Langenbecks Archiv fur Chirurgie最新文献

Unstable fractures of the upper thoracic spine are a therapeutic challenge because of the high rate of associated injuries and frequent occurrence of spinal cord lesions. This study focuses on the operative treatment of these injuries. We present nine patients with unstable injuries of the upper thoracic spine. According to the classification of Magerl et al., there are seven type C and two type B fractures. Eight patients had complete transverse lesions of the cord and one had no evidence of spinal cord injury. All patients presented associated injuries: nine patients had fractured ribs, three a fractured sternum and three a severe haemothorax. All underwent operative treatment: six posterior fusions only, two anterior interbody fusions only after thoractotomy owing to severe bleeding from ruptured intercostal arteries, and one a combined fusion after failure of posterior fusion. The treatment of these patients should be individualized, depending on the associated injuries, loss of blood owing to fractured spine and ruptured vessels and depending on the back pain resulting from an unstable thorax. In general, we prefer the posterior approach to unstable fractures of the upper thoracic spine.

Background: Medullary thyroid carcinoma (MTC) can--even in recurrent cases--only be treated surgically. Therefore, preoperative localization of the tumor is essential.

Methods: From April 1986 through April 1997, 137 patients with MTC were operated on at our clinic. In 22 patients with recurrent tumor which had not been radiologically localized, 28 selective venous catheterizations (SVC) with determination of calcitonin levels were carried out.

Results: In 23 examinations a suspected tumor could be identified (nine cervical unilateral, seven mediastinal, four cervical unilateral and mediastinal, one cervical bilateral and mediastinal, one liver, one cervical unilateral and liver). In 18 cases surgery was performed for recurrence (nine cervical revisions, one mediastinal dissection, six cervicomediastinal dissections, two laparotomies). In 15 of 18 cases, tumor tissue was found in the previously suspected area. In ten cases serum calcitonin levels dropped postoperatively by 6%-75%. A normalization of the hormone level was achieved only once by yet another operation. During further follow-up, five of the reoperated patients died from their disease. The other 17 patients are being followed up, whereby calcitonin levels are elevated but there is no clinical or radiological evidence of tumor.

Conclusions: Although in the patient cohort presented a normalization of serum calcitonin could be achieved only once, the authors consider SVC useful because it is the only means of localization of tumor tissue in cases of negative radiologic studies and therefore allows a planned approach to the operation procedure in these cases.

Objective: Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barrett's metaplasia or poor esophageal body motility.

Design: Retrospective study.

Setting: University hospital.

Patients: 138 GERD patients were analyzed regarding the development of Barrett's metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H2 blockers or omeprazole.

Main outcome measures: The rate of patients with Barrett's metaplasia or poor esophageal body motility with or without effective medical treatment.

Results: Barrett's metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P < 0.05), but these patients had a significantly shorter history of GERD.

Conclusions: Medical treatment with H2 blockers or omeprazole does not prevent the development of Barrett's metaplasia or poor esophageal body motility.

The structural health care law (known as the Gesundheitsstrukturgesetz or GSG) of the Federal Republic of Germany has been enacted to replace the covering cost prices by various forms of payment. On the basis of the Godesberg Diagnosis and Therapy Catalogue, a new system has been developed that assesses all new implications of the care benefit law. With the help of intelligent plausibility tests, a particular case (PC) or a special rate (SR) is suggested. The documentation system works without ICPM numbers. The conversion of diagnosis and therapies to ICD-10/ICPM numbers is possible. The results of the first half of 1995 and the second half of 1995 show that only two-fifths of operations can be assessed with PC or SR. Neither emphasis on certain operations nor the more differentiated illnesses are recognised as extra costs by the GSG regulations. Complete and correct documentation is achieved by a strict and stratified control system.

We report on the case of a 23-year-old female with a 5-year history of Gardner's syndrome, who developed a bifocal, papillary carcinoma of the thyroid. The combination of familial adenomatous polyposis with a thyroid cancer is a rare but well-documented association. Typically, histology reveals a multifocal, papillary tumour with a predominantly good prognosis. This type of carcinoma is almost exclusively confined to females in their second decade of life, and it may, in fact, precede the onset of the polyposis manifestation. Patients suffering from familial adenomatous polyposis should therefore undergo regular clinical examination of the thyroid gland. If a neoplastic lesion is suspected, immediate scintigraphic evaluation should be carried out, with fine-needle aspiration of equivocal foci if necessary, and/or intraoperative frozen section. When a carcinoma is found, total thyroidectomy with dissection of the central lymph compartments should be considered the treatment of choice because of the high likelihood of the tumour being multicentric.

The effect of electrical stimulation of both cervical vagal nerves on mucosal mast cells in the jejunum was investigated in an in vivo animal model with rats of both sexes. Males showed a significant increase of mast cell densities after electrical stimulation (1.0 mA, 5 Hz, 5 ms, 12 min) in the lamina propria. Simultaneously, we observed a significant increase of tissue histamine levels (ANOVA: P < 0.05), whereas serum levels remained unchanged. However, even though females had significantly higher levels throughout compared to males (ANOVA: P < 0.05), they did not show any significant reaction to electrical stimulation. These in vivo data support morphological and in vitro data from other investigators, who hypothesized a functional interaction between mucosal mast cells and nerves. However, degranulation seems to be a poor in situ indicator for mast-cell stimulation, as mast-cell densities increased in males, while the percentage of degranulated cells remained the same in all groups (about 40%). Instead, electrical stimulation of the vagal nerve seems to trigger histamine synthesis, or simply stabilization of mast cells. Interestingly, this phenomenon seems to be sex-dependent, suggesting a regulatory role for sex hormones in this scenario.

Although there is a 20% yeast colonization in the gastrointestinal tract of the population, fungal infections appear only rarely in secondary peritonitis. The risk of severe mycosis increases after a major operation and when a patient is taking broad-spectrum antibiotics, is on total parenteral nutrition, is catheterized, and/or is immune-suppressed. In the past years the incidence of nosocomial fungal infections (usually Candida spp.) has risen significantly. Five percent of CAPD-related peritonitis is caused by fungi. In enteral anastomosis breakdown, invasive mycosis occurs more often, with an accompanying lethality of up to 80%. In severe pancreatitis, up to 5% of peripancreatic necrosis is infected with fungi. The clinical course of severe mycosis, like the septic syndrome, is associated with fungemia in up to 50% of cases. As most of the facultative pathogenic fungi are part of the physiological flora, it is difficult to interpret mycological cultures. In order to diagnose invasive fungal infections, histopathological techniques and serologic tests for antigens and antibodies are available. Three antifungal agents (amphotericin B, flucytosine, fluconazole) are available for intravenous administration. Amphotericin B is given at doses of up to 1 mg/kg per day, in liposomal galenism up to 3 mg/kg per day. Combining amphotericin B with flucytosine (150-200 mg/kg per day) a synergistic effect is reached. Fluconazole at a dosage of 200-800 mg per day represents an alternative with similar antifungal activity and lower side effects.