Karl Kremer

Progress in carotid artery surgery at the base of the skull

From 1977 to 1984, 752 reconstructions of the supra-aortic arteries were performed at our service. In a group of 31 patients presenting with transient ischemic attacks (13) or minor strokes (15), preoperative multiplane angiograms identified lesions from various causes in extremely high locations (fibromuscular dysplasia, 10; atherosclerosis, 6; traumatic changes, 10; spontaneous dissection, 3; and mycotic aneurysms and others, 4) in 34 internal carotid arteries (aneurysms, 10; and stenosis, 24). Surgery was performed on 30 patients. Flow restoration was achieved by resection and vein graft replacement (20), gradual dilatation (5), thromboendarterectomy (6), and tangential clip for exclusion of a lateral aneurysm (1). Only one patient was treated with an extracranial-intracranial anastomosis because the stenosis extended into the carotid siphon. One patient was treated with heparin. Exposure of the internal carotid artery (ICA) at the base of the skull required dissection of the digastric muscle, careful mobilization of the cranial nerves, and detachment of the styloid process in 29 patients. Partial resection of the mastoid process was helpful in two patients. The carotid bone canal was opened from the lateral side in four cases to allow the most distal anastomosis 1 cm within the carotid canal. Back-bleeding was controlled by a balloon catheter. A shunt was impossible to use and clamping time averaged 62 +/- 40 minutes. Except for one recurrent stroke and two transient ischemic attacks no other neurologic deficits occurred. Cranial nerve damage could not be avoided in 21 cases (nervus recurrens, 7; nervus glossopharyngeus, 16; and nervus facialis, 4) but disappeared clinically within a 1- to 6-month period in all but two. Each surgical patient underwent control angiography, which demonstrated 30 arteries to be patent, two became occluded, and one had an insignificant stenosis. We conclude that standard surgical techniques are unsuitable for repair of highly located lesions of the ICA. Although extracranial-intracranial anastomosis has been proposed in patients with planned ligation of the ICA, the anatomic reconstruction remains advantageous because flow is restored to normal and the source of emboli is eliminated. With the use of a special approach, graft replacement can be performed up to the base of the skull.

Syndrome nach Gastrektomie unter besonderer Berücksichtigung der Refluxoesophagitis

Summary60 patients without suspicion of recurrence of stomach cancer have had a follow-up by mean of 65 months after the procedure of a total gastrectomy. In 16 cases an additional esophagomanometric and endoscopic-bioptic examination was performed. Up to 1975 the operative procedure of stomach replacement was a jejunal interposition, afterwards the technique of a jejunoplicatio. Clinical signs of an esophageal reflux were found in one half of the patients with a jejunoplicatio and in a third of the cases with a jejunal interposition. Endoscopic-bioptic evidence of a reflux-esophagitis has been found in 13 of 16 patients. A functioning sphincter mechanism of the lower esophagus could be demonstrated in 5 of 16 cases. There was no proof of a correlation between the results of endoscopic-bioptic and manometric examinations. A prevention or reduction of esophageal reflux is as well possible by the technique of jejunal interposition as by jejunoplication.Zusammenfassung60 Patienten nach Gastrektomie and ohne Anhalt fur ein Rezidiv der meist bösartigen Grunderkrankung können im Mittel 65 Monate nach der Operation, 16 davon auch oesophago-manometrisch und endoskopisch-bioptisch nachuntersucht werden. Das nach 1975 gewählte Verfahren des Magenersatzes der Jejunoplicatio wird mit dem vorher angewandten Verfahren, im wesentlichen der Jejunuminterposition, verglichen. Hauptsächlich wird die Beschwerdesymtomatik durch das Ausmaß der Refluxoesophagitis bestimmt; ein entsprechendes Krankheitsbild findet sich bei der Hälfte der Patienten mit einer Jejunoplicatio and in einem Drittel der Fälle mit der Jejunuminterposition. Endoskopisch and histologisch fanden sich bei 13 von 16 magenlosen Patienten Zeichen der Refluxoesophagitis. Ein manometrisch nachweisbarer, funktionsfähiger Sphinctermechanismus konnte nur bei 5 von 16 untersuchten Patienten verifiziert werden. Eine eindeutige Korrelation von endoskopisch bioptischen and manometrischen Befunden war nicht herzustellen. Nach den dargestellten Untersuchungsergebnissen zeigt sich das Verfahren der Jejunuminterposition gleichwertig mit dem der Jejunoplicatio.

25. Die transdiaphragmale Oesophagusresektion — Ein Verfahren zur kurativen und palliativen Behandlung des Oesophaguscarcinoms

SummaryFrom 12/80 to 1/85 133 patients with a carcinoma of the esophagus were admitted to the hospitals in Düsseldorf and Würzburg. 105 (7 total, 98 subtotal) of them were resected (79%), 14 were treated with a substemal bypass (average age: 60 years). 76% of all tumors were found in stage III and IV. The esophagus was replaced with stomach (98) and colon (7). For bypass the stomach (12) and jejunum (2) were used. The hospital mortality was 17.6% (all operations), 16.2% (resection) and 28.2% (bypass). The 2-year-survival-rate was only 15% (due to 76% of stage III and IV).ZusammenfassungVon 12/80–1/85 wurden von 133 eingewiesenen Oesophaguscarcinomen 119 (89,5%) operiert; 105mal wurde reseziert (79%), 14mal wurde ein substernaler Bypass angelegt. (Durchschnittsalter: 60 Jahre). 24% der Tumoren befanden sich im Stadium I und II (UICC), 76% im Stadium III und IV. Der Oesophagus wurde 7mal total (mit Kehlkopf) und 98mal subtotal reseziert. 98mal wurde der Magen und 7mal das Colon als Ersatzorgan verwandt; bei den 14 Bypass-Operationen 12mal der Magen und 2mal das Jejunum. Die Operationsletalitat betrug 17,6% (alle OPs) und 16,2% (Resektionen). Bedingt durch den hohen Anteil (76%) an den Stadien III und IV lag die 2-Jahres-Überlebensrate bei 15%.From 12/80 to 1/85 133 patients with a carcinoma of the esophagus were admitted to the hospitals in Düsseldorf and Würzburg. 105 (7 total, 98 subtotal) of them were resected (79%). 14 were treated with a substernal bypass (average age: 60 years). 76% of all tumors were found in stage III and IV. The esophagus was replaced with stomach (98) and colon (7). For bypass the stomach (12) and jejunum (2) were used. The hospital mortality was 17.6% (all operations), 16.2% (resection) and 28.2% (bypass). The 2-year-survival-rate was only 15% (due to 76% of stage II and IV).

169. Die Insuffizienz der oesophago-enteralen Anastomose

SummarySutural insufficiency occurred in 23% of 582 esophagoenteral anastomoses. In 43% it was responsible for the patients death. Leakage occurred in 18 % of hand-sutured anastomoses and 5% of stapler anastomoses. Mortality was 22%, 43% due to leakage. Progress was made in two operative procedures. In subpharyngeal esophagogastric anastomoses, the preparation of the gastric tube (Petrovski) was modified. The ligamenta gastrolienale covered the upper thoracic aperture. In 72 cases leakage was observed but was not responsible for the patients death. In esophagojejunal anastomoses, using the stapler technique there was leakage in 2 of 30 cases, with no reintervention. Safer procedures will help in calculating the risk.ZusammenfassungDie Statistik weist die Insuffizienz mit 23% aus. Bei 582 Anastomosen lag sie bei 18% in der manuellen-, bei 5% in der Stapler-Technik. Gesamtletalität 22 %. Fortschritte bringen 2 operative Verfahren. 1. Die oesophagogastrale subpharyngeale Anastomose (Skelettierung des Magenschlauches (Petrovsky) modifiziert (Kivelitz, Chirurg 51:717, 80). Bei 72 Fällen sahen wir 6 Insuffizienzen ohne Todesfolge. Ein weiterer Fortschritt ist die oesophagojejunale Anastomose mit dem EEA (Kremer, Chirurg, im Druck). (30 Fälle, 2 Insuffizienzen ohne Reintervention). Ziel ist die Sicherung der Operationsverfahren, um das Risiko kalkulierbar zu machen.

Prophylaxis and Therapy of Graft Infection in Vascular Surgery

Infection is the most dreadful complication in vascular surgery. The rate of primary infection in artificial grafts was reported to be in the range of 2% to 6% (3, 4). Despite strong efforts to avoid this complication, the rate of graft infection remained 1% to 3% (7, 9) for reconstructions using artificial graft material. Lately an extremely low infection rate of 0.3% was reported by Brewster and Darling (1). This excellent result was achieved in a personal series. In general, more significant progress has been made to manage graft infection itself. The mortality rate reported in the literature was 75% some Years ago (3). In 1979, Ehrenfeld et al. (2) reported a mortality rate of less than 15% using autogenous tissue reconstruction in the management of infected prosthetic grafts. It is the aim of this paper to present our material of the last 10 Years in regard to vascular infection and to evaluate some factors of importance contributing to this problem.

161. Postoperative Syndrome nach Gastrektomie und unterschiedlichen Verfahren des Magenersatzes

SummaryThe follow-up of 60 patients submitted to total gastrectomy and five techniques of gastric substitute are reported. Complaints caused by jejuno-esophageal reflux occurred in one-third of the patients with the Longmire method. In this method and with a jejunoplicatio esophagitis histologically revealed as low grade. Manometric examination of 16 patients who had undergone gastrectomy proved normal function of the lower esophagus sphincter in only 5. This loss of sphincter function is seen as an additional cause of reflux esophagitis.Zusammenfassung60 gastrektomierte Patienten mit 5 Verfahren des Magenersatzes wurden nachuntersucht. Beschwerden durch einen jejuno-oesophagealen Reflux werden nur von

87. Vorteile der maschinellen Naht im oesophagokardialen Überianesbereich

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159. Der Brustdrüsentumor des Mannes

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240. Die blinde Oesophagusdissektion mit collarer Oesophagogastrostomie als Palliativmaßnahmen beim Oesophaguscarcinom und ihre operationstypischen Gefahren

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