Prä- und postoperative infusionsbehandlung in der Kinderchirurgie

Ohne ZusammenfassungMit 6 Textabbildungen     

Strahlentherapieassoziierte Morbidität und Mortalität in der Rektumchirurgie

The treatment of rectal cancer has evolved significantly in recent decades. Both modern radiotherapy treatment concepts and surgical techniques have been able to improve oncological as well as functional outcomes for rectal cancer patients. Large-scale, multicenter, randomized trials have been able to demonstrate the benefits of neoadjuvant treatment over adjuvant radiotherapy. In addition, local tumor control is improved by neoadjuvant irradiation. Conversely, patients receiving a total mesorectal excision showed no survival advantage following irradiation vs. only surgically resected patients. In addition, radiation therapy is associated with a certain morbidity and mortality. This paper summarizes the available evidence regarding postoperative morbidity, mortality, and long-term chronic effects of neoadjuvant radiotherapy.     

Reduktion von perioperativer Letalit?t und Morbidit?t in der Koronarchirurgie mit Clampless-off-pump-Technik

Background

This study aimed to assess whether the use of the clampless off-pump coronary artery bypass grafting (CABG) technique decreases risk-adjusted mortality, stroke rate, and morbidity in an unselected patient population.

Patients and methods

Between July 2009 and November 2010, data of 1,282 consecutive patients undergoing isolated CABG were prospectively recorded in a clinical database. In 30.8% (n=395), the procedures were completed clampless off-pump, either using the PAS-Port automated central venous anastomosis system or as total arterial revascularization without central anastomoses. Propensity score (PS) matching was performed based on 15 variables representing preoperative risk factors to correct for selection bias. Procedural mortality, stroke rate, major complications, and resources utilization of clampless off-pump (lessOPCAB) and conventional CABG (cCABG) were compared.

Results

A total of 788?patients (394?pairs) undergoing CABG were able to be successfully matched. The clampless off-pump technique significantly decreased the rates of death (OR: 0.25, 95%-CI: 0.05?C1.17) and stroke (OR: 0.35, 95%-CI: 0.12?C0.98). Complications, including low output syndrome, prolonged ventilation, and reoperation, were also reduced by less OPCAB.

Conclusion

In a retrospective PS-matched analysis, less OPCAB lowers mortality, stroke rate, and other morbidity in an unselected group of patients with coronary artery disease.     

Prä- und postoperative Betreuung des Neugeborenen in der Klinik

Ohne Zusammenfassung     

Prävalenz, Komorbidität und Behandlungsintensität der peripheren arteriellen Verschlusskrankheit in der Hausarztpraxis

Background

In Germany, there is a lack of current, representative data on the prevalence, comorbidity and treatment intensity of peripheral arterial disease (PAD) in primary care.

Methods

An observational study was made of 6,880 patients (≥65 years; the only exclusion criterion being a life expectancy <6 months) from 344 representative general practices, with the GPs trained and supervised by 43 specialists in vascular medicine.

Results

A total of 42% of patients were males, with the mean age being 72.5 years, mean body mass index 27.3 kg/m², and mean blood pressure 144/81 mmHg. The prevalence of PAD, defined as ankle brachial index <0.9, was 18.0% (19.8% in males, 16.8% in females). Of these, 36.5% of patients had a history of some manifestation of atherothrombosis, about half had cardiovascular disease (CAD) or PAD, respectively, while a quarter had cerebrovascular disease (CVD). Patients with (isolated) PAD received antiplatelets or statins significantly less frequently than patients with CAD or CVD.

Conclusions

PAD screening should be performed on a regular basis in elderly patients (especially those with risk factors). Patients with PAD should be screened for further manifestations of atherothrombosis, and should receive non-drug and drug based secondary prevention to an increased extent.     

Einfluss von Rettungsmittel und Zielklinik auf die Letalität nach Polytrauma

BACKGROUND: The aim of this study was to document the present knowledge from the medical literature on (1) efficacy of aeromedical evacuation (helicopter emergency medical service, HEMS) and (2) influence of the level of the first receiving hospital on mortality of patients. METHODS: Systematic review of the literature between 1970 and 2003; identification of studies with an evidence level of at least III and included control group; own results. RESULTS: (1) 17 studies concerning the efficacy of HEMS were included into the review. No single study yielded shorter rescue times with the use of HEMS. 11 of 17 studies showed a significantly higher survival rate (8.2 to 52%) with the employment of HEMS especially with mid-degree polytrauma. (2) All 6 relevant studies dealing with hospital level found a considerable lower mortality rate (19 to 42%) for patients treated primarily at a level 1 trauma center or comparable institution. CONCLUSIONS: The analyzed studies showed a trend toward decreased mortality rates with the employment of HEMS. Considering the comparable hospital level and even longer rescue times with HEMS, these differences can be explained with higher quality of initial diagnosis and treatment of the HEMS rescue team. Furthermore, mortality rates can be lowered significantly through primary treatment at a level 1 trauma center. Thus, the more flexible choice of the first receiving hospital represents a specific, clinically relevant advantage of HEMS in emergency medicine.     

Qualität in der Polytraumaversorgung

Background

Improvement of the primary clinical management of severely injured patients is still the focus of several investigations. Besides the composition of the initial trauma team in general the need for a committed trauma team leader is also under discussion.

Expectations for the deployment of a trauma team leader

Currently there are no studies proving a positive effect of a trauma team leader especially regarding patient outcome; however, from a team psychological view a trauma team leader makes sense. Concerning certain aspects of the trauma management, such as adherence to committed algorithms or time needed, a positive effect of a trauma team leader has been shown.

Requirements of a trauma team leader

Which clinical specialty is predestined for functioning as trauma team leader remains unclear; however, certain medical as well as team psychological skills are necessary.     

Qualität in der Begutachtung

Importance of expert opinions in the accident insurance

The German statutory accident insurance administration (DGUV) relys on the assessments of experts to decide whether there is medical evidence for coverage of the determined health damage caused by a work-related injury. The number of expert reports needed by the DGUV is estimated to be 80,000 per year.

Quality of expert opinions in accident insurance

Some of the expert opinions are also reviewed and checked by social courts. Decrees by the DGUV have a high legal standard, i.e., only 17.6?% of all lawsuits against the administrative decisions prevail, which is significantly less than that for all the other social security administrations. This shows high legal quality and meticulous handling of the – in numerous cases – personal tragedies due to which a pension or acceptance procedure was initiated.

Quality management

To keep the medical expert opinion at a high level and even to improve it on both sides (contracting authority and expert), measures for a quality management are necessary. The following article gives an overview and outlook of the recent and planned activities in quality management to improve medical expert assessments.     

Die 3D-Bewegungsanalyse der oberen Extremität und ihre Anwendung in der Schulterendoprothetik

Background

The aim of this study was to analyze the range of motion of the shoulder and elbow during activities of daily living (ADL). Moreover, proprioception after shoulder arthroplasty was assessed.

Materials and methods

A new, marker-based 3D model for the upper extremities was used. Ranges of motion of the shoulder and elbow in 10 ADL were measured in a standardized fashion in seven subjects. Proprioception was measured in 26 patients with degenerative pathologies of the shoulder joint. A total of 13 patients received total shoulder replacement, 8 hemiarthroplasty, and 5 reverse prosthesis.

Results

A mean shoulder anteversion/retroversion of 100°, an abduction/adduction of 89°, and an external/ internal rotation of 205° were necessary to perform the ADL. The mean elbow extension/flexion was 110° and mean pro-/supination 127°. For the whole cohort, the proprioception value decreased 6 months after implantation of a shoulder prosthesis from 7.0° preoperatively to 8.1° postoperatively (p<0.05). There was a postoperative decrease of proprioception for all movements and for overall proprioception, but this was not significant. With regard to the different implants, a decrease of proprioception was also found, without reaching significance.

Conclusion

Complex, dynamic movements and joint angles of the upper extremity can be recorded using 3D motion analysis at any time. In contrast to other studies, decreased proprioception was found in the short term after shoulder prosthesis implantation.     

Verfahrenswechsel in der operativen Knochenbruchbehandlung der unteren Extremität,geplant und erzwungen

A change of treatment modality in osteosynthesis is based on one of two principles. On the one hand, fixation can be performed as part of a two-step procedure to reduce the side effects of fracture stabilization. On the other hand, a revision osteosynthesis may be required for the treatment of complications. Indications for a two-step procedure are fractures in polytraumatized patients and fractures with a tendency to swelling and ¶infection (pilon-tibial fractures). External fixator devices applied in a two-step procedure were used for stabilization of fractures involving severe soft tissue damage in past decades; unreamed nailing is now commonly preferred. Revision osteosynthesis may be appropriate in the treatment of complications. Such complications can be caused by failure of the osteosynthesis; they can also be due to delayed union or nonunion of fractures, osseous defects or infection. In the case of failed osteosynthesis the reasons for failure must be thoroughly studied and a variety of subsequent procedures considered for successful treatment.     

Einflussfaktoren auf die perioperative Morbidität und Mortalität in der primären Hüftendoprothetik

ZusammenfassungFragestellung Ziel der vorliegenden Studie war es festzustellen, welche präoperativen Parameter die Identifikation eines Risikopatienten für das Auftreten postoperativer Komplikationen nach endoprothetischem Gelenkersatz erlauben.Methodik In einer unselektierten, retrospektiven Studie wurde die Inzidenz von Risikofaktoren und perioperativen Komplikationen bei 628 Hüfttotalendoprothesenoperationen (549 Patienten) untersucht. In 426 Fällen wurde präoperativ eine Begleiterkrankung diagnostiziert. Intra- und postoperative Komplikationen (93 spezifisch orthopädische und 42 allgemeine) traten in 104 Fällen auf.Ergebnisse Eine steigende Risikogruppe im anästhesiologischen Risikoscore nach Lutz u. Klose sowie eine Zunahme der Operationsdauer und der Anzahl der Voroperationen standen in signifikantem Zusammenhang mit einer Zunahme an perioperativen Komplikationen. Dagegen zeigten adipöse Patienten eine statistisch signifikant geringere Rate an intra- und postoperativen Komplikationen sowie einen geringeren perioperativen Blutverlust. Die Durchführung der Operation in Allgemeinanästhesie führte zu einem signifikant höheren Bedarf an Transfusionseinheiten. Das Patientenalter, die Art sowie die Anzahl der Begleiterkrankungen beeinflussten die perioperative Komplikationsrate nicht.Schlussfolgerung Die Komplikationsrate elektiver Hüftendoprothesenoperationen zeigt keine Abhängigkeit von bislang vermuteten Risikofaktoren wie einem höheren Lebensalter oder der Art und Anzahl von Begleiterkrankungen. Risikopatienten für das Auftreten von Komplikationen sind nicht durch Einzelparameter, sondern nur unter Verwendung eines entsprechenden komplexen Scores zu bestimmen. Auch Adipositas ist kein Risikoparameter. Die verlängerte Operationszeit ist lediglich von ökonomischer Bedeutung.     

Early postoperative acute aortic dissection, the leading cause of sudden death after cardiac surgery? Critical role of the computed tomography scan

Iatrogenic acute aortic dissection (AOD) is known to occur during cardiac surgery or cardiac catheterization, whereas delayed AOD usually happens up to several years after an uneventful operation. Both entities usually are easily recognized, and their management is well described in the literature. Conversely, early postoperative AOD has not been described with any frequency in the literature, leading one to believe that once surgery is terminated, AOD is unlikely to occur and account for any early postoperative mortality or morbidity. We present our recent experience with 4 patients who sustained early postoperative AOD and whose diagnoses were facilitated by computed tomography (CT) scanning of the chest. Early postoperative acute AOD may not be uncommon and may account for more disasters and deaths than are acknowledged in the literature. Diagnosis is made expeditiously if such AOD is suspected and a CT scan of the chest is done. Prevention may be based on avoiding the manipulation of the ascending aorta and a tighter control of hypertension in the immediate postoperative period. The treatment of this AOD entity is not very difficult and is within the reach of every trained cardiac surgeon.     

Zur Unterbindung der grossen Gefässstämme in der Continuität bei Erkrankungen und Verletzungen der unteren Extremitäten

Ohne Zusammenfassung Ein Erratum zu diesem Beitrag ist unter zu finden.     

Botulinumtoxin in der Therapie der neurogenen Detrusorhyperaktivität

Due to elevated intravesical storage pressures, neurogenic bladder dysfunction carries a high risk of renal damage. Thus, the goals of neurourologic treatment are reduction of intravesical storage pressure and intermittent bladder emptying in order to protect renal function and to achieve continence. If anticholinergic medication is either ineffective or intolerable, several open and controlled studies showed that the injection of botulinum toxin A into the detrusor muscle is a minimally invasive, safe, and effective treatment option. These studies demonstrated an effective reduction of storage pressures and a significant increase in bladder capacity. The effect has been shown to last up to a year. As this treatment is not approved by European administrations, botulinum toxin A treatment fulfills all criteria for "justified off-label use." The reduction of intravesical storage pressure leads to an improvement of life expectancy due to upper urinary tract protection. Furthermore, quality of life can be improved by low incidence of urinary tract infections, secure continence, and physiologic catheterization intervals.     

Qualität in der klinischen Forschung

Clinical research—characteristics

Clinical research is a key component of developed health care systems, a major driving force of medical innovation, and, of course, an integral part of the German Federal Statutory Accident Insurance System. Specific institutions and well-trained experts are needed to cope with the rapidly emerging methodological, ethical, and administrative mandates of clinical research.

Quality assurance and independence

Similar to other areas of health care, clinical research must demonstrate and maintain a high degree of structural and process quality. Yet, it can be shown that this increases the internal and external validity of research findings, as well as their likelihood of publication in renowned scientific journals. Apart from content validity, the relationship between individual investigators, their institutions, as well as public and commercial sponsors must be disclosed to maintain the integrity of research.     

Qualität der Leichennierenentnahme in Deutschland

Background

Organ damage during organ procurement is believed to be an increasing problem among transplant centres. However, only very few published data are available. The purpose of our study was to examine the quality of kidney procurement in Germany.

Methods

We retrospectively analyzed all allograft renal transplants performed at our centre from 1996 to 2005. All kidneys were retrieved in Germany and allocated by Eurotransplant.

Results

From a total of 486 cadaveric kidneys, 103 (21.2%) were not correctly retrieved. Nevertheless, none of the organs had to be rejected. In 18 (3.7%), a technically insufficient organ retrieval was associated with a considerable extension of the surgical procedure or complications.

Conclusions

Technically insufficient kidney procurement rarely results in clinical consequences. However, surgeons performing organ retrieval should be better trained. Whether adequate technical proficiency is achieved with ten supervised cases, as requested by the German Medical Association, remains to be determined. In our opinion, a further interdisciplinary course that trains surgeons in more refined techniques of organ procurement is desirable.     

Stumpferhalt und Stumpfverlängerung an der unteren Extremität

Despite new techniques and better health programs in western industrialized nations, the numbers of amputations on the lower extremity remain constant. Approximately 100,000 amputations are performed annually in the U.S. and about 10,000 in Germany, more than 90% for gangrene resulting from ischemia and/or infection. Micro- and macroangiopathic changes in diabetes are the major cause of ischemia in the leg. The preservation of limb length and construction of an end bearing stump are important criteria for the functional outcome after amputation. Especially in trauma and tumor patients with "planned" amputations, all effort should be made to achieve an end bearing stump with sufficient length respectively an amputation level that is suitable for orthosis instead of prosthetic supplementation. After amputation, an interdisciplinary approach is mandatory to achieve sufficient soft tissue coverage or stump distalization. In case of insufficient bearing ability of the stump, various reconstructive possibilities must be considered to assure optimal outcome.     

Struktur- und Prozessqualität der stationären urologischen Rehabilitation

Inpatient rehabilitation and "Anschlussheilbehandlung" (rehabilitation soon after operation or acute intervention) are effective and economic for long-term improvement of urologic patients. Only therapy guided by urologic specialists during rehabilitation and afterwards guarantees the possibility of excellent results. Especially QOL and functional deficits are improved markedly by urologic rehabilitation. Therefore, inpatient urologic rehabilitation should be initiated more often in the future.