Davos, 23. – 25. Juni 2004

EIN PRODUKT DER FREHNER CONSULTING
Davos, 23. – 25. Juni 2004
2éme congrès annuel commun de la Société Suisse de Chirurgie
et de la Société Suisse de Chirurgie Thoracique et Cardio-Vasculaire
swiss knife 2004; special edition
©
2. Gemeinsamer Jahreskongress der Schweizerischen Gesellschaft für Chirurgie
und der Schweizerischen Gesellschaft für Thorax-, Herz- und Gefässchirurgie
INSERAT
PFIZER
Editorial
British Journal of Surgery als Schaufenster des
SGC-/SGTHG-Jahreskongresses
Le British Journal of Surgery,
vitrine du congrès annuel de la SSC et de la SSCTV
Liebe Kolleginnen und Kollegen
Chers collègues,
Erstmals werden die Abstracts des 2. Gemeinsamen Jahreskongresses der Schweizerischen Gesellschaft für Chirurgie (SGC) und der
Schweizerischen Gesellschaft für Thorax-, Herz- und Gefässchirurgie
(SGTHG) in einer Spezialausgabe von swiss knife publiziert. Das Editorial Board von swiss knife hat diese wichtige Aufgabe von unserem
ehemaligen Publikationsorgan Swiss Surgery übernommen, damit die
Dokumentation der wissenschaftlichen Tätigkeit der Schweizer
Chirurgen nicht in einer losen Blättersammlung vorliegt.
Pour la première fois, les abstracts du 2ème congrès annuel commun
de la Société Suisse de Chirurgie (SSC) et de la Société Suisse de
Chirurgie Thoracique et Cardio-Vasculaire (SSTCV) sont publiés dans
un numéro spécial de swiss knife. Le comité de rédaction de swiss knife
a repris cette tâche importante de notre ancien organe de publication
Swiss Surgery afin que les preuves de l’activité scientifique des chirurgiens suisses ne se résument pas en une collection de feuilles volantes.
Erfreulicherweise hat ausserdem das Editorial Board des British Journal of Surgery (BJS) der SGC offeriert, 80 Abstracts des Kongresses
in der Juli-Ausgabe des BJS zu publizieren. Dies gibt uns die Chance,
die wissenschaftlich innovativen Studien der SGC-/SGTHG-Mitglieder
auf internationalem Parkett vorzustellen. Diese Abstracts sind zitierbar
und können als Erstveröffentlichungen gelten. Leider ist diese Chance
meiner Ansicht nach für 2004 nicht optimal genutzt worden.
Damit aus dieser Plattform ein maximaler Nutzen resultiert, bedarf es
einer seriösen Planung mit einzuhaltenden Deadlines, formal richtiger
Eingabe der Abstracts und einer sorgfältigen, fundierten Evaluation
nach rein wissenschaftlichen Kriterien. Die Bewertungspunkte müssen
Originalität und Relevanz der Studie, methodische Aspekte inklusive
Statistik, Qualität der Resultate und Schlussfolgerungen sowie die
sprachliche Umsetzung umfassen, während typisch schweizerische
Rücksichten auf Regionen, Spitäler und Autoren auf dieser internationalen Ebene keine Rolle spielen dürfen. Schliesslich ist eine gemeinsame Diskussion des auswählenden Gremiums für eine
Feinabstimmung der Abstracts-Selektion notwendig. Nur so ist garantiert, dass einzig die relevantesten Arbeiten im BJS erscheinen.
Ich hoffe, dass es gelingt, die wissenschaftlichen Aktivitäten der Mitglieder für den Jahreskongress 2005 im Schaufenster des BJS besser
zu repräsentieren!
Allen Beteiligten in der Produktionslinie möchte ich für den grossartigen Einsatz danken, der es innert kürzester Zeit ermöglicht hat, diese
swiss knife special edition zu realisieren.
Par ailleurs, le comité de rédaction du British Journal of Surgery (BJS) a
proposé à la SSC de publier 80 abstracts de ce congrès dans le numéro
de juillet du BJS, ce qui ne peut que nous réjouir. Nous avons ainsi l’opportunité de présenter les travaux scientifiques innovants des adhérents
de la SSC et de la SSCTV dans une tribune internationale. Il est possible
de faire référence à ces abstracts qui peuvent être considérés comme
des premiers publications. Malheureusement, à mon avis, cette opportunité n’a pas suffisamment été mise à profit pour 2004.
Tirer le maximum d’avantages de cette plate-forme nécessite d’effectuer un travail de planification sérieux, avec des dates limites à respecter,
une saisie des abstracts sous la forme appropriée et une évaluation
minutieuse de leur contenu s’appuyant sur des critères purement scientifiques. Le mode d’appréciation doit prendre en compte l’originalité et
l’importance des travaux, les aspects méthodologiques, y compris statistiques, la qualité des résultats et des conclusions ainsi que celle de la
rédaction, les considérations typiquement suisses concernant les régions, les hôpitaux et les auteurs ne devant jouer aucun rôle à ce niveau
international. Enfin, une discussion regroupant tous les membres du
comité de sélection est nécessaire pour faire un choix judicieux parmi
les abstracts soumis pour publication. Ce n’est qu’ainsi que nous
aurons la garantie de voir paraître dans le BJS uniquement les travaux
les plus significatifs.
J’espère que, pour le congrès annuel 2005, nous réussirons à mieux
présenter les travaux scientifiques de nos membres dans la vitrine que
nous offre le BJS!
Mit dem ansprechenden Landschaftsbild von Davos auf der Titelseite
heisst Sie das Editorial Board von swiss knife zu einem interessanten
und stimulierenden Kongress willkommen!
Je tiens à remercier tous ceux qui, tout au long de la chaîne de production, n’ont pas ménagé leurs efforts afin de réaliser cette édition spéciale de swiss knife dans des délais extrêmement brefs. Avec une page de
couverture offrant un magnifique panorama sur Davos, le comité de
rédaction de swiss knife vous souhaite la bienvenue à un congrès qui
s’annonce intéressant et stimulant!
Markus Zuber
Markus Zuber
swiss knife 2004; special edition
3
INSERAT
stratec
Index
Sitzung 01
Viszeralchirurgie
1.01
Detection of pheochromocytoma: what is the most sensitive test?
1.02
Comparison of morbidity between sentinel lymph node biopsy (SLNB) alone versus axillary
dissection in early breast cancer:
A prospective swiss multicenter trial of 423 patients
1.03
Is there a way of sparing selective radical lymph node dissection (SRND) to melanoma patients with positive
sentinel nodes (SN)?
1.04
Laparoscopic roux-en-y gastric bypass is superior to laparoscopic gastric banding
1.05
Superobesity after laparoscopic gastric banding in the long time follow up
1.06
Peritoneal cavity exploration during a routine laparoscopic procedure
1.07
Closure of giant ventral incisional hernias by a modified components separation technique
1.08
Objective ability measurement: a systematic assessment of surgical trainees
1.09
Virtual reality simulation - the future surgical skills training tool?
Sitzung 03
Allgemeinchirurgie
3.01
The PHILOS for complex Fractures of the proximal humerus: Is angular stability really the key to better
functional results?
3.02
Erste Resultate der winkelstabilen 3,5/4,5 Metaphysenplatte bei Tibia- und Humerusfrakturen.
Eine Analyse von 37 Patienten
3.03
Minimal invasive perkutane Plattenosteosynthese (MIPO) bei distalen Tibiafrakturen
3.04
Experience with the locking compression plate (LCP) in fracture treatment of osteoporotic bone
3.05
Dorsal double plating for distal radius fx: differential indication and experience w/ 2.4 locking plates
3.06
Endoscopic carpal tunnel release as a standard treatment for carpal tunnel syndrome:
eight year’s experience with the chow technique
3.07
Der Einsatz eines Facharztes als „Notfallmanager“ verbessert die Betreuung der Patienten auf dem Notfall
3.08
Videotaping of trauma patients in the resuscitation room - a useful tool for quality improvement?
3.09
Wie realistisch sind die Operationszeiten des TARMED?
Sitzung 04
Thoraxchirurgie
4.01
Incidence of non-metastatic extrathoracic lesions detected by whole-body FDG PET-CT
imaging in patients with non-small-cell lung cancer
4.02
Comparative evaluation of intraoperative sentinel lymph node detection in non-small cell lung cancer (NSCLC)
by use of radioisotopic and colourimetric techniques (patent V blue and fluoresceine)
4.03
Neoadjuvant cisplatin based chemotherapy versus radiochemotherapy for stage III (N2) NSCLC:
Comparison of postoperative mortality, mediastinal downstaging and survival
4.04
Incidence and prevention of bronchial stump fistula after pneumonectomy in patients with and without
neo-adjuvant chemotherapy
4.05
The utility of pet scan in the evaluation of the response to neoadjuvant radio-chemotherapy
of esophageal cancer
4.06
Intraoperative photodynamic therapy for malignant pleural mesothelioma: comparison of
mTHPC versus Verteprofine in an experimental setting
4.07
Postpneumonectomy syndrome treated by implantation of expandable prosthesis
Sitzung 05
Video 1
5.01
La colpomyorraphie posterieure etendue
5.02
How we do it: sacral nerve stimulation
5.03
La liberation du nerf honteux interne par voie transgluteale dans le syndrome d’al coock
5.04
Treatment of chronic anal fissures with fissure excision and botulinum toxin type a injection
5.05
Technique du lambeau muqueux dans la cure des fistules anales trans et supra sphincteriennes
5.06
Recronstruction sphincterienne par overlapping pour incontinence post obstetricale
5.07
Central hepatectomy with total vascular occlusion
5.08
Resection of advanced hepatocellular carcinoma with thrombus in the portal vein and hepatic duct
5.09
Laparoscopic liver resections: experience in 13 cases
5.10
Laparoscopic treatment of giant solitary nonparasitic symptomatic biliary cysts
Sitzung 06
Viszeralchirurgie
6.01
Change of treatment strategy for colorectal liver metastasis by a novel PET/CT imaging technique
6.02
Integrated positron-emission tomography and computed tomography (PET/CT)
in gallbladder and bile duct cancer
6.03
Impact of concomitant unilateral portal vein ligation on selective intra-arterial
chemotherapy for downstaging of liver metastasis from colorectal cancer
6.04
Increased ischemic injury in the old mouse liver. A novel pathway of injury
6.05
13 years of surgical therapy of pancreatic carcinoma: a review
6.06
Histoire naturelle de la hernie hiatale para-oesophagienne:
chirurgie systématique pour chaque cas?
6.07
Would you undergo surgery again? Long-term results after laparoscopic fundoplication
6.08
Influence of mesh reinforcement on hiatal hernia repair
6.09
Value of abdominal CT scan in the emergency department for non-traumatic abdominal pain in adults
Sitzung 09
Video 2
9.01
Total thyroidectomy through video-assisted technique
9.02
Laparoscopic mesh-reinforced cruroplasty and anterior fundophrenicopexy
9.03
incarceération intra-thoracique post-traumatique du côlon transverse:
case-report et technique chirurgicale
9.04
How we do it: laparoscopic conversion of gastric banding to roux-en-y gastric bypass
9.05
Partial laparoscopic splenectomy
9.06
Die latero-terminale Anastomose bei der laparoskopischen Sigmaresektion
9.07
Resection of the colon without laparotomy - laparoscopic rectosigmoidectomy with transvaginal colon removal
9.08
One trocar appendectomy
9.09
Chirurgisch - medizinische Transcodierung in HTML: www.code-atlas.com
Sitzung 10
Viszeralchirurgie
10.01
Left-sided elective colorectal surgery with primary anastomosis without
mechanical bowel preparation – meta-analysis
10.02
Bedeutung der „Koprostase“ als chirurgische Diagnose?
10.03
The use of carbon dye in the sentinel lymph node procedure for colon cancer facilitates the detection
of small nodal tumor infiltrates
10.04
Operative Therapie der Divertikelerkrankung - wann ist heute die offene Resektion noch notwendig?
10.05
Resultate der laparoskopische-assistierten linksseitigen Kolonchirurgie
10.06
One Trocar Appendektomie - eine Alternative zur offenen oder laparoskopischen Appendektomie?
10.07
Surgical management of an unsuspected appendiceal mucocele
10.08
Pitfalls in laparoscopy: the vanishing appendix. Intussusception of the appendix due to mucinous cystadenoma.
10.09
Lymph node retrieval after abdominoperineal resection: a comparison of anal and rectal cancer
10.10
Long-term results after stapled rectal mucosectomy for hemorrhoids
10.11
Distale Rektumwanddoppelung nach Girona als valable therapuetische Option in der Fistelchirurgie
10.12
Complication exceptionnelle d’une ligarture elastique
10.13
Diagnostic et traitement du tail gut cyst a propos de 8 cas
10.14
Desmoid tumors associated with Gardner’s syndrome are more difficult to treat than colonic polyposis:
25 years follow up in an extended kindred of 61 persons
10.15
Textilome: migration complète d’une compresse intraabdominale
10.16
Hepatocellular adenoma in adults: management of single-uncomplicated, multiple and ruptured tumors.
10.17
Laparoscopic liver resections: experience in 13 cases
10.18
Intraoperative three-dimensional cholangiography
10.19
The accuracy of preoperative CT based liver volumetry in major liver surgery
dans le colon sigmoÏde et expulsion par les voies naturelles
10.20
First experiences with M.A.R.S. at the university hospital of bern
10.21
Long term results after pancreatoduodenectomy for cancer
10.22
Long-term results of surgical treatment for vater’s ampulla neoplasms
10.23
Adenoma of the ampulla vateri: A cause for secondary biliary cirrhosis
10.24
20 years of liver transplantation in Berne and in Switzerland
10.25
Optimal use of split liver grafts and of pediatric donors fulfills the need of liver transplantation in children
10.26
Transarterial chemoembolization before liver transplantation for hepatocellular carcinoma
10.27
Association of non-melanoma skin cancer with post-transplant malignancy in kidney transplant recipients
10.28
Medical morbidities in patients who survived 10 years after liver transplantation
10.30
The time point of a first acute rejection but not the actual graft function at rejection influence the
longterm kidney transplant survival
10.31
Ileum or colon conduit as bladder replacement for kidney transplantation: technical aspects and long-term outcome
10.32
Risk analysis for outcome of renal transplantation: a single centre experience
10.33
Laparoscopic cholecystectomy for acute cholecystitis: a prospective 7-year multicenter analysis of 5`289 cases
10.34
Conversion from laparoscopic to open cholecystectomy: the Swiss experience
10.35
Intra-and postoperative complications after laparoscopic surgery
10.36
Langzeitresultate der videoendoskopischen Oesophago-Diverticulostomie beim Zenkerschen Divertikel
10.37
Reduction of slippage-rate with new 11cm lapband and change of gastric banding technique
10.38
Conversion of vertical banded gastroplasty to roux-y gastric bypass
10.39
Upper digestive symptoms before and after roux-en-y gastric bypass
in Switzerland - a multiple regression analysis of the SALTS prospective data base
Sitzung 11
Allgemeinchirurgie
11.01
Proximal humerus fractures in elderly:
claim and reality of an anatomical fixation system with angular stability (PHILOS)
11.02
Penetrating abdominal stab wounds: a six year, single centre retrospective
swiss knife 2004; special edition
5
Index
on primary human osteoblasts
study and establishment of a treatment algorithm
11.03
Outcome following plate-osteosynthesis of comminuted intraarticular distal radius fractures
13.09
Melatonin in vivo prolongs cardiac allograft survival in rats
11.04
Experience with routine monitoring of intracompartmental pressure and
13.10
Induction of stable peripheral tolerance to concordant and discordant islet xenografts
11.05
Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography.
13.11
A prospective blind study
13.12
A new modified technique of ureteroureterostomy in rat kidney transplantation
Synchronous bilateral ductal carcinoma in situ associated with gynecomastia
13.13
Phylogenetic disparity influences the predominance of direct over indirect pathway of antigen presentation in
selective fasciotomy in minimal invasive osteosynthesis of tibial fractures.
11.06
by inhibition of signals 2 and 3
in a 30 year old patient following repeated injections of stanozolol: a case report
Effect of microcapsule composition and short-term immunosuppression on intraportal biocompatibility
islet xenotransplantation
11.07
Resultate nach konservativer Therapie ligamentärer Handgelenksverletzungen
11.08
Projet académie suisse intégrée de médecine militaire et de catastrophe
11.09
Implementing a whole-body multislice CT in the initial management of
13.15
polytraumatized patients – do we improve time?
13.16
13.14
Cytotoxic effects of camptothecin and cisplatin combined with Apo2L/TRAIL in a model of primary culture of
non-small cell lung cancer
Comparison of different cell isolation and culture methods for liver progenitor cells from adult rat bone marrow
Differential expression of anti-apoptotic protein bcl-2 in keratinizing vs. non-keratinizing squamous cell
11.10
Necrotizing fasciitis of upper extremity and chest wall
11.11
Stabilisation von proximalen Humerusfrakturen
13.17
mit einem neuen winkelstabilen Verriegelungsnagelsystem (Targon PH)
13.18
Intrathoracic photodynamic therapy on malignant mesothelioma bearing rats
11.12
Le Nodule de soeur Mary Joseph
13.19
Increased connexin43 is associated with human venous intimal hyperplasia
11.13
Appendicitis acuta duplex
13.20
Novel long-chain ceramides induce cell death in human colon cancer cells by aponecrosis
11.14
Syndrome de Bouveret: complication rare de la maladie lithiasique
11.15
Papillomatose der intrahepatischen Gallenwege, ein seltenes Krankheitsbild
Sitzung 14
Allgemeinchirurgie
11.16
Unusual acute appendicitis: amyand’s hernia
14.02
Midshaft fracture of the clavicle: prospective evaluation of ORIF with an elastic intramedullary titan nail
11.17
Team-performance im Schockraum-Management - wie beurteilen wir unsere Arbeit und Ausbildung?
14.03
Flexible endomedullary nailing of midthird clavicular fractures: surgery for a fracture that needs no surgery?
11.18
HPV typisation of condylomata accuminata and recurrent disease
14.04
11.19
Spontaneous splenic rupture: a rare complication of von willebrand disease
carcinoma of the anus
Histologic analysis of the irradiated anal sphincter
Intramedullary nailing (TEN®) for midclavicular fractures in athletic patients:
Indications, technical pitfalls and early results
11.20
Tätigkeit von nichtchirurgischen Oberärzten auf dem chirurgischen universitärem Notfall
11.21
Gastrointestinale Stromatumoren, 7 Fallbeispiele
11.22
Der Iso C-3D - Optionen und Grenzen eines Durchleuchtungsgerätes
Sitzung 16
Thoraxchirurgie
11.23
Laparoscopic repair of ventral hernias: a preliminary study
16.01
Long-term results after unilateral LVRS for emphysema
11.24
Lokale und systemische Reaktion auf Verschleisspartikel; eine vergleichende in vivo Studie mit rostfreiem Stahl
16.02
Thoracoscopic treatment of pulmonary sequestration: is it a safe operation?
11.25
Kommunikation mit den Hausärzten übers Internet: Das Pilotprojekt eHealth Chirurgie
16.03
14.07
Komplikationsrate und Outcome bei Versorgung lateraler Claviculafrakturen mittels Balserplatte
Die videoassistierte Thorakoskopie (VATS) mit Minithorakotomie: Eine weitere Möglichkeit der chirurgischen
Therapie im Stadium II des Pleuraempyems
Sitzung 12
Gefässchirurgie
12.01
Iliac artery rupture and retroperitoneal fibrosis related to an infected aorto-iliac endograft.
12.02
When the legs depend on the internal thoracic artery
16.05
12.03
Das Kompartment-Syndrom - eine seltene Komplikation der Varizenchirurgie
16.06
Catamential pneumothorax - clinical approach and review of the literature
12.04
Right forearm ischemia due to thrombosis of a lusorian artery stenosis
16.07
Extra-thoracic tracheal reconstruction using the latissimus dorsi muscle flap in three different ways:
12.05
16.04
Thorakoskopische Therapie des rezidivierenden Spontanpneumothorax: parietale Pleurektomie und
Pleuraabrasio im Vergleich
Patterns of recurrence after video-thoracoscopic treatment in patients with primary spontaneous pneumothorax
An experimental study in pigs
Early experience and preliminary results with a new polyurethaneurea vascular graft (PVG)
in vascular access surgery for chronic haemodialysis
12.06
Preliminary carotis- vertebralis transposition and carotis-subclavia bypass
Sitzung 17
Allgemeinchirurgie
allowing endovascular treatment of an aortic arch aneurysm
17.01
Laparoskopische partielle Fundoplicatio nach Toupet als generelle chirurgische Therapieform der gastro-
12.07
Behçet’s disease revealed by arterial aneurysms of the extremities
12.08
Traumatische Läsion der A. vertebralis
17.02
12 years laparoscopic cholecystectomy: one institution’s results of a prospetive trial of 4498 cholecystectomies
12.09
Temporärshunt zur Vereinfachung der Anastomosentechnik in der cruralen Bypasschirurgie
17.03
La chirurgie de l’obésité en Suisse. Résultats d’une enquête nationale
12.10
Renal artery stenosis by fibres from diaphragmatic crus is a rare cause of renovascular hypertension
17.04
Two colons – two cancers paradigm shift and clinical implications
12.11
Embolization of a high-output postnephrectomy arterio-venous fistula by an endovascular
17.05
oesophagealen Refluxkrankheit. 5 - Jahresresultate einer prospektiven Langzeitstudie
transfemoral bidirectional approach
12.12
Soft tissue sarcoma of the extremities and the retroperitoneum: results of treatment with special regard of
impact factos for local recurrency
Aneurysmata der Arteria mesenterica superior, A. gastroduodenalis
17.06
Utilité de l’analyse génétique dans la prise en charge du carcinome médullaire familial de la thyroïde
in Kombination mit einer Stenose des Truncus coeliacus (Fallbeispiel)
17.07
Totally extraperitoneal inguinal hernioplasty using a non fixed anatomical slit
polyester mesh: PARIETEX®ADP2.
12.13
Unterschenkelamputation – wie gelingt sie immer?
12.14
Successful surgery for traumatic carotid artery dissection
17.08
Chirurgie endoscopique des veines perforantes des membres inférieurs
12.15
Angiosarcoma of the abdominal aorta presenting with tumor embolisation to the leg
17.09
Surgical management of patients at risk in a rural hospital in cooperation with a regional hospital - does such
12.16
Comparative evaluation of multi-slice CT-angiography vs duplex ultrasound scan for longterm
a cooperation make sense?
follow-up of surgically excluded popliteal artery aneurysms
12.17
Traumatic brachial artery aneurysm as an occult source of emboli to the upper extremity
12.18
Akute obere GIT Blutung bei rupturierendem Aortenaneurysma und primärer aortoduodenaler Fistel
Sitzung 18
Viszeralchirurgie
18.01
Neoadjuvant short-term radiotherapy of low rectal cancer impairs healing
Sitzung 13
Forschung
13.01
Translational enhancement of hepatic insulin expression improves glycemic control in STZ-induced diabetic rats
13.02
Anti-CD154 mab treatment but not recipient CD154 deficiency leads to long-term survival of xenogeneic islet grafts
13.03
Collagenase for human islet isolation
18.03
Outcome of surgery for rectal cancer in octogenarians
13.04
Monitoring small bowel motility after colorectal surgery with MR imaging
18.04
Is the transverse coloplasty-anal reconstruction afflicted with an increased leak rate?
13.05
Increased ischemic injury in the old mouse liver. A novel pathway of injury
18.05
Quality of life after ileal pouch-anal anastomosis:
13.06
The effect of hematopoietic growth factors on survival in a novel surgical small for size liver remnant mouse model
13.07
Mechanical stability of intestinal anastomosis in healthy pigs is not altered by intraoperative hyperthermic
of rectal anastomoses after low anterior resection
18.02
comparison of patients with familial adenomatous polyposis and ulcerative colitis
18.06
chemoperfusion (IHCP) with mitomycin c
13.08
6
In vitro effect of low molecular weight heparin (Dalteparin) and fondaparinux (Arixtra®)
swiss knife 2004; special edition
Langjährige Erfahrung mit der trimodalen Therapie beim tiefsitzenden Rektumkarzinom:
Verhindert eine komplette Remission (CR) ausgedehnte Resektionen?
Renal transplant patients have a higher risk to develop complicated diverticulitis
compared to non-transplant patients
18.07
Appendizitis perforata. Laparoskopische Ergebnisse von 334 Patienten mit Appendizitis perforata.
Index
18.08
Quality of life after sacral nerve stimulation in patients with faecal incontinence
Sitzung 27
Viszeralchirurgie
18.09
Is Prophylactic Drainage Useful after Gastrointestinal Surgery?
27.01
Frozen section in thyroid surgery
27.02
Surgery for neuroendocrine pancreatic tumors – an increasing entity?
Sitzung 19
Forschung
27.03
Radioguided surgery for intestinal carcinoid tumor
19.01
Platelets: a novel pathway of liver regeneration
27.04
19.02
Glucose-dependent hepatic insulin expression in STZ-induced diabetic mice after systemic plasmid
DNA gene transfer
19.03
A rare combination of phaeochromocytoma & carcinoid tumor of Vater’s papilla in a patient with von
Recklinghausen neurofibromatosis
27.05
Treatment of fulminant liver failure by transplantation of microencapsulated primary or immortalized
GIST and a duodenal neuroendocrine tumour in a patient with von Recklinghausen’s disease:
A case report and review of literature
xenogeneic hepatocytes
27.06
Gastrointestinal stromal tumors: towards a clinically reliable prognostic scale
19.04
Magnetic resonance imaging provides accurate volume determination in regenerating mouse livers
27.07
Umbilical hernia: is the operation without a mesh graft still adequate?
19.05
Retransplantation of discordant xenogeneic islets using costimulatory blockade
27.08
Preoperative identification of malnutrition in surgical patients using bioelectrical impedance analysis
19.06
Different etiology of steatosis has different tolerance to ischemic-reperfusion injury
27.09
Pancreatic surgery for carcinoma - A 20-year experience in a single institution
19.07
Pancreatic islet engraftment after intrahepatic transplantation: Evidence of early graft loss
27.10
Kolorektale Karzinomchirurgie am Zentrum oder an der Peripherie? - Ein Outcome Vergleich
Sitzung 28
Thoraxchirurgie
28.01
Early experience with the minimally invasive repair of pectus excavatum in adults
in a syngeneic rat model
19.08
Hepatocyte specific metabolic activity can be induced in adult liver stem cells isolated from rodent bone marrow
Sitzung 21
Herzchirurgie
28.02
The role of surgery in the management of isolated mediastinal tuberculosis: report of 4 cases and review
21.01
Superior flow pattern of internal thoracic artery over saphenous vein grafts during OPCAB procedures
28.03
Multiple thoracic aneurysmal bone cysts: diagnostic and therapeutic challenges
21.02
Conversion of off-pump surgery to extracorporeal circulation: the importance of the LAD bypass in patients
28.04
Mediastinal Goiter: Sometimes the exposure comes from below
with severe coronary artery pathology
28.05
Douleurs rétrosternales et dysphagie aiguë. Rupture spontanée d’un kyste bronchogénique
21.03
Predictors of early and late outcome after reoperative coronary artery revascularization
28.06
Das primär adenoidzystische Karzinom der Lunge; eine seltene maligne Neoplasie
21.04
Prediction of mortality and prolonged Intensive care unit stay after off-pump coronary artery bypass grafting
28.07
An accidentally discovered endobronchial lipoma
Impact of surgical technique on right ventricular function: comparison of on-pump versus off-pump coronary
28.08
Neue Therapieoptionen - Hat die extrakorporale Membranoxygenation (ECMO) beim ARDS ausgedient?
revascularization; an echocardiographic study
28.09
Pulmonary vein thrombosis after lobectomy
21.06
Guidant heartstring: initial experience in OPCAB surgery
28.10
21.07
Impact of female gender on early outcome in OPCAB surgery
21.08
Evaluation of early graft-patency with multislice spiral computed tomography after CABG
28.11
Sitzung 24
Forschung
28.12
24.01
Tat-Her2/neu transduced DC induce a specific immune response and a reduction of tumor growth
24.02
E2F-1 interaction with human telomerase reverse transcriptase (HTERT) expression predicts survival after
Sitzung 29
Herzchirurgie
colorectal liver metastases resection
29.01
Proteome analysis of myocardial tissue in „young” transgenic mice overexpressing beta-1 adrenergic receptor
24.03
Heme Oxygenase-1 (HO-1) inhibition sensitize pancreatic cancer to adjuvant treatment
29.02
Prevention of surgical pericardial adhesions after implantation of a biodegradable hydrogel
24.04
Humoral & cellular immune responses in stage III-IV melanoma patients: implications for immunotherapy
29.03
Revascularisation coronarienne chirurgicale à cœur battant sous assistance circulatoire chez une population
21.05
Management of delayed Boerhaave syndrome with lobectomy and esophagoplasty by intrathoracic
transposition of a latissimus dorsi muscular flap.
Reconstruction trachéale par un muscle grand dorsal pour une déchirure chronique et récidivante
post-intubation.
Spontaneous intercostal pulmonary herniation after prolonged severe coughing –
a case report and review of literature
in breast cancer bearing mice
de patients à haut risque
24.05
NY-ESO-1/LAGE-1 tumor associated antigen expression in clinical samples: a tissue microarray study.
24.06
Molecular biology of squamous cell carcinoma of the anus: a comparison of HIV positive
29.04
Odyssee im Notfall - keine Seltenheit !
and HIV negative patients
29.05
New technique of proximal aortic anastomoses during OPCAB
24.07
TNF-mediated regulation of intracranial IL-18 in traumatic brain injury: a clinical and experimental study
29.06
The prognostic value of preoperative B-type natriuretic peptide in patient undergoing coronary bypass surgery
24.08
Regulation of neutrophil apoptosis in patients with sepsis by STAT-3
Sitzung 25
Gefässchirurgie
25.01
Vascular tissue engineering using synthetic biodegradable scaffolds
25.02
Peripheral vascular bypass operation using autlogous endothelialized PTFE-prosthesis
25.03
Endoprosthesis and IVUS: the tools for straightforward repair of traumatic aortic rupture
25.04
Thoracic and abdominal aortic aneurysm repair – does EVAR add safety to the combined repair?
25.05
Gluteal ischemia – serious complication after infrarenal aortic surgery?
25.06
Die Revaskularisation beim diabetischen Fuss. Langzeitergebnisse > 10 Jahre
25.07
Die extraanatomische laterale Rekonstruktion der Femoralgefässe
25.08
Sartorius-muscle flap for treatment of infected inguinal access after vascular prosthesis
25.09
Venous morbidity after superficial femoral vein harvest for infra-inguinal reconstructions
Sitzung 26
Herzchirurgie
26.01
„Lifesight“ improves concentration and reaction time in surgery
26.02
Impressum
Impact of a modfield harvesting technique of the internal thoracic artery on
morphhological changes of the endothelial layer
26.03
Preoperative optimization with nesiritide (BNP) in high-risk mitral valve surgery
26.04
Tricuspid valve repair with the Edwards MC3 annuloplasty system: early clinical results
26.05
Proteomics analysis – a promising tool to investigate ascending aortic disease
26.06
Risk for embolization at aortic cross clamping? Intraaortic filter captures particulate emboli.
26.07
Intravascular near-infrared spectroscopy is applicable for ischemia and reperfusion monitoring
during off-pump coronary bypass surgery
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swiss knife 2004; special edition
7
01
1.01
U. Güller 1, J. Turek 2, L. Delong 2, S. Eubanks 2, D. Oertli 1, J. Feldman 3
1
Department of Surgery, Division of General Surgery and Surgical Research, University
of Basel, 2Department of Surgery, Duke University Medical Center, Durham, NC/USA,
3
Durham VA Medical Center, Division of Medicine, Duke University, Durham, NC/USA
Detection of pheochromocytoma: what is the most sensitive test?
Background: Pheochromocytoma is a rare, catecholamine producing tumor with preferential localization in the adrenal gland. Despite its importance, this disease is still poorly described and the most sensitive test to establish the diagnosis remains to be defined. The objective of this investigation was to describe one of the largest ever published samples of pheochromocytoma patients and to define the most sensitive test to establish the diagnosis.
Patients and Methods: Prospective data collection was done on patients with pheochromocytoma treated at the Duke University Medical Center and the Durham Veterans Affairs
Hospital. All analyses including urinary homovanillic acid, vanillymandelic acid, dopamine,
epinephrine, norepinephrine, 5-Hydroxyindoleacetic acid, serotonine, as well as blood
dopamine, epinephrine, and norepinephrine were highly standardized. Iodine131-labeled
metaiodobenzylguanidine scinitgraphy scans (131I–MIBG) were independently reviewed by
two nuclear medicine physicians.
Results: A total of 156 patients (54.5% female) were enrolled in the present analysis.
Patients were predominantly white (73%). Spells and hypertension at diagnosis were present in 50.1% and 65%, respectively. Bilateral disease was found in 11.5%, malignant pheochromocytoma in 31%, and hereditary forms in 23.7%. Tumor size significantly correlated
with malignancy (p < 0.0001). Also, abnormal homovanillic acid (p<0.0001) and urine
dopamine levels (p<0.0001) highly correlated with malignant disease. The most sensitive
tests were 131I–MIBG (82%), urine norepinephrine (75.0%), and urine vanillymandelic acid
(74.0%). In combination, 131I–MIBG and urine norepinephrine had a sensitivity of 95.6%, 131I–
MIBG and urine vanillymandelic acid of 91.2%.
Conclusions: Large pheochromocytomas and abnormal levels of urine dopamine and/or
homovanillic acid are significantly correlated with malignant disease. The tests of choice to
establish the diagnosis of pheochromocytoma are 131I–MIBG scans, urine norepinephrine,
and urine vanillymandelic acid. A combination of urinary measurements and 131I–MIBG
does further improve the sensitivity.
1.02
I. Langer, G. Berclaz, O. Köchli, H. Moch, D. Oertli, F. Harder, M. Zuber
For the Swiss Multicenter Trial Sentinel Lymph Node Biopsy in Breast Cancer
Comparison of morbidity between sentinel lymph node biopsy (SLNB) alone versus axillary
dissection in early breast cancer: a prospective swiss multicenter trial of 423 patients
Background: Axillary lymphadenectomy (ALND) in breast cancer is associated with considerable morbidity. The percentage of node-positive patients is constantly decreasing.The
SLNB has proven to accurately reflect the status of the axillary lymph nodes. The hypothesis
was that patients undergoing SLNB only versus ALND will benefit significantly regarding
postoperative morbidity.
Methods: In this prospective multicenter trial, 696 patients with early-stage breast cancer and clinically negative axillary lymph nodes were accrued between January 2000 and December
2003. In total, 423 patients, who accomplished at least one follow-up exam after a median time
of 4 months, were eligible. All patients underwent SLNB. In case of SLN metastasis a completion
ALND was carried out. Morbidity criteria based on a standardized protocol were evaluated.
Results: SLNB only was performed in 290 patients, while 133 patients underwent consecutive ALND. Median follow-up was 4 months (range 3–12 months). Postoperative morbidity was observed in both groups, but significantly less frequently in the SLN group.
Lymphoedema
Hypertrophic scar
Shoulder restriction
Pain in upper arm
Numbness
SLN alone
03/290
1.0%
07/290
2.4%
09/290
3.1%
08/290
2.8%
29/290
10.0%
SLN + ALND
09/133
6.8%
15/133
11.3%
12/133
9.0%
16/133
12.0%
28/133
21.1%
p Value
0.002
0.0005
0.014
0.0004
0.003
Conclusions: The morbidity after SLNB only is not negligible. But the SLNB is associated
with significantly less postoperative morbidity compared with level I and II ALND.
1.03
M. Matter 1, D. Liénard 2, O. Gugerli 3, A. Lobrinus 3, F. Lejeune 2
Service de chirurgie Viscérale et Transplantation, CHUV, 2Centre
Pluridisciplinaire d’Oncologie, 3Institut Universitaire de Pathologie, CHUV
1
Is there a way of sparing selective radical lymph node dissection (SRND) to melanoma
patients with positive sentinel nodes (SN)?
Introduction: Patients evaluated by SN Biopsy (SNB) technique show a 20-25% rate of positive SN. This indicates 75-80% will not be proposed a selective radical lymph node dissection (SRND). There is a suggestion that patients with intermediate thickness melanoma accor-
8
swiss knife 2004; special edition
ding to AJCC-UICC staging will benefit of SNB, as well as selected T1 patients. However only
20-30% of patients with positive SN have positive non SN (NSN) in the SRND. The aim of the
study is to determine if a further selection of positive SN patients is feasible to avoid SRND in
selected patients.
Material and Method: Prospective cohort of consecutive patients since 1997 in one centre
and one surgical team, using triple technique (lymphoscintigraphy, blue dye, gamma
probe) and anatomopathologic examination including serial sectioning and immunohistochemistry with Melan A and protein S-100. Correlation with clinical and anatomopathological factors including S classification (1), univariate analysis with Chi-square test.
Results: In 267 patients with primary melanoma 58 (22,5%) had positive SN and 51 had
SRND (4 patients refused and 3 with isolated tumour cells (ITC) were initially not proposed).
Univariate analysis showed that T2-4 stage, localisation (limbs, trunk, head and neck), gender and number of basins were not significantly associated with positive SN. In contrast,
type of melanoma (SSM 15,3% / other 41,4% p<0,001), age (£60 17% / >60 31,3%
p<0,01) and ulceration (present 36,8% / absent 22,9% p<0,05) were clear risk factors for
positive SN.
Following SRND 10 patients (19,6%) had positive NSN. T stage, ulceration, S classification,
tumour burden in metastatic SN (ITC / <2mm / >2mm) and number of positive SN were not
significant predictors. Moreover up to 3 positive SN have been harvested in the 41 patients
having SN as the only positive node(s).
Discussion and Conclusion: no clinical or tumour related factor can significantly predict
positive NSN. While awaiting prospective randomised trials on survival benefit for SN and
SRND in positive SN patients, this procedure should be performed in all positive SN patients.
1. Starz H et al. Cancer 2001, 91: 2110-2120.
1.04
M. Weber, M. Müller, S. Wildi, D. Dindo, R. Hauser, PA. Clavien
University Hospital Zurich
Laparoscopic roux-en-y gastric bypass is superior to laparoscopic gastric banding
Background: Two techniques, laparoscopic gastric bypass or gastric banding, are currently widely used to treat morbid obesity. Since both procedures offer certain advantages, a
strong controversy exists which operation should be proposed. Therefore, data are needed
to identify the best therapy (Editorial, Ann Surg 237:17-18, 2003).
Methods: Since randomized trials are most likely not feasible due to the highly different invasiveness and irreversibility of these procedures, a matched-pair design of a large prospectively collected database appears to be the best method. Therefore, we used our prospective database including 678 bariatric procedures performed at our institution since 1997.
103 consecutive patients with laparoscopic gastric bypass were randomly matched to 103
patients with laparoscopic gastric banding according to age, BMI and gender.
Results: Both groups were comparable regarding age, gender, BMI, excessive weight, fat
mass and co-morbidity such as diabetes, heart disease and hypertension. Feasibility and
safety: All gastric banding procedures were performed laparoscopically, one gastric bypass
operation had to be converted to an open procedure. Mean operating time was 144 min for
gastric banding and 190 min for gastric bypass (p=0.001). Hospital stay was 3.3 days for
gastric banding and 8.4 days for gastric bypass. The incidence of early postoperative complications was not significantly different, but late complications were significantly more frequent in the gastric banding group (pouch dilatation). There was no mortality in both
groups. Efficiency: BMI decreased from 48.0 to 36.8 kg/m2 in the gastric banding group
and from 47.8 to 33.4 kg/m2 in the gastric bypass group within two years of surgery. These
differences were significant from the first postoperative month on.
Conclusion: Laparoscopic gastric banding and laparoscopic gastric bypass are feasible
and safe. Pouch dilatations after gastric banding are responsible for more late complications compared to gastric bypass. Laparoscopic gastric bypass offers a significant advantage regarding weight loss after surgery. Therefore, in our hands laparoscopic Roux-en-Y
gastric bypass appears to be the therapy of choice.
1.05
M. Thurnheer, L. Marti, J. Lange
Klinik für Chirurgie, Kantonsspital St.Gallen
Superobesity after laparoscopic gastric banding in the long time follow up
Introduction: The indication of the purely restrictive bariatric surgery at super-obesity
(BMI>50kg/m?) is discussed controversially and the data about long time course of these
patients after gastric banding is rare.
Method: 450 patients (81% women, age 38±8 years, BMI 47.3±4kg/m2) became a
gastric adjustable band carried out between 1.11.95 and 31.12.2003 in laparoscopic technique (95%). 365 patients (81%) were morbidly obese (BMI 36-49.9kg/m2), 85 patients
superobese (BMI 50-64kg/m2). The prospectively recorded data of the two groups were
analyzed regarding the excessive weight loss (EWL) and postoperative quality of life
(Moorehead Ardelt QOL).
Results: The excessive weight loss was in the group with a BMI under 50 kg/m2 (43.6±3,
n = 365) 47,6±17% after 2 years (n=250), 46,9±19,6% after 4 years (n=144) and
46,9±20,4% after 6 years (n=44). In the collective with preoperative BMI over 50 kg/m2
(54.5±3, n = 85) the EWL amounted to 41,5±13% (p<0.02, Mann-Whitney-U) after 2
years (n=59), 41,3±16% (p<0.16) after 4 years (n=46) and 39,7±18,2% (p<0.35) after 6
years (n=13). The quality of life index (QOL) was at the morbidly obese patients
1.33±0.75, with the superobese patients 1,16±0.92 (no significance between the two
groups) after 4 years.
Conclusions: The weight loss is significantly deeper with the superobese patients 2 years
after gastric banding and stagnates after this in the two groups on the same rank. The
group with morbid obesity surpasses the one of superobese patients for the quality of life
for this one though not significant. Therefore the indication of gastric banding at a BMI via
50 kg/m2 must be put restrainedly under one cover of broader clinical parameters like
accompanying illnesses, eating behavior, age and the function of the esophagus.
1.06
X. Delgadillo, M. Gonzalez, C. Becciolini, M. Merlini
La Chaux de Fonds General Hospital
Peritoneal cavity exploration during a routine laparoscopic procedure
Background: Laparoscopy is universally accepted as a minimally invasive technique with
low morbidity rates. The peritoneal cavity exploration during a routine laparoscopic procedure sometimes reveals incidental findings. We evaluate the effectiveness of a systematic
exploration and its consequences.
Methods: A prospective trial was conducted in our Department of Surgery from 1998 to
1999 to systematically assess the peritoneal cavity. A five year follow-up was also undertaken. 101 consecutive routine laparoscopic explorations were carried out by nine staff surgeons during 83 cholecystectomies, 4 gastric fundoplications, 6 sigmoidectomies and 8
miscellaneous procedures. A method to evaluate in percentage the completeness of abdominal organs examination through laparoscopy was perfected.
Results: 69 women and 32 men underwent the trial. 8 patients were excluded from the five
year follow-up study (7 deaths for non abdominal causes and 1 patient lost to follow-up).
The liver could be assessed in 84%, the stomach in 75%, the spleen in 40%, the colon in
56%, the pelvis in 40% and the small bowel in 32%. 48 operations revealed a normal peritoneal cavity, 35 described incidental findings: adhesions 77%, liver haemangioma 14%,
ovarian cyst 5% and minor findings 4%. Direct consequences of all incidental findings were
eleven lysis of adhesions (11 partial), two liver biopsies (non malignant haemangiomas)
and one ovarian cystectomy. The mean duration of the laparoscopic exploration was 11
min.(range 5 to 25 min). In the 5 year follow-up period, one patient died (11 months after
the laparoscopic exploration) of a peritoneal carcinomatosis from ovarian origin, non detected during the previous cholecystectomy because of important pelvic adhesions.
Conclusions: We conclude that peritoneal cavity exploration during a routine laparoscopic
procedure is a short and safe procedure. However, we believe that it is an unnecessary
manoeuver because it mainly discovers incidental minor findings with low surgical consequences. In our study the only case in wich laparoscopic routine exploration could have
revealed an important pelvic pathology was missed because tight adhesions.
1.07
R. Bühlmann 1, R. Schlüchter 1, R. Hollmann 2, C. Meuli-Simmen 2, R. Schlumpf 1
1
Klinik für Chirurgie, Kantonsspital, CH-5001 Aarau, 2Klinik für Plastische, Wiederherstellungsund Handchirurgie, Kantonsspital, CH-5001 Aarau
Closure of giant ventral incisional hernias by a modified components separation technique
Subject: Incisional hernias are a fairly common complication of median laparotomies appearing in about 10% over all. Repair techniques without mesh prosthesis are associated with
a recurrence rate up to 50%. Procedures using surgical meshes in sublay technique became the method of choice. Very large abdominal wall defects, commonly due to laparostoma techniques, require an extended operative procedure. For such instances we developed
a modification of the components separation technique.
Goal: The goal of this study was to prospectively evaluate our repair technique for giant incisional hernias.
Methods: Our operative technique included the classical steps of components separation
with release of the external oblique muscle along the linea semicircularis. However we combined this with implantation of a poplypropylene/polyglactin light weight mesh behind the
rectus muscle (sublay technique). Skin grafts over the intestines were deepithelialised
using CO2 laser and placed underneath the dorsal rectus sheath.
Results: 8 patients between 25 and 74 years of age underwent repair of a ventral giant hernia at our department (2001-2003). 4 cases presented with a skin grafted intestinal prolaps. The vertical and horizontal diameters of the defects ranged from 10-25 cm, mean operating time was 4.5 hours and mean postoperative stay 8.7 days. Return to normal acitivity
occurred after 1.5-4 months. Postoperative complications included one patient with delayed wound healing and temporary seroma formation. In a second case a slowly progressive and hardly symptomatic hernia superior to the right iliac crest occurred 11 months postoperatively. There were no ventral hernia recurrences and no deaths during mean follow up
of 17 months.
Conclusions: Tension free closure of large midline defects is well manageable with our
modified components separation technique. By this, anatomy and the dynamic competence of the abdominal wall are restored. Laser vaporization of skin grafted areas decreases risk of bowel lesions, operating time and blood loss. In addition, risk of hernia recurrence is supposed to be substantially reduced using the additional mesh in sublay technique.
1.08
M. Wagner, JM. Heinicke, D. Candinas
VCHK, Inselspital Bern, Bern
Objective ability measurement: a systematic assessment of surgical trainees
Introduction: Reduction of working hours confronts basic surgical training programmes. In
order to meet this development, efficient training programmes are needed in addition to
optimal evaluation of surgical candidates. Therefore, we compared the existing practice
with regard to conducting formal appraisals for surgical trainees in our surgical department
with a more objective assessment of surgical skills.
Methods: Formal appraisal of each trainee was conducted twice a year based on a standardized questionnaire and a structured interview. In addition, a three-task skills examination was implemented assessing theoretical surgical knowledge, surgical skills (knotting,
suturing) and handling a particular clinical scenario. Theoretical knowledge was assessed
with a multiple choice questionnaire. Knotting and suturing skills were video assessed. The
clinical scenario was judged according to fixed criteria. Final assessment was determined
according to a linear point scale.
Results: Median duration of surgical training was 26 months (3-72) in a total of 15 trainees.
Based on formal appraisal, the performance of 6 candidates was summarized as excellent,
4 were judged as good, 2 as moderate and 3 as poor. 10 trainees performed the three-task
skills examination. Each of the three different tasks was able to discriminate between a low
and high performance. There was no correlation between duration of surgical training and
total performance in the skills examination. However, there was a significant difference concerning the overall skill-test performance between trainees judged as poor to moderate and
those judged as good to excellent according to the formal appraisal.
Conclusion: Based on these initial results, simple duration of surgical training can not be
taken for granted to improve the capabilities of surgical candidates. Especially theoretical
surgical knowledge as well as the competence to handle routine clinical scenarios seems
to be highly variable among candidates and less affected by duration of training. Thus individual adaptations may be required in order to improve the quality of our surgical training
despite a shortening in working hours.
1.09
R. Rosenthal 1, WA. Gantert 1, C. Hamel 1, J. Metzger 2, P. Vogelbach 3, D. Scheidegger 1,
D. Oertli1. 1Departement Anästhesie und Chirurgie, Universitätskliniken Basel, 2Chirurgische
Klinik A, Kantonsspital Luzern, 3Chirurgische Klinik, Spital Dornach
Virtual reality simulation - the future surgical skills training tool?
Introduction: Traditionally, skills training takes place in the operating room. Economic, ethical and educational considerations have lead to the development of other training methods,
such as virtual reality. In endoscopic surgery, adequate performance depends on perceptual motor skills, cognitive skills and non-cognitive factors.
Aim: The present study investigates the correlation between perceptual motor skills assessed by the LS 500 Virtual Reality Surgical Simulator and the assessment of participants at
an international laparoscopic training course during pelvitrainer sessions.
Methods: 85 participants of the 20th International Gastrointestinal Surgery Workshop
(Davos 2003) performed two trials of a standardized task on the LS 500 Simulator consisting of clipping and cutting the cystic duct and artery. A number of objective performance
parameters, such as time to task, economy of movement (tool tip travel distance) and number of errors were recorded. Additionally, the participants were assessed by the course
instructors during all laparoscopic training sessions according to a structured observation
form. The LS 500 performance measurements were correlated with the assessment during
the pelvitrainer sessions.
Results: Performance on the Simulator was better in the second than in the first trial.
Significant correlation of the performance parameters time to task and economy of movement with the assessment during pelvitrainer sessions was found. This correlation was higher with data from the second than from the first trial.
performance trial 1: mean (range)
regression coefficient trial 1
time to task
4:10 (1:52-7:05)s 2:52 (1:35-7:24)s
task score
38.53 (0-100)
58.55 (0-100)
Travel distance left instrument
1.70 (0.35-6.79)m 1.19 (0.31-3.25)m
Travel distance right instrument
2.46 (0.98-4.39)m 1.78 (0.92-3.89)m
performance trial 2: mean (range)
regression coefficient trial 2
r=-0.409
r=-0.610
r=0.162
r=0.170
r=-0.112
r=-0.778
r=-0.509
r=-0.770
Conclusion: Given a standardized task on the LS 500 Simulator, some of its performance
parameters are a valid assessment of perceptual motor skills relevant in endoscopic surgery. Virtual reality is an important technology in surgical skills assessment and training.
swiss knife 2004; special edition
9
INSERAT
glaxo
03
3.01
D. Zeller, C. Meier, M. Dietrich, A. Platz
Department of Surgery, Stadtspital Triemli, Zurich, Switzerland
The PHILOS for complex fractures of the proximal humerus: is angular stability really the key
to better functional results?
Introduction: Complex fractures of the proximal humerus are difficult to stabilize and secondary displacement due to implant failure is not uncommon. A new generation of implants provide angular stability which increase the grip even in osteoporotic bone. We present our experience with the PHILOS in a group of mainly elderly patients.
Methods: Prospective consecutive case series, starting in 02/2003. Currently, the PHILOS
was used in 54 patients (mean age 68.6 years, range 22-90 years, 30 patients > 70 years)
for fractures of the proximal humerus (AO 11-A2 to 11-C2). Postoperatively the shoulder was
immobilized for 7 days followed by standardized physiotherapy. Outcome was measured
using the Constant score, SF-36 questionnaire and x-ray studies after 6- and 12 weeks, 6
months and 1 year. Until now 42 patients have been followed for at least 6 months. Operation
time, hospital stay, complications and functional outcome were evaluated. Complications
due to implant failure are critically discussed.
Results: Mean operation time was 88 minutes (range 55 to 145 minutes). Mean hospital stay
was 14 days (3 to 26 days). Local complications were observed in 5 patients (9.3 %). One
deep infection was recorded (1.9 %). 3 patients (5.6 %) had to undergo revision surgery due
to implant breakage or secondary fracture displacement with or without penetration of screw
tips into the joint. No AVN has occured yet. Analysis of the Constant score revealed a gradual
improvement between 6-and 12 weeks and 6 months postoperatively (from 51 to 64 and 78
points, respectively). Results at one-year follow-up will be presented as well.
Conclusions: Angular stability provides a better grip even in osteoporotic bone. Nevertheless
secondary displacement and penetration of the screw tips into the joint occurs. These problems can be minimized by additional fixation techniques (additional screws, medial buttressing, tension sutures) and the use of shorter locking screws. Functional results continue to
improve for at least six months after the operation justifying long-term physiotherapy.
3.02
M. Schneider, P. Regazzoni, N. Helmy
Universitätsspital Basel
Erste Resultate der winkelstabilen 3,5/4,5 Metaphysenplatte bei Tibia- und Humerusfrakturen. Eine Analyse von 37 Patienten
Einleitung: Winkelstabile Implantate finden zunehmend Beachtung und werden vor allem
bei osteoporotischem Knochen empfohlen. Wir möchten die präliminären Daten einer prospektiven Studie mit der winkelstabilen 3,5/4,5 Metaphysenplatte vorstellen.
Material und Methode: Prospektive Studie mit Erfassung aller Patienten der chirurgischen
Universitätsklinik Basel, welche vom 1.6.2002 bis 31.1.2004 bei Tibia- resp. Humerusfrakturen mit einer Metaphysenplatte versorgt wurden. Das Kollektiv umfaßte 37 Personen,
davon 16 Frauen (43.2%) und 21 Männer (56.8%), mittleres Alter 54.5 Jahre (Range 18-96
Jahre). Dabei wurden 24 Tibiafrakturen (64.9%) und 13 Humerusfrakturen (35.1%) versorgt. Die 4.5 Metaphysenplatte ist ein winkelstabiles Implantat mit Schrauben der
Dimension 4.5 für den Schaftbereich und 3.5er Schrauben für die Gelenksanteile. Dokumentiert wurden Heilungsrate, Komplikationen und die Klinik. Die Nachkontrollen erfolgten
nach 6 + 12 Wochen, 6 Monate und 1 Jahr postoperativ. Mittlerer Beobachtungszeitraum
11.7 Monate (Range 3-20 Monate).
Resultate: In 97.3% der Fälle zeigte sich eine komplikationslose Frakturheilung. In einem Fall
kam es zu einem Infekt. Bei 4 Personen (11.1%) war eine Osteosynthesematerialentfernung
nötig. In keinem Fall kam es zu einer Pseudoarthrose oder Implantatversagen.
Diskussion: Aufgrund der sehr guten Resultate (97.3%) können wir die Anwendung der winkelstabilen Metaphysenplatte bei Humerus- und Tibiafrakturen empfehlen. Durch die
Winkelstabilität ist das Implantat auch bei stark osteoporotischen Frakturen geeignet, was
aufgrund der sehr guten Ausheilungsraten auch bei sehr alten Patienten gezeigt werden
konnte. Durch ihr Design trägt die Platte im Bereich des medialen Malleolus nicht auf und
erlaubt bei Humerusfrakturen ein weit kraniales Anlegen ohne Impingementprovokation.
3.03
E. Hasenböhler, R. Babst
Kantonsspital Luzern, Chirurgische Klinik A Unfallchirurgie
Minimal invasive perkutane Plattenosteosynthese (MIPO) bei distalen Tibiafrakturen
Fragestellung: Die minimal invasive Plattenosteosynthese (MIPO) wurde seit Einführung der
Locked Compression Plate (LCP) relevant erleichtert. Dieses Implantat erlaubt als Fixateur
interne verwendet, die Fixierung der Frakturen in der „Brückenplattentechnik“ mit konsekutiver sekundärer Knochenheilung über Kallusformation. Heilungsdauer und schmerzlose
Belastbarkeit nach dieser Stabilisierung wurden bei distalen Tibiafrakturen, welche nicht für
eine Nagelosteosynthese qualifizierten, untersucht.
Methoden: Konsekutiv wurden 21 Patienten, 4 Frauen und 17 Männer im Alter von 19 bis 71
Jahre in der Zeit vom Dezember 2001 bis März 2003 in der beschriebenen Technik fixiert.
Die Fraktureinteilung erfolgte gemäss der AO-Klassifikation mit 10 Frakturen Typ 42 A, 3 Typ
B und 8 Typ C Frakturen. Von den 21 Patienten hatten fünf (5) eine II° offene Fraktur, welche
gemäss Gustillo eingeteilt wurden. Die durchschnittliche Operationszeit betrug
86.9min.(60min.-145min.) Eine 4.5 LCP-Platte wurde bei 19 Patienten und eine 3.5 LCPPilon Platte bei 2 Patienten benutzt. Wundheilungsstörungen oder Infekt traten keine auf. 19
Patienten wurden klinisch und radiologisch nach 6 Wochen, sowie 3-6-9 und 12 Monaten
nachkontrolliert. 2 Patienten mit Wohnsitz im Ausland konnten nicht untersucht werden.
Als Frakturheilung wurde die sichtbare Kallusüberbrückung einer Kortikalis, im lat. und ap.
Bild und die klinisch schmerzfreie Vollbelastung definiert.
Ergebnisse: Nach den genannten Kriterien beurteilt, war die Fraktur bei 6 Patienten nach 3
Monaten, bei 4 Patienten nach 6 Monaten und bei 3 Patienten nach 9 Monaten geheilt. Bei
1 Patient war eine Reosteosynthese nach 5 Monaten wegen einer verbogenen Platte notwendig. Alle 19 Patienten waren nach 12 Monaten geheilt.
Schlussfolgerung: Die MIPO Technik hat sich bezüglich der Weichteile und der KnochenBiologie bewährt. Die sekundäre Knochenbruchheilung ist aber speziell bei einfachen
Frakturmustern oft mit länger dauernden Beschwerden im Frakturbereich assoziiert. Auf
diesen Umstand sollten Operateur und Patient vorbereitet sein, wenn distalen Tibiafrakturen
in MIPO Technik und als Brückenplatten-Osteosynthesen durchgeführt werden.
3.04
CH. Sommer, M. Wullschleger, M. Walliser, H. Bereiter, A. Leutenegger
Departement Chirurgie, Kantonsspital, Spitäler Chur AG
Experience with the locking compression plate (LCP) in fracture treatment of osteoporotic bone
Introduction: Operative fracture treatment in osteoporotic bone is problematic. Mechanical
complications as screw loosening with loss of stability are frequent. Implant systems providing angular stability are one solution for better results. The Locking Compression Plate
system (LCP) offers to fix nearly all human bones with plates combined with angular stable
screws. We report our experience with the LCP in osteoporotic bone in the first four years of
application with special attention to the mechanical complications.
Patients and methods: Retrospective study of 90 patients older than 70 years with a fracture treated with a LCP from 2000-2003(total number of LCP fixations: 494). 83x fresh, 7x
pathologic or old fx. 65x upper extr.(20x prox. humerus, 32 distal radius), 25x lower. Followup > 3months: 69/90 patients (= 76.7%). 21x no FU (4x exitus, 6x < 3months, 11x lost).
Results: All 69 fractures healed. 21x complication: 16x mechanical: 9x major (= reoperation): 4x plate breakage (3x femoral shaft, 1x humerus), 3x screw protrusion into joint (all
cases on prox. humerus), 2x construct pull out. 7x minor complication: 3x screw protrusion
into joint (prox. humerus), 2x broken screw (trad. screws), 1x cut through (distal radius), 1x
bent plate. 5x nonmechanical complication: 2x infection, 3x other.
Discussion: Due to the poor bone quality mechanical complications are expected, but astonishingly quite rare seen. The cases with plate breakage are not related to the bone quality
nor the implant system and are caused by technical errors and/or poor patient compliance. The cut through and the screw protusions into the joint however are new complications
not yet seen with traditional small fragment implants and are closely related to the angular
stable system. Adaptation of the surgical technique (partial predrilling and use of shorter,
but higher number of screws in the epiphysis) may reduce the rate of this complication.
Overall the LCP is an excellent system for the stabilisation of fractures in osteoporotic bone
and enables a successful moderne fracture treatment also in the elderly patient.
3.05
DA. Rikli, A. Businger, J. Rosenkranz, R. Babst
Chirurgie A, Kantonsspital Luzern
Dorsal double plating for distal radius fx:
differential indication and experience with 2.4 locking plates
Introduction: treatment concepts for distal radius fractures have changed considerably in
the last years. The advance of locking plates have reinforced the tendency towards operative treatment. Various locking plate systems are currently available. Indications for dorsal,
palmar or combined dorso-palmar approaches are controversial. At our institution a clear
concept for the indication of palmar, dorsal or combined osteosyntheses has been established. In this paper we present our differential indication for dorsal double plating and our
experience with the new 2.4mm Titanium locking plates.
Patients and Method: 22 consecutive patients were prospectively documented. Dorsal
Double Plating was used to treat 18 intraarticular fx and 4 malunited extraarticular fx (early
corrective osteotomy). Standard x-rays were analysed for quality of reconstruction and loss
of reduction. Any complication during the course of treatment was documented. ROM of the
wrist was compared to the contralateral side and the subjective functional outcome was
assessed using the DASH score.
Results: no bone graft was used. All fx healed with no loss of reduction. All were treated by
immediate early function. No intraoperative complication or infection was noted. One algodystrophy healed w/o sequalae. No tendon irritation/rupture occurred. The functional
results were good to excellent in all cases. Implant removal was performed in 4.
Conclusion: there is a clear indication for dorsal double plating in a small subset of distal
radius fx. The method is save and produces predictable results. The amount of tendon problems has decreased compared to earlier series with different implants used for dorsal plating. There is still a rate of 20% implant removal.
swiss knife 2004; special edition
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3.06
2
1
1
1
F. Sorrentino , T. Mitschele , P. Beuchat , C. Sartoretti
Chirurgische Abteilung, Kreisspital für das Freiamt, Muri,
2
Chirurgische Klinik, Kantonsspital Olten
1
Endoscopic carpal tunnel release as a standard treatment for carpal tunnel syndrome:
eight year’s experience with the Chow technique
Introduction: The technique of endoscopic carpal tunnel release (ECTR) for treating carpal
tunnel syndrome (CTS), was developed in the early nineties in an effort to decrease the
most common complications after open procedures like hypertrophic or painful scars
and pillar pain. Skepticism is still expressed by some hand surgeons regarding this technique mainly because of major neurovascular complications and recurrences. Since 1996
we use in the hospital of Muri, the dual portal Chow technique as standard technique for
CTS. With this retrospective study we wanted to evaluate in a large series of patients the
safety and efficacity of ECTR using the Chow technique.
Materials and Methods: Between January 1996 and December 2003, 400 hands in 344
patients underwent ECTR using the Chow technique. The diagnosis based on clinical symptoms, electromyography and nerve conduction velocity tests. Demographic data as well
as objective and subjective data were collected on all patients based on chart review. In
addition we sent a questionnaire to every patient containing questions about general satisfaction of the treatment, duration of pain after operation, return to work after operation,
recurrences and reoperations.
Results: Three cases were converted to open procedure because of complications during the
operation. Two cases were reoperated within 6 weeks after primary operation because of
infection and sensory disorders. Most of the evaluated patients (95%) were completely asymptomatic or had very minor problems after ECTR. The final follow-up is not yet completed, but
most of the patients who sent back the questionnaire were completely satisfied with the procedure.
Discussion: ECTR was introduced in the last decade as a new technique for surgical treatment of CTS. Although many studies have showed a high success rate for the procedure,
there is still major controversy regarding the safety, success and the complication rate of
this procedure. Our study analysed a consecutive series of patients who had surgery by a
single surgeon and the results suggest that ECTR with the Chow technique is a reliable
alternative treatment for CTS and can be done safely.
3.07
F. Got, P. Saudan, M. Rudin, K. Käch
Chirurgische Klinik, Kantonsspital Winterthur
Der Einsatz eines Facharztes als „Notfallmanager“ verbessert die Betreuung der Patienten
auf dem Notfall
Einleitung: Lange Wartezeiten, komplizierte Abklärungen und ein zäher Informationsfluss stellen wesentliche Kritikpunkte am Betrieb in einer Notfallstation dar. Zur Verbesserung der
Patientenbetreuung, wird seit dem 1.9.2003 zu Zeiten mit der höchsten Frequenz an Notfällen
(8-22 Uhr) ein chirurgischer Facharzt als Notfallmanager (NM) eingesetzt. Er nimmt
Zuweisungen entgegen und weist die Fälle nach einer Erstbeurteilung seinen Mitarbeitern (2
Assistenzärzte, 1-2 Unterassistenten) zu. Schon früh werden die Patienten über die weiteren
Schritte orientiert. Die Hausärzte werden telefonisch und schriftlich informiert.
Methode: Vom 1.8.-30.9.2003 traten 1615 Patienten auf die interdisziplinäre Notfallstation
ein, davon 1455 (90%) zwischen 8 und 22 Uhr. 699 Patienten wurden vom Notfallmanager
gemanagt, 786 durch einen Assistenzarzt. Die Patienten wurden in 4 Gruppen eingeteilt:
Ambulante mit niedrigem (A) oder hohem (B) Abklärungs- und Behandlungsaufwand
(Röntgen, Ultraschall, Labor, CT, Gips), nichtoperative (C) oder operative (D) stationäre
Patienten. Die Reduktion der Aufenthaltsdauer steht als Ausdruck für die Effektivität des
Einsatzes des NM. Statistische Analyse mittels t-Test.
Resultate: Die durchschnittliche Aufenthaltsdauer sämtlicher Patientengruppen konnte mit
dem NM um 20% signifikant gesenkt werden (A: 18% 123 vs.101 Min.; B: 26% 139 vs. 102
Min.; C: 20% 216 vs. 172 Min.; D: 21% 205 vs. 161 Min.; p<0.005). Nur noch 50% der ambulanten Patienten waren > 90 Min. auf dem Notfall (Gruppe A: Reduktion um 19%, B um 35%,
p<0.005), bei operativen stationären Patienten dauerten noch 63% der Abklärungen > als
120 Minuten (Gruppe D: Reduktion um 14%, p<0.005). Die Patienten und Zuweiser bewerteten den rascheren Informationsfluss als positiv.
Schlussfolgerung: Organisiert ein Facharzt die Abklärung und Behandlung der Patienten auf
dem Notfall, reduziert dies die Aufenthaltszeit deutlich. Die Zufriedenheit der Patienten und
zuweisenden Aerzte steigt. Da sich andere Faktoren im Notfallbetrieb nicht verändert haben
(z.B. Wartezeiten Röntgen, Ultraschalloder auf Gipsverbände), ist die Reduktion der
Aufenthaltsdauer auf die Tätigkeit des NM zurückzuführen.
3.08
S. Gaum, M. Klaja, P. Rupp, H. Zimmermann
Notfallzentrum Inselspital Bern
Videotaping of trauma patients in the resuscitation room - a useful tool for quality
improvement?
For the outcome of trauma patients diagnostic modalities and therapy are in the first hour
of crucial importance. For quality management purposes a video camera was installed. The
evaluation of the video reviewing occurred by means of questionnaires. The performance of
12
swiss knife 2004; special edition
the teamleader was evaluated in five categories (identification and presence, clear instructions, general overview, fluent sequence according to ATLS and preparation) and three stages (bad, medium and good). The completness and the duration of the primary survey, performance of the log roll and systematic problems were reviewed. From May 2003 to
January 2004 253 trauma patients were treated in the resuscitation room and 37 (15%)
were subsequently videotaped. The small number of videotapes were partially due to nonacceptance by members of the resuscitation team.
Results of all 37 videotapes were as follows; the teamleader was clearly identified in all 37
videotapes. The overview and the clarity of the instructions were 34 times “good” and three
times “medium”, the fluent sequence according to ATLS was judged 26 times as “good”
and 11 times as “medium”, the preparation was in 28 cases “good”, 8 times “medium” and
once “bad”. The average time to primary survey was 2:12 min (min. 0:50 min, max. 4:30
min). The completeness was judged 22 times as “good”, 13 times “medium”. A log roll was
performed in 18 patients, the quality thereby was classified 15 times as “good” and 3 times
as “medium”. Seized systematic errors: in 13 cases (35%) the x-ray apparatus handicaped
the treatment of the patient; 8 times (22%) the different consultants disrupted the arranged
operational sequence by examining the patient before relocating and/or before completing
the primary survey.
Due to the finer details of trauma assessment not being remembered, we considered videorecording as a useful and suitable tool for quality improvement. To augment the usage of
viedotaping the acceptance by the personal staff has to be improved by discussions with all
members of the resuscitation team.
3.09
H. Gelpke, K. Käch, P. Wigger, M. Bär, M. Decurtins
Chirurgische Klinik, Kantonsspital Winterthur
Wie realistisch sind die Operationszeiten des TARMED?
Einleitung: Der TARMED entschädigt den Arzt für Leistungen am Patienten und die Infrastruktur separat. Der TARMED beruht auf dem Prinzip der Minutage, welche vom erfahrenen Facharzt als Leistungserbringer ausgeht. Diese Arbeit überprüft die Minutage des TM
gestuft nach Erfahrung des Operateurs an Schlüsseleingriffen für die Chirurgische
Weiterbildung.
Methode: Es standen die Schnitt-Naht-Zeiten vom 01.01.1998 bis 31.01.2004 von 37’554
Operationen zur Verfügung. Die Operateure wurden in die Kategorien A (Chefarzt,
Leitender Arzt), B (Oberarzt mit FMH) und C (Oberarzt, Assistenzarzt ohne FMH) eingeteilt.
Die Operationen waren durch 51’000 Codes des ICD-9 und Text definiert. Aus dieser
Datenmenge wurden 20 Eingriffe ausgewählt, wovon 17 für die Weiterbildung typisch sind.
Es waren dies Operationen an der Karotis, der Schilddrüse, der Lunge, der Gallenblase, der
Appendix, dem Kolon, bei Inguinalhernien, Varizen, Unterarmfrakturen und Femurfrakturen. So konnten 6939 Operationen eingeschlossen werden.
Resultate: Die Minutage gewichtet nach der Anzahl der Eingriffe wurde im Gesamtkollektiv
um 3.3% überschritten. Operateure der Kategorie A unterschritten sie um 28.3%, der
Kategorie B überschritten sie um 0.8% und der Kategorie C um 18.0%.
Schlussfolgerung: Die Minutage des TARMED ist realistisch und kann von den Fachärzten
realisiert werden. Die in Ausbildung stehenden Chirurgen erreichen die vorgegebenen
Zeiten der Minutage nicht.
04
4.01
D. Lardinois 1, H. Steinert 2, M. Tutic 1, G. Görres 2, R. Stahel 3, W. Weder 1
Division of Thoracic Surgery University Hospital Zurich, 2Division of Nuclear Medicine
University Hospital Zurich, 3Division of Oncology University Hospital Zurich
1
Incidence of non-metastatic extrathoracic lesions detected by whole-body FDG PET-CT
imaging in patients with non-small-cell lung cancer
Background: To assess the incidence and nature of unsuspected extrathoracic focal increased FDG accumulation in patients with non-small-cell lung cancer (NSCLC) staged with
whole-body integrated PET-CT.
Methods: Whole-body integrated PET-CT scans for staging of NSCLC were analysed in a
consecutive series of 300 patients, including 212 men and 88 women, with a mean age of
67 years (range 36-84 years). After application of 350-400 MBq FDG, whole-body PET-CT
was performed (Discovery LS, GE Medical System). Every solitary unsuspected focal abnormality was interpreted as highly suspicious for a metastasis. The true diagnosis was confirmed histopathologically.
Results: PET/CT imaging revealed 99 unsuspected extrathoracic lesions. Beside 62 lung cancer metastases, tumor unrelated focal abnormalities were found in 37 (12.3%) patients,
which represents 37.4% of all the extrathoracic findings. Histopathologic correlation could be
obtained in 89.2% of these 37 patients and revealed 6 malignancies including carcinoma of
the breast in 2 patients, carcinoma of the orbit, oesophagus, prostate, non-Hodgkin lymphoma in one patient each, as well as 27 benign tumors or inflammatory lesions. These 27 lesions consisted of 3 Warthin´s tumors, 1 granuloma of the lower jaw, 1 adenoma of the thyroid gland, 1 compensatory muscle activity due to vocal chord palsy, 2 arthritis, 4 reflux oesophagitis, 2 pancreatitis, 4 diverticulitis, 7 adenomas of the colon, 1 haemorrhoid, and 1 extrauterine pregnancy.
Conclusions: The critical analysis of additional PET positive lesions which may mimic metastases of NSCLC is important for correct staging and optimal therapy.
4.02
A. Meyer 1, C. Antonescu 2, E. Pezzetta 1, A. Bischof Delaloye 2, HB. Ris 1
1
Service de chirurgie thoracique et vasculaire, CHUV, Lausanne,
2
Service de médecine nucléaire, CHUV, Lausanne
Comparative evaluation of intraoperative sentinel lymph node detection in non-small cell
lung cancer (NSCLC) by use of radioisotopic and colourimetric techniques (patent V blue
and fluoresceine)
Objectives: Prospective comparative evaluation of intraoperative sentinel lymph node detection (SLND) by use 99m TC-nanocolloid, patent V blue dye and fluoresceine in patient with
NSCLC with respect to its usefulness and feasibility for clinical application.
Methods: Ten patients (M/F = 6:4, mean age 63 years) with stage I to II NSCLC undergoing
resection and mediastinal lymph node dissection were enrolled. After standard thoracotomy,2 ml of patent V blue dye, 1 ml of 10 % fluoresceine and 1 ml of 99m Tc-nanocolloid (
0,4 mCi) were injected into the peritumoral subpleural tissue. Intraoperative radioactivity
counting and detection of lymph node staining was performed at the level of interlobar (ATS
11), hilar (ATS 10), and subcarinal (ATS 4) nodes, and of paratracheal (ATS 4), aortopulmonar window (ATS 5) and mediastinal (ATS 6) nodes on the right, and left side, respectively.
Mesurements was started 10 minutes after injection and repeated every 10 minutes for 60
minutes. A Wood’s lamp was used for fluoresceine, and a gamma-probe (scinti Probe MR
100®, pol.hi.tech srl, Corsoli, Italy) for radioistopic detection. After completion of the measurements, lobectomy and lymph node dissection was performed.
Results: Concordant findings were obtained by the three different methods, with a progressive increase of hypercaptation of the dyes and radioactivity in the lymphatic tissues, first at
the interlobar, then at the hilar and finally at the mediastinal level. However, no particular
lymph node could be clearly identified by none of these technique in any patient at any time
point assessed within one hour after subpleural peritumoral injection.
4.03
E. Pezzetta 1, TH. Krueger 1, A. Zouhair 2, R. Stupp 3, HB. Ris 1
Sevice de Chirurgie Thoracique et Vasculaire CHUV Lausanne, 2Service de Radio-oncologie
CHUV Lausanne, 3Centre cordonné d’Oncologie CHUV Lausanne
1
Neonadjuvant cisplatin based chemotherapy versus radiochemotherapy for stage III (N2)
NSCLC: comparison of postoperative mortality, mediastinal downstaging and survival
Background: Prospective comparison of neoadjuvant cisplatin-based chemotherapy and
cisplatin – based radiochemotherapy followed by resection in patients with mediastinoscopically proven stage III N2 NSCLC regarding resectability, postoperative morbidity, pathological mediastinal downstaging, survival and DFS.
Methods: Eighty-two patients were enrolled between January 1996 to June 2003, 36 had
cisplatin (100mg/m2) and doxetacel-based chemotherapy (group I) and 46 cisplatinbased radiochemotherapy up to 48 Gy (group II), either with sequential (25 patients) or
concurrent accelerated hyperfractionated (21 patients) radiochemotherapy. All patients
had exclusion of distant metastases by bone scintigraphy, thoracoabdominal CT scan (or
PET scan), and brain IRM, and all underwent pre-induction mediastinoscopy, resection and
mediastinal lymph node dissection by the same surgeon (HBR).
Results: Group I and II comprised T1/2 tumors in 17 and 13 patients, T3 tumors in 16 and 19,
and T4 tumors in 3 and 14, respectively (p=0.01), with a similar distribution of right-sided
pneumonectomy in both groups (9 and10, respectively). There was no difference between
stage IIIA and IIIB patients with respect to overall and disease-free survival. Group I and group
II revealed a postoperative 90-d mortality of 2.8% and 4.3% (ns), a complete (R0) resection
rate of 92% and 93% (ns), mediastinal nodal downstaging (pN0 / pN1) of 62% and 78% of
the patients (p=0.008), a 3y- survival of 53% and 62% (ns) and a 3y-DFS of 34% and 58 %
(p=0.04), respectively. There was no difference in concurrent hyperfractionated accelerated
versus sequential radiochemoinduction with respect to postoperative morbidity, complete
resections, mediastinal nodal downstaging, survival and DSF.
Conclusion: Neoadjuvant cisplatin-based radiochemotherapy was associated with a similar
postoperative mortality, an increased pathological mediastinal downstaging and a better DFS
as compared to cisplatin doxetacel-based chemoinduction in patients with stage III (N2) NSCLC
although a higher number of T4 tumors were admitted to neoadjuvant radiochemotherapy.
4.04
T. Weber, M. Beshay, B. Hoksch, R. Stein, R. Schmid
Inselspital Bern, Devision of General Thoracic Surgery
Incidence and prevention of bronchial stump fistula after pneumonectomy in patients with
and without neo-adjuvant chemotherapy
Objective: Although the incidence of postpneumonectomy bronchial stump fistula (PBSF)
has decreased over recent years, it still represents a serious complication. In this regard the
benefit of surgical techniques to prevent PBSF are discussed controversially. To further clarify this item we analysed different coverage techniques in pneumonectomy patients with
and without neo-adjuvant chemotherapy (NEO).
Material: All 102 patients operated between 1.1.98 and 28.2.03 were included. 73 patients
had surgical therapy alone (group I) and 29 patients received NEO (group II). Following coverage techniques were performed: no coverage (NC), intercostal bundle (IB), pericardial fat
(PF), m. serratus flap (MS) and others (m. latissimus dorsi flap, pericardium, diaphragma,
parietal pleura). RESULTS: Overall 30 day mortality was 2.9% (n=3), in 17 patients (16.6%)
revision thoracotomy due to suspected empyema or PBSF was done, PBSF was finally diagnosed in 7 patients (6.8%). Surprisingly all PBSF were observed in group I without NEO (PBSF
rate 9.5%), Within group I, NC achieved similar PBSF rates (n=1/15, 6.6%) as all coverage
techniques together (6/58, 10.3%). NC was comparable to IB (PBSF 1/19, 5.2%) but considerably better than PF (4/24, 16.6%). The absence of PBSF in neo-adjuvant treated patients
might be attributed to the high percentage of MS coverage (48.2% group II vs. 6.8% group I).
Conclusion: NEO did not increase the risk for PBSF, provided that bronchial stump coverage,
preferably MS, was performed. On the other hand the low PBSF rate in patients without chemotherapy and no bronchial stump coverage may indicate, that individual risk factors or surgical preparation techniques are more important for the development of PBSF than the
applied coverage technique.
4.05
Y. Durmishi, P. Charbonnet, O. Nafidi, A. Spiliopoulos
Hôpitaux Universitaires de Genève
The utility of PET scan in the evaluation of the response to neoadjuvant radio-chemotherapy
of esophageal cancer
Introduction: The purpose of the present study is to prove the utility of the PET scan in the
evaluation of a neoadjuvant treatment of esophageal cancer, as well as to better assess the
operability and the probable effectiveness of a surgical intervention.
Method: The study also draws a comparison between the data obtained from the scintigraphic examination, the radioactive tracers, the echo-endography and the scanner on one hand,
and from the PET scan on the other, in order to determine respondent and non respondent
patients. The study covers a period of 24 months, from January 2000 until December 2002,
and includes 7 male patients. All patients underwent a PET scan before and after radio-chemotherapy. Six out of 7 underwent surgery, and 1 patient showed distant metastasis and had
thus already exceeded the stage for surgery. Once the pathological stage had been confirmed
after operation, the latter was compared to the data collected from a second PET scan after
neoadjuvant chemotherapy, but also to the echo-endoscopic data.
Results: We noted a reduction of the hypermetabolic locus on 3 PET scans, while 3 other
PET scans showed complete disappearance of the hypermetabolic locus. In only one case
the widespread hypermetabolic locus persisted, certainly linked to post-actinic esophagitis.
In other words, these results represent:
- 43% of decrease of the hypermetabolic locus
- 43% of complete disappearance of the locus
- 14% of persistence of the locus.
We have presented the assessment of the pathological stage by means of an echo-endoscopy and histological evaluation, and shown a clear decrease in the pathological stage compatible with the reduction of the hypermetabolic activity as documented by the second PET scans.
Conclusion: We believe that the PET scans is a necessary and efficient examination in the
evaluation of the response or non-response of esophageal cancer to neoadjuvant radiochemotherapy in view of a surgical intervention.
4.06
I. Opitz1, Y. Pan1, T. Krueger1, HJ. Altermatt2, HB. Ris1
1
Department of Thoracic and Vascular Surgery, University Hospital of Lausanne,
2
Institute of Pathology, Berne
Intraoperative photodynamic therapy for malignant pleural mesothelioma:
comparison of mTHPC versus Verteprofine in an experimental setting
Background: Comparison of the clinically approved sensitizers mTHPC (Foscan ) vs
Verteprofine (Visudyne®) for intraoperative intrathoracic photodynamic therapy (PDT) in malignant pleural mesothelioma (MPM) bearing rats (4 goups with n=3) with respect to anticancer activity and tumor selectivity.
Material & Methods: A locally growing MPM tumor was generated in 15 Fischer rats by subpleural mediastinal injection of 0.1ml of 1x106 syngenic malignant mesothelioma cells (II-45) via left
thoracotomy. Focal PDT was performed 5 days after tumor cell implantation (spot size 1.3cm
diameter) through a re-thoracotomy guided by in-situ dosimetry. 6 animals received mTHPC
(0.1mg/kg n=3, 0.2mg/kg n=3.) followed by light delivery of 0.2W/cm2, 20J/cm2 at 652 nm
4 days after i.v. sensitisation. 6 animals received Visudyne® (0,6mg/kg n=3, 1.2mg/kg n=3) followed by PDT (0.1W/cm2, 100J/cm2, 689 nm) 20min after i.v. sensitisation. Autopsy was performed at time of death or 5d after light delivery with histological evaluation.
Results: All 3 control animals revealed 5 days after tumor cell implantation a mediastinal tumor
nodule of 5mm diameter with an infiltrative growth pattern and without spontaneous necrosis.
0.1 and 0.2 mg/kg mTHPC resulted in a 0.5-1mm and 1-2 mm deep coagulation tumor necrosis, respectively. The adjacent normal mediastinal tissues were spared at both drug doses but
interstitial lung fibrosis was observed. 0.6mg/kg Verteprofine resulted in extensive subtotal
tumor necrosis. Adjacent mediastinal organs were not damaged but hemorrhagic necrosis of
the lung was observed. All 3 animals receiving 1.2mg/kg Verteprophine died few hours after
focal PDT, histological assessment revealed massive pulmonary blood congestion.
Conclusions: Focal PDT guided by in situ dosimetry was feasible on locally grown MPM generated by subpleural mediastinal implantation of II-45 cells in syngenic Fisher rats. Both, mTHPC
and Verteprofin resulted in a dose-dependent extent of tumor necrosis while sparing surrounding normal mediastinal structures. The extent of of tumor necrosis and lung injury was more
important after PDT with Verteprofin compared to mTHPC at PDT conditions usually applied
for clinical purposes.
®
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4.07
5.03
MK. Djebalili 1, N. Kritikos 2, G. Sgourdos 2, A. Spiliopoulos 2
1
Geneva University Hospital Cardiovascular Thoracic Unit,
2
Geneva University Hospital Thoracic Unit
K. Skala, G. Zufferey, J. Robert-Yap, B. Roche
Unité de Proctologie Hôpital Universitaire Genève
Postpneumonectomy syndrome treated by implantation of expandable prosthesis
Introduction: Postpneumonectomy syndrome is a late complication occurring almost exclusively after right pneumonectomy. The syndrome is caused by excessive shifting of mediastinal structures into the right hemithorax, leading to tracheobronchial compression, progressive dyspnea, stridor and recurrent pulmonary infections. The diagnosis can be made
by bronchoscopy and Computed Tomography.
Methods & Results: We report two cases of this entity, a 62-year and 66-year-old men who
presented the syndrome 3 and 2 years, respectively, after they had undergone right pneumonectomy because of lung cancer with no signs of malignancy relapse.Treatment consisted in surgical implantation of an expandable prosthesis in the empty cavity. An anatomic
correction of the shifted mediastinum was achieved, which in both cases resulted in functional improvement and Considerable symptomatic relief.
Conclusion: The implantation of an intrathoracic prosthesis can dramatically improve the
clinical symptoms and reduce the functional obstructive syndrome. The expandable prosthesis allowed well tolerated recentring of the mediastinum, avoiding a developpement of
tracheobronchial malacia.
05
5.01
K. Skala, G. Zufferey, J. Robert-Yap, B. Roche
Unité de Proctologie Hôpital Universitaire de Genève
La colpomyorraphie postérieure étendue
Les rectocèles symptomatiques peuvent répondre à un traitement chirurgical. La classification en trois stades de cette maladie permet d’associer à chaque stade un type d’intervention. Le type II qui est représenté par une rectocèle volumineuse intéressant tout le septum
rectovaginal avec début d’intussusception de la paroi rectale antérieure est corrigé par colpomyorraphie postérieure étendue. Cette intervention est réalisée par un abord vaginal en
incision arciforme au niveau de l’hymen afin de ne pas générer une nouvelle cicatrice au
niveau de la paroi postérieure du vagin. La dissection large doit être menée jusqu’au niveau
du cervix ou du cul-de-sac postérieur du vagin. La dissection doit s’étendre latéralement afin
de mettre en évidence les muscles releveurs de l’anus sur toute leur hauteur. A l’aide de
points séparés de Maxon 2.0 GU 46, on procède à une raphie des muscles releveurs de
l’anus sans tension. Les deux premiers points prennent en triangulation la paroi antérieure
du rectum afin de la fixer, pour ne pas transformer une rectocèle en un prolapsus anal
muqueux antérieur.
Nous avons pratiqué durant ces dix dernières années 564 colpomyorraphies postérieures
étendues. Les complications sont essentiellement de type hémorragique et de déhiscence
de la suture muqueuse. Les résultats fonctionnels montrent une disparition de la dyschésie
dans 93% des cas, une disparition de l’incontinence dans 97% des cas. Un collectif prospectif de 333 patientes avait mis en évidence une activité sexuelle conservée chez 95% de
ces patientes. Le suivi à long terme de ce même collectif démontrait une récidive dans 7%
des cas.
Conclusion: La colpomyorraphie postérieure étendue permet de corriger la rectocèle de
type II, ainsi que les troubles fonctionnels qui lui sont associée.
5.02
FH. Hetzer, D. Hahnloser, Y. Knoblauch, PA. Clavien, N. Demartines
University Hospital Zurich, Visc.& Transpl. Surgery
How we do it: sacral nerve stimulation
Sacral nerve stimulation (SNS) is a new promising therapy for patients with urinary and
bowel incontinence. Originally, the procedure was described in a three-step procedure: 1)
percutaneous nerve evaluation test (PNE) and temporary stimulation (screening) with a
test electrodes, 2) replacement of test electrodes by permanent electrodes and 3) permanent implantation internal pulse generator (IPG). Recently, modifications in the introducing
set and in the electrode allow to perform the SNS in a minimal invasive two step-procedure
and in local anaesthesia.
The two-step technique of SNS with the PNE and the implantation of permanent tined lead
is described. The first step take place in prone position and under latero-lateral pelvic fluoroscopy. A foramen needle and later the tined lead are inserted. Then the tunellisation and
the connection of the electrode to the external stimulator is presented. In a second step, by
patient with at least a 50% reduction of symptoms at the end of the screening phase, the
definitive implantation of the IGP is demonstrated.
Between May 2001 and January 2004, 28 PNE tests in 22 patients (12 women) were performed, median age was 58 years (range 32-86). In all but one patient, PNE was successfully. After the screening phase the IPG was implanted in 13 patients (65 %). We had no
infection, but one subcoutaneous seroma around the stimulator pocket, which needed an
intervention in local anaesthesia.
Both, PNE testing and implantation of the permanent electrode can be easily and safely performed at the same time and under local anaesthesia.
14
swiss knife 2004; special edition
La liberation du nerf honteux interne par voie transgluteale dans le syndrome d’al coock
La compression du nerf honteux interne se traduit par des douleurs systématisées, répétitives, majorées à la position assise de la région périnéale. Le diagnostic repose sur l’infiltration du nerf honteux à l’aide d’anesthésiques locaux. En cas de non-guérison après deux
infiltrations, une chirurgie de libération est proposée.
La chirurgie est menée par voie transglutéale postérieure pour mettre en évidence le ligament sacro-tubéreux qui est réséqué, puis le nerf honteux interne qui passe en chevalet audessus du ligament sacro-épineux. Le ligament sacro-épineux est sectionné, afin de pouvoir transposer le nerf honteux interne dans une position endo-pelvienne. En fin d’intervention, le fascia du canal d’Alcock est largement ouvert afin de libérer le nerf honteux dans toutes les zones où il pourrait être comprimé.
De 2001 à 2003, nous avons réalisé 12 libérations du nerf honteux. Nous nedéplorons
aucune complication. la symptomatologie douloureuse a disparu chez 9 patients.
En conclusion, la libération du nerf honteux interne par voie transglutéale est une intervention qui offre de bons résultats avec peu de complications.
5.04
H. Fehsenfeld, D. Hahnloser, PA. Clavien, N. Demartines, FH. Hetzer
University Hospital Zurich, Visc.&Transpl. Surgery
Treatment of chronic anal fissures with fissure excision and botulinum toxin type A injection
80% of acute anal fissures heal spontaneously or with conservative local therapy (nitro-glycerine cream). In contrast, chronic fissures are often resistant to conservative treatment,
and currently lateral internal sphincterotomy is considered by many to be treatment of choice. This procedure is however associated with the risk of permanent incontinence up to
10%. An alternative is the combination of fissure debridement and injection of Botulinum
Toxin Type A (BTA) without damage to the sphincter.
The technique of fissure debridement and injection of BTA is described. In modified lithotomy position and under general or spinal anaesthesia, the lateral margins of the anal fissure are excised in a triangle form and the floor of the fissure is cleaned with a sharp spoon.
Haemostasis if necessary is performed by electro coagulation. 100 IE of BTA are dissolved
in 2ml NaCl. 2 x 0,2ml of this solution (=2x 10 IE BTA) are injected with a small insuline
syringe and a 25 G needle just left- and right-lateral to the excised fissure into the internal
sphincter muscle. Postoperatively, stool regulation is recommended for at least 6 weeks.
The patients are discharged the same day.
Since 2001, we treated 45 out of 48 patients successfully with this technique. Only 3
patients required further interventions. We conclude that excision of the fissure and injection of BTA is a safe and reproducible treatment of chronic anal fissure without risk of
sphincter damage.
5.05
K. Skala, G. Zufferey, J. Robert-Yap, B. Roche
Unité de Proctologie Hôpital Universitaire de Genève
Technique du lambeau muqueux dans la cure des fistules anales
trans- et suprasphincteriennes
Le traitement d’une fistule comporte l’exérèse de tous les trajets fistuleux et de l’orifice de
drainage secondaire. Lorsque cette fistule passe au travers du plan musculaire, le traitement chirurgical peut entraîner une incontinence anale irréversible. La technique du lambeau muqueux a pour avantage de pratiquer l’excision de tout le tractus fistuleux, de l’orifice primaire, sans léser l’appareil sphinctérien. Cette vidéo démontre comment par dissection progressive, il est possible de pratiquer l’excision du trajet fistuleux au travers de l’appareil sphinctérien sans léser ce dernier. Une reconstruction après excision de l’orifice primaire, de la paroi musculaire et d’un abaissement d’un lambeau muqueux au-delà de la suture musculaire permettent une guérison de ces fistules dans 89,2%. On observe donc 10,8%
de récidives. En cas de récidive, il est toujours possible de répéter cette intervention. Notre
collectif de 153 patients montre 3 incontinences aux gaz temporaires, une incontinence
persiste en raison de la rigidité du canal anal due à la scarification des tissu suite à 11 opérations antérieures.
Conclusion: La technique du lambeau muqueux permet de traiter les fistules complexes, Le
taux de récidives est 11% et les résultats fonctionnels sont excellents.
5.06
G. Zufferey, J. Robert, K. Skala, B. Roche
Unité de Proctologie Hôpital Universitaire de Genève
Recronstruction sphincterienne par overlapping pour incontinence post obstetricale
L’incontinence post obstétricale représente 80% de toutes les incontinences anales. La lésion intéresse le sphincter interne et/ou externe. Sa localisation son étendue sont précisées
par l’échographie endo-anale. La vidéo démontre la technique de reconstruction du
sphincter par overlapping en insistant sur une dissection peu traumatique, menée suffisamment loin sur les lambeaux musculaires déchiquetés afin de permettre une apposition de
ces derniers et un chevauchement d’au moins 1 cm. La reconstruction doit être effectuée
sur toute la hauteur du canal anal, c’est-à-dire sur plus de 3 cm, afin d’obtenir un résultat
post opératoire satisfaisant en ce qui concerne l’incontinence.
En 10 ans, nous avons pratiqué 307 reconstructions sphinctériennes pour lésions post
obstétricales. La récupération de la continence complète est obtenue dans 87% des cas.
Les complications sont le fait de rupture secondaire de la reconstruction par passage de
fécalome chez deux patientes, d’abcès dans deux cas, de fistule une fois, de déhiscence de
la suture cutanée dans 17% des cas.
Conclusion: La reconstruction du sphincter par la technique de l’overlapping est une chirurgie fine, qui donne de bons résultats pour autant que les règles de chevauchement des lambeaux musculaires et de reconstruction de toute la hauteur du canal anal soient respectées.
5.07
PA. Clavien, L. McCormack, M. Selzner
University Hospital Zurich, Visc.&Transpl. Surgery
Central hepatectomy with total vascular occlusion
Large liver tumors in a central location often present a technical challenge for
liver resection. Tumor involvement of the vena cava or the proximal hepatic veins
are associated with a high risk for intra-operative bleeding despite vascular
inflow occlusion. To minimize the bleeding risk in these patients total vascular
exclusion of the liver may be indicated.
Case presentation: A 63-year-old patient with chronic hepatitis B presented with
non-specific upper abdominal pain. An abdominal CT demonstrated a large liver
mass in the segments IV, V, VIII. Angiography revealed a hyper-vascularized
tumor showing the features of a hepatocellular carcinoma (HCC). AFP was normal. The lesion was initially chemo-embolized and after mild downstaging was
scheduled for a central hepatectomy.
The abdominal cavity was opened through a bi-subcostal incision. The liver was
mobilized and the hepato-duodenal ligament encircled. The supra- and infrahepatic vena cava were isolated and the right adrenal vein was ligated. Total vascular occlusion was performed by clamping the portal vein, hepatic artery, and
the supra- and infrahepatic vena cava. Parenchyma transsection was performed
using the Kelly clamp technique and bipolar forceps under a total ischemia time
of 25 minutes. Histology evaluation demonstrated a HCC without vascular invasion and tumor free margins. The postoperative course was uneventful and the
patient was discharged 7 days after surgery, and tumor free at 1 yr.
Conclusion: Total vascular occlusion remains an important technique to safely
perform difficult central hepatectomy or for large tumors involving the vena cava
or the hepatic veins. Parenchyma transsection can be performed with minimal
blood loss and excellent control of the venous structures. The ischemia time
should be below 60 minutes to avoid irreversible liver injury.
5.08
PA. Clavien, L. McCormack, M. Selzner
University Hospital Zurich, Visc.&Transpl. Surgery
Resection of advanced hepatocellular carcinoma with thrombus
in the portal vein and hepatic duct.
Prognosis of hepatocellular carcinoma (HCC) with tumor thrombus in the main portal vein,
inferior vena cava, or extrahepatic bile duct treated by conventional therapies is poor, although surgical resection remains the best therapeutic option for these patients.
Case presentation: A 23-year-old woman was referred to us with obstructive jaundice and
intermittent fever. The CT scan showed a central liver tumor with vascular invasion of the
hepatic pedicle and intrahepatic dilatation of the bile ducts. The alpha-fetoprotein level was
19.800 ng/ml and serology for hepatitis B infection was positive. Pre-operative endoscopic
biliary stent was placed in order to reduce cholestasis of the remnant liver after resection.
Preoperative staging showed absence of extra-hepatic disease. With the diagnosis of
advanced HCC the patient was scheduled for surgery.
Explorative laparoscopy excluded peritoneal carcinomatosis and lymph node metastasis in
the hepatic pedicle. Intra-operative ultrasound showed a central liver tumor with thrombosis
of the right and main portal vein and common hepatic duct. We decided to perform a right
hemi-hepatectomy with complete resection of the extra-hepatic biliary tree. A thrombectomy
with partial resection of the main portal vein was performed with direct reconstruction.
Biliary reconstruction with hepato-jejunostomy using a Roux-en-Y was performed. Histology
confirmed the diagnosis of HCC with macroscopic vascular invasion. Postoperative outcome was uneventful with normal liver test 3 months after surgery.
Conclusions: When feasible, surgical resection for HCC with vascular and biliary invasion
offer the best quality of life in patients with advanced disease. These procedures should be
done only in high volume centers offering low mortality and morbidity rates.
5.09
F. Dahm, M. Weber, M. Selzner, L. McCormack, PA. Clavien
University Hospital Zurich, Visc.&Transpl. Surgery
Laparoscopic liver resections: experience in 13 cases
Background: Laparoscopic techniques have not been widely applied to liver surgery due to
safety and technical issues. Yet in selected cases, especially when a minor hepatic resection would necessitate a relatively large laparotomy, laparoscopic liver resections are indeed
feasible and larger numbers are being reported.
Method: Since June 2002 we selected 13 cases for laparoscopic resection of hepatic lesions. Median age was 45 years (26-78) and 12 patients had normal liver function. Standard
liver workup was supplemented by intraoperative ultrasound in each case. Laparoscopic
resections (8 left bi-segmentectomies, 4 wedge resections, 1 cyst deroofing) were performed by an experienced team of hepatobiliary and laparoscopic surgeons, using ultracision,
tissulink, clips, vascular stapler and argon beam. Hepatic inflow occlusion was done in 9
cases. All specimens were evacuated with an endobag. No conversion to open surgery
were necessary. Histological diagnosis were FNH (5), hemangioma (2), adenoma (1),
retention cyst (1), biliary hamartoma (1), HCC (1) and metastatic carcinoid (1), i.e. only 2
patients had an underlying malignancy.
Results: There was one intraoperative (pneumothorax) and one postoperative complication
(pneumonia and effusion). No liver specific complications ocurred. ALT and AST peaked at
a median of 92 (47-291) and 163 (53-301), while bilirubin and quick were almost unchanged. Patients were discharged after a median of 4 days (2-13).
Conclusion: Laparoscopic hepatic surgery is an excellent treatment modality for highly
selected cases, and is associated with low morbidity and early hospital discharge. Benign
lesions in the left lateral and anterior liver segments or superficially located are clear indications for laparoscopic resection. The role of laparoscopic resections in malignant lesions
still needs to be defined. Advanced skills in hepatobiliary and laparoscopic surgery are needed, supplemented with advanced technical infrastructure. For this reason laparascopic
liver surgery should be restricted to specialized centers.
5.10
N. Halkic, N. Koch, D. Gintzburger, R. Ksontini, K. Z’graggen
Service de Chirurgie Viscerale et Transplantation, CHUV, Lausanne
Laparoscopic treatment of giant solitary nonparasitic symptomatic biliary cysts
Introduction: Although hepatic cysts are frequent and usually clinically silent, large cysts
may become symptomatic. Different treatment options for symptomatic, benign and nonparasitic hepatic cysts have been proposed: enucleation, fenestration, deroofing or hepatic
resections. The aim of the study was to analyse the technical feasibility and safety of these
procedures by laparoscopy, and to evaluate the outcome on follow-up.
Results: Between September 1994 and December 2003, 15 patients underwent laparoscopic hepatic surgery for benign cystic lesions. Eleven patients had one solitary cyst, two had
two cysts and two had three cysts. There were eight males and seven females (mean age
56.4 years). Hydatic disease was excluded serologically and radiologically. The mean diameter of the cysts was 60.5 mm (30-170mm). The mean operative time was 105 min and
the mean postoperative hospital stay was 4.5 days. There was no mortality. During a mean
follow-up of 24 months (range 3-78), one patient had to be reoperated for a recurrence of
the cyst 4 months after surgery.
Discussion and conclusion: laparoscopic hepatic surgery (laparoscopic fenestration or
wide resection) may be the treatment of choice for solitary symptomatic hepatic cysts.
Surgery remains indicated only in case of severe symptoms or rapid growth of the lesion.
swiss knife 2004; special edition
15
6.01
06
M. Selzner1, TF. Hany 2, P. Wildbrett 1, L. McCormack 1, Z. Kadry 1, PA. Clavien 1
University Hospital Zurich, Visc.&Transpl. Surgery, 2University Hospital Zurich, Nuclear
Medicine
1
Change of treatment strategy for colorectal liver metastasis
by a novel PET/CT imaging technique
Background: Positron emission tomography (PET) has been used in combination with the
ceCT to improve evaluation of intra- and extrahepatic tumors in these patients. In this study
we compared ceCT and a novel fused PET/CT technique in patients evaluated for liver resection for metastatic colorectal cancer.
Material and Methods: Between April 2001 and July 2003 all patients evaluated for resection of liver metastases from colorectal cancer were entered into a prospective database. All
patients received a ceCT and a PET/CT. Both examinations were evaluated independently
by a radiologists/nuclear medicine physician. The sensitivity and the specificity of both tests
regarding the detection of intrahepatic tumor load, extra/hepatic metastases, and local
recurrence at the colorectal site were determined. As the main endpoint of the study we
determined the impact of the PET/CT findings on the therapeutic strategy.
Results: Seventy-six patients with a median age of 63 years were included in the study.
Comparable findings were provided by the ceCT and PET/CT for the detection of intra-hepatic metastases with a sensitivity of 95% and 91%, respectively. PET/CT was superior in establishing the diagnosis of intra-hepatic recurrences in patients with prior hepatectomy (specificity 50% vs 100%, p= 0.04). Local recurrences at the primary colo-rectal resection site
were detected by ceCT and PET/CT with a sensitivity of 53% and 93%, respectively (p=
0.03). Extra-hepatic disease was missed in the ceCT in one-third of the cases (sensitivity
64%), while PET/CT failed to detect extrahepatic lesions in only 11% of the cases (sensitivity 89%) (p= 0.02). In 21% of the patients the therapeutic strategy was changed because of
new findings in the PET/CT.
Conclusion: PET/CT is superior to ceCT for the detection of recurrent intra-hepatic tumors
after hepatectomy, extra-hepatic metastases and local recurrence at the site of the initial
colorectal surgery. PET/CT is now routinely performed at our institution in all patients evaluated for liver resection for metastatic colorectal cancer.
6.02
P. Wildbrett 1, H. Petrowsky 1, M. Schäfer 1, W. Jochum 2, T. Hany 3, PA. Clavien 1
1
University Hospital Zurich, Visc.&Transpl. Surgery, 2University Hospital Zurich, Pathology,
3
University Hospital Zurich, Nuclear Medicine
Integrated positron-emission tomography and computed tomography (PET/CT) in gallbladder and bile duct cancer
Introduction: The overall prognosis of malignant tumors of the intrahepatic biliary tree, extrahepatic bile duct and gallbladder remains poor. Therefore, better staging modalities are
urgently needed. Integrated positron-emission tomography and computed tomography
(PET/CT) is a new imaging modality that provides both anatomic and metabolic information of tumors. The goal of this study was to assess the metabolic activity, localization and
extension of the biliary tumor by PET/CT.
Methods: From May 2000 to May 2003 each patient who was treated for a malignancy of
the biliary tree at our institution had a PET/CT in addition to the standard work-up imaging.
The data of these patients were reviewed from a database and analyzed according to the
endpoints. Only those patients were analyzed whose tumor was histologically proven by
surgical resection specimen, biopsy or brush cytology. All imaging and data acquisition
were performed with a combined PET/CT inline system that was able to acquire CT images
and PET data for the same patient in one session.
Results: 38 patients with primary malignancies of the biliary tree were analyzed. Seventeen
patients had extrahepatic bile duct cancer (Klatskin tumor n=9, middle bile duct n=6, papilla vateri n=2), 10 patients intrahepatic cholangiocarcinoma and 11 patients gallbladder
cancer. All 11 patients with gallbladder cancer had a high FDG uptake into the tumor. High
specific FDG uptake of the tumor was observed in 8/17 extrahepatic bile duct cancers and
9/10 patients with intrahepatic cholangiocarcinomas. Sensitivity of PET/CT in gallbladder
cancer (100%) and intrahepatic cholangiocarcinoma (90%) was significantly different
compared to extrahepatic bile duct cancer (47%) (p=0,003).
Conclusion: These new and encouraging data demonstrate that PET/CT is an useful diagnostic tool for gallbladder cancer and intrahepatic cholangiocarcinoma to identify the primary tumor site. This may facilitate staging and resectability of these tumors. In contrast,
PET/CT of extrahepatic bile duct cancer had a low sensitivity to detect the primary tumor
and should therefore not be considered for the work-up of these tumor types.
6.02
P. Wildbrett 1, H. Petrowsky 1, M. Schäfer 1, W. Jochum 2, T. Hany 3, PA. Clavien 1
1
University Hospital Zurich, Visc.&Transpl. Surgery, 2University Hospital Zurich, Pathology,
3
University Hospital Zurich, Nuclear Medicine
Integrated Positron-Emission Tomography and Computed Tomography (PET/CT) in
Gallbladder and Bile Duct Cancer
Introduction: The overall prognosis of malignant tumors of the intrahepatic biliary tree, extrahepatic bile duct and gallbladder remains poor. Therefore, better staging modalities are
16
swiss knife 2004; special edition
urgently needed. Integrated positron-emission tomography and computed tomography
(PET/CT) is a new imaging modality that provides both anatomic and metabolic information of tumors. The goal of this study was to assess the metabolic activity, localization and
extension of the biliary tumor by PET/CT.
Methods: From May 2000 to May 2003 each patient who was treated for a malignancy of
the biliary tree at our institution had a PET/CT in addition to the standard work-up imaging.
The data of these patients were reviewed from a database and analyzed according to the
endpoints. Only those patients were analyzed whose tumor was histologically proven by
surgical resection specimen, biopsy or brush cytology. All imaging and data acquisition
were performed with a combined PET/CT inline system that was able to acquire CT images
and PET data for the same patient in one session.
Results: 38 patients with primary malignancies of the biliary tree were analyzed. Seventeen
patients had extrahepatic bile duct cancer (Klatskin tumor n=9, middle bile duct n=6, papilla vateri n=2), 10 patients intrahepatic cholangiocarcinoma and 11 patients gallbladder
cancer. All 11 patients with gallbladder cancer had a high FDG uptake into the tumor. High
specific FDG uptake of the tumor was observed in 8/17 extrahepatic bile duct cancers and
9/10 patients with intrahepatic cholangiocarcinomas. Sensitivity of PET/CT in gallbladder
cancer (100%) and intrahepatic cholangiocarcinoma (90%) was significantly different
compared to extrahepatic bile duct cancer (47%) (p=0,003).
Conclusion: These new and encouraging data demonstrate that PET/CT is an useful diagnostic tool for gallbladder cancer and intrahepatic cholangiocarcinoma to identify the primary tumor site. This may facilitate staging and resectability of these tumors. In contrast,
PET/CT of extrahepatic bile duct cancer had a low sensitivity to detect the primary tumor
and should therefore not be considered for the work-up of these tumor types.
6.03
N. Selzner 1, Z. Kadry 1, B. Pestalozzi 2, M. Selzner 1, L. McCormack 1, PA. Clavien 1
University Hostpital Zurich, Visc.&Transpl. Surgery, 2University Hospital Zurich, Oncology
1
Impact of concomitant unilateral portal vein ligation on selective intra-arterial chemotherapy
for downstaging of liver metastasis from colorectal cancer
We previously reported on the effectiveness of intra-arterial chemotherapy for downstaging of
unresectable colorectal liver metastases. We designed a pilot study to evaluate the effects of concomitant unilateral portal vein ligation (PVL) with selective intra-arterial chemotherapy on (1)
safety, (2) ability to induce contra-lateral hypertrophy, (3) tumor growth and (4) resectability.
Methods: Eleven patients with unresectable liver metastases were included. Selective chemotherapy was delivered using a pump device via a catheter placed in the gastro-duodenal artery. Each patient underwent concomitant unilateral PVL of the hemi-liver judged to have the higher tumor load. Patients were evaluated by CT scan every 3 cycles. Response to chemotherapy was defined by a decrease of tumor size by at least 30%. The results were compared to
those obtained in a similar group of patients previously reported without unilateral PVL.
Results: There were no surgical complications due to the surgery. All patients developed contra-lateral hypertrophy and significant atrophy of the “deportalized” hemiliver. No patient developed an increase in tumor load. Six of 11 patients (63%) had a response to chemotherapy in the
liver at 3 months. In 4 patients (36%) downstaging enabled curative resection after only 3
cycles of chemotherapy. All of these patients are currently alive and tumor free, with at least one
year of follow up. Compared to the previous group of 23 patients treated with a similar regimen
without PVL, the new strategy significantly shortened the timing between initiation of chemotherapy and resection (3 vs 11 months, p<0.01), with a trend toward increased resectability.
Conclusion: The combination of PVL with intra-arterial chemotherapy appears safe and is
associated with major atrophy of the “deportalized” hemiliver with contralateral hypertrophy. No negative impacts on tumor growth was observed, and the resectability rate was
superior to previously reported patients treated without PVL. The main advantage appears
to be a dramatic decrease in length of therapy prior to resection.
6.04
M. Selzner 1, N. Selzner 1, W. Jochum 2, PA. Clavien 1
University Hospital Zurich, Visc. & Transpl. Surgery, 2University Hospital Zurich, Pathology
1
Increased ischemic injury in the old mouse liver. A novel pathway of injury
Elderly people are currently more subject to liver surgery. However, the effect of age on ischemic/
reperfusion injury of the liver is unknown. Furthermore, the beneficial effect of ischemic preconditioning as a protective strategy against ischemic injury of old livers is not yet determined.
Methods: 60 minutes ischemia of the liver with or without ischemic preconditioning was
performed in C57BL/6 mice of 6 and 60 weeks of age. Some old mice were pretreated with
0.3ml Glucose 10% prior to ischemic preconditioning. Glycogen and ATP content of the liver
was determined by bioluminescence assay. Liver injury was evaluated by AST release.
Apoptosis was determined by TUNEL staining and caspase 3 activity.
Results: Young mice had 4-fold higher glycogen content in the liver than old mice prior to
surgery (6 vs 1.5 mg/ml) and at the end of reperfusion (1.84 vs 0.25 mcg/ml). Livers from
young mice had a significantly higher ATP content when compared with the old group prior
to surgery (0.85 vs 0.4 nmol/mg) and 4hr after reperfusion (0.6 vs 0.23 nmol/mg). Old
mice had significantly higher AST levels (12500 vs 8200 U/L; p<0.05) and caspase 3 activity (98 vs 67 AUF/mg; p= 0.04) after 4hr of reperfusion than young mice. In addition, old
mice had significantly more TUNEL pos. hepatocytes (55% vs 77%; p<0.05). Ischemic preconditioning in young mice resulted in a decrease of AST release (3200 vs 8200 U/L),
caspase 3 activity (39 vs 67 AUF/mg) and TUNEL staining (15% vs 55%). In contrast, ischemic preconditioning did not protect the old mice. Injecting glucose prior to preconditioning
into old mice significantly increased the intrahepatic ATP levels (0.5 vs 0.25 nmol/mg) with
a dramatic decrease of injury. Furthermore, old mice with glucose treatment prior to preconditioning developed less necrosis than old mice without glucose application (15% vs 60%).
Conclusion: Old livers have a lower energy state than young livers. Pretreatment of old mice
with glucose prior to preconditioning increases the hepatic energy state and results in
strong protection of preconditioning against reperfusion injury.
6.05
L. Marti, C. Marti, M. Zünd, J. Lange
Department of Surgery, Kantonsspital St. Gallen, Switzerland
13 years of surgical therapy of pancreatic carcinoma: a review
Background: In the Western world pancreatic carcinoma is the fourth frequent cause of
death in patients with malignant tumours, and postoperative 5-year survival rates > 20%
are rare. Despite this, surgical therapy offers the only chance of cure. It is therefore our
objective to analyse our own results.
Method: We examined the outcome for the 272 patients with pancreatic carcinoma who
have received treatment with us since the beginning of 1991. Our main interest was focused on such aspects as median survival rate, postoperative lethality, complications, recurrences and quality of life. We searched our electronic patient database, studied case histories, contacted the patients’ general practitioners, studied cancer registries and examined
the surviving patients. The histological results showed 224 cases of ductal adenocarcinoma, 22 neuroendocrine and 15 periampullary carcinomata. In 122 patients a partial duodenopancreatectomy was performed, 36 patients received a different curative resection,
and palliative bypass surgery was performed in 71 patients. The remaining 43 patients
received palliative chemotherapy.
Results: 30-day lethality after curative surgery was 3.8%. The 5-year survival rate following
Whipple’s operation was 22%, 24% after R0 resection and rose to 41% in patients without
lymph node involvement. Partial duodenopancreatectomies in the case of neuroendocrine
carcinoma showed a significantly better prognosis with a 5-year survival rate of 63%. The 5year survival rate of patients without neuroendocrine carcinoma was 17% after such operation. The median survival time after palliative surgery was 7 months vs. 8 months in patients
without surgery.
Conclusion: Although adenocarcinoma of the pancreas has a bad prognosis, therapeutic
nihilism is pointless at the curative operative stage. After all, an median survival time of 35
months can be achieved in patients with N0 stage. Further research will have to prove if neoadjuvant radio- and chemotherapy lead to significantly better results. Palliative bypass surgery does not contribute to better survival and should be performed in symptomatic
patients only.
6.06
F. Volonte, D. Azagury, PH. Morel, F. Terrier, O. Huber
Clinique et Policlinique de Chirurgie viscérale, Hôpitaux Universitaires de Genève
Histore naturelle de la hernie hiatale para-oesophagienne:
chirurgie systématique pour chaque cas?
Plusieurs auteurs affirment que la chirurgie est indiquée pour chaque patient chez qui le
diagnostic de hernie hiatale para-oesophagienne (HHPO) est posé, à cause des risques de
complication et du taux élevé de mortalité en cas de chirurgie en urgence. Ces conclusions
découlent d’études de séries chirurgicales, de sorte que le vrai risque lié à la HHPO dans la
population reste inconnu.
Nous avons interrogé la banque de données automatisée de notre service de radiologie en
cherchant tous les patients chez qui le diagnostic de HHPO avait été posé pendant ces 10
dernières années. L’histoire médicale de ces patients après diagnostic a été obtenue par
des questionnaires téléphoniques structurés. Les symptômes digestifs spécifiques ont été
évalués grâce au Gastro-Intestinal Quality of Life Index (GIQLI).
140 patients ont été identifiés. Le suivi a pu être obtenu pour 128(91%). 7 patients présentant des hernies par glissement pures ont été exclus. 121 patients avec HHPO confirmée et
une histoire médicale complète après le diagnostic forment notre groupe d’étude.
L’âge moyen au moment du diagnostic était de 69+/-13 ans. Le suivi moyen était de 71+/78 mois. Le score moyen du GIQLI était 112+/-15. 28 patients avec un GIQLI < 100 ont été
identifiés comme significativement symptomatiques. Les symptômes typiques de reflux
étaient graves dans 21 cas, la dysphagie dans 7 et les douleurs rétro sternales dans 6. 8
patients ont été opérés, 5 sévèrement symptomatiques en conditions électives et 3 en
urgence (1 décès).
Le risque de complication aiguë menant à la chirurgie en urgence était alors de 2,5% après
72+/-80 mois pour les 116 patients observés. La mortalité liée à la HHPO était de 0,8%
dans ce groupe. Le risque de décès lors d’observation est tout à fait comparable au risque
rapporté dans des séries récentes de chirurgie élective pour HHPO réalisées chez des
patients choisis. Une attitude expectative après diagnostic de HHPO semble alors justifiée.
6.07
R. Rosenthal, R. Peterli, MO. Guenin, B. Kern, P. Tondelli, M. von Flüe, C. Ackermann
Chirurgische Abteilung, St. Claraspital Basel
Would you undergo surgery again? Long-term results after laparoscopic fundoplication
Introduction: The evaluation of patient satisfaction and quality of life is a central issue of qua-
lity control after laparoscopic fundoplication. In the study presented, all patients after laparoscopic fundoplication since its introduction in 1992 were questionned about their actual
complaints and quality of life.
Methods: Between 1.1.1992 and 31.12.2002 (11 years), a total of 186 laparoscopic fundoplications were performed. Apart from the retrospective evaluation of details of surgery, all
patients were sent a questionnaire on their actual complaints and quality of life according
to the Gastrointestinal Quality of Life Index (GIQLI 1,2).
Results: The mean follow-up time was 4.6 years. The most frequent preoperative symptom
under medical therapy was regurgitation (54%), followed by heartburn (30%). Indications for
surgery were symptoms refractory to medical therapy in 88% and a disfavour for lifelong
medication in 41%. Preoperative evaluation showed an erosive esophagitis in 77% and a hiatal hernia in 92%.
Surgery consisted in a Nissen fundoplication in 98% and in a Toupet fundoplication (for severe motility disorder with reduced propulsive peristalsis) in 2%. Conversion to an open procedure was necessary in 10%. Mortality was 0%. 6 patients (3%) had to be reoperated on. The
results of the questionnaire showed that the preoperative reflux symptoms had disappeared
in 82% of the patients. 94% were satisfied with the result and would undergo surgery again.
The mean GIQLI was 115 points (healthy volunteers in the literature 121 points 1).
Conclusion: Laparoscopic fundoplication is a safe procedure to treat gastroesophageal
reflux disease. Patient satisfaction is high at long-term follow-up and postoperative quality
of life is nearly normal.
1. E. Eypasch et al. Der Gastrointestinale Lebenqualitätsindex. Chirurg 1993;64:264-274
2. E. Eypasch et al. Gastrointestinal Quality of Life Index: development, validation and application of a new instrument. Br J Surg 1995;82:216-222
6.08
BP. Müller-Stich 2, T. Kapp 1, F. Holzinger 3, C. Klaiber 1
Department of Surgery, Spital Aarberg, Aarberg, Switzerland, 2 Department of Surgery,
Kantonsspital St. Gallen, St. Gallen, Switzerland, 3Department of Surgery, CHUV, Lausanne,
Switzerland
1
Influence of mesh reinforcement on hiatal hernia repair
Background: After laparoscopic repair of hiatal hernias type II and type III, a high recurrence rate is reported. In order to solve this problem a mesh reinforcement of the narrowed hiatus is being discussed.
Methods: Fifty-nine laparoscopic hiatal repairs (17 with and 42 without mesh reinforcement) in 58 consecutive patients were performed at our hospital between 1992 und 2003.
After a median of 59 months (9-127), the symptomatic outcome was analysed with a standardised questionnaire, and after a median of 57 months (9-117) we analysed the recurrence rate with a barium contrast swallow. Follow-up was 90% related to the symptomatic
outcome and 92% for contrast studies.
Results: The recurrence rate after operations without mesh reinforcement was 22%, whereas there was no recurrence in patients with mesh reinforcement (p<0.05). However, only
half of the recurrences were symptomatic. Intra-operative complications were seen in 14%
of procedures (with mesh: 24%; without mesh: 10%; p=0.16), and the peri-operative complication rate was 17% (18%; 17%; p=0.93). There was no mesh-related complication and
no operation-related death. In the long-term follow-up 59% of patients (69%; 55%; p=0.34)
were asymptomatic or had only a mild gas bloating, 15% (25%, 11%; p=0.19) needed regularly PPIs, 96% (93%, 97%; p=0,50) assessed the outcome as good or excellent, and 98%
(94%; 100%; p=0.13) would choose the operation again.
Conclusions: Laparoscopic repair is save and successful in the treatment of hiatal hernias
type II and type III. Mesh reinforcement reduces the recurrence rate. No mesh-related complications occurred in our series.
6.09
S. Kohl 1, JM. Heinicke 2, H. Zimmermann 1, P. Vock 3, D. Candinas 2
Department of Emergency Medicine, Inselspital, University of Berne, 2Department of Visceral
and Transplantation Surgery, Inselspital, University of Bern, 3Department of Radiology,
Inselspital, University of Berne
1
Value of abdominal CT-scan in the emergency department for non-traumatic abdominal pain
in adults
Objective: The purpose of this study was to evaluate the impact of abdominal CT in the
emergency department on treatment plans for patients with non-traumatic abdominal pain.
Methods: Over a 1-year period, 90 consecutive patients with non-traumatic abdominal pain
in whom abdominal CT was demanded by the consultant abdominal surgeon on call after
the clinical examination were enrolled in a prospective study. The consultant abdominal surgeon was required to report: (1) the most likely diagnosis; (2) the level of estimated certainty and (3) the treatment plan for their patient before and after abdominal CT. This information was compared to the radiologist’s CT diagnosis. The subsequent outcome of each
patient was evaluated.
Results: Pre- and post-CT diagnoses were concordant in only 59%. Before CT the surgeons
indicated a diagnostic certainty of 5.6 on a scale from 1 to 10, it raised by 3.5 points after
the CT-scan. Post-CT diagnoses were consistent with the final diagnosis in 96 %.
Prior to CT, the management plan would have included hospital admission for 87 of 90
patients, but after CT only 59 patients were actually admitted thus avoiding 32% of hospital admissions. Prior to CT, in 64% of the cases a conservative or expectant treatment was
planned and 32 patients would have been operated on immediately. After CT only 75% of
swiss knife 2004; special edition
17
these actually required immediate surgery.
Conclusion: Contrast-enhanced abdominal CT frequently leads to modification of the initial
clinical diagnoses and treatment plan. It considerably raises diagnostic certainty, avoids
unnecessary operations and admissions, and thus contributes to improve efficiency in the
emergency management of patients with acute abdominal pain.
09
réséqué. Le defect diaphragmatique, mesurant environ 4 cm de diamètre, a été réparé à
l’aide d’un filet non-résorbable. Le patient est rentré à domicile 15 jours après son admission à l’hôpital en bon état général.
Conclusions: Un pneumothorax associé à l’incarcération intrathoracique de côlon non-perforé 20 ans après un traumatisme fermé de l’abdomen est une présentation rare de hernie
diaphragmatique post-traumatique. La thoracotomie dans le 8ème espace intercostal,
pouvant être facilement prolongé en phréno-laparotomie, est une excellente voie d’abord
permettant la réparation du diaphragme et la résection de structures digestives.
9.01
X. Delgadillo, F. Chèvre, J. Renggli, C. Becciolini, M. Merlini
La Chaux de Fonds General Hospital
Total thyroidectomy through video-assisted technique.
Background: We report our initial experience of total thyroidectomy by the video-assited
technique and we evaluate feasibility, safety and benefits of this new aproach.
Methods: Between April and December 2003, 10 female patients (mean 46.5 years) underwent a total thyroidectomy under video-assisted technique at our Department of Surgery.
Our pre-operative protocol included clinical examination, thyroideal laboratory blood tests,
ultrasonography or scintigraphy. We operated on under general anesthesia through a minimal medial-cervical skin incision (2 cm).
Results: Nine patients were operated on for multinodular goiter and one for a large solitary
nodule. The mean cranio-caudal axis of the glands excised were 4.5 +/- 0.5 cm. The mean
total glandular weight was 10.5 g ( range 8.3 - 11.7 g ) No conversion to an open procedure was necessary. Mean operative time was 180 min ( range 102 - 224 min.) Laryngeal nerves were identified in 97.5 % of patients. Post-operatively we noticed 2 cases of transient
hypocalcemia. Mean hospital stay was 2 days in 90% of patients.
Conclusions: Video-assisted thyroidectomy is a feasible, safe and effective technique in
selected cases. Patients benefit from the technique in terms of short hospital stay and better cosmetic results.
9.02
BP. Müller-Stich, A. Zerz, G. Linke, J. Lange
Surgical Department, Kantonsspital, St. Gallen
Laparoscopic mesh-reinforced cruroplasty and anterior fundophrenicopexy
Background: Mesh reinforcement is recommended in the treatment of large hiatal hernias
in order to reduce recurrences. At least in the treatment of hiatal hernias, however, the role
of fundoplication is uncertain. We question if a fundoplication is even needed in the treatment of gastroesophageal reflux when mesh reinforcement is used to prevent transdiaphragmatic herniation of the gastroesophageal junction.
Operative technique: The operation is performed with the patient in a 30° upright French position. The CO2-pneumoperitoneum is established and maintained with 12mmHg. 4-5 trocars are
then placed in the upper abdomen. Any transhiatally herniated structures are first repositioned.
Further preparations are done after placing a 56-F illuminated gastric tube. Upon incision of the
lesser omentum and the peritoneum over the crura of the diaphragm, the hernia sac, if existent,
is reduced completely. Additionally, a circular dissection of the oesophagogastric junction is performed. The crura are narrowed by 3-4 non-resorbable sutures, and an 8 x 8 cm polypropylene
mesh with a 2-cm hole is applied from behind, so that the oesophagus is surrounded circularly.
The mesh is then fixed towards the diaphragm, and the two leaves of the mesh are ventrally closed with 8-10 staples. Finally, a fundophrenicopexy is performed by reconstructing an acute His’
Angle with 7-10 non-resorbable sutures.
Results: We have operated on 10 patients either for symptomatic hiatal hernias or gastroesophageal reflux using the technique described above. After a 3-month follow-up all
patients showed good results without reflux and without dysphagia.
Conclusions: The laparoscopic mesh-reinforced cruroplasty with anterior fundophrenicopexy seems to be successful in the treatment of hiatal hernias as well as in the treatment of
gastroesophageal reflux.
9.03
D. Christoforidis 1, P. Nordback 1, HB. Ris 2
Service de Chirurgie Viscérale et Centre de Transplantation, CHUV, Lausanne,
2
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne
1
Incarceération intra-thoracique post-traumatique du côlon transverse:
case-report et technique chirurgicale
Introduction: La hernie diaphragmatique se manifestant des années après un traumatisme
abdominal fermé est une entité connue mais rare. L’incarcération des structures digestives
dans la cavité thoracique peut avoir des conséquences dévastatrices et nécessite toujours
un traitement chirurgical. La voie d’abord, classiquement abdominale dans la phase aiguë
et thoracique dans la phase chronique, doit être planifiée en fonction de la clinique et de
l’imagerie pre-opératoire.
Vidéo: Nous présentons un cas d’une hernie diaphragmatique droite post-traumatique qui
s’est manifestée environ 20 ans après un accident de voie publique avec traumatisme
fermé de l’abdomen. Le côlon transverse était incarcéré dans la cavité pleurale droite et présentait une longue déchirure séreuse, sans perforation mais accompagné d’un pneumothorax. Le patient a été opéré le lendemain de son admission par thoracotomie droite dans
le 8ème espace intercostal, prolongée en phréno-laparotomie. Le côlon transverse a été
18
swiss knife 2004; special edition
9.04
M. Müller, S. Wildi, PA. Clavien, M. Weber
Universitätsspital Zürich
How we do it: laparoscopic conversion of gastric banding to roux-en-y gastric bypass
Background: Countless laparoscopic gastric bandings have been implanted during the
recent years. Despite excellent short-term results, long-term failures and complications
have been reported in more than 20 % of patients. We have shown that the laparoscopic
conversion from gastric banding to Roux-en-Y gastric bypass is a feasible, safe and more
efficient rescue procedure than laparoscopic rebanding1. In this video presentation we
focus on technical aspects of this advanced laparoscopic procedure. Out of 249 laparoscopic gastric bypass procedures which have been performed in our department between
June 2000 until January 2004, 59 were laparoscopic conversion from previous banding
procedures to a bypass.
Video presentation: Pneumoperitoneum is established and 5 trocars are placed. The plication of the stomach wall is released from the band to restore the original anatomy. Then the
silicon band is cut and removed. The stomach is transected after calibration of the new
pouch of 25 cc. With experience, we performed the gastric transection above or below the
scar tissue of the band system to avoid gastric pouch staple-line insufficiency. The jejunum
is divided 50 cm distal to the duodeno-jejunal flexion. A stapled side-to-side jejunojejunostomy anastomosis is performed, with a Roux limb length of 150cm. The Roux limb is positioned antecolic to perform the gastrojejunal anastomosis with a circular stapler. A swamp
drain is left in place until the gastrographin swallow has shown a sealed anastomosis.
Results: Each procedure was performed laparoscopically, the conversion rate was zero.
Mean operating time was 215 min. Early complications occurred in 2 cases in the bypass
group; all underwent a laparoscopic re-exploration without the need for open surgery. There
was no mortality in this series. BMI in the gastric bypass group decreased from 42.0 to 31.8
kg/m? within one year of surgery.
Conclusion: Laparoscopic conversion to a gastric bypass is feasible and safe. Conversion
to gastric bypass offers a significant advantage in terms of further weight loss after surgery1. Therefore, this procedure should be considered as the rescue therapy of choice after a
failed laparoscopic gastric banding.
1. Weber et al.; Ann Surg 2003;238: 827–834
9.05
S. Breitenstein, F. Goti, M. Decurtins
Clinic of Surgery, Kantonsspital Winterthur
Partial laparoscopic splenectomy
Purpose: Preserving splenic tissue and function whenever possible decreases the risk of
postsplenectomy sepsis. The indications of partial splenectomy are mostly benign tumors,
splenic cysts as well as some cases of splenic trauma. Only few case reports of the laparoscopic procedure of partial splenectomy can be found in the literature.
Material and Methods: Our video shows a partial laparoscopic splenectomy (PLS) being
performed on a 35-year old patient. The tumor in question has a diameter of 2.1cm, located
peripherally and dorsolaterally in the middle segment of the spleen. We begin the preparation at the interior splenic pole, followed by the dorsolateral side. We can thus clearly localise the tumor as well as the hilus. Clipping of the local arterial branches demarcates the
affected area around the tumor. The resection of the splenic segment is performed with the
electrocoagulator as well as the ultrasonic scissors. The additional coagulation of the
resection plane is assisted by the argonbeamer. The splenic segment is removed in a laparoscopic bag. The histological analysis reveals a partially cystic Hemangioma.
Discussion: The terminal nature of the splenic blood supply makes the partial resection of
the spleen possible. The dissection of the splenic arterial branches permits a clear tissue
demarcation. A remarkably bloodless resection can be carried out. As showed in our video
this procedure can also be done laparoscopically. Several PLS case reports describe firstly
islolated splenic trauma with preoperative arteriography and embolization of a polar artery
and resection of the superior splenic pole, secondly dissection of the inferior splenic vessels
with resection of the inferior pole, thirdly two cases of PLS by resection of splenic cysts and
finally a PLS combined with an aneurysmectomy in the case of a splenic artery aneurysm.
Conclusion: Partial splenectomy has been advocated in a number of splenic pathologies.
On the basis of advanced laparoscopic technology and surgical experience in some cases
a partial laparoscopic splenectomy is feasible and safe and incorporates the traditional
advantages of the minimal invasive approach.
Conclusion: The technique of the one trocar appendectomy is a simple and safe alternative
to an open or a laparoscopic appendectomy in cases of uncomplicated appendicitis with a
normal position of the appendix. This procedure has all the advantages of laparoscopic surgery with a particularly impressive cosmetic result.
9.06
MO. Guenin, B. Kern, R. Peterli, C. Ackermann, M. von Flüe
St. Claraspital, Basel
Die latero-terminale Anastomose bei der laparoskopischen Sigmaresektion
Die laparoskopische Sigmaresektion ist mittlerweile eine weit verbreiterte operative Technik
bei Patienten mit symptomatischer Sigmadivertikulose. Bei Patienten mit Status nach komplizierter Divertikulitis kann aber die Festlegung des proximalen Resektionsrandes schwierig
sein. Häufig finden sich am proximalen Resektionsrand noch Divertikel, welche die Anlage
einer Tabaksbeutelnaht zum Einnähen des Staplerkopfes schwierig und zu einem Sicherheitsrisiko machen. Die latero-terminale Anastomose wird antimesenterial in einer divertikelfreien Zone angelegt. Dadurch kann zusätzlich an Länge gewonnen werden was zur spannungs- freien Anastomosierung beiträgt. Kaliber Unterschiede zwischen relativ engem Kolon
descendens und breitem proximalem Rektum sind dadurch auszugleichen.
Methode: Nach Mobilisation der linken Kolon werden die proximalen und distalen
Resektionsränder festgelegt. Es folgt die zentrale Ligatur der Gefäße und die Durchtrennung
des Mesolrektums mit dem Ligasure. Das Rektum wird unterhalb des Promontoriums mit dem
Endo-GIA® durchtrennt. Durch eine suprapubische Pfannenstielinzision wird das Präparat
geborgen und der Stapler- Kopf (Zircular 29mm) ins Kolon descendens eingeführt. Der Anvil
wird 4 cm proximal davon antimesenterial durch eine Tänie ausgeleitet und das Kolon
deszendens endständig mit dem Linearstapler verschlossen. Nach Verlagerung des Kolons
nach intraabdominal erfolgt die transanale Anastomose mit dem zirkulärem Stapler.
Resultate: Es handelt sich um eine einfache, gut reproduzierbare und sichere Technik die mit
geringer Morbidität durchführbar ist. Das Video zeigt unsere Technik und die ersten Resultate.
Schlussfolgerungen: Die guten Resultate rechtfertigen eine randomisierte Studie, wobei die
laterao-terminale laparosokopische Technik mit der herkömmlichen End-zu-End Staplertechnik verglichen wird.
9.09
J. Gerbitz
Spital Laufenburg
Chirurgisch-medizinische Transcodierung in HTML: www.code-atlas.com
Einleitung und Problemstellung: Die Codierung medizinischer Diagnosen (ICD-10) und
Prozeduren (CHOP) für Statistik und Leistungserfassung (SLK, Tarmed, TNL) ist fester
Bestandteil chirurgisch-ärztlicher Tätigkeit. Selten werden dabei die Möglichkeiten moderner Programmierung und Vernetzung (Hyperlinks) ausgeschöpft.
Material und Methode: Die in der Schweiz gebräuchlichen Verschlüsselungs-Kataloge: ICD10, CHOP, Tarmed wurden in HTML formatiert. Als Benutzer-Oberfläche bietet die metapherbasierte topologisch-anatomische Struktur des Code-Atlas® (Posterpreis 2003 der Schweizerischen Gesellschaft für Chirurgie) maus-gesteuerten Direktzugriff auf den Code. Sofern
inhaltlich sinnvoll, sind die Codes durch Hyperlinks 1:1, anderenfalls bereichsweise nach
Organgruppen und Körperregionen über Auswahl-Menüs miteinander verknüpft
(“Transcodierung”).
Resultate: Bei einer Hardware-Reaktionszeit von < 1 sec lassen sich alle Codierungen durch
maximal 3 Mausklicks (< 3 sec) einstellen. Überregional ist das System im Internet abrufbar und anwendbar, allerdings beschleunigt die lokale Installation auf dem PC oder im
Intranet die Zugriffszeit erheblich. Die Akzeptanz der Anwender liegt deutlich über herkömmlichen Systemen mit Listen und Freitext-Eingabe, die Fehlerquote ist signifikant geringer.
Diskussion: Die vollständige und zuverlässige 1:1 Transcodierung existierender Codes ist
nicht nur technisch, sondern auch inhaltlich nicht möglich. Mit der Struktur des Code-Atlas®
ist eine bereichsweise Gruppierung nach Organen und Körpersystemen möglich, so dass
diese code-übergreifend miteinander assoziiert werden können (Auswahl-Menüs). Das
HTML-formatierte, browser-unabhängige Interface kann als Codiertool in beliebige
Spitalsoftware integriert werden.
Zusammenfassung: Der elektronische Code-Atlas® bietet eine einfache, selbsterklärende
Benutzeroberfläche zur Codierung von Diagnosen und Operationen und erleichtert durch
seine Struktur die sinnvolle Transcodierung.
9.07
S. Breitenstein 1, P. Saudan 1, A. Rehn 2, T. Hess 2, M. Decurtins 1
1
Clinic of Surgery, Kantonsspital Winterthur, 2Clinic of Gynaecology, Kantonsspital Winterthur
Resection of the colon without laparotomy - laparoscopic rectosigmoidectomy
with transvaginal colon removal
Purpose: Laparoscopic colon surgery has progressively become established for the treatment of benign diseases of the colon. Removal of the colon is usually carried out through
minilaparotomy. In rare cases the evacuation may be transvaginal or transrectal.
Material and Methods: Our video shows a transvaginal colon removal from a 39 year-old
patient. The diagnosis of recurring sigmadiverticulitis and an uterus myomatosus led to a
combined laparoscopic rectosigmoidectomy and vaginal hysterectomy. The operation
begins with the laparoscopic mobilisation of the colon and the proximal part of the rectum.
Following identification and stapling of the sigmoidal blood vessels, the proximal rectum is
stapled. The next step is the proximal separation of the colon. The rectosigma is then deposited pericoecally. After vaginal hysterectomy the rectosigma is also removed transvaginally. The stapler head is placed into the abdomen. After closure of the vagina we apply a new
pneumoperitoneum. A transanal stapler anastomosis completes the operation.
Discussion: The necessity for such a combined operation, hysterectomy and rectosigmoidectomy, is rare. However as our video shows a transvaginal removal of the colon is possible. Laparoscopic introduction of the stapler head into the colon and the laparoscopic
purse-string suture present additional technical challenges.
Conclusion: Tansvaginal removal of the colon, simultaneously with a transvaginal hysterectomy, can be carried out safely by a surgical team with advanced laparoscopic colorectal
experience. This procedure maximises the advantages of the laparoscopic technique.
9.08
S. Breitenstein, M. Arigoni, M. Decurtins
Clinic of Surgery, Kantonsspital Winterthur
One trocar appendectomy
Purpose: Different techniques for appendectomy are currently in use. Both open appendectomy and laparoscopic appendectomy have similar rates of complications. Standard laparoscopic methods use three ports. Appendectomy techniques involving one ore two trocars
are rarely reported.
Material and Methods: Our video shows the so-called one trocar appendectomy technique.
The single port is localised umbilically. An open pneumoperitoneum is used and a 12 mm
trocar is introduced. During the operation the patient is slightly rotated to the left. The appendix is localised using an angulated optic system with a 5mm working channel. The appendix is laparoscopically clamped at the tip. Gas is released and the tip of the appendix is
gently pulled out through the umbilical incision. The mesoappendix is dissected outside of
the abdominal wall. Similar to the open technique the base of the appendix is ligated. The
base of the appendix is covered with a purse-string suture. The coecum is pushed back into
the abdomen. The suture is checked laparoscopically and the abdomen is rinsed. Finally
the umbilical incision is closed.
Discussion: The one trocar appendectomy is a combination of laparoscopic and conventional open operation techniques. This single trocar procedure has limits. Retrocoecal appendicitis, perforated appendicitis and situations with multiple adhesions have to be
approached using other techniques.
10
10.01
P. Bucher 1, B. Mermillod 2, P. Gervaz 1, CL. Soravia 1, Ph. Morel 1
Department of Surgery, Geneva University Hospital,
2
Division of Medical Statistics, Geneva University Hospital
1
Left-sided elective colorectal surgery with primary anastomosis without
mechanical bowel preparation – meta-analysis
Background: Mechanical bowel preparation (MBP) has been considered to be efficient to
decrease the risk of infectious complications after colic anastomosis. This dogma is not based
on solid evidence, but more on observational data and expert’s opinions.
Objectives: To assess the role of prophylactic MBP in terms of morbidity after elective colorectal surgery.
Materials and methods All publications describing MBP before elective colorectal surgery were
sought through Medline and hand search. All randomised, clinical trials, performed in order to
answer the hypothesis (i.e. comparison of MBP and MBP avoidance, before elective colorectal
surgery) were included. For Statistical analysis the Fleiss J.L. approach was used.
Results: 7 randomised control trials (RCT) were retrieved. Of the 1357 patients included in
these RCT, 673 were allocated to MBP group and 684 to no MBP group. Anastomotic leak:
5.5% in MBP group (37 of 673 patients) compared with 2.6% in no MBP group (18 of 684
patients); Odds ratio (OR) 2.15, 95% CI: 1.21 - 3.82 (P=0.01). Wound infection: 8% in MBP
group (54 of 673 patients) compared with 5.6% in no MBP group (38 of 684 patients); OR
1.51, 95% CI: 0.98 – 2.31. Intra-abdominal abscess: 3.1% in MBP group (15 of 489 patients)
compared with 2% in no MBP group (10 of 490 patients); OR 1.51, 95% CI: 0.67 - 3.41. Re-laparotomy (5 RCTs reporting this end point): 5.7% in MBP group (23 of 400 patients) compared
with 2.3% in no MBP group (9 of 398 patients); OR 2.64, 95% CI: 1.20 - 5.78. Extra-abdominal
morbidity: 21% in MBP group (83 of 403 patients) compared with 17% in no MBP group (68
of 397 patients); OR 1.26, 95% CI: 0.88 - 1.79. Mortality: 0.9% in MBP group (5 of 557 patients)
compared with 0.5% in no MBP group (3 of 561 patients); OR 1.69, 95% CI: 0.4 – 7.09.
Conclusions: The present results failed to support the hypothesis that MBP reduces anastomotic dehiscence rates and other complications. Moreover, MBP seems to contribute to a higher
risk of post-operative infectious complications after colorectal anastomosis. Thus, the routine
use of mechanical bowel preparation in patients undergoing elective colorectal surgery is questionable.
swiss knife 2004; special edition
19
10.02
T. Steffen, M. Zünd, J. Lange
Klinik für Chirurgie, Kantonsspital St. Gallen
Bedeutung der „Koprostase“ als chirurgische Diagnose?
Einleitung: Die Ausschlussdiagnose Koprostase bei akutem Abdomen und ansonsten
negativen Resultaten von Zusatzabklärungen ist nicht selten. In unserer Klinik werden
Patienten mit akutem/subakutem Abdomen stationär aufgenommen. So auch die
Patienten, bei welchen nach Durchführung der initialen Diagnostik die Diagnose
Koprostase verbleibt. Wir haben uns gefragt, wie die weiteren Verläufe dieser Patienten
waren und wie oft im Verlauf sich ein Diagnosewechsel ergab.
Methode: Zwischen 1.4.2001 und 31.1.2003 haben wir prospektiv alle Patienten der chirurgischen Notfallstation mit der Eintrittsdiagnose „Koprostase“ bzw. „Kolonpassagestörung“
erfasst und bezügl. ihrem weiteren Verlauf retrospektiv ausgewertet.
Resultate: In den 22 Monaten sind insgesamt 110 Patienten mit akutem Abdomen und der
genannten Diagnose über unsere Notfallstation eingetreten. 46% waren Männer und 54%
Frauen, das Durchschnittsalter lag bei den Männern bei 57 und bei den Frauen bei 54
Jahren. 54% der Patienten wurden mit der Eintrittsdiagnose „Koprostase“ auch entlassen,
bei den anderen Patienten ergaben die weiterführenden Abklärungen im Verlauf einen
Diagnosewechsel. Dies war bei Frauen mit 59% häufiger der Fall als bei Männern mit 47%.
Die im Verlauf gestellten Diagnosen waren sehr vielfältig. Es wurden u.a. folgende
Diagnosen gestellt:: Ileus, Cholezystolithiasis, Enteritis, Leberabszess, Passagestörung bei
Adhäsionen, Sigmadivertikulitis, Nierenstauung.
Schlussfolgerung: Koprostase und Kolonpassagestörung ist eine in der chirurgischen Notfallstation häufig gestellte Diagnose nach Ausschluss der häufigsten anderen Ursachen für
ein akutes Abdomen. In 46% der Fälle ergaben die Abklärungen im weiteren Verlauf der
Hospitalisation eine andere Diagnose. Wir empfehlen die grosszügige stationäre
Aufnahme von Patienten mit Kolonpassagestörung zur Verlaufsbeobachtung und ggf. weiteren Abklärung.
10.03
CT. Viehl 2, U. Guller 2, CT. Hamel 2, HM. Riehle 3, V. Banz 1, WR. Marti 2,M. Zuber 1
1
Department of Surgery, Kantonsspital Olten, Olten, CH, 2Department of Surgery, Division of
General Surgery, University of Basel, CH, 3Institut für klinische Pathologie, Basel, CH
The use of carbon dye in the sentinel lymph node procedure for colon cancer facilitates the
detection of small nodal tumor infiltrates
Introduction: Sentinel lymph node (SLN) mapping using a combination of isosulfan blue
and carbon dye has been recently described in patients with malignant melanoma. In contrast to the transient nodal staining by isosulfan blue, carbon dye led to a permanent mark,
as it is phagocyted by macrophages in draining lymph nodes. Nodal tumor infiltrates and
carbon particles were found in the same lymph node compartment. The objective of the present investigation regarding the use of carbon dye for SLN procedure in colon cancer – the
first one in the literature - was to evaluate whether the use of carbon dye facilitates the detection of small nodal tumor infiltrates.
Patients and methods: Nineteen patients underwent open, oncological standard resections
of localized colon cancer and SLN procedure according to a standardized protocol. All operations were performed by one surgeon. Isosulfan blue 1% and sterile filtered carbon dye
(mixed 1:1) were injected into the subserosa circumferentially around the tumor.
Mesenterial lymph nodes staining blue were marked as SLN. Serial sections of each SLN
were stained with H&E and with the pancytokeratin marker AE1/AE3. The intranodal localization of micrometastases (pN+[mi]) and isolated tumor cells (pN0[i+]), and of carbon
particles was correlated.
Results: Identification of at least one SLN was successful in 18 patients (identification rate
95%). Four patients (22%) were pN+, 11 (61%) were pN0(i-). Three patients (17%) were
upstaged to pN0(i+) as isolated tumor cells were detected in six of their SLN: in two patients
carbon dye and isolated tumor cells were found in the same nodal compartment, hence
facilitating the recognition of isolated tumor cells by the pathologist; one patient had no carbon dye in his SLN. SLN were significantly more likely to contain carbon particles than NonSLN (40 out of 80 SLN, and 81 out of 344 Non-SLN; p<0.0001, chi-square test) and to harbor nodal tumor infiltrates (p=0.0006, chi-square test).
Conclusions: The use of carbon dye in the sentinel lymph node procedure for colon cancer
facilitates the detection of small nodal tumor infiltrates and improves tumor staging.
10.04
S. Dätwiler, TH. Köstler, O. Schöb
Limmattalspital, Schlieren
Operative Therapie der Divertikelerkrankung - wann ist heute die offene Resektion
noch notwendig?
Hintergrund: Mit steigender Erfahrung hat sich das Indikationsspektrum für die laparoskopische Sigmaresektion auch auf die komplizierte Divertikelkrankheit erweitert; ist dieser Trend
lohnend und sinnvoll?
Methode: Es wurden retrospektiv die Daten des Limmattalspitals über die Zeitspanne von 4
Jahren (1.6.99-31.5.2003) ausgewertet.
Resultate: Es wurden 180 Sigmaresektionen bei Divertikelerkrankung durchgeführt, davon
28 offen (20 primär offen und 8 (5.2%) nach Konversion) und 152 (84%) laparoskopisch.
Der häufigste Konversionsgrund (62.5%) war intraabdominale Adhäsionen nach vorange-
20
swiss knife 2004; special edition
gangenen Baucheingriffen.
27 (15%) Sigmaresektionen erfolgten bei komplizierter Divertikelerkrankung (Fistel,
Perforation, Illeus, Blutung, Abszess). Von den 27 komplizierten Divertikelerkrankungen
wurden 17 (63%)primär offen operiert, 7 (70%)laparoskopisch und 3 (30%) mussten konvertiert werden. Wegen fistulierender Divertikelerkrankung wurden 9 Resektionen durchgeführt. In 6 (67%) Fällen konnte die Operation laparoskopisch durchgeführt werden, bei einer
Mortalität und Morbidität von 0%. Die postoperative Komplikationsrate betrug insgesamt
6%, wobei die Komplikationsrate nach Sigmaresektion bei komplizierter Divertikelerkrankungen besonders hoch war (37%). Die postoperative Mortalität betrug insgesamt 1%.
Schlussfolgerung: Für die unkomplizierte Divertikelerkrankung hat sich die laparoskopische
Sigmaresektion als Verfahren der ersten Wahl etabliert. Bei der komplizierten
Sigmadivertikelerkrankung gilt die primär offene Operation bei Notfalleingriffen nach wie
vor als Standardverfahren. Kontrovers ist die Verfahrenswahl bei der komplizierten
Divertikelerkrankung unter elektiven Bedingungen. Wir konnten an unserem Patientengut
zeigen, dass bei Vorliegen von kolovesikalen, kolointestinalen oder kolouterinen Fisteln die
laparoskopische Resektion mit einer niedrigen Konversionsrate und niedrigen postoperativen Komplikationsrate durchgeführt werden kann.
10.05
B. Boldog, M. Senn, B. Hüttenmoser, W. Schweizer
Kantonsspital Schaffhausen Abt. Chirurgie
Resultate der laparoskopische-assistierten linksseitigen Kolonchirurgie
Einleitung: Die Kolonresektion mit direkter Anastomose stellt einen Routineeingriff in der
Viszeralchirurgie dar. Die konventionelle Laparotomie bietet zwar eine gute Uebersicht und
eine hohe technische Sicherheit, stellt aber gegenüber der Laparoskopie für den Patienten
eine höhere Belastung mit vermehrten postoperativen Schmerzen und einer langsameren
Rekonvaleszenz dar. Eine Optimierung der laparoskopischen chirurgischen Intervention kann
erreicht werden, wenn der Präpara-tentfernungswechselschnitt primär als Zugang für die
unterstützende Hand des Chirurgen verwendet wird.
Patienten und Methoden: In unserer prospektiven Studie haben wir zwischen 1999 und 2003
bei 152 Patienten (109 Frauen, 43 Männer) eine laparoskopische hand-assistierte Kolonresektion vorgenommen. In 135 Fällen wurde eine anteriore Rektosigmoidresektion, in 8 Fällen
eine tiefe anteriore Rektumresektion und in 9 Fällen eine Hemikolektomie links durchgeführt.
Resultate: In keinem Fall war eine Konversion zur Laparotomie notwendig. Die mediane
Operationszeit lag bei 121 Minuten. Bei drei Fällen kam es zu einer klinischen Anastomoseninsuffizienz, die mittels Neuanastomose zweimal laparoskopisch und einmal offen therapiert
wurden. Ein Anus praeter wurde nie angelegt. Die Letalität war null. Der durchschnittliche Spitalaufenthalt lag bei 6 Tagen. Der postoperative Kostaufbau erfolgte deutlich rascher erfolgen
als in zwei retrospektiv evaluierten Kollektiven mit offener Resektion. Unser Evaluationsprotokoll
beinhaltet den intraoperativen Blutverlust, die Operationsdauer,den postoperativer Schmerzmittelbedarf und die Hospitalisationsdauer und vergleicht unsere prospektive Serie mit zwei
konsekutiven retrospektiven Kollektiven (1993-95 und 1990-98) mit offener Operation.
Schlussfolgerung: Die laparoskopische handassistierte Kolonresektion ist einfach, schnell,
sicher und komplikationsarm. Die Frühresultate zeigen einen deutlich höheren Patientenkomfort mit einer deutlichen Senkung des postoperativen Analgesiebedarf und ein besseres ästhetisches Resultat. Das Ergebnis ist überzeugend und mit der offenen Technik vergleichbar.
10.06
M. Arigoni, S. Breitenstein, M. Decurtins
Chirurgische Klinik, Kantonsspital Winterthur
One trocar appendektomie - eine Alternative zur offenen
oder laparoskopischen Appendektomie?
Einleitung: Zur Appendektomie werden heute verschiedene Operationstechniken angewendet. Die offene und die laparoskopische Operationstechnik haben vergleichbare Komplikationsraten. Die laparoskopische Appendektomie wird üblicherweise mit drei Trokarzugängen durchgeführt. Vereinzelt sind aber auch Operationstechniken mit nur einem oder mit
zwei Trokarzugängen beschrieben. Wir zeigen hier unsere Erfahrungen und Resultate mit
der sogenannten one trocar Appendektomie, einer Kombination zwischen offener und laparoskopischer Operationstechnik.
Material und Methode: Seit August 2003 haben wir bei 35 Patienten (16 Männer, 14
Frauen) eine one trocar Appendektomie durchgeführt. Wir haben die Patienten prospektiv
erfasst und insbesondere die Operationszeit, die Hospitalisationsdauer und die Komplikationen analysiert. Die Indikationen waren Unterbauchperitonismus, laborchemisch
erhöhte Entzündunsparameter sowie ultrasonographisch Nachweis einer Appendizitis
acuta. Intraoperativ lag die Appendix dreimal retrozökal, einmal zeigte sich eine perforierte
Appendizitis, einmal lag eine Abszedierung vor.
Resultate: Bei 32 Patienten konnte die one trocar Appendektomie erfolgreich durchgeführt
werden. Dreimal war die one trocar Appendektomie nicht erfolgreich, einmal wurde auf
eine offene Appendektomie konvertiert, zweimal wurden zwei zusätzliche Laparoskopiezugänge angelegt. In den 3 nicht erfolgreichen one trocar Appendektomie-Fällen lagen eine
retrozökale oder eine perforierte Appendizitis vor. Komplikationen traten bis auf eine Wundinfektion keine auf. Die mittlere Operationszeit betrug 56 (+/- 15) Minuten und die mittlere
Hospitalisationsdauer war 3 Tage.
Schlussfolgerung: Bei unkomplizierter, nicht retrozökaler Appendizitis ist die one trocar
Appendektomie eine sichere Alternative zur offenen oder laparoskopischen Appendektomie. Kontraindikationen sind die Appendizitis perforata sowie die retrozökale Appendizitis.
Die one trocar Appendektomie hat alle Vorteile der laparoskopischen Operationstechnik,
insbesondere ist das kosmetische Resultat beeindruckend.
10.07
10.09
B. Gloor 1, T. Berchtold 1, R. Weimann 2, D. Inderbitzin 1, M. Wagner 1, SA. Vorburger 1,
D. Candinas1. 1 Department of Visceral- and Transplant Surgery, Inselspital; University of
Berne, Switzerland, 2Department of Pathology, University of Berne, Switzerland
A. Sermier, P. Gervaz, M. Dao, JF. Egger, Ph. Morel
University Hospital Geneva
Surgical management of an unsuspected appendiceal mucocele
Background: Mucoceles from either benign or malignant mucinous neoplasms represent
the majority of appendiceal tumours. Aim: to determine the outcome during follow-up of
patients with incidental appendiceal mass. Methods: Retrospective study of 86 patients diagnosed with ‚appendiceal mass’ and/or mucocele’ and/or pseudomxyoma peritonei consecutively allocated at the department of pathology between 1989-2003. Results: There
were 37 women (43%) and 49 men (57%)) with a mean age of 55 and 50 years, respectively. In the absence of peritoneal spread at the time of appendectomy, the diameter of the
appendix was the only criterion to differentiate between malignant and benign disease.
Three pathological entities were analysed.
Group Pathology
N
Median Perforated
diameter
(range)
Initially
appendectomy
only
Eventual outcome
pseudomyxoma
peritonei
1
Simple
53
1.5
obstructive (62%) (0.6-5)
mucocele
9/53
(17%)
30/53
(57%)
2/53
(4%)
2
Cystadenoma
19
2
(22%) (1-4.5)
3/19
(16%)
15/19
(79%)
1/19
(5%)
3
Cystadeno- 14
3.8
carcinoma (16%) (1.8-10)
3/14
(21%)
7/14
(50%)
10/14
(71%)
One-way ANOVA showed a difference of medians between groups p<0.001 (Kruskal-Wallis).
Group 3 was significantly different from group 1 and 2. ROC-curve analysis revealed a sensitivity of 0.8 and a specificity of 0.6 for a cut-off value of 1.5 cm to discriminate between
malignancy and non-malignant tumours.
Pseudomyxoma peritonei was diagnosed (later) in 13 patients (11 men (85%) and 2
women (15%)). In 2 /13 (16%) the appendix was perforated at the time of initial surgery.
Initial surgical treatment in these 13 patients consisted of simple appendectomy in 9
patients (69%), locally extended resection in 3 (23%) and extended peritonectomy in one
(8%). An extended peritonectomy was performed in 7/12 patients with warm intraperitoneal chemotherapy in 4 after a median of 420 days (range 20 to 2950).
Conclusion: Our data show that the size of a mucocele is directly correlated to its malignant potential. Pseudomyxoma peritonei is primarily associated with the underlying pathology. Perforation of the appendix at initial surgery is of minor importance.
10.08
T. Roth 1, S. Dragoje 3, M. Gass 1, D. Candinas 1, JJ. Brugger 2
Department of Visceral and Transplantation Surgery, University Hospital, Berne,
2
Department of General Surgery, Hospital of the Providence, Neuchatel,
3
Department of Pathology, Neuchatel
1
Pitfalls in laparoscopy:
the vanishing appendix. Intussusception of the appendix due to mucinous cystadenoma
Introduction: Classically, invagination of a segment of bowel is a pediatric disease (90%),
which occurrs idiopatically. In contrast, the intussusception in adults occurrs rarely and is
due to an organic lesion such as a digestive tumor. Isolated intussusception of the appendix however is an exceptional finding.
Case report: A 26 year-old woman was admitted with a history of acute paroxystically abdominal pain of 24 hours duration. The pain migrated progressively to the right lower quadrant.
The patient had a temperature of 37.8° and a localised tenderness with rebound. Leukocytosis was elevated to 12.6. Surgical operation was indicated because of clinical suspicion
of acute appendicitis. Laparoscopy showed a normal bowel and pelvic organs, but the appendix was initially not visible. Finally a white tip of the appendix appeared on the caecum but the
incarceration of the appendix could not be released laparoscopically and needed a conversion through a Mc-Burney approach. The appendix was manually reduced and a 1.5 cm tumor
at it’s base was discovered necessitating a resection of the caecum. Histologically a mucinous cystadenoma was diagnosed. The patient left the hospital at the 4th postoperative day.
A barium enema failed to show any other colonic tumor.
Discussion: First described by Mc Kidd in 1858 in a child who died, intussusception of the
appendix is rare, in particular in adults. In 1964 only 118 cases were found in literature. The
aged varied between 10-months and 85 years. The invagination has polymorph presentations ranging from completely asymptomatic presentation to paroxystically pain or even
acute occlusion. Organic bowel lesions or particular anatomy could favour invagination. 51
patients had intussusception due to a mucocele of the appendix. Only in very few cases a
mucinous cystadenoma was the reason of invagination.
Conclusion: The intraoperative absence of an appendix without previous operation must be
carefully differentiated from agenesis. In such cases direct palpation of the caecum is advocated to rule out an intussusception. Further, in this particular case the association of mucinous cystadenoma of the appendix with colonic adenocarcinoma necessitated to rule out
the latter condition.
Lymph node retrieval after abdominoperinal resection:
a comparison of anal and rectal cancer
Background: The yield of lymph nodes (LN) in abdominoperineal resection (APR) specimen
is notoriously low, due in part to the effect of preoperative radiation therapy. This has important implications for staging, and may be worsened in patients with squamous cell carcinoma of the anus (SCCA), who are commonly treated with a higher dose (60-70 Gy) than
patients with rectal cancer (45-50 Gy). We hypothesized that the yield of LN retrieval in APR
specimen was radiation dose-dependant and, consequently inferior in patients with SCCA
by comparison with patients with rectal cancer.
Methods: We performed a retrospective study on 57 patients who underwent APR in a single institution between 1992 and 2003. Pathological reports were reviewed and the number of lymph nodes retrieved in APR specimen was correlated with:
1) Location (anal or rectal) of cancer
2) Dose of pelvic irradiation
Results: There were 36 males and 21 females, with a median age of 68 (range 22-89)
years. There were 9 patients operated for SCCA and 48 for rectal cancer. 89% and 69% of
patients with anal and rectal cancer respectively underwent neoadjuvant radiotherapy. The
mean ± SD number of LN in APR specimen was 11.5±6. The mean number of LN in APR
specimen was significantly lower in patients with SCCA than in patients with rectal cancer
(6.4±5.5 Vs. 12.2±5.7, t test p=0.009). However, in patients with rectal cancer the mean
number of LN was identical in irradiated and non-irradiated patients (12.2±5.4 Vs. 12±6,
p=0.89).
Conclusion: Pelvic irradiation at a dose of 60-70 Gy results in a significant decrease in the
yield of LN in APR specimen. This pathological alterations are not observed in rectal cancer
specimen, indicating that necrosis of pelvic LN is probably dose-dependant and restricted
to dose superior to 50 Gy.
10.10
PH. Füglistaler, MO. Guenin, R. Peterli, B. Kern, M. von Flüe, CH. Ackermann
Allgemeinchirurgische Abteilung, St.Claraspital Basel
Longterm results after stapled rectal mucosectomy for hemorrhoids
Introduction: Stapled rectal mucosectomy for hemorrhoids is an uncomplicated surgical
procedure causing minimal pain for treatment of hemorrhoids. The aim of this study was to
evaluate the long-term results with a follow-up of more than 1 year.
Patients and methods: This is a prospective study including 216 patients treated by stapled
rectal mucosectomy. Chief complaints preoperatively were prolapse (46%), anal bleeding
(35%), anal pain (11%), anal incontinence (5%) and anal itching (3%). Over all 77% of
patients presented with anal bleeding, 73% with prolapse and 42% with anal pain. All
patients were evaluated using a standardized questionnaire.
Results: Follow-up data were acquired for 193 of 216 patients (89%) with a mean follow-up
of 30(range 12-53) months. 88% of patients were satisfied or very satisfied by the operation. In 94% chief complaints were completely alleviated (66%) or improved (28%). For 9
patients reoperation was necessary during follow-up (rate of reoperation 5%). The most frequent reasons for reoperation were recurrence of hemorrhoidal prolapse (3%) and anal fissure (1%). 69% of patients experienced no anal incontinence, 21% mild, 7% moderate and
3% severe incontinence. 40% reported an urge-incontinence, which 17% of patients considered to be a mild and 8% a severe disturbance.
Conclusion: Stapled rectal mucosectomy is a suitable procedure to permanently control
most frequent symptoms of hemorrhoids such as hemorrhoidal prolapse, anal bleeding
and anal pain in a long-term follow-up. About 10% of patients remain unsatisfied by the outcome of the procedure. Main reasons are recurrence of hemorrhoidal prolapse and urgeincontinence. These results allow us to potentially improve preoperative patient selection
and to better inform patients.
10.11
T. Carstensen, B. Mölle, J. Lange, J. Girona
Kantonsspital St. Gallen, Chirurgie
Distale Rektumwanddoppelung nach Girona als valable therapuetische
Option in der Fistelchirurgie
Komplexe Fisteln u.a. vesicorektale, rektovaginale, im Rahmen einer chronisch entzündlichen Darmerkrankung (CED) oder auch postaktinische stellen eine besondere technische
Herausforderung dar.
Methode: Diese Technik wurde 1983 von R.C. Tiptaft basierend auf dem Advancement Flap
von A. Parks beschrieben und von J. Girona modifiziert. Sie kann sowohl endo- als auch
extraanal angewandt werden. Nach Fisteldarstellung/–excision und -verschluss
(Blase,Vagina, Sphinkter) erfolgt eine semicirculäre Rektumvollwandincision auf Höhe der
inneren Fistelöffnung, Dissektion von der Faszie mit proximaler Mobilisation. Nach kompletter, distaler Mucosektomie wird die Rektumwand gedoppelt, indem die distale Lefze an die
Rektumwand fixiert und die proximale über das mucosektomierte Areal gezogen und adaptiert wird. Die Mucosa wird zusätzlich in EKN vernäht. Procedere: Manovac Drainage über
48H, 2 Tage gelockerte Bettruhe, 2 Tage flüssige Kost mit anschliessendem langsamen
Kostaufbau unter medikamentöser Stuhlregulation.
swiss knife 2004; special edition
21
Ergebnisse: Es wurden 7 Patienten (1M/6W) Alter: 31-74 2001-02 operiert. Es lagen 2 rektovaginale davon 1 Rezidiv, 1 transsphinktäre nach Parks IIb(CED), 2 extrasphinktäre nach
Parks IVc (1 CED),1 vesicorektale und 1 postaktinische Fistel vor. Bis heute (Follow up 6-24
Monate) gibt es bei klinischer Beschwerdefreiheit kein Rezidiv. Es liegt jeweils eine volle
Kontinenzleistung für sämtliche Stuhlqualitäten vor, manometrisch keine signifikanten präoder postoperativen Unterschiede.
Folgerungen: Die Rektumwanddoppelung nach Girona bietet sich – besonders bei komplexen Fisteln – neben den konventionellen Techniken als zusätzliche therapeutische Option in
der analen Fistelchirurgie an.
10.12
K. Skala, G. Zufferey, J. Robert-Yap, B. Roche
Unité de Proctologie Hôpital Universitaire de Genève
Complication exceptionnelle d’une ligature elastique
La ligature élastique selon Baron réalise le traitement de choix des stades II et III de la maladie hémorroïdaire. Plusieurs milliers de ces gestes sont effectués chaque année dans le monde. La littérature rapporte des complications sous forme d’abcès, d’abcès hépatiques et
exceptionnellement de décès. Nous reportons le cas d’un patient qui nous a été présenté suite
à une telle ligature. Cette dernière a occasionné un volumineux abcès sous-lévatorien de l’hémi-quadrant inférieur droit entraînant une nécrose du tissu incriminé ainsi qu’une sclérose du
sphincter interne. Le traitement conservateur a permis de cicatriser cette lésion, le patient a
bénéficié d’une colostomie qui a pu être fermée, la continence est complète, mais l’anus est
marqué par une déformation allant de 5 à 7 heures en position gynécologique.
Les complications liées à la ligature élastique sont rares, elles doivent être reconnues rapidement, tout abcès doit être drainé en urgence, faute de quoi, une destruction tissulaire irréversible peut être observée.
10.13
R. Degolla, K. Skala, G. Zufferey, J. Robert-Yap,
B. Roche. Unité de Proctologie Hôpital Universitaire Genève
Diagnostic et traitement du tail gut cyst a propos de 8 cas
Introduction: Le tail gut cyst (TGC) est une formation polykystique qui se développe dans
l’espace rétrorectal. Ces malformations sont rares. L’aspect radiologique et hystopathologique de ces lésions font qu’on les distingue relativement facilement des autres kystes de
l’espace rétrorectal.
Methode: Huit patients adultes présentant des TGC ont été opérés entre 1994 et 2003.
Nous avons exclu de la casuistique toutes les autres formations kystiques rétrorectales, tels
que les tératomes et autres. Il s’agit essentiellement de patients de sexe féminin, d’âge de
20 à 54 ans, avec un âge moyen de 34 ans. L’imagerie diagnostique échographie endo
rectale, CT scan permet de localiser avec précision les lésions.
Le traitement a consisté en une résection du kyste par un abord périnéal dans 6 cas, un
abord intersphinctérien dans 2 cas. Dans un seul cas d’abord intersphinctérien nous avons
dû répéter l’intervention en raison d’une formation kystique résiduelle ignorée lors de la première intervention.
Le tail gut cyst est une lésion cystique bénigne rare, plus fréquente chez la femme. En raison de potentiel d’évolution vers la malignité, ces tails gut cyst doivent être excisés chirurgicalement par voie périnéale et de manière complète.
10.14
C. Pavlik 1, G. Gadient 2, HP. Simmen 1
1
Chirurgische Abteilung, Spital Oberengadin, Samedan,
2
Pathologisches Institut, Kantonsspital, Chur
Desmoid tumors associated with Gardner’s syndrome are more difficult to treat than colonic
poloyposis: 25 years follow up in an extended kindred of 61 persons
Gardners’s syndrome as a variant of familial adenomatous polyposis (FAP) is associated with
colonic adenomatosis and extracolonic manifestations such as soft tissue tumors and osteomas. Desmoid tumors are the most important extraintestinal growths that are of clinical concern. Desmoids occur in about 10% of FAP affecting mainly mesenteric structures as well as
the abdominal wall. Despite their lack of metastatic potential, these lesions can cause siginificant morbidity and mortality due to their ability to surround, compress, and erode adjacent tissues. Surgical trauma is considered to be one of the major risk factors for their developement.
But surgery is unavoidable in patients suffering from FAP requiring prophylactic colectomy.
However, radical surgical excision has proved to be the treatment of choice.
Since 25 years we observe an extended kindred of 61 people (3 generations: 22 women,
39 men), aged from 1-74 years. The diagnosis of desmoid tumor was made by clinical
inspection, CT scan and exploratory laparatomy. Particular attention was given to the anatomical site and to the history of previous surgery.
A total of 7 persons (4 women, 3 men) were affected by desmoid tumors. Desmoids were
found exclusively wthin the abdomen (small bowel mesentery) in 2, in the abdominal wall
alone in 3, and at both sites in another 2 patients. In 5 patients desmoid tumours were diagnosed 2-5 years following surgery for colonic resection. Desmoid tumors resulted in death
in 2 patients.
Abdominal wall desmoids rarely cause serious clinical problems, whereas those within the
abdomen can obstruct the bowel an ureters, as well as making abdominal surgery difficult
22
swiss knife 2004; special edition
or impossible. Often the desmoid tumors develope 2-5 years after operation. We made
good experience by radical resection of abdominal wall desmoids. For intraabdominal desmoids medical therapy may be an acceptable alternative since they are often not resectable. Intraabdominal desmoids may not cause any symptoms for long periods. Therefore we
advocate the widespread use of CT scans or MRI to detect these life threatening tumors with
unpredictable course as early as possible.
10.15
F. Volonte, M. Chilcott, O. Nafidi, PH. Morel
Clinique et Policlinique de Chirurgie Viscérale, Hôpitaux Universitaires de Genève
Textilome: migration complète d’une compresse intra-abdominale
dans le colon sigmoÏde et expulsion par les voies naturelles
Introduction: Le textilome, ou corps étranger chirurgical est une condition rare mais potentiellement dangereuse qui peut compliquer de façon importante tout type de chirurgie. Cela
amène souvent à des interventions chirurgicales supplémentaires et répétées associées à
une morbidité et mortalité importantes.
Description du cas: Il s’agit d’une patiente de 32ans, en bonne santé habituelle, connue pour
trois césariennes dont la dernière 4 mois avant son hospitalisation, qui présente des douleurs
abdominales crampiformes en fosse iliaque gauche. S’associent des diarrhées importantes
et des vomissements occasionnels. A son arrivée, le CT-Scan montre une masse hétérogène
bien délimitée de 10x5 cm, entourée d’une coque épaisse et en contact direct avec la paroi du
sigmoïde. Le diagnostic retenu est celui de textilome en voie de fistulisation avec le colon sigmoïde. L’indication opératoire est retenue. Le jour avant l’opération, la patiente ne présente
plus de douleurs et affirme avoir pu aller à selles de façon très importante. Un CT-Scan de contrôle montrera alors la disparition du corps étranger et, à la place, une cavité collabée à parois
épaisses en communication directe avec le colon sigmoïde.
Conclusions: Avec l’aide de ce cas, nous présentons une revue de la littérature centrée sur
l’évolution naturelle, le pronostic, la prise en charge et la prévention du textilome intra abdominale.
10.16
C. Toso, P. Majno, A. Andres, T. Berney, L. Buhler, PH. Morel, G. Mentha
Service de Chirurgie Viscérale, Hôpital Cantonal, Genève
Hepatocellular adenoma in adults:
management of single-uncomplicated, multiple and ruptured tumors
Background: hepatocellular adenomas (HA) can present as single-uncomplicated, multiple
or ruptured tumors. Although the characteristics of HA have been described often, some
controversy remains on the management of its various forms.
Methods: 25 consecutive patients operated for 58 HA (9 simple, 6 multiple,10 ruptured)
were reviewed.
Results: All simple HA (2.2 to 14cm in size) were removed. Two included foci of hepatocellular carcinoma. In the multiple HA group, additional tumors were identified during surgery
in 5/6 cases by ultrasonographies and biopsies. In three cases with multiple spread HA (7,
>10 and >10 HA), several lesions had to be left unresected. They remained unmodified after
4, 6 and 6 years of radiological follow-up. Patients with ruptured HA (1.7 to 10cm in size)
were initially managed with hemodynamic support and angiography, allowing the embolization of actively bleeding tumors in two patients. All ruptured tumors were subsequently
removed electively, 5.5 days (4-70) after admission.
Conclusion: Tumors suspect of HA should be resected, whatever the size, because HA can
bleed (10/25 patients) or contain malignant foci (2/25). Although it is desirable to remove
all lesions of multiple HA, this may not be possible in some patients, for whom long-term follow-up is advised. Ruptured HA can be primarily managed by hemodynamic support and
angiography, allowing secondary elective surgery.
10.17
F. Dahm, M. Weber, M. Selzner, L. McCormack, PA. Clavien
Universitätsspital Zürich
Laparoscopic liver resections: experience in 13 cases
Background: Laparoscopic techniques have not been widely applied to liver surgery due to
safety and technical issues. Yet in selected cases, especially when a minor hepatic resection would necessitate a relatively large laparotomy, laparoscopic liver resections are indeed
feasible and larger numbers are being reported.
Method: Since June 2002 we selected 13 cases for laparoscopic resection of hepatic lesions. Median age was 45 years (26-78) and 12 patients had normal liver function. Standard
liver workup was supplemented by intraoperative ultrasound in each case. Laparoscopic
resections (8 left bi-segmentectomies, 4 wedge resections, 1 cyst deroofing) were performed by an experienced team of hepatobiliary and laparoscopic surgeons, using ultracision, tissulink, clips, vascular stapler and argon beam. Hepatic inflow occlusion was done in
9 cases. All specimens were evacuated with an endobag. No conversion to open surgery
were necessary. Histological diagnosis were FNH (5), hemangioma (2), adenoma (1),
retention cyst (1), biliary hamartoma (1), HCC (1) and metastatic carcinoid (1), i.e. only 2
patients had an underlying malignancy.
Results: There was one intraoperative (pneumothorax) and one postoperative complication
(pneumonia and effusion). No liver specific complications ocurred. ALT and AST peaked at
a median of 92 (47-291) and 163 (53-301), while bilirubin and quick were almost unchanged. Patients were discharged after a median of 4 days (2-13).
Conclusion: Laparoscopic hepatic surgery is an excellent treatment modality for highly
selected cases, and is associated with low morbidity and early hospital discharge. Benign
lesions in the left lateral and anterior liver segments or superficially located are clear indications for laparoscopic resection. The role of laparoscopic resections in malignant lesions
still needs to be defined. Advanced skills in hepatobiliary and laparoscopic surgery are needed, supplemented with advanced technical infrastructure. For this reason laparascopic
liver surgery should be restricted to specialized centers.
10.18
G. Beldi 1, M. Styner 2, H. Waelti 2, D. Candinas 1
1
Dept. of Visceral and Transplant Surgery, Inselspital, University Hospital, Berne, Switzerland,
2
Maurice E. Müller Insitute, Berne, Switzerland
Intraoperative three-dimensional cholangiography
Background: In laparoscopic and open liver surgery full appreciation of the detailed biliary anatomy is the key to avoid biliary complications and its associated morbidity. Precise intraoperative assessment of the architecture of the biliary tree optimises intraoperative dissection and
helps to reduce damage to the intra- or extrahepatic bile ducts. Here we report our preliminary
experience with intraoperative three dimensional cholangiography in the clinical setting.
Methods: Isocentric C-arm fluoroscopy acquires a defined set of images in 60 to 120 seconds
during a 190° orbital rotation. Water soluble contrast medium is injected via the cystic duct.
The bile ducts are displayed by real-time rotational projections or multiplanar reconstructions.
This technique was evaluated initially by experiments in a human cadaver. Intraoperative data
acquisition was subsequently performed in three patients with centrally located liver malignancies: One hepatocellular carcinoma and two cholangiocellular carcinomas.
Results: Three dimensional cholangiography was safe and successfully performed in all
three patients. For each operation one intraoperative acquired dataset sufficiently revealed
important anatomical details of the architecture of the bile ducts.
Conclusion: Perioperative biliary imaging can be improved by the application of intraoperative three dimensional cholangiography. By defining landmarks of the liver in a three dimensional space, this technique has the potential to develop into an important tool for navigation in liver surgery.
10.19
BM. Schmied 1, M. Kremer 1, M. Thorn 3, P. Schemmer 2, HP. Meinzer 3, MW. Büchler 2,
K. Zgraggen 1
1
CHUV Lausanne, 2Universität Heidelberg, 3Deutsches Krebsforschungszentrum (DKFZ)
The accuracy of preoperative CT based liver volumetry in major liver surgery
Major hepatectomies often require preoperative three-dimensional visualization of the liver
volume and its biliary or vascular trees. Particularly in living donor liver transplantation the
exact illustration of the anatomical proportions are of crucial importance. Up to now there
are no reliable data concerning the accuracy of the calculated to the real liver volume.
In this study we tested in the porcine model the accuracy of a newly established algorithm
and compared it to 20 of the most common published techniques. A total of 15 pigs were
anesthetised and a three-phase CT scan of the liver in 3 mm slices was performed. A three
dimensional visualisation and calculation of the liver volumes was performed by computer assisted processing. Subsequently the pigs were hepatectomised and the liver volumes
were calculated by the principle of Archimedes. The arterial and venous vessel trees were
then plastinated and the parenchyma digested. The sculptures did undergo another thin sliced CT Scan. The real volumes of the vessel trees were again determined by the principle of
Archimedes. The calculated and measured volumes of the parenchyma and the vessel
trees were compared to each other and statistically analyzed.
Our results show that the virtual computer assisted volumetry of thin sliced CT scans produce precise data on liver volume, with a significant increase of the accuracy of the newly
developed algorithm (p<0,001). The calculated non functional liver volume represented by
the vessel trees count for about 8 % of the total liver volume but is significantly higher when
measured by the principle of Archimedes (12%). The portal venous phase reveals branches
up to the fourth grade, the arterial phase up to the 2nd grade. However, on the base of plastination the branches up to the 6th grade can be visualized and the real blood volume can
be measured more accurately.
The computer assisted three dimensional volumtery gives not only precise information of the liver
anatomy but also on liver volumes and the vessel trees. These information are of crucial importance in planning and performing major hepatectomies or living donor liver transplantation.
10.20
A. Ringger 1, D. Inderbitzin 1, J. Reichen 2, D. Candinas 1
1
Departement of Visceral and Transplantation Surgery, University Hospital Berne,
2
Departement of Clinical Pharmacology, University Hospital Berne
First experiences with M.A.R.S. at the university hospital of Berne
Standard medical supportive therapy in liver failure alone cannot provide sufficient hepatic
support to allow liver regeneration. M.A.R.S (Molecular absorbent re-circulating system) is
a device developed to dialyse blood and remove albumin-bound as well as water-soluble
toxins accumulated as a result of liver malfunction.
First results: A total of five patients (13 cycles) were treated with MARS since November
2002. Patient one was treated after radical resection of a cholangiocarcinoma for a small
size liver remnant presenting with fulminant liver failure. The patient left hospital 23 days
after resection. Patient two was treated for acute liver failure due to paracetamol intoxication. She left hospital 15 days after MARS treatment. Patient three was bridged with MARS to
retransplantation after primary non function of an orthotopic liver transplant and was discharged 17 days after MARS treatment and successful re-transplantation. In patient four
MARS treatment was initiated in a cirrhotic patient due to acute on ≤≤chronic liver failure
following emergency cholecystectomy but had to be discontinued due to the patients
request. The patient died 5 days thereafter. In patient five MARS treatment was stopped due
to persisting sepsis following aspiration in a cirrhotic liver remnant after radical resection of
a hepatocellular carcinoma. The patient died 2 days after the last treatment.
Conclusions: Due to the small number of patients as well as the diversity of aetiologies of
hepatic insufficiencies our experiences remains centred on individual cases. No technical
problems were observed. In our experience however, the lack of precise MARS treatment
parameters and parameters determining treatment success coincides with observations
made elsewhere.
10.21
Y. Durmishi, G. Chassot, P. Bucher, L. Buhler, A. Roth, G. Mentha, PH. Morel
Hôpitaux Universitaires de Genève
Long term results after pancreatoduodenectomy for cancer
Introduction: Pancreatic cancers and particularly pancreatic adenocarcinomas remain
common digestive cancers with high mortality rates. Curative surgical resection is the best
therapy for this type of neoplasia.
Method: We analysed retrospectively all cases of cephalic pancreatoduodenectomies performed for cancer between January 1994 and August 2003 at our institution. Patients with
stage II disease received adjuvant chemo-radiotherapy. The type of intervention, the pathological stage and the long-term follow-up were studied.
Results: A total of 123 patients were operated during this period. The technique used was
either a Whipple resection (DPC, n=85) or a pancreatoduodenectomy with conservation of
the pylorus (DPCPP, n=38). Histopathological diagnoses were adenocarcinoma of the pancreatic head (n=63), of Vater’s ampulla (n=24), of the distal choledochus (n=11), of the
duodenum (n=6), endocrine tumors (n=5), carcinoid tumors (n=5), mucous cystadenocarcinomas (n=2), as well as metastases or gastric cancers infiltrating the pancreas. The
postoperative mortality was 8,9% (11 deaths, 5 of which were classified ASA III) and morbidity was 45 %. The major common surgical complication was a leak of the pancreatic
anastomosis (18,6% or n=23). The median survival within the group of pancreatic adenocarcinomas was in correlation with the staging, i.e. over 800 days for patients with stage I,
and 370 days for patients with stage IIb. For patients with ampullomas, survival was significantly longer, i.e. a median time of 1172 days. Regarding distal choledochal cancer, median survival was 490 days. The median survival after DPCPP (680 days) was longer than
after DPC (439 days).
Conclusion: Curative treatment of pancreatic tumors remains a challenge. DPCPP should
be attempted for resectable tumors, as it allows better abdominal comfort and is not a risk
of shorter survival. A multidisciplinary approach, involving surgeons, gastro-enterologists,
radiologists and oncologists should allow further improvements of results.
10.22
P. Bucher, G. Chassot, Y. Durmishi, Ph. Morel
Visceral and Transplantation clinic, Department of Surgery, Geneva University Hospital
Long-term results of surgical treatment for vater’s ampulla neoplasms
Background: Vater’s ampulla neoplasm are quite rare, however they account for 40% of
resected bilio-pancreatic confluent tumors. Study aim was to review the long-term results of
surgical treatment of Vater’s ampulla neoplasms.
Methods: A retrospective review from 1993 to 2002 identified 55 patients admitted for
Vater’s ampulla neoplasm in our institution. Clinical, surgical, pathological and follow-up
data were reviewed.
Results: Among the Vater’s ampulla neoplasm reviewed, 10 were adenoma (median age
71) and 45 adenocarcinoma (median age 69). 60% percent of the adenoma were treated
surgically (ampullectomy 1, pancreaticoduodenectomy 5) with excellent long-term results.
Among the Vater’s ampulla adenocarcinoma the resecability rate was of 84%. 34 patients
had a pancreaticoduodenectomy and 4 an ampullectomy. Seven were treated by endoscopy due to poor condition. Of note among the resected patients the rate of false negative
during preoperative biopsies was of 45%. Actuarial five years survival after pancreaticoduodenectomy was of 68%, compare to 0% for ampullectomy and endoscopic treatment
(p<0.01). After curative resection (pancreaticoduodenectomy), the lymph node status
significantly influenced survival (P<0.01). And disease free survival at 5 years was of 84%
for N0 and of 27% for N1 (p<0.001). Among the pancreaticoduodenectomies, 55% consisted of pylorus preserving procedure which did not influence prognosis compare to absence of pylorus preservation.
Conclusion: Treatment of Vater’s Ampulla neoplasms through pancreaticoduodenectomy is
associated with good long-term results However, the prognosis of Vater’s ampulla adenocarcinoma after curative surgical resection is dependant on the lymph node status.
swiss knife 2004; special edition
23
10.23
1
1
2
1
E. Burri , C. Glaser , G. Cathomas , CA. Maurer
1
Chirurgische Klinik, Kantonsspital Liestal
2
Kantonales Institut für Pathologie, Kantonsspital Liestal
Adenoma of the ampulla vateri: a cause for secondary biliary cirrhosis
Case report: Secondary biliary cirrhosis (SBC) occurs after chronic obstruction of the bile
duct system. Gallstones, postoperative and postinflammatory bile duct strictures and chronic pancreatitis are the most common causes of chronic obstruction. Benign intraluminal
tumors of the biliary tree have been reported to cause SBC but are very rare and patients
with malignant disease hardly survive long enough to experience liver cirrhosis. We report
the cases of two patients with adenoma of the Papilla Vateri and secondary biliary fibrosis
and cirrhosis. A newly developed jaundice led to admission to the hospital in both cases.
Diagnostic work-up by abdominal ultrasound, computed tomography, endoscopic retrograde cholangiopancreaticography and laparoscopy with intraoperative liver biopsy revealed
a solitary tumor of the Papilla Vateri in both cases, in one associated with liver fibrosis and
in the other associated with liver cirrhosis due to chronic cholostasis. Viral hepatitis was
excluded and there was no history of alcohol abuse. The tumors were resected in one case
by pylore preserving partial pancreaticoduodenectomy and by ampullectomy in the other.
Final histological analysis confirmed adenoma of the Papilla Vateri in both cases and revealed malignant transformation in one patient.
Secondary biliary cirrhosis due to adenoma of the Papilla Vateri has to the best of our
knowledge not been previously reported.
10.24
CA. Seiler1, S. Schmid1, CA. Redaelli 1, P. Bischoff 1, B. Lauterburg 2, J. Reichen 2, D. Candinas 1
1
Dept of Visceral and Transplantation Surgery Inselspital,
University of Berne, Berne, Switzerland,
Dept of Clinical Pharmacology and Hepatology Inselspital,
2
University of Berne, Berne, Switzerland
20 years of liver transplantation in Berne and in Switzerland
Background: After the first Orthotopic Liver Transplantation (OLT) in the world, performed
more than 40 years ago, the first OLT in Switzerland was performed 1983 in Berne. OLT
meanwhile has become the standard treatment for end stage liver disease and nowadays
interest is focused more on long term survival and quality of life after liver transplantation
rather than technical aspects and short term results.
Patients and Methods: Prospective analysis of all 192 OLT performed in Berne divided into
3 periods (1983 – 1985; 1987 – 1990 and 1991 – 2004). Beyond peri-operative parameters long term follow up and quality of life (Visual Analogue Scale and Sickness Important
Profile) were evaluated.
Results: Actuarial patient survival 1, 5 and 10 years was: in the first period (1983 – 1985)
40%, 40%, and 20%; in the second period (1987 – 1990) 60%, 60% and 47%; in the third
period (1991 – 2004) 92%, 89%, and 81%, respectively. Actual 1 and 5 year patient survival is 94% and 93%, respectively. Detailed assessment showed the quality of life 1 year
after liver transplantation to equalise in the majority of cases the quality of live of sex and
age matched controls. In consequence, more than 70 % of the transplanted patients are
able to work normally and take care of their own and their family’s life. As a further consequence of this, adding direct and indirect costs for an OLT the average Swiss household
saves 21 878.— CHF per saved life year per liver transplanted patient compared to ongoing
conservative treatment and premature death.
Conclusion: 20 years ago liver transplantation was introduced in Switzerland under pioneering circumstances. Meanwhile OLT has become the standard treatment for end stage liver
disease achieving good long term survival, excellent quality of life and a good reintegration
of the patients into social and working life thereby contributing to a reduction of the overall
costs for the treatment of end stage liver disease.
10.25
P. Majno 1, C. Le Coultre 2, PH. Bugmann 2, L. Bühler 1, Th. Berney 1, Ph. Morel 1, G. Mentha 1
1
Transplantation and Visceral Surgery, 2Pediatric Surgery, University Hospitals, Geneva
Optimal use of split liver grafts and of pediatric donors fulfills the need of liver
transplantation in children
Introduction: It has been suggested that the techniques of liver reduction and living-donor
liver transplantation - costly in terms of available grafts and operative risk for the donors,
respectively - are obsolete thanks to in situ liver splitting and optimal use of pediatric grafts.
The aim of the present study is to evaluate the impact of the two latter options in a combined adult and pediatric program.
Methods: review of our experience of pediatric liver transplantation in the past 5 years,
when in-situ liver splitting has been the favored technique, and during which it has been
possible to optimize the use of pediatric grafts thanks to a supranational network allocating
organs that had no recipient in their native country.
Results: Since 1.06.1998 we performed 36 liver transplants in 35 children (median age: 1,6
years, rage : 0.4 –16 years). We used 17 whole size grafts (16 from pediatric donors and
one adult graft), 10 split-liver grafts: segments 2-3 in 9 cases (between a child and an
adult) and segments 1+4-8 in 1 case (between two children), and 9 reduced livers on pediatric grafts to compensate for a donor-recipient size mismatch. No graft that could be used
24
swiss knife 2004; special edition
for an adult was used for a child alone. Two children died on the waiting list (abdominal sepsis on intestinal obstruction and cerebral haemorrhage), all other children were transplanted after a median waiting time of 10 weeks. Four patients died: 3 after fulminant hepatitis
(primary non-function, GVH disease and brain oedema) and one with a myelodysplastic
syndrome of massive pulmonary embolism after a biliary repair. Vascular complications
occurred in 5 cases, none causing graft loss. Biliary complications occurred in 6 cases, 4
of which required re-operation. Survival at 1, 3 and 5 years was 89%.
Conclusions: In our country, the full use of pediatric donors and of the split liver technique
allowed to transplant all children without resorting to living donors or to grafts potentially
needed by adult recipients.
10.26
P. Majno 1, S. Terraz 2, O. Nafidi 1, L. Bühler 1, T. Berney 1, Ph. Morel 1, G. Mentha 1
1
Transplantation and Visceral Surgery, 2Radiology,
3
Pathology University Hospitals, Geneva
Transarterial chemoembolization before liver transplantation for hepatocellular carcinoma
Aim: To evaluate the effects of selective transarterial chemoembolization (s-TACE) in
patients with suspected hepatocellular carcinoma (HCC) before liver transplantation.
Patients and methods: 36 candidates to OLT and a total of 64 nodules suspected of HCC
(median 2.5 cm, interquartile range 1.5 to 3.2, range 0.7 to 6.5 cm) underwent 62 sessions of TACE with doxorubicin-lipiodol in 1-3 sessions. Catheter position was sub-segmental
23 (37%), segmental in 19 (31%) and unilobar in 20 (32%) sessions. Particles were added
unless complete stasis was observed (50% of the sessions). The delay between TACE and
OLT was 149 days (5 to 500 days). Histological findings in the explanted liver were correlated with all clinical, biologic and radiological parameters.
Results: Post embolization syndrome with pain and fever developed after 15 sessions
(24%).One patient developed an arterial pseudo-aneurysm at the puncture site, and one
patient had a variceal bleed that decompensated the cirrhosis form B to C at the time of
transplantation. No other complications were observed. Histological examination of the
explanted livers showed 48 HCC, 2 hepato-cholangio carcinomas, 5 dysplastic nodules, 5
regenerative nodules, 1 focal nodular hyperplasia, and 3 nodules could not be localized.
Among the 55 malignant or dysplastic nodules, we observed 100% necrosis in 25 (45%).
90%-99% necrosis in 8 (15%), 50%-89% necrosis in 7 (13%) and 0%-49% necrosis in 27.
Apart from completion of the embolization protocol before LT (p=0.003), no other factor
was associated with complete response on univariate analysis. (size p=0.09). Although
tumor differentiation could not be thoroughly assessed in necrotic nodules, in the 33 nodules with > 90% necrosis there was no vascular invasion, and capsular invasion was observed in only 1 nodule, while among the 22 nodules with < 90% necrosis, 13 nodules had
capsular and /or vascular invasion (p< 0.001).
Conclusions: s-TACE leads to >90% necrosis in the 60% of HCC or dysplastic nodules. The
absence of signs of invasivity in the nodules with good response suggests that response to
TACE could be used as a surrogate marker for favorable tumor biology.
10.27
PC. Nett 1, BD. Shames 2, LA. Fernandez 2, DM. Heisey 2, JD. Pirsch 2, HW. Sollinger 2
1
Universität Bern, Departement für Viszeral- und Transplantationschirurgie, Berne, Switzerland, 2University of Wisconsin, Hospital and Clinics, Division of Organ Transplantation,
Madison, USA
Association of non-melanoma skin cancer with post-transplant malignancy in kidney transplant recipients
Introduction: Patients with non-melanoma skin cancer (NMSC) are at increased risk to
develop secondary invasive malignancy. NMSC is the most frequent type of cancer occurring after kidney transplantation. However, it is unknown whether an association between
NMSC and the occurrence of invasive malignancy in kidney transplant recipients exists.
Material and Methods: Risk factors associated with increased post-transplant rate of malignancy were retrospectively analyzed in a single-center kidney transplant population by
means of Cox-proportional hazard and time-varying models.
Results: Between January 1994 and December 2000, 1571 kidney and simultaneous pancreas-kidney transplants were performed at the University of Wisconsin. 24 patients (1.5%) had
a history of pre-transplant NMSC. During an average follow-up of 3.9 years (range 1 to 7.2
years) 95 patients (6.0%) developed post-transplant cancer (58 NMSC, 30 invasive malignancy, and 7 both). The most common post-transplant invasive malignancy was lymphoma
(6.4%), breast (3.8%), and colorectal carcinoma (2.5%). An increasing age (RR=1.03,
P=0.024) and the presence of pre-transplant NMSC (RR=3.7, P=0.02) both resulted in a significant higher risk for post-transplant invasive malignancy. Analysis with the time-varying model
showed that the occurrence of post-transplant NMSC was an equally important prognostic
risk factor for development of post-transplant invasive malignancy (RR=3.4, P=0.028) leading
to an increased risk for death with functioning graft (RR=12.2, P<0.0001).
Conclusions: This retrospective analysis showed that kidney transplant recipients with a
history of pre- or post-transplant NMSC are at increased risk for invasive malignancy suggesting that the development of any non-melanoma skin cancer (pre- or post-transplant)
should increase vigilance for invasive malignancy.
10.28
1
1
1
O. Nafidi , P. Majno , Y. Durmishi
Transplantation and Visceral Surgery, University Hospitals, Geneva, 2Hepatogastroenterology, University Hospitals, Geneva
1
Medical morbidities in patients who survived 10 years after liver transplantation
Methods: cohort analysis all patients surviving longer than 10 years since the start of the
program in our hospital (July 1987).
Results: Of the 55 patients transplanted up to December 1993, 36 were alive after 10 years
(65,45 %),(median follow-up: 13 years). There were 12 females and 24 males, mean age
at transplantation 45 years (range 16 years –64 years). The indications were: cholestatic
diseases (13), Hepatitis C (10), Hepatitis B (6), fulminant hepatic failure (2), ethanol (3),
metabolic (2), retransplantation for chronic rejection (1). All patients had a triple immunosupppression of Azathioprine, Cyclosporine and prednisone, later adjusted to mycophenolate and low dose calcineurin in all except for 2 presently on rapamycin. Prednisone was
stopped in all patients except 6: 3 with de-novo autoimmune hepatitis, and 3 with concomitant medical indications. Recurrent primary disease was seen in 10 of 10 patients with
HCV, 2 at the stage of cirrhosis, in 2 / 10 patients with PBC, and in 1 of the 3 patients transplanted for alcoholic disease. No patient transplanted for HBV or PSC had recurrent disease. At 10 years, 50 % (18/ 36) are treated for hypertension, 11,1 % (4/ 36) for diabetes, and
11.1 % for hyperlipidaemia. Impaired renal function (GFR < 50 ml/ min) is observed in 22,5
% (8 / 36), and one patient needed a renal transplant. A vertebral bone-density loss of – 1
SD was seen in 32% (9/28) and in the femoral neck in 74 % (20/27), despite propylactic
treatment. Vertebral body fractures occurred in 16 % (6/36) and aseptic necrosis of the
femoral heads, requiring hip joint replacement in 6% (2/36). Extra-hepatic tumours occurred in 6/36 of the patients none causing patient’s death so far.
Conclusion: The overall health status was satisfactory in patients reaching 10 years after
transplantation, and recurrent liver disease was seldom a problem, except in HCV patients.
The complexity of medical problems, and in particular the danger of renal failure, mandates
to continue a specialized follow-up, associating nephrological and hepatological expertise.
10.30
PC. Nett 1, DM. Heisey 2, BD. Shames 2, LA. Fernandez 2, JD. Pirsch 2, HW. Sollinger 2
Universität Bern, Departement für Viszeral- und Transplantationschirurgie, Berne, Switzerland, 2University of Wisconsin, Hospital and Clinics, Division of Organ Transplantation, Madison, USA
1
The time point of a first acute rejection but not the actual graft function at rejection influence
the longterm kidney transplant survival
Introduction: The time point of a first acute rejection (AR) episode after kidney transplantation is correlated with a variable risk for graft loss. However, it is unknown whether the increased risk for kidney graft loss after a late AR episode is due to an impaired graft function. The
purpose of this retrospective study was to investigate if the time point of a first AR episode
influences the risk for kidney graft loss and whether this time-dependent risk is correlated
with the serum creatinine as an indicator for kidney graft function.
Material and Methods: In a retrospective study time-dependency of graft loss after a first AR
episode and the influence of actual graft function on graft survival were analyzed in a
cohort of 730 primary cadaveric donor kidney recipients by means of Cox-proportional
hazard and time-varying models.
Results: Statistical analysis revealed that a first AR within 0-30days, 31-365days, or
>365days post-transplant conferred a 3.1, 9.1, and 49.3-fold risk for graft loss compared to
the reference group without rejection (P<0.001). By including serum creatinine as an indicator for graft function at the time of a first rejection, the risk for graft loss decreased to 2.4,
7.1, and 21.8-fold, but remained still significant (P=0.023).
Conclusions: Our study provides further evidence that the risk of graft loss after kidney
transplantation increases the later the first episode of AR occurs. Although serum creatinine as an indicator for kidney graft function reduced the time-dependent risk of a first AR episode on graft loss, the impact of late AR seems to be only partly related to the actual graft
function at rejection.
10.31
F. Dahm, M. Weber, DR. Mattiello, N. Demartines, PA. Clavien
Universitätsspital Zürich
Ileum or colon conduit as bladder replacement for kidney transplantation: technical aspects
and long-term outcome
Background: Kidney transplantation is the standard of care for end-stage renal disease,
usually performed with implantation of the ureter into the recipient bladder. Rarely, kidney
transplantation has to be performed in patients with conduit urinary diversion due to congenital or acquired abnormalities of the lower urinary tract.
Method: Between 1975 and 2002 a total of 2080 kidney transplantations were performed.
Of these 19 transplantations were done in 16 patients with an ileal (15) or colon (1) conduit. These were 14 males and 2 females, with a mean age of 38 years (21-60). In all but
two patients conduits were constructed before transplantation (a mean of 8.6 years).
Urinary diversion was for neurogenic diseases (5), after neoplasia (5), congenital abnormalities (4) and other reasons (2). Perioperative mortality for conduits was 1/16, in a
patient who had already received his transplant. Furthermore one case of stomal prolapse
and one ureteral anastomotic stricture occurred. All patients were on hemodialysis for a mean
of 4.1 years prior to transplantation and received cadaveric organs (one non heart beating
donor). Etiology of renal failure was reflux nephropathy (7), chronic pyelonephritis (3), glomerulonephritis (3) and varia (6). Native kidneys were removed in 11 patients (7 bilaterally).
Results: Kidney transplantation was performed in standard heterotopic technique in the
iliac fossa, except for the modified ureteral implantation into the conduit. Transplantation
had no perioperative mortality. 14 complications occurred in 11 patients: ureteral stricture
(3), pulmonary edema (3), anastomotic leakage (1), vascular complications with graft
nephrectomy (1) and others (6). Five patients had acute rejection and two had delayed
graft function. Mean creatinine at 1 year was 150µmol/l.
Conclusions: We present one of the larger series of kidney transplantation in patients with
urinary diversion along with a technical guide. Although multistep operations are required
in these complex patients, it is feasible and the outcome acceptable. These patients should
not be excluded from transplantation.
10.32
D. Dindo, M. Weber, E. Stöckli, A. Frey, P. Ambuhl, N. Demartines, PA. Clavien
University Hospital Zurich
Risk analysis for outcome of renal transplantation: a single centre experience
Background: Quality assessment has gained increasing attention in medicine. However,
there is still a lack of a proper method assessing quality in renal transplantation. The dramatic organ shortage urges risk-adjusted, standardized outcome reports to compare
results within and among different centres to reach highest possible standards. This study
aimed to evaluate risk factors for graft failure in renal transplantation and to assess surgical outcome using a complication classification.
Methods: A retrospective study was carried out on 517 patients that were transplanted over
a ten years period in our institution. Systemic complications were differentiated from local
complications that were defined as complications involving the transplanted kidney, ureter
or urinary bladder. Postoperative complications were also assessed using a novel management-based five-scale classification. Risk factors for graft failure were analysed using multivariate logistic regression models.
Results: Self-limiting complications (grade I) occurred in 22.2% of the patients, pharmacological treatment (grade II) was indicated in 21.9%, invasive treatment of postoperative
complications (grade III) in 18.2% and complications requiring intensive care management
(grade IV) in 3.3% of the patients. 2.7% of the patients died within 30 days after transplantation (grade V). 21.5% of the grafts of the entire study population failed during the followup. If patients were censored for death with functioning graft (DWFG), failure rate was
18.4%. Multivariate analyses identified perioperative blood transfusion (p<0.001) and local
(p<0.001) as well as systemic complications (p<0.001) as independent risk factor for graft
loss (censored for DWFG) and cardiac history (p<0.001), perioperative blood transfusion
(p<0.001) and systemic complications (p<0.001; not censored for DWFG).
Conclusion: Risk-adjusted, standardized outcome data in kidney transplantation are required
for proper comparison of quality within and among centres. Therefore, this analysis endeavours to identify risk factors for creation of a risk profile for kidney transplant recipients.
10.33
U. Giger 1, JM. Michel 1, R. Vonlanthen 1, TH. Kocher 2, L. Krähenbühl 1
Department of General Surgery Kantonsspital Fribourg,
2
Swiss Association for Laparoscopic and Thoracoscopic Surgery
1
Laparoscopic cholecystectomy for acute cholecystitis:
a prospective 7-year multicenter analysis of 5`289 cases
Definition: Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic cholelithiasis. However, the laparoscopic approach has remained controversial for
patients with acute cholecystitis (AC) because higher conversion and complication rates such
as major bilde duct injuries compared to open cholecystectomy (OC) are reported.
Methods: The Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS)
keeps a prospective maintained computer data base. Treatment and outcome of all patients who underwent LC from January 1995 to December 2002 at currently 114 surgical
institutions (universities, district and county hospitals and surgeons in private practice)
were prospectively recorded and analysed.
Results: 5,289 patients with AC were investigated. A conversion rate of 15.9%, Veres needle and trocar injuries of 0.47% and perioperative bleeding complications of 3.3% were
observed. Bile duct injury occured in 0.3%. Furthermore, common bile duct stones were
found in 7.5%, malignant tumour in 0.43% and Mirizzi`s syndrome in 0.61%. Postoperative
morbidity and mortality was 11.8% and 0.4%, respectively. Reoperation was necessary in
1.3% of patients. Only 1.1% of patients required rehospitalisation during a 30 days followup period after the initial hospital discharge.
Conclusions: In this study, to our knowledge the largest series yet reported, early LC in AC is
technical feasible and safe. The main problem remains the high conversion rate which, however decreased over the evaluation-time. Although bile duct injuries remain more frequent in LC,
the perioperative morbidity in our series is much lower than that reported for OC.
swiss knife 2004; special edition
25
10.34
1
3
2
C. Kulli , T. Kocher , M. Schäfer
1
Dept. of Surgery, County Hospital of Bülach, Switzerland,
2
Dept. of Visceral and Transplantation Surgery, University of Zurich, Switzerland,
3
Swiss Association for Laparoscopic and Thoracoscopic Surgery, Aarberg, Switzerland
Conversion from laparoscopic to open cholecystectomy: the swiss experience
Aims: Laparoscopic cholecystectomy (LC) has almost completely replaced open cholecystectomy (OC) for treating symptomatic gallstone disease and acute cholecystitis. The
main goal of this study was to investigate the incidence and reasons of conversion from LC
to OC in the laparoscopic era beyond the learning curve in Switzerland.
Methods: The Swiss Association for Laparoscopic and Thoracoscopic Surgery prospectively collected the data of all patients undergoing laparoscopic cholecystectomy between
1995 and 2002. This database was investigated with special regard to patients that needed conversion from laparoscopic to open cholecystectomy.
Results: There were 25’071 patients (sex ratio male/female 0.46, mean age 55.1 yrs) with
symptomatic cholecystolithiasis (SCCL), 5’289 patients (sex ratio male/female 0.84,
mean age 58.8 yrs) with acute cholecystitis (AC) and 679 patients (sex ratio male/female
0.81, mean age 66.1 yrs) with gallbladder empyema (EMP). The overall conversion rates for
SCCL, AC and EMP were 6.4%, 15.9% and 36.4%, respectively. Conversion was mainly caused by the inability to correctly identify anatomical structures in the triangle of Calot (46%53%), the occurrence of intraoperative complications (15%-23%), and planned conversions (16%-25%). The conversion rates for all subgroups significantly declined from 1995 to
2002 (SCCL 7.9% to 4.4%, AC 20.5% to 10.8%, EMP 43% to 29.1%). In particular, the number of planned conversion decreased, while the surgeon’s experience increased. The mean
hospital stay decreased for SCCL, AC and EMP from 7.2d to 5.6d, 9.4d to 7.1d, and 11.1d to
9.8d, respectively. While the incidence of bile duct injuries for SCCL remained unchanged
(0.22%), there was a significant decrease for AC from 0.43% to 0.19%. The mortality for all
patients with conversion was 0.1%.
Conclusions: Although LC has been introduced almost 15 years ago, there is still a learning
curve that influences the treatment results of symptomatic gallstone disease and acute
cholecystitis. This is probably related to the increasing surgical experience which has been
achieved in non-specialized centers for laparoscopic surgery. The conversion rate was closely related to the surgical experience.
10.35
I. Opitz 1, W. Gantert 2, UF. Giger 1, L. Krähenbühl 1
1
Cantonal Hospital Fribourg, 2St. Anna Hospital Lucerne
Intra-and postoperative complications after laparoscopic surgery
in Switzerland - a multipleregression analysis of the SALTS prospective data base
Introduction: The aim of the underlying study was to evaluate intra- and postoperative complications of different laparoscopic procedures in a nationwide prospective multicenter
study in Switzerland for a time period of 1995-2001 after the initial learning curve.
Material and Methodes: Since 1989, SALTS has prospectiveley collected data from patients
undergoing laparoscopic or thoracoscopic surgery at 108 surgical institutions (university,
county and district hospitals, private practice). More than 130 items, including indication for
surgery, intraoperative course, local as well as general complication and mortality and follow-up were recorded on a computerized data-sheet.
Results: For the time period 45.000 procedures ( 52% cholecystectomy, 18% groin hernia
repair, 12% appendectomy, 4% colorectal resection, 14% others) were evaluated and analysed. In 0.05% of the whole patient group local morbidity occurred, whereas 3.3% developed general postoperative complications. The mortality rate was 0.2%. A multiple logistic
regression anaylsis was performed in order to identify the following predictors for the incidence of intra- and postoperative complications: age, BMI, sex, ASA-classification, indication of the operation, intraoperative technical problems, the operator`s experience, the duration of the operation, the fact of conversion. Additionally, a trend-analysis of the complication rate over the time period of 1995-2001 was performed.
Conclusion: Age, the fact of conversion and the indication of operation were independently
predicting factors for complication. Although laparoscopic procedures for these indications
occur nowadays quite often, the rate of complications is still substantial. These results
demonstrate that collection of data in form of a multicenter-study is essential for quality control. It permits to visualize and to understand the current problems in laparoscopic surgery
in order to improve the quality of daily surgical practice and nationwide teaching.
10.36
P. Bisang, T. Clerici, J. Lange
Klinik für Chirurgie, Kantonsspital St. Gallen
Langzeitresultate der videoendoskopischen Oesophago-Diverticulostomie
beim Zenkerschen Divertikel
Einleitung: Seit der Einführung von Videoendoskopen und endoskopischen Staplern 1993
wird der transorale Zugang zum Zenkerschen Divertikel zunehmend angewandt. Die
Langzeitresultate der transoralen, videoendoskopischen Stapler-Oesophagodiverticulostomie (ESD) sind jedoch noch unklar.
Methoden: Wir führten eine retrospektive Untersuchung an 37 konsekutiven Patienten
durch, die zwischen 1996 und 2003 an einem einzelnen Zentrum am Zenkerschen
26
swiss knife 2004; special edition
Divertikel operiert wurden. Bei den 20 ESD, 11 offenen Operationen und 6 Konversionen
interessierte insbesondere die Zufriedenheitsrate im Langzeitverlauf.
Resultate: Nach einem medianen Follow-up von 59 Monaten waren 80% der Patienten
nach ESD und 94% nach offener Operation zufrieden und hatten keine oder minimale
Symptome. Nach ESD wurden 3 Patienten (15%) aufgrund eines Rezidivs reoperiert, nach
offener Operation sahen wir im Langzeitverlauf 1 Rezidiv (6%). Die Morbidität war in der
endoskopischen Gruppe mit 7.7% kleiner als in der offenen Gruppe mit 17.7%. Die perioperative Gesamt-Mortalität war 2.7% (n=1, kein direkter Zusammenhang mit der Operation).
Operations- und Hospitalisationsdauer waren für die ESD deutlich kürzer (28 vs. 74 min; 5.5
vs. 9.6 Tage). Divertikel von 2 cm Grösse und kleiner führten immer zu einer Konversion.
Diskussion: Die ESD wies in unserem Kollektiv deutlich kürzere Hospitalisations- und
Operationszeiten und weniger Komplikationen auf als die offene Operation. Die Rezidivrate
war allerdings höher. Der Vorteil der geringeren Invasivität überwiegt in diesem bei uns
durchschnittlich knapp 70jährigen Patientengut. Mit 80% ist die Zufriedenheitsrate im
Langzeitverlauf nach einmaliger ESD als gut zu bezeichnen, wobei mit zunehmender
Erfahrung mit dieser relativ neuen Operationstechnik mit einer weiteren Verbesserung zu
rechnen ist und die ESD eine wiederholbare Methode darstellt. Sie ist bei uns deshalb
Therapie der Wahl, allerdings nur bei Divertikeln über 2 cm, da ansonsten zu häufig konvertiert werden muss.
10.37
B. Wölnerhanssen1, B. Kern1, T. Peters 2, C. Ackermann1, MO. Guenin1, M. von Flüe1, R. Peterli 1
1
Surgical Clinic, St.Claraspital Basel,
2
Interdisciplinary Center of Nutritional and Metabolic Diseases, St.Claraspital Basel
Reduction of slippage-rate with new 11cm lapband and change
of gastric banding technique
Background: Slippage describes a typical complication after Gastric Banding: dislocation of
the band with herniation of the stomach and consecutive pouch enlargement. With the perigastric technique for Gastric Banding slippages occur in 2-18%. We investigated the slippage-rate prior and after the introduction of the pars flaccida technique and the new 11 cm
LapBand and the long term results of the re-operated patients.
Methods: Between 12/96 and 2/04 a total of 360 patients with a mean BMI of 44 kg/m2
were operated: group A (n=168, mean follow-up 65 months) in perigastric technique with
the 9.75cm LapBand; group B (n=15, 44 months) in pars flaccida technique with the
9.75cm LapBand; group C (n=177, 21 months) with the new 11cm LapBand. Follow-uprate was 97%. Prospective series.
Results: In group A, a total of 28 (17%) slippages occurred, in group B one (7%) and two
(1%) in group C. The average yearly re-operation rate for slippage in the first 3 years postop was 3.8% in group A, 2.2% in group B, and 1.2% in group C. 19 patients showed a dorsal slippage (counter clockwise rotation of the band, herniation of dorsal fundus), suffering
either from food intolerance (68%), reflux (16%) or both (11%) or insufficient satiety (5%).
They were all laparoscopically re-banded after a median of 12 (3-60) months. 12 patients
needed rebanding after a median of 18 (8-38) months for lateral slippage (clockwise rotation of the band, herniation of antero-lateral fundus) that had suffered from food intolerance (67%), reflux (25%) or both (8%). The late postoperative course was independent of the
type of slippage: uneventful in 52% of the patients after re-banding, weight regain could be
seen in 35% and/or esophageal motility disorder in 23%, secondary band intolerance in
20%, and once a persistent dorsal slippage. 8 patients (26%) needed bilio-pancreatic diversion type duodenal switch.
Conclusion: Since the introduction of the pars flaccida technique and the new 11cm
LapBandâ we observed a significant reduction of slippages. Patients after re-banding had
a less favorable long term result compared to patients after LapBand alone.
10.38
A. Lechleiter, JM. Heinicke, B. Egger, D. Candinas
Viszeral- und Transplantationschirurgie Inselspital Bern
Conversion of vertical banded gastroplasty to roux-y gastric bypass
introduction and objective: Vertical banded gastroplasty (VBG) as a treatment for morbid
obesity has shown a high failure rate necessitating conversion to Roux-Y Gastric Bypass
(RYGB) which is a technically challenging operation. The purpose of this study is to review
the main reasons for, the safety of and the outcome after conversion.
Methods: In this study 19 consecutive conversions of VBG to RYGB performed in a single
university institution since 1999 were followed up with prospective data collection.
Results: At the time of VBG the 19 patients reported had a median age of 42 years (18-59)
and a median initial BMI of 49.2 kg/m2 (40.0-61.7). The median interval between VBG and
conversion to RYGB was 36 months (10-74). In 13 cases the reason for reoperation was a
disruption of the stapler line associated with a secondary gain of weight. In 7 cases the operation had to be performed due to a symptomatic stenosis of the mesh band, which was
associated with band erosion in one of them. Two patients were reoperated because of
unsatisfactory weight loss with no technical problem found. At the time of conversion the
median BMI was 41.6 kg/m2 (30.1-49.3). The technique used was a distal Roux-Y gastric
bypass with a side-to-side-gastroenterostomy and a short common channel of 150 cm
(median operating time 360 min). The median hospitalisation time was 14 days (8-29).
Two reoperations were necessary (1 intraabdominal abscess, 1 leak at the gastroenterostomy). The actual median follow-up time is 23 months (1-62). The 14 patients with a follow-up of at least 1 year lost a mean of 4.8 BMI points (0.5-16.4) following conversion. The
11 patients presenting a BMI of >40 kg/m2 at the time of conversion lost a mean of 6.7 BMI
points (0.5-16.4, median BMI 34.9 kg/m2 versus 43.0).
Conclusion: This study suggests that the high failure rate of VGB is mainly due to mechanical problems. Conversion of VBG to RYGB seems to bear an acceptable complication rate
and a satisfactory outcome with regard to weight loss, and thus should be performed in
patients with failed VBG.
10.39
D. Azagury, A. Modaressi, A. Scheiwiller, G. Chassot, A. Carecchio, Ph. Morel,
O. Huber
Clinique de Chirurgie Viscérale, Hôpitaux Universitaires de Genève
Upper digestive symptoms before and after roux-en-y gastric bypass
Aims: Determine: 1) the frequency of dysphagia, regurgitations, and anastomotic ulcers
after Roux-en-Y gastric bypass (RYGB); 2) the prevalence of gastro-esophageal reflux disease (GERD) in morbidly obese patients and 3) the efficacy of RYGB on GERD symptoms.
Methods: During follow-up, our patients were regularly screened for post-operative dysphagia, regurgitations and anastomotic ulcers. A GERD screening questionnaire was sent to
every patient. If GERD was suspected, patients were re-evaluated. The severity of pre- and
post-operative symptoms was measured by a 0-10 visual analogical scale (VAS).
Symptom frequency and drug intake were determined.
Results: By December 2002, 295 patients had more than 6 months follow-up.
Dysphagia: 16 patients (5.4%) had mild, 4 had moderate (1.4 %) and 1 had severe postoperative dysphagia (requiring a dilatation).
Regurgitations: Present in more than 50 % of patients after 3 months, persisting in 12 cases
only (4%) after one year.
Anastomotic ulcer: Confirmed in one case and suspected but not proven in another.
Preoperative GERD: 242 screening questionnaires were analysed. From 117 patients
suspected of GERD and investigated further, the diagnosis was confirmed in 59 (24 %).
Postoperative GERD: 50 of the 59 patients became symptom free (85%); 8 (14%) only had
negligible symptoms remaining (VAS ≤ 2); one patient did not improve and one developed
new minor symptoms. The mean VAS score dropped from 6.66 to 0.35. Out of 51 patients
taking proton pump inhibitors preoperatively, only 2 still take them regularly and another
one very occasionally.
Conclusions: One fourth of morbidly obese patients suffer from significant GERD. Besides
being an excellent bariatric operation, RYGB is very effective on GERD symptoms. Furthermore,
the rate of upper digestive “complications” is low and their clinical impact minimal.
Penetrating abdominal stab wounds:
a six year, single centre retrospective study and establishment of a treatment algorithm
Introduction: Penetrating abdominal injuries are rising in incidence in most European countries.
Classical surgical management has been mandatory laparotomy, but the advent of keyhole surgery and recent publications of a more conservative approach may be changing attitudes.
Material and Method: we present a six year (1998-2003) retrospective study of 50 consecutive cases of penetrating abdominal wounds, caused by knife injury, admitted to our hospital’s emergency department. All cases were reviewed on medical files.
Results: 50 patients of mean age 30.7 (16-66) with a female:male ratio of 1:7.3. There were
8 suicides for 42 aggressions. All but six patients underwent general anaesthesia and surgery. Of the 44 surgical cases there were 7 blank laparotomies and 6 blank laparoscopies,
(13/44, 29.5%) There were no deaths.
Discussion: The retrospective analysis of the 50 cases, with particular attention to the almost
30% of unnecessary surgeries have led to the establishment of a treatment algorithm which
we present here and hope to apply in a controlled study in our centre in the years to come.
11.03
PM. Lenzlinger, R. Stärkle, H. Büchel, GA. Melcher
Chirurgie, Spital Uster
Outcome following plate-osteosynthesis of comminuted intraarticular distal radius fractures
Introduction: The treatment of complex distal radius fractures remains a challenge. At our
institution these fractures are treated with open reduction and plate fixation through a volar
approach and, if necessary, a cancellous bone graft (CBG) and/or an additional dorsal
plate. Here, we report the prospective follow-up of 50 patients operated for complex intraarticular radius fractures (AO23-C3) during a five-year period from 1998 to 2002.
Materials and methods: Between January 1998 and December 2002 we treated 60
patients (m:w = 24:36, 54+/-13 yrs.) with 61 distal multifragmentary intraarticular fractures of the radius (AO 23-C3) with volar plate osteosynthesis. In 2001 the angular stable
2,4/2,7 mm T-Radiusplate became available and replaced the 3,5 mm T-Plate as the volar
implant. Additional dorsal implants or CBG were used, as considered necessary by the surgeon. We clinically examined 51 fractures 6 to 44 months (20+/-11) postoperatively. Ten
patients were lost to follow-up or declined participation. Outcome was measured subjectively as well as objectively using a modified Garland-score.
Results: Twenty-six fractures were stabilized by a conventional 3,5 mm T-Plate (conv. group
= C) and 25 by an angular stable implant (angular stable group = A).
Main results are shown in the table below:
Group
N
Dorsal plate
CBG
2° dislocation Outcome
A (anglular stable) 25
C (conventional) 26
48%*
77%*
44%
62%
8%
27%
*Fisher’s exact test
p < 0.05
(Garland good or better)
11.01
11
V. Quarz, D. Ludin, S. Styger, C. Wullschleger, P. Regazzoni, T. Gross
Trauma Unit, Department of Surgery, University Hospital Basel, Switzerland
Proximal humerus fractures in elderly:
claim and reality of an anatomical fixation system with angular stability (PHILOS)
Introduction: In view of the increasing number of proximal humerus fractures particularly in
elderly, the optimal treatment for displaced and unstable fracture types presents a challenge for the trauma surgeon. The use of new locking plate systems promises more stability of
fracture fixation especially in the osteoporotic bone.
Methods: Prospective one year follow up of all patients undergoing reconstructive surgery with
the PHILOS-plate +/- Ticron tension bending at our department. Complications, joint-(ConstantScore) and daily function (Dash-Score), personal satisfaction and radiological course were
documented.
Results: 86% of the 90 patients who passed already one year after the operation could be
examined. 43 patients were over 70 years old (mean age 81.3 years). According to the
Neer classification 2-part-fractures were found in 30 %, 3- and 4-part-fractures in 35% each.
Patients mean satisfaction was 1.65 on the visual analogue scale (VAS, 1=absolutely content, 10=totaly discontent). 84% of patients stated no or only slight impairment for activities
of daily living. The mean Constant-Score of the operated shoulder was 61 points (85% of
the contralateral side). The mean DASH-Score was 25 points (0-100, 0=no impairment). In
comparison to the 34 patients who were <=70 years old (mean age 56 years) there was
no relevant difference in the Constant-Score (83% of opposite side), the DASH-Score (mean
21.6 points) or satisfaction (mean VAS 2.0; unpaired t-test). 5 patients (11.6%) had to
undergo implant removal +/- subacromial decompression due to a complication: 2 impingements, 2 intraarticular screw protrusions, 1 osteonecrosis of the humeral head. The problem resolved in 2 cases (4.7%) completely, in other 2 cases partially.
Conclusions: Anatomical angular stabilised implants offer a major step forward in the therapy of osteoporotic fractures. Our results demonstrate that one year after fracture fixation with
the PHILOS over 80% of the treated elderly are free of complaints or impairment. Even in severe fractures of the proximal humerus older age per se is by no means a contraindication to
joint preserving surgery.
11.02
M. Chilcott, PH. Morel
Clinique de Chirurgie Viscérale, Hôpitaux Universitaires de Genève
88%
73%
Morbus Sudeck was observed in 1 case of group A and suspected and treated accordingly
in additional two cases (one each in groups A and C).
Conclusions: Volar plate fixation of comminuted intraarticular distal radius fractures is a
good and safe treatment modality. Dislocated dorsal fragments often require additional dorsal implants; in cases of metaphyseal impaction CBG may be used. However, with the new
angular stable volar plate these two procedures are considerably less frequently necessary. Thus, these plates afford equal or better results (clinical outcome and secondary dislocation) while often requiring a less invasive procedure.
11.04
C. Buchli1, M. Wullschleger1, J. van den Brand2, C. Sommer1
1
Departement Chirurgie, Kantonsspital, Spitäler Chur AG
2
Department of General Surgery, University Medical Center Utrecht, Netherlands
Experience with routine monitoring of intracompartmental pressure and selective fasciotomy in minimal invasive osteosynthesis of tibial fractures
Introduction: Minimal invasive osteosynthesis procedures of the tibial shaft seem to cause
more acute compartment syndromes (ACS). Therefore we analysed the incidence of ACS,
relevance of preoperative clinical examination and the effectiveness of selective fasciotomy
after monitoring of intracompartmental pressure (ICP) in a prospective study.
Patients and Methods: Consecutive patients with fractures of the tibia shaft (AO 42) or head
(AO 41) with shaft involvement that needed direct operative treatment were included.
Pathological and grade IIIc open fractures were excluded. Clinical assessment of ACS was
done and registered in the emergency room. At the start of operation ICP was measured in
all four compartments with a 20-G needle connected to a pressure transducer. After osteosynthesis a clinical reassessment was performed and ICP was measured again.
Indications for fasciotomy were ICP over 40mmHg or intracompartmental perfusion pressure (IPP= mean arterial pressure - ICP) below 40mmHg. Selected subcutaneous decompression of affected compartment(s) was performed. Again measurements were repeated.
If decrease of ICP was insufficient we converted to open fasciotomy. Postoperative repetitive clinical assessments were done initially every two hours and after 6 weeks.
Results: 47 patients were analyzed. 8 of them had open fractures. 21 nailing procedures, 14
minimal invasive plate osteosynthesis and 12 external fixations were performed. 12 of 47
patients had fasciotomy according to the protocol, one patient redeveloped ACS after selec-
swiss knife 2004; special edition
27
tive anterior fasciotomy. Two patients that required fasciotomy the next day. 6 of the 14
patients that had fasciotomy showed no signs of ACS at admission.
Conclusion: We found a high incidence of elevated ICP in this group. Almost half of the
patients with imminent ACS were not under suspicion at admission demonstrating the rate
of developing ACS during the delay from admission to the OR. Selective fasciotomy can be
performed savely if ICP is measured during surgery and it avoids unnecessary surgical
trauma. However close postoperative reassessment is important to detect delayed ACS.
11.05
C. Fusetti 1, PA. Poletti 2, T. Glauser 1, DR. Della Santa 1, S. Bianchi 2
1
Unité de Chirurgie de la Main, HCU Genève, 2Département de Radiologie, HCU Genève
Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography:
a prospective blind study
Aim: The scaphoid is the most commonly fractured carpal bone. Up to 25% of these fractures remain initially occult, representing a challenging diagnosis on the basis of unspecific
clinical signs and equivocal conventional radiographs. CT-Scan and MRI are high reliable
diagnostic modalities but they share some limitations in terms of availability and costs. The
aim of this prospective blind study was to determine the diagnostic accurancy of high-spatial-resolution sonography ( HSR-S) in the diagnosis of occult fractures of the scaphoid.
Material and Methode: HSR-S of the scaphoid bone was performed in 24 consecutive
patients with clinically suspected scaphoid fracture and normal initial radiographs. Three
levels of clinical suspicion were considered: high (10), moderate (8), and low (6). US was
performed within 24 hours by one experienced radiologist, blinded to the results of the clinically examination. US appearance was graded on three levels ( low = 16, moderate = 3
patients, high= 5 patients) on the basis of cortical discontinuity, articular effusion and soft
tissue hematoma. Data from early sonograms were then compared with CT tomogram.
Results: CT-Scan examinations proved fracture of the scaphoid in 5 patients (21%). In all
patients, fracture was suspected on sonograms showing cortical disruption associated
with local effusion. There was 3 sonographic uncertain findings and no false-negative
results. The global sensitivity was 100% , the specificity 74%, the positive predictive value (
PPV) 50% and the negative predictive value( NPV) 100%. An high US index of suspicion
was correlated with 100% of sensitivity, specificity, PPV and NPV.
Conclusion: HSR-S appears to be a reliable, available and cost-effective method for infirming occult fractures of the scaphoid. In absence of cortical disruption and periscaphoidal
effusion we don’t advocate others diagnostic tools. An high index of sonographic suspicion should lead to MRI or CT-Scan to depict the extent and the direction of the fracture for a
minimally invasive surgery.
11.06
RF. Staerkle 1, PM. Lenzlinger 1, SL. Suter 2, Z. Varga 3, GA. Melcher 1
1
Department of Surgery, Spital Uster, Uster, Switzerland,
2
Endocrine Practice, Maennedorf, Switzerland,
3
Institute of Clinical Pathology, University Hospital of Zurich, Zurich, Switzerland
Synchronous bilateral ductal carcinoma in situ associated with gynecomastia in a 30 year
old patient following repeated injections of stanozolol: a case report
Breast cancer in males is very rare (0.5% of all malignant breast disease). Only about 5%
of all male breast carcinomas are pure ductal carcinoma in situ (DCIS). A literature search
using “male” AND “DCIS” produced only one published case of a synchronous bilateral
DCIS in a male. We report here a case of synchronous bilateral DCIS in a patient treated for
gynecomastia following repeated injections of stanozolol, a non-aromatizeable androgen.
A 30 year old male body builder was admitted to our department for subcutaneous mastectomy for bilateral gynecomastia. The patient reported an abuse of stanozolol during three
months, one year prior to developing the gynecomastia. The familial medical history was
negative for breast cancer. Work-up of serum hormone levels was normal. Histological
examination of the resected tissue showed a bilateral and multifocal DCIS and resection
margins were not found to be disease-free. There are no published guidelines for the treatment of such a particular case. A multidisciplinary panel decided to perform a modified
radical mastectomy without axilla dissection, since there was no invasive carcinoma. The
patient underwent the second surgery 5 weeks following the primary procedure. The final
histological examination showed no more DCIS nor invasive carcinoma. Therefore no adjuvant therapy was indicated.
Only two larger series of pure DCIS in men are reported. It occurs at an older age and displays significantly different morphologic subtypes compared to female disease. This case
is insofar extraordinary as the patient was only 30 years of age at presentation for surgery
and the synchronous occurrence of bilateral DCIS in a male has only been reported once
before. Only limited data exists regarding risk factors, which may include a positive familial
history for female breast cancer, low levels of androgens, and high levels of estrogen.
Stanozolol is generally not believed to exert pro-estrogenic effects. However, one experimental
study provides indirect evidence that this compound may stimulate peripheral estrogen receptors. Therefore, its possible role in promoting male breast disease remains to be elucidated.
11.07
L. Mathys, G. Mark
Chirurgie Kantonsspital Chur
Resultate nach konservativer Therapie ligamentärer Handgelenksverletzungen
28
swiss knife 2004; special edition
Einleitung: Ligamentäre Verletzungen im Handgelenksbereich haben einen beträchtlichen
Einfluss auf die Funktion und Prognose bezüglich des Gebrauches der Hand des Patienten
im Alltag und Berufsleben. Goldstandart zu deren Nachweis ist die Arthroskopie, mit folgender arthroskopischer oder offener Bandrekonstruktion. Diesem Konzept wollen wir unsere
rein konservative Methode gegenüberstellen.
Material und Methode: Nach Ausschluss einer ossären Läsion mittels konventioneller
Radiologie wurden unsere Patienten mit einem MRI abgeklärt, bei Vorliegen von rein ligamentären Verletzungen wurde das Handgelenk für 5 bis 6 Wochen mittels NaviculareSarmientogips ruhiggestellt, mit anschliessender ergotherapeutisch begleiteter
Mobilisation. Ein Jahr nach Behandlungsabschluss kontrollierten wir die Patienten nach,
schwerpunktmässig bezüglich subjektivem Empfinden und Reintegration in den
Arbeitsprozess.
Resultate: 14 Patienten (Läsionen des TFCC und/oder radioulnarer resp. scapholunärer
Bandläsion) mit einem Durchschnittsalter von 38 Jahren wurden nachkontrolliert. 10 mal war
die dominante Hand betroffen, subjektiv war das Resultat 8 mal sehr gut, 3 mal zufriedenstellend und 3 mal mässig. 12 Patienten gingen wieder zu 100% ihrer ursprünglichen Arbeit nach,
2 mussten einen Arbeitswechsel vornehmen. Die mittlere Dauer von der Erstkonsultation bis
zur vollen Arbeitsfähigkeit betrug 4 Monate.
Diskussion: Unsere Resultate zeigen, dass auch eine konservative Behandlung der rein ligamentären Verletzungen des Handgelenkes zu einem guten Resultat führt. Weitere, vergleichende Studien zur Therapieplanung und allenfalls Stratifizierung je nach Ausmass der
Verletzung sind angezeigt. Der Einfluss auf die Arbeitsunfähigkeit der Patienten ist dabei nicht
unerheblich.
11.08
A. Sermier1, Ph. Morel1, PH. Gygax2, GA. Lupi2, H. Bürgi 2
1
Hôpital Universitaire de Genève,
2
Académie suisse intégrée de médecine militaire et de catastrophe
Projet académie suisse intégrée de médecine militaire et de catastrophe
Introduction: Le projet d’académie suisse intégrée de médecine militaire et de catastrophe
(ASIMC) est novateur et réunit dans un même effort la médecine civile, militaire et humanitaire suisse.
Objectifs: Afin d’augmenter le recrutement des médecins engagés dans l’armée, la protection civile et l’aide humanitaire suisse, les offices concernés de l’administration fédérale et
des cantons unissent leurs efforts dans le projet ASIMC. L’ASIMC a pour but de compléter la
formation des médecins et autres professionnels de la santé disposés à s’engager dans le
Service sanitaire coordonné et l’aide humanitaire suisse.
Organisation: L’ASIMC réunit un réseau interdépartemental (départements fédéraux de la
défense, de la protection de la population et des sports, des affaires étrangères et de l’intérieur), un réseau intercantonal (départements cantonaux de la sécurité militaire et civile, de
la santé) et interassociatif [Commission interfacultaire médicale suisse (CIMS), Swiss
Medical Rescue and Emergency Conference (SMEDREC), Fédération des Médecins
Helvétiques (FMH) et Hôpitaux suisses (H+)]. Participent également à l’ASIMC plusieurs
organisations partenaires, telles le Corps Suisse d’aide humanitaire (CSA), la Croix-Rouge
Suisse, les hautes écoles fédérales et les hôpitaux universitaires avec une distribution des
spécificités par centre (Lausanne : médecine de catastrophe, Berne : infectiologie, Bâle :
anesthésie et réanimation, Zürich : psychiatrie de guerre, Genève : chirurgie de guerre).
Activités: Formation pré- et post graduée (cours, stages hospitaliers et recherche scientifique), création d’un modèle d’avancement pour les étudiants en médecine compatible avec
le calendrier universitaire ainsi que des engagements en cas de crise ou de catastrophe.
11.09
R. Schröder, P. Rupp, R. Soyka, P. Henning, H. Zimmermann
Emergency and Trauma Unit, University Hospital of Berne, Switzerland
Implementing a whole-body multi-slice CT in the initial management of polytraumatized
patients – do we improve time?
Purpose: To evaluate the use of a whole-body fast 8- and 16-slice CT in the diagnostic workup
of polytraumatized patients in order to shorten the duration for diagnostic evaluations.
Methodes: In a first evaluation phase we collected data from trauma patients who underwent
whole body CT scanning from August 2002 until June 2003 (8-slice CT, located 130 meters
away from the ER). Further access to an elevator was necessary. Initially, standard treatment
guidelines using ATLS was conducted which included conventional x-rays and a FAST followed by CT scanning. In June 2003 we started to use a faster 16-slice CT located closer to the
ER (65 m) without requiring an elevator. Standard ATLS guidelines were also followed. From
March 2004 we will further modify our diagnostic approach.
Results: During the first evaluation 93 consecutive patients could be included, the median
time from patients arrival in the ER until commencement of the CT was 30 minutes. The duration of CT scanning itself took an average of 53 minutes which included transport time. Using
the new 16 slice CT (73 patients included until now) resulted in a patient turning maneuver
after imaging head and c-spine in order to get more adaequate images from the chest, abdomen and pelvis. The median time until CT commencement could significantly be reduced to
25 minutes (p=0.012), and the length of CT imaging to 45 minutes (p=0.009). There was also
a 63% reduction seen in the sum of all conventional x-rays of the trunk performed before
whole-body CT scanning. In particular, c-spine imaging was reduced by 87%.
Conclusions: These early results demonstrate that implementing a faster multislice CT, shortening the duration of transportation and reducing the number of conventional x-rays adae-
quately reduced time for diagnostic workup in trauma patients. However, the expected
improvement in time by using a faster CT was partially negated by the need to turn the
patient on the CT table in order to get higher quality images. A further assessment of whether additional modifications of the diagnostic approach is necessary to shorten the duration of diagnostic workup with subsequent clinical improvement remains to be seen.
11.10
N. Class, C. Köchli, I. Schwegler, R. Schlüchter, R. Schlumpf
Chirurgische Klinik, Kantonsspital Aarau
trouve pas d’étiologie primaire dans 29% des cas.
Les nodules de SMJ représentent 30% des tumeurs ombilicales. Dans 90% de ces cas, il
s’agit d’un adénocarcinome. Macroscopiquement, le nodule est ferme, d’aspect érythémateux et peut s’ulcérer. Microscopiquement, le dépôt tumoral peut être localisé au niveau du
derme, du tissu sous-cutané ou du péritoine. La ponction à l’aiguille fine pose le diagnostic,
et le bilan d’extension est pratiqué au moyen d’un CT-Scanner thoraco-abdomino-pelvien.
Le pronostic est sombre car la tumeur est habituellement associée à un cancer intrapéritonéal métastatique avancé.
11.13
Necrotizing fasciitis of upper extremity and chest wall
Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection characterized by
extensive necrosis of the superficial fascia, cutis and subcutaneous tissue with thrombosis
of the small vessels. The disease is mainly caused by Streptococcus pyogenes or synergistic infection of anaerobic and facultative anaerobic bacteria.
The paucity of cutaneous findings early in the course of the disease makes the diagnosis
difficult, but the progression of the NF is often fulminant, and the prognosis hinges on accurate diagnosis and immediate institution of appropriate treatment. The patients usually present in a reduced condition and with the triad of exquisite pain, swelling and fever. It is a lifethreatening infection with a lethality ranging up to 80%.
We present four cases of NF of the upper limb and the chest wall: two occuring after bursitis olecrani, one after intra-articular injection of the shoulder and one with infection of the
axilla without apparent trauma.The male patients were between 40 and 73 years old. In either case preoperative C-reactive protein was substantially raised (>260mg/L).In 2 patients
the bacterial cultures showed group A beta-haemolytic streptococci and in 2 cases
Staphylococcus aureus was isolated. The antibiotic treatment did take place with Rocephin
or Dalacin/Penicillin respectively with Floxapen. All four patients survived. In three cases
infection could be controled by radical surgical debridement. In one case a interscapulothoracic amputation (fore quater amputation) was performed to contain the infection.
Finally all the wounds were covered with a skin graft.
Prompt radical surgical debridement and postoperative intensive care along with appropriate antimicrobial treatment represent the corner-stones of therapy.
Though a high index of suspicion is important in view of the paucity of specific cutaneous
findings early in the cours of the disease.
M. Seifert
Chirurgische Abteilung Kant. Spital Wattwil
11.11
Syndrome de bouveret: complication rare de la maladie lithiasique
Définition: L’obstruction gastrique par lithiase biliaire au niveau du duodénum ou du pylore
(Syndrome de Bouveret) est une complication rare de la maladie lithiasique, environ 300
cas ont été rapportés dans la littérature depuis sa description en 1896.
Cas clinique: Un homme de 73 ans s’est présenté aux urgences en raison de vomissements incoercibles depuis 2 jours associés à une perte pondérale de 4kg en quelques
jours. L’abdomen était souple, sans péritonisme. L’ultrasonographie abdominale et la tomodensitométrie abdominale ont montré un épaississement localisé du duodénum occasionnant une sténose, avec une image compatible avec un calcul au niveau du pylore ainsi
qu’une aérobilie. La gastroscopie a montré un œdème de la muqueuse du duodénum à
l’origine de la sténose et a permis d’extraire un calcul biliaire de 3x2 cm. La fistule cholecysto-duodénale n’a pas pu être visualisé en raison de l’œdème. Les suites ont été simples
avec disparition de la symptomatologie digestive.
Discussion: Le syndrome de Bouveret est une forme rare (2%) d’iléus biliaire, caractérisé
par sa localisation pylorique ou duodénale après migration du calcul par une fistule
cholécysto-duodénale ou gastrique. La symptomatologie d’appel est souvent aspécifique
et inclus des nausées, vomissements, épigastralgies et des antécédents de coliques biliaires. Il est plus fréquent chez la femme (65%) âgée (70-80 ans). La gastroscopie confirme
dans la majorité des cas le diagnostic. Son traitement consiste en l’extraction du calcul soit
par voie endoscopique, soit par voie chirurgicale, voire sa fragmentation par lithotripsie
extra ou intra-corporelle.
Conclusion: L’extraction endoscopique du calcul peut être considérée comme traitement
définitif en l’absence de calculs vésiculaires résiduels. En cas d’échec ou de lithiase résiduelle, le traitement est chirurgical avec extraction du calcul par duodénotomie, cholecystectomie avec fermeture de la fistule. Dans certains cas, une simple entérotomie avec extraction du calcul peut être envisagé chez des patients à risque.
D. Gianom, A. Vollenweider
Chirurgische Klinik, Kreisspital Männedorf, Männedorf
Stabilisation von proximalen Humerusfrakturen mit einem neuen winkelstabilen Verriegelungsnagelsystem (Targon PH)
Die operative Versorgung von proximalen Humerusfrakturen ist nach wie vor Gegenstand
von Diskussionen bezüglich dem geeignesten Fixationsverfahren. Mit den meisten
Verfahren erreicht man keine Rotationsstabilität des Humeruskopfes, wodurch einerseits
eine funktionelle Behandlung schwierig ist und andererseits die Gefahr eines sekundären
Repositionsverlustes besteht.
Targon PH ist ein winkelstabiles Verriegelungsnagelsystem, bei dem die Verriegelungsschrauben im Humeruskopf winkel- und gleitstabil im Nagel verankert sind. Durch entsprechende Positionierung der Schraubenlöcher können die Tubercula mitgefasst werden. Der
Nagel erlaubt einerseits eine minimal invasive Osteosynthese, andererseits erfolgt eine
rigide Fixation der Kopffragmente als Voraussetzung für eine funktionelle Nachbehandlung.
Der Targon Nail ist seit Oktober 2003 an unserer Klinik im Einsatz. Seither haben wir 8
Patienten operiert. Wir stellen das Implantat und die Operationstechnik vor und berichten
über die kurzfristigen klinischen Resultate.
Der Targon Nail ist nicht die Lösung aller Probleme bei Humeruskopffrakturen, stellt jedoch
bei Beachtung der Indikationen eine wertvolle Bereicherung der chirurgischen Optionen bei
diesen Problemfrakturen dar.
11.12
X. Delgadillo, M. Gonzalez, M. Merlini
Hôpital de La Chaux de Fonds
Le nodule de soeur Mary Joseph
Cas clinique: Il s’agit d’une patiente de 59 ans qui présente depuis 3 semaines, l’apparition
d’un nodule ferme et indolore au niveau de l’ombilic, associé à une baisse de l’état général. Le
status révèle une palpation sensible en région épigastrique. Un US abdominal confirme l’absence de hernie ombilicale. Un CT-Scanner abdomino-pelvien montre une masse tumorale
infiltrante au niveau du corps et de la queue du pancréas en contact direct avec l’estomac et
le rein gauche. Une laparotomie exploratrice met en évidence une carcinose péritonéale étendue, et des biopsies pratiquées montrent un adénocarcinome du pancréas.
Discussion: Le nodule de Sœur Mary-Joseph (SMJ) est la découverte d’une métastase
ombilicale cutanée d’un cancer intrapéritonéal. Elle peut s’expliquer par une migration
tumorale par voie veineuse, lymphatique ou par extension directe le long du ligament rond.
Sœur Mary-Joseph Dempsey, infirmière assistante opératoire de William Mayo de 1890 à
1915, remarqua chez certains patients que les porteurs d’un cancer avancé présentaient à
l’ombilic un nodule ferme et indolore. Les sites les plus fréquents à l’origine du nodule de
SMJ sont l’estomac (26%), les ovaires (12%), le côlon (10%) et le pancréas (7%). On ne
Appendicitis acuta duplex
Fallbeschreibung: eine 35j. Patientin wird mit Verdachtsdiagnose einer akuten Appendizits
laparaskopisch operiert. Eine normale gelegene entzündete und perforierte Appendix wird
laparaskopisch entfernt. Wegen der Perfortion wurde eine Draingage eingelegt. Am 3. postoperativen Tag entleert sich daraus eitrige Flüssigkeit und die Patientin zeigt eine Unterbauchperitonitis. Es wird wieder laparaskopiert und wegen Unübersichtlichkeit eine
Unterbauchlaparatomie durchgeführt. Wir finden nochmals eine Appendix am Coecum
dorsalseitig, ebenfalls mit Entzündung und Perforation. Der weitere Verlauf war komplikationslos ausser einem Wundinfekt. Histologisch liegen zwei Befunde mit Appendizits mit
Perforation vor.
Diskussion: es existieren 4 Typen von doppelter Appendix nach Cave-Wallbridge.
Differentialdiagnostisch abzugrenzen ist das Coeumdivertikel. An die Möglichkeit einer doppelten Appendix ist zu denken und eine genaue Inspektion durchzuführen. Auch Jahre später kann so ein appendektomierter Patient noch eine Appendizitis erleiden. Eine Appendicitis duplex ist ein sehr seltener Befund.
11.14
C. Haller 1, C. Guenot 2, JM. Bruttin 2
1
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne,
2
Service de Chirurgie, Ensemble Hospitalier de la Côte, Morges
11.15
K. Sprengel 1, B. Boldog 1, R. Flury 2, W. Schweizer 1
1
Kantonsspital Schaffhausen, Abteilung Chirurgie,
2
Kantonsspital Winterthur, Institut für Pathologie
Papillomatose der intrahepatischen Gallenwege, ein seltenes Krankheitsbild
Einleitung: Papilläre Veränderungen der intrahepatischen Gallenwege sind selten und reichen von einzelnen Tumoren bis zur diffusen Papillomatose. Obwohl es sich histologisch
um semimaligne Tumore handelt, stellen sie mit Ihrem hohen Grad an Rezidivneigung,
Mucinproduktion und maligner Entartung ein schwerwiegendes Krankheitsbild dar.
Fallbericht: Wir berichten über eine 68-jährige Patientin, bei der wegen eines rechtsseitigen
Lebertumors mit intrahepatischer Cholestase eine Leberresektion der Segmente V-VIII unter
dem Verdacht eines Cholangiocarcinomes notwendig wurde. Postoperativ zeigte sich überraschend die histologische Diagnose einer multifokalen biliären Papillomatose mit fortgeschrittener Dysplasie. Bei der Rezidivoperation nach 9 Monaten wurde deutlich, dass eine
kurative Sanierung bei diffusem Wachstum aussichtslos erschien, wobei die Histologie
swiss knife 2004; special edition
29
inzwischen klar maligne Charakteristika zeigte. Für weitere 2 Jahre wurden wiederholt palliative Resektionen sowie Interventionen mittels ERCP-Stenting bei rezidivierendem Ikterus
mit zufriedenstellender Lebensqualität durchgeführt, bis die Patientin bei Unmöglichkeit
einer weiteren Intervention verstarb.
Diskussion: Caroli beschrieb 1959 die seltenen papillomatösen Tumore der intrahepatischen Gallenwege. Bisher existieren nur wenige Fallberichte. 50% der Patienten sterben
innerhalb der ersten 5 Jahre an Rezidiven mit Cholestase und Cholangitis. Die Therapie
besteht, sofern aufgrund der Ausdehnung möglich, in einer Leberteilresektion mit oder ohne
biliodigestiver Anastomose. Bei jungen Patienten kann eine Lebertransplantation in Betracht gezogen werden. Palliativ wurden in der Literatur die ERCP mit Stenteinlage, die
Lasertherapie sowie die intraluminale Iridium-192 Brachytherapie genutzt.
Schlussfolgerung: Die biliäre Papillomatose stellt eine seltene Differentialdiagnose bei einer
intrahepatischen Raumforderung dar und ist aufgrund ihres semimalignen Verhaltens ein
primär chirurgisch zu therapierendes Krankheitsbild. Bei fehlender oder unmöglicher kurativer Therapieoption kann durch rezidivierende Resekionen und endoskopische Interventionen eine gute Lebensqualität für einige Zeit erhalten werden.
11.16
M. Chilcott, I. Inan, PH. Morel
Clinique de Chirurgie Viscérale, Hôpitaux universitaires de Genève
Unusual acute appendicitis: amyand’s hernia
Introduction: Amyand’s hernia, first described in 1735 is a rare occurrence, consisting of
acute appendicitis within an inguinal hernia sac and accounts for only 0.13 % of all acute
appendicitis. This diagnosis, often established only at operation poses clinical and surgical
problems to many a young surgeon.
Material und Methode: Retrospective study by the authors on medical files and per-operative knowledge of all of the cases.
Results: Six patients of mean age 87 years (69 -95) were all operated on with success. One
male for five females. Four of the hernias were femoral and two inguinal, all on the right.
Appendicectomy was practised in all cases and a Mc Vay herniorraphy was practised for
femoral hernias and a Bassini technique for inguinal hernias. All but one case were discharged within one week. The last case died of cardiopulmonary complications on day 7.
Discussion: We present, in poster form, the results of our six case series in a highly illustrated form with multiple peroperative photos, illustrating both the anatomo-pathological situation and the surgical techniques used.
11.17
PH. Füglistaler 1, F. Amsler 2, W. Ummenhofer 3, R. Hügli 2, P. Regazzoni 1, T. Gross 2
1
Abteilung Traumatologie, Universitätskliniken Kantonsspital Basel, 2Universitätskliniken
Basel, CARCAS, 3Abteilung Anästhesie, Universitätskliniken Kantonsspital Basel
Teamperformance im Schockraum-Management wie beurteilen wir unsere Arbeit und Ausbildung?
Einleitung: Organisation und Kommunikation spielen eine entscheidende Rolle im interdisziplinären Management potentiell schwerverletzter Patienten. Ziel dieser Arbeit war es,
durch eine Selbstbewertung der involvierten Mitarbeiter die Qualität des Schockraum Managements zu erfassen.
Methode: Konsekutive anonyme schriftliche Befragung (Likert Skala 1-5) der involvierten klinischen Mitarbeiter aller traumatologischer Schockraumeinsätze in einem Universitätsspital zwischen 6/2002 und 12/2003 (p<0.05,ANOVA).
Resultate: 884 Mitarbeiter beantworteten den standardisierten Fragebogen in 171 Schockraumeinsätzen (81% ISS>15): 25% Chirurgen, 20% Anästhesisten, 18% Radiologen, 16%
Notfallpflegende und 21% übrige. Insgesamt zeigten sich 79% der Mitarbeiter zufrieden mit
der Gesamtbehandlungsqualität (Likert 4-5), 7% unzufrieden (Likert 1-2) und 14% unentschieden. Nahezu alle befragten Aspekte des Schockraum-Managements wurden im Falle
von polytraumatisierten Patienten (ISS>15) signifikant schlechter bewertet. In der detaillierten Analyse der einzelnen Teilbereiche wurden fachunabhängig Verantwortungsregelung
(Likert 4.6) und Kommunikation im eigenen Fachgebiet (Likert 4.4) am besten beurteilt. Am
meisten kritisiert wurden die Teilbereiche Zeitmanagement (Likert 3.8), eigene Ausbildung
(Likert 3.9) und Abläufe im Gesamtteam (Likert 3.9). Während sich in der Analyse einzelner Teilbereiche z.T. signifikante Unterschiede zwischen den Fachgebieten zeigten (z.B.
eigene Ausbildung, Abläufe im Gesamtteam p<0.001), wurde die Gesamtbehandlungsqualität einheitlich beurteilt. Unter den involvierten Mitarbeitern befanden sich 21% Leitende
Ärzte/Oberärzte (LA/OA) und 38% Assistenzärzte (AA). LA/OA stuften die eigene Ausbildung signifikant besser ein als AA (p<0.001). 2/3 aller LA/OA, aber nur 1/3 aller AA hatten
eine ATLS-Ausbildung absolviert.
Schlussfolgerung: Die standardisierte Mitarbeiterbefragung bietet ein kritisches und ergänzendes Messinstrumentarium zur Beurteilung der Behandlungsqualität im Notfallmanagement.
Die von Beteiligten genannten Defizite in Ausbildung und interdisziplinärer Zusammenarbeit
sollten objektiviert und korrigiert werden.
11.18
A. D’Ambrogio 1, T. McKee 2, R. Sahli 3, JC. Givel 1
1
Department of General Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne,
2
Pathology Institute, Centre Hospitalier Universitaire Vaudois, Lausanne,
3
Department of Microbiology, Centre Hospitalier Universitaire Vaudois, Lausanne
30
swiss knife 2004; special edition
HPV Typisation of Condylomata Accuminata and Recurrent Disease
Purpose: Human papillomavirus (HPV) infection causes condylomata accuminata. HPV 6
and 11 are most frequently involved in the disease. Recurrence is classical but no HPV type
has been shown to correlate with it.
Aim of the Study: The aims were to assess whether a correlation exists between the HPV
types and propensity to recur, as well as between HIV status and recurrence. Confirming
these hypotheses would make systematic typisation mandatory, so that patients at risk
could benefit from close follow-up.
Methods: Between 1990 and 2001, 90 patients underwent surgery for anal condylomata
accuminata. Polymerase Chain Reaction (PCR) for HPV typisation has been performed on
lesions from 52 patients; two groups have been defined: with/without recurrence. The correlation between HPV type and clinical evolution has been studied.
HIV status has also been considered.
Results: Seven(13.4%) of 52 patients 3 of whom were HIV positive showed recurrent disease. Among the 45(86.6%) patients without recurrence, 17 were HIV positive. In the recurrent
group, 16 lesions have been examined: 3(18,8%) were HPV type 6, 3(18.8%) HPV11,
1(6.2%) was HPV58, 1(6.2%) was positive for HPV but not typable and in 2(12.4%) no HPV
was found; 6 (37.6%) lesions contained combined types of HPV. HPV type 11 was present
in all of them. In the non-recurrent group, 45 lesions have been examined: 28(62.2%) were
HPV type 6, 7(15.6%) HPV11, 1(2.2%) was HPV61, 1(2.2%) HPV66, 1(2.2%) was homologous to HPV2a, 1(2.2%) was homologous to HPV27 and in 3(6.7%) no HPV was found; 3
lesions contained combined types of HPV. HPV6 was present in all of them but HPV11 has
never been found.
Conclusions: There is no correlation between the inclination to recur and HIV status. No specific HPV type seems to directly correlate with the incidence of recurrence but presence of
two or more HPV seems to be associated with increased recurrence risk.
11.19
C. Haller 1, C. Guenot 2, M. Gillet 3
1
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne, 2Service de Chirurgie,
Ensemble Hospitalier de la Côte, Morges, 3Service de Chirurgie viscérale, CHUV, Lausanne
Spontaneous splenic rupture: a rare complication of von Willebrand disease
Definition: Von Willebrand disease is one of the most common inherited bleeding disorders.
In this disease the von Willebrand factor is absent or present in a functionally abnormal form.
Case report: A 60-year-old woman known to suffer from von Willebrand disease presented
with complaints of sudden onset abdominal pain, diarrhoea and vomiting. Physical examination revealed that she was cold, clammy and shocked. The abdomen was slightly distended and was tender on the left side. Following resuscitation with crystalloids an blood, a CTScan was performed which showed free intraperitoneal blood and a splenic rupture grade
IV. Factor VIII and von Willebrand factor replacement therapy was started. Selective angiography was performed with embolization of the splenic artery. The evolution at two years is
favourable.
Discussion: Spontaneous rupture of spleen is usually seen in cases of pathologically enlarged spleens where the organ is predisposed to slight trauma overlooked by the patient or
in malaria, infectious mononucleosis, bacterial endocarditis, thyphoid, splenic tumours,
amyloidosis, leukemias and haemophilia. In the literature six cases of spontaneous splenic
rupture in haemophilic patient are reported but no case in von Willebrand disease is reported. The exact mechanisms leading to spontaneous rupture of the spleen remain unclear in
cases of haemophilic and von Willebrand disease.
Conclusion: This case demonstrates that selective embolization of splenic rupture in patient
with von Willebrand disease can be performed safely, but it is essential to correct the coagulopathy throughout the perioperative period.
11.20
L. Martinolli, M. Wolf, H. Zimmermann
Notfallzentrum Inselspital Bern
Tätigkeit von nichtchirurgischen Oberärzten auf dem chirurgischen universitären Notfall
Am chirurgischen Notfallzentrum des Inselspitals Bern sind seit dem 1.Mai 2003 auch
Internisten, Anästhesisten, Intensiv- und Notfallmediziner als Oberärzte tätig.
Die Internisten arbeiteten bereits im medizinischen Notfallzentrum und wurden erst nach
Abschluss eines Einführungskurses im chirurgischen Bereich eingesetzt.
Über einen begrenzten Zeitraum wurde die Tätigkeit der nicht-chirurgischen Oberärzte seitens der chirurgischen Kollegen supervisioniert.
Alle Oberärzte arbeiten in einem interdisziplinären Notfallzentrum und dies ermöglicht zu
jeder Zeit die Konsultation jeglicher chirurgischen Fachdisziplinen.
Wir haben nun das klinische und diagnostische Vorgehen zwischen den nichtchirurgischen Fachärzten und den Chirurgen anhand des Eiweisungsgrundes „Unklare Bauchschmerzen“ und „akutes Abdomen“ verglichen. Dabei konnten wird keine statistisch signifikante Unterschiede feststellen.
In einem zweiten Verfahren haben wir anhand eines Fragebogens die Assistenzärzte und
das Pflegefachpersonal im Bezug der Tätigkeit der nichtchirurgischen Fachärzten am chirurgischen Notfall befragt. Diese erhielten insgesamt eine hohe Akzeptanz aufgrund der stetigen Präsenz auf der Station, der Organisationsfähigkeit und der Patientenbetreuung.
Zum Schluss verglichen wir die Zeiten des „primary survey“. Bei den Chirurgen ergab die
Auswertung der Schockraumzeiten einen Mittelwert von 4,01 Minuten und bei den anderen
Fachdisziplinen einen Mittelwert von 4,42 Minuten. Die Daten zeigten keine statischen
Bedeutung und keine medizinische relevante Unterschiede.
Anhand dieser Evaluationen kann man daraus schliessen, dass keine relevanten
Unterschiede zwischen Chirurgen und nichtchirurgischen Fachärzten festgestellt werden
konnten und dass dieses Projekt in diesem Sinne weiterzuführen ist.
11.21
K. Sprengel 1, B. Boldog 1, R. Flury 2, W. Schweizer 1
Kantonsspital Schaffhausen, Abteilung Chirurgie,
2
Kantonsspital Winterthur, Institut für Pathologie
1
Gastrointestinale Stromatumoren, 7 Fallbeispiele
Einleitung: Seit Mitte der 90-iger Jahre wird vermehrt durch verbesserte histologische
Untersuchungsmethoden die Diagnose gastrointestinaler Stromatumor (GIST) gestellt. Er
leitet sich von interstitiellen Cajal-Zellen ab und kann leiomyogenen oder neurogenen differenzieren. Klassische zytomorphologische Malignitätskriterien sind nicht anwendbar,
wobei aber klinisch eine hämatogene Metastasierung vorliegen kann. Diagnosebeweisend
ist eine c-KIT-Posivität (CD 117) in 95% der Fälle als Mutation im c-Kit-Gen mit der Folge
einer dauerhaften Aktivierung der KIT-Rezeptor-Tyrosinkinase.
Patienten: 1997-2004 wurden an unserem Kantonsspital 7 Patienten mit GIST behandelt.
Die Lokalisation war viermal das Jejunum, zweimal der Magen und einmal der Ösophagus.
Die klinische Symptomatik variierte von Refluxbeschwerden bis zur Ileussymptomatik.
Entsprechend waren partielle Resektionen, teilweise gastroskopisch, bis zu ausgedehnten
multiviszeralen Eingriffen notwendig. Eine R0-Resektion war fünfmal möglich, zweimal
wurde die adjuvante Therapie mit Imatinib (Glivec) durchgeführt. Bei den Nachkontrollen
(2-29 Monate) zeigen die 5 überlebenden Patienten eine zufriedenstellende Lebensqualität.
Diskussion: GIST sind die häufigsten Weichteiltumoren des Gastrointestinaltraktes. Sie zeigen
einen Gipfel in der 5. und 6. Dekade. Aufgrund des submukösen Wachstums verursachen sie
erst spät Symptome. Die Lokalisation liegt in absteigender Häufigkeit im Magen, Dünndarm,
Kolon, Ösophagus und primär mesenterial. Prognoserelavante Faktoren sind Tumorgrösse,
Mitoseindex, Erkrankungsausdehung und Resektabilität. Die chirurgische R0-Resektion mit
einem Abstand von 2 cm ist anzustreben. Imatinib als Systemtherapie zeigt sehr gute
Ansprechraten. Die Abschätzung der Dignität ist problematisch, die Rezidivrate hoch.
Schlussfolgerung: Wir werden uns wohl in Zukunft mit dieser neuen Tumorentität und den
Behandlunsmodalitäten mit dem erst seit kurzem verfügbaren Tyrosinkinaseinhibitor
Imatinib (Glivec) sowie der multidisziplinären Therapie vermehrt auseinandersetzen müssen. Grössere Studien und Langzeitbeobachtungen sind notwendig.
11.22
S. Styger 1, S. Meckel 2, TH. Gross 1, R. Hügli 2, P. Messmer 3, P. Regazzoni 1
Abteilung Traumatologie, Kantonsspital Basel, 2Abteilung Radiologie, Kantonsspital Basel,
3
Abteilung Unfallchirurgie, Universitätsspital Zürich
1
Der Iso C-3D - Optionen und Grenzen eines Durchleuchtungsgerätes
Einleitung: Für die Frakturanalyse wird bei komplexen Gelenksfrakturen häufig zusätzlich
zur konventionellen, planaren (2D) Röntgenuntersuchung, ein Computertomogramm (CT)
zur dreidimensionalen (3D) Darstellung der Fraktur angefertigt. Diese dient zur präoperativen Planung und in speziellen Situationen auch zur postoperativen Qualitätskontrolle. Der
Nachteil des CT ist die geringe Mobilität, so dass intraoperative 3D-Rekostruktionen im
Operationsraum nicht möglich sind. Zudem stellt die CT-Untersuchung eine beträchtliche
Stahlenbelastung für den Patienten dar. Diese Nachteile regten die Entwicklung eines
Durchleuchtungsgerätes (Iso C-3D) an, das Schnittbilder in sagitaler, koronarer und axialer
Ebene sowie 3D-Rekonstruktionen herstellen kann.
Resulate: Präklinische Untersuchungen in der Literatur ergaben, dass sowohl die
Bildqualität als auch die Orts- und Kontrastauflösung des Iso C-3D mit dem Computertomogramm (CT) bei kleinen und mittelgrossen Gelenken vergleichbar sind. Für Objekte mit
einer Kantenlänge über 12cm ( Becken, Wirbelsäule) ist das Durchleuchtungsgerät dem CT
allerdings unterlegen, da diese auf Grund des limitierten Bilddurchmessers nicht in toto dargestellt werden können. Der Iso C-3D bietet ausserdem die Möglichkeit, intraoperative
Schnittbilder zur Qualitätskontrolle der Reposition oder Osteosynthese durchzuführen.
Schlussfolgerungen: Der Iso C-3D kann das Coputertomogramm (CT) bei der Analyse von
komplexen Frakturen bei kleinen und mittleren Gelenken ersetzen, bei Objekten über 12cm
Kantenänge allerdings sollte dem CT den Vorrang gegeben werden. Durch den intraoperartiven Einsatz kann bereits während der Operation eine Stellungskontrolle zur Qualitätssicherung durchgeführt werden, was eine eventuelle Korrektur in der gleichen Operation
erlaubt. Um Strahlenartefakte zu minimieren, ist ein Karbontisch für die 3D-Durchleuchtung
unverzichtbar, was bei der Anschaffung eines Gerätes mitkalkuliert werden sollte.
11.23
F. Chèvre, JC. Renggli, S. Mpyisi, X. Delgadillo, M. Droguett, C. Becciolini, M. Merlini
Service de Chirurgie Hôpital de la Chaux-de-Fonds
Laparoscopic repair of ventral hernias: a preliminary study
Introduction: Laparoscopic repair of ventral hernias was first described in 1993. It is a safe and
effective procedure that reduces length of hospital stay and morbidity. The technique was recently introduced in our institution and the preliminary results are reported in this article.
Methods: prospective non randomised follow-up study of patients with ventral incisional hernia
treated with a nonabsorbable mesh (Parietex composite) implanted intracorporeally by laparoscopy.
Results: Between October 2003 and February 2004 laparoscopic repair of ventral incisional hernias was performed in 10 patients, 7 men and 3 women. One of these repairs was
for a recurrent defect. All patients underwent an intracorporeal implantation of a nonabsorbable mesh ((Parietex composite). The average size of the mesh was 443 cm2 (144 – 600
cm2). The average operating time was 110 minutes (45-315 min). The average length of
hospital stay was 6.25 days (4-12 days). Two complications occurred in the same patient
and consisted of a urinary tract infection and a seroma. Conversions to open surgery were
not necessary. No recurrent ventral hernia occurred in the early follow-up period.
Conclusion: preliminary results are reported in a prospective non randomised study started
in October 2003. Laparoscopic technique is applicable in most patients presenting a ventral incisional hernia. The rate of conversion, the length of hospital stay and the rate of complications are low.
11.24
B. Burian 1, MA. Wimmer 3, J. Kunze 3, C. Sprecher 3, O. Schmitt 2, CN. Kraft 2
1
Kantonsspital Basel, Departement Chirurgie, 2Universitätsklinik Bonn,
Klinik und Poliklinik für Orthopädie, 3AO-Forschungsinstitut Davos
Lokale und systemische Reaktion auf Verschleisspartikel;
eine vergleichende in vivo Studie mit rostfreiem Stahl
Durch Fretting von Osteosynthesematerialien, z.B. zw. Schraubenkopf & Platte, entstehen
Abrieb- & Korrosionsprodukte, die eine Reihe von biologischen & -chemischen Reaktionen hervorrufen. Ziel dieser Studie war es, die kurzfristigen lokalen & systemischen Reaktionen von
implantierten rostfreien Stahl- & Titanpartikeln quantitativ zu beschreiben.
Mit einem speziellen Prüfstand wurde aus Reintitan (Ti) bzw. Implantatstahl (St) Abrieb in
Ringerlösung erzeugt.
4 mm3 des jeweiligen Materials wurden in Rückenhautkammern von Goldhamstern subkutan
implantiert. Die lokale Gefäßperfusion & das Leukozytenverhalten wurden mittels intravitaler
Fluoreszenzmikroskopie über 2 Wochen beobachtet. Blutproben wurden unmittelbar vor OP,
nach 24h & nach 14d entnommen. Nach Euthanasie der Tiere wurden die Implantatstelle,
Leber, Milz, Lunge, Herz & Nieren entnommen. Eine Hälfte der Organe wurde spektrometrisch
auf Ti,Cr & Ni analysiert, die andere Organhälfte & die Implantatstelle diente für histologische
Untersuchungen. Im Vergleich zur Kontrollgruppe (K) führte die Implantation der körperfremden Materialien in bd. Gruppen zur Aktivierung von Leukozyten. Die Entzündungsreaktion fiel
bei der St-Gruppe heftig aus & führte zu einem Ödem innerhalb von 8h. In der Ti-Gruppe zeigte
sich der Anstieg transient mit Erholung nach 3d. In bd. Gruppen konnten wir eine signifikant
erhöhte Konzentration der Elemente Ti,Cr & Ni in den Organen nachweisen. Bei den Blutproben
der Ti-Gruppe gab es im Vergleich zur K-Gruppe keine signifikanten Unterschiede, wobei in der
St-Gruppe der Cr- & Ni-Gehalt stets erhöht war. Die histologischen Untersuchungen der TiGruppe waren unauffällig. In den Schnitten der St-Gruppe fiel an der Implantatstelle eine starke
Inflammation mit Nekrosen auf. In allen Organen fanden sich lichtmikroskopisch keine pathologischen Vorkommnisse. Die Ergebnisse zeigen, dass eine akute,materialspezifische
Reaktion hinsichtlich Abrieb stattfindet. Ferner kommt es zu einer systemischen Verteilung der
Abriebpartikel innerhalb des Organismus. Der Nachweis im Blut legt die Blutbahn als einen
Transportweg nahe. Weitere Untersuchungen sind nötig, um Aufschluss über den genauen
Transportweg der Fremdstoffe zu erhalten.
11.25
L. Marti, H. Marlovits, J. Walker, J. Lange
Klinik für Chirurgie, Kantonsspital St. Gallen
Kommunikation mit den Hausärzten übers Internet: das Pilotprojekt eHealth Chirurgie
Grundlagen: Um dem Informationsbedürfnis der Hausärzte sowie deren Wunsch auf elektronischen Datentransfer nachzukommen, hat unsere Klinik beschlossen eine Kommunikationsplattform für das Internet aufzubauen. Es sollte ein rascher, papierloser und zeitlich
unabhängiger Informationsaustausch ermöglicht werden.
Methode: In Zusammenarbeit mit Firmen aus der Medizinalinformatik entwickelten wir eine
Kommunikationslösung für das Internet. Im Vordergrund stand die Gewährleistung der
Sicherheit und eine Anpassung an die internen Abläufe. 48 Hausärzte meldeten sich freiwillig
für den Pilotbetrieb. Aus sicherheitstechnischen Überlegungen verbot sich die Benutzung von
eMails. Die Sicherheit wurde gewährleistet durch: 1. Autorisierung und Identifikation, 2. Verschlüsselung, 3. Erstellen eines Zugriffschutzes auf eigene Systeme und 4. die Selektion der
Informationsempfänger.
Resultate: Die Hausärzte haben aktuell die Möglichkeit Patienten für Spitalaufenthalte und
Sprechstunden anzumelden, diese elektronisch am Tumorboard vorzustellen und Spezialistenauskünfte einzuholen. Diese Funktionen boten wir während der gesamten Projektzeit von
> 1 Jahr ohne Unterbruch, Serverabsturz oder Sicherheitspanne an. Obwohl ein grosses Interesse am Angebot bestand und 85% der Hausärzte die Applikation als gelungen beurteilten,
wurde diese nur von 25% rege genutzt. Die Hausärzte begründeten dies mit der Doppelspurigkeit, die entstünde, wenn an eine Klinik elektronisch und an die übrigen nur konventionell zugewiesen werden könne. Ihre Hauptanliegen sind: 1. Ausweitung auf mehrere Kliniken,
2. weitere Angebote (z.B. Labor), 3. Schnittstellen zu ihrer Software.
Schlussfolgerung: Generell besteht ein Bedürfnis der Hausärzte für eine Kommunikation mit
dem Spital über das Internet. Ein solches Angebot ist für diese nur interessant, wenn damit
ihr administrativer Aufwand sinkt und ihnen keine Kosten entstehen. Die Entwicklung einer
Kommunikationsplattform ist aufwendig, muss die Datensicherheit gewährleisten und an
eigene Prozesse angepasst sein. Durch eine breite Abstützung über mehrere Kliniken oder
Spitäler wird der Aufwand besser tragbar und das Angebot attraktiver.
swiss knife 2004; special edition
31
12.01
C. Haller, J. Rey, S. Deglise, E. Pezzetta, JM. Corpataux
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne
12
Iliac artery rupture and retroperitoneal fibrosis related to an infected aorto-iliac endograft
Case report: A 65-year-old man was admitted 28 months after aorto-bi-iliac endograft
deployment for aortic aneurysm. He complained of right lower abdominal pain. A CT-Scan
showed a right psoas haematoma with suspicion of active bleeding from the right external
iliac artery and a right-sided hydronephrosis. First, the bleeding was stopped by use of
endovascular deployment of a covered iliac stent. Right lumbotomy was then performed,
the haematoma was evacuated and a right-sided ureteral dilatation was seen due to a narrowing by retroperitoneal fibrosis at the level of the iliac artery. This required ureterolysis,
resection and cystoplasty. Blood cultures obtained at admission revealed S. aureus.
Discussion: In the literature, only five cases of iliac rupture after endograft infection have
been reported. The treatment of endograft infection is not standardized, due to the small
number of cases reported up to now. A conservative approach with 6 weeks of i.v. antibiotic regimen may be considered in the absence of a mycotic aneurysm or embolism. Other
authors recommend immediate removal of the endograft together with resection of the
artery, followed by venous or extra-anatomical reconstruction.
Conclusion: We reported an iliac artery rupture related to an infected aorto-iliac endograft
28 months after deployment. The associated ureteral stenosis at the level of the iliac-bifurcation is probably at the origin of the infection.
12.04
C. Haller 1, SD. Qanadli 2, J. Rey 1, E. Pezzetta 1, JM. Corpataux 1
1
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne, 2Service de radiodiagnostic
et radiologie interventionnelle, CHUV, Lausanne
Right forearm ischemia due to thrombosis of a lusorian artery stenosis
Definition: The lusoria artery is an anatomic variation of the right subclavian artery originating from the aortic arch and crossing the midline behind the oesophagus, with a reported
prevalence ranging from 0.4 to 2%. This anomaly is usually asymptomatic however dysphasia, coughing or thoracic pain may appear at the age of 40 year in 30-40% of cases.
Case report: A 74-year-old woman presented with acute ischemia of her right forearm.
Angiography suspected right subclavian artery thrombosis. The brachial artery was exposed and thrombectomy was performed with restoration of a valid inflow. Intraoperative radial and ulnar artery thrombolysis was performed due to distal extension of the thrombosis.
Angio-CT-Scan performed during follow-up revealed an ostial arteria lusoria stenosis and
stenting was successfully performed by use of a right transbrachial approach.
Discussion: We present a rare case of thrombosis of the right brachial artery, distal extension from thrombosis of an arteria lusoria stenosis. After thrombectomy, correction of the ostial stenosis was performed by percutaneous stent deployment via a right transbrachial
approach.
Conclusion: Aneurysm may appear on lusoria artery, but stenosis are quite rare. The
endovascular treatment of an ostial stenosis in an aberrant right subclavian artery (lusoria
artery) is feasible by a right transbrachial approach.
12.02
T. Wolff, L. Gürke, T. Eugster, P. Stierli
Universitäres Zentrum für Gefässchirurgie Aarau-Basel
When the legs depend on the internal thoracic artery
We describe the case of a 57 year old patient with severe ischemic pain in both legs due to
Leriche’s syndrome (occlusion of the infrarenal aorta). In the work up for planned aortic surgery, severe coronary 3-vessel disease was diagnosed. It was decided to perform coronary artery surgery first, followed by aortic surgery several weeks later. Coronary artery
bypass was performed off-pump and consisted of an internal thoracic artery bypass to the
left anterior descending and a single vein bypass to the right coronary artery. Soon after
coronary surgery, paresis of both legs was noted. On the second postoperative day severe
ischemia of both legs was diagnosed and emergency aorto-bifemoral bypass was performed. At this stage the patient was in septic shock and required intotrope support. Because
of progressive gangrene, through-knee amputation of one leg was necessary. The patient
developed progressive hemodynamic instability and multi-organ failure and died on the
22nd postoperative day. A careful re-analysis of the preoperative aortic angiogram showed
that both legs were perfused via collaterals from the internal thoracic artery to the epigastric
artery. This explains why the use of the internal thoracic artery as a coronary bypass graft
led to acute leg ischemia.A search in the literature reveals that our case is not unique: there
are several documented cases of leg ischemia following cardiac surgery, all of them in
patients where an internal thoracic artery bypass was used in the presence of severe aortoiliac disease. But there are also other clinical situations described in the literature where, in
the presence of aorto-iliac disease, non-vascular surgery has led to leg ischemia by interrupting collaterals that have become vital for leg perfusion.
12.03
A. Oesch, HU. Würsten, U. Laffer
Spitalzentrum Biel
Das Kompartment-Syndrom - eine seltene Komplikation der Varizenchirurgie
Einleitung: Schwere Komplikationen der Varizenchirurgie, wie tiefe Venenthrombose, LE und
Verletzung tiefer Gefässe, sind selten und gut bekannt. Dagegen wurde das KompartmentSyndrom kaum beschrieben und ist sehr selten. Anhand von zwei Fällen möchten wir auf
diese folgenschwere Komplikation aufmerksam machen.
Fallbericht: Zwei Patientinnen wurden wegen eines Varizenleidens abgeklärt und durch eine
klassische Crossektomie mit Hemistripping und Phlebexhairèse, ohne Blutsperre behandelt.
Nach 8, resp. 12 Stunden klagten beide Frauen über zunehmende Schmerzen im Bein. Trotz
Entfernung des Verbandes blieben die Beschwerden stark. Rasch wurde die Verdachtsdiagnose eines Kompartment-Syndroms gestellt und mittels Logendruckmessung bestätigt.
Bei beiden Patientinnen erfolgte dann eine notfallmässige Logenspaltung 16, resp. 12 Stunden postoperativ. In beiden Fällen konnte ein diffuses Muskeloedem ohne Einblutung festgestellt werden. Eine Patientin hat sich praktisch ohne Folgen erholt, bei der zweite musste eine
Achillessehnenverlängerung wegen einem Spitzfuss durchgeführt werden.
Diskussion: Komplikationen bei Varizenchirurgie sind meistens leicht (Lymphfisteln,
Wundheilungsstörungen, Schädigung eines Nerves). Schwere Komplikationen liegen unter 1%
(Verletzung V. femoralis communis, tiefe Venenthrombose oder LE). Praktisch nie wird das
Kompartment-Syndrom als Komplikation der Varizenchirurgie erwähnt. Die Ursachen für ein
Kompartment-Syndrom sind bestens bekannt nach Trauma oder arterieller Revaskularisation.
Nach Varizenchirurgie hingegen sind die Ursachen unklar. Als einzige Erklärung bleibt in unseren zwei Fällen wohl eine zu enge Bandage postoperativ unter Residualanästhesiebedingungen.
Schlussfolgerung: Das Kompartment-Syndrom ist eine seltene, aber schwere Komplikation
der Varizenchirurgie. Ein ungeklärter postoperativer Schmerz muss als Warnzeichen
erkannt werden, um eine rasche chirurgische Fasciotomie durchführen zu können. Nur so
können die neurologischen Spätfolgen des Kompartment-Syndroms vermieden werden.
32
swiss knife 2004; special edition
12.05
L. Giovannacci, S. Schlunke, A. Marx
Ospedale Regionale di Lugano
Early experience and preliminary results with a new polyurethaneurea vascular graft (PVG)
in vascular access surgery for chronic haemodialysis
Introduction: The polyurethaneurea vascular graft (VectraR) is a new material for synthetic
vascular access grafts in chronic haemodialysis for end stage renal insufficiency.
Compared to the commonly used extruded polytetrafluoroethylene (ePTFE) graft, PVG has
been reported to have similar characteristics in terms of primary and secondary patency
rates, adverse events and complications. The reported advantage of PVG is the absence
of perigraft edema after implantation, allowing therefore early graft cannulation for
haemodialysis within only a few days after graft implantation.
Patients and Methods: Since October 2003, we used the PVG as standard graft for
vascular access in patients with end stage renal insufficiency where autologous venous
vasculature was already used and therefore the creation of direct AV fistulas were
impossible. Overall 12 PVG grafts were implanted. This is, as far as we know, the greatest
series of PVG grafts implanted in Switzerland. Clinical parameters as e.g. intraoperative handling, time of first cannulation after implantation, patency rate, adverse events (post
cannulation haemorrhage, infection) were prospectively monitored. Colour doppler
ultrasound scan was routinely used for assessing graft morphology and access blood flow.
Results: All of our 12 implanted PVG but one are patent at the moment. The only failure
was due to postoperative infection and led therefore to the removal of the graft. Grafts were
cannulated routinely within 48h (!) after implantation. We had so far one post-cannulation
haemorrhage which stopped eventually and needed no specific therapy.
Conclusion: The first results of the largest PVG graft series in Switzerland are
encouraging. Since synthetic grafts are usually implanted in patient already on long stage
chronic haemodialysis, the very early graft cannulation after implantation has obviously
enormous advantages for the patient: time and therefore complications of provisory
hemodialysis using percutaneously introduced subclavian catheters can therefore drastically
be reduced. Our results are comparable to those reported in the literature.
12.06
E. Cereghetti, P. Stierli, E. Eugster, T. Wolff, L. Gürke
Universitäres Gefässzentrum Aarau-Basel
Preliminary carotis-vertebralis transposition and carotis-subclavia bypass allowing endovascular treatment of an aortic arch aneurysm
Purpose: Preliminary ancillary surgical procedures may enable endovascular repair of aortic
arch aneurysm. An open surgical repair of the aneurysm can thereby be avoided, resulting in
reduced morbidity and mortality.
Case report: A 65-year-old woman with new-onset dysphonie and paresis of the left laryngeal recurrens nerv was found to have a 4-cm pseudoaneurysm of the aortic arch (CT-scan).
An aortogram showed a saccular pseudoaneurysm (having 2-cm caudal length)originating
opposite the left subclavia and a common ostium between the left vertebral and the left subclavian artery. The history was notable for severe chronic obstructive pulmonary disease,
hypertension, diabetes mellitus and obesity. An endovascular therapy was planed. To allow
endovascular treatment, the left vertebral artery was transposed to the left carotid artery and
a left carotid- subclavia interposition graft was performed. Thereafter endovascular therapy of
the aneurysm was realized. There were neither intra nor postoperativ complications. The 1month follow up (CT scan) demostrated the successful endovascular aneurysm exclusion
and the patency of supraaortic vessels.
Conclusion: Preliminary ancillary open surgery may enable endovascular therapy of aortic
arch aneurysm in high risk patients.
12.07
1
2
1
2
S. Zeini , M. Christodoulou , H. Probst , N. Peloponissios , A. Richard
1
Hopital Regional de Sion, 2CHUV - Lausanne
1
Behçet’s disease revealed by arterial aneurysms of the extremities
Background: Behçet‘s disease is a recurrent multi-systemic disease of unknown cause. First
described in 1937, the disease is defined by a triad associating oral and genital ulcers and
uveitis. Its prevalence is 0.1 to 7.5 per 100000 inhabitants in Europe. Vascular onset is present in 3% of patients.
Case report: A 25-year.old male patient presented pulsatile bulging of the right wrist and the
left internal maleolus and thigh in a 2-month interval. Arteriogram showed pseudo-aneurysms of the right radial artery, the left tibial posterior and superficial femoral artery.
Treatment Surgical procedures comprised exclusion of the aneurysm and bypass for every
pseudo-aneurysm. The biological, haematological, immunological and pathological exams
were aspecific. The diagnosis was made on the association of oral ulcers and recurrent
arterial pseudo-aneurysms. A systemic treatment of corticoid and immunosuppression
drugs was initiated.
Conclusion: Arterial pseudo-aneurysm is an uncommon presentation of Behçet’s disease.
The management comprises a clinical assessment, immunological exams and arteriogram or duplex-ultrasound. Surgical vascular procedures prevent further complications
associated with a 5-per-cent mortality.
12.08
C.Hueber 1, T. Obeid 1, J. Huber 2, A. Mironov 3, L. Gürke 1, P. Stierli 1
Universitäres Zentrum für Gefässchirurgie Aarau/Basel, 2Klinik für Orthopädie, Kantonsspital
Aarau, 3Klinik für Radiologie, Kantonsspital Aarau
1
Traumatische Läsion der A. vertebralis
Einleitung: Traumatische Läsionen der A. vertebralis (AV) stellen weniger als 1% aller
Gefässverletzungen dar. Neben der penetrierenden Halsverletzung stellt auch das stumpfe
Halswirbelsäulen (HWS)-Trauma, insbesondere in Kombination mit vorbestehenden degenerativen Veränderungen, eine bekannte Ursache dar.
Patient und Methode: Wir berichten über einen 72 jährigen Patienten, der sich bei einem
stumpfen HWS-Trauma eine Verletzung der AV zuzog.
Ergebnisse: Der dialysepflichtige Patient mit langjährigem M. Bechterew zog sich bei einem
Autoselbstunfall eine dislozierte, instabile Fraktur von Halswirbelkörper 5/6 mit linksbetonter, sensomotorischer Paraparese zu. Die Indikation zur ventralen Spondylodese wurde
gestellt. Intraoperativ manifestierte sich nach Eröffnung des vorderen Längsbandes eine
starke arterielle Blutung aus dem Frakturbereich. Diese konnte erfolgreich tamponiert werden. Der Verdacht einer Verletzung der AV wurde angiographisch bestätigt. Es erfolgte
sogleich die kathetertechnische Embolisierung.
Diskussion: Läsionen der AV entstehen durch penetrierende oder stumpfe Gewalteinwirkung. Instabile Patienten mit stark blutenden Halswunden werden chirurgisch exploriert.
Stumpfe Verletzungen der AV entstehen meist durch Hyperextensions- oder Hyperflexionstraumen und führen zur Blutung, resp. Hämatom, Pseudoaneurysma, Embolie oder Okklusion. Muss eine HWS-Verletzung operativ versorgt werden, kann eine verletzte AV zu einer
starken Blutung führen. Je nach Lokalisation der Läsion, z.B. im V2-Abschnitt, kann eine
chirurgische Blutstillung extrem schwierig sein, und es empfiehlt sich zu tamponieren. Die
jetzt indizierte, selektive Angiographie demaskiert die Verletzung und erlaubt die kathetertechnische Embolisierung. Die verletzte AV sollte proximal und distal verschlossen werden.
Die Inzidenz einer Hirnstammischämie beträgt für die linke AV 3.1%, für die rechte 1.8%. Die
chirurgische Rekonstruktion der AV ist nur bei angiographisch nachgewiesener, inadäquater Kollateralisierung indiziert.
Schlussfolgerung: Bei Halswirbelsäulenverletzungen muss an eine begleitende Verletzung
der A. vertebralis gedacht werden.
12.09
G. Heller, H. Savolainen, M. Menth, MK. Widmer, T. Carrel, J. Schmidli
Klinik für Herz- und Gefässchirurgie, Inselspital, Bern
Temporärshunt zur Vereinfachung der Anastomosentechnik in der cruralen Bypasschirurgie
Einleitung: Die Anastomosentechnik in der crurale Bypasschirurgie ist duch arteriosklerotisch veränderte Gefässe delikat. Es stellt sich die Frage, wie man ohne störenden In- und
Backflow arbeiten kann. Alle bekannten Techniken –lokales Abklemmen extern, Oberschenkelblutsperre und Katheterintubation- weisen Nachteile auf. Wir verwenden temporäre Intraluminalshunts (Flo-Thru) der Fa Synovis welche die Zirkulation gewährleisten und trotzdem
ein Arbeiten ohne Blutung ermöglichen. Das Ziel ist es, diese Technik auf Durchführbarkeit
und ihre Vorteile zu untersuchen.
Methode: Alle Patienten erhielten einen femoro-cruralen autologen, gedrehten Venenbypass. Das arterielle Empfängersegment wurde freipäpariert und überprüft. Die Vene entnommen und eingezogen. Nach Gabe von Heparin erfolgte die proximale Anastomose. Die
crurale Arterie wurde eröffnet. Durch externe Kompression der Weichteile wurde der
Blutfluss kontrolliert und überprüft. Es erfolgte die Auswahl des Shunts nach Gefässgrösse.
Nach Einlage konnte die Anastomose durchgeführt werden. Kurz vor der Vollendung wurde
der Shunt entfernt, die Blutung wiederum extern kontrolliert.
Resultate: Fünf Patienten (4 Männer, 1 Frau) welche einen femoro-cruralen Bypass erhielten wurden so operiert. Das Alter der Patienten betrug 71,6 Jahre (57 bis 82). Wir haben in
allen Fällen den 3 mm Shunt verwendet. Einmal wurde ein kleinerer Durchmesser gewählt
und wegen Blutungen neben dem Shunt gegen einen Grösseren ausgetauscht. Wir sahen
keine technikrelevanten Komplikationen.
Diskussion: Wir sehen mehrere Vorteile im Gebrauch von Shunts in der peripheren
Bypasschirurgie. Es erfolgt kein Klemmen der Gefässe, was gerade bei einer Arteriosklerose vorteilhaft ist, kein vollständiges Freilegen und Denudieren des Gefässes. Eine Blutsperre ist nicht notwendig und das schon ischämische Bein somit immer perfundiert. Der
Intraluminalshunt verhindert zudem ein Mitfassen der Hinterwand.
Schlussfolgerung: Temoräre Intraluminalshunts in der pripheren Bypasschirurgie bilden
unserer Meinung nach eine Erleichterung der operativen Technik. Die Machbarkeit und
Vorteile haben wir bei unseren Patienten klar aufzeigen können.
12.10
J. Rey 1, S. Binaghi 2, C. Haller 1, S. Qanadli 2, HB. Ris 1, JM. Corpataux 1
Service de chirurgie thoracique et vasculaire, CHUV, Lausanne,
2
Service de radiologie, CHUV, Lausanne
1
Renal artery stenosis by fibres from diaphragmatic crus is a rare cause
of renovascular hypertension
Definition: renovascular hypertension is caused by atheromatous disease, fibromuscular
dysplasia of the renal arteries, renal vasculitis and more rarely by stenosis due to diaphragmatic crus.
Case report: A 39-year-man had a resistant hypertension with increased creatinemia.
Renal Doppler showed left ostial renal artery stenosis associated with superior mesenteric
artery stenosis of 80%. Cerebrovascular RMI permited to exclude other vascular anomaly.
An angioplasty with deployement of an autoexpansible stent was carried out with difficulties because of stent recoil on an elastic stenosis, requiring the placement of a second
stent. The angiographic result showed residual artery stenosis of 30 %. Plasma creatinine
values decreased from 180 to 120 mmol/l and systolic pressure remained high. After 6
months, a renal Doppler demonstrated left artery renal ostial acceleration and apparition of
turbulences among ostial right renal artery. The CT scan showed linear structure originating
in the left and right crus. Left aorto-renal bypass with saphenous vein interposition and
reimplantation of the right renal artery were carried out. Musculotendinous fibers from the
left and right diaphragm surrounded the superior mesenteric artery and both renal arteries
have been resected. Postoperative course was good with progressive decrease of creatinemia and normalisation of tensional values without any anti-hypertensive therapy.
Discussion: Stenosis of the renal artery by extrinsic compression is a rare cause of renovascular hypertension. In 1962 were described the first two cases of renal artery compression
by musculotendinous fibres and since then, less than 20 cases are found is the literature.
Young hypertensive patient without any risk factors and after exclusion of other etiology
should benefit from a renal angioscanner to evaluate diaphragm anatomy.
12.11
J. Duwe 1, E. Burri 1, D. Toia 2, P. Nussbaumer 3, CA. Maurer 1
Department of Surgery, Kantonsspital Liestal, 2Department of Radiology, Kantonsspital
Liestal, 3Department of Internal Medicine/Angiology, Kantonsspital Liestal
1
Embolization of a high-output postnephrectomy arterio-venous fistula by an endovascular
transfemoral bidirectional approach
An arterio-venous fistula between the renal artery and renal vein is a rare complication of
nephrectomy. Recurrence of hypertension after nephrectomy, increasing heart failure and
lumbar or upper abdominal bruit are the most characteristic clinical findings suggesting the
presence of a renal arterio-venous communication.
We report a case of a high-output, large-calibre, postnephrectomy arterio-venous fistula
(PNAVF) between the renal vessel stumps successfully treated by an endovascular transfemoral bidirectional approach. A 70-year-old woman had undergone right nephrectomy for
shrinking kidney 45 years ago and suffered from abdominal pain and dyspnoea due to
volume overload of the heart. Diagnosis was made by clinical signs and confirmed by colored duplex sonography and angiography. The aortogram revealed a massive shunt from
the aorta to the inferior vena cava via the stumps of right renal artery and renal vein.
For embolization we preferred a combined venous and arterial transfemoral percutaneous
approach with a catheter loop over the fistula that allowed to decrease the flow through the
fistula by a 13 mm Fogarty occlusion balloon catheter. This balloon occlusion of the fistula’s run-off allowed prevention of inadvertent embolization into the lungs. Following vascular obstruction of the venous part of the PNAVF, 9 coils with a diameter between 6 and 14
mm were inserted in the renal artery for transcatheter embolization. The overall length of the
coils was 2.09 meter. The fistula was embolized successfully with immediate improvement
of symptoms and without pulmonary embolization. The bidirectional endovascular
approach allows a reliable occlusion of centrally located high-output arterio-venous fistulas
without risk of systemic embolization.
12.12
R. Vonlanthen 1, JM. Corpataux 2, L. Krähenbühl 1
1
Klinik für Chirurgie, Kantonsspital Freiburg, Freiburg,
2
Klinik für Gefässchirurgie, CHUV, Universität Lausanne, Lausanne
Aneurysmata der Arteria mesenterica superior, A. gastroduodenalis in Kombination mit
einer Stenose des Truncus coeliacus (Fallbeispiel)
Hintergrund: Aneurysmata der Viszeralarterien sind selten (0.1-0.2% der Aneurysmata).
swiss knife 2004; special edition
33
Werden sie im Rahmen einer Ruptur (22%) diagnostiziert, sind diese mit einer Letalität von
9-75% verbunden. Meistens werden Viszeralarterienaneurysmata (VAA) zufällig entdeckt,
wie im folgenden Fallbeispiel.
Fallbeispiel: Eine 66 jährige Patientin, suchte wegen lumbalen Schmerzen ihren Hausarzt
auf. Die klinische Untersuchung der LWS ergab keinen pathologischen Befund. Radiologisch
(LWS ap/seitlich) zeigten sich neben einer Discarthrose zusätzlich zwei intraabdominale
Verkalkungen, die den Verdacht auf verkalkte Aneurysmata erweckten. Die CT zeigte neben
einem Aneurysma der Arteria mesenterica superior (AMS) an der Unterseite des Pankreaskorpus (Durchmesser 28mm), ein Aneurysma der A. gastroduodenalis (Durchmesser
12mm) sowie eines der Arteria lienalis (Durchmesser < 1cm). Um die die Aneurysmata besser lokalisieren zu können wurde eine Angio-CT und selektive Angiographie der AMS angefertigt. Dabei zeigten sich im Verlauf der AMS sechs weitere kleinere Aneurysmata (<1cm).
Zusätzlich fand sich eine 80% Stenose des Haupstammes des Truncus coeliacus mit einem
entsprechenden Umgehungskreislauf über die AMS respektive über die A. pacreatico-duodenalis/gastroduodenalis. Die hohe Mortalitätsrate bei Ruptur, impliziert die Behandlungsdringlichkeit für jedes VAA (>2cm), sofern keine Kontraindikationen bestehen. Erschwerend in unserem Fallbeispiel war die Stenose des Truncus coeliacus sowie die Vielzahl der kleinen VAA.
Wir haben uns auf eine Resektion des grössten Aneurysmas beschränkt (Aneurysma am Abgang AMS/Unterrand Pankreaskorpus). Der entstandene Defekt wurde mittels eines Venenpatchs gedeckt. Auf eine Embolisation der A. gastroduodenalis/pancraticoduodenalis (Umgehungskreislauf für die A. hepatica communis) wurde aufgrund der ansonsten mangelnden
Durchblutung der Leberarterie verzichtet.
Schlussfolgerung: VAA sind ein häufiger Zufallsbefund. Die Rupturhäufigkeit liegt je nach Lokalisation zwischen 2-90% und die Mortalitätsrate ist hoch (8.5-75%). Deshalb ist beim Vorliegen eines VAA (> 2cm) die Indikation zur elektiven Therapie gegeben, jedoch nur soweit es
die vorliegende Anatomie erlaubt.
12.13
M. Lüdin 1, P. Mäder 2, W. Nagel 1
1
Gefäss-, Thorax- und Transplantationschirurgie, 2Klinik für Chirurgie, St.Gallen
Unterschenkelamputation – wie gelingt sie immer?
Einleitung: In der Gefässchirurgie sind Amputationen oft Endpunkt einer ganzen Reihe von
gefässrekonstruktiven Eingriffen. Die Resultate sind, bedingt durch die Grunderkrankung aber
auch durch die Tatsache, dass diese Operationen meist von unerfahrenen Aerzten durchgeführt werden, häufig unbefriedigend. Wir wenden in unserer Klinik bei Unterschenkelamputationen erfolgreich eine Methode zur Festlegung der Schnittführung an, welche auf Anhieb
einen perfekten Stumpf garantiert und die Operation sehr vereinfacht.
Methode: Wir operieren grundsätzlich nach der Methode von Burghes. Eine Handbreite
unterhalb der Tuberositas tibiae wird der Unterschenkelumfang gemessen. Der Umfang
wird durch drei dividiert, dies entspricht dem Wert x in cm. Anschliessend wird jeweils von
der Tibiakante x cm nach medial und lateral abgetragen und markiert. Von diesen Punkten
wird wiederum x cm nach caudal abgemessen, so dass die an dieser Stelle dorsal verbleibende Zirkumferenz wiederum x cm beträgt. Nach Verbinden dieser Punkte ergibt dies grob
die Schnittführung. Unter der Voraussetzung, dass der M. soleus konsequent entfernt wird,
ergibt diese Schnittführung einen perfekt passenden dorsalen Haut-Muskellappen.
Patienten und Resultate: Wir haben seit Juli 2000 in unserer Klinik bei 63 Unterschenkelamputationen diese Methode angewandt, ohne dass je der Hautmuskellappen korrigiert oder
die Knochen nachgekürzt werden mussten.
Fazit: Mit der “Drittels-Methode” wird die Unterschenkelamputation ausserordentlich vereinfacht.
12.14
H. Misteli, TH. Wolff, TH. Eugster, L. Gürke, P. Stierli
Universitäres Zentrum für Gefässchirurgie Aarau-Basel
Successful surgery for traumatic carotid artery dissection
A 62 year old patient was struck against the neck by a heavy piece of wood. A superficial
wound was sutured and the patient was discharged. The patient had no neurological symptoms but returned the following day because of hoarseness of the voice. A CT scan of the
neck was performed which showed a floating thrombus in the left common carotid artery.
After referral to our vascular surgery unit, emergency operation was performed: The carotid
bifurcation was snared and a temporary shunt was placed between the common and internal carotid artery. The common carotid artery showed a subtotal occlusion by a fresh
thrombus that had formed at the site of an intimal tear of approx. 10 mm length. After thrombectomy, the intimal flap was fixed by tack-down sutures and the arteriotomy was closed
with a Dacron patch. The postoperative course was uneventful and the patient developed
no neurological symptoms.
Carotid artery dissection is a rare complication of blunt trauma to the neck but can also
occur spontaneously or after minor trauma such as spinal manipulation. The typical symptom is ipsilateral head pain, which is more common than pain in the neck region.
Neurological symptoms occur in 30 - 70 % of patients. The classical location is the internal
carotid artery and often the dissection continuous into the carotid sinus and is not accessible to surgery. Conservative treatment consists of oral anticoagulation and has generally
superior results to surgery. In our case the dissection was known to be local, accessible to
surgery and the floating thrombus meant there was a large risk of imminent cerebral embolism. These factors persuaded us to optain for surgery which turned out to be successful.
34
swiss knife 2004; special edition
12.15
CH. Nebiker, TH. Wolff, TH. Eugster, P. Stierli, L. Gürke
Universitäres Zentrum für Gefässchirurgie Aarau-Basel
Angiosarcoma of the abdominal aorta presenting with tumor embolisation to the leg
A 67 year old man developed acute ischemia of the left leg. Arteriography showed multiple
emboli in the arteries of the thigh and calf. A CT scan showed a partially thrombosed infrarenal aortic aneurysm of approx. 43 mm diameter and this was considered to be the source of embolism. The emboli were successfully treated by aspiration and Rotarex ablation
and oral anticoagulation was instituted. Aortic aneurysm surgery was deferred because of
fever of unknown origin. 5 months later the patient developed acute abdominal pain. A CT
scan revealed impending rupture of the aneurysm. Emergency surgery was performed. On
opening the aneurysm an unusual, crumbly mass was found in the lumen and sent for
histology. A bi-iliac PTFE graft was implanted. Histology revealed a high grade sarcoma of
the intima of the aortic wall. Postoperative MRI, CT and PET revealed a tumor mass in the
anterior aneurysm wall overlying the prosthesis and an enlarged paraaortic lymph node,
but there was no sign of distant metastases. 6 weeks later the suspected lesions were
resected. There was no macroscopic tumor visible. On histology there was microscopic
tumor residue in the aortic wall but not in the lymph node. 6 months later the patient is well
and has no signs of tumor recurrence.
Aortic angiosarcoma is extremely rare with only 86 cases published in the literature. The
mean age at presentation is 60 years, with a male to female ratio of 2:1. In most cases the
diagnosis was made only post mortem. The most common clinical presentation seems to
be peripheral embolization, as in our case. Tumors of the media and adventitia can produce back and abdominal pain. As for all angiosarcoma the prognosis is poor: Without therapy the average survival is reported to be 1.5 years. Surgical treatment with en bloc resection is recommended only when clear margins can be expected and when there is no sign
of metastasis. Nevertheless long-term survival after total resection has been described even
when the tumor presents by distal embolisation. This shows that tumor emboli do not
necessarily lead to distant metastasis.
12.16
S. Déglise 1, AL. Kelekis 2, N. Ducrey 3, C. Haller 1, SD. Qanadli 2, JM. Corpataux 1
1
Service de Chirurgie Thoracique et Vasculaire, CHUV, 2Service de Radiologie, CHUV, 3Service
d’Hypertension et Angiologie, CHUV
Comparative evaluation of multi-slice CT-angiography vs duplex ultrasound scan for longterm follow-up of surgically excluded popliteal artery aneurysms
Objective: Surgical exclusion and reconstruction of the vessel by vein graft interposition is
the procedure of choice for the management of popliteal artery aneurysms (PAAs).
However, little is known regarding the risk of recurrence and enlargement after this
approach. The aim of this study was to evaluate the outcome of surgically treated popliteal
aneurysms in this respect and to compare the role of multi-slice CT angiography (MSCT)
with color duplex ultrasound scan in the assessment of operated PAAs during follow-up.
Patients and Methods: Fifteen patients with 26 PAAs were evaluated with duplex ultrasound
scan and multi-slice CT with a mean follow-up time of 67 months. Aneurysmal progression,
graft patency and graft-related complications were analyzed.
Results: Duplex examination showed that 2 PAAs (10%) revealed a perfused aneurismal
sac whereas in the 19 others PAAs (90%), no evidence of intrasac blood flow was observed within the excluded aneurysms. In contrast, MSCT demonstrated blood flow in 6 excluded PAAs with an average increase of the diameter of 21 mm over time. Fifteen PAAs
demonstrated no blood flow and revealed an average decrease of 7 mm in diameter over
time. In addition, MSCT demonstrated 5 anastomotic aneurysms and 3 graft stenosis
which were not observed by Duplex examination.
Conclusions: Twenty-four percent of the patients after surgical exclusion of PAAs revealed a
perfused aneurysmal sac with an associated risk of increase of the aneurismal diameter
up to 60 mm during follow-up. MSCT was superior to duplex ultrasound scan examination
in detecting a residual sac perfusion and increase of aneurismal diameter after surgical
treatment of PAAs.
12.17
MK. Djebaili, E.Khabiri, A. Kalangos
Cardiovascular Surgery Unit Geneva University Hospital
Traumatic brachial artery aneurysm as an occult source of emboli to the upper extremity
Introduction: Aneurysms of the brachial artery are rare but potentially dangerous lesions
that threaten the upper extremity with vascular and neurological compromise. Most can be
treated effectively with surgical excision and vascular grafting.
Methods & Results: We report a case of a 64-year-old man with a medical history of traumatic shoulder dislocation 45 years ago. He presented an inaugural right upper limb ischemia with paresthesia in the right forearm with spontaneous resolution. Three days before
his admission to hospital same symptomatology occured and he was tooken to the operating room for embolectomy with good results and full recovery of his right hand. An extensive check up with an echocardiography, holter EKG, cardiac MRI, and blood analysis showed no source for an embolus. Eleven days later the patient complaint of pain, paresthesia,
numbness and coolness in the right forearm and hand. Angiography performed from the
right common femoral artery approach showed that the aortic arch was normal. The angiogram revealed irregularity at the junction of axillary an brachial artery, which was occluded,
in the initial portion, both radial and ulnar arteries were sub occluded distally and the radiologist concluded a brachial pseudoaneurysm. The patient underwent an operation. 6-x
4cm brachial artery aneurysm was removed, with interposition of polytetrafluoroethylene
graft (Impra ePTFE) 8 mm in diameter was fashioned; embolectomy of both ulnar and radial arteries was performed. The brachial, radial, ulnar pulses were palpable post operatively. He received one aspirin tablet a day and anticoagulant regimen for 3 months (INR range:
2 to 2.5). And the patient was discharged to home on the tenth postoperative day.
Conclusion: Brachial artery aneurysm is a rare entity with serious complications, most commonly by blunt trauma. Arteriography is the mainstay of diagnosis and treatement in these
lesions should be considered as soon as they become apparent to prevent limb loss or dysfunction.
12.18
S. Eichenberger, M. Zuber, L. Eisner
Departement Chirurgie, Kantonsspital Olten
Akute obere GIT Blutung bei rupturierendem Aortenaneurysma
und primärer aortoduodenaler Fistel
Die aortoduodenale Fistel ist eine seltene aber gefürchtete Ursache einer gastrointestinalen
Blutung. Sie tritt meist sekundär in Folge einer vorhergehenden Rekonstruktion bei
Aortenaneurysma auf, als Rarität primär bei nativem Aortenaneurysma. Die Diagnose der
primären aortoduodenalen Fistel gestaltet sich oft schwierig. Die Symptome Schmerz
(32%), palpable abdominale Masse (25%) und Blutung (64%) sind nicht immer vorhanden. Die Fistel kann oft sowohl endoskopisch als auch radiologisch nicht dargestellt werden, so dass die Diagnose nicht selten erst intraoperativ erfolgt.
Wir präsentieren den Fall eines 57 jährigen Patienten, der sich auf unserer Notfallstation mit
einer kreislaufaktiven GIT Blutung präsentierte. Eine notfallmässig durchgeführte obere
Panendoskopie zeigte eine unklare Sickerblutung im Pars II duodeni. Die Diagnose einer primären aortoduodenalen Fistel in Pars III duodeni bei rupturiertem infrarenalem
Aortenaneurysma konnte erst anlässlich der notfallmässigen Laparotomie gestellt werden.
Das Aneurysma wurde mit einem 18 mm Dacron-Tube-Graft ersetzt. Diese Prothese musste trotz resistenzgerechter Antibiose am 10. Tag wegen Protheseninfekt durch einen AortenHomograft ersetzt werden. Der Patient erholte sich erfreulich bevor es am 14. Tag erneut zu
einer (sekundären) aortoduodenalen Fistel mit nicht mehr beherrschbarer Blutung kam.
Die primäre aortoduodenale Fistel bleibt ein Krankheitsbild mit extrem hoher Morbidität und
einer Mortalität um 70%. In Abwesenheit einer klar diagnostizierten Blutungsquelle muss
sie als Blutungsursache bis zum Beweis des Gegenteils in Erwägung gezogen werden. Bei
präoperativer Diagnosestellung besteht die Therapie der Wahl im Ersatz der Aorta durch
einen Homograft.
13
13.01
PC. Nett 1, HW. Sollinger 2, T. Alam 2
1
Universität Bern, Departement für Viszeral- und Transplantationschirurgie, Berne, Switzerland,
2
University of Wisconsin, Hospital and Clinics, Division of Organ Transplantation, Madison, USA
Translational enhancement of hepatic insulin expression improves glycemic
control in STZ-induced diabetic rats
Introduction: Gene-therapy based hepatic insulin production is a promising strategy in the
treatment of insulin dependent diabetes mellitus (IDDM). We have previously shown that
hepatocytes engineered with Ad.3SAM2 including the liver-specific albumin promoter coupled with three glucose inducible regulatory elements (GIRE)s and the modified proinsulin,
improved glucose tolerance tests and corrected fasting hyperglycemia in streptozotocin
(STZ)-induced diabetic rats. However, due to insulin insufficiency, postprandial hyperglycemia was not fully corrected.
Material and Methods: To increase the insulin output we generated a new insulin gene construct (3SATEM) containing an additional translational enhancer sequence derived from
vascular endothelial growth factor (VEGF). The capacity of insulin expression of both constructs 3SAM2 and 3SATEM were tested in vitro and in vivo.
Results: Primary rat hepatocytes (1x106cells) exposed to 27.5mM glucose and transduced
with Ad.3SATEM showed a 3.1-fold increase of glucose-dependent insulin secretion
(435±45ng/ml) over a period of 24 hours compared to Ad.3SAM2 (142±21ng/ml), while
glucose responsiveness was still maintained. In vivo studies in STZ-induced diabetic rats
demonstrated that treatment with Ad.3SATEM in contrast to Ad.3SAM2 significantly increased insulin serum concentration under both postprandial (14.9±1.9?U/ml) and fasting
(5.9±1.2?U/ml) conditions (P<0.001), thus accelerating kinetics to restore postprandial
euglycemia and improving re-feeding tests. Both Ad.3SAM2- and Ad.3SATEM-treated
groups showed a significant reduction of postprandial hyperglycemia and reduced weightloss compared to diabetic control rats.
Conclusion: This study substantiates the feasibility of gene therapy-based treatment for
IDDM and provides novel information on the potential use of translational enhancement in
a preproinsulin gene construct (3SATEM) that substantially improved the output of hepatic
insulin secretion and accelerated kinetics to restore postprandial euglycemia in vivo.
13.02
G. Mai, P. Bucher, Ph. Morel, T. Berney, L. Bühler
Cell Transplantation Lab, Surgical Research Unit, Department of Surgery,
University Hospital Geneva
Anti-CD154 mAb treatment but not recipient CD154 deficiency leads to long-term survival of
xenogeneic islet grafts
Aim: Rejection of islet xenografts (IXG) is primarily mediated by a cellular immune response
and can be modulated by costimulatory blockade. The aim of our study was to evaluate the
role of CD40-CD154 pathway in the rejection process of concordant and discordant IXG.
Methods: Diabetic C57BL/6, CD40-KO or CD154-KO mice were transplanted (TX) under the
kidney capsule with either rat or human islets. For rat-to-mouse and human to-mouse combinations, 4 groups were performed (N=6 each group): Group 1, islet TX in C57BL/6 without therapy; Group 2, islet TX in C57BL/6 with anti-CD154 mAb therapy (MR1, 0.5mg i.p.
on days 0, 2 and 4); Group 3, islet TX in CD40-KO without therapy; Group 4, islet TX in
CD154-KO without therapy. Islet function was measured by glycemia and histology was
performed on regular intervals.
Results: Short-term MR1 therapy significantly prolonged both concordant (median graft survival (MGS) >120 versus 17 days, p < 0.001) and discordant IXG survival (MGS >120 versus 11 days, p < 0.005), compared to control. In CD40-KO mice, concordant IXG survival
was shorter compared to control (MGS 9 versus 17 days, p = 0.5), but discordant IXG survival was prolonged (MGS 27 versus 11 days, p = 0.06). In CD154-KO, concordant IXG survival (MGS 17 versus 17 days) and discordant IXG survival (MGS 16 versus 11 days) was
not significantly modified compared to control. In Group 1, histology obtained at rejection
showed dense graft infiltration by immune cells and IgG, IgM and C3 deposition. In Group
2, histology performed after 120 days showed a mixed cellular infiltrate around intact islets,
without antibody or C3 deposition. In Groups 3 and 4, a moderate cellular infiltrate was
observed at rejection, with no IgG, but moderate IgM and C3 deposition.
Conclusion: Short-term costimulatory blockade (MR1) allowed long-term survival of concordant and discordant IXG. Absence of CD40 and CD154 expression on lymphocytes did
not significantly modify concordant or discordant IXG survival, suggesting that other costimulatory pathways allowed efficient T cell activation. Furthermore, expression of CD154 is
required to achieve activation-induced apoptosis of donor-reactive T cells by MR1.
13.03
P. Bucher 1, Ph. Morel 1, A. Andres 1, D. Bosco 1, M. Kurfürst 2, L. Bühler 1, TH. Berney 1
1
Department of Surgery, Geneva University Hospital,
2
Nordmark Arzneimittel GmbH, Uetersen, Germany
Collagenase for human islet isolation
Aim: Advances in the success rate of human islet isolation are due in part to the availability of new purified enzyme blends. We evaluated a new enzyme preparation (collagenase
NB1), which, is composed of highly purified collagenase and can be reproducibly blended
with neutral protease.
Methods: Nine human islet isolations were performed with Collagenase NB1 supplemented
with neutral protease (Serva, group I). Yields, morphology, in vitro insulin secretion and islet
cell apoptosis (Cell Death Detection ELISA, Roche) were assessed. Results were compared to
those of nine isolations performed with Liberase (Roche, group II) and matched for circumstances of death. Donor mean age were 48 ± 11 and 46 ± 11 years for group I and II and
mean BMIs were 25 ± 2 and 26 ± 4 for group I and II, respectively. No significant differences
were observed in pancreas weights, warm and cold ischemia times between group I and II.
Results:
IE post-purification (x103)
IE/islet ratio
IE/gram of pancreas
Acute Insulin response (m U/L/100IE)
Islet cell apoptosis (12h culture)
Preparation with >250000IE
Collagenase
354± 65
0.83± 0.2
4020± 1200
695± 270
1.25± 0.03
9 (100%)
Liberase
272± 147
0.51± 0.1
2350± 1300
290± 240
7.25± 1.23
6 (66%)
P
0.08
<0.01
<0.05
<0.01
<0.05
<0.05
Islet morphology was significantly improved in group I with a higher proportion of intact islets.
Conclusion: This new enzyme preparation (Collagenase with neutral protease adjunct) was
as effective as Liberase in terms of islet yields and function. Islet morphology was improved
and rate of islet cell apoptosis was lower with this new collagenase.
13.04
S. Breitenstein 1, MA. Patak 2, JM. Fröhlich 2, H. Gelpke 1, M. Decurtins 1, KU. Wentz 2
Clinic of Surgery, Kantonsspital Winterthur, 2Institute of Radiology, Kantonsspital Winterthur
1
Monitoring small bowel motility after colorectal surgery with MR imaging
Purpose: Postoperative intestinal paralysis is a significant problem after abdominal surgery. Discomfort ranges from abdominal cramps to nausea and vomiting. It leads to delayed
hospital discharge and has a considerable impact on health care costs. Currently there are
only invasive techniques available to quantitatively assess small bowel motility. The aim of
our study was to test the use of Magnetic Resonance Imaging (MRI) as a non-invasive
method for the visualization and quantification of postoperative motility.
swiss knife 2004; special edition
35
Material and Methods: 25 patients were included into the study 3-5 days after colorectal
surgery (CRS). Neither bowel preparation nor additional drugs were used before or during
imaging. Three dynamic coronal scans (2D bFFE, TR/TE 2.7/ 1.3ms) were acquired in different imaging planes, each in apnea (17 sec) with a high temporal resolution (4 frames /
sec) using a 1.5T MR system (Philips INTERA).On each dynamic image cross-sectional jejunal and ileal bowel diameters were measured and plotted over time. The mean bowel
lumen diameter changes, resulting amplitudes and motility patterns were assessed.
Results: Imaging 3-5 days after CRS was well tolerated by all patients. Average duration
was 20 minutes. Small bowel diameters, amplitudes and motility patterns were obtained in
all 25 Patients. The mean diameter of the unprepared small bowel loops was 19,4 (+/ 2.4mm) and the mean cross sectional contraction amplitude 9.3 (+/- 5.3mm). Four motility patterns were identified: Paralysis, shivering, disordered contractions and sinusoidal
motion. These patterns were seen simultaneously in varying combinations and over different bowel segments.
Conclusion: MRI provides a well tolerated non-invasive method to study bowel motility in
patients after CRS. It does not require any bowel preparation or drug administration. A quantification of jejunal and ileal motility has thus become possible for the first time using cineMR. The clinical impact of these motility patterns has yet to be evaluated. A special focus
may be the effects of pharmacological therapy, hydration management and nutrition on
bowel motility after CRS.
13.05
M. Selzner 1, N. Selzner 1, W. Jochum 2, PA. Clavien 1
1
University Hospital Zurich, Visc. & Transpl. Surgery, 2University Hospital Zurich, Pathology
Increased ischemic injury in the old mouse liver. A novel pathway of injury
Elderly people are currently more subject to liver surgery. However, the effect of age on ischemic/
reperfusion injury of the liver is unknown. Furthermore, the beneficial effect of ischemic preconditioning as a protective strategy against ischemic injury of old livers is not yet determined.
Methods: 60 minutes ischemia of the liver with or without ischemic preconditioning was
performed in C57BL/6 mice of 6 and 60 weeks of age. Some old mice were pretreated with
0.3ml Glucose 10% prior to ischemic preconditioning. Glycogen and ATP content of the liver
was determined by bioluminescence assay. Liver injury was evaluated by AST release.
Apoptosis was determined by TUNEL staining and caspase 3 activity.
Results: Young mice had 4-fold higher glycogen content in the liver than old mice prior to
surgery (6 vs 1.5 mg/ml) and at the end of reperfusion (1.84 vs 0.25 mcg/ml). Livers from
young mice had a significantly higher ATP content when compared with the old group prior
to surgery (0.85 vs 0.4 nmol/mg) and 4hr after reperfusion (0.6 vs 0.23 nmol/mg). Old
mice had significantly higher AST levels (12500 vs 8200 U/L; p<0.05) and caspase 3 activity (98 vs 67 AUF/mg; p= 0.04) after 4hr of reperfusion than young mice. In addition, old
mice had significantly more TUNEL pos. hepatocytes (55% vs 77%; p<0.05). Ischemic preconditioning in young mice resulted in a decrease of AST release (3200 vs 8200 U/L),
caspase 3 activity (39 vs 67 AUF/mg) and TUNEL staining (15% vs 55%). In contrast, ischemic preconditioning did not protect the old mice. Injecting glucose prior to preconditioning
into old mice significantly increased the intrahepatic ATP levels (0.5 vs 0.25 nmol/mg) with
a dramatic decrease of injury. Furthermore, old mice with glucose treatment prior to preconditioning developed less necrosis than old mice without glucose application (15% vs 60%).
Conclusion: Old livers have a lower energy state than young livers. Pretreatment of old mice
with glucose prior to preconditioning increases the hepatic energy state and results in
strong protection of preconditioning against reperfusion injury.
13.06
G. Beldi, A. Keogh, S. Bisch-Knaden, P. Studer, D. Stroka, D. Candinas, D. Inderbitzin
Department of Visceral and Transplant Surgery, University Hospital Berne, Berne
The effect of hematopoietic growth factors on survival in a novel surgical small
for size liver remnant mouse model
Background: It is known that hematopoietic growth factors protect and stimulate regeneration of non-hematopoietic tissues.
Objective: To develop a standardised small for size liver remnant model in the mouse and to
determine the effect on survival of the systemically administered hematopoietic growth factors erythropoietin and granulocyte colony stimulating factor (G-CSF) supporting extensive
liver resection.
Methods: In 13 male balb-C mice the entire liver was resected and all five liver lobes (i.e. left,
median, right superior, right inferior, caudate) isolated and weighted. Based on the data obtained 62±2.9% (left, median lobe, n=45), 77±1.8% (left, median and right inferior lobe, n=12)
and 85±1.3% (left, median, right inferior and caudate lobe, n=20) hepatectomies were defined and performed. In a second series of experiments animals received daily either 5?g GCSF (n=12) or 10IU erythropoietin (n=13) for 5 days. Subsequently 85% hepatic resection
was performed and daily injection of hematopoietic growth factors continued.
Results: The total weight of the mouse liver was found to be 5.2±0.4% of body weight.
Survival without pre-treatment was 97% after 62% hepatic resection, 42.7% after 77% resection and 16.6% after 85% resection. In the G-CSF group survival was significantly higher with
40.0% than in the erythropoietin group 10.8% (p<0.05, log rank test).
Conclusion: The surgical 85% resection mouse model is suitable to test hepatic supportive
regimens in the setting of small for size liver remnants. Administration of G-CSF improves survival up to 40% whereas erythropoietin does not increase the regenerative capacity of the liver
remnant. The mechanism of the effect of GCS-F is being investigated.
36
swiss knife 2004; special edition
13.07
R. Inglin 1, O. Wagner 1, M. Borner 2, D. Candinas 1, B. Egger 1
1
Department of Visceral and Transplantation Surgery, University of Berne, Switzerland
2
Department of Medical Oncology, University of Berne, Switzerland
Mechanical stability of intestinal anastomosis in healthy pigs is not altered by intraoperative
hyperthermic chemoperfusion (IHCP) with Mitomycin C
Introduction: Intraperitoneal hyperthermic chemoperfusion (IHCP) with various agents
reduces incidence and progression of peritoneal carcinomatosis following oncological intestinal surgery. There are however reports on increased anastomotic leakage rate following
IHCP which might impede the widespread use of this therapeutic modality. Previously we
have shown that systemic administration of Insulin-like growth factor-I (IGF-I) improves
healing of bowel anastomosis in rats (Br J Surg 2001;88:90-98). The aim of the present
study was to evaluate whether locally administered IGF-I prevents anastomotic breakdown
in pigs undergoing IHCP.
Materials and Methods: 24 pigs were divided into 2 groups. Laparatomy and division of small
bowel and of the left colon was performed followed by intramucosal injections of IGF-I
(5mg/anastomosis, n=12) or vehicle (n=12) into the dissection margins. Hand-sutured continuous single layer anastomoses were performed followed by IHCP (4 Liters of circulating
Mitomycin-C solution,10mg/L,42.5°C,1h). Animals (6 of each group) were sacrificed on POD
2 and 4. Mechanical stability of anastomoses were evaluated by measuring bursting pressures (BP).
Results: In the IGF-I and the control group BP’s were surprisingly high and statistically not different. BP [mmHg; mean + SEM] in small intestinal anastomosis was 171±9 vs.177±9 (n.s.)
on POD 2 and 162±19 vs.162±19 (n.s.) on POD 4 in IGF-I treated and control animals,
respectively. BP in colon anastomosis was 104±4 vs.97±3 (n.s.) on POD 2 and 102±10
vs.102±5 (n.s.) on POD 4 in IGF-I treated and control animals, respectively. Similar BP’s were
measured in an additional control group with no IHCP (small bowel: 172±8; colon 105±6).
Conclusion: In contrast to our anticipation, IHCP with Mitomycin C even at high doses does
not impair healing and mechanical stability of bowel anastomosis in healthy pigs during the
early postoperative period. Since bursting pressures were similar to the additional group
without IHCP a beneficial effect of locally applied IGF-I could not be demonstrated. Further
studies with other chemotherapeutic agents are warranted and underway.
13.08
AE. Handschin 1, GA. Wanner 1, S. Hemmi 2, O. Trentz 1, G. Zund 2, OA. Trentz 2
1
Division of Trauma Surgery, University Hospital of Zurich, Switzerland,
2
Research Division, University Hospital of Zurich, Switzerland
In vitro effect of low molecular weight heparin (Dalteparin) and fondaparinux (Arixtra®) on
primary human osteoblasts
Introduction: Postoperative thromboembolism may requiere long-term heparin therapy. The
prolonged administration of heparin has been associated with an increased risk of heparininduced osteoporosis. Fondaparinux (Arixtra®) is a new antithrombotic drug, which, in contrast to heparin preparations, is a full synthetic, single chemical entity that has the ability to
specifically inhibit factor Xa. Because of the known interactions of other antithrombotic
agents on bone remodelling, we analysed the effect of Fondaparinux on human osteoblasts in vitro.
Methods: Primary human osteoblasts derived from the iliac crest were incubated with either low molecular weight heparin Dalteparin (Fragmin®) in concentrations of 30-900
µg/ml or Fondaparinux (Arixtra®) in concentrations of 25, 50, 100, 200 and 250 µg/ml.
After 1, 3 and 7 days, cell proliferation rates were measured using the MTT-Proliferation test.
Osteocalcin, collagen type I and alkaline phosphatase (ALP) concentrations were measured using ELISA and gene expression of these osteoblast markers were measured using
Reverse-transcription polymerase chain reaction (RT-PCR and Real-time PCR). The cultures
were analyzed histomorphologic using a vital fluorescence assay.
Results: Dalteparin incubation led to a significant, dose-dependent inhibition of osteoblast
proliferation (MTT) and expression of phenotype markers after 3 and 7 days (Osteocalcin,
ALP) (p<0.05). In the Fondaparinux treated cultures, cell proliferation rates were equal to
the control group. Osteocalcin and alkaline phosphatase concentrations and gene expression were significantly lower in the heparin-treated cultures (p<0.05), while expression of
these markers did not change following Fondaparinux treatment.
Conclusion: In the present study, the low molecular weight heparin Dalteparin significantly
inhibited osteoblast proliferation and expression of phenotype markers while Fondaparinux
did not cause an adverse in-vitro effect. Similar to the decreased incidence of heparin-induced thrombopenia described before, the risk of heparin-induced osteoporosis may be lower
using Fondaparinux for treatment and prevention of venous thromboembolism.
13.09
S. Korom 1, FJ. Jung 1, L. Yang 1, L. Härter 2, D. Lardinois 1, M. Keel 2, W. Weder 1
Division of Thoracic Surgery, University Hospital Zurich,
2
Department of Traumatology, University Hospital Zurich
1
Melatonin in vivo prolongs cardiac allograft survival in rats
Introduction: Melatonin, secreted by the pineal gland, is a multifunctional agent which (a) protects tissues from damage through free radical scavaging and attenuates ischemia/reperfusion injury in organ grafts; (b) acts synergistically with cellular antioxidants; (c) displays com-
plex, dose-dependent immunoenhancing and -suppressing effects in vitro and in vivo. We
analyzed the immunomodulatory effect of melatonin on acute allograft rejection.
Materials & Methods: Cardiac grafts were transplanted from LBNF1 to LEW rats and anastomosed to the abdominal great vessels. The effect of low dose (LD; 20 mg/kg/d) and high
dose (HD; 200 mg/kg/d) melatonin treatment in recipients compared to untreated controls
was investigated.
Results: HD melatonin therapy abrogated acute rejection, significantly prolonging allograft
survival (mean survival: 12.3d ± 1d SD; n = 8; P < 0.0001) compared to untreated controls
which rapidly reject the transplant (6.3d ± 1d n = 12). LD therapy did not extend survival
significantly (7.3d ± 1.1d; n = 12). Allospecific IgM showed a significant decrease in animals receiving HD therapy vs. untreated recipients at days 10 and 14 post transplantation
(P < 0.01), whereas in the LD group at day 10, a significant increase in allospecific IgM (P
< 0.01) over the HD cohort was demonstrated. HD treatment markedly reduced lymphocyte proliferative capacity compared to controls and the LD group.
Conclusion: HD melatonin treatment abrogated acute allograft rejection and significantly prolonged graft survival. Our results suggest an involvement of melatonin in humoral and cellular
immune pathways following perfused organ transplantation. These findings may indicate a
novel therapeutic approach, based on modulation of the neuroendocrine/immune axis
through melatonin as a possible future immunosuppressant in organ transplantation.
13.10
G. Mai, P. Bucher, Ph. Morel, T. Berney, L. Bühler
Cell Transplantation Lab, Surgical Research Unit, Department of Surgery,
University Hospital Geneva
Induction of stable peripheral tolerance to concordant and discordant islet xenografts
by inhibition of signals 2 and 3
Aim: Inhibition of signals 2 and 3 of T cell activation by costimulatory blockade (CB) and
rapamycin (RAPA) can establish peripheral tolerance to allografts by activation-induced
apoptosis of donor-reactive T cells. The aim of this study was to analyze the effects of CB
and RAPA on concordant and discordant islet xenografts (IXG).
Methods: Diabetic C57/BL6 mice were transplanted under the kidney capsule with either
rat or human islets. For both species combinations, the following groups were performed
(6 mice/group): Group 1, islet transplantation (Tx) without therapy; Group 2, RAPA (0.2
mg/kg i.p. every other day from day 0 to 14); Group 3, anti-CD154 mAb (MR1, 0.5 mg i.p on
days 0, 2 and 4); Group 4, combination with MR1 and RAPA; Group 5, (only rat-to-mouse)
combination with MR1, RAPA and early IL-2 (2000 U given i.p. bid from day 0 to 14 post-Tx);
Group 6 (only rat-to-mouse) combination with MR1, RAPA, and delayed IL-2 (given from day
100 to 114). Islet function was monitored by glycemia and histology.
Results: RAPA did not significantly prolong rat or human mean graft survival (MGS) compared to controls (24 and 16 days versus 17 and 11 days, respectively, p=0.05). MR1 alone
significantly prolonged both concordant and discordant xenograft survival (MGS 98 and
100days, p<0.001), but rejection still occurred. Combination therapy with MR1 and RAPA
allowed indefinite graft survival of concordant (5/6) and discordant (4/6) IXG. When exogenous IL2 was given at Tx with MR1 and RAPA, rapid rejection developed in all mice (MGS
7 days). In contrast, when IL-2 was given 100 days after Tx with MR1 and RAPA induction,
no rejection developed. In Groups 1, 2 and 5, histology showed graft infiltration by immune
cells with islet destruction at day 7. In Groups 3, 4 and 6, a mixed cellular infiltrate around
intact islets was observed.
Conclusion: Combination with RAPA and MR1 allowed indefinite graft survival of concordant and discordant IXG. Administration of exogenous IL-2 at time of Tx prevented tolerance induction, suggesting that classical anergy plays a role in the immediate post-transplant
period. Delayed administration of IL-2 failed to induce rejection, suggesting that anergy was
no longer critical.
13.11
C. Toso 1, Z. Mathe 1, Ph. Morel 1, J. Oberholzer 1, C. Wandrey 2, L. Bühler 1, T. Berney 1
1
Centre d’isolement et de transplantation cellulaire, Chirurgie viscérale, Genève,
2
Laboratoire des polymères et biomatériaux, EPFL, Lausanne
Effect of microcapsule composition and short-term immunosuppression
on intraportal biocompatibility
Background: With higher nutriment and oxygen supply and closer contact to blood, portal vein
is a possible alternative to peritoneum for transplantation of encapsulated cells. Data regarding intra-portal biocompatibility of microcapsules are lacking.
Methods: Cellular and fibrotic peri-capsular infiltration thickness was measured 3 and 7 days
after intra-portal implantation of microcapsules of various compositions in rats. Capsules
were as follows: polycation-containing microcapsules or polycation free microbeads built
with alginates of high or low viscosity, with various mannuronic/guluronic acid ratios and linked to barium or calcium. Overgrowth was caracterized using various colorations (hematoxylin-eosin, Giemsa, ED-1 for monocyte/macrophage, ?-actin for myofibroblasts, CD31 for
endothelial cells). The impact of 5 day immunosuppression (gadolinium chloride 20
mg/Kg/day, rapamycin 1 mg/Kg/day, tacrolimus 3 mg/Kg/day or a combination of the last
two) was further assessed 3, 7 and 42 days after implantation.
Results: Overall, overgrowth increased from day 3 to day 7 (p<0.001). Three and 7 days after
implantation, polycation-containing microcapsules induced more reaction than microbeads
(p<0.001 and <0.01). Considering polycation free beads, barium-alginate induced the weakest reaction. Biocompatibility of microbeads was independent of mannuronic/guluronic acid
ratio and viscosity. Infiltration was mainly a monocyte/macrophage-rich foreign body reaction, but an eosinophil-containing immuno-allergic reaction was also observed. Short term immunosuppression reduced infiltration in all conditions.
Conclusion: Biocompatibility after intraportal infusion was best for barium-alginate microbeads and poorest for polycation-containing microcapsules. Short and long term overgrowth could be significantly reduced by a 5 day-immunosuppression.
13.12
A. Pietsch 1, PC. Nett 2, DA. Hullett 3, HW. Sollinger 3
Universität Rostock, Abteilung für Allgemein- und Transplantationschirurgie, Rostock,
Germany, 2Universität Bern, Departement für Viszeral- und Transplantationschirurgie, Berne,
Switzerland, 3University of Wisconsin, Hospital and Clinics, Division of Organ Transplantation,
Madison, USA
1
A new modified technique of ureteroureterostomy in rat kidney transplantation
Introduction: Numerous modifications of surgical techniques for ureteric reconstruction have
been evaluated in order to reduce complications and to extend long-term survival. However,
ureteric complications still occur frequently, especially when the diameter of both donor and
host ureters are disproportionate.
Material and Methods: Male inbred Dark-Agouti (DA) and Brown-Norway (BN) rats with different
ureter diameter were used as donors and recipients (DA: 0.6-0.7mm versus BN: 1.3-1.5mm). In
group A (DA?BN; n=10) and in the control group (BN?BN; n=10), non-splinted ureter anastomosis was performed as previously described by Oesterwitz in an end-to-end interrupted suture
technique between the kidney and the bladder. In group B (DA?BN; n=20) the small ureter (diameter 0.6-0.7mm) of the donor (DA) was spatulated to enlarge the ureter stump for adequate
anastomosis with the wide, obliquely transected ureter (diameter 1.3-1.5mm) of the recipient
(BN) to avoid kinking. Surviving animals were sacrificed postoperative on day 60.
Results: The overall incidence of ureteric complications was 15% (3/20) when the modified
technique of non-splinted ureteroureterostomy was performed (group B) compared to 80%
(8/10) when the technique was performed as previously described by Oesterwitz (group A,
P<0.0001; see table 1). The control group (BN?BN) showed an incidence of ureteric complications of 10% (1/10). Operating time for ureteral anastomosis in group A and B was similar
(12.4±2.4min versus 17.1±1.6min; n.s.).
Table 1 Ureteric complication Group A Group B Control Stenosis of ureteric anastomosis 6/10
(60 %) 2/20 (10 % 1/10 (10%) Ureteric leakage 2/10 (20%) 1/20 (5%) 0/10 Overall 8/10
(80%) 3/20 (15%) 1/10 (10%)
Conclusion: Our modification proofs the feasibility of non-splinted ureteroureterostomy in a
technical highly demanding rat model of kidney transplantation with an acceptable rate of ureteric complication considering the disproportionate difference of diameter between the host
and the donor ureter.
13.13
A. Andres, C. Toso, Ph. Morel, D. Bosco, P. Bucher, T. Berney, L. Bühler
Laboratoire de Transplantation cellulaire, Chirurgie, Hôpitaux Universitaires de Genève
Phylogenetic disparity influences the predominance of direct over indirect pathway
of antigen presentation in islet xenotransplantation
T cells and macrophages play a major role in the rejection of xenografted islets. We investigated in vitro by mixed lymphocyte reaction (MLR) the importance of direct and indirect antigen presentation in rejection of concordant (rat-to-mouse) and discordant (human-tomouse) xenografts. In vivo, we performed rat-to-mouse and human-to-mouse islet transplantation and depleted recipient macrophages by using gadolinium chloride (GdCl). The
MLR showed a predominant direct antigen presentation for the mouse anti-rat combination.
In contrast, direct and indirect pathways were similar for the mouse anti-human combination. Survival of rat islets was not modified by GdCl therapy, but survival of human islets was
significantly prolonged in GdCl-treated mice, compared to controls. Our results indicate that,
in contrast to the concordant combination, the indirect pathway is important in discordant
islet xenograft rejection. Therefore, macrophage depletion can be considered as therapeutic tool in discordant islet xenotransplantation.
13.14
S. Frese 1, M. Miescher 1, M. Gugger 2, J. Zbären 3, RA. Schmid 1
General Thoracic Surgery, University Hospital Berne, Institute of Pathology, 2University
Hospital Berne, 3Department of Clinical Research, University Hospital Berne
1
Cytotoxic effects of camptothecin and cisplatin combined with Apo2L/TRAIL in a model
of primary culture of non-small cell lung cancer
Objective: The cytokine tumor-necrosis factor-related apoptosis-inducing ligand
(Apo2L/TRAIL) has been shown to preferentially induce apoptosis in cancer cells. A recent
study of our group demonstrated that non-small cell lung cancer cell lines can be sensitized to Apo2L/TRAIL-induced apoptosis by chemotherapeutic agents (J Thorac Cardiovasc
Surg. 2002 Jan;123(1):168-74). The aim of the present study was the evaluation of these
results in a model of primary culture of non-small cell lung cancer.
Methods: Lung cancer tissue and normal lung tissue obtained from 14 patients who underwent operation were cultured and treated with Apo2L/TRAIL alone and in combination with
cisplatin and camptothecin for different periods. Metabolic activity of the tissue was measured by Alamar blue. Markers for apoptosis were determined by Hoechst staining, immuno-
swiss knife 2004; special edition
37
histochemistry and Western blot. Statistics was performed using Anova nonparametric
repeated measures.
Results: Tissue from non-small cell lung cancer treated with cisplatin plus Apo2L/TRAIL,
camptothecin alone and camptothecin plus Apo2L/TRAIL for 72 hours showed significant
reduced metabolic activity. Importantly, none of these effects were seen in cultured normal
lung tissue from the same patients.
Conclusions: Our results obtained in a model of primary culture of lung cancer suggest that
the combination of Apo2L/TRAIL with cisplatin and camptothecin as well as camptothecin
alone might present effective strategies for the treatment of non-small cell lung cancer.
13.15
D. Inderbitzin 1, A. Keogh 1, I. Avital 2, D. Candinas 1
Department of Visceral and Transplant Surgery, University Hospital Berne,
2
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
1
Comparison of different cell isolation and culture methods for liver progenitor
cells from adult rat bone marrow
Liver progenitor cells can be isolated from adult bone marrow by different methods. Two
subpopulations of bone marrow cells were obtained either from the non-adherent cell fraction after a panning procedure on a polystyrene surface or by a two-step immunoisolation
procedure (Beta-2-Microglobulin negative/Thy-1 positive selection). To determine the
growth characteristics and the individual liver specific metabolic capacity, the bone marrow
cells were cultured under different conditions.
Methods: The two subpopulations were cultured either on a polystyrene dish or on a layer of
matrigel, in a 1:1 mixture of Dulbecco’s modified Eagle medium and Ham’s medium F12 supplemented with hepatocyte growth factor or in small hepatocyte media and seeded in high
(100’000 cells) or low (10’000 cells) density for 12 days. Real-time PCR on the Taqman system
(Applied Biosystems) was performed according to standard protocols for 18S rRNA, albumin,
Mrp1, and Mrp2. Urea formation and albumin secretion was determined by a colorimetric assay
and a sandwich ELISA in the culture media and standardized by 18S rRNA content.
Results: Both cell isolation procedures yielded albumin and multidrug resistance associated protein (Mrp1) positive cells. The Beta-2-Microglobulin negative/Thy-1 positive subpopulation of bone marrow cells cultured on matrigel in small hepatocyte media produced
significantly more urea from ammonia and also secreted a superior amount of albumin in
the culture media when compared to the panned cell fraction(p<0.001).
Conclusions: The role of the Beta-2-Microglobulin negative/Thy-1 positive subpopulation of
the bone marrow requires further investigation and could prove to be valuable for the development of novel cell based treatment strategies for congenital or acquired liver diseases.
13.16
P. Gervaz 1, A. Allal 2, Ph. Morel 1
1
University Hospital Geneva, Department of Surgery,
2
University Hospital Geneva, Department of Radiation Oncology
Differential expression of anti-apoptotic protein Bcl-2 in keratinizing vs. non-keratinizing
squamous cell carcinoma of the anus
Background: Histologically, tumors of the anal region are either keratinizing (K) or non-keratinizing (NK) squamous cell carcinomas (SCC). We hypothesized that these two variants
might represent, not only morphologically, but also biologically dissimilar malignancies.
The present study was undertaken to compare the expression of apoptosis-regulating proteins Bcl-2 and p53 in K vs. NK SCC of the anus (SCCA).
Methods: We performed an immunohistochemical analysis on 98 pre-treatment biopsies of
patients with anal canal cancers. Tissue sections were examined immunohistochemically
for expression of proteins Bcl-2 (clone 124, DAKO, 1:100) and p53 (clone DO7, DAKO,
1:200). Expression of p53 and Bcl-2 was considered positive when >5% of tumor cells
were stained. Tumor histology was correlated with protein expression as well as with other
clinical variables.
Results: There were 64 NK and 34 K SCC. The proportion of Bcl-2 positive tumors was statistically higher in NK carcinomas (51% vs. 23%, p=0.009). In addition, women were more
likely than men to present with NK carcinomas (71% vs. 45%, p=0.03) as well as with Bcl2 positive tumors (47% vs. 29%, p=0.05). The more the tumor is distal (anal margin) the
more the keratinizing subtype is observed (87% vs. 23%, p=0.0002). By contrast, there was
no correlation between p53 and tumor histology (p=0.83).
Conclusions: Our data demonstrate that non-keratinizing and keratinizing SCCA differ in
their Bcl-2 expression. In addition, significant differences were observed in the distribution
of these 2 histological subtypes according to gender and to tumor sublocation. These findings may indicate possible differences in the carcinogenesis process of these two histological subtypes.
13.17
P. Gervaz, G. da Silva, S. Wexner
Department of Colon & Rectal Surgery, Cleveland Clinic Florida
Histologic analysis of the irradiated anal sphincter
Background: There is accumulating evidence, both quantitative and qualitative, that pelvic
irradiation adversely affects anorectal function. However, histologic evidence of sphincter
injury has not been demonstrated. The purpose of this study was to perform histologic
38
swiss knife 2004; special edition
assessment of collagen deposition and nerve alteration in the internal anal sphincters of
rectal cancer patients who underwent abdominoperineal resection after adjuvant chemoradiation therapy. A second aim was to correlate the degree of histological changes with
the time interval between chemoradiotherapy and abdominoperineal resection.
Methods: Anal canal specimens were prospectively collected in patients undergoing abdominoperineal resection. Representative slides were cut transversely at the level of the dentate line. Using trichrome and S-100 protein staining, a single pathologist blinded to the
patients’ treatment assessed collagen deposition and nerve fiber densities in the internal
anal sphincter, respectively.
Results: There were 12 patients who received radiation for rectal cancer [chemoradiotherapy group] and 6 who were treated by surgery alone, including 4 patients with rectal cancer
(1 leiomyosarcoma) and 2 with Crohn’s disease [Control group]. There was a trend
towards increased fibrosis (replacement of more than 10% of normal structures by collagen) and nerve density in the chemoradiotherapy group compared to the Control group
(p=0.08 and p=0.05, respectively). Nerve density significantly increased as chemoradiotherapy to abdominoperineal resection interval increased (p=0.004).
Conclusion: Pelvic irradiation results in damage to the myenteric plexus of the internal anal
sphincter of patients with rectal cancer; these alterations appear to be time-dependent. A
trend towards increased collagen deposition was also observed. Together, these results
provide a morphological basis, which concurs to previously described physiologic and clinical alterations in the anal sphincter of patients irradiated for rectal cancer.
13.18
I. Opitz 1, T. Krueger 1, Y. Pan 1, N. Tran 1, HJ. Altermatt 2, HB. Ris 1
1
Department of Thoracic and Vascular Surgery, University Hospital of Lausanne,
2
Institute of Pathology, Berne
Intrathoracic photodynamic therapy on malignant mesothelioma bearing rats
Introduction: In order to study the PDT-related morbidity in association with surgery intraoperative PDT in MPM-bearing rats (8 groups with n=3) was evaluated under clinical conditions.
Material and Methods: A syngenic malignant mesothelioma cell line (II-45) was implanted
in the left pleural cavity. 6 days after tumor implantation (TI) and 4 days after i.v. sensitization (0.1 mg/kg mTHPC), a left-sided pneumonectomy (P) was performed, followed by PDT
with a light dose of 20J/cm2 at 652 nm. Group 1: spherical illumination to the entire chest
cavity guided by in-situ light dosimetry (fluence rate 15 mW/cm2), group 2: focal illumination of a tumor area of 1.3 cm in diameter at 150 mW/cm2. Control animals: TI only (group
3), TI with P (group 4), TI with P and sensitization but no irradiation (group 5), TI with P and
irradiation but no sensitization (group 6), TI with PDT of the entire chest cavity but without
P (group 7), and P with PDT of the chest cavity without TI (group 8). Postoperative observation time was 4, the extent of necrosis was assessed by histology.
Results: TI resulted in an invasively growing sarcomatous type of mesothelioma in all animals without spontaneous necrosis. All control animals and those with P and focal PDT survived four days without morbidity. All tumor-bearing animals undergoing P and PDT of the
entire chest cavity postoperatively died between 48h to 72h. Histological examination
revealed areas of 0.5-1 mm deep tumor necrosis (group 1), a 1-2 mm deep focal tumor
necrosisfor (group 2). No tumor necrosis was observed in control animals. Lung fibrosis
has been observed in animals without P after PDT.No normal tissue injury was seen in
tumor-free animals after pneumonectomy.
Conclusions: The MPM tumor model in rats MPM closely resembled to that observed in patients. Pneumonectomy and PDT of the entire chest cavity resulted in postoperative death of
tumor-bearing animals despite controlled light delivery. P and focal PDT, as well as PDT of
the entire chest cavity without pneumonectomy was well tolerated in all tumor-bearing animals. No injury of mediastinal organs was observed but interstitial lung fibrosis occurred
after PDT without pneumonectomy.
13.19
S. Deglise 1, H. Probst 1, D. Martin 2, F. Saucy 1, JM. Corpataux 1, JA. Haefliger 2
1
Servic de Chirurgie Thoracique et Vasculaire, 2Service de Médecine Interne
Increased connexin 43 is associated with human venous intimal hyperplasia
Background: The limitation of outcome of vascular interventions is due to lumen occlusion
secondary to intimal hyperplasia (IH), which consists of proliferation of medial smooth
muscle cells (SMC) and their migration to the subintimal space, where they produce extracellular matrix. Intercellular communication mediated by gap junctions is undoubtly necessary in the neointima formation. These channels, composed of proteins named connexins
(Cx), are involved atherosclerosis or angiogenesis. The aim of this study was to study the
presence and the distribution of four “vascular” connexins (Cxs37, 40, 43, 45) in the wall
of human saphenous vein and to evaluate whether these connexins are affected during the
development of IH in a model of organ culture.
Material and Methods: Human saphenous vein segments were harvested during operation
and stayed in culture for 14 days. The presence of IH was demonstrated by histomorphometrical analysis. Quantitative RT-PCR, Western Blots and immunofluorescence analyses were
performed on both segments to characterize the expression of Cx37, Cx40, Cx43 and Cx45.
Results: Presence of Cxs 37, 40, 43 and 45 in the human saphenous vein wall, both in native and cultured states, was demonstrated by RT-PCR and immunofluorescence studies
demonstrated that Cx43 was expressed predominantly in the SMC whereas Cx40 was only
expressed by the endothelial cells. After 14 days of culture, histomorphometrical analysis
showed a significant increase in the intimal thickness due IH. A time-course analysis of
Cx43 expression revealed a progressive increase during culture period. Quantitative RTPCR analysis showed that the expression of Cx43 increased six-fold in the vein after 14
days in culture (p < 0.01). Western blots analysis further revealed that levels of Cx43 were
increased (eightfold in samples stayed in culture (p< 0.001) but no changes of Cx40
expression was observed in cultured segments compared to native levels.
Conclusion: These four connexins are present in the human vein wall. Moreover, Cx43
expression is increased in IH. Its precise role is not known but Cx43 is involved in angiogenesis or endothelial wound repair. Thus, Cx43 could be a target in the inhibition of IH.
13.20
D. Dindo 1, A. Bielawska 2, R. Graf 1, PA. Clavien 1
1
Unviersity Hospital Zurich, 2Medical University of South Carolina, Charleston/USA
Novel long-chain ceramides induce cell death in human colon cancer cells by aponecrosis
Background: Ceramides are important lipid second messengers involved in cell growth, differentiation and cell senescence. Therapy with anti-cancer drugs such as anthracyclines
(e.g. Doxorubicin) is associated with an increase of endogenous ceramide levels.
Exogenous ceramides have emerged as potential chemotherapeutic drugs inducing apoptosis in a variety of cancer cells. However, these studies have been almost exclusively
restricted to the use of short-chain ceramides (C2-C8). It is still questioned whether the activity of such short-chain ceramides may be compared to the naturally occurring, long-chain
ceramides. Methods: To study the effect of long-chain ceramides in vitro, soluble cationic _pyridinium bromide D-erythro-C16-ceramide (LCL-30) and _ -pyridinium bromide L-threoC16-ceramide (LCL-87) were designed. The human colon cancer cell line SW403 was cultured in presence of LCL30 and LCL87. Doxorubicin was tested on its ability to enhance cell
death ellicited by these ceramides. Results: After addition of LCL30 and LCL87, the viability
of SW403 cells decreased in a concentration and time-dependent manner. In freshly isolated rat hepatocytes these ceramides had no effect. Conventional D-erythro-C2-, C6- and
C16-ceramides did not induce cell death in SW403 cells, while cells treated with either
LCL30 or LCL87 exhibited activation of apoptosis, with disruption of the mitochondrial
membrane potential (MMP; __m), cytochrome c release and caspase-9 and –3 activation.
The combination of either long-chain ceramide with Doxorubicin resulted in a synergistic
toxic effect. Ultrastructural analyses revealed swollen mitochondria and nuclear chromatin
condensation. However, no fragmentation of the nucleus or blebbing of the cellular membranes was observed. Conclusion: The novel, soluble long-chain ceramides LCL30 and
LCL87 induced cell death in SW403 cells but not in freshly isolated rat hepatocytes.
Doxorubicin enhanced the toxic effect in SW403 cells. Cells treated with these long-chain
ceramides showed hallmarks of apoptosis. However, ultrastructural analyses showed a
more necrotic phenotype. Therefore, an ‘aponecrotic’ cell death is proposed.
14.02
14
S. Schlunke, S. Lucchina, S. Bertoglio, S. Neuendorf, JA. Al Muaid, D. Donati, P. Biegger
Ospedale La Carità Locarno
Midshaft fracture of the clavicle:
prospective evaluation of ORIF with an elastic intramedullary titan nail
Dislocated and eventually shortened fractures of the clavicle midshaft often heal with some
permanent discomfort for the patients. The indications for open reduction and internal fixation
(ORIF) are well known; the usually preferred reconstruction plate or bridge spanning plate have
some also known disadvantages. Presenting our own cases (11 patients), we demonstrate
the advantages of the “elastic” stabilization by means of an intramedullary titan nail. The
patients have been followed prospectively, inquiring about subjective pain, use of analgesics
and mobility at 2, 4, 12 weeks and at 4 and 6 months. Radiological documentation of bone
healing was always carried out. We present in detail this simple operative method with its pitfalls, tricks and hints. It allows the patients an immediate functional after treatment without
limitation of the range of shoulder motion with very low complaints.
The presented study confirms the promising results of the yet published series in the literature,
which is also reviewed. It should help leading this simple but highly efficient fixation method to
a broader acceptance.
14.03
J. Mühlebach, J. Rosenkranz, R. Babst
Chirurgie A, Kantonsspital Luzern
Flexible endomedullary nailing of midthird clavicular fractures:
surgery for a fracture that needs no surgery?
Definition: Midthird fractures of the clavicle are mostly treated conservatively. Patients suffer from
pain until the fracture is consolidated and are at risk of functionally relevant shortening and of
pseudarthrosis. Flexible endomedullary nailing offers a minimally invasive alternative to avoid
these problems.
Method: From 11/2001 to 6/2003 19 midthird clavicular fractures were treated by flexible
endomedullary nailing (TEN®, Titan Elastic Nail) at our institution and were followed up clinically using Constant-Murley-Score (CMS) and Disability of Arm, Shoulder and Hand (DASH) Score and radiologically for 24 wks. postoperatively. Pain was assessed by visual analog
scale (VAS), duration of pain medication, sick leave and hospitalisation were noted.
Results: 11 male and 8 female patients with a mean age of 30.5 (15-55) years. According to
OTA classification fractures were classified as 06-A1 in 3, 06-A2 in 4, 06-A3 in 5, 06-B2 in 5
and 06-B3 in 2 cases. Closed reduction was achieved in 9, it was open in 10 cases. Median
operation time was 55 (20-140) min. Median hospitalisation was 3 days. Consolidation was
documented within 24 wks. in all but 2 cases, which developed hypertrophic non-union, one
patient was completely pain-free, the other was stabilized by plate osteosynthesis. No patient
healed with relevant shortening, all showed correct axial alignment. Age adapted CMS was on
average 104%, the mean DASH-score of 6 cases was 6.8%. Median time of sick-leave was 3
(0-12) wks. Pain medication was taken for 9 days on average.
Hypertrophic scarring occurred in 2 and local paraesthesia in another 2 patients. Hardware
removal was done electively in 9 cases after 6 months, 3 nails had to be removed because of
irritation due to the medial nail end.
Conclusions: Endomedullary nailing of mid-clavicular fractures might add to the patient`s
comfort with reduction of pain and sick-leave and can correct relevant shortening. Although
the technique is simple and minimally invasive it cannot guarantee fracture healing. For selected patients it might be a good alternative to conservative treatment or invasive plating.
14.04
C. Meier, P. Grueninger, A. Platz
Department of Surgery, Stadtspital Triemli, Zurich, Switzerland
Intramedullary nailing (TEN®) for midclavicular fractures in athletic patients: indications, technical pitfalls and early results
Introduction: Midclavicular fractures are common in young and athletic patients. With conservative treatment clavicular shortening occurs frequently. Functional outcome has been reported to be worse for a shortening of >1-2cm. As complete recovery with full function is essential for athletes, intramedullary nailing of the clavicle is a potential alternative to conservative
treatment. It is a minimally invasive procedure aiming at restoration of the clavicle’s length with
improved clinical outcome and earlier return to full activity.
Methods: Prospective consecutive case series. Between 09/2002 and 11/2003 13 patients entered the study. Only young patients (16- 50 years) with high activity levels were included. TEN® was
used for isolated, closed fractures of the mid clavicle (simple or wedge fractures) with a lack of
bony contact and/or shortening of >1-2cm. Operation time, local complications and functional
outcome were analyzed. Constant score and x-ray studies were evaluated after 1- and 6 weeks
and 3- and 6 months. The surgical technique and potential pitfalls are critically discussed.
Results: Mean age was 28 years (range 16-40 years). Mean operation time was 63 minutes
(range 33-123 minutes). Open reduction was necessairy for 7 fractures (53.8%) through a
2cm incision over the fracture site. Mean hospital stay was 1.5 days (range 1-5 days). No infection was observed. In 1 patient (7.7%) the hardware was removed prematurally after skin perforation of the nail due to a direct trauma. In 2 cases (15.4%) the TEN® had to be shortened at
its medial end due to persistent skin irritation. No refracture or nonunion was observed. In 7
patients (54%) the hardware has already been removed electively (mean 35 weeks, range 1856 weeks). The Constant score averaged 80 after 1 week and 96 after 6 weeks. Compared to
the contralateral side mean difference of length was 1,8mm (range -7 - +4mm).
Conclusions: Intramedullary nailing for midclavicular fractures is technically demanding. It providesrestoration of the length of the clavicle and allows immediate active mobilisation with
early return to normal activity. Functional results are excellent.
14.07
M. Kauper, R. Babst, J. Rosenkranz
Chirurgie A, Kantonsspital Luzern
Komplikationsrate und Outcome bei Versorgung lateraler Claviculafrakturen mittels Balserplatte
Es stehen verschiedene Stabilisierungsverfahren zur Behandlung lateraler Claviculafrakturen
zur Verfügung. Die Osteosynthese mittels Balserplatte ist eine etablierte Methode, um dieses
oft schwierige Therapieproblem zu lösen.
Methode: Konsekutive Fallkontrollstudie aller operativ mittels Balserplatte versorgten lateralen
Claviculafrakturen zwischen 5/98 und 10/03. Klinische Nachkontrolle nach 19 Monaten (431) mit Erhebung von Constant- und Dash-Score. Bei allen Patienten wurden zusätzlich
Röntgenbilder hinsichtlich Konsolidierung beurteilt.
Resultate: Es wurden 19 Patienten mit lateralen Claviculafrakturen (OTA 07A und OTA 07B)
mittels Balserplatte versorgt (18 männlich, 1 weiblich). 18 waren primäre Frakturen und eine
Pseudarthrose nach erfolgloser konservativer Therapie. Das Durchschnittsalter betrug 38.7
Jahre (19-63).8 Patienten wiesen zusätzliche Verletzungen auf. Die durchschnittliche
Operationszeit betrug 105 Minuten, die Hospitalisationszeit 8 Tage (2-35). Der Haken der
Platte wurde im Median nach 4.5 Monaten bei radiologisch konsollidierender Fraktur entfernt.
Bei 11 Patienten wurde die Platte zwischenzeitlich entfernt, 3 weitere sind für Anfang 2004
geplant. 47% der Patienten klagten vor Plattenentfernung über ein störendes Gefühl beim
Liegen auf der betroffenen Seite. Alle Frakturen heilten primär ab. Reoperation waren abgesehen von der OSME nicht nötig. Bei 16 Patienten wurde die OSME zweizeitig, bei 3 einzeitig
durchgeführt. Die Beurteilung der radiologischen Aufnahmen ergaben bei allen Patienten konsollidierte Frakturen. Es zeigte sich kein Hinweis auf subacromiale Osteolysen.
Bislang konnten 9 Patienten im Durchschnitt 19 Monate (4-31) nach operativer Versorgung klinisch nachuntersucht werden. Der Dashscore betrug im Median 19.3 (1.6 – 77.5), der altersadaptierte Constant Score der verletzten Schulter 88% (50-91) und der unverletzten Schulter
93%88-101).
Schlussfolgerung: Die osteosynthetische Versorgung lateraler Claviculafrakturen mittels
Balserplatte ist eine zuverlässige Methode mit guter Heilungsrate. Die ein- bzw. zweizeitige OSME
ist ein Nachteil der mit der sicheren Verankerung durch den Balserplattenhaken erkauft wird.
swiss knife 2004; special edition
39
16
16.01
E. Pezzetta 1, Z. El-Lamaa 2, TH. Geiser 3, HB. Ris 1
1
Service de Chirurgie Thoracique et Vasculaire CHUV, 2Service de Pneumologie CHUV,
3
Division de Pneumologie, Hôpital de l’Île, Berne
Long-term results after unilateral LVRS for emphysema
Introduction: significant functional and clinical improvements have been observed in patients
with severe emphysema after lung volume reduction surgery (LVRS). The procedure may be
performed as uni- or bi-lateral approach. We present a prospective long-term study of unilateral LVRS performed by VATS.
Methods: All patients referred for LVRS and qualifying for the procedure were treated unilaterally, the lung with the more heterogeneous pattern of disease (ct-scan, perfusion scintigraphy)
being chosen for the intervention. Postoperative mortality and morbidity were recorded. Lung
function, walking distance, dyspnea and the incidence of staged procedures were assessed
up to 5 years after unilateral LVRS.
Results: Forty-two patients were included and followed up to 5 years after the operation; 60%,
40%, 33%, 24% and 19% of the patients had a follow up of 1, 2, 3, 4 and 5 years, respectively.
There was no 30-d mortality. Four patients (9%) died during follow-up. 6 patients (14%) underwent staged LVRS after a mean interval between the two procedures of 34.6 months. FEV1
and 6MWD were significantly improved up to 1year, and RV and dyspnea significantly decreased up to 2 and 3 years, respectively. Mean 6MWD and dyspnea score index did both not
reach the bottom line at 5 years.
Conclusions: Unilateral LVRS is safe, associated with a low postoperative morbidity and may
offer improvements up to 5 years in patients with severe heterogeneous emphysema and
hyperinflation. Since the number of patients requiring a staged LVRS is low, this approach
should thus be considered as a valuable alternative to bilateral simultaneous LVRS.
16.02
PB. Kestenholz, D. Schneiter, S. Hillinger, W. Weder
University Hospital Zurich, Division of Thoracic Surgery, Zurich
Thoracoscopic treatment of pulmonary sequestration: is it a safe operation?
Objective: Pulmonary sequestration (PS) is a rare congenital malformation and may be the
cause of recurrent infections or haemoptysis. Thoracoscopic resection is feasible but may be
difficult due to inflammatory changes especially in the vicinity of the aberrant artery. The aim
of this study was to analyze the outcome of the treatment in our series.
Methods: We retrospectively reviewed the files of all consecutive patients who underwent thoracoscopic or open surgical treatment for PS from January 1991 to June 2003 at our institution. The following data were collected: sex, age, major complaint, diagnostic procedures, treatment, and short term outcome. Operative technique, localization of the sequestration, and
arterial blood supply were evaluated.
Results: 18 patients (10 women) with a median age of 34 (range 20-64) were surgically treated. Main symptoms were recurrent infection (12), haemoptysis (4), chest discomfort (1) and
dyspnoea (1). The diagnosis was made by CT- scan. 16 intralobar (all lower lobes, 9 on the
right) and 2 extralobar PS were found. 13 patients were treated thoracoscopically (8 lobectomies, 3 atypical segmentectomies, one extralobar resection and one occlusion of the aberrant
artery). One case had to be converted to a thoracotomy due to a bleeding. 5 patients were treated by open resection (2 lobectomies, 2 segmentectomies and one extralobar resection).
Complications included pneumonia in 5, hemothorax, pneumothorax after removing of the
chest tube, wound infection and one temporary palsy of the ulnaris nerve in one each. No
reoperation was necessary. There was no mortality. There were equal results in open and thoracoscopic procedures with a median hospital stay of 8(3-13) days.
Conclusion: The aberrant systemic artery can be freed and dissected despite the frequently
occurring inflammatory changes. Conversion rate to thoracotomy is very low. Thoracoscopic
treatment of pulmonary sequestration in this series was safe.
16.03
L. Molnar, HU. Würsten, U. Laffer
Chirurgische Klinik, Spitalzentrum, Biel-Bienne
Die videoassistierte Thorakoskopie (VATS) mit Minithorakotomie:
eine weitere Möglichkeit der chirurgischen Therapie im Stadium II des Pleuraempyems
Einleitung: Gemäss internationalen Richtlinien in der Behandlung der fibrinös-purulenten
Phase (Stadium II) des Pleuraempyems existieren die Thoraxdrainage mit Spül-/Lysetherapie
und die VATS als etablierte Massnahmen. Die offene Dekortikation ist primär dem Stadium III
vorbehalten. Da der Uebergang vom Stadium II ins Stadium III oftmals fliessend ist, scheint uns
die Möglichkeit der VATS mit Minithorakotomie als „Handport“ eine sinnvolle Alternative.
Methodik: In einer retrospektiven Studie von 1999 – 2003 wurden bei 50 Patienten gesamthaft 57 Operationen im Stadium II respektive III durchgeführt. Dabei erfolgten 14 thorakoskopische Operationen, 7 VATS mit Minithorakotomie, 9 Konversionen und 22 offene
Dekortikationen. In 5 Fällen kam es zu einer Reoperation. Bei 2 Patienten wurde eine offene
Dekortikation beidseits durchgeführt. Postoperativ erfolgte in den meisten Fällen eine
Nachbeatmung für 24 Stunden und die Thoraxdrainage für 5 Tage.
Resultate: Im Zeitpunkt der Operation fanden wir häufig eine „Uebergangssituation“ zwischen
40
swiss knife 2004; special edition
Stadium II und III, so dass wir in den letzten zwei Jahren primär eine VATS mit einer Minithorakotomie in 6 Fällen kombinierten, eine VATS mit Minithorakotomie erfolgte im Jahre 2000.
Die 5 Reoperationen waren eine VATS mit Spülung nach primärer thorakoskopischer
Operation, eine Thorakotomie und offene Dekortikation nach VATS, eine Thorakotomie und
offene Dekortikation nach VATS mit Minithorakotomie sowie 2 Rethorakotomien nach primär
offener Dekortikation. Dank der vielleicht hohen Konversionsrate von 9 Fällen sowie der
Kombination einer VATS mit einer Minithorakotomie in 7 Fällen konnte eine höhere
Reoperationsrate vermieden werden und nach primärer VATS musste nur in einem Fall in einer
zweiten Operation eine Thorakotomie mit offener Dekortikation durchgeführt werden.
Schlussfolgerung: Wir befürworten eine rasche und aggressive Behandlung des
Pleuraempyems und denken, dass die Minithorakotomie zusätzlich zur VATS eine Hilfe bei der
Dekortikation durch Unterstützung der manuellen Ausräumung respektive den Einsatz der
grösseren Instrumente aus der offenen Lungenchirurgie sein kann.
16.04
M. Dietrich 2, S. Korom 1, L. Carboni 1, D. Schneiter 1, W. Weder 1
Abteilung f. Thoraxchirurgie, Universitätsspital Zürich,
2
Chirurgische Klinik, Stadtspital Triemli Zürich
1
Thorakoskopische Therapie des rezidivierenden Spontanpneumothorax:
parietale Pleurektomie und Pleuraabrasio im Vergleich
Einleitung: Innerhalb der letzten Dekade wurde die chirurgische Therapie des rezidivierenden
Spontanpneumothorax durch die video-assistierte thorakoskopische Chirurgie (VATS) etabliert.
An mechanischen Pleurodeseverfahren wird die thorakoskopischen Pleurektomie und als Alternative die Pleuraabrasio durchgeführt. Ziel unserer Arbeit war ein Vergleich dieser beiden Verfahren.
Methode: Wir untersuchten 68 Patienten, welche zwischen 1/93 und 12/97 bei einem idiopathischen Spontan- oder Rezidiv-pneumothorax am USZ thorakoskopisch operiert wurden.
Prospektiv und fast ausschliesslich alternierend geplant erfolgte bei 34 Patienten eine thorakoskopische Pleurektomie, bei 34 eine Pleuraabrasio.
Resultate: Insgesamt kam es im Beobachtungszeitraum von durchschnittlich 3.6 Jahren zu
vier (5.9%) operationsbedürftigen Rezidiven, wobei in beiden Gruppen je ein Früh- und ein
Spätrezidiv auftrat. Interessanterweise fanden sich 3 der 4 Rezidive bei Patienten, bei welchen
keine Parenchymresektion durchgeführt wurde. Es zeigten sich vergleichbare, etwas verlängerte Drainage- (+0.9d) und Hospitalisatioszeiten (+0.7d) bei pleurektomierten Patienten.
Deutlich mehr Patienten der Pleurektomiegruppe litten an persistierenden Gefühlsstörungen
über der operierten Thoraxseite (45% vs. 26%) (p > 0.1). In 7.4% der Operationen gab es kleinere therapiebedürftige Komplikationen, dabei eine operative Reintervention.
Schlussfolgerung: Die thorakoskopische Pleurabrasio (mit Parenchymresektion) beim rezidivierenden Spontanpneumothorax hat sich zunehmend etabliert. Gegenüber der Pleurektomie
ist die Pleuraabrasio technisch einfacher und zeigt eine deutliche Tendenz weniger
Gefühlsstörungen an der Thoraxwand zu verursachen. Zwar laßen sich in einem Vergleich
zwischen Pleurektomie und Pleurabrasio keine Unterschiede im Hinblick auf Rezidiv- und
Komplikationsrate aufzeigen, aufgrund der in den letzten Jahren gewonnenen Erfahrung halten wir die Pleurabrasio, zusammen mit einer detailierten Beurteilung des Parenchyms und
ggf. Resektion für den optimalen Therapieansatz.
16.05
C. Buchli 1, P. Nussbaumer 1, M. Kuhn 2, A. Leutenegger 1, M. Furrer 1
Departement Chirurgie, Kantonsspital, Spitäler Chur AG
2
Pneumologie, Kantonsspital, Spitäler Chur AG
1
Patterns of recurrence after video-thoracoscopic treatment in patients with primary spontaneous pneumothorax
Objective: Primary spontaneous pneumothorax (PSP) occurs in young active patients and has
a high rate of recurrence without treatment. Video-Thoracoscopic (VT) bulla ablation combined with pleurodesis has gained acceptance as treatment modality in recurrent or persistant
pneumothorax. Our prospective quality control program demonstrated higher rates of second
recurrencies after VT for SPS than in the literature.
Patients and Methods: 386 VT were performed between 1996 and 2003. 80 consecutive operations concerned spontaneous pneumothorax. 14 VT performed in patients with secondary
spontaneous pneumothorax were excluded. Indications for VT treatment consisted of second
ipsilateral, first contralateral recurrence, bilateral simultaneous pneumothorax or persisting
pneumothorax after chest tube drainage (air leakage >5 days) and patients with professions
or activities at risk. During this study period all patients underwent preoperative CT scan and
had one chest tube drainage postoperatively. We analysed patients with new recurrence and
tried to define risk factors. Patients without recurrency served as controls. The 66 interventions
were perfomed in 61 patients.
Results For all SPS patients treated by VT morbidity concerned exclusively postop. air leakage (> 5
days, 24%), no mortality occured. The overall recurrency rate was 10.9%. Highly significant risk factors for further recurrencies were the individual case load of the surgeons and the incomplete expansion of the lung in postop. X-rays (71% vs. 29% in the control). We observed in 3 from 7 young
patients the formation of new bullae when comparing the two respective preoperative CT scans.
Conclusion Restrictive indicational guidelines for VT in SPS patients probably define a study
patient population that is at higher risk for further recurrencies than reported in other series
where more liberal inclusion criteria were used. The surgeon’s minor case load and the incomplete immediate apical contact of the lung to the thoracic wall were identified as major risk factors for further recurrencies. In very young patients we observed the formation of new bullae
that might also favore recurrency.
16.06
S. Korom 1, A. Missbach 2, D. Schneiter 1, PJ. Keller 3, M. Furrer 2, W. Weder 1
Division of Thoracic Surgery, University Hospital Zurich, 2Department of Surgery, Kantonsspital
Chur, 3Department of Gynecology and Obsterics, University Hospital Zurich
1
Catamential pneumothorax - clinical approach and review of the literature
Background: Catamenial pneumothorax (CPT) is a rare entity of spontaneous recurring pneumothorax in women. It has been associated with thoracic endometriosis, yet, varying clinical
courses and the lack of consistent findings during intraoperative evaluation form the basis for
conflicting etiologic theories.
Methods: We demonstrate the etiology and report on the clinical courses and surgical treatment of three women diagnosed with CPT. In addition, the world literature since the first description in 1958 is reviewed.
Results: Three women (31, 32 and 39) presented with recurrent, menses-associated rightsided spontaneous pneumothoraces. All of them had been explored thoracoscopically previously, and had undergone various unsuccessful procedures. Re-thoracoscopy revealed multiple
perforations (1-5mm in size) in the tendinous part of the right diaphragm, with histological proven endometrial implants. Following plication of the involved area, two patients were free of
recurrence for 18 and 10 months respectively. Laparoscopic evaluation in one woman with a
further recurrence revealed additional but asymptomatic pelvic endometriosis. This patient
has been free of recurrences after initiation of LHRH-analogue therapy for 15 months. From
219 described cases of CPT in the world literature, adequate clinical information was given for
185 patients (84.5%). Of those, 144 (77.8%) were treated surgically, with detailed intraoperative findings reported in 130 cases (90.2%). Thoracic endometriosis was diagnosed in 73
patients (56.2%), and diaphragmatic lesions in 54 (36.8%). Surgical treatment was described
for 120 patients (83%). In 47 women (38.4%) diaphragmatic lesions were repaired, and in 40
(33.3%) pleurodesis was performed.
Conclusions: CTP may be suspected in ovulating women with spontaneous pneumothorax,
even in the absence of symptoms associated with pelvic endometriosis. During thoracoscopic
exploration, visualization of the thoracic cavity and inspection of the diaphragmatic surface
should be achieved. Thoracoscopic plication of the involved diaphragm alone can be successful. In complicated cases, hormonal suppression therapy may be a helpful adjunct.
16.07
D. Christoforidis 1, P. Pasche 3, S. Simon-Valla 2, S. Gebhardt 2, L. Nauroy 1, HB. Ris 1, E. Pezzetta 1
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne,
2
Service de Pathologie, CHUV, Lausanne,
3
Service d’Oto-Rhino-Laryngologie, CHUV, Lausanne
1
Extra-thoracic tracheal reconstruction using the latissimus dorsi muscle flap in three different
ways: an experimental study in pigs
Introduction Reconstruction after resection of long tracheal segments remains an unsolved clinical problem. Following our clinical experience with intrathoracic transposition of the latissimus dorsi muscle for the coverage of lengthy tracheal resections, we investigated three different types of tracheal reconstruction in an experimental setting.
Methods A cervical segment of the trachea, 4 rings long and 1/3 of the anterior circumference
large was resected. A silicone stent was placed inside the lumen and the tracheal defect was
covered by a pedicled latissimus dorsi muscle flap, reinforced by three different techniques: a)
latissimus dorsi alone (n=3); b) latissimus dorsi together with a segment of the 10th rib which
was sutured into the defect with the pleural surface of the rib facing the lumen (n=3); c) latissimus dorsi flap prepared together with its thoracoabdominal fascia. A biodegradable thermomalleable multi-perforated polylactide plate (Macropore®) was embedded between the fascia
and the muscle and was sutured into the defect with fascia facing the lumen (n=3). Three
months later the silicone stent was removed and at 4 months, after control endoscopy, the animals were sacrificed, the trachea was excised en bloc and analyzed by histology.
Results The cross-sectional area at the most stenotic level of the reconstruction, expressed as
percentage of the cross sectional area of normal trachea, was 75%, 50% and 25% in group a,
85%, 50% and 40% in group b and 80%, 5%, and 5% in group c. Epithelialisation of the reconstructed trachea was almost complete in all animals in group a (80-90%), incomplete in group b
(40-60%) and absent in group c. Moreover, the plate in group c eroded in the tracheal lumen in
all animals.
Conclusions Large extra-thoracic tracheal defects can be closed by latissimus dorsi flaps with
satisfactory epithelialisation. However, structural support is needed for such defects. Pedicled
rib segments or embedded biodegradable polylactide plates have not shown their utility in this
respect in this model.
17
17.01
TH. Kapp 1, F. Holzinger 2, CH. Klaiber 1
1
Spital Aarberg, 2Service de Chirurgie Viscérale CHUV Lausanne
Laparoskopische partielle Fundoplicatio nach Toupet als generelle chirurgische Therapieform der gastrooesophagealen Refluxkrankheit. 5-Jahresresultate einer prospektiven
Langzeitstudie
Einleitung: Bei Patienten mit gastrooesophagealer Refluxkrankheit (GERD) kommen je
nach Oesophagusmotilität verschiedene laparoskopische Antirefluxverfahren zur
Anwendung. Wir haben aufgrund der relativ hohen Incidenz manschettenbedingter
Nebenwirkungen der Nissen-Fundopilicatio das Konzept des “tailored approach” verlassen
und führen bei allen Patienten mit Gerd unabhängig ihrer Oesophagusmotilität die partielle
Fundoplikatio nach Toupet als generelle Therapieform durch.
Methoden: In einer auf 5 Jahre ausgelegten prospektiven Studie werden die erzielten 5
Jahresresultate der ersten 100 konsektutiven GERD-Patienten evaluiert. Alle Patientendaten
wurden prospektiv in einer Datenbank erfasst. Alle Patienten erhielten präoperativ eine
Oesophagogastroskopie mit 24-Std-ph-Manometrie. Bei einem Drittel der Patienten (n=34)
erfolgte 8 Wochen postoperativ eine Kontrollmanometrie. Die klinischen Kontrollen erfolgten 1,2,6,12 und 60 Monate postoperativ. Evaluiert wurden der klinische De Meester Score,
Morbidität der Reoperationen, Mortalität, digestive Beschwerden sowie die Patientenzufriedenheit.
Ergebnisse: Der 5 Jahres Follow-up betrug 87% ( 5 Patienten starben, 8 lost in follow
up).Die 5-Jahresheilungsrate der GERD betrug im untersuchten Patientengut 88,5%. Bei
3,5 % der Patienten trat ein Rezidiv der GERD auf. Der mittlere klinische De Meester-Score
sank von präoperativ 4,27+/-1,5 Punkte auf 0,47+/- 0,9 Punkte 5 Jahre postopertiv
(p<0,0005). Wegen persitierender Dysphagiesymptome erhielten 5% der Patienten eine
postoperative Bougierbehandlung. Als Komplikationen waren zu verzeichnen: RefluxRezidiv (11,5%), Manschettendislokation (3,4%) sowie Gasbloatsyndrom (1,1%). Die
Reoperatinsrate betrug 5% bei einer Gesamtmorbidität von 16,0% und einer Moratlität von
0%. 96,6% der Patienten waren mit der Operation zufrieden und 95,4% würden sich wieder
operieren lassen.
Schlussfolgerung: Aufgrund der nachhaltig guten 5-Jahresresultate mit niedriger Rezidivund Dysphagierate können wir die partielle Fundoplicatio nach Toupet als generelle und
laparoskopische Therapieform der GERD empfehlen. Dem laparoskopisch versierten
Chirurgen steht damit eine sichere und wirksame Methode zur Verfügung.
17.02
B. Wölnerhanssen, C. Ackermann, MO. Guenin, B. Kern, P. Tondelli, M. von Flüe, R. Peterli
Surgical Clinic, St.Claraspital Basel
12 years laparoscopic cholecystectomy:
one institution’s results of a prospetive trial of 4498 cholecystectomies
Aims: We studied the development of indication, operation time, conversion rate, morbidity
and mortality from the beginning of laparoscopic cholecystectomy.
Method: Between June 1990 and August 2002 we prospectively evaluated 4498 patients
undergoing cholecystectomy, of which 3558 (79%) were done laparoscopically (lap), in
298 (6.6%) the procedure had to be converted from laparoscopic to open cholecystectomy
(Con) and 642 (14%) had primary open cholecystectomy (open).
Results: During these 12 years the proportion of gender (72% females) and age (average:
57yrs., range:14-102 yrs.) remained constant. The rate of open decreased steadily (49% in
1990, 7.2% in 2002). The average operation time of lap decreased in the first half year only,
remaining constant with an average of 74 min. thereafter (range: 20-330min.). The conversion-rate decreased in spite of widened indication of lap for even more complicated gallstone diseases from an initial 9.4% to 2.5%. Among intraoperative complications in lap and
Con, bile duct lesions remained constant with 5/3856 (0.1%, main bile duct transsection
3x, -puncture-lesions 2x). Bleeding, which led to conversion decreased (from 1.9% to 0.3%)
and the rate of gall bladder perforation increased (from 12% to 20.5%). The 30-day-morbidity was 2% in lap, 5% in Con and 11.5% in open; the mortality was 0% in lap CE, 0.7% in
Con and 1% in open.
Conclusion: Since the introduction of lap at our institution in 1990 the indication for this
minimal-invasive operation steadily increased and the conversion-rate decreased. In spite
of training unexperienced surgeons in our hospital (yet with a constant team of staff surgeons) the complication-rate could be held low. Even with vast experience in lap CE, up to 7%
of all cholecystetomies are technically difficult and remain to be carried out primarily in an
open technique. The lap has become the gold standard in the therapy of gallstone disease.
17.03
M. Suter
Hôpital du Chablais, Aigle
La chirurgie de l’obésité en Suisse. Résultats d’une enquête nationale
Introduction: La prévalence de l’excès pondéral et de l’obésité est en augmentation constante.
En l’absence de traitement conservateur efficace au stade de l’obésité morbide, la chirurgie
bariatrique demeure la seule méthode entraînant une perte pondérale significative et durable.
Malgré cela, les conditions de remboursement de cette chirurgie par les assurances devien-
swiss knife 2004; special edition
41
nent de plus en plus restrictives. Le but de ce travail est de faire le point sur les pratiques actuelle en Suisse.
Méthodes: Questionnaire envoyé durant l’été 2003 aux membres de la Société Suisse de
Chirurgie.
Résultats: 307 des 764 questionnaires envoyés ont été retournés (40,1 %). Seuls 58 chirurgiens (18,9 %) pratiquent la chirurgie bariatrique, le plus souvent par intérêt personnel (77,5
%), ou en raison de la demande des malades (74,1 %). 56,9 % des répondants effectuent
cette chirurgie depuis au moins 5 ans, 20,7 % depuis plus de 10 ans, alors que 6,4 % l’ont
arrêté. La plupart des chirurgiens (67,2 %) opèrent par année moins de 20 malades, adressés dans 75 % des cas par leur généraliste ou interniste. Une dizaine de chirurgiens effectuent environ la moitié des interventions. Les indications opératoires sont en accord avec le consensus international, et confirmées dans 87,9 % des cas par un groupe multidisciplinaire. Le
nombre d’interventions annuelles ne cesse d’augmenter. Les techniques utilisées évoluent:
avant tout restrictives durant la fin des années 90, elles incluent de plus en plus le by-pass
gastrique et même les dérivations bilio-pancréatiques. Près de 90 % des interventions sont
effectuées par laparoscopie.
Conclusions: La chirurgie de l’obésité prend de l’importance en Suisse parrallèlement à
l’augmentation de la prévalence de cette maladie. Une minorité de chirurgiens s’intéressent
à cette discipline hautement spécialisée, et peu d’entre eux en ont une grande expérience.
Pour faire face à l’épidémie d’obésité qui se développe rapidement, un accent devrait être
porté sur la sensibilisation et sur la formation des chirurgiens aussi bien aux techniques
chirurgicales bariatriques, relativement complexes, qu’à la prise en charge globale et à la
compréhension de l’obésité morbide.
17.04
P. Gervaz, Ph. Morel
Department of Surgery University Hospital Geneva
Two colons – two cancers paradigm shift and clinical implications
Embryological and physiological data suggest that proximal (in relation to the splenic flexure) and distal parts of the colon represent distinct anatomical and functional entities. Since
1990, molecular biologists have identified two distinct pathways, microsatellite instability
(MSI) and chromosomal instability (CIN), which are involved in the pathogenesis of colon
cancer (CC). On a molecular standpoint, there is increasing evidence that tumors located
proximal to the splenic flexure represent a distinct entity, with specific clinical and pathological characteristics. The vast majority of MSI tumors are located proximal to the splenic flexure, while CIN tumors are preferentially distributed in the left colon and rectum. In our
series of eighty-eight T3N0 patients, CIN was detected in 60% of left-sided Vs 16% of rightsided tumors, and 70% of MSI tumors were located proximal to the splenic flexure. Thus, a
new paradigm has emerged with the discovery that CC is a heterogeneous disease; furthermore recent data have demonstrated that these two distinct pathways in colorectal carcinogenesis are characterized by a different clinical outcome. Since patients with stage III MSI
tumors have a better prognosis than patients with stage III CIN cancers, it was logical to
assume that the risks and benefits of chemotherapy may differ between the two groups. In
a recent study of patients with stage III colon cancer, the benefit of 5-FU was restricted to
the patients with CIN. Surprisingly, 5-FU-based adjuvant chemotherapy actually decreased
overall and disease-free survival among patients with MSI tumors. The implications of this
new paradigm for clinicians are two-fold; 1) tumors originating from the proximal colon
have a better prognosis due to a high percentage of MSI-positive lesions; and 2) location of
the neoplasm in reference to the splenic flexure should be documented before group stratification in ongoing trials of adjuvant chemotherapy for colon cancer. In the future, clinical
decision-making regarding adjuvant chemotherapy might be stratified according to the MSI
status of cancers located proximally to the splenic flexure.
17.05
A. Missbach- Kroll, CH. Sommer, M. Furrer
Department of Surgery, Kantonsspital Chur, Switzerland
Soft tissue sarcoma of the extremities and the retroperitoneum:
results of treatment with special regard of impact factos for local recurrency
Background: Soft tissue sarcomas (STS) are rare malignant tumors. Not suspecting malignancy excisions without prior biopsies and without respecting safety margins are often
still performed. Radicality however is the most important prognostic factor even in an interdisciplinary oncological approach in STS. We analyzed our own results using an extremity
preserving strategy in peripheral and retroperitoneal STS with special regard of impact factors for local recurrency (LR).
Methods and Patients:
Out of 33 patients with STS treated at our institution since 1996, 23 had tumors located at extremities (18) or at the retroperitoneum (5). Treatment strategy consisted of either a preoperative
incisional biopsy or the direct “wide excisions” in case of an undoubtful MRI. Postoperative radiotherapy was optional. Overall survival and recurrency rates were calculated. Histological tumor
type, grading, radicality of the first resection as well as whether radiotherapy was performed or
not were studied in patients with LR in comparison to the whole group.
Results: The mean observation time was 38 months. Malignant fibrous histocytoma (MFH)
and liposarcoma were the most frequent tumor types. Overall tumor related mortality was
21% (17% in peripheral and 50% in retroperitoneal STS). Mean survival time was 27
months. LR occured in 17% of patients, distant metastasis in 22%. Mean time to LR alone
was 11 months. All patients with LR had prior non radical local excisions performed at other
42
swiss knife 2004; special edition
institutes. On the other hand were all patients with grade I and II STS, having had “wide excisions” and radiotherapy for grad >1 STS free of LR in this series. Functional results avoiding
amputation even in case of extensive resections were acceptable in all patients.
Conclusions: “Excisional biopsies” in patients with even a low suspicion of a STS should be
avoided. Using extremity preserving strategies in grade I and II STS good results can be reached if radical resection is performed by a so called “wide excision” followed by postoperative radiotherapy in case of grade >1 histology.
17.06
F. Pugin, P. Christofilopoulos, A. Spiliopoulos
Clinique et Policlinique de Chirurgie Thoracique, Hôpitaux Universitaires de Genève
Utilité de l’analyse génétique dans la prise en charge du carcinome médullaire familial
de la thyroïde
Introduction: Le proto-oncogène RET est impliqué dans le développement du cancer médullaire familial de la thyroïde, une tumeur rare, dérivant des cellules C. Il existe une corrélation
entre le type de mutation et l’agressivité de la tumeur. La découverte d’une mutation permet
d’identifier les individus à risque et sa caractérisation permet d’adapter l’âge auquel sera
proposé une thyroïdectomie prophylactique. Seule une douzaine de familles présentant la
mutation RET V804M ont été rapportées. Cette mutation rare semble être associée à un
type de tumeur moins agressive.
Méthode: Nous rapportons les cas de trois membres d’une famille, porteurs de la mutation
RET V804M.
Résultats: Une thyroïdectomie est réalisée chez une patiente de 52 ans présentant un carcinome médullaire de la thyroïde. La présence de la mutation RET V804M est retrouvée également chez la fille et le fils. Une thyroïdectomie prophylactique est réalisée chez la fille à 26
ans, et chez le fils à 23 ans, qui présentent tous deux un taux basal de calcitonine normal,
et un taux élevé après stimulation à la pentagastrine. L’examen histo-pathologique démontre la présence de deux foyers de micro-carcinome chez la première et une hyperplasie diffuse des cellules C chez le second.
Conclusion: La caractérisation de la mutation du proto-oncogène RET impliqué dans le cancer médullaire familial de la thyroïde permet dans certains cas de proposer une thyroïdectomie à l’âge adulte.
17.07
JA. Witzig, PH. Depierre, K. Francis, PH. Zurbuchen
Clinique Générale Beaulieu
Totally extraperitoneal inguinal hernioplasty using a non fixed anatomical slit polyester mesh:
PARIETEX®ADP2
Background: Many techniques for groin hernia repair have been described throughout the
world, with or without mesh, via open or laparoscopic approach. Today, the meta-analysis
of prospective studies prove (1) that repairs with mesh lead to less recurrences and (2) that
posterior laparoscopic approach less operative morbidity. We have selected to reinforce the
abdominal wall with a large prosthetic mesh via a preperitoneal laparoscopic approach.
Since 2000, in order to avoid pain due to fixation and to decrease surgery costs, we have
used a non fixed anatomical mesh.
Objective: The purpose of this study was to assess the efficacy and the tolerance of a non
fixed anatomical slit polyester mesh.
Methods: A prospective study was set up, including all consecutive patients between
February 2000 and December 2003. The specific design of the Parietex® ADP2 anatomical
mesh (SOFRADIM-Trevoux-France) with its lateral slit allows the mesh self fixation around
the spermatic pedicle. Patients were examined at 1 month, and every year. Indication,
immediate, short and long term complications and results were recorded.
Results: 247 patients (350 hernias) were included in the study for groin hernia repair (age:
50 ± 14 years and weight: 75 ± 12 kg). Only one complication occurred during surgery
(possible nervous damage). 243 patients (98,4%) were controlled at 1 month and no serious event was reported (abdominal ecchymosis 1,1%, haematoma 2.6%, seroma 5.1%,
testicular pain 5,7%, inguinal pain 4%). Over 1 year, 94% of the patients were clinically controlled and there was no recurrence.
Conclusion: The use of this non fixed anatomical slit polyester mesh exhibits no serious
complication. Over one year, no recurrence occured and the high rate of the patient satisfaction confirm the interest for the laparoscopic approach.
17.08
G. Zufferey, K. Skala, J. Robert-Yap, B. Roche
Unité de Proctologie Hôpital Universitaire de Genève
Chirurgie endoscopique des veines perforantes des membres inférieurs
Introduction
Durant la dernière décennie, la chirurgie des varices a progressé en raison de
3 facteurs principaux:
l’avènement de méthodes diagnostiques performantes non invasives
une nouvelle classification de l’insuffisance veineuse chronique
le développement de la chirurgie minimale invasive et de la chirurgie endosco
pique des veines perforantes.
Technique opératoire: La ligature des perforantes est indiquée au stade C3 à C6 de la mala-
die veineuse.L’intervention est réalisée sous garrot à l’aide d’une optique à visée axiale 0°
comportant un canal de travail. L’abord est mené au tiers supérieur de la face interne de la
jambe à 2 travers de doigt de l’épine antéro interne du tibia. Le fascia est incisé et le décollement de la loge est mené de proche en proche par un mouvement de balayage jusqu’à
rencontrer les diverses perforantes. Successivement celles-ci sont coagulées puis sectionnées. Un anesthésique local est instillé dans la loge en fin d’intervention. Le fascia et le plan
cutané sont refermés.
Matériel et méthode: De janvier 1997 à décembre 2002, 653 cures de varices ont été effectuées au centre de chirurgie ambulatoire de notre institution. Nous y avons associé 72 ligatures endoscopiques de perforantes (13.2 %). L’indication concernait 42 hommes et 30
femmes d’âge moyen 58.2 ans (40-82). 65 fois la procédure était ambulatoire. Nous y
avons associé 7 faciotomies.
Résultats et complications 3 hématomes et une infection de la loge de décollement sont
survenues dans le post opératoire immédiat. Nous avons dû ré hospitaliser 2 patients pour douleurs. Nous ne déplorons aucune lésion nerveuse, aucune complication cutanée, aucune thrombose veineuse profonde post opératoire.
Le contrôle de 63 patients à un an montre que 2 perforantes ont été omises chez 2 patients. Une
évolution de la maladie veineuse chez 8 patients a imposé une intervention contro latérale.
Conclusion: La technique de ligature endoscopique est indiquée pour les stades CEAP 3-4 à
6. Très efficace, elle entraîne moins de troubles cutanés que la technique de Linton. Elle se complique dans 5.5 % des procédures. Cette intervention peut être aisément associée à la cure
classique de varice. Elle s’effectue sur un mode ambulatoire dans 90.3 % des cas.
17.09
D. Heim 1, A. Kohler 2, U. Stricker 1, B. Noesberger 2
Spital Frutigen, 2 Spital Interlaken
1
Surgical management of patients at risk in a rural hospital in cooperation with a regional hospital - does such a cooperation make sense?
Introduction: Small rural hospitals do not dispose of an Intensive Care Unit (ICU). How to
manage patients at risk from rural hospitals requiring ICU wishing the surgeon from the
rural hospital to perform the operation and wishing postoperative rehabilitation in “his” hospital? To enable such a management a surgical cooperation between a rural hospital and
its larger neighbouring regional hospital has been established. Does such a cooperation
make sense and/or does it put the patient unnecessarily at further risk?
Method: The team of the rural hospital is performing the operation in the regional hospital.
Postoperative care on ICU by the team of the regional hospital. After ICU patient’s transfert
to “his” rural hospital for the rest of rehabilitation.
Results: From April 1999 to December 2003 40/ 2571 patients with the average age of 72
years (45-90 years) have been treated in this way. Their mean ASA Score was 2.8 (II-IV).
Surgery: 16 colonic resections, 8 cholecystectomies, 3 gastric resections, 3 internal fixations
of fractures and 10 other surgical procedures. Average stay on ICU 4.3 days (2-7 days) The
patients were discharged from the rural hospital after another 10 days (5-14 days).
Complications: 4 hematomas requiring reintervention (3 performed by the team of the regional hospital, 1 by the local team) and 1 burst abdomen (closure by the local team at the rural
hospital). One patient died 2 days after discharge from ICU from a myocardic infarction in the
rural hospital. No patient required readmission on ICU after discharge to the rural hospital.
Conclusions: On the overall few patients only had to be managed in the above mentioned
manner. The rate of complications is in regard to the severity of the surgical act and the
reduced general state of these patients acceptable. The fact, that more reinterventions were
performed by the team of the regional hospital reflects the high standard of this cooperation. Such a mangement means better use of infrastructural facilities such as ICU without
any loss of personal care for the patient at risk!
18
18.01
I. Winiger 1, B. Egger 1, R. Greiner 2, D. Candinas 1
1
Department of Visceral and Transplantation Surgery, University of Berne,
2
Department of Radiooncology, University of Berne
Neoadjuvant short-term radiotherapy of low rectal cancer impairs healing of rectal anastomoses after low anterior resection
Introduction: Data of randomised controlled multicenter trials show that patients with
advanced rectal cancer undergoing low anterior resection (LAR) and total mesorectal excision (TME) benefit from neoadjuvant preoperative short-term radiotherapy (STRT) (5x5Gy,
5 days) in terms of local recurrence rate and prolonged survival without serious adverse
effects. Of note, in these studies the lower border of the irradiation field was above 3cm of
the upper anal verge. In contrast to this experience we observed in our single center series
of patients with low rectal cancer undergoing STRT prior to LAR/TME a high rate of anastomotic breakdown (ALR).
Methods: In the past two years 64 patients with rectal cancer were treated at our institution.
45 of them underwent LAR/TME, of whom 17 had a low rectal cancer (distal tumor border
< 4cm above the upper anal verge). In this group (n=17) asymptomatic patients (no bleeding or stenosis) and patients with no need for downstaging of the tumor underwent STRT
(total dose of 25 Gy in 5 fractions during 5 days) (n = 6). All other patients underwent eit-
her immediate LAR/TME (n=8) or operation after a four weeks course of neoadjuvant
chemo-radiotherapy (n=3). Upon clinical signs anastomotic leakage was verified by computed tomography using a contrast agent or by contrast agent enema.
Results: There was no perioperative mortality and to date no local recurrence was noted. Overall
ALR in patients with low rectal cancer was 17.5% (3/17). In patients with STRT ALR was 50%
(3/6) and in the group without preoperative short-term irradiation ALR was 0% (0/11) (p<0.05).
Conclusion: Our prospectively collected single center data demonstrate in patients with low
rectal cancer undergoing LAR/TME a significantly higher ALR in the group with STRT compared to the group without STRT. Our experience suggests that STRT of the sphincter area
seems to be a major risk factor for postoperative breakdown of low anastomosis. In this
light we conclude that STRT of low cancers should be abandoned or only be performed
under controlled study conditions.
18.02
A. Schnider 1, R. Pescia 2, HR. Honegger 3, U. Metzger 1
1
Chirurgische Klinik Stadtspital Triemli Zürich, 2Klinik für Radioonkologie und Nuklearmedizin
Stadtspital Triemli Zürich, 3Institut für Medizinische Onkologie Stadtspital Triemli Zürich
Langjährige Erfahrung mit der trimodalen Therapie beim tiefsitzenden Rektumkarzinom:
Verhindert eine komplette Remission (CR) ausgedehnte Resektionen?
Retrospektiv wurden 84 Patienten mit tiefsitzendem Rektumkarzinom UICC II/III, die eine
neoadjuvante Chemoradiotherapie mit anschliessender Resektion erhielten analysiert.
Ansprechenrate, Morbidität, Sphinktererhalt, Lokalrezidive und 5-Jahresüberlebensrate werden diskutiert. Von 1995 bis 2004 wurden insgesamt 84 Patienten wegen eines tiefsitzenden Rektumkarzinoms (durchschnittlich 4,6cm ab Anokutanlinie (ACL)) neoadjuvant vorbehandelt (5-FU 1000mg/m2/24h Woche 1 und 5, RT 25x1,8 Wochen 1 bis 5). Nach
einem Intervall von 4-6 Wochen erfolgte die Operation.
Resultate Bei 12 Patienten (14%) konnte nach der neoadjuvanten Chemoradiotherapie eine
komplette pathologische Remission (CR) erzielt werden, bei 39 (47%) zeigte sich eine partielle Remission (PR), bei 17 (20%) eine stabile Situation und bei 16 (19%) eine Progression. 65 Patienten (77%) konnten sphinktererhaltend operiert werden (17 APR, 62 LAR, 2
Pelvine Exenterationen und 3 lokale Exzisionen). Chirurgische Komplikationen traten bei 23
der Patienten (27%) auf, 16 (19%) mussten reoperiert werden. Anastomoseninsuffizienzen
waren bei 5 von 65 Patienten (8%) und präsakrale Hämatome/Abszesse bei 7 von 84 Patienten (9%) zu beobachten. Die Hospitalisationsletalität bertrug 0%. Lokoregionäre Rezidive traten in 9,5% (8 von 84) und in 6 (7%) Fällen als alleinige Tumormanifestation auf, bei
einer medianen Nachbeobachtungszeit von 74 Monaten. Kein Patient mit CR zeigte ein Tumorrezidiv. 5 Jahresüberlebensrate und krankheitsfreies Ueberleben werden vorgestellt.
Schlussfolgerung Die trimodale Therapie beim Rektumkarzinom wird von den Patienten gut
toleriert und ermöglicht in Ergänzung zur chirurgischen Technik in vielen Fällen eine kontinenzerhaltende Operation. Eine CR kann in 14% erreicht werden. In einzelnen dieser Fälle
kann auf eine ausgedehnte chirurgische Resektion verzichtet werden.
18.03
E.Andereggen 1, F. Ris1, I. Neyroud 2, P. Gervaz 1, PH. Morel 1
Clinic of Visceral Surgery, University Hospital Geneva, 2Geneva Cancer Registry
1
Outcome of surgery for rectal cancer in octogenarians
Introduction: Life expectancy of the elderly population is increasing. Therefore, curative treatment of cancer in elderly patients represents an important challenge. The aim of this study was
to assess the outcome of surgery for rectal cancer in patients 80 years or more of age.
Method: A retrospective study of 29 patients older than 80 years who presented with the diagnosis of rectal adenocarcinoma in our institution between 1997 and 2001 was undertaken.
Results: 24 out of 29 patients (83%) underwent surgery, 23 being operated electively. Five
patients had no surgical procedure (in 3 cases the patient refused the operation; in 2 cases
the patients had locally advanced and/or metastatic disease and were considered irresectable). Six (25%) patients were classified as ASA II, 17 (71%) patients as ASA III and one
patient (4%) as ASA IV. Twenty out of 24 patients (83%) underwent resection with a curative intent (abdominoperineal resection N=7, low anterior resection N=7, Hartmann’s procedure N=2, transanal resection N=4). Four patients (17%) had a palliative procedure
(defunctioning colostomy). Eight out of 20 patients (33%) operated with curative intent
underwent preoperative radiotherapy.
Median hospital stay was 13 (range 10-35) days. Postoperative complications occurred in
11 patients (46%), and in 3 cases were surgically related ( 1 bleeding after transanal resection; 1 dehiscence of the perineal wound; and 1 anastomotic leak). Overall operative mortality was 12.5% (3/24 patients). When considering only elective procedure with curative
intent, operative mortality was 5% (1/20
patients) and 2-year overall survival was 80%. At the time of last follow-up, 13 patients were alive,
five of them with no evidence of recurrent disease at 5 years. Four out of the 7 deaths which
occurred 8 months to 5 years after surgery were due to medical causes unrelated to cancer.
Conclusion: In our experience, two thirds of patients older than 80 years who presented
with rectal cancer underwent surgery with curative intent. In this population, good results in
terms of short-term survival can be achieved, at the price of a relatively elevated postoperative mortality and morbidity.
swiss knife 2004; special edition
43
18.04
1
1
2
2
CA. Maurer , K. Kessler , T. Gläser , G. Schüder
1
Dept. of Surgery, Hospital of Liestal, CH, 2Dept. of Surgery, Hospital of Wertheim/Main, DE
Is the transverse coloplasty-anal reconstruction afflicted with an increased leak rate?
Background: The transverse coloplasty (Bern’s Pouch) was developed in a pig model by
Maurer and Z’graggen in 1997 and proposed for rectal replacement in humans in 1999. The
transverse coloplasty is a simple procedure consisting of a longitudinal antimesenterial colotomy of 8cm length, 2-3cm proximally to the later coloanal anastomosis, followed by a transverse double-layer closure of the colotomy. Despite the world-widely increasing acceptance of
this novel procedure some surgeons are sceptical for fear of increased leak rates.
Patients and methods: 78 consecutive patients with transverse coloplasty anal anastomosis between 1999 and 2004 were prospectively registered in two databases and retrospectively analyzed. The median age was 67.5 years (range 24 – 85 years). All patients had preoperative orthograde bowel preparation. Inferior mesenteric artery was always resected
and the part of colon used for reconstruction was the descending or transverse colon,
exclusively. All anastomoses were below 5cm from anal verge. All coloplasties were sutured and all but two coloanal anastomoses were stapled. Pelvic omentoplasty was used in
38 patients (49%) and transanal tube drainage for 3-5 days in 41 patients (53%). A protective stoma was performed in 45 patients (58%). Pelvic irradiation was applied in 13
patients (17%) preoperatively, and in 11 patients (14%) postoperatively. Radiological control of anastomosis/pouch was done in case of clinical or laboratory findings indicating
infection and always before stoma take-down.
Results: Postoperative signs of infection has been recorded in 10/78 patients. The causes
were: pneumonia (n = 2), urinary infection (n = 4), wound infection (n = 1), vein thrombosis/phlebitis (n= 1), central venous catheter infection (n = 1), unknown origin (n = 1). Only
one patient presented with a leak at the coloanal anastomosis in form of a colo-vaginal
fistula. Reoperation consisted in a loop colostomy. None of the other patients needed reoperation. None of the coloplasties showed a clinical or radiological leakage and there was no
abdominal or pelvic abscess.
Discussion: Our results suggest that the transverse coloplasty anal reconstruction is a safe
procedure.
18.05
P. Wuthrich, P. Gervaz, Ph. Morel
Department of Surgery, University Hospital Geneva
Quality of life after ileal pouch-anal anastomosis:
comparison of patients with familial adenomatous polyposis and ulcerative colitis
Background: Ileal pouch-anal anastomosis (IPAA) is the gold standard for treatment of
severe ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, the longterm quality of life (QoL) of patients who underwent this procedure has rarely been investigated. In addition, the impact of either the initial pathology (UC Vs FAP) and the type of
reconstruction (J- Vs S-pouch) on QoL remains to be determined.
Methods: A questionnaire-based evaluation of QoL using the Medical Outcomes Study
short-form (SF-36) was undertaken. The SF-36 questionnaire is composed of 36 items that
assess 8 health concepts; physical functioning (PF); role limitations due to physical problems (RP); bodily pain (BP); general health perception (GH); vitality (VT); social functioning (SF); role limitation caused by emotional problems (RE); and mental health (MH).
Results: 67 out of 106 (63%) patients who had an IPAA in our institution from 1981 to 2002
responded to the questionnaire. The median age at the time of the procedure was 38
(range 17-69) years and the median delay between the procedure and the assessment of
QoL was 83 (range 4-230) months. Forty-seven (70%) patients had UC and 15 (22%)
patients were operated upon for FAP. Pouch construction was of the J-type in 37 (55%)
cases. For the whole group, the results in terms of QoL were the following; PF = 50±9, RP =
44±16, BP = 49±13, GH = 47±11, VT = 46±13, SF = 44±12, RE = 40±20, MH = 42±14.
QoL was not significantly different between UC and FPA patients (Physical Component
Summary [PCS] = 52±9.7 in UC and 50±9.5 in FAP, t test p value = 0.39 ; Mental
Component Summary [MCS] = 42±16 in UC and 38±16 in FAP, p=0.40). Time-dependent
regression analysis demonstrated a trend towards decreasing QoL with time after IPAA
(Spearman rank correlation r=-0.24, p=0.05).
Conclusion: IPAA patients did not differ from the general population in all of 8 general health
categories assessed by the SF-36. All aspects of QoL appeared better preserved in UC compared with FPA patients although the difference did not reach statistical significance.
However, decreasing QoL with time is to be expected after this type of procedure.
18.06
P. Wildbrett, N. Demartines,M. Weber, C. Motta, V. Rousson, PA. Clavien
University Hospital Zurich
Renal transplant patients have a higher risk to develop complicated diverticulitis compared
to non-transplant patients
Introduction: Complicated diverticulitis is a serious complication after renal transplantation,
with more emergency operations than in the non-transplanted population. The aim of this
study was to assess (1) if renal transplant patients have a higher prevalence to develop
acute diverticulitis, (2) higher rates of complicated diverticulitis, and (3) a higher need for
emergency operations compared with a non-transplanted group.
44
swiss knife 2004; special edition
Methods: We retrospectively reviewed all kidney transplant patients between 1964 an 2003
at our institution. An in-depth search was performed for post transplant acute diverticulitis
requiring hospital admission (transplant group). Furthermore, non-transplanted patients
admitted for acute diverticulitis to our hospital between 2000 and 2003 formed a control
group. Free perforation, phlegmon, abscess or fistula were criteria for the definition of complicated diverticulitis. Data were analyzed regarding prevalence of acute diverticulitis, rates
of complicated diverticulitis and emergency operations as well as length of hospital stay.
Results: 1995 patients underwent renal transplantation during the study period. Twentythree of these patients (1,1%) were admitted to the hospital due to acute diverticulitis.
Furthermore, 122 non-transplanted patients with acute diverticulitis served as control
group. 90% of patients in the transplant group had a complicated diverticulitis compared to
only 35% of patients in the control group (p<0,001). An emergency operation was required
in 90% of patients with complicated diverticulitis in the transplant group vs only 67% of
patients in the control group (p=0,065). The mean hospital stay of patients with emergency operations was not significantly different between both groups (28 vs 18 days, p=0.27).
Conclusion: The prevalence of acute diverticulitis in renal transplanted patients is about 1%,
similarly to the general population. However, the study shows that diverticulitis in renal
transplant population presents typically in a complicated form whereas two third of nontransplant patients present with a non-complicated course.
18.07
B. Strub, M. Zünd, R. Warschkow, J. Lange
Chirurgische Klinik, Kantonsspital St. Gallen
Appendizitis perforata.
Laparoskopische Ergebnisse von 334 Patienten mit Appendizitis perforata
Einleitung: Die laparoskopische Appendektomie ist heute als sichere Operationsmethode
anerkannt. Das laparoskopische Management bei einer Appendizitis perforata wird in der
Literatur kontrovers diskutiert. In einigen Studien gilt eine Appendizitis perforata gar als
Kontraindikation für eine laparoskopische Appendektomie.
Die laparoskopische Appendektomie wird bei uns seit 1990 routinemässig durchgeführt.
Methode: Retrospektive Analyse von 334 Patienten mit einer Appendizitis perforata, welche
zwischen 11/91 und 11/03 primär laparoskopisch operiert wurden.
Resultate: 334 operierte Patienten. 140 Frauen (41.9%); 194 Männer (58.1%). Das mediane Alter betrug 48 Jahre (Range:13 - 94 J.). Bei 26.3 %.der Patienten war eine Konversion notwendig. Über die ganze Zeitspanne blieb die Konversionrate beinahe unverändert. Die mediane Hospitalisationsdauer betrug in der lap. Gruppe 7 Tage (Range: 3-23 Tg.), die mediane
Operationsdauer 70 Minuten (25-225 Min.).
In 90.6% der laparoskopischen Operationen wurde eine reine Appendektomie durchgeführt, in
den restlichen Fällen kam es zu einer Operationserweiterung (z.B Ileocoecalresektion;
Adhäsiolysen).
Postoperative Komplikationen traten bei 30.9% der Patienten auf. Die häufigsten Komplikationen
waren itraabdominelle Infekte (13), Ileus/-Subileussymptomatik (11) und Wundinfekte (7).
Diskussion: In der Literatur wird eine Komplikationsrate von 10-50% bei laparoskopischen
Appendektomien und von 10-40% bei offenen Appendektomien beschrieben. Unsere Erfahrungen zeigen, dass die laparoskopische Appendektomie bei einer Appendizitis perforata
eine sichere Methode ist. Die Konversionsrate ist relativ hoch. Der häufigste Grund für eine
Konversion ist die Unübersichtlichkeit bei Verwachsungen und Konglomerattumoren. Der
Entscheid zur Konversion wird meist primär zur Sicherheit des Patienten und nicht wegen
der Methode an sich gefällt.
18.08
FH. Hetzer, Y. Knoblauch, S. Buse, D. Hahnloser, PA. Clavien, N. Demartines
University Hospital Zurich, Visc.&Transpl. Surgery
Quality of life after sacral nerve stimulation in patients with faecal incontinence
Introduction Several studies demonstrate the success of sacral nerve stimulation (SNS) in
the treatment of faecal incontinence. The aim of this study was to assess the influence of
SNS on Quality of life (QoL).
Methods: SNS was performed in two steps, first a percutaneous nerve evaluation (PNE),
with insertion of a screening lead. The second step is the implantation of the internal pulse
generator (IPG). The permanent implantation is proposed if a reduction of symptoms of
more than 50% is observed during the screening phase. Quality of life was assessed by
three different scores (Eypasch, Royal London Hospital (RLH) and the SF-36). Faecal incontinence was graded by the Wexner-Score, urine incontinence by the Hanley-Score before
and 6 months after permanent implantation.
Results: Between May 2001 and January 2004, 28 PNE - tests were performed in 22
patients (male / female = 10/12) with a median age of 58 years (range 32-86). The permanent stimulator was implanted in 13 patients (59%). Mean follow-up was 7 months (120). The median preoperative Wexner-Score was 15.0 (8-20) and postoperative 4.3 (0-11),
P= 0.005. The preoperative urine incontinence score decreased from 2.1 (0-8) to 1 (0-2),
P= 0.655. Significant QoL improvement were found for the RLH-QoL score from 95.7 (6202) to 39.0 (10-119), P= 0.066 and for the SF-36 from preoperatively 65.3 (13-100) to
postoperatively 28.0 (7-80), P= 0.068. No difference was seen in the Eypasch score (preto post operative 99 to 98 P= 0.102. This later score is probably less specific for patients
with faecal incontinence.
Conclusion: In addition to an objective improvement of faecal incontinence score after SNS
permanent implantation, a significant improvement of the physical, emotional and social
quality of life score was documented. This positive influence of permanent SNS on continence and quality of life needs to be confirmed in long-term follow-up studies.
18.09
H. Petrowsky, N. Demartines, V. Rousson, PA. Clavien
University Hospital Zurich, Visc.&Transpl. Surgery
Is prophylactic drainage useful after gastrointestinal surgery?
Introduction: Prophylactic drainage (PD) is considered as method to reduce and detect
postoperative complications. On the other hand, there is growing evidence that routine drainage may not be useful or even harmful after many GI procedures. To determine if PD is useful in gastrointestinal (GI) surgery we performed a systematic review and meta-analysis.
Methods: A Medline search from 1966 to 2003 was performed to identify articles comparing PD with no drainage in GI surgery. The studies were reviewed and classified according
to their quality of evidence (U.S. Preventive Service Task Force). Sixteen randomized controlled trials (RCTs) were found for hepatopancreaticobiliary surgery, 2 for upper GI tract, and
12 for lower GI tract surgery. If sufficient RCTs were identified, we performed a meta-analysis to characterize the drain effect using the random effect model.
Results: There is evidence of level I that drains do not reduce complications after hepatic
resection, cholecystectomy, pancreatic resection, colonic or rectal resection with primary
anastomosis and appendectomy for any stage of appendicitis. The meta-analysis of 2 RCTs
on liver resection revealed an odds ratio (OR) for infected intraabdominal collections of 3.4
(p=0.10) with trend in favouring the no-drainage group whereas drainage status had no
influence on the rate of bile collections (OR 0.96; p=0.95). The meta-analysis of 7 RCTs on
colorectal surgery showed no benefit of a PD policy in reducing complications. The metaanalysis of 3 RCTs on appendectomy for gangraneous or perforated appendicitis demonstrated an advantage for non-drained patients for the endpoints wound infection (OR 1.75;
p=0.068) and fecal fistula (OR 12.4; p=0.039).
Conclusion: Many GI operations can be performed safely without PD. In some respect
drains were even harmful. Drains should be omitted after hepatic resection, cholecystectomy, pancreatic resection, colonic or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis, whereas PD remains indicated after esophageal
resection and total gastrectomy due to the potential fatal outcome in case of anastomotic
and gastric leakage.
19.01
19
M. Lesurtel 1, B. Aleil 2, W. Jochum 3, R. Graf 1, C. Gachet 2, PA. Clavien 1
1
Department of Visceral and Transplant Surgery, University Hospital Zürich,
2
INSERM 311, Etablissement Francais du Sang-Alsace, Strasbourg, France,
3
Department of Pathology, University Hospital, Zürich
Platelets: a novel pathway of liver regeneration
Background: Leukocyte recruitment triggers hepatocyte proliferation after partial hepatectomy. Since platelets interact with leukocytes and play an important role in liver ischemia/reperfusion injury, we attempted to assess the role of platelets in liver regeneration after partial
hepatectomy.
Methods: To assess liver regeneration, proliferating cell nuclear antigen (PCNA) and Ki67
expression were determined in male C57BL6 mice 48 hours after 70% hepatectomy. Two
models of thrombocytopenia and a model of inhibition of platelet function were developed.
Immune thrombocytopenia was induced by intraperitoneal injection of a monoclonal rat
antiplatelet antibody (immune group). Central thrombocytopenia was induced by a single
intraperitoneal injection of busulfan (busulfan group). To inhibit platelet aggregation, mice
were pretreated with clopidogrel (clopidogrel group). A forth group of mice was treated with
SR 25989 an enantiomer of clopidogrel which has the antiangiogenic property of clopidogrel but lacks its antiaggregant property (SR group).
Results: In the immune group, platelet counts decreased below 10% of normal. Busulfan
induced both thrombocytopenia and leucopoenia as assessed by platelet and leukocyte
counts which were below 15% of normal. Clopidogrel did not affect platelet and leukocyte
counts. In immune and busulfan groups, PCNA and Ki67 expression was reduced to 40%
compared to the controls (p<0.01). In the clopidogrel group, PCNA expression was reduced
to 60% compared to the controls (p<0.05), however decreased Ki67 expression did not reach
significance. Liver regeneration was not impaired in the SR group, in which platelet aggregation was normal.
Conclusion: These results suggest that platelets play an important role in liver regeneration
after hepatectomy.
19.02
PC. Nett 1, HW. Sollinger 2, T. Alam 2
1
Universität Bern, Departement für Viszeral- und Transplantationschirurgie, Berne, Switzerland,
2
University of Wisconsin, Hospital and Clinics, Division of Organ Transplantation, Madison, USA
Glucose-dependent hepatic insulin expression in STZ-induced diabetic mice after systemic
plasmid DNA gene transfer
Introduction: Gene-based therapy for the treatment of insulin dependent diabetes mellitus
(IDDM) requires the development of a surrogate beta-cell able to synthesize and release
insulin in response to glucose challenge in a physiological range. Some viral vectors transduce hepatocytes efficiently and express transgenes at high levels; however, non-viral vec-
tors have the advantage of being less toxic, less immunogenic and further lack the risks
associated with to viral vectors. Recent studies provide evidence that intravascular delivery
of plasmid DNA results in an effective gene transfer to hepatocytes.
Material and Methods: To test whether the systemic delivery of plasmid DNA is sufficient to
correct diabetic hyperglycemia, proinsulin plasmid DNA was injected via the tail vein into
streptozotocin (STZ)-induced diabetic mice. The construct included the liver-specific albumin promoter coupled with three glucose inducible regulatory elements (GIRE)s from the S14 gene and the modified proinsulin with (3SATEM) or without (3SAM2) an additional
translational enhancer sequence derived from vascular endothelial growth factor (VEGF).
Results: Compared to diabetic control mice, both 3SATEM- and 3SAM2-treated diabetic mice
showed a normalization of fasting blood glucose levels, a significant reduction of postprandial hyperglycemia and reduced weight-loss. Treatment with 3SATEM in contrast to 3SAM2
significantly increased insulin serum concentration under both postprandial (3SATEM:
8.0±4.8μU/ml, and 3SAM2: 2.8±1.0μU/ml) and fasting (3SATEM:
2.4±0.3μU/ml, and 3SAM2: 0.3±0.4μU/ml) conditions (P<0.05), thus accelerating kinetics to restore postprandial euglycemia.
Conclusions: Our data demonstrate that high levels of hepatic insulin expression can be
achieved by plasmid DNA injection via the tail vein avoiding the inherent risks of gene delivery by viral vectors. Additionally, the enhanced translational efficacy of our preproinsulin
construct (3SATEM) substantially improved the output of hepatic insulin secretion and
accelerated kinetics to restore postprandial euglycemia in vivo.
19.03
G. Mai 1, TH. Nguyen 2, PH. Morel 1, D. Trono 2, L. Buhler 1
1
Cell Transplantation Lab, Surgical Research Unit, Department
of Surgery, University Hospital Geneva,
2
Department of Genetics and Microbiology, University of Geneva Medical School
Treatment of fulminant liver failure by transplantation of microencapsulated primary or
immortalized xenogeneic hepatocytes
Aim: Shortage of human donors limits the number of liver transplantation (Tx) and new
sources of tissues are being searched. The aim of this study was to evaluate the potential
of encapsulated xenogeneic hepatocytes (EXH) Tx as a treatment of fulminant liver failure
(FLF) in mice.
Methods: Rat and human hepatocytes were isolated from normal liver by collagenase perfusion and digestion. Human hepatocytes were immortalized using lentiviral vectors coding
for SV 40 large T antigen, Bmi-1 and telomerase. Rat and immortalized human hepatocytes
were encapsulated in 400micron alginate-PLL-alginate membranes. In vitro, EXH were cultured for 2 weeks in albumin-free medium and albumin production was measured by ELISA.
In vivo, a model of FLF was established in C57/BL6 mice by acetaminophen administration
(700 mg/kg i.p) followed by a 30% hepatectomy. EXH were Tx intraperitoneally. The following groups were performed: Group 1 (N=20) injection of Hanks; Group 2 (N=12) Tx of
empty capsules; Group 3 (N=20) Tx of free primary rat hepatocytes (50x106 hepatocytes
per mouse); Group 4 (N=12) Tx of encapsulated primary rat hepatocytes (50x106 hepatocytes per mouse); Group 5 (N=12) Tx of encapsulated immortalized human hepatocytes
(50x106 hepatocytes per mouse). Animals were euthanized at regular intervals and histopathology of microcapsules was performed.
Results: In vitro, encapsulated primary rat hepatocytes showed continuous albumin secretion during 2 weeks, but encapsulated immortalized human hepatocytes showed minimal
albumin secretion. In Group 1, 2, 3, and 5, survival was 30-35%. In Group 4, Tx of encapsulated primary rat hepatocytes significantly increased survival rate to 80% (P<0.001).
Histopathology revealed that EXH were viable up to 2 weeks post-Tx.
Conclusions: Primary hepatocytes maintained synthetic functions after encapsulation,
whereas immortalized human hepatocytes showed minimal albumin secretion, suggesting
that hepatocytes may lose specialized functions after immortalization. After induction of
FLF, Tx of encapsulated, but not free, primary xenogeneic hepatocytes significantly improved survival. These results indicate that EXH can sustain metabolic functions during FLF and
allow regeneration of native liver tissue.
19.04
M. Gass 1, C. Stoupis 2, G. Beldi 1, E. Ayouni 1, B. Gloor 1, D. Candinas 1, D. Inderbitzin 1
Klinik für Viszerale und Transplantationschirurgie,
2
Klinik für Diagnostische und Interventionelle Radiologie
1
Magnetic resonance imaging provides accurate volume determination
in regenerating mouse livers
To test liver supportive regimens in mouse models of liver regeneration a non-invasive repetitive volume determination would provide an attractive tool for real-time measurement of
the therapeutic effect. The aim of the study presented was to develop a magnetic resonance (MR) based volumetric procedure to accurately determine the hepatic volume in the
regenerating mouse liver.
Methods: In Balb-C mice (20-25g, 6-8 weeks) under general intraperitoneal (i.p.) anaesthesia varying amounts of liver tissue was resected (i.e. 62%, n=8; 35%, n=3; 27%, n=2). MR
imaging was performed 24 hours later in a 1.5 Tesla Unit (Sonata, Siemens), using a phased-array coil for small parts (dedicated wrist coil) under i.p. anaesthesia. T1 and T2
weighted images (T1: VIBE, TR 11,3, TR 5.51 msec, T2: TSE, 3D, TR 3000, TE 113 msec) in
axial plane were acquired with continuous 1 mm thick slices. Two groups of animals were
compared: With (n=6) or without (n=7) intravenous administration of paramagnetic con-
swiss knife 2004; special edition
45
trast agent (GadovistÆ). Immediately after MR examination animals were killed, the livers
resected and weighted. The liver border was delineated in every single 1mm MR image by two
independent, blinded examinators and the hepatic volume calculated by the surface areas
determined. Simple linear regression analysis was performed from the data obtained.
Results: Correlation coefficients (CC) between liver volume measured and liver weight were
0.83 in T1 weighted images in the group without paramagnetic contrast injection. Injection of
paramagnetic contrast agent allowed superior liver delineation in T2 weighted images
(CC=0.96, p=0.002,) while discrimination in T1 pictures was difficult (CC=0.42). The standard
error of the estimate of the mean was 6.8% resulting in an accurate liver volume determination.
Conclusions: The MR-based volumetric protocol developed allows accurate and precise liver
volume measurement during regeneration in a mouse model. Repetitive individual volumetry
decreases inter-individual differences between animals thereby reducing the numbers of animals needed per group to detect significant differences in hepatic regeneration.
19.05
P. Bucher, G. Mai, Z. Mathe, D. Bosco, Th. Berney, L. B¸hler, Ph. Morel
Division of Surgical Research, Department of Surgery, University Hospital Geneva
Retransplantation of discordant xenogeneic islets using costimulatory blockade
Background: We analyzed the feasibility of xenogeneic islet retransplantation using costimulatory blockade.
Methods: Streptozotocin-induced diabetic mice were transplanted with human islets (HI).
On day 14, mice were nephrectomized (graftectomy) and retransplanted with HI obtained
from a different donor under the controlateral kidney capsule. Four groups were performed
(6 mice/group): Group I: 1st and 2nd Tx without MR1. Group II: 1st Tx without MR1, 2nd Tx
with MR1. Group III: 1st Tx with MR1, 2nd Tx without MR1. Group IV, 1st and 2nd Tx with
MR1. Anti-CD154 mAb (MR1) was given at 0.5 mg i.p. on days 0, 2 and 4 post-Tx. A control
group was transplanted only once without MR1 to evaluate the rejection process in nonsensitized mice. After 2nd Tx recipient mice serum was analyzed by cross-match on human
lymphocyte for detection of anti-human antibodies.
Results: In the control group, mean graft survival was 13± 7 days. Pre-transplant cross-matches were all negative.
Group
Therapy for 1st Tx
Therapy for 2nd Tx
Mean 2nd Tx Survival (days)
Cross-match
I
None
None
5± 3
+
II
None
MR1
16± 13
+
III
MR1
None
62± 15
+
IV
MR1
MR1
>100
-
Conclusion: Retransplantation of xenogeneic islets without therapy was associated with
accelerated rejection. After pre-sensitization to xeno-antigens, MR1 was unable to induce
tolerance to a 2nd Tx. MR1 given at the 1st Tx only, allowed prolonged survival of the 2nd
Tx, but rejection still occurred. MR1 given at 1st and 2nd Tx allowed long-term survival of
retransplanted xenoislets and prevented occurrence of anti-donor antibodies.
19.06
N. Selzner, M. Selzner, PA. Clavien
University Hospital Zurich
Different etiology of steatosis has different tolerance to ischemic-reperfusion injury
Due to the dramatic organ shortage fatty livers are commonly used for liver transplantation.
The role of micro- and macrovesicular steatosis in ischemia/ reperfusion injury is unclear.
Methods: ob/ob mice and mice with choline deficient diet were chosen as models for steatosis. 45 minutes of ischemia of the liver were performed in both mice. The amount of total
lipids was evaluated in the liver tissue. Liver injury was quantified by serum AST levels. Liver
necrosis was determined by H&E staining and the ATP content of the liver tissue by bioluminescence assay. The blood flow in the portal vein was evaluated by laser doppler.
Results: The amount of total intrahepatic lipids were similar in ob/ob and choline deficient
mice (50 vs 48 mcg/mg, p= 0.5), and were 5-times lower in the lean control group (9.2
mcg/mg). Ob/ob mice had more macro- than microvesicular steatosis (75% vs 25%),
while choline deficient animals had less macro- than microvesicular fat (30% vs 70%). After
45 minutes of ischemia and 4hr of reperfusion ob/ob mice had significantly higher AST
levels (20100 U/L) than choline deficient (7200 U/L) or lean mice (5400 U/L). After 4hr
and 24hr of reperfusion ob/ob mice had more necrosis in the liver tissue than choline deficient mice (4hr: 62% vs 41%; 24hr: 80% vs 65%). Lean mice had only minimal necrosis at
this time point. ATP levels were comparable in ob/ob and choline deficient mice prior to
ischemia and after reperfusion. Lean animals had a rapid normalization of the portal vein
perfusion after reperfusion (90% of the baseline within 1hr). Choline deficient mice had
60% of the baseline portal vein flow within 1hr of reperfusion. In contrast, ob/ob mice had
a decreased portal vein perfusion up to 24hr of reperfusion (15% of the baseline after 24hr).
Conclusion: Macrovesicular steatosis results in higher liver injury in the early phase after
ischemia and reperfusion. In contrast to lean livers both types of fatty livers results in a
necrotic form of cell death. The decreased portal vein flow following reperfusion is a possible mechanism of the early severe injury in mice with macrovesicular steatosis.
46
swiss knife 2004; special edition
19.07
W. Moritz 1, R. Züllig 2, Y. Tian 1, G. Cavallari 1, PA. Clavien 1, M. Weber 1
University Hospital Zurich, Visceral & Transpl. Surgery,
2
University Hospital Zurich, Internal Medicine
1
Pancreatic islet engraftment after intrahepatic transplantation:
evidence of early graft loss in a syngeneic rat model
Purpose: Pancreatic islet transplantation is a practical approach to restore glucose homeostasis in patients with diabetes. Despite a remarkable progress during the last three years,
a widespread application of clinical islet transplantation is limited by the high amount of
islet tissue that is required for a successful therapy. The aim of the study was to investigate
the process of intrahepatic islet engraftment in the early phase after transplantation beyond
the scope of a diabetic state, graft rejection and the recurrence of autoimmunity.
Methods: Islets were isolated from Lewis donor rats and transplanted into the caudate liver
lobes of syngeneic healthy recipient rats by portal administration. The liver was harvested
after one, three, eight and 14 days after transplantation and histology was examined.
Results: Blood glucose values in transplanted rats were comparable to those in sham operated rats. Histology from liver paraffin sections show islets grafts embolized in the portal
system, resulting in occasional focal necrosis and sporadic, transient macrovesicular steatosis. Insulin immunostaining indicates a reduction of functional b-cell mass with time by
50-80% within 14 days after transplantation which is paralleled by a decrease in average
islet size and disturbed islet integrity. Cellular infiltrates can be observed occasionally at day
three and eight post-transplantation.
Conclusion: The loss of transplanted b-cell mass within the first days after intrahepatic
transplantation in a syngeneic model suggests a non-specific inflammatory response,
which is consistent with the observed cellular infiltration. This indicates that early graft loss
in islet cell transplantation is provoked to a substantial part by non-immunogenic events
which may contribute to the high demand of donor tissue in clinical islet transplantation.
19.08
D. Inderbitzin, A. Keogh, G. Beldi, D. Stroka, B. Gloor, D. Candinas
Department of Visceral and Transplant Surgery, University Hospital Berne
Hepatocyte specific metabolic activity can be induced in adult liver stem cells isolated from
rodent bone marrow
Adult liver stem cells (ADULIS) can be isolated from rodent bone marrow. When cultured
under specific conditions ADULIS are transdifferentiating into a hepatocyte-like lineage and
are able to produce urea from ammonia. The aim of the study presented is to describe the
hepatocyte specific metabolic capacity of cultured ADULIS from normal or bile duct ligated
(BDL) rats in single or co-culture with hepatocytes, with or without Interleukin-3 (IL-3).
Methods: ADULIS were isolated by a two-step immunoisolation procedure (i.e. Beta-2microglobulin negativity/Thy-1 positivity) from rat femoral bone marrow and cultured on a
matrigel layer. Isogeneic hepatocytes were seeded on an inlay for co-culture experiments.
IL-3 was added in the corresponding experimental groups (10ng/ml). Urea formation was
determined with a colorimetric assay and 18S(rRNA) content used to standardize the metabolic signal for cell number.
Results: Relative urea synthesis in cultures from normal animals was 1.03±0.42 in single
and 1.38±0.41 in co-culture. With addition of IL-3 urea genesis was stronger: 1.68±0.6 in
single and 2.65±1.02 in co-culture (p<0.05). In cell cultures from seven days BDL rats relative urea formation was 1.58±1.43 in single and 2.63±1.32 in co-culture. With the addition
of IL-3 values were 2.39±0.51 in single and 3.16±0.81 in co-culture (p=n.s.). Co-culture
induced stronger ureagenesis under all culture conditions examined.
Conclusions: Addition of IL-3 to the cultures of adult liver progenitor cells from normal animals induced augmented hepatocyte specific metabolic capacity. Our data indicate a
broader biological spectrum for the haematopoietic growth factor IL-3 than previously
recognized. Co-culturing ADULIS with hepatocytes increased ureagenesis in all paired culture experiments. As there is no direct cell contact between hepatocytes and ADULIS, paracrine soluble factors must be involved. These factors should be isolated and might be used
to support the failing liver in vivopotentially by activation of the ADULIS pool in the bone marrow and the liver.
21
21.01
R. Tavakoli 1, M. Genoni 1, K. Graves 1, M. Wilhelm 1, C. Hofer 2, M. Turina 1
1
Cardiac Surgery Triemli Hospital, 2Anesthesiology Triemli Hospital
Superior flow pattern of internal thoracic artery over saphenous vein grafts during OPCAB
procedures
Background: The internal thoracic artery (ITA) is established as the conduit of choice for
revascularization of the LAD. However, the advantages of its use over that of the saphenous
vein (SV) for revascularization of the RCX or RCA are still debated.
Methods: From 11/01 to 08/03 intraoperative flow measurements were carried out in 462
consecutive patients (Euroscore 5.1) undergoing OPCAB (92% of isolated CABG during the
same period, 3.7±1.0 distal anastomoses/patient). RCX was grafted in 380 patients[176
ITA(46%), 204 SV] and RCA in 392 patients [55 ITA(14%), 337SV].
Results: Mean pulsatile index (PI) was significantly better for the single ITA/RCx grafts
(2.8±1.9;n=138) than for the single SV/RCx grafts (3.3±1.7, n=65;p=0.05). Mean flow did
not differ (28±22 and 31±25 ml/min;p=0.3). Accordingly, the PI was significantly better for
the single ITA/RCA grafts (2.2±1.2;n=55) than for the single SV/RCA grafts (3.4±2.6,
n=268;p=0.0001). The flow did not differ (30±16 and 32±22 ml/min;p=0.9). Early mortality and incidence of perioperative myocardial infarction were 1.5% (7/462) and 3.5%
(16/462) for the whole patients. The incidence of perioperative myocardial infarction tended to be lower in patients receiving an ITA to either the RCx or the RCA than in those receiving a SV [3/138 of ITA/RCx(2.2%) vs. 3/65 of SV/RCx (4.6%), 2/55 of ITA/RCA (3.6%) vs.
13/268 of SV/RCA (4.9%)] but Troponin release on the 1. postoperative day was significantly higher in patients with SV compared to those with ITA to either territories. Furthermore
the need for red blood cell transfusion was significantly lower in patients receiving an ITA
rather than a SV to both target vessels.
Conclusion: Matching better coronaries’ diameter, the ITA provides superior flow properties
than the SV to the RCx and RCA regions with reduced release of biological marker of myocardial ischemia. Whether this advantage persists after adjusting for the grade of the proximal coronary stenosis needs further studies.
21.02
M. Genoni 1, M. Wilhelm 1, R. Tavakoli 1, C. Hofer 2, S. Costabile 1, H. Löblein 1, M. Turina 1
Cardiac Surgery Triemli Hospital, Zurich, 2Anesthesiology Triemli Hospital, Zurich
1
Conversion of off-pump surgery to extracorporeal circulation:
the importance of the LAD bypass in patients with severe coronary artery pathology
Introduction: Off-pump bypass surgery (OPCAB) has been proven to be feasible in more
than 90% of patients requiring bypass surgery. In some cases, however, conversion to
extracoporeal circulation (ECC) is necessary due to hemodynamic instability. The purpose
of this study was to characterize such patients.
Patients and methods: From January to December 2003, 245 patients underwent OPCAB.
Preoperative characteristics and intra- and postoperative course of patients requiring conversion to ECC were analyzed.
Results: In 7 (6 male, 1 female, 67.7±6.0 years, EF 46.7±12.9) out of 245 patients (2.9%)
ECC was necessary. In those patients, Euroscore (6.5) tended to higher than in the whole
group (5.6). More patients (43%) underwent emergeny operation than in the total cohort
(7%) (p<0.05), all having instabil angina (total cohort: 35%; p<0.05). Two of the emergency patients received an intraaortic balloon pump before surgery, one intraoperatively. Four
patients (57%) showed a significant main stem stenosis (total cohort: 35%; p<0.05), three
patients (43%) a filiform LAD stenosis together with RCA occlusion. The time point of hemodynamic instability which required conversion to ECC was in 5 patients (71%) mobilization
of the heart for perfomance of the LAD anastomosis, and in 2 patients (29%) mobilization
for anastomoses to the criculflex artery. All patients received a left internal mammary artery (IMA) bypass to the LAD. One patient was completely revascularized with arteries (left
IMA jump plus right IMA), the remaining six received 2 to 4 venous bypasses (distal anastomoses: 3.6±0.7). One patient (14%) died from acute circulatory failure on the first postoperative day, and one patients (14%) exhibited perioperative ischemia. Length of intensive
care therapy was 1.7±0.7 days, length of hospital stay 7.1±3.1 days.
Discussion: Conversion to ECC as rescue-therapy in OPCAB is required only in a small number of OPCAB patients. They are characterized by a high percentage of emergency operations and most severe coronary artery pathology. In such patients, performance of LAD anastomosis is particularly cirtical and seems to determine the need for ECC.
21.03
A. Weber, R. Tavakoli, M. Genoni, S. Aydin, B. Seifert, M. Turina
Department for Cardiovascular Surgery, University Hospital, Zurich, Switzerland
Predictors of early and late outcome after reoperative coronary artery revascularization
Objectives: Reoperative coronary bypass surgery (redo-CABG) has been associated with
less favorable outcome compared to primary CABG. We investigated the factors affecting
early and late outcome after redo CABG.
Methods: From 01/1990 to 12/1999, 158 patients underwent redo CABG (2.8% of total iso-
lated CABG), with a mean age of 63±8 years (vs. 51±8 years at primary-CABG). The mean
interval between primary and redo-CABG was 140 months (range 19-259 months). Mean
follow up time was 47.6 months.
Results: Early mortality (EM) after redo-CABG was 8.9%. Interestingly, the presence of 3-vessel disease (p< 0.01) and an incomplete revascularization (p<0.01) at the primary operation were risk factors for early mortality after the redo CABG. Anginal class 3 or 4 (p<0.05),
emergency redo operation (p< 0.05), the need for intraoperative IABP (p<0.01) and duration of CPB (p<0.01) at reoperation were also risk factors for early mortality after redo
CABG.Estimated survival rates for hospital survivors after 1, 5 and 10 years were 98.5%,
79% and 64%. Peripheral arterial vascular disease (p<0.05) and renal insufficiency
(p<0.05) were risk factors for late mortality. Revascularization of the LAD at redo CABG was
a strong predictor of improved survival (p<0.01). The use of the internal thoracic artery at
redo CABG improved the late survival (p=0.05).
Conclusion: Although redo CABG carries a higher mortality than the primary coronary
bypass surgery, revascularization of the LAD and the use of arterial grafts at the time of
redo-CABG improve substantially the late outcome in these patients.
21.04
L. Furrer 1, C. Hofer 1, R. Tavakoli 2, K. Graves 2, M. Turina 2, A. Zollinger 1, M. Genoni 2
Anesthesiology Triemli Hospital, 2Cardiac Surgery Triemli Hospital
1
Prediction of mortality and prolonged intensive care unit stay after off-pump coronary artery
bypass grafting
Background and Goal of Study: Prolonged intensive care unit (ICU) stay contributes to
increased cost and resource utilization in cardiac surgery1;2. The aim of this study was to
evaluate prediction of outcome, i.e. 30d mortality, and postoperative duration of ICU stay in
patients undergoing off-pump coronary artery bypass grafting (OPCABG) using the
European System of Cardiac Operative Risk Evaluation (EuroSCORE)3.
Material and Methods: From Jan 1st, 2001 to Dec 31th, 2002 398 patients underwent
OPCABG in our institution (78% of all isolated CABG procedures performed during this
period). Patients were scored using the simple additive EuroSCORE. 30-day mortality and
duration of ICU stay were recorded. The discriminative power of the score was assessed by
calculating the area under the receiver operating characteristic curve (ROC). P<0.05 was
considered significant.
Results: EuroSCORE was 4.6±3.6 for these patients (age= 64.3±9.7 years, female/male
ratio=89/309, ejection fraction=58.1±15.3%). The preoperative risk profile was equally distributed (low risk [EuroSCORE 0-2]=0.4%, medium risk [EuroSCORE 3-5]=33.4% and high
risk group [EuroSCORE >6]=6.2%). Predicted 30-day mortality was 5.3%, observed 30-day
mortality was 1.5% (6 death during follow-up period). ROC for EuroSCORE to predict mortality was 66% (p=0.17; i.e. no significant difference from 0-hypothesis: ROC area = 50%).
Duration of ICU stay was 1.7±1.4 d. ICU stay and EuroSCORE correlated positively (Pearson
correlation coefficient [r]=0.48, p<0.001). ROC to predict ICU stay >1 d was 66.3%
(p<0.001). For ICU stay >2 d ROC was 74.8% (p<0.001), for >3 d, >4 d and >5 d 80.2%,
90.4%, and 91.7% (p<0.01).
Conclusion: The power of EuroSCORE to predict mortality in this sample of patients undergoing OPCABG was weak. By contrast, discriminative power to predict prolonged postoperative ICU stay was good. Use of the score might allow for more efficient allocation and thus
for cost reduction.
21.05
F. Bernet 1, I. Michaux 2, M. Filipovic 2, HR. Zerkowski 1, M. Seeberger 2
Division of Cardio-Thoracic Surgery, University Hospital Basel, 2Department of Anesthesia
1
Impact of surgical technique on right ventricular function: comparison of on-pump versus offpump coronary revascularization; an echocardiographic study
Background: The vulnerability of the right ventricle during cardiopulmonary bypass (CPB), as
well as the potential occurrence of pulmonary hypertension after CPB are well known. The
purpose of our study was to compare right ventricular (RV) function after myocardial revascularization with and without CPB using echocardiographic indexes of RV performance.
Method: 41 patients scheduled for elective coronary artery bypass surgery were randomized to either on-pump (n=21) or off-pump (n=20) surgery. Transthoracic echocardiographic examinations were performed on the evening before (baseline), 7 days, and 3 months
after surgery. We investigated the RV function using the velocity of the movement of the tricuspid lateral annulus measured by tissue Doppler imaging (TDI). TDI measurements of the
tricuspid annular velocity indicate systolic function by the systolic wave (Sm), and diastolic
function by the early wave (Em). Anesthetic management and surgical procedures were
performed in a standardized way. Cardioplegic arrest was induced in the CPB group with
intermittent antegrade cold blood cardioplegia. In the off-pump coronary artery bypass
group the Octopus (Medtronic) device was used.
Results: Both groups were similar in their preoperative demographic characteristics. The
intergroup comparison showed no difference between the two surgical groups for Sm and
Em parameters of the RV function (Mann-Whitney U- test). The intragroup comparisons
showed that Sm was significantly reduced 7 days and 3 months after surgery in both
groups; Em was significantly reduced 7 days after surgery in both group. Three months
after surgery, Em remained significantly reduced in the on-pump group but the reduction
was no longer significant in the off-pump group (Wilcoxon signed-ranks test).
Conclusions: Our results suggest that the systolic RV function, as indicated by TDI-Sm, is
similarly impaired in both groups after 7 days and remained impaired 3 months after sur-
swiss knife 2004; special edition
47
gery. Diastolic function, as indicated by Em, is similarly impaired 7 days after surgery in
both groups, and remained impaired 3 months later in the on-pump group. Whereas the
diastolic function in the off-pump group shows a trend towards the baseline value.
21.06
sion determined. The bovine mammarial artery was occluded. The evaluation of 1 radial
artery graft was not conclusive due to limited visualisation.
Conclusion: 16-sliced CT scan is an excellent non-invasive imaging diagnostic method for
early assessment of graft patency after CABG. It has therefore the potential to initiate an
early re-intervention in patients with perioperative myocardial infarction after CABG.
A. Weber, O. Reuthebuch, A. Kuenzli, M. Lachat, M. Turina
Department of Cardiovascular-Surgery, University Hospital, Zurich, Switzerland
Guidant heartstring: initial experience in OPCAB surgery
Purpose: The aim of this study was to evaluate the feasibility of the HEARTSTRING hemostatic seal system for proximal anastomoses in OPCAB surgery without the need of aortic side
clamping.
Material and Methods: Between May-November 2003, 50 proximal bypass anastomoses
were performed with the HEARTSTRING device in 29 consecutive patients (21 man;8
women) with calcified aorta (assessed by transesophageal echocardiography/digital palpation). Mean age was 68+/-7years. A mean of 1.7 anastomoses per patient was performed. Bypass patency was assessed by intraoperative flow measurements. Neurological
outcome was graded in 4 severities.
Results: Learning curve was completed after deployment of approximate 10 devices. Crack
of the seal occurred in 8 cases prior to deployment. No conversion to conventional side
clamping was needed. No stitching of the seal or wrapping of the suture around the seal
stem was adverted. Slight diffuse bleeding occurred with arterial pressure under 65mmHg.
Bypass-graft flow was 53.7+/- 23.9 l/min. No perioperative ischemic events occurred,
aswell as no postoperative neurological complications.
Conclusions: Proximal bypass aortic anastomoses can be performed safely without side
clamping using the HEARTSTRING hemostatic seal system. Anastomoses can be performed without remaining foreign material.
21.07
O. Scholz, F. Bernet, A. Todorov, HR. Zerkowski
Division of Cardio-Thoracic Surgery, University Hospital Basel
Impact of female gender on early outcome in OPCAB surgery
Background: The female gender is an independent predictor of adverse outcome after conventional coronary artery bypass surgery using cardiopulmonary bypass. The aim of this
study was to determine wether this gender difference would be applicable in off-pump coronary artery bypass surgery (OPCAB).
Methods: We compared retrospectively outcomes among 225 consecutive patients undergoing OPCAB over a 36-month period, operated by the same surgeon. The study included
49 women and 176 men, representing 16% of all isolated CABG procedures (1389) during
this period. Adverse outcomes were divided into minor (MIN) and major (MAJ) adverse outcomes. MIN included postoperative bleeding, atrial fibrillation, respiratory complication without prolonged ventilation and superficial wound infection. MAJ included myocardial
infarction, stroke, renal failure, prolonged ventilation,, mediastinitis and mortality within 30
days. Preoperative and intraoperative variables were evaluated as predictors of MIN and
MAJ by univariate and multivariate analyses.
Results: We have seen no gender differences concerning age and preoperative risk profile
(body mass index, diabetes, hypertension, peripheral vascular disease, renal failure, cerebrovascular disease, myocardial infarction and ejection fraction). 60% of both gender had
a 3 vessel diseases with a mean graft number of 2.97 in women and 2.79 in men (NS). Inhospital complications were as follow: atrial fibrillation 6.12% in women, 15.90% in men
(p=0.029), major bleeding 2.04% in women, 0.56% in men (p=0.49), pneumonia 0% in
women, 2.27% in men (p=0.045), myocardial infarction 0% in women, 1.13% in men
(p=0.45), stroke 0% in women, 0.56% in men (p=0.59). Overall mortality was 1.3% (3 of
225). In-hospital deaths was 0% in women and 1.70% in men (p=0.083). Prolonged ventilation, mediastinitis or acute renal failure was not noted in either group.
Conclusions: In our series OPCAB surgery, female gender up to now is not an independent
predictor of MIN and MAJ. In contrary, we suggest that in highly selected female patients
OPCAB surgery might have a beneficial effect on early outcome. Further evaluation with a
higher number of patients is mandatory to support this suggestion.
21.08
V. Goeber 1, HP. Dinkel 2, J. Gralla 2, F. Eckstein 1, M. Stalder 1, T. Carrel 1
1
Klinik für Herz,-Gefässchirurgie, Inselspital Bern, 2Klinik für Radiologie, Inselspital Bern
Evaluation of early graft-patency with multislice spiral computed tomography after CABG
Background: Early Evaluation of graft-patency after CABG can be important especially in
patients showing signs of perioperative myocardial infarction. At present there is no non-invasive imaging diagnostic method established. The Multislice Spiral Computed Tomography
(MSCT) is getting more and more an alternative solution towards the coronary angiography.
Methods: We evaluated in an ongoing feasibility study 7 patients (all male; mean age 64
years; all isolated 3-5fold CABG) within 3 to 8 days after CABG with 16-sliced MSCT scans
(Siemens Somatom Sensation 16; duration of rotation 0.37 sec). Scans were ECG-triggered, 3D reconstructed and evaluated by a radiologist.
Results: In all patients we were able to visualise all natural coronary arteries, all in all 6
venous grafts, 9 grafts with mammarial arteries, 5 grafts with radial arteries, 4 jump grafts
and 1 graft with bovine mammarial artery. There was no human graft or native artery occlu-
48
swiss knife 2004; special edition
24
24.01
CT. Viehl 1, DM. Frey 1, Y. Tanaka 1, UK. Liyanage 1, DC. Linehan 1, TJ. Eberlein 1,
PS. Goedegebuure 1
1
Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA,
2
Department of Surgery, Divisions of General Surgery and Surgical Research,
University of Basel
Tat-Her2/neu transduced DC induce a specific immune response and a reduction of tumor
growth in breast cancer bearing mice
Introduction: Dendritic cells (DC) transduced with full length proteins efficiently stimulate
antigen-specific CD8 T cells. We recently reported on the generation of a fusion protein between the protein transduction domain of the HI virus (Tat) and the extracellular domain of
Her2/neu. DC transduced with Tat-neu (DC/Tat-neu) induced CD8 T cells to specifically
recognize Her2/neu-expressing tumor cells in vitro. In this study we evaluated the in vivo
effect of DC/Tat-neu in a murine breast cancer model.
Methods: FVB/N mice received one or two weekly intraperitoneal (i.p.) immunizations with
DC/Tat-neu, one i.p. injection of DC/irrelevant Tat-fusion protein (DC/Tat-empty), or no DC
followed by a subcutaneous tumor challenge with syngeneic, neu+ breast cancer cells NT
5. Mice were monitored twice weekly for tumor development They were sacrificed after 69
days and resulting tumor volumes were measured. To test for tumor specific CD8+ T cells,
similarly treated mice were sacrificed two weeks after tumor challenge. CD8+ cells from
spleen and tumor draining lymph nodes (TDLN) were isolated through magnetic beads
separation and tested in an IFNgamma ELISPOT against NT5 and irrelevant tumor lines.
Results: Immunized mice developed palpable tumors significantly later than mice injected
with DC/Tat-empty (p=0.001 for two, and p=0.02 for one immunization, respectively), or
receiving no DC (p=0.002 and p=0.02, respectively). Similarly, immunized mice showed
smaller resulting tumors than mice injected with DC/Tat-empty (p=0.04 and p=0.01,
respectively) or untreated mice (p<0.001 and p<0.001, respectively). Twice immunized
mice harbor neu-specific CD8+ cells in spleen and TDLN that recognize the neu+ NT5 significantly better than neu- or haplotype mismatched tumor lines (p<0.001). Additionally, significantly more tumor specific CD8+ splenocytes were found in twice immunized mice than
in untreated animals (p<0.001).
Conclusions: These data suggest that protein transduced DC may be effective vaccines for
treatment of cancer.
Average tumor volume
(±SEM) (mm3)
2x DC/Tat-neu
1x DC/Tat-neu
1xDC/Tat-empty
No DC
84.6 (±12.9)
79.6 (±6.6)
128.3 (±14.0)
165.1 (±11.8)
24.02
SA. Vorburger 1, JN. Vauthey 2, G. Krummrey 1, JC. Soria 3, B. Fang 2, D. Candinas 1,
KK. Hunt 2
1
University of Berne, Inselspital, Berne, Switzerland,2 UT M.D. Anderson Cancer Center,
Houston, Tx, USA, 3Gustave Roussy Institute, Villejuif, Paris, France
E2F-1 interaction with human telomerase reverse transcriptase (HTERT) expression predicts
survival after colorectal liver metastases resection
Introduction: 80% to 95% of cancer cells show activation of telomerase, which is critically
regulated by human reverse telomerase transcriptase (hTERT). Several investigators have
shown that telomerase activity may be useful in predicting the behavior of gastrointestinal
cancers. Recently, it has been found, that the overexpression of the transcription factor E2F-1
downregulates hTERT activity in vitro. Because conflicting data exist on whether E2F-1 overexpression in tumor cells is a positive or negative prognostic factor, we evaluated the potential of
E2F-1 to counteract hTERT activation in the nature of metastatic colorectal disease.
Methods+Results: Reporter assays with cells either co-transfected with adenoviral vectors
expressing E2F-1 (AdE2F) and hTERT (AdhTERT) or with stable transfectants showed
hTERT-promoter downregulation by E2F-1. Western blot analysis of AdE2F transfected cancer- and normal cells confirmed the downregulation of constitutive hTERT activity.
Conversely, downregulation of E2F-1 by siRNA induced hTERT overexpression.
Immunohistochemical analysis (IHC) of LS174T xenograft flank tumors in nude mice
showed E2F-1 overexpression, hTERT downregulation and prolonged survival after intratumoral AdE2F application. In a case-cohort study paraffin-embedded tissue slides from 70
patients with completely resected colorectal liver metastases were analysed for E2F-1 and
hTERT expression by IHC. hTERT expression correlated with a poor 5 year survival
(P=0.001(Fisher’s exact); OR=0.14 [95% CI 0.05-0.52]), whereas, E2F-1 expression was
significantly associated with better survival (P=0.045; OR=4.7 [95% CI 1.23-16.4]). C2–
analysis of patient groups that survived <2 years (n=26), 2-5 years (n=24), >5 years
(n=20) identified the ratio of hTERT- to E2F-1 -expression as significant prognostic factor
(P<0.002).
Summary: In this study, we confirmed the potential of E2F-1 to suppress hTERT expression in
cancer cells and we showed its prognostic value for patients with resected liver metastases. To
our knowledge this is the first report that showed the downregulation of hTERT promoter activity in tumors by E2F-1 in vivo and that proved the clinical relevance of this interaction.
24.03
PO. Berberat 1, Z. Damrauskas 1, T. Giese 2, N. Giese 1, S. Meuer 2, MW. Büchler 1, H. Friess 1
1
Chirurgie I, Universitätsklinikum Heidelberg, 2Institut für Immunologie und Serologie, Universitätsklinikum Heidelberg
Heme Oxygenase-1 (HO-1) inhibition sensitize pancreatic cancer to adjuvant treatment
Pancreatic cancer shows very poor survival rates mainly due its aggressive growth behavior and its exceptional resistance to all forms of adjuvant treatment. The so-called protective gene heme oxygenase-1 (HO-1), which plays a key role in the defense against all kind of
cellular stress, is highly expressed in different human cancers. In several experimental solid
tumor models the inhibition of HO-1 activity decreased tumor growth, by induction of apoptosis and/or inhibition of angiogenesis, and prevented the occurrence of metastasis.In this
study we demonstrate that the cell specific down-regulation of HO-1 expression and activity sensitize pancreatic cancer cells to adjuvant treatment options.
Methods: The expression of HO-1 was analyzed in human pancreatic cancer samples in
comparison to normal pancreas by quantitative PCR, Western blot and confocal microcopy. Influence of radio- and chemotherapy on HO-1 expression in pancreatic cancer cell lines
was evaluated. Finally, HO-1 expression was specifically suppressed by siRNA transfection.
Alterations of growth behavior and resistance to adjuvant treatment were tested.
Results: Human pancreatic cancer showed significant over-expression of HO-1 in comparison to normal pancreas on mRNA and protein level. The cancer tissue revealed markedimmunostaining in tumor cells and in some tumor associated macrophages. Pancreatic cancer cell lines demonstrated divergent expression levels, from high to not detectable.
Treatment of the pancreatic cell lines with Gemcitabine or radiation strongly induced HO-1
expression. Targeted knockdown of this HO-1 expression led to pronounced growth inhibition of the pancreatic cancer cells and made tumor cells significantly more sensitive to
radio- and chemotherapy.
Conclusion: HO-1 seems to provide a growth advantage to pancreatic cancer cells and to
make them resistant against radio- and chemotherapy. Specific inhibition of HO-1 sensitizes
the tumor cells to adjuvant treatment and may therefore be a new valuable agent in the therapy of pancreatic cancer.
24.04
M. Adamina1, M. Bolli 2, P. Zajac1, WR. Marti 2, D. Oertli 2, GC. Spagnoli 1, M. Heberer 1
Institut für Chirurgische Forschung & Spitalmanagement, Kantonsspital Basel,
2
Allgemeinchirurgische Klinik, Kantonsspital Basel
1
Humoral & cellular immune responses in stage III - IV melanoma patients:
implications for immunotherapy
Aim: To assess humoral and cytotoxic T lymphocyte responsiveness in melanoma patients
undergoing active specific immunotherapy trials.
Methods: 24 stage III (n=5) and stage IV (n=19) melanoma patients were admitted to
immunization trials with a recombinant vaccinia virus encoding 3 tumor associated epitopes (TAA: gp100280-288, Mart-127-35 and tyrosinase1-9) and CD80/CD86 costimulatory molecules (rVV). Booster immunizations were performed with the same TAA epitopes.
Immunogens were administered i.d. in a first trial (trial I, patients 1-17) and intranodally in
a second, ongoing trial (trial II, patients 1-7). Frequencies of CTL precursor (CTLp) specific
for TAA or influenza matrix 58-66 (IM) control epitope were evaluated by limiting dilution
analysis prior and after immunization. Humoral response against rVV vector was measured by ELISA prior and after vaccination.
Results: Depending on specific responses to immunization (CTLp > 2fold pre-treatment)
patients were ranked as good responders (responsive to 3 or 2 epitopes) or poor responders (unresponsive or responsive to 1 epitope only). All stage III patients in both trials
showed CTL responses against all 3 epitopes. In contrast (p<0.05), 7/13 stage IV patients
were poor responders. 6/13 stage IV patients were good responders, one showing a complete, long lasting clinical response despite a high metastatic burden. Remarkably, CTLp
specific for IM in stage IV melanoma patients were significantly lower than that detectable
in healthy donors. rVV specific humoral response was increased (OD >50% of pre-treatment) in all stage III patients, but only in 6/13 stage IV patients (p<0.05). A significant correlation (p<0.05) emerged between low rVV specific humoral response (OD <50% of pretreatment) and poor CTL responses.
Conclusions: Immunocompromission in stage IV melanoma patients might hamper the
induction of tumor specific CTL responses. Conversely, induction of rVV specific humoral
responses does not prevent the generation of CTL specific for TAA. These data suggest that
stage III melanoma patients and immunocompetent stage IV patients are more likely to
respond to tumor specific immunotherapy.
24.05
M. Bolli, M. Adamina, E. Schultz-Thater, U. Guller, D. Oertli, GC. Spagnoli, M. Heberer
Institut für Chirurgische Forschung und Spitalmanagement, Kantonsspital Basel
NY-ESO-1/LAGE-1 tumor associated antigen expression in clinical samples:
a tissue microarray study
Background: Cancer testis tumor associated antigens (C/T TAA) expressed in tumors of different histological origin and in healthy testis represent potential targets for active specific
immunotherapy. NY-ESO-1 is able to induce both cellular and humoral immune responses.
Monoclonal antibodies (mAb) have been used to detect this antigen in small series of clinical tumor samples. Here we used tissue microarray (TMA) technology to assess NY-ESO-1
expression at the protein level on a panel of over 2.000 tumors, by taking advantage of a
mAb whose specificity was unambiguously established by epitope mapping.
Methods: D8.38 mAb was generated by using, as immunogen recombinant NY-ESO-1. Its
target epitope sequence was identified by random peptide library analysis. A TMA including
121 samples from 27 healthy tissues and 2052 tumor specimens from 100 different histologies was stained with D8.38 mAb. Samples were considered positive when at least 20%
of the tumor cells displayed moderate or strong specific staining.
Results: D8.38 mAb recognizes the aminoacid sequence encompassed by residues 26-40
in NY-ESO-1 TAA and shared by its alternatively spliced homolog LAGE-1. Four of five healthy testis tissues (positive controls) were stained by D8.38 whereas all other healthy tissues were negative. Concerning tumors, relatively high positivity frequencies were detected in
melanoma (12/38: 31.6%), large cell carcinomas of the lung (8/45: 17.8%), advanced
(pT2-4) stage bladder TCC (6/33: 18.2%), basalioma (6/33: 18.2%), fibrosarcoma (5/9:
55%) and rhabdomyosarcoma (2/9: 22%). In the last three tumor types NY-ESO-1/LAGE-1
expression was also found to be significantly associated with concomitant expression of
MAGE family TAA, as detected by 57B mAb.
Conclusions: These data derived from a large series of specimens confirm the high tumor
specificity of NY-ESO-1/LAGE-1 expression and support the use of this C/T TAA in active
specific immunotherapy of tumors of diverse histological origin.
24.06
P. Gervaz 2, D. Hahnloser 1, B. Wolff 1, S. Thibodeau1
1
Mayo Clinic Rochester, 2University Hospital Geneva
Molecular biology of squamous cell carcinoma of the anus:
a comparison of HIV positive and HIV negative patients
Aim: The molecular mechanisms involved in progression of squamous cell carcinoma of
the anus (SCCA) are poorly elucidated, as well as the potential role of HIV infection. Loss of
heterozygosity (LOH) is one of the mechanisms responsible for inactivation of tumor suppressor genes (TSG). We hypothesized that HIV-induced immunosuppression may contribute to an alternate molecular pathway in SCCA progression. This study was undertaken to
compare the molecular biology of SCCA in HIV positive and HIV negative patients.
Methods: We retrieved tumor specimen from 18 HIV negative and 10 HIV positive patients,
diagnosed with SCCA in two institutions. DNA from tumor and normal tissues was extracted, and then amplified by PCR. LOH patterns were investigated with 14 primers at 6 loci:
18q (DCC); 13q (Rb); 17p (p53); 11q; 2q; and 5q (APC). LOH was defined by a tumor
DNA/normal tissue DNA >2.
Results: HIV positive patients were younger (36± 7 Vs. 53± 13 years, p=0.001) and showed a trend towards tumors of larger size (3.7±1.6 Vs. 2.6±1.5 cm, p=0.09). A total of 46
allelic losses were observed in the whole group. LOH were the most frequent on chromosome 11q (13 out of 28 patients [46%]). When considering all loci, tumors in HIV negative
patients were more likely to present with LOH than tumors in HIV positive patients (38
LOH/108 loci [35.2%] vs. 8 LOH/60 loci [13.3%], p=0.002). Differences between the two
groups with regard to allelic losses were also observed at specific loci, such as 18q (7/18
[HIV-] vs. 0/10 [HIV+], p=0.03) and 17p (8/18 [HIV-] vs. 1/10 [HIV+], p=0.09).
Conclusion: Consistent LOH on chromosomes 17p, 18q and 11q were observed in HIV
negative patients with SCCA. By contrast, allelic losses at 17p and 18q seem to be rare in
tumors of HIV positive individuals. These data suggest that immunosuppression may promote SCCA progression through an alternate pathway, and that persistence of human
papillomavirus within the anal canal may play a central role in this process.
24.07
PF. Stahel, OI. Schmidt, CE. Heyde, W. Ertel
Dept. of Trauma and Reconstructive Surgery, Charité, Campus Benjamin Franklin, Berlin
TNF-mediated regulation of intracranial IL-18 in traumatic brain injury:
a clinical and experimental study
Interleukin-18 (IL-18) and tumor necrosis factor (TNF) are potent mediators of intracerebral
inflammation following traumatic brain injury. Regulation of IL-18 expression in the intracranial compartment through TNF has not yet been evaluated. We examined the posttraumatic release of IL-18 and TNF in cerebrospinal fluid of 10 patients following severe traumatic
brain injury. Using an experimental model of intracranial TNF injection in C57BL/6 mice,
the effects of TNF on IL-18 expression were investigated. In addition, IL-18 concentrations
were assessed in brains of wild-type C57BL/6 and TNF/lymphotoxin(LT)-a-/- mice in a
model of closed head injury for up to 7 days after trauma. Significant inverse correlation for
IL-18 and TNF levels were found in patients following traumatic brain injury (r= –0.6 to –0.8,
swiss knife 2004; special edition
49
P<0.05). In the experimental setting, increased IL-18 concentrations were detected in brain
homogenates of mice injected PBS (vehicle) only, while the intracerebral injection of 200 ng
mouse-recombinant TNF blocked IL-18 increase significantly within 24h. Both groups subjected to experimental brain injury showed significant increase of IL-18 concentrations,
however no significant differences between wild-type and TNF/LT-a-/- mice were found.
However, the gene knockout mice had significantly increased mortality within 24h and 7
days after trauma, compared to wild-type littermates. Based on the proposed „dual“ role of
TNF as pro- and anti-inflammatory mediator in neuroinflammation, we suggest that the TNFmediated inhibition of intracranial IL-18 expression may represent a so far unknown antiinflammatory mechanism after traumatic brain injury.
24.08
L. Mica, L. Härter, O. Trentz, M. Keel
Division of Trauma Surgery, University Hospital of Zurich
Regulation of neutrophil apoptosis in patients with sepsis by STAT-3
The reduction of spontaneous Apoptosis in neutrophil granulocytes (PMN) after severe
Trauma contributes to the pathogenesis of SIRS and sepsis. Endotoxins lead to activation of
transcriptionfactors like NF-?B and STAT-3. This study investigates the involvement of STAT3 in the regulation of PMN apoptosis in patients with sepsis.
PMN from patients with sepsis (n=7) and healthy controls (n=7) (1x106/mL) were stimulated 16 hours with LPS (1?g/mL). STAT-3 was inhibited by preincubation with Curcumin
(20?M). Apoptosis was measured in flow cytometry (FACS) after FITC-Annexin and propidiumiodide staining. Expression of STAT-3 mRNA was measured in RT-PCR and protein in
westernblot.
Inhibition of STAT-3 abolished the LPS-induced survival in PMN from patients with sepsis
(23.5 ± 2.6 to 47.7 ± 4.7) and from healthy controls (22.7 ± 2.9 to 55 ± 1.0). Expression
of STAT-3 mRNA was found in control PMN, but not in patients with sepsis. STAT-3 protein
was reduced in cells
25
25.02
JM. Gauer 1, P. Soyka 1, J. Meinhart 2, R. Flury 3, W. Schweizer 1
Kantonsspital Schaffhausen, Abteilung Chirurgie, Institut für angewandte cardiovasculäre
Biologie, 2Krankenhaus der Stadt Wien-Lainz, Austria, 3Dept. of Pathology, Kantonsspital
Winterthur, Switzerland
1
Peripheral vascular bypass operation using autologous endothelialized PTFE-prosthesis
Introduction: In the absence of suitable veins the peripheral bypassoperation using PTFE
prosthesis remains problematic due to poor patency rates. 1999 Zilla, Deutsch, Meinhart et
al. reported a patency-rate of 68% in 86 peripheral autologous endothelialized expanded
PTFE-reconstructions after 5 years. In spite of the intricate logistics we decided to start using
this method in patients requiring peripheral vascular reconstruction without suitable
venous graft material.
Methods: A piece of cepahlic vein is harvested and sent to the laboratory in Vienna under
clima-controled conditions (800 km). 3 to 4 weeks later the endothelialized Goretex Graft is
sent back. The bypass-operation is performed in standard technique, the graft is constantely filled with the nourishing medium. A piece of prosthesis is histologically examined, furthermore immunohistochemically the expression of CD 31 proves the viability of the endothelial layer. After operation patients receive platelet inhibitors and are checked for patency
with duplex-ultrasound after 3, 6 and 12 months.
Results In the first patient the procedure could not be performed since the endothelial cells
did not survive the December climate due to failure of the clima-container; the second
patient had too high levels of serum cholesterol and glucose which resulted in poor growht
of the endothelium.From the third patient onward (December 2001) logistics were established and since then we have sucessfully operated on 10 patients. In 6 cases a below knee
reconstruction was performed. In 8 patients the grafts are patent(6-26m).In 2 patients,
both with a below knee reconstruction, the graft occluded due to extremely poor run-of.
Conclusion Altough the logistics are intricate due to the distance between our insitution and
the laboratory, we believe that peripheral arterial reconstruction using autologous endothelialized ePTFE grafts is the methode of choice in the absence of suitable venous material.
The results are as good as in autologous vein reconstruction. Due to the strict selection of
suitable candidates the number of patients is stil low. We hope to report in the near future
about more cases.
25.01
25.03
BH. Walpoth 1, L. Karrer 1, E. Khabiri 1, M. Cikirikcioglu1, JC. Pache1, A. Kalangos 1, GL. Bowlin 2
1
Dept. of Cardiovascular Surgery, Geneva University Hospital, Switzerland,
2
Biomedical Engineering, Virginia Commonwealth University, Richmond, USA
1
Vascular tissue engineering using synthetic biodegradable scaffolds
Objective Small synthetic grafts are associated with high occlusion rates. New biodegradable materials may help to overcome this problem. Different vascular grafts materials were
evaluated as a biodegradable scaffold for tissue engineering.
Methods Four different biodegradable materials were made by electro-spinning: Poly(glycolic acid) (PGA) (0.14 g/ml); Poly(lactic acid) (PLA) (0.14 g/ml); copolymer of PGA and PLA,
PLGA (50:50); PGA + heparin (100 units/ml pre-spin solution). Grafts were first tested in an
arterio-venous femoro-femoral shunt in 5 domestic pigs. Grafts were perfused for 3 and 9
minutes and examined by scanning electron microscopy for semi-quantitative assessment
of thrombogenicity (score: 0 = best; 3 = worst). Secondly, pieces (1 cm length) of each graft
material were implanted sub-cutaneously in 16 Wistar rats (250g). At 2, 4, 8 and 12 weeks,
four animals were sacrificed for semi-quantitative (score: 0 = best; 3 = worst). histologic
evaluation of degradation rate, cellular in-growth and tissue reaction.
Results (mean ± 1SD; compiled for 2, 4, 8 and 12 weeks: *P< 0.05 vs. other materials)
Material
Thrombogenicity
Score Degradation rate Cellular ingrowth
Tissue reaction
PGA
PLA
PLGA
PGA+ heparin
1.6 ± 0.7
1.5 ± 0.9
1.7 ± 0.9
0.9 ± 0.6*
1.2 ± 1.0
2.0 ± 0.6*
1.7 ± 0.8*
1.0 ± 0.8
1.1 ± 1.0
0.6 ± 0.3*
0.7 ± 0.5*
1.1 ± 0.6
0.7 ± 0.9
2.0 ± 0.9*
0.7 ± 0.6
0.6 ± 0.7
PGA eluting heparin significantly improves blood thrombogenicity but has no influence on
degradation rate and tissue reaction in the subcutaneous rat implant model. Degradation
rate was high in most of the tested materials and increased over time. Degradation rate was
highest in PLA and lowest in PGA. Cellular in-growth was highest in PLA and lowest in PGA,
but tissue reaction was significantly lower in PLA.
Conclusions: Electro-spun biodegradable graft materials are promising with regard to
degradation rate and tissue reaction. PGA, especially with bound heparin, showed the best
results for thrombogenicity and degradation. This material may serve as a scaffold for vascular tissue engineering because of its optimal biocompatibility.
50
swiss knife 2004; special edition
B. Marty 1, LK. von Segesser 1, PG. Tozzi 1, P. Ruchat 3
CHUV Service de Chirurgie Cardiovasculaire, 3Service de Chirurgie Cardiovasculaire
Endoprosthesis and IVUS: the tools for straightforward repair of traumatic aortic rupture
Purpose: Open repair of thoracic aortic rupture is associated with a high rate of morbidity
and paraplegia in these polytraumatized patients. An endovascular approach showed to be
beneficial minimizing additional trauma load. Endoprosthetic treatment based on intravascular ultrasound (IVUS) for these lesions is presented.
Methods: Endovascular repair for traumatic aortic rupture was performed in 10 patients
(mean age 32+5). Target site identification, neck quality assessment and deployment control were performed by IVUS (Clearview, Boston Scientific Corp, USA), and an image intensifier (Siremobil compact, Siemens, GE). Enhanced computed tomographic scans and
plain X-rays were performed postoperatively and at follow-up (13+9 months)
Results: Visualization of the aortic lesion and device deployment at the target site were
achieved in 10/10 patients. Procedure time was 105+41 min and fluoroscopic time 5+2
min. There were no conversions. Mortality was 0 %, morbidity 10 % consisting of a brain
infarction. All aortic lesions were covered by the device, and follow-up confirmed complete
dissolution of the periaortic hematoma with stable device position.
Conclusions: Straightforward and effective treatment of traumatic aortic rupture is achieved by
IVUS. A unique advantage of IVUS is visualization of the entire aortic lesion during the procedure.
25.04
D. Mayer 1, T. Pfammatter 2, A. Künzli 1, M. Turina 1, M. Lachat 1
1
Cardiovascular Surgery, University Hospital of Zurich,
2
Department of Radiology, University Hospital of Zurich
Thoracic and abdominal aortic aneurysm repair – does EVAR add safety to
the combined repair?
Definition: To evaluate the safety of endovascular aneurysm repair (EVAR) in combined thoracic and abdominal aortic aneurysm repair.
Method: Retrospective analysis of a series of 29 EVAR patients who had a combined repair of
thoracic and abdominal aortic aneurysm between 1995 and 2004. 4 groups were identified:
group A (8 patients) with a combination of thoracic and abdominal EVAR, group B (13
patients) with a combination of thoracic EVAR and abdominal aortic graft replacement, group
C (4 patients) with a combination of abdominal EVAR and thoracic aortic graft replacement
and group D (4 patients) with multiple open surgical and/or endovascular aortic procedures.
Results: Overall 30 d mortality rate and overall 30 d neurologic complication rate was 10%
and 0%. In group A 1 patient died 20 d postoperative because of aspiration pneumonia, in
group B 2 patients died, one intraoperatively and one patient because of multi-organ failure 5 d postoperative. Subgroup analysis shows that pulmonary complications were lowest
in the combined thoracic and abdominal EVAR group (group A).
Long-term survival after a mean follow-up of 33.1 months (range: 1.2 – 66.0) was 73.9%
Conclusion: EVAR in combined thoracic and abdominal aortic aneurysm repair is a safe
procedure. Spinal cord ischemia was not observed despite repair of thoracic and abdominal aortic aneurysm.
25.05
V. Makaloski, J. Schmidli, G. Heller, A. Akert, E. Zingg, T. Carrel, H. Savolainen
Swiss Cardiovascular Centre
magna rekonstruiert. Die Vena femoralis wurde nur in zwei Fällen, beide jeweils mit e-PTFE
ersetzt. Postoperative Komplikationen waren in einem Fall eine grosse Lymphzyste und in
einem weiteren Fall eine ausgedehnte tiefe Wundinfektion. Die primäre Patency der
Arterienrekonstruktionen betrug nach 1-7 Jahren 100%. Die Patency des Ersatzes der
Venen war 0% ohne, dass damit weitere Folgen verbunden waren.
Konklusion: In Situationen, in denen der Gefässersatz schwierig ist, wie beispielsweise
nach einer Kompartimentausräumung oder nach einem ausgedehnten Debridement eines
schweren Gefässinfektes, empfehlen wir den extraanatomischen lateralen Gefässersatz
als elegante und sichere Methode.
Gluteal ischemia – serious complication after infrarenal aortic surgery?
Introduction: Because of the good collateral circulation of the pelvis, complications associated with occlusion of the internal iliac artery (IIA) are less common than those following
occlusion of the external iliac arteries. However, these uncommon complications can provoke devastating sequaelae after surgery of the infrarenal aorta such as gluteal ischemia
or necrosis.
Patients and method: Between 1998 and 2001, 218 consecutive elective infrarenal aortic
operations were performed at the University Hospital Berne. Of the 10 patients (4,6%, 8
men) who developed an early postoperative gluteal ischemia, six had abdominal aortic
aneurysm repair and four aorto-femoral bypass for aortic occlusive disease. Three
patients had aortic-bifemoral reconstruction and in seven an aorto-biiliac operation with
preservation of at least one IIA was performed.
Results: An ipsilateral ischemia was seen in 4 patients with an IIA ligated intraoperatively,
two of them ending with small unilateral buttock necrosis and 6 had bilateral buttock ischemia with one-side predominance. The median maximal elevation of creatine kinase was
11435 U/L. One patient required a repair of the proximal anastomosis, the nine
patients were treated conservatively with peridural analgesia, rehydration and specialised
soft beds. No patient needed plastic surgery reconstruction. The median stay in the ICU was
0.6±1.2 days, in the IMC-Unit 3.3±1.6 and average hospital stay was 19±8.2 days. There
was no in-hospital mortality and all patients were able to walk unassisted at discharge. At
three months all patients reported full recovery.
Conclusion: We conclude that gluteal ischemia after elective infrarenal aortic surgery is a
rare and unpleasant complication, which can primarily be treated conservatively. However,
the role of hypogastric revascularisation and the necessity of avoidance of postoperative
hypotension remain the gold standard for the prevention of pelvic malperfusion.
25.08
25.06
25.09
T. Eugster, T. Obeid, T. Wolff, L. Gürke, P. Stierli
Universitäres Gefässzentrum Aarau-Basel
H. Probst, N. Ducrey, M. Depairon, D. Hayoz, F. Saucy, JM. Corpataux
Centre Hospitalier Universitaire Vaudois
Die Revaskularisation beim diabetischen Fuss. Langzeitergebnisse >10 Jahre
Einleitung: Patienten mit Diabetes mellitus haben ein deutlich erhöhtes Risiko, eine peripher
arterielle Verschlusskrankheit zu entwickeln. Die Resultate der arteriellen Rekonstruktion
beim Diabetiker werden in der Literatur kontrovers diskutiert.
Methode: Wir haben unsere prospektiv erfassten Früh- und Langzeitergebnisse (1988 bis
12-2002) von autologen, infrainguinalen arteriellen Rekonstruktionen bei Diabetikern mit
denen von Nichtdiabetikern verglichen.
Resultate: Insgesamt wurden während der Beobachtungszeit 225 Venenbypässe bei
Diabetiker mit Fussläsionen und 190 Bypässe bei Patienten ohne Diabetes aber chronisch
kritischer Ischämie angelegt. Diabetiker und Nichtdiabetiker unterschieden sich nicht
bezüglich Geschlecht, Alter, Bypassart und Risikofaktoren. Die Offenraten waren für beide
Gruppen vergleichbar. Es bestand aber ein signifikanter Unterschied zu Ungunsten der
Patienten mit Diabetes bezüglich Beinerhalt. Diese Patienten benötigten signifikant mehr
grosse Amputationen (12.4% vs. 4%). Persistierende Fussinfekte waren in allen Fällen die
Ursache für Amputationen bei offenem Bypass.
Schlussfolgerung: Eine frühzeitige aggressive Abklärung und Therapie hinsichtlich Ischämie
beim Diabetiker mit Fussläsionen ist notwendig. Zusammen mit einem adäquaten
Débridement, einer resistenzgerechten Antibiose und einer interdisziplinären Fussnachsorge
kann auf diese Weise vielen diabetischen Patienten die Extremität erhalten werden.
Venous morbidity after superficial femoral vein harvest for infra-inguinal reconstructions
Background: The superficial femoral vein (SFV) is a well-established alternative conduit for
infra-inguinal reconstructions. The potential for acute or chronic venous hypertension after SFV
harvest may however result in significant morbidity. This study reports the efficiency of SFV as
conduit for infra-inguinal reconstructions and characterize the anatomic and physiologic
changes in harvest limbs and their relationship to the development of venous complications.
Methods: From May 1999 through November 2003, 23 SFV were harvested from 21 patients
undergoing infra-inguinal reconstructions. Bypasses were controlled by regular duplex-ultrasound. The venous morbidity was assessed by measurements of leg circumferences, straingauge plethysmography and quality of life, investigated by the VEINES-QOL scale.
Results: At a mean follow-up of 10.4 months (range 1-56), primary, secondary patency and
limb salvage rates of infra-inguinal bypasses using SFV are 71.4%, 76.2% and 85.7%
respectively. No patient had major venous claudication. Oedema was significantly present
in 9 patients. Strain-gauge plethysmography showed outflow obstruction in all patients. The
VEINES-QOL assessment showed no limitation in social and domestic activity, moderate
complain about leg heaviness despite presence of oedema.
Conclusion: The SFV harvest is a reliable conduit for infra-inguinal reconstructions and results
in moderate venous morbidity in terms of functional consequences and quality of life.
25.07
26.01
1
1
1
2
1
1
T. Obeid , R. Rosenthal , T. Eugster , F. Hefti , L. Gürke , P. Stierli
Universitäres Zentrum für Gefässchirurgie Aarau-Basel,
2
Kinderorthopädische Universitätsklinik Universitäts-Kinderspital beider Basel
1
Die extraanatomische laterale Rekonstruktion der Femoralgefässe
Einleitung: Weichteilsarkome oder schwere Gefässinfekte des Oberschenkels benötigen oftmals ausgedehnte Resektionen. Damit verbundene, arterielle und venöse Rekonstruktionen
sind aufgrund zu erwartender Wundheilungsstörungen oder Infekten oftmals erschwert. Die
richtige operative Strategie für den Gefässersatz ist von entscheidender Bedeutung.
Methode: Wir berichten über vier Patienten mit Weichteilsarkomen am Oberschenkel, bei welchen aufgrund einer medialen Kompartimentresektion eine Gefässrekonstruktion notwendig
wurde. Die Rekonstruktionen der Arterien und eventuell Venen erfolgte extraanatomisch.
Diese wurde zur Vermeidung einer Ischämie bereits vor der Kompartimentausräumung vorgenommen. Der Zugang zur infrageniculären Arteria poplitea erfolgte von lateral durch
Resektion des Fibulaköpfchens.
Resultate: Bei allen 4 Patienten wurden die Arterien mit der kontralateralen Vena saphena
JM. Gauer, P. Soyka, N. Ganzoni, W. Schweizer
Abteilung Chirurgie, Kantonsspital Schaffhausen
Sartorius-muscle flap for treatment of infected inguinal access after vascular prosthesis
Introduction: Infection of the inguinal acces wound after vascular reconstruction remains a
difficult problem especially if a vascular prosthesis has been implanted. The impossiblity
treating the infection may lead to abandonning the reconstruction. To avoid the infectionrelated failure of prosthetic revascularisation or anastomotic bleeding, we use a sartorius
flap technique to protect the vascular graft by separating it from the infected wound, provided the deep femoral artery is patent.
Patients and Methods: In 18 patients (8 with apparent infection, 10 with productive lymphfistula with or without cellulitis) after vasular reconstruction with PTFE grafting, the longitudinal access was enlarged proximally, a careful debridement performed and the origin of
the sartorius muscle at the anterior superior spina transsected. The muscle was mobilised
medially and laterally, up to three perforating vascular pedicles were ligated. The flap was
rotated medially thus covering the vascular compartment and fixed with one to two sutures.
The wound was dressed with Vacuseal technique. In one fistula-case a bilateral procedure
has been performed.
Results: In all cases the infection was controlled, after 3 to 4 Vacuseal changements the
inguinal wound could be secondarely closed with intact vascular reconstruction.
Conclusion: Using well vascularised muscle tissue to separate a PTFE graft from an apparent or threatening woundinfection is easy to perform, effective and in our hands a valuable technique for protecting the underlying vascular reconstruction.
26
A. Beuchat, S. Taub, AF. Corno, G. Codeluppi, LK. von Segesser
Cardiovascular Surgery, CHUV, Lausanne
“Lifesight” improves concentration and reaction time in surgery
Objective: High mental concentration and focus within the surgical field are of prime importance during surgery. However, monitoring of vital parameters (ECG, blood pressure, etc) is
usually displayed on a remote screen outside of the visual field. Having to shift attention
back and forth from the patient to monitors, while realizing complex surgical procedures
makes complete integration of remote information in real time extremely difficult.
Methods: Centralisation of various sources of information within the visual field of the surgeon can be achieved by combining modern wearable head-up displays. The cyber tool
allows the surgeons to simultaneously view the patient and the patient’s vital parameters
using vision-through over a wireless 2.4 GHz, potentially enhancing the speed, accuracy
and safety of surgical decisions.
Using a human patient simulator mannequin, a group of surgeons were given a series of
standardized surgical tasks to perform. The aim was to assess surgical and intellectual per-
swiss knife 2004; special edition
51
formance in a realistic surgical environment by measuring the quantity of surgical tasks
performed (A) during a given time and the reaction time (B) to recognize asystole using an
electrocardiogram monitor attached to the simulator. The performance ratio (A/B) was useful for comparison between cyber tools display and standard remote monitors.
Results: The amount of surgical tasks performed with traditional remote monitors accounted for 10.2±3.1 arbitrary units versus 11.1±2 for cyber tools (A: p=0.8 NS). Mean reaction
time for traditional remote monitors was 14.5±5.6 s versus 8.4±2.3 s for cyber tools (B:
p<0.01). The performance ratios (A/B) are 0.7 for traditional remote screens versus 1.3 for
cyber tools (higher = better). Mean head arising with monitors was 10±3 times per minute
against 0 times with the cyber tools.
Conclusion: During surgery, modern cyber tools allow for significant improvement of reaction time and concentration due to real time access to vital information, which is traditionally displayed on remote screens.
26.02
MT. Grapow 1, MA. Konerding 2, DC. Reineke 1, P. Matt 1, F. Bernet 1, HR. Zerkowski 1
1
Division Herz-Thoraxchirurgie, Kantonsspital Basel,
2
Institut für Anatomie, Joh.-Gutenberg-Universität Mainz, Deutschland
Impact of a modfield harvesting technique of the international thoracic artery on morphhological changes of the endothelial layer
In previous functional organ bath experiments and plasma protein analysis for adhesion
molecules the traditional harvesting method of internal thoracic artery (ITA) i.e., dissecting
distally and occlusion with a clip during the anastomoses of other grafts (CA) was put up
against a group, in which the ITA was preparated, kept perfused and dissected immediately before its anastomoses (PA). Results revealed significantly reduced endothelium-dependent relaxation to acetylcholine and significantly increased contraction to serotonin and
endothelin-1 in CA. Plasma concentration of sP-selectin and thrombomodulin investigated
from blood taken directly from the ITA were significantly higher in CA compared to PA. It was
of interest whether these observations can be correlated with structural changes of the
endothelial layer.
In a total of three patients two samples of the vessel were taken of each patient, the first
directly after its preparation, serving as a PA sample, then the artery was occluded with a
clip, stored and shortly before performing the anastomosis to the LAD the second specimen
was dissected and assigned to the CA group. These six samples were examined using
Scanning Electron Microscopy.
In blinded analysis by two independent observers all specimens were matched correctly to
the CA vs PA groups. Significant changes in endothelial cell surface structure and membrane topology were seen in CA. The PA group showed in general a more flatly extended endothelium with clearly recognizable cell borders with no signs of intimal fracture or endothelial cell loss. Exposure of basement membrane and loss of individual endothelial cells was
found only in CA. Extent and quality of morphological alterations suffice to induce pronounced functional endothelial cell impairment of the CA group.
These observations strongly support our above cited results showing significant deterioration in endothelial function and highly abnormal increase in contractility in the clipped artery group. Functional, biochemical and structural results suggest therefore that a maintained
perfusion of the ITA preserves endothelial function with possible influence on patency-rates.
26.03
S. Salzberg, F. Filsoufi, A. Gass, L. Aklog, D. Adams
Mount Sinai Medical Center, New York
Preoperative optimization with nesiritide (BNP) in high-risk mitral valve surgery
Background: Nesiritide is a recombinant human brain-type natriuretic peptide (BNP), which
decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while
increasing coronary blood flow and urine output. Mitral valve surgery in patients with impaired left ventricular function and pulmonary hypertension has been historically associated
with a high operative mortality. We hypothesized that preoperative optimization with BNP
may improve surgical outcomes.
Methods: From 5/03 to 9/03, 12 patients (7 male / 5 female, age 64, systolic PA 63mmHg,
EF 37%) undergoing mitral valve surgery (7 repairs, 4 replacement; 4 reoperations) for 34+ mitral regurgitation were treated for an average of 27 hours (13-55) preoperatively with
intra-venous BNP in an intensive care setting with PA catheter monitoring. The mean expected mortality by EUROSCORE was 25% (7.8-59%). Concomitant procedures included tricuspid valve repair (n=7), coronary artery bypass grafting (n=3) and left atrial maze (n=2).
Results: Mean systolic PA pressure (63 vs. 34 mmHg, p=0.0003), pulmonary capillary
wedge pressure (31 vs. 14 mmHg, p=0.001), central venous pressure (12 vs. 5 mmHg,
p=0.002) and weight (-3.7 kg, p=0.006) decreased significantly following BNP treatment,
which was well tolerated. All other hemodynamic parameters remained constant, mean
ventilatory time was 13 h and 30-day mortality was 0%.
Conclusion: Preoperative optimization using BNP may improve early outcomes in high-risk
patients undergoing mitral valve surgery. This may be due to improved ventricular loading conditions (decreased PA pressures, more effective diuresis) and/or a direct myocardial effect of
BNP. Further prospective evaluation of the role of BNP in cardiac surgery is warranted.
52
swiss knife 2004; special edition
26.04
F. Filsoufi, S. Salzberg, M. Goldman, L. Aklog, D.Adams
Mount Sinai Medical Center, New York
Tricuspid valve repair with the Edwards MC3 annuloplasty system: early clinical results
Background: Moderate to severe functional tricuspid regurgitation (TR) should be corrected in
patients with left sided valve disease to improve long-term outcome. The superiority of prosthetic remodeling annuloplasty over other surgical techniques has been well demonstrated.
We sought to determine the safety and efficacy of the new Edwards MC3 remodeling ring.
Material: From 8/02 to 12/03, 39 Patients (15M/24F, mean age 63, mean EF 49) underwent
tricuspid valve repair (TVR) for functional TR (grade ≥3) due to annular dilatation with the
Edwards MC3 system (Edwards Lifescience, Irvine, CA). Etiology of underlying left sided valvular disease was: rheumatic (n=19), degenerative (n=13), endocarditis (n=3), ischemic (n=2),
lupus (n=1) and congenital (n=1). 7 Patients underwent redo operations. Concomitant procedures were: mitral valve surgery (n=34), aortic valve replacement (n=4), coronary artery
bypass grafting (n=6), maze (n=11), ASD-repair (n=2) and Bentall (n=1).
Results: Operative mortality was 5.12 % (n=2). One late death occurred in a patient with
endocarditis. 8 patients (20%) required postoperative trans-venous pace-maker placement. Follow-up echocardiography was done in all patients before discharge. Mean TR
decreased to 1 (p<0.001) and mitral regurgitation to <1 (p<0.001) while EF increased to
52% (p=0.047).
Conclusion: Concomitant tricuspid valve repair for TR associated with left sided valve surgery carries low operative mortality in high-risk patients. The new Edwards MC3
Annuloplasty system is easy to implant and significantly reduces FTR, with excellent early
clinical results. Further follow-up and larger series are required to establish the long-term
stability of this annuloplasty ring.
26.05
P. Matt, M. Grapow, T. Grussenmeyer, SE. Dörge, F. Bernet, I. Lefkovits, HR. Zerkowski
Division of Cardio-Thoracic Surgery, University Hospital Basel
Proteomics analysis – a promising tool to investigate ascending aortic disease
Purpose: Ascending aortic disease such as aortic root dilatation, ascending aneurysm or
aortic dissection are of major interest in cardiac surgery. Little is known about the molecular pathways in the development and progression of these diseases. Proteomics analysis is
expected to hasten the understanding of the pathologic processes at the protein level.
Material and methods: Ascending aortic samples from patients undergoing elective coronary artery bypass (n=4), aortic valve (n=4) or ascending aortic replacement (n=4) were
excised, and frozen in liquid nitrogen. Samples were solubilized using a standard sample
buffer containing NP-40, high pI ampholines and urea. Two dimensional (2-D) gels were
prepared according to O`Farrell using the ISODALT system, in order to separate polypeptide components according to their charge and molecular size. Polypeptide spots were
visualized by silver-staining. 2-D gel images were analyzed employing the PDQuest software. The modelled spots were compared to previously established 2-D gel patterns of
myocardial tissue (n=4).
Results: Due to the fibrous character of the aortic tissue, the solubilization and protein separation was more tedious than in myocardial tissue. 2-D gel patterns of aortic samples showed
an average of 683 spots (range 512-786). In myocardial tissue (left ventricle) an average of
836 spots (range 624-912) were detected (p=NS). Statistical analysis revealed several spots
that varied among different aortic diseases: the spot match rate ranged from 34 to 84%. It was
not yet possible to differentiate between inter-individual and disease-related variations.
Conclusions: Proteomics analysis is a feasible and promising tool to investigate ascending
aortic disease. The solubilization and protein separation of aortic samples is a difficult task.
The number and quality of detected spots is comparable to myocardial tissue. Quantitative
spot intensity comparison is now under scrutiny.
26.06
JT. Christenson, D. Vala, J. Sierra, A. Kalangos
Hôpitaux Universitaire de Genève
Risk for embolization at aortic cross clamping?
intra aortic filter captures particulate emboli
Objectives: Particulate emboli play a significant role in the development of complications
after cardiac surgery. Intra-aortic filtration has shown to be safe and catches particulate
emboli, thus reducing the risk for emboli related complications. Intra-aortic filter has been
placed prior to declamping of the aorta. Aortic cross clamping is another high-risk period
for embolization. This study was undertaken to evaluate particulate emboli release during
cross clamping.
Material: In 15 consecutive patients undergoing cardiac surgery, two intra-aortic filters were
separately used. Filter A was inserted prior to aortic cross clamping and Filter B just before
aortic declamping. All filters (n=30) were examined for histopathologic evidence of particulates by an independent institution.
Results: Particulate emboli were identified in all filters deployed. Both Filter A and B contained macroscopic particles, primarily fibrous atheroma (10/15, 66.7% in each group).
The average number of particulates was 7.1±2.6 (Filter A) and 6.7±2.6 (Filter B), regardless
of epiaortic scanning and transesophageal echocardiography findings. In 10/15 (66.7%)
patients, and equal or greater number of particles was find in Filter A compared to Filter B.
There were no complications attributed to the filter identified.
Conclusions: This study has shown that there is a risk for particulate embolization at aortic
cross clamping, since all Filter A contained particulates. This suggests that intra aortic filtration ought to be routinely employed prior to aortic cross clamping, in order to avoid embolic complications.
26.07
F. Bernet, J. Wehrle, HR. Zerkowski, D. Baykut
Division of Cardio-Thoracic Surgery, University Hospital Basel
Intravascular near-infrared spectroscopy is applicable for ischemia and reperfusion monitoring during off-pump coronary bypass surgery
Objective: Near-infrared spectroscopy (NIRS) is a reliable diagnostic tool for tissue oxygenation monitoring by spectral analysis of oxygen-dependent agents. The interruption of myocardial O2-supply leads to changes in coronary venous blood by tissue deoxygenation and
accumulation of metabolites which are accessible for NIRS. NIRS absorbance spectra of
coronary venous blood in animal experiments indicate reproducible changes during ischemia and reperfusion which could be used for ischemia monitoring in off-pump coronary
surgery (OPCAB).
Method: To transfer NIRS signals into coronary sinus, a fiberoptic catheter comprising two
concentric fiber groups was developed with one fiber group for signal emission and the
other one for collection. For data analysis and processing, a miniature spectrophotometer
with multivariate statistical package was used. Continuous NIRS analysis of the coronary
venous blood was performed in six patients (three OPCAB / three on-pump cases using
blood cardioplegia) together with hemodynamic parameters, transesophageal echocardiography and ECG.
Results and perspectives: In on-pump patients, NIRS absorption patterns showed that myocardial O2-consumption was interrupted under myocardial protection and returned to baseline after aortic de-clamping. In OPCAB patients, absorption spectra were not markedly
changed which indicated that the myocardium was not suffered from ischemia during peripheral anastomoses, in accordance with hemodynamics and transesophageal echocardiography.
Conclusions: 1. There are significant differences in NIRS absorbance between on-pump and
OPCAB patients. 2. These differences represent changes in O2-consumption in beating and
arrested heart. 3. NIRS can be used as an appropriate tool for online monitoring of myocardial oxygen metabolism under varying dynamic conditions in OPCAB surgery.
27
27.01
SW. Schmid 1, CA. Seiler 1, R. Weimann 2, D. Candinas 1
Department of Visceral and Transplantation Surgery, University Hospital of Berne,
Switzerland, 2Department of Pathology, University Hospital of Berne, Switzerland
1
Frozen section in thyroid surgery
Background: The value of intraoperative frozen section examination for intraoperative diagnosis of thyroid cancer is an issue of considerable debate. The purpose of this study was
to determine the reliability of intraoperative frozen section analysis in our institution and its
impact on the intraoperative strategy.
Methods: All patients who underwent thyroid gland surgery between January and
December 2002 were identified in a prospective database and evaluated with regard to the
accuracy of intraoperative frozen section analysis (performed in all patients), and its imminent consequences on the selection of the surgical procedure.
Results: One hundred and seventeen patients underwent thyroid surgery. Indications for thyroid
resection were benign goitre (52 cases), hyperthyroid goitre (35), thyroid carcinoma (22), and
recurrent disease (8), including 1 carcinoma. All patients underwent either hemithyreoidectomy
± subtotal contralateral resection or a total thyreoidectomy. In malignant disease an ipsilateral
modified neck dissection (including bilateral cervico-central, and unilateral cervicolateral lymphadenectomy) was performed. 106 patients (90%) had a correct frozen section diagnosis; in
8 cases (7%) the frozen section analysis was inaccurate (6 follicular carcinomas and follicular
variants of papillary carcinomas, 1 papillary carcinoma, 1 medullar microcarcinoma). Three
samples (3%) were deferred and showed papillary carcinoma on final histology within 24 hours.
Frozen section analysis revealed a thyroid carcinoma in 5 cases and subsequently altered the
surgical strategy in these patients (4 papillary carcinoma, 1 Hurthle cell carcinoma).
Conclusion: Intraoperative frozen section analysis showed a high overall accuracy with a high
impact on intraoperative decision-making in newly detected malignant disease. Deferred results
are worked up within 24 hours aiming at a reoperation within 72 hours. The determination of
malignancy intraoperatively is difficult in lesions with follicular pattern and microcarcinomas
resulting in a lower accuracy of frozen section examination in these particular cases.
27.02
G. Siegel, M. Wagner, B. Egger, B. Gloor, CA. Seiler, D. Candinas.
Department of Visceral and Transplantation Surgery, Inselspital, University of Berne,
Berne, Switzerland
Surgery for neuroendocrine pancreatic tumors – an increasing entity?
Background: Neuroendocrine tumors (NETs) of the pancreas are rare diseases, arising predominantely from the pancreatic islets. While biologically active NETs are detected in an
early tumor stage, clinical diagnosis of biologically inactive tumors is difficult, therefore
patients with hormone inactive tumors often present in advanced tumor state. However,
NETs may have a better prognosis compared to adenocarcinomas of the pancreas if treated correctly.
Methods: The medical records of patients with NETs of the pancreas who underwent surgery at our institution between Jan 2001 and Dec 2003 were reviewed. The incidence of NETs
and the survival rates were compared to patients with adenocarcinoms of the pancreas.
Results: Between Jan 2001 and Dec 2003 a total of 127 patients with tumors of the pancreas were treated surgically in our department. 20 patients (15,7%) had NETs of the pancreas. 7 NETs were localized, metastasising or locally advanced tumors were found in 13
cases. Tumors were completely removed in 14 cases (70%). Surgical procedures consisted
in 8 pancreatectoduodenotomys, 6 left sided pancreatic resections and 3 local tumor enucleations. In 3 patients only a palliative gastroenterostomy was performed, due to advanced tumor state. All patients with localized tumors (7 patients) and also all patients with
metastasising tumors who where removed completely (6 patients) are still alive. In the
patient group with not completely removable tumors or palliative surgery 3 patients are still
alive, while 4 patients died (median survival 6.8 months, range 2-11 months).
Conclusion: NETs of the pancreas are more frequent than generally assumed. The survival of patients with NETs is better than in patients with adenocarcinomas, especially in
advanced and metastasic disease. Therefore aggressive surgery including multi-visceralresections with splenectomy, pancreatectomy, liver resections, colonic or gastric resections
should be considered. Even in patients with advanced disease a tumor debulking and
resection of metastases may lead to a prolongation of survival and improved quality of life
(reduction of side effects of hormone secretion).
27.03
MA. Chappuis 1, A. Bischof-Delaloye2, Y. Groebli 1
1
Unité Hospitalière de Neuchâtel, Département de Chirurgie,
2
CHUV, Lausanne, Service de Médecine nucléaire
Radioguided surgery for intestinal carcinoid tumor
Introduction: Carcinoid tumours differ from other malignancies in behaviour and
spread. Surgery is the only curative treatment. Preoperative imaging may fail to localize small
tumours. Laparotomy for midgut (pancreatic or small bowel) carcinoids may be unsuccessful in up to 30% of cases. Fusion of Indium-111-octreotide scintigraphy and computerized
tomography (SPECT/CT) has been shown to be useful in identification of infracentimetric
tumours. Radioguided surgery has been reported to help surgeons in the localization of such
tumours.
Case report: a 43 year old woman suffered from several episodes of acute watery diarrhoea
with major electrolyte imbalance and dehydration. A small carcinoid tumour of the duodenum
was found at endoscopy. Biologic markers were elevated. Octreotide scintigraphy showed 3
uptake foci in the right upper abdominal quadrant. Neither CT nor magnetic resonance imaging (MRI) could identify any tumour. Segmental resection of the duodenum was performed.
Only one tumour was found histologically. After a short symptom-free interval, the
patient resumed experiencing severe episodes of watery diarrhoea. Markers were still elevated. 2 small lesions were visible on SPECT. CT and MRI were again negative. In the absence of distant spreading we assumed the likelihood of curative surgery.
Methods: SPECT/CT fusion images showed the hot spots to correspond to lymph nodes of
the pancreatic region, which appeared normal on high resolution CT. Radioguided surgery
was performed 48 hours after iv injection of In-111- octreotide. Two nodes showed intense
radioactivity compared with the background and were removed. The metastatic nature was
confirmed histologically. The patient remained asymptomatic for more than one year, but
the markers did not return to normal. She refused new imaging procedures.Conclusion:
Although definite cure may not have been achieved in this case, SPECT /CT fusion images
and radioguided surgery have been useful for localizing and selective removing of centimetric lymph nodes metastases of a duodenal carcinoid tumour.
27.04
CJ. Geppert, M. Koch, A. Troendle
Spital Bern Tiefenau
A rare combination of phaeochromocytoma & carcinoid tumor of Vater’s papilla in a patient
with von Recklinghausen neurofibromatosis
A 58-year-old male suffering from Recklinghausen’s fibromatosis (NvR) presented as an
emergency with perforated diverticular disease & widespread peritonitis. During the laparotomy with Hartmann’s procedure the patient suffered multiple hypertensive crises with the
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systolic blood pressure rising to 250-300mmHg. The suspected phaechromocytoma was
demonstrated postoperatively by abdominal computertomography & I-123-MIBG-scintigraphy with bilateral phaeochromocytomas without extramedullary manifestation. After recovery an elective bilateral adrenalectomy with prae-operative alpha-blockade (phenoxybenzamin-HCL) was planned. Due to personal circumstances surgery was delayed. 5 months
later the patient presented yet again as an emergency with right-sided upper abdominal
pain & cholestatic jaundice. Investigations confirmed the diagnosis of gallstones & by ERCP
additionally a well-differentiated carcinoid tumor of Vater’s papilla. The patient was treated
by an adrenalectomy right, subtotal adrenalectomy left, duodenotomy, papillectomy &
papilloplasty, cholecystectomy & descendo-rectostomy. Histopathological investigations of
the carcinoid tumor failed to express somatostatin receptors. The carcinoid tumor was nonreactive to serotonin, weakly reactive to chromogranin & clearly reactive to synaptophysin.
After recovery, no progression of the disease was observed up to the present date.
A review of the literature shows that many patients with NvR are at high risk of developing duodenal somatostatin-rich carcinoids, gastrointestinal stromal & gastrointestinal autonomic
nerve tumors. Phaeochromocytomas are also associated with NvR, however, the triad of NvR,
phaechromocytoma and neuroeondocrine tumor of Vater’s papilla is a rare condition. There
are suggestions in the literature that neurofibromatosis, phaeochromocytoma & duodenal
carcinoid constitute a distinct & specific multiple endocrine neoplasia syndrome (NPDC
Syndrome).
27.05
L. Regusc, RE. Vandoni, B. Fournier, Ph. Gertsch
Servizio di Chirurgia, Ospedale San Giovanni, Bellinzona
GIST and a duodenal neuroendocrine tumour in a patient with von Recklinghausen’s disease: a case report and review of literature
Introduction: Gastrointestinal stromal tumours (GIST) or neuroendocrine tumours (NT) of
the small intestine have already been described in patients with von Recklinghausen’s
disease. We report an exceptional association of both GIST and NT of the small intestine
and von Recklinghausen’s disease.
Case report: A 62 year-old man presented in emergency with gastrointestinal bleeding and
anaemia. Eso-gastro-duodenoscopy identified, as the origin of the bleeding, a submucosal
tumour with a small ulceration at its apex in the first portion of the duodenum. No evidence
of metastases was found. CA 19-9 and CEA were normal. Laparotomy, besides a 3 cm
tumour of the lateral wall of the duodenum, also revealed a 2 cm tumour of the distal jejunum. A curative resection of both tumours was performed by local resection of the duodenum and segmental small bowel resection. The diagnosis of NT in the duodenum and GIST
in the jejunum were confirmed by immunohistology.
Discussion: Neuroendocrine tumours associated with neurofibromatosis, frequently localised in the Ampulla of Vater, are rarely associated with a neuroendocrine syndrome. They
may present with gastrointestinal bleeding, obstructive jaundice or abdominal pain. GIST in
von Recklinghausen’s disease has been described, and may be another expression of the
same disease. The association of both GIST and NT with von Recklinghausen’s disease is
exceptional. Treatment is essentially surgical, in association with oncological therapies.
27.06
P. Bucher 1, P. Villiger 1, JF. Egger 2, F. Ris 1, L. Bühler 1, Ph. Morel 1
Visceral and Transplantation Clinic, Geneva University Hospital,
2
Department of Pathology, Geneva University Hospital
1
Gastrointestinal stromal tumors: towards a clinically reliable prognostic scale
Background: Gastrointestinal stromal tumors (GIST) are mesenchymal tumors characterized
by constitutive overexpression of the tyrosine kinase receptor KIT. Their natural history range
from benign to highly malignant and prognostic factors are not well defined.
Methods: A retrospective review from 1993 to 2002 identified 87 patients (median age 58)
admitted for GIST. We tested the following prognostic scale: minor criteria: tumor size > 5cm,
mitotic count > 5/HPF, presence of necrosis, invasive component (to mucosa or serosis) and
Mib1 >10%; and major criteria: presence of lymph node invasion or metastasis. Presence of 4
of the five minor or 1 major criteria was diagnostic of high malignant potential GIST.
Results: Among the 87 GIST reviewed, 53 originate in the stomach, 30 in the small bowel,
2 in the colon and rectum and 2 in the mesentery. Cases diagnosed only at autopsy (7 from
the stomach) were further excluded for analysis. Tumor location did not correlates with prognosis. According to Fletcher scale, 16 GIST were classified as very low risk (median followup 39 months), 26 as low risk (median follow-up 77 months), 16 as intermediate risk
(median follow-up 71 months) and 29 as high risk (median follow-up 29 months)
(p<0.05). According to the present scale, 66 GIST were classified as low malignant potential (median follow-up 60 months, range 12-132) and 21 as high malignant potential (median follow-up 27 months, range 1-50). There was a significant correlation between survival
and classification as low or high malignant potential GIST, with 5 years survival of 95% and
21%, respectively (p<0.001). No recurrence were observed in the low malignant potential
GIST, while 17 cases with high malignant potential GIST either recurred after primary surgical treatment (10 cases) or had metastasis at diagnosis (7 cases) (p<0.01). Sensitivity of
Fletcher and this scales were similar, while specificity of this scale was higher for detection
of high risk GIST.
Conclusion: The present prognostic scale can reliably predict GIST behavior after primary
surgical treatment. It could be used to select patients who would benefit from adjuvant treatment after GIST resection.
27.07
F. Grieder, H. Gelpke, M. Decurtins
Kantonsspital Winterthur
Umbilical hernia: is the operation without a mesh graft still adequate?
Introduction: On the basis of very good results with the reinforcement of a mesh graft when
repairing inguinal- and incisional hernias, the question must be raised whether allo-plastic
materials are necessary for the operation on umbilical hernias. There is only one prospective randomized study in existence that compares suture and mesh repair. For this reason,
the patient`s data collected in our hospital were compared retrospectively.
Method: The data from 72 patients from the years 1994 until to 2002 were analyzed. 36
patients with suture-repair alone (that is 88% of all operated patients) were compared with
36 patients receiving a mesh reinforcement. All the follow-up examinations were carried out
by the same examiner by the means of a questionnaire, a clinical examination and an ultrasonic scan of the abdominal wall.
Results: Patients with suture repair alone showed an average risk of a recurrence of altogether 16.6%. The recurrence-rate increased to 44.4% if the BMI was higher than 28 and the
hernia diameter larger than 2cm (0.78 inch). Patients to whom these criteria did not apply
had a recurrence probability of only 8.3%. Patients who were supplied with a mesh had a
surprisingly high recurrence rate of 11%, which increased to 23%, if the mesh size was
smaller than 100cm? (15.5 sq inches) compared with 4.3% if the mesh size was larger
than 100cm?.
Conclusion: In summary, the repair of a umbilical hernia with suture repair alone can not be
considered sufficient for patients with a BMI>28 and a hernia size >2cm. In such cases,
augmentation with a mesh of sufficient size is advisable. In our patients with a mesh sizes
smaller than 100cm?, the probability of a recurrence increased rapidly. When recurrence
occur at the cranial edge of the mesh, the distinction from a newly arising epigastric hernia
is difficult. For this reason, a comparison with rates of recurrence in the literature is problematical and the expression “secondary hernia” would rather be more appropriate.
27.08
M. Schiesser, P. Kirchhoff, JM. Michel, M. Schäfer, PA. Clavien
University Hospital Zurich
Preoperative identification of malnutrition in surgical patients using bioelectrical impedance
analysis
Objective: Malnutrition is frequent in surgical patients, and is typically ignored or underestimated. A careful patient screening and assessment of malnutrition represents the key issue
to identify and properly treat these patients. Although there are numerous scores and
methods in clinical use to assess malnutrition, a widely accepted gold standard is still lakking. The goal of this current study was to investigate Bioelectrical Impedance Analysis
(BIA) as a simple, inexpensive, and non-invasive method to assess patient’s preoperative
nutritional status compared to the Nutrition Risk Score (NRS) and Nutrition Risk Index (NRI)
that are based either on anamnestic and/or laboratory findings.
Methods: We prospectively evaluated 200 consecutive patients (102 male, 98 female)
admitted in our surgical Department for elective gastrointestinal surgery. BIA was performed to determine body cell mass (BCM), phase angle and lean body mass (LBM).
Simultaneously, NRI and NRS were calculated for all patients. The results of BIA were compared to NRI and NRS by statistical analysis using non-parametric correlations.
Results: There were 41 (20%) malnourished patients (20 male, 21 female) who were identified by NRI and NRS, respectively. Using BIA, 56 patients were identified having a phase
angle lower than 6°, indicating a preexisting malnutrition. 102 patients revealed a %BCM
(BCM as percentage of total body weight) lower than 30%. The statistical analysis between
BIA and NRS revealed only a moderate overall concordance estimates resulting in a correlation co-efficient of 0.208 (spearman’s rho) for phase angle and 0.23 for %BCM.
Conclusions: The prevalence of malnutrition among surgical patients is increased (20%).
BIA is able to detect changes of tissue electrical properties reflecting abnormal body composition that are caused by malnourishment. However, there is only a moderate correlation
between BIA and NRS and NRI, respectively.
27.09
F. Herrle, B. Kern, C. Ackermann, R. Peterli, MO. Guenin, M. von Flüe
Department of Surgery, St. Claraspital, Basel, Switzerland
Pancreatic surgery for carcinoma - a 20-year experience in a single institution
Background: Today surgery for pancreatic cancer at high-volume institutions has a good clinical outcome with low mortality and morbidity.
Methods: All patients undergoing surgery for pancreatic cancer, periampullary carcinoma
or distal cholangiocarcinoma between 1984 and 2003 were analyzed retrospectively for
postoperative outcome and mortality.
Results: 124 patients were included. Pancreaticoduodenectomy (PD) was performed in 82
patients, distal pancreatic resection (DP) in 6 patients, bilio-digestive bypass (BP) in 25
patients and other interventions in 11 patients. Mean age was 65 years (34 –93). Mean
operating time was 6.6 hours (4.75-9) for PD, 4 hours (2.2-5.7) for DP and 3.3 hours (0.94.7) for BD. Surgery related complications occurred in 11.3% (14/124 patients), other postoperative complications in 22.6% (28/124). 8 patients (6.5%) had to be reoperated due to
intraabdominal hemorrhage (3 patients), anastomotic leakage (1 patient), ileus (2
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patients) and wound infection (2 patients). 30-day-mortality was 1.6 % (2/124). Overall
median time of hospital stay was 21 days (5-119). Median survival was 15.4 months overall (19.4 months for PD, 58.5 months for DP, 6.8 months for BD).
Conclusion: Our data show that surgery for pancreatic cancer can be done safely in a lowvolume center. Morbidity and mortality are comparable to high-volume institutions. A good
team-work between surgeon, anesthetist and intensive-care physician is required.
Discussion: Intrathoracic extrapulmonary manifestation of tuberculosis is rare and 50 % of
these cases affect the mediastinal lymph nodes. These patients are young immigrants.
Diagnosis relies on histological and microbiological analysis. This can be obtained by FNA
or bronchoscopy but with lower sensitivity than provided by surgical biopsy. The treatment
of symptoms may require resection due to compression or infiltration of the involved nodes
in adjacent organs such oesophagus or trachea.
27.10
28.03
1
1
2
3
2
1
M. Arigoni , S. Breitenstein , S. Arma , C. Meier , F. Fasolini , M. Decurtins
Chirurgische Klinik, Kantonsspital Winterthur, 2Ospedale Reginale, Mendrisio,
3
Stadtspital Triemli Zürich
A. Zwetkow 1, P. Nussbaumer 1, F. Hefti 2, M. Furrer 1
1
Departement Chirurgie, Kantonsspital Chur,
2
Kinderorthopädische Universitätsklinik beider Basel
Kolorektale Karzinomchirurgie am Zentrum oder an der Peripherie? - Ein Outcome Vergleich
Einleitung: Die Korrelation zwischen Outcome und dem Operationsvolumen einer
Chirurgischen Klinik in der Behandlung des kolorektalen Karzinoms wird in grossen
Multizenterstudien kontrovers diskutiert. Wir vergleichen unter diesem Gesichtspunkt die
Resultate von zwei unterschiedlich grossen Kliniken der Schweiz, dem Kantonsspital
Winterthur (KSW) und dem Regionalspital Mendrisio (OBV).
Material und Methode Die zwischen 1993 und 1997 im Kantonsspital Winterthur (n=277)
und die zwischen 1990 und 1997 im Regionalspital Mendrisio (n=173) wegen eines kolrektalen Karzinoms operierten Patienten wurden retrospektiv analysiert. Die Patientenkollektive,
die Morbiditäts- und Mortalitätsraten sowie die 5 - Jahres - Ueberlebensraten wurden miteinander verglichen.
Resultate: Insgesamt wurden 450 Patienten erfasst, 277 im Kantonsspital Winterthur (KSW),
173 im Regionalspital Mendrisio (OBV). Die Alters- und Geschlechtsverteilung sind vergleichbar. Das weitgehende Übereinstimmen von Tumorstadium und Tumorlokalisation
(Rektumkarzinome KSW 37,5%, OBV 35%) ermöglicht einen Vergleich der zwei
Populationen. Die Morbiditäsrate bettrug am KSW 39% (6% Anastomoseninsuffizienz) und
am OBV 26.5% (2.3%). Die postoperative Mortalität (30 Tage) war 4.4% im KSW und 4,6%
im OBV. Die 5-Jahres-Überlebensrate über alle Tumorstadien betrug insgesamt 48,5% (KSW)
und 44,5% (OBV).
Schlussfolgerung: Verglichen zum Zentrumspital KSW zeigt das periphere Spital OBV eine
leicht schlechtere 5-Jahres-Überlebensrate dafür eine bessere Morbiditätsrate bei vergleichbarer Mortalitätsrate. Sämtliche Outcomeparameter entsprechen jedoch für beiden Spitäler
den Daten der Literatur (Morbidität 20 - 30 %, Mortalität 4 – 6%, 5-Jahres-Überleben 40 –
60%). Eine sichere kolorektale Karzinomchirurgie ist gemäss unseren Resutaten am
Zentrumsspital wie auch am peripheren Spital möglich.
Multiple thoracic aneurysmal bone cysts: diagnostic and therapeutic challenges introduction
Aneurysmal bone cysts (ABC) are rarely located in ribs or shoulder girdle bones.
Demonstrating an uncommon case we want to discuss not only the difficulties in confirming histological diagnosis, but also the challenge in proper management at delicate thoracic locations.
Case report: A 52 years old patient is presenting a painful swelling of the left chest wall.
Thoracic X- ray shows a tumour of the third rib. The preoperative CT-guided core-biopsy is
histologically interpreted as a giant cell tumour tissue. Left sided resection of the ribs 2- 4 is
therefore performed. A marlex net plasty and a pediculated latissimus dorsi muscle flap are
used to close the defect. Definitive histology results in an ABC. Subscapular chest wall haematoma on the left side occurs two weeks after the operation under oral anticoagulation.
Surgical evacuation is performed. 19 months later the patient suffers from more pain and
less movement of the left shoulder. MRI reveals a new cystic tumour of the left scapula
(9x7cm) involving the glenoid region of the bone. To preserve the shoulder joint therapeutic embolization of the suprascapular artery, the thoracoacromial artery and other branches of the axillar artery are performed in two sessions. Pain is decreasing rapidly and two
years later progressive sclerosis of the slightly shrinking bone cyst is visible on the regular
CT scan follow-ups. The patient is highly satisfied with his state, he is able to abduct and elevate the left arm over 120 degrees.
Discussion: Correct diagnosis of an ABC in ribs and/or shoulder girdle bones seems to be
more difficult than at other locations. Alternatively to curettages or injections of steroids as
used in long bone ABC, chest wall resection with plastic reconstruction can be recommended liberally at these locations. On the other hand embolization offers a rarely used therapeutic strategy to conserve “non resectable” bones.
1
28.04
28.01
28
RM. Stein, M. Beshay, RA. Schmid
Division of General Thoracic Surgery, University Hospital Berne
Early experience with the minimally invasive repair of pectus excavatum in adults
Introduction: The well-known minimally invasive repair of pectus excavatum was developed and published by Donald Nuss and has become an established method for correction of funnel chest in children and juveniles. This operation combines the advantages of
minimal invasiveness without any exposing incision along the sternum, any resection of
cartilage, shorter operating time and slight blood loss together with excellent long-term
results. The routine application of this method with adults is analyzed and evaluated in a
prospective study.
Material and methods: We report a prospective study with patients beyond 16 years, who
received a correction of their pectus excavatum with one or two pectus bar.
Results: 26 patients, aged 16 to 46 years, who were operated on and followed up at our
division since september 2002.
Conclusions: The minimally invasive correction with pectus bar is - provided the appropriate surgical carefulness - a safe and efficient method for correction of pectus excavatum
in adults with excellent cosmetic results, though long-term results are still to be obtained.
28.02
S. Deglise, E. Pezzetta, C. Haller, HB. Ris
Service de Chirurgie Thoracique et Vasculaire, CHUV
The role of surgery in the management of isolated mediastinal tuberculosis:
report of 4 cases and review
Introduction: although rare, isolated mediastinal involvement can be encountered as a clinical presentation of thoracic tuberculosis. The disease may be symptomatic or asymptomatic and discovered incidentally. Non-invasive tests often fail to give definitive diagnosis. In
this setting, surgery has a place not only for diagnostic purposes but also sometimes for the
treatment of symptoms or complications.
Patients and Results: over a period of thirteen months, four patients underwent surgery in
the setting of isolated mediastinal tuberculosis. Two patients had subcarinal nodal biopsy
by video-mediastinoscopy. The two other patients were submitted to subcarinal or paratracheal nodal resection because of symptomatic disease related to infiltration or compression of neighbouring structures. Transmural oesophageal infiltration required debridement
and reconstruction of the oesophageal wall in one patient.
GL. Carboni, N. Class, T. Kinsbergen, R. Schlumpf, A. Bissat
Chirurgische Klinik, Kantonsspital Aarau
Mediastinal goiter: sometimes the exposure comes from below
Mediastinal goiter is a benign disease, usually resectable through a cervical incision with
minimal morbidity and mortality. Occasionally other surgical approaches are necessary.
We present three cases were exceptional dimensions, possible malignancy and recurrent
disease necessitated a combined thoracic and cervical approach and discuss the surgical
anatomy of mediastinal thyroid masses.
Patients: 3 male patients aged 64, 70 and 83 yrs were admitted with mediastinal thyroid
disease. The first had a slow growing goiter for 15 yrs and after large intrathoracic disease
resulted in dysphagia and dyspnea he was referred for surgery. The second had recurrent
mediastinal disease with high serum thyreoglobulin 13 yrs after transsternal resection of a
goiter. The third patient had recurrent disease in the mediastinum and neck 40 yrs after bilateral surgery for benign disease through a cervical approach and suffered of severe dysphagia
and paroxysmal dyspnea. All mediastinal masses were located posteriorly on the right side.
Methods: All patients received thoracic and cervical CT scan, pulmonary and cardiac function tests. A combination of an antero-lateral thoracotomy with a partial longitudinal median
sternotomy (hemiclamshell approach) and a Kocher cervical incision were used.
Intraoperative recurrent nerve monitoring was applied.
Results: Two patients had an uneventful postoperative course. One patient died 6 d after
resection due to cerebral ischemia.
Discussion: Thyroid disease that extends posterior and below the innominate artery is not
resectable through cervical incision. Vicinity of superior caval vein, thoracic duct, azygos
vein, esophagus and phrenic nerve mandates a good exposure for safe dissection.
Although rare, aberrant intrathoracic thyroid typically derives its blood supply from intrathoracic sources. Control of supraaortal branches and pulmonary hilar structures provides a
safe dissection in any unexpected anatomic variation.
Conclusions: Large mediastinal thyroid disease is rare. The hemiclamshell approach provides a superb exposure for posterior mediastinal thyroid masses. It is an invasive approach
with an acceptable morbidity.
28.05
A. Nougou, M. Suter
Hôpital du Chablais, Aigle
Douleurs rétrosternales et dysphagie aiguë. Rupture spontanée d’un kyste bronchogénique
Introduction: Les kystes bronchogéniques sont des entités cliniques rares, d’origine dysembryoplasique, en rapport avec des anomalies de développement de l’arbre trachéo-bronchi-
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que (ébauche diverticulaire sur la paroi ventrale de l’intestin antérieur). Lésions souvent
asymptomatiques, elles peuvent se révéler à l’occasion d’évènements aigus infectieux ou
compressifs.
Matériel et méthode: présentation d’un cas.
Résultat: Il s’agit d’une patiente tabagique de 42 ans qui consulte en urgence pour des
douleurs rétrosternales et une dysphagie d’apparition subite. L’examen clinique décrit une
hypoventilation de la base pulmonaire droite. Une légère leucocytose et une élévation de la
CRP sont présentes aux examens de laboratoire. La radio du thorax montre une cardiomégalie ainsi qu’un aspect effacé de la coupole diaphragmatique droite en rapport avec un
épanchement pleural. Le CT-SCAN thoracique met en évidence un important infiltrat médiastinal, d’aspect en partie liquidien prédominant dans le médiastin moyen associé à un
épanchement pleural droit. Le transit oesophagien est normal. Une médiastinoscopie réalisée à des fins diagnostiques permet l’évacuation d’un liquide d’aspect purulent et inodore,
en avant de la trachée et dans l’espace trachéo-bronchique. Les prélèvements effectués
sont stériles et les biopsies démontrent l’existence d’un kyste bronchogénique. Les symptômes décrits plus haut s’amendent rapidement. Le kyste bronchogénique est extirpé 4 mois
plus tard, sans complication.
Discussion: Les kystes bronchogéniques peuvent rester quiescents pendant de nombreuses années et se manifester de manière brutale par une complication (surinfection, hémorragie, ou rupture comme dans notre cas), amenant à recourir à des procédures diagnostiques inhabituelles. Ils doivent être évoqués dans le diagnostic différentiel des douleurs thoraciques. Lorsqu’ils sont symptomatiques, ils doivent être excisés en totalité, ceux découverts fortuitement et asymptomatiques devraient également l’être si le risque opératoire est
acceptable, afin de prévenir des complications.
28.06
S. Wienbeck1, D. DeLorenzi1, C. Küng1, G. Cathomas2, A. Huber1
1
Chirurgische Klinik Kantonsspital Bruderholz, 2Institut für Pathologie Kantonsspital Liestal
Das primär adenoidzystische Karzinom der Lunge: eine seltene maligne Neoplasie
Einleitung: Primäre adenoidzystische Karzinome (ACC) sind sehr seltene und in ihrem
Verhalten schlecht verstandene maligne Tumoren der Lunge. Sie machen insgesamt <
0,2% aller Tumoren der Lunge aus. Bisher wurden weltweit lediglich ca. 250 Fälle publiziert.
Das durchschnittliche 5-Jahres Überleben aller Patienten liegt dabei zwischen 65-79%,
sowie zwischen 53-57% nach 10 Jahren. Anhand von einem Fallbeispiel aus unserer Klinik
möchten wir diese seltene maligne Neoplasie vorstellen.
Methodik: Zur Ergebnisevaluation werden dabei die histologischen und radiologischen
Untersuchungen herangezogen.
Ergebnisse: Als Gewebe epithelialen Ursprungs, zeigt der Tumor insgesamt ein langsames,
diffus infiltrierendes Wachstum mit perineuraler Invasion, Infiltration des zentralen
Bronchialsystem, sowie umgebenden Lungengewebes. Gefäß- und Lymphsystem bleiben
unbeteiligt. Unsere histologisch gewonnenen Ergebnisse decken sich dabei insgesamt mit
denen aus der Literatur. Der Tumor weist in unserem Fall eine tubuläre Wachstumsform auf.
Es werden jedoch auch cribriforme und solide Wachstumstypen mit unterschiedlicher
Metastasierungstendenz beschrieben. Postoperativ erfolgten keine weiteren Therapien,
ohne Hinweise auf ein Rezidiv in der 6-Monats Kontrolle.
Schlussfolgerung: Gesicherte Daten bezüglich der Nachsorge bei ACC liegen noch nicht vor.
Die chirurgische Resektion bleibt dabei nach wie vor die Therapie der Wahl. Außerdem wird
eine gewisse Radiosensitivität des Tumors beschrieben, mit teilweise vollständigen
Remissionen unter Radiotherapie, deren Rolle jedoch noch unklar ist. Langfristige Ergebnisse
und neue Erkenntnisse für ein optimales Therapiekonzept stehen noch aus.
Literatur:
Moran CA et al: Primary Adenoid Cystic Carcinoma of the lung. Cancer 1994; 73:1390-7
Prommegger R, et al: Long-term results of surgery for adenoid cystic carcinoma of the trachea and bronchi. Eur J Surg Oncol 1998; 24: 440-444
28.07
FC. Grafen 1, J. Gresser 1, D. Lardinois 2
1
Department of Surgery,
2
Department of Thoracic Surgery, Zurich
An accidentally discovered endobronchial lipoma
A case report: Benign endobronchial tumors are very rare. Among them lipomas range
about 4,6%. Often they are discovered because of symptoms like cough, asthma, hemoptysis, sputum or because of pathologic radiographical findings. So was this case. A 46year-old man admitted hospital for an elective resection of a sinus pilonidalis.
He had an obstructive lung disease, adipositas per magna (38,5), nicotine abuse (80py)
and ejected sputum daily. His chest radiograph showed an atelectasis in the right upper
lobe which was specified by CT scan. The radiologic finding was described as a canvas-like
shadow. A tumor could not be proved neither any thickened lymph nodes. Afterwards a
bronchoscopy was performed to get some bioptic material and to localize the tumor.
During bronchoscopy a spheroidal tumor was seen which obstructed the right upper anterior segment. Histologic result was not representative because of difficulties in biopting the
tumor. The tumor was well located but malignancy was not excluded. That is why a surgical resection was chosen. The right upper lobe was removed and the tumor entirely excised.
The staging lymph node excision showed no malign cells.
Immediately post operationem the patient was extubated. After 36 hours he developed a
respiratory failure, wherefore he had to be reintubated for another 72 hours. Radiograph
revealed an atelectasis of the left inferior lobe. Bronchoscopy showed a mucus clot obstructing the entrance to the left inferior lobe. Airway clearing was regularly performed. Due to
regular physiotherapy to improve the respiratory situation the Patient recovered quickly and
was discharged on 13th day after intervention.
The excised tumor was histologically diagnosed as an endobronchial benign lipoma with
mature adipose tissue growth under a metaplastic respiratory epithelial layer.
According to literature the diagnosis was tried to be proven by radiograph, CT scan, bronchoscopy and histologic analysis. The risk factors obesity and smoking coincide also. First
choice for treatment is bronchoscopic laser resection. But a malignancy was not excluded
in this case, therefore a surgical resection was performed.
28.08
F. Rüter 1, U. Rüttimann 2, R. Dolanc 2, L. Fischler 2, H. Pargger 2, HR. Zerkowski 1
Univ.-Kliniik für Herz- und Thoraxchirurgie, Kantonsspital Basel,
2
Operative Intensivbehandlung des Departementes Anästhesie, Kantonsspital Basel
1
Neue Therapieoptionen - hat die extrakorporale Membranoxygenation (ECMO)
beim ARDS ausgedient?
Das akute Lungenversagen (ARDS) hat immer noch eine Mortalität von 40-60%. Bisher
stand neben der differenzierten Respiratortherapie zur Behandlung nur die extrakorporale
Membranoxygenation (ECMO) zur Verfügung. Wegen hoher Komplikationsraten ist der
Einsatz der ECMO im Vergleich zur konservativen Therapie umstritten. Das neue novalung“System als parakorporales, pumpenloses Device scheint eine (preisgünstige) Alternative.
Fallbericht: Nach Sturz aus 10 Metern Höhe wurde eine 15jährige Patientin mit schwerem
Thoraxtrauma, multiplen Rippenfrakturen und Lungenkontusionen zugewiesen. Nach bakterieller Pneumonie im Verlauf der Respiratortherapie entwickelte sie ein ARDS, das bei
abnehmender Compliance der Lunge und Hyperkapnie keine adäquate Oxygenierung
mehr zuliess. Aus vitaler Indikation wurde novalung“ eingesetzt.
Methode: Kern des Systems ist ein Polymethylpenten-Membranoxygenator zum O2- und CO2Austausch. Der geringe Flusswiderstand (Druckabfall 2 - 10 mmHg, Blutfluss 0,5 – 2,5 L/min)
erlaubt es, das Device arteriovenös im Nebenschluss durch den Patientenkreislauf zu versorgen. CO2-Elimination und Oxygenation erfolgen unter externer O2-Zufuhr von bis zu 12 L/min.
Je nach Blutflussrate und O2-Zufuhr wird eine lungenprotektive Beatmung bis zur ApnoeVentilation möglich. Nach Füllung des Systems mit heparinisierter Ringer-Laktat-Lösung
erfolgt die Kanüleneinlage in Seldinger Technik in A. und V. femoralis.
Verlauf: Unter Zufuhr von 8 L/min O2 normalisierte sich der PaCO2 der Patientin in wenigen
Minuten, der PaO2 verbesserte sich nach initial geringem Abfall in wenigen Tagen, sodass
unter Apnoe-Ventilation (PEEP 20mbar) der FiO2 von 1,0 auf 0,4 reduziert werden konnte.
Nach sukzessivem Wiederbeginn der mechanischen Ventilation wurde das System am 11.
Tag chirurgisch entfernt.
Schlussfolgerungen: Der Einsatz des Systems war erfolgreich und hat auch hinsichtlich des
pflegerischen und ärztlichen Aufwandes überzeugt. Die Effektivität im Rahmen grösserer
Fallzahlen und eine Erweiterung des Einsatzspektrums beispielsweise zum perioperativen
präemptiven Einsatz in der Thoraxchirurgie (bei Grenzindikationen) sollten nach weiteren
klinischen Studien evaluiert werden.
28.09
E. Burri, J. Duwe, M. Kocher, C. Kull, CA. Maurer
Chirurgische Klinik, Kantonsspital Liestal
Pulmonary vein thrombosis after lobectomy
Case report:Pulmonary vein thrombosis is a known complication after lung transplantation
but has rarely been reported after lobectomy or bilobectomy. We report the case of a left
upper pulmonary vein thrombosis following an uneventful left lower lobectomy for bronchial carcinoma. Postoperative arterial blood gas values and chest radiographs were normal.
On the fifth postoperative day the patient became progressively dyspneic, developed
hemoptysis and showed total opafication of the left lung without mediastinal shift on chest
radiography. The patient remained dyspneic despite intravenous antibiotic therapy for
suspected pneumonia and absence of obstruction at bronchoscopy. Diagnosis of left
upper pulmonary vein thrombosis was finally made by contrast-enhanced multisclice computed tomography followed by pulmonary angiography. Further clinical deterioration under
conservative treatment forced us to remove the remnant left upper lobe that already showed gangrenous alterations. The patient remains well half a year later.
Discussion: Pulmonary vein thrombosis following lobectomy or bilobectomy is very rare.
Only seven cases have been reported in the literature so far. Conservative treatment with
antibiotics and anticoagulants may be successful but in case of clinical deterioration the
affected lobe has to be resected. The mechanism of thrombosis remains unclear although
intraoperative torsion and injury of vessels seem to be most likely since pulmonary vein
thrombosis occurred in the operated hemithorax only.
swiss knife 2004; special edition
59
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28.10
C. Vallet, E. Pezzetta, M. Christodoulou, J. Rey, C. Haller, HB. Ris
Service de Chirurgie Thoracique et Vasculaire CHUV, Lausanne
Management of delayed Boerhaave syndrome with lobectomy and esophagoplasty by intrathoracic transposition of a latissimus dorsi muscular flap
Introduction: spontaneous esophageal perforation, also known as Boerhaave syndrome, is
a challenging condition especially if late recognized. Surgical treatment is indicated in the
large majority of cases and different procedures have been described. We present a case
of delayed diagnosed oesophageal perforation, with penetration in the right lower lobe,
which was successfully managed by lobectomy and esophago-myoplasty performed by
intrathoracic transposition of a pedicled latissimus dorsi muscular flap.
Case report: a 72-year old patient was referred to our hospital with an abscess of the right
lower lobe and a right pleural empyema related to spontaneous esophageal perforation
evolving for more than ten days. An hydrosoluble contrast study demonstrated a perforation of the distal esophagus. A right posterolateral thoracotomy was performed and the latissimus dorsi was dissected. After decortication of the right lung and lower lobectomy for an
intrapulmonary abscess a longitudinal 7 cm tear was noticed in the distal third of the esophagus. Because of excessive fragility and inflammatory appearance of the esophageal
wall, primary suture was avoided and a reconstruction by a muscular flap was decided.
The pedicled latissimus dorsi muscular flap was therefore transposed into the thorax and
sutured to the esophageal tear. After weaning the patient could progressively resume oral
feeding with long term satisfactory functional results and good endoscopic appearance.
Conclusion: early diagnosis and definitive surgical management are the key for successful
outcome in the management of spontaneous esophageal perforation. In case delayed diagnosis closure of the oesophageal defect by intrathoracic transposition of a latissimus
dorsi muscular flap may be considered as a valuable surgical alternative.
28.12
R. Stoll 1, A. Breitenbuecher, D. De Lorenzi 1, A. Huber 1
Chirurgische Klinik, Kantonsspital Bruderholz,
2
Medizinische Klinik, Kantonsspital Bruderholz
1
Spontaneous intercostal pulmonary herniation after prolonged severe coughing – a case
report and review of literature
Introduction: Intercostal herniation is an uncommon phenomenon. Normally it is seen posttraumatic, congenital or postoperativly. Spontaneous Pulmonary hernias are rarely described.
Case: We report the case of a 58-year-old man with acute chestpain and subjective feeling
of swelling at the left hemithorax after prolonged severe coughing. The Chest-X-ray was normal. The CT-scan detected an intercostal pulmonary herniation after cartilaginary fracture
of the left costal arc between 7th and 8th rib. At surgery an anterolateral defect of ruptured
intercostal muscles was confirmed. Surgical treatment consisted of closure the defect by
suturing the 7th and 8th rib.
Discussion: Mostly acquired pulmonary hernias are posttraumatic. Spontaneous intercostal pulmonary hernias can occure after vigorous coughing. If severe chestpain persisted,
surgical repair is the treatment of choice.
29
29.01
P. Matt, T. Grussenmeyer, M. Grapow, S. Engelhardt, I. Lefkovits, HR. Zerkowski
Division of Cardio-Thoracic Surgery, University Hospital Basel
28.11
A. Meyer 1, E. Pezzetta 1, Z. El Lama 2, HB. Ris 1
1
Service de chirurgie thoracique et vasculaire, CHUV, Lausanne,
2
Service de Pneumologie, CHUV, Lausanne
Reconstruction trachéale par un muscle grand dorsal pour une déchirure chronique et
récidivante post-intubation.
Introduction: Les lésions iatrogènes de l’arbre trachéo-bronchique restent une pathologie
très rares. La prise en charge dépend de la localisation et de la longueur de la lésion. Nous
décrivons un cas de déchirure chronique et récidivant après plusieurs intubations traité par
reconstruction trachéale au moyen d’un muscle grand dorsal.
Cas clinique:Il s’agit d’une patiente de 66 ans connue pour des épisodes d’emphysème
sous-cutanné cervical d’évolution spontanément favorable, opérée pour une plastie abdominale sous anesthésie générale. L’anesthésie s’est déroulée de façon standard par une
intubation endotrachéale sans difficulté au moyen d’un tube de diamètre 7,5 avec ballonnet à basse pression. L’extubation et les suites post-opératoires immédiates seront sans
particularité.17 heures après l’extubation, elle développe rapidement un emphysème souscutannée cervico-faciale et abdominal. Une radiographie du thorax et un CT-scan montreront un important emphysème sous-cutanné associé à une lésion postérieure de la trachée
au niveau de la pars membraneuse. La patiente est transférée dans notre institution pour
prise en charge.Lors de l’intervention, nous pratiquons une endoscopie au tube rigide qui
met en évidence une longue lésion chronique de 8 cm de la pars membraneuse recouverte de fibrine. Le défect sera recouvert par un lambeau pédiculé du muscle grand dorsal
après transposition intrathoracique et suture sans tension sur les bords du défect trachéal.
Résultats: L’extubation a lieu en post-opératoire immédiat. Des contrôles bronchoscopiques à
une, quatre semaines et 3 mois, montreront aucune déhiscence de la plastie, aucune sténose
et une absence d’herniation musculaire lors des cycles respiratoires. De plus à 3 mois, le muscle recouvrant le défect trachéal est recouvert d’un muqueuse épithéliale de type respiratoire.
Conclusions: La transposition intra-thoracique de lambeau musculaire est efficace pour la fermeture de longue déchirure chronifiée de la trachée si une fermeture directe de la pars membraneuse n’est pas réalisable. La bonne intégration du tissu musculaire dans la trachée est
démontré par le fait qu’il est progressivement recouvert par un épithélium de type respiratoire.
Proteome analysis of myocardial tissue in “young” transgenic mice overexpressing beta-1
adrenergic receptor
Purpose: Beta-adrenergic receptors play a central role in cardiac function and failure.
Overexpression of the beta-1 adrenergic receptor in transgenic mice leads to myocardial
hypertrophy and failure. We asked wether alterations at the protein level are detectable
already in young mice before signs of hypertrophy or failure occur.
Material and methods: Left ventricle of young beta-1 adrenergic receptor transgenic mice
(n=3) and the wild type (n=3) was dissected, and a portion solubilized using a standard
sample buffer containing NP-40, high pI ampholines and urea. Two dimensional (2-D) gel
electrophoresis was performed according to O`Farrell using the ISODALT system, in order
to separate polypeptide components to their charge and molecular size. Polypeptide spots
were visualized by silver-staining. 2-D gel images were analyzed employing the PDQuest
software.
Results: 2-D gels of myocardial tissue showed an average of 682 spots (range 622 to 799)
in transgenic
29.02
E. Khabiri, BH. Walpoth, D. Morel, A. Kalangos
Dept. of Cardiovascular Surgery, Geneva University Hospital, Switzerland
Prevention of surgical pericardial adhesions after implantation of a biodegradable hydrogel
Aim: Open-heart surgery inevitably creates post-operative pericardial adhesions; these render re-intervention difficult and dangerous. The aim of this study is to evaluate the application of a homologous biodegradable hydrogel on the heart before pericardial closure in an
experimental model.
Method: The hydrogel is made of homologous albumin. Fourteen New Zealand white rabbits (3 months, 4 kg) were operated under general anaesthesia with intubation. The gel
was implanted through a sternotomy and pericardiotomy. After sternotomy and wound closure rabbits survived from 1 to 8 weeks. After sacrifice macro and microscopic evaluation
for adhesions, tissue reaction and fibrosis was performed.
Results: All rabbits survived surgery and were sacrificed between weeks 1 and 8. Hydrogel
was still present after 3 weeks showing a severe inflammatory reaction with PMNs, eosinophiles, lymphocytes and fibroblasts. After 4 weeks the gel was reabsorbed showing a lesser inflammatory reaction which decreased over time. No major fibrosis was noted after gel
application.
Conclusion: Post-operative adhesion formation with fibrosis remains a problem during cardiac re-interventions. The preliminary results following the application of a biodegradable
homologous hydrogel are promising in this pre-clinical study.
swiss knife 2004; special edition
61
29.03
D. Delay, CH. Sierro, G. Girod, P. Vogt, F. Stumpe
Hôpital de Sion
Revascularisation coronarienne chirurgicale à cœur battant sous assistance circulatoire
chez une population de patients à haut risque
Problème: Les patients référés pour une chirurgie de revascularisation coronarienne ont un
age et un nombre de co-morbidités croissants souvent accompagnés d’une dysfonction
ventriculaire gauche. Dans ce contexte, l’utilisation de la technique habituelle combinant
circulation extra-corporelle et cardioplégie s’avère particulièrement délétère et une revascularisation à cœur battant n’est pas toujours hémodynamiquement possible. Chez ces
patients, nous proposons une autre approche, combinant une revascularisation à cœur
battant sous CEC de support.
Méthode: Entre aout 2003 et janvier 2004, 10 patients ont été opérés avec cette technique,
8 hommes et 2 femmes dont l’âge moyen était de 71.8 ± 8.9 ans. Huit d’entre eux présentaient une dysfonction ventriculaire gauche importante, 3 une insuffisance rénale sévère, 3
des sténoses carotidiennes bilatérales, 2 étaient sous ballon de contrepulsion. Leur euroscore moyen était de 8.3 ± 3.7. Le nombre d’anastomoses distales a été de 2.4 ± 0.7, le
temps de CEC de 69 ± 20 minutes.
Résultats: La sortie de CEC s’est déroulée normalement chez tous les patients. Il n’y a eu
aucun décès, et comme unique complication un accident ischémique cérébral transitoire.
Le séjour moyen aux soins intensifs a été de 2.1 ± 1.7 jours et le séjours hospitalier de 11.1
± 4.3 jours.
Conclusions: Cette technique de revascularisation, simple à mettre en œuvre, et qui assure
une perfusion myocardique et périphérique peropératoire optimale s’est révélée efficace,
dans notre expérience, chez une population de patients à haut risque.
29.05
M. Wilhlem 1, R.Tavakoli 1, C. Hofer 2, R. Behr 1, H. Löblein 1, M. Turina 1, M. Genoni 1
Cardiac Surgery Triemli Hospital, Zurich, 2Anesthesiology Triemli Hospital, Zurich
1
New technique of proximal aortic anastomoses during OPCAB
Background: Aortic dissection and neurological events have been described as major complications of off-pump coronary artery bypass (OPCAB) and are mainly attributed to the aortic injury following the partial clamping of the aorta. Therefore new techniques of proximal
aortic anastomsis are necessary to avoid the aortic clamping and to reduce the risk of neurological events.
Patients: 138/144 (96%) of consecutive patients needing isolated CABG (mean age 66±9
years, mean Euroscore 5.4±3.3) underwent an OPCAB procedure (1 without proximal aortic anastomoses). All proximal aortic anastomoses were performed using the HeartString
System®. Patients were assessed early after the operation for the patency of the proximal
aortic anastomoses by angiography and for major clinical complications. For hemodynamic instability 9 (6.5%) patients required preoperative and 3 (2.2%) patients intraoperative
an intraaortic balloon pump. Left internal mammary artery bypass to the LAD was performaed in 137/138 (99%)patients and right internal mammary artery was used in 39/138
(28%)patients.
Results: An average of 3.9±0.97 distal anastomoses/patient and a total of 243 proximal
aorto-venous anastomoses using the HeartString System® were performed. 30-day mortality was 2/138 (1.4%). Median CK value was 340±540 U/L, CK-MB 18±44 U/L and
Troponin 1.06±18 ìg/L. 46/138 patients (33%) required transfusion of blood products.
5/138 patients (3.6%) had a perioperative ischemia but no patient presented with new neurological event. The mean ICU stay was 1.8±4.1 days. In 22 patients an angiography was
performed 7 days after OPCAB. All 39 proximal aorto-venous and 82/85 (96%) distal anastomoses were patent.
Conclusions: Proximal aorto-venous anastomoses without aortic clamping are safely performed with the Heart String System and contribute to reduce the risk of neurological events
during OPCAB procedures.
29.06
29.04
H. Löblein 1, R. Tavakoli 1, M. Wilhelm 1, C. Hofer 2, B. Seiffert 3, M.Turina 1, M. Genoni 1
Cardiac Surgery Triemli Hospital, Zurich, 2Anesthesiology Triemli Hospital, Zurich,
3
Department of Biostatistics ISPM, University Zurich
1
V. Makaloski, H. Savolainen, B. Kipfer, B. Liesen, T. Carrel, J. Schmidli
Klinik für Herz- und Gefässchirurgie, Inselspital Bern
Odyssee im Notfall - keine Seltenheit !
Problemstellung: Trotz hoher Spitaldichte und kurzen Wegstrecken kommt es bei Notfällen
nicht selten vor, dass Patienten durch die halbe Schweiz in ein herz-gefässchirurgisches
Tertiärzentrum (TZ) transportiert werden. Reduktion von Akutbetten und Schliessung von
kleinen Spitälern belasten die Betten der TZ zusehends. Die Verfügbarkeit von freien
Intensiv-Betten in zuständigen TZ ist nicht immer vorhanden. Dies hat zur Folge, dass das
Behandlungsspital gelegentlich erst vom Helikopter aus gefunden werden kann.
Patienten und Resultate: Zwischen 2001-2003 wurden 14 Patienten mit notfallmässig diagnostizierten Aortendissektionen aus dem Einzugsgebiet der Kantone Zürich und Luzern
nach Bern ins Inselspital gebracht und behandelt. 10 Patienten (67%) hatten eine Typ-A und
4 (33%) eine Typ-B Dissektion, die mittels Angio-CT-Untersuchung bereits in einem
Regionalspital diagnostiziert wurden. Ein Patient mit Typ-B Dissektion verstrab in der
Ambulanz unterwegs nach Bern. Von den anderen Patienten mit Typ-B Dissektion wurde
eine Patientin wegen rupturiertem Bauchaortenaneurysma und akutem Leriche-Syndrom
operiert; die übrigen zwei Patienten wurden konservativ behandelt. Bei allen 10 Patienten
mit Typ-A Dissektion wurde notfallmässig ein Graftersatz der Aorta Ascendens durchgeführt. Alle behandelten Patienten konnten in den nachfolgenden Tagen zurück in die
zuweisenden Kliniken oder in deren TZ verlegt werden.
Schlussfolgerung: Trotz verzögertem Transport und lebensbedrohlichem klinischen
Zustand konnten die meisten dieser Patienten mit komplexer Aortenpathologie rechtzeitig
und erfolgreich behandelt werden. Dringliche Notfälle aus anderen Einzugsgebieten können die Resourcen des Behandlungsspitals zusätzlich erheblich belasten und zu
Behandlungsengpässen führen.
62
swiss knife 2004; special edition
The prognostic value of preoperative B-type natriuretic peptide in patient undergoing coronary bypass surgery
The natriuretic peptides are cardiac neurohormones secreted in response to volume expansion and pressure overload. Studies evaluating the prognostic implications of B-type natriuretic peptide(BNP) have been limited to cardiologic patients. However there are very few
reports on the prognostic value of BNP in surgical patients.
Methods: Preoperative BNP was measured consecutively in 90 patients undergoing coronary bypass surgery. The patients were divided into the following groups. Group 1 (n = 21):
BNP 49.9 pg/ml and 110 pg/ ml and 200 pg/ ml. We investigated the association between
preoperative BNP and Intensive care unit (ICU) days, hospital days, troponin I, creatinine,
and atrial fibrillation (AF). We adjusted analyses for age, gender, preoperative ejection fraction (EF), preoperative serum creatinine, chronic obstructive lung disease, critical preoperative state, recent myocardial infarction (MI), preoperative systolic PAP>60 mg HG and extracardiac arteriopathy.
Result: Preoperatively the BNP level correlated with preoperative EF (correlation coefficient
(cc) -0.322 p=0.02), age(cc 0.271 p=0.01), Euro score(cc 0.466 p<0.001), preoperative
serum creatinine (cc 0.217 p=0.04) and with recent MI (p=0.17), although there was no
significant correlation between levels of BNP and postoperative Troponin I, postoperative
Creatinine, postoperative AF and total hospital days. A significant correlation was found between BNP levels and the number of postoperative days in the ICU. In multiple logisticregression analysis the B-type natriuretic peptide level added significant independent predictive power to other clinical variables in predicting the postoperative duration in the ICU
(p=0.016, odd ratio=3.2).
Conclusions: Used in conjunction with other clinical information, preoperative measurement of BNP is useful in predicting the postoperative duration in the ICU. Additional investigations are needed to support our findings and to further evaluate the prognostic value of
BNP level in patients undergoing cardiovascular surgery.
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