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The introduction of new imaging techniques has markedly improved the diagnosis of hepatobiliary disorders. Due to their anatomic situation, a substantial percentage of malignancies located near the hilus is not suitable for surgical management. We discuss an effective palliative intervention to relieve jaundice. In many instances drainage is a superior choice when biliodigestive anastomoses are not technically feasible and palliative resection carries a high complication rate. We present an irrigatable exo-endodrainage method employing a modified port-a-cath system as a new alternative. In four patients, all older than 75 years, this system was implanted because of jaundice due to unresectable malignant stenosis of the extrahepatic bile duct. One patient (80 years old) died of pre-existing acute necrotizing pancreatitis, although hyperbilirubinemia was found to decrease on the 7th postoperative day. The other three patients showed complete normalization of their bilirubin levels and their port-a-cath systems remained open until their death (at 3 weeks, 6 months and 7 months respectively).

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We describe three new cases of Fournier's gangrene-a necrotizing fasciitis of urogenital or anorectal origin. Though in the initial report the disease was believed to be idiopathic, the source of infection or immuncompromising factors can be identified in nearly all cases today. We present a combination of aggressive surgical therapy and adjunctive use of Imipenem which was successful in the treatment of all our cases. By using fully resorbable nutrition colostomy could be avoided successfully.

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Following partial pancreaticoduodenectomy for periampullary and pancreatic cancer, the complication and mortality rates are particularly high. Various approaches have aimed at improving the postoperative result, with less than complete success. The discouraging results of others, and our own dissatisfaction, led us to evaluate an atraumatic, sutureless method for management of the residual gland. Following head resection, the remaining pancreas is occluded with a fibrin sealant (Tisseel c, Immuno AG, Vienna) via injection into the pancreatic duct, which is then ligated and left free in the peritoneal cavity. Among 44 patients treated with this method, there were no perioperative deaths. Three patients developed local complications (2 fistulae, 1 pancreatitis) due to technical errors that presumably resulted in incomplete occlusion. Evaluation of patients after two to three years indicates that the endocrine function of the pancreas has been largely conserved despite ductal occlusion.

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A major complication of abdominoperineal rectum excision for rectal or anal carcinoma is local wound infection. The main reason for this infection is that systemically administered antibiotic prophylaxis does not reach sufficiently high concentrations of antibiotic in the tissue of the sacroperineal wound. Since gentamicin-polymethylmethacrylate (PMMA) in the form of chains of beads has been confirmed as a useful tool in the treatment of local infection in bone and soft tissue surgery, we have evaluated its effect on the abdominoperineal rectum excision in a prospective, randomized trial. Forty-four patients with rectal or anal carcinoma entered the study. Only patients with stage Dukes D were excluded from the trial. Following randomized selection, the patients were treated either with local gentamicin and drainage (Group A) or drainage alone (Group B), using the Lloyd-Davies procedure. The two groups were comparable regarding age, sex, tumor stage and level, and risk factors predisposing for an infectious complication (anemia, nutritional status, blood transfusion). The postoperative mortality rate was 0% in both series. Analysis of local perineal wound healing revealed a statistically significant higher percentage of primary wound healing in Group A than in Group B (87% versus 46%; p less than 0.01). This led to a significantly shorter hospitalization period for patients in Group A (p less than 0.01). Gentamicin-PMMA chains have been demonstrated to exert a favorable effect on local wound healing and the postoperative outcome of patients with abdominoperineal rectum excision.

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In principle, many authors advocate a radical surgical approach for early gastric cancer (gastrectomy on principle). Our own experience with subtotal gastrectomy (including N1 + N2 lymphadenectomy; limited resection even without groups 11, 12) shows that this method yields comparable results. With an operative mortality of 2%, the survival rate was 84.3% after 5 years and 70.5% after 10 years, instead of the predicted values of 82.8% and 63.4%, respectively. Applied to the same age group without gastric carcinoma, this yields a 5-year survival rate of 101.8% and thus almost reaches Japanese standards.

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In the period between 1978 to 1987 16 female and 11 male patients with a median age of 35 years (range: 14 years to 85 years) underwent splenectomy for ITP. There was no lethality in the postoperative period. 77.8% of all patients are in a complete remission, only 22.2% showed a recurrence and need further conservative therapy.

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Recent progress in polychemotherapy employed in the treatment of gastrointestinal lymphomas has markedly improved prognosis. Between 1980 and 1986, 22 patients with malignant lymphomas of the gastrointestinal tract were treated at the Department of Surgery at the Hanusch Medical Center, in cooperation with the Department of Hematology and Oncology. 19 patients underwent surgery. The average observation time was 29 months. The rate of survival after 36 months was 64% in the entire patient population. Palliative-surgical interventions combined with chemotherapy equally produced satisfactory results.

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