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INTRODUCTION: As microsurgical reconstruction is now being increasingly performed on patients with critical peripheral perfusion and/or arterial occlusive disease in numerous centres, there is a need for standardisation of interdisciplinary diagnostic approach and treatment regimens in such critically ill patients. In a consensus workshop on reconstruction of the vascular compromised lower extremity during the 35th Annual Meeting of the German working group microsurgery of the peripheral nerves and vessels (DAM) in 2013 in Deidesheim, DAM members together with vascular surgeons and interventional radiologists attempted to establish interdisciplinarily routine pathways for diagnosis and therapy and to consolidate key recommendations for treatment. METHODS: By reviewing the literature and considering the results of the expert meetings, options and limits of therapy were illustrated and recommendations for successful cooperative treatment formulated. RESULTS: By means of interdisciplinary cooperation, limbs can be salvaged and the quality of live as well as survival of patients with severe peripheral vascular disease improved. Different techniques including angioplasty, bypass surgery and microsurgical free flaps can be applied and individualised concepts allow extremity salvage even in patients with severely compromised limbs. Revascularisation provides the possibility of free flap transfer while the risk for the patients is moderate. DISCUSSION: The poor general condition of the patient requires a sufficient interdisciplinary preoperative planning. By means of interdisciplinary cooperation, the limbs can be salvaged. This not only improves the quality of life but also increases the survival time of patients with occlusive vascular disease. Different concepts for this group of patients have been developed. Surgical treatment with a distal bypass or recanalisation and free flap not only allow for the coverage of large defects, but also represent a haemodynamic advantage by increased blood flow in the bypass. This is attributed to the additional vascular bed that is transplanted with the free flap. Limb salvage means relevant improvement, however, the initially less demanding procedure of amputation must always be considered.

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We describe a surgical emergency due to GI-bleeding caused by gastrointestinal autonomic nerve tumours (GANT s) in a patient with von Recklinghausen s disease. A 72 year old female patient with von Recklinghausen s disease was admitted with maelena. Endoscopy showed no active bleeding in the stomach and the colon. Therefore an angio-CT-scan was performed which revealed masses of the proximal jejunum as source of bleeding. Laparotomy was indicated and a 20 cm segment of jejunum which carried multiple extraluminal tumours was resected. The source of the bleeding was a 2 cm tumour which had eroded the mucosal surface. Immunohistologically, evidence of neuronal differentiation could be shown in the spindle-formed cells with positive staining for C-Kit (CD 117), CD 34, and a locally positive staining for synaptophysine and S100. This case report illustrates the association between neurofibromatosis and stromal tumours and should alert surgeons and gastroenterologist about gastrointestinal manifestations in patients with von Recklinghausen s disease.

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Se describe una urgencia quirúrgica por sangrado intestinal debidoa tumor gastrointestinal de nervios autónomos (GANT) asociadoa enfermedad de von Recklinghausen.Una mujer de 72 años con neurofibromatosis fue ingresadacon signos de melena. La endoscopia digestiva alta y baja fue negativa.Se indicó TAC con contraste que advirtió tumores yeyunalescomo causa del sangrado. Se realizó laparotomía y resecciónde un segmento de 20 cm de yeyuno que incluía varios tumores.La causa del sangrado activo fue lesión en mucosa intestinalpor erosión tumoral. El análisis por inmunohistoquímica de la piezamostró diferenciación neuronal, con células fusiformes con tinciónpositiva para el C-Kit (CD 117), CD 34.Esta nota clínica pone de manifiesto la asociación entre la neurofibromatosisy los tumores estromales y debe alertar a gastroenterólogosy cirujanos sobre las posibles manifestaciones intestinalesen pacientes con enfermedad de von Recklinghausen

We describe a surgical emergency due to GI-bleeding causedby gastrointestinal autonomic nerve tumours (GANT’s) in a patientwith von Recklinghausen’s disease.A 72 year old female patient with von Recklinghausen’s diseasewas admitted with maelena. Endoscopy showed no activebleeding in the stomach and the colon. Therefore an angio-CTscanwas performed which revealed masses of the proximal jejunumas source of bleeding. Laparotomy was indicated and a 20cm segment of jejunum which carried multiple extraluminal tumourswas resected.The source of the bleeding was a 2 cm tumour which haderoded the mucosal surface. Immunohistologically, evidence ofneuronal differentiation could be shown in the spindle-formedcells with positive staining for C-Kit (CD 117), CD 34, and a locallypositive staining for synaptophysine and S100.This case report illustrates the association between neurofibromatosisand stromal tumours and should alert surgeons and gastroenterologistabout gastrointestinal manifestations in patientswith von Recklinghausen’s disease

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Wireless capsule enteroscopy, being a novel, painless investigative technique, is reported to be significantly superior to push enteroscopy in its ability to find bleeding abnormalities in the small intestine. Here we report a case of acute jejunal obstruction following wireless capsule endoscopy. The patient had a 1-month history of gastrointestinal bleeding of unknown source. Further evaluation including gastroscopy and colonoscopy, angiography and computed tomography (angio-CT), and radio-labeled erythrocytes scan failed to reveal a source of bleeding. Therefore, wireless capsule enteroscopy was performed. Before capsule endoscopy, there was no clinical or imaging evidence of strictures or stenosis. At readmission it could be shown that there were two inflamed strictures of the small intestine. The capsule was detected at a stricture of the small intestine detected by abdominal ultrasonography and conventional computed tomography. The patient underwent a medical treatment with steroidal and other anti-inflammatory drugs for a total of 23 days and was discharged without complaints. Acute laparotomy after readmission with jejunal ileus proofed the capsule occluding two highly inflamed jejunal stenosis caused by Crohn disease. The present case demonstrates the potential for complications when wireless capsule enteroscopy is performed in the presence of intestinal strictures. Any history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery must be elicited in detail and may exclude the use of wireless capsule enteroscopy.

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OBJECTIVE: To evaluate the practical performance and the diagnostic power of a rapid, qualitative assay for the detection of cardiac Troponin T (indicated cut-off level: 0.3 ng/ml) in EMS patients presenting with acute myocardial ischemia. PATIENTS: 145 consecutive patients with non-traumatic chest pain treated by the Mobile Intensive Care Unit team. During phase 1 (73 patients), blood drawn at the emergency site was used to perform a Troponin T rapid assay under defined conditions at the hospital. During phase 2 (72 patients), the rapid assay was already performed at the emergency site. RESULTS: In phase 1 all tests were performed correctly, whereas 5.6% of the test results had to be declared invalid in phase 2. 17 (11.7%) of the 145 patients showed a positive test result. Analytic sensitivity was 100%, specificity 96.3%. 37 of the 145 patients (median duration of symptoms: 150 minutes) showed a myocardial infarction (MI). Related to the diagnosis of MI diagnostic sensitivity, specificity, positive and negative predictive values were 35.1, 96.3, 76.5, and 81.3%. Mortality in patients with a positive rapid assay was 35.3%, compared to 6.3% in patients with a negative test result (p < 0.001). CONCLUSIONS: The rapid assay allows the detection of Troponin T in concentrations above the cut-off level. Meticulous observance of the manufacturer's rules is imperative. A single preclinical rapid assay does not allow to exclude a MI. However, the test enables EMS personnel to identify patients who are at increased risk of dying from an acute coronary syndrome in the immediate future.

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In this report, the authors describe an innovative antitobacco advertising campaign in Arizona that was aimed at youth. The campaign utilizes traditional as well as non-traditional methods of research to determine the attitudes, behavior and values of today's adolescents. These creative methodologies led to rigorously tested and well-received media strategies.

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