Fragestellung: Seit ca. 15 Jahren stellt die LLETZ (large loop excision of the transformation zone) Konisation die Methode der Wahl bei der operativen Sanierung von zervikalen intraepithelialen Neoplasien (CIN) dar. Im Rahmen der LLETZ treten verglichen mit der Messerkonisation sowohl weniger intraoperative als auch postoperative Komplikationen auf. Die Fallzahlen der größten Studien lagen bis dato jedoch unter 500 Patientinnen, womit seltener auftretende Komplikationen nicht ausreichend erfasst werden konnten. Methodik: In die vorliegende Studie wurden 2105 Patientinnen inkludiert, die an der Medizinischen Universität Wien von 1997–2008 mittels LLETZ operiert wurden. Die statistische Analyse erfolgte mittels T-Test, Χ2-Test und multivariatem logistischem Regressionsmodell. Ergebnisse: Insgesamt wurden 264 (12,5%) intraoperative Komplikationen dokumentiert (verstärkte Blutungen: n=218 [10,4%], Perforation der A. uterina: n=3 [0,1%], Verbrennungen der Vaginalwand: n=9 [0,4%], sonstige Verletzungen mittels Stromschlinge: n=31 [1,5%], Uterusperforation: n=3 [0,1%], Eröffnung des Cavum Douglasi: n=1 [0,05%]). Folgende Maßnahmen wurden intraoperativ gesetzt: Nähte zur Blutstillung: n=155 (7,4%), Hämostyptikum (Tabotamp®, Tachosil®): n=33 (1,6%), Vaginaltamponade: n=29 (1,4%), Vaginaltamponade und Hämostyptikum: n=25 (1,2%). Postoperativ wurden 114 (5,4%) Komplikationen beobachtet (Nachblutungen: n=75 [3,6%], Vaginale Infektion: n=14 [0,7%], Endometritis: n=2 [0,1%], Zervikalstenose: n=8 [0,4%], sonstige nnb. Komplikationen: n=5 [0,2%]). Folgende postoperative Maßnahmen wurden gesetzt: Tamponade: n=36 (1,7%), Revision in Vollnarkose: n=29 (1,4%), Antibiotikum: n=13 (0,6%), Nähte zur Blutstillung ohne Vollnarkose: n=3 (0,1%), Erythrozyten Konserven: n=3 (0,1%). Das Auftreten einer intraoperativen Komplikation war sowohl uni- als auch multivariat mit dem Alter der Patientin (p=0,01; p=0,05) und LLETZ non in sano (p=0,008; p=0,03), jedoch nicht mit dem Vorliegen eines mikroinvasiven Zervixkarzinoms (p=0,1; p=0,8) assoziiert. Für das Auftreten von postoperativen Komplikationen konnte kein Risikofaktor identifiziert werden. Schlussfolgerung: Die LLETZ-Konisation stellt eine sichere Operationsmethode dar, wobei die Blutung mit 10,5% bzw. 3,6% die häufigste der intraoperativen bzw. postoperativen Komplikationen darstellt. Alter der Patientin und LLETZ non in sano zeigten sich als unabhängige Risikofaktoren für das Auftreten einer intraoperativen Komplikation.
Cerebral AVMs are known to be a source of intracranial hemorrhages and epileptic seizures. Their natural history indicates approximately 15% mortality and 35% morbidity over a 15-year period. This significant mortality and morbidity mandates a need for satisfactory treatment of this entity, ideally by elimination of AVMs. Microsurgical resection, endovascular embolization and radiosurgery (irradiation) are the three effective modes of treatment currently available. However, no objective criteria have been established for which mode(s) of treatment should be selected for individual patients with AVMs. Considering the complexity of AVMs and variable conditions of individual patients, neurosurgeons, intravascular interventionalists and radiosurgeons must make their own decisions on how to treat each patient based on their experience. In practice, treatment of small AVMs in non-functional areas is favored equally by each of these specialists, while they tend to avoid treatment of large AVMs, particularly those in functional areas of the brain. The authors report the surgical intervention of large AVMs, including those located in functional areas of the hemisphere by special techniques. One can demonstrate AVM compartments by using angiography and with the aid of color Doppler ultrasonography, each compartment can be outlined and dissected individually until all the compartments are isolated without causing any damage to the surrounding brain and the entireAVM is rendered shrunken and then removed. The concept of compartmental treatment of AVMs may be applied in the future to radiosurgery and intravascular embolization of large AVMs.
The natural history of patients with arteriovenous malformations (AVM's) suggests that serious morbidity associated with AVM's in functional areas is likely to be much greater than in silent areas. Various modes of treatment of AVM's in functional areas, including direct surgical intervention, embolization, and irradiation, have been considered to carry high risks. The authors advocate direct surgical intervention to these AVM's via a microsurgical technique based on knowledge of the hemodynamic anatomy of AVM's. The technique is designed to circumscribe the AVM without removing any surrounding cortical tissue or white matter and to preserve microcirculation in the functional area. Controlled hypotension (mean arterial blood pressure 40 to 60 mm Hg) is appropriate to enhance the safety of surgical procedures without causing metabolic and electrophysiological dysfunction. Another means to prevent neurological complications is multi-staged resection of larger AVM's, which permits obliteration compartment by compartment. This technique has the advantage of maintaining circulatory sufficiency in the functional area. There was no mortality among 56 patients who underwent the surgical procedure described. Of those, 55 patients resumed their preoperative occupation and one patient became self-sufficient.
Controlled hypotension is a safe and convenient means of allowing a surgeon to perform intracranial aneurysm, arteriovenous malformation and vascular tumor surgery. The mean arterial pressure between 40 and 60 mmHg induces diminished pulsatile arterial pressure, thus preventing rupture of these abnormal vasculatures. It is still possible to maintain cerebral metabolism in the functional level within this 40-60 mmHg blood pressure range. This statement is based on our experience of the physical and neurological outcome of patients after surgery, and on analyses of somatosensory evoked potential and redox of cytochrome a, a3 in the mitochondria of the cerebral cortical cells.
The effect of hypervolemic hemodilution or hypervolemic hemodilution with dopamine-induced hypertension on cerebral blood flow (CBF) was investigated during 1.2 MAC isoflurane anesthesia in rats (n = 24) subjected to middle cerebral artery occlusion (MCAO). Prior to MCAO each animal was randomized to one of the following groups: 1) control, mean arterial pressure (89 +/- 10 mmHg [mean +/- SD]), blood volume, and hematocrit (46 +/- 1) were not manipulated; 2) hypervolemic hemodilution (HH), 30 min before MCAO, 5% albumin was administered to reduce the hematocrit to 29-32%; or 3) hypervolemic hemodilution/dopamine hypertension (HH/Dop), hemodilution was accomplished and dopamine (10 micrograms.kg-1.min-1) was infused during the ischemic period to achieve a mean arterial pressure of 111 +/- 10 mmHg (mean +/- SD). Ten minutes after occlusion of the left middle cerebral artery, CBF was determined using 14C-iodoantipyrine. Five coronal brain sections were analyzed to determine the area within each brain section with CBF ranges of 0-15 ml.100 g-1.min-1 and 15-23 ml.100 g-1.min-1. The area of 0-15 ml.100 g-1.min-1 CBF was less in both the HH and HH/Dop groups compared with control (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
