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Die durchgreifende Okonomisierung des Deutschen Gesundheitssystems hat zu einem steigenden Kostenbewusstsein gefuhrt. Unter diesem Trend ist auch die arztliche Weiterbildung als moglicher Preistreiber identifiziert worden. Die theoretische und praktische Schulung von Jungarzten kostet Zeit und Geld. Doch eine detaillierte Kostenanalyse fehlt, denn der komplexe arztliche Alltag der Berufsanfanger lasst nur Einzelbetrachtungen zu. Berechnungen aus den USA beziffern die Kosten fur jeden Weiterbildungsassistenten mit 80 000 US$ pro Jahr. Gegenwartig wird in Deutschland die Weiterbildung indirekt uber die DRG-Fallpauschalen durch die Krankenkassen mitfinanziert. Mogliche Alternativen sind die Einfuhrung eines „Weiterbildungsfonds“, der uber eine prozentuale Abgabe der DRG’s und ein staatliches Zusatzentgelt finanziert wird. Ein solcher „Weiterbildungsfond“ unterstutzt nur die Kliniken, die ihren Berufsanfangern eine strukturierte und zertifizierte Weiterbildung anbieten konnen. Fur die weitere Diskussion ist jedoch primar eine detaillierte Kostenanalyse eines solchen strukturierten Curriculums notwendig.

BACKGROUND: Despite improved surgical techniques, anastomotic leakage is still a serious complication in colorectal surgery, resulting in increased morbidity and mortality. This study was initiated to investigate those clinical risk factors which may influence the onset of anastomotic wound-healing complications. METHODS: The postoperative courses were assessed in 400 consecutive patients who underwent colonic or rectal resection. Possible clinical risk factors were investigated by unvariate and multivariate analysis. RESULTS: 23 patients developed an anastomotic leakage (5.8 %). 10 patients could be treated conservatively, 13 had a second operation. In the multivariate analysis significant risk factors were perioperative radiotherapy (OR = 3.76 [95 % CI 1.03-13.7]), blood transfusion (OR = 2.98 [95 % CI 1.18-7.54]), alcohol consumption (OR = 2.94 [95 % CI 1.06-8.17]), and steroid medication (OR = 3.91 [95 % CI 1.17-13.07]). CONCLUSION: The clinically most important risk factors for leakage were radiotherapy and blood transfusion. Further analyses with a focus on the extracellular matrix, including other clinical factors may be valuable in identifying targets for improvement.

Isolated edematous swelling of Bauhin's valve is a rare finding in cases of non-specific abdominal complaints in the lower right abdominal quadrant. The differential diagnosis includes entities such as tumours, chronic gastrointestinal inflammation and ileocoecal intussusception as well as specific infections, all of which require individual therapy. Based on two current cases and a review of the literature, aetiology, clinical picture and diagnostic findings of isolated edema of the ileocoecal valve are described. The typical ultrasound findings are presented. Due to its potential of excluding other diseases, modern ultrasound offers promising results in the case of isolated edematous swelling of Bauhin's valve.

HISTORY AND ADMISSION FINDINGS A 21-year-old woman presented with predominantly right-sided cramp-like abdominal pain which had started the previous day. The abdomen was soft on palpation, the peristaltic sounds increased. Body temperature was normal. INVESTIGATIONS Routine laboratory tests were unremarkable, including white cell count (4.5 G/l). and C-reactive protein. TREATMENT AND COURSE She was admitted to hospital for observation. Because the symptoms persisted she underwent a right lower laparotomy because acute appendicitis was suspected. Intraperitoneal examination of the intestines revealed a soft, sponge-like foreign body just above the ileocecal valve. The overlying ileum was incised and a sponge removed. Postoperatively the patient reported having taken 4 capsules of CM3, a weight-reducing preparation, about 14 days ago. These capsules dissolve in the stomach and each releases a small sponge which expands and mechanically induces a feeling of satiation. The further course was unremarkable and she was discharged on the 8th postoperative day. CONCLUSION When producing weight-reducing preparations that act according to physico-mechanical principles, anatomical circumstances should be considered, and they should only be taken under medical supervision.

In order to reduce the high frequency of bowel movement after resection of the rectum in cases of rectal cancer, the creation of a colonic J-pouch was developed. Meanwhile this operation is well established. As a variation to the standard technique, von Flue introduced in 1994 the interposition of an ileocecal segment, intended to improve the reservoir function via its own distensibility. Despite the conserved neural and vascular integrity of the ileocecal segment, major complications arise such as pouchitis with necrosis. In these cases, resection of the pouch and permanent discontinuity of stool passage is routine therapy. Patients with permanent stoma face many difficulties both physical and psychological, and often the quality of life diminishes. In the literature there is no detailed case of colonic J-pouch reconstruction following resection of an insufficient ileocecal pouch. This operation is technically highly demanding but feasible.

The definitive closure of the abdominal wall may not be favorable in the treatment of several surgical conditions. Then the temporary closure of the abdominal wall with creation of a laparostomy is necessary. Indications for a laparostomy are planned re-explorations of the abdominal cavity, abdominal wall defects, severe abdominal infections or the onset of an abdominal compartment syndrome.