[Deciduosis of the appendix. Differential diagnosis of acute appendicitis]. / Deciduose der Appendix. Zur Differentialdiagnose der akuten Appendicitis.

Deciduosis of the appendix is a rare cause of acute appendicitis in pregnancy. Ectopic decidual cells localized in the submesothelial stroma may represent a physiologic reaction of the pluripotent stromal cells to progestational hormonal stimulation. Less frequently, deciduosis is based on a preexisting extragenital endometriosis, visible in a localization other than strictly submesothelial, in residuals of cyclic proliferation and bleeding, and in endometrial glandular formations embedded in the decidual cells.

Reconstruction of the arteria carotis communis in newborn following extracorporeal membrane oxygenation (ECMO).

With the help of ECMO it is possible to save the lives of newborn infants suffering from severe respiratory distress syndrome not responding to conservative treatment. Using Bartlett's classic venous-arterial perfusion technique in ECMO the right arteria carotis communis had to be sacrificed. Thus, despite the life-saving character of this new method, the ligation of the carotid with all its possible complications had often been a major argument against using this therapy. We are now therefore trying to reconstruct the arteria carotis after decannulating the vessel after extracorporeal membrane oxygenation. In our 8 cases so far, post-op examinations showed no obstruction of blood flow in the vessel. No neurological deficiencies were recorded.

[Organ preservation by reconstruction of Wirsung's duct in complete pancreas rupture]. / Organerhaltung durch Rekonstruktion des Ductus Wirsungianus bei kompletter Pankreasruptur.

Blunt abdominal traumas with pancreatic injuries often cause partial or subtotal resection of the organ, especially when the pancreatic duct is damaged. A reconstructive method for anastomosis of the duct is reported in a case of a 9-year-old boy with complete pancreatic rupture in which the whole organ could be salvaged.

[The "ideal" cholecystectomy. A prospective, randomized study]. / Die "ideale" Cholecystektomie. Eine prospektive, randomisierte Studie.

200 patients undergoing elective cholecystectomy were studied in a prospective randomized manner. This study suggests that the nasogastric tube and postoperative iv-infusions are unnecessary. We continue to use a subhepatic drain. Exception: the senior surgeon in a straightforward case.

[Iatrogenic damage of the bile ducts caused by cholecystectomy. Treatment and results]. / Iatrogene Schäden an den Gallenwegen infolge Cholecystektomie. Behandlung und Ergebnisse.

This report concerns 44 patients with iatrogenic injuries to the bile ducts treated at the Mannheim University Clinic from 1973 to 1987. Group A: 12 own patients with lesions of the common bile duct among 6020 operations for cholelithiasis, i.e. a risk of 0.19%. All 12 lesions were recognized during operation and immediately repaired with eventual success. Group B: 32 patients referred to us from another hospital after cholecystectomy alone or previous repair. 11 of these patients had progressive jaundice in the immediate postoperative period (1. to 9. week) due to unrecognized bile duct injury. The other 21 patients developed strictures after an uneventful postoperative course within time intervals varying from 3 months to 23 years. 72% of patients (Group B) had reconstructive surgery within two years after last operation in another hospital. We performed 47 reconstructive operations in 42 patients without hospital mortality including 5 second or third operations for recurrent stricture. Biliary-intestinal anastomosis (70%) as sutured mucosa-to-mucosa anastomosis was the most favoured method of reconstruction (30 Roux-Y hepaticojejunostomies and 3 choledochoduodenostomies). An end-to-end anastomosis was only performed in 3 cases of plain transection of the common duct. In management of high biliary strictures (type III and IV according to Bismuth's classification) preference would be given to Hepp-Couinaud's modification of hepaticojejunostomy using the left hepatic duct for a long side-to-side anastomosis. Overall morbidity amounted to 28% while the rate of relaparotomy for surgical complications was 13% (n = 6 without postoperative death). 10 patients died since reconstructive surgery, death being independent from bile duct injury in 5 cases. The injury related one-year-mortality was 4.5%. Overall stricture recurrence rate was 15% (18% for hepaticojejunostomy) with a mean follow-up of 72 months. Local infection was the most obvious cause of recurrence, thus a two stage procedure with postponement of reconstructive surgery must be recommended in case of subhepatic abscess or biliary fistula. Including second and third repairs, a good longterm result was achieved in over 80% of patients.

[Acute infrarenal aortic and bilateral pelvic artery occlusion]. / Der akute infrarenale Aorten- und beidseitige Beckenarterienverschluss.

Operations were performed on 75 cases of acute occlusion of the aorta and bilateral iliac arteries, between 1972 and 1987. The occlusions had been caused by embolisation in 48.6 per cent of these cases and by thrombosis in 31.4 per cent. Amputations had to be performed on 22 per cent, while the mortality rate at hospital amounted to 42.8 per cent. Surgical and anaesthetic risks were extremely high in 71 per cent of all patients. Complete ischaemia lasted more than six hours in 48 per cent. Intraoperative angioplasty was applied to twelve patients to control occlusion-induced stenoses and is believed to be capable of reducing hospital mortality.

[Acute aortic and iliac artery occlusion: a banality in vascular surgery?]. / Der akute Aorten- und Beckenarterienverschluss: eine gefässchirurgische Banalität?

From 1972 to 1986 70 acute occlusions of the aorta or bilateral iliac arteries were operated in our clinic. The occlusion was caused in 41 cases by embolisation, in 29 cases by thrombosis. Amputation rate was 22.8%, the mortality rate 42.8%. 71% of the patients were of extreme high risk regarding the operation as well as the anesthesia. In 44% of the patients the duration of complete ischemia was more than 6 h. Performance of intraoperative angioplasty (n = 10 patients) for dilatation of stenoses leading to thrombotic occlusions may lower the mortality rate.

Primary radiation therapy in the treatment of anal carcinoma.

From 1966 to 1981, 47 patients with a diagnosis of anal carcinoma were irradiated. This group was composed of 23 males and 24 females, with age ranging from 38-84 years (average 64.4 years). The average age of the males was eight years less than the females. Of the 47 patients, 39 had an intact anal canal following biopsy and were treated with curative intent. Thirty-one of these 39 had no evidence of nodal metastasis (N0) and eight had groin, pelvic and/or para-aortic nodal disease. Only three patients were treated with pre-irradiation chemotherapy; all had locally advanced disease. Five patients were treated preoperatively and 34 were treated definitively with cancericidal doses of irradiation. Acute radiation reactions requiring a rest-break were noted in 28% of patients, but all were managed as outpatients without untoward chronic sequelae. Chronic complications were noted in 13 patients, including two patients who required colostomy for severe anal stenosis and two who required A-P resection for large painful ulcers. Two of these four patients had received part of their treatment with an interstitial implant and one had an excessively high dose of perineal irradiation. Twenty-eight of 35 patients (80%) treated with irradiation alone have remained locally controlled without further treatment. An additional four have been salvaged by surgery. Only three patients had interstitial implants as part of their treatment course. Actuarial survival at five years for the N0 patients and the group as a whole are 95.6 and 79.3%, respectively. It is concluded that external beam irradiation alone, properly fractionated to cancericidal doses, can control anal carcinoma with acceptable morbidity rates and without the use of either chemotherapy or interstitial implants in most cases. There is also a strong correlation suggesting that anal intercourse and male homosexuality play a significant role in the etiology of this disease.

[Fibrin gluing of congenital esophageal malformations]. / Die Fibrinklebung angeborener Osophagusmissbildungen.

Gluing of oesophageal anastomoses in atresia effected by means of three or four sutures will definitely produce better results than suturing alone. The results of endoscopic closure of tracheo-oesophageal fistulas by gluing with fibrin are excellent. Furthermore, it is possible with fibrin gluing alone to treat iatrogenic perforations of the oesophagus in the newborn, following a false passage of nasogastric tubes from the hypopharynx into the mediastinum or pleural cavity.