[Limited resection or radiofrequency ablation for high risk patients]. / Limitierte Resektionen oder Radiofrequenzablationen bei Hochrisikopatienten.

The standard care for treatment of patients in good general conditions with stage 1 non-small cell lung cancer (NSCLC) is surgical resection by lobectomy and radical mediastinal lympadenectomy. Promising alternative treatments have been developed for high risk patients, who are (medically) inoperable due to bad general conditions. If lobe resection is not possible because of comorbidities or limited pulmonary function, we can offer less invasive surgical resection such as anatomic segmental resection or broad non-anatomic wedge resection. The results are similar to standard procedure, but the local recurrence rate is higher. Additional brachytherapy improves the outcome. Interventional radiological procedures are emerging as promising treatment options. First thermal methods such as radiofrequency ablation (RFA), microwave ablation (MWA) and kryoablation are available. In addition selective chemoembolisation by a vascular catheter-guided access allows local chemotherapy. The above-mentioned alternative treatments generate encouraging findings, but they should be applied only in clinical trials.

Morbidity in surgery: impact of the 50-hour work-week limitation in Switzerland.

PRINCIPLES: Work-hour regulations for residency programmes in Switzerland, including a 50-hour weekly limit, were set in on 1 January 2005. Patient safety was one of the major arguments for the implementation. As the effect of the restriction of residency work hours on patient care in Switzerland has not yet been evaluated on objective data, the aim of the present study was to assess its impact by comparing the patients' morbidity and mortality before (2001-2004) and after (2005-2008) the implementation. METHODS: Retrospective analysis of records of the Spitalzentrum Biel AG, a large referral center classified according to the Swiss Medical Association, collected in the database of the Association for Quality Assurance in Surgery (AQC), a prospective database of consecutive patients undergoing surgical procedures in Switzerland. A selection of 2,686 patients with common surgeries, operated on by residents, was performed. RESULTS: There were 1,259 (46.9%) patients meeting our inclusion criteria who were admitted during the period before introduction of work-hour limitation and 1,427 (53.1%) patients after introduction. The in-hospital mortality and postoperative surgical complication rate were significantly higher after the reform (p <0.05 and p <0.01, respectively). No significant differences could be found concerning the overall intraoperative (p = 0.61) and postoperative medical complication frequencies (p = 0.08). CONCLUSIONS: The work-hour limitation implemented in Switzerland was not associated with surgical patient safety measure improvement for common surgeries (i.e., morbidity and mortality rate). Further research on a nationwide basis is needed to assess the value of the higher surgical complication and mortality rate.

[Intercostal nerve syndrome]. / Das Intercostalnerven-Syndrom.

The intercostal nerve syndrome is caused by an impingement of the intercostals nerve at the level of the anterior rectus sheath. It may lead to acute or chronic abdominal pain, it should therefore be considered in the differential diagnosis of the acute or chronic abdomen. A positive Carnett-test and an effective local anaesthesia at the point of maximal tenderness allow the correct diagnosis. In our retrospective study 14 patients with 15 entrapment syndromes are described. If, sometimes after a few diagnostic and therapeutic detours, the diagnosis is established, surgical intervention with resection of the altered nerve at it's exit of the anterior rectus sheath can usually abolish the pain with little side effects.

[Ambulatory treatment of varicose veins]. / Ambulante Behandlung der Varikose.

Only a small part of the varicose veins need inpatient treatment. Restricting strippings to the diseased saphenous segments and the use of Muller's technique ('phlébectomie ambulatoire') permits the majority of patients to be treated on an ambulatory basis. In 1990 and 1991, 453 of 723 operations were performed under local anesthesia. 233 of the 686 insufficient long and short saphenous veins were treated by high ligation-with or without stripping-in local anesthesia. The limitations of ambulatory surgery are defined by the extension of the varices and by the presence of a seriously diseased long saphenous vein necessitating a stripping.

[Indications for and results of ambulatory varices therapy]. / Indikationen und Ergebnisse der ambulanten Varizentherapie.

The introduction of the stab-incision--phlebectomy (Muller's technique)--has opened a large field for ambulatory surgery. This is specially true when phlebectomy is combined with a saphena-femoral or saphena-popliteal ligature. In a series of 1825 operations including 1592 incompetent saphenous veins 1216 (67%) were performed under local anesthesia. Radical surgery of incompetent short saphenous veins as well as of minor forms of varicose long saphenous veins is feasible in local anesthesia. Regional or general anesthesia (609 operations) are still recommended for stripping procedures in advanced long saphenous varices. In most cases phlebectomy of varices (553) provides a better cosmetic result than sclerotherapy, the latter being the treatment of choice for small veins and telangiectasias. Ambulatory surgery and sclerotherapy are cost-effective and low-risk treatments. No deep vent thrombosis or pulmonary embolism was observed in this group, whereas 1 DVT and 2 PE occurred in the 609 operations performed under general anesthesia.

[Methods and current therapy of varicosis]. / Formen und moderne Therapie der Varikosis.

Improvements in the surgical approach to varicose veins have resulted in more elaborate and less traumatic surgery. Removing varicosities through mini-stab incisions just a few millimeters long, and individual shortening or even omitting of the stripping manoeuvre, reduce lesions to surrounding tissues and improve the cosmetic result. The condition sine qua non for tailored treatment is careful examination and classification of the varicose veins based on pathofunctional properties and less on the visible appearance. In addition to clinical examination, Doppler investigation is recommended to assess the origin of the varicosities. Evidence of a reflux from the deep into the superficial venous system is the criterion for stem varices and incompetent perforators. No leaking points of importance can be demonstrated in the other two groups of varicosities, namely in reticular varices and in spider webs. Treatment of these minor forms and of small perforators is sclerotherapy, whereas surgery is recommended for saphenous incompetence and big perforators.

Major lower extremity amputation in patients with peripheral arterial insufficiency with special reference to the transgenicular amputation.

The selection of the proper level for lower extremity amputation in patients with advanced arterial ischemia poses a multiplicity of problems with regard to operative mortality, stump healing, re-amputation rate and rehabilitation status. In a retrospective study all these parameters have been evaluated in 413 patients submitted to below-knee (bk, n = 196), transgenicular (tg, n = 93) and above-knee (ak, n = 124) amputation between 1971 and 1980. As compared to the ak resection, the bk amputation has the following advantages: lower operative mortality (9% vs. 30.5%), higher prosthetic fitting rate (85% vs. 66%) and significantly improved rehabilitation (walking with artificial limb: bk 84%, ak 22%). Regarding surgical mortality (8.5%) and prosthetic gait (66%), the tg amputation was nearly equivalent to the bk resection and turned out to be clearly superior to the ak amputation. As compared to the latter procedure, knee disarticulation and bk amputation had a greater risk of delayed wound healing and re-amputation at a higher level (ak: 13.5 resp. 1%, tg: 22.5 resp. 25%, bk: 35% resp. 16%). The patient with a bk amputation has the best prospect concerning a successful rehabilitation. Whenever the very important knee joint cannot be saved an ak amputation should be avoided in favour of a knee disarticulation.

[Acute ischemic syndrome of the foot following sclerotherapy of varicose veins]. / Das akute Ischämiesyndrom des Fusses nach Varizenverödung.

The inadvertent injection of the sclerosant into an artery is the most serious complication of sclerotherapy. Four cases are presented, in all of which the posterior tibial artery was involved with resulting necrosis of portions of the foot. In one case a below-knee amputation was necessary. The necrosis depends mainly on the amount of the injected sclerosant. A noteworthy improvement due to specific therapy seems rare and was seen in only one of our cases. In this instance regional fibrinolysis was performed, whereas in a second case this approach proved detrimental. It appears to be much simpler to prevent this severe complication by adequate injection technique.