[Traumatic lesions of the brachial plexus : Clinical symptoms, diagnostics and treatment]. / Traumatische Läsionen des Plexus brachialis : Klinische Symptome, Diagnostik und Therapie.

Brachial plexus lesions mostly occur in young patients as a result of high-speed accidents. They are often diagnosed and treated after a delay. This has been shown to worsen the prognosis of surgical reconstructions evidently. In 70-80% of traumatic lesions functional reinnervation can be achieved by various surgical procedures. An early sufficient diagnosis and the subsequent referral of the patient to an appropriate competence center for consultation and, if necessary, surgery are therefore essential.

Memory deficits in subsyndromes of chronic schizophrenia.

Recent psychopathological studies consistently identified a delusional, a negative, and a disorganized subsyndrome in chronic schizophrenia. The aim of the present study was to investigate these subsyndromes with respect to declarative, procedural and working memory deficits. While the delusional subsyndrome was associated with an impaired delayed recognition, the negative subsyndrome showed a marked deficit in delayed recall. In addition, the delusional and the negative subsyndrome shared procedural memory changes. The disorganized subsyndrome was associated with neurological soft signs and a poor working memory performance. These results do not seem to be effected by severity of illness, degree of chronicity, nor attentional deficits. Our findings support the differentiation of three subsyndromes in chronic schizophrenia and suggest that memory impairment in schizophrenia may reflect the involvement of different memory systems rather than an unspecific, global deficit.

The surgical trauma of abdominal wall incision. A comparison of laparoscopic vs open surgery with three-dimensional stereography.

BACKGROUND: Laparoscopic operations seem to respect the integrity of the abdominal wall better than conventional laparotomy, but the effects of surgical trauma are not well understood. The new technique of three-dimensional stereography makes it possible to describe and calculate the mobility of the abdominal wall and the nature of the underlying disturbances. METHODS: Three-dimensional stereography is a noninvasive optical method of measuring surface areas. Abdominal wall mobility can be assessed by comparing changes to the abdominal surface in its minimum and maximum excursions. Different parameters, such as height difference and curvature, are calculated. We studied patients undergoing different types of surgical procedures (laparoscopy and open surgery) by measuring their abdominal wall mobility before and after the procedure. We also compared these patients to a control group. Each group consisted of 30 patients, who were evaluated prospectively. RESULTS: We found a significant difference in abdominal wall mobility between patients treated via a laparoscopic approach, and those who had conventional surgery. At 7 days after laparoscopy, abdominal movement was always the same in the laparoscopic group as in the controls. By contrast, the open surgery group still showed a significant lack of mobility 12 days after the procedure. CONCLUSION: The new method of three-dimensional stereography makes it possible to compare the trauma associated with different surgical approaches as it affects the integrity of the abdominal wall. As compared with open surgery, laparoscopy has a significant positive effect on abdominal wall integrity.

Is laparoscopic cholecystectomy a mature operative technique?

BACKGROUND: More than 10 years after its introduction, laparoscopic cholecystectomy has become the method of choice for the treatment of cholecystolithiasis. However intraoperative difficulties with dramatic postoperative consequences have been reported. The aim of this study was to identify what role the two-dimensional view, the surgeon's experience, the instruments, technical tools and their (time) influence exercised on the operation course in daily laparoscopic operations. METHODS: The operative times for 30 laparoscopic cholecystectomies were investigated by ergonomic sequence analysis and analyzed statistically with the use of the Wilcoxon test. RESULTS: Comparing experienced and less experienced surgeons, a significant difference in the duration of the operation was observed (56 +/- 24 min compared to 75 +/- 13 min p = 0,025), especially in the laparoscopic intra-abdominal phase of the operation. The prolonged duration of the operation (15-20%) was mainly due to problems with the technical tools (40%) and the use of instruments (23.5%). Visualization had a minor influence (14.4%) on the duration of the operation, and the negative effect of the two-dimensional view (0.5%) was negligible. The last two factors did not cause any complications. CONCLUSIONS: The recognized difficulties still cause a loss of time and in some cases complications, which can only partly be compensated by the surgeon's experience. This leads to reluctance in the application of laparoscopic cholecystectomy in more complicated stages of the disease. Two-dimensional view satisfies the surgeon's demands for a safe procedure.

Shorter postoperative atony after laparoscopic-assisted colonic resection? An animal study.

BACKGROUND: The duration of the postoperative ileus after laparoscopic surgery remains a controversial topic. The aim of our study was to compare the restoration of intestinal motility after laparoscopically assisted and conventional resection of the distal colon in a canine model. METHODS: Two weeks after the implantation of three electrodes on the jejunum, the distal colon was resected in a laparoscopic-assisted or conventional procedure in two groups of four dogs each. Gastrointestinal motility was monitored by registration of the electromyograhic activity of the small intestine and by intermittent fluoroscopies of radiopaque markers. RESULTS: Electrical activity in the early postoperative period was characterized by the basic electrical rhythm and the absence of spike activity. The first postoperative activity front of the migrating motility complex (MMC), indicating the restoration of motility, occurred significantly earlier after laparoscopic-assisted resection (4.5 +/- 1 hr) than after conventional resection (31 +/- 10 h). Radiological observations showed a significantly delayed gastric emptying and a prolonged transit of radiopaque markers to the rectum after open surgery. CONCLUSION: These results support the hypothesis that laparoscopic-assisted resection of the colon leads to a shortened postoperative atony in comparison to open surgery.

Temporary closure of the abdominal wall (laparostomy).

The definitive closure of the abdominal wall, i.e., a closure of the fascial layer and skin may not be favorable in the treatment of numerous surgical conditions, e.g., peritonitis, trauma, or mesenteric ischemia. In these cases, the abdominal wall is temporarily closed, and a laparostomy is created to facilitate re-exploration or to prevent abdominal compartment syndrome. Regarding the technique and material used for the temporary closure, no prospective randomized data exists, but mesh materials are commonly used. They provide drainage of infectious material, permit visual control of the underlying viscera, facilitate access to the abdominal wall, preserve the fascial margin, enable healing by secondary intention, and allow mobilization of the patient. In the case of decreasing intra-abdominal pressure, meshes can be trimmed to centralize the rectus muscle and to facilitate definitive closure. Non-absorbable meshes have been frequently reported to cause enteric fistulae and persistent infection necessitating mesh explantation. While these infectious complications appear to occur less frequently with the use of absorbable materials, these meshes will finally lead to an incisional hernia, requiring repair with non-absorbable mesh after a period of 6-12 months. Nevertheless, in the complex situation requiring a temporary abdominal wall closure, use of absorbable mesh material is common and represents the state of the art.

[Laparoscopic surgery: expectations and reality]. / Laparoskopische Chirurgie: Erwartungen und Realität.

Despite the rapid development and widespread application of laparoscopic operation techniques, only laparoscopic cholecystectomy and laparoscopic fundoplication have replaced the open operations as standard techniques. Nowadays only about 10% of appendectomies and 25% inguinal hernias are performed by the laparoscopic approach. Colorectal operations are rarely performed laparoscopically. Demanding operative skills and uncertainty about the oncological quality have hindered the spread of laparoscopic colorectal resections. Studies at specialized centers have shown that it is possible to follow the principles of oncological surgery. First results of small series promise similar long-term results, but large prospective randomized trials are still unpublished. Depending on the extent of the operative procedure, laparoscopic operations result in reduced postoperative pain, fewer adhesions, shortened postoperative atonia and improved convalescence in comparison with open surgery. The direct costs of laparoscopic procedures are higher than open operations as a result of longer operation times and expensive equipment. As a result of shorter hospitalisation and quicker return to work, the overall health care costs may be reduced, but strong unbiased evidence is still lacking.

[Video thoracoscopic therapy of spontaneous pneumothorax. Technique and initial results]. / Videothoracoskopische Therapie des Spontanpneumothorax Technik und erste Ergebnisse.

The acceptance of operative therapy of spontaneous pneumothorax (SPT) has been tempered by the serious trauma of thoracotomy access. Development of videoequipment and miniaturized instruments allows now a thoracoscopic resection of bulla with minimal access. 25 patients with recurrent SPT (n = 15), primary resistant SPT (n = 5), and first SPT (n = 5) were treated from January 1991 thoracoscopically. Bullae resection was performed with an Roeder ligature or an Endo-GIA. Pleurodeses was induced by mechanical irritation or coagulation of the upper thoracic aperture with the argon beamer. Postoperative lung reinflation was rapid and without patchy collapse. The analgetic drug demand was dramatically reduced and patients were mobilised on the 1st postoperative day. Patients were discharged on the 4th postoperative day. Major complication were one hematothorax and one recurrence of SPT. The advantages of the thoracoscopic surgical treatment are rapid full expansion of the lung, decreased postoperative pain, short postoperative hospital stay and early return to normal activity.

[Assisted death in daily surgical practice--an interdisciplinary discussion with examples]. / Sterbehilfe im chirurgischen Alltag. Eine interdisziplinäre Diskussion anhand von Falldarstellungen.

New laws for assisted patient death in The Netherlands and Belgium have resulted in animated discussion about the permissibility of the practice in Germany. Physicians here are being confronted more and more by patients and their relatives with the wish for assisted death. Polls confirm that the majority of this population supports active death assistance, whereas doctors reject it. At a symposium in October 2002 (Clinically Assisted Death and Human Dignity-A Dutch-German Dialogue), case studies illustrating this question were presented. The present study compiles viewpoints of physicians, ethicists, theologians, jurist, politicians, and journalists.

Defecation mechanisms after anterior resection with J-pouch-anal and side-to-end anastomosis in dogs.

BACKGROUND: Colonic J-pouch-anal anastomosis or colonic side-to-end anastomosis is the reconstruction of choice after low anterior resection. However, the mechanisms of defecation after both reconstruction forms are still speculative. METHODS: Low anterior rectal resections were performed in 12 dogs with six colonic J-pouch-anal (pouch) and six coloanal side-to-end (SE) reconstructions. Four months postoperative stool frequency, intestinal transit time, and neorectal compliance were determined by radiography and barostat. Defecation mechanisms were evaluated radiographically during expulsion of artificial stool. RESULTS: One dog with pouch reconstruction could not be evaluated due to an anastomotic leak, while the others had uncomplicated course. Spontaneous stool frequency was significantly increased with both reconstruction methods (control 2.0+/-0.9, pouch 2.7+/-1.2, SE 3.3+/-0.9 day; p<0.05). Intestinal transit time was significantly higher with pouch reconstruction due to storage of stool in the pouch and the descending colon compared to SE (control 760+/-82, pouch 592+/-97, SE 550+/-87 min; p<0.05). Compliance and functional capacity were higher in pouch than in side-to-end reconstructions (pouch 5.0+/-0.7 ml/mmHg, 124+/-23 ml; SE 2.7+/-0.3 ml/mmHg, 92+/-24 ml; p<0.05). During defecation, there were no contractions of the pouch detectable. CONCLUSIONS: The colonic J-pouch reconstruction results in better functional outcome than side-to-end coloanal anastomosis. Our results show that pouch evacuation is passive and independent from pouch motility. The functional principle of the colonic J-pouch is not its reservoir function but a delay of colonic motility.

Evaluation of anastomotic microcirculation after low anterior rectal resection: an experimental study with different reconstruction forms in dogs.

BACKGROUND: Data on anastomotic microcirculation of coloanal anastomoses are contradictory. Therefore, it was the aim of the present study to investigate perianastomotic blood perfusion in a standardized experimental setting comparing three forms of reconstruction using laser fluorescence videography, a new method for the evaluation of microcirculation. METHODS: After a standardised rectal resection in dogs, reconstruction was performed as straight end-to-end (n = 6), side-to-end (n = 6), or J-pouch (n = 6) coloanal anastomosis. Bowel perfusion was evaluated using IC-View laser fluorescence videography. RESULTS: The perfusion index was significantly reduced in all three groups compared to the reference regions: endto-end anastomosis, median, 93% (range, 63%-136%); side-to-end-anastomosis, 65% (35%-138%); colonic-J-pouch anal anastomosis, 52% (32%-72%); p < 0.001). CONCLUSIONS: Straight coloanal anastomoses provide better anastomotic microcirculation after rectal resections than colonic-J-pouch anal anastomoses or side-to-end anastomoses. However this effect does not seem to be decisive for the prevention of anastomotic leaks.

[Ambulatory surgery interventions in childhood in a surgical clinic]. / Tageschirurgische (TCH) Eingriffe im Kindesalter an einer chirurgischen Klinik.

Between Jan. 1, 1980 and Dec. 31, 1990 1 688 children underwent One-Day-Surgery at the Surgical Department of the Rhenish-Westfalian Technical University. More than 85% of the operations were inguinal hernias (n = 765), phimoses (n = 324) and umbilical hernias (n = 185). The children's age ranged from 3 months up to 14 years. 27 patients (1.6%) could not be dismissed at the same day because of early complications. Two postoperative hemorrhages after circumcision led to readmissions and reoperation. More than 90% of the parents and 85% of the pediatrists were satisfied with the One-Day-Surgery. A responsible and successful One-Day-Surgery needs qualified surgeons, a well defined organizational structure and the observance of forensic problems.

[Jejunogastric invagination--a rare complication of stomach surgery]. / Die jejunogastrische Invagination--eine seltene Komplikation der Magenchirurgie.

The jejunogastric intussusception is a rare complication of gastric surgery. An acute and a chronic form of intussusception can be distinguished. Three anatomical types of jejunogastric invagination have been classified. Endoscopy is the diagnostic procedure of choice, early operative desinvagination the therapy of choice. The effectiveness of different operative procedures to prevent reinvagination is contested.

[Interrupted suture versus adhesive dressing in skin closure of pediatric inguinal hernia--a controlled randomized prospective study]. / Einzelknopfnaht versus Klebung beim Hautverschluss der kindlichen Leistenhernie--eine kontrollierte randomisierte prospektive Studie.

The skin closure with resorbable interrupted sutures (Dexon 6x0) was compared with adhesive plasters (Leukostrip) in a randomized prospective clinical trial with 100 children with an inguinal hernia. The same operative technique was used in both groups. There were no significant differences referring to the complication rates and the cosmetic results between both groups. Skin closure with adhesive plasters significantly saved operation-time and reduced costs. It can be recommended in cases of infantile inguinal hernias.

[Results of surgical therapy of choledocholithiasis--a retrospective study]. / Ergebnisse der chirurgischen Therapie der Choledocholithiasis--eine retrospektive Studie.

A multimodal therapeutic concept of choledocholithiasis with endoscopic and surgical procedures is presented. Between January 1986 and December 1990 106 patients with choledocholithiasis were operated. These patients are retrospectively analyzed. The success rate is 95.3%, the morbidity 18.7% and the mortality 0. These results are compared with the published data of the surgical or endoscopic therapy of the choledocholithiasis.