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The aim of the investigation was to determine the changes in intermediary metabolism that occur in cases of ileus, and to develop a concept for parenteral perioperative nutrition on a pathophysiological basis. Seventeen metabolically healthy patients, suffering from mechanical ileus, have been evaluated. Besides the nonspecific metabolic changes characteristic of the postaggressive metabolism (abnormalities in peripheral glucose utilization, gluconeogenesis, lipolysis, proteolysis) we were able to demonstrate elevated serum levels of albumin, lactate and arachidonic acid preoperatively in these patients. The plasma histamine levels lay within normal limits. In the immediate postoperative phase (i.e. from 1.-3. postoperative day) we found a marked reduction in the serum levels of glucoplastic amino acids (about 30%), albumin (40%), pre-albumin (80%) and cholesterol (50%). We therefore suggest that, apart from electrolyte solutions, patients with an ileus should receive fructose (1600 kcal/day) preoperatively and from the first postoperative day amino acids (1 g/kg of body weight) and human albumin (as required) should be administered in addition.

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The purpose of this investigation was to collect data concerning changes in carbohydrate and amino acid metabolism following different surgical operations (thoracotomies, laparotomies). Blood of 20 metabolically healthy adult surgical patients, who had to undergo elective surgery (lobectomies, pneumonectomies, colon resections) was examined preoperatively, immediately postoperatively and from 1.-4.postoperative day. The experimental data during the perioperative phase showed a similar pattern in both groups of patients: We found a significant elevation in the blood glucose level and there was also a rise in plasma cortisol and plasma free fatty acids levels. We found no significant changes of blood lactate, plasma insulin and branched chain amino acids. Simultaneously we found a drop in plasma albumin, pre-albumin and some glucoplastic amino acids (ALA, GLN, THR, PRO). It is concluded that major abdominal and thoracic surgery give rise to a nonspecific stress situation reflected in carbohydrate and amino acid metabolism with the following metabolic symptoms: Raised lipolysis and gluconeogenesis, disturbance of glucose utilisation and obvious peripheral insulin resistance. These perioperative metabolic effects show some similarities to the metabolic situation in diabetes mellitus type 2.

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Super-radical surgery upon shoulder-girdle and chest wall often means mutilation and is therefore a heavy burden for the patient. Nevertheless it can have very rewarding results, if the indications are correct. They include treatment of soft tissue tumours, under certain conditions of metastases within the thoracic wall and very rarely of trauma. Experiences with 9 patients, treated between 1983 and 1985, are reported. Indications for these operations and their prognosis are discussed.

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The cholecystolithiasis is the symptom of a disease. Recent radiological procedures, above all sonography, can be helpful not only in more frequent detection of gallstones, but they can also provide information, even without clinical symptoms, on pathological changes to gallbladder and biliary tracts. However, early diagnosis of carcinoma of the gallbladder still is rare. Mortality of gallbladder carcinoma has remained unchanged in the Federal Republic of Germany over the past ten years, whereas mortality following cholecystolithiasis has been lowered due to progress in medicine. The surgical risk rises along with age and is low up before 60 years. Indication for cholecystectomy continues to be a highly individual decision which should be considered with particular caution in cases of "asymptomatic" gallstones.

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Lately there has been an increased incidence of rupture of the Achilles tendon following the general increase in mass sports. Surgery is the treatment of choice, and various methods are being described. We have been using the wire suture method with fascia lata plasty for more then twenty years. The rate of infection is 3.8% and that of rerupture 1.2%, figures that correspond to those stated for other surgical methods. Moreover, 87% of the patients were very satisfied with the result of the operation; they are fit for work without any restriction, and some of them even practise their sports activities as before. For this reason we consider that wire suturing with fascia lata plasty is by no means obsolete in the treatment of rupture of the Achilles tendon.

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Traumatic ruptures of the diaphragm are acquired separations of the diaphragm which are aetiologically divided into indirect and rare direct ruptures. The force required to produce indirect ruptures will usually lead to additional intraabdominal lesions of liver and spleen as well as to rib fractures and fractures at the lower extremity. Hence the sequels of these accompanying lesions are often prominent in the clinical pattern to such an extent that 50 to 70% of the diaphragmatic ruptures remain primarily unrecognised. Abdominal and/or cardiorespiratory signs and symptoms become manifest only if there is an evisceration. Hence surgical strategy in preoperatively identified diaphragmatic ruptures depends on the localisation of the rupture, on the severity of the accompanying lesions, and the time until surgical treatment can be effected. Depending on the type and severity of the accompanying lesions an average lethality of 33% must be taken into account in fresh diaphragmatic ruptures. In chronic uncomplicated eviscerations the operations lethality is about one per cent.

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Pohl's hip screw--the classic form of a dynamic osteosynthesis--is an approved method in the treatment of the fracture of the femoral neck (lateral and pertrochanteric fractures). Between 1963 and 1983 over 200 patients were treated with Pohl's hip screw. At an averaged stay of 29 days in hospital half of them were rehabilitated. The mortality rate was 9.3%. More recent methods--e.g. the dynamic hip screw, propagated by AO--present more technical improvements but they are only variations of an old therapeutic principle proved over a generation.

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There are several sound arguments to operate on "silent" gallstones: The operative mortality following simple cholecystectomy in patients under 40 is zero. 50% of all patients with silent gallstones will be operated upon or develop symptoms within 10-20 years after the initial diagnosis. Carcinoma of the gallbladder is very rarely diagnosed in time and in most cases is incurable at the time of operation. The number of deaths in the FRG due to a carcinoma of the gallbladder has been consistently high in the last decade. Risk factors for cholecystectomy increase with the patients age. Therefore early cholecystectomy is recommended. Nevertheless indication for cholecystectomy is an individual decision.

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The problems of surgical treatment of older carcinoma patients consist of the indication for operation, careful preparation and intensive after-care. With adherence to these conditions curative operations are possible even in patients over 70 years of age shown by the example of colo-rectal operations. The mortality rate is 9.6%, only a little higher than the total (6%). The surgical decision has to take account of the expected outcome, and has to be individual. The expected quality of life should influence operative tactics.

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Since the introduction in the Federal Republic of Germany of free routine screening for colorectal carcinoma (digital examination of the rectum in 1971; test for occult blood in the faeces in 1977), the number of Dukes' stage A cases diagnosed at one hospital has increased by 30%. The average interval between onset of symptoms and diagnosis has shortened from 5 to 3.8 months, and the proportion of inoperable carcinomas has decreased by 10%.

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A peripheral adenosquamous carcinoma of the right lung with atypical rich vascularization of the central scar was misinterpreted as an arteriovenous malformation based on a chest X-ray examination and a dynamic computed tomographic study.

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