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Background: Patients with atraumatic abdominal pain are common in the emergency department and have a relatively high hospital mortality, with a very wide spectrum of different causes. Rapid, goal-directed diagnosis is essential in this context., Methods: In a Delphi process with representatives of different disciplines, a diagnostic treatment pathway was designed, which is called the Abdominal Pain Unit (APU)., Results: The treatment pathway was designed as an extended event process chain. Crucial decision points were specified using standard operating procedures., Discussion: The APU treatment pathway establishes a consistent treatment structure for patients with atraumatic abdominal pain. It has the potential to improve the quality of care and reduce intrahospital mortality over the long term., (© 2021. The Author(s).)

The radial forearm flap has become a standard for phalloplasty in gender confirmation surgery (gcS) from female to male (FtM). However, there is a lack of experience regarding the use of a prelaminated urethra compared with the older techniques reported by Chang and Gottlieb and Levine. This paper assesses the complications of the individual surgical steps pursuant to the Clavien-Dindo classification., Patients and Methods:  All patients undergoing gender reassignment surgery in our department between 1 January 2011 and 30 June 2017 using a radial forearm phalloplasty with a prelaminated urethra for gcS were included in this study. The total number of patients was 39. The complications after colpectomy, urethral prelamination, phalloplasty, implantation of testicular implants and glans-plasty were assessed. The follow-up after phalloplasty ranged between 6 and 80 months and was 32 months on average. Complications were classified according to Clavien Dindo., Results:  Phalloplasty was uneventful in 5 out of 39 patients (12.8 %). In 22 patients (56.4 %) a grade I complication occurred. Four patients (10.3 %) sustained a grade II complication, 16 (41 %) had a grade IIIb complication and one patient had a grade IV complication (2.6 %). Twenty-eight out of 39 patients (71.8 %) developed urethral fistulas in the direct postoperative course. However, only 8 of these patients (20.5 % of the total population) required surgical revision due to fistulas. Five patients developed a urethral stenosis (12.8 %) requiring surgical revision; in two of them this happened several times (8 stenoses in total). Flap losses occurred in two patients (5.1 %)., Conclusion:  Radial forearm phalloplasty with a prelaminated urethra has become a well-established procedure in female-to-male gender reassignment surgery. In our study, the rate of urological complications was significantly reduced to a level lower than those reported in previous studies. The number of fistulas was significantly reduced during our learning curve and by surgical modifications such as a visor flap at the site of the urethral anastomosis. This large series provides a database of complications classified according to Clavien Dindo for comparison with future techniques and innovations., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background An enterothorax with herniation of bowel segments through a diaphragmatic defect is a rare postoperative complication, which can occur in the early postoperative period as well as several months or even years after the primary procedure. In virtually all cases, this diagnosis requires surgical treatment with reposition of the herniated structures and closure of the diaphragmatic defect. The aim of this study was to describe a larger case series of a rare complication and to present a review of the literature. Material and Methods The data of all patients treated for postoperative enterothorax at our centre were retrospectively analysed with a special focus on time of occurrence, type of clinical symptoms, surgical treatment and postoperative morbidity. Results From March 2007 to October 2014, twenty patients underwent surgery due to postoperative enterothorax. Six cases (30 %) were early postoperative complications (mean 10th postoperative day); in 14 patients (70 %) the enterothorax presented with delay (mean 42 months after primary surgery). The variance of the clinical symptoms was wide, but in the majority of cases, patients presented with symptoms of ileus or new-onset dyspnoea. In two patients (10 %) the diagnosis was an incidental finding without clinical symptoms. Computed tomography (CT) was performed in 70 % (n = 14), chest X-rays in 30 % (n = 6) of patients for diagnosis. Immediate laparotomy was performed in 15 % (n = 3) of cases. The diaphragmatic defect involved the left side in 75 % of cases (n = 15). Surgical treatment was performed via laparotomy in all patients. The diaphragm was closed by a direct suture in 70 % of patients (n = 14); in six patients (30 %) an augmentation (mesh or tissue patch) was added. Overall postoperative morbidity was 55 %; for elective operations it was 0 %. One patient died in the further postoperative course. Conclusion Postoperative enterothorax may occur early or years after primary surgery. Surgical treatment should be performed in a timely manner even in asymptomatic patients to avoid further complications., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The demographic change in Germany with an aging population and the resulting necessity of adequate surgical care for older patients was lately discussed with concern. One major aspect is the estimated higher treatment costs in the care of the elderly., Materials and Methods: InEK data from all cases of patients over the age of 80, who were treated and discharged from 2008 to 2012 as inpatients at the Department of General, Visceral, Vascular and Thoracic Surgery at the Charité - Universitätsmedizin Berlin, Campus Mitte, were analysed. Of a total of 13,612 patients 626 patients were over the age of 80. Their lengths of stay, mode of discharge and discharge management as well as costs and reimbursements according to the relevant diagnosis-related groups were analysed., Results: Cases of elderly patients amounted to a stable 5 % of all cases from 2008 until 2012. Their mean length of stay was 14 (median, 9), range, 1-129 days. 80 % of patients could be regularly discharged, 9 % died, 8 % were transferred to another hospital, 2 % discharged into a nursing home and 1 % into a rehabilitation centre. The elderly patients had a patient clinical complexity level of mean 2.84. Costs per day amounted to a mean 778 (median: 627) €, range: 306-7740 €, total costs to 10,686 (median: 5140) €, range: 368-186,059 €. The mean deficit was 491 (median: 176) € per patient, range: - 30,470-75,144 €. The discharge management was significantly different in comparison to patients under the age of 80 with respect to avoidance of discharge at the weekend., Conclusion: Patients over the age of 80 are a relevant group in surgery. They have an increased perioperative risk, but patients should not be denied surgery solely because of their age. The perioperative management of the elderly has to be of maximum standardised quality. From an economic perspective it can be stated that elderly patients currently pose no exceptional financial risk to a surgical department, but contribute relevantly to the turnover, whereby special attention has to be paid to an early structured discharge management., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: New demands and possibilities of collaboration between hospitals and private practices in Germany have appeared, now that the way has been opened legally. A poll was conducted to analyse the current status of collaboration between outpatient gastroenterologists and hospital surgical departments and to identify possible future collaborations., Materials and Methods: One thousand twenty-six private practices specialising in endoscopy were found by contacting the Association of Statutory Health Insurance Physicians and additional internet research. Of these, 50% were randomly selected (513 private practices) and contacted by mail with anonymous questionnaires about cooperation with their clinical partners. Two hundred three (39.6%) practices responded, of which 200 could be analysed., Results: Of all practices reached, 75% considered the cooperation with clinics very valuable or even exceptional. Still, almost half (46%) suggested necessary improvements in these collaborations. Around a third of all contacted colleagues were already involved in projects following integrated care models. In about 80% of all participants, the main interest in integrated models was specified to be common therapy planning., Conclusion: The data analysis of this study shows a substantial interest of private-practice gastroenterologists in close collaboration with hospitals. It is now up to the hospitals to open contracts with their medical outpatient partners.

Methods: The possible association of brain tumour with headache was investigated in 100 patients seen for brain surgery. Preoperatively, 43 patients suffered from headache. These patients were thoroughly questioned about the nature of their pain. Investigation included the McGill Pain Questionnaire., Results: In only 11 of the patients was headache the primary symptom of a brain tumour. Pain intensity was found to be lower in patients with brain tumour then in those with extracranial tumours or headache of other origins. Female subjects, patients under 50 years of age and those with elevated intracranial pressure experienced more intensive pain. Diurnal variation in pain intensity was observed in 60% of patients with headache. There was no evidence, however, of an association with elevated intracranial pressure., Conclusions: Our investigations yielded new information concerning the epidemology of headache accompanying brain tumours. Headache is not an early cardinal symptom of brain tumours, as was generally believed earlier. With the help of the McGill Pain Questionnaire a fine quantitative and qualitative characterization of headache of different origins could be made. The connection between tumour localization and pain lateralization, as well as the possible mechanisms of intracranial pain projection was extensively analysed. The interpretations of the results are at best hypotheses and they do not help determine why more than half of the patients with brain tumour did not experience headache.

Two ELISA techniques were investigated comparatively regarding their IgM sensitivity and specificity in human toxoplasmosis. Results of the fractionated Toxo-IgM-IIF assay were used as a standard for comparison. In 96 of 264 specimens the Toxo-IgM-IIF assay was positive. Positive sera were investigated quantitatively, negative sera only in the serum dilution 1/50 in both the indirect and the reverse Toxo-IgM ELISA. Sensitivity of the indirect technique was calculated greater than 99% and specificity 97%. The corresponding values for the reverse technique were 66% for sensitivity and greater than 99% for specificity.