[Jejunum perforation following blunt abdominal trauma--a case report]. / Jejunumperforation nach stumpfem Bauchtrauma--ein Fallbericht.

We describe an intestinal perforation in a football player who had been hit with the knee in the abdomen. Perforation of the small bowel, following blunt abdominal trauma, is relatively rare. Its most frequent cause is a deceleration trauma, usually from a traffic accident. Clinical signs are frequently discrete and nonspecific. The most frequent symptom is abdominal pain. Lack of bowel sounds is reported in 64% oft the cases. Enteric lesions should be suspected in the presence of a corresponding history (deceleration trauma) and of other pathologies (fractures of vertebrae and/or pelvis). Sonography and computed tomography are rarely helpful. Delayed perforations have been described, necessitating prolonged observation for 48 to 72 h. after painful abdominal trauma. Repeated examinations are essential to rule out enteric perforation. Initially, less than 50% of the cases show free air, thus limiting the usefulness of thoracic and abdominal radiography. Mortality reaches 30%. This rate is adversely affected by concomitant lesions in other organs and by delay (more than 10 h.) in diagnosis. When laparotomy has been delayed and peritonitis is present, antibiotic treatment should be started immediately during surgical intervention (cephalosporin, aminoglycoside, metronidazole). Postoperative complications include septicaemia, wound infection and, rarely, enterocutaneous fistulae.

Pancreatic and hepatic abscesses: a late complication in 10 patients with chronic pancreatitis.

In this prospective long-term study of chronic pancreatitis (n = 336) over the last 3 decades, 10 patients with advanced calcific pancreatitis developed a sepsis associated with intra-abdominal abscesses (6 pancreatic, 4 hepatic). None of the known precipitating factors were present (e.g., no pancreatic necrosis or recent surgical/endoscopic interventions, no evidence of cholangitis). Nine of 10 patients had alcoholic chronic pancreatitis. Interestingly a pancreatojejunostomy in 9 of 10 patients had been performed up to 12 years previously. Cultures from abscess aspirates and/or blood were polymicrobial, mainly a mixed enteric flora in 8 patients. All patients recovered after an appropriate antibiotic therapy with or without drainage procedures. The pathogenesis of "spontaneous" abscess formation in advanced chronic pancreatitis and its relationship to pancreatojejunostomy remain to be established.

[Therapy of acute pancreatitis]. / Therapie der Pancreatitis acuta.

From 1973 to 1990 190 consecutive patients were admitted to the department of surgery of the Stadtspital Waid, Zurich, with a diagnosis of acute pancreatitis. 53 patients received conservative treatment, 93 patients with acute pancreatitis thought to be due to gallstones underwent cholecystectomy, in 23 cases combined with choledochotomy. 44 patient underwent pancreatic surgery. 10 diagnostic laparotomies, 14 necrosectomies, 6 pancreatic left resections and one subtotal pancreatectomy were performed. 9 pseudocysts and 4 pancreatic abscesses had to be drained. Over all mortality for operated patients was 29.5%, exceeding 50% for patients with operation within the first week of the disease. During the first ten years of our study we performed operations earlier and more often than in the following years (26 versus 17%). This more conservative management resulted in a marked reduction of mortality and complications. Today we try to control the first 8 to 10 days of the attack by intensive care and postpone pancreatic operations whenever possible to the second week.

[Surgical therapy of diverticular disease at the Waid City Hospital, Zurich, 1980-1990]. / Die chirurgische Therapie der Divertikelkrankheit am Stadtspital Waid Zürich 1980-1990.

Our experience with 431 patients suffering from diverticular disease is presented. Indications for emergency (severe bleeding, bowel obstruction, sigmoid perforation with peritonitis) and elective surgery (recurrent attacks of diverticulitis or bleeding, painful or obstructing diverticular disease, fistula, impossibility to exclude a cancer) are given. Resection of the perforated sigmoid by the Hartmann procedure helps to reduce mortality markedly for diffuse purulent and fecal peritonitis. A resection with primary anastomosis can be performed with equal safety for a more localised peritonitis. Aggressive indication for elective surgery helps to lower mortality and morbidity in symptomatic diverticular disease.

[Laparoscopic cholecystectomy. Results and experiences 1 year following introduction of a new surgical technique (139 cases)]. / Die laparoskopische Cholezystektomie. Ergebnisse und Erfahrungen ein Jahr nach Einführung der neuen Operationstechnik (139 Fälle).

Laparoscopic cholecystectomy is on the way to become the procedure of choice for treatment of uncomplicated cholelithiasis. First experiences are summarized: Within the first year after introduction 139 patients, 100 women and 39 men, have been treated by this novel technique. 33 open cholecystectomies were carried out in the same period. In addition to simple cholecystolithiasis 11 patients had prior biliary pancreatitis and/or sphincterotomy because of choledocholithiasis, 16 patients had suffered before from acute cholecystitis, 3 patients were operated on with the diagnosis of acute cholecystitis and 3 patients underwent simultaneous laparoscopic intervention. Seven times the laparoscopic procedure had to be converted into an open one because of intraoperative complications, twice because of a lesion to the common bile duct, three times because of intractable bleeding, once because of obscure anatomic conditions and once because of a technical failure in establishing the pneumoperitoneum. Four postoperative complications could be treated conservatively. In the average, patients complained about pain for 2 days, stayed in the hospital 4.4 days and assumed their usual activity after 13 days. An extension of indications for laparoscopic cholecystectomy should be sought stepwise according to gained experience. The problem of technical training of surgeons persists and must be solved in priority.

[Laparoscopic cholecystectomy--results of the first 100 cases]. / Die laparoskopische Cholezystektomie--Resultate der ersten 100 Fälle.

100 patients underwent laparoscopic cholecystectomy for symptomatic gallbladder stones. In seven cases the laparoscopic procedure had to be converted into an open cholecystectomy due to bleeding, choledochus injury and acute cholecystitis. There were no complications postoperatively. We feel that the indication of this method is advantageous. Independent of the size, the number and the chemical composition, this method is used for symptomatic gallbladder stones. All together the main advantages are higher comfort for the patient, better cosmetic results, shortening of hospital stay and sooner return to full activity.

[Laparoscopic cholecystectomy--results in the initial 100 cases]. / Die laparoskopische Cholezystektomie--Resultate der ersten 100 Fälle.

100 patients underwent laparoscopic cholecystectomy for symptomatic gallbladder stones. In seven cases the laparoscopic procedure had to be converted into an open cholecystectomy due to bleeding, injury to the choledochus and acute cholecystitis. There were no postoperative complications. We feel that the indication for this method is broad. Independent of the size, the number and the chemical composition of calculi, this method is used for symptomatic gallbladder stones. All together the main advantages are higher comfort for the patient, better cosmetic results, shortening of hospital stay and sooner return to full activity.

[Surgical therapy of severe idiopathic constipation]. / Die chirurgische Therapie der schweren, idiopathischen Obstipation.

Because surgery for severe idiopathic constipation is seldom indicated, careful preoperative evaluation is mandatory (colonoscopy with biopsy, whole gut transit study, evacuation proctography, electromyography, anorectal manometry) in order to classify chronic idiopathic constipation into two broad functional groups: "outlet obstruction" and "colonic inertia". Subtotal colectomy with ileorectal anastomosis yields a good outcome in 70-100% of cases with slow transit constipation. In contrast, there is a broad spectrum of surgical techniques in the treatment of outlet obstruction, among which anorectal myectomy seems to be appropriate for selected patients with good results in 54-92%. Our own small surgical experience with chronically constipated patients (n = 4, 1987-1989) is discussed and compared with the results in the literature.

[100 consecutive cases of surgical esophagus-cardia carcinoma]. / 100 konsekutive Fälle operierter Osophagus-Kardia-Karzinome.

100 esophagectomies were performed at the Waid Hospital in Zürich between 1981-1988. 55 patients underwent blunt esophagectomy without thoracotomy, 34 abdomino-thoracic resection with intrathoracic anastomosis, and 11 abdomino-thoracic resection with lymphadenectomy and cervical anastomosis. In 80% the tumor had spread through the esophageal wall or there were already regional lymph node metastases. Adenocarcinoma was found in 2/3 of the patients and epidermoid carcinoma in 1/3. 30-day mortality was 5%. The actuarial 5-year survival rate is 14%. Average hospital stay was 30 days. Blunt esophagectomy was mainly performed in older patients with tumor localization in the lower third. Abdomino-thoracic resection with cervical anastomosis was preferred for younger patients with tumor localization in the middle third. Surgical resection is the only curative therapy in esophageal cancer, but due to the often advanced tumor stage it is often only of palliative character.

[Retroperitoneal liposarcoma. Clinical aspects, diagnosis, therapy and prognosis]. / Retroperitoneales Liposarkom. Klinik, Diagnostik, Therapie und Prognose.

Retroperitoneal liposarcoma is a very rare tumor. There are about 250 cases in the world literature. This article discusses our four cases and the literature concerning this rare disease. The emphasis will be on the epidemiology, pathology, clinical presentation, diagnostic evaluation, therapeutic approach, and ultimate prognosis.

[Therapy and course of malignant extrahepatic bile duct tumors. Results in 93 cases]. / Therapie und Verlauf der malignen extrahepatischen Gallenwegstumoren. Ergebnisse von 93 Fällen.

Based on a retrospective study concerning the years 1974 to 1987 93 malignant extrahepatic bile duct tumors are being analyzed with regard to its histology, therapy and time of survival. The cases referred to herein are 49 tumors of the gallbladder and 44 bile duct tumors (25 tumors of the hepatic confluation, 10 tumors of the middle and 9 tumors of the distal portion of the bile duct). The middle and the distal hepatic duct tumors with 15.1 and 14.5 months respectively from the beginning of therapy have the longest time of survival on average. In contrast to those figures there are the bifurcation tumors with 9.9 months and the gallbladder tumors with 6.1 months of survival. So far 3 patients (2 with a gallbladder and 1 with a middle hepatic duct tumor) have survived as long as 3 years and are still alive. Only 1 patient, relating to a time of survival of 5 years, has been cured (gallbladder). 26.5% of these patients needed a second, 9.5% of them a third operation. A lengthy resection with curative intentions was done on 20.4% of the patients. 76.3% were treated palliatively, preferring, whenever possible internal drainage methods such as endoprosthesis or direct anastomosis drainage (hepaticojejunostomy, hepaticoduodenostomy, etc.).

[Experiences with 169 mechanical colorectal anastomoses (1981-1984)]. / Erfahrungen mit 169 maschinellen kolorektalen Anastomosen (1981-1984).

An account is given of 169 rectal anastomosis performed with the EEA-stapler between 1981 and 1984 in the Municipal Hospital Waid of Zurich. The average age of the patients was 63.8 years. 71.6% of the operations have been performed because of a rectosigmoidal carcinoma (50.4% of them with lymph node metastasis) and 28.4% because of a benign rectal disease. 44.4% of the anastomosis were localized at 3.5 to 7 centimeter, 34.9% between 7.5-11 and 20.7% higher than 11 centimeter above the anus. We used the biggest loading unit of 31 millimeter diameter in 89% of all cases. A primary anastomotic insufficiency was discovered intraoperatively in 6.5% (anastomosis sutured or redone). 3.1% of the patients had a temporary colostomy. We found a 4.3% rate of secondary anastomotic insufficiency. All those colo-cutaneous fistula healed spontaneously. Non specific complications as thromboembolism, urinary or wound infection and others were detected in 31.3% of the cases. We found a perioperative mortality rate of 2.5% with no intraoperative deaths. 91.4% of the patients had a follow-up over 2-5 years. There was a need of dilatation of anastomotic stenosis in 2.5% of the cases within the first 4-8 postoperative months. 40.2% of the cancer patients died during their follow-up, two thirds of them within the first two years. The local recurrence rate after 2-5 years of the cancer patients who were operated curatively was 22.3% and 10.7% for distant metastasis. 60.2% were disease free. 54.5% of the recurrent disease was found in patients with primary tumors stage Dukes C2 and D.(ABSTRACT TRUNCATED AT 250 WORDS)

Periampullary, colorectal and gastric cancer in two siblings.

We describe a sibship affected by subsequent periampullary, colorectal and gastric carcinoma. Three of 4 siblings (2 males, 1 female) developed a periampullary carcinoma at the age of 20, and the 2 brothers subsequently had colorectal and gastric carcinoma. One of them also had familial adenomatous polyposis. There is suggestive evidence of vertical transmission of a gene predisposing to a hereditary colorectal carcinoma syndrome.

[Characteristics of hereditary colorectal carcinoma without pre-existing polyposis]. / Charakteristika des hereditären kolorektalen Karzinoms ohne vorbestehende Polypose.

The report presents two families with inherited predisposition to colorectal carcinoma without preexisting polyposis coli. In these families the disease is characterized by early onset and tumor localization in the right side colon. Screening colonoscopy should be started early. Families of this kind are of greatest value for genetic marker studies.

[The nonresectable pancreatic tumor, an interdisciplinary problem. The surgeon's viewpoint]. / Der nichtresezierbare Pankreastumor, ein interdisziplinäres Problem. Standpunkt des Chirurgen.

In 204 patients with cancer of the pancreas (1973-1984), palliative treatment in 157 non-resectable tumors is analyzed retrospectively. 124 patients underwent biliodigestive anastomosis, 11 with simultaneous gastroenterostomy. In 13 patients a secondary gastroenterostomy was necessary due to duodenal obstruction. The mortality rate in this group was 38.5% compared with 9% in patients who underwent simultaneous gastroenterostomy. Where there is a calculated risk, the aim should be a single, definitive intervention, especially where the patient can no longer be provided with an endoscopic discharge.

[Emergency interventions in complicated colonic diverticulosis]. / Notfalleingriffe bei der komplizierten Kolondivertikulose.

An account is given in this paper of 480 patients who had been hospitalised for colonic diverticulosis or diverticulitis in the surgical department of the Municipal Waid Hospital of Zurich, between 1970 and 1986. Laparotomy had to be performed on 219 of them (45.6 per cent), among them 84 emergency interventions. The average age of these patients was 70.7 years. Indications for emergency surgery included diffuse or locally delimited peritonitis with abscess development in 72 patients, ileus in ten cases, and massive colon haemorrhage in two. The latter two cases were handled with good success by subtotal colectomy with ileorectostomy and, one of them with the source of bleeding known, by colotomy and suturing of that source of bleeding. Sigmaincontinence resection according to Hartmann has been considered the optional approach since 1977 to diffuse peritonitis and to many cases of ileus (n = 39). In more recent time, anastomosis has been used as primary approach to some patients who survived fibrinous abdominal peritonitis (n = 4). The mortality rate associated with drainage operations according to expectation, has been clearly higher than that following resection, the comparable figures being 32.3 and 17.2 per cent. That has been attributable to non-removal of the septic focus. After all, nowadays combined antibiotic therapy is commonly used for seven to ten days for simultaneous control of both aerobic and anaerobic pathogens. This has become routine practice and involves aminoglycoside, metronidazole, and ampicillin. Overall mortality associated with emergency interventions is clearly higher than that after planned operations, the figures being 22.6 and 4.4 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

[Estrogen and progesterone receptors in human liver: does their study contribute to a better understanding of benign contraceptive-associated liver tumors?]. / Ostrogen- und Progesteron-Rezeptoren der menschlichen Leber: trägt deren Untersuchung zum besseren Verständnis gutartiger, kontrazeptiva-assoziierter Lebertumoren bei?

The estrogen and progesterone receptor content of liver cytosol was measured in female patients with focal nodular hyperplasia associated with oral contraceptive use and compared with the receptor content of non-tumorous liver and of primary hepatocellular carcinomas. Receptors were found in very low concentrations or were not measurable at all. In one case of focal nodular hyperplasia the estrogen receptor content of the tumor was higher than that in the adjacent normal liver. Malignant liver tumors and the male liver were characterized by a low or non-measurable receptor content. The study of nuclear receptors combined with the use of monoclonal antibodies may be more helpful in elucidating the complex relationship between oral contraceptive use, benign liver tumors and hepatic steroid receptors.