Outcome and management of blunt liver injuries in multiple trauma patients.

BACKGROUND: In Germany, abdominal trauma in multiple- trauma patients can be observed in about 25-35% of all cases. Due to major bleeding complications, the initial treatment of blunt abdominal trauma in multiple-trauma patients has high priority. The aim of this study was to discuss management, treatment and outcome of blunt liver injury in multiple-trauma patients treated in our department. METHODS: The clinical records of 1192 multiple-trauma patients [injury severity score (ISS) 3-18] treated at the Surgical Department of the University Clinic of Essen from January 1975 to February 1998 were reviewed. Seventy-five patients with an ISS above 18 operated on due to a blunt liver injury could be included. The mean age was 29.82+/-1.80 years (60 males and 15 females). The degree of injury in this group was high (ISS 37.12+/-1.06). RESULTS: Twenty-three of the 75 (30.6%) patients died during their hospital stay. Deceased patients were older (27+/-2 years versus 37+/-4 years; P<0.01) and had a higher ISS (ISS=34.5+/-1 versus 43.2+/-2; P<0.01). In nine cases, death was strongly related to liver injury. Operational blood loss was higher in the group of multiply injured patients with liver injury and in those patients who did not survive (P<0.05). An increased mortality could be seen in this selected patient group when compared with our large collective of multiply injured patients. The age of the patients, the ISS and operative blood loss were the significant factors that influenced the operative mortality after blunt hepatic injuries in our study.

Subtotal adrenalectomy by the posterior retroperitoneoscopic approach.

The retroperitoneoscopic approach offers an established operative procedure for primary adrenal gland tumors. It allows a detailed view of the adrenal gland and its surrounding region. Therefore clear differentiation between normal and neoplastic adrenal tissue is sometimes possible, permitting a planned, unilateral, subtotal resection of the gland. Between July 1994 and August 1997 primary benign adrenal gland tumors (11 Conn adenomas, 4 phenochromocytomas, 4 Cushing adenomas, 3 hormonally inactive tumors; 2.4 +/- 1.2 cm in size; 8 on the right, 14 on the left) were removed from 22 patients by the posterior retroperitoneoscopic approach maintaining tumor-free portions of the ipsilateral adrenal gland. Two patients suffered from bilateral pheochromocytomas associated with multiple endocrine neoplasia (MEN-IIa) syndrome and had previously undergone complete adrenalectomy of the contralateral gland. Following subtotal resection the operating time and blood loss did not differ significantly (p > 0.05) from that seen with complete extirpation (46 patients operated during the same period). All patients with Conn adenomas and pheochromocytomas were biochemically and clinically cured (follow-up 11 months; range 1-31 months). The four patients with Cushing adenoma currently require decreasing cortisol substitution. In the two MEN-II patients adrenal gland cortical function could be maintained; one patient is on low-dose steroid supplementation and the other on none. No local recurrence of tumors has been observed. In selected cases the retroperitoneoscopically performed subtotal adrenal gland resection is a safe procedure that can potentially maintain the function of the adrenal gland cortex.

[Open approach or Veress needle in laparoscopic interventions? Results of a prospective randomized controlled study]. / Offener Zugang oder Veress-Nadel bei laparoskopischen Eingriffen? Ergebnisse einer prospektiv randomisierten Studie.

In a prospective randomized study on 50 patients undergoing laparoscopic surgery, the safety and feasibility of open access laparoscopy was analyzed and compared to the closed Veress needle technique. Open access laparoscopic surgery was performed in half the time needed for the Veress needle technique with equal safety and without complications or technical disadvantages. Furthermore, open access offers economical advantages, as disposable trocars are no longer needed. Therefore the open access technique is recommended as the standard for laparoscopic operations.

[Translaryngeal tracheostomy. Technique and initial results]. / Die translaryngeale Tracheostomie. Technik und erste Ergebnisse.

Translaryngeal tracheostomy is a new type of minimally invasive technique for bedside tracheostomy in intensive care patients. After percutaneous puncture of the trachea below the first tracheal ring, a conic tracheal cannula is fixed to an orally forwarded guide wire. The cannula is then pulled through in orthograde fashion set up, rotated and pushed forward caudally. Among the first 25 translaryngeal tracheostomies in 24 patients, only two complications appeared: one misplacement of the cannula and one infection of the stoma. During a median apnoea time of about 80 s an average PaCO2 increase of 8.0 +/- 6.8 mm Hg was documented; hypoxias could not be seen. Translaryngeal tracheostomy seems to be an appropriate alternative to established tracheostomy methods.