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Torsello G, Bisdas T, Debus S, Grundmann RT


Zentralbl Chir. 2015 Feb;140(1):18-26. doi: 10.1055/s-0034-1383241. Epub 2014 Dec 19.

Abstract

Background: This overview comments on the health-care relevance of peripheral arterial occlusive disease (PAOD) in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). We evaluated different treatment modalities in terms of cost-effectiveness.

Method: For the literature review, the Medline database (PubMed) was searched under the key words "critical limb ischemia AND cost", "critical limb ischemia AND economy", "peripheral arterial disease AND cost", "peripheral arterial disease AND economy".

Results: In the years 2005 to 2009, the hospitalisations of patients with PAOD rose disproportionately in Germany by 20 %, to 483,961 hospital admissions. By comparison, hospital admissions altogether increased by only 8 %. The average in-patient costs were estimated to be approximately € 5000 per PAOD-patient - a rather conservative estimate. For the patient with IC the economic data position is clear, supervised exercise training is by far the most cost-effective treatment option, followed by percutaneous transluminal angioplasty (PTA) and finally the peripheral bypass. In accordance with the guidelines of the UK, the latter is therefore indicated only if PTA fails or is technically not possible. In patients with CLI, the situation is not obvious. Indeed, a short-term economic advantage can be calculated for the PTA, the long-term comparison of both methods, however, is impossible due to insufficient data. In addition, the risk factors for the patient have to be included in the calculation. This was indeed demonstrated in the short-term, but could not be analysed in the long-term follow-up.

Conclusion: The issue of greater cost-effectiveness of open or endovascular treatment in patients with CLI is uncertain, the studies and patient populations are too heterogeneous. Further studies are urgently needed to structure the sequence of the various treatment options in guidelines and clinical pathways.

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Grundmann RT, Meyer F

Zentralbl Chir. 2014 Apr;139(2):184-92. doi: 10.1055/s-0034-1368231. Epub 2014 Apr 28.

Abstract

Background: This overview comments on gender-specific differences in incidence, risk factors and prognosis in patients with carcinoma of the liver, gallbladder, extrahepatic bile duct and pancreas.

Method: For the literature review, the MEDLINE database (PubMed) was searched under the key words "liver cancer", "gallbladder cancer", "extrahepatic bile duct carcinoma", "pancreatic cancer" AND "gender".

Results: There were significant gender differences in the epidemiology of the analysed carcinomas. The incidence of hepatocellular carcinoma (HCC) is much higher in men than in women, one of 86 men, but only 1 out of 200 women develop a malignant primary liver tumour in Germany in the course of their life. The lifetime risk for carcinomas of the gallbladder and extrahepatic bile ducts in Germany amounts to about 0.6 % for women and 0.5 % for men, specifically gallbladder carcinomas are observed more frequently in women than in men. For pancreatic cancer, no clear gender preference exists in Germany, although the mortality risk for men is higher than that for women (age-adjusted standardised death rate in men 12.8/100, 000 persons, in women 9.5). Remarkable is furthermore the shift of the tumour incidence in the last decades. Liver cancer has increased among men in Germany by about 50 % in the last 30 years, the incidence of gallbladder carcinoma has inversely dropped. The prognosis of these cancers across all tumour stages is uniformly bad in an unselected patient population. This is probably the main reason why only little - if any - gender differences in survival are described.

Conclusion: In addition to avoiding the known risk factors such as hepatitis B and C virus infection, alcohol abuse, and smoking, the avoidance of overweight and obesity plays an increasingly important role in the prevention of these cancers.

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„La vie est l’ensemble des fonctions qui résistent à la mort“

Prof. Dr. R.T. Grundmann

Aus Chirurgische Allgemeine (CHAZ) 2014; 15:366-370

Das Konzept des Hirntods scheint für die Organ­ transplantation unver­zichtbar, doch ist es keineswegs so unumstritten, wie es uns Laien­ beschlüsse (Bundestag) weisma­chen wollen. Dies mag zum Teil an Zweifeln bei der Handhabung der Diagnostik liegen [1], aber auch an seiner Zielsetzung. Ei­gentlich recht unverblümt hat das „Ad Hoc Committee of the Harvard Medical School to Ex­amine the Definition of Brain Death“ die Gründe aufgeführt, die es dazu bewegten, die heute allgemein übernommenen Hirn­ todkriterien zu definieren [2]. Es geht – liest man den Einleitungs­ text zwischen den Zeilen – eben auch um kommerzielle Interes­sen: Intensivstationsbetten sollen frei gemacht und damit Behand­lungskosten gesenkt werden und natürlich will man Organe für die Transplantation gewinnen. Dass letzteres Vorhaben sehr wohl etwas mit wirtschaftlichen Mo­tiven zu tun haben kann, wissen wir spätestens seit dem Trans­plantationsskandal.

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Prognose, Therapie, Screening und Kosteneffizienz

Prof. Dr. R.T. Grundmann

Diesen Artikel hier herunteladen

Zu diesem Thema hat vor kurzem der Autor ausführlich Stellung genommen. Die Veröffentlichung ist nachzulesen in der Zeitschrift chirurgische praxis 71, 119 – 136 (2009/2010),
Hans Marseille Verlag GmbH, München, (www.marseille-verlag.com). Im Folgenden seien die wichtigsten Aussagen zusammengefasst. 

Problemstellung

Die krankhaft erweiterte Bauchschlagader (Aneurysma) beinhaltet das Risiko, ab einer bestimmten Größe zu platzen (zu rupturieren), was in einem hohen Prozentsatz zum Tod des Patienten durch inneres Verbluten führen kann. Durch Vorsorgeuntersuchungen (“Massenscreening“) sollen Erweiterungen der Bauchschlagader bei beschwerdefreien Personen frühzeitig erkannt und dann vorsorglich (prophylaktisch) operiert werden, um so die Gefahr der Ruptur zu beseitigen.  Dabei  muss das Risiko der vorsorglichen und damit zu einem hohen Anteil in diesem Stadium (noch) nicht notwendigen Operation gegen die Wahrscheinlichkeit der Ruptur abgewogen werden. Nicht jede erweiterte Bauchschlagader platzt, dies hängt von der Größe des Aneurysmas ab. Auch stirbt die große Mehrzahl der beschwerdefreien Personen, bei denen eine Erweiterung der Bauchschlagader zufällig entdeckt wird, nicht an einer Ruptur des Gefäßes, sondern an anderen Ursachen, zum Beispiel einer chronischen Herzerkrankung.