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Endovascular revascularisation with paclitaxel-coated balloons for the treatment of peripheral artery disease has been shown to be an effective therapeutic option in the femoropopliteal segment. The antiproliferative effect of paclitaxel prevents restenosis. In contrast, in the infra-popliteal segment, the evidence is currently conflicting. However, there is evidence of an increased risk of amputation and mortality from the second year after angioplasty with paclitaxel-coated balloons. This may be due to a dose-dependent cytotoxic effect of paclitaxel. Sirolimus-coated balloons might therefore be an alternative because sirolimus is cytostatic rather than cytotoxic and thus has a wide therapeutic window.Three single-arm pilot studies (50, 25, and 50 patients, respectively) show that angioplasty with sirolimus-coated balloons leads to comparable results to those reported from paclitaxel-coated balloons (late lumen loss at 6 months: 0.29 mm; primary patency at 12 months: femoropopliteal 79%-82%, infra-popliteal 59%; freedom from target lesion revascularization at 12 months: femoropopliteal 83%-94%, infra-popliteal 86%). Randomised controlled trials comparing standard balloon angioplasty and paclitaxel-coated balloons for the treatment of intermittent claudication or chronic limb-threatening ischaemia are active and are expected to provide efficacy and safety results from mid 2024.This review presents the results of pilot studies on angioplasty with sirolimus-coated balloons for the treatment of peripheral artery disease and reviews currently ongoing randomised controlled trials., Competing Interests: Professor Teichgräber ist Leiter der klinischen Prüfung der SIRONA Studie und der LIMES Studie, unterstützt durch Concept Medical Inc., Tampa, FL, USA und Leiter der klinischen Prüfung von der EffPac Studie, unterstützt durch iVascular S.L.U., Barcelona, Spanien., (Thieme. All rights reserved.)

The oesophagogastric junction is increasingly gaining importance due to the difficulty of allocating adenocarcinomas that develop in this region to the stomach or the oesophagus. The present article gives an overview of important anatomic structures in this area, which are responsible for the closure of the distal oesophagus and the entry of the stomach. Moreover, the structures of the mucosa in healthy and under pathological conditions (e.g., oesophagogastric reflux disease and infection with Helicobacter pylori) are discussed in this article., (Georg Thieme Verlag KG Stuttgart · New York.)

Hepatic resections represent a standard procedure for both benign and malignant liver diseases. Nevertheless, typical complications arise follow-ing hepatic surgery. Besides common problems, such as bile leakage or impaired wound healing, rare complications, like progressive liver failure or portal vein thrombosis are observed. Mortality and morbidity after liver resection depend on the preoperative constitution of the patient, on the state of the liver parenchyma and on the re-main-ing liver volume. In particular, a marked steatosis increases both morbidity and mortality of hepatic resections. The advances of modern chemotherapy increases the number of surgical patients, who were previously not resectable. However, the chemotherapy induced hepatotoxicity implies additional problems, thus increasing the morbidity of liver resections. Therefore, before planning hepatic surgery, the individual situation of the patient has to be evaluated in order to maximise the security of the operative procedure.

Objectives: The aim of the study was to investigate surgical results and outcome using biliopancreatic diversion (BPD) and duodenal switch (BPD-DS) as a representative profile for Germany., Patients and Methods: From January 2005 to December 2007, overall 163 patients had undergone BPD (n = 72) and BPD-DS (n = 91) including 21 "redo" operations who were registered in the nation-wide multicentre (n = 48) observational -study for quality assurance of surgical treatment in morbid obesity. BPD and BPD-DS were performed in 5 of the 48 participating German surgical departments. A laparoscopic approach with no conversion was possible in 96.7 % of BPD and 50.6 % of BPD-DS, respectively., Results: Body weight (mean BMI, 53.6 kg / m(2)) was considerably reduced down to a mean BMI of 36.7 kg / m(2) (BPD) and 33.2 kg/m(2) (BPD-DS). The operating time in average was 134 min in BPD and 234 min in BPD-DS, respectively. Postoperative hospital stay was as follows: BPD, 8 d; BPD-DS, 15 d. The rate of general postoperative complications (pneumonia, urinary infection) was 17.6 % whereas the specific complication rate (disturbances of wound healing) was only 12.1 % (mortality, 0). Relaparotomy was required in 5 patients (post-operative bleeding, n = 3; anastomotic insufficiency, n = 2). In 50 % of the repeat cases, a laparoscopic -approach was initially favoured followed by conversion. Follow-up investigation revealed trocar hernia, n = 2 (within 1 year); abdominal hernia, n = 1 (within 6 months)., Conclusion: The surgical results obtained with BPD and, in particular, with BPD-DS represent data similar to those of a learning curve. Occurrence, type and rate of the reported complications are comparable with international data from the literature. The ongoing benchmarking project indicates the efforts for a continuous control and improvement of the quality in this type of surgical treatment.

Background: The polycystic ovary syndrome (PCOS) is the most frequent cause of female infertility with an estimated prevalence of 6-10% in premenopausal women. Due to its long-term metabolic and cardiovascular consequences, it poses a severe health problem. Visceral obesity and subsequent insulin resistance represent the core pathophysiology of PCOS, clearly suggesting that measures to reduce abdominal obesity should be pursued., Methods: Between February 1995 and October 2006, 204 patients underwent bariatric surgery in the SRH Hospital of Gera. 75% of the patients were female and three of them were suffering preoperatively from polycystic ovary syndrome and metabolic syndrome., Results: 104 months after laparoscopic adjustable gastric banding, the excess body weight loss (EBWL) was 49, 67 and 41% in these three patients, respectively. Glucose levels normalised completely. One patient became pregnant after weight reduction., Conclusions: In PCOS with metabolic syndrome, bariatric surgery is an option to reduce weight and to treat associated metabolic disorders. Surgery should be performed based on the body mass index, the metabolic disorders, and the wish of the patient to become pregnant.

Background: Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg., Methods: The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before., Results: 629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures., Conclusion: A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Case Report: We report on two rare endovascular procedures concerning aneurysmatic complications of arterial homografts. In both cases infected aortobifemoral grafts were explanted und replaced by cryopreserved aortofemoral homografts on the left side. The revascularisations on the right side were performed with the deep femoral vein in one case, and by desobliteration of the iliac artery in the other case. After 4 and 10 months, respectively, we found aneurysmatic enlargements of the aortic anastomoses. In both cases we excluded a false aortic aneurysm by uniiliac stentgrafts in combination with a femoro-femoral cross-over bypass for the contralateral leg. Both operations were carried out successfully. However, one patient developed an infection of the stent graft. We explanted the stent graft und performed an aortobifemoral bypass procedure with arterial cryopreserved homograft once again., Conclusions: Both aneurysmatic complications after aortofemoral homograft implantation could be treated successfully by an endovascular approach. Possible late complications caused by the implantation of homografts or by endovascular procedures can be only detected in due time by a follow-up at short intervals.

Background: Adjustable gastric banding is a popular bariatric operation in Europe. The rate of long-term complications like pouch dilatation, slippage and band migration and the long-term effect of weight loss are reported in meta-analysis and few studies for a period of more than five years. We report on experiences after gastric banding., Methods: Over a period of 10 years 168 patients with morbid obesity were treated with gastric banding. Preoperative data, postoperative weight loss and long-term complications were prospectively obtained and retrospectively analyzed., Results: Mean age of the patients was 41.7 years with a mean preoperative BMI of 49.6 kg/m2. No intraoperative or postoperative death occurred in the first 30 postoperative days. Intraoperative conversion rate was 7.1 %. 79.8 % of the patients (n = 134) were available for follow up (mean follow-up time 66.7 months). Long-term complications occurred in 22.5 % of the patients. 30 complications (17.8 %) were related to the band and 8 (4.7 %) to the access-port or to the tube. Mean excess weight loss was 39.6, 47.3, 44.2, 43.4 and 32 % after 1, 2, 4, 5 and 8 years., Conclusions: Laparoscopic gastric banding can achieve an effective weight loss. However band-related and functional complications will influence the late outcome. Pathways to choose the best surgical method for the individual patient are necessary to reduce failures after gastric banding.

Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. The data are registered in cooperation with the An-institute of quality control in surgery at the Otto-von-Guericke-Universität Magdeburg. The data registration occurs in an internet on-line data bank. Application for participation in this study is available on our correspondence address. All hospitals carrying out bariatric surgery are asked to take part in this study.

Background: Preoperative staging of rectal tumors is considered essential to tailor treatment for individual patients. The aim of the present study was to evaluate the accuracy of endorectal ultrasonography in preoperative staging of rectal cancer., Methods: 357 patients with rectal adenocarcinoma underwent endorectal ultrasonography evaluation during an eight year period. The evaluation was performed by four surgeons. We compared the endorectal ultrasonography staging with the pathology findings. Patients with preoperative chemoradiation were excluded from the study., Results: Overall accuracy in assessing the level of rectal wall invasion was 77.3 %, with 9.3 % of the tumors overstaged and 8.1 % understaged. Accuracy in assessing nodal involvement in 313 patients treated with radical surgery was 74.9 %, with 8.9 % overstaged and 8.9 % understaged., Conclusion: The accuracy of endorectal ultrasonography in assessing the deepth of tumor invasion is good, but lower than previosly reported. The technique is precise in distinguishing between benign tumors and invasive cancer. The results depend on the experience of the surgeon.

The diagnosis of perirectal masses can be accomplished by computer tomography and magnet resonance imaging if the rectum is contrasted. The accuracy of these methods is > 90 %. But often the assessment of the exact borders with respect to the rectum wall and to the genitalia is difficult. Therefore transrectal 3D-ultrasound is of major importance in the preoperative staging and postoperative follow-up of rectum cancer and allows the diagnosis of pararectal findings using the ultrasound-guided, transrectal aspiration. By ultrasound-guided aspiration biopsy we detected five cases of pararectal and especially presacral diseases including one case of endometriosis. The diagnostic algorithm is described.

The possibilities which actually exist in order to obtain an earlier diagnosis in pancreatic carcinoma, a better differentiation of mass-forming pancreatitis and of other pancreatic tumors and an improved staging for reducing unnecessary operations are presented and evaluated. Possible relevant hints of the history and indicators for diagnostic procedures in view of a pancreatic carcinoma are upper abdominal complaints especially in relation to a new developed diabetes mellitus and/or unexplained elevations of pancreatic enzymes. The endosonography in combination with a target biopsy is of important value as well for the diagnosis of pancreatic cancer as for differentiation against a segmental chronic pancreatitis. In cases where differentiation is impossible even intraoperatively, we recommend the use of intraoperative fine needle biopsy.

Introduction: For surgeons the acute intestinal ischaemia is still a diagnostic and therapeutic challenge. If clinically suspected, the diagnostic procedures such as duplex sonography and arterial angiography should be carried out immediately. Although the diagnosis is often quickly clear, perioperative mortality rate remains high. We report the acute local thrombolytic therapy as an alternative treatment., Case Report: A 80-year-old male patient was referred to our hospital with a complete occlusion of the superior mesenteric artery. Duplex sonography and the arterial angiogram confirmed the clinical diagnosis. Because the patient was assessed to be at high risk we decided to avoid an operation and local thrombolytic therapy using rt-PA and urokinase was carried out., Result: The local thrombolytic therapy was successful and led to a complete restoration of the arterial flow within the superior mesenteric artery. The clinical symptoms subsided and no complications were observed., Conclusion: Local thrombolytic therapy appears to be a suitable therapeutic option in patients suffering of mesenteric arterial occlusion. Although the duplex sonography often confirms the diagnosis with high accuracy the angiography remains the diagnostic gold standard.

The Less Invasive Stabilization System (LISS) is a minimally invasive technique indicated for fixation of periprosthetic fractures. This new system allows percutaneous placement of cortical-shaft screws and fixation of the fracture with fixed-angle locked screws with minimal surgical exposure of the mostly osteoporotic bone and without disturbance of the existing total joint replacement. Immediate range-of-motion exercises are begun postoperatively. A retrospective clinical review of 5 patients (2 total hip arthroplasties, 3 total knee arthroplasties) was performed to describe indications, surgical technique, intra- and postoperative complications and patient follow-up. Indications are periprosthetic distal femur fractures, per- and supracondylar fractures. Contraindications are none, except existing medical comorbidities. Extraarticular fractures were treated via stab incisions over the lateral femoral condyle. Fractures with intraarticular displacement were fixed via an anterolateral parapatellar approach to the knee joint. After anatomic reduction of femoral condyles, articular fragments are fixed with Kirschner wires, followed by closed reduction aligning the articular fragments controlling length, axis and rotation. The LISS is introduced proximally under the M. vastus lateralis along the femur. It is fixed with self-drilling cortical shaft screws, locked fixed-angle screws both proximally and distally. Range-of-motion exercises are begun on the second day postoperatively. Time to full weight bearing averaged 6-8 weeks depending on clinical and radiological findings. Benefits of the LISS technique include the minimally invasive approach with increased primary stability using monocortical fixings thus eliminating the need for spongiosaplasty and blood transfusion. Disadvantages of the percutaneous placement of the LISS include malplacement on the femur, proximal screw pull-out and postoperative rotational and axial malalignment.

Background: Beside non-operative treatment the therapeutic options for proximal fractures of the humerus range from closed reduction and transcutaneous K-wiring to total joint replacement. While the first is regarded as minimally invasive the latter is a rather complex intervention. Plating has been disregarded as combining the disadvantages of an extended approach with too often insufficient primary postoperative stability. The new concept of completely angle stabile plate fixation aims on improving this balance by achieving greater stability even in osteoporotic fractures., Study Design: This retrospective analysis compares 51 patients treated with a partially (39) or complete (12) angle stabile humeral plate (Königseeplatte in two modifications) with 32 patients treated according to surgeons preference with conventional plates or K-wires. Both groups were treated at the same department during the same period and did not differ in their age nor sex distribution., Results: Until discharge there were 2 secondary dislocations discovered in group 1 and 7 in group 2. The follow-up rate was 47.1 % (24/51) in group 1 and 46.8 % (15/32) in group 2. The time interval from surgery amounted to 1.2 (0.66-1.75) and 1.0 (0.72-1.32) years respectively. Among the patients available for follow-up in group 1 8 had sustained a two-, 8 a three- and 3 a four-part fracture according to Neer's classification. In group two there were accordingly 2 two-, 8 three- and 1 four part fractures. Clinical assessment using Neer's score revealed an average of 71,8 (63.9-79.8) points in group 1 and 67.6 (47.3-78.7) in group 2. When the results of Neer's scores were expressed in percentage of the unaffected arm a mean of 73.6 (65.6-81.8) in group 1 and 69.3 (51.8-86.9) was obtained. The only statistically significant difference was observed within the sub-group of three-part fractures: treated by angle stabile plates (group 1) these patients (n = 8) achieved a mean Neer-Score of 81 (77-86) compared to 68 (52-84) (n = 8). In group 1 70.8 % of patients followed-up presented an "excellent" or "good" result according to Neer's criteria, in group 2 60 % did so., Conclusion: We conclude from our first experience with angle stabile plates for fractures of the proximal humerus that particularly in three part fractures this method might improve functional outcome and is worth further consideration and testing.

There are about 1.5 million sports injuries in Germany every year, but concomitant vascular injuries are rarely encountered. Only single cases have been reported in the literature. The records of 216 patients with vascular injuries who were admitted to the university hospital in Jena between 1987 and 1996 were retrospectively reviewed. Six patients sustained a vascular injury during the accident in different kinds of sport. Vascular repair was successfully performed in three cases. Organ resection was necessary in two cases and one patient was treated conservatively. Most vascular lesions are related to blunt trauma which might create delayed symptoms of ischemia. Therefore measurement of limb pressures, Doppler scan, duplex ultrasonography and angiography are adjuncts in patients evaluation. In case of bleeding or complete ischemia the prompt arterial reconstruction is indicated and subsequently minimizes the risk of reperfusion injury.

The treatment of sepsis consists of focus control as well as supportive and adjuvant therapy. Especially the last option has been investigated during the last years. Different approaches showed promising results in animal experiments and phase-I trials but did not prove to be successful in large multicenter studies. The application of TNF-receptors or interleukin-1 receptor antagonists did not lead to an improvement of outcome in patients with sepsis. Most studies with TNF-antibodies also presented negative results. However, a recent large study with a monoclonal antibody against TNFalpha demonstrated a significant survival benefit. The recently published PROWESS study is the first investigation demonstrating the decrease of mortality in patients with sepsis after administration of protein C. Additionally, current data support the low-dose hydrocortisone therapy in patients with vasopressor dependent septic shock.

Early diagnosis of the different severities of septic inflammation is important for early implementation of specific therapies. Sepsis and severe sepsis are accompanied by clinical and laboratory signs of systemic inflammation. However, patients suffering from non-infectious inflammation may present with similiar signs and symptoms making it difficult to diagnose infection based on clinical findings alone. Bacteriological evidence of sepsis, though definitive and specific, may not be obtainable, is time-consuming and even may not occur concurrently with clinical signs of sepsis. It is therefore important to identify markers, which, by enabling an early diagnosis of sepsis and organ dysfunction, would allow early specific therapeutic interventions. Wheras C-reactive Protein is a more sensitive parameter for the diagnosis of non-systemic infections, Procalcitonin seems to be a useful parameter to improve the diagnosis and monitoring of therapy in patients with severe sepsis and septic shock.

Functional and aesthetic aspects make the reduction mammaplasty a favoured surgical procedure. The vertical technique, as well as the technique with central pedicle have clearly gained in importance next to the traditional T-cut technique. We provided questionnaires to a random sample of 110 patients who had been treated according to the method of Strömbeck-Weiner. The results were evaluated and compared with the literature. Our results show that the functional complaints were largely eliminated by the surgery and that the patients experienced a significant improvement in their psychological well being. The applied method produces a satisfactory shape of the breast with programmed ptosis, and to large extent retains the nipple-areola sensitivity. One shortcoming of this procedure is the scar formation which 20 % of the patients found bothering. However, 94 % of the patients would choose the procedure again. We conclude that the reduction mammaplasty with reverse T-technique according to Strömbeck-Weiner continues to be of value for patients with a desired weight reduction of more than 500-600 g and patients over the age of fourty.

Unlabelled: Despite of advanced surgical technique and multimodality therapy results following secondary resection of local recurrence after rectal cancer are discussed controversially., Patients and Methods: Between 1990 and 1999 81 patients with local recurrence of rectal cancer were treated at our surgical department. Median age was 63 years, 62 % of patients were male. 98 % of recurrences were in local advanced stage (74 % = rT4, 25 % = rT3), 44 % of patients had synchronous distant metastases., Results: 32 patients underwent resection of recurrent rectal cancer. Potential curative surgery was possible in 56 % of resections. Extended resections of adjacent organs were necessary in 21 patients. The 4-year survival in the curative group was 44 % compared to 19 % in patients with microscopic or gross residual disease., Conclusion: Optimistic long-term results in recurrent rectal cancer can only be achieved after curative resection. Preoperative radiochemotherapy in advanced cancers increases curative resection and probably survival rate.

Motor vehicle accidents may cause apart from physical also psychological aftermath. Despite of posttraumatic psychologic symptoms may remit after 2-3 months, 10-20% of the injured persons will develop sustainable psychopathological symptoms. This report aims at an overview on possible psychopathological disturbances and their perpetuating conditions. Possible treatments are shown and the necessity of an interdisciplinary cooperation with the aim of a secondary prevention is emphasized.

Despite the decreasing number of patients suffering tuberculosis and the use of modern broad spectrum antibiotics the pleural empyema did not lose its relevance. The main reasons are increasing numbers of patients with drug and alcohol abuse or immunodeficiency of different causes. We retrospectively analysed the data of 73 patients treated of pleural empyema between 1992 and 1998. Considering the known stages of pleural empyema we present the corresponding therapeutic results. All patients classified as stage I were treated with a chest drain and cure was achieved in all of them (100%). The treatment for patients classified as stage II was different: 5 out of 32 were treated with a continuous irrigation and suction chest drain system. 18 patients first underwent thoracoscopy and were afterwards treated with a continuous irrigation and suction system. Another 9 patients primarily underwent an early open decortication. In 40% the treatment with the suction and irrigation system was successful. Using video-assisted thoracoscopy (VATS) cure was achieved in 94.4%, with open decortication in 100%. The preferred treatment of patients classified as stage III is the open decortication. After the first operation 80% (30 patients) were cured. 6 patients needed thoracoplastic procedures after the first intervention. No patient was discharged neither with a permanent chest drain nor a permanent thoracic window. With the results a cause dependent analysis of morbidity and mortality was done. The overall morbidity rate was 27.9% and the overall mortality 5.4%. The treatment of pleural empyema still remains to be problematic. Corresponding to our results pleural empyema classified as stage I is best treated with a simple chest tube. The video-assisted thoracoscopy (VATS) lacks of complications and is a very efficient method in treating stage II. The method of choice in stage III is the open decortication which in the case of a chronic and recurrent or persistent infection should be followed by a thoracoplastic procedure.

155 patients were operated on pulmonary metastases in Jena during the period from 1.1.1984 to the 31.12.1994. The findings of 151 patients were analysed. 128 patients suffered from a carcinoma, 15 from a sarcoma, 6 from a malignant melanoma and 2 from a Wilms-tumor. The prognostic factors discussed in the international publications at present were investigated in those patients. Significant differences in the long-term survival were found for the following features: a possible radical resection, the tumor entity, the site, the histology and the grading of the primary tumor, the size and the site of the metastases and the resection of recurrent metastases. Tendencies are described for the type of dissemination and the staging of the primary tumor, the site of the pulmonary metastases in the lung lobes, solitary extrapulmonary metastases and more than 6 lung metastases. In addition patients who showed metastases of a renal cell carcinoma are considered separately.

Nonphysiological alkaline reflux after partial gastrectomy may produce a range of gastrointestinal disorders. The Bilitec probe is a fibroptic sensor that, for the first time, makes in vivo measurement of this reflux possible, by assay of spectrophotometric absorption of bilirubin. We studied 20 patients who had undergone partial gastrectomy for benign peptic ulcer disease. Ten patients had Billroth II reconstruction and ten had Roux-en-Y reconstruction. In the Roux-en-Y Group we found almost complete control of symptoms and no objective evidence of alkaline reflux as measured by the Bilitec probe. In the Billroth II group we detected by the fiberoptic sensor significant bile reflux into the stomach remnant. Based on these results we recommend Roux-en-Y gastrojejunostomy as the method of choice for reconstruction after distal gastric resection.

We report on a 72-year old male with a large aneurysm of descending thoracic aorta which was treated by implantation of a Dacron-covered self-expanding Nitinol stent graft (Talent, HOSMED). The patient was unfit for surgical aneurysm resection because of generalised atherosclerosis and cardiomyopathy. We think that stent implantation for descending thoracic aortic aneurysms is an attractive alternative to surgical aneurysm resection, especially in patients with enhanced operative risk. However, further experience, and especially long term-results, are required before more widespread application of intra-luminal stent implantation in the management of thoracic aortic aneurysms can be recommended.

In a retrospective study we compared the findings of our abdominal ultra-sound diagnostic of the gallbladder and the common bile duct with the results ot preoperative ERCP, intraoperative findings and the histological results. The test parameters were the size of the gallbladder, the number and the size of biliary calculi, the thickness and the constitution of the wall of the gallbladder and the consecutive grade of inflammation, the wideness of the common bile duct and the suspicion of a choledocholithiasis, respectively. In acute cholecystitis we performed laparoscopic cholecystectomy within 24 hours, in symtomatic cholecystolithiasis without cholecystitis an elective laparoscopic cholecystectomy. If there was suspicion of a choledocholithiasis we performed a preoperative ERCP. Altogether we had correct findings of the common bile duct in our ultrasound diagnostic in 133 of 136 cases (97.8%), only in 3 of 136 cases (2.2%) we had false negative ultrasound findings. With a generous indication to ERCP caused by anamnestic and/or laboratory findings the obstruction of the bile duct could be diagnosted and eliminated in 2 of these 3 cases preoperatively. In all cases of bile duct dilatation (7 mm and more) we found an obstruction of the common bile duct. Our results demonstrate that abdominal ultrasound is a high-efficiency method in the preoperative diagnostic of gallbladder and common bile duct stones.

The laparoscopic cholecystectomy has become the gold standard in the therapy of gall bladder stones in the last few years. The most contraindications of the first period of the laparoscopic era had been eliminated by the development of laparoscopic technique and growing experience. Since September 1995 the laparoscopic cholecystectomy has been established as routine procedure also for acute cholecystitis. From September 1995 to Dezember 1996 177 laparoscopic cholecystectomies were performed, 132 for symptomatic cholecystolithiasis and 45 for acute cholecystitis. Postoperative complications occurred in 8.3% in the elective group and in 8.8% in the acute cholecystitis group. There was no death in both groups. Patients left the hospital on day 3 (range 2-21) in the elective group, on day 4 (1-13) in the acute colecystitis group. There are no statistically significant differences. According to our results acute cholecystitis does not increase postoperative morbidity and mortality after laparoscopic cholecystectomy and has to be a contraindication for this method no longer.

The over notion, "acute gallbladder" includes the acute cholecystitis, also the gallbladder dropsy, the persistent colicky pain of the impaction, the complications of acute cholecystitis like the cholecystoempyema an necrotising the calculous impaction inflammation. In the last cases an emergency operation ist necessary. The acute cholecystitis and also the acute gallbladder dropsy have to be operated in an unit of time of 72 hours. By this patients the capability of operation and narcosis is a prerequisite. The late operation also the interval operation are united with greater operative technical difficulties an the danger of intraoperative complications. The indication for the cholecystostomy ist rare. Is an anaesthesia not possible a surgical stomy in local anaesthesia or a percutaneous transhepatic puncture drainage with sonography and CT-control ist possible. There are scarcely contra-indications for the laparoscopy.

This paper gives a short historical overview of the evolution of biliary surgery from John Stough Bobbs (1867) until the present day. The development of different diagnostic methods (from cholangiography to sonography) are described also, as well as the different therapeutic methods including laparoscopic cholecystectomy. Hans Kehr (1862-1916) was a distinguished pioneer in the development of biliary surgery.

Biliary tract injury, although uncommon, is the most feared complication of laparoscopic cholecystectomy. Early identification or exclusion of such injury is essential for successful management. Over a two year period (1995-1996) twenty-one from a total of 413 ERCPs in this Surgical Endoscopy Unit were performed because of suspected biliary injury after laparoscopic cholecystectomy. 16 patients were referred from other units. No abnormality was demonstrated in two cases. A clip-related stenosis requiring reoperation was shown in twei patients. The remaining 17 cases had biliary leakage, related to an aberrant bile duct in 2 cases or a cystic duct leak in 15, all of which were treated endoscopically by nasobiliary tube (7), endoscopic papillotomy (5) or a combination of both (5). All of these biliary leaks healed uneventfully no ERCP-associated morbidity.

Treatment of complex injuries of the hand aims at best possible reconstruction of function and quick social and professional rehabilitation. This objective is hardly to achieve in most cases due to the severity of injury. Outcome depends on patients' age and injury pattern and essentially on the strategy of surgical treatment. Errors in prehospital emergency treatment can hardly be corrected, no matter how excellent the surgical technique may be. Traumatic multiple finger or thumb amputations are clear indications for replantation. Beginning with osteosynthesis, suture of tendons and ligaments the restoration of blood supply is the most important step. Nerve reconstruction should be performed immediately, but if tension free repair is impossible, secondary nerve grafting is preferred. Primary skin closure should be carried out if possible, in case of defects skin grafts, local or free flaps have to be used.

Unlabelled: Intermittent catheterisation is the demanded therapy of bladder paralysis during the spinal shock. We investigated the realisation of this concept. In 1994 after first treatment in other hospitals 97 patients were treated in the Thuringian Spinal Cord Centre Sülzhayn. The primary treatment of the paralysed bladder was: indwelling catheter: 44 patients (45.4%), suprapubic catheter: 30 patients (30.9%). Only 15 patients (15.5%) were catheterized intermittently. No urological treatment was carried out in seven cases., Conclusion: The primary treatment of bladder analysis in spinal cord injured patients has to be improved.

Introduction: The influence of ASA treatment on haemostasis is still debated. There are doubts in case of emergency operations, especially in transplant patients, concerning dosage and change of medication., Methods: Our results are based on an analysis of the therapeutical behavior in German transplantation centers. The question of transplant suitability, dosage and haemostatic effects will be discussed in comparison to the literature., Results: 85.7% of the transplantation centers perform the operation despite of and under ASA treatment. In these cases an increased bleeding tendency is tolerated and observed in 33.3% of the centers. An increased mortality has not been reported. Most of the transplantation centers accept a dosage of 100 mg ASA daily. Only 14.3% of the transplantation centers refuse the operation in ASA treated patients., Conclusions: Correctly indicated ASA treatment (cardiac arrhythmia, patients with embolism or thrombosis) isn't a contraindication for renal transplantation (daily dosage up to 100 mg). In elective cases however, a preoperative change of the medication is recommended, e.g. the use of heparin instead of ASA.

54 patients suffering from esophageal cancer have been treated in a period from 1990 to 1994. In 29 cases curative resection was possible, corresponding to a resection rate of 54%. Average age of resected patients was 62 years. According to pTNM-classification the stages T1 and T2 amounted to 45%, T3 and T4 to 55%. Lymphatic node metastases were discovered with an incidence of 55%. In patients treated conservatively more unfavourable stage distributions and increased rates of lymphatic node metastasis were shown. Transthoracal-transabdominal esophageal resection was preferred as curative management. Lethality amounted to 13.8%. In 3 of 4 lethal cases after resection autopsy confirmed absence of tumor. Lethal complications were two respiratory insufficiencies, one suture line dehiscence and one alcoholic delirium. Survival rates were calculated by life-table-method. We consider the transthoracal-transabdominal esophageal resection as an acceptable therapeutic option in esophageal cancer offering a real chance of enduring curing.

Soft tissue condition and local blood circulation are most important concerning bone reconstruction and healing of fractures. Therefore additional damage of soft tissue caused by operations must be avoided. Using biological osteosynthesis as much stability as necessary and highest possible saving of vascularity should be achieved. Most important and actual techniques will be discussed in this paper. Today's method of choice in long bone shaft fractures is the unreamed interlokked nail. On the contrary exact reposition and minimal fixation with screws and plates is the standard in fractures near the joint to gain exercise stability.

This paper gives a short historical overview on the work of distinguished Professors such as Erich Lexer, Nikolai Guleke, Heinrich Kuntzen and Theo Becker, who worked in the Surgical University Hospital in Jena from 1911 to 1981. The main areas of their clinical and scientific activities are described, as well as the private and human qualities of these well-known personalities.

The traumatic soft tissue injury plays a central role in fracture healing. The knowledge of pathophysiological mechanisms has completely changed the management and therapy of injuries accompanied by soft tissue lesions. Treatment is aiming for prevention of the circle of hypoxia, microvascular perfusion disturbance, increased membrane permeability and potential infections. General therapeutic principles are decontamination, debridement, revascularisation and decompression. Modern methods of soft tissue treatment take these principles into consideration.

In 27 patients with disorders of the bile ducts we performed a bilio-jejunal anastomosis to eliminate the stenosis. The letality rate was 3.7%, the rate of complications following operation was 30%. After a period of 3 to 15 years 15 patients agreed to an inpatient follow-up examination. 80% of them regarded the postoperative results as subjectively good or very good. 60% were again completely able to work. Biochemical examinations, ultrasonography and sequencescintigraphy of the liver showed a higher rate of irregular findings despite missing symptoms. These findings were due to icteric or cholangitic predamages before surgical treatment. The determination of Gamma-Glutamyl-Transferase and alcaline Phosphatase as well as ultrasonography and sequencescintigraphy of the liver proved to be the most sensitive methods for evaluation of the late results.

Objective: Blood samples obtained from centralvenous catheters are commonly used on intensive care units. In this paper the question of valid conditions for sampling blood coagulation parameters of patients with heparinised catheters is examined and the data are compared with the literature., Study Design: Blood samples were obtained at the same time as well via centralvenous catheters as from the periphery. The results of the examination were compared to each other., Results: After the aspiration of 10 ml of blood via centralvenous catheters there were no differences between peripheral and central obtained samples as regards blood coagulation parameters.

Over a 10 years period 260 arterio-venous fistulas have been performed and followed up. The Brescia-Ciminoshunt was the most frequent type (n = 174). This type of fistula has been performed in about 85.2% of all cases as primary operation method. In secondary formations the saphena-interposition was used most frequently (49.4% of all cases). A shunt revision should be performed in cases of immediate thrombosis although a shorter life time of revisioned shunts compared with new formations is known. The new formation of a shunt should be considered if terminal thrombotic changes have been detected as well as in cases of shunt infection or shunt insufficiency.

In cases of joint fractures as well as in dislocated and open fractures of the hand special standards concerning operation methods have to be set. Treatment of soft tissue damage accompanying the fracture is in no other region of the body so important. Therefore the current efforts for development of an AO-classification for fractures of the hand taking into account the soft tissue damage are of major significance. Special features of miniosteosynthesis compared to conventional osteosynthesis are the subject of this study. The use of the miniplate especially in juxtaarticular fractures of the hand due to complex injuries or replantations can overcome the disadvantages of joint-bridging K-wires. Osteosyntheses of the hand are making high technical demands on surgeons and are not at all operations for beginners.

Late results of augmentation mammaplasty with dermis fat transplants and implants are presented and discussed separately. With correct handling and strict indication a mammary implant heals in without complications and with good results. The problem of capsular fibrosis is discussed. Prerequisites for augmentation mammoplasty are detailed information about and strict selection of candidates.

A case report of a 53-year-old man with lobar restricted pulmonary alveolar proteinosis is presented. The way from an accidental X-ray examination until the final histological diagnosis of the specimen taken at operation is followed. Typical diagnostic pitfalls are discussed.