Search

Congenital pseudarthrosis of the tibia (CPT) is a rare disease that has challenged trauma and orthopedic surgeons for a long time. Clinically CPT mostly presents with progressive varus and antecurvation malformation of the tibia in infancy and childhood. In many cases CPT is associated with neurofibromatosis or fibrous dysplasia. Without knowledge of the clinical picture a discontinuity of the tibia and/or fibula visible on an X‑ray can be misinterpreted as a simple fracture. Histopathological investigations have revealed that a pathological alteration of the periosteum in the region of the pseudarthrosis, a hamartoma, may be essentially responsible for this disorder. Consequently, to treat the CPT a resection of the hamartoma must also be carried out. Multimodal treatment approaches combining pharmacological and surgical treatment, such as the cross-union technique of Paley, seem to have improved the prognosis of CPT.Die kongenitale Pseudarthrose der Tibia (CPT) ist eine seltene Erkrankung, die Unfallchirurgen und Orthopäden seit langer Zeit herausfordert. Klinisch imponieren eine meist zunehmende Antekurvations- und Varusfehlstellung der Tibia im Säuglings- und im Kleinkindalter. Oft ist die CPT mit einer Neurofibromatose oder fibrösen Dysplasie vergesellschaftet. Eine Diskontunität der Tibia und/oder Fibula kann bei Unkenntnis des Krankheitsbildes als einfache Fraktur fehlgedeutet werden. Histopathologische Untersuchungen lassen vermuten, dass eine pathologische Veränderung des Periosts im Bereich der Pseudarthrose, das Hamartom, im Wesentlichen für dieses Krankheitsbild verantwortlich zu sein scheint. Somit muss zur Heilung der CPT auch eine Resektion des Hamartoms erfolgen. Multimodale Therapieansätze mit Vereinigung medikamentöser und operativer Ansätze wie z. B. die X‑Union-Technik von Paley scheinen im Verlauf eine günstigere Prognose aufzuzeigen.

Wearing a school backpack every day may cause postural problems and affect the gait pattern of children and adolescents. The aim of the present study was to analyze the influence of a 4 kg backpack load on the gait pattern and postural sway.The aim of the present study was to analyze the influence of a backpack load of 4 kg on the gait and postural sway of elementary school children.In this prospective study, a group of 12 elementary school children aged between 7 and 10 years without neurological or orthopedic problems participated. The measurements included a clinical examination, three-dimensional gait analysis with electromyographic recordings and measurement of postural sway on a force plate.The backpack load, on average 15% of the body weight, led to a slower walking speed, shorter step length and increased double-support phase. Increased anterior pelvic and trunk tilt, as well as hip flexion were also observed. Furthermore, the muscle activity and postural sway of the children were affected by the increased load.School backpacks weighing 4 kg caused changes in gait, muscle activity, posture and stability in elementary school children. Due to the weight of the backpack, the centre of mass shifted backwards and the children became less stable. During gait, this was compensated by increased anterior pelvic and trunk tilt and increased hip flexion. The activity of the paraspinal muscles was decreased and indicates that the backpack is carried passively. This may cause a negative long-term effect.HINTERGRUND: Das tägliche Tragen eines schweren Schulrucksacks kann möglicherweise Haltungsstörungen hervorrufen, die sich auf das Gangbild und die Standstabilität der Kinder und Jugendlichen auswirken.Ziel der vorliegenden Studie war es, den Einfluss einer Rucksacklast von 4 kg auf das Gangbild und die Standstabilität bei Grundschulkindern zu analysieren.In der prospektiven Arbeit wurde ein Kollektiv von zwölf Grundschulkindern zwischen 7 und 10 Jahren ohne neurologische oder orthopädische Probleme untersucht. Die Messungen beinhalteten eine klinische Untersuchung, eine dreidimensionale Ganganalyse mit elektromyografischen Aufzeichnungen und die Prüfung des ruhigen Stehens auf einer Kraftmessplatte.Die Rucksacklast von durchschnittlich 15 % des Körpergewichts führte zu reduzierter Ganggeschwindigkeit, verkürzter Schrittlänge und verlängerter Doppelunterstützungsphase. Zudem kam es zu einer erhöhten Oberkörpervorneigung, Beckenkippung und Hüftbeugung. Auch die Muskelaktivität und Stabilität der Kinder wurde durch die erhöhte Traglast beeinflusst.Schulrucksäcke mit einem Gewicht von 4 kg führten bei Grundschulkindern zu Änderungen von Gang, Muskelaktivität, Haltung und Standstabilität. Das Gewicht des Rucksacks verlagert den Körperschwerpunkt nach hinten und führt zur Instabilität. Dies wird beim Gehen durch eine vermehrte Oberkörpervorneigung, Beckenkippung nach vorne und vermehrte Hüftbeugung kompensiert. Die verminderte Paraspinalmuskelaktivität deutet darauf hin, dass der Rucksack passiv getragen wird. Dies könnte sich im Langzeitverlauf negativ auswirken.

It is understood that an effective brace therapy requires a primary curve angle reduction of 50% after administering the first orthotic brace.The aim of the study was to determine the efficacy of conservative brace therapy for scoliosis with a curve angle above 20° and to determine possible influencing factors.The current study included a cohort of 110 scoliosis patients with conservative brace therapy. The development of the scoliotic curve during brace therapy was documented for an average of 40 months. Influencing factors such as the initial Risser sign, age at the start of treatment, gender, curve patterns and body mass index were analyzed.The collective consisted of 88 patients with idiopathic and 22 with neuromuscular spinal deformities. At the beginning of the brace therapy, the average age was 12.2 ± 2.8 years with a mean scoliosis curve angle of 30.4° ± 12.5°. The primary brace reduced the scoliotic curve by 31% to 20.9°. In children and adolescents with lower maturity status, the success of the brace therapy was greater than in patients with a higher Risser sign. In addition, children with obesity had less success during brace therapy than normal- or underweight children.The initial curvature correction of 50% required for effective brace therapy could only be achieved in one third of the patients. On average, the correction was 31%.

Reduction and retention of the scoliotic curve in children with progressive spinal deformities.Progressive neuromyopathic scoliosis which cannot be controlled conservatively (especially by walking disability), and/or development of a thorax insufficiency syndrome (TIS).Insufficient soft tissue coverage; body weight 11.4 kg; body mass index (BMI) 25 or50 kg; missing osseous anchoring structures (ribs); adult skeleton (usually age 12 years at surgery); severe spasticity.Indirect correction and distraction of the spinal deformity by two extendable, paravertebral telescopic implants, anchored to the cranial ribs and the iliac crest; the spine is not compromised surgically.Early functional therapy, no brace; multiple surgical (VEPTR®-system) or externally (magnetically controlled rods) controlled extensions per year.The surgical paravertebral "no-touch" technique for spine correction is particularly suitable for children with neuromyopathic scoliosis with a body weight 11.4 kg. Our prospective group of children (n = 45), was treated with a combination of the classic vertical expandable prosthetic titanium rib (VEPTR®) anchored to the ribs and iliac crest combined with a magnetically controlled telescopic implant (MAGEC®). The primary correction of50% was achieved, while progression was effectively prevented over years. In 495 outpatient lengthening procedures, the rate of implant-associated complications requiring surgery was 3.7%. Of the 45 children, 13 (29%) underwent surgical revision. With the proposed surgical "no-touch" technique for scoliosis correction of pediatric neuromyopathic deformities, an effective reduction of the scoliotic curve can be achieved and maintained. Advantages of the method are a partial retention of spinal flexibility and a reduction of spinal ossifications, which facilitates dorsal spondylodesis as the final treatment.

In pediatric flat foot a differentiation has to be made between the flexible and the rigid form. The diagnosis is based on the history, clinical examination as well as pedobarography, gait analysis and imaging techniques. It is important to rule out neuropediatric conditions such as muscular dystrophies, Ehlers-Danlos- or Marfan syndrome. In children six years of age and younger a flexible flat foot is nearly always physiological (97% of all 19 months old children). Up to the age of ten years the medial column of the foot is developing. Only a minority of children (4% in ten year olds) has a persistent or progressive deformity. Beyond to age of ten there is a danger of deformity decompensation as well as an increased rigidity. Only a minority of children develops some pain ( 2%). A clear risk factor for persistent pediatric flat foot is obesity (62% of six year old children with flat foot are obese). Pathogenetic factors include muscular, bony or soft tissue conditions. However, there specific rule is still unclear. Prevention consists in a thorough parent information about the normal development as well as encouragement of regular sportive activities. Soft and large enough shoes should be carried as a protection. Barfoot walking has to be encouraged on uneven grounds. If physiotherapy is needed different methods can be applied. Orthosis treatment should include a proprioceptive approach. Surgical interventions in children are rare. If surgical treatment is planned a detailed algorhythm should be used before utilizing one of the many different surgical methods.Der kindliche Knick-Senk-Fuß ist eine 3-dimensionale Fußfehlstellung mit vermehrter Valgusstellung der Ferse, Abflachung der medialen Längswölbung und Abduktion des Vorfußes. Man unterscheidet die flexible von der kontrakten (rigiden) Form. Die Diagnostik gliedert sich in Anamnese, klinische Untersuchung, apparative Diagnostik wie Pedobarografie und die Ganganalyse sowie bildgebende Verfahren. Wichtig ist die Einbeziehung in ein Therapieschema von eventuell vorliegenden pädiatrischen oder neuropädiatrischen Erkrankungen (z. B. Muskeldystrophien, Ehlers-Danlos- oder Marfan-Syndrom u. Ä.). Es zeigt sich, dass bei Kindern ≤ 6 Jahre der flexible Knick-Senk-Fuß fast ausschließlich physiologisch vorkommt (bei 97% aller 19 Monate alten Kinder). Bis zum Alter von 10 Jahren bildet sich die mediale Fußlängswölbung zunehmend aus. Bei einem kleinen Anteil (10-jährige Kinder 4%) persistiert der Knick-Senk-Fuß oder wird progredient. Oberhalb von 10 Jahren besteht die Gefahr der Dekompensation mit zunehmender Rigidität. Nur die Minderheit der Kinder entwickelt eine Schmerzsymptomatik ( 2%). Ein Risikofaktor zur Persistenz des Knick-Senk-Fußes stellt das Übergewicht im Kindesalter dar (62% der 6-Jährigen mit Knick-Senk-Fuß sind übergewichtig). Pathogenetische Faktoren können muskulär, knöchern und bindegewebig sind, wobei hier der Einfluss der unterschiedlichen Faktoren kontrovers diskutiert wird. Die Hauptprävention besteht in einer umfassenden Aufklärung über eine normale kindliche motorische Entwicklung. Daraus resultiert die Eigenförderung der physiologischen Entwicklung durch tägliche Bewegung, das Anstreben eines normalen Gewichtes, das Tragen von weichen Schuhen mit ausreichender Länge und Weite zum Schutz und das Barfußlaufen auf wechselnden Untergründen. Im Falle einer nötigen Intervention kann Physiotherapie inklusive manueller Techniken nötig werden. Eine Einlagen- oder Orthesenversorgung sollte bevorzugt mit einer sensomotorischen Bettung erfolgen. Operative Eingriffe sind selten. Im Falle einer geplanten operativen Intervention muss ein differenziertes Indikationsschema angewandt werden. Verschiedenste operative knöcherne und weichteilige Methoden stehen zur Verfügung.

Erectile dysfunction (ED) is often associated with increased cardiovascular risk. There is increasing evidence suggesting that dysfunction of the vascular endothelium with reduced bioavailability of nitric oxide (NO) may be the pathogenetic link between ED and cardiovascular disease. The crucial importance of the NO-guanylatecyclase-cGMP-phosphodiesterase pathway for penile erection is mirrored by the efficacy of phosphodiesterase-5 (PDE5) inhibitors in the treatment of ED. In contrast to other currently available PDE5 inhibitors with a half-life time of about 4 h Tadalafil has a half-life time of about 17.5 h resulting in erectile responsiveness for up to 36 h after 1 single dose. Most clinical experience has been reported with on-demand use of PDE-5 inhibitors, but meanwhile several studies were able to demonstrate that Tadalafil given daily in low (2.5 and 5 mg) doses is both highly effective and well-tolerated. In three randomized, double-blind, placebo-controlled multi-center trials, various validated measures of erectile function indicated that once daily Tadalafil at doses of 2.5, 5, and 10 mg was significantly superior to placebo.In another mono-center trial, once daily Tadalafil has shown significant efficacy even after failure of on-demand treatment. In a controlled cross-over study of on-demand versus daily Tadalafil treatment, 72% of the patients preferred once daily administration, mainly because of superior and longer efficacy allowing a more spontaneous sexual life. Interestingly in a pilot study of on-demand versus chronic administration of Tadalafil for 4 weeks, only regular dosing improved several markers of endothelial function.

Torsional deformity in the lower extremities is well known in children and adolescents with hemiplegic cerebral palsy, however, little or nothing is known about possible differences in torsional behavior of the upper extremities. Alterations of torsion in the lower extremities influence the gait, alterations in the rotation behavior of the upper extremities, for example after fractures, lead to limited movement of the arms or to an altered movement radius. The aim of this study was to investigate whether there is a difference in humeral torsion between affected and non-affected arms in children and adolescents with hemiplegic cerebral palsy and which factors play a decisive role.A total of 33 children and adolescents with hemiplegic cerebral palsy (mean age 9.7 years, range 3-16 years) answered a questionnaire and were examined clinically, photographically and with a new ultrasound method. Severity of cerebral palsy was classified into three levels. Ultrasound measurements of humeral torsion were compared with the results from a normal collective (n=149).In approximately half (n=16, 48.5%) of the 33 children investigated, humeral torsion was directed more internally, in 17 (51.5%) children humeral torsion was directed more externally compared to the healthy side. The difference in humeral torsion between the affected and non-affected sides was significant (p0.05) in both groups. Differences in humeral torsion between the affected and non-affected sides in children with hemiplegic cerebral palsy were significantly increased (p0.00001) compared to differences in humeral torsion between left and right arms in healthy children. A correlation with the level of severity of hemiplegic cerebral palsy was observed but there was no correlation with age. Children and adolescents with external torsional deformity had a smaller range of rotation, a larger muscle force deficit of the affected upper extremity and did less sport using the affected arm than children and adolescents with internal torsional deformity.Humeral torsion deformity in children and adolescents with hemiplegic cerebral palsy was proven to exist in addition to the already well known difference in torsion of the lower extremities. Analogous to increased activity of external or internal rotator muscles codetermined by the palsy, increased external or internal humeral torsion occurs. External torsion deformity was associated with a smaller range of motion and seemed to have a greater importance for routine daily activities (e.g. muscle force, sports ability) than internal torsion deformity.

Inter- and intraobserver reliability and learning curve using Graf's ultrasonographic hip examination were assessed.189 participants of the basic, advanced and final courses on hip ultrasound using the Graf method (DEGUM) were asked to answer a questionnaire and to measure 34 normal and pathological sonographic hip examinations. Measurement differences and the learning curve during the different courses were evaluated.There was a significant (p = 0.001) improvement of the average angle between the basic (6.74 degrees [+/- 1.46 degrees ]) and the advanced course (6.22 degrees [+/- 1.17 degrees ]). However, there were no better results in the final course and no additional improvement. Participants had higher variations when measuring the beta-angle than the alpha-angle. A significant improvement was seen if the participants performed a large number of hip ultrasounds between the courses. Higher measurement differences were seen in pathological hip ultrasounds and in ultrasonographic examinations of poorer quality.During the educational courses on hip ultrasound using the Graf method, a high intra- and interobserver variability was seen. These findings were most prominent in measurement of the beta-angle, in pathological hip ultrasounds and in ultrasonographic hip examinations of poorer quality. The best results were achieved by participants who had performed a large number of examinations between courses. For the improvement of ultrasonographic measurements, a large number of self-performed examinations and a training in potential mistakes seem to be of great importance.

Children with congenital thoracic scoliosis associated with fused ribs and unilateral unsegmented bars adjacent to convex hemivertebrae will inevitably develop thoracic insufficiency syndrome and curve progression with hemithorax compression without treatment. It is assumed that the concave side of such curves and their unilateral unsegmented bars do not grow. In the past early spinal fusion was performed with consecutive short thoracic spines and loss of lung volume. Little attention has been paid to lung function. These patients often suffered from lung failure and early death due to a small thorax.A new surgical technique is based on an indirect deformity correction and enlargement of the thorax due to a longitudinal implant, the vertical expandable prosthetic titanium rib (VEPTR). The spine is not fused, thus promoting growth of the spine, the thorax and the lungs. Elongation of the implant is done every six months. Since 2002 this method has been performed on fifteen children in Basel as the first European center.Patients (mean age 6 years; 11 months to 12 years) were suffering from thoracic insufficiency syndrome due to unilateral unsegmented bars with fused ribs (n = 4), absent ribs (n = 2), bilaterally fused ribs (n = 2), hemivertebrae (n = 3) or neuromuscular scoliosis (n = 6). Doing fifteen primarily implantations and thirteen elongations there were three complications (two hook dislocations, one skin breakage). All patients improved cosmetically, functionally and radiologically which was shown on X-rays as a reduction of the Cobb angle from an average of 76 degrees (40-110 degrees ) to 55 degrees (30-67 degrees ).Expansion thoracoplasty and VEPTR implantation is a new treatment concept for children with thoracic insufficiency syndrome due to spinal deformities, which is based on distraction and expansion of the thorax thus allowing growth of the spine, the thorax and probably lungs. Presently it seems to be superior to any other method for the treatment of small children with progressive scoliosis and thoracic insufficiency syndrome.

The slipped capital femoral epiphysis (SCFE) is defined as a nontraumatic epiphyseal separation and slipping of the proximal femoral epiphysis, which usually occurs during the adolescent growth spurt. Slipping of the upper femoral epiphysis may be classified as acute, chronic, and acute on chronic. The etiology of the disease is still not fully understood but seems to be multifactorial. The typical SCFE during puberty has to be differentiated from the atypical form, which may be associated with an endocrinological disorder or with its therapy. The typical SCFE may be found in male patients, with increased height and weight. It is likely that the growth rate is slightly accelerated before slippage. Obesity is often associated with a decreased femoral anteversion accounting for abnormal mechanical shear forces at the growth plate. SCFE is treated surgically. Surgical methods are administered according to the degree of disease. Because of possible alterations of blood supply to the femoral head, acute SCFE is an emergency. Following SCFE, complications such as chondrolysis and avascular necrosis are feared.

The purpose of the study was to evaluate the prevalence of foot pain and foot deformities in adolescents. It was aimed to obtain information on the association between foot pain and foot deformities.A total of 2 368 adolescents (age 14.5 +/- 0.7 years) were evaluated. The frequency of foot pain was probed by using a self-reporting questionnaire. The foot deformities were evaluated during clinical examinations by school doctors.The prevalence of foot pain was 14.0 % and the prevalence of foot deformities was 13.7 %. The prevalence of pain was significantly higher in adolescents with foot deformity (17.8 %) than in persons without deformity (13.4 %), p0.05. The prevalence of a flexible flat foot was 6.2 % and the prevalence of a rigid flat foot was 0.5 %. Other deformities registered were splay foot (2.3 %) and flexible splay-flat foot (2.0). The prevalence of hallux-valgus deformity was 3.5 %. A total of 3.5 % patients were suffering from a plantar hyperkeratosis. This was significantly correlated to a high pain prevalence (the hyperkeratosis was significantly associated with a high prevalence of pain). Significant factors which were significantly associated with foot pain were foot deformity (1.4 fold) and hyperkeratosis (75 fold). Foot pain was 1.4 fold higher in children with foot deformity and 75 fold higher in feet with hyperkeratosis.The prevalence of foot pain and foot deformity in adolescent is high. Mild deformities (flexible flat foot and splay foot) are physiological variations without any association to foot pain. Pathological conditions that are associated with foot pain are the rigid flat foot, the hallux valgus and the cavus deformity. Plantar hyperkeratosis is an indicator of foot pathology.

Children with congenital thoracic scoliosis associated with fused ribs and unilateral unsegmented bars adjacent to convex hemivertebrae will invariably have curve progression without treatment. It is assumed that the unilateral unsegmented bars do not grow and therefore early spinal fusion has been performed in the past with consecutive short thoracic spines and loss of lung volume. A new surgical technique is based on an indirect deformity correction and enlargement of the thorax via a longitudinal implant, the vertical expandable prosthetic titanium rib (VEPTR). The length of the thoracic spine after VEPTR implantation was analyzed in 21 children with an average follow-up of 4.2 years. Eighteen children did not have any prior surgery while three had already undergone spinal fusion. Using a 3-D analysis of computed tomography, a significant growth of the concave (7.9 mm/7.1% increase per year) and convex (8.3 mm/6.4%) side of the thoracic spine was found with no significant difference between sides. Unilateral unsegmented bars showed significant growth as well. Contrary to common knowledge, we were able to demonstrate the growth of the concave side of the thoracic spine and of the unilateral unsegmented bars after expansion thoracoplasty and VEPTR implantation.

Non-randomized prospective multicenter studies involving a large number of patients are often capable to prove effectiveness of perioperative antimicrobial prophylaxis in situations where it is not feasible to carry out highly sophisticated clinical trials due to limitations in logistical or financial resources. Furthermore, these studies tend to give a true picture of the daily work and procedures in hospitals, contrary to controlled trials in clinical research which might suffer of multitudes of restrictions and exclusions. Some non-randomized studies each involving more than 1,000 patients on antibiotic prophylaxis in colonic and biliary surgery as well as appendectomy are discussed and its usefulness demonstrated.

For several decades it has been proven that adequate antimicrobial prophylaxis is effective in reducing postoperative septic complications also in appendectomy. The rational for this approach--including laparoscopic procedures--is discussed and national and international recommendations for antibiotic prophylaxis in appendectomy are cited. Unfortunately, in spite of all the evidence, less than 50% of all appendectomies in 1996 in Germany had been carried out under antibiotic cover--with serious consequences for many patients and increased costs for prolonged hospital stay and treatment due to the higher incidence of infectious postoperative complications. Surgeons are encouraged not to neglect facts and benefits concerning the use of appropriate prophylactic antimicrobials in all appendectomies.

The effectiveness of antimicrobial prophylaxis was evaluated on the basis of data collected in a study on quality management carried out in 28 East German hospitals, involving 4477 laparoscopic and conventional cholecystectomies (197 of which with revision of the common bile duct). In 3128 patients a laparoscopic procedure (with consecutive conversion to an open cholecystectomy in 236 cases) and in 1349 patients a primarily conventional open cholecystectomy had been performed (a total of 2217 cases with and 2260 cases without antibiotic cover). The results obtained were significantly better in the group receiving prophylaxis than in patients not under antimicrobial cover. This applied to septic wound healing disorders, general and specific postoperative complications, postoperative chest infections, re-operations and postoperative lethality. On the basis of these results, it is strongly recommended that, in the future, neither laparoscopic nor open conventional cholecystectomy should be carried out without proper perioperative antimicrobial prophylaxis-this all the more so since such measures also result in a shorter hospital stay and thus reduced costs.

Hodgkin's disease, especially its biology and pathogenesis, has been under discussion for more than 160 years. Numerous investigations have focused on the nature and clonality of Hodgkin cells, but so far no definitive answer have been yielded by immunohistochemistry, Southern blotting and PCR. However, the use of single-cell PCR has now made it possible to answer the question of the derivation of Hodgkin cells. Using a micromanipulator, Hodgkin cells can be picked out of histological sections and B-cell specific gene rearrangements (VDJ) can be amplified. With this technique it has proved possible to demonstrate the B-cell derivation of Hodgkin cells and their clonality. Mutated immunoglobulin genes in lymphocyte-predominant Hodgkin's disease indicate a germinal center cell origin of Hodgkin cells of this type. These findings, however, do not exclude cases of Hodgkin's disease with Hodgkin cells with a T-cell genotype.

This investigation characterizes the proliferating cells in Hodgkin's disease. We used the antibody PC 10 which reacts with the proliferating cell nuclear antigen (PCNA) and works on paraffin sections in combination with B- and T-cell markers in a double-staining technique. In all 38 cases of Hodgkin's disease (lymphocyte predominant type n = 10, nodular sclerosis type n = 10, mixed cellularity type n = 10, lymphocyte depletion type n = 8) a high percentage of the Hodgkin and Sternberg-Reed cells (95%-97%) expressed PCNA. There was no statistical significance between the different types. In contrast, only a small amount of the reactive lymphocytes (2.8%-3.4%) demonstrated positivity for PCNA in the four types of Hodgkin's disease. Nearly all of these lymphocytes were T-lymphocytes.

We have investigated seven cases of large cell lymphomas (LCL) developing simultaneously or metachronously to nodular lymphocyte-predominant Hodgkin's disease (nodular paragranuloma, NP) for the presence of EBV and the chromosomal translocation t(14;18) by use of the polymerase chain reaction (PCR). The expression of the bcl-2 oncogene product in these cases and in five cases of progressive transformation of germinal centres as a potential precursor of NP was detected immunohistochemically with the monoclonal antibodies bcl-2-100 and bcl-2-124. All cases investigated were negative for EBV genomic material. The chromosomal translocation t(14;18) was also absent. Expression of the bcl-2 oncogene could be detected only in one case of nodular paragranuloma and in an unrelated case of LCL. Hence, LCL developing out of NP differ from other germinal center derived high-grade lymphomas.

Heterotopic small bowel transplantation was performed in allogeneic rats with and without cyclosporine. Syngeneic animals served as controls. Small bowel allografts, lymphoid tissues and small bowel of the host were investigated by immunohistochemistry using antibodies against T-cells and macrophages. During rejection, increasing numbers of macrophages infiltrated preferentially the deep layers of the small bowel wall, whereas only a slight T-cell infiltration was observed. No histological changes were noted in the organs of the host. Cyclosporine prevented lymphoid as well as macrophage infiltration of the transplant. Rejection monitoring of small bowel transplants is possible by investigation of macrophage infiltration in deep biopsies including the submucosa.

A primary resection and reanastomosis of the colon is often the procedure of choice, even in the presence of a significant stenotic element, provided there are no mayor disturbances of water-electrolyte homeostasis. In a series of 100 consecutive colonic resections (23 complicated by perforation, 9 by ileus, and 2 by bleeding), 97 patients were treated by primary resection (92 without a protective colostomy). No untoward effects were noted specifically due to this technique. The overall mortality rate was 4%, a favorable result when compared with the cumulative risk of a multiple stage procedure.

Between 1970 and 1973 1333 patients with suspected appendicitis were seen at the University Hospital of Basle. Operations were performed on 87.5%, of whom 89.8% proved to have appendicitis. The incidence of perforation was 13.5%. A five-year follow-up study was carried out on 100 cases dismissed without operative revision and appendectomy. Of these patients 20 later had an appendectomy and 42% did not approve of the conservative attitude. The high rate of secondary appendectomies within 5 years seems to advocate liberal indication for appendectomy if appendicitis is considered.

A case of discrete, localised Morbus Ménétrier is reported, with pitting of a giant mucosal fold at the antrum, where the patients' main symptom was recurrent gastric haemorrhage. The presentation posed considerable diagnostic difficulties that were only clarified through a partial gastric resection and subsequent histological examination.

As an alternative to the extraluminal methods of Noble and Childs-Phillips, the intraluminal splinting of small bowel with the Baker-Tube offers a new possibility in the operative treatment of ileus secondary to adhesions. We report our experiences in 28 patients, using this procedure. An unselected group with severe adhesions was treated with the Baker-Tube, in the majority of the cases at the time of the emergency operation. The immediate postoperative course as well as the results of follow-up examinations 1/2 to 3 1/2 years after the operation are reported. Our experiences can be summarized as follows: 1. Generalized, extensive adhesions are the best indication for the intraluminal splinting. The Baker-Tube should be used with reserve in cases of early and often complicated relaparotomies, especially in the presence of diffuse peritonitis, because of the danger of bowel perforation at the tip of the Tube. 2. The procedure is less time consuming than Noble's operation and in addition allows immediate decompression of the small bowel while advancing the tube. A careful technique is important to prevent complications:--tight closure of the jejunostomy at the insertion point.--fixation of the jejunal loop to the abdominal wall with non absorbable sutures.--in cases of compromised lumen at the insertion point, an entero-entero-anastomosis between afferent and efferent loop should be done. With these precautions, fistulas, detachment of the jejunostoma and stenosis of the jejunal loop can be prevented. 3. Postoperative bowel function is usually rapidly restored, a distinct advantage when compared to the Noble procedure. 4. The rate of complications in our patients is lower than in a reported comparable group with Noble technique. 5. The recurrence rate is much lower than in a reported comparable group with Noble technique. Intraluminal splinting with the Baker-Tube can be recommended as an effective procedure in the treatment of ileus secondary to adhesions.

Aetiology of colonic perforation is reviewed and discussed. 8 cases of "spontaneous" ileo-colic perforations observed between 1975 and 1977 are presented. Two of these patients had recently undergone appendectomy, and 4 others showed a simultaneous distal carcinoma of the large bowel. Histo-pathological evaluation did not reveal the cause of intestinal perforation. Operative treatment and results are given.

A prospective study concerning 100 consecutive cases of colonic resections and anastomosis with single layer sutures is reported where radiological controls 10-12 days postoperatively had been carried out. An anastomotic insufficency was recognized clinically in 15%; in 6% a small leakage was only detectable radiologically. 50% of all anastomotic deficencies were seen in cases with preexisting perforation peritonitis or ileus, especially if an emergency resection had been necessary due to septic complications. 3 out of the 7 deaths were connected with dehiscence in the suture line.

4 cases of postoperative subhepatic abscess formation after cholecystectomy are reported, where absorbable hemostatic agents for control of bleeding had been used. The etiology of these complications is discussed. The use of local hemostyptica is strongly disadvised in all possibly bacteriologically contaminated procedures.

Prerequisites for anastomoses in intestinal surgery are: 1. no tension on the suture line, 2. preservation of vascularity, 3. cut bowel ends without malignant or severe inflammatory disease. Healing is influenced by general conditions, operative technique, kind and strength of suture material, number of sutures and layers and so on. Usually, a one step procedure with end-on single layer anastomosis is recommended.

An aerodynamic and bacteriological evaluation of a new sterile operating enclosure has been undertaken, comparing it with a conventional operating theatre under sham operating conditions with or without coincident use of either a surgical helmet or surgical face mask. Statistical analysis of these studies show the bacterial level in the sterile enclosure at the wound site is significantly lower than in ordinary operating theatre conditions whereas the use of a helmet with evacuating ducts effects these findings insignificantly.

A vascular interruption to the azygoportal zone, achieved by devascularisation about the cardia and a closed transmural ligation of the varices is described, which is combined with a simultaneous truncal vagotomy, pyloroplasty procedure and a fundoplication. This fourfold method combats the bleeding varices at several points: a direct disruption of vascular paths, haemodynamic control, reduced influence of peptic factors, the management of coincident ulcer pathology and the prevention of gastro-oesophageal reflux. The results from 5 patients are encouraging. This abdominal operation is swift, comparatively atraumatic and may be undertaken in emergency cases and in at-risk patients on an elective basis.

Small intestine perforations caused by systemic disorders are, except with M. Crohn, extremely rare. Therefore we report two cases of "spontaneous" small intestine perforations: one with hypersensitivity angiitis and one with Moya-Moya-disease, the latter not yet described in the literature.

6 cases of colonic endometriosis, treated by surgery, are presented. The average age was 50 years. All patients also had concomitant genital endometriosis and 5 of these 6 women have had previous pregnancies. Pathological findings were intramural colonic growth leading to stenosis and tumor like endometriomas. 3 times a sigma resection, once an ileo-cecal and once an anterior resection was carried out, there is in one instancy the stenosis could be overcome by enucleation. Postoperative course was uneventful, but one case later on developed a rectal carcinoma--first mistaken as recurrence of intestinal endometriosis.

100 consecutive colonic resections for carcinoma are reported. The average age was 67.5 +/- 10.8 years. In 93% of all cases primary resection without colostomy was carried out. The overall operative mortality rate was 1% and the mean hospitalization period 19.8 +/- 7.3 days.

Two series of 50 consecutive elective colonic resections with bowel preparation either with Neomycin (group A) or Neomycin combined with Metronidazole (group B) are presented. 17 bacterial inflammatory complications in group A versus 10 in group B were noted. It is concluded that the addition of an antianaerobic antibiotic agent in elective colonic surgery might be of beneficial effect.

Medical management of mass casualties and catastrophy are discussed and principles of treatment outlined, consisting in first aid, improvisation, sorting (triage), organised help and avoiding panic and epidemics. Preparedness and leadership, summarised under the heading "catastrophy planning" are the most important elements to counteract catastrophies.