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A differentiated therapy of chronic pancreatitis and pancreatic carcinoma calls for evaluation of the validity of findings. Excisional biopsies, punch biopsies, and fine-needle aspiration cytology (FNAC) are the options available for intrasurgical confirmation. In 606 prospective cases intrasurgical fine-needle aspiration biopsy and cytological assessment were carried out. There were 330 cases of pancreatic carcinoma and 276 cases of benign diseases of pancreas included. The level of sensitivity is 92.4 %, specificity is 99.3 %, predictive value of positive results is 99.3 % and of negative results is 91.6 %. FNAC is a suitable method for confirmation of pancreatic carcinoma.

UNLABELLED Chronic pancreatitis leads to changes of nearby organs with possible acute and chronic complications including lesions of the spleen. Among 341 patients operated upon between January 1981 and June 2002 in the surgical department Gera, we found 7 spontaneous spleen ruptures or such after minimal trauma and 4 pseudocysts, which expanded to the splenic hilus. In all cases splenectomy was carried out with resection of the tail of the pancreas with or without drainage of the pancreas. 2 patients with a history of splenectomy after minimal trauma underwent duodenum-preserving resection of the pancreatic head to Frey, and distal pancreatectomy, resp. CONCLUSIONS Lesions of the spleen belong to the rare complications of chronic pancreatitis. With known case history and mostly delayed course, the operative concept must be concentrated not only on the splenic lesion but also on the therapy of the chronic pancreatitis.

BACKGROUND The analgetic treatment of inoperable pancreatic cancer patients is of paramount importance. The relative ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. However, the assessment of the results and the effectiveness of the block carried out during laparotomy have been unclear. PATIENTS AND METHODS After 41 intraoperative celiac neurolytic blocks pain intensity was retrospectively analysed in 38 patients suffering from unresectable pancreatic carcinoma. The mean age of the patients was 59 years, the observation period after neurolysis ranged to 6 months. All patients underwent definitive neurolysis using 50 % ethanol in 0.5 % prilocaine. Immediate and long-term efficacy, analgetic consumption and mortality were evaluated at follow-up. The calculated parenteral equivalent morphine dosage (mg per day) was evaluated before as well as at different time points after treatment as an objective parameter to describe pain intensity. RESULTS 7 to 34 days (at discharge from the hospital) after block pain intensity was statistically highly significant reduced (p=0.016). Long-term results were obtained from 17 (10 to 12 weeks after intervention) and 9 (up to 20 weeks after intervention) patients respectively, demonstrating a long-lasting effect of the neurolysis. A statistical analysis was not possible because of the small patient 's number. CONCLUSIONS Intraoperative celiac neurolytic block is a safe and effective method of pain treatment in patients with unresectable pancreatic carcinoma. However, it alone provides complete pain relief until death only in a few cases. Therefore, it should be considered as an adjuvant treatment in the analgesic strategy. Combined palliative therapy is necessary in most of the cases.

Monopolar electrosurgery is querried because of the availability of new preparation-techniques in laparoscopic cholecystectomy. The advantage of simple handling, cheap application and high efficiency has to be set against the danger of tissue lesions e. g. the damage of the bile duct as demonstrated by four own cases. Especially the bipolar preparation-method and ultrasonic dissection are safer, but expensive and not as fast and effective as monopolar technique. Laser-heated instruments exist but are not in wide clinical use. The danger of tissue-lesions can be reduced by accurate preparation-principles and caution in dissection of the Calot-triangle.

Adjustable gastric banding is a popular bariatric operation in Europe. The rate of long-term complications like pouch dilatation, slippage and band migration and the long-term effect of weight loss are reported in meta-analysis and few studies for a period of more than five years. We report on experiences after gastric banding.Over a period of 10 years 168 patients with morbid obesity were treated with gastric banding. Preoperative data, postoperative weight loss and long-term complications were prospectively obtained and retrospectively analyzed.Mean age of the patients was 41.7 years with a mean preoperative BMI of 49.6 kg/m2. No intraoperative or postoperative death occurred in the first 30 postoperative days. Intraoperative conversion rate was 7.1 %. 79.8 % of the patients (n = 134) were available for follow up (mean follow-up time 66.7 months). Long-term complications occurred in 22.5 % of the patients. 30 complications (17.8 %) were related to the band and 8 (4.7 %) to the access-port or to the tube. Mean excess weight loss was 39.6, 47.3, 44.2, 43.4 and 32 % after 1, 2, 4, 5 and 8 years.Laparoscopic gastric banding can achieve an effective weight loss. However band-related and functional complications will influence the late outcome. Pathways to choose the best surgical method for the individual patient are necessary to reduce failures after gastric banding.

A differentiated therapy of chronic pancreatitis and pancreatic carcinoma calls for evaluation of the validity of findings. Excisional biopsies, punch biopsies, and fine-needle aspiration cytology (FNAC) are the options available for intrasurgical confirmation. In 606 prospective cases intrasurgical fine-needle aspiration biopsy and cytological assessment were carried out. There were 330 cases of pancreatic carcinoma and 276 cases of benign diseases of pancreas included. The level of sensitivity is 92.4 %, specificity is 99.3 %, predictive value of positive results is 99.3 % and of negative results is 91.6 %. FNAC is a suitable method for confirmation of pancreatic carcinoma.

From 1984 to 2001, 486 operations were carried out at the surgical clinic in Gera for pancreatic neoplasms, including 49 patients with rare neoplasms of the pancreas. In 23 patients malignant pancreatic tumors were present (9 solitary metastases, 9 endocrine carcinomas, 2 cystadenocarcinomas, 2 schwannomas and one non-Hodgkin's lymphoma). In 28 benign lesions a resection of the tumor was performed, concerning 8 insulinomas, 8 serous cystadenomas, 3 mucinous cystadenomas and 4 rare cystic tumors. A sarcoidosis, an autoimmune pancreatitis and a radiation fibrosis were diagnosed in 3 patients operated under the suspicion of a malignant pancreatic tumor. By means of own case examples and data from the literature these rare entities are described with their diagnostic and therapeutic special features.

The analgetic treatment of inoperable pancreatic cancer patients is of paramount importance. The relative ineffectiveness of pharmacological agents has led many investigators to recommend chemical neurolysis of the celiac ganglions for pain control. However, the assessment of the results and the effectiveness of the block carried out during laparotomy have been unclear.After 41 intraoperative celiac neurolytic blocks pain intensity was retrospectively analysed in 38 patients suffering from unresectable pancreatic carcinoma. The mean age of the patients was 59 years, the observation period after neurolysis ranged to 6 months. All patients underwent definitive neurolysis using 50 % ethanol in 0.5 % prilocaine. Immediate and long-term efficacy, analgetic consumption and mortality were evaluated at follow-up. The calculated parenteral equivalent morphine dosage (mg per day) was evaluated before as well as at different time points after treatment as an objective parameter to describe pain intensity.7 to 34 days (at discharge from the hospital) after block pain intensity was statistically highly significant reduced (p=0.016). Long-term results were obtained from 17 (10 to 12 weeks after intervention) and 9 (up to 20 weeks after intervention) patients respectively, demonstrating a long-lasting effect of the neurolysis. A statistical analysis was not possible because of the small patient 's number.Intraoperative celiac neurolytic block is a safe and effective method of pain treatment in patients with unresectable pancreatic carcinoma. However, it alone provides complete pain relief until death only in a few cases. Therefore, it should be considered as an adjuvant treatment in the analgesic strategy. Combined palliative therapy is necessary in most of the cases.

Chronic pancreatitis leads to changes of nearby organs with possible acute and chronic complications including lesions of the spleen. Among 341 patients operated upon between January 1981 and June 2002 in the surgical department Gera, we found 7 spontaneous spleen ruptures or such after minimal trauma and 4 pseudocysts, which expanded to the splenic hilus. In all cases splenectomy was carried out with resection of the tail of the pancreas with or without drainage of the pancreas. 2 patients with a history of splenectomy after minimal trauma underwent duodenum-preserving resection of the pancreatic head to Frey, and distal pancreatectomy, resp.Lesions of the spleen belong to the rare complications of chronic pancreatitis. With known case history and mostly delayed course, the operative concept must be concentrated not only on the splenic lesion but also on the therapy of the chronic pancreatitis.

In this paper the late results after operative therapy of biliopancreatic carcinomas will be presented. Tumors of this region have many things in common. That's why we investigated the 4 tumor entities together. We studied the case histories of 434 patients treated between 1981 and 1997. We analysed the in- and outpatient data of the "Klinikum der Stadt Gera", documents of the tumor board and informations that were obtained from the ambulatory treating physicians. 283 patients suffered from pancreatic carcinoma, 50 from bile duct carcinoma, 60 from gallbladder carcinoma and 41 from carcinoma of the papilla Vateri. The survival rates after curative or palliative operative therapy of the 4 tumor entities were calculated according to Kaplan-Meier. The rate of curative operations and the 5-year-survival-rate after curative resection were 32.8% and 19.0%, resp. in pancreatic carcinoma, 28.0% and 49.0% in bile duct carcinoma, 26.7% and 50.0% in gallbladder carcinoma and 71.0% and 44.0% in carcinoma of the papilla Vateri. Due to the higher resection rate the overall results in patients with carcinoma of the papilla Vateri were much better than the results in the other analysed cancers. Up to now resection is the only way to cure the 4 entities of malignant tumors of the biliopancreatic region.

Monopolar electrosurgery is querried because of the availability of new preparation-techniques in laparoscopic cholecystectomy. The advantage of simple handling, cheap application and high efficiency has to be set against the danger of tissue lesions e. g. the damage of the bile duct as demonstrated by four own cases. Especially the bipolar preparation-method and ultrasonic dissection are safer, but expensive and not as fast and effective as monopolar technique. Laser-heated instruments exist but are not in wide clinical use. The danger of tissue-lesions can be reduced by accurate preparation-principles and caution in dissection of the Calot-triangle.

Quality management of physicians' performance is supposed to guarantee optimal diagnostic and therapeutic procedures for patients. Quality control in the scope of prospective multicenter quality securing programs are based on the overall analysis of cases with selected tracer diagnoses. It serves as voluntary self-regulation for surgeons who perform an evaluation of their results in a team-based setting. Using colorectal cancer as an example, the quality management of diagnostic issues and surgical treatment are used to outline a treatment protocol for a surgical condition under quality securing aspects. We present the treatment protocol of colorectal cancer on the basis of three studies from 1985/1986, 1991/1993 and 1999. We emphasize our opinion that quality management should be addressed as an concern of the surgical profession, and not as an administrative problem.

Since 1984 we have been using the opportunity to registrate the dissected lymph nodes at different locations of the lymph nodes and the carcinoma in case of D-2 dissection by means of a lymph node dissection protocol. The total rate of lymph nodes by the several patients is an indirect sign for the quality of the lymph node dissection and the preparation work of the pathologist. In about 17% of all cases the number of all found lymph nodes by the pathologist was lower than 15 and so an exactly classification in the N-category was not possible. In case of an exactly lymph node dissection on one hand side the prognosis for the patients life can be improved and on the other hand side an exactly pathological classification is an opportunity to estimate the prognosis better than.

Since 1983 gastric banding has become a proven operative method, which reduces effectively excess weight in morbid obesity. Gastric banding has been popularized as a minimally invasive, completely reversible surgical treatment for morbid obesity. We report here our 4 year experiences of gastric banding with special reference to complications.There were 109 patients in total, of whom 92 were women. Median age was 41.5 years (range 17-62 years) and median body-mass-index (BMI) was 49.6 kg/m2 (range 36.7-82.6 kg/m2). From February 1995 to June 1997 39 patients were operated upon with the open technique. In June 1997 we started the laparoscopic gastric banding. 70 patients were treated with this method from June 1997 to February 1999.The weight loss 6 months postoperatively after gastric banding was 35.3% and 12 months after the operation 43.0% of the overweight. In 17 cases a re-operation was necessary. Indications for re-operations included pouch dilatation in 4 cases, slippage in 3 cases and complications connected with the port system. The operation technique and the kind of band fixation influenced the frequency of complications.A lot of complications especially after laparoscopic gastric banding can be prevented by a strong indication. Using the laparoscopic technique complications like pouch dilatation are diminished compared to the open technique. A standardized operation technique decreases the complication and re-operation rate. Conversions to the open technique were mostly necessary during the learning curve of LASGB (laparoscopic adjustable silicone gastric banding).

With the introduction of laparoscopic cholecystectomy (LCE) the method became very fast successful in clinical practice. To describe the actual situation we initiated in 1994/95 a clinical multicenter study with the name CESAQ. 29 hospitals participated in the study. 4,675 cholecystectomies were performed, a total number of 2,960 patients were operated upon with the laparoscopic and 1,468 with the conventional technique. Furthermore, conversion to open cholecystectomy was necessary in 247 cases. One part of the study focused on the results achieved for patients with acute cholecystitis. 9.4% of the laparoscopic but 37.3% of the conventional cholecystectomies were performed due to acute cholecystitis. We differentiated a simple (adhesions to gallbladder, hydrops) and complicated form (empyema, gangrenous gallbladder) of acute cholecystitis. Treating acute cases the incidence of intraoperative (simple 8.3%, complicated 12.1%) and specific postoperative complications (simple 9.2%, complicated 6.9%) was higher compared to elective procedures (intraoperative 4.6%, specific postoperative 3.7%). This is well known from the experience of open surgery. Nevertheless there were lower general complication rates (simple 5.5%, complicated 5.2%) and no mortality in acute cholecystitis when LCE was performed. Considering an early conversion to open cholecystectomy in cases of severe acute cholecystitis the indication for LCE can be made generously. Great surgical experience in LCE is a requirement for the laparoscopic management of acute cholecystitis.

An upside-down-stomach, usually occurring in eldery patients describes an extreme case of paraesophageal hernia. Due to the possibility of life threatening complications there is an urgent need for surgical intervention. In 1998 three patients suffering from complete upside-down-stomach were treated by laparoscopic surgery at our hospital. Two of them received a hiatoplastic with fundo- and corpophrenicopexy. In one case we did a 360 degrees-floppy Nissen's-fundoplication. Perioperatively, one patient developed a left sided pneumothorax Long-term follow-up 6 months postoperatively in our out-patient department revealed unconspicuous clinical and gastroscopical findings and high patient satisfaction with postoperative outcome. Our case reports show the possibility of adequate operating on upside-down-stomach by means of laparoscopic surgery. Minimal invasive methods provide a good overlock on the operating field and are poor in complications when done by an experienced surgeon, so that patients may profit from comfort of laparoscopic surgery.

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.

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.

In 500 mamma needle biopsies that were cytologically examined we found a precision of 87.4%, with 2.6% false negative, and 6.2% false positive results. In 19 cases a cytological diagnosis was not possible resulting in a sensitivity of 0.94 and a specificity of 0.86. False positive findings were due to misinterpretations of the cytological pictures, as were also false negative findings. In the latter cases sampling mistakes could also be the reason. Cytological diagnostic should only be made using triple diagnostic technique since the methods are complementary to each other in respect to their diagnostic security. Practical experience in the puncturing technique as well as an experienced cytologist are prerequisites using this method successfully as a diagnostic tool.

Reported in this paper are eight cases of femoral fracture in childhood which were vertically extended according to Weber. Positioning is described in minute detail. Axial errors and lateral displacement were continuously reduced by extremely non-invasive reduction. Shortening and rotational errors were totally corrected.

Quite a number of complications were found to occur time and again in the treatment of children for supracondylar humerus fracture, with displacement of the arm axis being a frequent long-term result. However, functionality of the arm usually has not been impaired.

This procedure was mostly performed in cases of recurrent ileus. The high mortality rate is due to the severe underlying diseases or postoperative complications.