[Unifocal autonomy and carcinoma of the thyroid gland]. / Unifokale Autonomie und Karzinom der Schilddrüse.

Two cases operated upon with the clinical diagnosis of unifocal autonomous functioning thyroid nodules (AFTN) are reported where the histological diagnosis revealed a well differentiated thyroid carcinoma (follicular, papillary) without metastasis. The pathogenesis of differentiated thyroid carcinomas in cases of AFTN may be coincident. Alternatively it may evolve from thyroid epithelial cells of the hot nodule, resulting in a "hot" well differentiated thyroid carcinoma. These cases show that under the clinical diagnosis of AFTN a differentiated thyroid carcinoma can be hidden occasionally.

[A comparative study of cytological and histological studies of the thyroid gland]. / Vergleichende Untersuchung zytologischer und histologischer Befunde der Schilddrüse.

We compare the results of fine-needle aspiration cytology of the thyroid gland with postoperative histological findings in 533 patients with thyroidectomy operated on between 1987 and 1994. The classification of the cytological preparations followed the proposal of Weiss and Pilz [35] with the groups 0-IV. In group 0 the most frequent findings were cystic changes in multinodular goitre or malpuncture, respectively. The groups I and II contained cases with multinodular goitre, thyroiditis and follicular adenomas, but 4 carcinomas too. The group III comprised particularly follicular adenomas and carcinomas (8 cases). Both cases in group IV were carcinomas. In group III (cytologic group with suspicious findings) there were 65 cases with false positive results of the cytologic investigation resulting in a specificity of 86.4%. 4 out of 14 thyroid carcinomas could not be detected by cytologic preparations corresponding to a sensitivity of 71.4% for carcinomas. The false negative rate for thyroid carcinomas in group II was caused by regression areas in the center of the tumors (3 cases) as well as one microcarcinoma. Preoperative fine-needle aspiration cytology of the thyroid gland reduces the number of patients operated on for multinodular goitre or cold nodules especially in cases suspicious of carcinoma.

[Reducing the rate of recurrent nerve paralysis by routine exposure of the nerves in thyroid gland operations]. / Senkung der Rate an Rekurrensparesen durch routinemässige Darstellung der Nerven bei Schilddrüsenoperationen.

UNLABELLED: The retrospective and comparative analysis of 734 benign operations of the thyroid gland during the years 1979-1993 without preparation and 1.022 operations between 1994 and 1996 with routine preparation of the recurrent laryngeal nerve shows a decrease of the permanent palsy rate from 5.99% to 0.88%. In 1996 0.48% pareses (2 cases in 410 operations) were seen. OPERATIVE TECHNIQUE: Before ligature of the blood-vessels at the hilum and before dorsal mobilisation of the thyroid lobe first the inferior thyroid artery and then the recurrent laryngeal nerve are identified which is located distally of the artery at the esophago-tracheal sulcus and is prepared until its entry in the larynx. RECOMMENDATION: We advice routine recurrent laryngeal nerve preparation in any operation of the thyroid gland. However, absolutely necessary is the identification of the nerve in the following situations: 1. Hemithyroidectomy, 2. Exstirpation of dorsal nodules of the hilum, 3. Morbus Basedow, 4. Reoperations, 5. Carcinomas.

[Changes in radical surgery of breast carcinoma in the last 20 years]. / Wandel der Radikaloperation des Mamma-Carcinoms in den letzten 20 Jahren.

UNLABELLED: The retrospective analysis of 383 female patients with breast cancer of all tumor stages from the department of surgery (323 patients since 1979) and the department of gynaecology (58 patients since 1993) shows the abandonment of the radical mastectomy according to Rotter-Halsted (116 patients until 1989), acceptance of the modified radical mastectomy (178 patients since 1979) and introduction and rise of the breast conserving operations (67 patients since 1983). In 1992 there was an extension of breast conservation treatment from T1 N0 to T2 N1-2 tumors (tumor diameter till 4 cm). Operation technique: 1. Circular incision above the tumor, 2. tumor excision in histologically healthy tissue, 3. lower axillary dissection (level I and II with > or = 10 lymph nodes), 4. no suture of the gland and drainage without suction, 5. postoperative computerised high energy radiotherapy of the conserved breast (Clinic of radiotherapy of the University of Leipzig). Because of the high operation risk a simple mastectomy without axillary dissection was performed in 22 of 383 patients. RESULTS: 3 of 383 patients died = 0.78% postoperatively due to tumor independent complications. One local tumor recurrence was observed 6 years after breast conserving therapy in 25 patients operated until 1992. In 42 patients operated since 1993 a tumor recurrence did not occur so far. The 5-year-survival-rate in 153 patients of all tumor stages amounted to 64%, in node-negative patients 80.3%, in node positive patients 51.7%. RECOMMENDATIONS: Breast conservation will be always recommended if the relation between tumor diameter and breast volume permits a cosmetic attractive result.

[The current risk of gallbladder and bile duct surgery]. / Das gegenwärtige Risiko von Gallenblasen- und Gallenwegsoperationen.

The lethal operative risk in gallbladder and bile duct operations decreased from 2.16% in the period 1964-1976 to 1.32% in the period 1979-1987.--Main operative risk factors are gallbladder and bile duct complications and the age beyond the 6th decade of life.--The lethality of choledocholithiasis actually amounts to the 37-fold of uncomplicated cholecystolithiasis and the lethality of all primary and secondary gallstone operations after the 6th decade of life amounts to the 38-fold in comparison with younger patients.--A further reduction of operative risk appears possible by reason: 1. Consequent early operation. 2. immediate operative or endoscopic removal of extrahepatic cholestasis, 3. complex intraoperative diagnostics of bile duct and papilla Vateri, 4. preoperative single dose AB prophylaxis or short-term therapy, 5. general low dose heparin prophylaxis, 6. primary endoscopic therapy in residual stones or irreversible stenosis of papilla Vateri and 7. interdisciplinary diagnosis and treatment of senile complications.

[Results following reflux-free stomach resection with Roux-en-Y anastomosis in gastroduodenal ulcer]. / Ergebnisse nach refluxfreier Magenresektion mit Y-Roux-Anastomose beim Gastroduodenalulkus.

The ulcer risk of Billroth-II-Y-Roux anastomosis, following distal two-third to three-quarter gastrectomy for complicated duodenal ulcer, ventricular ulcer, and pepto-jejunal ulcer was checked in 29 of 31 patients after surgery. (One patient had died after the operation and one rejected follow-up check for absence of complaints.) The same group of 29 patients underwent postoperative clinical examinations 1.6 years later, with additional nucleomedical, endoscopico-bioptic, and histological tests applied to 27 and additional secretion analysis to twelve of them. Twenty-eight patients were rechecked by Visick grading, approximately 3.9 years, following surgery. All 29 or 28 patients were clinically found to be in keeping with Visick I and II (100 per cent). Nucleomedical and endoscopic examinations did not reveal reflux in any of the 27 patients thus tested, and no recurrent ulcer was endoscopically recorded. Three patients refused to undergo endoscopy for absence of complaints. The time span of postoperative follow-up checks was as short as 1.6 years on average (between ten months and 4.5 years). Only trend information could, therefore, be derived from the histomorphological findings regarding minor mucosal changes, as compared to conventional techniques of resection. Reflux-free Y-Roux repair may be recommended as a mucosa-productive technique without increased ulcer risk, provided that gastrectomy is performed about 2 cm to 4 cm distal to the cardia.

[The thyrotropic function of the hypophysis and peripheral thyroid hormones after removal of bland and autonomous nodular goiters]. / Die thyreotrope Funktion der Hypophyse und die peripheren Schilddrüsenhormone nach Operation blander und autonomer Knotenstrumen.

Bilateral subtotal resection or enucleation or unilateral resection was performed in 60 patients (36 with bland nodular goitre, 24 with autonomic adenoma). The thyrotropic pituitary activity and the peripheral thyroid function were examined in all patients preoperatively and followed up for 12 months postoperatively. The results show that all patients with bilaterally resected bland nodular goitre require postoperative administration of thyroid hormone, since enhanced thyrotropic activity is seen not later than three months after surgery. Since thyrotropic function remains normal in unilaterally operated nodular goitre, thyroid hormone administration does not appear generally necessary. In patients with autonomic adenoma there is postoperatively variability of function, independent of the surgical method employed. In view of possible functional recompensation, final decision on the administration of thyroid hormones should not be made before the end of the sixth postoperative month. These results can be considered as guidelines for a differentiated postoperative management.

[Localized Ménétrier disease and stomach cancer]. / Lokalisierter Morbus Ménétrier und Magenkarzinom.

Corresponding to the state of knowledge of today the diffuse form of Morbus Ménétrier evidently develops from the localized one. This rare affection of the mucous membrane of the stomach ought to be regarded as a strong indication to operation to operation because the Ménétrier disease is not to cure conservatively, but in its diffuse development often results in complications threatening life and in extreme frequency tends to a kind of carcinomal degeneration, that is recognized too late mostly. The localized form in the distal stomach is to cured by a subtotal resection of the stomach, the diffuse form and the localization in the proximal stomach only by the gastrectomy.

[Electron microscopic findings in A-cells of the islands of Langerhans in diabetes mellitus]. / Elektronenmikroskopische Befunde an den A-Zellen der Langerhansschen Inseln beim Diabetes mellitus (IDDM, NIDDM).

A description is given of the electron microscopic-morphometric findings obtained for the islets of Langerhans of the pancreas and for the glucagon-producing A cells of one patient suffering from longstanding insulin-dependent diabetes mellitus (IDDM, type I diabetes), two patients with longstanding insulin-independent diabetes mellitus (NIDDM, type II diabetes), and one non-diabetic. A morphometric determination of the volume densities of the vascular connective tissue and the various endocrine cells per islet tissue and organelles/ultrastructures per A cell was made, and the diameters of the A-granules were measured. So far, no such studies have been made for human diabetes mellitus, and only a few are available for humans with sound metabolism. In general, the qualitative and, particularly, the quantitative electron microscopic results found for the IDDM patient show greater and clearer deviation from the control with normal metabolism than the findings obtained for the NIDDM patients. As regards the cellular composition of the pancreatic islets and changes caused by diabetes mellitus, the morphometric values obtained from electron micrographs are in essential agreement with comparable findings reported in the literature for light microscopic-histochemical and -immunohistochemical morphometry. The patient with insulin-dependent diabetes has a higher proportion of vascular connective tissue in the pancreatic islets than the non-diabetic. This increase is both relative and absolute and is primarily connected with the loss of B cells in this type of diabetes. In the IDDM patient, A cells were found in the islets but also scattered as single cells in the exocrine tissue and in the walls of pancreatic ductules. The ultrastructural composition of the A cells varies within wide limits even in persons with sound metabolism. Diabetes mellitus does not cause major qualitative alterations in the A cells. The A cells of the IDDM patient contained a remarkable number of nuclei and rarely showed A-granule crinophagia. The casuistic electron microscopic findings, most of which have been obtained for the first time, are discussed. Nothing can be said at this stage about the general applicability of the findings. The morphometric results obtained for the A cells can be interpreted as indicating increased metabolism with heightened glucagon synthesis and secretion in the case of the insulin-dependent diabetic and, to a lesser extent, in the NIDDM patients. This interpretation would support the assumption of a normally existing mutual local paracrine regulation of the A and B cells which stems from close topographical relations (contact, gap junctions).

[Requirements and use of peroperative bile duct diagnosis]. / Aufwand und Nutzen der peroperativen Gallenwegsdiagnostik.

At present the combination of pressure controlled cholangiography and debimetry can be regarded as the most efficient method in common duct exploration. This recommendation is based on 3907 own peroperative investigations.

Ultrastructural, immunohistological, and clinical findings in the pancreas in insulin-dependent diabetes mellitus (IDDM) of long duration.

Electron microscopical and immunohistological findings in small biopsies obtained at surgery from two subjects with longstanding type-I-diabetes [insulin-dependent diabetes mellitus (IDDM)] are described and demonstrated in relation to clinical data. The main findings are the first electron microscopical demonstration of A cells scattered as single cells in the exocrine pancreatic tissue and the detection of intermediate cells of the acinar-A cell type. Intermediate cells have never been reported before in the pancreas of diabetes in man.

[A careful method for the collection of pancreatic tissue for special morphological and biochemical studies]. / Eine schonende Methode zur Gewinnung von Pankreasgewebe für spezielle morphologische und biochemische Untersuchungen.

The examination of pancreas tissue is of essential necessity for special diagnostic problems and for the clarification of the etiology of pancreas diseases. The needle biopsy--mostly used--not always delivers sufficient material and is combined with uncontrollable complications. A new method is described in this paper which allows to obtain specimens of the pancreas during abdominal operations in a safty manner. Examples are demonstrated which establish the usefulness of the method for different examinations (light- and electron microscopy, immunhistology, histochemistry and biochemistry). In 48 cases no complications were observed.

Insulin secretion in maturity-onset-diabetes. Function of isolated islets.

An impaired insulin response to glucose is a characteristic finding in maturity onset diabetes (MOD). To clarify whether the decreased insulin response in vivo is related to a primary defect of the beta-cells, isolated islets of MOD - obtained by intraoperative biopsy - were examined for their insulin content, biosynthesis and release. The in vitro experiments showed that despite a missing or significantly reduced insulin response in vivo the isolated beta-cells of the same patients had a normal insulin content, a normal or even high biosynthesis, and insulin release could be induced by glucose. These results suggest that the primary defect in MoD cannot be related to an intrinsic failure of the beta-cells to response to glucose; extrapancreatic factors seem to influence their reaction to glucose. These factors may be of a higher level in those patients or the reaction of the beta-cells is more inhibited by the same concentrations in diabetic patients.

[Chronic pancreatitis; surgical therapy (author's transl)]. / Die operative Behandlung der chronischen Pankreatitis.

41 patients suffering from chronic pancreatitis underwent surgery from 1965 to May 1978. Mortality rate was 4,8%. Drainage operations and resections are the methods of choice today.