[Displaced pain pump because of a pendulous abdomen - dermatolipectomy as solution of the problem]. / Rezidivierende Luxation einer Schmerzpumpe aufgrund einer Fettschürze - Problemlösung durch Dermatolipektomie.

A female patient with a chronic pain syndrome after multiple operation on her muskuloskeletal system presented with a displaced pain pump in her lower left abdominal region. After an excessive weight loss due to gastric banding the patient developed a massive pendulous abdomen causing the complication. An interdisciplinary dermatolipectomy together with a refixation of the pump was performed. Since this operation a recurrence of the displacement has not been observed and consecutively the filling of the pump could be accomplished without radiological investigations. This rare case demonstrates the significance of interdisciplinary treatment in which a primarily aesthetic intervention was necessary for a successful therapeutic outcome.

Anti-infectious prophylaxis after splenectomy: current practice in an eastern region of Switzerland.

Overwhelming post-splenectomy infection (OPSI) is a long-term risk in asplenic patients, which may be minimised by appropriate preventive measures. In this survey anti-infectious strategies after splenectomy were evaluated in an eastern part of Switzerland. We found 91 individuals in the canton of Thurgau, who underwent splenectomy between 1998 and 2003. We assessed adherence to vaccination guidelines, the use of antibiotics and the awareness of the infectious risks by review of hospital charts and by structured interviews with patients and their general practitioners. The total vaccination rate was 64/91 (70%). 6 patients were vaccinated pre-operatively, 50 during the hospital stay and 8 after discharge by the general practitioner. 64 received vaccination against pneumococci, 6 against haemophilus influenzae and 3 against meningococci. Although 39 died during the study period, none died of overwhelming sepsis. None of the patients received a booster vaccination. Prophylactic long-term antibiotics were given to 2 children but to none of the 89 adults. Three adults had a supply of stand-by antibiotics at home. Less than half of the patients who were interviewed knew that asplenia puts them at greater risk for life-threatening infections and few practitioners were aware that travel and animal bites pose a special threat. We conclude that after splenectomy vaccination discipline and patient education should be substantially improved and suggest the publication of comprehensive guidelines.

[Intramedullary Kirschner wire osteosynthesis in treatment of distal metacarpal fractures]. / Die intramedulläre Kirschner-Drahtosteosynthese zur Behandlung distaler Metakarpalfrakturen.

The intramedullary Kirschner wire fixation of distal metacarpal fractures reported by Foucher et al. combines the known advantages of intramedullary implants with a reduction of iatrogenic soft tissue trauma. We applied this minimal invasive internal fixation technique in 38 patients with fractures dislocated by more than 20 degrees and/or with rotatory deformity. After opening the intramedullary cavity from the base of the respective metacarpal bone and after fracture reduction, two pre-bent Kirschner wires were intramedullary inserted in an orthograde fashion. The pre-bent distal end of the wire in the form of a hockey club allows an additional closed reduction of the displaced distal fracture fragment. Intraoperative complications did not occur. A fixation in a plaster splint followed for one week only. The elastic fixation of the wires working as springs is stable enough to allow physiotherapeutic exercises. After the third postoperative week, the intensity of physical exercise was increased. 36 of the 38 patients were followed. With one exception, all fractures were healed in a proper position. The wires were removed under local anaesthesia on an outpatient basis after six to eight weeks and full mobility of the fingers was achieved in 34 patients at that time. Complications included one redislocation and one distal wire perforation.

[Vacuum sealing of problem wounds]. / Vakuumversiegelung bei Problemwunden.

Within the scope of a retrospective study, the efficiency of the vacuum sealing technique, a recent alternative to methods used in treatment of both chronic or acute infected wounds and acute traumatic soft tissue defects, was evaluated in 120 patients in the period between January 1995 and November 1997. The vacuum sealing technique offers an effective therapeutic option for the temporary closure of defect as well as of infected wounds, decreases the risk of wound infection and offers advantage regarding patient's comfort and hospital hygiene.

Optimising the use of carotid duplex sonography.

AIM: We analysed factors influencing diagnostic yield and treatment and their potential for optimising the use of carotid duplex sonography (CDS). METHOD: Patients referred for CDS were divided into three groups: 1: high likelihood of carotid symptoms, 2: suspected presence of asymptomatic carotid lesions, 3: other indications. Clinical data, the grading of stenosis and the therapeutic consequences were analysed. The efficiency of diagnosis was tested with an algorithm. RESULTS: 344 patients were included. Groups 1, 2 and 3 contained > or = 1 pathological finding in the carotid or vertebral system in 68%, 86% and 55% respectively, whereas high-grade stenoses or occlusions of the internal carotid artery (ICA) were detected in 10.8%, 16% and 3.6% respectively. Age > 50, > 1 risk factor, carotid murmur and concomitant vascular disease were associated with a significantly higher diagnostic yield. Subsequent treatment in groups 1, 2 and 3 involved carotid thromboendarterectomy in 6.4%, 2% and 0.7% respectively and the start of treatment with a platelet aggregation inhibitor in 9%, 30% and 17% respectively. The optimisation algorithm would have saved 21% of CDS scans. CONCLUSION: Clinical pre-selection criteria determine the diagnostic yield of CDS. The potential for optimisation depends on the treatment regimen chosen for asymptomatic stenoses and secondary prophylaxis.

[Acute arterial occlusion of the extremities. Rate of success following simple embolectomy and following combined procedures]. / Der akute arterielle Verschluss der Extremitäten. Erfolgsrate nach einfacher Embolektomie und nach kombinierten Verfahren.

Acute arterial obstruction of the extremities represents the most common emergency in vascular surgery. Diagnosis is based on the typical history and clinical symptoms. Emboli in vessels without atherosclerotic changes can be removed by simple embolectomy. In atherosclerotic arteries or in cases of acute thrombotic occlusion preoperative angiography is recommended in order to perform extensive reconstructive procedures. 400 arterial reconstructions for acute obstruction of the extremities were analysed. 46 operations were done in the upper extremities. In the majority of the cases simple embolectomy was successful. Limb salvage was 100% although one embolectomy and one bypass procedure failed to restore full revascularization. Complication and mortality rate was low. 354 lower limbs were operated. 274 extremities could be saved (77.4%). Among 80 poor results 48 major amputations had to be done (13.5%). Perioperative mortality was 12.4%. Death was mainly attributed to myocardial infarction.

[Is in esophago-intestinal anastomosis the use of mechanical staplers an advantage?]. / Ist bei ösophagointestinalen Anastomosen die Verwendung maschineller Klammernahtgeräte vorteilhaft?

Sixty-seven consecutive esophageal anastomoses were performed in a period from 1984 to 1987. 35 esophagoenterostomies performed in manual single layer suturing were compared with 32 esophagoenterostomies using mechanical stapling. After manual suturing there was a leak in 8.6%. After mechanical suturing anastomotic failure was seen in 6.2%. The analysis of mortality and morbidity indicate the use of mechanical staplers as a favorable alternative.

[The value of various imaging technics in the preoperative diagnosis of choledocholithiasis]. / Der Stellenwert der verschiedenen bildgebenden Verfahren in der präoperativen Diagnostik der Choledocholithiasis.

In a retrospective study different methods of detecting choledocholithiasis-sonography, intravenous cholangiography, computed tomography and transhepatic cholangiography-have been compared to evaluate their accuracy. A total of 130 investigations in 93 patients were analysed. Choledocholithiasis could be predicted by sonography in 42.9%, by intravenous cholangiography in 60% and by transhepatic cholangiography in 85.7%. The overall accuracy rate with a single investigation was 51.6%. The combination of different methods increased the accuracy rate of 81.6%. We use sonography as the screening examination. In unclear cases transhepatic cholangiography has proven helpful in demonstrating choledocholithiasis. Only cholangiography, together with cholangioscopy, is performed intraoperatively. Due to high cost and limited availability, computed tomography should not be used as a basic examination.

Operated bronchial carcinoma: a review of 230 cases.

Two hundred and thirty patients, treated by resection for bronchial carcinoma, were analysed. The histological examination showed in 80% a squamous cell carcinoma, in 11.3% an adenocarcinoma, in 5.3% a large cell and in 3.4% a small cell carcinoma. There was a great difference between preoperative and postsurgical TNM-classification: 90% stage I preoperatively and only 68.3% after resection with mediastinal lymph node dissection. Twenty-four patients (10.4%) died during the first 30 days after operation. The main cause of death was cardiac failure or respiratory insufficiency. Forty-four patients (19.1%) had non-fatal complications. Atelectasis and pneumonia predominated. Survival without regard to stage and cell type was 27.6% at 5 years. As expected survival rate in T1N0M0 was best (40%). Therefore early detection of bronchial carcinoma is essential.

[Experiences with homologous umbilical cord veins in vascular reconstructive surgery]. / Erfahrungen mit homologen Nabelschnurvenen in der gefässrekonstruktiven Chirurgie.

12 homologous umbilical cord veins prepared according to the method of MINDICH from February to November 1978 were used as either femoro-femoral or femoro-popliteal bypass. 6 of the 12 implanted umbilical veins after an average of 4 months were still open and showed good results, whereas 4 were blocked by thrombosis due to bad outflow conditions or dissection. On two implants that had had to be removed, histological examinations were used, and these showed a destruction of the graft's wall. In contrast to the advantages of their problem-free availability and good technical suitability stands the destruction of these grafts observed by us and hence the questionable nature of tenacity in the receiver. Further experiences of longer duration dealing with this interesting subject of vascular substitute are needed.