The diagnosis of primary hyperparathyroidism is based on laboratory tests showing high levels of calcium and parathyroid hormone. Primary hyperparathyroidism is treated by surgery, which is indicated in symptomatic as well as in asymptomatic disease, provided the latter patients are at low risk. Primary parathyroidectomy should be successful in at least 90% of the patients. Epidemiological studies show that pHPT occurs much more often than operation statistics imply. This situation can be improved by a more consequent differential diagnosis that detects up all cases of hypercalcemia.
Experimental surgery in german various forms of organisation and different aims as regards cooperation between experimental and clinical surgery. The best and most effective form is that of an institute with good personnel, adequate finances and sufficient space. An essential prerequisite for good cooperation between experimental and clinical surgeons is that the scientific aims be initiated by both. Success is possible only, if continuity can be guaranteed over a longer period. This is possible only in well established institutes of experimental surgery.
External compression and kinking of the celiac axis is caused by the enlarged and fibrous median arcuate ligament of the diaphragm. The pathogenetic cause may be a functional ischemia or an irritation of the squeezed celiac ganglion. This painful syndrome is an unusual condition, which occurs at a maximum age of about 40 years and mostly in women. The diagnosis is established by exclusion of all other abdominal sources of pain and lateral aortography. The therapy can often be limited to longitudinal incision of the ligament; reconstructive procedures of the coeliac artery are sometimes necessary.
The operative approach to adrenal incidentalomas depends on the subclinical hormoneactivity and the risk of malignancy. In our 18 patients there were two pheochromocytomas (3 and 5 diameter), one with subclinical hormoneactivity and three malignancies, an adrenocortical carcinoma, a metastasis without primary and a lymphoma. The malignant tumors were larger than 5 cm. As tumors smaller than 3 cm are usually benign they should be observed. Because of the risk of malignancy there is a relative indication to operate on larger tumors.
Between 6/88 and 8/89 61 critically ill patients (sepsis, ARDS, pneumonia, multiple trauma, etc.) underwent elective percutaneous endoscopic tracheostomy (PET). Following dilation up to 36 Fr. a number 6-10 tracheostomy tube was introduced. The patients were ventilated 17 (2-68 days) before and 28 (4-160) days after PET. One patient died from cardiac arrest, and in 4 patients, because of tube obstruction or cuff defect, reintubation was necessary. Additionally 2 significant infections and a minor bleeding and a emphysema occurred. Elective percutaneous tracheostomy performed in the ICU seems to be a simple and cost-effective procedure.
: Three approaches are considered: the left thoracoabdominal approach, the right-sided retro- or supracolic route and the transabdominal access. Aorto-common hepatic venous bypass grafting is the preferred procedure in singular occlusions of the celiac axis. Reimplantation and aorto-mesenteric venous bypass are the treatments of choice in singular occlusions of the mesenteric artery. Occlusions of both upper intestinal arteries can be treated with a venous bridge bypass graft or by transaortic end-arterectomy. Operative mortality is low (0.9%). Remaining occlusion and recurrent symptoms occurred in 12 of 92 patients.
At the University of Frankfurt/M. we perform chemoembolization of the liver in patients with inoperable liver cell carcinoma. Before application of embolization material vasoconstriction of healthy blood vessels is achieved by intraarterial injection of norepinephrine. This procedure improves selectivity of tumor embolization. Methods, indications, contraindications and results are presented.
The diagnosis of primary hyperparathyroidism is based on laboratory tests showing high levels of calcium and parathyroid hormone. Primary hyperparathyroidism is treated by surgery, which is indicated in symptomatic as well as in asymptomatic disease, provided the latter patients are at low risk. Primary parathyroidectomy should be successful in at least 90% of the patients. Epidemiological studies show that pHPT occurs much more often than operation statistics imply. This situation can be improved by a more consequent differential diagnosis that detects up all cases of hypercalcemia.
Local recurrences of intraperitoneal malignancies are mainly localized at the primary tumor site and the peritoneal surface. Surgical procedures alone are neither able to further reduce the development of local recurrence nor to treat the already established recurrent disease. In this situation intraperitoneal chemotherapy as an "adjuvant" treatment modality could be thought helpful. Experimental and clinical trials have shown that high doses of cytotoxic agents can be applied to the abdominal cavity with less systemic side effects. While the recent published data are not promising for gastrointestinal malignancies, they seem to be more encouraging for ovarian cancer.
Persistent hypercalcemia following operation for hyperparathyroidism presents a challenge to both the patient and the surgeon. Between 1/79 and 3/90 a total of 351 patients with parathyroid disease were operated and 34 (10%) patients had persistent hyperparathyroidism. Average age was 62 years. 1/3 of pat. was asymptomatic and 1/3 had renal calculi. Preoperative studies were successful in diagnosing the affected side in 34% using CT, in 44% using sonography and in 63% when selective venous catheterization was used. A total of 44 operations were performed in 34 pat. Up to three operations were performed in 24% of patients. Eight of 34 pat. have refused additional surgery. Repeated surgery was successful in 24 pat. In eight pat. ectopic glands were identified and six of these were located in the mediastinum.
Between 50 to 60% of all polytraumatized patients have a thoracic injury with a mortality of 30 to 60%. The first diagnostic steps involving symptoms such as in- or expiratory pain, emphysema of the skin, flail chest or sipping noise lead via clinical examination to first and often definitive therapeutic procedures, i.e. intubation, artificial respiration and insertion of chest tube. X-ray of the chest, computed tomography as well as ultrasonic screening and monitoring of arterial blood gases are important in in-door technical diagnosis. The decision for emergency room thoracotomy or a regular or delayed operation has to be made at times. Complications (20%) to consider are pneumo- and haematothorax, pleural rind, pneumonia, broncho-pleural fistula and most of all pleural empyema.
Clinical and radiological features of Sudeck's dystrophy following radius fracture are described. Peripheral and endogenous factors are pointed out. Therapy consists in preventing and alleviating pain by primary immobilisation combined with gentle physical therapy of the non-involved parts of both upper extremities. Calcitonin, non-steroid antirheumatic and anxiolytic drugs should be administered simultaneously. The physician's care and tolerance of the mentally upset and labile patient are essential. Physiotherapy plays a major role in the long-standing rehabilitation process.
Bedside percutaneous tracheostomies are increasingly performed. This avoids patient transport to the operating room. Complications of this procedure are largely related to the blind nature of the technique. After laboratory studies, 4 patients underwent percutaneous endoscopic guided tracheostomy in a selective clinical trial. There were no procedure-related complications. Endoscopic guidance ensures precise low tracheostomy position, prevents paratracheal tube misplacement, and avoids inadvertent injuries.
In the University Hospital of Granada (Spain), 359 trauma surgical patients underwent intraoperative autotransfusion. Patients from group I (blood loss less than 2000 ml) did not requiere homologous blood transfusion. So the high risk involved in the type of transfusion was avoided. With patients from group II, however, that is, those with a blood loss of more than 2000 ml, we had to fall back on homologous transfusion in addition to retransfusing autologous blood. The main indication for intraoperative autotransfusion is without doubt abdominal and thoracic trauma which lead to high blood loss.
In the University Hospital of Granada (Spain), 359 trauma surgical patients underwent intraoperative autotransfusion. Patients from group I (blood loss less than 2000 ml) did not requiere homologous blood transfusion. So the high risk involved in the type of transfusion was avoided. With patients from group II, however, that is, those with a blood loss of more than 2000 ml, we had to fall back on homologous transfusion in addition to retransfusing autologous blood. The main indication for intraoperative autotransfusion is without doubt abdominal and thoracic trauma which lead to high blood loss.
A retrospective review covered 110 patients who had had 130 thoracotomies for 193 lung metastases between 1960 and 1988. The cumulative survival rate after 5 years was 39%, 24% after 10 years and 13% after 15 years. The median survival was 3.8 years; the average survival was 7 years. In a multivariate analysis, response to prior chemotherapy, local tumor extent (intrapulmonary versus extrapulmonary disease) and venous drainage (caval versus portal) were the most important prognostic factors. The number of metastases and the interval between primary tumor and lung metastases were of minor prognostic importance.
A retrospective examination involved 414 patients (260 m, 154 w, mean 60 y) with pleural metastasis/pleural effusion of the following primary tumors: 37.2% bronchogenic (23.2% malignant pl. mesothelioma), 14.5% breast, 8.7% adeno-ca (unknown primary) 2.4% gastrointestinal, 2.2% uterus/ovar, and 11.8% others. Thoracoscopy with histologic confirmation played a central role in our diagnostic procedures in 97% of the cases. Malignancy was defined by CEA (less than 5 mg/ml) (71.9%) and cytology (76.9%) in 90.4%. Our strategy had the following success rate: desiccation by pleural drainage (greater than 26 Charr) alone 74%, in combination with pleurodesis 81%, pleurectomy/decortication 95%, and extended pleuropneumonectomy (in 80% mesothelioma) 96%.
A total of 56 patients underwent preoperative high-resolution sonography (4 MHz); 33 had additional computed tomography (4 mm slices, contrast material as drip infusion) to localize abnormal parathyroid tissue in primary hyperparathyroidism. The sensitivity of sonography was 48% compared to 38% for computed tomography. The efficiency of both techniques was mostly dependent on size and location of the parathyroid. Computed tomography was superior in detecting ectopic parathyroids. Because of its low sensitivity sonography is only of facultative importance as a localization procedure for primary hyperparathyroidism. Computed tomography is indicated only for localizing ectopic parathyroid tissue after initial operation has failed.
From 1975 to 1987, 44 of 230 patients with cystic fibrosis under our care underwent a total of 66 operations. There were no direct intra- or postoperative complications. If an optimal and aggressive adjuvant treatment is given postoperatively, there are no increased risks associated with surgical procedures in cystic fibrosis patients. Treatment of spontaneous pneumothorax remains a problem. An alternative treatment for pneumothorax using transcutaneous fibrin pleurodesis is presented.
Magnetic resonance (MR) imaging of the trachea was performed in twenty-one children with congenital or acquired narrowing of the trachea or main bronchi. The demonstration of the trachea and the surrounding tissue and vessels on MR images permitted the evaluation of the cause of trachea, compression and the degree and location of collapse. MRI is a well-suited modality for characterizing tracheal narrowing without employing ionizing irradiation or intravenous contrast medium. In the cases presented MRI should be the diagnostic step of choice after tracheo-bronchoscopy. It is an enrichment of the diagnostic possibilities for extrinsic tracheal or bronchial stenosis in pediatric patients.
