[Pancreatic fistulae (author's transl)]. / Persistierende Pankreasfisteln.

The incidence of postoperative persistent external fistulae following inflammatory or traumatic lesions of the pancreas has increased over the past years. The choice of the optimum time for surgical rectification of this condition, as well as the operative technique is discussed in this review of the literature and 11 cases treated under our care over the past 15 years. It appears advisable 1) not to wait longer than about 6 weeks to carry out operative closure of the fistula (this period of time being necessary for the fistula to develop by granulation), 2) to undertake fistulo-jejunostomy with long section of the canal of the fistula, if possible, especially when applying the "pull through" method and 3) to place, if possible, the drainage tubing along the gastrocolic ligament, during the initial operation thereby selecting the most advantageous site for the development of any subsequent fistula.

[Cryosurgical treatment of tumors]. / Zur kryochirurgischen Tumorbehandlung

In 84 out of 164 carcinoma patients, admitted from June 1974 to September 1975 -- altogether 98 cryosurgical operations were performed according to the stage of the tumors. This was done as additional treatment to radical operation, as monotherapy, as additional treatment to palliative resection, or as a mono-palliative-therapy. After a discussion of the method, and a critical evaluation of the advantages and disadvantages (including new application areas) cryosurgery is proved to be superior to the conventional method in the destruction of tumor, e.g. in the liver, pancreas, roof of mesentery, and iliac region. The same is true when it is used as a palliative treatment in processes where access is difficult. On the other hand it seems that tumor-freezing shortens the life of patients, weakened through inanition.

[Unusual indication for 2/3 gastroduodenopancreatectomy in ulcer of the papilla, acute pancreatitis and massive ascites]. / Seltene Indikation zur 2/3 Gastroduodenopankreatektomie bei Papillenulcus, akuter Pankreatitis und massivem Ascites

UNLABELLED: A 32-year-old worker, an alcoholic with a history of duodenal ulcer for 2 years, was admitted because of weight loss, severe pain in the upper abdomen, and ascites. Serum lipase was 1200 mU. X-ray showed a possible postbulbar ulcer. Laparotomy was performed, and 10 1 ascitic fluid were evacuated, the latter caused by a peripancreatic callosity compressing the portal vein. FINDINGS: multiple necrotic areas in the pancreas; sequestrum cavity in the head of the pancreas connected with a callous ulcer at the duodenal papilla (histology: no malignancy). Two-thirds gastric resection, subtotal duodenopancreatectomy, extirpation of the gallbladder and common bile duct, splenectomy, gastroenteroanastomosis, and antecolic hepatojejunostomy were performed. After a transitory cerebrovascular incident, the patient was discharged on the 34th postoperative day. The patient has gained 11 kg, and works in the construction business. The pathogene development, frequency of complications, and therapy of postbulbar ulcer are described.

[Fatal outcome of a case with calcifying alcoholic pancreatitis (author's transl)]. / Unglücklicher Ausgang eines Falles mit kalzifizierender Alkoholpankreatitis

A case report is presented of a 38-year-old alcoholic welfare patient. Drainage of a pancreatic abscess, which had to be repeated, pyloromyotomy, cholecystectomy and sphincterotomy were undertaken in 1972 at another hospital. He was admitted on the present occasion because of weight loss, severe attacks of pain and diabetes. At operation multiple necrotic areas were found in the pancreas, with many stones in the parenchymatous tissue and in the main pancreatic duct and one large stone close to the pailla acting like a valve. Sub-total duodenopancreatectomy, resection of the pyloric region of the stomach, retrocolic hepaticojejunostomy and gastroenteroanastomosis was performed. The postoperative recovery took place without complications. 5 days after discharge the patient died in a hypoglycaemic coma at another hospital. He had administered 400 U. insulin to himself whilst in a drunken state. A short description is given of the aetiology and pathogenesis of calcifying pancreatitis. The choice of the surgical technique depends on the operative findings and the aim of therapy. Attention is called to the increase in late mortality in patients with pancreatectomy who do not abstain from alcohol.

[Perduodenal Sphincterotomy (author's transl)]. / Die perduodenale Sphinkterspaltung. (Ein neues Verfahren zur Behebung papillärer Abflussstörungen)

In spite of immaculate surgical technique conventional transduodenal sphincterotomy is attended by a non-lethal complication rate of about 5.8% and a mortality rate of about 4.5%, the most frequent cause being dehiscence of the duodenal suture. The primary and secondary pathogenesis hereof is explained by the particular predisposition duodenal laceration on account of its special anatomy and operative vulnerability. Bearing these facts in mind, the method of so-called perduodenal sphincterotomy (p. sph.) seemed to offer more promising results for the following reasons: 1. Splitting of the sphincter through a minute incision in the duodenum (stab incision with a tenotome). 2. The advantage of primary closure of the cystic duct in the transcystic approach with medium-sized probes for the splitting. Experimental evidence shows the cystic duct to be very resistent towards dilation and rupture, especially in the presence of inflammatory processes. From 1967 to 1973 in 1441 cases of gall-bladder surgery p. sph. was performed 374 times and transduodenal sphincterotomy only 121 times. The statistic evaluation of the outcome of both methods showed significantly better results with p. sph. with regard to the incidence of postoperative non-lethal complications and duration of hospitalization. Assessment of non-lethal postoperative mortality and follow-up studies on 79% of the operated patients over a period from 3 to 9 years showed that the results of both methods were equal. In our experience the p. sph. is not only advisable when sphincterotomy is generally indicated, but also in the following special situations: a) as so-called "emergency papillotomy" in poor-risk patients; b) if the transduodenal approach is impossible awing to technical difficulties (poor accessibility, low site of the papilla); c) if the indication for papilotomy is dubious it can be chosen as the less dangerous method; d) for reoperation on the sphincter. On account of its prevailing advantages this new method for repairing papillary drainage is practicable as a routine method in sphincteric surgery.

Investigation of cell-vitality in tumor specimen after cryosurgical operations.

Carcinomas of the gastro-intestinal tract were resected in 6 patients either by cryosurgery or in the usual, conventional manner without freezing the tumor. Cells from the tumorsections in each case were isolated by the use of enzymes and were examined for vitality following trypan-blue vital staining. In 5 out of 6 cryosurgical cases fewer than 10% of the cells were vital compared with sections from nonfrozen specimen. In one case the freezing method (cryosurgery) did not have any influence on the cell vitality. The cell-damaging effect of cryosurgical procedures proven in vitro suggests possible additional therapeutic effects in tumor-patients. Cryosurgery has proven useful in the treatment of hypertrophic prostates, when an unusual risk was involved. Recently it has also been used in the surgical treatment of carcinomas of the skin, the bladder and the cervix (1; 2, 3, 6). Approximately a year ago we started to use cryosurgery in our hospital in inoperable abdominal tumors. After freezing the primary tumor or its metastases a massive breakdown of the remaining tumor in-situ occurs, which might produce a palliative effect. As a result of freezing the tumor before resection, we expect a decrease in the spread of tumor cells during surgery and a stimulation and mobilization of specific immune response against the tumor (5). In order to increase our knowledge of the biological behaviour of cryosurgically treated tumors, we investigated in the present study teh cell-vitality in tumor tissues before and after cryosurgery.