Tierexperimentelle Untersuchungen mit einem neuen Kunststoff zur Auffüllung des Thoraxraumes nach Lungenresektion und zur sonstigen Verwendung in der Chirurgie

Ohne ZusammenfassungMit 2 Textabbildungen.     

Korrekturen bei voroperierten und stigmatisierten Patienten nach ?Facelifts��

The number of failed previous operations, and hence also of stigmatized patients, continues to rise. Insufficient training, the use of widely varying techniques, incorrect indications, as well as minimally invasive techniques, result in imperceptible (though promised) treatment results. In addition, unsightly scarring, adhesions, hair loss, deformities, eye changes, impaired function, and facial deformities can impair the patient??s daily life. Using examples, some the negative results and possible treatment concepts are discussed here. With the help of an extended or superextended face/neck lift and the construction of an internal scaffold??SMAS or high SMAS??it is usually possible to achieve the originally desired treatment result and thereby largely eliminate stigmatizing changes. Other tried and tested treatment methods underpin corrective surgery down to the smallest detail and help achieve a natural (unoperated) result.     

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.     

Diagnostik und Therapie von Funktionsst?rungen der H��ftmuskulatur nach Totalendoprothese

Abductor insufficiency after hip arthroplasty is a difficult and challenging problem whereby conservative therapy is often insufficient and surgical therapy is known to have failures with re-ruptures. Alternative approaches and arthroscopic surgery are proposed but in many cases they do not fulfill the expectations of patients.Our experience with temporary explantation of implants and transosseous refixation is good resulting in a pain-free patient in a high number of cases but the method is quite demanding and needs a cooperative patient. A functionless abductor muscle is not amenable to surgical treatment but only a surgical exploration can confirm the clinical suspicion.     

Vermeidung, Diagnostik und Therapie von Nervenl?sionen nach H��ftendoprothesenimplantation

Nerve palsy following total hip arthroplasty is a rare complication. Developmental dysplasia of the hip, previous fracture treatment and medical comorbidities are characteristic risk factors. By accurate preparation of the patient and a careful operative technique nerve palsy can be avoided in most cases. Nerve palsy following poor patient positioning during the perioperative period should be avoided by close cooperation with anesthesiologists.In cases of postoperative nerve palsy correct diagnostics should be carried out immediately. Further treatment options should be considered to minimize the damage. For patients with definite nerve palsy, devices such as a foot drop splint are often necessary and should be carried out as soon as possible.     

Versuche des Ersatzes und der Ausnutzung von Oberflächen-Sensibilität bei Armprothesen

Ohne ZusammenfassungMit 10 Textabbildungen (16 Einzelbilder)Herrn Professor Dr. med. S. Weil zum 80. Geburtstag gewidmet.     

Wertigkeit Bild gebender Verfahren bei Verletzungen des Fußes und des Knöchels und Akzeptanzmessung mit interaktiver Beteiligung von Tagungsteilnehmern

Trauma und Berufskrankheit - Laut den Statistiken der Berufsgenossenschaften zählen Fuß und Sprunggelenk zu den am häufigsten verletzten anatomischen Regionen der Haltungs- und...     

Ipsilaterale Begleitverletzungen an der oberen Extremit?t und des Schultergürtels nach proximalen Humerusfrakturen

Question.

The aim of this study was to elucidate associated injuries of the upper extremities and shoulder girdle in proximal humeral fractures and to evaluate their impact on clinical outcome.

Methodology.

Between January 2001 and March 2008 a total of 641 patients where operated due to proximal humeral fractures. All patients were retrospectively analyzed in terms of associated injuries and 58 patients (9?%) with associated injuries on the ipsilateral upper extremity were identified, of whom 36 (mean age 67 years, 24 women, 12 men) could be clinical examined (DASH and Constant scores) after a mean follow-up of 38 months.

Results.

The 58 patients with associated injuries where treated with plate osteosynthesis (38 patients), nail osteosynthesis (7?patients) and primary shoulder prosthesis in 12 patients. One patient received a screw osteosynthesis. Most associated injuries were distal radial fractures and nerve injuries. Appearance of distal radial fractures was linked to low-energy trauma, whereas high-energy trauma was related to elbow injuries, especially elbow dislocation. Proximal humeral fractures with glenohumeral dislocation were associated with a higher risk of nerve injury. Associated injuries occurred more often in women and mostly in patients aged 60 years and older. Men with associated injuries were distributed over the whole life span. Evaluation of 36 patients in follow-up revealed a mean DASH score of 35 points and a mean Constant score of 56 points. Osteosynthesis of proximal humeral fractures led to better results than primary arthroplasty.

Conclusion.

The combination of proximal humeral fracture and ipsilateral associated injury is common and related to osteoporotic bone. Treatment includes osteosynthesis of all fracture sites to allow fast mobilization. Functional results are dependent on type of treatment of proximal humeral fractures. This trial might help clinicians to identify a risk population for those injuries in respect to patient age, sex and energy of trauma.     

Veränderungen der Flüssigkeitsfiltrationskapazität und des Blutflusses nach Tourniquet bei Knieoperationen in Spinalanästhesie

An increased microvascular water permeability has been reported after ischemia/reperfusion both in animal models and in human studies. We studied the changes in fluid filtration capacity (FFK) after ischemia/reperfusion due to tourniquet in patients undergoing arthroscopy of the knee. Method: Healthy male volunteers (n=24, mean age 46.9±3.5) were studied prior to, 1 and 6 hours after arthroscopy of the knee, during which a tourniquet was applied to the thigh. FFK, isovolumetric venous pressure (P_vi) and arterial blood flow in the limb was measured in both legs (tourniquet leg and control leg) using computer assisted venous congestion plethysmography. Venous blood samples were obtained from a cubital vein prior to and from the femoral vein 2?mins after deflation of the tourniquet cuff. 12 patients received preoperatively an infusion of 6% Dextran (D) and 12 patients 500?ml of electrolyte solution (VE) an. Results: The mean duration of the tourniquet was (D) 56.0±6.9?min and (VE) 53.9±4.2?min which resulted in a significant increase in venous lactate concentration from (D) 1.4±0.1?mmol.l^?1 to 2.7±0.3?mmol.l^?1 and (VE) 1.3±0.1?mmol.l^?1 to 2.7±0.3?mmol.l^?1 (p<0.001). A significant decrease in pH from (D) 7.39±0.01 to 7.32±0.01 (p<0.001) and from (VE) 7.39±0.01 to 7.32±0.01 (p<0.001) was also seen. Preoperatively no significant differences in the FFK values of the tourniquet leg (D=5.3 (4.8–10.7) ml.×10^?3 min^–1. 100?ml tissue^?1 mmHg^?1=FFKU) and the control leg (5.2 (4.7–8.6 FFKU)) were observed. The maximum FFK value in D was seen 1 hour after ischemia/reperfusion in both, the tourniquet leg (7.5 (4.6–14.2 FFKU) and the control leg (7.8 (5.5–9.4 FFKU). In VE however the maximal FFK value were measured 6 hours after ischemia/reperfusion with an increase in the tourniquet leg from 5.2 (4.2–6.2 FFKU) to 8.1 (3.7–10.4 FFKU) and the control leg from 6.1 (3.6–7.0 FFKU) to 7.3 (6.1–8.3 FFKU) (Median (Range), One-way ANOVA). There were no significant differences in the FFK values between D and VE except for a lower P_vi in VE at the third measurement. No significant changes in the arterial blood flow were seen perioperatively as well as between the operated and non-operated leg. Conclusion: A tourniquet of <1 hour does impair tissue oxygenation as indicated by the increase in lactate and the decrease in pH. The duration of the tourniquet was however to short to have caused sufficient microvascular damage result in a more pronounced increase in fluid filtration capacity.     

Cisatracurium – ein Stereoisomer als „ideales” Relaxans? Histaminfreisetzung und Tryptasebestimmung nach Bolusapplikation von Cisatracurium: ein Vergleich mit Vecuronium

Cisatracurium (51W89, Nimbex, Glaxo-Wellcome), an intermediate-acting non-depolarizing neuromuscular blocking agent, is a stereoisomer of atracurium. Histamine releasing propensities and serum tryptase level have been investigated after administration of cisatracurium (3×ED₉₅, 5×ED₉₅) or vecuronium (3×ED₉₀) in surgical patients. Methods: After approval by our institutional review board, 62 patients (ASA I–II) were randomly assigned to three groups to receive either 3×ED₉₅ or 5×ED₉₅ cisatracurium, or 3×ED₉₀ vecuronium as a rapid bolus. A prick test was done the day before by scarification of the skin in the forearm. After premedication with 2?mg lormetazepam, anaesthesia was induced with thiopentone (4–12?mg/kg) and maintained with O₂/N₂O and isoflurane (1.5–2?vol.%). Six minutes after thiopentone, the patients received the relaxant, and after further 6?min 0.1–0.2?mg fentanyl was given and the trachea was intubated. Heart rate (HR) and blood pressure (BP) were monitored every minute. Blood samples for histamine were withdrawn 5?min prior 3 and 5?min after each drug administration (thiopentone, relaxants). Plasma histamine was measured by radioimmunoassay (RIA) with a sensitivity of approximately 10?pg/ml. Additionally, serum tryptase was measured by RIA at baseline (?10 and ?1?min) and 15 and 60?min after the relaxant administration. Levels for histamine >1000?pg/ml and for tryptase >2?µg/ml were considered significant. Cutaneous signs of histamine release were documented. Results: Ten patients showed a positive prick-test reaction. Only after thiopentone some cutaneous signs (4 flush, 1 erythema) of histamine release were observed. There were no cutaneous signs of histamine release correlating with cardiovascular changes. Analysis of the blood samples demonstrated no significant increase in the histamine level in all three groups. Only in 1 patient was a significant higher histamine level (1133?pg/ml) measured 5?min after 5×ED₉₅ cisatracurium. All measurements of serum tryptase were within the physiological limits. Discussion: In this study, with the particular time course of drug administration, neither cisatracurium nor vecuronium increased plasma histamine levels. Only after 5×ED₉₅ cisatracurium was 1 elevated histamine level documented after 5?min. In several studies increased histamine levels have been described, but without clinical manifestations. It is known that cutaneous signs can occur without increased plasma histamine levels due to the structural heterogeneity of mast cells. The cutaneous reactions in this study were caused by thiopentone. The tryptase values were within normal limits even in the patient with histamine release. No relationship between the positive results in the prick test and the incidence of cutaneous reactions and/or histamine release for drugs used in the induction of anaesthesia was observed. Whether cisatracurium has a potential for immunologic release is unknown.     

Untersuchungen über die Stabilität bei der Osteosynthese von Schaftfrakturen mit der Schrauben- und Plattenmethode der Arbeitsgemeinschaft für Osteosynthesefragen (AO)

Ohne ZusammenfassungMit 24 TextabbildungenHerrn Prof. Dr. Walter dick zum 65. Geburtstag.     

Chirurgische Leistungsdokumentation – Hilft viel wirklich viel? Vergleich der Auswirkung von maximaler und geringer Dokumentationstiefe klinischer Patientendaten auf das theoretische Ertragsvolumen einer chirurgischen Klinik nach Einführung des DRG-basierten Entgeltsystems

Introduction. The forthcoming introduction of a DRG-based account system in Germany aims at higher transparency and economic efficiency, particularly in the sector of in-patient health care. The availability of documentation of the highest quality, taking into account all potentially relevant diagnoses, appears to be the best method for achieving maximum revenue in individual surgical units. The aim of the study was to determine the relevance of various degrees of documentation depth on calculated DRG-based revenue. Furthermore, we evaluated whether improvements in the quality of documentation can be realized in current hospital organization. Methods. In a prospective study, clinical data from 402 in-patients were collected and revenues were calculated based on the Australian-Refined DRG system. Various qualities of documentation were defined. In order to find the medical sectors most sensitive to “under-documentation”, homogenous cases were classified into 23 treating groups, according to diagnosis. Results. In 267 cases, maximum revenue was determined only by one main diagnosis, while better results could be achieved in 137 cases (34%) by extended documentation quality. Half of this gain could only be achieved by an independent medical documentation specialist. An upper limit of documentation intensity (number ofdiagnoses) could be defined. Maximum gain did not require maximum number ofdiagnoses. Conclusions. Documentation depth has an important influence on the calculated revenue of surgical therapy based on AR-DRG system. The quality and depth of the documentation is not, in itself, sufficient. In order to be really effective, it requires the highest degree of professionalism from hospital staff.