Langenbecks Archiv fur Chirurgie. Supplement II, Verhandlungen der Deutschen Gesellschaft fur Chirurgie. Deutsche Gesellschaft fur Chirurgie. Kongress最新文献

In the majority of patients with esophageal cancer local tumor infiltration and/or distant metastases are responsible for the poor prognosis. Therefore to improve life expectancy additional modalities--chemotherapy alone or in combination with simultaneous radiation--have been introduced perioperatively. In spite of a possible increase of resectability convincing data are lacking which could argue for an uncontrolled introduction of the neoadjuvant approach outside investigational studies in early tumor stages (T1, T2).

Postoperative radiotherapy as a routine procedure has failed to show any benefit in prospective randomized studies. Local failure was diminished, but survival rates remained unchanged, probably because of radiation complications. By improvement of radiation techniques, however, reduction of single doses and total dose and focusing postoperative irradiation of lung cancer to high risk cases (N2, T4) survival rates with postoperative irradiation are about 20% after 5 years. The results of 191 treated patients are demonstrated.

Relaparotomy in children was necessary in 2.6% of 4902 cases because of adhesions (80% within 2 years). Adhesions can be differentiated histologically by the number of blood vessels. In the highly vascular adhesions arteries and veins are united in a common cord of connective tissue. Whereas the less vascular characteristically have a dense connective tissue rich in collagen. The number of capillaries distributed within the connective tissue varies. Some adhesions have a mixed tissue type of both tissues rich and poor in blood vessels. All adhesions are peripherally delimited by a different number of fibrous layers.

Advanced age and cardiovascular diseases cause of SMA occlusion. Shock is triggered and maintained by bowel ischemia. Since lactate is the end product of anaerobic glycolysis, lactacidosis is a valuable clinical parameter. Lactate values above 4-5 mmol/l are conclusive evidence in the presence of symptoms of acute SMA occlusion. Chance of survival are poor in stages II and III with advanced shock and non reversible gangrene. Revascularisation of the SMA combined with adequate bowel resection reduces the production of toxic and lethal substances in the intestinal mucosa, thus increasing the chance of survival. Determination of serum lactate should be an integral part of the diagnostic procedure and the close followup for it is both an adequate index of the grade of intestinal ischemia and a means of assessing whether a second-look is warranted.

The guidelines for conservative or operative treatment of fractures of the distal radius have been standardized for years. To decide whether conservative treatment is indicated the following factors are important: 1. the amount of metaphyseal impaction, 2. the presence of a joint surface, and 3. the remaining bony buttress. Conservative treatment is indicated in cases in which there is a chance to ensure retention. The difficulty of conservative treatment does not lie in special sophisticated steps of procedure. It is more important to consider the standardized technical procedures of reduction, adequate immobilization and surgical control.

Medicine is an empirical science in which there are very heterogeneous view about the importance of experience. Numerical data attempt to quantify the required experience for student education and clinical practice. Support systems, i.e. scores, decision trees, etc., facilitate decision-making for surgical indications and choice of operative techniques. They are aided by clinimetrical systems, i.e. controlled clinical trials and even computer assistance. Beyond all strategies of decision-making lies the accumulated individual experience of making the right decision at the right time. Experience is also at the bottom of the often cited intuition, clinical judgement and common sense.

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.

Injuries of the diaphragm are caused either by direct or indirect violence. In all such ruptures various portions of the abdominal viscera may have ascended into the thoracic cavity. The clinical manifestations are unpredictable and of infinite variety, and especially in massively traumatized patient masked by other injuries. A presumptive preoperative diagnosis of diaphragmatic injury from chest x-ray findings is only possible in about 50% of the cases. In other cases the diagnosis can be confirmed by water.soluble contrast enema into the stomach or colon. Rupture of the diaphragm is a strong indication for operation. In cases of fresh rupture we attempt repair of the diaphragm through a laparotomy incision. In old diaphragmatic rupture we prefer a thoracotomy incision.

In a randomized study the efficiency of the low molecular weight heparin (LMWH) Fragmin and unfractionated heparin Calciparin in preventing thromboembolic disease was examined. Ninety patients undergoing a herniotomy participated in the study. The LMWH also showed good efficiency in a laboratory test of anti-factor Xa-activity. There were no complications.