Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication-case report and review of the literature.

Introduction: Laparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC. Methods: Case report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022. Case Report: An 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation. Conclusion: Intraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC.

Comparable results using 2.0-mm vs. 3.5-mm screw augmentation in midshaft clavicle fractures: a 10-year experience.

PURPOSE: Absence of cortical alignment in wedge-shaped and multifragmentary fractures (Fx) results in decreased fixation stability. The aim of this study was to compare the outcome using 2.0- vs. 3.5-mm screws for open reduction and internal fixation (ORIF) in dislocated, wedge-shaped or fragmentary midshaft clavicle fractures. MATERIALS AND METHODS: Patients suffering from AO/OTA 15 2.A-C midshaft clavicle fractures were operatively treated between 2008 and 2018. 2.0- or 3.5-mm cortical screws were used to restore anatomic alignment in dislocated, wedge-shaped and fragmentary clavicle fractures. Data of radiologic outcome were collected until fracture consolidation was identified. RESULTS: 80 consecutive patients with a mean age of 44.5 ± 16.3 years, who were operatively treated for dislocated midshaft clavicle fractures were enrolled. 40 patients were treated using 2.0-mm and 40 patients using routine 3.5-mm cortical screws, respectively. Time to fracture consolidation was 12.8 ± 7.8 months. No mal- or non-unions occurred during routine follow-up until 18 months postoperatively. CONCLUSION: Restoring anatomic alignment in wedge or fragmentary clavicle fractures can ultimately be addressed using cortical screw augmentation. Both groups showed comparable results with respect to fracture reduction, fixation and stability as well as time to consolidation of the fracture, while the 2.0-mm screw diameter was associated with easier handling of small Fx fragments.

[External fixation for treatment of peripartum pubic symphysis separation : Clinical case and discussion]. / Fixateure externe zur Behandlung der intrapartalen Symphysensprengung : Fallbericht und Diskussion.

A complete peripartum pubic symphysis separation is a rare but severe complication of natural birth. Its incidence is estimated to be 0.03-3 ‰. Minor partial separations with a small width can be treated with a pelvic binder. Separations with major dehiscence should be treated by surgical reduction and fixation. This article presents the case of a 30-year-old woman who suffered a complete rupture of the pubic symphysis during the birth of her second child. Radiographic dehiscence was 39 mm. The operative treatment was carried out using a supra-acetabular external fixator for 12 weeks with a good result.

[Current treatment strategies for lower leg fractures in adults]. / Aktuelle Versorgungsstrategien der Unterschenkelfraktur des Erwachsenen.

Shaft fractures of the tibia and fibula mainly affect younger patients and are therefore of great socioeconomic importance. Due to the high proportion of high-energy direct trauma mechanisms and the thin soft tissue covering layer of the ventromedian tibia, open factures occur in up to 39%. A structured diagnostic and therapeutic approach is essential for successful treatment. Reamed intramedullary nailing is currently the gold standard surgical procedure. The suprapatellar approach, representing an interesting alternative to the popular infrapatellar approach, postoperative complications, such as anterior knee pain as well as the management of non-unions are discussed in this article. Furthermore, the indications and the application of minimally invasive plate osteosynthesis (MIPO) and external fixators are described. Every trauma surgeon should be familiar with the etiology and the surgical treatment of compartment syndrome. A firm knowledge of the classifications of open and closed soft tissue injury is mandatory.

[Incorrect aftercare of a surgically treated metatarsal fracture]. / Fehlerhafte Nachbehandlung einer operativ versorgten Mittelfußfraktur.

A 60-year-old patient suffered an ankle distortion resulting in a comminuted fracture of the fifth metatarsal. On the same day the accident occurred the patient presented to an emergency department and immediate operative treatment of the fracture was performed by intramedullary Kirschner wires with closed reduction and internal fixation. The aftercare was carried out on an outpatient basis by a registered orthopedist in accordance with the surgeon's instructions. In the radiological control 14 days after surgery a dislocation of the fracture was detected and 1 week later a rectification operation was carried out in a second clinic with removal of the Kirschner wires, open reduction and internal fixation with a locking plate. The patient suspected inadequate treatment by the first clinic, which in turn did not accept any inadequacies in the surgical treatment or the aftercare. In the subsequent legal dispute the appointed experts came to the conclusion that an initial good fracture position was achieved but that the aftercare treatment with a forefoot relief shoe was inadequate for the type of internal fixation chosen. The arbitration board came to the conclusion that the multifragmented fracture situation was treated by a questionably stable osteosynthesis using Kirschner wires. This should have required a very strict aftercare with partial weight bearing on crutches and immobilization in a stable orthosis or cast.

Survival benefit for patients treated in a certified head and neck tumor center.

OBJECTIVE: Increasing effort has been put in the implementation and certification of head and neck tumor centers in order to establish standardized, quality assured health care for head and neck tumor patients. This study evaluated survival rates after treatment in a certified head and neck tumor center (CHNTC) vs. a non-certified head and neck tumor center (non-CHNTC) in Middle Franconia, Germany. PATIENTS AND METHODS: Age, sex, possible obituary, and typical relevant prognostic variables were analyzed. Diagnosis was recorded according to ICD10. Clinical and pathological TNM staging, tumor grading, localization, R-stage, and morphology were assessed (ICD-0). Patients diagnosed with oral cancer (N=1047) were divided into groups based on where they received their primary treatment; CHNTCs or non-CHNTCs. RESULTS: Patients treated at CHNTCs had significantly higher survival rates vs. those treated at non-CHNTC (p=0.023) in univariate analysis. In a Cox regression model, survival rates for patients with pN0 and pN+ stage were similar at both types of centers. Men with pN0 had significantly lower survival rates (HR=0.497, p<0.001). Age had a statistically significant influence on survival rates independently from pN stage (HR=1.031 per year, p<0.001 in both groups). CONCLUSIONS: Patients treated at CHNTC had better survival rates than those treated at non-CHNTC.

[Anterolateral stabilization using the modified Lemaire technique for ACL deficiency]. / Anterolaterale Stabilisierung mittels modifizierter Lemaire-Plastik bei insuffizientem vorderem Kreuzband.

OBJECTIVE: Treatment of persistent anterolateral knee instability. INDICATIONS: Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity) RELATIVE CONTRAINDICATIONS: Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction. ABSOLUTE CONTRAINDICATIONS: General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee. SURGICAL TECHNIQUE: Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure. POSTOPERATIVE MANAGEMENT: Knee brace for at least 6 weeks. Range of motion (RoM): from postoperative day 1: flexion-extension 90-0-0°; first 2 weeks after surgery: partial weight bearing (20 kg). RESULTS: An anterolateral extra-articular reconstruction may reduce a persistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to a reconstruction of the anterolateral ligament. If a tenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such a procedure may include a high-grade pivot shift or revision ACL reconstruction as well as a persistent anterolateral rotatory instability following anatomic ACL reconstruction.

[Clavicular fractures : Diagnostics, management and treatment]. / Klavikulafrakturen : Diagnostik, Management und Therapie.

Clavicular fractures account for approximately 6% of bony injuries of the shoulder girdle. Patients suffering from this type of injury show 2 peaks (at the 2nd and 8th decades of life) where the majority occur in young active patients during recreational and sports activities. Besides an accurate patient history with a focus on the trauma mechanism, the clinical and radiological investigations are the cornerstones of the diagnostics. Slightly displaced fractures in a pediatric population as well as non-displaced fractures in adults can be treated conservatively. In cases of shortening and/or displacement and high functional demands, operative treatment of clavicular fractures, stable fixation and the possibility of early mobilization and therapy can be achieved; however, the indications for the procedure also depend on other factors. Surgical stabilization can substantially reduce the danger of non-union, which is why it is becoming more important.

Surgical repair of acute pectoralis major muscle ruptures.

OBJECTIVE: Surgical repair of a partial or complete tear of the pectoralis major muscle to restore internal rotation, adduction, and anteversion. INDICATIONS: Acute avulsion, acute tear of the tendinous insertion, acute tear of the musculotendinous region (<6 weeks after trauma). Relative indication: chronic retracted tear (>6 weeks). CONTRAINDICATIONS: Muscular tears, local infection, other general contraindications. SURGICAL TECHNIQUE: Open repair using suture anchors or flip buttons. POSTOPERATIVE MANAGEMENT: Week 1-3: early passive-assisted functional physical therapy. Week 3-6: early active-assisted functional physical therapy. Week 7-9: active assisted free range of motion (ROM). From week 9: free ROM. From week 12: exercise with resistance, careful strengthening. RESULTS: Between 2005 and 2017, 20 men with an acute or subacute tear of the pectoralis major muscle underwent surgery. Mean age 36 years (range 28-55 years). No previous antibiotic treatment or steroid abuse/treatment reported. Reasons for rupture were weight lifting (bench-press, n = 10), skiing and snowboard accidents (n = 3), fitness training (n = 3), soccer (n = 1), martial arts (n = 1), a canyoning accident (n = 1), and a simple fall (n = 1). Follow-up examinations were performed 6 weeks and 3 months postoperative. No infections or wound healing disorders; no revisions necessary. Normal muscle function via open refixation of the tendon stump. No re-rupture observed. Free ROM observed 3 months after surgery.

[Supramalleolar osteotomy in asymmetric ankle osteoarthritis : Short-term clinical and radiographic results]. / Supramalleolare Osteotomie bei asymmetrischer Arthrose des oberen Sprunggelenks : Kurzfristige klinische und radiologische Ergebnisse.

BACKGROUND: The main indication for the supramalleolar osteotomy is asymmetric ankle osteoarthritis with concomitant supramalleolar valgus or varus deformity. The aim of this prospective study was to analyze short-term clinical and radiographic outcomes in patients with asymmetric ankle osteoarthritis. METHODS: A total of 16 patients with asymmetric ankle osteoarthritis and concomitant supramalleolar deformity - 7 patients with valgus deformity, 9 patients with varus deformity - were treated. Intraoperative and postoperative complications were recorded and analyzed. The clinical and radiographic outcomes were assessed after a mean follow-up of 3.6 ± 1.1 years. RESULTS: In 10 of 16 patients, removal of hardware was performed. The AOFAS hindfoot score increased significantly after surgery. All categories of the SF-36 score showed significant improvement. The average range of motion also increased significantly. Radiographic assessment showed neutral hindfoot alignment at the latest follow-up. The postoperative clinical outcomes were comparable in both patient groups. The time until complete osseous union was significantly longer in patients with opening wedge osteotomy. CONCLUSION: This prospective study demonstrated encouraging short-term results in patients with asymmetric ankle osteoarthritis who underwent supramalleolar osteotomy. In progressive ankle osteoarthritis, joint-nonpreserving treatment options including total ankle replacement or ankle arthrodesis should be discussed.

[The Midfoot Fusion Bolt: a new perspective?]. / Der "Midfoot Fusion Bolt" - eine neue Perspektive?

BACKGROUND: There is no current guideline nor consensus regarding optimal surgical treatment of the midfoot Charcot. Due to the vast diversity of locations, it is difficult to make a general statement. Various different types of screws and plates are currently being used since they have been tested and declared to be most stable. The Midfoot Fusion Bolt is a new device which needs approval since long-term results are lacking. A short summary of currently published papers and results from our own institution are provided. OBJECTIVES: The aim of this study was to investigate short-term results including complications and review published surveys. METHODS: The Midfoot Fusion Bolt is a solid, intramedullary screw. An antegrade as well as a retrograde technique are postulated for insertion. A total of 16 patients/17 feet in two specialized foot and ankle centers were included. BMI, HbA1c, satisfaction rates, complication rates, and expert opinions were recorded. RESULTS: The bolts were used an average of 21.17 months (range 3-55 months) in 16 patients/17 feet. Between 2009 and 2014, six bolts had to be removed. We encountered 4 cases of postoperative ulceration: 2 cases healed postoperatively, while the other 2 cases led to amputation. The average fusion rate was 92.35 %. CONCLUSION: The Midfoot Fusion Bolt is no longer advised for single-device use only since there have been issues in terms of insufficient stability. However, stable conditions could be achieved with additional screws or plates, respectively. Prospective studies and biomechanical testing for general conclusions are still required to make a meaningful assessment.

[Diagnosis and therapy of obstructive sleep apnea syndrome in children with premature craniosynostosis syndromes]. / Diagnostik und Therapie des obstruktiven Schlafapnoe-Syndroms bei Kindern mit syndromalen Kraniosynostosen.

Sleep related breathing disorders are a common symptom in children with craniosynostosis syndromes, as upper airways may be narrowed by midfacial hypoplasia.To better characterize the sleep related apneas, 24 children with syndromal craniofacial dysplasia underwent 68 poly-somnographies. 9 patients had reexaminations after therapeutic procedures. 4 patients had severe obstructive sleep apnea syndrom (OSAS), 8 patients had moderate and 11 patients mild obstructive sleep apnea respectivly. Only one child had no obstructive sleep apnea. Children with Morbus Crouzon tended to have moderate to severe breathing disorders (9/14) whereas Apert patients mostly had no or light breathing disorders (6/7). Number of central apneas was increased as well. Sleep architecture was not significantly impaired. Apneas were more frequent during REM-sleep. Nasal CPAP, BiPAP and adenotonsillectomy improved respiratory parameters.Pulse oxymetry can be used as a screening method because of the good correla-tion of oxygen desaturation index with severity of OSAS. Frequent examinations and, if necessary, adaptation of therapy is indicated as OSAS in -these children may be rapidly changing. We suggest a guideline for diagnostics and therapy.

The amino acid variation of HLA-A*02:182 in a highly conserved region is predicted to be functionally similar to HLA-A*02:01:01:01 allele.

We here describe the identification of the novel human leukocyte antigen allele HLA-A*02:182 which has been detected in a potential bone marrow donor. The new allele differs from the sequence of HLA-A*02:01:01:01 only by a non-synonymous nucleotide exchange of Guanin (G) → Cytosin (C) at position 199 in exon 3 replacing amino acid (AA) Arginine (Arg, R) by Threonine (Thr, T) in codon 157. Since the HLA-A*02:01:01:01 allele differs from A*02:182 only at AA position 157, it is assumed that the protein structures of these alleles are highly similar. A mismatch between HLA-A*02:01:01:01 and HLA-A*02:182 is predicted to have a very low allogeneic potential in hematopoietic stem cell transplantation.

Microtechnology meets systems biology: the small molecules of metabolome as next big targets.

One of the key objectives of systems biology is to study and control biological processes in terms of interactions of components at different molecular levels. Advances in genome sequencing, transcriptomics and proteomics have paved the way for a systemic analysis of cellular processes at gene and protein levels. However, tools are still missing for a reliable and systemic analysis of the small molecules inside cells, the so-called metabolome. Due to the generally very low concentration, high turn-over rate and chemical diversity of metabolites their quantification under physiological, in vivo and dynamic conditions presents major challenges and the missing link for a real systems biology approach on the way from genome to cellular function. To this end, microfluidics can play an important role owing to its unique characteristics such as highly spatial and temporal resolution of sample treatment and analysis. Despite impressive progresses in microtechnology in recent years, many of the microfluidic studies or devices remain at the level of proof-of-principle and have been seldom applied to the real world of metabolomic analysis. In this review article, we first present the major obstacles and challenges for determining in vivo metabolite dynamics in complex biological systems. The progresses in microfluidics, their characteristics and possible applications to solving some of the compelling problems in metabolomic analysis are then discussed. Emphases are put on pinpointing the deficits of the presently available devices and technologies and directions for further development to fulfill the special need of systems biology.

Optical scattering lengths in large liquid-scintillator neutrino detectors.

For liquid-scintillator neutrino detectors of kiloton scale, the transparency of the organic solvent is of central importance. The present paper reports on laboratory measurements of the optical scattering lengths of the organic solvents phenylxylylethane, linear alkylbenzene (LAB), and dodecane, which are under discussion for next-generation experiments such as SNO+ (Sudbury Neutrino Observatory), HanoHano, or LENA (Low Energy Neutrino Astronomy). Results comprise the wavelength range of 415-440 nm. The contributions from Rayleigh and Mie scattering as well as from absorption/re-emission processes are discussed. Based on the present results, LAB seems to be the preferred solvent for a large-volume detector.

The predicted protein structures of the novel DRB1*0717 and DRB1*0701 are highly related.

This article describes the identification of the novel human leukocyte antigen (HLA) allele DRB1*07 7 that was detected in a potential stem-cell donor of Caucasian origin. Compared to DRB1*070101, the new allele is characterized by a nonsynonymous nucleotide exchange of C-->T at position 201 in exon 2 replacing Arg by Trp in codon 72. As this sequence variation has not been seen earlier in any other HLA-DRB allele, it is most probably the result of a point mutation.

Fluorescence decay-time constants in organic liquid scintillators.

The fluorescence decay-time constants have been measured for several scintillator mixtures based on phenyl-o-xylylethane (PXE) and linear alkylbenzene (LAB) solvents. The resulting values are of relevance for the physics performance of the proposed large-volume liquid scintillator detector Low Energy Neutrino Astronomy (LENA). In particular, the impact of the measured values to the search for proton decay via p-->K(+)nu is evaluated in this work.

Simultaneous detection of Brachyspira hyodysenteriae, Brachyspira pilosicoli and Lawsonia intracellularis in porcine faeces and tissue samples by multiplex-PCR.

Diarrhoea in growing and finishing pigs is usually caused by infectious agents and laboratory diagnosis is a prerequisite for efficient therapy. Cultivation of Brachyspira hyodysenteriae or Brachyspira pilosicoli and detection of Lawsonia intracellularis by means of immunofluorescence tests (IFT) are time-consuming and in some cases lack sensitivity. A multiplex-PCR was designed to detect simultaneously these three pathogens in faeces and tissue samples, allowing the differential diagnosis of dysentery, intestinal spirochaetosis and proliferative enteropathy. Detection limits for B. hyodysenteriae, B. pilosicoli and L. intracellularis were 10(4), 10(2) and 10(3) copies respectively. Agreement between multiplex-PCR and nested-PCR or cultivation was considered substantial to almost perfect. Agreement between multiplex-PCR and IFT in detecting L. intracellularis was only moderate, which was probably related to false-positive results given by IFT. The multiplex-PCR described herein is a valuable tool for the rapid and simultaneous detection of three different pathogens in porcine samples causing enteric diseases.

Ultrafast dynamics of intersubband excitations in a quasi-two-dimensional hole gas.

We present the first study of ultrafast hole dynamics after resonant intersubband excitation in a quasi-two-dimensional semiconductor. p-type Si0.5Ge 0.5/Si multiple quantum wells are studied in pump-probe experiments with 150 fs midinfrared pulses. Intersubband scattering from the second heavy-hole back to the first heavy-hole subband occurs with a time constant of 250 fs, followed by intrasubband carrier heating within 1 ps. Such processes give rise to a strong reshaping of the intersubband absorption line, which is accounted for by calculations of the subband structure, optical spectra, and hole-phonon scattering rates.