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Anastomotic dehiscence has become rarer, but as it still occurs in every patient group, it is vital that it be considered. Factors for anastomotic healing are discussed. The submucosa is the most important layer for a patent anastomosis. Single-layer anastomosis using only the submucosa gives excellent results. If precautionary drainage is desired, there should be no direct contact between anastomosis and drain. For treatment of severe peritonitis serial peritoneal lavage has recently been used at the Wuerzburg University Hospital.

Procalcitonin is a protein which is found in elevated concentrations in the blood circulation during systemic bacterial, fungal or protozoal infection. In contrast to classical acute-phase proteins like C-reactive protein or interleukin-6, it is not elevated after operative trauma. In this paper we present current opinions on the assumed induction mechanisms of the protein by cytokines and endotoxin. Furthermore, the clinical value for early detection of systemic infections in abdominal and transplantation surgery is demonstrated by examples from the literature. Our investigation shows that eight patients with necrotizing pancreatitis had a PCT mean value of 6.9 ng/ml on the day of admission. Seven patients with edematous pancreatitis had only a PCT mean value of 0.69 ng/ml. Despite these differences in the mean values, a significant difference between the normal value and the mean value of the group with necrotizing pancreatitis or edematous pancreatitis was not observed due to the wide range of PCT levels in the group of patients with necrotizing pancreatitis. The fact that only a few of the patients had a superinfected necrosis with systemic evasion of bacterias or their toxins may be the reason for this wide range. We suggest that a discrimination between superinfected necrotizing or sterile pancreatitis and edematous pancreatitis by PCT could be possible but more extensive studies with microbiological examination of the necrotic material are required to recognize the subgroups and to establish the real diagnostic efficiency of PCT in clinical practice, especially in the prediction of the outcome of acute pancreatitis.

This paper reviews the current "state of the art" with regard to psycho-traumatological issues in accidentally injured patients. A MEDLINE search (1985-1995) yielded a total of 135 references, out of which 60 publications were selected and reviewed. The body of knowledge about the psycho-social effects of serious injuries caused by accidents seems to be still limited. There are indications that accidents leave many patients suffering from not only the physical consequences but also considerable psychological problems. A frequent clinical manifestation of such problems is post-traumatic stress disorder (PTSD), but depression, anxiety and the somatoform disorder have also been observed, possibly even more frequently. There have been substantial discrepancies in epidemiological data in the literature, partially because the samples analyzed so far have not been homogeneous enough. It is also obvious that studies have been devoted almost exclusively to disorders and handicaps following (and occasionally prior to) the traumatic event. Seldom has the study focused on patient resources: practically no studies exist on the effects of protective psycho-social factors on the healing process following accidental injuries. More research is needed in order to be able to make predictions on the expected healing of patients during the acute stage of treatment following an accident. These future studies should deliver information on identifying high-risk patients who would require specific psycho-social intervention.

Tuberculosis occurred in 5 (1.2%) of 462 liver transplant recipients. De novo infection was assumed in 4 patients and a recurrent infection in 1. The clinical courses varied, from asymptomatic open lung tuberculosis to disseminated disease with cerebral tuberculoma and convulsions. Four patients survived with anti-tuberculous triple-drug therapy. Very few cases of tuberculosis after liver transplantation have been reported (4 patients in the medical literature and 5 patients in this paper). However, the incidence, course of infection, and outcome seem to be similar to those of tuberculosis in renal transplant recipients, approximately 150 cases of which are known.

In combination with the biofragmentable Valtrac ring a newly developed purse-string suture clamp offers the possibility of performing intraperitoneal anastomoses of the small and large bowel without the need for stapling devices. During this experimental study end-to-end anastomoses of the descending colon were constructed in five pigs. One animal was re-examined on day 1 after the operation and the others were all sacrificed on day 21 after. None of the animals showed any signs of an anastomotic leakage. Little scar tissue was seen macroscopically or histologically in the anastomotic region of the animals sacrificed 3 weeks after the operation. The operative technique presented in this paper might render the so-called assisted laparoscopic procedures for the right hemicolon unnecessary in the future.

With the spread of laparoscopic cholecystectomy more and more complications are being reported. For the first time in this paper a pseudoaneurysm of the right hepatic artery as a complication of laparoscopic cholecystectomy in a 55 year old patient is described. During embolization the aneurysm ruptured and an emergency laparotomy was performed. The right hepatic artery was ligated. The postoperative course up to follow-up at 6 months was uncomplicated.

The peritoneal cavity has a fascial skeleton that is kept under tension by permanent variable resting tone maintained by the abdominal muscles. The lateral abdominal muscles, the diaphragm and the pelvic floor are all components of this fasciomuscular support system. Voluntary and reflective changes in muscle tension allow the entry and exit of matter into and out of the spherical abdominal cavity by opening and closing of specialized wall segments called sphincters. We have previously demonstrated the existence of a resting tone in the tail muscles of mammals from which the human pelvic floor muscles are derived. The pelvic floor and its integrated sphincters form the anorectal organ of continence. This organ is much weaker in females than in males. The spinal centers that govern continence, contain in the female significantly fewer ganglion cells than the corresponding centers in the male. Childbirth and a commonly found tendency to develop constipation are additional stressors for the congenitally weaker female organ of continence. We explain in this paper why the abdominal wall and the pelvic floor may suffer stretch-induced denervation injuries during pregnancy and delivery. Such damage may persist in later life and can give rise to incontinence and "flabby abdomen". Based on our work in this field, we found a new differentiation between continent and incontinent constipation. Continent constipation is caused by spasticity of the pelvic floor characterized by abnormally high sphincter activity. This spastic pelvic floor syndrome can be treated successfully by psychotherapeutic techniques. Incontinent constipation, in contrast, is always associated with subnormal activity of the sphincters and may be a cause of rectal prolapse. It can be treated successfully by anterior rectosigmoid resection. Incontinent constipation will also require operative approximation of the levators in many cases. Improvement cannot be expected to result from this procedure, however, unless the pelvic floor shows some residual resting activity.

Many patients suffer from wrist disorders caused by tendon- and tendon-sheath-affections. Apart from this the successful treatment of these affections is an important implication concerning national economy. In Lower Saxony 2.3% of all RVO-insured patients have these disorders. Most tendon- and tendon-sheath-affections are due to chronic stress which is generally treated by a non-operative therapy. Only some need be treated by a surgical intervention. In this paper the most frequent painful tendon- and tendon-sheath-diseases are listed, their clinical appearance is shown and the different methods of treatment are discussed.

The present paper reports on a 43-year-old female patient who complained over a number of weeks of paroxysms of crampy pain in the mesogastrium. The diagnosis of ileoileal invagination was only made after she had been admitted to hospital for the third time. The following false diagnoses had been made during the 4-week course of the condition: "pyelonephritis", "acute appendicitis", "chronic appendicitis" and, most recently "psychosomatic abdominal distress". The patient was initially treated with antibiotics and finally with psychotropic drugs. Eventually ultrasound suggested the diagnosis of invagination of the small intestine, which was then verified by conventional barium follow-through radiography. The patient subsequently underwent resection of a segment of the small intestine. Entero-enteric invagination is a very rare event in adults, in which a single (often malignant) cause is identified as triggering the invagination. Peristalsis and ingested food push the tumor distad, thus acting as a motor for invagination. The preferred localizations are the junctions between freely moving segments to retroperitoneally fixed segments (e.g., ileocecal region). Ultrasound of the abdomen is the examination of choice for diagnosis of enteroenteric invagination. Surgical resection of the invagination and its cause (generally tumors) is indicated in adults.

A 21-year-old man sustained a burst fracture of the 7th cervical vertebral body complicated by a complete loss of sensory and motor functions. He was treated with a pedicled greater omentum flap interposed between the cervical and thoracic spine in a Latin American country. The purpose of this paper is to point out the atypical way of the initial mismanagement. By applying basic principles of fracture management, open reduction and internal fixation was performed resulting in spinal stability which should enhance any chance of recovery of the patient.

A duplex ultrasonographic system was used to examine the common femoral artery in left and right legs of 49 fit young men and 15 fit young women, to find out the normal blood flow in the human leg during rest. By this method the diameter of the vessel and the time average velocity could be measured and the blood flow calculated. Each person underwent three examinations of each leg after 10-min rests. The average diameter of the common femoral artery was 91 +/- 10 mm (95 mm in the men and 80 mm in the women), the average blood flow 226.2 +/- 82.1 ml/min (235.9 ml/min in the men and 189.6 ml/min the the women). Compared with other methods used for femoral blood flow studies, we found the duplex ultrasound system reliable, non-invasive, and infinitely repeatable. This method therefore also seems appropriate for clinical studies. In a few tests carried out in trauma patients we found a pronounced increase in blood flow after a few days, and also an expected increase in a patient with arterio-venous fistula and an expected decrease in one with arterial occlusive disease. These examinations were performed to establish a method for further examinations of long-lasting blood flow alterations in trauma patients, which will be reported in another paper.

Protein C and S are important factors in blood coagulation reported in many papers about people who suffered from thromboembolic diseases related to inherited or acquired deficiencies. Homozygous protein C/S deficiency is lethal in most cases without therapy. Heterozygous deficiency is moderate and complications occur between the 20.-50. year of age. Acquired protein C/S deficiency is a strong parameter for liver function. The typical clinical manifestations of protein C/S deficiencies are superficial and deep leg vein thrombosis, thrombosis of the mesenterial, cerebral, renal and axillary veins, portal vein thrombosis and pulmonary embolism. Most of the affected people live disease free over a longer period and develop thromboembolic complications during and after trauma, surgical interventions, pregnancy and puerperium. We report our experience with a 60 years old male who had developed a severe bilateral iliofemoral vein thrombosis with signs of pulmonary embolism after total hip replacement. An extended functional protein C deficiency (type II) was investigated by coagulation tests (Protein C Reagent, coagulometric from Behring Institute). A second female patient developed a descending iliofemoral vein thrombosis during pregnancy. Venous thrombectomy with arteriovenous fistula was performed, but reocclusion occurred after delivery. Redo-surgery was undertaken and a second reocclusion took place 10 days later. Further lysis therapy was not able to reopen the venous system. Whereas immunological and functional protein C levels showed normal ranges, the functional protein S level was markedly reduced (IL-Instrumentation Laboratory Protein S-Test).

The granulosa cell tumour is a rare and malignant neoplasia of the ovary. As it has a low grade of malignancy a long course of the disease is observed. Following surgical resection, life-long tumour follow-up is recommended. Based on a case report and a review of the literature, the possible sites of metastases are demonstrated. This paper presents the latest therapeutic concepts and discusses the usefulness of metastasis resection.

The present paper reports on the perioperative metabolic changes in a 70-year-old female patient in whom an acute (oedematous) pancreatitis occurred during the transduodenal excision of a villous adenoma of the duodenal papilla. Since blood was taken for metabolic investigations before, during and after surgery, data on the changes in the intermediary metabolism during the early phase of acute pancreatitis in humans was recorded. Raised activity of the pancreatic enzymes amylase and lipase was demonstrable just minutes after extirpation of the papillary tumour after intraoperative cholangiography had been performed via a choledochotomy. This showed occlusion of the duodenal papilla as well as imaging the pancreatic duct. The reflux of bile into the pancreatic duct is considered to be one of the causative factors of acute pancreatitis (Opie-syndrome). The following metabolic changes were registered at surgery and on the first day thereafter: reduction in the serum concentration of cholesterol ester, the triglycerides and the phospholipids by 30 to 50% of the preoperative values respectively, as well as lactacidaemia (up to 60 mg/dl). At the same time, the serum bilirubin concentration and the concentrations of the amino acids alanine and glutamate in the serum were temporarily raised. The question is, whether these metabolic changes were a direct consequence of the activity of the pancreatic enzymes of amino acid and lipid metabolism that were released into the blood, or whether reduced synthesis by the liver (lipoproteins, lecithin: cholesterol-acyl-transferase) was responsible for these changes.

Most hepatic traumas are easily cured, but the series of 135 consecutive hepatic wounds reported in the present paper is unusual in that the patients were specifically recruited from among patients subjected to neurosurgical or spinal operations, 25% of whom sustained severe hepatic injuries (classes IV and V) as a result of the surgery. The postoperative mortality was analyzed according to such potentially predictive factors as severity of the hepatic wound, the concomitant extraabdominal lesions, the initial shock, and the kind of surgical treatment. The statistical comparison of the factors affecting the results was analyzed by the Chi-square test. The postoperative mortality rate was 24.4% (33 deaths). This mortality rate is evidently related to the severity of the hepatic lesions and to the frequent associated lesions. The 14 deaths from benign and moderate hepatic injuries were due to concomitant lesions. Among the 19 deaths from severe lesions, 12 were directly related to the severity of the hepatic injury and 7 to associated wounds. Complications directly related to the hepatic trauma occurred in 39 cases with 16 deaths. In general, conservative surgical treatment can be performed with quite low mortality. Among the patients who require hepatic resection one of two dies of hemorrhage or coagulopathy. Among conservative procedures, perihepatic packing has proved to be efficient and safe. If perioperative cholangiography has excluded any leak from a major bilde duct, septic complications are rare. Therefore, the surgical treatment of hepatic trauma should be as conservative as possible, because this can stop hemorrhage and decrease the risk of coagulopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

In contrast to adults the protein and energy loss leads to hypermetabolism in the burned child. This is because their glycogen and fat reserves are limited. The catabolism finds expression in the rapid loss of weight resulting from reduction of the structure proteins. Therapeutic consequences will be discussed in this paper. Furthermore cases will be demonstrated where extensive third degree burns were able to be treated by mixed allografts and autografts.

In the management of accident patients a physician must be able to recognize the life-threatening complications of craniocerebral trauma. Therefore, he must be well versed in the symptomatology of such complications and by a short neurological examination be able to find out the risk to the patient. Only in this way is it possible to decide whether the patient has to be merely observed or additional neuroradiological investigation is necessary, whether he has to be transferred to a neurosurgical department or in emergency cases be operated on immediately. In acute epidural hematoma, e.g., with signs of midbrain compression, an instantaneous trephination is imperative; therefore, a general surgeon, too, should have the ability to perform such an operation, the technique of which is described in the paper.

The paper reports on 11 patients with very advanced melanoma, who were treated with a modified version of multiple-stage cancer therapy. No improvement in the course of the illness resulted, but survival may have been slightly prolonged.

The authors have organized therapeutic measures in simultaneous bullet injuries to the arteries and the veins of the extremities on the basis of experience attained in 26 cases. 1. Simultaneous reconstruction of an injured artery and its satellite vein must be aimed at in all instances; 2. even the smallest injuries to the arterial intima favour acute arterial thrombosis, if the satellite vein has been tied up simultaneously; 3. acute arterial occlusion is not caused by the isolated ligature of the vein but by the deep, extended venous thrombosis building up on it; 4. where a main vein is ligated, anticoagulant therapy must be initiated immediately to prevent deep venous thrombosis; 5. simultaneous reconstruction of both the arterial and the venous flow systems must be maintained by postoperative anticoagulant therapy. The paper goes into details of thrombectomy, the technical details of vein reconstruction, the question of whether the establishment of a temporary arteriovenous anastomosis is indispensable,, and injuries to veins associated with fractures and dislocations.

In this paper standardized and quantitative definitions of perioperative risk and risk factor using probabilities are given. A calculation of risk and risk factors is performed using data from a study on perioperative risk in colon resection and a study on a preoperative risk check in general surgery. The problem of one risk factor, a combination of two risk factors and the use of many risk factors to quantify preoperative risk is discussed. Confidence intervals are recommended as a standard method for presenting statistical results on perioperative risk.

The paper deals with the three main areas of indications for plastic surgery: 1. Reconstructive plastic surgery or treatment of defects resulting from trauma or disease. 2. Constructive plastic surgery or treatment of innate defects. 3. Anaplastic surgery or treatment of disfunction of appearance. By defining these different branches of plastic surgery criteria are elaborated that govern all plastic surgery. Differences between the general surgical approach and the plastic surgical approach are explained and emphasis is put on the patients' subjective situation and possible pressures from outside as well as environmental influences that may have bearing on the indication.

Wound textiles suitable for placing immediately over a wound and materials for securing them in position are discussed. Wound texiles have a curative function (blotting-paper effect, antigravitation effect). Conditions for their use are three-dimensional capillary drainage, plane compression, and nonstick and cooling properties. Cellulose fibers absorb moisture in all three dimensions, while synthetic fibers transport moisture around their strands in a two-dimensional course. The nonstick properties are achieved by means of overtwisted threads in the warp (tunnel effect) in woven fabrics, and in nonwoven fabrics (when moisture is produced) by combination with overstretched cellulose, producing corrugations, or (for drying) by the uneven incorporation of overtwisted fibers into the fabric, which produces a ventilating effect. The nonstick properties always become obvious when the dressings are moistened.

Numerous models of computer-aided diagnosis have been developed. However, only a few are used in the clinical routine. The methodology of computer-aided diagnosis is described briefly in this paper and a survey of clinical applications is given. Standards for evaluating these models are proposed and illustrated by examples. The inadequate assessment of most diagnostic systems is one of the main reasons for their limited clinical use. New methodological and technical developments will lead to more clinical applications, if the systems are evaluated adequately.

This paper present the results of follow-up examinations of 2801 operated inguinal hernias. In comparison with the high excision of the hernial sac plus "crude suture", the standard Bassini technique produces poorer results as regards recurrence, testicular atrophy and secondary maldescent. The mortality of elective herniotomy was 0.016% in this series.

Plating of the distal radius is indicated in: a) flexion fractures, b) irreducible intraarticular fractures, c) unstable extraarticular extension fractures, d) chisel fractures of the radial styloid process and the navicular bone, e) correction osteotomies after defective bone healing. The paper presents the final results of 124 radial plate fixations. 73.4% had excellent and good, 20.1% fair, and 6.5% bad results. There was a close correlation between radiologic appearance and clinical function. Early secondary surgery (4th-14th day) showed the best results. Old age had a highly negative influence.

There is reason to doubt the reliability of bone cement in joint replacements. In this paper we report about our indication for the cementless RM-Prosthesis and the follow-up examination of a group of 98 patients four and five years after total hip implantation. The rate of cup-loosening is lower than 1%, in five cases we had to observe stem-loosening. The artificial cup consists of high density polyethylene and has to be inserted with preload. The stem consists of polyacetal with a central metal reinforcement. A snap-fit 32 mm steel-head articulates with the acetabulum. From our experiments we know the importance of neutralisation of sharing and tension forces at the area of the greater trochanter.

Combined skeleto-vascular lesions of the proximal parts of the extremities endanger not only the limb but also life. Operative treatment has to be carried out as soon as possible. Stabilisation of the fracture has priority over vascular reconstruction. This paper reports 39 skeleto-vascular lesions. The most important singular factor to improve the prognosis is the reduction of the time interval between the accident and the restoration of regional blood flow. This can be achieved by avoiding time consuming diagnostic measures, quick stabilisation of the fracture by external fixation, temporary circulation by an intraluminal shunt, and by simultaneous operation. It is important to avoid a post-ischaemic compartment syndrome by early fasciotomy.

This paper lists the factors that affect the stress tolerance of patients undergoing surgery. Hypertonicity is observed in 64 percent of these patients, and signs of depleted coronany supply in 82.5 percent. The stress tolerance can be tested before surgery by means of gas analyses and determination of the minute volume and the pulmonary arterial pressure. During surgery, circulatory crises occur due to occlusion and release of large arterial branches. The anesthetic technique must be selected with due consideration of the increased risk. After surgery the oxygen consumption is increased, which lays heavier demands on the myocardial performance.

The paper reports on the status of radiotherapy of carcinomas of the oesophagus both preoperatively and postoperatively. It is evident that sufficient radiotherapy in combination with chemotherapy produces an improvement in the lethality rate, but has no effect on the five year-survival rate. The optimal solution is preoperative radiotherapy as practised Nakayama's group, with subsequent postoperative irradiation. The palliative results of megavolt radiotherapy alone are excellent with regard to quality of life, but the overall course of the disease is not affected.

Our joint urological and surgical statements demonstrate that in cases of injuries of the pelvic ring and urinary organs there are numerous measures which guarantee adequate primary treatment. They also make it possible to postpone final and definitive treatment. On the other hand predictable as well as unpredictable complication may prevent timely reconstructive operations and may thus impair the final outcome. The purpose of this paper is to emphasize the importance of the fact that the treatment of a polytraumatized patient should be planned by the surgeon who is most experienced in traumatology.

A short introduction about common techniques of regional anesthesia and statistical data about the percentage of such procedures carried out in our institute are presented. Important techniques and aims of regional anesthesia are clearly pointed out. The results of our study are discussed in detail, as are the advantages, disadvantages, indications, and contraindications of regional anesthesia. Finally the paper concludes with our impression of regional anesthesia, its significance and status in China.

80 male Sprague Dawley rats were divided in 8 groups of equal size. After median laparotomy defined abrasions of the serosa of abdominal wall, cecum and ileum were performed (400p, abrasive paper 280 grains/cm2, 8 cm2). The control group (I) received no medication. In the treatment groups 5 ml of the following agents were instilled before closure of the abdominal wall: normal saline (II), 16,250 IE Neomycin with 1250 IE Bacitracin (III), 30% dextrose (MW 70,000) (IV), 50,000 IE Streptokinase with 12,500 IE Streptodornase (V), or TCDO in concentrations of 10% (VI), 50% (VII), and 100% (VIII). All animals were relaparotomized on the 7th postoperative day, the adhesions were dissected and their extent was calculated by computer aid. Furthermore specimens were obtained for microscopic studies. Compared to the controls no reduction of adhesions could be achieved by dextrose. Significantly more adhesions were observed after treatment with Neomycin/Bacitracin. A reduction of about 23% was registered with normal saline and TCDO 10%. The greatest reduction of adhesions was seen after application of Streptokinase/Streptodornase as well as TCDO in concentrations of 50% and 100% (63%). The results were significant after evaluation with the t-test. Histologically there was a correlation between the extent of adhesions and the fibrin film. The new animal model has proven to result in reproducible data if used to evaluate substances for prevention of adhesions. Clinical studies with the best of these agents could serve as an approach to solve the problem of adhesion ileus.

The rare application of external stabilisation requires special knowledge of its indications and surgical assembly, which are closely linked to usually serious bone and soft-tissue damage, topographical prerequisites and biomechanical requirements. This paper differentiates the indications for external osteosynthesis of the femur, immobilisation using external fixation to bridge a joint, unstable fractures of the pelvic girdle, osteosynthesis and application of the fixateur externe in the region of the knee, hip and hand joints, as well as the foot. Combinations of internal and external osteosynthesis techniques in the femur and tibia are presented and discussed. Criteria are discussed for changing from primary external to final internal osteosynthesis, as well as osteotaxis indicated solely by the soft tissue or in plastic surgery.

In cases of a serious post-thrombotic syndrome in which conservative treatment has failed, the possibility of a venous femoralis bypass should be considered. Prerequisites for this procedure are an adaequate v. saphena magna and an open or recanalised v. poplitea at the confluens of the vv. tib. post. et vv. fib. This method was first described by May and Husni; we have modified it by replacing the original end-to-side anastomosis with a more effective end-to-end anastomosis and have added a subfascial av-fistula. Both procedures lower the ambulatory venous pressure. This operation has been performed 23 times; the paper presents the late results from 18 patients, 5 of whom underwent the operation over 8 years ago.

This paper describes the operative techniques appropriate to the treatment of coronary heart disease. The chapters deal with general preliminaries and indications for surgery, the selection of bypass material, surgical instruments for coronary opertaions, the methods of extracorporeal circulation, the distal coronary anastomosis, the proximal aortal anastomosis, intraoperative monitoring of results, intra- and postoperative myocardinal infarction, the fate of venous bypass grafts, operative treatment of the ruptured ventricular septum and papillary muscle, and ventricular aneurysmectomy.

The paper deals with a controlled study concerning 36 patients who underwent surgical papillotomy. Cholangiographic examinations were performed by infusion and endoscopic retrograde instillation, in ten patients additional percutaneaus "blind" biopsy of the liver. Some new remarkable details could be evaluated at the papilla Vateri itself as definite anatomic alteration after papillotomy. Planimetric studies could be added on special details because of the good x-ray-contrasts by endoscopic filling of the biliary tract. With some special reserves the results after surgical papillotomy in 30 controlled persons can be classified as good.