The history of this oldest among German surgical journals, in the second half of the twentieth century, is outlined from an editor's point of view. In this period, the journal mutated from a conservative refuge for lengthy theses to an innovative peer-review organ. Apart from original research and clinical reports, the journal now ran regular editorials, discussion panels and sections on Current Operative Techniques as well as Clinical Anatomy and finally developed into an English-language publication. This half-century of surgical progress-second to none in the history of surgery-is of course reflected in the contents of the journal. At the same time, specialisation and fragmentation of surgery from within and the advent of ever more competitive journals from without have presented a serious challenge to the survival of this traditional organ.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

OBJECTIVE:To find out if resections of cancers of the head of pancreatic are justified in patients over the age of 70 years.DESIGN:Retrospective study.SETTING:University hospital, Germany.SUBJECTS:519 patients with cancers of the pancreatic head, 93 (18%) of whom were aged 70 or over.MAIN OUTCOME MEASURES:Comparison of outcomes between those aged 70 or over, and those aged less than 70.RESULTS:There were 247 ductal adenocarcinomas, 134 carcinomas of the papilla of Vater, 79 carcinomas of the distal common bile duct, and 59 miscellaneous tumours. Of all variables compared (age, sex, symptoms, operations, clinical and pathological stage. morbidity, mortality, and long-term survival) the only significant difference between the groups was that leaks from the pancreaticojejunostomy occured more often in the older age group (p = 0.02). However, this did not influence overall morbidity or mortality.CONCLUSION:Patients' age is not a limiting factor in attempts at curative resection of cancers of the head of pancreas. If the tumour is resectable and patient is motivated and well enough, resection is indicated whatever the age.

BACKGROUND:Since the introduction of MRI, including imaging of the hepato-pancreatic duct system (MRCP) and 3D-MR angiography (3D-MRA), new pancreatic diagnostic procedures have been developed.METHODS AND PATIENTS:We report on 143 patients with benign and malignant diseases of the pancreas, who only received MRI preoperatively. All radiologic findings were confirmed intraoperatively.RESULTS:For resectability, MRI obtained sensitivity of 96.0% and specificity of 89.5% and for classification sensitivity of 99.1% and specificity of 95.2%.CONCLUSION:Based on our experience, the benign vs malignant nature of the disease, MRI is a safe and reliable method for pancreatic tumors being able to become the standard diagnostic procedure in the future.

OBJECTIVES To find out whether the Kausch-Whipple operation is adequate for the cure of rare tumours of the pancreatic head. DESIGN Retrospective study. SETTING University hospital, Germany. PATIENTS Of 640 patients who had Kausch-Whipple procedures between 1972 and 1998 we found 42 (6.6%) who were operated on for rare tumours of the pancreatic head. RESULTS Among these 42 patients 12 had functioning and non-functioning endocrine tumours, 11 had adenomas that were not locally resectable, 6 had leiomyosarcomas or oncocytomas, 4 had cystadenocarcinomas, 3 had acinar cell carcinomas, 2 had primary lymphomas, and 3 had metastases to the pancreatic head. Operative treatment (such as extended resection), postoperative course, and survival time after operation varied. Patients with adenomas had the most favourable mean survival time of 106.5 months. Among patients with cancer, those with endocrine malignancies had the best outcome with a mean survival duration of 58.3 months.

Hintergrund: Durch die Einführung der ultraschnellen Kernspintomographie (MRT), einschließlich der Darstellung des hepato-pankreatischen Gangsystems (MRCP) und der 3D-Gefäßdarstellung (MR-Angio) haben sich neue diagnostische Möglichkeiten in der Diagnostik von Pankreasveränderungen ergeben. Material und Methode: Wir berichten über 143 operierte Patienten mit benignen und malignen Pankreaserkrankungen, die ausschließlich eine MR-Diagnostik präoperativ erhalten haben. Alle radiologischen Befunde wurden intraoperativ überprüft. Ergebnisse: Es konnte für die Frage nach der Resektabilität eine Sensitivität von 96,0 % bei einer Spezifität von 89,5 % und bei der Festlegung der Dignität eine Sensitivität von 99,1 %, bei einer Spezifität von 95,2 % mit der MR-Pankreasdiagnostik erreicht werden. Schlussfolgerung: Nach unseren Erfahrungen mit der MR-Pankreasdiagnostik wird sich dieses sichere und komplikationslose diagnostische Verfahren als Standard durchsetzen.

Five southern German university centers cooperated in comparing the effect of surgical vs. nonsurgical therapy strategies on survival and sphincter preservation in the treatment of anal cancer. A standardized questionnaire was used to evaluate retrospectively (mean follow-up 30 months) treatment strategy and outcome (survival, colostomy rate, colostomy-free survival) in patients treated between 1987 and 1996. Of the 142 patients 65% had squamous cell, 20% basaloid, 6% adeno-, and 1% undifferentiated carcinoma (8% histology not recorded); 9% were classified in UICC stage I, 37% in stage II, 25% in stage III, and 4% in stage IV (25% not recorded). Primary treatment consisted of local excision (10%), excision plus radio- and/or chemotherapy (17%), radiotherapy (20%), radiochemotherapy (28%), or colostomy with or without resection, radiotherapy, and chemotherapy (23%). We observed no difference between these treatment groups in overall (P = 0.43) or colostomy-free survival (P = 0.14, log-rank). Primary colostomy was prevented in 77% of cases and decreased over the years. Mean overall survival (in months) was 42 in stage I, 38 in stage II, and 25 in stage III (P = 0.0013); mean colostomy-free survival was 36 in stage I, 26 in stage II, and 16 in stage III (P = 0.0021, log-rank). Outcome was not significantly related to therapeutic strategy (surgery or radio-chemotherapy. Primary surgical and nonsurgical strategies in treating anal cancer thus produced similar results, although radiochemotherapy is usually recommended for sphincter-endangering anal cancer. Challenges to be met in the future include the prevention of metastasis and long-term preservation of anal sphincter function.

Ziel: Beurteilung der Wertigkeit eines „globalen” MR-Protokolls in der Diagnostik von Pankreastumoren. Material und Methode: 46 Patienten mit Verdacht auf Pankreaskarzinom wurden mit einem definierten Protokoll unter Einbeziehung von T1- und T2-gewichteten Sequenzen, einer 2D-RARE MRCP-Sequenz und einer kontrastverstärkten 2-Phasen 3D-MRA untersucht. Ergebnisse: Alle Pankreastumoren wurden mit der Kombination von Schnittbild und MRCP nachgewiesen. Trotz des Einsatzes der MRCP gelang in 3 (6,5 %) von 46 Fällen eine sichere Differenzierung zwischen Pankreaskarzinom und chronischer Pankreatitis nicht. Qualitativ hochwertige 3D-MR-Angiogramme wurden in 43 (93,5 %) Fällen erzielt. In 6 (13 %) Fällen wurde eine aberrierende, aus der A. mesenterica superior entspringende rechte Leberarterie nachgewiesen. Die Genauigkeit der MRT in der Beurteilung der extrapankreatischen Tumorausdehnung betrug 95,7 %, des Lymphknotenstatus 80.4 %, der Detektion von Lebermetastasen 93,5 % und der Erfassung der lokalen Gefäßinfiltration 89,1 %. Schlußfolgerung: Die „globale” MRT-Untersuchung hat das Potential, nach klinischer Untersuchung und Sonographie das wichtigste Untersuchungsverfahren für die meisten Patienten mit Verdacht auf das Vorliegen eines Pankreastumors zu werden.

BACKGROUND Epidemiological data implicate that renal transplants from living unrelated donors result in superior survival rates as compared with cadaveric grafts, despite a higher degree of human lymphocyte antigen (HLA) mismatching. We undertook a center-based case control study to identify donor-specific determinants affecting early outcome in cadaveric transplantation. METHODS The study database consisted of 152 consecutive cadaveric renal transplants performed at our center between June 1989 and September 1998. Of these, 24 patients received a retransplant. Donor kidneys were allocated on the basis of prospective HLA matching according to the Eurotransplant rules of organ sharing. Immunosuppressive therapy consisted of a cyclosporine-based triple-drug regimen. In 67 recipients, at least one acute rejection episode occurred during the first month after transplantation. They were taken as cases, and the remaining 85 patients were the controls. Stepwise logistic regression was done on donor-specific explanatory variables obtained from standardized Eurotransplant Necrokidney reports. In a secondary evaluation, the impact on graft survival in long-term follow-up was further measured by applying a Cox regression model. The mean follow-up of all transplant recipients was 3.8 years (SD 2.7 years). RESULTS Donor age [odds ratio (OR) 1.05; 95% CI, 1.02 to 1.08], traumatic brain injury as cause of death (OR 2.75; 95% CI, 1.16 to 6. 52), and mismatch on HLA-DR (OR 3.0; 95% CI, 1.47 to 6.12) were associated with an increased risk of acute rejection, whereas donor use of dopamine (OR 0.22; 95% CI, 0.09 to 0.51) and/or noradrenaline (OR 0.24; 95% CI, 0.10 to 0.60) independently resulted in a significant beneficial effect. In the multivariate Cox regression analysis, both donor treatment with dopamine (HR 0.44; 95% CI, 0.22 to 0.84) and noradrenaline (HR 0.30; 95% CI, 0.10 to 0.87) remained a significant predictor of superior graft survival in long-term follow-up. CONCLUSIONS Our data strongly suggest that the use of catecholamines in postmortal organ donors during intensive care results in immunomodulating effects and improves graft survival in long-term follow-up. These findings may at least partially be explained by down-regulating effects of adrenergic substances on the expression of adhesion molecules (VCAM, E-selectin) in the vessel walls of the graft.

PURPOSE:To evaluate the accuracy of a non-invasive "all-in-one" staging MR method in patients with pancreatic tumors.MATERIAL AND METHODS:46 patients were prospectively evaluated by a combined MR imaging protocol including breath-hold T1- and T2-weighted pulse sequence, MRCP using a breath-hold 2D-RARE sequence, and breath-hold gadolinium-enhanced dual-phase 3D-MR angiography.RESULTS:All pancreatic tumors were detected by the combination of cross-sectional imaging and MRCP. In spite of the use of MRCP, definitive differentiation between pancreatic carcinoma and chronic pancreatitis was not possible in 3 (6.5%) out of 46 cases. High quality 3D-MR angiograms were obtained in 43 (93.5%) cases. In 6 (13%) patients 3D-MRA showed an aberrant right hepatic artery. The overall accuracy of MRI in assessing extrapancreatic tumor spread, lymph node metastases, liver metastases, and vascular involvement was 95.7%, 80.4%, 93.5%, and 89.1%, respectively.CONCLUSION:Due to its high accuracy, the "all-in-one" MR protocol may become the most important modality after clinical examination and ultrasound in the diagnostic work-up for most patients with suspicion of pancreatic tumors.

OBJECTIVE:To investigate the role of the monocyte/macrophage system in acute pancreatitisDESIGN:Prospective clinical studySETTING:University clinic, GermanySUBJECT:37 consecutive patients who presented with acute pancreatitis.MAIN OUTCOME MEASURE:Correlation between function of monocytes measured by HLA-DR expression and outcomeRESULTS:Patients were divided into three groups according to outcome: those with severe pancreatitis who died (n = 10), those with severe pancreatitis who survived (n = 15), and those with mild pancreatitis who survived (n = 12). There was a clear and significant difference between those with severe and those with mild disease. HLA-DR expression was initially depressed in both groups, but after the third day of treatment it started to recover significantly in those with mild disease (p < 0.05). The difference was also significant from day 7 onwards between those with severe disease who died and those with severe disease who survived (p < 0.05).CONCLUSION:Monocyte function as measured by HLA-DR expression (CD14+DR+) is reduced in patients with acute pancreatitis and does not recover in patients who are going to die (median < 20 relative antigen density units; RU).

With approximately 150 reported cases, fistulas between the abdominal aorta and inferior vena cava are rare. Preoperative clinical diagnosis of aortocaval fistula is difficult because the classical triad of abdominal pain, pulsatile abdominal mass, and abdominal machinery-like bruit may be absent in up to 50 % of patients. We report a case of aortocaval fistula complicating abdominal aortic aneurysm which was diagnosed preoperatively using breath-hold gadolinium-enhanced three-dimensional MR angiography.

Introduction: Looking back at the initially dismal record for pancreatic cancer surgery - Whipple him- self felt that a 30 - 35% mortality was justifiable (!) - sig- nificant progress has been made. Progress: The operative mortality has fallen below 5% and the serious complica- tions of pancretic resections such as leaks and haemorrhage have been reduced to some 10% and we are better equipped to deal with these if they occur. The 5-year-survival of pa- tients in whom pancreatic cancer was amenable to an R0- resection has risen to 30%. These are the surgical achieve- ments using the standard Kausch-Whipple technique alone. There has been no improvement in these results, either by increasing radicality (regional pancreatectomy) or by reducing it (pylorus-preserving pancreatoduodenec- tomy). The same can be said of all other modalities of oncological treatment that have been tried so far: adjuvant radiochemotherapy, regional chemotherapy, hormonal or genetic manipulations. Perspective: This does not mean that we should reduce efforts at improving early detection of the disease and unravelling its complex molecular biol- ogy. On the contrary, the results of surgery alone in spite of all improvements seem to have reached a plateau that gives little cause for complacency.

Bildgebung und Staging. Zwar ist die Diagnose eines Pankreasfrühkarzinoms noch immer ein Zufall. Dafür hat das ultraschnelle NMR ein viel genaueres Staging ermöglicht mit entsprechend höheren Resektionsquoten.

La duodénopancréatectomie céphalique (DPC) constitue le seul traitement curatif de l'adénocarcinome de la tête du pancréas et se caractérise par une morbidité initiale élevée et une faible survie à distance. Son intérêt est donc encore contesté. Le but de cette étude était d'évaluer les résultats immédiats et à distance de la DPC pour adénocarcinome de la tête du pancréas, et d'identifier les facteurs conditionnant la survie à distance.Il s'agit d'une étude rétrospective de 79 patients ayant eu une DPC à visée curative d'un adénocarcinome de la tête du pancréas entre 1982 à 2002. Ont été évalués : la mortalité opératoire, la survie des patients opérés, les facteurs pronostiques en analyse univariée et multivariée, et les données concernant les patients survivant à plus de cinq ans.Le taux de mortalité opératoire était de 1,3 %. La survie à un, trois et cinq ans était de 46, 26 et 11 %. La médiane de survie était de 12 mois. Les facteurs pronostiques identifiés étaient le stade T (classification TNM) et la radicalité de la résection. Après analyse multivariée, seule la radicalité de résection était un facteur pronostique indépendant. Cinq malades étaient survivants à plus de cinq ans. Ils ne différaient en rien des autres patients mais aucun n'avait de marge envahie ni d'envahissement veineux.Ces résultats (faible mortalité opératoire, survie à distance appréciable avec existence de survivants à long terme) suggèrent qu'il est licite de proposer une DPC à un maximum de patients en bon état général. La DPC reste le seul traitement curatif permettant une survie prolongée.Pancreaticoduodenectomy (PD) is the only curative treatment for adenocarcinoma of the pancreatic head but is associated with a significant early morbidity and a poor long term survival. Therefore, its value is still debated. The aim of this study was to evaluate early and distant results of PD for pancreatic adenocarcinoma, and to identify prognostic factors.Seventy-nine patients who underwent PD with curative intent for adenocarcinoma of the pancreatic head from 1982 to 2002 were studied retrospectively. The following data were evaluated: operative mortality, long-term survival, prognostic factors (through univariate and multivariate analysis), and characteristics of 5-year survivors.Mortality rate was 1.3%. Survival at 1, 3 and 5 years was 46%, 26% and 11%. The median survival was 12 months. The prognostic factors were the T stage (T.N.M. classification) and radicality of resection. After multivariate analysis, radicality of resection was the only independent prognostic factor. Five patients survived for more than 5 years. They did not differ of the other patients but none had positive margin or venous invasion.These results (low mortality, significant distant survival including some long term survivors) suggest that PD for pancreatic adenocarcinoma must be indicated in most low-risk patients. PD remains the only curative treatment allowing prolonged survival.