[Transanal endoscopic surgery of the rectum - testing a new method in animal experiments]

Surgery of the lower third of the rectum can be done without difficulty through the anus using an endoscopical approach. Polyps or tumors located in the upper two thirds of the rectum can be removed using the Mason or Kraske procedure, or by the transabdominal approach. A new endoscopic technique has been developed with the aim, to allow surgery in the whole rectum through the anus. The rectum is being dilated by mechanical means and air insufflation. An oblique angle stereoscopic endoscope as well as modified surgical instruments are used. In animals 47 excisions of mucosa were done, and the incisions were closed by continuous suture. Application of this technique in a clinical setting is planned.

Surgery of the venous system - present state of the art

The current status of surgery of the inferior vena cava, and the iliac and femoral veins in cases of phlebothrombosis, of postthrombotic syndrome, and in traumatic lesions is discussed. Each intervention in the venous system requires an exact preoperative diagnosis including phlebography and phlebodynamometry. After a mean observation period of 26 months, 41.4% excellent results were obtained following venous thrombectomy in cases of phlebothrombosis. Vena cava blockade as a prophylactic measure against pulmonary embolism is an accepted procedure now. It remains, however, limited to a few exceptional situations. Venous injuries proximal to the elbow and the knee can be successfully treated by direct suture or graft implantation with good functional results, whereas ligature of large veins causes postthrombotic syndrome of the limbs in over 50% of the cases. Chronic occlusion of iliac veins and postthrombotic syndrome may be treated by reconstructive methods, with the aid of a temporary arterio-venous fistula. The prerequisites of patent run-in and run-off reduce the number of operations to but a few cases.

Total parenteral nutrition as the sole therapy in Crohn's disease--a prospective study

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.

“Peel-Away-Introducer” – Eine neue Technik der Implantation von zentralen Venenkathetern für die langfristige parenterale Ernährung

Zur langfristigen parenteralen Ernährung werden Silikonkatheter benutzt, die bisher durch operative Freilegung der Vena subclavia oder -jugularis interna implantiert wurden. Der “peel-away-introducer” ermöglicht die Plazierung durch perkutane Gefäβblindpunktion in modifizierter Seldinger-Technik. Diese neue Methode der Katheterimplantation wird detailliert beschrieben.

Successful treatment of streptozotocin diabetes of the rat by transplantation of the islets from a single donor pancreas

A new digestion chamber was developed which made it possible to isolate 500 islets from the pancreas of one adult rat. The mesh chamber enabled us to remove islets out of the collagenase solution as soon as they are separated from pancreatic tissue. The islet injury due to collagenase was diminished, and the time of warm ischemia during digestion was considerably reduced. With this method it was possible to treat the diabetes successfully in eight of 14 rats. The condition of the remaining six rats was considerably improved, and no animal died due to diabetes during 90 days of surveillance as compared to a 50% death rate in the diabetic control group. A cataract did not occur in any transplanted rat, whereas it was observed in all surviving animals of the diabetic control group. If the complete separation of endocrine and exocrine tissue in a density gradient was abandoned the transplantation results improved significantly.

[Complaints after cholecystectomy (author's transl)]

Complaints after cholecystectomy are caused by bile duct disturbances (concrements in the choledochus, stenosis of the papilla, anatomic anomalies of the ducts), by diseases of neighbouring organs (pancreas, liver, stomach) or by functional disturbances. Diagnosis of organic disease can be established by appropriate means, that of functional disturbances by exclusion of organic causes. Therapy depends upon the underlying disease. Improvement of endoscopic procedures has let to the point, that in many cases secondary operations have become unnecessary. Close cooperation is necessary between internist, surgeon, and endoscopist, if an appropriate therapeutic procedure is to be found.

[Surgery of diseases of the veins (author's transl)]

The article describes the present state of surgery of the v. cava inferior, of the veins of the pelvis and legs in acute phlebothrombosis, post-thrombosis syndrome, traumatic lesions, congenital malformations and in tumour surgery. Every surgical performance concerned with the venous system must be diagnostically clarified by phlebography. The veins of the thigh and pelvis are well visualized by means of ascending phlebography. Closely meshed functional testing by means of phlebography control, as well as venous pressure measurements and peripheral phlebodynamometry are required for timely recognition of an early relapse and for assessing the results of surgery.

Dopamine treatment of human cadaver kidney graft recipients: a prospectively randomized trial

In a prospectively randomized trial, 50 human cadaver kidney graft recipients were tested for the effect of dopamine infusion on kidney function after transplantation. The kidneys were taken from beating-heart donors under optimal conditions. The dopamine infusion did not affect the dialysis frequency in the 1st week after transplantation, in the dopamine group only slightly better creatinine clearances could be detected. However, the diuresis increased significantly when dopamine was given and this resulted in the fact that in the dopamine group 47.4% of the patients were dialyzed although the diuresis amounted to more than 11/day as compared to 15.7% of such patients in the nondopamine group. These findings correspond to experimental data, which showed that the dopamine infusion of the recipient mainly ameliorated renal function in those cases where kidneys were taken after hypotensive injury of the donor.

Preoperative parenteral feeding in patients with gastrointestinal carcinoma

In a comparative clinical trial to examine the influence of 10 days of preoperative parenteral nutrition (PPN) on the postoperative complication rate for gastrointestinal carcinoma 59 patients (controls) received the regular hospital diet and 66 received PPN. The two groups were similar in nutritional status and in distribution of site and stage of tumour and type of operation. The rates of postoperative wound infection, pneumonia, major complications, and mortality were generally lower in the PPN group, but the differences were significant only for major complications and mortality. The clinical results can be explained by the improvement in various indices of humoral and cellular immunocompetence and the protein status in the PPN group and their deterioration in the control group during the preoperative course.

[Choice of donor and the results of renal grafting (author's transl)]

For the calculation of the donor influence on the results of renal grafting, all non-renal causes of transplant failure must be excluded. The following criteria for the selection of a suitable kidney donor were found: the urine production of the donor in the last hour before nephrectomy should amount to at least 200 ml and the age difference between donor and recipient should be not more than 20 years. Proteinuria, a high serum creatinine level, vascular anomalies and a long operation time for vascular anastomosis were unfavourable. The preservation time, the warm ischemia time and the sex of the donor have little effect. If no rejection crises occurred within the first 3 weeks after transplantation, the transplant survival rate increased from 45% to 71%.

Effect of hypotension on the results of kidney storage and the use of dopamine under these conditions

The influence of the length and severity of hypotension on the results of kidney preservation was examined in dogs. Successful 24-hr hypothermic kidney storage was possible, if the donor animal was subjected to hypovolemic hypotension (mean blood pressure 60 mm Hg) for a duration 1 to 4 hr. If the blood pressure was lowered to 50 mm Hg, successful kidney preservation could not be obtained. It was concluded that the level of hypotension was of more importance than its duration. After 24 hr of cold ischemia, the function of kidneys from hypotensive donors could be improved significantly if dopamine was given to the recipient. The preservation injury itself could not be counteracted by dopamine because dopamine did not improve the function of kidneys which were removed from normotensive donors but were stored for 24 hr under hypothermia.

[Electrostimulation test for intraoperative vagotomy control. Results of a prospective randomized study]

In a prospective random trial the intraoperative electro-stimulation test of Burge and Vane was conducted with 100 patients, in whom selective proximal vagotomy was performed for a duodenal ulcer. In 6 out of 50 patients histologically proved nerve fibres were found by the applying of the test. The postoperative acid values did not differ significantly between those patients who underwent the electrostimulation test and those who did not. The rate of recurrence was 8% in both groups 2-4 years after the operation. Obviously, the application of the test did not have any effect on the results.

[Indications for the various surgical procedures in hepatic echinococcosis]

This report deals with 38 patients suffering from hydatid disease of the liver. The most frequently performed operative procedures were hepatic resection (n = 16), filling the cavity with normal saline solution (n = 16), filling the cavity with normal saline solution (n = 8), and total cystectomy (n = 6). Hepatic resection is mainly indicated in patients with alveolar echinococcosis of the liver lobe have to be removed. In patients with only one hydatid cyst of the liver the simple method of saline filling should be preferred. The prerequisite of saline filling is that no biliary fistula exists. If the remaining cavity of the hydatid cyst fills with bile, it can be easily drained under local anaesthesia with computertomographic control. Mebendazole was given in two cases with alveolar echinococcosis of the liver that could not be treated surgically. In both cases this treatment proved to be effective.

[Results of renal transplantation 1968-1979 (author's transl)]

173 renal transplantations were done over a period of 12 years. Among these were 162 first, 10 second and one third transplantation. The one year survival rate of transplanted kidneys (all cases) was around 50%, patient survival was 81.6%. Survival rates did not depend statistically on tissue compatibility, immediate function of kidney, duration of kidney conservation, donor age, commencement of graft versus host reaction, and duration of preoperative dialysis. Although the number of HLA identity has increased during the observation period, there was no increase of transplant survival rate. This may possibly be explained by the negative influence of the steady increase of conservation time during the same period.

[Problems in the management of liver trauma (author's transl)]

In the last ten years 43 patients with blunt liver trauma and 11 with penetrating liver wounds have been treated. The mortality rate after blunt liver trauma was close to 63%; all penetrating wounds were survived. The prognosis after trauma depended significantly on the number of additional wounds, the extent of blood loss, and the age of the patients. Management of liver trauma was performed in most of the cases (n = 41) by suture and drainage. Packing of the wounds and resection were performed in four cases each. In nine cases, the bleeding did not stop sufficiently after suture, debridement, or packing of the wounds. It is concluded that in those cases hepatic resection or hepatic artery ligation - depending on the extent of trauma - should be done in future.