This report concerns 44 patients with iatrogenic injuries to the bile ducts treated at the Mannheim University Clinic from 1973 to 1987. Group A: 12 own patients with lesions of the common bile duct among 6020 operations for cholelithiasis, i.e. a risk of 0.19%. All 12 lesions were recognized during operation and immediately repaired with eventual success. Group B: 32 patients referred to us from another hospital after cholecystectomy alone or previous repair. 11 of these patients had progressive jaundice in the immediate postoperative period (1. to 9. week) due to unrecognized bile duct injury. The other 21 patients developed strictures after an uneventful postoperative course within time intervals varying from 3 months to 23 years. 72% of patients (Group B) had reconstructive surgery within two years after last operation in another hospital. We performed 47 reconstructive operations in 42 patients without hospital mortality including 5 second or third operations for recurrent stricture. Biliary-intestinal anastomosis (70%) as sutured mucosa-to-mucosa anastomosis was the most favoured method of reconstruction (30 Roux-Y hepaticojejunostomies and 3 choledochoduodenostomies). An end-to-end anastomosis was only performed in 3 cases of plain transection of the common duct. In management of high biliary strictures (type III and IV according to Bismuth's classification) preference would be given to Hepp-Couinaud's modification of hepaticojejunostomy using the left hepatic duct for a long side-to-side anastomosis. Overall morbidity amounted to 28% while the rate of relaparotomy for surgical complications was 13% (n = 6 without postoperative death). 10 patients died since reconstructive surgery, death being independent from bile duct injury in 5 cases. The injury related one-year-mortality was 4.5%. Overall stricture recurrence rate was 15% (18% for hepaticojejunostomy) with a mean follow-up of 72 months. Local infection was the most obvious cause of recurrence, thus a two stage procedure with postponement of reconstructive surgery must be recommended in case of subhepatic abscess or biliary fistula. Including second and third repairs, a good longterm result was achieved in over 80% of patients.
Background
End-of-life decisions, specifically the provision of euthanasia and assisted suicide services, challenge traditional medical and ethical principles. Austria and Germany have decided to liberalize their laws restricting assisted suicide, thus reigniting the debate about a meaningful framework in which the practice should be embedded. Evidence of the relevance of assisted suicide and euthanasia for the general population in Germany and Austria is limited.
Objective
The aim of this study is to examine whether the public awareness documented by search activities in the most frequently used search engine, Google, on the topics of palliative care, euthanasia, and advance health care directives changed with the implementation of palliative care services and new governmental regulations concerning end-of-life decisions.
Methods
We searched for policies, laws, and regulations promulgated or amended in Austria, Germany, and Switzerland between 2004 and 2020 and extracted data on the search volume for each search term topic from Google Trends as a surrogate of public awareness and interest. Annual averages were analyzed using the Joinpoint Regression Program.
Results
Important policy changes yielded significant changes in search trends for the investigated topics. The enactment of laws regulating advance health care directives coincided with a significant drop in the volume of searches for the topic of euthanasia in all 3 countries (Austria: −24.48%, P=.02; Germany: −14.95%, P<.001; Switzerland: −11.75%, P=.049). Interest in palliative care increased with the availability of care services and the implementation of laws and policies to promote palliative care (Austria: 22.69%, P=.01; Germany: 14.39, P<.001; Switzerland: 17.59%, P<.001). The search trends for advance health care directives showed mixed results. While interest remained steady in Austria within the study period, it increased by 3.66% (P<.001) in Switzerland and decreased by 2.85% (P<.001) in Germany.
Conclusions
Our results demonstrate that legal measures securing patients’ autonomy at the end of life may lower the search activities for topics related to euthanasia and assisted suicide. Palliative care may be a meaningful way to raise awareness of the different options for end-of-life care and to guide patients in their decision-making process regarding the same.
Blunt abdominal traumas with pancreatic injuries often cause partial or subtotal resection of the organ, especially when the pancreatic duct is damaged. A reconstructive method for anastomosis of the duct is reported in a case of a 9-year-old boy with complete pancreatic rupture in which the whole organ could be salvaged.
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