Value of coining on the improvement of endurance in slotted intramedullary nails.

Cracking of intramedullary nails, starting at the proximal end of the partial slot and propagating in a circumferential direction, has been observed. These partial cracks are relatively frequent, although full failures are very rare and do not disturb fracture healing. Coining is a cold-working process used to improve the endurance of structures with residual compressive stresses generated by plastic deformation. The influence of coining was investigated to evaluate its practical value in controlling these fatigue cracks. Bending and torsional tests were performed on high frequency machines. Coined zones of different shapes and depths were examined, comparing the elapsed number of load cycles with crack initiation. The results showed that the endurance of coined nails was improved by factors of approximately 10 and 5 in bending and torsion, respectively. This increase in fatigue life corresponds to a more than 50% larger dynamic load after a million cycles. Variations in coining shape and depth did not yield any significant differences.

[Diagnosis and therapy of liver injuries in the polytraumatized patient]. / Diagnostik und Therapie von Leberverletzungen beim polytraumatisierten Patienten.

We examined 120 patients with liver trauma, 100 retrospectively (1973-1986 group I) and 20 prospectively (1986-1987 group II). The severity of the liver injury was categorized in 5 grades (modified after Moore) and the degree of multiple trauma was assessed by the injury severity score (ISS). Patients in the liver injury groups were equally distributed among grades I to IV; there was one patient with a grade V injury in both the retrospective and prospective group. The overall mortality was 14%, 15% for the retrospective and 10% for the prospective group. Mortality was mainly due to concomitant injuries (head injuries, ARDS, multiple organ failure, pneumonia) and only 3 patients in the whole group died as a result of continuous bleeding or because of prolonged hemorrhagic shock due to the liver injury. The defined protocol for the prospective group included early efficient resuscitation and blood/fresh frozen plasma transfusion, systematic and rapid assessment of injuries and determination of priorities of treatment. Immediate ultrasonography or peritoneal lavage was used for assessment and diagnosis of a liver injury and early selection of treatment according to the grade of the liver injury: Conservative management for stable cases consisted of close supervision and repeated investigations (CT, angiography). Immediate operation was undertaken for continuing hemorrhage. Postoperative care in an intensive care unit with a low threshold for reoperation in cases of suspected sepsis, ongoing hemorrhage or necrosis of liver tissue was an important part of the treatment. Our results suggest that death in multiple trauma patients should almost never be due to liver injury alone. Conservative treatment may be justified in some patients, but early resuscitation and operation directed at definitive or provisional control of hemorrhage with removal of all devitalized tissue and liberal use of early reoperation are essential in the management of severe liver injury.

Pathogenesis of nodular goiter and its implications for surgical management.

Despite sufficient iodine supply, goiter continues to be of considerable surgical significance in formerly endemic countries. It now appears that iodine deficiency and increased thyrotropin stimulation are not the only causes of goiter. Xenotransplantation of human thyroid tissue onto nude mice allowed study of the regulation of growth and function in human goiter tissue. Grafts of human thyroid tissue growing in nude mice could be shown to react to endogenous mouse thyrotropic stimulation and suppression. 131I autoradiographs of xenotransplanted goiter tissue showed as marked a heterogeneity as did the original goitrous tissue prior to transplantation. There was no firm correlation between the morphologic appearance of a follicle and its iodine metabolism. Scintigraphically "cold" and "hot" goiter tissue differed from each other quantitatively but not qualitatively; i.e., both "hot" and "cold" tissue were composed of metabolically active and nonactive follicles. Iodine organification was not completely suppressible by thyroxine treatment; this indicates autonomous functional activity. The distribution of proliferating tissue labeled by 3-H-thymidine did not parallel the distribution of functionally active tissue labelled by 131I. Thyroxine treatment did not completely inhibit 3-H-thymidine incorporation, indicating autonomous growth. Thus, our pathogenetic concept of goiter formation is based on three mainstays: (1) goiter heterogeneity, (2) autonomy of growth and function, and (3) dissociation of growth and function in human goiter tissue. Thus, the surgeon dealing with goiter ought to remove all pathologically altered tissue, i.e., nodular tissue, irrespective of its appearance on scintiscans.

[Surgical treatment of hyperthyroid struma: surgery results, postoperative long-term course and study of a factor connected with recurrences]. / Die chirurgische Therapie der hyperthyreoten Struma: Operationsresultate, postoperativer Langzeitverlauf und Untersuchung einiger mit dem Auftreten von Rezidiven zusammenhängender Faktoren.

None of the 335 patients thyroidectomized for hyperthyroidism in our department of surgery between 1972 and 1982 died as a consequence of the operation. Reassessment of 226 of these patients by questionnaire 68 +/- 25 (SD) months after thyroidectomy revealed the following complications: postoperative paresis of the recurrent nerve (9%), persistent change of voice (2%), and persistent hypoparathyroidism (3.5%). 91 patients underwent a follow-up investigation 74 +/- 33 months after thyroidectomy. Only one had recurrent hyperthyroidism but 6 had a recurrence of the goiter. Patients with recurrent goiters had a significantly higher frequency of increased serum thyroglobulin levels than patients without goiters. These results emphasize the effectiveness of surgical therapy in hyperthyroidism, and suggest that serum thyroglobulin might be a useful predictor for goiter recurrence.

[Operative strategy in thyroid autonomy and Basedow hyperthyroidism]. / Operationsstrategie bei Schilddrüsen-Autonomie und Basedow-Hyperthyreose.

The different extra- and intrathyroid origin of hyperthyroidism, the advantages of the surgical procedure and the criteria for the extent of thyroid resection determine the operative tactics. For both forms of hyperthyroidism we recommend a rather extended resection of the diseased thyroid gland in order to prevent recurrent hyperthyroidism and recurrent thyroid growth as well. These recurrences require subtotal thyroidectomy for Graves' disease, monolateral partial lobectomy for a so-called toxic adenoma and bilateral partial lobectomy for toxic multi-nodular goiters. With these procedures lesions of the recurrent nerves and parathyroid glands can be prevented.

[Esophageal carcinoma: surgery using transhiatal esophagectomy without thoracotomy]. / Osophaguskarzinom: Operation durch transhiatale Osophagektomie ohne Thorakotomie.

During the period between 1982 and 1984, 25 patients with carcinoma of the esophagus underwent esophageal resection by the technique of blunt transhiatal esophagectomy without thoracotomy. The esophagus was replaced with stomach. The indications for blunt dissection of the esophagus are discussed and the operative technique is described. There was no postoperative mortality. Complications included pulmonary complications (19), anastomotic leak (9), left vocal cord paralysis (5) and stenosis of the cervical anastomosis (7). Postoperative hospitalization averaged 18 days. Following discharge from hospital patients are seen in follow-ups at 3-month intervals for 1 year, then at 6-month intervals. Quality of life is good. In the majority of patients with esophageal carcinoma, the goal of esophagectomy is palliation, not cure. Therefore, long-term prognosis of esophageal carcinoma is poor. Actual survival among the patients is 49% at 12 months, and mean survival 10.2 months. Transhiatal esophagectomy without thoracotomy is a safe procedure and far better tolerated by elderly and debilitated patients than a combined transthoracic and abdominal operation. We believe that this procedure is the treatment of choice for esophageal carcinoma at all levels.

Cytotoxicity of ether-linked phytanyl phospholipid analogs and related derivatives in human HL-60 leukemia cells and polymorphonuclear neutrophils.

A cytotoxic activity, highly selective for neoplastic cells, is expressed by 1-alkyl-2-methoxy-sn-glycero-3-phosphocholine and by other derivatives closely related to the chemical structure of platelet activating factor. The antineoplastic potencies of a new series of analogs tested in HL-60 human leukemia cells and human polymorphonuclear neutrophils are reported. The degree of cytotoxicity was documented according to the ability of each analog to 1) destroy leukemic or normal cells or 2) to release lactic acid dehydrogenase from these cells. An index of selectivity of the analogs for their cytotoxicity toward leukemia cells is presented. Substitution by the twenty carbon branched-chain phytanyl moiety in place of the straight chain alkyl ether-linked group at the sn-1 position of various phospholipid analogs resulted in a 3- to 10-fold reduction in their cytotoxic potency in HL-60 leukemia cells. The enantiomeric isomers (D-forms) of several of the analogs possessed slightly greater phospholipid analogs possessing the sn-2-acetyl (platelet activating factor) or sn-2- propionoyl substituents, both biologically active in their ability to aggregate platelets and to induce hypotension, were relatively innocuous in terms of the measured cytotoxic responses in both HL-60 cells and neutrophils.

[Autonomy and heterogeneity of the follicle in euthyroid and hyperthyroid human nodular goiter: answer to old riddles?]. / Autonomie und Heterogenität der Follikel in der euthyreoten und hyperthyreoten menschlichen Knotenstruma: die Lösung alter Rätsel?

The mechanisms responsible for the transformation of a morphologically and functionally normal thyroid into a heterogeneous eu- or hyperthyroid nodular goitre are summarized. The 3 basic processes of goitre pathogenesis are: 1. Each goitre develops from a normal thyroid gland by generation of new follicles. 2. New follicles are formed by multiplication of preferentially replicating cell clones of the follicular epithelium. Follicles already begin multiplying in response to a goitrogenic stimulus too weak to enhance metabolic functions other than replication. 3. The epithelial cells of normal follicles are not homogeneous and monoclonal, but belong to different populations with different metabolic equipment. Therefore, the daughter follicles may be metabolically different, e.g. in iodinating capacity. A certain degree of autonomous, i.e. TSH-dependent function is inborn to all follicles. The individual degree of autonomy of iodine turnover is not variable during goitrogenesis but determined by the metabolic individuality of the mother cell at the moment of folliculoneogenesis. These three basic processes explain the typical heterogeneity of nodular goitre. From autonomous highly iodinating cell families, autonomous "hot" daughter follicles arise which may be scattered all over the gland either as single follicles or as clusters of varying size (so-called "disseminated autonomy"). Particularly large clusters of "hot" follicles result in scintigraphically visible hot nodules, often called "toxic adenomas". Hyperthyroidism appears when the total joint autonomous hormone production of normal and "hot" follicles exceeds the requirements of the organism. The large majority of goitre nodules, including the so-called "toxic adenoma", are not true monoclonal benign neoplasias. Rather, they are built up by the same polyclonal heterogeneous follicles as extranodular goitre tissue. They have no choice but to expand in nodular fashion because they replicate within a poorly extensible network of connective tissue. This network of fibrous tissue results from scarring of multiple hemorrhagic necrosis occurring episodically during goitre growth.

[Should patients with portal hypertension undergo surgery?]. / Soll man Patienten mit portaler Hypertension operieren?

There is a noticeable similarity between the surgery of cancer and that of portal hypertension secondary to hepatic cirrhosis. The problems associated with the basic disease and with the surgical techniques used for its treatment are such that therapy should be determined by selection criteria, both when bleeding occurs and between bleeds. Highly experienced internists and surgeons are required and it is therefore advantageous if portal hypertension patients are referred to and concentrated in a small number of specialist centers. There the decision to operate should continue to be based on predetermined criteria, bearing in mind the patient's basic disease. If cirrhosis is in the foreground, as is so often the case, long-term social care should receive greater emphasis than hitherto in planning postoperative management.

[Surgery of benign goiter]. / Die Chirurgie der gutartigen Strumen.

All our thyroid patients are seen jointly by a specialist in nuclear medicine and by an endocrinologist. From 1972 to 1976 we operated on 564 patients; 433 were benign goitres (152 of them hyperthyroid) and 131 were malignant thyroid tumors. Operations for recurrent benign goitre were performed on 61 patients. The frequency of unilateral recurrent laryngeal nerve paralysis following a first operation (checked by laryngoscopy) was 4,4%. The surgical measures for avoiding this complication are discussed.