RESUMO
BACKGROUND: Surgical treatment of incisional hernia includes implantation of a mesh. The use of synthetic grafts in contaminated fields results in an increased risk of infection. In these cases a potential advantage is described for biological repair material. Evidence for this problem is lacking; therefore, we initiated a survey among surgeons in Germany concerning this question. MATERIAL AND METHOD: A survey concerning indications, experience and techniques of using synthetic and biological meshes was sent to 60 surgical departments. The emphasis of the survey was on the differentiation of clean and contaminated fields. RESULTS: The survey was answered by 42 %. The use of biological repair material was preferred in clean-contaminated, contaminated and soiled fields. Synthetic meshes were preferred in clean, rarely in clean-contaminated and not in contaminated or soiled situations. Primary suture repair was chosen in clean fields and barely in contaminated fields. For closure of giant hernias a component separation technique (CST) was favored by the majority of respondents. A single stage repair was preferred by most of the surgeons even in cases with simultaneous stoma takedown. A total of 72 % of the respondents were satisfied with the use of biological repair material, but the reimbursement was considered to be inappropriate. DISCUSSION: Although the response rate was low, this survey gives an idea of the attitude towards the use of synthetic and biological meshes. Biological repair material is favored for hernia repair in contaminated or soiled fields. The advantage of this choice is a one stage repair despite the contamination. As the results of this survey are not able to provide arguments for the use of different meshes this question should be further investigated with a randomized controlled trial.
Assuntos
Técnicas de Fechamento de Ferimentos Abdominais , Materiais Biocompatíveis , Hérnia Abdominal/cirurgia , Hérnia Incisional/cirurgia , Telas Cirúrgicas , Atitude do Pessoal de Saúde , Humanos , Recidiva , Reoperação , Infecção da Ferida Cirúrgica/cirurgia , Inquéritos e Questionários , Técnicas de SuturaRESUMO
Because of the standardization of different surgical procedures, the surgical treatment of inguinal hernias can be primarily performed on an outpatient basis. The surgical traditions, the hitherto existing financial plan as well as the pretensions of our society, however, have promoted in hospital treatment of hernias. Only since 1993, in accord with the "German Gesundheitsstrukturgesetz", has a new general framework come into existence that has enabled hospitals to opt for ambulant treatment, as well. Because of the discrepancy between stationary and ambulatory funding, the ambulant approach nevertheless has not become widely accepted. This might change after the introduction of the catalogue of feasible ambulant treatments and non-stationary procedures, as well as by the recent nation-wide decisions regarding extra budgetary funding for ambulant treatments. To what extent the "German Vertragsarztrechtsänderungsgesetz" constitutes a stronger tie between private medical practice and hospital-bound outpatient treatment remains to be seen.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Hérnia Inguinal/cirurgia , Admissão do Paciente/economia , Orçamentos , Serviços Contratados/economia , Análise Custo-Benefício , Alemanha , Hérnia Inguinal/economia , Humanos , Programas Nacionais de Saúde/economiaRESUMO
Lymph node staging is the most important prognostic factor after radical surgery for colorectal carcinoma. The probability of correctly classifying a colorectal tumor increases with the number of lymph nodes harvested. This number varies with the methods used by the pathologist. An accurate examination of the surgical specimens is essential for the correct assessment of the lymph node status of the tumor. The purpose of this study was to evaluate an easy fat clearance method using pure acetone. A total of 188 surgical specimens of colorectal carcinoma were investigated. The first lymph node preparation was made using the manual method. Thereafter, the mesenteric fat tissue was treated with pure acetone for 16 h and subjected to a second lymph node examination. In 111 of the samples the required number of 12 lymph nodes for TNM classification was not reached by the manual preparation method. With the acetone treatment, 12 or more lymph nodes were found 91% of these samples (average 27 lymph nodes). In 29 samples (15%) additional lymph node metastases could be detected. In 16 samples (8% of all investigated samples) an upstaging of the pN status was necessary. This indicates the importance of our method for the optimal lymph node staging of colorectal carcinomas. Lymph node preparation after acetone treatment is an easy, low cost method resulting in a much larger number of lymph nodes for more accurate staging.
Assuntos
Acetona/farmacologia , Neoplasias Colorretais/patologia , Linfonodos/patologia , Neoplasias Colorretais/cirurgia , Humanos , Metástase Linfática/patologia , Estadiamento de Neoplasias , RecidivaRESUMO
Surgery of the groin hernia has become more a question of the applied tension-free, mesh technique. Whereas studies on laparascopic versus open tension-free hernia repair or open-mesh versus open-nonmesh repair have been performed sufficiently, data regarding the open tension-free plug-and-patch technique are rather poor. During the period from January 2001 to October 2003, we followed and filed 766 hernia repairs in the plug-and-patch technique of Rutkow. Follow up was during the hospital stay, 4 weeks, and minimally 12 months after operation. The main follow-up variables were complications, recurrence rate, and pain. The mean operating time was 37.8 +/- 15.85 (12-135) minutes. In 141 (19.3%) patients (n=730), the ilioinguinal nerve was resected. The 1 intraoperative complication that occurred was a severed small intestine. Length of hospital stay was 2.09 +/- 1.35 (0-17) days, work leave lasted for 15.3 +/- 12.42 (0-60) days, and return to normal daily activities was possible within 6.54 +/- 6.86 (0-35) days. Twenty-two (2.9%) patients (n=766) developed a postoperative hematoma as the most common complication, and a reoperation was required 17 (2.2%) times during the hospital stay. Early complications included hematoma (3.7%), seroma (3.5%), infection (0.2%), necrosis of 1 testicle (0.2%), persisting scrotal swelling (1.5%), persisting pain (0.9%), and hypoesthesia (2.4%). Within 4 weeks, 4 (0.9%) patients were reoperated for 1 seroma, hematoma, infection, and testicle necrosis. After 605.4 +/- 154.5 (365-1018) days, the following 19 (5.7%) patient complaints were noted: persisting pain (2.1%), hypoesthesia (1.8%), foreign-body feeling (0.6%), scrotal swelling (0.6%), and 1 (0.3%) mesh dislocation. Six (1.8%) reoperations have been performed. The overall recurrence rate was 1.8% (n=6), for primary 1.5% (n=4), and 3.3% (n=2) for recurrent hernias; 96.3% of the patients would agree to undergo the same operation a second time. Tension-free repair of the inguinal hernia by the plug-and-patch technique is a quick and secure method that simplifies hernia surgery without compromising the high-quality standards such as a low recurrence rate and low pain load of the patient. Patients had a fast recovery with a subsequent short work leave. The method is a simple, effective, and economical operation, suitable as a standard performed in local anesthesia on an out-patient basis.
Assuntos
Hérnia Inguinal/cirurgia , Próteses e Implantes , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Prospectivos , Recidiva , Reoperação , Telas CirúrgicasRESUMO
Since 1991 Diagnostic Related Groups (DRGs) are systematically developed for standardized operation procedures. They are included in a Quality Management System of the DIN EN ISO 9001 ff. norm and are part of the process system. In additional the internal and external evaluation of quality completes a Modular Quality Management System (MQM). These procedures meet the requirements for a Total Quality Management (TQM).
Assuntos
Honorários Médicos/classificação , Preços Hospitalares/organização & administração , Custos Hospitalares/organização & administração , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Operatórios/economia , Gestão da Qualidade Total/organização & administração , Algoritmos , Controle de Custos/organização & administração , Alemanha , Humanos , Gestão da Qualidade Total/economiaRESUMO
At our hospital, a quality management system was developed according to the DIN EN ISO 9001. Additionally, several quality circles and an external quality control system with three tracer diagnoses were carried out and two studies were performed to detect the internal and external acceptance of the hospital. All strategies induce an increase in the quality of management and of the patients' outcome.
Assuntos
Administração Hospitalar/economia , Participação nas Decisões/economia , Garantia da Qualidade dos Cuidados de Saúde/economia , Gestão da Qualidade Total/economia , Colecistite/economia , Colecistite/cirurgia , Colelitíase/economia , Colelitíase/cirurgia , Controle de Custos , Fraturas do Colo Femoral/economia , Fraturas do Colo Femoral/cirurgia , Alemanha , Hérnia Inguinal/economia , Hérnia Inguinal/cirurgia , HumanosAssuntos
Pinos Ortopédicos , Fixação Intramedular de Fraturas/instrumentação , Fraturas do Quadril/cirurgia , Suporte de Carga/fisiologia , Idoso , Idoso de 80 Anos ou mais , Deambulação Precoce , Feminino , Fraturas do Quadril/mortalidade , Fraturas do Quadril/fisiopatologia , Humanos , Masculino , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Investigations were carried out by means of an autologous, heterotopic model for kidney transplantation applied to dogs. Duration of cold ischemia was 48 h. Four experimental groups were arranged. During the first 20 min following revitalization of the transplanted kidney, group 1 (HTK solution/80 cm perfusion height) showed a significant glomerular and tubular malfunction. In group 2 (HTK solution/120 cm perfusion height), only four urinary proteins with molecular weights of 25 kDa, 67 kDa, 100 kDa and > 100 kDa were found. The excretion of higher molecular proteins receded over the 20-min period of observation. In both group 3 (HTK/aspartate solution) and group 4 (HTK/tryptophan solution) the quantity of excreted glomerular and tubular protein was well above that of group 2. As opposed to the "Tryptophan" group, a complete restoration of renal function was observed in the "Aspartate" group after 4 weeks. In general, the "standard" HTK protective solution delivered with 120 cm perfusion pressure gave the most favorable results, with the lowest levels of proteinuria and a satisfactory recovery of renal function after revitalization.
Assuntos
Transplante de Rim , Proteinúria/urina , Albuminúria/urina , Animais , Ácido Aspártico/farmacologia , Cães , Glucose/farmacologia , Manitol/farmacologia , Peso Molecular , Período Pós-Operatório , Cloreto de Potássio/farmacologia , Procaína/farmacologia , Proteínas/química , Soluções , Triptofano/farmacologiaRESUMO
Investigations of changes in activity of renin and blood pressure after reperfusion of the kidney transplant using HTK solution were carried out by means of an autologous, heterotopic model of kidney transplantation applied to dogs. Duration of cold ischemia was 48 h. According to variations in the composition of the HTK perfusion solution three test groups were set up. During the first 20 min after recirculation in each test group the renal venous and arterial renin activities were measured. Parallel to renin activity, the arterial blood pressure was recorded. During the first few minutes following recirculation of the kidney transplant the renin levels in the venous blood of the kidney were higher in test group 1 (HTK solution, perfusion height 120 cm) than in either of the other two, showing a median maximal increase of 195 ng/ml.h. In test group 2 the maximal venous renin concentration fell to 145 ng/ml.h, while graphs take a more uniform course. Test group 3 (HTK/tryptophan) differed from the others in having further improved renin values. After the 7.5 min of observation normal venous renin concentrations were measured following earlier values for maximal increase between 23.1 ng/ml.h and 120 ng/ml.h (median 61.5 ng/ml.h). The best reperfusion of the kidney was observed in the tryptophan group, albeit without any recognizable positive effects on the other renal functions. Initially low renin values do not necessarily correlate with a smooth postoperative renal function and vice versa. Initial renin values cannot provide a secure basis for predicting instant as well as long-term postoperative functions.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Ácido Aspártico/farmacologia , Pressão Sanguínea/efeitos dos fármacos , Transplante de Rim/fisiologia , Preservação de Órgãos , Renina/sangue , Triptofano/farmacologia , Animais , Pressão Sanguínea/fisiologia , Cães , Glucose/farmacologia , Rim/irrigação sanguínea , Testes de Função Renal , Manitol/farmacologia , Cloreto de Potássio/farmacologia , Procaína/farmacologia , Traumatismo por Reperfusão/fisiopatologia , Transplante Autólogo , Transplante Heterotópico/fisiologiaRESUMO
It is known that HIV can be transmitted by allogenous bone transplantation. Hitherto neither chemical nor physical methods have existed to allow reliable disinfection and sterilization of bone specimens without reducing osteogenetic potency. Only demonstration or exclusion of the presence of HIV-1 in a bone specimen guarantees that infection will not occur. The method now presented for HIV detection is based on a polymerase chain reaction (PCR). This HIV microtiter-plate assay combines amplification of DNA molecules with a staining reaction. In cultures containing HIV-infected cells definite detection of viruses was possible when 50-100 cells per specimen were infected. Examination of 137 HIV-negative and 25 HIV-positive bone specimens showed sensitivity of 96% and specificity of 97.8% for the test. In subsequent studies, after drying on filter paper viral DNA was again demonstrable by the PCR. This means safe handling and uncomplicated transportation of non-infectious specimens to a central analysis laboratory are possible. This HIV test offers the possibility of quick and safe demonstration that specimens are free of HIV and is therefore likely to enhance the safety of bone transplantation considerably.
Assuntos
Transplante Ósseo , Osso e Ossos/virologia , Infecções por HIV/transmissão , HIV-1/isolamento & purificação , Reação em Cadeia da Polimerase/métodos , Infecções por HIV/prevenção & controle , Infecções por HIV/virologia , Humanos , Fatores de Risco , Transplante HomólogoRESUMO
The therapy of fibular ligament ruptures is still a controversial subject. Reports on healing processes following operative or conservative treatment have been verified hitherto by means of clinical examinations and stress tests. The MRT, as a highly sensitive non-invasive method, allows exact documentation of the ligament structures in the ankle joints. This technique was used in a randomized clinical trial over a 6-month period. The 29 patients (ages 17-51 years) had recent ligament rupture [admission criteria: clinical signs of trauma, talar tilt in anteroposterior stress radiographs (15 kp) > or = 10 degrees, talar shift > or = 10 mm] were examined with regard to ligament healing during functional therapy with AIRCAST pneumatic leg braces. Within the first week an MRT was done for verification of ligament injury. Treatment was conservative and functional: lower leg cast for 2 weeks and subsequent mobilization with protection provided by an AIRCAST brace. Follow-up examination was 3 months after injury, taking the form of clinical examination, a-p-radiographs with stress tests, and MRT. In all patients both clinical and radiological examination confirmed that ligament structures had healed, as was also verified by MRT.
Assuntos
Traumatismos do Tornozelo/reabilitação , Braquetes , Ligamentos Articulares/lesões , Imageamento por Ressonância Magnética , Complicações Pós-Operatórias/diagnóstico , Adolescente , Adulto , Traumatismos do Tornozelo/diagnóstico , Feminino , Seguimentos , Humanos , Ligamentos Articulares/patologia , Ligamentos Articulares/cirurgia , Masculino , Pessoa de Meia-Idade , Amplitude de Movimento Articular/fisiologia , Ruptura , Cicatrização/fisiologiaRESUMO
In Germany approximately 150,000 inguinal hernias are surgically corrected every year. In addition to developing an optimum operation technique it is also the responsibility of a surgeon to treat pain during and after surgery. In a prospective random double-blind study, the pain after herniotomy performed with intraoperative anesthesia of the ilioinguinal and iliohypogastric nerves with a long-acting local anesthetic combined with a vasoconstrictor was compared by means of scores on a scale from 1 to 10 with pain in a control group. The results suggest that the intraoperative anesthesia reduces pain after surgery both on the day of the operation and afterwards, when the effect of the local anesthetic has decreased. An optimum pain therapy therefore has to start during surgery. Use of a local anesthetic is especially suitable. Side effects of systemic analgesics are avoided, and perioperative risks of ambulant hernia surgery can be reduced.
Assuntos
Bupivacaína , Hérnia Inguinal/cirurgia , Bloqueio Nervoso , Dor Pós-Operatória/tratamento farmacológico , Adulto , Idoso , Método Duplo-Cego , Humanos , Canal Inguinal/inervação , Masculino , Pessoa de Meia-Idade , Medição da Dor , Nervos Periféricos/efeitos dos fármacos , Estudos ProspectivosRESUMO
ANF is totally filtrated by the kidney and is degradated in the brush border of the tubuli. In an experimental transplant model in dogs excretion of ANF is investigated after a cold ischemia period of 48 h and HTK-protection. The ANF-renin-antagonism was of interest respectively. The experiments demonstrated that the filtration in the glomeruli and the function of the endopeptidases in the brush border is normal after a cold ischemia period of 48 and HTK-protection. There is a linear correlation between the concentration of ANF in the renal vein and the aorta. An antagonism of ANF and renin could not be found. ANF is discussed as an additional ischemia parameter in renal transplantation.
Assuntos
Fator Natriurético Atrial/fisiologia , Taxa de Filtração Glomerular/fisiologia , Transplante de Rim/fisiologia , Preservação de Órgãos/métodos , Animais , Cães , Feminino , Glucose , Masculino , Manitol , Cloreto de Potássio , Procaína , Sistema Renina-Angiotensina/fisiologia , Transplante AutólogoAssuntos
Aneurisma/cirurgia , Divertículo/cirurgia , Doenças do Jejuno/cirurgia , Artéria Esplênica/cirurgia , Idoso , Aneurisma/complicações , Calcinose/cirurgia , Divertículo/complicações , Feminino , Humanos , Doenças do Jejuno/complicações , Jejuno/cirurgia , Esplenectomia , Tomografia Computadorizada por Raios XRESUMO
During her second pregnancy a 27-year-old woman had recurrent acute pancreatitis, in the course of which primary hyperparathyroidism was diagnosed. After regression of the acute signs and under conservative treatment a parathyroid tumour was removed in the 26th week of pregnancy. Comparison of surgical and conservative treatment of primary hyperparathyroidism during pregnancy has indicated that the risk of complications in the neonate is much lower after surgical removal of the adenoma than with an attempt to postpone by symptomatic drug treatment the parathyroidectomy until after delivery.
Assuntos
Hiperparatireoidismo/diagnóstico , Pancreatite/diagnóstico , Complicações na Gravidez/diagnóstico , Doença Aguda , Adenoma/diagnóstico , Adenoma/cirurgia , Adulto , Feminino , Humanos , Hiperparatireoidismo/etiologia , Hiperparatireoidismo/terapia , Pancreatite/terapia , Neoplasias das Paratireoides/complicações , Neoplasias das Paratireoides/cirurgia , Gravidez , Complicações na Gravidez/etiologia , Complicações na Gravidez/terapia , Complicações Neoplásicas na Gravidez/diagnóstico , Complicações Neoplásicas na Gravidez/cirurgia , RecidivaRESUMO
In 110 canine kidneys, we examined the time course of energy rich phosphates, lactate, intrarenal ph and renal morphology with Euro-Collins- or with HTK-protection of Bretschneider and compared these findings with unprotected kidneys during complete ischemia at 1 degree C and at 25 degrees C. Both kidney protective solutions prolonged energy-rich phosphate-decline by a factor of 3-4 compared with that of unprotected kidneys. The lactate increase was greater in Euro-Collins-protected kidneys than in HTK-protected and in unprotected kidneys, leading to pH values of 6.5 in Euro-Collins and to 6.4 in unprotected kidneys after 24 hours, in contrast to a pH-value of 7.3 with HTK-protection. This may be the reason for structural deterioration seen in unprotected and in Euro-Collins-protected kidneys after 12, and 48 h of ischemia at 1 degree C, whereas in HTK-protected kidneys a sufficient preservation of structure can be seen. In one human kidney, protected with Euro-Collins-solution, we were able to show that at 1 degree C intrarenal pH and lactate accumulation is similar to the levels in canine kidneys. In Euro-Collins preserved kidneys lactate accumulation at 25 degrees C is even greater than at 1 degree C, leading to inhibition of energy metabolism and to structural deterioration, whereas HTK-solution, because of its high buffer concentration, is able to maintain ischemic metabolism leading to sufficient protection of intrarenal pH and of adenine nucleotides as well as structural protection at 1 degree C and at 25 degrees C.
Assuntos
Rim , Preservação de Órgãos , Animais , Cães , Feminino , Congelamento , Glucose , Humanos , Soluções Hipertônicas , Rim/metabolismo , Rim/patologia , Transplante de Rim , Masculino , Manitol , Cloreto de Potássio , Procaína , Fatores de TempoRESUMO
In order to find early indicators of kidney transplant rejection before clinical symptoms were noticed, parameters of the coagulation, fibrinolytic and kallikrein-kinin systems were measured. Nineteen patients were followed before and daily after kidney transplantation during the first week and every second day in the following weeks. All patients received immunosuppressive therapy with cyclosporin and corticoids. Ten patients suffered from transplant rejection. The first rejection occurred on the 7th day after transplantation. Of all the parameters measured, kallikrein inhibition, beta-FXIIa inhibition, plasminogen and antithrombin III were early indicators of kidney transplant rejections. A rise in these parameters could be demonstrated 2-3 days before clinical signs were noticed. In the other 9 patients no significant rises in antithrombin III, plasminogen, kallikrein inhibition and beta-FXIIa inhibition could be found.