[Perioperative management of patients on NOACs]. / Perioperatives Management von Patienten unter NOAK.

Regarding thromboembolic events, non-vitamin K antagonists, so-called new oral anticoagulative agents (NOACs), have widely enlarged prophylaxis and therapy. In contrast to vitamin K antagonists they can be administered in a definite dose and do not need any regular control of coagulation parameters. Thus being simple in handling, these drugs have become enormously attractive for both patient and physician.In spite of all their advantages NOACs have to be considered carefully. They have a significant disadvantage: the plasma concentration is not detectable by a simple blood test, nor is there any antidote available. As a consequence the bleeding risk remains unknown.In this review we focus on two different settings in routine surgical work: the preoperative management of patients undergoing elective surgery differs significantly from that needed in urgent surgery.

The effect of physical therapy on respiratory complications following cardiac valve surgery.

STUDY OBJECTIVE: To determine whether higher personnel intensive chest physical therapy can prevent the atelectasis that routinely follows cardiac valve surgery. DESIGN: Randomized, controlled trial. SETTING: Tertiary care hospital. PATIENTS: Seventy-eight patients undergoing elective cardiac valve surgery between October 1991 and April 1993 were enrolled. INTERVENTIONS: Patients were randomized in an unmasked fashion to receive early mobilization and sustained maximal inflations (lower-intensity treatment) or to receive early mobilization, sustained maximal inflations, and single-handed percussions (higher-intensity treatment.) MEASUREMENTS AND RESULTS: Clinical efficacy was determined by extent of atelectasis, length of ICU stay, total length of hospital stay, and personnel costs. The extent of postoperative atelectasis was similar in both groups on the fifth postoperative day. Postoperative values of FVC and FEV1 were reduced to a similar extent in both groups. Hospital stays and ICU stays were similar regardless of treatment. Physical therapy costs were highest in the higher-intensity therapy group. CONCLUSIONS: Postoperative respiratory dysfunction is common but does not usually cause significant morbidity or prolong hospital stay. The routine prescription of high-intensity physical therapy does not improve patient outcomes but does add significantly to patient costs.

The prognostic significance of tumor cell detection in intraoperative pleural lavage and lung tissue cultures for patients with lung cancer.

METHODS: Three hundred forty-two patients with lung cancer and 99 patients with nonneoplastic lung diseases (control group) underwent intraoperative pleural lavage with 300 ml physiologic saline solution before (lavage I) and after resection (lavage II). RESULTS: Studies of the lavage fluid in all control patients were negative, that is, there were no false positive findings. Tumor cells were found in lavage I in 132 patients (38.6%) and also in lavage II in 99 of them. In stage I (pT1 N0, pT2 N0) lung cancer, tumor cell detection was possible in 47 patients (28.6%). The 4-year survival of patients with resected non-small-cell lung cancer was 24% (95% confidence interval, 16% to 32%) if lavage I results were positive and 52% (95% confidence interval, 45% to 59%) if lavage I results were negative (all stages, p = 0.007). For patients with stage I disease (n = 164) the 4-year survival was 35% (95% confidence interval, 18% to 52%) if lavage I results were positive (n = 47), and 69% (95% confidence interval, 60% to 78%) if lavage I results were negative (n = 117) (p = 0.037). On multivariate analysis the positive cytologic result in intraoperative pleural lavage was an additional prognostic factor for our patients. To prove how the tumor cells enter the pleural cavity, we performed tissue cultures of tumor-free parenchyma in 23 cases of lung cancer. Tumor cell detection by histology and immunohistology was possible in 16 cases (69.6%). Detection of tumor cells in pleural lavage fluid before resection proves that tumor cells have spread into the pleural cavity. CONCLUSION: The positive result in pleural lavage seems to be a prognostic predictor for patients with lung cancer.

Treatment of ruptures of the symphysis and iliosacral joint in pediatric patients.

The three osseous parts of the human pelvis form a continuous structure because of the symphysis and both iliosacral joints that-owing to their mobility-make possible a shock-absorption of vertical forces. The goal in the treatment of ruptures of the symphysis and/or of the sacroiliac joints is the restoration of functioning joints. Especially in the adolescent, a stiffening of these joints has to be avoided. Therefore, we treat ruptures of the pelvic joints with an overbridging banding that preserves the function of shock absorption. Due to utilisation of a banding, made up of polydioxanone, another operation to remove internal fixation material is not necessary. Rupture of the symphysis or iliosacral joint in the pediatric patient is very rare. Only three among the 67 patients whom we operated on because of a rupture of the symphysis or iliosacral joints between 1984 and 1990 were children. These were an eleven-year-old girl and a nine-year-old boy, who had suffered a rupture of the symphysis, and an eight-year-old boy with a disrupted iliosacral joint. In these children a banding with PDS suture was performed. At a follow-up examination, the children were free from pain and did not feel restricted in their daily routine or their physical activities.

[Use of an endoscopic stapler for transanal widening of anastomotic stenosis]. / Einsatz eines endoskopischen Klammerschneidegerätes zur transanalen Erweiterung einer Anastomosenstenose im Rectum.

Postoperative anastomotic stenosis of the colorectal region are reported in 0.5-13%. We present one patient with a benign anastomotic stenosis after resection of the sigmarectum who was treated using the linear cutter Endopath ELC 35.

[Lung resections for pulmonary infections in intensive care patients]. / Lungenresektionen wegen pulmonaler Infektionen bei Intensivpatienten.

Pneumonia occurs in about 60% of ventilated patients with a lethality of approximately 40%. Since 1980 we performed a thoracotomy in 16 patients of an intensive care unit suffering from a lung infection (mean age 34 years). In all patients an adequate antibiotic therapy was unsuccessful. By means of the computed tomography we could ascertain a lung infection limited to one part of the lung, mostly combined by an abscess. We performed 14 lobectomies and one atypical wedge resection and segment resection each. Postoperatively 8 patients died: Three of them because of a persisting septic shock and five because of their multiple injuries. Lung resection is a good treatment in case of a lung infection with septic complications.

[Traumatic bronchus rupture. Pathogenesis, surgical and postoperative management]. / Die traumatische Bronchusruptur. Pathogenese, operatives and postoperatives Management.

Tracheobronchial injuries are rare and associated with other injuries. We report about a traumatic rupture of the left main bronchus into the segmental bronchus of the lower lobe. After resection of the lower lobe a bronchoplastic repair of the main and upper bronchus was performed.

[Surgical treatment of tracheal injuries]. / Chirurgische Behandlung von Trachealverletzungen.

Traumatic and iatrogenic injuries of the trachea are rare. In case of suspected rupture of the trachea a bronchoscopy remains the 'gold standard' of diagnostic procedures. The injuries should be repaired as soon as possible through a right thoracotomy or a collar incision using resorbable sutures. In case of small lesions a conservative treatment may be discussed. Overall the prognosis of tracheal injuries is good.

[Thoracoscopic operation of primary spontaneous pneumothorax]. / Thoracoskopische Operation des primären Spontanpneumothorax.

Since May 1990 we have treated 35 patients with spontaneous pneumothorax and without underlying lung disease by thoracoscopic operation. All patients entered a prospective trial. There have been four recurrences during a minimum follow-up of 7 months (median 19 months). Two complete collapses had had only fibrin glue sealant without any resection of bullae. The others were partial relapses not requiring any treatment. There was a striking high incidence of pain complaints and sensory disturbances (13 out of 29) even months after pleurodesis by coagulation or pleurectomy. Reduced trauma and less postoperative restriction of pulmonary function together with low recurrence rates suggest a more liberal indication in patients with their first manifestation of the disease. Nevertheless indication and choice of pleurodesis should be restrictive and be studied further for its specific complications.

[Difficult diagnosis: acute appendicitis and appendiceal/cecal carcinoma]. / Die schwierige Diagnose: Akute Appendicitis und das Appendix-/Coecumbodencarcinom.

INTRODUCTION: Primary carcinoma of the appendix vermiformis/caecum is very rare. The diagnosis can often be ascertained only postoperatively by histopathological means. Preoperative diagnosis is unusual. METHOD AND RESULTS: We report on five patients with an adenocarcinoma of the appendix/base of caecom, all operated on between July 1998 and October 1999. CONCLUSION: A hemicolectomy "en principe" is not necessary. However, ileocaecal resection should have been performed during the first operation and there should be no positive lymph nodes. Postoperative diagnosis of a carcinoma after simple appendectomy necessitates Reoperation with right hemicolectomy.

[Congenital tracheoesophageal fistula in the adult]. / Congenitale oesophagotracheale Fistel beim Erwachsenen.

Congenital esophago-tracheal and esophago-bronchial fistulae are rare. Symptoms are recurrent pneumonia, cough, dysphagia and pain. The diagnosis is made by bronchoscopy or esophagoscopy. Every time the diagnosis is certain, the fistula has to be exstirpated by means of a thoracotomy and plastic reconstructive flap surgery.

[Bilateral rupture of the quadriceps tendon--case report and review of the literature]. / Die beidseitige Quadricepssehnenruptur--Fallbeschreibung und Literaturübersicht.

We report a very rare case of bilateral simultaneous rupture of the quadriceps tendons in a 64-year-old patient following a minor trauma. The reconstruction of the ruptured tendons was achieved by intertwined PDS-sutures which were supportively fixed in the patellae. After wound healing, the patient was mobilized in his two casts which were applied for 6 weeks. After the period of one year, a satisfactory result could be seen. We report the etiology, pathogenesis, diagnosis, therapy and postoperative treatment which are described in the literature.

[Acute stress-induced cholecystitis]. / Die akute Stresscholezystitis.

Acute posttraumatic and postoperative cholecystitis is a serious and life-threatening complication with mortality rates ranging from 10 to 50%. The pathogenesis is multifactorial: possible reasons are blood transfusions, dehydration, narcotics, shock and positive end-expiratory pressure (PEEP). Between 1980 and 1990 12 patients underwent surgery for acute cholecystitis. Six of them suffered from a so-called acute acalculous cholecystitis. Two patients died postoperatively. The symptoms are that of a "common" cholecystitis with leukocytosis, fever, abdominal distension and upper right abdominal pain. Sonography is a good method to establish the diagnosis and helps in the decision for cholecystectomy. Clinicians must remember the possibility of an acute cholecystitis in any surgical patient developing abdominal pain or unexplained fever.

[Stomach and duodenal cancers in familial adenomatosis coli]. / Magen- und Duodenalkarzinome bei familiärer Adenomatosis coli.

In the last years the number of patients with familial adenomatosis coli and metachrone carcinoma of the upper gastrointestinal tract is increasing. We describe two patients who, 9 and 15 years after colectomy for adenomatosis coli, developed a duodenal carcinoma. Each patient was treated with a partial duodeno-pancreatectomy. Another patient was resected prophylactically because of a diffuse adenomatosis of the duodenum three years after colectomy. We suggest that each patient with a history of colectomy for adenomatosis coli should have regular follow-ups including endoscopy of the upper gastrointestinal tract.

[Results of elective lymph node excision in melanoma of the trunk]. / Ergebnisse der elektiven Lymphknotendissektion beim Körperstamm-Melanom.

In our department, between 1979 and 1994, 254 patients, thereof 171 male, 83 female with the average age of 48.2 years underwent surgery because of stage 1 (T2) to stage 3 melanoma that was located on the trunk. Our retrospective analysis was based on those 211 patients who had been followed up by the department of dermatology in our medical center. It was the aim of our study-apart from determining the long-term-prognosis-to find out the number of patients in whom a curative resection could be only achieved by elective lymph node dissection. The 5-year survival rate amounted to 79% for all patients. For patients suffering from stage 1-disease (T2) it was 93%, for those with stage 2-disease 89%, and in case of stage 3-disease 49% respectively. After ELND had been performed, no lymph node metastases were found in patients (0/22) suffering from a T2-tumor. In case of T3-tumors, in 13% (11/82) and in case of T4-tumors in 30% (13/43) lymph node metastases were found. However, only 5 out of 11 patients, with the established diagnosis of a T3-tumor in whom positive lymph-nodes had been found by ELND, and merely 6 out of the 13 patients with a T4-tumor, are still alive after a mean follow-up period of 74 months. We conclude that ELND is not indicated in patients with T2-melanoma. In case of T3- and T4-melanoma, some doubts exist whether patients really benefit from this surgical procedure. Randomized prospective studies are necessary to clarify the importance of elective lymph node dissection.

[The importance of mediastinoscopy for accurate lymph node staging]. / Die Bedeutung der Mediastinoskopie für das korrekte Lymphknotenstaging.

The mediastinoscopy (MS) was developed 1959 by Carlens. Since the introduction of computertomography (CT) in the diagnostic of the thorax the MS was no longer used routinely. Because of the introduction of the CT in our clinic we performed only 111 MS between 1981 and 1992, in contrast to 185 MS between 1976 and 1981. No patient died perioperatively. Two patients had to be operated on for bleeding. The sensitivity of the modern CT-scan for a correct preoperative staging of a bronchial carcinoma runs up to 90% and the specifity up to 85%. Therefore a correct preoperative staging can only be reached histologically with the help of a MS. An exception are T1 and T2 tumors because of only 28% mediastinal lymph node metastases. We think that the MS should be performed more often in order to reach a correct, histologically ascertained staging preoperatively.

[Lung surgery in elderly patients, a retrospective study (1985-1994)]. / Lungenchirurgie im Senium, eine retrospektive Studie (1985-1994).

From 1985 to 1994, we performed 4568 thoracic operations, 234 of these patients (176 males, 58 females) were older than 70 years of age; the oldest patient was 82 years. Of these 234 patients, 144 suffered from bronchial carcinornas, 25 from lung metastases, 21 from recurrent pneumothoraces, 12 from thymomas, 21 from tuberculomas, hamartomas, an intrathoracic goiter or mesothelioma; in 11 patients, diagnostic thoracotomias or biopsies had been done. We did 146 anatomical resections, 59 atypical wedge resections, 14 decortications, pleurectomies, thymectomies or exstirpations of mediastinal tumors; in addition, three resections of an intrathoracic goiter were done. The hospital lethality was 3.8%, the total rate of complications 56%, mostly cardiac arrhythmias. The survival rate of the patients suffering from a bronchial carcinoma was the same as in younger patients.

[Effect of perioperative donor blood transfusion on prognosis of bronchial cancer]. / Der Einfluss der perioperativen Fremdblutgabe auf die Prognose des Bronchialkarzinoms.

Immunological research and experimental animal studies have shown that allogeneic blood has an immunosuppressive effect. Several clinical investigations have demonstrated the negative influence of blood transfusions on the prognosis after curative resection of colorectal carcinoma. However, there are only a few studies about the influence after complete removal of lung cancer, and the results are contradictory. In our retrospective study we analyzed the follow-up results of 224 patients (192 men, 32 women; average age 57 years) on whom we had performed a curative resection of their bronchogenic carcinoma. A total of 119 patients had received nonspecific random blood transfusions. The survival rate for patients with blood transfusions was significantly worse in comparison to the non-transfused group 2 years after the operation (74% vs 59%, P = 0.019); after 5 years, however, no difference could be seen (43% vs 43%). Even when we subdivided our patients according to tumor cell type, tumor stage, differentiation and method of resection, the negative influence of transfused blood was confirmed for the 2-year survival rate, but again had disappeared 5 years after the operation.

Effects of low-dose dopexamine on splanchnic oxygenation during major abdominal surgery.

OBJECTIVE: To study the influence of low-dose dopexamine on splanchnic oxygenation during major abdominal surgery. DESIGN: Prospective, randomized, placebo-controlled study. SETTING: University hospital. PATIENTS: Eighteen adult patients undergoing elective major abdominal surgery. INTERVENTIONS: The patients received either dopexamine at 1 microg/kg/min (group A, n = 9) or 0.90% saline as control (group B, n = 9). MEASUREMENTS AND RESULTS: To assess the splanchnic oxygenation, intestinal tissue PO2 (PtissO2) and gastric intramucosal Pco2 (PmucCO2) were measured, and the PCO2 gap (PmucCO2 - PaCO2) was calculated at baseline (T1) and after an infusion period of 60 mins (T2). There was no difference between the groups in the global oxygen transport parameters. Low-dose dopexamine increases PtissO2 on the serosal side of the small bowel (deltaPtissO2, 17+/-24 mm Hg in group A vs. -5+/-10 in group B). The changes in PtissO2 at the serosal side of the colon after dopexamine demonstrated a nonsignificant increase (deltaPtissO2, 7+/-11 mm Hg in group A vs. -11+/-23 mm Hg in group B). In both groups, the Pco2 gap (group A, 6+/-7 mm Hg [T1] and 5+/-6 mm Hg [T2], vs. group B, 9+/-10 mm Hg [T1] and 12+/-10 mm Hg [T2]) remained unchanged compared with the baseline. CONCLUSION: It is concluded that low-dose dopexamine improves PtissO2 at the serosal side of the gut, preferably at the small bowel. However, low-dose dopexamine did not improve gastric PmucCO2.