Additive CT-gesteuerte lumbale Sympathikolyse bei Patienten mit pAVK

Purpose

The aim of this study was to investigate of the influence of lumbar sympathicolysis on somatic regional oxygen saturation, temperature and arterial flow velocity in the lower extremities.

Patients and methods

In this study 70 patients with peripheral arterial occlusive disease (PAOD) stages IIb to IV according to Fontaine were treated with computed tomography (CT)-guided lumbar sympathicolysis after interventional or surgical therapy. Of the patients 23 (32.9%) were in stage IIb, 10 (14.3%) in stage III and 37 (52.9%) in stage IV. Somatic regional oxygen saturation in the distal lower extremities was recorded peri-interventionally with a near infrared spectroscopy system. Before and after intervention the temperature of the feet was measured using an infrared thermometer and the peak flow and end-diastolic flow velocity in the dorsalis pedis artery was determined by means of colour-coded duplex sonography.

Results

Regional oxygen saturation rose from 62.92% to 71.29% (p?<?0.001), temperature from 32.25C to 33.72C (p?<?0,001), peak flow from 49.56?cm/s to 62.33?cm/s (p?<?0.001) and end-diastolic flow from 7.03?cm/s to 18.80?cm/s (p?<?0.001). There were no significant differences between the PAOD stages or between patients with and without diabetes.

Conclusion

In patients with PAOD, CT-guided lumbar sympathicolysis carried out in addition to interventional or surgical therapy led to a measurable improvement in arterial blood flow.     

Gerinnungsaktive Medikamente zur Sekundärprophylaxe bei pAVK

Peripheral arterial occlusive disease (PAD) is associated with high cardiovascular risk. This paper reviews the published data on antithrombotic therapy for secondary prophylaxis of cardiovascular events with platelet aggregation inhibitors and anticoagulants. Patients with PAD should receive a platelet aggregation inhibitor (75 mg clopidogrel or 75–300 mg Aspirin) once daily. A combination treatment with several different platelet aggregation inhibitors is not recommended for this purpose. The administration of vitamin K antagonists or heparins also cannot be recommended, unless other conditions (e.g. atrial fibrillation) are present for which anticoagulation is indicated. The paper also deals with antithrombotic therapy for patients who have undergone peripheral bypass surgery and endovascular procedures.     

Intraoperative Kalorimetrie bei Aortengabelrekonstruktion

Oxygen uptake (V˙O₂) and carbon dioxide elimination (V˙CO₂) can be measured with an indirect calorimeter; this method is well established in routine monitoring of ICU patients to evaluate metabolic state as a reflection of stress. In various experimental studies it was demonstrated that anaesthetics can influence whole-body metabolism. The purpose of this study was to examine whether indirect calorimetry can be used intraoperatively during routine anaesthesia and whether presumable changes in metabolism can be detected immediately. Abdominal aortic cross-clamping changes circulation, nutritional supply of the lower extremities and thus V˙O₂ and V˙CO₂. We therefore used this operation for our study. Method. Eleven patients, mean age 64 years, undergoing reconstruction of the aortic bifurcation, were studied. After premedication with piritramid and atropine, total intravenous anaesthesia (TIVA) was performed with fentanyl and midazolam after an induction with thiopental. Patients were ventilated with a Servo-Ventilator 900 D and a constant F_iO₂ of 0.5, without N₂O. Routine monitoring consisted of ECG, pulsoximetry, CVP and continuous AP. V˙O₂ and V˙CO₂ were measured with a Deltatrac^® (Datex), and data were registered every minute. For statistical evaluation we used a Wilcoxon-Ranksum test for matched pairs, p<0.05 was considered significant. Data from specific time (5?min after intubation, 5?min before clamping; 5, 10 and 15?min after clamping, before declamping and 5 and 10?min after declamping and at the end of surgery) were calculated. In addition to absolute values, we compared the measured V˙O₂ and V˙CO₂ to baseline (5?min before clamping=MP2). Results. Mean operating time was 139?min±37; aortic cross-clamping time for the first extremity was 38?min and 55?min for the second. As expected, there was a significant decrease in V˙O₂ (90% of baseline) and V˙CO₂ (75% of baseline) during aortic cross-clamping. After declamping V˙O₂ again rose to 110% of baseline, or to 103% for the second limb. V˙CO₂ increased to only 90% and 82%, respectively. At the end of surgery V˙O₂ reached baseline, whereas V˙CO₂ remains at 83%. The respiratory quotient V˙CO₂: V˙O₂ was markedly reduced from 0.95±0.156 to 0.73±0.06 during surgery. The Deltatrac^® showed every change in V˙O₂ without delay; changes in V˙CO₂ seem to occur somewhat retarded. Discussion. Aortic cross-clamping leads to a marked decrease in V˙O₂ and V˙CO₂ reflecting the temporary reduction in whole-body metabolism. Declamping results in a compensatory rise, especially in V˙O₂. V˙CO₂ seems to increase less after declamping, perhaps due to the CO₂ pool of the organism or to a change in metabolism from carbohydrate to mainly fat oxidation. The results of this study demonstrate that indirect calorimetry can easily be performed during anaesthesia and surgery. Preconditions are a non-rebreathing system without airleak, constant FiO₂<0.6 and no use of nitrous oxide.     

Beobachtungen bei einer Tumorgruppe vom Oligodendrogliom-Typ

Zusammenfassung Auf Grund von Verlaufsuntersuchungen bei 75 operierten Oligodendrogliomfällen wird eine Untergruppe der Oligodendrogliome, das sogenannte entartete Oligodendrogliom, diskutiert.Nach histologischem Bild und klinischem Verhalten steht diese Gruppe zwischen den reinen Oligodendrogliomen und den Glioblastomen. Eine Überprüfung an Hand eines größeren Materials wird angeregt.

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Summary Based on a prolonged follow-up investigation among 75 patients operated on for an Oligodendroglioma, a subgroup of the Oligodendrogliomas, the so-called degenerate Oligodendroglioma is discussed.From the histological picture and the clinical features this group lies between the pure Oligodendrogliomas and the Glioblastomas. A rescrutiny based on a larger case material is suggested.

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Resumen El autor ha seguido durante un largo periodo de tiempo un grupo de 75 enfermos operados de oligodendrogliomas. El subgrupo de oligodendrogliomas Ilamado degenerados, es el que se discute. Argumentas histológicos y clínicos hacen que se les clasifique como un grupo intemedio entre los verdaderos oligodendrogliomas y los glioblastomas.

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Résumé L'auteur a suivi pendant longtemps 75 malades opérés d'oligodendrogliome. Le sous-groupe d'oligodendrogliome dit «dégénéré», est discuté. Des arguments histologiques et cliniques fout classer ce groupe comme intermédiaire entre les véritables oligodendrogliomes et les glioblastomes.

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Riassunto In seguito alle osservazioni sul decorso di 75 casi operati di oligodendriomi, viene discusso un sottogruppo dei cosidetti oligodendrogliomi «degenerati».Dal punto di vista istologico e del comportamento clinico questo gruppo sta tra i veri e propri oligodendrogliomi ed i glioblastomi.Gli AA. suggeriscono di controllare questa affermazione in base ad un materiale piú vasto.

     

Antikoagulation oder Antiaggregation in der Bypasschirurgie bei arterieller Verschlusskrankheit der Beine (pAVK)

Patients with atherosclerosis, especially when manifested as symptomatic arterial occlusive disease of the limbs, exhibit a high risk for ischemic complications. They are at high risk for myocardial infarction and stroke and are threatened by cardiovascular death. Treatment after bypass surgery has two targets: risk factors have to be managed as secondary prevention together with platelet anti-aggregation and life style modification, and therapy has to prevent bypasses from occluding, if possible lifelong. Anti-aggregation of platelets with ASS is of central importance under this aspect of graft patency. Oral anticoagulation with vitamin K antagonists with a median effective dosage is only favourable for venous grafts. In cases with oral anticoagulation, a higher risk of major hemorrhage compared to ASS has to be taken into account. There are no evidence based indications for therapy with clopidogrel, dipyridamole or dual platelet inhibition for peripheral arterial occlusive disease.     

Kombinationsverfahren zur Stabilisierung proximaler Tibiafrakturen

Reliable osteosynthesis techniques in the treatment of proximal tibial shaft fractures are still a problem. Intramedullary nailing leads to pitfalls in terms of delayed fracture healing or axial malalignment, while plate osteosynthesis of these fracture types may lead to implant failure. Thus, biomechanical tests to develop alternative strategies are needed to guarantee higher primary stability. Our studies in this direction demonstrate that the combination of the unreamed tibia nail (UTN) with a limited contact dynamic compression plate (LC-DCP) leads to significantly higher stability. A buttress plate together with a small external fixator can be used alternatively. By using these combined osteosyntheses, pitfalls may be avoided in most cases.     

Intraoperative autotransfusion bei massivblutungen nach Thorax-Bauch-Traumen

Zusammenfassung In der Chirurgischen Univeristätsklinik Granada (Spanien) wurde bei 359 traumatisierten Patienten intraoperativ eine Autotransfusion durchgeführt. Je nach Blutverlust wurden die Patienten in 2 Gruppen eingeteilt. Gruppe I (Blutverlust 2000 ml), Gruppe II (Blutverlust > 2000 ml). Bei Patienten der Gruppe I konnten wir auf die Gabe von Fremdblut verzichten. So konnten die erheblichen Risiken der homologen Bluttransfusion verbeugt werden. Makroskopische Hämoglobinurie trat nur bei Patienten auf, bei denen ein Autotransfusionssystem wie das von Solcotrans, Viavae usw. angewandt wurde. Mit dem Bentley-System wurde keine makroskopische Hämoglobinurie nachgewiesen. Bei Patienten der Gruppe II (Blutverlust >2000 ml) mußten wir in allen Fallen neben dem retransfundierten Eigenblut, homologes Blut transfundieren. Wenn die Transfusionsmenge insgesamt 4000 ml überschreitet, kommt es zu einer vermehrten Blutungsneigung, so daß eine Behandlung mittels Frischplasma, Thrombozytenkonzentraten and/oder Fibrinogen erforderlich wird. Die Letalität bei Gruppe II war sehr hoch, aber die Patienten starben an ihren schwerwiegenden Verletzungen oder an postoperativen Komplikationen, die nicht auf die Autotransfusion zurückzuführen waren. Eine Ausnahme bildeten 3 Patienten (massiv autotransfundiert von 12 000 bis 25 000 ml), die an Nierenversagen durch akute tubuläre Nekrose verstarben. Indikation fur die intraoperative Autotransfusion ist, ohne Zweifel, die traumatische intraabdominelle und/oder thorakale Verletzungen die mit hohen Blutverlusten einhergehen.

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Intraoperative autotransfusion for massive bleeding after thoracic and abdominal trauma

Summary In the University Hospital of Granada (Spain), 359 surgical trauma patients underwent intraoperative autotransfusion. The patients were divided into 2 groups, according to their blood loss: group I (blood loss 2000 ml) and group II (blood loss > 2000 ml). Patients from group I did not require homologous blood transfusion. So the high risk involved in this type of transfusion was avoided. Macroscopic haemoglobinuria was only found in those patients where the Solcotrans, Viavae type of autotransfusion system was used; with the Bentley ATS system, no macroscopic haemoglobinuria was registered. With patients from group II, however, that is, those with a blood loss of more than 2000 ml, we had to fall back on homologous transfusion in addition to retransfusing autologous blood. When the transfusion exceeds 4000 ml there is increasing bleeding, which requires treatment with fresh frozen plasma, platelets and/or fibrinogen. The mortality rate of patients in group II was very high but the patients died from the severity of their injuries or from postoperative complications which were not due to autotransfusion in itself with the exception of 3 patients who underwent massive autotransfusion (12 000 to 25 000 ml) and died from acute renal failure. The main indication for intraoperative autotransfusion is without doubt abdominal and thoracic trauma which lead to high blood loss.

     

54. Intraoperative maschinelle Autotransfusion bei Massivblutungen

Zusammenfassung Bei 79 Patienten vor allem mit massiven traumatischen Blutungen wurden mit dem Bentley-ATS im Mittel 6,31 Blut eingespart. Mit dem Haemonetics Cell Saver waren es bei 12 Patienten mit mittleren gefäßchirurgischen Blutungen durchschnittlich 0,51 Erythrocytenkonzentrat. Gerinnungsstörungen können bei beiden Geräten auftreten. Die Luftemboliegefahr entfällt beim Haemonetics. Die sofortige Verfügbarkeit von Blut ist bei beiden Systemen gegeben. Eine rasche und kontinuierliche massive Volumenzufuhr ist nur mit dem Bentley ATS möglich.     

Intraoperative Temperaturmessungen an der Zementknochengrenze bei TEP-Implantation

Zusammenfassung Es wird über Temperaturmessungen mit kanülierten Thermoelementen bei TEP-Implantationen der Hüfte mit Palacos^®, Sulfix-6 und Palacos^® nach Vorkühlen des Knochenlagers mit Eiswasser berichtet.Bei Palacos^® und Sulfix-6 wurden an der Zementknochengrenze Temperaturen, die höher als der Eiweißkoagulationspunkt lagen, gemessen. Als neue Implantationstechnik wird die Kühlung des Knochenlagers vor der Zementimplantation mit Eiswasser beschrieben. Mit dieser Technik konnte die Temperatur an der Zementknochengrenze im Durchschnitt bei 45°C gehalten werden.

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Intraoperative temperature measurements at the acrylic bone/cement interface in total hip endoprosthetic (TEP) implantations

Summary Temperature measurements are reported effected by aid of thermocouples enclosed in tubules in TEP-implantations of the hip. Two techniques were employed: the first using as acrylic bone cement Palacos^® or Sulfix-6 without concomitant cooling, the second Palacos^® after precooling of the femur with crushed ice/water mixtures.The first method yielded, at the acrylic bone cement/bone interface, temperatures above the coagulation point of the protein (56°C). The novel technique of implantation is described, i.e. the cooling of the bone with ice-water prior to the cement implantation. This technique provides a means of restricting the average temperature at the aforesaid interface to 45°C.

     

Intraoperative Farbdarstellung der Gallenwege bei der kongenitalen Gallengangsatresie

Ohne Zusammenfassung     

12.Intraoperative Röntgendiagnostik bei Mehrfachverletzten

Zusammenfassung Die Dringlichkeit der Behandlung unmittelbar lebensbedrohlicher Verletzungen verbietet bei Mehrfachverletzten oftmals eine eingehende präoperative Diagnostik. Routinemäßige Röntgenuntersuchungen bei Kombinationsverletzungen sind methodisch aufwendig und zeitraubend, so daß eine Kollision zwischen der gebotenen Dringlichkeit des Eingriffs und der wünschenswerten Diagnostik entsteht.Es wird eine neu entwickelte Röntgeneinrichtung für den Operationssaal beschrieben, die mit einem exzentrischen Deckenstativ und weiten Auslegern an 3 Drehpunkten den strengen Anforderungen an Betriebssicherheit und Antisepsis genügt. Ohne Umlagerung des Patienten lassen sich auch während eines dringlichen Eingriffs Röntgendurchleuchtungen, großformatige Aufnahmen, 70-mm Aufnahmen, Bandspeicherungen und Übertragungen durchführen, um sowohl bereits erreichte Behandlungsergebnisse zu kontrollieren, als auch primär nicht erkennbare oder nicht erkannte Verletzungen zu beurteilen. Es werden typische Beispiele von Mehrfachverletzungen mit traumatischer Carotisthrombose, intrakranieller Blutung, Schädelimpressionsfraktur, Beckenbrüchen, Blasenrupturen, multiplen Knochenbrüchen und Gefäßverletzungen demonstriert.

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Intra-operative X-ray diagnosis in multiple injuries

Summary The urgent need for treatment when injuries endanger life often prevent a detailed pre-operative investigation of a patient with multiple injuries. Routine radiographic, examinations in multiple injuries consume effort and time, so that a conflict develops between the needful urgency of primary surgical care and the desirability of more detailed diagnosis.Newly developed x-ray equipment intended for the operating theatre is described. It uses an eccentric covered stand with wide extending arms rotating on three pivots and satisfies all requirements of reliability and antisepsis. Without changing the position of the patient it is possible even during emergency operations to carry out x-ray screening, take large size pictures, 70-mm pictures, tape storage and transfers, as well as to check therapeutic results already obtained. It may also be possible to assess injuries not recognizable at first or not recognized.Typical examples of multiple injuries are demonstrated which include traumatic carotid thrombosis, intracranial haemorrhage, depressed cranial fractures, fractures of the pelvis, rupture of the bladder, multiple fractures of bones and injuries to bloodvessels.

     

158. Intraoperative Befunde bei akuter nekrotisierender Pankreatitis

Zusammenfassung 37 Patienten mit akuter nekrotisierender Pankreatitis wurden insgesamt 49mal zwischen dem 1. und 377. Tag nach Erkrankungsbeginn operiert. Anhand der nach der Erkrankungsdauer geordneten intraoperativen Befunde wurde der morphologische Wandel der Pankreatitis in den ersten Tagen, Wochen und Monaten rekonstruiert. Die Studie zeigt, daß eine verzögerte Operation der nekrotisierenden Pankreatitis, welche die vollständige Ausräumung der entstandenen Nekrosen bei gleichzeitiger Schonung vitalen Gewebes zum Ziel hat, nach Möglichkeit nicht vor der 3. Erkrankungswoche vorgenommen werden sollte.     

Intraoperative Phlebographie der Vena spermatica interna bei Varikozele

Zusammenfassung An Hand von 30 intraoperativen Phlebographien w?hrend der Ligatur der V. spermatica interna nachPalomo wird auf die einfache Durchführbarkeit dieser Untersuchung hingewiesen. Diese Methode erm?glicht, ohne wesentliche Belastung des Patienten, eine genaue Planung des operativen Vorgehens durch die Darstellung von Parallelvenen und Kreuzkollateralen, deren Unterbindung zur Verhinderung von Varikozelenrezidiven wichtig ist.

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Summary In 30 consecutive cases which were operated by thePalomo-technique for varicocele, an intraoperative phlebography was performed. It was shown that the angiography of the spermatic vein is an easily performable procedure which helps to identify al collateral veins in order to assure a complete ligation. This is of paramount interest in the prevention of recurrence of a varicocele.