Decholedochoduodenostomy - indications and operative technique (author's transl)

21 cases of decholedochoduodenostomy are reported. The reinterventions were necessary because of narrowing of the anastomosis, choledocholithiasis, developement of a blind-sack in the retroduodenal choledochal duct and because of intolerance of the duodenal-biliary reflux. In one case a broncho-biliary fistula was treated. In all cases an ascending cholangitis was observed. The indication for relaparotomy is decided on the basis of the anamnesis. The operative technique for decholedochoduodenostomy is described.     

Conservative or operative treatment of fractures of the head of the tibia (author's transl)

Whether fractures of the head of the tibia have to be treated conservatively or surgically in an active way depends on the type of the fracture. In cases with small dislocation conservative treatment should be given priority. Only fractures with badly dislocated fragments should be operated on (osteosythesis).     

The operative management of laryngo-tracheal stenosis (author's transl)

The different types of laryngo-tracheal stenoses are grouped by etiology and operative procedures for correction. The operations used are described in detail, and our experiences analysed.     

Osteochondritis dissecans of the humeral head

ISSUES: The colposcope was developed in 1925 and is well established in clinical gynecologic practice for defining and delineating cytologically detected lesions mainly of the cervix but also the vagina and vulva. Additionally, various endoscopic procedures in gastroenterology, pulmonary and urologic lesions enhance the cytologic detection and histologic verification of precancerous and cancerous lesions. The cost-effectiveness of all these devices and their applicability, particularly in countries with a limited health budget, is a major issue. This task force considered aspects of the present state of the art and the challenges in the 21st century. CONSENSUS POSITION: Automated cytology can interface with colposcopic examination in a number of significant ways. Automated cytologic analysis of conventional cervical smears can potentially direct colposcopic examination by predicting the nature of a lesion, assist in determining which patients should receive colposcopy and, in some settings, thereby reduce the number of colposcopies. Potentially, various combinations of automated cytology and colposcopy may be used to generate screening protocols that might result in more effective and inexpensive screening. The role of cervicography, or high-resolution cervical photography, as a screening device remains to be defined. Sensitivity for high grade lesions is generally no greater than that in cytology, and specificity appears lower. The interpretation of cervical photographs in triage of mildly abnormal cytology may prove to be useful in countries with established cytology programs. In areas of the world where cytology screening programs are not in place, the interpretation of cervical photographs may have its most dramatic effect. Cost-effectiveness analyses are needed. There are, at present, insufficient data for the evaluation of speculoscopy, a procedure using chemiluminescent illumination of the cervix for visualization of acetowhite areas. Basic training in colposcopy should be integrated into the residency programs of obstetrics and gynecology. Criteria for the adequate training of colposcopists should be developed. Continuing education programs in colposcopy should be developed when they are not already in existence. The cost-effectiveness of integrating colposcopy as a primary screening technique should be evaluated. Following a high-grade squamous intraepithelial lesion (HSIL) cytology result, colposcopically directed punch biopsy should be taken with or without endocervical curettage. This generally should precede the loop electrosurgical excision procedure (LEEP); however, in certain circumstances direct LEEP may be indicated. LEEP under colposcopic vision is an efficient way to treat an HSIL lesion of the cervix because the histologic extent and margins can be determined, unlike with laser surgery or cryosurgery. It is also more cost-effective than cold knife conization because general anesthesia and an operating room are unnecessary. Following LEEP, the endocervical canal should be examined colposcopically for any evidence of involvement. Lesions in the endocervix can then be removed with a different-shaped loop. Further research into Raman spectroscopy as a diagnostic aid in cervical pathology is needed, as is the use of micrococolpohysteroscopy for in vivo cytologic analyses, especially of the endocervical canal and transformation zone. Hysteroscopy is the most direct method for the diagnosis and treatment of intrauterine diseases. Hysteroscopic endometrial biopsy is more accurate than conventional biopsy methods. Cervical invasion of endometrial cancer can be detected by hysteroscopy. The depth of invasion, however, is more accurately determined by magnetic resonance imaging or computed tomography. ONGOING ISSUES: Many topics for ongoing research and/or implementation are mentioned under "Consensus Position," above. (ABSTRACT TRUNCATED)     

External ventricular drainage--a new aspect in the operative treatment of head injury (author's transl)

It is not only for CSF-removal in conservative treatment of oedema and control of the effectiveness of osmo-onco-therapy, contricosteroids, anticholinergics and aldosterone-antagonists, that external CSF drainage in severe cerebral trauma has proved of value. It has also made it possible to assess objectively the indications for bitemporal craniotomy in raised intracrainial pressure with an acute midbrain syndrome caused by tentorial herniation. Continuous monitoring of ICP permits an intervention at the right time and prevents one from operating too late, namely at a moment, when manifest neurological signs already indicate cerebral decompensaervative steps failing, a bitemporal craniectomy is indicated: in this way we lower intracranial pressure, liberate the rostral brain stem out of its strangulation and improve cerebral perfusion and metabolism.     

Results of 193 conservatively treated acute fractures of the carpal navicular--indications for operative treatment (author's transl)

The results of 193 conservatively treated acute fractures of the carpal navicular are presented. Ninety-eight (50.7%) had horizontal oblique fractures, 82 (42.5%) transverse, and 13 (6.8%) vertical oblique fractures. In 23 (11.9%) cases the fracture was located in the proximal third, in 125 (64.7%) in the middle third, and in 45 (23.4%) in the distal third. An unpadded cast extending from the elbow to the metacarpophalangeal joints including the thumb was used generally. On the following day the cast was always completed by addition of a volar plaster splint and a circular plaster bandage. Duration of immobilization lasted from 6 to 16 weeks (mean: 10 weeks). On average, 4.5 years after injury 190 (98.4%) fractures had healed by osseous union and 3 (1.6%) had a pseudarthrosis. The reasons for non-union were too short time of immobilization, and former diastasis between the fragments. The number of arthrosis in the radiocarpal joint in our patients amounted to less than 1%. Primary operative treatment (open reduction and screwing) is preferred for vertical oblique fractures and for fractures with a large diastasis between the fragments. Secondary operative treatment is performed if there are no signs of osseous consolidation.     

Surgical treatment of varices (author's transl)

Basically three possibilities are available for the treatment of the varicose symptom complex: 1. Varicosclerozation, 2. Surgery, 3. Compression. Dermatologists and internists understandably prefer varicosclerozation; surgeons, surgery. The best success, in my opinion, is achieved with all three possibilities of treatment are used in combination and adjusted individually to the vascular findings of each case. There is no effective varicosclerozation and no surgical treatment without subsequent compression. In no case, can treatment by medication be more than supportive for other effective measures. The goal of this article is to provide information regarding the present status of surgical treatment. Unavoidably, the indication for the other methods of treatment was also established.     

Prevention and non-medicinal treatment of hypertension (author's transl)

Due to the multifactorial origin of hypertensive heart disease there are several points of attack for prevention and for non-medicinal therapy. In recent decades prophylactic trials and studies on the therapeutic efficacy of non-medicinal measures in established hypertension have been neglected in favor of drug therapy so that at present only weight reduction and restriction of salt intake show a confirmed action. Further measures are: dietary increase of potassium, physical endurance training and behavior therapy methods. With the low cost of nonmedicinal measures and in view of possible side-effects of a pharmacological hypertension therapy, these should be applied or tested particularly in borderline hypertension.     

On the surgical treatment of cerebellar infarction (author's transl)

Recently we have experienced two cases of acute uncomplicated cerebellar infarction which had been surgically treated. Onset of the disease in both cases was an attack of vertigo with nausea and vomiting, followed by the signs of an expanding lesion in the posterior fossa. There were thirty-one surgically treated cases and only six were fatal so far as we have reviewed cases reported in the literature. The clinical pictures of cerebellar vascular accident are typical in most cases and those of cerebellar infarction are similar to those of cerebellar hemorrhage. These two are frequently indistinguishable on the clinical as well as angiographic grounds, however, CT-scan may be of great value in the differential diagnosis. It is important to realize the cerebellar infarction is also a surgical lesion and not to spend valuable time in differentiating cerebellar infarction from cerebellar hemorrhage. Low mortality rate and low morbidity in cerebellar infarction adequately treated surgically confirm importance for early exploration.     

Integrated treatment of the inoperable bronchial carcinoma (author's transl)

The inoperable bronchial carcinoma tends to early formation of metastases. If the tumor responds well to different cytostatic drugs, chemotherapy is absolutely necessary. In this case, combined therapy has better results than monotherapy. We use chemotherapy prior to radiotherapy in order to prevent hematogenic extension of the disease and to ameliorate the receptiveness of the primary tumor. In order to avoid local recurrence it is necessary to submit the primary tumor and the mediastinum to radiotherapy. A focal dose of 3000 rd within three weeks is considered to be sufficient. This dose generally does not cause severe myelosuppression, so that the chemotherapy can be continued. A report is given on the provisional results of different chemotherapeutic combinations. Further studies, however, are absolutely necessary in order to be in a position to give recommendations of common validity.