[Clinical use of new organ-saving technics in splenic surgery]. / Klinischer Einsatz neuer organerhaltender Techniken in der Milzchirurgie.

During a period of 19 months, 22 organ preserving splenic operations were performed. Eleven of these, were severe third degree traumatic bursting ruptures, which were treated using a resorbable compressive mesh. An intralienal pancreatic cyst, a case of splenomegaly suspicious for lymphoma, one traumatic and two accidental polar lesions were treated by partial splenic resection using stapler. In two patients with traumatic and four with accidental first and second degree lienal lesions, collagen tampon and fibrin adhesive were employed. None of these patients required a second laparotomy. Aside from an edematous tail pancreatitis, no complications arose. Two patients succumbed to their severe cranial injuries. In the same period, four posttraumatic splenectomies were performed. Thus, excluding incidental and technical splenectomies, the application of the described methods resulted in orthotopic splenic preservation in 78% of traumatic splenic ruptures.

Fibromatosis--a rare retroperitoneal tumour.

A case of retroperitoneal fibromatosis in a 28-year-old white male is presented. The soft tissue tumor, with a weight of 8000 g, was resected by laparotomy. Because of adhesions to the ascending colon and the right ureter, a hemicolectomy and partial resection of the right ureter had to be performed additionally. Intraabdominal fibromatoses are very infrequent tumorous lesions of the connective tissue, occurring retroperitoneally only in isolated cases. Their etiology is presumed to be a hereditary or gene-associated defect in the regulation of connective tissue growth. In addition, trauma and hormonal influences often appear as inductive cofactors.

Positive end-expiratory pressure and the damaged right ventricle. An experimental open versus closed chest study.

Hemodynamic changes after isolated impairment of right ventricular function (produced by increasing afterload by temporary banding of the pulmonary artery) were studied in 22 ventilated pigs during increased levels of positive end-expiratory pressure (4, 8, 12, and 16 cm H2O). In the open chest group, application of positive end-expiratory pressure produced only a slight decrease of cardiac index. After right ventricular damage a decrease of cardiac index of more than 25% occurred only when higher levels of positive end-expiratory pressure were applied. In contrast to the open chest group, the closed chest group showed more distinct cardiovascular responses after positive end-expiratory pressure. In the damaged right ventricle with a positive end-expiratory pressure of 16 cm H2O, right ventricular end-diastolic pressure increased more than 100%. With positive end-expiratory pressure, cardiac index decreased 34% before and 47% after right ventricular damage. We conclude that positive end-expiratory pressure induces a more pronounced decrease in cardiac index if right ventricular function is impaired. During open chest conditions with lower levels of positive end-expiratory pressure, these changes are only small, however, and probably irrelevant. During closed chest conditions, the hemodynamic changes are much more pronounced. High right ventricular end-diastolic pressures resulting from impaired right ventricular contractility as well as from high levels of positive end-expiratory pressure may have an impact on biventricular function and right ventricular coronary driving pressure.

[Results of emergency aortocoronary bypass surgery in patients with acute myocardial ischemia after percutaneous transluminal coronary angioplasty]. / Ergebnisse der dringlichen aortokoronaren Bypasschirurgie bei Patienten mit akuter Myokardischämie nach perkutaner transluminaler Koronarangioplastik.

From April 1980 to June 1985 7.3% (15) of 205 PTCA-treated patients required emergency operations. The spectrum of PTCA-induced ischemia included anginal pain alone (2/1, 13%) or transmural infarction (13/15, 87%) with hypotension (8/15), cardiac arrest (4/15), and severe cardiogenic shock (3/15, 20%). 14 patients underwent saphenous-vein-bypass-graft operation (ACBG) with a mean of 1.7 grafts performed per patient. The average time from onset of symptoms to completed revascularisation was 166.5 (110 to 290) minutes. Inspite of the use of IABP one hospital death (6.6%) occurred prior to the institution of ECC in a patient with previous ACBG surgery. No late death was observed during a mean follow up of 11.1 (1 to 33) months with 13/14 patients free of anginal symptoms. Retrospective assessment of postoperative serum enzyme levels of CPK and CK-MB showed evidence of myocardial infarctions in 7/14 (50%) patient. The incidence on ECG of Q-wave infarctions was 35,7% (5/14). With the exception of one patient, IABP was not used pre- or postoperatively. In patients with acute myocardial ischemia following PTCA-attempts immediate restoration of myocardial blood flow can stabilize left ventricular function and reduce the incidence and size of myocardial infarctions. The availability of emergency ACBG-surgery and facilities remain an important prerequisite of PTCA-programs due to the unpredictable natural course of PTCA-induced myocardial ischemia.

[Initial clinical experiences with the fibrin adhesive Beriplast in heart surgery]. / Erste klinische Erfahrungen mit dem Fibrinkleber Beriplast in der Herzchirurgie.

Fibrin glue Beriplast was used during cardiovascular surgery in 97 patients. The fibrin seal was used for hemostasis on anastomoses, patches and suture lines. Moreover, the glue was applied for epicardial fixation of aorto-coronary vein grafts to prevent postoperative graft kinking. Following extrapleural ligation of patent duct in premature infants, the parietal pleura was fastened to the thoracic wall to prevent extrapleural pneumothorax or hemorrhage. After accidental dissection of the thoracic duct in infants, leakage of chyle could be sealed successfully in 6 cases. Hemorrhage from the sealed surfaces of suture lines was not observed. Viral hepatitis occurred postoperatively in 2 patients (3% of the operations for acquired heart disease), both of whom had also received clotting factor concentrate and blood transfusion because of postoperative hemorrhage not related to fibrin sealed surfaces. A causal relation between the hepatitis and application of the pasteurized fibrin glue seems very unlikely. Although fibrin glue certainly cannot replace the surgical suture, it appears to be a valuable aid under special conditions.

[Myocardial changes in acute pulmonary artery embolism--an experimental study]. / Myokardveränderungen bei akuter Pulmonalarterienembolie--eine experimentelle Studie.

Massive pulmonary embolism usually causes acute right ventricular hypertension. Structural and hemodynamic effects of right ventricular overloading were studied in piglets (weight 17-22,5 kg). Pulmonary arterial obstruction (PAO) was achieved by temporary banding of the main pulmonary artery, the external diameter of the vessel being reduced to one-third (Group I) or by half (Group II) of the original size. In Group I PAO caused a twofold increase of systolic right ventricular pressure (RVP), whereas the systolic left ventricular pressure decreased to 30% of its original value; PAO was terminated after 25 seconds. After PAO, no changes of right or left ventricular function were observed in Group I. Electron microscopy revealed mitochondrial alterations and fragmentations of the sarcomeres. In Group II, PAO was maintained for 60 minutes. Due to PAO, the systolic RVP increased to twice the original value and the systolic aortic pressure decreased by 10%. During the PAO period, a continuous increase of enddiastolic RVP was observed in Group II. After termination of PAO, contractility parameters for the right ventricle were reduced, and right ventricular diameters (RVD) and enddiastolic RVP were increased in comparison to the pre-PAO values. As hemodynamic alterations increased corresponding to the duration of PAO, it is concluded that in case of acute pulmonary embolism early relief of right ventricular overloading may be important.

[Shunt malfunction due to a Blalock-Taussig anastomosis of the pulmonary vein]. / Shunt-Fehlfunktion durch Blalock-Taussig-Anastomose zur Pulmonalvene.

In two of 81 patients in whom a Blalock-Taussig shunt was created due to pulmonary atresia, the anastomosis was inadvertently placed on the pulmonary vein. The first case was a newborn with mirror-image dextrocardia, pulmonary valve atresia and a high ventricular septal defect. Subsequent to a Rashkind maneuver and treatment with prostaglandins, at the age of eleven days the shunt procedure was performed. Right sided pulmonary edema developed twelve hours after surgery and the infant died on the second postoperative day. Anastomosis of the shunt to the right pulmonary vein was revealed at autopsy. The second case was a six year-old boy admitted for corrective surgery with pulmonary valve atresia, main pulmonary artery atresia, large ventricular septal defect and patent ductus arteriosus. Because of additional systemic-pulmonary collaterals, the larger collaterals were ligated and the Blalock-Taussig shunt was carried out using a Goretex prosthesis. Nine months postoperatively, at follow-up cardiac catheterization, the ill-directed shunt was diagnosed and subsequently revised. The onset of ipsilateral pulmonary edema and increasing signs of congestive heart failure after surgical creation of a Blalock-Taussig shunt as well as the persistence of lowered oxygen partial pressure, cyanosis and poor general health, should alert the attending physician to rule out the rare complication of anastomosis to the pulmonary vein.

[Morphologic and functional myocardial changes in experimental pulmonary artery embolism]. / Morphologische und funktionelle Myokardveränderungen bei experimenteller Pulmonalarterienembolie.

After acute experimental obstruction of the pulmonary artery, focal ultrastructural lesions of the right ventricular myocardium were observed in domestic swine. These lesions, mainly myofibrillar fragmentation, were not reflected in hemodynamic measurements, which remained unchanged.

[Aortic valve replacement in cardioplegic heart arrest]. / Aortenklappenersatz im kardioplegischen Herzstillstand.

The St. Thomas cardioplegic solution was introduced in our clinic in January, 1980. Before, aortic valve replacements were carried out using cold ischaemic cardiac arrest as myocardial preservation technique. In 62 aortic valve replacements performed since January 1980, there was no hospital mortality. Moreover, there were fewer intraoperative and postoperative complications. Intraoperative serum potassium was not essentially elevated after cardioplegic perfusion of the heart, although most of the cardioplegic effluate passed into the extracorporeal circulation. Postoperative serum-creatinphosphokinase levels were significantly higher after cold ischaemic arrest than after cardioplegia.

Treatment of postsurgical chylothorax with fibrin glue.

The treatment of postsurgical chylothorax with fibrin glue is reported. Chylothorax developed in a 3 1/2-month-old infant 2 days after extrapleural ligation of a patent ductus arteriosus. At rethoracotomy the chyle leak could not be located. To stop chyle effusion, the region of the presumed leakage was sealed with fibrin glue and a pleural flap. It is suggested that early reoperation and closure of the chyle leak with fibrin adhesive should be considered in cases of postsurgical chylothorax in infants.

[Role of the pericardium in acute volume overload]. / Bedeutung des Perikards bei akuter Volumenbelastung.

The function of the pericardium in acute volume overloading may be defined as protection against ventriculo-atrial regurgitation at high filling pressures, limiting transmural pressures and, therefore, protecting against ventricular distension as well as supporting the filling of the ventricles by suction in the systolic contraction. Thus, it may be important to close the open pericardium carefully after open heart surgery. Pericardial drainage should prevent cardiac tamponade.

[Infrared contact coagulation for hemostasis in liver and spleen]. / Infrarot-Kontaktkoagulation zur Bluststillung an Leber und Milz.

With infrared contact coagulation (ICC) hemostasis of hepatic and splenic tissue is achieved by coagulation and mechanic compression of the bleeding surface. Thus, an eventual loss of energy due to a thick layer of blood can be avoided. After coagulation, the anti-adhesive effect of the cap of the ICC device prevents fresh bleeding. After experimental incisions on liver and spleen of various animal species hemostasis could be achieved quickly by application of ICC. Postoperative observation and histologic investigations were carried out until the 80th postoperative day. Hemostasis was observed in all cases, there were no signs of recidivant bleeding at relaparotomy. A slow absorption f necrotic tissue was observed. This could be a disadvantage regarding long term wound healing.

[Hemostasis in the liver induced with tissue glue - comparison of 2 glue-component combinations]. / Blutstillung an der Leber durch Gewebeklebung--Vergleich zweier Mehrkomponentenkleber.

After experimental hepatic resection in rabbits and piglets, haemostasis was achieved by using two types of tissue glue - fibrin glue and gelatin-resorcin-formaldehyde glue (GRF-glue). With both glues, an elastic adhesive film could be produced. Fibrin glue was completely absorbed by granulation tissue at the 11th postoperative day. After using GRF-glue a toxic necrosis and a subsequent demarcation of necrotic tissue could be observed, with the adhesive substance being not absorbed after 11 days. When used together with a collagen fleece, fibrin glue was not spilled away by tissue haemorrhage. Therefore it seems to be especially suited for haemostasis on the liver. With both glues, no leakage was observed after raising the portal vein pressure to 300 mm Hg during in vitro experiments.