[Vascular surgery within the scope of visceral surgery-oncologic interventions]. / Gefässchirurgie im Rahmen visceralchirurgisch-onkologischer Eingriffe.

The surgeon dealing with oncological operations within the abdominal cavity will be frequently confronted with vascular problems. These include surgically relevant vascular anomalies, arteriosclerotic changes, tumor infiltration of vessels and iatrogenic vascular lesions. The diagnosis, indications and, above all, the vascular surgical techniques applied during oncological procedures on the pancreas and liver are described in this review.

[Use of improved magnetic resonance tomography in vascular surgery with reference to efficiency and economy]. / Einsatz einer verbesserten Magnetresonanztomographie in der Gefässchirurgie unter Berücksichtigung der Effizienz und Okonomie.

The technique of Gadolinium-enhanced MR-angiography has become much better over the past year. The quality of the method is equal to conventional angiography. The advantages of MRA in comparison to conventional angiography today are: less strenuous for the patient, faster, CT or ERCP can be saved, MRA can be more economic.

[Hepatic encephalopathy after portosystemic shunt]. / Hepatische Enzephalopathie nach porto-systemischem Shunt.

A total of 28 cirrhotic patients with porto-systemic anastomosis were compared with 38 cirrhotic patients without porto-systemic shunts concerning their mental state and biochemical parameters of importance for hepatic encephalopathy. A group of 37 metabolically healthy individuals provided the reference values for the psychometric test results and the EEG power spectra. Laboratory values for both groups showed marginal elevation of bilirubin, while the ammonia levels were significantly increased in the operated group. A significant difference was found concerning both the tyrosine level and that of the branched-chain amino acids. None of the patients who had surgical treatment showed clinical evidence of hepatic encephalopathy. Regarding the results in the flicker photometry, the non-shunted cirrhotic patients differed significantly from the healthy control subjects. For both the shunted and non-shunted cirrhotic patients, the results of the Viennese determination test and the number connection test indicated subclinical encephalopathy. We conclude that the elevated ammonia level in patients with porto-systemic anastomosis does not cause a significant mental disturbance. In well-selected patients, the porto-systemic end-side shunt is an appropriate procedure in the treatment of esophageal varices.

[Peripheral vascular injuries in polytrauma]. / Periphere Gefässverletzungen beim Polytrauma.

Between 1972 und 1993 a total of 68 patients were treated at the Department of Surgery of the University Clinic of Mannheim for peripheral vascular injury resulting from multiple trauma. The average age of these patients was 31.3 years, and most of them were male (88.2%; n = 60). The injured vessels were localized evenly in all the extremities: 31 patients (45.5%) presented with arterial damage of the upper extremity, and 37 (54.5%) showed lesions along the femoro-popliteal arteries. The most frequent location of injured vessels in the multiply traumatized patient was the popliteal artery (n = 18, 26.5%), the distal part of the superficial femoral artery (n = 12, 17.6%), the brachial artery (n = 14, 20.6%) and the axillary artery (n = 10, 14.6%). The dominant cause, of trauma was road traffic accidents (72%), and 20 patients (29%) acquired their vascular injuries as motorcyclists. There were also 13 occupational accidents (19%) involving vascular injuries. In addition to a vascular trauma 34 patients (50%) had complicated fractures, and a further 34 patients (50%) had multiple fractures: 12 (17.6%) had head and brain damage, 5 (7.3%) had blunt abdominal trauma and 6 (8.8%) had blunt thoracic injury. The general amputation rate was 2.9% (n = 2). One patient died on the table of a torn off subclavian artery combined with multiple other injuries. Paresis of the plexus is a particular problem after vascular lesions of the upper extremity: in 22 patients (71%) paresis of the plexus persisted after successful vascular reconstruction (follow-up period between 3 months and 16 years, median time 3.45 years).(ABSTRACT TRUNCATED AT 250 WORDS)

[Intra-arterial DSA of the pelvic/leg vasculature using a 57 cm image intensifier]. / Intraarterielle DSA der Becken-/Beingefässe mit einem 57-cm-Bildverstärker.

100 consecutive intraarterial DSA's of the lower extremities obtained with a 57 cm image intensifier were evaluated retrospectively by 2 radiologists and 3 surgeons. The studies were considered diagnostic in 95% of the cases. The results, advantages and possible disadvantages are presented and compared to those associated with conventional film angiography and with i.v. DSA.

[Results of transvenous digital subtraction angiography with a 57 cm image intensifier in circulatory disorders of the lower extremities]. / Ergebnisse der transvenösen digitalen Subtraktionsangiographie mit einem 57-cm-Bildverstärker bei Durchblutungsstörungen der unteren Extremitäten.

The size of conventional image intensifiers is a limiting factor in performing transvenous digital subtraction angiography of the lower extremities. The results of transvenous digital subtraction angiography using a 57 cm image intensifier on 205 patients with vasoocclusive disease of the legs are presented. Two exposed fields sufficed in most cases for demonstration of all arteries, from the aortic bifurcation to the trifurcation at the lower leg. The principal advantages were the reduction of the contrast medium volume and the decrease in examination time. The reduced resolving power was a limiting factor in evaluating discrete wall lesions and of small vessels, but this did not induce diagnostic difficulties. The studies were evaluated retrospectively by an experienced vascular surgeon and in 85% of the cases were considered to be of diagnostic value.

[Regulation of ketone body levels before and following elective surgical operations during different intravenous feedings]. / Die Regulaton des Ketonkörperspiegels vor und nach elektiv-chirurgischen Eingriffen während unterschiedlicher intravenöser Nährstoffzufuhr.

44 patients who had to undergo gastric resection and 28 patients who had to undergo cholecystectomy were divided into 4 groups each. Each group received parenterally a different energy source and calorie-nitrogen ratio. We intended to investigate the influence of different intravenous regimens on pre- and postoperative acetoacetate and beta-hydroxybutyrate levels. Patients undergoing gastric resection who received 0.36 g glucose/kg BW x h together with 1.14 g/kg BW x day 1-crystalline amino acids had the lowest postoperative ketone body concentration. A comparable group who received 0.36 g/kg BW x day of a carbohydrate-mixture solution consisting of glucose-fructose and xylitol in a proportion of 1:1:1 had significantly higher ketone bodies. The comparison of glucose with xylitol in a hypocaloric dosage of 0.11 g/kg BW x h led to a physiologic ketosis only in the group with xylitol as energy source from postoperative day 2 on. In patients undergoing cholecystectomy, the sole infusion of amino acids in a dosage of 1.14 g/kg BW x h led to the highest ketone bodies from the operation day on. The intravenous infusion of a polyol-mixture solution containing xylitol and sorbitol in a relation of 1:1 in a dosage of 4.2 g/kg BW x day led to the lowest ketone body production. The infusion of a polyol-mixture solution in a dosage of 2 g/kg BW x day enabled the development of a physiologic ketosis. In this study we could demonstrate that the infusion of xylitol or a polyol-mixture solution in a dosage of 2-3 g/kg BW x day after elective surgery enables the development of physiologic ketosis.

[Comparison of xylose and glucose as energy sources in hypocaloric, postoperative parenteral nutrition]. / Vergleich von Xylit und Glukose als Energieträger im Rahmen der hypokalorischen postoperativen parenteralen Ernährungstherapie.

After a 5 day preoperative preparing period 24 metabolically healthy patients, who had to undergo gastric resection, were fed postoperatively by hypocaloric total parenteral nutrition for a 5 day period. Group I (n = 13) received 0,11 g Xylitol/kg BW X h; Group II (n = 11) received 0,11 g Glucose/kg BW X h; Both groups received 1,71 g L-crystalline amino acids/kg BW X day. During the whole postoperative period group II had significantly higher serum Glucose and Insulin levels. Due to the high postoperative Insulin concentration in group II. Free Fatty Acids, Acetate, beta-Hydroxybutyrate and Branched Chained Amino Acids were significantly lower. The augmented release of Muscle Amino Acids and the covering of a part of the energy expenditure by increased Fatty Acid oxidation in group I led to a higher postoperative synthesis rate of visceral proteins. From postoperative day 3 on Transferrin and from postoperative day 6 on Albumin and Total Protein were significantly higher in group I. This study could demonstrate, that due to its special role in the intermediary metabolism during the postoperative period Xylitol leads to a significantly higher regeneration rate of visceral proteins compared to Glucose during total parenteral nutrition.

[Differences in postoperative metabolism after pre- and postoperative beginning of total parenteral nutrition]. / Unterschiede im postoperativen Stoffwechselverhalten bei prä- und postoperativem Beginn der totalen parenteralen Ernährung. II. Mitteilung.

In this study we intended to investigate the influence of a 24-h-preoperative total parenteral nutrition (TPN) therapy--10 surgical patients, group 1--compared with the postoperative beginning of TPN--9 surgical patients, group 2--on the postoperative metabolism. Most probably due to preoperatively depleted glycogen storages in G 2, the urinary carbohydrate losses declined more rapidly postoperatively compared with G 1. 45 mMol/l of sodium did not cover the postoperative requirements of G 1. Although we administered 90 mMol/l of potassium/24 h, several patients of G 1 needed an additional substitution. No additional phosphate substitution was necessary in either group. Except for a slight positive balance on the operation day, fluid balance was well balanced on all the other days in G 1. From postoperative day 2 on, G 2 developed a deficit of free water. It could be demonstrated very clear in this study that the postoperative fluid and electrolyte requirements are strongly influenced even by a short-term preoperative fasting period.

[Postoperative metabolism--differences between pre- and postoperative start of total parenteral nutrition (author's transl)]. / Der postoperative Stoffwechsel--Unterschiede zwischen prä- und postoperativem Beginn der totalen parenteralen Ernährung.

We investigated the postoperative metabolism of patients undergoing gastric operation by beginning total parenteral nutrition pre- (group 1) and postoperatively (group 2). A third group remained fasting until 3 h after the surgical intervention. Because of the high serum glucose concentrations and the high glucose losses in the 24-h-urine on the operation day in group 1 and 2 only the basic glucose requirement (150--250 mg/24h) should be given in the early postoperative period. The low blood glucose concentration in group 3 and the elevated lactate values in group 2 underline this recommendation. Compared with group 2 and 3 group 1 had low free fatty acid concentrations of 250 muVal/l because of the continuous pre-, intra-, and postoperative infusion. Compared with normal metabolic conditions the free fatty acids don't seem to have the same insulinantagonising effect in the posttraumatic state. The fall of cholesterol after the surgical trauma reached its maximum after 12--15 h and amounted to about 40mg% in the first two groups. Albumin and total protein fell continuously in group 1 and 2. The electrophoresis in group 1 showed a rise of alpha 1-, and alpha 2-globulin to more than double the initial value, the beta-globulin showed only slight changes, the gamma-globulin dropped only slightly up to the 4th postoperative day. As a sign of an augmented catabolism the serum urea concentration rose during the postoperative state. Group 1 and 2 had a favourable nitrogen balance. The postoperative bilirubin rise could be held lower in group 1 compared to group 2.

[Two cases of perforation of the cecum following caesarean section (author's transl)]. / Zwei Fälle von Zökumperforation nach Sectio caesarea.

Two cases of perforation of the cecum following caesarean section are reviewed. Peritonitis, septic shock, and post-operative ileus are the most important causes of this life threatening complication. In addition, the operative technique is very important. The clinical signs are at first non-specific but the further course increases the likelyhood of the differential diagnosis of perforation of the Cecum. In the management, an early repeat laparotomy is important. The perforation is oversewn. Because of the possible renal and pulmonary complications post-operative intensive care is indicated.

[Differences in postoperative metabolism in reference to pre- and postoperative initiation of total parenteral nutrition. I]. / Unterschiede im postoperativen Stoffwechselverhalten bei prä- und postoperativem Beginn der totalen parenteralen Ernährung. I. Mitteilung.

We investigated the postoperative metabolism of patients undergoing gastric resection by beginning total parenteral nutrition pre- (group 1) and postoperatively (group 2). A third group remained fasting until 3 h after the surgical intervention. Because of the high serum glucose concentrations and the high glucose losses in the 24-h urine on the operation day in group 1 and 2 only the base glucose requirement (150--250 g/24/h) should be given in the early postoperative period. The low blood glucose concentration in group 3 and the elevated lactate values in group 2 underline this recommandation. Compared with group 2 and 3, group 1 had low free fatty acid concentrations of 250 micronVal/l because of the continuous pre-, intra-, and postoperative infusion. Compared with normal metabolic conditions, the free fatty acids do not seem to have the same insulin-antagonizing effect in the posttraumatic state. The fall of cholesterol after the surgical trauma reached its maximum after 12--15 h and amounted to about 40 mg% in the first two groups. Albumin and total protein fell continuously in group 1 and 2. The electrophoresis in group 1 showed a rise of alpha 1- and alpha 2-globulin to more than double the initial value, the beta-globulin showed only slight changes, the gamma-globulin dropped only slightly up to the 4th postoperative day. As a sign of an augmented catabolism the serum urea concentration rose during the postoperative state. Group 1 and 2 had a favourable nitrogen balance. The postoperative bilirubin rise could be held lower in group 1 compared to group 2.