[Primary adenocarcinoma of the jejunum. Diagnostic challenge by a rare tumour]. / Primäres Adenokarzinom des Dünndarms. Diagnostische Herausforderung durch eine seltene Tumorentität.

HISTORY AND ADMISSION FINDINGS: A 75 year old patient presented for many years with nausea and vomiting. The exacerbation of clinical presentation caused further investigation of the small bowel. INVESTIGATIONS: The source of nausea and vomiting had been achieved by double contrast enteroclysis in the upper jejunum and it was confirmed with a coloskop. TREATMENT AND COURSE: Histological result was a primary small bowel adenocarcinoma. The primary definitive therapy was a radical resection of the jejunal neoplastic loop, also as an important prognostic factor. Because of the tumour stadium adjuvant chemotherapy was not necessary. CONCLUSIONS: Tumours of small bowel are always a diagnostic challenge. With the help of an primary small bowel adenocarcinoma we suggest an algorithm of diagnostic possibilities adjusted to the clinical situation.

Functional T lymphocytes infiltrate implanted polyvinyl alcohol foams during surgical wound closure therapy.

Vacuum-assisted closure involving the implantation of polyvinyl alcohol foam is a technique recently developed for the treatment of patients suffering from either wound infection or chronic wounds. This method has been shown to improve and accelerate wound healing. However, little is known about the cell populations that infiltrate the foam, and their potential role in resolving the infection and promoting granulation tissue formation. Our study demonstrates that wound-implanted foams are mainly infiltrated with granulocytes, but that mononuclear cells, including macrophages and minor populations of T, B and natural killer lymphocytes, are also present. We show that foam-infiltrating T cells, especially CD4(+) T cells, constitute a phenotypically and functionally heterogeneous population influenced by wound-infecting bacteria. Thus, T lymphocytes could play a role in wound cleansing. In addition, our data indicate that implanted polyvinyl alcohol foams might be suitable microenvironments for manipulating T cell-mediated immune responses in patients.

[Benign bile duct stenoses. Treatment with flexible metal wire stent or silicone prostheses (Yamakava) in nonresectable stenoses or high surgical risk cases]. / Benigne Gallenwegstenosen. Behandlung mit flexiblen Metallgitterstents oder Silikonprothesen (Yamakava) bei nichtresezierbaren Stenosen oder hohem Operationsrisiko.

INTRODUCTION: High benign biliary stenoses, which can occur as a complication of disease or surgery, may be difficult to correct by open surgery and may also carry a high risk. An alternative to surgery is the percutaneous implantation of a flexible metallic stent or silicon prosthesis at the affected site. METHODS: Twelve patients with benign biliary stenoses have been operated on in our department since March 1992, and the therapeutic success was reviewed in this study. RESULTS: Six received a Palmaz stent and six a silicon prosthesis, with a follow-up after completion of treatment of more than 7 years and more than 3 years, respectively. Fifty percent of the patients with a stent experienced no problems and 66% of the stents remained patent (including one requiring operative intervention to restore patency). No further surgery was necessary in any of the patients with a silicon prosthesis. CONCLUSION: When the advantages and disadvantages of the various procedures are considered, long-term splinting with a wide-lumened silicon prosthesis (Yamakava) appears to be a promising alternative to surgery for the treatment of benign biliary stenosis.

Nebennierentuberkulose als seltene Ursache einer adrenocorticalen Insuffizienz (Morbus Addison).

Adrenocortical insufficiency (Addison's disease) is a functional diagnosis. At the beginning of this century, tuberculosis was recognized as the main etiological cause (50-70%). Today, however, tuberculosis represents only 10% of the cases. Adrenocortical insufficiency is mainly caused by autoimmune adrenalitis (more than 50%). Unilateral adrenocortical disease is usually asymptomatic or presents, as in the case described, with minor symptoms. This case report of adrenal tuberculosis illustrates the current challenges of diagnosis and therapy.

[Recurrent soft tissue infections after accidental inoculation with BCG vaccine]. / Rezidivierende Weichteilinfekte nach akzidenteller Inoculation mit BCG-Impfstoff.

Complications after BCG vaccine (bacilli Calmette-Guérin) occur rarely. They can reach from a local acute abscess to chronic ulceration's. Therapeutically concepts of these complications range from conservative to operative treatment. In the following case history recurrent soft tissue infections occurred after accidental inoculation with BCG vaccine. The time course of these recurrent infections with its therapeutic options is discussed and a treatment strategy is suggested. Currently, radical excision combined with antituberculotic treatment seems to be the most promising therapy of this specific soft tissue infection.

[Preoperative angiographic marking of angiodysplasia of the small intestine with platinum coils]. / Präoperative angiographische Markierung einer Angiodysplasie im Dünndarm mit Platinspiralen.

In patients with occult lower gastrointestinal bleeding, locating of the source of hemorrhage can be quite difficult. While multiple diagnostic tests, like arteriography, enteroclysis, nuclear scans, may confirm a small bowel source of bleeding, precise localization allowing a directed, conservative surgical resection may be problematic. We describe a patient presenting with hemorrhage from an angiodysplasia in the small intestine. The preoperative use of highly selective angiographically placed platinum coils into the feeding artery allowed us to precisely locate the angiodysplasia radiographically during operation and to resect a conservative length of small intestine. We believe that preoperative bleeding site localization with platinum coils is a simple, effective tool to aid surgical resection of small bowel angiodysplastic lesions.

[Lichtenstein alloplastic repair of inguinal hernia]. / Die alloplastische Reparatur des Leistenbruchs nach Lichtenstein.

Tension-free repair, a prerequisite for long-term stability, cannot always be achieved with conventional techniques established for groin reconstruction. Lichtenstein gathered substantial experience simply by closing the hernia in a tension-free fashion using prosthetic material. However, most surgeons fearing graft infection are reluctant to further evaluate this technique. In a feasibility study we entered 70 patients (29 patients with recurrent hernia) receiving a polypropylene mesh (Marlex) to bridge the defect from the inguinal ligament to the internal oblique muscle. Only 1 wound infection and 1 local hematoma requiring reoperation were observed. Nearly 2 years follow-up data revealed no case of recurrence. The Lichtenstein procedure deserves more attention from surgical community and might be a reliable technique esp. in large hernias and redos.