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Deciduosen der Appendix konnen in seltenen Fallen Ursache einer akuten Appendicitis wahrend der Schwangerschaft sein. Im submesothelialen Stroma lokalisierte Deciduazellverbande sind dem derzeitigen Kenntnisstand zufolge physiologische Reaktionen der pluripotenten Stromazellen auf progestationsdominierte hormonelle Stimuli. Seltener ist die Deciduose eine unter Schwangerschaftshormonen decidualisierte praexistente Endometriose, erkennbar an einer Lokalisation abweichend von der streng submesothelialen, an Residuen zyklisch rezidivierender Proliferation und Blutung und an eingestreuten endometrialen Drusenformationen.

Traditional cholecystectomy has been accepted as the goldstandard for the treament of gallstones. Since the indication for surgery, diagnostic investigations, technical approach and the results of the therapy proved to be excellent and reproducible, new therapeutic methods must prove to be better or at least as good as the conventional operation. During the last 3 years, laparoscopic cholecystectomy is the “shooting star” among operative procedures in general surgery. The great acceptance by the patients and their surgeons is mainly due to the minimal disturbance caused by the operation. In addition, the new method is as effective as conventional cholecystectomy. Although enthusiasm is understandable, the further development of laparoscopic cholecystectomy must be critically observed. Diagnostic evaluation and parts of the operative technique are not standardized so far, the list of indications is not definitely clear and long-term results are not yet available. Last but not least, bile duct injury. probably the most important technical complication, is still distinctly more frequent than with the traditional procedure. For all these reasons, conventional cholecystectomy today is still the gold-standard for the treatment of gallstones, although most likely laparoscopic surgery will take over this part in the future.

With the help of ECMO it is possible to save the lives of newborn infants suffering from severe respiratory distress syndrome not responding to conservative treatment. Using Bartlett's classic venous-arterial perfusion technique in ECMO the right arteria carotis communis had to be sacrificed. Thus, despite the life-saving character of this new method, the ligation of the carotid with all its possible complications had often been a major argument against using this therapy. We are now therefore trying to reconstruct the arteria carotis after decannulating the vessel after extracorporeal membrane oxygenation. In our 8 cases so far, post-op examinations showed no obstruction of blood flow in the vessel. No neurological deficiencies were recorded.

Deciduosis of the appendix is a rare cause of acute appendicitis in pregnancy. Ectopic decidual cells localized in the submesothelial stroma may represent a physiologic reaction of the pluripotent stromal cells to progestational hormonal stimulation. Less frequently, deciduosis is based on a preexisting extragenital endometriosis, visible in a localization other than strictly submesothelial, in residuals of cyclic proliferation and bleeding, and in endometrial glandular formations embedded in the decidual cells.

Hospital marketing is an intricate and complex process. Especially difficult is the transition the hospital marketer must make from designing marketing strategies to implementing those strategies. This transition usually causes the marketer to call upon a different set of skills. These skills involve managing the personnel needed to implement the designed marketing strategy. Unfortunately, little in the way of formal training is provided the marketer for developing these management skills. Therefore, the authors have comprised a series of tactical procedures designed to assist the hospital marketer to survive this transition. Using these tactics for decision-making guidelines may help to improve the management of the hospital's marketing effort.

Hauptsachliche Risikofaktoren bei der laparoskopischen Cholezystektomie (LC) sind die Laparoskopie (L) selbst, Instrumente, Befundkonstellation und intraoperative Komplikationen. Gefahren durch die L sind vielfaltig, aber selten. Die Anzahl der Kontraindikationen ist rucklaufig. Die gravierendste chirurgische Komplikation ist die Gallenwegsverletzung (BDI). In der Literatur wird sie zwischen 0–2,8% mit einem Durchschnitt von 0,56% angegeben. Die Operationsletalitat (OL) ist auserst selten (0,045% in 18 Serien mit 11 099 Fallen, publiziert 1991/92). Unter 700 LC’s traten in Mannheim keine BDI oder OL auf. Eine korrekte Indikationsstellung, Trainingskurse und subtile Operationstechnik sind Voraussetzung, um Gefahren zu begegnen und Fehler zu vermeiden.

Traumatische Pankreaslasionen beim stumpfen Bauchtrauma stellen hdufig eine Indikation zur partiellen bis subtotalen Organresektion dar, insbesondere bei Verletzungen des Ductus pancreaticus. Anhand einer Kasuistik eines 9jahrigen Jungen mit totaler Pankreasruptur wird ein Verfahren zur Gangrekonstruktion dargestellt, durch das eine vollstandige Organerhaltung moglich war.

Blunt abdominal traumas with pancreatic injuries often cause partial or subtotal resection of the organ, especially when the pancreatic duct is damaged. A reconstructive method for anastomosis of the duct is reported in a case of a 9-year-old boy with complete pancreatic rupture in which the whole organ could be salvaged.

Die laparoskopische Cholezystektomie ist ein inzwischen von Patienten und Chirurgen bevorzugtes Verfahren. Es ist wunschenswert, die fur diese Operation weniger oder nicht geeigneten Patienten moghchst bereits praoperativ zu erkennen. Die Kombination von entsprechender Anamnese, BKS-Erhohung, pathologischem Ultraschallbefund und negativem Cholezystogramm macht das Vorliegen einer Cholezystitis wahrscheinlich. Durch rationale Diagnostik konnen diese fur die laparoskopische Cholezystektomie weniger oder nicht geeigneten Patienten rechtzeitig erkannt werden.

Die Ausstellung ist in 3 Abschnitten unterteilt: 1. Konventionelle Cholezystektomie. Hier werden die Erfahrungen der Mannheimer Klinik mit 7028 Gallenstein-Eingriffen der letzten 20 Jahre analysiert (Gesamtmorbiditat: 3%, Gesamtmortalitat: 1,1%; Mortalitat bei elektiver Cholezystektomie: 0,2%). 2. Alternative Therapieformen (z.B. Lyse und Trypsie). Diese Verfahren haben den Nachteil der geringen Anwendbarkeit (10–20%), unbefriedigender Erfolgsquoten (bis zu 80%), langer Therapiedauer und hoher Rezidivquoten. 3. Laparoskopische Cholezystektomie. Hier werden die eigenen Ergebnisse der ersten 200 konsekutiven Eingriffe prasentiert (Letalitat: 0; elektives Umsteigen: 2; konservativ beherrschbare Komplikationen: 3).

Wahrend in der Vergangenheit auch die Milz(pseudo)zyste eine absolute Indikation zur Entfernung der Milz darstellte, ist mit den heute zur Verfugung stehenden chirurgisch-technischen Moglichkeiten ein

From 1972 to 1986 70 acute occlusions of the aorta or bilateral iliac arteries were operated in our clinic. The occlusion was caused in 41 cases by embolisation, in 29 cases by thrombosis. Amputation rate was 22.8%, the mortality rate 42.8%. 71% of the patients were of extreme high risk regarding the operation as well as the anesthesia. In 44% of the patients the duration of complete ischemia was more than 6 h. Performance of intraoperative angioplasty (n = 10 patients) for dilatation of stenoses leading to thrombotic occlusions may lower the mortality rate.

From 1972 to 1986 70 acute occlusions of the aorta or bilateral iliac arteries were operated in our clinic. The occlusion was caused in 41 cases by embolisation, in 29 cases by thrombosis. Amputation rate was 22.8%, the mortality rate 42.8%. 71% of the patients were of extreme high risk regarding the operation as well as the anesthesia. In 44% of the patients the duration of complete ischemia was more than 6 h. Performance of intraoperative angioplasty (n = 10 patients) for dilatation of stenoses leading to thrombotic occlusions may lower the mortality rate.

This report concerns 44 patients with iatrogenic injuries to the bile ducts treated at the Mannheim University Clinic from 1973 to 1987. Group A: 12 own patients with lesions of the common bile duct among 6020 operations for cholelithiasis, i.e. a risk of 0.19%. All 12 lesions were recognized during operation and immediately repaired with eventual success. Group B: 32 patients referred to us from another hospital after cholecystectomy alone or previous repair. 11 of these patients had progressive jaundice in the immediate postoperative period (1. to 9. week) due to unrecognized bile duct injury. The other 21 patients developed strictures after an uneventful postoperative course within time intervals varying from 3 months to 23 years. 72% of patients (Group B) had reconstructive surgery within two years after last operation in another hospital. We performed 47 reconstructive operations in 42 patients without hospital mortality including 5 second or third operations for recurrent stricture. Biliary-intestinal anastomosis (70%) as sutured mucosa-to-mucosa anastomosis was the most favoured method of reconstruction (30 Roux-Y hepaticojejunostomies and 3 choledochoduodenostomies). An end-to-end anastomosis was only performed in 3 cases of plain transection of the common duct. In management of high biliary strictures (type III and IV according to Bismuth's classification) preference would be given to Hepp-Couinaud's modification of hepaticojejunostomy using the left hepatic duct for a long side-to-side anastomosis. Overall morbidity amounted to 28% while the rate of relaparotomy for surgical complications was 13% (n = 6 without postoperative death). 10 patients died since reconstructive surgery, death being independent from bile duct injury in 5 cases. The injury related one-year-mortality was 4.5%. Overall stricture recurrence rate was 15% (18% for hepaticojejunostomy) with a mean follow-up of 72 months. Local infection was the most obvious cause of recurrence, thus a two stage procedure with postponement of reconstructive surgery must be recommended in case of subhepatic abscess or biliary fistula. Including second and third repairs, a good longterm result was achieved in over 80% of patients.

Gluing of oesophageal anastomoses in atresia effected by means of three or four sutures will definitely produce better results than suturing alone. The results of endoscopic closure of tracheo-oesophageal fistulas by gluing with fibrin are excellent. Furthermore, it is possible with fibrin gluing alone to treat iatrogenic perforations of the oesophagus in the newborn, following a false passage of nasogastric tubes from the hypopharynx into the mediastinum or pleural cavity.

200 patients undergoing elective cholecystectomy were studied in a prospective randomized manner. This study suggests that the nasogastric tube and postoperative iv-infusions are unnecessary. We continue to use a subhepatic drain. Exception: the senior surgeon in a straightforward case.

Operations were performed on 75 cases of acute occlusion of the aorta and bilateral iliac arteries, between 1972 and 1987. The occlusions had been caused by embolisation in 48.6 per cent of these cases and by thrombosis in 31.4 per cent. Amputations had to be performed on 22 per cent, while the mortality rate at hospital amounted to 42.8 per cent. Surgical and anaesthetic risks were extremely high in 71 per cent of all patients. Complete ischaemia lasted more than six hours in 48 per cent. Intraoperative angioplasty was applied to twelve patients to control occlusion-induced stenoses and is believed to be capable of reducing hospital mortality.

The performance of nuclear electric propulsion (NEP) systems has been evaluated for a wide variety of missions in an attempt to establish the commonality of NEP system requirements. Emphasis was given to those requirements and system characteristics which serve as guidelines for current technology development programs. Various interactions and tradeoffs between NEP system and mission parameters are described. The results show that the most significant factors in selecting NEP system size are launch mode (direct or spiral escape) and to a lesser extent, launch vehicle capability. Other factors such as mission and payload have little influence, thus allowing one NEP system to be used for many missions. The results indicated that a 100 kWe NEP would be suitable for most direct escape missions and a 250 kWe NEP system would be suitable for more demanding missions that use the spiral escape mode.

Nuclear space power systems computer simulation for preliminary system and mission analysis, considering Brayton, Rankine and thermionic systems

Bei 185 Patienten (8/74 bis 12/86) im Alter von 19–85 J. (Median 66 J.) wurde wegen Residualsteins bei noch liegendem T-Drain die EST vorgenommen. EST und Steinextraktion gelangen bei je 93%. Alle Komplikationen (9,3%) waren leicht und konservativ beherrschbar. Die Letalitat nach EST war 0, nach offener 2. Revision 1,8%. 34% waren zur Zeit der EST unter 50 J. alt. Kontrollen 2,5 bis 9 J. nach EST ergaben Beschwerdefreiheit bei 95%, AP-Erhohungen bei 7%, sonographisch Aerobilie bei 20%. Das Risiko der Spat-Cholangitis nach EST ist nach wie vor unbekannt. Beobachtungen uber 3–4 Jahrzehnte und leberhistologische Befunde sind erforderlich.

In einer randomisierten Studie wurden 200 Patienten in 2 Gruppen eingeteilt: „Konventionelle” Cholecystektomie (CE): Magensonde, Drainage und postop. Infusionsbehandlung; „ideale” CE: keine Drainage, keine Magensonde, keine postop. Infusionsbehandlung. Es gab keine signifikanten Unterschiede bezuglich Schmerzmittelbedarf, OP-Zeit, postop. Aufenthaltsdauer und Fieber-Tage, Beginn der Darmtatigkeit und postop. Komplikationsrate. 2 Komplikationen wurden hervorgehoben: In der 1. Gruppe kam es zu einem subhepatischen Abscess, in der 2. zu einer Gallefistel. Schlufolgerung: Unsere „ideale” CE: Keine Magensonde, keine Infusionsbehandlung, aber eine subhepatische Drainage.