Surgery and Environmental Influence as Risk-Factors for the Development of Deep Vein Thrombosis in Animal Experiments

The aim of this experimental study was to determine whether deep vein thrombosis (DVT) in animals occurs after osteosynthesis of the femur, and whether a postoperative drop in air pressure increases the frequence of DVT Thus, osteosynthesis of the femur was performed in 10 New Zealand rabbits. Postoperatively a drop in air pressure of 300 hPA was induced. After 40 h in the pressure cabin ascending phlebography was performed (Group A). In a control-group of 10 other rabbits surgery was performed without postoperative drop in air pressure (Group B) while in a second control only the drop in air pressure was induced without surgery (Group C).

The phlebographic studies showed DVT in 4 out of 10 rabbits in group A. In group B there was no demonstrable DVT while in group C one ease of DVT was seen. The difference between group A and group B and C is statistically significant. In conclusion, a rapid drop in air pressure seems to have significant impact on the pathogenesis of DVT in rabbits after osteosynthesis of the femur.

Klinische und experimentelle Untersuchungen zur Blutgerinnungsbeeinflussung durch Fettinfusionen

100 genau kontrollierte und weitere 225 ohne spezielle Überwachung im Rahmen der parenteralen Ernährung chirurgischen Patienten applizierte Fettinfusionen (Lipofundin) ergaben nur eine geringe Frequenz durchwegs leichter Nebenwirkungen und (in Übereinstimmung mit früheren Untersuchungen) keine erhöhte Quote von Thrombosen und Embolien. Im Tierexperiment können unmittelbar nach der Infusion keine signifikanten Veränderungen von Quick, Antithrombinzeit sowie Faktoren I, II, V, VII und X nachgewiesen werden, hingegen meist eine Hemmung der Euglobulinlyse, wahrscheinlich durch das Neutralfett. Das r im Thrombelastogramm ist meist verkürzt, offenbar infolge Phosphatidwirkung; die zum Teil beobachtete a-Abnahme ist ungeklärt. Im ThromboplastinGenerations-Test kann die Fettinfusion partiell die Funktion des ChloroformHirnextraktes i.ibernehmen. — Die Befunde werden mit den Angaben der Literatur verglichen. Sie gestatten, Gerinnungsstorungen von der Liste der Fettinfusions-Kontraindikationen zu streichen.

Kidney Transplantation Improves Survival and Is Indicated in Fabry’s Disease

BACKGROUND

Fabry's disease (FD) is an inborn error of glycosphingolipid catabolism with progressive systemic deposition of globotriaosylceramide thereby leading to renal and cardiac failure. Current therapy involves symptomatic medical management, dialysis, enzyme replacement therapy, kidney transplantation (KTx), and more recently gene therapy. Case fatalities occur in the fourth decade of life resulting from uremia unless dialysis or KTx is undertaken.

STUDY DESIGN

This is a retrospective study aimed at determining the effect of KTx on the long-term outcome of patients with FD.

RESULTS

Between 1964 and 1998, ten patients with FD received KTx at our institutions. Actuarial patient and graft survivals were 100% and 90% at 5 years; 76% and 66% at 10 years. One kidney graft was lost due to rejection. Patient survival data compared favorably at 5 years with survival of FD patients on hemodialysis alone (41%, P < .05). Five patients are alive at the time of this study, and five patients died with median survival time after KTx of 128 months (range: 74-160 months).

CONCLUSIONS

This study demonstrates an excellent outcome in patients with FD in the first decade after KTx. In the absence of a severe contraindication, we advocate KTx to improve the overall prognosis of patients with renal failure due to FD. Based on the data, enzyme replacement therapy after KTx seems indicated, as FD progresses posttransplant, leading to case fatalities in the second decade after KTx.

Experimental cryosurgery of the liver under magnetic resonance guidance

The feasibility and the advantages of magnetic resonance (MR)-guided interstitial cryosurgery of the liver in an 0.5 Tesla open MR system have been evaluated. Cryosurgery was performed using an Erbocryo PS system with a nonmagnetic cryoprobe of 6 mm diameter. The probe was inserted into the liver parenchyma under real-time MR control. Using continuous MR imaging two freezing cycles of 12 min each were applied. After conventional and dynamic gadolinium-enhanced MR imaging, the animals were sacrificed after 30 min, 3 hr, 24 hr, 7 days, and 21 days. Each lesion was analyzed using light microscopy. A total of seven cryolesions were made in five animals without any complications from cryosurgery. During real-time imaging, cryolesions appeared as a hemispherical growing signal loss with a mean volume of 16.4 cm3. Macroscopic volumes of the lesions showed a good correlation with dynamic enhanced MR images during follow-up, whereas real-time images usually showed an underestimation of the lesion volumes. Cryosurgery of the liver in an open-configuration MR system is a feasible and safe method. MR imaging allows the guidance and the follow-up of cryolesions of the liver with good accuracy.

[Mesenteric cyst as the etiology of abdominal pain--a case report]

INTRODUCTION

Mesenteric cysts are part of the differential diagnosis of abdominal tumors. We want to remember this diagnosis with the following case report.

CASE REPORT

A 35-year-old woman was admitted for abdominal pain that had begun two weeks previously. Sonographic examination and CT scan of the abdomen showed a 14 x 12 x 3 cm abdominal tumor without any relation to the uterus, adnexa or organs of the epigastrium. Laparotomy was performed and the cystic tumor removed.

DISCUSSION

Mesenteric cysts are rare. The pathogenesis is not uniform and the clinical and radiologic diagnosis is difficult. The symptoms of this condition vary from acute abdominal signs to non-specific abdominal features or incidental findings. Mesenteric cysts can be located anywhere in the mesentery from the duodenum to the rectum. The treatment of choice is resection.

CONCLUSIONS

Mesenteric cysts are rare abdominal conditions. The resection of the cyst and the verification of the diagnosis is the treatment of choice.

[The "buried bumper syndrome"--a rare complication of percutaneous endoscopic gastrostomy]

The buried bumper syndrome is a rare complication of percutaneous endoscopic gastrostomy (PEG). Hereby the PEG bumper is overgrown by hypertrophic gastric mucosa and embedded into the gastric wall. This is probably a consequence of enforced tightening of the PEG tube causing an ulcer in the gastric mucosa. Endoscopically the bumper is not visible anymore. The symptoms of the buried bumper-syndrome are a poorly transporting PEG tube, a PEG tube that cannot be mobilised, secretion along the tube and upper abdominal pain. Most often an endoscopic approach to remove the bumper is successful. If not, the operative removal of the plate is necessary. After endoscopic removal of the tube an endoscopic replacement of a PEG tube is technically possible.

Ultrasound scans done by surgeons for patients with acute abdominal pain: a prospective study

OBJECTIVE

To evaluate the routine use of abdominal ultrasonography (US) in patients admitted to the surgical emergency unit with acute abdominal pain.

DESIGN

Prospective study with a three-step evaluation of patients over a 12-month period.

SETTING

University hospital, Switzerland.

SUBJECTS

496 patients (male/female = 234/262; mean age 45 years) who presented with acute abdominal pain.

INTERVENTIONS

Every patient underwent routine investigations and had an abdominal US by the attending surgeon.

MAIN OUTCOME MEASURES

Clinical diagnosis, post-ultrasonography diagnosis and final diagnosis.

RESULTS

US improved the correct diagnostic rate from 348 (70%) to 414 (83%). The diagnostic accuracy for acute appendicitis and biliary tract disease improved after US from 455 (92%) to 488 (98%) and from 463 (93%) to 490 (99%), respectively; the corresponding sensitivities and specificities were 91% and 99% and 94% and 99%.

CONCLUSIONS

Ultrasonography should be part of routine surgical investigation and should be mastered and used by surgeons.

[Kidney retransplantation in relation to organ shortage]

This article reviews our experience with renal regrafting in the past 16 years with particular emphasis on long-term outcome and prognostic parameters. Among 1094 renal transplants there were 15.8% regrafts, and the proportion of patients awaiting a regraft procedure on our current waiting list is 33%. Graft and patient survival was similar for first and second transplants, but was significantly reduced when a third graft was performed. The main prognostic parameters were the time of function of the previous graft, mismatch for HLA-DR and the presence of panel-reactive antibodies.

[33 years kidney transplantation in Zurich]

This article summarizes our experience with renal transplantation over the past 33 years and shows progressive improvement of the clinical outcome over time. In parallel we observed an increasing proportion of elderly recipients and diabetics. The increasing shortage of cadaver grafts was compensated by using donor hearts from legally dead donors (heart no longer beating) and establishing a living donor program.

[Transanal endoscopic microsurgery--experiences at the Zurich University Hospital]

The advantages of TEM (transanal endoscoic microsurgery) are minimally invasive, exact and full thickness excision of tumors in the rectum and a very low morbidity with excellent comfort for the patient. In a retrospective study all transanal endoscopic operations at Zurich University hospital in the last 5 years have been analyzed (n = 18). 11 adenomas and 5 carcinomas of the rectum have been resected with TEM (one mucosectomy, 16 full wall resections and one segmental resection of the rectum). In the group of the carcinomas there were four preoperatively known carcinomas, one T1 carcinoma was discovered postoperatively in the analyzed tissue. Among the four known carcinomas was one T1 carcinoma, two T2 carcinomas (one of them was thought to be a T1 preoperatively) and one T3 carcinoma. One patient with T2 carcinoma wanted specifically a minimally invasive procedure, the other one with T2 carcinoma was an older patient who didn't qualify for laparotomy. The patient with T3 carcinoma also had a malignant lymphoma. The operation was tolerated well by all the patients. There was one case of peritoneal perforation treated laparscopically and one case of postoperative bleeding. An incontinence of gas in one patient disappeared after 3 months. There was no adjuvant treatment in the group of the T1 carcinomas. One patient with a postoperative T2 carcinoma did not want a chemotherapy. The other two patients with T2 and T3 were polymorbid. Among the resected adenomas there was no case of recurrence. One T2 carcinoma recurred. These results show that transanal endoscopic microsurgery (TEM) is an excellent technique to treat ademomas and T1 carcinomas of the rectum with the advantages of full thickness excision under good vision, a minimal rate of recurrence and maximal patient comfort. The indications for transanal microsurgery are rare. The techically demanding operation is not always simple and should be performed in larger centers only.

Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain

BACKGROUND

Thoracic epidural analgesia is considered the method of choice for postthoracotomy analgesia, but it is not suitable for every patient and is associated with some risks and side effects. We therefore evaluated the effects of an extrapleural intercostal analgesia as an alternative to thoracic epidural analgesia.

METHODS

In a prospective, randomized study, pain control, recovery of ventilatory function, and pulmonary complications were analyzed in patients undergoing elective lobectomy or bilobectomy. Two groups of 15 patients each were compared: one received a continuous extrapleural intercostal nerve blockade (T3 through T6) with bupivacaine through an indwelling catheter, the other was administered a combination of local anesthetics (bupivacaine) and opioid analgesics (fentanyl) through a thoracic epidural catheter.

RESULTS

Both techniques were safe and highly effective in terms of pain relief and recovery of postoperative pulmonary function. However, minor differences were observed that, together with practical benefits, would favor extrapleural intercostal analgesia.

CONCLUSIONS

These results led us to suggest that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia.

Percutaneous drainage of abdominal abscesses: are large-bore catheters necessary?

OBJECTIVE

To find out whether small-bore catheters (7 F) are as effective as the 14F sump drains generally used for drainage of abdominal abscesses.

DESIGN

Retrospective review.

SETTING

University hospital, Switzerland.

SUBJECTS

64 patients with intra-abdominal abscesses.

INTERVENTIONS

40 were drained with 7F pigtail catheters and 24 by 14F sump drains.

RESULTS

Drainage was successful in 34/40 (85%) and 20/24 (83%), respectively. There were 3 recurrences in the small-bore and 1 in the large-bore group (p=0.4). Mean drainage time was 8 (SD 5) days and 11 (SD 11) days, respectively (p=0.29). One patient (3%) developed a complication in the small-bore group and 2 (8%) in the large-bore group. 4/6 failures in the small-bore group and 1/4 failures in the large-bore group were pancreatic abscesses.

CONCLUSIONS

We conclude that percutaneous drainage with small-bore catheters is as effective as drainage with bigger tubes.

[Magnetic resonance tomography and interventional measures]

In contrast to conventional radiography or ultrasonography, magnetic resonance imaging (MRI) is influenced by different factors. As a consequence, tissues and fluids can be visualized using different techniques. Obviously MR imaging has a lot of advantages, but only a small number of disadvantages and contraindications. Without using X-rays, interventions can be done under real-time MR control. An open-configuration MR-system allows vertical access to the patient during interventions. The combination of laparoscopy and MR imaging enables the surgeon to observe organ surfaces as well as parenchymal structures at the same time. Depending on the high temperature sensitivity of MR imaging, this technique can be used to guide interstitial laser therapy or cryosurgical interventions.

[Bilateral video-assisted thoracoscopic volume reduction surgery for treatment of advanced pulmonary emphysema]

In a prospective study, we investigated the functional results, complications, and survival of patients who underwent bilateral video-assisted thoracoscopic (VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary emphysema (FEV1 0.77 +/- 0.03 [1], RV/TLC 0.65, 12' walking distance 482 +/- 26 [m]). From January 94 to March 97, 67 of 179 candidates underwent the operation, and 58 patients (mean age 64 +/- 1.1, range 42-78 years; 17 women) fulfilled the study criteria. There was no 30-day mortality; hyperinflation decreased to an RV/TLC ratio of 0.52 +/- 0.01 after 3 months; FEV1 increased to 1.2 +/- 0.08 [1]; and the 12' walking distance was 687 +/- 29 [m].

Intussusception of the small bowel due to Peutz-Jeghers syndrome: a case report

We report the case of a 45-year-old woman with an intussusception of the small bowel due to Peutz-Jeghers syndrome. Immediate laparotomy was performed, and approximately 5 cm of the small bowel had to be removed because of ischemic areas. Six other polyps were removed through buttonhole enterotomies. The Peutz-Jeghers syndrome is rare. Treatment is either surgery or a combination of surgery and intraoperative enteroscopy. Bowel resections must be kept to a minimum.

Long-term results of hepaticojejunostomy for benign lesions of the bile ducts

BACKGROUND

Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared.

METHODS

A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation.

RESULTS

Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition.

CONCLUSIONS

Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

[Detection of unexpected extrathoracic metastases in preoperative staging of non-small-cell bronchial carcinoma (NSCLC) with positron emission tomography (PET)]

Accurate staging of non-small cell lung cancer (NSCLC) is essential for subsequent treatment. This study was designed to evaluate the value of FDG-PET in detecting unexpected extrathoracic metastases (ETM) in patients with NSCLC qualifying for surgical treatment based on conventional staging. One hundred patients with stage IIIa or less were included and underwent clinical evaluation, chest and upper abdominal CT scan, mediastinoscopy, and routine laboratory tests. If clinical signs of EM were present additional diagnostic methods, were applied. A partial body FDG-PET was performed. All findings in the FDG-PET were confirmed histologically or radiologically. Unknown ETM were detected in 13 patients (14%) at 19 sites. Whole-body FDG-PET improves detection of unsuspected ETM in patients with NSCLC otherwise eligible for surgery. Fourteen percent of patients were understaged.

Long-term results of hepaticojejunostomy for benign lesions of the bile ducts

BACKGROUND

Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared.

METHODS

A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation.

RESULTS

Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition.

CONCLUSIONS

Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver

BACKGROUND

There is a necessity for an imaging method during laparoscopy to get a three-dimensional access to the target. In this study we evaluated laparoscopic interstitial laser therapy of the liver under magnetic resonance imaging guidance.

METHODS

Five domestic pigs underwent laparoscopy in an open-configuration magnetic resonance system. Under simultaneous real-time magnetic resonance imaging interstitial laser therapy was applied to the liver. Magnetic resonance images, macroscopic aspects of the lesions, and light microscopic findings were compared.

RESULTS

The interventions could be safely performed. There was no image artifact caused by instruments or by the carbon dioxide. Dynamic gadolinium-enhanced imaging proved to significantly predict the macroscopic volume of the laser lesions.

CONCLUSIONS

Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver combines the advantages of minimal invasive surgery and magnetic resonance imaging. Further development should focus on laparoscopic instruments and temperature sensitive sequences.

Stones spilled during cholecystectomy: a long-term liability for the patient

Within the last 2 years, an increasing number of case reports concerning stone spillage during laparoscopic cholecystectomy and its long-term consequences have been published. Recently three patients were treated for abscesses caused by spilled stones at our institution. One of them had the longest interval between cholecystectomy and abscess formation on record. Her abscess developed 20 years after open cholecystectomy. The second patient had been admitted with one of the few cases of cholelithopthysis reported after laparoscopic cholecystectomy. All three cases and their long history of recurrences clearly underline the necessity for open debridement and drainage with stone removal for definitive treatment of these patients.

Lung herniation through a postthoracoscopy chest wall defect: demonstration with spiral CT

The incidence of complications following thoracoscopy is approximately 10%, the most prevalent being prolonged air leak and chest pain. We report two cases of lung herniation through the chest wall defect created by thoracoscopy. Use of the Valsalva maneuver during CT scanning is recommended as a diagnostic imaging method in cases with suspected lung herniation.

Experimental technique for (laparoscopic) bowel anastomosis: transient endoluminally stented anastomosis (TESA)

A new technique for bowel anastomosis is presented. The principle of transient endoluminally stented anastomosis (TESA) is based on anastomosing the two bowel ends around a resorbable stent of polyglycolic acid (PGA) in seroserosal contact. To evaluate the feasibility of TESA for bowel anastomosis, laparoscopic colon anastomosis following sigma resection was performed in five juvenile pigs. Three animals were sacrificed 2 months postoperatively, and the anastomoses were examined radiologically and histologically. One animal was sacrificed at day 2, suffering from acute peritonitis due to small bowel leak but with regular colon anastomosis. One trial was terminated at the fourth postoperative day because of insufficiency of the colon anastomosis. Three animals did not have any complications during the 2-month follow-up. In these animals the colon anastomoses were not detectable radiologically at the time of death. The microscopic examination showed intact mucosal and muscular layers without foreign material. Our study demonstrates that laparoscopic application of TESA to colon anastomosis is a feasible method. These results will further stimulate our future research for an anastomosis technique avoiding remnant foreign material.

Long-term complete remission of melanoma liver metastases after intermittent intra-arterial cisplatin chemotherapy and surgery

This paper presents the case of a female patient with liver metastases of a malignant melanoma showing complete remission after 10 courses of regional, intra-arterial chemotherapy with cisplatin. The drug was administered as continuous infusion for 5 days. The daily dosage amounted to 30 mg/m2. The interval between courses was 6 weeks. Nausea and vomiting were seen after each course, while pathological serum creatinine levels only appeared after the eighth course. The only lesion in the liver still visible on CT scan after chemotherapy was removed by left hemihepatectomy. Meticulous histological examination revealed a big focus of necrotic tissue without any tumour cells. At the time of publication the patient is alive and disease-free over 9 years later.

Laparoscopic Roux-en-Y choledochojejunostomy

OBJECTIVE

Although surgical biliary bypass for nonresectable periampullary tumors is superior to endoscopic stent placement, the latter has become popular because of the "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. This study investigates the efficacy of a new endoscopic device designed for rapidly completing a small-diameter intestinal anastomosis under laparoscopic guidance.

METHODS

Eighteen female pigs (mean weight 35 kg, range 31 to 44) were randomly divided into three groups: animals undergoing handsewn (group H) or instrumental transient endoluminally stented anastomosis (TESA; groups P and D) laparoscopic Roux-en-Y choledochojejunostomy. For TESA two different reabsorbable stents were used, polyglycolic acid (PGA; group P) and polyurethane ester (Degrapol; group D). Blood chemistry, weight gain, and abdominal X-rays were taken weekly to document any possible migration or reabsorption of the radio-opaque stents. After 3 months, necropsy was performed. Patency of the biliary bypass and choledochojejunostomy were examined using fluoroscopy and measured by introducing graduated dilators into the anastomosis.

RESULTS

Fluoroscopy revealed immediate passage of contrast through the anastomosis in all animals. Weight gain, bilirubin, and alkaline phosphatase were within normal range in all groups. Diameter of the bile duct (group H 10.7 +/- 2.9 mm/group P 9.5 +/- 3.6 mm/group D 11.0 +/- 4.6 mm) and choledochojejunostomy (group H 4.5 +/- 1.1 mm/group P 4.7 +/- 1.8 mm/group D 3.6 +/- 1.9 mm) did not differ. The time required to complete the biliary bypass was significantly decreased when TESA was applied (group H 152 +/- 13 min/group P 86 +/- 14 min, P <0.001/group D 110 +/- 20 min, P <0.002).

CONCLUSIONS

Applying TESA, laparoscopic choledochojejunostomy can be performed rapidly and safely, revealing good bypass function over a period of 3 months. With regard to treatment for nonresectable periampullary tumors, TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.

Laparoscopic anterior extended seromyotomy with posterior truncal vagotomy: an experimental study

We describe a new laparoscopic modification of parietal cell vagotomy. The laparoscopic anterior extended seromyotomy with posterior truncal vagotomy was performed in five pigs weighing 21 to 25 kg each. Congo-red and pH tests were undertaken 2 weeks later by open gastrotomy. The photographs of the stained gastric mucosa made at the 5-min interval after Congo-red administration were analyzed with a computer-driven area calculation program. Preoperative and postoperative weights were taken for all animals. The experimental parietal cell vagotomy group was compared with the sham group and showed a minimal amount of nondenervated parietal cell mass (0.9 +/- 0.4% versus 28.2 +/- 3.9%, p < 0.05). The pH values showed an inhibition of gastric acid secretion (7.8 +/- 0.7 versus 2.2 +/- 0.4, p < 0.05). During postoperative follow-up, no significant difference in the weight increase of the experimental and the sham control group was noticed (1.6 +/- 0.6 kg versus 2.0 +/- 0.1 kg, p < 0.27). The laparoscopic anterior extended seromyotomy with posterior truncal vagotomy efficiently suppresses gastric acid secretion, preserving the motility of the antrum and pylorus and diminishing the risk of residual areas of innervation. This procedure avoids dissection of the esophagus and can provide an easier but equally effective operative treatment of ulcer disease compared with other types of parietal cell vagotomy.

[Passive smoking in the workplace: a survey in the Zurich University Hospital]

The consequences of involuntary smoking are well documented. We conducted a survey among all employees of the University Hospital, Zurich, to assess their smoking habits and feelings about restrictions or a ban on smoking. In March 1995, a questionnaire was mailed to all 5230 hospital employees, 2620 (50.1%) completed forms were sent back. 76% of all staff are confronted with cigarette smoke during their worktime. 83% of these employees are distressed by tobacco smoke, and 43% feel that involuntary smoking affects their health. 19% of all employees are smokers. 19% of these are distressed by smokers at work themselves, whereas 13% feel that they are discriminated against by non-smokers. Restriction to designated smoking rooms (68%) or a ban on smoking (27%) would be supported by 95% of all employees. Even 89% of the smokers support smoking restrictions. These results show that there is a considerable demand for a smoke-free working environment among university hospital staff.

[Value of Hartmann's operation as an emergency intervention in sigmoid diverticulitis]

INTRODUCTION

Improvements in antibiotic and intensive care treatment have facilitated the conservative therapy of patients suffering from complicated diverticulitis of the sigmoid for the time necessary for preparation in view of early elective resection of the sigmoid colon. Consequently, early elective resection of the sigmoid colon with primary anastomosis has become very popular as the treatment of choice in complicated diverticulitis. This has led us to a retrospective evaluation of our own results with both Hartmann's operation and resection with primary anastomosis.

PATIENTS AND METHODS

55 patients with complicated diverticulitis of the sigmoid colon were operated on at our institution between 1981 and 1990. Group I consisted of 33 patients (17 females and 16 males) aged 39 to 89 years who underwent Hartmann's operation. Group II included 11 patients (6 females and 5 males) aged 39 to 85 years treated by resection and primary anastomosis. The remainder of the patients was treated by a three-step procedure and should not be considered here.

RESULTS

In group I 25 patients (76%) suffered complications either at the Hartmann's operation or at descendorectostomy or both. Mortality was 6%. Only 76% of patients had their stoma closed after an average of 3.8 months. The average hospital stay of both operations combined amounted to 61 days. In group II 3 patients had complications, one of which was lethal (lung emboly). The total hospital stay in this group averaged 22 days.

CONCLUSIONS

For Hinchey stages I and II conservative treatment, bowel preparation and early elective resection with primary anastomosis should be attempted. In cases of general peritonitis (Stages III and IV) Hartmann's operation is still the treatment of our choice.

Preoperative risk assessment in elective general surgery

Despite improved surgical techniques there is still a risk of mortality in elective general surgery. In a prospective study preoperative data from 3250 patients were collected and compared with postoperative systemic complications, using univariate chi 2 analysis. Highly significant (P < 0.00001) variables were subjected to stepwise logistic regression analysis. The severity of operative procedure, higher American Society of Anesthesiologists (ASA) grade, symptoms of respiratory disease and malignancy were found to be significant risk factors predicting postoperative morbidity (P < 0.05). Using these four variables, a simple preoperative risk scoring system has been defined. Class A (up to 5 points) was defined as a low-risk group (systemic complication rate 5.0 per cent), class B (5-7 points) was intermediate risk (systemic complication rate 17.9 per cent) and class C (8-10 points) was high risk (systemic complication rate 33.3 per cent). Patients at high risk for perioperative and postoperative complications are more likely to be identified by this analysis than by using the ASA classification alone.

Long-term function of vascular access for hemodialysis

OBJECTIVES

To compare the outcome of autogenous arteriovenous fistulas (AVF) with interposition graft fistulas for hemodialysis access.

DESIGN

Retrospective clinical study.

SETTING

Department of Surgery, Zurich University Hospital.

METHODS

Primary and secondary patency rates were calculated by life tables. Factors potentially affecting patency were studied by comparison of life tables using the log rank test.

MAIN RESULTS

From 1980 to 1992, 414 patients were operated on for long-term vascular access. 720 fistulas were created including 429 AVF and 291 interposition grafts (150 bovine xenografts, 69 PTFE grafts, 59 sheep collagen grafts, 10 autologous and 1 homologous vein grafts). Secondary patency rates after 1 and 3 yr were 74/64% in AVF, 56/24% in bovine xenografts, 58/40% in PTFE grafts and 71/45% in sheep collagen grafts. The latter performed not significantly worse than AVF. Primary and secondary patency rates were significantly lower in women.

Laparoscopic ultrasonography during cholecystectomy

The routine use of intraoperative cholangiography during cholecystectomy has been debated extensively. Intraoperative ultrasonography was a quick, efficient alternative in open cholecystectomy. A prospective controlled trial to evaluate its usefulness in laparoscopic cholecystectomy is reported. Two groups of 100 patients each were examined during operation with laparoscopic ultrasonography and intraoperative cholangiography. In the first group an adapted urethral probe was used and in the second group a new specialized laparoscopic probe. Intraoperative cholangiography followed immediately after laparoscopic ultrasonography in each patient. In group 1 bile duct stones (n = 4) were detected with a sensitivity of 100 and 75 per cent, a specificity of 98 and 99 per cent, and an overall accuracy of 98 per cent for both ultrasonography and cholangiography. In group 2, 11 patients demonstrated common duct calculi. The sensitivity, specificity and overall accuracy for laparoscopic ultrasonography and intraoperative cholangiography were 91 and 64 per cent, 100 and 100 per cent, and 99 and 96 per cent respectively. The differences between groups 1 and 2 and between ultrasonography and cholangiography were not significant. Variations in the anatomy of the bile duct were observed in 21 patients in group 1 by laparoscopic ultrasonography and in 20 by intraoperative cholangiography. In group 2, 64 variations were demonstrated in 50 individuals by ultrasonography and 61 variations in 47 patients by cholangiography. Vascular variations were seen with ultrasonography in 22 and 24 patients in groups 1 and 2 respectively. In conclusion, laparoscopic ultrasonography (with either probe) proved as accurate as intraoperative cholangiography in detecting bile duct stones, and the specialized probe detected significantly more variations of the bile duct than the adapted probe.

[Long-term results in pancreas transplantation in diabetes in the pre-cyclosporin era]

Simultaneous transplantation of the pancreas and the kidney performed in our institution up to 1979 in patients with diabetic nephropathy and terminal renal failure did not result in long-term success. The same procedure was applied to 13 patients with the same indication from 1980 to 1982. The technique of pancreatic transplantation was a segmental transplantation with instantaneous or delayed duct occlusion. Immunosuppressive therapy included azathioprine and prednisone, and in some patients antilymphocyte globulin, but no cyclosporin. 5 of these patients are still living; 4 of them lost their pancreas transplant function after 2 months, 5 months, 9 months and 5 years respectively. One female patient is living 15 years after transplantation, with good function of both the pancreas and the kidney. This is the longest functional survival after pancreas and kidney transplantation in the world literature.

Comparison of two antilymphocyte globulins replacing cyclosporin A after first kidney allotransplantation and prolonged graft ischemia

ATG/Fresenius (5 mg/kgBW) and ATGAM (Upjohn, 12.5 mg/ kgBW) replacing cyclosporin A were given during 7 d after transplantation to 20 patients in 1992 and 30 patients in 1993, respectively. Numbers of mismatches, combined kidney-pancreas transplantation and severe infections were not different for the two groups. However, prednisone pulse therapies and additional antilymphocyte globulin treatments were more frequent after ATGAM than after ATG induction (p < 0.01, chi 2-test).

Catheter fracture: a rare complication of totally implantable subclavian venous access devices

Catheter fracture represents a rare problem among non-infectious complications following the insertion of totally implantable long-term central venous access systems for the application of chemotherapeutic agents. A literature survey revealed a total incidence of catheter fractures of 0-2.1%. Imminent catheter fracture can be identified radiologically, using different degrees of catheter narrowing between the clavicle and the first rib, called pinch-off sign. Two cases of catheter fracture are described and potential causes are discussed. Recommendations to avoid the pinch-off sign with the subsequent risk of catheter fracture and migration include a more lateral and direct puncture of the subclavian vein. In case of catheter narrowing in the clavicular-first rib angle, patients should be followed carefully by chest X-rays every 4 weeks. Whenever possible, the system should be removed within 6 months following insertion.

[Socioeconomic advantages of laparoscopic cholecystectomy]

A cohort of 100 consecutive patients cholecystectomized by laparoscopy was compared retrospectively under diverse socio-economic viewpoints to a cohort of 100 patients that underwent conventional cholecystectomy by means of the matched pair procedure. Laparoscopic cholecystectomy does not only combine enhanced comfort and less postoperative pain without loss of safety for the patient, but also offers objectively attainable socio-economic advantages in comparison to conventional, open cholecystectomy. Operation time was not prolonged in laparoscopic cholecystectomies. Patients stayed less long in the hospital and regained fitness for work earlier. The reduced time of inability to work could be lowered in the total cohort by 36% and was thus of great importance, particularly for working people. Costs saved by reduced time of hospitalization by laparoscopic cholecystectomy were balanced by higher additional costs of this procedure. Altogether, total costs for health insurance and other insurances induced by laparoscopic cholecystectomy were lower compared to those of conventional operation.

[Efficacy of basic surgical diagnosis in acute abdominal pain]

This report describes a retrospective study concerning 314 patients suffering from acute abdominal pain admitted to the surgical emergency unit of Zürich University Hospital in 1992. Basic diagnostic work-up (history, physical examination, blood tests, sonography and abdominal X-ray) revealed the final diagnosis in 188 patients. Sonography was essential in 77 cases. Only 33 patients required additional examinations, such as CT-scan, gastroscopy or contrast X-rays. Ninety-three patients were discharged with a final diagnosis of "non-specific abdominal pain" (NSAP) after their symptoms had improved. A follow-up examination of these patients 6-18 months later resulted in a final diagnosis of somatic diseases in 8% of cases. This study demonstrated that the basic surgical diagnostics are efficient and reveal the final diagnosis with minimal delay. Abdominal sonography is the most important diagnostic tool in this context and should, therefore, be mastered and employed by the surgeon himself.

[25 years of dialysis and kidney transplantation in children and adolescents]

Between 1970 and 1994 84 children and adolescents with end stage renal failure (ESRF) were started on renal replacement therapy (RRT). Renal transplantation was the main goal from the beginning. The long term results were evaluated with emphasis on survival, development and social integration. RRT was started in nearly half of the children (45%) between the age of 10 and 15 years and in 14% before 5 years. 52 patients were first treated by hemodialysis (HD) and 27 by peritoneal dialysis (PD, since 1979). 5 patients underwent preemptive transplantation. By December 1994, 75 patients had received 99 grafts, i.e. 75 1st, 21 2nd and 3 3rd grafts; 3 kidneys were from living related donors and 8 patients were transplanted elsewhere. 7 patients were still on dialysis and 2 had died before transplantation. Actuarial patient survival (Kaplan-Meier) after start of RRT is 88% at 10 years and 75% at 17-25 years. Actuarial patient survival after first transplantation increased from 91% (1970-1984) at 5 years to 97% (1985-1994). 7 of the first 10 patients transplanted from 1970-1974 are alive, all with functioning grafts (4 with their first graft). 9 patients died after transplantation: 4 of recurrent disease, 2 of viral (CMV, EBV) infections and 1 each of spinalioma, allergic shock and traffic accident. First graft survival was 37% at 10 years. It increased from 53% (1970-1984) to 72% (1985-1994) at 5 years. The main causes of first graft loss (n = 33) were irreversible rejection (21) and recurrent disease (7). All patients aged > 22 years were further evaluated: patients with start of RRT 1970-1979 (group A, n = 18) were compared with those starting RRT from 1980-1987 (B, n = 19). Mean adult height in A was less than in B (163.9 cm vs 168.5 cm in men; 146.3 cm vs 156.5 cm in women). 50% in A vs 32% in B had a disability. Fewer patients in A (39%) than in B (62%) were fully employed. Considerably more patients in A (61%) than in B (37%) lived with their parents or siblings although the mean age in A was 31 years vs 25 years in B. 3 women were married (all in B), 2 of them gave birth to 3 healthy children and the third was pregnant. Long term patient and graft survival, somatic development and social integration have improved over the years due to a variety of factors. A comprehensive approach is necessary in treating children with ESRF.

A novel dextran 40-based preservation solution

Although the University of Wisconsin (UW) solution has become the standard solution for the preservation of kidneys for transplantation, the importance of the colloid hydroxyethylstarch (HES), one of the key compounds of the UW solution, has been questioned repeatedly. It is now established that HES is not necessary for routine kidney preservation. However, colloids may still be advantageous in UW like solutions for the purpose of multiorgan procurements and the preservation of organs from marginal donors. It has been shown in various experimental models that dextran 40 may successfully substitute for HES. Dextran 40 is not only cheaper but also has a variety of biological effects that may be beneficial during the graft reperfusion phase. The aim of this clinical study was to examine the efficacy of a dextran 40-based preservation solution (Dex-PS) for its use in human kidney graft preservation and to compare the transplantation results with kidneys preserved with UW solution. A total of 87 kidneys were preserved with Dex-PS and matched with 87 kidneys preserved with UW solution. Both groups were comparable in terms of donor and recipient characteristics and both had a high proportion of kidneys from nonheart-beating donors. Patient survival and graft survival after 1 year were 95% and 86% for the Dex-PS group and 94% and 90% for the UW group, respectively (P = NS). Primary nonfunction, delayed graft function, postoperative need for dialysis, and follow-up of serum creatinine were statistically comparable between these two groups. We conclude that dextran 40 can safely replace HES in UW solution for the purpose of clinical kidney preservation. There were no statistically detectable differences in graft performance between the kidneys preserved with UW and those preserved with Dex-PS.

[Advantages of the laser in laparoscopic cholecystectomy]

Use of the holmium and Nd:YAG laser is clearly advantageous in laparoscopic cholecystectomy, i.e., less perforation of the gallbladder when compared to the use of the hook electrode, shorter intervention time and less postoperative pain. Laser-operated patients can therefore be discharged 1.5 days earlier than those patients in whom cholecystectomy had been performed using electrocautery.

[Magnetic resonance controlled minimal invasive surgery: initial results and perspectives]

The development of an open-configured MR-imaging system opens new perspectives in minimal invasive surgery. The combination of laparoscopy and real-time MR imaging allows the guidance of diagnostic interventions as well as interstitial therapies of parenchymal organs. In the near future, tumor diagnosis, therapy and follow-up can be done using the same technique.

Thirty-two years of renal transplantation in Zurich

This overview of the last 3 decades of renal transplantation at our center depicts the development from the early phase of clinical transplantation to the development of a standardized multiorgan transplant program. Between 1964 and 1996, a total of 1,703 kidney transplants were performed at the University of Zurich Hospital in Switzerland. Due to a relatively active program in the early years of renal transplantation our data provide some useful information on the long-term results of renal transplantation. We observed a steady improvement in outcomes following transplantation during the first 2 decades of our program paralleled by an improvement in graft half-life. In the last decade, however, the demographic characteristics of our recipient population have changed gradually, leading to an increased proportion of diabetics and elderly patients. Thus, during the past decade, transplant outcomes, in terms of early graft and patient survival, have stagnated. The increased proportion of diabetics being accepted for transplantation has helped to establish simultaneous kidney and pancreas transplantation as a routine procedure, thereby offering these patients the prospect of long-term rehabilitation. In order to increase the number of available kidneys for transplantation we have adopted 2 strategies. First, we have successfully used donor kidneys from non-heart-beating donors. Results achieved with this method can be equivalent to transplantation of organs from heart-beating donors when certain criteria are respected. Second, we are increasingly performing kidney transplants from living-related donors and hope to further expand our activities in this direction in the future.