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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.

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.

The ability of splenic tissue to regenerate after avascular transplantation at different target tissues is well documented but the capacity of splenic transplants to compensate the loss of spleen and the influence of the implantation site on the functional development of replants are still discussed contradictory, because little is known about specific functions of the transplants. Therefore, we investigated splenic implants in rats at different states of development and in different target tissues (intraomental and subcutaneous implantation site).

300 Pat. mit Cholecystohthiasis wurden einer ESWL zugefuhrt. 47 Pat. hatten einen Gesamtsteindurchmesser >3cm, 50 Pat. Steine mit Ringverkalkungen. Bisher traten bei 15 Pat. (5%) endoskop. beherrschbare Komplikationen auf: Pankreatitis 4 (1%), bihare Obstruktion 11 (3,7%).4 dieser Pat. hatten eine primare Steingrose >3 cm, 5 Pat. Kalksteine. Weitere 12 Pat. (4%) wurden cholecystektomiert:ak. Cholecystitits 5 (1,6%), rezidiv., heftige Koliken 5 (1,6%), keine Steindesintegration 2 (0,6%). 8 dieser Pat. hatten einen Gesamtsteindurchmesser 3 cm oder Kalksteine. Die erweiterte ESWL-Indikation fuhrte zu einem signifikanten Anstieg endoskop. (2,9% > 9,2%) als auch chir. (1,9 >8,2%) Folgeeingriffe.

Die Hemithyreoidektomie stellt beim suspekten kalten Solitarknoten die bessere Alternative gegenuber partiellen Resektionen dar, da bei definitivem Malignitatsnachweis die Notwendigkeit eines erneuten Eingreifens auf derselben Seite entfallt (Senkung des Komplikationsrisikos). Bei grosen and bei dorsal gelegenen Knoten wird durch Lobektomie das Belassen von dorsalen Knotenresten vermieden (Senkung des Rezidivrisikos, Senkung der Rate persistierender Autonomien). Ihre Durchfuhrung erfordert spezifische operative Erfahrung and Routine in der erhaltenden Darstellung von N. recurrens and Nebenschilddrusen. Unter dieser Voraussetzung ist sie gegenuber den partiell resezierenden Verfahren nicht mit einem erhohten Komplikationsrisiko verbunden.

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.

In einer experimentellen Studie an 66 Kaninchen verglichen wir zwei Arten der Transplantatzubereitung: 1. 4–5 Milzstucke von 1 mm Dicke steigenden Gewichts (5–800 mg) wurden am parietalen Peritoneum angenaht. 2. Milzhomogenate wurden ebenfalls in steigender Menge (5–800 mg) in 4–5 praformierte Taschen des parietalen Peritoneums eingebracht. Das regenerierte Milzgewebe wurde nach Laparotomie der Tiere in verschiedenen postoperativen Abstanden bis maximal 42 Tage postoperativ entnommen, gewogen und histologisch untersucht. Dabei zeigt sich eine lineare Beziehung von End- und Anfangsgewichten. Diese Korrelation gilt aber nur bis zu einer oberen Gewichtsgrenze von 200 mg bei den Homogenaten und 300 mg bei den Stucken. Insgesamt regenerierten Homogenate besser als Stucke.

Der ruckblick auf 40 jahre strumarezi-divprophylaxe zeigt in erster Linie, wie wichtig die organisierte und konsequente betreuung der patienten auch Jahre nach der Strumaresektion ist. Unser derzeitiges konzept der rezidivprophylaxe sieht eine lebenslange medikation mit 50 μg L-Thyroxin bei euthyreoten strumen ab dem 6. postoperativen tag, bei den autonomen adenomen ab dem 1. postoperativen Monat und bei den hyperthyreoten Strumen ab dem 3. postoperativen monat vor.

The study deals with the immunological capacity and perfusion rate of splenic grafts in pigs after autologous transplantation into the omentum majus. 12 months after operation the weight and relative blood flow of the regenerated splenic tissue were clearly reduced. The number of antibody forming cells in the grafts was only slightly decreased compared to the normal spleen, whereas the autotransplants could balance a serum-IgM-deficiency, observed due to splenectomy, 4 months after grafting. Furthermore the mitogenic stimulation of T- and B-lymphocytes showed different proliferation rates for the autotransplants compared to the spleen.

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.

Intraoperative manometry was performed in 771 patients undergoing cholecystectomy with (n = 158) and without (n = 613) interventions on the common bile duct and papilla. The method measures the resting pressure (RP) and pressure increase (PI) after injection of 1 ml NaCl/s as well as the time (TR) used for return to the initial pressure, using a Statham transducer. All values are recorded and statistically processed by the two-tailed t test. All three manometric parameters (RP, PI and TR) were statistically different (p less than or equal to 0.0001) between patients with and without alterations of the bile duct and papilla respectively. There was also a clear difference (p = 0.0001) of the TR (which is an indirect measure of the bile flow) between patients with stenosis of papilla (n = 55) and those who showed calculi in the bile duct (n = 103). In a further study we could demonstrate that histopathological changes of the papilla (specimen was taken during transduodenal papilloplasty because of isolated papilla stenosis) led to a prolonged TR, whereas TR in patients with negative histology was decreased. The sensitivity and specifity of this manometric method was very high, 92.4 and 98.6% respectively. This method of manometry enables to obtain precise data about pressure and flow in the bile duct uninfluenced by subjective reading errors in a simple and reproducible way. In our opinion it should complete other intraoperative diagnostic methods during cholecystectomy, particularly as manometry was the only method which led to the correct final diagnosis in 2% of 771 patients.

Over a 5-year period, 443 patients were treated for primary gallstone disease. There were 333 patients with negative preoperative findings in the common bile ducts (CBD) on sonography and liver enzymes estimation who underwent cholecystectomy without endoscopic retrograde cholangiography (ERC). Thirty-eight surgical explorations of the choledochus were necessary, and in 11 patients a second intervention (endoscopically) had to be performed. There were 110 patients with signs of stone formation in the bile ducts. These patients were submitted to examination of the CBD by ERC. Choledocholithiasis was found in 67 patients; in 47, endoscopic papillotomy and stone extraction were successful. On 7 occasions it was insufficient and in 13 patients it was not attempted due to the size of the stone. One second intervention (endoscopically) had to be performed in this group of patients. The sonographical and laboratory suspicion of bile ductstones could be disproved in 43 patients. In these cases, the preoperative ERC was negative. We therefore had information on the bile duct system preoperatively and no surgical bile duct exploration was necessary for diagnosis. Thirty-eight of 333 patients (11.4%) had a false-negative and 43 of 110 (39%) a false-positive sonographical or laboratory diagnosis. This shows that there is no other preoperative diagnostic test other than ERC for the precise preoperative evaluation of common bile duct stones. Morbidity, mortality and the rate of choledochus revision (especially negative explorations) can be reduced by preoperative endoscopic bile duct stone removal. In cases where bile duct stones are suspected, we recommend endoscopic retrograde cholangiography for clarification and, if stones are verified, endoscopic papillotomy and stone extraction followed by simple cholecystectomy for therapy, thus avoiding surgical bile duct explorations.

The study deals with the immunological capacity and perfusion rate of splenic grafts in pigs after autologous transplantation into the omentum majus. 12 months after the operation, the weight and relative perfusion of the regenerated tissue was clearly reduced. Independent of this fact, the splenic grafts could balance out an IgM-deficiency, observed due to splenectomy, 4 months after the transplantation. Furthermore, the number of antibody forming cells in the grafts was only slightly decreased compared to the normal spleen. These results show that regenerated splenic tissue is able to carry out specific immunological functions. One of the limiting factors in preventing postsplenectomy sequelae (i.e., sepsis) seems to be the poor regeneration weight and low perfusion of the grafts.

Fibrin sealing was employed in connection with lymph node dissections — on one hand intraoperatively in order to avoid lymph fistulae (n = 26) and on the other hand postoperatively in treatment of manifest lymph fistulae (n = 9). Thereby lymph fistulae could be avoided in 96.2% (n = 25) or a rapid successful treatment of the lymph fistulae could be achieved in seven of nine cases (77%). On average a quantity of 1 ml fibrin sealant was sufficient ; a high concentration of aprotinin (3500 U) and thrombin (500 U) was chosen. No side effects on the part of the fibrin sealing were noted.

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.

In the case of massive splenic rupture, heterotopic autologous transplantation of splenic tissue into the omentum majus may be used to restore splenic function. Yet little is known about specific functions of the transplants compared to the normal spleen. The goal of this study was to get more information about immunologic functions and protein expression in splenic transplants. As an animal model we used the pig, whose splenic morphology and immunoarchitecture is similar to that of the human spleen. Histologic examination of transplants revealed structures that were comparable to normal spleens (consisting of red and white pulp and including germinal centers). Immunologic tests such as the hemolytic plaque assay and mitogen stimulation revealed that the number of plaque-forming cells was not changed significantly, but the stimulation index for T cells was drastically increased in the autotransplants. Electrophoresis and immunochemical methods showed differences in the protein patterns between both tissues. Several proteins were found to be produced only in the spleen, or were produced in much higher amounts in the spleen than in the splenic transplants. More information about these differences between spleen and splenic transplants is needed before we can recommend a general clinical application of autologous spleen transplantation.

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.

Bisher ist die therapeutische Endoskopie zur Behandlung der Choledocholithiasis nur bei nicht op.-belastbaren Patienten oder von Folgezustanden nach chirurgischen Eingriffen anerkannt. Der Wert einer indizierten,praoperativen endoskopischen Diagnose/Therapie von Gallengangssteinen mit nachfolgender Cholecystektomie und intraop. Kontrolldiagnostik der tiefen Gallenwege wurde bei 443 Patienten mit Cholecystolithiasis nachgewiesen.Ergebnisse: Die Letalitat betrug 1,3%, bei chirurgischen Gallengangsrevisionen 3,4%, biliare Ursachen 0,2%. Komplikationsrate 7,6%, bei chirurgischen Gallengangsrevisionen 21%. Ubersehene Gallengangskonkremente 1,3%. Keine negativen, chirurgischen Choledochusrevisionen.

Bislang standen zur Vermeidung von postop. Lymphfisteln nach LK-Dissektionen nur die gewebsschonende Praparation, die Ligatur grosserer, sichtbarer Lymphgefasse und die Drainage des Wundgebietes zur Verfugung. Die Fibrinklebung kam im Rahmen von LK-Dissektionen einerseits intraop. zur Vermeidung von Lymphfisteln (n = 68), andererseits postoperativ manifester Lymphfisteln (n = 14) zur Anwendung. Damit konnten in 97,1% (n = 66) Lymphfisteln vermieden bzw. in 12 von 14 Fallen (85%) eine rasche, erfolgreiche Behandlung der Lymphfisteln erzielt werden. Durchschnittlich war 1 ml Fibrinkleber (3000 I.E./ml Aprotinin, 5001.E./ml Thrombin) ausreichend.

Die historische Entwicklung der Chirurgie der Struma ist fur osterreich mit den Namen Billroth, Mikulicz, Breitner, Urban, Kaspar, Huber verbunden. Stichwortartig unser Operationskonzept: Oberkorper des Patienten um ca. 60° aufgerichtet, querer Hautschnitt, Freilegung der Trachea durch Spaltung des Isthmus, Ligatur und Durchtrennung der oberen Polgefase, Ligatur der A. tyreoidea inferior schilddrusenfern, Darstellung des N. laryng. recurrens (bei Rezidivstrumen und Carcinomen obligat), intracapsulare keilformige Resektion, Redondrainage und Hautklammerung (beides fur 3 Tage), obligate Rezidivprophylaxe, dabei individuelles Vorgehen je nach praoprativer Morphologie und Funktion der Struma. Darstellung der Ergebnisse an Hand von 4601 Patienten von 1964–1982.