[The "new" Erlangen technique of funnel chest correction - minimalization of a well working procedure]. / Die "neue" Erlanger Trichterbrustkorrektur - Minimalisierung eines bewährten Verfahrens.

INTRODUCTION: In many operative fields there is a trend to be minimally invasive, so in chestwall surgery too. Because of this influence we developed a technique for routine measurements of the forces during surgery. So it was possible to make the Erlangen technique substantially less invasive. METHODS: Mobilisation of the sternum always begins with freeing of the xiphisternum. Then we use a spring balance with a measurement range of 20-230 N. This is attached to the sternum with a single-pronged hook, and then the sternum is raised to the desired position. DISCUSSION: Since the introduction of intraoperative measurements it has been possible to make the Erlangen technique substantially less invasive, i.e. division of the ribs at the outer rim of the funnel, previously always carried out, is no longer done. Of course we could also minimise the length of the incision.

Multiple endocrine neoplasia 2A syndrome: Surgical management.

BACKGROUND/PURPOSE: Currently, molecular genetic diagnostics allow familial types of medullary thyroid carcinoma to be detected at an asymptomatic stage and surgery thus to be performed at a time when prognosis is good. The current report aims to determine the appropriate age for safe prophylactic thyroidectomy in children with multiple endocrine neoplasia (MEN) 2A and mutations at codon 609 according to genotype-phenotype correlations and will discuss surgical procedures. METHODS: The authors describe the case of a family with hereditary MEN 2A syndrome. A DNA analysis of 7 family members confirmed the diagnosis by a mutation at codon 609 of the RET proto-oncogene. RESULTS: A phaeochromocytoma developed in 2 family members. Four had medullary thyroid carcinoma. A grandson underwent a prophylactic thyroidectomy at the age of 5 on account of genetic evidence. Despite the negative preoperative and intraoperative findings he already had an invasive medullary thyroid carcinoma. CONCLUSIONS: Few genotype-phenotype correlations have been established for MEN 2A disease. According to the natural history of the disease, families with the genotype RET cys609gly should have a more benign disease than high-risk families (mutations at codon 634, 618). From this report the authors conclude that prophylactic thyroidectomy in "609" families should be performed earlier than actually recommended, favorably at the age of 2 to 4 years. Further multicenter studies are needed to provide more clinical and prognostic data for less frequent (codon 609, 630, 791, and 891) RET genotypes.

[Minimal invasive pediatric surgery: development and progress by innovative technology]. / Minimalinvasive Kinderchirurgie: Entwicklung und Fortschritt durch innovative Technologie. Die ATCS-Klebung.

BACKGROUND: Minimally invasive pediatric surgery (MIPS) has a solid tradition in which technique and technology have made key contributions to an already broad range of indications. This surgical method still has a deficiency with regard to tissue management of large-area defects, however. Sealing techniques can further expand the range of application. METHOD: Technological evaluation provided outstanding data of fleece-bound collagen- and fibrinogen-based sealing systems (TachoComb) on biodegradability, adhesive strength and practicability. A relevant instrument was developed for MIS application and was introduced as the ATCS (AMISA-TachoComb-System). PATIENTS: From 1993-2000, ATCS sealing was carried out in the scope of thoracoscopy (105 procedures) and laparoscopy (53 procedures) and specifically for recurring pneumothorax, traumatic chylothorax and splenic trauma. RESULTS: Pneumothorax: 59 ACTS procedures in 49 patients (mean age: 11.4 yrs) with 6 reoperations (10.2%) and one recurrence (1.7%). The drainage dwell time was reduced (p < 0.05) using a conventional comparison (31.9 hours vs. 17 days) and further relevant parameters were also reduced. Chylothorax: 3 ATCS procedures in 3 patients (mean age: 6.3 years) with reduction in the drainage dwell time (p < 0.05) based on a conventional comparison (35 hours vs. 18 days). Splenic trauma: 17 ATCS procedures in 16 patients (mean age: 8.9 years) with one re-operation (5.9%) for associated liver trauma, organ conservation in each case and no significant drainage volumes. CONCLUSION: The ATCS is an innovative instrument for MIPS and ca be employed for efficient and socio-economic (e.g. DRGs) closure of large-area defects.

Balloon dilation is preferable to bougienage in children with esophageal atresia.

BACKGROUND AND STUDY AIMS: Esophageal strictures are a common problem after surgical repair in children with esophageal atresia. The traditional procedure in these patients is dilation using bougie dilators, usually controlled fluoroscopically or endoscopically. Nowadays, an alternative technique is balloon-catheter dilation. The aim of this study was to report our experience with pneumatic balloon dilation and to compare this method with previously performed bougienage with regard to efficacy. PATIENTS AND METHODS: Over 16 years, 34 patients who developed symptomatic strictures were encountered at our institution. In the first 9 years 12 patients underwent 178 bougienages (group C). In the last 7 years six patients who had undergone 202 previous bougienages (group B), and 16 patients who had undergone no bougienages (group A), underwent 52 dilations. The dilation was carried out under intravenous sedation using a combination of midazolam and etomidate. The balloon was placed in the stricture endoscopically and the procedure was performed under fluoroscopic and endoscopic control. RESULTS: In all patients the dilation was effective and involved minimal trauma. The strictures required 1 to 7 procedures (median 2) over a maximum of 18 months (median 3 months) for a good treatment result. The complications observed were two perforations, one of them with pneumothorax (both treated conservatively), and two compressions of the trachea (interruption of the procedure, but efficient dilation was eventually achieved). The method was more effective than bougienage (1 to 60 bougienages were required per patient, median 9). CONCLUSIONS: Compared with traditional bougienage, balloon dilation of esophageal strictures is less traumatic and more effective. Complications are rare and can be managed conservatively. In our opinion this procedure is the appropriate treatment for strictures, even in very small infants, after repair of esophageal atresia.

Collagen patches impregnated with antimicrobial agents have high local antimicrobial efficacy and achieve effective tissue gluing.

BACKGROUND: Local antimicrobial systems have gained importance, as illustrated by current research on drug delivery systems (DDS). We aimed to develop materials that combine hemostatic and antimicrobial efficacy as well as adhesiveness for use in surgical tissue management. MATERIALS AND METHODS: Materials were evaluated by in vitro studies employing microbiological and technological methods. RESULTS: Antimicrobial impregnation of a collagen fleece, which is a pre-coated fibrinogen-based adhesive and therefore ready-to-use (TachoComb), is significantly more efficient--both in terms of the antimicrobial efficacy (p < 0.001) as well as the adhesive strength (p = 0.03) -than coating an antibiotic-containing collagen fleece "on-site" with fibrin glue. CONCLUSION: Due to ease of practical handling and favorable pharmacoeconomics, this DDS is recommended for both open and minimally invasive surgery.

Reducing catheter-associated infections with silver-impregnated catheters in long-term therapy of children.

Central venous long-term catheters offer reliable, large-lumen vascular access with high flow rates for delivery of nutrition or for cell-containing infusions and perfusions. Catheter-associated infections (CAI) pose the greatest threat to such vascular access, despite existing preventive measures. In this article one prospective and one retrospective study of CAI in pediatric therapy are presented. Study I: A retrospective investigation from 1990 through 1995 of 60 conventional long-term catheters in 50 patients. The total number of days in which the catheters were in place was 11,818. The calculated CAI incidence was 1 per 1,000 days of catheter insertion. Bacteriologically demonstrated CAI (identical isolate on the catheter tip and in a blood culture) occurred in three instances (5%). Five cases (8.3%) were diagnosed with a therapy-resistant, septic clinical picture. Study II: A prospective, randomized comparison of long-term silver-impregnated (Erlanger silver catheters) and control catheters (Quinton Instrument Co.) was made with 41 patients (20 with a silver catheter, 21 with a Quinton catheter). To date, the silver catheters have been distinguished by sterile bacteriological findings, whereas three cases of CAI have been demonstrated with the comparative catheters. One patient recently underwent intensive care after becoming unstable with signs of septic shock and demonstrable Pseudomonas aeruginosa, and two other patients manifested coagulase-negative staphylococci on the catheter tips. In three of nine control catheters an incidence of 1.18 per 1,000 days of indwelling catheters was found, whereas no CAI has occurred with the eight microbiologically tested silver catheters.

[New approaches to tissue management in minimal invasive pediatric surgery]. / Neue Ansätze für Gewebemanagement auf dem Gebiet minimal invasiver Kinderchirurgie.

Tissue management in minimally invasive surgery plays an important role in the indication for and feasibility of surgical interventions. Hemostasis and sealing of larger areas are possible with minimally invasive tissue gluing in liquid and bandage-bound form. For effective and efficient application of the precoated collagen fleece (TachoComb) a modularly constructed applicator (AMISA) was designed that is suitable for a wide range of indications in MIS and allows selective leak closure (SLC) in parenchymatous tissues with different lesions (Pneumothorax, Chylothorax, rupture of liver/spleen, biopsies, fistulae).

[Cyst, pseudocyst or carcinoma? Space-occupying lesions of the pancreas in childhood and adolescence]. / Zyste, Pseudozyste oder Karzinom? Raumforderungen der Bauchspeicheldrüse im Kindes- und Jugendalter.

A total of 29 children and adolescents underwent surgery for cystic (n = 2) or pseudocystic (n = 23) lesions or papillary-cystic neoplasms (n = 2) of the pancreas. The special conditions of paediatric patients (differential diagnosis, management and prognosis of posttraumatic, postnecrotic, inflammatory and malignant diseases) are discussed in the present literature.

["As much as possible"--an outdated concept in advanced neuroblastoma?]. / "As much as possible"--ein überholtes Konzept bei fortgeschrittenem Neuroblastom?

Complete tumor resection is often impossible in disseminated stages of neuroblastoma. Therefore, the role of primary tumor resection in neuroblastoma patients of stage III and IV will be discussed here. Between 1972 and 1995, 66 neuroblastoma patients were operated in our department of pediatric surgery, 41 of whom were treated before 1989 and are the subject of retrospective study. Eight children belonged to stage III, 15 to stage IV and two to stage IV-S. Primary tumor resection was carried out in 19 of 25 patients with disseminated tumor stages. Total resection (RO) was achieved in three cases (16%). Microscopic tumor remains (R1) were present in four, with macroscopic remains in 12 cases. Three disseminated neuroblastomas received preoperative chemotherapeutic treatment, followed by a delayed complete operative tumor resection in two cases. Temporary tumor remission after an incomplete primary operation (R2) was achieved with adjuvant postoperative chemo- and radiotherapy in six of 12 patients. The mortality rate was high (stage III: n = 5/8, stage IV: n = 14/15, stage IV-S: n = 2/2). We recommend preoperative chemotherapy in cases of infiltrative tumor growth of stage III and generally in stage IV. This therapeutic regime improves the rate of complete tumor resection with less intraoperative complications.

[Congenital duodenal stenosis in adulthood]. / Kongenitale Duodenalstenose im Erwachsenenalter.

A high-grade duodenal stenosis in adults can, in rare cases, be congenital, and its cause is found in an intraduodenally sited membrane. The anamnesis reveals growth disorders with vomiting and meteorism and abdominal complaints. A perforation opening in this membrane is the reason for survival into adulthood. The X-ray appearance and deep duodenoscopy make the diagnosis easy. Volvulus in cases of malrotation, Ladd's ligaments, annular pancreas, and compression of the duodenum by mesenteric vessels must be considered in the differential diagnosis. When the intraduodenal membrane is resected it is most important to expose the papilla Vateri, since this not uncommonly ends in the area of the septum. If necessary, a duodenoduodenostomy is performed. If the windsock web abnormality is present the duodenum should be opened at the point of attachment of the diaphragm. The construction of a gastrojejunostomy should be avoided.

[Acute mesenteric vein thrombosis. A rare complication after splenectomy due to autoimmune hemolytic anemia in childhood]. / Akute Mesenterialvenenthrombose. Seltene Komplikation nach einer Splenektomie aufgrund einer autoimmunhämolytischen Anämie im Kindesalter.

Mesenteric vein thrombosis is a rare but severe complication in children requiring splenectomy. We report on a 5-year-old boy with an autoimmune hemolytic anemia who underwent splenectomy because of severe side effects from cortisone therapy. 10 months after splenectomy he presented with signs of a paralytic ileus. Laparotomy showed mesenteric vein thrombosis with hemorrhagic bowel infarction requiring resection of two thirds of the small intestine. An early recognition and thrombolytic or surgical treatment of mesenteric vein thrombosis may reduce the incidence of hemorrhagic infarction, peritonitis, and secondary complications in these patients.

[Congenital cystic bile duct dilatation. Presentation of clinical symptoms, diagnostic possibilities and therapy based on 6 cases]. / Angeborene zystische Gallengangerweiterungen. Darstellung der klinischen Symptomatik, der diagnostischen Möglichkeiten und der Therapie anhand von 6 Erkrankungsfällen.

BACKGROUND AND METHODS: Congenital cystic dilatation of the bile ducts represents an uncommon anomaly of the biliary system. We report on 6 patients suffering from cystic biliary duct dilatations which were treated in our hospital between 1980 and 1992. Clinical signs included upper abdominal pain, white or clay-colored stool, icterus and/or palpable tumor. According to the classification of Todani, 4 children had type Ia cysts, 1 child a type Va cyst and 1 child a type Ia cyst with extrahepatic biliary atresia. RESULTS: Among the diagnostic methods sonography is preeminent and permitted demonstration of intra- and extrahepatic biliary duct dilatations in all of our patients. In 2 patients small cystic dilatations could be distinguished from hepatic vessels by colour-coded Doppler sonography. CONCLUSION: The treatment of choice is the resection of the dilated extrahepatic biliary ducts followed by hepaticojejunostomy using the Roux-en-Y-technique.

[Acute pancreatitis with formation of a pancreatic pseudocyst in a six-month-old female infant]. / Akute Pankreatitis mit Pankreaspseudozystenbildung bei einem sechsmonatigen weiblichen Säugling.

Acute pancreatitis and pancreas pseudocysts are rare events in children. We report an infant aged six months with the cardinal symptoms of abdominal pain, vomiting and fever. After the exclusion of an acute abdominal emergency conservative therapy was started. Due to the persistence of the symptoms an explorative laparatomy had to be done on day four of the illness. A postoperative seen fistula of the pancreas was successfully closed by a sandostatin therapy.

[Disseminated intravascular coagulation caused by prenatal hemorrhage into a congenital mesoblastic nephroma. Case report]. / Verbrauchskoagulopathie durch pränatale Einblutungen in ein kongenitales mesoblastisches Nephrom. Fallbericht.

We report the case of a premature female newborn of the 35th gestational week with a congenital mesoblastic nephroma. The tumor was prenatally diagnosed in the 32nd week of gestation. By close sonographic controls, rapid enlargement was verified towards the end of the 35th week of gestation. This was probably caused by hemorrhage into the tumor. Anemia and postnatal disseminated intravascular coagulation followed. Cesarean section was done, because the anemia was suspected by Doppler sonographic evaluation. Disseminated intravascular coagulation could not be sufficiently controlled by conservative means but only by surgical removal of the tumor. The tumor turned out to be a congenital mesoblastic nephroma by histologic evaluation. Despite postoperative anuria and catecholamine dependency, our patient eventually showed a very favourable outcome. Diagnosis, clinical behavior and therapy of this tumor with a generally good prognosis are described and discussed.

[Techniques and experiences in funnel chest operations]. / Techniken und Erfahrungen mit Trichterbrustoperationen.

Hegemann's technique of funnel chest correction using transsternal metal bar stabilization was adapted from the method published by Sulamaa and coworkers in 1958. Until the end of 1991, about 2400 chest wall corrections were performed in our department, more than 2000 of them using modifications of the original method. The principles of external chest wall measurement, our classification method, and the current operative modifications are described. In long-term follow-up examinations less than 3% recurrences should be possible.

[Appendicitis in early childhood]. / Die Appendizitis im frühen Kindesalter.

Between 1982 and 1987 550 appendectomies in children under sixteen years of age were carried out in our surgical department. Only 21 patients were children under 4 years of age, accounting for 4% of all patients. The perforation rate however, was 44% in contrast to 12% in older children. One reason is the more difficult, und therefore often delayed, diagnosis. The mean duration of symptoms of appendicitis in young children was 3.4 days. In the special case of perforated appendicitis the mean duration of symptoms was 132 hours, as compared with 42 hours in children without perforation. Clinical examination is decisive for the diagnosis. Fever and vomiting are non-specific symptoms, but frequently present. Some 81% of the patients had leukocytosis over 15,000. If there are any doubts about the indication for appendectomy, x-ray examination should be carried out as a further useful diagnostic procedure.

[Perioperative antibiotic prophylaxis in reconstruction of the thoracic wall]. / Profilassi antibiotica perioperatoria nella ricostruzione della parete toracica.

Thirty youngs and children were submitted to surgical reconstruction of excavated chest. To prevent risk of infections (by Staphylococcus and mixed gram-negative flora) preoperative 100 mg/Kg body weight of cefotaxime was given. In all patients the operative wounds healed regularly. To evaluate cefotaxime level and that of its metabolites raised in the tissues, the very sensibles method HPLC was applied. Thus 45 minutes after antibiotic somministration, very high levels were present in cartilage 9.8 mmg/gr and in bones (9.3 mmg/gr). Related to Staphylococcus aureus (MHK 90 of about 2 mmg/ml) results are of value also for other surgical orthopedic operations.

Short-term and long-term problems after duraplastic enlargement of anterior abdominal wall.

Between 1974 and 1989, 49 out of 83 children with gastroschisis or omphalocele underwent duraplastic enlargement of the anterior abdominal wall. The solvent dried dura proved to be the most useful material, which could be left in place even after a scar had formed. Abdominal complications depend on preexisting damage of the intestine and on the intraabdominal pressure resulting from closure. Long-term disturbances of the gastrointestinal and abdominal wall function are comparable to the results of other reconstructive methods.