[Reconstruction of benign biliary tract stenoses. Experimental experience with autologous and heterologous transplants (author's transl)]

A pedicled autologous jejunum transplant and a free bovine collagen prosthesis were tried for the treatment of short, benign stenoses of the bile duct in animal experiments. In both cases at follow-up periods of 6--18 months an unrestricted flow of bile was recorded in the plastically dilated bile duct macroscopically, radiologically and by the chemical laboratory. On the basis of these results in animal experiments, 3 patients were treated with a pedicled jejunum transplant for the correction of short benign stenosis of the bile duct following previous cholecystectomy. All the patients are free from complaints after observation periods of 6 months, 1 year and 2 1/2 years.

[Therapy of benign bile duct stenosis (author's transl)]

Simple end-to-end reconstruction of benign bile duct stenosis is possible only in a few cases. To preserve the function of papilla of Vater as the best anticholangitis therapy, we developed a method of bile duct expansion by a pedunculated jejunal patch-graft in animal experiments. After these successful experiments three patients with iatrogenic short bile duct stenosis were treated with this operation. These patients remain free of pathologic clinical and radiological findings 8-30 months after surgery.

[Indication and operative technique in chronic occlusions of the innominate artery and proximal subclavian artery (author's transl)]

Surgery is indicated in clinical stage II and cases of subclavian steal syndrome. Endarterectomy by mid-sternotomy is the operation of choice for obliteration of the innominate artery. The lethality rate is 6%. Occlusion of the left proximal subclavian artery can be treated by transthoracic endarterectomy or extrathoracic bypass procedure. The bypass procedure is preferred because of low operative lethality rate (0.8% versus 7% in transthoracic procedure). Occlusions of the right proximal subclavian artery are treated by supraclavicular endarterectomy.

[Problem in indication and artificial ventilation during segmental resection of the trachea (author's transl)]

Based on clinical experience and lung function data (bronchial resistance and inspiratory and expiratory FEV1) obtained in experiments with stenosis in the front of the mouth, bronchial resistance and inspiratory and expiratory FEV1 should first be determined. Resection of tracheal stenosis is indicated at a bronchial resistance of more than 5 cm H2O/1/s. This corresponds to a stenosis diameter of less than 8 mm. In the case of carinal resection, one lung can be ventilated by artifical respiration for a short time only. The data obtained during resection confirm the well-known requirement of clamping the opposite pulmonary artery.

Experiences with different techniques of microvascular anastomosis

There are different opinions concerning the benefits of oblique anastomosis and stripping of the adventitia before microvascular anastomosis. For clarification of this question, microvascular anastomoses by different techniques were performed in the aortas and the femoral arteries of 80 female Wistar rats. The average diameter of the aortas in these rats was 1.4 mm, and the average diameter of the femoral arteries was 0.7 mm. The following procedures were carried out: transverse division of the vessel and end-to-end anastomosis; transverse division of the vessel with adventitial stripping of the ends before end-to-end anastomosis; oblique division of the vessel and end-to-end anastomosis; oblique division of the vessel with adventitial stripping before anastomosis. Forty of the animals were sacrificed after 5 hours, and the remaining 40 animals were sacrificed after 3 weeks, and histologic studies were performed. All anastomoses performed on the aorta were patent at the 5-hour follow-up. The 3-week follow-up showed no differences between the transverse anastomoses both with and without adventitial stripping, but there was an accumulation of false aneurysms in the groups with oblique anastomoses and adventitial stripping. In the animals that received femoral artery anastomoses, 80% of the transverse anastomoses without adventitial stripping were patent after 5 hours of 3 weeks. The animals that received oblique anastomoses without stripping had patent vessels after 3 weeks, but there was a significant accumulation of false aneurysms in the two groups that received adventitial stripping. As this study demonstrates, the patency rate of microvascular anastomoses in vessels less than 1 mm in diameter cannot be improved significantly by oblique division with or without adventitial stripping. In addition, adventitial stripping was followed by a high percentage of false aneurysms.

[Liver resection in focal nodular hyperplasia and liver cell adenoma (author's transl)]

Focal nodular hyperplasia of the liver was found in 3 women, and liver cell adenoma in a 4th woman. There is a possible association with the use of oral contraceptives. The indication for operation in these cases depends on the size of the tumour (danger of rupture of tumour and haemorrhage). It is also present when a malignant tumour cannot be excluded. Resection of the liver was performed predominantly with good results so far. Three of the patients described underwent the same surgical procedure. For the future one should aim at tumour enucleation alone.

[Parenteral feeding in outpatients. Indications, technic, experiences]

Home parenteral nutrition is indicated in the short bowel syndrome, chronic inflammatory bowel disease and as an adjunct to cancer therapy. For venous access the cannulation of a collateral of the subclavian vein and the central venous silastic catheter have proved helpful. Our own experience with 19 patients shows, that with careful supervision home parenteral nutrition can be performed with low risk.

[Late results after surgery in chronic pancreatitis (author's transl)]

122 patients were operated upon because of chronic pancreatitis within 15 1/2 years. Mortality during and immediately after surgery was 9.8%, later mortality was 4.9%. 104 patients were still alive at follow up. In 40 patients most of the pancreatic parenchyma was left during surgery. Late results were good or satisfactory in 67.5%; carbohydrate tolerance was impaired in 35%, and exocrine insufficiency of the pancreas was present in 32.5% of these cases. In another group most of the pancreas was removed; 86% of these patients improved permanentely, 46% had impaired carbohydrate metabolism, 83% exocrine insufficiency of the pancreas. Good results can be achieved, if impaired carbohydrate metabolism, 83% exocrine insufficiency of the pancreas. Good results can be achieved, if indications are carefully choosen. Personality traits of the patients have to be taken into account when choosing the surgical approach. Advantages of a two session surgical approach combined with conservative treatment are discussed.

Kidney storage at subzero temperatures using a hyperosmolar perfusate

32 dog kidneys were stored in a hyperosmolar perfusate (770 mosm/kg) at minus2 and plus4 degrees C, respectively, for 12-48 h and thereafter autotransplanted. 18 kidneys of the control group were stored in Collins solution at plus4 degrees C. The immediate function of the kidneys after transplantation was measured by p-aminohippuric acid and inulin clearances. Successful 24-hour preservation was possible by use of the hyperosmolar perfusate. Kidneys stored in the hyperosmolar perfusate at minus2 degrees C were better preserved than kidneys stored in Collins solution at plus4 degrees C. The addition of human albumin to the hyperosmolar perfusate did not improve the preservation results.

[Canine kidney preservation by intermittent perfusion with hypothermic Collins- or Sacks-solution (author's transl)]

37 canine kidneys were intermittently perfused with Collins- or Sacks-solution every 2--6 h. 32 of these kidneys were transplanted after 12--24 h storage time. Additionally, 24 kidneys were stored under hypothermia for 12--24 h and then transplanted (control group). During perfusion the oxygen consumption of the kidneys and the enzyme and lactate release were measured. It was impossible to improve the results of hypothermic storage preservation by intermittent perfusion of the kidneys, on the contrary kidney function deteriorated by the number of perfusion processes. The failure of intermittent perfusion is caused by the increase of renal vascular resistance during perfusion. From the oxygen consumption and lactate release measurement it was concluded, that the washout solutions for kidney preservation should contain more substrate which can be utilized under anaerobic conditions to improve the results of hypothermic storage preservation.

[Computer tomography on the pancreas. A diagnostic extension from the surgical aspect (author's transl)]

125 patients were subjected to computer tomography on account of suspected pancreatic disease. 48 patients were operated on--the computer tomography (CT) diagnosis was confirmed in 85.5% of the cases. Acute pancreatitis can be detected by CT if it is accompanied by an appropriate enlargement of the organ. Chronic pancreatitis can be recognized by deformations of the organ, calcifications or formation of pseudocysts. Pancreatic carcinoma is recognizable when it is larger than 3 cm accompanied by a change in the shape of the organ or if infiltration of neighboring structures has occurred. Computer tomography offers patients a safe, non-invasive method of performing follow-up examinations at short intervals.

[Indications for the correction of tracheal stenosis caused by prolonged artificial ventilation of polytraumatized persons (author's transl)]

Pronounced, short-length narrowing of the trachea combined with dyspnoea at rest is an absolute indication for partial resection. For stenoses of moderate degree the indications for surgical intervention are as yet not clearly defined. They depend not only on the clinical, roentgenological and tracheobronchoscopic findings, but also on the results of lung function tests. Changes in respiratory function become noticeable at reduction of under 30% of the tracheal diameter. Experiments with artificially induced stenosis have shown an exponential rise in flow resistance when the diameter of the trachea was narrowed to below 8 millimetre. observations made in patients have proved that the experimental results also apply clinically. The indications for surgery of a tracheal stenosis should be made dependent on the results of the determinations of flow resistance, whole body plethysmography and expiratory and inspiratory volume/1 sec. Flow resistance exceeding 5 cm H2O/1 sec, equivalent to narrowing to under 8 mm in diameter, is considered to be an indication for partial resection.

Surgical treatment of tracheal stenosis

During the last 3 1/2 years 8 patients underwent segmental resection of the trachea and one patient underwent resection of the carina at the Department of Surgery, University Hospital, Köln. Follow-up investigation in 6 month intervals showed good results in 6 patients. The complicated course of 1 of our patients with tumor infiltration of the trachea is discussed. In this case a large esophagotracheal fistula was covered with a vascularized esophageal segment. Suggestions for surgical indications in segmental resection of benign esophageal stenosis are outlined.

[Segmental venous replacemnet with heterologous graft (author's transl)]

Results of animal experiments are presented on the applicability in the low pressure system of a collagen prosthesis, which has been used successfully, for considerable time, in the arterial replacement in patients and dogs. Grafts of up to 7 cm in length were implanted into the suprarenal segment of the inferior vena cava (v. cava caudalis) in dogs and observed clinically over a period of more than 500 days. Histological investigations were made. With some limitations the results obtained are considered as good and point towards the applicability of the examined graft material in the low pressure system.

[Results of selective proximal vagotomy for gastroduodenal ulcer (author's transl)]

Between 1971 and 1976 selective proximal vagotomy (SPV) was performed in 526 patients with uncomplicated duodenal ulcer and in 37 with gastric ulcer. The operative mortality was 0.18%. The post-operative course was without complication in 90%. One to five years post-operatively 75% of patients with duodenal ulcer were largely without symptoms (Visick I and II), a dumping syndrome was present in 6.5%, diarrhoea in 4.2%, gastric outlet stenosis in 1% and recurrent ulcer in 10.9% of patients who could be re-examined. Recurrent ulcer occurred in eight of 36 patients re-examined after SPV for gastric ulcer. Results of SPV so far have shown it to be a useful alternative to gastric resection in the treatment of duodenal ulcer. But its place in the treatment of gastric ulcer remains undecided.

Replacement of the inferior vena cava and iliac veins with heterologous grafts in animal tests

The use of a modified bovine collagen graft as a low-pressure conduit was investigated by implantation into the iliocaval system of dogs. In the 210 day observation period, a patency rate of 87.5% was achieved. Nearly all graft failures occured within the first 14 days following implantation; failure after that time did not seem to be dependent upon length of time of implantation. Progressive organization of the neointima was seen histologically. New smooth muscle fibers were observed in the neointima with electron microscopic evidence of reconstitution of the subendothelial membrane. Continuing resorption of graft collagen coincided with its replacement by newly developed collagen type III fibers in a surface-parallel orientation.

[Bile duct reconstruction with pendunculate jejunal grafts (author's transl)]

A pedunculate patch, obtained from a disconnected segment of jejunum, was implanted into the longitudinal incision of the ductus choledochus. Intra-operatively, the findings were based upon direct cholecystocholangiography; postoperatively, upon laboratory tests. After an observation period of 12 months a new cholangiography of the transplant was made along with a selective picture of the mesenteric arteries. The choledochus duct with the transplant was examined histologically. Three dogs died immediately postoperatively of peritonitis due to suture insufficiency. Five dogs died of invaginate ileus. These animals, as well as the remaining 8 dogs showed macroscopically and microscopically a smooth and uneventful healing of the transplant at the end of the observation period. Radiographies showed free flow of the biliary duct system. The selective mesenteric arteriographies evidenced beginning anastomosis between the transplant and the capillaries of the bile duct. Based on the results presented, the pedunculate jejunal graft can be considered well suited as an expansion graft for the bile duct.

[Ligation with elastic ligature: an alternative in the treatment of hemorrhoidal diseases]

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.