Heinrich M. Schubert

The influence of nitrous oxide and remifentanil on cerebral hemodynamics in conscious human volunteers.

Remifentanil is increasingly used in the context of anesthesia, e.g., in patients presenting for MRI examinations, not only as an analgesic but also to replace nitrous oxide. Therefore, a comparative analysis of the effects of commonly used doses of remifentanil and of nitrous oxide on cerebral hemodynamics is warranted. The present study used contrast-enhanced magnetic resonance (MR) perfusion measurement to compare the effects of nitrous oxide (N(2)O/O(2) = 50%; n = 9) and remifentanil (0.1 microg/kg/min; n = 10) on regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV), and regional mean transit time (rMTT) in spontaneously breathing human volunteers. Remifentanil increased rCBF above all in basal ganglia, whereas in supratentorial gray matter the increase in rCBF was equal or even more pronounced when using nitrous oxide. In contrast, nitrous oxide produced a greater increase in rCBV in gray-matter regions than did remifentanil. In summary, nitrous oxide increased rCBV in all gray-matter regions more than did remifentanil. However, the increase in rCBF, especially in basal ganglia, was typically less pronounced than during infusion of remifentanil.

Capsular flap for coverage of an exposed implant after skin-sparing mastectomy and immediate breast reconstruction.

Native skin-flap necrosis following skin-sparing mastectomy (SSM) is treated by raising a capsular flap, formed as a consecutive physiological reaction around breast implant. Using this highly vascularised thin tissue layer as an implant coverage withdraws pressure from the defect and allocates a good background for wound healing.

Lornoxicam characteristically modulates cerebral pain-processing in human volunteers: a functional magnetic resonance imaging study

BACKGROUND Lornoxicam like other non-steroidal anti-inflammatory drugs (NSAIDs) is widely used for postoperative pain therapy. Evaluation of the effect of lornoxicam on cerebral processing of surgical pain was thus the aim of the present functional magnetic resonance imaging (fMRI) study. METHODS An fMRI-compatible pain model that mimics surgical pain was used to induce pain rated 4-5 on a visual analogue scale (VAS) at the anterior margin of the right tibia in volunteers (n=22) after i.v. administration of saline (n=11) or lornoxicam (0.1 mg kg(-1)) (n=11). RESULTS Lornoxicam, which significantly reduced pain sensation [VAS: mean (sd) 4.6 (0.7) vs 1.2 (1.5)], completely suppressed pain-induced activation in the SII/operculum, anterior cingulate cortex, insula, parietal (inferior), prefrontal (inferior, medial), temporal (inferior, medial/superior) lobe, cerebellum, and contralateral (e.g. left-sided) postcentral gyrus (SI). Only the hippocampus and the contralateral superior parietal lobe (BA 7) were activated. CONCLUSIONS As compared with saline, lornoxicam typically suppressed pain-induced brain activation in all regions except the hippocampus. Furthermore, de novo activation was found in the contralateral, superior parietal lobe (BA 7).

Successful aspiration of blood does not exclude malposition of a large-bore central venous catheter

1 Maruyama K, Mochizuki N, Hara K. High-degree atrioventricular block after the administration of atropine for sinus arrest during anesthesia (Letter). Can J Anesth 2003; 50: 528–9. 2 Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies for prevention. Anesth Analg 2001; 92: 252–6. 3 Johnston RR, Eger EI II, Wilson C. A comparative interaction of epinephrine with enflurane, isoflurane, and halothane in man. Anesth Analg 1976; 55: 709–12.

Die freie anterolaterale Oberschenkellappenplastik zur Weichteilrekonstruktion an den Extremitäten und im Kopf-Hals-Bereich

OBJECTIVE Stable soft tissue coverage of exposed bone, tendons, or hardware in the extremities or the head and neck area with a microsurgically grafted free flap. INDICATIONS Soft tissue defects measuring up to 42 × 15 cm in the extremities and the head and neck region. CONTRAINDICATIONS Previous surgery or trauma in the anterolateral thigh region. Insufficient personnel and/or technical resources. SURGICAL TECHNIQUE A line is marked from the anterior superior iliac spine to the superolateral patella pole, approaching the intermuscular septum between the rectus femoris and vastus lateralis muscle. The flap is centred on this line and after medial incision the perforators of the descending branch of the lateral circumflex femoral artery are identified and dissected to their origin. Afterwards the lateral incision is carried out and flap dissection is completed. After flap transfer microsurgical anastomoses are performed and the flap is sutured to the recipient region. POSTOPERATIVE MANAGEMENT Flap monitoring for 1 week. Strict elevation and immobilization after flap transfer to the extremities; bedrest for 1 week. Thrombosis prophylaxis. RESULTS From 2008-2011, 41 free anterolateral thigh flaps in 5 women and 36 men with an average age of 53 years (38-70 years) were performed for microsurgical soft tissue reconstruction. Total flap loss rate was 2.4 % and reoperation due to complications, e.g., hematoma, problems with microsurgical anastomosis, and partial flap loss was necessary in 13.8 % of patients.

A rare manifestation of sarcoidosis with sensomotoric neuropathy of the ulnar nerve as the only symptom

A 79-year-old woman was admitted complaining of progressive weakness and numbness of the right hand. The patient was otherwise healthy. The patients history was unremarkable. Clinical and electrophysiological examination revealed a compression of the ulnar nerve in the ulnar sulcus and in Guyons canal. Ultrasound evaluation showed a suspicious tumour proximal to the elbow close to the ulnar nerve. The ulnar sulcus was then released and an epineural and perineural lesion 3–4 cm proximal to the sulcus was excised under microscope. The histopathology confirmed the lesion as non-caseating sarcoid granulomas. The patient showed no other signs of systemic sarcoidosis, as neuropathy was the only symptom and the condition improved postoperatively. Sensory deficits and paraesthesia resolved fully. The extension of the minor finger remained slightly inferior compared with the not affected side. Sarcoid neuropathy is a rare neurological complication of sarcoidosis and has to be included in differential diagnosis of nerve conduction impairments.

Der freie Musculus-gracilis-Lappen zur Weichteildefektdeckung

OBJECTIVE Coverage of soft-tissue defects of various sizes by an easy-to-do and reliable free muscle/myocutaneous flap. INDICATIONS Soft-tissue defects of a size up to 10 x 22 cm. Functional muscle transfer, e.g., biceps muscle replacement. CONTRAINDICATIONS Poor soft-tissue conditions or lesions on both thighs. No recipient vessels. Inadequate personnel and/or technical resources. SURGICAL TECHNIQUE Approach via a longitudinal medial incision or via the thigh flexion fold. The flap can be designed with or without a skin island. After mobilization from its tendinous part up to its origin, the vascular pedicle is prepared until its origin from the deep femoral artery. After harvesting, transfer is performed by anastomosing and shaping, eventually followed by split-thickness skin grafting. POSTOPERATIVE MANAGEMENT Clinical controls and measurement of partial oxygen concentration until day 10. Immobilization for 10 days, if the recipient site is close to a joint. Thrombosis prophylaxis. RESULTS During the past 10 years, 254 free gracilis flaps were transplanted. Total flap loss rate was 4.3%, whereas reoperation due to hematoma or partial flap loss was necessary in 13.0%.ZusammenfassungOperationszielDeckung von Weichteildefekten unterschiedlichster Form und Größe durch eine zuverlässige freie Muskel- oder Muskel-Haut-Transplantation.IndikationenWeichteildefekte von bis zu ca. 10 × 22 cm.Funktioneller Muskelersatz, z.B. des Musculus biceps und der Gesichtsmuskulatur.KontraindikationenLokaler Weichteilschaden an beiden Oberschenkeln medialseitig.Mangelnde Anschlussmöglichkeiten im Empfängerareal.Fehlende technische oder personelle Ressourcen.OperationstechnikZugang längs medial oder in der medialen Oberschenkelbeugefalte mit oder ohne Präparation einer Hautinsel. Mobilisation des Musculus gracilis von dessen Ursprung bis in den sehnigen Anteil und anschließende Präparation des Hauptgefäßstiels bis zu dessen Ursprung aus den tiefen Oberschenkelgefäßen. Nach dem Absetzen Transfer mit mikrochirurgischem Anschluss und Einpassen sowie ggf. Spalthauttransplantatdeckung.WeiterbehandlungMonitoring mit Sauerstoffsättigungsmessgerät und/oder klinische Kontrollen für 10 Tage. Bei Gelenknähe postoperative Immobilisierung für ebenfalls 10 Tage. Thromboseprophylaxe.ErgebnisseWährend der vergangenen 10 Jahre wurden 254 freie Musculus-gracilis-Lappen transplantiert. Die Lappenverlustrate betrug 4,3%, operationsbedürftige Komplikationen wie Lappenteilverluste oder Hämatome traten bei 13,0% der Patienten auf.AbstractObjectiveCoverage of soft-tissue defects of various sizes by an easy-to-do and reliable free muscle/myocutaneous flap.IndicationsSoft-tissue defects of a size up to 10 × 22 cm.Functional muscle transfer, e.g., biceps muscle replacement.ContraindicationsPoor soft-tissue conditions or lesions on both thighs.No recipient vessels.Inadequate personnel and/or technical resources.Surgical TechniqueApproach via a longitudinal medial incision or via the thigh flexion fold. The flap can be designed with or without a skin island. After mobilization from its tendinous part up to its origin, the vascular pedicle is prepared until its origin from the deep femoral artery. After harvesting, transfer is performed by anastomosing and shaping, eventually followed by split-thickness skin grafting.Postoperative ManagementClinical controls and measurement of partial oxygen concentration until day 10. Immobilization for 10 days, if the recipient site is close to a joint. Thrombosis prophylaxis.ResultsDuring the past 10 years, 254 free gracilis flaps were transplanted. Total flap loss rate was 4.3%, whereas reoperation due to hematoma or partial flap loss was necessary in 13.0%.

Bipolar anastomosis technique (BAT) enables "fast-to-do", high-quality venous end-to-end anastomosis in a new vascular model.

The interrupted suture technique is most commonly used for microsurgical venous anastomosis. Needle-stitch trauma and intraluminal suture, however, potentially cause vascular wall damage, thrombosis, intimal hyperplasia or even stenosis. Therefore, the present study aimed to show the feasibility and reliability of a modified cuff technique (bipolar anastomosis technique (BAT)) for venous end-to-end anastomosis in a new chicken throat vascular model. In ex vivo experiments, freshly resected chicken jugular veins (N = 96) were used to find ideal BAT time to current settings for venous end-to-end anastomosis. Thereafter, the left jugular vein of chickens (N = 40) was dissected in vivo and subsequently anastomosed using BAT. The quality of anastomosis was evaluated by Doppler sonography immediately, at two hours and at two, six, 12, 16, and 29 weeks after surgery. Additional histological examination took place at two hours (N = 8) and at two (N = 6), six (N = 6), 12 (N = 6), 16 (N = 6) and 29 (N = 6) weeks after surgery. Immediately after surgery (N = 40) and at two hours (N = 38) venous anastomoses were found to be patent in Doppler sonography. Anastomotic rupture caused death in two animals within one hour after surgery. Thrombotic occlusion was found in one animal at six weeks after surgery. In the remaining animals (N = 37) only minimal stenosis which decreased to almost normal levels was sonographically found. The average time needed for anastomosis using BAT was less than two minutes. BAT allows fast venous end-to-end anastomosis in a chicken throat vascular model.

Bipolar anastomosis technique with removable instruments: an easy, fast, and reliable technique for vascular anastomosis.

The interrupted suture technique is most commonly used for microsurgical vascular anastomosis. For several reasons (e.g., exposure of suture material to blood, time needed), many attempts have been made to find other solutions. This article describes a new means of performing a microsurgical vascular anastomosis. The aim of this study was to show the feasibility and possible advantages of this new technique. The basic components at work here are a modified cuff and electrically generated heat used to unite the vessel walls. In this way, both endothelial layers are adapted without manipulating the inside of the vessel or leaving behind foreign matter. Various energy/coagulation time settings were used to perform arterial anastomoses (n = 42) in an isogeneic abdominal aorta interposition model in the rat. The quality of anastomosis was evaluated at days 1, 10, 21, and 120. Immediately after the welding process all anastomoses (n = 42) were patent. No stenosis was found at any observation time. Anastomosis time ranged from 3 to 18 minutes (average, 11 minutes). This new technique permits a vascular anastomosis to be performed easily and reliably with a high patency rate. With this technique, the authors are convinced that a skilled surgeon can create a high-quality anastomosis in a fraction of the time needed to sew an anastomosis.

Soft tissue reconstruction in the extremities and the head and neck area using the anterolateral thigh free flap

OBJECTIVE Stable soft tissue coverage of exposed bone, tendons, or hardware in the extremities or the head and neck area with a microsurgically grafted free flap. INDICATIONS Soft tissue defects measuring up to 42 × 15 cm in the extremities and the head and neck region. CONTRAINDICATIONS Previous surgery or trauma in the anterolateral thigh region. Insufficient personnel and/or technical resources. SURGICAL TECHNIQUE A line is marked from the anterior superior iliac spine to the superolateral patella pole, approaching the intermuscular septum between the rectus femoris and vastus lateralis muscle. The flap is centred on this line and after medial incision the perforators of the descending branch of the lateral circumflex femoral artery are identified and dissected to their origin. Afterwards the lateral incision is carried out and flap dissection is completed. After flap transfer microsurgical anastomoses are performed and the flap is sutured to the recipient region. POSTOPERATIVE MANAGEMENT Flap monitoring for 1 week. Strict elevation and immobilization after flap transfer to the extremities; bedrest for 1 week. Thrombosis prophylaxis. RESULTS From 2008-2011, 41 free anterolateral thigh flaps in 5 women and 36 men with an average age of 53 years (38-70 years) were performed for microsurgical soft tissue reconstruction. Total flap loss rate was 2.4 % and reoperation due to complications, e.g., hematoma, problems with microsurgical anastomosis, and partial flap loss was necessary in 13.8 % of patients.