[Preoperative arterial embolization of intralobar lung sequestration]. / Präoperative arterielle Embolisation einer intralobären Lungensequestration.

A case of a 43-year-old patient with recurrent pulmonary infections due to pulmonary sequestration is presented. MR-angiography revealed an aberrant artery originating from the abdominal aorta feeding the intralobar pulmonary sequestration. Platinum coil embolization of the aberrant artery was performed preoperatively to allow safe surgical resection on the following day. To our knowledge this is the first case in the literature in which elective coil embolization has been performed before resection of lung sequestration.

Is the function of the serratus anterior muscle disturbed following division during a standard thoracotomy?

In a prospective study the functional results after dissection or preservation of the serratus anterior muscle in the postero-lateral standard thoracotomy were evaluated. In 14 patients of our clinic with dissection and suture and in 14 patients with preservation of the serratus muscle the muscle function was assessed and compared preoperatively, within the first two post-operative weeks, and three months after the operation by the same physiotherapists. The two groups were blinded in regard to age, original disease, and mode of intervention. We compared the wing position of the scapula in the sitting position and the positioning of the scapula at fixation of the shoulder joint in the sitting and in the supine position. Using a four-grade function assessment scheme, both groups obtained the same functional results. There was no seroma in either group. After 2.8 (2.5 to 3.0) years all the surviving patients described symmetric functional conditions. We therefore conclude that in order to achieve a better view of the operative field the serratus muscle may be dissected close to the origin if it is then readapted.

Functional activity and transmembrane signaling mechanisms after cryopreservation of human internal mammary arteries.

PURPOSE: Cryopreserved human blood vessels are important tools in bypass surgery. However, several in vitro studies have demonstrated diminished postthaw functional activity. Therefore the aim of this study was to investigate the consequences of various freezing/thawing protocols and the role of protein kinase C in the postthaw functional activity of cryopreserved human arteries. METHODS: In vitro responses of frozen/thawed human internal mammary arteries (IMA) were used to investigate the functional activity after thawing at 15 degrees, 30 degrees, and 100 degrees C/min and after different prefreezing equilibration times (10, 60, 120, 240 minutes) with the cryomedium (Krebs-Henseleit solution containing 1.8 mol/L dimethyl sulfoxide and 0.1 mol/L sucrose) at room temperature followed by cryostorage at -196 degrees C. RESULTS: Prefreezing equilibration for 10 to 120 minutes diminished maximal alpha-adrenoceptor-mediated responses to noradrenaline to approximately 60%, and equilibration for 240 minutes attenuated noradrenaline effects to less than 25% of that produced by unfrozen controls. Contractile responses were slightly better when thawing was performed at 15 degrees C/min compared with 100 degrees C/min. The postthaw sensitivity to direct activation of protein kinase C by phorbol 12,13-dibutyrate was enhanced. Compared with unfrozen tissues (pD2 = 7.36 +/- 0.07, n = 32) maximal sensitization to phorbol 12,13-dibutyrate was observed in IMA that had been frozen after 60 minutes of equilibration with the cryomedium (pD2 = 8.31 +/- 0.09, n = 30). Responses to phorbol 12,13-dibutyrate of cryopreserved IMA were highly susceptible to blockade of calcium influx by nifedipine, whereas those of unfrozen IMA were resistant to nifedipine. Against noradrenaline nifedipine was equipotent in cryopreserved (pD'2 = 7.75 +/- 0.15, n = 8) and unfrozen IMA (pD'2 = 7.70 +/- 0.10, n = 6). Endothelium-dependent relaxant responses to acetylcholine were significantly attenuated after cryopreservation (Emax = 26% +/- 5%, n = 4) compared with unfrozen IMA (Emax = 71% +/- 4%, n = 4, p < 0.001); endothelium-independent relaxant responses to sodium nitroprusside were unchanged. CONCLUSIONS: Cryopreservation of human IMA under the conditions applied in this study (1) attenuated endothelial cell function and (2) induced an activation of protein kinase C, thereby increasing calcium influx through dihydropyridine-sensitive calcium channels. These experimental data suggest that postoperative administration of calcium channel blockers alone or combined with long-acting nitrates should effectively prevent the development of spasms in arterial grafts.

Video-assisted thoracoscopic surgery for fibrinopurulent pleural empyema in 67 patients.

BACKGROUND: The roles of different drainage procedures in the management of empyema have to be redefined now that video-assisted thoracoscopic surgery (VATS) has been introduced. The debridement of fibrinopurulent stage II empyema with the use of VATS was assessed prospectively in regard to control of infection and restoration of pulmonary function. METHODS: Between January 1992 and May 1996, all patients at our institution with fibrinopurulent empyema that did not respond to chest tube drainage and antibiotic therapy were treated by debridement with the use of VATS. The patients were followed up prospectively by clinical and radiologic assessments 3 and 6 months after the operation and by spirometry 6 months after the operation. RESULTS: Video-assisted thoracoscopic surgery was initiated in 67 patients, but conversion to open decortication was required because of the finding of advanced disease in 19 patients (28%). Forty-eight patients underwent successful debridement with the use of VATS. The mean operative time was 82.1 minutes (range, 50 to 135 minutes), the mean duration of postoperative chest tube placement was 4.1 days (range, 2 to 8 days), and the mean duration of postoperative hospitalization was 12.3 days (range, 4 to 42 days). No wound infections were observed during the postoperative course. Both the 30-day mortality rate and the recurrence (ie, need for thoracotomy) rate were 4%. The mean predicted vital capacity was 84.8% +/- 14.9% and the mean predicted forced expiratory volume in 1 second was 88.6% +/- 19.2% 6 months after the operation. CONCLUSIONS: Debridement with the use of VATS is safe and efficient for stage II empyema, but open decortication should be used for more advanced disease.

Experimental transplantation of size-reduced, adult kidneys into pediatric recipients.

BACKGROUND: Renal transplantation in infants is frequently complicated by graft thrombosis and accelerated rejection reactions. We herein tested the hypothesis that the amount of blood required to sustain normal perfusion of an adult renal allograft transplanted into a pediatric recipient would surpass the cardiac output and aortic blood flow of the recipient and that the ensuing low flow in full-size grafts (FSG) would induce a release of thrombogenic substances. METHODS: In a porcine renal transplant model, adult FSG were transplanted into pediatric recipients. Macro- and microhemodynamic as well as metabolic data were recorded. Surgically size-reduced grafts (RSG) served as controls. RESULTS: Donor weight was 55.1+/-4.8 kg and 9.6+/-0.9 kg for recipients. FSG weight was 122+/-16 g and 65+/-14 g for RSG. Blood flow in donor kidneys was 20% higher than the infrarenal aortic blood flow of recipients. After reperfusion, mean arterial pressure in recipients of FSG but not RSG dropped to 64 mmHg, despite an increase in cardiac output by 60%. FSG but not RSG were polyuric and proteinuric. The release of endothelin and thromboxane B2 into the circulation was higher from FSG when compared with RSG (P<0.05 for endothelin after 60 min; NS for thromboxane B2). CONCLUSIONS: After transplantation of FSG into pediatric recipients, the macrohemodynamic limitations of the recipient cause microcirculatory disturbances in the graft, which contribute to the release of vasoconstrictive and prothrombotic substances and an impaired early graft function. Some of those effects can be ameliorated by surgically size reducing the renal graft.

Blue toes due to floating plaque of the abdominal aorta: endovascular repair with stent.

A 60 year old male patient was admitted with so-called blue toes on both sides. Investigation, including real-time ultrasound, revealed a floating plaque on the dorsal side of the abdominal aorta as the most probable cause of the blue toes. By means of simultaneous fluoroscopy and ultrasound guided implantation of a stent it was possible to restore a free lumen of the aorta. The patient had an uncomplicated recovery. Post-operative colour coded Doppler ultrasound showed normal flow in the aorta. Follow-up examination one year after the procedure demonstrated no evidence of further embolic events and a patent aorta.

[Homograft in the therapy of cardiovascular diseases]. / Der Homograft in der Therapie von kardiovaskulären Erkrankungen.

Despite considerable progress in prosthetic valve technology, there is actually no ideal artificial heart valve that may be employed in all circumstances, when replacement of a diseased aortic valve is necessary. The choice for optimal valve substitute includes mechanical prosthesis, bioprosthetic xenografts, homografts and pulmonary autografts. More recently an aortic valve sparing operation has been proposed in younger patients presenting with anulo-aortic ectasia. The use of homograft heart valves has now been widely accepted in the treatment of congenital heart defects, as well as for an increasing number of valvular pathologies, especially in infective endocarditis. Heart valve preservation by cryopreservation techniques helps to store the small amount of donor material for special indications without loss of quality, thus permitting elective surgery. In vascular surgery, some concern persists regarding the use of prosthetic material for the treatment of mycotic aneurysms and graft infection. In situ repair with a new vascular prosthesis and resection followed by extra-anatomic reconstruction carry a high peri-operative mortality and substantial morbidity. Cryopreserved vascular homografts represent a valuable alternative in these challenging situations.

Retroperitoneal endoscopic neurectomy for nerve entrapment after hernia repair.

BACKGROUND: Entrapment neuralgia after open and laparoscopic hernia repair occurs in about 1-2 per cent of patients. If the pain persists accurate identification of the nerve involved and surgical treatment is an option. Entrapment neuralgia of the genital branch of the genitofemoral nerve and ilioinguinal nerve occurs, but damage to the femoral branch of the genitofemoral nerve, the lateral femoral cutaneous nerve and the femoral nerve is also described. This paper reports an endoscopic technique for neurectomy. METHODS: A balloon catheter is inserted bluntly into the lower retroperitoneum and insufflated to create a work space. Neurectomy is performed under endoscopic guidance. RESULTS: Three men with a mean age of 39 years were treated using this technique. A neurectomy of the genitofemoral nerve was performed in all three and in one neurectomy of the ilioinguinal nerve was also done. The mean operating time was 70 min and all the patients were completely pain-free after surgery. All patients were discharged within the first 2 days after operation and there were no complications. CONCLUSION: This retroperitoneal endoscopic technique is proposed as a new surgical approach for treating entrapment neuralgia. It is simple and effective at relieving symptoms.

[Surgical treatment of deep venous thrombosis--indications, possibilities and limitations in venous thrombectomy]. / Chirurgische Behandlung der tiefen Beinvenenthrombose--Indikation, Möglichkeiten und Grenzen der venösen Thrombektomie.

Venous thrombectomy as a treatment of deep venous thrombosis is discussed extremely controversial. Occasionally, however, surgical technique, goal of the therapy, indications and limitations are not really known. Indication for surgical treatment is an extensive acute deep vein thrombosis with clinical symptoms of less than 7 days. Goal of the therapy is the preservation of valve function and prevention of a postphlebitic syndrome. Further indications are an embolizing venous thrombosis, a floating thrombus and an ischemic thrombosis. In these cases the single goal of the treatment is to reduce the individual risk of the patient. The best long term results can be achieved in young patients (below 40 years of age) with no preexisting venous lesion and an acute iliofemoral thrombosis. Advantages, drawbacks and results of venous thrombectomy are discussed.

[Invasive diagnosis of mediastinal space-occupying lesions. On differential indications between cervical mediastinoscopy, parasternal mediastinotomy and video thoracoscopy]. / Invasive Diagnostik bei mediastinalen Raumforderungen. Zur Differentialindikation zwischen cervicaler Mediastinoskopie, parasternaler Mediastinotomie und Video-Thoracoskopie.

The role of video-thoracoscopy (VT) as an invasive diagnostic procedure for mediastinal lesions not reachable by cervical mediastinoscopy (CM) has still to be defined, particularly with regard to parasternal mediastinotomy (PMT). Diagnostic efficiency and morbidity of the three methods were assessed and compared in a consecutive series over a 18 months-period after determination of a new diagnostic strategy. Among 77 interventions in 73 patients the following distribution of the methods referred was achieved: 42 CM (paratracheal and anterior subcarinal biopsies), 17 PMT (biopsies of anterior mediastinal lesions) and 18 VT (3 paratracheal, 3 posterior subcarinal, 3 anterior, 5 aortico-pulmonary window, 4 posterior biopsies or resections). All procedures were performed in general anesthesia for VT the double-lumen technique was used. Drains could be removed not later than the second postoperative day. In 7/17 cases of PMT the pleural space was opened and drained. Mean operation time (incl. waiting period for intraoperative frozen section and complete resection in a few cases) was 77 (45-100) min for VT, 49 (10-180) min for PMT and 41 (20-105) min for CM. Histological diagnosis of biopsy specimens were conclusive in all VT cases, in 15/17 PMT (88%) and in 37/42 CM (88%). Two major complications occurred: one recurrent nerve palsy following VT-resection of a neurinoma originating from the recurrent nerve itself; in a second patient submitted to mediastinoscopic biopsy, venous bleeding had to be managed by surgical sternotomy. CM as the most approved method for paratracheal and anterior subcarinal biopsies has not lost its importance. PMT as a simple and usually extrapleural intervention can further be advocated for anterior mediastinal lesions. VT turns out to be rather a complementary than a competitive invasive mediastinal diagnostic procedure and is regarded as method of choice for diagnostic approach to posterior, posterior subcarinal and aorticopulmonary lesions.

Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum.

BACKGROUND: Radical debridement, followed by muscle flap cover, has significantly reduced morbidity and mortality of infected sternotomy wounds. The pectoralis major, rectus abdominis, and greater omentum flaps are most commonly used, whereas the latissimus dorsi muscle is rarely employed. METHODS: In 7 patients with persistent infection and necrosis of the sternum, radical and extensive debridement including the sternum, costochondral arches, manubrium and sternoclavicular joints was performed. A free latissimus dorsi flap was used for soft tissue reconstruction without additional stabilization of the chest wall. RESULTS: All flaps survived without revision of the anastomosis. In the follow-up period (22 months to 5 years) no recurrent infection was observed. Three patients died during the study period (3 to 24 months after operation) due to causes not related to sternum operation. No additional weakness, pain, or restricted movements of the shoulders due to missing sternum was observed. CONCLUSIONS: Our findings suggest that the use of free latissimus dorsi flap after complete sternectomy for infection has several advantages: it provides abundant tissue to allow radical and extensive debridement, obliterates completely the dead space, and helps to control infection. Even without additional chest wall reconstruction it gives enough stability to allow pain-free normal daily activities.

Surgery for acute ascending aortic dissection: closed versus open distal aortic repair.

One hundred twelve consecutive patients with acute ascending aortic dissection and submitted to immediate surgery were retrospectively analyzed with regard to perioperative mortality and morbidity. The patients were divided into two groups according to whether distal aortic repair was carried out by the open procedure (using deep hypothermic circulatory arrest, group A: 68 patients) or by the closed technique (without circulatory arrest, group B: 44 patients). Patients' ages ranged from 24 to 78 years (mean 57.4 years). No significant difference was found between the two groups in terms of age and sex distribution. However, the prevalence in the extent of clinical and anatomical alterations was significantly higher in group A (hemodynamic instability, pericardial tamponade and neurological deficit). The duration of hypothermic circulatory arrest for group A patients averaged 25 min and ranged from 12 to 65 min. The overall perioperative mortality was 17% (19/112 patients); it was 20.6% (14/68) in group A and 11.4% (5/44) in group B; the difference was not statistically significant but consistent with a clear trend. The trend towards a higher mortality in group A mainly reflected the more severe and complex anatomical characteristics and could not be attributed to the circulatory arrest per se. The period of deep hypothermic circulatory arrest in the survivors (25 min) was similar to that of the group with lethal outcome (32 min). Among the non-lethal complications, however, group A patients more frequently showed clinical signs consistent with cerebral injury: apart from the transient symptoms suggestive in reversible diffuse cerebral damage, five patients in group A had a permanent focal neurological deficit (versus one patient in group B).(ABSTRACT TRUNCATED AT 250 WORDS)

["Single shot" prevention in abdominal surgery. Antibiotics with long half-life (ceftriaxone, ornidazole) vs. antibiotics with short half-life (cefazolin, metronidazole, clindamycin)]. / "Single-Shot"-Prophylaxe in der Abdominalchirurgie. Antibiotika mit langer Halbwertzeit (Ceftriaxon, Ornidazol) vs. Antibiotika mit kurzer Halbwertzeit (Cefazolin, Metronidazol, Clindamycin).

Single-shot antibiotic prophylaxis is well established in abdominal surgery. There is evidence suggesting that it prevents wound infections and some authors report also prevention against postoperative urinary tract infection and pneumonia. From April 1988 to December 1990 we randomly assigned 429 patients with gastro-intestinal operations to a defined protocol: 210 patients (5 drop-outs) with elective operations of the upper GI-tract were given Ceftriaxone (half-life 8 hours, 102 patients) or Cefazolin (half-life 2 hours, 103 patients). 117 (12 drop-outs) patients with operations of the lower GI-tract were given Ceftriaxone/Ornidazole (half-life 13 hours, 50 patients) or Cefazolin/Metronidazole (half-life 8 hours, 55 patients). 102 (20 drop-outs) patients with appendicitis were given Ornidazole (40 patients) or Clindamycin (42 patients). There were no differences in sex, age or type of operation in the different groups. The overall postoperative infection-rate was low. In the upper GI-tract we found one wound infection in both groups, in the lower GI-tract two wound infections in the Ceftriaxone/Ornidazole-group vs. nine in the Cefazolin/Metronidazole-group (p < 0.05). In patients with appendicitis there were three infections in the Ornidazole-group and four in the Clindamycin-group. There was no statistically significant difference in pulmonary or urinary tract infections in all groups. Although the protocol for antibiotics with a short half-life included a second dose of antibiotics in cases of operations with a duration of more than four hours, this was forgotten in 19 of 39 concerned patients (49%!).(ABSTRACT TRUNCATED AT 250 WORDS)

Video-assisted thoracoscopic treatment of pleural empyema. A new therapeutic approach.

Pleural empyema is a disease which is not always recognized. Despite consecutive treatment and antibiotics its mortality rate is still high, especially in older patients with concomitant disease or in the case of delayed treatment. We report our experience with early video-assisted thoracoscopic surgery of pleural empyema in 13 patients, where chest tube drainage had failed. The clinical symptoms of empyema did not exceed 14 days, bacteriologic cultures were positive in 62%. In all patients the fever disappeared within 1 to 5 days (mean 3.5) post-operatively and they remained in hospital for an average of 11.5 days after video-assisted thoracoscopic surgery. Pulmonary function tests 6 months later revealed normal values without a substantial loss of lung volumes. No relapse of empyema occurred.

[Popliteal aneurysm]. / Das Poplitealaneurysma.

At our institution operative repair was undertaken for 67 popliteal aneurysms in 45 patients between 1986 and 1991. In 24 cases emergency surgery was necessary: acute critical ischemia due to thrombosis or embolism in 22 cases, and rupture of the aneurysm in 2 cases. Two patients died within the first 30 postoperative days. Four major amputations could not be avoided. On the other hand, elective surgical intervention was possible in 43 cases without operative morbidity and mortality. Given the high incidence of serious complications such as thrombosis or embolism in popliteal aneurysms, and the reduced success rate of surgery in acute critical ischemia, surgical correction upon diagnosis is especially recommended in aneurysms with intraluminal thrombus.

[Thoracoscopic treatment of recurrent or persistent spontaneous pneumothorax]. / Die thorakoskopische Behandlung des rezidivierenden oder persistierenden Spontanpneumothorax.

The video shows an endoscopic modification of the established conventional surgical therapy of recurrent or persistent spontaneous pneumothorax: The indications and endoscopic techniques of parietal pleurectomy, ligature of leaking bullae and wedge resection are demonstrated. Our first experience on 50 patients indicates, that minimal postoperative pain and a relatively short hospital stay (mean 3.6 days postop.) are the advantages of minimal invasive techniques also in thoracic surgery. Long-term results are however still lacking.

[Quality control after introduction of a new hernia technique. Barwell transversal fascia-plasty]. / Qualitätskontrolle nach Einführung einer neuen Hernientechnik. Transversalisfaszienplastik nach Barwell.

From 1987 to 1991 we operated on 320 patients with 360 inguinal hernias with the recently introduced transversalis fascial repair after Barwell. The transversalis fascia is duplicated with an atraumatic looped nylon 0.43 trainees performed 70% of the operations. The follow-up was 30 months (6-62) for 317 (88%) hernias (two examiners). Over all we observed eleven (3.5%) recurrences, in 8 cases after primary operation. Two of this recurrences were initially missed femoral hernias. In the learning phase we found five early recurrences in the first 60 patients and in the following 257 patients with the same follow-up only 6 recurrences. We conclude that with the new technique of transversalis fascial repair after Barwell very good results can be achieved even with a big number of young surgeons in training.

[Video-thoracoscopy diagnosis and treatment of persistent post-traumatic pneumothorax]. / Videothorakoskopische Diagnose und Behandlung des persistierenden posttraumatischen Pneumothorax.

Despite correct chest tube drainage, 2 patients had persistent pneumothorax after blunt chest trauma and were referred for further treatment. Videothoracoscopy revealed small lung lacerations caused by rib fragments. A small wedge resection performed via thoracoscopy by the use of an endostapler resulted in immediate and permanent relief of air leakage.

[Thoracoscopic lobectomy in the animal model]. / Die thoracoskopische Lobektomie im Tiermodell.

To evaluate the possibility of a pure thoracoscopic lobectomy by preparation and selective division of hilar structures we performed left cranial lobectomies in 5 Göttingen mini-pigs. The vessels and the main bronchus were isolated and divided by an Endo-GIA stapler. As an alternative technique we used clips or endoscopic ligation. Inside the thoracic cavity the resected lobes were divided into 2 or 3 parts by the Endo-GIA. They could be extracted without destroying the tissue therefore making macroscopic examination possible. The intraoperative blood loss was minimal and all the pigs survived the operation. Two pigs were sacrificed initially, the remaining three one month later. These three showed no evidence of pleural fistula or atelectasis in remaining lung tissue either macroscopically or histologically. It appears that thoracoscopic selective lobectomy is technically possible at least in pig studies. Further studies will show whether thoracoscopic lobectomy in patient with malignancy is as effective as open radical thoracotomy techniques and if endoscopic mediastinal division is possible.

Traumatic rupture of the thoracic aorta in childhood with special reference to the therapeutic strategy.

Acute traumatic tear of the thoracic aorta is extremely rare in childhood. Based upon our own experience with two children, the essential diagnostic and therapeutic measures are discussed with special reference to timing of surgery. Aortic disruption must be suspected in a child who sustains severe blunt chest injury and develops an abnormally wide mediastinum. Definite diagnosis is established by aortography or computed tomography. The appropriate therapeutic approach is determined by the clinical symptomatology and particularly by the severity of concomitant lesions. In the absence of a significant hemothorax and if no difference in pulse amplitude between upper and lower extremities is evident, the risk of free aortic rupture with intrathoracic exsanguination is presumed to be rather low if the patient reaches the hospital alive. In that situation, the continuity of the injured aorta is maintained by the adventitia and surrounding mediastinal structures. Therefore, these patients may derive the best benefit from an initially conservative management including pharmacological intervention to reduce the risk of free aortic rupture. This concept is particularly indicated if aortic disruption is associated with severe concomitant injury such as intraabdominal or intracranial lesions. Such injuries preclude safe aortic repair immediately after establishment of diagnosis. Delay of aortic repair until recovery from associated major injury allows heparinization and the use of a pump oxygenator, which is regarded as the most effective method to prevent spinal cord ischemia and to reduce the risk of paraplegia.