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1.
Background
Endoscopic vacuum therapy is a widespread method in the postoperative treatment of lower and upper gastrointestinal (GI) tract leakage.Objective
There is an absence of further technical development of the standardized material from 2007 for the lower GI tract.Material and methods
New strategies and new materials for endoscopic vacuum therapy are presented.Results
Alternative strategies in sponge placement, use of open-pore film drainage, use of a multiple sponge system, rinsing catheter, electronic pumps etc. enable the successful treatment of very complex pelvic defects.Conclusion
The wide variability of pelvic defects often necessitates a change in therapeutic strategies during the course of treatment for an optimized outcome.2.
H. Marung M. Höhn J.-T. Gräsner J. Adler T. Schlechtriemen 《Notfall & Rettungsmedizin》2016,19(7):548-553
Background
Simulation was established as a didactic tool in training of medical personnel on a broad basis about 20 years ago, allowing for risk-prone procedures to be practiced in a safe environment and thus improving patient safety.Method
Research of the current literature.Results
This holds true especially in high-risk areas (e.g. emergency medicine) where patients with instable vital conditions are treated under pressure often by unexperienced team constellations. Mandatory practical training required by medical councils is often insufficient in achieving the qualifications required for prehospital emergency physicians. A standardised simulation concept—with up to 25 different standardized scenarios—may be a better option to achieve this objective.Conclusions
High-quality implementation requires numerous personal and organisational prerequisites that should be monitored by medical councils in order to prevent a shortfall of standards. In the future the effectiveness of the method should be examined in order to optimize the training concept.3.
Background
In order that the thumb as the most important part of a functioning hand can assume its functions, it must be stable, sufficiently long, sensitively innervated and sufficiently able to move.Objective
Alternatives to a thumb reconstruction, demonstration of a thumb lengthening procedure using a semi-circular distraction fixator and development of therapy recommendations are presented.Material and methods
A search of the current literature on the callus distractor was carried out. The prototype of a semicircular distraction fixator is presented.Results
An average extension of 3?cm can be realised using callus distraction. The advantages predominate, so that this method should be included in every individual treatment plan, especially when other possibilities are not considered acceptable options.Conclusion
The choice of the appropriate thumb reconstruction procedure after a traumatic amputation depends on the amputation level, age, occupation and the functional necessity of the patient. Callus distraction is a technically simpler procedure in comparison to microsurgical alternatives for reconstruction of an amputated thumb. The most significant drawbacks lie in the missing fingernail area, the interphalangeal joint and the long treatment period. The five essential goals of thumb reconstruction (length, stability, movement, painless function and sensitivity) can all be addressed with this procedure.4.
V. Beck M. Apfelbeck M. Chaloupka A. Kretschmer F. Strittmatter S. Tritschler 《Der Urologe. Ausg. A》2018,57(1):29-33
Background
The development of a stricture of the vesicourethral anastomosis is a serious complication after radical prostatectomy. Strictures occur in 5–8% of patients after radical prostatectomy.Symptoms
Usually the clinical symptoms include an irritative and obstructive component similar to benign prostatic hyperplasia. In rare cases, patients suffer from partial or complete stress incontinence as a result of the anastomotic stricture.Diagnostics
The diagnostic workup is similar to the procedure for urethral strictures. In addition to uroflowmetry, a cystourethrogram (CUG) or, if necessary, a micturating cystourethrogram (MCU) can be performed. A urethrocystoscopy can be performed to ensure the diagnosis.Therapy
In most cases, endoscopic procedures were performed for treatment. Beside a transurethral dilation of the stricture or the Sachse urethrotomy, the most common procedure is transurethral resection to treat the stricture. However, all procedures are associated with a high recurrence rate. In recurrent strictures, open surgical procedures, usually a perineal reanastomosis, should performed early.Conclusion
Endourological procedures like transurethral resection are a good treatment option, but due to the high recurrence rates, open surgical procedures should be discussed and if necessary should be performed early.5.
T. Steiner 《Der Urologe. Ausg. A》2018,57(7):785-789
Background
Concepts for measuring and improving the quality of patient care in hospitals have become increasingly important in recent years.Objectives
The peer review procedure which has been developed by the Helios Clinic Group and Initiative for Quality Medicine (IQM) is described.Materials and methods
In peer review, medical records are reviewed by experienced external physicians. Inadequacies are identified, improvement protocols initiated, and concrete measures for improvement of patient care derived.Results
The described procedure is able to identify patient risks and errors during the course of treatment with the subsequent goal of avoiding repetition. In a retrospective, observational quality management study, peer review led to a significant decrease in mortality rates for various diseases.Conclusions
Peer review represents the optimal procedure of medical quality management by systematic review and open discussion with colleagues.6.
Background
Given the current and future security situation, it appears necessary to reform the training and appointment of senior emergency physicians and to harmonize these nationwide. The goal of the authors is to describe the current situation, identify needs for action and possible solutions, and thus to encourage discussions in authoritative bodies.Methods
Presentation of the current training and appointment practice, using the current situation in Bavaria as an example.Results
The aim is to establish a uniform and updated training of future senior emergency physicians, so that they can more efficiently fulfill future positions.Discussion
The current training of senior emergency physicians needs urgent revision with regard to general security policy development and the integrated security of the German authorities.7.
Background
Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.Study design
Case report.Objective
To report a clinical case with adjacent level infection after spinal fusion.Methods
We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.Results
After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.Conclusion
Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.8.
M. De Santis 《Der Urologe. Ausg. A》2018,57(11):1342-1345
Background
Prostate cancer (PCA) seems to be more of an immunologic desert than other tumor entities. It is striking that only rarely does prostate cancer show abundant immune cells and a proimmunogenic microenvironment.Objectives
Is immunotherapy in PCA effective and which patients can benefit.Materials and methods
A review of the literature and recent congress data are presented.Results
Preliminary results with sipuleucel-T for PCA cancer were very promising showing a significant overall survival benefit in randomised phase III studies and the US Federal Drug Administration (FDA) approval for this individualised vaccine. Contrary to other tumor entities this was not the immediate breakthrough to a new therapeutic era of immunotherapy but remained an isolated case and restricted to the USA. More recently, several trials evaluated immunotherapeutic agents but missed their preliminary endpoints. Interestingly, individual patients did benefit and showed long-term remission.Conclusions
Genome sequencing and new biomarkers are also paving a novel pathway towards individualised immunotherapy for PCA. On-going research and clinical trials are exploring the question of which patients will benefit.9.
Background
Sudden cardiac death is frequent, and prognosis of survival—even with an optimal rescue chain—is poor. Implantation of a miniaturized heart–lung machine during cardiopulmonary resuscitation (CPR) is referred to as extracorporeal CPR (eCPR). The current 2015 Advanced Life Support (ALS) guidelines advocate consideration of eCPR in selected patients.Objectives
Discussion of eCPR basics and requirements for material, staff, and local structures.Materials and methods
Review of current guidelines and published data.Results
eCPR, which can be performed within a controlled environment after in-hospital and out-of-hospital cardiac arrest, is associated with high technical and personnel expenses. The implantation of a heart–lung machine during CPR takes about 30 min. A study with early eCPR after sudden cardiac death reported a 54?% patient survival. Studies with greater delay between collapse and eCPR show less favorable results.Conclusion
An improved survival in selected patients using eCPR seems plausible, however has not been scientifically proven. A benefit in survival might be only achievable with early eCPR.10.
Background
Anterior cervical discectomy and fusion (ACDF) as well as posterior instrumentation of the cervical spine are frequently performed surgeries for cervical disc prolapse or spinal stenosis. Surgery itself harbors a very low risk of adverse events. Postoperative palsy of the C5 nerve root, however, is a severe complication and its origin is still not fully understood. The risk of such a C5 palsy is reported to be between 0 and 30%; 5% on average according to the literature.Objectives
To describe underlying pathomechanisms and to recommend strategies for risk reduction.Materials and methods
An extensive literature research via Medline was performed.Results
Potential risk factors are male gender, sagittal diameter below 5.6?mm, anterior approach, and higher age.Conclusions
Currently available data only originates from retrospective or anatomical studies. A prospective register study with the goal to put light on the pathogenesis is currently being performed.11.
D. Mammadova K. Hirsch B. Schwaiger B. Wullich W. Rascher 《Der Urologe. Ausg. A》2018,57(10):1200-1207
Background
Families with children and adolescents with end-stage renal disease came to Germany from the former Eastern Bloc countries before the wave of refugees in 2015, in order to enable their children to survive with adequate kidney replacement therapy and in the best case a kidney transplant.Methods
In a case study, medical records of 4 childen and adolescents were retrospectively analyzed. These patients who fled to Germany for the treatment of terminal renal failure applied for asylum and were successfully transplanted after the usual waiting period.Results
Four of the eight children and adolescents who came to Erlangen for treatment of terminal renal failure between 2003 and 2013 received a functioning kidney transplant (deceased donor kidney) after dialysis therapy was difficult due to lack of compliance to drug and dietary recommendations such as fluid restriction. Since children and adolescents are treated with chronic dialysis only with the aim of kidney transplantation, a living donation was discussed but was not possible for medical reasons. 3 recipients are symptom-free with a functional graft.Discussion
The case study demonstrates that children and adolescents fleeing to Germany due to their end stage renal disease are better integrated after kidney transplantation, have better chances of obtaining a good education and can be expected to live independently with their own income in the future.12.
T. Pillukat R. Fuhrmann J. Windolf J. van Schoonhoven 《Operative Orthopadie und Traumatologie》2016,28(1):47-64
Objective
Bony healing of dislocated distal radius fractures after open reduction and internal stabilization by locking screws/pins using palmar approach.Indications
Extraarticular distal radius fractures type A2/A3, simple extra- and intraarticular fractures type C1 according to the AO classification, provided a palmar approach is possible.Contraindications
Forearm soft tissue lesions/infections. As a single procedure if a volar approach not possible.Surgical technique
Palmar approach to the distal radius and fracture. Open reduction. Palmar fixation of the plate to radial shaft with single screw. After fluoroscopy, distal fragments fixed using locking screws.Postoperative management
Below-the-elbow cast for 2 weeks. Early exercise of thumb and fingers, wrist mobilization after cast removal. Complete healing after 6–8 weeks.Results
Ten patients averaged 100?% range of motion of the unaffected side after 43±21 months. No complications observed. DASH score averaged 12±16 points; Krimmer wrist score was excellent in 7, good in 2, and fair in one.13.
M. Walther S. Kriegelstein S. Altenberger A. Röser 《Operative Orthopadie und Traumatologie》2016,28(4):309-320
Objectives
Correction of calcaneal malalignment as part of a hindfoot correction procedure.Indications
Varus and valgus malalignment of the calcaneus, increased calcaneal pitch.Contraindications
Osteoarthritis of the subtalar joint. Fixed and symptomatic deformities of the subtalar joint.Surgical technique
After having identified and marked the desired planes of the osteotomy under image intensifier, a percutaneous v?shaped calcaneal osteotomy is performed. The osteotomy allows 3?dimensional correction of the calcaneus by defining the planes of the osteotomy. The procedure allows correction of varus and valgus deformities, as well as a change of the calcaneal pitch. The osteotomy is fixed by percutaneous screws.Postoperative management
Postoperative care includes a 6-week period of partial weight bearing with 10 kg. The ankle joint should be mobilized. After x?ray control of sufficient bone healing, weight bearing can be increased stepwise over another 4?week period up to full body weight. A full length orthotic is recommended for at least 12 months with heel cup and good medial support.Results
The procedure allows correction of calcaneal deformities with preservation of soft tissue, normally as part of a hindfoot correction, e.?g., in posterior tibial tendon insufficiency, varus deformities or total ankle replacement. In the literature and in our patients, the rate of injuries of the neurovascular bundle was not increased compared to open surgery. The average calcaneal shift was 1 cm, when necessary an additional correction was realized by rotation of the tuber calcanei.14.
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16.
Background
Mass casualties (MASCAL) are always a particular challenge for medical care and emergency services at the scene, as well as for the medical facilities, which care for the patients afterwards. Incidents due to a terrorist attack (TerrorMASCAL) are a particular challenge due to significant peculiarities and a very different situation.Objective
Within the scope of this work, the special aspects of a TerrorMASCAL are presented and explained with regard to the inner-clinic characteristics, in particular necessary surgical treatment.Material and methods
On the basis of the specifically acquired knowledge from the development of the Terror and Disaster Surgical Care® (TDSC®) course as well as a corresponding literature review, specific conceptual recommendations were developed and derived.Results
In the context of the in-hospital treatment of patients associated with a TerrorMASCAL scenario, numerous special features must be considered. This is related in particular to the number of patients and the influx of patients into the hospital, the special injury patterns, the infrastructural peculiarities and personnel resources. A very special focus also is on the applicable surgical care concepts with regard to the Early Total Care, Damage Control or Tactical Abbreviated Surgical Care.Discussion
TerrorMASCAL scenarios are different from the normal MASCAL situation in many ways and a variety of aspects need to be taken into consideration. In particular, an adapted preparation and training of the internal structures of the hospital is an essential component in the provision of public services.17.
Background
Pump thromboses are a frequent complication after implantation of a left ventricular assist device (LVAD) with an incidence of 10%.Objective
Evaluation of the risk factors and the necessary diagnostic tools, such as imaging investigations, determination of laboratory parameters and device settings. Recommendations for therapy and differentiation between pharmaceutical and surgical therapy.Material and methods
A literature search of PubMed and inclusion of own hospital recommendations for actions.Results
The diagnostics of a pump thrombosis are carried out by extraction of the data stored by the LVAD and are necessary to evaluate an increased pump performance. An increased lactate dehydrogenase 2.5 fold higher than normal values is highly suspicious of a pump thrombosis. For imaging investigations echocardiography provides indirect parameters, such as increased left ventricular end-diastolic diameter (LVEDD) and progressive mitral valve regurgitation, a frequent opening of the aortic valve and the flow velocity in the outflow cannula. A computed tomography (CT) scan can be used to detect a thrombus formation in the outflow cannula. Therapy can be carried out pharmaceutically using thrombolytic agents, such as recombinant tissue type plasminogen activator (rt-PA) or by a surgical replacement of the pump.Conclusion
The identification of a pump thrombosis is determined by the inclusion of various parameters. The therapy should be carried out individually and be device-specific.18.
Objective
Amputations and exarticulations of the toes may be necessary due to several reasons. The goal is to remove necrosis or infection prior to its spread to the midfoot region. From a functional or cosmetic point of view, amputation/exarticulation of a single toe plays no major role. However, this can be different with exarticulation of several toes.Indications
Necrosis, trauma, infection, tumor, deformity.Contraindications
Conditions where amputation/exarticulation of a toe is insufficient, e.?g., in progressing peripheral arterial disease.Surgical technique
The toe can either be amputated through the distal phalanx or exarticulated in the metatarsophalangeal joint.Postoperative management
Orthopedic shoes or orthotic devices are rarely necessary when a single toe is amputated/exarticulated. However, concomitant deformities of the foot have to be thoroughly addressed. If more than one toe is amputated, silicone spacers may be necessary to prevent the remaining toes from deviating.Results
Amputations and exarticulations of the toes are frequent and the procedure is technically simple. However, the complication rate is high due to typical indications making amputation necessary.19.
Background
Meta-analyses have a great impact on medical decision-making. Random errors are, however, often the reason for misinterpretation of interventional effects in meta-analyses.Objective
The aim of this article is to introduce authors and readers of meta-analyses to the problem of random errors. The article presents trial sequential analysis (TSA) as a suitable and user-friendly method that adjusts for the risk of random errors in meta-analyses.Material and methods
The practical application of TSA is illustrated and exemplified using regional anesthesiology procedures versus conventional pain therapy with respect to the prevention of persistent postoperative pain after breast cancer surgery or thoracotomy. The results were compared with those from conventional meta-analytical methods.Results
Conventional meta-analytical methods showed a significant advantage for patients after breast cancer surgery as well as after thoracotomy for regional anesthesia procedures with respect to the reduction of persistent postoperative pain. By means of TSA it could be concluded for thoracotomy that the evidence of this meta-analysis was sufficient. In contrast, the TSA for breast cancer surgery showed that based on the current data set and on the basis of relevant assumptions, it is potentially a false indication of an effect. There is currently no evidence that regional anesthesia leads to a significant reduction of persistent postoperative pain.Conclusion
The TSA is a suitable tool to minimize the risk of random errors and for a more reliable assessment of the evidence for the results of a meta-analysis.20.