[Albrecht von Haller. An illustrious ancestor]. / Albrecht von Haller. Ein grosser Vorfahr.

Albrecht von Haller (1708-1777) was one of the most famous and important men of the eighteenth century. His achievements make him comparable with Lessing and Newton. In Blumenbach's opinion he was one of the enlightenment's greatest thinkers in both versatility and depth. He contributed significantly to developments in medicine, physiology, botany, pharmacology, theology, literature, editing, chronicles, biography, geography, and during his later years in Switzerland jurisprudence and agrarian reform. On the occasion of the 300th anniversary of his birth, important scientific landmarks in his life are described, with special attention to his achievements in the fields of anatomy, physiology, surgery, and experimental research.

[Surgery school. Tradition-transition-change in paradigm?]. / Chirurgische Schule. Tradition-Wandel-Paradigmawechsel?

First Schools in Surgery already at the antiquity. During the medieval some slow developments in this regard throughout Europe, especially in France and Italy. In Germany because of the great changes and progresses in the medical sciences foundations of the first surgical schools in Vienna and Berlin. v. Langenbeck and Billroth have been the promoters. Tremendous changes in our time with a break of the generations, new structures at the universities, far reaching separation into subdisciplines of surgery and explosive technical developments question the meaning of surgical schools in the old sense. But there will apparently be a continuation, even in a changed matter and this on the background of a shift of the paradigm.

Acute psychological care by the operating surgeon.

The diagnosis of breast cancer causes severe psychological conflicts. This is because of the sudden need for a mutilating breast operation and because of the threatening confrontation with a potentially lethal disease. The consequence can be a spectrum of physical and mental sequelae, access to which the physician may find difficult. Here, the interpersonal relationship between the patient and the operating surgeon is of particular relevance, not only for the hospital phase but also in the time to follow. These effects therefore fall into the sector of psychosocial care. Within this framework, an improvement of the postoperative quality of life may be the result, probably via emotional processes. Various recent studies have confirmed the empirical finding that this care may result in an extension of the survival time. The acute psychological care by the operator involves: diagnostic, response to diagnosis, decision making of the patient, informed consent, the perioperative phase, postoperative information and the further "decision making" because of the operative findings, and discussion at the time of discharge. In connection with the informed consent there are several points of a heavy psychological load; namely, the likelihood of the diagnosis, the problem of the intraoperative histology and their consequences, procedure modalities, the possibility of a one-stage- or two-stage-operation, the meaning of the type of incision, the consequences and need for a lymph node excision, information about possible complications, discussion about postoperative treatment modalities, the prognosis and finally of psychological points of view. The influence of the surgeon is in this regard is of great importance. Especially as concerns the alternatives of tumorectomy with radiation and mastectomy (without radiation) and possible reconstruction. Other problems are connected to possible adjuvant chemotherapy or hormone therapy and perhaps bone marrow transplantation. Alternative conservative therapeutic modalities are, also of special interest.

Morbidity and mortality in 602 patients with acute pancreatitis seen between the years 1980-1994.

The course of a first attack of acute pancreatitis was evaluated in a retrospective study of 602 patients, who were admitted between 01.01.1980 and 30.09.1993 to the Centers of Internal Medicine and Surgery of the University of Göttingen (n = 417) and from 16.11.1986 to 30.06.1994 to the Municipal Hospital of Lüneburg (n = 185). Etiology was biliary tract disease in 227 (37.7%), alcohol abuse in 177 (29.4%), unknown in 133 (22.1%), and other causes in 65 (10.8%) patients. Mean hospital stay was 27.9 +/- 24 days (x +/- SD), median 23 days. Pancreatic pseudocysts developed in 14.3% of the patients, and surgical treatment was necessary in 11.1%. Within the first 48 hours, respiratory insufficiency was observed in 63.2% of the 204 patients undergoing arterial blood gas analysis while renal impairment occurred in 32.6% of 602 patients. Artificial ventilation was indicated in 12.5%, and dialysis in 7% of the patients. Mortality rate was 6.1%, correlating significantly with respiratory and renal impairment and procedures in connection with these complications and also with transfers from other hospitals.

Gastrin-releasing peptide and CCK after intraduodenal inhibition of proteases in dogs.

The intraduodenal application of a potent protease inhibitor (camostate, 600 mg) causes a significant increase in basal pancreatic secretion in the manner of a negative-feedback mechanism. The integrated protein secretion during the entire study period was 9.9 +/- 1.8 g in 120 min. The iv application of anti-GRP immunoglobulin caused a significant reduction to 5.0 +/- g in 120 min. No significant changes in the plasma concentrations of GRP and CCK were detectable. The increased secretion occurring after the administration of the protease inhibitor could be mediated by neural GRP-dependent mechanisms. These may also be relevant for CCK-dependent factors, which are only briefly mentioned.

[New trends in biliary surgery]. / Neue Tendenzen in der Gallenchirurgie.

On the basis of the experience gained in 893 laparoscopic procedures performed on the gallbladder, and with increasing frequency on the bile-ducts, and on the basis of a comprehensive review of the literature from 1992 and 1993 pertaining to this subject, a critical analysis of laparoscopic gallbladder surgery has been accomplished. As substantiated by recent publications, laparoscopic cholecystectomy has achieved wide acceptance in surgical practice. Over the course of the last two years, discussion has focussed on the avoidance of injury caused by Veress needle and trocar puncture and specific pneumoperitoneum-associated complications, as well as the minimisation of overlooked and/or spilled bile-duct calculi and the avoidance of iatrogenic bile-duct injuries. Procedures to be taken in order to achieve the necessary improvement in laparoscopic cholecystectomy are described.

[The Chang mesocaval side-to-side shunt, an alternative shunt form after previous operations and portal vein thrombosis]. / Der mesokavale Seit-zu-Seit-Shunt nach Chang, eine alternative Shuntform nach Voroperationen und bei Pfortaderthrombose.

Over the time period from July 01, 1983 to June 01, 1993, 15 patients with portal hypertension and relapsing bleedings from esophageal varicosis were treated with Chang's mesocaval side-to-side shunt at the Department of General Surgery, University Hospital of Göttingen. All patients were pre-operated in the upper abdomen or exhibited thrombosis of the portal vein. While five cases revealed a prehepatic block, ten patients had an intrahepatic block, based on cirrhosis of the liver (Child classification A or B). The time required for operations was 180 +/- 32 minutes; the pressure in the portal circulation decreased by 56%. In three cases, patients suffered relapsing bleedings despite of regular shunt conditions. Complications which were due to the procedure were seen in two patients (one revealed intraabdominal posthemorrhage, followed by therapy-resistant coagulopathy; the other patient exhibited stenosis of the anastomosis). One patient developed encephalopathy. Given a rigid indication, we regard the procedure described herein an alternative to the mesocaval interposition shunt, and we consider the low rate of thrombosis (so far < 10%) without continued postoperative anticoagulant therapy as well as the avoidance of an interposition as important advantages of this technique.

[Effect of pancreatic innervation on exocrine secretory performance of the pancreas]. / Einfluss der Pankreasinnervation auf die exokrine Sekretionsleistung der Bauchspeicheldrüse.

In the present study we examined the influence of extrinsic pancreatic innervation on exocrine pancreatic response to secretin, caerulein, tryptophan and fat, and furthermore the amino acid- and fat-stimulated release of neurotensin and CCK in dogs. Denervation of the pancreas did not alter secretory response to secretin and caerulein, whereas transsection of the extrinsic nerves significantly diminished the protein response to tryptophan and fat. Release of CCK was not altered by pancreatic denervation. However, fat-evoked neurotensin plasma levels were significantly increased after denervation of the pancreas.

[Closing the resection surface in left pancreatic resection with the surgical stapler]. / Verschluss der Resektionsfläche bei der Pankreaslinksresektion mit dem Klammernahtgerät.

In the present paper a technique is demonstrated wherein the closure of the pancreatic remnant following left pancreatectomy with absorbable staples was performed. The good results with minimal complications recommend this method.

Treatment of iatrogenic common bile duct injury during laparoscopic cholecystectomy through the laparoscopic insertion of a T-tube stent.

Iatrogenic injury to the common bile duct during laparoscopic cholecystectomy has previously necessitated an immediate laparotomy to alleviate bile leakage. In the course of 171 laparoscopic cholecystectomies performed at our hospital, intraoperative common bile duct injuries occurred in 2 patients. Each case was successfully treated using a laparoscopically placed T-tube, thus avoiding the need for a laparotomy. This novel intraoperative procedure successfully treated common bile duct injuries without resulting in postoperative complications.

Myogenic basis of motility in the pyloric region of human and canine stomachs.

In vitro gastric motility was investigated in 48 human and 16 canine stomachs by measuring the mechanical activity of isolated muscle strips under auxotonic conditions. For a precise regional differentiation, we recorded the mechanical activity of longitudinal and circular strips from fundus, corpus and antrum, as well as from circular preparations of the inner and outer layer of the pyloric sphincter and from the duodenum. The analysis showed that the anatomical division of the stomach into three distinct regions resulted physiologically in different patterns of contraction in vitro for each region. The fundus exhibited purely tonic spontaneous activity and a tonic contraction pattern after application of acetylcholine whereas the activity in the circular antrum was purely phasic. A combination of tonic and phasic contractions was found in the corpus and longitudinal antrum. A major difference in the basic spontaneous activity pattern was evident between man and dog. A gradient of intrinsic frequency in the stomach from proximal to distal was seen in the dog but not in man. A physiologically distinct area exists in the pyloric region of both species adjacent to the antrum and duodenum. The pyloric ring has its own spontaneous activity (minute-rhythm), reacts to the application of acetylcholine with relatively weak contractions and, unique to the dog, was delineated by histamine-induced maximal contractions. The results provide evidence that the pyloric ring is a distinct organ with specific functional characteristics in its cellular-myogenic structure.

[Pancreatico-pleural fistula. Clinical aspects and therapy of a rare disease entity]. / Pancreatico-pleurale Fisteln. Beitrag zur Klinik und Therapie eines seltenen Krankheitsbildes.

We report of 2 patients with pancreatic-pleural fistulas in chronic pancreatitis. In both cases abdominal symptoms were missed, the primary clinical manifestation was a recurrent pleural effusion with a high content of amylase. Endoscopic retrograde cholangiopancreaticography is necessary for a precise evaluation of the fistula and is indispensable to the surgical therapy. Computed tomography and ultrasonography showed in both cases a pancreatic pseudocyst. Our recommendation is surgical therapy when the fistula is not closed spontaneously within 2 weeks. Both patients were successfully treated by a left pancreatectomy.

Cystic neoplasms of the pancreas: a clinical and radiological study of eight cases.

Four patients with benign serous cystadenoma, one with mucinous cystadenoma, and three with mucinous cystadenocarcinoma treated in the university hospital of Göttingen between 1985 and 1988 were investigated. The main initial symptoms of these cystic tumors were abdominal pain (7/8), weight loss (3/8), maldigestion (3/8), and palpable abdominal mass (3/8), while laboratory investigations revealed nonspecific alterations (elevated ESR, mild hypochromic anemia). CA 19-9 was elevated in two patients, one of whom had cystadenocarcinoma; CEA also was elevated in this patient only. In all cases size, localization, and cystic character of the tumors were shown clearly by sonography and computed tomography; fine needle biopsy helped to distinguish between serous and mucinous cystadenoma in four of six cases. Because of their malignant potential, total extirpation of mucinous cystic tumors is the treatment of choice, while serous cystadenomas are benign and therefore may be treated conservatively in uncomplicated cases or high-risk patients.

[Surgical therapy of chronic pancreatitis]. / Chirurgische Therapie der chronischen Pankreatitis.

From a series of 411 surgical operations in chronic pancreatitis patients, 142 were analyzed with respect to indication, early and late mortality, and results. Average follow-up time was 10 years. Resective procedures were used in 51 patients and drainage in 24. Late mortality was twice as high for drainage (19%) as for resection (7.5%). The subjective late results were best for resection, since in these cases relapse occurred only in 16% and improvement of symptoms in 79%; for drainage the improvement rate was only 65% and the recurrence rate 39%. Drainage was followed by latent or manifest diabetes in 21% of cases, and resection in 63%. Deterioration of exocrine pancreas function was observed in 29% of resections but in only 14% of drainages. These data indicate that prognosis of the disease depends on the surgical procedure as well a withdrawal of alcohol.