Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Randomized Controlled Trial Comparative Study Clinical Trial
[Pain therapy after thoracoscopic interventions. Do regional analgesia techniques (intercostal block or interpleural analgesia) have advantages over intravenous patient-controlled opioid analgesia (PCA)?].
Systemic opioids and thoracic epidural analgesia are common techniques used to provide post-operative analgesia following thoracoscopy (video-assisted thoracic surgery). The aim of the present prospective randomised study was to evaluate the efficacy of two less invasive analgesic techniques, intercostal blocks (ICB) and interpleural analgesia (IPA). After approval from the ethics committee and informed consent from the patients, 36 patients scheduled for thoracoscopic surgery were randomly assigned to a group for postoperative pain management: group ICB: intercostal blocks of the segments involved with 5 ml 0.5% bupivacaine at the end of surgery and 6 h later; group IPA: interpleural analgesia with 20 ml 0.25% bupivacaine applied every 4 h using a catheter placed during surgery near the apex of the interpleural space; control group: IV-opiod-PCA with piritamide. ⋯ Nevertheless, effective pain management is necessary. We could not demonstrate a significant reduction in piritramide consumption for the techniques of regional analgesia tested here (ICB, IPA). We conclude that the use of these techniques is not complementary after thoracoscopy, since an opioid (PCA with piritramide) combined with a non-opioid (metamizol) resulted in satisfactory analgesia.
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Case Reports
[Atypical heparin-induced thrombocytopenia (HIT)--"heparin allergy" with thrombocytosis].
We report a truck driver with severe soft tissue contusion of both legs who developed atypical heparin-induced thrombocytopenia (HIT) after a thrombosis prophylaxis with unfractionated heparin; despite a thrombosis the patient showed a systemic allergic reaction to heparin in combination with elevation of thrombocytes and positive heparin-dependent antibodies. Six days after the initial trauma deep vein thrombosis of the left lower leg was diagnosed and fasciotomy was performed, preventing an imminent compartment syndrome. Another 5 days later the patient developed exanthema of the trunk and upper extremities and urticaria on his face, as well as severe headache. ⋯ We suggest a new classification of different pattern of heparin allergy types I-IV. The new types I and II are similar to HIT types I and II. Type III is the reaction of antibodies without decrease of thrombocytes, and type IV the reaction of antibodies associated with systemic allergic symptoms.
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Surgical drapes made of cotton are under increasing competition with various disposable products and reusable draping systems (e.g., made of synthetic fabrics like polyester). When making a choice to use one of these medical devices in practical surgery, major aspects like handling, hygienic safety and costs, but also environmental effects have to be taken into account. In this study a mixed system for patient drapes (reusable cotton drapes combined with a reduced set of impermeable single-use drapes made of cellulose/polyethylene) was compared to a system that is only based on single-use drapes with regard to ecology [life-cycle assessment (LCA)]. ⋯ Regarding water pollution no system proved superior. It is difficult to compare and weigh various environmental aspects like the polluting cultivation of cotton in distant countries (reusable drapes) and the higher figure of transportation necessary to deliver the single-use product within Germany. It is an important disadvantage of the mixed system that it combines the ecological burden of both cotton drapes and the single-use alternative.
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The management of 178 patients with liver trauma (132 male, 46 female; mean age 34 years (range 3-88) presenting from January 1979 to August 1996 is reviewed. There were 165 cases of blunt trauma and 13 cases of penetrating injury. 110 cases were classified as simple injuries (grade I or II) and 68 cases as complex injuries (grade III to V). The overall mortality was 32% (57 patients). ⋯ The majority of liver injuries can be managed by simple techniques, including electrocautery and application of hemostatic agents. In complex injuries hepatotomy, direct vessel ligation, and debridement of necrotic tissue is the method of choice (Pachter's procedure). In non-controlled bleeding, perihepatic picking is a standard method.
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For patients with liver metastases, surgery currently represents the only possibility for cure, with a mean 5-year survival rate of 25-35%. Due to refinement in operative and anesthetic techniques and improved critical care with decreased morbidity (< 25%) and mortality (< 5%), hepatic resection is a safe and efficient procedure. Surgery has repeatedly achieved long-term disease-free survival in 20-25% of patients. ⋯ Only 20-35% of these recurrent metastases appear to be resectable, resulting in an overall 3-year survival rate of about 30%. The morbidity and mortality from repeat hepatectomy is similar to that of first hepatic resection. All results together demonstrate that resection and re-resection of liver metastases can provide long-term survival rates and can be beneficial in a carefully selected group of patients without extrahepatic disease.