Accessible online at: www.karger.com/ver Belegen und gibt Anregungen für die klinisch-psychologische Forschung und Praxis, wobei auch Kosten-Nutzen-Relationen berücksichtigt werden. Anschließend stellt Weck Instrumente zur Erfassung psychotherapeutischer Kompetenzen vor, wobei vor allem die deutsche Version der ursprünglich von Young und Beck entwickelten Cognitive Therapy Scale (CTS) im Fokus steht [Weck et al., 2010]. Die Beurteilung psychotherapeutischer Kompetenzen anhand dieses Instruments erfolgt durch unabhängige und trainierte Rater im Rahmen von Audio-/Videoaufzeichnungen oder Live-Beobachtungen. Dieses Instrument ist sowohl für den Forschungsals auch Praxiskontext gut geeignet und erfasst allgemeine therapeutische Kompetenzen (z.B. interpersonelle Effektivität, Ressourcenaktivierung, etc.) und sitzungsstrukturierende Kompetenzen (z.B. Tagesordnung, Zeitaspekte, etc.). Weck gibt zusätzlich einen Studienüberblick über den Zusammenhang von psychotherapeutischen Kompetenzen und Therapieerfolg. Abschließend thematisiert Weck die Förderung psychotherapeutischer Kompetenzen, wobei er zunächst der Frage nachgeht, ob diese erlernbar sind. Er stellt unterschiedliche Trainingsmaßnahmen vor (z.B. Helping Skills Training), geht auf deren Evidenzbasierung ein und erläutert anschließend verschiedene Methoden zur Förderung psychotherapeutischer Kompetenzen (z.B. Training, Feedback, (Live-)Supervision). Der Autor schließt mit einer Zusammenfassung und diskutiert vor allem die Perspektive der klinisch-psychologischen Forschung. Wie der Klappentext verspricht, ist das Buch gut lesbar sowie kurz und knapp geschrieben. Im Hinblick auf die erwähnten Zielgruppen (Ausbildungstherapeuten mit großem Interesse am Thema sowie erfahrene Psychotherapeuten, die den Anspruch verfolgen, die eigene Tätigkeit zu reflektieren) ist die Publikation nicht spezifisch genug formuliert und gibt leider zu wenige praktische Empfehlungen. Als Zielgruppe hätten sicherlich auch Supervisoren aufgeführt werden können sowie Fachpersonal, das an der Verbesserung von Ausund Weiterbildung von Psychotherapeuten beteiligt ist. In jedem Fall lassen sich hilfreiche Erkenntnisse aus den Darstellungen ableiten. Der Leser, der sich theoretisch fundiert dem Thema psychotherapeutische Kompetenzen widmen möchte, findet in diesem Buch einen wertvollen Überblick zu relevanten Theorien, Modellen und Instrumenten sowie Anregungen für deren Implikation in der Praxis.

Central to the successful surgically treatment numerous liver diseases is the ability of the organ to regenerate. The understanding of the process of self-renewal has both changed and progressed over the last few decades. For many years, the assumption was that the liver regenerates primarily through the division of mature liver cells. However, over the last few years there has been increasing evidence of the participation of stem cells. Intrahepatic stem cells, so-called oval cells, are activated under conditions of severe or chronic liver disease and originate from the canals of Hering. In addition, extrahepatic stem cells may migrate from the bone marrow into the liver when the regenerative capacity of the liver itself is depleted. It is not yet fully clear how the different stem cell populations interact with both each other and the mature liver cell population to achieve homeostatic cell and differentiation equilibrium in the diseased and/or regenerating organ. In any case, the outstanding growth potential of liver stem cells may become a clinically viable option in the field of cell transplantation.

Background: The aim of this study was to determine the accuracy of prediction of the surgeon's 'gut-feeling' in estimating postoperative outcome.Methods: A prospective series of 1077 consecutive patients undergoing major hepatobiliary or gastrointestinal surgery were studied. Patients having elective (n = 827) and emergency (n = 250) procedures were included. The surgeon predicted the development of postoperative complications immediately after completion of surgery on a scale from 0 to 100 per cent. These predictions were compared with the actual outcome and with predictions made using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM). The Portsmouth predictor equation (P-POSSUM) was applied for the estimation of mortality.Results: The observed morbidity and mortality rates were 29.5 and 3.4 per cent respectively. POSSUM predicted a morbidity rate of 46.4 per cent and P-POSSUM a mortality rate of 6.9 per cent. The surgeon's gut-feeling was more accurate in the prediction of morbidity at 32.1 per cent. On the basis of gut-feeling, surgeons overpredicted morbidity in elective surgery, but underestimated the risk of complications in the emergency setting. The (P)-POSSUM scoring system overpredicted morbidity and mortality for elective and emergency operations.Conclusion: The surgeon's gut-feeling is a good predictor of postoperative outcome, especially after elective surgery. (P)-POSSUM overpredicted morbidity and mortality in this series of major gastrointestinal and hepatobiliary operations.

Einleitung: Regenerierenden Ressourcen von Vorläuferzellen wird aufgrund der Spenderorganknappheit ein zukunftsträchtiges Potential zum Organersatz beigemessen. In dieser vergleichenden Untersuchung werden in vitro proliferierende Hepatozyten und in vivo generierte Vorläuferzellen charakterisiert.

Background/Purpose: Over the last 20 years, hepatocyte transplantation (HcTx) has advanced from the experimental to the clinical stage. To date, HcTx has been performed in 30 patients in the United States. Regardless whether hepatocytes are transplanted into the spleen and migrate to the liver or are injected directly into the portal vein, transplanted liver cells will, to some extent, congest the recipient liver microcirculation. The potential negative consequences of intrasplenic HcTx were the subject of this study.Methods: By using intravital microscopy, the authors investigated whether intrasplenic HcTx of 20 X 10(6) allogenic hepatocytes would influence liver perfusion, excretory liver function, and nonparenchymal cells (Kupffer and Ito cells) in vivo.Results: The sinusoidal perfusion rate declined significantly from 94% (control) to 84% on day 1 and 76% on day 7. Bile acid excretion decreased in a similar fashion from 0.924 mg/h (control) to 0.669 mg/h on day 7. The authors observed a significant increase of Ito cells from 81.1 cells per microscopic field (control) to 97.1 (day 1) and an increase of Kupffer cells (KC; 6.1 cells per microscopic field on day 1 v3.8 on control).Conclusions: This study shows an acute impairment of hepatic microcirculation and hepatucellular function along with an recruitment and activation of nonparenchymal cells in the early posttransplantation period after intrasplenic HcTx. Kupffer cell recruitment indicates an activation of local host defense, and Ito cell activation implies the initiation of liver repair mechanisms owing to ischemia-related cell damage. (C) 2004 Elsevier Inc. All rights reserved.

Im Anbetracht des Alters des Patienten und den typischen Refluxsymptomen ist hier als Erstes die Verdachtsdiagnose „Refluxkrankheit” zu stellen. Die DD der Refluxkrankheit ist der gesamte Formenkreis der Dysphagie.Dazu zählen das Ulkusleiden, Tumore im Ösophagus, Magen und Duodenum, Magenausgangstenose, Duodenalobstruktion- oder kompression, Achalasie und Ösophagusdivertikel. Neben der ausführlichen Anamnese (Übergewicht, Essgewohnheiten, etc.) sind eine Ösophagogastroduodenoskopie, eine ambulante ph-Metrie und Manometrie zu empfehlen.

BACKGROUND AND AIMS:Alterations in microvascular perfusion of the intestine after hepatic ischemia/reperfusion have been suggested as an important cause of postoperative septic complications. We therefore investigated small bowel microcirculation and mucosal injury after liver ischemia/reperfusion in a rat model. Furthermore, we analyzed the effects of the regulatory peptides vasoactive intestinal polypeptide and gastrin-releasing peptide for their splanchnic vasoactivity.METHODS:Hepatic ischemia was induced by clamping of the left hepatic artery and vein for 40 min, followed by 60 min of reperfusion. The control group was treated similarly, but without clamping of the liver vessels. Ten minutes after clamping of the hepatic vessels, vasoactive intestinal polypeptide or gastrin-releasing peptide, respectively, were continuously infused intravenously in the experimental groups. Small bowel microcirculation and mucosal injury were assessed using intravital microscopy and the Chiu-score, respectively.RESULTS:The functional capillary density of the small intestine following ischemia and reperfusion of the left hepatic lobe significantly decreased compared to normal controls in both the mucosa and the smooth intestinal muscle. Red blood cell velocity decreased, whereas leukocyte-endothelium adherence, stasis index and the mucosal injury score increased. Administration of vasoactive intestinal polypeptide resulted in an increase of functional capillary density in the mucosa and of the red blood cell velocity and a decrease in the stasis index. The mucosal injury score was significantly higher in reperfused animals without treatment. The application of gastrin-releasing peptide resulted in an isolated increase of the red blood cell velocity. Leukocyte adherences could not be altered by the regulatory peptides.CONCLUSION:We conclude that hepatic ischemia/reperfusion injury leads to significant alterations of small bowel microcirculation and mucosal injury. Vasoactive intestinal polypeptide and gastrin-releasing peptide attenuate the damage in a different manner.

Background: To date, the effects of increased abdominal pressure, as given during carbon dioxide (CO2) pneumoperitoneum, on hepatic microcirculation and biliary excretion are unknown.

During acute rejection leukocyte-endothelial cell interaction (LEI) fuelled by the activation of co-stimulatory molecules such as the CD154/CD40 ligand/receptor dyad causes a decrease in micro-circulatory blood flow that leads to graft failure. Down-regulating CD40 expression in the endo-thelium by employing a decoy oligonucleotide (dODN) neutralising the transcription factor STAT-1 may help to maintain microcirculatory blood flow.

Die Technik der extraperitonealen Hernioplastik (TEP) ist ein sicheres Verfahren zur endoskopischen Versorgung der Leistenhernie unter spezieller Berücksichtigung bilateraler Leistenhernien und Rezidivleistenhernien. Die Methode ist durch eine niedrige Komplikationsrate (2-12 %) und geringe Rezidivrate (0-3,1 %) gekennzeichnet. Die vorliegende Arbeit befasst sich mit den anatomischen Grundlagen der Leistenregion, der Operationsindikation, der Operationstechnik und den perioperativen Komplikationen unter Berücksichtigung der aktuellen Literatur. Abschließend werden die Daten der eigenen Klinik aufgeführt.

In the past decade laparoscopic surgery replaced many open operations in general surgery. Apart from therapeutic uses in cholecystectomy, appendectomy, hernia surgery, gastric fundoplication, and increasingly also large intestine surgery, it is indicated diagnostically first of all for unclear abdominal findings and for staging of intra-abdominal malignancies. To date laparoscopy has been used occasionally for diagnosis and therapy of mesenteric ischemia. Patients suffering from mesenteric ischemia are usually old and have comorbid conditions. Quick diagnosis and therapy are necessary due to the pathogenesis of the disease. The low rate of morbidity as well as the easy availability of laparoscopy in principle favor the employment of laparoscopy also for mesenteric ischemia. Against the background of increasing experience in the area of laparoscopic surgery, this study gives an overview of the present value of laparoscopy for mesenteric ischemia.

The laparascopic transabdominal preperitoneal (TAPP) repair of an inguinal hernia is an established technique associated with notably low rates of recurrence and complication. Inguinal pain and anal bleeding following a TAPP procedure may result from the penetration of the repair mesh into the sigmoid colon. In this case report, we discuss this particular complication following the TAPP procedure. Subsequently, we describe the diagnostics as well as the surgical treatment necessary.

Objectives Delayed gastric emptying (DGE) has been specifically attributed to pylorus-preserving pancreaticoduodenectomy (PPPD). As PPPD has been shown to be comparable with the classic Kausch-Whipple pancreaticoduodenectomy (KWPD) in terms of oncological radicality, DGE has advanced to be the leading argument for hemigastrectomy in PD. Methods A prospective, nonrandomized comparison of patients undergoing PPPD (n = 113), KWPD (n = 19), and duodenum-preserving, pancreatic head resection (DPPHR, n = 18) for various diseases was performed. First, groups were analyzed with regard to structural similarity; then, they were compared with special emphasis on DGE and other postoperative complications. Finally, further prognostic factors were sought that had an impact on DGE. Results The PPPD group was comparable with the KWPD group, but not to the DPPHR population. The in-clinic course after DPPHR compared favorably with PPPD as well as KWPD, and, here, no DGE occurred. The overall morbidity rates of PPPD and KWPD were comparable; 1 patient died in hospital (mortality rate, 0.7%). The gastric tube after PPPD and KWPD could be withdrawn at a median of 2 and 3 days, respectively, a liquid diet was started after 4 and 5 days, respectively, and a full diet was tolerated after 10 days each (n.s.). DGE was distributed evenly among PPPD (12%) and KWPD patients (21%, n.s.), and it was noted almost exclusively when other postoperative complications were present (P < 0.0001). No further prognostic factors influencing DGE could be identified. Conclusion Pylorus preservation does not increase the frequency of DGE. DGE almost exclusively occurs as a consequence of other postoperative complications. Therefore, DGE should not be used as an argument to advocate hemigastrectomy in PPPD.

Zusammenfassung Einleitung. Die neoadjuvante Radio-/Chemotherapie (neoRT/CT) des lokal fortgeschrittenen Rektumkarzinoms erfordert eine genaue prätherapeutische Einschätzung der Tumorinfiltrationstiefe (T-Status) und der lokoregionalen Lymphknotenmetastasierung (N-Status): Zum Staging und Restaging wird allgemein die Kontrastmittelgestützte Computertomographie (CT) und in spezialisierten Zentren die rektale Endosonographie (rES) favorisiert. Methoden. Von 01/98–05/01 wurde bei 102 Patienten (Pat.) mit einem Adenokarzinom des Rektums prospektiv der T- und N-Status per CT und rES bestimmt [Gruppe I: n=61 Pat.ohne neoRT/CT;Gruppe II: n=41 Pat.vor und nach neoRT/CT] und mit dem histopathologischen (y)pTNM-Befund verglichen. Ergebnisse. In Gruppe I traf die rES-Vorhersage bzgl.der Tumorinfiltrationstiefe (uT) in 75% zu (CT: 48%); 10% (CT: 41%) der Malignome wurden falsch zu niedrig (“understaging”) und 15% (CT: 11%) falsch zu hoch (“overstaging”) eingeschätzt.Der N-Status wurde per rES in 75% richtig erhoben (CT: 57%), das “understaging” lag bei 8% (CT: 30%) und das “overstaging” bei 17% (CT: 13%). In Gruppe II entsprach die rES-Vorhersage einer nach neoRT/CT verbliebenen Tumorinfiltration (yuT) in 66% (27/41 Pat.) dem ypT-Befund (CT: 51%).Lediglich 2% der Pat.wurden im Restaging mittels rES falsch zu niedrig (CT: 22%) und 32% (CT: 27%) falsch zu hoch eingeschätzt.Der yuN-Status entsprach in 68% (28/41 Pat.) der Histologie (CT: 76%), wobei ein “understaging” in 20% (CT: 17%) und ein “overstaging” in 12 % vorlag (CT: 7%). Eine komplette Remission (CR) initialer uT3-Rektumkarzinome wurde in 2 von 8 als ypT0 befundeten Fällen erfaßt.Demgegenüber sagte die CT bei allen 20 Pat. – allerdings ohne Festlegung auf das Remissionsausmaß – einen Tumorregress voraus. Eine CR initial vermuteter N-Infiltrationen konnte bei 17/19 Pat.(90%) per rES und bei 10/12 Pat. (83%) per CT korrekt vorausgesagt werden. Schlussfolgerung: Bei der prätherapeutischen T- und N-Beurteilung ist die rES der CT deutlich überlegen (T-Status: p=0.0164, N-Status: p=0.0035).Im Restaging ermöglicht die rES eine genauere, jedoch statistisch nicht signifikante Beurteilung der residuellen Tiefeninfiltration (yT-Status: p=0,0833; yN-Status: p=0,7962) und der lokalen Tumorremission.

Die intestinale Ischämie und Reperfusion (IIR) stellt mit einer perioperativen Mortalität von bis zu 80% ein bedeutendes klinisches Problem dar. Neben dem betroffenen Dünndarm haben postoperative Funktionsstörungen der primären Schockorgane wie Lunge und Niere eine besondere Bedeutung. Ziel der vorliegenden Studie war es die Auswirkungen der IIR auf die Nierendurchblutung sowie den intestinalen Mukosaschaden unter besonderer Berücksichtigung der vasoaktiven Hormone VIP (vasoaktive intestinal polypeptide) und GRP (gastrin releasing peptide) am Rattenmodell zu untersuchen.

In contrast to laparoscopic cholezystectomy, 20 years after its introduction laparoscopic appendectomy could not establish as the standard procedure in the treatment of patients with the suspicion of acute appendicitis. The primary reason is the only marginal improvement of the morbidity in comparison to the conventional technique. In comparison to conventional laparotomy the advantage of the laparoscopic technology is its value as a diagnostic tool. To the background of the international literature the today’s differential indication of laparoskopic appen-dectomy is presented.

Totally extraperitoneal preparation (TEP) of an inguinal hernia is an established method of treating inguinal hernias associated with an acceptable complication rate (2–12%) and low rate of recurrence (0–3%). This is the first reported case of sensorimotor paralysis of the femoral nerve following the complete endoscopic mesh treatment of a primary inguinal hernia to the left side. Following a discussion of the necessary diagnostic and therapeutic steps, traumatic postsurgical paralysis of the nerve as well as spontaneous paralysis of the femoral nerve are discussed. The prognosis is positive given the lack of macroscopic evidence of any direct damage to the nerve.