[Intraoperative consulting. An easy addition to the surgical safety checklist for perioperative quality assurance]. / Intraoperatives Controlling. Einfache Ergänzung der Checkliste zur perioperativen Qualitätssicherung.

BACKGROUND: It has been proven that pre-operative and postoperative surgical safety checklists designed to improve team communication and consistency of care are useful tools to improve surgical outcome. The aim of this study was to investigate the effectiveness of intra-operative consultation (IOC) with regard to its feasibility. IOC comprises an assessment of definite pathways in the operative procedure by another surgeon present in the operating theatre in a consultative capacity during specific steps of the operation. METHODS: Between January and December 2008 a total of 2,004 operations were evaluated according the IOC. Data on the frequency of the feasibility of IOC and on whether IOC led to decisions influencing the course of the procedure were analyzed. RESULTS: A total of 1,369 IOCs were carried out including regular IOC in 1,102 cases (80%) and tactical IOC in 267 cases (20%). In 90 cases (7%) consultation resulted in minor changes and in 100 cases (7%) major clinically relevant revision of the operative strategy was deemed necessary. CONCLUSION: It was found that IOC is feasible in the majority of operations. In the case of tactical IOC a large number of treatment-relevant decisions are taken. This means that in the area of operative disciplines IOC represents a potential preventive strategy within the framework of quality management and a useful addition to the WHO checklist to improve safety in surgery.

[Peritonitis: attempt to evaluate therapeutic surgical options]. / Chirurgische Therapieoptionen bei Peritonitis : Versuch einer Wertung.

The choice of optimal concept in the therapy of severe peritonitis is essential to outcome. In approximately 10-15% of patients suffering severe peritonitis, single-stage surgery is not sufficient and additional operative therapy is required. Different therapeutic strategies such as the open-package procedure, staged abdominal repair, and on-demand relaparotomy have been developed for these situations. However, it is difficult to compare the effectiveness of each regimen because stratification tools are lacking. This paper describes advantages and disadvantages of the various therapeutic options in peritonitis and their clinical implementation.

Percutanous and intraoperative ultrasound-guided radiofrequency ablation of hepatic tumours.

PURPOSE: Ultrasonography (US)-guided Radiofrequency ablation (RFA) is increasingly used to treat liver tumours. The aim of this study was to evaluate the impact of multidisciplinary patient selection on clinical results. MATERIALS AND METHODS: From January 2002 to December 2004, 69 consecutive patients with malignant hepatic tumours were presented to our clinic for RFA-treatment. After a multidisciplinary tumour board decision, 33 patients (47.8%) with 70 liver tumours underwent RFA using a 14-gauge needle electrode via a percutaneous (26) or surgical (7) approach, either alone or combined with resection (3) or chemoembolisation (3). 36 patients (52.2%) were excluded from RFA treatment, mainly because of extensive disease or failure of prior chemotherapy. With a median of 20 months (range 6 - 42 months), all 69 patients were followed clinically to assess survival, and the 33 patients who received additional treatment were examined by contrast-enhanced CT to assess local success. RESULTS: Complete necrosis was obtained in 64/70 of ablated tumours (91.4%).The corresponding mean sizes (ranges) of lesion vs. necrosis achieved were 2.3 cm (0.9 - 5.0) vs. 3.7 cm (2.1 - 5.7). Two complications (6.6%) occurred, including one liver abscess and one postablational syndrome. At the time of the tumour board decision, the RFA (33) and non-RFA (36) group differed in mean sizes of tumours (2.3 vs. 3.5 cm), average tumours per patient (2.1 vs. 3.8), and failure of prior chemotherapy (2/33 vs. 22/36). From 36 patients judged to be ineligible for RFA, 24 (66.6%) underwent RFA at another institution. When comparing survival of patients who underwent RFA at our institution (33) vs. those who underwent RFA outside (24) vs. those who underwent no RFA (12), 1/33 (3%) vs. 9/24 (37.5%) vs. 8/12 (66.6%) died within 6 month and 27/33 (81.2%) vs. 5/24 (29.2%) vs. 2/12 (16.7%) were alive after 20 months median follow up. CONCLUSION: US-guided RFA offers a safe local treatment option to destroy small liver tumours (< 3 cm). Carefully and multidisciplinary selected patients may derive benefit, but uncritical application leads to unsatisfying clinical results.

[Mucocele of the appendix. Incidental sonographic discovery and laparoscopic resection]. / Mukozele der Appendix. Sonographischer Zufallsbefund und laparoskopische Resektion.

HISTORY AND ADMISSION FINDINGS: A 76-year-old currently asymptomatic man was admitted for routine sonography of the abdomen. 15 years he had had intermittently symptomatic cholecystolithiasis. 25 years before a colon contrast showed a normal coecum but no filling of the appendix. SUBSEQUENT INVESTIGATION: Sonographic examination showed the known cholecystolithisasis but additionally revealed as an incidental finding a tubular-cystic structure with a thin, echogenic wall and a hypoechogenic lumen. The lesion was located in the right upper quadrant, not compressible and arising from the coecum. Computed tomography confirmed a mucocele of the appendix without ascites and no inflammatory changes, peritoneal thickening or nodules. TREATMENT AND COURSE: Laparoscopic resection of the unruptured appendiceal mucocele together with cholestectomy was performed. On gross examination, the resected mucocele proved to be macroscopally an intact mass with a thin wall and full of white gelatinous material measuring 3 cm in diameter and 8 cm long. The histologic diagnosis was mucinous cystadenoma. The patient was discharged on the second postoperative day and recovered uneventfully. Because of the clear association of appendiceal cystadenoma with colorectal tumor a colonoscopy was performed which showed a normal colon. CONCLUSION: The differential diagnosis of a cystic mass in the right lower quadrant without previous appendectomy should include an appendiceal mucocele. If preoperatively there are no signs of malignancy, laparoscopic resection can be performed. In patients with histologic diagnosis of appendiceal cystadenoma: the colon should be examined to exclude synchronous colon tumors.

[Myocardial ischemia in hypertensive patients]. / Myokardischämien bei Hypertonikern.

AIM: To examine the frequency of myocardial ischemia in hypertensive patients with insufficiently adjusted blood pressure. It was to clarify the question if there is a difference between hypertensives with silent ischemic episodes alone and hypertensives with symptomatic episodes as well, referring to the degree of severity of ischemia. A resulting question was: if there is a difference between them, might it be possible to influence this by lowering the blood pressure? PATIENTS AND METHODS: 104 hypertensive patients had a check-up before and after the suspension of normotensive blood pressure by means of a 24-hour long-term ECG. Significant results for a myocardial ischemia were horizontal and descending ST segment depression > or = 0.1 mV for the duration > or = 1 min. RESULTS: 38 of the examined hypertensives showed 316 silent and 19 symptomatic episodes of myocardial ischemia. Hypertensives with additionally symptomatic episodes (n = 8) showed a severity of ischemia (ST-total area) which was significantly higher than in patients with only silent episodes (9.3 [2.7-65.3] mV min vs 2.6 [0.1-42.6] mV min, p < 0.05). After reduction of the blood pressure these patients as well as patients with silent episodes a lone (2.6 [0.1-42.6] mV min vs 0 [0 to 39.3] mV min, p < 0.0001) were found to have a decline of the ST-total area (9.3 [2.7-65.3] mV min vs. 0 [0-46.5] mV min, p < 0.05). There was no significant difference between them any longer. CONCLUSION: The severity of ischemia in insufficiently adjusted hypertensive patients with additionally symptomatic myocardial ischemia is higher than in the case of patients with silent episodes alone. After reaching a normotensive blood pressure again a difference was no longer evident.

[Surgical therapy of abdominal infection--reliable strategies]. / Operative Therapie bei abdomineller Sepsis--Bewährte Strategien.

The differential treatment of abdominal sepsis is based on surgical eradication of the infectious focus, intensive care, and administration of antibiotics. The eradication of the focus can be done by interventional or operative procedures. Between January 1980 and December 2000, 2214 patients with peritonitis were treated in AK Hamburg-Altona. A total of 1520 cases were successfully treated by standard therapy; 694 cases needed treatment by staged lavage. The postoperative mortality in this group was 17.3%. Objective comparison is difficult because of diversity of patient groups and the complexity of chosen surgical therapy. Therefore none randomized clinical study does exist up to the present. Indication and application of selected therapeutic technique result from clinical criteria and experience.

Low-density lipoprotein receptor-related protein in atherosclerosis development: up-regulation of gene expression in patients with coronary obstruction.

The low-density lipoprotein receptor-related protein (LRP) is a multifunctional cell-surface receptor that binds and mediates the endocytosis of several structurally and functionally distinct ligands. Involved in a variety of biological processes, including the regulation of the coagulation-fibrinolysis balance, the lipoprotein metabolism, cellular migration, proliferative processes and degenerative diseases, it has very recently become an interesting candidate for functional studies of the development of atherosclerosis. We investigated the individual cellular LRP gene expressions in 100 patients with angiographically confirmed severe coronary obstructions (myocardial infarction, patients with coronary angioplasty and patients with coronary bypass). Using a competitive reverse transcriptase polymerase chain reaction analysis we measured the specific LRP mRNA levels in monocytes from venous blood. In comparison with 110 unselected controls (122.1 ag/cell) the patient group demonstrated significantly higher LRP message levels (171.92 ag/cell). We found the most evident increase in the coronary angioplasty group (+43.5%). Investigating the intraindividual range of expression in healthy controls over a period of 4 weeks, we found nearly constant individual levels. Our results demonstrate a significant correlation of increased LRP mRNA levels with atherosclerotic processes (P<0.001), suggest an important implication of the LRP in atherosclerotic vascular processes, and emphasize the inclusion of LRP investigations in risk constellation studies.

[Surgical therapy of diffuse peritonitis--staged lavage]. / Chirurgische Therapie der diffusen Peritonitis--Etappenlavage.

Better understanding of pathophysiology and improved techniques of intensive medical care resulted in new concepts of aggressive treatment for diffuse peritonitis. All consider the importance of surgical removal of the infectious focus but also the necessity of further treatment following first surgical intervention in cases of severe peritonitis. No randomised clinical study yet exists. Indication and application of selected therapeutic technique result from clinical criteria and experience. Presently used concepts are described and evaluated from a clinical viewpoint.

[Fournier gangrene]. / Die Fourniersche Gangrän.

Fournier's gangrene is a rapidly spreading soft tissue infection. Applying our main principles of therapy to the four patients we have treated in the past 4 years, all patients survived. One case report is presented in detail. Early diagnosis is essential. CT plays an important role. Aggressive resuscitation, daily surgical exploration and debridement remain the key to the management of this disease. The prevention of orchidectomy is one of our aims. Faecal diversion is seldom necessary.

[Open foramen ovale in patients with arterial vascular occlusions of the retina and optic nerve]. / Offenes Foramen ovale bei Patienten mit arteriellen Gefässverschlüssen der Netzhaut und des Sehnervs.

BACKGROUND: We examined the frequency and significance of persistent foramen ovale (PFO) in patients with ocular circulatory disturbance. PATIENTS AND METHODS: Forty patients with acute arterial occlusions of the posterior bulb segment were investigated by means of transthoracic and transesophageal echocardiography (TEE). The parallel presence of cerebral ischemia was clarified on the basis of existing CCT findings and by additional HMPAO-SPECT investigation. RESULTS: PFO was identified in nine of the patients investigated. The probability of paradoxical embolism arises from further findings: eight of those with PFO (89%) showed echocardiographic signs of right heart strain, indicating previous pulmonary embolism, compared with only three of those without PFO (10%). Five of those with PFO showed a potential source of embolism, two of them with phlebothromboses in their clinical history and three with additional atrial septal aneurysm. Cardiovascular risk factors were prevalent in the group without PFO. Both groups had a mean age of approximately 60 years. Signs of cerebral ischemia were present in the SPECT or CT findings for four of the patients with PFO and nine of those without. CONCLUSIONS: From our findings, it appears highly probable that ocular arterial occlusion is caused by paradoxical embolism. PFO should be taken into account in establishing a diagnosis, including diagnosis in elderly patients.

Effects of cardiac output on disposition kinetics of sorbitol: recirculatory modelling.

1. The purpose of this study was to determine the effects of cardiac output on distribution and elimination kinetics of the marker compound sorbitol. 2. The disposition kinetics of sorbitol were investigated after rapid intravenous injection and arterial sampling in nine patients who had undergone cardiac catheterization whereby the cardiac output was measured. 3. A minimal circulatory model consisting of pulmonary and systemic subsystems, both of which were characterized by an inverse Gaussian transit time density function, fitted the data very well. The method involves numerical inverse Laplace transform of the model equations. 4. The mixing clearance introduced as a novel non-compartmental parameter of distribution dynamics was significantly correlated with cardiac output. The steady-state volume of 14 l matched the extracellular volume. The systemic extraction ratio of 23% may reflect the fractional liver blood flow. 5. This pharmacokinetic model can be applied when an independent observation of cardiac output is available. In contrast to the conventional compartmental (or sum of exponential) approach it contains fewer adjustable parameters which can be more readily interpreted in physiological terms.

[Endoscopic therapy of postoperative biliary fistula]. / Endoskopische Therapie von postoperativen Gallefisteln.

A postoperative biliary fistula is a rare but severe complication of biliary surgery. Clinical signs, ultrasound and ERC lead to the diagnosis. Within three years, 37 patients with postoperative bile duct fistulas after cholecystectomy underwent endoscopic therapy. In all patients the biliary fistula healed completely within seven days after insertion of a nasobiliary tube. The nasobiliary tube for postoperative biliary fistulas offers regular radiological controls and reduces the necessity of operative reinterventions on the biliary system.

[Case reports of arteriovenous fistulas of coronary vessels in adulthood]. / Fallbeispiele arteriovenöser Fisteln der Koronargefässe im Erwachsenenalter.

It is reported on the diagnosis and therapy of arteriovenous fistulae of coronary arteries. With the help of 5 casuistic instances external fistulae could be demonstrated by invasive diagnostic procedures. In three cases the fistulae drained from the left coronary into the pulmonary artery, at the second instance from the right coronary artery into the right ventricle, in the fifth instance from the right coronary artery into the right atrium. In addition to this there were coronary stenoses which needed a bypass. In all cases the tentative diagnoses were confirmed intraoperatively. The indication to operative ligatures of the congenital fistulae is discussed and supported depending upon the picture of the complaint.