From 1983 to 1992, 216 free jejunal transplants were performed after resection of malignant tumours for reconstructing the upper oesophageal tract. In two patients reconstruction was performed secondarily and in four cases within the framework of recurrence treatment. In 25 cases the jejunal transplant was sewn in tubular form to the circular insert of the hypopharynx, whereas in the remaining 188 cases the jejunum transplant was sewn as patch. A jejunum transplant was most frequently employed in the tonsillar region (n = 75). Reconstruction of the body of the tongue was performed in 42 cases and of the hypopharynx in 29 cases. Of the 213 patients treated, 175 were irradiated postoperatively. The most severe complications were in 5 cases death from the sequels of the operating, abdominal complications in 15 cases and complete loss of the transplant in 22 cases. Protracted inability to swallow occurred in 15 cases and pneumonia in 16 patients. The five-year survival probability was 39% for the 42 patients suffering from carcinomas of the oral cavity, 53% for the 90 patients with oropharyngeal carcinoma in stage III and 33% in stage IV, as well as 40% with the 29 patients suffering from hypopharyngeal carcinomas. An essential advantage of the free jejunum transplants were the excellent functional reconstruction results. This is demonstrated by examples of various cases. Since the number of treated patients is still too low, it is at present not yet possible to compare this approach with other therapeutic concepts, such as enoral laser surgery resection or radiochemotherapy.

Viele Kehlkopfkarzinome kommen für keine der etablierten Larynx-Teilresektionen in Frage, sei es wegen ihrer Ausdehnung, sei es wegen des Tumorsitzes. Die totale Laryngektomie erscheint dann unausweichlich. Dennoch: Onkologisch wäre eine subtotale Resektion des Kehlkopfes in vielen Fällen absolut ausreichend. Wird der verbleibende Larynxrest in einen Stimmshunt integriert, lassen sich zumindest die Sprech- und die Sphinkterfunktion des Kehlkopfes erhalten, wenngleich das Lumen des Stimmshunts für die Atmung nicht mehr ausreicht, so daß ein permanentes Tracheostoma unausweichlich ist. Dieses Prinzip der subtotalen Laryngektomie mit innerviertem Stimmshunt — 1974 von Mozolewski und 1980 von Pearson beschrieben — schließt eine wesentliche Lücke in der operativen Therapie des Larynxkarzinoms.

BACKGROUND:Cystic enlargement of the extrahepatic bile duct system is a rare abnormal finding. A congenital origin is usually supposed; however, the pathogenesis is unknown. We report on our experience with extrahepatic bile duct cysts with special regard to cause, treatment, and recurrent disease.METHODS:From 1976 to 1991, 13 patients, 35 to 74 years of age, were treated for extrahepatic bile duct cysts. Seven patients had previously undergone cholecystectomy. Two patients were admitted because of recurrent disease; neither had undergone curative resection.RESULTS:In 11 patients a biliojejunal anastomosis with a Roux-en-Y was created after cyst resection; one patient underwent a diverticular stalk resection with end-to-end anastomosis of the choledochal duct. After a mean follow-up of 68 months eight of 10 patients were alive, two of whom complained about cholangitis. Recurrent diffuse dilatation of the remaining choledochus developed in one patient; one other patient died of cholangiocellular carcinoma 2 years after operation.CONCLUSIONS:In patients who had undergone previous cholecystectomy or with recurrent disease an acquired malformation cannot be excluded. Surgical treatment is always indicated because of imminent complications and should aim at complete resection of cystic tissue. Periodic postoperative evaluation is necessary to detect recurrent disease and malignant transformation.

This retrospective study deals with the outcome of 401 patients with laryngeal carcinoma who were treated between 1975 and 1986 either by operation alone or by operation and irradiation. The patients as a group, the concepts of treatment, and the course of disease as found retrospectively are described. T and N categories are compared with the respective pT and pN categories: T and pT categories corresponded in 83.3% of the cases while there was only a 67.4% correspondence between each N and pN category. The survival rates using the Kaplan-Meier estimation according to the localization and extension of laryngeal tumor, pN category and method of resection are discussed in detail.

This retrospective study deals with the outcome of 401 patients with laryngeal carcinoma who were treated between 1975 and 1986 either by operation alone or by operation and irradiation. The patients as a group, the concepts of treatment, and the course of disease as found retrospectively are described. T and N categories are compared with the respective pT and pN categories: T and pT categories corresponded in 83.3% of the cases while there was only a 67.4% correspondence between each N and pN category. The survival rates using the Kaplan - Meier estimation according to the localization and extension of laryngeal tumor, pN category and method of resection are discussed in detail.

We report 155 free jejunal transplants carried out since August 1984. The complications and the indications for the use of free intestinal transplants in the reconstruction of defects of the oral cavity and pharynx are recorded. Also we report the use of the revascularised latissimus dorsi myocutaneous flap and the fascicutaneous radial forearm flap in head and neck reconstruction.

Large defects after extended maxillectomy and orbital exenteration were immediately reconstructed using a modification of the revascularized musculocutaneous latissimus dorsi flap. Three skin islands were transplanted based on the muscular part of the flap. The first island replaced the hard palate, the second the lateral nasal wall and the third was used together with the preserved eyelids to reconstruct an eye socket. The muscular part of the flap was folded spirally so that each skin island reached the site to be reconstructed.

Large defects after extended maxillectomy and orbital exenteration were immediately reconstructed using a modification of the revascularized musculocutaneous latissimus dorsi flap. Three skin islands were transplanted based on the muscular part of the flap. The first island replaced the hard palate, the second the lateral nasal wall and the third was used together with the preserved eyelids to reconstruct an eye socket. The muscular part of the flap was folded spirally so that each skin island reached the site to be reconstructed.

Unsere Methode der transperiostalen Ligatur der A. sphenopalatina wurde in Anlehnung an eine von Simpson 1982 publizierte Technik entwickelt.

Many pathological changes in pharynx and larynx can cause problems in endotracheal intubation. Their preliminary signs and symptoms are often uncharacteristic. Thus prophylaxis is not always possible. Some representative diseases of larynx and pharynx are demonstrated by means of endoscopic photographs and by case reports. The photos were taken during endoscopic examinations in an ENT-clinic. The method of anaesthesia used in these cases is described, as well as prophylactic measures to be taken, if a difficult intubation may be expected. Finally, the procedure in case of an unexpected critical intubation is discussed.

Manche einseitigen glottischen T3-Karzinome bringen den auf funktionserhaltende Kehlkopfchirurgie bedachten Laryngologen in Konflikt, vor allem wenn sie nach dorsal über den Processus vocalis des Stellknorpels hinausgegriffen, dessen mediale Schleimhautfläche überwachsen und die subglottische Zone der hinteren Kommissur erreicht haben. Früher war ein in diesem laryngealen Wetterwinkel angetroffener Karzinomausläufer das unabweisbare Signal zur Kehlkopftotalexstirpation. Heute sind wir, sofern das Malignom vorwiegend exophytisches und abgrenzbares Wachstum erkennen läßt, zu schonenderen Maßnahmen bereit. Erlaubt der skizzierte Befund eines dorsal und subglottisch expandierten glottischen T3-Karzinoms eine cricoidschonende Hemilaryngektomie? Nein, den heute gebräuchlichen und bewährten Techniken nach Som und Ogura trauen wir, obschon sie den dorsalen Arytaenoidpfeiler in den Resektionsblock miteinbeziehen, nicht die umfassende Radikalität zu.

We report 155 free jejunal transplants carried out since August 1984. The complications and the indications for the use of free intestinal transplants in the reconstruction of defects of the oral cavity and pharynx are recorded. Also we report the use of the revascularised latissimus dorsi myocutaneous flap and the fascicutaneous radial forearm flap in head and neck reconstruction.

Der myokutane Latissimus-dorsi-Lappen wird in der rekonstruktiven Chirurgie unseres Faches vergleichsweise selten verwendet; wie wir meinen zu Unrecht. Gefäßgestielt ist sein Anwendungsspektrum dem des wesentlich häufiger gebrauchten myokutanen Pectoralis-major-Lappens zumindest ebenbürtig. Darüber hinaus besteht die Möglichkeit der freien Transplantation mit mikrovaskulärer Reanastomosierung. Die Gewinnung eines Latissimus-dorsi-Lappens ist mit Sicherheit deutlich aufwendiger als die eines Pectoralis-major-Lappens. Nach unserer Erfahrung wird dieser vermehrte Aufwand durch wesentliche Vorteile wettgemacht: Der Gefäßstiel ist beim Latissimus-dorsi-Lappen großkalibriger und länger. Auch die Vasa perforantia sind deutlich stärker als beim Pectoralis-Lappen. Die subkutane Fettschicht fällt demgebenüber meist deutlich dünner aus. Insgesamt ist die Hautinsel fester mit dem Muskelstiel verbunden. Die Reichweite des Latissimus-dorsi-Lappens ist größer. Bei gleichseitiger Neck dissection wird die Schulterfunktion geringer beeinträchtigt als nach Hebung eines Pectoralis-major-Lappens. Zudem besteht bei Patientinnen nicht die Gefahr einer Atrophie oder Verziehung der Brust.

Between August 1984 and August 1987 77 free intestinal grafts were transplanted in our Department of otorhinolaryngology using microvascular anastomoses. These reconstructions were necessary after tumour resections in the oral cavity, in the pharynx, and the cervical oesophagus. Patients, operative technique, perioperative treatment, and complications are described. The definition of oncologic results is still problematic. Only trends have been discovered. In conclusion, complications, functional results, and the advantages of free intestinal grafts are discussed.

Zwischen August 1984 und August 1987 wurden in der Hals-Nasen-Ohren-Klinik des Katharinenhospitals Stuttgart 77 freie Dünndarmverpflanzungen mit mikrovaskulärer Reanastomosierung durchgeführt. Sie dienten der plastischen Rekonstruktion von Mundhöhle, Pharynx und zervikalem Ösophagus nach Tumorresektion. Das Patientenkollektiv, die Operationstechnik, die perioperative Behandlung und die Komplikationen werden beschrieben. Die Beurteilung der onkologischen Behandlungsergebnisse ist derzeit noch problematisch; Tendenzen lassen sich jedoch ablesen. Komplikationen, Ergebnisse und die Vorteile der Methode werden abschließend diskutiert.

From 1982 to 1985 65 patients with a fracture of the cranial and middle portion of the visceral skull underwent surgical reconstruction using mini-plate osteosynthesis (Champy set). In this group we can distinguish four typical fractures where plate osteosynthesis with functional stability has proved successful (e.g.: piece fracture of the inferior margin of the orbita, bursting fracture of the zygomatic bone, impression fracture of the anterior wall of the frontal sinus, comminuted fracture of the interorbital region). The technical details of surgery are given special emphasis and possible complications are discussed.