Operative Therapie bei Spondylolyse und Spondylolisthese

The therapy for spondylolysis and spondylolisthesis is challenging in view of the large variety of treatment options. A general, standardized therapeutic concept has still not been established. Adequate therapy depends on different parameters and personal experience. Beside direct repair surgery of spondylolysis and low grade spondylolisthesis, dorsal, ventral and combined dorsoventral surgery, with or without instrumentation, are indicated depending on patients age and severity of the slip. Complications such as pseudarthrosis and progression of the slip develop in a given percentage of cases, but these are not significantly correlated with clinical symptoms. Decompression is necessary in high grade slippage with neurologic impairment, especially paresis. Reposition is associated with a higher risk of neurologic complications. Fusion in situ without instrumentation, even in moderate and severe spondylolisthesis, shows good clinical results with high fusion rates and without the increased risk of progression and pseudarthrosis. In many cases, it is an effective, safe and economic therapeutic option.     

Operative Therapie des benignen Prostatasyndroms (BPS)

Surgical treatment of lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) comprises a variety of treatment modalities. Transurethral resection of the prostate (TURP) is considered the gold standard. In the last decade various new techniques have emerged with encouraging functional results. However, long-term data are missing in order to evaluate the efficacy and safety. This review aims to describe new widely available techniques and to assess the underlying evidence.     

177. b) Operative Therapie und Verfahrenswahl bei der Lungenembolie

Zusammenfassung In den letzten Jahren wurden große Fortschritte mit der Embolektomie unter Anwendung der Herz-Lungen-Maschine erzielt. Diese Methode ist aber nur anwendbar bei Patienten, welche die Embolie 1-2 Std überleben, weil exakte Diagnostik und das Anschließen der Herz-Lungen-Maschine immer noch gewisse Zeit erfordern.Für Kranke, die schon nach wenigen Minuten bewußtlos werden und einen Kreislaufstillstand aufweisen, steht diese Zeit nicht mehr zur Verfügung. Sie können aber bei einer darauf eingestellten Klinikorganisation ohne weitere diagnostische Maßnahmen und ohne frustrane konservative Reanimationsversuche noch durch die sofortige transsternale Embolektomie mit vorübergehender Cava-Abklemmung gerettet werden.Dieses Verfahren ist auch in Krankenhäusern und Kliniken durchführbar, die nicht im Besitz einer Herz-Lungen-Maschine sind. In Gießen haben von insgesamt 64 Patienten bisher 15 länger als 8 Tage überlebt, 9 konnten gesund entlassen werden. Die weit verbreitete Ansicht, daß diese Kranken auch ohne erfolgreiche Notembolektomie am Leben geblieben wären, ist falsch. Der deletäre klinische Verlauf vor dem Eingriff und die bei der Embolektomie entfernten großen Thromboemboli beweisen den lebensrettenden Wert unserer Operationen.

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Summary In the past few years great advances in embolectomy have been achieved through the use of the heart-lung maschine. This method, however, can be applied only in patients who survive the embolism for one or two hours because accurate diagnosis and the connection of the heart-lung machine still require some time. For patients who become unconscious after a few minutes and show circulatory arrest this time is no longer available. They can, however, still be saved by immediate transsternal embolectomy with temporary clamping of the vena cava without further diagnostic measures and useless conservative attempts at reanimation if the clinic is suitably organised. This method can also be employed in hospitals and clinics which do not possess a heart-lung machine. At Giessen 15 out of 64 patients have so far survived for over 8 days, and 9 were discharged cured. The commonly held view that these patients would have survived even without successful emergency embolectomy is erroneous. The deleterious clinical course before the operation and the large thrombo-emboli removed by embolectomy prove the lifesaving importance of our operations.

     

Operative und konservative Therapie von Acetabulumfrakturen-Indikation und Ergebnisse

Between 1975 and 1983 38 patients with a fracture of the acetabulum were treated-28 patients were operated upon, 10 patients were treated conservatively. 26 in 28 patients treated operatively and 8 in 10 patients treated conservatively could be checked up. 3 of the cases treated operatively could not be evaluated, as the operation had been realized less than two years before. Following an accurate indication for the operative treatment 14 in 23 patients proved an efficient osteosynthesis. In 5 in 8 cases treated conservatively good results were obtained. In aged patients and in certain types of fractures of the acetabulum, especially in comminuted fractures, conservative treatment is still justified.     

Diagnose und Therapie bei Vorhoftumore

Zusammenfassung Bei 10 Patienten mit Vorhofmyxom oder Lipom werden Symptome, Diagnose und Therapie beschrieben. Die Diagnose wurde 8mal klinisch gestellt, 2mal (Lipome des rechten Vorhofes) erst intraoperativ. 9 Patienten überlebten den Eingriff. Rezidive wurden bis zu 5 Jahren nach der Operation nicht beobachtet.      

Diagnostik und Therapie bei Quadrizepssehnenruptur

Rupture of the quadriceps tendon is less common than rupture of the Achilles or biceps tendon or rotator cuff rupture. Males are more frequently affected with a male/female ratio of 4:1. Peak incidence is between 55 and 66 years (5–6 years in children). Rerupture has an incidence of up to 3%. The majority of patients describe a severe sharp pain above the patella, where a gap above the patella is palpable. X-ray is able to exclude fractures. Ultrasound and MRI represent complementary diagnostic methods. Distinction is made between a traumatic origin and a history of overuse with degeneration. In addition, it is frequently associated with a number of chronic metabolic disorders. Acceptance as treatment covered by employers’ liability insurance is based on the same rules as those for injuries to other tendons. Early functional after-care is important following surgery. Partial ruptures may be treated conservatively. Despite persistent femoral muscle atrophy, most patients achieve almost unrestricted knee mobility.     

Operative Therapie der abdominellen und retroperitonealen Sarkome

Retroperitoneal soft tissue sarcomas are characterized by a high rate of local recurrence. Complete tumor resection is the only potentially curative therapeutic option. The concept of a systematic compartmental resection is to remove the tumor en bloc with a margin of uninvolved tissue and organs. This is frequently only achieved by multivisceral resection which often includes kidney, colon, pancreas and parts of the diaphragm or the psoas muscle. The adoption of such a policy of multivisceral organ resection improves the proportion of curative resections and, ultimately, results in lower local recurrence rates. The present article comprehensively describes the operative procedures, perioperative treatment and the oncological results of surgery for retroperitoneal sarcomas. The role of surgery in oncological treatment plans and the importance of specialized centres are outlined in detail.     

T4-Rektumkarzinom Operative und multimodale Therapie

BACKGROUND: In locally advanced rectal cancer with infiltration of neighbouring organs (uT4), resectability and local control are difficult to achieve. Combined preoperative radiochemotherapy may result in increased resectability and reduced local recurrence rates. PATIENTS AND METHODS: Thirty-four patients with biopsy-proven locally advanced rectal cancer were treated by preoperative radiochemotherapy. All tumours had been staged as uT4 lesions by endorectal ultrasound or computed tomography. Radiotherapy was applied in standard blocks, 5 x 1.8 Gy up to 45 Gy. Chemotherapy consisted of two cycles of 5-fluorouracil (300-350 mg/m2/day) and leucovorin (50 mg). In 20 patients, additional thermotherapy was carried out using the Sigma 60 applicator BSD 2000 once a week prior to radiotherapy. Surgery was performed 4-6 weeks after radiochemotherapy. Postoperatively, all patients received four cycles of 5-fluorouracil and leucovorin. RESULTS: Treatment-induced toxicity occurred in 26% of the patients (WHO grade III (n = 6) and IV (n = 3)). The resectability rate was 76% (26/34 patients) (R0 resectability n = 21; 62%). The pathological complete response rate was 6% (n = 2) and the partial response rate was 47% (n = 16). A local failure was observed in six patients after median time of 16 months (range 7-36 months). Patients with R0 resection achieved a 5-year disease-free survival rate of 55% and a survival rate of 71%. The overall 5-year survival rate for all patients with advanced uT4 rectal cancer was 49%. CONCLUSIONS: Our data on preoperative combined treatment in locally advanced T4 rectal cancer revealed encouraging downstaging, local control, and survival rates.     

Adjuvante Therapie bei Sepsis und ARDS

Ohne Zusammenfassung     

Operative Therapie von idiopathischen Skoliosen und juvenilen Kyphosen

Indication for operative treatment of idiopathic scoliosis and juvenile kyphosis is mainly cosmetic. There is also a higher incidence of pain in scoliosis patients, and reduced pulmonary function in severe deformity, especially in severe deformities present at the age of 5 years (early onset). Scoliotic curves of less than 30 degrees will not progress in adults, whereas curves of 50-75 degrees will further progress a mean of 25 degrees during 40 years. Progression in adults with juvenile kyphosis is not well documented. Operative treatment aims to stop progression, to control spinal growth, or to perform correction and fusion by spinal instrumentation and bone grafts. These goals can be achieved either by an anterior, a posterior, or a combined approach. Correction principles are compression, distraction, derotation and translation. The forces applied by correction are transferred by fixation devices (pedicle screws, anterior screws, hooks, sublaminar wires) to the spine. The higher correction forces are, the higher is the correction achieved, but also the risk of fracture and torn out implants. Mobilisation reduces rigidity and allows to achieve a better correction with equal forces. The best mobilisation techniques are disc excision, facet joint removal, and techniques to mobilise the thorax.     

Aktuelle Aspekte der medikamentösen Therapie bei benignem Prostatasyndrom (BPS)

Two groups of drugs, α blockers and 5-α-reductase inhibitors (5ARI), are currently widely used for the medical treatment of benign prostatic syndrome (BPS). Alpha blockers are characterized by a rapid onset of efficacy. If given at an adequate dose, all α blockers have a similar efficacy, yet quantitative differences regarding side effects exist. The onset of clinical efficacy of 5ARIs is delayed and dependent on prostate volume. Symptom improvement is generally less pronounced than with α blockers, yet this difference declines with time. 5ARI, in contrast to α blockers, reduce prostate volume and the risk of long-term BPS complications such as prostate surgery or acute urinary retention. The combination therapy of α blockers and 5ARI is superior to either monotherapy; however, this superiority becomes evident only after prolonged (>1 year) therapy. Because of additive side effects, this combination should be reserved for BPS patients with a high risk of progression. Regarding plant extracts, no definitive recommendation can be given because of a limited number of high-quality clinical trials. The use of antimuscarinics in men with BPS with a dominance of storage symptoms and without significant obstruction is promising, although further trials, particularly with a longer study duration, are required.     

Phytotherapie bei BPS

For decades, plant extracts have been amongst to the most popular drugs for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH)/benign prostatic enlargement (BPE). Only a few of the many published studies meet the criteria of the WHO-BPH consensus conference. The few placebo-controlled, long-term (>/=6 months) studies suggest a positive effect of some extracts (saw palmetto, beta-sitosterol, urtica, rye-grass, saw palmetto/urtica combination) on LUTS; an effect on uroflow, post-void residual volume, prostate volume and PSA was not consistently demonstrable. Randomised trials against an active comparator (alpha1-blocker, 5alpha-reductase inhibitors) are difficult to interpret. Due to the lack of prospective studies, several meta-analyses have been published that can not, however, replace prospective studies. None of the BPH-guidelines currently recommend plant extracts, yet universally conclude that this is an interesting approach. Further prospective studies using WHO standards are required to reliably determine the role of such extracts in the management of elderly men with LUTS due to BPH/BPE.     

Operative und nichtoperative Behandlung bei Pseudarthrosen

This review article summarizes our present knowledge on the physiological and on impaired processes in bone healing. All the clinical procedures applied are based on empirical clinical data and do not qualify as evidence-based medicine. Against this backdrop, high-energy shockwave treatment may well be a treatment alternative in selected patients who have already undergone surgery but are still suffering from a pseudarthrosis. For the time being, however, this form of therapy should be used only in clinical studies.     

Therapie und Ergebnisse bei lateralen Klavikulafrakturen

= 3) waren schlecht. Die konservative Therapie stabiler Frakturen ergab in allen F?llen gute bis sehr gute Ergebnisse. Die Therapie instabiler Frakturen führte zu guten Ergebnissen, wenn die Frakturinstabilit?t erkannt und bei der Therapie entsprechend berücksichtigt wurde. Laterale Klavikulafrakturen mit zus?tzlicher Sprengung des Akromioklavikulargelenks, und Frakturen, bei denen die Instabilit?t auf einen Abri? des Processus coracoideus zurückzuführen sind, sollten in der bestehenden Klassifikation gesondert berücksichtigt werden. Die PDS-Gurtung erm?glicht bei in-stabilen Frakturen mit kleinem peripheren Fragment oder bei zus?tzlicher Verletzung des Akromioklavikulargelenks eine ad?quate Frakturstabilisierung.