Die Kosten der präoperativen Anämie bei Hüftgelenkrevisionsoperationen

Die Anaesthesiologie - Die Anämie hat eine hohe Prävalenz bei Patienten vor Hüftgelenkrevisionsoperation und ist mit einer erhöhten Komplikationsrate assoziiert. Die vorliegende...     

Evidenzlage zur minimalinvasiven Chirurgie beim Ösophaguskarzinom

Surgery remains the mainstay of potentially curative treatment of esophageal cancer; however, esophageal resection is still associated with a relevant morbidity and mortality. Furthermore, patients frequently suffer from concomitant comorbidities and present in a reduced nutritional status. The rationale of minimally invasive surgery is the reduction of surgical trauma with subsequent minimization of (pulmonary) complications and mortality without compromising oncological quality. Minimally invasive esophageal resection was established nearly two decades ago and since then some centers worldwide have adopted this approach as the preferred option for surgical treatment of esophageal cancer. Minimally invasive esophageal resection can be safely performed and provides excellent results in experienced hands. Currently, there is only one randomized trial available comparing open and minimally invasive resection. It was demonstrated that the latter significantly reduced pulmonary complications with comparable mortality and oncological outcome. However, in the majority of studies these convincing results could not be confirmed. Reduced blood loss and a shortened hospital stay were shown to be the main advantages of the minimally invasive approach. Due to technical modifications, patient selection and a remarkable heterogeneity of current studies, a final conclusion on the value of minimally invasive esophagectomy is difficult to be drawn. Based on the current evidence, a noncritical use of minimally invasive resection for esophageal cancer cannot be recommended; however, in selected patients and with appropriate expertise this approach is at least comparable to open esophagectomy.     

Die neue S3-Leitlinie zum Ösophaguskarzinom

The current German S3 guideline represents the recommendations for the diagnosis and therapy of squamous cell carcinomas and adenocarcinomas of the esophagus based on evidence from the literature and interdisciplinary expert consensus. Esophagogastroscopy with biopsy, endosonography, and spiral CT scan of the neck, thorax, and abdomen are decisive in staging and the choice of therapy. For a curative approach, surgery, especially transthoracic esophagectomy and gastric pull-up, is the most important therapeutic option, except in the case of mucosal carcinomas or cervical squamous cell carcinomas. The significance of total minimally invasive esophageal resection or a hybrid technique is still uncertain. In category cT3 or resectable cT4 tumors, neoadjuvant radiochemotherapy should be performed in squamous cell carcinomas or adenocarcinomas. Alternatively, perioperative chemotherapy can be carried out in adenocarcinoma. Palliative resections should be avoided and replaced by interventional procedures for palliation.     

Die Verantwortung des Anästhesisten in der präoperativen Risikoabklärung

There is an increasing number of publications in the medical literature which address the medical and legal obligations of a specialist in a given field. These articles, mostly editorials, seek to delineate the optimal course of treatment based on the current state of the art and science of medicine. However, we believe that the unreflected adoption of these often highly theoretical ideas and suggestions carries its own dangers. For one thing, there is the threatening financial crisis in the public health system. In addition, the feasibility of implementing these suggestions in routine medical and surgical practice is questionable. Last but not least, suggestions and guidelines for preoperative risk management by, for instance, Lingnau and Strohmenger 2002 cross the well established boundaries of the various medical and surgical specialties, which obviously demands careful deliberations among the specialties involved. So far, few specialty boards have seen fit to act on these suggestions. Our article on the medical and legal responsibilities of the anaesthesiologist in perioperative risk management restates the aforementioned concerns. We attempt to point out medical and legal points of controversy. In particular, we caution against the ever present danger of a bona fide adoption of visionary guidelines as the "standard of care" by both medical and legal experts. We feel that it is imperative to carefully evaluate editorial comments and suggestions, however well meaning, in the light of established teaching and practice, lest these comments and suggestions become the basis of an unjustified determination of a physicians innocence or guilt in a court of law.     

Die präoperative computertomographische Abklärung bei Tibiakopffrakturen

Within the last decade computed tomography has become an important instrument for skeletal diagnosis. In this study the value of helical CT-scan was compared with plan X-rays and conventional tomography in 45 patients having sustained an intraarticular tibia plateau fracture. Between plan roentgenogramms and CT-scan the fracture classification according to the AO-classification was changed in 40% of all patients, in 39 cases the amount of impression or dislocation increased with a mean of 4.2 mm. Especially tiny fragments were better visible and therefore responsible for the shift of many B1 fractures to group B3. The difference between conventional tomography and computed tomography was less impressive, a change of fracture classification could be observed in only 6.7% of all cases.     

Die Anzeigestellung zur operativen Behandlung der inneren männlichen Genitaltuberkulose

Ohne ZusammenfassungMit 4 Textabbildungen     

Die Bedeutung der Toxämie bei der operativen Kollapstherapie der Lungentuberkulose

Zusammenfassung Im Anschlu? an die Thorakoplastik treten bei zahlreichen Lungentuberkul?sen vorübergehend Fernsymptome auf, die vermutlich durch Toxine hervorgerufen werden. Die gleichen Erscheinungen sind gelegent lich bei florider Lungentuberkulose, besonders in deren Anfangstadien und nach Einspritzung relativ hoher Tuberkulindosen, beobachtet worden. Diese Erscheinungen betreffen vorwiegend solche Kranke, die im postoperativen Stadium spezifisch entzündliche Komplikationen aufweisen; zeitlich treten sie meist mit diesen zusammen auf. Kein wesentlicher Zusammenhang der postoperativen Kreislauffunktion mit den toxischen Fernsymptomen. Bei Lungentuberkul?sen fand sich in 15% vor der Operation, in 20% nach der Thorakoplastik kulturell Bacill?mie. Keine Abh?ngigkeit der toxischen Erscheinungen von der Bacill?mie. Die Tuberkulinallergie nimmt im allgemeinen nach der Thorakoplastik ab. Besonders deutlich ist die Abnahme bei Kranken, deren postoperativer Verlauf durch schwere entzündliche Erscheinungen kompliziert ist. Diese Kranken sind auch vorwiegend an manifesten toxischen Symptomen beteiligt. Der postoperative Allergiesturz kann als prognostisch ungünstig gewertet werden.      

Die präoperative Behandlung chronischer Ventilationsstörungen zur Erweiterung der Indikation bei thoraxchirurgischen Eingriffen

Ohne Zusammenfassung     

Indikationen und Gegenindikationen der präoperativen Antikoagulantienbehandlung

Ohne ZusammenfassungMit 6 Abbildungen     

Diagnostik und Behandlung der präoperativen Anämie

Die Anaesthesiologie - Die präoperative Anämie findet sich in den industrialisierten Ländern bei 14–40 % der zu operierenden Patienten. Sie geht schweregradabhängig...     

Zeit für einen Paradigmenwechsel bei der präoperativen Nüchternheit

Die Anaesthesiologie -     

Aussagekraft der Magnetresonanztomographie bei der präoperativen Diagnostik von Rotatorenmanschetten- und Labrumläsionen der Schulter

Background

MR imaging is the method of choice in the identification of soft tissue structures. In shoulder injuries, it is widely used for the diagnosis of rotator cuff and labral lesions. In this study, the significance of MR imaging was evaluated by correlating the preoperative imaging with the results from shoulder arthroscopy.

Methods

From 8/2003 to 8/2007, 162 arthroscopic shoulder examinations in 161 patients were performed. In 146 of these patients, MR imaging was performed before surgery. Images in the transverse, paracoronal, and parasagittal planes using T1- and T2-weighting were obtained. The retrospective study included 146 patients (60 women, 86 men, mean age 52 years). MRI was performed after shoulder injury or in the case of unexplainable, persisting shoulder pain because of clinical aspects of the examination. MR imaging is compared with the arthroscopic findings. The χ² test and contingency tables were used for statistical evaluation.

Results

A transmural rotator cuff tear was diagnosed preoperatively by MRI in 76 patients. During shoulder arthroscopy, 82 transmural cuff tears were found. One tear identified by MRI could not be verified by arthroscopy. A total of 7 lesions were not identified preoperatively, which included 4 cases of subscapularis tendon and 1 of the supraspinatus tendon. Thus, sensitivity of MR imaging was 0.90 with a specificity of 0.91. A labral lesion was diagnosed by MRI in 16 patients, while during arthroscopy, 31 labral lesions were found. One MRI lesion could not be confirmed. Except for one lesion, none of the 13 SLAP lesions could be diagnosed by MRI. Thus, the sensitivity of MR imaging was 0.52 and specificity was 0.89.

Discussion

Native MR imaging is a reliable diagnostic procedure for the evaluation of transmural rotator cuff tears. Labral lesions, however, and especially SLAP lesions can not always be identified during routine native MRI. Here special scans, for instance in the ARBER position, or contrast-enhanced techniques should be taken into consideration to improve the correlation to arthroscopic results.     

Die operativen Verfahren an amputierten Gliedern zur Ausnützung der Stumpfkräfte

Ohne Zusammenfassung     

Stellenwert einer präoperativen Klassifikation erwarteter intraoperativer Schwierigkeiten

Background

This study examined the validity of the classification of intraoperative difficulties and its usefulness in surgical practice.

Material and methods

Data on general surgical patients were collected in four German hospitals within a multicentre validation study. Before and immediately after surgery, the operating surgeon rated the relative difficulty of the operation using a score of 1 (easy), 2 (not easy), 3 (difficult) and 4 (very difficult). Data on the duration of surgery and on the occurrence of intraoperative and postoperative complications were collected. Multivariate regression models were constructed to examine whether different clinical variables and the surgeon’s preoperative assessment of surgical difficulty increased the power of the prognostic model. The R² statistics, which describe explained variance (EV) as a percentage was used to compare regression models.

Results

From July 2010 to August 2011 overall 500 patients were analyzed. Most patients were classified as being ideal (30?%) or relatively ideal (49?%) candidates for surgery. Preoperative and postoperative classification results were identical in 64?% of patients and were partly determined by classical risk factors (ASA score, number of previous surgeries, type of surgery, body mass index and gender). The addition of the surgeon’s risk estimation to the multivariate models improved the prediction of duration of surgery (from 41.4% to 45.5?% EV), complications (from 22.5% to 24.5?% EV) and length of stay (from 32.6% to 34.5?% EV).

Conclusions

The classification of intraoperative difficulty can be applicable in surgical daily practice in terms of surgical decision-making in difficult intraoperative situations as well as in operating room management. It could also be useful for other surgical disciplines.     

Erfahrungen mit der präoperativen Strahlenbehandlung des Oesophaguskrebses

Ohne ZusammenfassungMit 10 TextabbildungenEhemaliger Stipendiat der A. v. Humboldt-Stiftung.Wissenschaftlicher Assistent der Chirurgischen Klinik der Universität Erlangen-Nürnberg (Direktor Prof. Dr.G. Hegemann). 1963 mit Unterstützung der Deutschen forschungsgemeinschaft und der F. Thyssen-Stiftung Gastarzt der Chirurgischen Universitätsklinik Chiba.     

Beiträge zur operativen Behandlung des Kropfes

Ohne Zusammenfassung