Retroperitoneoskopische Nierenchirurgie

Retroperitoneoscopy enables quick, simple, and direct access to the retroperitoneal cavity. We describe our operative technique and discuss the advantages and disadvantages of retroperitoneoscopy. We report on our experience with this operative technique after 360 procedures: nephrectomy, partial nephrectomy, living donor nephrectomy, cryotherapy of renal tumors, pyeloplasty, adrenalectomy, and further operations. In addition, we discuss indications that are suitable for beginners to retroperitoneoscopy and some topics that require special attention.     

Zugangswege zum Oberflächenersatz am Hüftgelenk

A large variety of approaches are described for standard total hip arthroplasty. All of them are technically based on three different approaches: anterior, anterolateral, or posterior. In recent hip resurfacing, the posterior approach is common, due to large instruments used to ream the femur. Better exposure of the acetabulum is achieved by the posterior approach, but this technique puts the important extraosseous blood supply to the femoral head at risk. The anterior approach preserves blood supply and gives better options to treat the femoroacetabular impingement. If specific surgical modifications and instruments designed for minimally invasive surgery are used, hip resurfacing can be performed with an anterolateral technique. Excellent functional and clinical outcomes have been reported after all three approaches.     

Palacos im Herzen

For more than 20 years percutaneous vertebroplasty has been used in the minimally invasive treatment of vertebral fractures. We report on a patient with embolisation of bone cement into the pulmonary artery and the right ventricle, which was perforated. The final diagnosis was delayed due to a combination of complications, previous disorders as well as a second embolisation.     

Heparininduzierte Thrombozytopenie

Heparin-induced thrombocytopenia (HIT) represents a serious side effect caused by an atypical immune response to platelet factor 4 leading to platelet activation and thrombin formation. These patients are at high risk of thromboembolism, with a rapid drop in platelet count between days 5 and 14 after the initiation of heparin treatment. In single cases, especially after major surgery, platelet count reduction might be absent or hidden by preceding thrombocytosis. Different clinical manifestations of HIT include unspecific skin reactions with potential necrosis at the site of heparin injection, mostly after the application of unfractionated heparin but also with low molecular weight heparin. In heparin-induced skin necrosis, administration of unfractionated or low molecular weight heparin is contraindicated and heparin therapy should be stopped immediately. Instead, an alternative anticoagulant in the form of a direct thrombin inhibitor such as argatroban, and respectively lepirudin, or danaparoid sodium must be administered. Due to frequent misinterpretations of heparin-induced unspecific skin reactions, especially in the absence of thrombocytopenia, we present two case reports which should increase the awareness of HIT’s various clinical pictures.     

Was gibt’s Neues beim Harnblasenkarzinom?

A review of the current literature provides new scientific insights into the diagnosis, prognosis and novel molecular targets for bladder cancer. The new WHO classification refines our staging system and influences treatment options. International clinical databases provide new tools for calculating the individual risk for bladder cancer recurrence and progression. Systematic gene cluster analysis defines multimarker panels that can serve as robust predictors of outcome. Discoveries of new signaling pathways in bladder cancer are leading to novel molecular targets for innovative therapies.     

Bedeutung des Immunmonitorings in der unfallchirurgischen Intensivmedizin

Early evaluation of the prognosis after multiple trauma or major surgery is known to be difficult. Inflammatory markers can be used in attempts to identify patients who are at risk of developing posttraumatic complications. The inflammatory mediators that are most widely used in ICUs are C-reactive protein (CRP), cytokines (TNF-α, IL-6, IL-8, IL-10) and procalcitonin (PCT), IL-6 and PCT apparently being the most reliable immune markers for the assessment of a patient’s clinical status. However, no single inflammatory parameter alone can predict the clinical course and outcome of multiple trauma patients. This is also hardly surprising, in view of the complexities of pathologic processes and of molecular mechanisms and gender-dependent factors. Therefore, laboratory markers (e.g. lactate, pH), clinical assessment and inflammatory parameters should all be used in evaluation of the prognosis and the clinical status of multiply traumatised patients.     

Ultrastrukturelle Veränderungen am Nierenparenchym durch ESWL unter Acetylsalicylsäure (ASS)

BACKGROUND: The risk of hemorrhagic complications after extracorporeal shock-wave lithotripsy (ESWL) increases in patients with aspirin intake, but the hematoma-inducing mechanism has not been understood completely at the ultrastructural level. METHODS: The effect off shock-waves on the kidneys of male Wistar-rats (n=24) was investigated in an experimental setting using a special ESWL device. Ultrastructural examination was performed by light-, transmission electron- and scanning electron microscopy. RESULTS: Shock-wave induced tissue damage appeared in all kidneys independently of aspirin intake. Endothelial detachment, lethal cell injury, gaps and mechanical disruption of the glomerular basement membrane were regularly found. After 1 week, repair processes were completed with evidence of permanent fibrosis in some cases. CONCLUSIONS: ESWL can induce modest as well as fatal damage to renal tissue cells. Therefore, after an ESWL-induced hematoma a second ESWL should not be performed within 1 week of the first treatment.     

Kombinierte Nieren-Pankreas-Transplantation

BACKGROUND: Differences in graft survival due to gender have been reported after transplantation of the kidney, liver, and heart. However, little is known about the role of donor and recipient gender in simultaneous pancreas-kidney transplantation. METHODS: Single-centre analysis was performed of first simultaneous pancreas-kidney transplantations performed between 1994 and 2005 at the Bochum Transplant Center in Germany (n=218). RESULTS: Recipients of female donor organs exhibited acute organ rejections earlier and more frequently (P<0.05). Male recipients of organs from male donors had a lower risk of acute rejection than recipients of female donor organs (P<0.05). In addition to female donor gender, higher donor age and early kidney dysfunction were risk factors for perioperative rejection (P<0.05). Long-term kidney and pancreas function was best in male-donor-to-female-recipient transplants over the time periods of 7 and 3 years, respectively (P<0.05). Risk factors of long-term organ failure were: the need of revision laparotomy, organ rejection, and early postoperative organ dysfunction (P<0.05). CONCLUSION: This is the first report of graft function after simultaneous pancreas-kidney transplantation looking specifically at gender differences with respect to donor and recipient. There was an increased risk of organ rejection of female donor organs.     

Total-videoendoskopische Strumaresektion via“axillobilateral breast approach”

BACKGROUND: The axillobilateral breast approach (ABBA) is a procedure allowing thyroid resection without scarring at the neck. We operated on a series of 26 patients with this technique. METHOD: Via incisions at the edge of the mamilla and axilla, trocars are placed subcutaneously under the platyma. Dissection is performed bluntly and with an ultrasonographic scalpel under videoscopic control. The procedure itself corresponds to conventional surgery. The specimen is removed through the axillary trocar. RESULTS: Twenty-six female patients underwent thyroid resection using the ABBA technique. Subtotal resection was performed in 24. Mean operation times were 111 min (unilateral) and 187 min (bilateral). In none of these cases was conversion necessary. One transient recurrent laryngeal nerve palsy and one paresis of the arm plexus were found postoperatively. CONCLUSION: In selected patients the ABBA technique is feasible and safe with the mandatory radicalness. The primary aim of this method is the cosmetic result.     

Das Kurzdarmsyndrom in Deutschland

Objective

As data about prevalence and standard of care in short bowel syndrome (SBS) are not available for Germany, this study estimated the prevalence and assessed the medical infrastructure to potentially improve care of SBS patients.

Methods

In a validated approach for prevalence estimation in rare diseases, a randomized census of 478 size-stratified hospitals with surgical, internal medicine and pediatric departments was conducted to estimate SBS prevalence. The number of SBS patients, specialized outpatient clinics and caregiver expertise were assessed.

Results

The response rate was 85?% of randomized hospitals (405/478). Strata-derived estimation yielded a total of 2,808 SBS patients in Germany for 2011/2012 (95?% CI: 1750.3865), translating into a prevalence estimation for 34/million inhabitants (95?% CI: 21.47). Overall expertise in SBS treatment was only rated “satisfactory” by most caregivers. While 86 specialized outpatient clinics were identified, there was no central registry to access these resources.

Conclusion

Short bowel syndrome, with a newly estimated prevalence of 34/million inhabitants is not a very rare medical condition in Germany. The interdisciplinary approach needed for optimal care for SBS patients would be greatly facilitated by a central registry.