10 Jahre laparoskopische Lebendnierenspende

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated.We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.     

100 Jahre Urologenkongress

Ohne Zusammenfassung     

100 Jahre Sexualmedizin

Ohne Zusammenfassung     

30 Jahre Sentinel-Lymphknotendiagnostik beim Peniskarzinom

Cabanas, working 30 years ago, was the first to use the term "sentinel lymph node" in urology. His definition of the sentinel lymph node was based on typical anatomical patterns and therefore could not do justice to any individual variability in lymphatic drainage. This meant that application of the technique yielded high false-negative rates, and because of this it was largely abandoned. Dynamic visualization of lymphatic drainage by blue dye in melanoma patients resulted in a renaissance of the sentinel node concept in penile cancer in the mid-1990s. With constant improvements and standardization of the technique it proved possible to reduce the incidence of false-negative results from the initial 22% to 4.8%. This technique requires that specialists in urology, pathology, and nuclear medicine collaborate closely, and high standards are also essential in quality control.     

„Tissue inhibitor of metalloproteinase 2“ und „insulin-like growth factor-binding protein 7“

Acute kidney injury (AKI) occurs in up to 30% of patients after cardiac surgery and in approximately 1% results in kidney failure necessitating dialysis. This has given rise to the term cardiac surgery-associated AKI (CSA-AKI). The mortality associated with AKI is 15–30% and CSA-AKI increases the mortality independent of comorbidities. Patients with AKI must be rapidly identified in order to initiate prophylactic or therapeutic interventions at an early stage and avoid further renal damage. Serum creatinine concentrations and diuresis, which are the gold standard in the diagnosis and definition of AKI, are not suitable for this early recognition. Following very promising results of initial studies many new biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C have not become established in the clinical routine. In many multicentric studies insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinase 2 (TIMP2), which are inductors of cell cycle arrest, were found to be superior to all of the other 340 biomarkers investigated with respect to prediction of AKI. Even studies purely involving cardiothoracic surgery confirmed the high sensitivity and specificity in the early recognition of impending AKI. A recently published randomized trial showed that early recognition of AKI and timely initiation of preventive or therapeutic interventions based on these promising biomarkers, can inhibit the progression of AKI.     

Zwanzig Jahre diagnostisches Hirschsprung-Kompetenzzentrum in Basel

Background

The experience gained by the Basel Hirschsprung Competence Center over 20 years is presented.

Materials and Methods

A total of 19,365 rectal mucosal biopsies were investigated in the 20 years between 1987 and 2006. All biopsies of rectal mucosa originated from 6,615 children aged between 1 week and 4 years. Biopsies were collected in teaching hospitals all over Germany and transported on dry ice by Intercity Courier Service. Serial sections of frozen tissue were made using a cryostat. Enzyme histochemical staining was performed.

Results

A total of 935 cases of Hirschsprung’s disease (14%) were observed (769 cases of classical Hirschsprung’s disease, 68 total colon aganglionosis, 98 ultrashort rectum aganglionosis). Total colon aganglionosis was found in 1.0% and the frequency of ultrashort Hirschsprung’ disease was 1.4%. The quality of the histological results was confirmed by a second independent investigator. There were neither false positive nor false negative diagnoses. Enzyme histochemical staining results were readable within 2 h. Acetylcholinesterase, which is significantly increased in Hirschsprung’s disease, was used for nerve fiber staining. Succinic and lacticdehydrogenases and nitric oxide synthase served as confirmatory proof of aganglionosis (elective nerve cell staining of the submucous plexus).

Conclusion

Among 100 children with chronic constipation an average of 12 children were diagnosed with Hirschsprung’s disease. Of these 2% showed total colon aganglionosis or ultrashort Hirschsprung’s disease. Enzyme histochemical diagnosis of Hirschsprung’s disease proved 100% reliable and time saving.     

Das Elektrokardiogramm 100 Jahre nach Einthoven

The surface electrocardiogram (ECG) is an important diagnostic tool even 100 years after the studies of Einthoven, particularly for diagnosis of arrhythmias and acute coronary syndrome. Supraventricular tachycardias (SVT) are paroxysmal tachycardias as sinus tachycardia, atrial tachycardia, AV-nodal reentry-tachycardia and tachycardia due to accessory pathways. SVT are characterized by a ventricular heart rate >100/min and small QRS complexes (QRS width <0,12 s) during tachycardia. It is important to analyze the relation between p wave and QRS complex, to look for an electric alternans as a leading finding for an accessory pathway. Wide QRS complex tachycardias (QRS width ≥0,12 s) occur in SVT with aberrant conduction, SVT with bundle branch block or ventricular tachycardia (VT). In broad complex tachycardias, AV dissociation, negative or positive concordant pattern in V1–V6, a notch in V1 and qR complexes in V6 in tachycardias with left bundle branch block morphologies are findings indicating VT. In addition, a R/S-relation in V6 favors VT when right bundle branch block tachycardia morphologies are present. By analyzing the surface ECG in the right way with a systematic approach, the specificity and sensitivity of correctly identifying a SVT or VT can be raised >95%.     

„Terminale“ Dehydratation,Teil 2

The approach in the clinical fluid management of the dying is still controversially discussed in specialist circles and also in the general population. In this article the importance of establishing the therapeutic indications is emphasized against the background of a lack of evidence. Options to achieve noninvasive objectification of assumed dehydration as well as assessment of the reversibility of the symptoms are shown and the importance of monitoring of all therapeutic actions is discussed. The pathophysiological foundation of reversible disorders of fluid homoeostasis are described and distinguished from the irreversible disorders leading to terminal dehydration. If clinically assisted hydration (CAH) is indicated, the hydration status must be assessed individually as well as in advance and all therapeutic measures must be constantly adjusted to the results of non-invasive monitoring procedures.     

Zehn Jahre „Praktischer Kurs für Viszeralchirurgie Warnemünde“

Background

Skill courses for surgery offer a good but cost and personnel-intensive possibility to obtain practical and theoretical knowledge by the employment of a close teacher-pupil contact of a large group of surgeons. The goal of the study presented here was to evaluate the satisfaction and benefits of the practical course for visceral surgery in Warnemünde after 10 years of course experience

Material and methods

All participants in the annual course for visceral surgery were included since 1999. During this 1-week course conventional and laparoscopic exercises are performed under direct guidance of an experienced tutor. The participants are divided into 3 groups based on their surgical experience (e.g. <3 years, 3–5 years, >5 years). All participants received a standardised questionnaire before and after successful course completion for the collection of relevant data (e.g. demography, training, surgical experience and course evaluation).

Results

A total of 1,062 participants (435 female, 627 male, mean age 37 years) participated in the course. The average surgical experience of the participants was 5 years. Of the participants 489 came from a hospital of basic medical care, 499 from a hospital of maximum medical care and 74 from a university hospital. Of the participants 96% had no or only little experience with skill courses (1,020 out of 1,065) and 827 participants had no or only few possibilities for training outside of the operation room (78%). The conventional part of the course was evaluated by 77% of the participants as very good and by 50% as very good for the laparoscopic part. Only 8.3% of the participants were willing to finance the costs of the course by themselves.

Conclusions

The practical course for visceral surgery leads to a subjective success in learning. Participation in the course leads to a high satisfaction and offers a cost-intensive possibility for a standardised surgical training. But there are too few experiences with skill courses and possibilities for surgical training outside the operation room so far.     

10 Jahre PSA – Chemoprävention

Ohne Zusammenfassung     

Lebensqualität polytraumatisierter Patienten 2 Jahre nach Unfall

Objective:

The present study analyses long-term survival, functional outcome and quality of live 2 years after trauma.

Patients and methods:

The complete consecutive data sets of patients admitted through the ER from 8/1998 until 8/2000 was documented and analyzed by a standardized protocol (GOS: Glasgow Outcome Score, SF-36, EuroQuol) precisely 2 years after trauma. 2-year mortality was based on the information provided by family physicians and community officials.

Results:

A total of 482 patients (mean ISS 24) was prospectively included (mean age 39 years). 2 years after trauma 26% had died. 68% were fully rehabilitated according to GOS, the rest remained severely disabled whereof 13% needed permanent care. EuroQuol and SF-36 revealed chronic pain and anxiety states in >50% of the patients. Everyday activities and mobility were permanently impaired in 40–50%. The social situation after trauma included increased unemployment (5% to 13,5%), disablement (0% to 15,3%), retraining (9,9%) and job changes (15,8%). Very often (30%) patients had to tolerate significant financial losses. Private live and family situation was seemingly unchanged.

Conclusions:

Patients after severe multiple trauma often suffer from significant psychophysical and socioeconomic impairment requiring adequate treatment and care from both health system and family resources. Based on structured early rehabilitation and occupational reintegration a coherent, long-term restructuring effort is needed for these patients.     

20 Jahre Notfallmedizin in der DIVI(N)

Ohne Zusammenfassung

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„Intermediate-risk-“ und „High-risk-Prostatakarzinompatienten“

Introduction

We examined the quantity and localization of pelvic lymph node (LN) metastases in patients undergoing extended pelvic lymphadenectomy (ePLND).

Materials and methods

A total of 174 patients with intermediate and high-risk prostate cancer underwent radical prostatectomy (RP) and ePLND. We analyzed the relationship between the number of LNs removed and the number, frequency and topography of LN metastases.

Results

In group 1 (intermediate risk patients, n=115) the average number of LNs removed was 20.5, LN metastases were found in 15 patients (13 %) and the localizations were in the external iliac artery 19 %, the internal iliac artery 32 %, the obturator foramen 36 %, the common iliac artery 7 %, Marcille’s triangle 3 % and sacral regions 3 %. In group 2 (high-risk patients, n=59) the average number of LNs removed was 23.9, LN metastases were found in 19 patients (32 %) and the localizations were the external iliac artery 15 %, the internal iliac artery 26 %, the obturator foramen 19 %, the common iliac artery 29 %, Marcille’s triangle 6 % and sacral regions 5 %. The full number of metastases was detected only if more than 15 LNs were removed in group 1 and 18 LNs in group 2.

Conclusions

At least 15 LNs in the intermediate risk group and at least 18 LNs in high risk group should be removed. The ePLND should include the common iliac artery, the internal iliac artery, Marcille’s triangle and sacral regions.     

Akute Maßnahmen beim „limb salvage“-Prozedere Teil 2

The quality of the primary care of Gustilo–Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60?%. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36–48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3–9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain “decontamination” and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.