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Neurolysis is a procedure which has to be performed if the gliding apparatus of a peripheral nerve does not function, and consequently, adhesions and fibrosis develop. The gliding tissue has to provide the ability for the nerve to adapt to the different position of the extremity by longitudinal passive movement. The paraneurium provides movements between the nerve and the surrounding tissue; the interfascicular epineurium provides the possibility of the movement within the nerve. Internal neurolysis is defined as surgery within the nerve if the epifascicular epineurium is completely transected. A classification of different degrees of fibrosis is given with special reference to the procedure which has to be done in each case. Neurolysis is a step-wise procedure with the aim to decompress the fascicles and which is immediately stopped if this aim is achieved. In very severe cases, if the gliding tissue does not regenerate, a gliding tissue flap to envelope the nerve may solve the problem.

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Background: Up to now the cytostatic oxaliplatin was classified as nonvesicant. This is the first report on tissue necrosis induced by oxaliplatin extravasation in literature. A clinical course following oxaliplatin extravasation is reported. Case Report: A 52-year-old white female with adenocarcinoma of the colon and hepatic and pulmonary metastases received palliative chemotherapy consisting of oxaliplatin, leucovorin, and 5-fluorouracil. By mistake oxaliplatin infusion extravasated subcutaneously in the left forearm; consequently, a painless red swelling occurred without any sign of further damage of the tissue. The infusion cannula was removed and oxaliplatin was infused into the right median cubital vein at the elbow. Again oxaliplatin extravasated subcutaneously. A severe painful necrotic reaction of the underlying flexor muscles of the right elbow developed, disabling the patient for 2 months, showing red-brown painful swelling, sclerosis of the skin, induration, fixation, and immobilization of the right elbow. Nonsteroidal analgesics and antibiotics were given, and lymphatic drainage and physiotherapy performed as generally accepted polypragmatic unspecific therapeutic procedure. After 2 months, the patient was able to bow and extend the right elbow except for an extension deficit of 20°, pro- and supination became possible again, pain had completely resolved and strength recovered without limitation. Sclerosis of the skin and stiffness of the underlying tissue were slowly subsiding. Conclusion: Oxaliplatin can induce severe necrosis of underlying muscles by extravasation and therefore must be considered as a vesicant. Therefore oxaliplatin should be applied via a central venous access.

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Reconstruction of the esophageal passage after severe complications of the esophagogastric anastomosis (disconnection, long stenosis) remains a surgical challenge. We describe the course of five patients with cervical defects (n = 4) or stenosis (n = 1) after complications of the cervical esophagogastric anastomosis and successful reconstruction by free jejunal transfer. Cause of failure of the anastomosis was ischemia in two, and compression, bleeding and unknown reasons in the other three patients respectively. In four patients, subsequent treatment consisted of disconnection of the anastomosis. In all cases, reconstruction by free jejunal transfer was done between 8 weeks and 12 months after primary surgery. A perforation of the graft was observed in one patient (decubital ulcer from the split sternum). All patients regained normal swallowing function. Free jejunal transfer is a safe method for reconstruction of short defects with a satisfactory functional result and minimal surgical trauma.

The application of a minimum requirement regulation based on volume-outcome considerations in the German health care system must be performed very sensitively, because significant effects are to be expected.

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