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Mutations in the gene coding for Sequestosome 1 (SQSTM1) have been genetically associated with amyotrophic lateral sclerosis (ALS) and Paget disease of bone. In the present study, we analyzed the SQSTM1 coding sequence for mutations in an extended cohort of 1,808 patients with frontotemporal lobar degeneration (FTLD), ascertained within the European Early-Onset Dementia consortium. As control dataset, we sequenced 1,625 European control individuals and analyzed whole-exome sequence data of 2,274 German individuals (total n = 3,899). Association of rare SQSTM1 mutations was calculated in a meta-analysis of 4,332 FTLD and 10,240 control alleles. We identified 25 coding variants in FTLD patients of which 10 have not been described. Fifteen mutations were absent in the control individuals (carrier frequency <0.00026) whilst the others were rare in both patients and control individuals. When pooling all variants with a minor allele frequency <0.01, an overall frequency of 3.2 % was calculated in patients. Rare variant association analysis between patients and controls showed no difference over the whole protein, but suggested that rare mutations clustering in the UBA domain of SQSTM1 may influence disease susceptibility by doubling the risk for FTLD (RR = 2.18 [95 % CI 1.24-3.85]; corrected p value = 0.042). Detailed histopathology demonstrated that mutations in SQSTM1 associate with widespread neuronal and glial phospho-TDP-43 pathology. With this study, we provide further evidence for a putative role of rare mutations in SQSTM1 in the genetic etiology of FTLD and showed that, comparable to other FTLD/ALS genes, SQSTM1 mutations are associated with TDP-43 pathology.

Objectives: "Fast-track" rehabilitation is a multimodal perioperative treatment concept for accelerating postoperative recovery which has been already used successfully in visceral surgery. Of its use in thoracic surgery however, almost no data exist and the relevance of this concept for pulmonary operations is unknown., Patients and Methods: In this prospective study we examined a new perioperative fast-track treatment concept for thoracic surgery and evaluated the results. This program employs detailed information of patients, intensive perioperative respiratory therapy, thoracic peridural analgesia, forced mobilization, and an early start of postoperative normal food intake., Results: Fifty consecutive patients with benign or malignant diseases of the lung aged an average of 64 years (range 22-78) were operated on thoracoscopically (n=15) or with thoracotomy (n=35) and treated perioperatively using the fast-track program. All patients were mobilized beginning 4 h postoperatively and had normal food. The incidence of general postoperative complications was 0% in this study. Postoperative stay lasted 4.5 days (range 1.5-28.5). There was no increase in surgical complications, and 6% of the patients were readmitted. The patients' acceptance of this concept was high., Conclusion: Fast-track rehabilitation resulted in a decreased rate of general complications and accelerated rehabilitation in thoracic surgery.

There are absolute and relative indications for complete removal of the thymus gland. In the complex therapy of autoimmune-related myasthenia gravis, thymectomy plays a central role and is performed with relative indication. In case of thymoma with or without myasthenia, thymectomy is absolutely indicated. Thymus resection is further necessary for cases of hyperparathyroidism with ectopic intrathymic parathyroids or with certain forms of multiple endocrine neoplasia. The transcervical operation technique traditionally reflected the well-founded desire for minimal invasiveness for thymectomy. Due to the requirement of radicality however, most of these operations were performed using sternotomy. With the evolution of therapeutic thoracoscopy in thoracic surgery, several pure or extended minimally invasive operation techniques for thymectomy have been developed. At present uni- or bilateral, subxiphoid, and modified transcervical single or combination thoracoscopic techniques are in use. Recently a very precise new level of thoracoscopic operation technique was developed using robotic-assisted surgery. There are special advantages of this technique for thymectomy. An overview of the development and experiences with minimally invasive thymectomy is presented, including data from the largest series published so far.

Background: New demands and possibilities of collaboration between hospitals and private practices in Germany have appeared, now that the way has been opened legally. A poll was conducted to analyse the current status of collaboration between outpatient gastroenterologists and hospital surgical departments and to identify possible future collaborations., Materials and Methods: One thousand twenty-six private practices specialising in endoscopy were found by contacting the Association of Statutory Health Insurance Physicians and additional internet research. Of these, 50% were randomly selected (513 private practices) and contacted by mail with anonymous questionnaires about cooperation with their clinical partners. Two hundred three (39.6%) practices responded, of which 200 could be analysed., Results: Of all practices reached, 75% considered the cooperation with clinics very valuable or even exceptional. Still, almost half (46%) suggested necessary improvements in these collaborations. Around a third of all contacted colleagues were already involved in projects following integrated care models. In about 80% of all participants, the main interest in integrated models was specified to be common therapy planning., Conclusion: The data analysis of this study shows a substantial interest of private-practice gastroenterologists in close collaboration with hospitals. It is now up to the hospitals to open contracts with their medical outpatient partners.

Background: Although it is a significant part of surgical treatment, informing patients beforehand seems to be more and more neglected, mainly due to the enormous amount of work and time pressure on surgical personnel., Material and Methods: A video clip explaining groin hernia surgical repair was produced as additional information for patients. In it, visual material from actual practice describes the disease, the operation itself, all the perioperative aspects, and patients' own experiences. In a prospective comparison study, the length of patient education, its quality, patient satisfaction, and the duration of hospitalization and time off work were compared between patients who saw the video clip (n=50) and those who did not (n=50)., Results and Conclusion: In summary, the time spent informing the video group was shorter (P<0.05) and their total satisfaction and evaluation of the information material were both higher (P>0.05) for comparable duration of treatment and time off work. This informative video was adopted without problems in our daily clinical life and, besides reducing the time needed to inform patients, it has significantly improved patient understanding of the operative procedure and their satisfaction with treatment.

Object: The aim of multimodal perioperative treatment concepts is to lower the extent of general complications after elective colonic resection and "traditional" perioperative therapy and to allow hospital discharge only a few days following the operation., Materials and Methods: In this prospective study, we examined a new perioperative treatment plan for accelerating postoperative recovery and evaluated the results. This so-called "fast-track" program employs combined thoracal peridural analgesia, forced mobilization, and rapid renourishment within the clinic., Results: Sixty-four consecutive patients with benign or malignant disease of the large intestine aged an average of 66 years (range 54-71) were operated on. Thirty received conventional resection and 34 were operated on laparoscopically and treated perioperatively using the fast-track program. The hospital diet was given in all cases on the 1st postoperative day, and the first bowel movement occurred on the 2nd day (range 2-3). The patients could be released on the 4th postresection day (range 4-5). General and local postoperative complications were observed in five patients each (8%), including two cases of anastomotic insufficiency., Conclusion: In colonic surgery, the "fast-track" method accelerated convalescence, lowered the number of general complications, and reduced the duration of hospital stay. Therefore, evaluation of "fast-track" concepts is warranted in other types of elective abdominal surgery.

Earlobe keloids are benign, fibrous proliferations that show a high rate of recurrence of up to 80% following surgical excision. Traumas to the earlobe such as ear piercing, burns or surgical interventions are important in the pathogenesis of the disease. In addition to surgical keloid excision and reconstruction of the earlobe, several adjuvant therapeutic concepts have been described to prevent recurrence. Here we present the case of a female patient who suffered from severe bilateral keloid development after piercing of both ears. The report gives an overview of the relevant therapeutic concepts in the treatment of earlobe keloids and their possible complications. In addition, the question of written informed consent before ear piercing is discussed.

Introduction: The increasing use of the internet has led to a variety of medical web pages and an increasing amount of information about hospitals. Little is known about the extent to which this new medium is already used by patients as a source of information. For patients with inguinal hernia, for example, a frequent surgical symptom with large method variety, the value of the internet as a source of information should be examined., Methods: One hundred patients facing an elective inguinal hernia repair at the Surgical Department Charité Berlin took part in a prospective observation study (a questionnaire with 10 questions) between July 1999 and March 2001. The questions referred to the possibility of PC/internet access, other sources of information (e.g., general practitioner, friends, internet) as well as the criteria by which the clinic was chosen. Patients were asked to answer basic questions about the development and treatment of inguinal hernia and to give a self-assessment of their knowledge of inguinal hernia (0 = no knowledge; 10 = maximum knowledge)., Results: The questionnaire revealed that 39% of the patients (average age 47 +/- 16 years) had a PC in their homes, 24% of those with internet access; 11% had internet access at other places. It also showed that 53% of the patients sought medical information from their general practitioner, 29% from friends, and 18% from the internet. Young patients (median age 29 years), employees and patients with private internet access use the internet with significantly more frequency. Their medical knowledge as well as their self-assessment of medical knowledge was significantly higher (median 19 versus 7 points and median 8.6 versus 5.7, respectively) and they chose the clinic because of the information from their research on the internet., Conclusion: At present, the internet still plays a subordinate role as a source of information for patients with an inguinal hernia. The increasing presence of this medium as well as the higher internet acceptance of future patients indicates that it has a promising future as a source of medical information.

Between November 1995 and August 2000 we performed adjustable silicone gastric banding laparoscopically in 252 patients. The body mass index varied from 37 to 86 kg/m2. We report on a 38-year-old woman who was operated on in 1997 with a body mass index of 47 kg/m2 (167 cm, 132 kg). The postoperative follow-up was uneventful until January 2000. The patient lost weight until she weighed 78 kg. Then she complained of diffuse epigastric pain. Gastroscopy revealed gastritis. Omeprazol was prescribed. No amelioration occurred. Endoscopic control showed partial intragastric migration of the band. After laparoscopic removal of the band, the patient was free of symptoms. Band erosion is a possible complication of adjustable gastric banding. As is known from intragastric penetration of the Angelchik prosthesis, the clinical symptoms of this complication may be mild. Since the follow-up of most patients with gastric banding is less than 5 years, more complications similar to that one described may be diagnosed in the future.

Laparoscopic surgery of the upper gastrointestinal tract is nowadays associated with little morbidity and mortality. Cardiomyotomy with semifundoplication for management of achalasia and the various forms of fundoplication for treatment of reflux syndrome have proved beneficial and have largely replaced conventional surgery. Independent of the operative approach, it has not yet been established with certainty whether gastroesophageal reflux can best be prevented by 360 degrees fundoplication or semifundoplication. A perforated peptic ulcer can be treated effectively by laparoscopic overstitching of omental patch-plasty, although the superiority of the laparoscopic method has yet to be proved. Benign lesions and early malignancies are currently resected laparoscopically, but the role of laparoscopy in the curative treatment of advanced gastric carcinoma remains to be clarified. Diagnostic laparoscopy is used to avoid unnecessary laparotomy in inoperable cancer and to ascertain whether neoadjuvant therapy is indicated in advanced gastric carcinoma.

Introduction: Oral feeding is usually offered following surgery of the lower gastrointestinal tract when clinical signs of normal intestinal motility are present. However, some studies have shown that early oral feeding is well tolerated with low morbidity., Methods: A prospective cohort study was performed to evaluate whether early oral feeding according to a standardized schedule is tolerated under normal clinical circumstances. One hundred consecutive patients following small- or large-bowel resection with anastomosis were offered fluids on post-operative day 1, soup on post-operative day 2, mashed food on post-operative day 3 and a regular diet on post-operative day 4. Parenteral nutrition was only given if necessary. Tolerance of oral feeding and the amount of food were checked twice a day. End points of the study were nausea (VAS score 1-100), vomiting (> 200 ml), reinsertion of a nasogastric tube, level of food intake, parenteral nutrition (ml), appetite and well-being., Results: Loop ileostomies were done in 21 patients, colonic resections above the sigmoid in 32, and sigmoid and rectal resections in 47. The average age was 63 +/- 13 years. The frequency of nausea was less than 30% and of vomiting less than 10%. Only in two cases was a nasogastric tube inserted. Forty-three percent of all patients tolerated feeding very well according to the schedule. On post-operative day 3 more than 60% tolerated oral intake, on post-operative day 4, 74% and on post-operative day 5, 88%. Only 22% of the patients needed parenteral fluids on post-operative day 4. The first bowel movement was noted after 2.8 +/- 1.1 days. Surgical complications were documented in 18 patients and general complications in 6 patients., Conclusion: Most patients tolerated early oral feeding very well according to the schedule with low morbidity. Therefore, early feeding is now a substantial component of the postoperative treatment following small- or large-bowel resections.

In a prospective study the perioperative results of plug-and-patch repair were investigated in patients > or = 65 years, and quality of life was assessed using the SF36 preoperatively and 3 months after the procedure in 34 consecutive patients. From August 1994 to February 1999 147 patients with a mean age of 73 +/- 5 years (65-92 years) were operated on using the plug-and-patch technique, mostly under local anesthesia (LA: n = 124, 84%, ITN: n = 23, 16%). Preoperative risk factors were alcohol consumption, hypertonus, diabetes mellitus, ischemic heart disease, smoking, cerebrovascular disease, hyperlipidaemia and pulmonary disease. Most of the patients were ASA II (ASA I: n = 14, 9%, ASA II: n = 82, 56%, ASA III: n = 51, 35%). No intraoperative complications occurred, postoperative complications consisted of superficial wound hematoma (n = 6, 3.7%) and infection (n = 1, 0.6%), seroma (n = 7, 3.8%), urinary retention (n = 3, 1.8%) and ilioguinal pain syndrome (n = 3, 3.8%). The total amount of postoperative analgesic consumption was 4.9 +/- 1.8 g Novalgin for about 4 +/- 3 days. The duration of postoperative hospitalization was 2 +/- 1 days and limitation of daily activities 6 +/- 3 days. Clinical examinations after 3 months revealed no recurrence or late complications. Investigation of quality of life showed a significant improvement in the SF36 domains of physical activity, pain, vitality, and social functioning after the operation. No significant change was observed for physical, emotional, and global health.

A case of isolated dislocation of the hamate bone is reported. Mechanism of the injury and treatment are described including a review of the literature.

Background: The Whipple operation (PD) is the standard operation in patients with cancer of the head of the pancreas and the periampullary region. However, the pylorus-preserving duodenopancreatectomy (PPPD) is supposed to be superior in gastrointestinal function., Methods: In a prospective randomized trial (October 1994-October 1998) PD and PPPD were compared in terms of global and gastrointestinal quality of life, operation time, duration of hospital stay, transfusions and perioperative morbidity. Quality of life was analyzed under standardized conditions (EORTC-QLQ-30) pre- and postoperatively (weeks 2, 6, 12, 24, 36, 48, and 60)., Results: A duodenopancreatectomy was performed in 48 patients because of cancer of the head of the pancreas (n = 38) and the periampullary region (n = 10) (PD, n = 24; PPPD, n = 24). The PD and PPPD groups did not differ according to age, gender or UICC stage. Operation time was shorter in the PPPD group (206 +/- 48 vs 306 +/- 54 min) (P < 0.05). Morbidity did not differ between the two groups (PPPD 20% vs PD 30%, P > 0.05). While there was no difference in global quality of life, gastrointestinal quality of life was postoperatively increased in the PPPD group regarding appetite, nausea and diarrhea (P < 0.05). While the preoperative body weight was reached after 6 months in 85% of the PPPD group (n = 20), this was true in only 60% of the PD-group (n = 14) (P < 0.05)., Conclusion: PPPD seems to be associated with a better postoperative gastrointestinal quality of life than PD.

Background: In a prospective trial (October 1996-April 1998) the effect of octreotide and tamoxifen on the recurrence of pancreatic carcinoma after R0 resection was evaluated., Methods: Patients with a local recurrence after curative resection of ductal adenocarcinoma of the pancreas were treated with 100 micrograms of octreotide three times a day and tamoxifen 20 mg once daily. The median survival time, quality of life (EO-RTC-QLQ-30) and side effects of the octreotide-tamoxifen group were compared with a historic cohort (n = 14) of patients treated in our department (9/95-9/96) according to the "best supportive care" concept., Results: Recurrences were diagnosed after R0 resection in a mean time of 13 +/- 6.8 months. Patients treated with octreotide and tamoxifen had a significantly (P < 0.05) longer median survival time (7 months; range: 3-12) vs 3.5 months; range: 1.5-5). The octreotide-tamoxifen group suffered less from lack of appetite, nausea, fatigue, and pain and needed fewer analgesics. The only side effect of the octreotide-tamoxifen therapy was moderate diarrhea in 2 patients at the beginning of the therapy., Conclusion: Since combined therapy with octreotide and tamoxifen can be administered comfortably for outpatient treatment, this seems to represent progress in the palliative therapy of pancreatic cancer.

Background: Laparoscopic techniques are currently used for curative resection of colorectal cancer although long-term results from controlled clinical trials are not available yet that prove laparoscopic procedures are adequate., Methods: All patients who under-went a curative resection of a colorectal tumor from 1995 to 1997 were included in a prospective cohort study to evaluate the short- and long-term results., Results: Laparoscopic colorectal resections were accomplished in 68 patients. In only 3 patients was an adenoma (stage 0) found, and 10 patients had multiple liver metastases at the time of palliative resection. An oncological resection was performed in 55 patients. The average age was 62.8 +/- 14.6 years (29 female and 26 male patients). Eleven right colectomies, 1 left colectomy, 21 sigmoid resections, 16 proctosigmoidectomies and 6 abdominoperineal resections were carried out. Two patients (3.6%) were lost during follow-up. The median follow-up was 27.1 months (range 9.1-45.1 months). No port-site metastases were found. Two patients who are still alive after sigmoid resection suffered from a recurrence. The first patient underwent only limited lymphadenectomy because of synchronous malignant lymphoma. The second patient developed bilateral lung metastases. Only one patient died during the follow-up period because of myocardial infarction., Conclusion: Although the follow-up is short, it seems that the recurrence rate is low. Controlled multicenter clinical trials are currently performed to evaluate whether laparoscopic surgery is really adequate to treat colorectal cancer.

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is rare. Among local pathologic alterations like fibrosis and cirrhosis, arteriovenous shunts lead to hypercirculatory heart failure and require efficient therapy. Present therapeutic strategies consist of percutaneous selective embolization or complete ligation of the hepatic artery. We describe a 53-year-old woman with HHT in whom percutaneous selective embolization of the left hepatic artery failed because of unfavorable anatomy. Instead of ligation a new method of adjustable banding of the hepatic artery was tested. After small-incision laparotomy an expander prosthesis was put on the proper hepatic artery. By filling the prosthesis via the implanted port system the hepatic perfusion could be reduced under control. This method led to effective reduction of the liver perfusion and heart time volume and to successful treatment of heart failure. The method described is an alternative treatment to ligation of the hepatic artery in cases in which percutaneous embolization failed or is not possible.

To evaluate whether laparoscopic appendectomy shortens the convalescence and the postoperative period until return to work when compared to conventional appendectomy, a prospective randomized trial was performed. The major endpoint of the study was the time until return to work; minor endpoints were postoperative pain, fatigue, operative time and postoperative morbidity. In all, 54 patients with a mean age of 29.5 +/- 10.1 years were randomized to open (n = 28) or laparoscopic appendectomy (n = 26). Age, sex, body mass index (BMI), American Society of Anesthesiology (ASA) rating, job status as well as histologic degree of inflammation of the appendix were comparable in the two groups. Operative time was 59.2 +/- 15.8 min for laparoscopic and 59.8 +/- 24.4 min for conventional appendectomy (P = 0.9). Some 16 laparoscopic appendectomies (62%) were performed by board-certified surgeons, while 23 conventional appendectomies (82%) were performed by residents (P = 0.003). Postoperative morbidity was comparable between the two groups. After laparoscopic appendectomy, pain was rated significantly lower on the first, second and fourth postoperative day when compared to the conventional group. There were no difference in postoperative fatigue between the groups. Time to return to work was 17.0 +/- 6.2 days in the laparoscopic group and 18.2 +/- 6.0 days in the conventional group (p = 0.5). Laparoscopic appendectomy has no advantages in terms of convalescence and time to return to work when compared to open appendectomy and should therefore be limited to selected cases.

The clinical effect of perioperative nutrition was analyzed from 28 controlled clinical trials. Preoperative nutritional support is indicated only in patients with high-grade malnutrition and can reduce the postoperative morbidity and mortality in these patients. If the nutritional status is normal preoperatively, artificial nutrition may influence the postoperative outcome negatively. A clinical benefit from postoperative nutritional support has been proven only in patients not able to eat an adequate oral diet within 1 week. In 20% of these case a cardiopulmonary complication was observed during total parenteral nutrition. The infusion of D5W is sufficient in the majority of surgical patients even after major procedures.

Patients who had undergone elective resection for primary colorectal cancer were included in a prospective study. The purpose of the study was to specify the current role of laparoscopic surgery in the treatment of colorectal cancer. Therefore, the reasons for performing the resection conventionally were documented under the general guideline that all colorectal cancer should be resected laparoscopically. Of 111 patients treated in 1995, only 22 underwent a laparoscopic resection and 4 patients a laparoscopic-assisted resection. Age, sex and tumor stage were comparable between groups. Operative time was longer in the laparoscopy group; duration of postoperative ileus and postoperative hospital stay were shorter. The most frequent indications for using a conventional approach were rectal cancer (n = 29), adhesions (n = 15), randomly selected patients (n = 14) and advanced cancer (n = 12). Cardiovascular risk factors were not so important. Laparoscopic techniques were only applied in a minority of patients with colorectal cancer (24-37%). Laparoscopic sphincter-preserving surgery is currently not recommended for rectal cancer in the middle and lower rectum. General risk factors are rarely a contraindication for a laparoscopic approach.

Inflammatory cells, in particular monocytes/macrophages, release pro-inflammatory mediators in response to several infectious and non-infectious stimuli. The excessive release of these mediators, resulting in the development of whole body inflammation, may play an important role in the pathogenesis of sepsis and septic shock. TNF-alpha, acting synergistically with cytokines such as IL-1, GM-CSF and IFN-gamma, is the key mediator in the induction process of septic shock, as shown in several experimental models. Based on this concept and on the encouraging results obtained in several experimental models, a number of clinical sepsis trials targeting the production or action of TNF-alpha or IL-1 have been performed in recent years. Unfortunately, these trials have failed to demonstrate a therapeutic benefit. One reason for this may be the lack of exact immunologic analyses during the course of septic disease. Recently, we demonstrated that there is a biphasic immunologic response in sepsis: an initial hyperinflammatory phase is followed by a hypo-inflammatory one. The latter is associated with immunodeficiency which is characterized by monocytic deactivation, which we have called "immunoparalysis". While anti-inflammatory therapy (e.g. anti-TNF antibodies, IL-1 receptor antagonist, IL-10) makes sense during the initial hyperinflammatory phase, immune stimulation by removing inhibitory factors (plasmapheresis) or the administration of monocyte activating cytokines (IFN-gamma, GM-CSF) may be more useful during "immunoparalysis".

Cystic neoplasms of the pancreas are rare but in the last years more frequently detected. Within a 10-year-period we treated 30 patients, including 8 serous cystadenomas, 6 mucinous cystadenomas, 12 mucinous cystadenocarcinomas, 2 cystic neuro-endocrine tumors and 1 papillary cystic tumor respectively acinar cell cyst-adenocarcinoma. 80% of the patients had symptoms, experienced abdominal pain, weight loss, weakness or abdominal mass. In eight patients the tumors had been misdiagnosed as a pancreatic pseudocyst. The correct type of cystic tumor was diagnosed by preoperative investigations only a few cases. All patients with serous or mucinous cystadenomas are well and without evident recurrence after resection of the tumor. However the survival time of malignant cystic tumors varied strongly. The curative resection of these tumors give patients the chance of long-term survival.

Quality of life (QL) following resection of carcinoma of the colon (n = 68) and rectum (n = 58) was studied in 126 patients 12 months postoperatively and in 34 patients at regularly intervals, starting with a preoperative assessment. QL was assessed by the patients themselves using the EORTC QL questionnaire (QLQ-30) and by a psychologist using the Spitzer index. Between self-assessment and evaluation by the independent observer, a significant but not very strong correlation (r = 0.48) was determined and QL was evaluated as being better by the observer. Although somatic and emotional problems were significantly more common in patients with rectal cancer following abdominoperineal resection and the Spitzer index was significantly lower in these patients, the subjectively perceived global QL did not differ from that after sphincter-preserving resection. Of several factors analysed, tumour recurrence was the decisive factor determining postoperative QL. In disease-free patients QL had deteriorated on discharge from hospital but was restored within 3-6 months postoperatively.

Although laparoscopic techniques in gastric surgery have become an important part of upper gastrointestinal surgery, they are mainly utilized for organ preserving procedures. A standardized technique for laparoscopic gastrectomy has not yet been described in detail. The purpose of this study was to develop a standardized technique for laparoscopic gastrectomy with reconstruction by a stapled termino-lateral esophago-je-junostomy and Roux-en-Y-anastomosis in a cadaver model. The resected stomach was removed through an enlarged trocar incision. The described technique has been successfully performed in one patient with early gastric cancer.

17 patients with a Caroli's syndrome are reviewed with emphasis on clinical features and late results (follow-up: 2-10 years). The group consists of 9 women and 8 men ranging in age from 17 to 80 years (mean of 42.6). 14 patients had a diffuse form, 5 of whom had periportal fibrosis with secondary biliary cirrhosis, which in 3 cases resulted in a portal hypertension with hepatic failure. In only 3 cases the dilatation was limited to the left lobe of the liver. 9 of the patients had previously undergone surgery in the form of cholecystectomy and choledocholithotomy elsewhere. The disease was complicated by lithiasis (14 intrahepatic, 9 extrahepatic). Curative treatment was only possible in the 3 patients with unilobar Caroli's syndrome (partial liver resection). In 5 patients we performed a cholecystectomy and choledocholithotomy combined in 2 cases with a transduodenal sphincterotomy. There was no operative death. Endoscopic treatment consisted in removal of stones and decompression of the biliary tree by sphincterotomy in 9 cases and endoscopic retrograde biliary drainage (endoprosthesis) in 5 cases. Excepting the 3 curative operated patients who are asymptomatic respectively 2, 4 and 5 years after surgery, the remaining cases had repeated bouts of acute pains accompanied by recurrent episodes of cholangitis. A late mortality of 23.5% (4 patients) is proof of the poor prognosis of this disease.

A total of 23 patients with extrahepatic biliary cysts (11 type I, 4 type II, 4 type III and 4 type IVa according to the classification by Todani) seen at our institution in a 15-year period were reviewed with emphasis on management and long-term results at follow-up of 3 weeks-12 years. Associated hepatobiliary disease occurred in 4 patients, including one case with malignant degeneration in the cyst 23 years after cystenterostomy, and an association of a gallbladder carcinoma with a choledochocele in the other patient. Radical excision of the dilated bile duct and reconstruction by Roux-en-Y hepatico-jejunostomy was performed in 13 cases (9 type I, 3 type II and 1 type III), combined in 3 cases with an antireflux valve. All 13 operated on patients remained in good health for 6 months to 12 years. These results confirm the need for complete early excision of type I, (II) and IVa cysts at all ages before severe complications can occur. Endoscopic treatment of type III choledochocele should be limited to the management of smaller lesions.

Surgical treatment of primary and secondary malignant chest wall tumors present various difficulties depending on their localisation in the anterior, lateral and posterior thoracic wall. The reconstruction and the flap-plastics have to fulfill the functional and cosmetic demands. We report on 35 patients, 22 female and 13 male, ranging in ages from 19-69 (mean 44.59) years. There were 17 primary and 18 secondary tumors. The operation included excision of the thoracic shield, partial or total breast-bone and clavicle resection. Materials used for reconstruction were PTFE-patches, lyophilized dura and ribs. Soft tissue reconstruction was performed by sliding-flap plastics. The one-year survival rate was 90.6%.

The effects of pyloroplasty following subtotal oesophagectomy and gastric substitution with cervical oesophago-gastric anastomosis were studied in a prospective randomized trial. 52 patients received extramucosal pyloroplasty and were compared to a control group of 55 patients, in whom no drainage procedure was performed. 6 patients died postoperatively. One of these patients died following the insufficiency of pyloroplasty. The other causes of death were not related to the performance or non-performance of pyloroplasty. Regarding to patients subjective self-assessment of abdominal discomfort and radiologic emptying of the gastric tube no statistical significant differences between both groups were noted 2 weeks and 6 months postoperatively. Two patients with pyloroplasty, but no patient of the control group, suffered 12 months postoperatively from severe vomiting due to fibrotic stricture of the pylorus. The results of this study suggest, that usually no pyloroplasty should be performed following subtotal oesophagectomy and interposition of a gastric tube with oesophagogastric anastomosis in the neck.

During the period March 3, 1992 to September 30, 1993 36 video-assisted thoracoscopic operations were performed at the Surgical Department of the University of Cologne. In 12 cases wedge resection of peripheral pulmonary nodules were carried out. Two of the patients underwent video-assisted thoracoscopic lobectomy of the left lower lobe due to peripheral primary bronchogenic carcinoma. In 6 cases biopsy of the lung or pleura was undertaken. Further indications were partial pleurectomy and resection of blebs (n = 12). Pleural effusion was drained under thoracoscopic vision twice. No intraoperative complications occurred. Two patients proceeded to thoracotomy after persistence of pneumothorax following thoracoscopic pleurectomy. The postoperative course of the remaining patients was uneventful and was especially characterized by the reduction in pain and disability. In accordance to the experience of other authors we believe that thoracoscopic surgery is a method with a promising future. Further investigations have to evaluate indications, different techniques, and long term results.

Esophageal perforations are rare but most often caused by instrumental lesions during endoscopy. We describe a cases of the iatrogen esophageal perforation accompanied with perforation of the pericardium. Chest radiograph with Gastrografin swallow revealed the perforation. The principles of operative treatment and the postoperative course are demonstrated.

Metastatic cancer to the esophagus is unusual. Breast cancer represents one of the most frequent solid tumors metastasizing to the esophagus. Less than 100 histologically confirmed cases were reported up to now. By suggestion of Laforet the entity of postmastectomy-dysphagia was inaugurated as a syndrome, characterized by dysphagia, occurring many years after mastectomy due to metastatic breast cancer. Surgical therapy by means of esophagectomy and esophagogastrostomy is a safe procedure and can provide a survival time of several years in combination with other therapies due to reliable palliation.

Since 15 years we use absorbable polyglycolic acid sutures (Dexon) for closure of partial median sternotomies. In a consecutive series of 121 refixations, minor superficial wound infections developed in 4 patients. All infections healed completely by local treatment. No major sternal complication occurred. Of 92 patients, who were still living, 82 patients were controlled between 3 and 180 months postoperatively. 80 (98%) sternotomies were consolidated completely; 71 (87%) without any dislocation and 9 (11%) with a small dislocation of the fragments. In 2 cases (2%) an isolated pseudarthrosis of the transverse osteotomy occurred; in both cases the median osteotomy was consolidated completely. In the literature no comparable publication about closure of partial median sternotomies could be found. According to our experiences we consider, that the closure of partial upper sternotomies with polyglycolic acid sutures is as a practical and reliable method.

In the period from 1967 till 1988 an accidental splenectomy was carried out at 1318 colon resections because of a malignant tumor in 34 cases (2.5%). The preoperative risk of this patient group was increased clearly in opposite to the whole patient clientele. So every fifth suffering from ileus or subileus was operated as in emergency. The complication rate, time of rest and clinic lethality were increased. The five-years survival rate did not change significantly in stage T1 and T2 in comparison with the whole patient clientele. In the stage T3, however, a significant prolonged survival rate was found out in the target group. Therefore the oncological aspect does not supply any reason to preserve the spleen in colorectal tumor surgery.

Since 1964 245 resections of the esophagus because of cancer were performed at the University Hospital of Cologne. Hospital mortality was 27%. It was reduced to 12.1% during the last 5 years. Surgeon's experience turned out to be of major influence upon hospital mortality whereas tumor and organ related risk factors or kind of the operating procedure didn't influence hospital mortality at all. Five year survival rates that included hospital mortality were 15.5% and were 23.2% without. Patient's late outcome was influenced significantly by tumor staging and histological grading. Radical operating procedure--blunt dissection or transthoracal esophagectomy--were of no prognostic value.

During a 8-year period, recurrent swelling of the right knee-joint was observed in a 31-year-old female. Although only minimal pain was present, flexion of the knee-joint was severely limited. Bearing in mind the extent of the swelling, the initial diagnostic procedures were suggestive of a malignant neoplasm. Biopsy of the knee-joint led however to the diagnosis of a pigmented villo-nodular synovitis. The postoperative course after synovectomy of the knee-joint was uneventful. Although benign, this lesion has to be followed-up closely, due to the recurrence-rate of 33%.

In order to compare different groups of intensive-care patients and therapeutic interventions a measuring system is needed reflecting the patient's pathophysiologic status with great accuracy. The APACHE-system designed by Knaus et al. (APS) meets the requirements when comparing groups of patients. This prospective study was undertaken to determine whether APS is useful to forecast survival and death of 764 individual patients of a surgical ICU. The results were compared to daily statements obtained from the head surgeon of the intensive-care department. Both the physician and APS gave true judgements in 95% of the cases. Overestimation of the operative procedures by the physician was revealed to be a major source of error in wrong statements. When a combination of APS and physician's judgement was used the forecasts were found true in 99% of the patients. The authors conclude that APS by itself is not able to give a sufficient prognosis in an individual ICU patient but is an excellent tool to assure or modify the physician's opinion.