Chirurg

[Surgical technical guidelines in intestinal ischemia]

Year 1998
Betzler M.
Klinik fur Allgemeine Chirurgie, Unfallchirurgie und Gefasschirurgie, Alfried Krupp von Bohlen und Halbach Krankenhaus, Essen.
Acute occlusive mesenteric ischemia is caused by a local impairment of splanchnic blood flow and poses a particular surgical challenge. Acute superior mesenteric occlusion is a medical/surgical emergency mandating prompt diagnosis (clinical awareness, angiography) and therapy (exploratory laparotomy with possible arterial reconstruction; embolectomy, thrombectomy; and/or bowel resection). The difficulty of early diagnosis is probably the most important cause of the high mortality which varies from 70% to 90% in arterial and functional mesenteric ischemia and from 20% to 70% in an acute thrombosis of the mesenteric veins. Improved survival from nonocclusive mesenteric ischemia is dependent upon the identification of high-risk groups and on aggressive diagnostic and therapeutic measures (intra-arterial infusion of papaverine through the angiographic catheter with or without bowel resection). For assessment of bowel viability, the clinical judgement during first- or second-look exploration is still the most reliable parameter. The surgical management of chronic mesenteric ischemia includes aortomesenteric grafting and transaortic endarterectomy in the majority of patients with comorbidity of cardiovascular arteriosclerotic diseases and results in a high rate of symptom-free patients. Prophylactic reconstruction of visceral arteries is indicated only in certain limited circumstances.

[Vascular surgery within the scope of visceral surgery-oncologic interventions]

Year 1998
Trede M. Rumstadt B. Storz LW.
Chirurgische Klinik, Klinikum Mannheim, Fakultat der Universitat Heidelberg.
The surgeon dealing with oncological operations within the abdominal cavity will be frequently confronted with vascular problems. These include surgically relevant vascular anomalies, arteriosclerotic changes, tumor infiltration of vessels and iatrogenic vascular lesions. The diagnosis, indications and, above all, the vascular surgical techniques applied during oncological procedures on the pancreas and liver are described in this review.

[Ruptured aortic aneurysm as an unexpected finding in laparotomy for acute abdomen]

Year 1998
Schildberg FW. Heiss MM.
Chirurgische Klinik und Poliklinik, Ludwig-Maximilians-Universitat, Klinikum Grosshadern, Munchen.
The ruptured abdominal aortic aneurysm as an incidental finding in emergency laparotomy for acute abdominal symptoms is a rare event. For this reason it is more important to know the necessary diagnostic and therapeutic strategies. Nowadays sonography facilitates the preoperative diagnosis. The performance of an additional computed tomography or angiography depends on the clinical appearance of the patient. In hemodynamically instable patients with a ruptured aneurysm, an immediate laparotomy is mandatory. If intraoperatively the aortic aneurysm has a diameter of more than 5 cm and shows no signs of rupture, implantation of an aortic prosthesis is indicated. This procedure has also priority when patients with a ruptured aneurysm are suffering from an additional abdominal disease. If additional septic reasons are diagnosed intraoperatively, the abdominal operation has to be performed synchronously with the aortic prosthesis. Alternatively, the use of an antimicrobial vascular prosthesis or resection of the aortic aneurysm with extra-anatomic bypass has to be considered. The technical difficulty of the operation is in the control of the proximal aorta. The lethality of operations for ruptured aneurysm has been consisted high (between 21 and 70%) in the past. In an elective operation, mortality has how improved up to 5%. This indicates that the essential prognostic factors, degree of retroperitoneal hematoma and hemorrhagic shock, and the condition of the patient, are not influenced by modern patient management. However, a further dominant prognostic parameter for lethality, how qualified the surgeon is in vascular surgery, can be influential.

[Hemorrhagic pseudocysts and pseudoaneurysms in pancreatitis. Diagnosis and therapy]

Year 1998
Wagner J. Messmer P. Herzog U. Pippert H. Harder F. von Flue M.
Departement fur Chirurgie, Universitatsklinik Basel.
Acute hemorrhage from pseudocysts and pseudoaneurysms is a threatening complication of chronic pancreatitis. Whilst surgical intervention still has high perioperative mortality (16.8%), transcatheter arterial embolization is becoming more frequently used for suitable cases and appears to have lower mortality (6.1%). We report on six patients treated in our unit. Four of them underwent primary surgical treatment, the other two were treated by embolisation. One of the latter patients subsequently required laparotomy for further treatment. All six patients survived. Comparing the literature covering the periods between 1951 and 1981 and between 1982 and 1996, transcatheter embolisation seems to be valuable in controlling this type of bleeding, thereby reducing mortality.

[Postcholecystectomy complaints one year after laparoscopic cholecystectomy. Results of a prospective study of 253 patients]

Year 1998
Peterli R. Merki L. Schuppisser JP. Ackermann C. Herzog U. Tondelli P.
Allgemeinchirurgische Klinik, St. Claraspital Basel.
AIMS: We studied the nature and frequency of symptoms 1 year after laparoscopic cholecystectomy in order to define pre- and perioperative factors that influence the long-term outcome. METHOD: Between September 1994 and August 1995 we prospectively evaluated 268 patients undergoing laparoscopic cholecystectomy using a standard questionnaire. After an average of 16 months (12-25 months) the patients were asked about their symptoms using a similar questionnaire by telephone or were followed up clinically if necessary. RESULTS: In the long-term follow-up the severity of the symptoms according to the Visick score were: Visick I (no symptoms): 164 patients (65%); Visick II: 72 (28%); Visick III: 12 (5%); Visick IV: 5 (2%). The aetiologies of the postcholecystectomy syndrome were: residual stones 1%, subhepatic liquid formation 0.8%, incisional hernia 0.4%, peptic diseases 4%, wound pain 2.4%, functional disorders 26%. Patients with typical or atypical symptoms preoperatively showed no difference in the outcome 1 year after laparoscopic cholecystectomy. Neither did the number and location of laparotomies prior to cholecystectomy or the gallbladder perforation or loss of stones intraoperatively influence the severity of the postcholecystectomy symptoms. CONCLUSIONS: One year after laparoscopic cholecystectomy 93% of the patients have no or only minor abdominal symptoms. Neither the number and location of the laparotomies prior to cholecystectomy nor the loss of gallstones intraoperatively have an impact on the long-term result.

[Cholecystectomy in high risk patients. A comparison between conventional and laparoscopic procedures]

Year 1998
Popken F. Kuchle R. Heintz A. Junginger T.
Klinik fur Allgemein- und Abdominalchirurgie, Universitat Mainz.
Laparoscopic cholecystectomy offers many advantages, but cardiopulmonary impaired patients may be endangered by the haemodynamic and respiratory effects of the pneumoperitoneum. Between June 1990 and December 1995, laparoscopic cholecystectomies were performed on 19 high-risk patients (ASA IV) and conventional cholecystectomies on 26 patients with the same operative risk (ASA IV). Out of 45 patients, 5 (11.1%) suffered intraoperative cardiopulmonal complications. Three belonged to the group with laparoscopic cholecystectomy (15.8%) and two to the group with open laparotomy (7.7%). General postoperative complications occurred in 15 cases (33.3%), whereby patients of the conventional cholecystectomy group were concerned more often [46.2% (n = 12) versus 15.8% (n = 3), P = 0.03]. The number of days spent in hospital after open cholecystectomy was higher (P = 0.01) (11.6 +/- 5.6 days in the laparotomy group versus 7.6 +/- 5.0 days in the laparoscopy group). The classification as a high-risk patient indicates an elevation of the perioperative rate of complications in laparoscopic and open cholecystectomy, whereby the rate of postoperative complications is lower in the laparoscopic group.

[Simplified appendectomy without stump embedding. Experiences of 20 years conventional and 5 years laparoscopic application]

Year 1998
Houben F. Willmen HR.
Chirurgische Klinik, Kreiskrankenhauses Grevenbroich.
Since 1975, the Department of Surgery in the Grevenbroich Community Hospital (Germany) has applied a simplified technique of open appendectomy. The inhouse modified procedure without stump embedding has been performed in 3,448 cases to date. The same approach has been used in 1,463 laparoscopic appendectomies since 1991. In the laparoscopic procedure the stump is ligated solely with Roeder's loop. None of the 4,911 patients who have undergone either open or laparoscopic appendectomy have developed stump inadequacy or stercoral fistulae. According to the special literature, the complication rate after appendectomies without stump embedding is lower than that after standard procedures. In retrospect, laparoscopic appendectomy with simple ligation has confirmed the results achieved with simple ligation in open appendectomies. The technique should therefore become more common practice in open appendectomies, as well.

[Carbohydrate-deficient transferrin (CDT) as preoperative alcohol marker in surgical risk patients]

Year 1998
Schroder W. Vogelsang H. Bartels H. Luppa P. Busch R. Holscher AH.
Klinik und Poliklinik fur Visceral- und Gefasschirurgie, Universitat zu Koln.
In a prospective study the preoperative risk of alcohol addiction was evaluated in 46 patients with squamous cell carcinoma of the esophagus. In all patients the alcohol marker carbohydrate-deficient transferrin (CDT) was measured prior to esophagectomy and correlated with the incidence of postoperative withdrawal symptoms (yes/no) and the postoperative course (good/moderate/poor/fatal). Withdrawal symptoms were more frequently observed in cases of elevated CDT values (median of CDT with withdrawal 17.0 U/l vs without withdrawal 10.7 U/l; P = 0.0006). CDT values were significantly increased in case of a complicated postoperative course (median of CDT for moderate/poor/fatal postoperative course 14.0 U/l vs good course 10.8 U/l; P = 0.02). The CDT value correlated (P = 0.04) with the patient's history of preoperative alcohol consumption (normal/increased/high). In a multivariate logistic regression analysis CDT and preoperative alcohol consumption were independent parameters to predict significantly the postoperative course and withdrawal. The sensitivity was 71.4% and the specificity 84.4% selecting the parameter "postoperative withdrawal" and a CDT cut-off point of < 15.3 U/l. CDT can effectively identify patients with high alcohol consumption prior to esophagectomy.

[Renal angiomyolipoma as a rare cause of retroperitoneal hemorrhage]

Year 1998
Gawenda M. Erasmi H. Lorenzen J. Ernst S.
Klinik und Poliklinik fur Visceral- und Gefasschirurgie, Universitat zu Koln.
Angiomyolipomas are hamartomas that may be found sporadically or associated with tuberous sclerosis (M. Bourneville-Pringle). Clinically, this long-term asymptomatic tumor becomes evident as an acute retroperitoneal hemorrhage or by symptoms of a flank mass. Due to the high percentage of fat components in this tumor type, computed tomography is far superior to other radiological procedures. In view of two of our own case reports, the therapeutic strategies are discussed, paying regard to the actual literature in this field.

[Indications for antireflux surgery of the esophagus]

Year 1998
Stein HJ. Feussner H. Siewert JR.
Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universitat Munchen.
In the Western world gastroesophageal reflux disease constitutes the single most common benign disorder of the upper gastrointestinal tract. Current medical therapy with proton pump inhibitors allows physicians to provide complete symptom relief and healing of acute esophageal mucosal injury in practically all affected patients. However, up to 50% of patients require maintenance therapy to prevent relapse. In these patients laparoscopic antireflux surgery offers an attractive and cost-effective alternative to potentially life-long medical therapy. Consequently, every patient with persistent or recurrent symptoms and/or complications of gastroesophageal reflux who depends on maintenance medical therapy to remain in remission is a potential candidate for laparoscopic antireflux surgery, particularly if of young age, suffering from side effects of medical therapy or worrying about long-term safety of the conservative treatment alternatives. A careful selection of patients, objective documentation of gastroesophageal reflux disease by 24-h esophageal pH monitoring, and meticulous attention to the technical details of the procedure are essential for a successful outcome of antireflux surgery.

[Open antireflux surgery]

Year 1998
Oertli D. Harder F.
Departement Chirurgie, Allgemeinchirurgische Klinik, Universitat Basel.
In over 80% of patients with gastroesophageal reflux disease, the Nissen antireflux fundoplication gives good long-term results. Dysphagia, inability to belch or vomit as well as the gas bloat syndrome are possible sequelae after fundoplication. The frequency of these symptoms could be reduced by modification of the original Nissen-Rossetti fundoplication into the so-called "floppy" Nissen fundoplication, a short and loose wrap of mobilized gastric fundus. Failures of the antireflux procedure are mainly due to disruption or displacement of the wrap with the telescope phenomenon. Here, reoperation with refashioning of the original wrap may lead to same functional results like a primary fundoplication. Technical alternatives may selectively be chosen, when gastroesophageal reflux disease is complicated by fixated hiatal hernia, esophageal shortening, or serious esophageal motility disorders. Such specific anatomic or functional abnormalities are detected by preoperative endoscopy, barium swallow, 24-h pH monitoring, and manometry. Alternative techniques are mainly transthoracic repairs, including the Nissen fundoplication, Collis gastroplasty, and the Belsey Mark IV. Modifications of the 360 degrees Nissen operation are partial fundoplications like the Hill repair and the Toupet dorsal fundoplication. Because of a high failure rate in the long-term follow-up, application of the ligamentum teres cardiopexy and of the Angelchik prosthesis is not recommended.

[Laparoscopic antireflux procedures]

Year 1998
Klingler PJ. Hinder RA. Smith SL. Branton SA. Floch NR. Seelig MH.
Department of Surgery, Mayo Clinic Jacksonville, USA.
Laparoscopic antireflux surgery is rapidly replacing traditional operations for the treatment of medically refractory gastroesophageal reflux disease. These procedures are technically demanding. Troublesome side effects can be minimized by carefully selecting patients and using a meticulous and appropriate technique. Extensive follow-up data are now emerging and indicate that these procedures can offer long-term control of symptoms with few permanent side effects.

[Endoscopic intraluminal valvuloplasty--a therapy of the future for gastroesophageal reflux]

Year 1998
DeMeester TR. Mason RJ. Filipi CJ.
Department of Surgery, University of Southern California, Los Angeles, CA, USA.
A new endoscopic intraluminal valvuloplasty is described. The procedure provides a simple, easy out-patient approach for antireflux surgery and is applicable to patients with early gastroesophageal reflux disease as an alternative to chronic life-long medical therapy. The feasibility, durability and efficacy of the procedure in baboons are reported.

[Can internal intestinal splinting prevent ileus recurrence? Results of a retrospective comparative study]

Year 1998
Mais J. Eigler FW.
Klinik fur Allgemeine Chirurgie, Universitatsklinikums Essen.
The high rate of recurrence after the treatment of adhesive obstruction demands special prophylactic treatment. In a 13-year period, 52 out of 95 patients with major adhesions were provided with a long nasointestinal tube for intestinal splinting intraoperatively. The was being left in situ on an average of 6.6 days. After an observation period of at least 36 months a recurrence was seen in 2 of these 52 patients (3.9%; causes: volvulus after 6 months/fibrinous peritonitis on the 6th postoperative day). Amongst the 43 'non-splinted' patients, recurrence of adhesive obstruction was documented in 8 cases (18.6%; causes: adhesions after 0.3-136.9 months). In the course of after-care abdominal complaints were significantly fewer in patients who had been splinted. Complications concerning the nasointestinal tubes did not occur. The rate of perioperative complications was similar in both groups.

[Diverticulitis of the cecum and ascending colon]

Year 1998
Fluckiger R. Styger S. Huber A.
Chirurgische Klinik, Kantonsspital Bruderholz.
Right colon diverticulitis, representing 1-3.6% of cases of diverticular disease is an uncommon cause of right lower quadrant pain. Its presentation is difficult to distinguish from acute appendicitis. Patients are between 35 and 50 years old, have a history of 2-3 days of abdominal pain and few gastrointestinal symptoms. The diagnosis is best confirmed by computed tomography and colonoscopy. Conservative treatment is justified in uncomplicated disease, whereas perforations, abcesses and inflammatory tumors require resection. We describe the cases of six patients treated at our institution from 1991 to 1996. Presentation, geographic variations, diagnostic procedures and management are discussed.

[Country-wide survey of therapeutic procedures in hemorrhoids and anal fissure]

Year 1998
Kraemer M. Bussen D. Leppert R. Sailer M. Fuchs KH. Thiede A.
Chirurgische Universitatsklinik, Julius-Maximilians-Universitat Wurzburg.
A survey among coloproctologists was performed to assess current therapeutic concepts for the treatment of hemorrhoidal disease and anal fissure. A total of 261 clinical and non-clinical proctologists participated, representing the entire range of therapies in hospital and practise. A wealth of widely differing, in some aspects contradictory concepts were recorded, leaving almost no subject entirely undisputed. There are controversies regarding the different therapeutic alternatives as well as indications for surgery and choice of operative procedure. Future research has to address the existing controversies in order to reach a higher degree of standardization in the therapy of these common proctological disorders.

[Multimodal therapy of tumors of the upper gastrointestinal tract]

Year 1998
Fink U. Stein HJ. Siewert JR.
Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technischen Universitat Munchen.
Adjuvant and neoadjuvant therapeutic principles have in recent years received increasing attention in the management of patients with carcinoma of the upper gastrointestinal tract. A series of randomized prospective trials has demonstrated that adjuvant postoperative radiation or chemotherapy does not result in a convincing survival advantage after complete tumor resection in gastric or esophageal cancer. The available data on the role of neoadjuvant preoperative therapy in these patients as yet permit no conclusion. While neoadjuvant therapy may reduce the tumor mass in a substantial portion of patients, a series of randomized controlled trials has shown that, compared to primary resection, a multimodal approach does not result in a survival benefit in patients with loco-regional, i.e. potentially resectable, tumors. In contrast, in patients with locally advanced tumors, i.e. tumors for which complete removal with primary surgery appears unlikely, neoadjuvant therapy increases the chance for complete tumor resection on subsequent surgery. However, only patients with objective histopathologic response to preoperative therapy appear to benefit from this approach. Compared to preoperative chemotherapy alone, combined radio-chemotherapy increases the rate of response, particularly in squamous cell esophageal cancer, but may also increase postoperative morbidity and mortality. Neoadjuvant therapy should therefore currently only be performed in experienced centers within the context of prospective clinical trials. The identification of factors that would allow prediction of response to neoadjuvant or adjuvant therapy is the focus of ongoing studies.

[Combination therapy in oncology--hepatocellular carcinoma]

Year 1998
Bismuth H. Fecteau A.
Hepato-Biliary Surgery and Liver Transplant Research Center, Hopital Paul Brousse, Villejuif.
Hepatocellular carcinoma (HCC) is being diagnosed with increasing frequency in the Western world as a consequence of the hepatitis C epidemia. Multimodal therapy is now the only effective treatment option to offer a chance of complete tumor control in HCC. Liver transplantation and liver resection, including the selection criteria and patient evaluation, are discussed. The benefits and complications of transarterial chemoembolization and cryotherapy are also reviewed. Liver transplantation is now thought to offer the best treatment option in early HCC and should be regarded as the first line of treatment in selected patients.

[Combination therapy in oncology (multimodal treatment) in pancreatic tumors]

Year 1998
Ihse I. Andersson R. Axelson J. Hansson L.
Department of Surgery, Lund University, Sweden.
The majority of patients with pancreatic cancer have systemic disease already at diagnosis, and nearly all patients will develop recurrence following radical resection. Thus, surgical treatment alone is insufficient. The paper focuses on adjuvant multimodal treatment and reviews the current status of pre- and postoperative chemoradiation, intraoperative radiotherapy (IORT), adjuvant chemotherapy, and regional infusion therapy. Studies in this area are hampered by often being non-randomized and with too few patients included. Overall there presently is no adjuvant multimodal treatment which can be suggested for routine use. However, two ongoing prospective randomized studies (ESPAC-1 and an EORTC study) will have enough statistical power to give reliable information on the topic. It is hoped that these and other studies will form the basis for further proper clinical trials on multimodal treatment in pancreatic cancer with the aim at long last to improve the extremely poor survival in these patients.

[Multimodal therapy of colon carcinoma]

Year 1998
Lehnert T. Herfarth C.
Sektion Chirurgische Onkologie, Universitat Heidelberg.
A large variety of immunological and cytotoxic adjuvant treatment concepts and application routes have been observed to be effective in colon cancer by randomized trials during the past three decades. Presently adjuvant 5-fluorouracil based chemotherapy is favoured for patients with lymph node metastases (UICC stage III), since this treatment was associated with a 5-10% increase in 5-year survival. Uncertainty persists regarding the optimal use of adjuvant treatment, since marked differences in prognosis have been recognized within stage III and because the impact of surgical treatment on long-term survival has not been thoroughly controlled for in past trials. Current and future studies will have to determine precisely which patients will benefit most from adjuvant treatment and which combination of surgical and adjuvant treatment will be most effective.

[Multimodal therapy of rectal carcinoma]

Year 1998
Lehnert T. Herfarth C.
Sektion Chirurgische Onkologie, Universitat Heidelberg.
Multimodal therapy for rectal carcinoma is--in contrast to colon cancer--largely based on adjuvant or neoadjuvant radiotherapy. Although radiotherapy reduces local recurrence rates, overall survival is hardly improved, while on the other hand specific complications of radiotherapy are recognized. Extended neoadjuvant treatment concepts including chemotherapy may improve long-term outcome, but to date this has not been demonstrated conclusively by randomized trials. New developments include intraoperative radiotherapy and the combination of hyperthermia with radiochemotherapy. Initial results from randomized studies are promising, but require confirmation by larger trials. At the same time the importance of optimal surgical treatment has been recognized as a prerequisite for favourable long-term results. Since this aspect has not received due attention in past protocols the optimal combination of surgery with other modalities and their time sequence cannot be determined presently.

[Conversion of experimental research findings to treatment of acute pancreatitis]

Year 1998
Foitzik T. Klar E. Buhr HJ.
Chirurgische Klinik, Freie Universitat Berlin.
Performing prospective, randomized controlled studies in patients with severe acute pancreatitis is limited due to low disease incidence and organizational and financial problems. Thus, animal models simulating the clinical condition have been developed for testing innovative therapeutic procedures. Despite objections regarding the applicability of data obtained from animal experiments to clinical practice, the experience gained from these studies could not only be used in clinical study proposals but also, in part, directly influenced the clinical management of acute pancreatitis. This is illustrated by studies regarding the influence of contrast medium, isovolemic hemodilution and various antibiotics.

[Effect of the surgeon on treatment quality in acute appendicitis]

Year 1998
Junginger T. Kuchle R.
Klinik und Poliklinik fur Allgemein- und Abdominalchirurgie, Johannes Gutenberg-Universitat Mainz.
The quality of the surgical therapy in cases of acute appendicitis is influenced by the rate of perforating appendicitis, the rate of bland appendicitis and the perioperative morbidity. During a prospective follow-up 271 patients were treated at our department between 1 April 1993 and 30 July 1996. The rate of perforating appendicitis was 3.7%, and that of bland appendicitis was 19.6%. The rate of perforating appendicitis did not differ significantly according surgeon, who decided to operate. However, the number of patients with bland appendicitis did differ significantly among different operators. There were also significant differences in the rate of wound infections. No correlation was found between the rates of perforating and bland appendicitis was not found. In summary the operator affects the quality of the surgical treatment in cases of suspected appendicitis by differences in the timing and performance of the surgical procedure.

[Hydrosonography as an alternative or supplement to endosonography in stomach carcinoma]

Year 1998
Kuntz C. Dux M. Pollock A. Buhl K. Herfarth C.
Chirurgische Universitatsklinik, Heidelberg.
Transabdominal ultrasound in the hydrotechnique (hydrosonography) was compared with endosonography for the locoregional staging of gastric cancer. For this purpose 52 consecutive patients were examined by endosonography (7.5 and 12 MHz) and hydrosonography (3.75 MHz). Forty-nine of the 52 tumors could be examined by endosonography and 41 by hydrosonography. The T-staging accuracy rate of endosonography was 74% and 46% for hydrosonography. Carcinoma of the cardia are often classified as uT3 and hT3 preoperatively and pT2 postoperatively due to infiltration of the subserosal fat. The N-staging accuracy rate of endosonography was 86% and 61% for hydrosonography. Based on these results, transabdominal ultrasound in the hydrotechnique (hydrosonography) cannot replace endosonography in gastric cancer staging. However, when performed in conjunction with conventional ultrasound, hydrosonography provides useful information about the local tumor stage, especially in cases of advanced and stenotic tumors.

[Prognostic factors in perforating diverticulitis of the large intestine]

Year 1998
Hansen O. Graupe F. Stock W.
Abteilung fur Chirurgie, Marien-Hospital Dusseldorf.
Morbidity and mortality after emergency procedures in 105 patients with perforated colonic diverticulitis were evaluated in a retrospective study. In different stages of diverticulitis (Hinchey classification: I, 8.6%; II, 14.3%; III, 57.1%; IV, 20.0%) mortality was 12.4%. Preoperative sepsis syndrome with leucopenia and disturbed liver function, cardiac risk factors and obesity were independent prognostic factors in multiple logistic regression. Accompanied by immunosuppression the mortality rate remarkably increased to 33%. The stage of peritonitis showed no influence on the prognosis. In multivariate analysis, surgical procedure (primary resection 12.4%. Hartmann's procedure 61.9%, non-resection procedures 25.7%) showed influence only on increased general complications.

[Evacuation defecography and defecoflometry in diagnosis of chronic constipation. A prospective comparative study of 49 patients]

Year 1998
Ommer A. Kohler A. Athanasiadis S.
Abteilung fur Coloproktologie, St. Joseph-Hospital Laar, Duisburg.
Chronic constipation can be divided in two large groups: slow-transit constipation, caused by pathological intestinal transit, and obstructive defecation disorder, caused by pelvic and rectal wall abnormalities. Videodefecography and defecoflowmetry are methods used to study dynamic evacuation of the rectum. Videodefecography also enables visual estimation of rectal evacuation. Defecoflowmetry allows analysis of anal and rectal pressures. Within this prospective study we utilized and compared these methods in 19 patients with slow transit and 30 patients with obstructive disease. In patients with slow transit, both investigations demonstrated a significantly higher defecation rate than in obstructive defecation disorder (slow transit: defecoflowmetry 65%, videodefecography 80%; obstructive defecation disorder: 50% and 58%). The evacuation time was pathologically prolonged in both types of constipation, with a range of 43-55 s. Rectoceles are demonstrated in 94% of cases with slow transit and in 72% with obstructive defecation disorder. Also, we often found obstructive components in slow-transit constipation patients. Normal defecography or defecoflowmetry can rule out obstructive defecation disorder. We conclude that videodefecography and defecoflowmetry are important items in the complex diagnostic regimen needed in evaluation of chronic constipation.

[Laparoscopic 2/3 resection of the stomach with intracorporal Roux-en-Y anastomosis]

Year 1998
Zornig C. Emmermann A. Blochle C. Jackle S.
Abteilung fur Allgemeinchirurgie, Universitatskrankenhaus Eppendorf, Hamburg.
In a patient with recurrent ulcer disease under medication, which was complicated by episodes of bleeding, a laparoscopic partial gastric resection with intracorporal Roux-en-Y anastomosis was performed. The operation was completed within 3 h with blood loss < 10 ml. The postoperative hospital stay of 6 days was uncomplicated as was the further follow-up (2 months so far). This operation and the study of results published in the literature showed us that a gastric resection can certainly be performed laparoscopically in the appropriate patient.

[Inflammatory esophageal stenosis with intramural pseudodiverticulosis of the esophagus]

Year 1998
Sachs M. Lorenz M. Encke A.
Klinik fur Allgemein- und Gefasschirurgie, Johann Wolfgang Goethe-Universitat Frankfurt am Main.
Esophageal intramural pseudodiverticulosis is a very rare disease with unknown etiology, which especially affects male patients between 45 and 65 years. This disease is characterized by dilatation of the esophageal submucosal glands and their outlets. Stenosis caused by esophagitis due to intramural pseudodiverticulosis is found in most of the known patients. All patients presented with dysphagia, usually of long duration. The characteristic radiographic appearance is numerous intramural esophageal contrast-filled diverticulosis-like pouches--4 mm in depth.

[Perforation into the heart--a rare complication of stomach ulcer in hiatal hernia]

Year 1998
Riepe G. Braun S. Swoboda L.
Abteilung fur Allgemein-, Gefass- und Thoraxchirurgie, Allgemeines Krankenhaus Harburg, Hamburg.
Perforation into the heart is a rare ulcer complication in a hiatal hernia. Because of the massive bleeding, medical help is often in vain. The case of a 73-year-old patient reported by our department confirms this. Endoscopic treatment was not possible because of the extraordinary amount of blood in the stomach, and the high intraoperative blood loss was lethal. If gastric ulcers occur in upper regions of the stomach, the possibility of the presence of an paraesophageal hernia and elective surgical treatment must be considered.

[Unusual coincidence of partially active endocrine tumors]

Year 1998
Seeber CT. Walgenbach S. Dienes HP. Junginger T.
Klinik und Poliklinik fur Allgemein- und Abdominalchirurgie, Johannes Gutenberg-Universitat Mainz.
We report on a female patient who developed five different tumors between the age of 53 and 62 years. The following tumors were diagnosed, three of which showed endocrine activity: uterine myoma; hemangiopericytoma of the meninges; pleural mesothelioma; preperitoneal leiomyoma; medullary carcinoma of the thyroid (sporadic form) in a hyperthyroid goiter. Coexistence of hyperthyroidism and medullary carcinoma of the thyroid is rare. Paraneoplastically induced hypoglycemia--in this patient induced by the pleural mesothelioma and less by the preperitoneal leiomyoma--is of similarly infrequent occurrence. Tumors of epithelial or mesenchymal origin may cause hypoglycemia as a result of peptide secretion, exerting an insulin-like effect. The detection of IGF-I and IGF-II in the serum confirms the diagnosis. Insulinoma can be differentiated by the absence of hyperinsulinemia.

[Helicobacter 98--epidemiology and significance in carcinogenesis]

Year 1998
Stolte M. Meining A.
Institut fur Pathologie, Klinikum Bayreuth.
Gastritis caused by infection with Helicobacter pylori is one of the most common infectious diseases worldwide. There are data on the epidemiology, pathophysiology and histology of this disease that show that Helicobacter pylori gastritis plays an important role in gastric carcinogenesis. However, we must remember that only a very few among those infected with Helicobacter pylori will develop gastric cancer. Hence, one of the main targets of future research will be to identify individuals who carry a greater risk for developing gastric cancer and may therefore benefit from eradication of Helicobacter pylori in terms of gastric cancer prevention.

[Helicobacter pylori infection and ulcer]

Year 1998
Malfertheiner P. Blum AL.
Klinik fur Gastroenterologie, Hepatologie und Infektiologie, Otto-von-Guericke-Universitat Magdeburg.
Our understanding of ulcer pathogenesis has dramatically changed since the discovery of Heliobacter pylori. Peptic ulcer is now recognized as a chronic gastric infectious disease. H. pylori can be considered the pacemaker, with other known risk factors ultimately contributing to the ulcer formation. Treatment of H. pylori in peptic ulcer disease cures the acute lesion and prevents relapse and complications. In clinical management a positive diagnosis of H. pylori is required and other potential causes for ulcer formation must be excluded before starting treatment. The standard treatment in H. pylori positive ulcer consists of PPI in standard dose and two antibiotics either clarithromycin 2 x 500 mg and amoxycillin 2 x 1 g or metronidazole 2 x 400 mg and clarithromycin 2 x 250 mg (or 500 mg) for 7 days. The simultaneous presence of H. pylori and NSAID intake requires distinct management. Following bleeding complication a PPI needs to be given beyond 7 days until ulcer healing is endoscopically confirmed.

[Helicobacter and lymphoma]

Year 1998
Fischbach W.
II. Medizinische Klinik, Klinikum Aschaffenburg.
The gastrointestinal tract represents the most common extranodal site of malignant non-Hodgkin's lymphoma. Epidemiological, histomorphological, molecular biological and experimental animal studies undoubtedly underline the important role of Helicobacter pylori for the development and progression of primary gastric lymphoma of MALT (mucosa-associated lymphoid tissue). Eradication of Helicobacter pylori is an important therapeutic option in low-grade gastric, MALT lymphoma of localized stage E I.

[Early stomach carcinoma--pathologic-anatomic findings and prognosis]

Year 1998
Bosing N. Verreet PR. Ohmann C. Roher HD.
Klinik fur Allgemein- und Unfallchirurgie, Heinrich-Heine-Universitat, Dusseldorf.
BACKGROUND: The therapy for early gastric cancer (endoscopy, gastric resection, D1/2 dissection) is controversial. MATERIALS AND METHODS: In a retrospective study (4/86-12/95) we analyzed the prognosis of 57 early gastric cancer patients with respect to pathological findings and surgical therapy. RESULTS: The R0 resection rate was 100%. In 7% multifocal tumor growth was seen. The 5-year survival rate was 70%. LN-metastases were found in 12% of all cases, more often in pT1b than in pT1 a tumors (17 vs 9%) and more often in large carcinomas than in small carcinomas (> 1000 mm2: 27%; < 300 mm2: 0%). Long-term survival was significantly better in pN0 patients than in patients with LN metastasis (P = 0.020). CONCLUSION: Prognosis of early gastric cancer after curative resection is good.

[Clinical and imaging aspects of gallstone ileus. Experiences with 108 individual observations]

Year 1998
Freitag M. Elsner I. Gunl U. Albert W. Ludwig K.
Klinik fur Allgemein- und Abdominalchirurgie, Krankenhaus Dresden-Friedrichstadt.
Cases of gallstone ileus (108) were analyzed retrospectively over 30 years. Even today, when laparoscopic cholecystectomy is done, the incidence of this rare disease remains the same. History, clinical and X-ray findings are non-specific. Aerobilia was seen in 17% of the patients. Since 1992 sonography has provided an exact diagnosis in 10 of 15 cases. In the triad of known gallstone, non-specific epigastric pain with assumed small intestinal obstruction, and impossible detection of a stone in the gallbladder, there is strong suspicion of a gallstone ileus. The evidence is given if the gallstone is seen in the bowels. Intraoperatively more than one stone was found in the intestines in 20%, and cholecystoduodenal fistulas were encountered in 83%. Other fistulas are rare. There has been no significant change in mortality for 30 years.

[Ultrasound criteria of gallstone ileus]

Year 1998
Manner M. Stickel W.
Chirurgische Abteilung, Kreiskrankenhaus Calw.
During a 4-year period we treated four patients with gallstone ileus by enterotomy and extraction of the impacted concrement. Diagnosis was quickly established by abdominal ultrasound examination in all cases. Lacking visibility of the gallbladder in the clinical setting of ileus and subileus proved to be a sonographic clue of gallstone ileus and prompted a thorough search for the obturating gallstone which could definitely be demonstrated as an intraluminal semicircular reflex with strong echos and a sonic shadow in all patients. Thus, due to early diagnosis and timely surgical intervention, even in the absence of full-blown ileus, all of our elderly patients and those with a multitude of diseases still had a favorable outcome.

[Primary non-Hodgkin lymphoma of the pancreas]

Year 1998
Hamm M. Rottger P. Fiedler C.
Klinik fur Allgemein-, Viszeral- und Gefasschirurgie, Krankenhaus Duren, Akademisches Lehrkrankenhaus der RWTH Aachen.
A 71-year-old patient had been suffering from pain-free obstructive jaundice for 8 weeks. Ultrasonography and computed tomography revealed an inhomogeneous mass (diameter 7 x 6 cm) in the head of the pancreas. In combination with a CA 19-9 of 329 U/l, the findings were highly suggestive of a pancreatic carcinoma. Endoscopic implantation of a pigtail drain into the dilated choledochal duct was performed. A partial duodenopancreatectomy (Whipple's procedure) became necessary because of continuous bleeding with hemodynamic disorders after endoscopic papillotomy. In the histopathological examination a low-grade malignant non-Hodgkin lymphoma of the pancreas (follicular centroblastic-centrocytic) was diagnosed. The differential diagnosis of primary pancreatic lymphoma from pancreatic carcinoma is usually impossible. Neither clinical nor laboratory nor imaging methods indicate to the correct diagnosis. In cases of relatively large pancreatic tumor masses and impression of the pancreatic duct without infiltration, a primary pancreatic lymphoma should be considered and a histological diagnosis by biopsy should be performed.