Early functional outcome after low anterior resection with total mesorectal excision (TME) and colo-anal anastomosis for colorectal carcinoma can be improved by the restoration of the colonic reservoir. This can be achieved by the construction of a colonic J-pouch. The technique is safe and has been refined during the last years. A decrease in stool frequency, urgency, and incontinence rates during the first two postoperative years with an improved quality of life has been observed. Alternative methods with similar functional results are provided by the ileocecal reservoir, the transverse coloplasty pouch or the side-to-end anastomosis. Colonic J-pouch reconstruction should be considered as an superior alternative to straight coloanal anastomosis in patients undergoing anterior resection.
Only patients with a clinical and pathohistological response to neoadjuvant therapy have a significantly improved survival. Therefore the identification of predictors for response and procedures for the early identification of nonresponders appear to be mandatory. Preliminary data of biochemical investigations of target enzymes for several cytostatics (e.g. TS, ERCC1) appear to be promising. Early changes of the tumor metabolism in the FDG-PET enable the identification of nonresponders with a negative predictive value of 88-95%. In near future these findings should lead to consequences in the design and realization of clinical studies.
Three information systems are described, whose data are simultaneously used for quality management and others tasks. They show, that the completeness of documented diagnoses is dependent of their appraisal of the physicians. The support of coding by information technology brings an essential improvement. The compliance of physicians with rules has to be reviewed in regular intervals. Quality assurance of a process should be made in short intervals, to be able to intervene in time. Individual efficiency control stimulates each participant to improve his work. These examples show, that information systems can undertake quality management and other tasks besides. Such systems are important, when hospitals attend KTQ-certification.
In recent years the number of the patients with occlusive disease of the peripheral arteries is increasing also in Japan. For such patients there are many methods to make final diagnosis. Among a lot of methods we have chosen color duplex sonography for functional diagnosis in the patients with occlusive disease of the peripheral artery. During 2 years we have investigated color duplex sonography in addition to digital subtraction arteriography for 40 patients (68 limbs) with occlusive disease of the peripheral artery. First of all waveform of blood flow and the systolic velocities of the dorsal- and the posterior tibial arteries as well as the brachial artery were observed and measured. The blood flow volume and the ratio of systolic velocities and flow volume of lower to upper extremity (AVI, AFI) were measured and their values were also analysed in each patient. These data were compared with Fontaine's classification as a clinical symptom. For the patients with Fontaine class I, or II conservative treatments were carried out, and operative interventions such as bypass graft, or endovascular operation were carefully performed for the patients with Fontaine's class III or IV. Consequently, clinical symptoms and waveforms of systolic flow, and its velocity were remarkably improved by surgical interventions. Thus, color duplex sonography was a useful procedure to make diagnosis and to decide operative indication in the patients with occlusive disease of the peripheral artery.
Patients after crural or pedal revascularization need a consequent surveillance to prevent graft failure. We compared the results of the clinical examination including duplexscanning with contrast-enhanced magnetic resonance angiography (MRA). 26 bypass grafts were evaluated for potential stenosis in five locations. Using both techniques, 93 of 109 locations were classified identically. 10 of 16 locations which were categorized differently were reviewed angiographically (DSA). In contrast to duplexscanning, MRA detected 3 high grade stenosis, which had to be dilatated percutaneously. MRA should be used regularly in surveillance programs of distal bypass grafting.
A strategy to protect the inferior laryngeal nerve (ILN, recurrent and non-recurrent) as well as the superior laryngeal nerve (SLN) includes the reason for and extend of the operation to avoid recurrent goiter, selection of an experienced institution and operating team, a cautious intubation, adequate and anatomical operating technique, recognition of risk factors and postoperative treatment with a sufficient dosage of hormone and/or iodine. The ILN should be dissected routinely in view of its anatomical variation. The "capsular dissection technique" should be applied. The "laterialisation technique" of the upper pole protects the SLN with regard to its anatomic variability. Neuromonitoring of both nerves can be helpful under difficult circumstances.
The surgical suture should be chosen in dependence of the tissue being operated upon and be oriented on the main properties of its chemical composition. Synthetic absorbable suture materials are the first choice in the majority of the procedures, to prevent the formation of foreign body reaction--excepting sites subjected to continuous mechanical stress, for example hernias, orthopedic and vascular surgery. By causing lesser tissue damage and interfilament bacterial transport, monofilament sutures are preferable than multifilament ones. However, knotting monofilament sutures requires additional skills in comparison to multifilament strains, due to their special handling an knotting properties.
Based on pathological-anatomical findings, early (2 months) and late (2 years) local and distant recurrencies are presented, considering topographic aspects following surgery of primary pulmonary tumours, metastatic pathways and time intervals. Morphological criteria for differentiating two tumours from metastases, systemic recurrencies of the basic disease following early micrometastatic spread, as well as the grading of tumour regression in surgical samples following radio chemotherapy are shown.
Primary malignancy after solid organ transplantation has a more than three-fold incidence compared to the normal population. Causes are intensity and duration of immunosuppression, pre-operatively undetected, occult malignancy or pre-cancerous lesions in the recipient, direct or indirect tumor transmission via the transplant and environmental factors. Measures for prevention comprise antiviral treatment of individuals at risk for primary EBV-infection and prevention of sun exposure. Early detection follows general medical guidelines and, in addition, selective screening of certain risk groups of patients. Treatment of solid tumors follows established guidelines of professional working parties. Post-transplant lymphoproliferative disorders can often be treated with anti-CD antibody (rituximab). Antiproliferative immunosuppressants like rapamycin may seem promising with regard to a possibly reduced incidence of de-novo malignancy in the future.
The head of the anaesthetic department in a teaching district general hospital affiliated to the University Heidelberg, gives an appraisal of her 20 year experience in dealing with organising part-time employment for doctors in her department. The project proved so successful that most doctors in the department changed from full-time to part-time employment. On average two thirds of the doctors choosing part-time employment are female, one third male. The advantages exceeded by far the disadvantages. The greater number of colleagues aids problem-solving. The disadvantages were overcome by organisational means and also by the active participation of the highly motivated colleagues. This project proved it is possible to make hospital work more attractive.
220 of 268 polytraumatized patients (82.1%) presented an additional head injury, which increased the mortality significantly. By the Hannover Polytrauma Score we could demonstrate that the severity of the polytrauma and the prognosis depended on the extent of the brain injury. Important risk factors were skull fractures and shock on arrival. 66.7% of the patients with a severe brain trauma and a skull fracture died; without this fracture, only 36.8% died. 76.1% of the children with a systolic blood pressure (SBP) > 80 mm Hg survived, but only 31.2% with a SBF < or = 80 mm Hg did not die. For all polytraumatized children we recommend a computer tomography of the head. In spite of a negative initial CT a follow up CCT should be performed.
Injuries of the fingertips are often but not always of a simple, easily healing kind. If there are complications they are induced by the severity of the trauma itself or because the patient himself or the physician treating the injury is misjudging its severity. This leads to an inadequate therapy, which may very well be the cause of a dramatic development, ending in loss of function of the injured hand if it comes to the worst. By the means of some selected examples the pitfalls in the treatment of fingertip injuries shall be pointed out.
The antibody SC-1 is a human IGM molecule, which binds to a tumor specific receptor. This SC-1 receptor is detectable on biopsies, it is present in about 50% of gastric cancers. After binding of the antibody to the receptor the tumor cells go into apoptosis. 50 patients expressing the SC-1 receptor on their tumors have been treated with SC-1 prior to gastrectomy. In 80% of cases apoptosis induction could be demonstrated in the tumors. The only side effect of the SC-1 therapy was a reversible episode of fever during antibody infusion in 8% of our patients.
There are no prospective randomized studies available to decide which surgical approach should be superior to treat sigmoid diverticulosis. Analysis of clinical studies evaluating laparoscopic or conventional surgery are presenting results as follows: for elective surgery morbidity ranges between 12-20% and mortality rates between 0-2% indicating comparable complication rates. For emergency operations only data from open surgery are available, with morbidity of 33-57% and mortality rates of 7-16%. Advantages of conventional approach are availability, reliability of the surgical technique and there is no patient selection required. Laparoscopic access may offer superior patients comfort and reduce cost, length of hospital stay and resocialisation. It remains to be proven, which approach may be the option of choice in the future, while this surgical technique is still developing.
Gynecomastia develops when there is an increase in the ratio of estrogen to androgens. Whereas mild forms of gynecomastia are frequently encountered in the male population, any breast enlargement that is prominent, painful, progressive or of recent onset always requires a careful evaluation, as it may be an important clue to disease elsewhere. Underlying causes are plenty and include drugs, congenital and acquired disorders of androgen and estrogen production, various tumors, renal failure, cirrhosis of the liver, and thyrotoxicosis. Evaluation includes a careful patient's history, physical examination of sexual characteristics and the breast tissue, and measurements of serum LH, FSH, testosterone, estradiol, hCG-beta, TSH and tests of liver and kidney function.
Fractures of the distal end of the femur are rare. Premature partial closure of the physis may occur after metaphyseal fractures. After epiphyseal fractures it has a high incidence of occurrence. The cause of physeal arrest is not known. Stimulation of the physes ends in leg length discrepancy and was seen in 50% of all cases. Spontaneous correction of an axis deviation is possible after antecurvation up to an age of 5 years. But this should be only accepted during therapy of metaphyseal fractures of the distal femur. Side-to-Side deviations remodel in all cases. Aim of therapy in distal epiphyseal fractures should be an anatomical reduction and a definitive retention. Screw osteosynthesis seems to have an advantage.
Liver failure following trauma or surgery is associated with a mortality of between 15-->50%, depending on the extent of the operation, pre-operative functional impairment of the liver as well as the occurrence of concomitant infectious disease. The liver can be the source as well as the target of posttraumatic liver failure (PLF). PLF can be caused by a reduction of liver perfusion due to hypotension, catecholamines or increased intraabdominal pressure. Further contributing factors include prolonged parenteral nutrition, endotoxemia, and potentially hepatotoxic drugs (sedatives, anticonvulsive drugs, antibiotics etc.). PLF is mostly associated with MOF. The Child classification and the APACHE score may predict prognosis before surgery and serum bilirubin levels thereafter. Prevention and therapy is based on treatment of shock and tissue hypoxia. It should be accompanied by appropriate diagnostic measures and followed by an aggressive medical and surgical approach.
Breakdown of skin microcirculation is supposed to play a key role in pathophysiology of burn injury. The aim of the study was to develop a burn model, which allows repetitive quantitative in vivo analysis of microcirculation after burn injury with special focus on leukocyte endothelium interaction over a longer period of time. Male hairless mice (SKH-1/hr) were used. Deep partial thickness burns were inflicted in no-touch-technique to the ears. Intravital fluorescent microscopy in combination with FITC-dextran as a plasma-marker was used to assess standard microcirculatory parameters. Leukocytes were stained with rhodamine-6-G to study their interaction with the endothelium.
