Cranioplasty of an extremely large cranial defect caused by transitional meningioma with a knitted polypropylen-polyester prothesis “Codubix”

Summary The authors report a case of transitional cell meningioma of the convexity which destroyed a large portion of the calvarium and invaded subcutaneous tissue. The tumour was totally removed and a large cranial defect/430 cm² in size/ was filled with a polypropyleno-polyester knitted prothesis Codubix with an excellent result.The problems of chronioplastic closure of such an unusually large skull defect and the advantages of the use of the material Codubix are discussed.     

A new safe and aesthetic approach to suction abdominoplasty

Suction abdominoplasties are associated with a number of surgical complications, mainly in obese people and diabetic patients. The aesthetic result is often spoiled by poor balance caused by improper distance between the guide points of an harmonious abdomen (e.g., minimum of 10 cm between the pubic scar and the umbilicus). Almost all surgical complications are caused by extensive undermining and can be avoided by an en bloc resection without any undermining (the suction lipectomy of the upper flat creates a mesh undermining which is almost as efficient). A new neo-umbilicoplasty, described here, can be situated in the right position with good aesthetic results.     

The no-reflow phenomenon is a post-mortem artifact

Summary Post-ischemic reperfusion impairment, (no-reflow phenomenon), was studied in rats subjected to 8–30 minutes of global brain ischemia. During ischemia, rapid and complete loss of cerebral blood flow, EEG and³¹P-high energy phosphates (ATP/PCr) was observed.Brain intravascular perfusion defects were examined by injecting carbon blackintravenously in a group of rats with stable cardiopulmonary function and in another group subjected to rapid thoracotomy andintraarterial infusion of the carbon marker. Results indicate that global brain ischemic or non-ischemic control rats givenintraarterial carbon black after thoracotomy had varying degrees of vessel filling defects in brain resulting in pale tissue areas suggestive of impaired perfusion (no-reflow). All rats given carbon blackintravenously whether global brain ischemic or not, showed normal cerebrovascular filling of the carbon black and absence of pale tissue areas. In addition, post-ischemic cerebral reperfusion following 8–30 minutes global brain ischemia can reverse neuroelectric, energy metabolite and cerebral blood flow loss in rats whose cardiopulmonary function is not compromised.These findings indicate that the no-reflow phenomenon is an agonal or post-mortem artifact observed in the presence of cardiopulmonary failure.     

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.     

Prognostic evaluation before operative extirpation and radiotherapy of solitary brain metastasis

Summary This is a retrospective study of 134 patients operated on for solitary brain metastasis at the University Hospital in Uppsala, Sweden between 1963 and 1982. All the patients underwent postoperative radiation therapy. A statistical evaluation of different prognostic factors was made in order to create a prognostic model, a so-called risk profile, to be used for future patients. The most important factors for the making of risk profiles were found to be the histological diagnosis followed by the location in the brain, then the state on admission and the age at admission in that declining order. All these variables separately and together,i.e., as risk profiles, were matched against the outcome during survival as Karnofsky's scores and against the length of survival time. The results are shown in a diagram giving the surgeon grounds for his decision-making for or against operation and also for pre-operative information.     

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.     

82. Fragen der chirurgischen Weiterbildung: Gegenwärtiger Stand

Zusammenfassung Weiterbildung — die Einführung eines approbierten Arztes in ein anerkanntes Fachgebiet — ist im Begriff und System von Ausbildung (des Studenten) und lebenslanger Fortbildung (des fertigen Arztes) zu unterscheiden. Sie schafft das Fundament, auf dem sich Wissen und Können der Angehörigen einer Disziplin aufbauen, und setzt damit Wertmaßstäbe im eigenen Land und über die Grenzen hinaus. Weiterbildungsordnung (WO) und als Richtlinien bezeichnete Ausführungsbestimmungen regeln den Ablauf der Weiterbildung (W). Neu ist im wesentlichen die Verlängerung der Weiterbildungszeit von 5 auf 6 Jahre, die Einführung von Teilgebieten (in der Chirurgie Teilgebiet Kinder-Chirurgie und Teilgebiet Unfall-Chirurgie) mit dem Ziel, abgerundeten Subspezialitäten im Rahmen des Gesamt-Fachgebiets eine Autonomie zu geben, sowie ein umfangreicher Operations-Katalog. Die WO ist damit richtungweisend für die weitere Entwicklung des Fachgebietes und begründet erhebliche Anforderungen sowohl an den Facharzt-Aspiranten als auch an den Erfahrenen, der die W leitet. Die Einführung eines Befähigungsnachweises als einer in der ausschließlichen Kompetenz der ärztlichen Selbstverwaltung gelegenen Abschlußkontrolle wird befürwortet.

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Summary Postgraduate medical education in an approved specialty by definition and set-up differs from both undergraduate medical education and the life-long continuing medical education after completion of training. Postgraduate education in medicine is the basis for the knowledge and proficiency of a specialist and sets standards at home and abroad. Postgraduate education is laid down in principle in the Weiterbildungsordnung and regulated by the Richtlinien. Major innovations are a prolongation of training from 5 to 6 years, the introduction of subspecialties (pediatric surgery, traumatology), in order to give these established groups autonomy within the field of surgery and finally a sizable list of operations to be performed. The new Weiterbildungsordnung will guide the future development of surgery and imposes demands both on those in training and those responsible for it. An examination as "proof of competence"' is recommended, but should remain within the competence of the medical profession.

     

The effect of anaesthesia and surgery for benign disease of the upper urinary tract on circulating leucocyte subpopulations identified with monoclonal antibodies

Summary Circulating lymphocyte subpopulations were monitored, using monoclonal antibodies and flow cytometry, in six patients undergoing surgery for benign disease of the upper urinary tract. A significant decrease in the total number of circulating lymphocytes was observed. This could be attributed to a significant decrease of T cells of both major subsets — the so-called T helper (Th) and T suppressor/cytotoxic (Ts) subpopulations. When the results of the T cell subsets were expressed as a ratio (leu-3a⁺/leu2a⁺, T helper/suppressor) no significant change was noted. In contrast neither B cells nor natural killer (NK) and antibody dependent killer (K) cells were significantly affected. This selective loss of T cells from the circulation may be relevant to post operative infection and should be considered in the course of immunological monitoring.Supported by the Cancer Research Campaign     

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 transkutan induktiv gesteuert werden. Ein für das Tierexperiment speziell entwickelter Prototyp des Gerätes wurde an Schafen erfolgreich erprobt.Die Längendifferenzen der unteren Extremitäten stellen eine schwere Störung der kinetischen Gliederkette dar. Die Störung der Statik führt zur Fehlbelastung der Gelenke und damit zur konsekutiven Arthrose. Der durch die Beinlängendifferenz verursachte Schaden übersteigt somit weitaus den Grad der kosmetischen Störung.

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Results of animal experiments with an implantable femur distractor for operative leg lengthening

Summary A new femur distractor for operative leg lengthening has been developed. The new instrument consists of an electronically controllable distractor set including a power unit and a two-part guide rail. The whole system can be implanted totally and gives rigid fixation throughout the period of distraction. The operations forward motion, stop and backward motion can be regulated transcutaneously by radio control. A prototype especially developed for animal experiments has been tested successfully in sheep.

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Das Forschungsprojekt wurde mit Mitteln der BMFT finanziert. Die tierexperimentellen Untersuchungen wurden in der Bayerischen Landesanstalt für Tierseuchenbekämpfung München-Oberschleißheim — Leitung Professor G. Beck — durchgeführt.     

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.     

Preliminary experience with intracorporeal laparoscopic ultrasonography using a sector scanning probe

Laparoscopic ultrasonography is a novel technique which may be useful in screening for choledocholithiasis during laparoscopic cholecystectomy. Following concerns regarding the learning curve and accuracy associated with the adoption of this user-dependent technology, we have prospectively evaluated a commercially available 90° sector scanning laparoscopic ultrasound probe during elective laparoscopic cholecystectomy. Laparoscopic ultrasonography was performed in 60 patients and identified common duct stones in nine patients (one false positive and one false negative), and previously unsuspected duct stones were defined in three out of four patients. The gallbladder and portal vein were constantly defined anatomical landmarks throughout the study, whereas the suprapancreatic bile duct, intrapancreatic bile duct, and pancreatic duct were identified in 100%, 80%, and 85% of patients in the third consecutive group of 20 patients examined. Laparoscopic ultrasonography has the potential to accurately identify common duct stones during laparoscopic cholecystectomy and thereby implement a policy of superselective operative cholangiography. However, adequate training for surgeons unfamiliar with this technology is recommended.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Triple approach for diagnosis and grading of meningiomas: Histology,morphometry of Ki-67/feulgen stainings,and cytogenetics

Summary With regard to meningioma grading and the recently introduced atypical meningioma, we evaluated 160 cases retrospectively by conventional histology and image analysis. For that, the cell nuclei were stained with a Ki-67 (MIB1)/Feulgen-method on paraffin sections, thus enabling the assessment of both the Ki-67 proliferation index and nuclear morphometric features, such as tumour cell arrangement, nuclear pleomorphism, and cellularity.It could be demonstrated that the Ki-67 proliferation index is the most important criterion for distinguishing anaplastic meningiomas (WHO grade III) (mean Ki-67 index: 11%) from those of common type (WHO grade I) (mean Ki-67 index: 0.7%). The parameter for the relative volume weighted mean nuclear volume is another valuable morphometric feature. The atypical meningioma (WHO grade II) which should represent an intermediate category between common type and anaplastic meningiomas is characterized by a mean Ki-67 proliferation index of 2.1%. Common type meningiomas which comprise almost 50% of the cases of this series have a relapse rate of 9%. Atypical and anaplastic meningiomas recurred in 29% and 50%, respectively. Since the term atypical meningioma is confusing in the context of tumour grading, the term intermediate type meningioma is proposed.Furthermore, the results of cytogenetic analyses of 142 cases of this series were evaluated and compared with the meningioma grades. Thereby, 25 cases disclosed, independent of the typical loss of one chromosome 22, cytogenetic features assumed to be progression-associated, e.g., the gain or loss of different chromosomes and the deletion of the short arm of one chromosome 1 (hyperdiploidy, increased hypodiploidy, Ip-), when correlated to the histological and morphometric findings or the high relapse rate.For meningioma diagnosis and grading, a practical guideline is proposed based upon histology, morphometry (Ki-67), and cytogenetics.     

Small intestinal lymphoma

This paper reviews small intestinal lymphoma. Although a major emphasis is placed on primary small intestinal lymphoma of the Western type, the important topic of lymphoma in celiac disease is discussed. Our own recent experience of 7 patients with lymphoma in celiac disease is presented. The lymphoma of immunoproliferative small intestinal disease (Mediterranean lymphoma) and the associated -chain disease are also reviewed, with emphasis on the differences from the Western type of primary small intestinal lymphoma.

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Resumen Este artículo revisa el tema del linfoma intestinal. Aunque se hace énfasis principal en el linfoma intestinal primario del tipo Occidental, también se discute el tópico relativo al linfoma en la enfermedad celiaca. Se presenta un estudio sobre nuestra experiencia reciente con 7 pacientes con linfoma en enfermedad celiaca. También se revisan la enfermedad inmunoproliferativa del intestino delgado (linfoma Mediterráneo) y la enfermedad de cadena asociada, con énfasis en sus diferencias con el tipo Occidental de linfoma primario del intestino delgado.

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Résumé Cet article est consacré au lymphome de l'intestin grÊle. Bien que centré sur le lymphome primitif (dit lymphome de type occidental) il concerne également le lymphome qui traduit une manifestation d'une maladie immunoproliférative de l'intestin (qualifié de lymphome de type méditerranéen) et ce à partir d'une expérience de 7 malades présentant une maladie coeliaque. Ce second type et la maladie associée de la chainealpha sont également étudiés en s'attachant à souligner les éléments distinctifs qui les séparent du lymphome primitif.

     

Razabrasion: An alternative approach to perioral rhytides

Persistence of perioral rhytides is a frequent source of patient concern following standard rhytidectomy. Dissatisfaction with the limited results and occasional complications that result from mechanical, manual, and chemical abrasive methods of management prompted application of the steel blade dermal shave technique to this problem. Manual oscillation of a sterile commercial razor blade with depth and width controlled by digital pressure eradicates all but the deepest perioral wrinkles. Eleven patients have undergone razabrasion within the past 19 months without complication. Local anesthesia is sufficient. Topographically distant but synchronous facial operations may be performed safely, but undermining of the shaved facial skin should be avoided for 6 months after razabrasion. Later results will be studied to define the longevity of the effect, but we are encouraged that the method offers the most gentle, most rapid, and best controlled (as to level of dermal shave) current method of tangential dermal splitting. The paper describes the technique of razabrasion of perioral rhytides and reports our early results.     

Hepatic arterial variations and liver-related diseases of 100 consecutive donors

We prospectively studied anatomical variations and diseases of the liver in 100 consecutive donor operations during a period of 1 year. The normal arterial anatomy with a single hepatic artery (HA) from the celiac trunk was seen in 76% of all cases. Seven of twelve different major variations of the HA may be considered as rare, one of which cannot be found in the earlier literature. During harvesting, 6% of the livers were discarded, 3% on the basis of infection and 1% because of a polycystic disease. Two cases were rejected as the liver was found to be severely hypoperfused or hypoxic in an otherwise stable donor. Severe steatosis was macroscopically and histologically diagnosed in 3% of the cases, and in three donors a benign tumour was found in the liver or in the gall bladder. Two primarily nonfunctioning livers in the present series of 94 recipient operations were retrieved from this group of severely steatotic livers. As the donor liver was totally normal in only 2 out of 3 of the cases, the present study underlines the importance of searching for extremely variable anomalies of the HA and for liver-related diseases during organ harvesting.     

Double-blind study with dipyrone versus tramadol and butylscopolamine in acute renal colic pain

Summary To investigate the combined analgesic and spasmolytic effect of dipyrone, 104 patients suffering from severe or excruciating colic pain due to a confirmed calculus in the upper urinary tract were randomized to receive i.v. either 2.5 g dipyrone (36 patients), 100 mg tramadol (35 patients), or 20 mg butylscopolamine (33 patients) in a multicentre, observer-blind, parallel-group study conducted in 8 German centres. The three treatment groups were homogeneous when analyzed by age, sex, height, and baseline pain intensity. Dipyrone was significantly more effective than tramadol in reducing pain for the primary endpoint, pain intensity differences (PID) at 20, 30, and 50 min after drug administration, and was significantly more effective than butylscopolamine at 30 and 50 min for the secondary efficacy endpoint, pain intensity differences on a categorical scale. Dipyrone had the highest SPID_{0–2 h} of the three drugs (P<0.05). Only 5 patients receiving dipyrone needed rescue medication as compared with 13 patients given tramadol and 11 patients receiving butylscopolamine. Adverse events were observed in 4 patients receiving butylscopolamine and in 1 patient each given dipyrone and tramadol. Distinct pain relief as assessed on a visual analogue scale (VAS) is a reliable method of determining the onset of analgesic action in the colic pain model.     

Flow cytometric study on cell kinetics of brain tumours and their cultured cells

Summary With the aid of flow cytometry (FCM), distribution of DNA content in 40 cases of brain tumour, primary culture cell, and secondary culture cell can be determined and chronological change after subculture is studied from the analysis of their cell cycle. In most primary cultures, proliferating index (PI) is likely to decrease, which suggests that environmental change might affect the growth activity. In comparison with that of the original sample, DNA-histogram of the secondary culture can be divided into the following 3 types: the type recovering to the original pattern (adapting type), in which astrocytoma, ependymoma, glioblastoma and medulloblastoma are included, 2) the type increasing more at G2 + M phase than the original (proliferating type), in which meningioma and some of glioblastoma are included, and 3) the type decreasing so far as to induce degeneration or death (degenerating type), in which pituitary adenoma and neurinoma are included. FCM is of great usefulness for the study of cell kinetics of a tumour cell undergoing culture and the present method will be available for the respective study of biological characteristics of the cultured cell, established cell line or sensitivity test for antineoplastic agents.     

„Multi-targeting drugs“ und „multi-drug targeting“ beim metastasierten Nierenzellkarzinom

Ohne ZusammenfassungD. Rohde: Vorstandsmitglied der AUO.Association for Urogenital Oncology (AUO): Multi-targeting drug and multi-drug targeting in metastatic renal cell carcinoma. Co-inhibition of EGF-R     

Correction of the acid-base balance and postoperative diuresis

The significance of the correction of postoperative acidosis for the kidney's excretory activity has been studied on clinical material. The volume of the urine discharged during the first 24 postoperative hours was significantly increased in patients (corrected group) whose acid-base balance had been restored according to careful calculation. Intensified diuresis in the first 12 hours accounted for 70% of this increase. There was no appreciable difference between the corrected and the noncorrected group concerning specific gravity and pH-value of the urine and serum ionogram. Values of urinary electrolytes, as observed in the corrected group, were not essentially different from the usual postoperative values. It is suggested that the correction has no effect on the hormonal factors influencing postoperative renal functions. Readjustment of the acid-base balance facilitates a quicker normalization of tubular function.     

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.