[What patient needs which stoma?]. / Welcher Patient braucht welches Stoma?

Patients with small bowel obstruction hardly ever need a stoma. Advanced peritoneal carcinomatosis (mostly due to colorectal or ovarial cancer) may require a proximal palliative fecal diversion. Likewise stomatas for colonic ileus became less frequent. The type of the stoma and its necessity depend on the patient's condition, on the duration and the cause of the obstruction, i.e. on the condition and the damage of the bowel. Terminal sigmoidostomy has its place mainly as a part of the Hartmann's procedure treating sigmoid diverticulitis with inflammatory pseudotumor, with free perforation and diffuse peritonitis. For oncological reasons Hartmann's resection should not be performed for rectal cancer--except for very old patients in bad condition. Colonic ileus due to colorectal cancer can usually be treated by resection and primary anastomosis. In case of delayed ileus it may be better to resect the proximal colon and to perform an ileocolostomy to avoid complications. Risky anastomoses due to damaged bowel or for patients in bad condition may be protected by a loop-ileostomy or a loop transverse colostomy. They are both easy to perform and to close with very few complications. Summarizing we may conclude that very few patients really need a stoma today--patients showing special risks such as diffuse peritonitis, absceding inflammation or damaged bowel as a result of delayed ileus.

An unusual manifestation of Meckel's diverticulum: bleeding and perforation--a case report.

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Bleeding of the diverticulum from a peptic ulcer due to ectopic gastric mucosa makes up 25% of all complications in the disease. We report a case of a 20 year old male with chronic anemia, severe hematochezia and perforation due to Meckel's diverticulum. Segmental small bowel resection was performed. Difficulty of preoperative diagnosis is discussed, indication for incidental diverticulectomy is established and the literature reviewed.

[Therapy of acute pancreatitis]. / Therapie der Pancreatitis acuta.

From 1973 to 1990 190 consecutive patients were admitted to the department of surgery of the Stadtspital Waid, Zurich, with a diagnosis of acute pancreatitis. 53 patients received conservative treatment, 93 patients with acute pancreatitis thought to be due to gallstones underwent cholecystectomy, in 23 cases combined with choledochotomy. 44 patient underwent pancreatic surgery. 10 diagnostic laparotomies, 14 necrosectomies, 6 pancreatic left resections and one subtotal pancreatectomy were performed. 9 pseudocysts and 4 pancreatic abscesses had to be drained. Over all mortality for operated patients was 29.5%, exceeding 50% for patients with operation within the first week of the disease. During the first ten years of our study we performed operations earlier and more often than in the following years (26 versus 17%). This more conservative management resulted in a marked reduction of mortality and complications. Today we try to control the first 8 to 10 days of the attack by intensive care and postpone pancreatic operations whenever possible to the second week.

[Laparoscopic cholecystectomy. Results and experiences 1 year following introduction of a new surgical technique (139 cases)]. / Die laparoskopische Cholezystektomie. Ergebnisse und Erfahrungen ein Jahr nach Einführung der neuen Operationstechnik (139 Fälle).

Laparoscopic cholecystectomy is on the way to become the procedure of choice for treatment of uncomplicated cholelithiasis. First experiences are summarized: Within the first year after introduction 139 patients, 100 women and 39 men, have been treated by this novel technique. 33 open cholecystectomies were carried out in the same period. In addition to simple cholecystolithiasis 11 patients had prior biliary pancreatitis and/or sphincterotomy because of choledocholithiasis, 16 patients had suffered before from acute cholecystitis, 3 patients were operated on with the diagnosis of acute cholecystitis and 3 patients underwent simultaneous laparoscopic intervention. Seven times the laparoscopic procedure had to be converted into an open one because of intraoperative complications, twice because of a lesion to the common bile duct, three times because of intractable bleeding, once because of obscure anatomic conditions and once because of a technical failure in establishing the pneumoperitoneum. Four postoperative complications could be treated conservatively. In the average, patients complained about pain for 2 days, stayed in the hospital 4.4 days and assumed their usual activity after 13 days. An extension of indications for laparoscopic cholecystectomy should be sought stepwise according to gained experience. The problem of technical training of surgeons persists and must be solved in priority.

[Anastomosis of the facial nerve using fibrin glue, apropos of 60 cases]. / Anastomose du nerf facial par colle de fibrine exclusive, à propos de 60 cas.

The facial nerve was repaired with only fibrin glue anastomosis in 60 cases. The facial nerve was repaired by end-to-end (21 cases) or cable graft (28 cases) anastomosis. In 11 cases, a hypoglosso-facial anastomosis was performed. Grade 3 facial regeneration was observed in 62% of cases after one year follow-up. End-to-end or cable graft anastomosis provided the best results when the anastomosis were glued into the petrous bone or the parotid. The anastomosis should be performed without tension and the vascularization of nerve should be preserved if possible.

[Cancers of the soft palate. Apropos of 135 cases]. / Les cancers du voile du palais. A propos de 135 cas.

Results of treatment of 135 cases of squamous cell carcinoma of soft palate treated between 1962 and 1983 in the ORL department of Hôpital Laennec, Paris, showed prognosis to be related to 3 main factors. Firstly, the frequency of syndromes and metasynchronous multiple primary cancers. Secondly, the presence of local recurrences. Their frequency should be reduced by performing first intention excision of the tumoral site with wide extension to the anterior and particularly the posterior pillars, and by the routine use of induction chemotherapy. Thirdly, nodal recurrences that can be prevented by routine prophylactic treatment of bilateral cervical lymph chains.