Technical and clinical success of infrarenal endovascular abdominal aortic aneurysm repair: A 10-year single-center experience.

OBJECTIVE: The aim of our retrospective study was to review our single-center experience with aortic abdominal aneurysm (AAA) repair retrospectively. MATERIAL AND METHODS: From 1995 to 2005, 70 consecutive patients affected by AAA were treated by endovascular stent-graft repair. Mean follow-up was 23.9 months. Follow-up investigations were performed at 6 and 12 months and yearly thereafter. Five different stent-graft designs were compared to each other. Primary technical success (PTS), assisted primary technical success (APTS), primary clinical success (PCS) and secondary clinical success (SCS) were evaluated. RESULTS: All over PTS was achieved in 94.3%, APTS in 97.1%, PCS in 61.4%, APCS in 64.3% and SCS in 70%. There were 3 type I endoleaks, 25 type II endoleaks, 4 type III endoleaks, 8 limb problems, 5 conversions to open surgery, 10 aneurysm sac expansions and 14 device migrations. Patients with newer generation devices showed better results than patients with first generation prosthesis. In addition results were better for grafts with suprarenal fixation (versus infrarenal fixation) and grafts with barbs and hooks (versus grafts without barbs and hooks). Patients with bad anatomic preconditions showed a higher complication rate. CONCLUSION: Contrary to first generation products, new stent-graft designs show acceptable technical and clinical results in endovascular AAA aneurysm repair. However, this therapy still should be reserved only for patients with significant comorbities and suitable anatomic conditions.

A portable shield for a neutron howitzer used for instructional and research purposes.

Neutron howitzers are routinely used in universities to activate samples for instructional laboratory experiments on radioactivity. They are also a convenient source of neutrons and gammas for research purposes, but they must be used with caution. This paper describes the modeling, design, construction, and testing of a portable, economical shield for a 1.0 Curie neutron howitzer. The Monte Carlo N Particle Transport Code (MCNP5) has been used to model the (239)PuBe source and the howitzer and to design the external neutron and gamma shield.

Test-retest reliability of electrophysiological parameters related to cognitive motor control.

Previously, the continuous performance test was demonstrated to elicit distinct electrophysiological correlates of cognitive response during execution (Go) and inhibition (NoGo) of an anticipated motor response. A robust method for topographical quantification of these brain electrical microstates has been established recently. Test reliability is crucial to allow application in the assessment of neuropsychiatric disorders. The present study evaluates the reliability of the Go and NoGo centroid locations as well as the NoGo anteriorisation (NGA) in 23 healthy individuals. Our results show supreme test-alternate retest reliabilities of Pearson's product moment correlations and intraclass correlation coefficients of r> or =0.63 (P< or =0.001) for these parameters which assert a quality well within the range reported for those of other electrophysiological standard paradigms. Go and NoGo centroid locations as well as the NGA are, therefore, reliable correlates of prefrontal motor control and may contribute to the understanding of disorders with allied impairments.

Traumatic pseudoaneurysm of the brachiocephalic artery following medianoscopy: initial endovascular repair followed by open surgery--a case report.

Endovascular stent graft repair of traumatic vessel injuries is gaining worldwide acceptance as a minimally invasive alternative to open surgical repair. However, effective endovascular repair fails if the aneurysm is not completely excluded. Conversion to open surgery may be unavoidable in such cases. Herein we describe the case of a 45-year-old man who was referred to our hospital with a pseudoaneurysm of the proximal brachiocephalic artery caused by biopsy during diagnostic medianoscopy. The pseudoaneurysm was primarily treated by stent-graft implantation into the proximal brachiocephalic artery. As a result of the unfavorable location of the lesion exclusion of the aneurysm failed and the initial therapy had to be extended to open reconstruction of the brachiocephalic artery. A bypass procedure from the aortic arch to the right common carotid artery was performed with reinsertion of the right subclavian artery to exclude the pseudoaneurysm.

Stent-graft repair for acute traumatic thoracic aortic rupture.

Traumatic rupture of the thoracic aorta is potentially life-threatening and leads to death in 75 to 90 per cent of cases at the time of injury. In high-risk patients, as traumatic injuries of the aorta combine with multiple associated injuries, endoluminal repair is now reported as a promising therapeutic strategy with encouraging results. This study determined the outcome of patients with traumatic thoracic aortic injury treated endovascularly during the past 7 years at our institution. Thirteen patients, 11 males and 2 females (mean age, 39 years; range, 19-82), with traumatic rupture of the otherwise unremarkable descending aorta (10 acute, 3 chronic), out of a series of 64 endovascular thoracic stent-graft procedures, were treated by implantation of Talent (n = 8), Vanguard (n = 5), and Excluder (n = 2) self-expanding devices between January 1996 and August 2003. The immediate technical success rate was 92 per cent (12/13). One patient showed a proximal endoleak type I, which was treated successfully by an additional stent-graft procedure. Secondary success rate was 100 per cent. The mortality rate was 0 per cent. Two additional stent-graft procedures were performed due to type I endoleaks after 18 and 28 months. There was no other intervention-related morbidity or mortality during the mean follow-up time of 26.4 months' (range, 6-86). Endovascular stent-graft repair of traumatic thoracic aortic injuries is a safe, effective, and low-morbidity alternative to open thoracic surgery and has promising midterm results.

Clinical and objective data on spinal cord stimulation for the treatment of severe Raynaud's phenomenon.

Ischemic vascular disease of the upper extremity represents a difficult therapeutic problem wherein medical treatment often fails. Epidural spinal cord stimulation has been shown to be an effective alternative in severe peripheral arterial disease. Although this method has been used for nearly two decades only limited experience exists in Raynaud's phenomenon of the upper limbs. In addition objective parameters to prove therapeutic success are not well defined. Herein we describe a patient with severe primary Raynaud's phenomenon over several years who had significant pain relief and complete healing of ischemic digital ulcerations after spinal cord stimulation. Pain level was evaluated using a visual rating scale before and after surgery. Microcirculatory parameters were assessed before and after spinal cord stimulation by capillary microscopy and laser Doppler anemometry. Significant improvement of red blood cell velocity, capillary density, and capillary permeability was demonstrated. At follow-up 18 months after surgery the patient had no complaints and all ulcerations of her fingertips had healed. Spinal cord stimulation appears to be an effective treatment in severe cases of Raynaud's phenomenon and we recommend its use in the case of failed medical therapy. Pain rating and capillary microscopy enable one to assess and visualize the effects of spinal cord stimulation.

Changes in P300 latency and amplitude in schizophrenic patients and healthy controls during the examination.

In 30 schizophrenic patients (sixteen of the paranoid subtype, 14 of the nonparanoid) and healthy controls (n = 30) event-related potentials were obtained with a somatosensory reaction-time (RT) version of the "oddball paradigm" by stimulating the right (first run) and the left (second run) median nerve. Variations of P300 amplitude and latency and of RT within the average (30 trials) were studied by fractionating off-line the original averages in three subaverages. After stimulation of the right median nerve oscillations on P300 amplitude and latency were observed. After stimulation of the left median nerve there was a trend toward a decrease of the P300 amplitude that reached significance at the electrode P3 for patients (p = 0.014) and at the electrode P4 for controls (p = 0.025). The P300 latency showed variations for patients and controls. The mean-RT was prolonged across the subaverages only for schizophrenics, reaching significance after stimulation of the right median nerve. Paranoid and nonparanoid schizophrenic patients showed similar results on P300 and RT parameters across the subaverages. These results are discussed in terms of the influence of motivation and task involvement on the P300 amplitude. These could be unspecific factors that account for the habituation of the P300 along the examination.

Functional relationship between brain regions in schizophrenia evaluated with Pearson's correlation between event-related potentials.

As part of a study of the somatosensory P300 event-related potential (ERP) in paranoid and nonparanoid schizophrenic patients (8) Pearson's product-moment correlations between ERP waveforms were calculated to study the functional relationship between brain areas. ERP were recorded from F3, F4, P3 and P4; interhemispheric (F3 to F4; P3 to P4) and intrahemispheric (F3 to P3; F4 to P4) correlations were obtained. There was no significant difference among the paranoid and nonparanoid patients and healthy controls for both the interhemispheric and the intrahemispheric correlations. The lack of disruption of functional relationship between brain areas on the patients do not support the hypofrontality and the laterality hypothesis of schizophrenia. However, the use of neuroleptics by the patients, the study of the whole waveforms and not parts of them and the use of linked-ears reference could account for these negative results.

[Treatment strategies for gastroesophageal reflux disease]. / Strategien zur Behandlung der gastroösophagealen Refluxkrankheit.

Gastroesophageal reflux disease (GERD) is a very common disorder. Therapeutic options include lifestyle modifications, medical therapy, laparoscopic antireflux surgery, and three more recent options-injection therapy to the lower esophageal sphincter, endoscopic sewing procedures, and radio frequency ablation therapy. Medical therapy is effective in most patients but not always successful with advanced disease. Up to 70% of subjects do not have adequate nocturnal control of gastric acid secretion with 20 mg of omeprazole given twice per day. Patients who do not tolerate medical therapy, who respond inadequately, or who want to avoid life-long drug therapy are candidates for alternate treatments. Studies on endoscopic procedures such as polymethylmethacrylate (PMMA) injection, the Stretta procedure,and endoscopic suturing techniques all suffer from having small study groups for each procedure,unknown durability, short follow-up, and the absence of randomized, controlled procedures. Limitations on endoscopic techniques are esophageal motility disorders, severe esophagitis, and larger hiatal hernias. Laparoscopic antireflux surgery remains a well-established, durable alternative to long-term medical therapy. It has the benefits of convenience, safety, minimal complications, improved quality of life, and low cost. Alternative methods will have to earn their place against this gold standard.

Placement of endovascular stent-grafts for emergency repair of acute traumatic aortic rupture: a single-centre experience.

The aim of this retrospective study was to evaluate mid- and long-term results of endovascular stent-graft placement for emergency repair of acute traumatic thoracic aortic rupture. From 1996 through 2005, 22 consecutive patients (mean age: 38.7 years) underwent endovascular repair of acute traumatic thoracic aortic rupture located at the aortic isthmus in most cases. All patients were at high surgical risk due to severe associated injuries. The endografts were inserted via femoral or iliac artery access under fluoroscopic guidance. Follow-up was performed postinterventionally, at 6 and 12 months and yearly thereafter, and included clinical examination and computed tomography (CT) scans. Technical and clinical success rates were 86.3%. Mean follow-up was 31.7 months. Three patients developed early type I endoleak due to the inability of the rigid graft to adapt to the curved aortic contour. In two of them conversion to open surgery was necessary. One patient had late type I endoleak and died. No other complications were observed. The outcome was successful in most patients. The mid- and long-term results of our current study are promising. However, early type I endoleak represents a problem, especially in adolescent patients with a marked curvature of the aortic arch.

Somatosensory event-related potentials and selective attention impairment in young chronic schizophrenics.

Somatosensory event-related potentials (SERP) were recorded in 30 chronic young schizophrenic patients and in 15 age-matched controls. Objective SERP parameters were latencies, amplitudes and the determination of areas of the cognitive components N1 and P3 by integration. Highly significantly reduced areas and prolonged latencies of the N1 component and significantly prolonged reaction times (RT) discriminate schizophrenics in psychopathological remitted state from controls. A significant correlation between decreased N1 areas and prolonged RTs (p less than 0.01), respectively high self-rating subscores 'disturbance of selective attention' (p less than 0.05) can be found only in the SERPs of the left hemisphere. Nevertheless, a reduced N1 area cannot be interpreted as an indicator of vulnerability for schizophrenia, but only for selective attention impairment.

Laparoscopic reoperation after failed antireflux surgery.

INTRODUCTION: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated. PATIENTS: One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients). RESULTS: Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall. CONCLUSION: Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure.

[Normative aspects of somatosensory evoked P300 components]. / Normative Aspekte der somatosensorisch evozierten P300-Komponente.

Using a somatosensory version of the oddball-paradigma the influence of age and gender on the P300-component and the comparison of the potential after stimulation of the right and left median nerve was studied in 30 healthy right handed volunteers (age: 20-35 years). Latency, amplitude, area and duration of the P300-potential were analysed. No relationship between age, gender and the P300-parameters were observed. The amplitude and the area of the potential obtained from the F3 electrode were greater after stimulation of the right median nerve compared to the potential after stimulation of the left median nerve. All other results were not significantly different. Strong positive correlations between the results after stimulation of the right and left median nerve were observed. These results showed that by a young group of volunteers age and gender did not influence the P300-component. Although the P300-Parameters had a between-subject variability, their mean remained constant over the study, their correlation coefficients were strong positive and the side of stimulation did not influence them (except for the electrode F3).

[Electromyographic studies on the masticatory muscles after the preparation of terminal molars as denture abutments]. / Elektromyographische Untersuchungen an der Kaumuskulatur nach Präparation endständiger Molaren als Brückenpfeiler.

When the occlusal surfaces of terminal molars are ground off during bridge preparation, the occlusal support for the condyle of the affected side disappears and thus the intermaxillary distance declines. The effect of this process on the masticatory muscles was examined electromyographically in nine patients. It was found that the muscle activity especially in the m. temporalis is immediately reduced by 30 to 40%.

[Elementary electromyographic analysis and motion patterns of the myoglossus muscle]. / Elementare elektromyographische Analyse und Bewegungsmuster des M. myloglossus

In five fully dentulous and one edentulous patient, the m. myloglossus was examined by means of concentric needle electrodes and implanted wire electrodes. It was not possible to achieve absolute inertia with the conductors. The individual potentials of motoric units are bi- and triphasic. The duration was 3 to 5 msec, and the amplitude was 200 to 800 muvolt. The portion of polyphasic potentials is about 5%. With moderate innervation the discharge frequency is 2 to 8/sec. With maximum innervation, interference activity is observed. Kinetic studies showed that the m.myloglossus acts as typical antagonist in lateral tongue movements and as synergist when raising tongue and throat. From these findings conclusions may be drawn with regard to prosthetics.

Nipple complication caused by a mesenteric GORE-TEX sling reinforcement in a Kock ileal reservoir: report of a case.

INTRODUCTION: The surgical trend after proctocolectomy at present is to perform a pelvic pouch reservoir with an ileoanal anastomosis. Before that a continent ileal Kock pouch was the procedure of choice, which enabled the patient to collect the intestinal discharge for several hours and avoid involuntary escape of reservoir contents, thus making the wearing of plastic bags unnecessary. Although in the majority of patients an increased life quality can be observed, different complications with a Kock pouch may occur. METHODS: We present a case of a young female with signs of outlet obstruction several years after a Kock reservoir was performed because of complicated ulcerative colitis. The obstruction was caused by a fecal-coated GORE-TEX sling that had penetrated through the nipple-valve base into the pouch. The mesenteric sling was introduced as a modification of the original Kock procedure to reinforce the efferent ileal segment, thus preventing nipple prolapse. The perforation site was closed with interrupted sutures and an ileostomy was performed. RESULTS: Three months thereafter, the ileostomy was closed and at a follow-up visit one year later the patient had no complaints and a well-functioning reservoir. CONCLUSION: If continence is desired after definitive ileostomy or if failure of the ileoanal reservoir occurs, a Kock pouch procedure still has a place in the surgical armamentarium of colorectal surgery. Many experts today do not use sling reinforcement maneuvers, and most of these procedures seem to work well without it.

[Effectiveness of locoregional rt-PA lysis in acute leg and arm vein thrombosis]. / Wirksamkeit der loko-regionalen rt-PA-Lyse bei Bein- bzw. Armvenenthrombose.

39 patients suffering from a thrombosis of the peripheral venous system were treated with a loco-regional lysis, using rt-PA. Two cycles of 40 mg rt-PA a day were applicated by means of a special drainage-management, using perforans veins. During lytic therapy, 20,000 to 30,000 IE of unfractionized heparin were additionally administered. Laboratory work including aPTT and fibrinogen measurement was performed every 8 hours. Additionally a phlebography was performed after 24 hours. Patients received an anticoagulative therapy using sintrom or marcumar the following 3 months. We obtained a successful thrombolysis without any major complications in 90%. Minor complications included 3 peripheral pulmonary embolisms. Duplex sonographic and plethysmographic follow up was performed in 25 patients one year after operation. In two patients with ankle edema insufficient valves at the popliteal vein were found with both diagnostic modalities. 23 patients showed no signs of insufficient valves neither clinically nor at duplex sonography and plethysmography. The locoregional lysis appears to be an effective method for the treatment of acute peripheral vein thrombosis.

Neuropathic pain after femoropopliteal bypass surgery.

OBJECTIVE: This retrospective study was performed to investigate prolonged postoperative pain in the area of the proximal or distal scar or the bypass tunnel after femoropopliteal bypass surgery to treat symptomatic peripheral arterial disease. PATIENTS AND METHODS: Ninety-three patients with peripheral arterial disease who underwent femoropopliteal bypass surgery between January 2000 and December 2002 were included in the study. The short-form McGill Pain Questionnaire was used to score pain. Ultrasound examination of the soft tissue around the graft was performed to exclude other pathologic conditions responsible for pain, such as inflammatory processes, perigraft reactions, swollen lymph nodes, and hematomas. RESULTS: Pain in at least one scar existed in 22 patients on average 13.9 +/- 9.8 months after surgery. In 10 patients pain existed simultaneously along the inguinal scar and the above-knee or below-knee scar. Pain along the bypass tunnel was experienced by seven patients. Most patients had mild to moderate pain. The mean numeric ranking score of pain severity in patients with pain was 4.2 +/- 2.3. The occurrence of prolonged postoperative pain was not associated with age, gender, diabetes, indication for surgery, material or type of bypass, number of preceding operations, or postoperative wound complications. Only follow-up time after femoropopliteal bypass surgery tended to be lower in patients with pain compared with those without pain. CONCLUSION: Prolonged postoperative neuropathic pain along the distal and proximal incision or the bypass tunnel exists in one fourth of patients after femoropopliteal bypass surgery. Patients should be informed of this kind of complication before surgery. The results of our study justify further investigations of the origin and treatment of this pain, to find effective methods to reduce the incidence of prolonged postoperative pain after femoropopliteal bypass surgery.