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In the period from June 1994 to February 1997, a laparoscopic gastroenterostomy was carried out without intraoperative complications or mortality. In 12 out of 13 patients with gastric outlet obstruction due to inoperable tumor of the upper GI tract (gastric, gallbladder or pancreas carcinoma). From the above, a total of 4 patients had postoperative complications (30.7%), three of which could be treated without further operation. The average duration of the operation was 130 min (range 70-285 mins) followed by an approximal postoperative hospital stay of 17 days (8-41 days).

Hepatocellular carcinoma is one of the most common human cancers with an annual incidence of about 1,000,000 cases worldwide. Although hepatocellular carcinoma is predominant in hepatitis B virus endemic areas, it has also become a major problem in Europe, Japan and North America in close association with the increasing incidence of hepatitis C virus infection. The pathogenetic role of hepatitis C virus infection in the development of HBsAg-negative hepatocellular carcinoma needs to be clarified. In this paper the case of a 66-year-old HBsAg-negative and anti-HCV positive female who developed hepatocellular carcinoma in a cirrhotic liver is reported. After 1 year of follow up, urgent laparotomy had to be performed due to highly differentiated ovarian metastases of the hepatocellular carcinoma. Plus- and minus-stranded HCV-RNA was detected by reverse transcription and "nested" polymerase chain reaction in both the patient's serum and in the metastatic ovarian tissue.

Jejunogastric intussusception is a rare complication after gastric surgery and when its diagnosis is delayed a high mortality rate can be expected. This paper reports on the characteristic findings of this entity at ultrasound and CT examination. Both diagnostic procedures have a high sensitivity. Sonography is the method of first choice because the diagnosis can be made with a high grade of certainty. CT allows the differentiation of the distinct stages of the disease and the views given by CT are often more easily accepted by the surgeons.

We present a patient with an ACTH producing neuroendocrine tumor of the hepatic bile duct which was detected by chance during abdominal surgery for Cushing's syndrome. Diagnostic strategy and surgical therapy in patients with neuroendocrine tumors are discussed. The diagnostic problems caused by combination with an endocrine function disorder like Cushing's syndrome are pointed out.

The case of a 71-year-old man with a primary hepatocellular carcinoma in a non-cirrhotic liver is reported. There were no risk factors of hepatocellular carcinoma (HCC)-like liver cirrhosis, alcohol drinking, tobacco smoking, exposure to vinyl chloride, thorotrast, aflatoxin or alpha 1-antitrypsin deficiency. Serologically, the patient was positive for antibodies to the hepatitis B virus (anti-HBc, anti-HBs) and for anti-hepatitis C virus (HCV) antibodies. Virologically, positive and negative strands of HCV RNA could be detected in the patient's serum and tumorous liver tissue by reverse transcription polymerase chain reaction as a sign of persistent HCV replication. Histologically, the HCC was completely surrounded by liver tissue which showed the signs of nodular regenerative hyperplasia. Indeed, the mechanism of hepatocarcinogenesis remains to be clarified. However, this case supports the observation that HCC may also develop in patients with HCV infection without preexisting liver cirrhosis.

Venous aneurysms are rare: only 311 cases of venous aneurysms and 56 cases of aneurysms in vein transplants have been reported since 1939 to date. 62% of the patients suffering from venous aneurysms were less than 40 years of age. The most frequently involved vessels were the internal jugular vein (n = 56), the portal vein (n = 28), the v. saphena magna (n = 30) the popliteal vein (n = 23), the azygos vein (n = 22) and the vena cava superior (n = 20). The diameters of the aneurysms were between 1 and 16 cm. Symptoms, if at all noticeable, depend on the localisation of the aneurysm, but they are unspecific in the majority of cases. The most frequent finding was the space- occupying growth seen in 190 patients (52%). Pulmonary embolisms originating from venous aneurysms were seen in 19/311 (6.1%), a rupture of an aneurysm in 4/311 (1.2%) of the venous aneurysms and 5/56 (8.9%) of the aneurysms in transplant veins, respectively. and were fatal in 1 (0.3%) and 2 (3.6%) of the cases, respectively. Of the 205 patients who were operated on, 3 (1.5%) died from intraoperative complications.

301 patients, operated for Crohn's disease in a ten-year period (1980-1989) were analyzed retrospectively, regarding perioperative risk of bowel resection (n = 336). The overall mortality rate was 0.6% (elective 0, emergency 6%). The reasons of this low mortality rate are of different nature. Very important is a meticulous perioperative treatment and a standardized operative approach.

The manifestation of Crohn's disease with perforation in pregnancy has been described in one case only. In our case, a 25-year-old woman in the 28th week of pregnancy was admitted to our hospital with signs of an acute abdomen. Due to deterioration of the maternal and foetal situation, the child was delivered by a Caesarean section. Subsequently, exploration of the abdomen showed an ileum perforation with diffuse fibrinous peritonitis. In this case, the definitive diagnosis could not be made prior to laparotomy. The aim of surgical therapy in such cases should be the limited resection with end to end anastomosis. In diffuse peritonitis, discontinuous resection and secondary reconstruction after three to six months is preferred.

An inquiry concerning bleeding of esophageal varices included 1076 surgical and medical departments in the Federal Republic of Germany (West). Prevailing forms of treatment are acute sclerotherapy or esophageal balloon tamponade followed by long-term sclerotherapy. In case of medically uncontrollable bleeding oesophagogastric devascularization procedures are preferred to portacaval shunt. Beta-blockers are applied in medical departments for the prophylaxis of recurrence. Only after several rebleedings, despite of sclerotherapy, approx. half of the departments consider an elective shunt. The distal splenorenal shunt described by Warren and portacaval anastomosis clearly prevail over all other shunts.

During the past few years pancreatic pseudocysts have been seen more frequently. Between 1.1. 1978 and 31.12. 1987 145 patients with pancreatic pseudocysts were operated at the Surgical Clinic of Mainz University. In 93 cases internal drainage was performed with a morbidity of 11.8% and a lethality of 1.1%. External drainage and pancreas resection had a lethality of 6.5% resp. 4.7%. After a mean follow-up of 7.3 years patients with non-resection therapy had a better endocrine function but a worse pain relief than those with pancreas resection. Pseudocyst recurrences developed after internal drainage in 9.3. after external drainage in 55.5% and after resection therapy in 1 of 5 cases. Cystojejunostomy within Y-Roux-anastomosis is therefore a safe method with good long-term results for the treatment of pancreatic pseudocysts.

From March 1980 to December 1981 partial duodenopancreatectomy and occlusion of the pancreatic duct of the remaining tail of the pancreas was carried out in 22 patients. Indication was severe chronic pancreatitis in 17 cases, cancer of the ampulla of Vater in 4 cases and cancer of the duodenum in 1 case. 1 patient (duodenal cancer) died because of necrosis of the residual pancreas. The treatment of exocrine pancreatic insufficiency does not create problems. Only patients presenting with preoperative latent diabetic metabolism seem to develop postoperatively a manifest Insulin dependent diabetes mellitus. The obtained results are very satisfactory and justify to conclude that this operative procedure gives real help to patients with severe chronic relapsing pancreatitis.

One year after total duodenopancreatectomy a clinical and laboratory evaluation including exhaustive bicycle ergometry was performed in 6 male patients. The insufficiency of the exocrine pancreas can be compensated by at least 10 g pankreatin per day. During physical exercise patients had higher arterial values of lactate and free glycerol after duodenopancreatectomy than 7 healthy individuals and 6 diabetic patients type I. This metabolic overreaction was due to a deficiency of pancreatic glucagon and resulted in an impaired hepatic gluconeogenesis. There was no detectable increase in growth hormones and only a small one in catecholamines. The physical condition of patients after duodenopancreatectomy was clearly worse.

Maximum islet cell stimulation with oral glucose loading and intravenous application of glucagon and tolbutamide was done in patients with partial duodenopancreatectomy and occlusion of the pancreatic duct (n = 9), in patients with total duodenopancreatectomy (n = 5) and in healthy test persons (n = 3) in order to test endocrine capacity of the residual pancreas. After partial duodenopancreatectomy and occlusion of the pancreatic duct a clear reduction of the endocrine capacity of the pancreas is found, which can be demonstrated with the statistically significant reduced secretion of insulin and c-peptide. Further deterioration of endocrine pancreatic function then does not take place in the later postoperative course. In patients with total duodenopancreatectomy residual islet cell function could not be demonstrated.

From 1968 till 1977 we observed 150 patients with carcinoma of the head of the pancreas and the ampulla of Vater. In 29% a radical operation (duodeno-pancreatectomy) could be practiced. The prognosis of carcinoma of the head of the pancreas is much less favourable in comparison to the carcinoma of the ampulla of Vater.

From 1961 to 1981, 132 patients suffering from squamous cell carcinoma of the oesophagus were seen at the Bad-Cannstadt-Municipal-Hospital. In 53 cases only a palliative procedure could be performed: 20 patients had tube intubation, 29 gastrostomy, only 4 an exploratory laparotomy. The mortality rate of palliative operations is a high one, postoperative complications are frequent, the mean postoperative survival time is about 4.3 months. As the method of choice, preference is given to tube intubation, gastrostomy should be no longer performed with the exception of a few special cases.

The pathogenesis and clinical study of the aneurysms of the splenic artery will be represented from the available literature. Retrospective from the literature 144 cases were taken into consideration and a further 6 added on. The problems of the diagnosis will be discussed, the importance of the selective angiography as the only possible means for a definate pre-operative diagnosis emphasized. Different methods of operation will be described, in which the removal of the aneurysm together with a splenectomy represents the method of choice.

We studied the hemodynamics of hepatic blood flow before and after creation of portacaval shunts in 28 patients. Electromagnetic flow recordings were used to measure hepatic arterial flow (HAF) and portal venous flow (PVF) with respect to total hepatic blood flow (THBF). No correlation between PVF and portal pressure was found, but PVF was directly related to liver function. The concept that patients with low PVF tolerate shunts better (with respect to postoperative course and encephalopathy) than those with high PVF was not supported. Our investigations suggest the existence of a compensatory mechanism that tends to maintain THBF by increasing HAF following creation of a shunt. This compensatory increase occurs only in those patients with good liver function and normal or enlarged livers.

From 1961 to 1980 resection of the esophagus and replacement with stomach was carried out in 61 patients with esophageal carcinoma. Operative mortality was 36% in all cases; during the last 5 years it has been reduced to 21%. Postoperative staging according to the "International Union Against Cancer" was done in all patients. Patients with early tumour stage are very rarely presented. Survival rate depends on tumour stage. Radical operation resulted in a 2-year survival rate of 21% and in a 5-year survival rate of 10% including operation mortality. In cases of advanced carcinoma palliative operation does not prolong life, but increases the quality of life with normal ability to swallow.

A hemorrhage from esophageal varices is a rare complication of osteomyelosclerosis. Treatment and pathogenesis of this life-threatening complication is controversial. Following splenectomy in two patients, esophageal varices and ascites disappeared. The theory of an increased portal blood flow secondary to splenomegaly is supported with these two cases.

In 1976-1979 a total duodenopancreatectomy was employed in 18 patients with chronic relapsing pancreatitis. Indication for operation in all patients was due to pain long year lasting, and resistant to therapy efforts. Indication was also given, for we recorded in 15 patients loss of weight of 15 kg on an average, because eating was very painful for these patients. 4 patients were jaundiced, in another two patients we suspected a pancreasneoplasm preoperatively. For ten patients we observed a postoperative period without any complication, two patients died postoperatively. Later on patients were mostly affected by diabetes, which could not be controlled at all, while maldigestion could be treated easily. Therefore total duodenopancreatectomy should not be the general operative treatment in chronic pancreatitis and should rather be reserved for special cases.

In 6 male patients, who had duodenopancreatectomy, oral fat respectively carbohydrate tolerance tests were performed. Intake of at least 10 g pancreatine did reduce the ensuing steatorrhea. Increased oral intake of carbohydrates led to increased levels of glucose in blood and urine. In addition, the patients were subjected to excessive exercise tests; in the course of these tests hormones, substrates and metabolites of fat and carbohydrate metabolism were measured. The values were compared to corresponding values from 6 type I diabetes patients and 7 normal persons. In the operated group lactate and free glycerol increased because of reduced hepatic glucose neogenesis, catecholamines increased little, and HGH not at all. Capacity for work was reduced in the operated group. Malassimilation and diabetes may be compensated for by drug therapy after duodenopancreatectomy. However, endocrine as well as metabolic derangements do follow duodenopancreatectomy, and ought to be taken into account preoperatively, since they may reduce the benefit of surgery in patients with chronic pancreatitis.

Noble's operation was employed in 48 cases. In 33 patients, the operation was performed because of acute ileus. Indication for operations is discussed. Postoperative complications are rare. Two patients died, but there was no direct relationship to Noble's operation. The later operative results are favorable, and no patient has suffered from an ileus relapse.