Auch das Krankenhaus muß sich heute den aktuellen politischen und wirtschaftlichen Herausforderungen stellen. Die Analyse der letzten Jahre zeigt eine zunehmende Bürokratisierung und Häufung von -unberechtigten- Einsprüchen von Seiten der Kostenträger gegen unsere korrekten Rechnungen. U. E.gehört es jedoch zu den Spielregeln, daß der Leistungserbringer seine Kosten gemäß der geltenden Vorschriften zeitnah bezahlt bekommt. Optimale Abrechnung durch exakte Codierung, leistungsstarke EDV und Einsatz des Chirurgen (Schriftwechsel mit den Krankenkassen) sowie rigoroses Einfordern der berechtigten Forderungen sichern über die Erlösoptimierung die wirtschaftliche Existenz des Krankenhauses zum Wohle der Patienten und der Mitarbeiter.

This is a case report of a female patient who during a routine follow-up after a gastrectomy showed a tumor of the ileo-cecal valve, which--according to all radiologic diagnostic procedures--was highly suspected to be a malignant tumor. However, the histologic diagnosis was benign lipoma. The incidence and the characteristics of gastrointestinal lipomas in the actual literature will be reviewed.

The repair of multiple recurrences of inguinal hernias remains a surgical challenge. In 38 patients with a problematic recurrent inguinal hernia we implanted a polypropylene mesh (Prolene) in order to reinforce the transversalis fascia and to repair the inguinal hernia. 20 of these were medial and 14 lateral hernias; 4 patients had a combination of both types. All patients were prospectively included into this study and were seen in median follow-up periods of 3 and 6 months, as well as 4 and 9 years. As early complications hematoma of the wound (n = 3), scrotal edema (n = 1), temporary pain at the wound site (n = 12) and paresthesia (n = 13) occurred. Two patients (n = 2) developed a femoral hernia and one patient suffered from a persisting nerve injury of the ilioinguinal nerve. Due to the low complication and recurrency rate the tension free repair with polypropylene mesh is a effective method for treatment of problematic recurrent hernias.

Following severe trauma or major surgery patients develop functional alterations of host defense mechanisms which contribute an enhanced susceptibility towards microbial infections. Several studies have demonstrated that a specialized nutritional regimen may improve immune functions. We analyzed leukocyte functions from 40 patients undergoing major upper gastrointestinal surgery in a randomized placebo-controlled double-blind study. Patients were divided into two groups, one received 5 days pre-operatively an orally given experimental supplement enriched with omega-3-fatty acids, arginine, and ribonucleic acid (RNA), the other an isocaloric, control supplement. The experimental group generated significantly more leukotriene B(5) (LTB(5)) as compared to the control group. In contrast, the capacity to generate leukotriene B(4) (LTB(4)) as well as the synthesis of interleukin-8 (IL-8) was not significantly different in both groups. Additionally, lymphocyte/monocyte proliferation was analyzed and donor specific heterogeneities were observed; but no significant differences were found between the two nutritional regimens.

Bei allgemeiner Operabilität der Patienten bedeutet das Auftreten einer Narbenhernie auch die Indikation zur operativen Korrektur. In Abhängigkeit von den Spannungsverhältnissen und betroffenen Gewebeschichten kann der Hernienver-schluß durch Fasziendoppelung oder Stoß-auf-Stoß-Naht mit oder ohne Auf- bzw. Unterlage von Kunststoff- oder Cutislappen erfolgen. Für das Auftreten eines Hernien-rezidivs spielt die Nahtspannung eine viel größere Rolle als die Operationsmethode. Bauchwanddefekte können gut mit Cutis oder Kunstgewebe überbrückt werden. Bei permanenter Eingeweideeventration empfiehlt sich eine präoperative Bauchhöhlendehnung durch ein Penumoperitoneum.

PROBLEM:Within the course of the last ten years, a possible association between carcinoma of the colon and prior cholecystectomy has been discussed.METHODOLOGY:In 342 patients with colorectal carcinoma, and in a control group of 182 patients with gastric carcinoma, the rate of prior cholecystectomy was investigated.RESULTS:The cholecystectomy rate in the case of colon carcinoma patients was 7.9, and thus differed non-significantly from that of the control group (5.5%). At least in our case material, no relationship was found between cholecystectomy and carcinoma of the colon. The results reported in other studies are compared and discussed.

The diagnostic value of carcinoembryonic antigen (CEA) was studied prospectively in 18 patients with ascites of malignant and 28 patients with ascites of benign genesis. Both sensitivity and specificity reached 83%. With a prevalence of malignant disease of 38%, the positive and negative predictive values were 75% and 89%, respectively. In contrast to frequent false-positive CEA values in the serum of liver cirrhotics (48.3%), false-positive CEA values in the ascites of the same patients were observed in only 17.3%. It is thus recommended that if CEA determination is to be employed, it should be done in the ascites itself.

Chronic instability of the lateral upper ankle joint ligament is usually diagnosed by clinical and radiological examination. For the evaluation of an ultrasound method of testing lateral instability of the ankle joint we carried out a prospective study. We examined 23 adults who were actively engaged in some form of sport (21 male, 2 female, mean age 32 years) and had a preexisting lateral instability of the ankle. The instability was measured in the standard planes using Scheuba's stress apparatus with simultaneous ultrasound monitoring. The ultrasound examination was performed by positioning the 5-MHz applicator on the lateral side of the Achilles tendon, thus defining a plane from which the instability could be measured in both examination planes by observing the deviation between dorsal inferior edge of the tibia and the dorsal border of the talar roll. For the two examination planes, Spearman's rank-correlation coefficient between the radiological and ultrasound methods was 0.83 and 0.92. The sensitivity of the ultrasound method was 0.90, and the specificity was 0.85. Our study showed a good correlation between the two methods. A pathological talar tilt according to radiological criteria was also revealed by ultrasonography. Thus, all the advantages of ultrasound are now available for the evaluation of chronic lateral instability of the ankle joint.

Chronic instability of the lateral upper ankle joint ligament is usually diagnosed by clinical and radiological examination. For the evaluation of an ultrasound method of testing lateral instability of the ankle joint we carried out a prospective study. We examined 23 adults who were actively engaged in some form of sport (21 male, 2 female, mean age 32 years) and had a preexisting lateral instability of the ankle. The instability was measured in the standard planes using Scheuba's stress apparatus with simultaneous ultrasound monitoring. The ultrasound examination was performed by positioning the 5-MHz applicator on the lateral side of the Achilles tendon, thus defining a plane from which the instability could be measured in both examination planes by observing the deviation between dorsal inferior edge of the tibia and the dorsal border of the talar roll. For the two examination planes, Spearman's rank-correlation coefficient between the radiological and ultrasound methods was 0.83 and 0.92. The sensitivity of the ultrasound method was 0.90, and the specificity was 0.85. Our study showed a good correlation between the two methods. A pathological talar tilt according to radiological criteria was also revealed by ultrasonography. Thus, all the advantages of ultrasound are now available for the evaluation of chronic lateral instability of the ankle joint.

In a prospective study of 119 patients with breast carcinoma the value of ultrasonography for surgical therapy was compared with the value of clinical results and mammography. The tumor localization (in 96.8%) and the exact preoperative staging following the pTNM-system (tumor size in 85.8%, lymph node involvement in 77.2%) were better predicted by ultrasonography than by mammography and clinical examination. Especially the multicentric-multifocal carcinomas (20 of 29 cases) were better detected. Preoperative ultrasonography especially improves planning a conservative management of breast cancer.

127 cases of breast carcinoma were examined in a prospective study. By means of preoperative ultrasonography the staging following the pTNM-system validates the tumor size in 85.5% and the lymph node involvement in 77.2%. Multicentric-multifocal carcinomas were diagnosed by ultrasonography in 20 of 29 cases, merely 9 of 29 by mammography. Ultrasonography of specimen is recommended in cases of negative clinical findings and positive ultrasound examination to verify tumour excision. In addition to clinical exploration and mammography the ultrasonography of the breast obtains a diagnostic significance for planning a conservative management of breast cancer.

A female patient with dermatomyositis with the typical clinical findings of this disease, corresponding histological muscular changes and neurological findings is described. Since in the further course of the disease, recurrent gastric carcinoma was diagnosed, this case again emphasizes the significance of dermatomyositis as a paraneoplastic syndrome, and the need for tumor screening when dermatomyositis is diagnosed in advanced adulthood.

Records of 292 patients with colorectal cancer, operated at St.-Josef-Hospital between 1973 and 1984 were studied using Cox regression model to elucidate the prognostic influence of tumor site. Neither in univariate nor in multivariate analysis any significant independent influence of tumor site on prognosis could be detected. Male sex, older age and more advanced tumor stage were independently associated with poorer prognosis.