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Presented in this work is a rare injury of a blunt abdominal trauma in a child. Besides a partial rupture of the kidney and a retro-/intraperitoneal haematoma, a further injury occurred from the accident: an initially clinically indetectable tear of the A. iliaca communis which was found intraoperatively and with systematic CT analysis. Traumatic blood vessel lesions of the abdominal aorta and in particular the iliac blood vessels are very rare in children. By such violent impact injuries, it is therefore vital to perform a clinical examination of the foot pulse, systematic analysis of radiology diagnostics, and intraoperative exploration. The growth phase should be considered for therapy of the blood vessels depending on the child's age group. As the long-term results of graft implants are practically unknown, if possible a primary suture or vein patch should be performed.

High-velocity traumas, especially falls from a height, are a major cause of morbidity and mortality in children. Despite the height of fall is a poor predictor of major injury, we must be aware of relevant injuries especially of the head and the musculoskeletal system. The aim is to recognize all relevant problems, or better to avoid the fall. We report a case from a fall of 13.5 meters with an ellbow-fracture and contusions of the head.

Aim of the Study: The epidemiology, therapy and results of proximal humeral fractures in a touristic area were investigated and our concept for treatment presented., Methods: Between 1.1.1999 and 30.04.2000 adult patients with proximal humeral fractures were included, the fractures classified (Codman/Neer and AO) and results determined after an average of 9 months., Results: 62 adults were treated. 59 (95 %) had an accident during leisure time, mainly skiing accidents (52 %). 7 patients (11 %) had an associated luxation of the shoulder. 51 (82 %) were treated conservatively, 11 (18 %) operatively with a T-plate. The conservatively treated had to wear a Gilchrist-cast for an average of 29 (operatively 13) days, started passive movement after 20 (operatively 9) days, and active movement after 44 (operatively 45) days. The 32 employed (52 %) were not able to work for 46 days on average. Overall, 52 patients (84 %) were totally or mostly satisfied with the result. 5 among the 13 patients (38.5 %) with 3- or 4-part-fractures, and 4 among the 11 operated patients (36.4 %) were not satisfied with the result., Conclusions: Proximal humeral fractures are common skiing injuries, they need a long and intensive treatment and are economically expensive. The Codman/Neer and AO-classifications are equal. The results for simple, mainly conservatively treated fractures (Codman/Neer 1, 2A, 2-part) are good. Complex, mainly operatively treated fractures (Codman/Neer 3- and 4-part) have a much poorer prognosis. Diagnostically the computed tomography with 3-D-reconstruction is recommended for a better representation of the fracture and a safer choice of the therapeutical strategy.

Stress fractures of the cuboid bone are very rare. As in our present case these fractures are seen mostly in ambitious sportsmen and women. The symptoms described are nonspecific. The case history and a clinical examination, in combination with a conventional x-ray picture, should provide evidence of such a suspected fracture. Bone scintigraphy, a CT scan or magnetic resonance imaging may be necessary to confirm the diagnosis. Treatment is based mainly on immobilisation by means of a plaster cast of the lower leg or, if necessary, with ready-made splints. In the present case, healing was obtained by conservative measures after a few weeks. Also important is appropriate adaptation of the patient's further sporting activity, if necessary supplemented by foot-orthopedic measures such as arch supports or correct footwear. Especially in sports involving running, the importance of optimal footwear for the treatment or prevention of problems of overstrain is well known.

Introduction: Before laparoscopic cholecystectomy and endoscopic therapy became gold standard the nonsurgical treatment of symptomatic cholelithiasis, i.e. contact dissolution using methyl-tert-butyl ether (MTBE), was a valuable alternative. Even nowadays, stone dissolution may be helpful in critically ill patients., Case Report: A 85-year-old man admitted in poor general condition due to cholangitis with septicemia following endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and partial stone removement because of impending perforation of the gallbladder empyema was treated by a percutaneous cholecystostomy with a pigtail catheter. After clinical improvement a successful contact dissolution was initiated by irrigation of the common bile duct and gallbladder with MTBE. The patient is asymptomatic three months after treatment., Discussion: Symptomatic cholelithiasis is usually treated by endoscopic techniques. Percutaneous cholecystostomy in association with contact litholysis using MTBE is an effective treatment in patients who can not be operated due to critical conditions. The success rate in case of cholesterol stones averages 70 to 95% depending on number and size of stones. It is a non-invasive treatment with few side effects., Conclusion: In high-risk patients with severe cholecystitis, percutaneous catheter cholecystostomy combined with contact litholysis using MTBE is a successful, safe, and cheap treatment.

Despite the frequent exposure of operating room personnel to blood and other body fluids and the obvious risk of occupational transmission of HIV infection, the real incidence of injuries after needle sticks or cuts in the operating room has not been well investigated. Every injury occurring in the operating room during one thousand consecutive elective and emergency procedures was studied and the risk for acquiring an HIV infection was calculated. There were 50 injuries during 761 elective procedures (6.6%) and 23 injuries during 239 emergency operations (9.6%). There was one single injury during 91 minimally invasive endoscopical procedures (1.1%). The surgeon was the person most frequently injured (3.5%). The injury rate of the scrub nurse varied between 1.4% and 2.8% according to the surgeon's experience. The operating room personnel is at risk for an occupational transmission of blood born pathogens. If the seroprevalence of HIV in surgical patients is estimated at 0.4% the calculated probability for a surgeon to acquire HIV infection over a 30-year career amounts to 0.3%.

Minimal invasive surgery had a considerable impact on common surgical techniques and has almost replaced established operative procedures such as cholecystectomy. However, the laparoscopic approach for the treatment of acute appendicitis is still not very popular. We discuss the role of laparoscopy for appendectomy and include three studies from our institution (University Hospital Zürich, Switzerland) and prospective studies reported in the literature. We conclude that laparoscopic appendectomy, when compared with the open approach, has the following advantages for the diagnosis and treatment of acute appendicitis. (1) Diagnostic laparoscopy is an effective and relatively atraumatic tool to investigate the abdominal cavity, which results in a sensitivity of almost 100%. This allows for accurate decision making, which is especially advantageous in young women and obese patients. (2) Prospective studies demonstrate that laparoscopic appendectomy is at least as good as open appendectomy and that the laparoscopic approach results in a reduced postoperative infection rate. (3) The similar complication rate after laparoscopic appendectomy, when performed by residents rather than staff surgeons, underlines the feasibility and teaching potential of this minimal invasive procedure.

Little is known about how many bacteria are present at an infectious focus at the onset of antibiotic therapy. The number of cfu was determined in pus and infected peritoneal fluids obtained from 41 patients. Pathogens were detected in 71% of specimens. There were high concentrations of bacteria in culture-positive samples, in both soft-tissue and peritoneal infections, averaging 2 x 10(8) cfu/mL. These concentrations were much higher than the standard inoculum size used in in-vitro susceptibility tests, 5 x 10(5) cfu/mL. The impact of this discrepancy on antibacterial efficacy was studied with amikacin, ciprofloxacin, imipenem and piperacillin against Escherichia coli and Staphylococcus aureus. The inhibitory and bactericidal activities of amikacin and ciprofloxacin determined with high inocula were two to four times lower than with standard inocula, whereas the activity of piperacillin was diminished at least 128-fold. Similar activity was observed with these drugs in Mueller-Hinton broth and peritoneal fluid. The bactericidal activity of imipenem was reduced in peritoneal fluid. Thus, conditions prevailing at the infection site may compromise antibiotic activity determined in vitro.

Aim: We demonstrate the management and treatment of dislocation of the knee associated with vascular injury. The goal of the treatment is to avoid complications due to ischemia. The injured vessel can be repaired either by direct suture or by interposition of a saphenous vein graft. Capsule and ligaments should be reconstructed secondarily., Patients and Methods: The charts of ten patients treated in the Division of Traumatology of the University of Zurich between 1979 and 1996 have been retrospectively checked., Results: In eight of ten patients the injured vessel has been reconstructed with a saphenous vein graft, in one patient the artery has been repaired by direct suture. In one patient a flap of the intima has been refixed by endarterectomy. In five patients the knee has been stabilised with a transfixation (external fixation). In two patients the ligaments and the capsule were reconstructed at the time of vascular repair, in seven patients the reconstruction has been performed secondary., Conclusions: In case of a dislocation of the knee the examination of the vessels is mandatory. In case of a critical perfusion the "on table"--angiography is the procedure of choice. As an alternative method duplex sonography has been established. The vascular reconstruction is performed by saphenous vein graft interposition. We recommend to reconstruct ligamentous and capsular structures secondary.

Background: Reactive oxygen intermediates (ROI) have been implicated in many pathophysiological processes of inflammatory tissue damage and tissue repair. In the present study we compared the production of ROI in three different types of tissue damage in surgical patients., Methods: Peritoneal fluid specimens were harvested during the initial operation and postoperatively from 25 surgical patients with abdominal trauma, intraabdominal infection, and intestinal obstruction. The optical density at 412 nm, representing the peroxidation of hemoglobin, was measured to assess intraperitoneal ROI production. Patients were categorized into 3 groups: (A) infected patients with good outcome, (B) patients after trauma or obstruction with good outcome, and (C) patients with poor outcome due to persistent or secondary infection and multiple organ failure. Analysis of variance (ANOVA) and paired t test were used for statistical analysis., Results: Overall, the ROI production decreased significantly at days 2 and 3 compared with day 0 and 1 (P = 0.0013). No initial differences of intraoperative ROI concentrations were found among the three groups; however, patients with a poor outcome showed increased ROI values after 4 to 5 days (P = 0.038) when compared with the good outcome group., Conclusions: We have demonstrated that intraperitoneal ROI production (1) can be measured in patients with intraabdominal tissue damage, (2) is not different between patients with intraabdominal infections, abdominal trauma, or intestinal obstruction, and (3) correlates with the clinical picture and the presence of an inflammatory intraabdominal focus or tissue damage.

Basic Problem and Objective: The immune response to parenteral antigens is reduced in persons without spleen. The seroconversion rate was measured after application of a new type of vaccine against hepatitis A (immunopotentiating reconstituted influenza virus virosome [IRIV]) in patients who had undergone a splenectomy after trauma., Patients and Methods: 26 patients (23 men and 3 women, mean age 34.9 +/- 9.7 [25-65] years) with anti-hepatitis A virus (HAV) antibody titres < 20 mIU/ml (maximally 17 mIU/ml) were given a single dose of 0.5 ml of the IRIV hepatitis A vaccine 1 to 14 (mean 9.4) years after splenectomy. Immediately after the immunisation and 14 and 28 days afterwards anti-HAV titres were determined. A titre rise to < 20 mIU/ml was counted as seroconversion. At the first and last titre measurement immunoglobulins, neopterin and beta-microglobulin levels were also measured as additional markers., Results: The seroconversion rate was 69.2% (18/26) after 14 days (geometric titre mean: 39 mIU/ml) and rose to 88.5% (23/26) after 28 days (geometric titre mean 74 mIU/ml). Seroconversion occurred in the three nonresponders after a second dose of the vaccine. All measurements of the immunological markers were within normal limits., Conclusion: A single dose of a new type of vaccine against hepatitis A confers adequate protection even in those persons who had a splenectomy.

Two cases of fractures of the humeral neck in association with an axillary artery injury are reported. Even now, there are still only 14 well-documented cases in the literature. Trauma, pattern of injuries and treatment are analyzed. The treatment is focused on preservation of hand function, which is more important than shoulder motion. Neurovascular damage causes an impairment of hand function. The priorities of treatment (reperfusion versus osteosynthesis) are dictated by the degree of ischemia. Long-term disability is determined by brachial plexus injury.

Despite surgical advances and new antibiotics, upper extremity infections continue to present a serious problem. Soft tissue infections of the upper extremities were prospectively examined to elucidate incidence, cause, bacterial pathogens involved, and treatment. Special attention was paid to infections associated with parenteral drug abuse. During an 18-month period all patients over 16 years of age presenting for treatment of an established infection were included in the study. Conservative treatment consisted of immobilization and antibiotics. Radical débridement with removal of all necrotic tissue was the guideline for operative care. In addition, for both regimens a penicillinase-resistant antibiotic was administered. A total of 415 patients (271 men and 144 women; mean age 36.7 +/- 14.5 years) were enrolled into the study, 55 of whom were parenteral drug abusers; 45 of these were HIV-reactive. Infections of fingers (excluding paronychia), paronychia and abscesses at injection sites were the most common diagnoses. Operative and conservative treatment were performed in 285 and 130 patients respectively. Staphylococcus and streptococcus species were the predominant organisms recovered from 212 specimens of pus. Anaerobic bacteria and yeasts were of minor importance. Therefore, a penicillinase-resistant antibiotic is a good initial choice.

The effect of dosing regimen on nephrotoxicity, high frequency ototoxicity, efficacy and serum kinetics was studied in a prospective, randomised clinical study. Therapy was started with total daily doses of 6 mg/kg given once (od) or thrice (tid) daily to 56 and 57 patients, respectively. Subsequent doses were adjusted according to serum levels. No major differences in toxicity or efficacy were noticed between od and tid regimens: clinical failures occurred in two and two patients, four and five patients suffered from a decrease of > or = 20 dB at least unilaterally at one frequency between 8 and 18 kHz, six and seven patients had a > 25 mumol/L or > 25% increase in serum creatinine, respectively. Serum creatinine or creatinine clearance did not change significantly during either therapy. Major differences between the two study groups were limited to pharmacokinetic parameters. Od dosing resulted in higher peak (mean of 21.6 vs 7.2 mg/L) and lower trough levels (0.5 vs 1.4 mg/L). Half-lives of netilmicin determined between 1 and 8 h increased significantly during therapy with tid (from a mean of 2.75 to a mean of 3.33 h, P < 0.01) but not significantly with od (rise from 2.8 to 3.03 h). Much longer half-lives were determined between 8 and 24 h in the od group (mean of 5.7 h, P < 0.01). In conclusion, only minimal differences in toxicity and efficacy were observed. Their clinical relevance appears to be minimal.

Objectives: To determine the efficacy of laparoscopic appendectomy compared with open appendectomy in patients with acute appendicitis and to compare the morbidity between the two groups., Design: Prospective sampling of 102 patients who underwent diagnostic laparoscopy and laparoscopic appendectomy for acute appendicitis and retrospective hospital chart review of 204 patients who underwent open appendectomy for acute appendicitis., Results: The mean +/- SD duration of surgery was 83 +/- 29 minutes in the laparoscopic group and 64 +/- 30 minutes in the open appendectomy group (P < .001). Hospital stay was shorter in the laparoscopic group (P < .04). There was no difference in the complication rate between the patients who underwent laparoscopic appendectomy (13%) and the patients who underwent open appendectomy (11%). The occurrence of postoperative ileus was correlated with the duration of operation (P < .01) but not with laparoscopic appendectomy., Conclusions: The results confirm that laparoscopic appendectomy had a longer time of surgery, a shorter hospital stay, and no difference in complications. Further investigation will likely establish that laparoscopic appendectomy can be considered the "gold standard."

Ice hockey is considered to be one of the fastest and roughest of all sports. Prospective injury reports of the North American National Hockey League, the Canadian Amateur Hockey Association and of several European teams (UdSSR, CSSR, Sweden and Switzerland) are reviewed to evaluate the patterns, anatomic locations, circumstances and sequelae of ice hockey-related injuries. Although different injury reporting systems are used in North America and Europe, knee injuries (sprains of the collateral ligaments) accounted for the majority of games missed (40%), followed by injuries to the shoulder (dislocation, acromio-clavicular joint separation, rotator cuff strain and tears, 20%), the groin (15%), and the back (10%). Mandatory helmets and face masks reduced the number of facial and eye injuries to a quarter from 1972 to 1983. The frequency of only concussion but also cervical spine lesions is increasing. The prevention of head, face, eye and neck injuries should mainly be accomplished by enforcement of current rules (mandatory helmets with face masks) and institution of new rules. Improvement in protective equipment would also have the effect of decreasing the frequency of injuries. Ice hockey is the fastest team sport and involves both finesse and controlled aggression. It is also considered to be one of the roughest of all sports. In recent years, ice hockey has grown tremendously in popularity, not only in the United States and in Canada but also in many European countries [1]. The number of both professional and amateur hockey players has increased with the expanding interest in the sport around the world [1].(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis of chylothorax following blunt chest trauma is rare, only few cases have been reported. We describe three patients with chylothorax following blunt chest trauma. Conservative treatment consists of drainage, in severe cases mechanical ventilation with PEEP and total parenteral nutrition. In case of persisting and/or increasing chylus production, thoracotomy and ligation of the thoracic duct may be required. In all of our patients thoracostomy was the definite therapeutic modality, no thoracotomy was necessary.

The osteosynthesis of subcapital humerus fractures with the commonly used plates is often critical because of the little space subacromial, the irritation of the blood supply by the broad plates and the poor proximal anchorage without angle stability. The osteosynthesis with blade plates (children hip plate or blade plates for small adults) for isolated subcapital fractures or a blade plate like modified DC-plate for subcapital fractures with a shaft component or severe osteoporosis is thought to be a reliable alternative. We treated 34 patients aged between 18 and 85 years (mean 44 years) with blade plates. 33 patients had a good fracture healing and subjectively free shoulder motion after 3 months. One patient had distal implant loosening because of insufficient medial contact. The fracture healed after refixation.

Lead concentration of pellets is over 95%. Four patients who had sustained shotgun injury with retained shotgun bullets in the body are described. In 3 of 4 patients the blood level of lead was increased, as well as the concentration of Delta-ALA in the urine. In all four patients symptoms due to lead intoxication were absent. Usually the surgical goal is limited to a proper debridement of large wounds in the soft tissue. Therefore it is mandatory to assess the lead level in the blood and the concentration of Delta-ALA in the urine. Thus asymptomatic lead intoxication can be recognized and treated.

Objective: To find out if the concentrations of biochemical variables in peritoneal fluid differed in the presence or absence of infection., Design: Prospective study., Setting: University hospital, Switzerland., Subjects: 80 patients undergoing abdominal operations, 23 of whom were operated on for an intra-abdominal infection. 57 Patients with no sign of infection served as controls., Main Outcome Measures: Concentrations of 24 biochemical variables measured in specimens of peritoneal fluid obtained during the operation., Results: Major differences between specimens taken from infected and uninfected patients including: glucose 5.4 compared with 0.8 mmol/l, lactate 7.9 and 17.2 mmol/l, aspartate aminotransferase 83 and 520 U/l, phosphate 1.1 and 3.7 mmol/l, potassium 4.5 and 10.1 mmol/l, lactate dehydrogenase 2021 and 7998 U/l, and gamma-glutamyl transferase 57 and 169 U/l., Conclusion: Intra-abdominal infection significantly alters the composition of peritoneal fluid. The assessment of milieu factors at the site of infection may help in the design of more predictive in vitro tests to guide antimicrobial treatment of intra-abdominal infections. In addition, the knowledge of discriminatory variables in peritoneal fluid may be useful in the diagnosis of intra-abdominal infection.

Snowboarding is increasing dramatically in popularity in Switzerland as well as other countries. Work aimed at improving the design of the boards and of the boots and bindings has also increased rapidly during recent years. Most injured snowboarders are fit young men and boys who describe themselves as beginners and have had a minimal amount of instruction at an officially approved training centre. Appropriate snowboard training has mostly been quite inadequate, and protective devices (e.g. waterproofed support gloves). The anatomical distribution and the types of injuries sustained in snowboarding differ from those in alpine skiing. The wrist (and forearm) and the ankle are the most frequent locations of injuries (23%) as against the knee and thumb in alpine skiing. Sprains and strains were the most frequent types of injuries (46%), followed by fractures (28%) and contusions (13.5%). The snowboard injury rate was higher than in alpine skiing (1.7-8/1000 snowboard days versus 2-4/1000 ski days). Falling forward on the slope was the major mechanism of injury (80%), and torsion the next most frequent (20%). Snowboarding injuries were sustained most often on ice and hardpacked snow, compared with soft powder snow for alpine skiing injuries. Appropriate preseason conditioning, snowboarding lessons from a certified instructor, appropriate selection of rigorously tested equipment and use of protective devices are the main steps that must be taken to prevent injuries.

Low pH (< 7.1) and pO2 (< 6.5 kPa) and high pCO2 (> 8 kPa) of peritoneal fluid have been previously associated with the presence of intra-abdominal infection. These parameters were monitored in drainage fluid following emergency laparotomy in 40 patients operated on for intra-abdominal infections and also in 15 patients who underwent laparotomy for another reason than infection. Significant differences were observed beginning on the fourth postoperative day between the 48 patients who improved or were cured and the seven patients in whom therapy failed due to anastomotic breakdown or abscess formation. Anastomotic leaks or abscesses were radiologically confirmed. In five of the seven failures, complications were first detected by analysis of pH, pO2 and pCO2 before clinical symptoms became evident. Specificity for each of these parameters in drainage fluid samples obtained after the second postoperative day was > 94%. Assessment of the three parameters allowed for simple, cost-effective, rapid and early detection of infectious complications following abdominal surgery.

Fractures can occur during violent muscular violence such as occur in the course of epileptic seizures, though this is rare (0.3%). The proximal part of the humerus is most frequently affected. The typical lesion is bilateral posterior dislocation or fracture-dislocation. We present a rare case of bilateral anterior fracture-dislocation of the shoulder sustained as the result of an epileptic fit. The treatment given was open reduction, refixation of the anterior labrum and screw fixation of the fragments. A review of the literature revealed only 18 cases of bilateral anterior dislocations caused by convulsive seizures.

The term "Necrotizing soft tissue infections" describes a group of limb- and sometimes lifethreatening infections mostly of the limbs. The necrotizing soft tissue infections are classified, depending on the involved tissue level, microbiology and clinical course: 1. primarily located in the subcutaneous level and fascia: 1.1 hemolytic streptococcal gangrene, 1.2 necrotizing fasciitis, 1.3 gram-negative, synergistic, necrotizing cellulitis, 1.4 clostridial cellulitis, 1.5 anaerobic nonclostridial-cellulitis; 2. primary located in the muscle: 2.1 clostridial myonecrosis, 2.2 streptococcal myositis. Between 1989 and 1992 17 patients with necrotizing soft tissue infections were treated at the Department of Surgery, University Hospital of Zurich. Incipient necrotizing soft tissue infections are underestimated easily due to atypical or minor initial signs. The infections may be caused by a variety of bacteria, spread rapidly and can lead to a critical condition. The surgical treatment has to be aggressive with extensive debridement of the affected areas supported by intensive care. Delayed or even omitted surgical treatment, inappropriate therapeutic concepts and incomplete debridement with compromises may have fatal consequences. Repeated debridement as well as amputation of the affected limb is justified to guarantee the patient's survival.

A once-daily dosing regimen for aminoglycosides is less expensive, at least as effective and possibly less toxic than multiple-daily dosing regimens. Once-daily dosing might also allow the frequency of measuring the serum concentrations of these antibiotics to be reduced since two of the major objectives of monitoring, high peak and low trough concentrations, are more likely to be achieved with this regimen. A novel strategy for monitoring serum concentrations which relies on a single sample obtained 8 h after a dose, as opposed to both trough and peak samples, is evaluated here. Serum kinetics of netilmicin were studied prospectively in 51 adult patients with initial serum creatinine concentrations of < 130 mumol/L who were treated with a median daily dosage of 400 mg. Concentrations measured 8 h after administration were within the target range of 1.5-6 mg/L in 113 of 134 dosing intervals studied. Concentrations above and below this range correlated significantly with higher and lower 24-h trough concentrations and areas under the curve respectively. There was also a significant correlation between 8-h netilmicin concentrations and nephrotoxicity (P < 0.05); a relative increase of > or = 25% in the serum creatinine concentration or an absolute increase of > 25 mumol/L was detected in 0 of 7 patients with an 8-h concentration of < 1.5 mg/L, in 3 of 33 patients (9.1%) with an 8-h concentration of 1.5-6 mg/L and in 4 of 11 patients (36%) with an 8-h concentration of > 6 mg/L.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnostic significance of pH, pO2 (partial pressure of oxygen), and pCO2 (partial pressure of carbon dioxide) was studied in pus, peritoneal fluid, and drainage fluid obtained during or after abdominal surgery. Measurements of these fluids in 59 patients with clinically and bacteriologically documented abdominal or anorectal infection (median pH: 6.75, median pO2: 28 mm Hg, median pCO2: 89 mm Hg) differed significantly (p < 0.001) from data of 105 patients undergoing elective laparotomy for a reason other than infection (median pH: 7.49, median pO2: 144 mm Hg, median pCO2: 92 mm Hg). The combined use of a threshold criterion for pH and pO2 allowed for excellent discrimination between infected (pH less than 7.1, pO2 less than 49 mm Hg) and noninfected patients, with positive and negative predictive values of 98% and 99%, respectively. In conclusion, conditions prevailing during standard in vitro susceptibility tests more closely reflect physiologic conditions as opposed to the conditions prevailing at the site of abdominal infections. Measurements of pH and pO2 allow for an easy, quick, sensitive, and specific diagnosis of bacterial abdominal infection.

Since standard susceptibility tests reflect the physiological rather than the pathological conditions prevailing within an infected abdomen, as recently documented, the effect of reduced pH and pO2 and increased pCO2 on the activity of antibiotics in vitro was studied. MICs were determined in vitro under standard culture conditions (MICstandard) and modified conditions (MICmodification) simulating the previously determined pathological values. Various classes of antibiotics were affected differently by the modified conditions. However, within an antibiotic class similar results were obtained for gram-negative and gram-positive pathogens. Median MICmodification/MICstandard ratios were 4 for aminoglycosides, 2 for quinolones and clindamycin, 1 for cephalosporins, and 0.5 for penicillins and vancomycin. Anaerobic conditions and a pH of 6.4 further increased the ratio of aminoglycosides to 8. Ratios were similar within an antibiotic class at inocula of 10(5) or 10(7) cfu/ml. All MICs determined in tests with imipenem against gram-negative and gram-positive bacteria and with vancomycin against gram-positive organisms were below the susceptibility breakpoint, whatever conditions and inocula were employed. In contrast, the percentage of MICs in susceptibility range using high inocula and modified conditions decreased to 78% for penicillins, 73% for cephalosporins, 22% for aminoglycosides, 11% for quinolones and 0% for clindamycin. In conclusion, routine susceptibility testing may overestimate the activity of aminoglycosides and underestimate the activity of beta-lactams under the conditions prevailing during abdominal infection.

Ice hockey is one of the fastest and roughest of all sports. Based on prospective injuries reports of the North American National Hockey League, the Canadian Amateur Hockey Association and three European teams (USSR, Sweden and Switzerland) the patterns, topography, circumstances and sequelae of the head injuries related to ice hockey are described. Although mandatory helmets and face masks have reduced the large number of facial and eye injuries, the rates of head injury and concussion are still to high. A number of steps must be taken by the hockey organisations, players, equipment manufacturers and health-care professionals to prevent injuries for specific prevention of head, face and eye injuries the rules should be strictly enforced, e.g. no checks from behind, high-sticking penalties, and mandatory helmets with face masks.

Netilmicin and clindamycin were administered to 47 patients with an intraabdominal infection who underwent emergency laparotomy. Thirty-one patients were cured, seven were improved, and therapy failed in nine patients despite the fact that all aerobic bacteria isolated from these patients were sensitive to netilmicin as determined by standard in vitro susceptibility tests. The pH of peritoneal and drainage fluid collected intraoperatively and during follow-up correlated with clinical outcome. Acidic pH was found in 21 of 33 (64%) specimens sampled from patients with therapeutic failure compared to 17 of 80 (21%) obtained from the categories "cured" and "improved" (p < 0.001). Netilmicin concentrations in serum or peritoneal/drainage fluid did not correlate with clinical outcome. Netilmicin levels were above the minimal inhibitory concentration of the pathogens in 59 of 64 (92%) drainage fluid specimens in which aerobic bacteria were isolated. Aerobic bacteria were isolated in 91% of drainage fluid specimens if the pH was less than 7.0, compared to 37% if pH was more than 7.0 (p < 0.001). Reduction of pH antagonized aminoglycoside activity in vitro against clinical isolates of Escherichia coli. Surgical reexploration should be considered in cases of deterioration following a laparotomy associated with detection of acidic drainage fluid.

The detection of occult abscesses can draw a long chain of diagnostic procedures as the procedures as the presented case documents. Next to conventional X-ray studies and examination by ultrasound scintigraphy is available. Studies of the skeleton by the latter using phosphonates for osteomyelitis or 111-I-labeled neutrophils or 99m-Tc-labeled monoclonal antibodies against neutrophilic surface-antigens for the detection of abscesses in soft tissues are of recent interest. MR-imaging is used for preoperative planning after successful detection.

The osteosynthesis of proximal humerus fractures with the commonly used plates is often critical because of the small space subacromial, the irritation of the blood supply by the broad plates and the poor proximal anchorage without angle stability. The osteosynthesis with a children hip plate or a angle plate like modified DC-plate is thought to be a reliable alternative.

The pathophysiology of necrotizing fasciitis remains unclear in patients with no apparent immunologic disorders. Between 1987 and 1990 we treated six patients with necrotizing fascitis and septic-toxic multiple organ failure, three patients survived. The mean age was 38 years (25-62). In all patients the primary bacteriological examination revealed streptococcus. Between the first symptoms and an adequate therapy were 4 days in surviving patients and 7 days in patients who died. Four patients showed spread of the gangrene into the adjacent tissue: muscles (n = 3), bowel (n = 2), mediastinum (n = 1). Adequate débridement was not possible or not performed in patients with spread into the abdominal cavity or the mediastinum. These patients did not survive. The duration of intensive care treatment in surviving patients were 14 to 78 days. We conclude that survival of patients with severe necrotizing fasciitis is influenced by the delay before adequate treatment, the localisation of the gangrene and intensive care facilities.

The examination of rectum and colon with barium sulfate is a method which is increasingly replaced by the endoscopy; therefore, the routine of doing this examination is increasingly vanishing. This means that the risk of this method increases. We report a case and discuss the symptomatology as well as the management of a perforation of the rectum during an examination with barium sulfate.

Milieu factors such as pH, pO2, and pCO2 have previously been shown to permit reliable intraoperative discrimination of infected and non-infected peritoneal or drainage fluid. The presence of infection was associated with pH less than 7.1, pO2 less than 6.5 kPa and pCO2 greater than 8 kPa. These variables were monitored in the immediate postoperative period to quantify clinical improvement and to evaluate their potential for the early detection of infective complications. 21 patients underwent laparotomy for intraabdominal infections such as perforated appendicitis or perforated sigmoid diverticulitis. 5 were operated on for reasons other than infection. Fluid was sampled from a drainage tube every second day for a mean period of 7 days for determination of pH, pO2, and pCO2. A score ranging from 0 (normal) to 6 (severely ill) was calculated from these measurements. Specimens were obtained intraoperatively from 14 patients with documented infections and their mean score averaged 5 (range 3-6). Specimens were obtained on days 4 and 6 from 18 patients whose progress was uneventful and their mean score was 0.3 (range 0-2). 4 of these 26 patients developed postoperative infections after anastomotic breakdown, and each of their scores increased 1-2 days before the infection became clinically obvious, reaching values ranging from 3-6. In contrast, only 1 of 18 patients who made uneventful progress scored greater than 2 after day 3 (p less than 0.01). We conclude that assessment of milieu factors in peritoneal or drainage fluid permits quick and easy monitoring of the postoperative course.

In a prospective investigation infections of the upper extremity are examined with respect to incidence, bacterial pathogens, operative or conservative treatment, and duration of disability for work. A total of 255 patients (pts) (170 men, 85 women; mean age 37 years, range 16-85) were entered into the study. In a 12-month period 163 (64%) were treated as outpatients, the condition of 92 pts (36%) required hospitalisation. Conservative and operative treatment was performed in 82 (32%) and 173 (68%) pts, respectively. Conservative treatment included fixation by cast as well as antibiotics (penicillinase resistant penicillin), usually given by the oral route for a mean of 4 days. Surgical procedures consisted of excision and debridement. Intraoperatively intravenous antibiotics were instituted for a mean of 3 days, followed by oral application for another 4 days. In 135 of 173 pts who underwent surgery, sufficient material for bacterial culture was obtained. There was a polymicrobial infection in 50% of pts. Most common isolated pathogens were Staphylococcus aureus, beta-hemolytical streptococci group A, and indigenous skin flora in 34%, 21%, and 11%, respectively. Among the 255 pts there were 26 HIV-positive iv drug abusers, who suffered from abscesses at injection sites. The infections in these immunocompromised HIV-positive pts did not reveal differences with respect to number and species of isolated pathogens as compared to immunocompetent pts. Resistant bacteria were not found. Response to treatment was satisfactory usually within a few days in all but 12 pts (4.7%) in which the failure could be attributed to inadequate primary debridement.

Gram-positive bacteria are the predominant organisms in hand infection and in burn wounds of the upper extremities. In a recent study of isolates from patients who were treated at our institution, Staphylococcus aureus and beta-hemolytic Streptococcus group A organisms were the most common organisms in infection of the hand; they were found in 36.3% and 14.4% of cases, respectively. The most common organisms in burn wounds were Enterococcus species, S. aureus, and Escherichia coli, which were found in 21.2%, 20.5%, and 16.7% of patients, respectively. Between 1969 and 1989, the prevalence of Pseudomonas species in burns decreased markedly, whereas that of S. aureus remained relatively stable and that of Enterococcus increased substantially. Over this period, both enterococci and coagulase-negative staphylococci emerged as troublesome pathogens in patients with burns. Methicillin-resistant S. aureus, which was first seen in our institution in 1981, continues to be found in a small proportion of patients. We have achieved successful results in certain surgical settings with the use of gentamicin-dispersing polymethyl-methacrylate beads to provide sufficient antimicrobial concentrations in poorly vascularized or avascular tissue. Additional topical antimicrobials that are potent against gram-positive bacteria are needed.

The lymphocele is a seldom complication after kidney transplantation (2.2% of our patients). This manifestation occurs typically 3-4 months after transplantation, as a late complication it's a rarity. The rupture of a kidney graft because of a trauma is unique in our clinical experience, which contains more than 1200 kidney transplantations. We report the case of a 28-year-old man who had 19 years after transplantation a traumatic rupture of the kidney graft. Because of the trauma a preexistent chronic lymphocele got clinically manifest. The histology of the lymphocele wall shows fatty and collagen tissue with a strong fibrosis. The diagnostic and therapeutic procedure is described. There are different possible relations between the rare problems:--the tight lymphocele carries over the force on the graft--the lymphocele has grown together with the graft at the lower pole and ruptures in this place--a little graft rupture makes a clinical manifest bleeding in the lymphocele because the deficiency of perirenal tissue.

Since July 1986 we started with following all patients with condylomata acuminata including HIV-testing and human papilloma virus (HPV) identification by DNA-DNA-hybridisation (southern blot). Seventy patients are included, 39 of them are seropositive. The ratio male to female is 59 to 11, in seropositives 35 to 4, in negatives 24 to 7. The average age is 28 and 31 years respectively. The number of homosexuals and junkies is significantly higher in seropositives. Seventeen patients are in HIV-stage II, 11 in stage III and 10 in stage IV according to CDC-classification. Characteristic for the seropositives was an extensive growth on the rectal mucosa and the very rapid growth of initially subtotally resected lesions in order to prevent stenosis. Sixty-five patients were treated by one stage radical operation with electrocauter. Surprisingly recurrency is more frequent in seronegatives, however, the lesion is much smaller in this group. A hypothesis to explain this observation is brought forward. Postoperative complications occurred only in HIV-stages III and IV. We therefore recommend single shot antibiotic prophylaxis in these patients. The HPV-identification showed no malignancy associated HPV-types in both groups but a higher incidence of HPV 11 in higher HIV-stages which we cannot explain. We conclude from our series that, if operation is indicated, one stage radical electrocoagulation of condylomata acuminata is a necessary procedure in seropositive patients and a save one in negative patients but antibiotic prophylaxis should be given in stage III and IV. Anal condylomata acuminata are a hint for possible HIV-positivity.

During an 8-month-period, 241 patients suffering from abdominal pain unrelated to trauma (mean age 48 years) attended the emergency room of the Department of Surgery of the University Hospital, Zürich. Forty-three percent presented during working hours, while 57% were admitted during the night or at the weekend. Clinical examination, abdominal roentgenograms (upright and supine) and sonography were the most commonly used diagnostic tools. Forty percent suffered from abdominal pain of unknown origin. The most common diagnosis on admission was appendicitis, but only half of these cases proved to be appendicitis. In 36% the diagnosis on admission corresponded both to the initial diagnosis made by a member of staff during his first visit, and to the final diagnosis. The initial diagnosis agreed with the final diagnosis in 57%. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostic evaluation are less important than the clinical evaluation. The decision between operative and nonoperative treatment was based mainly on clinical findings.

The term risk is understood to be the danger of the occurrence of an undesired, life-threatening event. The probability of this undesired event is greater in the presence of a risk factor than in its absence. In general surgery, these risk factors can be classified into five groups: The environment, the surgeon, the operation per se, the disease, and the patient himself. Abdominal surgery is especially suited to clarify and to illustrate this classification. Some typical risk factors are described, and for each group the measures for risk prevention or risk reduction are discussed.

During a 19-month period 549 patients (278 women, 271 men) suffering from abdominal pain unrelated to trauma (mean age 48.2 years) entered the emergency room of the Department of Surgery of the University Hospital Zürich. 43% presented during business hours, whereas 57% were admitted during nighttime and/or weekends. Clinical examination, abdominal roentgenograms (upright and supine) as well as sonography were the most commonly used diagnostic tools. 40% suffered from abdominal pain of unknown cause. The most common diagnosis on admission was appendicitis. Only half of these cases really proved to be an appendicitis. In 36% the diagnosis on admission corresponds both to the initial diagnosis made by a member of staff during his first visit, as well as to the final diagnosis. The initial diagnosis agrees in 57% with the final diagnosis. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostics are less important than the clinical evaluation. The decision between operative or nonoperative treatment was mainly based on clinical findings.

40 false aneurysms have been diagnosed at the University Hospital in Zürich during the last three years. These aneurysms are mainly (24) anastomotic aneurysms with synthetic arterial substitutes. 6 false aneurysms were found after arterial catheterization. The majority of these 40 aneurysms (60%) were localized in vicinity of joints. The time interval between the original procedure (anastomosis, arterial catheterization, trauma) and the diagnosis of false aneurysm varies from a few days to 21 years. In seven cases a endarterectomy preceded the development of a false aneurysm. Three therapeutic groups are presented.

In 10 patients with peripheral arterial occlusive disease intraarterial infusions were performed using a totally implantable port system. The port is fixed to the gluteal fascia on the outside of the iliac wing. The inferior epigastric artery is dissected through an additional incision above the inguinal ligament. A 2 mm catheter is connected to the port and inserted through the epigastric artery into the external iliac artery. Using this new suprainguinal technique the groin remains intact permitting surgical and interventional procedures. In one case a dislocation of the catheter occurred. The reason for this complication was an unsafe surgical fixation. The totally implantable port system is an alternative to conventional intraarterial infusions. There are several advantages using the suprainguinal technique as described above.

Ligation of the internal iliac artery mostly remains without consequences because of the well established collateral network. In patients with compromised collateral circulation however, acute interruption of both hypogastric arteries during aorto-iliac surgery or transluminal embolisation can lead to necrosis of the gluteal muscles and other adjacent organs (rectum, bladder, lumbosacral plexus). Experience with 3 similar cases after aorto-iliac surgery demonstrates two main intraoperative mechanisms: 1. Embolisation, 2. Ligature of both internal iliac arteries in patients with compromised arteriosclerotic collaterals. Despite of adequate therapy, mortality is over 70%. The most important feature during aorto-iliac operations is to preserve at least one internal iliac artery by either reimplantation of the main stem or by an additional bypass to this artery.

Recommendations for optimal therapeutic peak concentrations of aminoglycosides are often not differentiated with respect to duration of infusion and timing of peak sample thereafter. To document the relevance of the timing, 139 dose intervals were analyzed in 58 patients during administration of gentamicin, amikacin, and netilmicin. Serum concentrations measured immediately after 30-min infusions were compared with concentrations obtained 90 min later (2 h values). The ratio of 30 min/2 h concentrations showed considerable variability. This ratio was less than 1.5 in 15% of the dose intervals analyzed and greater than 3 in 8% of the intervals. The poor correlation between concentrations measured at 30 min and at 2 h was documented by the coefficients of variation of 0.82, 0.30, and 0.67 for gentamicin, amikacin, and netilmicin, respectively. This variability was not explained by interindividual differences, renal function, or drug half-life. However, the initial decrease in concentrations was significantly lower in patients with impaired renal function (p less than 0.001). These data suggest that timing is critical for the sampling of serum to determine peak levels in patients and the definition of optimal therapeutic concentrations.