135. Akutes Abdomen bei den durch Immunreaktionen vermittelten Erkrankungen

Zusammenfassung Die Bewertung des akuten Abdomens als echte oder vorgetäuschte Komplikation bei einer Immunvasculitis ist ausserordentlich schwierig. Trotz der modernen laborchemischen und bildgebenden Untersuchungsverfahren ist die Zahl der Fehlbeurteilungen gross, wobei die üb rflüssige, fehlindizierte Notlaparotomie genauso verhängisvoll sein kann wie die unterlassene chirurgische Intervention. Wichtig ist eine sorgfältige Verlaufsbeobachtung unter Einschluss der Sonographie und evtl. der Laparoskopie und die Beachtung der Erfahrungen von H. Bailey bei der PSH, dass Komplikationen oft vermutet, aber nur 'selten angetroffen werden.     

103. Endoskopische Untersuchungsverfahren beim akuten Abdomen

Zusammenfassung Als Verfahren für die Endoskopie stehen neben der Oesophago-gastroduodenoskopie die Koloskopie und die Laparoskopie zur Verfügung. Die beiden ersten Verfahren werden nur in seltenen Ausnahmefällen evtl. zur Abgrenzung vermuteterv Zweiterkrankungen und bei Gravidität sinnvoll eingesetzt werden können. Die Laparoskopie ist eine diagnostische Weiterentwicklung der Peritonealspülung und kann bei intraabdominellen Blutungen oder bei Peritonitis sinnvoll eingesetzt werden.     

Zur Diagnose und Therapie des stumpfen Bauchtraumas

Zusammenfassung Es wird über 1511 Patienten berichtet, welche mit der Verdachtsdiagnose „Stumpfes Bauchtrauma” an der Universit?tsklinik für Chirurgie (Graz) zwischen 1948 und 1983 aufgenommen wurden. Wenn sich auch nur bei 524 eine Organverletzung verifizieren lie?, so mu? schon am Unfallort die Verdachtsdiagnose aus Unfallhergang, Fremdanamnese und Abdominalbefund gestellt werden. Im Spital erg?nzen das konventionelle R?ntgen, die Sonographie bzw. das Computer-tomogramm die diagnostischen M?glichkeiten und verkürzen so die Zeit bis zur chirurgischen Intervention. Hier steht bei Verletzungen der Leber und Milz die Verwendung des Fibrinklebers im Vordergrund. Gerade bei der Milz bemüht man sich heute, das Organ zu erhalten. Die Verkürzung der Diagnosezeit k?nnte die Mortalit?t verringern und damit die Chancen des Verletzten wesentlich verbessern. Auszugsweise vorgetragen am 25. ?sterreichischen Chirurgenkongre?, Graz 1984.     

Fibreoptic bronchoscopy for early diagnosis of bronchogenic carcinoma: A comparison of yield of biopsy,bronchial lavage and brush biopsy

Fifty-one patients with endoscopically visible bronchogenic carcinoma underwent fibreoptic bronchoscopy. At the same sitting, bronchial brush cytology was taken followed by collection of bronchial washings after lavage with 10 ml of 0.9 per cent saline. Three specimens of bronchial tissue were taken from different sites of a tumour. Bronchial biopsy, was found to be the most sensitive procedure as it was positive in 36 (70.5%) patients as compared to bronchial was (64.7%) and brush cytology (55%). Bronchial lavage alone was positive in five and only brush cytology was contributory in four. Massive bleeding was encountered in three patients and one of them required urgent blood transfusion. There was no mortality. It is concluded that the diagnostic yield of endoscopy procedures is enhanced by combining all the three techniques simultaneously     

Arthroscopy in the diagnosis of acute injuries to the knee joint

Summary This study evaluates the role of arthroscopy in the diagnosis of acute injuries to the knee. One hundred and fifty four patients with a suspected ligament injury or effusion of the knee joint underwent arthroscopy. A haemarthrosis was present in 82% and a bloodless effusion in 10%. Meniscal tears were found in 19% of the knees. Fresh ligament ruptures were present in 71% and an associated haemarthrosis in 95% of these; 65% were partial tears. The commonest isolated lesion was a complete or partial tear of the anterior cruciate, which occurred in 15% of cases. More than one ligament injury occurred in 56%, the commonest combination being tears of the anterior cruciate and medial collateral ligaments. In a high percentage of cases, arthroscopy revealed unsuspected injuries of significance in management. In 39%, an open or closed procedure followed arthroscopy. There were no complications from the diagnostic arthroscopy. We conclude that arthroscopy provides a more accurate diagnosis than clinical examination alone, and is especially valuable for assessing the patient with a haemarthrosis of the knee.

---

Résumé Le but cette étude est d'évaleur le rôle de l'arthroscopie dans le diagnostic des lésions traumatiques récentes du genou. Cent cinquante et un sujets chez lesquels on pouvait soupçonner une lésion ligamentaire ou un épanchement du genou ont subi une arthroscopie. Il existait une hémarthrose dans 82% des cas et une hydarthrose dans 10%. On a découvert une déchirure d'un ménisque dans 19% des genoux. Il y avait une rupture ligamentaire récente dans 71% des cas, et chez 95% d'entre eux une hémarthrose y était associée. La lésion isolée la plus fréquente était la rupture, partielle ou complète du ligament croisé antérieur, qui existait dans 15% des cas. On notait l'atteinte de plus d'un seul ligament dans 56% des cas, l'association la plus habituelle étant la déchirure des ligaments croisé et latéral interne. Dans une importante proportion de cas l'arthrose a mis en évidence des lésions inattendues, nécessitant des mesures thérapeutiques particulières. Chez 39% des patients l'arthroscopie a ét suivie d'un traitement chirurgical, à ciel ouvert ou non. L'arthroscopie à visée diagnostique n'a entraîné aucune complication. Les auteurs concluent que l'arthroscopie permet un diagnostic lésionnel plus précis que le simple examen clinique et qu'elle est particuliérement utile chez les sujets qui présentent une hémarthrose du genou.

     

Acute glomerulonephritis in three siblings and suspected <Emphasis Type="Italic">emm</Emphasis>49-type <Emphasis Type="Italic">Streptococcus pyogenes</Emphasis> infection

Three siblings with poststreptococcal acute glomerulonephritis are presented. Streptococcal infection, impetigo, and pharyngitis preceded the acute glomerulonephritis. In one patient, emm49-type Streptococcus pyogenes was isolated, a strain which has not been reported as nephritogenic in Japan.     

Open Abdomen after Severe Acute Pancreatitis

Abstract The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2–3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9–12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.     

腹腔镜治疗外科急腹症122例临床分析

目的探讨腹腔镜技术外科急腹症的诊断和治疗价值. 方法回顾分析2001年1月～2003年3月收治的122 例外科急腹症病人的腹腔镜检查与治疗效果. 结果全部病例通过腹腔镜均获得明确诊断.腹腔镜下完成手术117例,中转开腹5例,死亡2例.中转开腹原因主要是视野受限、严重粘连致暴露解剖分离困难. 结论腹腔镜对外科急腹症诊断和鉴别诊断准确,极具价值.多数外科急腹症可在腹腔镜下完成治疗,但对某些病例的治疗有一定的局限性.     

Constrictive pericarditis: Clinical profile and management

One-hundred and sixteen patients were surgically treated for constrictive pericarditis over a period of 18 years. Twenty-eight patients were less than 15 years old. All patients had exertional dyspnoea and elevated jugular venous pressure. Eighty-eight patients had NYHA class III or IV functional disability. Only 2 cases had atrial fibrillation. Seventeen patients had roentgenographic evidence of pericardial calcification. Fluoroscopy showed diminished cardiac movements in 110 cases. Cardiac catheterisation in 77 patients demonstrated classical haemodynamic pattern of constrictive pericarditis. All our patients underwent subtotal pericardiectomy through a left anterolateral approach. Seventy-one patients had histological evidence of tuberculous pericarditis. Nearly 88 per cent of the followed up cases reported good to excellent relief. The hospital mortality was 6.9 per cent. Our observations and inferences are compared with those of other published reports.     

Hemolytic uremic syndrome associated with Entamoeba histolytica intestinal infection

Amebiasis secondary to Entamoeba histolytica (E. histolytica) continues to be a major source of morbidity and mortality worldwide, mainly in developing countries. An association between amebic dysentery and hemolytic uremic syndrome (HUS) has been mentioned, but a cause-and-effect relationship has never been confirmed. We report the case of an 11-year-old healthy white female who developed severe bloody diarrhea after drinking contaminated unboiled water, developing classic HUS and requiring acute intermittent hemodialysis. The etiological study confirmed numerous cysts and hematophagous trophozoites of E. histolytica on stool smear, but without evidence of other pathogens. This report contributes to the concept that classic post-diarrheal HUS, usually related to colitis secondary to enterohemorragic Shiga-toxin producing Escherichia coli (E.coli) strains, may be associated with other pathogens, including E. histolytica. Additional information regarding mechanisms of virulence of E. histolytica and host immunological reaction is needed to clarify the temporal association of these two disorders (HUS and amebiasis).     

Continuing role of thoracoplasty for pulmonary tuberculosis: Review of 155 cases

Standard thoracoplasty or thoracoplasty with intercostal myoplasty was performed in 155 cases of pulmonary tuberculosis or tubercular empyema. Resectional surgery was not possible in these cases due to bilateral extensive disease and poor cardiorespiratory reserve. Sixty patients had fibrocavitary lesions, 30 were persistently sputum positive and 36 suffered recurrent haemoptysis. Following surgery, obliteration of cavity, sputum conversion and control of haemoptysis could be achieved in 58, 27 and 36 cases respectively. There was no mortality. Twenty six patients with chronic empyema were cured. Two patients out of 3 with post pneumonectomy empyema were cured.     

Acute tubulointerstitial nephritis in association withYersinia pseudotuberculosis infection

A 4-year-old girl was diagnosed as having acute renal failure due to tubulointerstitial nephritis. The girl presented with remittent fever. vomiting and non-oliguric acute renal failure with sterile pyuria and tubular reabsorptive dysfunction. Ultrasound examination revealed that the kidneys were markedly enlarged with diffuse hyperechogenicity in the cortex when the abnormal renal function was present and were restored in size and echogenicity when the renal function normalised. A diagnosis ofYersinia pseudotuberculosis infection was based on a rise in haemagglutination titres against the organism.     

The Genetic Epidemiology of Breast Cancer Genes

Genetic susceptibility to breast cancer in women is conferred by a large number of genes, of which six have so far been identified. In the context of multiple-case families, BRCA1 and BRCA2 are the most important. Mutations in these genes confer high lifetime risks of breast cancer and ovarian cancer, and more moderate risks of prostate cancer and some other cancer types. Mutations in the CHEK2 and ATM genes, by contrast, cause much more modest (2-4 fold) risks of breast cancer. Genes so far identified explain approximately 20% of the familial aggregation of breast cancer. The remaining susceptibility genes have, so far, proved illusive, suggesting that they are numerous and confer moderate risks. A variety of techniques including genome-wide association studies, use of quantitative intermediate endpoints, and resequencing of genes may be required to identify them. The identification of such genes can provide a basis for targeted prevention of breast cancer.     

Ventilatory support following open heart surgery

One thousand consecutive patients undergoing open heart surgical procedures were evaluated for the need for ventilation in the postoperative period. All cases of mitral valve replacement (237) and double valve replacement (85) were electively ventilated. Fifty-two other patients required ventilation for various reasons which included low cardiac output with inotropic support, ventricular arrhythmias, left atrial pressure above 18 mm Hg, bleeding, hypo or hyperthermia, unsatisfactory blood gases, neurological problems, overdosage of narcotics, incomplete reversal of relexants and flooded lungs at the end of operation. Twenty patients needed ventilation beyond 4 days. Prolonged ventilatory support was maintained with nasotracheal tube and only 3 patients required tracheostomy after 12 days for cerebral and pulmonary complications. The pulmonary complications encountered during postoperative ventilation were stiff lungs, copious secretions and bleeding in 20 patients.     

Legionella infection with acute renal failure and thrombocytopenia mimicking allograft rejection

A patient is described who developed cavitary Legionella pneumonia 2 weeks after kidney transplantation. The initial pulmonary symptoms were followed by severe thrombocytopenia and acute renal failure. Although acute irreversible graft rejection was suspected, this was not supported by the pathology findings in the resected kidney, which were compatible with tubular damage. We presume that the extrapulmonary symptoms were caused by Legionellosis.     

Deep infection following femoral neck fracture osteosynthesis

Summary During the last decade a decrease in postoperative infections in femoral neck fracture osteosynthesis was noted which led us to review all femoral neck fractures for infection. In a retrospective series of 1894 femoral neck fractures, the majority of which were included in other limited prospective studies, a total of 15 deep infections were diagnosed (0.8%). Staph. aureus was the most common bacterium cultured, and the diagnosis was established more than 4 months postoperatively in 9 of the patients. A total of 658 of the 1894 patients, who had pre- or peroperative tetracycline administration for measuring bone turnover, had two deep infections (0.3%). Among the remaining 1236 patients without antibiotic prophylaxis, 13 deep infections were diagnosed (1.0%). This difference suggests considering antibiotic prophylaxis in femoral neck fracture osteosynthesis. Eight of the infections led to THR, usually two-stage ; no signs of recurrent infection ensued, and the hip function of these patients was restored. The remaining 7 patients had Girdlestone procedures, also without recurrent infection, but with inferior functional outcome.     

Left atrial myxoma

8 patients with atrial myxoma were reviewed. They ranged from 5 years to 55 years. Recently echocardiography has been the most helpful diagnostic procedure. Hemodynamically they simulated mitral valve disease with severe pulmonary hypertension. Tumour was demonstrated by angiocardiography. One of these tumours presented into the right atrium through an associated atrial septal defect. All of them underwent open heart surgery and removal of the tumour. One died as a result of septicemia. Others have had excellent hemodynamic improvement.     

A simple and safe technique for the proper placement of intercostal drainage tubes

A simple and safe technique for accurate placement of intercostal drainage tubes with the help of metal urethral dilators is described.     

Benign fibrovascular polyp of the oesophagus

A case of fibrovascular polyp of the oesophagus is described. Endoscopy, ultrasonography and CT scan were useful to confirm the intraluminal location of the mass.