[Management of ruptured aortic aneurysms in routine service of a surgical department]. / Die Versorgung rupturierter Aortenaneurysmen im Routinebetrieb einer chirurgischen Abteilung.

In the year 1989 859 patients with infrarenal aortic aneurysms were treated in the Hessen county (5.6 mill inhabitants) (private survey). 64% of the ruptured aneurysms were operated in 24 departments for general surgery and 36% were operated in the 7 departments for vascular surgery. Corresponding numbers for elective operations are 55% respectively 45%. The results after resection of the aneurysms in our 22 patients with ruptured aneurysms (1986-1989) reveal a letality of 50%. No patient arriving at our clinic alive was excluded from operation. Letality in electively operated patients (n = 131) during the same period was 2.3% (n = 3).

Parathyroid localization.

Twenty-nine consecutive patients with suspected primary hyperparathyroidism were examined preoperatively using ultrasound, sonographically guided fine needle aspiration, and aspirate immunostaining for PTH. In 25 patients, localization of enlarged parathyroid glands was successful. In 2 patients, the tumors were located retrosternally and, thus, could not be detected by ultrasound. One patient had a multinodular goiter which impeded localization. In 1 patient with renal osteodystrophy, 2 enlarged parathyroid glands in the neck were not visualized preoperatively. Cytology was not diagnostic, although some cytological features were suggestive of parathyroid cells. Immunostaining of the aspirated smears for PTH, however, correctly diagnosed all preoperatively localized lesions. Ultrasound should be the routine procedure of choice for preoperative localization of abnormal parathyroid glands in primary hyperparathyroidism. Fine needle aspiration and immunocytochemistry can supply confirmation, if necessary.

[Operative treatment of asymptomatic carotid stenosis]. / Operative Behandlung asymptomatischer Carotisstenosen.

Over a period of five-and-a-half years 183 patients with high-grade asymptomatic carotid stenoses in stage I were operated upon. Postoperative mortality was 0.5%; there was no permanent morbidity. Cumulative survival rate after four years was 68%. The proportion of patients without neurological disorders after five years was nearly 100%. Asymptomatic re-stenoses were found in 6% of patients. Principal cause of death during the follow-up period was of cardiac origin (9 of 17).

[Imipenem/cilastatin in surgical intensive medicine]. / Imipenem/Cilastatin in der chirurgischen Intensivmedizin.

26 patients from the surgical intensive care unit, University Hospital Lübeck, received imipenem/cilastatin for severe abdominal, respiratory or urogenital infections. 500 mg imipenem/cilastatin were infused i.v. over 30 min q. i. d. The treatment was successful in 84,6% of the patients suffering from severe infections. Two cases were considered to be failures. 36 of the 43 isolated pathogens (83.7%) were eliminated. Transitory elevations of liver enzymes were the most frequent side-reactions observed; an increase in serum creatinine, diarrhoea or fungal colonization were less common.

[Surgical therapy of cerebrovascular insufficiency with reference to advanced age]. / Chirurgische Therapie der zerebrovaskulären Insuffizienz unter Berücksichtigung des Lebensalters.

After brief discussion of epidemiology, aetiology, localization, diagnosis and surgical management of vascular stenoses leading to cerebral insufficiency, the results of 433 carotid artery TEAs are reported. Short- and long-term results were investigated to determine to what extent age of the patients affects outcome. The analysis of our patients sample showed with respect to perioperative mortality, morbidity and long-term outcome no significant difference between the under- and over-70-year age groups. In stage I (asymptomatic bruits) the perioperative mortality of the younger group (N = 119) was 1% and in the older group no perioperative death occurred. The long-term survival rate and the proportion of patients without neurological dysfunction after 4 years was 65% and 85% respectively for the younger group and 88% and 80% for the over 70-year age group. In stage II patients (with transient ischaemic attacks) the perioperative mortality was the same for both groups (2%). The long-term survival rate for the younger group (N = 106) was 77% and 76% in the older group (N = 91) proportion of patients without neurological dysfunction was 87% for the younger group and 93% for the older patient sample. There were no patients with stage III occlusion (acute stroke) in our patient sample. In stage IV (completed stroke) the younger patients had a perioperative mortality of 5.7%. In the older group (N = 18) no patient died perioperatively. The 2-year survival rates were 61% for the older age group and 57% für the younger. The corresponding proportions of patients without neurological dysfunction after 4 years were 83% and 71% for the older and younger patient groups respectively.

[Profundaplasty--a palliative operation in leg arterial occlusion of the aged?]. / Die Profundaplastik--eine Palliativoperation beim Beinarterienverschluss des alten Menschen?

In a retrospective study the relevance of revascularisation of the deep femoral artery was evaluated in 100 geriatric patients with obliterative atherosclerosis. The results of profundaplasty were good in 91% of patients with claudication (follow-up 47 months). In patients with rest pain the limb salvage rate was 77% (follow-up 39 months). In comparison with femoropopliteal or femorocrural bypass the results were at least even but had lower lethality. In a state of gangrene the limb salvage rate was 39% overall (follow-up 31 months). Diabetics had a limb salvage rate of 28% versus 43% in non diabetics. In a state of claudication and rest pain with stenosis of the deep femoral artery its revascularisation is in our view the treatment of first choice. In a state of gangrene bypass implantation, especially in diabetics, seems to have better results, but as additional palliation before primary amputation profundaplasty should be performed.

[Recent aspects in the diagnosis and therapy of inflammatory aneurysms of the abdominal aorta]. / Neurere Aspekte zur Diagnostik und Therapie des inflammatorischen Bauchaortenaneurysmas.

The so-called inflammatory infrarenal abdominal aneurysm is characterized by huge perianeurysmal retroperitoneal fibrosis, which may achieve a size of more than 1 to 2 cm. It impeats the surgical proceeding enormously. By means of computed tomography a diagnosis of this kind of aneurysm can already be given before the operation. A therapy of the fibrosis resp. the hereby caused complications especially in the urinary system is not an essential in the first place due to the fact that these complications tend to vanish spontaneously after the resection of the aneurysm.

[The so-called inflammatory aneurysm of the abdominal aorta]. / Das sogenannte "inflammatorische Aneurysma" der Bauchaorta.

The computer tomographic appearances of four patients with the rare inflammatory aneurysm of the abdominal aorta are described. The condition, whose aetiology is not known, affects mostly men in the fifth, sixth and seventh decade. Computed tomography shows, in addition to the typical changes due to an aortic aneurysm, horse-shoe shaped, circular, homogeneous peri-aneurysmal masses, which enhance after intravenous contrast. Bolus injection of contrast is necessary in order to differentiate these from a dissection or retroperitoneal lymphoma. Distinction between these conditions is possible as a result of the various types of enhancement which occur in the aortic lumen, in fibrosis and in lymphoma.

[Diagnosis and surgery of an insulinoma using a glucose-controlled insulin infusion system]. / Diagnostik und Operation eines Insulinoms unter Einsatz eines glukosekontrollierten Insulininfusionssystems (GCIIS).

A 71-year-old woman with insulinoma was studied. Preoperatively, using the glucose controlled insulin infusion system (GCIIS) for glucose clamping at various blood glucose levels, autonomous insulin production was demonstrated and intravenous glucose needs for maintenance of normoglycaemia were evaluated. The results of a somatostatin suppression test, guided by the GCIIS, supported the postulation of a well differentiated beta cell adenoma with reduced storage capacity. These assumptions were later confirmed by histochemical and ultrastructural investigations. Hypoglycaemia during surgery was avoided by means of the GCIIS. Upon clamping of the plasma glucose at 90 mg/dl, 15.5 g dextrose had to be given until resection of the tumour. Immediately thereafter, a sharp rise in plasma glucose to 140 mg/dl together with a need for 4.1 U insulin showed that the insulinoma tissue had been removed completely.

[Validity of different methods for reducing tension of anastomoses following circular resection of the trachea]. / Wertigkeit unterschiedlicher Massnahmen zur Minderung der Anastomosenspannung nach Kontinuitätsresektion der Trachea.

In 23 corpses different methods to decrease tension over tracheal anastomosis after circular resection were investigated. Starting tracheal resection underneath the first tracheal ring and employing forward flection of the head, cervico-mediastinal mobilization, dissection of the lung hilus, supra-hyoidal larynx mobilization, and implantation of the left main bronchus into the bronchus intermedius, 78% of the whole trachea could be resected. Resecting the thoracic trachea from the level of its bifurcation in direction to the larynx and employing all methods for mobilization the maximum length of resection decreased by 20%, since larynx mobilization and hilus dissection had no effect.

[Wound healing of tracheal anastomoses]. / Wundheilung von Trachealanastomosen.

In an experimental study on 54 dogs wound healing of tracheal anastomosis under low tension was compared to tracheal anastomosis under higher tension. It was shown that after unproblematic wound healing a higher tension over the anastomosis led to an increased tensile strength in shorter time. Histologically it correlated to an increased and better alignment of collagen fibers in the direction of the tension. This effect became even more significant using resorbable suture material which proved to have better tissue compatibility.

[Treatment of tumour-associated and scarred tracheal stenoses. Changing pathophysiological perspectives (author's transl)]. / Behandlung tumorbedingter und narbiger Trachealstenosen. Wandlung des pathophysiologischen Verständnisses.

Although tracheal resections have been in use for quite some time, they were largely outweighed by procedures of plastic reconstruction, since tracheal resections were extensible to only 2 to 4 cm. At the present time, however, a resection length of up to 70% of the trachea, i. e. 7 to 8 cm, is impossible. The therapy of choice for most obstructive diseases of the trachea is the circular tracheal resection with end-to-end anastomosis. Plastic reconstruction is most indicated for stenoses of the cricoid cartilage. Tracheal protheses should only be used when a primary anastomosis cannot be carried out due to excessive tension. As a rule, this applies to resection lengths exceeding 7 to 8 cm.

[Trachea reconstruction in inflammatory stenosis and tumors]. / Trachea-Rekonstruktionen bei entzündlichen Stenosen und Tumoren.

Primary resection of the trachea and direct anastomosis is indicated whenever inflammatory stenoses and tumors of the trachea are present. In our own series of 27 patients operated upon there were 17 stenoses by scars, two malacias of the trachea, six adenoid-cystic carcinomas, one adenoma of the bronchus and one chondroma. One patient died on the 16th postoperative day from stress-ulcer bleeding. Another patient died three months after the resection of the trachea following reoperation from a recurrence of the stenosis. There was bleeding out of the tracheostoma with aspiration. One patient had a stenosis of the cricoid three years after the tracheal resection had been performed. The stenosis could be treated successfully by reconstructive surgery. None of the other 24 patients had complications. Data on the late results are given. New reports in the literature and our own experience indicate that a tracheal resection with a direct anastomosis seems to be a standardized procedure. Using the right indication for the operation good early and late results can be achieved.

[Tracheoesophageal fistula after blunt thoracic trauma: recognition and treatment]. / Die tracheo-oesophageale Fistel nach stumpfem Thoraxtrauma: Erkennung und Behandlung.

Three cases of tracheoesophageal fistula as a result of nonpenetrating chest trauma were surgically repaired. Another 31 cases were found in the literature. 'Thrown against a steering wheel' was the cause of injury in the majority of patients. Though the fistula became characteristically symptomatic 3 to 7 days after the accident, the diagnosis was often delayed for several months. No patient recovered without operation. After demarcation of the area of contusion and necrosis, especially in the esophagus wall, surgical repair is the therapy of choice.

[Diagnosis and treatment of tracheo-oesophageal fistula (author's transl)]. / Die tracheo-ösophageale Fistel nach stumpfem Thorax-Trauma Erkennung und Behandlung.

Three cases of tracheo-oesophageal fistula as an extremely rare complication of blunt chest trauma are described in detail. 32 similar cases reported in the medical literature are analysed and the pathogenesis of this type of injury is discussed.

[Mediastinal angiography. A helpful method to evaluate to operability of mediastinal and lung tumors (author's transl)]. / Mediastinale Phlebographie: Eine wertvolle Entscheidungshilfe zur Operabilitätsbeurteilung und Operationsplanung von Lungen- und Mediastinaltumoren.

Preoperative mediastinal angiography, as a simple method, shows alterations of pulmonary and venous mediastinal circulation. It enables the surgeon to evaluate the operability of malignant thoracic neoplasms without performance of other diagnostic procedure with a higher rate of complications, e.g. mediastinoscopy or explorative thoractomy.