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Unlabelled: We studied developments in indication, operation time, conversion rate, morbidity, and mortality from the beginning of laparoscopic cholecystectomy. Between 1990 and 2002 we prospectively evaluated 4498 patients undergoing cholecystectomy (CE), of whom 79% were treated laparoscopically (lap). In 6.6%, the procedure had to be converted from laparoscopic to open cholecystectomy (con), and 14% were performed open from the beginning (open). During the above time period, the rate of open CE decreased steadily (49% in 1990 to 7.2% in 2002). The average operation time of lap CE remained constant with an average of 74 min (range 20-330). The conversion rate decreased in spite of broader indication for lap CE in even more complicated gallstone diseases, from an initial 9.4% to 2.5%. Among intraoperative complications in lap and con, bile duct lesions remained constant with 5/3856 (0.1%), bleeding which led to conversion decreased from 1.9% to 0.3%, and the rate of gall bladder perforation increased from 12% to 20.5%. Thirty-day morbidity was 2% in lap CE, 5% in con, and 11.5% in open. The mortality was 0% in lap, 0.7% in con, and 1% in open., Conclusion: Since the introduction of laparoscopic cholecystectomy the indication for this minimal-invasive operation steadily increased, the conversion-rate decreased and the complication-rate could be held low. Even with fast laparoscopic experience 7% of all cholecystectomies are technically difficult and remain to be carried out primarily in an open technique. The laparoscopic cholecystectomy has become the gold standard in the therapy of gallstone disease.

Crohn's disease and ulcerative colitis are specific inflammatory bowel diseases. Quality of life can be considerably limited. It does not depend on the form of therapy that Crohn's disease is highly recurrent, whereas colitis ulcerosa is curable by proctocolectomy. For both forms of disease surgery is an important option. It has to be included early in the therapy concept and not as last choice. Quality of life in patients with Crohn's disease can be raised significantly by surgery. Meticulous selection of the patients are essential to the policy of surgery as well as a regular aftercare. Best profit for those patients are treatment with an interdisciplinary team, consisting of gastroenterologists, nutrition advisers, psychologists, surgeons and radiologists.

Surgery of pancreatic and biliary tract carcinomas includes an extensive surgical dissection with removal of all neural and lymphoid tissue together with a skeletonization of hepatoduodenal structures. Skeletonization or autodigestion may lead to pseudaneurysms of perihepatic arteries. Rupture of one of these aneurysms may cause a severe upper gastrointestinal bleeding. Only a few cases of these serious complications are reported in literature.

Treatment of idiopathic constipation requires precise definition of the physiological and pathophysiological changes. A colorectal work-up including colonoscopy, colorectal passage, colonic transit study, anorectal manometry, cinedefecography and electromyography help to distinguish between four different forms of idiopathic constipation: slow transit constipation, outlet obstruction, a combination of both problems and irritable bowel syndrome. 70% of patients with chronic constipation suffer from irritable bowel syndrome. In these cases there is no indication for surgery. Patients with pelvic outlet obstruction due to paradoxical puborectalis contraction can be successfully treated with biofeedback. Outlet obstruction due to rectal prolapse, rectocele and intussusception require surgery. Total colectomy with ileorectal anastomosis is the surgical option for selected patients with slow transit constipation. Where there is a mixed disorder, biofeedback for the outlet obstruction must be applied prior to colectomy for the inert colon. Thorough preoperative physiologic testing is mandatory for a successful outcome. When cases are carefully diagnosed and selected, the operative results are excellent.

Unlabelled: The choice of the best reconstruction technique following resection of either the stomach or the rectum remains a matter of discussion. While there is no problem in reconnecting intestinal segments, which do not serve as a reservoir, there are many different operation techniques to replace the stomach and rectum, producing significantly different functional results. The ileocecal segment offers an excellent intestinal reservoir combined with an antireflux mechanism, thus presenting an ideal replacement for the stomach. For replacement of the rectal reservoir as well, the ileocecal segment may be used in the first line of treatment., Method: The ileocecal segment was used in 20 patients following gastric resection and lymphadenectomy to reconstruct the intestinal passage between the esophagus and the duodenal stump (group A). In some further 44 patients (group B) the ileocecal segment was used to replace the rectum between the descending colon and the dentate line following resection for very low-grade rectal cancer. Mortality and morbidity were investigated in both groups. In group A quality of life, weight loss, dumping and reflux symptoms were evaluated. In group B continence, discrimination, defecation quality, urge and the patient satisfaction were investigated. All data were recorded prospectively., Results: Early and late mortality were not different compared to other reconstruction types. In each group one patient died within 60 days postoperatively due to myocardial infarction. The morbidity following stomach replacement was 20%, following rectal replacement 4.6% during hospitalization and 13.8% during follow-up, respectively. One patient complained about heartburn, but endoscopically no pathology was detected in any patient. Three months postoperatively the patients' weight remained stable or started to increase. Three months following rectal replacement 87% of the patients were continent with further improvement over 2 years. Soiling mainly during the night remained over 2 years in 44%. 88% of the patients were completely satisfied 2 years postoperatively., Conclusion: The replacement of either the stomach or the rectum using the ileocecal segment with an adequate surgical technique is safe and produces excellent functional outcome regarding the reconstruction of the intestinal passage as well as the reservoir function of the primary organ. Furthermore, preservation of the duodenal passage after gastrectomy may prevent dysregulation of the endocrine and exocrine pancreatic hormones.

The hand-sutured coloanal anastomosis requires adequate and atraumatic exposure of the anal canal in order to avoid sphincter damage. We evaluated a new modified anal retractor to improve exposure of the anal canal and thread handling during construction of hand-sutured coloanal anastomosis. This new device was used during all coloanal and transperineal procedures performed in 1997 in our hospital. This new device is safe and extremely comfortable for the surgeon. It speeds up the procedure and keeps sutures out of the way when completing a coloanal anastomosis.

Introduction: The optimal inguinal hernia repair technique is a matter of debate. The Shouldice operation has long been regarded as the gold standard. While specialized hernia clinics have reproduced good results, a recurrence rate for trainees and non-specialized surgeons of between 10% and 15% seems to be more common. Laparoscopic hernia surgery has brought decreasing postoperative morbidity, low post-operative disability and early return to work. These advantages of a tension-free technique are due to the use of a prosthetic mesh. It is largely the efforts of Gilbert, Lichtenstein and Rutkow/Robbins which have popularized the use of prosthetic mesh by an open anterior approach in the USA., Methods: Since January 1997 we have prospectively evaluated the open mesh plug repair described by Rutkow/Robbins in Basel and Lugano. We have operated on 110 patients (103 male, 7 female). All patients were interviewed 4 weeks postoperatively at our clinic., Results: There were no major complications. Two patients underwent reoperation for drainage of a haematoma. There was no early recurrence or infection. After 4 weeks 82% of all patients were back to normal activity. An early return to work has been noted (10 days on average for sedentary workers)., Conclusion: The main advantages of this technique are simplicity, low cost, reduced post-operative disability and early return to work. It is much too early to say anything concerning recurrence in this series.

In clinical practice a long Roux-en-Y reconstruction is most often used for gastric replacement. Among various postgastrectomy symptoms, alcaline reflux is the most disturbing. A great variety of different pouch reconstructions with or without duodenal bypass only control reflux in part. The ileocoecal interposition has been placed between the oesophagus and the duodenum as a gastric substitute in 14 patients without postoperative mortality. This preliminary series demonstrates an excellent control of alcaline reflux and a good quality of life, according to the Eypasch score. Dysphagia or stasis in the distal oesophagus are absent as is gas bloating. This type of reconstruction, which is simpler than some of the pouch reconstructions, probably deserves more attention and may perhaps be perfected by varying the length of ileum and volume of ascending colon to be interposed.

Failure to find the gallbladder at the usual or most common atypical sites during surgery for cholecystolithiasis is a rare but known problem. Although ultrasonography has 95% sensitivity for the diagnosis of cholelithiasis, occasionally a small contracted gallbladder with stones and chronic cholecystitis will be difficult to visualize and can lead to erroneous interpretation. We report on the case of a patient presenting with abdominal colic and ultrasonographically confirmed cholecystolithiasis. During laparoscopic cholecystectomy, the gallbladder could not be detected. After laparoscopic staging followed by endoscopic retrograde cholangiopancreatography and abdominal computed tomography, agenesis of the gallbladder was confirmed. This method can be considered for diagnosis of gallbladder agenesis without the need for laparotomy and thorough exploration.

Surgery of rectal cancer aims at providing satisfactory quality of life at an early postoperative stage. Low postoperative morbidity and good defecation quality early after rectal reconstruction by means of a colonic reservoir are essential conditions for good quality of life.

The mesenterial venous thrombosis is a rare and independent cause of intestinal ischemia. 5 to 15% of all intestinal ischemias are due to venous problems. The lack of specific clinical symptoms and laboratory data often leads to a delayed diagnosis with irreversible intestinal infarction. Only by thorough searching by means of modern diagnostic devices is it possible to make an early diagnosis and treat the ischemic situation timely. Several therapeutical options are at hand. A timely and adequate application of these aids mostly depends on the clinical experience of the medical team as well as on an optimal interdisciplinary collaboration (radiology, hematology, angiology, gastroenterology, surgery). We want to analyze the problems related to diagnostics and management on the basis of 2 cases with different manifestations of a mesenterial venous thrombosis. We ascertain that: (1) the enhanced-CT analysis and/or the duplex-sonography mostly lead to a diagnosis, (2) the prognosis benefits from an immediate heparinization, (3) the request for large-scale intestinal resection, keeping a safety-space, has been replaced by the technique of limited resection, followed by earlier second-look-operations.

Standard adrenalectomy for pheochromocytoma was until recently performed via the transperitoneal open approach. The disadvantage of the open procedure is a more painful and longer recovery. With good surgical experience in laparoscopic techniques and in endocrine surgery, laparoscopic adrenalectomy can be performed safely without complications. The advantage of the laparoscopic technique is excellent vision of the operative field with magnification even of very small vessels. The first two cases of laparoscopic right adrenalectomy at our institution are described.

The purpose of this review is to summarize new developments in the surgical treatment of benign and malignant tumors of the rectum, focusing on oncological requirements and postoperative functional aspects which affect the quality of life. One of the developments is the transanal endoscopic microsurgical (TEM) approach to resection of adenomas and low risk early cancers in the rectum. Another focus is total rectum resection with colo-anal reconstruction with a colon pouch. This procedure reconstructs anorectal anatomy and provides nearly normal function. The reconstruction exists in two forms, (a) the colon-J-pouch and (b) the ileocecal interposition pouch (cecum pouch), which was developed at our institution. The review includes 33 consecutive patients with a rectum tumor. Standardized tumor-specific and functional staging determines which technique is used. 12 patients were operated on using the transanal endoscopic approach, 3 patients had a posterior proctotomy, another patient a transanal local excision and 17 patients total rectum resection with colon pouch reconstruction as described above.

Aims: Injuries of the small bowel following a blunt abdominal trauma are rare (incidence 6%). The diagnosis is difficult and therefore often missed. The aim of this paper is to acquire an useful diagnostic sequence of our own results in comparison to the literature., Methods: The diagnostic procedures and the time of the final diagnosis of 13 patients with this rare injury have been retrospectively analysed., Results: Two of these 13 patients died in the emergency room. Five of the remaining 11 patients had signs of peritonitis at the first examination. These were confirmed by findings either in peritoneal lavage (3), ultrasound (1) or X-ray (1). Patients without signs of peritonitis revealed no pathological signs at the first examination with these diagnostic tools. Correct diagnosis was achieved on 7/11 patients within 24 hours. The diagnosis of small bowel injury was confirmed by the rest of the patients (n = 4) after an average of 11 days after trauma., Discussion/conclusion: Initial assessment with diagnostic tools as ultrasound, peritoneal lavage or X-ray is poor. Therefore repetitive controls (Nowadays by ultrasound) are indicated. The CT is a valuable tool to detect an organ lesion in hemodynamic stable patients with positive proof of liquid in the ultrasound. Today the value of the diagnostic laparoscopy is not established. It should be considered that a local ischemia due to the blunt trauma can cause a delayed perforation.

Extramammary perianal morbus Paget is a rare disease; so far, only a few more than 100 cases have been reported on or described worldwide. Diagnosis, differential diagnosis, therapy, and prognosis of intra-epidermally growing adenocarcinoma are explained and discussed by means of a well-documented case.

Surgery for carcinoma of the esophagus and cardia represents potentially curative therapy in early stage of tumor. In the advanced stage of tumor palliation is the only remaining therapeutic aim. In a retrospective study covering the period 1984-1992 we analyzed 51 patients who underwent surgery for esophageal or cardia cancer to determine whether palliation by surgery is feasible. We also analyzed morbidity and mortality of peri- and postoperative complications. In 88% we carried out standard esophagectomy consisting of abdomino-thoracic access, gastric interposition with thoracic anastomosis and extramucous pyloromyotomy. In the light of postresection histology, 53% of the operations were potentially curative (UICC stage I and II) [1], 47% palliative (UICC stage III and IV) [1]. Perioperative 30-days mortality was nil, perioperative 30-days morbidity 11% (3 patients developed pneumonia postoperatively, 2 patients with cervical anastomosis developed dehiscence of anastomosis which in both cases healed completely with conservative therapy, while a further patient with cervical anastomosis suffered persistent paralysis of the recurrent nerve. All patients were fully able to feed themselves at the time of discharge. 43% of patients had recurrent dysphagia and 24% underwent endoscopic dilatation. Three-year survival was 26%. From these results it may be concluded that esophageal resection represents either good palliation with low morbidity for the majority of patients with non-resectable carcinoma of the esophagus or potentially curative therapy with low morbidity in early stage of tumor.

Sessile polyps of the proximal and middle part of the rectum are difficult and sometimes impossible to remove by snaring techniques. The conventional transanal approach to this level results in inappropriate survey and security. Parasacral techniques and low anterior resection require disproportionate measures to treat these adenomas. Transanal endoscopic microsurgery (TEM) is a relatively new operative technique to remove sessile polyps of the entire rectum, developed by Buess et al. [1] in Germany. The system uses a special endorectal scope connected to a stereoscopic angulated optical system for visualization. A continuous pressure-controlled insufflation of carbon dioxide keeps the rectum open for exposure. The excision is done by electrocautery in the submucosal plane or as full thickness excision in the submuscular plane. The defect is closed with an intrarectal running suture. Our report demonstrates the indications and limits of this technique and compares it to conventional techniques mentioned above. 12 patients with different kinds of tumor have been selected and serve as basis for our discussion. TEM offers excellent survey in the entire rectum and permits removal of villous adenomas and incidental low risk and early rectal cancers. High risk patients tolerate this procedure well. Unsuitable are circular and long-distance adenomas and transmural growing benign tumors of the proximal rectum.

Coloanal reconstruction is a sphincter saving operation following total rectal resection to treat rectal cancer 3 to 11 cm above the dentate line. Total rectal resection in this situation is justified from the oncological and surgical viewpoint because the local recurrence rate and morbidity are not different from the "gold standard", abdominoperineal resection sacrificing the anal sphincter. Although patients undergoing straight coloanal reconstruction preserve continence, they are often disturbed by high stool frequencies and imperative urge. We set out to establish whether construction of a colon-j-pouch could ameliorate the quality of defecation and thus prove useful. In this study the pre- and postoperative results of a pilot study with 4 consecutive patients following colon-j-pouch-anal reconstruction are presented. Perioperatively, 3 of 4 patients suffered from intermittent disturbances of urinary voiding. Sexual function was disturbed in 3 of 4 patients. All patients were completely continent. The preliminary results showed a decreased sphincter pressure at rest of 40 mm Hg (SD: 5) and a normal squeeze pressure. Endoanal ultrasound demonstrated a normal anal sphincter morphology. Pouch compliance yielded 4.7 ml/cm H2O and was better than after straight coloanal reconstruction in the control group (2.8 ml/cm H2O). The stool frequency at 6 months was 3/24 hours without imperative urge. The colon transit time lasted 49 hours and was in the normal range. No pouch evacuation disorders were observed. These results show a minimal morbidity in colon-j-pouch-anal reconstruction with preservation of complete continence in the follow-up time.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypertension (sustained and/or paroxysmal) is the most common symptom of pheochromocytoma. Correct evaluation nearly always leads to the diagnosis, and complete surgical excision is the definitive treatment. Our study deals with preoperative evaluation, operative morbidity and long-term results after surgery. During the 12-year period (1981-1992) 31 patients (48 years, 25-85) with pheochromocytoma were treated at our institution. The selected preoperative management was reviewed on the basis of patient records. Long-term follow-up was carried out consecutively and personally. All patients received alpha-adrenergic blockers to achieve preoperative normotension and volume repletion. All resections were performed by laparotomy; two of the early cases were extended into the chest. 27 of 29 patients (93.1%) had elevated levels of urinary vanillylmandelic acid; a similar sensitivity was noted in the urinary catecholamines (24/26 = 92.3%). In anatomical localization CT-scan was accurate in 100% (27/27). MIGB scintigraphy was of help in 21 of 23 (91.3%) and, in the most recent patients, MRI was helpful in 3 of 3 (100%). No patient died during the first 30 days after surgery. One patient developed an anaphylactic reaction after cephalosporin administration (morbidity: 3.2%). 2 patients (6.4%) with malignant pheochromocytoma developed a recurrent tumor during the follow-up period. Resection of pheochromocytomas by laparotomy has a low perioperative morbidity and mortality after standardized preparation. A positive MIBG scintigraphy allows extra-adrenal localization. Better resolution and multiplanar imaging are the advantages of MRI. Perioperative management and new imaging techniques--eliminating arteriography and venous sampling among others--have simplified surgical treatment and improved its safety.

Laparoscopic techniques also offer the patient the advantages of minimally-invasive surgery for the treatment of reflux disease. With a appropriate training it is possible to perform laparoscopic fundoplication. Our experience with the first 16 patients is favourable. The rate of conversion to open procedure (4 from 16) and the operating times (median 176 minutes) are due to the learning curve, as known from laparoscopic cholecystectomy. The indications for surgery in patients with reflux disease remain unchanged and should not be extended. However, the good early results should facilitate the decision for surgery. The generalized use of this method should be postponed until more studies have clearly demonstrated the possible short- and long-term advantages of the laparoscopic procedure over open technique.

Splenectomy intended to treat hypersplenism can, in the presence of portal hypertension (PTH), lead to extrahepatic portal and mesenteric vein thrombosis. The management of possible variceal bleeding in patients with extrahepatic portal vein occlusion following splenectomy in portal hypertension is a problematic and challenging undertaking. We report on the management of variceal bleeding in 2 noncirrhotic patients with PTH who developed portal vein thrombosis following ill-advised splenectomy. It must be stressed again that splenectomy alone intended to control hypersplenism in portal hypertension is to be avoided at all costs. Options for the treatment of portal and mesenteric vein thrombosis and variceal bleeding are proposed.

Endorectal ultrasound is the most reliable method in staging rectal cancer and is superior to computed tomography. In a prospective series of 152 consecutive patients, comparison of preoperative ultrasound staging and postoperative histopathological staging resulted in an overall accuracy of 90.1%. Overstaging was observed in 9.2%, understaging in 0.7%. Peritumoral inflammatory changes, preoperative radiotherapy and localization of the tumor in the lower rectum were the main reasons for overstaging. Understaging was seen in stenotic or only minimal invasive tumors. Accuracy in staging lymph nodes was 78.5%. Inflammatory changes in the nodes were responsible for either overstaging or understaging. Whether diagnosis will be improved with a higher frequency--mainly in lymph nodes--has yet to be proved. With knowledge of the reasons for misinterpretation, endorectal sonography is--mainly in the lower rectum--a valuable aid in evaluation of surgical procedure.

Surgery for carcinoma of the esophagus and cardia represents potentially curative therapy in the early stage of the tumor. In the advanced stage of tumor, palliation is the only remaining therapeutic aim. In a retrospective study covering the period 1984-1992 we analyzed 51 patients who underwent surgery for esophageal or cardia cancer to determine whether palliation by surgery is feasible. We also analyzed mortality and morbidity of peri- and postoperative complications. In 88% we carried out standard esophagectomy consisting of abdomino-thoracal access, gastric interposition with thoracal anastomosis and extramucosal pyloromyotomy. In the light of postresection histology, 53% of the operations were potentially curative (UICC stage I and II) and 47 palliative (UICC stage III and IV). Perioperative 30-day mortality was nil, and perioperative 30-day morbidity 11% (3 patients developed pneumonia postoperatively, 2 patients with cervical anastomosis developed dehiscence of anastomosis which in both cases healed completely with conservative therapy, while a further patient with cervical anastomosis suffered persistent paralysis of the recurrent nerve. All patients were fully able to feed themselves at the time of discharge. 43% of patients had recurrent dysphagia and 24% underwent endoscopic dilatation. Three-year survival was 26%. From these results it may be concluded that esophageal resection represents good palliation with low morbidity for the majority of patients with non-resectable carcinoma of the esophagus.

Axillofemoral bypass grafting is an accepted method for the treatment of vascular insufficiency of the lower limb. It is especially useful in high risk patients whose conditions preclude aortofemoral bypass grafting. The goal of our study is to evaluate whether the benefit of this operation outweigh the potential risks in the age group "sixty-plus". We performed 23 axillofemoral bypass grafting procedures (axillofemoral in 20, axillobifemoral in 3 cases) mainly be mean of 8 mm Dacrom prosthesis. The 30-day operative mortality rate was 8.7% and the cumulative 5-year patient survival rate was 52.2%. Overall the 1- and 5-year life table patency rate were 80% and 64%, respectively. The cumulative limb salvage was 90% and 72% at 1 and 5 years. We obtained an average reduction in Fontaine classification of 2 stages in the first year and 1.3 stages after 5 years. The comparison of the cumulative survival rate with the limb salvage rate indicates that advanced age should not be considered a contraindication to performing an axillofemoral bypass graft. The reduction in Fontaine stage means a remarkable improvement in quality of life.

The "Hartmann operation" for complication of acute diverticulitis or obstruction of the rectosigmoid is a safe procedure with few complications. However, it needs a second operation to reconstruct the continuity of the intestinal tract with more difficulties. The goal of our report is to show the 30-day morbidity and the late sequelae after colostomy closure with special concern to the late anorectal function. We analyzed 43 patients who underwent colostomy closure after Hartmann's procedure between 1985 and 1990. We controlled personally 35 patients after 32 months (range: 5-64 months) concerning their bowel habits, anal sphincter function (digital measure) and endoscopic anastomosis diameter. There were no deaths, but there was a 9% perioperative morbidity (1 anastomotic leak, 1 anastomotic bleeding and 2 wound infections). In the further course 2/35 patients were incontinent for gas and liquid stool. Further 3 patients lost water after coughing and had a poor sphincter rest tone. Our results demonstrates a low 30-day morbidity after reversal of Hartmann's procedure. It needs further investigation to show, if a damaged sphincter muscle or a lower rectum capacity could be responsible for these results.

Intestinal non-rotation has been recognized as a cause of obstruction in neonates and children. It is very rarely seen in the adult and assumes surgical significance owing to the potential risk of midgut or ileocecal volvulus. However, it can also cause significant intermittent abdominal pain in the adult. We describe six personally observed patients with this malformation and analyze 38 case reports published in the English and German literature since 1923. We establish that in the acute symptomatic form only emergency laparotomy can provide the correct diagnosis and decrease the risk of bowel disturbance. In the chronic forms, barium studies of the whole intestinal tract reveal varying degrees of midgut malrotation and the non-rotation is confirmed in each case. Also in these forms, exploratory laparotomy with a consequent staging of the abdominal situs is to be recommended. In the operation described by Ladd the ascending colon is sutured at the colon descendens and sigmoideum. After this procedure the mesenterial pedicle is fixed and the risk of midgut torsion remains minimal. All reported cases after surgery are symptom-free.

Among the fractures of the proximal humerus--a typical kind of injury affecting elderly people, as well as gainfully employed patients, the comminuted and dislocated humeral head fractures have a specific position because of therapeutical reasons. By means of a retrospective analysis, a review is given of the results of 26 comminuted humeral head fractures type IV-VI according to Neer, treated with a Neer prosthesis type II at the surgical clinic of the Kantonsspital Lucerne between 1983 and 1989. Our interest is mainly concentrated on the functional results and on their correlation with biomechanical and perioperative factors. We use the fracture-classification and functional evaluation as described by Neer. For the results classified as "failures" (13 cases) the functional deficits of the glenohumeral joint mobility are essential. The scores reveal no significant correlation to the age of the patients, to the time interval between trauma and operation, as well to the duration of the postoperative physiotherapy. On the other hand the scores of patients with preoperative manipulation of the fractured joint (i.e. osteosynthesis, reduction attempts, physiotherapy) were significantly worse than those with primary prosthetic replacement. Furthermore, because of the insufficient restitution of the lever arm conditions, the implantation of the small-head component (15 mm) leads to significantly less favorable functional scores, with a corresponding radiological hyperpression in the cranial articular space. Our analysis leads to the following conclusions: 1. Under the condition of a conclusive preoperative diagnosis a primary prosthetic procedure is recommended depending on the type of fracture.(ABSTRACT TRUNCATED AT 250 WORDS)

The operative treatment of subcapital femoral neck fractures of stages Garden III and IV in the young patient is still a problem. The current methods of osteosynthesis show a high rate of avascular necrosis of the femoral head. We controlled 24 patients with subcapital femoral neck fracture, who were treated with a dynamic hip screw (DHS). The average age of these patients is 55 years. They were examined after 30-89 months from the operation. All patients were assessed regarding clinical and radiological parameters. All of the six patients with femoral neck fractures of stages Garden I and II had no pain, their clinical results were good. In one of these patients we found a partial avascular necrosis of the femoral head. Four out of the 18 patients with femoral neck fractures of stages Garden III and IV had painful complications, 3 of them needed a reoperation. Fourteen patients of the group with femoral neck fractures of stages Garden III and IV had no pain and wer satisfied with the result. But in this group we found 7 patients with partial avascular necrosis of the femoral head. These results are discussed and compared with data published elsewhere.

The intestinal non-rotation is a rare fetal disorder of the gut torsion. Its manifestation is very rarely seen in the adult, either in form of a volvulus of the midgut or ileocecal with an acute onset, or as chronic recurrent abdominal pain. Each diagnostic or therapeutic delay increases the risk of strangulation and may end as an abdominal disaster. We describe three own cases and we try to elucidate the diagnostic and therapeutic problems. Our proceeding: In the acute symptomatic form the explorative laparotomy with a consequent staging of the abdominal situs is the safest way to get an exact diagnosis. Therapeutically the procedure described by LADD is the best torsion prophylaxis; the ascending colon is sawn to the descending colon. Due to a paratopia, the appendectomy is recommended. In the chronic forms the contrast enema and the gastrointestinal barium study are the main diagnostic procedures. In the operation described by Fitzgerald and the ascending colon and the mesentery of the small bowel are--after incision of the common mesentery--fixed at their anatomical site.

Surgical treatment of esophageal cancer is largely palliative. To clarify the indication it is necessary to assess the effectiveness of the palliation in relief of dysphagia and the operative risks. In a retrospective study we analyzed the perioperative morbidity and follow-up in 25 patients with carcinoma of the esophagus treated between 1984 and 1988 (5 years). With combined anesthesia, early extubation and intensive pulmonary therapy, no perioperative respiratory insufficiency was observed. Perioperative mortality was 0%. An anastomotic leak in 2 patients with a cervical anastomosis was healed in both cases by conservative management. On hospital discharge all patients were able to eat normally. 13 patients died after 1 year on average (4 months to 3 years). 12 patients are alive 6 months to 4 years after operation, 10 of them without symptoms. Our results show that with optimal perioperative management of esophageal carcinoma low morbidity is possible and good palliation of dysphagia is feasible.

Acute arterial obstruction of the extremities represents the most common emergency in vascular surgery. Diagnosis is based on the typical history and clinical symptoms. Emboli in vessels without atherosclerotic changes can be removed by simple embolectomy. In atherosclerotic arteries or in cases of acute thrombotic occlusion preoperative angiography is recommended in order to perform extensive reconstructive procedures. 400 arterial reconstructions for acute obstruction of the extremities were analysed. 46 operations were done in the upper extremities. In the majority of the cases simple embolectomy was successful. Limb salvage was 100% although one embolectomy and one bypass procedure failed to restore full revascularization. Complication and mortality rate was low. 354 lower limbs were operated. 274 extremities could be saved (77.4%). Among 80 poor results 48 major amputations had to be done (13.5%). Perioperative mortality was 12.4%. Death was mainly attributed to myocardial infarction.