G. Steinau

Zwerchfellverletzungen – Klassifikation, Diagnostik und Therapie

Summary. Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.Zusammenfassung. Bei stumpfen thorakalen und abdominalen Verletzungen wird das Zwerchfell in der Diagnostik oft vernachlässigt. Eine Zwerchfellverletzung wird entweder durch direkte oder indirekte Gewalteinwirkung verursacht. Das klinische Beschwerdebild ist sehr variabel und wird besonders bei polytraumatisierten Patienten durch andere Verletzungen maskiert. Zwischen 1987 und 1995 sind 17 Patienten mit Zwerchfellverletzungen behandelt worden. Bei 4 dieser Verletzten lag eine isolierte Ruptur des Diaphragmas vor; bei den übrigen 13 fanden sich zusätzlich Begleitverletzungen. Präoperativ konnte mit folgenden Untersuchungsmethoden die korrekte Diagnose gestellt werden: Sonographie in 12, Röntgenthorax in 6, CT-Abdomen in 2 Fällen, MDP und CT-Thorax in 1 Fall. Während der ersten 2 Tage nach dem Unfalleintritt sind 15 Patienten, einer innerhalb des 1. Jahres und einer erst 23 Jahre später, therapiert worden, 2 Verletzte starben an den Folgen der Begleitverletzungen.

Contralateral inguinal hernia in childhood and youth: which child will develop a contralateral inguinal hernia?

This work addresses the controversial topic of the exploration of the contralateral side in the presence of a one-sided inguinal hernia in infancy. In a prospective study of 368 children with one-sided inguinal hernia, we demonstrated the consecutive development of a contralateral hernia in 22 (6%) of the children. We found that the child’s age at first operation represents a risk factor for the development of a consecutive hernia. At an age of less than two months we found a highly significant (P < 0.0001) accumulation of consecutive hernias. These consecutive contralateral hernias appear significantly often (P < 0.0009) within the first two post-operative months in children at least two months old. In view of these findings, we see an indication for routine simultaneous repair on both sides for children aged less than two months at first presentation.

Diaphragm replacement: An experimental animal study

SummaryWe performed an open experimental study for evaluation of rapidly absorbable material of bovine serosa for diaphragm replacement. A total of 100 Sprague-Dawley rats were randomly assigned to five groups of equal size. In the control group (n=20) incision of the diaphragm was followed by primary suture. The animals of the four other groups underwent partial resection of the left hemidiaphragm. The defects were repaired by lyophilized dura, polytetrafluorethylene (PTFE), autologous transversus muscle or rapidly absorbable bovine serosa. We performed electromyography (EMG) and postmortem physical examinations of elasticity and load capacity of the different materials as well as histologic examinations after three and six months. A total of 89 animals survived and were subject to the analysis. There were no differences between the groups concerning growth and weight gain. The EMG showed normal function for the absorbable material and the transversus muscle. Only scanty physiologic waves were registered in the PTFE group. Load capacity measurements showed the lowest value of 4.71 N for the native diaphragm; all other materials had much higher values (17.66 N – 51.99 N) with a peak load capacity in the PTFE group. Measurements of elasticity displayed similar results. The native diaphragm had the lowest value (1516 N/m); much higher values were found in all the other materials tested (3905 N/m – 7654 N/m) with again peak values for PTFE. The differences of all materials compared to native diaphragm were statistically significant (p<0.05). The histologic examinations revealed strong foreign body reactions in the dura and PTFE groups. The absorbable bovine serosa had vanished three months postoperatively. Short-term absorbable bovine serosa tested successfully as a partial replacement of the diaphragm in this experimental study on rats. There may be additional indications for this material if a temperary replacement is intended.

Etiology of Appendicitis in Children: The Role of Bacterial and Viral Pathogens

ABSTRACT Background: Although acute appendicitis is the most common cause for abdominal surgery in children, its etiology is still largely unknown. The aim of this study was to evaluate the role of bacterial and viral pathogens for the etiology of appendicitis in children. Methods: Between 2000 and 2010, 277 children underwent appendectomy in our institution. On this collective, a retrospective study was performed on to identify the presence of bacterial or viral pathogens. Results: Intraoperatively, 39% of cases showed acute, 9% of cases chronic, and 41% of cases ulcerous inflammation. Bowel perforation was found in 7% of cases and four percent of the children had no inflammation of the appendix at all. Escherichia coli was the predominant bacterium with an incidence of 27.4%, followed by streptococci (9.8%). Concerning viral pathogens, adenovirus was the most common with an incidence of 5.4% followed by rotavirus (4.7%). Significant correlations between histopathological findings and present pathogens were found: in cases of bowel perforation there were significantly more infections with E. coli bacteria (32.2%, p < .001), streptococci (12.2%, p < 0.001), and Pseudomonas aeruginosa (6.7%, p < .001) whereas chronic inflammations were accompanied with a significantly elevated rate of yersinia infections (2.5%, p = .016). Acute inflammations were significantly more often associated with campylobacter (1.7%, p = .011) and oxyures infections (6.1%, p < .001). In relation to the patients’ age, a significant accumulation of different pathogens was observed. CRP- and leukocyte counts showed differences between viral and bacterial inflammations. Conclusions: Our data indicates that appendicitis in children might be triggered by bacterial and viral pathogens and that the type of pathogen directly correlates with patient age, type of inflammation, and level of inflammation values. To confirm and further evaluate these findings, additional studies need to be conducted.

Medizin zwischen Humanität und Wettbewerb

BACKGROUND An open medical market is supposed to be a promising tool for preserving the meagre resources of the German public health care system. The competition between humane and economic practice induces conflicts which burden physicians as well as patients. To analyse this problem by scientific means, inpatients were interviewed with the help of a standardised protocol. PATIENTS AND METHODS During 10 weeks 524 inpatients were interviewed. The structured questionnaire consisted of nine closed-ended questions with multiple-choice answers. Question 3 included a free amendment. The gender ratio was balanced, and the age pattern represented the typical patient collective of our clinic. RESULTS AND CONCLUSION The majority of patients expect negative changes in their medical service and the social attitude towards patients and physicians due to promoted medical competition. Besides an increasing financial load, losses in trust, self-determination, and therapeutic freedom are expected. Instead a responsible transparency will not be achieved. Patients still judge the economically dominated reforms on the German health care market with scepticism or even hostility. In their point of view future discussions must aim at a more modern attitude towards health economics in order to bridge the schism they perceive between medical competition and humanitarianism. The understanding of strong financial management as a prime condition for stable social security is the basis of synergies to deal with upcoming reforms.

Recommendations for treatment of contralateral inguinal hernias in children

SummaryIt is impossible to determine whether or not a child will develop a contralateral hernia after inguinal hernia repair. There exists no risk score for the occurrence of a contralateral hernia. This well-known fact prompted us to perform the underlying study. In a retrospective trial, we reviewed the files of all children operated on for inguinal hernias in our department from January 1986 until December 1994. During this period, we performed 1721 hernia repairs on 1708 children aged 0–16 years. In 96 (5.6%) of these patients, the indication to operate was a contralateral hernia following previous unilateral repair. Comparison of the ages at the time of primary inguinal repair of those children who developed a contralateral hernia (n=96) and those who did not (n=1612) showed a significantly increased incidence of contralateral hernias if the primary operation was performed before the age of two months (p<0.0001). Diseases predisposing to hernias were found in 38% of all children (prematurity, dystrophia, ventriculo-peritoneal shunt, ascites, asthma). The authors recommend a contralateral exploration for children under the age of two months if they have any predisposing disease.

Zwerchfellrekonstruktion mit verschiedenen Materialien

The relative merits of three methods of diaphragmatic hernia repair were evaluated in animals. Eighty Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other three groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized Dura, in 20 with polytetrafluoroethylene (PTFE) and in another 20 with absorbable serosa from a cow. Seventy-two animals survived the operation; they were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months. The EMG showed normal function for the absorbable material. Only scanty physiological waves were registered in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations amount to strong foreign body reactions with Dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively. It is concluded that bovine serosa can be recommended for diaphragmatic hernia.ZusammenfassungBisher gebräuchliche allogene Implantate zum Zwerchfellersatz waren mit dem Nachteil der nicht oder nur schwer verzögerten Resorbierbarkeit behaftet. Hieraus ergab sich eine hohe Rate an Thoraxfehlbildungen als auch eine nicht geringe Zahl von Rezidiven. Demgegenüber ist die Muskellappenplastik nach Hecker (M. abdominis obliqus internus and transversus) mit dem Risiko einer Bauchwandhernie and einer verlängerten Operationszeit behaftet. In einer tierexperimentellen Studie an 80 Ratten haben wir lyophilisierte Dura, PTFE mit vollresorbierbarer Rinderserosa verglichen. Als Kontrollgruppe ist eine primary fortlaufende Prolenenaht durchgeführt worden. In Äthernarkose sind nach medianer Laparotomie zunächst Resektionen des linken Zwerchfells bis auf einen schmalen Randwall vorgenommen worden. Die Untersuchungen beinhalteten EMG-Ableitungen nach 3 und 6 Monaten, physikalische Tests (Dehnbarkeit and Maximalbelastbarkeit) und histologische Untersuchungen. Die EMG-Ableitungen zeigten einen physiologischen Erregungsablauf für das vollresorbierbare Material, demgegenüber ließen sich nur rudimentdre Erregungsabläufe in der PTFE-Gruppe nachweisen. Von den physikalischen Ergebnissen her sind alle getesteten Matrialien als Zwerchfellersatz geeignet. Die histologischen Untersuchungen zeigten erhebliche Fremdkörperreaktionen für die Duraund PTFE-Implantate. Schon nach 3 Monaten post operationem war die ursprüngliche Rinderserosa nicht mehr nachweisbar. Nach unseren Ergebnissen ist ein vollresorbierbares Material als Zwerchfellersatzmaterial im Tierexperiment geeignet.The relative merits of three methods of diaphragmatic hernia repair were evaluated in animals. Eighty Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other three groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized Dura, in 20 with polytetrafluoroethylene (PTFE) and in another 20 with absorbable serosa from a cow. Seventy-two animals survived the operation; they were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months. The EMG showed normal function for the absorbable material. Only scanty physiological waves were registered in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations amount to strong foreign body reactions with Dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively. It is concluded that bovine serosa can be recommended for diaphragmatic hernia.

Experimental investigation of the elasticity of the human diaphragm

BackgroundTraumatic diaphragmatic ruptures affect mainly the left side. In an experimental study in human corpses we examined the stretch behaviour of the left and right diaphragmatic halves.MethodsIn a total of 8 male and 8 female corpses each diaphragmatic half was divided into 4 different segments. Each segments stretch behaviour was investigated. In steps of 2 N the stretch was increased up to 24 N.ResultsIn the female the left diaphragm showed a stronger elasticity compared to the right. Additionally the left diaphragm in females showed a higher elasticity in comparison to the left in males. Traumatic diaphragmatic ruptures affect mostly the central tendineous part or the junction between tendineous and muscular part of the diaphragmatic muscle. Accordingly we found a lower elasticity in these parts compared with the other diaphragmatic segments.ConclusionIn summary it can be said that albeit some restrictions we were able to determine the elasticity of different diaphragmatic segments quantitatively and reproduceably with our presented method. Thereby a comparison of results of different diaphragmatic segments as well as of both diaphragmatic halves and of both genders was possible

Short-term absorbable material for diaphragmatic replacement.

Abstract To evaluate absorbable materials for use for replacement of the diaphragm, we implanted materials in experimentally-created diaphragmatic defects in pigs. As a short-term absorbable material, bovine serosa (BS) was used. Its absorption was complete after 4–6 weeks. In a control group, the defect was repaired with a continuous running polypropylene suture. In two other groups the defect was closed with lyophilized dura (LD) and a modified transverse abdominal muscle flap according to Hecker, respectively. Physical studies (load capacity and elasticity) and histologic investigations were performed in one-half of the animals of each group after 3 and 6 months, respectively. Considering their physical properties, it could be shown that all materials tested are suitable for replacement of the diaphragm, but that BS best resembled native diaphragm. We conclude that short-term absorbable BS is suitable for replacement of the diaphragm in pigs.

Inzidenz von kontralateralen Leistenhernien im Säuglings- und Kindesalter

Inguinal hernia is a frequent surgical disease during infancy, occuring in 1 to 2% of all mature newborns and rise up to 30% of all premature babies. In 9.5% a contralateral hernia is found after unilateral operation. In our own patients this rate was 5.6%. The development of a contralateral hernia was significantly more often found in boys than in girls. If the hernia occured during the first two months of life, a contralateral hernia developed later highly significant (p>0.0001). Within the first two postoperative years the second hernia arose in 84.9%. We recommended to routinely operation for a contralateral hernia in all children younger than two months.ZusammenfassungDie Inzidenz von Leistenhernien im Kindesalter beträgt 1–2%, bei Frühgeborenen steigt sie bis auf 30% an. In 9,5% der Fälle ist nach unilateraler Hernienversorgung mit der Ausbildung einer kontralateralen Hernie zu rechnen. Bei den eigenen Patienten bildete sich bei 96 Kindern (5,6%) eine kontralaterale Hernie aus. Signifikante Unterschiede bestanden hinsichtlich des Geschlechts. Jungen sind häufiger von der Ausbildung einer kontralateralen Hernie betroffen als Mädchen. War eine Hernie in den ersten 2 Lebensmonaten aufgetreten, so mußte im späteren Leben hochsignifikant mit dem Auftreten einer kontralateralen Hernie gerechnet werden (p>0,0001). Diese tritt in 84,9% der Fälle innerhalb der beiden ersten postoperativen Jahre auf. Daher halten wir die routinemäßige Simultanoperation der kontralateralen Seite bei Kindern <2 Monaten für indiziert.