14

Methodik: Anhand des Krankengutes der Kinderurologischen Abteilung der Universitfit Er[angen werden Indikationen und unterschiedliche Therapiekonzepte der Nierenverletzungen in ihrem Wandel seit 1970 analysiert und mit den Ergebnissen anderer Zentren verglichen. Ergebnisse: Im Zeitraum yon 1970-1986 fanden sich bei 67 urologischen Verletzungen 44 renale Traumen und im Zeitraum von 1987 inklusive 2001 bei 44 Verletzungen 31 Nierentraumen. Das Verletzungsausma6 der Nieren war in beiden Gruppen mit jeweits ca. 50% leichten bzw. schweren Traumen ann~ihernd ausgeglichen. Wfihrend in der friihen Serie mit 84% operativer Therapie ein aggressives chirurgisches Vorgehen praktiziert wurde, fanden sich in dieser Gruppe doch 14 Nephrektomien, entsprechend 38%. Der Trend zum konservativen Therapiekonzept lfigt sich in der aktuellen Serie seit 1987 klar erkennen. Hier zeigt sich ein konservativer Therapieanteil yon 71%, wobei selbst schwere Lazarationen mit Hohlsystemer6ffnung etc. vielfach erfolgreich konservativ behandelt werden konnten. Die operative Frequenz yon 29% endete in nur einem Fall mit der Nephrektomie. Ein Vergleich der Komplikationsraten beider Serien unserer Klinik zeigt zwar ein etwas ungfinstigeres Abschneiden der tiberwiegend konservativen aktuellen Gruppe, wobei jedoch lediglich bei einem Patienten eine Sekundfirnephrektomie erforderlich wurde. Schlul/foigerungen: Die vorliegenden Serien mit Nierentraumen im Kindesalter in den vergangenen 30 Jahren belegen den diagnostischen und therapeutischen Wandel. Konsequente bildgebende Diagnostik erlaubt heute ein exaktes Staging der meisten Verletzungen und verhindert so unn6tige Explorationen, die im Frtihstadium nicht selten zur Nephrektomie ftihren. Das konservatives Management selbst bei schweren renalen Vertetzungen scheint sich langt'ristig durchzusetzen.

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acute scrotal pain Were included in the analysis. After clinical assessment a dopplersonographic study with a "high-end'" instrument was performed. Serum biochemistry, a full blood count, ESR and a midstream urine completed the assessment. If the Doppler investigation documented a lack of arterial perfusion of the testis the organ was explored surgically. Patients with intact perfusion were followed clinically and by ultrasound. Results: 22 infants and children aged one day to 17 years (median: 7.7 years) were included in this study. In five cases sonography demonstrated absent arterial perfusion, and two of those testes appeared to show unusually echogenic parenchyma. In all those 5 patients surgical exploration confirmed testicular torsion. Amongst the other 17 patients we found three cases with increased testicular perfusion and ten patients with increased perfusion of the Epididymis. In 5 cases sonography suggested a torted hydatid. All conservatively treated patients were followed clinically and by ultrasound, with longitudinal assessments being available for up to 2 years after the acute presentation. Conclusions: Doppler sonography enabled an unequivocal statement regarding testicular perfusion in all cases. Operative evaluation and/or clinical progress and longitudinal ultrasound observation confirmed the initial Doppler diagnosis in all cases. We therefore feel that diagnostic ultrasound, if performed correctly and with modern equipment, can be reliably used to exclude testicular torsion in infants and children.

BURN INJURIES A44.

Cultivated Allogenic Keratinocyts in Burned Children A42.

Management of Cystic Testicular Lesions in B o y s P. N~che~; R. Wolf ~ (Department of Surgery, '.':Department of Radiology, University Children's Hospital, Zurich, Switzerland) Background: Differential diagnosis of cystic testicular lesions includes epidermoid cyst, dermoid cyst, prepubertal teratoma, juvenile granulosa cell tumor, cystic dysplasia of the rete testis, testicular cystic lymphangioma, simple testicular cyst and cystic degeneration after torsion. Methods: We present 3 patients with cystic testicular lesions where ultrasound suggested a benign intratesticular process. Therefore a testicular sparing operation has been performed in all 3 boys. Results: Histology confirmed a benign tumor in all 3 cases (cystic dysplasia of the fete testis 2x, epidermoid cyst Ix). Follow-up was uneventful in all 3 boys. Conclusions: Although cystic testicular lesions are uncommon it is important to unerstand all potential diagnoses to choose the best management. With exception of simple testicular cyst with pathognomonic ultrasound features, the definitive diagnosis of cystic testicular lesions depends on histological evaluation. Nevertheless a non-operative management nowadays is also discussed in patients with cystic dysplasia of the fete testis. Past dogma that all testicular lesions were malignant until proved otherwise is no longer valid. Normally solid germ cell tumors very rarely undergo necrosis with cystic degeneration.

A43.

Acute Testicular Torsion in Children. How accurate Is Sonographic Evaluation? P. G[imhe~; R. Wunsch, J. TrOger, K. L. Waag (Department of Pediatric Surgery, University Hospital Mannheim, Germany) Background: Acute testicular torsion in children is an emergency and has to beassessed urgently. Doppler sonograpby is increasingly used in conjunction with a careful clinical evaluation whenever this condition is suspected. Despite this increase in available information. surgical exploration of the scrotum often appears necessary to secure a diagnosis. In this retrospective study we attempted to define the usefulness of Doppler sonography in the diagnostic workup of the acutely painful scrotum. Methods: All patients admitted in 1999-2001 with a diagnosis of

G. Meissl (Division of Reconstructive and Plastic Surgery, Department of Surgery, University Vienna) Background: Each year approximately 100 children with burn injuries must be treated as inpatients, 75% are scald injuries, contact and flame burns are 15% respectively 8%. The most affected children are babies from 0.5 till 1.5 years. The most common extension of total burned surface area injuries till 20%. Methods: In the earlier time conservative treatment was performed e.g. in the years 1980-1990, 61% were conservatively treated and in 39% operative necrectomy and grafting was performed. In the last 10 to 15 years the concept changed, similar as in adults, and more and more centres started with operative treatment. It is today much easier to decide to operate for instance burned areas of deep 2 ° . It is not necessary to wait for spontaneous healing of superficial burned areas and operate the remaining parts, you can do it very early in your treatment and cover the defects with cultivated allogenic keratinocyt-sheets. You prevent an enlargement of the wounds, because you need much less autologous skin grafts. The healing of the wound and the grafts is faster, the time of hospital staying is reduced even so the morbidity. Results: Function and aesthetic appearance is very satisfying. In our skin bank these sheets are every time available. The donor patients are tested for HIV, hepatitis and CMV. I present the first 12 children which were treated by early tangential excision and covering with cultivated allogenic keratinocytes. Conclusions: Of these 12 children 10 had an uneventfull postoperative course without hypertrophic scars immediately and in late time. 2 showed complications, one deyeloped a delayed woundhealing and one showed hypertrophic scars, because parts of the sheets don't take completely.

A45.

Ergebnisse der Behandlung thermischer Verletzungen in einem Kinderzentrum R. Finke, U. Sitka (Universitf.tskliniken und Polikliniken fiir Kinderchirurgie, Kinder- und Jugendmedizin, Martin-Luther-Universit,it Halle-Wittenberg, Deutschland) Grundlagen: Eine retrospektive Analyse und kritische Bewertung der Indikationen, IVlethoden und Ergebnisse der Behandlung thermischer Verletzungen im Kindesalter.

Eur. S u r g . . Vol. 34 - Supplement No 181 - 2002

Methodik: In den Jahren 1990 bis 2001 mugten 209 Kinder mit einer thermischen Verletzung stationfir behandelt werden. 135 bis zum Jahr 1996 behandelte Kinder wurden in einer retrospektiven klinischen Studie nachuntersucht. Ergebnisse: Das Durchschnittsalter zum Unfallzeitpunkt betrug 5,2 Jahre, der Anteil schwerer Verletzungen nach den Kriterien der ABA 70%. Nur 40% der Kinder erhielten nach dem Unfall eine ad~iquate Erste Hitfe. Bei der HNfte der Kinder war innerhalb der ersten 24 Stunden nach dem thermischen Unfall eine enterale ErnS.hrung m6glich, lediglich 10% mul3ten l~inger als 4 Tage parenteral ern~ihrt werden. Die mittlere Gesamtverweildauer betrug 1,77 Tage pro% thermisch verletzter KOE Die erste Nekrosektomie erfolgte bei Verbrfihungen im Mittel nach 6,8 Tagen, bei Verbrennungen nach 3,9 Tagen. Bei knapp der Htilfte der Kinder waren eine oder mehrere Transplantationen yon autologer oder heterologer Spalthaut, Dermisfquivalenten oder kultivierten Keratinozyten notwendig. Die erste Transplantation erfolgte bei Verbrennungen nach 5,3 Tagen, bei Verbrahungen nach 13,1 Tagen. Bei knapp einem Drittel der Kinder traten w~ihrend oder nach der Behandlung Komplikationen auf, die Letalit~it betrug 0,74%. Die h~iufigste Komplikation war die Ausbildung hypertropher Narben, die zweithtiufigste die Infektion. SehluBfoigerungen: Die Indikation zur Operation ist abh~ingig vom Ausmag der thermischen Tiefensch~idigung, dagegen entscheidet die flfichige Ausdehnung fiber die zu w~ihlende Operationsmethode. Eine frfihzeitige enterale Ern~ihrung ist anzustreben. Aus funktionellen und fisthetischen Grtinden sollte Spalthaut im Kindesalter vom Kopf entnommen werden. Mischhauttechniken, Dermis~iquivalente, heterologe Spalthaut sowie autologe Keratinozyten erweitern das Behandlungsspektrum und erm(Sglichen einem frtihzeitigen Wundverschlug. Die Letalit~it und Komplikationsrate nach thermischen Verletzungen sind im Kindesalter nicht h/3her als bei Erwachsenen. A46.

Wann ist der beste Zeitpunkt zur Therapie von l I u n d III°-igen Verbrennungen und Verbriihungen i m Kindesalter? Meyer Th., Meyer B., HiJcht B. (Abteilung ffir Kinderchirurgie der Chirurgischen Universit'atsklinik Wtirzburg, Deutschland) Grundlagen: Verbrenm,ngen und Verbrtihungen zfihlen nehen den Verkehrsunf/illen zu den zweithfiufigsten Verletzt, ngen im Kindesalter. Wfihrend erstgradige Verbrennungen und VerbriJhungen in der Regel keine tirztlichen Mal3nahmen erfordern, stellen die zweit- und drittgradige Verbrennungen und Verbrfihungen im Kindesalter in Abh~ingigkeit vom Ausma[3 h~iufig nicht nut ein kosmetisches, sondern auch ein funktionelles Problem dar. Unstimmigkeit besteht jedoch auch heute noch tiber den optimalen Zeitpunkt der chirurgisch-rekonstruktiven Behandlung. Methodik: Im Zeitraum von Januar 1995 bis Dezember 2000 wurden 184 Kinder (47,5% Mfidchen und 52,5% Jungen) im Alter von 1,5 Monaten bis 14,25 Jahren (Mittelwert: 3,7 Jahre; Median: 2 Jahre) auf Grand einer Verbrennung oder Verbrfihung in der Kinderchirurgischen Abteilung der Chirurgischen Universit~itsklinik in Wfirzburg stationfir behandelt. Eine chirurgische Defektdeckung erfolgte nach einer initialen konservativen Therapie in der Regel am 12. Tag nach Verbrennungs- bzw. Verbrtihungstrauma. Ergebnisse: (1) Verbrennungsursache: Flfissigkeiten: 67,5%, feste Gegensttinde: 11,3%, offene Flammen: 11,3% und sonstige: 9,9%. (2) Tiefengrad der Lfisionen: I ° = 4,3%, II°a = 8,6%, II°b = 39,6% und IIl° 47,5%. (3) Verbrennungsausdehnung: 0,5% bis 35% der K6rperoberflfiche (KOF, Mittelwert: 7,6% der KOF, Median: 5% der KOF). (4) In 83,8% der Ffille war neben einer rein konservativen Therapie zusfitzlich eine chirurgische Intervention erforderlich, wobei in fiber 95% eine Hautransplantation (Mesh-Graft und/oder Spalthauttransplantate) am 12. Tag nach Trauma erforderlich war. (5) Krankenhausaufenthalt: 1 bis 115 Tage (Mittelwert: 16,8 Tage, Median: t4 Tage). (6) Weitgehend komplikationsloses Einheilen der Spalthautdeckung mit guter Funktionalittit unter Kompressionsbehandlung. Schlullfolgerungen: Verbrennungen und Verbrfihungen stelten im Kindesalter ein nicht zu unterschfitzendes Risiko dar, das in der Mehrzahl der F~ille zu tiefen, hiiufig drittgradigen Defekten fiihrt,

15

die weiterer funktioneller und kosmetischer Therapie bedfirfen. Eine plastisch rekonstruktive Deckung der Areale am 12. Tag nach Trauma, hat unserer Meinung nach den Vorteil, dab sich die Grenzen zwischen IIa- und IIb-gradigen Verbrennungen deutlich demarkiert haben, und so eine optimale Therapie - unter Schonung der Spenderareale - erfolgen kann. A47.

Strukturell-funktioneile Veriinderungen der Haut nach thermischen Verletzungen R. Finke (Universittitsklinik und Poliklinik ffir Kinderchirurgie der Martin-Luther-Universittit Halle-Wittenberg, Deutschland) Grundlagen: Analyse stmkturell-funktioneller Ver~inderungen der Haut mittels objektiver Untersuchungsmethoden und Evaluierung des Einflusses verschiedener Behandlungsverfahren. Methoden: Hochfrequente Ultraschallsysteme erm6glichen es, die Schichten der Haut darzustellen und Aussagen tiber ihre akustischen Eigenschaften zu gewinnen (Epidermis- und Koriumdicke, Koriumechogenit~it). Bei der Laser-Doppler-Fluxmetrie (LDF) ver~indert sich die Wellenltinge eines Helium-Neon-Lasers dutch Retiexion an bewegten Zellen proportional zu deren Geschwindigkeit (Flux ats Ma/3 der mikrovaskul~iren Perfusion). Die Messung der mechanischen Hauteigenschaften erfolgte mit einem Kutanometer. Zur Beurteilung und Charakterisierung morphologischer Ver~indemngen wurden verschiedene histologische sowie immunhistologische Methoden eingesetzt.

Ergebnisse: Histologische und immunhisto- Befunde der non-invasiven logische Befunde Methoden Anderung der Struktur des kollagenen und weitgehender Verlust des elastischen Fasersystems

Zunahme der Koriumdicke und Abnahme der elastischen Verformbarkeit

Homogenisierung und Verquellung des Kollagens in den obeten Narbenschichten

Abnahme der Koriumechogenitfit und des Fluxes

Fehlende Integration des KollaVertinderung der Koriumechogens der Spalthauttransplantate in genitfit und -dicke sowie der die ortsstfindige Kollagenstruktur elastischen Verformbarkeit Vermindemng der Anzahl der Blutkapillaren in den oberen Narbenabschnitten

Reduzierung des Fluxes

Nachweis NSE-positiver Zellelemente im adventitiellen Bindegewebe

Positive Hyperthermiereaktion in der LDF

Schlugfoigerungen: Strukturell-funktionelle Vertinderungen in thermischen Narben k6nnen mit den non-invasiven Untersuchungsmethoden ausreichend dargestellt werden. Verf.ndert sich eine Kategorie so bedingt dies einen Wandel der anderen. A48.

Erfahrungsbericht fiber die Lokaltherapie yon zwei schwerstbrandverletzten Kindern V. Engel, R. t3. Mi~ritz, F. Linke, O. Beck (Klinik und Poliklinik ffir Kinderchirurgie der Johannes Gutenberg-Universit'at Mainz, Deutschland) Grundlagen: Die Behandlung yon schwerstbrandverletzten Kindern (> 50% K6rperoberfliiche) stellt neben der intensivmedizinischen Therapie der Verbrennungskrankheit eine Herausforderung in der lokalen Wundbehandtung und des Hautersatzes dar. Methodik: In den Jahren 2000 und 2001 his einsch[. Oktober wurden im Brandverletztenzentrum ffir Kinder (Universit~t Mainz) 34 bzw. 41 Patienten mit thermischen Verletzungen behandelt. Davon waren jeweils 6 Kinder mittel- und grol3flfichig (> 10%) und tiefgradig thermisch (ab lib °) verletzt. Zwei Kinder waren schwerstbrandverletzt. Probleme der primfiren Wunddeckung, des plastischen Hautersatzes und der rehabilitativen Versorgung werden diskutiert.

16

Ergebnisse: Behandelt wurden ein farbiger Knabe (67/12 Jahre air) mit 65% betroffener K6rperoberflfiche nach Verbrennung und ein M~idchen (34/12 Jahre) mit 50% K6rperoberfl~iche verbrannt mit Frittierfett. Aufgmnd der Ausdehnung und Tiefe der Verletzung waren vielffiltige Magnahmen mit Escharotomie, frOhzeitige grogfl~ichigen Nekrektomien, tempor~ire Wunddeckung, sukzessive Spalthauttransplantation in mesh-Technik notwendig. Zusfitzlich wurden gez/ichtete Keratinozyten eingesetzt. Trotz friihzeitiger komplexer Rehabilitation kam es bei vorliegender Disposition zu Narbenbildung, Keloiden und Kontrakturen mit Funktionseinschr~inkungen. Die kosmetisch und funktionell insgesamt gfinstigen Ergebnisse konnten mit zus~tzlicher plastisch-chirurgischer Intervention erreicht werden. Schlu6folgerungen: Schwerstbrandverletzte Kinder haben unter den Bedingungen modemer Intensivmedizin eine gute Chance zu tiberleben. Eine um so gr66ere Bedeutung kommt hierbei der aggressiven prim~iren Lokaltherapie und der raschest m6glichen Wunddeckung zu. Der definitive Hautersatz erfordert ein Konzept, welches einer intensiven interdiszliplin~iren Zusammenarbeit und auch ein komplexes organisatorischen Vorgehens bedarf. Die Methodenwahl richtet sich nicht nur nach der eingeschrfinkten Hautverfiigbarkeit, sondern auch nach plastisch-chirurgischen Gesichtspunkten. Die Frtihrehabilitation muf3 bereits stationer beginnen und setzt sich in einer langfristigen Betreuung mit dem Einsatz vielfgltiger Behandlungsansfitzen fort (Physiotherapie, Hautpflege, Kompressionstherapie, Silikonapplikation, plastisch-chirurgische Intervention, psychische Betreuung). Diese komplexe Versorgung schwer thermisch verletzter Kinder wird in daffir spezialisierten Brandverletztenzentren bestm6glich geleistet werden. A49. Use of Lyophilized H u m a n A m n i o n in the Treatment of Burn Injury S. Mdrzheuser, P. Degenhardt, H. Mau (Charit~ Campus Virchow Klinikum, Otto-Heubner-Zentrum ftir Kinder- und Jugendmedizin, Klinik ftir Kinderchirurgie, Berlin, Germany) Background: Local burn wound managment is one of the most important aspects of burn therapy as it is of major importance to close the wound as early as possible. Several methods of burn wound managment are available today, from tangential excision to biological dressings or topical antimicrobial creams. The treatment of burned patients is a difficult clinical problem not only because of the extent of the physiologic abnormality caused by the burn itself, but also because of the persistence of a large, open wound. If this wound is not promptly closed, malnutrition, loss of fluid, protein and evaporation of heat, loss of energy as well as bacterial invasion set the stage for extensive complications. Furthermore regeneration of the epithelium and preparation of the wound if it needs grafting is essential. Methods: With these facts in mind, we describe the use of lyophilized human amnion as temtmrary coverage in the managment of superficial, partial-thickness and full-thickness burn wounds. Lyophilized human amnion is prepared by the Institut of Transfusion and Transplantation of the Charit6 in Berlin. All children with a burn wound of more than 10% of the total body surface area or with circular or semi-circular lesion of the extremities or wounds going across joints are taken to the operating room and treated in general anaesthesia. The local wound is cleaned with normal saline, the adjacent skin is desinfected with mucous membrane desinfection. All blisters are snipped and all the debris is removed. After rehydration, amnion is expanded and applied to the wound. The injury is covered completly. In rare cases margins are secured with sutures. A non-adherent, humid-dry, immobilizing dressing is applied over the top to protect the wounds. First dressing change is done on day five in the operating room. Wounds are inspected and a decision has to be taken if any areas require excision and grafting. In superficial and partialthickness burns the membrane starts rolling out at the edges when epithelialization is complete and can be peeled or bathed off. In deep partial-thickness and full-thickness burns the area is covered with membrane until excision and grafting is due. Sometimes, one more attempt at membrane application is tried after devitalized skin has been removed, so that the wound can epithelize under the membrane from the remaining dermal elements.

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Results: Our experience with amnion shows that the material can be used to cover all parts of the body. Adherence to the wound surface is satisfactory and prevents toss o f fluid, protein, evaporation of heat and loss of energy. Under coverage of the dressing the wound is protected from bacterial infection. Deep partial-thickness and full-thickness burns can be visualized well in the progress of wound healing. Conclusions: Human amnion seems to be a good preparatory measure if grafting is needed. The material can be preserved long time, preperation and use of lyophilized human amnion is cost effective. A50. Early Enteral Nutrition in S e v e r e l y Burned Children - Still a Current Problem? A. Schneider, K. Rothe, J. Bennek (Department of Paediatric Surgery, University Leipzig, Germany) Background: In children suffering severe burn injuries an caloric demand up to 200% of the basal metabolic rate has been estimated. Due to intestinal-protective and immunostimulatoric effects, early enteral nutrition is demanded in these patients. Our aim was to examine how far both recommendations are realisable in clinical practice. Methods: Retrospective investigation of kind, amount, and duration of enteral nutrition in our patients was performed (1995-2000, n = 50, age 6 -+ 5 y, burned body area 13,2 _+ 13,9%). The caloric demand of our patients has been calculated using different formulas (standardb Curreri 2, Galveston-Shriner3). Differences in caloric demands and the enteral given part of nutrition on the first seven days after injury where compared. Results: Distinct differences in the calculated caloric demands of our patients, depending on formula and age, appeared (1862 -+ 816 kcal t vs. 1163 + 770 kcal 2 vs. 1756 + 837 kcal3). The enteral given part of nutrition reached not before the fourth day after injury about a third of the calculated amount. Reasons are mainly fasting periods before surgical and diagnostical procedures and application problems. Conclusions: The reasonable demand of early enteral nutrition of burned children is still difficult and incompletely realisable in clinical practice. In our opinion the realistic caloric demand of burned children is less than actually estimated. An improvement should be achievable by minimising non-nutritive time gaps. The early enteral nutrition remains an important part of the therapy in bum-injured children. A51,

Top Sites - Top Graft M. Meuli, C. M. Schiestl, K. Timm, U. Fehr, R. Biihlmann, C. A. Gitzebnann (Burn Center, Department o f Surgery, University Children's Hospital, Zurich, Switzerland) Background: Harvesting split skin from the scalp still raises controversy because of issues like shaving, bleeding, infection, and the risk of alopecia. The aim of the study was to analyse and compare complications associated with harvesting the scalp versus harvesting other donor sites. Methods: Charts of 500 children necessitating split thickness skin grafts were reviewed with regard to donor site location, number of harvests per donor site, and donor site complications. Results: 323 boys and 177 girls with a mean age of 5.5 years (3 d-15.5 y) were studied, in 245 patients the scalp was harvested once, in 32 twice, in 8 three times, and in 2 patients four times in a row. In 84 patients, the scalp and additional donor sites were harvested, and in 129 patients only non-scalp donor sites were used. Complications from scalp harvests (n = 287 = 100%) included donor site infection with spotty alopeoia in 1 patient (0.3%), visibility of a minute frontal donor site area following hairline trespassing in 1 patient (0.3%), harvest induced alopecia (6 x 3 cm) in 2 (0.6%), and minimal scalp hair growth in the grafted area in 2 patients (0.6%). Excessive bleeding, delayed healing, and hypertrophic scar formation were not observed, Complications from nonscalp donor sites (n = 213 = 100%) included severe infection in 1

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patient (0.5%), hypertrophic scar formation in 11 (5%), and visible donor sites in all patients (t00%). Conclusions: Single as well as multiple harvesting of the scalp is efficient and sate in pediatric patients of any age. The overall complication rate is very low. In contrast, the incidence of problems associated with harvesting non-scalp donor sites is significantly higher. These results support our long-standing concept to use the scalp as first choice donor site.

A 52. Burns of the Growing Hand: Adequate Surgical Treatment

17

lungsprozesse ist. Atraumatische Verbandswechsel sorgen for anhaltende Wundruhe und eine beschleunigte Heilung. Hauptwirkung der Low-Level-Laserstrahlung (Lasotronic R Med 2000, alpha-Laser) ist die Stimulation der Mitochondrien, woraus eine vermehrte Energielieferung f~ir den Zellstoffwechsel resultiert. Die dermalen Kollagen-/Glykosaminglykan-Anteite des Integra R (Fa. Ethicon) dienen ats Fasergertist zur Einsprossung von Fibroblasten, Makrophagen, Lymphozyten und Kapillaren, die ein neovaskulfires Netzwerk for eine Neodermis bilden. Exemplarisch werden Therapie und Verlauf bet 5 Kindern (1,5--4 Jahre) mit komplexen tiefen thermischen L~isionen unter Behandlung mit der Kombinationstherapie beschrieben. Ergebnisse: Alle L/isionen zeigten eine rasche Abheilung und verminderte Infektionsrate bet gutem kosmetischem und funktionellen Resultat. Die Verbandswechsel sind schonend durchf0hrbar. Sehlugfolgerungen: Basierend auf den guten Erfahrungen mit der Anwendung der Einzelkomponenten bet oberfl~ichlicheren L~isionen, zeigt die Kombinationstherapie auch bet komplexen tiefen thermischen L~isionen sehr gute Resultate.

M. Ohlbauet; E. Muzika, M. Haug, Hildegunde Piza-Katzer (Department of Plastic and Reconstructive Surgery, University of Innsbruck) Background: Burn injuries to the hand often cause significant functional loss and aesthetic deformity. Primary adequate reconstruction of the burned hand is a priority for both functional and aesthetic reasons. Approximately one-half of all burn injuries occur in children. The choice of reconstructive procedures and subsequent management are of particular importance in children, since continued growth of the hand must be taken into account and psychological and physical adjustment to residual deformities may affect subsequent choices of life-style and occupation. Optimal reconstruction of the burn-injured growing hand presupposes well-planned acute care management both to maximize function of a burned hand and also to avoid post-burn deformities of the hand such as complete or incomplete claw deformity, palmar contracture, web space deformity (web space contracture, adduction contracture, syndactylism), hypertrophic scar and contracture bands, amputation and nail bed deformity. Methods: All operations performed at the Innsbruck University Clinic of Plastic and Reconstructive Surgery on burn-injured hands in children between 1995 and 2000 were reviewed in detail. Assessment of the initial deformities and final results was made by reviewing clinical notes, sequential routine preoperative and postoperative photographs, precise measurements of joint motion, and personal evaluation by direct examination. Only those patients whose range of motion, functional status, and cosmetic appearance could be assessed at a follow-up scheduled at least 6 months after the reconstructive procedures were included in the analysis. 30 patients met these criteria. Results: The results of various types of operative procedures and postoperative care in the surgical management were analysed and compared. Conclusions: I. Immediate attention to the function of the growing hand during the acute phase of burn treatment will maximize function and minimize the need for reconstructive procedures. 2. With proper therapy following grafting there is a greater probability that full range of motion will be maintained and fixed contractures avoided. 3. Postoperatively, yearly check-ups are recommended for burn-injured growing hands.

A55,

A53,

Is it Patchwork? - Combination of Different Skin Transplantat Techniques in Severe Thermal Injury

Moderne Therapiekonzepte in der Verbrennungsbehandlung. Erfahrungen mit feuehter Wundbehandlung, Low Level Laser und Integra n bet Kindern A. Fette (Kinderchirurgie Regensburg - Klinik St. Hedwig; Akademisches Lehrkrankenhaus der Universit~it Regensburg, Deutschland) Grundlagen: Die etabtierte Behandhmg thermischer Lfisionen aller Schweregrade sttitzt sich auf die trockene Wundbehandlung, Salbenapplikation und Spalthautdeckung yon gr6Beren Gewebedefekten. Kann mit der feuchten Wundbehandlung, subthermischen Lasersystemen und dermaler Regenerationsmatrix bet gleicher Sicherheit eine schnellere und bessere Abheilung erreicht werden? Methodik: Folienverbfinde (Suprasorb R, Lohmann & Rauscher, Vacu Seal R, KCI) schaffen ein physiologisches, feuchtes Wundmilieu. das ein ideales Mikroklima for die k6rpereigenen Wundhei-

A54. Behandlung thermischer Gesichtsverletzungen im Kindesalter mit Dermis~quivalenten R. Finke, G. Klohs, M. Milzsch (Universit~itsklinik und Poliklinik for Kinderchirurgie der Martin-Luther-Universitfit Halle-Wittenberg, Deutschland) Grundlagen: Evaluation der M6glichkeiten des Hautersatzes im Gesicht bet groBfl~ichigen thermischen Verletzungen im Kindesalter. Methode: Seit 1996 konnten in der Behandlung thermischer Verletzungen im Kindesalter Dermfiquivalente (integra®) eingesetzt werden. Die Behandlungsergebnisse wurden mittels klinischer und noninvasiver Untersuchungsmethoden sowie histologischen und immunhistologischen Kriterien evaluiert. Ergebnisse: Bet 3 Kindern mit grogflfichigen Verletzungen, im Mittel 55% thermisch geschfidigte KOF, war es auf Grund fehlender und geeigneter Spenderareale notwendig drittgradige Verletzungen im Gesichts- und Halsbereich mit integra® und autologer Spalthauttransplantation zu behandeln. Die Nekrosektomie im Gesicht und integra®-Transplantation erfolgte im Mittel 10 Tage nach dem thermischen Unfall, die anschliegend notwendige autologe Spalthauttransplantation im Mittel nach 32 Tagen. Der l~ingste Nachbeobachtungszeitraum betrfigt 48 Monate. An Hand des Behandlungsverlaufes werden die Vorztige und Probleme der Anwendung von Dermisfiquivalenten bet thermischen Verletzungen im Gesichtsbereich dargestetlt und diskutiert, Schlullfolgerungen: Fehlen geeignete Spenderareale ist bet grogflachigen thermischen Verletzungen im Kindesalter die Behandlung drittgradiger Verletzungen im Gesicht mit DermisS.quivalenten und anschliegender autologer Spalthauttransplantation eine Methode, die zu befriedigenden kosmetischen und funktionellen Ergebnissen f(ihrt.

T. Gresing, P. llling (Abteilung ffir schwerbrandverletzte Kinder des Kinderkrankenhauses Park Sch6nfeld, Kassel, Deutschland) Background: The surgical treatment of extensive thermal injury needs the combination of different skin transplantation techniques to receive an optimal functional and cosmetic result. Methods: We report about a 14 year old female patient with a III° to IV ° degree of thermal injury by an high voltage accident. 72% of the body surface were involved. In this case we used split graft transplantation in MEEK technique, autolog transplantation of ceratinocytes in sandwich technique with MEEK grafts and the transplantation of artificial skin dermis Integra®. Results: The use of the MEEK technique were preferable for the protection of extensive affected skin areas. Skin regions with a high functionality, wich were treated with dermis Integra®, showed no signs of contraction. The same result could be seen in the autolog transplantation of ceratinocytes in combination with MEEK grafts in similar areas.

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Eur. Surg. • Vol. 34 • S u p p l e m e n t

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Conclusions: In case of extensive thermal injuries the surgical treatment should consists of the combination of different therapeutic strategies to achieve the best results for the patient.

A58. Scarified Skin and Keloids after Burn Injuries Innovative Biotechnological Cell Therapy

A56. Scar Correction: How Integer Is Integra®?

A. Bettermann, J. Wit, A. Salomon, 1-1. Graf~ttidt, R. Paus, 1t. Hiibner (Kinderchirurgische Klinik der Humboldt-Universit~it zu Berlin, Charit6, Campus Virchow Klinikum, Berlin, Deutschland) Background: Scarified wounds and keloids after burn injuries especially with functional limitations are sometimes hindering children in their evolution. Common methods of plastic surgery may not allways be successfull, which makes biotechnological methods usefull, though it needs some more expenditure. Tissue engineering will be an important alternative for such scar problems. Methods: Cultivating different types of autologous skin cells is now a good experinced nearly standardized method. As a novum of the cultivating technique we developed the encapsulation of skin cells in micro hollow spheres, to fasten the cell growth and to simplify the operating procedure. Those capsules can be made from different biocompatible matrices and stabilized in deep freezed conditiones for a longer time. These very small Bioreactors are very usefull for the natural supported o ~ a n repair, because cells can organize themself by early interactions and growing mechanisms for becoming next to tissue formationsl Results: After having first successfull experiences with common autologous cell cultivation methods we developed a new cultivation technique until employment maturity but it needs for the out house application the special GMP - production certification. The ethical commitee allowence was reached, first observations were documented. Conclusions: The amelioration of common cell culture techniques can fasten the clinical use of autologous skin cell transplantation and simplify the operating procedure for the indication of bad scars and keloids with functional disorders. This cultivating method opens this kind of cell tranpslantation for other indications like a special tissue engineering facility.

C M. Schiesd, C. A. Gitzebnann, M. Meuli (Burn Center, Department of Surgery, University Children's Hospital, Zurich, Switzerland) Background: Integra artificial skin is composed of a biosynthetic matrix (dermis equivalent) and a silicon sheet (epidermis equivalent). Initially, Integra was used for wound covering following debridement of severe burns. 3 weeks after applying Integra to the wound surface a vascularized neodermis forms which is then covered with a thin split thickness skin graft after removal of the silicon sheet. The objective of this prospective pilot study was to evaluate the use of Integra for corrective surgery on scars. Methods: A total of 8 reconstructive interventions were performed on children who had suffered burns and showed functionally and cosmetically inferior scarring. Integra was applied according to a standard protocol following excision of the substantial scar tissue areas. 3 weeks later, split thickness skin grafts were applied after removal of the silicon sheet. To prevent future scarring, follow-up and rehabilitation was carried out according to our standardized rehabilitation program (physiotherapy, positioning, use of splints, compression and silicon media). Results: Adherence and sufficient vascularization of the Integra was uneventful in 7 cases (87%), whereas Integra had to be reapplied in one case (13%). The latter, initially tailed lntegra implantation, was attributed to increased lymph flow from the excised area on the lateral ankle. Take-rates of the split thickness skin grafts were 95% in 7 patients (87%). In one case (13%) a second skin grafting was necessary following a take of only 50%. During the mean follow-up time of 16 months (5-36 months), the newly formed skin composite showed high functional (elasticity, mechanical tolerance, minimal sensitivity) and cosmetic (texture and colour) results. Conclusions: Integra is suitable for wound covering applied following corrective surgery for scar tissue and results in a skin composite showing high functional and cosmetic results.

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EXPERIMENTAL SURGERY, VARIA A57. Low Level Laser Therapy for Treatment of Paediatric Scalds and Burns A. Fette (Kinderchirurgie Regensburg - Klinik St. Hedwig; Akademisches Lehrkrankenhaus der Universit~it Regensburg, Deutschland) Background: Low intensity laser radiation is supposed to stimulate revascularisation, mitochondria, endorphins, lymphocytes, fibroblasts, macrophages and therefor improves wound healing. Methods: 8 children, age 1 to 6 years, with l-III ° scalds and burns (2 to 10% TBSA) have been treated with commercial low level laser radiation systems (Helbo Laser 250, Lasotronic Med 2000, alpha-Laser). The laser schedules include: wavelength: 654;670 nm, power: 90-250 mW, energy densitiy: 1-2-4/cm2. Non contact, spot and plane application. Results: The first boy with II ° scalds on his left flank and arm showed complete re-epithelisation after the third laser procedure. The left thigh of the second boy (multi organ failure, pseudomonas sepsis, > 25% deep surface burn, mesh graft) was treated only by laser resulting in excellent debridement and wound healing after 3 weeks. None of the microbials could be detected inside the laser treated area. Two girls with scalds mainly in their faces could be treated without any sequelae. Three other children with burned palms and buttocks, repectively, also showed quick re-epithelisation after their laser procedures. Low Level Laser therapy was painless, well accepted by the children and could be performed without anesthesia. Conclusions: Low Level Laser Therapy seems to be a painless and easy application device inducing quick healing/epithelisation and slow down infection rates in thermic lesions leading to a really acceptable cosmetic result.

A59. The Effects of Increased Intrapulmonary Oncotic Pressure Upon Fetal Lung Growth A. Dzakovic, A. Kaviani, R. W. Jennings, J. M. Wilson, D. O. Fauza (Department of Surgery, Children's Hospital, Boston, U.S.A.) Background: Fetal tracheal occlusion doesn't always lead to accelerated lung growth. Reasons for an adverse outcome include decreased lung liquid production late in gestation, fetal stress, and a short window between intervention and postoperative premature labor. This study was aimed at determining whether positive oncotic pressure induced in the fetal lung liquid could safely maximize the effects of tracheal occlusion, enhancing short term lung growth acceleration. Methods: Fetal lambs (n = 21) underwent open surgery late in gestation (mean 125 + 2.7 days, term = 145 days) and were divided in four groups: group I (n = 5) consisted of sham-operated controls; group II (n = 5) underwent simple tracheal occlusion (TO); group III (n = 5) received TO and 60cc of saline injected into the trachea; and group IV (n = 6) underwent TO and intratracheal infusion of 60cc of isosmotic. 6% Dextran 70. All fetuses were delivered near full-term, 14-18 days postoperatively (mean 15.9 __. 1 days). Their lungs were studied by standard morphometric techniques and the basic chemical profile of the lung liquid was analyzed. Statistical analysis was by ANOVA and Bonferroni correction for multiple comparisons, with P values less than 0.01 considered significant. Results: The hmg volume to body weight ratio (LV:BW) was significantly different among groups. LV:BW was higher in group IV than in all other groups, but there was no difference between groups 1I and III, which both were significantly higher than group I. Airspace fraction was not significantly different among groups and