Zentralblatt für Chirurgie
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Post-laminectomy segmental hypermobility as well as appositional ossification were suggested by many authors to contribute to the unsatisfactory long-term results of laminectomy. The aim of this study was to find out whether segmental instability, among other factors, influences the degree of appositional ossification following laminectomy. ⋯ Simultaneous lumbar fusion with laminectomy is proved to be associated with less appositional ossification. Therefore lumbar fusion should be considered when planning surgery for spinal stenosis.
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Four thesis related to economics of intensive care medicine are derived from an analysis of the intensive care unit of the university hospital of Basel, Switzerland, and the respective literature: (1) Intensive care medicine is costly but rationing can be avoided by rationalization. (2) Exemption or withdrawal of intensive care cannot be justified in the absence of accurate predictors of costs and outcomes of individual patients. (3) Intensive care physicians must not act as judges but on behalf of patients incapable of decision making. They must represent patients' interests vis-à-vis authorities and reimbursing institutions. (4) Analyses of cost-efficiency are instrumental for process improvement of intensive care, for negotiations on reimbursement and for the regulatory decisions of the authorities. Tools for economic analyses of intensive care medicine are therefore worthy of further development.
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Despite the decreasing frequency of gastric cancer in most Western countries prognosis could not be improved by surgery alone in the past. Advanced tumor stage due to late diagnosis is one of the reasons for this observation. Contrary to breast and colorectal cancer, postoperative chemotherapy failed to improve prognosis in gastric cancer. ⋯ Intraperitoneal, adjuvant chemotherapy showed a positive impact on survival in Asian studies only, but was also used successfully as a part of a multimodality approach in Western phase II trials. Since neoadjuvant therapy proved to create downstaging of tumor size in some patients with advanced gastric cancer some working groups tried to influence prognosis of potentially resectable tumors by preoperative chemotherapy, surgical resection and postoperative, adjuvant therapy in the recent past. However, the efficacy of this therapeutic approach has to be reconfirmed in a controlled, phase III fashion.
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Objective of this study was to show the different causes and the importance of pulmonary complications after esophageal surgery and their management by general and intensive care measures. In the University Hospital for General and Abdominal Surgery of Mainz 222 patients were treated for esophageal cancer from 9/1985 to 5/1997. Data of 214 patients were available for this investigation. ⋯ Postoperative psychosyndrome, recurrent nerve palsy and ASA-risk stratification were accompanied by elevated rates of pneumonia. Careful selection of patients for esophageal resection, atraumatic surgical technique and reduction of general and surgical complications and intensive care measures can help to avoid postoperative pulmonary complications. Reduction of mediators activated by surgical trauma is not feasible so in the moment prevention of aspiration seems to be the most effective therapy in the postoperative course.
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Comparative Study
[Role of adenosine triphosphate (ATP) in trauma-induced and elective hypothermia].
In trauma patients hypothermia is a frequent event. According to the literature the majority of trauma patients are presenting a core temperature of less than 34 degrees C at admission. In contrast to the benefit of hypothermia in elective surgery, clinical experience with hypothermia in trauma patients has identified hypothermia to be one major cause of severe posttraumatic complications. It was hypothetized that this diverse effect of hypothermia is related to depletion of high energy phosphates like adenosine-tri-phosphate (ATP) in trauma patients. To verify this hypothesis the relation of ATP plasma levels and hypothermia was examined in a clinical study. ⋯ Hypothermia in elective surgery, established by active cooling, preserves the ATP storage and maintains an aerobic metabolism, which both contribute to the beneficial effect of hypothermia in ischemia/reperfusion in cardiovascular surgery. However, in trauma patients hypothermia is caused by insufficient heat production due to utilization of ATP under anaerobic metabolic conditions. Low ATP plasma levels combined with hypothermia seem to be a predisposition for posttraumatic complications like organ failure.