Das koronare Stealsyndrom

The internal mammary artery is being used more frequently for the revascularization of the coronary arteries in patients with angina pectoris. A stenosis of its donor vessel can result in a so-called coronary steal syndrome. The clinical and investigational aspects as well as the therapeutic options for this phenomenon are discussed. A 59-year-old man, active in sports, was suffering from renewed pain in the arm and angina pectoris when participating in sports after revascularization of the coronary arteries with the internal mammary artery. The reason for the recurrent complaints was a stenosis of the proximal left subclavian artery, which was successfully treated with PTA. The so-called coronary steal syndrome can be suspected clinically when the radial arterial pulse is decreased or absent and a significant fall in systolic blood pressure and a supraclavicular bruit are found. The diagnosis is confirmed by angiography. Percutaneous dilatation, mostly combined with primary stenting, is the therapy of choice in the treatment of a stenosis. The occluded subclavian artery is best treated surgically by transposition of the subclavian artery into the common carotid artery.     

Das arterioarterielle Interponat als Dialysezugang

We report on two patients who received arterio-arterial PTFE grafts as vascular access for chronic hemodialysis. In both patients prior surgery for arteriovenous fistulas using either subcutaneous veins or arteriovenous, artificial PTFE grafts had failed due to recurrent thrombosis and septic complications. The arterio-arterial grafts were each positioned as a subcutaneous loop on the thigh and anastomosed with the common femoral artery and the superficial femoral artery or the profunda femoris, respectively. Postoperatively, both patients received coumadine for anticoagulation. Nine months after surgery no complications were observed in the former patient. The latter patient experienced recurrent thrombotic occlusion of the graft and a new graft was required which was anastomosed end-by-end onto the common femoral artery. As yet, 5 months after the second operation, no further complications have been reported. In conclusion, in patients lacking suitable veins for arterio-venous anastomoses, artificial arterio-arterial grafts may provide vascular access for chronic hemodialysis.     

Dialysefistelassoziiertes Stealsyndrom –Ist ein Fistelerhalt möglich?

Dialysis fistula-associated steal syndrome (DASS) is a rare complication, with many factors involved in its origin. We present two patients with different forms of steal syndrome. In case 1, that of a patient with acute monomelic neuropathy, it was possible to conserve the fistula (by fistula banding), and good hand function was achieved. In case 2, however, that of a patient with dystrophic syndrome, neither initial banding nor later closure of the fistula led to any improvement in the defective function of the hand. In contrast to chronic alterations, in acute neuropathies preservation of the fistula by banding might be indicated; our case is the first documented case of its kind.     

Reoperationen nach der Fundoplicatio nach Nissen

Zusammenfassung 1. Die Ursachen der unbefriedigenden Ergebnisse der Operation der Fundoplikation nach Nissen sind in der Regel durch taktische und technische Fehler zu erklären. 2. Die Fixation des Magens zum Zwerchfell ist eine Ursache der Entstehung des Schmerzsyndroms, des TeleskopPhänomens, des teilweisen oder vollständigen Auseinanderweichens der Fundoplikationsmanschette mit nachfolgender Entwicklung eines Rezidivs der Refluxoesophagitis. 3. Die Fundoplicatio sollte in Kliniken durchgeführt werden, die Erfahrung mit Eingriffen an der Speiseröhre und am Magen haben. 4. Die Fundoplikationsmanschette muß man aus zwei Wänden (des vorderen und des hinteren) Magens nach der breiten Mobilisation des Kardiabereiches mit der obligatorischen Fixation der Manschette zur Speiseröhre bilden, die ermöglicht, Komplikationen wie Schmerzsyndrom, Abgleiten der Manschette, Rezidive der Refluxoesophagitis zu vermeiden.

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Reoperations after nissen fundoplication

Summary 1. The main causes of unsatisfactory results after Nissen fundoplication can usually be explained by tactical and technical mistakes. 2. The fixation of the stomach to the diaphragm is one case of the development of pain syndrome, telescopic phenomenon and relative or complete dispersion of fundoplication with subsequent development of a recurrent reflux oesophagitis. 3. The fundoplication should be done only in hospitals which have experience in oesophageal and gastric surgery. 4. The collar of fundoplication should be formed with the two sides (the anterior and the posterior) of the stomach after extensive mobilisation of the cardia region. The operation includes the obligatory fixation of the collar to the oesophagus in order to avoid complications like pain syndrome, sliding of the collar and recurrent reflux oesophagitis.

     

Langzeitbeschwerden nach minimal-invasiven thoraxchirurgischen Operationen und nach Thoracotomie

Einleitung: Minimal-invasive Techniken haben in der Thoraxchirurgie zu einer Verminderung von unmittelbar postoperativen Schmerzen geführt. über die H?ufigkeit chronischer postoperativer Beschwerden liegen jedoch nur wenige Beobachtungen vor. Ziel der vorliegenden Untersuchung war es, am Beispiel von Patienten mit Spontanpneumothorax die H?ufigkeit von chronischen Beschwerden nach minimal-invasiven Eingriffen zu evaluieren. Methoden: Es wurden 60 Patienten unter Verwendung eines standardisierten Fragebogens befragt und die H?ufigkeit, Intensit?t und Charakteristik von chronischen Schmerzen und Beschwerden erfa?t. Die mediane Beobachtungszeit betrug 59 Monate. Mit Hilfe des gleichen Fragebogens wurden weiterhin 27 Patienten nach anterolateraler Thoracotomie bei benignen Grunderkrankungen im Median 24 Monate postoperativ untersucht. Ergebnisse: Nach minimal-invasiver Operation gaben 19 (31,7 %) von 60 Patienten an, unter chronischen Beschwerden zu leiden. Analgeticabedürftige Schmerzen zeigten 2 Patienten (3,3 %). Auf einer visuellen Analogskala (0 = kein Schmerz bis 100 = st?rkster vorstellbarer Schmerz) bewerteten 17 Patienten die Schmerzintensit?t in einem Bereich < 20, und bei 2 Patienten (3.3 %) war die Schmerzintensit?t > 50. überwiegend wurde der Schmerz als schneidend beschrieben (9/60 Patienten, 15 %). Nach Thoracotomie klagten 14 (51,8 %) Patienten über chronische Beschwerden, davon 5 (18,5 %) mit Analgeticabedarf. Die mittlere Schmerzintensit?t (Analogskala) betrug nach minimal-invasiver Operation 3,6 Punkte, nach Thoracotomie 14,4 Punkte (p = 0,01). Schlu?folgerungen: Auch nach minimal-invasiven thoraxchirurgischen Eingriffen kommen chronische Beschwerden vor. Diese sind aber seltener und weniger belastend als nach Thoracotomie.     

Langzeitbeschwerden nach minimal-invasiven thoraxchirurgischen Operationen und nach Thoracotomie

Zusammenfassung. Einleitung: Minimal-invasive Techniken haben in der Thoraxchirurgie zu einer Verminderung von unmittelbar postoperativen Schmerzen geführt. über die H?ufigkeit chronischer postoperativer Beschwerden liegen jedoch nur wenige Beobachtungen vor. Ziel der vorliegenden Untersuchung war es, am Beispiel von Patienten mit Spontanpneumothorax die H?ufigkeit von chronischen Beschwerden nach minimal-invasiven Eingriffen zu evaluieren. Methoden: Es wurden 60 Patienten unter Verwendung eines standardisierten Fragebogens befragt und die H?ufigkeit, Intensit?t und Charakteristik von chronischen Schmerzen und Beschwerden erfa?t. Die mediane Beobachtungszeit betrug 59 Monate. Mit Hilfe des gleichen Fragebogens wurden weiterhin 27 Patienten nach anterolateraler Thoracotomie bei benignen Grunderkrankungen im Median 24 Monate postoperativ untersucht. Ergebnisse: Nach minimal-invasiver Operation gaben 19 (31,7 %) von 60 Patienten an, unter chronischen Beschwerden zu leiden. Analgeticabedürftige Schmerzen zeigten 2 Patienten (3,3 %). Auf einer visuellen Analogskala (0 = kein Schmerz bis 100 = st?rkster vorstellbarer Schmerz) bewerteten 17 Patienten die Schmerzintensit?t in einem Bereich < 20, und bei 2 Patienten (3.3 %) war die Schmerzintensit?t > 50. überwiegend wurde der Schmerz als schneidend beschrieben (9/60 Patienten, 15 %). Nach Thoracotomie klagten 14 (51,8 %) Patienten über chronische Beschwerden, davon 5 (18,5 %) mit Analgeticabedarf. Die mittlere Schmerzintensit?t (Analogskala) betrug nach minimal-invasiver Operation 3,6 Punkte, nach Thoracotomie 14,4 Punkte (p = 0,01). Schlu?folgerungen: Auch nach minimal-invasiven thoraxchirurgischen Eingriffen kommen chronische Beschwerden vor. Diese sind aber seltener und weniger belastend als nach Thoracotomie.      

Ueber Brand nach Thrombosirung von Schlagadern und nach Erfrierung

Ohne Zusammenfassung     

Auftreten eines Karzinosarkoms nach Radiotherapie eines Lokalrezidivs nach radikaler Prostatektomie

Carcinosarcoma of the prostate is an extremely rare tumor. In the case of rapid tumor progression, especially after radiation therapy to the pelvis or after hormone deprivation therapy because of prostate cancer, this tumor entity should be considered, and immediate histological confirmation is required. The only curative therapy is immediate radical surgical excision. We report about the first case of a carcinosarcoma after salvage radiation therapy for local recurrence of adenocarcinoma of the prostate years after radical prostatectomy.     

Sepsis nach Eigenbluttransfusion

Postoperatively, after an uncomplicated vaginal hysterectomy, a 58-year-old female patient developed the signs of disseminated intravascular coagulation and fever, which progressed to a septic shock. She received two units of autologous blood, one during and one after the operation. A blood culture from the patient and one unit of the autologous blood showed abundant growth of Pseudomonas cepacia and Serratia marcescens within 24?h and culture of this blood bag also showed slight growth of Staphylococcus epidermidis within 48?h. Culture of the second blood unit showed slight growth of Propionibacterium acnes. The source of bacterial contamination could not be identified. Autologous blood products thus also include a risk of infection that shouldn't be underestimated, and a strict medical indication to retransfusion is indispensable.     

Innominatumosteotomie nach Salter

The prevalence of congenital hip dysplasia in Germany is 2–4?% and that of hip dislocation is 0.5–1?%. If early therapy is not successful or the hip dysplasia or dislocation is diagnosed too late (children of over 1 year of age) surgical treatment is indicated to increase the femoral coverage. The innominate osteotomy, published by Robert B. Salter 1961, is a worldwide established technique to improve the lateral and ventral coverage of the femoral head in primary or secondary hip dysplasia or dislocation. In this paper we discuss Salter’s technique and present indications, the perioperative procedure, operative modifications and operative extensions and demonstrate the anatomical requirements, postoperative biomechanical changes and long-term results.     

Shuntligatur nach Nierentransplantation

Cardiac diseases are very common in hemodialysis patients; therefore, an additional cardiac burden of an unnecessary vascular access is an important issue. Crucial considerations before shunt occlusion affect the prognosis of the transplant, the cardiac condition of the patient and the magnitude of blood flow. It is wise to wait 1 year after transplantation before ligation of the access may be considered, with good renal function shown by an estimated glomerular filtration rate (eGFR) > 40 ml/min. This should only be carried out if there are no apparent risk factors for graft loss. If the prognosis of the transplant is not clear the shunt blood flow should be determined and action should only be taken if the flow rate is high (e.g. ligature or throttling). This algorithm must be adjusted to the degree of heart insufficiency and to the individual cardiac situation.     

Ischiasneuropathie nach Beckenbodenrekonstruktion

After the surgical treatment of a recurrent enterocele and rectocele using a polypropylene implant, a patient developed a reversible paralysis. Haematoma was excluded. To search for the cause of the paralysis, polypropylene implants were inserted in four ethanol-preserved cadavers. Their dissection showed a safe distance at all points between the implant and the sciatic nerve. The patient’s paralysis was most likely due to the lithotomy position, with an overstretching of the sciatic nerve during the intraoperative flexion of the hip joint.     

Nierenaktinomykose nach Ureterosigmoidostomie

Actinomycosis is a chronic infectious disease caused by a gram-positive anaerobe. The bacterial disease is known to predominantly affect the oropharyngeal mucosa and soft tissues as well as the gastrointestinal tract. However, renal involvement by actinomycosis is exceedingly rare. Thus, renal actinomycosis is usually diagnosed by means of histopathological assessment of nephrectomy specimens because affected patients seek medical care due to (peri-) renal mass lesion clinically mimicking cancer. To best of our knowledge, we present the first case worldwide reporting on a 65-year-old man diagnosed with renal actinomycosis following ureterosigmoidostomy in whom nephrectomy was performed due the clinical suspicion of renal cancer (stage cT4). Subsequently, calculated antibiotic therapeutic regimens were initiated after the diagnosis was suspected by the pathologist. During the entire postsurgical follow-up comprising a total of 6 months, the patient did not experience any local or systemic recurrence. In summary, detailed information concerning the etiology, the clinical symptoms as well as diagnostic and therapeutic options are discussed in our case report.     

Komplikationen nach Kreuzbandersatzplastiken

Reconstruction of the cruciate ligaments is elective surgery performed mainly on younger people. Therefore, complications are especially tragic. Diagnostics and indications include the possibility of complications. The complexity of an injury must be thoroughly appreciated, and to avoid intraoperative complications, it is important for the surgeon to have a comprehensive anatomical knowledge. A great number of stabilization procedures exist, each with its own learning curve and specific risks. Therefore, lab training of surgeons appears reasonable. The frequency of thromboembolism in the early postoperative stage should be minimized by evidence-based prophylaxis. Early diagnostics and treatment of thrombosis, embolism, and infection are required, and consultants should be brought in if necessary. Postoperative movement malfunction as arthrofibrosis can be widely avoided by the correct choice of the point for surgery and the surgical procedure. If arthrofibrosis occurs, mobility must be restored at an early stage, with special focus on full extension. A failure of reconstructed cruciate ligaments during rehabilitation and reintegration into sports is mostly based on overload of the ligaments. The stability of the reconstructed ligaments at the respective time point and motor function as well as the patient's physical condition should be reasonably considered. A medium-term graft failure is often based on surgical errors. So-called biological failure occurs only rarely.     

Komplikationen nach Klavikulafrakturen

To prevent complications it is recommended to treat non-displaced clavicle fractures conservatively, while in contrast displaced fractures should be approached surgically with open reduction and stable plate fixation. For operative management, surgical techniques should be employed that preserve soft tissue. The use of appropriate plate thickness as well as plate and screw lengths, and the correct positioning of the plate osteosynthesis are critical in avoiding complications. Cautious aftercare plays a decisive role. Management of complications includes the surgical concept of plate osteosynthesis with briding implant in combination with autogenous bone graft. In the case of atrophic nonunion additional biological activation can be administered. The treatment principles for infection subsequent to a previous operation entail eradication of the infection with radical resection of the affected bone and soft tissues, diligent soft tissue management, and sufficient bony stabilization following control of infection. In cases of malunion and neurovascular compression syndrome, corrective osteotomy or decompression by callus resection may be necessary.     

Lymphfistel nach Vertebralischirurgie

Lymphatic fistula is one of the most common complications after vertebral surgery of the distal segment. We compared the number of lymphatic fistulas after reconstructions of the distal vertebral artery (VA) in two periods: 1985–1991 and 1992–1997. Since 1992, we ligated every structure suspected to be a lymph vessel. From 1985 to 1997, a total number of 361 operations on the distal VA were performed: 105 operations on the right and 256 on the left side. In the first period, 133 distal VA reconstructions were performed out of which 7 patients (5.2%) showed a lymphatic fistula. In the second period, 228 distal VA reconstructions were performed out of which 6 patients (2.6%) suffered from a lymphatic fistula. We were able to decrease the complications of lymphatic fistulas from 5.2% to 2.6% in the past. On one hand this is due to the growing experience of the performing surgeon and on the other hand due to the application of a ligature to any lymph vessel.