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The assessment of the quality of medical practice is a legitimate requirement by society. Reliable methods for measurement of the quality of performance are sought worldwide. Quality is often quantified by using administrative data and in Germany this method has been implemented by the health insurance company AOK.(1) How is the AOK quality system rated by senior consultant surgeons? (2) How valid are quality statements derived from administrative data?This article was compiled following the PRISMA (i.e. preferred reporting items for systematic reviews and meta-analyses) statement for qualitative systematic reviews. In order to answer the first question the Professional Association of German Surgeons (Berufsverband der Deutschen Chirurgen) initiated two surveys and to answer the second question a structured literature search following the PICO (i.e. patient problem or population, intervention, comparison control or comparator and outcomes) format was initiated. In addition numerous websites were contacted.Of the responding senior consultant surgeons 95% considered that the AOK method of quality measurement by administrative data is not objective. One third was definitely wrongly classified. The literature search revealed that no validation data exist for the AOK indicators, including the Elixhauser comorbidity risk score. Altogether, the sensitivity of indicators is poor when good sensitivity is defined by the Institute for Applied Quality Improvement and Research in Health Care (AQUA Institute) as ≥ 80 90%.Quality statements resulting from administrative data alone are unreliable.

Due to logistic, organizational and economic advantages, interdisciplinary emergency centers are gaining more and more acceptance compared to established, discipline-specific and independent emergency rooms. Organizational concepts for interdisciplinary emergency centers need to consider the mandate for comprehensive patient care and the consequential performance spectrum. Thus, the implementation of generally accepted guidelines and specifications is demanding.Currently developed concepts of the accordant interdisciplinary working groups try to fulfill these premises. Further fundamental criteria to be met are the quality and education of medical and nursing staff, which are predominantly doing their jobs within the interdisciplinary emergency centers. The concept of the German surgical societies and connected organizations is not the implementation of a new definition of the role of emergency specialized physicians but rather a substantial advancement of the existing and established regulations for further education. Therefore, a further advanced-training program for clinical emergency medicine has to be implemented in addition to the existing emergency education within the common trunk, which every physician has to pass through during discipline-specific education. Furthermore, this program should complement the existing pre-clinical emergency education, which can be acquired after specialization.The accordant criteria to be developed and the coordination with the German Medical Association (Bundesärztekammer) are currently prioritized on the agenda of the interdisciplinary working group. Due to reasons of compatibility with the regulations for further education, specific management skills for future heads and directors of such interdisciplinary emergency centers should not be stipulated within the advanced-training program for clinical emergency medicine but should be gained through specific course concepts beyond this program.

To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008.A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously.A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551).Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

Acute gastrointestinal bleeding (AGIB) requiring transfusion and surgical treatment still constitutes a life-threatening situation. The purpose of this paper was to examine the treatment outcome for this group of patients as a function of various risk factors and to present our diagnostic and therapeutic regime.A retrospective analysis of data from 154 patients with AGIB who underwent surgical procedures and received massive transfusions in a university hospital between 1999 and 2008 was carried out.The patients were divided into two groups. Group I include 91 patients with acute upper gastrointestinal bleeding and group II included 63 patients with lower gastrointestinal bleeding. The average age was 67 years (range 29-93 years) in group I and 70 years (39-97 years) in group II. The initial hemoglobin level was 8.4 g/dl in group I and 10.5 g/dl in group II. Univariate analysis of mortality revealed the following significant risk factors for group I: postoperative need for ventilation (p=0.007), prolonged ICU stay (p=0.004) and anticoagulants in the medical history. The risk factors in group II were blood transfusions10 units (p=0.031), postoperative need for ventilation (p=0.004), necessary reoperations (p=0.016) and an initial hemoglobin level8.0 g/dl (p=0.043). The complication rate was 76.9% (mortality rate 34.1%) in group I and 60.3% (mortality rate 15.9%) in group II.Examination and stabilization of the patient is directly followed by diagnostic localization. The indication for surgery is mainly limited to peracute, uncontrollable and recurrent forms of gastrointestinal bleeding. The mortality rate for these critically ill, negatively selected patients remains high and could not be lowered in the last decade. Postoperative need of ventilation is a predictor for poor prognosis.

CT scanning of the lungs is the standard procedure for preoperative evaluation of central lung tumors. The extent of the tumor and infiltration of central lung structures or lung segments are decisive parameters to clarify whether surgery is possible and the extent of resection. With computer-assisted methods for the segmentation of anatomical structures based on CT data (Fraunhofer MeVis, Bremen) an enhanced, three-dimensional selective visualization is now possible.From August 2007 through June 2009, 22 patients with central lung tumors were treated at the department of thoracic surgery, University of Schleswig-Holstein, campus Lübeck. There were 15 males and 7 females with a mean age of 60.2 years (range 41-74 years), 18 patients had a long history of smoking, while 4 patients had never smoked. Of the patients 20 had a primary lung carcinoma, 1 patient had local recurrent lung cancer after lobectomy and 1 patient had a central lung metastasis from a non-pulmonary primary carcinoma. A multi-slice detector computer tomogram (MSDCT) scan was performed in all cases. All data were three-dimensionally reconstructed and visualized using special computer-aided software (Fraunhofer MeVis, Bremen). Pulmonary lung function tests, computed postoperative lung volume, bronchoscopic findings, general condition of the patients and the three-dimensionally reconstructed CT data were used for an individual risk analysis and surgical planning.According to the risk analysis 14 out of the 22 patients were surgically treated, 7 patients were staged as functionally inoperable and 1 as technically inoperable. A pneumonectomy was performed in 5 cases, a lobectomy/bilobectomy in 4 cases, an extended lobectomy in 3 cases and 1 case each of a wedge resection and a sleeve resection. Of the 14 patients 2 were classified as stage Ia/b, 7 patients as stage IIa/b and 5 patients as stage IIIa. The median length of time spent in hospital was 8.5±33 days and the mortality rate was 0%. The three-dimensional visualization of the tumor and its anatomical relationship to central pulmonary vessels and the airway system was feasible in all cases. The three-dimensional reconstruction was confirmed in all cases by surgical exploration.Three-dimensional reconstruction of CT scan data is a new and promising method for preoperative presentation and risk analysis of central lung tumors. The three-dimensional visualization with anatomical reformatting and color-coded segmentation enables the surgeon to make a more precise strategic approach for central lung tumors.

Diagnostics and therapy of anorectal disorders remain a surgical question. In close cooperation between different departments (radiology and gastroenterology, urology and gynecology, dermatology and psychology), the role of radiologic imaging is of growing importance. Exact knowledge of functional anatomy and precise clinical examination constitute the basis of the according therapeutic strategies. In this context radiology has contributed decisively. Developments in imaging techniques, e.g. dynamic MRI, highly contributed to better understanding of complex functional pelvic floor disorders. The combination of nanotechnology and high-resolution imaging allows precise staging, especially in rectal cancer. Furthermore, advances in virtual colonoscopy could lead to widely acceptable and patient-friendly screening for colorectal malignancies.

Diagnostics and therapy of anorectal disorders are still questions of surgery. Exact knowledge of functional anatomy and precise clinical examination constitute the basis for the resulting therapeutic strategies. Three-dimensional endosonography and technical advances in flexible endoscopy using high-resolution chromoendoscopy and narrow-band imaging enable exact staging and diagnosis, even of malignancies in earliest stages. Furthermore new in-vivo staining methods combined with high-resolution imaging facilitate the discrimination of inflammatory and neoplastic lesions, which often lead to diagnostic difficulties in chronic inflammatory bowel disease. Developments in neurologic testing, including surface electromyography and sacral nerve stimulation, complement the diagnostic armamentarium.

Applying the principle "practice makes perfect" to interventional medicine would mean that surgeons and departments with high treatment volumes for special procedures should have better results than low-volume institutions. In the last three decades several studies were published dealing with the association of therapy volume and treatment quality, e.g. in oncologic and vascular surgery as well as interventional cardiology. Concerning colorectal cancer it has been shown that an individual surgeon's case load is important but by far not the only therapy-associated prognostic factor. For example interdisciplinarity and multimodality including adequate pathological classification are no less important. For continual improvement of clinical outcome, quality management and control will grow in importance. Thus, it is necessary to develop structures and to specify standards for colorectal surgery. Based on the data available it is not yet possible to define minimum volumes for colorectal surgery.

Minimizing the access trauma of surgical interventions is becoming an essential task in modern surgery in order to make the treatment more comfortable for the patient. Minimally invasive surgery has had a major impact on the improvement of surgical results over the last decade. This is why such surgery is often named as the third patient friendly revolution in surgery after the introduction of asepsis and anesthesia. Operations that caused a huge strain on the patients in the past and led to immense costs for society because of the patient's lost working time and extensive rehabilitation, have lost their fear thanks to this technique. The physical strain is lower, the cosmetic effect is considerable and the costs for society might be reduced due to the significantly shorter duration of convalescence. Despite its known advantages, which have been reported in numerous studies, minimally invasive surgery has recently gained increased interest because of the installation of new accounting systems as well as strict budgeting and restricted resources. Realistic cost-benefit analysis and objectified quality controls are needed in order to guarantee innovative and patient friendly basic approaches in medicine in the future.

Acute abdomen is not a disease in itself but a description of a complex of symptoms combined with severe abdominal pain developed within a time frame of less than 24 h. All strategies for the management of acute abdomen underline the need for an interdisciplinary approach to diagnosis and therapy. This requires focused and intelligent use of efficient diagnostic procedures. Diagnostic laparoscopy may be a key to solving the diagnostic dilemma of unspecific acute abdomen. Furthermore, it allows not only direct inspection of the abdominal cavity but also surgical intervention, if needed. In particular the rate of negative laparotomies can be reduced.

Adequate therapy of obstructed defecation (pelvic outlet obstruction) is often challenging, as the etiology and clinical symptoms include a wide range of disorders. Standardized diagnostic assessment has to differentiate between obstructed defecation caused by either pelvic outlet obstruction or slow transit constipation. Additionally, morphologic changes of colon, rectum, or the pelvic floor have to be separated from functional disorders. Providing defecography or dynamic MR of the pelvic floor, common causes of outlet obstruction such as sigmoidoceles, in which surgery is indicated, and rectal prolapse can be diagnosed with high accuracy. However, the diagnosis and therapeutic options in symptomatic rectocele and intussusception are controversial. Patients with functional disorders such as rectoanal dyssynergia are candidates for conservative treatment (biofeedback). To identify patients who will benefit from surgery for obstructed defecation, careful patient selection remains the crucial issue in diagnostic assessment.

Clinical symptoms in descending perineum syndrome show considerable variations, ranging from obstructed defecation to combined fecal and urinary incontinence and including different types of prolapse. Differential diagnosis has to compete with this complexity. Common pelvic floor disorders associated with descending perineum are rectocele, rectal prolapse, enterocele, and sigmoidocele. Standardized diagnostic tools include detailed history and clinical examination with proctorectoscopy as well as anorectal manometry, endoanal ultrasound, defecography, and dynamic MR of the pelvic floor. The diagnosis and proposed therapy have to be developed within an interdisciplinary concept.

Radio frequency ablation (RFA) represents a new technique for local destruction of liver tumors. Indication and procedure are poorly validated at present.To record the actual nationwide RFA application in Germany, a survey of 2026 hospitals with standardized questionnaires was conducted.With a respond rate of 17.5%, results from 58 hospitals covering 1700 ablated patients were analyzed. In 25.9% of them, RFA is already used in potentially curative resectable tumors, in 22.4% even when incomplete ablation for tumor mass reduction is expected. Of the 58 hospitals, 75% combine resection and RFA to reach a so-called R-0 situation. The maximal tumor sizes they quoted for achieving complete ablation ranged from3 cm to 11 cm. In contraindications for RFA, the tumor size, number of tumors, critical localization of the tumor, and disorders of liver function were mentioned the most.This survey documents significant discrepancies in indication, application, procedure, and results in RFA for liver tumors. The lack of general standards and an overestimation of the method may lead to uncritical application, neglect of standard therapy, or unsatisfying results.

Controversial discussion focuses on the application of laparoscopic curative resection for cancer due to oncologic radicality,tumor cell dissemination, and port site metastases. Considering the limitations of laparoscopic surgery, it is necessary to objectively evaluate whether laparoscopic surgery is associated with an improved quality of curative treatment. Therefore, controlled studies comparing the results of laparoscopic vs conventional cancer surgery are mandatory. To date, comparable findings on short-term outcome of laparoscopy with open resection can only be shown for colorectal cancer. However, long-term data including recurrence and survival are still missing as randomized studies (phase IIIb) are still to be completed. Consequently, laparoscopic curative resection should only be performed within controlled trials. In terms of the upper GI tract, minimally invasive surgery has proven to be technically feasible in expert centers including limited resections for early gastric cancer, left pancreatectomies, or hepatic resections for malignancy. Finally, laparoscopy has gained acceptance in the field of diagnosis (e.g., staging laparoscopy, laparoscopic ultrasound) and palliative treatment (e.g. gastroenterostomy, thermoablation) without the need for controlled studies.

The aim of our study was to investigate the influence of polypropylene meshes on the proliferation and apoptosis of human cell cultures in vitro.Human fibroblasts and HeLa cells were incubated in different densities (10(4), 3.10(4), 10(5) cells/well) together with polypropylene meshes (Prolene, 2 x 2 cm) in six-well culture dishes over a 48-h period. Cells without meshes served as controls. Cells were spun on slides and stained with the monoclonal antibody MIB-1. To calculate the proliferation indices, stained nuclei were counted. Apoptotic indices were determined by flow cytometric analysis, using FITC-conjugated Annexin-V and propidiumjodide for staining.Fibroblasts showed only a slight reduction of the proliferation index (PI) from 64% (controls) to 60% (meshes). Increasing cell density leads to a decrease in the PI of both groups. The PI of HeLa cells was similar in mesh groups and controls and independent of cell density. The apoptotic index (AI) of fibroblasts was significantly higher in the mesh group (3.7%) in comparison with the controls (1.9%). The same was observed for HeLa cells (AI mesh group: 4.5%, AI controls: 1.2%). Furthermore, an increase of AI was found with increasing cell density in both cell lines.Whereas meshes did not influence the proliferation of the cell lines examined, they seem to have a marked influence on apoptosis, as a significant increase of AI was observed in the mesh group in contrast to controls.

A blunt trocar for open laparoscopy is presented. Its modified design leads to better visual control of the trocar tip during insertion. Thus the risk of misplacement of the trocar is reduced.

It is not easy to define haemorrhoidal complaints precisely since this automatically means the entire aetiology and pathogenesis. What Stelzner describes as a complex compound of arteriovenous links in the rectal mucosa with an interlace of unstriated muscles, elastic fibres and connective tissue forms the anatomic base of the "corpus cavernosum recti". This cavernous vascular padding is a crucial component of the continence organ and ensures a gas-tight seal. According to Thomson's studies, haemorrhoids are to be regarded as a consequence of the disintegration of muscular and elastic components, caused by a distal shift of the vascular padding. The changes can cause growth up to prolapse, as well as haemorrhage or congestion. The reasons have not yet been conclusively clarified. Malfunctioning intestines--in particular constipational changes with hard stool--seem to be causal factors. The mechanisms of function and control of arteriovenous links as well as the influence of hereditary, social and cultural disposition continue to be unclear.

We would like to introduce a new trocar technique for minimal invasive surgery. The new trocar is a spiral whose coil becomes ever increasingly stronger towards the centre. Because of this, there is a smooth transition between spiral, screw and rod. The outer diameter remains the same. The spiral-trocar is screwed through the abdominal wall like a corkscrew. Because of this, the primary channel of puncture runs spirally. Furthermore, the channel is dilated and centralised so that the trocar's rod together with its sleeve can be pushed through the abdominal wall. This trocar design demonstrates the following advantages: The trocar can be screwed through the abdominal wall in a controlled manner without having to apply axial pressure. This prevents any unintentional perforation of organs. Because different layers of the tissue are penetrated at different places, they overlap, thus sealing one another after removal of the sleeve. The puncture channel was minimal, thus leaving very little risk of trocar site hernia.The spiral-trocar was examined and compared with other types of trocars in vivo and vitro.During these tests, the spiral-trocar demonstrated a high level of safety and good usability.The spiral-trocar is an easily cleanable, reusable product without a mechanical sealing device and can be used together with most sleeves. This makes it very cost effective.

Within the framework of interdisciplinary palliative treatment strategies for gastrointestinal neoplasms, surgical therapeutic options are of essential importance. They are dominated by the reconstruction of the gastrointestinal passage, ensuring drainage of secretion and the alleviation of pain. Conventional, minimal-invasive and endoscopic procedures are employed individually or in a combined way, integrating all conservative therapies. In many cases, an unnecessary laparotomy with its high morbidity, mortality and prolonged hospitalisation can thus be avoided. This paper describes and discusses current surgical and endoscopic techniques for the palliative treatment of patients suffering from advanced gastrointestinal malignant tumours.

From 1994 to March 1997, 12 patients with 15 drug-related abscesses of the groin were treated at the Surgical Department of Lübeck Medical University. Besides laboratory, serological and microbiological examinations, the standard diagnostic investigation consisted of sonography or duplex sonography. If indicated, the diagnosis was extended to include, for example, clarification of the retroperitoneum by CT. The most common accompanying disease was deep femoral vein thrombosis. Substitution was planned individually. After surgical débridement and perioperative administration of a beta-lactam-protected acylaminopenicillin, open wound treatment was successfully carried out in 13 cases; secondary closure was performed four times in cases of good compliance. One abscess led to necrotising of the femoral artery; saphenous vein was interposed because of erosion bleeding and formation of aneurysm. In a second case, the bifurcation was reconstructed with saphenous vein after external resection of an infected false aneurysm and early occlusion. Both defects were covered by rotation of sartorius muscle and mesh graft. On the basis of the treatment concept, a rapid and successful intervention was possible; complications such as sepsis, amputation or withdrawal delirium did not occur. Resistance against the antibiotic was not observed. In the case of infected aneurysm, we prefer the autogenous saphenous vein graft followed by rotation of sartorius muscle and mesh graft. Ligation or excision leads to high rates of claudication or amputation; extended reconstructions are threatened by insufficient compliance of the patients; the use of synthetic grafts is endangered by further bacteraemia or infections.

Low resection and intersphincteric extirpation of rectal cancer in the distal third of the rectum has become an accepted sphincter-saving method. From December 1990 to December 1994, 42 patients (17 women and 25 men) with a mean age of 67.2 years had a low resection or extirpation of the rectum at our institution. Eighteen patients received a transanal sutured anastomosis, 24 a stapler anastomosis. We had a lethality rate of 2.5% and a anastomotic insufficiency rate of 14%.

Surgeons treating a patient with lower abdominal pain of uncertain etiology are caught between the extremes of conservative and operative treatment. After clinical examination and ultrasonography, explorative laparoscopy has been shown by several studies to solve this therapeutic dilemma. Using laparoscopy prolonged observation, the incidence of perforation and unnecessary laparotomies can be reduced dramatically, in particular, the rate of negative appendectomies is lowered from 30-40% to about 15%. This leads to shortened stay in hospital, increased efficiency and decreased financial costs.

In this study we expanded ileal segments of 8 pigs with an intraluminal expander over a period of 6 to 8 weeks till the volume had reached approximately sixfold of the starting volume. The morphological and morphometrical examinations showed flattened villi with elongated crypts and especially an increase in the thickness of the muscularis. The villi appeared flattened through scanning microscopy as well, but the structure of the microvilli was nearly normal. The proliferative activity in the muscularis, estimated immunohistochemically by a monoclonal antibody against PCNA, showed a threefold increase. So it can be assumed, that the increased thickness of the muscle layer was caused not only by muscle cell hypertrophy but also by hyperplasia. The activity of the alpha-glucosidase, a brush border enzyme, was clearly reduced. The minor cause of this effect was the direct damage of the microvilli from the expander, but the major cause was the exclusion of the ileal segment from the small bowel passage and the resulting lack of nutrients. With our technique it seems possible to create an ileum pouch, a stomach substitute or a urinary bladder substitute.

The importance of the complication incisional hernia after laparoscopic surgery was determined by analyzing our own cases and extensive review of the literature. The data recorded give its incidence as 1 in 550 cases. The most frequent event was intestinal incarceration with a high portion of Richter's hernias. To avoid postlaparoscopic hernias the important step is suturing the fascia when the trocar diameter exceeds 5 mm. When external suturing of the fascia is impossible, the laparoscopic technique using the Reverdin needle is a sufficient procedure for fascial closure after minimally invasive surgery.

The data of 27 patients who suffered from malignant tumors of the small bowel between 1970 and 1992 were retrospectively documented and evaluated. In the mainly elderly patients (5th to 8th decade of life) the tumor was most frequently localized in the ileum (41%), followed by the jejunum (30%) and the duodenum (22%). Adenocarcinoma was the most frequent histological diagnosis. Only 28% of the tumors were limited to the intestinal wall. 40% had metastases, local or to other organs. Due to diagnostic problems only 30% of these tumors were found preoperatively. In 22% of the cases an explorative laparotomy and in 33% an emergency operation because of ileus and/or peritonitis led to the correct diagnosis. Still, in 64% of the patients a R0-resection was possible. Nevertheless, the median period of survival was only 24.8 months. But patients who were R0-resected survived 65 months.

Twenty-one patients were treated for Zenker's diverticulum in the Würzburg University Department of Surgery between 1977 and 1989. Surgery was done in 15 cases (8 single-session resections with myotomy of the upper esophageal sphincter, and 7 resections without myotomy). The postoperative course was uneventful in 73%. Wound infection developed in 2 cases, and suture insufficiency and transient paralysis of the recurrent nerve in one each. In 3 patients, postoperative x-ray prior to release from the hospital revealed retention of contrast medium in a discrete, pocket-like protrusion between the cricoid and the pharynx. Follow-up was done after a mean interval of 4 years (range: 5 months-10.5 years) in 10 of the 15 operated patients. Two of them developed relapses about 1-1.3 cm in size within 8 months and 7 years, resp. Myotomy had not been done in either case. Neither patient had complaints. Esophageal manometry was performed in 6 patients. Resting tone of the upper esophageal sphincter was clearly diminished at 12-30 mm Hg (normal 40-50 mm Hg); maximum contraction pressure was also reduced at 30-75 mm Hg (normal 90-110 mm Hg). However, the decisive factor was the exact temporal coordination of pharyngeal contraction with sphincter relaxation. For this reason it is our unconditional recommendation that myotomy of the upper esophageal sphincter be regarded as an essential step in resection of Zenker's diverticula.

A new treatment of anal incontinence has been presented. This method combines the postanal repair of Parks with a sphincteroplasty by autologous large saphenous vein. The vein has no trophic requirements and has a high containing economy. Manometrically, a highly active high pressure zone has been proven. Histologic examinations have shown flubless healing in the intestinal wall of the free vein transplant when prestretched accordingly.

Intesive histological and biomechanical examinations have shown that the smooth muscles of the human gastrointestinal tract can be freely transplanted to take over the functions of a sphincter. In this study it has been shown how conventional colostomy can be converted into a continent one with the aid of a sphincter plasty. The operational technique, especially encircling the rectum, provides protection at the same time against prolapse of the anus praeternaturalis.

After appendectomy 60 appendices were examined for their biomechanical characteristics. The active contraction capability and the relaxation after noradrenaline were registered in Tyrode's solution by a tension recorder, and a length/tension graph was drawn up. After histological examination of the appendices, the findings were classified as the classical inflammation stadium. It was shown that the appendix wall can retain its physiological properties up to an advanced stage of inflammation. Physiological decomposition and paralysis of the appendix wall occur only when gangrene sets. Examination also showed that in the subacute inflammation stage scars are formed which cause motility disorders which, in their turn, also cause inflammation.

All forms of ileus have one thing in common, namely a disorder of the intestinal motility, which, with increasing distension of the intestinal wall, finally leads to paralysis of the intestine. With the increase in distension mechanical and functional colon changes take place which are discussed in this study. During peristalsis the strain on the wall is directed against the intra-luminal course of pressure. In spite of the increase of the internal pressure from 5 cm H2O to 100 cm H2O, the tension of the wall remains low or even decreases (roughly 500 dyn/mm2). In ileus patients, however, the strain on the intestinal wall increases enormously (about 100000 dyn/mm2). The maximum contraction capacity of the large intestine's muscle system (50,000 dyn/mm2) is high and similar to that of the skeletal muscles.

Femoropopliteal and femorocrural bypasses are standardized procedures. There is given a patency rate of 70-90% after a period of 5 years according to the progress of the disease and to the used graft material. Bypassing the lower limb in AOD (stage III and IV by Fontaine) it is possible to implant a femoropedal bypass. In our patients we had a patency rate of 81.3% during a follow-up time of 13 months. An av-shunt nearby the distal anastomosis seems to be important.

Using autotransplants of an autonomous intestinal muscle segment a sphincter substitute and consequently a continent colostomy can be produced in humans and dogs. The histological study of the intestinal muscle section resected 1--28 weeks after implantation shows, in dogs, a good healing process and vascularization of the transplant muscle, which explains the clinical success. Even after many weeks only slight atrophy and fibrosis can be observed. Only a few of the intramural nerve plexuses perish. Some of the small intestine sphincters remain incontinent. The specimens show a more or less extensive hemorrhagic necrosis of the transplant with high inflammation. The reason for these complications is thought to be the mucosa glands, which were not completely removed from the vulnerable small intestine of the dog before the transplantation.

The diffuse peritonitis is a syndrome during the course of which biochemical reactive chains are activated according to a cascade principle. Most of these biochemical reactive chains develop within an acid environment. The solutions applied for abdominal lavage so far had neutral pH value. The present acute peritonitis experiment has shown that a peritoneal pH increase during lavage therapy stopped the septic reactive chain and thus improved significantly the rate of survival in the test animals. These experimental findings ar now subject for clinical examination.

Reduced cardiac output is the pathogenetic cause of non-occlusive ischemic enteropathia. The abdominal symptoms develop latently and surgery prevalently ensues during the stage of intestinal wall necrosis or perambulating peritonitis. There is a lethality of 50-100% and 50% at this clinic. Prerequisites of early diagnosis are: anamnesis and clinical finding, - laboratory constellation, - sonography, - mesentericography. In early stages, conservative treatment by vasodilators is promising. The laparotomy, however, is indicated in most cases in order to identify necrosis or perforation and to allow surgery according to its stages.

Prostaglandins (E1, E2, F2alpha) produce and intensify peristaltic contractions in the healthy human intestinal muscle system according to dosage (threshold I-10(-4) microng/ml--maximum effective concentration 1 microng/ml). By subsequent introduction of adrenaline, the intestinal muscle system activated by prostaglandines can be completely relaxed again. Intestinal muscles from patients with Crohn's disease show a marked deviation from this behaviour: 1. The intestinal muscle system is extremely sensitive to prostagladins: maximum concentrations are already reached by about a thousand times smaller concentration than in the intestines. 2. The dose of adrenaline does not lead to dialtion, which is usual, but to contraction of the muscle system. These changes in the contractility of the intestine can explain some components of the clinical symptomatology of Crohn's disease.

The effects of perioperative antibiotic prophylaxis in elective colon surgery was evaluated in a prospective study on 100 patients. Bowel cleansing was done by orthograde lavage. The patients were divided into 5 groups receiving equally cefotaxime 3 x 2 g, lamoxactam 3 x 2 g, cefmenoxime 3 x 1 g, mezlocillin 3 x 5 g an piperacillin 3 x 4 g. Mucosa biopsies of the resected colon were taken for aerobic and anaerobic cultures. Further mucosal serum probes were frozen immediately for determination of tissue and serum levels of the antibiotics. Our results show that bacterial growth of the colon mucosa was significantly reduced. Anaerobes were identified in only 8%. The tissue concentrations exceeded the MIC-levels of the identified bowel organisms many times over. The clinical infection rate was 4%. All administered antibiotics can be recommended without reservation.