Perianal disease is a frequent manifestation of Crohn's disease and occasionally is the presenting symptom. However, most lesions are or become asymptomatic and remain so for many years. A series of 109 patients with perianal fissures and fistulas has been followed for 10 years. Fourteen have died, 7 from unrelated disorders. Ten have had an excision of the rectum but only 5 for perianal disease. Of the remaining 85 patients, 24 asymptomatic patients were not reexamined, and 61 were investigated extensively by sigmoidoscopy biopsy or manometry. Many fissures and most fistulas had healed, but some had progressed to some degree of anal stenosis, usually asymptomatic. A very conservative policy is proposed.

There has been a controversy for years concerning the value of the prophylactic gastroenterostomy (GE) in patients suffering from irresectable pancreatic cancer. A retrospective analysis of the patients undergoing palliative bypass-operations for pancreatic cancer at Zurich University Hospital between 1982 and 1990 revealed 53 patients (28 male, 25 female) with an average age of 68 years. Twenty-one patients received a double bypass, 18 received a hepaticojejunostomy, 12 a primary and 2 a secondary GE. Mortality and morbidity for double bypass were 14% and 33%, for hepaticojejunostomy 5% and 28% and for primary GE 25% and 50%. Secondary GE was associated with a mortality and morbidity of 1 of 2 cases. Two patients received a secondary GE and two more showed signs of duodenal obstruction amounting to 20% incidence for secondary duodenal obstruction. Delayed gastric emptying was observed in only 2 patients with primary GE. These data suggest the use of a prophylactic double bypass.

There has been a controversy for years concerning the value of the prophylactic gastroenterostomy (GE) in patients suffering from irresectable pancreatic cancer. A retrospective analysis of the patients undergoing palliative bypass-operations for pancreatic cancer at Zurich University Hospital between 1982 and 1990 revealed 53 patients (28 male, 25 female) with an average age of 68 years. Twenty-one patients received a double bypass, 18 received a hepaticojejunostomy, 12 a primary and 2 a secondary GE. Mortality and morbidity for double bypass were 14% and 33%, for hepaticojejunostomy 5% and 28% and for primary GE 25% and 50%. Secondary GE was associated with a mortality and morbidity of 1 of 2 cases. Two patients received a secondary GE and two more showed signs of duodenal obstruction amounting to 20% incidence for secondary duodenal obstruction. Delayed gastric emptying was observed in only 2 patients with primary GE. These data suggest the use of a prophylactic double bypass.

The biofragmentable ring (Valtrac) to perform a sutureless bowel anastomosis was used in a short period until complications rate became to big. There were six ileo-colostomies with the 28 mm ring and 7 colo-colostomies with the 31 mm ring. In 4 patients additional sutures were placed because the ring was shining through the tissue. Thirteen patients (4 women, 9 men) with a mean age of 63 years (36-78) were included. Complications occurred in 3 men (71, 36 and 63 years old). Two of them had an additional suturing. One demonstrated insufficiency at day four with many small gabs in the anastomotic line according to the ring design. Histology demonstrated perfect microcirculation. The second patient developed a fistula three weeks after operation. Both had an ileo-colostomy. The third operated because of a gastrocolic fistula with cachexia reentered hospital seven weeks postoperatively with a new gastrocolic fistula on X-ray. He died with a cardiac arrest. Postmortem was refused. We conclude from our results that the Valtrac ring should be used only by experienced surgeons, there is no reduction in operation time, and ileo-colostomy needs special care. We believe that surgeons using an extramucosal monofilament running suture for colonic anastomosis are more unlikely to switch to the Valtrac ring than those using other technics.

The introduction of laparoscopic cholecystectomy as method of choice for gall stone treatment reopened the question whether to continue with routine intraoperative cholangiography or to switch over to a selective indication. In order to set an accurate indication for selective intraoperative cholangiography it was our goal to develop a tool for preoperative identification of patients with a high risk of common bile duct stones. A preoperative score, indicating the risk of common bile duct stones, was designed. A history of jaundice, elevated levels of bilirubin, alkaline phosphatase, amylase (serum), ALAT (GPT) or ASAT (GOT), a common bile duct wider than 10 mm or containing concrements and multiple gallstones smaller than 10 mm were valued as risk indicators, whereas normal wide bile duct, large or solitary gallstones were valued as decreasing the risk of common bile duct stones. The retrospective screening of 289 consecutive conventional cholecystectomies (1986-1990) for these risk indicators demonstrated a good correlation of the risk score with the occurrence of common bile duct stones. A prospective application of the score, with improved ultrasound examination and routine preoperative intravenous cholangiography, mandatory for laparoscopic cholecystectomy at our institution, will define the high risk group definitely and allow an accurate selective use of intraoperative cholangiography.

Der primäre Hyperparathyreoidismus (PHPT) verursacht unter anderem septische Ulzera und Pankreatitiden. 71 Patienten wurden 82mal parathyreoidektomiert. Es starb niemand. Eine Rekurrensparese trat bei 4% (1. Op.) resp. 14% (Reop.) auf. Bei 4 Patienten persistierte die Hyperkalzämie nach der 1. Operation. Während einer Beobachtungszeit von max. 3 Jahren entstanden nur 3 echte Rezidive. Die Letahtät der Perforation resp. Blutung des peptischen Ulkus liegt in unserer Khnik bei 7% resp. 24%; die Letahtät der akuten Pankreatitis bei 25 — 50%, weshalb die PHPT so früh wie möglich operiert werden soll, da der Eingriff im Vergleich risikoarm ist.

Since laparoscopic cholecystectomy has been established at our institution, the routine use of intraoperative cholangiography was abandoned but preoperative intravenous cholangiography and sonography are mandatory. However, these investigations are not always conclusive and in some cases not applicable. We have therefore started to use selective intraoperative laparoscopic cholangiography for laparoscopic cholecystectomy. Our technique and the materials required for this peroperative investigation are described in the present article.

The introduction of laparoscopic cholecystectomy as method of choice for gall stone treatment reopened the question whether to continue with routine intraoperative cholangiography or to switch over to a selective indication. In order to set an accurate indication for selective intraoperative cholangiography it was our goal to develop a tool for preoperative identification of patients with a high risk of common bile duct stones. A preoperative score, indicating the risk of common bile duct stones, was designed. A history of jaundice, elevated levels of bilirubin, alkaline phosphatase, amylase (serum), ALAT (GPT) or ASAT (GOT), a common bile duct wider than 10 mm or containing concrements and multiple gallstones smaller than 10 mm were valued as risk indicators, whereas normal wide bile duct, large or solitary gallstones were valued as decreasing the risk of common bile duct stones. The retrospective screening of 289 consecutive conventional cholecystectomies (1986-1990) for these risk indicators demonstrated a good correlation of the risk score with the occurrence of common bile duct stones. A prospective application of the score, with improved ultrasound examination and routine preoperative intravenous cholangiography, mandatory for laparoscopic cholecystectomy at our institution, will define the high risk group definitely and allow an accurate selective use of intraoperative cholangiography.

During studying the literature a big confusion around the item abscess can be recognized. Especially in the English publications it is used for sterile tissue necrosis, infected necrosis, infected pseudocyst or suppuration. Pancreas phlegmon means there a sterile mass of pancreas and peripancreatic oedema. With us an abscess still is a located plus collection surrounded by a more or less tight capsule and a phlegmon is a diffuse purulent infection in the tissue. This definition is important because the frequency and prognosis of a true abscess is far below an infected necrosis (with us 4 abscess in 48 necrotising pancreatitis but 54% infected necrosis). Abscess formation needs two to four weeks whereas pseudocyst develops rather fast in one to two weeks. Although spontaneous resorption of pseudocyst is possible, we recognized ten and operated on all of them either by internal drainage or by resection of the tail of the pancreas. Mortality of one series of 124 patients with acute pancreatitis was at 30 days 4% and 27%, respectively, when necrosis was present and overall mortality having treated all patients to final discharge was 5% and 44%, respectively. Mortality rate was constant in the last years but Ranson score was continuously increasing.

The only causal treatment of primary hyperparathyroidism (PHPT) is parathyroidectomy. There are indications in the literature that despite operation expectation of life is shortened because of an increased frequency of cardiovascular and malignant diseases leading to the recommendation for early surgery even in uncomplicated PHPT. It is easier to convince an asymptomatic patient of an operation when he is informed about complications and consequences of an expectative attitude. Therefore, we reviewed our 71 patients operated upon during a 4-year-interval, 58 of whom were followed-up. During 82 operations 115 pathologically altered parathyroid glands were removed. Two persistent paralyses of the recurrent nerve occurred, however, without alteration of the voice. Follow-up of 82% of patients revealed 2 cases of recurrent nephrolithiasis (1 hypercalcaemia, 1 normocalcaemia). Three (5%) true recurrences were found, but neither a pancreatitis nor a peptic ulcer was noted during long-term follow-up. None of the 137 patients operated for a bleeding or perforated peptic ulcer during the last 10 years and 1 of 55 patients with acute pancreatitis during the past 8 years suffered from a PH-PT. However, morbidity and mortality of these two conditions was high. Although correlation to PHPT was low we recommend early operation of PHPT because of the low morbidity rate, zero lethality and reduced expectation of life.

Between July 1986 and May 1987 23 patients suffering from anal condylomata acuminata were treated at the University Hospital of Zurich. The influence of HIV-infection on the disease is described. An almost equal frequency of recurrencies between positives and negatives was observed in a three year follow-up time. However, in positive patients recurrence was earlier and much more extensive. A two-stage procedure which sometimes is advocated in very extensive lesions gave very bad results in HIV positives. We use a radical excision by electrocoagulation on the mucosa and perianally and avoid circular necrosis in the lower anal canal only. Infectious complications are not to be feared except in patients with symptomatic HIV-infection resulting in the recommendation for a antibiotic prophylaxis in such cases.

Abdominal adhesions are due to a locally decreased peritoneal fibrinolytic capacity occurring mainly in ischemic areas of the peritoneum. They help to guarantee the supply of blood to these areas, acting as a protective mechanism ("vascular graft"). With respect to abdominal surgery a general suppression of the ability to form adhesions would therefore seem to be questionable. We consider the currently employed or discussed methods with their advantages and disadvantages. No optimal solution to the problem of adhesions has been found so far. Nevertheless, appropriate surgical technique can permit us to control adhesion formation to a certain degree. If adhesions are unavoidable, placement of the greater omentum should be done carefully in the areas of risk.

Unilateral pulmonary edema can develop after evacuation of pleural liquid and pneumothorax, after pneumonectomy at the contralateral side and as a special form in left ventricular failure. Unilateral ipsilateral pulmonary edema in the remaining parenchyma after operations of the lung has been described very rarely. Eight patients are here described, once after a decortication and seven times after a pulmonary resection. Radiologic signs occurred generally 12-24 h after the operation and persisted for three to seven days. The first postoperative X-ray was always more or less normal. We believe that the cause of the edema is a mechanical traumatisation of the remaining parenchyma of the lung at the time of the operation which results to a capillary leak. Left ventricular failure and excessive fluid application after the operation can be a risk factor. Generally no clinical signs are present during the edema, but respiratory insufficiency, as with patient 8 can occur. Therefore it is important to distinguish unilateral pulmonary edema from other diagnosis like pneumonitis, hemothorax and atelectasis.

Surgical risk research aims at detecting and ultimately eliminating risk factors of operative procedures. In general surgery, the risk can be divided into the following groups of factors: The environment, the surgeon, the anaesthesia, the operative intervention per se, the disease to be treated surgically and the patient. The protocol of a prospective study of risk factors is described, including all elective operations performed on in-hospital patients of one institution under general or spinal anaesthesia. The study is designed to cover 10 years. The objective is to eliminate mortality of elective interventions by the end of the century.

Between July 1986 and May 1987 23 patients suffering from anal condylomata acuminata were treated at the University Hospital of Zurich. The influence of HIV-infection on the disease is described. An almost equal frequency of recurrencies between positives and negatives was observed in a three year follow-up time. However, in positive patients recurrence was earlier and much more extensive. A two-stage procedure which sometimes is advocated in very extensive lesions gave very bad results in HIV positives. We use a radical excision by electrocoagulation on the mucosa and perianally and avoid circular necrosis in the lower anal canal only. Infectious complications are not to be feared except in patients with symptomatic HIV-infection resulting in the recommendation for a antibiotic prophylaxis in such cases.

The term risk is understood to be the danger of the occurrence of an undesired, life-threatening event. The probability of this undesired event is greater in the presence of a risk factor than in its absence. In general surgery, these risk factors can be classified into five groups: The environment, the surgeon, the operation per se, the disease, and the patient himself. Abdominal surgery is especially suited to clarify and to illustrate this classification. Some typical risk factors are described, and for each group the measures for risk prevention or risk reduction are discussed.

Unilateral pulmonary edema can develop after evacuation of pleural liquid and pneumothorax [2,4], after pneumonectomy at the contralateral side [5] and as a special form in left ventricular failure [1]. Unilateral ipsilateral pulmonary edema in the remaining parenchyma after operations of the lung has been described very rarely. Eight patients are here described, once after a decortication and seven times after a pulmonary resection. Radiologic signs occurred generally 12-24 h after the operation and persisted for three to seven days. The first postoperative X-ray was always more or less normal. We believe that the cause of the edema is a mechanical traumatisation of the remaining parenchyma of the lung at the time of the operation which results to a capillary leak. Left ventricular failure and excessive fluid application after the operation can be a risk factor. Generally no clinical signs are present during the edema, but respiratory insufficiency, as with patient 8 can occur. Therefore it is important to distinguish unilateral pulmonary edema from other diagnosis like pneumonitis, hemothorax and atelectasis.

The aim of this study was to determine whether significant improvement in perineal wound healing could be achieved by placing parts of greater omentum into the sacral cavity after rectal excision. 74 patients were evaluated, in 38, parts of the greater omentum were mobilised into the presacral cavity. The omentum flap increased primary healing from 41% to 61%. Sinus formation was reduced. Since using routine omentoplasty all wounds have healed by five months. Complications occurred only twice. In one patient the omentum became partially necrotic, while in another small bowel obstruction occurred due to herniation beneath the root of the flap. We conclude from our results that omentoplasty after rectal excision is a useful method to improve perineal wound healing and should be performed as routine procedure.