[Varicose vein operation under inpatient conditions]. / Die Varizenoperation unter stationären Bedingungen.

The change of surgical operations from inpatient to outpatient conditions as a method of lowering costs in health care has lead to a significant rise in the number of outpatient operations, especially in varicose vein surgery. Hospitalisation is still required in special cases. The criteria of 146 patients with varicose veins for admittance to inpatient treatment were retrospectively reviewed. The clinical findings, the designated operation and the specific personal factors were assessed. We found in just under 70% of the patients the indication for hospital admittance whereas in slightly over 30% the outpatient management was ascertained. Through this selection the total number of inpatients could be reduced, leading on the other hand to a relative increase in the number of difficult cases with more severe conditions requiring more complex management.

Early detection of cerebral ischemia during carotid endarterectomy using transcranial Doppler sonography and somatosensory evoked potentials.

Cerebral function during carotid endarterectomy can reliably be monitored using somatosensory evoked potentials (SEP). Transcranial Doppler sonography (TCD) is a noninvasive method providing on-line data about cerebral hemodynamics. The combination of both techniques during carotid surgery is helpful in evaluating the hemodynamic ("input") and the functional ("output") consequences of carotid clamping within a short time. In the present report, combined TCD and SEP monitoring early detected left hemispheric ischemia in a 68-year-old woman subjected to left carotid endarterectomy. The impairment of cerebral perfusion occurred before carotid clamping due to an intraoperative thrombosis of the left internal carotid artery as could be revealed after declamping. A temporary shunt was not inserted. Postoperatively, the patient had a new transient neurological deficit. In this case, TCD correctly indicated cerebral ischemia as confirmed by SEP recording. For carotid artery surgery, combined TCD and SEP may be helpful in detecting those patients who will profit from temporary shunting if this is not done routinely.

Aortic arch replacement by posterolateral exposure.

Aortic arch replacement was carried out in a 54 year old male patient with an unexpected type A-dissection, using partial femoro-femoral bypass and hypothermic arrest, through a left side posterolateral thoracotomy. After the replacement of the aortic arch from the ascending to the descending aorta a warm-up perfusion was done through an 8 mm side arm Dacron prosthesis attached to the descending segment of the 30 mm Dacron graft. This technique was demonstrated to be safe and protective in our patient and can be used as an alternative surgical method in the treatment of aortic arch dissection or aneurysms of the transverse aortic arch.

Resection of a heart tumor using autotransplantation.

A 38 year old male patient presented with a cardiac tumor. Echocardiography and visualization of the left atrium revealed a large myxoma. Surgical resection of the tumor was performed with the aid of cardiopulmonary bypass. The extensive size of the tumor base and its localisation at the posterior left atrial wall made a conventional approach impossible. Therefore radical resection of the tumor was undertaken using autotransplantation. After a routine postoperative course, the patient was discharged on the twenty seventh hospital day.

The interstitial pH of the working gastrocnemius muscle of the dog.

In isolated gastrocnemius muscles from 19 dogs the interstitial H+ activity ([H+]int) was measured with bulb-type buffer-filled glass minielectrodes. The muscles were working isotonically and perfused with blood. In addition arterial and venous pH, venous O2 saturation, muscle temperature, and blood flow were meausred continuously at rest, during 12 min of sustained exercise, and in the recovery period. Lactate (LA-) release and O2 consumption were calculated by the Fick principle. The experiments were performed under normal acid-base conditions and during artificially induced metabolic acidosis and alkalosis. 1. In normal acid-base balance [H+]int at rest was 54 +/- 3.3 neq/l (= pH 7.24), while venous H+ ([H+]ven) was 45 +/- 4.7 neq/l (= pH 7.34) A[H+] gradient was always observed between interstitial fluid and venous blood. 2. Immediately after onset of exercise [H+]int decreased transiently. After about 15 s [H+]int increased rapidly up to values of 105 +/- 7 neq/l (= pH 6.98). In the recovery period [H+]int diminished and reached control values after about 20-30 min. [H+]ven increased up to 74.4 +/- 8.4 neq/l (= pH 7.13). Maximal gradients between [H+]int and [H+]ven were 36 neq/l (= pH 0.2). 3. During repeated exercise the decrease in [H+]int at the onset of exercise was more extensive, while the subsequent increase was lowered. These changes correspond to a smaller LA- release. 4. During metabolic alkalosis at the onset of exercise [h+]int decreased less, during metabolic acidosis more than under normal acid-base conditions. Thereafter during metabolic alkalosis maximal values of 95.4 +/ 2 neq/l (= pH 7.03), during metabolic acidosis of 180 +/- 8.6 neq/l (= pH 6.74) were reached. This led to [H+] gradients between interstitial fluid and venous blood which were much higher in metabolic acidosis than in normal acid-base balance or in metabolic alkalosis. In metabolic acidosis [H+]int decreased very sle rapidly than during metabolic alkalosis or during normal acid-base conditions. It is concluded that the H+ activity measured is that within the interstitial space. Exercise hyperemia is not caused by changes of [H+]int. Mechanisms are discussed which may explain H+ gradients between interstitial fluid and venous blood and rapid changes of [H+]int at the onset of exercise.