Plattenepithelkarzinom des ?sophagus

The prognosis of locally advanced squamous cell carcinomas (SCC) of the esophagus after surgery only is poor. Therefore a definitive chemoradiotherapy (RCTx) was also discussed as the therapy of choice. Besides tumor biology, patient-related factors, such as alcohol and nicotine abuse increase the perioperative mortality and morbidity. Multimodal treatment can improve the outcome in comparison to surgery alone. A recently published meta-analysis confirmed that preoperative RCTx followed by surgery improves the prognosis compared to surgery alone in SCC of the esophagus. After chemotherapy this effect is less pronounced. Patients with a complete histopathological response (pCR) after preoperative RCTx have a 5-year survival rate of more than 55% and a low probability of local recurrence. However, a pCR cannot be predicted neither by negative biopsy nor by negative FDG-PET uptake after RCTx. Up to now FDG-PET has shown a low impact for response prediction or therapy modification in SCC of the esophagus in clinical studies. Responding patients should be transferred to surgery after preoperative treatment, because of a reduced perioperative morbidity and mortality and improved prognosis.     

Einleitung des Pr?sidenten

A. Eröffnung, Mitgliederversammlung, SchlußveranstaltungSchlußveranstaltung

Einleitung des Präsidenten     

Verletzungen des Mittelfu?es

Injuries of the midfoot are often missed and therefore underestimated. The diagnosis and primary treatment are crucial for the outcome. An accurately made diagnosis and therapy initially can anticipate the extent of post-traumatic malpositioning, arthrosis and the number of subsequent surgeries. Diagnostics should liberally include computed tomography with multiplanar reconstructions; clinically a compartment syndrome should be treated at an early stage. Surgery includes anatomical reconstruction of the relevant joints and ligamentous structures and restoration of axes and lengths of the columns of the foot. Innovations comprise intraoperative 3-D imaging and computer-assisted surgery for quality control. New methods for ligamentous injuries are transosseous suturing and endobutton techniques, which have not yet become established.     

Besonderheiten des ?lteren Notfallpatienten

The number of elderly patients is constantly increasing in emergency medicine. It is important to be familiar with the particularities of the diagnostics and treatment of elderly patients in order to prevent incorrect assessments. Some of these particularities in the treatment of geriatric patients will be discussed in greater detail based on the example of an 82-year-old female patient with pneumonia. In addition to the compilation of the medical history, certain symptoms such as dyspnoea and delirium will be addressed, as will diagnostic pitfalls such as the assessment of body temperature and laboratory values. ??Geriatrics... is a term... to cover the same field in old age that is covered by the term pediatrics in childhood...?? Ignatz Leo Nascher (1863?C1944).     

Benigne Erkrankungen des ?sophagus

Gastroesophageal reflux disease (GERD) is the most frequent benign disorder of the upper gastrointestinal (GI) tract and other defined disease entities, such as achalasia and diffuse esophageal spasm, also belong to this group. In addition to surgical therapy, medicinal therapy also has an important role in all 3 of these disorders. Therefore, it is very important to follow precise indication criteria based on diagnostic evaluation and patient selection as well as to use an optimal operative technique. The therapeutic spectrum for achalasia varies from Botox injections and endoscopic dilatation to laparoscopic myotomy which achieves a success rate up to 90%. Patients with diffuse spasm suffer from severe dysphagia, thoracic pain and burning sensations and even respiratory problems. Surgical therapy consists of thoracoscopic long myotomy and in selective cases with persisting pain even esophagectomy and gastric pull-up. Therapeutic options for GERD predominantly involve conservative medicinal therapy with proton pump inhibitors and selective laparoscopic antireflux procedures. Minimally invasive techniques have led to a higher acceptance of surgical therapy. The two major procedures most frequently used are total Nissen fundoplication and posterior partial Toupet fundoplication.     

Differenzialdiagnose des Lymph?dems

Primary or secondary lymphedema is normally a chronic disease caused by insufficiency of the lymphatic system and deranged lymph transport. Although the diagnosis of lymphedema can be easily determined from the clinical history and physical examination, it is nevertheless often not recognized. Lymphangioscintigraphy has proven to be extremely useful for detecting specific lymphatic abnormalities and has largely replaced the conventional oil contrast lymphangiography. Combined physical therapy is the treatment of choice, namely the rigorous application of physical means of manual lymph drainage.     

Rekonstruktion des Au?enbandapparats mittels Kniebeugesehnentransplantat bei chronischer Au?enbandinstabilit?t des OSG

Objective

Reconstruction of the anterior talofibular (ATFL) and calcaneofibular (CFL) ligament in patients with chronic lateral ankle instability.

Indications

Symptomatic chronic lateral ankle instability.

Contraindications

Bony malalignment, advanced arthritic changes of the ankle joint, diabetic foot syndrome.

Surgical technique

Reconstruction of the ATFL and CFL with a free gracilisor or semitendinosus tendon graft through a V-shaped tunnel at the insertion site of the ATFL on the talar neck as well as a transfibular tunnel directed anterior to posterior through the fibula tip to a blind ending tunnel in the calcaneus at the insertion site of the CFL. Insertion of the graft through the talar tunnel, passing both graft ends through the fibular tunnel to the calcaneus. Fixation with a bioabsorbable screw.

Postoperative management

Short leg cast for 10?C14?days and partial weight-bearing. Afterwards ankle brace for 6?weeks and functional physical therapy.

Results

From December 2003 to August 2005, reconstruction of the ATFL and CFL with a hamstring tendon autograft was performed in 20 patients with chronic lateral instability of the ankle joint. All patients were evaluated after a mean follow-up time of 1.8?years (15?C36?months). Clinical evaluation referred to the AOFAS score. Stress radiography was performed for objective assessment of lateral ankle stability. Postoperatively 19 of 20 patients reported good subjective stability with no further ankle sprains. The mean postoperative AOFAS score was 92 of 100 points (72?C100). Stress radiography showed a significant reduction of both lateral ankle instability and talar tilt.     

Medikament?se Therapiem?glichkeiten des Oligo-Astheno-Teratozoospermie-Syndroms

Medical treatment of oligoasthenoteratozoospermia (OAT) syndrome includes many different treatment concepts. The targeted causes in the treatment of OAT syndrome are either hormonal, as for example hypothalamic, pituary, or, seldom, hyperprolactinemic disturbances, or acute or chronic urogenital infections, as well as ejaculatory disorders. Often no pathogenic reason for OAT syndrome can be found and targeted. Most treatment concepts in the past tried to improve sperm quality. Administration of antiestrogens, antioxidants, hormones, and micronutrients has been tried and used to improve sperm quality. The present article provides an overview of current medical treatment options for OAT syndrome, including former unsuccessful treatment concepts. The article furthermore sketches out potential treatment options, which might be available in the future.     

Pr?klinische Anwendung des Larynxtubus

Laryngeal tubes (LT) are increasingly being used for emergency airway management. This article reports on two patients in whom out-of-hospital intubation with a single-lumen LT was associated with massive pulmonary aspiration in one patient and gastric overinflation in the other. In both cases peak inspiratory pressures exceeded the LT leak pressure of approximately 35?mbar. This resulted in gastric inflation and decreased pulmonary compliance and increased inspiratory pressure further, thereby creating a vicious circle. It is therefore recommended that laryngeal tube suction (LTS) should be used in all cases of emergency airway management and a gastric drain tube be inserted through the dedicated second lumen. Apart from gastric overinflation, incorrect LT/LTS placement must be detected and immediately corrected, e.g. in cases of difficult or impossible gastric tube placement, permanent drainage of air from the gastric tube, decreasing minute ventilation or an ascending capnography curve.     

Excision oder Strahlenbehandlung des Melanoblastoms?

Ohne Zusammenfassung     

Praktische Diagnostik des S?ure-Base-Haushalts

The first part of this overview on diagnostic tools for acid-base disorders focuses on basic knowledge for distinguishing between respiratory and metabolic causes of a particular disturbance. Rather than taking sides in the great transatlantic or traditional-modern debate on the best theoretical model for understanding acid-base physiology, this article tries to extract what is most relevant for everyday clinical practice from the three schools involved in these keen debates: the Copenhagen, the Boston and the Stewart schools. Each school is particularly strong in a specific diagnostic or therapeutic field. Appreciating these various strengths a unifying, simplified algorithm together with an acid-base calculator will be discussed.     

Tumor des ?sophagokardialen ��bergangs

The presence of heterotopic pancreatic tissue in the gastroesophageal junction is a very rare entity. An exact preoperative diagnosis is only rarely possible despite all available diagnostic procedures. We report on the case of a submocous tumor of the gastroesophageal junction which became symptomatic due to reflux problems and was successfully removed by endoscope-assisted laparoscopic resection.     

Kn?cherne Segmentdefekte des Unterschenkels

Segmental bone defects mostly result from high energy accidents and are characterized by combined injuries in many types of tissue. The most important requirement for success of bony reconstruction and salvage of the extremity is a sufficient soft tissue covering with vital, well-perfused and infection-free tissue. After radical sequential debridement all techniques in the plastic surgery reconstruction repertoire can be used. Free flaps in particular fulfil all requirements for such compound defects. In cases of segmental defects >6?cm a ??one-stage reconstruction?? with free vascularized bone transfer is the current state of the art. If an infection is additionally present, a well-perfused muscle flap, such as a musculocutaneous latissimus dorsi flap or gracilis flap should be selected. The optimal time point of reconstruction is early secondary defect covering within the first 24-72?h after trauma. An acute defect covering with emergency free-flaps is rarely indicated. All operative procedures should be performed in an interdisciplinary cooperation between trauma and plastic surgeons. However, despite the high success rate of extremity salvage due to modern combined treatment techniques, a permanent restriction of function and reduction in quality of life should be considered and integrated into treatment concepts.     

Die Arthrodese des Gro?zehengrundgelenks

Objective

Fusion of the first metatarsophalangeal joint and realignment of the great toe in patients with painful arthritis to achieve pain-free walking.

Indications

Hallux rigidus grade 3/4, hallux valgus et rigidus, claw toe deformity of the great toe, salvage after endoprosthesis or cheilectomy, avascular necrosis of the first metatarsal head arthritis of the first metatarsophalangeal joint.

Contraindications

Infection, painful arthritis of the interphanageal joint (relative contraindication), and severe osteoporosis (relative contraindication).

Surgical technique

Dorsal approach to the first metatarsophalangeal joint. Removal of all osteophytes and circumferential capsular release. Debridement of the sesamoids. Cartilage resection (flat cuts or “cup and cone” reaming) and multiple drilling of the subchondral layer. In case of osseous defects, interposition of a corticocancellous bone graft. Trial reduction and assessment of the toe alignment. Fixation with two screws, one lag screw and dorsal plating, or dorsal plating only. Wound closure in layers.

Postoperative management

Full weight bearing in a postoperative shoe or partial weight bearing in a short cast for 4–6 weeks. If the X-ray reveals sufficient bone healing, patients are allowed to wear sneakers with a stiff sole for 3–6?months. Sport activities with impact loading are limited for at least 3?months. Final X-ray control after 6?months.

Results

A total of 70?feet with a fusion of the first metatarsophalangeal joint were followed up after 28?months. Postoperative complications (7.3%): 5?wound slough, 1?infection, and 6?painful delayed union. Modified AOFAS forefoot score (max. 85?points) was 43?(32–58) points preoperatively and 82?(71–85) points postoperatively. Great toe alignment was perfect in 57?feet. Nine toes showed a valgus (>?20°) and 4?toes a varus malalignment. Fifty-four attained full ground contact. Eight patients reached the ground by flexion of the interphalangeal joint and 8?patients presented with dorsiflexion of the great toe. X-ray showed consolidation of the arthrodesis in 64 feet (91.4%), while 8 feet (4?with interposition of a bone graft) revealed signs of incomplete healing. These patients were advised to have an annual clinical and radiological reassessment performed.     

Neurourologische Funktionsst?rungen des unteren Harntraktes bei Erkrankungen des ZNS

The lower urinary tract (LUT) is regulated by a complex neural network that is subject to supraspinal control. Neurological disorders, especially of the central nervous system (CNS), can rapidly lead to disruption of this control. Multiple sclerosis, Parkinson's disease, multiple system atrophy, and stroke are neurological disorders which quite frequently cause dysfunction of the LUT. With respect to the pathophysiology of bladder dysfunction in CNS diseases there are various hypotheses regarding the individual disorders: disturbances of neural communication between the frontal cortex and pontine micturition center, between the pontine micturition center and the lumbosacral parts of the spinal cord, and between the basal ganglia, thalamus, and anterior cingulate gyrus appear to play a pivotal role in the development of bladder dysfunction. The symptoms and urodynamic presentation of LUT dysfunction can vary considerably depending on the disease and disease progression and can change in the course of the disease. The incidence and prevalence of LUT dysfunctions rise with increasing progression of the underlying neurological disease.Various conservative, minimally invasive, and open surgical procedures are available to prevent harmful sequelae and to improve the quality of life of these patients. As yet, however, few data exist on most of the treatment options in cases of the above-mentioned CNS diseases. Intermittent self-catheterization and antimuscarinic medications are among the most important conservative treatment options. Injection of botulinum neurotoxin type A into the detrusor muscle and increasingly sacral or pudendal neuromodulation are among the most important minimally invasive treatment options. Surgical methods include reconstructive continent or incontinent urinary diversion.When planning therapy the patient's current needs and neurological limitations as well as possible disease progression must be taken into consideration. It is often advisable to consult with and enlist the cooperation of the attending neurologist when planning treatment.