Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure. We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

Benign strictures of the common bile duct after surgery or due to gallstones may lead to obstruction and derangement of bile drainage in the extrahepatic biliary system. Although the treatment of choice in these situations is the endoscopic dilatation, in some cases with stenosis of a long segment of the bile duct a partial replacement with a vascularised jejunal patch may be possible and useful. To our knowledge, there are no reports on long-term results of the procedure, We describe the course, the surgical technique and long-term results of four patients with a jejunal patch reconstruction of the common bile duct. Ten years after surgery there were no radiologic or laboratory signs of a restenosis of the common bile duct.

Traumatic arterioportal fistulas (APF) are very rare. The most common reasons are liver biopsy and liver injuries. They are also caused by liver tumours and vessel anomalies. This is a case-report of a patient who developed an APF after blunt abdominal trauma. The fistula bearing part of the liver was resected in two sessions. In cases of large APFs with a flow from multiple collaterals the therapy of choice is the embolization. If not possible a selective excision of the fistulous sac or the resection of the fistula containing liver segment are recommended.

Enteral nutrition is an economic and effective way for nutritional support in the posttraumatic and postoperative phase. Early enteral nutrition may preserve the nitrogen balance, the structure and function of the gut mucosa as well as the immune competence. However, there is no consensus about the administration of early enteral nutrition, which reduces its use in the clinical routine. Suitable enteral accesses are of critical importance for the concept of early enteral nutrition after trauma or elective abdominal surgery. Different nasoenteral tubes are usable in patients who are not laparotomized. If a laparotomy is performed, nasoenteral tubes as well as intraoperatively placed percutaneous tubes (e.g. needle catheter jejunostomy) can be used for early enteral nutrition.Enteral feeding should start within 12-24 h after trauma or operation, not only to prevent structural damages of the gut mucosa but also to improve the tolerability and practicability of enteral feeding. Further, the motility of the gastrointestinal tract can be improved if enteral nutrition is started early. A delayed start of substrate administration is not beneficial for the homeostasis of patients. Enteral nutrition should be increased gradually in the days following surgery. Early enteral nutrition can be performed either with a nonelemental diet or by immunonutrition. Elemental diets are usually not indicated. For monitoring of the early enteral nutrition frequent clinical investigations are necessary. If complications like diarrhea or distension occur, feeding should be reduced or, if necessary, temporarily stopped.

Enteral nutrition is an economic and effective way for nutritional support in the posttraumatic and postoperative phase. Early enteral nutrition may preserve the nitrogen balance, the structure and function of the gut mucosa as well as the immune competence. However, there is no consensus about the administration of early enteral nutrition, which reduces its use in the clinical routine. Suitable enteral accesses are of critical importance for the concept of early enteral nutrition after trauma or elective abdominal surgery. Different nasoenteral tubes are usable in patients who are not laparotomized. If a laparotomy is performed, nasoenteral tubes as well as intraoperatively placed percutaneous tubes (e. g. needle catheter jejunostomy) can be used for early enteral nutrition. Enteral feeding should start within 12–24 h after trauma or operation, not only to prevent structural damages of the gut mucosa but also to improve the tolerability and practicability of enteral feeding. Further, the motility of the gastrointestinal tract can be improved if enteral nutrition is started early. A delayed start of substrate administration is not beneficial for the homeostasis of patients. Enteral nutrition should be increased gradually in the days foIlowing surgery. Early enteral nutrition can be performed either with a nonelemental diet or by immunonutrition. Elemental diets are usually not indicated. For monitoring of the early enteral nutrition frequent clinical investigations are necessary. If complications like diarrhea or distension occur, feeding should be reduced or, if necessary, temporarily stopped.

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.

Um eventuelle Abweichungen vom regelrechten Heilverlauf darzustellen, wurden prospektiv bei 10 Patienten mit nicht revaskularisierbarer paVK im Stadium IV nach offener Amputation der unteren Gliedmaße Wundbiopsien untersucht. Diese wurden an den Tagen 0, 10 und 20 entnommen, (immun)histologisch wurden die Infiltratzusammensetzung (CD68, PMN-Elastase), die Angiogenese (v.-Willebrandt-Faktor), und Expression von Wachstumsfaktoren (bFGF, TGF-β) nachgewiesen. Es konnten die Ausbildung eines entzündlichen Infiltrates, eine Angiogenese und die Expression der Wachstumsfaktoren bFGF und TGF-β dargestellt werden. Ein Mangel dieser Faktoren scheint somit nicht ursächlich für die komplizierte Wundheilung der paVK IV zu sein.

In this study mitoxantrone (Mtx) induced DNA strand breaks were measured with the alkaline elution technique in short term cell cultures derived from human gliomas. Glioblastomas or astrocytomasfrom 5 patients who underwent intracranial surgery were cultured and incubated 1 h with different concentrations of Mtx (0, 0.01, 0.1 and 1.0 μg/ml). The alkaline elution methodwas modified to measure DNA lesions in human gliomas. Mtx inducedDNA strand breaks in a dose dependent manner in all cell culturestested. There was a linear increase of DNA strand break frequencyinduced by Mtx between 0.01—1.0 μg/ml. Concerning these in vitro data, Mtx might be potentially useful for the treatment ofpatients with malignant brain tumors.

Medial or lateral pedicle screw penetration with the potential to affect neural structures in a well-known and frequent problem associated with posterior spinal fusion. We evaluated the placement of pedicle screws (n = 141) in 36 patients following posterior lumbar spinal fusion with Socon or Kluger instrumentation via a lateral transpedicular approach. The examination was based on CT and MR images performed after removal of the instrumentation, on average 1 year after implantation. We found seven pedicle screws with lateral cortical penetration of the pedicle and five screws with medial cortical penetration of the pedicle (8.5% pedicle penetration overall). No severe radicular complications accompanied these pedicle penetrations. The mean insertion angles of the pedicle screws at the L4 level were 22.6° and 23.1° for the left and the right side, respectively. At the L5 level the mean insertion angle was 20.5° on the left side and 21.5° on the right, and at the S1 level the mean angle was 16.2° on the left and 15.2° on the right. The results of this study indicate that the lateral transpedicular approach is a safe procedure for pedicle screw insertion.

OBJECTIVE:To determine if early postoperative feeding of patients with upper gastrointestinal malignancy, using an enteral diet supplemented with arginine, dietary nucleotides, and omega-3 fatty acids (IMPACT, Sandoz Nutrition, Bern, Switzerland) results in an improved clinical outcome, i.e., reduced infectious and wound complications and decreased treatment costs when compared with an isocaloric, isonitrogenous control diet.DESIGN:A prospective, randomized, placebo-controlled, double-blind, multicenter trial of the clinical outcome and a retrospective cost-comparison analysis.SETTING:Surgical intensive care units in three different German university hospitals.PATIENTS:Of 164 patients enrolled in the study, 154 patients were eligible for analysis. They were admitted to the intensive care unit after upper gastrointestinal surgery for cancer and they received an enteral diet via needle catheter jejunostomy. Infectious complications were defined as sepsis or systemic inflammatory response syndrome, pneumonia, urinary tract infection, central venous catheter sepsis, wound infection, and anastomotic leakage. The complication events were prospectively divided into two groups: early (postoperative days 1 to 5) and late (after the fifth postoperative day) postoperative complications. The treatment costs of each complication were analyzed and compared in both groups.INTERVENTIONS:Patients were randomized to receive either the immunonutritional diet (n = 77) or an isocaloric and isonitrogenous placebo diet (n = 77). Enteral feeding was initiated 12 to 24 hrs after surgery, starting with 20 mL/hr and advanced to a target volume of 80 mL/hr by postoperative day 5.MEASUREMENTS AND MAIN RESULTS:Clinical examination and adverse gastrointestinal symptoms were recorded on a daily basis. Both groups tolerated early enteral feeding well, and the rate of tube feeding-related complications was low. Postoperative complications occurred in 17 patients in the immunonutrition group vs. 24 patients in the control group (NS). Further, in the early phase (postoperative day 1 to 5), complications occurred to a similar extent in both groups (12 patients in the immunonutritional group vs. 11 patients in the control group). However, in the late phase (after postoperative day 5), considerably fewer patients in the experimental diet group experienced complications compared with the control group (5 vs. 13, p < .05). In addition, the frequency rate of complicating events were recorded in each group. In the experimental diet group, a total of 22 complicating events were recorded vs. a total of 32 events in the placebo diet group (NS). However, the occurrence of late complicating events, i.e., complicating events after the fifth postoperative day, was significantly reduced in the immunonutrition group when compared with the control group (8 vs. 17 events, p < .05). The total costs for the treatment of the complications were 83,563 German marks in the experimental diet group vs. 122,430 German marks in the control group, resulting in a cost-reduction of 38,867 German marks. (At the end of December 1995, the conversion rate from German marks to U.S. dollars was 1.4365 German marks to $1.00.)CONCLUSIONS:Early enteral feeding with an arginine, dietary nucleotides, and omega-3 fatty acids supplemented diet, as well as an isonitrogenous, isocaloric control diet (placebo) were well tolerated in patients who underwent upper gastrointestinal surgery. In patients who received the supplemented diet, a significant reduction in the frequency rate of late postoperative infectious and wound complications was observed. Thereby, the treatment costs were substantially reduced in the immunonutrition group as compared with the control group.

OBJECTIVETo find out whether an enteral diet supplemented with arginine, RNA, and omega-3 fatty acids modulated the production of interleukin-1 (IL-1), interleukin-2 (IL-2), IL-2 receptor, interleukin-6 (IL-6), and tumour necrosis factor alpha (TNF-alpha) after operations for upper gastrointestinal cancer.DESIGNProspective double blind clinical study.SETTINGUniversity hospital, Germany.SUBJECTS42 patients randomised into two groups (n = 21 each), one of which was given an isocaloric and isonitrogenous placebo diet and one of which was fed the same diet supplemented with arginine, RNA, and omega-3 fatty acids.INTERVENTIONSThe cytokines were measured before operation and on postoperative days 1, 3, 7, 10, and 16.MAIN OUTCOME MEASURESComparison of concentrations of cytokines in the two groups.RESULTSAmong those receiving the placebo diet (after spontaneous stimulation) IL-6 concentrations were significantly higher on days 3 and 7 (p < 0.05) and TNF-alpha concentrations on day 7. In contrast (after stimulation with phytohaemagglutinin) mean concentrations of IL-2 receptor were significantly higher on days 3 and 7, and of IL-1 beta and IL-2 on day 16 (p < 0.05) in the group receiving the supplemented diet.CONCLUSIONSupplementation of an enteral diet with arginine, RNA and omega-3 fatty acids can modulate the acute phase reaction as indicated by the reduction in concentrations of TNF-alpha and IL-6 in the group fed the supplemented diet. Patients receiving the supplemented diet also showed accelerated recovery in the concentrations of IL-1 beta and IL-2 receptor.

Goiter recurrence is a well known fact in the surgical therapy of thyroid diseases. Extremely rare the goiter recurrence is localized in the subcutis or the muscle of the neck. We report on two patients with this type of recurrence. The reason may be an autologous implantation of thyroid follicle cells intraoperatively. It can be avoided by removing all particles of the thyroid gland from the operation area.