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Hintergrund: Die diffuse Peritonitis ist ungeachtet moderner chirurgischer und intensivmedizinischer Therapieverfahren eine Erkrankung mit hoher Morbiditat und Mortalitat. Ziel dieser Arbeit war es, im eigenen Krankengut den Stellenwert der Relaparotomie „on demand“ (ROD) bei Patienten mit diffuser Peritonitis kritisch zu evaluieren. Patienten und Ergebnisse: In einer retrospektiven Untersuchung wurden die Therapieverlaufe von 231 Patienten mit diffuser Peritonitis analysiert. Diese wiesen einen durchschnittlichen Mannheimer Peritonitis-Index (MPI) von 25,3 auf. Die Gesamtletalitat im untersuchten Kollektiv betrug 14,3 %. Bei 214 Patienten gelang wahrend der Indexoperation eine suffiziente Fokussanierung, sodass diese im Rahmen des ROD-Konzepts weiterbehandelt wurden. Bei 178 dieser Patienten bestand keine Notwendigkeit einer Reoperation, wahrend 36 dieser Patienten im weiteren Verlauf relaparotomiert wurden. Die Letalitat dieser beiden Subgruppen betrug 9 % (keine Relaparotomie) bzw. 27 % (Relaparotomie). Schlussfolgerung: Anhand des untersuchten Kollektivs zeigt sich, dass das Konzept der Relaparotomie „on demand“ nach effektiver Herdsanierung und entsprechender suffizienter Lavage im klinischen Alltag sinnvoll und praktikabel ist. Allerdings besteht weiterhin die dringliche Notwendigkeit, Parameter zu identifizieren, welche die Selektion von Patienten zur Relaparotomie vereinfachen.

Background Recent studies give rise to the hypothesis, that adjuvant chemoradioimmunotherapy with 5-fluorouracil (5-FU), cisplatin and interferon-α (IFN-α) might be a possible new treatment of pancreatic cancer in resected patients. We report the up-to-now experience at our institution. Patients and methods Eleven patients with histological diagnosis of localized carcinoma of the pancreas ( n = 7) or periampullary ( n = 4) were prospectively analyzed. Four patients were deemed unresectable because of local invasion of adjacent organs (neoadjuvant setting) and seven patients underwent curative resection (adjuvant setting). Eight patients were classified as T3 carcinomas and three T4 carcinomas. Fifty-five per cent (6/11) of the patients presented with positive lymph node involvement. One histological Grade I, six Grade II and three Grade III were detected. External conformal irradiation to a total dose of 50.4 Gy with 1.8 Gy per day was delivered. All patients received a concomitant chemotherapy with continuous 5-FU 200 mg/m 2 per day on 28 treatment days and intravenous bolus cisplatin 30 mg/m 2 per week (Day 2, 9, 16, 23, 30). A recombinant r-IFN-α was administered on three days weekly during Week one to five of the radiotherapy course as subcutanous injections with 3*3 Mio. I.U. weekly. Results The four-year overall survival rate for all patients was 55%. In the neoadjuvant group, three of four patients died due to progressive disease; in the adjuvant group, combined chemoradioimmunotherapy lead to controlled disease in five of seven patients. The overall toxicity was well-managed. Conclusion Our data strengthens the hypothesis of concomitant chemoradioimmunotherapy with 5-FU, IFN-α and cisplatin as a possible new treatment of pancreatic cancer in resected patients.

Isolated tumor cells (ITCs) in cancer patients are retrieved mostly using immunohistochemistry with antibodies directed against antiepithelial antigens (for example Ber-EP4), which are supposed not to be present in metastatic-free tissue. To date, there has been ongoing controversy whether those cells have biologic significance and are linked with tumor progression and impaired patient’s prognosis. Therefore, the aim of this study was to further characterize Ber-EP4-positive cells in various tissues, with special emphasis on their tumorigenic origin. The frequency and prognostic impact of ITCs in lymph nodes displayed by means of monoclonal antibody Ber-EP4 were evaluated in retrospective (n = 292) and prospective (n = 100) collectives of various gastrointestinal carcinomas free of metastatic disease in conventional histopathology (pN0). Furthermore, the frequency of ITCs in the peritoneal cavity and bone marrow was analyzed in case of absence of overt distant metastasis (pM0) in the prospective collective. Ber-EP4-immunoreactive cells were further characterized for tumorigenic origin using morphological criteria and immunohistochemical double staining for Ber-EP4 and p53. Ber-EP4-positive cells could be revealed in lymph nodes in 44.3% of pN0-gastrointestinal carcinomas, in the peritoneal cavity in 19%, and in the bone marrow in 10%. In lymph nodes, BerEP4-immunoreactive cells exhibited a metastatic-atypical morphology in 59%; however, it was always typical for true tumor cells in the peritoneal cavity or bone marrow. The cumulative 5-year survival rate was adversely affected by Ber-EP4-immunoreactive cells in uni- and multivariate analysis, irrespective of the underlying cell morphology (68% for Ber-EP4 negative, 41% for Ber-EP4 positive with atypical and typical morphology each). In the case of a p53-positive primary tumor, 70% of the corresponding ITCs also overexpressed p53, while the remainder was deemed p53 negative (p = 0.002). ITCs detected by the antiepithelial antibody Ber-EP4 are present in a substantial proportion of apparently tumor-free lymph nodes. These cells impair patients’ prognoses, irrespective of the underlying cell morphology. As approximately one third of Ber-EP4-positive cells in p53-positive primary tumors do not overexpress p53; their true tumorigenic origin needs to be further investigated.

Ziel der Untersuchung war es, die relative Haufigkeit und prognostische Relevanz von okkulten Tumorzellen in lokoregionaren Lymphknoten des Pankreaskarzinoms zu bestimmen. Von 115 Patienten mit einem Adenokarzinom des Pankreas (n=84), einem Papillenkarzinom (n=19) oder einem distalen Choledochuskarzinom (n=12) waren 48 Patienten (42%) nodal-negativ (pN0). Hier wurden bei 41 pN0-Patienten insgesamt 271 LK retrospektiv mithilfe des antiepithelialen monoklonalen Antikorpers Ber-EP4 auf okkulte Tumorzellen hin untersucht. Bei 16 der untersuchten 41 pN0-Patienten konnten Ber-EP4-immunoreaktive Zellen entsprechend einer okkulten Tumorzelldissemination in Lymphknoten gesichert werden (39%). Das Auftreten einer okkulten Tumorzelldisseminierung war unabhangig von gangigen Prognosefaktoren wie Tiefeninfiltration pT3/pT4, Differenzierungsgrad G3 und G4 oder nicht kurativer Resektion (jeweils p>0,05). Allerdings war eine okkulte Tumorzelldisseminierung bei Choledochuskarzinomen (100%) signifikant haufiger als bei Papillenkarzinomen (20%) oder Adenokarzinomen (36%; p=0,009). Okkulte Tumorzellen schrankten die Patientenprognose sowohl in einer uni- als auch in einer multivariaten Analyse signifikant ein (5-Jahres-Uberlebensrate 53% fur pN0(i−), 10% fur pN0(i+) und 9% fur pN1/N2; p=0.0047). Bei etwa einem Drittel aller nodal-negativen Pankreaskarzinompatienten lasst sich zum Zeitpunkt der Resektion eine okkulte Tumorzelldissemination nachweisen, die prognostisch einer lymphogenen Makrometastasierung entspricht und die neben der Radikalitat der Resektion einen unabhangigen Prognosefaktor darstellt. Eine klinische Konsequenz konnte sich hieraus mit Verfugbarkeit wirksamer Adjuvantstherapien ergeben.

Adenocarcinomas of the pancreatic gland are the fifth leading cause of cancer death in the USA and western Europe with a 5-year survival rate of less than 5% and a median survival of less than 6 months [76]. They bear histological resemblance to the pancreatic ducts and are referred to as pancreatic ductal adenocarcinoma [5,34,53]. Due to the late occurrence of symptoms and the high metastatic potential, pancreatic adenocarcinomas have a dismal prognosis. Since the pancreaticoduodenectomy, a surgical resection that includes the pancreatic head, the duodenum, common bile duct and the gallbladder was introduced in 1912 by Kausch, surgery still remains the primary curative treatment. However, the 5-year survival for patients undergoing resection, is only about 20% [76] and about 80% of all cancers are unresectable at the time of diagnosis [2]. In order to improve the clinical management of cancer patients, it is mandatory to understand the genetic basis of pancreatic cancers. This review describes the histological progression of pancreatic adenocarcinomas and summarizes the underlying chromosomal and genetic alterations.

To determine the frequency and prognostic impact of isolated tumor cells (ITC) in regional lymph nodes judged to be tumor free in conventional histopathology among gastric cancer patients.Among 161 patients who underwent gastrectomy and D2-lymphadenectomy, 56 were staged pN0(35%). Archival paraffin blocks of 1148 resected regional lymph nodes of those pN0 patients were reevaluated for ITC using monoclonal antibody Ber-EP4. Patients with and without ITC were compared with regard to the distribution of various clinicopathological factors. Prognostic impact of ITC was tested in uni- and multivariate analysis.Of 56 pN0 patients, 33 (59%) exhibited single Ber-Ep4 immunoreactive cells or small cell clusters in at least one lymph node. The occurrence of ITC was not dependent on other clinicopathological factors. ITC impaired patients' prognoses significantly in uni- as well as multivariate analyses [estimated 5-year survival rate: 82% for pN0((i-))vs 58% for pN0((i+))(p = 0.059) and 15% for pN1/2 (p = 0.0005 and p0.0001, respectively)].ITC are a frequent event in apparently tumor-free lymph nodes of gastric cancer patients and are overlooked by conventional histopathology. They are encountered even in limited stages of disease and impair patients' prognoses. This should be borne in mind when advocating local resection for early gastric cancer.

Per Simulation von Operationstechniken haben Weiterbildungskurse in der Viszeralchirurgie zum Ziel, Naht-, Resektions- und Rekonstruktionstechniken am Gastrointestinaltrakt zu vermitteln. Vor, nach und 5 Jahre nach erstmaligem Stattfinden des Weiterbildungskurses fur gastrointestinale Chirurgie in Norderstedt wurde eine Befragung der Teilnehmer hinsichtlich der Ausbildungssituation, des Lernerfolges und der Umsetzung des Erlernten in der eigenen Klinik durchgefuhrt. Wahrend bei gut 1/3 der Teilnehmer die Ausbildungssituation als unzureichend beschrieben wird, ist die Zufriedenheit mit diesem Kurs mit 94% sehr hoch: 27% der Teilnehmer trauten sich nach dem Kurs zu, selbststandig eine Anastomose zu nahen. Grunde fur die Ablehnung neuer Techniken waren in nur 7% bei den Teilnehmern selbst zu finden, in 41% konnten die Vorgesetzten nicht uberzeugt werden. Mehr noch als die Vermittlung neuer Techniken liegt die Bedeutung eines solchen Kurses in der Ubung von Fahigkeiten, die im Operationssaal aus verschiedenen Grunden zu kurz kommen.

Einleitung: Herkommliche szintigraphische Techniken bei der Blutungsquellensuche benutzen in der Regel eine statische Akquisition und erfolgen selten kontinuierlich uber einen langeren Zeitraum. Ziel der Studie war es, die diagnostische Genauigkeit einer dynamischen und uber Stunden kontinuierlichen Blutungsquellenszintigraphie (BQS) mit 99 mTc-markierten autologen Erythrocyten bei der Abklarung ungeklarter gastrointestinaler Blutungen zu evaluieren. Methoden: Wir untersuchten 40 Patienten (mittleres Alter: 57 Jahre) mit trotz ausfuhrlicher Diagnostik unklarer gastrointestinaler Blutung. Transfusionspflichtig waren 16 Patienten. Die Akquisition erfolgte dynamisch und kontinuierlich bis zu 6 Std p. i. . Die Auswertung erfolgte in Unkenntnis der endgultigen Diagnose unter Verwendung einer cinematographischen Darstellung. Ergebnisse: Die dynamische BQS war bei 23 Patienten positiv und identifizierte bei 22 Patienten korrekt den Ausgangsort der Blutung. Die Sensitivitat und Spezifitat der Szintigraphie betrug 95 % und 94 %, der positive und negative pradiktive Wert lag bei 95 % und 94 %. 43 % der Szintigraphien wurden innerhalb von 1,5 Std und 82 % innerhalb von 5 Std positiv. Transfusionspflichtige Patienten zeigten im Vergleich mit nichttransfusionspflichtigen Patienten haufiger (16 vs 7 Patienten) und fruher (im Mittel 2,83 vs 5,28 Std p. i.) einen positiven Befund. Die szintigraphische Blutungslokalisation ermoglichte sowohl im Dick- als auch im distalen Dunndarmbereich ein limitiertes und befundadaptiertes chirurgisches Vorgehen. Bei einer proximalen Dunndarmblutung war die exakte Lokalisation der Blutungsquelle szintigraphisch hingegen nicht moglich. Schlusfolgerungen: Die BQS mit 99 mTc-markierten autologen Erythrocyten, die uber einen ausreichend langen Zeitraum erfolgt, und eine Befundung im Cine-mode-Verfahren weisen eine hohe diagnostische Richtigkeit bei der Abklarung einer unklaren gastrointestinalen Blutung auf. Die Szintigraphie ermoglicht durch eine hinreichend genaue Lokalisationsangabe ein selektiveres und sicheres therapeutisches Vorgehen.

Das Vicrylnetz-Wrapping stellt eine wenig verbreitete, jedoch akzeptierte Alternative zum konventionellen „Bauchtuch-Packing“ des schweren Lebertraumas dar. Bei gesicherten Vorteilen fehlt bisher die Beschreibung von verfahrensspezifischen Komplikationen. Hier wird der Fall einer polytraumatisierten Patientin mit schwerem Lebertrauma dargestellt, bei der sich nach Vicrylnetz-Wrapping beider Leberlappen zweitzeitig eine Leberischamie eingestellt hat, die durch ein progredientes posttraumatisches Odem einerseits und die Kompression der Leber durch die Vicrylnetze andererseits bedingt war. Eine engmaschige Kontrolle der Serumtransaminasen, insbesondere nach beidseitigem Vicrylnetz-Wrapping, ist daher zwingend, um diese Komplikation durch eine umgehende Relaparotomie zu beherrschen.

Leakage from a cervical esophagogastric anastomosis still accounts for major morbidity and mortality after subtotal esophageal resection. Its prevalence might adversely be affected by drainage of the

A single centre study was conducted to examine the frequency of cholecystectomies, both open and laparoscopic, up to 2 years prior to the diagnosis of pancreatic cancer. In particular, it was of interest to investigate whether there is a diagnostic delay in a significant number of pancreatic cancer patients and if these patients already have symptoms or findings at the time of cholecystectomy that might have been indicative of the underlying malignant disease.It is demonstrated that 17 out of 186 pancreatic cancer patients (9%) underwent a cholecystectomy within the 2 years prior to cancer diagnosis.A significant number of these patients showed a considerable weight loss at the time of the cholecystectomy. It is hypothesized that symptoms which led to cholecystectomies in these patients were most likely related to the pancreatic cancer. Owing to the resulting delay of pancreatic cancer diagnosis the resection rate with curative intent decreases to 35% from 44% in the whole series.Patients suffering from cholecystolithiasis and showing atypical symptoms or other notable findings such as considerable weight loss might be assessed in more detail pre- as well as postoperatively in order to minimize the diagnostic delay in pancreatic cancer and to avoid unnecessary operations.

INTRODUCTION:: The clinical impact of sentinel lymph node biopsy (SLNB) in colon cancer is still controversial. The purpose of this prospective multicenter trial was to evaluate its clinical value to predict the nodal status and identify factors that influence these results. METHODS:: Colon cancer patients without prior colorectal surgery or irradiation were eligible. The sentinel lymph node (SLN) was identified intraoperatively by subserosal blue dye injection around the tumor. The SLN underwent step sections and immunohistochemistry (IHC), if classified free of metastases after routine hematoxylin and eosin examination. RESULTS:: At least one SLN (median, n = 2) was identified in 268 of 315 enrolled patients (detection rate, 85%). Center experience, lymphovascular invasion, body mass index (BMI), and learning curve were positively associated with the detection rate. The false-negative rate to identify pN+ patients by SLNB was 46% (38 of 82). BMI showed a significant association to the false-negative rate (P 22 patients enrolled), the sensitivity increased to 88% (14 of 16). Moreover, 21% (30 of 141) of the patients, classified as pN0 by routine histopathology, revealed micrometastases or isolated tumor cells (MM/ITC) in the SLN. CONCLUSIONS:: The contribution of SLNB to conventional nodal staging of colon cancer patients is still unspecified. Technical problems have to be resolved before a definite conclusion can be drawn in this regard. However, SLNB identifies about one fourth of stage II patients to reveal MM/ITC in lymph nodes. Further studies must clarify the clinical impact of these findings in terms of prognosis and the indication of adjuvant therapy.

Background The aim of this study was to determine the accuracy of prediction of the surgeon's ‘gut-feeling’ in estimating postoperative outcome. Methods A prospective series of 1077 consecutive patients undergoing major hepatobiliary or gastrointestinal surgery were studied. Patients having elective (n = 827) and emergency (n = 250) procedures were included. The surgeon predicted the development of postoperative complications immediately after completion of surgery on a scale from 0 to 100 per cent. These predictions were compared with the actual outcome and with predictions made using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM). The Portsmouth predictor equation (P-POSSUM) was applied for the estimation of mortality. Results The observed morbidity and mortality rates were 29·5 and 3·4 per cent respectively. POSSUM predicted a morbidity rate of 46·4 per cent and P-POSSUM a mortality rate of 6·9 per cent. The surgeon's gut-feeling was more accurate in the prediction of morbidity at 32·1 per cent. On the basis of gut-feeling, surgeons overpredicted morbidity in elective surgery, but underestimated the risk of complications in the emergency setting. The (P)-POSSUM scoring system overpredicted morbidity and mortality for elective and emergency operations. Conclusion The surgeon's gut-feeling is a good predictor of postoperative outcome, especially after elective surgery. (P)-POSSUM overpredicted morbidity and mortality in this series of major gastrointestinal and hepatobiliary operations.

OBJECTIVES Delayed gastric emptying (DGE) has been specifically attributed to pylorus-preserving pancreaticoduodenectomy (PPPD). As PPPD has been shown to be comparable with the classic Kausch-Whipple pancreaticoduodenectomy (KWPD) in terms of oncological radicality, DGE has advanced to be the leading argument for hemigastrectomy in PD. METHODS A prospective, nonrandomized comparison of patients undergoing PPPD (n = 113), KWPD (n = 19), and duodenum-preserving, pancreatic head resection (DPPHR, n = 18) for various diseases was performed. First, groups were analyzed with regard to structural similarity; then, they were compared with special emphasis on DGE and other postoperative complications. Finally, further prognostic factors were sought that had an impact on DGE. RESULTS The PPPD group was comparable with the KWPD group, but not to the DPPHR population. The in-clinic course after DPPHR compared favorably with PPPD as well as KWPD, and, here, no DGE occurred. The overall morbidity rates of PPPD and KWPD were comparable; 1 patient died in hospital (mortality rate, 0.7%). The gastric tube after PPPD and KWPD could be withdrawn at a median of 2 and 3 days, respectively, a liquid diet was started after 4 and 5 days, respectively, and a full diet was tolerated after 10 days each (n.s.). DGE was distributed evenly among PPPD (12%) and KWPD patients (21%, n.s.), and it was noted almost exclusively when other postoperative complications were present (P < 0.0001). No further prognostic factors influencing DGE could be identified. CONCLUSION Pylorus preservation does not increase the frequency of DGE. DGE almost exclusively occurs as a consequence of other postoperative complications. Therefore, DGE should not be used as an argument to advocate hemigastrectomy in PPPD.

The aim of this study was to define the value of MRI of the pancreas for preoperative local staging of patients with a suspected pancreatic mass. Ninety-four patients (41 women, 53 men; age range 32-87 years) with a suspected pancreatic tumor underwent preoperative staging with MRI on a 1.5-T system. The MRI protocol included breath-hold MR cholangiopancreatography in turbo spin-echo technique, biphasic contrast-enhanced 3D MR angiography, and MRI of the upper abdomen with breath-hold T2-weighted half-Fourier acquired single-shot turbo spin-echo and T1-weighted fast-low-angle-shot (pre- and postcontrast) sequences. Data were collected prospectively and analyzed by two radiologists in agreement modality. Evaluation criteria were vascular involvement, resectability, and a characterization benign vs malignant. Results were compared to histopathology in 78 patients. Sixteen patients were followed-up. In 74 of 94 patients a solid tumor or an inflammation of the pancreas ( n=62) or the papilla ( n=12) was detected. In this group, MRI had a sensitivity of 98%, a specificity of 92%, and an accuracy of 96% in the characterization of malignant tumors. Regarding only the solid tumors, the positive predictive value of MRI was 87% with respect to resectability. Other pathologic findings included adenoma or inflammation of the duodenum ( n=5), carcinoma or benign stenosis of the choledochus duct ( n=7) and carcinoma of the gall bladder ( n=2). In 6 patients MRI did not depict any pathologic findings, and follow-up confirmed this interpretation. Magnetic resonance imaging allows a local preoperative staging in patients with suspected pancreatic tumor. Limitations, however, concern to the diagnostics of peritoneal and/or liver metastases.

Die laparoskopische Fundoplicatio ist das Verfahren der Wahl zur operativen Therapie der schweren Refluxerkrankung. Bei Anwendung des standardisierten Operationsverfahrens der 360°-„floppy“-Fundoplicatio last sich nicht nur ein dauerhafter Therapieerfolg erzielen, sondern es kommt auch zu einer statistisch signifikanten Befindlichkeitsbesserung bei den Patienten, die mit Hilfe des Gastrointestinalen Lebensqualitatsindex (GLQI) gemessen werden kann

Background The most frequent complication following gastroenterostomy (GE) for gastric outlet obstruction is delayed gastric emptying (DGE), which occurs in roughly 20% of patients. There is evidence that DGE may be linked to the longitudinal incision of the jejunum and that a transverse incision (cross‐section GE) may decrease the incidence of DGE following GE. Patients and methods In contrast to the orthodox GE, the jejunum is severed transversely up to a margin of 1.5 cm at the mesenteric border and the anastomosis is created with a single running suture. A Braun anastomosis is added 20–30 cm distally to the GE. Patients were followed prospectively with special regard to the occurrence of DGE. Results Between 1 August 1994 and 1 August 1998, 25 patients underwent cross‐section GE, mostly because of an irresectable periampullary carcinoma. Eight patients exhibited clinical signs of gastric outlet obstruction preoperatively, while in 17 the GE was performed on a prophylactic basis. A biliary bypass was added in 15 patients. There was no disruption of the GE, but one patient died in hospital (4%). The nasogastric tube was withdrawn on the first postoperative day (range 0–6 days), a liquid diet was started on the fifth day (range 2–7 days) and a full regular diet was tolerated at a median of 9 days (6–14 days).The incidence of DGE was 4%: only the single patient who died fulfilled the formal criteria for DGE. Discussion In contrast to orthodox GE, DGE seems to be of minor clinical importance following cross‐section GE. As the technique is easy to perform, is free of specific complications and leads to a low incidence of DGE, it should be considered as an alternative to conventional GE.

Background: Ingestion of food has been shown to modulate the lower-oesophageal-sphincter pressure (LESP). Fat is especially effective in decreasing the postprandial LESP. As there is good evidence that neurotensin (NT) is able to decrease the LESP, we conducted the present trial to determine whether NT could possibly be a mediator of the fat-induced decrease of the LESP. Methods: Six half-breed dogs were fitted for cervical side-to-side oesophagostomy to allow repeated oesophageal intubation; plasma NT immunoactivity was recorded during infusion of NT and after intragastric instillation of 200 ml of a fat solution. Experiments were repeated, with the specific NT antibody GN25 administered intravenously. Results: The optimal dose of NT required to simulate a postprandial situation was 50 pmol/kg/h. Infusion of this NT dose led to a statistically significant decrease of the LESP. Simultaneous administration of the NT antibody (immunoneutralisation) significantly inhibited this effect. Intragastric fat decreased the LESP and increased plasma NT. Immunoneutralisation of endogenously released NT led to an earlier restoration of baseline LESP, but this effect was not statistically significant. Conclusions: NT and intragastric fat modulate the LESP. NT appears to mediate the postprandial, fat-induced decrease of the LESP. Research with specific NT-receptor antagonists is necessary to determine the exact role of NT and other regulatory peptides in this context.

Background: Delayed gastric emptying (DGE) is the most frequent postoperative complication after pylorus-preserving pancreaticoduodenectomy (PPPD). This prospective, non-randomized study was undertaken to determine whether the incidence of DGE may be reduced by modifying the original reconstructive anatomy with a retrocolic duodenojejunostomy towards an antecolic duodenojejunostomy. Patients and methods: The study was comprised of 51 patients who underwent PPPD between August 1994 and November 1997. The operation was carried out as originally described but was modified by performing the duodenojejunostomy antecolically. Clinical data were recorded prospectively, with special regard to DGE. Results: After PPPD, the nasogastric tube could be removed at a median of 2 days (range 1–22 days) postoperatively; in two patients, the nasogastric tube was reinserted because of vomiting and nausea. A liquid diet was started at a median of 5 days (3–11 days); the patients were able to tolerate a full, regular diet at a median of 10 days (7–28 days). The overall incidence of DGE was 12% (n=6). No postoperative complications other than DGE were exhibited by 36 patients (71%). In this group, DGE was only seen in one patient (3%). In the second group, where postoperative complications other than DGE occurred (n=15), five patients (30%) exhibited DGE (P=0.002). Conclusions: DGE after PPPD seems to be of minor clinical importance following uncomplicated surgery. When taking the results into consideration, it can be said that, despite the lack of a control group, antecolic duodenojejunostomy might be the key to a low incidence of DGE after PPPD. In our experience, DGE is linked to the occurrence of other postoperative complications rather than to pylorus preservation.

In der Literatur haben sich bisher die im TNM-System zusammengefaβten Parameter Tumorin-filtration (T-Kategorie), Lymphknotenbefall (N-Kategorie) und Metastasierung (M-Kategorie) als herausragende prognostische Faktoren beim Magenkarzinom etabliert. Um den Einflus weiterer Patientenfaktoren und Tumorcharakteristika auf die Prognose beurteilen zu konnen, wurden daher in der vorliegenden Arbeit 5 klinische und 13 pathologisch-anatomische Faktoren untersucht. 200 Patienten mit einem histologisch gesicherten Magenkarzinom wurden prolektiv und konsekutiv mittels eines speziell entworfenen, standardisierten EDV-gerechten Erhebungsbogens erfast. Die uni- und multivariate Analyse wurde in der Untergruppe der kurativ resezierten Patienten (R0, n = 108) durchgefuhrt. In der univariaten Analyse zeigten die Variablen Tumorgrose, Tumorlokalisation, T-Kategorie, N-Kategorie, Anzahl befallener Lymphknoten, Befall der Lymphknotenkompartimente, Stadieneinteilung und Quotient befallener/asservierter Lymphknoten einen statistisch signifikanten Einflus. Bei gleichzeitiger Berucksichtigung mehrerer Faktoren in der multivariaten Analyse konnte ein statistisch signifikanter Einflus nur fur die Faktoren Anzahl befallener Lymphknoten und Tumorgrose nachgewiesen werden. Unter Berucksichtigung der Ergebnisse in der Literatur erscheint das Ausmas des Lymphknotenbefalls mehr als jeder andere Faktor fur die Prognoseschatzung richtungweisend zu sein, wobei der Anzahl der befallenen Lymphknoten zusatzlich zur TNM-Klassifikation eine besondere Rolle zukommt.

“Surgical therapy still yields the best results in esophageal cancer!” Although the status of radio- and chemotherapy is still controversial, this quotation by Nakayama in 1979 [1] is still valid today.