Zentralblatt für Chirurgie
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The treatment and outcome of the respiratory failure decisively depend on its pathophysiological background. Besides simple blood gas analysis the investigation of the respiratory mechanics, interstitial lung water and the monitoring of the pulmonary pressure are necessary for an exact diagnosis. As a scoring method of lung failure the classification by Murray and Morell is most common. ⋯ New methods as negative pressure ventilation, extracorporeal lung ventilation and liquid or partial liquid ventilation are not common yet and should be used only under special conditions. As a supplement of these modes of ventilation the application of prostacyclins, nitric oxide, surfactant and inhibitors of the arachidonic pathway is under clinical investigation. A limitation of the treatment of lung failure should be considered in irreversible multiple organ failure.
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The avoidance of (unrecognized) bile duct injuries (1) and the management of bile duct stones (pre-, intra- or postoperatively?) (2) are believed to be the main problems in laparoscopic cholecystectomy (LCE) at present. They must be a challenge for surgery to develop and improve the concepts of minimally invasive therapy for treatment of cholelithiasis. Intraoperative cholangiography (IOC) plays a very important role and is the basis of innovative, laparoscopically assisted procedures (3) for single session therapy of gallbladder and bile duct stones. (1) A detailed analysis of the literature proves the value of IOC for avoidance or early recognition of iatrogenic bile duct injuries. ⋯ The combination of two independent procedures (LCE and ERC/PT) for treatment of cholelithiasis increases mortality and morbidity. Thus, the outcome of "therapeutic splitting" is not clearly superior to conventional treatment by open surgery.2+ common bile duct exploration allows final diagnosis and treatment in a single session. Additional risks and costs caused by choledochotomy as well as by pre- or post-operative endoscopic retrograde procedures (ERC, EPT) are avoided.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
[Treatment concepts and results in non-infected post-traumatic pseudarthroses of the femur and tibia].
Different methods of internal and external fixation are used to treat aseptic posttraumatic nonunion of the femur and tibia. The advantages and disadvantages of the different methods will be demonstrated by analysing the clinical course and the outcome of our patients. Utilizing these data, a therapeutic concept tailored to the individual situation is recommended. ⋯ Due to the good soft tissue coverage and vascularisation internal fixation is favored for the treatment of femoral nonunions. The fixator should only be used if distraction osteogenesis is necessary because of a bony defect. Due to the problematic soft tissue situation and poorer vascularisation on the external fixator is preferred in the treatment of tibial nonunions if a change of method is indicated. For this purpose, we currently use predominantly the Ilizarov-apparatus because of its biomechanical properties and the convincing results. Initial problems with its use could markedly be reduced with growing experience.
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Causes of septic multiple organ failure are endotoxin induced mechanisms, exotoxin induced mechanisms and sepsis associated immunosuppression. Pharmacological intervention is limited. ⋯ The prevention of systemic infections is mandatory. Approaches to new therapeutical concepts are outlined.
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During a period of 11 years operative placement of a Greenfield vena caval filter was planned in 132 patients. The clinical records of these patients were reviewed retrospectively. Main indications for filter placement were pulmonary embolism in patients with deep venous thrombosis in spite of anticoagulation therapy (45%) and patients with contraindications for anticoagulation (40%). ⋯ CT scans of the abdomen or venacavography studies were obtained in 60 patients. Major complications as recurrent pulmonary embolism (8%), caval thrombosis (13%), penetrations of struts through the caval wall (33%), tilting of filters (25%), migration (5%) and filter fracture (two cases) were observed. In conclusion, indication should be restricted to certain cases with failure of surgical intervention or drug therapy (thrombectomy, lysis, anticoagulation).