[Prevention of bile duct injuries after laparoscopic cholecystectomy. "The critical view of safety"]. / Der ''Sicherheits-Blic'' als Beitrag zur Risikoreduktion bei der laparoskopischen Cholezystektomie.

INTRODUCTION: Iatrogenic injuries of the bile duct and hepatic artery represent a continuous problem after laparoscopic cholecystectomy. In this observational study we report about our experiences applying the "critical view of safety", defined as unambiguous identification of the cystic duct and artery by creation of an infundibular window, in order to minimise bile duct lesions and conversion rate. METHODS: Between July 2002 and November 2004 100 consecutive laparoscopicly started cholecystectomies were prospectively investigated. The central surgical step of dissection aimed at reaching the "critical view of safety" and its photo printing before cutting the cystic duct and artery, otherwise a conversion was carried out without exception. Primary endpoints of the study were the conversion rate, secondary endpoints the incidence of intra- and postoperative complications, operation time and histological results. RESULTS: 53 of the 100 primary laparoscopic operated patients showed the signs of an acute cholecystitis, 44 patients offered partially multiple abdominal operations in their history. In 19 patients we performed a "therapeutic splitting". Only in 3 patients it was not possible to apply the "critical view of safety" resulting in a conversion to open cholecystectomy. The mean operation time was 81 minutes and the postoperative hospital stay ranged to 5.4 (1-18) days. Postoperatively an insufficiency of cystic duct, a navel infection, an abdominal wall haematoma, an urinary tract infection and a pneumonia occurred in one patient each. DISCUSSION: Pivotal factors leading to bile duct injury after laparoscopic cholecystectomy are systematic mistakes in the surgical technique, an insufficient surgical training and human failure of the surgeon. The introduction of the "critical view of safety" represents an objective, understandable and compulsory criterion for minimising the risk of iatrogenic injuries of the bile duct and decision on conversion to open cholecystectomy.

[Reconstruction of bile duct lesions by an autologous vein graft and a bio-degradable endoluminal stent in an animal model: technique and clinical impact]. / Rekonstruktion von Gallengangsdefekten mit autologem Veneninterponat und resorbierbarem Stent im Tiermodell: Technik und klinische Bedeutung.

INTRODUCTION: In this study a new treatment of bile duct lesions was investigated. A segment of the bile duct was replaced by an autologous venous interponate which had been endoluminally stented with a braided bio-degradable stent. METHODS: A total of 18 pigs (20-28 kg) was divided into three equal groups (I-III). In each group a 2 cm segment of the jugular vein was harvested. The animals in Group I (vein group, n = 6) underwent resection of a 2 cm long segment of the common bile duct which was replaced solely by the venous interponate, in Group II (stent group, n = 6) the venous interponate had been endoluminally stented by a braided bio-degradable stent. Group III (control group, n = 6) underwent only a circular mobilization of the common bile duct. Postoperatively survival rate, general condition as well as the weight were observed and checked for 6 months. During surgery and finally after sacrifice after 6 months blood and tissue samples were taken and semiquantitatively scored concerning grade of inflammation and fibrosis. RESULTS: In the stent and control group all animals survived in good condition. 3 pigs of the vein group died within 3 weeks showing signs of biliary peritonitis, another one died due to a high grade stenosis of the common bile duct with secondary biliary cirrhosis after 4 months. In the stent group all animals survived until sacrifice after 6 months. On examination the venous interponate was laminated with bile duct epithelium showing the diameter of the implanted stent. CONCLUSION: The reconstruction of bile duct lesions by a venous interponate in combination with a bio-degradable stent is easy to perform and represents a clinically interesting alternative to the biliodigestive anastomosis because of the preservation of the sphincter oddi. After 6 months the stent is completely absorbed and the venous interponate is laminated with bile duct epithelium.

[Pharmacologic modification of postprandial bile duct kinetics--ultrasound measurement of the lumen of the bile duct]. / Pharmakologische Beeinflussung der postprandialen Gallengangskinetik--Sonographische Lumenmessung des Gallenganges.

UNLABELLED: The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. PURPOSE: Since the symptoms usually occur postprandially, we used ultrasonography to examine whether hymecromone could reverse the contraction of the common bile duct (CBD) after ingestion of a standardised test meal. METHOD: The study was designed as a prospective, double-blind randomised cross-over study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. The subjects were then given either 400 mg of hymecromone or placebo i.v. and the measurement series was repeated. RESULTS: After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo, a maximum increase of 36% was measured 10 minutes after administration of hymecromone. CONCLUSION: The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone. Sonography proved a suitable tool for examining the physiological changes.

[Surgical management of bone metastases of the lower extremity with AO interlocking nail]. / Zur operativen Versorgung von Skelettmetastasen der unteren Extremität mittels AO-Verriegelungsmarknagel.

Between January 1991 and June 1995 we have operated on 19 patients (9 male, 10 female) with 22 skeletal metastases of the lower limb (19 femora, 3 tibiae) using a static interlocking nail. Closed intramedullary nailing without resection of the metastasis has been established as our standard procedure. We have stabilized 15 patients with advanced osteolysis and seven pathological fractures. Sixteen patients underwent postoperative local radiation therapy with 40 Gy. As intraoperative complications we have observed one fracture of an osteolysis and one death due to fat embolism. Postoperatively there were observed one seroma, one haematoma and one patient with non fatal pulmonary embolism following DVT. Two patients died within the first 30 postoperative days because of tumor progression. All patients surviving longer than 30 days could be mobilized under full weight-bearing. Morphine like analgetics for metastasis related pain were no longer needed. A secondary instability has not been observed within a mean survival time of 199 days (811 longest follow up). Closed intramedullary nailing in combination with postoperative local radiation therapy seems to be an appropriate and technically non demanding procedure to stabilize skeletal metastases of the lower limb in patients with a short or medium-term expectation of life.

[Effect of intestinal ultrasound on choice of surgical procedure in acute abdominal pain]. / Der Einfluss der Darmsonographie auf die chirurgische Verfahrenswahl beim akutem Bauchschmerz.

UNLABELLED: Differential diagnosis in patients with acute abdominal pain represents a difficult assignment in surgery involving the indication for urgent operation and the operation technique. AIM: The value of sonography in diseases of the bowels for correct indication for early laparotomy was investigated. METHOD: In a retrospective analysis we compared the result of sonography on 159 patients with acute abdominal pain with the first clinical assessment. RESULTS: The sensitivity of this technique was found to be 38.9% for acute appendicitis, 57.1% for diverticulitis and 76.9% for obstructive ileus. The specificity ranged above 90% in each case. In consideration of more than two sonomorphological criterias for pathological alterations of the intestines the positive predictive value achieved 100%. CONCLUSION: Low diagnostic sensitivity with high specificity implies the necessity to intensity routine ultrasonic investigation of the gut.

Postprandial bile-duct kinetics under the influence of 4-methylumbelliferone (hymecromone).

The physiological correlate of biliary colic is a rapid increase in pressure in the presence of biliary obstruction. The relaxing action of hymecromone on the biliary tract provides a pharmacotherapeutic approach. As the symptoms usually occur postprandially we used ultrasonography to examine whether hymecromone was able to reverse the contraction of the common bile duct (CBD) after ingestion of a standardized test meal. The study was designed as prospective, double-blind randomized crossover study versus placebo in 20 healthy volunteers. The width of the CBD was measured ultrasonographically in the fasting subjects and at 1, 3, 5, 10, 15 and 20 minutes after ingestion of a test meal. Then the subjects were given either 400 mg of hymecromone or placebo and the measurement series was repeated. After ingestion of the test meal the width of the CBD decreased by a maximum of 20% after 15 minutes. While there was only a slight increase in the width of the CBD after subsequent administration of placebo, a maximum increase of 36% was measured 10 minutes after administration of hymecromone. The postprandial contraction of the CBD can be reversed within a short time by i.v. administration of hymecromone.

[Reliability of ultrasound ileus diagnosis]. / Stellenwert der sonographischen Ileusdiagnostik.

We investigated in this study if we would be able to find the correct indication for laparotomy earlier by sonographical examination than by clinical and radiological findings. In 48 of 594 patients with unknown abdominal diseases we found an intestinal obstruction by laparotomy. The indication based on clinical and radiological findings in 37 patients (sensitivity: 77.1%). In comparison the indication for laparotomy was predetermined correctly only after sonographical examination in 45 patients (sensitivity: 89.6%). According to the number of sonographical findings the reliability of the indication for laparotomy increased. The examination by sonography is a valuable tool in the diagnosis of intestinal obstruction.