Zentralbl Chir

[Risk factors and pathogenic microorganisms in patients with insufficient esophagojejunostomy after gastrectomy]

Year 1998
Schardey HM. Kramling HJ. Cramer C. Kusenack U. Hadersbeck J. Schildberg FW.
Chirurgische Klinik, Klinikum Grosshadern der Ludwig-Maximilians-Universitat Munchen.
It was the aim of the study to find by retrospective analysis of data from totally gastrectomized patients risk factors for the development of esophago-jejunal anastomotic leakage, that may be avoidable or influenced therapeutically. PATIENTS AND METHODS: The study design was retrospective involving 838 patients with total gastrectomy for gastric cancer from the years 1973-1993. In 134 cases leakage of the esophago-jejunostomy occurred. The relative risk for the development of leakage associated with individual parameters was determined by comparing the data from 704 patients without leakage to the data from 134 patients presenting with this complication. For a subgroup of 86 patients with anastomotic leakage microbiological data of swabs taken from the anastomoses were available, which were evaluated with respect to potentially pathogenic bacilli. RESULTS: The overall leakage rate of esophago-jejunal anastomoses was 15.9% (n = 134). The mortality rate during this time period amounted to 14.3%. Leakage was a most highly significant factor for mortality (p = 0.0001). Significant risk factors for leakage of the esophago-jejunostomy were tumors of the cardia, splenectomy, a duration of operating time of more than 5 hours and manual suture technique compared to stapler anastomoses. Tumor unrelated associated disease, tumor stage and a history of other preexisting gastric diseases were not associated with an increased relative risk. At the time of the initial clinical manifestation of leakage the following pathogenic bacilli could be isolated from leaking anastomoses with decreasing incidence: E. coli, S. aureus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae a.o. The bacterial spectrum has not changed during the observation period of 20 years. SUMMARY: With the exception of the choice of suture techniques the identified clinical risk factors cannot be avoided or influenced therapeutically due to a lack of potentially curative treatment alternatives. In contrast potentially pathogenic bacilli associated with leakage can be prevented from coming in contact with anastomoses thereby preventing infection and leakage.

[Surgical therapy of non-Hodgkin lymphoma of the stomach]

Year 1998
Zippel K. Agnes A. Zieren HU.
Klinik und Poliklinik fur Chirurgie, Medizinischen Fakultat der Humboldt-Universitat Berlin.
The value of surgical treatment is less well defined in gastric lymphoma than in gastric carcinoma. Therefore, we analysed the outcome of 245 patients with gastric malignancies, which were treated from 1.1.1988 to 31.12.1995 in the Department of Surgery/Charite. Twenty patients suffered from a non-Hodgkin-lymphoma and only 14 (8%) were diagnosed correctly by preoperative endoscopical biopsy. Seven patients with limited lymphoma underwent primary surgical therapy (total gastrectomy n = 4, subtotal gastrectomy n = 3). Seven patients with disseminated lymphoma (stage EIII-IV) were treated by neoadjuvant chemotherapy (CHOP), that was followed by gastrectomy (R0: n = 2, R1: n = 4) or explorative laparotomy (n = 1). Five patients (25%) were diagnosed as undifferentiated carcinoma and underwent total gastrectomy with D2-lymphadenectomy (R0: n = 5). One patient (5%) underwent emergency surgery due to gastric perforation. One patient (5%) died in hospital due to insufficient anastomosis after total gastrectomy and preoperative chemotherapy. Nine patients with high-grade malignant lymphomas received postoperative chemotherapy. The 1-, 2,- and 5-year-survival-rate was 95%, 89% and 44%. Although, many questions are still open, surgical therapy remains an important option in the multimodal treatment of gastric lymphoma.

[Microcystic adenoma of the pancreas--a case report]

Year 1998
Freitag M. Schonlebe J. Pollack T. Ludwig K.
Klinik fur Allgemein- und Abdominalchirurgie, Krankenhauses Dresden-Friedrichstadt-Stadtisches Klinikum Dresden.
A 65-year-old female patient with microcystic adenoma of the pancreatic head is reported. Under suspicion of a malignant pancreatic tumour a kephalic duodenopancreatectomy (Kausch-Whipple) was performed. Diagnosis, therapy, prognosis and pathological anatomical aspects of benign microcystic adenoma are discussed.

[As lumbago treated, delayed diagnosis of large intestine perforation with extremely severe peritonitis--case report with focus on the value of diagnostic laparoscopy]

Year 1998
Hofmann GO. Nikutta M. Brauns L. Sassen C. Buhren V.
Berufsgenossenschaftliche Unfallklinik, Murnau.
We report on a colon perforation with peritonitis which remained clinically undetected until the 4th day post trauma although the patient suffered from lumbalgia-like symptoms. He then developed an acute abdomen with sudden onset, being caused by a sigmoidal rupture and a consecutive diffuse peritonitis. A colon resection was performed according to the Hartmann procedure. Almost 36 revisions were necessary due to necrosis and perforation. Having treated the peritonitis successfully it was possible to close the abdomen and to remove the stomata. The case is discussed in relation to standard diagnostic procedures while a special interest is focused on the usage of sonography, explorative laparoscopy and laparotomy. We finally introduce the algorithm being applied to similar cases at our trauma center.

[Diagnosis of liver tumors--what is necessary for therapy planning?]

Year 1998
Hinterthaner M. Muller A. Ulrich A. Decker P. Hirner A. Layer G.
Klinik und Poliklinik fur Chirurgie, Rheinischen Friedrich-Wilhelms-Universitat Bonn.
For the surgical treatment of liver tumors, two initial steps are necessary: functional operability must be proven and oncological and local inoperability must be ruled out. The diagnostic process consists of a series of steps, beginning with non-invasive procedures such as laboratory findings and sonography, continuing with CT, CTAP, laparoscopy in the case of hepatic cirrhosis, up to explorative laparotomy. The potential operability is re-checked after each step. Punction, MRI and scintigraphy are implemented in special cases. The early implementation of MRI is of particular value for the diagnosis of certain benign processes.

[Diagnosis of liver tumors--when is scintigraphy of value?]

Year 1998
Gratz KF. Weimann A.
Abteilung Nuklearmedizin und spezielle Biophysik, Medizinische Hochschule Hannover.
This paper illustrates the importance of utilizing radionuclide techniques to characterize in vivo benign liver masses. Examining the physiologic tumor function cholescintigraphy offers a highly specific pattern for identifying focal nodular hyperplasia (FNH): hypervascularisation, hepatocellular uptake and impaired transport of the bilirubin like tracer documented as trapping in later images. An hemangioma is diagnosed with high probability in case of a positive bloodpoolscintigraphy. But false-positive results have been reported. Therefore, a second unrelated examination, e.g. ultrasound, magnetic resonance imaging or dynamic computerized tomography is necessary to establish this diagnose in a sufficient certainty. If complications due to tumor growth are not expected, both, FNH and hemangioma need no further therapy. High sensitivity is necessary to establish resectability or tumor spread. Scintigraphic techniques are advantageous in scanning completely the whole body. On the other hand, there are limitations as low resolution and anatomical orientation, low specific activity in the tumor and artificial activity near by the tumor. To measure therapy effects and to detect recurrencies especially in borderline-cases positron emission computed tomography (PET)-technology is recommended, because PET offers a specific-parametric evaluation.

[Ultrasound in diagnosis of benign and malignant liver tumors]

Year 1998
Linhart P. Bonhof JA. Baque PE. Pering C.
Deutsche Klinik fur Diagnostik, Wiesbaden.
Sonography has a high sensitivity in diagnosing circumscript lesions in the liver when modern machines are used by a skilled examiner. The exact analysis of the sonographic imaging characteristics allows definite diagnosis in the majority of cases. The high prevalence of benign liver tumors has to be considered. It is substantiated by an evaluation of 731 own patients. The characteristics of the most important circumscribed liver lesions are presented and suggestions for the diagnostic work-up are provided.

[Diagnostic imaging of benign and malignant liver tumors: computerized tomography or magnetic resonance tomography?]

Year 1998
Schunk K. Schadmand-Fischer S. Thelen M.
Klinik und Poliklinik fur Radiologie, Johannes Gutenberg-Universitat Mainz.
A reliable preoperative detection and characterization of all liver lesions is necessary for the clarification of the operability of a patient. In patients, who are considered as good candidates for a partial liver resection, a double spiral-CT with an oral bowel opacification and an intravenous contrast medium administration is recommended. In those patients, who continue to be candidates for partial liver resection after CT, a CT arterioportography with arterial and portalvenous liver enhancement should be performed as the present gold standard of preoperative liver diagnostics. The aim of CT arterioportography is the further selection of patients for liver surgery. Because of its high specificity, MRI is useful for the characterization of liver lesions of unknown histology. For the differentiation between malignant (metastases) and benign (hemangioma) liver lesions, MRI is the method of choice. Because of the expected technical developments of MRI, a short-term comparison of CT and MRI in prospective studies is necessary.

[Cystic liver, an indication for liver transplantation or decompressive resection?]

Year 1998
Kremer B. Vogel I. Klomp HJ. Henne-Bruns D.
Klinik fur Allgemeine Chirurgie und Thoraxchirurgie, Christian-Albrechts-Universitat Kiel.
In patients suffering from polycystic liver disease sclerosing therapy, decompressive hepatic resection and liver transplantation represent the main therapeutic options. Since 1987, 10 females with highly symptomatic polycystic liver disease underwent hepatic resection for decompression (five left lateral bisegmentectomies, one left hemihepatectomy, one right central and three bilateral atypical resections). Despite of a 0% lethality 3 patients developed complications, in two cases an abscess had to be drained and in one case a postoperatively increasing hepatic insufficiency required urgent liver transplantation. Patient's symptoms were remarkably improved in 8 cases, but only 6 patients had a long lasting benefit over years. One patient was resected a second time three years after the first operation and is free of symptoms for another five years. 6/96 the "European Liver Transplant Registry" has listed 81 patients after liver transplantation because of polycystic liver disease. 5-year survival is 78.2%. So liver transplantation offers a therapeutic alternative for patients severely suffering from symptoms or increasing hepatic insufficiency.

[Non-parasitic liver cysts: laparoscopic and conventional fenestration]

Year 1998
Heintz A. Junginger T.
Klinik und Poliklinik fur Allgemein- und Abdominalchirurgie, Johannes Gutenberg-Universitat Mainz.
From 1992 till 1997 10 patients with solitary non-parasitic liver cysts were treated by laparoscopically fenestration of the cysts. The size of the cysts varied between 8 and 16 cm (median 13.5). Conversion to laparotomy was required in one patient because of intraoperative bleeding. In nine patients the laparoscopic procedure was finished successfully. In these cases we observed no intraoperative complications (9/10), intraoperative blood loss amounted up to 100 ml. Median operative time amounted to 82.5 minutes (55-155). No postoperative complications were observed. In two patients a cystadenoma was proven by postoperative histology, in both cases a liver resection was performed. During a median follow-up of 33 (2-43) months 2 of 7 patients treated with laparoscopically fenestration developed a recurrence (28%).

[Diagnostic and therapeutic strategies in hepatocellular adenoma]

Year 1998
Weimann A. Fronhoff K. Gratz KF. Maschek H. Bartels M. Klempnauer J. Ringe B. Pichlmayr R.
Klinik fur Abdominal- und Transplantationschirurgie, Medizinischen Hochschule Hannover.
While liver hemangioma and focal nodular hyperplasia are not considered an indication for surgery in asymptomatic patients resection has been recommended for hepatocellular adenoma because of the risk of rupture and malignant transformation. Problems arise from differential diagnosis and the appropriate surgical radicality including the indication for liver transplantation. This retrospective analysis deals with 58 patients who underwent surgery for hepatocellular adenoma: resection of different extension: n = 54, liver transplantation n = 4. In 39.6% of the patients the tumor was an incidental finding. In 62.0% of the character of the lesion was unclear prior to surgery. Tumor rupture and bleeding occurred in 17.2%, malignant transformation in 6.9%. Surgical morbidity was 27.6%, mortality 5.2% with the transplant patients alive for 1.5, 7, 9 and 10 years. Two and five years after resection 2 patients developed hepatocellular carcinoma in the liver remnant. The results confirm the indication for surgery in hepatocellular adenoma. Diagnostic approach for solid liver tumors without serum increase of tumor markers should rule out FNH and hemangioma. In all other patients surgery should be considered whenever possible with the radicality of malignant disease. Liver transplantation can be discussed even in asymptomatic patients with multiple adenoma.

[Focal nodular hyperplasia and liver cell adenoma: operation or observation?]

Year 1998
Ott R. Hohenberger W.
Chirurgische Klinik mit Poliklinik, Universitat Erlangen-Nurnberg.
PATIENTS: In a 15-year period a total of 146 patients underwent surgery for benign hepatic tumors, including 54 focal nodular hyperplasias (FNH) and 23 hepatic cell adenomas (65 hemangioma and 4 cholangioma). METHODS: The medical records of these patients were retrospectively analyzed with respect to tumor-related symptoms, surgical procedures and postoperative complications. RESULTS: Regardless of the type of the tumor, 70% of the patients had no or only non-specific symptoms. Most frequently, surgery was indicated due to questionable dignity of the lesion (adenoma 70%, FNH 41%). In hepatic cell adenomas (HCA) also perforation or bleeding of the tumor (17%) and severe symptoms (13%) required urgent operation. In two of three cases local excision of the lesion or segmental hepatic resection were performed, whereas extended resection procedures became necessary only in 20 (FNH) to 34% (HCA). The mean duration of postoperative intensive care treatment was significantly shorter in FNH and HCA than in other benign hepatic tumors (1.0 vs. 2.0 days, p < 0.01). After resection of FNH no fatalities or significant complications were observed. In HCA morbidity was 13% without related mortality (hemangioma: 3% mortality; 11% morbidity). CONCLUSION: The elective resection of benign hepatic tumors can be achieved with very low mortality and morbidity, and usually provides longterm relief of annoying symptoms. Whenever HCA is suspected surgery should be performed, since severe symptoms and spontaneous hemorrhage (30%) are common in this tumor. Also hepatocellular carcinoma can be excluded only by histologic work-up of the operative specimen. In focal nodular hyperplasia (FNH), complications are rare and malignant transformation does not occur even when observation is employed only. Resection should be restricted to symptomatic or growing tumors with subsequent cholestasis or to cases with uncertain diagnosis.

[Value of colonoscopy in tumor after-care after colorectal carcinoma]

Year 1998
Jansen M. Riesener KP. Truong S. Schumpelick V.
Chirurgische Klinik und Poliklinik, RWTH Aachen.
The significance of colonoscopic follow up is discussed controversially. Colonoscopy after resection of colorectal cancer offers the possibility of direct inspection and to take biopsies for the early detection of local recurrence or additional neoplasms. In a retrospective study we examined the benefit of regular colonoscopies. Between 1/1995 and 4/1996 237 colonoscopies were performed on 164 patients after resection of colorectal cancer. The evaluation was done due to the stage of the primary tumor, the age of the patients, the time after operation and the number of previous colonoscopies. 54 adenomas were found in 35 of 164 patients. 32% of the adenomas were diagnosed in the ascending colon or colon transversum. Additionally three carcinomas were found. There were two local recurrences and one metachronous neoplasm. Two patients were diagnosed without clinical symptoms and were able to undergo potential curative resection again. Because of the number and the localisation of diagnosed neoplasms colonoscopic surveillance should be performed every six months in the first two years after resection of colorectal cancer.

[Detection of hL6-mRNA: new possibilities in serologic tumor diagnosis of colorectal carcinomas]

Year 1998
Schiedeck TH. Christoph S. Duchrow M. Bruch HP.
Klinik fur Chirurgie, Medizinische Universitat zu Lubeck.
A study was performed to detect circulating tumor cells in patients with colorectal cancer using mRNA coding for the tumor associated antigen L6. The mRNA was determined by Reverse Transcriptase Polymerase Chain Reaction and gel-electrophoresis. The L6 results were compared with the CEA levels. Peripheral blood samples were taken from 109 patients with histologically verified colorectal cancer. Statistics were carried out using CHI Square and Sokal and Rohlf's-test. Preoperatively 81.65% showed positive L6 mRNA, whereas only 58.7% had elevated CEA titers (p < 0.05). In all patients of the control group (n = 52) no L6 was detectable. Concerning our results L6 seems to be a sensitive and precise tool for diagnosing circulating tumor cells in colorectal cancer.

[10 years results after repair of recurrent problem inguinal hernia with prolene mesh]

Year 1998
Bauer KH. Kemen M. Senkal M. Zumtobel V.
Chirurgische Klinik, Ruhr-Universitat Bochum, St. Josef Hospital.
The repair of multiple recurrences of inguinal hernias remains a surgical challenge. In 38 patients with a problematic recurrent inguinal hernia we implanted a polypropylene mesh (Prolene) in order to reinforce the transversalis fascia and to repair the inguinal hernia. 20 of these were medial and 14 lateral hernias; 4 patients had a combination of both types. All patients were prospectively included into this study and were seen in median follow-up periods of 3 and 6 months, as well as 4 and 9 years. As early complications hematoma of the wound (n = 3), scrotal edema (n = 1), temporary pain at the wound site (n = 12) and paresthesia (n = 13) occurred. Two patients (n = 2) developed a femoral hernia and one patient suffered from a persisting nerve injury of the ilioinguinal nerve. Due to the low complication and recurrency rate the tension free repair with polypropylene mesh is a effective method for treatment of problematic recurrent hernias.

[Technique of laparoscopic pancreatocysto-jejunostomy]

Year 1998
Baca I. Schultz C. Gotzen V.
Klinik fur Allgemein- und Unfallchirurgie, Zentralkrankenhaus Bremen Ost.
Usually the development of a pancreatic pseudocyst in the course of pancreatitis is followed by surgical intervention. In case of operation an internal drainage is preferred to an external according to general experience. We have developed a simplified technique of pancreatocysto-jejunostomy without Braun- or Roux-Y-anastomosis. Here we present our surgical strategy in the laparoscopic technique.

[Is there an indication for general perioperative antibiotic prophylaxis in laparoscopic plastic hernia repair with implantation of alloplastic tissue?]

Year 1998
Schwetling R. Barlehner E.
Chirurgische Klinik, Klinikum Buch, Berlin.
The implantation of alloplastic material in laparoscopically operated groin hernias is usually connected with perioperative prophylaxis by antibiotics. We doubted the usefulness of the general application in these operations. Therefore we made a prospective randomized study in 80 patients, beginning since April 1996. 40 of them received perioperatively antibiotics, other 40 ones remained without antibiotics. These 80 patients underwent an unilateral hernioplasty and were without major anaesthesiologic risk. Both the groups were statistically comparable. As a result, no patient of both the groups suffered from an infectious complication. Thus, we can recommend the laparoscopic implantation of alloplastic meshes in "simple hernias" without perioperative antibiotic prophylaxis. In risk patients, antibiotics should still given further.

[Lipoma: a rare differential gastrointestinal tumor diagnosis]

Year 1998
Geier B. Senkal M. Eickhoff U. Bauer KH. Zumtobel V.
Chirurgische Klinik, Ruhr-Universitat Bochum, St. Josef Hospital.
This is a case report of a female patient who during a routine follow-up after a gastrectomy showed a tumor of the ileo-cecal valve, which--according to all radiologic diagnostic procedures--was highly suspected to be a malignant tumor. However, the histologic diagnosis was benign lipoma. The incidence and the characteristics of gastrointestinal lipomas in the actual literature will be reviewed.

[Retrospective view of the development of surgical therapy of gallstones]

Year 1998
Trebing G. Schroder H.
Klinik und Poliklinik fur Chirurgie, Friedrich-Schiller-Universitat Jena.
This paper gives a short historical overview of the evolution of biliary surgery from John Stough Bobbs (1867) until the present day. The development of different diagnostic methods (from cholangiography to sonography) are described also, as well as the different therapeutic methods including laparoscopic cholecystectomy. Hans Kehr (1862-1916) was a distinguished pioneer in the development of biliary surgery.

[Indications for surgical therapy of gallstones]

Year 1998
Koch A. Gastinger I.
Chirurgische Klinik, Carl-Thiem-Klinikum Cottbus.
4675 patients which underwent a cholecystectomy because of gallstone disease were included in a prospective multi-institutional study from 01/09/1994 to 31/08/1995 at 29 east-german hospitals. 3,207 (68.6%) patients had done a laparoscopic cholecystectomy (LCE). 1,468 (31.4%) patients received a primary open cholecystectomy (KCE). A conversion rate of 7.7% (n = 247) was seen. In 32.8% of LCE and in 39.5% of KCE diagnostic procedures of the common bile duct were not performed at all. The rate of open revision of the common bile duct was 4.5% (n = 211). The highest postoperative morbidity and operative mortality were found in KCE with revision of the common bile dutct.

[Current surgical treatment status of gallstones in East Germany]

Year 1998
Asperger W. Lippert H. Gastinger I. Lorenz D.
Ostdeutsche Arbeitsgruppe Leistungserfassung und Qualitatssicherung in der Chirurgie.
The changes of surgical treatment of gallstone disease to the laparoscopic procedure was performed just at the same time in East Germany was destroyed the socialism. That's why the new operative technique was possible in many hospitals in 1992/93 first. To describe the actually situation and the trend we started a prospective multi-institutional study included 29 East German surgical departments of all kinds. The most interesting things were perioperative antibiotic prophylaxis, laparoscopically procedures in elderly or high risc patients, the management of common bile duct stones and the minor and major complications. We discuss the results and the comparison with the results of externe quality assurance.

[Preoperative diagnosis in laparoscopic cholecystectomy: is intravenous cholangiography currently still justified?]

Year 1998
Schramm H. Buttner K. Junemann K. Hohmann U.
Chirurgische Klinik I, Klinikums Gera.
Laparocopic cholecystectomy requires essentially the safe exclusion of choledocholithias. The aim of this study was to compare the intravenous cholangiography and ERCP in addition to a basic program (case history, laboratory results ultrasound) with references to the diagnostic ability and therapeutic consequences in patients with choledocholithiasis. The results show, that the intravenous cholangiography not provides extra important informations after the case history, ultrasound and laboratory findings and therefore its general use is not justified. Instead of the intravenous cholangiography the preoperative ERCP should be performed generously if choledocholithiasis is suspected, especially because the ERCP offers the possibility to extract the stone.

[Surgical therapy of choledocholithiasis]

Year 1998
Kockerling F. Scheuerlein H. Schneider C. Hohenberger W.
Chirurgische Universitatsklinik Erlangen.
Following the introduction of endoscopic papillotomy and stone extraction, surgical bile duct revision has decreased considerably in importance during the past two decades. Surgical bile duct revision is associated with an appreciably higher rate of complications than endoscopic stone extraction. The result has been that most working groups now favour a "therapeutic splitting" approach. This means that, wherever possible, endoscopic revision of the bile duct is first attempted. If, during laparoscopic cholecystectomy, intraoperative cholangiography reveals the presence of bile duct stones, they may, after consultation with the endoscopist, be left in place for removal by endoscopic papillotomy at some later date. Only in the case of very young patients and exceptionally, a highly experienced laparoscopic surgeon may attempt a transcystic extraction of such stones. Continuing indications for conventional surgical treatment of choledocholithiasis are local factors obstructing access to the papilla (gastrectomy, stenosis of the pylorus) and other bile duct changes requiring correction (choledochocele, strictures, stenoses, Mirizzi's syndrome, over-looked impacted stone obstructing an over-long cystic duct stump, intrahepatic lithiasis).

[Value and technique of laparoscopic choledochus revision in choledocholithiasis]

Year 1998
Czarnetzki HD. Schulz S. Jantschulev M.
Klinik fur Chirurgie, Klinikum Sudstadt Rostock.
Despite a large scale indication to ERCP, 5% of unsuspected stones are shown by principally intraoperative cholangiography in our patients. Praeoperative diagnostic makes it possible to select the individual optimal therapy for each patient, the possibility of saving the Papilla vateri gives the large scale indication to laparoscopic common bile duct exploration. Also suspected stones gets a one-time cure therapy by complete laparoscopic operation. After balloon-dilatation of cysticus duct to 6 mm, the laparoscopic choledochoscopy is possible through the cysticus duct. Little stones are flushed into the duodenum or extracted by Segura-basket through the cysticus duct. Big stones needs a Laser- or electrohydraulic lithotripsy, the stonefragments can be flushed into the duodenum or aspirated through the cysticus duct. Multiple big or proximal incarcerated stones gives the indication for laparoscopic choledochotomy. Effective extraction is possible by big Segura-basket, residual stones are taken out under choledochoscopic control by little Segura-basket. Incarcerated stones needs the lithotripsy. Microdrainage of the common bile duct and only in special indication the T-tube saves the gall-flow to restitution of papilla function, the common bile duct is closed by running suture in Lahodny-technique. After the regular postoperative cholangiography on third day after operation, the microdrainage can be taken out. In 96% of all laparoscopic cholecystectomies the intraoperative cholangiography was successful. Only 3 of 103 patients needs a postoperative EPT because of residual fragments after trans cystic duct exploration. 8 laparoscopic choledochotomies shows the successness of endoscopic techniques, the postoperative complications can be the same then in conventional operation.

[Endoscopic therapy of cholangiolithiasis by percutaneous approach. Percutaneous gallstone therapy]

Year 1998
Martin P. Lotterer E. Kleber G. Fleig WE.
Klinik und Poliklinik fur Innere Medizin I, Martin-Luther-Universitat Halle-Wittenberg.
PATIENTS AND METHODS: In a retrospective study, the results of percutaneous transhepatic therapy of bile duct stones under cholangioscopic control (PTCS) were evaluated in 32 patients in which a endoscopic retrograde stone removal was impossible or failed. RESULTS: Previous gastric surgery was the most common reason for choosing the percutaneous route (22 cases). Five patients had biliodigestive anastomosis, two pyloric obstructions, and in three patients the retrograde stone removal failed. Complete stone removal was obtained after 3 to 11 (median 5) percutaneous procedures in all cases, in 28 patients by electrohydraulic lithotripsy, and in the remaining 5 cases by mechanical extraction alone. There was no complication due to cholangioscopy and lithotripsy themselves. Two cases had major complications which needed laparotomy (4%, one case had capsular bleeding from the liver, another one had catheter perforation of the duodenum). In addition, three cases (7%) had minor complications which required no therapy during the percutaneous fistula procedure. Two elderly multimorbid patients (4%) died during hospitalisation after successful stone removal not related to the performed procedure. CONCLUSION: The percutaneous transhepatic cholangioscopy (PTCS) and lithotripsy are highly effective techniques for endoscopic treatment of bile duct stones. Because of an increased rate of complications during the fistula procedures, both methods should be restricted to cases with difficult anatomic situation and high risk of surgery.

[Endoscopic diagnosis and therapy of cholecysto- and choledocholithiasis]

Year 1998
Korner T.
Klinik fur Innere Medizin II, Klinikum Suhl.
Not only for systematical reasons a differentiation of gallstones disease between cholecystolithiasis and choledocholithiasis is sensible. Although the two diseases are basically caused by gallstones, they generally differ in diagnostic and therapeutic strategies. While the cholecystolithiasis is the domain of visceral surgeons and today almost exclusively and definitively cured by microinvasive cholecystectomy, for the treatment of choledocholithias there are required the endoscopic procedures of physicians.

[Therapy of acute cholecystitis from the surgical viewpoint]

Year 1998
Schramm H.
Chirurgische Klinik I, Akademisches Lehrkrankenhaus, Friedrich-Schiller-Universitat Jena.
The over notion, "acute gallbladder" includes the acute cholecystitis, also the gallbladder dropsy, the persistent colicky pain of the impaction, the complications of acute cholecystitis like the cholecystoempyema an necrotising the calculous impaction inflammation. In the last cases an emergency operation ist necessary. The acute cholecystitis and also the acute gallbladder dropsy have to be operated in an unit of time of 72 hours. By this patients the capability of operation and narcosis is a prerequisite. The late operation also the interval operation are united with greater operative technical difficulties an the danger of intraoperative complications. The indication for the cholecystostomy ist rare. Is an anaesthesia not possible a surgical stomy in local anaesthesia or a percutaneous transhepatic puncture drainage with sonography and CT-control ist possible. There are scarcely contra-indications for the laparoscopy.

[Laparoscopic cholecystectomy as routine intervention in acute cholecystitis]

Year 1998
Meyer L. Rupprecht J. Kahler G. Hoffmann C. Kronert T. Scheele J.
Abteilung Allgemeine und Viszerale Chirurgie, Friedrich-Schiller-Universitat Jena.
The laparoscopic cholecystectomy has become the gold standard in the therapy of gall bladder stones in the last few years. The most contraindications of the first period of the laparoscopic era had been eliminated by the development of laparoscopic technique and growing experience. Since September 1995 the laparoscopic cholecystectomy has been established as routine procedure also for acute cholecystitis. From September 1995 to Dezember 1996 177 laparoscopic cholecystectomies were performed, 132 for symptomatic cholecystolithiasis and 45 for acute cholecystitis. Postoperative complications occurred in 8.3% in the elective group and in 8.8% in the acute cholecystitis group. There was no death in both groups. Patients left the hospital on day 3 (range 2-21) in the elective group, on day 4 (1-13) in the acute colecystitis group. There are no statistically significant differences. According to our results acute cholecystitis does not increase postoperative morbidity and mortality after laparoscopic cholecystectomy and has to be a contraindication for this method no longer.

[Gallbladder carcinoma--an unexpected finding after laparoscopic cholecystectomy]

Year 1998
Hohaus T. Hellmich G. Freitag M. Ludwig K.
Klinik fur Allgemein- und Abdominalchirurgie, Krankenhaus Dresden-Friedrichstadt, Akademisches Lehrkrankenhaus, Technischen Universitat Dresden.
The carcinoma of the gallbladder can be found mostly in a late stage. We have to expect a incidental carcinoma of the gallbladder in 1-2% after conventional cholecystectomy. We report 9 cases of unexpected carcinoma of the gallbladder after 1700 laparoscopic cholecystectomies. The time of survival were--dependent on tumor stage--2 to 36 month. We outline special items of this disease within the context of minimal-invasiv surgery.

[Possibilities and limits of invasive endoscopy in treatment of endoscopic surgical complications after operations of the biliary tract]

Year 1998
Schilling D. Zopf T. Adamek HE. Riemann JF.
Medizinische Klinik C, Klinikum der Stadt Ludwigshafen gGmbH, Ludwigshafen.
Minimal invasive methods compete with surgical treatment in the therapy of complications after cholecystectomy. We demonstrate our results of endoscopic therapy. 52 patients with postoperative complications (39 stenoses, 5 leakages, 6 stenoses and leakages, 2 complete obliterations of bile duct) were treated by transpapillary or transhepatic biliary drainage over a time period of 12 months. In 73% of patients who completed the therapy protocol successful treatment was possible. In 4 cases a restenosis occurred. 4 patients underwent surgical treatment. We think endoscopic management is the therapy of first choice for postoperative biliary complications. Biliary stricture should be dilatated for 12 months by biliary endoprosthesis, leakage can be drained for shorter time periods.

[Value and sensitivity of abdominal ultrasound in preoperative histologic diagnosis before laparoscopic cholecystectomy]

Year 1998
Hoffmann C. Trebing G. Meyer L. Scheele J.
Abteilung fur Allgemeine und Viszerale Chirurgie, Friedrich-Schiller-Universitat Jena.
In a retrospective study we compared the findings of our abdominal ultra-sound diagnostic of the gallbladder and the common bile duct with the results ot preoperative ERCP, intraoperative findings and the histological results. The test parameters were the size of the gallbladder, the number and the size of biliary calculi, the thickness and the constitution of the wall of the gallbladder and the consecutive grade of inflammation, the wideness of the common bile duct and the suspicion of a choledocholithiasis, respectively. In acute cholecystitis we performed laparoscopic cholecystectomy within 24 hours, in symtomatic cholecystolithiasis without cholecystitis an elective laparoscopic cholecystectomy. If there was suspicion of a choledocholithiasis we performed a preoperative ERCP. Altogether we had correct findings of the common bile duct in our ultrasound diagnostic in 133 of 136 cases (97.8%), only in 3 of 136 cases (2.2%) we had false negative ultrasound findings. With a generous indication to ERCP caused by anamnestic and/or laboratory findings the obstruction of the bile duct could be diagnosted and eliminated in 2 of these 3 cases preoperatively. In all cases of bile duct dilatation (7 mm and more) we found an obstruction of the common bile duct. Our results demonstrate that abdominal ultrasound is a high-efficiency method in the preoperative diagnostic of gallbladder and common bile duct stones.

[Early and late outcome of biliodigestive anastomosis and transduodenal papillotomy in benign diseases of the bile ducts]

Year 1998
Braun L.
Chirurgische Klinik Detmold.
The results of a prospective study of 188 choledochoduodenostomies, 51 choledocho-jejunostomies, and 114 transduodenal papillotomies in patients with benign diseases are presented. The operations were performed between 1974 and 1997. The status of the patients was checked every one to two years. During the same time period a total of 5128 patients with benign disorders of the gall bladder or biliary tract was operated upon. In consequence to the important progress of endoscopic diagnostic and therapeutic options indications and methods of biliary surgery have changed significantly. Open procedures at the choledochal duct, biliodigestive anastomoses, and transduodenal papillotomies are recently performed only in rare instances.

[Diagnosis and therapy of biliary complications after laparoscopic cholecystectomy by ERCP]

Year 1998
Kahler G. Muller C. al-Sibaie A. Scheele J.
Abteilung fur Allgemeine und Viszerale Chirurgie, Friedrich-Schiller-Universitat Jena.
Biliary tract injury, although uncommon, is the most feared complication of laparoscopic cholecystectomy. Early identification or exclusion of such injury is essential for successful management. Over a two year period (1995-1996) twenty-one from a total of 413 ERCPs in this Surgical Endoscopy Unit were performed because of suspected biliary injury after laparoscopic cholecystectomy. 16 patients were referred from other units. No abnormality was demonstrated in two cases. A clip-related stenosis requiring reoperation was shown in twei patients. The remaining 17 cases had biliary leakage, related to an aberrant bile duct in 2 cases or a cystic duct leak in 15, all of which were treated endoscopically by nasobiliary tube (7), endoscopic papillotomy (5) or a combination of both (5). All of these biliary leaks healed uneventfully no ERCP-associated morbidity.

[Endoscopic interventions of the biliary tract in postoperative complications after cholecystectomy for preventing relaparotomy]

Year 1998
Korner T. Brennenstuhl M. Kristahl H. Graf S.
Klinik fur Innere Medizin II, Klinikum Suhl.
The postoperative complication rate of laparoscopic cholecystectomy (LC) is about 5-6%. The most frequent complications are residual gallstones in the common bile duct, biliary leckage, biliary fistula and duct stenosis. In the period between 01.11.94 and 01.04.96 we performed 1620 endoscopic retrograde cholangio pancreatographies including 410 papillotomies at the second Department of Medicine in the Clinic of Suhl. Thereby in 2.1% (34 cases) of patients a complication after laparosopic cholecystectomy was seen and endoscopically controlled. Residual bile duct stones were removed without any problems by papillotomy and stone extraction. Biliary leckage were brigded by stent implantation. In case of aberrant cystic duct it was also possible to implant a stent depending on anatomical situation. All patients were followed up over a period of 6 to 8 month after endoscopic procedure. All except two patients showed an occlusion of biliary leckage and the bile duct stent could be revved. In one case, a younger patient, with a failed endoscopic occlusion of biliary fistula had to undergo a further operation because of residual gallbladder tissue. In the other case, a 84-years old patient, we use a new method, developed at our department, for selective embolization of the cystic duct to prevent a relaparotomy. The leckage was sufficiently closed. Endoscopic intervention is indicated in case of postoperative complication after LC and successful in the majority of cases. This should primarily discussed between surgeon and physician. Only secondarily a relaparotomy should be performed, if endoscopic procedures have failed.

[Standards, perspectives and limits of conservative therapy of chronic inflammatory bowel diseases]

Year 1998
Rogler G. Andus T. Scholmerich J.
Klinik und Poliklinik fur Innere Medizin I, Universitat Regensburg.
Improvement and standardization of the conservative therapy of inflammatory bowel disease has lead to a better prognosis for the patients. During the acute flare of Crohn's disease steroids are still the standard therapy, whereas 5-aminosalicylic acid (5-ASA) preparations are used for maintenance therapy during remission. In contrast ulcerative colitis may be treated with 5-ASA also for acute exacerbations. The development of new drugs as for example the topical steroids helps to improve life quality of the patients by reducing adverse side effects. Potent immunosuppressants as azathioprine and methotrexate are useful in chronic active and refractory disease. Cyclosporin A plays a role in severe steroid refractory colitis. In the future immunomodulation by application of antiinflammatory cytokines or antibodies to inflammatory cytokines may have its place in the treatment of IBD patients. In some cases, however, the conservative therapy reaches its limits. Mistakes in the therapy are made, when these limits are not recognized and complications are not discovered in time.

[Necessary diagnosis before and reliable examinations after surgical interventions in chronic inflammatory bowel diseases]

Year 1998
Becker K. Stallmach A. Zeitz M.
Innere Medizin II, Medizinische Klinik und Poliklinik, Universitat des Saarlandes, Homburg/Saar.
The primary diagnosis of chronic inflammatory bowel disease (Crohn's disease, ulcerative colitis) is performed by standardized procedures in specialized Gastroenterology Departments or Ambulances. For the assessment of disease activity the clinical presentation of the patient is most important. This is also true for the indication for surgical interventions. In certain instances laboratory markers, endoscopic and histologic examinations, ultrasound, X-ray, and cross-sectional imaging like computed tomography (CT) or magnetic resonance imaging (MRI) give important additional informations. Depending on the clinical situation surgeons and gastroenterologists decide on the most useful technical examinations for planning the operative strategy. After surgery, diagnostic procedures focus on disease progression and complications. Disturbances of intestinal function as consequence of the operation have also to be considered in the routine diagnostic program.

[Surgical concepts in Crohn disease of the terminal ileum and colon]

Year 1998
Ecker KW. Hulten L.
Abteilung fur Allgemeine Chirurgie, Abdominal- und Gefasschirurgie, Chirurgische Universitatsklinik Homburg/Saar.
Most patients with Crohn's disease have to be operated on. Necessity to loose some amount of the intestine and time-point of the surgical intervention may be derived from the irreversible cascade of the inflammatory process and the limitations of the conservative treatment. In ileocecal disease indications for surgery are represented by stenotic and/or penetrating complications of the inflamed bowel, whereas in Crohn's colitis acute or terminal medical refractority is predominating. Standard-procedures result from constantly definable patterns of the disease manifestation: ileocecal resection and colectomy/-proctocolectomy. In segmental colitis sometimes "resections within Crohn's" may be adequate in a first attempt to avoid anticipating the natural course by surgical means. In these cases the further prognosis depends on the treatment possibilities of the remaining colon. In contrast, true recurrence is a new inflammation of the neoterminal ileum and may indicate repeated resections. The frequence decreases with the number of resections. Nevertheless nutritional status is restored even by multiple resections, whereas specific functional sequelae of the resection--distal resection- and dehydration syndromes--are well treatable mostly. In the case of appropriate timing of the operation and the reoperation operative morbidity and mortality are remarkable low today resulting in an almost normal life expectancy. Most important as negative prognostic factor remains sepsis resulting from pre-existing or postoperative infectious complications. Keeping this in mind experimental pharmaco-therapy to delay the operation and not profoundly substantiated tendencies to minimize surgery are to be considered only with critical scepticism. At the moment, future research is thought to be more successful in focussing prophylaxis of ileal recurrence than avoiding surgery.

[Gastroduodenal involvement and circumscribed intestinal stricture in Crohn disease]

Year 1998
Makowiec F. Starlinger M.
Abteilung fur Chirurgie, Landeskrankenhaus Klagenfurt.
Symptomatic gastroduodenal Crohn's disease (CD) is rare although new endoscopic/histologic data indicate a typical focally enhanced gastritis in up to half of all patients with CD. One third of the patients with symptomatic gastroduodenal CD undergo surgery, most of them for (gastro-) duodenal obstruction. Gastroenterostomy with vagotomy is the surgical treatment of choice. Resection, strictureplasty or balloon dilatation can be performed in selected patients. Enterogastric and enteroduodenal fistulas are rare, frequently missed during routine examination and often detected only during laparotomy. Treatment of those fistulas consists of resection of distal bowel (fistula origin) with suture closure of the fistula opening in the stomach/duodenum. Recurrence rate after surgery for gastroduodenal CD is lower than in ileal and/or colonic disease, and only a minority of the patients requires further surgical intervention. Bowel obstruction is a frequent indication for surgery in CD. Interventional or surgical therapy should be performed in chronic-recurrent obstruction, progressive stenosis and stenosis refractory to medical treatment. In short fibrous stenosis of the small bowel or ileocecal anastomosis without acute inflammation or perforating complications balloon dilatation or, if endoscopic access is not possible, strictureplasty should be performed. In all other cases, especially in colonic strictures with their increased risk of malignancy, resection is the treatment of choice. The results of balloon dilatation, strictureplasty or resection are comparable with five year reoperation rates reported between 20% and 38%.

[Surgical treatment of Crohn disease based on the inflammatory pattern]

Year 1998
Lindemann W. Honig A. Feifel G. Ecker KW.
Abteilung fur Allgemeine Chirurgie, Abdominal- und Gefasschirurgie, Chirurgische Universitatsklinik Homburg/Saar.
286 patients with Crohn's disease were classified on the basis of the inflammatory pattern at their first operation as type 1 (Ileitis: n = 116), type 2a (segmental colitis: n = 60), and type 2b (total colitis: n = 108); 2 patients remained unclassified. At the same age at operation of 31.9 +/- 10.7 yrs symptoms were known in type 1 for 3.4 +/- 3.9 yrs, but for 7.5 +/- 5.7 yrs in type 2b. Main indication in type 1 was stenosis (56.9%), whereas in type 2b intractabilitiy (68.5%) predominated. Type 2a was intermediate concerning duration of symptoms and relationship of indications including fistulas. Standard-procedures were ileocecal resection (92.2%) in type 1, and colectomy (90.7%) in type 2b. In type 2a ileocolic resections and partial colectomies were mostly done. During the following 3.9 +/- 3.8 yrs reoperation rate due to disease progression was 13.6% in type 1, 25.5% in type 2a and 18.5% in type 2b. The cumulative risk of ileal resection at ten years due to new inflammation was significantly (p < 0.01) higher in the case of ileocolic/ileorectal anastomosis than of ileostomy (38% vs. 11%). In contrast, cumulative probability of a colorectal resection was significantly (p < 0.05) higher in type 2 (16%) when compared to type 1 (1.5%). Primary ileal loss was significantly (p < 0.01) higher in type 1 (37 +/- 23 cm) compared with type 2a (25 +/- 28 cm) and type 2b (17 +/- 21 cm). Loss of continence occurred in 0%, 3.3% and 53.7% respectively. With reoperations additional loss of ileum decreased in all types, whereas in type 2 loss of anorectal function increased. Including reoperations the rate of major complications was 9.8% and lethality was 0.8% (3/386). Resections in Crohn's disease are unavoidable due to shrinking therapeutical alternatives in the course of the disease. Owing to limited resections, loss of bowel may not exceed ileum in type 1, whereas the same resectional policy cannot avoid the total loss of the colorectum eventually in type 2. Both limited surgery and repeated resections help to maintain function as long as possible. Due to the high safety-standard the number of operations does not impair the success of the surgical concept.

[Drug prevention of Crohn disease recurrence in the neo-terminal ileum after ileocolic resection]

Year 1998
Vermeire S. Rutgeerts P.
Department of Medicine, University Hospital Leuven/Belgium.
Crohn's recurrence is the appearance of objective signs defined radiologically, endoscopically or pathologically of Crohn's disease in the bowel of a patient who has previously had a resection of all macroscopically diseased tissue. New lesions can be visualized endoscopically within weeks to months after ileal resection and ileocolonic anastomosis in the neoterminal ileum. The evolution of these lesions mimics the natural history of ileal Crohn's disease at the onset. If we are able to prevent recurrence of early lesions we would probably interrupt the natural course of the disease. The drugs tested until today include different 5-ASA formulations, metronidazole and budesonide. 5-ASA seems to have a limited protective effect. High dose metronidazole started immediately after surgery decreases endoscopic and symptomatic recurrence rates but is associated with a lot of side effects. Budesonide 6 mg/day o.m. reduces endoscopic recurrence after one year only in patients operated upon for inflammatory activity. Studies with immunosuppression for recurrence prevention are currently underway. Thus, today 5-ASA-formulations are recommended as general pharmaco-prophylaxis.

[Laparoscopically assisted surgery in Crohn disease]

Year 1998
Hildebrandt U. Schiedeck T. Kreissler-Haag D. Lindemann W. Ecker KW. Bruch HP. Feifel G.
Abteilung fur Allgemeine Chirurgie, Abdominal-, und Gefasschirurgie, Universitat des Saarlandes, Homburg/Saar.
From Jan. 1993 to Apr. 1997 intestinal resections in Crohn's disease have been performed in 275 patients. 89 patients have been operated on laparoscopic assisted. The following parameters were analyzed: previous laparotomies, extent of resection, steroid medication, conversionrate, complications, operative time and postoperative stay. Endpoints were: conversionrate, complications, reconvalescence and overall satisfaction with the laparoscopic technique. Results: The duration of the disease ranged from 1 to 16 years (x = 6). 47 patients were under steroid medication at the time of surgery. 30 patients had undergone previous laparotomies. In 10 patients the operation had to be converted into open surgery. The following procedures have been performed: ileocaecal resections (45), anastomotic resections (14), small bowel resections (4), hemicolectomies (12), colectomies (9), loopileostomies (4), adhesiolysis (1). Minor complications occurred in 6.7% of patients, major complications in 5.6%. Operative time ranged from 70 to 420 minutes (x = 173.7). The postoperative hospital stay was 13.3 days in the average. Conclusion: The morbidity of 12.3% is not higher than in open surgery. When complications do not occur the patients benefit from early convalescence, better cosmetics and shorter hospital stay.

[Surgical management of anorectal complications in Crohn disease]

Year 1998
Winkler R.
Abteilung fur Allgemeinchirurgie, Chirurgische Klinik, Martin-Luther-Krankenhaus Schleswig.
Anorectal manifestations can be expected in about 40% of all patients suffering from Crohn's disease. The frequency increases with extension of disease towards the anal canal. If the rectum is involved, they are obligatory present and contribute to the necessity of a stoma formation. Surgical indication is mostly given, especially in cases with putrid secretion. Primary aim of therapy is the control of peri-anorectal infection by excision of all the inflamed extramural tissue. Wether the underlying fistulas are excised too, depends on their topography to the sphincter system. Fistulas, running distal of the midth of the spincter, are radically excisebal and will definitely heal in over 90%. More than 60% of all fistulous anorectal manifestations belong to this type. Rectovaginal fistulas are provided with fistuloplasty, however healing conditions are problematous and healing will only be gained in about 50%. Fistulas in the upper third of the sphincter or above the sphincteric plane (rectal fistula) are managed by seton drainage of the transmural tract and complete excision of the infected tissue around, so that disease is reduced to its most simply condition. The further aim then is to derive it to cicatrous concretisation, so that infection will not expand again and patients will be free of pain. However this needs prolongation of seton drainage for at least 6 to 12 months.

[Surgical options in ulcerative colitis]

Year 1998
Hulten L. Ecker KW.
No information.
Surgery is needed in every second patient with pancolitis. Historically four surgical options have been developed: conventional ileostomy, ileorectostomy, continent ileostomy (Kock's pouch) and ileo-anal pouch. However, in emergent or unclear situations subtotal colectomy, ileostomy and preservation of the rectum is the most suitable operation. After recovery and in elective indications proctectomy and proctocolectomy establish the general surgical standard. Today, in most cases ileo-pouch-anal anastomosis is performed instead of creation of an ileostomy. Both lowered frequency of defecation and acceptable continence contribute to a better quality of life. However, functional disturbances are not uncommon and result in most cases from complications of the demanding technique. Definitive cure of the colitis is in interference with the risk of pouchitis in about 30%. The cumulative probability to loose the pouch may rise to 15-20% in the long-term course. Thus, ileorectostomy may be considered as a first step of surgical treatment, since pelvic nerve damage is excluded, function is much better and persistent proctitis can be treated topically. The attractively is that ileo-anal pouch can be performed later on, when decreasing function and increasing risk of malignant change will eventually require proctectomy. A Kock-pouch is seldom considered, especially in patients with ileostomy wishing sure fecal control. But the continent reservoir becomes more and more interesting again since it can be reconstructed from a failed ileo-anal pouch without loss of bowel. Conventional ileostomy should be reserved for patients not suitable for reconstructive methods or those who consider pough operations risk. However, it is the safest procedure with absolute cure of disease. The optimal choice of method considers medical and surgical aspects as well as patients conception and desire.

[Technique and results of ileoanal pouches in ulcerative colitis after colectomy and proctomucosectomy]

Year 1998
Runkel N. Kroesen A. Buhr HJ.
Chirurgische Klinik I und Poliklinik, Universitatsklinikum Benjamin Franklin, Freie Universitat Berlin.
The continence preserving restorative proctocolectomy is the operation of choice for ulcerative colitis. Many technical aspects of the J-pouch procedure have been standardised. We prefer the hand-sewn pouch-anal anastomoses and construct a protective ileostomy in most patients. Latter allows to carefully assess the sphincter function postoperatively and--if necessary--to train the sphincter before restoring continence. The frequency of postoperative ileus is comparable to that after other major intraabdominal surgery. Septic pelvic complications occur in up to 10% of patients and determine the long-term prognosis of pouch function. Following pouch reconstruction, the stool frequency remains increased (4-6 per day) and continence may be partially impaired especially at night. These consequences are accepted by most patients. Because the ileoanal pouch procedure is a difficult and complicated operation, it should be performed by experienced surgeons only.

[Direct ileum pouch-anal anastomosis in ulcerative colitis: function and complications after stapler technique]

Year 1998
Schippers E. Braun J. Willis S. Schumpelick V.
Chirurgische Klinik, Universitatsklinikum der RWTH, Aachen.
Stapled ileal pouch-anal anastomosis after proctocolectomy enables a continence preserving reconstruction. We assessed complications and functional outcome after ileoanal pouch-anastomosis in 86 consecutive patients with ulcerative colitis. There was no postoperative mortality. 2 patients required permanent ileostomy and pouch excision for manifestation of unsuspected Crohn's disease. Major postoperative complications consisted of pelvic sepsis (n = 2), anastomotic leakage (n = 4), bleeding (n = 1), pancreatitis (n = 3) and peritonitis (n = 1). Both frequencies of bowel movements and degree of continence improved with time. Two years after take down of the deviation ileostomy frequency of bowel movements was 5,6 [2]/die. At this time no patient complained of major incontinence. Minor incontinence was reported with 9% and 14% during day-time and night-time respectively. It is concluded that direct stapled ileal pouch-anal anastomosis is a safe procedure with excellent functional results for patients with ulcerative colitis.

[Changes in colitis surgery. I: Is there a standard in primary surgical treatment?]

Year 1998
Ecker KW. Kreissler-Haag D. Franz S. Feifel G.
Abteilung fur Allgemeine Chirurgie, Abdominal- und Gefasschirurgie, Chirurgische Universitatsklinik Homburg/Saar.
In a 15 years period surgery of ulcerative colitis expanded from ileostomy (IS) via Kock's pouch (KP) and ileoanal pouch (IAP) to ileorectal anastomosis (IRA). Interactions between availability of methods and frequency of operations are investigated retrospectively in order to establish an optimal primary procedure. With an overall amount of 80 operations the yearly operative frequency raised in correlation to the introduction of continence reconstructive procedures. As a consequence of this fact history of disease was shortened to less than 8 year and global colitis-associated morbidity markedly decreased. For patients readiness to undergo operation Kock's pouch was only important at the beginning (n = 9/11.3%). Most decisive was IAP (n = 49/61.3%) which could be realized last even in an one-stage-procedure with better early results due to improved patients conditions and simplified technical modifications. IRA (n = 7/8.8%) played only a limited role in the last years for selected patients, whereas IS (n = 15/18.8%) kept reserved for contraindications to reconstructive surgery. For all procedures operative complications decreased from 46.1% (12/26) to 11.0% (6/54) and lethality to 0%. Late complications were related to proctectomy (nerve damage) and construction of IAP (pouchitis in 34.8% and defunctioning of the pouch in 10.4%), whereas IRA was free of specific morbidity so far. Surgery of ulcerative colitis is characterized today by restoration of anal continence. The advantage of the changed surgical concept lies within the ability to perform colectomy at an earlier stage of the disease. Safe construction of IAP is the most important technical progress. Early operation of colitis and late morbidity of pouch justify (preliminary) IRA. Thus, surgical standard in colitis-surgery is defined more individually.

[Changes in colitis surgery. II: Corrective interventions and conversion operations]

Year 1998
Kreissler-Haag D. Haberer M. Feifel G. Ecker KW.
Abteilung fur Allgemeine Chirurgie, Abdominal- und Gefasschirurgie, Chirurgische Universitatsklinik Homburg/Saar.
Over a period of 9 years in 48 patients already operated on for ulcerative colitis secondary surgical interventions had to be planned. 25 patients had an ileostomy (IS), 10 a Kock-pouch (KP), 11 an ileoanal pouch (IAP) and 2 an ileorectal anastomosis (IRA). Whereas in 4 patients only the subjective wish for another procedure with better quality of life predominated, in 44 patients (91.7%) also objective, sometimes multiple indications for reoperation existed. In 37 patients main indications were complications or dysfunctions of the preexisting procedures, combined with the need for further resection of the colitis in 6 of them. Resection of the residual colitis was the main indication in the remaining 7 patients. The aim of the reoperation in all patients was both complete elimination of the eventually persisting colitis and restoration of quality of life in the best way wished or possible. Our of 25 IS 3 remained, 3 were reconstructed, 17 were converted to KP and 2 to IAP. Out of 10 KP one remained and in 9 corrective surgery of the nipple valve was performed. Out of 11 IAP 2 had to be resected with construction of IS, 5 were converted to KP and 4 were corrected. Two IRA were converted to IAP. The rate of early complications was 8.3% (n = 4), lethality was zero. Late complications occurred in 13 cases (27.1%) and were associated ten times with KP. Complications of KP decreased with time to zero due to technical modifications. They could always be corrected restoring function. Since only one KP had to be resected due to severe pouchitis, KP was an important secondary procedure for 31 out of 48 patients also in the long-term course ensuring both complete elimination of colitis and good quality of life owing to voluntary fecal control.

[Laparoscopically-assisted proctocolectomy with ileoanal pouch in ulcerative colitis]

Year 1998
Hildebrandt U. Lindemann W. Kreissler-Haag D. Feifel G. Ecker KW.
Abteilung fur Allgemeine Chirurgie, Abdominal-, und Gefasschirurgie, Universitat des Saarlandes, Homburg/Saar.
Laparoscopic assisted proctocolectomy with ileoanal pouch is a technical alternative to the conventional open procedure. The aim of this technique are better cosmetics. Mobilisation of the colon is achieved laparoscopically. Rectal resection, J-pouch creation, and pouchanal anastomosis are performed via a Pfannenstiel incision. Laparoscopic assisted proctocolectomy has been performed in five selected patients, three female and two male aged 17 to 36 years. Operative time ranged from 305 to 420 minutes. Intra- and postoperative complications were not encountered. Postoperative hospital stay ranged from 13 to 16 days. On a scale from 1 to 10 the average quality of life was graded 9 and the overall satisfaction level with the results of surgery scored 10. Function was identical to open surgery in not selected patients.

[Thoracoscopic resection of epiphrenic esophageal diverticula by an intracavitary/endoluminal combined intervention]

Year 1998
Horbach T. Kockerling F. Scheuerlein H. Reck T. Hohenberger W.
Chirurgische Klinik mit Poliklinik, Universitat Erlangen-Nurnberg.
Epiphrenic oesophageal diverticula are of the pulsation type, the underlying cause is a motility disorder. Resection is indicated by severe symptoms like dysphagia, regurgitation or aspiration and should be performed after endoscopic dilatative treatment of the neuromotor disturbance. Thoracoscopic resection under endoluminal endoscopic surveillance is considered to be a reliable procedure with low morbidity for the patient.

[Restorative surgery of a Hartmann status for relief of chronic sphincter problems]

Year 1998
Imhof M. Zacherl J. Herbst F. Jakesz R. Fugger R.
Abteilung fur Allgemeinchirurgie, Chirurgischen Universitatsklinik Wien.
The Hartmann situation is a temporary intestinal diversion to treat diseases of the rectosigmoid. In case of benign rectosigmoidal disorders the entirely laparoscopic performance of the colon disconnection and reconstruction is an advantage due to its minimal invasive nature. A patient suffering from chronic anorectal fistula with temporary relief exclusively performed by laparoscopic approach is reported.

[Clinical effects of childbirth with median episiotomy and anal sphincter injury on fecal incontinence of primiparous women]

Year 1998
Franz HB. Benda N. Gonser M. Backert IT. Jehle EC.
Universitats-Frauenklinik, Klinikum der Eberhard-Karls-Universitat Tubingen.
Obstetric damage of the anorectal continence organ can lead to impaired anal continence. To assess the effect of birth, either with or without direct injury of the anal sphincter, 123 primiparae were studied. 41 patients with a midline episiotomy and 82 patients with an additional injury of the anal sphincter were assessed at a median of 21 weeks postpartum and compared with 18 healthy volunteers. Anorectal manometry as well as a standardized questionnaire were employed. Patients with an additional injury of the anal sphincter reported persistent flatus incontinence significantly more often (p = 0.0069) than patients with a midline episiotomy only. Incontinence of solid or liquid stool occurred only transiently. Compared to nulliparae in all primiparae a significant shortening of anal canal and a decreased squeeze pressure were observed. In addition, a significantly reduced resting pressure was seen in patients with an anal sphincter injury. The rectoanal inhibitory reflex was absent significantly more often following anal sphincter tear (p = 0.0023). Vaginal delivery, both with and without anal sphincter injury, leads to early detectable changes in anorectal sphincter function.

[Value of electrotherapy within the scope of conservative treatment of anorectal incontinence]

Year 1998
Sprakel B. Maurer S. Langer M. Diller R. Spiegel HU. Winde G.
Klinik und Poliklinik fur Allgemeine Chirurgie, Westfalischen Wilhelms-Universitat Munster.
The following study reports on transanal electric stimulation as a conservative method of treatment in anal incontinence. In the centre of interest are clinical examinations on 45 patients that underwent a combined treatment with the IT-system 100 from Reha-Medi and pelvic floor training. A collective of 29 patients only treated with pelvic floor training was used as a control group. The results were based on a thorough medical history ascertainment and the corresponding clinical examinations at the beginning and end of the treatment. Our findings were classified according to the modified score of incontinence of Holschneider [16]. After therapy 42.2% of patients with electric stimulation therapy and 27.6% of the control group showed continence. 40 respectively 62.1% were non responder without relevant benefit. In the electric stimulation group the median score before and after therapy amounted to 6.57 versus 9.24 points. The control group achieved 6.72 respectively 8.58 points. The differences are statistically significant (p < 0.05, Student t-test). Concerning the results in relation to the cause of the incontinence, no significant differences between idiopathic and traumatic origin of the insufficiency of the sphincter mechanism are found in both groups. Therefore all variations of anorectal incontinence are seen as indication for treatment. The international literature as well as our own results confirm that electric stimulation is effective and may be in special cases a major factor in the conservative treatment of anorectal incontinence.

[How can the prognosis of acute mesenteric artery ischemia be improved? Results of a retrospective analysis]

Year 1998
Meyer T. Klein P. Schweiger H. Lang W.
Chirurgische Klinik und Poliklinik, Universitat Erlangen-Nurnberg.
AIM: Acute mesenteric ischemia is difficult to diagnose and is combined with a high mortality. In a retrospective analysis it was investigated how to improve the poor prognosis of the disease. PATIENTS AND METHODS: Between January 1988 through December 1994 a total of 46 patients were operated on for acute mesenteric ischemia. Mesenteric artery occlusion was present in three quarters of the cases (n = 35). These were analysed according to symptoms, diagnosis, mechanism of occlusion, operative procedure and prognosis. Distribution of gender was almost balanced (19 women, 16 men) with a median age of 70.5 years. RESULTS: Embolic arterial occlusion was predominant (n = 22). Most frequently, the superior mesenteric artery was exclusively concerned (n = 22). Serum levels of lactate and leucocytes were preoperatively elevated in over 90% (median values: lactate 53 U/l, leucocytes 15050/ml). In 16 patients diagnosis was made on the ground of clinical parameters and/or angiography, but 19 patients were not diagnosed until operation. 19 patients were operated within 6 hours, 12 patients within 24 hours after admission (> 24 hours: n = 4). Vascular reconstructive procedures only, such as thrombectomy and/or aortomesenteric bypass were performed in 9 cases, in a further 7 cases combined with bowel resection. Bowel resection alone was done in 7 patients, 12 patients had only diagnostic laparotomy. 13 patients survived, 10 of them had been treated with vascular reconstruction. CONCLUSION: Acute mesenteric ischemia ought to be suspected in every patient with uncertain abdominal pain, because only early diagnosis can improve prognosis. Measurement of serum lactate is diagnostically helpful, although not proving. In case of elevated lactate levels and uncertain abdominal symptoms angiography of the mesenteric vessels should be performed early. At operation, blood flow in the mesenteric arteries should be restored whenever possible.

[Fiber optic measurements with the Bilitec probe for quantifying bile reflux after aboral stomach resection]

Year 1998
Kronert T. Kahler G. Adam G. Scheele J.
Abteilung Allgemeine und Viszerale Chirurgie, Friedrich-Schiller-Universitat Jena.
Nonphysiological alkaline reflux after partial gastrectomy may produce a range of gastrointestinal disorders. The Bilitec probe is a fibroptic sensor that, for the first time, makes in vivo measurement of this reflux possible, by assay of spectrophotometric absorption of bilirubin. We studied 20 patients who had undergone partial gastrectomy for benign peptic ulcer disease. Ten patients had Billroth II reconstruction and ten had Roux-en-Y reconstruction. In the Roux-en-Y Group we found almost complete control of symptoms and no objective evidence of alkaline reflux as measured by the Bilitec probe. In the Billroth II group we detected by the fiberoptic sensor significant bile reflux into the stomach remnant. Based on these results we recommend Roux-en-Y gastrojejunostomy as the method of choice for reconstruction after distal gastric resection.

[The so-called Spigelian hernia--a rare lateral hernia of the abdominal wall]

Year 1998
Sachs M. Linhart W. Bojunga J.
Klinik fur Allgemeinchirurgie, Klinikum der Johann Wolfgang Goethe-Universitat Frankfurt am Main.
A patient with Spigelian hernia is presented and the main pathological and clinical features are discussed. Its true incidence is probably greater than the small number of patients reported in the literature due to failure to recognize the clinical picture. A hernia through a defect in the Spigelian fascia (aponeurosis of the transverse muscle of the abdomen) is called Spigelian hernia. The semilunar (Spigelian) line is defined as the line forming the transition from muscle to aponeurosis in the transverse muscle of the abdominal wall. It is a lateral convey line between the costal arch and the pubic tubercle. The part of the aponeurosis that lies between this semilunar line and the lateral edge of the rectus muscle is called the "Spigelian fascia" (correct: Spigelian aponeurosis). The hernia is located intramurally because the hernia is covered by the aponeurosis of the external oblique aponeurosis, so that both, the hernial sac and the orifice, can often not be detected by palpation. Clinical symptoms are not characteristic but most patients have a distinct tender point above the hernial orifice.

[Value of computerized tomography in diagnosis of Boerhaave syndrome]

Year 1998
Klaue HJ. Baron Y. Bauer E.
Klinik fur Chirurgie, Stadtisches Krankenhaus Kiel, Christian-Albrechts-Universitat zu Kiel.
The mortality rate of spontaneous oesophageal rupture can be reduced by rapid diagnostic evaluation and early therapeutic intervention above all. We report on the prompt diagnosis of Boerhaave syndrome by thoracoabdominal CT scan and oesophagoscopy in a 75 year old female patient with false negative oesophagogram. The oesophageal rupture was transabdominally approached and closed by suture and a gastric fundus patch 6 hours after admission to the hospital. Pleural space lavage and drainage was done thru a left thoracotomy. The patient developed bronchopneumonia and sepsis and was discharged from the hospital 8 weeks post admission.

[Primary malignant melanoma of the esophagus]

Year 1998
Friedrich T. Emmrich P.
Chirurgische Klinik I, Universitat Leipzig.
Primary malignant melanoma of the esophagus is extremely rare. Less than 200 cases have been published worldwide up to now. We report a case of a 65-years old male suffering from dysphagia for four months. The endoscopy showed a polypoidal tumor of black colour in the distal part of the esophagus. The histological diagnosis of the initial biopsy specimen was melanoma. Partial esophagectomy and lymph node sampling were performed. The resected specimen showed a polypoid tumor with black pigmentation of 8 x 5 x 3 centimeter. Histopathology revealed a primary malignant melanoma of the esophagus stage pT2 pN1 M0 and grading three. The patient died 8 months after resection from general metastatic disease. Age, sex, symptoms, duration of symptoms and time of survival are similar as described in former cases.