Premature craniosynostosis a retrospective analysis of a series of 52 cases

Summary A retrospective analysis of a consecutive series of 52 cases with premature craniosynostosis is presented.Excellent functional, cosmetic, and social results could be achieved by resection of prematurely fused sutures and the creation of artificial growth sutures. Pronounced skull deformities have been corrected using the basket handle, the visor plasty, and the T-bone techniques or a combination of several of these skull form correction techniques. The surgical correction of the skull base by the frontal advancement technique in combination with orbitotomy was only necessary in 2 of our cases and could have been considered in 2 additional cases viewed retrospectively.Our results support the hypothesis that the primary cause of skull deformity is the premature closure of vault sutures and not a primary deformity of the skull base.     

19. Das TNM-System in der Chirurgie

Zusammenfassung Für Therapiefolge und prognostische Aussagen ist die Feststellung des Ausbreitungsgrades einer bösartigen Geschwulst entscheidend. Zur Klassifizierung wurde für die meisten Organe international das TNM-System durch die UICC festgelegt. Dabei werden die deskriptiven, klinisch feststellbaren, prätherapeutischen Befunde der Primärgeschwulst (T), der regionalen Lymphknoten (N) und der Fernabsiedlungen (M) gruppiert und in einer TNM-Tumorformel zusammengefaßt. Die Belange operativer Fachdisziplinen bedürfen hier wichtiger Ergänzungen. 50–120 Tumorformeln bei jedem Organkrebs sind eine Voraussetzung zur interdisziplinären Standardisierung der Krebsbehandlung, was an Beispielen dargelegt wird.

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TNM system and surgery

Summary Estimation of the pretherapeutic degree of spread of a malignant tumor is essential for decisions on therapy and prognosis. A uniform principle for the classification of tumors of all organs, the TNM System, has been stipulated on an international basis by the UICC. The findings of the primary tumor (T), the regional lymph nodes (N) and the metastases (M) are grouped and defined. The findings are summarized in a so-called TNM Tumor formula. This needs a supplement for the surgical specialties. About 50–120 tumor formulas for each organ tumor are indispensible in the interdisciplinary standardization of tumor treatment; this is discussed with examples.[]

     

78b. Sicherheit chirurgischer Arbeit

ZusammenfaBung Aufgrund mehr als 10jähriger Studien werden Wege für eine freiwillige QualitätBicherung chirurgischer Arbeit aufgezeigt. Neben kurzfristigen MaBnahmen (z. B. Strategie der Therapie) ist langfristig 1. eine Pilotstudie mit dem Ziel vorgesehen, über die ErfaBung vergleichbarer Werte AufschluB über Mängel und Fehler in der chirurgischen Versorgung zu gewinnen und 2. eine Organisation (nach dem Vorbild des holländischen Concilium chirurgicum), um kollegiale Visitationen chirurgischer ArbeitBtätten durchführen zu können. Beide - streng freiwillige - Einrichtungen sollen Grundlage für eine die Selbstachtung der Chirurgen fördernde, staatliches Eingreifen verhindernde QualitätBicherung werden.     

PTSD among vietnam veterans: An early look at treatment outcome using direct therapeutic exposure

Vietnam combat veteran inpatients were evaluated after being treated in a PTSD special treatment unit. Selected pretreatment measures that included mental and physical problems, combat variables, PTSD symptoms, and the standard MMPI scales found no clinically meaningful differences between a group that was found to be successes and another group found to be failures, based on predetermined cutoff scores on the VETS scale, a reliable outcome measure for veteran patients. At 3 months post-therapy, a significantly greater number of subjects treated with Direct Therapeutic Exposure (DTE) (flooding therapy) as compared to another group treated with a more conventional individual therapy, were identified as successes as opposed to failures, based on the VETs scale. Also, the number of failures was greater for those treated with the more conventional therapy and the number of successess was greater for those treated with DTE, when compared to all other subjects in the sample. These preliminary results were interpreted as indicating that DTE, when offered as part of an inpatient milieu, shows promise as an effective treatment for chronic/severe combat veteran PTSD sufferers.     

Blood loss during liposuction using the tumescent technique

Blood loss during liposuction has been a concern when more than 1500 mL of material are removed during one session. Several authors have claimed that blood loss is dramatically reduced when the targeted area is infiltrated with large amounts of dilute lidocaine with epinephrine (tumescent or superwet technique). Using this technique, 25 consecutive cases in which the liposuction aspirate was expected to be 1000 mL or more were investigated with pre- and postoperative measurements of hemoglobin. In addition, hemoglobin was also measured in the fluid fraction of the aspirate. The mean ± SD aspirated volume was 1658 ± 518 ml, and the mean ± SD fall in postoperative hemoglobin was 0.7 ± 0.6 g/100 mL (5.4% ± 4.9%). The mean amount of blood per liter of aspirate was calculated to be 10.5 ± 5.2 mL. These results clearly demonstrate that the blood loss when using the tumescent or superwet technique is dramatically reduced compared with the dry or classical wet technique.     

219. Ursachen und Behandlungsprobleme der syminetrischen Unterschenkelfraktur

Zusammenfassung Als Ursache der symmetrischen Unterschenkelfrakturengibt es direkte Trauma durch Kantensturz, Fahrzeugkollision oder Stoßstangenanprall. Gehäuft treten die zweizeitigen Kombinationsverletzungen Beine, Kopf, Becken auf. Lokal überwiegen die offenen Trümmerbrüche verschiedener Höhe. Gefäß-Nerven-Verletzung ist relativ selten. Therapeutisch erfordert die Mehrfachverletzung individuelle Indikationsstellung nach vitaler Dringlichkeit. Daher Osteosynthese praktisch nur verzögert primär möglich, und dann eventuell mit zwei Operationsgruppen. Vorbeugend sind verbesserte Sicherheitssysteme zur Unfallverhütung zu fordern.     

Maternal pregnancy vomiting and offspring salt taste sensitivity and blood pressure

The purpose of this study was to investigate the relationship between salt taste perception and blood pressure (BP) in normotensive adolescents as modified by maternal fluid losses during the first trimester of gestation. Seventy-two healthy adolescents (42 boys) aged between 9.0–21.1 years, recruited from the population-based RICARDIN study, were included. A maternal questionnaire about the duration of pregnancy, birth weight and vomiting or diarrhoea in the first trimester of gestation was collected. The sample was categorized into: vomiter descendents, those whose mother reported significant vomiting in the first trimester of gestation and non-vomiter descendents the remaining. Height, weight, and standardised BP measurement were recorded. Salt gustatory performance was assessed using a behavioral sensitivity test to determine the lower NaCl gustatory threshold, and a behavioral discrimination test, measuring the ability to distinguish among different saline solutions. Salt taste sensitivity showed a significant correlation with systolic BP (SBP) in vomiter descendents ( r =–0.66; P =0.003), but not in non-vomiter descendents. Adjusted by gender, and actual height and weight, salt sensitivity performance remained significantly related to SBP. An association between descendents SBP and maternal vomiting during gestation exists, adding a new element of evidence to the Barker hypothesis.     

Ureteral stents — materials and new forms

Summary Three different types of polymers are currently used for self-retained ureteral stents: thermoplastic materials such as polyurethanes, and thermoset elastomers such as silicone and hydrogels. Polyurethane stents are easy to form and have high drainage capacity, whereas silicone shows the best biocompatibility but a lower drainage efficacy than the former. A mock urinary system consisting of a collecting system and a 9-F tube was used to evaluate the flow characteristics of various double-pigtail stents in cases of urinary obstruction. For simulation of an unobstructed urinary system a human urogenital system was used. Inner flow polyurethane stents showed the best drainage as compared with inner flow silicone and outer flow ESWL stents in an obstructed ureter, whereas ESWL stents maintained the best flow in an unobstructed ureter or in respect to conventional stents with obstructed sideports.     

Composition and calcium binding of proteinpolysaccharides of calf nasal septum and scapula

Proteinpolysaccharide (PP-L) of resting and ossifying zones of calf scapular cartilage and of calf nasal septum cartilage was extracted with aqueous 0.15 M KCl and fractionated into a series of products: PP-L3, PP-L4, PP-L5, PP-L6. An additional proteinpolysaccharide fraction, PP-L2, was extracted from the cartilage residues with hydroxylamine. Differences in chemical composition among corresponding proteinpolysaccharides obtained from the three cartilage sources were, in general, small. The calcium binding capacity of the PP-L, PP-L2, and PP-L3 samples, as measured by equlibrium dialysis, appeared to reflect principally their uronic acid and exchangeable sulfate contents. Application of a cation exchange technique indicated that PP-L from resting and ossifying zones of scapular cartilage had similar affinities for tracer quantities of calcium. However, the affinity of PP-L from both zones of scapular cartilage for tracer quantities of calcium was greater than that of PP-L from nasal septum. The data obtained from this study do not indicate sufficient differences between the chemical composition and calcium affinity of proteinpolysaccharides from resting and ossifying scapular cartilage to account for the calcium uptake in the ossifying zone.This work was supported by the U.S. Atomic Energy Commission and by U.S. Public Health Service Special Fellowship (QTS), 1-F3-GM-16, 179–01.     

Urethro-vesical function during spinal shock

Summary Twenty spinal shock patients were investigated with simultaneous urethrovesical, anal and rectal pressure recordings and EMG of the external urethral and anal sphincters. Dynamic and static urethral pressure profiles (UPP) were carried out with empty and full bladder. Baldder filling was accompanied by an increased resistance in the internal sphincter zone, which in turn was paralleled in the majority of cases by an elevation of pressure in the membranous urethra without concomitant increase of its EMG activity. This is suggestive of an increased sympathetic activity in the bladder neck area and in the smooth muscle component of the external urethral sphincter. Dynamic pullthrough UPP's displayed higher resistances in the membranous urethra than static interrupted UPP's pointing to the role played by the urethral muscosal receptors in eliciting artefactual results. Higher pressures were recorded in the juxtabulbar portion of the membranous urethra than in its mid portion pointing to a gradient of pressure within the external urethral sphincter itself. The amount of EMG activity recorded in the anal and urethral sphincters at rest was somewhat decreased; high pressures and distinct reflex activity were recorded in both sphincters showing that they escape spinal shock characterized primarily by areflexia. After defining spinal shock a rational explanation based upon neuroanatomical and neurophysiological findings is offered as to why somatic activity of the sacral segments escapes it as evidenced by clincial, urodynamic, and electromyographic recordings.     

Letalität und postoperative todesursachen in der kinderchirurgie Mortality and post-operative cause of death in pediatric surgery

Zusammenfassung Die postoperativen Todesursachen der Jahre 1959 bis 1990 wurden am eigenen, kinderchirurgischen Krankengut nach dem Schema von Petrén analysiert. Die Todesursache postoperative Infektion ist von ehemals 45/o auf 2 % gesunken. Todesursache postoperative Pneumonie ging von 10% auf 4 % zurück. Tod durch begleitende Fehlbildung stieg von 3 auf 15 % an. Die Todesursache Grundkrankheit ist mit 18% der Todesfälle gleichgeblieben. Postoperative Todesursachen durch Fehldiagnosen liegen bei 2%, Todesursache Behandlungsfehler ist von 18% rückläufig auf 4%. Während der überschauten Zeitspanne von 41 Jahren wurden 115 598 Kinder stationär operiert. Im ersten Fünljahresabschnitt betrug die postoperative Sterblichkeit 2.2%, im letzten Fünfjahresabschnitt 0,12%.

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We analysed our patients in pediatric surgery from 1959 to 1990 in regard to post-operative causes of death according to the Petren scheme. Post-operative infection as a cause of death dropped from 45% to 2%, post-operative pneumonia from 10% to 4%. Death due to accompanying congenital defects has increased from 3 % to 15%. The cause of death main disease remained the same with 18 %. Post-operative causes of death due to wrong diagnoses ranged at 2%, wrong treatment as cause of death decreased from 18 % to 4 %. In the 41 years' range of our survey, 115,598 children were operated as in-patients. During the first 5-year-period postoperative mortality was 2.2%, during the last 5-year-period 0.12%.

     

Absorptiometry and “osteoporosis”: problems

connecting the dots between diverse clinical and other matters and an updated bone physiology reveals relationships that could modify some ideas about the roles and uses of absorptiometry in osteoporosis work. Herein, absorptiometry means that part of clinical densitometry that depends on X-ray absorption by bone and other tissues, thus excluding ultrasound methods and magnetic resonance imaging. The modifications concern, in part, some limitations of bone mineral density data, the kinds of physiological information that absorptiometry can and cannot provide, the relative importance of bone mass and whole-bone strength, how to define and study bone health and osteoporosis, and two kinds of osteoporotic fractures. As those modifications concern important national health care issues, they deserve answers based on hard evidence. Identifying those modifications might help others to evaluate them.     

Reconstruction of bony defects using the Ilizarov “bone transport” technique

Summary Ilizarov's method of percutaneous transosseous osteosynthesis allows management of complex skeletal deformities using elastic external fixation, atraumatic corticotomy and gradual adaptations between bony fragments. One particular application, useful in the reconstruction of bony defects, is the lift or bone transport technique, in which in fact internal lengthening is carried out. Using some of their first cases as illustrations, the authors describe the technique and its potential problems.     

61. Hämodynamische Spätergebnisse nach Ligatur der Vena cava inferior

Zusammenfassung 22 Patienten mit tiefer Beinvenenthrombose (DVT) und direkter operativer Ligatur der Vena cava (LIVC) wurden mit Hilfe der Strain Gauge Plethysmographie durchschnittlich 9 Jahre postoperativ nachuntersucht. Acht Patienten (36%) waren symptomfrei, ein Ulcus cruris trat bei vier Patienten (18%) auf. Patienten LIVC ohne frühere DVT wiesen keinen signifikanten Unterschied im venous reflux auf im Vergleich zu Kontrollpersonen. LIVC-Patienten mit DVT zeigten signifikante Unterschiede im venous reflux. Die Spatmorbidität dürfte eher von durchgemachten DVT als von LIVC herrühren.     

71 b. Akute Cholecystitis — Frühcholecystektomie?

Zusammenfassung Durch kontrollierte Studien ist heute bewiesen, daß die operative Behandlung der akuten Galle bessere Ergebnisse erbringt als eine verzögerte Operation oder eine konservative Behandlung. An der Chirurgischen Universitätsklinik Würzburg wurden von 1969 bis 1983 397 Patienten wegen akuter Galle operiert; die Ergebnisse werden mitgeteilt.     

55. Organisationsfragen in der Intensivmedizin

Zusammenfassung Der Begriff Intensivmedizin gliedert sich in die Intensivüberwachung und die Intensivbehandlung. In der klinischen Praxis gehen zwar beide Bereiche oft ineinander über, trotzdem sind sie wegen der unterschiedlichen Anforderungen begrifflich klar voneinander zu trennen. Der Gesamtbettenbedarf für die Intensivmedizin beträgt in der allgemeinen Chirurgie 7–10%, für die Intensivbehandlung im engeren Sinne 3–5%. Die Besetzung mit Pflegepersonal richtet sich in der Intensivüberwachung nach einem Personal: Bettenschlüssel von 1:1, in der Intensivbehandlung von 2:1. Für die Intensivüberwachung wird 1 Arzt auf 3 Betten, für die -behandlung neben dem ärztlichen Leiter der Betteneinheit 1 Arzt auf 2 Betten benötigt. Aus organisatorischen Gründen besitzen die Intensiveinheiten der meisten Krankenhäuser interdisziplinären Charakter. Das bedingt neue Formen ärztlicher Zusammenarbeit; aus dem konsiliarisch zugezogenen Arzt wird der mitbehandelnde Arzt, der für seinen Teil der Therapie die volle Verantwortung übernimmt. Trotzdem muß die ärztlich-organisatorische Leitung der Betten-einheit in einer Hand liegen. Die Befugnisse dieses ärztlichen Leiters berühren aber nicht die Fachkompetenzen der anderen beteiligten Ärzte.

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Organizational problems of intensive care

Summary The term Intensive Care includes both Intensive Observation and Intensive Therapy.In clinical practice, however, those two terms are not distinctly defined although they must be clearly separated because of their different characteristics.The number of beds required for Intensive Care amounts to 7 to 10% for general surgery, whereas 3 to 5% are needed for Intensive Therapy. The ratio of nurses to beds is 1 to 1 for Intensive Observation and 2 to 1 for Intensive Therapy. For Intensive Observation one doctor is needed for 3 beds while for Intensive Therapy one doctor is needed for 2 beds each in addition to a head physician in charge of the Intensive Care ward. For organizational reasons the Intensive Care wards of most hospitals are inter-departmental. This calls for new forms of cooperation among doctors; the consulting doctor is also a doctor in charge who shall be fully responsible for his part in the therapy. Nevertheless, the medical and organizational administration of the Intensive Care ward must be in the hands of one person whose competences, however, do not coincide with the expert competences of the other doctorsin charge.

     

Diagnostic value of automatically interpreted oculopneumoplethysmography

The diagnostic value of the Gee-oculopneumoplethysmography test for the detection of hemodynamically significant carotid artery obstructions has frequently been questioned due to the rather low agreement with arteriography. The kappa-corrected diagnostic accuracy of this test has been reported to be in the range between 0.54 and 0.68. These values indicate a fair to good agreement with arteriography. One of the causes for this rather low agreement is the variability in the interpretation of oculopneumoplethysmography recordings. Automatic analysis of oculopneumoplethysmography recordings might minimize the risks of misinterpretation and might improve the clinical significance of the Gee-oculopneumoplethysmography test. By assessing the signals of a conventional Gee-oculopneumoplethysmography apparatus in a personal computer, this automatic analysis has been realized. In a clinical study (population of 85 patients) the diagnostic value of automatic analysis of oculopneumoplethysmography recordings has been evaluated. The automatically interpreted Gee-oculopneumoplethysmography test had a kappa-corrected diagnostic accuracy of 0.71 on a per side base and of 0.76 on a per patient base.     

Cerebral reperfusion in brain death of a newborn. Case report

A case of sudden infant death after 15 minutes of successful resusciation of cardiovascular function is presented. While apnoic cranial nerve areflexia and electrocerebral silence persisted, angiography and transcranial Doppler sonography demonstrated nearly normal cerebral perfusion, which even increased day by day inspite of the persistence of other signs of brain death. The phenomenon cerebral reperfusion is concluded to be compatible with the diagnosis of brain death.     

Digital subtraction angiography (DSA): New perspectives in angiography

Summary Digital subtraction angiography (DSA) has strongly influenced angiographic procedures. Because it is less invasive it has increased the total number of angiographies in all places where it was introduced. The paper gives an introduction to the procedure explaining the roles of digital and subtraction in DSA. It is written from a technical point of view. The examples are taken from and with the DVI system.