Pulmonary function testing after operative stabilisation of the chest wall for flail chest.

OBJECTIVE: This is a prospective evaluation of chest wall integrity and pulmonary function in patients with operative stabilisation for flail chest injuries. METHODS: From 1990 to 1999, 66 patients (56 men, 10 women; mean age 52.6 years) with antero-lateral flail chest (> or =4 ribs fractured at > or =2 sites) underwent surgical stabilisation using reconstruction plates. Clinical assessment and pulmonary function testing were performed at 6 months following surgery. RESULTS: Fifty-five (83%) patients had various combinations of injuries of the thorax, head, abdomen and extremities. Sixty-three (95.5%) patients underwent unilateral and 3 (4.5%) patients bilateral stabilisation with a median delay of 2.8 days (range 0-21 days) from admission. The 30-day mortality was 11% (seven of 66 patients). Immediate postoperative extubation was feasible in 31 of 66 patients (47%) and extubation within 7 days following stabilisation in 56 of 66 patients (85%). No plate dislocation was observed during the follow-up. The shoulder girdle function was intact in 51 of 57 patients (90%). Chest wall complaints were noted in 6 of 57 (11%) patients, requiring removal of implants in three cases. All patients returned to work within a mean period of 8 (range 3-16) weeks following discharge. Pulmonary function testing (n=50) at 6 months after the operation revealed a significant difference of predicted vs. recorded vital capacity (VC) and forced expiratory volume in 1s (FEV1) (P=0.04 and P=0.0001, respectively; Wilcoxon signed-rank test). The median ratio of the recorded and predicted total lung capacity (TLC) was shown to be significantly higher than 0.85 (P=0.0002; Wilcoxon signed-rank test), indicating prevention of pulmonary restriction. CONCLUSION: Antero-lateral flail chest injuries accompanied by respiratory insufficiency can be effectively stabilised using reconstruction plates. Early restoration of the chest wall integrity and respiratory pump function may be cost effective through the prevention of prolonged mechanical ventilation and restriction-related working incapacity.

[Assessment of intraoperative duplex sonography during carotid endarterectomy]. / Wertigkeit der intraoperativen Duplexsonographie bei der Carotisendarterektomie.

INTRODUCTION: Carotid endarterectomy (CEA) for prevention of strokes mandates a high amount of experience and a meticulous surgical technique. Intraoperative morphologic as well as hemodynamic monitoring of the endarterectomized arteries is rarely performed. The purpose of this study was to determine the value of intraoperative colour-coded-duplex-sonography to recognize eventual intraoperative technical problems that might result in serious cerebral damage. METHODS: Prospective analysis of the medical data of all patients who underwent CEA for treatment of high-grade carotid stenosis between 1996 and 1999. Adequacy of the repair was assessed intraoperatively by duplexsonography. RESULTS: Of 142 consecutive patients with a median age of 68 (43-84) years, 104 (73 %) were men and 38 (27 %) were women. 9 patients (6 %) had bilateral CEAs. Intraoperative duplexsonography revealed abnormalities during 11 (7 %) of 151 CEAs. 4 (3 %) were considered major and underwent immediate revision. There was one (0.7 %) temporary neurologic deficit (hyperperfusion syndrome) and 2 (1.3 %) cases of fatal intracerebral hemorrhage. 6 (4 %) postoperative surgical complications occurred, i. e. 3 cases of major wound hematoma (with revision) and 3 cases of temporary cranial nerve palsy. Median length of follow-up was 11 (3-35) months. No late neurologic event occurred during follow-up. 5 (3 %) patients developed asymptomatic restenosis. DISCUSSION: Routine intraoperative duplexsonography is a valuable and reliable diagnostic tool to detect correctable technical problems during CEA that subsequently may lead to neurological deficits, fatal stroke or a high incidence of restenosis.

[Video-assisted thoracosopic sympathectomy: spectrum of indications and our own results (1995-1997)]. / Videoassistierte thorakoskopische Sympathektomie: Indikations-spektrum und eigene Resultate (1995-1997).

INTRODUCTION: Video-assisted thoracoscopic (VATS) sympathectomy is the most frequently used technique for surgical sympathectomy of the upper limbs. It has proven to be particularly effective in hyperhidrosis of the hands. The aim of this study is to review and discuss possible indications and analyse our own results from 1995 to 1997, including technical details on the use of a new 2-mm thoracoscope and instrumentation. PATIENTS AND METHODS: Data of all 14 consecutive patients were prospectively assessed (8 females, 6 males, mean age 44 years; range 22-74 years). A total of 26 thoracoscopic sympathectomies were performed. Indications included: 7 cases of hyperhidrosis, 4 of inoperable and medically intractable angina pectoris, 3 of vascular diseases of the upper extremity. All patients were reexamined 3 months postoperatively and late follow-up was obtained in all patients, with a mean follow-up of 20 months postoperatively (4-36 months) by questionnaire. RESULTS: 22 Th2-Th5 and 4 Th2-Th4 resections of the sympathetic chain were performed. There was no conversion to open surgery. The mean operating time was 67 minutes (range 50-90 min.). One (3.8%) unilateral Horner syndrome occurred with complete recovery during follow up. Compensatory sweating occurred in 7 (50%). The mean hospitalisation was 4.7 days for all patients and 2.8 days for those with hyperhidrosis. In 10 patients (71.5%), symptoms of the underlying disease had completely ceased on the day of discharge, and in 4 (28.5%) the symptoms had improved. Two months postoperatively a unilateral relapse occurred in one patient with Raynaud's disease. After a mean of 20 months, the quality of life was improved in 12 (85%) and was unchanged as compared to preoperatively in 2 (15%). CONCLUSIONS: Primary hyperhidrosis showed the best results after thoracoscopic sympathectomy. Although experience with angina pectoris is still limited, thoracoscopic sympathectomy seems to be a valuable alternative in otherwise inoperable cases. In upper-extremity vascular diseases the operation can be performed as a last therapeutic option, but relapse often occurs in these patients. 2-mm instrumentation decreases trauma and postoperative pain and improves cosmetic results, which obviously may play a role in younger patients with hyperhidrosis. Patients should be warned about compensatory sweating before thoracic sympathectomy.

[Mesh-plug operation: a simple, rapid and complication-free technique for managing inguinal hernia]. / Mesh-plug-Operation: eine einfache, schnelle und komplikationsarme Technik zur Leistenhernienversorgung.

INTRODUCTION: The optimal inguinal hernia repair technique is a matter of debate. The Shouldice operation has long been regarded as the gold standard. While specialized hernia clinics have reproduced good results, a recurrence rate for trainees and non-specialized surgeons of between 10% and 15% seems to be more common. Laparoscopic hernia surgery has brought decreasing postoperative morbidity, low post-operative disability and early return to work. These advantages of a tension-free technique are due to the use of a prosthetic mesh. It is largely the efforts of Gilbert, Lichtenstein and Rutkow/Robbins which have popularized the use of prosthetic mesh by an open anterior approach in the USA. METHODS: Since January 1997 we have prospectively evaluated the open mesh plug repair described by Rutkow/Robbins in Basel and Lugano. We have operated on 110 patients (103 male, 7 female). All patients were interviewed 4 weeks postoperatively at our clinic. RESULTS: There were no major complications. Two patients underwent reoperation for drainage of a haematoma. There was no early recurrence or infection. After 4 weeks 82% of all patients were back to normal activity. An early return to work has been noted (10 days on average for sedentary workers). CONCLUSION: The main advantages of this technique are simplicity, low cost, reduced post-operative disability and early return to work. It is much too early to say anything concerning recurrence in this series.

[Mesenteric venous thrombosis (MVT): a problem in diagnosis and management]. / Die Mesenterialvenenthrombose (MVT): Ein Problem in Diagnostik und Management.

The mesenterial venous thrombosis is a rare and independent cause of intestinal ischemia. 5 to 15% of all intestinal ischemias are due to venous problems. The lack of specific clinical symptoms and laboratory data often leads to a delayed diagnosis with irreversible intestinal infarction. Only by thorough searching by means of modern diagnostic devices is it possible to make an early diagnosis and treat the ischemic situation timely. Several therapeutical options are at hand. A timely and adequate application of these aids mostly depends on the clinical experience of the medical team as well as on an optimal interdisciplinary collaboration (radiology, hematology, angiology, gastroenterology, surgery). We want to analyze the problems related to diagnostics and management on the basis of 2 cases with different manifestations of a mesenterial venous thrombosis. We ascertain that: (1) the enhanced-CT analysis and/or the duplex-sonography mostly lead to a diagnosis, (2) the prognosis benefits from an immediate heparinization, (3) the request for large-scale intestinal resection, keeping a safety-space, has been replaced by the technique of limited resection, followed by earlier second-look-operations.