Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Abdominal organs such as the rectum and urinary bladder are rarely involved in Klippel-Trénaunay syndrome, but may occasionally be the source of severe blood loss. Since frequently no isolated source of bleeding is identified, severe blood loss can result in a critical condition. This article describes an unusual multimodal treatment concept for a patient with Klippel-Trénaunay syndrome associated with severe recurrent rectal bleeding. ⋯ Preoperative work-up revealed a complete alteration of the rectum and the distal parts of the sigmoid/colon by hemangiomas, with diffuse bleeding from the destroyed rectal mucosa. Preoperatively the superior rectal artery was embolized. After a 48-h interval, sphincter-preserving complete rectal excision including the sigmoid/colon was performed followed by a colon pouch anal anastomosis and protective loop ileostomy.
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Injuries precede the vast majority of all odontoid pseudarthroses. Because of specific anatomic conditions type II injuries lead more often than other types to non unions. For its development insufficient internal or external fixation and a persisting fracture gap are crucial. ⋯ Therapeutical recommendations need to be differentiated. Unstable non unions are most often responsible for persistent pain, may result in acute or chronic myelopathy++ and therefore - as well as ossa odontoidea - need operative fixation. In considerably displaced non unions a closed reduction manoeuver with long term traction should be tried. The operative treatment of choice is the posterior transarticular screw fixation C1/C2 desirably in a percutaneous technique. Tight, "stable" pseudarthroses in the sense of a persisting fracture gap in painfree patients should first be controlled radiologically. If the odontoid position remains unchanged, non operative treatment may be continued.
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Since 1993 a report card system for fractures of the neck of the femur has been established in the Department of External Quality Assurance of the Chamber of Physicians of Westphalia-Lippe. Several indicators of good quality have changed significantly since then: conservative treatment decreased from 6.8 % in 1993 to 4.2 % in 1997, lethality decreased from 6.9 % to 5.4 %, average length of stay decreased from 30.9 days to 24.9 days, average length of stay before operation decreased from 2.6 to 2.1 days, the frequency of operations on weekends increased, complications in wound healing increased from 4.9 to 6.0 %, and cardiopulmonary complications decreased from 11.2 % to 7.8 %. Between 1993 and 1997, 54.3 % were dismissed to go home; the percentage of patients sent to rehabilitation facilities after acute care rose from 8.3 % in 1993 to 20.1 % in 1997. ⋯ Operative treatment was performed in more than 90 % of all fractures in all counties of Westphalia-Lippe. However, there was a wide and significant geographical variation in the choice between osteosynthesis and hip replacement: the percentage of hip replacements differed between 57 % and 82 % among different counties. Average length of stay before the operative procedure for patients undergoing reduction and rigid internal fixation of the fracture is still too long (1.6 days in 1997).