The aim of this paper is to demonstrate an example of evidence-based medicine for a clinically relevant and frequent disease - gastro-oesophageal reflux disease - for which an increasing number of laparoscopic operations is performed. A consensus development conference was performed on this topic in 1996. During the following 3-year period, increase of knowledge shown by the number of publications was monitored and the consecutive changes of the consensus as well as its consequences and impact were analysed. The six published randomised clinical trials revealed important information about the technique of the laparoscopic operation focussing on the gastric fundic mobilisation and the modification of the anti-reflux wrap. Five consecutive consensus conferences were performed and published. Citations of the 1996 consensus conference could not be found in the major surgical journals - not even by participants of the conference. The responsibility of societies to run such conferences continues.

No abstract

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.

ZusammenfassungSeit ca. 50 Jahren sind Radiosynoviorthesen (RSO) und chemische Synoviorthesen (CSO) zur intraartikulären Therapie entzündlicher Gelenkzustände im Gebrauch. Für die Radiosynoviorthese wird am Kniegelenk Yttrium 90 -Citrat eingesetzt, an den übrigen großen Gelenken Rhenium 186 -Sulfid und an kleinen Gelenken Erbium 169 -Citrat. Für die chemische Synoviorthese werden Osmiumsäure und Natriummorrhuat verwendet, jedoch findet Osmiumtetroxid aufgrund seiner knorpelschädigenden Wirkung im deutschsprachigen Raum keine Anwendung mehr. Abhängig von Indikation und Nachbeobachtungsdauer kann bei beiden Verfahren mit einer Besserung der Symptomatik bei 40 bis 90 % der Patienten gerechnet werden. Die besten Ergebnisse lassen sich bei der Hämophilie-Arthropathie und in den frühen Stadien der rheumatoiden Arthritis erzielen mit deutlicher Verlangsamung der radiologischen Progression. In den Spätstadien der RA und bei aktivierten Arthrosen ist häufig noch eine symptomatische Wirkung zu erreichen. Für Arthrosen sollten diese Therapieformen jedoch ausschließlich bei eindeutiger Dominanz entzündlicher Symptome zum Einsatz kommen. Bei rheumatischen Erkrankungen hält der Effekt der Synoviorthesen länger an als der einer intraartikulären Kortikoidinjektion, so dass RSO und CSO als sinnvolle Zwischenstufe der Lokaltherapie vor der Indikation zur operativen Synovektomie angesehen werden kön-nen. Darüber hinaus haben sie sich als ergänzende Verfahren zur Verbesserung der Radikalität einer operativen Synovektomie bewährt. AbstractFor almost 50 years radiosynoviorthesis (RSO) and chemical synoviorthesis (CSO) have a place in the treatment of persistent inflammatory joint conditions. For radiosynoviortheses the following β-emitting nuclides are used: yttrium 90 citrate for knee joints, rhenium 186 sulfide for shoulder, elbow, wrist and ankle joints and erbium 169 citrate for small joints. Nowadays only osmic acid and sodium morrhuate are in use for chemical synoviothesis but, due to the toxic effect of osmium tetroxide on cartilage, in German-speaking countries almost exclusively sodium morrhuate is used for this purpose. Depending on the indication and the follow-up time a success rate between 40 and 90 % can be expected for both methods. The best results are seen with hemophilic arthropathy and the early stages of rheumatoid arthritis with a significant influence on the radiological progression. In late stages of RA and in osteoarthritic joints, an alleviation of the arthritic symptoms can be achieved. But as a prerequisite of the use in osteoarthritis, symptoms of inflammation like swelling, effusion and pain at rest should be dominant. Because the effect of intraarticular therapy is more long-lasting with synoviothesis than with corticosteroids, RSO and CSO can be regarded as an intermediate step of local treatment prior to operative synovectomy. Additionally, these methods have proved to be effective as a supplementary treatment for the improvement of radicality after open or arthroscopic synovectomy.

No abstract