What is the value of minimizing access trauma for patients?]

Minimizing the access trauma of surgical interventions is becoming an essential task in modern surgery in order to make the treatment more comfortable for the patient. Minimally invasive surgery has had a major impact on the improvement of surgical results over the last decade. This is why such surgery is often named as the third patient friendly revolution in surgery after the introduction of asepsis and anesthesia. Operations that caused a huge strain on the patients in the past and led to immense costs for society because of the patient's lost working time and extensive rehabilitation, have lost their fear thanks to this technique. The physical strain is lower, the cosmetic effect is considerable and the costs for society might be reduced due to the significantly shorter duration of convalescence.Despite its known advantages, which have been reported in numerous studies, minimally invasive surgery has recently gained increased interest because of the installation of new accounting systems as well as strict budgeting and restricted resources.Realistic cost-benefit analysis and objectified quality controls are needed in order to guarantee innovative and patient friendly basic approaches in medicine in the future.     

Radiofrequency-ablation of unresectable primary and secondary liver tumors: results in 88 patients

Background and aims Radiofrequency-ablation (RFA) is increasingly used for destruction of unresectable primary and secondary liver tumors. We report our experience in the use of RFA for the management of unresectable hepatic malignancies. Patients and methods Between February 2000 and December 2004 we have undertaken 120 RFA procedures to ablate 426 unresectable primary or metastatic liver tumors in 88 patients. RFA was performed via laparotomy (n=68), laparoscopy (n=9) or a percutaneous approach (n=43). Primary liver cancer was treated in seven patients (8%) and metastatic liver tumors were treated in 81 patients (92%). All patients were followed to assess complications, treatment response and recurrence of malignant disease. Results Procedure-related complication rate was low (3.4%). During a mean follow-up of 21.2 months, 15 patients had local tumor progression (17%), 21 patients (23,9%) had new malignant disease and 27 patients (30.7%) died from intervention-unrelated complications of their malignant disease. Additional liver lesions were identified in 27 (35%) of 77 cases by intraoperative ultrasound. Thirty-six patients received simultaneous resection and RFA. Conclusion RFA is a safe, well-tolerated and effective treatment for patients with unresectable primary and secondary liver malignancies.     

Does the end-to-end venous anastomosis offer a functional advantage over the end-to-side venous anastomosis in high-output arteriovenous grafts?

This study explores the hemodynamics, mechanics, and biologic response of end-to-end versus end-to-side venous anastomoses in a canine arteriovenous graft model. Femoral polytetrafluoroethylene grafts were implanted bilaterally in a paired fashion (n = 22). Detailed local hemodynamic measurements were made by use of color Doppler ultrasound imaging at 1, 4, 8, and 12 weeks after implant. Measurements included volumetric flow rate and Doppler-derived spectral window (percent window) as a measure of turbulence. Amplitude and velocity of vessel wall movement were also measured. Volume of perivascular tissue vibration quantitated kinetic energy transfer through the vessel wall. Volumetric flow rate (end to end, 1013 +/- 70 ml/min; end to side, 1015 +/- 72 ml/min), percent window (end to end, 6.6% +/- 0.6%, end to side, 5.6% +/- 0.4%) and volume of perivascular tissue vibration (end to end, 19.6 +/- 1.2 ml, end to side, 16.3 +/- 1.8 ml) were statistically equivalent in the two graft types (end to end vs end to side p greater than 0.05). Both graft types developed venous intimal-medial thickening of a similar magnitude: end to end, 0.35 +/- 0.05 mm, end to side, 0.43 +/- 0.09 mm, normal vein 0.070 +/- 0.004 mm (analysis of variance [ANOVA] p less than 0.001, p less than 0.01 for end to end or end to side vs control, end to end vs end to side p greater than 0.05 by Student-Newman-Keuls test). The best correlations with venous intimal-medial thickening were obtained from inverse percent window (r = 0.84, p less than 0.001) and volume of perivascular tissue vibration (r = 0.68, p less than 0.001). In the end to end configuration the relative amplitude of venous wall movement decreased, and the relative velocity of wall motion increased over time. We conclude that in the circumstances of this high flow arteriovenous graft model the end-to-end venous anastomosis does not significantly differ from the end-to-side venous anastomosis in terms of flow stability, turbulence, or kinetic energy transfer. The magnitude of the hyperplastic response is statistically equivalent for the two anastomotic types, but the pattern is somewhat different, possibly providing evidence for differences in stress distribution. Differences in the relative amplitude and velocity of vessel wall movement suggest that anastomotic geometry may affect the way in which kinetic energy is dissipated at the graft/vessel interface.     

Ergebnisse der tiefen Rectumresektion und intersphinctärer Rectumexstirpation

Zusammenfassung. Die tiefe Rectumresektion und intersphinct?re Rectumexstirpation beim Rectumcarcinom des distalen Rectumdrittels ist eine inzwischen akzeptierte, sphinctererhaltende Therapie. Im Zeitraum zwischen Dezember 1990 und Dezember 1994 wurden 42 Patienten, 17 Frauen und 25 M?nner, mit einem Durchschnittsalter von 67,2 Jahren dieser Operation unterzogen. An 20 Patienten wurde eine transanale Handnaht durchgeführt, bei den übrigen eine Stapler-Anastomose angelegt. Die Letalit?tsrate betrug 2,5 %; die Anastomoseninsuffizienzrate 14 %.      

Beeinflußt Heparin den Verlauf einer chronischen abszedierenden Peritonitis im Tiermodell?

After laparotomy and inoculation of aBacteroides fragilis suspension (2 ml with 10⁸ CFU/ml), we induced chronic abscess-forming peritonitis in rats (n=19, untreated). Fifteen animals were treated with heparin 30 IU, administered s.c. from day 1 after inoculation of the bacteria onwards. The main groups were divided into three subgroups (n=8/5/6 andn=5/5/5), which were observed for 3/7/14 days, respectively. On days 3 and 7, abdominal swabs were not onlyB. fragilis positive, but also showed severe polyvalent mixed infection after translocation of intestinal bacteria into the abdominal cavity. In the heparin group,B. fragilis positive swabs were reduced and translocation was inhibited (P<0.05 for days 3 and 7). In the untreated group, blood cultures wereB. fragilis positive on days 3/7/14 in 3/2/1 animals versus 0/1/1 in the heparin group. Adhesions were found in the untreated group in 1/4/5 animals, whereas in the heparin group there were no adhesions (P<0.05 for days 7 and 14). However, intra-abdominal abscesses were also diminished in the heparin group (0/2/1) compared with the untreated animals (2/4/6,P<0.05 for day 14). Therefore, heparin was shown to have a favourable influence on chronic abscess-forming peritonitis in an animal model.