[Surgical infections: the role of laparoscopic surgery]

Surgical diagnostic and therapy in intraabdominal infections should be fast and definite. Infectious diseases of the abdomen are appendicitis, cholecystitis, peptic ulcer perforations, colonic perforations (mostly diverticulitis), gynaecologic infections and other rare indications. The role of laparoscopy especially in the treatment of intraabdominal infections is presented for different diagnoses. Besides its therapeutic options, laparoscopy plays a crucial role as diagnostic tool in intraabdominal infections. The decision for a laparoscopic or open access to the abdomen should be made individually under consideration of the diagnoses and the laparoscopic training of the operating team.

[Typical and avoidable doctor's errors in surgical gastroenterology]

Everyone makes mistakes, and even the greatest efforts may fail to eliminate them completely. In contrast, typical errors and miscalculations--which by the very fact of being typical are predictable--can and must be avoided. The reasons for such mistakes may be lack of experience, inadequate interdisciplinary cooperation, and ignorance of the current state of the art. This applies equally, and in particular, to the field of surgical gastroenterology. Intensive interdisciplinary discussions, a healthy surgical hierarchy, a knowledge of pertinent guidelines and the latest literature and, last, but not least--against the present background of discussions about working hour and diagnosis-related groups--a rested and motivated physician, are the pillars of error-free patient management.

[Laparoscopic cholecystectomy--surgical standard in cholelithiasis]

Laparoscopic surgery showed a dramatic development in the last years of the 20th century. From the beginning laparoscopic cholecystectomy (LCCE) has been the pacemaker of this development. Today laparoscopic cholecystectomy is the first choice for treatment of cholecystolithiasis in nearly all surgical clinics. Therefore laparoscopic cholecystectomy is the most common part of minimal invasive technique. LCCE is the golden standard in therapy of gallstones, more than 90% of cholecystectomies in specialized clinics are done laparoscopically. It is an established, evidence based operation today. Open cholecystectomy is left for special indications only. A problem of LCCE is the occult carcinoma of the gallbladder. In histological proven carcinoma of the gallbladder LCCE is the adequate operation only for Tis and T1 carcinoma. In T2 and T3 carcinoma a radical oncologic resection with lymph node dissection should be performed. Due to the poor prognosis T4 tumors should be left with laparoscopic biopsy only.

Intraoperative suspicion of gallbladder carcinoma in laparoscopic surgery: what to do?

The frequency of gallbladder cancer in Europe is less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, patients with gallstones have gallbladder removal much earlier in their gallstone history. So the percentage of gallbladder carcinomas will decrease in the future. We report on our surgical procedures in patients with suspicious gallbladders having laparoscopic gallbladder removal, and how to proceed after the diagnosis of gallbladder carcinoma. From June 1990 to December 2001, we have performed 7,130 cholecystectomies in a single department. 47 of these patients (0.66%) were identified as having carcinoma. There were 40 females and 7 males, with a mean age of 70.6 years. In 17 cases (36%) there was a preoperative suspicion of malignancy. Most commonly, in 30 cases (64%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. We recommend removal with a bag for all gallbladders with a suspected wall or scleroatrophic calcified gallbladder area. In stage Tis or T1 laparoscopy + cholecystectomy is sufficient. For T2 and T3 we perform reoperation with liver bed resection and lymphadenectomy.

Chirurgie der Gallenblase und Gallenwege durch MIC

The laparoscopic cholecystectomy is the most used minimally invasive surgical technique. Seventy-five percent of all gallstone diseases are actually treated by this procedure, as proved by an impressive comparison of Swiss, Austrian and German data. More than 265,000 cholecystectomies are analyzed. Twelve percent of all operations are performed in an acute situation, intraoperative complications are found in 1%; the postoperative complications is 5%. The lethality in all countries is between 0.1 and 0.2%.

How to proceed in patients with carcinoma detected after laparoscopic cholecystectomy

Carcinoma of the gallbladder is a rare disease. Gallbladder carcinoma is detected in less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, gallbladders are now removed much earlier than they used to be. With the increase of cholecystectomies, the diagnosis of unexpected gallbladder carcinoma became more frequent. We report on how to proceed in patients with a diagnosis of gallbladder carcinoma and discuss the additional problems that have arisen since laparoscopic cholecystectomy became established. From June 1990 to December 1999, we performed 6230 cholecystectomies in the surgical department of Moabit Hospital in Berlin. Of these, 42 (0.6%) were identified as carcinoma. There were 37 women and five men, and the mean age was 69 years. In 16 patients (39%), there was a preoperative suspicion of malignancy. In 26 patients (61%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathologic examination of the resected gallbladder. In these patients, an open repeat operation was necessary in seven cases to achieve an adequate curative resection and staging. This involved additional liver bed resection and lymph node dissection of the hepatoduodenal ligament. Abdominal wall (port site) recurrence in the absence of distant metastasis was present only in two patients. We recommend removal using a bag in all gallbladders with wall thickening, irregularities, or scleroatrophic calcified gallbladder area. In stage Tis or T1, laparoscopic cholecystectomy is sufficient. In stage T2 and T3, we perform a repeat operation with liver bed resection and lymphadenectomy.

[Reuse of instruments for minimal invasive surgery--status and prospects]

The development of instruments for minimal invasive surgery (MIS) is moving in the direction of the miniaturization of mechanical components, a combination of multiple functions in a single instrument, and the introduction of new techniques, in particular those reducing bleeding and thermal damage when cutting blood vessels. These tendencies have consequences for the reprocessability of the instruments, usually making reprocessing more difficult. In particular cleaning--the removal of contaminations from tiny lumina, joints, etc., is highly demanding. In addition, proof of successful cleaning is difficult, and no standardised method of doing this in practice is currently available. An overview of the problems associated with the reprocessing of instruments for minimal invasive surgery is given, and a numbers of possible solutions are discussed.

The clinical suitability of laparoscopic instrumentation. A prospective clinical study of function and hygiene

On the basis of experience gained from 6,000 laparoscopies (73% cholecystectomies) at the Moabit Hospital in Berlin, we carried out a cohort study to analyze the failure rate and decontamination of labeled "tracer" instruments processed in three test trays that were each subjected to 100 cycles. The majority of repairs focused on the functional parts of separable scissors and damaged or lost components. At 4%, the repair index after laparascopic use was less than that of a previously documented investigation period covering 1990 to 1996. A comparison of the costs of disposable and reusable instruments showed that reusable instruments were more cost-effective by a factor of > or =10, indicating that the price gap reported in our previous calculation for 1992 and 1994 has closed only slightly. After 100 cycles, we found traces of proteinaceous material in the eluate on every fourth instrument inspected (eight of 32); half of them (four) gave a positive reading when tested with a hemoglobin pseudoperoxidase test stick. It must be said, however, that similar residual contamination has been found on instruments used in conventional open surgery, with no indication of clinical relevance. This study was designed to examine the clinical suitability of laparoscopic instruments in terms of function and hygiene. Improvements in instrument design and cleanability must focus in particular on the reproducibility of cleaning results, because cleaning is the most important step in processing sterile supplies. As the number of minimally invasive operations has risen considerably, a mere visual check no longer meets the requirements prescribed by modern quality assurance. A multicenter study of residual proteins found on tracer instruments in all surgical fields is now in progress.

Sterile and economic instrumentation in laparoscopic surgery. Experiences with 6,000 surgical laparoscopies, 1990-1996

BACKGROUND

Because so many common surgical problems can now be addressed by the laparoscopic approach, the issue of sterile processing has to be reconsidered.

METHODS

Selected laparoscopic instrumentation was analyzed regarding wear and tear and decontamination after sterile processing following 6,000 surgical laparoscopies carried out between 1990 and 1996 at the Academic Hospital Moabit, Berlin.

RESULTS

Fewer than 7.9 (parts of) instruments failed per 100 laparoscopies. Most of the repairs involved scissors. The main problems were blunting, burnt or disconnected electromechanical components, defective insulation, and damaged or lost parts of dismantable instruments. Residues of human blood proteins were detected on a few instruments. The effect of intraluminal rinsing was documented by measuring the iron content (as an indicator for blood contamination). A comparison of costs showed that it was >10 times cheaper to use instrumentation with reusable components.

CONCLUSIONS

The sterile processing of economic reusable instrumentation for laparoscopies needs staff well trained in sterile supply. Instrument design should allow easy dismantling and rinsing of internal parts. Insulating compounds present a problem for decontamination. Disinfection with aldehydes before cleaning the lumina of instruments must be avoided because protein coagulation will occur. A tube-in-tube concept for tubular instruments offering compatibility should be favored.

[Laparoscopic instruments in practical clinical tests--prospective study of functional aspects and residual contamination]

Wear, tear, and possible contamination after 100 clinical cycles of three test trays were investigated on laparoscopic "tracer" instruments in a prospective clinical study. Failure was below 4 per 100 laparoscopies, and remaining contamination was detected after passing 100 cycles in 20%, which happened to control instruments from open surgery as well. Further clinical data of contamination levels for apparently clean instruments must be collected to evaluate and correlate to microbiological testing.

[Sequential therapy concept in choledocholithiasis]

Of 4023 Patients with gallstone disease, 124 were treated for common bile duct stones by endoscopy (ERC/EPT). Stone clearance was completed in 81% of the patients. Due to a morbidity of 5.9% and a mortality of 0.6%, the concept of preoperative ERC followed by laparoscopic cholecystectomy seems to reduce risk for the patients.

Cardiovascular and metabolic responses to anesthetic-induced malignant hyperthermia in swine

BACKGROUND

Several cardiovascular disturbances, such as tachycardia and hypotension, are observed during human and porcine malignant hyperthermic (MH) crises. However, the pathophysiologic mechanisms responsible for the deterioration of cardiovascular function during MH are not completely known. The purpose of this study was to elucidate the changes in left ventricular (LV) function and metabolism and the systemic and regional hemodynamics during anesthetic-induced MH in swine.

METHODS

The study was carried out in 12 open-chest MH-susceptible pigs and in 8 healthy control (non-MH-susceptible) pigs under the same conditions. The cardiovascular and metabolic responses to halothane (1% inspired) and succinylcholine (3 mg.kg-1 intravenously 15 min after the start of halothane administration) were studied. Global hemodynamic and LV variables (expressed as means +/- SEM) were determined over a period of 90 min after the beginning of halothane exposure. Simultaneous investigations were performed on hindleg and cardiac muscle to compare the regional functional and metabolic changes in these tissues.

RESULTS

MH was triggered in all MH-susceptible pigs. Early (10-30 min) cardiovascular changes during the development of MH consisted of a rapid increase in heart rate (from 86 +/- 4 to 204 +/- 8 beats.min-1), cardiac index (+84%), and peak rate of change in LV pressure (+150%); stroke volume index (-24%) and mean aortic pressure (-13%) decreased progressively even in the early stage of MH. These alterations were accompanied by an early and persistent reduction in systemic vascular resistance (maximally -57%) with an increase in aortic pressure amplitude. Early changes in coronary and peripheral hemodynamics during the development of MH consisted of a three-fold increase in coronary blood flow in conjunction with a marked decrease (-77%) in coronary vascular resistance. The early circulatory changes were associated with a fourfold increase in myocardial and a 2.5-fold increase in peripheral O2 consumption. The ratio of the LV stroke work index (LVWI) to myocardial O2 consumption (MVO2) was significantly decreased, by a factor of 5. Increased catecholamine concentrations and myocardial lactate and H+ production could be demonstrated throughout the MH crisis. In the late stage of MH (> 30 min), pronounced hypotension and a subsequent decrease in cardiac index were noted. These changes were associated with a significant reduction in LV end-diastolic pressure, from 9 +/- 1 to 6 +/- 1 mmHg (P < 0.05), and in the rate of change in LV pressure, by a maximum of -25%. Coronary vascular resistance remained reduced while coronary blood flow decreased. Peripheral (hind-leg) blood flow initially increased by 48% while peripheral vascular resistance decreased by 42%, followed by a fivefold increase in peripheral vascular resistance with a marked decrease in peripheral blood flow (-88%) in the late phase of MH.

CONCLUSIONS

The current findings indicate that metabolic status during MH is characterized by a demand ischemia of the heart and of the skeletal muscle. Insufficient coronary blood flow and increased metabolism as a result of tachycardia and increased concentrations of catecholamines are the dominant factors contributing to the dramatic alteration in cardiac performance during porcine MH. Acidosis, hypovolemia, and hyperkalemia, especially in the late phase of MH, are additional essential factors responsible for the progressive cardiovascular deterioration and cardiac death.

[Ligation of the cystic duct--experience in 1,750 laparoscopic cholecystectomies]

Between 3/1990-3/1993 laparoscopic cholecystectomy was performed in 1750 patients in the mean age of 49.8 (7-83). In 48 patients (2.7%) the procedure had to be shifted to open surgery. The overall complication rate was 3.9%, the mortality 0.11%. The PDS-clip Absolok 300 was regularly used for occluding the cystic duct and the cystic artery. Clip-associated complications were never observed. The induced duct occlusion proved save even against operative manipulation. But special characteristics of the clip and its application had to be considered.

Accumulation characteristics of human colon carcinomas after monoclonal antibody ex vivo perfusion

Human colon carcinomas were operatively resected and the tumour-bearing segments interposed into an oxygenised ex vivo perfusion system. Pressure, flow, temperature, pH and metabolic parameters were controlled. Over a period of 45 min the 131I-labelled monoclonal antibody AUA1 was administered and its distribution in the tumour tissue analysed scintigraphically. The accumulated activity was determined in different tissues. The results showed that the AUA1 uptake increased with the degree of histological tumour differentiation. The main tumour:non-tumour ratio reached 0.8 in poorly, 4.1 in moderately and 5.9 in highly differentiated adenocarcinomas. Introducing the oxygenised erythrocyte-enriched perfusion media significantly increased the viability of the colon tissue. The ex vivo perfusion system will help to analyse factors determining monoclonal antibody accumulation in human colon carcinomas.

Pharmacokinetic behavior of ciprofloxacin both in native cardiac and porcine valves treated in glutaraldehyde

When judging a probable therapeutic success for antibiotic management of bioprosthetic endocarditis, sufficient drug levels in heterologous valve tissues play a very important role. The pharmacokinetic behavior of ciprofloxacin was investigated in native and porcine valvular tissues and compared with plasma levels during a 90- to 120-min period of surgery. Analysis was carried out by HPLC using excised valvular tissues (Hancock T 505). In all, 15-20 patients were investigated in each group. The antibiotics were administered intravenously or per os. Tissue concentrations after onset of the procedures showed ciprofloxacin plasma concentrations of 2.09-0.47 micrograms g in the native and 3.98-1.99 micrograms/g in the heterologous valvular tissues.

[Results and critical analysis of the treatment of obesity with the intragastric balloon]

In 54 patients with excessive obesity a silicone balloon was implanted endoscopically into the stomach. The overweight amounted to 76% (median) by Broca's formula. The therapeutical plan included balloon-implantation, dietary treatment, psychotherapeutical guidance, kineto-therapy and balloon-extraction. According to their therapeutical compliance there were three different groups of patients: G1 - maintenance of therapy; G2 - discontinuation of therapy; G3 - no additional therapy at all after balloon implantation. Up to the sixth week a weight reduction of 9.5-20.5 kg could be demonstrated in all groups. Only in the first group a further weight reduction by a mean of 20 kg after 20 weeks was noted. Patients in group 2 and 3 - in some the balloon was still implanted - had a renewed weight increase sometimes surmounting the original weight.

COMPLICATIONS

3 gastric respectively duodenal ulcers, one subileus. The long-term success can only be obtained by a multi-component therapy plan.

[Abdominal pseudotumor as the clinical manifestation of Whipple's disease. T-cell index as an indicator of disease activity and a parameter of the duration of therapy?]

A large nonresectable upper-abdominal tumor in a 61-year-old woman was found to have been caused by inflammatory infiltration and mechanical obstruction of the mesenteric lymph nodes resulting in obstruction to lymphatic flow. Biopsy at the root of the mesentery and of abdominal lymph nodes raised the suspicion of Whipple's disease, a diagnosis confirmed by a small-intestine biopsy. Long-term antibiotic treatment was successful. Quantitative changes in the composition of the T-cell subpopulations at the time of the diagnosis reverted to normal in the course of treatment.

Sialic acid in human serum and cerebrospinal fluid. Comparison of methods and reference values

Sialic acid was estimated simultaneously by three methods: chemical determination based on Warren's method (Meth. Enzymol. 6, 463-464 (1963) with slight modifications, enzymatic measurement with a commercially available test kit, and high performance liquid chromatography (HPLC) according to Silver et al. (J. Chromatogr. 224, 381-388 (1981). These methods showed closely correlated (r greater than 0.930) results and displayed similar precision data. Interference studies demonstrated sufficient specificity for the chemical assay, which was 5-6 times more sensitive than the enzymatic test and hence chosen for the establishment of reference values. From 249 sera from healthy people between 16 and 63 years the 0.025-0.975-reference intervals were calculated to be 1.57-2.63 mmol/l for 127 men, and 1.69-2.64 mmol/l for 122 women with no significant dependence on age and sex. From 43 cerebrospinal fluids from healthy adults the respective values were 17.3-50.4 mumol/l. These data correspond to those of the literature. Some chemical assays employing thiobarbituric acid were compared. They proved reliable in contrast to the reaction of serum with 4-dimethylaminobenzaldehyde.

Comparative study of hormonal counter-regulation during GCIIS-guided insulin hypoglycemia tests using human insulin (recombinant DNA) and pork insulin

Human insulin (BHI, recombinant DNA) and pork insulin (PI) were compared in 10 healthy volunteers. Using a glucose controlled insulin infusion system for the performance of the insulin hypoglycemia test (IHT), a comparable dosage of both insulins had to be infused (BHI 0.129 +/- 0.007 vs PI 0.115 +/- 0.01 U/kg; mean +/- SEM). Blood glucose slopes and nadirs did not differ significantly (BHI 30 +/- 2 vs PI 29 +/- 2 mg/dl). There was no difference in C-peptide inhibition (minimum for BHI 0.50 +/- 0.08 vs PI 0.42 +/- 0.08 micrograms/l). Maximum hormone responses were identical for ACTH (BHI 78.4 +/- 11.3 vs PI 76.0 +/- 8.7 pg/ml), cortisol (BHI 246 +/- 20 vs PI 252 +/- 15 ng/ml) and GH (BHI 43.8 +/- 7.3 vs PI 49.4 +/- 6.7 ng/ml). Peak levels of prolactin did not differ significantly (BHI 1,335 +/- 315 vs PI 1,766 +/- 614 microU/ml). The urinary excretion pattern of epinephrine in three 120 min periods before, during and after IHT was identical (before IHT: BHI 0.9 +/- 0.2 vs PI 0.6 +/- 0.1 micrograms/120 min; during IHT: BHI 12.6 +/- 2.2 vs PI 13.4 +/- 2.5 micrograms/120 min; after IHT: BHI 2.5 +/- 0.7 vs PI 3.7 +/- 1.3 micrograms/120 min). No differences in the minima of serum potassium levels were observed (BHI 3.38 +/- 0.04 vs PI 3.33 +/- 0.05 mmol/l). We conclude that the biological effects of human insulin and pork insulin are comparable. Our data do not support the assumption of a different hypothalamic handling of human insulin (recombinant DNA) and porcine insulin.

Determination of the theophylline solubilizer salicylamide-O-acetic acid in serum and urine using high-performance liquid chromatography

A high-performance liquid chromatographic method for the determination of the theophylline solubilizer salicylamide-O-acetic acid has been developed in the range 0.5 to 10 microg/ml for human serum and 5 to 400 microg/ml for urine. Reversed-phase ion-pair chromatography was employed with tetrabutylammonium hydrogen sulphate as counterion and 2-nitrophenylacetic acid as internal standard. Preliminary pharmacokinetic single-dose studies show that the sensitivity and the selectivity of the assay are adequate to measure lower concentrations in the late beta-phase.

[Plasma catecholamines, insulin and glucose in the postoperative phase. Cause and duration of the post-stress syndrome after abdominal surgery]

Plasma catecholamine, insulin secretion, and serum glucose levels were measured to determine the extent and duration of the postaggression syndrome following major abdominal surgery: 1. There was a significant increase in plasma catecholamine levels (epinephrine and norepinephrine) during the first postoperative week. -2. Glucose dependent insulin secretion remained elevated for more than 6 days following major abdominal surgery. -3. Postoperative glucose assimilation was reduced for more than 1 week. -4. There is a negative correlation between plasma catecholamine levels and reduced insulin secretion following the administration of glucose in the postoperative phase. -5. Inhibition of insulin secretion should be included in the therapeutic considerations for the first postoperative week in all patients undergoing major abdominal surgery.

[Endotoxins in bacterial peritonitis]

Tests for the presence of endotoxin in blood and peritoneal fluid were performed at short intervals in 19 patients with peritonitis, 9 following gastric perforation, and 10 with perforation of the large bowel. A highly sensitive precipitation technique (LAL test) was used. Endotoxin was demonstrated in peritoneal fluid during the early stage of peritonitis in 15 of 19 patients (79%), while blood determination revealed endotoxin in 7 of 19 cases within the first 48 h. During the clinical course circulating endotoxin was recovered in 12 of 19 patients, which implies endotoxinemia in 63% of the cases. The prognostic significance of endotoxin determinations was high, since circulating endotoxin was demonstrated within the first 72 h in 8 of 9 patients with a fatal course. Demonstration of circulating endotoxin is a time-consuming and complicated procedure with great clinical significance in patients with gram-negative peritonitis.

[Insulin secretion after surgery: measurements after abdominal operations]

The study includes measurements of glucose and insulin in 30 patients after surgical trauma. The times of measurements were between the 2nd and 6th, 6th and 10th, and 10th and 21st postoperative days. An intravenous glucose load (1 g/kg body weight/60 min) was used. For the exact measurement of secretion of the islet cells we also determined insulin and glucose in portal venous blood. The following conclusions were made: (1) Measurements of insulin in the peripheral venous blood has no exact correlation to insulin secretion in the postoperative period. The insulin concentration in the portal vein blood after a glucose load shows significant variations to the insulin concentration in the cubital vein blood. (2) A greater surgical trauma (abdominal operation) causes a disorder of glucose utilization in the first postoperative week. (3) The insulin secretion after intravenous glucose load is significantly diminished during the first operative week.

Insulinsekretion nach chirurgischem Trauma: Messungen nach abdominellen Operationen

Untersucht wurde bei 30 Patienten zwischen dem 2. und 21. post-operativen Tag nach einem chirurgischen Trauma die Glukosever-wertung und Insuunsekretion. Die Untersuchungen erfolgten bei den Patienten nach einer Oberbauchoperation in zeitlich verschiedenen Abständen vom Operationstag mit intravenöser Glukosebelastung (Dosierung: 1 g/kg Körpergewicht/60 min i.v.). Die Meβzeitpunkte lagen zwischen dem 2.-6., 6.-10. und 10.–21. postoperativen Tag. Zur genauen Erfassung der Sekretionsleistung der Inselzellen des Pankreas wurden Insulin und Glukose auch im Pfortaderblut be-stimmt. Folgende Schluβfolgerungen wurden gezogen: Messungen der Insulinkonzentration im peripher-venösen Blut ge-statten in der postoperativen Periode keine exakte Aussage über die Insuunsekretion, da die Insulinkonzentration im Pfortaderblut nach Glukosezufuhr signifikante Unterschiede zur Insulinkonzentration im Kubitalvenenblut aufweist. Ein gröβeres chirurgisches Trauma (Oberbauchoperation) verur-sacht eine Störung der Glukoseverwertung über die 1. postoperative Woche hinaus.Die Insuunsekretion ist bei intravenöser Glukoseapplikation in der 1. postoperativen Woche signifikant vermindεrt.

[Surgery of gastric cancer in patients older than 70 years (author's transl)]

In this study it is reported about operative mortality and long-term results of surgery of gastric carcinoma in patients over the age of 70 years. The operative mortality in 50 patients with a distal partial gastrectomy was 16%, the mortality in 24 patients with total gastrectomy was 33.3% and in 14 patients with a proximal gastrectomy the mortality was 28%. The main cause of death (40%) was a pneumonia. There was no correlation between frequency of pneumonia and preoperative results of measurement of lung function. Only advanced arteriosclerotic disease in the heart and brain has a fatal influence on mortality rate. In the old patients the long-term results are determined by the staging of the tumor at the time of operation, too. In the 60 patients, who had left the hospital and who are in our control, the half year survival rate was 78.3%, the 1-year survival rate was 58.3% and the 2-years survival rate is exceeding 41.6%. 14 patients of the 17, who are still alive and who are after 2 1/2 years again explored, are in a very good condition. In comparison with the literature it is to conclude that for the indication to surgery of gastric carcinoma there is important not only the real age of the patient but rather the biological and mental condition of the patient.

[Isolated stenoses and occlusion of the coeliac artery--a comparative angiographic and clinical study (author's transl)]

14 patients with occlusion (7 patients) or extreme stenosis (7 patients) of the arteria coeliaca underwent operation because of heavy abdominal complaints. The constriction of the arteria coeliaca was caused by arteriosclerosis (2 patients), ligamentum arcuatum medianum (8 patients), ligamentum arcuatum medianum and ganglion tissue (2 patients). For the restitution of a normal blood circulation in the epigastric organs the following was necessary: in 10 patients a decompression, in 3 patients an aortocoeliacal bypass and in 1 patients an enlargement plastic with vein patch. The angiographic findings indicate a connection between the arteria coeliaca occlusion or extreme stenosis and the extent of the collateral blood supply. High pressure gradients between aorta and arteria coeliaca, significantly decreased medium pressures in the arteria hepatica communis and noticably frequent morphologic changes in the epigastric organs could be seen intraoperatively.

[Clinical experiences with autologous blood transfusion in vascular surgery]

In a prospective study 30 patients with high operative risk in vascular surgery underwent preoperative phlebotomy. Blood loss during operation could be replaced by bank autologous blood. The clinical data during and after operation are compared with the data of a control group. The use of banked autologous blood does not even endanger patients with poor cardiorespiratory function. As a clinical procedure it is easily performed and reduces the cost of medical care. The method of preoperative phlebotomy reduces the need of homologous blood by 75%. The number of patients receiving homologous blood is reduced by 50%. Banked autologous blood is an important help for the anesthetist. The basic physiologic principles of the method are discussed as well as advantage and disadvantage of preoperative hemodilution. The authors suggest to withdrawal of 800 ml autologous blood before every operation in which the blood loss will be higher than 500 ml.

Effects of selective gastric vagotomy and pyloroplasty on oral and intravenous glucose tolerance and insulin secretion

In peripheral and portal venous blood, the immunoreactive insulin (IRI) and glucose levels in response to orally and intravenously administered glucose were measured in 14 patients with selective gastric vagotomy and pyloroplasty (SGV+P) and in 17 control subjects with other abdominal surgery. After intravenously administered glucose, the insulin and the glucose levels were nearly identical in both groups. After orally administered glucose, there were remarkable differences. Despite their early postoperative situations, and in contrast to the control patients, the SGV+P subjects showed no hyperglycemia. The measurements of IRI in the portal vein suggested that in SGV+P patients, the response of the islet cells is accelerated. In patients with SGV+P, the release of an insulinotropic intestinal factor and the preserved vagal innervation of the pancreas may be responsible for the accelerated insulin response of the undisturbed glucose tolerance.

On the transport of tripeptide antibiotics in bacteria

The two tripeptide antibiotics L-2-amino-4-methylphosphinobutyryl-alanyl-alanyl-alanine (L-phosphinothricyl-alanyl-alanine) and L-(N5-phosphono)methionine-S-sulfoximinyl-alanyl-alanine, both inhibitors of the glutamine synthetase, are transported into the cell of Escherichia coli K 12 via the oligopeptide transport system. The uptake by this system is proved first of all by cross-resistance with tri-L-ornithine using oligopeptide-transport-deficient mutants, and secondly by antagonism tests demonstrating competitive reversal of the action of the antibiotic by several peptides which have been shown to be transported via the oligopeptide transport system, e.g. tri-L-alanine, tetra-L-alanine, tri-L-lysine, tri-L-serine, tri-glycine, glycyl-glycyl-L-alanine and the synthetic tripeptide L-azadenyl-aminohexanoyl-alanyl-alanine. On the other hand, there is no effect on the action of the antibiotic in antagonism tests with compounds which use different transport systems, such as L-alanyl-alanine, L-lysyl-lysine, glutathione and the synthetic amino acid azaadenylaminohexanoic acid, i.e. 2-amino-6-(7-amino-3H-v-triazolo-[4,5-d]-pyrimidin-3-yl)hexanoic acid. Another inhibitor of the glutamine synthetase, L-methionine-S-dioxide (methioninesulfone) could be converted into a tripeptide form by linkage to L-alanyl-alanine analogously to the tripeptide antibiotics described above. Whereas the free L-methionine-S-dioxide seems to be transported via the methionine transport system, the tripeptide form is transported via the oligopeptide transport system. Thus, this glutamine synthetase inhibitor can be taken up by the cell via two different transport mechanisms. Our results indicate that this could provide a synergistic effect. The syntheses of the new tripeptides L-azaadenylaminohexanoyl-alanyl-alanine and L-methionine-S-dioxidyl-alanyl-alanine were performed by dicyclohexylcarbodiimide couplings of the unusual N-protected L-alpha-amino acids azaadenylaminohexanoic acid and L-methionine-S-dioxide to L-alanyl-alanine-tert-butyl ester followed by common deprotection steps. Tri-L-ornithine was synthesized without carboxyl protection via two successive couplings of hydroxybenzotriazol esters of Nalpha-butoxycarbonyl-Ndelta-benzyloxycarbonyl-L-ornithine.

Insulin response and portal-peripheral insulin difference during the oral glucose tolerance test in patients after abdominal operations

Following abdominal surgery, insulin and glucose concentrations in the portal vein, and a peripheral vein are compared in patients during control periods and after oral administration of glucose. During the control period, the glucose concentrations are identical in both veins. After glucose loads with the prompt increase of portal glucose concentration the portal-peripheral difference also increases (p less than 0.01). During the control period the insulin concentration in the portal vein is double as compared to peripheral blood (p less than 0.005). After glucose load the increasing portal insulin as well as the peripheral and portal glucose correlate with the portal-peripheral insulin difference (p less than 0.001). Furthermore, there is a significant positive correlation between the peripheral glucose area as a parameter of glucose tolerance and the portal insulin area as a semiquantitative parameter of insulin secretory capacity (p less than 0.001). It can be concluded that in the early postoperative period in patients with a diminished oral glucose tolerance (large glucose areas) there is an even greater insulin response in comparison to patients with normal oral glucose tolerance. On the other hand, however, in those patients with diminished glucose tolerance, the insulin response is essentially delayed.