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Inbred animals (Lewis rats) were used to investigate the regeneration of autologously implanted splenic tissue at intra-omental and subcutaneous sites. Quantitative immunohistology with monoclonal antibodies against lymphocytes and macrophages was performed to analyse the cell density of red pulp (RP), periarteriolar lymphoid sheath (PALS), marginal zone (MZ) and follicle, 7-180 days after transplantation. Antigenic, allogeneic and mitogenic stimulation and Northern blotting were also performed. Transplant groups differed from spleen only in the reduced size of PALS; however, quantitative analysis demonstrated subtle differences between spleen and transplants. The cell density of B-cells and ED-1+ macrophages was reduced in the RP, Tsupp/cyt-cells were decreased and B-cells increased in PALS, and B-cells and Thelper-cells reduced in the MZ. No differences could be detected between the transplant groups. Flow-cytometric analysis of cell suspensions from spleen and transplants revealed a reduction of T-cells (OX-19+), MHC-I and transferrin-receptor-bearing cells in both transplant groups, and a decrease in the number of Thelper-cells and ED-3+ macrophages in subcutaneous transplants. Both transplant groups were defective regarding the allogeneic and pokeweed mitogen response. Aberration of the lipopolysaccharide response was restricted to subcutaneous transplants, which additionally showed abnormal expression of interferon-gamma, interleukin-5 and interleukin-6 mRNA. Thus, subtle alterations of the newly developed microenvironment and/or lymphocyte-homing may influence the regeneration of splenic tissue; the implantation site may represent an important parameter in functional reorganisation.

This paper presents the results of a combined endoscopic-surgical approach with management of acute biliary pancreatitis in 91 patients. The diagnosis was always made by means of endoscopic-retrograde cholangiography. Papillary or bile duct stones, or unmistakable signs of previous stone passage, and in exceptional cases flow obstruction due to preiampullary diverticuli were considered criteria for a positive diagnosis. All 91 patients were subjected to endoscopic sphincterotomy with/without stone extraction subsequent to the diagnostic cholangiogram. Endoscopic intervention was performed as soon as possible after admission to hospital, but by 48 hours at the latest. Cholecystectomy was carried out in all patients who were free of risk factors and without previous cholecystectomy, during the disease-free interval. The complication rate of this combined endoscopic-surgical approach amounted to 10.9%; the mortality rate was 3.3%. The achieved results suggest that endoscopic sphincterotomy with stone extraction in the acute phase of biliary pancreatitis is the method of choice in order to interrupt the process of this disease. In combination with the final surgical treatment of gallstone disease by cholecystectomy to avoid recurrences, the prognosis of acute biliary pancreatitis can be significantly improved by using this combined endoscopic-surgical management.

In anatomical preparations performed during autopsy we developed a well-defined approach for the identification of the recurrent laryngeal nerve during surgery on the thyroid gland. The principle of this concept is to visualize the nerve near the branching of the inferior thyroid artery, where it shows a 30 degree angle to the trachea in a direction running from caudal lateral to cranial medial and lies in front of, behind, or between the branches of the artery. This preparation mode has been prospectively performed in 100 patients undergoing thyroid surgery. In 159 (= 97.6%) sides of the neck out of 163 we identified the nerve at the typical site. The topographical relation of the recurrent nerve to the inferior thyroid artery revealed the following differences for the right and left side of the neck: On the right side the nerve was found to be behind in 48%, in front in 33% and between the branches of the artery in 15% of cases. In contrast, on the left side the nerve was found to be dorsal in 53%, ventral in 23% and between the branches in 23%. Of 163 nerves at risk we observed primary nerve palsy in 2 cases (1.2%), and a definitive palsy rate of 0.6% at the 3-month follow-up. In conclusion, we recommend the described approach for the identification of the recurrent laryngeal nerve during thyroid surgery whenever complete mobilisation of the thyroid lobe (e.g. thyroidectomy, lobectomy, resection of retrotracheal adenomas) is necessary.

A total of 50 patients--37 female and 13 male--with an average age of 50 +/- 27 years (23-86 years), suffering from rim-calcified gallbladder stones, underwent extracorporeal shock-wave lithotripsy (ESWL), using an ultrasound-guided overhead module of Lithostar Plus (Siemens Company). The total number of stones was 87, with an average diameter of 16 +/- 7 (7-38) mm. 29 patients had a solitary stone, 13 had two and 8 patients three or more stones. All patients received adjunct medication of 10 mg/kg body weight chenodeoxycholic and ursodeoxycholic acid 14 days prior to ESWL as a single bedtime dose. An average number of 5,300 +/- 2,200 shock waves (1,200-15,000) was applied for stone disintegration. The corresponding energy amounted to 750 bar. 29 patients needed one, 21 two or more treatments. After ESWL a variety of clinical abnormalities was observed: flank pain (15%), transient microhaematuria (33%) and transient macrohaematuria (2%). Subsequent to ESWL 5 patients suffered from complications such as biliary obstruction 3 weeks to 9 months after treatment and had to undergo ERCP. Three times endoscopic papillotomy was performed to remove stones from the common bile duct. Up to now 4 patients have undergone cholecystectomy: acute cholecystitis (n = 3), recurrent colicky pain (n = 1). 20 patients have been followed up over a 12-month period; 12 of them are completely free of stones and fragments.

The implantation of splenic tissue at different implantation sites (intraomental and subcutaneous) into one animal (Lewis rats) results in the development of splenic nodules at both sites. In a quantitative immunohistological analysis of splenic compartments such as red pulp (RP), periarteriolar lymphoid sheaths (PALS), marginal zone (MZ) and follicles (F) the T-cell reduction was related to the T(helper) cells in the MZ and T(supp/cyt) cells in the PALS. In contrast, the cell density of B cells and ED-1+ macrophages in the PALS and T(supp/cyt) cells in the MZ was increased. Significant differences between the implantation sites were restricted to CD5+ cells (thymocytes and T cells) in the MZ and OX-33+ cells (B cells with LCAB antigen) in the PALS. The reorganisation of the compartments of subcutaneous implants showed a delay of one week as compared with omental ones. Functional assays like haemolytic plaque assay, mitogen stimulation and mixed lymphocyte assay elicited an analogous delay of the functional maturation of IgM-positive B cells, a reduced proliferation of both transplant groups after pokeweed mitogen (PWM) stimulation, a decreased response after lipopolysaccharide (LPS) stimulation in solely subcutaneous replants and no differences concerning the mitogens concanavalin A (ConA) and phytohaemagglutinin (PHA). Both transplant groups showed a significantly reduced allogeneic response. The results of the functional analysis and the abnormal mRNA expression of Il-5, Il-6 (Interleukin 5 and 6), GMCSF (Granulocyte-Macrophage-Colony-Stimulation-Factor) and IFN-gamma (Interferon gamma) in subcutaneous replants indicate subtle molecular alterations (independent of a spleen-like immunoarchitecture) at this site.(ABSTRACT TRUNCATED AT 250 WORDS)

Out of 284 patients with acute pancreatitis 73 (26%) had pancreas necrosis. Of these 73 cases 43 patients with infected pancreas necrosis were treated surgically, whereas conservative treatment proved successful in the remaining 30 cases with so-called sterile necrosis. Our interdisciplinary treatment combined delayed surgery for the better demarcation of the necrotic tissue, with extended intensive care therapy and epigastral laparostomy; through this laparostomy surgical revision with necrosectomy and peritoneal lavage was performed daily for 15 (+/- 6) days, necessitating long-term artificial respiration for an average of 15 (4/168) days. The mortality rate in the 43 patients with infected pancreas necrosis amounted to 16.2% (n = 7); none of the patients with sterile necrosis died. In cases of multiple organ failure the mortality rate was significantly higher (30%) than with failure of only one organ system (4.3%). The mortality rate in all cases with pancreas necrosis (n = 73) amounted therefore to 9.5%. Serious complications of laparostomy occurred in 28% (n = 12) of the 43 patients, whereby 8 of these cases were gastrointestinal fistulae, with a fatal outcome in one patient. The overall mortality rate in the total group of 284 patients with acute pancreatitis was 2.8%.

Highly malignant thyroid tumours are frequently diagnosed only at an advanced stage where radical resection is no longer feasible. By the wide application of fine needle aspiration biopsy as a diagnostic tool in nodular thyroid diseases occasionally early stages of these tumours can be diagnosed. Despite early detection in 23% of our patients with anaplastic carcinomas and sarcomas of the thyroid gland and subsequent radical resection an improvement in the long-term outcome was not achieved. In contrast, thyroidectomy and appropriate oncologial therapy may result in long-term survival of patients with early stages of thyroid lymphomas.

The widely differing mortality rates of severe gastroduodenal hemorrhage reported in the literature (10-30%), are due to very inhomogeneous patient groups. The purpose of this study was therefore to rank various clinical and endoscopical factors by giving them points from 0 to 6, both to establish comparable groups and to use them as prognostic parameters for a potential fatality rate. One hundred and ninety-three patients with severe gastroduodenal bleeding, verified at emergency gastroscopy immediately after admission, were admitted to this prospective study. The statistical assessment of the prognosis for these 8 factors revealed a linear correlation between increasing score and mortality rate for the following risk factors: patient age, activity and intensity of hemorrhage, type and number of associated illnesses, various therapeutic procedures. Only the type of the source and the site of the hemorrhage did not correlate well. By adding up the points of all risk factors for every patient we calculated the overall score and established a correlation to the mortality rate: A definite statistical correlation was demonstrated between increasing score and fatal outcome. If a patient with a score of less than 20 points did survive in 100%, the mortality rate increased linearly to 83.3% in patients with a score of 40 points. Using this scoring system it is possible to establish comparable groups of patients - which seems indispensable for a critical examination of various therapeutic procedures. Furthermore, this score can serve as a predictor of the probability of a fatal outcome shortly after patient admission.

This project was undertaken to evaluate in a prospective fashion the effects of selective preoperative endoscopic-retrograde cholangiography and stone extraction (ERCP-ST EXTR) on the results of biliary tract surgery. Over a 6-year period, 728 patients with primary or secondary biliary tract disease were admitted to the First Surgical Department, landeskrankenanstalten, Salzburg, Austria. If, based on preoperative screening, the possibility of common bile duct stones (CBDS) existed, the patients were subjected to ERCP-ST EXTR. Two to 4 days later, these patients underwent a simple cholecystectomy with intraoperative cholangiogram and functional manometry. Evaluation criteria for this study were morbidity, mortality, and retained stone (RST) rates. The overall complication rate for the entire series was 6%. In patients who underwent operative common duct stone removal (n = 78), the complication rate amounted to 21.8%. The rate was reduced to 2.1% by ERCP-ST EXTR. The RST rate was likewise reduced from 2.2% to 0.5% by ERCP-ST EXTR. Mortality in patients with CBDS fell from 3.8% to 1% through the use of this method. In those patients with secondary stones who were treated by ERCP-ST EXTR only, morbidity was 2%, the RST rate was 0%, and mortality was 0%. It is concluded that selective ERCP-ST EXTR, followed by simple cholecystectomy, is a suitable treatment protocol and that this approach may reduce complication and mortality rates.

Several clinical and laboratory studies have demonstrated the risk of sepsis in connection with encapsulated bacteria. The importance of clearing these organisms by the spleen is now well accepted. In contrast, the present work deals with the clearance of non-encapsulated gram-negative bacteria (Escherichia coli). The animals used for the experiments (a heterogeneous population of rabbits) were divided into a control group, a splenectomized group, and an autotransplanted group. The histological examination of the splenic transplants revealed typical splenic tissue including lymphatic follicles with germinal activity 42 days after transplantation. For estimation of the clearance capacity different amounts of bacteria were injected i.v. into the rabbits, and colony-forming bacterial cells in the blood were counted at certain intervals. In the control group no bacteria could be detected in the blood after 7 min. All animals of the splenectomized and autotransplanted groups showed a remarkable decrease in clearance efficiency (no bacteria in the blood after 19 min). No difference in the clearance kinetics could be shown between splenectomized and autotransplanted animals. Measuring the uptake of bacterial cells into different organs elicited low incorporation in the spleen as compared to non-immunocompetent organs, but no difference between normal spleen and splenic replants. However, saturation with E. coli cells reached higher limits in the normal spleen than in autotransplants. The immunologic capacity with respect to IgM-producing lymphocytes was measured by the hemolytic plaque assay. The results showed a severe malfunction of the autotransplants as compared to the normal spleen (only 2% of the activity of the control group). Vaccination against E. coli increased the clearance efficiency in all three groups. The data presented in this paper point out that several functions of the spleen cannot be carried out by autotransplants. The reasons, therefore, may be limited transplant mass and/or decreased specific functions.

Palliative surgical treatment of malignant oesophago-gastric strictures has been disappointing. Resections in an advanced tumor stage are heroic interventions with a high mortality rate. Alimentary fistulas do not release from annoying saliva regurgitation but unnecessarily mutilate the terminal patient. The positioning of a tube under endoscopic control into the constricting neoplasma has the following advantages: 1. deglutition and saliva drainage are restored; 2. morbidity- and mortality rate is low; 3. duration of hospitalization is brief (1-2 days).

Emergency operations were performed on 20 patients for perforated sigma diverticulitis with diffuse (n = 15) or locally delimited (n = 5) peritonitis, between 1979 and June 1986. The average age of the patients was 65.7 years. Sigma resection with closure of the rectosigmoid and colostomy, that is Hartmann's operation, was performed on all of them. The postoperative lethality was as high as 45 per cent (nine patients), but this was not attributable to complications for which the surgical method had to be blamed. Only one patient died of anastomosis dehiscence, following additional resection of part of the small intestine. All the other deaths (n = 8) had been caused by internal organic complications. Hence, lethality is believed to be controllable only by close cooperation from the very beginning between surgeon and specialist in intensive therapy. Re-anastomosis (generally three months from primary operation) can be simplified by means of mechanical staplers, with the risk being reduced to nearly nil. These are benefits that support the recommendation of Hartmann's operation as an emergency approach to perforated sigma diverticulitis. It can be performed even by the less experienced surgeon on night duty.

In a 17-year period 1848 patients with hyperthyroidism were operated on. Fourteen (0.76%) had a coexisting thyroid malignancy. Preoperative scintiscan and pathologic diagnoses were compared: 10 malignancies were in cold nodules, two were unidentifiable preoperatively due to small size, and two were in hot areas. Five patients had papillary cancer, four follicular, three anaplastic, and two medullary. Patients with uninodular toxic goiter had a low rate of associated malignancy (0.27%, 3/1108). In contrast, patients with multinodular toxic goiter had an incidence of 1.63% (11/676). No patient with Graves' disease (n = 64) had a carcinoma. Extensive use of fine-needle aspiration biopsy enabled preoperative diagnosis in a majority of the cases (9/14, 64%). We conclude that the incidence of coexisting thyroid malignancy and hyperthyroidism is rare in our endemic iodine-deficiency goiter area.

Recurrent laryngeal nerve injury still remains the major problem in thyroid gland surgery and is influenced both by morphology and function of the goitre and essentially by the resection technique. Between 1982 and 1985 a total of 825 patients was operated on for the first time due to a benign goitre. In period A (Jan. 1982 to Dec. 1983) we always-- preceding the resection of the goitre--performed the ligature of the A.thyreoidea inferior (n = 412) whereas in period B (Jan. 1984 to Dec. 1985) we dispensed with it (n = 413). In neither of the two periods the preparation of the N.laryngeus recurrens--save few exceptional cases--was performed. The immediate postoperative recurrent laryngeal nerve palsy rate decreased from 4.9% in period A to 2.2% in period B, the persistent palsy rate (laryngeal control half a year postoperatively) from 2.18% to 0.48%. Due to the change to smaller, more hyperfunctional goitres in endemic areas we believe it possible to perform the resection of benign goitres without the preliminary ligature of the A.thyreoidea inferior and the preparation of the recurrent laryngeal nerve. On one hand this can lead to the facilitation of the surgical task, on the other hand to the decrease of the injury risk on the recurrent laryngeal nerve.

The venous flow to the heart can be heard by an ultrasound device. This blood flow ceases at a certain intrathoracic pressure (VAP). By 219 pressure readings VAP could be proved to correlate significantly with the central venous pressure (rs = 0.748). In 90.4% of the measurements the difference was less than 5 cm H2O.

The intrathoracic pressure rises when exhaling into a manometer to such an extent that finally the venous flow of blood to the right heart stops. It is supposed that this venous stop flow pressure (VSFP) is equal to the central venous pressure. In a clinical trial by two independent examiners in 97% of the cases a correlation within a range of 5 cm H2O was found (70 measurements). Thus the central venous pressure can be measured noninvasively with an ultrasound device.

Combined endoscopic and surgical intervention was undertaken in 728 consecutive patients with primary or secondary gallstone disease. In primary gallstone disease the combined treatment resulted in a residual stone rate of 1.28%, and 1.09% for the total group. Intervention on the lower biliary tract (n = 228) resulted in a morbidity rate of 7.4% and a mortality rate of 1.3%. The corresponding figures with purely endoscopic procedures were 1.2 and 0.0%, respectively. Intraoperatively manometrically tested papillary function after endoscopic papillotomy (EPT) revealed no significant difference from normal. In patients with proven biliary pancreatitis the mortality rate after EPT was 2.9%. These results indicate that routine inclusion of endoscopy into the surgical treatment concept for gallstone disease can improve the overall results.

In a review of 37012 autopsies over the last 20 years 202 deceased adults who had had a splenectomy were investigated. The incidence of infections and thromboembolic complications related to death in these patients was compared with that of a matched deceased population (n = 403) who had not undergone splenectomy. Death-related pneumonia was diagnosed frequently in the splenectomy group and to a lesser extent in the control group (57.9 versus 24.7 percent, P < 0.001). Lethal sepsis with multiple organ failure occurred in 6.9 per cent of the splenectomy group and in 1.5 per cent of the controls (P < 0.001). Purulent pyelonephritis was observed in 7.9 per cent of the splenectomy group and was significantly more frequent than in the control group with its rate of 2.2 per cent (P < 0.001). Finally, pulmonary embolism was the major or a contributory cause of death more often in the splenectomy group than in the control group (35.6 versus 9.7 per cent, P < 0.001). We conclude that splenectomy generates a considerable life-long risk of severe infection and of thromboembolism.

24 patients (8 female, 16 male) with severe gastroduodenal haemorrhage were treated by vagotomy; in 17 cases highly selective vagotomy was performed, in 3 case truncal vagotomy + pyloroplasty and in 4 patients vagotomy was combined with excision or purse-string suture of the ulcer. Treatment was effective in 23 patients, without recurrence of haemorrhage. In 19 patients vagotomy not only curbed the bleeding but provided definitive therapy (Visick I-II); 4 patients died (mortality rate 16%).

The present study deals with the morphological and functional development of intraomentally and subcutaneously implanted splenic tissue. Spleens and splenic transplants from 138 Lewis rats were investigated with immunohistological, immunological and molecular biological methods at different times after operation (up to 200 days postoperatively). The analysis of the development revealed a nonsignificant reduction concerning the weight of subcutaneous replants and a nonsignificant decrease of the weight of female transplants of both groups at different phases after operation. The cell composition of cell suspensions from spleen and both transplant types showed a deficiency of T, B, MHC-I+ cells and a certain macrophage subset (ED-3+ cells) in transplants. In a quantitative immunohistological analysis of compartments (red pulp, periarteriolar lymphoid sheaths, marginal zone and follicles) the T cell reduction was related to the Tsupp/cyt cells and T cell receptor bearing cells in the periarteriolar lymphoid sheaths, whereas the density of T helper cells was normal. In addition, a different homing of kappa-light chain positive and leukocyte common antigen (B cell type)-positive B cells in follicles and marginal zone was detected. The amount of two macrophage subsets (ED-1+ and ED-2+ cells) was increased in the red pulp. Only minor differences in the immunoarchitecture of transplants at different implantation sites were measured. A functional analysis of spleen compared to both transplant groups elicited a B cell defect after LPS stimulation in subcutaneous transplants and a reduced allogeneic response of both transplant types but a normal proliferation of T cells after ConA stimulation and a correct IgM antibody response against sheep red blood cells. The in vivo mRNA expression and the expression kinetics of interferon-gamma and granulocyte-macrophage colony-stimulating factor after antigen stimulation differed in both transplant groups with a remarkable permanent expression of both mediators in subcutaneous transplants. It can be summarized that the results clearly indicate a development of spleen-like immunoarchitecture of intraomental replants with subtle cellular, functional and molecular alterations. In contrast, despite a comparable development, some severe functional defects occurred in subcutaneous implants pointing out the important role of interactions between the regenerating splenic tissue and the target tissue on a functional and molecular level.