Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation.Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding.The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding.Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.

External proton and 6,7Li beams, of energies around 24 and 48 MeV respectively, were produced and characterized dosimetrically at the Tandem accelerator TANDAR in Buenos Aires and used for radiobiology studies on tumor and normal cell cultures. The beam monitoring instrumentation of a dedicated beam line is discussed. Relative biological effectiveness (RBE) values (at 10% survival) have been measured as functions of projectile energy (0–21 MeV) for protons and 6,7Li ions for different tumor (PDV, PDVC57) and reference cell lines (V79). The RBE values for these cell lines have been determined here for the first time but are similar to those reported in the literature for other cell lines.

In Zusammenarbeit mit unseren Nephrologen stellten wir uns die Frage, ob ein hyperdynamer Shunt zur Vermeidung kardialer Folgeerkrankungen frühzeitig zu diagnostizieren ist, um ihn dann einer operativen Intervention zuzuführen.

Zur Klärung der Fragestellung, ob durch eine obligate Darstellung des N. Laryngeus recurrens (NLR) eine Verminderung der postoperativen NLR-Pareserate erreicht werden kann, führten wir eine retrospektive Untersuchung an 1.556 Patienten durch, die einer Schilddrüsenresektion wegen eines benignen Leidens unterzogen wurden. In der Gruppe der Patienten, bei denen eine Darstellung erfolgte (67%) war das relative Risiko einer persistierenden Nervenläsion mit 0.006 gegenüber 0.027 in der Gruppe, in der keine Darstellung erfolgte (32,8%) signifikant niedriger. Ein signifikanter Einfluß auf die Entwicklung einer passageren Nervenläsion konnte nicht nachgewiesen werden. Aufgrund der Ergebnisse bei den persistierenden Paresen ist eine obligate Darstellung des NLR bei resezierenden Schilddrüseneingriffen zu fordern.

Im Rahmen einer retrospektiv angelegten Studie wurde die Wertigkeit der präoperativen Feinnadelzytologie in bezug auf die Planung eines operativen Eingriffs an der Schilddrüse, der Patientenaufklärung und der postoperativen Therapie evaluiert. Das Kollektiv setzte sich aus 359 Eingriffen an der Schilddrüse zusammen, wobei in lediglich 16,2% der Fälle eine zytologische Untersuchung erfolgte. Bei zytologisch hochgradigem Verdacht auf ein Malignom konnte dieses histologisch in allen Fällen bestätigt werden. In nur einem Fall mußte die benigne Zytologie intraoperativ revidiert werden (falsch-negative Aussage). Aus unserer Sicht sollte aufgrund der hohen Aussagefähigkeit die Zytologie mehr in das präoperative Routineprogramm eingebunden werden.

PATIENTS AND METHODS:risk factors of recurrent laryngeal nerve (RLN) palsy after thyroid gland surgery were evaluated retrospectively in 1556 patients who were submitted to an operation because of a benign thyroid disease. Recurrences were also excluded.RESULTS:RLN palsy occurred in 6.6%. In relation to the nerves at risk the incidence of primary postoperative nerve damages was 4.3%. After a long-term follow-up of in total 18 months the incidence of permanent nerve palsy was 1.6% (related to the nerves at risk: 1.1%) as 75.5% of the paralyses were transient in an average of 6.2 months. Substernal goitres especially when sternotomy became necessary, the ligature of the inferior laryngeal artery, serious perioperative complications and total lobectomy in comparison to subtotal resection were important risk factors for primary postoperative RLN palsy (p < 0.05 resp. p < 0.01). The ligature of the inferior laryngeal artery and the extension of resection were indeed significant risk factors also for permanent nerve damages, but the other factors had no influence on the risk of permanent RLN palsy. However, the non-exposure of RLN in subtotal lobectomy was significantly associated (p < 0.01) with permanent, but not with transient nerve palsy.CONCLUSION:The exposure of the RLN is one of the most important procedures during thyroid surgery and particular also during subtotal lobectomy to reduce the rate of permanent RLN damages.

Die präoperative Angiographie hat in der Diagnostik des drohenden Shuntverschlusses zur unmittelbaren Planung von Interventionen bzw. Operationen weiterhin eine große Bedeutung. Im Routine-Monitoring, zur Planung von Erst- und Neuanlagen sowie beim thrombotischen Shuntverschluß ist sie weitgehend durch weniger invasive Methoden (klinische Untersuchung, Druckmessungen, Sonographie) ersetzbar.

Patients and methods: Risk factors of recurrent laryngeal nerve (RLN) palsy after thyroid gland surgery were evaluated retrospectively in 1556 patients who were submitted to an operation because of a benign thyroid disease. Recurrences were also excluded. Results: RLN palsy occurred in 6.6 %. In relation to the nerves at risk the incidence of primary postoperative nerve damages was 4.3 %. After a long-term follow-up of in total 18 months the incidence of permanent nerve palsy was 1.6 % (related to the nerves at risk: 1.1 %) as 75.5 % of the paralyses were transient in an average of 6.2 months. Substernal goitres especially when sternotomy became necessary, the ligature of the inferior laryngeal artery, serious perioperative complications and total lobectomy in comparison to subtotal resection were important risk factors for primary postoperative RLN palsy (p<0,05 resp. p<0,01). The ligature of the inferior laryngeal artery and the extension of resection were indeed significant risk factors also for permanent nerve damages, but the other factors had no influence on the risk of permanent RLN palsy. However the non-exposure of RLN in subtotal lobectomy was significantly associated (p<0.01) with permanent, but not with transient nerve palsy. Conclusion: The exposure of the RLN is one of the most important procedures during thyroid surgery and particular also during subtotal lobectomy to reduce the rate of permanent RLN damages.

Contrast angiography is still very important in evaluating the luminal anatomy of failing shunts and their venous runoff systems prior to intervention or surgical revision. For access monitoring, prior to primary AV fistulas or in case of a thrombosed access, angiography can be replaced by less invasive methods (physical examination, pressure measurements, color-flow doppler).

Das Multiorganversagen, die terminale Phase septischer Sekundärkomplikationen bei Polytraumatisierten, stellt ein multifaktorielles Geschehen dar und ist bis heute mit einer Letalität von 40–70% Haupttodesursache auf chirurgischen und anästhesiologischen Intensivstationen.

History and clinical findings: Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation.Investigations: Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency oesophagogastroduodenoscopy and coloscopy as well as angiography again failed to fmd the source of bleeding.Treatment and course: The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding.Conclusion: Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.

Rezidiveingriffe an der Schilddrüse in unserem Endemiegebiet sind häufig und mit einer hohen Komplikationsrate verbunden [1, 2]. Um Angaben über Häufigkeit, Indikation und Komplikationen von Schilddrüsen(rezidiv)eingriffen zu erhalten, haben wir unser Patientengut zwischen 1983 und 1994 retrospektiv analysiert. In einer ersten Episode von 1983 bis 1990 betrug der Anteil der Rezidivstrumen in unserem Krankengut 13%. Davon hatten 19,2% bereits eine vorbestehende Recurrensparese. Die Recurrensparese beim Rezidiveingriff war mit 3,5% im Vergleich zum Ersteingriff (1,7%) verdoppelt. Aufgrund dieser Ausgangslage war unser Ziel 1990 a) die Senkung der Rezidivrate und b) die Senkung der chirurgischen Morbitität. Wir haben deshalb seit 1991 unsere operative Taktik geändert und sind dazu übergegangen a) mindestens eine einseitige Lobektomie, bei bilateralem Befund, ergänzt durch eine kontralaterale Strumektomie durchzuführen. Diese Taktikänderung beruht auf den molekularbiologischen Erkenntnissen der experimentellen Endokrinologie (episodische Replikation von multiplen Clustern und funktionelle Polymorphie in geklonten Schilddrüsenknoten), welche beweist, daß die Fähigkeit zur Polymorphie, d. h. zum Knotenwachstum, ubiquitär in der Schilddrüse vorhanden ist und durch Kummulation von Wachstumsfaktoren klonales Wachstum auslöst [3–5]. Im weiteren haben wir b) obligatorisch bei jedem Strumaeingriff den Nervus recurrens sowie die Nebenschilddrüse konsequent dargestellt.

HISTORY AND CLINICAL FINDINGS:Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation.INVESTIGATIONS:Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding.TREATMENT AND COURSE:The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding.CONCLUSION:Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.