Biomedical subjects
Publications and source records attributed to W Hepp.
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From 1.1.1971 until 31.12.1990 we observed and provided 331 patients with 344 acute injuries of arteries. Reasons was iatrogenic and traumatic injuries. In 94% of iatrogenic injuries and in 67.7% of traumatic injuries a full restitutio could be achieved. In 11.9% the extremity was saved with a resting functional deficit, in 11.9% an amputation was required, 9.5% hat a letal outcome.
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A total of 40 scintigraphic examinations were performed after vascular reconstructive surgery in 27 patients in whom there was a clinical suspicion of vascular graft infection. Whole-body gamma camera images were obtained at 4 and 24 h after i.v. administration of 111 MBq 123I-labeled antigranulocyte antibody Anti-NCA95. Scan results were interpreted without clinical information and were subsequently correlated with computed tomography. Prosthetic vascular graft infection was confirmed in 9 patients and excluded in 18 by surgical findings, bacteriology and/or clinical course. Scintigraphy revealed true-positive results in 16 of 40 and false-negative results in 1 of 40 examinations. True-negative results were found in 19 and 16, false-positive results in 4 and 7 examinations at 4 and 24 h p.i., resp. The sensitivity was calculated to be 94% for both early (4 h) and late (24 h) images whereas the specificity was 83% and 70%, resp. In all cases the application of the murine antibody was safe and no side effects or complications were noted. Limitations of this diagnostic procedure are accumulations of granulocytes in hematomas which may be observed in the non-complicated early course following reconstructive surgery.
Since 1971 69 patients have been operated on for lesions of branches of the aortic arch (71 surgical procedures). In 80% of the patients extrathoracic reconstructions were performed, mainly carotid-subclavian bypasses (64%) using knitted dacron grafts (6 mm and 8 mm diameter). A transthoracic approach was used in 20% of the patients. No patient died after operation and no ischemic neurological deficit occurred. The cumulative survival rate was 89% after five and 59% after ten years. The cumulative patency rate in the survivors was 100% after transthoracic approach after five and ten years. Identical patency rates were observed after extrathoracic carotid-subclavian bypass using 8 mm dacron grafts, whereas in 6 mm grafts the patency rate was only 67% after five and ten years. 85% of all patients were symptom-free and additional 10% improved. These results confirm that carotid-subclavian bypass using 8 mm dacron grafts has a long term patency rate identical to those after anatomical transthoracic procedures.
From 1 January 1982 to 30. June 1986, 436 operations on the internal carotid artery were performed: 164 were asymptomatic (37.6%). Morphologic indication was stenoses greater than 70% only. Supra-aortic multivessel disease played a major role. The operative mortality amounted to 0.6% (total 0.9%) and the perioperative mortality, 1.8%. The cumulative morbidity was 1.6% after the first and 1.8% after the second year, whereas the cumulative survival rate measured 89.8% after one and 80.4% after three years. Therefore surgery for asymptomatic carotid internal stenoses is justified under conditions of the restrictive indication. It also seems to be more favorable as regards early and late results.
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Every patient suffering from arterial occlusive disease has to be considered a candidate for a bilateral amputation. Below-knee amputation is preferable if at all possible. Poor wound healing and reamputation at a higher level are factors to be expected in 20-30% of these patients. Therefore primary above-knee amputation is indicated only if a more distal amputation level is not possible, or if lower amputation offers no advantage to the patient. The question must be answered in each individual case.
After 685 reconstructive vascular operations (1982-1984) on account of arterial occlusive disease in the supra-aortic arteries as well as in the aorto-iliac and femoro-popliteal segments there occurred 9 deep infections (1.31%); most infected by-passes were extra-anatomical type. In 2 cases an aseptic by-pass was performed; in 4 cases an open local treatment was performed (early broad splitting of the soft tissues and laying open the entire infected graft, surgical wound debridement and local application of antiseptic solution); in 3 cases there was no other possibility than to remove the implant and amputate the leg. Each of the 2 methods described has its specific indications: the aseptic by-pass has to be performed in retroperitoneal and inguinal infections; the open local treatment has to be performed in cases of extra-anatomical by-passes and operations in the femoro-popliteal-cruralis or supra-aortic region. The correct use of these 2 treatment modalities, with their specific indications, allows a conservative management of deep tissue infections.
Every patient suffering from arterial occlusive disease has to be considered a candidate for a bilateral amputation. Infragenual amputation is preferable if at all possible. Poor wound healing and reamputation at a higher level are factors to be expected in 20-30% of these patients. Therefore primary above-knee amputation is indicated only if a more distal amputation level is not possible, or if lower amputation offers no advantage to the patient. The question must be answered in each individual case.
33 CT-studies of 26 patients with alloplastic vascular prostheses were evaluated and compared with postoperative digital subtraction-angiography in 16 cases. 13 patients had no pathologic findings confirmed by further clinical development. In 4 cases bypass infection was diagnosed, which CT findings were perigraft gas (2/4), perigraft fluid (4/4), cm-enhancement (4/4) and fistulas (2/4). 10-21 d. post.-op. sterile hematomas were found in 3 patients. Further 3 cases had 5 weeks-2 post.-op. perigraft seromas. CT was method of first choice for diagnostic of perivascular alterations after bypass surgery. DSA was complementary to CT and should be performed to detect vascular complications.
Aseptic bypass graft and graft-preserving open local treatment have proved to be the two suitable procedures for therapy of infected grafts in vascular surgery (stage III Szilagyi). 18 deep wound infections in vascular surgery were treated 1982-1986; rate of infection was 1.2%. The infection was successfully treated with preservation of life and limb in 66.7%. Amputation was unavoidable in 5 patients (27.8%). 2 patients (11.1%) died. By applying the above-discussed principles of management the results could be drastically improved.
To substantiate the early results of extracorporeal shock-wave fragmentation of gallstones, we used this nonsurgical procedure to treat 175 patients with radiolucent gallbladder calculi. Chenodeoxycholic acid and ursodeoxycholic acid were administered as adjuvant litholytic therapy. The gallstones disintegrated in all patients except one and completely disappeared in 30 percent of all patients within 2 months after lithotripsy, in 48 percent at 2 to 4 months, in 63 percent at 4 to 8 months, in 78 percent at 8 to 12 months, and in 91 percent at 12 to 18 months. In patients with solitary stones up to 20 mm in diameter, the corresponding values were 45, 69, 78, 86, and 95 percent, respectively. Shock-wave therapy had no adverse effects except cutaneous petechiae (14 percent) and transient gross hematuria (3 percent). One third of the patients had one or more episodes of biliary colic before all the fragments disappeared. Two patients had mild pancreatitis, which necessitated endoscopic sphincterotomy in one. The patient with insufficient stone fragmentation underwent elective cholecystectomy; no additional operations were necessary. Extracorporeal shock-wave lithotripsy combined with medical therapy for stone dissolution is a safe and effective treatment in selected patients with radiolucent gallbladder calculi.
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