Langenbecks Archiv fur Chirurgie最新文献

{"title":"[Surgical management of dysfunctions of dialysis fistulas].","authors":"W Wahl, J Bredel, E Wandel, M Schnütgen, M Mann, T Junginger","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Due to the superficial position of shunt vessels we do not use complicated equipment or diagnostic procedures in the morphological assessment of shunt insufficiency or shunt occlusion. Preoperatively, we merely conduct a clinical examination including inspection, pulse, palpation of the shunt veins and arteries with and without venous congestion, and shunt auscultation. Subsequently, we reoperate the shunt under local anesthesia, at which time the anastomosis is usually checked and repositioned. From January 1995 to May 1996, 539 shunt operations were performed in 371 patients, whereby 263 of these were reoperations. The reoperations were performed due to shunt occlusion (n = 144), shunt stenoses (n = 60), shunt aneurysms (n = 17), steal syndrome (n = 3), and rare complications such as hematoma, shunt infection, seroma, and other disturbances (n = 6) (32 patients were treated in other clinics after reoperation or the functional disturbance of the shunt was not recorded). Angiography was only conducted if the clinical examination did not provide enough information about the shunt problems, and so, preoperatively, only six angiographic examinations were conducted (stenosis, n = 3; aneurysm, n = 1; steal syndrome, n = 2). All reoperations, with only few exceptions (PTFE shunt), were conducted under local anesthesia. At reoperation, 184 new proximal shunts were made, 14 thrombectomies conducted, seven PTFE fistulas made, 13 shunts positioned on the opposite side, five shunts ligated, and eight various other operations performed (32 patients were given further treatment elsewhere or no treatment records were available). If during reoperation flow disturbances were suspected (arterial stenosis) or the blood was flowing towards center (proximal venous stenosis) angiography was performed intraoperatively to assess the condition of the vessels. The 4% rate of early occlusion using this procedure was very low. Only 21 patients had to have more than two reoperations. After 2 years 65% of the reoperated AV fistulas were still functional. Without further diagnostic procedures, we performed immediate, outpatient reoperation under local anesthesia, preferably positioning new proximal shunts so that dialysis could be conducted immediately using the existing dialysis shunt. Only if there were particularly complex functional shunt disturbances (steal syndrome, proximal venous flow disturbance, or arterial stenosis) did we employ other diagnostic procedures (angiography, DSA). With this approach the functional shunt disturbances could be eliminated quickly and effectively, which also minimized the cost and stress for the patient.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 5","pages":"237-42"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20338474","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[O2 utilization during hyperthermic extremity perfusion with rhTNF alpha and melphalan].","authors":"J Haier, P Hohenberger, K Beck, P M Schlag","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>During isolated limb perfusion (ILP) severe metabolic impairment with a subsequent alteration in oxygen consumption can be observed. The mechanisms responsible for this may be extracorporeal circulation, hyperthermia, and application of cytostatic drugs and cytokines. Thirty-three patients underwent ILP with rhTNF alpha and melphalan for melanoma or soft-tissue sarcoma. Cardiopulmonary monitoring consisted of arterial and mixed venous blood-gas analysis and a Swan-Ganz catheter was inserted after induction of general anesthesia prior to any surgical intervention. Arterial (SaO2) and mixed venous (SvO2) oxygen saturation, serum lactate and end-expiratory CO2 concentration were determined peri- and postoperatively for 72 h. Oxygen supply and consumption rates were measured systemically (DO2I, VO2I) and in the extracorporeal circuit ('DO2I, 'VO2I). For statistical analysis we used the t-test. During extracorporal circulation an increase of DO2I and VO2I was observed. A slight increase of lactate values began during the wash-out phase. Immediately after reperfusion. DO2I, VO2I and lactate increased significantly with normalization until the 2nd postoperative day. SaO2 and SvO2 remained unchanged. A significant correlation between regional toxicity and the postoperative maximum of serum lactate values was found. The increase of DO2I and VO2I in the tissues during ILP and after reperfusion was achieved by a significant increase in cardiac output while the oxygen extraction rate was not altered. Elevation of lactate values after reperfusion and the increase in oxygen utilization might be due to oxygen depletion in the perfused limb. This could contribute to the development of lactacidosis or rhabdomyolysis. Therefore, to minimize toxicity it seems to be mandatory to measure adequate tissue oxygen supply during ILP.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 3","pages":"128-33"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20260668","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Progress in laparoscopic sigmoid resection in elective surgical therapy of sigmoid diverticulitis].","authors":"T Junghans, B Böhm, W Schwenk, K Gründel, J M Müller","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>The full significance of laparoscopic technique in elective surgery of sigmoid diverticulitis has yet to be determined. However, it seems worthwhile to evaluate how minimally invasive surgery could be integrated into the surgical treatment of diverticulitis disease. Between January 1995 and August 1996, 26 patients with sigmoid diverticulitis underwent elective surgery. Following diagnostic laparoscopy, seven patients were treated with primary conventional resection, 15 patients with laparoscopic resection and four patients with laparoscopic-assisted surgery. One laparoscopic resection had to be converted to a median laparotomy. Postoperative complications (n = 2) only appeared in the group of conventional resections. Conventional resections required less time than laparoscopic or laparoscopic-assisted resections, but postoperatively, patients with laparoscopic resection were able to defecate sooner and required a shorter hospital stay. For 60% of the patients with diverticulitis disease of the colon, elective laparoscopic resection may prove to be the best alternative of surgical treatment. In selected patients it is a sound technique with a low complication rate. We recommend that all patients with diverticulitis disease requiring elective surgery undergo diagnostic laparoscopy to determine whether or not laparoscopic resection is a viable option.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 5","pages":"266-70"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20339178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Infections after liver resections in the elderly].","authors":"T Koperna, M Kisser, F Schulz","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>From 1986 to 1995, 97 patients older than 65 years of age underwent hepatic resection at the Department of General Surgery, Hospital Lainz, Vienna. The population consisted of 39 men and 58 women with a mean age of 74 +/- 5.5 years. Primary neoplasia was the cause of resection in 35 patients, gallbladder cancer in 16 patients, and metastatic disease to the liver in 40 patients. Six patients underwent hepatic resection because of benign disease. The overall rate of major resections (> or = 3 liver segments) was 73% and the overall mortality was 13.5%. Sixty-five postoperative complications were recorded in 42 patients, and infection was the leading problem in nearly all of these patients (95%). The histologic type of tumor rather than the magnitude of resection had an influence on clinical mortality and morbidity. All complications occurred in patients with malignant disease (P = 0.03). Adverse effects on postoperative morbidity were observed in adenocarcinoma of the hepatic ducts, gallbladder carcinoma, and cholangiocellular carcinoma (P = 0.003). Intraabdominal infections were found in 25% of our patients and were due to biliary leakage in 58%, but had no significant impact on survival. Pneumonia was the leading complication in association with patient survival. All patients who developed pneumonia as a late complication during a complicated course died postoperatively (P = 0.0001). All of these patients had a reduced grade of mobilization. Severe preoperative liver dysfunction carried a significantly higher risk for postoperative morbidity and mortality (P = 0.003 and 0.01), which showed an incremental risk with age > 80 (P = 0.002 and 0.0004). Right lobectomies and extended right lobectomies carried a significantly increased risk for postoperative morbidity (P = 0.004). Infection is associated with nearly every complication recorded after hepatic resection in the elderly. Pneumonia as a late complication poses a worse prognosis in elderly patients who underwent hepatic resection. Patients older than 65 years of age and especially those older than 80 years of age are more liable to succumb to complications that are predominantly infectious. Better local drainage procedures may reduce intra-abdominal infectious complications and early mobilization of the patients may improve the rate of systemic infectious complications and final outcome.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 4","pages":"192-6"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20372593","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Merkel cell tumor or neuroendocrine skin carcinoma].","authors":"U Meyer-Pannwitt,&nbsp;K Kummerfeldt,&nbsp;P Boubaris,&nbsp;J Caselitz","doi":"10.1007/s004230050079","DOIUrl":"https://doi.org/10.1007/s004230050079","url":null,"abstract":"<p><p>Merkel cell carcinoma is a rare malignant tumor of the skin with predominance in older patients; 78.6% of patients are older than 59 years. Female and male patients are equally involved in the age group below 60 years. After 60 years, Merkel cell carcinomas are more often observed in female patients. The tumor is most often located in the head and neck region (50.8%) or the extremities (33.7%). The average size is 29 mm at presentation. Clinically, only a presumptive diagnosis of Merkel cell carcinoma can be established. The definite diagnosis is made by histological, especially immunohistological methods (detection of intermediate filaments and neuroendocrine markers). The therapy of choice is local excision. Secondary therapy may be a combination of operation and radiation or chemotherapy. Since this combination may reduce the risk of recurrences it should be applied for patients with poor prognostic features. Especially in young patients, additional lymphadenectomy should be discussed. Clinical control is necessary. Distant metastases should be treated by chemotherapy. Bad prognostic features are: lymph node metastasis, size larger than 2 cm, male sex.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 6","pages":"349-58"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20422338","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Procalcitonin. A new marker for acute phase reaction in acute pancreatitis].","authors":"T Bertsch,&nbsp;A Richter,&nbsp;H Hofheinz,&nbsp;C Böhm,&nbsp;M Hartel,&nbsp;J Aufenanger","doi":"10.1007/s004230050081","DOIUrl":"https://doi.org/10.1007/s004230050081","url":null,"abstract":"<p><p>Procalcitonin is a protein which is found in elevated concentrations in the blood circulation during systemic bacterial, fungal or protozoal infection. In contrast to classical acute-phase proteins like C-reactive protein or interleukin-6, it is not elevated after operative trauma. In this paper we present current opinions on the assumed induction mechanisms of the protein by cytokines and endotoxin. Furthermore, the clinical value for early detection of systemic infections in abdominal and transplantation surgery is demonstrated by examples from the literature. Our investigation shows that eight patients with necrotizing pancreatitis had a PCT mean value of 6.9 ng/ml on the day of admission. Seven patients with edematous pancreatitis had only a PCT mean value of 0.69 ng/ml. Despite these differences in the mean values, a significant difference between the normal value and the mean value of the group with necrotizing pancreatitis or edematous pancreatitis was not observed due to the wide range of PCT levels in the group of patients with necrotizing pancreatitis. The fact that only a few of the patients had a superinfected necrosis with systemic evasion of bacterias or their toxins may be the reason for this wide range. We suggest that a discrimination between superinfected necrotizing or sterile pancreatitis and edematous pancreatitis by PCT could be possible but more extensive studies with microbiological examination of the necrotic material are required to recognize the subgroups and to establish the real diagnostic efficiency of PCT in clinical practice, especially in the prediction of the outcome of acute pancreatitis.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 6","pages":"367-72"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20422340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Local effects and changes in wound drainage in the free peritoneal cavity].","authors":"R Ernst,&nbsp;C Wiemer,&nbsp;E Rembs,&nbsp;J Friemann,&nbsp;A Theile,&nbsp;K Schäfer,&nbsp;V Zumtobel","doi":"10.1007/s004230050083","DOIUrl":"https://doi.org/10.1007/s004230050083","url":null,"abstract":"<p><p>In a prospective randomised study 30 mongrel rabbits received two standard colon-resections. Three types of drains were tested: (latex-rubber-) Penrose-drains, rubbertube- and silicontube-drains, which were placed in the lower abdomen. As a closed drainage-system the extraperitoneal tip of the drain was placed in a closed subcutis-pocket. One of the two colon-anastomoses also was drained. The findings were recorded on the 7th postoperative day. A single mechanic alteration was found, an ulcer caused by a silicon-drain, that pushed against the abdominal wall. The other signs of mechanic irritation were microscopically unspecified inflammatory reactions to the foreign body drain. There was no ascending infection caused by the drain. All infections came from complications of the colon resections. In contrast to common opinions the drains in the lower abdomen showed no adhesions to the abdominal wall or organs. Only the entrance of the drain into the peritoneum and the cotton-gaze of Penrose-drains showed in nearly all cases adhesions. The large amount of adhesions to the anastomosis-drains came from complications of the colon-anastomoses. As a cause of material, rubber- and latex-rubber-drains showed large fibrin-clots on their surfaces. 7 days after the operation only about 20% of the drains had sufficient function. The rest was occluded by fibrin-clots in the lumen of the drain or the cotton-gaze. Over all there is no difference in changes and effects of the three different types of drains, but silicon as material showed advantages.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 6","pages":"380-92"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20422827","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Adjuvant therapy of peritonitis with taurolidine. Modulation of mediator liberation].","authors":"K H Staubach","doi":"10.1007/pl00014640","DOIUrl":"https://doi.org/10.1007/pl00014640","url":null,"abstract":"<p><p>Despite aggressive surgical treatment, prompt antibiotic therapy, and modern intensive care, up to one half of patients still die of diffuse peritonitis. There must be a distinction between infection as a microbiological phenomenon and sepsis as a complex, deleterious, inflammatory host response. Physiologic and metabolic changes during the latter process by taxonomically different organisms or different sources of infection are often clinically indistinguishable. Taurolidine, an amino acid derivate, seems to cover a variety of effects in peritonitis. As secondary peritonitis is associated with a significant cytokine release that is compartementalized in the peritoneal cavity, taurolidine is bactericidal, antiendotoxic, and antiadherent locally and, on the other hand, may modulate the systemic cytokine-mediated inflammatory response after being adsorbed systemically by the peritoneum. Current management of peritonitis can clear the peritoneal cavity of microorganisms and their products but patients continue to die of uncontrolled cytokine-induced systemic inflammation. In patients that undergo daily staged, planned relaparotomies they should not only be treated locally by taurolidine but also systemically by intravenous administration. The latter should, as a sort of sequential therapy, be continued, especially when the peritoneal cavity has been closed after a series of relaparotomies.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 4 Suppl 1","pages":"S26-30"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1007/pl00014640","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20267722","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Morphologic parameters for quantitative determination of inflammatory activity of the peritoneum].","authors":"A. Woltmann, S. Weiss, B. Martens, R. Broll, S. Krüger, H. Bruch","doi":"10.1007/S004230050059","DOIUrl":"https://doi.org/10.1007/S004230050059","url":null,"abstract":"","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"23 1","pages":"231-6"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83253836","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"[Bilateral laparoscopic transperitoneal adrenalectomy in pheochromocytoma].","authors":"T Manger, S Piatek, S Klose, D Kopf, D Kunz, H Lehnert, H Lippert","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Laparoscopic transperitoneal and endoscopic extraperitoneal adrenalectomy are two safe options in minimally invasive surgery associated with a very low morbidity. Comparative studies with the conventional access to the adrenal gland demonstrated the advantages of the endoscopic technique. The anterior transperitoneal approach yields a better exposure of the anatomic structures and allows the surgeon to orient himself more easily, while at the same time he may perform additional laparoscopic maneuvers. In two cases of bilateral pheochromocytoma a bilateral laparoscopic adrenalectomy was performed simultaneously by employing the transperitoneal approach. The duration of surgery was approximately 210 and 270 min, respectively, with an intraoperative blood loss of about 350 and 400 ml. There were no complications following this procedure. Already on the 1st postoperative day, the patients could be fully mobilized. Furthermore, immunological data obtained perioperatively support the minimal invasiveness of this technique.</p>","PeriodicalId":17985,"journal":{"name":"Langenbecks Archiv fur Chirurgie","volume":"382 1","pages":"37-42"},"PeriodicalIF":0.0,"publicationDate":"1997-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20104092","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}