[Atypical blast injury of the left hand : Multiple trauma with severe injury especially of the left hand]. / Atypische Explosionsverletzung der linken Hand : Polytrauma mit schwerer Verletzung insbesondere der linken Hand.

There is an accumulation of blast injuries on New Year's Eve due to fireworks.During an attempt to manufacture a firework the substances being mixed in a mortar exploded. The left hand of the patient was severely injured.During the operative treatment with radical débridement and generous amputation without osteosynthesis, a basic hand function according to Entin could initially be preserved; however, at a later stage the fourth finger could not be preserved, so that a prosthesis became necessary.This case report shows the importance of expertise in hand surgery in the treatment of such severe injuries. A toe-to-hand transplantation represents an additional treatment option.

[Not "only" a dislocation of the hip: functional late outcome femoral head fractures]. / Wenn die Hüfte nicht "nur" luxiert: Funktionelle Spätergebnisse nach Hüftkopffrakturen.

BACKGROUND: Traumatic hip dislocation combined with fracture of the femoral head is a rare condition for which little known in terms of long-term prognosis. The aim of the retrospective study presented here was to evaluate the clinical and radiological outcome of this specific injury. PATIENTS AND METHODS: In a 23 year period, 18 patients (17 male) with an average age of 25.6 (range 15-55 years) were treated. There were four type-I, three type-II, no type-III, and 11 type-IV fractures according to the Pipkin classification (1957). RESULTS: The average time to sufficient reduction was 136 min (60-420 min), two by open means. A total of 16 patients were operated for open reduction and internal fragment fixation, 13 through a dorsal approach. All patients filled out a standardized questionnaire, and clinical and radiological examinations were also carried out on average 12.6 years (range 59-247 months) after injury. Four scoring systems were used to classify the outcome: Thompson and Epstein (1951): very good = 1, good = 10, fair = 4, poor = 3; Merle D'Aubigne (1954): very good = 9, good = 5, fair = 0, poor = 4; Harris (1969): Pipkin I = 81 points, Pipkin II = 97 points, Pipkin IV = 73 points (mean); Brooker (1973): grade I = 5, grade II = 1, grade IV = 2. CONCLUSION: Quality of life was not reduced in most patients in the long term, however three of four patients suffering Pipkin type-IV fractures developed functional restrictions with poor results. We conclude that acute reduction of the dislocated joint and anatomical reconstruction of the femoral head instead of primary hip replacement may end in good to excellent results in type-I and type-II fractures. Due to the young age of these patients, joint reconstruction should always be the first choice even in type-IV fractures with a higher probability of poor prognosis.

[Surgical therapy of unspecific and specific Spondylodiscitis]. / Operative Therapie der unspezifischen und spezifischen Spondylodiszitis.

AIM: The aim of this study was to evaluate the clinical and radiological results of surgical treatment of thoracic and lumbar vertebral osteomyelitis by means of one-stage extrafocal posterior stabilisation, anterior debridement, and anterior column reconstruction. METHOD: A retrospective analysis of the peri- and postoperative parameters of 62 patients with a clinical and radiographic follow-up of 2.6 years that were available for 46 patients was performed. In 42 cases, the anterior column was restored with structural bone grafts, in 20 patients, expandable titanium cages filled with morsellised autologous bone and antibiotic collagen sponges were used. To assess the course of spinal alignment a radiometric analysis was undertaken. Furthermore, the Roland-Morris score (RMS) was applied to evaluate the back pain-related disability. RESULTS: The diagnosis was made no earlier than 2.7 months after the first symptoms. Preoperatively, 40 % of the patients presented with neurological impairment, of these 76 % improved after surgery. Staphylococcus aureus was the most common pathogen isolated (32 %), Mycobacterium tuberculosis was found in 11 % of the patients. Except for one patient with revision for persistent infection and consecutive failure of the bone graft, primary eradication of the infection was achieved in all cases. At follow-up, bony fusion was radiographically observed in all patients. When using cages, the segmental loss of correction was significantly lower than when using bone grafts (1.0 vs. 4.1 degrees ). At follow-up the RMS averaged 6.6. CONCLUSION: One-stage extrafocal posterior stabilisation combined with anterior debridement and anterior column reconstruction with bone grafts or titanium cages is a safe and effective strategy for patients with vertebral osteomyelitis in need of surgery. Titanium cages have proven to be biomechanically advantageous, especially in cases of extensive destruction and are not associated with higher rates of persistence or recurrence of infection compared to autologous bone grafts.

Evaluation of an in situ setting injectable calcium phosphate as a new carrier material for gentamicin in the treatment of chronic osteomyelitis: studies in vitro and in vivo.

A study was performed to investigate the effectiveness of hydroxyapatite cement (HAC) as a new carrier system in the treatment of chronic, posttraumatic osteomyelitis. In the in vitro study, release of gentamicin from standard cylinders of HAC were measured by agar diffusion test. As a representative for mechanical properties, compression strength was measured in order to detect changes when mixing HAC with gentamicin. In the in vivo study, bone infection was induced according to the model of Norden by injection of 1 ml Na-morrhuat and 3 x 10(6)CFU Staphylococcus aureus. After 3 weeks, when chronic stage of infection was obtained, 17 animals were treated by debridement and filling the marrow either with HAC alone or HAC mixed with gentamicin (32 mg/g). Animals of the control groups were left untreated. After 6 weeks, all animals were sacrificed. Hematological, radiological, microbiological and histological examinations were carried out by covered investigation. Best evidence of the efficiency of treatment was observed in histopathological and microbiological findings. In all swabs of the control groups, taken 6 weeks following infection S. aureus were detected which were clonal to the strain used for induction of osteomyelitis. In HAC/gentamicin-treated animals, no growth was detectable after 7 days of culturing in BHI bouillon. In the HAC/gentamicin-treated group, there was no histopathological evidence of infection. In all other groups different stages of chronic osteomyelitis were found. No side effect was observed, neither locally nor systemically by HAC or gentamicin. Therefore, HAC is considered to be a very effective carrier for antibiotics in treatment of chronic, posttraumatic osteomyelitis.

[A new irrigation-suction boring system facilities low-pressure intramedullary boring of isolated swine femurs]. / Ein neues Spül-Saug-Bohrssystem ermöglicht die druckarme Markraumbohrung an isolierten Schweinefemora.

AIM: Intramedullary nailing is the treatment of choice for the stabilization of fractures of long tubular bones. An important disadvantage of this method is the increase in intramedullary pressure and the resulting release of fat into the venous blood system during reaming of the medullary canal. We have developed a new type of rinsing-suction-reamer (SSB) in order to minimize these disadvantages. Trials were initiated to investigate whether it is possible to ream the medullary canal with the SSB without pressure increase in comparison with the standard AO-reamer (AOB). METHODS: Reamed intramedullary nailing was performed in 20 isolated pig femora. The intramedullary pressure was recorded continuously. RESULTS: While stepwise reaming was performed, the pressure only rose above the physiological level in AOB. During insertion of the guide wire and the nail, comparable values were measured for AOB and SSB. CONCLUSION: Our experiments show that reaming of the medullary canal is possible without a pressure increase using the SSB in comparison with AOB.

A case of "boomerang" bullet ricochet.

A .375 Holland & Holland Magnum Winchester Fail Safe bullet was fired against a steel plate. The big-game hunting bullet (17.4 g, approx. 810 m/s) has a solid copper-alloy hollow point design including a lead core limited to the rear portion. The range of firing was 20 m and the angle of impact was 90 degrees. A large fragment (10.9 g) consisting of the main part of the copper portion was deformed in a peculiar manner similar to a tube or ring and wounded the left hand of the person shooting. The unique fragment trajectory strictly against the line of fire and the velocity sufficient to shatter bone after a distance of 20 m can be explained by an extraordinary deformation mechanism. Unlike in tissue, the high resistance of the steel plate caused the lead core in the rear of the bullet to move forward perforating the central copper barrier behind the hollow point cavity. Thus, the peculiar fragment was created. The subsequent backwards acceleration of the ring-like fragment was probably caused by the partly elastic impact of the copper-alloy portion against the hard steel plate. Due to the perpendicular impact resulting in a centric and symmetrical deformation, the fragment moved in a direction exactly backwards along the original line of fire.

[Therapy and prognosis of enchondroma of the hand]. / Therapie und Prognose bei Enchondromen der Hand.

Enchondromas are the most common bone tumors of the hand. In a retrospective study, medical records and radiographs of 112 patients were reviewed. These patients were operated on between January 1973 and June 1997. After extirpation of the tumor, the defect was preferably treated with bone grafting in 102 patients. A malignant transformation (chondrosarcoma) was diagnosed in 2 patients. Follow-up examination of 92 patients with a mean follow-up of 1.6 years (range: 7 months to 14 years) yielded excellent or good results in 76 patients (82.6%), according to the evaluation scheme of Wilhelm and Feldmeier. Four recurrences were probably related to an incomplete resection of the tumor. The authors conclude that enchondromas of the hand should be treated surgically to prove the diagnosis and to prevent a pathologic fracture.

The use of an in situ curing hydroxyapatite cement as an alternative to bone graft following removal of enchondroma of the hand.

Following curettage of enchondromata of the phalanges we filled the resultant bone cavity with hydroxyapatite cement in eight patients to avoid cancellous bone grafting. This material differs significantly from the ceramic hydroxyapatite commonly used in clinical practice. It is produced by the combination of two calcium phosphates which, in the presence of water, form a paste that cures to a solid implant with a microporous structure. Like ceramic hydroxyapatite, this cement is highly biocompatible and does not provoke a foreign body giant cell reaction, a sustained inflammatory response or a toxic reaction. We performed a prospective study with X-rays and clinical assessment up to 1 year after the operation. There were no complications, and all patients regained full function of the hand.

[Fractures of the distal forearm. Which therapy is indicated when?]. / Brüche am distalen Unterarm. Welche Therapie ist wann indiziert?

Every 15th case of a bone fracture in patients aged more than 65 years concerns the distal radius in Germany. This means the second rank of all geriatric fractures following fractures of the hip. According to the approved and increased apply of operative stabilisation there are arising more and more reports upon poor results of nonsurgical treatment. Especially in older patients the main reason for the discontented outcome of conservative management is osteoporosis, which is an affirmative circumstance for the genesis of fracture but also for secondary mal-aligment of comminuted thin cortical walls and crushed porotic cancellous bone. The rational of this perception is either filling artificial bonelike tissue--avoiding the need of harvest cancellous bone graft from a second surgical site--into the resultant cavity following reduction, or supplementary trans-styloidal or intrafocal K-wiring until remodeling is obtained within an average of 10 weeks. Both arrangements should be secured in addition with a trans-articular external fixation. According to a literature review and our own experiences of 92 follow up cases of distal radius fractures in patients who were older than 65 years this procedure seems to be superior at present for A-2, A-3 and most cases of type-C fractures of the distal radius, despite the disadvantage of joint immobilisation for about 5 weeks. Type B-fractures, however, should be provided better with an internal fixation. Sudeck's algodystrophia is the mostly serious complication of the distal radius fracture and its treatment in older patients. Recognising punctually neurovegetative stimulated patients, treat them cautiously and coming in on their special situation is usually the best way to reduce this risk. To pay attention to the topography of the nerves during the application of the pins and to act at the first signs of complications immediately is also very important. We examined 92 patients who were older than 65 years with a fracture of the distal end of the radius in a follow up study. In this group we treated 62 distal radius fractures of the type A and C of the AO classification with an trans-articular external fixateur and with supplementary measures if necessary. Additionally we filled the bone cavity with an artificial bone graft (Endobon) following closed reduction in 32 cases, 12 times a complementary K-wiring was added and in 8 cases the external fixateur was combined with both. Sudeck's disease appeared in 1.1% of all cases. In 5 cases we recorded complications with an obligation to treatment as well. Lesion of the superficial branch of the radial nerve were noted in 2 cases (2.1%), as far as we extended the surgical approach for the pin application. Technical problems from the site of the external fixateur appeared in 3 cases, two of them could be attributed to an infirmity of the fixateurs ball joints which is now eliminated by the producer. 4 patients with a type-B fracture was provided by plating, additionally 4 patients with a type-C fracture because of non-compliance. The external fixateur is an essential part of a differentiated treatment with reference to the several types of distal radius fractures in older patients.

Results of transarticular fixator application in distal radius fractures.

From January 1989 until October 1993, 102 patients with 103 distal radius fractures were included in a prospective study with the Pennig wrist fixator (Orthofix, Srl, Italy). 90.5% of these patients were reviewed with a minimum follow-up of 12 months. Using the functional outcome score according to Gartland and Werley, we obtained 41% excellent, 46% good, 10% fair and 3% poor results. Additional procedures such as K-wires, bone grafting or radio-ulnar stabilizations were carried out in 61% of cases. The complications included five fixator displacements, four of which happened with the prototype used until the first half of 1990. Two major pin-track-infections required surgical intervention, three patients in the beginning of the series encountered irritations of the superficial radial nerve, one pin cut out of the second metacarpal bone and one patient sustained algodystrophy. The results show the significance of an anatomical reduction, the restoration of the radial length seems to be of special importance to obtain good functional outcome. This can not always be achieved with the fixator alone; often additional procedures are required in order to obtain an anatomical joint reconstruction. The advantage of this fixator lies in its lightweight and small-size design as well as in its easy application technique and the possibility to carry out the reduction after mounting the fixator with the double ball joint centered on the fracture level and the carpus.

CT of metal implants: reduction of artifacts using an extended CT scale technique.

PURPOSE: The purpose of this work was to use an extended CT scale technique (ECTS) to reduce artifacts due to metal implants and to optimize CT imaging parameters for metal implants using an experimental model. METHOD: Osteotomies were performed in 20 porcine femur specimens. One hundred cobalt-base screws and 24 steel plates were used for osteosynthesis in these specimens. Artificial lesions were produced in 50 screws, such as osteolysis near the screws (mimicking lysis due to infection, tumor, or loosening), displacement of the screws, as well as fractures of the screws. All specimens were examined using eight different CT protocols: four conventional (CCT) and four spiral (SCT) CT protocols with different milliampere-second values (130 and 480 mAs for CCT, 130 and 300 mAs for SCT), kilovolt potentials (120 and 140 kVp), and slice thicknesses (2 and 5 mm). The images were analyzed by three observers using a standard window (maximum window width 4,000 HU) and ECTS (maximum window width 40,000 HU). Receiver operating characteristic analysis was performed, and image quality was assessed according to a five level scale. RESULTS: Metal artifacts were significantly reduced using ECTS (p < 0.05). The highest diagnostic performance was obtained using ECTS with the thinnest slice thickness. Metal artifacts were more pronounced using SCT. In this experimental model, exposure dose and kilovolt potential had no significant impact on diagnostic performance (p > 0.05). CONCLUSION: ECTS improved imaging of metal implants. In this study, no significant effects of exposure dose and kilovolt potential were noted. Metal artifacts were more prominent using SCT than using CCT.

[Callus distraction of the first metacarpal bone for thumb reconstruction after traumatic amputation]. / Die Kallusdistraktion des ersten Mittelhandknochens zur Daumenrekonstruktion nach traumatischer Amputation.

From 1990 to 1997, callus distraction of the first metacarpal bone was performed on 34 patients with a traumatic amputation of the thumb, if replantation was not possible. After a period of 7 +/- 11 months (range, 1-48), a corticotomy and continuous distraction with an external fixator was carried out. Of the patients, 31 (91%) were reviewed after treatment. The follow-up period range was 41 +/- 32 months. With this method, the average lengthening of the thumb was 78% in comparison to the uninjured side. Complications were rupture of the callus in one case, four patients suffered a superficial wound infection, and seven patients showed pin tract infection without osteitis. At follow-up examination, 20 patients (64.5%) showed excellent, 9 (29%) good and 2 patients (6.5%) unsatisfying results.

[Late sequelae and treatment strategies of distal radio-ulnar dissociation after undetected Essex-Lopresti lesion]. / Spätfolgen und Behandlungsstrategien der distalen Radioulnardissoziation nach unerkannter Essex-Lopresti-Läsion.

The Essex-Lopresti lesion, a combination of radial head fracture and distal radioulnar dislocation, rarely occurs but nevertheless represents a frequently unknown result after forearm fracture. The responsible physician soon has to initiate surgical treatment to prevent his patient from permanent pain of the wrist. Previously unrecognised distal radioulnar dislocation remains to be an unsolved problem. A generally accepted management concept does not exist. Since rupture of the membrana interossea nearly ever occurs, resection of the radial head is followed by radial shifting and seems to be obsolete under these circumstances. An exemplary case is presented and surgical management in this situation is discussed.

[The treatment of unstable fractures of the distal radius using a bridging external fixator. Results from a long-term evaluation]. / Die Behandlung instabiler distaler Radiusfrakturen mit einem transarticulären Fixateur externe. Ergebnisse einer Langzeitbeobachtung.

INTRODUCTION: The aim of our study was to evaluate external fixation in the treatment of unstable distal radius fractures in a long-term follow-up. METHODS: Within 8 years 174 patients with severely displaced distal radius fractures were included in a prospective study and treated with an external wrist fixator (Orthofix Srl, Italy). A total of 148 patients were reviewed with an average follow-up time of 28 months. RESULTS: Using the functional outcome score according to Gartland and Werley, we obtained 29.3 % excellent, 42.5 % good, 10.3 % fair and 2.9 % poor results; 14.9 % of the patients were not available for follow-up. Additional procedures were carried out in 54.1 % to obtain dorsal stabilization. The list of complications included two major pin-tract infections requiring surgical intervention, one pin cut out of the second metacarpal bone, one fixator dislocation, and one patient had algodystrophy. The length of the radius and joint congruity did not significantly from the situation when the fixator has been removed at the end of the treatment. CONCLUSION: The results show the importance of anatomical reduction, and especially restoration of radial length, in order to obtain good functional outcome.

[Significance of score systems in open complex trauma of the pelvis]. / Zur Bedeutung von Score-Systemen beim offenen Komplextrauma des Beckens.

A quantitative analysis of the injury severity of 40 patients with open pelvic fractures was performed. Data were analyzed using the Statistical-Analysis-System (SAS Institute Inc., Cary, NC) with regard to patients' age, gender, trauma mechanism, classification and nature of the pelvic injury, associated lesions, and mortality. Trauma-scoring included the Hannover-Polytrauma-Score [11], the Pelvis-Fracture-Scale [2] and the Pelvis-Score [19]. Five patients died. The survivors had a mean Polytrauma-Score of 34.1, the nonsurvivors had a mean Polytrauma-Score of 44.6 (p = 0.7; Mann-Whitney-test). The nonsurvivors required highly significant more units of blood transfusions than the survivors (49.4 vs. 14.1; p = 0.003; Mann-Whitney-test). The loss of blood was related to the severity of the injury according to the Polytrauma-Score. There was no significant difference in the Pelvis-Fracture-Scale of survivors and nonsurvivors. Neither there was a significant correlation between the fracture type and the Polytrauma-Score nor between the fracture type and the mortality. The Pelvis-Score--with the variable "bleeding" defined as "major vessel lesion"--was significantly higher in the nonsurvivors than in the survivors (12.0 vs. 4.9; (p = 0.04; Mann-Whitney-test). In conclusion, in this retrospective study the Polytrauma-Score and the Pelvis-Score proved effective regarding some important aspects of the prognostic estimation of the general injury and the pelvic trauma, respectively. The Hannover-Pelvis-Fracture-Scale allows an exact documentation of the pelvic trauma as it pays proper attention not only to the fracture classification but especially to the soft tissue damage.

Photoablation of bone by excimer laser radiation.

BACKGROUND AND OBJECTIVES: The aim of the present study was to compare the usefulness of mechanical osteotomy tools and common laser systems with the ultraviolet (UV) laser in the field of the central nervous system and its bony capsule. STUDY DESIGN/MATERIALS AND METHODS: The cranial bones of 42 living rats were treated with UV laser radiation with wavelengths of 193 nm and 248 nm. The morphology and physical effects were evaluated by means of optical and scanning electron microscopy. RESULTS: This study shows the special characteristics of excimer versus infrared lasers or mechanical tools, such as high precision, no thermic damage, little depth effect, and no delay of healing processes. CONCLUSION: The excimer laser is an interesting instrument for microsurgery of bones in orthopaedics, neurosurgery, and otolaryngology.

[Gangrene of the fingers caused by accidental intra-arterial injection of diazepam]. / Fingergangrän nach akzidenteller intraarterieller Injektion von Diazepam.

HISTORY: A 51-year-old woman was accidentally given an intra-arterial injection of 10 mg diazepam to control an acute claustrophobic anxiety attack. She complained of severe knocking pain in the entire left arm during the injection. On the second day the hand and lower arm were red an swollen and she complained of increasingly feeling cold and having paraesthesias. On the fifth day the radial half of the palm as well as the first to third digits showed livid discoloration. In the further course necrotic areas developed in the palmar aspect of the distal phalanx of the thumb and of the index finger proximal to the middle phalanx. INVESTIGATION: Angiography on the tenth day after the injection revealed very poor perfusion of the radial artery as far as the wrist, occlusion of the superficial palmar arterial arch and occlusions of the digital arteries of the five fingers. TREATMENT AND COURSE: Infusion of 25,000 IU heparin over 24 h brought no improvement. On the 24th day after the diazepam injection the palmar aspect of the distal phalanx of the thumb and the index finger became necrotic, requiring amputation of the latter and, after removal of necrotic tissue, flap-plasty using subcutaneous soft tissue of the extensor surface of the index finger to cover the defect on the thumb. The patient was without symptoms on discharge and the wounds were healing well. CONCLUSION: Every doctor should be aware of the dangers of accidental intra-arterial injection. The slightest suspicion and symptoms require immediate and adequate treatment to save the limb.

Anterior interosseous nerve compression after supracondylar fracture of the humerus: a metaanalysis.

OBJECT: The authors conducted a metaanalysis of reports of anterior interosseous nerve syndrome, a rare nerve compression neuropathy that affects only the motor branch of the median nerve. This syndrome is characterized by paralysis of the flexor pollicis longus, the flexor digitorum profundus to the index finger, and the pronator quadratus, with weakness on flexion of the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger without sensory loss. METHODS: The authors reviewed reports of 34 cases of anterior interosseous nerve syndrome combined with supracondylar fractures of the humerus in children. They have added a new case identified in a 7-year-old boy in whom a diagnosis was made from the clinical findings and whose treatment and outcome are analyzed. The ages of patients reported in the literature ranged from 4 to 10 years. Ten patients (29%) were treated with closed reduction and application of a cast, whereas 25 patients (71%) were treated with open reduction and fixation of the fracture. CONCLUSIONS: All patients regained full flexion and strength after 4 to 17 weeks. The fractures that were surgically treated showed no entrapment of the anterior interosseous nerve.

[Differential anterior interosseous nerve syndrome diagnosis]. / Zur Differentialdiagnose des N.-interosseus-anterior-Syndroms.

The differential diagnosis of the rupture of flexor pollicis longus tendon and profundus tendon to index finger to the interosseus anterior nerve syndrome can be difficult and can lead to misinterpretation of the clinical impression. Two cases are reported to demonstrate this problem. In the first case a spontaneous rupture of flexor pollicis longus was found, when first an interosseus anterior nerve syndrome was suspected. In a second case surgical exploration of flexor pollicis longus tendon and profundus tendon to index finger was done on the assumption of a rupture, that revealed intact tendons. In a second operation neurolysis of the interosseus anterior nerve was carried out with full recovery of flexion of the thumb and index finger.

Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients.

OBJECTIVE: To determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT, Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outcome, i.e., reduced infectious and wound complications and decreased treatment costs when compared with an isocaloric, isonitrogenous control diet. DESIGN: A prospective, randomized, placebo-controlled, double-blind, multicenter trial of the clinical outcome and a retrospective cost-comparison analysis. SETTING: Surgical intensive care units in three different German university hospitals. PATIENTS: Of 164 patients enrolled in the study, 154 patients were eligible for analysis. They were admitted to the intensive care unit after upper gastrointestinal surgery for cancer and they received an enteral diet via needle catheter jejunostomy. Infectious complications were defined as sepsis or systemic inflammatory response syndrome, pneumonia, urinary tract infection, central venous catheter sepsis, wound infection, and anastomotic leakage. The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth postoperative day) postoperative complications. The treatment costs of each complication were analyzed and compared in both groups. INTERVENTIONS: Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postoperative day 5. MEASUREMENTS AND MAIN RESULTS: Clinical examination and adverse gastrointestinal symptoms were recorded on a daily basis. Both groups tolerated early enteral feeding well, and the rate of tube feeding-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs. 24 patients in the control group (NS). Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 patients in the immunonutritional group vs. 11 patients in the control group). However, in the late phase (after postoperative day 5), considerably fewer patients in the experimental diet group experienced complications compared with the control group (5 vs. 13, p < .05). In addition, the frequency rate of complicating events were recorded in each group. In the experimental diet group, a total of 22 complicating events were recorded vs. a total of 32 events in the placebo diet group (NS). However, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced in the immunonutrition group when compared with the control group (8 vs. 17 events, p < .05). The total costs for the treatment of the complications were 83,563 German marks in the experimental diet group vs. 122,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks. (At the end of December 1995, the conversion rate from German marks to U.S. dollars was 1.4365 German marks to $1.00.) CONCLUSIONS: Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery. In patients who received the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was observed. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.