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A retrospective study of the possible value of standardized follow-up examinations was undertaken in a group of 251 patients (163 men, 88 women; mean age at diagnosis 58 [33-78] years) who had undergone putatively curative gastric resection for adenocarcinoma between 1.1. 1978 and 31. 12. 1987 and had survived at least 3 months after the operation. 113 patients (45%) regularly had follow-up examinations according to a standardized diagnostic protocol, 67 (27%) only irregularly, while 71 (28%) had none. Follow-up examination revealed tumour recurrence in 53 patients (30%), which in 18 (34%) was still asymptomatic. In one of these patients resection of the recurrence was again undertaken with curative intent, a palliative operation was performed in five, chemotherapy in seven, three received radiotherapy and 37 were treated purely symptomatically. The results do not indicate that the survival rate was improved by the standardized follow-up protocol and it is concluded that symptom-oriented and individualized follow-up examination without standardized protocol is sufficient in this type of case, except for scientific purposes.

AIM To determine whether a thoracoscopic lobectomy used for treatment of primary non-small cell lung cancer shows a higher or lower morbidity in comparison to the conventional resection (thoracotomy) postoperatively. METHODOLOGY 42 patients with the presumption diagnosis of a lung cancer received a thoracoscopic lobectomy (n=28) or a conventional lobectomy (n=14). Postoperative complication rate (30 days) was analysed prospectively. There were no differences between the groups referring to age, co-morbidity, localisation of the tumor and stage. RESULTS Patients with a conventional operation revealed a significant higher morbidity in comparison to the patients of the thoracoscopic group (50 % vs. 14.2 %, p=0.03). CONCLUSION The thoracoscopic lobectomy represents a safe operation method and an alternative to the conventional operation (thoracotomy).

BACKGROUND: The prognosis of gallbladder carcinoma is generally poor. The 5-year survival rate amounts to less than 5% in most series due to the high proportion of advanced stages at the time of diagnosis. Early stages are commonly found only with histological work-up after cholecystectomy (CCE). In these cases the question arises whether or not reoperation for completion resection would be indicated. PATIENTS/METHODS: A retrospective analysis examined all patients of the Clinic of Surgery (Charite) in Berlin with gallbladder carcinoma operated on between January 1981 and August 1993. A literature search was carried out using the MEDLINE retrieval system for the key words "gallbladder carcinoma", "surgical therapy", and "reoperation" limited to the period after 1970. RESULTS: The retrospective results of the own clinic and the analysis of the literature review demonstrate significantly higher survival rates after reoperation compared to CCE alone and observation for all cases of gallbladder carcinoma with stages T1b or higher stages. The extended radical CCE can be performed with low morbidity. With preceding laparoscopic CCE the trocar sites have to be completely excised. DISCUSSION: To avoid the situation of postoperative diagnosis of gallbladder carcinoma, the surgeon should intraoperatively during CCE perform a careful macroscopic control of the gallbladder. Suspect findings should be followed intraoperatively by histological examination. Nevertheless, local spread of GBCa and distribution of lymphatic metastases can certainly not be assessed completely after simple CCE. Based on the published results and because of low morbidity reoperation is indicated for most cases of GBCa when diagnosed postoperatively.

Background/aims To determine whether a Longmire-Interposition with or without a pouch used for reconstruction after gastrectomy influences the postoperative complication rate. Methodology 49 patients who underwent gastrectomy with Longmire-Interposition with (n = 33) or without (n = 16) an additional pouch and 46 patients with a Roux-en-Y-reconstruction were analysed retrospectively. Complication rate and mortality were studied. Results There were no significant differences between the reconstruction groups for postoperative complications (Roux-en-Y vs. Longmire-Interposition with and without pouch: 30.4% vs. 28.6% for the morbidity; 4.3% vs. 4.1% for the mortality). Conclusion These findings suggest that a Longmire-Interposition with or without a pouch for reconstruction after total gastrectomy is not connected with a higher morbidity or mortality in comparison to a Roux-en-Y-reconstruction.

Immunologic investigations of laparoscopic and conventional procedures have recently been performed during cholecystectomy or colon resection, but the results might have been influenced by the amount of dissection or the presence of malignant tumor. Because fundoplication is characterized by moderate dissection and no resection, we supposed it to be an appropriate procedure for comparing immunologic changes during laparoscopic and conventional surgery.Immunologic analysis (interleukin [IL]-6, IL-10, leukocytes, HLA-DR monocytes) was carried out on the peripheral blood of 34 patients who underwent elective Nissen fundoplication by the laparoscopic (LAP; N = 26) or conventional (OPEN; N = 8) technique for gastroesophageal reflux disease. Blood samples were obtained before and 1 and 4 hours after the beginning of the operation and on days 1, 2, 4, 7 after the procedure.A very fast and significant (P0.01) increase of the proinflammatory cytokines (IL-6, IL-10) and leukocytes and a decrease of cell-mediated functions (HLR-DR monocytes) were detected. Most of the analyzed measures had returned to preoperative values by 2 days after the procedure. All of the changes were similar in the two groups with the exception of IL-6. Throughout the post-operative study period, IL-6 concentrations were higher in the OPEN group, being significant 4 hours, 1 day, 2 days, and 4 days after the operation.The investigation measures do not give evidence that laparoscopic fundoplication is superior to conventional fundoplication in its immunologic effects.

A case of traumatic diaphragmatic rupture is reported in which herniated stomach mimicked a tension pneumothorax. Tube thoracostomy by trocar caused insertion of the pleural drain into the intrathoracic stomach. CT scan of the thorax after oral administration of contrast material revealed the correct diagnosis. After removal of the drain and retraction of the stomach into the abdomen the gastric perforation and diaphragmatic defect could be closed by suture. The further course of the patient was uneventful. This case report underlines the importance of differential diagnosis of symptoms in a case with a history of blunt chest trauma and shows the risks of unnecessary use of a trocar.

In recent years, as the importance of humoral-mediated rejection has increasingly become recognized, the fact that endomyocardial biopsies (BX) evaluated according to the criteria of the International Society for Heart and Lung Transplantation often produce false-negative results has become a matter of concern. To evaluate the reliability of measuring intramyocardial ECG amplitude (IMEG) and immunofluorescence evaluation (FITC-labeled anti-IgG/IgM staining) of endomyocardial biopsies (IFM), heterotopic neck-heart transplantation (HTX) was performed on eight beagles previously sensitized through skin transplantations. After HTX, IMEG, echo, and donor-specific antibodies in serum (IgG, IgM) were determined daily and myocardial biopsies (IFM, BX) were performed once every 2 days. Accelerated (humoral) rejection occurred on the 5th (4th–5th) postoperative day and sensitivity of IMEG, IFM, and BX was 100 %, 75 %, and 12.5 %, respectively. In each case rejection was recognized so early that it was possible to initiate therapy with “restitutio ad integrum”. Our results show that, as opposed to endomyocardial biopsy (IFM, BX), IMEG diagnosis detected humoral-mediated rejection early and with high reliability.

Im Rahmen einer retrospektiven Untersuchung wurden 50 Resektionen wegen primarer Lebermalignome, die vom 1. 6. 1979 bis zum 31. 12. 1991 an der Chirurgischen Universitatsklinik Koln durchgefuhrt wurden, analysiert. Die Resektionsrate betrug 28 %. Die Kliniksletalitat betrug insgesamt 22 % und konnte in den letzten 5 Jahren auf 4% gesenkt werden. Die Ein-, Dreiund Funfjahresuberlebensraten betrugen unter Einschlus der Kliniksletalitat 55%, 30% und 24%. Wichtigster Prognosefaktor war die chirurgische Radikalitat. In einer Literaturanalyse wurden die Ergebnisse von 8725 Leberresektionen wegen primarer Lebermalignome, die zwischen 1980 bis 1992 publiziert wurden, untersucht. Die Resektionsrate betrug im Durchschnitt 32 ± 17%. Die Kliniksletalitat konnte von 15 ± 5% (Resektionen vor 1970) auf 6 ± 2% (Resektionen nach 1980) gesenkt werden. Die Ein-, Drei- und Funfjahresuberlebensraten betrugen 66 ± 17%, 39 ± 15% und 27 ± 10%. Bis auf eine geringere Kliniksletalitat asiatischer Studien (4 % vs. 7%) waren die Resektionsraten und Langzeitergebnisse von asiatischen, amerikanischen und europaischen Studien durchaus vergleichbar. Die Langzeitprognose wird in erster Linie durch die erreichte chirurgische Radikalitat sowie die Grose und Ausdehnung des Tumors zum Zeitpunkt der Resektion beeinflust. Die Effektivitat adjuvanter Therapien ist noch nicht ausreichend untersucht.

During the past 10 years, postoperative mortality associated with surgical treatment of oesophageal carcinoma has been reduced by one-half. However, it appears that all efforts to improve long-term survival with extensive excisional procedures and adjuvant chemotherapy and radiotherapy have failed. Fifty-six of 100 patients presenting to the surgeon with an oesophageal carcinoma have resectable disease. Recent studies suggest that seven of them will die from postoperative complications and 49 patients will be discharged from the hospital after an average of 3 weeks. Of these patients, 27 will survive the first, 12 the second, and ten the fifth year. Although it may be possible to further reduce postoperative complications and mortality, the chances of improving the long-term prognosis of patients with oesophageal carcinoma seem small.

Although recent experimental and clinical trials have documented that postoperative inflammation and changes in different immunologic parameters are less pronounced after laparoscopic approaches in comparison to open surgery, it still remains unclear what influence the pneumoperitoneum itself has on immunologic defense and function. This is mainly due to the endpoints of the different studies which investigate changes in the so-called immunologic parameters (cell subunits, C-reactive protein, cytokines, catecholamines or other stress hormones in plasma samples) rather than analyzing immunologic functions, such as cell activation, production of proteins, cell proliferation or in vivo immune defenses. So far, especially in clinical trials, no correlation has been demonstrated between the changes in immunologic parameters and relevant postoperative clinical endpoints, such as postoperative complications. Thus further clinical prospective randomized studies with relevant clinical endpoints and additional investigations of immunologic parameters are needed to prove the consequences of either minimally invasive surgery or open procedures on postoperative immune functions.

Objective: Coating of ventricular assist devices (VADs) with heparin improves the biocompatibility and may reduce the need for systemic anticoagulation. However, heparins are associated with the risk of formation of heparin/platelet factor 4 antibodies (HPF4/A) and the development of heparin-associated thromboemboli. We analyzed the occurrence of HPF4/A and thromboembolism in patients with heparin-coated and noncoated VADs. Methods: One hundred patients were enrolled in the investigation. Fifty-seven received a heparin-coated (group 1) and 43 a noncoated (group 2) VAD. HPF4/A testing was performed before and 2 and 12 weeks after implantation by the heparin platelet factor 4 enzyme-linked immunosorbent assay. Results: There was no significant difference in the occurrence of HPF4/A in the 2 groups ( P =.102). Before the operation, 21 of the patients in group 1 had positive test responses and 25 in group 2. No patient had HPF4/A after termination of systemic heparinization. In group 1 there was no significant difference in the incidence of recurrent pump thromboses in patients who had positive test responses for HPF4/A (n = 11) when compared with those who had negative test responses (n = 9, P =.89). Twenty-one patients had HPF/A but no thromboembolism. However, all 22 patients who had thromboembolism had HPF4/A. Conclusions: Heparin coating of the VAD surface does not enhance the occurrence of HPF4/A-associated immunologic or thrombogenic reactions. However, the presence of these antibodies is strongly associated with an increased risk of thromboembolism in patients with a VAD. (J Thorac Cardiovasc Surg 2001;121:331-5)

Background: Due to a low survival rate even after a R0 resection of cancer of the head of the pancreas, a strict indication for a pancreaticoduodenectomy seems to be sensible. We have therefore analyzed our patients for possible prognosis factors. Methods: In a retrospective trial the courses of disease of all patients (1981–1996) with resected histologically proven carcinoma of the head of the pancreas were analyzed. The following patient-specific parameters were evaluated and examined in a single or multivariate analysis of prognosis factors: age, gender, tumor size (T status), lymph node involvement (N status), dimension of resection, operation method, time of operation, morbidity, clinic lethality and survival rate. Results: Between 1981 and 1996, 500 patients with ductal adenocarcinoma of the head of the pancreas were treated surgically. The rate of resection increased from 32.1% (1981–1986) to 37.8% (1991–1996) whereas the mortality rate decreased from 13.3 to 7.3%. The 5-year survival rate after resection was 11.8% with a median survival time of 13.8 months. In a multivariate analysis, only small tumors (T1, p < 0.016), the R0 status (p < 0.017) and the resection had a significant influence on the survival rate. Conclusion: Prognosis factors in the treatment of pancreatic cancer were tumor size (T1), tumor resection and R0 status.

Background: Therapeutic strategies to prevent port site recurrences in laparoscopy surgery of malignancies have not been investigated until now. Methods: The effects of taurolidine, heparin, and povidone iodine on the growth of rat and human colon adenocarcinoma as well as gallbladder carcinoma were investigated in vitro. Furthermore, cytokine release of growth-stimulating IL-1β by peritoneal macrophages was measured after incubation with carbon dioxide and additional incubation with the different agents. In the third experiment, prevention of intra- and extraperitoneal metastases by intraperitoneal instillation of the different agents during laparoscopy was investigated in a colon carcinoma model in the rat. Tumor cells were administered intraperitoneally in 100 rats, and pneumoperitoneum (8 mm Hg) was established over 30 min with carbon dioxide. Rats received either tumor cells, cells + heparin, cells + povidone iodine, cells + taurolidine, or cells + taurolidine + heparin. Results: In vitro, tumor cell growth decreased after incubation with taurolidine, taurolidine/heparin, and povidone iodine. Cytokine release was stimulated by incubation with carbon dioxide and could only be suppressed by incubation with taurolidine in vitro. In vivo, intraperitoneal tumor weight was lower in rats receiving heparin (251 ± 153 mg) and povidone iodine (134 ± 117 mg) compared to the control group (541 ± 291 mg), but even less when taurolidine (79 ± 82 mg) or taurolidine/heparin (18.3 ± 30 mg) were instilled. Conclusion: Heparin slightly inhibits intraperitoneal tumor growth in vivo, while povidone iodine and taurolidine cause a significant decrease in tumor cell growth in vitro as well as intraperitoneal tumor growth in vivo. Cytokine release of peritoneal macrophages is only suppressed by taurolidine. Total tumor take and trocar metastases are only suppressed by taurolidine and taurolidine/heparin.

Background: The pathogenesis of port site recurrences after laparoscopic surgery for malignant disease is still unknown. Whether different gases used to establish pneumoperitoneum have an influence on immunologic function and therefore on promotion of tumor growth has not yet been investigated. Methods: Tumor growth of colon adenocarcinoma DHD/K12/TRb was evaluated in a rat model after insufflation either with CO2 (n = 25) or helium (n = 25) and in a control group (n = 25). Tumor growth was measured subcutaneously and intraperitoneally 5 weeks after insufflation. Beside tumor growth, immunologic changes (peripheral leukocyte subpopulations, plasma levels of TNFα and IL-10) were evaluated during the perioperative course in all animals. Results: Subcutaneous tumor growth was promoted by the CO2 (99 ± 55 mg; p < 0.01) compared to the helium (40 ± 41 mg) and control groups (36 ± 33 mg). Total intraperitoneal tumor weight was 718 ± 690 mg in the CO2 group compared to the helium (549 ± 233 mg) and control groups (521 ± 221 mg). While peripheral leukocyte subpopulations only differed between the laparoscopic groups and the control group during the perioperative course, TNFα plasma levels were significantly decreased and IL-10 plasma levels significantly increased in the CO2 group compared to the helium and control groups in the postoperative course. Conclusion: The insufflation of CO2 promotes tumor growth compared to the helium and control groups in a rat model. In addition, increased tumor growth was associated with a significant increase in IL-10 and a decrease in TNFα plasma levels.

To study the influence of laparotomy and laparoscopy on local and systemic inflammation in a rat model of peritonitis.Bacteremia, peripheral leukocyte subpopulations, tumor necrosis factor alpha (TNF-alpha) plasma levels, and ex vivo secretion of peripheral blood mononuclear cells were investigated after laparotomy and laparoscopy in a prospective randomized experimental study.Surgical department of a university hospital.60 male inbred Wistar rats.Standardized fecal inoculum was injected intraperitoneally and rats underwent laparotomy (n=20), laparoscopy (n=20), or no further manipulation (control group, n=20). Blood samples were obtained during the perioperative course to determine bacteremia, leukocytic subpopulations, TNF-alpha plasma levels, and ex vivo secretion. The number of intraperitoneal abscesses was determined in each animal after 1 week.The hypothesis of the experiment was that laparoscopy with carbon dioxide leads to an increase of local and systemic inflammation in comparison with the laparotomy and control groups.One hour after intervention, bacteremia was significantly higher in the laparotomy and laparoscopy groups compared with the control group (P=.01). Fecal inoculum caused significant monocytopenia and lymphocytopenia in all groups within 1 hour after intervention (P.05), with complete recovery on day 2 only in the laparoscopy and control groups. Laparotomy caused a significant increase in TNF-alpha plasma levels and decrease of ex vivo production of TNF-alpha compared with the other 2 groups (P.05).Laparotomy and laparoscopy increased the incidence of bacteremia and systemic inflammation in this peritonitis model. The inflammatory response was significantly higher in the laparotomy group compared with the laparoscopy group.

In einer experimentellen Untersuchung an Sprague-Dawley-Ratten wurden die Auswirkungen von parenteral zugefuhrten LCT-Fetten auf das Tumorwachstum des Yoshida-Sarkoms in seiner Aszites form uberpruft. Dabei wurden 4 Gruppen mit je 10 tumortragenden (TTR) and 10 nicht tumortragenden Ratten (NTTR) gebildet, denen parenteral LCT-Fette in unterschiedlicher Dosierung (Gruppe 1–3) zugefuhrt, bzw. die enteral ad libitum ernahrt wurden (Gruppe 4). Es zeigt sich, das die tumortragenden Ratten (TTR) cine hohere Stickstoffretention aufwiesen, als die nicht tumortragenden Ratten (NTTR). Dabei fiel auf, das die NTTR einen hoheren Stickstoffgehalt in der Muskulatur hatten. Der Stickstoffanteil nahm dabei mit zunehmendem Fettanteil ab. Die Betrachtung des Sarkoms ergab, das sich sowohl der Stickstoffgehalt des Aszites, wie auch die Menge and die Zellzahl des Tumors umgekehrt proportional zur Menge des parenteral zugefuhrten Fettes verhielt. Fur den Wirt konnten wir zeigen, das er die zugefuhrten Energiemengen nicht unmittelbar fur sich verwerten konnte. Der Tumor wachst nicht proportional mit der ihm zugefuhrten Energie, sondern mus sich vom Katabolismus des Wirtes ernahren.

Die Prognose der Oesophagusperforation ist abhangig von der Ursache und Lokalisation, sie wird jedoch hauptsachlich durch das Zeitintervall zwischen Verletzung und Therapiebeginn bestimmt. Spontane und intraoperative Speiserohrenverletzungen sind am gefahrlichsten. Therapie der Wahl ist die direkte Naht mit Drainage des Wundgebietes. Falls das nicht moglich ist, sollte eine Oesophagektomie oder die collare Oesophagusausleitung bedacht werden. Die Verletzung kann sich mit sehr unspezifischen Symptomen prasentieren, pathologische Befunde auf der Thoraxubersichtsaufnahme oder der Kontrastmittelaustritt bei der intraluminaren Darstellung mit Gastrographin bestatigen die Diagnose jedoch in fast allen Fallen.

Die Mangelernährung ist eine quantitiv erfaβbare Gröβe, die das Ergebnis einer Karzinomoperation negativ beeinflussen kann. Durch eine geeignete präoperative Ernährungstherapie kann der Ausgangszustand von Karzinompatienten verbessert werden. Dies führt insbesondere bei ausgedehnten Eingriffen am oberen Gastrointestinaltrakt zu einer signifikanten Senkung der postoperativen Morbidität und Mortalität. Der Wert der postoperativen Ernährungstherapie kann im Tierexperiment durch forcierte Ernährung stimuliert werden, im klinischchirurgischen Bereich dürfte dem jedoch keine wesentliche Bedeutung zukommen.

The probability of recurrence was determined in 58 patients after intestinal resection for Crohn's disease using the statistical method of death tables. Within the first 10 years after resection a recurrence must be expected in 84.1% of patients. In 41.6% of cases a second resection becomes necessary. Age, sex, and disease duration preoperatively had no influence on the recurrence. Curative treatment of Crohn's disease is not possible by surgery and the indication for operation should thus be limited primarily to life-threatening complications.

The effect of total parenteral nutrition (TPN) as sole therapy was studied in 30 consecutive cases of complicated Crohn's disease. After insertion of a Broviac-type central venous catheter patients were nourished parenterally for 3 weeks in the hospital and then for an additional 9 weeks at home. During this time no medication or oral intake was allowed. Surgery was avoided in 25 patients by TPN. These patients returned to work, ate normal meals and needed no medical support. In 5 cases it was not possible to control the acute disease and the patients were treated by resection. During TPN, catheter-related sepsis occurred in 3 patients (0·9 cases/1000 days TPN) and catheter embolism in 2. Four other patients developed intrahepatic cholestasis. A relapse of Crohn's disease was observed in 17 cases 3–48 months after the course of TPN. The cumulative recurrence rate is 60 per cent after 2 years and 85 per cent after 4 years. Compared with the results of resection, obtained from a 10-year period before TPN was instituted at our hospital, the cumulative recurrence rate after TPN is four times higher. It is concluded that TPN is not an alternative to resection in the treatment of Crohn's disease and should be reserved for patients with multifocal lesions, when surgery is not advisable because of the risk of a short bowel syndrome.

Die Mangelernahrung bei Tumorpatienten kann als auslosender Faktor von Morbiditat and Mortalitat angesehen werden. Eine entgegensteuernde Ernahrungstherapie steigert das Wohlbefmden des Patienten, es kann aber auch den Tumor zu einem Wachstumsschub anregen. Unsere Studie bestatigt die Induktion des Tumorwachstums nicht. Die Grose des Tumors war um so kleiner und kompakter, je groser das Energie- and Nahrstoffangebot ist. Die Stickstoffretention im Malignomtrager nimmt mit sinkendem Energie und Nahrstoffangebot zu. Deshalb kann vermutet werden, das das Malignom seinen Energie- and Nahrstoffbedarf aus dem Katabolismus des Wirtes bezieht and nicht aus exogen angebotenen Energie und Nahrstofftragern. Vergessen werden durfen dabei nicht die Besonderheiten des Tiermodells.

Rubber band ligation, first described by Blaisdell, is an effective way of treating internal haemorrhoids. Treatment is ambulatory, thus saving time and costs. Experiences with 72 patients show this method to be superior to injection therapy and haemorrhoidectomy because of the simplicity of technique, the short period of treatment and the minimal discomfort for the patients. In our opinion rubber band ligation is the treatment of choice in managing internal haemorrhoids.

Es wurde ein Modell zur parenteralen Ernährung der nicht fixierten oder sedierten Ratte, basierend auf einfachsten technischen Hilfsmitteln und auf Nährlösungen, wie sie in jeder Klinik greifbar sind, erarbeitet. Die durchschnittliche Überlebenszeit beträgt 6–8 Wochen. Die Ratten nehmen unter der parenteralen Ernährung an Gewicht zu und sind in einem guten gesundheitlichen Zustand. Die kumulative Stickstoffbilanz ist bei einer medianen Retention von 95 % der zugeführten Menge hoch positiv.