[Is the thyroidectomy a surgical standard procedure for therapy of Graves' disease?]. / Stellt die Thyreoidektomie ein Standardverfahren zur Behandlung des Morbus Basedow dar?

Surgery is an important therapeutic option in the treatment of Graves' disease. Nevertheless it is still controversial discussed wether the extent of resection correlates with the rate of surgical complications and the therapeutic success. Therefore we performed a retrospective analysis on 75 surgically treated patients. 58 of these 75 patients were examined after a median interval of 34.2 months. The examination focussed on the appearance of temporary and permanent palsy of the recurrent laryngeal nerve, hypoparathyroidism, recurrences, and on the postoperative course of thyroid-stimulating-hormone-receptor antibody (TSH-ab) titers. Total thyroidectomy has been performed in 51 and bilateral resection with a remnant thyroid volume less than 2 ml each side in 24 patients. We could not confirm a significant difference concerning the postoperative complication rates between both groups. In the bilateral resection group we saw 3 cases of recurrent goitre and a more unfavourable course of TSH-ab titers than in the thyroidectomy group. For these reasons we propose the total thyroidectomy as surgical standard procedure for therapy of Graves' disease.

[Villous bile duct adenoma with mucinous bile ]. / Villöses Gallengangsadenom mit gallertartiger Galle.

HISTORY AND ADMISSION FINDINGS: A 75-year-old woman was admitted because of colicky upper abdominal pain. Physical examination was unremarkable. INVESTIGATIONS: Alkaline phosphatase and gamma-glutamyl transpeptidase activities as well erythrocyte sedimentation rate were increased. Sonography revealed mild enlargement of the hepatocholedochal duct to 1.1 cm. Retrograde endoscopy showed a band-like immobile structure in the cystic duct. TREATMENT AND COURSE: At operation the hepatocholedochal duct was found to contain a greenish mucinous mass: no cause was discovered. Three years later a tumor, 1 x 0.5 cm, was found in the common hepatic duct at sonography, with clinical signs of recurrent chronic cholitis and early liver damage. Because of hepatic dysfunction and hypersplenism no surgical intervention was undertaken. When cholestasis progressed further, a partial full-thickness resection of the hepatic duct with removal of the tumor and the mucinous bile had to be performed two years later. Histological examination revealed a villous adenoma with slight epithelial dysplasia and mucus formation. CONCLUSIONS: Villous bile duct adenoma is a very rare cause of cholestasis. Mucous production can lead to mucinous bile, with resulting chronic cholecystitis and secondary biliary cirrhosis. The adenoma should be completely excised because of the danger of malignant transformation and risk of local recurrence.

Cancer of the rectum--palliative endoscopic treatment.

Three methods of palliative endoscopic treatment of malignant strictures of the rectum are presented: laser therapy and its combination with the implantation of either plastic prostheses, or self-expanding metal stents. The aim of all procedures is to avoid a colostomy at least in older patients with shorter life expectancy and incurable tumours. The additional application of a stent maintains the luminal patency and prevents the repetition of laser therapy. Since 1988 we have treated 60 patients with these techniques. First, two to six sessions of laser therapy were necessary for recanalization of the stenosis. In the time following this the patients returned two to eight times for regular laser therapy before they died from the carcinoma. In spite of laser therapy one patient developed an obstruction and another suffered from an iatrogenic perforation of the rectal cancer. In both cases a stoma was fashioned. To avoid repetitive laser sessions we successfully inserted a plastic endoprosthesis in seven cases. In another two cases the implantation failed because of perforation and the patients had to undergo surgery. For the next 10 cases we have used flexible self-expanding metal stents. Serious complications or signs of re-obstruction were not observed until the patients' death. The survival time ranged from 2 to 25 months.

[Endoscopic drainage of pancreatic pseudocysts]. / Endoskopische Drainage von Pankreaspseudozysten.

AIM OF STUDY: To compare retrospectively the endoscopic treatment of pancreatic pseudocysts by retrograde pancreatic drainage (ERPD), cystogastrostomy (ECG) or cystoduodenostomy (ECD). PATIENTS AND METHODS: Between 1987 and 1995 pancreatic pseudocysts were successfully treated endoscopically in 30 patients (13 women, 17 men; mean age 49 [18-89] years): ERPD was accomplished through papillary insertion of 5-7 F prostheses into the cysts or pancreatic duct in 9 patients; ECG achieved drainage of cysts in the body or tail of the pancreas in 15 patients, and ECD for cysts in the head of the pancreas in three. Combined ERPD and ECG was necessary in three patients. RESULTS: Significant pain relief was achieved in all patients, accompanied by increased appetite and weight. Occlusion or dislocation of the prosthesis required renewed endoscopic drainage in three patients. The prostheses were removed, 2-12 months after implantation, when pain relief had occurred and clinical as well as radiological findings had become normal. Recurrence 10-22 months after removal of the drain was observed in four patients, of whom two had a successful second drainage procedure. Surgical intervention became necessary in three patients because of inadequate drainage or (one case) bleeding. CONCLUSION: These data indicate that endoscopic drainage of pancreatic pseudocysts gives good results with a low complication rate and no deaths. The procedure is thus an alternative to the at present prevailing operative treatment.

[Intestinal angiodysplasias as initially unrecognizable cause of recurrent gastrointestinal hemorrhage]. / Intestinale Angiodysplasien als zunächst nicht erkennbare Ursache rezidivierender gastrointestinaler Blutungen.

HISTORY AND CLINICAL FINDINGS: Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation. INVESTIGATIONS: Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding. TREATMENT AND COURSE: The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding. CONCLUSION: Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.

[Reliability of ultrasound ileus diagnosis]. / Stellenwert der sonographischen Ileusdiagnostik.

We investigated in this study if we would be able to find the correct indication for laparotomy earlier by sonographical examination than by clinical and radiological findings. In 48 of 594 patients with unknown abdominal diseases we found an intestinal obstruction by laparotomy. The indication based on clinical and radiological findings in 37 patients (sensitivity: 77.1%). In comparison the indication for laparotomy was predetermined correctly only after sonographical examination in 45 patients (sensitivity: 89.6%). According to the number of sonographical findings the reliability of the indication for laparotomy increased. The examination by sonography is a valuable tool in the diagnosis of intestinal obstruction.

[Complications after laparoscopic cholecystectomy]. / Komplikationen nach laparoskopischer Cholezystektomie.

We report on complications of laparoscopic cholecystectomy which needed surgical intervention. These complications occurred in 10 out of 250 patients operated at our hospital and 2 patients admitted with complications. In 3 cases the common bile duct was cut and a hepaticojejunostomy was carried out. 3 patients with an insufficiency of the cystic duct were treated by laparotomy. In 2 cases common bile duct stones had to be endoscopically removed. 1 patient suffered from a pneumothorax due to damage of the diaphragm. The tear was laparoscopically sewn. In one case the abdominal aorta had to be oversewn because of its damage by the needle during creation of the pneumoperitoneum. One patient with adhesions suffered from a perforation of the gut as the trocar was introduced. 2 patients developed an umbilical hernia and underwent surgical herniotomy. In spite of all advantages minimal access surgery of the gallbladder seems to be affected with more serious complications than open approach.

Endoscopic management of pancreatic pseudocysts.

Recently, endoscopic interventional procedures were introduced for nonsurgical therapy of symptomatic pancreas pseudocysts. We reported 25 patients treated by endoscopic retrograde pancreas drainage (ERPD), endoscopic cystogastrostomy (ECG), or endosopic cystoduodenostomy (ECD).ERPD was performed in 9 patients by placement of a 5 Fr. or 7 Fr. endoprosthesis transpapillary into the cyst or the main pancreatic duct. ECG was carried out in 10 cases, in 7 of these, a double pigtail catheter was additionally inserted. Three patients suffering from pseudocysts of the pancreas head were treated by ECD. In a further 3 cases, ERPD and ECG were combined.All patients reported a dramatic reduction of pain with a simultaneous increase of appetite and body weight. The drainage tubes were removed after disappearance of symptoms, and abnormal clinical and endoscopic findings within 2 to 12 months. In 4 cases, a recurrence of the cyst was found 10 and 22 months later, in 3 cases the endoprostheses had to be renewed because of catheter occlusion or dislocation. 2 patient underwent surgical treatment after insufficient endoscopic drainage due to haemorrhage or recurrence.Endoscopic treatment of pancreatic pseudocysts yielded good results with low rates of recurrence and complications. According to our experiences we think endoscopic interventional techniques will oust surgery from its present dominant position in the next years.

Endoscopic drainage of pancreatic pseudocysts.

Seventeen patients with pancreatic pseudocysts were treated by endoscopic drainage. In nine cases we performed endoscopic retrograde pancreatic drainage (ERPD) by inserting 7-Fr pigtail catheters via the papilla into the cyst or into the main pancreatic duct. In two cases transduodenal cystotomy (ECD) and in eight cases transgastral cystotomy (ECG) are performed by using coagulator and papillotome. In five cases of ECG an endoprosthesis was inserted into the cyst. In two cases combination therapy of ERPD and ECG was performed. All patients reported reduction of continuous pain and postprandial epigastralgia after placement of endoprosthesis. After disappearance of symptoms and abnormal endoscopic findings within a period of 2-12 months the drainage tubes were removed. In one case postoperative dislocation of the prosthesis was observed; no serious complication was not encountered. The period of observation varied from 5 to 40 months. Two patients are presently under treatment with endoprostheses. Endoscopic drainage yielded good results in the treatment of pancreatic pseudocysts.