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Alkylation of the Reissert compound 1 by methyl 2-bromomethylbenzoate ( 2) followed by spontaneous intramolecular cyclization affords dibenzo [ a, g]quinolizinone 4 which in turn can be reduced to benzyl ether 5 by LiAlH/NaBH. Debenzylation of 5 by ethanolic HCl furnishes the title compound 6 in improved total yield. [ABSTRACT FROM AUTHOR]

Objective: Comparison of the effectiveness of local anaesthesia (LA) in piglet castration with the combination of scrotal and inguinal application of procaine 2 % and lidocaine 5 % to the intratesticular application of lidocaine 1 % using following parameters: adrenaline (A), noradrenaline (NA), defensive movements and coordinated movement patterns., Material and Methods: In 2 substudies 232 male suckling piglets (3-6 days of age) were randomly allocated to study groups. In groups L5 and group P2 lidocaine 5 % and procaine 2 % was applied inguinally and scrotally, respectively, while piglets of groups H (handling) and K (castration without local anaesthesia) were only fixated as for an injection. In group L1 lidocaine 1 % was injected intratesticularly. After 30 min piglets were were castrated, whereas animals of group H were again only fixated. In substudy 1 (n = 112) blood samples were taken to determine the concentration of catecholamines after castration. During injection and castration defensive movements were judged. In substudy 2 (n = 120) piglets completed a chute to document the individual stress level., Results: Groups H and L1 demonstrated significantly less defensive movements during fixation for injection/injection compared to the other study groups (p ≤ 0.05). After the injection piglets of group P2 had significantly more difficulties in the chute and needed > 50 % more time to complete the course. In all study groups defensive movements during castration were the highest at the moment of severing the spermal cord. Group K obtained the highest possible rating of 8 and differed significantly from the other groups as well as when cutting the skin (p ≤ 0.05). Both the concentration of A and NA significantly rose in all groups. The increase in A and NA was significantly higher in group 2, as well as the increase in NA in group K, both in comparison to the other study groups (p ≤ 0.05)., Conclusion: None of the applied techniques for local anaesthesia achieved a complete elimination of pain during castration of suckling piglets. The behaviour analysis indicated an altogether higher distress for P2. After castration, this injection led to a neuroendocrine pain reaction that was comparable to or higher than that of group K. In both lidocaine groups (L1, L5) the pain reaction after castration tended to be lower. These results provide approaches to apply longer acting LA with a higher analgesic potency in an appropriate dosage and with an appropriate method of application., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Comparison of the effectiveness of local anaesthesia (LA) in piglet castration by procaine 2 % and lidocaine 5 % both through combined inguinal and scrotal application as well as by intratesticular application of lidocaine 1 %. The parameters used were serum cortisol and chromogranin A (CgA) concentrations as well as wound healing, body weight and animal losses., Material and Methods: In 2 substudies, a total of 232 male piglets aged 3-6 days were included. Substudy 1 (112 piglets): Group H: fixation of piglets as for an injection; group L5: inguinal and scrotal injection of lidocaine 5 %; group P2: inguinal and scrotal injection of procaine 2 %; group L1: intratesticular injection of lidocaine 1 %. In all the groups, blood samples were taken 45 minutes before and 30 minutes post-injection (p. i.). Substudy 2 (120 piglets): Group H: handling only as for an injection and castration; group K: handling as for an injection and castration without LA after 30 minutes. Groups L5, P2 and L1: management as in substudy 1 and castration after 30 minutes. Blood samples were taken 75 minutes before as well as 30, 60 and 240 minutes post-castration (p. c.). The evaluated parameters were serum cortisol and CgA concentrations, wound healing, body weight and piglet losses., Results: Substudy 1: The elevation of the cortisol and CgA concentrations in group P2 p. i. were significantly higher than in the other groups. The mean total cortisol concentration of group P2 p. i. was significantly higher than those of the other groups. Substudy 2: At 30 minutes p. c., all the groups displayed a significant increase in the cortisol concentration compared to group H. In group P2, the highest total cortisol concentration was measured 60 minutes p. c. and the elevation of the cortisol level was significantly higher than in the other groups. In group L1, a significantly greater increase in the CgA level was observed at 60 minutes p. c. when compared to the other groups. Regarding wound healing, body weight and losses, there were no significant differences between the groups., Conclusion: The combined inguinal and scrotal injection of procaine 2 % induced a greater neuroendocrine stress response than the inguinal and scrotal injection of lidocaine 5 % and the intratesticular injection of lidocaine 1 %. LA using procaine 2 %, lidocaine 5 % or lidocaine 1 % did not completely eliminate pain during castration. Castration under LA with procaine 2 % induced a greater pain reaction than castration without LA. Both groups castrated with LA using lidocaine (L1, L5) tended to display lower pain responses after castration than group K. On the basis of the findings of this study, other local anaesthetics that have a stronger effect could be further investigated according to their pain-killing effects in an appropriate application route., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Mastopexy in massive weight loss patients is challenging. The breast mound is often unstable and deflated, with a loose inelastic skin envelope. It has become apparent that mammaplasty techniques in these cases should rely more on glandular recontouring rather than on the skin envelope for shaping. Published methods include plication, suspension and autoaugmentation. The residual local tissue (glandular breast tissue, fat tissue, dermoglandular fat flap) is utilised to its full extent in order to reshape a form-stable breast with full upper pole projection. The evolution of a technique is presented., Patients and Methods: In this study we retrospectively analysed 68 massive weight loss patients who underwent an extended Ribeiro technique with a superomedial pedicle mastopexy and suspension by an inferior dermoglandular flap. The current procedure involves incorporating the lateral intercostal artery perforator flap (LICAP flap) and medial breast pillar additionally to the inferior dermoglandular Ribeiro flap. This essentially autoaugments the upper pole by creating an "autoprosthesis", narrows the widened breast, and redefines the inframammary fold. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility and surgical revision rate were obtained., Results: From 01/2011 to 12/2016, we performed 136 autoaugmentation mastopexies. The average age was 41.2 years, average body mass index (BMI) was 27,1 kg/m 2 , average weight loss was 54.3 kg, average sternal notch-NAC distance was 32.3 cm, average operation time was 109 minutes. In 12 breasts, a free-nipple graft was necessary. The complication rate was 5.1 %, surgical revision rate was 17.6 %. 95 % of the patients were "very satisfied" or "satisfied" with the aesthetic result. Nipple sensibility was rated as "very good" or "good" by 85 % of patients., Conclusion: Modification of the Ribeiro technique by using the medial and lateral breast pillar (LICAP flap) allows autoaugmentation of the upper pole. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, with the aim of reducing the incidence of recurrent ptosis. The presented technique is a reproducible and reliable method with a low complication rate., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Reduction mammaplasty in patients with gigantomastia is challenging even to very experienced plastic surgeons. Extremely elongated pedicles impair the vascular supply of the nipple-areola complex. Breast shaping and effective reduction are difficult due to the severely stretched skin envelope. The Ribeiro technique is the standard technique for reduction mammaplasty in our clinic. The aim of this study is to review our approach in patients with gigantomastia in comparison to the current literature., Patients Und Methods: From 01/2009 to 12/2016, we performed 1247 reduction mammaplasties in 760 patients. In 294 reduction mammoplasties (23.6 %), resection weight was more than 1000 g per breast corresponding to the definition of gigantomastia. The Ribeiro technique with a superomedial pedicle and inferior dermoglandular flap for autologous augmentation of the upper pole was implemented as standard procedure. In cases with a sternal notch-nipple distance > 40 cm, free nipple grafting was performed. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical revision rate were obtained and retrospectively analysed., Results: In 174 patients, 294 reduction mammaplasties were performed with a resection weight of more than 1000 g per breast. Average resection weight was 1389.6 g (range, 1000-4580 g). Average age was 43.5 years (range, 18-76 years), average body mass index (BMI) was 29.2 kg/m 2 (range, 19-40 kg/m 2 ), average sternal notch-nipple distance was 34.8 cm (range, 27-52 cm), average operation time was 117 minutes (range, 72-213 minutes). A free nipple graft was necessary in 30 breasts. Overall complication rate was 7.8 %; secondary surgical revision rate was 16 %. 93 % of the patients were "very satisfied" and "satisfied" with the aesthetic result. Nipple sensitivity was rated "very good" and "good" in 88 %., Conclusion: The Ribeiro technique is a well established, versatile standard technique for reduction mammaplasty, which helps to create high-quality reproducible results with longterm formstable shape. In gigantomastia, this procedure is also very effective to achieve volume reduction and aesthetically pleasing results with a low complication rate., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Inherited disorders of platelet function are a heterogeneous group. For optimal prevention and management of bleeding, classification and diagnosis of the underlying defect are highly recommended. An interdisciplinary guideline for a diagnostic approach has been published (AWMF # 086-003 S2K; Hämostaseologie 2014; 34: 201-212). Underlying platelet disorder, platelet count, age and clinical situation modify treatment. Exclusive transfusion of platelet concentrates may be inappropriate as potentially adverse effects can outweigh its benefit. A stepwise and individually adjusted approach for restitution and maintenance of haemostasis is recommended. Administration of antifibrinolytics is generally endorsed, but is of particular use in Quebec disease. Restricted to older children, desmopressin is favourable in storage pool disease and unclassified platelet disorders. Although licensed only for patients with Glanzmann thrombasthenia and alloantibodies, in clinical practice rFVIIa is widely used in inherited platelet disorders with severe bleeding tendency. This guideline aims at presenting the best available advice for the management of patients with inherited platelet function disorders.

Introductions: Gynecomastia is a persistent benign uni- or bilateral enlargement of the male breast ranging from small to excessive findings with marked skin redundancy. In this paper we introduce an algorithm to facilitate the selection of the appropriate surgical technique according to the presented morphological aspects., Patients and Methods: The records of 118 patients (217 breasts) with gynecomastia from 01/2009 to 08/2012 were retrospectively reviewed. The authors conducted three different surgical techniques depending on four severity grades. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and the need to re-operate were observed and related to the employed technique., Results: In 167 (77%) breasts with moderate breast enlargement without skin redundancy (Grade I-IIa by Simon's classification) a subcutaneous semicircular periareolar mastectomy was performed in combination with water-jet assisted liposuction. In 40 (18%) breasts with skin redundancy (Grade IIb) a circumferential mastopexy was performed additionally. An inferior pedicled mammaplasty was used in 10 (5%) severe cases (Grade III). Complication rate was 4.1%. Surgical corrections were necessary in 17 breasts (7.8%). The patient survey revealed a high satisfaction level: 88% of the patients rated the aesthetic results as "very good" or "good", nipple sensitivity was rated as "very good" or "good" by 83%., Conclusion: Surgical treatment of gynecomastia should ensure minimal scarring while respecting the aesthetic unit. The selection of the appropriate surgical method depends on the severity grade, the presence of skin redundancy and the volume of the male breast glandular tissue. The presented algorithm rarely leads to complications, is simple to perform and shows a high satisfaction rate and a preservation of the nipple sensitivity., (© Georg Thieme Verlag KG Stuttgart · New York.)

The oculocardiac reflex (OCR) is a well-known phenomenon in ophthalmic surgery, but is rarely described in aesthetic blepharoplasty surgery. It was first mentioned in 1908 by Ascher and Dagnini. Since then, ophthalmologists and anaesthesiologists have regarded the onset of the oculocardiac reflex as a significant intraoperative problem, which is undermined by several case reports that describe dysrhythmias which have haved caused morbidity and death. Per definition the OCR is caused by ocular manipulation and involves intraoperative bradycardia by a change of 20 beats/minute compared to the preoperative heart rate or any dysrhythmia during the manipulation via a trigeminal-vagal-mediated reflex arc. Having operated on a 48-year-old, healthy woman in our clinic, who underwent a cardiac arrest during the blepharoplasty procedure, followed by a successful resuscitation, we investigated the onset of the OCR in our blepharoplasty patients within the last 3 years. The onset of the OCR was noted in 22 of 110 (20 %) blepharoplasty patients, mainly affecting younger, low-weighted patients operated under local anaesthesia. Awareness and treatment of this potentially life-threatening oculocardiac reflex are necessary. In most cases the onset of the reflex may be avoided by a gentle operation technique and by refraining from severe traction to the muscle or fat pad. The best treatment of a profound bradycardia caused by the OCR is to release tension to the muscle or fat pad in order to permit the heart rate to return to normal. Intraoperative monitoring is of utmost importance.

Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysaesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favoured by insurance companies and bearing of costs for surgical therapy therefore is rejected. Expenses of conservative treatment as well as costs related to appeal and lawsuits against insurance decisions exceed the case-based lump sum of reduction mammaplasty manifold. Conservative treatments do not eliminate the causes of the illness. Therefore the rejection of a medically indicated reduction mammaplasty has to be regarded as unfavourable and economically inefficient.

A 54-year-old female patient was admitted due to a slow growing, painless resistance on the dorsum of the left hand. The intraoperative aspect of the tumor showed a yellow to white doughy tissue mass infiltrating the metacarpal musculature and bone. After immunohistopathological staining, the diagnosis of a Merkel cell carcinoma was confirmed. A high frequency of local recurrences (25 to 77 %) and lymph node metastases (50 %) are characteristic features of Merkel cell carcinoma. In 30 % of the cases, the disease has a fatal outcome. In primary Merkel cell tumors, surgical excision is the basic therapy, although this carcinoma is highly radiosensitive. Thus, besides surgical treatment, radiation should be included into the treatment concept. In the presented case, after radical excision of the tumor and sentinel-lymphnode biopsy, the patient has been free of local recurrence and metastases for 13 months.

Gastroesophageal reflux disease (GERD) has a high prevalence of 40% in Western countries. A dysfunction of the lower esophageal sphincter of unknown origin is the main etiology. Less common pathophysiological reasons are disorders of esophageal motility, delayed gastric emptying, gastric acid hypersecretion and bile reflux. As causal surgical therapy for these disorders fundoplication has been developed 50 years ago. This technique uses a wrap of gastric fundus around the distal esophagus as reflux barrier. Because of severe postoperative complications (dysphagia, gas bloat syndrome, gastric ulcer) and recurrence after fundoplication, medical therapy became the treatment of choice with the development of H2-receptor antagonists and proton pump inhibitors in the 1970s. However, after improvement of surgical technique and introduction of laparoscopic fundoplication in 1991 surgery offers a secure and effective causal therapy. Randomized controlled trials proof the superiority of fundoplication versus medical therapy in regard of long term results, recurrence and cost effectiveness as well as the superiority of laparoscopic versus conventional open fundoplication in regard of recovery and cost effectiveness with equal long term results. Therefore, laparoscopic fundoplication by an experienced laparoscopic surgeon is the surgical therapy of choice. However the high prevalence of GERD requires careful selection of patients for surgery. A thorough preoperative evaluation including upper gastrointestinal endoscopy with biopsy, esophageal manometry and 24 h-pH monitoring as well as upper gastrointestinal contrast study is essential. Today the indication for fundoplication is seen in young symptomatic patients, requiring a long-term medical therapy, in hiatal hernia with threatening complications as well as in complications of severe GERD, especially Barrett-esophagus. At present the advantages of total (Nissen) or partial (Toupet) wrap as well as the benefit of dissection of the short gastric vessels for total fundoplication are still unclear, especially concerning long-term results. To answer these technical questions further randomized controlled trials with long-term follow-up have to be performed.