[Abdominal wall defects caused by postoperative infections]. / Bauchwanddefekte durch postoperative Infektionen.

Infectious defects of the abdominal wall often result from deeper subfascial infections of the abdominal wall caused by a persisting intraabdominal inflammation or the result of laparotomy in peritonitis. Therapies applied are first of all the removal of the sources of infection and a careful debridement of the abdominal wall. There are several ways of temporarily covering the abdominal wall, but there is no ingenious solution. In our own experience the application of zip fastening and PGS nets have proved successful. In case of deeper infections of the abdominal wall the most awkward situation is the laying open of small intestine loops in a granulating wound which may lead to a revitalization of chronic small intestine fistulae. In these cases a differentiated and repeated surgical approach and extensive resection of small intestine parts, and consequently a high rate of complications and lethality cannot be avoided. Extensive defects of the abdominal wall exposing parts of small intestines after such operations require temporary covering and in this case we use Vypro net which, under the most favourable circumstances, can represent a final solution.

[Infected abdominal wall and burst abdomen]. / Die infizierte Bauchdecke und der Platzbauch.

Deep wound infection of the abdominal wall and postoperative abdominal wound rupture are dangerous complications of laparotomy that require emergency operative intervention. The wound infection quota after laparotomy is between 5 and 10%. While subcutaneous infections heal without consequences after wound treatment, deep infections of incisional wounds are a problem. The cause is often an intra-abdominal infection. There are some standard operational measures: consistent debridement of the necrotic parts, careful re-exploration of the intra-abdominal site and early fascial closure with special sutures. All other procedures depend on the individual case. Abdominal wall rupture only occurs in 1% of the cases, but the mortality is high (15-45%). Besides local wound factors and the technical aspects, there a many general causes. Abdominal wall rupture also requires emergency operation. Repeated wound closure without further steps is possible in half of the cases. The mass technique should be used. Both deep wound infections and rupture are important complications in the development of incisional hernias.

[Intuition in medicine and surgery. Prerequisites and limits]. / Intuition in der Medizin und Chirurgie. Voraussetzungen und Grenzen.

Intuition as a philosophical category is commonly acknowledged, but certainly not undisputed. In medicine being a practical science and partly characterized by irrational decisions, intuitive thinking in diagnosis and therapy seems to be an essential part of successful medical activity. Preconditions for an intuitive comprehension of the patient in its whole as well as an unusual process in clinical life are know-how, experience and profound knowledge of the normal and pathological findings. Besides, the physician's and surgeon's moral integrity setting limits to the acceptance of intuition has to be rated as an aid to decision-making. Increase of technics, standards and rules narrow the intuitive scope in a high degree. Loss of intuition as a tool of medical thinking and acting may lead to a spiritual impoverishment of our profession and to a technocratic medicine.

[Below-knee amputation according to Robb-Persson. Technique and clinical results]. / Die Unterschenkelamputation nach Robb-Persson. Technik und klinische Ergebnisse.

The successful rehabilitation and the quality of life of below-knee amputees depend to a great extent on the load-bearing capacity of the amputation stump. Robb and Persson's operating method, utilizing a sagittal cut was used in 154 be low-knee amputations in the period 1982-1992 that were retrospectively analysed. In 91% of the cases, advanced vascular disorders related to diabetes mellitus were the main cause for the loss of a limb. Postoperative mortality amounted to 31.8%, the re-amputation rate was 4.5%. Rehabilitation up to full walking capability was achieved by 75% of the surviving patients. 46 patients were re-examined between 1 and 6 years after amputation. In 85% of the cases the condition of the stump was found to be good to very good. The functional rehabilitation results are comparable to those of other operating methods. The advantages of the Robb-Persson below-knee amputation method are the simplicity of the technique and a secure and longlasting effective stump cover, resulting in favourable long-term results.

[Anterior rectum resection and abdominoperineal rectum excision: guidelines for decision making]. / Anteriore Rektumresektion und abdominoperineale Rektumexstirpation: Richtlinien für die Entscheidungsfindung.

Carcinomae of the upper third of the rectum are, almost without exception, and without loss of continence, resectable. The diagnosis of an intact sphincter function is significant in the pre-operative phase, when deciding whether to carry out an anterior rectum resection or an abdominoperineal rectum exstirpation. Concerning tumours as from G3 in the middle and distal thirds, a safety margin of at least 5 cm distal must be kept, thus making an anterior resection impossible. Stage IV tumours whose growth has infiltrated neighbouring organs or the pelvic wall are also not suitable for resection. Should anatomical circumstances such as excessive adipositae, very large carcinomae, narrow pelvis and enlargement of the uterus or prostata prevent the safe dissection of the mesorectum a sphincter-retaining operation is also not indicated. Oncologic safety is of the highest priority when considering such cases.

[Therapy and prognosis of gallbladder cancer]. / Therapie und Prognose des Gallenblasenkarzinoms.

Prognosis is the same poor as it was for patients with gallbladder carcinoma. Our experiences are based on a review of 92 cases of primary carcinoma of the gallbladder. It should be possible to improve the results of preoperative diagnosis in early stages (tumor-stage I and II) by using ultrasound more and more. Is the gallbladder carcinoma found at histopathological examination after cholecystectomy accidentally, an extended operation with resection of the liver segments IV b, V and VI and lymph node dissection of the hepatoduodenal ligament and of the pancreaticoduodenal and celiac lymph nodes must be recommended. In consideration of risk factors such as age, sex, bigness of gallstones and pathological ultrasound findings we recommend an enlargement of indication for cholecystectomy by asymptomatic cholecystolithiasis and cholecystic disease without gallstone. We don't advocate a prophylactic cholecystectomy.

[Post-traumatic pancreatic pseudocyst in children]. / Posttraumatische Pankreaspseudozyste im Kindesalter.

This is a report on a posttraumatic pancreas-pseudocyst of a six year old girl. The fast grow of this pancreatic pseudocyst demanded the surgical intervention in form of the cystogastrostomia. The most important factor for the decision for the operation was the sonographic imagic.

[Late results following ankle joint osteosyntheses]. / Spätergebnisse nach Sprunggelenksosteosynthesen.

Follow-up checks were performed on 106 patients, between four and 16 years after osteosynthesis on the upper ankle joint. Good to very good results by Weber's criteria were recorded from 57.5 per cent. That percentage had been much higher in other comparable studies. The high percentage of poor results from the authors' patients was attributed to malreduction, incorrect osteosynthesis, and delay of surgical treatment in many cases. The prognosis was found to be clearly deteriorated by distal tibial edge fractures. Long-time results can best be favourably influenced by high-accurate reduction and osteosynthesis and high rates of primary operations.

[Pathogenesis of cancer of the operated stomach]. / Zur Pathogenese des Karzinoms im operierten Magen.

Carcinoma in the postsurgical stomach has to be considered as a prognostically hopeless late complication in the wake of reflux-causing stomach operations. Morphological, autoradiographic, microbiological, and biochemical investigations of animal models and analyses of 19,595 postmortem records have supported the view that enterogastric reflux, bacterial colonisation, primarily by nitrate-reducing enterobacteria, alteration of the intragastric pH condition as well as consecutive morphological and functional changes to gastric mucosa are factors of pathogenetic relevance. Reflux-preventing surgical methods should be adopted to handle the problem, among them application of Roux-en-Y anastomosis or jejunal interposition following gastrectomy. Systematic postsurgical follow-up care is considered to be just as important.

[Animal experiment studies on the role of ischemia in the pathogenesis of acute pancreatitis]. / Tierexperimentelle Untersuchungen zur Rolle der Ischämie in der Pathogenese der akuten Pankreatitis.

The influence of a short-term ischemia of the pancreas for the pathogenesis of a hemorrhagic necrotising pancreatitis was investigated in 28 mongrel dogs. Ischemia of the pancreas in 20 minute intervals repeated three times did not leave any macroscopic, histologic or electron microscopic changes and no alterations of the level of the alpha-amylase, the lipase, and the glucose in the serum. An ischemia of 20 minutes' duration by starvation of the celiac artery and the superior mesenteric artery produces a hemorrhagic necrotising pancreatitis under the precondition of a following pancreatic edema by ligature of the pancreatic duct and secretomotoring with secretin and pancreozymin. The necrosis starts histologically in the perilobular adipose and affects the parenchyma later. Whether the lipase is the starting enzyme for the acute pancreatitis or only conditions the early adipose necrosis should be discussed after these findings. Already a fugitive pancreatic edema produces a hemorrhagic necrotising pancreatitis after previous ischemic damage.

[Isolated acinus cells in the significance of ischemia in the pathogenesis of acute pancreatitis]. / Untersuchungen an isolierten Azinuszellen zur Bedeutung der Ischämie in der Pathogenese der akuten Pankreatitis.

Additionally to the pancreatic edema short-time ischemia represents an essential factor in formation of an experimentally induced acute pancreatitis. The consequences of such an ischemia at the guinea pig pancreas on the cellular energy metabolism were investigated in isolated exocrine cells. It was shown that intact acinus cells can be isolated as well as from normally perfused and ischemic pretreated pancreata. The energy metabolism was characterized by the difference between resting and maximum respiration after stepwise uncoupling. This parameter represents a dynamic measure and allows an estimate of the load capacity of the cellular energy metabolism. Exocrine cells isolated after ischemia (20 minutes), had a smaller load capacity than cells from normally perfused pancreata. This indicates an alteration of energy supply after ischemia. The consequences of this reduced supply on energy dependent repairing and protective mechanisms are discussed in terms of the pathogenesis of acute pancreatitis.