Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract.

BACKGROUND: Alcoholics are at risk of developing major complications in the postoperative period. Adequate prophylactic treatment, as well as preoperative abstinence, can significantly decrease the rate of complications. However, the preoperative diagnosis of alcoholism is difficult to establish. The purpose of this study was to assess whether three preoperative visits, an alcohol-related questionnaire (CAGE), and the laboratory markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) would increase the rate of detection of chronic alcoholics. METHODS: The study included the Departments of ENT, Facial and Maxillofacial Surgery, and General Surgery of a university hospital; 705 male patients were assessed for tumor surgery of the upper digestive tract and were allocated to 5 different groups. All patients were seen three times, and five different strategies were used to detect chronic alcoholics. The gold standard was the diagnosis of alcohol misuse made by an experienced (blinded) investigator according to the DSM-III-R. The main outcome measurements were the detection rates of the different test strategies. RESULTS: By clinical routine alone, only 16% were detected during the first visit and 34% after three visits. If the CAGE questionnaire was added, sensitivity increased to 64%. The further addition of GGT or CDT led to 80 and 85% detections, respectively. A combination of all tests had a sensitivity of 91%. CONCLUSIONS: To detect more alcoholic patients at risk for major complications, patients should be seen more often, and additional diagnostic tools such as the CAGE, CDT, and GGT should be used before surgery.

[Injectable silicon--long term sequelae after use in plastic surgery]. / Injizierbares Silikon Folgen der Anwendung in der plastischen Chirurgie. Folgen der Anwendung in der plastischen Chirurgie.

The injection of fluid silicone was formerly an acceptable therapy for recontouring post-traumatic or age-related changes of the face and neck. About 20 years after the use of silicone injections, the number of patients presenting with late complications is increasing. Such complications include migration of the silicone, granuloma formation, chronic cellulitis, skin ulcers and and scarring, all of which are difficult to treat medically or surgically. Recent data in the literature support the notion that fluid silicon is a potential carcinogen. These patients require a careful approach combining the limited surgical possibilities with the support needed to live with such a problem. Using a case report as an example, we discuss the diagnostic and therapeutic problems associated with this phenomenon which is relatively uncommon in Europe.

Human demineralised bone matrix as a bone substitute for reconstruction of cystic defects of the lower jaw.

In a retrospective study validated by a standardized clinical and radiological examination, the bone regeneration in 90 patients with cystic mandibular defects was examined. In 50 patients bony defect reconstructions with human demineralised bone matrix (HDBM) were carried out, while in a comparable group of 40 patients the hollow pockets were left to regenerate bone spontaneously. The bone regeneration after the implantation of human demineralised bone matrix (HDBM) was subjected to a comparative validation. Osteoinductive proteins present in HDBM (bone morphogenetic proteins) can diffuse into the implant seat and induce new bone formation (osteoinduction). A markedly faster and more thorough bone regeneration was demonstrated after the surgical therapy of cystic mandibular lesions with HDBM than without. HDBM also proved to be exceptionally biocompatible.

Validation of bone conversion in osteoconductive and osteoinductive bone substitutes.

Bone reconstruction can be performed with an autogeneic graft from various donor regions. Osteoconductive and osteoinductive bone substitutes originate from substances of diverse chemical and morphological types and can have a synthetic or a biological derivation. Alongside autogeneic bone transplants and allogenic and xenogeneic bone implants, alloplastic bone replacements of synthetic or semi-synthetic origin are being used for defect reconstruction. In an animal model in rabbits five bone substitutes and one autogeneic graft were surgically incorporated into identical bone defects (10times 10 mm in size) in six anatomically defined regions of the skull. With scintigraphic and histological methods, the metabolic dynamics of the bone is examined as it reacts to the transplantation of autogeneic bone or to implanted bone replacement material.The different autogeneic, xenogeneic and alloplastic bone replacement materials can be differentiated according to the functional quality of the new tissue and the dynamics of the bone conversion thus induced. In the comparison of mineralized, osteoconductive bone subsitutes (TCP, HA, calcium carbonate ceramics) with demineralized, osteoinductive implants (DBM new, DBM old) and autogeneic bone grafts, the bone inducing matrices show the largest quantity of new bone formation, making possible a volume-constant reconstruction.

Refinement of velopharyngoplasty in patients with cleft palate by covering the pharyngeal flap with nasal mucosa from the velum.

The velopharyngoplasty performed using the popular Sanvenero-Rosselli method improves the speech quality of patients with cleft palate suffering from persistent velopharyngeal insufficiency despite successful closure of the hard and soft palates. However, often a relatively narrow pharyngeal bridge results due to healing not only by granulation and scar contraction, but also due to the insertion of the inferior tip of the flap into a narrow bed. Elevation of two velar flaps with nasal mucosa to cover the exposed muscular undersurface of the pharyngeal flap produces a broader recipient bed into which the pharyngeal flap can be spread. The speech quality of 27 patients treated with this modified method (group B) was compared with that of 27 patients without this modification (group A). Eight weeks after velopharyngoplasty (followed by uneventful wound healing) the speech quality of group B was significantly better than that of group A (p<0.03 MannWhitney U-test). This difference was even more evident when comparing the preoperative with the postoperative speech quality (p<0.005). Thus, covering the exposed muscular layer of the pharyngeal flap with nasal mucosa of the velum is an important modification of velopharyngoplasty for the improvement of speech quality.

[Speech improvement with velopharyngoplasty in patients with lip-jaw-palate clefts]. / Verbesserung der Sprache mit Hilfe der Velopharyngoplastik bei Patienten mit Lippen-Kiefer-Gaumenspalten.

BACKGROUND: Despite successful closure of the hard and soft palate and intensive speech therapy a velopharyngeal insufficiency is not completely avoidable in each case of cleft palate. An improvement by velopharyngoplasty should be possible. PATIENTS AND METHODS: Two hundred and ninety patients suffering from cleft palate were examined before and one year after velopharyngoplasty according to Sanvenero-Rosselli. Four main symptoms of the affected speech were assessed: changes of the resonance, inappropriate nasal air emission, articulary disorders (deviations from articulation areas), and non-physiological facial expression during speaking, each divided into three grades. Afterwards, the complete speech quality was classified. RESULTS: Assessing the symptoms separately and summarised the therapy including velopharyngoplasty was suitable to improve the speech quality in 83.1% of the cases, resulting in a widely unaffected speech. The improvement was greater in younger patients undergoing operation (Gamma-test, p < 0.001). But the final results were independent from age due to poorer initial situation in younger patients (Gamma-test, p < 0.001). CONCLUSIONS: The velopharyngoplasty is an important method for repair of velopharyngeal insufficiency in patients with cleft palate. In each individual case it is necessary to consider carefully if and when this operation should be performed. An intensive interdisciplinary co-operation of all specialists involved in the treatment is indispensable.

[Keratocysts of the jaws with an expansion to the skull base]. / Keratozysten der Kiefer mit Ausbreitung in die Schädelbasis.

Ceratocysts prefer attaint the jaws solitarily or multiply. Familiar heapings are described in connection with the naevoid basal cell carcinoma syndrome (Gorlin-Goltz-Syndrome). In most of the patients they are removable simply by enucleation. The histological typing as a cyst suggests a harmlessness of the disease. There is a significant higher amount of recurrent cysts compared to other odontogenous cysts, whereas clinical symptoms are absent for a long time. That give reasons for findings of breakthrough to the skull base. There are no real alternatives for the impairing operation procedures. It is reported about 69 patients with ceratocysts. In 6.9% a breakthrough to the skull base was found. Therefore a radical operation procedure and a close meshed postoperative checking management with regular MRI and conventional x-ray will be demanded.

[3-phase bone scintigraphy of microsurgically attached bone transplants as early graft survival assessment]. / Die Dreiphasen-Knochenszintigraphie mikrochirurgisch angeschlossener Knochentransplantate als früher Vitalitätsnachweis.

Vascularized bone grafts do not allow direct graft monitoring during the early postoperative period. The first two weeks are critical for the blood supply and viability of the graft. Three-phase bone scintigraphy, performed between the 7th and 14th postoperative day, was valuable in predicting the survival of vascularized bone grafts. It is a simple and safe method for the evaluation of blood supply of both the graft and the graft-surrounding tissue. Clinical data, obtained from studying 17 patients,/led to the conclusion that three-phase bone scintigraphy plays an important role in the process of decision-making on surgical reexploration.

Prognostic importance of the expression of CD44 splice variants in oral squamous cell carcinomas.

Considering squamous cell carcinomas (SCCs) of the oral cavity and oropharynx the molecular mechanisms underlying the infiltration and destruction of adjacent tissue as well as the metastatic spread are largely unknown. In this context, the detection of defective expression of cellular adhesion molecules in the tumour cells, e.g. CD44, might be important and correlated with prognosis. Paraffin-embedded tumour-tissue from 99 patients with primary oral and oropharyngeal SCC, additionally including corresponding lymph-node metastases in nine cases, was analysed for expression of the CD44 splice variants v4, v5, v6, v7, and v9 by means of immunohistochemistry. A diminution of at least one of the examined CD44 isoforms compared to the normal oral epithelium was observed in 39.4% of the squamous cell carcinomas. No correlations could be found between CD44 expression and pT- or pN-stage. However, decreased expression of v9 was correlated with higher histological grade (p < 0.001). Moreover, reduced CD44 expression was a statistically significant independent predictor for shorter survival time (p = 0.002) as well as shorter recurrence-free interval (p = 0.004) in addition to pT- and pN-stage. The separate analysis showed that particularly the decreased v7 (p = 0.04) and v9 (p < 0.02) expression in the tumour cells was associated negatively with survival.

[Craniofacial abnormalities in the Charité Virchow Collection]. / Kraniofaziale Fehlbildungen in der Virchow-Sammlung der Charité.

On 27 June 1899 Rudolf Virchow (1821-1902) inaugurated the Museum of Pathology at the Charité Hospital. The collection comprised 23,500 pathologic-anatomical specimens. Most of the collection was destroyed in World War II. About 2000 samples were saved. Meanwhile the stock has increased to about 9000 objects. The development, contents and structure of the famous Virchow Collection are described with special reference to craniofacial deformities.

[Natural coral calcium carbonate as alternative substitute in bone defects of the skull]. / Natürliches korallines Kalziumkarbonat als alternativer Ersatz bei knöchernen Defekten des Schädels.

A biomaterial derived from natural corals with surgical applications is the calcium carbonate Biocoral. Since 1992 the author has been using this material as a bone graft substitute in maxillofacial surgery. Eighty-nine clinical implantations were done in 68 patients for different indications. The results suggested that coral grafts are well tolerated and are simultaneously partially ossified as the calcified skeleton is resorbed. Clinical cases show that use of this material has been successful.

[Craniofacial deformities in the Virchow Collection at the Charité Hosptial]. / Kraniofaziale Fehlbildungen in der Virchow-Sammlung der Charité

On 27 June 1899 Rudolf Virchow (1821-1902) inaugurated the Museum of Pathology at the Charité Hospital. The collection comprised 23 500 pathologic-anatomical specimens. Most of the collection was destroyed in World War II. About 2000 samples were saved. Meanwhile the stock has increased to about 9000 objects. The development, contents and structure of the famous Virchow Collection are described with special reference to craniofacial deformities.

[Biocoral--an alternative bone substitute]. / Biocoral--ein alternativer Knochenersatz.

Biocoral is a biomaterial derived from natural corals, and it has surgical applications. Since 1992 the author has been using this material as a bone graft substitute in maxillofacial surgery. Seventy-seven clinical implantations were done for different indications. The results suggest that coral grafts are well tolerated and become partially ossified when the calcified skeleton is resorbed. This material has been demonstrated to be successful.