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The most common complications after abdominal surgery - wound infections and the development of incisional hernia - are associated with the opening and closing of the abdominal wall. Depending on the selection of patients, wound infection rates of up to 19 % and hernia rates of up to 38 % are reported. Based on a summary of the actual literature, the abdominal wall should be closed with continuous slowly absorbable sutures with a suture length to wound length ratio of over 4 using small stitches. While antiseptic suture material may help to reduce wound infections after abdominal incision, preventing the development of incisional hernia is still a unsolved problem. As there is still no standard surgical technique for abdominal wall closure, surgeons should pay greater attention to the standardisation and documentation of techniques and wound care.

Stenotic peripheral and dilatative arteriosclerotic diseases have different pathomechanism although associations between both diseases are well known. The adhesion molecule MUC18 is a cell membrane glycoprotein also known as the melanoma cell adhesion molecule. As MUC18 has proangiogenic potency in melanoma and prostate cancer this study investigated the role of MUC18 in patients with stenotic or dilatative arteriosclerotic disease as a putative biochemical marker.Using qRT-PCR, Western Blot and immunohistochemistry techniques, the expression of MUC18 in arteriosclerotic arteries from major lower limb amputates (AP, N.=15) as well as specimen from femoral endarterectomies (TEA, N.=20) and in dilatative aortic diseases using abdominal aortic aneurysms (AAA, N.=13) was evaluated. Human visceral arteries without macroscopic arteriosclerosis from liver transplants served as controls (AN, N.=19).MUC18 mRNA and protein expression could be found in AN, AP, TEA and AAA tissues. Immunohistochemical analysis showed that a complete and intact intima was the predominant location of MUC18 expression. Although in stenotic arteriosclerotic disease (AP and TEA) the intima was widely calcified, qRT-PCR analysis showed overexpression compared to normal tissue. Interestingly, MUC18 expression was significantly down-regulated in dilatative compared to stenotic arteriosclerotic disease and normal arteries.In peripheral stenotic arteriosclerotic disease the proangiogenic potency of MUC18 may play a role in angiogenesis of collaterals, whereas in dilatative aortic diseases the induction of collaterals is typically not evident. The results support the hypothesis of a role in angiogenesis of MUC18 in stenotic arteriosclerotic disease.

Einleitung Mit der Zunahme der kardiovaskularen Erkrankungen steigt die Anzahl arterieller Punktionen. Es werden vermehrt arterielle Verschlusssysteme eingesetzt.

Eine 36-jahrige Patientin klagte seit 3 Monaten uber zunehmende thorakolumbale Wirbelsaulenbeschwerden ohne Besserung unter Schmerz- und Physiotherapie. Rontgenaufnahmen der Wirbelsaule zeigten neben einem altersentsprechenden Befund einen verkalkten Rundherd rechts paravertebral. Sonographisch stellte sich ein zystischer Tumor in Projektion auf den dorsalen rechten Leberlappen dar, der kernspintomographisch jedoch extrahepatisch lag. Im Rahmen der explorativen Laparotomie erfolgte eine Adrenalektomie rechts aufgrund eines zystischen Nebennierentumors, der histologisch einer adrenalen Pseudozyste entsprach. Die Beschwerden der Patientin verschwanden unmittelbar postoperativ.

The special anatomic situation and the multitude of combinations of oncological therapeutic and reconstructive modalities in tumors of the cervical region require intensive interdisciplinary planning and discussion during tumor staging, surgical resection, and (neo)adjuvant treatment. We discuss here the various treatment modalities for tumors of the pharynx and cervical esophagus.

Partial skin and fat necrosis is the most common complication occurring in TRAM flaps. It is related to disturbances of the microcirculation and oxygenation in the contralateral part of the flap. It may be hypothesised that the development of necrosis is promoted by the vasoconstrictor endothelin, the production of which is enhanced in ischaemic flap tissues. The purpose of this study was to evaluate the effect of tezosentan, a new endothelin receptor blocker, on microcirculation and oxygenation in experimental TRAM flaps. The administration of tezosentan began preoperatively (3 mg/kg body weight) and then continued at a rate of 1.5 mg/kg/h. A TRAM flap with a skin island measuring 16 x 8 cm was raised in the middle of the epigastrium in minipigs. The flap was pedicled on the right superior epigastric vessels. Microcirculatory blood flow was measured with laser Doppler flowmetry and tissue oxygen tension was measured with a Clark-type microprobe. Dominant subcutaneous veins were cannulated in both the ipsilateral and the contralateral parts of the flap. Subdermal tissue oxygen tension in the contralateral part of the flap was significantly reduced 4h after surgery to 5 mmHg (ca. 48 mmHg in normal tissue) in the control group, but to only 12 mmHg in the group that had been administered tezosentan (P< 0.05). Furthermore, tezosentan significantly attenuated venous hypertension (14 mmHg versus 24 mmHg), as well as lactate (4.0 mmol/l versus 5.6 mmol/l) and haemoglobin (10.2 g/dl versus 11.4 g/dl) concentrations in the venous effluent of the contralateral part of the flap, although microcirculatory blood flow remained virtually unchanged. Our findings suggest that tezosentan improves oxygenation and metabolism in the jeopardised contralateral flap tissue, probably as a result of a decrease in venous vascular resistance and fluid extravasation.

Since September 1st, 2009, the most recent version of the German "Betreuungsrechtsänderungsgesetz" has been validated by the legislators. It precisely sets out how physicians and nursing staff have to deal with a written declaration of a patient's will. This new law focuses in a special way on advance directives, describes the precise rules for the authors of an advance directive and shows both its sphere of action and its limitations. This article aims to give an overview on the legal scope of advance directives, and to illustrate potential limitations and conflicts. Furthermore, it shows the commitments and rights of the medical team against the background of an existing advance directive.

Work densification caused by lack of young surgeons with increased clinical documentation keeps surgeons busy. It is proven by many studies that surgeons work significantly longer hours per week and deal with a larger amount of medical and non-medical documentation than staff members in conservative disciplines. The aim of the study was to investigate surgeons work distribution in a surgical university department and to evaluate by means of a work sampling analysis whether it can be standardised and slimmed down by systematic use of IT-supported, process-managed work-flow. In addition the data obtained are compared wuith those from other studies on similar topics.Based on the results of an independent pilot observational study, 21 surgeons (14 residents, 7 staff surgeons) had to document over a 10-day period in a self-observation once in an hour their actual activity in a two dimensional matrix concerning medical activity (13 items) and patient contact (5 items). After the study, each physician had to estimate his/her own work distribution. Real percentages of the self-observation study were compared to the physicians' estimates of work distribution. IT-supported clinical pathways have been implemented since 2004 in our department.Over a ten-day evaluation period (1830 observation points), surgeons spent 30.2% of their activity in the operating theatre or on direct patient care. During 13.9% they were in meetings and they spent 10.8% of their time on documentation. Time needed for studying medical records (9.2%) and ward rounds (9.0%) ranged in a similar way. There was a significant accordance of estimated and real work distribution concerning the 5 most frequent daily activities. In only 14% there was no direct patient relationship.Application of work sampling analysis in surgery is a valid procedure for the evaluation of work flows in the course of personal observations. Surgeons working time in a hospital is limited. To achieve a maximum of direct patient care, clinical documentation has to be optimised by process automatisation within the context of IT-supported clinical pathways. Surgeons are able to estimate very exactly the distribution of their daily activities so that data of working time estimations is valuable.

The most common complications after abdominal surgery - wound infections and the development of incisional hernia - are associated with the opening and closing of the abdominal wall. Depending on the selection of patients, wound infection rates of up to 19 % and hernia rates of up to 38 % are reported. Based on a summary of the actual literature, the abdominal wall should be closed with continuous slowly absorbable sutures with a suture length to wound length ratio of over 4 using small stitches. While antiseptic suture material may help to reduce wound infections after abdominal incision, preventing the development of incisional hernia is still a unsolved problem. As there is still no standard surgical technique for abdominal wall closure, surgeons should pay greater attention to the standardisation and documentation of techniques and wound care.

Surgical site infections are one of the most common complications after surgical procedures. The use of perioperative antibiotic prophylaxis can successfully reduce the number of wound infections. The indications, timing and choice of antibiotics are discussed critically. Taken together antibiotic prophylaxis should be evaluated depending on wound contamination, the type of operation and patient-specific risk factors. In the second part of this work the current literature on the effectiveness of endoluminal tubes in abdominal surgery is analyzed. While many surgeons use these tubes regularly in elective abdominal surgery, only few data are available on this topic. The use of nasogastric tubes in elective surgery should be avoided.

A 71-year-old patient had been referred to our hospital with the diagnosis, made by angio-computed tomography (CTA), of a covered ruptured abdominal aortic aneurysm (AAA) resulting in an aortocaval fistula (ACF).The physical examination revealed macrohematuria and high-output heart failure with increasing circulatory insufficiency.An open endovascular procedure was not possible because the AAA had extended into both internal iliac arteries. A bifurcated prosthesis connecting to both femoral arteries was then successfully implanted and the infrahepatic aortocaval fistula closed by a patch through the AAA. Ischemic colitis, diagnosed on postoperative day 2 (POD 2), was successfully treated with antibiotics. CTA, done on POD 5, revealed a small residual ACF, filling retrogradely from the right external iliac artery via the surgically closed aneurysmal sack. Closure of the residual ACF was achieved with an Amplatz occluder inserted into the right external iliac artery, introduced percutaneously via the right femoral artery. The postoperative course was uneventful and the patient discharged on POD 13.The coincidence of AAA and ACF is rare. However, the morbidity and mortality are high and require early diagnosis and immediate treatment.

In clinical routine the process of presurgical visit and signed informed consent is imperfectly realized in surgical patients.A total of 450 consecutive patients were interviewed after a presurgical visit for informed consent using a questionnaire. The aim of the study was to investigate the amount of knowledge gained by informed consent. Patient satisfaction with medical treatment and logistic workflow was correlated with real waiting times and process times.Mean information duration was 36.1±0.8 min. In patients with no appointed time, waiting times and overall stay was shorter. Patient's satisfaction with medical treatment and time process was significantly higher in the elderly. Longer conversation with the surgeon was associated with a higher assessment of surgeons' medical experience irrespective of his specialist's state. Real waiting times did not affect patient's satisfaction.A walk-in clinic for presurgical visit and signed informed consent can improve patient satisfaction. It allows an excellent patients information in an appropriate time-frame. Clinical pathways can improve patient satisfaction and information concerning the lining up operation and disease pattern.

Einleitung: Bei nicht ausreichendem Restparenchym ist die Pfortaderastligatur (PAL) ein effektives vorbereitendes Verfahren für eine sekundäre Leberresektion Material und Methoden: BALB/c Mäuse (n=56) erhielten entweder eine PAL oder eine Sham-Behandlung des linken Leberlappens.[for full text, please go to the a.m. URL], 127. Kongress der Deutschen Gesellschaft für Chirurgie

Implantation of venous access port systems can be performed in local or general anesthesia. In spite of the increasing rate of interventionally implanted systems, the surgical cut-down represents a safe alternative. Thus, the question arises whether--in context to the increasing health-economic pressure--open implantation in general anesthesia is still a feasible alternative to implantation in local anesthesia regarding OR efficiency and costs.In a retrospective analysis, 993 patients receiving a totally implantable venous access device between 2001 and 2007 were evaluated regarding OR utilization, turnover times, intraoperative data and costs. Implantations in local (LA) and general anesthesia (GA) were compared.GA was performed in 762 cases (76.6 %), LA was performed in 231 patients (23.3 %). Mean operation time was similar in both groups (LA 47.27 +/- 1.40 min vs. GA 45.41 +/- 0.75 min, p = 0.244). Patients receiving local anesthesia had a significantly shorter stay in the OR unit (LA 95.9 +/- 1.78 min vs. GA 105.92 +/- 0.92 min; p0.001). Specifically, the time from arrival in the operating room to surgical cut (LA 39.57 +/- 0.69 min vs. GA 50.46 +/- 0.52 min; p0.001) was shorter in the LA group. Personnel and material costs were significantly lower in the LA group compared with the GA group (LA: 400.72 +/- 8.25 euro vs. GA: 482.86 +/- 6.23 euro; p0.001) Blood loss as well as duration and dose of radiation were similar in both groups.Our study shows that implantation of totally implantable venous access port systems in local anesthesia is superior in comparison to the implantation under general anesthesia regarding procedural times in the OR unit and costs. With the same operation duration, but less personnel and material expenditure, implantation in local anesthesia offers a potential economic advantage by permitting faster changing times. Implantation in GA only should be performed at a special request by the patient or in difficult venous conditions.

Introduction: The organ predilection of metastasis can be regulated by chemokines. Various chemokine receptors namely CXCR4, CCR6 and CCR7 have recently been shown to be involved in the regulation of metastasis. Therefore, we were challenged to investigate these chemokine receptors with view to their[for full text, please go to the a.m. URL], 126. Kongress der Deutschen Gesellschaft für Chirurgie

At present, atypical as well as anatomic liver resections are recommended as the surgical therapy for gallbladder cancer (GC) at stagesor = T 2. The aim of this study was to compare atypical with anatomic resections (mostly resections of segments IV b / V with selective vascular occlusion using the round ligament approach).Between November 1994 and January 2007, n = 56 patients were treated for GC. The staging, operative and histological results and the postoperative course were recorded. In addition, the survivals at a mean follow-up of 13 (range: 3-54) months were estimated and compared between the two study groups.We performed 28 liver resections for GC (n = 14 atypical and n = 14 anatomic resections). In the anatomic resection group, there was one extended right hepatectomy as well as thirteen segment IV b / V resections. The volume of the resected liver specimen, the frequency of the Pringle manoeuvre, the transfusion requirements, and the duration of the operation did not differ between the two study groups. However, in only 64 % of the atypical resections, the recommended resection margin of at least 3 cm could be achieved. One patient died after extended hepatectomy. There were no other major complications. The mean follow-up was 16 +/- 5 months in the anatomic and 22 +/- 7 months in the atypical resection group. Survival was not statistically different between the two study groups.Segment IV b / V resections are attractive procedures to treat GC due to their lower invasiveness in spite oncological adequacy. However, we could not demonstrate any superiority in terms of survival for the segment IV b / V liver resections. Nevertheless, extended liver resections are rarely necessary in the operative treatment of GC.

Progressive health care implies progress also in physician/patient interaction, especially with regard to moribund patients and their relatives. Advance health care directives emerged from the desire to influence medical treatment even in borderline situations. In spite of the present political and public discussions in Germany, advance directives are rarely of much importance in everyday surgical practice. By means of questionnaires, this study aimed at the frequency of advance directives among the patients of a surgical hospital and at related influencing factors.Between August 2007 and January 2008, 450 patients at our hospital were interviewed, prior to scheduled surgery, on the topic of advance health care directives by means of anonymous questionnaires. In addition to questions about the existence of or the intention to draw up advance directives, the study focussed particularly on the relationship between patient and attending physician. Patient-specific and sociodemographic data were collected as well.Of the patients interviewed, 16.7% stated they had drawn up advance directives, while 21.3% did not know about the possibility of drawing up such a document. A mere 9.7% of the patients interviewed saw no need for such directives, whereas the majority (65.3%) considered it an option. Among the factors influencing the drawing up of advance directives, age and prior experience with severe disease figured significantly. Of the patients interviewed, 64.8% wished for more information on the topic of advance health care directives and health care proxies. The wish was expressed by 80.1% of patients that the attending surgeon mention the topic prior to surgery.Although the proportion of patients that draw up advance health care directives continues to be less than one fifth, surgical patients have a great need for information regarding the topic. Surgical hospital personnel should also set themselves to this task.

Background: Liver regeneration after hepatectomy (Phx) for colorectal liver metastases stimulates metastatic tumor growth through the release of potent growth factors. The mTOR inhibitor rapamycin (RAPA) has been shown to exhibit potent anti-tumor activities in experimental models. However, it is unknown whether RAPA is also capable of exerting these effects under the conditions of hepatectomy-associated liver regeneration. We therefore analyzed tumor growth characteristics and neovascularization after RAPA or cyclosporine A (CyA) treatment after liver resection in a model of colorectal metastasis in mice. Methods: 1×105 GFP-transfected CT26.WT colorectal cancer cells were implanted into the dorsal skinfold chambers of syngeneic BALB/c mice, followed by a 70% Phx. Thereafter, animals were assigned to 3 groups: the first group received 1.5 mg/kg/d RAPA intraperitoneally (i.p.), the second group received 10 mg/kg/d CyA i.p. and the third group received sham treatment. Tumor growth, neovascuarization, leukocyte adhesion, tumor cell proliferation and apoptotic cell death were studied using intravital fluorescence microscopy and immunohistochemistry during a 12-day observation period. Results: CyA treatment induced a slight but not significant decrease of tumor growth compared to controls, whereas RAPA significantly inhibited tumor growth. This finding was associated with a significantly reduced microvascular density within the tumors and a strongly diminished microvascular blood perfusion. Leukocyte adhesion within the tumor microvessels was significantly attenuated after CyA but in particular after RAPA treatment. Immunohistochemistry revealed a significant reduction of tumor cell proliferation after RAPA treatment compared to controls. In contrast, CyA only slightly reduced the number of proliferating tumor cells. Apoptotic cell death was not affected by the immunosuppressive treatment regimens. Conclusion: These results clearly indicate that RAPA is capable of inhibiting tumor growth of colorectal metastasis also during hepatectomy-associated liver regeneration. This effect is most probably caused by the reduction of angiogenesis and microvascular blood perfusion.

Introduction: Portal hyperperfusion occurs after partial hepatectomy (PHx) or small-for-size liver transplantation. Since no negative HABR can be observed after PHx, but very well after reduced size transplantation, other regulating systems of liver perfusion have to be responsible for compensation of expected hepatic arterial blood flow reduction. Therefore we analyzed the role of the NO-synthase (NOS) system in regulation of liver blood flow after 70% PHx. Materials and Methods: Sprague-Dawley rats underwent 70% liver resection or sham operation. Both groups were treated with the functional NOS-inhibitor N(G)-nitro-L-arginine-methyl ester (L-NAME). Before and after L-NAME administration hepatic arterial and portal venous blood flows were analyzed by ultrasonic flow measurement and a HABR was provoked by portal venous flow reduction. Furthermore expression of endothelial NOS (eNOS) and inducible (iNOS) in the liver tissue were determined by use of Western blot. Results: Portal blood flow was 2-fold increased after 70% hepatectomy. This, however, did not provoke a negative hepatic arterial buffer response. In contrast, hepatectomy associated portal hyperperfusion resulted in a significantly decreased hepatic arterial blood flow, when iNOS and eNOS were blocked by L-NAME administration. Quantification of Western blot analysis showed a distinct increase of iNOS as well as eNOS in liver tissue. Conclusion: These novel findings demonstrate that the expected but not observed negative HABR after major liver resection is counter-balanced by increased hepatic NO-release in consequence of an enhanced expression of iNOS and eNOS.

Background: After major hepatectomy, postoperative hepatic failure still remains a serious problem. In experimental models, erythropoietin (EPO) and its analogue darbepoetin (DPO) have been shown to improve liver function and liver regeneration. In case of malignant hepatic tumors, the use of EPO is still controversially discussed, suggesting that EPO could stimulate growth of remnant micrometastases leading to early tumor relapse. We therefore studied the influence of DPO-treatment on tumor growth in a model of experimental colorectal liver metastasis. Methods: BALB/c mice received 1×105 syngeneic CT26.WT colorectal cancer cells into the left liver lobe and were randomized into 4 groups: the first group received portalvenous injection (i.p.) of 10μ/kg DPO; the second group received PBS i.p. and served as control; the third group underwent a 50% hepatectomy (Phx) and received PBS i.p.; the fourth group underwent Phx and received 10μ/kg DPO i.p. After 7 days, tumor growth, angiogenesis and leukocyte adhesion were analyzed using intravital fluorescence microscopy. Results: After tumor cell implantation, DPO induced a slight, but not significant increase of tumor volume compared to controls, whereas Phx significantly stimulated tumor growth. Application of DPO after Phx caused an additional stimulation of tumor growth with a significantly increased tumor volume compared to Phx only. DPO also induced tumor angiogenesis and significantly increased microvascular density compared to controls. DPO after Phx also caused an increase of capillary density compared to Phx only. DPO treatment significantly reduced leukocyte adhesion within the tumors as compared to controls. After Phx, leukocyte adhesion within the tumor mass was significantly enhanced, whereas additional DPO treatment again inhibited leukocyte adhesion. Conclusion: Our study indicates that DPO stimulates tumor growth especially after liver resection due to an increase of angiogenesis within the colorectal metastases.

Clinical pathways (CPs) are considered to be a device of clinical process management, which describe the optimal way of a special type of patient with its diagnostic and therapeutic medical treatment. Apart from these economic aspects CPs can make a contribution to an optimization of the health quality management as well as to an improvement of medical staffs and patients satisfaction. In our hospital clinical pathways supported by information technology (IT-supported CPs) were implemented world-wide for the first time in a running Hospital Information System (SAP/i.s.h.med) and used by routine. The aim of the study was to investigate the influence of IT-supported CPs on patient satisfaction.The patient satisfaction was examined BEFORE introduction of IT-supported CPs by standardized questionnaires in 64 Patients (45f/19m, median age: 64,9 +/- 1,24 years) and in 62 patients (38f/24m, median age: 63,3 +/- 1,49 years) AFTER introduction of IT-supported CPs by standardized questionnaires. Different CPs were selected and grouped by simple, middle and high complexity, each to benign and malignant illnesses.By introduction of IT-supported CPs patient satisfaction can be improved. CPs already evaluated as very good before introduction of CPs could be improved only slightly, whereas badly evaluated CPs exhibited a large optimization potential.On the one hand patient satisfaction may be improved by the introduction of CPs. On the other hand CPs- when IT-supported- do not result unavoidably in an industrial medicine. This subjective estimate of the patient contributes to a better customer-and patient-oriented quality management, whereby an appropriate optimization of the recognized deficits can be simply realized by IT-supported CPs.

A 39-year-old female patient presented with a 3-year history of lower back pain which had not been alleviated by pain treatment combined with physiotherapy. Radiological findings were normal with the exception of a cystic paravertebral tumor in the left retroperitoneum. The cyst was primarily regarded as a coincidental finding because no criteria for malignancy were present. Magnetic resonance tomography, however, the cyst showed a progressive increase in size and the pain remained unchanged so that surgical resection was performed. The histopathological examination showed a lymphangioma and the pain was nearly completely resolved after surgery.

In 2006 the longest strike so far in the German health service occurred. Contrary to most hospitals in public authorities, the medical doctors of the University Hospital of Homburg/Saar did not participate in the strike, leading to pronounced tensions between patients, strikers and medical staff.The effect of the strike on operating room (OR) management, medical personnel resource planning, and surgical training were compared with the remaining period of the year 2006.Elective surgical procedures were accomplished significantly more frequently by more qualified surgeons, leading to shorter OR time; surgical training was performed significantly less. The rate of emergency operations and the care of tumor patients increased significantly during the strike.Surgical training was neglected during the strike. Transferring non-job-related tasks to medical doctors and expanding their working time allowed optimal utilization of the limited resources.

In analogy to industrial process management, clinical pathways have been introduced for operational process organisation in orthopedic and interventional procedures as well as for conservative treatments. Within this study, introduction and continuous, systematic application of clinical pathways at a surgical department of a university hospital was investigated.Analysis was performed by IT-based (SAP/i. s. h.med) evaluation of the registered data regarding pathway violations. Additionally, patients' records were matched with the computerized data for quality assurance of pathway documentation.501 patients were entered in 16 clinical pathways (31 +/- 39 patients per pathway). The mean period from the introduction of a distinct pathway to the data acquisition of the present study ranged from 2 to 14 months (mean 7+/-7.5 months). Pathway violations correlated with the complexity, but not with the period since the pathway was introduced. Organisational reasons next to medical reasons (i. e. delayed gastric function or wound healing) were the most frequent causes for pathway violations.Clinical pathways may not only be realised for operative procedures or conservative treatments, but represent a clinical and administrative management instrument at a surgical department of a university hospital for daily work routine. They are suitable as an instrument for clinical quality and risk management, as an economic control instrument in reorganisation phases as well as in the routine of surgical clinics.

Mittels der ICG-Fluoreszenzmessung lassen sich erhebliche Storungen der Homogenitat der intestinalen Perfusion ausfindig machen. HO-1 scheint hierbei vor allem einer vermehrten Perfusionsstorung entgegenzuwirken. Die bei BDL postulierte vermehrte intestinale Translokation ist moglicherweise Folge dieser Perfusionsdefekte.

The clinical presentation of acute pancreatitis varies significantly from mild self-limiting discomfort to a severe life-threatening condition. Once the disease process is initiated, the severity of the disease is largely determined by a complex network of activated inflammatory mediators such as cytokines, proteolytic enzymes, reactive oxygen species, and many more which render the local injury to a systemic disease with multiple organ dysfunction, sepsis, and considerable mortality. Remarkable progress in diagnostic modalities, intensive care technologies, and organ preserving surgical techniques have decreased mortality of severe acute pancreatitis during the past decades. However, the treatment of acute pancreatitis still remains largely supportive and no specific approach exists to prevent evolving complications. A large body of clinical and experimental evidence suggests that cytokines are key factors in the pathomechanism of local and systemic complications of acute pancreatitis. Targeting cytokine activity as therapeutic approach to acute pancreatitis is a challenging concept and the results of modulating activation of TNF-alpha, IL-1beta, IL-2, IL-10, PAF and various chemokines has indeed been promising in the experimental setting even if tested under therapeutic conditions. However, experience from a limited number of clinical trials on anti cytokine strategies in acute pancreatitis has remarkably emphasized that translating successful experimental observations into reproducible clinical associations seems to be difficult.

The special anatomic situation and the multitude of combinations of oncological therapeutic and reconstructive modalities in tumors of the cervical region require intensive interdisciplinary planning and discussion during tumor staging, surgical resection, and (neo)adjuvant treatment. We discuss here the various treatment modalities for tumors of the pharynx and cervical esophagus.

Background: Cryosurgery is an interesting alternative in the treatment of non-resectable liver tumors. The freeze-thaw procedure, however, maybe associated with life-threatening thrombocy-topenia due to local platelet trapping, and success of tumor ablation may be compromised by inadequate parenchymal cell destruction. Methods: Because aprotinin is capable to inhibit the initiation of both coagulation and fibrinolysis, we herein studied by whole body scintigraphy of Indium-111 -labelled platelets and semi-quantitative histology in a porcine model of hepatic cryosurgery whether this serin protease inhibitor is effective to attenuate platelet trapping and to improve tissue destruction. Results: 15 minutes cryotherapy (- 168 °C) induced a 31.7 ± 3.5 cm3 cryolesion at the 7th POD, which presented with massive platelet trapping (14.0 ± 1.7% cryolesion activity /whole body activity) and incomplete parenchymal cell destruction (0.9 ±0.3; score of hepatocyte nuclear destruction within the margin of the cryolesion). Aprotinin treatment, i.e. 500,000 IU initial bolus injection and additional 500,000 IU infusion over 3 h, did not affect the size of the cryolesion (28.9 ±3.1 cm3), but was capable to significantly reduce local platelet activity (1.9 ±1.9%; p< 0.001), and to completely induce hepatocyte nuclear destruction (3.0 ±0.0; p < 0.001). Conclusion: Thus, our study indicates that aprotinin (i) inhibits cryoablation-associated platelet trapping and (ii) improves tissue destruction. The serine protease inhibitor may therefore represent a valuable adjunct in cryosurgery of hepatic tumors.

The process of chronic rejection (CR) threatens long-term organ graft survival and is the major remaining barrier preventing successful clinical transplantation. The etiology of CR remains speculative, but its correlation with acute rejection episodes, HLA mismatch and immunosuppressive non-compliance suggests that active immune attack is responsible. The authors hypothesize that transforming growth factor beta-1 (TGF beta-1) plays a causal role in regulating and modulating both the acute and the chronic rejection. To investigate this hypothesis in rats, recombinant adenoviruses (rAdv)-mediated gene transfer encoding downregulating antisense--or upregulating bioactive TGF beta-1 transgene were used to infect orthotopic aortic grafts. In a high responder MHC class I histocompatibility difference (ACI to Lewis rat) and in syngeneic controls (Lewis to Lewis) both expression vectors were detected 1, 2 and 12 weeks following transplantation by intragraft cytokine transcription. Aortic segments were divided and processed for histology and RNA extraction. TGF beta-1 RNA expression was then evaluated by semi-quantitative RT-PCR (s26 standardized, HPLC quantitated). Histological evaluation was performed by a transplant pathologist in a blinded fashion. All analysis were prospective and repeated in triplicate. Untreated allografts were used as background controls for the acute and chronic rejection showing an endogenous up-regulation of TGF beta-1 at early time points (1 wk 2.7 +/- 0.5; 2 wk 9.2 +/- 6.1) and a decreased TGF beta-1/s26 ratio in chronic rejection (12 wk 1.2 +/- 0.11). Successful rAdv-transgene activity was, however, detected in low levels in all aortic layers showing a 25%-35% transfection rate whereas beta-galactosidase control gene expression was found as far as 35 days post transplant. Administration of down-regulating antisense TGF beta-1 gene into transplant segments significantly decreased the intragraft TGF beta-1 transcription (1 wk 0.8 +/- 0.2; 2 wk 1.9 +/- 0.5; 12 wk 0.7 +/- 0.15) and was correlated with absence of ongoing acute graft rejection in allografts (p0.01) during the first 2 weeks. The degree of intimal hyperplasia proliferation was also decreased by 40% in chronic allograft rejection. The transfection of upregulating bioactive TGF beta-1 vector led to clear increase of the TGF beta 1 gene expression but had no significant effect on immune response either on syngeneic nor allogeneic grafts. These data suggest that TGF beta-1 plays a key role in modulating the early stage of acute rejection and is a crucial mediator of the outcome of chronic rejection. Down regulation of intragraft TGF beta-1 gene expression shows immunosuppresisve property and could be used to develop clinically relevant strategies in transplantation.

Complications of gastroduodenal ulcers such as bleeding and perforation have been afflicted with a mortality of up to 40 % in the past. Altered ulcer manifestation by improvement of medical treatment as well as advances in surgical techniques and intensive care medicine might currently have improved the outcome of these severely ill patients.A retrospective analysis of 73 patients with emergency operation for bleeding or perforated gastric (n = 50) and duodenal ulcer (n = 23) between 10/1994 and 7/2001 was performed.The median age was 58 years (17-90 years) with 30 % of patients exceeding the age of 70 years. Eighty-one percent of patients had perforation, 19 % had bleeding. Factors predisposing for gastroduodenal ulcers were present in 88 %. Five percent of gastric perforations were due to gastric malignancies. Diagnosis of perforation was made in 88 % by conventional X-rays, in 12 % of perforations no free abdominal gas was detectable. A local surgical procedure (excision of ulcer and sutures/pyloroplasty) was performed in 64/73 patients (88 %), partial gastroduodenal resection was necessary in 9 patients (12 %). Histologic examination for helicobacter pylori was positive in 30/39 specimens (77 %). In-hospital mortality was 14 %, both for patients with bleeding and perforated ulcers. Surgical complications were 12 %.Altered ulcer manifestation, minimized surgical therapy and improved intensive care medicine led to a recent reduction in postoperative mortality of patients suffering from perforated or bleeding gastroduodenal ulcer. A further reduction of this still high mortality might be expected by improvement of surgical training and/or restriction of therapy to a limited number of surgeons.

Vordringliches Ziel der Behandlung osophagealer Perforationen (spontan, iatrogen oder postoperativ) ist die Vermeidung einer vital bedrohlichen Mediastinitis. Trotz verbesserter intensivmedizinischer Masnahmen ist die Mortalitat hoch und das chirurgische Vorgehen kontrovers. Mit dem Konzept der primaren Herdsanierung und fruhzeitigen Rekonstruktion wurden seit 5/2000 samtliche Patienten mit einer Osophagusperforation prospektiv erfasst und pra-, und perioperative Daten sowie Outcome retrospektiv analysiert.

Perforated or bleeding gastric cancer is a life threatening situation that occurs in less than 10% of all patients with gastric cancer in the Western world. Three quarters of these complicated gastric carcinomas show advanced stages (UICC stages III and IV). Diagnosis is made intraoperatively only in the majority of patients. Emergency gastrectomy is superior to any type of local excision and/or local repair regarding surgical mortality and long-term survival and should be the intervention of choice. Stage-related long term survival of patients with emergency gastrectomy is comparable to that of electively resected patients. Minimalism and nihilism are therefore not appropriate in the treatment of complicated gastric cancer and are often deleterious. Subtotal gastrectomy without D2 lymphadenectomy is regarded as the adeqauate procedure in most cases.

Esophageal resection with fundus rotation gastroplasty. Anastomotic failure after esophageal resection remains a surgical problem with high clinical relevance. Anastomotic failure can be attributed to tension at the anastomosis especially in cervical anastomoses, as well as a perfusion deficit due to resection of the arterial arcade along the gastric lesser curvature. We attributed the anatomical deficiencies of conventional gastroplasties by developing a technique, that utilizes the whole gastric fundus and maintains the arterial arcade along the gastric lesser curvature: fundus rotation gastroplasty. Experimentally those tubes are 20 % longer than conventional tubes according to Kirschner/Akiyama and twice as good perfused. Clinically low failure rates of 7 % for cervical and thoracic anastomoses are achieved.

German private health insurance faces new challenges. The classical tools of cost containment are no longer sufficient to keep up with ever increasing expenses for health care, and international competitors with managed care experience from their home markets are on the point of entering business in Germany. Although the American example of managed care is not fully compatible with customer demands and state regulations, some elements of this approach will gradually be introduced. First agreements were signed with networks or individual preferred providers in outpatient care and rehabilitation medicine. Insurance companies become more and more interested in supporting evidence based guidelines and programmes for disease and case management. The pros and cons of various other health management tools are discussed against the specific background of the quite unique German health care system.

Low flow or no flow is a prefinal step after reperfusion of hepatic allografts. Adenosine is an intrinsic key regulator of physiological and pathological hepatic blood flow.In a model of rat liver transplantation, the effect of donor pretreatment with adenosine deaminase inhibitors (0, 0.1, 1, 10 micromol erythro-9-[2-hydroxy-3-nonyl]adenine) was studied on hepatic interstitial adenosine concentrations, microcirculatory flow, leukocyte adhesion, and graft survival by means of microdialysis sampling, intravital video microscopy, and laser Doppler flowmetry.Donor pretreatment with 1 micromol erythro-9-[2-hydroxy-3-nonyl]adenine increased interstitial adenosine concentrations 5- to 10-fold, for more than 24 hr of cold storage. In LDF studies, mean donor blood flow was increased from 420 +/- 42 perfusion units (PU) to 832 +/- 52 PU and from 475 +/- 79 to 720 +/- 81 PU after reperfusion, and in intravital video microscopy studies from 247 +/- 24 to 281 +/- 39 pl/sec. There was no difference in the number of leukocytes sticking, but a significantly lower percentage of leukocytes rolling (26.1 +/- 1.9 vs. 36.5 +/- 7.5%) along the endothelial wall in the treatment group. Transplant survival after 44 hr cold storage in UW solution was 8/10 in the treatment group and 1/13 in the control group.Donor pretreatment with erythro-9-[2-hydroxy-3-nonyl]adenine increases survival of critically injured liver grafts. Donor or recipient treatment rather than addition of protectants to cold storage solutions are successful strategies to overcome preservation injury and possibly adverse donor factors.

Anastomotic failure remains to be one of the main problems in esophageal surgery with leakage rates up to 30% being reported currently. We addressed that problem by modifying the gastric-tube formation in utilizing all of the gastric fundus and omitting the resection of the lesser gastric curvature and accompanying vessels. Experimentally, those fundus-rotation gastroplasties were significantly longer and better perfused than conventional gastroplasties. In a clinical series of 53 patients (45 male, eight female, range 42-83 years) undergoing esophageal resection (49 malignancies, four non-malignant esophageal disease), four anastomotic leakages were found (7.5%). Three patients died due to a bronchial leak and adult respiratory distress syndrome, one with a complete gastric-tube necrosis and one with a colon perforation, sepsis and multiorgan failure. Eight patients developed a significant anastomotic stricture requiring repeated endoscopic dilatations. From our experimental and clinical experience, we conclude that the favorable length and perfusion of fundus-rotation gastroplasties allow for safe anastomosis at either the cervical or thoracic level.