Langenbecks Archiv fur Chirurgie最新文献

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 in patients with end-stage renal disease can be reduced 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 paracetamol overdose. Auxiliary liver transplantation may then be considered.

We report a case of a breast tumor. As carcinoma of the breast was suspected, a biopsy was taken and a very rare osteoclastoma originating in the rib was identified. Semimalignant bone tumors tend to recur locally. The symptoms are nonspecific; the initial diagnosis is often made late. To differentiate the diagnosis, one should think about primary and secondary bone diseases and tumors of the organs of the thorax. In our case, the tumor was completely resected, including the ribs, and the defect was covered with a corium plasty. In this way, we are able to save the breast. We discuss different methods for covering chest wall defects.

The shape of the acromion is strongly associated with impingement syndrome and with rotator cuff tears. It is notoriously difficult to image the acromion with conventional radiography. We have developed MRI techniques to depict the acromion in its longitudinal axis. Furthermore, we have measured the subacromial space in both external and internal rotation. In previous studies, three types of acromial shape have been described with the type III or hooked acromion being present in 66% of cases with rotator cuff tears. We studied 31 normal shoulders in 29 people using MRI. Within this population aged 24-36 years, mean age 31 years, no type III acromions were found. Twenty-one were type I (67.7%) and 10 were type II (32.3%). In addition, we found no difference in subacromial height in external or internal rotation. Low rates of intra- and interobserver error were found. These results imply that the hooked acromion is not present in the normal population and is, therefore, likely to be an acquired abnormality.

A second case of true carcinosarcoma of the colon is reported. A 79-year-old women was diagnosed as having an obstructing tumour of the caecum and liver metastases in both lobes. Histological examination of operative specimen from a right hemicolectomy revealed malignant epithelial and mesenchymal components. Despite postoperative chemotherapy, the patient died of liver failure resulting from extensive metastatic growth.

Today there is a variety of different interlocking intramedullary nail designs available for the femur-each designed with a different approach to achieve stability for fracture fixation. We compared different nail types in the bone-implant complex (BIC) of four unreamed solid nails and a slotted, reamed nail to see if there are major differences in stiffness for axial load, bending and torsion. We simulated comminuted mid-shaft fractures by a 2 cm defect osteotomy in paired human cadaver femora. Each bone was tested intact in a Universal testing machine. The results were recorded, osteotomy and osteosynthesis were performed, and the BIC was tested. Relative stiffness was calculated for each individual bone. For P-values less than 0.01 ('least significance difference test') the difference between groups was considered to be significant. In torque testing the unslotted solid nails showed significantly more stiffness (0.6-1.8 Nm/degree) compared to the slotted nail (0.2 Nm/degree). Compared to intact bone (6.9 Nm/degree), both groups of nails were significantly less stiff (relative stiffness 2-20%). In axial load and bending testing, the large-diameter unreamed nail showed greater higher stiffness (32-68%). This study shows that stiffness of the BIC in interlocking femoral nails is more dependent on nail profile than on the press-fit of nails in the medullary canal. For torque stiffness the absence of a slot is of special importance. According to our study, all of the unslotted nails tested give adequate stability for fracture fixation.

Patients and methods: In a prospective protocol 25 consecutive patients with diffuse peritonitis were treated in the Surgical Clinic of the RWT-University in Aachen, Germany, from January to December 1995. According to the "Mannheim Peritonitis Score" three different stages were treated with different surgical procedures and a selective antibiotic regimen. Group-A patients with prognostically favorable peritonitis (MPS 0-20) were treated with the so-called standard procedure, group-B patients (MPS: 21-29) with closed postoperative lavage. The antibiotic regimen was cefotaxime (2 x 2 g) and metronidazole (2 x 500 mg) for both group-A and group-B patients. Severe group-C cases (MPS > 29) were treated with the so-called Etappenlavage (multiple reexplorations and intra-operative lavage) and received a combination of three antibiotics (2 x 2 g cefotaxime; 2 x 500 mg metronidazole and 2 x 200 mg ofloxacin).

Results: Eight patients belonged to group A, 10 to group B, and 7 to group C. The mortality was 0% (group A), 20% (group B), and 29% (group C), respectively. The actual overall mortality of the whole group was 16% (4/25). The statistically expected mortality was 36%, according to the APACHE-II-Score (P = 0.0982).

Empyema continues to be a significant problem in spite of improved surgical techniques and the use of new, more potent antimicrobial agents. This report describes our experience in the treatment of empyema at the Clemens Hospital in Münster, Germany, from 1990 to 1996. Basic to conservative treatment are closed drainage with intensive irrigation and instillation of Taurolin, a chemotherapeutic agent against bacterias, yeasts and mycetes. This treatment has been employed since 1990 and given 86 patients with just empyema or in combination with decortication. The superiority of this method to other methods of treatment is discussed on the basis of our results.

Simple cold storage of livers for transplantation activates glycolysis due to lack of oxygen. Energy derived from glycolysis may be critical for cell survival and liver cell death may occur once glycolysis is inhibited in the liver due to accumulation of end products or lack of substrates (glycogen). The relationship between cell death (lactate dehydrogenase, LDH release), anaerobic glycolysis (lactate production), and glycogen content of liver tissue was studied during cold incubation of liver slices in UW solution. Rat livers slices from male Sprague Dawley rats were incubated at 4 degrees C in UW solution, with continuous gentle shaking, under conditions of chemical hypoxia (KCN, 5 mM). The rate of lactate production, LDH release-ATP and glycogen content were measured spectrophotometrically and by HPLC. Lactate increased nearly linearly for the first 48 h of incubation; total lactate which had accumulated after 48 h was 33.9 +/- 0.81 mumol/g and at 96 h nearly the same, 31.3 +/- 1.2 mumol/g. Glycolysis stopped, apparently, because of the depletion of liver slice glycogen which was initially 228.8 +/- 1.7 mumol/g wet wt. It decreased to 34.7 +/- 2.7 mumol/g at 48 h and to 18.7 +/- 1.1 mumol/g at 72 h and remained at this level for the next 24 h. An increased leakage of LDH occurred once glycogen metabolism (and accumulation) ceased. LDH release could be stimulated after only a few hours of cold incubation of liver tissue slices by adding glycolysis inhibitor (iodoacetic acid) to the medium. After 24 h. LDH release was 24.4 +/- 1.8% and increased to 52.8 +/- 5.2% (P < 0.05, Student's t-text) with iodoacetic acid. Adding a glycolytic substrate (fructose, 10 mM) to the medium maintained lactate production for 96 h. The stimulation of glycolysis by fructose also reduced cell death: LDH release was significantly lower at 72- and 96-h incubation (P < 0.001, two-way ANOVA). The ATP content was significantly higher with fructose (P < 0.001). Adding glucose (20 mM) and fructose (10 mM) in combination resulted in prolonged cell survival, significantly delayed glycogen depletion and significantly higher ATP content at 48 and 72 h (two-way ANOVA). Livers from rats who had fasted for 24 h demonstrated the same LDH release at 48 h when incubated with glucose (20 mM) and fructose (10 mM). In conclusion, LDH leakage from hypoxic cold-stored liver slices is related to anaerobic glycolysis. Anaerobic glycolysis appears to continue slowly under hypothermia and provides sufficient energy for maintenance of cell viability. A stimulation of glycolysis in the cold is possible by fructose and results in prolonged cell survival under hypothermic conditions. Glycogen depletion can be slowed down by combining glucose and fructose.

The gasless videoendoscopic implantation of GELSOFT aortobifemoral vascular prostheses times 6 x 6 mm in diameter using an extraperitoneal approach was tested in ten porcine experimental models at the Surgical Department of the University of Cologne, Germany. Gasless videoendoscopic surgery is performed with a laparolift-laparofan system. Aortobifemoral GELSOFT prostheses were successfully implanted in nine of ten animals, whereby one animal died during preparations for surgery of massive coronary infarctions. Average surgical durations using the extraperitoneal approach were 270 min. Dissection of the infrarenal aorta until occlusion took 45 min, average aortic occlusion 75 min, and iliacofemoral occlusion 45 min for the left side and 75 min for the right side. After successful videoendoscopic implantation of aortobifemoral GELSOFT prostheses all nine animals underwent laparotomy and resection of the aortobifemoral prosthetic segment. The quality of the endoscopically sutured aortic end-to-side anastomoses was examined in vitro under artificial circulation of glycerol/Ringer's lactate solution for evaluation of possible leakage and bursting pressures and then compared to conventionally sutured end-to-side anastomoses of 6-h-old porcine abdominal aorta and GELSOFT prostheses 6 mm in diameter. The maximum bursting pressure of all endoscopically sutured anastomoses was 480 mmHg mean pressure: the minimum was 140 mmHg mean pressure. The minimum leakage per minute was less than 10 ml/min for systolic pressure values between 120 and 350 mmHg. All endoscopically sutured aortic end-to-side anastomoses were comparable to conventionally sutured anastomoses concerning in vitro evaluation of bursting pressure and leakage per minute.