Eingeladener Kommentar zu: „Einmal- versus wiederverwendbare Instrumente in der laparoskopischen Cholezystektomie — Kostenkalkulation und Nutzwertbestimmung”

Schlu?folgerungen Unser Motto in der Chirurgie sollte hei?en: „An erster Stelle steht die Qualit?t, erst sekund?r kommen die Kosten.“ In diesem Sinne verstehen wir auch die vorgelegte Arbeit vonKriwanek et al. (1). Durch den Gebrauch von wiederverwendbaren Instrumenten (oder Kombinationen davon) konnten die Kosten der LC um 50 bis 70% reduziert werden. Die Qualit?t für den Chirurgen litt jedoch unter dem reinen Gebrauch von wiederverwendbaren Instrumenten. Deshalb erachten es die Autoren für sinnvoll, eine Kombination zwischen Wegwerfinstrumenten und wiederverwendbaren Instrumenten anzuwenden. Damit entsteht unter leichter Erh?hung der Kosten keine Qualit?tseinbu?e und demzufolge ein maximaler Nutzen für die Patienten (nicht jedoch für die Spital?konomen). Jede Kosten-Nutzen-Analyse unterliegt jedoch einem stetigen Flu? und ver?ndert sich demzufolge auch mit der Einführung neuer Produkte und Technologien von Seite der Industrie. Interessant für die gesamte Laparoskopie wird es jedoch dann, wenn solche Kosten-Nutzen-Analysen auf andere Gebiete wie z. B. die Therapie der Leistenhernie oder der Gallengangssteine übertragen werden. Diese Ergebnisse werden die weitere Zukunft der laparoskopischen Chirurgie wesentlich beeinflussen. Deshalb gilt es für uns Chirurgen, eine Sensibilit?t für ?konomische Aspekte zu entwickeln und Kosten-Nutzen-Analysen für das eigene Spital (wie hier gezeigt) zu erarbeiten.     

Cryotherapy in rectal cancer. A palliative local tumor treatment]

Cryotherapy was applied to 182 rectal cancer patients in the Department of General Surgery, University of Ulm, between 4/1982 and 4/1991. Recipients of this tumor freezing therapy were patients whose general condition was bad, patients with an advanced inoperable carcinoma, patients with tumor recurrence and patients refusing operation. Rectal carcinomas, mostly in an advanced stage, were usually freezed several times. Only 4 patients with general inoperability reached the survival time margin of 5 years. In 18 patients local tumor destruction was possible by application of cryotherapy. In 80% of cases disagreeable tumor symptoms like tenesma, mucous discharge and oozing hemorrhages could be reduced or completely removed. Perianal pain and intense tumor bleeding could be relieved temporarily or definitely in only 50% of patients. An artificial anus could be avoided in 80% of cases by local tumor destruction/reduction or arrest of tumor growth. The mean survival time of patients with tumor recidivation was 11 months after onset of the recurrence. Tumor progression, incontinence and iatrogenic rectal perforation made an artificial anus necessary in 14 patients.     

Induction of mediator release from human glomerular mesangial cells by the terminal complement components C5b-9.

Exposure of cultured human glomerular mesangial cells (GMC) to normal human serum and an activator of the complement system results in rapid uptake of the terminal complement proteins C5b-9 by the cells. This 'innocent bystander' complement attack, however, does not result in cell killing, but in the stimulation of the GMC to release prostaglandin E (PGE), interleukin 1 (Il-1) and tumor necrosis factor (TNF). Endogenously synthesized Il-1 in turn activates PGE release, indicating that the C5b-9 attack initiates an autocrine feedback stimulation. Together with the fact that C5b-9 is found in many forms of glomerulonephritis, the data point to a role of the terminal complement proteins in the initiation and perpetuation of an inflammatory response.     

Coping strategies and individual meanings of illness.

Every person has a subjective understanding of their own illness. The personal attitude towards disease and the corresponding coping mechanisms go beyond biomedical factors to influence the course of the disease. Lipowski described eight different disease concepts which were supplemented by the theory of control conviction (external-internal control). Several hypotheses about disease concepts, coping strategies and psychopathology were globally confirmed in a study of 205 chronic patients: Ability to control and acceptance lead to a more active and problem-related coping, whereas emotional coping modi occur more often in persons who do not accept their illness or do not consider it to be controllable. Results confirm the necessity of a differentiated analysis.     

Differential effects of luminol,nickel, and arsenite on the rejoining of ultraviolet light and alkylation-induced DNA breaks

When Chinese hamster ovary cells were treated with ultraviolet (UV) light or methyl methanesulfonate (MMS), a large number of DNA strand breaks could be detected by alkaline elution. These strand breaks gradually disappeared if the treated cells were allowed to recover in a drug-free medium. The presence of nickel or arsenite during the recovery incubation retarded the disappearance of UV-induced strand breaks, whereas the disappearance of MMS-induced strand breaks was retarded by the presence of arsenite or of luminol, a new inhibitor for poly(ADP-ribose) synthetase. Luminol, however, had no apparent effect on the repair of UV-induced DNA strand breaks, and nickel had no effect on the repair of MMS-induced DNA strand breaks. When UV- or MMS-treated cells were incubated in cytosine arabinofuranoside (AraC) plus hydroxyurea (HU), a large amount of low molecular weight DNA was detected by alkaline sucrose sedimentation. The molecular weight of these DNAs increased if the cells were further incubated in a drug-free medium. This rejoining of breaks in cells pretreated with UV plus AraC and HU was inhibited by nickel and by arsenite, but not by luminol. The rejoining of breaks in cells pretreated with MMS plus AraC and HU was inhibited by luminol and by arsenite, but not by nickel. These results suggest that different enzymes may be used in DNA resynthesis and/or ligation during the repairing of UV- and MMS-induced DNA strand breaks, and that nickel, luminol, and arsenite may have differential inhibitory effects on these enzymes. © 1994 Wiley-Liss, Inc.     

Abdominalchirurgisch relevante Aspekte des Suizidversuchs

In this retrospective study of 24 patients who were treated at our clinic during the last 22 years after having attempted suicide, we evaluated aspects concerning abdominal-and transplantation surgery. There was a predominance of “hard” (70%) versus “soft” (30%) methods for suicide attempt. Intra-abdominal injuries resulting from attempted suicide by stabbing or shooting should lead to laparotomy— the prognosis is then good. Surgical treatment after intoxication, especially caustic ingestion, depends on endoscopic and clinical findings. The highly increased rates of suicide significantly by kidney transplantation. The risk of suicide after transplantation is further diminished with improved immunosuppressive treatment. Only in a few cases there is an indication for liver transplantation— in some cases of fulminant hepatic failure caused by self-administered paracetomol overdose. Auxiliary liver transplantation may then be considered.     

The value of ventilation scintigraphy after single lung transplantation.

BACKGROUND: A decrease in forced expiratory volume in 1 second (FEV(1)) as a diagnostic criterion for bronchiolitis obliterans syndrome (BOS) after single lung transplantation may be influenced significantly by the presence of the native lung. To quantify and to discriminate between the relative contribution of graft and native lung to the FEV(1), we retrospectively investigated the diagnostic value of combined FEV(1) measurements and ventilation scintigraphy in pulmonary dysfunction after single lung transplantation in 11 recipients with pulmonary vascular disease, 3 with obstructive lung disease, and 3 with restrictive lung disease. METHODS: We assessed function of the native lung and the graft, and subsequently calculated an adjusted grading of BOS by correcting routine FEV(1) measurements using linear interpolation of bi-annual lung ventilation scans. RESULTS: The contribution of the native lung to the total FEV(1) was slight (median, 9%) in recipients with obstructive disease compared with recipients with vascular (38%) or restrictive lung diseases (27%). Adjusted BOS grading was not useful in patients with obstructive disease. In the other patient groups, the onset of adjusted BOS Grade 1 and standard BOS Grade 1 was at a median of 220 days (range, 127-1146 days) and 836 days (184-3065 days), respectively. CONCLUSION: Ventilation scintigraphy is a useful adjunct in the (early) diagnosis of BOS in recipients of single lung transplants who have vascular and restrictive lung diseases.