Thoracoscopic resection of an ectopic giant parathyroid adenoma: indication, technique, and three years follow-up.

We report on a case of a large mediastinal parathyroid adenoma resected successfully using a thoracoscopic approach. Apart from a slight hypocalcemia, which normalized within three days, the patient recovered quickly and was discharged with an excellent functional and cosmetic result. 36 months after the operation no symptoms of recurrency of hyperparathyroidism were evident and laboratory results were normal. Complete thoracoscopic removal of mediastinal parathyroid adenoma seems to be possible as demonstrated by this example.

[Acute Leriche syndrome in a previously healthy woman: differential diagnosis of embolic occlusion]. / Akutes Leriche-Syndrom bei einer bisher gesunden Frau: die Differentialdiagnose zum embolischen Verschluss.

The case report describes an acute total ischemia of both legs in a young otherwise healthy woman. Based on the patient's history, the physical findings and further investigations, the differential diagnosis is discussed. The emergency procedure with a successful desobliteration of a strictly localized arteriosclerotic plaque by Fogarty catheter was followed by open thrombendarterectomy 10 days later because of a persistent stenosis. Finally the clinical manifestations of such rare occlusive disease of the aorta are discussed as well as the bilateral ischemic syndrome of the lower extremities originally described by Leriche in 1940.

[Organization and significance of quality control in recent surgical methods exemplified by 85 consecutive thoracoscopic interventions]. / Organisation und Bedeutung von Qualitätskontrollen neuer Operationsmethoden am Beispiel von 85 konsekutiven thoracoskopischen Eingriffen.

The rapid evolution or rather revolution of minimally invasive surgical techniques is stimulating new technical and clinical innovations. Quality control is of great importance in new areas of technical development where standards do not yet exist. By recording detailed documentation of patient data, indications, operative procedures and initial follow-up we can compare this new technology with the gold standard therapy. This documentation system for thoracoscopic interventions was developed together with the Swiss Group of Laparoscopic and Thoracoscopic Surgeons. This pilot project of 85 consecutive thoracoscopic interventions will demonstrate the acceptability, clinical application and ease with which data can be analyzed. Operative techniques are described in detail: 20 diagnostic interventions with biopsy, 19 apical parietal pleurectomies (+/- resections of bullous lung tissue), 10 therapeutic lung tissue resections, 19 palliative pleurodesis, 5 treatments of pleural empyema, 1 mediastinal tumor resection, 1 esophagectomy, 4 thoracic sympathectomies plus 6 other procedures. Data entry is efficient with mean total time of 10 min for each record. All of the data are entered into a computer database. The possibilities for interpreting and combining this data are presented. The operative techniques can easily be related with history, indications, anesthesia, complications and results. First evaluation of thoracoscopic efficiency is possible. In addition, a detailed analysis of intra- and postoperative complications and of the hospital course can be performed.

[Antibiotic therapy in ambulatory surgery]. / Zur Antibiotikatherapie in der ambulanten Chirurgie.

Antibiotic therapy in outpatient surgical care is reviewed. In the first section some skin and soft-tissue infections are discussed, where antibiotics are likely to achieve clinical cure. In the second section we examine, where surgical treatment alone is essential for successful eradication of the infection. Wound management, where antibiotics are still controversial, is mentioned in the last section. Some pharmacological data on the discussed antibiotics are given.

[Preventive use of antibiotics in surgery: a review]. / Antibiotikaprophylaxe in der Chirurgie: eine Ubersicht.

As a rule, prophylactic antibiotics should only be given pre- or perioperatively as a single shot. Cephalosporins of the first and second generation are still quite effective and appear to be the most widely used drugs for this purpose. In some cases a second drug, like i.e. metronidazole, can be added. For each surgical specialty, the most appropriate prophylactic regimen is discussed.

[Acute infection following osteosynthesis]. / Akuter Infekt nach Osteosynthesen.

Local infection manifest within 14 days of internal fixation is usually confined to the soft tissues. Indeed it may initially be taken for a wound-healing reaction. Colonization is either primary in open fractures, peroperative during internal fixation, or haematogenous from a remote focus within the injured patient. Successful treatment demands immediate readmission to hospital and energetic management by the rules of septic surgery, if chronic infection is to be avoided. The stability of internal fixation can then often be preserved.

Internal fixation of proximal radial head fractures.

The treatment of choice for proximal radial head fractures remains controversial. The goal of any treatment for an intra-articular fracture must be the complete restoration of the joint and its function. Nonoperative treatment leads to full motion in cases of less than 1-2 mm of fracture displacement. Resection of the radial head can be recommended only for very comminuted fractures. All other fracture types should be treated by open reduction and internal fixation. Our own personal follow-up observation of 19 patients who had surgical intervention demonstrated restoration of elbow function after an average follow-up time of 11.7 months. Five patients had a slightly restricted range of motion of less than 10 degrees extension and flexion as well as less than 8 degrees pronation and supination, without signs of arthritis. Because complications were minimal, we recommend internal fixation of displaced proximal radial head fractures to restore the anatomic function of the elbow. This is especially true in cases with accompanying proximal ulna fractures and/or ruptured collateral ligaments of the elbow joint and/or disruption of the distal radio-ulnar joint.

[Glucose or sugar substitutes in parenteral infusions? The choice of carbohydrates in postoperative infusion therapy]. / Glukose oder Zucker-Austauschstoffe? Zur Wahl der Kohlenhydrate in der postoperativen Infusionstherapie.

The aim of parenteral nutrition should be to optimise fluid, energy and nitrogen balance. In the post-traumatic or post-operative phase a stress induced glucose intolerance may occur and it may become difficult to meet the patient's energy requirements with glucose alone. For these reasons the use of sugar substitutes (fructose, sorbitol and xylitol) in combination with glucose is recommended as an alternative. Patients receiving a mixed sugar solution of glucose, fructose and xylitol at a ratio of 1:2:1 require less exogenous insulin and yet maintain a lower blood glucose concentration. Used in limited quantities, we encountered no side effects either in patients undergoing elective surgery or requiring intensive care.

[Does every hospital need a catastrophe plan?]. / Braucht jedes Spital einen Katastrophenplan?

The organisation of any hospital to manage the medical supply in case of general disaster should guarantee the maximum effectiveness. The increase of output has to be realised on the emergency ward, OR, JCU and on the general wards. The planning should include the management, the competence and the coordination inside and outside the hospital.

[Comparative studies during postoperative infusion of glucose or a combination of glucose, fructose and xylitol over five days (author's transl)]. / Vergleichende Untersuchungen während fünftägiger postoperativer Infusion von Glucose oder einer Kombination von Glucose, Fructose und Xylit.

Two groups of 12 cholecystectomized or vagotomized patients were given central venous infusions of either a combination of glucose, fructose and xylitol at the ratio of 1:2:1 or of glucose alone for 5 days. The dose was increased stepwise from 1.43 g/kg/h on operation day up to 7.14 g/kg/24 h on the fourth day after surgery, which equals 100-500 g/24 h for the average 70 kg patient. On both infusion regimens mean blood glucose values ranged from 98-124 mg/100 ml. Urinary losses of infused substrates amounted to 0.2-0.8 g/24 during glucose infusion and to 2.22-13.4 g/24 h during infusions of the carbohydrate combination. Regarding mean blood or serum values of lactate, pyruvate, uric acid, sodium, potassium, phosphorus, insulin and free fatty acids, no significant differences were found between the two types of carbohydrate infusion. Side effects were not observed. The results obtained allow conclusion that in clinical situations with moderate stress, such as the selective operations mentioned above, the combination of glucose, fructose and xylitol studied offers no advantage over glucose alone. However, in severely ill patients presenting with more pronounced glucose intolerance, further studies with sugar substitutes are warranted.

Comparison between glucose and a combination of glucose, fructose, and xylitol as carbohydrates for total parenteral nutrition of surgical intensive care patients.

The effects of four day periods of infusions of 600 gm/24 hours glucose and 600 gm/24 hours of a combination of glucose, fructose, and xylitol were compared. This study was performed during total parenteral nutrition of twelve postoperative patients with major complications. The mean plasma glucose level was significantly lower during the infusion of the combination of sugars (154.2+/-19.5 mg/100 ml versus 193.9+/-15.0 mg/100 ml[p is less than 0.005). Furthermore, the required dosage of exogenous insulin was significantly lower (18.9+/-12.3 units/day versus 43.7+/-19.7 units/day [p is less than 0.01). Mean renal carbohydrate losses were 0.85 per cent during glucose infusion and 1.7 per cent during infusion of the combination. The influence of both infusion regimes on values for pH, base excess, lactate, pyruvate, free fatty acids, insulin, sodium, potassium, chloride, magnesium, phosphorus, bilirubin, alkaline phosphatase, SGOT, and SGPT 0.85 has been investigated. No clinical side effects were observed. It is concluded that the administration of the investigated combination of glucose, fructose, and xylitol is justified in patients in whom hyperglycemia during infusion of glucose alone is difficult to control with insulin.

[Problems with hyperalimentation in intensive care units (author's transl)]. / 46. Probleme der parenteralen Ernährung in der Intensivpflege

The application of parenteral nutrition in patients in intensive care units can be limited by shock, septicemia and metabolic disorders. Stress- or trauma-induced glucose intolerance sometimes makes it difficult to maintain the caloric requirements with glucose. Sugar substitutes seem to be of advantage in these cases. Meticulous care is essential to avoid severe complications arising from the use of the central venous feeding catheters.