[Sigmoid diverticulitis -- indications for surgery and choice of procedure]

The first attack of uncomplicated diverticulitis is treated conservatively. Sigmoid resection is indicated for recurrent diverticulitis, in patients with manifest stenosis or fistula and for such emergencies as perforation, ileus or bleeding. Early surgery after the first episode is recommended for patients under 50 years of age, or immunocompromised patients. This is particularly true for patients with radiological signs of severe diverticulitis. Today elective sigmoid resection is a laparoscopic procedure. Properly carried out, the operation effects a definitive cure. The morbidity and mortality of the operation is low, and re-operations for recurrent diverticulitis are the exception. In the emergency situation a two-stage procedure is often necessary.

[Indications for intramedullary stabilization of shaft fractures in childhood. What is reliable, what is assumption?]

For some 15 years the elastically stable medullary nailing (ESIN) has been used in fracture treatment in children. The group of Nancy (Prevot and colleagues) first described the procedure for shaft fractures in children. Now the method is the standard procedure for stabilisation of long bone diaphyseal and metaphyseal fractures. During recent years a number of papers have described good and excellent results with this method, especially for shaft fractures of femur and forearm. In some papers there are also methods for articular fractures in more demanding techniques presented. Also when we have no evidence-based studies, we can say from the experience out of the last years that the ESIN is a biological, minimally invasive fracture treatment to achieve a high level of reduction and stabilisation in fractures in children. The use of titanium nails leeds to a higher rate of flexural elasticity and so the titanium nails are more recommended for this method.

Emergency laparoscopy. Technical support for the laparoscopic diagnosis of intestinal ischemia

BACKGROUND

Laparoscopic diagnosis of intestinal ischemia is difficult. Dark-colored bowels are not a reliable indicator for infarction, because there is no correlation between color and oxygenation. The same picture is produced by intraluminal blood or feces. False diagnoses are described.

METHODS

We analyzed various techniques for assessing intestinal oxygenation and perfusion to support laparoscopic diagnosis. In this study laparoscopy was performed on eight pigs. A 10-cm segment of intestine was fixed to the abdominal wall and rendered ischemic. Measurements of the ischemic segment and normal intestine were taken using laser-Doppler, Doppler ultrasound, spectrophotometer, and pulse oximeter. Doppler ultrasound and pulse oximetry were unsuitable in our model, as was laser-Doppler flowmetry.

RESULTS

Only the spectrophotometer proved a highly sensitive means of assessing bowel oxygenation.

CONCLUSIONS

This method provides the desired additional information about intestinal oxygenation, thus helping to interpret the laparoscopic picture of dark bowels.

Comparison of laparoscopic handsewn suture techniques for experimental small-bowel anastomoses

Laparoscopic techniques have only rarely been applied to procedures on the small bowel. A comparison of three handsewn intracorporeal anastomoses was carried out. Thirty pigs were divided into three groups, and a different technique was used in each group (SK, single knot; RS, running suture; CL, clip suture). Half of the animals had a relaparoscopy on day 4. The duration of the procedure was recorded, and the quality of anastomotic healing was assessed by morphological, radiological, mechanical, and biochemical examinations. The animals were sacrificed on postoperative day 14. The anastomoses in the SK group took significantly longer than in the RS or CL groups. The mean duration of relaparoscopy was 28 min. Bursting pressure values and hydroxyproline concentrations were without any significant difference. The SK and CL groups showed a good alignment of the layers and the RS showed necrosis and overlying mucosa. Most complications were noted in RS. The results demonstrate that manual small-bowel anastomoses can be performed laparoscopically. Single-knot and clip sutures are reliable techniques. The ongoing development of new instruments and the three-dimensional technique will basically improve the construction of intracorporeal anastomoses.

Effects of the Pringle maneuver on hemodynamics during laparoscopic liver resection in the pig

The Pringle maneuver (PM) is recognized in conventional liver surgery as a method of controlling bleeding. To determine the hemodynamic effects of the PM during pneumoperitoneum (PP) for laparoscopic liver resection, we measure hemodynamic and blood gas changes in 7 healthy pigs. All variables were recorded 5 min before and 10 and 30 min after employing PP or PM and 10 min after discontinuation of PM. After the induction of PP, cardiac index and arterial carbon dioxide tension significantly increased, accompanied by a significant decrease in pH. After the beginning of PM, cardiac index and mean arterial and central venous pressures decreased significantly, whereas the heart rate rose markedly. After discontinuation of the PM, the systemic vascular resistance index decreased, and the heart rate remained elevated. These results demonstrate severe hemodynamic deterioration with PP and a subsequent PM. The latter should, therefore, be considered only as a last resort for the control of bleeding during laparoscopic liver surgery.

[Endoscopic hemostasis in bleeding gastroduodenal ulcer--a contribution to the cost aspect]

Endoscopic injections of fibrin glue for the treatment of gastroduodenal ulcer hemorrhage have been increasingly used instead of sclerosing agents since 1987. Sclerosants have the drawback that they themselves have tissue-destroying or rather ulcerogenic effects. A difficult form of administration and a relatively high price are set against the good biological properties of the fibrin glue. In a randomized study comparing fibrin glue with polidocanol there was a statistically significant lower rebleeding rate in the fibrin group. The data of this study were analysed with regard to economic aspects. They showed an improved cost-benefit and cost-effectiveness ratio of the fibrin glue compared with polidocanol.

Vacuum-supported endoscopic access

The rapid increase in the number of endoscopic operations performed has resulted in a corresponding rise in the incidence of severe complications. This issue has generated widespread concern at recent congresses. It is now indisputable that safer access to the abdominal cavity is required. We have developed a technique of vacuum-supported visual access which allows the surgeon to anticipate dangerous sites of access and avoid injuries to internal organs or retroperitoneal blood vessels. The procedure has two major advantages: Firstly, a pre-peritoneal approach allows the surgeon to visualise the structures behind the peritoneum, and secondly, puncture of the insufflation-needle is facilitated and the depth of insertion is minimised. The underlying principle is to use negative pressure to elevate the peritoneum. Using this approach, the principles of open surgery are adhered to during abdominal access, thereby avoiding visceral injury.

Experience with TEM in Germany

Transanal endoscopic microsurgery (TEM) presents a minimally invasive procedure for local removal of large adenomas as well as early carcinomas of the rectum. 57 surgical departments/clinics, which practice this method in Germany were asked about their experience. 44 questionnaires were evaluated. Indications for the 1,900 recorded operations were 1,411 adenomas, 433 carcinomas (curative intention: 286; palliative intention: 147), and 56 other procedures. The conversion rate to laparotomy was dependent on the experience with this surgical method (1.2%-11.6%). A radical rectal resection as a second step was performed in 5.7% of patients in the case of advanced carcinoma in the histologic examination of the specimen. Complications appeared in 120 patients (6.3%), 77 patients (4.0%) recovered with conservative treatment, and 43 (2.3%) had to undergo surgery. The mortality rate was 0.2% (3/1,900 pts).

[Laparoscopic techniques in therapy of choledocholithiasis]

Several methods for therapy of common bile duct stones (CBDS) during laparoscopic cholecystectomy are available. After intraoperative cholangiography laparoscopic removal of CBDS can be achieved via the cystic duct or a choledochotomy using a thin cholangioscope, balloon catheters and Dormia baskets. Lithotripsy (electrohydraulic or laser) is necessary in presence of larger stones. Also combined procedures with intraoperative antegrade or retrograde papillotomy have been described. Published studies show that laparoscopic common bile duct exploration can be performed successfully by experienced surgeons. However, these procedures are demanding and time-consuming. Further evaluation is essential.

Effect of human bowel wall distension on translocation of indigenous bacteria and endotoxins

The effect of colonic distension on the translocation of indigenous bacteria and endotoxins was prospectively assessed in 50 consecutive patients undergoing colonoscopy. Semiquantitative bacteriologic cultures, chromogenic LAL testing for endotoxemia, and serial determinations of inflammatory markers were used. At the end of the endoscopic procedure, true bacteremia was found in only two patients with obstructing colorectal cancer. There was no evidence of systemic endotoxemia either being induced or increased during the observation period. The endotoxin detoxifying plasma capacity was elevated in patients with preexisting inflammation and did not change within this period. Levels of TNF-alpha, interleukin-6 (IL-6), and elastase (E alpha 1PI) did not differ from baseline values. C3 alpha levels increased in 20% of the patients, whereas fibrinopeptide A values rose by up to 10(2) during colonoscopy. However, since neither endotoxin, TNF alpha, nor IL-6 levels were found to be elevated in this study, the excessive activation of the coagulation system must be related to the distension of bowel wall vessels rather than to an effect of endotoxins escaping from the lumen.

[Contribution and limitations of peroperative radiotherapy combined with excision-curettage in the treatment of gastric cancers]

Macro- or microscopic residual tumor after surgery is the dominating prognostic factor in the treatment of gastric cancer. The majority of patients die of local recurrence and peritoneal spread. Therefore, in addition to gastrectomy and extended lymphadectomy (compartments 1 & 2) in some centers a adjuvant intraoperative radiotherapy is performed. Recent results of adjuvant intraoperative radiotherapy for gastric cancer revealed a lower local recurrence but there was no improvement in the survival rate for advanced tumor stages. These results are confirmed by our prospective study including 36 patients till now: in the group of 21 survivors there is no sign of a local recurrence. In 15 patients which died meanwhile there was only one case of local recurrence (median follow-up: 9 months, range 1-30 months). Peritoneal spread and liver metastasis were observed as the most frequent cause of death (tumor stage IIIB and IV only).

Laparoscopic cholecystectomy after unsuccessful shock-wave therapy

Extracorporeal shock-wave therapy of gallstones was begun at the Surgical Department of the University of Freiburg, Germany, in March 1988; 85 patients were treated up to September 1991. The stone-free rate differed with the gallstone group. Patients with solitary stones less than 20 mm in diameter showed a significantly higher rate after 18 months of lithotripsy and dissolution therapy than patients with multiple stones (p < 0.01), that is, 83% and 49%, respectively. Open cholecystectomy was necessary for seven patients with complications following fragmentation. After starting laparoscopic cholecystectomy, eight patients decided in favor of this procedure because of constant biliary symptoms. These patients had a mean duration of dissolution therapy of 19 months. The minimal invasive procedure is an alternative for patients with unsuccessful lithotripsy and lysis who initially demanded conservative treatment. Indication for shock-wave therapy is limited to only a small group of patients with solitary cholesterol gallstones less than 20 mm who reject laparoscopic surgery.

[PC-assisted planning and documentation of the surgical schedule]

A computer program for personal computers was developed to support and control the schedule in the operation theatre. With this program a great amount of operational and medical data will be recorded (e.g. the duration of operation and anesthesia, the number of operating rooms occupied, the personnel involved, the diagnosis and surgical therapy). The screen shows up-to-date information about the ongoing events. All data can be easily evaluated for different criteria. In a four years period the program presented has proved valuable for daily routine planning and documentation in a great operation unit.

Value of endoscopic retrograde cholangiopancreatography in determining the cause but not course of acute pancreatitis

We have recently shown that ERCP is the most useful technique for detecting a biliary origin of acute pancreatitis and can be done without side effects. We now report on a second series of 50 patients with acute pancreatitis in whom ERCP, computed tomography (CT), ultrasound (US), and clinical and laboratory assessment were performed within the first 24 to 48 hours of hospitalization. A score for ERCP, CT and US was used to assess the severity of the disease. Patients were followed up until discharge or death and their condition classified according to outcome as mild (less than or equal to 1 complication), severe (greater than 1 complication) or fatal. ERCP was superior in detecting choledochal stones (ERCP 100%, US 25%, CT 50%) and dilated intrahepatic ducts (ERCP 75%, US 75%, CT 37%) but not gallbladder stones (ERCP 70%, US 100%, CT 60%). When the ERCP severity score was calculated there was no relevant difference between patients thereafter having a mild course (0.66 +/- 0.91, range 0-3), a severe course (1.3 +/- 0.80, range 0-3), or a fatal outcome (1.0 +/- 1.1, range 0-3). In contrast, the CT score was different in all three groups (mild: 3.0 +/- 1.9; severe: 5.3 +/- 3.2; lethal: 6.3 +/- 3.1) as was the US score (mild: 1.5 +/- 1.3; severe: 3.2 +/- 2.3; lethal: 4.4 +/- 1.4). It is concluded from these results that ERCP is of value in defining the origin of acute pancreatitis. When a biliary origin is detected this can lead to immediate treatment using endoscopic sphincterotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous interventions on the bile duct in obstructive jaundice. A meaningful or excruciating prolongation of life?]

The percutaneous transhepatic access to the bile duct opens a wide spectrum of diagnostic and therapeutic procedures. This means specific diagnosis and therapy of the obstructive jaundice even in patients in bad general conditions and therefore unfavourable prognosis. As in most cases curative therapy is no longer possible, survival time can be taken into consideration. There are no great problems concerning the performance of technical procedures. But it is the justifiability of the interventions that has to be reconsidered in each of the cases. The facts that the quality of life can be improved and the possibility to discharge the patient as soon as possible should be the guidelines in having the patients undergo these therapeutic procedures. The evaluation of our case material from 1985-1991 show that just in this respect the introduction of the endoprosthesis (thick calibrated endoprosthesis, stents) is a great progress, with a mean survival time between 8 and 10 months, and with normalization of laboratory values in 75-100%.

Elevation of serum interleukin-6 concentration precedes acute-phase response and reflects severity in acute pancreatitis

Experimental studies have shown that interleukin-6 induces all major acute-phase proteins in the liver, including C-reactive protein. In 50 patients with acute pancreatitis, the serum concentrations of interleukin-6 and C-reactive protein were determined daily during the first week of hospitalization. Patients were divided into three groups according to clinical criteria: mild pancreatitis (less than or equal to 1 complication; n = 25), severe pancreatitis (greater than or equal to 2 complications; n = 15), and lethal outcome (n = 10). Patients with mild disease showed initially slightly elevated levels of interleukin-6 (22.0 +/- 9.8 U/mL) that decreased to low levels within 4 days (5.0 +/- 1.0 U/mL). In patients with severe pancreatitis, serum concentrations of interleukin-6 were initially clearly elevated (35.0 +/- 7.5 U/mL) and remained slightly elevated until day 7 (13.0 +/- 2.0 U/mL). Patients with lethal outcome had markedly elevated initial interleukin-6 concentrations (61.0 +/- 15.0 U/mL) that decreased but were still elevated at day 7 (26.0 +/- 2.5 U/mL). In all three groups, C-reactive protein concentrations followed the course of interleukin-6 concentrations by 1 day. There was a positive correlation between maximal interleukin 6 concentrations and maximal increases in the serum concentrations of C-reactive protein (r = 0.66). At days 1 and 2, increased (greater than 15 U/mL) interleukin-6 concentrations (positive predictive value, 91%; negative predictive value, 82%) predicted a severe or lethal course of the disease more accurately than elevated [greater than 0.10 g/L (greater than 10 mg/dL)] C-reactive protein concentrations (positive predictive value, 67%; negative predictive value, 79%). In conclusion, elevated serum concentrations of interleukin-6 followed by increased levels of C-reactive protein reflect the severity of acute pancreatitis.

[Laparoscopic cholecystectomy]

In a short space of time, laparoscopic cholecystectomy has become the operative treatment of choice in cholecystolithiasis. The performance of the operation, however, requires complex equipment, and became at all possible only with the aid of video technology. The indication depends both on the patient's symptoms and the experience of the operator. Prior surgery in the upper abdomen and complications of gallstones are considered relative contraindications, and portal hypertension an absolute contraindication. The advantages of this minimally invasive operative procedure are the minimal traumatization and improved postoperative well-being. The need for pain-killer is low, gastric tube and selective drainage are not required. Dietary build-up and mobilization are possible early on. Postoperative hospitalization is 2 to 3 days. The future will bring further developments in the field of laparoscopic operative interventions.

[Diagnosis and management of lower gastrointestinal hemorrhage. Retrospective analysis of 233 cases]

In a retrospective analysis the diagnostic procedure was evaluated in patients with acute lower gastrointestinal bleeding. Bleeding sources were localized distally to the ligament of Treitz in 233 patients (1979-1988). Patients with hemorrhoidal bleeding were not included. Following exclusion of an upper gastrointestinal bleeding the diagnostic procedure was initiated with a recto-/colonoscopy. Lesions were detected in 77% of the treated patients (n = 136). Angiography localized the bleeding in 68%, in combination with colonoscopy the identification of the bleeding source reached 86.5% in the treated patients. Following scintigraphy the bleeding source was determined in 89.7% of these patients. The sensitivity of colonoscopy (0.93) was superior to the angiography (0.78) and to the scintigraphy (0.75). Apart from neoplasms and adenomas angiodysplasia and Meckel's diverticula were the most common sources of the bleeding in patients who underwent operation. In 61 patients endoscopic therapy was performed, however, 6.5% of these patients had to be operated on later because of persistent bleeding. All together 79 patients underwent operation, 31 for bleeding and 48 for other reasons. 12 patients died, 6 of them were operated on for the bleeding, the other for neoplasms.

Effects of a three-drug antineoplastic protocol of wound healing in rats: a biomechanical and histologic study on gastrointestinal anastomoses and laparotomy wounds

Using biomechanical and histologic approaches, the effect of perioperative administration of a drug protocol containing 5-fluoruracil, Adriamycin, and mitomycin C (FAM) on the healing of gastrointestinal anastomoses and laparotomy wounds in rats was examined. Application of FAM immediately before operation resulted in significant impairment of wound healing in the early postoperative period. Once the proliferation of fibroblasts and collagen synthesis had led to an increase of mechanical strength, no negative effect on wound healing could be detected applying the same chemotherapeutic agents. These findings indicate the early inflammatory phase of the wound healing process to be most vulnerable to the chemotherapeutic effects. This has significant implications if the theoretical advantages of starting adjuvant chemotherapeutic treatment in the immediate postoperative period are implemented.

[Percutaneous transhepatic endoscopy and targetted tissue removal with an F-10.2 maneuverable thin cholangioscope]

Due to the flexibility and an external control mechanism of our thin calibrated cholangioscope (10.2 F) an inspection of the bile ducts via percutaneous transhepatic access is possible without too much discomfort for the patient. A 3.6 F working channel enables target-specific biopsies under optical control. It does not only enable histological diagnosis of the tumour itself but above all the exact definition of the proximal and distal tumour borders. This is a decisive criterion of operability and operation planning especially in tumours of the hepatic bifurcation. Expansion of the compressive lesion may be determined for palliative treatment. Percutaneous stone extraction by contact lithotripsy or with a Dormia basket is technically possible via the working channel under endoscopic view. An inspection of the peripheral branches of the same and the other liver lobe from one access only is made possible by easy maneuverability and flexibility of the endoscope.

[Percutaneous diagnosis and therapy of the bile ducts and gallbladder. Feasibility and status]

Percutaneous transhepatic access to the bile duct has opened up new possibilities not only for diagnosis by means of cholangiography and cholangioscopy with endoscopically guided biopsy by small-bore equipment, but also for the treatment of benign and malignant obstructive jaundice. In malignant disease recanalization of the obstruction is possible by means of laser, intracavitary irritation, internal bile drainage in Klatskin tumors, large-diameter endoprostheses (e.g., a Y-shaped prosthesis) or metal stents. In benign disease, balloon dilatation of inflammatory stenoses, stone extractions from the bile duct or gallbladder by means of Dormia baskets, ultrasound or piezoelectric shockwave-contact lithotripsy and chemical litholysis are possible. Very often percutaneous access is a real alternative to surgical intervention.

Bacteremia following operative endoscopy of the upper gastrointestinal tract

The rate of bactaeremia following surgical endoscopy of the upper gastrointestinal tract is reported with up to 50% depending on the therapeutic measure performed. In a prospective study we examined 160 patients treated by surgical endoscopy of the upper digestive tract. The rate of bactaeremia showed a significant difference with 12.5% after diagnostic and 28.96% after surgical endoscopy. Our results recommend a single shot antibiotic prophylaxis depending on the endoscopic measure performed and the patient's individual risk.

[Wide-gauge bile duct endoprostheses with a port irrigation system. A new method of prolonging the drainage function]

The maintenance of adequate drainage by the bile ducts is crucial in all the endoscopic or percutaneous transhepatic procedures used today for the treatment of obstructive jaundice. We use wide-gauge polyurethane bile duct endoprostheses (F16; 5.3 mm - F20; 6.7 mm). Occlusion need not be expected to occur earlier than 4-6 months after placement. The implantation of a subcutaneous port system connected to the prosthesis by means of an F5 (1.6 mm) catheter allows not only X-ray examination of the function, but also lavage of the prosthesis and the biliary ducts. It is possible to add bile-dissolving substances, thus preventing crystallization of bile. In this way the patency of the prosthesis can be maintained for substantially longer. This also means a definite improvement in the quality of life.

[Extracorporeal piezoelectric gallstone lithotripsy: initial surgical experience with a new treatment. Technique and indications]

The extracorporeal piezoelectric lithotripsy (EPL) is a new method for non-operative therapy of symptomatic gallbladder and problematic bile duct stones. The rare intrahepatic calculi were similarly disintegrated. Best results were reached with EPL as adjuvant measure or combined with oral cheno- and ursodeoxycholic acid therapy. EPL compared to other lithotripsy techniques is performed without any analgesia. That means advantage and patient's benefit.

Large-bile-duct stones--extracorporeal piezoelectric lithotripsy as adjuvant measure for endoscopic basket extraction

Extracorporeal piezoelectric lithotripsy (EPL) was performed in 12 patients with large-bile-duct stones and intrahepatic stones. The Piezolith 2300 lithotripter (Wolf, Knittlingen, FRG) was used in all patients in whom routine endoscopic approaches for removal of the calculi had failed or were considered inappropriate because of large stone size or difficult localization. In 9 of the 12 patients the stones were fragmented. Complete stone clearance from the bile ducts was obtained in 8 of 10 patients by EPL alone or combined with one of the following: endoscopic extraction, mechanical lithotripsy or installation of solvents. Adjuvant EPL in conjunction with endoscopic therapy increased the success rate of nonsurgical treatment for bile duct stones from 73% to 95%. No clinically significant side effects or complications were noted.

Granulocyte elastase in assessment of severity of acute pancreatitis. Comparison with acute-phase proteins C-reactive protein, alpha 1-antitrypsin, and protease inhibitor alpha 2-macroglobulin

Complexes of granulocyte elastase and alpha 1-antitrypsin are markers for granulocyte activation. In 75 patients with acute pancreatitis these complexes were immunologically determined daily in plasma during the first week of hospitalization. Patients were classified into three groups: mild pancreatitis (I, less than or equal to 1 complication, N = 34), severe pancreatitis (II, greater than or equal to 2 complications, N = 29), lethal outcome (III, N = 12). Initially, granulocyte elastase (mean +/- SEM) was lower in group I (348 +/- 39 micrograms/liter) as compared to groups II (897 +/- 183 micrograms/l) and III (799 +/- 244 micrograms/liter), P less than 0.001 for I vs II + III. Initial elastase concentrations greater than 400 micrograms/liter were consistent with a severe or fatal course of the disease but did not distinguish between severe and lethal pancreatitis. In patients with mild or severe disease, mean elastase concentrations decreased continuously during the following days (197 +/- 15 micrograms/liter in mild cases, 325 +/- 30 micrograms/liter in severe cases at day 7). In patients with lethal disease, however, mean elastase concentrations even increased at day 2 and remained higher than 700 micrograms/liter during the observation period. At days 1 and 2 the predictive value for severe or lethal disease of raised (greater than 400 micrograms/liter) elastase concentrations [positive predictive value (PPV) 82%, negative predictive value (NPV) 81%] was better than that of elevated (greater than 100 mg/liter) C-reactive protein (PPV 73%, NPV 73%), elevated (greater than 4.0 g/liter) alpha 1-antitrypsin (PPV 59%, NPV 50%), or decreased (less than 1.5 g/liter) alpha 2-macroglobulin (PPV 82%, NPV 67%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cholelithiasis--non-surgical intervention. Definitive and combined use]

New endoscopic and radiological techniques, together with pharmacological developments, prompted by high-surgical risk patients or those developing bile duct stones after prior cholecystectomy--but also by the wish to have less invasive alternatives available, have led to a variety of non-operative therapeutic modalities in gallstone diseases. Both endoscopic and radiological procedures are employed to remove stones from the biliary tract and gallbladder. Extracorporeal lithotripsy and chemical litholysis are being increasingly employed to treat gallbladder stones. Laparoscopic cholecystectomy is a new operative possibility. These different approaches, sometimes used in combination, are associated with different preconditions for success. Indications and results must be measured against the gold standard of cholecystectomy.

Technical aid for facilitating emergency endoscopy

Emergency endoscopy is usually complicated by unfavorable examination conditions. The irrigating capability of the instrument is inadequate. The use of an easy-to-operate volume- and pressure-driven irrigation pump has proved very efficient and safe in the hands of an experienced endoscopist, and helps establish the correct diagnosis or provide proper treatment.

Endoscopic percutaneous gastrostomy using a modified instrument for puncture of the abdominal wall and the stomach

A new instrument for the puncture of the abdominal wall and stomach while performing endoscopic percutaneous gastrostomy is described. It has several advantages as compared with the instruments used so far, one of which is that it makes the method safer and easier.

[Posthepatic jaundice caused by abnormalities of the pancreaticobile duct system in early childhood]

Anomalies of the pancreatico-biliary tract present the most frequent cause of posthepatic cholestasis in the young child, whereas calculous disease or infections or compression by vascular abnormalities or neoplasms are less frequent. Generally, abdominal pain and jaundice begin acutely and increase following progressive biliary congestion. The preoperative diagnosis by ERCP or PTC or the intraoperative diagnosis of a relevant pancreaticobiliary anomaly stress the necessity of an operative management performing a bypass of the Sphincter Oddi and of the site of the anomaly. Local operative revision alone seems to be associated with a frequent relapse of cholestasis.

[The value of ultrasound diagnosis in blunt abdominal and thoracic injuries]

In a prospective study, real-time ultrasonography was applied as the initial imaging procedure in 103 consecutive patients with blunt abdominal or thoracic trauma. Additional peritoneal lavage was not performed. Pathological findings were present in 22 patients (21%). Sensitivity of the examination was 95.5%, with two false positive results, specificity was 97.5% with one false negative result. Lesions of intraabdominal or thoracic organs were demonstrated directly by ultrasonography in 14 patients. In the remaining patients free fluid was discovered in the abdominal cavity. Splenic and hepatic lesions occurred most frequently followed by hematothorax. Ultrasonography can be recommended as the initial imaging procedure, giving a high amount of information in the primary diagnosis of blunt abdominal thoracic trauma.

[A new Y-endoprosthesis for drainage of bile duct obstruction of the hepatic bifurcation]

Biliary decompression in cases of central tumorous biliary obstruction requires surgical or internal/external catheter bypass techniques. The development of a 14-F Y-shaped-polyurethane endoprosthesis stent provides the possibility to drain the left and right biliary system simultaneously. The endoprosthesis is placed by a combination of external transhepatic and endoscopic approach. The tip of the singular choledochal stent segment is placed within the choledochus or duodenum.

Endoscopic percutaneous cecostomy (EPC)

Endoscopic decompression of the distended colon has become a useful method of treating non-obstructive colonic ileus. We propose a method of establishing a cecal fistula by means of percutaneous puncture of the colon and pull-through of a Pezzer catheter. Although until now we have only performed this procedure twice, it seems to be a valuable therapeutic approach in cases of paralytic distension of the large bowel.

[Percutaneous transhepatic cholangioscopy. A new method for the diagnosis of bile duct malignancies]

Percutaneous transhepatic cholangioscopy combines the advantages of endoscopic and radiological examinations. It makes it possible to assess the intraluminal spread of bile duct disease as well as histological and cytological examination of biopsies obtained under vision. Eight PTCs were performed without complication in seven patients with cancer of the bile duct. In four, the histology and extent of the tumour was defined endoscopically before any surgical intervention. In three others the results of treatment were objectified. A flexible choledochoscope, as used intraoperatively, was employed (CHF-P10). A stepwise dilatation of the percutaneous access-route was undertaken in several sessions in order to avoid bleeding complications. The procedure is done without general anaesthesia.

[Percutaneous transhepatic cholangioscopy. A new approach to the diagnosis of bile duct tumors]

New surgical and radiotherapeutic regimens for the treatment of carcinoma of the bile ducts require histologic diagnosis as well as diagnostic delineation of the tumor. Percutaneous transhepatic cholangioscopy fulfils these requirements. This technique combines the advantages of radiological and endoscopic diagnostic procedures in the biliary tract. Cholangioscopy has been performed successfully in four patients with malignant tumors of the bile ducts and we did not observe any complications.