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Background: Subcostal incisions for open cholecystectomy (OC) denervate the right upper and middle abdomen. Methods: Sensory and abdominal muscle function (Janda's muscle function test, Cybex 6000) was evaluated. Healthy volunteers (10 women, 12 men) were compared with 13 women and 12 men after OC and 11 women and 11 men after laparoscopic cholecystectomy (LC). For computed tomography (CT) studies, a spiral scanner was used. Results: Of the OC patients, 21 (95.5%) complained of dys- and anesthesias below the incision. Of the LC patients, only nine (2.4%) reported anesthesias around the port sites. Normal subjects scored significantly higher in muscle strength (p <.01). LC patients scored higher than OC patients at 10° and 20° trunk flexion (p <.05). Depending on the flexion angles, the men in all groups developed 30–114% more muscle power than the women. Denervation of the abdominal muscles was confirmed by CT. Conclusion: OC reduced skin sensitivity and abdominal muscle function. Although the procedure is minimally invasive, LC also causes sensory and functional losses, albeit minor ones.

Abstract.: Whereas primary resection to remove the septic focus stands undisputed in the therapy of spontaneous perforation of the colon, there is still no consensus as to whether to perform a primary anastomosis or a staged procedure (Hartmann). Prospective randomized studies comparing both concepts are lacking. Obviously these two competing therapies fit different groups of patients whose diseases differ concerning etiology, localisation and severity. Analysis of the literature of the past few years defined some criteria that help to decide when to omit primary anastomosis: MPI > 20, APACHE II score > 15, preoperative organ insufficiency, Hinchey grade III or IV and ASA score IV. In these cases a discontinuity resection is recommended. Primary resection with anastomosis and Hartmann procedure are not competing operations but situation-dependent therapeutic concepts in spontaneous colonic perforation.

Background: Although gastric bypass is an effective treatment for morbid obesity, the postoperative results are unsatisfactory in 10% of all patients. Therapeutic failures after an operation performed with the sole purpose of reducing the risk of obesity-associated diseases have to be taken seriously. The goal of this study was to investigate the causes of these failures. Method: From 1979 to 1993, 165 gastric bypass operations (technique: Mason-Griffen) were performed. Long-term results were obtained in 60 patients after an average of 6.6 years (range 3–13). On follow-up all patients were examined and asked about their level of statisfaction with the weight loss achieved and changes in eating habits. Results: In 6 patients the weight reduction was regarded as insufficient (BMI>35 and reduction of BMI<10). The causes of these failures were technical in 3 cases (gastric pouch to 0 large in 1, dilatation of gastrojejunostomy in 2). Three patients had a high calorie intake through an intact gastric bypass by snacking. Three patients regarded the operation as a failure although they had achieved significant weight loss, because they could no longer eat the usual amounts of food. Conclusion: Correct surgical technique and preoperative information on the changes in eating habits after a gastric bypass operation are the most important steps in preventing therapeutic failures.

Summary.: Background: Although the majority of surgeons regard Hartmann's operation as therapeutic standard in perforations of the colon complicated by peritonitis this procedure has been critically discussed in recent years. Advocates of one-stage techniques criticized bad postoperative results (high morbidity and mortality) and long-term outcome (low rates of intestinal restoration). The aim of our study was to investigate whether the late results after Hartmann's operation justify this criticism. Method: From 1982 to 1997 Hartmann's operations were performed in 103 patients for colonic perforations. In 63 % of cases inflammatory diseases caused colonic complications. The average Mannheimer Peritonitis Index (MPI) was 19. Seventeen patients died postoperatively (mortality: 16.5 %). In 69 patients (80 %) intestinal restoration could be performed after an average interval of 122 days (complication rate: 6 %, no mortality). On follow-up, patients were asked to give information on their general state, changes of housing, abdominal complaints, and quality of life. Results: Data on 93 % of patients could be obtained. The median follow-up time was 75 months. Eleven patients had died; the remaining 72 were investigated. 86 % described the quality of their lives as good or very good; only 11 % indicated severe loss of activity. Quality of life did not differ between patients in whom intestinal continuity had been restored and those in whom it had not been restored. Anastomotic strictures developed in 7 % of cases, always after stapled anastomosis. Conclusions: According to our results, long-term outcome after Hartmann's operation is good. 80 % of patients underwent intestinal restoration with low morbidity (6 %) and no mortality. A great majority of patients indicated the quality of their lives as good or very good: this assessment was not dependent on restoration of intestinal continuity.

Zusammenfassung: Grundlagen: Bis heute liegen ber die Hufigkeit, Art und Ergebnisse der Behandlung der akut nekrotisierenden Pankreatitis (ANP) in sterreich nur Daten aus 6 Spitlern vor. Dies veranlate uns zur Durchfhrung einer landesweiten Umfrage. Methodik: 95 chirurgische Abteilungen in sterreich wurden angeschrieben. Fragen wurden zu folgenden Themenbereichen gestellt: Art, Gre und Infrastruktur des Spitals, Definition der ANP, Bewertung diagnostischer Manahmen, Indikation zur Operation und Verfahrenswahl, Ergebnisse der in Jahren 1992 und 1993 behandelten Patienten. Ergebnisse: 76 Abteilungen (80%) antworteten, 52 mit operativer Erfahrung bei ANP. 77% dieser verfgten ber ein CT, 60% ber ein Angio-CT, 87% ber eine Intensivstation. Der CT wurde in der Diagnose die hchste Aussagekraft zugesprochen; allerdings gaben nur 43% der Abteilungen den Perfusionsausfall in der Angio-CT als beweisend fr eine ANP an. Die wesentlichen Indikationen fr eine Operation waren die Infektion der Nekrose und das Organversagen. Die bevorzugte Operation (von 65% der Abteilungen) war die Nekrosektomie. Im befragten zeitraum wurden 336 Operationen durchgefhrt (Letalitt 32%). Der Vergleich der Ergebnisse aus Spitlern mit grerer Erfahrung und solchen mit geringen Operationszahlen spricht dafr, da die Diagnose der ANP und der infizierten Nekrose nicht in allen Fllen exakt gestellt worden war. Schlufolgerungen: In sterreich werden die international gltigen Definitionen der ANP und deren Infektion nur von einer Minderzahl der Abteilungen verwendet. Die mitgeteilten Ergebnisse der Therapie mssen daher relativiert werden. Eine korrekte Terminologie und die Verwendung von Scores zur Bewertung des Schweregrades einer ANP sind fr zuknftige Untersuchungen unbedingt notwendig.

Zusammenfassung: Das pharmakokinetische Verhalten von 5-Fluorouracil (5-FU) wurde nach alleiniger Bolusgabe und in Kombination mit Interferon alpha 2b (IFN) gepr�ft. 13 Patienten mit fortgeschrittenem kolorektalen Karzinom erhielten eine i.v. Bolusinjektion von 5-FU 750 mg/m2 und IFN 5 Millionen Einheiten (MU) 3mal w�chentlich subkutan. 5-FU-Plasmaspiegel wurden mittels HPLC �ber einen Zeitraum von 1 Stunde am Tag 1 vor Interferongabe sowie in der 2. oder 3. Behandlungswoche jeweils 1 Stunde nach der letzten Interferoninjektion bestimmt. Dabei zeigten die Pharmakokinetikparameter von 5-FU unter dem Einflu� von IFN eine signifikante �nderung, indem die fiktive Initialkonzentration (C0) um 60% sowie die Fl�che unter der Kurve (AUC) um 56% anstieg und die totale Plasmaclearance (Cltot) um 55% reduziert wurde. Diese Daten liefern eine teilweise Erkl�rung f�r den f�r die Kombination IFN und 5-FU postulierten Synergismus, sowohl hinsichtlich erh�hter therapeutischer Wirkung wie auch verst�rkter Toxizit�t.

Colonic perforation is an abdominal emergency with high morbidity and mortality. This retrospective study was performed to evaluate the prognostic relevance of several factors and to characterize patients at high risk. One hundred and twelve patients (61 women, 51 men) were treated for colonic perforation from 1979 to 1992. Diverticulitis [65 patients (58%)] and carcinoma [24 patients (21%)] were the commonest pathology. In 62 cases (55%) perforation was found to be covered; 50 (45%) times it was free. 34 (30%) patients had diffuse peritonitis. Resection with primary anastomosis was performed 43 times (7 times with a protective colostomy). Resection without restoration of the intestinal continuity was carried out 53 times (including 49 Hartmann operations). Suture with drainage was performed 16 times mainly after iatrogenic perforation (8 times with a colostomy). The overall mortality was 19.6% (22 patients). The prognostic importance of various factors was investigated by univariate analysis (Wilcoxon and Chi-square test) and stepwise logistic regression including sex, age, underlying disease, localization and type of perforation, degree of peritonits, per-or postoperative organ failure, surgical procedure, reoperation, sepsis and the Mannheimer Peritonitis Index (MPI) score. Age over 65 years (relative risk 4.6, P=0.0089), organ failure (relative risk 40, P=0.001) and MPI (relative risk for an increase of 10 points 2.72, P=0.001) proved to be the only risk factors of significance. The patient's course is determined by the septic state, while the underlying pathology and degree of peritonitis did not significantly influence survival.

Zusammenfassung.: Ziel unserer Untersuchung war es, postoperative und Langzeitergebnisse des Operationskonzeptes einer radikalen Tumorchirurgie beim komplizierten colorectalen Carcinom zu analysieren. 126 (11,7 %) von 1.071 im Zeitraum 1986 bis 1997 wegen eines Dickdarmcarcinoms behandelten Patienten kamen wegen eines Ileus (84; 7,8 %) oder einer Perforation (42; 3,9 %) zur Operation. Die postoperative Letalitt lag mit 19 % beim Ileus und 38 % bei Perforationen signifikant hher als bei unkomplizierten Carcinomen (6 %). Bei beiden Komplikationen war die postoperative Sterblichkeit beim Vorliegen eines properativen Organversagens erhht. Nach Perforationen fhrten das Vorliegen einer diffusen Peritonitis und hherer Tumorstadien, beim Ileus kardiale Begleiterkrankungen zu erhhten Letalittsraten. Die Langzeitergebnisse waren nicht vom Auftreten einer Komplikation, sondern von den Tumorstadien abhngig. Das Konzept einer radikalen Tumorresektion, auch in Akutsituationen, ist nach unseren Resultaten zu befrworten, da Patienten, die die postoperative Phase berleben, keine schlechtere Prognose hatten, als jene mit unkomplizierten Carcinomen.

Abstract: In order to assess the therapeutic potential of CO2 laser in breast cancer, a randomized study was performed. One hundred and thirty-nine women were randomly assigned to laser or conventional technique (scalpel and electrocautery) groups. Age, clinical tumour stage and pre- or post-menopausal state were set up as criteria of randomization. A radical mastectomy with axillary lymph node dissection was performed in our patients. Statistical analysis showed no difference between the two therapy groups regarding blood loss, post-operative drainage, operating time and hospital stay. All patients were examined on a regular basis—median follow-up time was 5.5 years. Recurrence was equal in both groups (four in each group). Kaplan-Meier evaluation of survival demonstrated no difference between the groups. Evaluation of prognostic factors by the proportional hazards regression model demonstrated an increased risk for the advanced clinical tumour stage (relative risk 2.37,p=0.05) and for patients who did not receive hormone therapy (relative risk 4.85,p=0.0001). The mode of surgical therapy did not affect prognosis. An interaction between treatment and clinical stage was found (ratio of relative risks, 5.87,p=0.01). Thus a differential effect of laser treatment on survival depending on tumour size could be demonstrated. According to our study CO2 laser treatment does not in general offer significant advantage over conventional technique. However, due to the study design, our findings are preliminary; definite results have to be awaited. The therapeutic potential of laser in breast conserving surgery remains to be investigated.

Background:While patients’ needs for adequate preoperative information are generally recognized, data evaluating the effectiveness of the consultation before laparoscopic cholecystectomy have not been published until today. This prospective study was performed to investigate the success of preoperative information. Methods:A combination of oral and written information was given to all patients in two interviews. Information concentrated on indications for surgery, operative procedures, and risks. Patients were asked to answer questionnaires 5 days after the operation. Results:From January 1996 to January 1997, 200 patients were interviewed. Ninety-seven percent indicated to wish detailed information. Eighty-four percent indicated a high level of satisfaction with the presented information. While the levels of knowledge concerning indications for surgery and procedures were satisfactory in 85 and 51% respectively, only 30% were able to name at least one risk factor of laparoscopic cholecystectomy. Conclusion:This study demonstrated that patients’ evaluation of their surgical knowledge and the process by which it was communicated to them did not correspond to their ability to recall this information after surgery.

Summary.: Mediastinitis caused by infection with Clostridium perfringens and spontaneous rupture of the esophagus are both life threatening conditions. The combination of these two entities led to septic multiorgan failure in a 38-year-old woman. The patient was treated successfully by esophagectomy and postoperative lavage through a partially open abdomen. The lack of information regarding emesis, the leading symptom of Boerhaave's syndrome, caused delayed diagnosis: the triad of emesis, severe epigastric pain and emphysema of the skin was not established until 30 h after the onset of symptoms.

Dorso-ventral lavage procedures in the treatment of abdominal sepsis are often complicated by technical and nursing problems. With the help of the Incise Pouch, which consists of an adhesive foil with a plastic bag around it, we have succeeded in solving the main problems of the torso-ventral lavage procedure. (1) All the lavage solution is collected in the bag and drawn into a vacuum pump. The suction drains are placed directly in the bag. This enables us to measure the lavage solution exactly. (2) There is no leakage of liquid into the bed, so that the patient remains dry. (3) The danger of intestinal fistulas or intraabdominal bleeding caused by suction drains is eliminated (by putting them into the bag of the Incise Pouch). If reexploration of the abdominal cavity (“on demand” or planned) is done, the Incise Pouch remains in position. This method makes early diagnosis and treatment of postoperative complications possible.

Zusammenfassung: Grundlagen: Die offene Behandlung schwerster Formen der nekrotisierenden Pankreatitis oder diffusen Peritonitis fhrt zur Bildung von Bauchwandlcken, wenn das Laparostoma nicht primr verschlossen werden kann. Methodik: An unserer Abteilung wurden seit 1989 bei 31 Patienten Bauchdeckenverschlsse nach offener Abdominalbehandlung durchgefhrt (20mal nach Pankreatitis, 11 mal nach Peritonitis). 9mal erfolgte ein Verschlu der Bauchdecke im 1. Aufenthalt, 22mal nach einem medianen Intervall von 10 Monaten. In 28 Fllen konnte die Lcke mittels Naht (Polydioxanon, PDS) versorgt werden. 3mal wurden bei Bauchwanddefekten zustzlich zu einer Naht Fremdgewebe implantiert. Ergebnisse: Alle Patienten berlebten den rekonstruktiven Eingriff; 3mal traten Wundinfektionen, 1mal eine Nachblutung auf. Alle noch lebenden Patienten (26) wurden nachuntersucht (medianes Intervall zur Operation 38 Monate). Bei 8 Patienten waren Narbenhernien aufgetreten, 5 davon waren asymptomatisch. Bei 14 Patienten fanden wir keinen Kraftverlust der Bauchmuskulatur, 20 konnten ihren Beruf wie vor der Erkrankung ausben. Schlufolgerung: Der Bauchdeckenverschlu nach offener Abdominalbehandlung lt sich mittels einfacher Naht mit akzeptablen Ergebnissen durchfhren. Das Auftreten von Bauchdekkenlcken stellt angesichts der Schwere der Grundkrankheit kein schwerwiegendes Argument gegen das Therapiekonzept der offenen Abdominalbehandlung dar.