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The operative technique of endoscopic extraperitoneal inguinal and femoral hernia repair without fixation of the polypropylene patch is presented. The results of 725 inguinal and femoral hernia repairs are demonstrated and discussed.

The technique of laparoscopic sigma-/rectum-resection and the technique of the laparoscopic abdominoperineal excision of the rectum are discussed under oncological aspects. The results of 24 laparoscopic resections of sigma and rectum and of 15 laparoscopic abdominoperineal excisions of the rectum are demonstrated.

As a result of 1277 laparoscopic cholecystectomies, which were performed as a standard procedure in uncomplicated and complicated symptomatic cholecystolithiasis, the complication-rates of conventional cholecystectomy and laparoscopic cholecystectomy are compared. It can be demonstrated, that the adoption of the principles of conventional cholecystectomy into laparoscopic technique and a careful preparation can reach the same high level of safety as the so called "gold-standard".

Sympathetic skin reflex (SSR) was evaluated in the lower extremities of 60 normal volunteers aged 17 to 72 (mean age 38 +/- 16 years, 28 females, 32 males). SSR was obtainable in all volunteers and most often consisted of a biphasic wave with initial negative deflection. Mean latency was 2.16 +/- 0.20 s. Mean variation in a second repetitive measurement was 0.21 +/- 0.14 s. The SSR was not age- or sex dependent. There was a weak positive correlation of the SSR with the height of the volunteers (r = 0.271; p = 0.037). SSR was investigated in 39 patients with polyneuropathy (age 59 +/- 18). SSR was pathological in 51% on one or both legs. There was no correlation of the SSR to the aetiology nor to the type of lesion (axonal versus demyelinating polyneuropathy) nor to clinical symptoms. The applicability of the SSR is reviewed from the literature regarding polyneuropathy, erectile dysfunction, central degenerative diseases, multiple sclerosis, sympathetic reflex dystrophies, spinal and peripheral nerve lesions. SSR is briefly compared to alternative methods. SSR appears to be a reasonable method to describe a small section of the autonomic nervous system (sympathetic sudomotor function) and to calculate group differences. There appears to be no close correlation to any of the autonomic disturbances in individual patients.

The importance of 15N as tracer in medical research is increasing. Since 1965 many results were obtained in cooperation of surgeons (Surgical clinic of Karl-Marx-University; Bezirkskrankenhaus St. Georg, Leipzig) and coworkers of Central Institute of Isotope and Radiation research. Using 3 test models (15N-labelled amino acid solution, permanent infused; 15N-labelled glycine, given as one single dose; 15N-labelled casein, oral given) healthy persons, patients in stress condition and after gastric operations and rats after performing several types of gastric operations were studied. Possibilities of calculations with mathematical models are shown.

The 15N-tracer technique gives new opportunities to medical research for investigation of normal and pathological nitrogen metabolism. Analysis of 15N kinetic data derived from total nitrogen excretion in the urine allows to calculate quantitatively certain parameters of protein synthesis and protein metabolism. At the same time analysis of serum samples will allow measurement of 15N-nitrogen incorporation into particular protein or non-protein fractions of the plasma. In the study reported here patients with different liver parenchyme lesions (acute hepatitis, chronic active hepatitis, biliary obstruction, cirrhosis of the liver, hepatic coma) were investigated with a standardized 15N-tracer method developed by us. It could be shown, that protein turnover in patients with liver insufficiency is significantly decreased as compared to healthy persons. Decrease of protein synthesis is associated with a still more pronounced decrease of protein catabolism. There are significant differences in dynamics of 15N in patients with hepatic coma as compared to other patients with liver parenchyme disease without portal encephalopathy. Nevertheless, even in hepatic coma 15N incorporation into plasma proteins can be shown. Differences in the 15N elimination kinetics of the non-protein pool between patients with chronic active hepatitis, biliary obstruction and hepatic coma could be found.

The 9th observation of esophageal intramural diverticulosis is reported. The findings are compared with those of former publications. Clinically dysphagia is a leading symptom. Suction biopsy proved diverticulosis being the correct interpretation for radiological findings. The etiology is discussed. The change between symptom-free intervals with diverticulosis only and episods of dysphagia by secondary inflammation (reflux esophagitis, moniliasis, stenosis) stresses the importance of such secondary complications. These inflammations can hide the real diagnosis for a long time. The radiological findings are the key for diagnosis, however, they can be very small for years. During this period a diagnosis can only be achieved by knowledge of the disease and the skilful search for early symptoms.

Indication and significance of roentgenological procedures referring to esophageal and gastric motility are discussed with special reference to a number of functional disorders. Cinematography and tape-recording are necessary for fast peristaltic motion as in vascular, neurological and myogenic diseases of the upper esophageal sphincter. Pharmacological response may for instance help to differentiate functional from morphological disorders or postoperative complains. Combinations of roentgenological and radioisotopical studies or manometry may be usefull for special diagnostic problems.

Cannulation of the papilla has been successful in 144 out of 197 ERCPs. The rate of success increases with the experience of the endoscopist. The intended filling of the pancreatic duct was successful in 87%, of the bile ducts in 64% and of both duct systems in 28%. The correct diagnosis was made in 77% of pancreatic affections, 71% of biliary diseases and in 43% when both duct systems had to be evaluated. 10 ERCP findings disagreed with the final diagnosis, mainly because the distinction between acute and chronic pancreatitis was not correct. The differentiation of chronic pancreatitis from pancreatic carcinoma is not easy and the evaluation of processes localized to the papilla may be difficult. Complications occurred in 6.6%. It is concluded that the ERCP should be limited to regional hospital centers and should be performed only in cases with well defined indications.

The radiological workup of 15 patients with a carcinoid has been evaluated. As 7 of the 15 patients presented for emergency operation, only the remaining 8 had barium studies (7 barium meals and 1 barium enema). Two of the barium meals were even retrospectively, entirely negative. In two others, initially the diagnosis was missed despite radiological signs, which had been overlooked on follow-up films. Fluoroscopic examination of the small bowel would probably have ensured the detection of the lesion. At the time of diagnosis nine tenth of the tumours were already infiltrating and more than half of them metastasizing. The presence of the carcinoid syndrome implies the production of the causative hormones in the liver or the pulmonary circulation. In order to find the primary intestinal carcinoid in a cureable stage- that is, before it has metastasized-, all patients with diarrhoea and repeated bouts of abdominal pain should have a careful follow-up examination of the small bowel. This examination must include fluoroscopies.

This study compares the effect of two amino acid solutions on protein metabolism after injury by measuring nitrogen balance, 15N-elimination, total body protein synthesis and utilisation of administered nitrogen in an experimental study using pigs. Protein synthesis and nitrogen utilisation were determined using a 15N-tracer technique with recourse to mathematical model concepts. The non-surgical control animals had a lower urinary nitrogen excretion, a more favourable nitrogen balance, a higher 15N-retention, greater total body protein synthesis and utilisation of the infused amino acids during infusion of an amino acid solution with a standard amino acid pattern (A) than the operated animals (solution B). Comparison of the post-operative data shows that if solution A is compared with solution B whose amino acid content takes account of changes in plasma amino acid metabolism following trauma, solution B yields the better results in respect of 15N-retention as well as total body protein synthesis and nitrogen utilisation.

By use of stable isotope labeled amin acid 15N-glycine the effects of truncular subdiaphragmatic vagotomy and of pyloroplasty, which are comprised in the method of bionomic gastric operations, were studied separately. The assessment of nitrogen equilibrium in rats after only truncular vagotomy, only pyloroplasty, truncular vagotomy combined with pyloroplasty, and without surgery serving as controls yielded results as following: After truncular vagotomy the 15N equilibrium was worse than in the control animals or after pyloroplasty only. The cause of that is an enhanced nitrogen loss in urine. After truncular vagotomy with pyloroplasty, though, 15N excretion in feces was significantly higher than after only pyloroplasty. It may be concluded from these results that truncular vagotomy is primarily responsible for the disturbances in protein metabolism. Pyloroplasty in combination with truncular subdiaphragmatic vagotomy also causes a higher nitrogen excretion in the feces indeed.

It is possible to investigate the influence of parenteral applicated L-amino acids on protein metabolism of whole organism by the help of 15N-tracer technique in this paper described. We can determine the utilization of nitrogen parenteral applicated quantitatively. On the basis of graphical methods the protein synthesis rate can be calculated. We get this from mathematical models, based on 3-pool-model. The calculation bases on 15N-elimination in urine after intravenous infusion of 15N labeled amino acids solution during the time of 24 h (endproduct method). We describe 3 graphical methods, using the so-called values of plateau of cumulative 15N-excess amount (96 h) (plateau method A) or 15N abundance after 24 h (plateau method B) and the slope of the curve of 15N excess, amount at 24 h ('slope' method). By the help of these methods the therapeutical nutritive conceptions can be evaluated.

The following examinations have been carried out with various methods of diagnostic imaging: 148 CT, 69 US, 56 Ly. Data on the rate of accuracy of the various methods of examination in the individual abdominal regions. CT examinations rose from 1980 to 1985 from 83 percent to 100 percent. US examinations ranged between 50 to 25%. Lymphographies dropped from 54% to 0%. Owing to the early dissemination pattern of the NHL with frequent primary extranodal involvement, lymphography is no longer indicated. In the abdominal region including the pelvis, CT is superior to US accuracy also with those abdominal findings that have been histologically verified. CT cuts show a better reproducibility and more accurate basis for therapeutic controls. The problem of the mere characteristic of the "size of the lymph node" with non-invasive diagnostic imaging will be discussed. The costs of the various methods of examination are compared with each other. The strategy of examination has changed.

In 7 convalescent patients we studied utilisation of a single dose of 15N-labelled glycine. In intervals we estimated total-N, urea-N, NH3-N and their 15N-abundances (urine). The following results were obtained. The peak of ammonium-15N appeared 25 minutes earlier than the peak of urea-15 N. The cumulative elimination of total-15N amounted to 25% of uptake after 24 hours and to 34.4% after 6 days. 12 hours after application 53% of the total amount, excreted within 6 days, were already eliminated. 24 hours after administration 80% of total-15N was urea-15N and 2.8% NH3-15N. Further we found correlations between N-balance (N-application minus excretion) and elimination of 15N-urea: If N-balance got more negative, the amount of cumulative elimination, the portion of urea-15N to total-15N and the percentage of elimination after 12 hours related to 6 days were elevated. That means that in stress condition utilisation of glycine to urea is higher and accelerated. The model seems acceptable, to get information concerning metabolic situation in a simple way.

1. Under stress an increased amount of labelled amino acids is incorporated. 2. Under the conditions of stress amino acids too participate in the process of synthesis. 15N-glycine was used as tracer in a quantity of 0.64 g of amino acid and 24 kcal per kg per day, that is at a 0.027 g per kcal. hour infusion rate, so that the infused 15N corresponded to 75% of the total residual nitrogen in healthy subjects and 57% in operated patients. 3. Sixteen percent of the infused 15N is secreted with the urine of healthy subjects as urine nitrogen, and 57% as urine nitrogen and 4--5% as ammonia nitrogen with the urine of the operated cases. 4. In contrast to normal conditions, under stress a higher percentage of the infused amino acids participates in energy production. 5. Stress enhances uropoiesis as in regards both quantity and speed. 6. No difference in acid-base balance was found in the case of postoperative infusion; urinary and plasma concentrations remained within normal limits.

The quality of esophageal voice and speech after laryngectomy depends on several factors. Negative influences are produced by irradiation, resection of the hyoid bone and radical neck dissection. The factors important in esophageal speech were analyzed, with consideration given to the functional morphology of the pseudoglottis and the reconstructed hypopharynx. Phoniatric, laryngologic and radiologic aspects are considered.

After surgery for gastric or duodenal ulcer the resorption of amino acids is changed due to alteration of morphology and function of stomach, bile system, pancreas and small bowel. We used the stable isotope labelled amino acid 15N-glycine in patients after partial gastrectomy (B II), truncal vagotomy with pylorplasty as well as antrectomy and in healthy persons. It could be shown that in contrast to the control group the absorption of the amino acid in the surgical group took place more rapid and more intensive.

The case of a 30-year-old woman with intra- and extrahepatic biliary dilatations (Caroli's disease) is reported. The features of the disease and its differential diagnosis are discussed. Special reference is given to the diagnostic approach by endoscopic retrograde cholangiography and to treatment with Chenodeoxy-cholicacid.

The results of endoscopic retrograde cholangio-pancreatography were evaluated in a prospective study of 126 patients in respect of diagnostic accuracy, as compared with surgery and clinical follow-up. The diagnosis was incorrect in 11 patients; in seven it failed to differentiate between acute and chronic pancreatitis. The discrepancies in the other four patients are described in detail, particularly with reference to prepapillary filling defects. The indications, advantages and limitations of ERCP are discussed.

A standardized 15N tracer method is described for the assessment of the nitrogen and protein metabolism in healthy and pathological changed organism. The method represents an isotope technical procedure for the application in the clinical research and practice. The single parts of this routine method are: --the clinical preparation of the patient/proband by means of a standardized nutritional regime, --the tracer administration (single dose) and the sampling (urine, blood), --the 15N-tracer technique (sample chemistry, emissions-spectrometric isotope analysis), --the mathematical evaluation of 15N tracer data.