381. Die operative Therapie beim Thoraxtrauma — eine retrospektive Studie

Zusammenfassung Nach multiplem Trauma sinken intracelluläre Aktivität und Konzentration der Elastase in polymorphkernigen Leukocyten (PMNL), die aus Blut ( = 67 U und 6154 g/10⁹ PMNL) und bronchoalveolärer Lavage (BAL)-Flüssigkeit ( = 44 U und 5957 g/10⁹ PMNL) isoliert wurden im Vergleich zu PMNL Gesunder ( = 106 U und 9962 g/10⁹ PMNL). Gleichzeitig wurde ein Anstieg der extracellulären Elastase-Konzentration in Plasma von = 84 g/1 auf = 399 g/1 und in BAL Flüssigkeit von = 8 g/1 auf = 561 g/1 beobachtet. Die durch Stimulation freigesetzte Elastase wird teilweise von einem spezifischen Receptor auf PMNL erneut gebunden. Die Ergebnisse unterstützen die PMNL-vermittelte ARDS-Pathogenese.     

New method of anesthesia in neurosurgery

Zusammenfassung Die Endotrachealnarkose ist die Methode der Wahl bei allen Operationen am Gehirn und Rückenmark.Eine extreme Blutdrucksenkung mil Pendiomid birgt die Gefahr einer anoxischen Schädigung parenchymalöser Organe in sich. Es ist daher die kontrollierte Blutdrucksenkung bei gleichzeitiger Stoffwechselsenkung durch Anwendung von Phenothiazine vorzuziehen.Die Dämpfung der vegetativen und psychischen Funktionen durch die Phenothiazine ist als Operationsvorbereitung besser als die Anwendung von Opiaten oder Barbituraten.

---

Summary The endotracheal anesthesia is the preferred method for all operations on brain and spinal cord.An excessive lowering of the blood pressure by means of Pendiomid may lead to an anoxic damage of the parenchymatous organs.Therefore the controlled hypotension is preferred with a simultaneous metabolic decrease by means of Phenothiazine.It is better to prepare the patient for the operation with decreasing of the vegetative and psychical functions by means of Phenothiazine than using opiates or barbiturates.

---

Resumen La narcosis endotraqueal es el método preferido para todas las intervenciones sobre el cerebro y médula espinal.Una disminución excesiva de la presión arterial por medio del Pendiomid Ileva en sí el peligro de un daño anóxico sobre los órganos parenquimatosos. Por esto, es preferible lá hipotensión controlada, con contemporánea disminución del recambio material con el empleo de Phenothiazina.La obnubilación de las funciones vegetatives y psíquicas como preparación a la intervención se obtiene mejor con la Phenothiazina que no con opiáceos y barbitúricos.

---

Résumé La narcose intratrachéale est la méthode préférée pour toutes les interventions sur le cerveau et sur la moëlle épinière.Une diminution extrême de la tension artérielle au moyen du «Pendiomid» peut devenir la cause d'une anossie des organes parenchymateux. Voilá la raison parce que une ipotension contrôlée avec diminution simultanée du métabolisme tissulaire au moyen de la «Phénothiazine» est une méthode á préférer. Afin de diminuer les fonctions végétatives et psychiques pour la préparation á l'intervention, il vaut mieux employer la «Phénothiazine» que les opiacées ou les barbituriques.

---

Riassunto L'anestesia endotracheale è il melodo di preferenza per tutti gli interventi sul cervello e sul midollo spinale.Una eccessiva diminuzione della pressione arteriosa per mezzo del Pendiomid porta con sè il pericolo di una anossia degli organi parenchimatosi. Perciò è da preferire l'ipotensione controllata con contemporanea riduzione del metabolismo tissulare per mezzo della Phenothiazina.L'obnubilamento delle funzioni vegetative e psichiche come preparazione all'intervento si ottiene meglio con la Phenothiazina che non con oppiacei o barbiturici.

---

---

Vorgetragen auf der 30. Tagung der Bayerischen Chirurgenvereinigung vom 24. und 25. Juli 1953 in München.     

Pre-operative and post-operative radiotherapy and rectal cancer

The appropriate role for additional radiotherapy in patients with resectable rectal cancer is not yet settled. Irradiation has been considered by surgeons and radiotherapists as superfluous since no effect on survival has been shown. However, numerous trials have demonstrated that perioperative radiotherapy decreases an often high local recurrence rate while others believe it has a definite place in routine management. Several surgeons have, on the contrary, claimed that a skilled surgeon compared to a less skilled surgeon, will get the same acceptably low local recurrence rates. Since we will probably never have a randomized trial comparing good and bad surgeons, this argument cannot be settled. A further obstacle arises in the difficulty of persuading surgeons to organize their routine work so that it is performed in an optimal way by those specializing in this field. The question also arises whether radiotherapy should be delivered pre-operatively, postoperatively or as a sandwich technique, i.e., both pre-operatively and postoperatively. According to radio-biological considerations and results from reported trials, the best effect on local tumor control has been achieved using pre-operative radiotherapy.

---

Resumen Aún no se ha defindo la indicación apropriada para radioterapia adicional en pacientes con cáncer rectal. La irradiación ha sido considerada como superflua por cirujanos y radioterapeutas, puesto que no se ha demostrado efecto sobre la sobrevida. Sin embargo, numerosos ensayos clínicos han demostrado que la radioterapia perioperatoria disminuye la que con frecuencia es una elevada tasa de recurrencía local, mientras ostros creen que tiene un lugar definido en el manejo rutinario. Por el contrario, varios cirujanos han planteado que un cirujano hábil comparado con uno menos hábil, logra las mismas aceptables tasas de recurrencia, alg que jamás se ha decidido, puesto que nunca habremos de realizar ensayos comparando buenos cirujanos con malos cirujanos. Un obstáculo adicional surge de la dificultad en cuanto a persuadir a los cirujanos de organizar su trabajo rutinario de tal manera que sea realizado en forma óptima por aquellos que se especializan en este campo. También ha surgido el interrogante sobre si la radioterapia debe ser administrada preoperatoriamente, postoperatoriamente o como técnica de sandwich, o sea tanto pre como postoperatoriamente. Según consideraciones radio-biológicas y los resultados de los ensayos clínicos, el mejor efecto sobre el control local del tumor ha sido logrado mediante el uso de radioterapia preoperatoria.

---

Résumé La place de la radiothérapie adjuvante chez les patients ayant un cancer du rectum reste discutée. La radiothérapie est estimée superflue par certains chirurgiens et radiothérapeutes car aucun bénéfice n'a eté clairement démontré en ce qui concerne la survie. De nombreux essais cliniques ont indiqué, cependant, que la radiothérapie périopératoire diminuait le taux habituellement élevé des récldives locales, et certains estiment que la radiothérapie a toujours une place dans le schéma thérapeutique. D'autres, au contraire, croient que la quialité et l'expérience de l'opérateur influencent directement le taux de récidives, et équivalent l'efficacité de la radiothérapie. Puisqu'il est peu probable qu'on réalise une étude randomisée entre les bons et les mauvais chirurgiens, on ne peut régler cette querelle. Un autre obstacle incontournable semble être de persuader les chirurgiens d'organiser leur travail de façon à ce que cette chirurgie soit faite par des spécialistes. Le meilleur moment pour réaliser la radiothérapie (préopératoire, postopératoire, ou les deux) reste à déterminer. Selon les données radiobiologiques et les résultats des essais contrôlés, il semble que le meilleur contôle sur les récidives locales soit obtenu par la radiothérapie préopératoire.

     

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.     

Role of endogenous interferon gamma in murine tumor growth and tumor necrosis factor alpha antitumor efficacy

Background: The anticancer role of tumor necrosis factor-alpha (TNF-) has been limited by toxicity. These experiments evaluate blocking endogenous interferon-gamma (IFN-) activity to abrogate TNF- toxicity. Methods: C57Bl/6 mice bearing MCA 105 tumor were treated with TNF- and anti-IFN- antibody (Ab) to evaluate the effect on the acute lethality of TNF- and their efficacy as evaluated by tumor growth rate, tumor histology, and survival. Results: Anti-IFN- Ab decreased TNF- lethality. Anti-IFN- Ab alone increased tumor growth significantly more than did nonimmune IgG (p₂<0.0001). Tumor-bearing mice that received nonimmune IgG and TNF- had slower tumor growth (p₂<0.02) and a trend toward improved survival (p=0.07) compared with saline-treated controls. Anti-IFN- Ab abrogated the antitumor effect of TNF-, prevented acute tumor necrosis histologically, and resulted in tumor growth rate and host survival similar to that of controls. The findings in mice that received anti-IFN- Ab and high-dose TNF- were comparable with those in mice that received a lower, equitoxic dose of TNF- alone. Conclusions: Blocking endogenous IFN- accelerates tumor growth in this model and partially abrogates the toxic and antitumor activity of exogenous TNF- equally. This suggests that blocking endogenous IFN- activity is not a useful strategy for limiting TNF- treatment toxicity.Presented in part at the 45th Annual Cancer Symposium of The Society of Surgical Oncology, New York, New York, March 15–18, 1992.     

Elevated concentrations of the β-subunit of S100 protein in renal cell tumors in rats

Concentrations of and -subunits of S100 protein (S100- and S100-) in rat kidney neoplasms, including renal cell and mesenchymal tumors, were determined using a highly sensitive enzyme immunoassay, and both types immunohistochemically localized in tissue sections. Concentration of S100- in each histological type of rat tumor were lower than in normal kidney, whereas levels of S100- (mean±SE: 29.7±14.2 ng/mg protein, n=15) in renal cell tumors were significantly higher than in normal kidneys (0.55±0.06 ng/mg protein, n=7), or mesenchymal tumors (1.21±0.43 ng/mg protein, n=9). In normal rat kidney tissues S100- was immunohistochemically positive in epithelial cells of the distal tubules, the thin limbs of loops of Henle, and the collecting ducts. No appreciable immunostaining for S100- was found in any nephron segment. Both S100- and S100- were positive for renal cell tumors, indicating new appearance of the latter during renal carcinogenesis in rats.     

Über einen bemerkenswerten,bisher nicht bekannten Fremdkörperileus

Zusammenfassung Es wird über einen höchst ungewöhnlichen Fall von Obturationsileus berichtet, den ein gut pflaumengroßer Fremdkörper im Dünndarm verursachte. Der Fremdkörper bestand zum Teil aus Speiseresten, im wesentlichen aber aus UHU-Klebstoff (polymerisiertem Polyvinylacetat), welcher die Speisereste zusammenballte. Histochemisch gelang es, die Fremdmassen als UHU-Alleskleber zu identifizieren. Nachträglich gab der Patient zu, den Klebstoff lange Zeit als Kaugummiersatz benutzt und oftmals verschluckt zu haben. Nach operativer Entfernung des Fremdkörpers durch Enterotomie komplikationslose Heilung.Mit 1 TextabbildungHerrn Prof. Dr.F. Spath zum 65. Geburtstag gewidmet.     

In comparison: 1.064 μm-1.318 μm Nd-YAG continuous wave lasers. In vitro and in vivo experiments for endoscopic tumour therapy in the gastrointestinal tract

In in vitro and animal experiments the tissue effects of the 1.318m Nd-YAG laser were compared to those of the standard 1.064m Nd-YAG laser in order to evaluate the advantages of the new wavelength with a ten times higher absorption in water for gastroenterological tumour treatment. Under irradiation parameters related to clinical endoscopic practice, the laser of the wavelength 1.318m needs for both vaporization and coagulation significantly less energy than the 1.064m laser. Since vaporization at 1.318m is always accompanied by a higher coagulation effect compared to 1.064m the risk of late necrosis and resulting perforation appears to be increased.     

173. Tierexperimentelle Ergebnisse mit einem voll implantierbaren Distraktionsgerät zur operativen Beinverlängerung

Zusammenfassung Zur operativen Beinverlängerung wurde ein neues Femur-Distraktionsgerät entwickelt. Das Gerät besteht aus einem elektronisch programmierbaren Distraktionsaggregat einschließlich Kraftquelle und einer zweiteiligen Führungsschiene. Das Gesamtsystem ist voll versenkbar und schafft Übungsstabilität während der Distraktionsphase. Die Funktionen Vorlauf — Stop —Rücklauf können transcutan induktiv gesteuert werden. Ein für das Tierexperiment speziell entwickelter Prototyp des Gerätes wurde an Schafen erfolgreich erprobt.     

Distal Margin Requirements After Preoperative Chemoradiotherapy for Distal Rectal Carcinomas: Are ≤ 1 cm Distal Margins Sufficient?

Background:Sphincter-sparing alternatives to abdominoperineal resection (APR) in the treatment of rectal cancer often are underused out of concern for inadequate distal margins and local failure. The present study addresses whether sphincter-sparing techniques with distal margins 1 cm adversely influence oncological outcome in patients given preoperative chemoradiotherapy.Methods:Thirty-seven patients with rectal cancer 8 cm from the anal verge were enrolled in the study. Preoperative external beam radiotherapy (5400 Gy) was administered together with continuous infusion of 5-fluorouracil (300 mg/m²/day). Surgical resection was performed in 36 patients with pathological assessment of tumor response and margins. Patients with sphincter-sparing resection and distal margins > 1 cm or 1 cm and those who underwent APR were compared.Results:Thirty-six patients completed preoperative chemoradiotherapy, with successful sphincter-preservation in 28 patients. At a median follow-up of 33 months, there were 12 recurrences overall, which included 11 distant failures and four pelvic failures. Disease-free survival (DFS) was not different between those who had an APR compared with sphincter-sparing resection with distal margins 1 cm. DFS was worse (P < .02) when radial margins were 3 mm compared with > 3 mm.Conclusions:Sphincter preservation is feasible in more than 75% of patients with tumors 8 cm from the anal verge after preoperative chemoradiotherapy. Sphincter-sparing surgery with distal margins 1 cm can be used without adversely influencing local recurrence or DFS. Limited radial margins ( 3 mm), however, are associated with increased disease recurrence.Presented at the 1998 Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 18, 1998     

Behandlung der Speichenbrüche am peripheren Ende mit dem Faustgipsverband

Zusammenfassung Es wird über die Ruhigstellung von schweren Brüchen der Speiche an ihrem peripheren Ende nach der Einrichtung mit einem kurzen Faustgipsverband berichtet. Diese Verbandanordnung hat den Vorteil, daß sich die gute Stellung der Bruchstücke nach dem Einrichten bis zu ihrer Heilung erhalten läßt. Bei richtiger Verbandtechnik, die ausführlich beschrieben wird und aktiver Bewegungstherapie kann der kurze Faustgipsverband auch bei alten Leuten ohne schädigende Folgen angelegt werden.Mit 3 Textabbildungen (11 Einzelbilder)Herrn Professor Dr. Lorenz Böhler zum 80. Geburtstag gewidmet.     

Potentiation of transforming growth factor (TGF-β1) by natural coral and fibrin in a rabbit cranioplasty model

The association of a biodegradable material and a growth factor could be of clinical value for treating bone defects. We therefore tested the association of transforming growth factor (TGF-1) in fibrin glue and coral granules to heal skull defects in rabbits. Adult rabbits underwent a double trepanation symmetrically in both parietal bones. Using histomorphometry, we compared bone repair after 1 month in control animals (n=5) and in animals treated with either TGF-1 as a single injection of 1 g in methylcellulose (n=5) or in fibrin glue (n=5), or with coral granules in fibrin glue (n=4) or with coral granules and TGF-1 1 g in fibrin glue (n=5). We measured the diameter of the remaining defect and the surface of the bone growth. TGF-1 without coral in either methyl cellulose or fibrin induced a partial closure of the defect as assessed by a significant decrease in the defect diameter, compared with the control group. However, the association of TGF-1 in fibrin and coral induced an area of the bone growth higher than in any other groups (P<0.05). Two months after surgery, this triple association induced a better healing of the defect than coral alone or control group. In each group treated with TGF-1, the mineralization rate was increased not only at the treated side but also in the contralateral defect which was untreated, suggesting a diffusion of the growth factor. Indeed, when pooled together, the diameter of the defect at the contralateral side of 14 animals that had received TGF-1 was reduced compared with the control group. Significant coral granules resorption occurred between month 1 and 2 and was unchanged by the addition of TGF-1. In conclusion, the triple association of coral granules and TGF-1 in fibrin could be of interest for treating bone defects.     

33. Der „kalte” Schilddrüsenknoten

Zusammenfassung Der kalte Schilddrüsenknoten gilt als typischer Verdachtsbefund für ein Schilddrüsencarcinom. Seine tatsächliche Dignität ist mit klinischen Mitteln sowie Szintigraphie und Sonographie letztlich nicht zu klären. Das beste abgrenzende Selektionskriterium ist die Feinnadel-Punktionscytologie, wodurch mit Gültigkeit für das Kropfendemiegebiet etwa die Hälfte als suspekte Befunde von dem anderen Teil hochwahrscheinlich gutartiger Veränderungen getrennt und für die Operationsindikation reserviert werden kann.     

In transit metastases of malignant melanoma treated by high dose rTNFα in combination with interferon-γ and melphalan in isolation perfusion

To increase the therapeutic efficacy of recombinant tumor necrosis factor alpha (rTNF) and reduce the systemic side effects, a protocol was designed using isolation perfusion of the limbs with hyperthermia for in transit metastases of melanoma. A triple combination of high dose rTNF + recombinant interferon-gamma (rIFN-) + melphalan was chosen because of a synergistic anti-tumor effect of rTNF with rIFN- and of rTNF with alkylating agents reported in the literature. Twenty-nine patients of mean age 60 years (range 22–82 years) entered the study after informed consent and received a total of 31 isolation perfusions with the triple combination. There were 24 women and 5 men with multiple progressivein transit melanoma metastases of the lower limb (stage IIIa or IIIab). rTNF at the unique dose of 4 mg was injected as a bolus in the arterial line, under mild hyperthermic conditions (40 to 40.5°C) for 90 minutes. rIFN- was given subcutaneously on days –2 and –1 and in the perfusate, with rTNF, at the dose of 0.2 mg. Melphalan was administered in the perfusate at dose giving a concentration of 40 µg/ml.In all the 31 isolation perfusions performed in the triple combination protocol, in order to prevent a septic shock-like syndrome which had been encountered in 2 patients treated outside this protocol for sarcoma and carcinoma, the patients received dopamine continuous infusion at 3 µg/kg/min from the start of isolation perfusion and for 48 hours, and only showed mild hyptension and very transient chills and temperature. Regional toxicity attributable to rTNF was minimal. There have been 16 patients with hematologic toxicity consisting of neutropenia (11 cases, 1 case grade 4 and 1 case grade 3) and neutropenia with thrombocytopenia (12 cases, 1 case grade 4 and 4 cases grade 2). Eighteen of 29 patients had been previously treated with melphalan in isolation perfusion (n=13) or with cisplatinum (n=2), rTNF-Melphalan (n=1), or rTNF alone (n=2). Median follow-up has been 41 weeks. The 29 patients are evaluable: there have been 26 (90%) complete remissions (CR), 3 (10%) partial remissions (PR), and no failures. Actuarial disease-free survival and total survival have been 63% and 73%, respectively, at 12 months. In all cases, softening of the nodules was obvious within 3 days after isolation perfusion and time to definite response ranged between day 6 and 22.This interim analysis of a phase II study suggests that high dose of rTNF can be administered with acceptable toxicity by isolation perfusion with dopamine and hyperhydration. Tumor responses can be evidenced in all patients, with 90% CR. Furthermore, combination of rTNF, rIFN-, and melphalan seems to achieve high efficacy with minimal toxicity, even after failure of prior therapy with melphalan alone.

---

Resumen Se diseñó un protocolo que utiliza la perfusión aislada de las extremidades con hipertermia a fin de incrementar la eficacia terapéutica del factor necrotizante tumoral alfa recombinante (rFNT) y reducir sus efectos secundarios sistémicos, en el tratamiento de metástasis en tránsito del melanoma. Se escogió una combinación triple de alta dosis de rFNT + interferóngamma recombinante (rIFN-) + melfalán en virtud del efecto sinergístico antitumoral del rTNF con el IFN- y del rTNF con los agentes alquilantes informados en la literatura. Veintinueve pacientes con edad promedio de 60 años (rango 22–82) ingresaron al estudio bajo consentimiento informado y recibieron un total de 31 perfusiones aisladas con la triple combinación. Hubo 24 mujeres y 5 hombres con metástasis en tránsito de melanoma de la extremidad inferior (estado IIa o IIIab). El rTNF en la dosis única de 4 mg fue inyectado en bolo en la línea arterial, bajo condiciones levemente hipertermicas (40 a 50°C) por 90 minutos. El rIFN- fue administrado en los días –2 y –1 en el líquido perfusión, con rTNF en la dosis de 0.2 mg. El melfalán fue administrado en el líquido de perfusión en una dosis para proveer una concentración de 40 µg/ml.En todos los casos de perfusión aislada en el protocolo de triple combinación, y con el objeto de prevenir un cuadro del tripo de shock-syndrome que había sido observado en 2 pacientes tratados por sarcoma y carcinoma por fuera de este protocolo, se administró dopamina en infusión continua a una rata de 3 µg/kg/min desde el comienzo de la pefusión aislada y, por 48 horas; los pacientes sólo exhibieron hipotensión leve y escalofríos y fiebre transitorios. La toxicidad regional atribuible as rTNF fue mínima. Se han presentado 16 casos con toxicidad hematológica consistente en nuetropenia (11 casos, uno grado 4 y uno grado 3) y neutropenia con trombocitopenia (12 casos, uno grado 4 y cuatro grado 2). Dieciocho de 29 pacientes habían sido previamente tratados con melfalán en perfusión aislada (13/29) o con cisplatino (2/29), rTNF-melfalán (1/29) or rTNF solamente (2/29). El promedio del sequimiento fue 41 semanas. Los 29 pacientes son valorables: ha habido 26 remisiones completas (90%), 3 remisiones parciales (10%) y ninguna falla. Las tasas de sobrevida actuarial libre de enfermedad y de sobrevida total han sido 63% y 73%, respectivamente, a 12 meses. En la totalidad de los casos apareció evidente el ablandamiento de los nódulos en los primeros 21 días después de la perfusión aislada y el intervalo hasta la respuesta difinitiva varió entre el día 6 y el día 22.El análisis interim de un estudio de fase II sugiere que la alta dosis de rTNF puede ser administrada con aceptable toxicidad por perfusión aislada con dopamina e hiperhidratación. Las respuestas tumorales pueden ser evidenciadas en la totalidad de los pacientes, con 90% de remisión completa. Además, la combinación de rTNF, rIFN- y melfalán parece ser de elevada eficacia con toxicidad mínima, aún después de una falla terapéutica con melfalán sólo.

---

Résumé Pour augmenter l'efficacité thérapeutique du facteur recombinant de nécrose tumorale alpha (rTNF) et pour réduire les effets secondaires, on a élaboré un protocole utilisant une perfusion isolée des extrémités associée à une hyperthermie chez les patients atteints de métastases d'un mélanome. En raison d'un effet synergique antitumoral, de rTNF et de l'interféron gamma recombinant (rIFN) d'une part et de rTNF et des agents alkylisants d'autres part (effet rapporté dans la littérature), on a utilisé une triple combinaison de rTNF à hautes doses, rIFN et melphalan. Vingt neuf patients d'âge moyen de 60 ans (extrêmes 22–82 ans) ont été inclus dans cette étude après avoir donné leur consentement éclairé. Ils ont reçu un total de 31 perfusions de la tripe association. Il y avait 24 femmes et 5 hommes ayant des métastases multiples extensives des membres inférieurs (stade III a ou II ab). rTNF a été administré à une dose unique de 4 mg injectée en bolus par voie artérielle, dans des conditions d'hyperthermie modérée (40 à 40.5°C) pendant 90 minutes. rTNF a été donné en souscutanée aux jours –2 et –1 mélangé à la perfusion de rTNF à la dose de 0.2 mg. Le melphalan a été administré à la concentration de 40 mg/ml. Pour éviter un syndrome de choc rencontré chez deux patients traités hors protocole pour sarcome et carcinome, tous les patients de ce protocole ont reçu de la dopamine en perfusion continue à la dose de 3 µg/kg/mn depuis le début de la perfusion et pendant 48 heures, et n'ont eu qu'une hypotension modérée avec des frissons transitoires. La toxicité attribuée au rTNF était minime. On a eu 16 cas de toxicité hématologique comprenant une neutropénie (11 cas, 1 grade 4, 1 grade 3) et neutropénie avec thrombopénie (12 cas, 1 grade 4, 4 grade 2). Dix huit patients avaient déjà été traités par Melphalane en perfusion isolée (13/39) ou en association avec du cisplatinium (2/29) ou par l'association rTNF-melphalan (1/29) ou le rTNF seul (2/29). Le suivi moyen était de 41 semaines. Sur les 29 patients évalués, il y a eu 26 rémissions complètes (RC) (90%), 3 rémissions partielles (RP) (10%) et ancun décès. Les survies actuarielles sans maladie et globale à 12 mois sont respectivement de 63 et de 73%. Dans tous les cas, les nodules se sont assouplis en moins de 3 jours après le début de la perfusion. Le délai de réponse au traitement variait entre 6 et 22 jours. L'analyse intermédiaire de l'étude de phase II suggère que de fortes doses de rTNF peuvent être administrées avec une faible toxicité en perfusion associées à la dopamine et à une hyperhydratation. La réponse tumorale était évidente chez tous les patients avec une CR de 90%. De plus, l'association de rTNF, IFN et melphalan semble donner une grande efficacité avec une toxicité minime, même en cas d'échec antérieur avec le melphalan utilisé seul.

     

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.     

A versatile procedure for the closure of small skin defects

The author describes a method for the primary, direct closure of wide skin lesions, combining the lazy S, crown, and the H-advancement flap techniques. The lazy S edges of the flaps permit the satisfactory use of adjacent surrounding skin with good aesthetic results, when the flaps alone would otherwise be placed under too much strain.     

Case Report: Intracerebral Hemorrhage After γ-Knife Surgery for Metastatic Brain Tumor

The authors report a case of a 69-year-old man with metastatic brain tumors who died of spontaneous intracerebral hemorrhage 3 days after -knife surgery. He had been suffering from lung cancer with multiple systemic metastasis. Preoperative magnetic resonance images showed two well-defined round lesions with intratumoral hemorrhage in the left frontal and right occipital lobe. There was no bleeding tendency in the hematological examination and the patient was normotensive. -Knife surgery was performed on both lesions in a single session. However, the patient died of massive intracerebral hemorrhage from the left frontal lesion 3 days after the surgery. There have been no previous reports of mortality resulting from spontaneous intracerebral hemorrhage after -knife surgery in metastatic brain tumors documented in the literature. It is likely that the two events, -knife surgery and spontaneous intracerebral hemorrhage, occurred separately and were not associated. However, it is worth noting that there is a possibility of bleeding after -knife surgery, especially in a metastatic brain tumor with preexisting intratumoral hemorrhage as in our case.     

Tetracycline double-labeling of iliac trabecular bone in 41 normal adults

Summary A histomorphometric evaluation of the iliac crest trabecular bone remodeling was performed after tetracycline double-labeling in 41 normal Danes (12 males and 29 females) aged 19 to 56 years. The fraction of formative (osteoid covered) and resorptive surfaces was unrelated to age but higher in males than in females (P<0.02 andP<0.05, respectively). The appositional rate (0.65±0.12 m/day) was unrelated to age and sex, whereas the fractional labeled surfaces were higher (P<0.01) in the males (0.18±0.08 m²/m²) than in the females (0.12±0.05 m²/m²), and among the females inversely related to age (R=–0.38,P<0.05). The bone formation rate at BMU level (0.50±0.20 m³/m²/day) was unrelated to sex, but among the females inversely related to age R=–0.49,P<0.01). The bone formation rate at tissue level was higher (P<0.02) in the males (0.13±0.07 m³/m²/day) than in the females (0.07±0.03 m³/m²/day) and among the females inversely correlated to age (R=–0.43,P<0.05). The age- and sex-dependent variations in the dynamic parameters underline the importance of a more elaborated normal material.     

Vertical lengthening of the unilateral cleft lip after a triangular flap repair

Summary A triangular flap repair for unilateral cleft lip is stated to have the potential problem of creating a lip that is too long. Although preoperative measurements were performed with calipers, the gap created in the medial segment was directly measured during the procedure, in order to determine the size of the flap more precisely. Ninety patients with complete unilateral cleft lips underwent a triangular flap repair using this method. The symmetry of the Cupid's bow was evaluated at a follow-up period averaging between six years and three months. Sixty-two lips obtained symmetry and the remaining 28 cases showed a lip which was too long; none of the lips were too short. The comparison between 27 primary palate clefts (UCLA) and 63 primary and secondary palate clefts (UCLP) showed no significant difference in the surgical result. The preoperative shortness of the lip on the cleft side was significantly greater in the too long group (5.01 ± 0.95 mm) than in the symmetry group (4.40 ± 0.87 mm). The width of the flap used was significantly larger in the too long group (3.76 ± 0.79 mm) than in the symmetry group (3.42 ± 0.69 mm). The triangular flap repair with intraoperative measurements is considered to be beneficial, although preoperative measurements provide an optimal design in most cases. It is suggested that the use of a wider triangular flap results in a lip which tends to be too long in spite of the preoperative shortness on the cleft side.