Background: In case of ureter defect lesions elaborate surgical interventions are necessary like ureter replacement using small bowel or autotransplantation. We developed a new technique for ureter defect reconstruction in a pig model using a vein and resorbable polylactate-acid (PLLA) stent. Methods: External jugular vein was removed in 42 pigs and used as an autologous vein graft. A three cm segment was resected from the proximal ureter and replaced by the vein with or without endoluminal biodegradable PLLA stent. 14 animals served as controls. Survival, kidney function and morphological changes of the neo-ureter and the kidney were observed for 7 days respectively six months. Results: The degradable stent material had been completely broken down after six months and the vein had been relined with urothel showing Ck7-positive columnar epithelium and newly formed capillaries in the neo-ureteral wall. All animals showed normal kidney function in follow up. Conclusions: Using an autologous vein graft and a bio-degradable endoluminal stent is feasible for ureter defect reconstruction. Due to the preservation of physiological urine passage and anti-reflux mechanism it constitutes an interesting alternative method.

INTRODUCTIONIatrogenic injuries of the bile duct and hepatic artery represent a continuous problem after laparoscopic cholecystectomy. In this observational study we report about our experiences applying the "critical view of safety", defined as unambiguous identification of the cystic duct and artery by creation of an infundibular window, in order to minimise bile duct lesions and conversion rate.METHODSBetween July 2002 and November 2004 100 consecutive laparoscopicly started cholecystectomies were prospectively investigated. The central surgical step of dissection aimed at reaching the "critical view of safety" and its photo printing before cutting the cystic duct and artery, otherwise a conversion was carried out without exception. Primary endpoints of the study were the conversion rate, secondary endpoints the incidence of intra- and postoperative complications, operation time and histological results.RESULTS53 of the 100 primary laparoscopic operated patients showed the signs of an acute cholecystitis, 44 patients offered partially multiple abdominal operations in their history. In 19 patients we performed a "therapeutic splitting". Only in 3 patients it was not possible to apply the "critical view of safety" resulting in a conversion to open cholecystectomy. The mean operation time was 81 minutes and the postoperative hospital stay ranged to 5.4 (1-18) days. Postoperatively an insufficiency of cystic duct, a navel infection, an abdominal wall haematoma, an urinary tract infection and a pneumonia occurred in one patient each.DISCUSSIONPivotal factors leading to bile duct injury after laparoscopic cholecystectomy are systematic mistakes in the surgical technique, an insufficient surgical training and human failure of the surgeon. The introduction of the "critical view of safety" represents an objective, understandable and compulsory criterion for minimising the risk of iatrogenic injuries of the bile duct and decision on conversion to open cholecystectomy.

The incidence of severe bile duct injuries has significantly increased since the introduction of laparoscopic cholecystectomy. The ideal reconstruction procedure for traumatic defects of the bile duct should be technically simple and should preserve both the physiological passage of bile and the sphincter of Oddi. In this article we describe a new technique for bile duct reconstruction in a pig model by means of an autologous vein graft that is splinted by a endoluminal biodegradable polylactate acid stent. In 12 pigs the external jugular vein was removed and used as an autologous vein graft. After performing a median laparotomy a 2-cm segment was resected from the bile duct. The common bile duct was reconstructed by a venous interponate that had been endoluminally stented by a biodegradable polylactate acid stent. For the examination of stent degradation, 2 pigs were sacrificed at 3, 4, and 5 months (stent degradation group) and the remaining 6 pigs at 6 months (survival group). All the pigs in the survival group survived for 6 months before being sacrificed. After 4 months the stent material had been completely broken down and the vein graft had been relined with bile duct epithelium. Thus, this new technique for bile duct reconstruction using an autologous vein graft with an endoluminal stent is simple to perform and reliable, and constitutes an interesting alternative to bilodigestive anastomosis due to the preservation of the papilla of Vateri.

Wir untersuchten eine neue Behandlungsmethode von Defektläsionen des Gallenganges durch Ersatz mit einem Veneninterponat, das mit einem bio-degradablen Stent endoluminal geschient wurde. 24 Schweine wurden auf vier Gruppen aufgeteilt. In Gruppe I wurde ein Gallengangssegment durch ein venöses Interponat ersetzt, in Gruppe I und II zusätzlich gestentet. Gruppe IV diente als Kontrolle. Zur Untersuchung der Stentdegradation erfolgten in Gruppe II Opferungen von jeweils 2 Tieren nach 3, 4 und 5 Monaten, in Gruppe 3 nach 6 Monaten. In den Gruppen II — IV überlebten alle Tiere in gutem Zustand. Das Interponat war mit Gallengangsepithel ausgekleidet und zeigte den Durchmesser des Stents. Nach 4 Monaten war das Stentmaterial abgebaut. Die vorgestellte Technik stellt wegen des Erhalts des Sphincter Oddi eine interessante Alternative zur biliodigestiven Anastomose dar.

INTRODUCTION:In this study a new treatment of bile duct lesions was investigated. A segment of the bile duct was replaced by an autologous venous interponate which had been endoluminally stented with a braided bio-degradable stent.METHODS:A total of 18 pigs (20-28 kg) was divided into three equal groups (I-III). In each group a 2 cm segment of the jugular vein was harvested. The animals in Group I (vein group, n = 6) underwent resection of a 2 cm long segment of the common bile duct which was replaced solely by the venous interponate, in Group II (stent group, n = 6) the venous interponate had been endoluminally stented by a braided bio-degradable stent. Group III (control group, n = 6) underwent only a circular mobilization of the common bile duct. Postoperatively survival rate, general condition as well as the weight were observed and checked for 6 months. During surgery and finally after sacrifice after 6 months blood and tissue samples were taken and semiquantitatively scored concerning grade of inflammation and fibrosis.RESULTS:In the stent and control group all animals survived in good condition. 3 pigs of the vein group died within 3 weeks showing signs of biliary peritonitis, another one died due to a high grade stenosis of the common bile duct with secondary biliary cirrhosis after 4 months. In the stent group all animals survived until sacrifice after 6 months. On examination the venous interponate was laminated with bile duct epithelium showing the diameter of the implanted stent.CONCLUSION:The reconstruction of bile duct lesions by a venous interponate in combination with a bio-degradable stent is easy to perform and represents a clinically interesting alternative to the biliodigestive anastomosis because of the preservation of the sphincter oddi. After 6 months the stent is completely absorbed and the venous interponate is laminated with bile duct epithelium.

Die Therapie der Wahl bei Defektläsionen des D. choledochus, die als Komplikationen der laparoskopischen Cholzystektomie oder bei Tumorresektionen auftreten, stellt derzeit die Choledochojejunostomie dar. Deren Langzeitprognose ist durch Komplikationen wie z. B. Cholangitiden eingeschränkt. Ziel der Studie war die Überbrückung eines Gallengangdefekts mit einem Veneninterponat, das durch einen neuen resorbierbaren endoluminalen Stent in einem tierexperimentellen Modell am Schwein geschient wurde. Material und Methoden:Bei 18 Schweinen (Deutsche Landrasse, 20 – 25 kg) wurde ein 2 cm langes Segment der V. jugularis interna entnommen. In der Venengruppe wurde über eine mediane Laparotomie ein ebenfalls 2 cm langes Segment aus dem D. choledochus reseziert und durch das Veneninterponat, das End-zu-End mit 6-0 PDS eingenäht wurde, rekonstruiert. In der Stentgruppe erfolgte zusätzlich die endoluminale Schienung des Veneninterponats mit Poly-L-Milchsäure-Stent. In der Kontrollgruppe wurde der D. choledochus nur mobilisiert. Postoperativ wurden überleben, Allgemeinzustand und Gewichtsverlauf bis 5 Monate beobachtet. Zur Untersuchung der Kinetik der Stentdegradation wurden in der Stentgruppe jeweils 2 Tiere nach 3, 4 und 5 Monaten geopfert. Zum OP- und Opferungszeitpunkt erfolgten Blut- und Biopsieentnahmen aus Leber und Gallengang, die semiquantitativ auf Entzündung, Fibrose und Fremdmaterial untersucht und in einem Score bewertet wurden. Ergebnisse:Alle Eingriffe ließen sich komplikationsfrei mit Op-Zeiten unter 90 Minuten durchführen. In der Kontrollgruppe überlebten alle Tiere im guten AZ. In der Stentgruppe überlebten die Tiere bis zum geplanten Zeitpunkt der Opferung, das Veneninterponat war mit Gallengangsepithel ausgekleidet und heilte mit dem Durchmesser des implantierten Stents ein. Das Stentmaterial war nach 4 Monaten vollständig abgebaut, parallel mit einem Rückgang der Cholangitis. Die Serumchemie zeigte keine signifikanten Unterschiede zur Kontrollgruppe. 1 Tier zeigte eine Abknickung des Veneninterponats. In der Venengruppe starben 3 Tiere innerhalb von 2 Wochen mit Nekrose des Veneninterponats und galliger Peritonitis. Weitere 2 Tiere verstarben innerhalb von 3 Monaten mit hochgradig stenosiertem Veneninterponat und eitriger Cholangitis. 1 Tier überlebte 5 Monate und zeigte eine hochgradige Stenose des D. choledochus mit ausgepägter sekundärer biliärer Leberzirrhose. Zusammenfassungg:Durch Schienung mittels resorbierbarem Stent können perioperative Komplikationen wie z. B. Stenose und Nekrose des Veneninterponats, vermieden werden. Nach 4 Monaten ist der Stent vollständig resorbiert und das Veneninterponat mit Gallengangsepithel ausgekleidet. In Kombination mit dem resorbierbaren Stent stellt das Veneninterponat bei erhaltenem Sphinkter Oddi eine viel versprechende Alternative zur Hepatikojejunostomie in der Behandlung von Gallengangsdefekten dar.

Eine retrospektive Fehleranalyse soll die Grundlage schaffen, die Komplikationsrate von 12,3% im eigenen Patientengut bei der laparoskopischen Hernioplastik (TAPP-Technik) zu senken. 34 (94,4%) der Komplikationen traten postoperativ, 2 (5,6%) intraoperativ auf. Im Rahmen von Rezidivhernioplastiken erfolgte jeweils 1 Blasen- und 1 Iliacal-venenläsion. Für 16 (47,1%) der 34 postoperativen Komplikationen konnte eine mögliche Ursache erhoben werden. Hämatome, Serome, Nerven-, Gefäß- und Organ-Verletzungen konnten in 38,8% auf Rezidiveingriffe oder Appendektomien mit durch Narbenbildung erschwerter Präparation zurückgeführt werden. 2 (5,6%) Komplikationen ergaben sich infolge operationstechnischer Fehler. Insgesamt konnte für 18 (50%) der Komplikationen eine Kausalität hergestellt werden. Durch Drainagen bei Rezidiveingriffen und frühe Konversion bei unübersichtlichem Situs sollte die Komplikationsrate weiter zu senken sein.

Mit dem breiten Einsatz von Ultraschall konkurriert die interventionelle Drainage mit dem chirurgischen Vorgehen. Aus unserer eigenen Erfahrung versuchen wir die Beschreibung des aktuellen Standes der ultraschallgeführten perkutanen Drainage intraabdomineller Abszesse. Seit 1992 führten wir bei 37 Patienten 39 Drainageeinlagen durch. In der Mehrzahl entstanden die Abszesse postoperativ. 25 Patienten konnten geheilt werden, einschließlich zweier Fälle mit Rezidivdrainage. 6 Drainagen waren als Palliation effektiv. Ein Patient mit Leberzirrhose verstarb an generalisierter Peritonitis. Bei fast allen intraabdominellen Abszessen ist ein sonographiegeführter perkutaner Drainageversuch wegen seiner hohen Heilungsrate bei niedriger Mortalität gerechtfertigt.

The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. Purpose: Since the symptoms usually occur postprandially, we used ultrasonography to examine whether hymecromone could reverse the contraction of the common bile duct (CBD) after ingestion of a standardised test meal. Method: The study was designed as a prospective, double-blind randomised cross-over study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. The subjects were then given either 400 mg of hymecromone or placebo i.v. and the measurement series was repeated. Results: After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo; a maximum increase of 36% was measured 10 minutes after administration of hymecromone. Conclusion: The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone. Sonography proved a suitable tool for examining the physiological changes.

The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone. Sonography proved a suitable tool for examining the physiological changes.

Der Einfluß einer täglichen Routine-Sonographie auf das Behandlungskonzept chirurgischer Intensivpatienten im Vergleich mit einer indizierten Sonographie wurde in Abhängigkeit vom untersuchten Organsystem ermittelt. Bei 70 konsekutiven Patienten führten wir 830 Untersuchungen durch. Indikation und therapeutische Konsequenzen wurden für jede Untersuchung dokumentiert. Häufige Befunde waren Pleuraergüsse bei 23, intraabdominelle Flüssigkeit bei 11 und Atelektasen bei 5 Patienten. Postoperative pathologische Befunde waren 4 Hämatome und 2 Abszesse. Therapeutische Konsequenzen wurden bei 15 Patienten gezogen, in allen Fällen aufgrund einer indizierten Sonographie, so daß für kein Organsystem die tägliche Routine-Sonographie einen klinischen Vorteil zeigte.

Between January 1991 and June 1995 we have operated on 19 patients (9 male, 10 female) with 22 skeletal metastases of the lower limb (19 femora, 3 tibiae) using a static interlocking nail. Closed intramedullary nailing without resection of the metastasis has been established as our standard procedure. We have stabilized 15 patients with advanced osteolysis and seven pathological fractures. Sixteen patients underwent postoperative local radiation therapy with 40 Gy. As intraoperative complications we have observed one fracture of an osteolysis and one death due to fat embolism. Postoperatively there were observed one seroma, one haematoma and one patient with non fatal pulmonary embolism following DVT. Two patients died within the first 30 postoperative days because of tumor progression. All patients surviving longer than 30 days could be mobilized under full weight-bearing Morphine like analgetics for metastasis related pain were no longer needed. A secondary instability has not been observed within a mean survival time of 199 days (811 longest follow up). Closed intramedullary nailing in combination with postoperative local radiation therapy seems to be an appropriate and technically non demanding procedure to stabilize skeletal metastases of the lower limb in patients with a short or medium-term expectation of life.

Die präoperative Abklärung und gegebenenfalls Sanierung des Ductus hepatocholedochus (DHC) durch eine endoskopische retrograde Cholangiogaphie (ERC) ist Voraussetzung für die Durchführung der laparoskopischen Cholezystektomie. Anamnese, Klinik, Labor und Standard-Sonographie erfassen jedoch nicht alle Fälle einer biliären Abflußstörung. Wir haben daher unter diesem Aspekt präoperativ die Lumenveränderungen des DHC nach Reizmahlzeit sonographisch untersucht.

Between January 1991 and June 1995 we have operated on 19 patients (9 male, 10 female) with 22 skeletal metastases of the lower limb (19 femora, 3 tibiae) using a static interlocking nail. Closed intramedullary nailing without resection of the metastasis has been established as our standard procedure. We have stabilized 15 patients with advanced osteolysis and seven pathological fractures. Sixteen patients underwent postoperative local radiation therapy with 40 Gy. As intraoperative complications we have observed one fracture of an osteolysis and one death due to fat embolism. Postoperatively there were observed one seroma, one haematoma and one patient with non fatal pulmonary embolism following DVT. Two patients died within the first 30 postoperative days because of tumor progression. All patients surviving longer than 30 days could be mobilized under full weight-bearing. Morphine like analgetics for metastasis related pain were no longer needed. A secondary instability has not been observed within a mean survival time of 199 days (811 longest follow up). Closed intramedullary nailing in combination with postoperative local radiation therapy seems to be an appropriate and technically non demanding procedure to stabilize skeletal metastases of the lower limb in patients with a short or medium-term expectation of life.

The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. As the symptoms usually occur postprandially we used ultrasonography to examine whether hymecromone was able to reverse the contraction of the common bile duct (CBD) after ingestion of a standardized test meal. The study was designed as prospective, double-blind randomized crossover study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and at 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. Then the subjects were given either 400 mg of hymecromone or placebo and the measurement series was repeated. After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo, a maximum increase of 36% was measured 10 minutes after administration of hymecromone. The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone.

UNLABELLED:Differential diagnosis in patients with acute abdominal pain represents a difficult assignment in surgery involving the indication for urgent operation and the operation technique. AIM:The value of sonography in diseases of the bowels for correct indication for early laparotomy was investigated. METHOD:In a retrospective analysis we compared the result of sonography on 159 patients with acute abdominal pain with the first clinical assessment. RESULTS:The sensitivity of this technique was found to be 38.9% for acute appendicitis, 57.1% for diverticulitis and 76.9% for obstructive ileus. The specificity ranged above 90% in each case. In consideration of more than two sonomorphological criterias for pathological alterations of the intestines the positive predictive value achieved 100%. CONCLUSION:Low diagnostic sensitivity with high specificity implies the necessity to intensity routine ultrasonic investigation of the gut.

We investigated in this study if we would be able to find the correct indication for laparotomy earlier by sonographical examination than by clinical and radiological findings. In 48 of 594 patients with unknown abdominal diseases we found an intestinal obstruction by laparotomy. The indication based on clinical and radiological findings in 37 patients (sensitivity: 77.1%). In comparison the indication for laparotomy was predetermined correctly only after sonographical examination in 45 patients (sensitivity: 89.6%). According to the number of sonographical findings the reliability of the indication for laparotomy increased. The examination by sonography is a valuable tool in the diagnosis of intestinal obstruction.

Differental diagnosis in patients with acute abdominal pain represents a difficult assignment in surgery involving the indication for urgent operation and the operation technique.Aim The value of sonography in diseases of the bowels for correct indication for early laparotomy was investigated.Method In a retrospective analysis we compared the result of sonography on 159 patients with acute abdominal pain with the first clinical assessment.Results The sensitivity of this technique was found to be 38.9 % for acute appendicitis, 57.1 % for diverticulitis and 76.9 % for obstructive ileus. The specificity ranged above 90 % in each case. In consideration of more than two sonomorphological criterias for pathological alterations of the intestines the positive predictive value achieved 100 %.Conclusion Low diagnostic sensitivity with high specificity implies the necessity to intensify routine ultrasonic investigation of the gut.