarding patient age (39?±?16 years, mean?±?SD), disease severity on admission to the ICU (APACHE II scores 22?±?5), duration of ICU treatment (47?±?39 days) or duration of mechanical ventilation (39?±?38 days) were found. Overall ICU mortality during the two decades was 37.3?% (range 25.0?%–38.1?%) between 1995 and 2001 and a non-significant increase in values between 36.8?% and 58.3?% during the time interval from 2002 und 2005. The p_aO₂/F_IO₂-ratio on ICU admittance improved significantly between 1990 and 2000 (69?±?5 between 1990 and 1994 versus 101?±?12 between 1995 and 2000, p?<?0.01) and remained nearly unchanged thereafter. Long-term outcome was evaluated on average 5.0?±?3.1 years after discharge from the ICU. During the time period between 1985 and 1994 survivors of ARDS showed significant impairments in all 8 categories of the SF-36 HRQL instrument when compared to an age and sex-matched normal population with maximal differences regarding physical function (z?=???1.01), general health perception (z?=???1.17) and mental health (z?=???1.3). Patients who were treated from 1995 to 2005 were still impaired in 7 out of 8 categories of HRQL but reported significantly better mental health (49.6?±?16.5 vs. 68.6?±?17.8, p?<?0,01) and better physical function than individuals from the previous decade (49.6?±?16.5 vs. 73.4?±?27.5, p?=?0,03). The difference of mental health was no longer significant when compared to a healthy age and sex matched control group (p?=?0.14) but the difference in physical function still was (z?=???0.48, p?<?0.01). The incidence of severe post-traumatic stress defined as a PTSS-10 score ≥?35 was 20.4?% and remained unchanged throughout the 2 decades of observation. The PTSS-10 scores correlated with the number of traumatic memories present (r?=?0.43, p?<?0.01, n?=?125). More than 50?% of long-term survivors were able to return to full time work with no significant changes during the 2 decades of observation. The introduction of new modalities of ARDS treatment were associated with higher p_aO₂/F_IO₂-ratios on ICU admittance but had no effect on short-term outcomes including duration of ICU therapy, mechanical ventilation or mortality. The ARDS patients are still at risk for post-traumatic stress and persistent impairments in HRQL. Apart from some improvements in HRQL, the outcome of ARDS therapy remained largely unchanged during two decades.     

Leitlinien zur Diagnostik und Therapie des akuten Herzinfarktes in der Prähospitalphase

Im Jahre 1996 hat die European Society of Cardiology Leitlinien zum Management des akuten Infarkts erstellt, die im Hinblick auf die Pr?hospitalphase im vorigen Jahr durch gemeinsame Empfehlungen der Europ?ische Gesellschaft für Kardiologie und des European Resuscitation Council erg?nzt wurden [32, 36]. Das in Deutschland bestehende, notarztbegleitete Rettungssystem besitzt ein besonderes Potential zur qualifizierten Frühbehandlung des Infarkts. Die begrenzten Ressourcen und die Praktikabilit?t der Methoden setzen der Versorgung im Pr?hospitalbereich jedoch auch klare Grenzen. Dies zusammen unterstreicht die Notwendigkeit von Leitlinien für diesen aus quantitativer Sicht bedeutenden Schwerpunkt der Notfallmedizin. Anstatt “Myokardinfarkt” wird in der Leitlinie gelegentlich der Begriff “akutes Koronarsyndrom” verwendet. Er umfasst neben dem akuten Infarkt auch die schwere bzw. instabile Angina pectoris ohne Infarkt.     

Stellenwert der Stammzelltherapie für die Behandlung der Belastungsinkontinenz

Parallel to a fundamental change in the therapeutic approach to managing stress incontinence, an increasing number of patients ask for reconstruction of the outer, striated urethral sphincter as therapy for urinary stress incontinence. Regenerative medicine is starting to offer solutions using stem cells as a part of oncological therapy or in reconstructive surgery. In addition to the many auspicious experimental approaches, one published study reports the effective therapeutic use of myogenic stem cells in urinary stress incontinent patients. Before this procedure is adopted into general clinical practice, further studies with validated evaluations and a sound legal basis are needed.     

Diagnose, Therapie und Sekundärprophylaxe der akuten Lungenembolie

Acute venous thromboembolism is a common cardiovascular emergency. Acute pulmonary embolism (PE) is present in one third of these patients. With an average lethality rate of 11% within the first two weeks following diagnosis, approximately 40,000 patients in Germany die annually as a result of PE; therefore, their diagnosis and therapy is of particular importance. For this reason, the European Society of Cardiology published guidelines on diagnosis and therapy in 2000. The current article presents and discusses the points as updated and extended in the 2008 version of the guidelines, including: (1) initial risk stratification – when PE is already suspected; (2) diagnostic procedures and algorithms; (3) further risk stratification; (4) therapeutic strategies in the acute phase; (5) further management and (6) long-term anticoagulation and secondary prophylaxis.     

Der direkte anteriore Zugang in der Revisionshüftendoprothetik

Objective

The objective of this paper is to describe a minimally invasive approach to revision total hip arthroplasty.

Indications

Indications for revision hip arthroplasty are septic or aseptic loosening of one or both components of a hip arthroplasty. In revisions the direct anterior approach (DAA) allows for a small incision if only the cup has to be revised or in cases of stem revision; the femoral preparation can be performed strictly endofemorally from the proximal direction. The gluteal muscles can be preserved whether the approach is limited to the original interval between the musculus tensor fasciae latae and the rectus, or has to be extended.

Contraindications

If preservation of the gluteal muscles is desired, the DAA and its extension are the method of choice. For endofemoral revision other than detachment of the musculus tensor fasciae latae, hyperextension and adduction of the operated leg are important. If these cannot be achieved, an alternative operative strategy or a different approach should be considered. As this approach allows for extensions proximally and distally along the femur, it competes with lateral approaches to the hip joint and femur, and does not have additional specific contraindications. The availability of specific curved, angulated, or offset instruments is mandatory.

Surgical Technique

The starting point of the incision is found two fingerbreadths lateral and two finger breadths distal to the anterior superior iliac spine. The fascia of the musculus tensor fasciae latae is incised sharply at its midpoint. The interval is prepared strictly subfacially and medially to the musculus tensor fasciae latae to expose the hip joint.

Postoperative Management

For this approach we don??t have any specific recommendations. Postoperative management depends mostly on the extension of the approach and the type of reconstruction performed. If the approach can be limited to the minimally invasive direct anterior portal, reduced muscle damage should result in faster rehabilitation.

Results

The retrospective analysis was performed on the data obtained from 48 revision operations with the minimally invasive direct anterior approach to total hip arthroplasty. The median cut-suture time was 108?min (42?C282?min); patients spent a median time of 10?days (4?C33?days) in the hospital from the day of the operation. The most common revision operations were cup replacement with an augmentation ring (13 out of 48), stem revision (11 out of 48), cup replacement (9 out of 48), H-TEP complete (3 out of 48), removing of ossifications (2 out of 48), cap revision (2 out of 48) and H-TEP removal with insertion of a spacer (2 out of 48). Complications attributed to the procedure were reported in 9 of the 48?cases: 1 wound-healing disorder, 1 late infection, 1 hematoma, 1 deep vein thrombosis, 1?perforation (by the spacer) and 1?ossification. Two patients were diagnosed with trochanteric pain syndrome. In one case an implant loosening was diagnosed 12?months after the revision.     

Der minimal-invasive vordere Zugang in der Hüftendoprothetik

A modified anterior approach to the hip developed by the senior author has been utilized in performing over 7000 hip replacement operations at this joint replacement center in the past three decades. It can be readily applied to both primary and revision surgery, and involves muscle splitting and sparing of the major hip muscles, innervation, and function. Since the late 1970s, Yale orthopaedic residents have been taught this minimally invasive anterior approach using one, two, or three mini-incisions without fluoroscopy, special operating room tables, or special retractors. The authors' overall experience has documented a very low incidence of dislocation and minimal perioperative complications. While a smaller skin incision is desirable by patients for cosmetic reasons and decreased healing time, what goes on beneath the skin is far more important. A well-placed total hip replacement should never be compromised. While many of these patients can ambulate the same or first postoperative day quite well, the authors do not advocate outpatient total hip arthroplasty as some proponents have. Bone is still cut, tissues bleed, clots can form, and the traditional complications of arthroplasty, while reduced, can still occur.     

Aktueller Stellenwert der konventionellen Radiographie und Sonographie in der frühen Versorgung traumatisierter Patienten

Conventional radiography (CR) and ultrasound are an elementary part of the diagnostic workflow in the early phase of trauma management. In recent years their clinical value has decreased due to the innovations of computed tomography (CT). The diagnostic superiority of CT has been shown by the higher sensitivity for the detection of traumatic organ lesions. As a result CR has already been become obsolete for head injuries. Furthermore, CT is continuously gaining importance concerning the management of thoracic, pelvic and spinal injuries; however, CR remains the first-line method for the evaluation of simple trauma of the extremities and in contrast, ultrasound is considered to be a sensitive modality for the detection of free fluid after blunt abdominal trauma. In addition the combination of widespread availability, easy handling and the lack of ionizing radiation contribute to the value of ultrasound as a screening method.     

Der IT-gestützte Behandlungspfad als Routinearbeitsinstrument in der Unfallchirurgie

Background

Today clinical pathways are established as a basis for the operational and organizational structure of surgical, interventional and conservative treatment in many hospitals. In our study we evaluate the establishment and systematic applicability of IT-based clinical pathways in a tertiary care facility.

Methods

We evaluate and compare the treatment of coxarthrosis with hip joint endoprosthesis either following an IT-based clinical pathway or without clinical pathway.

Results

All patients who had received a hip joint endoprosthesis from 1 January 2006 to 31 October 2009 were included. The duration of stay is significantly longer in the group without pathway. Furthermore there was a significant increase in the documentation of wound inspection after surgery in the ??pathway patients??. The preoperative urinalysis was done significantly more often in the pathway group.

Conclusion

IT-based clinical pathways are applicable for routine use in trauma departments. For certain surgical procedures they are a suitable management device, even in a tertiary care facility. Clinical pathways lead to an improved operational structure of medical treatment and moreover to a complete and continuous documentation through the electronic file.     

Der modulare MRP-Titanrevisionsschaft in der Revisionsendoprothetik des Hüftgelenks

In revision arthroplasty of the hip, femoral defects and fractures must be bridged by a long stem. The implant has to be adapted exactly to the diameter of the cortical tube and has to be placed distally beyond the pathologic area. The titanium modular revision prosthesis (MRP) stem consists of the titanium alloy Ti6Al7Nb and is offered in various diameters, lengths, and special devices, which allows individual and load-stable reconstruction. The aim of the current study is to scrutinize first clinical and radiological results of the titanium MRP revision stem in revision arthroplasty of the hip. We report the midterm results of 130 non-cemented revision arthroplasties of the hip using the titanium MRP revision stem with a mean follow-up of 2.9 years (minimum: 1 year, maximum: 8 years), including 56 men and 74 women. The indication for revision arthroplasty was aseptic loosening of the cup and stem in 94 cases, loosening of the stem in 17 cases, reimplantation in a Girdlestone situation in 11, and periprosthetic fractures in 8 cases. The Harris hip score improved from 50.9+/-24.6 preoperatively to 88.5+/-11.5 postoperatively. The score according to Merle d'Aubigné improved from 9.8+/-4.0 preoperatively to 15.2+/-2.8 postoperatively. We found three recurrent dislocations, two lesions of the sciatic nerve, three cases of persisting deep infection, two periprosthetic fractures, and one case of subsidence of the stem of 2 cm required revision of the MRP stem. Atrophy of the proximal femur was visible in all cases with a stem diameter >17 mm (39/130). Stable primary fixation was achieved in 129 of 130 cases. The titanium MRP revision has proved to be a very reliable implant in cementless revision arthroplasty of the hip.     

Zur Therapie der angeborenen Hüftgelenksverrenkung

Ohne Zusammenfassung Mit 2 Abbildungen im Text